Epidemiological transition to mortality and refracture following an initial fracture

MRI-Based Vertebral Bone Quality Score Can Predict the Imminent New Vertebral Fracture After Vertebral Augmentation

BACKGROUND AND OBJECTIVES

The incidence of imminent new vertebral fracture (NVF) is notably high after vertebral augmentation (VA), but accurately assessing the imminent risk of NVF remains a great challenge. The aim of this study was to investigate whether the MRI-based vertebral bone quality (VBQ) score can predict the risk of imminent NVF after VA within a 2-year period.

METHODS

A total of 135 patients age 50 years and older who suffered from painful osteoporotic vertebral compression fracture and treated with VA were enrolled in this retrospective study. Each patient's VBQ scores were calculated from T1-weighted, T2-weighted, and short tau inversion recovery sequences of preoperative lumbar MRI. The clinical factors and VBQ score were integrated to create a predictive model by using the logistic regression algorithm and visualize by nomogram. Receiver operating characteristic curve, calibration curve, and decision curve analyses were used to evaluate the predictive performance of the nomogram.

RESULTS

The mean VBQ-T1WI and VBQ-T2WI scores of the NVF group were 4.61 ± 0.55 and 0.89 ± 0.14, respectively, which were significantly higher than those of the without NVF group (3.99 ± 0.54 and 0.79 ± 0.12, respectively, P < .001), as well as the VBQ-combined score (0.75 ± 1.30 vs -0.80 ± 1.26, P < .001), which is the combination of VBQ-T1WI and VBQ-T2WI scores. On multivariate analysis, the predictors of imminent NVF included age (odds ratio [OR] = 1.064, 95% CI = 1.009-1.122, P = .022), previous vertebral fracture (OR = 2.089, 95% CI = 0.888-4.915, P = .091), and VBQ-combined score (OR = 2.239, 95% CI = 1.529-3.279, P < .001). The nomogram achieved superior performance with an area under the receiver operating characteristic curve of 0.838 (95% CI: 0.773-0.904) in predicting the imminent NVF compared to the clinical factors or VBQ-combined score alone.

CONCLUSION

The VBQ score obtained from lumbar MRI can be used to assess the VBQ and predict the imminent NVF after VA in patients with osteoporotic vertebral compression fracture.

Fracture risk assessment in the presence of competing risk of death

PURPOSE

To identify the optimal statistical approach for predicting the risk of fragility fractures in the presence of competing event of death.

METHODS

We used real-world data from the Dubbo Osteoporosis Epidemiology Study that has monitored 3035 elderly participants for bone health and mortality. Fragility fractures were ascertained radiologically. Mortality was confirmed by the State Registry. We considered four statistical models for predicting fracture risk: (i) conventional Cox's proportional hazard model, (ii) cause-specific model, (iii) Fine-Gray sub-distribution model, and (iv) multistate model. These models were fitted and validated in the development (60% of the original sample) and validation (40%) subsets, respectively. The model performance was assessed by discrimination and calibration analyses.

RESULTS

During a median follow-up of 11.3 years (IQR: 7.2, 16.2), 628 individuals (34.5%) in the development cohort fractured, and 630 (34.6%) died without a fracture. Neither the discrimination nor the 5-year prediction performance was significantly different among the models, though the conventional model tended to overestimate fracture risk (calibration-in-the-large index =  - 0.24; 95% CI: - 0.43, - 0.06). For 10-year risk prediction, the multistate model (calibration-in-the-large index =  - 0.05; 95% CI: - 0.20, 0.10) outperformed the cause-specific (- 0.23; - 0.30, - 0.08), Fine-Gray (- 0.31; - 0.46, - 0.16), and conventional model (- 0.54; - 0.70, - 0.39) which significantly overestimated fracture risk.

CONCLUSION

Adjustment for competing risk of death has minimum impact on the short-term prediction of fracture. However, the multistate model yields the most accurate prediction of long-term fracture risk and should be considered for predictive research in the elderly, who are also at high mortality risk. Fracture risk assessment might be compromised by the competing event of death. This study, using real-world data found a multistate model was superior to the current competing risk methods in fracture risk assessment. A multistate model is considered an optimal statistical method for predictive research in the elderly.

The Association of nutritional status and physical activity on osteoporotic refractures among older adults

BACKGROUND

This paper focuses on revealing the relationship between the Geriatric Nutritional Risk Index (GNRI) and Activity of Daily Living (ADL) with osteoporotic refracture.

METHODS

Data from 1068 inpatients with osteoporotic fractures were analyzed. Binary logistic regression, Cox proportional hazard regression and Kaplan-Meier curves were performed for osteoporosis characteristics and its risk factors. Receiver operating characteristic (ROC) curve was developed to predict the cut-off value.

RESULTS

The study showed that older age, lower ADL and lower GNRI were independent risk factors for osteoporotic fracture with OR of 1.039, 0.946, 0.892 and HR of 1.033, 0.967, 0.947 respectively. According to the results of ROC, the predictive accuracy of GNRI was high with an area under ROC (AUC) of 0.715, sensitivity of 76.6%, specificity of 53.5% and a threshold value of 99.65.

CONCLUSION

Older age, lower ADL and lower GNRI were independent risk factors for osteoporotic refracture.

Clinical Outcomes and Cost-Effectiveness of Osteoporosis Screening With Dual-Energy X-ray Absorptiometry

OBJECTIVE

This study aimed to evaluate the clinical outcomes and cost-effectiveness of dual-energy X-ray absorptiometry (DXA) for osteoporosis screening.

MATERIALS AND METHODS

Eligible patients who had and had not undergone DXA screening were identified from among those aged 50 years or older at Kaohsiung Veterans General Hospital, Taiwan. Age, sex, screening year (index year), and Charlson comorbidity index of the DXA and non-DXA groups were matched using inverse probability of treatment weighting (IPTW) for propensity score analysis. For cost-effectiveness analysis, a societal perspective, 1-year cycle length, 20-year time horizon, and discount rate of 2% per year for both effectiveness and costs were adopted in the incremental cost-effectiveness (ICER) model.

RESULTS

The outcome analysis included 10337 patients (female:male, 63.8%:36.2%) who were screened for osteoporosis in southern Taiwan between January 1, 2012, and December 31, 2021. The DXA group had significantly better outcomes than the non-DXA group in terms of fragility fractures (7.6% vs. 12.5%, P < 0.001) and mortality (0.6% vs. 4.3%, P < 0.001). The DXA screening strategy gained an ICER of US$ -2794 per quality-adjusted life year (QALY) relative to the non-DXA at the willingness-to-pay threshold of US$ 33004 (Taiwan's per capita gross domestic product). The ICER after stratifying by ages of 50-59, 60-69, 70-79, and ≥ 80 years were US$ -17815, US$ -26862, US$ -28981, and US$ -34816 per QALY, respectively.

CONCLUSION

Using DXA to screen adults aged 50 years or older for osteoporosis resulted in a reduced incidence of fragility fractures, lower mortality rate, and reduced total costs. Screening for osteoporosis is a cost-saving strategy and its effectiveness increases with age. However, caution is needed when generalizing these cost-effectiveness results to all older populations because the study population consisted mainly of women.

BONEcheck: A digital tool for personalized bone health assessment

Objectives

Osteoporotic fracture is a significant public health burden associated with increased mortality risk and substantial healthcare costs. Accurate and early identification of high-risk individuals and mitigation of their risks is a core part of the treatment and prevention of fractures. Here we introduce a digital tool called 'BONEcheck' for personalized assessment of bone health.

Methods

The development of BONEcheck primarily utilized data from the prospective population-based Dubbo Osteoporosis Epidemiology Study and the Danish Nationwide Registry. BONEcheck has 3 modules: input data, risk estimates, and risk context. Input variables include age, gender, prior fracture, fall incidence, bone mineral density (BMD), comorbidities, and genetic variants associated with BMD.

Results

Based on the input variables, BONEcheck estimates the probability of any fragility fracture and hip fracture within 5 years, subsequent fracture risk, skeletal age, and time to reach osteoporosis. The probability of fracture is shown in both numeric and human icon array formats. The risk is also contextualized within the framework of treatment and management options on Australian guidelines, with consideration given to the potential fracture risk reduction and survival benefits. Skeletal age was estimated as the sum of chronological age and years of life lost due to a fracture or exposure to risk factors that elevate mortality risk.

Conclusions

BONEcheck is an innovative tool that empowers doctors and patients to engage in well-informed discussions and make decisions based on the patient's risk profile. Public access to BONEcheck is available via https://bonecheck.org and in Apple Store (iOS) and Google Play (Android).

Bone health in ageing men

Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.

The imminent risk of a fracture-existing worldwide data: a systematic review and meta-analysis

The overall incidence of imminent fracture after a prior fragility fracture was 7.58% in the first year and 11.58% in the first 2 years. Approximately half of re-fractures occurred in the first 2 years after a fragility fracture. Older patients that have suffered from a fragility fracture should be treated promptly, with immediate care and a secondary fracture prevention to prevent the high imminent risk of a fracture.

INTRODUCTION

Imminent fractures refer to the fractures that occur within 2 years of an initial fracture. It is well known that the risk of a subsequent fracture is not constant with time and occurs shortly after the initial one. This systematic review and meta-analysis aimed to present the existing data on imminent fracture worldwide.

METHODS

Literature search was conducted in Pubmed, Embase, and Web of Science databases until 26 October 2021 for studies reporting the incidence of imminent osteoporotic fractures among people aged 50 years or older. The overall incidence of imminent fracture was pooled and subgroup analyses of index fracture sites and regions on incidence of imminent fracture were performed, with the 95% confidence interval (CI) being calculated. Percentage of imminent fracture occurring in follow-up period was calculated and pooled by meta-analysis. Hazard ratio (HR) was used to estimate the gender differences on the imminent risk of fracture.

RESULTS

A total of 1446 articles were identified. Nineteen observational studies were eligible for our systematic review, in which 18 were used for quantitative analysis. Pooled overall incidence of imminent fracture in the first year after an osteoporotic fracture was 7.58% (95% CI 5.84 to 9.31%) and cumulative incidence in the first 2 years was 11.58% (95% CI 8.94 to 14.21%). Subgroup analysis showed that in the first 2 years, the pooled incidence in Asia was 7.30% (95% CI 3.42 to 11.18%), whilst incidence in Europe/North America was 13.17% (95% CI 10.14 to 16.20%). In included studies with follow-up period of more than 5 years, pooled imminent fracture percentage in the first 2 years was 47.24% (95% CI 26.18 to 68.30%). Hazard ratio (HR) on gender showed that women had an overall slight increase in risk of imminent fractures (HR 1.18, 95% CI 1.11 to 1.25).

CONCLUSION

The incidence of imminent fracture is high globally at 11.58%. Approximately half of all refractures occur in the first 2 years after an index fragility fracture. Older patients that have suffered from a fragility fracture should be treated promptly. Also, immediate care and secondary fracture prevention are necessary to prevent the high imminent risk of a fracture, especially within the first 2 years.

All-cause mortality risk in older patients with femoral neck fracture

Introduction

The mortality rate after hip fracture is high. However, the 1-year mortality rate after femoral intertrochanteric fracture and femoral neck fracture differs (Gibson-Smith D, Klop C, Elders PJ, Welsing PM, van Schoor N, Leufkens HG, et al., Osteoporos Int 25:2555-2563, 2014), although both are types of hip fracture. A previous real-world single-center prospective cohort study showed that older age and high Charlson comorbidity index score were risk factors for femoral intertrochanteric fracture. Additionally, therapy with zoledronic acid 5 mg (Aclasta) was a protective factor (Li XP, Zhang P, Zhu SW, Yang MH, Wu XB, Jiang XY, J Orthop Surg Res. 16:727, 2021). We wished to determine the risk factors for all-cause mortality in femoral neck fracture patients.

Aim

To identify the risk factors for postoperative all-cause mortality in aged patients with femoral neck fracture.

Materials and methods

We enrolled 307 aged patients with femoral neck fracture; 38 were lost to follow-up after 2–3 years. The patients’ general characteristics, bone mineral density, and anti-osteoporosis treatment after operation were recorded as potential risk factors. Kaplan–Meier curves and multivariate Cox proportional hazards models were constructed to analyze the influence of each factor on all-cause mortality.

Results

This was a real-world single-center prospective cohort study showing that (1) most of the patients who died were male, older (mean age of the patients who died: 84.8 years vs. 77.9 years for survivors), and had more comorbidities compared with surviving patients. Previous fracture history, body mass index, femoral neck T score, hemoglobin and 25-hydroxy vitamin D levels did not differ significantly between patients who died vs. survived. (2) Differing from patients with intertrochanteric fractures, older patients with femoral neck fracture experienced no reduction in all-cause mortality with treatment with zoledronic acid.

Conclusion

In Chinese patients with femoral neck fracture, physicians should pay careful attention to male patients, older patients, and those with high numbers of comorbidities.

Protective effect on bone of nacre supplementation in ovariectomized rats

Nacre has emerged as a beneficial natural product for bone cells and tissues, but its effect was only studied by gavage in the ovariectomized mouse model. We sought to assess the antiosteoporotic effect of nacre through a nutritional supplementation in the ovariectomized rat model. Sixteen‐week‐old female Wistar rats were either Sham‐operated or bilateral ovariectomized (OVX) and then fed with standard diet (Sham and OVX groups) or standard diet supplemented with either 0.25% CaCO₃ or nacre (OVX CaCO₃ and OVX Nacre group, respectively) for 28 days (n = 10/group). The bone microarchitecture was assessed at appendicular and axial bones by micro‐computed tomography (μCT). Histomorphometric analysis was performed to determine cellular and dynamic bone parameters. Bone metabolism was also evaluated by biochemical markers and gene expression levels. Nacre‐based diet prevented the OVX‐induced bone loss better than that of the CaCO₃ supplement, given the significant changes in trabecular bone volume fraction (BV/TV) both at the femoral distal metaphysis (difference, 35%; p = 0.004) and at the second lumbar spine (difference, 11%; p = 0.01). Trabecular osteoclast surfaces (Oc.S/BS) were also 1.5‐fold lower at the tibial proximal metaphysis in OVX Nacre group compared with OVX CaCO₃ group (p = 0.02)_. By principal component analysis (PCA), OVX Nacre group formed a cluster away from OVX group and with a trend closest to Sham group. These data were consistent with biological measurements demonstrating a positive profile related to nacre supplementation, which blunted an increase in serum CTX level and enhanced serum P1NP secretion 14 days post‐OVX compared with CaCO₃ supplementation. Bmp2 mRNA expression in OVX Nacre group was +1.76‐fold (p = 0.004) and +1.30‐fold (p = 0.20) compared with OVX and OVX CaCO₃ groups, respectively. We conclude that supplementation with nacre could effectively limit bone loss induced by estrogen deficiency just after OVX in rats by modulating the negative imbalance of bone turnover. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

All-cause mortality risk in aged femoral intertrochanteric fracture patients

Introduction

The 1-year mortality rate after femoral intertrochanteric fracture is higher than that of femoral neck fracture, which also belongs to hip fracture (Cui et al. in Arch Osteoporos 14(1):55, 2019). With the application of the concept of co-management model of orthopedics and geriatrics, the short-term and long-term mortality of all types of hip fractures has decreased (Van Heghe et al. in Calcif Tissue Int, 2021, https://doi.org/10.1007/s00223-021-00913-5). However, the mortality of Chinese femoral intertrochanteric fracture patients under this model has not been reported in the literatures.

Aim

This paper aims to study the risk factors of postoperative all-cause mortality in aged patients with femoral intertrochanteric fracture under the co-management model of orthopedics and geriatrics.

Materials and methods

This is a single-center prospective cohort study based on the real world, under the co-management of orthopedics and geriatrics, 363 patients aged ≥ 65 years with femoral intertrochanteric fracture were enrolled and followed up for 2–3 years; 52 patients were lost to follow up. Age, gender, body mass index (BMI), history of comorbidities, hip Bone Mineral Density (BMD), fracture history, 25(OH)D level, hemoglobin level, anti-osteoporosis treatment were risk factors to be tested. Kaplan–Meier survival curves and multivariate Cox proportional hazards models were constructed to analyze the impact of factors on all-cause mortality.

Results

(1) Most of the dead patients were older (the mean age was 83.4 years, compared with 79.8 years for surviving patients), with more complications and without anti-osteoporosis medication; gender, pre-fracture history, BMI, total hip BMD, hemoglobin, 25(OH)D had no difference between the dead and the living patients. (2) Elderly patients with Intertrochanteric fracture can benefit from the early treatment of Zoledronic Acid (within 3 days after the operation).

Conclusion

Under the co-management of orthopedics and geriatrics, to Chinese patients with Femoral Intertrochanteric fracture, Doctors should pay more attention to their age and chronic disease, and give anti-osteoporosis treatment if allowed.

Personalized fracture risk assessment: where are we at?

Introduction: Osteoporotic fracture imposes a significant health care burden globally. Personalized assessment of fracture risk can potentially guide treatment decisions. Over the past decade, a number of risk prediction models, including the Garvan Fracture Risk Calculator (Garvan) and FRAX®, have been developed and implemented in clinical practice. Areas covered: This article reviews recent development and validation results concerning the prognostic performance of the two tools. The main areas of review are the need for personalized fracture risk prediction, purposes of risk prediction, predictive performance in terms of discrimination and calibration, concordance between the Garvan and FRAX tools, genetic profiling for improving predictive performance, and treatment thresholds. In some validation studies, FRAX tended to underestimate fracture by as high as 50%. Studies have shown that the predicted risk from the Garvan tool is highly concordant with clinical decision. Expert opinion: Although there are some discrepancy in fracture risk prediction between Garvan and FRAX, both tools are valid and can aid patients and doctors communicate about risk and make informed decision. The ideal of personalized risk assessment for osteoporosis patients will be realized through the incorporation of genetic profiling into existing fracture risk assessment tools.

Bone age is not just for kids

More informed discussions between physicians and older adults about the consequences of an initial osteoporotic fracture could encourage more patients to consider treatments that protect against future fracture.