The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide

A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures

BACKGROUND

Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment.

METHODS

Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios.

RESULTS

In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay.

CONCLUSION

Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.

Assessment of submicron bone tissue composition in plastic-embedded samples using optical photothermal infrared (O-PTIR) spectral imaging and machine learning

Understanding the composition of bone tissue at the submicron level is crucial to elucidate factors contributing to bone disease and fragility. Here, we introduce a novel approach utilizing optical photothermal infrared (O-PTIR) spectroscopy and imaging coupled with machine learning analysis to assess bone tissue composition at 500 nm spatial resolution. This approach was used to evaluate thick bone samples embedded in typical poly(methyl methacrylate) (PMMA) blocks, eliminating the need for cumbersome thin sectioning. We demonstrate the utility of O-PTIR imaging to assess the distribution of bone tissue mineral and protein, as well as to explore the structure-composition relationship surrounding microporosity at a spatial resolution unattainable by conventional infrared imaging modalities. Using bone samples from wildtype (WT) mice and from a mouse model of osteogenesis imperfecta (OIM), we further showcase the application of O-PTIR spectroscopy to quantify mineral content, crystallinity, and carbonate content in spatially defined regions across the cortical bone. Notably, we show that machine learning analysis using support vector machine (SVM) was successful in identifying bone phenotypes (typical in WT, fragile in OIM) based on input of spectral data, with over 86 % of samples correctly identified when using the collagen spectral range. Our findings highlight the potential of O-PTIR spectroscopy and imaging as valuable tools for exploring bone submicron composition.

Feasibility study of opportunistic osteoporosis screening on chest CT using a multi-feature fusion DCNN model

A multi-feature fusion DCNN model for automated evaluation of lumbar vertebrae L1 on chest combined with clinical information and radiomics permits estimation of volumetric bone mineral density for evaluation of osteoporosis.

PURPOSE

To develop a multi-feature deep learning model based on chest CT, combined with clinical information and radiomics to explore the feasibility in screening for osteoporosis based on estimation of volumetric bone mineral density.

METHODS

The chest CT images of 1048 health check subjects were retrospectively collected as the master dataset, and the images of 637 subjects obtained from a different CT scanner were used for the external validation cohort. The subjects were divided into three categories according to the quantitative CT (QCT) examination, namely, normal group, osteopenia group, and osteoporosis group. Firstly, a deep learning-based segmentation model was constructed. Then, classification models were established and selected, and then, an optimal model to build bone density value prediction regression model was chosen.

RESULTS

The DSC value was 0.951 ± 0.030 in the testing dataset and 0.947 ± 0.060 in the external validation cohort. The multi-feature fusion model based on the lumbar 1 vertebra had the best performance in the diagnosis. The area under the curve (AUC) of diagnosing normal, osteopenia, and osteoporosis was 0.992, 0.973, and 0.989. The mean absolute errors (MAEs) of the bone density prediction regression model in the test set and external testing dataset are 8.20 mg/cm3 and 9.23 mg/cm3, respectively, and the root mean square errors (RMSEs) are 10.25 mg/cm3 and 11.91 mg/cm3, respectively. The R-squared values are 0.942 and 0.923, respectively. The Pearson correlation coefficients are 0.972 and 0.965.

CONCLUSION

The multi-feature fusion DCNN model based on only the lumbar 1 vertebrae and clinical variables can perform bone density three-classification diagnosis and estimate volumetric bone mineral density. If confirmed in independent populations, this automated opportunistic chest CT evaluation can help clinical screening of large-sample populations to identify subjects at high risk of osteoporotic fracture.

Diagnostic performance of radiomics for predicting osteoporosis in adults: a systematic review and meta-analysis

This study aimed to assess the diagnostic accuracy of radiomics for predicting osteoporosis and the quality of radiomic studies. The study protocol was prospectively registered on PROSPERO (CRD42023425058). We searched PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to June 1, 2023, for eligible articles that applied radiomic techniques to diagnosing osteoporosis or abnormal bone mass. Quality and risk of bias of the included studies were evaluated with radiomics quality score (RQS), METhodological RadiomICs Score (METRICS), and Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tools. The data analysis utilized the R program with mada, metafor, and meta packages. Ten retrospective studies with 5926 participants were included in the systematic review and meta-analysis. The overall risk of bias and applicability concerns for each domain of the studies were rated as low, except for one study which was considered to have a high risk of flow and time bias. The mean METRICS score was 70.1% (range 49.6-83.2%). There was moderate heterogeneity across studies and meta-regression identified sources of heterogeneity in the data, including imaging modality, feature selection method, and classifier. The pooled diagnostic odds ratio (DOR) under the bivariate random effects model across the studies was 57.22 (95% CI 27.62-118.52). The pooled sensitivity and specificity were 87% (95% CI 81-92%) and 87% (95% CI 77-93%), respectively. The area under the summary receiver operating characteristic curve (AUC) of the radiomic models was 0.94 (range 0.8 to 0.98). The results supported that the radiomic techniques had good accuracy in diagnosing osteoporosis or abnormal bone mass. The application of radiomics in osteoporosis diagnosis needs to be further confirmed by more prospective studies with rigorous adherence to existing guidelines and multicenter validation.

Automated Screening of Hip X-rays for Osteoporosis by Singh's Index Using Machine Learning Algorithms

Introduction

Osteoporosis is a significant and growing global public health problem, projected to increase in the next decade. The Singh Index (SI) is a simple, semi-quantitative evaluation tool for diagnosing osteoporosis with plain hip radiographs based on the visibility of the trabecular pattern in the proximal femur. This work aims to develop an automated tool to diagnose osteoporosis using SI of hip radiograph images with the help of machine learning algorithms.

Methods

We used 830 hip X-ray images collected from Indian men and women aged between 20 and 70 which were annotated and labeled for appropriate SI. We employed three state-of-the-art machine learning algorithms-Vision Transformer (ViT), MobileNet-V3, and a Stacked Convolutional Neural Network (CNN)-for image pre-processing, feature extraction, and automation. Each algorithm was evaluated and compared for accuracy, precision, recall, and generalization capabilities to diagnose osteoporosis.

Results

The ViT model achieved an overall accuracy of 62.6% with macro-averages of 0.672, 0.597, and 0.622 for precision, recall, and F1 score, respectively. MobileNet-V3 presented a more encouraging accuracy of 69.6% with macro-averages for precision, recall, and F1 score of 0.845, 0.636, and 0.652, respectively. The stacked CNN model demonstrated the strongest performance, achieving an accuracy of 93.6% with well-balanced precision, recall, and F1-score metrics.

Conclusion

The superior accuracy, precision-recall balance, and high F1-scores of the stacked CNN model make it the most reliable tool for screening radiographs and diagnosing osteoporosis using the SI.

Effects of adjunctive esketamine on depression in elderly patients undergoing hip fracture surgery: a randomized controlled trial

BACKGROUND

Depression is a prevalent perioperative psychiatric complication among elderly hip fracture patients. Esketamine has rapid and robust antidepressant effects. However, it is unknown whether it can alleviate depressive symptoms in elderly patients who undergo hip fracture surgery. This study aimed to explore whether the adjunctive esketamine in patient-controlled intravenous analgesia (PCIA) could improve depressive symptoms in elderly patients undergoing hip fracture surgery.

METHODS

A single-center, prospective, double-blind and randomized controlled clinical trial was carried out from July 2022 to August 2023 at the Wenzhou People's Hospital among 90 patients, aged ≥ 65 years with hip fracture undergoing elective surgery. Participants were randomly allocated to either the esketamine group (group S) or the control group (group C). In Group S, patients were administered 0.5 mg/kg of esketamine as a PCIA adjuvant for 48 h, while the control group received saline. The primary outcome was the assessment of depressive symptoms using the Geriatric Depression Scale-15 (GDS-15) on postoperative day 2. The secondary outcomes were assessments of depressive symptoms on postoperative day 7 and postoperative day 30, serum levels of brain-derived neurotrophic factor (BDNF) and 5-hydroxytryptamine (5-HT), postoperative pain intensity, the number of effective PCIA presses, sufentanil consumption, and adverse events.

RESULTS

The prevalence and GDS-15 scores of depression were significantly lower in group S on postoperative day 2 (28.6% vs. 53.5%; 3.5 ± 1.8 vs. 4.3 ± 1.7, P < 0.05). In group S, the number of effective PCIA presses was significantly lower on postoperative day 2 than that in group C [2(1-4) vs. 1(0-2), P<0.05]. Higher levels of BDNF (23.8 ± 1.7 ng/mL vs. 25.3 ± 2.0 ng/mL, P < 0.05) and 5-HT (219.5 ± 19.5 ng/mL vs. 217.0 ± 22.2 ng/mL, P < 0.05) in the blood were observed on postoperative day 2 in group S.

CONCLUSION

In elderly patients aged ≥ 65 years undergoing hip fracture surgery, the administration of adjunctive esketamine in PCIA could improve depressive symptoms and increase levels of BDNF and 5-HT in the blood.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200061956 (Date: 13/07/2022).

The Reciprocal Relationship Between Lumbar Intervertebral Disk Degeneration and the MRI-based Vertebral Bone Quality Score

STUDY DESIGN

Retrospective longitudinal study.

OBJECTIVE

To investigate the association between lumbar intervertebral disk degeneration (DD) and the vertebral bone quality (VBQ) score.

BACKGROUND

The VBQ score that is based on magnetic resonance imaging has been proposed as a measure of lumbar spine bone quality and is a significant predictor of healthy versus osteoporotic bone. However, the role of segmental contributing factors on VBQ is unknown.

METHODS

Nonsurgical patients who underwent repeated lumbar magnetic resonance imaging scans, at least three years apart primarily for low back pain were retrospectively included. VBQ was assessed as previously described. DD was assessed using the Pfirrmann grading (PFG) scale. PFG grades were summarized as PFG L1-4 for the upper three lumbar disk levels, as PFG L4-S1 for the lower two lumbar disc levels, and as PFG L1-S1 for all lumbar disc levels. Multivariable linear mixed models were used with adjustments for age, sex, race, body mass index, and the clustering of repeated measurements.

RESULTS

A total of 350 patients (54.6% female, 85.4% White) were included in the final analysis, with a median age at baseline of 60.1 years and a body mass index of 25.8 kg/m 2 . VBQ significantly increased from 2.28 at baseline to 2.36 at follow-up ( P = 0.001). In the unadjusted analysis, a significant positive correlation was found between PFG L1-4 , PFG L1-S1 , and VBQ at baseline ( P < 0.05) that increased over time ( P < 0.005). In the adjusted multivariable analysis, PFG L1-4 ( β = -0.0195; P = 0.021), PFG L4-S1 ( β = -0.0310; P = 0.007), and PFG L1-S1 ( β = -0.0160; P = 0.012) were independently and negatively associated with VBQ.

CONCLUSIONS

More advanced and long-lasting DD is associated with lower VBQ indicating less bone marrow fat content and potentially stronger bone. VBQ score as a marker of bone quality seems affected by DD.

Conservative Versus Operative Treatment of Proximal Humerus Fractures in Older Individuals

BACKGROUND

Little is known about the frequency and results of conservative treatment of proximal humerus fractures (PHF) in older individuals.

METHODS

Billing data of the BARMER health insurance carrier for all patients of age ≥ 65 for the years 2005-2021 were retrospectively analyzed with multivariable Cox regression models, taking account of the patients' age, sex, and individual comorbidity profiles. The defined primary endpoints were overall survival (OS), major adverse events (MAE), thromboembolic events (TE), and complications of surgery or of trauma. Multivariable p-values for the effect of treatment on all primary endpoints were jointly adjusted using the Bonferroni-Holm method.

RESULTS

Of 81 909 patients, 54% were treated conservatively. Conservative treatment was more common in those who received their diagnosis as outpatients (79.5%, vs. 37.2% for inpatients). Operative treatment was associated with significantly longer overall survival (long-term hazard ratio [HR] 0.89, 95% confidence interval [0.86; 0.91]), fewer MAE (0.90 [0.88; 0.92]), and fewer TE (0.89 [0.87; 0.92]), but more complications due to surgery or trauma (1.66 [1,.4; 1.78]; all p < 0.001). By 6 months after diagnosis, 3.1% of the patients who were initially treated conservatively had undergone surgery. Risk factors for failure of conservative treatment were alcohol abuse, obesity, cancer, diabetes mellitus, Parkinson disease, and osteoporosis.

CONCLUSION

The conservative treatment of PHF is associated with a lower overall rate of complications due to surgery or trauma, but also with more MAE, more TE, and higher mortality. These findings underline the need for individualized and risk-adjusted treatment recommendations.

CT image-based biomarkers for opportunistic screening of osteoporotic fractures: a systematic review and meta-analysis

The use of opportunistic computed tomography (CT) image-based biomarkers may be a low-cost strategy for screening older individuals at high risk for osteoporotic fractures and populations that are not sufficiently targeted. This review aimed to assess the discriminative ability of image-based biomarkers derived from existing clinical routine CT scans for hip, vertebral, and major osteoporotic fracture prediction. A systematic search in PubMed MEDLINE, Embase, Cochrane, and Web of Science was conducted from the earliest indexing date until July 2023. The evaluation of study quality was carried out using a modified Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) checklist. The primary outcome of interest was the area under the curve (AUC) and its corresponding 95% confidence intervals (CIs) obtained for four main categories of biomarkers: areal bone mineral density (BMD), image attenuation, volumetric BMD, and finite element (FE)-derived biomarkers. The meta-analyses were performed using random effects models. Sixty-one studies were included in this review, among which 35 were synthesized in a meta-analysis and the remaining articles were qualitatively synthesized. In comparison to the pooled AUC of areal BMD (0.73 [95% CI 0.71-0.75]), the pooled AUC values for predicting osteoporotic fractures for FE-derived parameters (0.77 [95% CI 0.72-0.81]; p < 0.01) and volumetric BMD (0.76 [95% CI 0.71-0.81]; p < 0.01) were significantly higher, but there was no significant difference with the pooled AUC for image attenuation (0.73 [95% CI 0.66-0.79]; p = 0.93). Compared to areal BMD, volumetric BMD and FE-derived parameters may provide a significant improvement in the discrimination of osteoporotic fractures using opportunistic CT assessments.

Femoral osteoporosis prediction model using autosegmentation and machine learning analysis with PyRadiomics on abdomen-pelvic computed tomography (CT)

Background

With the advancement of artificial intelligence technology and radiomics analysis, opportunistic prediction of osteoporosis with computed tomography (CT) is a new paradigm in osteoporosis screening. This study aimed to assess the diagnostic performance of osteoporosis prediction by the combination of autosegmentation of the proximal femur and machine learning analysis with a reference standard of dual-energy X-ray absorptiometry (DXA).

Methods

Abdomen-pelvic CT scans were retrospectively analyzed from 1,122 patients who received both DXA and abdomen-pelvic computed tomography (APCT) scan from January 2018 to December 2020. The study cohort consisted of a training cohort and a temporal validation cohort. The left proximal femur was automatically segmented, and a prediction model was built by machine-learning analysis using a random forest (RF) analysis and 854 PyRadiomics features. The technical success rate of autosegmentation, diagnostic test, area under the receiver operator characteristics curve (AUC), and precision recall curve (AUC-PR) analysis were used to analyze the training and validation cohorts.

Results

The osteoporosis prevalence of the training and validation cohorts was 24.5%, and 10.3%, respectively. The technical success rate of autosegmentation of the proximal femur was 99.7%. In the diagnostic test, the training and validation cohorts showed 78.4% vs. 63.3% sensitivity, 89.4% vs. 98.1% specificity. The prediction performance to identify osteoporosis within the groups used for training and validation cohort was high and the AUC and AUC-PR to forecast the occurrence of osteoporosis within the training and validation cohorts were 90.8% [95% confidence interval (CI), 88.4-93.2%] vs. 78.0% (95% CI, 76.0-79.9%) and 94.6% (95% CI, 89.3-99.8%) vs. 88.8% (95% CI, 86.2-91.5%), respectively.

Conclusions

The osteoporosis prediction model using autosegmentation of proximal femur and machine-learning analysis with PyRadiomics features on APCT showed excellent diagnostic feasibility and technical success.

Use of data-independent acquisition mass spectrometry to identify an objective serum indicator of the need for osteoporotic therapeutic intervention

Osteoporosis is characterized by weakened bone microstructure and loss of bone mass. Current diagnostic criteria for osteoporosis are based on the T-score, which is a measure of bone mineral density. However, osteoporotic fragility fractures can occur regardless of the T-score, underscoring the need for additional criteria for the early detection of patients at fracture risk. To identify indicators of reduced bone strength, we performed serum proteomic analysis using data-independent acquisition mass spectrometry with serum samples from two patient groups, one with osteoporosis but no fractures and the other with osteopenia and fragility fractures. Collective evaluation of the results identified six serum proteins that changed to a similar extent in both patient groups compared with controls. Of these, extracellular matrix protein 1 (ECM1), which contributes to bone formation, showed the most significant increase in serum levels in both patient groups. An ELISA-based assay suggested that ECM1 could serve as a serum indicator of the need for therapeutic intervention; however, further prospective studies with a larger sample size are necessary to confirm these results. The present findings may contribute to the provision of early and appropriate therapeutic strategies for patients at risk of osteoporotic fractures. SIGNIFICANCE: This study aimed to identify objective serum indicators of the need for therapeutic intervention in individuals at risk of osteoporotic fracture. Comprehensive proteome analyses of serum collected from patients with osteoporosis but no fractures, patients with osteopenia and fragility fractures, and controls were performed by data-independent acquisition mass spectrometry. Collective evaluation of the proteome analysis data and ELISA-based assays identified serum ECM1 as a potential objective marker of the risk of fragility fractures in patients with osteoporosis or osteopenia. The findings are an important step toward the development of appropriate bone health management methods to improve well-being and maintain quality of life.

Achieving osteoporosis treat-to-target goals with teriparatide or alendronate: sub-analysis of Japanese Osteoporosis Intervention Trial-05 (JOINT-05)

INTRODUCTION

The purpose of this study was to evaluate whether bone mineral density (BMD) ≥ -2.5 SD could be used as the treat-to-target (T2T) goal when treating osteoporosis with teriparatide (TPTD) and alendronate (ALN), and to investigate the relationship with incident vertebral fracture by re-analyzing data from a randomized, controlled trial (JOINT-05) involving postmenopausal Japanese women at high fracture risk.

MATERIALS AND METHODS

Participants received sequential therapy with once-weekly TPTD for 72 weeks, followed by ALN for 48 weeks (TPTD-ALN group) or ALN monotherapy for 120 weeks (ALN group). BMDs were measured at the lumbar spine (L2-4), total hip, and femoral neck at 0, 24, 48, 72, and 120 weeks by dual-energy X-ray absorptiometry. The T2T goal was BMD ≥ -2.5 SD, and the endpoint was the proportion of participants with baseline BMD < -2.5 SD in three measurement sites achieving BMD ≥ -2.5 SD.

RESULTS

A total of 559 participants were selected. BMD ≥ -2.5 SD at 120 weeks in the L2-4, total hip, and femoral neck sites was achieved in 20.5%, 23.1%, and 5.9%, respectively, in the TPTD-ALN group and 22.2%, 11.7%, and 7.3%, respectively, in the ALN group. Incident vertebral fractures occurred in areas of both lower and high BMD.

CONCLUSION

During the 1.5-year treatment period, more than 20% of participants achieved BMD ≥ -2.5 SD as a T2T goal at L2-4. Since the achievement level differed depending on the BMD measurement site, the appropriate site should be selected according to the baseline BMD level.

Osteoporosis, Osteoarthritis, and Subchondral Insufficiency Fracture: Recent Insights

The increased incidence of osteoarthritis (OA), particularly knee and hip OA, and osteoporosis (OP), owing to population aging, have escalated the medical expense burden. Osteoarthritis is more prevalent in older women, and the involvement of subchondral bone fragility spotlights its association with OP. Notably, subchondral insufficiency fracture (SIF) may represent a more pronounced condition of OA pathophysiology. This review summarizes the relationship between OA and OP, incorporating recent insights into SIF. Progressive SIF leads to joint collapse and secondary OA and is associated with OP. Furthermore, the thinning and fragility of subchondral bone in early-stage OA suggest that SIF may be a subtype of OA (osteoporosis-related OA, OPOA) characterized by significant subchondral bone damage. The high bone mineral density observed in OA may be overestimated due to osteophytes and sclerosis and can potentially contribute to OPOA. The incidence of OPOA is expected to increase along with population aging. Therefore, prioritizing OP screening, early interventions for patients with early-stage OA, and fracture prevention measures such as rehabilitation, fracture liaison services, nutritional management, and medication guidance are essential.

Is the association between pulse wave velocity and bone mineral density the same for men and women? - A systematic review and meta-analysis

BACKGROUND

Brachial aortic Pulse Wave Velocity (baPWV) and bone mineral density (BMD) are important indicators of cardiovascular health and bone strength, respectively. However, the gender-specific association between baPWV and BMD remains unclear. The aim of our study is to evaluate the relationship between baPWV and BMD in men and women populations METHODS: A comprehensive search was conducted in electronic databases for relevant studies published between the 1th and 30rd of April 2023. Studies reporting the correlation between baPWV and BMD in both males and females were considered. A random-effects model was used to calculate pooled correlation coefficients (r).

RESULTS

Relevant data for both genders were found in six articles. In all publications included in the meta-analysis, the total number of studied individuals was 3800, with 2054 women and 1746 men. Pooled correlation coefficient was -0,24 (95 % CI: -0.34; -0.15) in women population, and -0.12 (95 %CI: -0.16, -0.06) in men.

CONCLUSIONS

Based on the published data, we found that baPWV is negatively correlated with bone density in women. However, in men we do not find such a relationship. These findings suggest the importance of considering gender-specific factors when assessing the cardiovascular and bone health relationship.

Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients

INTRODUCTION

The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients.

MATERIALS AND METHODS

We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation.

RESULTS

Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period.

CONCLUSIONS

Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Radiofrequency Echographic Multispectrometry (REMS) can Overcome the Effects of Structural Internal Artifacts and Evaluate Bone Fragility Accurately

PURPOSE

This study measured bone mineral density (BMD) in a Japanese population using the novel non-ionizing system using radiofrequency echographic multispectrometry (REMS) and compared the results with those obtained using traditional dual-energy X-ray absorptiometry (DXA). We aimed to identify any discrepancies between measurements obtained using these instruments and identify the influencing factors.

METHODS

This cross-sectional study examined patients with osteoporosis treated at a single center from April to August 2023. We examined BMD assessment by DXA and REMS in lumbar spine and proximal femur. Patients were categorized into two groups: those with discrepancies between lumbar spine BMD measured by DXA and REMS, and those without. Semiquantitative evaluation of vertebral fractures and abdominal aortic calcification scoring were also performed and compared between the two groups, along with various patient characteristics.

RESULTS

A total of 70 patients (88.6% female; mean age 78.39 ± 9.50 years) undergoing osteoporosis treatment were included in the study. A significant difference was noted between DXA and REMS measurement of BMD and T-scores, with REMS recording consistently lower values. The discrepancy group exhibited a higher incidence of multiple vertebral fractures and increased vascular calcification than the non-discrepancy group. Multivariate analysis indicated that diabetes mellitus, severe vertebral fractures, and increased abdominal aortic calcification scores were significantly associated with discrepancies in lumbar spine T-scores.

CONCLUSION

This study suggests that REMS may offer a more accurate measurement of BMD, overcoming the overestimation of BMD by DXA owing to factors such as vertebral deformities, abdominal aortic calcification, and diabetes mellitus.

The incremental risk of fragility fractures in aging men

INTRODUCTION

While the United States Preventative Services Task Force recommends osteoporosis screening for women 65 years and older, there is no definitive recommendation for routine osteoporosis screening in men. The purpose of this study was to determine the age at which the odds of fragility fractures (FFx) increase in men to help guide future policy discussions evaluating an optimal screening strategy in this population.

METHODS

Men older than 49 years were identified in the PearlDiver Patient Records Database. Patients were excluded if they had a prior fragility fracture, if they were at high risk for osteoporosis due to comorbidities, or if they carried a diagnosis of and/or were on treatment for osteoporosis. The prevalence of FFx was trended for each age group. A stratum-specific likelihood ratio (SSLR) analysis was conducted to identify data-driven strata that maximize the incremental FFx risk by age for men. Logistic regression analyses controlling for potential confounders were conducted to test these identified strata.

RESULTS

The incidence of FFx started to increase after the age of 64 years for men. Further, the identified data-driven age strata associated with a significant and incremental difference in fragility fractures were the following: 50-64, 65-69, 70-72, 73-75, 76-78, 79-80, and 81+. When compared to the youngest age stratum (50-64 years), multivariable regression showed the risk of fragility fracture incrementally increased starting in those aged 70-72 (RR, 1.31; 95% CI. 1.21-1.46; p < 0.001) with the highest risk in those aged 81+ (RR, 5.35; 95% CI, 5.10-5.62; p < 0.001).

CONCLUSION

In men without a pre-existing history of osteoporosis, the risk of fragility fractures starts to increase after the age of 70. Further work building upon these data may help to identify a specific age at which routine bone health screening in males can help to minimize fractures and their associated morbidity and mortality.

Correlation between bone density, bone metabolism markers with lipid metabolism markers and body mass index

PURPOSE

We aimed to explore the relationship between bone mineral density (BMD), bone metabolism markers, and blood lipid-related indicators, body mass index (BMI) in elderly individuals.

METHODS

A retrospective analysis was conducted on 710 patients. Patients' gender, age, height, weight, bone density values, T-scores, bone metabolism markers (including serum N-terminal propeptide of type I collagen (s-PINP), serum C-terminal telopeptide of type I collagen (s-CTX) and 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) and lipid-related indicators (including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and Castelli index 1 (TC/HDL-C index) and Castelli index 2 (LDL-C/HDL-C index) were recorded. Correlations between variables were analyzed, and patients were grouped according to gender and T-score for intergroup comparisons.

RESULTS

HDL-C negatively correlates with BMD and s-CTX. TG, Castelli index, and BMI positively correlate with BMD. BMI negatively correlates with s-PINP. 1,25(OH)2D3 negatively correlates with TC, LDL-C, and Castelli index. LDL-C positively correlates with BMD in males, and TC negatively correlates with s-PINP. In females, HDL-C negatively correlates with BMD, and s-CTX positively correlates with Castelli index. 1,25(OH)2D3 negatively correlates with TC, LDL-C, and Castelli index. TG and Castelli index were higher in normal bone mass group, while HDL-C is higher in the osteoporosis group. TG and BMI positively predicted bone mass density, while HDL-C negatively predicted bone mass density.

CONCLUSIONS

HDL-C may have a predictive role in osteoporosis, particularly in women. The likelihood of osteoporosis is lower in individuals with high BMI or hyperlipidemia. Some lipid metabolism markers can be used to predict osteoporosis, and further research is needed.

PKM2 is a Novel Osteoporosis-Associated Protein in Chinese

                       Purpose:Osteoporosis is characterized by low bone mineral density (BMD) and high risk of osteoporotic fracture (OF). Peripheral blood monocytes (PBM) can differentiate into osteoclasts to resorb bone. This study was to identify PBM-expressed proteins significant for osteoporosis in Chinese Han elderly population (>65 years), and focused on two phenotypes of osteoporosis: low BMD and OF.

METHODS

Label-free quantitative proteomics was employed to profile PBM proteome and to identify differentially expressed proteins (DEPs) between OF (N=27) vs. non-fractured (NF, N=24) subjects and between low BMD (N=12) vs. high BMD (N=12) subjects in women. Western blotting (WB) was conducted to validate differential expression, and ELISA to evaluate translational value for secretory protein of interest.

RESULTS

We discovered 59 DEPs with fold change (FC)>1.3 (P<1×10-5), and validated the significant up-regulation of pyruvate kinase isozyme 2 (PKM2) with osteoporosis (P<0.001). PKM2 protein upregulation with OF was replicated with PBM in men (P=0.04). Plasma PKM2 protein level was significantly elevated with OF in an independent sample (N=100, FC=1.68, P=0.01). Pursuant functional assays showed that extracellular PKM2 protein supplement not only promoted monocyte trans-endothelial migration, growth, and osteoclast differentiation (marker gene expression), but also inhibited osteoblast growth, differentiation (ALP gene expression), and activity.

CONCLUSION

The above findings suggest that PKM2 protein is a novel osteoporosis-associated functional protein in Chinese Han elderly population. It may serve as a risk biomarker and drug target for osteoporosis.

VDR gene ApaI polymorphism and risk of postmenopausal osteoporosis: a meta-analysis from 22 studies

OBJECTIVE

The ApaI polymorphism (G > T, rs7975232) of the vitamin D receptor (VDR) gene in the risk of postmenopausal osteoporosis has been widely researched, and the results have yielded conflicts. Therefore, we performed an updated pooled analysis to comprehensively assess the association between VDR ApaI polymorphism and postmenopausal osteoporosis risk.

METHODS

We searched eligible studies about ApaI polymorphism and osteoporosis through the PubMed, Embase, CNKI and Wanfang databases; case-control studies containing available genotype frequencies of A/a were chosen. We used the odds ratio with 95% confidence interval to assess the strength of this association. Sensitivity analysis and publication bias assessment were performed. Trial sequential analysis (TSA) was performed to evaluate a sufficient sample.

RESULTS

Twenty-two studies assessed the relationship between ApaI polymorphism and the risk of osteoporosis in postmenopausal women. The comprehensive analyses showed no significant association for ApaI polymorphism with postmenopausal osteoporosis in the overall population, equally valid for Asian and Caucasian subgroups with any genetic model. TSA still indicated the results were robust.

CONCLUSION

The present meta-analysis suggests that the VDR ApaI genotype may not affect the risk of postmenopausal osteoporosis in Asians and Caucasians.

Radiomic analysis of the proximal femur in osteoporosis women using 3T MRI

Introduction

Osteoporosis (OP) results in weak bone and can ultimately lead to fracture. MRI assessment of bone structure and microarchitecture has been proposed as method to assess bone quality and fracture risk in vivo. Radiomics provides a framework to analyze the textural information of MR images. The purpose of this study was to analyze the radiomic features and its abilityto differentiate between subjects with and without prior fragility fracture.

Methods

MRI acquisition was performed on n = 45 female OP subjects: 15 with fracture history (Fx) and 30 without fracture history (nFx) using a high-resolution 3D Fast Low Angle Shot (FLASH) sequence at 3T. Second and first order radiomic features were calculated in the trabecular region of the proximal femur on T1-weighted MRI signal of a matched dataset. Significance of the feature's predictive ability was measured using Wilcoxon test and Area Under the ROC (AUROC) curve analysis. The features were correlated DXA and FRAX score.

Result

A set of three independent radiomic features (Dependence Non-Uniformity (DNU), Low Gray Level Emphasis (LGLE) and Kurtosis) showed significant ability to predict fragility fracture (AUROC DNU = 0.751, p < 0.05; AUROC LGLE = 0.729, p < 0.05; AUROC Kurtosis = 0.718, p < 0.05) with low to moderate correlation with FRAX and DXA.

Conclusion

Radiomic features can measure bone health in MRI of proximal femur and has the potential to predict fracture.

Secoisolariciresinol diglucoside regulates estrogen receptor expression to ameliorate OVX-induced osteoporosis

OBJECTIVE

Secoisolariciresinol diglucoside (SDG) is a phytoestrogen that has been reported to improve postmenopausal osteoporosis (PMOP) caused by estrogen deficiency. In our work, we aimed to investigate the mechanism of SDG in regulating the expressions of ERs on PMOP model rats.

METHODS

Ovariectomization (OVX) was used to establish PMOP model in rats. The experiment was allocated to Sham, OVX, SDG and raloxifene (RLX) groups. After 12-week treatment, micro-CT was used to detect the transverse section of bone. Hematoxylin and Eosin staining and Safranine O-Fast Green staining were supplied to detect the femur pathological morphology of rats. Estradiol (E2), interleukin-6 (IL-6), bone formation and bone catabolism indexes in serum were detected using ELISA. Alkaline phosphatase (ALP) staining was used to detect the osteogenic ability of chondrocytes. Immunohistochemistry and Western blot were applied to detect the protein expressions of estrogen receptors (ERs) in the femur of rats.

RESULTS

Compared with the OVX group, micro-CT results showed SDG could lessen the injury of bone and improve femoral parameters, including bone mineral content (BMC) and bone mineral density (BMD). Pathological results showed SDG could reduce pathological injury of femur in OVX rats. Meanwhile, SDG decreased the level of IL-6 and regulated bone formation and bone catabolism indexes. Besides, SDG increased the level of E2 and conversed OVX-induced decreased the expression of ERα and ERβ.

CONCLUSION

The treatment elicited by SDG in OVX rats was due to the reduction of injury and inflammation and improvement of bone formation index, via regulating the expression of E2 and ERs.

Minimal short-term decline in functional performance and quality of life predicts better long-term outcomes for both in older Taiwanese adults after hip fracture surgery: a prospective study

BACKGROUND

Hip fracture can lead to long-term loss of mobility and self-care ability in older adults. Despite initial decreases in functional performance after hip fracture surgery, patients tend to gradually recover. However, recovery can vary, with some regaining their abilities quickly while others becoming functionally dependent. In this study, we investigated whether the level of short-term postoperative decline in activity of daily living (ADL) performance and quality of life (QoL) can predict the 1-year outcomes for both following hip fracture surgery in older Taiwanese adults.

METHODS

This prospective cohort study included 427 older adults (≥ 60 years) who underwent hip fracture surgery at a single tertiary medical center in Taiwan between November 2017 and March 2021. We collected pre-fracture data, including the patients' demographics, Charlson comorbidity index (CCI) scores, and responses to a questionnaire (Short Portable Mental State Questionnaire [SPMSQ]) for dementia screening. Moreover, their scores on the EuroQol-5D questionnaire (for evaluating QoL) and the Barthel Index (for assessing ADL performance) were collected at pre-fracture status and at 3- and 12-months following surgery. Changes in ADL and QoL three months post-surgery compared to pre-fracture status were evaluated, and the associations of these parameters (and other potential factors) with 1-year outcomes for ADL and QoL were investigated.

RESULTS

We analyzed the data of 318 patients with hip fracture and complete follow-up data regarding ADL performance and QoL at 3- and 12-months post-surgery. After adjusting for covariates, multivariate linear regression revealed that changes in ADL and QoL at 3 months post-surgery from pre-fracture status were positively and significantly associated with 1-year outcomes for both (p < .001 for both). Furthermore, pre-fracture CCI and SPMSQ scores were independent predictive factors associated with 1-year ADL outcomes (p = .042 and < .001, respectively).

CONCLUSIONS

Patients who exhibit a smaller decline in functional performance and quality of life three months after hip fracture surgery from pre-fracture status are likely to have improved long-term ADL and QoL.

TRIAL REGISTRATION

TMU-JIRB N201709053.

Genetic Prediction of Lifetime Risk of Fracture

CONTEXT

Fragility fracture is a significant public health problem because it is associated with increased mortality. We want to find out whether the risk of fracture can be predicted from the time of birth.

OBJECTIVE

To examine the association between a polygenic risk score (PRS) and lifetime fracture risk.

METHODS

This population-based prospective study involved 3515 community-dwelling individuals aged 60+ years who have been followed for up to 20 years. Femoral neck bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry. A PRS was created by summing the weighted number of risk alleles for each single nucleotide polymorphism using BMD-associated coefficients. Fragility fractures were radiologically ascertained, whereas mortality was ascertained through a state registry. Residual lifetime risk of fracture (RLRF) was estimated by survival analysis.

RESULTS

The mortality-adjusted RLRF for women and men was 36% (95% CI, 34%-39%) and 21% (18%-24%), respectively. Individuals with PRS > 4.24 (median) had a greater risk (1.2-fold in women and 1.1-fold in men) than the population average risk. For hip fracture, the average RLRF was 10% (95% CI, 8%-12%) for women and ∼5% (3%-7%) for men; however, the risk was significantly increased by 1.5-fold and 1.3-fold for women and men with high PRS, respectively.

CONCLUSION

A genetic profiling of BMD-associated genetic variants is associated with the residual lifetime risk of fracture, suggesting the potential for incorporating the polygenic risk score in personalized fracture risk assessment.

Effects of denosumab on bone mineral density and bone metabolism in patients with end-stage renal disease: A systematic review and meta-analysis

INTRODUCTION

The effects of denosumab on bone mineral density (BMD) and metabolism in patients with end-stage renal disease (ESRD) remain controversial. Hence, we performed a systematic review and meta-analysis of observational studies.

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were searched in June 2022 to identify studies that evaluated the risk of denosumab-associated hypocalcemia and changes in bone metabolism, changes in BMD from baseline to post-treatment in patients with ESRD.

FINDINGS

Twelve studies with 348 participants were included. The pooled incidence of hypocalcemia during denosumab treatment was 35.0% (95% confidence interval [CI], 25%-46%; I2  = 63.6%). There were no significant changes in either the serum calcium or phosphate levels from the baseline to post-treatment period; the mean differences were 0.04 mg/dL (95% CI, -0.12 to 0.20 mg/dL) and -0.39 mg/dL (95% CI, -0.89 to 0.12 mg/dL). We found significant changes in the alkaline phosphatase and parathyroid hormone levels; the standardized mean differences were -2.98 (95% CI, -5.36 to -0.59) and -3.12 (95% CI: -4.94 to -1.29), respectively. Denosumab may increase BMD, with mean differences of 9.10% (95% CI: 4.07%-14.13%) and 9.00% (95% CI: 5.93%-12.07%) for the femoral neck and lumbar spine, respectively.

DISCUSSION

Denosumab increased the BMDs of the lumbar spine and femoral neck in patients with ESRD. The onset of hypocalcemia must be carefully monitored during denosumab administration.

What are the Effects of Exercise on Trabecular Microarchitecture in Older Adults? A Systematic Review and Meta-analysis of HR-pQCT Studies

The objective of this review was to determine the effects of exercise on high-resolution peripheral quantitative computed tomography (HR-pQCT) derived trabecular microarchitecture parameters in older adults. Five electronic databases were systematically searched by two independent reviewers. Inclusion criteria were adults age ≥ 50, any type of exercise as part of the intervention, and trabecular microarchitecture assessed via HR-pQCT. Data was extracted from included studies, and where suitable, included in a meta-analysis. Quality of included studies was appraised. Seven studies (397 participants) were included. All participants were postmenopausal women. Interventions included jumping, whole-body vibration, and power/plyometric training. All studies were rated as either weak or moderate quality. Meta-analysis (5 studies) showed no significant changes in any parameters when considering all exercise or sub-analysing based on type. Exercise was not found to have significant effects on trabecular microarchitecture in postmenopausal women over the age of 50. These findings should be interpreted with caution due to the small number of studies investigating few modes of exercise, their weak to moderate quality, and risk of bias. High-quality studies are needed to determine the effects of additional types of exercise in a more diverse population of older adults, including men.

Osteoporosis prediction in lumbar spine X-ray images using the multi-scale weighted fusion contextual transformer network

Osteoporosis is a bone-related disease characterized by decreased bone density and mass, leading to brittle fractures. Osteoporosis assessment from radiographs using a deep learning algorithm has proven a low-cost alternative to the golden standard DXA. Due to the considerable noise and low contrast, automated diagnosis of osteoporosis in X-ray images still poses a significant challenge for traditional diagnostic methods. In this paper, an end-to-end transformer-style network was proposed, termed FCoTNet, to overcome the shortcoming of insufficient fusion of texture information and local features in the traditional CoTNet. To extract complementary geometric representations at each scale of the transformer module, we integrated parallel multi-scale feature extraction architectures in each unit layer of FCoTNet to utilize convolution to aggregate features from different receptive fields. Moreover, in order to extract small-scale texture features which were more critical to the diagnosis of osteoporosis in radiographs, larger fusion weights were assigned to the feature maps with small-size receptive fields. Afterward, the multi-scale global modeling was conducted by self-attention mechanism. The proposed model was first investigated on a private lumbar spine X-ray dataset with the 5-fold cross-validation strategy, obtaining an average accuracy of 78.29 ± 0.93 %, an average sensitivity of 69.72 ± 2.35 %, and an average specificity of 88.92 ± 0.67 % for the multi-classification of normal, osteopenia, and osteoporosis categories. We then conducted a controlled trial with five orthopedic clinicians to evaluate the clinical value of the model. The average clinician's accuracy improved from 61.50 ± 10.79 % unaided to 80.00 ± 5.92 % aided (18.50 % improvement), sensitivity improved from 64.38 ± 8.07 % unaided to 83.31 ± 5.43 % aided (18.93 % improvement), and specificity improved from 80.11 ± 4.72 % unaided to 89.94 ± 3.82 % aided (9.83 % improvement). Meanwhile, the prediction consistency among clinicians significantly improved with the assistance of FCoTNet. Furthermore, the proposed model showed good robustness on an external test dataset. These investigations indicate that the proposed deep learning model achieves state-of-the-art performance for osteoporosis prediction, which substantially improves osteoporosis screening and reduced osteoporosis fractures.

Untreated osteoporosis and higher FRAX as risk factors for tooth loss: a 5-year prospective study

INTRODUCTION

Studies have shown that an impaired bone condition, represented by osteoporosis and increased fracture risk, may potentially aggravate periodontal disease and, consequently, the risk of tooth loss. This 5-year prospective study aimed to investigate whether systemic bone condition represents risk factor for tooth loss due to periodontal disease amongst elderly women.

MATERIAL AND METHODS

Seventy-four participants, aged ≥ 65 years, who attended the 5-years recall for periodontal evaluation were involved. Baseline exposures were osteoporosis and fracture risk probabilities (FRAX). Women were grouped according to bone mineral density (BMD) and years of bone treatment for osteoporosis. The primary outcome at a 5-year follow-up was the number of tooth loss due to periodontal disease. Periodontitis staging and grading, and causes of tooth loss were recorded.

RESULTS

The multivariate Poisson regression models showed that women with untreated/shortly treated osteoporosis were 4 times more likely to present higher number of tooth loss due to periodontal disease than those with normal BMD or treated for ≥ 3 years (risk ratio (RR) = 4.00, 95% CI 1.40-11.27). Higher FRAX was also linked to tooth loss (RR = 1.25, 95% CI 1.02-1.53). Receiver-operating characteristic (ROC) curve suggested that women with history of ≥ 1 tooth losses have higher chances of worse major FRAX (sensitivity = 72.2%; specificity = 72.2%).

CONCLUSION

In this 5-year study, higher FRAX and untreated osteoporosis were risk factors for tooth loss. Women with normal BMD or treated for osteoporosis for ≥ 3 years did not show increased risk. Management of skeletal conditions should be emphasized with periodontal care for the prevention of tooth loss in elderly women.

Sodium butyrate enhances titanium nail osseointegration in ovariectomized rats by inhibiting the PKCα/NOX4/ROS/NF-κB pathways

BACKGROUND

Elevated levels of oxidative stress as a consequence of estrogen deficiency serve as a key driver of the onset of osteoporosis (OP). In addition to increasing the risk of bone fractures, OP can reduce the bone volume proximal to titanium nails implanted to treat these osteoporotic fractures, thereby contributing to titanium nail loosening. Sodium butyrate (NaB) is a short-chain fatty acid produced by members of the gut microbiota that exhibits robust antioxidant and anti-inflammatory properties.

METHODS

OP fracture model rats parameters including bone mineral density (BMD), new bone formation, and the number of bonelets around the implanted nail were analyzed via micro-CT scans, H&E staining, and Masson's staining. The protective effects of NaB on such osseointegration and the underlying mechanisms were further studied in vitro using MC3T3-E1 cells treated with carbonyl cyanide m-chlorophenylhydrazone (CCCP) to induce oxidative stress. Techniques including Western immunoblotting, electron microscopy, flow cytometry, alkaline phosphatase (ALP) staining, and osteoblast mineralization assays were employed to probe behaviors such as reactive oxygen species production, mineralization activity, ALP activity, protein expression, and the ability of cells to attach to and survive on titanium plates.

RESULTS

NaB treatment was found to enhance ALP activity, mineralization capacity, and Coll-I, BMP2, and OCN expression levels in CCCP-treated MC3T3-E1 cells, while also suppressing PKC and NF-κB expression and enhancing Nrf2 and HO-1 expression in these cells. NaB further suppressed intracellular ROS production and malondialdehyde levels within the cytosol while enhancing superoxide dismutase activity and lowering the apoptotic death rate. In line with these results, in vivo work revealed an increase in BMD in NaB-treated rats that was associated with enhanced bone formation surrounding titanium nails.

CONCLUSION

These findings indicate that NaB may represent a valuable compound that can be postoperatively administered to aid in treating OP fractures through the enhancement of titanium nail osseointegration.

Association of PFN1 Gene Polymorphisms with Bone Mineral Density, Bone Turnover Markers, and Osteoporotic Fractures in Chinese Population

Recent studies have discovered an association between the PFN1 gene and Paget's disease. However, it is currently unknown whether the PFN1 gene is related to osteoporosis. This study was performed to investigate the association of Single-Nucleotide Polymorphisms (SNPs) in the PFN1 gene with Bone Mineral Density (BMD) as well as bone turnover markers and osteoporotic fractures in Chinese subjects. A total of 2836 unrelated Chinese subjects comprising 1247 healthy subjects and 1589 osteoporotic fractures patients (Fracture group) were enrolled in this study. Seven tagSNPs (rs117337116, rs238243, rs6559, rs238242, rs78224458, rs4790714, and rs13204) of the PFN1 gene were genotyped. The BMD of the lumbar spine 1-4 (L1-4), femoral neck, and total hip as well as bone turnover markers, such as β-C-Terminal telopeptide of type 1 collagen (β-CTX) and Procollagen type 1 N-terminal Propeptide (P1NP), were measured. The association between 7 tagSNPs and BMD and bone turnover markers was analyzed in 1247 healthy subjects only. After age matching, we selected 1589 osteoporotic fracture patients (Fracture group) and 756 nonfracture controls (Control group, selected from 1247 healthy subjects) for a case-control study, respectively. For the case-control study, we used logistic regression to investigate the relationship between 7 tagSNPs and osteoporotic fractures risk. In the All group, the PFN1 haplotype GAT was associated with the β-CTX (P = 0.007). In the Female group, the PFN1 haplotype GAT was associated with the β-CTX (P = 0.005). In the Male group, the rs13204, the rs78224458, and the PFN1 haplotype GAC were associated with the BMD of the L1-4 (all P = 0.012); the rs13204, the rs78224458, and the PFN1 haplotype GAC were associated with the BMD of the femoral neck (all P = 0.012); the rs13204 and rs78224458 were associated with the BMD of the total hip (both P = 0.015); and the PFN1 haplotype GAT was associated with the β-CTX (P = 0.013). In the subsequent case-control study, the rs13204 and rs78224458 in the male group were associated with the risk of L1-4 fracture (P = 0.016 and 0.010, respectively) and total hip fracture (P = 0.013 and 0.016, respectively). Our study reveals that PFN1 gene polymorphisms are associated with BMD in Chinese males and β-CTX in Chinese people and confirmed the relationship between PFN1 gene polymorphisms and Chinese male osteoporotic fractures in a case-control study.

Development of a nomogram model for prediction of new adjacent vertebral compression fractures after vertebroplasty

BACKGROUND

Vertebroplasty is the main minimally invasive operation for osteoporotic vertebral compression fracture (OVCF), which has the advantages of rapid pain relief and shorter recovery time. However, new adjacent vertebral compression fracture (AVCF) occurs frequently after vertebroplasty. The purpose of this study was to investigate the risk factors of AVCF and establish a clinical prediction model.

METHODS

We retrospectively collected the clinical data of patients who underwent vertebroplasty in our hospital from June 2018 to December 2019. The patients were divided into a non-refracture group (289 cases) and a refracture group (43 cases) according to the occurrence of AVCF. The independent predictive factors for postoperative new AVCF were determined by univariate analysis, least absolute shrinkage and selection operator (LASSO) logistic regression, and multivariable logistic regression analysis. A nomogram clinical prediction model was established based on relevant risk factors, and the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA) were used to evaluate the prediction effect and clinical value of the model. After internal validation, patients who underwent vertebroplasty in our hospital from January 2020 to December 2020, including a non-refracture group (156 cases) and a refracture group (21 cases), were included as the validation cohort to evaluate the prediction model again.

RESULTS

Three independent risk factors of low bone mass density (BMD), leakage of bone cement and "O" shaped distribution of bone cement were screened out by LASSO regression and logistic regression analysis. The area under the curve (AUC) of the model in the training cohort and the validation cohort was 0.848 (95%CI: 0.786-0.909) and 0.867 (95%CI: 0.796-0.939), respectively, showing good predictive ability. The calibration curves showed the correlation between prediction and actual status. The DCA showed that the prediction model was clinically useful within the whole threshold range.

CONCLUSION

Low BMD, leakage of bone cement and "O" shaped distribution of bone cement are independent risk factors for AVCF after vertebroplasty. The nomogram prediction model has good predictive ability and clinical benefit.

Intravenous zoledronate for postmenopausal women with osteopenia and osteoporosis: a systematic review and metanalysis

BACKGROUND

Osteoporosis compromises bone strength and increases the risk of fractures. Zoledronate prevents loss of bone mass and reduces the risk of fractures.

OBJECTIVES

To determine the efficacy and safety of zoledronate in postmenopausal women with osteopenia and osteoporosis.

DESIGN AND SETTINGS

A systematic review and meta-analysis was conducted within the evidence-based health program at the Universidade Federal de São Paulo.

METHODS

An electronic search of the CENTRAL, MEDLINE, Embase, and LILACS databases was performed until February 2022. Randomized controlled trials comparing zoledronate with placebo or other bisphosphonates were included. Standard methodological procedures were performed according to the Cochrane Handbook and the certainty of evidence for the Grading of Recommendations Assessment, Development, and Evaluation Working Group. Two authors assessed the risk of bias and extracted data on fractures, adverse events, bone turnover markers (BTM), and bone mineral density (BMD).

RESULTS

Twelve trials from 6,652 records were included: nine compared zoledronate with placebo, two trials compared zoledronate with alendronate, and one trial compared zoledronate with ibandronate. Zoledronate reduced the incidence of fractures in osteoporotic [three years: morphometric vertebral fractures (relative risk, RR = 0.30 (95% confidence interval, CI: 0.24-0.38))] and osteopenic women [six years: morphometric vertebral fractures (RR = 0.39 (95%CI: 0.25-0.61))], increased incidence of post-dose symptoms [RR = 2.56 (95%CI: 1.80-3.65)], but not serious adverse events [RR = 0.97 (95%CI: 0.91-1.04)]. Zoledronate reduced BTM and increased BMD in osteoporotic and osteopenic women.

CONCLUSION

This review supports the efficacy and safety of zoledronate in postmenopausal women with osteopenia for six years and osteoporosis for three years.

PROSPERO REGISTRATION NUMBER

CRD42022309708, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=309708.

Osteonecrosis of the jaws in patients under osteoporosis treatment: a nine-year experience report

Objective

This study aimed to report the experience of medication-related osteonecrosis of the jaws (MRONJ) in osteoporotic patients for nine years, and their associated initiating factors.

Materials and methods

The numbers of invasive oral procedures (IOP) (tooth extraction, dental implant placement, and periodontal procedures) and removable prostheses performed from January 2012 to January 2021 were obtained from the digital records of a large public dental center. There were an estimated 6,742 procedures performed in patients under osteoporosis treatment.

Results

Two cases (0.03%) of MRONJ were registered in nine years amongst patients with osteoporosis who had dental treatment at the center. From the 1,568 tooth extractions, one patient (0.06%) developed MRONJ. There was also one case from the 2,139 removable prostheses delivered (0.05%).

Conclusion

The prevalence of MRONJ associated with osteoporosis treatment was very low. The protocols adopted seem to be adequate for the prevention of this complication. The findings of this study reinforce the rare frequency of MRONJ associated with dental procedures in patients submitted to the pharmacological management of osteoporosis. An integral analysis of systemic risk factors and oral preventive strategies may be considered regularly in the dental treatment of these patients.

Clinical significance of serum cystatin C-to-creatinine ratio as a surrogate marker for incident osteoporotic fracture predictions

Background

Detection of appropriate indicators is valuable for preventing incidental osteoporotic fractures. We statistically evaluated the significance of serum cystatin C-to-creatinine ratio (CysC/Cr) as a surrogate marker for incident major osteoporotic fractures (MOF) prediction.

Methods

Eligible patients with simultaneous measurement of CysC/Cr and bone mineral density in the lumbar spine and proximal femur were selected, and their fracture histories until 5 years after baseline were observed in the retrospective area cohort data. Patients who were followed up until termination or the first osteoporotic fracture were included, and loss of follow-up or death was excluded. Candidate risk factors for osteoporotic fractures were tested for risk ratios using a cox regression analysis. Receiver operating characteristic tests were performed on factors with significantly higher risk ratios and evaluated with Kaplan-Meier survival analysis to determine the hazard ratios of the factors.

Results

A total of 175 patients of whom 28 had incident MOF, 38 men, and 137 women, were enrolled. The mean age was 70.2 years. A significantly higher risk ratio was shown in the presence of prevalent MOF, hyper fall-ability, lifestyle-related diseases, chronic kidney diseases ≥ Grade3a, and higher CysC/Cr. All parameters had cutoff indices and showed significantly higher hazard ratios.

Conclusions

These results suggested that CysC/Cr may be a predictive marker of incident osteoporotic fractures. It might work as a screening tool for MOF risk.

Physiopathology of Osteoporosis: Nursing Involvement and Management

Osteoporosis is a major public health problem today. We are facing an aging society where the average life expectancy continues to increase. Osteoporosis affects more than 30% of postmenopausal women due to hormonal changes that occur during this time. Postmenopausal osteoporosis is therefore of particular concern. The aim of this review is to identify the etiology, pathophysiology, diagnosis and treatment of this disease and lay the foundation for the role nurses should play in preventing postmenopausal osteoporosis. Several risk factors are associated with osteoporosis. In addition to age and sex, genetics, ethnicity, diet, or the presence of other disorders determine the development of this disease. The key factors include exercise, a balanced diet, and high levels of vitamin D. This is primarily from a solar source, and infancy is the time when future bone formation is greatest. There are now medications that can complement these preventive measures. The work of nursing staff is not only prevention, but also early detection and early treatment. In addition, imparting information and knowledge about the disease to the population is key to preventing an osteoporosis epidemic. In this study, a detailed description is provided of the biological and physiological disease, the preventive measures currently being researched, the information currently available to the population, and how health professionals address osteoporosis from a preventive perspective.

CNN-based evaluation of bone density improves diagnostic performance to detect osteopenia and osteoporosis in patients with non-contrast chest CT examinations

PURPOSE

As osteoporosis is still underdiagnosed by clinicians and radiologists, the aim of the present study was to assess the performance of an Artificial intelligence (AI)-based Convolutional Neuronal Network (CNN)-Algorithm for the detection of low bone density on routine non-contrast chest CT in comparison to clinical reports using DEXA scans as reference.

METHOD

This retrospective cross-sectional study included patients who underwent non-contrast chest CT and DEXA between April 2018 and June 2018 (n = 109, 19 men, mean age: 67.7 years). CT studies were evaluated for thoracic vertebral bone pathologies using a CNN-Algorithm, which calculates the attenuation profile of the spine. The content of the radiological reports was evaluated for the description of osteoporosis or osteopenia. DEXA was used as the reference standard. To estimate correlation the Spearman test was used and the comparison of the different groups was performed using the Wilcoxon rank sum test. Diagnostic was evaluated by performing a receiver operating characteristic curve analysis.

RESULTS

The DEXA examination revealed normal bone density in 42 patients, while 49 patients had osteopenia and 7 osteoporosis. There was a statistically significant correlation between the mean CNN-based attenuation of the thoracic spine and the bone density measured on the DEXA in the hip (r = 0.51, p < 0.001) and lumbar spine (r = 0.34, p = 0.01). The mean attenuation was significantly higher in patients with normal bone density (172 ± 44.5 HU) compared to those with osteopenia or osteoporosis (125.2 ± 33.8 HU), (p < 0.0001). Diagnostic performance in distinguishing normal from abnormal bone density was higher using the CNN-based vertebral attenuation (accuracy 0.75, sensitivity: 0.93, specificity: 0.61) compared to clinical reports (accuracy 0.51, sensitivity: 0.14, specificity: 0.53).

CONCLUSION

CNN-based evaluation of bone density may provide additional value over standard clinical reports for the detection of osteopenia and osteoporosis in patients undergoing routine non-contrast chest CT scans. This additional value could improve identification of fracture risk and subsequent treatment.

Adipopenia is associated with osteoporosis in community-dwelling non-underweight adults independent of sarcopenia

The effect of fat deficit on bone metabolism is understudied. This study showed that low body fat percent (adipopenia) in non-underweight community adults was associated with elevated odds of osteoporosis independent of low lean mass, highlighting potential clinical importance of adipopenia as an osteoporosis risk factor particularly in older adults.

PURPOSE

Although underweight is risk factor for osteoporosis, the association of low body fat percent (adipopenia) with osteoporosis in non-underweight adults remains unclear.

METHODS

Among individuals aged ≥ 50 years with body mass index ≥ 18.5 kg/m² in the Korean National Health and Nutrition Examination Survey 2008-2011, appendicular lean mass (ALM) and body fat percent (BFP) were measured using dual-energy x-ray absorptiometry. Low lean mass was defined as ALM/height² < 7.0 kg/m² and < 5.4 kg/m² in men and women, respectively. Osteoporosis was defined as a bone mineral density (BMD) T-score ≤ -2.5 at the lumbar spine, femoral neck, or total hip. Participants were grouped into adipopenia (BFP < 17% in men; < 30%, in women; 1 standard deviation below the mean), normal, and obesity (BFP > 30% in men; > 40% in women) groups.

RESULTS

Of the 5,830 participants (women 50.2%, mean age 63.9 years), 793 had adipopenia. The adipopenia group had a higher prevalence of osteoporosis (31%) than the normal (21%) or obesity groups (27%; p < 0.001). The presence of adipopenia was associated with 61% elevated odds of prevalent osteoporosis (p < 0.001) independent of low lean mass and covariates, which remained robust using different thresholds for adipopenia. Individuals with adipopenia and low lean mass had 3.5-fold elevated odds of osteoporosis compared to those with normal lean mass and fat percent. The association between adipopenia and osteoporosis was stronger in older women compared to middle-aged women (OR 1.93 vs. 0.99, P for interaction = 0.023).

CONCLUSION

Adipopenia was associated with osteoporosis in non-underweight adults, independent of low lean mass and covariates.

Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools

BACKGROUND

To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care.

METHODS

For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach.

RESULTS

We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I2 = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I2 = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I2 = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I2 = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated.

CONCLUSION

An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragility fracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.

Psychometric properties of the Chinese version of the self-care scale for older adults undergoing hip fracture surgery: A translation and validation study

Objective

The purpose of this study was to translate and verify the reliability and validity of the Chinese version of the self-care scale for older adults undergoing hip fracture surgery.

Methods

A total of 502 older adult/adults patients after hip fracture surgery were recruited from Liaoning, Shanxi, and Beijing, China. The reliability of the Chinese version of the scale was measured by internal consistency, split-half reliability, and retest reliability, and the validity was evaluated by the content validity index and structure validity index.

Results

The Chinese version of the HFS-SC scale had a Cronbach's alpha coefficient of 0.848, and the Cronbach's alpha coefficients for the five dimensions ranged from 0.719 to 0.780. The split-half reliability of the scale was 0.739, and the retest reliability was 0.759. The content validity index (S-CVI) was 0.932. The five-factor structure, supported by the eigenvalues, total variance explained, and the scree plot accounted for 66.666% of the total variance. In confirmatory factor analysis, the model fit results were as follows, X2/df = 1.847, GFI = 0.914, AGFI = 0.878, PGFI = 0.640, IFI = 0.932, TLI = 0.912, CFI = 0.931, RMSEA = 0.058, PNFI = 0.679. The indicators of the model's fit were within reasonable bounds.

Conclusion

The Chinese version of the self-care scale for older adults undergoing hip fracture surgery has suitable reliability and validity. The scale can be used to assess the level of older adult/adults self-care in China following hip replacement surgery and serves as a useful benchmark for identifying potential intervention targets to raise the level of older adult/adults self-care following hip replacement surgery.

Positive Effect of Parathyroidectomy Compared to Observation on BMD in a Randomized Controlled Trial of Mild Primary Hyperparathyroidism

Mild or asymptomatic disease is now the dominating presentation of primary hyperparathyroidism (PHPT). However, bone involvement with decreased bone mineral density (BMD) and an increased risk of fractures has been demonstrated. Indications for parathyroidectomy (PTX) in mild PHPT have been debated for years. There is a need of long-term randomized studies comparing PTX with observation without intervention (OBS). Here, we present bone health data from the Scandinavian Investigation of Primary Hyperparathyroidism (SIPH), a randomized controlled trial, comparing PTX to OBS. This study included 191 patients (96 OBS/95 PTX), and 129 patients (64 OBS/65 PTX) were followed for 10 years to the end of study (EOS). BMD was measured with dual-energy X-ray absorptiometry (DXA), peripheral fractures were noted, and spine radiographs were obtained for vertebral fracture assessment. There was a significant treatment effect of PTX on BMD compared with OBS for all analyzed compartments, most explicit for the lumbar spine (LS) and femoral neck (FN) (p < 0.001). The mean changes in T-score from baseline to 10 years were from 0.41 for radius 33% (Rad33) to 0.58 for LS greater in the PTX group than in the OBS group. There was a significant decrease in BMD for all compartments in the OBS group, most pronounced for FN, Rad33, and ultradistal radius (UDR) (p < 0.001). Even though there was a significant treatment effect of PTX compared with OBS, there was only a significant increase in BMD over time for LS (p < 0.001). We found no difference between groups in fracture frequency in the 10-year cohort, neither with modified intention-to-treat (mITT) analysis nor per protocol analysis. Because BMD is only a surrogate endpoint of bone health and PTX did not reduce fracture risk, observation could be considered a safe option for many patients with mild PHPT regarding bone health in a 10-year perspective. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The Influence of Adherence to Orthosis and Physiotherapy Protocol on Functional Outcome after Proximal Humeral Fracture in the Elderly

In the treatment of proximal humeral fractures (PHF), patients are often recommended to wear a sling or orthosis and to perform physiotherapy. However, some patients, especially elderly ones, struggle to comply with these rehabilitation regimens. Therefore, the aim of the study was to evaluate whether these incompliant patients have a worse functional outcome than those who adhere to the rehabilitation protocol. After receiving a diagnosis of a PHF, patients were divided into four groups according to fracture morphology: conservative with sling, operative with sling, conservative with abduction orthosis, and operative with abduction orthosis. At the 6-week follow-up, compliance regarding brace use and physiotherapy performance were assessed, as well as the constant score (CS) and complications or revision surgeries. The CS as well as the complications and revision surgeries were also surveyed after one year. In 149 participants, with a mean age of 73.9 ± 7.2 years, only 37% terminated orthosis and only 49% underwent physiotherapy as recommended. The statistical analysis showed no significant difference in the CS, complications, and revision surgeries between the groups.

Avicularin Alleviates Osteoporosis in Ovariectomized Mice by Inhibiting Osteoclastogenesis through NF-κB Pathway Inhibition

Osteoporosis (OP) is mainly manifested by bone loss and bone degeneration. OP is considered a risk factor for pathological fractures, as well as impacts the health of middle-aged and elderly individuals. Drug therapy remains the main treatment scheme for OP; however, its efficacy is limited and has been associated with serious side effects. Therefore, it is important to develop new, effective, and safe treatment methods for OP. Avicularin (AL) is a flavonoid and quercetin derivative from various plants. Our study showed that AL disrupts osteoclast activation and resorptive function via inhibition of the RANKL-induced osteoclast differentiation together with the resorption capacity of bone marrow-derived macrophages (BMMs). Hence, AL prevents the activation and resorptive activity of osteoclasts. The results of qPCR showed that genes related to osteoclasts exhibited downregulated expression after AL treatment. Furthermore, AL inhibited RANKL-induced phosphorylation as well as degradation of the inhibitor IκBα of the NF-κB pathway, together with P65 phosphorylation in BMMs. We used an OP mouse model that was established by ovariectomy (OVX). Relative to untreated OP mice, mice that received AL treatment showed a significant increase in bone mineral density; however, the expression of TRAP, NFATC1, mmp9, and CTX-1 was significantly reduced. These results indicate that AL disrupts osteoclastogenesis via inhibition of the NF-κB pathway, which in turn improves OVX-induced OP.

Bisphosphonates for osteoporosis in people with cystic fibrosis

BACKGROUND

Osteoporosis is a disorder of bone mineralisation occurring in about one third of adults with cystic fibrosis. Bisphosphonates can increase bone mineral density and decrease the risk of new fractures in post-menopausal women and people receiving long-term oral corticosteroids. This is an updated version of a previous review.

OBJECTIVES

To assess the effects of bisphosphonates on the frequency of fractures, bone mineral density, quality of life, adverse events, trial withdrawals, and survival in people with cystic fibrosis.

SEARCH METHODS

We searched the Cystic Fibrosis and Genetic Disorders Group's Trials Register of references (identified from electronic database searches and hand searches of journals and abstract books) on 5 May 2022. We performed additional searches of PubMed, clinicaltrials.gov and the WHO ICTRP (International Clinical Trials Registry Platform) on 5 May 2022.

SELECTION CRITERIA

Randomised controlled trials of at least six months duration studying bisphosphonates in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Authors independently selected trials, extracted data and assessed risk of bias in included studies. Trial investigators were contacted to obtain missing data. We judged the certainty of the evidence using GRADE.

MAIN RESULTS

We included nine trials with a total of 385 participants (272 adults and 113 children (aged five to 18 years)). Trial durations ranged from six months to two years. Only two of the studies were considered to have a low risk of bias for all the domains.  Bisphosphonates compared to control in people with cystic fibrosis who have not had a lung transplant Seven trials included only adult participants without lung transplants, one trial included both adults and children without lung transplantation (total of 238 adults and 113 children). We analysed adults (n = 238) and children (n = 113) separately. Adults Three trials assessed intravenous bisphosphonates (one assessed pamidronate and two assessed zoledronate) and five trials assessed oral bisphosphonates (one assessed risedronate and four assessed alendronate). Bisphosphonates were compared to either placebo or calcium (with or without additional vitamin D). Data showed no difference between treatment or control groups in new vertebral fractures at 12 months (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.02 to 2.09; 5 trials, 142 participants; very low-certainty evidence) and two trials (44 participants) reported no vertebral fractures at 24 months. There was no difference in non-vertebral fractures at 12 months (OR 2.11, 95% CI 0.18 to 25.35; 4 trials, 95 participants; very low-certainty evidence) and again two trials (44 participants) reported no non-vertebral fractures at 24 months. There was no difference in total fractures between groups at 12 months (OR 0.57, 95% CI 0.13 to 2.50; 5 trials, 142 participants) and no fractures were reported in two trials (44 participants) at 24 months. At 12 months, bisphosphonates may increase bone mineral density at the lumbar spine (mean difference (MD) 6.31, 95% CI 5.39 to 7.22; 6 trials, 171 participants; low-certainty evidence) and at the hip or femur (MD 4.41, 95% 3.44 to 5.37; 5 trials, 155 participants; low-certainty evidence). There was no clear difference in quality of life scores at 12 months (1 trial, 47 participants; low-certainty evidence), but bisphosphonates probably led to more adverse events (bone pain) at 12 months (OR 8.49, 95% CI 3.20 to 22.56; 7 trials, 206 participants; moderate-certainty evidence). Children The single trial in 113 children compared oral alendronate to placebo. We graded all evidence as low certainty. At 12 months we found no difference between treatment and placebo in new vertebral fractures (OR 0.32, 95% CI 0.03 to 3.13; 1 trial, 113 participants) and non-vertebral fractures (OR 0.19, 95% CI 0.01 to 4.04; 1 trial, 113 participants). There was also no difference in total fractures (OR 0.18, 95% CI 0.02 to 1.61; 1 trial, 113 participants). Bisphosphonates may increase bone mineral density at the lumbar spine at 12 months (MD 14.50, 95% CI 12.91 to 16.09). There was no difference in bone or muscle pain (MD 3.00, 95% CI 0.12 to 75.22), fever (MD 3.00, 95% CI 0.12 to 75.22) or gastrointestinal adverse events (OR 0.67, 95% CI 0.20 to 2.26). The trial did not measure bone mineral density at the hip/femur or report on quality of life.  Bisphosphonates compared to control in people with cystic fibrosis who have had a lung transplant One trial of 34 adults who had undergone lung transplantation compared intravenous pamidronate to no bisphosphonate treatment. It did not report at 12 months and we report the 24-month data (not assessed by GRADE). There was no difference in the number of fractures, either vertebral or non-vertebral. However, bone mineral density increased with treatment at the lumbar spine (MD 6.20, 95% CI 4.28 to 8.12) and femur (MD 7.90, 95% CI 5.78 to 10.02). No participants in either group reported either bone pain or fever. The trial did not measure quality of life.

AUTHORS' CONCLUSIONS

Oral and intravenous bisphosphonates may increase bone mineral density in people with cystic fibrosis, but there are insufficient data to determine whether treatment reduces fractures. Severe bone pain and flu-like symptoms may occur with intravenous bisphosphonates. Before any firm conclusions can be drawn, trials in larger populations, including children, and of longer duration are needed to determine effects on fracture rate and survival. Additional trials are needed to determine if bone pain is more common or severe (or both) with the more potent zoledronate and if corticosteroids can ameliorate or prevent these adverse events. Future trials should also assess gastrointestinal adverse effects associated with oral bisphosphonates.

Identification and experimental validation of key m6A modification regulators as potential biomarkers of osteoporosis

Osteoporosis (OP) is a severe systemic bone metabolic disease that occurs worldwide. During the coronavirus pandemic, prioritization of urgent services and delay of elective care attenuated routine screening and monitoring of OP patients. There is an urgent need for novel and effective screening diagnostic biomarkers that require minimal technical and time investments. Several studies have indicated that N6-methyladenosine (m6A) regulators play essential roles in metabolic diseases, including OP. The aim of this study was to identify key m6A regulators as biomarkers of OP through gene expression data analysis and experimental verification. GSE56815 dataset was served as the training dataset for 40 women with high bone mineral density (BMD) and 40 women with low BMD. The expression levels of 14 major m6A regulators were analyzed to screen for differentially expressed m6A regulators in the two groups. The impact of m6A modification on bone metabolism microenvironment characteristics was explored, including osteoblast-related and osteoclast-related gene sets. Most m6A regulators and bone metabolism-related gene sets were dysregulated in the low-BMD samples, and their relationship was also tightly linked. In addition, consensus cluster analysis was performed, and two distinct m6A modification patterns were identified in the low-BMD samples. Subsequently, by univariate and multivariate logistic regression analyses, we identified four key m6A regulators, namely, METTL16, CBLL1, FTO, and YTHDF2. We built a diagnostic model based on the four m6A regulators. CBLL1 and YTHDF2 were protective factors, whereas METTL16 and FTO were risk factors, and the ROC curve and test dataset validated that this model had moderate accuracy in distinguishing high- and low-BMD samples. Furthermore, a regulatory network was constructed of the four hub m6A regulators and 26 m6A target bone metabolism-related genes, which enhanced our understanding of the regulatory mechanisms of m6A modification in OP. Finally, the expression of the four key m6A regulators was validated in vivo and in vitro, which is consistent with the bioinformatic analysis results. Our findings identified four key m6A regulators that are essential for bone metabolism and have specific diagnostic value in OP. These modules could be used as biomarkers of OP in the future.

Prediction of femoral strength of elderly men based on quantitative computed tomography images using machine learning

Hip fracture is the most common complication of osteoporosis, and its major contributor is compromised femoral strength. This study aimed to develop practical machine learning models based on clinical quantitative computed tomography (QCT) images for predicting proximal femoral strength. Eighty subjects with entire QCT data of the right hip region were randomly selected from the full MrOS cohorts, and their proximal femoral strengths were calculated by QCT-based finite element analysis (QCT/FEA). A total of 50 parameters of each femur were extracted from QCT images as the candidate predictors of femoral strength, including grayscale distribution, regional cortical bone mapping (CBM) measurements, and geometric parameters. These parameters were simplified by using feature selection and dimensionality reduction. Support vector regression (SVR) was used as the machine learning algorithm to develop the prediction models, and the performance of each SVR model was quantified by the mean squared error (MSE), the coefficient of determination (R² ), the mean bias, and the SD of bias. For feature selection, the best prediction performance of SVR models was achieved by integrating the grayscale value of 30% percentile and specific regional CBM measurements (MSE ≤ 0.016, R² ≥ 0.93); and for dimensionality reduction, the best prediction performance of SVR models was achieved by extracting principal components with eigenvalues greater than 1.0 (MSE ≤ 0.014, R² ≥ 0.93). The femoral strengths predicted from the well-trained SVR models were in good agreement with those derived from QCT/FEA. This study provided effective machine learning models for femoral strength prediction, and they may have great potential in clinical bone health assessments.

Analysis of Communal Molecular Mechanism Between Chronic Obstructive Pulmonary Disease and Osteoporosis

Background

Chronic obstructive pulmonary disease (COPD) patients with osteoporosis (OP) usually experience more frequent exacerbations, worse quality of life, and heavier economic burden, however, few studies have investigated common molecular mechanisms of COPD and OP.

Objective

To explore the relationship between COPD and OP through bioinformatics analysis.

Methods

The miRNA microarray data of COPD and OP were retrieved from the Gene Expression Database (GEO), and the differentially expressed microRNAs (DEmiRNAs) were screened and the intersection was obtained. The Targetscan, miRDB, and miRWalk databases were used to predict the target genes of DEmiRNA, and the gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed using the R package clusterProfiler, the STRING database was used to analyze the target protein-protein interaction network (PPI) and screens to determine the core modules and core genes.

Results

Two DEmiRNAs (miR-23a-5p, miR-194-3p) have been found in COPD and OP, which have predicted 76 and 114 target genes, respectively. GO functional annotations of miR-23a-5p were significantly enriched in CD40 signaling pathway, ubiquitin-conjugating enzyme activity, etc; KEGG pathways of miR-23a-5p were significantly enriched in ubiquitin-mediated proteolysis, folate biosynthesis, and regulation of actin cytoskeleton. GO function annotations of miR-194-3p were significantly enriched in T cell activation regulation, ubiquitin protein ligase activity, and DNA transcription factor binding; KEGG pathways of miR-194-3p were significantly enriched in cell adhesion molecules, intercellular tight junctions, and lysosomal pathway. PPI analysis found target coding proteins formed complex regulatory networks. Ten core genes (TP53, SRC, PXN, CHD4, SYK, TNRC6B, PML, KAT5, BRD1 and IGF2) were picked out among them, then we used the MCODE plugin found three core subnetworks.

Conclusion

Two identical DEmiRNAs (miR-23a-5p, miR-194-3p) exist in the peripheral blood of COPD and OP patients, which are important biomarkers for COPD patients with OP and may represent novel targets for diagnosis and treatment of COPD patients with OP.

Attributable disease burden related to low bone mineral density in Iran from 1990 to 2019: results from the Global Burden of Disease 2019

PURPOSE

Low bone mineral density (BMD) including low bone mass and osteoporosis is a bone state that carries the risk of fractures and the consequent burden. Since Iran has an aging population and is considered a high-risk country regarding fracture, the objective of this study was to report the low BMD attributable burden in Iran from 1990 to 2019 at national and subnational levels.

MATERIALS AND METHODS

In this study, the Global Burden of Disease (GBD) study 2019 estimates of exposure value and attributable burden were used. For each risk-outcome pair, following the estimation of relative risk, exposure level, and the Theoretical Minimum Risk Exposure Level (TMREL), the Population Attributable Fractions (PAFs) and attributable burden were computed. The Summary Exposure Value (SEV) index was also computed.

RESULTS

Although the age-standardized DALYs and deaths decreased (- 41.0 [95% uncertainty interval: - 45.7 to - 33.2] and - 43.3 [- 48.9 to - 32.5]), attributable all age numbers in Iran increased from 1990 to 2019 (64.3 [50.6 to 89.1] and 66.8 [49.7 to 102.0]). The male gender had a higher low BMD attributed burden in Iran at national and subnational levels except for Tehran. Among low BMD-associated outcomes, motor vehicle road injuries and falls accounted for most of the low BMD-attributed burden in Iran. The SEV for low BMD remained constant from 1990 to 2019 in the country and females had higher SEVs.

CONCLUSION

Low BMD and the associated outcomes has to gain attention in Iran's health system due to an aging population. Hence, timely interventions by health systems and the population at stake might assist in reducing the burden attributed to low BMD.

A multifunctional drug consisting of tetracycline conjugated with odanacatib for efficient periodontitis therapy

The treatment of periodontitis can be very challenging due to its complex etiologies. A new pharmacologic strategy entitled “host-modulation therapy,” has been introduced to improve periodontal treatment outcomes. Supposedly, a multifunctional drug with the potential for bacterial infection prevention, host-response modulation and bone healing promotion would be a promising option for periodontitis therapy, but related studies remain substantially lacking. In this study, we successfully conjugated tetracycline with odanacatib (a selective inhibitor of cathepsin K) to construct a multifunctional drug (TC-ODN). We discovered that TC-ODN could promote macrophages polarizing toward anti-inflammatory phenotype and promote osteogenesis of PDLSCs under inflammatory microenvironment. In vivo, TC-ODN could be absorbed and distributed specifically to the bone after systemic administration, and accumulation of TC-ODN increased bone mineral density in ovariectomized rats. Importantly, periodontal administration of TC-ODN could successfully promote bone healing in periodontitis rats with alveolar bone loss. The findings in our study uncovered the excellent biocompatibility and multifunction of TC-ODN, including bone-targeted accumulation, immunoregulation, anti-inflammatory activity and promotion of bone healing, which might contribute to the clinical treatment of periodontitis.

Risk factors of transport gap bending deformity in the treatment of critical-size bone defect after bone transport

Background

The purpose of this study was to investigate the risk factors of transport gap bending deformity (TGBD) in the treatment of critical-size bone defect (CSBD) after the removal of the external fixator.

Methods

From January 2008 to December 2019, 178 patients with bone defects of the lower extremity caused by infection were treated by bone transport using a unilateral external fixator in our medical institution. TGBD was defined as the bone callus in the distraction area with a deviation to the force line of the femur (> 10°) or tibia (> 12°) after removal of the external fixator. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes. After the data were significant by the T-test or Pearson’s Chi-square test was analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of TGBD.

Results

A total of 178 patients were enrolled in the study, with a mean follow-up time of 28.6 ± 3.82 months. The positive result of the bacteria isolated test was observed in 144 cases (80.9%). The rate of excellent and good in the bone outcomes (excellent/good/fair/poor/failure, 41/108/15/14/0) was 83.7%, and 92.3% in the functional results (excellent/good/fair/poor/failure, 50/98/16/14/0) according to the ASAMI criteria. TGBD after removal of external fixator occurred in twenty-two patients (12.3%), including 6 tibias, and 16 femurs. Age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, osteoporosis, glucocorticoid intake, duration of infection > 24 months, EFT > 9 months, EFI > 1.8 month/cm were associated significantly with a higher incidence of TGBD in the binary logistic regression analysis (P < 0.05). The incidence more than 50% was found in patients with femoral defect (76.1%), osteoporosis (72.7%), BMI > 25 kg/m² (69.0%), diabetes (59.5%), glucocorticoid intake (54.7%). In the multivariate logistic regression analyses, the following factors were associated independently with TGBD, including age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, and osteoporosis.

Conclusions

Bone transport using a unilateral external fixator was a safe and practical method in the treatment of CSBD caused by infection. The top five risk factors of TGBD included femoral defect, BMI > 25 kg/m², duration of bone infection > 24 months, age > 45 years, and diabetes. Age > 45 years, BMI > 25 kg/m², femoral defect, osteoporosis, and diabetes were the independent risk factors. The higher incidence of TGBD may be associated with more risk factors.

Pharmacological, Nutritional, and Rehabilitative Interventions to Improve the Complex Management of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease: A Narrative Review

Osteoporosis is a highly prevalent condition affecting a growing number of patients affected by chronic obstructive pulmonary disease (COPD), with crucial implications for risk of fragility fractures, hospitalization, and mortality. Several risk factors have been identified to have a role in osteoporosis development in COPD patients, including corticosteroid therapy, systemic inflammation, smoke, physical activity levels, malnutrition, and sarcopenia. In this scenario, a personalized multitarget intervention focusing on the pathological mechanisms underpinning osteoporosis is mandatory to improve bone health in these frail patients. Specifically, physical exercise, nutritional approach, dietary supplements, and smoke cessation are the cornerstone of the lifestyle approach to osteoporosis in COPD patients, improving not only bone health but also physical performance and balance. On the other hand, pharmacological treatment should be considered for both the prevention and treatment of osteoporosis in patients at higher risk of fragility fractures. Despite these considerations, several barriers still affect the integration of a personalized approach to managing osteoporosis in COPD patients. However, digital innovation solutions and telemedicine might have a role in optimizing sustainable networking between hospital assistance and community settings to improve bone health and reduce sanitary costs of the long-term management of COPD patients with osteoporosis.