Osteoporotic fractures, DXA, and fracture risk assessment: meeting future challenges in the Eastern Mediterranean Region

Male-female disparity in clinical features and significance of mild vertebral fractures in community-dwelling residents aged 50 and over

This investigation examined the clinical implications of mild vertebral fractures in older community-dwelling residents. Focusing on the locomotion health of older individuals, the earlier reported Obuse study enrolled 415 randomly sampled Japanese residents aged between 50 and 89 years, 411 of whom underwent X-ray evaluations for pre-existing vertebral fractures. A blinded assessment of vertebral fractures based on Genant's criteria was conducted on the T5-L5 spine for rating on a severity scale. Grade 1 mild fractures were not linked to age in males, but increased with aging in females. Female participants had fewer Grade 1 and 2 fractures (P = 0.003 and 0.035, respectively) but more Grade 3 fractures (P = 0.013) than did males independently of age (Grade 1, 2, and 3: 25%, 16%, and 9% in females and 40%, 22%, and 6% in males, respectively). Weak negative correlations were observed between the number of fractures and bone mineral density in females for all fracture grades (Spearman's rho: 0.23 to 0.36, P < 0.05). Our study showed that Grade 1 mild vertebral fractures in males lacked pathological significance, while in females they potentially indicated fragility fractures and were related to poor lumbopelvic alignment.

Osteoporotic hip and vertebral fractures in the Arab region: a systematic review

Asia is projected to account for the largest proportion of the rising burden of osteoporotic fractures worldwide. Data from the Middle East is scarce. We performed a systematic review on the epidemiology of vertebral and hip osteoporotic fractures in 22 Arab League countries, using Scopus, PubMed, and Embase. We identified 67 relevant publications, 28 on hip and 39 on vertebral fractures. The mean age of patients was 70-74 years, female to male ratio 1.2:2.1. Age-standardized incidence rates, to the UN 2010 population, were 236 to 290/100,000 for women from Kuwait and Lebanon, lower in Morocco. Risk factors for hip fractures included lower BMD or BMI, taller stature, anxiolytics, and sleeping pills. Most patients were not tested nor treated. Mortality derived from retrospective studies ranged between 10 and 20% at 1 year, and between 25 and 30% at 2-3 years. Among 39 studies on vertebral fractures, 18 described prevalence of morphometric fractures. Excluding grade 1 fractures, 13.3-20.2% of women, mean age 58-74 years, had prevalent vertebral fractures, as did 10-14% of men, mean age 62-74 years. Risk factors included age, gender, smoking, multiparity, years since menopause, low BMD, bone markers, high sclerostin, low IgF1, hypovitaminosis D, abdominal aortic calcification score, and VDR polymorphisms. Vertebral fracture incidence in women from Saudi Arabia, mean age 61, was 6.2% at 5 years, including grade 1 fractures. Prospective population-based fracture registries, prevalence studies, predictive models, fracture outcomes, and fracture liaison services from Arab countries are still lacking today. They are the pillars to closing the care gap of this morbid disease.

The association between low bone mineral density and coronary artery calcification in osteoporotic and non-osteoporotic patients in a tertiary center in Saudi Arabia

BACKGROUND

Cardiovascular disease (CVD) and osteoporosis are major health-care concerns worldwide. The evidence is contradictory on whether a relationship exists between low bone mineral density (BMD) determined by dual-energy absorptiometry (DXA scan) and coronary artery calcification (CAC) measured by computed tomography. Currently, there are no data on patients from Saudi Arabia.

OBJECTIVE

Examine the relationship between CAC and BMD in both genders and study the influence of traditional coronary artery disease (CAD) risk factors and osteoporosis.

DESIGN

Retrospective, cross-sectional, analytical.

SETTING

Single tertiary care center.

PATIENTS AND METHODS

We searched radiology databases for patients who underwent both DXA and CAC score scanning within six months of each other. The inclusion criterion was an absence of any history of CAD.

MAIN OUTCOME MEASURE

Association between osteoporosis and CAC.

SAMPLE SIZE

195 (34 osteoporosic, 161 normal BMD or osteopenic) RESULTS: Most of the study population (57.4%) were females. The mean age of all patients was 63.6 (10.1) years. Participants with CAC scores of 0 were significantly younger than those who had CAC scores >0. The presence of diabetes mellitus, hypertension, and hypercholesterolemia was higher in patients with CAC scores >0. CAC score and other CAD risk factors were not significantly different between the osteoporotic and nonosteoporotic groups, except for body mass index. A high CAC score (>100) was present in 28%, 20%, 11%, and 30% of participants with no osteoporosis, osteoporosis of the lumbar spine, osteoporosis of the femoral neck, and participants with osteoporosis of both the lumbar spine and femoral neck, respectively (P=.762), suggesting there is no association between CAC and the presence of osteoporosis.

CONCLUSIONS

Osteoporosis is not associated with higher CAC scores in Saudi Arabia and CAD risk factors are not significantly prevalent in osteoporosis. It appears that CAC and osteoporosis are independent age-related diseases that share common risk factors.

LIMITATIONS

Single-center, retrospective.

CONFLICT OF INTEREST

None.

Prevalence of osteoporosis with the World Health Organization diagnostic criteria in the Eastern Mediterranean Region: a systematic review and meta-analysis

A systematic review and meta-analysis was conducted on the prevalence of osteoporosis in the Eastern Mediterranean Region. The overall pooled prevalence of osteoporosis was 24.4%. The prevalence has increased significantly over the recent years. The highest pooled prevalence was in Saudi Arabia (32.7%), and the lowest was in Kuwait (15.1%).

PURPOSE

To conduct a systematic review and meta-analysis on the prevalence of osteoporosis in the Eastern Mediterranean Region (EMR), as defined by the World Health Organization.

METHODS

We included all observational studies reporting the prevalence of osteoporosis among general population. We searched literatures from the databases of PubMed, Scopus, Web of Science, and Index Medicus for the EMR published between January 2000 and December 2017 with no restriction of language. Two reviewers independently contributed in study selection and data extraction. STATA software was used for analyzing the collected data.

RESULTS

A total of 1692 citations were retrieved. After excluding the irrelevant articles, 36 eligible studies were included. The overall pooled prevalence rate of osteoporosis in the EMR on 31,593 participants was 24.4% (95% confidence interval [CI], 20.4-28.4). Based on femoral densitometry, the prevalence of osteoporosis was 16.8% (95% CI, 9.5-24.2), and based on spinal densitometry, it was 24.3% (95% CI, 19.4-29.2). The pooled prevalence in males was 20.5% (95% CI, 10.5-30.5), compared with 24.4% (95% CI, 20.2-28.6) in females. The prevalence rate was significantly higher in 2007-2015 (32.7%; 95% CI, 25.1-40.3) than in 2000-2006 (19.8%; 95% CI, 12.5-27).

CONCLUSIONS

Our findings indicate a considerable prevalence of osteoporosis among the people of the EMR. The prevalence has increased during recent years, showing that osteoporosis is becoming a critical health problem in this region. Prevention and control measures need to be implemented by health service authorities.

Risk Factors for Proximal Junctional Fracture Following Fusion Surgery for Osteoporotic Vertebral Collapse with Delayed Neurological Deficits: A Retrospective Cohort Study of 403 Patients

Introduction

Approximately 3% of osteoporotic vertebral fractures develop osteoporotic vertebral collapse (OVC) with neurological deficits, and such patients are recommended to be treated surgically. However, a proximal junctional fracture (PJFr) following surgery for OVC can be a serious concern. Therefore, the aim of this study is to identify the incidence and risk factors of PJFr following fusion surgery for OVC.

Methods

This study retrospectively analyzed registry data collected from facilities belonging to the Japan Association of Spine Surgeons with Ambition (JASA) in 2016. We retrospectively analyzed 403 patients who suffered neurological deficits due to OVC below T10 and underwent corrective surgery; only those followed up for　≥2 years were included. Potential risk factors related to the PJFr and their cut-off values were calculated using multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis.

Results

Sixty-three patients (15.6%) suffered PJFr during the follow-up (mean 45.7 months). In multivariate analysis, the grade of osteoporosis (grade 2, 3: adjusted odds ratio (aOR) 2.92; p=0.001) and lower instrumented vertebra (LIV) level (sacrum: aOR 6.75; p=0.003) were independent factors. ROC analysis demonstrated that lumbar bone mineral density (BMD) was a predictive factor (area under curve: 0.72, p=0.035) with optimal cut-off value of 0.61 g/cm² (sensitivity, 76.5%; specificity, 58.3%), but that of the hip was not (p=0.228).

Conclusions

PJFr was found in 16% cases within 4 years after surgery; independent risk factors were severe osteoporosis and extended fusion to the sacrum. The lumbar BMD with cut-off value 0.61 g/cm² may potentially predict PJFr. Our findings can help surgeons select perioperative adjuvant therapy, as well as a surgical strategy to prevent PJFr following surgery.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

A two-level subject-specific biomechanical model for improving prediction of hip fracture risk

BACKGROUND

Sideways fall-induced hip fracture is a major worldwide health problem among the elderly population. However, all existing biomechanical models for predicting hip fracture mainly consider the femur related parameters. Their accuracy is limited as hip fracture is significantly affected by loading conditions as well. The objective of this study was to develop a biomechanical model for improving assessment of hip fracture risk by subject-specific prediction of fall-induced loading conditions.

METHOD

All information required to construct the models was extracted from the subject's whole-body and hip medical image in order to make the models subject-specific. Fall-induced hip fracture risk for eighty clinical cases was calculated under two sets of loading conditions: subject-specific determined by the proposed model, and non-subject-specific obtained from empirical functions. The predicted hip fracture risk indices were then compared with clinical observations.

FINDINGS

It was found that the subject-specific prediction of fall-induced loading conditions significantly improves the hip fracture risk assessment. Consistent to the clinical observations, the fracture risk predicted by the proposed model suggested that obesity is a protective factor for hip fracture and underweight subjects are more likely to experience a hip fracture.

INTERPRETATIONS

This study shows that hip fracture risk is affected by a number of factors, including body weight, body height, impact force, body mass index, hip soft tissue thickness, and bone quality. The proposed model provides a comprehensive, fast, accurate, and non-expensive method for prediction of hip fracture risk which should lead to more effective prevention of hip fractures.

Frax score calculations in postmenopausal women with subclinical hypothyroidism

OBJECTIVE

The aim of our study was to evaluate the relationship between the elevated TSH and fracture risk in postmenopausal women with subclinical hypothyroidism for evaluation of individuals with a high risk for osteoporotic fractures.

DESIGN

FRAX score calculation (10-year estimated risk for bone fracture) and measurement of bone markers (osteocalcin and beta cross-laps) were performed in 82 postmenopausal women with newly discovered subclinical hypothyroidism (mean age 59.17±7.07, mean BMI 27.89±3.46kg/m2, menopause onset in 48.05±4.09 years of age) and 51 matched controls (mean age 59.69±5.72, mean BMI 27.68±4.66kg/m2, menopause onset in 48.53±4.58 years of age) with normal thyroid function.

RESULTS

The main FRAX score was significantly higher in the group with subclinical hypothyroidism than in the controls (6.50±4.58 vs. 4.35±1.56; p=0.001). Hip FRAX score was significantly higher in the group with subclinical hypothyroidism (1.11±1.94 vs. 0.50±0.46; p=0.030). There was no significant difference in bone markers: osteocalcin (23.99±12.63 vs. 21.79±5.34 ng/mL; p=0.484) and beta cross-laps (365.76±184.84 vs. 306.88±110.73 pg/mL; p=0.21) between the two groups.

CONCLUSIONS

Postmenopausal patients with subclinical hypothyroidism, in particular of autoimmune origin, have higher FRAX scores and a thus greater risk for low-trauma hip fracture than euthyroid postmenopausal women. Our results point to the need to monitor postmenopausal patients with subclinical hypothyroidism for avoidance of fractures.

Assessing the impact of osteoporosis on the burden of hip fractures

The aim of the study was to determine the number of hip fractures within defined countries for 2010 and the proportion attributable to osteoporosis. The number of incident hip fractures in one year in countries for which data were available was calculated from the population demography in 2010 and the age- and sex-specific risk of hip fracture. The number of hip fractures attributed to osteoporosis was computed as the number of hip fractures that would be saved assuming that no individual could have a femoral neck T-score of less than -2.5 SD (i.e., the lowest attainable T-score was that at the threshold of osteoporosis (=-2.5 SD). The total number of new hip fractures for 58 countries was 2.32 million (741,005 in men and 1,578,809 in women) with a female-to-male ratio of 2.13. Of these 1,159,727 (50 %) would be saved if bone mineral density in individuals with osteoporosis were set at a T-score of -2.5 SD. The majority (83 %) of these "prevented" hip fractures were found in men and women at the age of 70 years or more. The 58 countries assessed accounted for 83.5 % of the world population aged 50 years or more. Extrapolation to the world population using age- and sex-specific rates gave an estimated number of hip fractures of approximately 2.7 million in 2010, of which 1,364,717 were preventable with the avoidance of osteoporosis (264,162 in men and 1,100,555 in women). We conclude that osteoporosis accounts for approximately half of all hip fractures. Strategies to prevent osteoporosis could save up to 50 % of all hip fractures.