Assessment of fracture risk

Fracture Risk Assessment and Drug Holiday in a Real-Life Setting

PURPOSE

Describe fracture risk assessment practices among physicians treating osteoporosis in a real-life setting.

METHODS

This is a retrospective cohort study in a tertiary academic center. Inclusion criteria involved adults (aged ≥18 years) who received minimum adequate therapy (bisphosphates, raloxifene, or denosumab ≥ 3 years or teriparatide ≥ 18 months). Of 1,814 charts randomly selected and reviewed, 274 patients met the inclusion criteria. Risk stratification tools included fragility fractures, Dual-energy X-ray Absorptiometry (DXA), and fracture risk assessment using the FRAX tool. Fracture risk assessment was performed before therapy initiation (N= 274) and at the time of institution of the drug holiday (N=119). High-risk patients were defined as the presence of a fragility fracture, T-score ≤-2.5, or a high-risk score by FRAX calculation. FRAX scores were independently calculated by the research team for comparison and assessment purposes.

RESULTS

Before initiation of therapy (N=274) versus upon starting a drug holiday (DH; N=119), 29.9% versus 3.4% had a history of fragility fractures (P<0.001), 58.8% versus 67.2% had a DXA scan performed (P>0.05), 10.5% versus 10.9% of physicians calculated a FRAX score (P>0.05), and 71.5% versus 66.4% were considered at high risk and eligible for therapy. A DXA scan was performed after DH in 40.2% of these patients and at least once in 95.3% of the entire cohort.

CONCLUSION

The reporting of FRAX score in DXA scan reports may significantly increase its utilization in fracture risk assessment. We recommend comprehensive fracture risk assessment utilizing history of prevalent osteoporosis fractures, DXA assessment, and FRAX scoring.

Patterns of Osteoporosis Medications Selection after Drug Holiday or Continued Therapy: A Real-World Experience

PURPOSE

Published literature on physicians' preferences and sequential treatment (Rx) patterns of osteoporosis therapy is scarce.

METHODS

A retrospective cohort study of patients who received at least 3 consecutive years of bisphosphonates, denosumab, and/or raloxifene, or at least 18 months of teriparatide for osteoporosis. Data gathering spanned 10 years from October 2007 until September 2016 at a tertiary care center in USA.

RESULTS

12,885 patients were identified based on receiving at least one Rx at any point in time, 1,814 patients were randomly reviewed, and 274 patients met the inclusion criteria. The mean age was 68.8 ± 10.7 years and females represented 90.9%. Primary care physicians constituted 65.7% and rheumatologists 22.6% of the prescribers. Prior to instituting a drug holiday, alendronate was the most common initial Rx (Percentage, mean duration ± standard deviation in years): 69.0%, 5.4±2.4y followed by ibandronate (9.5%, 4.9±2.1y) and raloxifene (9.1%, 5.2±1.6y). Denosumab was the most common second course of Rx accounting for 29.3% of the total of 82 patients who were subsequently prescribed another therapy, followed by alendronate (24.4%) and zoledronate (20.7%). Among patients who were placed on a drug holiday and eventually restarted on an osteoporosis therapy, denosumab was the most common treatment instituted (n=21) accounting for 40% of the total, followed by alendronate (32%) and zoledronate (16%). There was a progressive decline of osteoporosis therapy over the duration of the study.

CONCLUSION

Alendronate was the most common initial therapy. Denosumab was the most common second course of treatment prescribed.

Current state of computer-assisted trauma surgery

Computer assisted surgery (CAS) was first used in neurosurgery. Currently, CAS has gained popularity in several surgical disciplines including urology and abdominal surgery. In trauma and orthopaedic surgery, computer assisted systems are used for fracture reduction, planning and positioning of implants as well as the accurate implantation of hip and knee prostheses. The patient's anatomy is virtualized and the surgical instruments integrated into the digitized image background, thus allowing the surgeon to navigate the surgical instruments and the bone in an improved, virtual visual environment. CAS improves overall accuracy, reducing intraoperative radiation exposure and minimizing unnecessary surgical dissection combined with increased patient and surgeon safety. However, limitations include prolonged surgical time, technical errors and cost implications. This article will outline the current state of computer assisted trauma surgery including its implications and specific challenges in orthopaedic trauma surgery.