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Zubick P, Dahlke S. Family/caregiver influence on osteoporosis management for older people: an integrative review. Osteoporos Int 2024; 35:1153-1163. [PMID: 38622263 DOI: 10.1007/s00198-024-07081-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 04/17/2024]
Abstract
An integrative literature review was conducted to understand family/caregiver influence on osteoporosis management for older people. Findings include caregivers' overprotection, caregivers' risks for fragility fractures due to caregiving role, poor bone health in caregivers, and caregivers' burden and facilitators. Caregivers should be included in bone health and discharge planning. Literature on family/caregiver influence on osteoporosis management for older people is sparse. Older people are prone to osteoporosis and fragility fractures due to their age, often triggering the need for a caregiver after experiencing a fragility fracture. These fractures pose significant costs to the patient and health systems and are projected to increase with the aging population. This study applied an integrative literature review methodology to key literature findings on family/caregiver influence on osteoporosis management for older people. Key findings include caregivers' tendency to overprotect persons who experience hip fracture by limiting mobilization, thus impeding recovery, caregivers' risks for their own fragility fractures due to the demands of their caregiving role, risks of poor bone health in caregivers, and caregivers' experience of significant burden for which facilitators have been identified. Family caregivers of older people with osteoporosis have unique needs and require support and resources, especially after their loved one experiences a hip fracture. Informal caregivers must be considered in bone health education and discharge planning. They should be considered in the creation of osteoporosis guidelines and within the work of fracture liaison services. More research is needed to increase understanding about family caregiver influence on osteoporosis management.
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Affiliation(s)
- Paula Zubick
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Ave NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Ave NW, Edmonton, Alberta, T6G 1C9, Canada.
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Tang N, Gao L, Song J, Li Y, Song M, Qiu C, Shao M, Chen J, Li S, Wang Q, Su Q, Gao Y. Risk analysis for subsequent fracture of osteoporotic fractures in Chinese women over age 60: a nationwide cross-sectional study. Sci Rep 2024; 14:13319. [PMID: 38858454 PMCID: PMC11164976 DOI: 10.1038/s41598-024-64170-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024] Open
Abstract
Prevention of subsequent fracture is a major public health challenge in the field of osteoporosis prevention and treatment, and older women are at high risk for osteoporotic fractures. This study aimed to examine factors associated with subsequent fracture in older Chinese women with osteoporosis. We collected data on 9212 older female patients with osteoporotic fractures from 580 medical institutions in 31 provinces of China. Higher odds of subsequent fractures were associated with age of 70-79 years (OR 1.218, 95% CI 1.049-1.414), age ≥ 80 (OR 1.455, 95% CI 1.222-1.732), index fracture site was vertebrae (OR 1.472, 95% CI 1.194-1.815) and hip (OR 1.286, 95% CI 1.041-1.590), index fracture caused by fall (OR 1.822, 95% CI 1.281-2.591), strain (OR 1.587, 95% CI 1.178-2.139), no inducement (OR 1.541, 95% CI 1.043-2.277), and assessed as high risk of fracture (OR 1.865, 95% CI 1.439-2.416), BMD T-score ≤ -2.5 (OR 1.725, 95% CI 1.440-2.067), history of surgery (OR 3.941, 95% CI 3.475-4.471) and trauma (OR 8.075, 95% CI 6.941-9.395). Low risk of fall (OR 0.681, 95% CI 0.513-0.904), use of anti-osteoporosis medication (AOM, OR 0.801, 95% CI 0.693-0.926), and women who had received fall prevention health education (OR 0.583, 95% CI 0.465-0.730) associated with lower risk. The areas under the curve of the prediction model was 0.818. The sensitivity was 67.0% and the specificity was 82.0%. The prediction model showed a good ability to predict the risk of subsequent fracture in older women with osteoporotic fractures and are suitable for early self-measurement which may benefit post-fracture management.
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Affiliation(s)
- Nan Tang
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Ling Gao
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Jie Song
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Yeyuan Li
- Beijing Haidian District Wanshou Road Community Health Service Center, Beijing, 100017, China
| | - Mi Song
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Chen Qiu
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Mengqi Shao
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Jingru Chen
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Shan Li
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Qingmei Wang
- Central Patient Management Department, 1th Medical Center, PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
| | - Qingqing Su
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China.
| | - Yuan Gao
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China.
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Vincent G, Adachi JD, Schemitsch E, Tarride JE, Ho N, Wani RJ, Brown JP. Postfracture survival in a population-based study of adults aged ≥66 yr: a call to action at hospital discharge. JBMR Plus 2024; 8:ziae002. [PMID: 38596507 PMCID: PMC11001756 DOI: 10.1093/jbmrpl/ziae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 04/11/2024] Open
Abstract
Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50 yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66 yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6 yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66-85 yr, 51.9%-63.9%; ≥86 yr, 34.5%), followed by vertebral fractures in males (66-85 yr, 53.2%-69.4%; ≥86 yr, 35.5%), and hip fractures in females (66-85 yr, 69.8%-79.0%; ≥86 yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86 yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients.
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Affiliation(s)
- Geneviève Vincent
- Medical Affairs Division, Amgen Canada Inc., Mississauga, ON L5N 0A4, Canada
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Emil Schemitsch
- Division of Orthopaedic Surgery, Western University, London, ON N6A 3K7, Canada
| | - Jean-Eric Tarride
- McMaster Chair in Health Technology Management, Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON L8S 4L8, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON L8S 4L8, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
| | - Nathan Ho
- Medical Affairs Division, Amgen Canada Inc., Mississauga, ON L5N 0A4, Canada
| | - Rajvi J Wani
- Research Division, Amgen Canada Inc., Mississauga, ON L5N 0A4, Canada
| | - Jacques P Brown
- CHU de Québec Research Centre and Laval University, 2705 Boulevard Laurier, TR-83, Québec, QC L5N 0A4, Canada
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Chen JF, Yu SF, Chiu WC, Ko CH, Hsu CY, Lai HM, Chen YC, Su YJ, Kang HY, Cheng TT. Development and Comparison of Treatment Decision Tools for Glucocorticoid-Induced Osteoporosis. Diagnostics (Basel) 2024; 14:452. [PMID: 38396490 PMCID: PMC10887529 DOI: 10.3390/diagnostics14040452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Long-term Glucocorticoid (GC) use results in compromised bone strength and fractures, and several treatment recommendations have been developed to prevent fractures, but none have been validated in a real-world setting. This study aims to create a treatment decision tool and compares this tool to the treatment suggestions from the American College of Rheumatology (ACR), International Osteoporosis Foundation and European Calcified Tissue Society (IOF-ECTS), and GC-adjusted Fracture Risk Assessment Tool (GC-FRAX), above the intervention threshold. We utilized registry data gathered at Chang Gung Memorial Hospital at Kaohsiung, Taiwan, between September 2014 and April 2021. This research is a single-center, observational, and case-controlled study. We recruited participants using prednisone for at least 2.5 mg/day or the equivalent dose for over 3 months, excluding those younger than 40, those with malignancies, or those currently undergoing anti-osteoporosis therapy. The primary endpoint was new fragility fractures within 3 years, including morphometric vertebral fractures detected at baseline and with a follow-up thoracic-lumbar spine X-ray. Participants were randomly allocated into derivation and validation sets. We developed the Steroid-Associated Fracture Evaluation (SAFE) tool in the derivation cohort by assessing the weights of exploratory variables via logistic regression. Prediction performance was compared in the validation set by the receiver operating characteristic (ROC) curve, the area under the curve (AUC), and sensitivity and specificity. A total of 424 treatment-naïve subjects were enrolled, and 83 (19.6%) experienced new fractures within 3 years. The final formula of the SAFE tool includes osteoporosis (1 point), an accumulated GC dose ≥ 750 mg within 6 months (or equivalent prednisolone of ≥4.5 mg/day for 6 months) (1 point), a BMI ≥ 23.5 (1 point), previous fractures (1 point), and elderliness of ≥70 years (2 points). In the validation set, a treatment decision based on the SAFE ≥ 2 points demonstrated an AUC of 0.65, with a sensitivity/specificity/accuracy of 75.9/54.0/58.9, with an ACR of 0.56 (100.0/11.0/31.0), IOF-ECTS 0.61 (75.9/46.0/52.7), and GC-FRAX 0.62 (82.8/42.0/51.2). Among current GIOP recommendations, the SAFE score serves as an appropriate treatment decision tool with increased accuracy and specificity.
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Affiliation(s)
- Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Han-Ming Lai
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Yu-Jih Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Hong-Yo Kang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
- Center for Menopause and Reproductive Medicine Research, Department of Obstetrics and Gynecology, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
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Jurina A, Delimar V, Giljević Z, Filipec Kanižaj T, Matković A, Vidović D, Jurjević N, Vidjak V, Duić Ž, Ćuk M, Japjec M, Dujmović T, Radeljak A, Kardum Paro MM, Vučić-Lovrenčić M, Starešinić M. Fragility spinal fractures among cirrhotic liver transplant candidates in Croatia. Injury 2024; 55:111171. [PMID: 37952477 DOI: 10.1016/j.injury.2023.111171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/21/2023] [Accepted: 10/28/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Existing data on fragility spinal fractures prevalence in liver transplant candidates are scarce and inconsistent. This may be due to other comorbidities, besides hepatic osteodystrophy (HO), that contribute to bone loss and fragility fracture prevalence in chronic liver disease (CLD). OBJECTIVES The aim of this study was to investigate the prevalence of spinal thoracic and lumbar fragility fractures among cirrhotic, non-chronic kidney disease (CKD), non-diabetic liver transplant candidates and to explore their relationship with clinical characteristics, laboratory markers and dual-energy x-ray absorptiometry (DXA) results. MATERIAL AND METHODS This cross-sectional observational study was conducted at Merkur University Hospital, Croatia, between February 2019 and May 2023. Adult patients with liver cirrhosis referred for liver transplantation were included. Patients with acute infection, CKD, diabetes mellitus, malignancies, inflammatory bone diseases and those on corticosteroid or antiresorptive therapy were excluded. Clinical, laboratory and radiological assessment was carried out and patients were accordingly allocated into non-fractured and fractured group for the purpose of statistical analysis. RESULTS A total of 90 patients were included in the study. There was 123 fractures, 87 (70.7 %) in the thoracic and 36 (29.3 %) in the lumbar region. Eighty-nine (72.4 %) fractures were grade 1, 31 (25.2 %) were grade 2 and 3 (2.4 %) were grade 3. Patients in the fractured group were significantly older (p < 0.001). No significant differences between fractured and non-fractured group according to laboratory and DXA parameters were noted. Subgroup with lumbar fractures had significantly lower bone mineral density values at L1-L4 region. Statistically significant negative correlation between bone specific alkaline phosphatase (BALP) and hip total BMD (rho = -0.414, p < 0.001) and spine total BMD (rho = -0.258, p = 0.014) values was found. CONCLUSION Present study confirmed detrimental impact of CLD and HO on bone strength. DXA measurement correlated with the presence of lumbar fragility fractures. A combination of standard X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period and BALP could be useful for detecting HO in CLD. Searching for other risk factors and implementing bone turnover markers and additional imaging techniques for bone loss evaluation in liver transplant candidates is needed.
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Affiliation(s)
- Andrija Jurina
- Division of general and sport traumatology and orthopaedics, Department of surgery, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Valentina Delimar
- Special Hospital for Medical Rehabilitation Krapinske Toplice, Gajeva 2, 49217 Krapinske Toplice, Croatia.
| | - Zlatko Giljević
- Division of Endocrinology, Department of internal medicine, Zagreb University Hospital Centre, Kišpatićeva 12, 10000 Zagreb, Croatia; School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Tajana Filipec Kanižaj
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; Division of Gastroenterology, Department of internal medicine, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Andro Matković
- Clinical Department of Diagnostic and Interventional Radiology, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Dinko Vidović
- Sestre milosrdnice University Hospital Centre, Clinic of Traumatology, Draškovićeva 19, 10000 Zagreb, Croatia; School of Dental Medicine, University of Zagreb, Gundulićeva 5, 10000 Zagreb, Croatia
| | - Nikolina Jurjević
- Clinical Department of Diagnostic and Interventional Radiology, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Vinko Vidjak
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; Clinical Department of Diagnostic and Interventional Radiology, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Željko Duić
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; Department of Gynaecology and Obstretrics, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Mario Ćuk
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia; Department of Pediatrics, Zagreb University Hospital Centre, Kišpatićeva 12, Rebro 10000 Zagreb, Croatia
| | - Mladen Japjec
- Division of general and sport traumatology and orthopaedics, Department of surgery, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Tomislav Dujmović
- Division of general and sport traumatology and orthopaedics, Department of surgery, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Andrea Radeljak
- Department of Clinical Chemistry and Laboratory Medicine, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Mirjana Marjana Kardum Paro
- Department of Clinical Chemistry and Laboratory Medicine, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Marijana Vučić-Lovrenčić
- Department of Clinical Chemistry and Laboratory Medicine, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Mario Starešinić
- Division of general and sport traumatology and orthopaedics, Department of surgery, Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia; School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
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Redman IA, Sivanesan V. A Five-Year Retrospective Audit on Bone Protection Prescribing in Patients With Fragility Fractures in Primary Care. Cureus 2023; 15:e45532. [PMID: 37731682 PMCID: PMC10507999 DOI: 10.7759/cureus.45532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 09/22/2023] Open
Abstract
Background Fragility fractures typically occur in the elderly population due to low-energy trauma in the context of underlying osteoporotic bone disease. These fractures are becoming increasingly more common as the population of the United Kingdom ages, representing a significant public health issue. In the community, a joint care approach is adopted between general practitioners and fracture liaison services for the management of patients with fragility fractures. Despite this, preventive care for these patients remains substandard. This project aimed to conduct an audit of patients with a coded diagnosis of a fragility fracture in our primary care practice to ascertain fracture type and the prescription of bone protective agents. When necessary, the appropriate therapy was commenced per best practice guidelines. Methodology A search of patients with the diagnosis of Fragility fracture on our electronic patient database, SystmOne, was conducted for the period of April 2019 to April 2023 inclusive. A retrospective audit of electronic patient records was done to identify patient demographic data, fracture types and dates, osteoporosis prescriptions, vitamin D/calcium supplementation, and bone densitometry scan results (dual-energy X-ray absorptiometry). Results A total of 47 patients were identified with a coded diagnosis of a Fragility fracture, of whom 36 were females and 11 were males. The average age of the patients was 76.89 years with a range of 50 to 97. In total, 49 fractures were identified. More than two-thirds of the fractures identified were either distal forearm or neck of femur fractures (18 and 15, respectively). Of the 47 patients identified, 33 were on bone protection agents. Further, 26 received both bisphosphonates and calcium/vitamin D supplementation. Seven patients were on bisphosphonate monotherapy, and the remaining two patients were on vitamin D/calcium supplementation alone. Of the 47 patients, 12 had neither form of therapy prescribed. Conclusions Despite the joint effort between fracture liaison services and general practitioners, the secondary prevention of fragility fractures within the community remains inadequate. Fragility fractures are associated with significant morbidity, mortality, and re-fracture rates and incur significant costs to the National Health Service. Local practitioners must routinely evaluate their data to identify opportunities to improve patient care. Effective and timely treatment could be key to the prevention of new or second fractures.
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Affiliation(s)
- Ishtar A Redman
- General Practice, Ealing Hospital, London North West University Healthcare NHS Trust, London, GBR
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Johansen A, Sahota O, Dockery F, Black AJ, MacLullich AMJ, Javaid MK, Ahern E, Gregson CL. Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture. Age Ageing 2023; 52:afad172. [PMID: 37776543 PMCID: PMC10542103 DOI: 10.1093/ageing/afad172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 10/02/2023] Open
Abstract
Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population.
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Affiliation(s)
- Antony Johansen
- University Hospital of Wales and College of Medicine, Cardiff University, Cardiff CF14 4XW, UK
- Falls and Fragility Fracture Audit Programme, Royal College of Physicians, London NW1 4LE, UK
| | - Opinder Sahota
- Department of Health Care of Older People, Nottingham University Hospital, Nottingham NG7 2UH, UK
| | | | - Alison J Black
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
| | - Alasdair M J MacLullich
- Ageing and Health Research Group, University of Edinburgh, Edinburgh EH9 3EG, UK
- Scottish Hip Fracture Audit (SHFA), Edinburgh, UK
| | - M Kassim Javaid
- Falls and Fragility Fracture Audit Programme, Royal College of Physicians, London NW1 4LE, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford OX3 7HE, UK
| | - Emer Ahern
- Cork University Hospital and University College Cork, Cork, Ireland
- Health Service Executive, Dublin 8D08 W2A8, Ireland
- Irish Hip Fracture Database (IHFD), National Office of Clinical Audit, Dublin 2, D02 VN51, Ireland
| | - Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol BS10 5NB, UK
- Older Persons Unit, Royal United Hospital NHS Trust, Combe Park, Bath BA1 3NG, UK
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El Miedany Y, Toth M, Elwakil W, Saber S. Post-Fracture Care Program: Pharmacological Treatment of Osteoporosis in Older Adults with Fragility Fractures. Curr Osteoporos Rep 2023:10.1007/s11914-023-00791-w. [PMID: 37300602 DOI: 10.1007/s11914-023-00791-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE OF REVIEW To present and discuss the recently published scientific evidence on the approach, mode of action, and timing of osteoporosis therapy initiation after fragility fractures. RECENT FINDINGS A comprehensive management approach is required to reduce mortality and morbidity associated with fragility fractures. This will help to reduce the risk of missing the diagnosis of osteoporosis as the underlying disorder while at the same time promoting the timely treatment of osteoporosis. The target is to minimize the incidence of post-traumatic disability and to reduce the imminent fracture risk. This article will present a Bone-Care algorithm for the diagnosis and management of fragility fractures in patients presenting for trauma surgery. This algorithm has been developed based on recently published national as well as international guidelines for implementation in standard clinical practice. International figures revealed that only a small proportion of those patients at high risk of sustaining a fragility fracture receive osteoporosis therapy. Based on the best currently available evidence, it is safe to start osteoporosis therapy in the acute post-fracture period (the optimal therapeutic window of romosozumab is the late endochondral phase/throughout bone remodeling). The right Bone-Care pathway ensures the delivery of a comprehensive management approach that meets the global call to action. All parameters including risk, benefit, compliance, and cost should be considered on an individual base for all kinds of therapy.
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Affiliation(s)
- Yasser El Miedany
- Institute of Medical Sciences, Canterbury Christ Church University, Canterbury, UK.
| | - Mathias Toth
- King's College, London, UK
- Darent Valley Hospital, Kent, UK
| | - Walaa Elwakil
- Rheumatology, Physical Medicine and Rehabilitation, Alexandria University, Alexandria, Egypt
| | - Sally Saber
- Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt
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Agarwal AR, Cohen JS, Tarawneh OH, Gu A, Debritz J, Golladay GJ, Thakkar SC. The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty. Osteoporos Int 2023:10.1007/s00198-023-06746-2. [PMID: 37166492 DOI: 10.1007/s00198-023-06746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/05/2023] [Indexed: 05/12/2023]
Abstract
The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.
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Affiliation(s)
- Amil R Agarwal
- Johns Hopkins Department of Orthopaedic Surgery, Adult Reconstruction Division, 10700 Charter Drive, Suite 205, Columbia, MD, 21044, USA.
- Department of Orthopaedic Surgery, The George Washington University, Washington, USA.
| | - Jordan S Cohen
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Omar H Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Alex Gu
- Department of Orthopaedic Surgery, The George Washington University, Washington, USA
| | - James Debritz
- Department of Orthopaedic Surgery, The George Washington University, Washington, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Savyasachi C Thakkar
- Johns Hopkins Department of Orthopaedic Surgery, Adult Reconstruction Division, 10700 Charter Drive, Suite 205, Columbia, MD, 21044, USA
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10
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Thériault G, Limburg H, Klarenbach S, Reynolds DL, Riva JJ, Thombs BD, Tessier LA, Grad R, Wilson BJ. Recommendations on screening for primary prevention of fragility fractures. CMAJ 2023; 195:E639-E649. [PMID: 37156553 PMCID: PMC10166624 DOI: 10.1503/cmaj.221219] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Fragility fractures are a major health concern for older adults and can result in disability, admission to hospital and long-term care, and reduced quality of life. This Canadian Task Force on Preventive Health Care (task force) guideline provides evidence-based recommendations on screening to prevent fragility fractures in community-dwelling individuals aged 40 years and older who are not currently on preventive pharmacotherapy. METHODS We commissioned systematic reviews on benefits and harms of screening, predictive accuracy of risk assessment tools, patient acceptability and benefits of treatment. We analyzed treatment harms via a rapid overview of reviews. We further examined patient values and preferences via focus groups and engaged stakeholders at key points throughout the project. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence for each outcome and strength of recommendations, and adhered to Appraisal of Guidelines for Research and Evaluation (AGREE), Guidelines International Network and Guidance for Reporting Involvement of Patients and the Public (GRIPP-2) reporting guidance. RECOMMENDATIONS We recommend "risk assessment-first" screening for prevention of fragility fractures in females aged 65 years and older, with initial application of the Canadian clinical Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD). The FRAX result should be used to facilitate shared decision-making about the possible benefits and harms of preventive pharmacotherapy. After this discussion, if preventive pharmacotherapy is being considered, clinicians should request BMD measurement using dual-energy x-ray absorptiometry (DXA) of the femoral neck, and re-estimate fracture risk by adding the BMD T-score into FRAX (conditional recommendation, low-certainty evidence). We recommend against screening females aged 40-64 years and males aged 40 years and older (strong recommendation, very low-certainty evidence). These recommendations apply to community-dwelling individuals who are not currently on pharmacotherapy to prevent fragility fractures. INTERPRETATION Risk assessment-first screening for females aged 65 years and older facilitates shared decision-making and allows patients to consider preventive pharmacotherapy within their individual risk context (before BMD). Recommendations against screening males and younger females emphasize the importance of good clinical practice, where clinicians are alert to changes in health that may indicate the patient has experienced or is at higher risk of fragility fracture.
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Affiliation(s)
- Guylène Thériault
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Heather Limburg
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Scott Klarenbach
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Donna L Reynolds
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - John J Riva
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Brett D Thombs
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Laure A Tessier
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Roland Grad
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Brenda J Wilson
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
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11
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Bégin MJ, Ste-Marie LG, Huard G, Dorais M, Räkel A. Increased Imminent Fracture Risk in Liver Transplant Recipients Despite Bisphosphonate Therapy. Transplant Proc 2023; 55:576-585. [PMID: 37012143 DOI: 10.1016/j.transproceed.2023.02.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/29/2023] [Accepted: 02/24/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Bone loss is significant after orthotopic liver transplant (OLT) and is associated with increased fracture risk and decreased quality of life. In post-transplant fracture prevention, the cornerstone of therapeutic management is bisphosphonates. METHODS We conducted a retrospective study in a cohort of 155 OLT recipients who received a bisphosphonate prescription at hospital discharge between 2012 and 2016 to investigate post-OLT fragility fracture incidence and predictive risk factors. RESULTS Before OLT, 14 patients presented a T score < -2.5 SD, and 23 patients (14.8%) had a history of fracture. During follow-up, the cumulative incidence of fractures on bisphosphonates (99.4% risedronate/alendronate) was 9.7% at 12 months and 13.1% at 24 months. The median time to first fragility fracture was 10 months (IQR, 3-22 months) and thus within the first 2 years of follow-up. Predictive factors of fragility fractures in multivariate Cox regression analyses included age 60 years or older (hazard ratio [HR], 2.61; 95% CI, 1.14-6.01; P = .02), post-transplant diabetes mellitus (HR, 3.82; 95% CI, 1.55-9.44; P = .004), and cholestatic disease (HR, 5.93; 95% CI, 2.30-15.26; P = .0002). Additionally, the female sex was associated with a strong trend toward increased fracture risk in univariate analysis (HR, 2.27; 95% CI, 1.00-5.15; P = .05), as well as a post-transplant absolute decrease in bone mineral density at the femoral neck and total hip (P = .08). CONCLUSIONS This real-world study reports a high incidence of fractures post-OLT despite bisphosphonate therapy. Age 60 years or older, post-transplant diabetes mellitus, cholestatic disease, female sex, and femoral neck and/or total hip bone mineral density loss contribute to increased imminent fracture risk in liver transplant recipients.
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12
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Jiang Y, Zhu Y, Zhang B, Feng D. Characteristics of subsequent contralateral proximal femoral fracture: more convenient access is needed to treat osteoporosis. J Orthop Surg Res 2023; 18:126. [PMID: 36810116 PMCID: PMC9945589 DOI: 10.1186/s13018-023-03621-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/15/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Patients with proximal femoral fracture (PFF) have high mortality and many complications. Osteoporosis increases the risk of subsequent fractures, leading to subsequent contralateral PFF. This study was performed to analyze the features of individuals with subsequent PFF following surgical therapy of first PFF and to ascertain whether such patients received an examination or treatment of osteoporosis. The reasons for lack of examination or treatment were also analyzed. METHODS This retrospective study involved 181 patients with subsequent contralateral PFF who underwent surgical treatment in Xi'an Honghui hospital from September 2012 to October 2021. The patients' sex, age, hospital day, mechanism of injury, surgical procedure, fracture interval, fracture type, fracture classification, and Singh index of the contralateral hip at the time of the initial and subsequent fractures were recorded. Whether the patients took calcium and vitamin D supplements, used anti-osteoporosis medication, or underwent a dual X-ray absorptiometry (DXA) scan was recorded, as was the start time of each. Patients who had never undergone a DXA scan or received anti-osteoporosis medication took part in a questionnaire. RESULTS The 181 patients in this study comprised 60 (33.1%) men and 121 (66.9%) women. Patients with initial PFF and subsequent contralateral PFF had a median age of 80 years (range 49-96 years) and 82 years (range 52-96 years), respectively. The median fracture interval was 24 (7-36) months. Contralateral fractures occurred at the highest incidence between 3 months and 1 year (28.7%). The Singh index was not significantly different between the two fractures. In 130 (71.8%) patients, the fracture type was the same. No significant difference was found in the fracture type or fracture stability classification. A total of 144 (79.6%) patients had never received a DXA scan or anti-osteoporosis medication. The main reason for not treating osteoporosis further was concern about the safety of drug interactions (67.4%). CONCLUSIONS Patients with subsequent contralateral PFF were of advanced age, had a higher proportion of intertrochanteric femoral fractures, had more severe osteoporosis, and had longer hospital stays. The difficulty managing such patients requires multidisciplinary involvement. Most of these patients were not screened or formally treated for osteoporosis. Advanced-age patients with osteoporosis need reasonable treatment and management.
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Affiliation(s)
- Yuxuan Jiang
- grid.43169.390000 0001 0599 1243Department of Orthopaedic Trauma, Hong Hui Hospital, Xi’an Jiaotong University School of Medicine, Xi’an, 710054 Shaanxi Province China
| | - Yangjun Zhu
- grid.43169.390000 0001 0599 1243Department of Orthopaedic Trauma, Hong Hui Hospital, Xi’an Jiaotong University School of Medicine, Xi’an, 710054 Shaanxi Province China
| | - Binfei Zhang
- grid.43169.390000 0001 0599 1243Department of Joint Surgery, Hong Hui Hospital, Xi’an Jiaotong University School of Medicine, Xi’an, 710054 Shaanxi Province China
| | - Dongxu Feng
- grid.43169.390000 0001 0599 1243Department of Orthopaedic Trauma, Hong Hui Hospital, Xi’an Jiaotong University School of Medicine, Xi’an, 710054 Shaanxi Province China
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13
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Increased Risk of Hospital Readmissions and Implant-Related Complications in Patients Who Had a Recent History of Fragility Fracture: A Matched Cohort Analysis. J Arthroplasty 2023; 38:266-273. [PMID: 36055439 DOI: 10.1016/j.arth.2022.08.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND With the increasing utilization of total knee arthroplasty (TKA) in a continually aging US population, the number of patients who have low bone mineral density who undergo TKA may concomitantly increase. This study aimed to assess the rates of short-term complications following TKA in patients who did and did not have a recent history of a prior fragility fracture. METHODS A matched retrospective cohort study analyzing 48,796 patients was performed using a national database to determine the impact of a preceding fragility fracture on rates of short-term complications following TKA. The rates of complications at 1 and 2 years post-TKA were analyzed using multivariate logistic regressions. RESULTS Prior fragility fracture was associated with increased rates of 1-year hospital readmissions (hazard ratio = 1.30, 95% CI, 1.22-1.38), periprosthetic fractures (odds ratio [OR] = 2.72, 95% CI, 1.89-3.99), non-infection-related revisions (OR = 1.32, 95% CI, 1.09-1.60), secondary fragility fractures (OR = 4.62, 95% CI, 4.19-5.12), prosthesis dislocations (OR = 1.76, 95% CI, 1.22-2.56), prosthesis instabilities (OR = 1.64, 95% CI, 1.25-2.15), and periprosthetic infections (OR = 1.49, 95% CI, 1.29-1.71), with similar trends in implant-related complications also seen at the 2-year mark. Patients who filled a prescription for osteoporosis pharmacotherapy had clinically similar rates of these complications compared to those who did not. CONCLUSION Sustaining a fragility fracture prior to TKA is associated with an increased risk of hospital readmission and significant implant-related postoperative complications, potentially increasing the morbidity and mortality of TKA in these patients.
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14
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Wong RMY, Wong PY, Liu C, Wong HW, Chung YL, Chow SKH, Law SW, Cheung WH. The imminent risk of a fracture-existing worldwide data: a systematic review and meta-analysis. Osteoporos Int 2022; 33:2453-2466. [PMID: 35776148 DOI: 10.1007/s00198-022-06473-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022]
Abstract
UNLABELLED The overall incidence of imminent fracture after a prior fragility fracture was 7.58% in the first year and 11.58% in the first 2 years. Approximately half of re-fractures occurred in the first 2 years after a fragility fracture. Older patients that have suffered from a fragility fracture should be treated promptly, with immediate care and a secondary fracture prevention to prevent the high imminent risk of a fracture. INTRODUCTION Imminent fractures refer to the fractures that occur within 2 years of an initial fracture. It is well known that the risk of a subsequent fracture is not constant with time and occurs shortly after the initial one. This systematic review and meta-analysis aimed to present the existing data on imminent fracture worldwide. METHODS Literature search was conducted in Pubmed, Embase, and Web of Science databases until 26 October 2021 for studies reporting the incidence of imminent osteoporotic fractures among people aged 50 years or older. The overall incidence of imminent fracture was pooled and subgroup analyses of index fracture sites and regions on incidence of imminent fracture were performed, with the 95% confidence interval (CI) being calculated. Percentage of imminent fracture occurring in follow-up period was calculated and pooled by meta-analysis. Hazard ratio (HR) was used to estimate the gender differences on the imminent risk of fracture. RESULTS A total of 1446 articles were identified. Nineteen observational studies were eligible for our systematic review, in which 18 were used for quantitative analysis. Pooled overall incidence of imminent fracture in the first year after an osteoporotic fracture was 7.58% (95% CI 5.84 to 9.31%) and cumulative incidence in the first 2 years was 11.58% (95% CI 8.94 to 14.21%). Subgroup analysis showed that in the first 2 years, the pooled incidence in Asia was 7.30% (95% CI 3.42 to 11.18%), whilst incidence in Europe/North America was 13.17% (95% CI 10.14 to 16.20%). In included studies with follow-up period of more than 5 years, pooled imminent fracture percentage in the first 2 years was 47.24% (95% CI 26.18 to 68.30%). Hazard ratio (HR) on gender showed that women had an overall slight increase in risk of imminent fractures (HR 1.18, 95% CI 1.11 to 1.25). CONCLUSION The incidence of imminent fracture is high globally at 11.58%. Approximately half of all refractures occur in the first 2 years after an index fragility fracture. Older patients that have suffered from a fragility fracture should be treated promptly. Also, immediate care and secondary fracture prevention are necessary to prevent the high imminent risk of a fracture, especially within the first 2 years.
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Affiliation(s)
- Ronald Man Yeung Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Pui Yan Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chaoran Liu
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hiu Wun Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yik Lok Chung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Simon Kwoon Ho Chow
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sheung Wai Law
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wing Hoi Cheung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
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15
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Silva BC, Madeira M, d'Alva CB, Maeda SS, de Holanda NCP, Ohe MN, Szejnfeld V, Zerbini CAF, de Paula FJA, Bandeira F. Definition and management of very high fracture risk in women with postmenopausal osteoporosis: a position statement from the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Brazilian Association of Bone Assessment and Metabolism (ABRASSO). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:591-603. [PMID: 36191263 PMCID: PMC10118822 DOI: 10.20945/2359-3997000000522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Several drugs are available for the treatment of osteoporosis in postmenopausal women. Over the last decades, most patients requiring pharmacological intervention were offered antiresorptive drugs as first-line therapy, while anabolic agents were considered a last resource for those with therapeutic failure. However, recent randomized trials in patients with severe osteoporosis have shown that anabolic agents reduce fractures to a greater extent than antiresorptive medications. Additionally, evidence indicates that increases in bone mineral density (BMD) are maximized when patients are treated with anabolic agents first, followed by antiresorptive therapy. This evidence is key, considering that greater increases in BMD during osteoporosis treatment are associated with a more pronounced reduction in fracture risk. Thus, international guidelines have recently proposed an individualized approach to osteoporosis treatment based on fracture risk stratification, in which the stratification risk has been refined to include a category of patients at very high risk of fracture who should be managed with anabolic agents as first-line therapy. In this document, the Brazilian Society of Endocrinology and Metabolism and the Brazilian Association of Bone Assessment and Metabolism propose the definition of very high risk of osteoporotic fracture in postmenopausal women, for whom anabolic agents should be considered as first-line therapy. This document also reviews the factors associated with increased fracture risk, trials comparing anabolic versus antiresorptive agents, efficacy of anabolic agents in patients who are treatment naïve versus those previously treated with antiresorptive agents, and safety of anabolic agents.
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Affiliation(s)
- Barbara C Silva
- Unidade de Endocrinologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
- Unidade de Endocrinologia, Hospital Felício Rocho, Belo Horizonte, MG, Brasil
- Departamento de Medicina, Centro Universitário de Belo Horizonte (UNI-BH), Belo Horizonte, MG, Brasil,
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Miguel Madeira
- Divisão de Endocrinologia e Metabolismo, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Catarina Brasil d'Alva
- Departamento de Medicina Clínica, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Sergio Setsuo Maeda
- Unidade de Endocrinologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Narriane Chaves Pereira de Holanda
- Divisão de Endocrinologia e Metabolismo, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Monique Nakayama Ohe
- Unidade de Endocrinologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Vera Szejnfeld
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Cristiano A F Zerbini
- Centro Paulista de Investigação Clínica, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Francisco José Albuquerque de Paula
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Francisco Bandeira
- Divisão de Endocrinologia e Metabolismo, Faculdade de Medicina, Universidade de Pernambuco, Recife, PE, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
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16
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Geusens P, Appelman-Dijkstra NM, Zillikens MC, Willems H, Lems WF, van den Bergh J. How to implement guidelines and models of care. Best Pract Res Clin Rheumatol 2022; 36:101759. [PMID: 35729036 DOI: 10.1016/j.berh.2022.101759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In subjects older than 50 years, the presence of clinical risk factors (CRFs) for fractures or a recent fracture is the cornerstone for case finding. In patients who are clinically at high short- and long-term risk of fractures (those with a recent clinical fracture or with multiple CRFs), further assessment with bone mineral density (BMD) measurement using dual-energy absorptiometry (DXA), imaging of the spine, fall risk evaluation and laboratory examination contributes to treatment decisions according to the height and modifiability of fracture risk. Treatment is available with anti-resorptive and anabolic drugs, and from the start of treatment a lifelong strategy is needed to decide about continuous, intermittent, and sequential therapy. Implementation of guidelines requires further initiatives for improving case finding, public awareness about osteoporosis and national policies on reimbursement of assessment and therapy.
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Affiliation(s)
- Piet Geusens
- Department of Rheumatology, Maastricht University, Minderbroedersberg 4-6, 6211 LK Maastricht, Netherlands.
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine-Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Netherlands.
| | - Hanna Willems
- Department of Geriatrics, Amsterdam University Medical Center, De Boelelaan 1117 1081 HV Amsterdam, Netherlands.
| | - Willem F Lems
- Department of Rheumatology, Amsterdam University Medical Center, De Boelelaan 1117 1081 HV Amsterdam, Netherlands.
| | - Joop van den Bergh
- Department of Internal Medicine, VieCuri Medisch Cenrum, Tegelseweg 210, 5912 BL Venlo, Netherlands.
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Oliveira T, Kendler DL, Schneider P, Juby AG, Wani RJ, Packalen M, Avcil S, Li S, Waters-Banker C, Graves E, McMullen S, Brown J. Trends in osteoporotic fracture and related in-hospital complications during the COVID-19 pandemic in Alberta, Canada. Arch Osteoporos 2022; 17:109. [PMID: 35920903 PMCID: PMC9349109 DOI: 10.1007/s11657-022-01114-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/25/2022] [Indexed: 02/03/2023]
Abstract
Fragility fractures (i.e., low-energy fractures) account for most fractures among older Canadians and are associated with significant increases in morbidity and mortality. Study results suggest that low-energy fracture rates (associated with surgical intervention and outcomes) declined slightly, but largely remained stable in the first few months of the COVID-19 pandemic. PURPOSE/INTRODUCTION This study describes rates of low-energy fractures, time-to-surgery, complications, and deaths post-surgery in patients with fractures during the coronavirus disease (COVID-19) pandemic in Alberta, Canada, compared to the three years prior. METHODS A repeated cross-sectional study was conducted using provincial-level administrative health data. Outcomes were assessed in 3-month periods in the 3 years preceding the COVID-19 pandemic and in the first two 3-month periods after restrictions were implemented. Patterns of fracture- and hospital-related outcomes over the control years (2017-2019) and COVID-19 restrictions periods (2020) were calculated. RESULTS Relative to the average from the control periods, there was a slight decrease in the absolute number of low-energy fractures (n = 4733 versus n = 4308) during the first COVID-19 period, followed by a slight rise in the second COVID-19 period (n = 4520 versus n = 4831). While the absolute number of patients with low-energy fractures receiving surgery within the same episode of care decreased slightly during the COVID-19 periods, the proportion receiving surgery and the proportion receiving surgery within 24 h of admission remained stable. Across all periods, hip fractures accounted for the majority of patients with low-energy fractures receiving surgery (range: 58.9-64.2%). Patients with complications following surgery and in-hospital deaths following fracture repair decreased slightly during the COVID-19 periods. CONCLUSIONS These results suggest that low-energy fracture rates, associated surgeries, and surgical outcomes declined slightly, but largely remained stable in the first few months of the pandemic. Further investigation is warranted to explore patterns during subsequent COVID-19 waves when the healthcare system experienced severe strain.
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Affiliation(s)
- T Oliveira
- Amgen Canada Inc, Mississauga, ON, Canada
| | - D L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - P Schneider
- Division of Orthopaedic Trauma, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - A G Juby
- Department of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada
| | - R J Wani
- Amgen Canada Inc, Mississauga, ON, Canada
| | - M Packalen
- Amgen Canada Inc, Mississauga, ON, Canada
| | - S Avcil
- Amgen Canada Inc, Mississauga, ON, Canada
| | - S Li
- Medlior Health Outcomes Research Ltd, Suite 210 - 28 Quarry Park Blvd, Calgary, AB, T2C 5P9, Canada
| | - C Waters-Banker
- Medlior Health Outcomes Research Ltd, Suite 210 - 28 Quarry Park Blvd, Calgary, AB, T2C 5P9, Canada
| | - E Graves
- Medlior Health Outcomes Research Ltd, Suite 210 - 28 Quarry Park Blvd, Calgary, AB, T2C 5P9, Canada
| | - S McMullen
- Medlior Health Outcomes Research Ltd, Suite 210 - 28 Quarry Park Blvd, Calgary, AB, T2C 5P9, Canada.
| | - J Brown
- Department of Medicine, Laval University and CHU de Québec Research Centre, Quebec City, QC, Canada
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18
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Alajlouni DA, Bliuc D, Tran TS, Blank RD, Cawthon PM, Ensrud KE, Lane NE, Orwoll ES, Cauley JA, Center JR. Muscle Strength and Physical Performance Are Associated With Risk of Postfracture Mortality But Not Subsequent Fracture in Men. J Bone Miner Res 2022; 37:1571-1579. [PMID: 35689796 PMCID: PMC9378706 DOI: 10.1002/jbmr.4619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/10/2022] [Accepted: 06/04/2022] [Indexed: 11/14/2022]
Abstract
Muscle strength and physical performance are associated with incident fractures and mortality. However, their role in the risk of subsequent fracture and postfracture mortality is not clear. We assessed the association between muscle strength (grip strength) and performance (gait speed and chair stands time) and the risk of subsequent fracture and mortality in 830 men with low-trauma index fracture, who participated in the Osteoporotic Fractures in Men (MrOS) USA Study and had their index measurements assessed within 5 years prior to the index fracture. The annual decline in muscle strength and performance following index fracture, estimated using linear mixed-effects regression, was also examined in relation to mortality. The associations were assessed using Cox proportional hazards models adjusted for age, femoral neck bone mineral density (FN BMD), prior fractures, falls, body mass index (BMI), index fracture site, lifestyle factors, and comorbidities. Over a median follow-up of 3.7 (interquartile range [IQR], 1.3-8.1) years from index fracture to subsequent fracture, 201 (24%) men had a subsequent fracture and over 5.1 (IQR, 1.8-9.6) years to death, and 536 (65%) men died. Index measurements were not associated with subsequent fracture (hazard ratios [HRs] ranging from 0.97 to 1.07). However, they were associated with postfracture mortality. HR (95% confidence interval [CI]) per 1 standard deviation (1-SD) decrement in grip strength: HR 1.12 (95% CI, 1.01-1.25) and gait speed: HR 1.14 (95% CI, 1.02-1.27), and 1-SD increment in chair stands time: HR 1.08 (95% CI, 0.97-1.21). Greater annual declines in these measurements were associated with higher mortality risk, independent of the index values and other covariates. HR (95% CI) per 1-SD annual decrement in change in grip strength: HR 1.15 (95% CI, 1.01-1.33) and in gait speed: HR 1.38 (95% CI, 1.13-1.68), and 1-SD annual increment in chair stands time: HR 1.28 (95% CI, 1.07-1.54). Men who were unable to complete one or multiple tests had greater risk of postfracture mortality (24%-109%) compared to those performed all tests. It remains to be seen whether improvement in these modifiable factors can reduce postfracture mortality. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Dima A. Alajlouni
- Bone BiologyGarvan Institute of Medical ResearchSydneyAustralia
- Faculty of MedicineUNSW SydneySydneyAustralia
| | - Dana Bliuc
- Bone BiologyGarvan Institute of Medical ResearchSydneyAustralia
- Faculty of MedicineUNSW SydneySydneyAustralia
| | - Thach S. Tran
- Bone BiologyGarvan Institute of Medical ResearchSydneyAustralia
- Faculty of MedicineUNSW SydneySydneyAustralia
| | - Robert D. Blank
- Bone BiologyGarvan Institute of Medical ResearchSydneyAustralia
| | - Peggy M. Cawthon
- Research InstituteCalifornia Pacific Medical CenterSan FranciscoCAUSA
- Department of Epidemiology and BiostatisticsUniversity of California, San Francisco Coordinating CenterSan FranciscoCAUSA
| | - Kristine E. Ensrud
- Center for Care Delivery and Outcomes ResearchMinneapolis VA Healthcare SystemMinneapolisMNUSA
- Division of Epidemiology and Community HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Nancy E. Lane
- Department of MedicineUniversity of California at Davis, School of MedicineSacramentoCAUSA
| | - Eric S. Orwoll
- Department of MedicineOregon Health and Science UniversityPortlandORUSA
| | - Jane A. Cauley
- Department of Epidemiology, Graduate School of Public HealthUniversity of PittsburghPittsburghPAUSA
| | - Jacqueline R. Center
- Bone BiologyGarvan Institute of Medical ResearchSydneyAustralia
- Faculty of MedicineUNSW SydneySydneyAustralia
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19
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Bell A, Kendler DL, Khan AA, Shapiro C M M, Morisset A, Leung JP, Reiner M, Colgan SM, Slatkovska L, Packalen M. A retrospective observational study of osteoporosis management after a fragility fracture in primary care. Arch Osteoporos 2022; 17:75. [PMID: 35513573 PMCID: PMC9072526 DOI: 10.1007/s11657-022-01110-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/18/2022] [Indexed: 02/03/2023]
Abstract
In many countries, osteoporosis is predominantly managed by primary care physicians; however, management after a fragility fracture has not been widely investigated. We describe osteoporosis care gaps in a real-world patient cohort. Our findings help inform initiatives to identify and overcome obstacles to effective management of patients after fragility fracture. PURPOSE A fragility fracture is a major risk factor for subsequent fracture in adults aged ≥ 50 years. This retrospective observational study aimed to characterize post-fracture management in Canadian primary care. METHODS A total of 778 patients with an index fragility fracture (low-trauma, excluding small bones) occurring between 2014 and 2016 were identified from medical records at 76 primary care centers in Canada, with follow-up until January 2018. RESULTS Of 778 patients (80.5% female, median age [IQR] 73 [64-80]), 215 were on osteoporosis treatment and 269 had osteoporosis diagnosis recorded prior to their index fracture. The median follow-up was 363 (IQR 91-808) days. Of patients not on osteoporosis treatment at their index fracture, 60.2% (n = 339/563) remained untreated after their index fracture and 62.2% (n = 23/37) continued untreated after their subsequent fracture. After their index fracture, fracture risk assessment (FRAX or CAROC) was not performed in 83.2% (n = 647/778) of patients, and 59.9% (n = 466/778) of patients did not receive bone mineral density testing. Of patients without osteoporosis diagnosis recorded prior to their index date, 61.3% (n = 300/489) remained undiagnosed after their index fracture. At least one subsequent fracture occurred in 11.5% (n = 86/778) of patients. CONCLUSION In the primary care setting, fragility fracture infrequently resulted in osteoporosis treatment or fracture risk assessment, even after multiple fragility fractures. These results suggest a fragility fracture is not recognized as a major risk factor for subsequent fracture and its occurrence does not prompt primary care physicians to intervene. These data urge initiatives to identify and overcome obstacles to primary care physicians' effective management of patients after fragility fractures.
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Affiliation(s)
- Alan Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - David L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Aliya A Khan
- Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada
| | - Marla Shapiro C M
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Anne Morisset
- Department of Medicine, Division of Internal Medicine, Sherbrooke University, Sherbrooke, QC, Canada
| | - Jean-Pierre Leung
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada
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20
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Cost-effectiveness of romosozumab for the treatment of postmenopausal women at very high risk of fracture in Canada. Arch Osteoporos 2022; 17:71. [PMID: 35471711 PMCID: PMC9042964 DOI: 10.1007/s11657-022-01106-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/31/2022] [Indexed: 02/03/2023]
Abstract
This study evaluated the cost-effectiveness of 1 year of romosozumab followed by alendronate versus oral bisphosphonates alone in women with postmenopausal osteoporosis at very high risk for fracture in Canada. Results showed that romosozumab sequenced to alendronate is a cost-effective treatment option, dominating both alendronate and risedronate alone. PURPOSE To demonstrate the value of romosozumab sequenced to alendronate compared to alendronate or risedronate alone, for the treatment of osteoporosis in postmenopausal women with a history of osteoporotic fracture and who are at very high risk for future fracture in Canada. METHODS A Markov model followed a hypothetical cohort of postmenopausal osteoporotic women at very high risk for future fractures, to estimate the cost-effectiveness of romosozumab and alendronate compared to oral bisphosphonates alone. A total treatment period of 5 years was assumed. Quality-adjusted life years and costs were estimated for each comparator across health states defined by different types of fragility fractures. RESULTS Romosozumab/alendronate was associated with a lifetime gain of 0.103 and 0.127 QALYs and a cost reduction of $343 and $3805, relative to alendronate and risedronate, respectively. These results were driven by a reduction of the number of fractures (2561 per 1000 patients, versus 2700 for alendronate and 2724 for risedronate over lifetime). Romosozumab/alendronate had the highest probability of being cost-effective, relative to alendronate and risedronate, at any willingness to pay threshold value. CONCLUSION Romosozumab/alendronate was associated with reduced costs and greater benefit relative to other comparators. Probabilistic, deterministic, and scenario analyses indicate that romosozumab/alendronate represents the best value for money; the uncertainty analyses are robust, and therefore romosozumab should be considered for reimbursement by public drug plans in Canada .
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21
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Gregson CL, Compston JE. New national osteoporosis guidance-implications for geriatricians. Age Ageing 2022; 51:6565793. [PMID: 35403198 PMCID: PMC9760060 DOI: 10.1093/ageing/afac044] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Indexed: 02/05/2023] Open
Abstract
Fragility fractures are painful, debilitating, often life-changing and accounted for an estimated 2.4% of pre-pandemic health care spending in the UK. Those who are older, frail and multimorbid have the highest fracture risk and therefore the most to gain from anti-osteoporosis treatments to reduce this risk. Currently, an unacceptable treatment gap exists between those eligible for and those who receive treatment. This commentary discusses the major changes to the new, National Institute for Health and Care Excellence accredited, UK National Osteoporosis Guideline Group (NOGG) guidance (published March 2022) most relevant to the management of older people's bone health. Changes include intervention thresholds; using fracture probabilities from FRAX; for patients too frail to undergo DXA; greater emphasis on vertebral fracture detection and the use of intravenous zoledronate as a first-line anti-osteoporosis therapy; the new concept of 'very high fracture risk' which should prompt consideration of use of parenteral anti-osteoporosis therapy; new guidance regarding anabolic treatment options; concerns regarding denosumab cessation; and the urgent need to get patients with a fragility fracture onto treatment to reduce re-fracture risk with follow-up to check tolerance and ensure adherence.
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Affiliation(s)
- Celia L Gregson
- Address correspondence to: Celia L. Gregson, Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. Tel: +44 (0)117 4147842.
| | - Juliet E Compston
- Cambridge Biomedical Campus, University of Cambridge, Cambridge, CB2 0AH, UK
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22
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Schemitsch E, Adachi JD, Brown JP, Tarride JE, Burke N, Oliveira T, Slatkovska L. Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients. Osteoporos Int 2022; 33:113-122. [PMID: 34379148 PMCID: PMC8354846 DOI: 10.1007/s00198-021-06080-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/20/2021] [Indexed: 01/06/2023]
Abstract
In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs. PURPOSE This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients. METHODS A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017. RESULTS Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture. CONCLUSION A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.
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Affiliation(s)
- Emil Schemitsch
- Division of Orthopaedic Surgery, Western University, London, ON, Canada
| | | | - Jacques P Brown
- CHU de Québec Research Centre and Laval University, Québec, QC, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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23
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Abstract
Therapy to activate bone formation is required to reverse and restore the damaged bone architecture found in women with postmenopausal osteoporosis. The osteoanabolic drugs include teriparatide, which has been available for several years, and abaloparatide and romosozumab, novel osteoanabolic drugs that have become available more recently. By stimulating bone formation, these drugs produce greater increases in bone mass and bone strength, and they do so more quickly compared to the commonly used anti-remodeling (also called antiresorptive) drugs such as bisphosphonates. In head-to-head trials, teriparatide and romosozumab reduce fracture risk more effectively than do oral bisphosphonates in women with osteoporosis and high fracture risk. Osteoanabolic drugs have little role in the prevention of bone loss during early menopause, but they have an important place in the treatment of women at very high risk of fracture or who remain at high fracture risk after a course of bisphosphonate therapy. Primarily because of the high cost of the drugs, these therapies are initiated by specialists rather than primary-care physicians in most countries. This review will present the evidence for efficacy and safety of these drugs so that clinicians may discern their appropriate use when caring for postmenopausal women with osteoporosis.
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Affiliation(s)
- M R McClung
- Oregon Osteoporosis Center, Portland, OR, USA.,Mary McKillop Center for Health Research, Australia Catholic University, Melbourne, VIC, Australia
| | - A L Clark
- Kaiser Center for Health Research, Portland, OR, USA.,Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR, USA.,Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, OR, USA
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