Evaluation of patients with a recent clinical fracture and osteoporosis, a multidisciplinary approach

Risk Factors for Fragility Fractures in Chronic Lymphocytic Leukemia

Abnormal bone health and fragility fractures (FF) are more common in patients with chronic lymphocytic leukemia (CLL). We hypothesize that there may be risk factors in CLL patients with osteoporosis that increase the risk of FFs. We conducted a cohort study encompassing all patients diagnosed with CLL from January 1, 2000, to July 31, 2020, utilizing International Classification of Diseases (ICD) codes related to abnormal bone health (osteopenia, osteoporosis, and/or presence of FF) within a single tertiary care institution. Of the 89 patients included, 55 (62%) were female with a mean age of 68 ± 11 years at cohort entry. Fifty-nine (66%) had at least one FF present (pFF) and 30 (34%) did not have an FF (nFF). There were no differences in IGHV (Immunoglobulin heavy chain variable region gene) mutation status, chromosomal abnormalities, or the presence of a complex karyotype. The spine accounted for 81% of identified FF. T-score <-2.5 was more common in those without FF (pFF 38% vs. nFF 71%, P = 0.02). DXA evaluation was not conducted for 36 (40%) individuals within the cohort. Risk factors for fragility fractures included male sex (relative risk [RR] 8.1, 95% confidence interval [CI] 2.1-31.7), diabetes mellitus (RR 1.4, 95% CI 1.04-1.8), smoking (RR 1.3, 95% CI 1.02-1.8), Rai stage >0 (RR 1.4, 95% CI 1.04-1.9), and T-score >-2.5 (RR 1.8, 95% CI 1.1-3.1). There is a high frequency of vertebral FFs in people with CLL despite T-scores not being in the osteoporotic range. Increased awareness to screen and treat vertebral FFs in people with CLL is needed.

Vitamin D Supplementation and Its Impact on Different Types of Bone Fractures

Vitamin D helps to balance the levels of calcium and phosphorus to maintain proper bone structure. It is also involved in essential biological roles and displays a wide spectrum of potential benefits in the human body. Since there are many types of fractures that occur at specific ages and due to different circumstances, the influence of vitamin D on the frequency of a particular fracture may differ. Thus, the authors investigated the possible preventive effect of vitamin D on the risks of vertebral fractures, hip fractures, stress fractures and pediatric fractures. Additional aspects of vitamin D, especially on recuperation after injures and its impact on the severity of particular fractures, were also discussed. It was suggested that vitamin D supplementation may contribute to a reduction in hip fracture risk due to reduced bone turnover, decreased frequency of falls and improved muscle function. Furthermore, vitamin D appears to lower the risk of stress fractures in athletes and military recruits. Due to a nonunified protocol design, presented investigations show inconsistencies between vitamin D supplementation and a decreased risk of vertebral fractures. However, a vitamin D preventive effect on pediatric fractures seems to be implausible.

Biological secondary contributors to osteoporosis in fractured patients, is an early systematic assay relevant?

OBJECTIVE

To evaluate the prevalence of biological abnormalities leading to secondary osteoporosis in recently fractured patients.

METHODS

Adults older than 50, hospitalized for a non-vertebral fracture from July 2015 to October 2016, were assessed for bone fragility contributors in the orthopedics department. Bone mineral density (BMD) measurements and vertebral fracture assessment (VFA) were performed within 3 months. We assessed the prevalence of biological abnormalities in all the patients with recent fracture and in subgroups.

RESULTS

Among 439 hospitalized patients for non-vertebral low trauma fracture, 372 had biological tests (285 women, mean age 77.5 ± 13 years) and 353 (94.6%) had at least ≥ 1 biological abnormality, most frequently vitamin D insufficiency (< 75 nmol/L) (80%). Hypercalcemia was found in 22 (7.7%) patients, explained by possible primary hyperparathyroidism in 6 cases, and by the other causes of hypercalcemia including postoperative low albumin. A high PTH level was observed in 64 (20.8%) patients. We found 3 monoclonal bands. Results were similar in patients with and without vertebral fracture or osteoporosis. Finally, many biological abnormalities can be explained by the postoperative context (low TSH, hypogammaglobulinemia, low albumin, low alkaline phosphatase) and need a control.

CONCLUSION

This study performed in patient with recent low trauma non-vertebral fractures showed that 94.6% of patients had at least one contributor to bone fragility, which was the vitamin D insufficiency in most of cases. We found a high proportion of biological abnormalities which require additional explorations but most of them can be explained by the postoperative context.

The Phenotype of Patients with a Recent Fracture: A Literature Survey of the Fracture Liaison Service

The aetiology of fractures in patients aged 50 years and older is multifactorial, and includes bone- and fall-related risks. The Fracture Liaison Service (FLS) is recommended to identify patients with a recent fracture and to evaluate their subsequent fracture risk, in order to take measures to decrease the risk of subsequent fractures in patients with a high risk phenotype. A literature survey was conducted to describe components of the bone- and fall-related phenotype of patients attending the FLS. Components of the patient phenotype at the FLS have been reported in 33 studies. Patient selection varied widely in terms of patient identification, selection, and FLS attendance. Consequently, there was a high variability in FLS patient characteristics, such as mean age (64-80 years), proportion of men (13-30%), and fracture locations (2-51% hip, <1-41% vertebral, and 49-95% non-hip, non-vertebral fractures). The studies also varied in the risk evaluation performed. When reported, there was a highly variability in the percentage of patients with osteoporosis (12-54%), prevalent vertebral fractures (20-57%), newly diagnosed contributors to secondary osteoporosis and metabolic bone disorders (3-70%), and fall-related risk factors (60-84%). In FLS literature, we found a high variability in patient selection and risk evaluation, resulting in a highly variable phenotype. In order to specify the bone- and fall related phenotypes at the FLS, systematic studies on the presence and combinations of these risks are needed.

High prevalence of secondary factors for bone fragility in patients with a recent fracture independently of BMD

In this study, we demonstrate a high prevalence of secondary factors in patients with a recent fracture independently of bone mineral density (BMD). Our results suggest that patients with a recent fracture should be screened for secondary factors for bone fragility regardless of BMD values.

INTRODUCTION

Secondary factors for bone fragility are common in patients with osteoporosis who have sustained a fracture. The majority of fragility fractures occurs, however, in patients with osteopenia, and it is not known whether secondary factors may contribute to fracture risk in these patients or in those with normal BMD.

METHODS

Prospective cohort study evaluating the prevalence of secondary factors for bone fragility in consecutive patients referred to our fracture liaison service from June 2012 to June 2014 after a recent fracture.

RESULTS

Seven hundred nine patients were included, 201 (28 %) with osteoporosis, 391 (55 %) with osteopenia and 117 (17 %) with normal BMD. Mean age was 66.0 ± 9.8 years, 504 (73 %) were women and 390 (57 %) had one or more underlying secondary factor. Evaluation of clinical risk factors using fracture risk assessment tool (FRAX) identified 38 % of patients with ≥1 secondary factor including smoking (18 %), excessive alcohol use (12 %), glucocorticoid use (12 %) and rheumatoid arthritis (3 %). Laboratory investigations revealed chronic kidney disease in 13 %, monoclonal gammopathy also in 13 % and primary or secondary hyperparathyroidism in 1 and 6 %, respectively. Secondary factors for bone fragility were equally prevalent in patients with osteoporosis, osteopenia or normal BMD.

CONCLUSIONS

Our findings demonstrate a high prevalence of secondary factors for bone fragility in patients who have sustained a recent fracture, independently of BMD. The significant number of documented factors, which were treatable, suggest that patients who sustained a fracture should be screened for secondary factors for bone fragility regardless of BMD values to optimise secondary fracture prevention.

Secondary osteoporosis and metabolic bone disease in patients 50 years and older with osteoporosis or with a recent clinical fracture: a clinical perspective

PURPOSE OF REVIEW

The purpose of this review is to provide guidance to clinicians about which laboratory tests should be performed in patients with osteoporosis or with a recent fracture.

RECENT FINDINGS

Newly diagnosed secondary osteoporosis and other metabolic bone diseases (SECOB) have been found in 5-48% of patients with osteoporosis. In patients with a recent fracture, new SECOB is found in 10-47% of patients with osteoporosis, and in 26-51% if all patients with a fracture regardless of bone mineral density (BMD) are screened. More than one SECOB can be found in the same patient, even when they have already known SECOB. In primary hyperparathyroidism, hyperthyroidism, hypercortisolism, and multiple myeloma, both SECOB and its treatment have an impact on BMD and fractures. For other SECOBs, no treatment is available, or there are no data about the effect of treatment of the SECOB on BMD and fractures.

SUMMARY

We recommend performing the following tests in all patients with osteoporosis or a recent clinical fracture: calcium, phosphate, creatinine, albumin, erythrocyte sedimentation rate in all patients, 24 h urine calcium in men and serum testosterone in men less than 70 years. On indication, additional tests can be performed.

Fall-Related Injuries in Community-Dwelling Older Adults in Qom Province, Iran, 2010-2012

Background:

Falls and related injuries are common health problems in the elderly. Fractures, brain and internal organ injuries and death are the common consequences of the falls, which result in dependence, decreased self-efficacy, fear of falling, depression, restricted daily activities, hospitalization and admission to the nursing home and impose costs on the individual and the society.

Objectives:

The purpose of this study was to determine the types of fall-related injuries and the related risk factors in the elderly population of Qom province, Iran.

Patients and Methods:

This retrospective study was performed on 424 elderly people (65 years and over) referred to Shahid Beheshti Hospital, Qom, Iran, due to falls between 2010 and 2012. The ICD-10 codes of external causes of injury from w00 to w19 related to falls were selected from the health information system of the hospital and demographic variables of the patients and external causes of falls were extracted after accessing the files of the patients. Data were analyzed using SPSS version 18 (SPSS Inc., USA). The duration of hospital stay and its relationship with underlying variables were investigated using t test and ANOVA. The level of significance was considered P < 0.05.

Results:

Among 424 elderly people, 180 cases (42.45%) were male and the mean age of the patients was 78.65 ± 7.70 years. Fall on the same level from slipping, tripping, and stumbling was the most common external cause with 291 victims (68.60%), and hip fracture in 121 patients (29.00%), intertrochanteric fracture in 112 patients (26.90%), and traumatic brain injury in 51 patients (12.20%) were the most common causes of hospital stay. The mean hospital stay was 7.33 ± 3.63 days.

Conclusions:

Lower limb fracture and traumatic brain injury were the most common causes of hospitalization, which resulted in the longest hospital stay and highest hospitalization costs in the elderly.

The value of laboratory tests in diagnosing secondary osteoporosis at a fracture and osteoporosis outpatient clinic

BACKGROUND

As more and more patients meeting the criteria for osteoporosis are referred to a fracture and osteoporosis outpatient clinic (FO clinic), the laboratory costs to screen for secondary osteoporosis also increases. This study was conducted to determine the value of screening on underlying diseases at an FO clinic by obtaining a standard set of laboratory tests.

METHODS

We included all 541 patients ≥50 years with a fracture referred to our FO clinic, during the period January 2005 to January 2007. The bone mineral density (BMD) was measured by dual energy x-ray absorptiometry and expressed as a T score. A standard set of laboratory tests was obtained to screen on underlying diseases.

RESULTS

Laboratory results were as often abnormal in patients with a normal BMD compared to patients with a low BMD. Underlying diseases were infrequently diagnosed. However, the prevalence of secondary osteoporosis in men was quite high, up to 18.2%. The costs to diagnose 1 patient with an underlying disease did vary between €92 and €972 depending on the group of patients described.

CONCLUSION

Screening all patients, referred to an FO clinic, for underlying diseases by obtaining a standard set of laboratory tests is probably not useful since laboratory tests are as often abnormal in patients with a normal BMD compared to patients with a low BMD. Moreover, the prevalence of secondary osteoporosis is low, while laboratory costs are substantial.

Prevalence of subclinical contributors to low bone mineral density and/or fragility fracture

OBJECTIVE

The prevalence of subclinical contributors to low bone mineral density (BMD) and/or fragility fracture is debated. We evaluated the prevalence of subclinical contributors to low BMD and/or fragility fracture in the presence of normal 25-hydroxyvitamin D (25OHVitD) levels.

DESIGN

Prospective observational study.

METHODS

Among 1095 consecutive outpatients evaluated for low BMD and/or fragility fractures, 602 (563 females, age 65.4±10.0 years) with apparent primary osteoporosis were enrolled. A general chemistry profile, phosphate, 25OHVitD, cortisol after 1-mg overnight dexamethasone suppression test, antitissue transglutaminase and endomysial antibodies and testosterone (in males) were performed. Serum and urinary calcium and parathyroid hormone levels were also evaluated after 25OHVitD levels normalization. Vertebral deformities were assessed by radiograph.

RESULTS

In total, 70.8% of patients had low 25OHVitD levels. Additional subclinical contributors to low BMD and/or fragility fracture were diagnosed in 45% of patients, with idiopathic hypercalciuria (IH, 34.1%) and primary hyperparathyroidism (PHPT, 4.5%) being the most frequent contributors, apart from hypovitaminosis D. Furthermore, 33.2% of IH and 18.5% of PHPT patients were diagnosed only after 25OHVitD levels normalization. The subclinical contributors to low BMD and/or fragility fracture besides hypovitaminosis D were associated inversely with age (odds ratio (OR) 1.02, 95% CI 1-1.04, P=0.04) and BMI (OR 1.1, 95% CI 1.05-1.17, P=0.0001) and directly with fragility fractures (OR 1.89, 95% CI 1.31-2.73, P=0.001), regardless of BMD.

CONCLUSIONS

Subclinical contributors to low BMD and/or fragility fracture besides hypovitaminosis D are present in more than 40% of the subjects with apparent primary osteoporosis. Hypovitaminosis D masks a substantial proportion of IH and PHPT patients.

[Aspects of interest on vitamin D for the traumatologist and orthopaedic surgeon]

Vitamin D deficiency or insufficiency is a clinical problem particularly prevalent in elderly patients with low-energy fractures, particularly hip fractures, but has also been associated with stress fractures and high energy fractures. There is much evidence that supports the need to maintain adequate levels of vitamin D in the blood in order to; reduce the number of fragility fractures, furthering the consolidation of these, improve neuromuscular function of patients, prevent falls, prevent surgical infections, or improve the length of arthroplasties. However, it is rare for the orthopaedic surgeon to request the values of vitamin D in these patients and give the appropriate treatment It is recommended to maintain levels higher than 30-40ng/ml (75-100nmol/l) and increase vitamin D intake, in almost all cases, from 800 to 1,000IU/day to achieve these levels.

The (a)-Symptomatic Vertebral Fracture: A Frequently Discovered Entity With Clinical Relevance in Fracture Patients Screened on Osteoporosis

OBJECTIVE

Description of the prevalence of vertebral fractures in a fracture and osteoporosis outpatient clinic (FO-Clinic) and evaluation of the value of spinal radiographs by screening on osteoporosis.

DESIGN

Retrospective data collection, description, and analysis.

METHODS

All patients admitted to the FO-Clinic during the period of December 2005 until October 2006 were enrolled in this study. At the FO-Clinic spinal radiographs were obtained and bone mineral density (BMD) was measured by Dual energy X-ray-Absorptiometry (DXA).

RESULTS

During the study period, a total of 176 patients were screened at our FO-Clinic. In 41.5% of these patients, a vertebral fracture was diagnosed. There appeared to be an indication for anti-osteoporotic medication in 95 of the 176 patients. Of these 95 patients, 77% could be identified by spinal radiographs. Moreover, only 36% of all patients with a vertebral fracture did suffer from osteoporosis.

CONCLUSION

The prevalence of vertebral fractures in patients screened at an FO-Clinic is high and spinal radiographs can identify up to 77% of patients in which anti-osteoporotic medication should be considered. However, fracture risk is not only dependent on bone quality but also on bone density. Therefore, the preferred method of screening on osteoporosis is DXA with vertebral fracture assessment and, if necessary, spinal radiographs. If DXA is not available, spinal radiographs might be used as a first step in osteoporosis screening.

Secondary causes of osteoporosis in fracture patients

OBJECTIVE

Identification and treatment of osteoporosis in the fragility fracture population and interventions to reduce the risk of future fracture are improving in orthopaedic practice. This study investigated the prevalence of vitamin D insufficiency and deficiency and other secondary causes of low bone density in patients who have sustained a fragility fracture and were referred from fracture clinic to a metabolic bone disease clinic (MBDC) for further assessment.

DESIGN

Retrospective chart audit.

SETTING

University hospital fracture clinic.

PATIENTS

Three hundred ninety-nine patients referred from the orthopaedic division to the MBDC over a 3-year period.

INTERVENTION

A standardized chart audit form was developed, and electronic charts were retrospectively audited.

MAIN OUTCOME MEASUREMENTS

Secondary causes of osteoporosis and routine blood test results.

RESULTS

Three hundred eight of 399 patients had blood investigations completed. A total of 98 patients (32%) had 125 secondary causes of osteoporosis other than vitamin D deficiency or insufficiency recorded in their electronic chart, including medication use, premature ovarian failure, hypogonadism, smoking, excessive alcohol use, renal impairment, gastrointestinal conditions, and endocrine conditions. Mean serum vitamin D level was 69.0 nmol/L in 83 men and 75.4 nmol/L in 186 women. Serum vitamin D levels were deficient at ≤25 nmol/L in 7 patients, insufficient at 26-74 nmol/L in 137 patients, and sufficient at ≥75 nmol/L in 125 patients. Investigation of causes of secondary osteoporosis can inform and influence specific treatment regimens.

CONCLUSIONS

More than one-half of patients sustaining a fragility fracture and referred to the MBDC were vitamin D insufficient or deficient, and nearly one-third had a secondary cause of osteoporosis other than vitamin D insufficiency/deficiency. A standardized list of blood and urine analyses and radiographs has been implemented for fragility fracture patients and selected other fracture patients who are undergoing investigation for osteoporosis.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Osteoporosis, frailty and fracture: implications for case finding and therapy

In almost all patients with incident fractures, the absolute risk of subsequent fracture and mortality is highest immediately after the fracture is incurred; the risk is substantially increased in frail elderly patients. The risk factors for incident fractures, such as bone fragility, tendency to fall and the presence of metabolic bone disease, remain underdiagnosed and undertreated. Here, we review the evidence that demonstrates the influence of these risk factors on susceptibility to subsequent fracture and mortality after an incident fracture, and discuss the tools available to predict these outcomes. In this Review, we also propose a systematic, coordinator-based approach to assessment of risk, allocation of treatment and follow-up in all patients over 50 years of age who present with a fracture. The aim of this proposed multistep procedure is to improve the prevention of secondary fracture, decrease mortality rates and reduce patient undertreatment or overtreatment.

Assessing osteoporosis risk factors in Spanish menopausal women

OBJECTIVES

(1) To assess the prevalence of osteoporosis risk factors in Spanish menopausal women; (2) to detect medical and lifestyle risk factor differences between perimenopausal and postmenopausal women; (3) and to identify the main factors responsible for osteoporosis.

METHODS

Cross-sectional descriptive study encompassing women aged 45-65 across Spain. The study population sample was collected through random sampling and a total of 10,514 women were included. Socio-demographic, medical history, and lifestyle data were assessed.

RESULTS

The prevalence of osteoporosis risk factors was 67.6%. The most common risk factors were physical inactivity (53.6%), use of medication related to osteoporosis risk (45.9%), and low calcium intake (30.1%). There were statistically significant differences between peri- and postmenopausal women in terms of smoking status, alcohol intake, personal history, poor dairy product intake, and medication use that could increase risk. Logistic regression analysis showed that osteoporosis was significantly associated with age, family history, age at onset of menopause, Kupperman Index, prolonged immobilization, weight loss, and other diseases that increase the probability of developing osteoporosis.

CONCLUSIONS

A high prevalence of women taking osteoporosis risk-related medication was observed in our study. There was correlation between the menopausal symptoms' degree of severity and the risk of suffering from osteoporosis.

Bone quality: educational tools for patients, physicians, and educators

BACKGROUND

Defining bone quality remains elusive. From a patient perspective bone quality can best be defined as an individual's likelihood of sustaining a fracture. Fracture risk indicators and performance measures can help clinicians better understand individual fracture risk. Educational resources such as the Web can help clinicians and patients better understand fracture risk, communicate effectively, and make decisions concerning diagnosis and treatment.

QUESTIONS/PURPOSES

We examined four questions: What tools can be used to identify individuals at high risk for fracture? What clinical performance measures are available? What strategies can help ensure that patients at risk for fracture are identified? What are some authoritative Web sites for educating providers and patients about bone quality?

METHODS

Using Google, PUBMED, and trademark names, we reviewed the literature using the terms "bone quality" and "osteoporosis education." Web site legitimacy was evaluated using specific criteria. Educational Web sites were limited to English-language sites sponsored by nonprofit organizations

RESULTS

The Fracture Risk Assessment Tool® (FRAX®) and the Fracture Risk Calculator (FRC) are reliable means of assessing fracture risk. Performance measures relating to bone health were developed by the AMA convened Physician Consortium for Performance Improvement® and are included in the Physician Quality Reporting Initiative. In addition, quality measures have been developed by the Joint Commission. Strategies for identifying individuals at risk include designating responsibility for case finding and intervention, evaluating secondary causes of osteoporosis, educating patients and providers, performing cost-effectiveness evaluation, and using information technology. An abundance of authoritative educational Web sites exists for providers and patients.

CONCLUSIONS

Effective clinical indicators, performance measures, and educational tools to better understand and identify fracture risk are now available. The next challenge is to encourage broader use of these resources so that individuals at high risk for fracture will not just be identified but will also adhere to therapy.

Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands

SUMMARY

Implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at a Fracture Liaison Service (FLS) was evaluated. Despite one guideline, all FLSs differed in the performance of patient selection and prevalence of clinical risk factors (CRFs) indicating the need for more concrete and standardised guidelines.

INTRODUCTION

The aim of the study was to evaluate the implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at FLSs in the Netherlands.

METHODS

Five FLSs were contacted to participate in this prospective study. Patients older than 50 years with a recent clinical fracture who were able and were willing to participate in fracture risk evaluation were included. Performance was evaluated by criteria for patient recruitment, patient characteristics, nurse time, evaluated clinical risk factors (CRFs), bone mineral density (BMD) and laboratory testing and results of CRFs and BMD are presented. Differences between FLSs were analysed for performance (by chi-square and Student's t test) and for prevalence of CRFs (by relative risks (RR)).

RESULTS

All FLSs had a dedicated nurse spending 0.9 to 1.7 h per patient. During 39 to 58 months follow-up, 7,199 patients were evaluated (15 to 47 patients/centre/month; mean age, 67 years; 77% women). Major differences were found between FLSs in the performance of patient recruitment, evaluation of CRFs, BMD and laboratory testing, varying between 0% and 100%. The prevalence of CRFs and osteoporosis varied significantly between FLSs (RR between 1.7 and 37.0, depending on the risk factor).

CONCLUSION

All five participating FLSs with a dedicated fracture nurse differed in the performance of patient selection, CRFs and in the prevalence of CRFs, indicating the need for more concrete and standardised guidelines to organise evaluation of patients at the time of fracture in daily practice.

Osteoporosis in men: the value of laboratory testing

Evaluation of 234 men referred for osteoporosis found many with undiagnosed secondary causes and multiple unrecognized risk factors.

INTRODUCTION

Studies in women with postmenopausal osteoporosis suggest that many have unrecognized disorders affecting bone. Men are considered more likely to have underlying, possibly correctable causes. We studied the prevalence of risk factors, secondary causes, and laboratory abnormalities in men with and without previously known causes for osteoporosis.

METHODS

We reviewed the charts of 234 men with osteoporosis diagnosed by bone mineral density testing. In addition to screening chemistries, 25-hydroxyvitamin D, testosterone, luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, and spot urinary calcium-to-creatinine ratio were measured.

RESULTS

The mean age was 70.6 years and mean weight was 76.4 kg. The mean T-score for spine, femoral neck, and forearm was -2.2, -2.4, and -2.3, respectively. Evaluation revealed secondary osteoporosis in 75% overall including hypogonadism, vitamin D deficiency, hypercalciuria, subclinical hyperthyroidism, and hyperparathyroidism. In those men with known secondary osteoporosis at the time of dual energy X-ray absorptiometry testing, additional diagnoses were found in just over half. Vitamin D deficiency and insufficiency were very common, and other common risk factors for osteoporosis included age >65, current smoking, and prior fracture. Half of the subjects had ≥ 4 risk factors.

CONCLUSION

Evaluation revealed a specific cause in about half of men thought to have primary osteoporosis. Among men with known secondary osteoporosis, additional risk factors and secondary causes were frequently identified. In conclusion, a relatively modest evaluation of men with osteoporosis will often provide useful information.

Risk of subsequent fracture and mortality within 5 years after a non-vertebral fracture

SUMMARY

The absolute 5-year risk of subsequent non-vertebral fractures (NVFs) in 1,921 patients presenting with a NVF was 17.6% and of mortality was 32.3%. These risks were highest within the first year, indicating the need to study which reversible factors can be targeted to immediately minimise subsequent fracture risk and mortality.

INTRODUCTION

NVFs are the most frequent clinical fractures in patients presenting at the emergency unit because of a clinical fracture. The aim of the study was to determine the 5-year absolute risk (AR) of subsequent NVF and mortality in patients at the time they present with a NVF.

METHODS

Between 1999 and 2001, 1,921 consecutive patients 50+ years from a level 1 trauma centre were included. All NVFs were confirmed on radiograph reports, and mortality was checked in the national obituary database. Available potential risk factors for a subsequent NVF and mortality (age, sex and baseline fracture location: major-hip, pelvis, multiple ribs, proximal tibia/humerus and distal femur; minor-all others) were expressed as hazard ratios (HR) with 95% confidence intervals (CI) using multivariable Cox regression analysis.

RESULTS

The AR for a subsequent NVF was 17.6% and was related to age (HR per decade, 1.44; 95%CI, 1.29-1.60). The AR for mortality was 32.3% and was related to age (HR per decade, 2.59; 95%CI, 2.37-2.84), male sex (HR, 1.74; 95%CI, 1.44-2.10), major fracture at baseline (HR, 5.56; 95%CI, 3.48-8.88; not constant over time) and subsequent fracture (HR, 1.65; 95%CI, 1.33-2.05). The highest risks were found within the first year (NVFs, 6.4%; mortality, 12.2%) and were related to age and, in addition, to baseline fracture location for mortality.

CONCLUSIONS

Within 5 years after an initial NVF, nearly one in five patients sustained a subsequent NVF and one in three died. One third of subsequent NVFs and mortality occurred within 1 year, indicating the need to study which reversible factors can be targeted to immediately prevent subsequent fractures and mortality.

The definition and clinical significance of nonvertebral fractures

Nonvertebral fractures form the bulk of osteoporotic fractures and yet, other than hip fractures, are often dismissed, particularly in the younger age groups. Thus, less than 30% of women with osteoporotic fractures and less than 10% of men worldwide are receiving appropriate treatment. This article discusses the incidence, cost, and consequences of nonvertebral fractures. Recent evidence suggests these fractures form the bulk of costs to the community and herald an increased risk of refracture and premature mortality that applies to all types of nonvertebral, and not just hip, fractures.

Assessment of bone quality within the tuberosities of the osteoporotic humeral head: relevance for anchor positioning in rotator cuff repair

BACKGROUND

Tears of the rotator cuff are highly prevalent in patients older than 60 years, thereby presenting a population also suffering from osteopenia or osteoporosis. Suture fixation in the bone depends on the holding strength of the anchoring technique, whether a bone tunnel or suture anchor is selected. Because of osteopenic or osteoporotic bone changes, suture anchors in the older patient might pull out, resulting in failure of repair.

HYPOTHESIS

The aim of our study was to analyze the bone quality within the tuberosities of the osteoporotic humeral head using high-resolution quantitative computed tomography (HR-pQCT).

STUDY DESIGN

Descriptive laboratory study.

METHODS

Thirty-six human cadaveric shoulders were analyzed using HR-pQCT. The mean bone volume to total volume (BV/TV) as well as trabecular bone mineral densities (trabBMDs) of the greater tuberosity (GT) and the lesser tuberosity (LT) were determined. Within the GT, 6 volumes of interest (VOIs) within the LT, and 2 VOIs and 1 control volume within the subchondral area beyond the articular surface were set.

RESULTS

Comparing BV/TV of the medial and the lateral row, significantly higher values were found medially (P < .001). The highest BV/TV, 0.030% + or - 0.027%, was found in the posteromedial portion of the GT (P < .05). Regarding the analysis of the LT, no difference was found comparing the superior (BV/TV: 0.024% + or - 0.022%) and the inferior (BV/TV: 0.019% + or - 0.016%) portion. Analyzing trabBMD, equal proportions were found. An inverse correlation with a correlation coefficient of -0.68 was found regarding BV/TV of the posterior portion of the GT and age (P < .05).

CONCLUSION

Significant regional differences of trabecular microarchitecture were found in our HR-pQCT study. The volume of highest bone quality resulted for the posteromedial aspect of the GT. Moreover, a significant correlation of bone quality within the GT and age was found, while the bone quality within the LT seems to be independent from it.

CLINICAL RELEVANCE

The shape of the rotator cuff tear largely determines the bony site of tendon reattachment, although the surgeon has distinct options to modify anchor positioning. According to our results, placement of suture anchors in a medialized way at the border to the articular surface might guarantee a better structural bone stock.

Strategies for treatment to prevent fragility fractures in postmenopausal women

The objective of treatment of osteoporosis is to decrease the risk of fractures in patients at high risk for a first or subsequent fracture. The efficacy of treatment will depend on the efficiency and level of implementation of clinical case finding to select patients at risk, the results of additional investigations, the efficacy, tolerance and safety of medical intervention and the adherence to treatment during follow-up. Each of these steps is critical in treatment in daily practice. Failure to consider one or another step can result in suboptimal fracture prevention or overtreatment. The aim of case finding is to identify patients for treatment, who have disease characteristics of patients in whom fracture prevention has been demonstrated in randomised controlled trials (RCTs). These include patients with a low-trauma hip or vertebral fracture, with a low bone mineral density (BMD) or with a high risk of fracture based on the presence of clinical risk factors (CRFs) for osteoporosis and fractures such as included in the FRAX case-finding algorithm, with or without BMD. Case finding starts clinically, with systematic or opportunistic doctor- and/or patient-driven evaluation for the presence of CRFs, but its implementation is low. Further investigations aim to assess the risk of fracture(s) and to have baseline measurements for the subsequent monitoring of treatment, to exclude diseases that mimic osteoporosis, to identify the cause of osteoporosis and contributory factors and to select the most appropriate treatment. Medical intervention consists of providing information about osteoporosis to the patient, lifestyle advice, optimalisation of calcium intake and vitamin D status, fall prevention to reduce fall risk, correction of reversible contributors to secondary osteoporosis and a wide array of drugs for prevention of a first or subsequent vertebral, hip and non-vertebral, non-hip fracture. Drug treatment is based on manipulation of bone remodelling by inhibiting bone resorption (bisphosphonates, selective oestrogen-receptor modulator (SERMs), calcitonin), stimulating bone formation (parathyroid hormone) or mixed effects (strontium ranelate). Follow-up allows to check tolerance and safety, to optimise adherence and to decide about adequacy of response, duration and switching of therapy.

Markers of autoimmune liver diseases in postmenopausal women with osteoporosis

INTRODUCTION

Osteoporosis is a common complication of chronic liver diseases. However, there is limited information about autoimmune liver diseases as a factor of secondary osteoporosis. Therefore, we aimed to investigate the autoantibodies of autoimmune liver diseases in patients with osteoporosis.

METHODS

One hundred fifty female patients with postmenopausal osteoporosis were included. Bone mineral density was measured by dual energy X-ray absorptiometry. We analysized autoantibodies including antinuclear antibodies, liver membrane antibodies, anti-liver/kidney microsomal autoantibodies1, liver-specific protein, antismooth muscle antibodies, and anti-mitochondrial antibodies by indirect immunofluorescence. Serum was assayed for the levels of aminotransferases.

RESULTS

The mean age of the patients was 63,13 ± 8,6 years. The mean values of L1-L4 T-scores and femur total T-scores were -3,08 ± 0,58 and -1,53 ± 0,81, respectively. Among the 150 patients with osteoporosis, 14 (9.3%) were antinuclear antibodies, four (2.7%) were liver membrane antibodies, three (2.0%) were anti-liver/kidney microsomal autoantibodies1, and two (1.3%) were liver-specific protein positive. None of the patients had anti-mitochondrial antibodies or smooth muscle antibodies positivity. The mean values of levels of aminotransferases were within normal range.

CONCLUSIONS

The presence of liver membrane antibodies, liver-specific protein, and anti-liver/kidney microsomal autoantibodies1 has permitted us to see that there may be some suspicious clues of autoimmune liver diseases in patients with osteoporosis as a secondary risk factor. On the other hand, there is a need for comprehensive studies with a larger sample size and studies designed to compare the results with a normal population to understand the clinical importance of our findings.

Progress in osteoporosis and fracture prevention: focus on postmenopausal women

In the past decade, we have witnessed a revolution in osteoporosis diagnosis and therapeutics. This includes enhanced understanding of basic bone biology, recognizing the severe consequences of fractures in terms of morbidity and short-term re-fracture and mortality risk and case finding based on clinical risks, bone mineral density, new imaging approaches, and contributors to secondary osteoporosis. Medical interventions that reduce fracture risk include sufficient calcium and vitamin D together with a wide spectrum of drug therapies (with antiresorptive, anabolic, or mixed effects). Emerging therapeutic options that target molecules of bone metabolism indicate that the next decade should offer even greater promise for further improving our diagnostic and treatment approaches.