Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research

Clinical Significance of Incident Osteoporotic Fractures After Kidney Transplantation: A National Korean Cohort Study

RATIONALE & OBJECTIVE

Recipients of kidney allografts are at risk of osteoporotic fractures (OF), but the association of OF with transplant patient outcomes remains uncertain due to common coexisting risks and complex medical conditions. This study sought to assess whether the overall incidences of OF among recipients of kidney allografts compared to that of patients receiving maintenance dialysis for kidney failure.

STUDY DESIGN

A national retrospective cohort study.

SETTING & PARTICIPANTS

145,090 Korean patients newly diagnosed with kidney failure between 2009 and 2019.

EXPOSURE

Kidney transplantation versus dialysis resulting in OF, and OF increasing risk of death.

OUTCOME

Incident OF overall and by site (hip, spine, forearm, and humerus); death.

ANALYTICAL APPROACH

Comparison of patients receiving maintenance dialysis with recipients of kidney allografts matched by age, sex, year of new index date, duration of dialysis, and presence of hypertension and diabetes mellitus. Cause-specific Cox proportional hazards regression models estimated the association between modality of kidney replacement therapy and OF. Cox models incorporating OF as a time-updated covariate were used to estimate the association of OF and mortality.

RESULTS

A total of 11,413 pairs were matched. Over the entire study period, 541 (4.7%) OFs in allograft recipients and 657 (5.8%) in matched dialysis comparators occurred, respectively. After 5.5 years of follow-up evaluation, the risk of incident OF was lower in kidney transplant recipients compared with matched dialysis comparators (adjusted hazard ratio[AHR], 0.73 [95% CI, 0.64-0.84], P<0.001). The differences in fracture rates were primarily driven by differences in hip fractures. Incident OF was associated with increased mortality risk (AHR, 2.18 [95% CI, 1.57-3.02], P<0.001) and death-censored allograft failure (AHR, 1.42 [95% CI, 1.02-1.97], P=0.040).

LIMITATIONS

Use of claims data, and no data on bone mineral density or hyperparathyroidism; the definition of OF that was used encompassed traumatic fractures.

CONCLUSIONS

Kidney allograft recipients have a lower rate of incident OF compared with dialysis patients, but when OF occurs it is associated with a higher rate of death and allograft loss.

Parental fracture history is associated with offspring early-life fracture risk: The Geelong Osteoporosis Study

AIMS

Fractures during childhood and adolescence are common as peak bone mass has not yet been accrued. Previous studies have reported that offspring are at higher risk of a fragility fracture if one or both parents have experienced a fracture, however, it is not known if this association holds true for fractures experienced in early life, and if so, whether there are differential risk profiles across the sexes. Therefore, this study aimed to determine the associations between maternal and paternal fracture history and offspring fracture risk in early life.

METHODS

At baseline, Geelong Osteoporosis Study participants self-reported fracture history for themselves and their parents. This analysis included personal fracture data relating to birth until 20 years of age and parental fracture for 1336 female and 1174 male participants who provided complete data, including age and site of fracture. Multivariable logistic regression models were used to assess the odds of participant fracture in childhood or adolescence in association with paternal and/or maternal fracture.

RESULTS

In total, 141 (12.2 %) female and 323 (25.7 %) male participants reported at least one fracture by age 20 years. For females, there were 247 maternal and 211 paternal parents with fractures and in males, 233 maternal and 189 paternal fractures. A maternal fracture was associated with an increased odds of early life fracture in female participants (OR 1.86; 95 % CI 1.17-2.95) but not male participants (OR 1.16; 95 % CI 0.81-1.65), while a paternal fracture was associated with an increased odds of early life fracture in males (OR 1.47; 95 % CI 1.01-2.14) but not females (OR 1.61; 95 % CI 0.98-2.64).

CONCLUSION

Parental fracture history appears to have sex-specific associations with offspring early life fracture risk. Whereby maternal fracture history is associated with an increased risk of early life fracture in females, while paternal fracture history is associated with early life fracture risk in males.

Osteoporotic fracture risks of thiazides and dihydropyridines in angiotensin modulator users

This study examined the impact of thiazide and RAAS antihypertensive medications vs DHP-RAAS medications on fracture risk. The close alignment of such settings with clinical use, combined with the potential bone benefits of ACEis and ARBs, provides enhanced accuracy in bone health evidence.

PURPOSE

To determine whether thiazides, combined with either angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), offer bone-protective benefits compared with dihydropyridine (DHP) drugs combined with ACEi or ARB.

METHODS

This retrospective cohort study was conducted on the US Collaborative Network from the TriNetX database on March 5th, 2024. It included hypertensive ACEi or ARB users under thiazide or DHP drug treatments spanning from January 1st, 2015, to December 31st, 2022, with exclusion criteria applied. The primary outcome is a composite typical osteoporotic fracture (TOPF). Kaplan Meier analyses were performed after 1:1 propensity-score matching (PSM) with a 5-year follow-up. Besides investigating fracture-related outcomes in thiazide-ACEi/ARB and DHP-ACEi/ARB users, this study explores whether the effects differ between ACEi and ARB users. Subgroup analyses were also performed, and the heterogeneity among the results was assessed using Cochran's Q-tests.

RESULTS

Post-PSM results yield 54,240 patients per cohort in the primary analysis, aging 61.5 ± 12.2 versus 61.4 ± 13.7 (thiazide-ACEi/ARB versus DHP-ACEi/ARB) with predominantly white ethnicity. Thiazide-ACEi/ARB users exhibit lower TOPF risk than DHP-ACEi/ARB users (hazard ratio (HR) = 0.65, 95% confidence interval (CI) 0.61-0.70), and such benefits from thiazides are similar between ACEi and ARB users (ACEi: HR = 0.69; ARB: HR = 0.67, Cochran's Q-test p-value = 0.78). Additionally, the effects of thiazides reveal significant heterogeneity between patients with and without inflammatory polyarthropathy (ICD-10, M05-M14) and benzodiazepine usage (Cochran's Q-test p-value = 0.01, 0.04).

CONCLUSION

Thiazides are associated with lower risks of typical osteoporotic fractures compared to DHP drugs in patients treated with ACEi or ARB, while such benefits may diminish in those with a diagnosis of inflammatory polyarthropathy and benzodiazepine usage.

Correlation Between Bone Metabolism Indices and Osteoporotic Thoracolumbar Vertebrae Fracture in Postmenopausal Women

Background

This study aims to explore the correlation between bone metabolism indices and osteoporotic thoracolumbar vertebrae fracture (OTVF) in postmenopausal women.

Methods

A total of 447 female patients with postmenopause and underwent OTVF in our hospital were selected as group A. Three hundred eighty-seven out-patients without fractures were selected as group B. Bone metabolism index including the serum levels of total Serum procollagen type N-terminal propeptide (tPINP), the age-related type I cross linked C-telopeptide (β-CTX) and 25-hydroxyvitamin D (25-OHD) were collected and compared. The relation between bone metabolism indices and OTVF was analyzed.

Results

The mean tPINP in group A was 61.72 ± 28.43, which was notably higher than group B (P < 0.01). Meanwhile, greater β-CTX were higher founded in group A than group B (0.778 ± 0.316 vs 0.669 ± 0.303 μg/l). However, the 25-OHD in group A was significantly lower than that in group B (P < 0.05). Multivariate logistic regression analysis revealed that the serum level of tPINP (OR: 0.008, P = 0.011), the serum level of β-CTX (OR: 0.805, P = 0.002) and the serum level of 25-OHD (OR: -0.029, P = 0.003) were independently correlated with postmenopausal OTVF.

Conclusion

Bone metabolic markers play an important role in predicting OTVF. As a reflection of bone mass and bone strength, BMD is inadequate in predicting OTVF. High expression of bone metabolism indicators β-CTX, tPINP and relatively low expression of 25-OHD suggest an increased risk of OTVF. Early detection of postmenopausal bone metabolism abnormalities can be used for early intervention to reduce the incidence of OTVF.

Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis

INTRODUCTION

Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).

METHODS

A systematic search of the literature was undertaken using the Medline®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.

RESULTS

A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.

CONCLUSIONS

This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Predicting fragility fractures based on frailty and bone mineral density among rural community-dwelling older adults

OBJECTIVE

We aim to investigate the association between bone mineral density (BMD) measurement and fragility fractures and assess the predictive value of combining BMD measurement and frailty for fracture risk assessment.

METHODS

This retrospective cohort study analyzed data from 5126 rural Koreans in the Chungju Metabolic Disease Cohort study. Frailty was defined using Fried's frailty phenotype. Fractures were assessed via structured medical interviews. Adjusted odds ratios (ORs) were calculated considering age, sex, body mass index, behavior, BMD, handgrip strength, medications, and comorbidities.

RESULTS

The study cohort consisted of 5126 participants comprising 1955 (38.1%) males and 3171 (61.9%) females. Osteoporosis significantly increased the fracture risk across all types, except vertebral fracture, with adjusted OR (95% CI) of 1.89 (1.23-3.47) for any fracture, 2.05 (1.37-2.98) for hip fracture, 2.18 (1.06-4.50) for other fracture, and 1.71 (1.03-3.63) for major osteoporotic fracture (MOF). Frail individuals exhibited significantly increased risk for any fracture (OR 2.12; 95% CI, 1.21-3.71), vertebral fracture (2.48; 1.84-3.61), hip fracture (2.52; 1.09-3.21), other fracture (2.82; 1.19-8.53), and MOF (1.87; 1.01-3.47). The combination of frailty and BMD further increased the risks, with frail individuals demonstrating elevated ORs across BMD categories. In subgroup analyses, men showed a significant association between frailty with osteoporosis in hip fracture and MOF. Frail women with osteoporosis exhibited the highest risks for all fractures, particularly vertebral (OR 5.12; 95% CI, 2.07-9.68) and MOF (OR 5.19; 95% CI, 2.07-6.61). Age-specific analysis revealed that individuals aged 70 and older exhibited markedly higher fracture risks compared with those under 70. The combination of frailty and low BMD further elevated the fracture risk. Frailty was applied with BMD and demonstrated superior risk prediction for MOF compared with that with either score alone (area under the curve 0.825; P = .000).

CONCLUSIONS

Combining frailty with BMD provides a more accurate fracture risk assessment for individuals over 50 years.

Sirtuins: exploring next-gen therapeutics in the pathogenesis osteoporosis and associated diseases

OBJECTIVE

Osteoporosis poses a substantial public health challenge due to an ageing population and the lack of adequate treatment options. The condition is marked by a reduction in bone mineral density, resulting in an elevated risk of fractures. The reduction in bone density and strength, as well as musculoskeletal issues that come with aging, present a significant challenge for individuals impacted by these conditions, as well as the healthcare system worldwide.

METHODS

Literature survey was conducted until May 2023 using databases such as Web of Science, PubMed, Scopus, and Google Scholar.

RESULT

Sirtuins 1-7 (SIRT1-SIRT7), which are a group of Nicotinamide adenine dinucleotide (NAD+)-dependent deacetylases, possess remarkable capabilities to increase lifespan and combat diseases related to aging. Research has demonstrated that these proteins play an important role in regular skeletal development and maintenance by directly impacting bone cells. Their dysfunction could be a factor in various bone conditions. Studies conducted on animals before clinical trials have shown that administering Sirtuins agonists to mice provides a safeguard against osteoporosis resulting from aging, menopause, and immobilization. These findings imply that Sirtuins may be a viable target for addressing the irregularity in bone remodeling and treating osteoporosis and other skeletal ailments.

CONCLUSION

The purpose of this review was to present a thorough and current evaluation of the existing knowledge on Sirtuins biology, with a particular emphasis on their involvement in maintaining bone homeostasis and contributing to osteoporosis. Additionally, the review examines potential pharmacological interventions targeting Sirtuins for the treatment of osteoporosis.

Understanding the Korean Dialysis Cohort for Mineral, Vascular Calcification, and Fracture (ORCHESTRA) Study: Design, Method, and Baseline Characteristics

INTRODUCTION

End-stage renal disease (ESRD) is a growing disease worldwide, including Korea. This is an important condition that affects patient outcome. To provide optimal management for mineral disturbance, vascular calcification, and bone disease in ESRD patients, the Korean dialysis cohort for mineral, vascular calcification, and fracture (ORCHESTRA) study was conducted by enrolling Korean dialysis patients.

METHODS

Sixteen university-affiliated hospitals and one Veterans' Health Service Medical Center participated in this study. This prospective cohort study enrolled approximately 900 consecutive patients on dialysis between May 2019 and January 2021. Enrolled subjects were evaluated at baseline for demographic information, laboratory tests, radiologic imaging, and bone mineral densitometry (BMD) scans. After enrollment, regular assessments of the patients were performed, and their biospecimens were collected according to the study protocol. The primary outcomes were the occurrence of major adverse cardiovascular events, invasive treatment for peripheral artery disease, and osteoporotic fractures. The secondary outcomes were hospitalization for cerebrovascular disease or progression of abdominal aortic calcification. Participants will be assessed for up to 3 years to determine whether primary or secondary outcomes occur.

RESULTS

Between May 2019 and January 2021, all participating centers recruited 900 consecutive dialysis patients, including 786 undergoing hemodialysis (HD) and 114 undergoing peritoneal dialysis (PD). The mean age of the subjects was 60.4 ± 12.3 years. Males accounted for 57.7% of the total population. The mean dialysis vintage was 6.1 ± 6.0 years. The HD group was significantly older, had a longer dialysis vintage, and more comorbidities. Overall, the severity of vascular calcification was higher and the level of BMD was lower in the HD group than in the PD group.

CONCLUSION

This nationwide, multicenter, prospective cohort study focused on chronic kidney disease-mineral and bone disorder and aimed to provide clinical evidence to establish optimal treatment guidelines for Asian dialysis patients.

Unilateral percutaneous vertebroplasty in osteoporotic vertebral compression fractures: A clinical efficacy evaluation

Osteoporotic vertebral compression fractures, often resulting from low-energy trauma, markedly impair the quality of life of elderly individuals. The present retrospective study focused on the clinical efficacy of unilateral percutaneous vertebroplasty (PVP) in the treatment of osteoporotic compression fractures. A total of 68 patients, representing 92 vertebral bodies, who underwent the unilateral PVP technique from March 2020 to January 2023 were evaluated. Key parameters such as visual analogue scale (VAS) values, Oswestry disability index (ODI) scores, Cobb angle measurements, and anterior vertebral height (AVH) were documented pre- and post-surgery. The mean follow-up period was 15.41±3.74 months. The mean pre-operative VAS score was 8.08±0.79, which was significantly reduced to 2.25±0.71 by 24 h post-surgery and stabilized at 1.58±0.51 by the final follow-up. The ODI showed a significant improvement from a pre-operative average of 67.75±7.91 to 19.74±2.90 post-surgery, and was maintained at a low level of 28.00±4.89 at the last assessment. Radiological evaluations revealed significant alterations in Cobb angle and AVH post-operation. Notably, during the follow-up, eight patients developed new compression fractures in different vertebral segments. In conclusion, the unilateral PVP method is safe and efficient for the management of osteoporotic vertebral compression fractures.

Lateral Lumbar Interbody Fusion within Three-level for Patients with Neurological Symptoms due to Vertebral Fragility Fractures in the Lumbar Spine

There is a lack of agreement on whether minimally invasive lateral lumbar intervertebral fusion (LLIF) is a suitable treatment option for vertebral fragility fractures (VFFs). Hence, we sought to evaluate the efficacy and safety of LLIF in the management of VFF with neurological deficits in the lumbar spine. Between April 2015 and March 2020, we conducted a retrospective observational study of patients with VFF treated with three-level or less LLIF. The participants had previously received conservative treatment but had not been able to control their neurological symptoms. To assess the outcomes of the LLIF procedures, the patients were followed up for a minimum of 1 year. Clinical and radiological results, which include the timing and location of the bony fusion, were analyzed. The study involved 19 patients with 23 vertebral fracture levels. The residual height of the fractured vertebra was found to be 57.0 ± 12.3% of the height of the adjacent level. The mean Japanese Orthopedic Association score significantly improved postoperatively. Postoperative radiological parameters were significantly maintained at 1 year, and lumbar lordosis was maintained at the last follow-up (45.0 ± 26.7). In total 31 LLIF levels, bone fusion was observed in four levels at 6 months postoperatively, in 16 levels at 1 year, and in 23 levels at the last follow-up. The facet joint had the highest bony fusion location. LLIF within three levels can be safely performed in certain VFF cases with sufficient residual vertebral height.

Cumulative exposure to remnant cholesterol and the risk of fragility fractures: a longitudinal cohort study

Objective

To investigate the association between cumulative remnant cholesterol (cumRC) and the risk of new-onset fragility fractures.

Methods

This study included individuals who participated in the 2006, 2008, and 2010 Kailuan health examinations. Baseline characteristics were compared between groups according to cumRC quartiles. The incidence density was calculated, and the log-rank test was used to compare the cumulative incidence. Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI), and restricted cubic spline was used to examine the possibly non-linear relation between cumRC and the risk of fragility fractures. Additional analyses were performed with stratification by age (≥ or <65 years).

Results

A total of 43,839 individuals were included in this study. During the median follow-up period of 10.97 years, a total of 489 fragility fractures occurred. Multivariable Cox proportional hazards regression model 3 showed that the Q1 and Q4 groups versus the Q2 group were associated with a higher HR of fragility fracture (HR 1.61, 95% CI: 1.23-2.11; HR 1.38, 95% CI: 1.06-1.81), and restricted cubic spline regression analysis showed a non-linear relationship between cumRC level and the risk of fragility fractures (P Overall association < 0.001, P Non-linear association = 0.001). The association was significant in the age group <65 years but not in the age group ≥65 years. The sensitivity analyses were consistent with the main results.

Conclusions

Both too high and too low cumRC levels were associated with a greater risk of fragility fractures, and this association was more significant in young and middle-aged people.

Position Statement: Postmenopausal Osteoporosis Treatment Strategies in Korea

Classifying patients with osteoporosis according to fracture risk and establishing adequate treatment strategies is crucial to effectively treat osteoporosis. The Korean Society for Bone and Mineral Research has issued a position statement regarding appropriate treatment strategies for postmenopausal osteoporosis. According to previous fragility fracture history, bone mineral density (BMD) test results, fracture risk assessment tool, and several clinical risk factors, fracture risk groups are classified into low, moderate, high, and very-high-risk groups. In high-risk groups, bisphosphonates (BPs) and denosumab are recommended as first-line therapies. Sequential BP treatment after denosumab discontinuation is required to prevent the rebound phenomenon. In the very high-risk group, anabolic drugs (teriparatide or romosozumab) are recommended as a first-line therapy; sequential therapy with antiresorptive agents is required to maintain BMD gain and reduce fracture risk. Fracture risk was reassessed annually, and the treatment plan was determined based on the results, according to the osteoporosis treatment algorithm for fracture risk.

Prediction of Progressive Collapse in Osteoporotic Vertebral Fractures Using Conventional Statistics and Machine Learning

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to determine prognostic factors for the progression of osteoporotic vertebral fracture (OVF) following conservative treatment.

SUMMARY OF BACKGROUND DATA

Few studies have evaluated factors associated with progressive collapse (PC) of OVFs. Furthermore, machine learning has not been applied in this context.

MATERIALS AND METHODS

The study involved the PC and non-PC groups based on a compression rate of 15%. Clinical data, fracture site, OVF shape, Cobb angle, and anterior wedge angle of the fractured vertebra were evaluated. The presence of intravertebral cleft and the type of bone marrow signal change were analyzed using magnetic resonance imaging. Multivariate logistic regression analysis was performed to identify prognostic factors. In machine learning methods, decision tree and random forest models were used.

RESULTS

There were no significant differences in clinical data between the groups. The proportion of fracture shape ( P <0.001) and bone marrow signal change ( P =0.01) were significantly different between the groups. Moderate wedge shape was frequently observed in the non-PC group (31.7%), whereas the normative shape was most common in the PC group (54.7%). The Cobb angle and anterior wedge angle at diagnosis of OVFs were higher in the non-PC group (13.2±10.9, P =0.001; 14.3±6.6, P <0.001) than in the PC group (10.3±11.8, 10.4±5.5). The bone marrow signal change at the superior aspect of the vertebra was more frequently found in the PC group (42.5%) than in the non-PC group (34.9%). Machine learning revealed that vertebral shape at initial diagnosis was a main predictor of progressive vertebral collapse.

CONCLUSION

The initial shape of the vertebra and bone edema pattern on magnetic resonance imaging appear to be useful prognostic factors for progressive collapse in osteoporotic vertebral fractures.

Risk factors affecting hip fracture patterns in an elderly Korean patient population

Hip fracture in the elderly patient population, particularly the Korean patient cohort, is one of the most serious complications of osteoporosis and currently increasing alongside age. In this study, we attempted to identify various factors that could either indicate the risk for an intertrochanteric or femoral neck fracture in an osteoporotic Korean hip fracture patient cohort ≥ 65 years old. A retrospective analysis of 168 patients was performed for those who underwent surgical treatment for either an intertrochanteric or femoral neck fracture at Daegu Catholic University Medical Center from January 2013 to December 2015. Inclusion criteria included patients who sustained a intertrochanteric or femoral neck fracture between the designated time frame, ≥65 years old, and of Korean ethnicity. Differences between the T-score and Z-score regarding bone mineral density (BMD) and the relationship between BMD and subtype of the fracture for the intertrochanteric (n = 92) and femoral neck fracture (n = 76) groups were obtained. Demographical factors (age, sex, weight, height, and body mass index [BMI]) were analyzed as potential risk factors for intertrochanteric or femoral neck fractures using software. Of the total 168 patients, mean weight and BMI values were found to be lower in the intertrochanteric fracture group (P = .033) compared to the femoral neck fracture group (P = .044). Additionally, Z-scores for the intertrochanteric fracture group were lower in the trochanter (P = .030), intertrochanteric (P = .029), and Ward's triangle (P = .029) regions. Regarding the intertrochanteric fracture group, the A3 subgroup showed lower T-scores of the trochanteric region than the A1 fracture subgroup (P = .010). In an elderly Korean hip patient cohort, lower body weight, BMI, and BMD Z-scores are correlated with a higher incidence of intertrochanteric fractures when compared to femoral neck hip fractures.

The Korean hip fracture registry study

BACKGROUND

The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model.

METHODS

The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey.

DISCUSSION

KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants.

TRIAL REGISTRATION

Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).

Bioinformatics analysis combined with molecular dynamics simulation validation to elucidate the potential molecular mechanisms of Jianshen Decoction for treatment of osteoporotic fracture

Osteoporotic fracture (OPF) is a prevalent skeletal disease in the middle-aged and elderly. In clinical practice, Jianshen Decoction (JSD) has been used to treat OPFs. However, the specific effective components and mechanisms of JSD on OPF have not been explored. Therefore, this study used bioinformatics analysis combined with molecular dynamics simulation validation to explore the molecular mechanism of JSD treatment of OPF. Public databases (TCMSP, Batman TCM) were used to find the effective active components and corresponding target proteins of JSD (screening conditions: OB ≥ 30%, drug-likeness ≥ 0.18, half-life ≥ 4). Differentially expressed genes (DEGs) related to OPF lesions were obtained based on the gene expression omnibus database (screening conditions: adjust P value < .01, | log2 FC | ≥ 1.0). The BisoGenet plug-in and the CytoNCA plug-in of Cytoscape were used to derive the potential core target proteins of JSD in the treatment of OPF. The JSD active ingredient target interaction network and the JSD-OPF target protein core network were constructed using the Cytoscape software. In addition, the R language Bioconductor package and clusterProfiler package were used to perform gene ontology (GO)/Kyoto Encylopedia Of Genes And Genome (KEGG) enrichment analysis on core genes to explain the biological functions and signal pathways of core proteins. Finally, molecular docking and molecular dynamics simulations were carried out through PyMOL, AutoDockTools 1.5.6, Vina, LeDock, Discovery Studio (DS) 2019, and other software to verify the binding ability of drug active ingredients and core target proteins. A total of 245 targets and 70 active components were identified. Through protein-protein interaction (PPI) network construction, 39 core targets were selected for further research. GO/KEGG enrichment analysis showed that the DNA-binding transcription factor binding, RNA polymerase II-specific DNA-binding transcription factor binding, MAPK signaling pathway, and ErbB signaling pathway were mainly involved. The results of molecular docking and molecular dynamics simulations supported the good interaction between MYC protein and Quercetin/Stigmasterol. In this study, bioinformatics, molecular docking, and molecular dynamics simulations were used for the first time to clarify the active components, molecular targets, and key biological pathways of JSD in the treatment of OPF, providing a theoretical basis for further research.

Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review

Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem.

PURPOSE

Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries.

METHODS

We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures.

RESULTS

All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women.

CONCLUSION

Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.

Absolute Bed Rest Duration of 3 Days for Osteoporotic Vertebral Fractures: A Retrospective Study

STUDY DESIGN

Retrospective case-control study.

PURPOSE

To reduce unnecessary absolute bed rest (ABR), this study sought to determine the optimal aimed length of ABR in older patients getting conservative treatment for osteoporotic vertebral fractures (OVFs).

OVERVIEW OF LITERATURE

OVFs are quite common in elderly patients. ABR is a vital part of conservative treatment for OVFs, although the length of ABR may increase patient. No recommendations regarding how long ABR should last.

METHODS

This study was conducted in 134 patients with OVFs initially treated conservatively. The patients were split into two groups: 3-day and 7-day ABR. From the time of injury to 1, 4, and 12 weeks after injury, compression rate (CR) and local kyphotic angle (LKA) were assessed and compared between the two groups. Any complications such as pneumonia, deep vein thrombosis, delirium, and urinary tract infection known to be related to ABR were examined based on the electronic medical record.

RESULTS

Forty-four patients underwent ABR for 3 days and 90 underwent ABR for 7 days. There was no significant difference in CR and LKA between the two groups at the time of injury versus 1, 4, and 12 weeks after injury. The patients were divided into two groups: those who received a 3-day ABR and those who received a 7-day ABR. CR and LKA were measured and compared between the two groups from the time of damage to 1, 4, and 12 weeks after injury. The ABR-related complication rate was 43.4% in the 7-day ABR group and 22.7% in 3-day ABR group (p=0.02). The duration of hospital stay was significantly shorter in the 3-day ABR group (12.8 days) than in the 7-day group (16 days) (p=0.01).

CONCLUSIONS

Considering radiological outcomes, prognosis, complications, patient convenience, and economic impact, a 3-day ABR period is appropriate for the conservative treatment of OVFs.

Recommendations on the post-acute management of the osteoporotic fracture - Patients with "very-high" Re-fracture risk

Osteoporosis is a systemic skeletal disease where there is low bone mass and deterioration of bone microarchitecture, leading to an increased risk of a fragility fracture. The aim of this clinical guideline from Fragility Fracture Network Hong Kong SAR, is to provide evidence-based recommendations on the post-acute treatment of the osteoporotic fracture patient that presents for clinical care at the Fracture Liaison Service (FLS). It is now well established that the incidence of a second fracture is especially high after the first 2 years of the initial osteoporotic fracture. Therefore, the recent osteoporotic fracture should be categorized as “very-high” re-fracture risk. Due to the significant number of silent vertebral fractures in the elderly population, it is also recommended that vertebral fracture assessment (VFA) should be incorporated into FLS. This would have diagnostic and treatment implications for the osteoporotic fracture patient. The use of a potent anti-osteoporotic agent, and preferably an anabolic followed by an anti-resorptive agent should be considered, as larger improvements in BMD is strongly associated with a reduction in fractures. Managing other risk factors including falls and sarcopenia are imperative during rehabilitation and prevention of another fracture. Although of low incidence, one should remain vigilant of the atypical femoral fracture. The aging population is increasing worldwide, and it is expected that the treatment of osteoporotic fractures will be routine. The recommendations are anticipated to aid in the daily clinical practice for clinicians.

The Translational potential of this article

Fragility fractures have become a common encounter in clinical practise in the hospital setting. This article provides recommendations on the post-acute management of fragility fracture patients at the FLS.

Validation of Operational Definition to Identify Patients with Osteoporotic Hip Fractures in Administrative Claims Data

As incidences of osteoporotic hip fractures (OHFs) have increased, identifying OHFs has become important to establishing the medical guidelines for their management. This study was conducted to develop an operational definition to identify patients with OHFs using two diagnosis codes and eight procedure codes from health insurance claims data and to assess the operational definition’s validity through a chart review. The study extracted data on OHFs from 522 patients who underwent hip surgeries based on diagnosis codes. Orthopedic surgeons then reviewed these patients’ medical records and radiographs to identify those with true OHFs. The validities of nine different algorithms of operational definitions, developed using a combination of three levels of diagnosis codes and eight procedure codes, were assessed using various statistics. The developed operational definition showed an accuracy above 0.97 and an area under the receiver operating characteristic curve above 0.97, indicating excellent discriminative power. This study demonstrated that the operational definition that combines diagnosis and procedure codes shows a high validity in detecting OHFs and can be used as a valid tool to detect OHFs from big health claims data.

Operational Definition Identifying Osteoporotic Vertebral Fractures in the Claims Database

BACKGROUND

We analyzed the International Classification of Diseases, 10th edition (ICD-10) diagnostic codes, procedure codes, and radiographic image codes for vertebral fracture (VF) used in the database of Health Insurance Review and Assessment Service (HIRA) of Korea to establish a validated operational definition for identifying patients with osteoporotic VF in claims data.

METHODS

We developed three operational definitions for detecting VFs using 9 diagnostic codes, 5 procedure codes and 4 imaging codes. Medical records and radiographs of 2,819 patients, who had primary and subordinated codes of VF between January 2016 and December 2016 at two institutions, were reviewed to detect true vertebral fractures. We evaluated the sensitivity and positive predictive value (PPV) of the operational definition in detecting true osteoporotic VF and obtained the receiver operating characteristic (ROC) curve.

RESULTS

Among the 2,819 patients who had primary or secondary diagnosis codes for VF, 995 patients satisfied at least one of the criteria for the operational definition of osteoporotic VF. Of these patients, 594 were judged as having true fractures based on medical records and radiographic examinations. The sensitivity and PPV were 62.5 (95% confidence interval [CI], 59.4-65.6) and 59.7(95% CI, 56.6-62.8) respectively. In the receiver operating characteristic analysis, area under the curve (AUC) was 0.706 (95% CI, 0.688-0.724).

CONCLUSION

Our findings demonstrate the validity of our operational definitions to identify VFs more accurately using claims data. This algorithm to identify VF is likely to be useful in future studies for diagnosing osteoporotic VF.

Effects of the Revised Reimbursement Guideline for Anti-Osteoporosis Medication in South Korea

BACKGROUND

The Korean National Health Insurance (NHI) reimbursement guideline was revised in May 2015 with the aim of preventing secondary osteoporotic fractures. Here we compared the: (1) rate of bone mineral density (BMD) measurements; (2) prescription rate of anti-osteoporosis medication within 3 months after hip fracture surgery (HFS); (3) incidence of a second hip fracture; and (4) first-year mortality rate after HFS.

METHODS

This before-after study used the revised reimbursement system as a reference period. We retrospectively reviewed the medical records of 515 patients who underwent HFS at a tertiary referral hospital between January 2014 and December 2016. The period 1 group underwent HFS in 2014, while the period 2 group underwent HFS in 2016.

RESULTS

Despite the fact that there was no significant intergroup difference in BMD measurement rate, the period 2 group had a higher prescription rate for anti-osteoporosis drugs within 3 months of HFS. However, the incidence of a second hip fracture did not differ between groups. The first-year mortality rate was higher in the period 1 versus period 2 group.

CONCLUSIONS

Revision of the NHI guideline in May 2015 was associated with an increased prescription rate of anti-osteoporosis medication in osteoporotic hip fracture patients.

Osteosarcopenia—The Role of Dual-Energy X-ray Absorptiometry (DXA) in Diagnostics

Osteoporosis and sarcopenia lead to increased mortality, but their early diagnosis allows preventive measures and treatment to be implemented. The dual-energy X-ray absorptiometry (DXA) method enables the assessment of both bone mineral density (BMD) and bone quality based on the trabecular bone score (TBS), the Bone Strain Index (BSI), hip structure analysis (HSA), and comprehensive hip axis length (HAL). The main complications of osteoporosis are fractures, and a BMD value or T-score together with TBS can be also applied in fracture risk calculation using the Fracture Risk Assessment Tool (FRAX). In recent years, the interest in sarcopenia has increased. There are many methods for assessing the quality, quantity and function of muscles. Total body DXA provides information not only about the BMD of the whole skeleton or the amount of lean tissue (identified as fat-free mass), but also about the amount and distribution of adipose tissue. Some parameters obtained from DXA measurements related to muscle and/or fat mass are used in the assessment of osteosarcopenia. The following article presents a wide range of possibilities for the use of the DXA method in the diagnosis of osteosarcopenia because DXA is a useful technique for the diagnosis of bone density and body composition together.

Bone Mineral Density and Trabecular Bone Score in Predicting Vertebral Fractures in Male Employees of the Electricity Generating Authority of Thailand

Purpose

Osteoporotic VF is frequently asymptomatic and affects not only women but also men. Identifying patients at risk is essential for early management and prevention. BMD and the TBS are measurements of bone strength and trabecular microarchitecture, respectively. Their role in VF prediction in men is less well-studied. We determined the BMD and TBS predictive ability for osteoporotic VF in men.

Methods

A total of 115 male participants of the Electricity Generating Authority of Thailand (EGAT) cohorts without a history of VF who completed the baseline BMD and TBS measurements in 2012 and a thoracolumbar spine radiograph in 2017 were recruited. The VF was assessed using the Genant semiquantitative method. Logistic regression analysis was performed to identify factors associated with the fracture. The area under the receiving operator curve (AUC) was analyzed to define VF predictive ability.

Results

Forty subjects (34.78%) had VFs. The unadjusted relative risks (95% confidence interval) for VF for one standard deviation decrease in the TBS and low TBS were 1.319 (1.157-1.506) and 2.347 (1.496-3.682), respectively, and remained significant after BMD and age adjustment. For VF prediction, combined models had a greater AUC than models predicted from a single variable. The use of low TBS, femoral neck BMD, and age provided the best AUC (0.693).

Conclusion

BMD and the TBS could predict osteoporotic VF in male EGAT employees. The use of both BMD and the TBS in the VF prediction process improved predictive ability.

Age-Related Trends in Body Composition among Women Aged 20-80 Years: A Cross-Sectional Study

The determinants of body composition are likely to vary geographically due to the diversity of genetic and environmental factors between populations. Age-related trends in body composition in a population help understanding the health issues that are linked with different body compartments. In general, such studies are scarce in the South Asian region and this cross-sectional study examined the age-related trends in body composition in a selected group of healthy women aged 20-80 years in Sri Lanka. The study included randomly selected 784 healthy women aged 20-80 years from the Southern province, Sri Lanka. Women were divided into five age groups: 20-29 years (n = 79), 30-39 years (n = 144), 40-49 years (n = 185), 50-59 years (n = 281), and ≥60 years (n = 85). Total body bone mineral density (TBBMD, g/cm²), total body bone mineral content (TBBMC, g), total body fat mass (TBFM, kg), and total body lean mass (TBLM, kg) were measured with central-type dual-energy X-ray absorptiometry (DXA). Multivariate analysis of variance with Bonferroni post hoc test was performed. The age-related trends of TBBMD and TBBMC were similar with a peak in 40-49-year age group. Between 50 and 59 and ≥60 age categories, TBBMD and TBBMC showed a rapid decline: 16% and 23%, respectively. The rate of TBBMD decline was 0.008 g/cm² per year after 50 years. TBFM increased by 14% between age categories 20-29 and 40-49 years and remained unchanged after 49 years. TBLM increased by 15% between age groups 20-29 and 40-49 years and then decreased by 13% between age categories 50-59 and ≥60 years. Of the 13% decrease in TBLM after 50 years, 9% loss occurred after 59 years. The trends observed help to understand the occurrence of diseases linked with body composition.

Factors Associated with Mechanical Complications in Intertrochanteric Fracture Treated with Proximal Femoral Nail Antirotation

Purpose

Although proximal femoral nail antirotation (PFNA; Synthes, Switzerland) has demonstrated satisfactory results when used for the treatment of intertrochanteric fractures, mechanical complications may occur. To better quantify the risk of mechanical complications when proximal femoral nail antirotation is used to treat intertrochanteric fractures, this study aimed to: (1) characterize the frequency of mechanical complications and extent of blade sliding and their correlation with reduction quality and (2) identify factors associated with mechanical complications.

Materials and Methods

A review of medical records from 93 patients treated for intertrochanteric fractures with a minimum of 6-months of follow-up between February 2014 and February 2019 was conducted. Blade position was evaluated using Tip-apex distance (TAD) and Cleveland index. The extent of blade sliding was evaluated using the adjusted Doppelt's method for intramedullary nailing. Individuals were classified as having or not having mechanical complications, and reduction quality and radiologic outcomes were compared between the two groups.

Results

Mechanical complications occurred in 12 of 94 hips (12.8%), with 11 out of 12 being from the intramedullary reduction group. There was no significant difference in TAD between groups; however, there were significant differences were noted in Cleveland index, AO/OTA classification, reduction quality and extent of blade sliding. The mean blade sliding distance was 1.17 mm (anatomical group), 3.28 mm (extramedullary group), and 6.11 mm (intramedullary group), respectively (P<0.001). Data revealed that blade sliding was an associated factor for mechanical complications (odds ratio 1.25, 95% confidence interval 1.03–1.51).

Conclusion

The extent of blade sliding determined using the adjusted Doppelt's method was significantly associated with mechanical complications suggesting that prevention of excessive sliding through proper intraoperative reduction is important to help achieve satisfactory treatment outcomes.

Statin Therapy and the Risk of Osteoporotic Fractures in Patients with Metabolic Syndrome: a Nested Case-Control Study

OBJECTIVE

We aimed to investigate the association between statin use and the risk of major osteoporotic fractures in patients with metabolic syndrome (MetS).

METHODS

A nested case-control study was performed in patients with MetS (≥50 years) who had no history of osteoporotic fracture using the Korean National Health Insurance Service-Health Screening Cohort. This study included 17,041 patients diagnosed with new-onset osteoporotic fractures and controls matched in a 1:1 ratio by age, sex, body mass index, cohort entry date, and follow-up duration. Conditional logistic regression analysis was used to evaluate covariate-adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

During a 4-year follow-up period, the risk of major osteoporotic fractures was significantly reduced by 9% (OR, 0.91; 95% CI, 0.85-0.97) in statin users compared with that in non-users. Among subtypes of major osteoporotic fracture, a risk reduction with statin therapy was significant for vertebral fracture (OR, 0.86; 95% CI, 0.79-0.94) but not for non-vertebral fracture (OR, 0.97; 95% CI, 0.88-1.06). Longer duration (OR, 0.97; 95% CI, 0.96-0.99, per 1-year increase) and higher cumulative dose (OR, 0.97; 95% CI, 0.95-0.99, per 365 defined daily doses) of statins were negatively associated with the risk of major osteoporotic fracture.

CONCLUSION

This study supports the hypothesis that statin therapy has a beneficial effect on major osteoporotic fractures, especially vertebral fractures, in patients with MetS.

Estimating the future clinical and economic benefits of improving osteoporosis diagnosis and treatment among women in South Korea: a simulation projection model from 2020 to 2040

Using a microsimulation model, the impact of increased diagnosis and treatment of postmenopausal women with osteoporosis on anticipated reduction in fractures and associated costs in South Korea from 2020 to 2040 was projected.

INTRODUCTION

The economic burden of osteoporosis was US $5.1B in 2011 in South Korea. Osteoporosis is expected to strain resources in South Korea as the population most susceptible to osteoporotic fracture, females > 50 years old, is projected to increase by 32% from 2020 to 2040.

METHODS

A microsimulation model was developed to project annual incidence and costs of osteoporotic fractures among postmenopausal women from 2020 to 2040. Fracture risk was estimated using the simplified Fracture Risk Assessment Tool (FRAX). The fracture estimates were based on annualized FRAX risk and impact of treatment. Korean National Health Insurance data informed treatment and case-finding rates in the reference case. Two scenarios were evaluated: 50% increases to (i) case finding (screening rate and subsequent treatment rate) and (ii) treatment rate among those at highest risk.

RESULTS

Among individuals modeled in the reference case from 2020 to 2040, 41.2 M fractures at a cost of US $263.6B were projected. Increased treatment scenario prevented 4.4 M fractures and saved US $13.5B. Increased case-finding scenario prevented 4.0 M fractures and saved US $11.1B.

CONCLUSION

Implementation of policies to enable increasing case finding or treatment may result in fewer fractures and substantial cost savings across the healthcare system. These results highlight the importance of early screening, diagnosis, and preventive treatment.

Intravenous bisphosphonate therapy does not delay fracture healing in inter-trochanteric femur fractures - A randomised controlled study

Hip fractures in elderly are commonly associated with osteoporosis and surgical outcome is influenced by its concurrent management. The purpose of our study is to determine the association between timing of bisphosphonate administration in inter-trochanteric (IT) fractures and fracture healing. Patients with IT fractures (aged≥50 years) and T-score ≤ -1.5 [WHO defines osteopenia as T-score between -1 and -2.5, and osteoporosis as T-score ≤ -2.5 on DEXA scan (which was obtained post-operatively in our cohort)], who underwent proximal femoral nailing were included. Patients were divided into three groups: group 1a-intravenous bisphosphonate {ivBP [zoledronic acid (ZA)]} given within one week, group 1b-ZA at six weeks and group 2-control group. Post-operative radiographs were assessed for reduction parameters [neck-shaft angle, tip-apex distance, reduction variance]. Radiological union was determined using RUSH score and functional outcome (at one year) with Modified Harris Hip Scores. 41 (23 males), 40 (15 males) and 42 (15 males) patients were included in groups 1a, 1b and 2, respectively (no statistical difference in sex distribution among the groups; p = 0.12). Mean age in groups 1a, 1b and 2 was 71.8 ± 8.1, 75.9 ± 8.5 and 72.3 ± 10.6 years (p = 0.09). There was no significant difference in the pattern of injuries (AO classification) among the groups (p = 0.72). Mean time to union in groups 1a, 1b and 2 was 13.7,13.7 and 14.2 weeks, respectively (p = 0.69). Mean time to union in AO types A1, A2 and A3 fractures was 13.2 ± 2.1, 13.7 ± 2.8 and 16.1 ± 4.9 weeks (p = 0.01). We did not observe any association between T-scores and fracture union (hip:p = 0.52, spine:p = 0.93).The functional outcome was similar among groups (p = 0.96). Early administration of ZA did not negatively influence fracture healing in patients undergoing fixation of IT fractures. Among the various other factors analyzed, there was a statistically significant association between the fracture type (AO type A3) and longer time to fracture union.

Measures of physical performance as a predictor of fracture risk independent of BMD: The Chungju metabolic disease cohort study

BACKGROUND

Bone mineral density (BMD) assessments alone might not be sufficient for assessing fracture risk in the whole population, and decreased balance is an important risk factor for fracture. The aim of this study was to evaluate the association between baseline physical performance and fracture risk.

METHODS

This community-based cohort study was conducted in rural areas. The follow-up examination was performed in 4015 subjects for approximately 4 years. We used the one-leg standing time (OLST) to assess static balance and the timed up-and-go test (TUGT) to assess dynamic balance. Fractures were assessed during the medical interview.

RESULTS

The participants were divided into quartile groups according to their performance level, and the lowest baseline OLST performance was associated with a 2.1-fold increased risk of major osteoporotic fracture (MOF) independent of age, gender, hip BMD, fall incidence, and lifestyle factors. The participants in the low performance quartile of baseline OLST or TUGT performance had an increased incidence of osteoporosis and falling compared to that in the participants in the highest baseline performance quartile after adjusting for covariates. Among the participants with a femoral neck T-score above -2.5, the participants with an OLST below 14 s had a 1.7-fold higher risk of MOF than the participants with an OLST of 14 s or more.

CONCLUSIONS

The measurement of static balance by the OLST predicted the risk of fracture in Korean adults independent of BMD and fall history. Our results suggest that the OLST may have clinical utility in identifying individuals at risk of fracture, especially those who might not be adequately identified by BMD measurements alone.

Characteristics of Osteoporosis & Osteoporotic Fractures in Korea Based on Health Insurance Review and Assessment (HIRA) Database: 2009-2017

To investigate the incidence and characteristics of osteoporosis and osteoporotic fractures in Korea, we used the Health Insurance Review and Assessment Service (HIRA) database. Patients over 50 years old, who were diagnosed or treated for osteoporosis and osteoporotic fractures in all hospitals and clinics, were analyzed between 1 January 2009 and 31 December 2017 by using the HIRA database that contains prescription data and diagnostic codes. These data were retrospectively analyzed by decade and age-specific and gender-specific incidents in each year. We also evaluated other characteristics of patients including medication state of osteoporosis, primary used medical institution, regional-specific incidence of osteoporosis, and incidence of site-specific osteoporotic fractures. The number of osteoporosis patients over 50 years old, as diagnosed by a doctor, steadily increased from 2009 to 2017. The number of osteoporosis patients was notably greatest in the 60's and 70's age groups in every study period. Patients undergoing treatment for osteoporosis increased significantly (96%) from 2009 to 2017. Among the patients diagnosed with osteoporosis, the proportion who experienced osteoporotic fracture increased gradually (60%) from 2009 to 2017. The number of patients with osteoporotic fractures of the spine and hip was highest in the 70 to 90 age range, and the number of patients with osteoporotic fractures in the upper and lower extremities was highest in the 50 to 70 age range. Understanding the trends of osteoporosis in Korea will contribute to manage the increased number of patients with osteoporosis and osteoporotic fractures.

FRAX score with and without bone mineral density: a comparison and factors affecting the discordance in osteoporosis treatment in Thais

We investigate the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD. We found that predictions were concordant in 83.8% of patients. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD.

INTRODUCTION

The Fracture Risk Assessment Tool (FRAX) is used to calculate the 10-year probability of fracture using important clinical factors, with bone mineral density (BMD) as an optional input variable. We aimed to determine the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD and to identify relevant clinical risk factors associated with discordance.

METHODS

This was a cross-sectional study conducted in patients between 40 and 90 years of age who were screened for osteoporosis by BMD measurement using dual energy X-ray absorptiometry (DXA) from 2010 to 2018 at a university hospital in Thailand. A FRAX questionnaire was administered to determine demographic data and osteoporotic risk factors. FRAX scores with and without BMD were calculated for each participant using the Thai reference, and patients were categorized into either the treatment or non-treatment group based on a cut-off of 3% 10-year probability of hip fracture. When FRAX scores with and without BMD results were consistent, they were considered concordant. Otherwise, they were deemed discordant. Clinical risk factors were compared between the concordant and discordant groups.

RESULTS

A total of 3545 participants were included in the study. The majority (83.8%) were in the concordant group. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were significantly associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD.

CONCLUSION

FRAX scores with and without BMD yielded concordant predictions regarding the 10-year probability of hip fracture suggesting pharmacological treatment. However, this concordance declined in elderly and osteoporotic participants and in those with FRAX without BMD around intervention threshold. BMD data may be required in these populations in order to facilitate accurate risk assessment.

Osteoporotic Fractures of the Spine, Hip, and Other Locations after Adjuvant Endocrine Therapy with Aromatase Inhibitors in Breast Cancer Patients: a Meta-analysis

BACKGROUND

Aromatase inhibitors (AIs) play an important role in the endocrine therapy of postmenopausal breast cancer patients, with a recent tendency to extend the duration of their use. However, AIs may increase the risk of osteoporotic bone fractures. This meta-analysis evaluated the risk of osteoporotic fractures of the hip, spine, and other locations in breast cancer patients using AIs.

METHODS

We performed a systematic search to identify randomized controlled clinical trials that investigated osteoporotic fractures in breast cancer patients on AI therapy. The main outcomes were the incidence and risk of osteoporotic fractures in general and of hip, vertebral, and non-vertebral fractures in AI users and controls.

RESULTS

The systematic review found a total of 30 randomized controlled trials including 117,974 participants. The meta-analysis showed a higher incidence of osteoporotic fracture in AI users: The crude risk ratio for all osteoporotic fractures was 1.35 (95% confidence interval [CI], 1.29-1.42; P < 0.001), for hip fractures 1.18 (95% CI, 1.02-1.35; P < 0.001), for vertebral fractures 1.84 (95% CI, 1.36-2.49; P < 0.001), and for non-vertebral fractures 1.18 (95% CI, 1.02-1.35; P < 0.001), respectively, compared to the controls.

CONCLUSION

Our meta-analysis suggested an increased risk of osteoporotic fractures for AI therapy in patients with breast cancer that was most expressed for vertebral fractures. Breast cancer patients on AIs need to be monitored for osteoporosis and osteoporotic fractures, and active prevention measures should be implemented.

Traumatic fractures in China from 2012 to 2014: a National Survey of 512,187 individuals

The China National Fracture Study has been conducted to provide a national dataset of traumatic fractures across China. A national representative sample of 512,187 individuals was selected. The population-weighted incidence rates, distribution, injury mechanisms, and risk factors for traumatic fractures were identified for various groups of individuals.

INTRODUCTION

The China National Fracture Study (CNFS) has been conducted to provide a comprehensive and up-to-date national dataset of traumatic fractures across China. This study aims to report the national incidences and distributions of traumatic fractures that occurred in 2012, 2013, and 2014 and to analyze the risk factors.

METHODS

A national representative sample of individuals was selected from 24 rural counties and 24 urban cities of 8 provinces using stratified random sampling and the probability proportional to size (PPS) methodology. Participants were interviewed to identify whether they sustained traumatic fractures of the trunk and/or four extremities that had occurred in 2012, 2013, and 2014. The main risk factors associated with traumatic fractures were analyzed by multiple logistic regression models.

RESULTS

A total of 512,187 individuals, including 259,649 males and 252,538 females, participated in the CNFS. The population-weighted incidence rates of traumatic fractures in China were calculated to be 2.5 (95% CI, 2.2-2.8) per 1000 population in 2012, 2.8 (95% CI, 2.5-3.3) in 2013, and 3.2% (95% CI, 2.8-3.6) in 2014. The population-weighted incidence rates of fragility fractures among participants aged 65 years and older were calculated to be 27.4 (95% CI, 21.4-33.4) per 1000 population in 2012, 36.0 (95% CI, 28.6-43.5) in 2013, and 42.4 (95% CI, 34.9-49.9) in 2014. The most common cause of fracture was low-energy injuries, followed by traffic accidents. For all age groups, sleeping less than 7 h was a risk factor for traumatic fractures. Alcohol consumption and previous fracture history were identified as risk factors for adults aged 15 years and over. Cigarette smoking was found to be a risk factor for males aged 15-64 years old. For individuals aged 15-64 years old, underweight incurred a risk effect for males and overweight for females. Alcohol consumption, sleeping less than 7 h per day, living in the central and eastern regions, a body mass index less of than 18.5, and having a previous fracture history were identified as strong risk factors for fragility fractures.

CONCLUSION

The national incidence, distribution, and injury mechanisms for traumatic fractures were revealed in the CNFS. Risk factors were identified for various groups of individuals.

[Short-term effectiveness comparison of unipedicular versus bipedicular percutaneous kyphoplasty for osteoporotic vertebral compression fractures with posterior wall broken]

Objective

To compare the short-term effectiveness and safety of unipedicular versus bipedicular percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fracture (OVCF) with posterior wall broken.

Methods

The clinical data of 68 patients with OVCF with posterior wall broken and without posterior ligament complex injury and spinal cord nerve injury between June 2013 and December 2018 were retrospectively analyzed. According to the different operative approaches, the patients were divided into two groups: group A (36 cases received PKP via bilateral pedicle puncture) and group B (32 cases received PKP via unilateral pedicle paracentesis). There was no significant difference between the two groups in gender, age, fracture vertebra distribution, time from injury to operation, preoperative pain visual analogue scale (VAS) score, Oswestry disability index (ODI), and height of injured vertebra ( P>0.05). The operation time, intraoperative fluoroscopy times, and bone cement volume were recorded and compared between the two groups. The VAS score and ODI score were used to evaluate the effectiveness before operation, at 1 day and 6 months after operation; the height of injured vertebra was measured on the lateral X-ray film, and the recovery height of injured vertebra at 1 day after operation and the loss height of injured vertebra at 6 months after operation were calculated; the intraoperative and postoperative complications of the two groups were recorded.

Results

The operation time, intraoperative fluoroscopy times, and bone cement volume of group B were significantly less than those of group A ( P<0.05). All patients were followed up 10-35 months, with an average of 18 months. During the operation, there were 2 cases (5.56%) of cement leakage in group A and 9 cases (28.13%) in group B, showing significant difference ( χ ²=4.808, P=0.028). There was no adverse reactions of bone cement, iatrogenic spinal cord injury, infection of puncture port, or other complications in the two groups. During the follow-up period, there were 3 cases (8.3%) of adjacent vertebral fractures in group A and 2 cases (6.3%) in group B, showing no significant difference between the two groups ( χ ²=0.027, P=0.869). The height of injured vertebra of the two groups at 1 day and 6 months after operation were significantly improved when compared with preoperative ones ( P<0.05). There was no significant difference in the height of injured vertebrae and the recovery height of injured vertebra at 1 day after operation between the two groups ( P>0.05). However, at 6 months after operation, the height of injured vertebra in group B was significantly lower than that in group A ( P<0.05), and the loss height of injured vertebra in group B was significantly higher than that in group A ( P<0.05). The VAS score and ODI score at 1 day and 6 months after operation were significantly improved when compared with preoperative ones in both groups ( P<0.05), but there was no significant difference between the two groups ( P>0.05).

Conclusion

Both bipedicular and unipedicular PKP can obtain satisfactory effectiveness for the treatment of OVCF with posterior wall broken, but the former may have advantages of lower cement leakage rate and less height loss.

Physicians' Attitudes on Management of Osteopenia in South Korea

Background

Osteopenia patients have a risk of fracture and may develop osteoporosis. We investigated physicians’ management of osteopenia patients in South Korea.

Methods

A survey was conducted using a questionnaire including 6 items: (1) do you think anti-osteoporosis medications are necessary in osteopenia patients?; (2) what is your preference to manage osteopenia patients, except for anti-osteoporosis medications?; (3) what is your indication for the anti-osteoporosis medication in osteopenia patients?; (4) what kind of anti-osteoporosis medication do you prefer to treat osteopenia patients?; (5) do you use bisphosphonates?; and (6) if not, what is the reason for not using?.

Results

Among the 173 participants, 150 (86.7%) replied that anti-osteoporosis medications were necessary in osteopenia patients. Indications for the medication were (1) past medical history of pathologic fracture in 85 (49.1%); (2) T-score <-2.5 on dual energy X-ray absorptiometry in 73 (42.2%); (3) previous history of osteoporosis in 44 (25.4%); (4) risk of fracture according to fracture risk assessment tool in 34 (19.7%); and (5) progressive bone loss in 31 (17.9%). One hundred and sixteen (67.1%) favored bisphosphonates, 93 (53.8%) selective estrogen-receptor modulator, and 24 (13.9%) hormone replacement therapy. Thirty-one (17.9%) replied that they do not use bisphosphonates due to (1) restricted reimbursement by the health insurance in 24 (77.4%); and (2) bisphosphonate-related complications in 19 (61.3%).

Conclusions

Most respondents (86.7%) thought anti-osteoporosis medications were necessary in osteopenia patients, but 17.9% of the respondents did not use bisphosphonates. Restricted reimbursement by the national health insurance was the major obstacle against the use of bisphosphonates.

Risk Factors for Severe Proximal Humerus Fracture and Correlation Between Deltoid Tuberosity Index and Bone Mineral Density

Introduction:

The aims of this study were to investigate (1) whether demographic factors would be risk factors for severe proximal humerus fracture (PHF), (2) relationship of radiological parameters with bone mineral density (BMD), deltoid tuberosity index (DTI), or severe PHF, and (3) correlation between DTI and BMD.

Methods:

We conducted a cross-sectional study based on radiographs and medical records taken during admission or the visit to the orthopedic clinic. We reviewed consecutive 100 adult patients who were diagnosed with PHF in our hospital from March 2014 to December 2016. Three- and 4-part fractures were regarded as severe PHFs. Univariable and multivariable logistic regression analyses were performed to evaluate risk factors for severe PHF. Also, we investigated the correlation between BMD and DTI using the additional BMD data of the patients who underwent shoulder surgeries.

Results:

This study included 62 nonsevere PHFs and 38 severe PHFs. There were 30 male and 70 female patients with a mean age of 66.4 ± 16.4 years. Mean T score of BMD was −2.5 ± 0.9 at the time of injury. Logistic regression analyses showed that age (odds ratio: 1.044, range: 1.011-1.079, P = .009) and sex (odds ratio of females: 3.763, range: 1.236-11.459, P = .020) were related to severe PHF. The group satisfying the radiological parameter criteria had significantly higher rates of severe PHF. The correlation coefficient (r) between DTI and T score was 0.555 (P < .001).

Discussion and Conclusion:

Older age and female were the independent risk factors for severe PHF. Conversely, BMD and other medical comorbidities were not risk factors for severe PHF. Deltoid tuberosity index showed significantly high intraclass correlation coefficient and a strong correlation with the T score of BMD. Therefore, DTI may be useful for screening osteoporosis in PHF patients.

Level of Evidence:

Level IV, Cross-sectional study.

A Combination Treatment of Raloxifene and Vitamin D Enhances Bone-to-Tendon Healing of the Rotator Cuff in a Rat Model

BACKGROUND

Tearing and degeneration of the rotator cuff at the tendon-to-bone junction are common in adults aged ≥50 years. Few studies have reported on the relationship between estrogen and the rotator cuff enthesis. In addition to preventing bone loss, selective estrogen receptor modulators have been shown to improve tendon and muscle quality.

PURPOSE

To evaluate the effects of raloxifene (RLX) and vitamin D on rotator cuff tendon-to-bone healing in a rat model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 29 female rats (58 shoulders) were assigned to 4 groups: (1) control group, (2) ovariectomy (OVX)-only group, (3) no RLX group (OVX and rotator cuff repair [RCR]), and (4) RLX group (OVX, RCR, and RLX). Rats that did not undergo rotator cuff tear (RCT) surgery were divided into the control and OVX-only groups according to OVX surgery. Rats that underwent RCT surgery and RCR were divided into the no RLX and RLX groups according to RLX and vitamin D administration. An estrogen-deficient state was induced by OVX at 12 weeks of age. Bone mineral density (BMD) and trabecular bone characteristics were measured by micro-computed tomography, and healing of the tendon-to-bone junction was evaluated by biomechanical testing, histomorphometry, and micro-magnetic resonance imaging (MRI).

RESULTS

The mean final body weight (BW; 461.6 ± 47.3 g) of the OVX-only group was significantly higher and BMD (0.25 ± 0.07 g/cm³) was significantly lower (P < .001) than the mean final BW (338.5 ± 35.1 g) and BMD (0.48 ± 0.05 g/cm³) of the control group. In contrast, the RLX group showed that the BW (369.6 ± 35.8 g) and BMD (0.41 ± 0.08 g/cm³) were not significantly different from the control group. The RLX group had a significantly higher histomorphometric total score (8.50 ± 1.05) than the no RLX group (4.83 ± 2.48). On biomechanical testing, the RLX group (29.7 ± 9.1 N) showed a significantly higher load to failure than the no RLX group (19.4 ± 8.8 N). On micro-MRI, the RLX group had a more homogeneous low signal and tendon continuity than the no RLX group.

CONCLUSION

The combination treatment of RLX and vitamin D prevented a decrease in local BMD (greater tuberosity of the proximal humerus) and enhanced tendon-to-bone healing of the rotator cuff in a rat model.

CLINICAL RELEVANCE

This study induced an estrogen-deficient state similar to the human postmenopausal state and used drugs that are actually being prescribed in a clinical situation.

Impact of Bone Mineral Density on the Incidence of Age-Related Vertebral Fragility Fracture

BACKGROUND

Vertebral fragility fracture (VFF) is a common fracture related to osteoporosis. However, VFF might be asymptomatic and often occurs in patients without osteoporosis. Therefore, we investigated the characteristics of age-related VFF and their correlation with bone mineral density (BMD). Furthermore, we analyzed other factors affecting VFF.

METHODS

Medical records from a single center were retrospectively reviewed for 2,216 patients over 50 years old with vertebral fractures conservatively treated from 2005 to 2016. Patients' age, gender, body mass index (BMI), BMD, fracture level, previous vertebral fractures, and anti-osteoporosis medications were obtained. Patients were divided into fragility/non-fragility groups and age sub-groups. The odds ratio for VFF in relation to BMD was evaluated. We also identified other predictive factors for VFF by age groups.

RESULTS

The fragility group had a higher women ratio, older age, lower BMI, lower BMD, and greater incidence of previous vertebral fractures than the non-fragility group. VFFs were seen in 41.18% of normal BMD patients aged 50-59 and 67.82% of those aged 60-69. The proportion of VFFs increased with age in all WHO osteoporosis classifications. Patients with osteopenia and osteoporosis were 1.57 and 2.62 fold more likely to develop VFFs than normal BMD. In the younger group (under 70), age, women, BMD, and previous vertebral fracture were significant factors affecting VFF, and in the older group (70 and over), age, women, and BMD were factors. In the fragility group, anti-osteoporosis medication rates were 25.08% before and 45.96% after fracture.

CONCLUSION

Considerable VFFs occurred in the younger age groups without osteoporosis and age itself was another important predictor of VFF especially in older age groups. The discrepancy between the incidence of VFF and BMD suggests the necessity of supplemental screening factors and anti-osteoporosis treatment guidelines using only BMD should be reconsidered.

Alarm Services as a Useful Tool for Diagnosis and Management of Osteoporosis in Patients with Hip Fractures: A Prospective Observational Multicenter Study

Background

Alarm services in the Order Communication System improve awareness for related physicians including orthopaedic surgeons, internal medicine doctors, and other relevent doctors. This prospective observational multicenter study was to compare the diagnostic and treatment rates of osteoporosis between an alarm service group and a no alarm service group.

Methods

From January 2017 to december 2017, The subjects included patients aged 50 years or older with hip fractures from 16 hospital-based multicenter cohorts. Among the 16 hospitals, 5 university hospitals established an alarm service for osteoporosis management (i.e., Alarm group) and 11 university hospitals did not set-up alarm services (i.e., Control group). The rate of dual energy X-ray absorptiometry (DXA) test and the initiation rate of antiosteoporosis medications between the 2 groups were compared at enrollment and at 6 months follow-up.

Results

During the study period, 1,405 patients were enrolled. The DXA examination rate and initiation rate of osteoporosis treatment between the Alarm group and the Control group were 484 patients (89.8%) vs. 642 patients (74.1%) (P<0.001) and 355 patients (65.9%) versus 294 patients (33.9%) (P<0.001), respectively. At 6 months follow-up, the rate of anti-osteoporosis management between the 2 groups decreased (57.8% vs. 29.4%).

Conclusions

This prospective multicenter study demonstrates that alarm services can improve awareness of physicians, and it resulted in a significantly higher rate of examination of DXA and initiation of anti-osteoporosis medication in the Alram group. Therefore, alarm service is a simple and effective tool to increase anti-osteoporosis management as part of the fractuure liaison service in South Korea.

Clinical Characteristics of Primary and Secondary Osteoporotic Fractures: Data from Single Referral Center Emergency Department

Background

To investigate the characteristics of patients with osteoporotic fractures (OF) who visited the emergency room, we analyzed the frequency and distribution of primary and secondary OF.

Methods

From March 2015 to April 2017, 406 patients with OF were assigned to wrist (W; n=132), spine (S; n=78), and hip (H; n=196) according to the site. All subjects were classified as having primary fracture or secondary fracture. Age, fracture site, the risk of future fracture using Fracture Risk Assessment Tool (FRAX) were compared.

Results

The mean age at fracture site was significantly different among the 3 groups, groups W (66.57±10.03), S (73.50±9.07), and H (78.50±7.72). The most common site of OF were in the order of wrist, spine, and hip with the increase of age. The FRAX scores significantly increased (P<0.001) in the order of W (8.35±5.67), S (10.74±6.99), and H (13.88±7.98) in total patient, and same in primary fracture group (W, 7.50±4.18; S, 9.76±5.91; H, 11.93±6.61; P<0.001). The main site of prior fractures in secondary fracture was same lesion, which means that the prior fracture of secondary wrist fracture was wrist fracture such as spine for spine, hip for hip.

Conclusions

We determined that as age increasing, the major sites of OF were different and FRAX scores increased. The most common site for secondary fracture was the same one. Hence, the risk of subsequent fracture in same site should be noted after patient suffered OF.

Trends in the Diagnosis of Osteoporosis in Patients with Distal Radius Fractures Based on a National Claims Database

Background

A history of osteoporotic fractures is strongly associated with the subsequent osteoporotic fractures. To prevent subsequent fractures, the diagnosis and treatment of osteoporosis following osteoporotic fractures are very important. A distal radius fracture (DRF) is the second most common type of osteoporotic fracture in South Korea. We analyzed the rate of osteoporosis diagnosis within 6 months post-DRF.

Methods

We used data from the Korean Health Insurance Review and Assessment Service nationwide claims database from 2010 to 2016. International Classification of Diseases, 10th revision codes and procedures codes were used to identify patients aged over 50 years with newly diagnosed DRFs; the osteoporosis assessments of these patients were then analyzed. We used Cochran-Armitage trend test to examine trends in osteoporosis diagnosis.

Results

A search of database identified 77,209 DRFs in patient aged above 50 years of age from 2011 to 2016. Among these patients, only 19,305 (25.0%) underwent diagnostic examination for osteoporosis. The number of osteoporosis examinations increased slightly, but not significantly, every year (P=0.061).

Conclusions

Clinicians who treat DRFs shoulder also evaluated patients for osteoporosis after DRFs.

Bisphosphonates for Secondary Prevention of Osteoporotic Fractures: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

PURPOSE

To investigate the comparative efficacies of the five most commonly used bisphosphonates for the secondary prevention of osteoporotic fractures in a Bayesian network meta-analysis.

METHODS

Five databases and the reference lists of all acquired articles from inception to July 2017 were searched. A Bayesian random-effects model was employed, and vertebral, hip and nonvertebral nonhip fractures were assessed by odds ratios (ORs) and 95%credible intervals. Furthermore, with respect to each endpoint, rank probabilities for each bisphosphonate were evaluated using the surface under the cumulative ranking curve (SUCRA) value.

RESULTS

Thirteen eligible studies were identified involving 11,822 patients with osteoporotic fractures. Overall in the pairwise meta-analyses, bisphosphonate use significantly reduced the risk of new vertebral, hip, and nonvertebral nonhip fractures, with ORs and 95% confidence intervals of 0.56 (0.49-0.64), 0.69 (0.48-0.98), and 0.82 (0.70-0.97), respectively. In network meta-analyses, significant differences were found between placebo and any one of the five bisphosphonates for new vertebral fractures. The rank probability plot and the SUCRA calculation results suggested that alendronate was the best intervention (14.6%) for secondary prevention of vertebral fractures, followed by zoledronate (15.3%) and etidronate (22.1%). In terms of the incidence of new hip fractures, alendronate was associated with the lowest incidence (18.5%), followed by zoledronate (43.1%) and risedronate (52.5%). However, zoledronate ranked lowest (16.6%) regarding the incidence of new nonvertebral nonhip fractures, followed by risedronate (23.8%) and alendronate (44.1%).

CONCLUSIONS

Bisphosphonates show significant efficacy for secondary prevention of new vertebral fractures, and alendronate is most likely to be successful at secondary prevention of vertebral and hip fractures compared with the other four bisphosphonates.

Elevated ceramides 18:0 and 24:1 with aging are associated with hip fracture risk through increased bone resorption

We assessed whether circulating ceramides, which play a role in a number of degenerative changes with aging, significantly differed according to fragility hip fracture (HF) status. We also performed a human study using bone marrow (BM) aspirates, directly reflecting the bone microenvironment, in addition to in vitro experiments. Peripheral blood and BM samples were simultaneously collected from 74 patients 65 years or older at hip surgery for either HF (n = 28) or for other causes (n = 46). Ceramides were measured by liquid chromatography-tandem mass spectrometry. Age was correlated positively with circulating C16:0, C18:0, and C24:1 ceramide levels. Patients with fragility HF had 21.3%, 49.5%, 34.3%, and 22.5% higher plasma C16:0, C18:0, C18:1, and C24:1 ceramide levels, respectively, than those without HF. Higher C16:0, C18:0, C18:1, and C24:1 ceramide levels were positively related to bone resorption markers in both blood and BM samples. Furthermore, in vitro studies showed that C18:0 and C24:1 ceramides directly increased osteoclastogenesis, bone resorption, and expression levels of osteoclast differentiation markers. These results suggested that the association of increased ceramides, especially C18:0 and C24:1, with adverse bone phenotypes in elderly people could be explained mainly by the increase in osteoclastogenesis and bone resorption.

[Influence of specific osteoporosis drugs on fracture healing]

BACKGROUND

For the treatment of disturbed fracture healing, drugs could be given in addition to surgical procedures. Specific osteoporosis drugs affect the bone metabolism and are used to treat osteoporosis, particularly after a fragility fracture has occurred. Therefore, their use would be conceivable to improve a disturbed fracture healing.

OBJECTIVE

This article presents the available and upcoming specific osteoporosis drugs and investigates whether these substances affect fracture healing in the context of osteoporosis. Furthermore, it is discussed whether disturbed fracture healing can be improved by the use of these substances.

MATERIAL AND METHODS

A literature search (PubMed) was conducted using key terms. Preclinical studies, clinical studies, reviews and meta-analyses were considered in order to present the current knowledge in a clinically relevant context.

RESULTS

Preclinical and clinical studies show that specific osteoporosis drugs have no relevant negative impact on the healing of fragility fractures. A tendency to improve a disturbed fracture healing was attributed to bone anabolic substances; however, studies are inconsistent and there is no approval for this application.

CONCLUSION

Following a fragility fracture, osteoporosis should be diagnosed according to the guidelines and, if necessary, treated with specific osteoporosis drugs, since in principle they do not impair fracture healing but significantly reduce the risk of subsequent fractures. Approval to improve fracture healing requires further investigations.

COL1A1, CCDC170, and ESR1 single nucleotide polymorphisms associated with distal radius fracture in postmenopausal Mexican women

Objective: The aim of this study was to analyze the genetic association of five ESR1 single nucleotide polymorphisms (SNPs) (rs3020331, rs851982, rs1999805, rs2234693, rs3020404), four COL1A1 SNPs (rs1800012, rs2075555, rs2412298, rs1107946), and two SNPs on the CCDC170 gene (rs9479055, rs4870044) with distal radius fracture (DRF) in a group of postmenopausal Mexican women.Methods: A case-control study was conducted. Cases (n = 182) were women above the age of 38 years with low-energy DRF, and controls (n = 201) were women without. Analysis was done through real-time polymerase chain reaction. Frequencies and Hardy-Weinberg equilibrium were calculated. A multivariate analysis including bone mass index, age, menarche, and menopause as covariables was carried out. Finally, haplotype and linkage disequilibrium (LD) analyses were performed.Results: COL1A1 rs1107946 was strongly associated with DRF. Both CCDC170 SNPs showed strong association with DRF. For the ESR1 gene, four SNPs (rs2234693, 3020404, rs3020331, and rs851982) showed very strong association with DRF. Additionally, the region between the latter two showed strong LD.Conclusions: A strong association of DRF with variants in these genes was found, including haplotypes and a region with strong LD on ESR1. The results suggest that these SNPs could be useful to detect the population at risk of presenting DRF among Mexican perimenopausal women.

The Detrimental Effects of Kynurenine, a Tryptophan Metabolite, on Human Bone Metabolism

CONTEXT

Studies in aged mice support a role for kynurenine, a tryptophan metabolite, in age-induced bone loss; however, the role of kynurenine in human bone metabolism is not well understood.

OBJECTIVE

To assess whether the kynurenine level in bone marrow (BM) aspirates, directly reflecting the bone microenvironment, is associated with osteoporosis-related phenotypes and bone biochemical markers.

DESIGN AND SETTING

A case-control study conducted in a clinical unit.

PARTICIPANTS AND MAIN OUTCOME MEASURES

BM samples were collected from 72 patients at the time of hip surgery for either fragility hip fracture (HF) (n = 27) or for other causes (n = 45). In these samples, kynurenine was measured by liquid chromatography-tandem mass spectrometry, and the levels of tartrate-resistant acid phosphatase 5b (TRAP5b), bone-specific alkaline phosphatase (BSALP), receptor activator of nuclear factor-κB ligand (RANKL), and osteoprotegerin (OPG) were measured by immunoassay.

RESULTS

Age was positively correlated with BM kynurenine level. After adjustment for confounders, subjects with fragility HF had a 39.7% higher BM kynurenine level than those without, and the OR per SD increment in BM kynurenine level for fragility HF was 3.80. The BM kynurenine level was inversely associated with bone mass at the total femur. Higher kynurenine concentrations were significantly associated with higher TRAP-5b and RANKL levels, but not with BSALP and OPG levels, in BM plasma.

CONCLUSION

These results suggest that increased kynurenine levels during aging may contribute to the bone fragility seen in the elderly through increased bone resorption, with a resultant imbalance in bone remodeling.

Study on Zoledronic Acid Reducing Acute Bone Loss and Fracture Rates in Elderly Postoperative Patients with Intertrochanteric Fractures

OBJECTIVE

To observe the effect of zoledronic acid on the reduction of acute bone loss and fracture rate in elderly postoperative patients with intertrochanteric fracture.

METHODS

From August 2012 to January 2015, a total of 482 patients with senile osteoporotic femoral intertrochanteric fracture, who accepted proximal femoral intramedullary fixation under anesthesia were analysed. The patients were divided into two groups. Treatment group (353 cases) were treated with 100 mL/5 mg of zoledronic acid injection in 1 week after operation, as well as orally taken 600 mg/d of calcium carbonate and active vitamin D3 400 IU/d. Control group (129 cases) were given the same dose of calcium carbonate and active vitamin D3 orally. Efficacy evaluation were conducted during different periods of medication RESULTS: Compared with pre-medication, indexes of bone metabolism (TARP-5b, CTX) in the treatment group were brought down, especially significantly statistically different after 12 months of medication. The treatment group performed superior to control group in alleviating the pain of back and posture changing (P < 0.05), improving bone density (P < 0.05), depressing re-fracture rate (P < 0.01) after 24 months of medication. In addition, BP, PF and MH dimension scores were demonstrated with statistical significance (P < 0.05).

CONCLUSIONS

The application of zoledronic acidin elderly postoperative patients with intertrochanteric fracture can not only relieve acute bone loss, reduce the incidence rate of re-fracture, alleviate osteoporosis pain and the pain from osteoporotic fracture, but also improve bone metabolism and quality of life, which may offer an acceptable clinical opinion.

Comparison of the efficacy between once-monthly oral ibandronate and risedronate among Korean women with osteoporosis: a nationwide population-based study

Using a nationwide database from the Korean National Health Insurance Service, this study showed that once-monthly oral ibandronate (150 mg) had better anti-fracture efficacy than once-monthly oral risedronate (150 mg), as seen on assessing overall and non-vertebral fractures among Korean elderly women with osteoporosis.

INTRODUCTION

Once-monthly oral bisphosphonates have been used widely without appropriate comparison. Therefore, we aimed to compare the anti-fracture efficacy of once-monthly ibandronate (150 mg) and once-monthly risedronate (150 mg).

METHODS

We conducted a retrospective cohort study among Korean women aged ≥ 60 years from 2006 to 2015 using a nationwide database from the National Health Insurance Service Senior Cohort. The primary outcome was the first occurrence of fracture related to osteoporosis after the initial prescription of bisphosphonates. A Cox proportional model was used to estimate the incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for overall and site-specific fractures between the two treatments, after adjusting for possible confounding factors.

RESULTS

After propensity score matching, the ibandronate and risedronate groups, with 3454 patients each, were assembled from 36,701 new once-monthly ibandronate or risedronate users. After 4 years of follow-up, the ibandronate group had significantly lower incidence rates of overall and non-vertebral fractures than the risedronate group (IRR 0.822, 95% CI 0.698-0.968, P = 0.919 and IRR 0.798, 95% CI 0.647-0.985, P = 0.036, respectively).

CONCLUSIONS

Once-monthly ibandronate (150 mg) shows better anti-fracture efficacy than once-monthly risedronate (150 mg). However, further large-scale studies are required to confirm our findings and to determine site-specific differences, especially regarding the vertebral and hip areas.