Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation

Comparison of radiological and functional outcomes of conservative treatment with teriparatide and denosumab in thoracolumbar osteoporotic vertebral fracture

Teriparatide and denosumab, anti-osteoporosis medications with different mechanisms, have been widely used in the patients with osteoporotic vertebral fracture (OVF) considered as advanced osteoporosis. Teriparatide has been shown to enhance bone formation and fracture healing in OVF, but there are still no sufficient evidences discussing about the role of denosumab in newly developed OVF. In this study, we found the similar radiological deformation and functional outcomes of conservative treatment with teriparatide and denosumab in thoracolumbar (TL) OVF, and teriparatide showed a more frequent incidence of fracture union with paravertebral bone bridge formation compared to denosumab.

INTRODUCTION

Teriparatide and denosumab have been widely used to treat advanced osteoporosis and prevent subsequent fractures in patients with OVCF. Unlike teriparatide, which is considered to be effective in fracture healing, there is still no clear role and evidence for the effect of denosumab in acute OVCF. This study compared the radiological and functional outcomes of conservative treatment with teriparatide and denosumab in TL-OVF.

METHODS

This retrospective study enrolled 78 women with mean age of 74.69 ± 7.66 (60-92) years diagnosed as a TL-OVF with no neurological deficits. All patients were treated conservatively with teriparatide (34 of group T, once-daily 20 μg) or denosumab (44 of group D, once-6 months 60 mg) for 6 months. We evaluated the radiological deformation (kyphotic angle, segmental vertebral kyphotic angle, and compression ratio) and the incidence of fracture union with paravertebral bone bridge formation (FUPB) and functional outcomes using the visual analog scale (VAS) and Oswestry Disability Index (ODI) at 0, 3, and 6 months.

RESULTS

In the radiological deformation and functional outcomes, there were no significant differences at 0, 3, and 6 months between the two groups (P > 0.05). However, the incidence of FUPB at 6 months was higher in group T (20/34, 58.8%) compared to group D (11/44, 25.0%) (P = 0.004), and teriparatide was the most statistically significant factor for achieving FUPB (OR 4.486, P = 0.012) in multivariable logistic analysis.

CONCLUSIONS

Teriparatide and denosumab, despite of their different pharmacological mechanisms, showed similar radiological deformation and functional outcomes in the conservative treatment of TL-OVF. However, teriparatide showed a significantly higher incidence of fracture union with paravertebral bone bridge formation.

Sequential Therapy for the Long-Term Treatment of Postmenopausal Osteoporosis

Osteoporosis is a chronic condition characterized by decreased bone mass, loss of skeletal integrity, and increased susceptibility to fracture. Drugs used to treat osteoporosis can be classified as those that block bone resorption (antiresorptive), stimulate bone formation (anabolic), or do both. While all currently approved medications reduce the risk of fragility fractures in high-risk populations, they are generally unable to fully restore bone strength in most patients with established disease. Thus, the majority of patients require disease management over many years. Unfortunately, the continuous use of a single drug has limitations, both in terms of efficacy and safety, and so sequential therapy is commonly required. Given the expanding list of pharmacological agents currently available, careful consideration needs to be given as to which drugs to use and in what sequence. This review will evaluate the differential effects of antiresorptive, bone-forming, and dual-acting drugs when used in specific sequences and will explore the current evidence favoring the initial use of bone-forming/dual-acting drugs followed by antiresorptive medications. This review will also examine the notion that long-term treatment with an antiresorptive drug may diminish the efficacy of subsequent treatment with a bone-forming/dual-acting drug. Finally, this review will explore the current evidence pertaining to the specific issue of how to best prevent the clinical ramifications of denosumab cessation.

Fixation of Distal Radius Fractures Under Wide-Awake Local Anesthesia: A Systematic Review

BACKGROUND

The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events.

METHODS

Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion.

RESULTS

Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients.

CONCLUSIONS

A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.

New Emerging Aspect of Herbal Extracts for the Treatment of Osteoporosis: Overview

As the global population ages, osteoporosis is becoming a more common silent disease. Osteoporosis is characterized by decreased bone quality and strength, which increases the risk of fragility fractures in the elderly. According to estimates, 50% of women eventually suffer from an osteoporotic fracture. Due to increasing disability, more frequent hospital hospitalizations, and most critically, fragility fractures have been linked to a reduced quality of life. Osteoporotic fractures have been linked to an increased mortality risk; and must be considered in awareness as a serious health concern. There are anti-osteoporotic medications available that improve bone quality. Considering the availability of various treatment options, still there are a lot of underserved needs in the treatment of fractures and osteoporosis. For example, the application of natural products and herbal resources for fracture healing, because of the androgen-like and antioxidant characteristics of the plants, they can play a crucial for accelerating the repair of bone fractures. In this article, we'll discuss the herbal remedies that are essential for treating osteoporosis (bone disease).

The Minimum Clinically Important Difference for the Patient-Rated Wrist Evaluation in Surgical Fixation of Distal Radius Fractures: Does Hand Dominance Make a Difference?

BACKGROUND

Distal radius fractures (DRFs) are common orthopaedic injuries. They can be treated in many ways, but the volar locking plate (VLP) is more frequent. Currently, there is limited information regarding the minimum clinically important difference (MCID) in surgically treated DRFs. The purpose of this study was to calculate MCID values for the Patient-Reported Wrist Evaluation (PRWE) in the setting of VLP-treated DRFs.

METHODS

A retrospective review was conducted for patients with isolated, surgically-treated DRFs with a VLP. Exclusions included any concomitant procedure other than a carpal tunnel release, skeletal immaturity, polytrauma, open fracture, or missing PRWE data. MCID was calculated using PRWE, an overall health question, and the anchor-based method.

RESULTS

A total of 131 patients were identified. Approximately 54.2% injured their dominant hand. AO/OTA classification 23C was the most common (n=89, 67.9%). Average baseline, 6-week, and 12-week PRWE were 71.8 ± 19.6, 34.3 ± 20.1, and 21.2 ± 18.0 respectively. This corresponds to an average change from baseline PRWE at 6 weeks and 12 weeks of -37.5 ± 23.4 and -50.6 ± 22.3, respectively. Average MCID values for 6 weeks and 12 weeks were 43.1 ± 18 and 56.0 ± 20.0, respectively (p<0.001). Hand dominance did not correlate with MCID value (rs = 0.084 at six weeks, rs = 0.099 at 12 weeks). MCID value additionally did not correlate with sex, AO/OTA classification, smoking status, ASA score, or BMI. Treatment at a level 1 trauma center and diagnosis of anxiety and/or depression correlated with a higher 6-week MCID value (rs = 0.308 and rs = 0.410, respectively). Increasing age weakly correlated with higher 12-week MCID value (rs = 0.352).

CONCLUSIONS

This study demonstrated an MCID calculation using an overall health anchor. MCID value varied with follow-up time and correlated weakly with age, diagnosis of anxiety and/or depression, and treatment facility, but it did not correlate with injury of the dominant hand. Future research should analyze how to apply MCID and identify successful treatment in the setting of DRF care.

Implant cost variation in surgically treated distal radius fractures

Aims & objectives

The purpose of this study was to evaluate for cost variation in distal radius fractures (DRFs) treated with a volar locking plate (VLP) and to identify key factors that affect the total construct cost.

Materials & methods

A retrospective case series was conducted for a single healthcare system. A total of 140 patients with a DRF treated with a VLP from May 2014 to December 2021 were identified. Patients were excluded for polytrauma, open fractures, and skeletal immaturity.

Results

Most patients were female (n = 120, 85.7%) and were on average 59 ± 13.7 years old. Patients most often injured their dominant hand (n = 75, 53.6%) and presented with an AO/OTA 23C fracture (n = 93, 66.4%). Twenty-two surgeons were included with fellowship training in hand or trauma and orthopaedic or plastic surgery residency. Orthopaedic hand-trained surgeons treated the highest proportion of 23C fractures (69.8%). Ninety patients (64.3%) were treated at a surgery center. The average cost was $1289.67 ± $215.32 (range: $857.83-$2156.95). The most expensive fixation constructs used a variable angle locking screw ($1316.75 ± $264.99) or a multidirectional threaded peg ($1321.67 ± $192.94). Multivariable regression analysis revealed none of the study variables to be significant contributors to construct cost (all p-values >0.27).

Conclusions

Surgically treated DRFs with a VLP demonstrated similar total implant costs regardless of fracture pattern, surgeon specialty, or treatment facility. Contrary to previous literature, VLPs showed minimal cost variation, although some surgeons were able to decrease the overall cost by reducing the number of screws used.

Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease

BACKGROUND

Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied.

OBJECTIVES

To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia.

PATIENTS AND METHODS

Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 min after the blockade were compared with those obtained previously.

RESULTS

A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. 14.8% of the patients presented MAP equal to or less than 60 mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant.

DISCUSSION

Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.

The Relationship between Dietary Na/K Ratio and Bone Mineral Density in Korean Middle-Aged Women

BACKGROUND

Dietary Na+ or Na+/K+ ratio has been reported to be associated with bone mineral density (BMD). However, this remains unclear, and only a few studies have been reported on the Korean population. Therefore, this study aimed to determine the association between dietary Na+, K+, and Na+/K+ ratios and BMD in middle-aged Korean women.

METHODS

This study used data from the Korea National Health and Nutrition Examination Survey 2008-2011. A total of 3,690 women aged >50 years were included. Study participants were classified into quartiles (lowest quartile Q1-highest quartile Q4) according to dietary Na+, K+, and Na+/K+ ratio, and we examined the association of these parameters with BMD. Total femur and lumbar spine BMD were measured using dual-energy X-ray absorptiometry. Multiple linear regression analyses were performed using IBM SPSS ver. 19.0.

RESULTS

The mean age was 62 years, and a significant negative trend in the β-coefficient regarding dietary Na+ was only observed in the total femur BMD. However, the total femur and lumbar spine BMD decreased from Q1 to Q4 regarding the dietary Na+/K+ ratio (P-value for trend: 0.044 for total femur BMD and 0.002 for lumbar spine BMD).

CONCLUSION

A significant negative trend in the β-coefficient for both total femur and lumbar spine BMD was observed regarding the Na+/K+ ratio. Therefore, based on the results of this study, a higher dietary Na+/K+ ratio may be associated with a lower BMD.

Pre-operative anemia was associated with all-cause mortality in patients with vertebral fracture who underwent percutaneous vertebroplasty

PURPOSE

We investigated the association between pre-operative anemia and long-term all-cause mortality in patients with vertebral fracture who underwent a vertebroplasty.

MATERIALS AND METHODS

We retrospectively selected patients who were admitted for vertebroplasty for vertebral compression fracture between 2013 and 2020. Patients who had pathologic fractures or had no assessment of bone mineral density were excluded. Relevant information was collected from electronic medical records. Patients' survival status was confirmed at the end of March 2021. Cox-proportional hazard models were conducted to examine the effects of anemia (<12 g/dL vs. ≥12 g/dL) and pre-operative hemoglobin levels (as a continuous variable) on all-cause mortality with multivariate adjustments.

RESULTS

A total of 167 patients were analyzed (mean age 75.8 ± 9.3 years, male 25.7%). After a median follow-up duration of 2.1 years, pre-operative anemia (hemoglobin <12 g/dL vs. ≥12 g/dL) was independently associated with a higher risk of all-cause mortality (hazard ratio 2.762, 95% CI 1.184 to 6.442, p = 0.019). An increase in pre-operative hemoglobin was associated with a lower risk of all-cause mortality after multivariate adjustment (hazard ratio 0.775, 95% CI 0.606 to 0.991, p = 0.042).

CONCLUSION

Pre-operative anemia (<12 g/dL) was independently associated with survival outcome among patients with vertebral compression fractures who underwent vertebroplasty. Our findings highlight anemia as a risk factor of long-term mortality in this elderly surgical population.

The role of Meteorin-like in skeletal development and bone fracture healing

Meteorin-like protein (Metrnl), homologous to the initially identified neurotrophic factor Meteorin, is a secreted, multifunctional protein. Here we used mouse models to investigate Metrnl's role in skeletal development and bone fracture healing. During development Metrnl was expressed in the perichondrium and primary ossification center. In neonates, single cell RNA-seq of diaphyseal bone demonstrated strongest expression of Metrnl transcript by osteoblasts. In vitro, Metrnl was osteoinductive, increasing osteoblast differentiation and mineralization in tissue culture models. In vivo, loss of Metrnl expression resulted in no change in skeletal metrics in utero, at birth, or during postnatal growth. Six-week-old Metrnl-null mice displayed similar body length, body weight, tibial length, femoral length, BV/TV, trabecular number, trabecular thickness, and cortical thickness as littermate controls. In 4-month-old mice, lack of Metrnl expression did not change structural stiffness, ultimate force, or energy to fracture of femora under 3-point-bending. Last, we investigated the role of Metrnl in bone fracture healing. Metrnl expression increased in response to tibial injury, however, loss of Metrnl expression did not affect the amount of bone deposited within the healing tissue nor did it change the structural parameters of healing tissue. This work identifies Metrnl as a dispensable molecule for skeletal development. However, the osteoinductive capabilities of Metrnl may be utilized to modulate osteoblast differentiation in cell-based orthopedic therapies.

Effect of Lactobacillus Fermentum as a Probiotic Agent on Bone Health in Postmenopausal Women

BACKGROUND

Probiotics are live microorganisms that confer health benefits on the host. Many animal studies have shown that among the probiotics, lactobacilli exert favorable effects on bone metabolism. Herein, we report the results of a randomized controlled trial performed to investigate the effect of Lactobacillus fermentum (L. fermentum) SRK414 on bone health in postmenopausal women.

METHODS

The bone turnover markers (BTMs) and bone mineral density (BMD) in participants in the study group (N=27; mean age, 58.4±3.4 years) and control group (N=26; mean age, 59.5±3.4 years) were compared during a 6-month trial. BTMs were measured at pretrial, 3 months post-trial, and 6 months post-trial, while BMD was measured at pre-trial and 6 months post-trial. Changes in the gut microorganisms were also evaluated.

RESULTS

Femur neck BMD showed a significant increase at 6 months post-trial in the study group (P=0.030) but not in the control group. The control group showed a decrease in osteocalcin (OC) levels (P=0.028), whereas the levels in the study group were maintained during the trial period. The change in L. fermentum concentration was significantly correlated with that in OC levels (r=0.386, P=0.047) in the study group at 3 months post-trial.

CONCLUSIONS

Probiotic (L. fermentum SRK414) supplementation was found to maintain OC levels and increase femur neck BMD during a 6-month trial in postmenopausal women. Further studies with a larger number of participants and a longer study period are required to increase the utility of probiotics as an alternative to osteoporosis medication.

Analyzing the Risk Factors of Mortality after Osteoporotic Hip Fractures Using the National Health Insurance Service Sample Cohort 2.0 Database

Purpose

The purpose of this study is to determine risk factors that affect mortality following osteoporotic hip fracture in patients 50 years or older using the National Health Insurance Service (NHIS) sample cohort 2.0 database.

Materials and Methods

Data from 2,533 patients who satisfied the inclusion criteria for the NHIS sample cohort 2.0 database were used in this study. Data from patients who suffered osteoporotic hip fractures between 2002-2015 were used. An analysis of correlations between the incidence of osteoporotic hip fractures and various factors (sex, age, underlying diseases, etc.) was performed. Analysis of the associations between the mortality of osteoporotic hip fracture and the various factors with hazard ratio (HR) was performed using Cox regression models.

Results

Patient observation continued for an average of 38.12±32.09 months. During the observation period, a higher incidence of hip fracture was observed in women; however, higher mortality following the fracture was observed in men (HR=0.728; 95% confidence interval [CI], 0.635-0.836). The incidence and mortality of fractures increased when there were increasing age, more than three underlying diseases (HR=1.945; 95% CI, 1.284-2.945), cerebrovascular diseases (HR=1.429; 95% CI, 1.232-1.657), and renal diseases (HR=1.248; 95% CI, 1.040-1.497). Also, higher mortality was observed in patients who were underweight (HR=1.342; 95% CI, 1.079-1.669), current smokers (HR=1.338; 95% CI, 1.104-1.621), and inactivity (HR=1.379; 95% CI, 1.189-1.601).

Conclusion

Male gender, the presence of cerebrovascular or kidney disease, a more than three underlying diseases, underweight, a current smoker, and inactivity were risk factors that increased mortality.

Associations of visceral adipose tissue with bone mineral density and fracture: observational and Mendelian randomization studies

BACKGROUND

The associations between visceral adipose tissue (VAT) and bone mineral density (BMD) or fracture have been controversial and the causality of the associations remains to be assessed. This study aimed to explore the associations of VAT^ (predicted value of VAT mass) with BMD and fracture risk in men and women, and to examine their potential causation by two-sample Mendelian randomization (MR) analyses.

METHODS

UK Biobank is a large, population-based prospective cohort study that recruited more than 500,000 participants aged 40-69 in the United Kingdom from 2006 to 2010. In this study, we used a validated and reliable prediction model to estimate the VAT amount of the participants. On this basis, linear and nonlinear multivariable statistical models were used to explore the association of VAT^ with BMD and fracture risk in different groups of sex and BMI. In observational analyses, the multivariable linear regression model and Cox proportional-hazards model were used to assess VAT^ association with BMD and fracture risk, respectively. Inverse variance weighting was used as the main result of MR analysis.

RESULTS

In 190,836 men, an inverted U-shaped association was observed between VAT^ and heel BMD (P for nonlinearity < 0.001), with a turning point of VAT^ = 1.25 kg. Per kg increase in VAT^ was associated with a 0.13 standard deviation (SD) increase in heel BMD (P = 1.5 × 10^-16) among men with lower amounts of VAT^, and associated with a 0.05 SD decrease in heel BMD (P = 1.3 × 10^-15) among men with higher amounts of VAT^. In 193,592 women, per kg increase in VAT^ was monotonically associated with a 0.16 SD increase in heel BMD (P = 1.2 × 10^-136, P for VAT^-sex interaction = 8.4 × 10^-51). During a median follow-up of 8.2 years, VAT^ was associated with lower risks of hip fractures in the overall men and women (P for VAT^-sex interaction = 1.9 × 10^-4 for total fractures; 1.5 × 10^-4 for other fractures). There were significant interactions of VAT^ and BMI on heel BMD and fracture risks in men only (P for VAT^-BMI interaction = 5.9 × 10^-31 for heel BMD; 2.7 × 10^-4 for total fractures; 5.7 × 10^-3 for hip fractures; 6.8 × 10^-3 for other fractures). In two-sample MR analyses, evidence of causality was not observed between VAT^ and DXA-derived BMD or fractures.

CONCLUSIONS

These novel findings demonstrated gender-dependent associations of VAT^ with BMD and fracture risk, with the association in men being modified by adiposity. Evidence of causality was not observed, suggesting that the observational association of VAT^ with BMD and fracture risk could be the result of confounding.

Management of menopause: a view towards prevention

Women spend approximately one-third of their lives with menopause, which occurs around 50 years of age. It is now appreciated that several important metabolic and cardiovascular disease risks emerge during the menopausal transition. Many important conditions occur 10-15 years after menopause, including weight gain and obesity, metabolic syndrome, diabetes, osteoporosis, arthritis, cardiovascular disease, dementia, and cancer; therefore, the occurrence of menopause heralds an important opportunity to institute preventative strategies. These strategies will lead to improved quality of life and decreased mortality. Various strategies are presented for treating symptoms of menopause and diseases that are asymptomatic. Among several strategies is the use of hormone therapy, which has efficacy for symptoms and osteoporosis, and can improve metabolic and cardiovascular health. When instituted early, which is key, in younger postmenopausal women (under 60 years) oestrogen has been found to consistently decrease mortality with a favourable risk-benefit profile in low-risk women. Prospective data show that long-term therapy might not be required for this benefit.

Synthesis and Characterization of Antibiotic–Loaded Biodegradable Citrate Functionalized Mesoporous Hydroxyapatite Nanocarriers as an Alternative Treatment for Bone Infections

The continuing growth of bacterial resistance makes the top challenge for the healthcare system especially in bone-infections treatment. Current estimates reveal that in 2050 the death ratio caused by bacterial infections can be higher than cancer. The aim of this study is to provide an alternative to currently available bone-infection treatments. Here we designed mesoporous hydroxyapatite nanocarriers functionalized with citrate (Ctr–mpHANCs). Amoxicillin (AMX) is used as a model drug to load in Ctr–mpHANCs, and the drug loading was more than 90% due to the porous nature of nanocarriers. Scanning electron microscopy shows the roughly spherical morphology of nanocarriers, and the DLS study showed the approximate size of 92 nm. The Brunauer–Emmett–Teller (BET) specific surface area and pore diameter was found to be about 182.35 m²/g and 4.2 nm, respectively. We noticed that almost 100% of the drug is released from the AMX loaded Ctr–mpHANCs (AMX@Ctr–mpHANCs) in a pH-dependent manner within 3 d and 5 d at pH 2.0 and 4.5, respectively. The sustained drug release behaviour was observed for 15 d at pH 7.4 and no RBCs hemolysis by AMX@Ctr–mpHANCs. The broth dilution and colony forming unit (CFU) assays were used to determine the antimicrobial potential of AMX@Ctr–mpHANCs. It was observed in both studies that AMX@Ctr–mpHANCs showed a significant reduction in the bacterial growth of S. aureus, E. coli, and P. aeruginosa as compared to Ctr–mpHANCs with no bacteria-killing. Thus, we proposed that Ctr–mpHANCs can be used as a drug carrier and a treatment option for bone infections caused by bacteria.

The Association between Helicobacter pylori Seropositivity and Bone Mineral Density in Adults

Objectives

Current evidence on the associations between Helicobacter pylori (H. pylori) infection and bone mineral density (BMD) is conflicting. Therefore, a nationally representative sample of adults was analyzed to investigate the associations of H. pylori seropositivity and BMD in this study.

Methods

A retrospective cross-sectional study was conducted with 2555 subjects aged 40-85 years in the US National Health and Nutrition Examination Survey (NHANES) 1999–2001. Multivariable logistic regression models were performed to evaluate the associations between H. pylori seropositivity and BMD. Subgroup analyses stratified by sex, age, race, and body mass index (BMI) were performed.

Results

No association was found between H. pylori seropositivity and BMD (β = 0.006, 95% CI: -0.003 to 0.015, P = 0.177). In the subgroup analyses stratified by age, a positive association was observed between the H. pylori seropositivity and total BMD among subjects aged 40-55 years (β = 0.018, 95% CI: 0.004 to 0.033, P = 0.012); in the subgroup analyses stratified by sex, a positive association was observed between the H. pylori seropositive and total BMD in male (β = 0.019, 95% CI: 0.007 to 0.032, P = 0.003); in the subgroup analyses stratified by age and sex, the total BMD was higher in men aged 40-55 years with H. pylori seropositive than those with H. pylori seronegative (β = 0.034, 95% CI: 0.013 to 0.056, P = 0.002).

Conclusions

In conclusion, no association between H. pylori seropositive and total BMD was demonstrated among most middle-aged and elderly adults. H. pylori infection may not be one key factor in the loss of BMD.

Influence of Different Surgical Timing after Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fractures: A Retrospective Study

BACKGROUND

A large number of people suffer from osteoporotic vertebral compression fractures (OVCFs) worldwide. Percutaneous kyphoplasty (PKP), considered a minimally invasive surgery, has been widely used to treat OVCFs and achieves satisfactory outcomes. However, the surgical timing of PKP is still under discussion.

METHODS

A total of 149 patients were enrolled in the study and were divided into 3 groups according to different surgical timing. Group A (n = 52) included patients who required emergency surgery. Group B (n = 50) included patients who required surgery around a week after injury. Group C (n = 47) included patients who required surgery a month or more after injury. Characteristics of patients and radiological images were recorded. The Visual Analog Scale (VAS) scores and the Oswestry Disability Index (ODI) scores were analyzed before, 1 day, 1 month, and 6 months after surgery. In addition, compression rates of anterior vertebral height (AVH) were calculated and the kyphosis Cobb angle was measured before and after surgery.

RESULTS

There was a significant difference in the VAS and ODI scores between the three groups at 1 day, 1 month, and 6 months after PKP. The VAS and ODI scores of Group C were higher than those of Groups A and B. The AVH compression rates of Group C were significantly higher than those of Groups A and B postoperatively 1 day, 1 month, and 6 months. The kyphosis Cobb angles in Group C was significantly larger than those in Groups A and B at 1 day and 1 month after PKP.

CONCLUSIONS

Emergency PKP showed more advantages in both clinical and radiological outcomes. We recommend early PKP for the treatment of OVCFs.

Effects of probiotics on bone mineral density and bone turnover: A systematic review

Probiotic supplements have been shown to improve bone health in animal models, although it remains uncertain whether these beneficial effects extend to humans. We undertook a systematic review of the literature to determine the effects of probiotic interventions on skeletal outcomes in postmenopausal women. MEDLINE, EMBASE, CENTRAL, and the Cochrane Database of Systematic Reviews were searched from inception to October 2020 for controlled trials comparing the effects of probiotic-containing supplements with placebo on bone mineral density (BMD) or bone turnover markers. Risk of bias was assessed using the Cochrane Risk of Bias 2 Tool. Of 338 records identified, six randomized, placebo-controlled trials (n = 632) were eligible for inclusion. All studies assessed postmenopausal women for durations of 6-12 months; three were considered to be at high risk of bias. Four studies examined Lactobacillus-containing probiotics, one assessed a proprietary blend of lactic acid bacteria, and one evaluated Bacillus subtilis. Effects of probiotic interventions on BMD were inconsistent, with the majority of studies demonstrating no benefit at the spine or hip. Probiotic effects on bone turnover markers were similarly heterogeneous. High quality studies are needed to determine whether probiotic interventions have a role in maintaining bone health in humans.

Association between Osteoporosis and Low Hemoglobin Levels: A Nested Case-Control Study Using a National Health Screening Cohort

An association between anemia and an increased risk of osteoporosis has been suggested. The goal of this study was to estimate the association of hemoglobin (Hb) level with osteoporosis. A total of 69,760 osteoporosis patients aged ≥ 40 years old from the Korean National Health Insurance Service Health Screening Cohort were enrolled. From an identical cohort database, 69,760 comparison participants were randomly selected. Hb levels before the onset of osteoporosis were evaluated. The association of Hb level with osteoporosis was analyzed using a conditional logistic regression model adjusted for obesity, smoking status, alcohol consumption, systolic blood pressure, diastolic blood pressure, fasting blood glucose, total cholesterol, and the Charlson comorbidity index score. Fifteen percent of the osteoporosis group and 14.17% of the comparison group had anemia. The Hb level was associated with 0.98-fold lower odds for osteoporosis (95% confidence intervals = 0.97-0.99, p < 0.001). A low Hb level was associated with a high risk of osteoporosis in the adult population. There was a consistent association between a low Hb level and osteoporosis in patients with comorbidities.

Association Between Body Mass Index and Functional Outcomes in Elderly Patients with Extra-articular Distal Radius Fracture: A Prospective Observational Study

INTRODUCTION

The association between body mass index (BMI) and functional outcomes is unknown in elderly individuals with distal radius fracture (DRF).

OBJECTIVE

The aim of this study is to evaluate if there is association between BMI and functional outcomes in patients older than 60 years with DRF treated conservatively.

MATERIALS AND METHODS

A prospective observational study was performed. A total of 228 patients with extra-articular DRF were prospectively recruited. All patients were categorized by their BMI as normal, overweight, or obese. Functional outcomes were assessed after cast removal and at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to assess upper limb and wrist/hand function, respectively, while the Jamar Dynamometer was used to assess grip strength.

RESULTS

Of the total number of patients, 184 were female (80.7%), 87 were overweight (38.2%), and 111 were obese (48.7%). After cast removal, the correlations between BMI and functional outcomes were DASH 0.06 (p = 0.578), PRWE 0.04 (p = 0.692), and grip strength - 0.02 (p = 0.763). At 1-year follow-up, the correlations were DASH 0.55 (p = 0.036), PRWE 0.32 (p = 0.041), and grip strength - 0.21 (p = 0.043).

CONCLUSION

This study suggests that at 1-year follow-up, there was a low-to-moderate association between BMI and poor functional outcomes in elderly patients with extra-articular DRF treated conservatively.

LEVEL OF EVIDENCE

Level IV, observational prospective study.

Potential of biomarkers during pharmacological therapy setting for postmenopausal osteoporosis: a systematic review

Background

Biochemical markers of bone turnover (BTMs), such as the bone alkaline phosphatase (bALP), procollagen type I N propeptide (PINP), serum cross-linked C-telopeptides of type I collagen (bCTx), and urinary cross-linked N-telopeptides of type I collagen (NTx), are used to manage therapy monitoring in osteoporotic patients. This systematic review analyzed the potential of these BMTs in predicting the clinical outcomes in terms of BMD, t-score, rate of fractures, and adverse events during the therapy setting in postmenopausal osteoporosis.

Methods

All randomized clinical trials (RCTs) reporting data on biomarkers for postmenopausal osteoporosis were accessed. Only articles reporting quantitative data on the level of biomarkers at baseline and on the outcomes of interest at the last follow-up were eligible.

Results

A total of 36,706 patients were retrieved. Greater values of bALP were associated with a greater rate of vertebral (P = 0.001) and non-vertebral fractures (P = 0.0001). Greater values of NTx at baseline were associated with a greater rate of adverse events at the last follow-up (P = 0.02). Greater values of CTx at baseline were associated with a greater rate of adverse events leading to discontinuation (P = 0.04), gastrointestinal adverse events (P = 0.0001), musculoskeletal adverse events (P = 0.04), and mortality (P = 0.04). Greater values of PINP at baseline were associated with greater rates of gastrointestinal adverse events (P = 0.02) at the last follow-up.

Conclusion

The present analysis supports the adoption of BMTs during pharmacological therapy setting of patients suffering from osteoporosis.

Level of evidence

I, systematic review of RCTs

Femoral Neck Hounsfield Units as an Adjunct for Bone Mineral Density After Combat-Related Lower Extremity Amputation

OBJECTIVES

To correlate femoral neck Hounsfield units (HUs) measured on a computed tomography (CT) scan to dual-energy x-ray absorptiometry (DEXA) T-scores allowing evaluation of bone mineral density (BMD) over time after lower extremity trauma-related amputation.

DESIGN

Retrospective cohort study.

SETTING

United States military trauma referral center.

PATIENTS

Military combat-related lower extremity amputees with both DEXA and CT scans within 6 months of each other.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Correlation between femoral neck comprehensive mean HUs and BMD and HUs threshold for low BMD.

RESULTS

Regression model correlation (r) between CT HU and DEXA T-score was r = 0.84 [95% confidence interval (CI) 0.52-0.94] and r = 0.81 (95% CI 0.57-0.92) when CT imaging was separated from DEXA by less than 4 and 5 months, respectively. Beyond 5 months separation, correlation decreased to r = 0.60 (95% CI 0.29-0.80). Using a receiver operator characteristic curve for mean comprehensive HUs to determine low BMD with 4-month cut-off, a threshold of 151 HUs was 97% sensitive and 84% specific to identify low BMD, whereas 98 HUs was 100% sensitive and 100% specific to identify osteoporosis.

CONCLUSION

Using opportunistic CT, clinicians can reliably estimate BMD in trauma-related amputees. This information will inform providers making decisions regarding weightbearing and bisphosphonate therapy to limit further loss. Future phases of this study will aim to use this correlation to study the effects of weightbearing advancement timing, bisphosphonate therapy, and interventions on the natural history of bone density after amputation.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Assessing the Relationship Between Bone Density and Loss of Reduction in Nonsurgical Distal Radius Fracture Treatment

PURPOSE

Whether low bone mineral density affects loss of reduction for distal radius fractures (DRFs) managed without surgery is unknown. Our purpose was to understand how bone mineral density, based on second metacarpal cortical percentage (2MCP) measurement, affects DRF healing after nonsurgical treatment.

METHODS

We retrospectively reviewed 304 patients from 2 health systems with DRFs treated without surgery. The AO classification, 2MCP (<50% indicating osteoporosis), and fracture stability based on Lafontaine criteria were determined from prereduction radiographs. Radial inclination, radial height, volar tilt, ulnar variance, and intra-articular stepoff were measured on initial and 6-week final follow-up radiographs and compared. Bivariate analysis was used to evaluate the association between Lafontaine criteria or 2MCP and changes in radiographic parameters. Radiographic parameters with significant associations in bivariate analysis were evaluated in multivariable models adjusted for age, sex, initial radiographic parameters, reduction status, and AO fracture type.

RESULTS

Across all patients, after 6 weeks of nonsurgical treatment, ulnar variance (shortening of the radius) increased by an average of 1.4 mm. Bivariate analysis showed that lower 2MCP and unstable fractures per Lafontaine criteria were each significantly associated with an increase in ulnar variance (P < .05). In adjusted multivariable models, having both 2MCP less than 50% and an unstable fracture together was associated with an additional 1.2-mm increase in ulnar variance (P < .05).

CONCLUSIONS

A 2MCP in the osteoporosis range and unstable fractures by Lafontaine criteria were each associated with a significant increase in ulnar variance after nonsurgical treatment for DRFs. Patients with unstable fractures and 2MCP less than 50% are likely to have an additional increase of greater than 1 mm in ulnar variance at the end of nonsurgical fracture treatment than patients with similar injuries, but without these features. Using initial radiographs to identify patients with low bone mineral density that may be at risk for more substantial loss of reduction can assist with decision making for managing DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Ability of Exercise to Mitigate Caloric Restriction-Induced Bone Loss in Older Adults: A Structured Review of RCTs and Narrative Review of Exercise-Induced Changes in Bone Biomarkers

Despite the adverse metabolic and functional consequences of obesity, caloric restriction- (CR) induced weight loss is often contra-indicated in older adults with obesity due to the accompanying loss of areal bone mineral density (aBMD) and subsequent increased risk of fracture. Several studies show a positive effect of exercise on aBMD among weight-stable older adults; however, data on the ability of exercise to mitigate bone loss secondary to CR are surprisingly equivocal. The purpose of this review is to provide a focused update of the randomized controlled trial literature assessing the efficacy of exercise as a countermeasure to CR-induced bone loss among older adults. Secondarily, we present data demonstrating the occurrence of exercise-induced changes in bone biomarkers, offering insight into why exercise is not more effective than observed in mitigating CR-induced bone loss.

Seasonality of mortality and in-hospital complications in hip fracture surgery: Retrospective cohort research using a nationwide inpatient database

AIM

Among older patients undergoing hip fracture surgery, previous studies have shown a seasonal variation of in-hospital surgical complications. However, little is known about seasonal effects on mortality and systemic complications after hip fracture surgery. In the present study, we evaluated whether mortality and in-hospital systemic complications are influenced by seasonal differences.

METHODS

We enrolled patients from a nationwide database who underwent hip fracture surgery between 2010 and 2018. The primary outcome was in-hospital mortality. The secondary outcomes were in-hospital systemic complications. The association between the seasonality and in-hospital outcomes was investigated using multivariable Cox, logistic regression and causal mediation analysis.

RESULTS

With 425 856 patients (mean age 83.5 years; 79% women), overall in-hospital mortality was 5324 (1.2%). Fall and winter were associated with a higher mortality than spring (hazard ratio [HR] 1.16; P < 0.001; HR 1.14; P = 0.001, respectively). Across all the seasons, there were 36 834 overall systemic complications (8.6%), with respiratory infection being the most frequent (18 637 [4.4%]). Among these complications, only respiratory infection showed seasonal variation, with a higher prevalence in fall and winter. The mediated effect of respiratory infection on mortality was significantly higher in fall and winter compared with spring (fall, HR 1.06, proportion mediated 36.7%; winter, HR 1.14, proportion mediated 55.0%; all P < 0.001).

CONCLUSIONS

We found a significantly higher mortality in fall and winter after hip fracture surgery. Specifically, in winter, the increased in-hospital death was largely attributed to the increased incidence of respiratory infection. Geriatr Gerontol Int 2021; 21: 398-403.

The association between keloid and osteoporosis: real-world evidence

Background

Keloids are characterized by disturbance of fibroblast proliferation and apoptosis, deposition of collagen, and upregulation of dermal inflammation cells. This benign dermal fibro-proliferative scarring condition is a recognized skin inflammation disorder. Chronic inflammation is a well-known contributor to bone loss and its sequelae, osteoporosis. They both shared a similar pathogenesis through chronic inflammation. We assessed whether keloids increase osteoporosis risk through using National Health Insurance Research Database.

Methods

The 42,985 enrolled patients included 8597 patients with keloids but no history of osteoporosis; 34,388 controls without keloids were identified from the general population and matched at a one-to-four ratio by age, gender. Kaplan-Meier method was applied to determine cumulative incidence of osteoporosis. Cox proportional hazard regression analysis was performed after adjustment of covariates to estimate the effect of keloids on osteoporosis risk.

Results

Of the 8597 patients with keloids, 178 (2.07%) patients were diagnosed with osteoporosis while in the 34,388 controls, 587 (1.71%) were diagnosed with osteoporosis. That is, the keloids patients had 2.64-fold higher risk of osteoporosis compared to controls after adjustment for age, gender, Charlson Comorbidity Index and related comorbidities. The association between keloids and osteoporosis was strongest in patients younger than 50 years (hazard ratio = 7.06%) and in patients without comorbidities (hazard ratio = 4.98%). In the keloids patients, a high incidence of osteoporosis was also associated with advanced age, high Charlson Comorbidity Index score, hyperlipidemia, chronic liver disease, stroke, and depression.

Conclusions

Osteoporosis risk was higher in patients with keloids compared to controls, especially in young subjects and subjects without comorbidities.

Craniofacial and Long Bone Development in the Context of Distraction Osteogenesis

BACKGROUND

Bone retains regenerative potential into adulthood, and surgeons harness this plasticity during distraction osteogenesis. The underlying biology governing bone development, repair, and regeneration is divergent between the craniofacial and appendicular skeleton. Each type of bone formation is characterized by unique molecular signaling and cellular behavior. Recent discoveries have elucidated the cellular and genetic processes underlying skeletal development and regeneration, providing an opportunity to couple biological and clinical knowledge to improve patient care.

METHODS

A comprehensive literature review of basic and clinical literature regarding craniofacial and long bone development, regeneration, and distraction osteogenesis was performed.

RESULTS

The current understanding in craniofacial and long bone development and regeneration is discussed, and clinical considerations for the respective distraction osteogenesis procedures are presented.

CONCLUSIONS

Distraction osteogenesis is a powerful tool to regenerate bone and thus address a number of craniofacial and appendicular skeletal deficiencies. The molecular mechanisms underlying bone regeneration, however, remain elusive. Recent work has determined that embryologic morphogen gradients constitute important signals during regeneration. In addition, striking discoveries have illuminated the cellular processes underlying mandibular regeneration during distraction osteogenesis, showing that skeletal stem cells reactivate embryologic neural crest transcriptomic processes to carry out bone formation during regeneration. Furthermore, innovative adjuvant therapies to complement distraction osteogenesis use biological processes active in embryogenesis and regeneration. Additional research is needed to further characterize the underlying cellular mechanisms responsible for improved bone formation through adjuvant therapies and the role skeletal stem cells play during regeneration.

Association of Insulin Resistance and β-cell Function With Bone Turnover Biomarkers in Dysglycemia Patients

BACKGROUND

The interrelation between glucose and bone metabolism is complex and has not been fully revealed. This study aimed to investigate the association between insulin resistance, β-cell function and bone turnover biomarker levels among participants with abnormal glycometabolism.

METHODS

A total of 5277 subjects were involved through a cross-sectional study (METAL study, http://www.chictr.org.cn, ChiCTR1800017573) in Shanghai, China. Homeostasis model assessment of insulin resistance (HOMA-IR) and β-cell dysfunction (HOMA-%β) were applied to elucidate the nexus between β-C-terminal telopeptide (β-CTX), intact N-terminal propeptide of type I collagen (P1NP) and osteocalcin (OC). β-CTX, OC and P1NP were detected by chemiluminescence.

RESULTS

HOMA-IR was negatively associated with β-CTX, P1NP and OC (regression coefficient (β) -0.044 (-0.053, -0.035), Q4vsQ1; β -7.340 (-9.130, -5.550), Q4vsQ1 and β -2.885 (-3.357, -2.412), Q4vsQ1, respectively, all P for trend <0.001). HOMA-%β was positively associated with β-CTX, P1NP and OC (β 0.022 (0.014, 0.031), Q4vsQ1; β 6.951 (5.300, 8.602), Q4vsQ1 and β 1.361 (0.921, 1.800), Q4vsQ1, respectively, all P for trend <0.001).

CONCLUSIONS

Our results support that lower bone turnover biomarker (β-CTX, P1NP and OC) levels were associated with a combination of higher prevalence of insulin resistance and worse β-cell function among dysglycemia patients. It is feasible to detect bone turnover in diabetes or hyperglycemia patients to predict the risk of osteoporosis and fracture, relieve patients' pain and reduce the expenses of long-term cure.

Updated incidence and costs of hip fractures in elderly Italian population

PURPOSE

We aimed at updating our previous researches about the burden of hip fractures in elderly Italian population.

METHODS

We analyzed national hospitalizations records from 2000 to 2014 to compute age- and sex-specific standardized rates.

RESULTS

1,335,375 hospitalizations were recorded in people ≥ 65 (1,031,816 women: 77.27% and 303,559 men: 22.73%) over 15 years, passing from 73,493 in year 2000 to 94,525 in 2014, with an overall increase of 28.62% over the 15-year period (females: + 25.1%; males: + 41.2%). About 84.9% of total hip fractures were suffered by patients aged ≥ 75 years old. Direct hospitalization costs and rehabilitation costs increased from 343 to 457 million Euros and from 392 to 504 million Euros from year 2000 to 2014, respectively. Overall costs of hip fractures raised from 735 to 961 million Euros (+ 30.74% from 2000 to 2014).

CONCLUSION

The number of hip fractures and related hospitalizations costs in Italian elderly population is still increasing due to the absolute number of fractures occurring in people ≥ 65 years old and particularly over 75 years old.

Deep Learning With Electronic Health Records for Short-Term Fracture Risk Identification: Crystal Bone Algorithm Development and Validation

Background

Fractures as a result of osteoporosis and low bone mass are common and give rise to significant clinical, personal, and economic burden. Even after a fracture occurs, high fracture risk remains widely underdiagnosed and undertreated. Common fracture risk assessment tools utilize a subset of clinical risk factors for prediction, and often require manual data entry. Furthermore, these tools predict risk over the long term and do not explicitly provide short-term risk estimates necessary to identify patients likely to experience a fracture in the next 1-2 years.

Objective

The goal of this study was to develop and evaluate an algorithm for the identification of patients at risk of fracture in a subsequent 1- to 2-year period. In order to address the aforementioned limitations of current prediction tools, this approach focused on a short-term timeframe, automated data entry, and the use of longitudinal data to inform the predictions.

Methods

Using retrospective electronic health record data from over 1,000,000 patients, we developed Crystal Bone, an algorithm that applies machine learning techniques from natural language processing to the temporal nature of patient histories to generate short-term fracture risk predictions. Similar to how language models predict the next word in a given sentence or the topic of a document, Crystal Bone predicts whether a patient’s future trajectory might contain a fracture event, or whether the signature of the patient’s journey is similar to that of a typical future fracture patient. A holdout set with 192,590 patients was used to validate accuracy. Experimental baseline models and human-level performance were used for comparison.

Results

The model accurately predicted 1- to 2-year fracture risk for patients aged over 50 years (area under the receiver operating characteristics curve [AUROC] 0.81). These algorithms outperformed the experimental baselines (AUROC 0.67) and showed meaningful improvements when compared to retrospective approximation of human-level performance by correctly identifying 9649 of 13,765 (70%) at-risk patients who did not receive any preventative bone-health-related medical interventions from their physicians.

Conclusions

These findings indicate that it is possible to use a patient’s unique medical history as it changes over time to predict the risk of short-term fracture. Validating and applying such a tool within the health care system could enable automated and widespread prediction of this risk and may help with identification of patients at very high risk of fracture.

Exercise-Induced Myokines can Explain the Importance of Physical Activity in the Elderly: An Overview

Physical activity has been found to aid the maintenance of health in the elderly. Exercise-induced skeletal muscle contractions lead to the production and secretion of many small proteins and proteoglycan peptides called myokines. Thus, studies on myokines are necessary for ensuring the maintenance of skeletal muscle health in the elderly. This review summarizes 13 myokines regulated by physical activity that are affected by aging and aims to understand their potential roles in metabolic diseases. We categorized myokines into two groups based on regulation by aerobic and anaerobic exercise. With aging, the secretion of apelin, β-aminoisobutyric acid (BAIBA), bone morphogenetic protein 7 (BMP-7), decorin, insulin-like growth factor 1 (IGF-1), interleukin-15 (IL-15), irisin, stromal cell-derived factor 1 (SDF-1), sestrin, secreted protein acidic rich in cysteine (SPARC), and vascular endothelial growth factor A (VEGF-A) decreased, while that of IL-6 and myostatin increased. Aerobic exercise upregulates apelin, BAIBA, IL-15, IL-6, irisin, SDF-1, sestrin, SPARC, and VEGF-A expression, while anaerobic exercise upregulates BMP-7, decorin, IGF-1, IL-15, IL-6, irisin, and VEGF-A expression. Myostatin is downregulated by both aerobic and anaerobic exercise. This review provides a rationale for developing exercise programs or interventions that maintain a balance between aerobic and anaerobic exercise in the elderly.

Bone health assessment in clinical practice is infrequenty performed in patients with chronic pancreatitis

BACKGROUND

Chronic pancreatitis (CP) patients have a high prevalence of osteoporotic fractures. In addition to prevalence of osteoporotic fractures, we evaluated how often bone health is assessed by dual-energy x-ray absorptiometry (DXA) in clinical practice, and the performance of Fracture Risk Assessment Tool (FRAX®) in predicting fracture risk in CP patients.

METHODS

Medical records of CP patients age ≥40 years prospectively enrolled in the North American Pancreatitis Study 2 (NAPS2) from the University of Pittsburgh Medical Center from 2000 to 2014 were retrospectively reviewed to gather additional relevant data before, at, and after enrollment until December 2016. We determined if patients underwent DXA, compared their observed prevalence of fractures with published data from two large US studies based on administrative data, and their predicted fracture risk with US population based on FRAX®.

RESULTS

Only 21% (49/239) patients were evaluated by DXA during their care. The observed cumulative prevalence of fragility fractures in NAPS2 CP patients (9.2%, 95% confidence interval 5.9-13.6) was significantly greater than in controls (1.46% and 2.16%, p ≤ 0.001 for each comparison) and CP patients (4.66%, and 5.13%, p < 0.005 for each comparison) in the two US administrative data studies. The FRAX® 10-year probability of major osteoporotic fracture of ≥20% (5.1% vs. 8.3%, p > 0.05) and for hip fracture of ≥3% (19.6% vs. 18.9%, p > 0.05) in NAPS2 CP patients did not differ from the US population.

CONCLUSIONS

Despite their high risk of fragility fractures, bone health is infrequently assessed in CP patients. FRAX® may not adequately predict fracture risk in CP patients.

BMP gene delivery for skeletal tissue regeneration

Musculoskeletal disorders are common and can be associated with significant morbidity and reduced quality of life. Current treatments for major bone loss or cartilage defects are insufficient. Bone morphogenetic proteins (BMPs) are key players in the recruitment and regeneration of damaged musculoskeletal tissues, and attempts have been made to introduce the protein to fracture sites with limited success. In the last 20 years we have seen a substantial progress in the development of various BMP gene delivery platforms for several conditions. In this review we cover the progress made using several techniques for BMP gene delivery for bone as well as cartilage regeneration, with focus on recent advances in the field of skeletal tissue engineering. Some methods have shown success in large animal models, and with the global trend of introducing gene therapies into the clinical setting, it seems that the day in which BMP gene therapy will be viable for clinical use is near.

A systematic review of the indirect and social costs studies in fragility fractures

Fragility fractures (FF) are the main clinical consequence of osteoporosis. FF lead to a loss in quality of life (QL), increased dependency and higher costs due to loss of productivity. Despite this, very few studies have been performed about the indirect or social costs of FF. The objective of this review was to systematically synthesize published evidence regarding indirect costs of FF. We conducted a systematic literature review of empirical studies published as peer review papers between 1998 and 2019. A total of 295 papers were found about costs and osteoporosis. After an iterative process, only 16 papers fit the criteria of selection. Despite the important consequences for QL, only seven studies have included research of the issue and only one about dependency. Treatments are cost-effective, but adherence is low. Multiple fractures, older age and low socioeconomic profile imply higher costs. Most studies are performed using the human capital methodology. The main two variables are loss of productivity and absenteeism. Most of the people included in the samples are out of the active population. Those studies that include a follow-up period vary in a range between 3 months and 2 years. Depending on sample and methodology, the indirect costs (IC) are between 2 and 50%. The direct costs associated with FF generally far outweigh the IC. There is a lack of studies about the effects of treatments and adherence and about the dependency system. The changing role of women in coming generations will increase indirect costs.

Development of a Value-based Algorithm for Inpatient Triage of Elderly Hip Fracture Patients

INTRODUCTION

The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives.

METHODS

From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost).

RESULTS

Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group.

CONCLUSIONS

A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients.

LEVEL OF EVIDENCE

Prognostic, level II.

Effect of subclinical hyperthyroidism on osteoporosis: A meta-analysis of cohort studies

OBJECTIVE

The effect of subclinical hyperthyroidism (SH) on bone mineral density (BMD) remains unclear, as do the linking mechanisms. This review aims to investigate the relationship between SH and bone loss in terms of the gender-dependent effects of SH on BMD.

METHODS

The PUBMED, EMBASE, OVID, MEDLINE, SINOMED and COCHRANE LIBRARY databases (inception to August 12, 2019) were searched for cohort studies investigating the effects of SH on BMD. Eligible studies were subjected to qualitative and quantitative analysis using a random-effects model meta-analysis with the Cochrane systematic evaluation method.

RESULTS

Twelve cohort studies involving 275,086 participants who were followed for 3 months to 13 years were included based on predefined inclusion and exclusion criteria. The results indicated that SH did not affect lumbar spine BMD in females or males. However, a significant reduction in femoral neck BMD was observed in females, but not in males. Further, there was a significant increase in hip fractures events in both females and males with SH.

CONCLUSIONS

The present findings indicate that SH is significantly associated with hip fracture risk, and therefore, it is important to assess the risk of fractures in patients with SH. Future studies should focus on methods for accurately determining this risk in patients with SH and providing them with timely and efficient diagnosis and treatment.

Osteoporosis Management in the Era of COVID-19

Osteoporosis is a chronic condition that reflects reduced bone strength and an associated increased risk for fracture. As a chronic condition, osteoporosis generally requires sustained medical intervention(s) to limit the risks for additional bone loss, compromise of skeletal integrity, and fracture occurrence. Further complicating this issue is the fact that the abrupt cessation of some therapies can be associated with an increased risk for harm. It is in this context that the COVID-19 pandemic has brought unprecedented disruption to the provision of health care globally, including near universal requirements for social distancing. In this Perspective, we provide evidence, where available, regarding the general care of patients with osteoporosis in the COVID-19 era and provide clinical recommendations based primarily on expert opinion when data are absent. Particular emphasis is placed on the transition from parenteral osteoporosis therapies. It is hoped that these recommendations can be used to safely guide care for patients with osteoporosis until a return to routine clinical care standards is available. © 2020 American Society for Bone and Mineral Research.

Early Osteoporosis Risks and Associated Factors among Caregivers Working in Disability Institutions: IOF One-Minute Osteoporosis Risk Check

This study employed the International Osteoporosis Foundation's One-Minute Osteoporosis Risk Test to examine factors related to the osteoporosis risk of institutional caregivers. In this cross-sectional study, a self-developed structured questionnaire comprising the One-Minute Osteoporosis Risk Test was used to obtain data on the caregivers' demographic data, health habits, working style, and osteoporosis risk. Seven disability welfare institutions were selected as research sites, and 465 copies of questionnaires were distributed to the institutions' employees, with 455 valid responses collected for a valid return rate of 98%. SPSS for Windows (Version 20.0) was used to analyze questionnaire data; descriptive-statistical frequency, a χ² test, and logistic regression were used to determine the correlation between demographic data, health habits, working style, and osteoporosis risk. The results revealed that primary risk factors include < 30 min of daily exercise (38%), lack of dairy product or calcium tablet intake (28%), and < 10 min of daily outdoor activity or not taking vitamin D supplements (29.9%). In total, 395 (86.8%) of the respondents scored less than 5 in the osteoporosis risk test; the remaining 60 (13.2%) scored 5 or higher, revealing a high risk of early osteoporosis. An independent variable analysis revealed that the risk factors of early osteoporosis include age, education level, having undergone bone density tests, prior disease diagnosis, long-term medication use, physical fitness, dietary habits, and average time of exposure to sunlight. In the multivariate analysis, poor physical fitness (odds ratio [OR] = 2.18, 95% confidence interval [CI]: 1.12-4.27, p = 0.023) and average daily time of exposure to sunlight (OR = 0.24, 95% CI: 0.59-2.59, p < 0.001) were significantly correlated with osteoporosis risk. In other words, respondents with poor physical fitness were 2.18 times as likely to have osteoporosis as those with good physical fitness, and those exposed to sunlight for 30 min or longer every day were 0.24 times as likely to have osteoporosis as those exposed to sunlight for less than 30 min every day. Accordingly, institutions must encourage employees to spend more time in the sun every day and improve their physical fitness through exercise.

Systemic Parathyroid Hormone Enhances Fracture Healing in Multiple Murine Models of Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a multisystemic disease that afflicts more than 415 million people globally-the incidence and prevalence of T2DM continues to rise. It is well-known that T2DM has detrimental effects on bone quality that increase skeletal fragility, which predisposes subjects to an increased risk of fracture and fracture healing that results in non- or malunion. Diabetics have been found to have perturbations in metabolism, hormone production, and calcium homeostasis-particularly PTH expression-that contribute to the increased risk of fracture and decreased fracture healing. Given the perturbations in PTH expression and the establishment of hPTH (1-34) for use in age-related osteoporosis, it was determined logical to attempt to ameliorate the bone phenotype found in T2DM using hPTH (1-34). Therefore, the present study had two aims: (i) to establish a suitable murine model of the skeletal fragility present in T2DM because no current consensus model exists; and (ii) to determine the effects of hPTH (1-34) on bone fractures in T2DM. The results of the present study suggest that the polygenic mouse of T2DM, TALLYHO/JngJ, most accurately recapitulates the diabetic osteoporotic phenotype seen in humans and that the intermittent systemic administration of hPTH (1-34) increases fracture healing in T2DM murine models by increasing the proliferation of mesenchymal stem cells. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

The Effect of Denosumab on Bone Mass in Super Elderly Patients

BACKGROUND

Denosumab is a potent antiresorptive drug leading to significant reduction in the risk of vertebral and non-vertebral fractures in postmenopausal osteoporosis. The effect of denosumab in super-elderly patients lacks data to date and few literature has proven the efficacy to this specific group. The purpose of this study was to determine the effectiveness and safety of denosumab in the super-elderly.

METHODS

We retrospectively evaluated 60 patients older than 80 with osteoporosis treated with denosumab. Patients were treated with denosumab every 6 months for 12 months 2017 to 2020. The primary endpoint was defined by the changes in bone mineral density (BMD) of 3 measurement sites: the lumbar spine, femoral neck, and total hip. Changes in bone turnover markers, serum calcium, serum phosphate, and 25-hydroxy-vitamin D were also observed.

RESULTS

All 60 patients were female, and the mean age was 83.9±3.1, from age 80 to 94. After 12 months of denosumab treatment, significant increases in BMD were observed; 3.02±2.74% for the lumbar spine (P=0.000), 3.10±6.90% for the femoral neck (P=0.005), and 2.89±5.80% for the total hip (P=0.002) The bone turnover marker C-terminal telopeptide of type I collagen and osteocalcin significantly declined after 12 months of treatment (-34.8±45.9%; P=0.002 and -35.5±38.9%; P=0.004 respectively). Symptomatic hypocalcemia and serious adverse drug reactions that required drug discontinuation were not observed during treatment.

CONCLUSIONS

Denosumab is thought to be an anti-osteoporotic medication that is sufficiently effective and safe even for the super-elderly.

A fall in the previous 12 months predicts fracture in the subsequent 5 years in postmenopausal women

PURPOSE

The purpose of this study was to evaluate if a history of falls predicts future postmenopausal fractures and if this prediction variesaccording to frequency, mechanism, and severity of falls and site of fractures.

METHODS

This study used data from OSTPRE prospective cohort. Total study population consisted of 8744 postmenopausal women (mean age 62.2 years) who responded to postal enquiry in 1999 (baseline) and in 2004 (follow-up).

RESULTS

Women were classified by frequency (non/occasional/frequent fallers), mechanism (slip/nonslip), and severity (injurious/ non-injurious) of falls and fractures by site (major osteoporotic/other). A total of 1693 (19.4%) women reported a fall during the preceding 12 months in 1999; 812 a slip fall, 654 a nonslip, 379 an injurious fall, and 1308 a non-injurious fall. A total of 811 women (9.3%) sustained a fracture during the 5-year follow-up period (1999-2004); 431 major osteoporotic fractures and 380 other fractures. Compared with non-fallers, earlier falls predicted subsequent fractures with an OR of 1.41 (95% CI 1.19-1.67, p ≤ 0.001), 1.43 (95% CI 1.14-1.80, p = 0.002) for earlier slip falls, and 1.35 (95% CI 1.04-1.74, p = 0.02) for earlier nonslip falls. Earlier injurious falls predicted future fractures (OR = 1.64, 95% CI 1.21-2.23, p ≤ 0.01), especially other fractures (OR = 1.86, 95% CI 1.24-2.80, p ≤ 0.01), but not major osteoporotic fractures (OR = 1.37, 95% CI 0.89-2.10, p = 0.151). Fracture risk predictions for earlier non-injurious falls was OR = 1.36, 95% CI 1.12-1.64, p = 0.002. These risk patterns remain same after adjustments.

CONCLUSION

History of falls (especially injurious falls) predicts subsequent fractures (mainly other fractures compared with major osteoporotic fractures) inpostmenopausal women. We aimed to investigate if history of falls (frequency, mechanism, and severity) is a predictor of future fractures in postmenopausal women. Our results indicate that history of falls (especially injurious falls) appeared to be an indicator for subsequent fracture overall. Earlier injurious falls were stronger predictors for future other fractures than for typical major osteoporotic fractures.

Hardware removal rates after surgical treatment of proximal femur fractures : Nationwide trends in Finland in 1997-2016

BACKGROUND

Various internal fixation methods have been used to treat proximal femur fractures and occasionally the fixation material is removed. However, nationwide trends of hardware removals are not known. Thus, this study investigated the hardware removal rates after proximal femur fractures in Finland during 1997-2016.

MATERIALS AND METHODS

Finnish adults aged 18 years or older in 1997-2016 formed the basic study population. From the National Hospital Discharge Register patients with trochanteric femur fracture treated with an intramedullary nail (IMN) or dynamic hip screw (DHS), and patients with femoral neck fracture treated with screw fixation, were included. Hardware removal and secondary prosthesis rates were assessed.

RESULTS

Altogether 41,253 patients underwent proximal femoral fracture fixation surgery in Finland in 1997-2016. Of these, 16,152 were DHS surgery and 15,724 IMN surgery and 8491 underwent screw operation of femoral neck fracture. The total removal rates of DHS and IMN were 5.5% and 5.4%. The total removal rate of screw fixations of the femoral neck was higher, 18.5%. The total removal rates during the first 3 years after the IMN more than halved in 1997-2013, from 7.6% to 3.7%, whereas the removal rate of the DHS or screw fixation of femoral neck fractures did not show consistent trend. The rate of secondary prosthesis operations following DHS and IMN was low (1.8% for both). This was in clear contrast to the prosthesis rate following screw fixations of the femoral neck (7.2%).

CONCLUSIONS

IMN operations largely replaced DHS operations in trochanteric fractures of the proximal femur in Finland in 1997-2016. The removal and secondary prosthesis rates of the DHS and IMN were clearly lower than the corresponding rates after screw fixations of the femoral neck fracture.

LEVEL OF EVIDENCE

III, Epidemiologic study.

Measurement of Forearm Bone Density by Dual Energy X-Ray Absorptiometry Increases the Prevalence of Osteoporosis in Men With Celiac Disease

BACKGROUND & AIMS

Guidelines advise measurement of bone mineral density (BMD) in patients with a diagnosis of celiac disease. The lumbar spine (LS) and hip sites are usually measured. Although skeletal sites rich in trabecular bone are believed to be vulnerable to osteoporosis in patients with celiac disease, most studies have not measured the cortical distal 1/3-radius.

METHODS

We collected data from 721 patients (mean age, 43.6 years; 68.4% female) with celiac disease who underwent 3-site dual energy x-ray absorptiometry (DXA, at a median 1.22 years after diagnosis). We assessed skeletal site- and sex-specific osteoporosis prevalence and the incremental utility of 1/3-radius measurement by DXA.

RESULTS

Mean T- and Z-scores were normal in patients, but 43.3% had osteopenia and 19.6% had osteoporosis. Osteoporosis was found in 12.1% of patients at the LS, 5.3% of patients at the total hip, 7.6% of patients at the femoral neck, and 11.5% of patients at the 1/3-radius. A greater degree of villous atrophy at diagnosis was associated with male sex and lower T-scores at the 1/3-radius (P = .03), but not other skeletal sites. Isolated forearm osteoporosis was detected in 4.9% of patients. A higher proportion of patients with isolated forearm osteoporosis were male and had a greater weight and body mass index (all P < .01, compared to patients with osteoporosis only at other sites). Z-scores were lower at the LS and 1/3-radius and osteoporosis was more common in men than women. In men, the 1/3-radius was the most frequent site for osteoporosis. Among patients 50 years or older, isolated forearm osteoporosis was present in 10.7%.

CONCLUSIONS

Based on DXA analysis of patients with celiac disease, the prevalence of osteoporosis appears to be underestimated-particularly in men when BMD at the 1/3-radius is not measured. Degree of villous atrophy is associated with BMD at the 1/3-radius and nearly 5% of patients have osteoporosis limited to that site. Recommendations for osteoporosis screening in patients with celiac disease should include measurement of the distal 1/3-radius in addition to the hip and LS.

Cost-Effectiveness of Osteoporosis Screening Using Biomechanical Computed Tomography for Patients With a Previous Abdominal CT

Osteoporosis screening rates by DXA are low (9.5% women, 1.7% men) in the US Medicare population aged 65 years and older. Addressing this care gap, we estimated the benefits of a validated osteoporosis diagnostic test suitable for patients age 65 years and older with an abdominal computed tomography (CT) scan taken for any indication but without a recent DXA. Our analysis assessed a hypothetical cohort of 1000 such patients in a given year, and followed them for 5 years. Separately for each sex, we used Markov modeling to compare two mutually exclusive scenarios: (i) utilizing the CT scans, perform one-time "biomechanical computed tomography" (BCT) analysis to identify high-risk patients on the basis of both femoral strength and hip BMD T-scores; (ii) ignore the CT scan, and rely instead on usual care, consisting of future annual DXA screening at typical Medicare rates. For patients with findings indicative of osteoporosis, 50% underwent 2 years of treatment with alendronate. We found that BCT provided greater clinical benefit at lower cost for both sexes than usual care. In our base case, compared to usual care, BCT prevented hip fractures over a 5-year window (3.1 per 1000 women; 1.9 per 1000 men) and increased quality-adjusted life years (2.95 per 1000 women; 1.48 per 1000 men). Efficacy and savings increased further for higher-risk patient pools, greater treatment adherence, and longer treatment duration. When the sensitivity and specificity of BCT were set to those for DXA, the prevented hip fractures versus usual care remained high (2.7 per 1000 women; 1.5 per 1000 men), indicating the importance of high screening rates on clinical efficacy. Therefore, for patients with a previously taken abdominal CT and without a recent DXA, osteoporosis screening using biomechanical computed tomography may be a cost-effective alternative to current usual care. © 2019 American Society for Bone and Mineral Research.

Conversion of Hemiarthroplasty to THA Carries an Increased Risk of Reoperation Compared With Primary and Revision THA

BACKGROUND

There is limited information on the complications and costs of conversion THA after hemiarthroplasty for femoral neck fractures. Previous studies have found that patients undergoing conversion THA experience higher risk complications, but it has been difficult to quantify the risk because of small sample sizes and a lack of comparison groups. Therefore, we compared the complications of patients undergoing conversion THA with strictly matched patients undergoing primary and revision THA.

QUESTIONS/PURPOSES

(1) What are the risks of complications, dislocations, reoperations, revisions and periprosthetic fractures after conversion THA compared with primary and revision THA and how has this effect changed over time? (2) What are the length of hospital stay and hospital costs for conversion THA, primary THA, and revision THA?

METHODS

Using a longitudinally maintained total joint registry, we identified 389 patients who were treated with conversion THA after hemiarthroplasty for femoral neck fractures between 1985 and 2014. The conversion THA cohort was 1:2 matched on age, sex, and year of surgery to 778 patients undergoing primary THA and 778 patients undergoing revision THA. The proportion of patients having at least 5-year followup was 73% in those who underwent conversion THA, 77% in those who underwent primary THA, and 76% in those who underwent revision THA. We observed a significant calendar year effect, and therefore, compared the three groups across two separate time periods: 1985 to 1999 and 2000 to 2014. We ascertained complications, dislocations, reoperations, revisions and periprosthetic fractures from the total joint registry. Cost analysis was performed using a bottom-up, microcosting methodology for procedures between 2003 and 2014.

RESULTS

Patients who converted to THA between 1985 and 1999 had a higher risk of complications (hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.7-3.1; p < 0.001), dislocations (HR, 2.3; 95% CI, 1.3-4.2; p = 0.007), reoperations (HR, 1.7; 95% CI, 1.2-2.5, p = 0.005), and periprosthetic fractures (HR, 3.8; 95% CI, 2.2-6.6; p < 0.001) compared with primary THA. However, conversion THAs during the 1985 to 1999 time period had a lower risk of reoperations (HR, 0.7; 95% CI, 0.5-1.0; p = 0.037), revisions (HR, 0.6; 95% CI, 0.5-0.9; p = 0.014), and periprosthetic fractures (HR, 0.6; 95% CI, 0.4-0.9; p = 0.007) compared with revision THA. The risk differences across the three groups were more pronounced after 2000, particularly when comparing conversion THA patients with revision THA. Conversion THA patients had a higher risk of reoperations (HR, 1.9; 95% CI, 1.0-3.4; p = 0.041) and periprosthetic fractures (HR, 1.7; 95% CI, 1.0-2.9; p = 0.036) compared with revision THA, but there were no differences in the complication risk (HR, 1.4; 95% CI, 0.9-2.1; p = 0.120), dislocations (HR, 1.5; 95% CI, 0.7-3.2; p = 0.274), and revisions (HR, 1.4; 95% CI, 0.7-3.0; p = 0.373). Length of stay for conversion THA was longer than primary THA (4.7 versus 4.0 days; p = 0.012), but there was no difference compared with revision THA (4.7 versus 4.5 days; p = 0.484). Similarly, total inpatient costs for conversion THA were higher than primary THA (USD 22,662 versus USD 18,694; p < 0.001), but there was no difference compared with revision THA (USD 22,662 versus USD 22,071; p = 0.564).

CONCLUSIONS

Over the 30 years of the study, conversion THA has remained a higher risk procedure in terms of reoperation compared with primary THA, and over time, it also has become higher risk compared with revision THA. Surgeons should approach conversion THA as a challenging procedure, and patients undergoing this procedure should be counseled about the elevated risks. Furthermore, hospitals should seek appropriate reimbursement for these cases.

LEVEL OF EVIDENCE

Level III, therapeutic study.

No Major Differences in Recovery After Hip Fracture Between Home-Dwelling Female and Male Patients

BACKGROUND

Studies comparing recovery of men and women after hip fracture have reported conflicting results, some reporting worse recovery in male patients, while others found no differences between genders.

METHODS

Recovery was compared in 105 male and 433 female patients with hip fractures and in age-matched groups of patients 50 years or older, who were home-dwelling and received similar rehabilitation. Residential status, walking ability, hip pain and activities of daily living function were recorded at admission and 4 and 12 months postoperatively, along with mortality and re-operations.

RESULTS

No differences were observed between men and women 4 and 12 months postoperatively regarding residential status (p = 0.181 vs p = 0.883), mortality rates (p = 0.232 vs p = 0.880) or total activities of daily living scores (p = 0.546 vs p = 0.435). Walking ability was better among male patients prefracture (p < 0.001) and 4 and 12 months after fracture (p < 0.001, p = 0.031, respectively). In age-matched pair analysis, no differences were found regarding mortality, residential status, walking ability, or ADL score. Cox regression analysis identified mortality risk factors as being age, prefracture ADL score, American Society of Anesthesiologists score 4-5 and place of rehabilitation. Sex was not mortality risk factor.

INTERPRETATION

Home-dwelling male and female patients had similar courses of recovery from hip fracture, although there were singular differences in specific activities of daily living functions and postoperative pain. There were no differences in mortality, even when prefracture characteristics were considered. Mortality was higher among older patients and who had high American Society of Anesthesiologists scores and low prefracture activities of daily living scores.

Direct conversion of fibroblasts to osteoblasts as a novel strategy for bone regeneration in elderly individuals

Mortality caused by age-related bone fractures or osteoporosis is steadily increasing worldwide as the population ages. The pace of the development of bone regeneration engineering to treat bone fractures has consequently increased in recent years. A range of techniques for bone regeneration, such as immunotherapy, allografts, and hydrogel therapy, have been devised. Cell-based therapies using bone marrow-derived mesenchymal stem cells and induced pluripotent stem cells derived from somatic cells are considered to be suitable approaches for bone repair. However, these cell-based therapies suffer from a number of limitations in terms of efficiency and safety. Somatic cells can also be directly differentiated into osteoblasts by several transcription factors. As osteoblasts play a central role in the process of bone formation, the direct reprogramming of fibroblasts into osteoblasts may hence be a new way to treat bone fractures in elderly individuals. Here, we review recent developments regarding the therapeutic potential of the direct reprogramming of cells for bone regeneration.

Reprogramming cells that produce connective tissue to form bone instead could help prevent fractures in the elderly. Bones weaken with age, and fractures are a significant health risk in ageing populations. Most current bone regeneration treatments use stem cells, which can differentiate into any type of cell and have infinite capacity to divide; however, they are difficult to source and can lead to tumor formation. Jongpil Kim at Dongguk University in South Korea and coworkers have reviewed a new method that uses genetic signals to transform connective tissue-forming cells into bone-producing cells. The reprogrammed cells have been shown to generate new bone at the desired site, and because they have already lost their capacity for infinite division, tumor formation risk is greatly reduced. This method shows promise to expand treatment options for fractures and osteoporosis.

Hyperhomocysteinemia as a Risk Factor and Potential Nutraceutical Target for Certain Pathologies

Hyperhomocysteinemia is recognized as a risk factor for several diseases, including cardiovascular and neurological conditions. Homocysteine (HCys) is a key metabolite involved in the biosynthesis and metabolism of methionine (Met), which plays a pivotal role in the physiological cell's life cycle. The biochemistry of Met is finely regulated by several enzymes that control HCys concentration. Indeed, balanced activity among the enzymes is essential for the cell's well-being, while its malfunction could raise HCys concentration which can lead to the onset of several pathological conditions. The HCys concentration increase seems to be caused mainly by the widely diffused polymorphisms of several enzymes. Nowadays, a blood test can easily detect elevated concentrations of HCys, referred to as Hyperhomocysteinemia (HHCys). Prolonged exposure to this condition can lead to the onset of cardiovascular disease and can lead to the development of atherosclerosis, stroke, inflammatory syndromes like osteoporosis and rheumatism, as well as neuronal pathologies including Alzheimer's and Parkinson's diseases. In this review, we analyzed the literature of several pathological conditions in which the molecular pathways of HHCys are involved. Interestingly, several observations indicate that the calibrated assumption of correct doses of vitamins such as folic acid, vitamin B6, vitamin B12, and betaine may control HHCys-related conditions.