Refractures in patients at least forty-five years old. a prospective analysis of twenty-two thousand and sixty patients

Non-osteoporotic fractures are associated with increased risk of subsequent major osteoporotic fractures

We studied the association between non-osteoporotic fractures and future major osteoporotic fractures, using UK health records. Non-osteoporotic fractures were found to increase the risk of major osteoporotic fractures, although to a lesser extent than osteoporotic fractures. This highlights the importance of considering all previous fractures in assessing future fracture risk.

PURPOSE

Previous studies demonstrated that osteoporotic fractures-minor and major-increase the risk for future major osteoporotic fractures; we test whether non-osteoporotic fractures are also associated with such increased risk.

METHODS

The study is a retrospective cohort study using UK primary care electronic health records. Exposure groups were defined according to fracture location prior to the year 2011 (index date): major, minor, and non-osteoporotic. The outcome of incident major osteoporotic fractures following the index date was compared between the exposure groups and the general population.

RESULTS

The general study population included 1,951,388 patients. The exposure groups included 39,931 patients with a prior major osteoporotic fracture, 19,397 with a prior minor osteoporotic fracture, and 50,115 patients with a prior non-osteoporotic fracture. The standardized Incidence Rate Ratio for future major osteoporotic fractures was 2.73 (95% confidence interval: 2.64-2.82), 2.43 (2.32-2.54), and 1.83 (1.74-1.92), respectively.

CONCLUSION

Non-osteoporotic fractures are significantly associated with increased risk for future major osteoporotic fractures relative to the general population, yet to a lesser extent compared to major and minor osteoporotic fractures.

Generalizability of Deep Learning Classification of Spinal Osteoporotic Compression Fractures on Radiographs Using an Adaptation of the Modified-2 Algorithm-Based Qualitative Criteria

RATIONALE AND OBJECTIVES

Spinal osteoporotic compression fractures (OCFs) can be an early biomarker for osteoporosis but are often subtle, incidental, and underreported. To ensure early diagnosis and treatment of osteoporosis, we aimed to build a deep learning vertebral body classifier for OCFs as a critical component of our future automated opportunistic screening tool.

MATERIALS AND METHODS

We retrospectively assembled a local dataset, including 1790 subjects and 15,050 vertebral bodies (thoracic and lumbar). Each vertebral body was annotated using an adaption of the modified-2 algorithm-based qualitative criteria. The Osteoporotic Fractures in Men (MrOS) Study dataset provided thoracic and lumbar spine radiographs of 5994 men from six clinical centers. Using both datasets, five deep learning algorithms were trained to classify each individual vertebral body of the spine radiographs. Classification performance was compared for these models using multiple metrics, including the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and positive predictive value (PPV).

RESULTS

Our best model, built with ensemble averaging, achieved an AUC-ROC of 0.948 and 0.936 on the local dataset's test set and the MrOS dataset's test set, respectively. After setting the cutoff threshold to prioritize PPV, this model achieved a sensitivity of 54.5% and 47.8%, a specificity of 99.7% and 99.6%, and a PPV of 89.8% and 94.8%.

CONCLUSION

Our model achieved an AUC-ROC>0.90 on both datasets. This testing shows some generalizability to real-world clinical datasets and a suitable performance for a future opportunistic osteoporosis screening tool.

Zoledronic acid for osteoporosis after distal radius fracture surgery: Prospective longitudinal study

Background

Distal radius fractures (DRFs) are the most frequent first-ever osteoporotic fragility fractures. However, most patients are treated only for fractures and not for osteoporosis. Therefore, we investigated early osteoporosis intervention using zoledronic acid.

Methods

This prospective study enrolled 30 patients aged 50 years or older who had no history of fragility fractures or osteoporosis treatment and who underwent surgical treatment for DRFs. Patients whose lumbar spine or femur bone mineral density (BMD) values were less than 80% of the young adult mean (YAM) were treated with a 5-mg intravenous infusion of zoledronic acid. Lumbar spine and femur YAM BMD values, TRACP-5b and PINP were statistically evaluated using the paired t-test. The relationship between adverse effects, age, body mass index (BMI), and creatinine clearance (CCr) was statistically examined using Mann-Whitney's U test. The incidence of the bone fusion and secondary fractures within the 60-months postoperative period were assessed.

Results

The mean lumbar spine and femur YAM BMD values before treatment were 76.1 ± 13.1% and 70.7 ± 8.5%. This indicates osteopenia in both locations. These values differed significantly between the pre-treatment period and each subsequent period. Five patients with a target YAM BMD value over 80% within 60 months after treatment were observed. The TRACP-5b and PINP values differed significantly between the pre-treatment period and each subsequent period. Adverse drug reactions were observed in 12 patients (40%). Age, BMI, and CCr did not show statistically significant differences in the occurrence of adverse effects. Bone fusion was confirmed at a mean of 3.6 months postoperatively. Secondary fractures were observed in 3 patients within 60 months after treatment.

Conclusion

DRFs occur at a younger age than other fragility fractures, and it is important to intervene aggressively with osteoporosis treatment to prevent secondary fractures.

Level of evidence

Level V.

Pathophysiological mechanism of acute bone loss after fracture

BACKGROUND

Acute bone loss after fracture is associated with various effects on the complete recovery process and a risk of secondary fractures among patients. Studies have reported similarities in pathophysiological mechanisms involved in acute bone loss after fractures and osteoporosis. However, given the silence nature of bone loss and bone metabolism complexities, the actual underlying pathophysiological mechanisms have yet to be fully elucidated.

AIM OF REVIEW

To elaborate the latest findings in basic research with a focus on acute bone loss after fracture. To briefly highlight potential therapeutic targets and current representative drugs. To arouse researchers' attention and discussion on acute bone loss after fracture.

KEY SCIENTIFIC CONCEPTS OF REVIEW

Bone loss after fracture is associated with immobilization, mechanical unloading, blood supply damage, sympathetic nerve regulation, and crosstalk between musculoskeletals among other factors. Current treatment strategies rely on regulation of osteoblasts and osteoclasts, therefore, there is a need to elucidate on the underlying mechanisms of acute bone loss after fractures to inform the development of efficacious and safe drugs. In addition, attention should be paid towards ensuring long-term skeletal health.

Decrease in osteoporotic fracture in the western Kitakyushu region by the STOP-Fx study

INTRODUCTION

The Seamless Treatment of Osteoporosis against Fractures (STOP-Fx) study was initiated to provide and continue therapeutic interventions for registered patients with osteoporotic fractures.

MATERIALS AND METHODS

Women who visited six hospitals in the western Kitakyushu area for osteoporotic fractures between October 2016 and December 2018 were included in the study. Data collection for primary and secondary outcomes was conducted from October 2018 to December 2020, 2 years after STOP-Fx study enrollment. The primary outcome included the number of surgeries for osteoporotic fractures after the STOP-Fx study intervention, while secondary outcomes were the intervention rate of osteoporosis treatment, incidence and timing of secondary fractures, and factors associated with secondary fractures and loss to follow-up.

RESULTS

Concerning the primary outcome, the number of surgeries for osteoporotic fractures decreased since the STOP-Fx study initiation: 813 in 2017, 786 in 2018, 754 in 2019, 716 in 2020, and 683 in 2021. Regarding the secondary outcome, of the 805 patients enrolled, 445 were available for follow-up at 24 months. Of the 279 patients who were untreated for osteoporosis at enrollment, 255 (91%) were on treatment at 24 months. There were 28 secondary fractures, which were associated with increased tartrate-resistant acid phosphatase-5b and decreased lumbar spine bone mineral density during enrollment in the STOP-Fx study.

CONCLUSION

As the demographics and medical area served by six hospitals in the western Kitakyushu region have not changed significantly since the STOP-Fx study initiation, the STOP-Fx study may have contributed in decreasing the number of osteoporotic fractures.

Deep Learning Classification of Spinal Osteoporotic Compression Fractures on Radiographs using an Adaptation of the Genant Semiquantitative Criteria

RATIONALE AND OBJECTIVES

Osteoporosis affects 9% of individuals over 50 in the United States and 200 million women globally. Spinal osteoporotic compression fractures (OCFs), an osteoporosis biomarker, are often incidental and under-reported. Accurate automated opportunistic OCF screening can increase the diagnosis rate and ensure adequate treatment. We aimed to develop a deep learning classifier for OCFs, a critical component of our future automated opportunistic screening tool.

MATERIALS AND METHODS

The dataset from the Osteoporotic Fractures in Men Study comprised 4461 subjects and 15,524 spine radiographs. This dataset was split by subject: 76.5% training, 8.5% validation, and 15% testing. From the radiographs, 100,409 vertebral bodies were extracted, each assigned one of two labels adapted from the Genant semiquantitative system: moderate to severe fracture vs. normal/trace/mild fracture. GoogLeNet, a deep learning model, was trained to classify the vertebral bodies. The classification threshold on the predicted probability of OCF outputted by GoogLeNet was set to prioritize the positive predictive value (PPV) while balancing it with the sensitivity. Vertebral bodies with the top 0.75% predicted probabilities were classified as moderate to severe fracture.

RESULTS

Our model yielded a sensitivity of 59.8%, a PPV of 91.2%, and an F1 score of 0.72. The areas under the receiver operating characteristic curve (AUC-ROC) and the precision-recall curve were 0.99 and 0.82, respectively.

CONCLUSION

Our model classified vertebral bodies with an AUC-ROC of 0.99, providing a critical component for our future automated opportunistic screening tool. This could lead to earlier detection and treatment of OCFs.

Sex differences in systemic bone and muscle loss following femur fracture in mice

Fracture induces systemic bone loss in mice and humans, and a first (index) fracture increases the risk of future fracture at any skeletal site more in men than women. The etiology of this sex difference is unknown, but fracture may induces a greater systemic bone loss response in men. Also sex differences in systemic muscle loss after fracture have not been examined. We investigated sex differences in systemic bone and muscle loss after transverse femur fracture in 3-month-old male and female C57BL/6 J mice. Whole-body and regional bone mineral content and density (BMC and BMD), trabecular and cortical bone microstructure, muscle contractile force, muscle mass, and muscle fiber size were quantified at multiple time points postfracture. Serum concentrations of inflammatory cytokines (IL-1β, IL-6, and TNF-α) were measured 1-day postfracture. One day postfracture, IL-6 and Il-1B were elevated in fracture mice of both sexes, but TNF-α was only elevated in male fracture mice. Fracture reduced BMC, BMD, and trabecular bone microstructural properties in both sexes 2 weeks postfracture, but declines were greater in males. Muscle contractile force, mass, and fiber size decreased primarily in the fractured limb at 2 weeks postfracture and females showed a trend toward greater muscle loss. Bone and muscle properties recovered by 6 weeks postfracture. Overall, postfracture systemic bone loss is greater in men, which may contribute to sex differences in subsequent fracture risk. In both sexes, muscle loss is primarily confined to the injured limb and fracture may induce greater inflammation in males.

Altered canalicular remodeling associated with femur fracture in mice

We previously showed that femur fracture in mice caused a reduction in bone volume at distant skeletal sites within 2 weeks post-fracture. Osteocytes also have the ability to remodel their surrounding bone matrix through perilacunar/canalicular remodeling (PLR). If PLR is altered systemically following fracture, this could affect bone mechanical properties and increase fracture risk at all skeletal sites. In this study, we investigated whether lacunar-canalicular microstructure and the rate of PLR are altered in the contralateral limb following femoral fracture in mice. We hypothesized that femoral fracture would accelerate PLR by 2 weeks postfracture, followed by partial recovery by 4 weeks. We used histological evaluation and high-resolution microcomputed tomography to quantify the morphology of the lacunar-canalicular network at the contralateral tibia, and we used quantitative real-time polymerase chain reaction (RT-PCR) and RNA-seq to measure the expression of PLR-associated genes in the contralateral femur. We found that at both 2 and 4 weeks postfracture, canalicular width was significantly increased by 18.6% and 16.6%, respectively, in fractured mice relative to unfractured controls. At 3 days and 4 weeks post-fracture, we observed downregulation of PLR-associated genes; RNA-seq analysis at 3 days post-fracture showed a deceleration of bone formation and mineralization in the contralateral limb. These data demonstrate notable canalicular changes following fracture that could affect bone mechanical properties. These findings expand our understanding of systemic effects of fracture and how biological and structural changes at distant skeletal sites may contribute to increased fracture risk following an acute injury.

Relationship between distal radius fracture severity and 25-hydroxyvitamin-D level among perimenopausal and postmenopausal women

AIMS

Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency.

METHODS

This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared.

RESULTS

The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities.

CONCLUSION

Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D3 supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study. Cite this article: Bone Jt Open 2022;3(3):261-267.

The effect on subsequent fracture risk of age, sex, and prior fracture site by recency of prior fracture

The risk of a recurrent fragility fracture varies by age and sex, as by site and recency of sentinel fracture.

INTRODUCTION

The recency of prior fractures affects subsequent fracture risk. Variable recency may obscure other factors that affect subsequent fracture risk. The aim of this study was to quantify the effect of a sentinel fracture by site, age, and sex where the recency was held constant.

METHODS

The study used data from the Reykjavik Study fracture register that documented prospectively all fractures at all skeletal sites in a large sample of the population of Iceland. Fracture incidence was compared to that of the general population determined at fixed times after a sentinel fracture (humeral, clinical vertebral, forearm, hip, and minor fractures). Outcome fractures comprised a major osteoporotic fracture and hip fracture.

RESULTS

Sentinel osteoporotic fractures were identified in 9504 men and women. Of these, 3616 individuals sustained a major osteoporotic fracture as the first subsequent fracture, of whom 1799 sustained a hip fracture. Hazard ratios for prior fracture were consistently higher in men than in women and decreased progressively with age. Hazard ratios varied according to the site of sentinel fracture with higher ratios for hip and vertebral fracture than for humerus, forearm, or minor osteoporotic fracture.

CONCLUSION

The risk of a recurrent fragility fracture varies by age, sex, and site of sentinel fracture when recency is held constant.

High Risk of Hip and Spinal Fractures after Distal Radius Fracture: A Longitudinal Follow-Up Study Using a National Sample Cohort

The purpose of the present study was to estimate the risk of hip and spinal fracture after distal radius fracture. Data from the Korean National Health Insurance Service—National Sample Cohort were collected between 2002 and 2013. A total of 8013 distal radius fracture participants who were 50 years of age or older were selected. The distal radius fracture participants were matched for age, sex, income, region of residence, and past medical history in a 1:4 ratio with control participants. In the subgroup analysis, participants were stratified according to age group (50–59, 60–69, or ≥70 years) and sex (male or female). Distal radius fracture patients had a 1.51-fold and 1.40-fold higher incidence of hip fracture and spinal fracture in the adjusted models, respectively. Among males, patients of all ages had a significantly higher incidence of hip fracture, and those who were 50 to 69 years of age had a significantly higher incidence of spinal fracture. Among females, those older than 70 years had a significantly higher incidence of hip fracture, and patients of all ages had a significantly higher incidence of spinal fracture. Previous distal radius fracture has a significant impact on the risk of subsequent hip and spinal fractures.

Effect of Single Versus Multiple Fractures on Systemic Bone Loss in Mice

Systemic bone loss after initial fracture contributes to an increased risk of secondary fracture. Clinical research has revealed an association between the risk of future fracture and the number or magnitude of prior fractures. However, the change in systemic bone mass after single versus multiple fractures is unknown. We used ipsilateral femur and tibia fractures as multiple fractures and a femur or tibia fracture as a single fracture to investigate the influence of single versus multiple fractures on systemic bone mass. Seventy-two adult male C57BL/6J mice underwent transverse osteotomies of the ipsilateral femur and/or tibia with subsequent internal fixation. The dynamic change of in vivo whole-body BMD was assessed at 4 days, 2 weeks, and 4 weeks after fracture. The microstructure of the L₅ vertebral body and contralateral femur was assessed using micro-CT (μCT) and biomechanical tests (vertebral compression test and three-point bending test) at 2 and 4 weeks. Tartrate-resistant acid phosphatase (TRAP) staining, sequential fluorescence labeling, and systemic inflammatory cytokines were also quantified. A greater decrease in whole-body BMD was observed after multiple than single fractures. The trabecular bone volume fraction, trabecular number, and trabecular thickness of the L₅ vertebral body were significantly reduced. There were no significant differences in cortical thickness, trabecular bone microstructure, or bone strength in the contralateral femur. At 4 days and 2 weeks, we observed significant increases in the serum levels of IL-6 and TNF-α. We also observed an increase in the osteoclast number of the L₅ vertebral body at 4 days. These data indicate that systemic bone loss might increase with the number or severity of prior fractures, and the mechanism may be partly associated with an increased osteoclast number and a more severe inflammatory response. © 2020 American Society for Bone and Mineral Research (ASBMR).

Multidisciplinary expert consensus on secondary fracture prevention in Spain

The study aimed to achieve expert consensus to optimize secondary fracture prevention in Spain. Relevant gaps in current patient management were identified. However, some aspects were considered difficult to apply. Future efforts should focus on those items with greatest divergences between importance and feasibility.

PURPOSE

To establish a Spanish multidisciplinary expert consensus on secondary fracture prevention.

METHODS

A two-round Delphi consensus was conducted, guided by a Scientific Committee. The 43-item study questionnaire was designed from a literature review and a subsequent multidisciplinary expert group (n = 12) discussion. The first-round questionnaire, using a 7-point Likert scale, assessed the experts' opinion of the current situation, their wish for items to happen, and their prognosis that items would be implemented within 5 years. Items for which consensus was not achieved were included in the second round. Consensus was defined as ≥ 75% agreement or ≥ 75% disagreement. A total of 102 experts from 14 scientific societies were invited to participate.

RESULTS

A total of 75 (response rate 73.5%) and 69 (92.0%) experts answered the first and second Delphi rounds, respectively. Participants mean age was 51.8 years [standard deviation (SD): 10.1 years]; being 24.0% rheumatologists, 21.3% primary care physicians, 14.7% geriatricians, 8.0% internal medicine specialists, 8.0% rehabilitation physicians, and 8.0% gynecologists. Consensus was achieved for 79.1% of items (wish, 100%; prognosis, 58.1%). Effective secondary prevention strategies identified as requiring improvement included: clinical report standardization, effective hospital primary care communication (telephone/mail and case managers), health-related quality of life (HRQoL) questionnaires use, and treatment compliance monitoring (prognosis agreement 33.3%, 47.8%, 18.8%, and 55.1%, respectively).

CONCLUSION

A consensus was reached by health professionals in their wish to implement strategies to optimize secondary fracture prevention; however, they considered some difficult to apply. Efforts should focus on those items with currently low application and those with greatest divergence between wish and prognosis.

Deep Learning for Osteoporosis Classification Using Hip Radiographs and Patient Clinical Covariates

This study considers the use of deep learning to diagnose osteoporosis from hip radiographs, and whether adding clinical data improves diagnostic performance over the image mode alone. For objective labeling, we collected a dataset containing 1131 images from patients who underwent both skeletal bone mineral density measurement and hip radiography at a single general hospital between 2014 and 2019. Osteoporosis was assessed from the hip radiographs using five convolutional neural network (CNN) models. We also investigated ensemble models with clinical covariates added to each CNN. The accuracy, precision, recall, specificity, negative predictive value (npv), F1 score, and area under the curve (AUC) score were calculated for each network. In the evaluation of the five CNN models using only hip radiographs, GoogleNet and EfficientNet b3 exhibited the best accuracy, precision, and specificity. Among the five ensemble models, EfficientNet b3 exhibited the best accuracy, recall, npv, F1 score, and AUC score when patient variables were included. The CNN models diagnosed osteoporosis from hip radiographs with high accuracy, and their performance improved further with the addition of clinical covariates from patient records.

Is ankle fracture related to low bone mineral density and subsequent fracture? A systematic review

OBJECTIVES

Ankle fractures are common in the elderly. However, their association with osteoporosis remains controversial. This systematic review aims to determine the relationship between ankle fracture and bone mineral density (BMD), and to investigate the risk of subsequent fractures after ankle fracture.

METHODS

MEDLINE and Scopus publications were searched from inception to March and April 2019, respectively. Articles were selected by 2 independent reviewers for cross-sectional, cohort, or case-control studies comparing BMD or subsequent fracture risk in low-energy ankle fractures patients with that of the normal population. Data extraction was performed by 2 investigators. Discrepancies were resolved with the third reviewer. Quality assessment was conducted using the modified Newcastle-Ottawa Scale.

RESULTS

Overall, 19 articles were included. The quality assessment showed a generally low-to-moderate risk of bias among studies, mainly due to potential confounders and inadequate follow-up. Of 13 studies exploring BMD in ankle fractured-patients, lower central and peripheral BMD was found in 3 and 2 studies, respectively. The risk of subsequent fracture was examined in 11 studies with relative risks ranging from 0.7 to 4.59. An increased risk of any subsequent fractures in women, both genders, and men was found in 5, 2, and 1 articles, respectively.

CONCLUSIONS

Despite the lack of clear association with BMD, the contribution of ankle fracture to increased subsequent fracture risk and its associated microarchitectural changes cannot be overlooked. Moreover, its potential role as an early predictor of future fracture may promote secondary prevention. Further studies with longer follow-up and stricter confounder control are recommended.

Results of advanced core decompression in patients with osteonecrosis of the femoral head depending on age and sex-a prospective cohort study

Background

Core decompression is a common surgical technique to treat osteonecrosis of the femoral head. The aim of this study is to evaluate the effect of the parameters “age” and “sex” on the outcome of this type of treatment.

Methods

A prospective cohort study was performed. Eighty-six osteonecrotic hips with a mean follow-up of 32.5 months (± 24.8) after advanced core decompression were analysed regarding age- and sex-dependent treatment failure. Additionally, the modified Harris Hip Score and Numeric Rating Scale were compared regarding the parameters age and sex.

Results

The mean hip survival of the male participants was 51.3 months (39.4% treatment failure), whereas females presented a longer, thus not significant, mean survival of 61.4 months (30% therapy failure; p = 0.48). The further evaluation revealed significantly better survival in the patients aged < 40 years (mean survival 66.09 months, 16% treatment failure) in comparison to those aged ≥ 40 years (mean survival 50.14 months, 46% therapy failure; p = 0.03). The modified Harris Hip Score and Numeric Rating Scale results of patients whose treatment did not fail during the study period were similar, irrespective of the patient’s sex or age.

Conclusions

The study shows that the number of therapy failures is significantly higher in older patients, with 40 years of age marking the borderline. Patients’ sex does not seem to affect the outcome of treatment, and postoperative clinical scores appear to be identical with individuals not affected by therapy failure. Since age and sex are unalterable parameters, the study helps to provide valuable predictions regarding the chances of long-term hip survival after treatment of osteonecrosis.

Mortality and cause of death in distal radius fracture patients: A longitudinal follow-up study using a national sample cohort

The various harmful impacts of distal radius fractures (DRFs) may cause adverse effects. Although previous studies have reported the adverse effects of DRFs on mortality, most studies were performed in adults of advanced age and paid little attention to confounding factors of mortality. Furthermore, most of these studies investigated the overall impact of DRFs on mortality without differentiating the specified causes of death.The purpose of the present study was to estimate the risk of mortality in DRF patients according to the cause of death.Data from the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) from 2002 to 2013 were collected. A total of 27,295 DRF participants who were 50 years or older were 1:4 matched with control participants for age, sex, income, and region of residence. The causes of death were grouped into 12 classifications.DRFs were not associated with increased overall mortality. The adjusted hazard ratio (HR) of mortality was 1.04 (95% confidence interval [CI] = 0.98-1.11, P = .237). The adjusted HR for mortality was not significantly different according to age. The odds ratio of overall mortality was 1.03 (95% CI = 0.97-1.11, P = .329).DRFs were not associated with a significant increase in mortality.

Recurrent Fragility Fractures: A Cross-sectional Analysis

INTRODUCTION

Despite growing rates of fragility fractures, there has been a lack of research investigating the risk and characteristics of recurrent fragility fractures.

METHODS

The Medicare Standard Analytic Files database was used to identify patients from 2005 to 2009 who were older than 65 years, had a diagnosis of osteoporosis or osteopenia, and sustained a fragility fracture of the proximal humerus, distal radius, hip, ankle, or vertebral column. The incidence and type of recurrent fragility fracture were tracked over a 36-month period.

RESULTS

A total of 1,059,212 patients had an initial fragility fracture from 2005 to 2009. Of these patients, 5.8% had a subsequent fragility fracture within 1 year for their initial fracture, 8.8% within 2 years, and 11.3% within 3 years. At 3-year follow-up, hip fractures were the most common type of subsequent fracture, regardless of the initial fracture type (6.5%, P < 0.001). Vertebral compression and proximal humerus fractures (13.8% and 13.2%, respectively) were most likely to be associated with a recurrent fragility fracture.

CONCLUSION

Patients who have any type of fragility fracture have a notable risk of subsequent fractures within 3 years, especially hip fractures. These patients should be evaluated and treated for underlying risks factors, including osteoporosis and/or osteopenia.

LEVEL OF EVIDENCE

Retrospective, level III.

Age Dependence of Systemic Bone Loss and Recovery Following Femur Fracture in Mice

The most reliable predictor of future fracture risk is a previous fracture of any kind. The etiology of this increased fracture risk is not fully known, but it is possible that fracture initiates systemic bone loss, leading to greater fracture risk at all skeletal sites. In this study, we investigated systemic bone loss and recovery after femoral fracture in young (3-month-old) and middle-aged (12-month-old) mice. Transverse femur fractures were created using a controlled impact, and whole-body bone mineral density (BMD), trabecular and cortical microstructure, bone mechanical properties, bone formation and resorption rates, mouse voluntary movement, and systemic inflammation were quantified at multiple time points post-fracture. We found that fracture led to decreased whole-body BMD in both young and middle-aged mice 2 weeks post-fracture; this bone loss was recovered by 6 weeks in young but not middle-aged mice. Similarly, trabecular bone volume fraction (BV/TV) of the L5 vertebral body was significantly reduced in fractured mice relative to control mice 2 weeks post-fracture (-11% for young mice, -18% for middle-aged mice); no significant differences were observed 6 weeks post-fracture. At 3 days post-fracture, we observed significant increases in serum levels of interleukin-6 and significant decreases in voluntary movement in fractured mice compared with control mice, with considerably greater changes in middle-aged mice than in young mice. At this time point, we also observed increased osteoclast number on L5 vertebral body trabecular bone of fractured mice compared with control mice. These data show that systemic bone loss occurs after fracture in both young and middle-aged mice, and recovery from this bone loss may vary with age. This systemic response could contribute to increased future fracture risk after fracture; these data may inform clinical treatment of fractures with respect to improving long-term skeletal health. © 2018 American Society for Bone and Mineral Research.

The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures

BACKGROUND

Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention.

METHODS

A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention.

RESULTS

Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model.

CONCLUSIONS

In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.

Systemic Bone Loss After Fracture

A history of prior fracture is the most reliable indicator of prospective fracture risk. Increased fracture risk is not confined to the region of the prior fracture, but is operant at all skeletal sites, providing strong evidence of systemic bone loss after fracture. Animal and human studies suggest that systemic bone loss begins shortly after fracture and persists for several years in humans. In fact, bone quantity and bone quality may never fully return to their pre-fracture levels, especially in older subjects, demonstrating a need for improved understanding of the mechanisms leading to systemic bone loss after fracture in order to reduce subsequent fracture risk. Although the process remains incompletely understood, mechanical unloading (disuse), systemic inflammation, and hormones that control calcium homeostasis may all contribute to systemic bone loss. Additionally, individual factors can potentially affect the magnitude and time course of systemic bone loss and recovery. The magnitude of systemic bone loss correlates positively with injury severity and age. Men may also experience greater bone loss or less recovery than women after fracture. This review details the current understanding of systemic bone loss following fracture, including possible underlying mechanisms and individual factors that may affect this injury response.

Epidemiology of distal radius fractures in a geographically defined adult population

Distal radial fractures are the most common adult orthopaedic fracture. We sought to determine whether the incidence of this injury is changing and identify trends in its occurrence. We analysed data for all adult patients presenting to University Hospitals of Leicester with a distal radial fracture from 2007-2016. Incidence rates were calculated using United Kingdom population data. Poisson regression techniques were used to analyse weekly, seasonal and annual variation in fracture incidence. There was no significant change in average age or incidence of fracture. Increased incidence was associated with inclement weather conditions. Younger patients more commonly sustain fractures on weekends. We predict a 23% rise in the number of fractures in the United Kingdom in the next 20 years. The incidence of fracture does not appear to be changing, although the number of fractures is growing. Weekly and seasonal trends are apparent. Level of evidence: III.

Incident fracture is associated with a period of accelerated loss of hip BMD: the Study of Osteoporotic Fractures

Bone loss following a fracture could increase the risk of future fractures. In this study, we found that elderly women who had an upper body fracture or multiple fractures lost more bone at the hip than those who did not fracture. This suggests a possible systemic bone loss response initiated by fracture.

INTRODUCTION

A prior fracture is one of the strongest predictors of subsequent fracture risk, but the etiology of this phenomenon remains unclear. Systemic bone loss post-fracture could contribute to increased risk of subsequent fractures. Therefore, in this study, we investigated whether incident fractures, including those distant to the hip, are associated with accelerated loss of hip bone mineral density (BMD) in elderly women.

METHODS

We analyzed data from 3956 Caucasian women aged ≥ 65 years who were enrolled in the Study of Osteoporotic Fractures and completed hip BMD measurements at study visit 4 (year 6) and visit 6 (year 10). Clinical fractures between visits 4 and 6 were ascertained from triannual questionnaires and centrally adjudicated by review of community radiographic reports. Subjects provided questionnaire information and clinical variables at examinations for known and potential covariates. Generalized linear models were used to calculate average annual percent change in total hip BMD between visits 4 and 6 for each incident fracture type and for upper body and lower body fractures combined. A subset of women (n = 3783) was analyzed for annual total hip BMD change between study visits 4 and 5 and between study visits 5 and 6 to evaluate change in total hip BMD during these 2-year intervals.

RESULTS

Women with incident upper body fracture or incident lower body fracture exhibited reductions in total hip BMD of 0.89 and 0.77% per year, respectively, while women who did not fracture exhibited reductions in total hip BMD of 0.66% per year during the 4-year period. Accelerated loss of hip BMD was isolated to the 2-year time interval that included the fracture. Loss of total hip BMD was not affected by the number of days from fracture to follow up DXA.

CONCLUSIONS

Systemic bone loss following fracture may increase the risk of future fractures at all skeletal sites. There is a need for improved understanding of mechanisms leading to apparent accelerated bone loss following a fracture in order to reduce subsequent fracture risk.

Bone healing in an aged murine fracture model is characterized by sustained callus inflammation and decreased cell proliferation

Geriatric fractures take longer to heal and heal with more complications than those of younger patients; however, the mechanistic basis for this difference in healing is not well understood. To improve this understanding, we investigated cell and molecular differences in fracture healing between 5-month-old (young adult) and 25-month-old (geriatric) mice healing utilizing high-throughput analysis of gene expression. Mice underwent bilateral tibial fractures and fracture calluses were harvested at 5, 10, and 20 days post-fracture (DPF) for analysis. Global gene expression analysis was performed using Affymetrix MoGene 1.0 ST microarrays. After normalization, data were compared using ANOVA and evaluated using Principal Component Analysis (PCA), CTen, heatmap, and Incromaps analysis. PCA and cross-sectional heatmap analysis demonstrated that DPF followed by age had pronounced effects on changes in gene expression. Both un-fractured and 20 DPF aged mice showed increased expression of immune-associated genes (CXCL8, CCL8, and CCL5) and at 10 DPF, aged mice showed increased expression of matrix-associated genes, (Matn1, Ucma, Scube1, Col9a1, and Col9a3). Cten analysis suggested an enrichment of CD8+ cells and macrophages in old mice relative to young adult mice and, conversely, a greater prevalence of mast cells in young adult mice relative to old. Finally, consistent with the PCA data, the classic bone healing pathways of BMP, Indian Hedgehog, Notch and Wnt clustered according to the time post-fracture first and age second.

CLINICAL SIGNIFICANCE

Greater understanding of age-dependent molecular changes with healing will help form a mechanistic basis for therapies to improve patient outcomes. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:149-158, 2018.

Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture

The human body undergoes several physiological adaptations as a result of the aging process. Amongst other organs, the skeleton is also affected and when bone fragility is present, an increase in both morbidity and mortality has been reported. Identification of risk factors to calculate the probability for a given patient to develop a fragility fracture it is therefore of paramount importance. Moreover, the existence of an in house protocol for diagnostic work up using biochemical tests and imaging investigations is essential. In the herein study we discuss a diagnostic protocol that has been developed in our clinic based on knowledge from the literature and our clinical experience.

Risk of hip fracture following a wrist fracture-A meta-analysis

AIMS

This purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture.

METHOD

Studies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included. Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool. A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies.

RESULTS

12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93-4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used.

CONCLUSION

Risk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43). Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture. This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.

Second fractures among older adults in the year following hip, shoulder, or wrist fracture

We report on second fracture occurrence in the year following a hip, shoulder or wrist fracture using insurance claims. Among 273,330 people, 4.3 % had a second fracture; risk did not differ by first fracture type. Estimated adjusted second fracture probabilities may facilitate population-based evaluation of secondary fracture prevention strategies.

INTRODUCTION

The purpose of this study was estimate second fracture risk for the older US population in the year following a hip, shoulder, or wrist fracture.

METHODS

Observational cohort study of Medicare fee-for-service beneficiaries with an index hip, shoulder, or wrist fragility fracture in 2009. Time-to-event analyses using Cox proportional hazards models to characterize the relationship between index fracture type (hip, shoulder, wrist) and patient factors (age, gender, and comorbidity) on second fracture risk in the year following the index fracture.

RESULTS

Among 273,330 individuals with fracture, 11,885 (4.3 %) sustained a second hip, shoulder or wrist fracture within one year. Hip fracture was most common, regardless of the index fracture type. Comparing adjusted second fracture risks across index fracture types reveals that the magnitude of second fracture risk within each age-comorbidity group is similar regardless of the index fracture. Men and women face similar risks with frequently overlapping confidence intervals, except among women aged 85 years or older who are at greater risk.

CONCLUSIONS

Regardless of index fracture type, second fractures are common in the year following hip, shoulder or wrist fracture. Secondary fracture prevention strategies that take a population perspective should be informed by these estimates which take competing mortality risks into account.

Trabecular bone loss at a distant skeletal site following noninvasive knee injury in mice

Traumatic injuries can have systemic consequences, as the early inflammatory response after trauma can lead to tissue destruction at sites not affected by the initial injury. This systemic catabolism may occur in the skeleton following traumatic injuries such as anterior cruciate ligament (ACL) rupture. However, bone loss following injury at distant,unrelated skeletal sites has not yet been established. In the current study, we utilized a mouse knee injury model to determine whether acute knee injury causes a mechanically significant trabecular bone loss at a distant, unrelated skeletal site (L5 vertebral body).Knee injury was noninvasively induced using either high-speed (HS; 500 mm/s) or lowspeed(LS; 1 mm/s) tibial compression overload. HS injury creates an ACL rupture by midsubstance tear, while LS injury creates an ACL rupture with an associated avulsion bone fracture. At 10 days post-injury, vertebral trabecular bone structure was quantified using high-resolution microcomputed tomography (lCT), and differences in mechanical properties were determined using finite element modeling (FEM) and compressive mechanical testing. We hypothesized that knee injury would initiate a loss of trabecular bone structure and strength at the L5 vertebral body. Consistent with our hypothesis, we found significant decreases in trabecular bone volume fraction (BV/TV) and trabecular number at the L5 vertebral body in LS injured mice compared to sham (8.8% and 5.0%, respectively), while HS injured mice exhibited a similar, but lower magnitude response (5.1% and 2.5%, respectively). Contrary to our hypothesis, this decrease intrabecular bone structure did not translate to a significant deficit in compressive stiffness or ultimate load of the full trabecular body assessed by mechanical testing or FEM. However,we were able to detect significant decreases in compressive stiffness in both HS and LS injured specimens when FE models were loaded directly through the trabecular bone region (9.9% and 8.1%, and 3, respectively). This finding may be particularly important for osteoporotic fracture risk, as damage within vertebral bodies has been shown to initiate within the trabecular bone compartment. Altogether, these data point to a systemic trabecular bone loss as a consequence of fracture or traumatic musculoskeletal injury, which may be an underlying mechanism contributing to increased risk of refracture following an initial injury. This finding may have consequences for treatment of acute musculoskeletal injuries and the prevention of future bone fragility.

Mortality after distal radial fractures in the Medicare population

The occurrence of a low energy fracture of the distal radius increases the risk for another, more serious fracture, such as a proximal femoral fracture. Early mortality after a proximal femoral fracture has been widely studied, but the association between a distal radial fracture and mortality is unknown. The date of death for all Medicare beneficiaries who sustained an isolated distal radial fracture in 2007 was determined using Medicare Vital Statistics files. The adjusted mortality rate for each age-sex group was calculated and compared with published US mortality tables. Distal radial fractures were not associated with an increased mortality rate. In fact, beneficiaries had a significantly lower mortality rate after distal radial fractures than the general population. This may be related to the injured beneficiaries' involvement in the healthcare system. Mortality rate did not vary significantly based on time from injury. Our results indicate that any mortality is unlikely to be attributable to the distal radial fracture or its treatment. Level of evidence: III.

Inadequate management for secondary fracture prevention in patients with distal radius fracture by trauma surgeons

We evaluated the secondary fracture prevention in 1445 patients with distal radius fracture by trauma surgeons. The rate of patients with distal radius fracture who underwent bone mineral density (BMD) examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

INTRODUCTION

To clarify the status of osteoporosis interventions after distal radial fractures by trauma surgeons who play the main role in treatment for these fractures, we performed a survey involving multiple institutions in Japan.

METHODS

We asked 155 board members of the Japanese Society for Fracture Repair for their cooperation and performed a survey in 48 institutions with which members who gave cooperation were affiliated. The subjects consisted of consecutive patients with distal radial fractures occurring between January and December 2012. The presence or absence of a diagnosis of osteoporosis and bone mineral density examination after fracture was investigated.

RESULTS

A total of 1445 patients with distal radial fractures were evaluated in this study. BMD examination for diagnosis and treatment for osteoporosis after fracture was performed respectively in 126 (8.7 %) and 193 (13.4 %) of 1445 patients. Treatment for osteoporosis was performed in 93 (73.8 %) of 126 patients who underwent BMD examination after fracture and 100 (8.2 %) of 1219 who did not undergo BMD examination. Of the 126 patients who underwent BMD examination after fracture, 89 showed a BMD <80 % of the young adult mean as a criterion for the initiation of drug treatment for osteoporosis in Japan and 77 (86.5 %) of the 89 patients were treated with drugs.

CONCLUSIONS

The rate of patients with distal radial fractures who underwent BMD examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

Eldecalcitol is more effective for the prevention of osteoporotic fractures than alfacalcidol

Eldecalcitol, a vitamin D3 analogue, significantly reduces the risk of new vertebral fractures and increases bone mineral density (BMD) more than does alfacalcidol. To determine the effect of eldecalcitol on the incidence of all fragility fractures caused by osteoporosis, we conducted post hoc analyses of the phase III clinical trial to evaluate the incidence of the osteoporotic fractures defined in the World Health Organization (WHO) Technical Report, and, also, the incidence of the major osteoporotic fractures utilized in the WHO Fracture Risk Assessment Tool (FRAX), and compared those in the eldecalcitol group with those in the alfacalcidol group. We also analyzed the incidence of osteoporotic fractures stratified by prespecified risk factors for fractures. Eldecalcitol treatment reduced the incidence of osteoporotic fractures defined by the WHO more than alfacalcidol treatment (18.6 % vs. 25.2 %; hazard ratio, 0.70; 95 % CI, 0.54-0.93). Prevalent vertebral fractures, two or more prevalent vertebral fractures, and total hip BMD T score less than -2.5 were the risk factors for new osteoporotic fractures with significant differences between the two treatments. Eldecalcitol also decreased the incidence of major osteoporotic fractures in the FRAX more than alfacalcidol (11.1 % vs. 16.3 %; hazard ratio, 0.66; 95 % CI, 0.46-0.94). In conclusion, treatment with eldecalcitol reduced the risk of fragility fractures caused by osteoporosis compared with alfacalcidol administration, which may result from a potent effect of eldecalcitol on BMD, bone structure, and bone turnover.

Do the hospitalized patients with osteoporotic fractures require endocrinologists' help?

AIM

Osteoporotic fractures are a crucial cause of morbidity and mortality in patients with fragility fractures and impose huge economic burden on health care services. Orthopedic surgeons are often the only clinicians seen by the patients with osteoporotic fractures. The improvement in osteoporosis management is an urgent require; therefore, the aim of this study was to determine the efficacy of consultation with an endocrinologist in osteoporosis management of patients with a fragility fracture.

METHODS

This survey was undertaken in three phases that focused on patients with osteoporotic fractures who were admitted to five tertiary care, level-I, trauma hospital. Patients were evaluated through a questionnaire which was designed to determine whether physicians manage underlying osteoporosis.

RESULTS

The number of patients who underwent a bone mineral density test increased from a rate of 3.6% to 91% after the intervention, as calcium and vitamin D supplementation from 18% to 92%, bisphosphonate prescription from 0.5% to 83%. Also, the overall medication usage increased from 9% to 87%. A small number of patients (3%) were followed up in contrast to a rate of 73% in the third phase.

CONCLUSION

Orthopedic surgeons are not completely engaged in osteoporosis care for patients with a fragility fracture; therefore, a consultation with an endocrinologist is required to enable orhopedic surgeons to provide an effective osteoporosis care for their patients with an osteoporotic fracture.

Knowledge of orthopaedic surgeons in managing patients with fragility fracture

PURPOSE

Fragility fractures represent a major health problem, as they cause deformity, disability and increased mortality rates. Orthopaedic surgeons should identify patients with fragility fractures and manage their osteoporosis in order to reduce the risk of future fracture; therefore, orthopaedic surgeons' knowledge about managing fragile fracture should be evaluated.

METHODS

A questionnaire was administered to 2,910 orthopaedic surgeons to address the respondents' knowledge. The questions covered the topics of diagnosis, treatment and approach to a patient with a fragility fracture. The data-collection period for this survey spanned one year.

RESULTS

There were 2,021 orthopaedic surgeons who participated in this study. Less than 10% of the respondents included bone mass densitometry (BMD) when evaluating patients with fragile fractures 32% prescribed proper dosage of calcium and vitamin D; approximately 30% would refer if falling from a height was suspected.

CONCLUSIONS

The majority of orthopaedic surgeons questioned lacked knowledge of fragility fracture management. This is reflected by limited knowledge of osteoporosis assessment and treatment in most areas. An appropriate method should be created to manage patients with fragility fractures to guarantee the patient the best possible care.

Prevalence and costs of osteoporotic patients with subsequent non-vertebral fractures in the US

This study assesses prevalence of subsequent fractures during the year after incident osteoporosis-related non-vertebral fractures among privately insured and Medicare populations and compares costs between patients with and without subsequent fractures. Many non-vertebral fracture patients incur subsequent fractures, and those who do are significantly more costly during the year after incident fracture.

INTRODUCTION

To estimate the prevalence of subsequent osteoporosis-related non-vertebral (NV) fractures during the year following an incident NV fracture and compare costs between NV fracture patients with and without subsequent fractures.

METHODS

Using insurance claims data (1999-2006), privately-insured (ages 18-64 years) and Medicare (ages 65+ years) patients with ≥1 subsequent osteoporosis-related NV fracture within a year of an incident osteoporosis-related NV fracture were matched to controls with incident NV fractures but no subsequent fractures. Subsequent fractures were identified as any claim for an NV fracture occurring >3 months after the incident NV fracture (>6 months were required for fractures occurring at the same site as the incident fracture). The study assessed prevalence of subsequent fractures and compared costs (from the payer's perspective) between patients with and without subsequent fractures over the year following an incident NV fracture.

RESULTS

Among privately insured NV fracture patients, 14.1% had any subsequent NV fractures, 1.6% had subsequent hip fractures, and 13.0% had subsequent non-vertebral, non-hip (NVNH) fractures, while 22.6% of Medicare NV fracture patients had subsequent NV fractures, 9.4% had subsequent hip fractures, and 15.5% had subsequent NVNH fractures. Mean excess health care costs per privately insured subsequent fracture patient were $9,789 ($19,072 vs. $9,914, p < 0.01), while excess medical costs per Medicare subsequent fracture patient were $12,527 ($31,904 vs. $19,377, p < 0.01).

CONCLUSIONS

NV fracture patients are at substantial risk for subsequent NV fractures within 1 year, and patients who incur subsequent fractures are significantly more costly than those who do not during the year following an incident fracture.

[2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis]

OBJECTIVE

Due to increasing improvement in the diagnosis, evaluation and management of osteoporosis and the development of new tools and drugs, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and other health professionals involved in the treatment of patients with osteoporosis.

METHODS

Recommendations were developed following a nominal group methodology and based on a systematic review. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Evidence from previous consensus and available clinical guidelines was used.

RESULTS

We have produced recommendations on diagnosis, evaluation and management of osteoporosis. These recommendations include the glucocorticoid-induced osteoporosis, premenopausal and male osteoporosis.

CONCLUSIONS

We present the SER recommendations related to the biologic therapy risk management.

Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision

SUMMARY

The cost-effectiveness of Fracture Liaison Services (FLSs) for prevention of secondary fracture in osteoporosis patients in the United Kingdom (UK), and the cost associated with their widespread adoption, were evaluated. An estimated 18 fractures were prevented and £21,000 saved per 1,000 patients. Setup across the UK would cost an estimated £9.7 million.

INTRODUCTION

Only 11% to 28% of patients with a fragility fracture receive osteoporosis treatment in the UK. FLSs provide an efficient means to identify patients and are endorsed by the Department of Health but have not been widely adopted. The objective of this study was to evaluate the cost-effectiveness of FLSs in the UK and the cost associated with their widespread adoption.

METHODS

A cost-effectiveness and budget-impact model was developed, utilising detailed audit data collected by the West Glasgow FLS.

RESULTS

For a hypothetical cohort of 1,000 fragility-fracture patients (740 requiring treatment), 686 received treatment in the FLS compared with 193 in usual care. Assessments and osteoporosis treatments cost an additional £83,598 and £206,544, respectively, in the FLS; 18 fractures (including 11 hip fractures) were prevented, giving an overall saving of £21,000. Setup costs for widespread adoption of FLSs across the UK were estimated at £9.7 million.

CONCLUSIONS

FLSs are cost-effective for the prevention of further fractures in fragility-fracture patients. The cost of widespread adoption of FLS across the UK is small in comparison with other service provision and would be expected to result in important benefits in fractures avoided and reduced hospital bed occupancy.

Exercise prescription after fragility fracture in older adults: a scoping review

The purpose of this study is to identify and chart research literature on safety, efficacy, or effectiveness of exercise prescription following fracture in older adults. We conducted a systematic, research-user-informed, scoping review. The population of interest was adults aged ≥45 years with any fracture. "Exercise prescription" included post-fracture therapeutic exercise, physical activity, or rehabilitation interventions. Eligible designs included knowledge synthesis studies, primary interventional studies, and observational studies. Trained reviewers independently evaluated citations for inclusion. A total of 9,415 citations were reviewed with 134 citations (119 unique studies) identified: 13 knowledge syntheses, 95 randomized or controlled clinical trials, and 11 "other" designs, representing 74 articles on lower extremity fractures, 34 on upper extremity, eight on vertebral, and three on mixed body region fractures. Exercise prescription characteristics were often missing or poorly described. Six general categories emerged describing exercise prescription characteristics: timing post-fracture, person prescribing, program design, functional focus, exercise script parameters, and co-interventions. Upper extremity and ankle fracture studies focused on fracture healing or structural impairment outcomes, whereas hip fracture studies focused more on activity limitation outcomes. The variety of different outcome measures used made pooling or comparison of outcomes difficult. There was insufficient information to identify evidence-informed parameters for safe and effective exercise prescription for older adults following fracture. Key gaps in the literature include limited numbers of studies on exercise prescription following vertebral fracture, poor delineation of effectiveness of different strategies for early post-fracture mobilization following upper extremity fracture, and inconsistent details of exercise prescription characteristics after lower extremity fracture.

Rapid remineralization of the distal radius after forearm fracture in children

BACKGROUND

Bone mineral content (BMC) and density (BMD) have been shown to diminish after fracture and immobilization in adults. Distal radius fractures are common in children, and unlike adults, there is a low incidence of refracture. The primary aim of this study was to assess the change in radial BMC and BMD after upper extremity fracture and casting in healthy pediatric patients.

METHODS

Patients were recruited at the time of distal radius fractures casting. The nonfractured (non-Fx) distal radius was initially scanned by dual energy x-ray absorptiometry (baseline), and then both arms were scanned at the time of cast removal (CastOff), and 4, 8, 12, 24, and 52 weeks post CastOff.

RESULTS

Twenty-one patients were enrolled (13 male, 13 Caucasian; 10.4±2.5 y) with an average length of casting of 38±11 days. Eighteen patients (86%) completed all protocol requirements. At CastOff, there was no significant difference in total BMC or BMD between the Fx and non-Fx arms. From CastOff to 24 weeks, the overall change in BMC and BMD for the non-Fx arm was +4.2% and +0.2%, respectively, whereas for the Fx arm, the change was +8.3% and +3.4%, respectively. By 24 weeks, the difference in the overall change in BMD between the Fx and non-Fx arms was statistically significant (greater than instrumental error; P<0.05). However, by 52 weeks, these differences were no longer significant. The increased mineralization was unrelated to age, sex, arm dominance, or calcium intake.

CONCLUSIONS

These data show that there is rapid remineralization after a simple forearm fracture in children, with a transient elevation in BMD in the Fx arm after casting. This novel finding suggests that bone may be stronger around the site of fracture and could significantly change how we counsel young patients recovering from forearm fracture. Future research should focus on children immobilized for varying lengths of time and those with repeat fractures, using volumetric techniques of bone geometry and strength assessment.

CASE SERIES

Therapeutic Studies-investigating the results of treatment, Level IV.

Age-specific incidence of first and second fractures of the hip

We determined the age-specific incidence of a second fracture of the hip and compared it with that of a primary fracture in a study population drawn from 6331 patients admitted to Nottingham University Hospital with a primary fracture of the hip over a period of 8.5 years. The incidence of a second fracture was determined using survival analysis. The mean age-specific incidence rates of primary hip fracture were calculated using census data. The overall incidence of a second fracture was 2.7% at one year and 7.8% at 8.5 years. That of a primary fracture was 50 per 100 000 in women aged 55 to 64 years rising to 3760 in those aged 84 years and over. The incidence of a second fracture in women aged 55 to 64 years was 2344 per 100 000. Patients of this age had a relative risk of 45 (95% confidence interval 13 to 155) for further fracture when compared with the population at risk of a first fracture. The incidence of a second fracture in women aged > 84 years was 2451 per 100 000 (relative risk 0.7, 95% confidence interval 0.5 to 0.9). A similar trend was seen in men. Patients sustaining a primary fracture of the hip between the ages of 55 and 64 years have a much greater risk of further fracture than the normal population, whereas those over 84 years have a similar risk. These findings have important implications for the provision of fracture prevention services in primary and secondary care.

Is prophylactic fixation a cost-effective method to prevent a future contralateral fragility hip fracture?

OBJECTIVE

: A previous hip fracture more than doubles the risk of a contralateral hip fracture. Pharmacologic and environmental interventions to prevent hip fracture have documented poor compliance. The purpose of this study was to examine the cost-effectiveness of prophylactic fixation of the uninjured hip to prevent contralateral hip fracture.

METHODS

: A Markov state-transition model was used to evaluate the cost and quality-adjusted life-years (QALYs) for unilateral fixation of hip fracture alone (including internal fixation or arthroplasty) compared with unilateral fixation and contralateral prophylactic hip fixation performed at the time of hip fracture or unilateral fixation and bilateral hip pad protection. Prophylactic fixation involved placement of a cephalomedullary nail in the uninjured hip and was initially assumed to have a relative risk of a contralateral fracture of 1%. Health states included good health, surgery-related complications requiring a second operation (infection, osteonecrosis, nonunion, and malunion), fracture of the uninjured hip, and death. The primary outcome measure was the incremental cost-effectiveness ratio estimated as cost per QALY gained in 2006 US dollars with incremental cost-effectiveness ratios below $50,000 per QALY gained considered cost-effective. Sensitivity analyses evaluated the impact of patient age, annual mortality and complication rates, intervention effectiveness, utilities, and costs on the value of prophylactic fixation.

RESULTS

: In the baseline analysis, in a 79-year-old woman, prophylactic fixation was not found to be cost-effective (incremental cost-effectiveness ratio = $142,795/QALY). However, prophylactic fixation was found to be a cost-effective method to prevent contralateral hip fracture in: 1) women 71 to 75 years old who had 30% greater relative risk for a contralateral fracture; and 2) women younger than age 70 years. Cost-effectiveness was greater when the additional costs of prophylaxis were less than $6000. However, for most analyses, the success of prophylactic fixation was highly sensitive to the effectiveness and the relative morbidity and mortality of the additional procedure.

CONCLUSION

: Prophylactic fixation with a cephalomedullary nail was not found to be cost-effective for the average older woman who sustained a hip fracture. However, it may be appropriate for select patient populations. The study supports the need for basic science and clinical trials investigating the effectiveness of prophylactic fixation for patient populations at higher lifetime risk for contralateral hip fracture.

Physician follow-up care for osteoporosis after fragility fractures

Osteoporosis affects > 10 million Americans each year. The disease is characterized by low bone mass and decreased bone strength, and patients often sustain fragility fractures. Previous research highlights low rates of identification and treatment of the disease after a fragility fracture, yet patients are still overlooked. This study identified patients who did not receive proper osteoporosis care after a fragility fracture in Southeastern Pennsylvania. In a telephone interview, we asked patients who had sustained a fragility fracture in 2008 and were treated at one orthopedic practice about information on events before and after their fractures. We concluded that a patient's bone health had suboptimal care if, after the fracture, the patient had no doctor interview, did not receive bone mineral density testing, and did not begin or change medications. Of the 224 patients who participated in our study, we determined that 149 (67%) patients received insufficient osteoporosis care. One hundred fourteen (63%) women and 35 (80%) men received inadequate osteoporosis care. The high incidence of unsatisfactory care, particularly in men, indicates that osteoporosis care continues to be a problem. We believe that one contributing factor is physician accountability for care. Our study indicates that no specific specialist takes responsibility for follow-up care, possibly signifying the lack of an adequate system for identifying and treating the disease. The opportunity to address this issue should be a high priority for both primary care physicians and orthopedic surgeons.

Factors influencing the treatment of osteoporosis following fragility fracture

Treatment rates of osteoporosis after fracture are very low. Women who suffer a fragility fracture have a greater chance of receiving anti-fracture treatment if they had low bone mineral density (BMD), a fracture at the hip, femur or pelvis, administration of calcium and vitamin D supplements and/or an age > or =60 years.

INTRODUCTION

This investigation identifies the predictors of osteoporosis treatment 6 to 8 months following fragility fracture in women >50 years of age.

METHODS

In this prospective cohort study, women were recruited 0 to 16 weeks following fracture and classified as having experienced fragility or traumatic fractures (phase 1). Six to 8 months following fracture, women completed a questionnaire on demographic features, clinical characteristics and risk factors for osteoporosis (phase 2). Osteoporosis treatment was defined as initiating anti-fracture therapy (bisphosphonate, raloxifene, nasal calcitonin and teriparatide) after fracture in those previously untreated.

RESULTS

Of the 1,273 women completing phase 1, 1,001 (79%) sustained a fragility fracture, and of these women, 738 were untreated for osteoporosis at phase 1 and completed the phase 2 questionnaire. Significant predictors of treatment included BMD result, fracture site, administration of calcium and vitamin D supplements at the time of fracture and age > or =60 years. All other risk factors for osteoporosis, such as fracture history after the age of 40 years, family history of osteoporosis and comorbidities did not significantly influence the treatment rate.

CONCLUSIONS

Physicians largely based their decision to treat on BMD results and not on the clinical event-fragility fracture.

The use of hospital registries in orthopaedic surgery

A hospital registry is a collection of prospectively recorded information about patients who have a specific condition or who received a specific type of treatment. Hospital registries are beneficial for the patient, physicians, and administrators and serve several purposes, with the primary purpose being quality control. This article focuses on the role of registries at the hospital level and their advantages compared with other data sets. We also discuss how to implement a hospital registry and how to ascertain registry quality. Finally, we describe the problems inherent in any hospital-based registry and the ways in which the data collected in a registry can be appropriately analyzed.

Proximal humeral fracture as a risk factor for subsequent hip fractures

BACKGROUND

With the aging of the world's population, the social and economic implications of osteoporotic fractures are at epidemic proportions. This study was performed to test the hypothesis that a proximal humeral fracture is an independent risk factor for a subsequent hip fracture and that the risk of the subsequent hip fracture is highest within the first five years after the humeral fracture.

METHODS

A cohort of 8049 older white women with no history of a hip or humeral fracture who were enrolled in the Study of Osteoporotic Fractures was followed for a mean of 9.8 years. The risk of hip fracture after an incident humeral fracture was estimated with use of age-adjusted Cox proportional hazards regression analysis with time-varying variables; women without a humeral fracture were the reference group. Cox regression analysis was used to evaluate the timing between the proximal humeral and subsequent hip fracture. Risk factors were determined on the basis of a review of the current literature, and we chose the variables that were most predictive and easily ascertained in a clinical setting.

RESULTS

Three hundred and twenty-one women sustained a proximal humeral fracture, and forty-four of them sustained a subsequent hip fracture. After adjustment for age and bone mineral density, the hazard ratio for hip fracture for subjects with a proximal humeral fracture relative to those without a proximal humeral fracture was 1.83 (95% confidence interval = 1.32 to 2.53). After multivariate adjustment, this risk appeared attenuated but was still significant (hazard ratio = 1.57; 95% confidence interval = 1.12 to 2.19). The risk of a subsequent hip fracture after a proximal humeral fracture was highest within one year after the proximal humeral fracture, with a hazard ratio of 5.68 (95% confidence interval = 3.70 to 8.73). This association between humeral and hip fracture was not significant after the first year, with hazard ratios of 0.87 (95% confidence interval = 0.48 to 1.59) between one and five years after the humeral fracture and 0.58 (95% confidence interval = 0.22 to 1.56) after five years.

CONCLUSIONS

In this cohort of older white women, a proximal humeral fracture independently increased the risk of a subsequent hip fracture more than five times in the first year after the humeral fracture but was not associated with a significant increase in the hip fracture risk in subsequent years.

Role of quantitative ultrasound to predict fracture among institutionalised older people with a history of fracture

The fracture predictive value of quantitative ultrasound (QUS) may be modified by previous fracture status. Non-significant associations between QUS parameters and fracture risk were observed among frail older people with a history of fracture. These findings suggest that QUS measurements for frail older people might be more useful in those without a fracture history.

INTRODUCTION

Quantitative ultrasound has been shown to predict risk of fracture in various populations. However, this ability may be modified by the presence of previous fracture in very frail older people.

METHODS

We assessed bone strength by QUS and clinical risk factors at baseline for 1,982 institutionalised older people. Fractures were ascertained for 2 years from baseline and validated by X-ray reports.

RESULTS

Study participants were very old (mean age = 85.7 +/- 7.1 years) and frail (70% using walking aids). Forty-five percent reported a history of fracture. During a mean follow-up period of 1.64 years, 335 participants suffered a fracture or fractures. Fracture rates were significantly higher in participants with a history of fracture compared with those without a history of fracture (16.0 vs 9.2 per 100 person years, p < 0.001). Significant associations between fracture risk and QUS parameters (broadband ultrasound attenuation and velocity of sound) were observed among participants without a history of fracture (both p < 0.01), but not among those who had a fracture history (both p >/= 0.7).

CONCLUSIONS

In very frail older people, QUS measurements may be more useful for assessing fracture risk in those without a history of fracture after age 50.