Periprosthetic fractures are osteoporotic fractures: missed opportunities for osteoporosis diagnosis

Joint replacement surgery is common in older adults, leading to increasing periprosthetic fracture (PPFx) occurrence. We reviewed all PPFx seen over a 4-year period at an academic hospital. Clinical osteoporosis could be diagnosed based on existing data in 104 (67%) at the time of PPFx. Periprosthetic fractures are generally osteoporosis-related.

PURPOSE

Periprosthetic fractures (PPFx) cause morbidity, mortality, and cost. This study's purpose was to describe osteoporosis-related data available at the time of PPFx.

METHODS

The electronic medical record (EMR) of PPFx patients seen over 4 years in a university orthopedic practice were reviewed. Demographic data and osteoporosis relevant parameters were collected. Prior DXA studies were reviewed, and L1 Hounsfield unit (HU) measurements were performed on CT scans obtained within 2 years before PPFx. Clinical osteoporosis was defined as prior diagnosis, prescribed osteoporosis treatment, T-score ≤  - 2.5, HU ≤ 100, or prior fracture.

RESULTS

Records of 156 PPFx patients (115 F/41 M), mean (SD) age 75.4 (11.9), were reviewed. Almost all 153/156 (98%) of these fractures were femoral. Falls caused 139 (89%); 12 (8%) were spontaneous. Mean time post-arthroplasty was 7.9 (6.3) years. Prior fragility fracture(s) occurred in 72 (46%); 14 were PPFx. Osteoporosis was previously diagnosed in 45 (29%) and medications prescribed in 41 (26%). Prior to PPFx, DXA data were available in 62, mean (SD) lowest T-score was - 1.9 (0.9) and was ≤  - 2.5 in 19. CT data were available in 46; mean (SD) L1 HU was 79.0 (29.4) and was ≤ 100 in 35. Based on existing data, clinical osteoporosis could have been diagnosed in 104 (67%) at the time of PPFx.

CONCLUSION

Periprosthetic fractures are osteoporosis-related. They occur in older adults, often female, and result from falls; BMD, when assessed, is low. Data available at the time of PPFx often allows osteoporosis diagnosis; this should prompt evaluation and pharmacologic treatment consideration.

Dual-energy X-ray Absorptiometry Trends Among US Medicare Beneficiaries: 2005-2019

INTRODUCTION

Bone density measured using dual-energy X-ray absorptiometry (DXA) volume, performance site and interpreters have changed in the US since 2005. The purpose of this report is to provide updated trends in DXA counts, rates, place of service and interpreter specialty for the Medicare fee-for-service population.

METHODS

The 100 % Medicare Physician/Supplier Procedure Summary Limited Data Set between 2005-2019 was used. DXA counts and annual rates per 10,000 Medicare beneficiaries were calculated. Annual distributions of scan performance location, provider type and interpreter specialty were described. Place of service trends (significance assigned at p < 0.05) of the mean annual share of DXA utilization were identified using linear regression.

RESULTS

Annual DXA use per 10,000 beneficiaries peaked in 2008 at 832, declined to 656 in 2015 then increased (p < 0.001) by 38 per year to 807 in 2019. From 2005 to 2019 DXA performance in office settings declined from 70.7 % to 47.2 %. Concurrently, outpatient hospital (OH) DXA increased from 28.6 % to 51.7 %. In 2005, 43.5 % of DXAs were interpreted by radiologists. This increased (p < 0.001) in the office and OH, averaging 0.3 and 2.0 percentage points per year respectively, reaching 73.5 % in 2019. Interpretation by most non-radiologist specialties declined (p < 0.001).

CONCLUSIONS

From 2005-2019, total DXA use among Medicare beneficiaries declined reaching a nadir in 2015 then returned to 2005 levels by 2019. Office DXA declined since 2005 with 51.7 % of all scans now occurring in an OH setting. The proportion of DXAs interpreted by radiologists increased over time, reaching 73.5 % in 2019.

Effect of Romosozumab Treatment in Postmenopausal Women With Osteoporosis and Knee Osteoarthritis: Results From a Substudy of a Phase 3 Clinical Trial

OBJECTIVE

Romosozumab is a bone-forming agent approved for osteoporosis treatment. Here we report results of the protocol-specified, noninferiority osteoarthritis substudy of the fracture study in postmenopausal women with osteoporosis (FRAME), which evaluated the effect of romosozumab versus placebo on knee osteoarthritis in patients with a clinical history of osteoarthritis.

METHODS

Women in FRAME with a history of knee osteoarthritis were eligible for enrollment in the osteoarthritis substudy; key inclusion criteria were osteoarthritis-related signal knee pain, morning stiffness lasting less than 30 minutes, knee crepitus, and knee osteoarthritis confirmed by x-ray within 12 months. The protocol-specified outcomes were change from baseline through month 12 in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, incidence of worsening knee osteoarthritis, and treatment-emergent adverse events (TEAEs) with romosozumab versus placebo. In a post hoc analysis, percentage change from baseline to month 12 in bone mineral density (BMD) was assessed.

RESULTS

Of 7180 women in FRAME, 347 participated in the osteoarthritis substudy (placebo, 177; romosozumab, 170). At month 12, no significant difference in progression of knee osteoarthritis was observed with romosozumab versus placebo (least squares mean total WOMAC score: -2.2 vs. -1.3; P = 0.71). Incidence of worsening symptoms of knee osteoarthritis was comparable between romosozumab (17.1%) and placebo (20.5%) (odds ratio 0.9 [95% confidence interval: 0.5, 1.7]; P = 0.69). Incidence of TEAEs of osteoarthritis was numerically lower with romosozumab (13 [7.7%]) versus placebo (21 [12.0%]). BMD gains were higher with romosozumab.

CONCLUSION

Romosozumab treatment did not impact knee pain or function in postmenopausal women with osteoporosis and knee osteoarthritis and resulted in significant BMD gains in these women.

Clinical Use of Trabecular Bone Score: The 2023 ISCD Official Positions

Osteoporosis can currently be diagnosed by applying the WHO classification to bone mineral density (BMD) assessed by dual-energy x-ray absorptiometry (DXA). However, skeletal factors other than BMD contribute to bone strength and fracture risk. Lumbar spine TBS, a grey-level texture measure which is derived from DXA images has been extensively studied, enhances fracture prediction independent of BMD and can be used to adjust fracture probability from FRAX® to improve risk stratification. The purpose of this International Society for Clinical Densitometry task force was to review the existing evidence and develop recommendations to assist clinicians regarding when and how to perform, report and utilize TBS. Our review concluded that TBS is most likely to alter clinical management in patients aged ≥ 40 years who are close to the pharmacologic intervention threshold by FRAX. The TBS value from L1-L4 vertebral levels, without vertebral exclusions, should be used to calculate adjusted FRAX probabilities. L1-L4 vertebral levels can be used in the presence of degenerative changes and lumbar compression fractures. It is recommended not to report TBS if extreme structural or pathological artifacts are present. Monitoring and reporting TBS change is unlikely to be helpful with the current version of the TBS algorithm. The next version of TBS software will include an adjustment based upon directly measured tissue thickness. This is expected to improve performance and address some of the technical factors that affect the current algorithm which may require modifications to these Official Positions as experience is acquired with this new algorithm.

Effect of BMI-Discordant Abdominal Tissue Thickness on Fracture Probability: A Registry-Based Study

FRAX, which is used to assess fracture probability, considers body mass index (BMI), but BMI may not reflect individual variation in body composition and distribution. We examined the effect of BMI-discordant abdominal thickness on FRAX-derived fracture probability for major osteoporotic fracture (MOF) and hip fracture. We studied 73,105 individuals, mean age 64.2 years. During mean 8.7 years, 7048 (9.6%) individuals sustained incident MOF, including 2155 (3.0%) hip fractures. We defined abdominal thickness index (ATI) as the difference between abdominal thickness measured by dual-energy X-ray absorptiometry (DXA) and thickness predicted by BMI using sex-stratified regression. ATI was categorized from lower (<-2 cm, -2 to -1 cm) to higher (1-2 cm, >+2 cm) with referent around zero (-1 to +1 cm). Adjusted for FRAX probability, increasing ATI was associated with incident MOF and hip fracture (p < 0.001). For the highest ATI category, MOF risk was increased (hazard ratio [HR] = 1.23, 95% confidence interval [CI] 1.12-1.35) independent of FRAX probability. Similar findings were noted for hip fracture probability (HR = 1.28, 95% CI 1.09-1.51). There was significant age-interaction with much larger effects before age 65 years (HR = 1.44, 95% CI 1.23-1.69 for MOF; 2.29, 95% CI 1.65-3.18 for hip fracture). In contrast, for the subset of individuals with diabetes, there was also increased risk for those in the lowest ATI category (HR = 1.73, 95% CI 1.12-2.65 for MOF; 2.81, 95% CI 1.59-4.97 for hip fracture). Calibration plots across ATI categories demonstrated deviation from the line of identity in women (calibration slope 2.26 for MOF, 2.83 for hip fracture). An effect of ATI was not found in men, but this was inconclusive as the sex-interaction terms did not show significant effect modification. In conclusion, these data support the need to investigate increased abdominal thickness beyond that predicted by BMI and sex as a FRAX-independent risk factor for fracture. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

MRI-based vertebral bone quality score: relationship with age and reproducibility

Vertebral bone quality (VBQ) score is an opportunistic measure of bone mineral density using routine preoperative MRI in spine surgery. VBQ score positively correlates with age and is reproducible across serial scans. However, extrinsic factors, including MRI machine and protocol, affect the VBQ score and must be standardized.

PURPOSE

The purposes of this study were to determine whether VBQ score increased with age and whether VBQ remained consistent across serial MRI studies obtained within 3 months.

METHODS

This retrospective study evaluated 136 patients, age 20-69, who received two T1-weighted lumbar MRI within 3 months of each other between January 2011 and December 2021. VBQ(L1-4) score was calculated as the quotient of L1-L4 signal intensity (SI) and L3 cerebral spinal fluid (CSF) SI. VBQ(L1) score was calculated as the quotient of L1 SI and L1 CSF SI. Regression analysis was performed to determine correlation of VBQ(L1-4) score with age. Coefficient of variation (CV) was used to determine reproducibility between VBQ(L1-4) scores from serial MRI scans.

RESULTS

One hundred thirty-six patients (mean ± SD age 44.9 ± 12.5 years; 53.7% female) were included in this study. Extrinsic factors affecting the VBQ score included patient age, MRI relaxation time, and specific MRI machine. When controlling for MRI relaxation/echo time, the VBQ(L1-4) score was positively correlated with age and had excellent reproducibility in serial MRI with CV of 0.169. There was excellent agreement (ICC > 0.9) of VBQ scores derived from the two formulas, VBQ(L1) and VBQ(L1-4).

CONCLUSION

Extrinsic factors, including MRI technical factors and age, can impact the VBQ(L1-4) score and must be considered when using this tool to estimate bone mineral density (BMD). VBQ(L1-4) score was positively correlated with age. Reproducibility of the VBQ(L1-4) score across serial MRI is excellent especially when controlling for technical factors, supporting use of the VBQ score in estimating BMD. The VBQ(L1) score was a reliable alternative to the VBQ(L1-4) score.

Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta-analysis

Bariatric surgery is associated with a postoperative reduction of 25(OH) vitamin D levels (25(OH)D) and with skeletal complications. Currently, guidelines for 25(OH)D assessment and vitamin D supplementation in bariatric patients, pre- and post-surgery, are still lacking. The aim of this work is to analyse systematically the published experience on 25(OH)D status and vitamin D supplementation, pre- and post-surgery, and to propose, on this basis, recommendations for management. Preoperatively, 18 studies including 2,869 patients were evaluated. Prevalence of vitamin D insufficiency as defined by 25(OH)D < 30 ng/mL (75 nmol/L) was 85%, whereas when defined by 25(OH)D < 20 ng/mL (50 nmol/L) was 57%. The median preoperative 25(OH)D level was 19.75 ng/mL. After surgery, 39 studies including 5,296 patients were analysed and among those undergoing either malabsorptive or restrictive procedures, a lower rate of vitamin D insufficiency and higher 25(OH)D levels postoperatively were observed in patients treated with high-dose oral vitamin D supplementation, defined as ≥ 2,000 IU/daily (mostly D3-formulation), compared with low-doses (< 2,000 IU/daily). Our recommendations based on this systematic review and meta-analysis should help clinical practice in the assessment and management of vitamin D status before and after bariatric surgery. Assessment of vitamin D should be performed pre- and postoperatively in all patients undergoing bariatric surgery. Regardless of the type of procedure, high-dose supplementation is recommended in patients after bariatric surgery.

Actualisation 2023 des lignes directrices de pratique clinique pour la prise en charge de l’ostéoporose et la prévention des fractures au Canada

Contexte:

Au Canada, plus de 2 millions de personnes vivent avec l’ostéoporose, une maladie qui accroît le risque de fracture, ce qui fait augmenter la morbidité et la mortalité, et entraîne une perte de qualité de vie et d’autonomie. La présente actualisation des lignes directrices vise à accompagner les professionnelles et professionnels de la santé au Canada dans la prestation de soins visant à optimiser la santé osseuse et à prévenir les fractures chez les femmes ménopausées et les hommes de 50 ans et plus.

Méthodes:

Le présent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d’Ostéoporose Canada sur le diagnostic et la prise en charge de l’ostéoporose au pays. Nous avons utilisé l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectué l’assurance de la qualité conformément aux normes de qualité et de présentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les médecins de premier recours et les patientes et patients partenaires ont été représentés à tous les niveaux des comités et des groupes ayant participé à l’élaboration des lignes directrices, et ont participé à toutes les étapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des intérêts concurrents a été entamé avant l’élaboration des lignes directrices et s’est poursuivi sur toute sa durée, selon les principes du Réseau international en matière de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et préférences de la patientèle, des ressources, de l’équité, de l’acceptabilité et de la faisabilité; la force de chacune des recommandations a été déterminée en fonction du cadre GRADE.

Recommandations:

Les 25 recommandations et les 10 énoncés de bonne pratique sont répartis en sections : activité physique, alimentation, évaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, durée et séquence du traitement, et monitorage. La prise en charge de l’ostéoporose devrait se fonder sur le risque de fracture, établi au moyen d’une évaluation clinique réalisée avec un outil d’évaluation du risque de fracture validé. L’activité physique, l’alimentation et la pharmacothérapie sont des éléments essentiels à la stratégie de prévention des fractures, qui devraient être personnalisés.

Interprétation:

Les présentes lignes directrices ont pour but d’outiller les professionnelles et professionnels de la santé et la patientèle afin qu’ensemble ils puissent parler de l’importance de la santé osseuse et du risque de fracture tout au long de la vie adulte avancée. La détection et la prise en charge efficace de la fragilité osseuse peuvent contribuer à réduire les fractures et à préserver la mobilité, l’autonomie et la qualité de vie.

Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update

BACKGROUND

In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older.

METHODS

This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework.

RECOMMENDATIONS

The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized.

INTERPRETATION

The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life.

Adjusting Trabecular Bone Score (TBS) for Level-Specific Differences Reduces FRAX®-Based Treatment Reclassification in Patients with Vertebral Exclusions: The Manitoba BMD Registry

Trabecular bone score (TBS) is a FRAX®-independent risk factor for fracture prediction. TBS values increase from cranial to caudal, with the following mean differences between TBSL1-L4 and individual lumbar vertebrae: L1 -0.093, L2 -0.008, L3 +0.055 and L4 +0.046. Excluding vertebral levels can affect FRAX-based treatment recommendations close to the intervention threshold. We examined the effect of adjusting for level-specific TBS differences in individuals with vertebral exclusions due to structural artifact on TBS-adjusted FRAX-based treatment recommendations. We identified 71,209 individuals aged ≥40 years with TBS and FRAX calculations through the Manitoba Bone Density Program. In the 24,428 individuals with vertebral exclusions, adjusting TBS using these level-specific factors agreed with TBSL1-L4 (mean difference -0.001). We compared FRAX-based treatment recommendations for TBSL1-L4 and for non-excluded vertebral levels before and after adjusting for level-specific TBS differences. Among those with baseline major osteoporotic fracture risk ≥15 %, TBS with vertebral exclusions reclassified FRAX-based treatment in 10.6 % of individuals compared with TBSL1-L4, and was reduced to 7.2 % after adjusting for level-specific differences. In 11,131 patients where L1-L2 was used for BMD reporting (the most common exclusion pattern with the largest TBS effect), treatment reclassification was reduced from 13.9 % to 2.4 %, respectively. Among individuals with baseline hip fracture risk ≥2 %, TBS vertebral exclusions reclassified 7.1 % compared with TBSL1-L4, but only 4.5 % after adjusting for level-specific differences. When L1-L2 was used for BMD reporting, treatment reclassification from hip fracture risk was reduced from 9.2 % to 5.2 %. In conclusion, TBS and TBS-adjusted FRAX-based treatment recommendations are affected by vertebral level exclusions for structural artifact. Adjusting for level-specific differences in TBS reduces reclassification in FRAX-based treatment recommendations.

Liver enzyme inducing anticonvulsant drug use is associated with prevalent vertebral fracture

Among those who use of liver-enzyme inducing anticonvulsant medication for more than 2 years, 27% have a prevalent vertebral fracture on vertebral fracture assessment (VFA) lateral spine imaging. VFA imaging at the time of bone densitometry may be appropriate for older individuals who are chronic users of these medications.

PURPOSE

It is unclear whether prevalent vertebral fractures are associated with use of anticonvulsant drugs, especially those that induce liver enzymes (LEI) that metabolize drugs and vitamin D. Our purpose was to estimate the prevalence of vertebral fracture on densitometric lateral spine images according to duration of prior anticonvulsant medication use.

METHODS

Our study population was 11,822 individuals (mean [sd] age 76.1 [6.8] years, 94% female) who had bone densitometry with VFA between 2010 and 2018. Cumulative prior exposure to LEI anticonvulsants (carbamazepine, phenobarbital, phenytoin, valproic acid, n = 538), non-LEI anticonvulsants (clonazepam, gabapentin, levetiracetam, others, n = 2786), and other non-clonazepam benzodiazepines (n = 5082) was determined using linked pharmacy records. Prevalent vertebral fractures were identified on VFA images using the modified ABQ method. Logistic regression models were used to estimate the association of anticonvulsant drug exposure with prevalent vertebral fractures.

RESULTS

Prevalence of one or more vertebral fractures was 16.1% for the entire analytic cohort, and 27.0%, 19.0%, and 18.5% for those with ≥ 2 years of prior LEI anticonvulsant use, non-LEI anticonvulsant use, and other benzodiazepine use, respectively. Adjusted for multiple covariates, use of prior LEI anticonvulsant medication for ≥ 2 years was associated with prevalent fracture on VFA (OR 1.48 [95% CI 1.04, 2.10]).

CONCLUSION

LEI anticonvulsant use for ≥ 2 years is associated with higher vertebral fracture prevalence. Lateral spine VFA imaging at the time of bone densitometry may be appropriate for older individuals who have used LEI anticonvulsant medications for ≥ 2 years.

FRAX® Adjustment Using Renormalized Trabecular Bone Score (TBS) from L1 Alone may be Optimal for Fracture Prediction: The Manitoba BMD Registry

Lumbar spine trabecular bone score (TBS) used in conjunction with FRAX® improves 10-year fracture prediction. The derived FRAX risk adjustment is based upon TBS measured from L1-L4, designated TBSL1-L4-FRAX. In prior studies, TBS measurements that include L1 and exclude L4 give better fracture stratification than L1-L4. We compared risk stratification from TBS-adjusted FRAX using TBS derived from different combinations of upper lumbar vertebral levels renormalized for level-specific differences in individuals from the Manitoba Bone Density Program aged >40 years with baseline assessment of TBS and FRAX. TBS measurements for L1-L3, L1-L2 and L1 alone were calculated after renormalization for level-specific differences. Corresponding TBS-adjusted FRAX scores designated TBSL1-L3-FRAX, TBSL1-L2-FRAX and TBSL1-FRAX were compared with TBSL1-L4-FRAX for fracture risk stratification. Incident major osteoporotic fractures (MOF) and hip fractures were assessed. The primary outcome was incremental change in area under the curve (ΔAUC). The study population included 71,209 individuals (mean age 64 years, 89.8% female). Before renormalization, mean TBS for L1-3, L1-L2 and L1 was significantly lower and TBS-adjusted FRAX significantly higher than from using TBSL1-L4. These differences were largely eliminated when TBS was renormalized for level-specific differences. During mean follow-up of 8.7 years 6745 individuals sustained incident MOF and 2039 sustained incident hip fractures. Compared with TBSL1-L4-FRAX, use of FRAX without TBS was associated with lower stratification (ΔAUC = -0.009, p < 0.001). There was progressive improvement in MOF stratification using TBSL1-L3-FRAX (ΔAUC = +0.001, p < 0.001), TBSL1-L2-FRAX (ΔAUC = +0.004, p < 0.001) and TBSL1-FRAX (ΔAUC = +0.005, p < 0.001). TBSL1-FRAX was significantly better than all other combinations for MOF prediction (p < 0.001). Incremental improvement in AUC for hip fracture prediction showed a similar but smaller trend. In conclusion, this single large cohort study found that TBS-adjusted FRAX performance for fracture prediction was improved when limited to the upper lumbar vertebral levels and was best using L1 alone.

Effects of Severe Lumbar Spine Structural Artifact on Trabecular Bone Score (TBS): The Manitoba BMD Registry

Trabecular bone score (TBS) is a bone mineral density (BMD)-independent risk factor for fracture. During DXA analysis and BMD reporting, it is standard practice to exclude lumbar vertebral levels affected by structural artifact. Although TBS is relatively insensitive to degenerative artifact, it is uncertain whether TBS is still useful in the presence extreme structural artifact that precludes reliable spine BMD measurement even after vertebral exclusions. Among individuals aged 40 years and older undergoing baseline DXA assessment from September 2012 to March 2018 we identified three mutually exclusive groups: spine BMD reporting performed without exclusions (Group 1, N=12,865), spine BMD reporting performed with vertebral exclusions (Group 2, N=4867), and spine BMD reporting not performed due to severe structural artifact (Group 3, N=1541). No significant TBS difference was seen for Group 2 versus Group 1 (referent), whereas TBS was significantly greater in Group 3 (+0.041 partially adjusted, +0.043 fully adjusted). When analyzed by the reason for vertebral exclusion, multilevel degenerative changes significantly increased TBS (+0.041 partially adjusted, +0.042 fully adjusted), while instrumentation significantly reduced TBS (-0.059 partially adjusted, -0.051 fully adjusted). Similar results were seen when analyses were restricted to those in Group 3 with a single reason for vertebral exclusions, and when follow up scans were also included. During mean follow-up of 2.5 years there were 802 (4.2 %) individuals with one or more incident fractures. L1-L4 TBS showed significant fracture risk stratification in all groups including Group 3 (P-interaction >0.4). In conclusion, lumbar spine TBS can be reliably measured in the majority of lumbar spine DXA scans, including those with artifact affecting up to two vertebral levels. However, TBS is significantly affected by the presence of extreme structural artifact in the lumbar spine, especially those with multilevel degenerative disc changes and/or instrumentation that precludes reliable BMD reporting.

Efficacy and Safety of Transdermal Abaloparatide in Postmenopausal Women with Osteoporosis: A Randomized Study

Anabolic therapies, recommended for patients at very high fracture risk, are administered subcutaneously (SC). The objective of this study was to evaluate the efficacy and safety of the abaloparatide microstructured transdermal system (abaloparatide-sMTS) as an alternative to the SC formulation. This phase 3, noninferiority study (NCT04064411) randomly assigned postmenopausal women with osteoporosis (N = 511) 1:1 to open-label abaloparatide administered daily via abaloparatide-sMTS or SC injection for 12 months. The primary comparison between treatment groups was the percentage change in lumbar spine bone mineral density (BMD) at 12 months, with a noninferiority margin of 2.0%. Secondary endpoints included percentage change in total hip and femoral neck BMD, bone turnover markers, dermatologic safety, and new clinical fracture incidence. At 12 months, percentage increase from baseline in lumbar spine BMD was 7.14% (SE: 0.46%) for abaloparatide-sMTS and 10.86% (SE: 0.48%) for abaloparatide-SC (treatment difference: -3.72% [95% confidence interval: -5.01%, -2.43%]). Percentage change in total hip BMD was 1.97% for abaloparatide-sMTS and 3.70% for abaloparatide-SC. Median changes from baseline at 12 months in serum procollagen type I N-terminal propeptide (s-PINP) were 52.6% for abaloparatide-sMTS and 74.5% for abaloparatide-SC. Administration site reactions were the most frequently reported adverse events (abaloparatide-sMTS, 94.4%; abaloparatide-SC, 70.5%). Incidence of serious adverse events was similar between groups. Mild or moderate skin reactions occurred with abaloparatide-sMTS with no identifiable risk factors for sensitization reactions. Few new clinical fractures occurred in either group. Noninferiority of abaloparatide-sMTS to abaloparatide-SC for percentage change in spine BMD at 12 months was not demonstrated; however, clinically meaningful increases from baseline in lumbar spine and total hip BMD were observed in both treatment groups. © 2023 Radius Health, Inc and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Trabecular Bone Score Vertebral Exclusions Affect Risk Classification and Treatment Recommendations: The Manitoba Bmd Registry

Lumbar spine trabecular bone score (TBS), a texture measure derived from spine dual-energy x-ray absorptiometry (DXA) images, is a bone mineral density (BMD)-independent risk factor for fracture. Lumbar vertebral levels that show structural artifact are excluded from BMD measurement. TBS is relatively unaffected by degenerative artifact, and it is uncertain whether the same exclusions should be applied to TBS reporting. To gain insight into the clinical impact of vertebral exclusion on TBS, we examined the effect of lumbar vertebral exclusions in routine clinical practice on tertile-based TBS categorization and TBS adjusted FRAX-based treatment recommendations. The study population consisted of 71,209 individuals aged 40 years and older with narrow fan-beam spine DXA examinations and retrospectively-derived TBS. During BMD reporting, 34.3% of the scans had one or more vertebral exclusions for structural artifact. When TBS was derived from the same vertebral levels used for BMD reporting, using fixed L1-L4 tertile cutoffs (1.23 and 1.31 from the McCloskey meta-analysis) reclassified 17.9% to a lower and 6.5% to a higher TBS category, with 75.6% unchanged. Reclassification was reduced from 24.4% overall to 17.2% when level-specific tertile cutoffs from the software manufacturer were used. Treatment reclassification based upon FRAX major osteoporotic fracture probability occurred in 2.9% overall, but in 9.6% of those with baseline risk ≥15%. For treatment based upon FRAX hip fracture probability, reclassification occurred in 3.4% overall, but in 10.4% in those with baseline risk ≥2%. In summary, lumbar spine TBS measurements based upon vertebral levels other than L1-L4 can alter the tertile category and treatment recommendations based upon TBS-adjusted FRAX calculation, especially for those close to or exceeding the treatment cut-off. Manufacturer level-specific tertile cut-offs should be used if vertebral exclusions are applied.

FRAX Adjustment by Trabecular Bone Score with or Without Bone Mineral Density: The Manitoba BMD Registry

Trabecular bone score (TBS), a texture measure derived from spine dual-energy x-ray absorptiometry (DXA) images, is a FRAX®-independent risk factor for fracture. The TBS adjustment to FRAX assumes the presence of femoral neck BMD in the calculation. However, there are many individuals in whom hip DXA cannot be acquired. Whether the TBS-adjustment would apply to FRAX probabilities calculated without BMD has not been studied. The current analysis was performed to evaluate major osteoporotic fracture (MOF) and hip fracture risk adjusted for FRAX with and without femoral neck BMD. The study cohort consisted of 71,209 individuals (89.8% female, mean age 64.0 years). During mean follow-up 8.7 years, 6743 (9.5%) individuals sustained one or more incident MOF, of which 2037 (2.9%) sustained a hip fracture. Lower TBS was significantly associated with increased fracture risk when adjusted for FRAX probabilities, with a slightly larger effect when BMD was not included. Inclusion of TBS in the risk calculation gave a small but significant increase in stratification for fracture probabilities estimated with and without BMD. Calibration plots showed very minor deviations from the line of identity, indicating overall good calibration. In conclusion, the existing equations for incorporating TBS in FRAX estimates of fracture probability work similarly when femoral neck BMD is not used in the calculation. This potentially extends the range of situations where TBS can be used clinically to those individuals in whom lumbar spine TBS is available but femoral neck BMD is not available.

Urinary 2- to 16α-hydroxyestrone ratio did not change with cruciferous vegetable intake in premenopausal women

The mass ratio of urinary 2-hydroxyestrone to 16-α-hydroxyestrone (2:16) is hypothesized as a biomarker of breast cancer risk in premenopausal women, with higher ratios being theoretically protective. Cruciferous vegetable intake has been associated with higher urinary 2:16 in some studies. We investigated whether a whole-food supplement made from dried Brussels sprouts and kale would increase urinary 2:16 in comparison with placebo or cruciferous vegetables in women. This randomized, parallel arm, placebo-controlled, partly blinded study included 78 healthy premenopausal women (38-50 y) with screening urinary 2:16 ≤3.0. Subjects received either six capsules containing 550 mg dried Brussels sprouts and kale per capsule, 40 g daily alternating broccoli or Brussels sprouts, or placebo for eight weeks. Urinary 2:16 and creatinine were measured at baseline, four, and eight weeks. Intent-to-treat repeated measures-ANOVA with multiple imputation (n=100) for missing values identified no treatment effect (P=0.9) or treatment-by-time interaction (P=0.6); however, a significant time effect was noted (P=0.02). Per-protocol analyses including complete cases found no treatment effect (P=1) or treatment-by-time interaction (P=0.6); however, the significant time effect remained (P=0.03). Restricting analysis to subjects with >80% compliance maintained the time effect (P=0.02). Using Pearson correlations, android-pattern and android:gynoid fat were predictive of change (P≤0.05). In conclusion, neither cruciferous supplements nor an added vegetable serving altered urinary 2:16 in premenopausal women with eight weeks treatment. This ratio did vary with time, which is important for designing future trials.

Advances in Osteoporosis Therapy: Focus on Osteoanabolic Agents, Secondary Fracture Prevention, and Perioperative Bone Health

PURPOSE OF REVIEW

This review summarizes recently published data and other developments around osteoanabolic osteoporosis therapies in patients with very high fracture risk, including those undergoing bone-related surgery.

RECENT FINDINGS

Two osteoanabolic agents, abaloparatide and romosozumab, were recently approved for treatment of patients with osteoporosis at high fracture risk. These agents, along with teriparatide, are valuable for primary and secondary fracture prevention. Orthopedic surgeons are well positioned to facilitate secondary fracture prevention via referrals to fracture liaison services or other bone health specialist colleagues. This review aims to help surgeons understand how to identify patients with sufficiently high fracture risk to warrant consideration of osteoanabolic therapy. Recent evidence around the perioperative use and potential benefits of osteoanabolic agents in fracture healing and other orthopedic settings (e.g., spinal fusion and arthroplasty) in individuals with osteoporosis is also discussed. Osteoanabolic agents should be considered for patients with osteoporosis at very high fracture risk, including those with prior osteoporotic fractures and those with poor bone health who are undergoing bone-related surgery.

Fracture risk gradient assessed by categories of bone mineral density and trabecular bone score: the Manitoba BMD Registry

Trabecular bonescore (TBS) helps to predict fracture risk in older adults. In this registry-based cohort study of patients aged 40 years and older, reduction in bone mineral density (BMD) and TBS are complementary for fracture risk prediction enhancement with lower BMD imparting greater risk than reduction in TBS.

PURPOSE

Trabecular bone score (TBS) enhances fracture risk prediction independent of bone mineral density (BMD) in older adults. The purpose of this study was to further evaluate the gradient of fracture risk based on TBS tertile categories and WHO BMD categories, adjusted for other risk factors.

METHODS

Using the Manitoba DXA registry, patients aged 40 years and older with spine/hip DXA and L1-L4 TBS were identified. Any incident fractures, major osteoporotic fractures (MOF), and hip fractures were identified. Cox regression models were used to estimate unadjusted and covariate-adjusted hazard ratios (HR, 95%CI) for incident fracture by BMD and TBS category and for each SD decrease in BMD and TBS.

RESULTS

The study population included 73,108 individuals, 90% female with mean age 64 years. Mean (SD) minimum T-score was - 1.8 (1.1), and mean L1-L4 TBS was 1.257 (0.123). Lower BMD and TBS, both per SD, by WHO BMD category and by TBS tertile category, were significantly associated with MOF, hip, and any fracture (all HRs p < 0.001). However, the quantum of risk was consistently greater for BMD than TBS, with HRs showing non-overlapping CIs.

CONCLUSION

TBS is complementary to BMD in prediction of incident major, hip, and any osteoporosis-related fracture, but reductions in BMD impart greater risk than reductions in TBS on both continuous and categorical scales.

Contributions of Clinical and Technical Factors to Longitudinal Change in Trabecular Bone Score and Bone Density: A Registry-Based Individual-Level Analysis

Lumbar spine trabecular bone score (TBS), a gray-level texture measure derived from spine dual-energy X-ray absorptiometry (DXA) images, is a bone mineral density (BMD)-independent risk factor for fracture. An unresolved question is whether TBS is sufficiently responsive to change over time or in response to widely used osteoporosis therapy at the individual level to serve as a useful biomarker. Using the Manitoba DXA Registry, we identified 11,643 individuals age 40 years and older with two fan-beam DXA scans performed on the same instrument within 5 years (mean interval 3.2 years), of whom 6985 (60.0%) received antiresorptive osteoporosis medication (majority oral bisphosphonate) between the scans. We examined factors that were associated with a change in lumbar spine TBS, lumbar spine BMD, and total hip BMD exceeding the 95% least significant change (LSC). Change exceeding the LSC was identified in 23.0% (9.3% increase, 13.8% decrease) of lumbar spine TBS, 38.2% (22.1% increase, 16.1% decrease) lumbar spine BMD, and 42.5% (17.6% increase, 24.9% decrease) total hip BMD measurement pairs. From regression models, the variables most strongly associated with significant change in TBS (decreasing order) were tissue thickness change, acquisition mode change, weight change, and spine percent fat change. Consistent with the insensitivity of TBS to oral antiresorptive therapies, use of these agents showed very little effect on TBS change. In contrast, for both spine BMD change and total hip BMD change, osteoporosis medication use was the most significant variable, whereas tissue thickness change, acquisition mode change, and weight change had relatively weak effects. In summary, change in spine TBS using the present algorithm appears to be strongly affected by technical factors. This suggests a limited role, if any, for using TBS change in untreated individuals or for monitoring response to antiresorptive treatment in routine clinical practice with the current version of the TBS algorithm. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Vertebral Level Variations in Trabecular Bone Score and Effect on Fracture Prediction: The Manitoba BMD Registry

Trabecular bone score (TBS), a texture measure derived from spine dual-energy x-ray absorptiometry (DXA) images, is a bone mineral density (BMD)-independent risk factor for fracture. TBS is reportedly insensitive to degenerative changes, and it is uncertain whether the same rules for excluding lumbar vertebral levels from BMD measurement should be applied to TBS. The current analysis was performed to explore inter-vertebral variation in TBS measurements from L1 to L4, how this relates to clinically identified structural artifact resulting in vertebral level exclusion from BMD reporting, and area under the curve (AUC) for incident fracture. The study population comprised 70,762 individuals aged 40 years and older at the time of baseline spine DXA assessment (mean age 64.1 years, 89.7% female), among whom 24,289 (34.3%) had one or more vertebral exclusions. Both TBS and BMD showed a similar cranial/caudal inter-vertebral gradient. Compared with L1-4, TBS from L1 alone was lower (mean difference -0.096; -7.6%) while TBS from L4 alone was 0.046 (3.6%) greater, similar in those without and with visual structural artifact. During mean follow-up of 8.7 years, 6744 (9.5%) individuals sustained incident major osteoporotic fractures. TBS from L1 alone gave significantly higher AUC for incident fracture than L1-4, which was in turn significantly higher than L2, L3 and L4 alone, seen in those without and with visual structural artifact. In contrast, AUCs for BMD showed minimal variation from L1 to L4, and was higher for L1-4 than for any individual lumbar vertebral level. In summary, we found inter-vertebral TBS variations within the lumbar spine are overall similar to BMD but are relatively unaffected by visual structural artifact. Fracture outcomes showed the strongest association with TBS measured from L1 alone. Further investigation is need to understand the cause and clinical application of these differences.

Intraoperative physician assessment of bone: correlation to bone mineral density

This study evaluated the intraoperative physician assessment (IPA) of bone status at time of total knee arthroplasty. IPA was highly correlated with distal femur and overall bone mineral density. When IPA identifies poor bone status, formal bone health assessment is indicated.

PURPOSE

Intuitively, intraoperative physician assessment (IPA) would be an excellent measure of bone status gained through haptic feedback during bone preparation. However, no studies have evaluated the orthopedic surgeon's ability to do so. This study's purpose, in patients undergoing total knee arthroplasty (TKA), was to relate IPA with (1) the lowest bone mineral density (BMD) T-score at routine clinical sites; and (2) with distal femur BMD.

METHODS

Seventy patients undergoing TKA by 3 surgeons received pre-operative DXA. Intraoperatively, bone quality was assessed on a 5-point scale (1 excellent to 5 poor) based on tactile feedback to preparation. Demographic data, DXA results, and IPA score between surgeons were compared by factorial ANOVA. Lowest T-score and distal femur BMD were associated with IPA using Spearman's correlation.

RESULTS

The mean (SD) age and BMI were 65.8 (7.6) years and 31.4 (5.1) kg/m², respectively. Patient demographic data, BMD, and IPA (mean [SD] = 2.74 [1.2]) did not differ between surgeons. IPA correlated with the lowest T-score (R = 0.511) and distal femur BMD (R = 0.603-0.661). Based on the lowest T-score, no osteoporotic patients had an IPA above average, and none with normal BMD was classified as having poor bone.

CONCLUSIONS

IPA is highly correlated with local (distal femur) and overall BMD. This study supports the International Society for Clinical Densitometry position that surgeon concern regarding bone quality should lead to bone health assessment. As IPA is comparable between surgeons, it is logical this can be widely applied by experienced orthopedic surgeons. Future studies evaluating IPA at other anatomic sites are indicated.

Bone density and trabecular bone score to predict fractures in adults aged 20-39 years: a registry-based study

Trabecular bone score (TBS) enhances fracture risk assessment in older adults; whether this is true in younger people is uncertain. In this registry-based study of adults aged 20-39 years, low BMD, but not low TBS, predicted fracture.

PURPOSE

Trabecular bone score (TBS), a bone texture measurement, is associated with fracture risk independent of bone mineral density (BMD) in older adults. In adults aged 20-40 years, TBS remains stable and its role in fracture risk assessment is unclear. We utilized the Manitoba Bone Density Registry to explore the relationship of fracture risk with BMD and TBS in younger adults.

METHODS

Women and men aged 20-39 years referred for DXA testing were studied. Incident major and any fractures were captured from health records. Categories based on WHO BMD T-score classification and TBS tertile were considered using Cox regression models to estimate covariate-adjusted (including sex) hazard ratios (aHR, 95%CI) for incident fracture by category, and each SD decrement in BMD and TBS.

RESULTS

The study included 2799 individuals (77% female, mean age 32 years). Mean (SD) minimum T-score was - 0.9 (1.1) and TBS 1.355 (0.114); 7% had osteoporosis and 13% were in the lowest TBS tertile. Incident major osteoporotic fracture (MOF) and any fracture risk was elevated in those with osteopenia (aHRs 1.20/1.45) and osteoporosis (aHRs 4.60/5.16). Fracture risk was unrelated to TBS tertile. Each SD decrement in BMD was associated with increased MOF risk (aHR 1.64) and any fracture (aHR 1.71); lower TBS was unrelated to fractures.

CONCLUSION

In young adults, low BMD, but not low TBS, was predictive of MOF and any fracture. Routine clinical TBS measurement is not recommended for young adults. Further study is indicated to evaluate whether TBS is beneficial in subsets of younger adults.

Periprosthetic fractures: an unrecognized osteoporosis crisis

Total joint replacement is common and increasing. Many of these patients have low bone mineral density preoperatively, and arthroplasty leads to bone loss. As falls are common before and after arthroplasty, it is unsurprising that periprosthetic fractures, defined as those associated with an orthopedic device, whether a joint replacement or other internal fixation devices, are not rare. These fractures engender morbidity and mortality comparable to osteoporosis-related hip fractures but remain largely unrecognized and untreated by osteoporosis/metabolic bone disease clinicians. Indeed, recent osteoporosis guidelines are silent regarding periprosthetic fractures. The purposes of this clinical review are to briefly describe the epidemiology of arthroplasty procedures and periprosthetic fractures, raise awareness that these fractures are osteoporosis-related, and suggest approaches likely to reduce their occurrence. Notably, bone health evaluation is essential following the occurrence of a periprosthetic fracture to reduce subsequent fracture risk. Importantly, in addition to such secondary fracture prevention, primary prevention, i.e., bone health assessment and optimization prior to elective orthopedic procedures, is appropriate.

CT required to perform robotic-assisted total hip arthroplasty can identify previously undiagnosed osteoporosis and guide femoral fixation strategy

Osteoporosis can determine surgical strategy for total hip arthroplasty (THA), and perioperative fracture risk. The aims of this study were to use hip CT to measure femoral bone mineral density (BMD) using CT X-ray absorptiometry (CTXA), determine if systematic evaluation of preoperative femoral BMD with CTXA would improve identification of osteopenia and osteoporosis compared with available preoperative dual-energy X-ray absorptiometry (DXA) analysis, and determine if improved recognition of low BMD would affect the use of cemented stem fixation. Retrospective chart review of a single-surgeon database identified 78 patients with CTXA performed prior to robotic-assisted THA (raTHA) (Group 1). Group 1 was age- and sex-matched to 78 raTHAs that had a preoperative hip CT but did not have CTXA analysis (Group 2). Clinical demographics, femoral fixation method, CTXA, and DXA data were recorded. Demographic data were similar for both groups. Preoperative femoral BMD was available for 100% of Group 1 patients (CTXA) and 43.6% of Group 2 patients (DXA). CTXA analysis for all Group 1 patients preoperatively identified 13 osteopenic and eight osteoporotic patients for whom there were no available preoperative DXA data. Cemented stem fixation was used with higher frequency in Group 1 versus Group 2 (28.2% vs 14.3%, respectively; p = 0.030), and in all cases where osteoporosis was diagnosed, irrespective of technique (DXA or CTXA). Preoperative hip CT scans which are routinely obtained prior to raTHA can determine bone health, and thus guide femoral fixation strategy. Systematic preoperative evaluation with CTXA resulted in increased recognition of osteopenia and osteoporosis, and contributed to increased use of cemented femoral fixation compared with routine clinical care; in this small study, however, it did not impact short-term periprosthetic fracture risk.

Fracture in Patients with Normal Bone Mineral Density: An Evaluation of the American Orthopaedic Association's Own the Bone Registry

BACKGROUND

Fractures often occur in patients with normal dual x-ray absorptiometry (DXA)-measured bone mineral density (BMD). DXA does not consider clinical fracture risk factors or bone quality. We hypothesized that patients with normal BMD who sustain a fracture have other characteristics suggesting abnormal bone and an elevated fracture risk requiring additional bone health evaluation and potential anti-osteoporotic treatment.

METHODS

A total of 7,219 patients who were ≥50 years of age, had sustained a fracture from July 2016 to July 2021, and had DXA data in the American Orthopaedic Association's Own the Bone (AOA OTB) registry were included in this study. The index and prior fracture site data were obtained. BMD status was classified by the World Health Organization T-score criteria. The Fracture Risk Assessment Tool (FRAX) scores with and without BMD were calculated in patients with normal BMD. An elevated risk was defined as a major osteoporotic fracture risk of ≥20% or a hip fracture risk of ≥3%.

RESULTS

The mean patient age (and standard deviation) was 70.8 ± 9.71 years, 84% of patients were female, and 92% of patients were Caucasian. Normal BMD was present in 8.6% of patients. The index fracture was a major osteoporotic fracture in 68.6% of patients with normal BMD and 75.6% of patients with osteoporosis. The most common site for index and prior fractures other than major osteoporotic fractures was the foot and ankle; of patients with normal BMD, 13.9% had this as the most common index site and 17.4% had this as the most common prior site. The FRAX risk calculated without BMD was elevated in 72.9% of patients with normal BMD, and the FRAX risk calculated with BMD was elevated in 12.0% of patients.

CONCLUSIONS

Most patients with a fracture and normal BMD met indications, including a prior fracture or elevated FRAX risk, for anti-osteoporotic therapies. Most patients were Caucasian and therefore potentially had a higher baseline fracture risk. The FRAX risk calculated without BMD was elevated more often than the FRAX risk with BMD, implying that clinical risk factors, which highlight multiple opportunities for non-pharmacologic secondary fracture prevention, should be considered along with DXA. Fractures other than major osteoporotic fractures were more common in patients with normal BMD, suggesting that minor fractures in adults who are ≥50 years of age should be considered sentinel events warranting further evaluation. Surgeons must recognize that other important risk factors apart from BMD may help to guide further bone health evaluation.

LEVEL OF EVIDENCE

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

Proposed bone health screening protocol to identify total knee arthroplasty patients for preoperative DXA

This study evaluates a novel, simple bone health screening protocol composed of patient sex, age, fracture history, and FRAX risk to identify total knee arthroplasty patients for preoperative DXA. Findings supported effectiveness, with sensitivity of 1.00 (CI 0.92-1.00) and specificity of 0.54 (CI 0.41-0.68) when evaluating for clinical osteoporosis.

PURPOSE

Bone health optimization is a process where osteoporotic patients are identified, evaluated via modalities such as dual-energy X-ray absorptiometry (DXA), and treated when indicated. There are currently no established guidelines to determine who needs presurgical DXA. This study evaluates the effectiveness of a simple screening protocol to identify TKA patients for preoperative DXA.

METHODS

This prospective cohort study began on September 1, 2019, and included 100 elective TKA patients. Inclusion criteria were ≥ 50 years and primary TKA. All patients obtained routine clinical DXA. The screening protocol defining who should obtain DXA included meeting any of the following: female ≥ 65, male ≥ 70, fracture history after age 50, or FRAX major osteoporotic fracture risk without bone mineral density (BMD) adjustments ≥ 8.4%. Osteoporosis was defined by the World Health Organization (WHO) criteria (T-score ≤  - 2.5) or clinically (T-score ≤  - 2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture). Sensitivity and specificity were calculated.

RESULTS

The study included 68 females and 32 males, mean age 67.2 ± 7.7. T-score osteoporosis was observed in 16 patients while 43 had clinical osteoporosis. Screening criteria recommending DXA was met by 69 patients. Screening sensitivity was 1.00 (CI 0.79-1.00) and specificity was 0.37 (CI 0.27-0.48) for identifying patients with T-score osteoporosis. Similar sensitivity of 1.00 (CI 0.92-1.00) and specificity of 0.54 (CI 0.41-0.68) were found for clinical osteoporosis.

CONCLUSIONS

A simple screening protocol identifies TKA patients with T-score and clinical osteoporosis for preoperative DXA with high sensitivity in this prospective cohort study.

Ethnicity and Fracture Risk Stratification from Trabecular Bone Score in Canadian Women: The Manitoba BMD Registry

Lumbar spine Trabecular Bone Score (TBS), a grey-level texture measure derived from spine dual-energy x-ray absorptiometry (DXA) images, is a bone mineral density (BMD)-independent risk factor for fracture. An unresolved and controversial question is whether there are ethnic differences that affect the utility of TBS for fracture risk assessment. The current analysis examined whether self-identified ethnicity (White, Asian, Black) in women age 40 years and older referred for DXA testing affected fracture risk stratification from TBS using a large clinical registry. The study population comprised 63,078 White women, 1,915 Asian women and 329 Black women (n=329) with mean follow up 9.0±5.2 years. There were between group differences in BMI (Black>White>Asian), lumbar spine fat percentage (Asian>White>Black) and lumbar spine tissue thickness (Black>White>Asian). Despite this, lumbar spine TBS was not significantly different between the subgroups, though there was a significant difference in lumbar spine and total hip BMD (Black >White>Asian). TBS provided significant stratification for MOF and any fracture for all ethnicity subgroups, and for hip fracture in White and Asian subgroups (insufficient numbers for analysis in Black women). No significant difference in White vs. Asian or White vs. Black women were identified using a Bonferroni adjusted p-value. In summary, we found that lumbar spine TBS measurements were similar among White, Asian and Black women referred for DXA assessment in Manitoba, Canada. TBS and BMD measurements significantly stratified fracture risk in all three populations without a meaningful difference between groups. This suggests that TBS does not need to be used differently in White vs. non-White populations.

Should vertebral fracture assessment be performed in Fracture Liaison Service patients with non-vertebral fracture?

Prior non-vertebral fractures, except of the ankle, are associated with increased likelihood of vertebral fracture. As knowledge of vertebral fracture presence may alter care, vertebral fracture assessment (VFA) is indicated in patients with prior fracture.

INTRODUCTION

Vertebral fractures are often unappreciated. It was recently advocated that all Fracture Liaison Service (FLS) patients have densitometric VFA performed. We evaluated the likelihood of vertebral fracture identification with VFA in patients with prior fracture using the Manitoba Bone Density database. METHODS : VFA was performed in patients with T-scores below - 1.5 and age 70 + (or younger with height loss or glucocorticoid use) obtaining bone densitometry in Manitoba from 2010 to 2018. Those with prior clinical vertebral fracture, pathologic fracture, or uninterpretable VFA were excluded. Vertebral fractures were identified using the modified ABQ method. Health records were assessed for non-vertebral fracture (excluding head, neck, hand, foot) diagnosis codes unassociated with trauma prior to DXA. Multivariable odds ratios (ORs) for vertebral fracture were estimated without and with adjustment for age, sex, body mass index, ethnicity, area of residence, income level, comorbidity score, diabetes mellitus, falls in the last year, glucocorticoid use, and lowest BMD T-score.

RESULTS

The study cohort consisted of 12,756 patients (94.4% women) with mean (SD) age 75.9 (6.8) years. Vertebral fractures were identified in 1925 (15.1%) overall. Vertebral fractures were significantly more likely (descending order) in those with prior pelvis, hip, humerus, other sites, and forearm, but not ankle fracture. There was modest attenuation with covariate adjustment but statistical significance was maintained.

CONCLUSIONS

Prior hip, humerus, pelvis, forearm, and other fractures are associated with an increased likelihood of previously undiagnosed vertebral fracture, information useful for risk stratification and monitoring. These data support recommending VFA in FLS patients who are age 70 + with low BMD.

Consensus and Controversial Aspects of Vitamin D and COVID-19

OBJECTIVES

This work aims to review and discuss controversial topics in the field of vitamin D, SARS-CoV-2 infection, and COVID-19.

PARTICIPANTS

The International Conferences "Controversies in Vitamin D" are a series of workshops that started in 2017 featuring international experts and leaders in vitamin D research and clinical practice. The 5th annual conference was held in Stresa, Italy, from 15 to 18 September 2021.

EVIDENCE

Before the event, participants reviewed available studies on their assigned topic, drafted a related abstract, and presented their findings at the time of the conference. Relevant literature that became available since was also discussed within the panel and updated accordingly.

CONSENSUS

Before the event, the drafted abstracts had been merged to prepare a preliminary document. After the conference presentations, in-depth discussions in open sessions led to consensus. The document was subsequently modified according to discussions and up-to-date literature inclusion.

CONCLUSIONS

There is quite consistent evidence for an association between low 25 OH vitamin D (25(OH)D) levels and poor COVID-19 outcomes, despite heterogeneous publications of variable quality. However, the low vitamin D status in COVID-19 patients might also reflect reverse causality. Vitamin D supplementation might have a positive role in COVID-19 prevention. The evidence supporting a beneficial effect of vitamin D treatment in decreasing the risk of COVID-19 complications is conflicting. Conclusive statement regarding the beneficial effect of vitamin D in this context await high-quality randomized controlled trials.

The Efficacy and Safety of Abaloparatide-SC in Men With Osteoporosis: A Randomized Clinical Trial

Abaloparatide significantly increased bone mineral density (BMD) in women with postmenopausal osteoporosis and decreased risk of vertebral, nonvertebral, and clinical fractures compared with placebo. The Abaloparatide for the Treatment of Men with Osteoporosis (ATOM; NCT03512262) study evaluated the efficacy and safety of abaloparatide compared with placebo in men. Eligible men aged 40 to 85 years with osteoporosis were randomized 2:1 to daily subcutaneous injections of abaloparatide 80 μg or placebo for 12 months. The primary endpoint was change from baseline in lumbar spine BMD. Key secondary endpoints included BMD change from baseline at the total hip and femoral neck. A total of 228 men were randomized (abaloparatide, n = 149; placebo, n = 79). Baseline characteristics were similar across treatment groups (mean age, 68.3 years; mean lumbar spine BMD T-score, -2.1). At 12 months, BMD gains were greater with abaloparatide compared with placebo at the lumbar spine (least squares mean percentage change [standard error]: 8.48 [0.54] versus 1.17 [0.72]), total hip (2.14 [0.27] versus 0.01 [0.35]), and femoral neck (2.98 [0.34] versus 0.15 [0.45]) (all p < 0.0001). The most common (≥5%) treatment-emergent adverse events were injection site reaction, dizziness, nasopharyngitis, arthralgia, bronchitis, hypertension, and headache. During 12 months of abaloparatide treatment, men with osteoporosis exhibited rapid and significant improvements in BMD with a safety profile consistent with previous studies. These results suggest abaloparatide can be considered as an effective anabolic treatment option for men with osteoporosis. © 2022 Radius Health Inc and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

RF03 | PMON303 Serum 25-Hydroxyvitamin D Concentration Significantly Decreases in COVID-19 Patients With Pneumonia During the First 48 Hours After Hospital Admission

Objectives

Although 25(OH)D is generally considered the best marker for assessing vitamin D body stores, its role as a marker during acute illness is less well established. Indeed, acute inflammatory insult may reduce circulating 25(OH)D. The objective was to examine serum 25(OH)D levels during the evolution of acute COVID-19 pneumonia.

Material and methods: This pilot study was undertaken as a prospective cohort study. Patients with severe COVID-19, defined as clinical signs of pneumonia and respiratory rate &gt; 30 breaths/minute or severe respiratory distress or oxygen saturation &lt; 90% on room air, were admitted to the internal medicine department between 1 November and 31 December. Blood samples were taken on admission (day 0) and every 24 hours for the subsequent four days (days 1-4). Patients were not supplemented with vitamin D preparations during the monitoring period. All patients received 6 milligrams of dexamethasone daily during the monitoring period.

Results

22 patients (6 females, 16 males; median age 60.6 years) were included. On admission, 59% of patients were 25(OH)D sufficient (&gt;30 ng/ml), and 41% of patients had 25(OH)D inadequacy (&lt;30 ng/ml) according to the existing guidelines. A significant fall in mean 25(OH)D concentration from admission to day 2 (first 48 h) was observed (30,7 ng/ml vs. 26,4 ng/ml; p&lt;0.0001). No subsequent significant fall in 25(OH)D concentration was observed between day 2 and 3 (26, 4 ng/ml vs. 25,9 ng/ml; p=0.2300) and day 3 and day 4 (25,8 ng/ml vs. 25,9 ng/ml; p=0.7026). The absolute 25(OH)D change between hospital admission and day 4 was 4.8 ng/mL (p&lt;0.0001) and was not associated with mortality or the need for high flow oxygen (p=0.2113 and p=0.6467, respectively). On day 4, the number of patients with 25(OH)D inadequacy (&lt;30 ng/ml) increased by 18% (p=0.0180).

Conclusions

Serum concentration of 25(OH)D decreases significantly during the first 48 hours after hospital admission in acutely ill COVID-19 patients and should be therefore interpreted with caution. Whether low 25(OH)D in COVID-19 reflects tissue level vitamin D deficiency or represents only a laboratory phenomenon remains to be elucidated in prospective randomized trials of vitamin D supplementation.

Presentation: Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Humeral BMD can be Measured With DXA and Is Lower in the Surgical Arm After Total Shoulder Arthroplasty

BACKGROUND

As arthroplasty leads to bone loss, we hypothesized that humeral bone mineral density (BMD) is lower after total shoulder arthroplasty (TSA) in the operative versus non-operative arm. However, there is no clinical approach to measure humeral BMD with dual-energy x-ray absorptiometry (DXA). The purposes of this pilot study were to develop DXA methodology to measure humerus BMD, propose humerus regions of interest (ROIs), compare TSA BMD to the non-operative arm, correlate humeral BMD with standard sites, and evaluate measurement reproducibility.

METHODOLOGY

Thirty-eight adults 1-5 years post-TSA had standard clinical DXA scans plus full humerus scans using the atypical femur fracture feature; precision was assessed in a subset (n = 32). Six custom ROIs were used to measure BMD throughout the humerus. Radius and humeral BMD were compared between arms by paired t-test and correlated ipsilaterally using Pearson's Correlation. Custom ROI BMD precision was assessed using the International Society for Clinical Densitometry (ISCD) advanced precision calculator.

RESULTS

Study included 38 subjects (24M/14F), with mean (SD) age and time post-surgery of 69.6 (7.7) years and 2.5 (1.3) years respectively. BMD was lower (p &lt; 0.01) at all custom humerus sites (3.8% to 8.2%) on the surgical side but not different at radius sites. Humeral BMD correlated positively with ipsilateral ultra-distal and 1/3 radius (r = 0.54 to 0.86; p &lt; 0.05). Custom BMD precision (%CV) ranged from 6.0-16.0%.

CONCLUSIONS

Humerus BMD can be measured using DXA and is lower in the TSA arm. Radius BMD correlated with humeral BMD but was not lower in the surgical arm. BMD precision was worse than usual clinical sites; use of software optimized for the femur is a notable limitation and likely contributes to suboptimal precision. Further study to assess the clinical utility of humeral BMD is needed. Automation and optimization of these measurements should improve precision.

Clinical risk factor status in patients with vertebral fracture but normal bone mineral density

BACKGROUND CONTEXT

Normal bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DXA) is present in approximately 10% of older adults with fracture. BMD alone does not evaluate bone quality or clinical risk factors, and therefore, may not adequately capture a patient's fracture risk. Thus, despite a normal DXA-measured BMD, the underlying bone may be abnormal, suggesting that further bone health evaluation, and potentially, pharmacologic treatment may be warranted.

PURPOSE

To determine the prevalence of normal BMD, clinical fracture risk factors, and quantitative risk of fracture using the Fracture Risk Assessment Tool (FRAX) in vertebral fracture patients with normal BMD enrolled in the Own the Bone registry, thus facilitating identification of those who meet criteria for anti-osteoporosis therapy.

STUDY DESIGN/SETTING

Retrospective, national registry-based cohort.

PATIENT SAMPLE

From July 2016 to July 2021, 1,807 patients age ≥50 who sustained a vertebral fracture and had DXA data available from within 2 years prior to enrollment in the American Orthopaedic Association's Own the Bone (AOA OTB) registry were included.

OUTCOME MEASURES

World Health Organization (WHO) DXA T-score based bone classification criteria; FRAX risk scores of major osteoporotic fracture or hip fracture.

METHODS

Demographic data, prior fracture site, and clinical fracture risk factors were collected. BMD status was classified by the WHO T-score criteria: ≥ -1.0 normal, -1.1 to -2.4 osteopenia, and ≤ -2.5 osteoporosis, with low bone mass including either osteopenia or osteoporosis. In normal BMD patients, FRAX scores were calculated with and without BMD, with the treatment threshold defined as a major osteoporotic fracture risk ≥20% or hip fracture risk ≥3%.

RESULTS

Mean±SD age was 72.0±9.7, 78.1% were female, and 92.4% were Caucasian. Normal BMD was present in 7.9%. Clinical fracture risk factors including alcohol use ≥3 units/day and history of ≥2 falls in the year prior to enrollment were more common in normal BMD (11.2% and 28%, respectively) compared to low bone mass patients (3.4% and 25.2%, respectively). A prior vertebral fracture had occurred in 49.5% with normal BMD compared to 45.8% with low bone mass, while a prior non-major osteoporotic fracture occurred in 28.9% and 29.3% of normal BMD and low bone mass patients, respectively. In normal BMD patients, either a prior fracture or FRAX risk with BMD meeting treatment thresholds was present in 85%.

CONCLUSIONS

Clear indications for receipt of pharmacologic therapy, ie, prior fracture or elevated fracture risk, were present in most patients with vertebral fracture and normal BMD enrolled in the AOA OTB. Prior non-major osteoporotic fractures were common and may be useful indicators of underlying bone disease. Surgeons must recognize that other important risk factors apart from BMD may indicate poor bone health, and thus, help guide further bone health evaluation.

Proceedings of the 2022 Santa Fe Bone Symposium: Current Concepts in the Care of Patients with Osteoporosis and Metabolic Bone Diseases

The 22^nd Annual Santa Fe Bone Symposium (SFBS) was a hybrid meeting held August 5-6, 2022, with in-person and virtual attendees. Altogether, over 400 individuals registered, a majority of whom attended in-person, representing many states in the USA plus 7 other countries. The SFBS included 10 plenary presentations, 2 faculty panel discussions, satellite symposia, Bone Health & Osteoporosis Foundation Fracture Liaison Service Boot Camp, and a Project ECHO workshop, with lively interactive discussions for all events. Topics of interest included fracture prevention at different stages of life; how to treat and when to change therapy; skeletal health in cancer patients; advanced imaging to assess bone strength; the state of healthcare in the USA; osteosarcopenia; vitamin D update; perioperative bone health care; new guidelines for managing primary hyperparathyroidism; new concepts on bone modeling and remodeling; and an overview on the care of rare bone diseases, including hypophosphatasia, X-linked hypophosphatemia, tumor induced osteomalacia, osteogenesis imperfecta, fibrodysplasia ossificans progressiva, and osteopetrosis. The SFBS was preceded by the Santa Fe Fellows Workshop on Osteoporosis and Metabolic Bone Diseases, a collaboration of the Endocrine Fellows Foundation and the Osteoporosis Foundation of New Mexico. From the Workshop, 4 participating fellows were selected to give oral presentations at the bone symposium. These proceedings represent the clinical highlights of 2022 SFBS presentations and the discussions that followed, all with the aim of optimizing skeletal health and minimizing the consequences of fragile bones.

Bone Texture Assessment on Lateral VFAs Using the Texture Research Investigational Platform (TRIP) and its Fracture Discrimination Ability

Texture Research Imaging Platform applies trabecular bone score (TBS) measurement principles to images acquired with multiple modalities to assess bone texture at various skeletal sites. This study aimed to assess the bone texture score in dual-energy X-ray absorptiometry-acquired lateral vertebral fracture assessment (VFA) images (BTS_VFA), evaluate its reproducibility, and vertebral fracture discrimination ability. Subjects included 178 VF cases and 178 non-VF controls, 136 women and 42 men in each group, age 55-92 years, from two research centers. Cases and controls were matched for age (±5 years), body mass index (±5 kg/m²) and TBS. All participants underwent dual-energy X-ray absorptiometry TBS assessment from standard posterior-anterior lumbar spine scans and BTS_VFA assessment. VF presence was determined using VFA images applying the Genant's method. BTS_VFA was lower among fractured women compared to non-fractured (0.626 ± 0.109 vs 0.675 ± 0.099, p < 0.01), but not among men. In a binary logistic regression adjusted for study center and sex, for each SD lower BTS_VFA, there was a 40% increase (OR 1.40, 95% CI (1.13-1.74)) in the risk of having a prevalent VF; area under the curve (95% CI) 0.616 (0.557-0.675). Inter-assessor and inter-centers ICCs for BTS_VFA measurements were very good; 0.96 (0.64-0.99) and 0.98 (0.95-0.99), respectively. The BTS_VFA precision (coefficient of variation) was 2.42%. This feasibility study demonstrates the potential to assess trabecular bone texture in lateral VFA images with good reproducibility. BTS_VFA can discriminate between fractured and non-fractured women independent of their age, body mass index and TBS. In conclusion, BTS_VFA, a potential trabecular texture assessment that excludes the posterior elements, may have value in fracture prediction or as a novel approach to be further investigated in spine surgery planning.

A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization

Introduction

Osteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA.

Materials/Methods

This retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ -2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ -2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD].

Results

The study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.).

Discussion/Conclusion

A simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.

Effect of degeneration on bone mineral density, trabecular bone score and CT Hounsfield unit measurements in a spine surgery patient population

This study investigated the impact of spinal degeneration on bone mineral density (BMD), trabecular bone score (TBS), and CT Hounsfield units in an at-risk population. We found that BMD was increased by degeneration, whereas TBS and HU were unaffected. These findings support that TBS is not adversely affected by spinal degeneration.

INTRODUCTION

This study evaluated the impact of spinal degeneration on BMD and TBS measured by dual-energy x-ray absorptiometry (DXA) and on CT HU in a spine surgery patient population.

METHODS

A retrospective study of 63 patients referred for consideration of spine surgery or with history of spine surgery was performed. Patients were included if a DXA scan and a CT containing the lumbar spine were obtained within 18 months of each other. DXA data were collected and analyzed by vertebral level. Individual vertebrae were assessed for degenerative changes by qualitative evaluation of the anterior and posterior elements using CT. Degeneration scores were compared to BMD T-scores, TBS and CT HU at individual vertebral levels L1-4, and after applying International Society for Clinical Densitometry (ISCD) criteria for excluding vertebrae from diagnostic consideration.

RESULTS

Mean patient age and BMI were 67.2 years and 27.8 kg/m², respectively; 79.4% were female. Mean (SD) lowest T-scores of the hip, spine, and lowest overall T-score were - 1.3 (1.4), - 1.7 (0.9), and - 1.9 (1.0), respectively. Osteoporosis was present by T-score in 38% and osteopenia in 52%; 10% had a history of osteoporotic fracture. The mean degeneration score of individual vertebrae was 4.1 on a 0-6 scale. T-score correlated moderately with degeneration score (Spearman's rho 0.484, p < 0.001), whereas TBS and HU were unrelated. ISCD excluded vertebrae had a higher degeneration score than included vertebrae (p =  < 0.001).

CONCLUSIONS

In a spine surgery population, TBS and CT HU values are unrelated to degeneration score and thus appear unaffected by lumbar vertebral degenerative changes. Additionally, these data support the ISCD criteria for vertebral exclusion.

Femur and Tibia BMD Measurement in Elective Total Knee Arthroplasty Candidates

Distal femur BMD declines ∼20% following total knee arthroplasty (TKA) potentially leading to adverse outcomes. BMD knowledge before and following TKA might allow interventions to optimize outcomes. We hypothesized that distal femur and proximal tibial BMD could be reproducibly measured with existing DXA technology. Elective TKA candidates were enrolled and standard clinical DXA plus bilateral PA and lateral knee scans acquired. Manual regions of interest (ROIs) were placed at distal femur and proximal tibia sites based on required TKA machining and periprosthetic fracture location. Intra- and inter-rater BMD reliability was assessed by intra-class correlation (ICC). Custom and standard proximal femur BMD were correlated by linear regression and paired t test evaluated BMD differences between planned surgical and contralateral side. One hundred subjects (68F/32M), mean (SD) age and BMI of 67.2 (7.7) yr and 30.8 (4.8) kg/m² were enrolled. Lowest clinical BMD T-score was < -1.0 in 65% and ≤ -2.5 in 16%; 34 had prior fracture. BMD reproducibility at all custom ROIs was excellent; ICC > 0.96. Mean BMD at custom ROIs ranged from 0.903 to 1.346 g/cm² in the PA projection and 0.891 to 1.429 g/cm² in the lateral. Lower BMD values were observed at the proximal tibia, while the higher measurements were at the femur condyle. Custom knee ROI BMD was highly correlated (p < 0.0001) with total and femur neck with better correlation at ROIs adjacent to the joint (R² = 0.62-0.67, 0.49-0.55 respectively). In those without prior TKA (n = 76), mean BMD was lower (2.8%-6.6%; p < 0.05) in the planned surgical leg at all custom ROIs except the PA tibial regions. Individual variability was present with 82% having a custom ROI with lower BMD (up to 53%) in the planned operative leg. Distal femur and proximal tibial BMD can be measured using custom ROIs with good reproducibility. Suboptimal bone status is common in TKA candidates and distal femur/proximal tibia BMD is often lower on the planned operative side. Routine distal femur/proximal tibial BMD measurement might assist pre-operative interventions, surgical decision-making, subsequent care and outcomes. Studies to evaluate these possibilities are indicated.

Effect of semi-recumbent vibration exercise on muscle outcomes in older adults: a pilot randomized controlled clinical trial

Background

Many older adults with physical limitations living in residential care apartments are unable to exercise in a standing position and are at risk for declining in muscle function leading to falls and injury. Novel approaches to achieve exercise benefits are needed. The purpose of this study was to test the effect of semi-recumbent vibration exercise on muscle outcomes in older adults living in residential care apartment complexes (RCACs).

Methods

A randomized, crossover design was used to examine the effect of semi-recumbent vibration exercise on muscle function and mass among 32 RCAC residents (mean age 87.5 years) with physical limitations. Participants received a randomized sequence of two study conditions: sham or vibration for 8 weeks each separated by a 4-week washout. Before and after the 8 weeks of vibration treatment and sham treatment, muscle mechanography was used to assess muscle function including jump power, weight-corrected jump power, and jump height. Short physical performance battery (SPPB) and handgrip strength were also used to measure muscle function. Bioelectrical impedance spectroscopy was used to estimate skeletal muscle mass. The effect of the vibration treatment on muscle outcomes was analyzed through mixed effects linear regression models.

Results

Vibration exercise leads to better jump height (p < .05) compared to sham exercise but also poorer chair rise performance (p = 0.012). Other muscle functions tests and muscle mass parameters showed non-significant changes.

Conclusion

This small pilot study showed no conclusive results on the effect of semi-recumbent vibration exercise on muscle function and mass in older adults living in RCAC. However, the promising signals of improved jump performance could be used to power larger studies of longer duration with various vibration doses to determine the benefit of vibration exercise in this physically impaired, high-risk population with few exercise capabilities.

Trial registration

The study is registered at clinicaltrials.gov (NCT02533063; date of first registration 26/08/2015).

Clinical aspects of SARS-CoV-2 infection and vitamin D : COVID-19 and the endocrine system: special issue for reviews in endocrine and metabolic disorders (Felipe Casaneuva, Editor in Chief) A. Giustina and JP Bilezikian, Guest Editors

In December 2019, the first cases of severe acute respiratory syndrome due to a new coronavirus (SARS-Cov-2), later designated as Covid-19, were described in China. With rapid advance of the infection to several continents, in March 2020, WHO declared this to be a pandemic. In April 2020, the first papers suggesting a possible role of Vitamin D deficiency in the severity of this infection began to appear and dozens of articles evaluating a potential relationship of vitamin D with COVID have emerged subsequntly. This possibility was raised based on pre-existing evidence of the effects of Vitamin D on the immune system, and more specifically on acute respiratory viral infections. In addition, most Covid-19 victims belong to groups at risk for vitamin D deficiency such as the elderly, obese, chronically ill, and specific ethnic groups. Although with some contradictory reports exist, most observational and cohort studies find a relationship of low vitamin D status with greater Covid severity, others, including the few interventional studies available show inconsistent results. This paper aims to present the rapidly expanding literature to date regarding the clinical relevance of vitamin D in Covid-19 and, consequently, the reasonableness of avoiding its deficiency to keep the immune system able to respond in the best way to this acute viral infection. In the meantime, we wait for publication of several prospective randomized controlled studies that are underway, evaluating the effects of treatment with vitamin D or metabolites on the severity of Covid-19 outcomes.

Opportunistic Use of Lumbar Magnetic Resonance Imaging for Osteoporosis Screening

Magnetic resonance imaging (MRI) is a routine assessment before spine surgery. We found that the opportunistic use of MRI with the vertebral bone quality (VBQ) score has good diagnostic ability, with a threshold value of VBQ > 3.0, in recognizing patients who may need further osteoporosis evaluation.

INTRODUCTION

The purpose of this study was to determine whether the opportunistic use of magnetic resonance imaging (MRI) is useful for identifying spine surgical patients who need further osteoporosis evaluation.

METHODS

This retrospective study evaluated 83 thoracolumbar spine surgery patients age ≥ 50 who received T1-weighted MRI. Opportunistic MRI was evaluated with the vertebral bone quality (VBQ) score, VBQ (fat) score, and signal-to-noise ratio (SNR). Each uses the median L1-L4 vertebral body signal intensities (SI) divided by either the L3 cerebrospinal fluid (CSF) SI, average SI of the L1 and S1 dorsal fat, or standard deviation (SD) of the background SI dorsal to the skin. Single-level VBQ was calculated as the ratio of the L1 vertebral body and L1 CSF SIs. Receiver-operator curve analysis was performed to determine diagnostic ability.

RESULTS

The mean age was 70.10, 80% were female, and 96% were Caucasian. The mean ± SD VBQ, single-level VBQ, VBQ (fat), and SNR were 3.39 ± 0.68, 3.56 ± 0.81, 3.95 ± 1.89, and 113.18 ± 77.26, respectively. Using area under the curve, the diagnostic ability of VBQ, single-level VBQ, VBQ (fat), and SNR for clinical osteoporosis were 0.806, 0.779, 0.608, and 0.586, respectively. Diagnostic threshold values identified with optimal sensitivity and specificity were VBQ of 2.95 and single-level VBQ of 3.06.

CONCLUSION

Opportunistic use of MRI is a simple, effective tool that may help recognize patients who are at risk for complications related to bone disease. A VBQ > 3.0 can identify patients who need additional diagnostic evaluation.