Martínez, Angel Antonio; Ferrandez, Luis; Gil, Enrique; Moreno, Alonso
We conducted a multicentre study, divided into a retrospective and a prospective portion. The retrospective study evaluated osteoporotic hip fractures that occurred during 2002. The prospective study evaluated osteoporotic hip fractures that occurred during May 2003. The study was conducted in 77 hospitals in Spain and comprised patients 60 years of age and over. In the retrospective study we registered 13,195 hip fractures. Of the patients, 74% were women and 26% were men. The mean age was 80.7±8.4 years. The average incidence was 6.94±0.44 hip fractures per 1,000 inhabitants/year (95% CI, 6.07–7.82). In the prospective study, we registered 1,399 hip fractures. This represents a monthly incidence of 0.60±0.04 hip fractures per 1,000 inhabitants/year (95% CI, 0.51–0.69). Of the subjects, 74% were women and 26% were men. The mean age was 81.4±8.1 years. Using these data, we calculated the average annual prevalence in 2003 to be 7.20 fractures per 1,000 inhabitants. Thirty-three percent had previously suffered a hip fracture. Prior to the fracture, only 18% had received medical treatment for osteoporosis. After discharge from the hospital, only 26% were receiving pharmacological treatment for osteoporosis. PMID:16328387
McClung, Michael R
Osteoporosis is characterized late in the course of the disease by an increased risk of fracture, particularly in the elderly. It occurs in both sexes, affecting approximately 8 million women and 2 million men aged > or = 50 years (1). While low bone density is a predictor of fractures, it is not the only determinant of fracture risk. Other factors include advanced age, altered bone quality, a personal or family history of falls, frailty, poor eyesight, debilitating diseases, and high bone turnover. A diet with sufficient calcium and vitamin D is important to minimize bone loss and, along with regular exercise, to maintain muscle strength. Bisphosphonates have been shown to reduce the risk of hip fracture. For elderly patients, the use of hip protectors may be used as a treatment of last resort. Regardless of the age of the patient, individual patient risk factors must be considered to target appropriate treatment and prevent fracture.
A number of different bone geometries have been reported to be correlated with osteoporosis, bone mineral density and fractures. Those correlations are used for diagnosis, treatment and prediction of fracture risk in osteoporosis cases. However there have been no studies of significant bone parameters predicting osteoporosis and hip fracture in Thailand To evaluate the correlation between geometric parameters of the proximal femur and both the Singh index and bone mineral density as well as to investigate the relationship between those two metrics and osteoporotic hip fracture in the Thai population. Forty-four Thai patients with osteoporotic hip fractures andforty-five healthy Thai people matched for age and gender were included in the present study. Bone mineral density and bone geometry from plain hip radiographs of non-fracture sites in the fracture group and proximal femur radiographs of the same site in the healthy group were measured That data were analyzed to determine levels of correlation. Bone geometries were also analyzed to determine hip fracture predictive capacity. Correlation between the Singh index and bone mineral density was significant (p < 0.01), with a moderate degree of agreement. The radiograph measurement of the width ofthefemoral medial neck cortex was the only parameter which was statistically significantly correlated with both osteoporosis and with osteoporotic hip fracture (p = 0.014 and p = 0.035, respectively). Each 1 mm reduction in the width of the femoral medial neck cortex increased the osteoporotic hip fracture risk by a factor of 2.7 (OR = 0.37, 95% CI = 0.15-0.93). In the Thai population, bone geometry from plain radiographs can help predict the risk of osteoporotic hip fracture. Osteoporosis is correlated with a low Singh index value. The width of the femoral medial neck cortex is a reliable predictor of hip fracture risk.
Föger-Samwald, Ursula; Vekszler, György; Hörz-Schuch, Edith; Salem, Sylvia; Wipperich, Markus; Ritschl, Peter; Mousavi, Mehdi; Pietschmann, Peter
A common manifestation of age-related bone loss and resultant osteoporosis are fractures of the hip. Age-related osteoporosis is thought to be determined by a number of intrinsic factors including genetics, hormonal changes, changes in levels of oxidative stress, or an inflammatory status associated with the aging process. The aim of this study was to investigate gene expression and bone architecture in bone samples derived from elderly osteoporotic women with hip fractures (OP) in comparison to bone samples from age matched women with osteoarthritis of the hip (OA). Femoral heads and adjacent neck tissue were collected from 10 women with low-trauma hip fractures (mean age 83±6) and consecutive surgical hip replacement. Ten bone samples from patients undergoing hip replacement due to osteoarthritis (mean age 80±5) served as controls. One half of each bone sample was subjected to gene expression analysis. The second half of each bone sample was analyzed by microcomputed tomography. From each half, samples from four different regions, the central and subcortical region of the femoral head and neck, were analyzed. We could show a significantly decreased expression of the osteoblast related genes RUNX2, Osterix, Sclerostin, WNT10B, and Osteocalcin, a significantly increased ratio of RANKL to Osteoprotegerin, and a significantly increased expression of the enzymes superoxide dismutase 2 (SOD2) and glutathione peroxidase GPX3, and of the inflammatory cytokine IL6 in bone samples from hip fracture patients compared to controls. Major microstructural changes in OP bone were seen in the neck and were characterized by a significant decrease of bone volume, trabecular number, and connectivity density and a significant increase of trabecular separation. In conclusion, our data give evidence for a decreased expression of osteoblast related genes and increased expression of osteoclast related genes. Furthermore, increased expression of SOD2 and GPX3 suggest increased
Broderick, J. M.; Bruce-Brand, R.; Stanley, E.; Mulhall, K. J.
Osteoporotic hip fractures are a major cause of morbidity and mortality in the elderly. Furthermore, reduced implant anchorage in osteoporotic bone predisposes towards fixation failure and with an ageing population, even low failure rates represent a significant challenge to healthcare systems. Fixation failure in fragility fractures of the hip ranges from 5% in peritrochanteric fractures through to 15% and 41% in undisplaced and displaced fractures of the femoral neck, respectively. Our findings, in general, support the view that failed internal fixation of these fragility fractures carries a poor prognosis: it leads to a twofold increase in the length of hospital stay and a doubling of healthcare costs. Patients are more likely to suffer a downgrade in their residential status upon discharge with a consequent increase in social dependency. Furthermore, the marked disability and reduction in quality of life evident before salvage procedures may persist at long-term followup. The risk, of course, for the elderly patient with a prolonged period of decreased functioning is that the disability becomes permanent. Despite this, however, no clear link between revision surgery and an increase in mortality has been demonstrated in the literature. PMID:23476139
Background Proximal femoral geometry may be a risk factor of osteoporotic hip fractures. However, there existed great differences among studies depending on race, sex and age of subjects. The purpose of the present study is to analyze proximal femoral geometry and bone mineral density (BMD) in the osteoporotic hip fracture patients. Furthermore, we investigated proximal femoral geometric parameters affecting fractures, and whether the geometric parameters could be an independent risk factor of fractures regardless of BMD. Methods This study was conducted on 197 women aged 65 years or more who were hospitalized with osteoporotic hip fracture (femur neck fractures ; 84, intertrochanteric fractures; 113). Control group included 551 women who visited to check osteoporosis. Femur BMD and proximal femoral geometry for all subjects were measured using dual energy X-ray absorptiometry (DXA), and compared between the control and fracture groups. Besides, proximal femoral geometric parameters associated with fractures were statistically analyzed. Results There were statistically significant differences in the age and weight, cross-sectional area (CSA)/length/width of the femoral neck and BMD of the proximal femur between fracture group and control group. BMD of the proximal femur in the control group was higher than in the fracture group. For the femoral neck fractures group, the odds ratio (OR) for fractures decrease in the CSA and neck length (NL) of the femur increased by 1.97 times and 1.73 times respectively, regardless of BMD. The OR for fractures increase in the femoral neck width increased by 1.53 times. In the intertrochanteric fracture group, the OR for fractures increase in the femoral neck width increased by 1.45 times regardless of BMD. Conclusions We found that an increase of the femoral neck width could be a proximal femoral geometric parameter which plays important roles as a risk factor for fracture independently of BMD. PMID:27622182
Oliveira, A; Vaz, C
Several common age-related mechanisms and factors influence muscle and bone, affecting functionality of both tissues. Sarcopenia is closely linked with osteoporosis, and their combined effect may exacerbate negative health outcomes. Fall-related fractures are some of the most serious consequences of these two systemic pathologies, with hip fracture being a major complication affecting osteoporotic and sarcopenic elderly. This work aims to review the literature on the current state of knowledge about the relations between sarcopenia and osteoporosis and to present the association between sarcopenia and osteoporosis and the risk of hip fracture. A literature search was performed in PubMed and Scopus databases for articles with the predefined terms "sarcopenia," "muscular atrophy," "femoral fractures," "hip fractures," "osteoporosis," and "bone density." There is a growing and significant interest being directed to sarcopenia and associated risk for osteoporotic hip fracture, but there still is a notorious heterogeneity in the methodology and cohort size of the available studies. Collectively, most of the studies herein analyzed indicate that sarcopenia could be a predictor of risk for hip fracture. The simultaneous evaluation of sarcopenia and osteoporosis may be of importance in identifying those patients in higher risk of suffering an osteoporotic hip fracture and who could benefit from preventive or therapeutic interventions, or both.
Díez-Manglano, J; López-García, F; Barquero-Romero, J; Galofré-Alvaro, N; Montero-Rivas, L; Almagro-Mena, P; Soriano, J B
Osteoporosis is a frequent comorbidity in patients with chronic obstructive pulmonary disease (COPD). We have studied the risk of major osteoporotic fracture and hip fracture in patients with COPD. A multicenter cross-sectional study was performed in Spain in 26 hospitals of 16 regional communities. Patients diagnosed with COPD who required admission to the Internal Medicine Service due to exacerbation of their respiratory disease were enrolled. COPD was confirmed by post-bronchodilator spirometry in stable state: maximum expiratory volume in the first second (FEV₁) < 80% of the theoretical value and quotient FEV(1)/FVC < 0.70 and percent predicted after the administration of a bronchodilator. Dyspnea was evaluated with the modified Medical Research Council (mMRC) dyspnea scale. The principal variable was the likelihood of fracture evaluated with the FRAX® tool for the Spanish population. Three hundred and ninety two patients, 347 (88%) men, with a mean (SD) age of 73.7 (8.9) years and a mean FEV₁ of 1.23 liters (43.3% of predicted) were enrolled. Only 37 patients (9.4%), 27 men and 10 women had been diagnosed previously of osteoporosis. Overall, 1.8% (95% CI: 0.9-3.6) had a 10-year probability of major osteoporotic fracture ≥ 20% and 49.7% (95% CI: 44.8-54.7) had a probability of hip fracture ≥ 3%. No relationship was observed between the probability of fracture and GOLD stage or mMRC dyspnea scale. The diagnosis of osteoporosis is uncommon in our COPD patients. However, half of them have a high probability of a hip fracture in the next 10 years. Copyright © 2011 Elsevier España, S.L. All rights reserved.
Huang, Chenshu; Tang, Rongrui
Objective: To explore the relationship between tea drinking habits and osteoporotic hip/femur fractures. Methods: Paired case-control method was used for face-to-face interviews from January 2010 to June 2014. Patients (n=435) with newly osteoporotic hip/femur fracture and 435 controls with the same gender and age (±3) were given questionnaire survey. The survey content included general situation, detailed tea drinking and other diet condition, health-related behavior and family history of fractures, etc. Results: Single factor logistic analysis showed that the habit of drinking tea can significantly reduce the risk of hip/femur fracture. Cumulative year of tea drinking, the cumulative amount of tea and tea concentration (low dose group) have the maximum protection for fracture, while the high dose group is weaker in protection (trend test, P<0.05). After adjustment for age, energy, BMI, education degree, parents’ history of fracture, second hand smoke exposure, calcium supplements, and equivalent energy consumption of physical activity, etc, the above association still showed significant linear trend, but the associated strength was slightly reduced. But stratified analysis found that the effect of tea drinking was only statistically significant in men. And there were no statistically significant differences of people with different education degree. Conclusions: Regular tea drinking can reduce the risk of osteoporotic hip/femur fractures in middle-aged and elderly men. PMID:27182250
Barbour, Kamil E; Lui, Li-Yung; Ensrud, Kristine E; Hillier, Teresa A; LeBlanc, Erin S; Ing, Steven W; Hochberg, Marc C; Cauley, Jane A
Hip fractures are the most devastating consequence of osteoporosis and impact 1 in 6 white women leading to a two- to threefold increased mortality risk in the first year. Despite evidence of inflammatory markers in the pathogenesis of osteoporosis, few studies have examined their effect on hip fracture. To determine if high levels of inflammation increase hip fracture risk and to explore mediation pathways, a case-cohort design nested in a cohort of 4709 white women from the Study of Osteoporotic Fractures was used. A random sample of 1171 women was selected as the subcohort (mean age 80.1 ± 4.2 years) plus the first 300 women with incident hip fracture. Inflammatory markers interleukin-6 (IL-6) and soluble receptors (SR) for IL-6 (IL-6 SR) and tumor necrosis factor (TNF SR1 and TNF SR2) were measured, and participants were followed for a median (interquartile range) of 6.3 (3.7, 6.9) years. In multivariable models, the hazard ratio (HR) of hip fracture for women in the highest inflammatory marker level (quartile 4) was 1.64 (95% confidence interval [CI], 1.09-2.48, p trend = 0.03) for IL-6 and 2.05 (95% CI, 1.35-3.12, p trend <0.01) for TNF SR1 when compared with women in the lowest level (quartile 1). Among women with 2 and 3-4 inflammatory markers in the highest quartile, the HR of hip fracture was 1.51 (95% CI, 1.07-2.14) and 1.42 (95% CI, 0.87-2.31) compared with women with zero to one marker(s) in the highest quartile (p trend = 0.03). After individually adjusting for seven potential mediators, cystatin-C (a biomarker of renal function) and bone mineral density (BMD) attenuated HRs among women with the highest inflammatory burden by 64% and 50%, respectively, suggesting a potential mediating role. Older white women with high inflammatory burden are at increased risk of hip fracture in part due to poor renal function and low BMD. © 2014 American Society for Bone and Mineral Research.
Berry, Sarah D; Samelson, Elizabeth J; Pencina, Michael J; McLean, Robert R; Cupples, L Adrienne; Broe, Kerry E; Kiel, Douglas P
Screening for osteoporosis with bone mineral density (BMD) is recommended for older adults. It is unclear whether repeating a BMD screening test improves fracture risk assessment. To determine whether changes in BMD after 4 years provide additional information on fracture risk beyond baseline BMD and to quantify the change in fracture risk classification after a second BMD measure. Population-based cohort study involving 310 men and 492 women from the Framingham Osteoporosis Study with 2 measures of femoral neck BMD taken from 1987 through 1999. Risk of hip or major osteoporotic fracture through 2009 or 12 years following the second BMD measure. Mean age was 74.8 years. The mean (SD) BMD change was -0.6% per year (1.8%). Throughout a median follow-up of 9.6 years, 76 participants experienced an incident hip fracture and 113 participants experienced a major osteoporotic fracture. Annual percent BMD change per SD decrease was associated with risk of hip fracture (hazard ratio [HR], 1.43 [95% CI, 1.16 to 1.78]) and major osteoporotic fracture (HR, 1.21 [95% CI, 1.01 to 1.45]) after adjusting for baseline BMD. At 10 years' follow-up, 1 SD decrease in annual percent BMD change compared with the mean BMD change was associated with 3.9 excess hip fractures per 100 persons. In receiver operating characteristic (ROC) curve analyses, the addition of BMD change to a model with baseline BMD did not meaningfully improve performance. The area under the curve (AUC) was 0.71 (95% CI, 0.65 to 0.78) for the baseline BMD model compared with 0.68 (95% CI, 0.62 to 0.75) for the BMD percent change model. Moreover, the addition of BMD change to a model with baseline BMD did not meaningfully improve performance (AUC, 0.72 [95% CI, 0.66 to 0.79]). Using the net reclassification index, a second BMD measure increased the proportion of participants reclassified as high risk of hip fracture by 3.9% (95% CI, -2.2% to 9.9%), whereas it decreased the proportion classified as low risk by -2.2% (95
Dincel, V Ercan; Sepici-Dincel, Aylin
Bone morphogenetic proteins (BMPs), major contributors to tissue repair, have become one of the most exciting fields in rheumatic and orthopaedic research. In our study we aimed to evaluate the relationship between osteoporotic hip fractures and the serum levels of BMPs to reveal their potential roles in the diagnosis of patients. The study group included 62 patients with osteoporotic hip fracture (Group 1; intertrochanteric fracture, Group 2; collum femoris fracture) and the control group. All fractures were due to low energy trauma, simple falls. For all subjects BMD measurements were in agreement for osteoporosis and no significant differences were observed between the two fracture groups. Biochemical markers; BMP-4 and BMP-7 (pg/mL) were determined by commercial Elisa kits from the serum samples. The mean and standard error values of serum samples for BMP-4 and BMP-7 in Group 1 (100.70 +/- 10.03, 74.41 +/- 6.31 respectively) and in Group 2 (112.34 +/- 11.52, 81.91 +/- 10.14 respectively) were not statistically different however for both groups only BMP-7 values increased statistically when compared to the control group. BMP-7 measurements may not only serve as potential biochemical markers for determining disease severity but also the increased levels, an osteogenic factor and bone stimulating agent in vivo, after trauma elevated levels are adaptive or protective and therefore may reduce the severity of the fracture.
Föger-Samwald, Ursula; Patsch, Janina M; Schamall, Doris; Alaghebandan, Afarin; Deutschmann, Julia; Salem, Sylvia; Mousavi, Mehdi; Pietschmann, Peter
Osteoporosis is extremely frequent in post-menopausal women; nevertheless, osteoporosis in men is also a severe and frequently occurring but often underestimated disease. Increasing evidence links bone loss in male idiopathic osteoporosis and age related osteoporosis to osteoblast dysfunction rather than increased osteoclast activity as seen in postmenopausal osteoporosis. The aim of this study was to investigate gene expression of osteoblast related genes and of bone architecture in bone samples derived from elderly osteoporotic men with hip fractures (OP) in comparison to bone samples from age matched men with osteoarthritis of the hip (OA). Femoral heads and adjacent neck tissue were collected from 12 men with low-trauma hip fractures and consecutive surgical hip replacement. Bone samples of age matched patients undergoing hip replacement due to osteoarthritis served as controls. One half of the bone samples was subjected to RNA extraction, reverse transcription, and real-time polymerase chain reactions. The second half of the bone samples was analyzed by static histomorphometry. From each half samples from four different regions, the central and subcortical region of the femoral head and neck, were analyzed. OP patients displayed a significantly decreased RUNX2, Osterix and SOST expression compared to OA patients. Major microstructural changes in OP bone were seen in the subcortical region of the neck and were characterized by a significant decrease of bone volume, and a significant increase of trabecular separation. In conclusion, decreased local gene expression of RUNX2 and Osterix in men with hip fractures strongly supports the concept of osteoblast dysfunction in male osteoporosis. Major microstructural changes in the trabecular structure associated with osteoporotic hip fractures in men are localized in the subcortical region of the femoral neck.
Schousboe, John T; Vo, Tien; Taylor, Brent C; Cawthon, Peggy M; Schwartz, Ann V; Bauer, Douglas C; Orwoll, Eric S; Lane, Nancy E; Barrett-Connor, Elizabeth; Ensrud, Kristine E
Trabecular bone score (TBS) has been shown to predict major osteoporotic (clinical vertebral, hip, humerus, and wrist) and hip fractures in postmenopausal women and older men, but the association of TBS with these incident fractures in men independent of prevalent radiographic vertebral fracture is unknown. TBS was estimated on anteroposterior (AP) spine dual-energy X-ray absorptiometry (DXA) scans obtained at the baseline visit for 5979 men aged ≥65 years enrolled in the Osteoporotic Fractures in Men (MrOS) Study and its association with incident major osteoporotic and hip fractures estimated with proportional hazards models. Model discrimination was tested with Harrell's C-statistic and with a categorical net reclassification improvement index, using 10-year risk cutpoints of 20% for major osteoporotic and 3% for hip fractures. For each standard deviation decrease in TBS, there were hazard ratios of 1.27 (95% confidence interval [CI] 1.17 to 1.39) for major osteoporotic fracture, and 1.20 (95% CI 1.05 to 1.39) for hip fracture, adjusted for FRAX with bone mineral density (BMD) 10-year fracture risks and prevalent radiographic vertebral fracture. In the same model, those with prevalent radiographic vertebral fracture compared with those without prevalent radiographic vertebral fracture had hazard ratios of 1.92 (95% CI 1.49 to 2.48) for major osteoporotic fracture and 1.86 (95% CI 1.26 to 2.74) for hip fracture. There were improvements of 3.3%, 5.2%, and 6.2%, respectively, of classification of major osteoporotic fracture cases when TBS, prevalent radiographic vertebral fracture status, or both were added to FRAX with BMD and age, with minimal loss of correct classification of non-cases. Neither TBS nor prevalent radiographic vertebral fracture improved discrimination of hip fracture cases or non-cases. In conclusion, TBS and prevalent radiographic vertebral fracture are associated with incident major osteoporotic fractures in older men independent of each other
Yang, Shuman; Leslie, William D; Walld, Randy; Roos, Leslie L; Morin, Suzanne N; Majumdar, Sumit R; Lix, Lisa M
Parental hip fracture (HF) is associated with increased risk of offspring major osteoporotic fractures (MOFs; comprising hip, forearm, clinical spine or humerus fracture). Whether other sites of parental fracture should be used for fracture risk assessment is uncertain. The current study tested the association between objectively-verified parental non-hip MOF and offspring incident MOF. Using population-based administrative healthcare data for the province of Manitoba, Canada, we identified 255,512 offspring with linkage to at least one parent (238,054 mothers and 209,423 fathers). Parental non-hip MOF (1984-2014) and offspring MOF (1997-2014) were ascertained with validated case definitions. Time-dependent multivariable Cox proportional hazards regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs). During a median of 12 years of offspring follow-up, we identified 7045 incident MOF among offspring (3.7% and 2.5% for offspring with and without a parental non-hip MOF, p < 0.001). Maternal non-hip MOF (HR 1.27; 95% CI, 1.19 to 1.35), paternal non-hip MOF (HR 1.33; 95% CI, 1.20 to 1.48), and any parental non-hip MOF (HR 1.28; 95% CI, 1.21 to 1.36) were significantly associated with offspring MOF after adjusting for covariates. The risk of MOF was even greater for offspring with both maternal and paternal non-hip MOF (adjusted HR 1.61; 95% CI, 1.27 to 2.02). All HRs were similar for male and female offspring (all pinteraction >0.1). Risks associated with parental HF only (adjusted HR 1.26; 95% CI, 1.13 to 1.40) and non-hip MOF only (adjusted HR 1.26; 95% CI, 1.18 to 1.34) were the same. The strength of association between any parental non-hip MOF and offspring MOF decreased with older parental age at non-hip MOF (ptrend = 0.028). In summary, parental non-hip MOF confers an increased risk for offspring MOF, but the strength of the relationship decreases with older parental age at fracture. © 2016 American
Schousboe, John T.; Vo, Tien; Taylor, Brent C.; Cawthon, Peggy M.; Schwartz, Ann V.; Bauer, Douglas C.; Orwoll, Eric S.; Lane, Nancy E.; Barrett-Connor, Elizabeth; Ensrud, Kristine E.
Trabecular Bone Score (TBS) has been shown to predict major osteoporotic (clinical vertebral, hip, humerus, and wrist) and hip fractures in post-menopausal women and older men, but the association of TBS with these incident fractures in men independent of prevalent radiographic vertebral fracture is unknown. TBS was estimated on AP spine DXA scans obtained at the baseline visit for 5,979 men age ≥65 years enrolled in MrOS and its association with incident major osteoporotic and hip fractures estimated with proportional hazards models. Model discrimination was tested with Harrell’s C-statistic and with a categorical net reclassification improvement index, using 10-year risk cutpoints of 20% for major osteoporotic and 3% for hip fractures. For each standard deviation decrease in TBS, there were hazard ratios of 1.27 (95% C.I. 1.17 to 1.39) for major osteoporotic fracture, and 1.20 (95% C.I. 1.05 to 1.39) for hip fracture, adjusted for FRAX with BMD 10 year fracture risks and prevalent radiographic vertebral fracture. In the same model, those with prevalent radiographic vertebral fracture compared to those without prevalent radiographic vertebral fracture had hazard ratios of 1.92 (95% C.I. 1.49 to 2.48) for major osteoporotic fracture and 1.86 (95% C.I. 1.26 to 2.74) for hip fracture. There were improvements of 3.3%, 5.2%, and 6.2%, respectively, of classification of major osteoporotic fracture cases when TBS, prevalent radiographic vertebral fracture status, or both were added to FRAX with BMD and age, with minimal loss of correct classification of non-cases. Neither TBS nor prevalent radiographic vertebral fracture improved discrimination of hip fracture cases or non-cases. In conclusion, TBS and prevalent radiographic vertebral fracture are associated with incident major osteoporotic fractures in older men independent of each other and FRAX 10 year fracture risks, and these data support their use in conjunction with FRAX for fracture risk assessment in older
Cummings, S R; Nevitt, M C; Browner, W S; Stone, K; Fox, K M; Ensrud, K E; Cauley, J; Black, D; Vogt, T M
Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study. We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films. During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using one's arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age. Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking
Zheng, Hailiang; Li, Ming; Yin, Pengbin; Peng, Ye; Gao, Yuan; Zhang, Lihai; Tang, Peifu
Background Calcaneal quantitative ultrasound (QUS), which is used in the evaluation of osteoporosis, is believed to be intimately associated with the characteristics of the proximal femur. However, the specific associations of calcaneal QUS with characteristics of the hip sub-regions remain unclear. Design A cross-sectional assessment of 53 osteoporotic patients was performed for the skeletal status of the heel and hip. Methods We prospectively enrolled 53 female osteoporotic patients with femoral fractures. Calcaneal QUS, dual energy X-ray absorptiometry (DXA), and hip structural analysis (HSA) were performed for each patient. Femoral heads were obtained during the surgery, and principal compressive trabeculae (PCT) were extracted by a three-dimensional printing technique-assisted method. Pearson’s correlation between QUS measurement with DXA, HSA-derived parameters and Young’s modulus were calculated in order to evaluate the specific association of QUS with the parameters for the hip sub-regions, including the femoral neck, trochanteric and Ward’s areas, and the femoral shaft, respectively. Results Significant correlations were found between estimated BMD (Est.BMD) and BMD of different sub-regions of proximal femur. However, the correlation coefficient of trochanteric area (r = 0.356, p = 0.009) was higher than that of the neck area (r = 0.297, p = 0.031) and total proximal femur (r = 0.291, p = 0.034). Furthermore, the quantitative ultrasound index (QUI) was significantly correlated with the HSA-derived parameters of the trochanteric area (r value: 0.315–0.356, all p<0.05) as well as with the Young’s modulus of PCT from the femoral head (r = 0.589, p<0.001). Conclusion The calcaneal bone had an intimate association with the trochanteric cancellous bone. To a certain extent, the parameters of the calcaneal QUS can reflect the characteristics of the trochanteric area of the proximal hip, although not specifically reflective of those of the femoral neck
Gee, Andrew H; Tonkin, Carol; Ewing, Susan K; Cawthon, Peggy M; Black, Dennis M; Poole, Kenneth ES
ABSTRACT Hip fracture risk is known to be related to material properties of the proximal femur, but fracture prediction studies adding richer quantitative computed tomography (QCT) measures to dual‐energy X‐ray (DXA)‐based methods have shown limited improvement. Fracture types have distinct relationships to predictors, but few studies have subdivided fracture into types, because this necessitates regional measurements and more fracture cases. This work makes use of cortical bone mapping (CBM) to accurately assess, with no prior anatomical presumptions, the distribution of properties related to fracture type. CBM uses QCT data to measure the cortical and trabecular properties, accurate even for thin cortices below the imaging resolution. The Osteoporotic Fractures in Men (MrOS) study is a predictive case‐cohort study of men over 65 years old: we analyze 99 fracture cases (44 trochanteric and 55 femoral neck) compared to a cohort of 308, randomly selected from 5994. To our knowledge, this is the largest QCT‐based predictive hip fracture study to date, and the first to incorporate CBM analysis into fracture prediction. We show that both cortical mass surface density and endocortical trabecular BMD are significantly different in fracture cases versus cohort, in regions appropriate to fracture type. We incorporate these regions into predictive models using Cox proportional hazards regression to estimate hazard ratios, and logistic regression to estimate area under the receiver operating characteristic curve (AUC). Adding CBM to DXA‐based BMD leads to a small but significant (p < 0.005) improvement in model prediction for any fracture, with AUC increasing from 0.78 to 0.79, assessed using leave‐one‐out cross‐validation. For specific fracture types, the improvement is more significant (p < 0.0001), with AUC increasing from 0.71 to 0.77 for trochanteric fractures and 0.76 to 0.82 for femoral neck fractures. In contrast, adding DXA‐based BMD to a
Treece, Graham M; Gee, Andrew H; Tonkin, Carol; Ewing, Susan K; Cawthon, Peggy M; Black, Dennis M; Poole, Kenneth E S
Hip fracture risk is known to be related to material properties of the proximal femur, but fracture prediction studies adding richer quantitative computed tomography (QCT) measures to dual-energy X-ray (DXA)-based methods have shown limited improvement. Fracture types have distinct relationships to predictors, but few studies have subdivided fracture into types, because this necessitates regional measurements and more fracture cases. This work makes use of cortical bone mapping (CBM) to accurately assess, with no prior anatomical presumptions, the distribution of properties related to fracture type. CBM uses QCT data to measure the cortical and trabecular properties, accurate even for thin cortices below the imaging resolution. The Osteoporotic Fractures in Men (MrOS) study is a predictive case-cohort study of men over 65 years old: we analyze 99 fracture cases (44 trochanteric and 55 femoral neck) compared to a cohort of 308, randomly selected from 5994. To our knowledge, this is the largest QCT-based predictive hip fracture study to date, and the first to incorporate CBM analysis into fracture prediction. We show that both cortical mass surface density and endocortical trabecular BMD are significantly different in fracture cases versus cohort, in regions appropriate to fracture type. We incorporate these regions into predictive models using Cox proportional hazards regression to estimate hazard ratios, and logistic regression to estimate area under the receiver operating characteristic curve (AUC). Adding CBM to DXA-based BMD leads to a small but significant (p < 0.005) improvement in model prediction for any fracture, with AUC increasing from 0.78 to 0.79, assessed using leave-one-out cross-validation. For specific fracture types, the improvement is more significant (p < 0.0001), with AUC increasing from 0.71 to 0.77 for trochanteric fractures and 0.76 to 0.82 for femoral neck fractures. In contrast, adding DXA-based BMD to a CBM-based predictive model
Schousboe, J T; Paudel, M L; Taylor, B C; Virnig, B A; Cauley, J A; Curtis, J R; Ensrud, K E
In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report. Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported. We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF. Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06-1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data. A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures).
Paudel, M. L.; Taylor, B. C.; Virnig, B. A.; Cauley, J. A.; Curtis, J. R.; Ensrud, K. E.
Summary In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report. Introduction Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported. Methods We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF. Results Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06–1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data. Conclusions A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures). PMID:23208073
Zhang, Hua; Xu, Zhongwei; Zhou, Aiguo; Yan, Wenlong; Zhao, Pei; Huang, Xiao; Zhang, Jian
Abstract The aim of this study was to evaluate the efficacy of supplementary fixation in hip arthroplasty with the use of Kirschner-wires and tension band for geriatric patients suffering unstable intertrochanteric osteoporotic fractures. A total of 103 patients aged more than 75 years were recruited. A bipolar or total hip replacement was performed with additional application of Kirschner-wires and tension band, and the participants were followed up for 2 to 11 years. Physical component summary (PCS), mental component summary (MCS), visual analog scale (VAS), and Harris hip score were utilized to evaluate patients’ hip pain and function, as well as the mental condition postoperatively after 1.5 months, 3 months, 6 months, 1 year, and annually thereafter until the latest follow-up in 2015. Patients showed a significant improvement in all scores between 1.5 months and 1 year (P < 0.001), with the good efficacy lasting at least until the 2-year follow-up. None of the patients showed dislocation, implant loosening, or nonunion of the fracture throughout the follow-up period. In conclusion, it was beneficial to treat unstable intertrochanteric osteoporotic fractures in aged patients with hip arthroplasty coupled with Kirschner-wires and tension band. PMID:28072698
Guerado, Enrique; Sandalio, Rosa M; Caracuel, Zaira; Caso, Enrique
Hip fractures are an acute and worsening public health problem. They mainly affect elderly people, a population group that is highly vulnerable to disease and accidents, and to falls in particular. Although it has been suggested that osteoporosis is the cause of hip fractures, they mainly occur after a fall has been suffered. The underlying causes of a fall are not related to osteoporosis, although pharmaceutical companies have coined the term "osteoporotic fracture" for hip fractures in the elderly. Drug treatments for osteoporosis have not diminished the frequency of these injuries, nor have they prevented the occurrence of a subsequent fracture. Since pharmaceutical interests require osteoporosis to be considered a disease, rather than a normal condition of senescence, they go further by assuming that treatment for osteoporosis is essential, and that this policy will diminish the incidence of hip fractures. On the other hand, the origin and treatment of conditions that may be conducive to provoking falls are very difficult to elucidate. In this paper, we consider some of the medical and social problems that arise in this area, as well as conflicts of interest regarding the aetiopathogenesis and prevention of hip fracture, and propose a new paradigm for the prevention of falls.
Guerado, Enrique; Sandalio, Rosa M; Caracuel, Zaira; Caso, Enrique
Hip fractures are an acute and worsening public health problem. They mainly affect elderly people, a population group that is highly vulnerable to disease and accidents, and to falls in particular. Although it has been suggested that osteoporosis is the cause of hip fractures, they mainly occur after a fall has been suffered. The underlying causes of a fall are not related to osteoporosis, although pharmaceutical companies have coined the term “osteoporotic fracture” for hip fractures in the elderly. Drug treatments for osteoporosis have not diminished the frequency of these injuries, nor have they prevented the occurrence of a subsequent fracture. Since pharmaceutical interests require osteoporosis to be considered a disease, rather than a normal condition of senescence, they go further by assuming that treatment for osteoporosis is essential, and that this policy will diminish the incidence of hip fractures. On the other hand, the origin and treatment of conditions that may be conducive to provoking falls are very difficult to elucidate. In this paper, we consider some of the medical and social problems that arise in this area, as well as conflicts of interest regarding the aetiopathogenesis and prevention of hip fracture, and propose a new paradigm for the prevention of falls. PMID:27114929
Alves, Sandra Maria; Economou, Theodoros; Oliveira, Carla; Ribeiro, Ana Isabel; Neves, Nuno; Goméz-Barrena, Enrique; Pina, Maria Fátima
The aim is to examine the temporal trends of hip fracture incidence in Portugal by sex and age groups, and explore the relation with anti-osteoporotic medication. From the National Hospital Discharge Database, we selected from 1st January 2000 to 31st December 2008, 77,083 hospital admissions (77.4% women) caused by osteoporotic hip fractures (low energy, patients over 49years-age), with diagnosis codes 820.x of ICD 9-CM. The 2001 Portuguese population was used as standard to calculate direct age-standardized incidence rates (ASIR) (100,000 inhabitants). Generalized additive and linear models were used to evaluate and quantify temporal trends of age specific rates (AR), by sex. We identified 2003 as a turning point in the trend of ASIR of hip fractures in women. After 2003, the ASIR in women decreased on average by 10.3 cases/100,000 inhabitants, 95% CI (-15.7 to -4.8), per 100,000 anti-osteoporotic medication packages sold. For women aged 65-69 and 75-79 we identified the same turning point. However, for women aged over 80, the year 2004 marked a change in the trend, from an increase to a decrease. Among the population aged 70-74 a linear decrease of incidence rate (95% CI) was observed in both sexes, higher for women: -28.0% (-36.2 to -19.5) change vs -18.8%, (-32.6 to -2.3). The abrupt turning point in the trend of ASIR of hip fractures in women is compatible with an intervention, such as a medication. The trends were different according to gender and age group, but compatible with the pattern of bisphosphonates sales.
Barak, Uri; Rosenthal, Yoav; Arami, Amir; Kosashvili, Yona; Velkes, Steven
The widespread use of bisphosphonates for treating osteoporosis in the last two decades has raised concern about the complication of atypical hip fractures secondary to bisphosphonate treatment. These fractures may be the result of a minor trauma to the hip or without any trauma at all. It may be heralded by prodromal groin or hip pain. Prolonged bisphosphonate treatment and atypical fractures may exist, but the nature and the extent of this linkage are still unknown. Currently, there is a lack of adequate evidence-based methods or a consensus about the treatment of this unique phenomenon. We retrospectively examined the records of all subtrochanteric hip fracture cases admitted to our department in the years 2010-2014. During that period, we treated a total of 1315 patients:726 patients with pertrochanteric fractures, 514 patients with subcapital fractures and 75 patients with distal subtrochanteric fractures. Among those, 16 patients (1.2%) qualified as atypical hip fractures. The location of the fracture, period of bisphosphonates use, fixation type, complications and recovery were recorded. The average age of the patients in our study was 76.9 years. All patients were treated with bisphosphonates and over 80% of the patients were treated specifically with Alendronate prior to the fracture. Mean treatment time was 7.8 years. Most of the fractures (75%) were subtrochanteric, and the others were at the femur midshaft. All patients received surgical fixation and all accomplished union of the fractures. It seems reasonable to assume a causative relationship between a long term use of bisphosphonates and the occurrence of atypical hip fractures. It is a relatively rare complication; nevertheless, it should be kept in mind during a long term use of bisphosphonates. According to our department's clinical experience we found no delay in bone union with these atypical hip fractures. It seems reasonable to prophylactically fixate atypical stress fractures before they
Cooper, C; Cole, ZA; Holroyd, CR; Earl, SC; Harvey, NC; Dennison, EM; Melton, LJ; Cummings, SR; Kanis, JA
Osteoporosis constitutes a major public health problem through its association with age-related fractures, most notably those of the proximal femur. Substantial geographic variation has been noted in the incidence of hip fracture throughout the world, and estimates of recent incidence trends have varied widely; studies in the published literature have reported an increase, plateau, and decrease, in age-adjusted incidence rates for hip fracture among both men and women. Accurate characterisation of these temporal trends is important in predicting the health care burden attributable to hip fracture in future decades. We therefore conducted a review of studies worldwide, addressing secular trends in the incidence of hip and other fractures. Studies in western populations, whether in North America, Europe or Oceania, have generally reported increases in hip fracture incidence through the second half of the last century, but those continuing to follow trends over the last two decades have found that rates stabilise, with age-adjusted decreases being observed in certain centres. In contrast, some studies suggest that the rate is rising in Asia. This synthesis of temporal trends in the published literature will provide an important resource for preventing fractures; understanding the reasons for the recent declines in rates of hip fracture may help understand ways to reduce rates of hip fracture worldwide. PMID:21461721
Background Osteoporotic hip fractures represent major cause of disability, loss of quality of life and even mortality among the elderly population. Decisions on drug therapy are based on the assessment of risk factors for fracture, from BMD measurements. The combination of biomechanical models with clinical studies could better estimate bone strength and supporting the specialists in their decision. Methods A model to assess the probability of fracture, based on the Damage and Fracture Mechanics has been developed, evaluating the mechanical magnitudes involved in the fracture process from clinical BMD measurements. The model is intended for simulating the degenerative process in the skeleton, with the consequent lost of bone mass and hence the decrease of its mechanical resistance which enables the fracture due to different traumatisms. Clinical studies were chosen, both in non-treatment conditions and receiving drug therapy, and fitted to specific patients according their actual BMD measures. The predictive model is applied in a FE simulation of the proximal femur. The fracture zone would be determined according loading scenario (sideway fall, impact, accidental loads, etc.), using the mechanical properties of bone obtained from the evolutionary model corresponding to the considered time. Results BMD evolution in untreated patients and in those under different treatments was analyzed. Evolutionary curves of fracture probability were obtained from the evolution of mechanical damage. The evolutionary curve of the untreated group of patients presented a marked increase of the fracture probability, while the curves of patients under drug treatment showed variable decreased risks, depending on the therapy type. Conclusion The FE model allowed to obtain detailed maps of damage and fracture probability, identifying high-risk local zones at femoral neck and intertrochanteric and subtrochanteric areas, which are the typical locations of osteoporotic hip fractures. The
Osteoporotic fracture has been found associated with many clinical risk factors, and the associations have been explored dominantly by evidence-based and case-control approaches. The major challenges emerging from the studies are the large number of the risk factors, the difficulty in quantification, the incomplete list, and the interdependence of the risk factors. A biomechanical sorting of the risk factors may shed lights on resolving the above issues. Based on the definition of load-strength ratio (LSR), we first identified the four biomechanical variables determining fracture risk, i.e., the risk of fall, impact force, bone quality, and bone geometry. Then, we explored the links between the FRAX clinical risk factors and the biomechanical variables by looking for evidences in the literature. To accurately assess fracture risk, none of the four biomechanical variables can be ignored and their values must be subject-specific. A clinical risk factor contributes to osteoporotic fracture by affecting one or more of the biomechanical variables. A biomechanical variable represents the integral effect from all the clinical risk factors linked to the variable. The clinical risk factors in FRAX mostly stand for bone quality. The other three biomechanical variables are not adequately represented by the clinical risk factors. From the biomechanical viewpoint, most clinical risk factors are interdependent to each other as they affect the same biomechanical variable(s). As biomechanical variables must be expressed in numbers before their use in calculating LSR, the numerical value of a biomechanical variable can be used as a gauge of the linked clinical risk factors to measure their integral effect on fracture risk, which may be more efficient than to study each individual risk factor.
The effect of osteoporotic treatment on the functional outcome, re-fracture rate, quality of life and mortality in patients with hip fractures: a prospective functional and clinical outcome study on 520 patients.
Makridis, Konstantinos G; Karachalios, Theofilos; Kontogeorgakos, Vasilios A; Badras, Leonidas S; Malizos, Konstantinos N
Numerous high quality studies have shown the positive effects of various osteoporotic medical treatment regimens on bone mass and on the reduction of risk for new spinal, hip and non-spinal fractures in osteoporotic patients. However, the effect of osteoporotic treatment on the functional and clinical outcome of patients who have sustained hip fractures and been treated surgically has not yet been addressed. Five hundred and twenty patients out of 611 who were admitted (2009-2011), operated on due to a hip fracture and completed their follow-up evaluations were included in this study. Data related to functional outcome scores, re-fracture rate, quality of life and mortality rate were prospectively recorded, analysed and correlated to osteoporotic medical treatment. There were 151 (25%) men and 369 (71%) women with a mean age of 80.7 years (range, 60 to 90 years). At a mean follow-up of 27.5 months (range, 24 to 36 months) a mortality rate of 23.6% at 2 years was recorded. Mean values of functional and quality of life scores were found to have progressively improved within two years after surgery. Seventy-eight (15%) patients were taking osteoporotic treatment before their hip fracture and 89 (17.1%) started afterwards. Osteoporotic treatment proved to be an important predictor of functional recovery (all p values<0.05), re-fracture rate (p=0.028) and quality of life (EQ-5D, all dimensions, p values<0.05). Osteoporotic treatment did not affect post-fracture mortality rates. Osteoporotic treatment taken before or initiated after fracture is a strong predictor of functional and clinical outcome in patients with hip fractures treated surgically. Copyright © 2014. Published by Elsevier Ltd.
Dai, Zhaoli; Wang, Renwei; Ang, Li-Wei; Yuan, Jian-Min; Koh, Woon-Puay
While epidemiologic studies suggest that bone turnover biomarkers may predict hip fracture risk, findings are inconsistent and Asian data are lacking. We conducted a matched case-control (1:1) study nested in the Singapore Chinese Health Study, a population-based prospective cohort of Chinese men and women (45-74years) recruited from 1993 to 1998 in Singapore. One hundred cases with incident hip fracture and 100 individually matched controls were randomly selected from 63,257 participants. Serum bone turnover biomarkers, namely bone alkaline phosphatase (bone ALP), osteocalcin (OC), procollagen type I N propeptide (PINP), N-terminal and C-terminal crosslinking telopeptide of type I collagen (NTX-I and CTX-I) were measured using immunoassays. Hip fracture cases had significantly higher serum levels of OC, PINP, CTX-I and NTX-I than controls (p<0.05). There was a dose-dependent positive relationship between OC, PINP, CTX-I and NTX-I and risk of hip fracture (all Ps for trend≤0.006), where the risk was significantly increased by 4.32-8.23 folds for the respective BTM [Quartile (Q) 4 vs. Q1]. The odds ratio [OR (95% CI)] at the highest quartile (Q4) was 6.63 (2.02-21.18) for PINP and 4.92 (1.67-14.51) for CTX-I. The joint effect of PINP and CTX-I showed a 7-fold increase in risk (OR: 7.36; 95% CI: 2.53-21.41) comparing participants with higher levels of PINP (Q4) and CTX-I (Q3-Q4) to those with low levels of PINP (Q1-Q3) and CTX-I (Q1-Q2). Our data demonstrated that higher serum levels of bone turnover biomarkers were associated with increased risk of hip fracture in an Asian population. Copyright © 2015 Elsevier Inc. All rights reserved.
Dai, Zhaoli; Wang, Renwei; Ang, Li-Wei; Yuan, Jian-Min; Koh, Woon-Puay
While epidemiologic studies suggest that bone turnover biomarkers may predict hip fracture risk, findings are inconsistent and Asian data are lacking. We conducted a matched case-control (1:1) study nested in the Singapore Chinese Health Study, a population-based prospective cohort of Chinese men and women (45–74 years) recruited from 1993–1998 in Singapore. One hundred cases with incident hip fracture and 100 individually matched controls were randomly selected from 63,257 participants. Serum bone turnover biomarkers, namely bone alkaline phosphatase (bone ALP), osteocalcin (OC), procollagen type I N propeptide (PINP), N-terminal and C-terminal crosslinking telopeptide of type I collagen (NTX-I and CTX-I) were measured using immunoassays. Hip fracture cases had significantly higher serum levels of OC, PINP, CTX-I and NTX-I than controls (p<0.05). There was a dose-dependent positive relationship between OC, PINP, CTX-I and NTX-I and risk of hip fracture (all Ps for trend≤0.006), where the risk was significantly increased by 4.32–8.23 folds for the respective BTM [Quartile (Q) 4 vs. Q1]. The odds ratio [OR (95% CI)] at the highest quartile (Q4) was 6.63 (2.02–21.18) for PINP and 4.92 (1.67–14.51) for CTX-I. The joint effect of PINP and CTX-I showed a 7-fold increase in risk (OR: 7.36; 95% CI: 2.53–21.41) comparing participants with higher levels of PINP (Q4) and CTX-I (Q3-Q4) to those with low levels of PINP (Q1-Q3) and CTX-I (Q1-Q2). Our data demonstrated that higher serum levels of bone turnover biomarkers were associated with increased risk of hip fracture in an Asian population. PMID:26555636
Cauley, Jane A; Cawthon, Peggy M; Peters, Katherine E; Cummings, Steven R; Ensrud, Kristine E; Bauer, Douglas C; Taylor, Brent C; Shikany, James M; Hoffman, Andrew R; Lane, Nancy E; Kado, Deborah M; Stefanick, Marcia L; Orwoll, Eric S
Almost 30% of hip fractures occur in men; the mortality, morbidity, and loss of independence after hip fractures are greater in men than in women. To comprehensively evaluate risk factors for hip fracture in older men, we performed a prospective study of 5994 men, primarily white, age 65+ years recruited at six US clinical centers. During a mean of 8.6 years of 97% complete follow-up, 178 men experienced incident hip fractures. Information on risk factors including femoral neck bone mineral density (FNBMD) was obtained at the baseline visit. Cox proportional hazards models were used to calculate the hazard ratio (HR) with 95% confidence intervals; Fine and Gray models adjusted for competing mortality risk. Older age (≥75 years), low FNBMD, currently smoking, greater height and height loss since age 25 years, history of fracture, use of tricyclic antidepressants, history of myocardial infarction or angina, hyperthyroidism or Parkinson's disease, lower protein intake, and lower executive function were all associated with an increased hip fracture risk. Further adjustment for competing mortality attenuated HR for smoking, hyperthyroidism, and Parkinson's disease. The incidence rate of hip fracture per 1000 person-years (PY) was greatest in men with FNBMD T-scores <-2.5 (white women reference database) who also had 4+ risk factors, 33.4. Men age ≥80 years with 3+ major comorbidities experienced hip fracture at rates of 14.52 versus 0.88 per 1000 PY in men age <70 years with zero comorbidities. Older men with low FNBMD, multiple risk factors, and multimorbidity have a high risk of hip fracture. Many of these assessments can easily be incorporated into routine clinical practice and may lead to improved risk stratification. © 2016 American Society for Bone and Mineral Research. © 2016 American Society for Bone and Mineral Research.
Piscitelli, Prisco; Metozzi, Alessia; Benvenuti, Enrico; Bonamassa, Lorenzo; Brandi, Gemma; Cavalli, Loredana; Colli, Emanuela; Fossi, Caterina; Parri, Simone; Giolli, Lorenzo; Tanini, Annalisa; Fasano, Alfonso; Di Tanna, Gianluca; Brandi, Maria Luisa
osteoporosis, depression and other neuro-psychiatric disorders are very common after 50 years of age. Although these conditions recognize several and specific etiologic factors, they however appear to share physiologic, environmental processes and risk factors which may explain their possible association. we have built up a specific research project (the CODE study, Connections between the outcomes of osteoporotic hip fractures and depression, delirium or dementia in elderly patients), and carried out a preliminary survey on 55 hip fractured elderly patients (42 women, mean age 85 years old and 13 men, mean age 82 years old), hospitalized at SS. Annunziata hospital in Florence from July to September 2010. there was a significant difference (p=0.010) in the functional recovery after surgery (as measured by Cumulated Ambulation Score, CAS) between depressed and non-depressed subjects (n=38), with a worse recovery and a lower CAS score in depressed patients (n=17). We also observed a higher prevalence of depression in the osteoporotic-fragile elderly people (69,1% of total sample). our preliminary survey has validated the suitability of the CODE study protocol in assessing connections between outcomes of osteoporotic hip fractures and depression in elderly patients, fostering the extension of the study (and suggesting also the inclusion of delirium and dementia) within a multicentric prospective study aimed to provide specific information and guidelines for osteoporotic fractured patients with concomitant depression or other neuro-psychiatric disorders.
Yang, Lang; Palermo, Lisa; Black, Dennis M; Eastell, Richard
A bone fractures only when loaded beyond its strength. The purpose of this study was to determine the association of femoral strength, as estimated by finite element (FE) analysis of dual-energy X-ray absorptiometry (DXA) scans, with incident hip fracture in comparison to hip bone mineral density (BMD), Fracture Risk Assessment Tool (FRAX), and hip structure analysis (HSA) variables. This prospective case-cohort study included a random sample of 1941 women and 668 incident hip fracture cases (295 in the random sample) during a mean ± SD follow-up of 12.8 ± 5.7 years from the Study of Osteoporotic Fractures (n = 7860 community-dwelling women ≥67 years of age). We analyzed the baseline DXA scans (Hologic 1000) of the hip using a validated plane-stress, linear-elastic finite element (FE) model of the proximal femur and estimated the femoral strength during a simulated sideways fall. Cox regression accounting for the case-cohort design assessed the association of estimated femoral strength with hip fracture. The age-body mass index (BMI)-adjusted hazard ratio (HR) per SD decrease for estimated strength (2.21; 95% CI, 1.95-2.50) was greater than that for total hip (TH) BMD (1.86; 95% CI, 1.67-2.08; p < 0.05), FN BMD (2.04; 95% CI, 1.79-2.32; p > 0.05), FRAX scores (range, 1.32-1.68; p < 0.0005), and many HSA variables (range, 1.13-2.43; p < 0.005), and the association was still significant (p < 0.05) after further adjustment for hip BMD or FRAX scores. The association of estimated strength with incident hip fracture was strong (Harrell's C index 0.770), significantly better than TH BMD (0.759; p < 0.05) and FRAX scores (0.711-0.743; p < 0.0001), but not FN BMD (0.762; p > 0.05). Similar findings were obtained for intracapsular and extracapsular fractures. In conclusion, the estimated femoral strength from FE analysis of DXA scans is an independent predictor and performs at least as well as FN BMD in predicting incident
Cauley, Jane A; Barbour, Kamil E; Harrison, Stephanie L; Cloonan, Yona K; Danielson, Michelle E; Ensrud, Kristine E; Fink, Howard A; Orwoll, Eric S; Boudreau, Robert
Cytokines play major roles in regulating bone remodeling, but their relationship to incident fractures in older men is uncertain. We tested the hypothesis that men with higher concentrations of pro-inflammatory markers have a higher risk of fracture. We used a case-cohort design and measured inflammatory markers in a random sample of 961 men and in men with incident fractures including 120 clinical vertebral, 117 hip, and 577 non-spine fractures; average follow-up 6.13 years (7.88 years for vertebral fractures). We measured interleukin (IL)-6, C-reactive protein (CRP), tumor necrosis factor alpha (TNFα), soluble receptors (SR) of IL-6 (IL-6SR) and TNF (TNFαSR1 and TNFαSR2), and IL-10. The risk of non-spine, hip, and clinical vertebral fracture was compared across quartiles (Q) of inflammatory markers using Cox proportional hazard models with tests for linear trend. In multivariable-adjusted models, men with the highest (Q4) TNFa cytokine concentrations and their receptors had a 2.0-4.2-fold higher risk of hip and clinical vertebral fracture than men with the lowest (Q1). Results were similar for all non-spine fractures, but associations were smaller. There was no association between CRP and IL-6SR and fracture. Men in the highest Q of IL-10 had a 49% lower risk of vertebral fracture compared with men in Q1. Among men with ≥3 inflammatory markers in the highest Q, the hazard ratio (HR) for hip fractures was 2.03 (95% confidence interval [CI] 1.11-3.71) and for vertebral fracture 3.06 (1.66-5.63). The HRs for hip fracture were attenuated by 27%, 27%, and 15%, respectively, after adjusting for appendicular lean mass (ALM), disability, and bone density, suggesting mediating roles. ALM also attenuated the HR for vertebral fractures by 10%. There was no association between inflammation and rate of hip BMD loss. We conclude that inflammation may play an important role in the etiology of fractures in older men. © 2016 American Society for Bone and Mineral Research.
García-Sempere, Aníbal; Hurtado, Isabel; Sanfélix-Genovés, José; Rodríguez-Bernal, Clara L; Gil Orozco, Rafael; Peiró, Salvador; Sanfélix-Gimeno, Gabriel
Osteoporotic medication after hip fracture is widely recommended by clinical practice guidelines, and medication adherence is essential to meet clinical trial risk reduction figures in the real world. We assessed primary and secondary non-adherence to osteoporosis medications in patients discharged following a hip fracture and identified factors associated with secondary non-adherence. From a population-based retrospective cohort of 19,405 patients aged 65 years and over discharged from a hip fracture in the region of Valencia (Spain) from January 1, 2008 and June 30, 2012, we followed, over a minimum of 365 days, 4,856 patients with at least one osteoporotic medication prescribed within the first six months after discharge. Less than one third of the patients discharged alive after a hip fracture received osteoporotic treatment. Primary non-adherence among naïve patients was low. However, long-term secondary adherence measured by Proportion of Days Covered with medication (PDC) and persistence was largely suboptimal, with naïve users having worse results than experienced patients. Secondary non-adherence was associated with primary non-adherence and age, dementia or sedative treatments for naïve users and with being male, being older than 85 and having dementia for experienced users. Three quarters of naïve users and two thirds of experienced users had interrupted treatment at 48 months.
Yang, Lang; Palermo, Lisa; Black, Dennis M; Eastell, Richard
A bone fractures only when loaded beyond its strength. The purpose of this study was to determine the association of femoral strength, as estimated by finite element (FE) analysis of DXA scans, with incident hip fracture in comparison to hip BMD, FRAX® and hip structure analysis (HSA) variables. This prospective case-cohort study included a random sample of 1941 women and 668 incident hip fracture cases (295 in the random sample) during a mean±SD follow-up of 12.8±5.7 yrs from the Study of Osteoporotic Fractures (n=7860 community-dwelling women ≥67 yr of age). We analyzed the baseline DXA scans (Holgoic 1000) of the hip using a validated plane-stress, linear-elastic finite element (FE) model of the proximal femur and estimated the femoral strength during a simulated sideways fall. Cox regression accounting for the case-cohort design assessed the association of estimated femoral strength with hip fracture. The age-BMI-adjusted hazard ratio (HR) per SD decrease for estimated strength (2.21, 95% CI 1.95–2.50) was greater than that for TH BMD (1.86, 95% CI 1.67–2.08; p<0.05), FN BMD (2.04, 95% CI 1.79–2.32; p>0.05), FRAX® scores (range 1.32–1.68; p<0.0005) and many HSA variables (range 1.13–2.43; p<0.005), and the association was still significant (p<0.05) after further adjustment for hip BMD or FRAX® scores. The association of estimated strength with incident hip fracture was strong (Harrell's C index 0.770), significantly better than TH BMD (0.759, p<0.05) and FRAX® scores (0.711–0.743, p<0.0001) but not FN BMD (0.762, p>0.05) Similar findings were obtained for intra- and extra-capsular fractures. In conclusion, the estimated femoral strength from FE analysis of DXA scans is an independent predictor and performs at least as well as FN BMD in predicting incident hip fracture in postmenopausal women. PMID:24898426
Hillier, S; Inskip, H; Coggon, D; Cooper, C
Osteoporotic fractures constitute a major public health problem. These fractures typically occur at the hip, spine and distal forearm. Their pathogenesis is heterogeneous, with contributions from both bone strength and trauma. Water fluoridation has been widely proposed for its dental health benefits, but concerns have been raised about the balance of skeletal risks and benefits of this measure. Fluoride has potent effects on bone cell function, bone structure and bone strength. These effects are mediated by the incorporation of fluoride ions in bone crystals to form fluoroapatite, and through an increase in osteoblast activity. It is believed that a minimum serum fluoride level of 100 ng/ml must be achieved before osteoblasts will be stimulated. Serum levels associated with drinking water fluoridated to 1 ppm are usually several times lower than this value, but may reach this threshold at concentrations of 4 ppm in the drinking water. Animal studies suggest no effect of low-level (0-3 ppm) fluoride intake on bone strength, but a possible decrease at higher levels. Sodium fluoride has been used to treat established osteoporosis for nearly 30 years. Recent trials of this agent, prescribed at high doses, have suggested that despite a marked increase in bone mineral density, there is no concomitant reduction in vertebral fracture incidence. Furthermore, the increase in bone density at the lumbar spine may be achieved at the expense of bone mineral in the peripheral cortical skeleton. As a consequence, high dose sodium fluoride (80 mg daily) is not currently used to treat osteoporosis. At lower doses, recent trials have suggested a beneficial effect on both bone density and fracture. The majority of epidemiological evidence regarding the effect of fluoridated drinking water on hip fracture incidence is based on ecological comparisons. Although one Finnish study suggested that hip fracture rates in a town with fluoridated water were lower than those in a matching town
Cawthon, Peggy M; Ewing, Susan K; McCulloch, Charles E; Ensrud, Kristine E; Cauley, Jane A; Cummings, Steven R; Orwoll, Eric S
Previous studies in older men have not evaluated whether loss of BMD or BMC accelerates nonlinearly with age. This study aimed to describe hip bone loss (both in BMC and BMD) in older men and to test whether BMD loss accelerates with age in an exponential manner in a cohort of 4720 community-dwelling men >or=65 yr of age. Men had two to three measures of femoral neck (FN) BMD (by DXA) over an average follow-up of 4.6 yr. Change in BMD during follow-up was estimated from mixed effects regression models; the significance of a quadratic term for age was evaluated. Mean FN BMD loss was 0.013 g/cm(2) (-1.72%) during follow-up. The quadratic term for age was significant, and the model showed that bone loss accelerated with age. Estimated loss of FN BMD over follow-up for men 85 yr of age (0.021 g/cm(2)) was 2.5 times greater than the loss expected for men 65 yr of age (0.008 g/cm(2)); such bone loss in 85-yr-old men may be sufficient to increase the risk of hip fracture by 25% (HR per 0.021 g/cm(2) cross-sectional decrease in FN BMD: 1.25; 95% CI: 1.18-1.31) over 4.6 yr. Men with lower BMD at baseline lost the most BMD over follow-up. Although average bone loss over time is modest in older men, there is considerable variability in rate of loss. Older men and those with lower BMD lose bone more rapidly, offering potential explanation for the increasing risk of fracture with advancing age.
Perroud, H A; Dagatti, M S; Amigot, B; Levit, G P; Tomat, M F; Morosano, M E; Masoni, A M; Pezzotto, S M
The aim of this study was to analyze the association between the presence of actinic lesions (solar keratosis and non-melanoma skin cancer) and osteoporotic hip fractures in older patients. Both pathologies are common conditions in this age group. Since cumulative sun exposure is difficult to quantify, the presence of actinic lesions can be used to indirectly analyze the association between ultraviolet radiation and osteoporotic hip fractures. This was an observational case-control study. We reviewed the centralized medical records of patients with hip fracture (cases, n = 51) and patients with other diseases hospitalized in the same institution and period (controls, n = 59). The mean age of the patients was 80 ± 8.3 years (range 50-103 years). Differences in maternal hip fracture history were found between cases and controls (14.8 and 8 %, respectively; p = 0.047). Falls history in the past year was higher in cases than in controls (p < 0.0001). Actinic lesions were observed in 32.7 % of patients (prevalence rate 23.5 % in cases, 40.7 % in controls; p = 0.04). When considering patients with actinic lesions, controls have a higher FRAX score compared with cases. Although sun exposure is recommended for bone health, it represents a risk factor for actinic lesions. The presence of actinic lesions may indicate a lower osteoporotic hip fracture risk. A balance between adequate lifetime sun exposure and protection against its adverse effects is required for each patient, in the context of geographic location.
Fink, Howard A; Vo, Tien N; Langsetmo, Lisa; Barzilay, Joshua I; Cauley, Jane A; Schousboe, John T; Orwoll, Eric S; Canales, Muna T; Ishani, Areef; Lane, Nancy E; Ensrud, Kristine E
Prior studies suggest that increased urine albumin is associated with a heightened fracture risk in women, but results in men are unclear. We used data from Osteoporotic Fractures in Men (MrOS), a prospective cohort study of community-dwelling men aged ≥65 years, to evaluate the association of increased urine albumin with subsequent fractures and annualized rate of hip bone loss. We calculated albumin/creatinine ratio (ACR) from urine collected at the 2003-2005 visit. Subsequent clinical fractures were ascertained from triannual questionnaires and centrally adjudicated by review of radiographic reports. Total hip BMD was measured by DXA at the 2003-2005 visit and again an average of 3.5 years later. We estimated risk of incident clinical fracture using Cox proportional hazards models, and annualized BMD change using ANCOVA. Of 2982 men with calculable ACR, 9.4% had ACR ≥30 mg/g (albuminuria) and 1.0% had ACR ≥300 mg/g (macroalbuminuria). During a mean of 8.7 years of follow-up, 20.0% of men had an incident clinical fracture. In multivariate-adjusted models, neither higher ACR quintile (p for trend 0.75) nor albuminuria (HR versus no albuminuria, 0.89; 95% CI, 0.65 to 1.20) was associated with increased risk of incident clinical fracture. Increased urine albumin had a borderline significant, multivariate-adjusted, positive association with rate of total hip bone loss when modeled in ACR quintiles (p = 0.06), but not when modeled as albuminuria versus no albuminuria. Macroalbuminuria was associated with a higher rate of annualized hip bone loss compared to no albuminuria (-1.8% more annualized loss than in men with ACR <30 mg/g; p < 0.001), but the limited prevalence of macroalbuminuria precluded reliable estimates of its fracture associations. In these community-dwelling older men, we found no association between urine albumin levels and risk of incident clinical fracture, but found a borderline significant, positive association with rate of hip
Xie, H-L; Wu, B-H; Xue, W-Q; He, M-G; Fan, F; Ouyang, W-F; Tu, S-L; Zhu, H-L; Chen, Y-M
In this case-control study, we examined the relationship between the consumption of fruit and vegetables and risk of hip fractures in 646 pairs of incident cases and controls in elderly Chinese. We found that greater consumption of both fruit and vegetables in men and vegetables in women was associated with a lower risk of osteoporotic hip fractures in elderly Chinese. The association between fruit and vegetable consumption and the risk of osteoporotic fractures remains controversial due to limited published evidence. The purpose of this study was to determine whether consuming fruits and vegetables has a protective effect against hip fractures. Between January 2008 and December 2012, 646 (162 males, 484 females) incident cases (70.9 ± 6.8 years) of hip fractures were enrolled from five hospitals, with 646 sex- and age-matched (±3 years) controls (70.7 ± 6.8 years) from hospitals or the community. Face-to-face interviews were conducted to assess habitual dietary intakes using a 79-item food frequency questionnaire and various covariates by structured questionnaires. Multivariate conditional logistic regression analyses showed dose-dependent inverse correlations between the intake of total fruit (p-trend = 0.014), total vegetables (p-trend <0.001), fruits and vegetables combined (p-trend < 0.001) and the risk of hip fractures after adjustment for sociodemographic characteristics, dietary factors and other potential confounders. The adjusted odds ratios (95% confidence interval) for hip fractures in the top quartiles (vs. the lowest quartiles) for the intake of fruits, vegetables and the combination of fruits and vegetables were 0.53 (0.32-0.87), 0.37 (0.23-0.60) and 0.25 (0.15-0.41), respectively. Stratified analyses showed that the benefits remained significant in males (p = 0.001) but not in females (p = 0.210) (p-interaction 0.045). Among the subcategories of fruits and vegetables, similar associations were observed for all subgroups except light
... make older people more likely to trip and fall — one of the most common causes of hip ... Taking steps to maintain bone density and avoid falls can help prevent hip fracture. Signs and symptoms ...
Fisher, A; Srikusalanukul, W; Davis, M; Smith, P
Background Considerable controversy exists regarding the contribution of mineral/bone metabolism abnormalities to the association between cardiovascular diseases (CVDs) and osteoporotic fractures. Aims and methods To determine the relationships between mineral/bone metabolism biomarkers and CVD in 746 older patients with hip fracture, clinical data were recorded and serum concentrations of parathyroid hormone (PTH), 25-hydroxyvitamin D, calcium, phosphate, magnesium, troponin I, parameters of bone turnover, and renal, liver, and thyroid functions were measured. Results CVDs were diagnosed in 472 (63.3%) patients. Vitamin D deficiency was similarly prevalent in patients with (78.0%) and without (82.1%) CVD. The CVD group had significantly higher mean PTH concentrations (7.6 vs 6.0 pmol/L, P < 0.001), a higher prevalence of secondary hyperparathyroidism (SPTH) (PTH > 6.8 pmol/L, 43.0% vs 23.3%, P < 0.001), and excess bone resorption (urinary deoxypyridinoline corrected by creatinine [DPD/Cr] > 7.5 nmol/μmol, 87.9% vs 74.8%, P < 0.001). In multivariate regression analysis, SHPT (odds ratio [OR] 2.6, P = 0.007) and high DPD/Cr (OR 2.8, P = 0.016) were independent indictors of CVD. Compared to those with both PTH and DPD/Cr in the normal range, multivariate-adjusted ORs for the presence of CVD were 17.3 (P = 0.004) in subjects with SHPT and 9.7 (P < 0.001) in patients with high DPD/Cr. CVD was an independent predicator of SHPT (OR 2.8, P = 0.007) and excess DPD/Cr (OR 2.5, P = 0.031). CVD was predictive of postoperative myocardial injury, while SHPT was also an independent predictor of prolonged hospital stay and in-hospital death. Conclusion SHPT and excess bone resorption are independent pathophysiological mediators underlying the bidirectional associations between CVD and hip fracture, and therefore are important diagnostic and therapeutic targets. PMID:23460043
Klop, Corinne; Welsing, Paco M. J.; Leufkens, Hubert G. M.; Elders, Petra J. M.; Overbeek, Jetty A.; van den Bergh, Joop P.; Bijlsma, Johannes W. J.; de Vries, Frank
Background Incidence rates of non-hip major osteoporotic fractures (MOF) remain poorly characterized in the Netherlands. The Dutch FRAX® algorithm, which predicts 10-year probabilities of hip fracture and MOF (first of hip, humerus, forearm, clinical vertebral), therefore incorporates imputed MOF rates. Swedish incidence rate ratios for hip fracture to MOF (Malmo 1987–1996) were used to perform this imputation. However, equality of these ratios between countries is uncertain and recent evidence is scarce. Aims were to estimate incidence rates of hip fracture and MOF and to compare observed MOF rates to those predicted by the imputation method for the Netherlands. Methods Using hospitalisation and general practitioner records from the Dutch PHARMO Database Network (2002–2011) we calculated age-and-sex-specific and age-standardized incidence rates (IRs) of hip and other MOFs (humerus, forearm, clinical vertebral) and as used in FRAX®. Observed MOF rates were compared to those predicted among community-dwelling individuals ≥50 years by the standardized incidence ratio (SIR; 95% CI). Results Age-standardized IRs (per 10,000 person-years) of MOF among men and women ≥50 years were 25.9 and 77.0, respectively. These numbers were 9.3 and 24.0 for hip fracture. Among women 55–84 years, observed MOF rates were significantly higher than predicted (SIR ranged between 1.12–1.50, depending on age). In men, the imputation method performed reasonable. Conclusion Observed MOF incidence was higher than predicted for community-dwelling women over a wide age-range, while it agreed reasonable for men. As miscalibration may influence treatment decisions, there is a need for confirmation of results in another data source. Until then, the Dutch FRAX® output should be interpreted with caution. PMID:26633011
Cheung, Wing Hoi; Miclau, Theodore; Chow, Simon Kwoon-Ho; Yang, Frank F; Alt, Volker
As the world population rises, osteoporotic fracture is an emerging global threat to the well-being of elderly patients. The process of fracture healing by intramembranous ossification or/and endochondral ossification involve many well-orchestrated events including the signaling, recruitment and differentiation of mesenchymal stem cells (MSCs) during the early phase; formation of a hard callus and extracellular matrix, angiogenesis and revascularization during the mid-phase; and finally callus remodeling at the late phase of fracture healing. Through clinical and animal research, many of these factors are shown to be impaired in osteoporotic bone. Animal studies related to post-menopausal estrogen deficient osteoporosis (type I) have shown healing to be prolonged with decreased levels of MSCs and decreased levels of angiogenesis. Moreover, the expression of estrogen receptor (ER) was shown to be delayed in ovariectomy-induced osteoporotic fracture. This might be related to the observed difference in mechanical sensitivity between normal and osteoporotic bones, which requires further experiments to elucidate. In mice fracture models related to senile osteoporosis (type II), it was observed that chondrocyte and osteoblast differentiation were impaired; and that transplantation of juvenile bone marrow would result in enhanced callus formation. Other factors related to angiogenesis and vasculogenesis have also been noted to be impaired in aged models, affecting the degradation of cartilaginous matrixes and vascular invasion; the result is changes in matrix composition and growth factors concentrations that ultimately impairs healing during age-related osteoporosis. Most osteoporotic related fractures occur at metaphyseal sites clinically, and reports have indicated that differences exist between diaphyseal and metaphyseal fractures. An animal model that satisfies three main criteria (metaphyseal region, plate fixation, osteoporosis) is suggested for future research for
Gabriel, S E; Tosteson, A N A; Leibson, C L; Crowson, C S; Pond, G R; Hammond, C S; Melton, L J
Osteoporotic fractures are a major cause of morbidity in the elderly, the most rapidly growing segment of our population. We characterized the incremental direct medical costs following such fractures in a population-based cohort of men and women in Olmsted County, Minnesota. Cases included all County residents 50 years of age and older with an incident fracture due to minimal or moderate trauma between January 1, 1989 and January 1, 1992. For each case, a control of the same age (+/- 1 year) and sex who was attended in the local medical system in the same year was identified. Total incremental costs (cases - controls) in the year after fracture were estimated. Unit costs for each health service/procedure were obtained through the Mayo Cost Data Warehouse, which provides a standardized, inflation-adjusted estimate reflecting the national average cost of providing the service. Regression analysis was used to identify factors associated with incremental costs. There were 1263 case/control pairs; their average age was 73.8 years and 78% were female. Median total direct medical costs were $761 and $625, respectively, for cases and nonfracture controls in the year prior to fracture, and $3884 and $712, respectively, in the year following fracture. The highest median incremental costs were for distal femur ($11756) and hip fractures ($11241), whereas the lowest were for rib fractures ($213). Although hip fractures resulted in more incremental cost than any other fracture type, this amounted to only 37% of the total incremental cost of all moderate-trauma fractures combined. Regression analyses revealed that age, prior year costs and type of fracture were significant predictors of incremental costs (p<0.03 for all comparisons). The incremental costs of osteoporotic fractures are therefore substantial. Whereas hip fractures contributed disproportionately, they accounted for only one-third of the total incremental cost of fractures in our cohort. The use of incremental
Aranguren-Ruiz, M I; Acha-Arrieta, M V; Casas-Fernández de Tejerina, J M; Arteaga-Mazuelas, M; Jarne-Betrán, V; Arnáez-Solis, R
To evaluate, from a clinical perspective, and with easily identifiable variables, those factors that influence the survival of patients admitted to a care unit designed for the comprehensive treatment of patients with hip fracture after being surgically treated. A prospective study was conducted on a cohort of patients (n=202) aged 65 years or older with a low impact hip fracture, who were surgically intervened in a tertiary hospital. An analysis was performed to determine mortality at 90 days, and at one and 2years after surgery using demographic, clinical, analytical, and functional variables. The independent risk factors of mortality in the 3periods analysed were age (P=.047, P=.016, and P=.000 at 90 days, 1, and 2 years, respectively) and a low Barthel index (P=.014, P=.005, and P=.004 to 90 days, 1, and 2 years, respectively). Male sex (P=.004) and a high risk for anaesthesia (P=.011) were only independent risk factors of mortality at 2years after surgery. Age and dependency were the major determining factors of mortality at 30 days, 1, and 2 years after surgery for hip fracture. Both are easily measurable to identify patients susceptible to poor outcomes, and could benefit from a more thorough care plan. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.
Lippuner, K; Johansson, H; Kanis, J A; Rizzoli, R
A Swiss-specific FRAX model was developed. Patient profiles at increased probability of fracture beyond currently accepted reimbursement thresholds for bone mineral density (BMD) measurement by dual X-ray absorptiometry (DXA), and osteoporosis treatment were identified. This study aimed to determine which constellations of clinical risk factors, alone, or combined with BMD measurement by DXA, contribute to improved identification of Swiss patients with increased probability of fracture. The 10-year probability of hip and any major osteoporotic fracture was computed for both sexes, based on Swiss epidemiological data, integrating fracture risk and death hazard, in relation to validated clinical risk factors, with and without BMD values. Fracture probability increased with age, lower body mass index (BMI), decreasing BMD T-score, and all clinical risk factors used alone or combined. Several constellations of risk factor profiles were identified, indicating identical or higher absolute fracture probability than risk factors currently accepted for DXA reimbursement in Switzerland. With identical sex, age and BMI, subjects with parental history of hip fracture had as high a probability of any major osteoporotic fracture as patients on oral glucocorticoids or with a prevalent fragility fracture. The presence of additional risk factors further increased fracture probability. The customised FRAX model indicates that a shift from the current DXA-based intervention paradigm, toward a fracture risk continuum based on the 10-year probability of any major osteoporotic fracture may improve identification of patients at increased fracture risk.
Johnell, O; Kanis, J A
The aim of this study was to quantify the global burden of osteoporotic fracture worldwide. The incidence of hip fractures was identified by systematic review and the incidence of osteoporotic fractures was imputed from the incidence of hip fractures in different regions of the world. Excess mortality and disability weights used age- and sex-specific data from Sweden to calculate the Disability Adjusted Life Years (DALYs) lost due to osteoporotic fracture. In the year 2000 there were an estimated 9.0 million osteoporotic fractures of which 1.6 million were at the hip, 1.7 million at the forearm and 1.4 million were clinical vertebral fractures. The greatest number of osteoporotic fractures occurred in Europe (34.8%). The total DALYs lost was 5.8 million of which 51% were accounted for by fractures that occurred in Europe and the Americas. World-wide, osteoporotic fractures accounted for 0.83% of the global burden of non-communicable disease and was 1.75% of the global burden in Europe. In Europe, osteoporotic fractures accounted for more DALYs lost than common cancers with the exception of lung cancer. For chronic musculo-skeletal disorders the DALYs lost in Europe due to osteoporosis (2.0 million) were less than for osteoarthrosis (3.1 million) but greater than for rheumatoid arthritis (1.0 million). We conclude that osteoporotic fractures are a significant cause of morbidity and mortality, particularly in the developed countries.
Yang, Lang; Burton, Annabel C; Bradburn, Mike; Nielson, Carrie M; Orwoll, Eric S; Eastell, Richard
This prospective case-cohort study aimed to map the distribution of bone density in the proximal femur and examine its association with hip fracture. We analyzed baseline quantitative computed tomography (QCT) scans in 250 men aged 65 years or older, which comprised a randomly-selected subcohort of 210 men and 40 cases of first hip fracture during a mean follow-up period of 5.5 years. We quantified cortical, trabecular, and integral volumetric bone mineral density (vBMD), and cortical thickness (CtTh) in four quadrants of cross-sections along the length of the femoral neck (FN), intertrochanter (IT), and trochanter (TR). In most quadrants, vBMDs and CtTh were significantly (p < 0.05) lower in cases compared to the subcohort and these deficits were present across the entire proximal femur. To examine the association of QCT measurements with hip fracture, we merged the two quadrants in the medial and lateral aspects of the FN, IT, and TR. At most sites, QCT measurements were associated significantly (p < 0.001) with hip fracture, the hazard ratio (HR) adjusted for age, body mass index (BMI), and clinical site for a 1-SD decrease ranged between 2.28 (95% confidence interval [CI], 1.44-3.63) to 6.91 (95% CI, 3.11-15.53). After additional adjustment for total hip (TH) areal BMD (aBMD), trabecular vBMDs at the FN, TR, and TH were still associated with hip fracture significantly (p < 0.001), the HRs ranged from 3.21 (95% CI, 1.65-6.24) for the superolateral FN to 6.20 (95% CI, 2.71-14.18) for medial TR. QCT measurements alone or in combination did not predict fracture significantly (p > 0.05) better than TH aBMD. With an area under the receiver operating characteristic curve (AUC) of 0.901 (95% CI, 0.852-0.950), the regression model combining TH aBMD, age, and trabecular vBMD predicted hip fracture significantly (p < 0.05) better than TH aBMD alone or TH aBMD plus age. These findings confirm that both cortical and trabecular bone contribute to hip
Lenski, Markus; Büser, Natalie; Scherer, Michael
Background and purpose Patients with osteoporosis who present with an acute onset of back pain often have multiple fractures on plain radiographs. Differentiation of an acute osteoporotic vertebral fracture (AOVF) from previous fractures is difficult. The aim of this study was to investigate the incidence of concomitant AOVFs and previous OVFs in patients with symptomatic AOVFs, and to identify risk factors for concomitant AOVFs. Patients and methods This was a prospective epidemiological study based on the Registry of Pathological Osteoporotic Vertebral Fractures (REPAPORA) with 1,005 patients and 2,874 osteoporotic vertebral fractures, which has been running since February 1, 2006. Concomitant fractures are defined as at least 2 acute short-tau inversion recovery (STIR-) positive vertebral fractures that happen concomitantly. A previous fracture is a STIR-negative fracture at the time of initial diagnostics. Logistic regression was used to examine the influence of various variables on the incidence of concomitant fractures. Results More than 99% of osteoporotic vertebral fractures occurred in the thoracic and lumbar spine. The incidence of concomitant fractures at the time of first patient contact was 26% and that of previous fractures was 60%. The odds ratio (OR) for concomitant fractures decreased with a higher number of previous fractures (OR =0.86; p = 0.03) and higher dual-energy X-ray absorptiometry T-score (OR =0.72; p = 0.003). Interpretation Concomitant and previous osteoporotic vertebral fractures are common. Risk factors for concomitant fractures are a low T-score and a low number of previous vertebral fractures in cases of osteoporotic vertebral fracture. An MRI scan of the the complete thoracic and lumbar spine with STIR sequence reduces the risk of under-diagnosis and under-treatment. PMID:28056595
Datta, Nabanita S
Osteoporosis and age-related bone loss is associated with changes in bone remodeling characterized by decreased bone formation relative to bone resorption, resulting in bone fragility and increased risk of fractures. Stimulating the function of bone-forming osteoblasts, is the preferred pharmacological intervention for osteoporosis. Recombinant parathyroid hormone (PTH), PTH(1-34), is an anabolic agent with proven benefits to bone strength and has been characterized as a potential therapy for skeletal repair. In spite of PTH’s clinical use, safety is a major consideration for long-term treatment. Studies have demonstrated that intermittent PTH treatment enhances and accelerates the skeletal repair process via a number of mechanisms. Recent research into the molecular mechanism of PTH action on bone tissue has led to the development of PTH analogs to control osteoporotic fractures. This review summarizes a number of advances made in the field of PTH and bone fracture to combat these injuries in humans and in animal models. The ultimate goal of providing an alternative to PTH, currently the sole anabolic therapy in clinical use, to promote bone formation and improve bone strength in the aging population is yet to be achieved. PMID:22474638
Bawa, Harpreet S; Weick, Jack; Dirschl, Douglas R
This investigation assessed the effectiveness of initiating anti-osteoporotic therapy after a fragility fracture in preventing subsequent fractures. The Truven Health MarketScan databases, which contain de-identified, integrated, person-specific claim data, were queried from 2003 to 2012. The study population included individuals fifty years of age or older who sustained a fragility fracture, defined as any fracture of the wrist, proximal part of the humerus, hip, or vertebra, and had three years of continuous enrollment following fracture. Patients were stratified into either an anti-osteoporotic therapy group or a no-treatment group. Subsequent fracture was defined as a fragility fracture occurring more than ninety days following the index fracture. Subjects were followed for three years. Unadjusted and age and sex-adjusted odds ratios for subsequent fracture were calculated for both groups. This investigation included 31,069 subjects, of whom 10.6% were treated with anti-osteoporotic therapy following the index fracture. The anti-osteoporotic therapy group was older and had a greater proportion of female patients compared with the no-treatment group. The three-year subsequent fracture rates were 7.5% in the anti-osteoporotic therapy group and 9.7% in the no-treatment group. Unadjusted odds ratios for subsequent fracture showed that the anti-osteoporotic therapy group experienced a risk reduction of 33% after an index wrist fracture, 48% after an index proximal humeral fracture, 28% after an index hip fracture, 20% after an index vertebral fracture, and 25% after all fractures combined. Age and sex-adjusted odds ratios showed that the anti-osteoporotic therapy group experienced a reduction in risk of 50% after an index wrist fracture, 52% after an index proximal humeral fracture, 34% after an index hip fracture, 43% after an index vertebral fracture, and 40% after all fractures combined. The number needed to treat to prevent a subsequent fragility fracture was
Bone metabolism and the 10-year probability of hip fracture and a major osteoporotic fracture using the country-specific FRAX algorithm in men over 50 years of age with type 2 diabetes mellitus: a case-control study.
Bhattoa, Harjit P; Onyeka, Ugo; Kalina, Edit; Balogh, Adam; Paragh, Gyorgy; Antal-Szalmas, Peter; Kaplar, Miklos
The aim of the study was to evaluate the 10-year probability of hip fracture and a major osteoporotic fracture using the FRAX algorithm, vitamin D status, bone mineral density (BMD), and biochemical markers of bone turnover in men over 50 years of age with type 2 diabetes mellitus (T2DM). We estimated FRAX-predicted 10-year fracture probability, levels of 25-hydroxyvitamin D (25-OH-D), markers of bone turnover, and bone mineral density at the L1-L4 (lumbar spine (LS)) and femur neck (FN) in 68 men with T2DM and compared these with an age-matched group (n = 68). The mean (range) age of the T2DM group was 61.4 (51-78) years. The prevalence of hypovitaminosis D (25-OH-D <75 nmol/L) was 59 %. The mean (range) FRAX hip fracture and FRAX major osteoporotic fracture was 0.7 (0-2.8) and 3.2 (0-8.5) %, respectively. BMD at the FN (0.974 vs. 0.915 g/cm(2), p = 0.008) and LS (1.221 vs. 1.068 g/cm(2), p < 0.001) was significantly higher in the T2DM cohort as compared to the healthy age-matched males. 25-OH-vitamin D (67.7 vs.79.8 nmol/L, p < 0.001), crosslaps (0.19 vs. 0.24 μg/L, p = 0.004), and osteocalcin (13.3 vs. 15.7 μg/L, p = 0.004) were significantly lower in the T2DM group. There was no difference in FRAX-related fracture probability between the two groups. Acknowledging the limitations of our study size, we suggest that the increased BMD in T2DM and the noninclusion of T2DM as a secondary risk factor in the FRAX algorithm may be probable explanations for the discordance between literature-observed and FRAX-related fracture probabilities.
Gao, Chunxia; Wei, Donglei; Yang, Huilin; Chen, Tao; Yang, Lei
Osteoporosis is a serious public health problem affecting hundreds of millions of aged people worldwide, with severe consequences including vertebral fractures that are associated with significant morbidity and mortality. To augment or treat osteoporotic vertebral fractures, a number of surgical approaches including minimally invasive vertebroplasty and kyphoplasty have been developed. However, these approaches face problems and difficulties with efficacy and long-term stability. Recent advances and progress in nanotechnology are opening up new opportunities to improve the surgical procedures for treating osteoporotic vertebral fractures. This article reviews the improvements enabled by new nanomaterials and focuses on new injectable biomaterials like bone cements and surgical instruments for treating vertebral fractures. This article also provides an introduction to osteoporotic vertebral fractures and current clinical treatments, along with the rationale and efficacy of utilizing nanomaterials to modify and improve biomaterials or instruments. In addition, perspectives on future trends with injectable bone cements and surgical instruments enhanced by nanotechnology are provided. PMID:26316746
Gao, Chunxia; Wei, Donglei; Yang, Huilin; Chen, Tao; Yang, Lei
Osteoporosis is a serious public health problem affecting hundreds of millions of aged people worldwide, with severe consequences including vertebral fractures that are associated with significant morbidity and mortality. To augment or treat osteoporotic vertebral fractures, a number of surgical approaches including minimally invasive vertebroplasty and kyphoplasty have been developed. However, these approaches face problems and difficulties with efficacy and long-term stability. Recent advances and progress in nanotechnology are opening up new opportunities to improve the surgical procedures for treating osteoporotic vertebral fractures. This article reviews the improvements enabled by new nanomaterials and focuses on new injectable biomaterials like bone cements and surgical instruments for treating vertebral fractures. This article also provides an introduction to osteoporotic vertebral fractures and current clinical treatments, along with the rationale and efficacy of utilizing nanomaterials to modify and improve biomaterials or instruments. In addition, perspectives on future trends with injectable bone cements and surgical instruments enhanced by nanotechnology are provided.
Cooper, Cyrus; Westlake, Sarah; Harvey, Nicholas; Javaid, Kassim; Dennison, Elaine; Hanson, Mark
Osteoporosis is a major cause of morbidity and mortality through its association with age-related fractures. Although most effort in fracture prevention has been directed at retarding the rate of age-related bone loss and reducing the frequency and severity of trauma among elderly people, evidence is growing that peak bone mass is an important contributor to bone strength during later life. The normal patterns of skeletal growth have been well characterised in cross-sectional and longitudinal studies. It has been confirmed that boys have higher bone mineral content (BMC), but not volumetric bone density, than girls. Furthermore, there is a dissociation between the peak velocities for height gain and bone mineral accrual in both genders. Puberty is the period during which volumetric density appears to increase in both axial and appendicular sites. Many factors influence the accumulation of bone mineral during childhood and adolescence, including heredity, gender, diet, physical activity, endocrine status, and sporadic risk factors such as cigarette smoking. In addition to these modifiable factors during childhood, evidence has also accrued that fracture risk might be programmed during intrauterine life. Epidemiological studies have demonstrated a relationship between birth weight, weight in infancy, and adult bone mass. This appears to be mediated through modulation of the set-point for basal activity of pituitary-dependent endocrine systems such as the HPA and GH/IGF-1 axes. Maternal smoking, diet (particularly vitamin D deficiency), and physical activity also appear to modulate bone mineral acquisition during intrauterine life; furthermore, both low birth size and poor childhood growth are directly linked to the later risk of hip fracture. The optimisation of maternal nutrition and intrauterine growth should also be included within preventive strategies against osteoporotic fracture, albeit for future generations.
Objective Osteoporotic fractures impose a huge economic burden on society. Though several cost of illness studies from other countries exist, no equivalent study has been conducted in Austria. Our study aims at assessing costs resulting from osteoporotic fractures in Austria in the year 2008 from a societal perspective. Methods We took both direct and indirect costs into consideration. Direct costs encompass medical costs such as expenses for pharmaceuticals, inpatient and outpatient medical care costs, as well as other medical services (e.g., occupational therapies). Non-medical direct costs include transportation costs and medical devices (e.g., wheel chairs or crutches). Indirect costs refer to costs of productivity losses due to absence of work. Moreover, we included costs for early retirement and opportunity costs of informal care provided by family members. For our analysis, we combined data of official statistics, expert estimates as well as unique patient surveys that are currently conducted in the course of an international osteoporotic fracture study in Austria. Results For the year 2008, the total annual financial burden incurred by osteoporotic fractures in Austria amounted to approx. €685.2 million, the largest fraction of which was due to the opportunity cost of family care (30.2%), followed by costs for hospitalization (26.6%). Conclusions The financial burden of osteoporotic fractures in Austria is substantial. Our findings may have implications for future economic analyses, and also support health care authorities in their decision making. PMID:22827971
Haffner-Luntzer, Melanie; Kemmler, Julia; Heidler, Verena; Prystaz, Katja; Schinke, Thorsten; Amling, Michael; Kovtun, Anna; Rapp, Anna E.; Ignatius, Anita; Liedert, Astrid
The heparin-binding growth and differentiation factor midkine (Mdk) is proposed to negatively regulate osteoblast activity and bone formation in the adult skeleton. As Mdk-deficient mice were protected from ovariectomy (OVX)-induced bone loss, this factor may also play a role in the pathogenesis of postmenopausal osteoporosis. We have previously demonstrated that Mdk negatively influences bone regeneration during fracture healing. Here, we investigated whether the inhibition of Mdk using an Mdk-antibody (Mdk-Ab) improves compromised bone healing in osteoporotic OVX-mice. Using a standardized femur osteotomy model, we demonstrated that Mdk serum levels were significantly enhanced after fracture in both non-OVX and OVX-mice, however, the increase was considerably greater in osteoporotic mice. Systemic treatment with the Mdk-Ab significantly improved bone healing in osteoporotic mice by increasing bone formation in the fracture callus. On the molecular level, we demonstrated that the OVX-induced reduction of the osteoanabolic beta-catenin signaling in the bony callus was abolished by Mdk-Ab treatment. Furthermore, the injection of the Mdk-Ab increased trabecular bone mass in the skeleton of the osteoporotic mice. These results implicate that antagonizing Mdk may be useful for the therapy of osteoporosis and osteoporotic fracture-healing complications. PMID:27410432
Lim, Soo; Koo, Bo Kyeong; Lee, Eun Jung; Park, Jin Ho; Kim, Myoung Hee; Shin, Kun Hong; Ha, Yong Chan; Cho, Nam Han; Shin, Chan Soo
Osteoporosis is a major public health problem in both Western and Asian populations. Because the aged population in Korea is increasing, the number of osteoporotic fractures is thought to be also increasing. However, there has been no nationwide analysis of osteoporotic fractures in Korea. We analyzed the incidence and cost of hip fracture from 2001 to 2004 by using data from the Health Insurance Review Agency, Korea. In the over 50 years age group, the number of hip fractures in women increased from 250.9/100,000 persons in 2001 to 262.8/100,000 in 2004, a 4.7% increase. However, that in men decreased from 162.8/100,000 in 2001 to 137.5/100,000 in 2004, a 15.5% decrease. Direct medical care costs of hip fracture increased from $62,707,697 in 2001 to $65,200,035 in 2004, and the proportional cost of hip fractures in the national medical costs increased by 4.5% over 4 years (from 0.200% in 2001 to 0.209% in 2004). On analysis of the population-based data obtained from the whole country from 2001 to 2004, the incidence rate of hip fractures in women, not in men, and its cost have increased in Korea. The gender distribution of hip fractures underlines the need for aggressive intervention in osteoporosis in elderly women.
Hans, Didier; Durosier, Claire; Kanis, John A; Johansson, Helena; Schott-Pethelaz, Anne-Marie; Krieg, Marc-Antoine
This study aimed to develop a hip screening tool that combines relevant clinical risk factors (CRFs) and quantitative ultrasound (QUS) at the heel to determine the 10-yr probability of hip fractures in elderly women. The EPISEM database, comprised of approximately 13,000 women 70 yr of age, was derived from two population-based white European cohorts in France and Switzerland. All women had baseline data on CRFs and a baseline measurement of the stiffness index (SI) derived from QUS at the heel. Women were followed prospectively to identify incident fractures. Multivariate analysis was performed to determine the CRFs that contributed significantly to hip fracture risk, and these were used to generate a CRF score. Gradients of risk (GR; RR/SD change) and areas under receiver operating characteristic curves (AUC) were calculated for the CRF score, SI, and a score combining both. The 10-yr probability of hip fracture was computed for the combined model. Three hundred seven hip fractures were observed over a mean follow-up of 3.2 yr. In addition to SI, significant CRFs for hip fracture were body mass index (BMI), history of fracture, an impaired chair test, history of a recent fall, current cigarette smoking, and diabetes mellitus. The average GR for hip fracture was 2.10 per SD with the combined SI + CRF score compared with a GR of 1.77 with SI alone and of 1.52 with the CRF score alone. Thus, the use of CRFs enhanced the predictive value of SI alone. For example, in a woman 80 yr of age, the presence of two to four CRFs increased the probability of hip fracture from 16.9% to 26.6% and from 52.6% to 70.5% for SI Z-scores of +2 and -3, respectively. The combined use of CRFs and QUS SI is a promising tool to assess hip fracture probability in elderly women, especially when access to DXA is limited.
Pisani, Paola; Renna, Maria Daniela; Conversano, Francesco; Casciaro, Ernesto; Di Paola, Marco; Quarta, Eugenio; Muratore, Maurizio; Casciaro, Sergio
Osteoporosis is a silent disease without any evidence of disease until a fracture occurs. Approximately 200 million people in the world are affected by osteoporosis and 8.9 million fractures occur each year worldwide. Fractures of the hip are a major public health burden, by means of both social cost and health condition of the elderly because these fractures are one of the main causes of morbidity, impairment, decreased quality of life and mortality in women and men. The aim of this review is to analyze the most important factors related to the enormous impact of osteoporotic fractures on population. Among the most common risk factors, low body mass index; history of fragility fracture, environmental risk, early menopause, smoking, lack of vitamin D, endocrine disorders (for example insulin-dependent diabetes mellitus), use of glucocorticoids, excessive alcohol intake, immobility and others represented the main clinical risk factors associated with augmented risk of fragility fracture. The increasing trend of osteoporosis is accompanied by an underutilization of the available preventive strategies and only a small number of patients at high fracture risk are recognized and successively referred for therapy. This report provides analytic evidences to assess the best practices in osteoporosis management and indications for the adoption of a correct healthcare strategy to significantly reduce the osteoporosis burden. Early diagnosis is the key to resize the impact of osteoporosis on healthcare system. In this context, attention must be focused on the identification of high fracture risk among osteoporotic patients. It is necessary to increase national awareness campaigns across countries in order to reduce the osteoporotic fractures incidence. PMID:27004165
Yoo, Je-Hyun; Ha, Yong-Chan; Lee, Dong Yeon; Gong, Hyun Sik; Park, Si Young; Yang, Kyu Hyun
Osteoporotic fractures are one of the most common causes of disability and a major contributor to medical care costs worldwide. Prior osteoporotic fracture at any site is one of the strongest risk factors for a new fracture, which occurs very soon after the first fracture. Bone mineral density (BMD) scan, a conventional diagnostic tool for osteoporosis, has clear limitations in diagnosing osteoporotic fractures and identifying the risk of subsequent fractures. Therefore, early and accurate diagnosis of osteoporotic fractures using the clinical definition which is applicable practically and independent of BMD, is essential for preventing subsequent fractures and reducing the socioeconomic burden of these fractures. Fractures caused by low-level trauma equivalent to a fall from a standing height or less at major (hip, spine, distal radius, and proximal humerus) or minor (pelvis, sacrum, ribs, distal femur and humerus, and ankle) sites in adults over age 50, should be first regarded as osteoporotic. In addition, if osteoporotic fractures are strongly suspected on history and physical examination even though there are no positive findings on conventional X-rays, more advanced imaging techniques such as computed tomography, bone scan, and magnetic resonance imaging are necessary as soon as possible. PMID:26713308
Richmond, Bradford J
Vertebral augmentation procedures such as vertebroplasty and kyphoplasty were developed to reduce pain and improve quality of life for patients with osteoporotic vertebral compression fractures. However, the use of vertebral augmentation has been debated and questioned since its inception. This article addresses some of these issues.
The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the Metaphyseal-Diaphyseal Index, a solution to preventing intra-operative periprosthetic fracture.
Chana, Rishi; Mansouri, Reza; Jack, Chris; Edwards, Max R; Singh, Ravi; Keller, Carmel; Khan, Farid
This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted.A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out. The Vancouver Classification was used to classify periprosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (CBR) score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes. Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture. Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine occurred in the cemented group (5.9%), P < 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, P < 0.001 and 90 day mortality 19.7%, P < 0.03. MDI's AUC was 0.985 compared to CBR's 0.948, P < 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. Multivariate regression analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r = 0.99, P < 0.001. JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are good
The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the Metaphyseal-Diaphyseal index, a solution to preventing intra-operative periprosthetic fracture
This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted. A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out. The Vancouver Classification was used to classify periprosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (CBR) score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes. Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture. Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine occurred in the cemented group (5.9%), P < 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, P < 0.001 and 90 day mortality 19.7%, P < 0.03. MDI's AUC was 0.985 compared to CBR's 0.948, P < 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. Multivariate regression analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r = 0.99, P < 0.001. JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are
... References Goulet JA. Hip dislocations. In: Browner BD, Jupiter JB, Krettek C, Anderson PA, eds. Skeletal Trauma: ... Baumgaertner MR. Intertrochanteric hip fractures. In: Browner BD, Jupiter JB, Krettek C, Anderson PA, eds. Skeletal Trauma: ...
Klop, Corinne; de Vries, Frank; Bijlsma, Johannes W J; Leufkens, Hubert G M; Welsing, Paco M J
FRAX incorporates rheumatoid arthritis (RA) as a dichotomous predictor for predicting the 10-year risk of hip and major osteoporotic fracture (MOF). However, fracture risk may deviate with disease severity, duration or treatment. Aims were to validate, and if needed to update, UK FRAX for patients with RA and to compare predictive performance with the general population (GP). Cohort study within UK Clinical Practice Research Datalink (CPRD) (RA: n=11 582, GP: n=38 755), also linked to hospital admissions for hip fracture (CPRD-Hospital Episode Statistics, HES) (RA: n=7221, GP: n=24 227). Predictive performance of UK FRAX without bone mineral density was assessed by discrimination and calibration. Updating methods included recalibration and extension. Differences in predictive performance were assessed by the C-statistic and Net Reclassification Improvement (NRI) using the UK National Osteoporosis Guideline Group intervention thresholds. UK FRAX significantly overestimated fracture risk in patients with RA, both for MOF (mean predicted vs observed 10-year risk: 13.3% vs 8.4%) and hip fracture (CPRD: 5.5% vs 3.1%, CPRD-HES: 5.5% vs 4.1%). Calibration was good for hip fracture in the GP (CPRD-HES: 2.7% vs 2.4%). Discrimination was good for hip fracture (RA: 0.78, GP: 0.83) and moderate for MOF (RA: 0.69, GP: 0.71). Extension of the recalibrated UK FRAX using CPRD-HES with duration of RA disease, glucocorticoids (>7.5 mg/day) and secondary osteoporosis did not improve the NRI (0.01, 95% CI -0.04 to 0.05) or C-statistic (0.78). UK FRAX overestimated fracture risk in RA, but performed well for hip fracture in the GP after linkage to hospitalisations. Extension of the recalibrated UK FRAX did not improve predictive performance. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Friedman, Susan M.; Menzies, Isaura B.; Bukata, Susan V.; Mendelson, Daniel A.; Kates, Stephen L.
Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts. PMID:23569663
Baddoura, R; Hoteit, M; El-Hajj Fuleihan, G
The purpose was to report on the burden of osteoporotic fractures in the Eastern Mediterranean Region (EMR) and the use of bone mineral density (BMD) dual-energy X-ray absorptiometry (DXA) databases for osteoporosis diagnosis. PubMed electronic database was reviewed using the following MeSH terms: "Hip fractures," "Fractures, Compression," "Radius Fractures," "Osteoporosis," "Bone density," and "Middle East" up to July 2009. Incidence of hip fractures varied across the EMR between 100 and 295 per 100,000 person-years in women and 71 and 200 per 100,000 person-years in men. No data were found on other nonvertebral osteoporotic fractures. Prevalence of radiographic vertebral fractures older than 65 yr ranged between 15% and 25% in women and 7.3% and 18% in men. By 2020, the number of hip fractures older than 50 yr would increase by 20%. DXA manufacturer's reference curves for the spine were higher than population-specific ones. At the hip, National Health and Nutrition Examination Survey (NHANES) and population-based curves were comparable. Estimates of the relative risk of vertebral fracture per SD decrease in BMD using NHANES and local data set were similar, that is, 1.61 (1.17-2.23) and 1.49 (1.14-1.95), respectively. The EMR is similar to southern Europe regarding incidence rates of hip fracture, suggesting the health burden to be significant. Using DXA at the hip, population-specific reference databases did not perform better than NHANES on which the FRAX model has been developed highlighting the need for reviewing fracture risk assessment strategies in the EMR. Copyright Â© 2011. Published by Elsevier Inc.
Mulley, G.; Espley, A. J.
In a series of 57 hemiplegic patients who subsequently fractured their hips, it was found that hip fracture occurred significantly more often on the hemiplegic side. Hip fracture was equally common in right- and left-sided hemiplegia, and often occurred within one year of the stroke. Two factors seem to be important in the genesis of hip fractures in hemiplegic patients: the tendency of stroke patients to fall to the affected side as a result of impaired locomotor function, and the development of disuse osteoporosis in the hemiplegic limb. PMID:471862
Nazrun, Ahmad Shuid; Tzar, Mohd Nizam; Mokhtar, Sabarul Afian; Mohamed, Isa Naina
Purpose Osteoporotic fracture is the main complication of osteoporosis. The current management is to discharge patients as early as possible so they can get back to their daily activities. Once discharged, there are three main issues relating to morbidity, mortality, and risk of a subsequent fracture that need to be addressed and discussed. Therefore, the aim of this systematic review was to summarize and evaluate the evidence from published literature, to determine the outcome of osteoporotic fracture patients after their hospital discharge. Methods The MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched, using the terms “osteoporosis”, “fracture”, “osteoporotic fracture”, “hip fracture”, and “vertebral fracture”. We included only human studies published in English between 2004 and 2014. The reference lists of included studies were thoroughly reviewed in search for other relevant studies. Results A total of 18 studies met the selection criteria. Most were observational and cohort studies. Out of all the studies, five studies looked into the morbidity, six studies looked into the risk of subsequent fractures, and seven studies looked into mortality. Vertebral fracture caused the greatest health burden, but hip fracture patients were the main users of informal care after hospital discharge. There was an increased risk of a subsequent fracture after a primary fracture compared with the control group, a cohort comparison, or the general population. Osteoporotic fractures, especially hip fractures, are associated with higher mortality rate despite the advances in the management of osteoporotic fracture cases. Conclusion There is strong evidence to show that after hospital discharge, osteoporotic fracture patients are faced with higher morbidity, subsequent fractures, and mortality. PMID:25429224
Siggeirsdottir, K; Aspelund, T; Jonsson, B Y; Mogensen, B; Gudmundsson, E F; Gudnason, V; Sigurdsson, G
The incidence of the most common fracture types in Iceland is reported based on individual data from the Reykjavik Study 1967-2008. Time trend is reported for the major osteoporotic fractures (MOS) 1989-2008. This study aims to assess the incidence of all fractures in Iceland, with emphasis on the rate of hip fractures, and compare the incidence with other populations as well as examine the secular changes. Individuals from the prospective population-based cohort Reykjavik Study were examined between 1967 and 2008 (follow-up 26.5 years), which consisted of 9,116 men and 9,756 women born in 1907-1935, with age range 31-81 years. First fracture incidence was estimated using life table methods with age as the timescale. Fracture rate increased proportionally with age between the sexes for vertebral and proximal humerus but disproportionally for hip and distal forearm fractures. The ratio of first fracture incidence between the sexes varied considerably by site: 2.65 for hip fractures and the highest for distal forearm fractures at 4.83. By the age of 75, 36.7% of women and 21% of men had sustained a fracture, taking into account competing risk of death. The incidence of hip fractures was similar to results previously published from USA, Sweden, Norway, and Scotland. The incidence of MOS fractures in both sexes decreased over the last decade, except hip fractures in men, which remained unchanged, as reflected in the women/men ratio for the hip, which changed from 2.6 to 1.7. This study adds information to scarce knowledge on the relative fracture incidence of different fractures. The incidence of MOS fractures increased in the latter part of the last century in both sexes and declined during the last decade, less dramatically for men. This information is important for planning health resources.
Raised serum albumin in hip osteoarthrosis: a comparative study in women of some blood chemical parameters in aging and in cases of femoral neck fractures, osteoporotic vertebral crush fractures, and hip osteoarthrosis.
Rapin, C H; Lagier, R
Twelve blood parameters were studied in five groups of women totalling 120 subjects--group I: 26 blood donors (average age 45.2 years, range 23-66); group II: 18 patients with various cerebral, cardiovascular, or infectious illnesses (average age 79.9 years, range 66-92); group III: 28 patients with femoral neck fractures (average age 79.4 years, range 56-95); group IV: 12 patients with hip osteoarthrosis (average age 71.7 years, range 60-87); group V: 36 patients with vertebral crush fractures associated with postmenopausal and involutional osteoporosis (average age 63.0 years, range 51-75). The parameters measured were total proteins, albumin, total, alpha 1, alpha 2, beta, and gamma globulins, total calcium, phosphates, alkaline phosphatase, bilirubin, and haemoglobin. Statistical analysis showed that each group differed from the others even with adjustment for age. Among the discriminant parameters, serum albumin had a distinctive position. Significantly high concentrations of serum albumin in the group with osteoarthrosis raise the question of the possible existence of a population prone to osteoarthrosis in whom the serum albumin level may reflect a special nutritional state associated with the well known bone density in subjects with hip osteoarthrosis. Albumin values in patients with femoral neck fractures are lower than normal but non-significantly. The difference between the group with vertebral crush fractures and that with femoral neck fractures seems to be due to age. PMID:3401055
Age- and gender-specific numbers of patients with hip fracture increase with age and peaked at the age 80-84; however, age- and gender-specific incidences increase exponentially with age. According to the recent nation-wide survey, the most common cause of hip fractures was a simple fall, 68.8% sustained fractures in-doors, and the incidences were higher in the winter than the summer period. More than 90% of patients with hip fracture were treated surgically and about 3/4 of patients with femoral neck fractures were treated with hemi-arthroplasty. Hip fractures for Asian people including Japanese are lower than those for Caucasians living in Northern Europe and North America; however, recent reports from the Asian area indicated an increase in the incidence with time.
Verhaar, Harald J J; Lems, Willem F
At present there are two parathyroid hormone (PTH) analogues (PTH 1 - 34 and PTH 1 - 84) registered for the treatment of established osteoporosis in postmenopausal women (PTH 1 - 34 and PTH 1 - 84) and in men (PTH 1 - 34 only) who are at increased risk of having a fracture. The efficacy and safety of PTH 1 - 34 and PTH 1 - 84 in the management of osteoporosis is evaluated by reviewing published literature and presentations from scientific meetings through to 2010. This review focuses on data on fracture risk reduction and safety endpoints of PTH analogues. The adverse reactions reported most are nausea, pain in the extremities, headache and dizziness. Exogenous PTH analogues, given as daily subcutaneous injections, stimulate bone formation, increase bone mass and bone strength, and improve calcium balance. In postmenopausal women with osteoporosis, PTH analogues reduced the risk of vertebral (PTH 1 - 34 and PTH 1 - 84) and non-vertebral fractures (only PTH 1 - 34). In men and women with glucocorticosteroid-induced osteoporosis, PTH 1 - 34 reduced the risk of vertebral fractures. In general, PTH analogues are well tolerated with an acceptable safety profile: they can be used for the prevention and treatment of fractures in postmenopausal women with severe, established osteoporosis.
Ettinger, Bruce; Liu, Hau; Blackwell, Terri; Hoffman, Andrew R; Ensrud, Kristine E; Orwoll, Eric S
We evaluated the performance of the Fracture Risk Calculator (FRC) in 5893 men who participated in the baseline visit (March 2000-April 2002) of the Osteoporotic Fractures in Men Study. FRC estimates for 10-yr hip and major osteoporotic (hip, clinical spine, forearm, and shoulder) fractures were calculated and compared with observed 10-yr fracture probabilities. Possible enhancement of the tool's performance when bone mineral density (BMD) was included was evaluated by comparing areas under receiver operating characteristic curves and by Net Reclassification Improvement (NRI). A total of 5893 men were followed-up for an average of 8.4 yr. For most quintiles of predicted fracture risk, the ratios of observed to predicted probabilities were close to unity. Area under the curves improved when BMD was included (p<0.001; 0.79 vs 0.71 for hip fracture and 0.70 vs 0.66 for major osteoporotic fracture, respectively). Using National Osteoporosis Foundation clinical treatment thresholds, BMD inclusion increased NRI significantly, 8.5% (p<0.01) for hip and 4.0% (p=0.01) for major osteoporotic fracture. We conclude that the FRC calibrates well with hip and major osteoporotic fractures observed among older men. Further, addition of BMD to the fracture risk calculation improves the tool's performance.
Nguyen, T; Sambrook, P; Kelly, P; Jones, G; Lord, S; Freund, J; Eisman, J
OBJECTIVE--To investigate the utility of risk factors such as bone mineral density, lifestyle, and postural stability in the prediction of osteoporotic fractures. DESIGN--Longitudinal, epidemiological, and population based survey. SETTING--City of Dubbo, New South Wales. SUBJECTS--All residents of Dubbo aged > or = 60 on 1 January 1989. MAIN OUTCOME MEASURE--Incidence of fracture for individual subjects. RESULTS--The overall incidence of atraumatic fractures in men and women was 1.9% and 3.1% per annum respectively. The predominant sites of fracture were hip (18.9%), distal radius (18.5%), ribs and humerus (11.9% in each case), and ankle and foot (9.1% and 6.6% respectively). Major predictors of fractures in men and women were femoral neck bone mineral density, body sway, and quadriceps strength. Age, years since menopause, height, weight, and lifestyle factors were also correlated with bone mineral density and body sway and hence were indirect risk factors for fracture. Discriminant function analysis correctly identified 96% and 93% (sensitivities 88% and 81%) of men and women, respectively, who subsequently developed atraumatic fractures. Predictions based on this model indicated that a woman with a bone mineral density in the lowest quartile in the hip together with high body sway had a 8.4% probability of fracture per annum. This represented an almost 14-fold increase in risk of fracture compared with a woman in the highest bone mineral density quartile with low postural sway. An individual with all three predictors in the "highest risk" quartile had a 13.1% risk of fracture per annum. CONCLUSIONS--Bone mineral density, body sway, and muscle strength are independent and powerful synergistic predictors of fracture incidence. PMID:8251809
Meunier, P J
For a 50-year old Caucasian woman today, the risk of a hip fracture over her remaining life-time is about 17%. Tomorrow the situation will clearly be worse because the continuous increase in life expectancy will cause a three-fold increase in worldwide fracture incidence over the next 60 years. Through diagnostic bone mass measurements at the hip and assessment of biochemical parameters, a great deal has been learned in recent years about reduction of hip fracture risk. Preventive strategies are based on prevention of falls, use of hip protectors, and prevention of bone fragility. The latter includes the optimization of peak bone mass during childhood, postmenopausal estrogen replacement therapy, and also late prevention consisting in reversing senile secondary hyperparathyroidism, which plays an important role in the decrease of skeletal strength. This secondary hyperparathyroidism, which results from both vitamin D insufficiency and low calcium intake, is preventable with vitamin D3 and calcium supplements. They have recently been shown capable of providing effective prevention of hip fractures in elderly women living in nursing homes, with a reduction of about 25% in the number of hip fractures noted in a 3-year controlled study in 3,270 women (intention-to-treat analysis). In conclusion, it is never too early to reduce the risk of osteoporosis and never too late to prevent hip fractures.
Kannus, P; Parkkari, J; Sievänen, H; Heinonen, A; Vuori, I; Järvinen, M
There were an estimated 1.66 million hip fractures world-wide in 1990. According to the epidemiologic projections, this worldwide annual number will rise to 6.26 million by the year 2050. This rise will be in great part due to the huge increase in the elderly population of the world. However, the age-specific incidence rates of hip fractures have also increased during the recent decades and in many countries this rise has not leveled off. In the districts where this increase has either showed or leveled off, the change seems to especially concern women's cervical fractures. In men, the increase has continued unabated almost everywhere. Reasons for the age-specific increase are not known: increase in the age-adjusted incidence of falls of the elderly individuals with accompanying deterioration in the age-adjusted bone quality (strength, mineral density) may partially explain the phenomenon. The growth of the elderly population will be more marked in Asia, Latin America, the Middle East, and Africa than in Europe and North America, and it is in the former regions that the greatest increments in hip fracture are projected so that these regions will account for over 70% of the 6.26 million hip fractures in the year 2050. The incidence rates of hip fractures vary considerably from population to population and race to race but increase exponentially with age in every group. Highest incidences have been described in the whites of Northern Europe (Scandinavia) and North America. In Finland, for example, the 1991 incidence of hip fractures was 1.1% for women and 0.7% for men over 70 years of age. Among elderly nursing home residents, the figures can be as high as 6.2% and 4.9%. The lifetime risk of a hip fracture is 16%-18% in white women and 5%-6% in white men. At the age of 80 years, every fifth woman and at the age of 90 years almost every second woman has suffered a hip fracture. Since populations are aging worldwide, the mean age of the hip fracture patients are
Sánchez-Hernández, N; Sáez-López, P; Paniagua-Tejo, S; Valverde-García, J A
To evaluate the efficiency of a clinical pathway in the management of elderly patients with fragility hip fracture in a second level hospital in terms of length of stay time to surgery, morbidity, hospital mortality, and improved functional outcome. A comparative and prospective study was carried out between two groups of patients with hip fracture aged 75 and older prior to 2010 (n=216), and after a quality improvement intervention in 2013 (n=196). A clinical pathway based on recent scientific evidence was implemented. The degree of compliance with the implemented measures was quantified. The characteristics of the patients in both groups were similar in age, gender, functional status (Barthel Index) and comorbidity (Charlson Index). Median length of stay was reduced by more than 45% in 2013 (16.61 vs. 9.08 days, p=.000). Also, time to surgery decreased 29.4% in the multidisciplinary intervention group (6.23 vs. 4.4 days, p=.000). Patients assigned to the clinical pathway group showed higher medical complications rate (delirium, malnutrition, anaemia and electrolyte disorders), but a lower hospital mortality (5.10 vs. 2.87%, p>.005). The incidence of surgical wound infection (p=.031) and functional efficiency (p=.001) also improved in 2013. An increased number of patients started treatment for osteoporosis (14.80 vs. 76.09%, p=.001) after implementing the clinical pathway. The implementation of a clinical pathway in the care process of elderly patients with hip fracture reduced length of stay and time to surgery, without a negative impact on associated clinical and functional outcomes. Copyright © 2015 SECOT. Published by Elsevier Espana. All rights reserved.
Boardman, Matthew J; Herman, Martin J; Buck, Brian; Pizzutillo, Peter D
Hip fractures account for <1% of all pediatric fractures. Most are caused by high-energy mechanisms, but pathologic hip fractures also occur, usually from low-energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Surgical options vary based on the child's age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth-wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.
Bliuc, Dana; Center, Jacqueline R
Increased mortality risk is accepted for hip and vertebral fracture. Recent data suggest that other fracture types have also been linked to excess mortality. This article reviews the existing evidence on the pattern and determinants of postfracture mortality. The pattern of mortality over time following hip and vertebral fractures has recently been clarified. Nonhip nonvertebral fractures at major, and even minor sites in older individuals have also been associated with excess mortality. Studies have revealed the higher excess mortality in men and in younger age groups for all fracture types. Despite the increasing knowledge on the fracture-mortality association, little is known about its cause. The role of co-morbidities is inconsistent across studies. Recent findings suggest low bone mass, bone loss and muscle weakness are linked to both fracture and mortality risk, and thus may play a role in postfracture mortality. Nonhip nonvertebral fractures have recently been associated with mortality risk. Larger studies are needed to better understand which specific fractures and factors contribute to fracture-associated mortality risk. The role of bone loss in postfracture mortality needs to be validated in more studies, because of its potential reversibility with antifracture therapies.
Åivo, J; Kurki, S; Sumelahti, M-L; Hänninen, K; Ruutiainen, J; Soilu-Hänninen, M
Increased risk of osteoporotic fractures in multiple sclerosis (MS) patients compared with general population has been reported. The purpose of this study was to assess the risk of osteoporotic and other low-energy fractures in an MS cohort from a large hospital district in southwest Finland. Age-adjusted total and gender-specific prevalence for definite MS per 100 000 in a population of 472 139 was calculated as a point prevalence in December 31, 2012. Patients with MS and comorbid fractures were identified by searching for ICD-9 and ICD-10 codes during a period from 2004 to 2012 from hospital administrative data in Turku University Hospital (TYKS) in southwest Finland Case ascertainment was performed by review of medical records. Osteoporotic fracture was defined as a low-energy fracture of the pelvis, hip, femur, tibia, humerus, collar bone, ulna/radius, vertebrae, or rib. The control population was a 10-fold age- and gender-matched population. The point prevalence (N 1004) of MS was 212.6/10(5) (CI 199.5-225.8) in December 31, 2012. A total of 100 (9.9%) of 1004 confirmed MS cases experienced at least one fracture during the study period. Relative risks (RRs) for all fractures (1.33, 95% CI 1.10-1.60) and osteoporotic fractures (1.50, 95% CI 1.18-1.90) were significantly increased in patients with MS compared with controls. In particular, RRs for hip fractures (5.00, 95% CI 2.96-8.43) and fractures of humerus (2.36, 95% CI 1.32-4.42) were elevated in patients with MS vs controls. We observed high prevalence of MS in southwest Finland and confirmed increased age-adjusted comorbid risk for osteoporotic fractures and other low-energy fractures compared with individually matched controls. © 2016 John Wiley & Sons A/S.Published by John Wiley & Sons Ltd.
Pollock, N; Hamilton, B
An elite Kenyan runner presented with a tibial fracture sustained during an international cross-country race. There was no clear history of symptoms suggestive of preceding overload and no radiological features of stress fracture. He was found to have sustained an osteoporotic, insufficiency fracture. There are no previous case reports of an osteoporotic fracture in a male athlete. Possible aetiologies and directions for future investigation are presented.
Lee, K M; Chung, C Y; Kwon, S S; Won, S H; Lee, S Y; Chung, M K; Park, M S
We report the bone attenuation of ankle joint measured on computed tomography (CT) and the cause of injury in patients with ankle fractures. The results showed age- and gender-dependent low bone attenuation and low-energy trauma in elderly females, which suggest the osteoporotic features of ankle fractures. This study was performed to investigate the osteoporotic features of ankle fracture in terms of bone attenuation and cause of injury. One hundred ninety-four patients (mean age 51.0 years, standard deviation 15.8 years; 98 males and 96 females) with ankle fracture were included. All patients underwent CT examination, and causes of injury (high/low-energy trauma) were recorded. Mean bone attenuations of the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis were measured on CT images. Patients were divided into younger age (<50 years) and older age (≥50 years) groups, and mean bone attenuation and causes of injury were compared between the two groups in each gender. Proportion of low-energy trauma was higher in the older age group than in the younger age group, but the difference was only significant in female gender (p = 0.011). The older age group showed significantly lower bone attenuation in the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis than the younger age group in both genders. The older age group showed more complex pattern of fractures than the younger age group. With increasing age, bone attenuations tended to decrease and the difference of bone attenuation between the genders tended to increase in the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis. Ankle fracture had features of osteoporotic fracture that is characterized by age- and gender-dependent low bone attenuation. Ankle fracture should not be excluded from the clinical and research interest as well as from the benefit of osteoporosis management.
Hernández, J L; Marin, F; González-Macías, J; Díez-Pérez, A; Vila, J; Giménez, S; Galán, B; Arenas, M S; Suárez, F; Gayola, L; Guillén, G; Sagredo, T; Belenguer, R; Moron, A; Arriaza, E
Bone fragility fractures constitute the principal complication of osteoporosis. The identification of individuals at high risk of sustaining osteoporotic fractures is important for implementing preventive measures. The purpose of this study is to analyze the discriminative capacity of a series of osteoporosis and fracture risk factors, and of calcaneal quantitative ultrasound (QUS), in a population of postmenopausal women with a history of osteoporotic fracture. A cross-sectional analysis was made of a cohort of 5195 women aged 65 or older (mean +/- SD: 72.3 +/- 5.4 years) seen in 58 primary care centers in Spain. A total of 1042 women (20.1%) presented with a history of osteoporotic fracture. Most fractures (93%) were non-vertebral. Age-adjusted odds ratios corresponding to each decrease in one standard deviation of the different QUS parameters ranged from 1.47 to 1.55 (P < 0.001) for fractures. The age-adjusted multivariate analysis yielded the following risk factors independently associated with a history of osteoporotic fracture: number of fertile years, a family history of fracture, falls in the previous year, a history of chronic obstructive airway disease, the use of antiarrhythmic drugs, and a low value for any of the QUS parameters. The area under the receiver operating characteristic curve of the best model was 0.656. In summary, a series of easily assessable osteoporotic fracture risk factors has been identified. QUS was shown to discriminate between women with and without a history of fracture, and constitutes a useful tool for assessing fracture risk. Various of the vertebral and hip fracture risk factors frequently cited in North American and British populations showed no discriminative capacity in our series--thus suggesting that such factors may not be fully applicable to our population and/or to the predominant type of fractures included in the present study.
Napoli, Nicola; Schwartz, Ann V.; Palermo, Lisa; Jin, Jenny J.; Wustrack, Rosanna; Cauley, Jane A.; Ensrud, Kristine E.; Kelly, Michael
Context: Patients on long-term bisphosphonate therapy may have an increased incidence of low-energy subtrochanteric and diaphyseal (SD) femoral fractures. However, the incidence and risk factors associated with these fractures have not been well defined. Objective: The objective of the study was to determine the incidence of and risk factors for low-energy SD fractures in the Study of Osteoporotic Fractures (SOF). Design: Low-energy SD fractures were identified from a review of radiographic reports obtained between 1986 and 2010 in women in the SOF. Among the SD fractures, pathological, periprosthetic, and traumatic fractures were excluded. We assessed risk factors for SD fractures as well as risk factors for femoral neck (FN) and intertrochanteric (IT) hip fractures using both age-adjusted and multivariate time-dependent proportional hazards models. During this follow-up, only a small minority had ever used bisphosphonates. Results: Forty-five women sustained low-energy subtrochanteric/diaphyseal femoral fractures over a total follow-up of 140 000 person-years. The incidence of SD fracture was 3.2 per 10 000 person-years compared with a total hip fracture incidence of 110 per 10 000 person-years. A total of about 12% of women reported bisphosphonate use at 1 or more visits. In multivariate analyses, age, total hip bone mineral density (BMD), bisphosphonate use, and history of diabetes emerged as independent risk factors for SD fractures. Risk factors for FN and IT fractures included age, BMD, and history of falls or prior fractures. Bisphosphonate use was protective against FN fractures, whereas there was an increased risk of SD fractures (hazard ratio 2.58, P = .049) with bisphosphonate use after adjustment for other risk factors for fracture. Conclusions: In SOF, low-energy SD fractures were rare occurrences, far outnumbered by FN and IT fractures. Typical risk factors were associated with FN and IT fractures, whereas only age, total hip BMD, and history of
Langdahl, Bente Lomholt; Harsløf, Torben
A vertebral fracture is a serious symptom of osteoporosis. Vertebral fractures cause moderate-to-severe back pain for a shorter or longer duration, increase the risk of a subsequent vertebral fracture approximately four-fold, reduce quality of life significantly and are associated with increased mortality. In order to choose the optimal treatment for the patient, the severity and type of osteoporosis should be investigated. Prevention of new osteoporotic fractures can be accomplished through treatment with both antiresorptive and anabolic treatments. The antiresorptive treatment modalities comprise calcium, vitamin D, bisphosphonates, hormone therapy, selective oestrogen receptor modulators (SERMs), strontium ranelate, receptor activator of NF-kB ligand (RANKL) antibody and calcitonin. The anabolic treatments comprise teriparatide and parathyroid hormone [(PTH)-(1–84)]. Adherence with treatment of osteoporosis is generally poor and therefore once the choice of treatment has been made and the patient has been instructed properly, long-term adherence to the treatment should be secured through information and regular control visits. PMID:22870463
Wongtriratanachai, Prasit; Chiewchantanakit, Siripong; Vaseenon, Tanawat; Rojanasthien, Sattaya; Leerapun, Taninnit
Hip fractures are a major public health problem. Patients who have suffered a hip fracture have an increased risk of a subsequent hip fracture. This study examines the incidence ofsecondhip fractures and attempts to identify underlying risk factors. To examine the incidence ofsecond hip fractures in osteoporotic patients at Chiang Mai University Hospital and to identify risk factors related to second hip fractures. A retrospective review was conducted of all low-energy mechanism hip fracture patients admitted during 2008 and 2009. Analysis of second hip fractures was conducted using survival analysis and logistic regression analysis. A total of 191 patients were observed for 391.68 person-years (mean 2.05 person-years per patient). Among that group, nine second hip fractures were identified, an overall incidence rate of 0.023 second fractures per person-year. Second hip fractures tended to occur within the first year following an initial hip fracture. There were no significant differences related to either gender or comorbid medical conditions. Logistic regression analysis revealed that increased risk of a second hip fracture was associated with age (highest between 80 to 89 years) and patients who were not treated for osteoporosis following their initial fracture. The incidence of second hip fractures at Chiang Mai University Hospital was 0.023 per person-year Careful follow-up of older patients, especially those over 80, and treatment ofosteoporosis with bisphosphonate plus vitamin D and calcium supplements was correlated with a reduction in the incidence of second hip fractures.
Aguilar Del Rey, Francisco Javier; Pérez González, Olga
The aim of this study was to examine the epidemiological data on osteoporotic fractures in Andalusia in the period 2000-2010. In view of the lack of epidemiological studies of fractures in Andalusia, we set out to ascertain the number and incidence rates of osteoporotic fractures and their distribution by gender and age, location, comorbidity, seasonality and secular trend. Cohort study observed over a period of 11 years analysing the data provided by the Minimum Basic Data Set register for the period 2000-2010. There were a total of 96,458 osteoporotic fractures, with a crude incidence rate of 374.18 fractures per 100,000 population. Fractures increased in this period by 27% (p<.01, IC 95%, 0.71; 0.73). We found a trend change in female/male ratio, from 3.4 to 3.2, and in the reduction in fractures in the last two years, especially in the past year, with a decrease of 11.2% in hip fractures (p<.001, IC 95%, 0.88; 0.895). In this period, there has been an increase in fractures as a consequence of the ageing of the population, but also a change in trend, with fractures decreasing in some age groups. The incidence rate of fractures varies between different countries and regions of Spain, and between different provinces of Andalusia. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
Seo, M R N; Park, S Y; Park, J S; Jin, W; Ryu, K N
Objectives To evaluate the incidence and pattern of spinous process fractures (SPFs) in patients with osteoporotic compression fractures (OCFs) of the thoracolumbar spine. Methods Spinal MRI or CT of 398 female patients (age range 50–89 years, mean age 70 years) who had OCFs in the thoracolumbar spine were retrospectively reviewed. The incidence, location and imaging results for the SPFs were evaluated. Results Of the 398 patients who had thoracolumbar OCFs, 14 (3.5%) had SPF. In six patients with single compression fractures, the SPF occurred at the level just above the vertebral compression fracture. In six out of seven patients with multiple continuous compression fractures, the SPF occurred just one level above the uppermost level of the compression fracture. The remaining one patient who had thoracolumbar spinal fixation at T12–L2 with continuous compression fractures in T12–L5 had a SPF in L2. In one patient who had multiple compression fractures in discontinuous levels (fractures at T10 and L1, respectively), the SPF occurred at T12. The directions of the fractures were vertical or oblique vertical (perpendicular to the long axis of the spinous process) in all cases. Conclusion In the presence of an OCF in the thoracolumbar spine, a SPF was found in 3.5% of cases, and most of the fractures were located just one level above the compression fracture. Therefore, in patients who have OCF, the possibility of a SPF in the level just above the compression fracture should be considered. PMID:21343317
Whitehouse, Kathrin; Horne, Simon; Gay, David
A 78-year-old woman presented 28 days after a low-impact fall, where she sustained a right pubic ramus fracture, with increasing left hip pain and fever. Her blood results showed a high white cell count and deranged urea and electrolytes. An MRI revealed multiple osteoporotic fractures and bilateral gluteal abscesses with left iliopsoas abscess, which had likely formed in a haematoma of a sacral fracture. She received a long course of intravenous antibiotics and CT-guided drainage of the abscesses. She developed symptoms of cauda equina, but no evidence of epidural extension of the abscess was found at operation. She required neurorehabilitation. This case highlights the complications of pelvic osteoporotic fractures, and high associated morbidity and mortality in the elderly population.
Chen, Ying-Chou; Lin, Wei-Che
Adjacent fracture of the cemented vertebrae result from crushed fragile trabeculae during follow-up, suggesting impaired bone marrow integrity. This study aimed to determine if anti-osteoporotic therapy can decrease the risk of adjacent fracture in patients after vertebroplasty. This retrospective study reviewed of cases of osteoporotic patients with magnetic resonance imaging (MRI)-proven acute vertebral fractures between 2001 and 2007. Osteoporotic patients were investigated as determined by pre-operative MRI with subsequent adjacent fracture of the cemented vertebrae and for the possibility of anti-osteoporotic therapy decreasing the progression of collapse after a minimum of 6 months follow-up. All associated co-morbidities were recorded, as well as the use of anti-osteoporotic drugs (i.e., bisphosphonate, raloxifen, calcitonin, and teriparatide). Cox regression analysis was also performed. The 192 vertebral fractured patients who underwent vertebroplasty and anti-osteoporotic therapy had a mean age of 74.40 ± 6.41. The basic characteristics of patients with and without adjacent fracture differed in age, body mass index, rheumatoid arthritis, and use of glucocorticoids and anti-osteoporotic drugs (Table 1). Using the Kaplan-Meier curve, anti-osteoporotic therapy after vertebroplasty had a significant effect on adjacent fracture (p = 0.037, by log rank text). After adjusting for potential confounders, patients with anti-osteoporotic therapy still had a lower adjacent fracture rate than patients without anti-osteoporotic therapy (p = 0.006; HR: 2.137, 95 % CI: 1.1238-3.690). The adjacent fracture rate also increased in old age (p = 0.019; HR: 1.049; 95 % CI:1.008-1.039) and among smokers (p = 0.026; HR: 3.891; 95 % CI: 1.175-12.890). In this study, adjacent fracture of cemented vertebrae is inevitable after vertebroplasty but can be mitigated by anti-osteoporotic therapy to increase bone mass.
Nielson, Carrie M; Orwoll, Eric; Bauer, Douglas C; Cauley, Jane A
Objective To study the causes and consequences of radiologically confirmed rib fractures (seldom considered in the context of osteoporosis) in community dwelling older men. Design Prospective cohort study (Osteoporotic Fractures in Men (MrOS) Study). Setting and participants 5995 men aged 65 or over recruited in 2000-2 from six US sites; 99% answered mailed questionnaires about falls and fractures every four months for a mean 6.2 (SD 1.3) year follow-up. Main outcome measures New fractures validated by radiology reports; multivariate Cox proportional hazard ratios were used to evaluate factors independently associated with time to incident rib fracture; associations between baseline rib fracture and incident hip and wrist fracture were also evaluated. Results The incidence of rib fracture was 3.5/1000 person years, and 24% (126/522) of all incident non-spine fractures were rib fractures. Nearly half of new rib fractures (48%; n=61) followed falling from standing height or lower. Independent risk factors for an incident rib fracture were age 80 or above, low bone density, difficulty with instrumental activities of daily living, and a baseline history of rib/chest fracture. Men with a history of rib/chest fracture had at least a twofold increased risk of an incident rib fracture (adjusted hazard ratio 2.71, 95% confidence interval 1.86 to 3.95), hip fracture (2.05, 1.33 to 3.15), and wrist fracture (2.06, 1.14 to 3.70). Only 14/82 of men reported being treated with bone specific drugs after their incident rib fracture. Conclusions Rib fracture, the most common incident clinical fracture in men, was associated with classic risk markers for osteoporosis, including old age, low hip bone mineral density, and history of fracture. A history of rib fracture predicted a more than twofold increased risk of future fracture of the rib, hip, or wrist, independent of bone density and other covariates. Rib fractures should be considered to be osteoporotic fractures in the
Kuliwaba, J. S.; Truong, L.; Codrington, J. D.; Fazzalari, N. L.
The human skeleton has the ability to modify its material composition and structure to accommodate loads through adaptive modelling and remodelling. The osteocyte cell network is now considered to be central to the regulation of skeletal homeostasis; however, very little is known of the integrity of the osteocyte cell network in osteoporotic fragility fracture. This study was designed to characterise osteocyte morphology, the extent of osteocyte cell apoptosis and expression of sclerostin protein (a negative regulator of bone formation) in trabecular bone from the intertrochanteric region of the proximal femur, for postmenopausal women with fragility hip fracture compared to age-matched women who had not sustained fragility fracture. Osteocyte morphology (osteocyte, empty lacunar, and total lacunar densities) and the degree of osteocyte apoptosis (percent caspase-3 positive osteocyte lacunae) were similar between the fracture patients and non-fracture women. The fragility hip fracture patients had a lower proportion of sclerostin-positive osteocyte lacunae in comparison to sclerostin-negative osteocyte lacunae, in contrast to similar percent sclerostin-positive/sclerostin-negative lacunae for non-fracture women. The unexpected finding of decreased sclerostin expression in trabecular bone osteocytes from fracture cases may be indicative of elevated bone turnover and under-mineralisation, characteristic of postmenopausal osteoporosis. Further, altered osteocytic expression of sclerostin may be involved in the mechano-responsiveness of bone. Optimal function of the osteocyte cell network is likely to be a critical determinant of bone strength, acting via mechanical load adaptation, and thus contributing to osteoporotic fracture risk.
Hodsman, Anthony B; Leslie, William D; Tsang, James F; Gamble, Greg D
Wrist fractures are the most prevalent type of fracture occurring in postmenopausal women. We sought to contrast the probability of recurrent osteoporotic fractures after a primary wrist fracture with other important primary fracture sites. A historical cohort study comprising 21,432 women 45 years or older referred for bone mineral density (BMD) testing. Longitudinal health service records were assessed for the presence of fracture codes before and after BMD testing (359,737 person-years of observation). A total of 2652 women (12.4%) experienced a primary fracture (wrist, vertebra, humerus, hip) prior to BMD testing, of which wrist fractures were the largest single group (1225 [46.2%]). The adjusted hazard ratio (HR) for recurrent osteoporotic fracture following a primary wrist fracture (HR, 1.58; 95% confidence interval [CI], 1.29-1.93) was lower than for other primary fractures (HR, 2.66; 95% CI, 2.30-3.08). Primary wrist fractures were not significantly associated with subsequent hip fractures (adjusted HR, 1.29; 95% CI, 0.88-1.89), whereas other primary fracture sites were individually and collectively significant predictors of future hip fractures (HR, 1.72; 95% CI, 1.31-2.26). The 10-year probability of any recurrent fracture after a primary wrist fracture was 14.2% (95% CI, 11.9%-16.5%), which was significantly less than for other primary fractures (spine, 25.7%; hip, 24.9%; humerus, 23.7%; P < .001 for all comparisons vs wrist) but greater than in those without prior fractures (10.8%; P < .001). The relationship between BMD and fracture risk was much stronger after a primary wrist fracture (HR, 2.20 per standard deviation; 95% CI, 1.70-2.80) than after other primary osteoporotic fractures (HR, 1.21; 95% CI, 1.05-1.40), reflecting the dominance of the other fracture information over BMD. Wrist fractures are the most common of the clinical osteoporotic fractures in patients referred for BMD testing. However, the risk of recurrent fractures in the 10 years
Jamal, Sophie A; Arampatzis, Spyridon; Harrison, Stephanie Litwack; Bucur, Roxana C; Ensrud, Kristine; Orwoll, Eric S; Bauer, Douglas C
Hyponatremia may be a risk factor for fracture. To determine the relationship between hyponatremia and fracture we conducted cross-sectional and longitudinal analyses using data from the Osteoporotic Fractures in Men Study (MrOS). The MrOS study enrolled 5122 community dwelling men aged ≥ 65 years from six centers across the United States. We excluded men taking bisphosphonates, those with unknown medication history, those without serum sodium measures, or those with out of range assays for serum sodium. Serum sodium was measured at study entry. Subjects were followed for fractures (nonspine (including hip), hip, and incident and prevalent morphometric) for up to 9 years. We used cox proportional hazards models to analyze the association between serum sodium levels (<135mmol/L versus ≥135mmol/L) and risk of nonspine and hip fractures, with results presented as hazard ratios (HR) and 95% confidence intervals (CI). We examined the association between morphometric vertebral fractures and serum sodium using logistic regression models, presented as odds ratios (OR) and 95% CI. Hyponatremia was observed in 64 men (1.2% of the cohort). After adjusting for age, BMI, study center, and other covariates, we found that, compared to men with serum sodium ≥ 135mmol/L, those with serum sodium <135mmol/L, had an increased risk hip fracture (HR=3.04; 95% CI: 1.37 to 6.75), prevalent (OR=2.46; 95% CI: 1.22 to 4.95) and incident (OR=3.53; 95% CI: 1.35 to 9.19) morphometric spine fractures but not nonspine fractures (OR=1.44; 95% CI: 0.85 to 2.44). Adjusting for bone mineral density did not change our findings. Our data demonstrate that hyponatremia is associated with up to a doubling in the risk of hip and morphometric spine fractures, independent of BMD. Further studies, to determine how hyponatremia causes fractures and if correction of hyponatremia decreases fractures, are needed. PMID:25294595
Bliuc, Dana; Nguyen, Nguyen D; Milch, Vivienne E; Nguyen, Tuan V; Eisman, John A; Center, Jacqueline R
There are few data on long-term mortality following osteoporotic fracture and fewer following subsequent fracture. To examine long-term mortality risk in women and men following all osteoporotic fractures and to assess the association of subsequent fracture with that risk. Prospective cohort from the Dubbo Osteoporosis Epidemiology Study of community-dwelling women and men aged 60 years and older from Dubbo, Australia, who sustained a fracture between April 1989 and May 2007. Age- and sex-specific standardized mortality ratios (SMRs) compared with the overall Dubbo population for hip, vertebral, major, and minor fractures. In women, there were 952 low-trauma fractures followed by 461 deaths, and in men, 343 fractures were followed by 197 deaths. Age-adjusted SMRs were increased following hip fractures (SMRs, 2.43 [95% confidence interval [CI], 2.02-2.93] and 3.51 [95% CI, 2.65-4.66]), vertebral fractures (SMRs, 1.82 [95% CI, 1.52-2.17] and 2.12 [95% CI, 1.66-2.72]), major fractures (SMRs, 1.65 [95% CI, 1.31-2.08] and 1.70 [95% CI, 1.23-2.36]), and minor fractures (SMRs, 1.42 [95% CI, 1.19-1.70] and 1.33 [95% CI, 0.99-1.80]) for both women and men, respectively. Mortality was increased for all ages for all fractures except minor fractures for which increased mortality was only apparent for those older than 75 years. Increased mortality risk persisted for 5 years for all fractures and up to 10 years for hip fractures. Increases in absolute mortality that were above expected, for 5 years after fracture, ranged from 1.3 to 13.2 per 100 person-years in women and from 2.7 to 22.3 per 100 person-years in men, depending on fracture type. Subsequent fracture was associated with an increased mortality hazard ratio of 1.91 (95% CI, 1.54-2.37) in women and 2.99 (95% CI, 2.11-4.24) in men. Mortality risk following a subsequent fracture then declined but beyond 5 years still remained higher than in the general population (SMR, 1.41 [95% CI, 1.01-1.97] and SMR, 1.78 [95% CI, 0
Buchbinder, Rachelle; Golmohammadi, Kamran; Johnston, Renea V; Owen, Richard J; Homik, Joanne; Jones, Allyson; Dhillon, Sukhvinder S; Kallmes, David F; Lambert, Robert G W
Percutaneous vertebroplasty is widely used to treat acute and subacute painful osteoporotic vertebral fractures although recent placebo-controlled trials have questioned its value. To synthesise the available evidence regarding the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures. We searched CENTRAL, MEDLINE and EMBASE up to November 2014. We also reviewed reference lists of review articles, trials and trial registries to identify any other potentially relevant trials. We included randomised and quasi-randomised controlled trials (RCTs) including adults with painful osteoporotic vertebral fractures of any duration and comparing vertebroplasty with placebo (sham), usual care, or any other intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events. At least two review authors independently selected trials for inclusion, extracted data, performed 'Risk of bias' assessment and assessed the quality of the body of evidence for the main outcomes using GRADE. Eleven RCTs and one quasi-RCT conducted in various countries were included. Two trials compared vertebroplasty with placebo (209 randomised participants), six compared vertebroplasty with usual care (566 randomised participants) and four compared vertebroplasty with kyphoplasty (545 randomised participants). Trial size varied from 34 to 404 participants, most participants were female, mean age ranged between 63.3 and 80 years, and mean symptom duration varied from a week to more than six months.Both placebo-controlled trials were judged to be at low overall risk of bias while other included trials were generally considered to be at high risk of bias across a range of criteria, most seriously due to lack of
Sosa, Daysi Duarte; Eriksen, Erik Fink
The aim of the study was to test, whether bone material strength differs between different subtypes of osteoporotic fracture and assess whether it relates to vertebral fracture severity. Cortical bone material strength index (BMSi) was measured by impact microindentation in 66 women with osteoporotic fracture and 66 age- and sex-matched controls without fracture. Bone mineral density (BMD) and bone turnover markers were also assessed. Vertebral fracture severity was graded by semiquantitative (SQ) grading. Receiver operator characteristic (ROC) curves were used to examine the ability of BMSi to discriminate fractures. Subjects with osteoporotic fractures exhibited lower BMSi than controls (71.5 ± 7.3 vs. 76.4 ± 6.2, p < 0.001). After adjusting for age and hip BMD, a significant negative correlation was seen between BMSi and vertebral fracture severity (r (2) = 0.19, p = 0.007). A decrease of one standard deviation (SD) in BMSi was associated with increased risk of fracture (OR 2.62; 95% CI 1.35, 5.10, p = 0.004). ROC curve areas under the curve (AUC) for BMSi in subjects with vertebral fracture (VF), hip fracture (HF), and non-vertebral non-hip fracture (NVNHFx), (mean; 95% CI) were 0.711 (0.608; 0.813), 0.712 (0.576; 0.843), 0.689 (0.576; 0.775), respectively. Combining BMSi and BMD provided further improvement in the discrimination of fractures with AUC values of 0.777 (0.695; 0.858), 0.789 (0.697; 0.882), and 0.821 (0.727; 0.914) for VFx, HFx, and NVNHFx, respectively. Low BMSi of the tibial cortex is associated with increased risk of all osteoporotic fractures and severity of vertebral fractures.
Matussek, J; Boluki, D; Füssel, S; Grifka, J
Even in times of kyphoplasty and vertebroplasty, braces remain an efficient option in the treatment of osteoporotic hyperkyphosis due to imminent or manifest vertebral wedging with the obligatory pain and fracture risk of adjacent vertebraes. In the same fashion, acute osteoporotic fractures with considerable backpain can be treated with an adequate orthosis besides analgetics and osteological drugs. Essential is the careful selection of the right brace for a given type of osteoporotic fracture: Overall brace-frames (Stagnara type) should be used only in highly unstable or multiple osteoporotic fractures with impact onto the spinal canal where surgery is not possible. These brace frames should be administered only for the shortest possible period (8-12 weeks) to reduce muscle atrophy and immobilization. However, in the typical stable osteoporotic wedge fracture, light weight constructions like the Jewett or Bähler-Vogt brace or - in less severe cases - dynamic braces (e.g. TorsoStretch brace or SpinoMedActive brace) should be used to minimize muscle atrophy and demineralisation. Brace treatment at its best though, can be only one step in the cascade of measures to fight demineralisation and the clinical consequences: General physiotherapy, analgetics and specific osteological drugs and minerals add essentially to the treatment.
... er Total Hip Replacement cont. • Dislocation • Limb length inequality • Poor fracture healing • Repeat fracture • Lack of in- ... Surgeons (AAOS). To learn more about your orthopaedic health, please visit orthoinfo.org. Page ( 5 ) AAOS does ...
McCloskey, Eugene V; Johansson, Helena; Oden, Anders; Austin, Matt; Siris, Ethel; Wang, Andrea; Lewiecki, E Michael; Lorenc, Roman; Libanati, Cesar; Kanis, John A
Denosumab has been shown to reduce the incidence of vertebral, nonvertebral, and hip fractures. The aim of the current study was to determine whether the antifracture efficacy of denosumab was dependent on baseline fracture probability assessed by FRAX. The primary data of the phase 3 FREEDOM study of the effects of denosumab in women with postmenopausal osteoporosis were used to compute country-specific probabilities using the FRAX tool (version 3.2). The outcome variable comprised all clinical osteoporotic fractures (including clinical vertebral fractures). Interactions between fracture probability and efficacy were explored by Poisson regression. At baseline, the median 10-year probability of a major osteoporotic fracture (with bone mineral density) was approximately 15% and for hip fracture was approximately 5% in both groups. In the simplest model adjusted for age and fracture probability, treatment with denosumab over 3 years was associated with a 32% (95% confidence interval [CI] 20% to 42%) decrease in clinical osteoporotic fractures. Denosumab reduced fracture risk to a greater extent in those at moderate to high risk. For example, at 10% probability, denosumab decreased fracture risk by 11% (p = 0.629), whereas at 30% probability (90th percentile of study population) the reduction was 50% (p = 0.001). The reduction in fracture was independent of prior fracture, parental history of hip fracture, or secondary causes of osteoporosis. A low body mass index (BMI) was associated with greater efficacy. Denosumab significantly decreased the risk of clinical osteoporotic fractures in postmenopausal women. Overall, the efficacy of denosumab was greater in those at moderate to high risk of fracture as assessed by FRAX. Copyright © 2012 American Society for Bone and Mineral Research.
Naves Díaz, M; Díaz López, J B; Gómez Alonso, C; Altadill Arregui, A; Rodríguez Rebollar, A; Cannata Andía, J B
The present work, performed as follow-up of the prevalence study of vertebral fractures (EVOS Study), evaluates in a 6 year period the incidence of vertebral fractures and other osteoporotic fractures in Oviedo (Asturias, Spain) in people older than 50 years. The study was performed in a cohort from the Oviedo's local registry in 1986. 624 men and women were followed by 3 postal questionnaires. The first questionnaire referred to the history of falls and fractures that happened during the follow-up period performed. Between the 2nd and 3rd follow-up subjects were invited to repeat the X-rays previously performed in the initial study. The incidence of osteoporotic fractures was higher in women than in men. In both sexes, vertebral fracture was the one which reached the highest incidence. Compared with men, Colles' fracture in women occurred earlier, with 5 times higher incidence. The incidence of hip fracture was twice higher in women than in men. A prevalent vertebral fractures increased until 5 times the incidence of vertebral and hip fracture. Among the osteoporotic fractures, vertebral fracture had a highest incidence values in both sexes. Although vertebral and hip fractures were twice incident in women compared with men, the incidence of Colles fracture was five times higher in women. A pre-existing vertebral fracture is an important risk factor to develop a new vertebral or hip fracture.
Beattie, Karen; Adachi, Jonathan; Ioannidis, George; Papaioannou, Alexandra; Leslie, William D; Grewal, Ruby; MacDermid, Joy; Hodsman, Anthony B
The WHO fracture risk assessment (FRAX) and Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tools can both be used to determine an individual's 10-year risk of osteoporotic fracture. However, these tools differ in their risk calculation. For participants <65 years with a wrist fracture, FRAX provides a lower fracture risk estimate than CAROC resulting in fewer decisions to initiate therapy. The purpose of the current report is to compare fracture risk prediction rates using the CAROC and the FRAX® tools. Individuals ≥50 years with a distal radius fracture resulting from a fall from standing height or less were recruited from a single orthopedic clinic. Participants underwent a DXA scan of their lumbar spine and hip. Femoral neck (FN) bone mineral density (BMD) and fracture risk factors were used to determine each participant's 10-year fracture risk using both fracture risk assessment tools. Participants were categorized as low (<10 %), moderate (10-20 %), or high (>20 %) risk. Stratified by age (<65 years, >65 years), the proportion of participants in each category was compared between the tools. Analyses included 60 participants (mean age 65.7 ± 9.6 years). In those <65 years (n = 26), the proportion of individuals at low, moderate, and high risk differed between the FRAX and CAROC tools (p < 0.0001). FRAX categorized 69 % as low (CAROC 0 %) and 3 % as high (CAROC 12 %) risk. For individuals >65 years, almost all were at least at moderate risk (FRAX 79 %, CAROC 53 %), but fewer were at high risk using FRAX (18 vs. 47 %, p < 0.0003). For participants <65 years with a wrist fracture, FRAX provides a lower estimate of 10-year fracture risk than CAROC resulting in fewer decisions to initiate therapy. However, almost all participants >65 years were at moderate or high risk under both FRAX and CAROC and should at least be considered for pharmacotherapy.
Esenyel, Meltem; Ozen, Aynur; Esenyel, Cem Zeki; Rezvani, Aylin; Sariyildiz, Mustafa Akif; Ergin, Onder
Objective: Although bone mineral density (BMD) is an important predictor of hip fracture, there is a large overlap of BMD values between those who fracture their hips and those who do not. The aim of this study was to evaluate differences in the structural parameters of the hip in patients with osteopenia and osteoporosis in the hip region and to assess their relationship with osteoporotic fracture risk, age and gender. Materials and Methods: In this observational retrospective study, 150 patients with osteopenia (100 postmenopausal women and 50 men ≥50 years of age) and 125 patients with osteoporosis in the hip (100 postmenopaussal women and 25 men ≥50 years of age) were included. In addition to densitometry measurements by DEXA (Dual Energy X-ray Absorbimetry), structural variables were determined using the Hip Strength Analysis program (HSA). Results: In logistic regression analyses, the femoral neck BMD (odds ratio (OR), 2.6; 95% Confidence Interval (CI) 1.8–3.8), age (OR per 10 years 1.4; 95% CI, 1.1–1.9), femoral neck shaft angle (NSA) (OR 1.5; 95% CI, 1.2–2.1), Femur Strength Index (FSI) (OR 1.6; 95% CI 1.3–2.2), and Cross sectional area (CSA) (OR 1.6; 95% CI 1.2–2.1) were all associated with osteoporotic fractures in women and men. Osteopenic patients had smaller femoral neck-shaft angles (NSA) compared to osteoporotic patients (p<0.05). This angle was larger in women (p<0.05); and women had decreased (FSI) (p<0.001) and CSA (p<0.05), which cause increased fracture risk. Conclusion: Spatial distribution of bone tissue is a useful determinant of fracture risk. PMID:25610167
Kim, Ha Young; Ha, Yong-Chan; Kim, Tae-Young; Cho, Hyemin; Lee, Young-Kyun; Baek, Ji-Yeon; Jang, Sunmee
The present study estimated healthcare costs of osteoporotic fractures including spine, hip, distal radius and humerus in Koreans over 50 years of age using national claims data. Korea National Health Insurance data between 2008 and 2011 was searched for all claims records of outpatient visits or hospital admissions of patients ≥50-year-of-age. Osteoporosis-related fractures were identified using certain the International Classification of Diseases, Tenth Revision codes and site-specific physician claims for procedures in a patient age cut-off value of 50 years. The healthcare costs included acute phase costs accounting for emergency medical care given immediately after fracture, costs due to further hospitalization and surgical procedures, physiotherapy sessions according to the site of the fracture, and outpatient visits in the year after discharge. The total estimated healthcare costs of osteoporotic fractures in 2011 was $722 million. From 2008 to 2011, the total number and healthcare costs of osteoporotic fractures increased 28.9% (from 127,070 to 163,823) and 31.6% (from $549 million to $722 million), respectively. The portion of national health care expenditure was ranged from 2.3% in 2008 to 2.2% in 2011. The mean healthcare cost of osteoporotic fractures per person increased 2.1% from $4,321 in 2008 to $4,410 in 2011.The mean healthcare costs were highest for hip fractures followed by spine, humerus, and distal radius fractures. Total Healthcare costs of osteoporotic fractures in South Koreans ≥50-year-of-age increased between 2008 and 2011. This trend will likely continue, which is an important health problem in the elderly population and economically.
Bone provides momentary strength and fatigue strength, and bone strength decreases with age. In elderly men and women with fragile bones osteoporotic fractures frequently occur. Fragility fracture occurs as a consequence of the decrease in momentary strength, and fragility fracture is one of the pathological fractures. In patients with the decrease in fatigue strength, insufficiency fractures frequently occurs. Insufficiency fracture is the same term as stress or fatigue fracture.
Ensrud, Kristine E; Blackwell, Terri L; Cawthon, Peggy M; Bauer, Douglas C; Fink, Howard A; Schousboe, John T; Black, Dennis M; Orwoll, Eric S; Kado, Deborah M; Cauley, Jane A; Mackey, Dawn C
To examine the degree of trauma in major osteoporotic fractures (MOF) in men versus women, we used data from 15,698 adults aged ≥65 years enrolled in the Osteoporotic Fractures in Men (MrOS) study (5994 men) and the Study of Osteoporotic Fractures (SOF) (9704 women). Participants were contacted tri-annually to ascertain incident fractures, which were confirmed by radiographic reports and coded according to degree of self-reported trauma. Trauma was classified as low (fall from ≤ standing height; fall on stairs, steps, or curb; minimal trauma other than fall [coughing, turning over]); moderate (collisions with objects during normal activity without associated fall); or high (fall from > standing height; severe trauma [motor vehicle accident, assault]). MOF included hip, clinical vertebral, wrist, and humerus fractures. Mean fracture follow-up was 9.1 years in SOF and 8.7 years in MrOS. A total of 14.6% of the MOF in men versus 6.3% of the MOF in women were classified as high trauma (p < 0.001); men versus women more often experienced fractures resulting from severe trauma as well as from fall > standing height. High-trauma fractures were more significantly common in men versus women at the hip (p = 0.002) and wrist (p < 0.001) but not at the spine or humerus. Among participants with MOF, the odds ratio of a fracture related to high-trauma fracture among men versus women was 3.12 (95% confidence interval [CI] 1.70-5.71) after adjustment for traditional risk factors. Findings were similar in analyses limited to participants with hip fractures (odds ratio [OR] = 3.34, 95% CI 1.04-10.67) and those with wrist fracture (OR = 5.68, 95% CI 2.03-15.85). Among community-dwelling older adults, MOF are more likely to be related to high trauma in men than in women. These findings are not explained by sex differences in conventional risk factors and may reflect a greater propensity among men to engage in risky behavior. © 2015 American Society for Bone and Mineral Research
Langsetmo, Lisa; Shikany, James M; Cawthon, Peggy M; Cauley, Jane A; Taylor, Brent C; Vo, Tien N; Bauer, Douglas C; Orwoll, Eric S; Schousboe, John T; Ensrud, Kristine E
Dietary protein is a potentially modifiable risk factor for fracture. Our objectives were to assess the association of protein intake with incident fracture among older men and whether these associations varied by protein source or by skeletal site. We studied a longitudinal cohort of 5875 men (mean age 73.6 ± 5.9 years) in the Osteoporotic Fractures in Men (MrOS) study. At baseline, protein intake was assessed as percent of total energy intake (TEI) with mean intake from all sources = 16.1%TEI. Incident clinical fractures were confirmed by physician review of medical records. There were 612 major osteoporotic fractures, 806 low-trauma fractures, 270 hip fractures, 193 spine fractures, and 919 non-hip non-spine fractures during 15 years of follow-up. We used Cox proportional hazards models with age, race, height, clinical site, TEI, physical activity, marital status, osteoporosis, gastrointestinal surgery, smoking, oral corticosteroids use, alcohol consumption, and calcium and vitamin D supplements as covariates to compute hazard ratios (HRs) with 95% confidence intervals (CIs), all expressed per unit (SD = 2.9%TEI) increase. Higher protein intake was associated with a decreased risk of major osteoporotic fracture (HR = 0.92; 95% CI, 0.84 to 1.00) with a similar association found for low-trauma fracture. The association between protein and fracture varied by protein source; eg, increased dairy protein and non-dairy animal protein were associated with a decreased risk of hip fracture (HR = 0.80 [95% CI, 0.65 to 0.98] and HR = 0.84 [95% CI, 0.72 to 0.97], respectively), whereas plant-source protein was not (HR = 0.99 [95% CI, 0.78 to 1.24]). The association between protein and fracture varied by fracture site; total protein was associated with a decreased risk of hip fracture (HR = 0.84 [95% CI, 0.73 to 0.95]), but not clinical spine fracture (HR = 1.06 [95% CI, 0.92 to 1.22]). In conclusion, those with high protein intake
Bouee, S; Lafuma, A; Fagnani, F; Meunier, P J; Reginster, J Y
The objective of this study was to estimate the unit costs of non-vertebral osteoporotic fractures in five European countries based on the results of the SOTI and TROPOS clinical trials in postmenopausal osteoporotic women. The information recorded in the Case Report Forms was used. The perspective of third party payers was adopted. Hip fracture unit cost was the highest. The ranges of costs among countries was narrow for hip from 8,346 euros (Italy) to 9,907euros (France), but wider for other fractures: 890 euros (Spain) to 2,022 euros (Italy) for wrist, 1,167euros (Spain) to 3,268 euros (Italy) for pelvis, 837euros (Spain) to 2,116 euros (Italy) for sternum/clavicle, 565 euros (Spain) to 908 euros (France) for rib, 1,518 euros (Spain) to 3,651 euros (Belgium) for humerus, 1,805 euros (Spain) to 3,521 euros (Italy) for leg. The costs of those fractures should be considered when estimating the cost of osteoporosis.
Hip fractures are common and serious consequence of osteoporosis. Bone mineral density (BMD) measurement and the World Health Organization (WHO) fracture risk assessment tool are considered to predict the hip osteoporotic fractures. In this study, their sensitivities in hip fracture cases are evaluated. BMD and WHO probability of fracture risk were determined in 71 hip fractures ≥ 50 years of old. Totally, 65% of patients had ≤-2.5 BMD T score. 81% of patients had above the upper interventional threshold of WHO fracture risk probability model. Sensitivities were low in 50-59 year age group with progression in older age groups. Results of BMD T score and fracture risk probabilities were not significant between men and women. There were 23% and 49% sensitivities of less than or equal to -2.5 T score in the 50-59 and 60-69 year age groups with a 31% sensitivity of greater than 3% probability of hip fracture risk in the 50-59 year age group, both of which were not valid for predicting hip fracture risk.
Korea's demographic profile is undergoing tremendous change as the country rapidly ages at one of the fastest rates in the world. Indeed, the country is expected to become an "aged society" in 2018 when the proportion of elderly is estimated to reach 14.3% of the total population. With the notable increase in the number of elderly individuals, the incidence of osteoporotic fractures will also likely increase. Osteoporosis is a systemic musculoskeletal disease that is characterized by the decreased bone quantity and the abnormalities of the microstructures. There are both conservative and surgical treatment modalities for the fracture: conservative treatments include pharmacological treatments and orthosis; surgical treatments include vertebroplasty, kyphoplasty, and reconstructive surgery. Clinicians should consider the severity of osteoporosis, the concurrent osteoporotic fracture, the age and sex of the patient, and the underlying diseases in making a patient-tailored prescription. PMID:24967055
Monzón, Daniel Godoy; Iserson, Kenneth V.; Jauregui, José; Musso, Carlos; Piccaluga, Francisco; Buttaro, Martin
Introduction: This study aimed to determine the dislocation and reoperation rate, functional outcomes, and the survival rate of the unique subset of very old but lucid and independent patients with hip fractures following a total hip arthroplasty (THA) and geriatric team-coordinated perioperative care. Method: Between 2000 and 2006, previously independent ambulatory patients ≥80 years old presenting with an intracapsular hip fracture were given THAs under the care of an integrated orthopedic surgery–geriatric service. Their fracture-related complications, ambulation, mental status, and survival were followed for 5 to 11 years postinjury. Results: Five years postinjury, 57 (61.3%) patients of the original study group were living. In all, 3 (3.2%) patients had postoperative hip dislocations (and 2 patients had dislocation twice) and 2 reoperations were needed within the first postoperative month. There were no hip dislocations or reoperations after the first year. Radiographs obtained on 88% of the surviving patients at 5 years postoperatively showed that all remained unchanged from their immediate postoperative images. Nearly half of the patients were still able to ambulate as they did preoperatively and their mixed-model equation was statistically unchanged. Conclusion: This study of patients >80 years old with previously good functional status demonstrates that with appropriate surgical (best prosthesis, good operating technique, and regional anesthesia) and geriatric (pre- and postoperative assessments, close follow-up, medication adjustments, and fall-prevention instruction) care, they have few hip dislocations and reoperations, survive postfracture at least as long as their noninjured contemporaries, and continue to function and ambulate as they did prior to their injury. PMID:24660092
Ziadé, Nelly; Jougla, Eric; Coste, Joël
Background We developed a methodology using vital statistics to estimate the impact of osteoporotic fractures on the mortality of an entire population, and applied it to France for the period 2000-2004. Methods Current definitions of osteoporotic fractures were reviewed and their components identified. We used the International Classification of Diseases with national vital statistics data for the French adult population and performed cross-classifications between various components: age, sex, I-code (site) and E-code (mechanism of fracture). This methodology allowed identification of appropriate thresholds and categorization for each pertinent component. Results 2,625,743 death certificates were analyzed, 2.2% of which carried a mention of fracture. Hip fractures represented 55% of all deaths from fracture. Both sexes showed a similar pattern of mortality rates for all fracture sites, the rate increased with age from the age of 70 years. The E-high-energy code (present in 12% of death certificates with fractures) was found to be useful to rule-out non-osteoporotic fractures, and to correct the overestimation of mortality rates. Using this methodology, the crude number of deaths associated with fractures was estimated to be 57,753 and the number associated with osteoporotic fractures 46,849 (1.85% and 1.78% of all deaths, respectively). Conclusion Osteoporotic fractures have a significant impact on overall population mortality. PMID:19761614
Gao, Li-hong; Li, Shan-shan; Shao, Chong; Fu, Wen-zhen; Liu, Yu-juan; He, Jin-wei; Zhang, Zhen-lin
Aim: A previous study shows that bone morphogenetic protein 7 (BMP7) gene polymorphisms are associated with bone mineral density (BMD) in 920 European Americans. To determine the association of BMP7 polymorphisms and BMD and osteoporotic fracture susceptibility, we performed a case-control association study in postmenopausal Chinese women with or without osteoporotic fracture. Methods: A total of 3815 unrelated postmenopausal Chinese women (1238 with osteoporotic fracture and 2577 healthy controls) were recruited. BMDs of the lumbar spine 1–4 (L1–4) and proximal femur (including total hip and femoral neck) were measured using dual-energy X-ray absorptiometry. Eight tagging single nucleotide polymorphisms (SNPs) in BMP7 gene, including rs11086598, rs4811822, rs12481628, rs6025447, rs230205, rs17404303, rs162316 and rs6127980, were genotyped. Results: Among the 8 SNPs, rs6025447 and rs230205 were associated with total hip BMD (P=0.013 and 0.045, respectively). However, the associations became statistically insignificant after adjusting for age, height and weight. The TGTG haplotype of BMP7 gene was associated with total hip BMD (P=0.032), even after adjusting for age, height and weight (P=0.048); but the association was insignificant after performing the Bonferroni multiple-significance-test correction. Moreover, the 8 SNPs and 9 haplotypes of BMP7 gene were not associated with L1–4 or femoral neck BMD or osteoporotic fracture. Conclusion: This large-sample case-control association study suggests that the common genetic polymorphisms of BMP7 gene are not major contributors to variations in BMD or osteoporotic fracture in postmenopausal Chinese women. PMID:27264311
Amin, Shreyasee; Kopperdhal, David L; Melton, L Joseph; Achenbach, Sara J; Therneau, Terry M; Riggs, B Lawrence; Keaveny, Tony M; Khosla, Sundeep
Finite-element analysis (FEA) of quantitative computed tomography (QCT) scans can estimate site-specific whole-bone strength. However, it is uncertain whether the site-specific detail included in FEA-estimated proximal femur (hip) strength can determine fracture risk at sites with different biomechanical characteristics. To address this question, we used FEA of proximal femur QCT scans to estimate hip strength and load-to-strength ratio during a simulated sideways fall and measured total hip areal and volumetric bone mineral density (aBMD and vBMD) from QCT images in an age-stratified random sample of community-dwelling adults age 35 years or older. Among 314 women (mean age ± SD: 61 ± 15 years; 235 postmenopausal) and 266 men (62 ± 16 years), 139 women and 104 men had any prevalent fracture, whereas 55 Women and 28 men had a prevalent osteoporotic fracture that had occurred at age 35 years or older. Odds ratios by age-adjusted logistic regression analysis for prevalent overall and osteoporotic fractures each were similar for FEA hip strength and load-to-strength ratio, as well as for total hip aBMD and vBMD. C-statistics (estimated areas under ROC curves) also were similar [eg, 0.84 to 0.85 (women) and 0.75 to 0.78 (men) for osteoporotic fractures]. In women and men, the association with prevalent osteoporotic fractures increased below an estimated hip strength of approximately 3000 N. Despite its site-specific nature, FEA-estimated hip strength worked equally well at predicting prevalent overall and osteoporotic fractures. Furthermore, an estimated hip strength below 3000 N may represent a critical level of systemic skeletal fragility in both sexes that warrants further investigation.
Esses, Stephen I; McGuire, Robert; Jenkins, John; Finkelstein, Joel; Woodard, Eric; Watters, William C; Goldberg, Michael J; Keith, Michael; Turkelson, Charles M; Wies, Janet L; Sluka, Patrick; Boyer, Kevin M; Hitchcock, Kristin
This clinical practice guideline is based on a series of systematic reviews of published studies on the treatment of symptomatic osteoporotic spinal compression fractures. Of 11 recommendations, one is strong; one, moderate; three, weak; and six, inconclusive. The strong recommendation is against the use of vertebroplasty to treat the fractures; the moderate recommendation is for the use of calcitonin for 4 weeks following the onset of fracture. The weak recommendations address the use of ibandronate and strontium ranelate to prevent additional symptomatic fractures, the use of L2 nerve root blocks to treat the pain associated with L3 or L4 fractures, and the use of kyphoplasty to treat symptomatic fractures in patients who are neurologically intact.
Fracture around the acetabulum and femur in total hip arthroplasty is a possible complication, sometimes with difficult surgical solution, namely when a sepsis is present. Periprosthetic hip fractures were classified according to a modified Vancouver classification. We treated 112 patients (67 men and 45 women) with periprosthetic hip fractures: 105 femoral fractures (94%) and seven acetabular fractures (6%). Mean follow-up was 10.6 years. For Type A (seven cases - 7%), B1 (10 cases - 10%) or C (13 cases - 12%) fractures around well fixed femoral stems we only fixed the fractures. For Type B2 (17 cases - 16%), B3 (46 cases - 44%) and D (12 cases - 11%, with associated fractures, not contemplated in the Vancouver classification) we used an uncemented long femoral stem, fixation with metallic cables and cancellous bone allografts to fill the femoral bone loss. We observed a deep infection in three patients (2.7%), three early hip dislocations treated by closed reductions, two cases with asymptomatic trochanteric non-union and one femoral refracture. In the three infection cases we performed two-stage revision with cementless hip prosthesis, using an antibiotic-loaded cement hip spacer (three to eight months), a six weeks period of parenteral antibiotics and we performed articular aspiration before revision surgery. Until now, we did not observe any re-infection. It is very important to make an early diagnosis, isolate micro-organisms and ensure their antibiotic susceptibility. The surgery solution depends on the well fixed implants and periprosthetic osteolysis and articular instability.
Nielson, Carrie M; Marshall, Lynn M; Adams, Annette L; LeBlanc, Erin S; Cawthon, Peggy M; Ensrud, Kristine; Stefanick, Marcia L; Barrett-Connor, Elizabeth; Orwoll, Eric S
Low body mass index (BMI) is a risk factor for fracture, but little is known about the association between high BMI and fracture risk. We evaluated the association between BMI and fracture in the Osteoporotic Fractures in Men Study (MrOS), a cohort of 5995 US men 65 years of age and older. Standardized measures included weight, height, and hip bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA); medical history; lifestyle; and physical performance. Only 6 men (0.1%) were underweight (<18.5 kg/m2); therefore, men in this category were excluded. Also, 27% of men had normal BMI (18.5 to 24.9 kg/m2), 52% were overweight (25 to 29.9 kg/m2), 18% were obese I (30 to 34.9 kg/m2), and 3% were obese II (35 to 39.9 kg/m2). Overall, nonspine fracture incidence was 16.1 per 1000 person-years, and hip fracture incidence was 3.1 per 1000 person-years. In age-, race-, and BMD-adjusted models, compared with normal weight, the hazard ratio (HR) for nonspine fracture was 1.04 [95% confidence interval (CI) 0.87–1.25] for overweight, 1.29 (95% CI 1.00–1.67) for obese I, and 1.94 (95% CI 1.25–3.02) for obese II. Associations were weaker and not statistically significant after adjustment for mobility limitations and walking pace (HR = 1.02, 95% CI 0.84–1.23, for overweight; HR = 1.12, 95% CI 0.86–1.46, for obese I, and HR = 1.44, 95% CI 0.90–2.28, for obese II). Obesity is common among older men, and when BMD is held constant, it is associated with an increased risk of fracture. This association is at least partially explained by worse physical function in obese men. © 2011 American Society for Bone and Mineral Research. PMID:20814955
Nielson, Carrie M; Marshall, Lynn M; Adams, Annette L; LeBlanc, Erin S; Cawthon, Peggy M; Ensrud, Kristine; Stefanick, Marcia L; Barrett-Connor, Elizabeth; Orwoll, Eric S
Low body mass index (BMI) is a risk factor for fracture, but little is known about the association between high BMI and fracture risk. We evaluated the association between BMI and fracture in the Osteoporotic Fractures in Men Study (MrOS), a cohort of 5995 US men 65 years of age and older. Standardized measures included weight, height, and hip bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA); medical history; lifestyle; and physical performance. Only 6 men (0.1%) were underweight (<18.5 kg/m(2)); therefore, men in this category were excluded. Also, 27% of men had normal BMI (18.5 to 24.9 kg/m(2)), 52% were overweight (25 to 29.9 kg/m(2)), 18% were obese I (30 to 34.9 kg/m(2)), and 3% were obese II (35 to 39.9 kg/m(2)). Overall, nonspine fracture incidence was 16.1 per 1000 person-years, and hip fracture incidence was 3.1 per 1000 person-years. In age-, race-, and BMD-adjusted models, compared with normal weight, the hazard ratio (HR) for nonspine fracture was 1.04 [95% confidence interval (CI) 0.87-1.25] for overweight, 1.29 (95% CI 1.00-1.67) for obese I, and 1.94 (95% CI 1.25-3.02) for obese II. Associations were weaker and not statistically significant after adjustment for mobility limitations and walking pace (HR = 1.02, 95% CI 0.84-1.23, for overweight; HR = 1.12, 95% CI 0.86-1.46, for obese I, and HR = 1.44, 95% CI 0.90-2.28, for obese II). Obesity is common among older men, and when BMD is held constant, it is associated with an increased risk of fracture. This association is at least partially explained by worse physical function in obese men.
Ferric carboxymaltose with or without erythropoietin for the prevention of red-cell transfusions in the perioperative period of osteoporotic hip fractures: a randomized contolled trial. The PAHFRAC-01 project
Background Around one third to one half of patients with hip fractures require red-cell pack transfusion. The increasing incidence of hip fracture has also raised the need for this scarce resource. Additionally, red-cell pack transfusions are not without complications which may involve excessive morbidity and mortality. This makes it necessary to develop blood-saving strategies. Our objective was to assess safety, efficacy, and cost-effictveness of combined treatment of i.v. ferric carboxymaltose and erythropoietin (EPOFE arm) versus i.v. ferric carboxymaltose (FE arm) versus a placebo (PLACEBO arm) in reducing the percentage of patients who receive blood transfusions, as well as mortality in the perioperative period of hip fracture intervention. Methods/Design Multicentric, phase III, randomized, controlled, double blinded, parallel groups clinical trial. Patients > 65 years admitted to hospital with a hip fracture will be eligible to participate. Patients will be treated with either a single dosage of i.v. ferric carboxymaltose of 1 g and subcutaneous erythropoietin (40.000 IU), or i.v. ferric carboxymaltose and subcutaneous placebo, or i.v. placebo and subcutaneous placebo. Follow-up will be performed until 60 days after discharge, assessing transfusion needs, morbidity, mortality, safety, costs, and health-related quality of life. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruited patients per arm is set at 102, a total of 306 patients. Discussion We think that this trial will contribute to the knowledge about the safety and efficacy of ferric carboxymaltose with/without erythropoietin in preventing red-cell pack transfusions in patients with hip fracture. ClinicalTrials.gov identifier: NCT01154491. PMID:22353604
Ziadé, Nelly; Jougla, Eric; Coste, Joël
Osteoporotic fractures are one of the leading causes of death in the elderly population, but mortality may have been reduced by the advances in management and prevention during recent decades. The authors analyzed the population-level impact of these fractures on mortality in France from 1968 to 2004. About 20 million death certificates registered in metropolitan France from 1968 to 2004 were analyzed. Osteoporotic fractures were identified by using a previously developed methodology. Age-specific and standardized mortality rates were calculated by site of fracture and sex, and time trends were evaluated. Associated causes of death were compared between the extreme periods of the study by the observed/expected pairs method; 440,890 (2.2%) death certificates reported an osteoporotic fracture. Osteoporotic fractures overall, particularly hip and skull fractures, declined by half during the study period, exceeding the decline in general mortality and resulting in fracture-deceased subjects being older. However, pelvis, vertebral, and rib fractures became more frequent. Associated causes of death increased with time, except for decubitus ulcers, indicating a change in the pattern of the death process. Despite a 50% decline, osteoporotic fractures still have a significant impact on mortality. The pattern of the death process has changed, with an increased role for comorbidities.
Roerholt, C; Eiken, P; Abrahamsen, B
Initiation and compliance with anti-osteoporotic therapy was assessed in 152,777 fracture patients in a national population-based cohort study. Prescription rates were low, especially following hip fracture. Persistence has improved with almost 2/3 of patients who began raloxifene or weekly alendronate obtaining treatment durations equalling those of the licensing trials. Reducing the societal fracture burden remains challenging due to failure to treat fragility fractures and non-compliance with treatment. We used national registers to identify patients born 1945 or earlier who sustained a fracture 1997-2004 (N = 152,777). Initiation of anti-osteoporotic therapy was defined as redemption of at least one prescription in the year following fracture. Persistence was defined as duration of time maintaining a medication possession ratio >75%. Treatment initiation within 1 year was highest after spine fracture: 39.6% of women began therapy in 2004 compared with 19.5% in 1997. In men, 16.5% began therapy in 2004 vs. 8.0% in 1997. Following hip fracture, 9.2% of women and 4.1% of men began therapy in 2004 vs. 3.4% and 0.7% in 1997, respectively. Median persistence (years) was 2.8 for daily alendronate, 3.8 for weekly alendronate, 2.5 for etidronate and 4.7 for raloxifene. The risk of discontinuing or changing therapy increased with age. Prescription rates for anti-osteoporotic medication are very low, especially in hip fracture and in men. Rates were <1/3 of those reported in the US. Persistence has improved with almost 2/3 of patients who began raloxifene or weekly alendronate now obtaining treatment durations equalling those of the licensing trials.
Gan, Minfeng; Zou, Jun; Zhu, Xuesong; Wang, Genlin; Yang, Huilin
Balloon kyphoplasty (BKP) is an effective method for osteoporotic vertebral compression fractures. However osteoporotic spinal fractures with middle column compromise are mentioned as a relative contraindication to BKP. Thus we investigated the safety and efficacy of BKP in the treatment of osteoporotic spinal fractures with middle column compromise but without neurological deficit. In this retrospective study, 45 patients who suffered osteoporotic fractures with middle column compromise but without neurological deficits were treated by BKP from May 2007 to December 2010. The final follow-ups were finished during the time of July 2011-September 2011. The mean follow-up period was 20.2 months. The height of the compromised vertebral body, the kyphotic angle and spinal canal compromise were measured before surgery, one day after surgery, and at the final follow-up. A visual analogue scale (VAS) and the Oswestry disability index (ODI) were chosen to evaluate pain and functional activity. The mean VAS and ODI scores improved significantly from pre- to post-operation (p<0.05), and this improvement was sustained at the final follow-up. The mean anterior vertebral body height ratio improved from 57.6%± 11.8% preoperatively to 86.2%± 12.2% postoperatively (p<0.05), so did the mean middle vertebral body height ratio. The kyphotic angle improved from 16.3° ± 3.7° preoperatively to 9.3° ± 2.6° postoperatively (p<0.05). At final follow-up, BKP stabilised vertebral height and prevented further kyphotic deformity. While there were no differences in spinal canal compromise between pre-operation and one day after surgery (p>0.05), there was a significant difference from the measurement at the final follow-up (p<0.05). BKP is a safe and effective method for osteoporotic spinal fractures with middle column compromise but without neurological deficit. Spontaneous remodelling of the spinal canal also occurs after BKP. Copyright © 2014 Elsevier Ltd. All rights reserved.
Candel Romero, Carmen; Forner Cordero, Ángeles; Sánchez Santos, José Cristóbal; Pereiró Berenguer, Inmaculada
Link low levels of vitamin D, osteoporotic fracture and falls. Transversal observational study with the study variables of age, levels of vitamin D, osteoporotic fracture and falls. The study population was patients evaluated by the Rehabilitation Department, Hospital of Sagunto, from January 2013 to December 2014. Of the 242 patients who underwent vitamin D analysis, 70.6% showed levels under 30ng/ml. Forty-eight percent of the patients with below normal levels of vitamin D suffered a fracture, opposed to 32.4% patients with normal levels. Thus, controlling by age, patients with low levels of vitamin D are 4.8 times more likely to suffer a fracture than those with normal levels. Regarding falls, controlling by age, there is a higher risk of falling (adjusted OR 2.68) in those patients with low levels of vitamin D. Patients with low vitamin D levels are more likely to suffer falls and fractures. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
Chen, Jian Sheng; Hogan, Chris; Lyubomirsky, Greg; Sambrook, Philip N
This study investigated whether women with cardiovascular disease (CVD) would have an increased risk of fractures as osteoporosis and CVD share many common risk factors. From February 2006 to January 2007, 17,033 women aged ≥50 years (mean 71.8, range 50-106) were recruited by 1,248 primary care practitioners and interviewed by trained nurses. For each woman, 10-year probability of a future major osteoporotic fracture was estimated using the World Health Organization Fracture Risk Assessment Tool (FRAX). The study showed that the 10-year probability of a major osteoporotic fracture was higher for 6,219 CVD women compared to 10,814 non-CVD women after adjustment for age, BMI, current smoking, and alcohol use (adjusted geometric means 14.3 and 13.8%, respectively; P < 0.001). With regard to high risk of fracture (i.e., 10-year probability ≥ 20%), the adjusted odds ratio for CVD was 1.23 (95% CI 1.13-1.35, P < 0.001). However, compared to non-CVD women, CVD women were more likely to report a previous fracture, to have a secondary osteoporosis, and to use glucocorticoids. Among the 4,678 women who were classified as having a high fracture risk, current use rate of bone-related medications (i.e., any one of bisphosphonates, raloxifene, PTH, vitamin D, calcium, or hormone therapy) was 50.2% in the CVD group and 56.9% in the non-CVD group. Women with CVD were at increased risk of fracture partly due to bone-specific risk factors such as history of previous fracture, use of glucocorticoids, and secondary osteoporosis. This risk is not being treated appropriately by primary health physicians.
Alnaib, M; Waters, S; Shanshal, Y; Caplan, N; Jones, S; St Clair Gibson, A; Kader, D
Pelvic osteoporotic fractures (POFs) are often associated with considerable morbidity and mortality mainly as a result of infections and cardiovascular events. Patients usually need prolonged institutionalization, rehabilitation, and follow-up, with a high rate of dependency and cost. The most common sites of POFs include the pubic rami, sacrum, ilium, and acetabulum. Combined pubic rami (PROFs) and sacral osteoporotic fractures (SOFs) have been reported, mostly in retrospective studies, describing the mechanism of injury and incidence. The aim of this study was to evaluate the association between PROFs and SOFs and to assess the effect of combined PROFs and SOFs on patients' mobility, discharge destination, and length of stay. We prospectively studied 67 patients with low-impact PROFs and/or SOFs. There were 54 (80.4%) female and 13 (19.6%) male patients, and the average age was 87.5 (range 65-96) years. All patients were assessed by the fracture liaison service. Patients had magnetic resonance imaging or bone scan when there was history of low back pain following the injury or lumbosacral tenderness on clinical examination. The mean length of stay for all patients was 45 (± 35) days. Mortality rate was 10.4%. A significant relationship was found between low back pain and a positive finding of sacral fracture. Patients with combined PROFs and SOFs showed significantly longer length of stay than those with isolated PROFs. The presence of low back pain and tenderness in patients who had low-impact pelvic injuries was highly suggestive of the presence of an associated SOF. There was a high association between sacral and PROFs. The length of stay of patients with PROFs associated with sacral osteoporotic fractures was significantly longer than that of patients with PROFs only. Therefore, we recommend considering the high association between SOFs and PROFs in planning the management and rehabilitation of patients with POFs.
Silva, Lígia; Sampaio, Luzia; Pinto, José; Brito, J Silva; Ventura, Francisco S
Pregnancy-associated osteoporosis is rare and self--limiting. We report two clinical cases, with beginning of back pain during a 1st pregnancy. In the 1st case, the pain became severe after a fall, and she had other risk factors of fracture, like low calcium intake, and a treatment with thyroid hormones for weight loss. In the 2nd case, we did not find any. Both were diagnosed of osteoporosis by bone densitometry and radiology (multiple vertebral compression fractures). They had a favorable progression with life-style measures, calcium and vitamin D supplementation, and oral biphosphonate in the 2nd case. Nevertheless, both still suffer the impact.
Poole, Kenneth E S; Skingle, Linda; Gee, Andrew H; Turmezei, Thomas D; Johannesdottir, Fjola; Blesic, Karen; Rose, Collette; Vindlacheruvu, Madhavi; Donell, Simon; Vaculik, Jan; Dungl, Pavel; Horak, Martin; Stepan, Jan J; Reeve, Jonathan; Treece, Graham M
Hip fractures are mainly caused by accidental falls and trips, which magnify forces in well-defined areas of the proximal femur. Unfortunately, the same areas are at risk of rapid bone loss with ageing, since they are relatively stress-shielded during walking and sitting. Focal osteoporosis in those areas may contribute to fracture, and targeted 3D measurements might enhance hip fracture prediction. In the FEMCO case-control clinical study, Cortical Bone Mapping (CBM) was applied to clinical computed tomography (CT) scans to define 3D cortical and trabecular bone defects in patients with acute hip fracture compared to controls. Direct measurements of trabecular bone volume were then made in biopsies of target regions removed at operation. The sample consisted of CT scans from 313 female and 40 male volunteers (158 with proximal femoral fracture, 145 age-matched controls and 50 fallers without hip fracture). Detailed Cortical Bone Maps (c.5580 measurement points on the unfractured hip) were created before registering each hip to an average femur shape to facilitate statistical parametric mapping (SPM). Areas where cortical and trabecular bone differed from controls were visualised in 3D for location, magnitude and statistical significance. Measures from the novel regions created by the SPM process were then tested for their ability to classify fracture versus control by comparison with traditional CT measures of areal Bone Mineral Density (aBMD). In women we used the surgical classification of fracture location ('femoral neck' or 'trochanteric') to discover whether focal osteoporosis was specific to fracture type. To explore whether the focal areas were osteoporotic by histological criteria, we used micro CT to measure trabecular bone parameters in targeted biopsies taken from the femoral heads of 14 cases. Hip fracture patients had distinct patterns of focal osteoporosis that determined fracture type, and CBM measures classified fracture type better than a
Ha, Yong-Chan; Baek, Ji-Hoon; Ko, Young-Bong; Park, Sang-Min; Song, Sang-Heon
Although vertebral fracture in patients is a predictor of subsequent hip fracture, no study has assessed the mortality and functional outcome in hip fracture patients with previous vertebral fracture. Between September 2009 and December 2012, we evaluated 246 patients over 50-years-of-age diagnosed with femoral neck or intertrochanteric fractures who underwent surgery. The patients were categorized into two groups and two subgroups. Group Ia comprised 150 patients with previous vertebral fracture at the time of hip fracture. Group Ib comprised 96 patients with no vertebral fracture. Group IIa consisted of 76 patients <80-years-of-age with previous vertebral fracture. Group IIb comprised 69 patients <80-years-of-age without previous vertebral fracture. The mortality rate and functional outcome of osteoporotic hip fracture patients with and without vertebral fractures were compared. The cumulative mortality rate at 6 and 12 months post-fracture was 19 and 23 % in Group Ia and 6 and 7 % in Group Ib, respectively. In subgroup analysis, the cumulative mortality rate at 6 and 12 months was 13 and 17 % in Group IIa and 3 and 4 % in Group IIb, respectively. Shut-in patients at the final follow-up included 51 of 103 (49.5 %) patients in Group Ia and 19 of 83 (22.9 %) patients in Group Ib. In subgroup analysis, the shut-in patients included 18 of 58 (31.0 %) patients in Group IIa and 10 of 62 (16.1 %) patients in Group IIb. Previous vertebral fracture was associated with a poor functional outcome and increased mortality in patients with hip fracture.
Giangregorio, Lora M; Macintyre, Norma J; Thabane, Lehana; Skidmore, Carly J; Papaioannou, Alexandra
Vertebral fractures are associated with increased morbidity (e.g., pain, reduced quality of life), and mortality. Therapeutic exercise is a non-pharmacologic conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. Our objectives were to evaluate the benefits and harms of exercise interventions of four weeks or greater (alone or as part of a physical therapyintervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo on the incidence of future fractures and adverse events among adults with a history of osteoporotic vertebral fracture(s). We were also examined the effects of exercise on the following secondary outcomes: falls, pain, posture,physical function, balance,mobility, muscle function,quality of life and bone mineral density of the lumbar spine or hip measured using dual-energy X-ray absorptiometry (DXA).We also reported exercise adherence. We searched the following databases: The Cochrane Library ( Issue 11 of 12, November 2011), MEDLINE (2005 to 2011), EMBASE (1988 to November 23, 2011), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to November 23, 2011), AMED (1985 to November 2011), and PEDro (Physiotherapy Evidence Database, www.pedro.fhs.usyd.edu.au/index.html, 1929 to November 23, 2011. Ongoing and recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform (to December 2009). Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. We considered all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo
Giangregorio, Lora M; MacIntyre, Norma J; Thabane, Lehana; Skidmore, Carly J; Papaioannou, Alexandra
Background Vertebral fractures are associated with increased morbidity (e.g., pain, reduced quality of life), and mortality. Therapeutic exercise is a non-pharmacologic conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. Objectives Our objectives were to evaluate the benefits and harms of exercise interventions of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or place boon the incidence of future fractures and adverse events among adults with a history of osteoporotic vertebral fracture(s). We were also examined the effects of exercise on the following secondary outcomes: falls, pain, posture, physical function, balance, mobility, muscle function, quality of life and bone mineral density of the lumbar spine or hip measured using dual-energy X-ray absorptiometry (DXA). We also reported exercise adherence. Search methods We searched the following databases: The Cochrane Library (Issue 11 of 12, November 2011), MEDLINE (2005 to 2011), EMBASE (1988 to November 23, 2011), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to November 23, 2011), AMED (1985 to November 2011), and PEDro (Physiotherapy Evidence Database, www.pedro.fhs.usyd.edu.au/index.html, 1929 to November 23, 2011. Ongoing and recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform (to December 2009). Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. Selection criteria We considered all randomized controlled trials and quasi-randomized trials comparing exercise or active
Chen, Lin; Yang, Long; Yao, Min; Cui, Xue-Jun; Xue, Chun-Chun; Wang, Yong-Jun; Shu, Bing
Biomechanical tests are widely used in animal studies on osteoporotic fracture healing. However, the biomechanical recovery process is still unknown, leading to difficulty in choosing time points for biomechanical tests and in correctly assessing osteoporotic fracture healing. To determine the biomechanical recovery process during osteoporotic fracture healing, studies on osteoporotic femur fracture healing with biomechanical tests in ovariectomized rat (OVX) models were collected from PUBMED, EMBASE, and Chinese databases. Quadratic curves of fracture healing time and maximum load were fitted with data from the analyzed studies. In the fitted curve for normal fractures, the predicted maximum load was 145.56 N, and the fracture healing time was 88.0 d. In the fitted curve for osteoporotic fractures, the predicted maximum load was 122.30 N, and the fracture healing time was 95.2 d. The maximum load of fractured femurs in OVX rats was also lower than that in sham rats at day 84 post-fracture (D84 PF). The fracture healing time was prolonged and maximum load at D84 PF decreased in OVX rats with closed fractures. The maximum load of Wister rats was higher than that of Sprague-Dawley (SD) rats, but the fracture healing time of SD and Wister rats was similar. Osteoporotic fracture healing was delayed in rats that were < = 12 weeks old when ovariectomized, and at D84 PF, the maximum load of rats < = 12 weeks old at ovariectomy was lower than that of rats >12 weeks old at ovariectomy. There was no significant difference in maximum load at D84 PF between rats with an osteoporosis modeling time <12 weeks and > = 12 weeks. In conclusion, fracture healing was delayed and biomechanical property decreased by osteoporosis. Time points around D95.2 PF should be considered for biomechanical tests of osteoporotic femur fracture healing in OVX rat models. Osteoporotic fracture healing in OVX rats was affected by the fracture type but not by the strain of the rat.
Chen, Lin; Yang, Long; Yao, Min; Cui, Xue-Jun; Xue, Chun-Chun; Wang, Yong-Jun; Shu, Bing
Biomechanical tests are widely used in animal studies on osteoporotic fracture healing. However, the biomechanical recovery process is still unknown, leading to difficulty in choosing time points for biomechanical tests and in correctly assessing osteoporotic fracture healing. To determine the biomechanical recovery process during osteoporotic fracture healing, studies on osteoporotic femur fracture healing with biomechanical tests in ovariectomized rat (OVX) models were collected from PUBMED, EMBASE, and Chinese databases. Quadratic curves of fracture healing time and maximum load were fitted with data from the analyzed studies. In the fitted curve for normal fractures, the predicted maximum load was 145.56 N, and the fracture healing time was 88.0 d. In the fitted curve for osteoporotic fractures, the predicted maximum load was 122.30 N, and the fracture healing time was 95.2 d. The maximum load of fractured femurs in OVX rats was also lower than that in sham rats at day 84 post-fracture (D84 PF). The fracture healing time was prolonged and maximum load at D84 PF decreased in OVX rats with closed fractures. The maximum load of Wister rats was higher than that of Sprague-Dawley (SD) rats, but the fracture healing time of SD and Wister rats was similar. Osteoporotic fracture healing was delayed in rats that were < = 12 weeks old when ovariectomized, and at D84 PF, the maximum load of rats < = 12 weeks old at ovariectomy was lower than that of rats >12 weeks old at ovariectomy. There was no significant difference in maximum load at D84 PF between rats with an osteoporosis modeling time <12 weeks and > = 12 weeks. In conclusion, fracture healing was delayed and biomechanical property decreased by osteoporosis. Time points around D95.2 PF should be considered for biomechanical tests of osteoporotic femur fracture healing in OVX rat models. Osteoporotic fracture healing in OVX rats was affected by the fracture type but not by the strain of the rat. PMID:27055104
Deng, Yan-Hua; Zhao, Lin; Zhang, Min-Jia; Pan, Chun-Ming; Zhao, Shuang-Xia; Zhao, Hong-Yan; Sun, Li-Hao; Tao, Bei; Song, Huai-Dong; Wang, Wei-Qing; Ning, Guang; Liu, Jian-Min
To investigate the effects of genetic and non-genetic factors on bone mineral densities (BMDs) and osteoporotic fractures. This was a cross-sectional study to investigate the relationships between 18 SNPs and non-genetic factors with BMDs and osteoporotic fractures in 1012 Chinese Han women. Five SNPs in genes GPR177, CTNNB1, MEF2C, SOX6, and TNFRSF11B were associated with L1-4 or total hip BMDs. rs11898505 in SPTBN1 gene was associated with osteoporotic fractures. Subjects carrying the largest number of risk alleles (highest 10 %) not only had lower BMD values as compared to those carrying the least number of risk alleles (lowest 10 %), they also had a higher risk of fracture [P = 0.002, OR = 2.252, 95 %CI (1.136, 4.463)]. Results from multivariate stepwise regression analysis revealed that age [P < 0.001, OR = 1.038, 95 % CI (1.018, 1.058)], number of falls in a year [P < 0.001, OR = 2.347, 95 % CI (1.459, 3.774)], the G risk allele in rs11898505 [P = 0.023, OR = 1.559, 95 % CI (1.062, 2.290)], and the L1-4 BMD [P = 0.017, OR = 0.286, 95 % CI (0.102, 0.798)] were associated with the occurrence of osteoporotic fractures. Genetic (rs11898505) and non-genetic factors (age, number of falls in a year and L1-4 BMD) could work in concert to contribute to the risk of osteoporotic fractures.
Moroni, Antonio; Faldini, Cesare; Pegreffi, Francesco; Giannini, Sandro
This study was done to determine if elderly patients with trochanteric fractures and with osteoporosis could benefit from treatment with a dynamic hip screw fixed with HA-coated AO/ASIF screws. One hundred twenty patients with AO, A1, or A2 trochanteric fractures were selected. Patients were divided into two groups and randomized to receive a 135 degree-four-hole dynamic hip screw fixed with either standard lag and cortical AO/ASIF screws (Group A), or HA-coated lag and cortical AO/ASIF screws (Group B). Lag screw cutout occurred in four patients in Group A, but not in any patients in Group B. In Group A, the femoral neck shaft angle was 134 degrees +/- 5 degrees postoperatively and 127 degrees +/- 12 degrees at 6 months. In Group B, the femoral neck shaft angle was 134 degrees +/- 7 degrees postoperatively and 133 degrees +/- 7 degrees at 6 months. The Harris hip score at 6 months was 60 +/- 25 in Group A and 71 +/- 18 in Group B. The superior results of Group B can be attributed to the increased screw fixation provided by the HA-coated screws. We recommend lag screws coated with HA for dynamic hip screw fixation, especially in osteoporotic bone.
Reginster, J-Y; Malaise, O; Neuprez, A; Bruyere, O
Osteoporosis results from a decrease in bone strength yielding increased susceptibility to fractures. Hip and spine fractures are a major cause of morbidity and mortality in the elderly population. With an increasingly ageing world population, early prevention of bone loss is essential for adequate control of this condition. Strontium ranelate (PROTELOS((R))), an oral drug for postmenopausal osteoporosis, has been reported to decrease bone resorption and to stimulate bone formation. The efficacy in reducing vertebral fractures, non-vertebral including hip fractures, and the safety of strontium ranelate has been initially demonstrated over 3 years in the SOTI (Spinal Osteoporosis Therapeutic Intervention) and TROPOS (TReatment Of Peripheral OSteoporosis) studies and confirmed recently over up to 5 years. A preplanned analysis of a sub-group of patients aged 80 years and over showed that, currently, strontium ranelate is the only antiosteoporotic agent to reduce vertebral and non-vertebral fractures in this age group.
Bone loss results in osteoporosis and increased susceptibility to bone fractures. Importantly, osteoporosis is a major cause of morbidity and mortality in the elderly population. With a constantly increasing aging population worldwide, early prevention of bone loss is essential for adequate control of this condition. Strontium ranelate, an oral treatment for postmenopausal osteoporosis, is unique in its mode of action as it is the sole anti-osteoporotic agent that both decreases bone resorption and increases bone formation. Its efficacy to reduce vertebral and non-vertebral fractures including those of the hip, in addition to its safety profile has been demonstrated in the Spinal Osteoporosis Therapeutic Intervention (SOTI) and Treatment of Peripheral Osteoporosis (TROPOS) clinical studies over 3 years and recently confirmed over the long-term. Furthermore, a pre-planned analysis of a sub-group of patients aged 80 years and over demonstrated that, currently, strontium ranelate is the only anti-osteoporotic agent to reduce vertebral and non-vertebral fractures in this age group.
Wong, A.K.O.; Cawthon, P.M.; Peters, K.W.; Cummings, S.R.; Gordon, C.L; Sheu, Y.; Ensrud, K.; Petit, M.; Zmuda, J.M.; Orwoll, E.; Cauley, J.
Objective To assess bone-muscle (B-M) indices as risk factors for incident fractures in men. Methods Participants of the Osteoporotic Fractures in Men (MrOS) Study completed a peripheral quantitative computed tomography scan at 66% of their tibial length. Bone macrostructure, mechanical properties and muscle area were computed. Areal bone mineral density (aBMD) and body composition was assessed with dual-energy X-ray absorptiometry. Four year incident non-spine and clinical vertebral fractures were ascertained. B-M indices were expressed as bone-to-muscle ratios for: strength, mass and area. Discriminative power and hazards ratios (HR) for fractures were reported. Results In 1163 men (age: 77.2 ± 5.2 years, BMI: 28.0 ± 4.0 kg/m2, 7.7% ≥ 1 fracture), B-M indices were smaller in fractured men except for bending and areal indices. Smaller B-M indices were associated with increased fracture risk (HR: 1.30 to 1.74) independent of age and body mass index. Strength and mass indices remained significant after accounting for lumbar spine aBMD. B-M indices did not improve fracture discrimination beyond total hip aBMD. However, aBMD already explains part of the variance in B-M indices. Conclusion Mass and bending B-M indices are risk factors for fractures men, but may not improve fracture risk prediction beyond that provided by total hip aBMD. PMID:25198219
Knobe, M; Siebert, C H
Osteoporotic fractures of the femoral neck and trochanteric region pose an ever-expanding existential problem both for the individual and for society. Despite numerous innovations and advances regarding implant design, mortality and the systemic and mechanical complication rates remain high. Depiction of treatment options for femoral neck fractures and trochanteric femur fractures in the elderly comparing joint replacement and osteosynthesis. A search of the Medline, Embase and Cochrane databases was carried out focusing on hip fracture treatment. Randomized or quasi-randomized controlled trials, meta-analyses and reviews comparing joint replacement or fixation implants in the elderly were included. Displaced fractures of the femoral neck often require total joint arthroplasty whereas trochanteric fractures are amenable to internal fixation. Cemented total hip replacement as opposed to cementless techniques is recommended in the elderly and yields good functional results in active patients. Hemiarthroplasty is the treatment of choice in infirm patients with multiple comorbidities and cognitive impairment. Trochanteric fractures (AO/OTA types A1 and A2) can be successfully treated with intramedullary or extramedullary fixation. Adequate reduction and stable fixation are prerequisites for uneventful healing. A meticulous operative technique can prevent iatrogenic complications. In summary, there are many parameters affecting the outcome in the treatment of fragility and hip fractures. Technical features as well as surgeon characteristics play an important role and the ultimate solution has yet to be developed. Even though fracture morphology may indicate a specific treatment option, patient characteristics play an important role in decision-making. The development of centers of fragility fracture care in Germany could help to lower the complication rate and increase quality of life in hip fracture patients in the future.
Tanaka, Shiro; Yoshimura, Noriko; Kuroda, Tatsuhiko; Hosoi, Takayuki; Saito, Mitsuru; Shiraki, Masataka
We aimed to (i) explore risk factors for major osteoporotic fracture or immobilization; (ii) develop a prediction model that can be used to assess the risk of fracture and immobilization; and (iii) assess external validity of the final model. A total of 1787 postmenopausal Japanese women were followed in a hospital-based cohort study. Endpoints included the annual incidence of major osteoporotic fracture and immobilization. For each endpoint, multivariate Poisson regression models were fitted separately and risk factors were screened through backward variable selection. The predictive accuracy of the final model (FRISC) was evaluated in two independent community-based cohorts. Over a median follow-up of 5.3 years, a total of 383 major osteoporotic fractures (279 clinical vertebral, 44 hip, 60 distal forearm) and 83 immobilizations occurred in the developmental dataset. Backward variable selection confirmed that the following are risk factors for major osteoporotic fracture: age, weight, prior fracture, back pain, and lumbar bone mineral density (BMD). Age, prior fracture and dementia were significant risk factors for immobilization. Hosmer-Lemeshow tests did not indicate any significant deviation between the observed fracture frequency and prediction from the FRISC in the independent validation dataset. The C statistic for the FRISC was 0.727 (95% confidence interval: 0.660 to 0.794) and was higher than that for BMD alone significantly (p=0.03). We developed a novel prediction model for fracture and immobilization, FRISC, and the clinical risk factors in the FRISC allows better identification of populations at high risk of fracture than BMD alone. A web application is available at http://www.biostatistics.jp/prediction/frisc. Copyright © 2010 Elsevier Inc. All rights reserved.
Colón-Emeric, Cathleen; Pieper, Carl F.; Grubber, Janet; Van Scoyoc, Lynn; Schnell, Merritt L; Van Houtven, Courtney Harold; Pearson, Megan; Lafleur, Joanne; Lyles, Kenneth W.; Adler, Robert A.
Purpose With ethical requirements to the enrollment of lower risk subjects, osteoporosis trials are underpowered to detect reduction in hip fractures. Different skeletal sites have different levels of fracture risk and response to treatment. We sought to identify fracture sites which cluster with hip fracture at higher than expected frequency; if these sites respond to treatment similarly, then a composite fracture endpoint could provide a better estimate of hip fracture reduction. Methods Cohort study using Veterans Affairs and Medicare administrative data. Male Veterans (n=5,036,536) aged 50-99 years receiving VA primary care between1999-2009 were included. Fractures were ascertained using ICD9 and CPT codes and classified by skeletal site. Pearson correlation coefficients, logistic regression and kappa statistics, were used to describe the correlation between each fracture type and hip fracture within individuals, without regards to the timing of the events. Results 595,579 (11.8%) men suffered 1 or more fractures and 179,597 (3.6%) suffered 2 or more fractures during the time under study. Of those with one or more fractures, rib was the most common site (29%), followed by spine (22%), hip (21%) and femur (20%). The fracture types most highly correlated with hip fracture were pelvic/acetabular (Pearson correlation coefficient 0.25, p<0.0001), femur (0.15, p<0.0001), and shoulder (0.11, p<0.0001). Conclusions Pelvic, acetabular, femur, and shoulder fractures cluster with hip fractures within individuals at greater than expected frequency. If we observe similar treatment risk reductions within that cluster, subsequent trials could consider use of a composite endpoint to better estimate hip fracture risk. PMID:26151123
Colón-Emeric, Cathleen; Pieper, Carl F; Grubber, Janet; Van Scoyoc, Lynn; Schnell, Merritt L; Van Houtven, Courtney Harold; Pearson, Megan; Lafleur, Joanne; Lyles, Kenneth W; Adler, Robert A
With ethical requirements to the enrollment of lower risk subjects, osteoporosis trials are underpowered to detect reduction in hip fractures. Different skeletal sites have different levels of fracture risk and response to treatment. We sought to identify fracture sites which cluster with hip fracture at higher than expected frequency; if these sites respond to treatment similarly, then a composite fracture endpoint could provide a better estimate of hip fracture reduction. Cohort study using Veterans Affairs and Medicare administrative data. Male Veterans (n=5,036,536) aged 50-99 years receiving VA primary care between 1999 and 2009 were included. Fractures were ascertained using ICD9 and CPT codes and classified by skeletal site. Pearson correlation coefficients, logistic regression and kappa statistics were used to describe the correlation between each fracture type and hip fracture within individuals, without regard to the timing of the events. 595,579 (11.8%) men suffered 1 or more fractures and 179,597 (3.6%) suffered 2 or more fractures during the time under study. Of those with one or more fractures, the rib was the most common site (29%), followed by spine (22%), hip (21%) and femur (20%). The fracture types most highly correlated with hip fracture were pelvic/acetabular (Pearson correlation coefficient 0.25, p<0.0001), femur (0.15, p<0.0001), and shoulder (0.11, p<0.0001). Pelvic, acetabular, femur, and shoulder fractures cluster with hip fractures within individuals at greater than expected frequency. If we observe similar treatment risk reductions within that cluster, subsequent trials could consider the use of a composite endpoint to better estimate hip fracture risk. Published by Elsevier Inc.
Khalil, Naila; Cauley, Jane A; Wilson, John W; Talbott, Evelyn O; Morrow, Lisa; Hochberg, Marc C; Hillier, Teresa A; Muldoon, Susan B; Cummings, Steven R
Lead is stored in the skeleton and can serve as an endogenous source for many years. Lead may influence the risk of fracture, through direct effects on bone strength or indirectly by disturbing neuromuscular function and increasing the risk of falls. The objective of this analysis is to test the hypothesis that women with higher blood lead levels experience higher rates of falls and fracture. This was a prospective cohort study of 533 women 65–87 yr of age enrolled in the Study of Osteoporotic Fractures at two U.S. research centers (Baltimore, MD; Monongahela Valley, PA) from 1986 to 1988. Blood lead levels (in μg/dl) were measured in 1990–1991 by atomic absorption spectrophotometry and classified as “low” (≤3; lower 15th percentile, referent); “medium” (4–7); or “high” (≥8; upper 15th percentile). Total hip BMD was measured by DXA twice, 3.55 yr apart. Information on falls was collected every 4 mo for 4 yr. Incident nonspine fractures were identified and confirmed over 10 yr. Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% CI of fracture. Generalized estimating equations were used to calculate the incident rate ratio of falls (95% CI). The mean blood lead level was 5.3 ± 2.3 (SD) μg/dl (range, 1–21 μg/dl). Baseline BMD was 7% lower in total hip and 5% lower in femoral neck in the highest compared with lowest blood lead group (p < 0.02). Hip bone loss tended to be greater in the high lead group, but differences were not significant. In multivariable adjusted models, women with high blood lead levels had an increased risk of nonspine fracture (HR = 2.50; 95% CI = 1.25, 5.03; p trend = 0.016) and higher risk of falls (incident rate ratio = 1.62; 95% CI = 1.07, 2.45; p trend = 0.014) compared with women with lowest lead level. Blood lead levels are associated with an increased risk of falls and fractures, extending the negative health consequences of lead to include osteoporotic fractures. PMID:18410230
Capizzi, Silvio; Di Pietro, Maria Luisa; Veneziano, Maria Assunta; La Torre, Giuseppe; Nicolotti, Nicola; Sferrazza, Antonella
Objective. The Health Technology Assessment (HTA) approach was applied to denosumab in the prevention of osteoporotic fractures in postmenopausal women. Method. Epidemiological, clinical, technical, economic, organizational, and ethical aspects were considered. Medical electronic databases were accessed to evaluate osteoporosis epidemiology and therapeutical approaches. A budget impact and a cost-effectiveness analyses were performed to assess economic implications. Clinical benefits and patient needs were considered with respect to organizational and ethical evaluation. Results. In Italy around four millions women are affected by osteoporosis and have a higher risk for fractures with 70,000 women being hospitalized every year. Bisphosphonates and strontium ranelate are recommended as first line treatment for the prevention of osteoporotic fractures. Denosumab is effective in reducing vertebral, nonvertebral, and hip/femoral fractures with an advantage of being administered subcutaneously every six months. The budget impact analysis estimated a reduction in costs for the National Health Service with the introduction of denosumab. Furthermore, the economic analysis demonstrated that denosumab is cost-effective in comparison to oral bisphosphonates and strontium ranelate. Denosumab can be administered in outpatients by involving General Practitioners in the management. Ethical evaluation is positive because of its efficacy and compliance. Conclusion. Denosumab could add value in the prevention of osteoporotic fractures. PMID:24689066
Burns, R B; Moskowitz, M A; Ash, A; Kane, R L; Finch, M; McCarthy, E P
Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). Prospective cohort study. We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.
Clement, R Carter; Ahn, Jaimo; Mehta, Samir; Bernstein, Joseph
Management of geriatric hip fractures in a protocol-driven center can improve outcomes and reduce costs. Nonetheless, this approach has not spread as broadly as the effectiveness data would imply. One possible explanation is that operating such a center is not perceived as financially worthwhile. To assess the economic viability of dedicated hip fracture centers, the authors built a financial model to estimate profit as a function of costs, reimbursement, and patient volume in 3 settings: an average US hip fracture program, a highly efficient center, and an academic hospital without a specific hip fracture program. Results were tested with sensitivity analysis. A local market analysis was conducted to assess the feasibility of supporting profitable hip fracture centers. The results demonstrate that hip fracture treatment only becomes profitable when the annual caseload exceeds approximately 72, assuming costs characteristic of a typical US hip fracture program. The threshold of profitability is 49 cases per year for high-efficiency hip fracture centers and 151 for the urban academic hospital under review. The largest determinant of profit is reimbursement, followed by costs and volume. In the authors’ home market, 168 hospitals offer hip fracture care, yet 85% fall below the 72-case threshold. Hip fracture centers can be highly profitable through low costs and, especially, high revenues. However, most hospitals likely lose money by offering hip fracture care due to inadequate volume. Thus, both large and small facilities would benefit financially from the consolidation of hip fracture care at dedicated hip fracture centers. Typical US cities have adequate volume to support several such centers.
Papaioannou, A.; MacIntyre, N. J.; Ashe, M. C.; Heinonen, A.; Shipp, K.; Wark, J.; McGill, S.; Keller, H.; Jain, R.; Laprade, J.; Cheung, A. M.
Summary A consensus process was conducted to develop exercise recommendations for individuals with osteoporosis or vertebral fractures. A multicomponent exercise program that includes balance and resistance training is recommended. Introduction The aim was to develop consensus on exercise recommendations for older adults: (1) with osteoporosis and (2) with osteoporotic vertebral fracture(s). Methods The Grading of Recommendations Assessment, Development, and Evaluation method was used to evaluate the quality of evidence and develop recommendations. Outcomes important for decision making were nominated by an expert panel and patient advocates. They included falls, fractures, bone mineral density (BMD), and adverse events for individuals with osteoporosis/vertebral fractures, and pain, quality of life, and function for those with vertebral fracture. Meta-analyses evaluating the effects of exercise on the outcomes were reviewed. Observational studies or clinical trials were reviewed when meta-analyses were not available. Quality ratings were generated, and informed the recommendations. Results The outcome for which evidence is strongest is falls. Point estimates of the effects of exercise on falls, fractures, and BMD vary according to exercise type. There is not enough evidence to quantify the risks of exercise in those with osteoporosis or vertebral fracture. Few trials of exercise exist in those with vertebral fracture. The exercise recommendations for exercise in individuals with osteoporosis or osteoporotic vertebral fracture are conditional. The panel strongly recommends a multicomponent exercise program including resistance and balance training for individuals with osteoporosis or osteoporotic vertebral fracture. The panel recommends that older adults with osteoporosis or vertebral fracture do not engage in aerobic training to the exclusion of resistance or balance training. Conclusions The consensus of our international panel is that exercise is recommended for
Di Stefano, Marco; Isaia, Giovanni Carlo
In this study, we evaluated the ability of different quantitative ultrasound (QUS) parameters (speed of sound, SOS, coefficient of variation, CV, = 0.34% and broadband ultrasound (US) attenuation, BUA, CV = 3.25% measured at the heel by an Hologic Sahara unit; Ad-Sos and ultrasound bone profile score (UBPS) at the proximal phalanges by an Igea DBM Sonic 1200 unit, Ad-Sos CV = 0.57%) to detect differences between osteoporotic patients with vertebral fractures and osteoporotic patients without fractures. We examined 87 women with primary osteoporosis: 53 women with femoral neck bone mineral density (BMD) T scores less than -2.5 SD and no vertebral fractures and 34 women with one or more vertebral fractures, regardless of T score values. Considering all the patients together, the correlations between QUS parameters and BMD resulted in statistical significance (p < 0.05) only for BUA and femoral neck BMD. Lumbar and femoral neck BMD did not statistically differ between the two groups, while UBPS, which is a quality control of measurement and is correlated with bone quality, was significantly higher in women without fractures than those with fractures; the other QUS parameters were not statistically different. Our data indicate that, among QUS parameters, only UBPS is able to detect differences among osteoporotic patients with and without vertebral fractures.
Among the available agents for osteoporosis, anti-resorptive drugs do not increase bone formation, whereas anabolic agents do not reduce bone resorption. Strontium ranelate (SR) uniquely does both, rebalancing bone turnover in favour of bone formation. In the Spinal Osteoporosis Therapeutic Intervention (SOTI) study, a 4-year trial, SR treatment reduced vertebral fracture risk by 33% (P < 0.001), and symptomatic vertebral fracture risk by 36% (P < 0.001). SR also significantly improved quality of life as assessed by the Quality-of-Life Questionnaire in Osteoporosis (QUALIOST) instrument. In the Treatment of Peripheral Osteoporosis Study (TROPOS) study, a 5-year trial, SR significantly reduced total fracture risk by 20% (29.1 vs 33.9%; P < 0.001), total non-vertebral fracture risk by 15% (18.6 vs 20.9%; P = 0.032) and hip fracture risk by 43% (7.2 vs 10.2%; P = 0.036) in the subgroup that is at high risk for hip fracture. Analysis of pooled data from these two studies found that SR is also safe and effective in patients aged >or=80 years, reducing the risk of vertebral fracture over 5 years by 31% (P = 0.010) and non-vertebral fracture by 26% (P = 0.019). Adherence to treatment in the trials exceeded 80%, and the adverse event profile of SR was similar to that of placebo. Taken together, these long-term findings clearly demonstrate that SR is safe and effective in reducing both vertebral and non-vertebral (particularly hip) fracture risks for at least 5 years of pre-planned follow-up.
Misra, Devyani; Peloquin, Christine; Kiel, Douglas P.; Neogi, Tuhina; Lu, Na; Zhang, Yuqing
Purpose Nitrates, commonly used anti-anginal medications, also have beneficial effect on bone remodeling and bone density, particularly with intermittent use. However, their effect on fracture risk is not clear. We examined the relation of short-acting nitrate use (proxy for intermittent use) to the risk of hip fracture in a large cohort of older adults with ischemic heart disease. Materials and Methods Participants ≥ 60 years old with ischemic heart disease and without history of hip fracture from The Health Improvement Network (THIN), an electronic medical records database in the UK, were included. The association of incident (new) use of short-acting nitrate formulations (nitroglycerin sublingual/spray/ointment or ISDN injection/sprays) with incident (new-onset) hip fracture risk was examined by plotting Kaplan-Maier curves and calculating Hazard ratios (HR) using Cox proportional hazards regression models. Competing risk by death was analyzed in separate analyses. Results Among 14, 451 pairs of matched nitrate users and non-users (mean age 72±7.6, 41% women for each cohort), 573 fractures occurred during follow up (257 nitrate users; 316 non-users). Hip fracture risk was 33% lower among short-acting nitrate users compared with non-users (HR=0.67, 95% CI 0.53–0.85, p=0.0008). Competing risk analysis by death did not change effect estimates. Conclusion In this large population-based cohort of older adults with ischemic heart disease, we found significant reduction in hip fracture risk with use of short-acting nitrates (intermittent use). Future studies are warranted given the potential for nitrates to be potent, inexpensive and readily available anti-osteoporotic agents. PMID:27720852
Eklund, Fredrik; Nordström, Anna; Björnstig, Ulf; Nordström, Peter
The influence of bone mass, bone size and previous low energy fractures upon prospective fractures has not been investigated in a referral osteoporotic population. We investigated the association between bone mass, bone size, previous fractures, body constitution, and prospective validated fractures in 5701 women and 1376 men, aged 30 years and older. Bone mass measurements of the femoral neck were collected at a single study center in Sweden. Most of the subjects were measured on suspicion of osteoporosis. Data on validated low energy retrospective and prospective fractures in the cohort were collected from the corresponding health care district. Bone mineral density (BMD, g/cm(2)) and estimated volumetric BMD (vBMD, g/cm(3)) were shown to be good independent predictors for fracture in both women and men (Hazard ratio per standard deviation decrease (HR)=1.27-1.52, p<0.05). Bone size did not predict prospective fractures in either sex (HR=0.91-0.99, p>0.05), and bone size completely explained the higher BMD in men than in women. In women, retrospective low energy fractures (HR=1.78, p<0.001) and height (HR=1.02, p=0.006) were additional independent predictors of osteoporotic fractures after adjusting for age and BMD. In conclusion, we show that in a large osteoporotic referral population, age, BMD and previous fractures are independent predictors of prospective low energy fractures. These results add additional strength to the recent change in focus towards a multivariate analysis when assessing the future risk of fracture.
Elevated homocysteine is a strong risk factor for osteoporotic fractures among elders, yet it may be a marker for low B vitamin status. Objective: To examine the associations of plasma concentrations of folate, vitamin B12, vitamin B6 and homocysteine with bone loss and hip fracture risk in elderly...
Che, M; Ettinger, B; Liang, J; Pressman, A R; Johnston, J
The purpose of this study was to evaluate outcomes of a disease-management program designed to increase rates of bone-mineral-density (BMD) testing and initiation of osteoporosis medication among patients with a recent osteoporotic fracture. We identified 744 consecutive patients aged>or=55 years who were seen at either of 2 of 14 Kaiser Permanente medical facilities in Northern California (KPNC) after sustaining a fracture of the hip, spine, wrist, or humerus between April 2003 and May 2004. These patients were invited to participate in a study of the Fragile Fracture Management Program, whose protocol used fracture-risk assessment tools to determine treatment recommendations. Postfracture care of study participants was compared with usual postfracture care received by osteoporotic-fracture patients at 12 other KPNC facilities. Of the 744 patients who were invited to participate in the study, 293 (39%) agreed to participate, and 169 (23%) completed the evaluation. Of these 169 patients (127 women, 42 men), 65 (51%) of the women and 7 (17%) of the men qualified for drug treatment; of these 72 patients, 6 (86%) of the men and 41 (63%) of the women accepted the offered treatment. At the two study locations, rates of care (BMD testing or prescribing osteoporosis medication) were about twice as high as rates of usual postfracture care observed at 12 other medical centers in KPNC. Compared with patients who received usual care for osteoporotic fracture, patients participating in a postfracture disease management program had substantially higher rates of medical attention given for osteoporosis; however, the overall yield of the program was low. This low uptake rate was related to factors not previously appreciated: many patients refused participation in the program; a high proportion of younger women-and men of all ages-did not qualify for treatment; and treatment was refused by one in three study-qualified women and by one in seven study-qualified men. Additional
Flais, J; Coiffier, G; Le Noach, J; Albert, J D; Faccin, M; Perdriger, A; Thomazeau, H; Guggenbuhl, P
The majority of patients do not receive anti-osteoporotic treatment following a major osteoporotic fracture, despite the guidelines and the availability of effective anti-osteoporotic treatments. The fight against factors limiting the diagnosis and treatment of osteoporosis should become a priority to improve secondary prevention after an initial osteoporotic fracture. Despite the availability of effective anti-osteoporotic treatments, osteoporosis management is currently insufficient. The main objective of this study was to assess the prevalence of anti-osteoporotic treatments introduced after an initial prior major osteoporotic fracture during hospitalization for recurring fractures. We conducted an observational, cross-sectional, bicentric study that included all patients aged over 50 years who were hospitalized or seen in consultation for major osteoporotic fracture. One hundred twenty-eight out of two hundred four (62.7%) patients had a past history of major osteoporotic fracture and therefore had an indication of treatment based on guidelines. Among these patients, only 43/128 (33.5%) had received anti-osteoporotic treatment as secondary prevention after the initial fracture. The main causes of non-prescription identified were the attending physicians' ignorance of the indication of treatment (n = 30; 35.3%), ignorance of the fracture (n = 17; 20%), and comorbidities (n = 12; 14.1%). The failure to introduce treatment was associated with the presence of comorbidities with a Charlson Comorbidity Index ≥6 (OR = 0.34 [0.16-0.73], p < 0.05), dementia (OR = 0.23 [0.08-0.72], p < 0.05), and past history of proximal femur fracture (OR = 0.20 [0.04-0.91], p < 0.05). Two thirds of patients with a past history of major osteoporotic fracture presenting with a new fracture were not treated. The main reason for lack of treatment seems to stem from the incorrect assessment of the patient's fracture risk. Although major osteoporotic fracture leads to an
Firooznia, H.; Rafii, M.; Golimbu, C.; Schwartz, M.S.; Ort, P.
The trabecular bone mineral content (BMC) of the spine was measured by computed tomography in 185 women aged 47-84 years with vertebral fracture (n = 74), hip fracture (n = 83), and both vertebral and hip fracture (n = 28). Eighty-seven percent of vertebral-fracture patients, 38% of hip-fracture patients, and 82% of vertebral- and hip-fracture patients had spinal BMC values below the fifth percentile for healthy premenopausal women and values 64%, 9%, and 68% below the fifth percentile for age-matched control subjects. No significant loss of spinal trabecular bone was seen in patients with hip fracture. If it is assumed that the rate of trabecular bone loss is the same in the spine and femoral neck, then hip fracture (unlike osteoporotic vertebral fracture) is not associated with disproportionate loss of trabecular bone. Hip fracture occurs secondary to weakening of bone and increased incidence of falls. Bone weakening may be due to disproportionate loss of trabecular or cortical bone, proportionate loss of both, or other as yet undetermined qualitative changes in bone.
Seeliger, Claudine; Karpinski, Katrin; Haug, Alexander T; Vester, Helen; Schmitt, Andreas; Bauer, Jan S; van Griensven, Martijn
Osteoporosis as a systemic skeletal disorder is characterized by increased bone fragility and the risk of fractures. According to the World Health Organization, osteoporosis is one of the 10 most common diseases and affects approximately 75 million people in Europe, the United States, and Japan. In this context, the identification of specific microRNA (miRNA) signatures is an important step for new diagnostic and therapeutic approaches. The focus of interest on miRNAs as biomarkers came with new publications identifying free circulating extracellular miRNAs associated with various types of cancer. This study aimed to identify specific miRNAs in patients with osteoporotic fractures compared with nonosteoporotic fractures. For the array analysis, miRNAs were isolated from the serum of 20 patients with hip fractures, transcribed, and the samples were pooled into 10 osteoporotic and 10 nonosteoporotic specimens. With each pool of samples, human serum and plasma miRNA PCR arrays were performed, which are able to identify 83 different miRNAs. Subsequently, a separate validation analysis of each miRNA found to be regulated in the array followed with miRNA samples isolated from the serum of 30 osteoporotic and 30 nonosteoporotic patients and miRNA samples isolated from the bone tissue of 20 osteoporotic and 20 nonosteoporotic patients. With the validation analysis of the regulated miRNAs, we identified 9 miRNAs, namely miR-21, miR-23a, miR-24, miR-93, miR-100, miR-122a, miR-124a, miR-125b, and miR-148a, that were significantly upregulated in the serum of patients with osteoporosis. In the bone tissue of osteoporotic patients, we identified that miR-21, miR-23a, miR-24, miR-25, miR-100, and miR-125b displayed a significantly higher expression. A total of 5 miRNAs display an upregulation both in serum and bone tissue. This study reveals an important role for several miRNAs in osteoporotic patients and suggested that they may be used as biomarkers for diagnostic purposes and
Byun, Ji-Hye; Jang, Sunmee; Lee, Sumin; Park, Suyeon; Yoon, Hyun Koo
Background The efficacy of bisphosphonates for osteoporotic fracture has been consistently reported in recent randomized controlled trials (RCTs) enrolling hundreds of patients. The objective of this study was to update knowledge on the efficacy of available bisphosphonates in the prevention of vertebral and non-vertebral fractures. Methods An approach “using systematic reviews” on PubMed and Cochrane Library was taken. Twenty-four RCTs investigating the effects of bisphosphonates for the prevention of osteoporotic fracture were included in final analysis. A pairwise meta-analysis was conducted with a random effects model. Subgroup analysis was performed according to the type of bisphosphonate. Results The use of bisphosphonate decrease the risk of overall osteoporotic fracture (odds ratio [OR] 0.62; P<0.001), vertebral fracture (OR 0.55; P<0.001) and non-vertebral fracture (OR 0.73; P<0.001). Subgroup analysis indicated that zoledronic acid showed the lowest risk reduction (OR 0.61; P<0.001) for overall osteoporotic fractures but no significance was observed for etidronate (OR 0.34; P=0.127). Conclusions This update meta-analysis re-confirmed that bisphosphonate use can effectively reduce the risk of osteoporotic fracture. However, there is a lack of evidence regarding etidronate for the prevention of osteoporotic fracture. PMID:28326300
Jang, Eun Jin; Lee, Young-Kyun; Choi, Hyung Jin
Background Fracture-risk assessment tool (FRAX) using just clinical risk factors of osteoporosis has been developed to estimate individual risk of osteoporotic fractures. We developed prediction model of fracture risk using bone mineral density (BMD) as well as clinical risk factors in Korean, and assessed the validity of the final model. Methods To develop and validate an osteoporotic FRAX, a total of 768 Korean men and women aged 50 to 90 years were followed for 7 years in a community-based cohort study. BMD as well as clinical risk factors for osteoporotic fracture including age, sex, body mass index, history of fragility fracture, family history of fracture, smoking status, alcohol intake, use of oral glucocorticoid, rheumatoid arthritis, and other causes of secondary osteoporosis were assessed biannually. Results During the follow-up period, 86 osteoporotic fractures identified (36 in men and 50 in women). The developed prediction models showed high discriminatory power and had goodness of fit. Conclusions The developed a Korean specific prediction model for osteoporotic fractures can be easily used as a screening tool to identify individual with high risk of osteoporotic fracture. Further studies for validation are required to confirm the clinical feasibility in general Korean population. PMID:26981519
Smith, Alexander K; Cenzer, Irena Stijacic; John Boscardin, W; Ritchie, Christine S; Wallhagen, Margaret L; Covinsky, Kenneth E
To establish the prevalence and correlates of disability during the 2 years before hip fracture. Data from participants who experienced hip fracture in the Health and Retirement Study (HRS) with hip fracture identified using linked Medicare claims. Each participant was interviewed at varying time points in the 2 years before hip fracture. Disability was defined as self-report of the need for assistance in any activity of daily living (walking across the room, eating, bathing, dressing, using the toilet, transferring). Based on the timing between interview and hip fracture, prevalence of disability was calculated in the cohort as a whole over the 2 years before hip fracture and in subgroups defined according to demographic and clinical characteristics. The HRS is a nationally representative longitudinal study (1992-2010). HRS participants aged ≥65 with hip fracture (mean age at fracture 84, 77% female). The adjusted prevalence of disability was 20% (95% confidence interval (CI) = 14-25%) 2 years before hip fracture, with little change until approximately 10 months before fracture, when it started to rise, reaching 44% (95% CI = 33-55%) in the month before hip fracture. The prevalence of disability was highest in the last month before fracture for persons aged 85 and older (53%) and for those with dementia (60%). Care models for hip fracture need to consider not only the acute medical and surgical needs, but also the high level of need for supportive care and caregiver assistance that chronically disabled individuals require. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.
Hack, Juliana; Bliemel, Christopher; Ruchholtz, Steffen; Bücking, Benjamin
Hip fractures are among the most common fractures in elderly people. The annual number of femoral fractures is even expected to increase because of an aging society. Due to the high number of comorbidities, there are special challenges in treating geriatric hip fracture patients, which require a multidisciplinary management. This includes surgical treatment allowing full weight bearing in the immediate postoperative period, osteoporosis treatment and falls prevention as well as an early ortho-geriatric rehabilitation program.
Drew, S; Judge, A; Cooper, C; Javaid, M K; Farmer, A; Gooberman-Hill, R
There is variation in how services to prevent secondary fractures after hip fracture are delivered and no consensus on best models of care. This study identifies healthcare professionals' views on effective care for the prevention of these fractures. It is hoped this will provide information on how to develop services. Hip fracture patients are at high risk of subsequent osteoporotic fractures. Whilst fracture prevention services are recommended, there is variation in delivery and no consensus on best models of care. This study aims to identify healthcare professionals' views on effective care for prevention of secondary fracture after hip fracture. Forty-three semi-structured interviews were undertaken with healthcare professionals involved in delivering fracture prevention across 11 hospitals in one English region. Interviews explored views on four components of care: (1) case finding, (2) osteoporosis assessment, (3) treatment initiation, and (4) monitoring and coordination. Interviews were audio-recorded, transcribed, anonymised and coded using NVivo software. Case finding: a number of approaches were discussed. Multiple methods ensured there was a 'backstop' if patients were overlooked. Osteoporosis assessment: there was no consensus on who should conduct this. The location of the dual energy X-ray absorptiometry (DXA) scanner influenced the likelihood of patients receiving a scan. Treatment initiation: it was felt this was best done in inpatients rather request initiation in the post-discharge/outpatients period. Monitoring (adherence): adherence was a major concern, and participants felt more monitoring could be conducted by secondary care. Coordination of care: participants advocated using dedicated coordinators and formal and informal methods of communication. A gap between primary and secondary care was identified and strategies suggested for addressing this. A number of ways of organising effective fracture prevention services after hip fracture were
LeBlanc, Kim Edward; Muncie, Herbert L; LeBlanc, Leanne L
Hip fractures cause significant morbidity and are associated with increased mortality. Women experience 80% of hip fractures, and the average age of persons who have a hip fracture is 80 years. Most hip fractures are associated with a fall, although other risk factors include decreased bone mineral density, reduced level of activity, and chronic medication use. Patients with hip fractures have pain in the groin and are unable to bear weight on the affected extremity. During the physical examination, displaced fractures present with external rotation and abduction, and the leg will appear shortened. Plain radiography with cross-table lateral view of the hip and anteroposterior view of the pelvis usually confirms the diagnosis. If an occult hip fracture is suspected and plain radiography is normal, magnetic resonance imaging should be ordered. Most fractures are treated surgically unless the patient has significant comorbidities or reduced life expectancy. The consulting orthopedic surgeon will choose the surgical procedure. Patients should receive prophylactic antibiotics, particularly against Staphylococcus aureus, before surgery. In addition, patients should receive thromboembolic prophylaxis, preferably with low-molecular-weight heparin. Rehabilitation is critical to long-term recovery. Unless contraindicated, bisphosphonate therapy should be used to reduce the risk of another hip fracture. Some patients may benefit from a fall-prevention assessment.
Bottai, Vanna; Giannotti, Stefano; Raffaetà, Gloria; Mazzantini, Maurizio; Casella, Francesco; De Paola, Gaia; Menconi, Agnese; Falossi, Francesca; Guido, Giulio
Summary Osteoporosis (OP) is a silent disease unless a fracture occurs; it is a major health problem, mainly due to fragility fractures, that occur at vertebral and peripheral sites. Vertebral fractures (VF) are probably the most common fragility fractures, but they go often unrecognized. The main clinical symptoms of VF are acute and chronic back pain, spinal deformity, reduced mobility and impaired quality of life. They are frequently associated with other fragility fractures. We examined 478 patients at our outpatient clinic, who were referred for fragility fracture occurrence. The most common fragility fractures was hip fractures. However, after execution of spine X-rays in patients who had sustained hip fracture, we found that a large proportion of them had VF, which had not been reported in their medical history. PMID:27920807
Dagan, Noa; Cohen-Stavi, Chandra; Leventer-Roberts, Maya; Balicer, Ran D
To directly compare the performance and externally validate the three most studied prediction tools for osteoporotic fractures-QFracture, FRAX, and Garvan-using data from electronic health records. Retrospective cohort study. Payer provider healthcare organisation in Israel. 1 054 815 members aged 50 to 90 years for comparison between tools and cohorts of different age ranges, corresponding to those in each tools' development study, for tool specific external validation. First diagnosis of a major osteoporotic fracture (for QFracture and FRAX tools) and hip fractures (for all three tools) recorded in electronic health records from 2010 to 2014. Observed fracture rates were compared to probabilities predicted retrospectively as of 2010. The observed five year hip fracture rate was 2.7% and the rate for major osteoporotic fractures was 7.7%. The areas under the receiver operating curve (AUC) for hip fracture prediction were 82.7% for QFracture, 81.5% for FRAX, and 77.8% for Garvan. For major osteoporotic fractures, AUCs were 71.2% for QFracture and 71.4% for FRAX. All the tools underestimated the fracture risk, but the average observed to predicted ratios and the calibration slopes of FRAX were closest to 1. Tool specific validation analyses yielded hip fracture prediction AUCs of 88.0% for QFracture (among those aged 30-100 years), 81.5% for FRAX (50-90 years), and 71.2% for Garvan (60-95 years). Both QFracture and FRAX had high discriminatory power for hip fracture prediction, with QFracture performing slightly better. This performance gap was more pronounced in previous studies, likely because of broader age inclusion criteria for QFracture validations. The simpler FRAX performed almost as well as QFracture for hip fracture prediction, and may have advantages if some of the input data required for QFracture are not available. However, both tools require calibration before implementation. Published by the BMJ Publishing Group Limited. For
von der Linden, P; Gisep, A; Boner, V; Windolf, M; Appelt, A; Suhm, N
A biomechanical investigation on eight pairs of human cadaver proximal femurs was performed to evaluate the impact of a new augmentation method on the internal fixation of osteoporotic proximal femur fractures. The study focused on enhancing implant purchase to reduce the incidence of implant cut-out in osteoporotic bone. In a left-right comparison, a conventional hip screw fixation (control) was compared to the new cement augmentation method. After bone bed preparation through high pressure irrigation to remove fat, blood, and bone debris, the bones were augmented with low viscosity polymethylmethacrylate (PMMA) cement. Step-wise fatigue testing was performed by cyclically loading the femoral heads in a physiological manner, beginning at 1,500 N and increasing 500 N every 5,000 cycles to 4,000 N, and continuously monitoring head displacement. Failure was defined as >5.0 mm head displacement. The head displacement at 2,000 N was significantly smaller (p=0.018) for the augmented group as compared to the conventionally treated bones (0.09+/-0.01 mm vs. 0.90+/-0.32 mm; mean+/-SEM). The displacement rate at the second load step was significantly higher (p=0.018) for the conventionally treated bones as compared to the augmented ones. All of the nonaugmented specimens failed during testing, where 50% of the augmented specimens did not fail. The promising results of these experiments suggest that this new standardized irrigation/augmentation method enhances the implant anchorage and offers a potential solution to the problem of implant cut-out in osteoporotic metaphyseal bone. Copyright (c) 2006 Orthopaedic Research Society.
Zhu, Yuefeng; Shen, Jie; Cheng, Qun; Fan, Yongqian; Lin, Weilong
Objective To study the relationship of plasma homocysteine (Hcy), bone turnover biomarkers (BTB), and bone mineral density (BMD) with osteoporotic fracture (OPF) in elderly people. Methods Eighty-two patients (aged 65 years or older) admitted to our orthopedics department between October 2014 and May 2015 were randomly divided into three groups: 1) OPF group: 39 cases with the mean age 81.82±5.49 years, which included 24 females and 15 males; 2) high-energy fracture (HEF) group: 22 cases with the mean age 78.88±5.75 years, which included 16 females and six males; 3) non-bone-fracture group: 21 cases with mean age 79.75±5.47 years without bone fracture, which included 14 females and seven males. Plasma Hcy, BTB, and BMD were measured. Analysis of variance and multiple regression analysis were used in the statistical analysis. Results There was no significant difference in either age or sex among the three groups. There were significant differences in plasma Hcy and hip BMD between the OPF and HEF groups; there was also significant difference in plasma Hcy, 25-(OH) Vit D, and hip BMD between the OPF and non-fracture groups. There was no difference in lumbar spine BMD between the OPF group and the other two groups. There was no significant difference in plasma Hcy, 25-(OH) Vit D, hip or lumbar spine BMD between the HEF and non-fracture group. There was no significant difference in procollagen type I N-propeptide of type I collagen, serum C-terminal cross-linking telopeptide of type I collagen, and parathyroid hormone among the three groups. Plasma Hcy was linearly correlated with age and serum C-terminal cross-linking telopeptide of type I collagen, but not correlated with either hip or lumbar spine BMD or any other BTBs. Conclusion In this study, we found that the plasma Hcy level in elderly patients with OPF is higher than that of nonosteoporotic patients. It is not correlated with BMD, but positively correlated with bone resorption markers. An increased Hcy
Gullberg, B; Johnell, O; Kanis, J A
The aims of this study were to estimate the present and future incidence of hip fracture world-wide. From a survey of available data on current incidence, population trends and the secular changes in hip fracture risk, the numbers of hip fractures expected in 2025 and 2050 were computed. The total number of hip fractures in men and women in 1990 was estimated to be 338,000 and 917,000 respectively, a total of 1.26 million. Assuming no change in the age- and sex-specific incidence, the number of hip fractures is estimated to approximately double to 2.6 million by the year 2025, and 4.5 million by the year 2050. The percentage increase will be greater in men (310%) than in women (240%). With modest assumptions concerning secular trends, the number of hip fractures could range between 7.3 and 21.3 million by 2050. The major demographic changes will occur in Asia. In 1990, 26% of all hip fractures occurred in Asia, whereas this figure could rise to 37% in 2025 and to 45% in 2050. We conclude that the socioeconomic impact of hip fractures will increase markedly throughout the world, particularly in Asia, and that there is an urgent need to develop preventive strategies, particularly in the developing countries.
Chen, Peiqi; Krege, John H; Adachi, Jonathan D; Prior, Jerilynn C; Tenenhouse, Alan; Brown, Jacques P; Papadimitropoulos, Emmanuel; Kreiger, Nancy; Olszynski, Wojciech P; Josse, Robert G; Goltzman, David
Vertebral fractures are the most common osteoporotic fracture, and patients with prevalent vertebral fractures have a greater risk of future fractures. However, radiographically determined vertebral fractures are not identified as a distinct risk factor in the World Health Organization (WHO) fracture risk assessment tool. The objective of this study was to evaluate and compare potential risk factors including morphometric spine fracture status and the WHO risk factors for predicting 5-yr fracture risk. We hypothesized that spine fracture status provides prognostic information in addition to consideration of the WHO risk factors alone. A randomly selected, population-based community cohort of 2761 noninstitutionalized men and women > or =50 yr of age living within 50 km of one of nine regional centers was enrolled in the Canadian Multicentre Osteoporosis Study (CaMOS), a prospective and longitudinal cohort study following subjects for 5 yr. Prevalent and incident spine fractures were identified from lateral spine radiographs. Incident nonvertebral fragility fractures were determined by an annual, mailed fracture questionnaire with validation, and nonvertebral fragility fracture was defined by investigators as a fracture with minimal trauma. A model considering the WHO risk factors plus spine fracture status provided greater prognostic information regarding future fracture risk than a model considering the WHO risk factors alone. In univariate analyses, age, BMD, and spine fracture status had the highest gradient of risk. A model considering these three risk factors captured almost all of the predictive information provided by a model considering spine fracture status plus the WHO risk factors and provided greater predictive information than a model considering the WHO risk factors alone. The use of spine fracture status along with age and BMD predicted future fracture risk with greater simplicity and higher prognostic accuracy than consideration of the risk factors
Lorrain, Jacques; Paiement, Guy; Chevrier, Normand; Lalumière, Gaston; Laflamme, Georges-Henri; Caron, Pierre; Fillion, Anne
Through a survey of the literature and an analysis of selected national and regional statistics, a review of the incidence of osteoporosis and its consequences was performed. Results illustrate that the consequences of osteoporosis are preventable and should sensitize clinicians to the importance of early detection and the identification of risk factors for disease prevention and to early treatment once disease has been established. A marked increase in the annual incidence of hip fractures in all Canadians is noted. Whereas the incidence was less than 20,000 in 1981, the incidence of hip fracture grew to 27,342 in 1995, with 73% occurring in women. It is estimated that in Canada at least one in four women older than 50 years will have one or more osteoporosis-related fractures in their lifetimes. The consequences of these fractures are considerable, both for patients and healthcare services. Only half of all victims regain total autonomy, and the total direct costs in Canada stemming from osteoporosis are estimated to be $1.3 billion per year.
Yoo, Jae-Sung; Ryu, Jee-Won; Yu, Kun-Woong
Background Bisphosphonates are generally known to adversely affect fracture healing because they inhibit osteoclastic bone resorption. However, some authors argue that bisphosphonates have no adverse effect on the restoration of the mechanical integrity of long bones after fractures. It is unclear whether bisphosphonates can be initiated safely in patients with acute proximal humerus fractures. The aim of this study was to determine whether the early use of a bisphosphonate affects healing and outcomes of osteoporotic proximal humerus fractures treated with a locking compression plate. Methods Between August 2004 and June 2013, a total of 82 osteoporotic patients who underwent locking plate fixation of proximal humerus fractures were enrolled retrospectively. The patients were divided into two groups according to the timing of the commencement of treatment with alendronate after surgery: group A (n = 34, initiation of the bisphosphonate treatment within two weeks after surgery) and group B (n = 48, control group, initiation of the treatment three months after surgery). Patients were assessed for radiographic union at 2, 6, 10, and 16 weeks, 6 months, and 1 year after surgery. Clinical assessments were performed using the Constant score and American Shoulder and Elbow Surgeons (ASES) score at 1 year after surgery. Results No significant differences were observed between the two groups with respect to radiographic and clinical outcomes after locking plate fixation. All patients obtained fracture union, and the mean time to radiographic union was similar in group A and group B (6.3 and 6.6 weeks, respectively; p = 0.67). Conclusions This study shows that the early initiation of bisphosphonate treatment does not affect bone union or clinical outcomes in patients with an osteoporotic proximal humerus fracture treated by locking compression plate fixation. PMID:27904727
Cohen-Stavi, Chandra; Leventer-Roberts, Maya; Balicer, Ran D
Objective To directly compare the performance and externally validate the three most studied prediction tools for osteoporotic fractures—QFracture, FRAX, and Garvan—using data from electronic health records. Design Retrospective cohort study. Setting Payer provider healthcare organisation in Israel. Participants 1 054 815 members aged 50 to 90 years for comparison between tools and cohorts of different age ranges, corresponding to those in each tools’ development study, for tool specific external validation. Main outcome measure First diagnosis of a major osteoporotic fracture (for QFracture and FRAX tools) and hip fractures (for all three tools) recorded in electronic health records from 2010 to 2014. Observed fracture rates were compared to probabilities predicted retrospectively as of 2010. Results The observed five year hip fracture rate was 2.7% and the rate for major osteoporotic fractures was 7.7%. The areas under the receiver operating curve (AUC) for hip fracture prediction were 82.7% for QFracture, 81.5% for FRAX, and 77.8% for Garvan. For major osteoporotic fractures, AUCs were 71.2% for QFracture and 71.4% for FRAX. All the tools underestimated the fracture risk, but the average observed to predicted ratios and the calibration slopes of FRAX were closest to 1. Tool specific validation analyses yielded hip fracture prediction AUCs of 88.0% for QFracture (among those aged 30-100 years), 81.5% for FRAX (50-90 years), and 71.2% for Garvan (60-95 years). Conclusions Both QFracture and FRAX had high discriminatory power for hip fracture prediction, with QFracture performing slightly better. This performance gap was more pronounced in previous studies, likely because of broader age inclusion criteria for QFracture validations. The simpler FRAX performed almost as well as QFracture for hip fracture prediction, and may have advantages if some of the input data required for QFracture are not available. However, both tools require calibration
Lippuner, Kurt; Golder, Matthias; Greiner, Roger
The aim of this study was to estimate the hospitalization incidence and the total number of hospital days related to all fractures and osteoporotic fractures in the year 2000 in Switzerland and to compare these with data from other frequent disorders in men and women. The official administrative and medical statistics database of the Swiss Federal Office of Statistics (SFOS) from the year 2000 was used. It covered 81.2% of all registered patient admissions and was considered to be representative of the entire population. We included the ICD-10 codes of 84 diagnoses that were compatible with an underlying osteoporosis and applied the best matching age-specific osteoporosis attribution rates published for the ICD-9 diagnosis codes to the individual ICD-10 codes. To preserve comparability with previously published data from 1992, we grouped the data related to the ICD-10 fracture codes into seven diagnosis pools (fractures of the axial skeleton, fractures of the proximal upper limbs, fractures of the distal upper limbs, fractures of the proximal lower limbs, fractures of the distal lower limbs, multiple fractures, and osteoporosis) and analyzed them separately for women and men by age group. Incidences of hospitalization due to fractures were calculated, and the direct medical costs related to hospitalization were estimated. In addition, we compared the results with those from chronic pulmonary obstructive disease (COPD), stroke, acute myocardial infarction, heart failure, diabetes and breast carcinoma from the same database. In Switzerland during 2000, 62,535 hospitalizations for fractures (35,586 women and 26,949 men) were registered. Fifty-one percent of all fractures in women and 24% in men were considered as osteoporotic. The overall incidences of hospitalization due to fractures were 969 and 768 per 100,000 in women and men, respectively. The hospitalization incidences for fractures of the proximal lower limbs and the axial skeleton increased exponentially after
Falch, J A; Ilebekk, A; Slungaard, U
During the 2-year period 1978-1979, a total of 2109 hip fractures (of the proximal end of the femur) occurred in Oslo. The age- and sex-specific annual incidence was the highest ever reported. A previous hip fracture had occurred in 13 per cent of the women and 6.8 per cent of the men. In 1979, a total of 5920 hip fractures was reported in Norway. Compared with Oslo, all other counties had a lower incidence. The number of fractures in Oslo was five times greater in 1982 compared with 1950. This increase cannot be explained only by the increasing number of elderly persons.
The incidence of hip fracture has been studied extensively, but there is still some doubt whether the age-specific incidence is increasing. The proportion of trochanteric fractures has varied and has also been said to be increasing. We studied data on 1,730 prospectively registered cases from 1998–2003 and computed age- and gender-specific incidence rates for intracapsular and trochanteric fractures. The incidence of hip fracture for women over 50 years was 1,263 and for men 452 per 100,000. The proportion of trochanteric fractures was 38% for women and 41% for men. There was no significant difference in the proportion of trochanteric fractures either between or within the genders, and the proportion did not exceed 50% in any age group. These findings confirm the high incidence of hip fracture in Norway but do not indicate any increase. The proportion of trochanteric fractures also seems to be stable. PMID:17033761
Soveid, Mahmood; Serati, Ali Reza; Masoompoor, Masoomeh
Hip fracture, the most serious complication of osteoporosis, puts the burden of a lot of costs for treatment on any health system. Previous reports on rates of hip fracture in Asian countries differ a lot. The aim of this study was to estimate the incidence rate of hip fracture in Shiraz, Iran. In Shiraz, Iran, all operating-room logs with diagnosis of hip fracture were reviewed for hip fractures caused by a simple fall in patients over 50 years, during March 21, 2000, to March 21, 2003. According to patients' medical records, age, sex, type of fracture (intertrochanteric, neck, subtrochanteric) and patients' regions according to Shiraz municipality divisions were obtained. The age-adjusted incidence rates of hip fracture standardized to the 1985 US white population (325.74/100,000 for men and 519.05/100,000 for women) and to the 1989 US white population (384.61/100,000 for men and 548.17/100,000 for women) were the highest in Asia. The intertrochanteric fractures were significantly higher among females ( p =0.003). The incidence of intertrochanteric and neck fractures were increased with age. In all age groups, females had higher incidence rates, except for ages over 80 years, in which males had higher incidence rates than females. In wealthier regions of the city, the incidence rates were higher than in other regions. High incidence of hip fracture in our population, especially in males over 80 years, shows that preventive strategies for hip fracture and osteoporosis should be considered in males as well as females. Further studies are needed to find incidence rates in other cities, especially in the very urbanized city of Tehran.
Skorupski, Nicole; Alexander, Ivy M
The purpose of this article is to increase awareness of osteoporosis incidence in patients with hip fracture among providers and allied health professionals, to increase osteoporosis recognition and treatment in post hip-fracture patients, and to provide guidance on how to improve continuity of care and collaboration between members of the multidisciplinary healthcare team. Recent evidence from the literature is reviewed to identify effective management strategies for post low-energy trauma hip-fracture patients and prevention of future osteoporotic fracture, regardless of osteoporosis diagnosis prior to the initial fracture. Despite the availability of accurate screening technologies and highly efficacious antiosteoporosis medications, implementation of these measures for low-energy trauma hip-fracture patients remains critically low. This is because of a number of factors including hesitancy to integrate care across specialty lines, lack of reliable referral systems, and resistance to change. There is also a lack of recognition of the connection between low-energy trauma hip fracture and osteoporosis by many healthcare professionals. All members of the multidisciplinary care team are called to action to adopt osteoporosis evaluation and treatment strategies that research has shown to be effective on a larger scale in the post hip-fracture setting. ©2012 The Author(s) Journal compilation ©2012 American Association of Nurse Practitioners.
Brace is one of the most commonly used interventions to manage osteoporotic vertebral fracture. However, its authentic effectiveness remains unclear. The aim of this study was to investigate the efficacy of brace in patients with osteoporotic vertebral fractures. We conducted a literature review and meta-analysis following the guideline and handbook of the Cochrane collaboration. Ten published articles were included in this study and data from 4 randomized controlled trials were analyzed. Low quality evidence proved using Spinomed brace could bring large and significant beneficial effect to patients with sub-acute osteoporotic vertebral fractures. Very low quality evidence proved no significant difference between Spinomed orthosis, rigid brace and soft brace when they were used in patients with acute fractures. Therefore, it might be applicable to recommend middle term use of Spinomed orthosis to patients with subacute fracture. In addition, this study emphasized the need for high quality randomized controlled trials. PMID:27550495
Jin, Yuan Zhe; Lee, Jae Hyup
Brace is one of the most commonly used interventions to manage osteoporotic vertebral fracture. However, its authentic effectiveness remains unclear. The aim of this study was to investigate the efficacy of brace in patients with osteoporotic vertebral fractures. We conducted a literature review and meta-analysis following the guideline and handbook of the Cochrane collaboration. Ten published articles were included in this study and data from 4 randomized controlled trials were analyzed. Low quality evidence proved using Spinomed brace could bring large and significant beneficial effect to patients with sub-acute osteoporotic vertebral fractures. Very low quality evidence proved no significant difference between Spinomed orthosis, rigid brace and soft brace when they were used in patients with acute fractures. Therefore, it might be applicable to recommend middle term use of Spinomed orthosis to patients with subacute fracture. In addition, this study emphasized the need for high quality randomized controlled trials.
Takahara, Kenji; Kamimura, Mikio; Moriya, Hideki; Ashizawa, Ryohei; Koike, Tsuyoshi; Hidai, Yohei; Ikegami, Shota; Nakamura, Yukio; Kato, Hiroyuki
Recently percutaneous vertebroplasty (PVP) was frequently performed for treatment of osteoporotic vertebral fractures (VFs). It is widely accepted that new compression fractures tend to occur adjacent to the vertebral bodies, typically within a month after PVP. To determine the risk factors among several potential predictors for de novo VFs following PVP in patients with osteoporosis. We retrospectively screened the clinical results of 88 patients who had been treated by PVP. Fifteen cases were excluded due to non-union. Of the remaining 73 patients, 19 (26.0%) later returned with pain due to a new vertebral compression fracture. One patient with a non-adjacent fracture and 2 patients with adjacent factures occurring 3 months later were excluded from the study. The 9 male patients were excluded to avoid gender bias. Ultimately, we divided the 61 remaining postmenopausal female patients (mean age: 78.9 years) into the collapse group (14 patients) who had experienced adjacent vertebral collapse after PVP and the non-collapse group (47 patients) who had not. Logistic regression analysis was performed to identify the risk factors for new VFs after PVP. All 14 cases of adjacent VF occurred within the first month after surgery. The collapse group had significantly advanced age, higher urinary N-terminal cross-linking telopeptide of type I collagen, and lower lumbar and hip bone mineral density (BMD) scores as compared with the non-collapse group. The odds ratios for age, lumbar, total hip, femoral neck, and trochanteric BMD were 4.5, 8.2, 4.5, 7.2, and 9.6, respectively. Positive likelihood ratios suggested that age more than 85 years, lumbar BMD less than 0.700 [-2.6SD], total hip BMD less than 0.700 [-1.8SD], neck BMD less than 0.600 [-2.1], and trochanter BMD less than 0.600 conferred an elevated risk of adjacent VF. Our study revealed that advanced age and decreased lumbar and hip BMD scores most strongly indicated a risk of adjacent VF following PVP.
Qin, De-An; Song, Jie-Fu; Wei, Jie; Shao, Jin-Kang
To explore the reasons of secondary fracture after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs) and discuss the measure of prevention and cure. From January 2011 to January 2013, the clinical data of 180 patients with primary OVCFs treated by PVP were retrospectively analyzed. There were 75 males and 105 females, aged from 68 to 95 years old with an average of (79.50 ± 5.45) years. The involved vertebrae were identified according to the clinical symptoms and imaging data. PVP were performed in 362 vertebrae and the patients were followed up with an average of 12 months. Subsequent vertebral fractures were found through the pain's reappearance and MRI or bone scan. The patients were divided into secondary fracture group and no-secondary fracture group according to the subsequent fractures or no. Secondary fracture group was divided into two groups according to gender, and the patients with secondary fracture were also categorized into the original surgical vertebral fractures, adjacent vertebral fracture and remote vertebral fractures. The age, gender, the cement volume, the cement leakage, secondary fracture site, the incidence and type of secondary fracture were observed and compared among different groups. Among the 362 vertebrae of PVP, there were 109 vertebrae in male and 253 vertebrae in female. And 27 vertebrae (10 in male and 17 in female) of 22 cases (9 males and 13 females) occurred secondary fracture. The second PVP were performed in 13 cases (16 vertebrae) and the third PVP in 2 cases (4 vertebrae); 7 cases (7 vertebrae) were treated with conservative therapy. There was no statistically significant difference on age, gender, cement volume and leakage between secondary fracture group and no-secondary fracture group (P > 0.05). There was no statistically significant difference on the incidence and type of secondary fracture between male and female (P > 0.05). No significant difference was found on the adjacent
Coomber, Ross; Porteous, Matthew; Hubble, Matthew J W; Parker, Martyn J
When treating a hip fracture with a total hip replacement (THR) the surgical technique may differ in a number of aspects in comparison to elective arthroplasty. The hip fracture patient is more likely to have poor bone stock secondary to osteoporosis, be older, have a greater number of co-morbidities, and have had limited peri-operative work-up. These factors lead to a higher risk of complications, morbidity and perioperative mortality. Consideration should be made to performing the THR in a laminar flow theatre, by a surgeon experienced in total hip arthroplasty, using an anterolateral approach, cementing the implant in place, using a large head size and with repair of the joint capsule. Combined Ortho-geriatric care is recommended with similar post-operative rehabilitation to elective THR patients but with less expectation of short length of stay and consideration for fracture prevention measures. Copyright © 2016. Published by Elsevier Ltd.
Arakaki, Harumi; Owan, Ichiro; Kudoh, Hirohisa; Horizono, Hidehiro; Arakaki, Kaoru; Ikema, Yasunari; Shinjo, Hirotaka; Hayashi, Kaori; Kanaya, Fuminori
This study investigated the current incidence of hip fractures in Okinawa prefecture and compared the data with those obtained in our previous study, which was conducted using similar methods in 1987/1988. All patients, aged 50 years or older and residing in Okinawa, admitted to Okinawa hospitals in 2004 for a fresh hip fracture were identified from hospital registries. Details were obtained from the medical records and radiographs of all patients and classified according to fracture type (cervical or trochanteric), age, sex, and fracture location. Subtrochanteric fractures and pathological fractures were excluded. A total of 1,349 patients (242 men and 1,107 women) were admitted for a fresh hip fracture in 2004. Their average age was 76.9 years for men and 82.4 years for women. There were 671 cervical fractures, 654 trochanteric fractures, and 24 unclassified proximal femoral fractures. Comparing the data from 1987/1988 to those from 2004, the total number of hip fractures increased by 188%, from 469 to 1,349. The age-adjusted incidence rates per 100,000, standardized to the 2000 US population, were 75.7 and 296.1 in 1987/1988 and 123.6 and 420 in 2004 for men and women, respectively. The incidence rates in all age groups (at 5-year intervals) were higher in 2004 than in 1987/1988, indicating that people 50 years of age or older became more susceptible to hip fractures. Accordingly, the accretion of the hip fracture incidence rate was greater than that which could be explained purely by changes in population size and structure.
Cole, Raymond E.; Harris, Steven T.
Context Nonvertebral fractures (NVFs) are the most costly and disabling type of osteoporotic fractures. Bisphosphonate therapy effectively reduces the risk for NVFs; however, fracture protection depends critically on adherence and persistence. Approved bisphosphonate regimens with extended dosing intervals increase patient convenience, help patients remain on therapy, and improve fracture protection in clinical practice. Evidence Acquisition To assess evidence for NVF reduction with extended-interval bisphosphonates, we searched PubMed for phase 3 clinical trials, meta-analyses, and reviews of approved nitrogen-containing bisphosphonate regimens with monthly or less frequent dosing (monthly oral ibandronate, monthly or intermittent oral risedronate, quarterly intravenous [IV] ibandronate, and yearly IV zoledronic acid). These references were augmented by ISI Web of Science cited reference searches, ISI Proceedings searches, and hand searches of relevant conference proceedings and review bibliographies. Evidence Synthesis Monthly oral and quarterly IV ibandronate reduce NVF risk significantly more than daily oral ibandronate and placebo, as shown by meta-analyses stratified by ibandronate dose (annual cumulative exposure). Intermittent and monthly oral risedronate have shown bone density gains similar to those seen with daily oral risedronate. Incidence rates of NVF, reported as adverse events, were also similar. Yearly IV zoledronic acid reduced NVF risk by 25% and hip fracture risk by 41% compared with placebo in its pivotal trial for postmenopausal osteoporosis. Conclusions Extended-interval bisphosphonates offer similar or superior NVF protection with less lifestyle disruption compared with daily or weekly treatment. By removing obstacles to adherence and persistence, extended-interval oral and IV bisphosphonate regimens provide valuable therapeutic options to enhance real-world effectiveness and reduce NVF incidence. PMID:19295933
Jiang, Y; Rong, X X; Chen, P; Xu, Y J; Zhu, G X
Objective: To explore the treatment of senile osteoporotic femoral fractures after using internal fixation of bone cement dry prosthetic. Methods: Twelve patients aged from 74 to 94 years with mean age of (84.0±2.5) years with internal fixation of bone cement dry prosthetic surgery who were treated at Department of Orthopaedics in Nanjing Medical University Affiliated Wuxi Second Hospital between May 2013 and May 2015 were retrospectively analyzed. There were 8 male and 4 female, 10 cases of tumble and 2 cases of traffic injury. The fracture types with AO type included 1 case of A1 type, 5 cases of A2 type, 3 cases of A3 type, 1 case of B1 type, 2 cases of B2 type. The steel plate internal fixation with bone cement dry prosthetic method was chosen to treat senile severe femoral fracture. Postoperative observation of postoperative pain assessment, hip joint activity and walking ability were evaluated. Paired simple t test and Wilcoxon rank sum test were used to compare the differences of pain score and the ability to walk. Results: Twelve cases received an average of (16.0±3.6) months follow-up. The average hospitalization days are (9.0±1.4) days and average of intraoperative time was (68.0±10.6) minutes. Intraoperative blood loss compared to normal was (106.0±24.2) ml. Patients began walking load and activities in two weeks. The gait and joint activities gradually restored and there were no obvious deformity and no loose internal fixation. All of the patients didn't have fracture shift with breaking plates or screws deformation and have no bone cement reaction. The walking ability was (4.1±0.9) points, the hip joint activities were 98.5°±7.7° and pain scores were 1.22±0.58 by Holden grading standards. The differences of walking ability (Z=-3.126, P<0.05) and pain scores (t=23.047, P<0.001) between pre- and post-operative were statistically significant. One patient had contralateral hip pain, 2 patients had lateral thigh pain, 10 patients returned to
Andersson, Åsa G.; Seiger, Åke; Appelros, Peter
Background. Our aim was to determine the incidence of hip fractures within two years after stroke, to identify associated factors, to evaluate which test instruments that best could identify people at risk, and to describe the circumstances that prevailed when they sustained their hip fractures. Method. A total of 377 persons with first-ever stroke were followed up for a 24-month period. Stroke severity, cognition, and associated medical conditions were registered. The following test instruments were used: National Institutes of Health Stroke Scale, Mini-Mental State Examination, Berg Balance Scale, Timed Up & Go, and Stops Walking When Talking. Result. Sixteen of the persons fractured their hip within the study period, which corresponds to an incidence of 32 hip fractures per 1000 person-years. Persons with fractures more often had impaired vision and cognitive impairment and more had had previous fractures. Of the investigated test instruments, Timed Up & Go was the best test to predict fractures. Conclusion. The incidence of hip fractures in persons with stroke was high in this study. Persons with previous fractures, and visual and cognitive defects are at the greatest risk. Certain test instruments could be used in order to find people at risk, which should be targeted for fall preventive measures. PMID:23691433
Tosounidis, Theodoros H; Castillo, Raul; Kanakaris, Nikolaos K; Giannoudis, Peter V
Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.
Azagra, Rafael; Zwart, Marta; Encabo, Gloria; Aguyé, Amada; Martin-Sánchez, Juan Carlos; Puchol-Ruiz, Nuria; Gabriel-Escoda, Paula; Ortiz-Alinque, Sergio; Gené, Emilio; Iglesias, Milagros; Moriña, David; Diaz-Herrera, Miguel Angel; Utzet, Mireia; Manresa, Josep Maria
The FRAX® tool estimates the risk of a fragility fracture among the population and many countries have been evaluating its performance among their populations since its creation in 2007. The purpose of this study is to update the first FRIDEX cohort analysis comparing FRAX with the bone mineral density (BMD) model, and its predictive abilities. The discriminatory ability of the FRAX was assessed using the 'area under curve' of the receiver operating characteristic (AUC-ROC). Predictive ability was assessed by comparing estimated risk fractures with incidence fractures after a 10-year follow up period. One thousand three hundred eight women ≥ 40 and ≤ 90 years followed up during a 10-year period. The AUC for major osteoporotic fractures using FRAX without DXA was 0.686 (95 % CI 0.630-0.742) and using FN T-score of DXA 0.714 (95 % CI 0.661-0.767). Using only the traditional parameters of DXA (FN T-score), the AUC was 0.706 (95 % CI 0.652-0.760). The AUC for hip osteoporotic fracture was 0.883 (95 % CI 0.827-0.938), 0.857 (95 % CI 0.773-0.941), and 0.814 (95 % CI 0.712-0.916) respectively. For major osteoporotic fractures, the overall predictive value using the ratio Observed fractures/Expected fractures calculated with FRAX without T-score of DXA was 2.29 and for hip fractures 2.28 and with the inclusion of the T-score 2.01 and 1.83 respectively. However, for hip fracture in women < 65 years was 1.53 and 1.24 respectively. The FRAX tool has been found to show a good discriminatory capacity for detecting women at high risk of fragility fracture, and is better for hip fracture than major fracture. The test of sensibility shows that it is, at least, not inferior than when using BMD model alone. The predictive capacity of FRAX tool needs some adjustment. This capacity is better for hip fracture prediction and better for women < 65 years. Further studies in Catalonia and other regions of Spain are needed to fine tune the FRAX tool's predictive
LeBoff, Meryl S.; Cobb, Haley; Gao, Lisa Y.; Hawkes, William; Yu-Yahiro, Janet; Kolatkar, Nikheel S.; Magaziner, Jay
Objective Celiac disease is associated with decreased bone density, however, the risk of fractures in celiac disease patients is unclear. We compared the prevalence of celiac disease between a group of women with hip fractures and a group of women undergoing elective joint replacement surgery and the association between celiac disease and vitamin D levels. Methods Two hundred eight community dwelling and postmenopausal women were recruited from Boston, MA (n=81) and Baltimore, MD (n=127). We measured tissue transglutaminase IgA by ELISA to diagnose celiac disease and 25-hydroxyvitamin D (25(OH)D) levels by radioimmunoassay in both women with hip fractures (n=157) and the control group (n=51), all of whom were from Boston. Subjects were excluded if they took any medications or had medical conditions that might affect bone. Results Median serum 25(OH)D levels were significantly lower (p< 0.0001) in the hip fracture cohorts compared to the elective joint replacement cohort (14.1 ng/ml vs. 21.3 ng/ml, respectively). There were no differences in the percentage of subjects with a positive tissue transglutaminase in the women with hip fractures versus the control group (1.91% vs. 1.61%, respectively). Conclusion Vitamin D levels are markedly reduced in women with hip fractures, however hip fracture patients did not show a higher percentage of positive tissue transglutaminase levels compared with controls. These data suggest that routine testing for celiac disease among hip fracture patients may not prove useful, although larger prospective studies among hip fracture subjects are needed. PMID:23732553
Pluskiewicz, W; Adamczyk, P; Franek, E; Leszczynski, P; Sewerynek, E; Wichrowska, H; Napiorkowska, L; Kostyk, T; Stuss, M; Stepien-Klos, W; Golba, K S; Drozdzowska, B
The aim of the cross-sectional study was to establish the degree of conformity between 10-year probability of osteoporotic fracture, assessed by FRAX, and using the nomograms, as proposed by Nguyen at al. Postmenopausal Polish women (2012) were examined in their mean age of 68.5+/-7.9 years (age range 55-90 years). Fracture probability by FRAX was based on age, BMI, prior fracture, hip fracture in parents, steroid use, rheumatoid arthritis, alcohol use, secondary osteoporosis and T-score for femoral neck BMD. Fracture probability by Nguyen's nomograms was based on age, the number of prior fractures, the number of falls and T-score for femoral neck BMD. The mean conformity rate was 79.1% for any fracture risk (for threshold 20%) and 79.5% for hip fracture (threshold 3%). Any and hip fracture risks were significantly higher for both methods in women with fracture history in comparison to those without fracture and increased with ageing. The influence of prior fracture and ageing was more evident in Nguyen's nomograms. ROC analyses of any fracture risk in FRAX and Nguyen's methods demonstrated the area under curve (AUC) at 0.833 and 0.879, respectively. Similar analyses for hip fracture demonstrated AUCs for FRAX and Nguyen's technique at 0.726 and 0.850, respectively. The AUCs for Nguyen's nomograms were significantly larger than the AUCs for FRAX (p<0.0001). The mean conformity for any fracture risk is 79.1% and 79.5% for hip fracture. Nguyen's nomograms seem to be more efficient in fracture risk assessment, especially for hip fractures, due to a higher accuracy of the method. The information on the number of falls during the last year and multiple fractures ought to be incorporated into the method of fracture risk prediction. The degree of conformity was assessed in a group of 2012 women between 10-year FRAX prognosis of fracture and Nguyen et al.'s nomograms. The mean conformity for any fracture risk is 79.1% and 79.5% for hip fracture. Nguyen's nomograms seem to
Lane, Nancy E; Parimi, Neeta; Lui, Li-Yung; Wise, Barton L; Yao, Wei; Lay, Yu-An Evan; Cawthon, Peggy M; Orwoll, Eric
Uric acid (UA) is produced from purines by the enzyme xanthine oxidase, and elevated levels may cause arthritis and kidney stones. Conversely, UA also appears to function as an antioxidant and may protect against the oxidative stress associated with aging and disease. We performed a prospective fracture case-cohort study to understand the relation of UA and fracture risk in older men enrolled in the Osteoporotic Fractures in Men (MrOS) study. In the cohort of 5994 men aged 65 years and older attending the baseline MrOS examination, we evaluated a subgroup 1680 men in a case-cohort study design. The analytic group included 387 men with incident nonspine fractures (73 hip) and a random sample of 1383. Serum UA was measured in baseline serum samples. Modified proportional hazards models that account for case-cohort study design were used to estimate the relative hazards (RH) of hip and nonspine fracture in men for serum UA. Models were adjusted for age, race, clinic site, body mass index, vitamin D, parathyroid hormone, walking speed, Physical Activity Scale for the Elderly (PASE) score, frailty, and total. Subjects with incident nonspine fractures were older, had lower total hip bone mineral density (BMD), and higher serum phosphorus. There was an 18% decreased risk of nonspine fractures (95% confidence interval [CI] 0.71-0.93; p = 0.003) per 1 SD increase of baseline serum and 34% decreased risk of nonspine fractures in quartile 4 of UA versus quartiles 1, 2, and 3 (95% CI 0.49-0.89; p = 0.028) compared with nonfracture cases after multivariate adjustment. Hip fractures were not significantly associated with UA. Total hip BMD was significantly higher in the group of men with high UA levels compared with lower UA levels and increased linearly across quartiles of UA after multivariate adjustment (p for trend = 0.002). In summary, higher serum UA levels were associated with a reduction in risk of incident nonspine fractures but not hip fractures and higher hip BMD.
Zapatero, Antonio; Barba, Raquel; Canora, Jesús; Losa, Juan E; Plaza, Susana; San Roman, Jesús; Marco, Javier
The aim of the present study is to analyze the incidence of hip fracture as a complication of admissions to internal medicine units in Spain. We analyzed the clinical data of 2,134,363 adults who had been admitted to internal medicine wards. The main outcome was a diagnosis of hip fracture during hospitalization.Outcome measures included rates of in-hospital fractures, length of stay and cost. A total of 1127 (0.057%) admittances were coded with an in-hospital hip fracture. In hospital mortality rate was 27.9% vs 9.4%; p < 0.001, and the mean length of stay was significantly longer for patients with a hip fracture (20.7 days vs 9.8 days; p < 0.001). Cost were higher in hip-fracture patients (6927€ per hospitalization vs 3730€ in non fracture patients). Risk factors related to fracture were: increasing age by 10 years increments (OR 2.32 95% CI 2.11-2.56), female gender (OR 1.22 95% CI 1.08-1.37), admission from nursing home (OR 1.65 95% CI 1.27-2.12), dementia (1.55 OR 95% CI1.30-1.84), malnutrition (OR 2.50 95% CI 1.88-3.32), delirium (OR 1.57 95% CI 1.16-2.14), and anemia (OR 1.30 95%CI 1.12-1.49). In-hospital hip fracture notably increased mortality during hospitalization, doubling the mean length of stay and mean cost of admission. These are reasons enough to stress the importance of designing and applying multidisciplinary plans focused on reducing the incidence of hip fractures in hospitalized patients.
Background The aim of the present study is to analyze the incidence of hip fracture as a complication of admissions to internal medicine units in Spain. Methods We analyzed the clinical data of 2,134,363 adults who had been admitted to internal medicine wards. The main outcome was a diagnosis of hip fracture during hospitalization. Outcome measures included rates of in-hospital fractures, length of stay and cost. Results A total of 1127 (0.057%) admittances were coded with an in-hospital hip fracture. In hospital mortality rate was 27.9% vs 9.4%; p < 0.001, and the mean length of stay was significantly longer for patients with a hip fracture (20.7 days vs 9.8 days; p < 0.001). Cost were higher in hip-fracture patients (6927€ per hospitalization vs 3730€ in non fracture patients). Risk factors related to fracture were: increasing age by 10 years increments (OR 2.32 95% CI 2.11-2.56), female gender (OR 1.22 95% CI 1.08-1.37), admission from nursing home (OR 1.65 95% CI 1.27-2.12), dementia (1.55 OR 95% CI1.30-1.84), malnutrition (OR 2.50 95% CI 1.88-3.32), delirium (OR 1.57 95% CI 1.16-2.14), and anemia (OR 1.30 95%CI 1.12-1.49). Conclusions In-hospital hip fracture notably increased mortality during hospitalization, doubling the mean length of stay and mean cost of admission. These are reasons enough to stress the importance of designing and applying multidisciplinary plans focused on reducing the incidence of hip fractures in hospitalized patients. PMID:23298165
Masala, Salvatore; Ciarrapico, Anna Micaela; Vinicola, Vincenzo; Mammucari, Matteo; Simonetti, Giovanni
A retrospective study was conducted in 179 consecutive patients (48 males, 131 females; mean age: 72.0 ± 8.59 years; range: 51–93) with single symptomatic acute amyelic osteoporotic vertebral fracture presenting between September 2004 and September 2005 to the Santa Lucia Foundation in Rome, Italy. Vertebral fractures usually become manifest due to pain which can be debilitating. Treatment depends on the presence or absence of spinal cord involvement. In the first case, surgical stabilization is mandatory. In the second case, treatment may be performed either by conservative medical therapy (CMT) or percutaneous vertebroplasty (PVT). The aim of this study was to evaluate the effectiveness, costs and cost-effectiveness of percutaneous vertebroplasty. After 2 weeks of analgesic therapy, 153 patients presented refractory pain and were offered treatment by PVT. A total of 58 patients accepted and underwent PVT (PVT group), while 95 refused and underwent conservative medical therapy (CMT group). Follow-up was performed by specialist consults, spine radiography and MRI and a self-assessment questionnaire evaluating pain using a Visual Analogue Scale (VAS) and function using an ambulation and an Activities of Daily Living (ADL) scale. A 12-month follow-up was obtained in 86 of 95 (90.5%) CMT group patients and 54 of 58 (93.1%) PVT group patients. Significant reduction of VAS and improvement of ambulation and ADL was observed in both groups at 1 week and 3 and 12 months (P < 0.05; Wilcoxon signed rank test), however, these results were significantly superior in the PVT group at 1 week and 3 months (P < 0.05; Mann–Whitney U test). Average cost per patient at 1 week and 3 and 12 months were respectively 755.49 ± 661.96, 3791.95 ± 3341.97 and 4299.55 ± 3211.53 € (CMT group) and 3311.35 ± 0.32, 3745.30 ± 3.59 and 4101.05 ± 755.41 € (PVT group). PVT resulted significantly more cost-effective than CMT with regards to the three scales at
Sadat-Ali, Mir; Gullenpet, Abid Hussain; Azam, Md Quamar; Al-Omran, Ammar K
AIM: To evaluate the relationship between a vertebral fracture and a hip fracture in Saudi Arabians with osteoporosis. METHODS: In this retrospective study, 154 Saudi Arabian patients with osteoporosis-related hip fractures were analyzed for the presence of a vertebral fracture. Radiographs were retrieved from the IPAC (Image Picture Archiving and Computing) System, an imaging retrieval system, and were reviewed independently by two of the authors, Abid Hussain Gullenpet, and Mir Sadat-Ali, and later reviewed jointly. Patients admitted with proximal hip fracture who were ≥ 50 years and had undergone Thoraco-lumber imaging and a dual energy X-ray absorptiometry (DEXA) scan were included in the study. Patients with a history of significant trauma to the spine and those with a malignancy or connective tissue disorder were excluded from the analysis. RESULTS: Out of 154 patients with hip fractures, 78 had a fracture of the femoral neck while 76 had an intertrochanteric hip fracture. Of the 111 patients who were finally included in the study, after applying inclusion and exclusion criteria, 76 patients with an average age of 67.28 ± 12 years had no fractures of the spine. Thirty-five patients with an average age of 76.9 ± 14.5 years (31.53%) had a total of 49 vertebral fractures. Patients with vertebral fractures were significantly older than those without fractures P < 0.001. Overall, 24.7% of these patients had an asymptomatic vertebral fracture. Further analysis showed that 11 males (18.96%) and 24 females (45.28%) had suffered a previous asymptomatic vertebral fracture. Interestingly, all women who participated in this study and who presented with a femoral neck fracture had experienced a prior asymptomatic vertebral fracture. CONCLUSION: We recommend that all elderly patients who go to the radiology department for a chest X-ray also have a DEXA scan and a lateral thoracic spine radiograph. PMID:23362467
Most femoral neck fractures are osteoporotic fractures in the elderly. The one-year mortality after neck fracture in this group is 24%.For hemiarthroplasty (HA) the bipolar heads have a risk reduction for reoperation due to acetabular erosion compared with monoblock heads. Surprisingly, the bipolar head had an increased reoperation risk for dislocation, infection and for periprosthetic fracture.Total hip arthroplasty (THA) after fracture has a four-fold raised risk for dislocation compared with THA after osteoarthritis. A larger head on the same neck (head to neck ratio) results in a theoretically larger range of movement and hence less risk for dislocation. The dual mobility bearing has, theoretically, the largest range of movement and good clinical results.Functional results are better for THA compared with HA. Arthroplasty for fracture has much better results compared with arthroplasty after a failed internal fixation; the risk for reoperation is more than doubled for the latter.A Swedish hip arthroplasty register study found a 20-fold higher risk for periprosthetic fracture when comparing uncemented HA with matt cemented HA. Also a polished cemented stem had 13½-fold higher risks compared with a matt.The mortality during the first day after surgery is higher for cemented compared with uncemented arthroplasties, but lower after one week, one month and one year. Analysing the time points together resulted in no difference.A matt cemented THA with a maximum head size, maybe dual mobility, has the best results, and is also for the low-demanding elderly.
Huang, Tsan-Wen; Chuang, Po-Yao; Lin, Shih-Jie; Lee, Chien-Yin; Huang, Kuo-Chin; Shih, Hsin-Nung; Lee, Mel S.; Hsu, Robert Wen-Wei; Shen, Wun-Jer
Abstract Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing. Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared. A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months
Huang, Tsan-Wen; Chuang, Po-Yao; Lin, Shih-Jie; Lee, Chien-Yin; Huang, Kuo-Chin; Shih, Hsin-Nung; Lee, Mel S; Hsu, Robert Wen-Wei; Shen, Wun-Jer
Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing.Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared.A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications
Triantafyllopoulos, Ioannis K; Lambropoulou-Adamidou, Kalliopi; Nacopoulos, Cleopatra C; Papaioannou, Nikolaos A; Ceausu, Iuliana; Depypere, Herman; Erel, C Tamer; Pérez-López, Faustino R; Schenck-Gustafsson, Karin; van der Schouw, Yvonne T; Simoncini, Tommaso; Tremollieres, Florence; Rees, Margaret; Lambrinoudaki, Irene
Osteoporotic vertebral fractures are associated with significant morbidity, excess mortality as well as health and social service expenditure. Additionally, women with a prevalent osteoporotic vertebral fracture have a high risk of experiencing a further one within one year. It is therefore important for the physician to use a diagnostic and therapeutic algorithm for early detection and effective treatment of vertebral fractures. The aim of this position statement is to provide and critically appraise evidence on the management of women with a vertebral osteoporotic fracture. Literature review and consensus of expert opinion. The management of women with osteoporotic vertebral fractures includes measures to reduce pain providing early mobility, to support the affected spine ensuring fracture healing, as well as starting treatment for osteoporosis itself. Any other underlying pathology should be sought and treated. Early detection and treatment is essential as there is an increased risk of further fractures in patients with vertebral fractures. Treatment will depend on the underlying causes of bone loss, efficacy in any particular situation, cost and patient preference. Copyright © 2014. Published by Elsevier Ireland Ltd.
Sosa, Manuel; Saavedra, Pedro; Gómez-de-Tejada, María-Jesús; Navarro, María-del-Carmen; Jódar, Esteban; García, Esther; Fuentes, Rafael
Vertebral fracture is often underdiagnosed. Patients with hip fracture may suffer from vertebral fracture without knowing it. The diagnosis of vertebral fracture is sometimes difficult because there is no consensus regarding the definition of osteoporotic vertebral fracture, and several indexes may be used to diagnose it and the concordance between several observers may not be optimal. To study the concordance in the diagnosis of vertebral fracture done by three different doctors: an orthopedic surgeon, a radiologist, and a bone mineral metabolism expert. A lateral thoracic-lumbar spine X-Ray was performed in 177 patients suffering from hip fracture to assess the presence or absence of vertebral fractures. Three different observers applied Genant's criteria for it. Concordance between observers was measured using Cohen's kappa coefficient. Patients suffering from hip fractures have undiagnosed vertebral fractures in a range that varies from 41.8 to 47.5% depending on the observer. The concordance in the diagnosis of vertebral fractures is quite low, ranging a Cohen's kappa coefficient from 0.43 to 0.55 and a percentage of concordance varying from 64 to 72%. The best concordance was found between observers 1 and 3. Depending on the observer who made the diagnosis, the prevalence of previously undiagnosed vertebral fractures in patients with HF varied widely. We selected three different observers to assess the possible differences in the diagnosis of vertebral fractures among these patients and using the same method (Genant's semi-quantitative assessment), surprisingly, there was little concordance among the three of them. Patients with hip fracture have high prevalence of undiagnosed vertebral fractures. The diagnosis of these fractures varies widely depending on the observers and the Cohen's kappa coefficient and percentage of concordance is rather low.
Hong, Choon Chiet; Nashi, Nazrul; Makandura, Milindu Chanaka; Tan, Jiong Hao Jonathan; Peter, Luke; Murphy, Diarmuid
INTRODUCTION Pertrochanteric fractures after low-energy trauma are common among osteoporotic patients. Although the use of intramedullary devices to treat such fractures is becoming increasingly popular, there is a paucity of data comparing the outcomes of the use of short cephalomedullary nails (SCN) with the use of long cephalomedullary nails (LCN). This study aimed to compare the outcomes of treatment using LCN with treatment using SCN for patients with osteoporotic pertrochanteric fractures. METHODS A retrospective review of 64 patients with osteoporotic pertrochanteric fractures who were treated with either LCN or SCN and had a minimum follow-up of one year was performed. Primary outcome measures include complications, revision surgeries and union rates. Secondary outcome measures include duration of surgery, estimated blood loss, length of hospital stay, and ambulatory and mortality status at one year. RESULTS There was no significant difference in the clinical and functional outcomes of the patients who were treated with LCN and those who were treated with SCN. However, there was a higher incidence of heterotopic ossification in the latter group, and a slightly greater average estimated blood loss and duration of surgery in the former group. Patients treated with LCN tended to be more osteoporotic. CONCLUSION Our study found no significant difference in terms of complications, revision surgeries, union rates and ambulatory status between the patients who were treated with LCN and those who were treated with SCN. Both LCN and SCN provided safe and reliable outcomes in the treatment of osteoporotic pertrochanteric fractures. PMID:26948107
Lalmohamed, A; Welsing, P M J; Lems, W F; Jacobs, J W G; Kanis, J A; Johansson, H; De Boer, A; De Vries, F
The FRAX tool has been calibrated to the entire Dutch population, using nationwide (hip) fracture incidence rates and mortality statistics from the Netherlands. Data used for the Dutch model are described in this paper. Risk communication and decision making about whether or not to treat with anti-osteoporotic drugs with the use of T-scores are often unclear for patients. The recently developed FRAX models use easily obtainable clinical risk factors to estimate an individual's 10-year probability of a major osteoporotic fracture and hip fracture that is useful for risk communication and subsequent decision making in clinical practice. As of July 1, 2010, the tool has been calibrated to the total Dutch population. This paper describes the data used to develop the current Dutch FRAX model and illustrates its features compared to other countries. Age- and sex-stratified hip fracture incidence rates (LMR database) and mortality rates (Dutch national mortality statistics) for 2004 and 2005 were extracted from Dutch nationwide databases (patients aged 50+ years). For other major fractures, Dutch incidence rates were imputed, using Swedish ratios for hip to osteoporotic fracture (upper arm, wrist, hip, and clinically symptomatic vertebral) probabilities (age- and gender-stratified). The FRAX tool takes into account age, sex, body mass index (BMI), presence of clinical risk factors, and bone mineral density (BMD). Fracture incidence rates increased with increasing age: for hip fracture, incidence rates were lowest among Dutch patients aged 50-54 years (per 10,000 inhabitants: 2.3 for men, 2.1 for women) and highest among the oldest subjects (95-99 years; 169 of 10,000 for men, 267 of 10,000 for women). Ten-year probability of hip or major osteoporotic fracture was increased in patients with a clinical risk factor, lower BMI, female gender, a higher age, and a decreased BMD T-score. Parental hip fracture accounted for the greatest increase in 10-year fracture probability
Many risk factors have been identified for hip fracture, including female, advanced age, osteoporosis, previous fractures, low body weight or low body mass index, alcohol drinking, smoking, family history of fractures, use of glucocorticoid, factors related to falls, and bone strength. The factors related to falls are number of fall, frail, post stroke, paralysis, muscle weakness, anti-anxiety drugs, anti-depression drugs, and sedatives. Dementia and respiratory disease and others have been reported to be risk factors for secondary hip fracture.
Carpintero, Pedro; Caeiro, Jose Ramón; Carpintero, Rocío; Morales, Angela; Silva, Samuel; Mesa, Manuel
Nowadays, fracture surgery represents a big part of the orthopedic surgeon workload, and usually has associated major clinical and social cost implications. These fractures have several complications. Some of these are medical, and other related to the surgical treatment itself. Medical complications may affect around 20% of patients with hip fracture. Cognitive and neurological alterations, cardiopulmonary affections (alone or combined), venous thromboembolism, gastrointestinal tract bleeding, urinary tract complications, perioperative anemia, electrolytic and metabolic disorders, and pressure scars are the most important medical complications after hip surgery in terms of frequency, increase of length of stay and perioperative mortality. Complications arising from hip fracture surgery are fairly common, and vary depending on whether the fracture is intracapsular or extracapsular. The main problems in intracapsular fractures are biological: vascularization of the femoral head, and lack of periosteum -a major contributor to fracture healing- in the femoral neck. In extracapsular fractures, by contrast, the problem is mechanical, and relates to load-bearing. Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis, good pain control at the perioperative, detection and management of delirium, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and advancement of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients. PMID:25232517
Cristancho, P.; Lenze, E. J.; Avidan, M. S.; Rawson, K. S.
Background Hip fracture is often complicated by depressive symptoms in older adults. We sought to characterize trajectories of depressive symptoms arising after hip fracture and examine their relationship with functional outcomes and walking ability. We also investigated clinical and psychosocial predictors of these trajectories. Method We enrolled 482 inpatients, aged ≥60 years, who were admitted for hip fracture repair at eight St Louis, MO area hospitals between 2008 and 2012. Participants with current depression diagnosis and/or notable cognitive impairment were excluded. Depressive symptoms and functional recovery were assessed with the Montgomery–Asberg Depression Rating Scale and Functional Recovery Score, respectively, for 52 weeks after fracture. Health, cognitive, and psychosocial variables were gathered at baseline. We modeled depressive symptoms using group-based trajectory analysis and subsequently identified correlates of trajectory group membership. Results Three trajectories emerged according to the course of depressive symptoms, which we termed ‘resilient’, ‘distressed’, and ‘depressed’. The depressed trajectory (10% of participants) experienced a persistently high level of depressive symptoms and a slower time to recover mobility than the other trajectory groups. Stressful life events prior to the fracture, current smoking, higher anxiety, less social support, antidepressant use, past depression, and type of implant predicted membership of the depressed trajectory. Conclusions Depressive symptoms arising after hip fracture are associated with poorer functional status. Clinical and psychosocial variables predicted membership of the depression trajectory. Early identification and intervention of patients in a depressive trajectory may improve functional outcomes after hip fracture. PMID:27032698
Cristancho, P; Lenze, E J; Avidan, M S; Rawson, K S
Hip fracture is often complicated by depressive symptoms in older adults. We sought to characterize trajectories of depressive symptoms arising after hip fracture and examine their relationship with functional outcomes and walking ability. We also investigated clinical and psychosocial predictors of these trajectories. We enrolled 482 inpatients, aged ⩾60 years, who were admitted for hip fracture repair at eight St Louis, MO area hospitals between 2008 and 2012. Participants with current depression diagnosis and/or notable cognitive impairment were excluded. Depressive symptoms and functional recovery were assessed with the Montgomery-Asberg Depression Rating Scale and Functional Recovery Score, respectively, for 52 weeks after fracture. Health, cognitive, and psychosocial variables were gathered at baseline. We modeled depressive symptoms using group-based trajectory analysis and subsequently identified correlates of trajectory group membership. Three trajectories emerged according to the course of depressive symptoms, which we termed 'resilient', 'distressed', and 'depressed'. The depressed trajectory (10% of participants) experienced a persistently high level of depressive symptoms and a slower time to recover mobility than the other trajectory groups. Stressful life events prior to the fracture, current smoking, higher anxiety, less social support, antidepressant use, past depression, and type of implant predicted membership of the depressed trajectory. Depressive symptoms arising after hip fracture are associated with poorer functional status. Clinical and psychosocial variables predicted membership of the depression trajectory. Early identification and intervention of patients in a depressive trajectory may improve functional outcomes after hip fracture.
Dietary antioxidants such as vitamin C may play a role in bone health. We evaluated associations of vitamin C intake (total, dietary and supplemental) with incident hip fracture and non-vertebral osteoporotic fracture, over a 15 to 17-y follow-up, in the Framingham Osteoporosis Study. 366 men and 59...
Cosar, Murat; Ozer, A Fahir; Alkan, Bahadır; Guven, Mustafa; Akman, Tarık; Aras, Adem Bozkurt; Ceylan, Davut; Tokmak, Mehmet
Anterior transodontoid screw fixation technique is generally chosen for the management of type II odontoid fractures. The nonunion of type II odontoid fractures is still a major problem especially in elderly and osteoporotic patients. Eleven osteoporotic type II odontoid fracured patients were presented in this article. We have divided 11 patients in two groups as classical and Ozer's technique. We have also compared (radiologically and clinically) the classical anterior transodontoid screw fixation (group II: 6 cases) and Ozer's transodontoid screw fixation technique (group I: 5 cases) retrospectively. There was no difference regaring the clinical features of the groups. However, the radiological results showed 100% fusion for Ozer's screw fixation technique and 83% fusion for the classical screw fixation technique. In conclusion, we suggest that Ozer's technique may help to increase the fusion capacity for osteoporotic type II odontoid fractures.
Papa, John A
To chronicle the conservative treatment and management of an osteoporotic patient presenting with acute back pain resulting from a lumbar compression fracture. A 74-year old male presented with acute back pain in the thoracolumbar region after an episode of lifting. Radiographic evaluation revealed generalized demineralization and a moderate wedge compression fracture at L1. The conservative treatment approach included postural education, activity modification, interferential current, taping into extension, Graston Technique(®), and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale, medication use, and a return to activities of daily living (ADLs). The patient attained long-term symptom resolution with no recurrence of pain at 12 month follow-up. A combination of conservative rehabilitation strategies may be successfully implemented to treat osteoporotic patients with mild to moderate osteoporotic vertebral compression fracture of the lumbar spine.
Background Today, while there are effective drugs that reduce the risk of osteoporotic fracture, yet there are no broadly accepted criteria that can be used to estimate risks and decide who should receive treatment. One of the actual priorities of clinical research is to develop a set of simple and readily-available clinical data that can be used in routine clinical practice to identify patients at high risk of bone fracture, and to establish thresholds for therapeutic interventions. Such a tool would have high impact on healthcare policies. The main objective of the ESOSVAL-R is to develop a risk prediction scale of osteoporotic fracture in adult population using data from the Region of Valencia, Spain. Methods/Design Study design: An observational, longitudinal, prospective cohort study, undertaken in the Region of Valencia, with an initial follow-up period of five years; Subjects: 14,500 men and women over the age of 50, residing in the Region and receiving healthcare from centers where the ABUCASIS electronic clinical records system is implanted; Sources of data: The ABUCASIS electronic clinical record system, complemented with hospital morbidity registers, hospital Accidents & Emergency records and the Regional Ministry of Health's mortality register; Measurement of results: Incident osteoporotic fracture (in the hip and/or major osteoporotic fracture) during the study's follow-up period. Independent variables include clinical data and complementary examinations; Analysis: 1) Descriptive analysis of the cohorts' baseline data; 2) Upon completion of the follow-up period, analysis of the strength of association between the risk factors and the incidence of osteoporotic fracture using Cox's proportional hazards model; 3) Development and validation of a model to predict risk of osteoporotic fracture; the validated model will serve to develop a simplified scale that can be used during routine clinical visits. Discussion The ESOSVAL-R study will establish a
Investigation of alendronate-doped apatitic cements as a potential technology for the prevention of osteoporotic hip fractures: critical influence of the drug introduction mode on the in vitro cement properties.
Schnitzler, Verena; Fayon, Franck; Despas, Christelle; Khairoun, Ibrahim; Mellier, Charlotte; Rouillon, Thierry; Massiot, Dominique; Walcarius, Alain; Janvier, Pascal; Gauthier, Olivier; Montavon, Gilles; Bouler, Jean-Michel; Bujoli, Bruno
Combination of a bisphosphonate (BP) anti-osteoporotic drug, alendronate, with an apatitic calcium phosphate cement does not significantly affect the main properties of the biomaterial, in terms of injectability and setting time, provided that the BP is introduced chemisorbed onto calcium-deficient apatite, one of the components of the cement. In contrast to other modes of introducing the BP into the cement formulation, this mode allows to minimize alendronate release in the cement paste, thus limiting the setting retardant effect of the BP. An original approach based on high frequency impedance measurements is found to be a convenient method for in situ monitoring of the cement setting reaction. The release profile of the drug from a cement block under continuous flow conditions can be well described using a coupled chemistry/transport model, under simulated in vivo conditions. The results show that the released alendronate concentration is expected to be much lower than the cytotoxic concentration.
Shuid, Ahmad Nazrun; Mohamad, Sharlina; Mohamed, Norazlina; Fadzilah, Fazalina Mohd; Mokhtar, Sabarul Afian; Abdullah, Shahrum; Othman, Faizah; Suhaimi, Farihah; Muhammad, Norliza; Soelaiman, Ima Nirwana
Fracture healing is a complex process, which is further complicated if the bone is osteoporotic. Calcium is one of the important minerals in bone and has been found to prevent osteoporosis but its role in fracture healing of osteoporotic bone is still unclear. We carried out a study on the effects of calcium supplementation on the late phase healing of fractured osteoporotic bone using an ovariectomized rat model. Twenty-four female Sprague-Dawley rats were divided into three groups: sham-operated (SO), ovariectomized-control (OVXC), and ovariectomized + calcium supplements (Ca). The right femurs of all the rats were fractured at mid-epiphysis and a K-wire was inserted for internal fixation. After 2 months of treatment, the rats were sacrificed and the femora were dissected out for radiological and biomechanical assessment. As expected, osteoporosis resulted in impaired healing as shown by the poor radiological and biomechanical properties of the OVXC group. CT scans showed significantly lower callus volumes in the SO and Ca groups compared to the OVXC group. Radiological scoring of fracture healing and callus staging of the SO and Ca groups were better than the OVXC group. However, the biomechanical parameters of the Ca group were significantly lower than the SO group and similar to the OVXC group. Therefore, calcium supplements may appear to improve fracture healing of osteoporotic bone but failed to improve strength. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Cawthon, Peggy M; Shahnazari, Mohammad; Orwoll, Eric S; Lane, Nancy E
The lifespan of men is increasing and this is associated with an increased prevalence of osteoporosis in men. Osteoporosis increases the risk of bone fracture. Fractures are associated with increased disability and mortality, and public health problems. We review here the study of osteoporosis in men as obtained from a longitudinal cohort of community-based older men, the Osteoporotic Fractures in Men Study (MrOS).
Bruyère, O; Roux, C; Badurski, J; Isaia, G; de Vernejoul, M C; Cannata, J; Ortolani, S; Slosman, D; Detilleux, J; Reginster, J-Y
Strontium ranelate (SR) increases bone mineral density (BMD) in postmenopausal osteoporotic women and reduces vertebral and non-vertebral fracture incidence. Hip fracture reduction has also been observed during 3-year treatment with SR in osteoporotic women at high risk of hip fracture. The objective of this study is to analyse the association between BMD changes and hip fracture incidence during treatment with SR. In this post-hoc analysis, 465 women aged over 74 years with low BMD at the femoral neck (T-score < or = -2.4 according to NHANES normative values) were selected from the population of a recently published study (the Treatment of Peripheral Osteoporosis Study - TROPOS). BMD was assessed at the femoral neck at baseline and after a follow-up of 3 years. Hip fractures were reported by study investigators. After adjusting for age, body mass index, femoral neck BMD at baseline and number of prevalent vertebral fractures, we found that for each 1% increase in femoral neck BMD observed after 3 years, the risk to experience a hip fracture after 3 years decreased by 7% (95% CI: 1-14%) (p = 0.04). In patients experiencing a hip fracture over 3 years of treatment with SR, femoral neck BMD increased by (mean [SE]) 3.41 (1.02)% compared to 7.23 (0.81)% in patients without hip fracture (p = 0.02). In this post-hoc analysis of women undergoing 3 years of SR treatment, an increase in femoral neck BMD is associated with a decrease in hip fracture incidence.
Pedersen, Tonny J; Lauritsen, Jens M
Background and purpose Pre-fracture functional level has been shown to be a consistent predictor of rehabilitation outcomes in older hip fracture patients. We validated 4 overall pre-fracture functional level assessment instruments in patients aged 65 or more, used the prediction of outcome at 4 months post-fracture, and assessed cutoff values for decision making in treatment and rehabilitation. Patients and methods 165 consecutive patients with acute primary hip fracture were prospectively included in the study. Pre-fracture Barthel-20, Barthel-100, cumulated ambulation score, and new mobility score were scored immediately after admission. Outcome defined as mortality, residential status, and independent walking ability was assessed at 4 months. Results 3 of the assessment instruments, namely Barthel-20, Barthel-100, and new mobility score, correlated with outcome at 4 months post-fracture and were valid predictors. Thresholds were estimated. We found no evidence that Barthel-100, with its finer granularity, performs better than Barthel-20 as a predictor. Interpretation Our findings indicate that pre-fracture scores of Barthel-20 and new mobility score have predictive ability, and further investigation of usage for guidance of clinical and rehabilitation decisions concerning hip fracture patients is warranted. PMID:27329799
Herrera, Antonio; Mateo, Jesús; Gil-Albarova, Jorge; Lobo-Escolar, Antonio; Artigas, José M; López-Prats, Fernando; Mesa, Manuel; Ibarz, Elena; Gracia, Luis
The aim of this work is to study the prevalence of osteoporotic vertebral fractures in Spanish women over 45 years of age, based on the selection of a nationwide sample. An observational, cross-sectional, multicenter study was conducted during 2006, in all of Spain's regions. The sample analyzed was of 5000 individuals, representative of the female population over age 45 in Spain. A questionnaire was used to determine which factors are most often associated with vertebral fractures. We also assessed whether the Prevalent Vertebral Fracture Index, proposed by Vogt, is useful in indicating a possible osteoporotic vertebral fracture. Five hundred orthopedic surgeons, from various Spanish regions, were trained in different aspects of the study: inclusion and exclusion criteria, management of the risk factor questionnaire, and implementation of the Vogt questionnaire. The number of fracture cases was 1549 (31.79%). 528 Women (34.08%) had a single vertebral fracture, and 1021 (65.92%) had multiple vertebral fractures. The following factors were statistically significantly associated with vertebral fracture: age, late menarche, early menopause, diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, height loss, daily physical activity, corticosteroid therapy, personal history of osteoporotic fracture and previous diagnosis of osteoporosis. The differences in Vogt score according to age and fracture status were statistically significant. The conclusion of the study is that vertebral osteoporotic fracture in the female Spanish population is frequent. The high prevalence in the Spanish population older than 60 years is probably related to malnutrition in the period from 1936 to 1952. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Omsland, T K; Magnus, J H
A growing elderly population is expected worldwide, and the rate of hip fractures is decisive for the future fracture burden. Significant declines in hip fracture rates in Norway, the USA, France, Germany, and the UK are required to counteract the impact of the ageing effects. This study aims to evaluate the consequences of the expected growth of the elderly population worldwide on the hip fracture burden using Norway as an example. Furthermore, we wanted to estimate the decline in hip fracture rates required to counteract the anticipated increase in the burden of hip fracture for Norway, the USA, France, Germany, and the UK. The burden of future postmenopausal hip fractures in Norway were estimated given (1) constant age-specific rates, (2) continued decline, and (3) different cohort scenarios. Based on population projection estimates and population age-specific hip fracture rates in women 65 years and older, we calculated the required declines in hip fracture rates needed to counteract the growing elderly populations in Norway, the USA, France, Germany, and the UK. The level of age-specific hip fracture rates had a huge impact on the future hip fracture burden in Norway. Even if the hip fracture rates decline at the same speed, a 22 % increase in the burden of hip fractures can be expected by 2040. An annual decline in hip fracture rates of 1.1-2.2 % until 2040 is required to counteract the effects of the growing elderly population on the future burden of hip fractures in Norway, the USA, France, Germany, and the UK. Hip fracture rates have a great impact on the burden of hip fractures. The rates will have to decline significantly to counteract the impact of a growing elderly population. A change in preventive strategies and further studies are warranted to identify the complex causes associated to hip fractures.
Parker, Benjamin D; Bauer, Douglas C; Ensrud, Kristine E; Ix, Joachim H
Osteocalcin (OC) is produced by osteoblasts and vascular smooth muscle cells. In animal models, serum OC levels are strongly correlated with vascular calcium content, however, the association of OC with vascular calcification in humans is uncertain. The Study of Osteoporotic Fractures (SOF) enrolled community-living women, age > or =65 years. The present study included a subsample of 363 randomly selected SOF participants. Serum total OC was measured by ELISA, and abdominal aortic calcification (AAC) was evaluated on lateral lumbar radiographs. We examined the cross-sectional association between serum OC and AAC. The mean serum OC level was 24 +/- 11 ng/ml and AAC was present in 188 subjects (52%). We observed no association of OC and AAC in either unadjusted or adjusted analyses. For example, each standard deviation higher OC level was associated with an odds ratio (OR) for AAC prevalence (AAC score >0) near unity (OR = 1.06; 95% CI, 0.82-1.36) in models adjusted for CVD risk factors. Further adjustment for intact parathyroid hormone, bone-specific alkaline phosphatase, 25-hydroxyvitamin D, and hip and spine bone mineral density did not materially change the results (OR = 1.22; 95% CI, 0.86-1.75). Similarly, higher OC levels were not associated with severity of AAC (P = 0.87). In conclusion, among community-living older women, serum OC is not associated with AAC. These findings suggest that serum OC levels may more closely reflect bone formation than vascular calcification in humans.
Bhandari, Mohit; Sprague, Sheila; Schemitsch, Emil H
Hip fractures are a significant cause of morbidity and mortality worldwide and the burden of disability associated with hip fractures globally vindicate the need for high-quality research to advance the care of patients with hip fractures. Historically, large, multi-centre randomized controlled trials have been rare in the orthopaedic trauma literature. Similar to other medical specialties, orthopaedic research is currently undergoing a paradigm shift from single centre initiatives to larger collaborative groups. This is evident with the establishment of several collaborative groups in Canada, in the United States, and in Europe, which has proven that multi-centre trials can be extremely successful in orthopaedic trauma research.Despite ever increasing literature on the topic of his fractures, the optimal treatment of hip fractures remains unknown and controversial. To resolve this controversy large multi-national collaborative randomized controlled trials are required. In 2005, the International Hip Fracture Research Collaborative was officially established following funding from the Canadian Institute of Health Research International Opportunity Program with the mandate of resolving controversies in hip fracture management. This manuscript will describe the need, the information, the organization, and the accomplishments to date of the International Hip Fracture Research Collaborative.
Bhandari, Mohit; Sprague, Sheila; Schemitsch, Emil H.
Summary Hip fractures are a significant cause of morbidity and mortality worldwide and the burden of disability associated with hip fractures globally vindicates the need for high-quality research to advance the care of patients with hip fractures. Historically, large, multi-centre randomized controlled trials have been rare in the orthopaedic trauma literature. Similar to other medical specialties, orthopaedic research is currently undergoing a paradigm shift from single centre initiatives to larger collaborative groups. This is evident with the establishment of several collaborative groups in Canada, in the United States, and in Europe, which has proven that multi-centre trials can be extremely successful in orthopaedic trauma research. Despite ever increasing literature on the topic of his fractures, the optimal treatment of hip fractures remains unknown and controversial. To resolve this controversy large multi-national collaborative randomized controlled trials are required. In 2005, the International Hip Fracture Research Collaborative was officially established following funding from the Canadian Institute of Health Research International Oppurtunity Program with the mandate of resolving controversies in hip fracture management. This manuscript will describe the need, the information, the organization, and the accomplishments to date of the International Hip Fracture Research Collaborative. PMID:19550238
Sorbi, R; Aghamirsalim, M
Osteoporosis has been described as a progressive skeletal disorder until a patient experiences a fragility fracture. The number of patients with osteoporotic fractures is increasing at an exponential rate. Orthopaedic surgeons, most of the time, first clinicians seen by patients at the time of fracture, do not routinely consider osteoporosis management. Therefore, we compared the knowledge of orthopaedic surgeons and internists regarding medical treatment required: which group would have more abilities to keep patients with osteoporotic fractures under management? We hypothesize that internists may have more abilities to assess and treat osteoporosis for patients with osteoporotic fractures; therefore, referring these patients to this specialized team for post-fracture medical consultation is required. A questionnaire composed of seven closed questions was administered to 4700 orthopaedic surgeons and internists. This question list addressed the orthopaedic surgeons' and internists' knowledge in managing patients with osteoporotic fractures. The questions were designed in a way to cover the topics of diagnosis, treatment, and approach to an osteoporotic patient with osteoporotic fractures. In this survey, 3431 respondents were included. Only 118 (fewer than 10%) orthopaedic surgeons would order bone mineral densitometry (BMD) in osteoporotic fractures in contrast to 1544 (79%) internists. Approximately 1485 (76%) internists against 487 (33%) orthopaedic surgeons prescribe proper dosage of calcium and vitamin D. Typical orthopaedic surgeon is not naturally inclined to manage patients with osteoporotic fractures. The existing management gap between the occurrence of an osteoporotic fracture and the identification and treatment of osteoporosis requires multifaceted intervention. Improved communication between orthopaedic surgeons and internists may reduce this gap between fracture occurrence and osteoporosis management. Level III prospective diagnostic study
Parisi, M S; Díaz, A G; Oliveri, M B; Di Gregorio, S; Mautalen, C A
We herein describe a family whose female members are all osteoporotic: a postmenopausal mother and her three premenopausal daughters. The mother aged 60 presented axial and peripheral fractures, and very low bone mineral density (BMD). She reported that her grandmother had suffered a hip fracture. The eldest daughter aged 30 suffered multiple vertebral fractures during pregnancy and lactation associated with very low BMD. In view of these observations, the other two daughters aged 29 and 27 years respectively were evaluated. BMD was found to be severely diminished according to densitometric values for osteoporosis established by WHO, but they had no history of bone fractures. Probably the strong genetic component in bone mass is responsible for the severely diminished BMD observed in all the women in this family, as well as the occurrence of bone fractures in two of them. To our knowledge, there are no similar reports in the literature. Our results evidence the importance of evaluating bone mass in the offspring of an individual presenting severe osteoporosis, in order to detect family members with low bone mass and at high risk of developing bone fractures.
Sáez López, Pilar; Sánchez Hernández, Natalia; Paniagua Tejo, Sonsoles; Valverde García, José Antonio; Montero Díaz, Margarita; Alonso García, Noelia; Freites Esteve, Alfonso
Hip fracture in the elderly often occurs in patients with high co-morbidity. Effective management requires a comprehensive and multidisciplinary approach. To evaluate the effect of a quality improvement intervention in the detection and treatment of complications in elderly patients admitted for hip fracture. A comparative study was conducted between two groups of patients admitted for hip fracture prior to 2010, and after a quality improvement intervention in 2013. The intervention consisted of implementing improved multidisciplinary measures in accordance with recent scientific evidence. The degree of compliance of the implemented measures was quantified. Patients admitted due to hip fracture in 2010 (216 patients) and 2013 (196 patients) were similar in age, sex, Barthel Index, and a reduced Charlson Index, although there were more comorbidities in 2013. After implementation of the protocols, the detection of delirium, malnutrition, anemia, and electrolyte disturbances increased. A larger number of patients in 2013 were precribed intravenous iron (24% more) and osteoporosis treatment (61.3% more). The average stay was reduced by 45.3% and surgical delay by 29.4%, achieving better functional efficiency. The implementation of a clinical pathway in geriatric patients with hip fracture is useful to detect and treat complications at an early stage, and to reduce pre-operative and overall stay, all without a negative clinical or functional impact. Copyright © 2014 SEGG. Published by Elsevier Espana. All rights reserved.
Kim, Seoyoung C.; Kim, Mi-Sook; Sanfélix-Gimeno, Gabriel; Song, Hong Ji; Liu, Jun; Hurtado, Isabel; Peiró, Salvador; Lee, Joongyub; Choi, Nam-Kyong; Park, Byung-Joo; Avorn, Jerry
Purpose While current osteoporosis management guidelines recommend use of pharmacologic treatment following hip fracture, the care of such patients has been suboptimal. The objective of this cross-national study is to quantify the use of and adherence to osteoporosis medication following hip fracture in three countries with different health care systems- the United States, Korea and Spain. Methods In three cohorts of patients aged ≥65 years hospitalized for hip fracture, we calculated the proportion receiving ≥1 osteoporosis drug after discharge. Adherence to osteoporosis treatment was measured as the proportion of days covered (PDC) during the first year following the hip fracture. Results We identified 86,202 patients with a hip fracture - 4,704 (U.S. Medicare), 6,700 (U.S. commercial), 57,631(Korea), and 17,167 (Spain). The mean age was 77–83 years and 74–78% were women. In the year prior to the index hip fracture, 16–18% were taking an osteoporosis medication. Within 3 months following the index hip fracture, 11% (U.S. Medicare), 13% (U.S. commercial), 39% (Korea), and 25% (Spain) of patients filled ≥1 prescription for osteoporosis medication. For those who filled one or more prescriptions for an osteoporosis medication, the mean PDC in the year following the fracture was 0.70 (U.S. Medicare), 0.67 (U.S. commercial), 0.43 (Korea) and 0.66 (Spain). Conclusions Regardless of differences in health care delivery systems and medication reimbursement plans, the use of osteoporosis medications for the secondary prevention of osteoporotic fracture was low. Adherence to osteoporosis treatment was also suboptimal with the PDC<0.70 in all three countries. PMID:25660252
Franck, Helmut; Boszczyk, Bronek M; Bierschneider, Michael; Jaksche, Hans
Osteoporotic vertebral compression fractures (VCFs) are associated with a series of clinical consequences leading to increased morbidity and even mortality. Early diagnosis and therapeutic intervention is desirable in order to remobilise patients and prevent further bone loss. Not all fractures are, however, sufficiently treatable by conservative measures. Here, vertebroplasty and kyphoplasty may provide immediate pain relief by minimally invasive fracture stabilisation. In cases of acute fractures, kyphoplasty has the potential to reduce kyphosis and restore the normal sagittal alignment of the spine. The complex nature of systemic osteoporosis, coupled with the intricate biomechanics of vertebral fractures, leads to a clinical setting which is ideally treated interdisciplinarily by the rheumatologist and spine surgeon.
Cauley, Jane A.; Lui, Li-Yung; Genant, Harry K.; Salamone, Loran; Browner, Warren; Fink, Howard A.; Cohen, Peter; Hillier, Teresa; Bauer, Doug C.; Cummings, Steven R.
More severe hip fractures such as displaced femoral neck (FN) fractures and unstable intertrochanteric (IT) fractures lead to poorer outcomes, but risk factors for severe fractures have not been studied. To identify risk factors for severe types of hip fracture, we performed a prospective cohort study and obtained preoperative hip radiographs from women who sustained an incident hip fracture (excluding traumatic fractures). A single radiologist scored the severity of FN fractures by the Garden System: grades I and II, undisplaced; grades III and IV, displaced. The severity of IT hip fractures was rated by the Kyle System: grades I and II, stable; grades III and IV, unstable. A total of 249 women had FN fractures: 75 (30%) were undisplaced. A total of 213 women had IT fractures: 59 (28%) were stable. Both types of hip fracture increased with age, but older age was even more strongly associated with more severe hip fractures. Low BMD was more strongly related to undisplaced FN fractures (p interaction BMD × FN type, p = 0.0008) and stable IT fractures (p interaction BMD × IT type, p = 0.04). Similar findings were observed for estimated volumetric BMD and hip geometric parameters. Corticosteroid use was only associated with displaced FN fractures, and Parkinson's disease was only associated with stable IT fractures. Little difference was reported in the self-reported circumstances surrounding each type of fracture. In conclusion, the lower the BMD, the greater the likelihood of experiencing a hip fracture that is less displaced and more stable. PMID:19113930
Yi, Youngsuk; Choi, Kyoung Baek; Lim, Chae-Lyul; Hyun, Jong-Pil; Lee, Hyeon-Youl; Lee, Kun Bok; Yun, Lillian; Ayverdi, Asli; Hwang, Sally; Yip, Vivian; Noh, Moon Jong; Lee, Kwan Hee
Bone morphogenetic protein 2 (BMP2) was selected as a transgene to regenerate osteoporotic bone defects after several BMPs were tested using a bone formation study in nude mice. Human chondrocytes were transduced with a BMP2-containing retroviral vector, and single clones were selected. The cells were characterized over numerous passages for growth and BMP2 expression. The single clones were irradiated and tested for viability. BMP2 expression lasted for 3 weeks before dying off completely after approximately 1 month. Irradiated and non-irradiated transduced chondrocytes successfully healed fractures in osteoporotic rats induced by ovariectomy. The osteoinducing effect of irradiated cells was better than that of their non-irradiated counterparts or a chondrocytes-only control. This study showed that delivering BMP2 from the transduced and irradiated chondrocytes could be an effective and safe method of repairing osteoporotic bone fractures.
Anthony, Chris A; Duchman, Kyle R; Bedard, Nicholas A; Gholson, James J; Gao, Yubo; Pugely, Andrew J; Callaghan, John J
The purpose of this study is to (1) identify the incidence of surgical delay in hip fractures, (2) evaluate the time point surgical delay puts patients at increased risk for complications, and (3) identify risk factors for surgical delay in the setting of surgical management of hip fractures. A multi-center database was queried for patients of 60 years of age or older undergoing surgical treatment of a hip fracture. Surgical delay was defined by days from admission until surgical intervention. Univariate analyses and multivariate analyses were performed on all groups. A total of 4215 patients underwent surgery for their hip fracture. Of those experiencing surgical delay, 3304 (78%) patients experienced surgical delay of ≥1 day, 1314 (31%) had delay of ≥2 days, and 480 (11%) experienced delay of ≥3 days. There was a significant difference in complications if patients experienced surgical delay of ≥2 days (P ≤ .01). Multivariate analyses identified multiple risk factors for delay of ≥2 days including congestive heart failure (odds ratio 3.09, 95% confidence interval 2.04-4.66) and body mass index ≥40 (odds ratio 2.31, 95% confidence interval 1.31-4.08). Subgroup analysis identified that patients undergoing total hip arthroplasty were not at risk for complications with surgical delay of ≥2 days. Surgical delay of ≥2 days in the setting of hip fractures is common and confers an increased risk of complications in those undergoing non-total hip arthroplasty procedures. We recommend surgical intervention prior to 48 hours from hospital admission when possible. Healthcare systems can utilize our non-modifiable risk factors when performing quality assessment and cost accounting. Copyright © 2017 Elsevier Inc. All rights reserved.
Prentice, Heather A; Paxton, Elizabeth W; Hunt, Jessica J; Grimsrud, Christopher D; Weiss, Jennifer M
Hip fracture registries offer an opportunity to identify and to monitor patients with rare conditions and outcomes, including hip fractures in pediatric patients. To report patient demographics and surgical outcomes of pediatric patients treated surgically for hip fractures in a large integrated health care system. Pediatric patients (< 21 years old at the time of fracture) with hip fractures were identified between 2009 and 2012 using our health care system's hip fracture registry. Patient characteristics, type of fracture, surgical treatment, and short-term complications. Among 39 patients identified, 31 (79.5%) were male, and the median age was 15 years old (interquartile range: 11-17 years). Most patients were Hispanic (n = 17, 43.6%) or white (n = 14, 35.9%). There were 8 patients (20.5%) with 15 comorbidities. Delbet Type IV (intertrochanteric) fractures were the most common fracture type (n = 22, 56.4%), and fixation method was equally distributed between intramedullary, screw and sideplate, and screws (n = 12, 30.8% for each). Most surgeries were performed by medium-volume surgeons (n = 22, 56.4%) at medium- and high-volume hospitals (n = 37, 94.9%). Three 90-day readmissions (7.7%), 1 infection (2.6%), 1 malunion (2.6%), and 1 revision (2.6%) were observed in this cohort during the study period. In our series using registry data, hip fractures younger than age 21 years were more common in boys and Hispanic patients. Intertrochanteric fractures (Delbet Type IV) were the most frequently observed type in our community-based hip fracture registry. Short-term complications were infrequent.
Prentice, Heather A; Paxton, Elizabeth W; Hunt, Jessica J; Grimsrud, Christopher D; Weiss, Jennifer M
Context: Hip fracture registries offer an opportunity to identify and to monitor patients with rare conditions and outcomes, including hip fractures in pediatric patients. Objective: To report patient demographics and surgical outcomes of pediatric patients treated surgically for hip fractures in a large integrated health care system. Design: Pediatric patients (< 21 years old at the time of fracture) with hip fractures were identified between 2009 and 2012 using our health care system’s hip fracture registry. Main Outcome Measures: Patient characteristics, type of fracture, surgical treatment, and short-term complications. Results: Among 39 patients identified, 31 (79.5%) were male, and the median age was 15 years old (interquartile range: 11–17 years). Most patients were Hispanic (n = 17, 43.6%) or white (n = 14, 35.9%). There were 8 patients (20.5%) with 15 comorbidities. Delbet Type IV (intertrochanteric) fractures were the most common fracture type (n = 22, 56.4%), and fixation method was equally distributed between intramedullary, screw and sideplate, and screws (n = 12, 30.8% for each). Most surgeries were performed by medium-volume surgeons (n = 22, 56.4%) at medium- and high-volume hospitals (n = 37, 94.9%). Three 90-day readmissions (7.7%), 1 infection (2.6%), 1 malunion (2.6%), and 1 revision (2.6%) were observed in this cohort during the study period. Conclusion: In our series using registry data, hip fractures younger than age 21 years were more common in boys and Hispanic patients. Intertrochanteric fractures (Delbet Type IV) were the most frequently observed type in our community-based hip fracture registry. Short-term complications were infrequent. PMID:28241902
... https://medlineplus.gov/news/fullstory_163802.html Hip Fracture's Link to Early Death May Last Years People ... HealthDay News) -- Older people who suffer a hip fracture face a much higher risk of death soon ...
Akinbo, Oluwaseun; Tyagi, Vineet
Acute hip pain following total hip arthroplasty (THA) could have numerous causes to include stress fracture of the pelvis. Stress fractures of the pelvis are rare and have been reported to involve the medial wall and the pubic ramus. A unique case is presented demonstrating the clinical presentation and management of an acute stress fracture of ilium and anterior column following a THA. A 72-year-old man underwent an uncomplicated right THA. He was noted to have femoral head resorption and thin osteoporotic bone intraoperatively. He initially did well postoperatively and ambulating without pain or assistive devices. Within 1 month of surgery, he returned with acute right hip pain without any traumatic event. Radiographs showed migration of the acetabular component and computed tomography scan confirmed a fracture through the ilium. The patient underwent revision surgery, where the fracture was reduced and internal fixation was achieved with a reconstruction plate and acetabular cage construct. At 9 months postoperatively, the patient remained pain-free with full weight bearing and with stable radiographs. Elderly patients who undergo THA may have low bone mineral density. These patients can develop stress fractures in their pelvis after surgery. These fractures may involve the medial wall, posterior column, or posterior wall. In patients who develop atraumatic pain postoperatively, it is important to consider for potential stress fractures of the ilium and evaluate appropriately with imaging. In these cases, revision surgery can be necessary to provide fixation of the stress fracture.
Ohtori, Seiji; Yamashita, Masaomi; Inoue, Gen; Yamauchi, Kazuyo; Suzuki, Munetaka; Orita, Sumihisa; Eguchi, Yawara; Ochiai, Nobuyasu; Kishida, Shunji; Takaso, Masashi; Takahashi, Kazuhisa
Elderly patients with osteoporosis sometimes experience lumbar vertebral fracture and may feel diffuse nonlocalized pain in the back, the lateral portion of the trunk, and the area surrounding the iliac crest. The pattern of sensory innervation of vertebral bodies remains unclear. Some sensory nerves from the L2 and L5 vertebral bodies may enter the paravertebral sympathetic trunks and reach the L2 dorsal root ganglion. Our randomized controlled study was to clarify the effect of L2 spinal nerve block on low back pain originating from acute osteoporotic lumbar vertebral fracture. Patients with low back pain originating from acute L3 or L4 osteoporotic vertebral fractures received a spinal nerve root block (L2 block group, n = 30) or subcutaneous injection (control, n = 30). Both groups received 1.5 mL of 1% lidocaine. The visual analog scale score, Roland Morris Disability Questionnaire, and Short Form questionnaire were examined before and after treatment. In both groups, spinal nerve blocks were significantly effective in alleviating low back pain (P < .05). One hour, 1 week, and 2 weeks after treatment, the visual analog scale score improved more in the L2 block group than in the control group (P < .05). From 1 month to 4 months after treatment, there were no significant differences in the pain scores between groups (P > .05). We conclude that L2 spinal nerve block for acute L3 or L4 osteoporotic vertebral body fracture was effective for 2 weeks, but it had no long-term effects on pain and social function. L2 spinal nerve block treatment for L3 or L4 osteoporotic vertebral body fracture was effective. This results suggest that the L2 dorsal root ganglion may innervate the L3 and L4 vertebral bodies in humans. L2 spinal nerve block for lumbar osteoporotic vertebral fracture may be a useful strategy to treat acute low back pain.
Hayer, Prabhnoor Singh; Deane, Anit Kumar Samuel; Agrawal, Atul; Maheshwari, Rajesh; Juyal, Anil
Aims: To assess the effect of zoledronic acid (ZOL) on fracture healing in osteoporotic patients with intertrochanteric fracture based on radiological evaluation and to study the correlations between severity of osteoporosis, age, gender, and time taken to fracture union. Settings and Design: An open label study was conducted on 43 patients at a tertiary care center. Subjects and Methods: The osteoporosis status of all the included patients was documented using a double-energy X-ray absorptiometry scan. A single dose of injection ZOL 5 mg was administered intravenously to all the patients after fixation during their hospital stay. Follow-up of the patients was done at 1, 3, and 6 months after surgery until union was seen radiologically. Statistical Analysis Used: Data were entered into Microsoft Office Excel version 2007, and interpretation and analysis of obtained data were done using summary statistics. Pearson correlation between age, gender, bone mineral density (BMD), and time taken to fracture union was done using the IBM SPSS Version 22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Results: The average age of the patients included in the study was 71.27 ± 11.48 and the average BMD was -4.58±1.42. All the fractures united by the 6th month of follow-up, which was similar to the union rate in comparison with the literature. The correlations between the gender, BMD, age, and time to union were calculated, and all the r values obtained showed very low correlation and the P values in all the variables were not significant. Conclusion: The bisphosphonate therapy did not adversely affect radiologically determined fracture union, and no correlations between severity of osteoporosis, age, gender, and time taken to fracture union were found to be significant. PMID:28251108
Kim, H; Baek, K H; Lee, S-Y; Ahn, S H; Lee, S H; Koh, J-M; Rhee, Y; Kim, C H; Kim, D-Y; Kang, M-I; Kim, B-J; Min, Y-K
Postmenopausal women with osteoporotic fracture (OF) had higher plasma dipeptidyl-peptidase 4 (DPP4) levels than those without. Furthermore, higher plasma DPP4 levels were significantly associated with higher bone turnover and a higher prevalence of OF. These results indicated that DPP4 may be associated with OF by mediating bone turnover rate.
Wähnert, Dirk; Hofmann-Fliri, Ladina; Richards, R. Geoff; Gueorguiev, Boyko; Raschke, Michael J.; Windolf, Markus
Abstract The increasing problems in the field of osteoporotic fracture fixation results in specialized implants as well as new operation methods, for example, implant augmentation with bone cement. The aim of this study was to determine the biomechanical impact of augmentation in the treatment of osteoporotic distal femur fractures. Seven pairs of osteoporotic fresh frozen distal femora were randomly assigned to either an augmented or nonaugmented group. In both groups, an Orthopaedic Trauma Association 33 A3 fractures was fixed using the locking compression plate distal femur and cannulated and perforated screws. In the augmented group, additionally, 1 mL of polymethylmethacrylate cement was injected through the screw. Prior to mechanical testing, bone mineral density (BMD) and local bone strength were determined. Mechanical testing was performed by cyclic axial loading (100 N to 750 N + 0.05N/cycle) using a servo-hydraulic testing machine. As a result, the BMD as well as the axial stiffness did not significantly differ between the groups. The number of cycles to failure was significantly higher in the augmented group with the BMD as a significant covariate. In conclusion, cement augmentation can significantly improve implant anchorage in plating of osteoporotic distal femur fractures. PMID:25415673
Wiggin, Molly; Hemmati, Pouya; Switzer, Julie
Objectives: In older patients, bone mineral density (BMD) diminishes with age, increasing susceptibility to femoral neck fractures. Evidence has emerged that patients who should have dual x-ray absorptiometry scans to evaluate their bone health are not doing so. Because computed tomography (CT) attenuation has now been correlated with BMD thresholds relating to osteoporosis, virtually any existing CT scan that includes the L1 vertebra can be used to assess BMD. This study evaluates the utility of CT attenuation in characterizing BMD in patients after femoral neck fractures. Methods: The electronic medical records of adults who presented to a level I trauma center with hip fractures were evaluated for eligibility. Those with a CT scan of the abdomen or other CT scan with a complete view of the L1 vertebra were included. To measure attenuation, a region of interest was selected to include the body of the L1 vertebra in the axial plane and exclude the cortices and posterior venous complex. Results: Of the 589 patients reviewed, 217 met inclusion criteria; 112 were aged 18 to 64, while 105 were ≥65. Eight (7.1%) patients in the younger cohort had a mean CT attenuation below the 110-HU threshold set for 90% specificity, whereas 31 (29.5%) patients in the older cohort had a mean CT attenuation below this threshold. Using the 160-HU threshold set for 90% sensitivity, 39 (34.8%) patients of the younger cohort and 74 (70%) patients of the older cohort were osteoporotic; all differences in CT attenuation by age were strongly significant (P < .0001). Conclusions: A significantly larger proportion of older patients with hip fractures had osteoporosis, helping validate the utility of CT attenuation in this context. In addition, a large proportion of these patients already had these images available, thus potentially helping limit cost and unnecessary medical investigations. PMID:26246948
Briot, Karine; Maravic, Milka; Roux, Christian
The incidence of hip fractures decreased in France in both genders, especially in the elderly, from 2002 to 2008, in parallel with availability of bone densitometry and effective anti-osteoporotic treatments. However prescriptions of these treatments are decreasing, since 2008, and recent studies show declining of osteoporosis management after fragility fractures. The aim of this study was to assess the incidence of hip fractures in men and women aged 60 years and over, from 2002 to 2013 in France. Data were drawn from the French Hospital National Database which includes all hospitalizations of the country. Hospital data for hip fractures between 2002 and 2013 were numbered and the incidence rates per 1,000,000 adjusted on age (60-74; 74-84, and ≥ 85 years), and gender was calculated using the data of the French population. The number of hip fractures increased in women (+5%; from 49,287 in 2002 to 50,215) and in men (+22%, from 12,716 to 15,482) aged over 60 years. Between 2002 and 2013, the French population increased by 21 and 29% in women and men of this age group; thus, incidence of hip fractures decreased by 14% in women (6929 and 5987 per million in 2002 and 2013, respectively) and a slight decrease of -1% was observed in men (2344 and 2316). The decrease in incidence is also confirmed in the very elderly (≥ 85 years), with a decrease of -29% and -24% in women and men respectively. Over the last 12 years, the incidence of hip fractures decreased in France in women and men aged over 60 years. This decrease is also observed in the subjects (≥ 85 years and older in both genders). Further studies are needed to assess potential changes in risk factors of hip fractures during the last decade.
Karaaslan, Fatih; Mutlu, Mahmut; Mermerkaya, Musa Uğur; Karaoğlu, Sinan; Saçmaci, Şerife; Kartal, Şenol
This study examined the role of trace elements in osteoporosis by comparing the trace-element concentrations in bone and the radiographic bone density and bone mineral density (BMD) of patients with osteoporotic femur fractures and osteoarthritis. The study enrolled 30 patients operated on for proximal femoral fractures after falls, and another 30 patients undergoing hip arthroplasty at the same center for hip osteoarthritis. Bone samples were obtained during the surgical procedures. The density of the bone samples was assessed using computed tomography and the Hounsfield scale. The levels of Ca(II), Mg(II), and other trace elements in the bone samples were determined using flame atomic absorption spectrometry and inductively coupled plasma mass spectrometry. In addition, BMD, Z-scores, and T-scores were measured in the unaffected hips of all patients using dual-energy X-ray absorptiometry. Magnesium (1,908 ± 507 versus 2,540 ± 435, P<0.05), calcium (10.4 ± 3.5 versus 13.9 ± 3.7, P<0.05), and zinc (2,342 ± 1,252 versus 3,145 ± 1,604, P<0.05) μg g(-1), levels were significantly lower in the bone samples in the fracture group. The groups did not differ in the other biochemical parameters. All dual-energy X-ray absorptiometry findings were significantly worse in the fracture group than in the osteoarthritis group. However, the groups did not differ in femoral neck density assessed radiologically using the Hounsfield scale. The following parameters were negatively correlated with age: magnesium, r=-0.436, P<0.001; calcium, r=-0.331, P=0.01; T-score, r=-0.381, P=0.003; Z-score, r=-0.267, P=0.043; and BMD, r=-0.365, P=0.004. Ca(II), Mg(II), and Zn(II) appear to play important roles in bone breakdown/synthesis. Further studies of the roles of trace elements in the etiology and treatment of osteoporosis are warranted. We found decreased bone levels of Ca, Mg, and Zn in patients with osteoporotic fractures compared to subjects with osteoarthritis.
Karaaslan, Fatih; Mutlu, Mahmut; Mermerkaya, Musa Uğur; Karaoğlu, Sinan; Saçmaci, Şerife; Kartal, Şenol
Purpose This study examined the role of trace elements in osteoporosis by comparing the trace-element concentrations in bone and the radiographic bone density and bone mineral density (BMD) of patients with osteoporotic femur fractures and osteoarthritis. Patients and methods The study enrolled 30 patients operated on for proximal femoral fractures after falls, and another 30 patients undergoing hip arthroplasty at the same center for hip osteoarthritis. Bone samples were obtained during the surgical procedures. The density of the bone samples was assessed using computed tomography and the Hounsfield scale. The levels of Ca(II), Mg(II), and other trace elements in the bone samples were determined using flame atomic absorption spectrometry and inductively coupled plasma mass spectrometry. In addition, BMD, Z-scores, and T-scores were measured in the unaffected hips of all patients using dual-energy X-ray absorptiometry. Results Magnesium (1,908±507 versus 2,540±435, P<0.05), calcium (10.4±3.5 versus 13.9±3.7, P<0.05), and zinc (2,342±1,252 versus 3,145±1,604, P<0.05) μg g−1, levels were significantly lower in the bone samples in the fracture group. The groups did not differ in the other biochemical parameters. All dual-energy X-ray absorptiometry findings were significantly worse in the fracture group than in the osteoarthritis group. However, the groups did not differ in femoral neck density assessed radiologically using the Hounsfield scale. The following parameters were negatively correlated with age: magnesium, r=−0.436, P<0.001; calcium, r=−0.331, P=0.01; T-score, r=−0.381, P=0.003; Z-score, r=−0.267, P=0.043; and BMD, r=−0.365, P=0.004. Conclusion Ca(II), Mg(II), and Zn(II) appear to play important roles in bone breakdown/synthesis. Further studies of the roles of trace elements in the etiology and treatment of osteoporosis are warranted. We found decreased bone levels of Ca, Mg, and Zn in patients with osteoporotic fractures compared to
Dick, Alastair G; Davenport, Dominic; Bansal, Mohit; Burch, Therese S; Edwards, Max R
The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.
Wang, Chang-Bi; Lin, Chien-Fu Jeff; Liang, Wen-Miin; Cheng, Chi-Fung; Chang, Yu-Jun; Wu, Hsi-Chin; Wu, Trong-Neng; Leu, Tsai-Hsueh
Osteoporotic hip fractures cause high mortality in the elderly population. However, few population studies reported the long-term mortality of hip fracture among the elderly in Asian population. This study assessed the incidence, excess mortality, and risk factors after osteoporotic hip fractures through inpatients aged 60 years or older. A total of 143,595 patients with hip fracture were selected from Taiwan National Health Insurance database in the years 1999 to 2009 and followed up until the end of 2010. Annual incidence, mortality and SMR, and mortality and SMR at different periods after fracture were measured. From 1999 to 2005, hip fracture incidence gradually increased and then fluctuated after 2006. From 1999 to 2009, the male-to-female ratio of annual incidence increased from 0.60 to 0.66, annual mortality for hip fracture decreased from 18.10% to 13.98%, male-to-female ratio of annual mortality increased from 1.38 to 1.64, and annual SMR decreased from 13.80 to 2.98. Follow-up SMR at one, two, five, and ten years post-fracture was 9.67, 5.28, 3.31, and 2.89, respectively. Females had higher follow-up SMR in the younger age groups (60-69 yr of age) but lower follow-up SMR in the older age groups (over 80 yr of age) compared with males. Among the studied patients, incidence is gradually decreasing along with annual mortality and SMR. Hip fracture affects short-term but not long-term mortality.
Kim, Sang-Min; Kang, Kyung-Chung; Kim, Ji Wan; Lim, Seung-Jae
Background The use of osteoanabolic agents to facilitate fracture healing has been of heightened interest to the field of orthopaedic trauma. This study aimed to evaluate the evidence of teriparatide for fracture healing and functional recovery in osteoporotic patients. Methods We performed a literature search in PubMed, EMBASE, Web of Science, and the Cochrane Library using terms including “Fracture” [tiab] AND “Teriparatide [tiab] OR “PTH” [tiab]. Results This systematic review included 6 randomized clinical trials, 4 well-controlled retrospective studies, and 1 retrospective post hoc subgroup analysis. Fracture location was 2 in pelvis, 3 in proximal femur, 1 in distal femur, 1 in shoulder, 2 in wrist and 2 in spine. The use of teriparatide yielded positive effects on radiographic bone healing in 6 studies, but was not associated with better radiographic outcome in 3. In terms of functional recovery, teriparatide injection was related with decrease in pain or shorter time to mobilization in 6 studies, but not related with pain numerical scale and mobility in 3. Conclusions Our findings suggest that teriparatide provide selective advantages to fracture healing or functional recovery in the management of osteoporotic fractures. A better understanding of the role of teriparatide on osteoporotic fractures requires greater evidences from large volume prospective trials. PMID:28326303
Lane, Nancy E; Parimi, Neeta; Corr, Maripat; Yao, Wei; Cauley, Jane A; Nielson, Carrie M; Ix, Joseph H; Kado, Deborah; Orwoll, Eric
Normal mineral metabolism is critical for skeletal integrity, and recently serum fibroblast growth factor 23 (FGF23) levels were found to be directly related to overall fracture risk in elderly Swedish men. To confirm this association, we performed a prospective case-cohort study to understand the relation of FGF23 and fracture risk in older white men enrolled in the Osteoporotic Fractures in Men (MrOS) study. In the cohort of 5994 men attending the baseline MrOS examination, we evaluated a subgroup of 387 men with incident nonvertebral fracture including 73 hip fractures and a sample of 1385 men randomly selected from the cohort with baseline mineral and calcium hormone measurements. FGF23 was measured in baseline serum samples by ELISA (Millipore, Billerica, MA, USA). Modified Cox proportional hazards models that account for case-cohort study design were used to estimate the relative hazards (RH) of fracture in men across quartiles of FGF23. Subjects were also stratified by renal function, and RH per strata was estimated in men with the highest quartile of FGF23 compared with quartiles 3, 2, and 1. Overall, there was no difference in risk of nonspine or hip fracture by baseline FGF23. However, associations differed by strata of eGFRCrCy . Among men with eGFRCrCys <60 mL/min/1.73 m2 (n = 73/313 nonspine fractures), the RH in the highest quartile of FGF23 compared with the rest was 2.02 (95% confidence interval [CI] 1.07-3.79), but in men with eGFRCrCy , >60 mL/min/1.73 m2 (304/1370 fractures) the RH was 0.91 (95% CI 0.66-1.25) after adjustment for age, clinic site, body mass index, race, total hip bone mineral density, vitamin D, parathyroid hormone, alcohol use, physical activity, fracture history, and serum phosphorus. Serum FGF23 levels are not associated with incident fractures in elderly men overall. However, higher levels of serum FGF23 are associated with fracture risk in those with poor renal function.
Background Knowledge on the epidemiology of non-hip fractures in Spain is limited and somewhat outdated. Using computerized primary care records from the SIDIAP database, we derived age and sex-specific fracture incidence rates for the region of Catalonia during the year 2009. Methods The SIDIAP database contains quality-checked clinical information from computerized medical records of a representative sample of >5,800,000 patients (80% of the population of Catalonia). We conducted a retrospective cohort study including all patients aged ≥50 years, and followed them from January 1 to December 31, 2009. Major osteoporotic fractures registered in SIDIAP were ascertained using ICD-10 codes and validated by comparing data to hospital admission and patient-reported fractures records. Incidence rates and 95% confidence intervals were calculated. Results In total, 2,011,430 subjects were studied (54.6% women). Overall fracture rates were 10.91/1,000 person-years (py) [95%CI 10.89–10.92]: 15.18/1,000 py [15.15–15.21] in women and 5.78/1,000 py [5.76–5.79] in men. The most common fracture among women was wrist/forearm (3.86/1,000 py [3.74–3.98]), while among men it was clinical spine (1.25/1,000 py [1.18–1.33]). All fracture rates increased with age, but varying patterns were observed: while most of the fractures (hip, proximal humerus, clinical spine and pelvis) increased continuously with age, wrist and multiple rib fractures peaked at age 75–80 and then reached a plateau. Conclusions Our study provides local estimates of age, sex and site-specific fracture burden in primary health care, which will be helpful for health-care planning and delivery. A proportion of fractures are not reported in primary care records, leading to underestimation of fracture incidence rates in these data. PMID:22639802
Hotchen, Andrew J.; Vonberg, Frederick W.; Ironside, Emily C.; Ross-Thriepland, Stephen; Avery, Naomi; Pearce, Oliver J. N.
Objectives: This study sought to assess the value of differing pre-operative measures in prediction of post-operative non-surgical site infection (NSSI) and length of hospital stay following hip fracture surgery. Methods: All patients admitted during a one year period with a hip fracture to our department were included in the study (n=207). Primary outcome measures were ten independent risk factors correlated to the development of non-surgical site infection following surgery for hip fracture. Secondary outcome measures were duration of hospital stay and inpatient mortality. Results: The patients who had severe cognitive impairment had a 71.0% risk of developing non-surgical site infection. Patients who had multiple medical co-morbidities also had increased risk of developing non-surgical site infection at 59.1%. Patients who developed NSSI on average stayed in hospital 13.1 days longer than patients who did not (31.6 vs. 18.5, p < .001). Conclusions: This study demonstrates the importance of reducing post-operative infection in hip fracture patients in view of reducing morbidity, mortality and cost. These patients can be stratified by risk factors and interventions can be employed in view of reducing inpatient post-operative infection rates in this cohort. PMID:28138499
Langan, P; Fontanetta, A P
A case report of a 12-year-old boy who suffered a dislocated hip in a football game. He was unable to walk and was in severe pain when seen in the emergency room. Efforts at closed reduction of the displacement were complicated by the development of a transepiphyseal fracture.
Sáez-López, P; Brañas, F; Sánchez-Hernández, N; Alonso-García, N; González-Montalvo, J I
Hip fractures (HF) are prevalent and involve high morbidity and mortality so improving their management is important. HF registries are a good way to improve knowledge about this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs.
Abourazzak, Fatima E; Allali, Fadoua; Rostom, Samira; Hmamouchi, Ihsane; Ichchou, Linda; El Mansouri, Laila; Bennani, Loubna; Khazzani, Hamza; Abouqal, Redouane; Hajjaj-Hassouni, Najia
Objective The aim of the study was to evaluate factors influencing quality of life (QOL) in Moroccan postmenopausal women with osteoporotic vertebral fracture assessed by the Arabic version of ECOS 16 questionnaire. Methods 357 postmenopausal women were included in this study. The participants underwent bone mineral density (BMD) measurements by DXA of the lumbar spine and the total hip as well as X-ray examination of the thoraco-lumbar spine to identify subclinical vertebral fractures. Patients were asked to complete a questionnaire on clinical and sociodemographic parameters, and osteoporosis risk factors. The Arabic version of the ECOS16 (Assessment of health related quality of life in osteoporosis questionnaire) was used to assess quality of life. Results The mean age was 58 ± 7.8 years, and the mean BMI was 28.3 ± 4.8 kg/m2. One hundred and eight women (30.1%) were osteoporotic and 46.7% had vertebral fractures. Most were categorized as Grade1 (75%). Three independent factors were associated with a poor quality of life: low educational level (p = 0,01), vertebral fracture (p = 0,03), and history of peripheral fracture (p = 0,006). Worse QOL was observed in the group with vertebral fracture in all domains except "pain": Physical functioning (p = 0,002); Fear of illness (p = 0,001); and Psychosocial functioning (p = 0,007). The number of fractures was a determinant of a low QOL, as indicated by an increased score in physical functioning (p = 0,01), fear of illness (p = 0,007), and total score (p = 0,01) after adjusting on age and educational level. Patients with higher Genant score had low QOL in these two domains too (p = 0,002; p = 0,001 respectively), and in the total score (p = 0,01) after adjusting on age and educational level. Conclusion Our current data showed that the quality of life assessed by the Arabic version of the ECOS 16 questionnaire is decreased in post menopausal women with prevalent vertebral fractures, with the increasing number and the
Palacio, J; Albareda, J
Low-energy osteoporotic pelvic fractures in the elderly are a very common problem. They are usually stable fractures, non-life threatening and only require conservative treatment. The pelvic bone structure is closely related to important vascular structures. The Corona Mortis, located in the retropubis, has an important anastomotic value as it serves as communication between the internal and external iliac vessels. The case is presented of an 87 year-old woman, who, after a casual fall, was diagnosed with an osteoporotic fracture of the left pubic rami associated to a lesion of the Corona Mortis, which led to a severe picture of haemodynamic instability. After angiography with supra-selective embolisation of the lesioned vessel, and the transfusion of several haemoderivatives, the patient progressed satisfactorily, and was discharged after a few days.
Ensrud, Kristine E; Ewing, Susan K; Taylor, Brent C; Fink, Howard A; Stone, Katie L; Cauley, Jane A; Tracy, J Kathleen; Hochberg, Marc C; Rodondi, Nicolas; Cawthon, Peggy M
A standard phenotype of frailty was associated with an increased risk of adverse outcomes including mortality in a recent study of older adults. However, the predictive validity of this phenotype for fracture outcomes and across risk subgroups is uncertain. To determine whether a standard frailty phenotype was independently associated with risk of adverse health outcomes in older women and to evaluate the consistency of associations across risk subgroups defined by age and body mass index (BMI), we ascertained frailty status in a cohort of 6724 women>or=69 years and followed them prospectively for incident falls, fractures, and mortality. Frailty was defined by the presence of three or more of the following criteria: unintentional weight loss, weakness, self-reported poor energy, slow walking speed, and low physical activity. Incident recurrent falls were defined as at least two falls during the subsequent year. Incident fractures (confirmed with x-ray reports), including hip fractures, and deaths were ascertained during an average of 9 years of follow-up. After controlling for multiple confounders such as age, health status, medical conditions, functional status, depressive symptoms, cognitive function, and bone mineral density, frail women were subsequently at increased risk of recurrent falls (multivariate odds ratio=1.38, 95% confidence interval [CI], 1.02-1.88), hip fracture (multivariate hazards ratio [MHR]=1.40, 95% CI, 1.03-1.90), any nonspine fracture (MHR=1.25, 95% CI, 1.05-1.49), and death (MHR=1.82, 95% CI, 1.56-2.13). The associations between frailty and these outcomes persisted among women>or=80 years. In addition, associations between frailty and an increased risk of falls, fracture, and mortality were consistently observed across categories of BMI, including BMI>or=30 kg/m2. Frailty is an independent predictor of adverse health outcomes in older women, including very elderly women and older obese women.
Nurmi-Lüthje, Ilona; Lüthje, Peter; Kaukonen, Juha-Pekka; Kataja, Matti
Several studies have shown that the mortality of elderly hip fracture patients is higher than that in the general population, and is higher in male than in female hip fracture patients. The objective of this study was to investigate factors affecting overall mortality at a minimum of 11 years following a new hip fracture. The sex, age, pre-fracture serum 25-hydroxyvitamin D level, American Society of Anesthesiologists physical status classification (ASA class), 1- to 12-month mortality, and 2- to 11-year mortality of hip fracture patients were collected. The use of anti-osteoporotic medication and prescribed calcium and vitamin D supplements during the first 3 post-operative years were checked. The survival of the patients was analyzed using both the Bayesian multivariate analysis and the life table method. The mean age of females at the time of the index hip fracture was 80.5 years and of males was 73 years. The protective factors were age <80 years; ASA class 1-2; serum 25-hydroxyvitamin level ≥ 50 nmol/L; post-fracture use of calcium and vitamin D supplementation; post-fracture concomitant use of calcium and vitamin D supplementation and anti-osteoporotic drugs; and male sex. The excess mortality was higher among women than men. Survival was highest among patients with a vitamin D level of ≥ 50 nmol/L. Post-fracture concomitant use of calcium and vitamin D and anti-osteoporotic drugs was positively associated with survival. Our results indicate a positive relationship between a sufficient pre-fracture vitamin D serum concentration (≥ 50 nmol/L) and survival, and a potential relationship between reduced mortality and the concomitant post-fracture use of prescribed calcium plus vitamin D supplementation and anti-osteoporotic medication.
Guo, Yan; Yang, Tie-Lin; Dong, Shan-Shan; Yan, Han; Hao, Ruo-Han; Chen, Xiao-Feng; Chen, Jia-Bin; Tian, Qing; Li, Jian; Shen, Hui; Deng, Hong-Wen
DDR2 gene, playing an essential role in regulating osteoblast differentiation and chondrocyte maturation, may influence bone mineral density (BMD) and osteoporosis, but the genetic variations actually leading to the association remain to be elucidated. Therefore, the aim of this study was to investigate whether the genetic variants in DDR2 are associated with BMD and fracture risk. This study was performed in three samples from two ethnicities, including 1,300 Chinese Han subjects, 700 Chinese Han subjects (350 with osteoporotic hip fractures and 350 healthy controls) and 2,286 US white subjects. Twenty-eight SNPs in DDR2 were genotyped and tested for associations with hip BMD and fractures. We identified 3 SNPs in DDR2 significantly associated with hip BMD in the Chinese population after multiple testing adjustments, which were rs7521233 (P = 1.06×10-4, β: -0.018 for allele C), rs7553831 (P = 1.30×10-4, β: -0.018 for allele T), and rs6697469 (P = 1.59×10-3, β: -0.015 for allele C), separately. These three SNPs were in high linkage disequilibrium. Haplotype analyses detected two significantly associated haplotypes, including one haplotype in block 2 (P = 9.54×10-4, β: -0.016) where these three SNPs located. SNP rs6697469 was also associated with hip fractures (P = 0.043, OR: 1.42) in the Chinese population. The effect on fracture risk was consistent with its association with lower BMD. However, in the white population, we didn't observe significant associations with hip BMD. eQTL analyses revealed that SNPs associated with BMD also affected DDR2 mRNA expression levels in Chinese. Our findings, together with the prior biological evidence, suggest that DDR2 could be a new candidate for osteoporosis in Chinese population. Our results also reveal an ethnic difference, which highlights the need for further genetic studies in each ethnic group.
Czerwinski, E; Kanis, J A; Trybulec, B; Johansson, H; Borowy, P; Osieleniec, J
This study determined the incidence and probability of hip fractures in Poland based on verified hospital discharge notes from all of Poland. In the over-50-year-old population, hip fracture incidence was found to be 89/100,000 for men and 156/100,000 for women. Poland is among the countries with the lowest hip fracture risk in Europe. It is recommended that intervention thresholds should be based on an assessment of absolute fracture risk. Probability of hip fracture is calculated from the incidence of hip fracture in a given population and the incidence of death. The aim of this study was to determine the incidence and the absolute risk of hip fracture for men and women in Poland. The study was based on National Health Fund data from all of Poland for the year 2005. Hospital discharge notes reporting an incident fracture were identified from among all those containing a matching ICD code. Lifetime and 10-year fracture probabilities were calculated taking into account the mortality risk and BMD. In 2005, there were 17,625 hip fractures diagnosed in Poland which was 30.2% less than the number of hospital discharge notes containing such a diagnosis in that year. In the over-50-year-old population, hip fracture incidence was found to be 89/100,000 for men and 165/100,000 for women. In the 50-65-year band, hip fracture incidence was higher in men than in women. The remaining lifetime probability of hip fracture at the age of 50 years was 2.0% for men and 4.5% for women which are among the lowest in Europe. Hip fracture incidence and thus the probability of hip fracture risk in Poland is amongst the lowest in Europe. The authors recommend establishing a standard method for determining hip fracture incidence in a given country in order to standardize data.
Englund, U; Nordström, P; Nilsson, J; Bucht, G; Björnstig, U; Hallmans, G; Svensson, O; Pettersson, U
In a population-based case-control study, we demonstrate that middle-aged women who were active with walking or in different physical spare time activities were at lower risk of later sustaining a hip fracture compared to more sedentary women. In middle-aged women participating in the Umeå Fracture and Osteoporosis (UFO) study, we investigated whether physical activity is associated with a subsequent decreased risk of sustaining a hip fracture. The UFO study is a nested case-control study investigating associations between bone markers, lifestyle, and osteoporotic fractures. We identified 81 female hip fracture cases that had reported lifestyle data before they sustained their fracture. Each case was compared with two female controls who were identified from the same cohort and matched for age and week of reporting data, yielding a total cohort of 237 subjects. Mean age at baseline was 57.2 ± 5.0 years, and mean age at fracture was 65.4 ± 6.4 years. Conditional logistic regression analysis with adjustments for height, weight, smoking, and menopausal status showed that subjects who were regularly active with walking or had a moderate or high frequency of physical spare time activities (i.e. berry/mushroom picking and snow shovelling) were at reduced risk of sustaining a hip fracture (OR 0.14; 95% CI; 0.05-0.53 for walking and OR 0.19; 95% CI; 0.08-0.46, OR 0.17, 95% CI; 0.05-0.64 for moderate and high frequency of spare time activities, respectively) compared to more sedentary women. An active lifestyle in middle age seems to reduce the risk of future hip fracture. Possible mechanisms may include improved muscle strength, coordination, and balance resulting in a decreased risk of falling and perhaps also direct skeletal benefits.
Maalouf, Naim M; Zhang, Song; Drechsler, Henning; Brown, Geri R; Tebas, Pablo; Bedimo, Roger
Osteoporosis is increasingly reported in the aging HIV-positive population, and co-infection with hepatitis C virus (HCV) may further increase the risk of osteoporosis. However, it remains unclear whether HCV-related increased fracture risk is a function of the severity of liver disease. We calculated the time-updated alanine aminotransferase to platelet ratio index (APRI) score (an indirect marker of hepatic fibrosis) in all HIV-infected patients enrolled in the Veterans Affairs' Clinical Case Registry between 1984 and 2009. The association between HCV co-infection and incident osteoporotic fracture (defined as closed wrist, vertebral, or hip fracture) was assessed in univariate and multivariate Cox survival models adjusting for traditional risk factors for osteoporosis and APRI score or the presence of cirrhosis. A total of 772 osteoporotic fractures were identified among 56,660 HIV-infected patients (98.1% male; 31.3% HCV co-infected; median age 44.0 years) contributing 305,237 patient-years of follow-up. Fracture rates were significantly higher among HIV/HCV patients than HIV-only patients (2.57 versus 2.07/1000 patient-years, relative risk = 1.24, p < 0.0001). In a Cox multivariable model including age, race, smoking, drug use, body mass index, and antiretroviral therapy, HCV co-infection remained an independent predictor of osteoporotic fractures after controlling for presence of cirrhosis (hazard ratio [HR] = 1.32; p <0.001) or APRI score (HR = 1.30; p = 0.003). Among HIV/HCV co-infected patients, cirrhosis strongly predicted osteoporotic fractures (HR = 1.65; 95% confidence interval [CI] 1.11-2.44; p = 0.012), but APRI score was a weaker predictor (HR = 1.008; 95% CI 1.002-1.014; p = 0.015). In conclusion, among HIV-infected patients, severity of liver disease partly explains the HCV-associated increased risk of osteoporotic fractures. Other determinants of this increased risk remain to be defined.
Näsman, P; Ekstrand, J; Granath, F; Ekbom, A; Fored, C M
The cariostatic benefit from water fluoridation is indisputable, but the knowledge of possible adverse effects on bone and fracture risk due to fluoride exposure is ambiguous. The association between long-term (chronic) drinking water fluoride exposure and hip fracture (ICD-7-9: '820' and ICD-10: 'S72.0-S72.2') was assessed in Sweden using nationwide registers. All individuals born in Sweden between January 1, 1900 and December 31, 1919, alive and living in their municipality of birth at the time of start of follow-up, were eligible for this study. Information on the study population (n = 473,277) was linked among the Swedish National In-Patient Register (IPR), the Swedish Cause of Death Register, and the Register of Population and Population Changes. Estimated individual drinking water fluoride exposure was stratified into 4 categories: very low, < 0.3 mg/L; low, 0.3 to 0.69 mg/L; medium, 0.7 to 1.49 mg/L; and high, ≥ 1.5 mg/L. Overall, we found no association between chronic fluoride exposure and the occurrence of hip fracture. The risk estimates did not change in analyses restricted to only low-trauma osteoporotic hip fractures. Chronic fluoride exposure from drinking water does not seem to have any important effects on the risk of hip fracture, in the investigated exposure range.
Fabi, David W
Hip fracture is one of the most common injuries among the elderly and, because the population is aging, it is expected to remain a major clinical challenge and public health problem for the foreseeable future. The clinical importance of early mobilization and prompt participation in physical therapy after hip fracture surgery is now widely recognized. Because postoperative pain can impair mobility and delay physical therapy, much attention is now being paid to finding more effective ways of controlling pain after hip fracture. Oversedation with opioid drugs inhibits communication between the patient and the health care team, can delay ambulation and rehabilitation therapy, and may increase the probability of the patient requiring a skilled nursing facility, which adds further cost to the overall health care system. Multiple pain pathways contribute to the perception of postoperative pain, and although opioids are highly effective in blocking nociceptive pain through inhibition of the mu receptors, they do not block other pain pathways. Multimodal analgesia involves the use of several anesthetic and analgesic modalities that are strategically combined to block pain perception at different sites in the peripheral and central nervous systems. This balanced, multifaceted approach provides more effective control of postoperative pain than opioid drugs alone, allows lower doses of opioids to be used as part of the multimodal regimen (thereby reducing the risk of opioid-related adverse events and complications), and may facilitate more rapid recovery and improve certain outcome measures related to recovery time. One prospective randomized study evaluating the clinical value of multimodal pain management in elderly patients undergoing bipolar hip hemiarthroplasty found that a multimodal regimen, including preemptive pain medication and intraoperative periarticular injections, reduced pain on postoperative days 1 and 4, and reduced overall opioid use. This article describes
Tanaka, Masato; Sugimoto, Yoshihisa; Takigawa, Tomoyuki; Ozaki, Toshifumi; Konishi, Hitoshi
The instrumentation of the osteoporotic spine may sometimes result in failure due to the loosening or pullout of the conventional pedicle screw. Moreover, augmentation of screws with polymethylmethacrylate (PMMA) has risks of complications. We developed a new and original pedicle nail system with PMMA for osteoporotic vertebral fractures. A clinical evaluation of this novel pedicle nail system utilized in patients with an osteoporotic vertebral collapse was performed to determine the effectiveness and safety of this technique. Thirty-four elderly patients who suffered from osteoporotic compression fractures were treated by posterolateral fusion using the pedicle nail system. The mean follow-up period was 37 months. Of the 25 patients with neurological symptoms, two patients improved two stages at the Frankel level. Fifteen patients improved one stage at the Frankel level, and eight other patients improved, however, their improvement did not exceed a Frankel level. Nine cases with neuralgia symptoms improved from 4.4 to 2.2 points on average on the Denis pain scale (p < 0.01). The fusion rate was 94% as determined by X-rays of flexion and extension, and the correction of the compression fracture site was maintained well. A pedicle nail system stabilizes the spinal column with osteoporosis and reduces the instrumentation failure. The technique for the insertion of the pedicle nail reduces complication from cement augmentation. The authors speculate that the strategy using the pedicle nail system for osteoporotic spine may be effective and safe when the surgery is performed through a posterior approach. PMID:20414689
Guerado, Enrique; Cruz, Encarnacion; Cano, Juan Ramon; Crespo, Pascual Vicente; Alaminos, Miguel; Sánchez-Quevedo, Maria del Carmen; Campos, Antonio
Elderly people, due to neurological conditions and muscular atrophy, present a greater propensity to falls and thus are very susceptible to hip fractures. Other variables, such as osteoporosis, may also be related to the etiopathogenesis of hip fractures, although osteoporosis is in fact a concurrent disease, and merely a coadjutant cause. Nonetheless, osteoporosis can make fracture patterns more severe and interfere with osteosynthesis. Osteoporosis is the radiological image of osteopenia, a pathological concept meaning a smaller quantity of bone per unit of volume. The radiological expression of osteopenia is therefore that of bone tissue with a lower radiological density than normal. In the context of hip fractures, bone mineral density and bone architecture of the femoral neck together with protein expression profiles and cross-links of this anatomical area are of special interest which is reviewed in the current paper. Spatial variations in bone mineral density in the femoral neck were found in the literature with increased porosity from the periosteal to the endosteal region and also from the distal to the proximal part of the femoral neck. Furthermore, increased crystal size, increased cortical porosity, reduced osteocyte lacunar density and an increased Ca/P ratio associated with higher concentrations of Ca and P were described in hip fracture patients compared to control patients. Osteocalcin/collagen type 1 expression ratio and enzymatic cross-link content in high-density bone was found to be significantly lower in hip fractures compared to controls. In conclusion, further research in bone mineral density and associated parameters are of interest to deepen the understanding of osteoporotic hip fractures. Copyright © 2016 Elsevier Ltd. All rights reserved.
Tian, Faming; Zhang, Liu; Kang, Yuchuan; Zhang, Junshan; Ao, Jiao; Yang, Fang
effect of simvastatin locally applied from a bioactive polymer coating of implants on osteoporotic fracture healing at late period. Methods:Femur fracture model was established on normal or osteotoporotic mature female SD rats, intramedullary stabilization was achieved with uncoated titanium Kirschnerwires in normal rats(group A),with polymer-only coated vs. polymer plus simvastatin coated titanium Kirschner wires in osteoporotic rats(group B and C, respectively).Femurs were harvested after 12 weeks, and underwent radiographic and histologic analysis, as well as immunohistochemical evaluation for BMP-2 expression. Results:Radiographic results demonstrated progressed callus in the simvastatin-treated groups compared to the uncoated group.The histologic analysis revealed a significantly processed callus with irregular-shaped newly formed bone trabeculae in simvastatin-treated group. Immunohistochemical evaluation showed markedly higher expression levels of B:MP-2 in simvastatin-treated group.Conclusions: The present study revealed a improved fracture healing under local application of simvastatin in osteoporotic rat,which might partially from upregulation of the B:MP-2 expression at fractured site.
Lips, Katrin Susanne; Kauschke, Vivien; Hartmann, Sonja; Thormann, Ulrich; Ray, Seemun; Kampschulte, Marian; Langheinrich, Alexander; Schumacher, Matthias; Gelinsky, Michael; Heinemann, Sascha; Hanke, Thomas; Kautz, Armin R.; Schnabelrauch, Matthias; Schnettler, Reinhard; Heiss, Christian; Alt, Volker; Kilian, Olaf
Insertion of bone substitution materials accelerates healing of osteoporotic fractures. Biodegradable materials are preferred for application in osteoporotic patients to avoid a second surgery for implant replacement. Degraded implant fragments are often absorbed by macrophages that are removed from the fracture side via passage through veins or lymphatic vessels. We investigated if lymphatic vessels occur in osteoporotic bone defects and whether they are regulated by the use of different materials. To address this issue osteoporosis was induced in rats using the classical method of bilateral ovariectomy and additional calcium and vitamin deficient diet. In addition, wedge-shaped defects of 3, 4, or 5 mm were generated in the distal metaphyseal area of femur via osteotomy. The 4 mm defects were subsequently used for implantation studies where bone substitution materials of calcium phosphate cement, composites of collagen and silica, and iron foams with interconnecting pores were inserted. Different materials were partly additionally functionalized by strontium or bisphosphonate whose positive effects in osteoporosis treatment are well known. The lymphatic vessels were identified by immunohistochemistry using an antibody against podoplanin. Podoplanin immunopositive lymphatic vessels were detected in the granulation tissue filling the fracture gap, surrounding the implant and growing into the iron foam through its interconnected pores. Significant more lymphatic capillaries were counted at the implant interface of composite, strontium and bisphosphonate functionalized iron foam. A significant increase was also observed in the number of lymphatics situated in the pores of strontium coated iron foam. In conclusion, our results indicate the occurrence of lymphatic vessels in osteoporotic bone. Our results show that lymphatic vessels are localized at the implant interface and in the fracture gap where they might be involved in the removal of lymphocytes, macrophages
Svensson, H K; Olofsson, E H; Karlsson, J; Hansson, T; Olsson, L-E
Vertebral compression fractures (VCF) cause pain and decreased physical ability, with no known well-established treatment. The aim of this study was to illuminate the experience of living with a VCF. The results show that fear and concerns are a major part of daily life. The women's initial contact with health-care providers should focus on making them feel acknowledged by offering person-centered and tailored support. In the past decade, osteoporotic-related fractures have become an increasingly common and costly public health problem worldwide. Vertebral compression fracture (VCF) is the second most common osteoporotic fracture, and patients with VCF describe an abrupt descent into disability, with a subsequent desire to regain independence in everyday life; however, little is known of their situation. The aim of this study was to illuminate the lived experience of women with an osteoporotic VCF. Ten women were interviewed during 2012-2013, starting with an open-ended question: could you tell me what it is like to live with a vertebral compression fracture? The verbatim transcribed interviews were analyzed using a phenomenological hermeneutical approach. The narrative provided descriptions of living in turmoil and chaos, unable to find stability in their life with little improvement regarding pain and physical function. Shifts from periods of constant pain to periods of fear of constant pain created a loss of confidence and an increased sense of confinement. The structural analysis revealed fear and concerns as the most prominent experience building on five themes: struggling to understand a deceiving body, breakthrough pain fueling fear, fearing a trajectory into isolation, concerns of dependency, and fearing an uncertain future. Until researchers find a successful prevention or medical/surgical treatment for osteoporotic VCFs, health-care providers and society abandon these women to remain in a painful and never ending story.
Lips, Katrin Susanne; Kauschke, Vivien; Hartmann, Sonja; Thormann, Ulrich; Ray, Seemun; Kampschulte, Marian; Langheinrich, Alexander; Schumacher, Matthias; Gelinsky, Michael; Heinemann, Sascha; Hanke, Thomas; Kautz, Armin R; Schnabelrauch, Matthias; Schnettler, Reinhard; Heiss, Christian; Alt, Volker; Kilian, Olaf
Insertion of bone substitution materials accelerates healing of osteoporotic fractures. Biodegradable materials are preferred for application in osteoporotic patients to avoid a second surgery for implant replacement. Degraded implant fragments are often absorbed by macrophages that are removed from the fracture side via passage through veins or lymphatic vessels. We investigated if lymphatic vessels occur in osteoporotic bone defects and whether they are regulated by the use of different materials. To address this issue osteoporosis was induced in rats using the classical method of bilateral ovariectomy and additional calcium and vitamin deficient diet. In addition, wedge-shaped defects of 3, 4, or 5 mm were generated in the distal metaphyseal area of femur via osteotomy. The 4 mm defects were subsequently used for implantation studies where bone substitution materials of calcium phosphate cement, composites of collagen and silica, and iron foams with interconnecting pores were inserted. Different materials were partly additionally functionalized by strontium or bisphosphonate whose positive effects in osteoporosis treatment are well known. The lymphatic vessels were identified by immunohistochemistry using an antibody against podoplanin. Podoplanin immunopositive lymphatic vessels were detected in the granulation tissue filling the fracture gap, surrounding the implant and growing into the iron foam through its interconnected pores. Significant more lymphatic capillaries were counted at the implant interface of composite, strontium and bisphosphonate functionalized iron foam. A significant increase was also observed in the number of lymphatics situated in the pores of strontium coated iron foam. In conclusion, our results indicate the occurrence of lymphatic vessels in osteoporotic bone. Our results show that lymphatic vessels are localized at the implant interface and in the fracture gap where they might be involved in the removal of lymphocytes, macrophages
Background The lack of epidemiologic information on osteoporotic hip fractures hampers the development of preventive or curative measures against osteoporosis in South Korea. We conducted a population-based study to estimate the annual incidence of hip fractures. Also, we examined factors associated with post-fracture mortality among Korean elderly to evaluate the impact of osteoporosis on our society and to identify high-risk populations. Methods The Korean National Health Insurance (NHI) claims database was used to identify the incidence of hip fractures, defined as patients having a claim record with a diagnosis of hip fracture and a hip fracture-related operation during 2003. The 6-month period prior to 2003 was set as a 'window period,' such that patients were defined as incident cases only if their first record of fracture was observed after the window period. Cox's proportional hazards model was used to investigate the relationship between survival time and baseline patient and provider characteristics available from the NHI data. Results The age-standardized annual incidence rate of hip fractures requiring operation over 50 years of age was 146.38 per 100,000 women and 61.72 per 100,000 men, yielding a female to male ratio of 2.37. The 1-year mortality was 16.55%, which is 2.85 times higher than the mortality rate for the general population (5.8%) in this age group. The risk of post-fracture mortality at one year is significantly higher for males and for persons having lower socioeconomic status, living in places other than the capital city, not taking anti-osteoporosis pharmacologic therapy following fracture, or receiving fracture-associated operations from more advanced hospitals such as general or tertiary hospitals. Conclusion This national epidemiological study will help raise awareness of osteoporotic hip fractures among the elderly population and hopefully motivate public health policy makers to develop effective national prevention strategies
Wongtriratanachai, Prasit; Luevitoonvechkij, Sirichai; Songpatanasilp, Thawee; Sribunditkul, Siripoj; Leerapun, Taninnit; Phadungkiat, Sompant; Rojanasthien, Sattaya
Hip fracture is a major health problem in Thailand. This study attempted to examine the incidence, related factors, and trends of hip fracture in Chiang Mai, Thailand. All hip fracture data among patients aged 50 yr or older were collected from hospitals in Chiang Mai, Thailand from August 1, 2006 to July 3, 2007. Data from the 1997 Chiang Mai hip fracture study were used for comparison. In the study period, 690 hip fractures were reported: 203 males and 487 females (male to female ratio was 1 to 2.4), with a mean age of 76.7 yr. The estimated cumulative incidence was 181.0 per 100,000, and the adjusted incidence was 253.3 (males: 135.9; females: 367.9). A simple fall was the most common mechanism (79%) of fracture, and 80% of the hip fractures occurred in patients aged 70 yr or older. The highest incidence of hip fracture was observed in patients older than 85 yr (1239). At 6 mo postfracture, most patients (61%) used a walking aid. Compared with the 1997 data, hip fracture incidence had increased by an average of 2% per yr, and the incidence of hip fracture had increased significantly from August 1, 2006 to July 31, 2007, especially in patients older than 75 yr. In patients older than 84 yr, the incidence increased by a factor of 2. Urgent strategies for the prevention and treatment of osteoporosis, and hence hip fracture, are needed.
Bowers, Thomas M.; Parker, Martyn J.
Background: The aim of the study was to refine current evaluation systems used to assess outcome after a hip fracture and to devise a simple and practical system to assess all hip fracture patients. Methods: Three continuous scales were defined for pain, mobility and functional independence. These were all found to have an acceptable degree of inter-observer agreement. The pre-fracture mobility and independence scores were related to the one-year mortality for a consecutive series of 381 patients. Results: Scores for mobility and functional independence were highly predictive of mortality (p < 0.0001). Conclusions: It is recommended that the outcome after hip fracture should be standardised to these principle outcomes of pain, regain of mobility and independence and mortality. These scores can be use to assess progress and identify those who may require additional assessment or intervention. PMID:27259572
The utility of dual-energy X-ray absorptiometry, calcaneal quantitative ultrasound, and fracture risk indices (FRAX® and Osteoporosis Risk Assessment Instrument) for the identification of women with distal forearm or hip fractures: A pilot study.
Esmaeilzadeh, Sina; Cesme, Fatih; Oral, Aydan; Yaliman, Ayse; Sindel, Dilsad
Dual-energy X-ray absorptiometry (DXA) is considered the "gold standard" in predicting osteoporotic fractures. Calcaneal quantitative ultrasound (QUS) variables are also known to predict fractures. Fracture risk assessment tools may also guide us for the detection of individuals at high risk for fractures. The aim of this case-control study was to evaluate the utility of DXA bone mineral density (BMD), calcaneal QUS parameters, FRAX® (Fracture Risk Assessment Tool), and Osteoporosis Risk Assessment Instrument (ORAI) for the discrimination of women with distal forearm or hip fractures. This case-control study included 20 women with a distal forearm fracture and 18 women with a hip fracture as cases and 76 age-matched women served as controls. BMD at the spine, proximal femur, and radius was measured using DXA and acoustic parameters of bone were obtained using a calcaneal QUS device. FRAX® 10-year probability of fracture and ORAI scores were also calculated in all participants. Receiver operating characteristic (ROC) analysis was used to assess fracture discriminatory power of all the tools. While all DXA BMD, and QUS variables and FRAX® fracture probabilities demonstrated significant areas under the ROC curves for the discrimination of hip-fractured women and those without, only 33% radius BMD, broadband ultrasound attenuation (BUA), and FRAX® major osteoporotic fracture probability calculated without BMD showed significant discriminatory power for distal forearm fractures. It can be concluded that QUS variables, particularly BUA, and FRAX® major osteoporotic fracture probability without BMD are good candidates for the identification of both hip and distal forearm fractures.
Ho, Michael; Garau, Giorgio; Walley, Gayle; Oliva, Francesco; Panni, Alfredo Schiavone; Longo, Umile Giuseppe
We compared a minimally invasive surgical technique to the conventional (open approach) surgical technique used in fixation of hip fractures with the dynamic hip screw (DHS) device. Using a case-control design (44 cases and 44 controls), we tested the null hypothesis that there is no difference between the two techniques in the following outcome measures: duration of surgery, time to mobilisation and weight bearing postoperatively, length of hospital stay, mean difference of pre- and postoperative haemoglobin levels, position of the lag screw of the DHS device in the femoral head, and the tip–apex distance. The minimally invasive DHS technique had significantly shorter duration of surgery and length of hospital stay. There was also less blood loss in the minimally invasive DHS technique. The minimally invasive DHS technique produces better outcome measures in the operating time, length of hospital stay, and blood loss compared to the conventional approach while maintaining equal fixation stability. PMID:18478227
Behrbalk, Eyal; Uri, Ofir; Folman, Yoram; Rickert, Marcus; Kaiser, Radek; Boszczyk, Bronek Maximilian
Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. Methods Five patients (average age 62 ± 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months. Results Patients' self-reported back pain decreased from 7.2 ± 0.8 to 3.0 ± 0.7 (0 to 10 numerical scale; p < 0.001). Patients' back-related disability decreased from 60 ± 10% to 29 ± 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 ± 5 degrees to 40 ± 4 degrees (p < 0.001), and the sagittal vertical axis was corrected from 112 ± 83 mm to 38 ± 23 mm (p = 0.058). One patient had cement leakage without subsequent neurologic deficit. Decreased blood pressure was observed in another patient during the cement injection. No correction loss, hardware failure, or neurologic deficiency was seen in the other patients. Conclusion The surgical technique described here, despite its complexity, may offer a safe and effective method for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. PMID:27781192
Dragomir-Daescu, Dan; Buijs, Jorn Op Den; McEligot, Sean; Dai, Yifei; Entwistle, Rachel C.; Salas, Christina; Melton, L. Joseph; Bennet, Kevin E.; Khosla, Sundeep; Amin, Shreyasee
Clinical implementation of quantitative computed tomography-based finite element analysis (QCT/FEA) of proximal femur stiffness and strength to assess the likelihood of proximal femur (hip) fractures requires a unified modeling procedure, consistency in predicting bone mechanical properties, and validation with realistic test data that represent typical hip fractures, specifically, a sideways fall on the hip. We, therefore, used two sets (n = 9, each) of cadaveric femora with bone densities varying from normal to osteoporotic to build, refine, and validate a new class of QCT/FEA models for hip fracture under loading conditions that simulate a sideways fall on the hip. Convergence requirements of finite element models of the first set of femora led to the creation of a new meshing strategy and a robust process to model proximal femur geometry and material properties from QCT images. We used a second set of femora to cross-validate the model parameters derived from the first set. Refined models were validated experimentally by fracturing femora using specially designed fixtures, load cells, and high speed video capture. CT image reconstructions of fractured femora were created to classify the fractures. The predicted stiffness (cross-validation R2 = 0.87), fracture load (cross-validation R2 = 0.85), and fracture patterns (83% agreement) correlated well with experimental data. PMID:21052839
Verettas, Dionysios-Alexandros; Chloropoulou, Pelagia-Paraskevi; Drosos, Georgios; Vogiatzaki, Theodosia; Tilkeridis, Konstantinos; Kazakos, Konstantinos
Patient: Female, 68 Final Diagnosis: Periprosthetic fractures of the acetabulum and femur after bipolar hip arthroplasty Symptoms: Inability to walk Medication: — Clinical Procedure: Revision cup and internal fixation femur Specialty: Orhopedics and Traumatology Objective: Rare co-existance of disease or pathology Background: Although periprosthetic fractures of the femur are a recognized complication of total hip arthroplasty, periprosthetic fractures of the acetabulum are rare. Simultaneous periprosthetic fractures of both the acetabulum and the femur have not been reported, to our knowledge. Case Report: We report a simultaneous fracture of the acetabulum and the femur in a 68-year-old female patient who had previously sustained a subcapital fracture of the femur, treated with a bipolar uncemented prosthesis. We discuss the possible mechanism of this combination of fractures. Conclusions: Simultaneous periprosthetic fractures of the femur and the acetabulum can occur if, in the presence of osteoporotic bone, the metallic femoral head has migrated medially in the acetabulum while the femoral stem is not loose. PMID:28003639
Kemmis, Karen; Stuber, Diana
The purpose of this article is to present information that will assist the diabetes educator in screening patients with diabetes for risk of osteoporosis and fracture, to offer appropriate treatment options for patients, and to identify potential referrals to other providers for patients with diabetes and increased risk of fracture.
Bauer, Douglas C; Garnero, Patrick; Harrison, Stephanie L; Cauley, Jane A; Eastell, Richard; Ensrud, Kris E; Orwoll, Eric
We used data from the Osteoporotic Fractures in Men (MrOS) study to test the hypothesis that men with higher levels of bone turnover would have accelerated bone loss and an elevated risk of fracture. MrOS enrolled 5995 subjects >65 yr; hip BMD was measured at baseline and after a mean follow-up of 4.6 yr. Nonspine fractures were documented during a mean follow-up of 5.0 yr. Using fasting serum collected at baseline and stored at -190 degrees C, bone turnover measurements (type I collagen N-propeptide [PINP]; beta C-terminal cross-linked telopeptide of type I collagen [betaCTX]; and TRACP5b) were obtained on 384 men with nonspine fracture (including 72 hip fractures) and 947 men selected at random. Among randomly selected men, total hip bone loss was 0.5%/yr among those in the highest quartile of PINP (>44.3 ng/ml) and 0.3%/yr among those in the lower three quartiles (p = 0.01). Fracture risk was elevated among men in the highest quartile of PINP (hip fracture relative hazard = 2.13; 95% CI: 1.23, 3.68; nonspine relative hazard = 1.57, 95% CI: 1.21, 2.05) or betaCTX (hip fracture relative hazard = 1.76, 95 CI: 1.04, 2.98; nonspine relative hazard = 1.29, 95% CI: 0.99, 1.69) but not TRACP5b. Further adjustment for baseline hip BMD eliminated all associations between bone turnover and fracture. We conclude that higher levels of bone turnover are associated with greater hip bone loss in older men, but increased turnover is not independently associated with the risk of hip or nonspine fracture.
Martocchia, Antonio; Curto, Martina; Comite, Fabrizia; Scaccianoce, Sergio; Girardi, Paolo; Ferracuti, Stefano; Nicoletti, Ferdinando; Falaschi, Paolo
Osteoporotic hip fracture needs a specific approach and treatment, since elderly patients are at high risk for adverse outcomes after surgery. In particular, delirium often occurs in the peri-operative period, and it is associated with death, hospital-acquired complications, persistent cognitive impairments, poor functional recovery after surgery and increased healthcare costs. The pre-operative assessment of the risk factors for delirium improves the preventive measures. The delirium diagnostic tools should be included in the standard of orthogeriatric cure for hip fracture. Given the increasing complexity of the clinical pictures, we present a review of the available treatment options for delirium in patients with hip fracture. The metabolic pre-operative disorders and the management of co-morbid diseases are specific targets of treatment in order to optimize the outcomes after surgery. In particular, elderly patients with Alzheimer's disease are highly vulnerable to hip fracture and delirium, and they are severely frail with reduced physiologic reserves. An integrated approach combining environmental and pharmacological strategies is useful in the delirium treatment, with a close collaboration between the orthopedic and geriatric team.
Bonnaire, F; Straßberger, C; Kieb, M; Bula, P
Proximal femoral fractures in the elderly are still increasing and are almost always associated with osteoporosis. Especially the over 80-year-olds are increasing and at risk in this respect. In the treatment of these patients new knowledge has been achieved over the last years. An interdisciplinary, multimodal approach with early involvement of internists, geriatricians, anesthetists, osteologists, social workers, care facilities and outpatient trauma and orthopedic surgeons seems to generate a better outcome with fewer complications. In cases of suspected proximal femoral fracture diagnostic imaging should include a computed tomography scan of the posterior pelvic ring to detect commonly occurring fragility fractures of the lateral mass of the sacrum. Early surgery within the first 48 h has a significant positive effect with respect to general and local complications and early mortality. Medical and organizational barriers to an early operation, such as anticoagulant medication, limited capability of communication due to mental dysfunction and lack of operation capacity are continuously declining and subsequently complication rates are decreasing annually in Germany. Endoprosthetics are still associated with higher perioperative mortality than osteosynthesis (4.4 % versus 5.8 %). The innovations in the field of implants and surgical technique also contribute to these lower complication rates. While endoprosthetic treatment is still the gold standard for severely dislocated femoral neck fractures, non-dislocated or slightly dislocated fractures should be fixed with a stable extramedullary implant. For pertrochanteric fractures extramedullary stabilization can only be recommended for stable types of fractures. Every instable trochanteric fracture should be fixed with an intramedullary implant. The use of third generation nails has implicated a significant reduction of complication rates regarding cut-out and reoperations. Rotational fixing of the head
Borgström, F; Lekander, I; Ivergård, M; Ström, O; Svedbom, A; Alekna, V; Bianchi, M L; Clark, P; Curiel, M D; Dimai, H P; Jürisson, M; Kallikorm, R; Lesnyak, O; McCloskey, E; Nassonov, E; Sanders, K M; Silverman, S; Tamulaitiene, M; Thomas, T; Tosteson, A N A; Jönsson, B; Kanis, J A
The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss. The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS. ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire. The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not. The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.
Shawky, Ahmed; Kroeber, Markus
Case report. This study reports if shortening reconstruction procedure through posterior approach only can be used in osteoporotic unstable fracture as well as post-traumatic burst fracture. An 80-year-old female patient with unstable burst osteoporotic fracture of L1 underwent posterior approach corpectomy and shortening reconstruction of the spinal column by non-expandable cages. The surgery was uneventful, with average blood loss. Using of small profile cages has helped us to avoid root injury. Augmentation of the screw with cement and the compressive force applied to the spine column aids in obtaining a rigid construct with good alignment without any neurological complication. Shortening reconstruction procedure through only posterior approach is a viable option in treating unstable osteoporotic fracture as well as post-traumatic fractures. Using non-expandable cage is advocated to avoid cage subsidence.
Stephens, Kelly I.; Rubinsztain, Leon; Payan, John; Rentsch, Chris; Rimland, David; Tangpricha, Vin
Objective We evaluated the utility of the World Health Organization Fracture Risk Assessment Tool (FRAX) in assessing fracture risk in patients with human immunodeficiency virus (HIV) and vitamin D deficiency. Methods This was a retrospective study of HIV-infected patients with co-existing vitamin D deficiency at the Atlanta Veterans Affairs Medical Center. Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry (DEXA), and the 10-year fracture risk was calculated by the WHO FRAX algorithm. Two independent radiologists reviewed lateral chest radiographs for the presence of subclinical vertebral fractures. Results We identified 232 patients with HIV and vitamin D deficiency. Overall, 15.5% of patients met diagnostic criteria for osteoporosis on DEXA, and 58% had low BMD (T-score between −1 and −2.5). The median risk of any major osteoporotic and hip fracture by FRAX score was 1.45 and 0.10%, respectively. Subclinical vertebral fractures were detected in 46.6% of patients. Compared to those without fractures, those with fractures had similar prevalence of osteoporosis (15.3% versus 15.7%; P>.999), low BMD (53.2% versus 59.3%; P = .419), and similar FRAX hip scores (0.10% versus 0.10%; P = .412). While the FRAX major score was lower in the nonfracture group versus fracture group (1.30% versus 1.60%; P = .025), this was not clinically significant. Conclusion We found a high prevalence of subclinical vertebral fractures among vitamin D–deficient HIV patients; however, DEXA and FRAX failed to predict those with fractures. Our results suggest that traditional screening tools for fragility fractures may not be applicable to this high-risk patient population. PMID:26684149
Stephens, Kelly I; Rubinsztain, Leon; Payan, John; Rentsch, Chris; Rimland, David; Tangpricha, Vin
We evaluated the utility of the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) in assessing fracture risk in patients with human immunodeficiency virus (HIV) and vitamin D deficiency. This was a retrospective study of HIV-infected patients with co-existing vitamin D deficiency at the Atlanta Veterans Affairs Medical Center. Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry (DEXA), and the 10-year fracture risk was calculated by the WHO FRAX algorithm. Two independent radiologists reviewed lateral chest radiographs for the presence of subclinical vertebral fractures. We identified 232 patients with HIV and vitamin D deficiency. Overall, 15.5% of patients met diagnostic criteria for osteoporosis on DEXA, and 58% had low BMD (T-score between -1 and -2.5). The median risk of any major osteoporotic and hip fracture by FRAX score was 1.45 and 0.10%, respectively. Subclinical vertebral fractures were detected in 46.6% of patients. Compared to those without fractures, those with fractures had similar prevalence of osteoporosis (15.3% versus 15.7%; P>.999), low BMD (53.2% versus 59.3%; P = .419), and similar FRAX hip scores (0.10% versus 0.10%; P = .412). While the FRAX major score was lower in the nonfracture group versus fracture group (1.30% versus 1.60%; P = .025), this was not clinically significant. We found a high prevalence of subclinical vertebral fractures among vitamin D-deficient HIV patients; however, DEXA and FRAX failed to predict those with fractures. Our results suggest that traditional screening tools for fragility fractures may not be applicable to this high-risk patient population.
Fink, Howard A; Kuskowski, Michael A; Marshall, Lynn M
small, retrospective studies suggest that major life events and/or sudden emotional stress may increase fall and fracture risk. The current study examines these associations prospectively. a total of 5,152 men aged ≥65 years in the Osteoporotic Fractures in Men study self-reported data on stressful life events for 1 year prior to study Visit 2. Incident falls and fractures were ascertained for 1 year after Visit 2. Fractures were centrally confirmed. a total of 2,932 (56.9%) men reported ≥1 type of stressful life event. In men with complete stressful life event, fall and covariate data (n = 3,949), any stressful life event was associated with a 33% increased risk of incident fall [relative risk (RR) 1.33, 95% confidence interval (CI) 1.19-1.49] and 68% increased risk of multiple falls (RR = 1.68, 95% CI = 1.40-2.01) in the year following Visit 2 after adjustment for age, education, Parkinson's disease, diabetes, stroke, instrumental activities of daily living (IADL) impairment, chair stand time, walk speed, multiple past falls, depressive symptoms and antidepressant use. Risk increased with the number of types of stressful life events. Though any stressful life event was associated with a 58% increased age-adjusted risk for incident fracture, this association was attenuated and no longer statistically significant after additional adjustment for total hip bone mineral density, fracture after age 50, Parkinson's disease, stroke and IADL impairment. in this cohort of older men, stressful life events significantly increased risk of incident falls independent of other explanatory variables, but did not independently increase incident fracture risk.
Pareja Sierra, T; Bartolomé Martín, I; Rodríguez Solís, J; Bárcena Goitiandia, L; Torralba González de Suso, M; Morales Sanz, M D; Hornillos Calvo, M
Due to its high prevalence and serious consequences it is very important to be well aware of factors that might be related to medical complications, mortality, hospital stay and functional recovery in elderly patients with hip fracture. A prospective study of a group of 130 patients aged over 75 years admitted for osteoporotic hip fracture. Their medical records, physical and cognitive status prior to the fall, fracture type and surgical treatment, medical complications and functional and social evolution after hospitalization were evaluated. Patients with greater physical disability, more severe cognitive impairment and those who lived in a nursing home before the fracture had worse functional recovery after surgery. Treatment with intravenous iron to reduce transfusions reduced hospital stay and improved walking ability. Infections and heart failure were the most frequent medical complications and were related to a longer hospital stay. The prescription of nutritional supplements for the patients with real indication improved their physical recovery after the hip fracture CONCLUSIONS: Evaluation of physical, cognitive and social status prior to hip fracture should be the basis of an individual treatment plan because of its great prognostic value. Multidisciplinary teams with continuous monitoring of medical problems should prevent and treat complications as soon as possible. Intravenous iron and specific nutritional supplements can improve functional recovery six months after hip fracture. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.
Jaglal, Susan B.; Sherry, Paul G.; Schatzker, Joseph
Objectives To assess the magnitude and the burden of hip fracture on the health care system, including time trends in hip fracture rates, in-hospital death rates, length of hospital stay (LHS) and discharge destination. Design A retrospective study of discharge abstracts. Setting The Province of Ontario. Patients All patients (n = 93 660) over the age of 50 years and with a diagnosis of hip fracture discharged from hospital between 1981 and 1992 (excluding transfers). Main Outcome Measures Age-sex standardized hip fracture rates per 1000 population, in-hospital death rates and age-adjusted mean LHS. Results The overall hip fracture rate was 3.3 per 1000 persons (1.7 per 1000 men and 4.6 per 1000 women). There was no change in rates between 1981 and 1992 (p = 0.089), but there have been increases in the numbers of hip fractures. There was no change in the in-hospital death rate over time (p = 0.78). The age-adjusted mean LHS in 1981 was 28.6 days compared with 22.2 days in 1992. The numbers of hip fractures will increase from 8490 in 1990 to 16 963 in 2010. Conclusions Despite stable age-adjusted rates of hip fractures, the doubling of the number of hip fractures by the year 2010 due to an aging population will become an increasing burden on the health care system. PMID:8769920
Spencer, Simon J; Blyth, Mark J G; Lovell, Frances; Holt, Graeme
The association between hip fracture and reduced bone mineral density is well documented, with reduced bone mineral density predisposing to fracture. However, it is unknown whether an association exists between the magnitude of bone density lost and the severity of the hip fracture sustained. One hundred forty-two patients (96 women, 46 men) with a mean age of 74 years (range, 49-92 years) who sustained a hip fracture following a simple ground-level fall and were treated for this injury were reviewed. All patients had undergone dual-energy x-ray absorptiometry bone scanning of the contralateral hip and lumbar spine. Fractures were classified as intra- or extracapsular or subtrochanteric and then subclassified by degree of severity as simple (stable) or multifragmentary (unstable) fracture patterns.Although a low hip bone mineral density (T- or Z score <2.5) was associated with an increased risk of extracapsular fracture (P=.025) compared with other fracture types, no association existed between bone mineral density and the severity of the resultant hip fracture. Although an association exists between bone mineral density and the risk of fragility fractures, the results of the current study suggest that the severity of hip fractures does not follow this correlation. Therefore, no assumption can be made about bone mineral density of the proximal femur based on the severity of the fracture observed on plain radiographs. Copyright 2012, SLACK Incorporated.
Cong, Yu; Zhao, Jian-ning
One of the complications of total hip arthroplasty is intraoperative periprosthetic fracture. Periprosthetic fracture is divided into acetabular fracture and femoral fracture. Risk factors for intraoperative periprosthetic fracture include use of minimally invasive techniques, press-fit cementless stems, revision operations and osteoporosis. It has been recognized that treatment of intraoperative periprosthetic fractures should be based on the classification of the Vancouver system for intraoperative fractures.
Khandelwal, Stutee; Khandewal, Stutee; Chandra, Malini; Lo, Joan C
There is limited data pertaining to osteoporotic fractures among North American women of South Asian (SA) descent. This study examines fracture incidence and risk factors among post-menopausal SA, Chinese and White women undergoing mineral density (BMD) testing within a large healthcare organization in Northern California. Using data from a retrospective study of women aged 50-85 years with femoral neck BMD measured between 1997 and 2003, we identified a subset of women of SA race and an age-matched subgroup of Chinese (1:5) and White (1:10) women and examined rates of incident wrist, humerus and hip fractures up to 10 years following BMD. Clinical and demographic risk factors were identified using health plan databases. Multivariable Cox regression analyses were conducted to examine predictors of incident fractures. The study cohort included 449 SA, 2245 Chinese and 4490 White women, with an average age of 58.4 ± 6.1 years. The prevalence of femoral neck osteoporosis was higher among SA (8.9%) compared to White (6.5%) women and tended to be lower than Chinese (11.9%) women. More SA (7.1%) and White (9.6%) women had prior fracture compared to Chinese women (4.5%) and racial differences in smoking, rheumatoid arthritis, glucocorticoid use and hormone replacement therapy were seen. During a median of 8.4 years follow-up, wrist fracture incidence was similar among SA and White women (286 and 303 per 100,000 person-years, respectively) but significantly lower among Chinese women (130 per 100,000 person-years). In multivariable analyses, lower BMD, prior fracture and White and SA race (compared to Chinese race), were associated with a higher relative rate of wrist fracture. Lower BMD, prior fracture, older age and White but not SA race were also associated with a higher relative rate of non-vertebral (wrist, humerus or hip) fractures. Post-menopausal South Asian women differed from Chinese and White women with respect to prevalence of femoral neck osteoporosis, certain
del Toro, M D; Nieto, I; Guerrero, F; Corzo, J; del Arco, A; Palomino, J; Nuño, E; Lomas, J M; Natera, C; Fajardo, J M; Delgado, J; Torres-Tortosa, M; Romero, A; Martín-Rico, P; Muniain, M Á; Rodríguez-Baño, J
Hip hemiarthroplasty (HHA) and total hip arthroplasty (THA) infections are usually considered as one entity; however, they may show important differences. We analyze these differences, as well as predictors of treatment failure (TF) and poor functional status among patients with prosthetic hip infections (PHIs). A multicenter cohort study of consecutive patients with PHIs was performed. The main outcome variable was TF after the first surgical treatment performed to treat the infection. Multivariate analysis was used to identify predictors of TF. A total of 127 patients with PHI were included (43 HHA, 84 THA). Patients with HHA infections were more frequently women (88% vs. 54%; p < 0.001), had comorbidities (86% vs. 67%, p = 0.02), and were older (median age 79 vs. 65 years, p < 0.001), and the reason for arthroplasty was more frequently a fracture (100% vs. 18%, p < 0.001). Failure of initial treatment and crude mortality were more frequent among HHA patients (44% vs. 23%, p = 0.01 and 28% vs. 7%, p = 0.001, respectively). However, HHA was not associated with TF in the multivariate analysis when hip fracture was considered; thus, variables independently associated with TF were hip fracture, inadequate surgical management, prosthesis retention, and higher C-reactive protein level. Failure of the first surgical treatment was associated with poorer functional status. HHA and THA infections showed significant differences in epidemiology, clinical features, and outcome. Although patients with HHA infections had a higher risk of TF, this was related to the reason for hip implant: a hip fracture. Success of the initial management of infection is a predictor of better clinical and functional outcome.
Fang, Christian; Gudushauri, Paata; Wong, Tak-Man; Lau, Tak-Wing; Pun, Terence; Leung, Frankie
In osteoporotic hip fractures, fracture collapse is deliberately allowed by commonly used implants to improve dynamic contact and healing. The muscle lever arm is, however, compromised by shortening. We evaluated a cohort of 361 patients with AO/OTA 31.A1 or 31.A2 intertrochanteric fracture treated by the dynamic hip screw (DHS) who had a minimal follow-up of 3 months and an average follow-up of 14.6 months and long term survival data. The amount of fracture collapse and shortening due to sliding of the DHS was determined at the latest follow-up and graded as minimal (<1 cm), moderate (1-2 cm), or severe (>2 cm). With increased severity of collapse, more patients were unable to maintain their premorbid walking function (minimal collapse = 34.2%, moderate = 33.3%, severe = 62.8%, and p = 0.028). Based on ordinal regression of risk factors, increased fracture collapse was significantly and independently related to increasing age (p = 0.037), female sex (p = 0.024), A2 fracture class (p = 0.010), increased operative duration (p = 0.011), poor reduction quality (p = 0.000), and suboptimal tip-apex distance of >25 mm (p = 0.050). Patients who had better outcome in terms of walking function were independently predicted by younger age (p = 0.036), higher MMSE marks (p = 0.000), higher MBI marks (p = 0.010), better premorbid walking status (p = 0.000), less fracture collapse (p = 0.011), and optimal lag screw position in centre-centre or centre-inferior position (p = 0.020). According to Kaplan-Meier analysis, fracture collapse had no association with mortality from 2.4 to 7.6 years after surgery. In conclusion, increased fracture collapse after fixation of geriatric intertrochanteric fractures adversely affected walking but not survival.
Museyko, O; Bousson, V; Adams, J; Laredo, J -D; Engelke, K
For quantitative computed tomography (QCT), most relevant variables to discriminate hip fractures were determined. A multivariate analysis showed that trabecular bone mineral density (BMD) of the trochanter with "cortical" thickness of the neck provided better fracture discrimination than total hip integral BMD. A slice-by-slice analysis of the neck or the inclusion of strength-based parameters did not improve fracture discrimination. For QCT of the proximal femur, a large variety of analysis parameters describing bone mineral density, geometry, or strength has been considered. However, in each given study, generally just a small subset was used. The aim of this study was to start with a comprehensive set and then select a best subset of QCT parameters for discrimination of subjects with and without acute osteoporotic hip fractures. The analysis was performed using the population of the European Femur Fracture (EFFECT) study (Bousson et al. J Bone Min Res: Off J Am Soc Bone Min Res 26:881-893, 2011). Fifty-six female control subjects (age 73.2 ± 9.3 years) were compared with 46 female patients (age 80.9 ± 11.1 years) with acute hip fractures. The QCT analysis software MIAF-Femur was used to virtually dissect the proximal femur and analyze more than 1000 parameters, predominantly in the femoral neck. A multivariate best-subset analysis was used to extract the parameters best discriminating hip fractures. All results were adjusted for age, height, and weight differences between the two groups. For the discrimination of all proximal hip fractures as well as for cervical fractures alone, the measurement of neck parameters suffices (area under the curve (AUC) = 0.84). Parameters characterizing bone strength are discriminators of hip fractures; however, in multivariate models, only "cortical" cross-sectional area in the neck center remained as a significant contributor. The combination of one BMD parameter, trabecular BMD of the trochanter, and one geometry
Karres, Julian; Kieviet, Noera; Eerenberg, Jan-Peter; Vrouenraets, Bart C
Early mortality following hip fracture surgery is high and pre-operative risk assessment for the individual patient is challenging. A risk model could identify patients in need of more intensive perioperative care, provide insight in the prognosis and allow for risk-adjustment in audits. This study aimed to develop and validate a risk prediction model for 30-day mortality following hip fracture surgery: the Hip fracture Estimator of Mortality Amsterdam (HEMA). Data on 1050 consecutive patients undergoing hip fracture surgery between 2004 and 2010 were retrospectively collected and randomly split into a development cohort (746 patients) and validation cohort (304 patients). Logistic regression analysis was performed in the development cohort to determine risk factors for the HEMA. Discrimination and calibration were assessed in both cohorts using the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, and by stratification into low-, medium- and high-risk groups. Nine predictors for 30-day mortality were identified and used in the final model: age ≥ 85 years, in-hospital fracture, signs of malnutrition, myocardial infarction, congestive heart failure, current pneumonia, renal failure, malignancy and serum urea >9 mmol/L. The HEMA showed good discrimination in the development cohort (AUC = 0.81) and the validation cohort (AUC = 0.79). The Hosmer-Lemeshow test indicated no lack of fit in either cohort (P > 0.05). The HEMA is based on preoperative variables and can be used to predict the risk of 30-day mortality following hip fracture surgery for the individual patient. Prognostic Level II.
Mohamad, Sharlina; Shuid, Ahmad Nazrun; Mohamed, Norazlina; Fadzilah, Fazalina Mohd; Mokhtar, Sabarul Afian; Abdullah, Shahrum; Othman, Faizah; Suhaimi, Farihah; Muhammad, Norliza; Soelaiman, Ima Nirwana
OBJECTIVE: Osteoporosis increases the risk of bone fractures and may impair fracture healing. The aim of this study was to investigate whether alpha-tocopherol can improve the late-phase fracture healing of osteoporotic bones in ovariectomized rats. METHOD: In total, 24 female Sprague-Dawley rats were divided into three groups. The first group was sham-operated, and the other two groups were ovariectomized. After two months, the right femora of the rats were fractured under anesthesia and internally repaired with K-wires. The sham-operated and ovariectomized control rat groups were administered olive oil (a vehicle), whereas 60 mg/kg of alpha-tocopherol was administered via oral gavage to the alpha-tocopherol group for six days per week over the course of 8 weeks. The rats were sacrificed, and the femora were dissected out. Computed tomography scans and X-rays were performed to assess fracture healing and callus staging, followed by the assessment of callus strengths through the biomechanical testing of the bones. RESULTS: Significantly higher callus volume and callus staging were observed in the ovariectomized control group compared with the sham-operated and alpha-tocopherol groups. The ovariectomized control group also had significantly lower fracture healing scores than the sham-operated group. There were no differences between the alpha-tocopherol and sham-operated groups with respect to the above parameters. The healed femora of the ovariectomized control group demonstrated significantly lower load and strain parameters than the healed femora of the sham-operated group. Alpha-tocopherol supplementation was not able to restore these biomechanical properties. CONCLUSION: Alpha-tocopherol supplementation appeared to promote bone fracture healing in osteoporotic rats but failed to restore the strength of the fractured bone. PMID:23018307
Stoffel, Karl K; Leys, Toby; Damen, Nikki; Nicholls, Rochelle L; Kuster, Markus S
Fractures of the osteoporotic proximal femur are a significant source of mortality and morbidity in today's ageing population. Even with modern fixation techniques such as the sliding hip screw, a certain percentage of fixations will fail due to cut-out of the screw. This study presents a new method for augmenting hip screws with cement to reinforce the fixation. Unstable pertrochanteric fractures were created in paired osteoporotic cadaver femora (n=10). The fractures were fixed using either standard fixation techniques (dynamic hip screw), or using a dynamic hip screw augmented with cement. Cement was introduced using a customised jig to guide cement into a region superior to the screw in the femoral head. Cut-out resistance was assessed using a biaxial material testing machine, with loading applied in compression until failure. The new cement augmentation technique significantly improved the cut-out strength of the fixation (mean 42%; P=0.032). The failure mechanism for both groups was the same, with failure occurring through compression of the cancellous bone superior to the screw. The mean increase in temperature at the femoral neck was 3.7 degrees C in augmented bones, which is much lower than values previously reported for polymethylmethacrylate cements. Several benefits with this technique have emerged. The method is technically straightforward. The risk of cement penetration into the joint is reduced, and cement is targetted to the areas of the femoral head where it is most needed. The exothermic reaction is minimised by reducing the volume of cement used. The first clinical results are promising.
Wang, Yi-Xiang J; Griffith, James F; Zeng, Xian-Jun; Deng, Min; Kwok, Anthony W L; Leung, Jason C S; Ahuja, Anil T; Kwok, Timothy; Leung, Ping Chung
Osteoporotic Fractures in Men (Hong Kong) and Osteoporotic Fractures in Women (Hong Kong) represent the first large-scale prospective population-based studies on bone health in elderly (age≥65 years) Chinese men (n=2,000) and women (n=2,000). We undertook the current study to investigate the prevalence of lumbar disc space narrowing in these subjects, and to identify the potential relationship between disc space narrowing and sex, bone mineral density (BMD), and other demographic and clinical data. On lumbar lateral radiographs, L1/L2-L4/L5 disc space was classified into 4 categories: 0=normal; 1=mild narrowing; 2=moderate narrowing; 3=severe narrowing. We compared demographic and clinical data between subjects with and those without total disc space narrowing scores≥3. Disc space narrowing was more common in elderly women than in elderly men. The mean±SD disc space narrowing score for the 4 discs was 2.71±2.21 for men and 3.08±2.50 for women (P<0.0001). For the 3 age groups of 65-69 years, 70-79 years, and ≥80 years, the average disc space narrowing score increased with increasing age in both men and women, and to a greater degree in women than in men. The average disc space narrowing score differences between women and men were 0.12, 0.40, and 0.90, respectively, in the 3 age groups. For both men and women, a disc space narrowing score≥3 was associated with older age, higher spine and hip BMD, low back pain, and restricted leg mobility. The prevalence and severity of disc space narrowing are higher in elderly women than in elderly men. With increasing age, disc space narrowing progresses at a greater rate in women than in men. A disc space narrowing score≥3 is associated with higher spine and hip BMD. Copyright © 2013 by the American College of Rheumatology.
Hahn, Myung Hoon
Background Recently, as an independent fracture factor from Bone mineral density (BMD), muscle weakness due to the fatty degeneration of thigh muscles have been attracting attentions as causes of hip fracture. The purpose of this study is to investigate the correlation between the body composition and BMD and fatty degeneration of thigh muscles of the female patients over 65 years old with osteoporotic hip fracture. Methods This study was conducted with 178 female osteoporotic hip fracture patients. Total hip BMD was measured using dual energy X-ray absorptiometry. Cross-sectional area (CSA), cross-sectional muscle area (CSmA), muscle attenuation coefficient (MAC), and intramuscular adipose tissue (IMAT) of gluteus maximus, hip abductors, quadriceps and hamstring muscle were measured with computed tomography. Normalized IMAT (nIMAT) was calculated by dividing the fat area in the muscle into the size of each muscle. The correlation between each measurement is examined then the differences between the intertrochanteric fracture group and the femoral neck fracture group were analyzed. Results CSmA and MAC of quadriceps were the largest and nIMAT was the lowest. CSA and CSmA of the four muscles showed a statistically significant positive correlation with weight, height, body mass index (BMI), and BMD. MAC of 2 gluteal muscles was positively correlated with weight, BMI and BMD. nIMAT of all four muscles was positively correlation with weight and BMI but nIMAT of 2 mid-thigh muscles was positively correlation with BMD. Conclusions Muscle size and fatty degeneration in the thigh muscles were most positively correlated with the body weight. BMD was positively correlation with CSA and CSmA of all thigh muscles, and MAC of 2 gluteal muscles and fatty degeneration of 2 mid-thigh muscles. There was no statistically significant difference in the size of the femoral muscle and the degree of fatty degeneration between the two fracture groups. PMID:27965943
Lim, Vanessa; Li, Jun; Gong, Yinhan; Yuan, Jian-Min; Wu, Tsung Sheng; Hammond, Geoffrey; Jin, Aizhen; Koh, Woon-Puay; Yong, E.L.
There is paucity of data from Asian women on the association between serum estrogens and osteoporotic hip fracture risk. We conducted a case-control study nested within a population-based prospective cohort, The Singapore Chinese Health Study, to evaluate serum estrogens levels, ERα-mediated estrogenic activity and hip fracture risk in postmenopausal Asian women. Among 35,298 women who were recruited between 1993 and 1998, 15,410 women donated blood for research between 1999 and 2004. From this subcohort, we identified 140 cases who subsequently suffered hip fracture after blood donation, and 278 age-matched controls. Serum levels of total estrone, estradiol and sex hormone binding globulin levels were measured in a blinded fashion among cases and controls. ERα-mediated estrogenic activity of serum samples was quantified using a sensitive ERα-driven cell bioassay. Women with hip fracture had lower serum estrogens than control women. Compared to the lowest quintile, women in the highest quintile of free estradiol exhibited a statistically significant 57% reduction in risk of hip fracture (95% confidence interval (CI), 6%–80%), with a dose-dependent relationship (p for trend = 0.021). High levels of ERα-mediated estrogenic activity was also associated with decreased risk of hip fracture (p for trend=0.048). Overall, women with relatively high levels of both free estradiol and ERα-mediated estrogenic activity had a 55% reduction in hip fracture risk (95% CI, 17%–76%) compared to women with low levels of both. High levels of free estradiol and ERα-mediated estrogen activity in sera were associated with reduced hip fracture risk in Chinese postmenopausal women. PMID:22445734
Nakamura, Kazutoshi; Iki, Masayuki
Increased intake or supplementation of vitamin D is often recommended for normal bone health; however, its preventive effect on osteoporosis has not been fully evaluated. The aim of this review is to gather evidence of the efficacy of the optimization of vitamin D nutrition in preventing osteoporosis and osteoporotic fractures. PubMed was used for searching the relevant literature using the MeSH terms "Bone Density (limited to "human", "female", and "English" literature)" or "Fractures (limited to "human", "age ≥45 years", and "English" literature)", and "Vitamin D". The searches yielded 19 randomized controlled trials (RCTs), nine cohort studies, 19 case-control studies, 19 cross-sectional studies, and one meta-analysis. We attempted to answer three questions: 1) does increased vitamin D intake prevent bone loss in peri- and postmenopausal women?, 2) does increased vitamin D intake prevent osteoporotic fractures in the elderly?, and 3) does increased vitamin D in take positively affect peak bone mass attainment in young women? The answer to questions 1 and 2 is that a vitamin D intake of 10-17.5 μg/day (400-700 IU/day) or more is effective in preventing bone loss in late postmenopausal women and an intake of 17.5-20 μg/day (700-800 IU/day) or more together with a calcium supplement reduces the risk of osteoporotic fractures. For question 3, some lines of evidence support the negative effect of low vitamin D nutrition on the attainment of peak bone mass in young women. Further studies are needed to clarify the effect of vitamin D in this age group.
Basso, Trude; Klaksvik, Jomar; Syversen, Unni; Foss, Olav A
Fourth generation composite femurs (4GCFs, models #3406 and #3403) simulate femurs of males <80 years with good bone quality. Since most hip fractures occur in old women with fragile bones, concern is raised regarding the use of standard 4GCFs in biomechanical experiments. In this study the stability of hip fracture fixations in 4GCFs was compared to human cadaver femurs (HCFs) selected to represent patients with hip fractures. Ten 4GCFs (Sawbones, Pacific Research Laboratories, Inc., Vashon, WA, USA) were compared to 24 HCFs from seven females and five males >60 years. Proximal femur anthropometric measurements were noted. Strain gauge rosettes were attached and femurs were mounted in a hip simulator applying a combined subject-specific axial load and torque. Baseline measurements of resistance to deformation were recorded. Standardized femoral neck fractures were surgically stabilized before the constructs were subjected to 20,000 load-cycles. An optical motion tracking system measured relative movements. Median (95% CI) head fragment migration was 0.8mm (0.4 to 1.1) in the 4GCF group versus 2.2mm (1.5 to 4.6) in the cadaver group (p=0.001). This difference in fracture stability could not be explained by observed differences in femoral anthropometry or potential overloading of 4GCFs. 4GCFs failed with fracture-patterns different from those observed in cadavers. To conclude, standard 4GCFs provide unrealistically stable bone-implant constructs and fail with fractures not observed in cadavers. Until a validated osteopenic or osteoporotic composite femur model is provided, standard 4GCFs should only be used when representing the biomechanical properties of young healthy femurs. Copyright © 2014 Elsevier Ltd. All rights reserved.
Cawthon, Peggy M; Ewing, Susan K; Mackey, Dawn C; Fink, Howard A; Cummings, Steven R; Ensrud, Kristine E; Stefanick, Marcia L; Bauer, Doug C; Cauley, Jane A; Orwoll, Eric S
Low bone mineral density (BMD) increases fracture risk; how changes in BMD influence fracture risk in older men is uncertain. BMD was assessed at two to three time points over 4.6 years using dual-energy X-ray absorptiometry (DXA) for 4470 men aged ≥65 years in the Osteoporotic Fractures in Men (MrOS) Study. Change in femoral neck BMD was estimated using mixed effects linear regression models. BMD change was categorized as "accelerated" (≤-0.034 g/cm(2) ), "expected" (between 0 and -0.034 g/cm(2) ), or "maintained" (≥0 g/cm(2) ). Fractures were adjudicated by central medical record review. Multivariate proportional hazards models estimated the risk of hip, nonspine/nonhip, and nonspine fracture over 4.5 years after the final BMD measure, during which time 371 (8.3%) men experienced at least one nonspine fracture, including 78 (1.7%) hip fractures. Men with accelerated femoral neck BMD loss had an increased risk of nonspine (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.4-2.8); nonspine/nonhip (HR = 1.6; 95% CI 1.1-2.3); and hip fracture (HR = 6.3; 95% CI 2.7-14.8) compared with men who maintained BMD over time. No difference in risk was seen for men with expected loss. Adjustment for the initial BMD measure did not alter the results. Adjustment for the final BMD measure attenuated the change in BMD-nonspine fracture and the change in BMD-nonspine/nonhip relationships such that they were no longer significant, whereas the change in the BMD-hip fracture relationship was attenuated (HR = 2.6; 95% CI 1.1-6.4). Total hip BMD change produced similar results. Accelerated decrease in BMD is a strong, independent risk factor for hip and other nonspine fractures in men. Copyright © 2012 American Society for Bone and Mineral Research.
Jang, Eun Jin; Park, ByeongJu; Kim, Tae-Young; Shin, Soon-Ae
Background Asian-specific prediction models for estimating individual risk of osteoporotic fractures are rare. We developed a Korean fracture risk prediction model using clinical risk factors and assessed validity of the final model. Methods A total of 718,306 Korean men and women aged 50–90 years were followed for 7 years in a national system-based cohort study. In total, 50% of the subjects were assigned randomly to the development dataset and 50% were assigned to the validation dataset. Clinical risk factors for osteoporotic fracture were assessed at the biennial health check. Data on osteoporotic fractures during the follow-up period were identified by ICD-10 codes and the nationwide database of the National Health Insurance Service (NHIS). Results During the follow-up period, 19,840 osteoporotic fractures were reported (4,889 in men and 14,951 in women) in the development dataset. The assessment tool called the Korean Fracture Risk Score (KFRS) is comprised of a set of nine variables, including age, body mass index, recent fragility fracture, current smoking, high alcohol intake, lack of regular exercise, recent use of oral glucocorticoid, rheumatoid arthritis, and other causes of secondary osteoporosis. The KFRS predicted osteoporotic fractures over the 7 years. This score was validated using an independent dataset. A close relationship with overall fracture rate was observed when we compared the mean predicted scores after applying the KFRS with the observed risks after 7 years within each 10th of predicted risk. Conclusion We developed a Korean specific prediction model for osteoporotic fractures. The KFRS was able to predict risk of fracture in the primary population without bone mineral density testing and is therefore suitable for use in both clinical setting and self-assessment. The website is available at http://www.nhis.or.kr. PMID:27399597
Doshi, H. K.; Selvaraj, Dahshaini; Chan, William; Naidu, G.; Ramason, R.
Introduction: Although there is evidence of improved functional outcomes with our “integrated care pathway” for geriatric hip fractures, we do not know if there is a significant difference in functional recovery of activities of daily living and attainment of independence in self-care between patients who underwent fixation and those treated with arthroplasty. Objective: To determine whether such a difference exists in surgically fixed hip fractures. Materials and Methods: Patients with hip fracture treated surgically were divided into group A (internal fixation, n = 213) and group B (arthroplasty, n = 199). Demographic data, Charlson comorbidity index (CCI) score, time to surgery, and length of stay were recorded. Inpatient complications and mortality rates were also documented. Modified Barthel Index (MBI) scores were recorded for the following intervals: prefall, discharge, 6-month, and at 1-year follow-up. Results: The mean age (A: 80 years and B: 81years), CCI (A: 5.41 and B: 5.43), and length of stay (A: 13.6 days and B: 15.2 days) were not significantly different. However, there was a significant difference (P < .05) in time to surgery (A: 102.2 hours and B: 86.6 hours). Complication rates were about 6% in both groups (A = 6.57%: urinary infections = 13, wound infections = 1 and B = 6.03%: urinary infections = 10, wound infections = 1, pressure ulcer = 1). The preinjury MBI scores were significantly different (P < .05; A: 91.65 and B: 88.19), however, there was no significant difference in scores measured at discharge (A: 60.79 and B: 59.39), 6 months (A: 77.65 and B: 77.47) and 1 year (A: 80.71 and B: 83.03). Patients who underwent surgery for hip fracture had overall recovered 90.9% of their preinjury function (overall MBI at 1 year: 81.83). Conclusion: The MBI scores reflect the extent of attainment of independence in self-care, and actual functional recovery is gauged from the percentage of recovery of preinjury function at 1 year postsurgery. We
Nasiri Sarvi, M; Luo, Y
Osteoporotic hip fracture, mostly induced in falls among the elderly, is a major health burden over the world. The impact force applied to the hip is an important factor in determining the risk of hip fracture. However, biomechanical researches have yielded conflicting conclusions about whether the fall-induced impact force can be accurately predicted by the available models. It also has been debated whether or not the effect of impact force has been considered appropriately in hip fracture risk assessment tools. This study aimed to provide a state-of-the-art review of the available methods for predicting the impact force, investigate their strengths/limitations, and suggest further improvements in modeling of human body falling. We divided the effective parameters on impact force to two categories: (1) the parameters that can be determined subject-specifically and (2) the parameters that may significantly vary from fall to fall for an individual and cannot be considered subject-specifically. The parameters in the first category can be investigated in human body fall experiments. Video capture of real-life falls was reported as a valuable method to investigate the parameters in the second category that significantly affect the impact force and cannot be determined in human body fall experiments. The analysis of the gathered data revealed that there is a need to develop modified biomechanical models for more accurate prediction of the impact force and appropriately adopt them in hip fracture risk assessment tools in order to achieve a better precision in identifying high-risk patients. Graphical abstract Impact force to the hip induced in sideways falls is affected by many parameters and may remarkably vary from subject to subject.
Chen, Jian Sheng; Cameron, Ian D; Simpson, Judy M; Seibel, Markus J; March, Lyn M; Cumming, Robert G; Lord, Stephen R; Sambrook, Philip N
This study aims to investigate the risk of subsequent fractures after low-trauma fracture in frail older people. A total of 1412 elderly residents (mean age 86.2 years, SD 7.0 years, female 77%) were recruited from aged care facilities in Australia. Residents were assessed and then followed for any fracture for 2 years and hip fractures for at least 5 years. Residents with and without a newly acquired fracture in the first 2 years were compared for risk of subsequent hip fracture. Residents with a nonhip fracture in the first 2 years had an increased risk of subsequent hip fracture for about 2.5 years, whereas those with a hip fracture had a similar risk over the whole period compared with those with no fracture. During these 2.5 years, 60, 28, and 6 subsequent hip fractures occurred in the nonfracture group (n = 953), the nonhip fracture group (n = 194), and the hip fracture group (n = 101), respectively, resulting in the probability of subsequent hip fracture of 8.0%, 19.9%, and 10.4%, respectively. Compared with the nonfracture group, the hazard ratio (HR) was 2.82 [95% confidence interval (CI) 1.73-4.59; p < .001] for the nonhip fracture group and 1.48 (95% CI 0.63-3.49, p = .37) for the hip fracture group after adjusting for age, sex, residence type, calcaneal broadband ultrasound attenuation, fracture history, weight, lower leg length, immobility, cognitive function, and medications. Frail institutionalized older people with newly acquired fractures are at increased risk of subsequent hip fracture for the next few years. Accordingly, despite their advanced age, they are a high-priority target group to investigate interventions that might reduce the risk of hip fracture.
Ip, T. P.; Leung, J.
Hip fracture is associated with high morbidity, mortality, and economic burden worldwide. It is also a major risk factor for a subsequent fracture. A literature search on the management of osteoporosis in patients with hip fracture was performed on the Medline database. Only one clinical drug trial was conducted in patients with a recent hip fracture. Further studies that specifically address post-fracture management of hip fracture are needed. The efficacy of anti-osteoporosis medication in older individuals and those at high risk of fall is reviewed in this paper. Adequate nutrition is vital for bone health and to prevent falls, especially in malnourished patients. Protein, calcium, and vitamin D supplementation is associated with increased hip BMD and a reduction in falls. Fall prevention, exercise, and balance training incorporated in a comprehensive rehabilitation program are essential to improve functional disability and survival. Exclusion of secondary causes of osteoporosis and treatment of coexistent medical conditions are also vital. Such a multidisciplinary team approach to the management of hip fracture patients is associated with a better clinical outcome. Although hip fracture is the most serious of all fractures, osteoporosis management should be prioritized to prevent deterioration of health and occurrence of further fracture. PMID:21058000
Gilula, L; Persenaire, M
Two injectable materials for the treatment of vertebral compression fractures, Cortoss and PMMA, were compared in a prospective, randomized study. Our purpose was to analyze the incidence and nature of subsequent fractures following treatment, one of the secondary outcomes. A prospective study was conducted at 21 US sites by 38 investigators by using Cortoss randomized 2:1 to PMMA in 256 patients blinded to treatment assignment. Inclusion criteria were 1-2 osteoporotic fractures causing significant pain or worsening vertebral collapse on radiographs and visual analog scale pain measuring ≥50 mm. Assessments were conducted pretreatment, on treatment day, and at 7 posttreatment intervals. Imaging studies underwent independent blinded review. Internal and independent monitors, including the FDA, verified data. Of the 256 patients, 45/162 Cortoss-treated (27.8%) and 30/94 PMMA-treated (31.9%) patients experienced new fractures, most within 30-365 days. In patients with 1 acute or subacute fracture and no previous fractures, subsequent fracture incidence was less in patients treated with Cortoss (17.6%) than with PMMA (27.3%). In this subgroup, adjacent fractures occurred in 10.3% of patients treated with Cortoss and 18.2%, with PMMA, a 43.4% lower incidence in the Cortoss group. Compared with PMMA, Cortoss use resulted in fewer subsequent fractures, especially in patients with first fractures. In patients without previous fractures, the subsequent fracture rate was also lower in Cortoss-treated versus conservatively treated patients in other studies. This reduced subsequent fracture rate may be due to differences in the material and mechanical properties of Cortoss compared with PMMA. As finite-element analysis modeling demonstrated, Cortoss restores a more physiologic load transfer through the treated vertebra. Patients treated with Cortoss were less likely to be hospitalized for new fractures.
Marcus, Daniel B; Lee, Paul C; Fish, David E
To report a case in which pain preceded computer axial tomography (CT) and scintigraphic findings in an osteoporotic vertebral compression fracture. Report of a patient presenting to a physical medicine/pain medicine outpatient clinic. Eighty-seven-year-old female with history of osteoporosis and previous vertebral compression fracture with new onset, atraumatic, axial thoracic pain. Thoracic spine CT, bone scintigraphy, kyphoplasty (Kyphon-Medtronic, Sunnyvale, CA). Not applicable. History and physical exam were suggestive of thoracic compression fracture. CT and bone scintigraphy were negative for vertebral compression fracture. A CT of the pulmonary arteries during an unrelated hospital admission less than two weeks after initial presentation revealed a compression fracture at T7. Pain report was unchanged except for an increase in intensity. Follow-up X-ray and CT revealed a compression fracture at T7 with loss of 80% of vertebral height. Pain was successfully treated with kyphoplasty. CT and bone scintigraphy performed early after pain onset did not reveal a vertebral compression fracture. Within 2 weeks, fracture was evident on further imaging. The pain resolved following an intervention directed at the fracture. The patient's pain preceded CT and scintigraphic evidence of the osteoporotic vertebral compression fracture. It is possible that pain is an early sign of impending osteoporotic compression fracture, or microtrabecular fracture, prior to anatomic and physiologic changes. Magnetic resonance imaging may be the imaging study of choice rather than bone scintigraphy in identification of noncollapsed osteoporotic compression fracture. Earlier identification and treatment of vertebral compression fractures may reduce kyphosis and associated sequelae.
Scott, C E H; MacDonald, D; Moran, M; White, T O; Patton, J T; Keating, J F
To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture. Between 1992 and 2016, 49 patients (33 male) with mean age of 57 years (25 to 87) underwent cemented THA at a mean of 6.5 years (0.1 to 25) following acetabular fracture. A total of 38 had undergone surgical fixation and 11 had been treated non-operatively; 13 patients died at a mean of 10.2 years after THA (0.6 to 19). Patients were assessed pre-operatively, at one year and at final follow-up (mean 9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant survivorship was assessed. An age and gender-matched cohort of THAs performed for non-traumatic osteoarthritis (OA) or avascular necrosis (AVN) (n = 98) were used to compare complications and patient-reported outcome measures (PROMs). The mean time from fracture to THA was significantly shorter for patients with AVN (2.2 years) or protrusio (2.2 years) than those with post-traumatic OA (9.4 years) or infection (8.0 years) (p = 0.03). Nine contained and four uncontained defects were managed with autograft (n = 11), bulk allograft (n = 1), or trabecular metal augment (n = 1). Initial fracture management (open reduction and internal fixation or non-operative), timing of THA (>/< one year), and age (>/< 55 years) had no significant effect on OHS or ten-year survival. Six THAs were revised at mean of 12 years (5 to 23) with ten-year all-cause survival of 92% (95% confidence interval 80.8 to 100). THA complication rates (all complications, heterotopic ossification, leg length discrepancy > 10 mm) were significantly higher following acetabular fracture compared with atraumatic OA/AVN and OHSs were inferior: one-year OHS (35.7 versus 40.2, p = 0.026); and final follow-up OHS (33.6 versus 40.9, p = 0.008). Cemented THA is a reasonable option for the sequelae of acetabular fracture. Higher complication rates and
Background The number of hip fractures has doubled in the last 30–40 years in many countries. Age-adjusted incidence has been reported to be decreasing in Europe and North America, but is there a decreasing trend in all age groups? Patients and methods This population-based study included all hip-fracture patients over 50 years of age (a total of 2,919 individuals, 31% of whom were men) admitted to Umeå University Hospital, Sweden, from 1993 through 2005. Results The incidence of hip fracture declined between the periods 1993–1996 and 2001–2005: from 706 to 625 hip fractures per 105 women and from 390 to 317 hip fractures per 105 men. However, there was a 114% increase in the number of fractures in women aged 90 or older (12 and 25 hip fractures/year, respectively, in the two time periods). For the period 2001–05, women ≥ 90 years of age accounted for almost the same numbers of hip fractures as women aged 75–79 (27 fractures/year). The rate increased during this period, from 2,700 per 105 women to 3,900 per 105 women > 90 years. In men there were declining trends for both relative and absolute numbers. Interpretation Although age-adjusted incidence declined in the population > 50 years of age, absolute fracture rate and incidence increased in the very old. Women over 90 now have the same absolute number of hip fractures every year as women aged 75–79 years. There was a right-shift in hip fracture distribution towards the oldest old, probably due to an increased number of octo/nonagenarians, a new population of particularly frail old people that hardly existed earlier. Better health among septuagenarians may also have delayed the age at which fractures occurred. This changing pattern will strain orthopedic and geriatric resources even more. PMID:19916682
Meriläinen, Sanna; Nevalainen, Tanja; Luukinen, Heikki; Jalovaara, Pekka
The aim of this study was to elucidate factors related to hip fracture in patients who fall on the hip in order to identify those patients who might benefit from the use of hip protectors. The study was performed by comparing 146 persons who had fallen and sustained a soft tissue injury in the hip region with 146 cervical hip fracture and 146 trochanteric hip fracture patients matched for age, sex and place of residence. The fall group was drawn from a prospectively collected cohort of 1,061 elderly people participating in an epidemiological survey on fall injuries; the fracture group was drawn from a prospectively recorded hip fracture database of the Oulu University Hospital (n = 1,714). Demographic data, place and mechanism of falling, walking ability, associated diseases, medication. In a stepwise polychotomous conditional logistic regression analysis, the following significant and independent risk factors for both fracture types were seen: low weight, tall height, falling from standing height and respiratory disease. Falling indoors was a risk for only trochanteric fractures, while inability to walk alone outdoors was a risk for only cervical hip fractures. Elderly persons with low weight, tall height, respiratory disease, tendency to fall indoors and inability to walk alone outdoors should be candidates for the use of hip protectors.
Calvo, Emilio; Morcillo, Diana; Foruria, Antonio M; Redondo-Santamaría, Enrique; Osorio-Picorne, Fernando; Caeiro, Jose R
Although most proximal humeral fractures are attributed to osteoporosis, they are usually not considered individually in osteoporotic studies because of their lower incidence. The purpose of this study was to evaluate the incidence of nondisplaced proximal humeral fractures in comparison with other outpatient-treated osteoporotic fractures, as well as to assess their functional impact and effects on patient-perceived quality of life. In this multicenter, cross-sectional, prospective study, all osteoporotic fractures in postmenopausal women aged 50 years or older treated nonoperatively in 358 trauma centers were recorded during a 3-month period. Fractures were considered osteoporotic if caused by a low-energy trauma. Pathologic fractures were excluded. The incidence of proximal humeral fractures in relation to other osteoporotic fractures was calculated. Patients were interviewed by telephone 6 months after the fracture with the Disabilities of the Arm, Shoulder and Hand and EuroQoL 5D questionnaires. This study comprised 5,147 women (mean age, 72.6 ± 7.5 years) with 5,268 fractures. Of these, 912 (17.5%) had had proximal humeral fractures. The mean Disabilities of the Arm, Shoulder and Hand score was 26.6 ± 25.7. Of the women, 67.3% had pain or discomfort and disclosed significant reductions in functional capacity, especially with regard to self-care (44.5%), daily life activities (56.5%), and anxiety or depression (32.7%). Nondisplaced proximal humeral fractures are among the most common fractures associated with osteoporosis, and they can be a major cause of functional disability and reduction in subjective patient-perceived health. Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Rull, Miguel Angel Ochoa-Hortal; Cano-García, María del Carmen; Arrabal-Martín, Miguel; Arrabal-Polo, Miguel Angel
Introduction: Calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. The objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previously known renal lithiasis compared to women without osteoporosis and without renal lithiasis. Methods: In total, 87 women were included in the study. They were divided into two groups: Group 1 with 55 postmenopausal women with osteoporotic fracture and without renal lithiasis; and Group 2 with 32 postmenopausal women without osteoporosis and without history of renal lithiasis. The following parameters of phospho-calcium metabolism were analyzed: calciuria 24-hour, oxaluria 24-hour, uricosuria 24-hour, and citraturia 24-hour. The presence of hypercalciuria, hyperoxaluria, hyperuricosuria, and hypocitraturia was compared between groups. Statistical significance was set at p ≤ 0.05. Results: The mean age was 70.1 ± 13.8 in Group 1 and 56.7 ± 6.4 in Group 2 (p = 0.0001). Women in Group 1 had higher levels of serum alkaline phosphatase (p < 0.05) and fasting urinary calcium/creatinine ratio (p < 0.05). The percentage of patients with hypercalciuria in Group 1 (40%) was higher compared to Group 2 (18.8%) and statistically significant (p = 0.04). There were no statistically significant differences in the percentage of hyperoxaluria, hyperuricosuria, and hypocitraturia between groups. This study has its limitations including its cross-sectional nature at a unique centre and its low number of patients. Conclusion: The determination of urinary calcium and fasting calcium/creatinine ratio in postmenopausal women with osteoporotic fracture without renal lithiasis may facilitate individualization of medical therapy and decreasing lithogenic risk. PMID:26085877
Chen, Hsin-Yao; Chen, Chiu-Liang; Chen, Wei-Liang
Background Pedicle screw instrumentation for treating spinal disorder is becoming increasingly widespread. Many studies have advocated its use to facilitate rigid fixation for spine; however, adjacent segmental disease is a known complication. Instrumented fusion for osteoporotic spines remains a significant challenge for spine surgeons. Prophylactic vertebroplasty for adjacent vertebra has been reported to reduce the complications of junctional compression fractures but has raised a new problem of vertebral subluxation. This case report is a rare and an extreme example with many surgical complications caused by repeated instrumented fusion for osteoporotic spine in a single patient. This patient had various complications including adjacent segmental disease, vertebral subluxation, and junctional fractures on radiographs and magnetic resonance images. Case presentation An 81-year-old Taiwanese woman underwent decompression and instrumented fusion of L4-L5 in Taiwan 10 years ago. Due to degenerative spinal stenosis of L3-L4 and L2-L3, she had decompression with instrumented fusion from L5 to L1 at the previous hospital. However, catastrophic vertebral subluxations with severe neurologic compromise occurred, and she underwent salvage surgeries twice with prolonged instrumented fusion from L5 to T2. The surgeries did not resolve her problems of spinal instability and neurologic complications. Eventually, the patient remained with a Frankel Grade C spinal cord injury. Conclusion Adjacent segmental disease, junctional fracture, and vertebral subluxation are familiar complications following instrumented spinal fusion surgeries for osteoporotic spines. Neurologic injuries following long instrumentation are often serious and difficult to address with surgery alone. Conservative treatments should always be contemplated as an alternative method for patients with poor bone stock. PMID:27555778
Cawthon, Peggy M; Blackwell, Terri L; Cauley, Jane; Kado, Deborah M; Barrett-Connor, Elizabeth; Lee, Christine G; Hoffman, Andrew R; Nevitt, Michael M; Stefanick, Marcia L; Lane, Nancy E; Ensrud, Kristine E; Cummings, Steven R; Orwoll, Eric S
Background Recently, several consensus definitions for sarcopenia have been developed. Objective To evaluate the associations and discriminative ability of definitions of sarcopenia against clinical outcomes. Design Osteoporotic Fractures in Men study Setting Six clinical centers Participants 5,934 community-dwelling men aged ≥65 yrs Measurements Sarcopenia definitions evaluated were: International Working Group (IWG), European Working Group for Sarcopenia in Older Persons (EWGSOP), Foundation for the NIH (FNIH) Sarcopenia, Baumgartner, and Newman. Recurrent falls were defined as ≥2 self-reported falls in the year after baseline (N=694, 11.9%). Incident hip fractures (N=207, 3.5 %) and deaths (N=2003, 34.1%) were confirmed by central review of medical records over 9.8 years. Self-reported functional limitations were assessed at baseline and again 4.6 years later. Logistic regression or proportional hazards models estimated associations between sarcopenia and falls, hip fractures or death. The discriminative ability of the sarcopenia definitions (compared to referent models) for these outcomes was evaluated with areas under the receiver operator curve (AUCs) or C-statistics. Referent models included age alone for falls, function limitations and mortality, and age and BMD for hip fractures. Results The association between sarcopenia by the various definitions and risk of falls, functional limitations, and hip fractures was variable; all definitions were associated with increased mortality risk. However, none of the definitions materially changed discrimination based on AUC and C-statistic when compared to referent models (change ≤1% in all models). Conclusions Sarcopenia definitions as currently constructed did not consistently improve prediction of clinical outcomes in relatively healthy older men. PMID:26502831
García Pascual, E
Repairing hip fractures is one of the most common surgical procedures and has greater morbidity and mortality. This procedure is also a process that involves a greater need for blood products. Numerous factors influence morbidity, mortality and the use of blood products: patient age, concomitant diseases and drug treatments that change hemostasis and hemorrhaging (preoperative, intraoperative and postoperative), which are usually significant. On top of all this is the presence in a high percentage of cases of preoperative anemia, which can have one or more causes. It is therefore essential to establish an appropriate management of perioperative anemia and optimize the transfusion policy. The aim of this review is to briefly analyze the epidemiology of hip fractures as well as establish a basis for treating perioperative anemia and transfusion policies, proposing guidelines and recommendations for clinical management based on the most current studies. Copyright © 2015 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.
Sisljagić, Vladimir; Jovanović, Savo; Mrcela, Tomislav; Radić, Radivoje; Belovari, Tatjana
In surgery of fractured long bones, a patient suffering from osteoporosis represents constant challenge to a surgeon and applied material and instruments that need to destroy as little as possible of an already damaged bone. One potential way of increasing the contact surface between the implants and osteoporotic bone is injection of bone cement (methyl-metacrilat, Palakos) into a prepared screw bed. This method of osteosynthesis was therefore subjected to experimental research to prove that application of modified osteosynthesis using bone cement in treatment of fractures in osteoporotic patients has advantage over the standard method of osteosynthesis because this modified method enables significantly greater firmness and stability of the osteosynthesis, which is the essential precondition of a successful fracture healing. The research was carried out on six macerated cadaveric preparations of a shin bone from the osteological collection from Institute for Anatomy, School of Medicine, University "J. J. Strossmayer". All samples of long bones were artificially broken in the middle part of the diaphysis and then standard osteosynthesis and modified osteosynthesis with screws filled with bone cement were performed on the samples. Results show that under identical static action of the moment of torsion in the modified osteosynthesis torsion angle deviation is lower than in the standard osteosynthesis. In modified osteosynthesis with bone cement the first results for angle of torsion deviation greater than 0.2 degrees were noticed after 120 minutes, while in the standard method of osteosynthesis they were noticed already in the first minute.
Ren, Hai-long; Jiang, Jian-ming; Chen, Jian-ting; Wang, Ji-xing
This study evaluated the risk factors of new vertebral compression fractures (VCFs) following percutaneous vertebroplasty (PVP). From June 2005 to January 2011, patients with osteoporotic VCFs (OVCFs) who were treated with PVP and met this study's inclusion criteria were retrospectively reviewed. Observed parameters were age, sex, bone mineral density, body mass index, amount of bone cement, cement leakage into the disk, preoperative kyphosis, preoperative degree of anterior vertebral compression, preoperative degree of middle vertebral compression, kyphosis correction, anterior vertebral height restoration, middle vertebral height restoration, and number of initial symptomatic fractures (levels treated). The data were analyzed by univariate and multivariate analysis for the emergence of new fractures after PVP to determine related risk factors. A total of 182 patients met the inclusion criteria. There were 155 female and 27 male patients with a mean age of 69.7 years (range 49-91 years). The follow-up period was 24-50 months (average 26.4 months). A total of 294 VCFs among 182 patients were observed, 28 new VCFs occurred in 21 patients (21/182, 11.5 %) during the follow-up period. Statistical analysis indicated that higher BMI (P = 0.004) and a greater number of initial symptomatic fractures (P = 0.017) were significantly associated with new VCFs after PVP. It is the most obvious that the risk of new fractures increased 2.518-fold (95 % CI 1.176-5.395), when the number of initial VCFs increased by one level. The incidence of new symptomatic VCFs after PVP was higher in osteoporotic patients with initial multiple-level fractures.
Cheng, Bi-Hua; Chen, Pau-Chung; Yang, Yao-Hsu; Lee, Chuan-Pin; Huang, Ko-En; Chen, Vincent C.
Abstract This study was conducted to investigate the effects of depression and antidepressant medications on hip fracture. The database of the Taiwan National Health Insurance with medical records of more than 1,000,000 individuals was searched for patients who had hip fracture with or without depression from 1998 to 2009. Patients with the following conditions were excluded: hip fracture due to cancer or traffic accidents, hip fracture that occurred before the diagnosis of depression, and use of antidepressants before the diagnosis of depression. A matched cohort of 139,110 patients was investigated, including 27,822 (17,309 females; 10,513 males) with depression and 111,288 (69,236 females; 42,052 males) without depression (1:4 randomly matched with age, sex, and index date). Among these patients, 232 (158 females and 74 males) had both hip fracture and depression, and 690 (473 females and 217 males) had hip fracture only. The Cox proportional-hazards regression method was used to determine the effect of depression on hip fracture. The hazard ratio (HR) for each clinical parameter was calculated after adjusting for confounders including sex, age, Charlson comorbidity index, urbanization, osteoporosis, and antidepressants. Results showed that patients with major depressive disorder had a 61% higher incidence of hip fracture than those without depression (HR 1.61, 95% confidence interval [CI] 1.19–2.18, P = 0.002). The risk of hip fracture for patients with less severe depressive disorder (dysthymia or depressive disorder, not otherwise specified) was not statistically higher than that of patients with no depression (HR 1.10, 95% CI = 0.91–1.34, P = 0.327). Among the patients with depression, females had a 49% higher incidence for hip fracture than males (HR 1.49, 95% CI 1.30–1.72, P < 0.001). The incidence of hip fracture also increased with age and Charlson comorbidity index scores. Analyses of both all (139,110) patients and only patients (27,822) with
Background The WHO has recently published the FRAX® tool to determine the absolute risk of osteoporotic fracture at 10 years. This tool has not yet been validated in Spain. Methods/design A prospective observational study was undertaken in women in the FRIDEX cohort (Barcelona) not receiving bone active drugs at baseline. Baseline measurements: known risk factors including those of FRAX® and a DXA. Follow up data on self-reported incident major fractures (hip, spine, humerus and wrist) and verified against patient records. The calculation of absolute risk of major fracture and hip fracture was by FRAX® website. This work follows the guidelines of the STROBE initiative for cohort studies. The discriminative capacity of FRAX® was analyzed by the Area Under Curve (AUC), Receiver Operating Characteristics (ROC) and the Hosmer-Lemeshow goodness-of-fit test. The predictive capacity was determined using the ratio of observed fractures/expected fractures by FRAX® (ObsFx/ExpFx). Results The study subjects were 770 women from 40 to 90 years of age in the FRIDEX cohort. The mean age was 56.8 ± 8 years. The fractures were determined by structured telephone questionnaire and subsequent testing in medical records at 10 years. Sixty-five (8.4%) women presented major fractures (17 hip fractures). Women with fractures were older, had more previous fractures, more cases of rheumatoid arthritis and also more osteoporosis on the baseline DXA. The AUC ROC of FRAX® for major fracture without bone mineral density (BMD) was 0.693 (CI 95%; 0.622-0.763), with T-score of femoral neck (FN) 0.716 (CI 95%; 0.646-0.786), being 0.888 (CI 95%; 0.824-0.952) and 0.849 (CI 95%; 0.737-0.962), respectively for hip fracture. In the model with BMD alone was 0.661 (CI 95%; 0.583-0.739) and 0.779 (CI 95%; 0.631-0.929). In the model with age alone was 0.668 (CI 95%; 0.603-0.733) and 0.882 (CI 95%; 0.832-0.936). In both cases there are not significant differences against FRAX® model. The overall
Hip fractures are common in the elderly. Published studies have not shown significant differences in mortality rates between hip fracture patients who were managed nonoperatively and operatively. This retrospective study looked at 340 patients with hip fractures who were admitted to a local hospital over one year, and compared the long-term mortality between those treated operatively and nonoperatively. All patients with hip fractures were identified retrospectively from the hospital's hip registry. Mortality data was collected through nationwide electronic medical records and telephone interviews. Overall mortality rates at one (14.4%) and two years (24.4%) were comparable to those of other studies. Hip fracture patients who were treated nonoperatively had a higher risk of mortality at both one (29.8%) and two years (45.6%) after fracture (p < 0.05). Their risk of mortality was four times higher at one year and three times higher at two years after fracture than the operative group. Patients with a higher American Society of Anesthesiologists (ASA) grade did not show an increased risk in mortality compared to patients with a lower ASA grade at both one year (p = 0.072) and two years (p = 0.360) after fracture. Elderly patients with hip fractures should be managed surgically and counselled regarding the increased risk of mortality if treated nonoperatively. Copyright: © Singapore Medical Association.
Goregaonkar, Arvind B
Introduction Osteoporotic vertebral fractures relate to poorer quality of life and higher long-term mortality. In a resource-poor setup, conservative management assumes great importance as primary means of treatment. We assess the clinico-pathological epidemiology of osteoporotic vertebral fractures and prospectively evaluate the effectiveness of conservative management in their treatment. Materials & Methods Thirty consecutive patients, diagnosed with osteoporotic vertebral fracture, underwent the predetermined protocol of conservative treatment (bed rest, titrated analgesia, antiosteoporosis pharmacotherapy, bracing, and supervised physical therapy) after assessment of basic demographic data and clinical examination. They were evaluated every three months for nine months, using visual analog scale (VAS) for backpain, Oswestry Disability Index (ODI), and radiological and hematological parameters. Results The mean age of the patients was 66.9 +/-7.6 years and the female: male ratio was 14:1. All (100%) women were postmenopausal and the mean time since menopause was 16.75 +/- 8.12 years. The presenting complaints were backpain (100%) and deformity (53.33%). Neurodeficit was noted in one (3.33%) patient. Higher age was correlated to greater vertebral collapse (p=0.001) and higher kyphotic angle (p=0.002). At nine months after treatment, there was a significant decrease in the VAS score (p<0.0001) and the ODI score (p<0.0001), with the final VAS score improving by 49.25% and the ODI score improving by 47.23% from the baseline. There was progressive increase in vertebral collapse (p=0.0474) with no change in kyphotic or scoliotic angles. With treatment there was a consistent increase in serum calcium (p<0.0001), phosphorous (p<0.0001), and vitamin D3 (p<0.0001) levels, and decrease in parathyroid hormone levels (p<0.0001). Conclusions A multidisciplinary conservative treatment is effective as the primary treatment for patients with osteoporotic
Sanzone, Anthony G
The high incidence of hip fracture, together with considerable associated morbidity, mortality, and cost of care, makes this injury a major clinical challenge. Of particular importance is the pain associated with hip fracture, which can have potentially severe consequences and may lead to delayed recovery. The prevailing opioid-dependent model of analgesia, however, presents multiple drawbacks and risks that can compromise outcomes in the hip fracture population. The pain management process has essential preoperative, intraoperative, and postoperative components, yet data on the comparative effectiveness of different pain management interventions in patients undergoing surgery for hip fracture are not clear cut. A Cochrane database review that included 83 different pain management studies indicated that there are not enough well-designed studies to show unequivocally which pain management approaches work well after hip fracture surgery. Yet a growing body of data on certain interventions, such as nerve blocks and multimodal analgesia, supports consideration of these options.
File, P; Wood, J P; Kreplick, L W
Traumatic hip pain is a commonly encountered complaint in the emergency department. Occasionally, initial radiographs fail to show a fracture. A delayed diagnosis can result in significant patient morbidity. Diagnostic algorithms have been formulated to evaluate the patient with hip pain and negative initial radiographs. The auscultatory percussion technique can alert the physician of the presence or absence of an occult hip fracture. Consequently, the physician may order a more sophisticated imaging technique.
Butin, Sarah; Griffoul, Isabelle; Espitalier, Fabien; Salamé, Ephrem; Mulleman, Denis; Goupille, Philippe
Bone loss is a complication for patients with liver diseases and after transplantation, which results in increased fracture risk. The aim of this study was to determine the incidence of osteoporotic vertebral fractures following liver transplantation. We performed a prospective study of patients who were awaiting liver transplantation. Patients were seen at baseline (visit 1) and one year after transplantation (visit 2). At each visit, risk factors of osteoporosis were collected, biochemical tests were performed and bone mineral density with Vertebral Fracture Assessment was assessed. One hundred and fifteen patients were in the pre-transplant group and 33 patients were in the post-transplant group. In the pre-transplant group, the prevalence of vertebral fractures was 23.5%. The prevalence of densitometric osteoporosis was higher at the lumbar spine than at the femoral neck. In the post-transplant group, the prevalence of vertebral fractures at visit 1 and visit 2 was 33.3% and 60.6% respectively with an incidence of 23.1 fractures per 100 patient-years. Bone fragility was highly prevalent before transplantation and worsens one year after transplantation. Bone status should be evaluated in patients with liver diseases before transplantation to identify patients at high risk of fracture and help clinicians to prescribe appropriate preventive care.
Plaza, Javier Quintana; Garzón, Lorena Benito; Gimenez, Beatriz Bravo; Moraleda, Belén Fernández-Montes; Collía, Francisco; Rodríguez-Lorenzo, Luis M
The gradual aging of the population results in increased incidence of osteoporotic bone fractures. In a good quality bone, the fixation with the usual methods is adequate, but not in osteoporotic bone, in which consolidation delays and other complications are common, with failure rates for screws up to 25%. To test fibronectin loaded hydroxyapatite as a complementary treatment for osteoporotic fractures. This study was performed in a vivo model; 42 female osteoporotic adult rabbits 4-5kg (White New Zealand) were used. Two groups (hydroxyapatite and fibronectin loaded hydroxyapatite) and a control group were tested. 3 time points 24h, 48h and 5days were studied. Defects were created in both femurs, in one of them, a cannulated screw (4mm) and a biocompatible material were placed; in the other femur a screw was inserted without supplemented material forming the control group. Osteoporosis was induced from models already known throughout administration of steroids. Samples were analyzed histologically and through imaging (micro Ct). Basal levels of BMD are observed below to normal when compared to other studies (0.25/0.3 instead of 0.4). Global and dependent of time analysis of samples, show no significant differences for samples analyzed. However, an important trend was noted for variables that define the trabecular bone microarchitecture. Indices that define trabecular microarchitecture in the comparative analysis found to have statistical differences (p<0.01). Osteosynthesis in an osteoporotic bone is a challenge for the surgeon, due to a reduced bone mineral density and different bone architecture. The main finding was the verification of the hypothesis that the trabecular bone parameters increases with our augmentation material in weak rabbit bone quality. Also, the histological analyses of samples show an increase of non inflammatory cells in protein samples (OHAp-Fn) from the first 24hours. An early response of rabbit osteroporotic bone to a complementary
Pieper, Carl F.; Colon-Emeric, Cathleen; Caminis, John; Betchyk, Kathleen; Zhang, Jie; Janning, Cheri; Shostak, John; LeBoff, Meryl S.; Heaney, Robert; Lyles, Kenneth W.
Background Vitamin D is important for gastrointestinal absorption of calcium and phosphorus, for bone mineralization, and is one useful therapeutic component in the prevention and treatment of osteoporosis and osteoporotic fractures. Low levels of 25 hydroxyvitamin D have been implicated as a risk factor for falls, for all fractures in general and for hip fractures in particular. At present there is a gap in the diagnosis and treatment of vitamin D deficiency in older adults with hip fractures. Purpose To explore the distribution of and correlates to levels of vitamin D in a population of patients with a recent hip fracture. Sample 25 hydroxyvitamin D levels were measured in 526 screened subjects and 385 ultimately randomized patients who were part of the HORIZON RFT multinational trial, a randomized, placebo-controlled, double-blind trial testing the efficacy of a yearly intravenous bisphosphonate, zoledronic acid, in the prevention of new clinical fractures in patients with recent hip fracture repair. Results In screened patients, levels of 25 hydroxyvitamin D were low (median=14.7 ng/mL, IQR=7.80,22.5,), and 51% were at or below the clinically meaningful threshold of 15 ng/mL. In randomized patients, in bivariate analyses, level of 25 hydroxyvitamin D was significantly (p<0.05) related to male gender (r=0.12), calcium (r=0.16), and bone mineral density at the femoral neck (r=0.22). Low serum 25 hydroxyvitamin D (<15ng/mL) was related only to low calcium (odds=0.15 95%CI= 0.03, 0.63) in multivariate logistic models controlling for gender, age, race, BMI, living at home, alkaline phosphatase, and creatinine clearance. However, low serum calcium is an insensitive and poorly specific means of identifying patients with vitamin D deficiency, with an area under the ROC of 0.6. Conclusions We conclude that vitamin D insufficiency is a common problem in this population of subjects who have recently suffered a hip fracture. This insufficiency is related only to calcium in
From January 2005 to December 2007, we recruited 173 patients age 65 and older with acute hip fracture and a Folstein mini mental score of at least 15 into an ongoing double-blind RCT with vitamin D. 69% of hip fracture patients were admitted from home and 31% from institutions, 79% were women. Mean...
LeBlanc, Erin S.; Hillier, Teresa A.; Pedula, Kathryn L.; Rizzo, Joanne H.; Cawthon, Peggy M.; Fink, Howard A.; Cauley, Jane A.; Bauer, Douglas C.; Black, Dennis M.; Cummings, Steven R.; Browner, Warren S.
Background Fractures have been associated with subsequent increases in mortality, but it is unknown how long that increase persists. Methods 5580 women from a large community-based multicenter US prospective cohort of 9704 (Study of Osteoporotic Fractures) were followed prospectively for almost 20 years. We age-matched 1116 hip fracture cases with four controls (n=4464). To examine the effect of health status, we examined a healthy older subset (n=960) aged 80+ who attended the 10-year follow-up examination, and reported good/excellent health. Incident hip fractures were adjudicated from radiology reports by study physicians. Death was confirmed by death certificates. Results Hip fracture cases had two-fold increased mortality in the year after fracture compared to controls [16.9% vs. 8.4%; Odds Ratio (OR)=2.4; 95% Confidence Interval (CI) 1.9, 3.1]. When examined by age and health status, short-term mortality was increased in those aged 65 to 70 (16.3% vs 3.7%; OR=5.0; 2.6, 9.5), aged 70 to 79 (16.5% vs 8.9%; OR=2.4; 1.8, 3.3), and only in aged 80+ with good/excellent health (15.1% vs. 7.2%; OR=2.8; 1.5, 5.2). After the first year, survival of hip fracture cases and controls was similar except in those aged 65 to 70 who continued to have increased mortality. Conclusions Short-term mortality is increased after hip fracture in women aged 65 to 79 and in exceptionally healthy women 80 or older. Women 70 and older return to previous risk levels after a year. Interventions are needed to decrease mortality in the year after hip fracture, when mortality risk is highest. PMID:21949033
Chen, Jian Sheng; Sambrook, Philip N; Simpson, Judy M; Cameron, Ian D; Cumming, Robert G; Seibel, Markus J; Lord, Stephen R; March, Lyn M
risk factors for hip fracture in community-dwelling individuals have been extensively studied, but there have been fewer studies of institutionalised older people. a total of 1,894 older people (1,433 females, 461 males; mean age 86 years, SD 7.1 years) were recruited from 52 nursing homes and 30 intermediate-care nursing care facilities in Australia during March 1999 and February 2003. We assessed clinical risk factors for hip fracture and skeletal fragility by calcaneus broadband ultrasound attenuation (BUA) at baseline and then followed up for fracture for 4 years. Hip fractures were validated by x-ray reports. Survival analysis with age as a time-dependent covariate was used to analyse the data. during a mean follow-up period of 2.65 years (SD 1.38), 201 hip fractures in 191 residents were recorded, giving an overall hip fracture incidence rate of 4.0% per person year (males 3.6% and females 4.1%). Residents living in intermediate-care hostels had a higher crude hip fracture rate (4.6% vs. 3.0%) than those living in high-care nursing homes. In multivariate analysis, an increased risk of hip fracture was significantly associated with older age, cognitive impairment, a history of fracture since age 50, lower body weight, longer lower leg length and poorer balance in intermediate-care hostel residents, but not with lower BUA. institutionalised older people, who are at a higher risk of hip fracture than community-dwelling individuals, have differences in some risk factors for hip fracture that should be considered in targeting intervention programs.
Estai, Mohamed Abdalla; Suhaimi, Farihah Haji; Das, Srijit; Fadzilah, Fazalina Mohd; Alhabshi, Sharifah Majedah Idrus; Shuid, Ahmad Nazrun; Soelaiman, Ima-Nirwana
Osteoporotic fractures are common during osteoporotic states. Piper sarmentosum extract is known to possess antioxidant and anti-inflammatory properties. To observe the radiological changes in fracture calluses following administration of a Piper sarmentosum extract during an estrogen-deficient state. A total of 24 female Sprague-Dawley rats (200-250 g) were randomly divided into 4 groups: (i) the sham-operated group; (ii) the ovariectomized-control group; (iii) the ovariectomized + estrogen-replacement therapy (ovariectomized-control + estrogen replacement therapy) group, which was supplemented with estrogen (100 μg/kg/day); and (iv) the ovariectomized + Piper sarmentosum (ovariectomized + Piper sarmentosum) group, which was supplemented with a water-based Piper sarmentosum extract (125 mg/kg). Six weeks after an ovariectomy, the right femora were fractured at the mid-diaphysis, and a K-wire was inserted. Each group of rats received their respective treatment for 6 weeks. Following sacrifice, the right femora were subjected to radiological assessment. The mean axial callus volume was significantly higher in the ovariectomized-control group (68.2 ± 11.74 mm³) than in the sham-operated, estrogen-replacement-therapy and Piper sarmentosum groups (20.4 ± 4.05, 22.4 ± 4.14 and 17.5 ± 3.68 mm³, respectively). The median callus scores for the sham-operated, estrogen-replacement-therapy and Piper sarmentosum groups had median (range, minimum - maximum value) as 1.0 (0 - 2), 1.0 (1 - 2) and 1.0 (1 - 2), respectively, which were significantly lower than the ovariectomized-control group score of 2.0 (2 - 3). The median fracture scores for the sham-operated, estrogen-replacement-therapy and Piper sarmentosum groups were 3.0 (3 - 4), 3.0 (2 - 3) and 3.0 (2 - 3), respectively, which were significantly higher than the ovariectomized-control group score of 2.0 (1 - 2) (p<0.05). The Piper sarmentosum extract improved fracture healing, as assessed by the reduced callus
Background This study aimed to validate the effectiveness of the Osteoporosis Self-assessment Tool for Asians (OSTA) in identifying postmenopausal women at increased risk of primary osteoporosis and painful new osteoporotic vertebral fractures in a large selected Han Chinese population in Beijing. Methods We assessed the performance of the OSTA in 1201 women. Subjects with an OSTA index > -1 were classified as the low risk group, and those with an index ≤ -1 were classified as the increased risk group. Osteoporosis is defined by a T-score ≤ 2.5 standard deviations according to the WHO criteria. All painful, new vertebral fractures were identified by X-ray and MRI scans with correlating clinical signs and symptoms. We determined the sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve for correctly selecting women with osteoporosis and painful new vertebral fractures. Results Of the study subjects, 29.3% had osteoporosis, and the prevalence of osteoporosis increased progressively with age. The areas under the ROC curves of the OSTA index (cutoff = -1) to identify osteoporosis in the femoral neck, total hip, and lumbar spine were 0.824, 0.824, and 0.776, respectively. The sensitivity and specificity of the OSTA index (cutoff = -1) to identify osteoporosis in healthy women were 66% and 76%, respectively. With regard to painful new vertebral fractures, the area under the ROC curve relating the OSTA index (cutoff = -1) to new vertebral fractures was 0.812. Conclusions The OSTA may be a simple and effective tool for identifying the risk of osteoporosis and new painful osteoporotic vertebral fractures in Han Chinese women. PMID:24053509
Yang, Yong; Wang, Bingqiang; Fei, Qi; Meng, Qian; Li, Dong; Tang, Hai; Li, Jinjun; Su, Nan
This study aimed to validate the effectiveness of the Osteoporosis Self-assessment Tool for Asians (OSTA) in identifying postmenopausal women at increased risk of primary osteoporosis and painful new osteoporotic vertebral fractures in a large selected Han Chinese population in Beijing. We assessed the performance of the OSTA in 1201 women. Subjects with an OSTA index > -1 were classified as the low risk group, and those with an index ≤ -1 were classified as the increased risk group. Osteoporosis is defined by a T-score ≤ 2.5 standard deviations according to the WHO criteria. All painful, new vertebral fractures were identified by X-ray and MRI scans with correlating clinical signs and symptoms. We determined the sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve for correctly selecting women with osteoporosis and painful new vertebral fractures. Of the study subjects, 29.3% had osteoporosis, and the prevalence of osteoporosis increased progressively with age. The areas under the ROC curves of the OSTA index (cutoff = -1) to identify osteoporosis in the femoral neck, total hip, and lumbar spine were 0.824, 0.824, and 0.776, respectively. The sensitivity and specificity of the OSTA index (cutoff = -1) to identify osteoporosis in healthy women were 66% and 76%, respectively. With regard to painful new vertebral fractures, the area under the ROC curve relating the OSTA index (cutoff = -1) to new vertebral fractures was 0.812. The OSTA may be a simple and effective tool for identifying the risk of osteoporosis and new painful osteoporotic vertebral fractures in Han Chinese women.
Fischer, Verena; Haffner-Luntzer, Melanie; Prystaz, Katja; Scheidt, Annika Vom; Busse, Björn; Schinke, Thorsten; Amling, Michael; Ignatius, Anita
Calcium and vitamin-D (Ca/VitD) deficiency is a major risk factor for osteoporosis. It may also contribute to the compromised bone healing frequently observed in osteoporotic patients, since calcium is essential for fracture-callus mineralization. Additionally, clinical data suggest systemic bone loss following fracture, which may aggravate osteoporosis and thus increase the risk for fragility fractures in osteoporotic patients further. However, the role of Ca/VitD in fracture healing and posttraumatic bone turnover has to date been poorly investigated. Here, we studied bone regeneration and posttraumatic bone turnover in C57BL/6 J mice with ovariectomy-induced osteoporosis. Mice were fed a standard or a Ca/VitD-deficient diet. Notably, fracture healing was only marginally disturbed in Ca/VitD-deficient mice. However, deficient mice displayed significantly increased serum parathyroid hormone levels and osteoclast activity, as well as reduced bone mass in the intact skeleton post-fracture, suggesting considerably enhanced calcium mobilization from the intact skeleton during bone regeneration. Ca/VitD supplementation initiated post-fracture prevented posttraumatic bone loss by reducing bone resorption and furthermore improved bone repair. These results imply that adequate Ca/VitD supply post-fracture is essential to provide sufficient calcium for callus-mineralization in order to prevent posttraumatic bone loss and to reduce the risk for secondary fractures in osteoporotic patients with Ca/VitD deficiency.
Schousboe, J T; Paudel, M L; Taylor, B C; Kats, A M; Virnig, B A; Dowd, B E; Langsetmo, L; Ensrud, K E
Older women with pre-fracture slow walk speed, high body mass index, and/or a high level of multimorbidity have significantly higher health care costs after hip fracture compared to those without those characteristics. Studies to investigate if targeted health care interventions for these individuals can reduce hip fracture costs are warranted.
Ascenzi, Maria-Grazia; Chin, Jesse; Lappe, Joan; Recker, Robert
Areal bone mineral density (BMD) by DXA, although an important index, does not accurately assess risk of fragility fracture. Another bone structural parameter, the orientation of type I collagen, is known to add to risk determination, independently of BMD. Accordingly, we investigated the Haversian systems of transiliac crest biopsies from non-osteoporotic women with low-trauma fractures, matched to healthy women without fracture by age and BMD. We employed circularly polarized light (CPL) microscopy because 1) each of the extinct and bright birefringent signals of CPL corresponds to a specific collagen arrangement; and 2) CPL can employ magnification suitable to provide data, of manageable size, from the whole cortical component of a section of biopsy. Under CPL, the coaxial layers of osteons, called lamellae, appear either birefringent extinct or bright. On a section transverse to the Haversian system, the extinct lamella comprises mainly collagen forming small angles, and the bright lamella comprises mainly collagen forming large angles, relative to the general orientation of the Haversian system. We performed semi-automatic morphometry for birefringent and structural parameters for which we computed intra- and inter-observer errors. The statistical analysis used a linear mixed model to compare fracturing and non-fracturing groups while addressing pairing of fracturing and non-fracturing subjects, and linear regression to assess differences between matched subjects. We found significant reduction in 1) lamellar width and area for extinct lamella and bright lamella; 2) percentage of extinct birefringence in osteons, and 3) single osteon area; in the fracturing group; and in lamellar width in the fracturing subject of all pairs. Our results evidence the need to investigate, in a larger sample of subjects, the distribution of collagen orientation as a parameter diagnostic of increased fracture risk.
Ojo, Folasade; Al Snih, Soham; Ray, Laura A.; Raji, Mukaila A.; Markides, Kyriakos S.
OBJECTIVE: To examine the association between previous fracture and risk of new hip and nonhip fractures over a seven-year period among older Mexican Americans. METHOD: Data used are from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE) (1993-2001). Measures included history of previous fracture (hip fracture only, a nonhip fracture, hip and nonhip fractures, and no fractures), sociodemographic factors, smoking status, medical conditions (arthritis, diabetes, stroke and cancer), activities of daily living disability, and high depressive symptoms. Cox proportional regression model was used to estimate the seven-year incidence of fractures. RESULTS: Of the 2,589 subjects, 42 reported a hip fracture, 328 reported a nonhip fracture, and 2,219 did not report a fracture at baseline. After controlling for all covariates, the hazard ratio (HR) of new hip fracture at seven-year follow-up was 6.48 (95% CI: 3.26-12.97) for subjects with only hip fracture at baseline and 1.96 (95% CI: 1.22-3.16) for subjects with nonhip fracture at baseline. The HR of new nonhip fracture was 1.90 (95% CI: 0.96-3.77) for subjects with only hip fracture at baseline and 2.62 (95% CI: 1.95-3.52) for subjects with nonhip fracture at baseline. CONCLUSIONS: A previous history of fractures in older Mexican Americans is the strongest predictor of recurrent fractures at hip and nonhip sites, independent of other health measures. Our findings of recurrent fractures suggest the need for more aggressive detection and adequate treatment of osteoporosis- and fall-related factors in this population. PMID:17444431
Sundh, D; Nilsson, A G; Nilsson, M; Johansson, L; Mellström, D; Lorentzon, M
Hip fractures cause increased mortality and disability and consume enormous healthcare resources. Only 46% of hip fracture patients have osteoporosis at the total hip according to dual-energy X-ray absorptiometry (DXA) measurement. Cortical porosity increases with ageing and is believed to be important for bone strength. To investigate whether older women with hip fracture have higher cortical porosity than controls, and if so whether this difference is independent of clinical risk factors and areal bone mineral density (aBMD). From an ongoing population-based study, we identified 46 women with a prevalent X-ray-verified hip fracture and 361 control subjects without any fractures. aBMD was measured with DXA. High-resolution peripheral quantitative computed tomography was used to measure bone microstructure at the standard (ultradistal) site and at 14% (distal) of the tibial length. Women with a previous hip fracture had lower aBMD at the femoral neck (-11.8%) and total hip (-14.6%) as well as higher cortical porosity at the ultradistal (32.1%) and distal (29.3%) tibia compared with controls. In multivariable logistic regression analysis, with adjustment for covariates (age, height, weight, smoking, calcium intake, physical activity, walk time, oral glucocorticoids, parental hip fracture, rheumatoid arthritis, previous fall, current bisphosphonate treatment and femoral neck aBMD), cortical porosity at the ultradistal [odds ratio per standard deviation increase (95% confidence interval) 2.61 (1.77-3.85)] and distal [1.57 (1.12-2.20)] sites was associated with prevalent hip fracture. Cortical porosity was associated with prevalent hip fracture in older women independently of femoral neck aBMD and clinical risk factors. © 2017 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.
Kwak, Mi Kyung; Choi, Dughyun; Lee, Jae Hyuk; Kim, Hye Jeong; Park, Hyeong Kyu; Suh, Kyo Il; Yoo, Myung Hi; Byun, Dong Won
Recently, it has been suggested that decrease in serum sodium level is associated with osteoporosis. However, no study in Korea has reported the association of decrease in serum sodium level with osteoporosis. In this study, we investigated the relationship between the decrease in serum sodium level and severity of osteoporotic fracture in patients. We enrolled 290 subjects who were admitted and operated at Soonchunhyang University Hospital due to major fractures. For the control group, we enrolled 1,027 subjects who visited a health promotion center. We carried a 1:1 matching with age and sex from the case group. In a total of 164 age- and sex-matched subjects, serum sodium level was significantly lower in the fracture group than in the non-fracture group (P=0.001). Serum sodium level was significantly lower in the severe osteoporosis group than that in the non-severe osteoporosis group (P=0.002). Old age and decrease in serum sodium level were independent risk factors of osteoporosis (odds ratio [OR]=1.088, P=0.008, confidence interval [CI]=[1.022-1.157]; OR= 0.840, P=0.037, CI=0.713-0.989). Serum sodium level was significantly lower in the fracture group than that in the non-fracture group and in the severe osteoporosis group than that in the non-severe osteoporosis group. Based on our results, the decrease in serum sodium level could be an independent risk factor for osteoporosis.
Masoni, Ana; Morosano, Mario; Tomat, María Florencia; Pezzotto, Stella M; Sánchez, Ariel
In this observational, case-control study, 376 inpatients were evaluated in order to determine the association of risk factors (RF) and hip fracture; 151 patients had osteoporotic hip fracture (cases); the remaining were controls. Data were obtained from medical charts, and through a standardized questionnaire about RF. Mean age of the sample (+/- SD) was 80.6 +/- 8.1 years, without statistically significant difference between cases and controls; the female:male ratio was 3:1 in both groups. Fractured women were older than men (82.5 +/- 8.1 vs. 79.7 +/- 7.2 years, respectively; p < 0.01). Physical activity, intake of alcohol and tobacco, and sun exposure were low in all patients. Falls among cases happened predominantly at home (p < 0.001). Among female cases, time spent in household duties was a RF (p = 0.007), which was absent in males. In multivariate analysis, the following RF were significantly more frequent: Cognitive impairment (p = 0.001), and previous falls (p < 0.0001); whereas the following protective factors were significantly different from controls: Calcium intake during youth (p < 0.0001), current calcium intake (p < 0.0001), and mechanical aid for walking (p < 0.0001). Evaluation of RF and protective factors may contribute to diminish the probability of hip fracture, through a modification of personal habits, and measures to prevent falls among elderly adults. Present information can help to develop local and national population-based strategies to diminish the burden of hip fractures for the health system.
Lee, Bong-Gun; Sung, Yoon-Kyoung; Kim, Dam; Choi, Yun Young; Kim, Hunchul; Kim, Yeesuk
The purpose was to evaluate the prevalence and location of simultaneous fracture using bone scans in patients with hip fracture and to determine the risk factors associated with simultaneous fracture. One hundred eighty two patients with hip fracture were reviewed for this study. Clinical parameters and bone mineral density (BMD) of the lumbar vertebra and femoral neck were investigated. To identify acute simultaneous fracture, a bone scan was performed at 15.4±4.1days after hip fracture. The prevalence and location of simultaneous fracture were evaluated, and multivariate logistic regression analysis was performed to determine the risk factors. Simultaneous fracture was observed in 102 of 182 patients, a prevalence of 56.0%. Rib fracture was the most common type of simultaneous fracture followed by rib with vertebral fracture. The BMD of the lumbar vertebra was significantly lower in patients with simultaneous fracture (p=0.044) and was identified as an independent risk factor (odds ratio: OR 0.05, 95% confidence interval: CI 0.01-0.57). The prevalence of simultaneous fracture was relatively high among patients with hip fracture, and BMD was significantly lower in patients with simultaneous fracture than in patients without it. Surgeons should be aware of the possibility of simultaneous fracture in patients with hip fracture. Copyright © 2016 Elsevier Ltd. All rights reserved.
Tzermiadianos, Michael N.; Renner, Susan M.; Phillips, Frank M.; Hadjipavlou, Alexander G.; Zindrick, Michael R.; Havey, Robert M.; Voronov, Michael
This study investigated the effect of endplate deformity after an osteoporotic vertebral fracture in increasing the risk for adjacent vertebral fractures. Eight human lower thoracic or thoracolumbar specimens, each consisting of five vertebrae were used. To selectively fracture one of the endplates of the middle VB of each specimen a void was created under the target endplate and the specimen was flexed and compressed until failure. The fractured vertebra was subjected to spinal extension under 150 N preload that restored the anterior wall height and vertebral kyphosis, while the fractured endplate remained significantly depressed. The VB was filled with cement to stabilize the fracture, after complete evacuation of its trabecular content to ensure similar cement distribution under both the endplates. Specimens were tested in flexion-extension under 400 N preload while pressure in the discs and strain at the anterior wall of the adjacent vertebrae were recorded. Disc pressure in the intact specimens increased during flexion by 26 ± 14%. After cementation, disc pressure increased during flexion by 15 ± 11% in the discs with un-fractured endplates, while decreased by 19 ± 26.7% in the discs with the fractured endplates. During flexion, the compressive strain at the anterior wall of the vertebra next to the fractured endplate increased by 94 ± 23% compared to intact status (p < 0.05), while it did not significantly change at the vertebra next to the un-fractured endplate (18.2 ± 7.1%, p > 0.05). Subsequent flexion with compression to failure resulted in adjacent fracture close to the fractured endplate in six specimens and in a non-adjacent fracture in one specimen, while one specimen had no adjacent fractures. Depression of the fractured endplate alters the pressure profile of the damaged disc resulting in increased compressive loading of the anterior wall of adjacent vertebra that predisposes it to wedge fracture. This data suggests that
Aydin, Ali; Halici, Zekai; Albayrak, Abdulmecit; Polat, Beyzagul; Karakus, Emre; Yildirim, Omer Selim; Bayir, Yasin; Cadirci, Elif; Ayan, Arif Kursad; Aksakal, Ahmet Murat
The aim of this study was to examine the effects of carnitine on bone healing in ovariectomy (OVX) and inflammation (INF)-induced osteoporotic rats. The rats were randomly divided into nine groups (n = 8 animals per group): sham-operated (Group 1: SHAM); sham + magnesium silicate (Mg-silicate) (Group 2: SHAM + INF); ovariectomy (Group 3: OVX); ovariectomy + femoral fracture (Group 4: OVX + FRC); ovariectomy + femoral fracture + Mg-silicate (Group 5: OVX + FRC + INF); ovariectomy + femoral fracture + carnitine 50 mg/kg (Group 6: OVX + FRC + CAR50); ovariectomy + femoral fracture + carnitine 100 mg/kg (Group 7: OVX + FRC + CAR100); ovariectomy + femoral fracture + Mg-silicate + carnitine 50 mg/kg (Group 8: OVX + FRC + INF + CAR50); and ovariectomy + femoral fracture + Mg-silicate + carnitine 100 mg/kg (Group 9: OVX + FRC + INF + CAR100). Eight weeks after OVX, which allowed for osteoporosis to develop, INF was induced with subcutaneous Mg-silicate. On day 80, all of the rats in groups 4-9 underwent fracture operation on the right femur. Bone mineral density (BMD) showed statistically significant improvements in the treatment groups. The serum markers of bone turnover (osteocalcin and osteopontin) and pro-inflammatory cytokines (tumour necrosis factor α, interleukin 1β and interleukin 6) were decreased in the treatment group. The X-ray images showed significantly increased callus formation and fracture healing in the groups treated with carnitine. The present results show that in a rat model with osteoporosis induced by ovariectomy and Mg-silicate, treatment with carnitine improves the healing of femur fractures.
Gruber, M; Dinges, J; Müller, D; Baum, T; Rummeny, E J; Bauer, J
Vertebral fractures are the most common complication of osteoporosis. Routine chest radiographs are a potential screening method, but a significant under-reporting has been described previously. The purpose of this study was to evaluate the effect of a specific training on the detection rate of vertebral fractures of a radiology resident. 936 routine lateral chest radiographs of postmenopausal women were evaluated by a radiology resident (R1) during clinical routine. After the evaluation of 470 radiographs (pre-training group), R1 underwent a specific training based on the teaching initiative of the IOF/ESSR. Afterwards the remaining 466 radiographs were evaluated (post-training group). As a standard of reference, all radiographs were reviewed by two radiologists in consensus (R2 + 3). A semi-quantitative method (spinal fracture index, SFI) was used to assess vertebral fractures. Kappa-values as statistical measure of agreement between R1 and R2 + 3 for the detection of vertebral fractures (Genant Severity > 0) increased from κ = 0.311 (95 % CI: 0.217 - 0.405; "fair agreement") in the pre-training group to κ = 0,882 (95 % CI: 0,835 - 0,929; "almost perfect agreement") in the post-training group. Similar results were observed for severe fractures (Genant Severity > 1). Especially fractures with Genant Severity 1 were not detected by R1 before training. A brief training is essential to increase the awareness of radiologists to correctly report osteoporotic vertebral fractures and may help to initiate appropriate therapy in patients with vertebral fractures. © Georg Thieme Verlag KG Stuttgart · New York.
Objective. The present paper examines pertinent literature sources published in the peer-reviewed English language between 1980 and November 1, 2010 concerning hip fractures. The aim was to highlight potential intervention points to offset the risk of incurring a hip fracture and its attendant disability. Methods. An in-depth search of the literature using the key terms: disability, epidemiology, hip fracture, prevention, and risk factors was conducted, along with data from the author's research base detailing the disability associated with selected hip fracture cases. All articles that dealt with these key topics were reviewed, and relevant data were tabulated and analyzed. Results. Hip fractures remain an important but potentially preventable public health problem. Among the many related remediable risk factors, low physical activity levels are especially important. Related determinants of suboptimal neuromuscular function also contribute significantly to hip fracture disability. Conclusion. Physical activity participation can help to reduce the prevalence and excess disability of hip fractures and should be encouraged. PMID:21584248
Xie, Weixing; Jin, Daxiang; Ma, Hui; Ding, Jinyong; Xu, Jixi; Zhang, Shuncong; Liang, De
The risk factors for cement leakage were retrospectively reviewed in 192 patients who underwent percutaneous vertebral augmentation (PVA). To discuss the factors related to the cement leakage in PVA procedure for the treatment of osteoporotic vertebral compression fractures. PVA is widely applied for the treatment of osteoporotic vertebral fractures. Cement leakage is a major complication of this procedure. The risk factors for cement leakage were controversial. A retrospective review of 192 patients who underwent PVA was conducted. The following data were recorded: age, sex, bone density, number of fractured vertebrae before surgery, number of treated vertebrae, severity of the treated vertebrae, operative approach, volume of injected bone cement, preoperative vertebral compression ratio, preoperative local kyphosis angle, intraosseous clefts, preoperative vertebral cortical bone defect, and ratio and type of cement leakage. To study the correlation between each factor and cement leakage ratio, bivariate regression analysis was employed to perform univariate analysis, whereas multivariate linear regression analysis was employed to perform multivariate analysis. The study included 192 patients (282 treated vertebrae), and cement leakage occurred in 100 vertebrae (35.46%). The vertebrae with preoperative cortical bone defects generally exhibited higher cement leakage ratio, and the leakage is typically type C. Vertebrae with intact cortical bones before the procedure tend to experience type S leakage. Univariate analysis showed that patient age, bone density, number of fractured vertebrae before surgery, and vertebral cortical bone were associated with cement leakage ratio (P<0.05). Multivariate analysis showed that the main factors influencing bone cement leakage are bone density and vertebral cortical bone defect, with standardized partial regression coefficients of -0.085 and 0.144, respectively. High bone density and vertebral cortical bone defect are
Robles, María José; Formiga, Francesc; Vidán, M Teresa
The fracture of the proximal femur or hip fracture in the elderly usually happens after a fall and carries a high morbidity and mortality. One of the most common complications during hospitalization for hip fracture is the onset of delirium or acute confusional state that in elderly patients has a negative impact on the hospital stay, and prognosis, worsening functional ability, cognitive status and mortality. Also the development of delirium during hospitalization increases health care costs. Strategies to prevent and treat delirium during hospitalization for hip fracture have been less studied. In this context, this paper aims to conduct a review of the literature on strategies that exist in the prevention and treatment of delirium in elderly patients with hip fracture. Copyright © 2013 Elsevier España, S.L. All rights reserved.
Streeten, Elizabeth A; McBride, Daniel J; Lodge, Amy L; Pollin, Toni I; Stinchcomb, David G; Agarwala, Richa; Schäffer, Alejandro A; Shapiro, Jay R; Shuldiner, Alan R; Mitchell, Braxton D
The incidence of hip fracture was estimated in a community of Old Order Amish and compared with available data from non-Amish whites. Hip fracture rates were 40% lower in the Amish, and the Amish also experienced higher BMD. Understanding the patterns of fracture risk across populations could reveal insights about bone health and lead to the earlier detection and prevention of osteoporosis. Toward this aim, we compared hip fracture incidence and bone mineral density (BMD) between an Old Order Amish (OOA) community, characterized by a rural and relatively active lifestyle, and non-Amish U.S. whites. All hospital admissions for hip fracture among OOA individuals in Lancaster County, PA, were identified between 1995 and 1998 from four area hospitals. Hip fracture incidence was calculated by cross-referencing an available Anabaptist genealogy database with communities located within these hospital service areas and compared with non-Amish whites obtained from National Hospital Discharge data. Additionally, BMD at the hip was compared between 287 Amish subjects and non-Amish whites from the National Health and Nutrition Examination Survey III survey. OOA experienced 42% fewer hip fractures than would be expected had they experienced the same rate of hip fracture as observed in non-Amish whites (p < 0.01) and a higher mean BMD that was significant in women (p < 0.05) but not men. Further evaluation of lifestyle and/or genetic differences between Amish and non-Amish populations may shed insights into etiologic factors influencing hip fracture risk.
Cengiz, Ömer; Polat, Gökhan; Karademir, Gökhan; Tunç, Oytun Derya; Erdil, Mehmet; Tuncay, İbrahim; Şen, Cengiz
We aimed to evaluate the effects of intertrochanteric femoral fractures on mortality, morbidity, and cost of zoledronate treatment in elderly patients treated by osteosynthesis. Based on Evans classification, 114 patients with unstable intertrochanteric femoral fractures were treated with osteosynthesis. After the surgical treatment of intertrochanteric fractures, the treatment group (M/F, 24/32; mean age, 76.7 ± SD years) received zoledronate infusion, and the control group (M/F, 20/38; mean age, 80.2 ± SD years) received placebo. Postoperative control visits were performed at 6-week, 3-month, 6-month, and 12-month time points. Functional level of patients was evaluated by the modified Harris hip score and Merle d'Aubigné hip score. By 12 months, the mean HHS in treatment and control groups was 81.93 and 72.9, respectively. For time of death of the patients, mortality was found to be 57.1% (16/28) on the first 3 months and 92.9% (26/28) on the first six months. The mortality rate in the treatment and control groups was 14.3% (8/56) and 34.5% (20/58), respectively. The use of zoledronic acid after surgical treatment of intertrochanteric femoral fractures in osteoporotic elderly patients is a safe treatment modality which helps to reduce mortality, improves functional outcomes, and has less side effects with single dose use per year. PMID:27092280
Sheu, Yahtyng; Amati, Francesca; Schwartz, Ann V; Danielson, Michelle E; Li, Xiaojuan; Boudreau, Robert; Cauley, Jane A
Elevated vertebral bone marrow fat (BMF) among individuals with osteoporosis has been established in histomorphometric studies. Several studies have found a negative correlation between BMF and bone mineral density (BMD) at the spine in men and women across different age groups. Animal studies have also observed bone loss with increased BMF in mice with induced diabetes. Our study objective was to test the hypothesis that the association between BMF and BMD varies by diabetic status. We performed a cross-sectional study of 156 men aged 74-96years from the Osteoporotic Fractures in Men study at the Pittsburgh clinical site. All men had spine BMF scans using proton magnetic resonance spectroscopy and spine and hip BMD scans by dual-energy X-ray absorptiometry. BMF was expressed as lipid to "lipid+water" ratio (%). Men were considered diabetic if they self-reported a physician diagnosis of diabetes, diabetes medication or had a fasting glucose ≥126mg/dl. Men with diabetes (n=38) had a significantly higher spine BMF (58.9 vs. 54.6%, p=0.0035), spine BMD (1.20 vs. 1.10g/cm(2), P=0.007) and total hip BMD (1.00 vs. 0.94g/cm(2), p=0.04) than those without, while no differences were observed for body weight, body mass index or waist circumference. Pearson correlation tests showed no significant correlation of spine BMF with age or BMD in non-diabetics. Significant inverse correlations were observed between BMF and BMD (-0.30 for femoral neck and -0.39 for total hip) among diabetic men. In conclusion, men with diabetes had a higher BMF compared to non-diabetic men. The correlation between BMF and BMD differed by diabetes status. Further investigation of the association of diabetes with BMF and BMD may provide a better understanding of the high fracture rates among individuals with diabetes despite their higher BMD.
Carpintero, Pedro; Gil-Garay, Enrique; Hernández-Vaquero, Daniel; Ferrer, Humbert; Munuera, Luis
To establish a protocol for the treatment of fragility fractures in the hospital setting based on treatment of osteoporosis. An intervention protocol was implemented in patients with fragility fractures based on (1) indicating the diagnosis of osteoporotic fracture in the summary of discharge; (2) "lifestyle recommendations"; and (3) therapy for osteoporosis. Thirty-one hospitals were involved and they were informed of the importance of protocol compliance. In the first phase, a retrospective study was conducted to establish the number of low-energy fractures treated and the percentage of them that had complied with the protocol (n = 887). Then, prospectively, the same data were collected for the patients managed for 1 year (n = 6,826) in three sections of 4-month intervals. The percentage of compliance increased from 8.2 to 57.2% in the first point, from 12.6 to 42.4% in the second, and from 10.3 to 43.2% in the third. The implementation of programs to improve osteoporosis treatment is very useful for ensuring adherence in the management of osteoporosis following admission due to fragility fracture.
Li, Yizhong; Lin, Jinkuang; Cai, Siqing; Yan, Lisheng; Pan, Yuancheng; Yao, Xuedong; Zhuang, Huafeng; Wang, Peiwen; Zeng, Yanjun
The aim of this study was to assess the influence of bone mineral density and hip geometry on the fragility fracture of femoral neck and trochanteric region. There were 95 menopausal females of age ≥ 50 years with fragility fracture of hip, including 55 cases of femoral neck fracture and 40 cases of trochanteric fracture. Another 63 non-fractured females with normal bone mineral density (BMD) were chosen as control. BMD, hip axis length, neck-shaft angle and structural parameters including cross surface area, cortical thickness and buckling ratio were detected and compared. Compared with control group, the patients with femoral neck fracture or trochanteric fractures had significantly lower BMD of femoral neck, as well as lower cross surface area and cortical thickness and higher buckling ratio in femoral neck and trochanteric region. There were no significant differences of BMD and structural parameters in the femoral neck fracture group and intertrochanteric fracture group. Hip axis length and neck-shaft angle were not significantly different among three groups. The significant changes of BMD and proximal femur geometry were present in the fragility fracture of femoral neck and trochanteric region. The different types of hip fractures cannot be explained by these changes.
Kellie, S E; Brody, J A
Sex-, race- and age-specific hip fracture rates were determined using Health Care Financing Administration data for Medicare-reimbursed hip fracture hospitalizations from 1980 to 1982. Rates were highest in White women, lowest in Black men, and intermediate in White men and Black women. Proportions of hip fracture patients dying during hospitalization and those discharged to nursing homes, respectively, were: White men (10.5%; 49%); Black men (9.3%; 32%); White women (5.0%; 54%); and Black women (8.2%; 30%). PMID:2305917
Pinheiro, Marcelo M; Schuch, Natielen J; Genaro, Patrícia S; Ciconelli, Rozana M; Ferraz, Marcos B; Martini, Lígia A
Background Adequate nutrition plays an important role in bone mass accrual and maintenance and has been demonstrated as a significant tool for the prevention of fractures in individuals with osteoporosis. Objective The aim of the present study was to evaluate bone health-related nutrients intake and its association with osteoporotic fractures in a representative sample of 2344 individuals aged 40 years or older in Brazil. Methods In a transversal population-based study, a total of 2420 individuals over 40 years old were evaluated from March to April 2006. Participants were men and women from all socio-economic classes and education levels living around the Brazilian territory Individuals responded a questionnaire including self reported fractures as well a 24-hour food recall. Nutrient intakes were evaluated by Nutrition Data System for Research software (NDSR, University of Minnesota, 2007). Low trauma fracture was defined as that resulting of a fall from standing height or less. Nutrient intakes adequacies were performed by using the DRI's proposed values. Statistical analysis comprises Oneway ANCOVA adjusted by age and use of nutritional supplements and multiple logistic regression. SAS software was used for statistical analysis. Results Fractures was reported by 13% of men and 15% of women. Women with fractures presented significantly higher calcium, phosphorus and magnesium intakes. However, in all regions and socio-economical levels mean intakes of bone related nutrients were below the recommended levels. It was demonstrated that for every 100 mg/phosphorus increase the risk of fractures by 9% (OR 1.09; IC95% 1.05–1.13, p < 0.001). Conclusion The results demonstrated inadequacies in bone related nutrients in our population as well that an increase in phosphorus intake is related to bone fractures. PMID:19178745
Johansson, Helena; Odén, Anders; Lerner, Ulf H; Jutberger, Hans; Lorentzon, Mattias; Barrett-Connor, Elizabeth; Karlsson, Magnus K; Ljunggren, Osten; Smith, Ulf; McCloskey, Eugene; Kanis, John A; Ohlsson, Claes; Mellström, Dan
Adipocytes and osteoblasts share a common progenitor, and there is, therefore, potential for both autocrine and endocrine effects of adiponectin on skeletal metabolism. The aim of the present study was to determine whether high serum adiponectin was associated with an increased risk of fracture in elderly men. We studied the relationship between serum adiponectin and the risk of fracture in 999 elderly men drawn from the general population and recruited to the Osteoporotic Fractures in Men (MrOS) study in Gothenburg, Sweden. Baseline data included general health questionnaires, lifestyle questionnaires, body mass index (BMI), bone mineral density (BMD), serum adiponectin, osteocalcin, and leptin. Men were followed for up to 7.4 years (average, 5.2 years). Poisson regression was used to investigate the relationship between serum adiponectin, other risk variables and the time-to-event hazard function of fracture. Median levels of serum adiponectin at baseline were 10.4 µg/mL (interquartile range, 7.7-14.3). During follow-up, 150 men sustained one or more fractures. The risk of fracture increased in parallel with increasing serum adiponectin (hazard ratio [HR]/SD, 1.46; 95% confidence interval [CI], 1.23-1.72) and persisted after multivariate-adjusted analysis (HR/SD, 1.30; 95% CI, 1.09-1.55). Serum adiponectin shows graded stepwise association with a significant excess risk of fracture in elderly men that was independent of several other risk factors for fracture. Its measurement holds promise as a risk factor for fracture in men.
Bokrantz, Tove; Ljungman, Charlotta; Kahan, Thomas; Boström, Kristina B; Hasselström, Jan; Hjerpe, Per; Mellström, Dan; Schiöler, Linus; Manhem, Karin
The objective is to investigate if treatment with thiazides reduces the risk of osteoporotic fractures in hypertensive patients in primary healthcare. Further we aimed to examine the impact of duration of thiazide use, the consequences of discontinuation of treatment, and the possible difference in effect between men and women. This retrospective cohort study includes 57 822 individuals, 45 years and older, diagnosed with hypertension during 2001-2008 in the Swedish Primary Care Cardiovascular Database. Patients were followed from 1 January 2006 (or the date of their first diagnosis of hypertension if that date came later), until they had an incident osteoporotic fracture, died, or reached the end of the study at 31 December 2012. Patients exposed to thiazides were compared with patients never exposed to thiazides. Current use of thiazides was associated with significantly reduced risk of osteoporotic fractures [hazards ratio 0.89; 95% confidence interval (CI) 0.81-0.98], and increased with longer treatment periods (hazards ratio 0.87; 95% CI 0.78-0.97 after 2 years). However, discontinuation of thiazides increased the risk of osteoporotic fractures (hazards ratio 1.18; 95% CI 1.04-1.33), but attenuated with longer duration past treatment period. When analyzing men and women separately, similar results were seen, although only significant in men. This large observational study confirms that thiazide therapy in hypertensive patients is associated with a reduced risk of osteoporotic fractures. The protective effect increased with longer treatment periods. However, discontinuation of treatment increased the risk of fractures, which emphasizes the importance of continuous treatment.
A total of 59 (13.5 per cent) of 437 patients with cervical hip fractures died within the first 3 months, compared with an expected mortality rate of 2.6 per cent in the comparable general population (P < 0.05). The average age at death was 86 years (range, 62-98). The 3-months mortality rate among patients admitted from institutions was 24/105 = 23 per cent compared with 35/332 = 10.5 per cent for patients admitted from their own homes (P < 0.05). The 3-months mortality rate for patients with Garden 1 + 2 fractures was 9.4 per cent compared with 14 per cent for Garden 3 + 4 (P < 0.05). This series seems to suggest that non-cemented hemi-arthroplasty may be associated with an increased 3-months mortality rate of 21 per cent compared with 13.9 per cent (P < 0.05) for patients with the same age distribution. This may be due to a relatively high deep-infection rate following non-cemented hemi-arthroplasty.
In this review, I consider the varied mechanisms in cortical bone that help preserve its integrity and how they deteriorate with aging. Aging affects cortical bone in two ways: extrinsically through its effects on the individual that modify its mechanical loading experience and 'milieu interieur'; and intrinsically through the prolonged cycle of remodelling and renewal extending to an estimated 20 years in the proximal femur. Healthy femoral cortex incorporates multiple mechanisms that help prevent fracture. These have been described at multiple length scales from the individual bone mineral crystal to the scale of the femur itself and appear to operate hierarchically. Each cortical bone fracture begins as a sub-microscopic crack that enlarges under mechanical load, for example, that imposed by a fall. In these conditions, a crack will enlarge explosively unless the cortical bone is intrinsically tough (the opposite of brittle). Toughness leads to microscopic crack deflection and bridging and may be increased by adequate regulation of both mineral crystal size and the heterogeneity of mineral and matrix phases. The role of osteocytes in optimising toughness is beginning to be worked out; but many osteocytes die in situ without triggering bone renewal over a 20-year cycle, with potential for increasing brittleness. Furthermore, the superolateral cortex of the proximal femur thins progressively during life, so increasing the risk of buckling during a fall. Besides preserving or increasing hip BMD, pharmaceutical treatments have class-specific effects on the toughness of cortical bone, although dietary and exercise-based interventions show early promise.
Wu, Anna H.; Wang, Renwei; Ang, Li-Wei; Heng, Derrick; Yuan, Jian-Min; Yu, Mimi C.
Although there is some epidemiologic evidence that soy may reduce risk of osteoporotic fracture in women, it is not known whether this risk reduction also occurs for men. The authors examined gender-specific associations between soy intake and hip fracture risk in the Singapore Chinese Health Study, a prospective cohort of 63,257 Chinese living in Singapore. At recruitment between 1993 and 1998, each subject was administered a food frequency questionnaire and questions on medical history and lifestyle factors. As of December 31, 2006, 276 incident cases of hip fracture in men and 692 cases in women were identified via linkage with hospital discharge databases. For both genders, hip fracture risk was positively associated with cigarette smoking and was inversely associated with body mass index. There was a statistically significant association of tofu equivalents, soy protein, and isoflavones with hip fracture risk among women but not among men. Compared with women in the lowest quartile of intakes for tofu equivalents (<49.4 g/day), soy protein (<2.7 g/day), and isoflavones (<5.8 mg/1,000 kcal/day), those in the second–fourth quartiles exhibited 21%–36% reductions in risk (all P < 0.036). Risk levels were comparable across the second, third, and fourth quartiles of soy intake categories. PMID:19720865
Sosa, M; Saavedra, P; de Tejada, M J G; Navarro, M; Cabrera, D; Melton, L J
Hip fracture incidence in the Canaries was studied in two 5-year periods (1989-1993 and 2008-2011). The incidence in 2007-2011 was 24 % higher than in 1989, but did not differ between 2007-2011 and 1993. These findings suggest a trend to stabilize the incidence of hip fracture. A dramatic increase in hip fractures between 1988 and 2002 was reported in Northern Spain. We performed the present study in Gran Canaria, the Canary Islands, to compare changes in the incidence of hip fracture between 1989-1993 and 2007-2011. We recorded every osteoporotic hip fracture admitted to any hospital in Gran Canaria in the population 50 years of age or older. In 1989-1993, we collected 1175 hip fractures (72 % women; mean age 78.2 ± 9.9 years), and the total incidence rate was 152.1 cases/100,000 population/year. In 2007-2011, we collected 2222 hip fracture cases (71 % women; mean age 79 ± 9.8 years). The total incidence was 180.9/100,000/year. A Poisson model showed that the incidence of fractures increased by 7.1 % (95 % CI = 3.1 %; 11.8 %) each year in 1989-1993, while there was no statistically significant variation (p = 0.515) during the period 2007-2011. The incidence in 2007-2011 was 24 % higher than in 1989 (first year in the first period) but did not differ between 2007-2011 and 1993 (the last year of the first period). Incidence rates were 76.7 % (95 % CI = 63.9 %; 90.5 %) higher in women than in men, but the female/male ratio remained unchanged. The age-adjusted incidence of hip fractures increased by 7.3 % each year from 1989 to 1993. The proportions of trochanter and cervical fractures were similar in the two time periods, but the mean hospital stay was reduced from 11 days in 1989-1993 to 7 days in 2007-2011. These findings suggest a trend to stabilize the incidence of hip fracture in the Canary Islands due to a decrease in men, while in women, the incidence increased.
Liu, Xiong; Wu, Wei-dong; Fang, Ya-feng; Zhang, Mei-chao; Huang, Wen-hua
To evaluate the postoperative stability of osteoporotic distal radius fractures fixed with distal locking screws with different length. A comminuted extra-articular dorsally unstable distal radius fracture, treated with volar locking plate system, was created. The 18 specimens were randomized into 3 groups based on distal locked screws with different length: Group A had unicortical screws with 50% length to the dorsal cortex. Group B had unicortical screws with 75% length to the dorsal cortex. Group C had bicortical screws. Axial compression and bending loads were imposed on the models before and after cycling testing as well as load to clinical and catastrophic failure. Minimum change in stiffness was observed before and after fatigue for all groups. The final stiffness to bending forces was statistically similar in all groups, but stiffness to axial compression was statistically significant different: Group A approached significance with respect to groups B and C (P = 0.017, 0.009), whereas stiffness in group B and C was statistically similar (P = 0.93). Load to clinical failure was significantly less for group A (456.54±78.59 N) compared with groups B (580.24±73.85 N) and C (591.07±38.40 N). Load to catastrophic failure was statistically similar between groups, but mean values for Group A were 18% less than means for Group C. The volar locking plate system fixed with unicortical locking screws with at least 75% length not only produced early stability for osteoporotic distal radius fractures, but also avoided extensor tendon complications due to dorsal screw protrusion.
Liu, Xiong; Wu, Wei-dong; Fang, Ya-feng; Zhang, Mei-chao; Huang, Wen-hua
Objectives To evaluate the postoperative stability of osteoporotic distal radius fractures fixed with distal locking screws with different length. Methods A comminuted extra-articular dorsally unstable distal radius fracture, treated with volar locking plate system, was created. The 18 specimens were randomized into 3 groups based on distal locked screws with different length: Group A had unicortical screws with 50% length to the dorsal cortex. Group B had unicortical screws with 75% length to the dorsal cortex. Group C had bicortical screws. Axial compression and bending loads were imposed on the models before and after cycling testing as well as load to clinical and catastrophic failure. Results Minimum change in stiffness was observed before and after fatigue for all groups. The final stiffness to bending forces was statistically similar in all groups, but stiffness to axial compression was statistically significant different: Group A approached significance with respect to groups B and C (P = 0.017, 0.009), whereas stiffness in group B and C was statistically similar (P = 0.93). Load to clinical failure was significantly less for group A (456.54±78.59 N) compared with groups B (580.24±73.85 N) and C (591.07±38.40 N). Load to catastrophic failure was statistically similar between groups, but mean values for Group A were 18% less than means for Group C. Conclusions The volar locking plate system fixed with unicortical locking screws with at least 75% length not only produced early stability for osteoporotic distal radius fractures, but also avoided extensor tendon complications due to dorsal screw protrusion. PMID:25080094
Mattyasovszky, S G; Kurth, A A; Drees, P; Gemidji, J; Thomczyk, S; Kafchitsas, K
Minimally invasive cement augmentation of painful osteoporotic vertebral compression fractures in elderly patients. Painful osteoporotic vertebral compression fractures in elderly patients (> 65 years of age) after conservative therapy failure. Painful aggressive primary tumors of the spine or osteolytic metastases to the spine with high risk of vertebral fracture in the palliative care setting. General contraindications for surgical interventions. Local soft-tissue infection. Osteomyelitis, discitis or systemic infection. Coagulopathy refractory to treatment or bleeding diathesis. Asymptomatic vertebral compression fractures. Burst of the posterior vertebral column with high degree of spinal canal stenosis. Primary or metastatic spinal tumors with epidural growth. Prone position on a radiolucent operating table. Fluoroscopic localization of the fractured vertebra using two conventional C-arm devices (anteroposterior and lateral views). Fluoroscopic localization of the fractured vertebra using two conventional C-arm devices (anteroposterior and lateral views). An introducer is inserted through a small skin incision into the pedicle under fluoroscopic guidance. To create a site- and size-specific three-dimensional cavity in the center of the fractured vertebra, the navigational VertecoR™ MidLine Osteotome was inserted through the correctly sited introducer and guided fluoroscopically. As the MidLine Osteotome allows angulation of the tip up to 90° by rotating the handle, a cavity over the midline of the vertebral body can mainly be created through one pedicle. The radiofrequency activated cohesive ultrahigh viscosity PMMA cement (ER(2) bone cement) is injected stepwise on demand by remote control under continuous pressure from the hydraulic assembly into the vertebral body. Bed rest for 6 h postoperatively in supine position. Early mobilization without a corset on the day of surgery. Specific back and abdominal exercises that strengthen the back and abdominal
El Maghraoui, Abdellah; Koumba, Boris A; Jroundi, Imane; Achemlal, Lahsen; Bezza, Ahmed; Tazi, Mohamed A
Hip fracture has never been studied before, either in Morocco or in the adjacent countries of the south bank of the Mediterranean Sea. The aim of this study was to investigate the incidence rate of hip fracture in 2002 in Rabat Province, a large area in the northwest of The Kingdom of Morocco, by the use of register information and medical records collected from the five public hospitals of the region. The hip fracture data were restricted to cervical or trochanteric types. There was a total of 150 hip fractures (83 in women and 67 in men) in the over-50-year-old population in the Province of Rabat during 2002. The age-adjusted 1-year cumulative incidence of hip fracture was 52.1/100,000 [95% confidence interval (CI) 40.9-63.3/100,000] in women and 43.7/100,000 (95% CI 33.3-52.2/100,000) in men. The standardized incidence rate against the 1985 US population was 80.7/100,000 (95% CI 78.5-93.0/100,000) for women and 58.5/100,000 (95% CI 47.9-68.1/100,000) for men. The mean (standard deviation) age of patients with a hip fracture was 70.7 (9.4) years for women and 70.4 (10.0) years for men. The overall female-to-male ratio of hip fracture was 1.19 for age-adjusted hip fracture incidence and 1.30 for standardized incidence. A marked increase in incidence rate was found for both men and women with increasing age, becoming exponential after the age of 50 years. The mean age for hip fracture was 70.7 (9.4) years in women and 70.4 (10.0) years in men (P > 0.05). Women had a cervical-to-trochanteric ratio of 0.97 compared to men, at 1.03. The characteristics of hip fractures described in this study suggest that fragility fractures occur in North Africa, although substantially less frequently than in most European, North American and Asian countries but more frequently than sub-Saharan African countries, in agreement with the north-south gradient observed in the epidemiology of osteoporosis. The low incidence of hip fragility fracture rate is most likely the result of
Lau, T W; Leung, F; Siu, D; Wong, G; Luk, K D K
Geriatric hip fracture is one of the commonest fractures in orthopaedic trauma. There is a trend of further increase in its incidence in the coming decades. Besides the development of techniques and implants to overcome the difficulties in fixation of osteoporosis bone, the general management of the hip fracture is also very challenging in terms of the preparation of the generally poorer pre-morbid state and complicate social problems associated with this group of patients. In order to cope with the increasing demand, our hospital started a geriatric hip fracture clinical pathway in 2007. The aim of this pathway is to provide better care for this group of patients through multidisciplinary approach. From year 2007 to 2009, we had managed 964 hip fracture patients. After the implementation of the pathway, the pre-operative and the total length of stay in acute hospital were shortened by over 5 days. Other clinical outcomes including surgical site infection, 30 days mortality and also incidence of pressure sore improved when compared to the data before the pathway. The rate of surgical site infection was 0.98%, and the 30 days mortality was 1.67% in 2009. The active participation of physiotherapists, occupational therapists as well as medical social workers also helped to formulate the discharge plan as early as the patient is admitted. In conclusion, a well-planned and executed clinical pathway for hip fracture can improve the clinical outcomes of the geriatric hip fractures.
Li, Wei-Long; Yu, Xiao; Huang, Zhi-Ping
Objective This study was performed to investigate the effect of parathyroid hormone (PTH) on healing in osteoporotic fractures via a phospholipase C (PLC)-independent pathway and explore the mechanism of PTH-mediated bone formation. Methods Ninety-six 12-week-old C57BL/6J female mice underwent bilateral ovariectomy. One month later, the lower third of the femur was fractured and the mice were treated using saline, PTH(1-28), PTH(1-34), zoledronic acid (ZA), PTH(1-28)+ZA, and PTH(1-34)+ZA. The mice were killed at weeks 2 and 4 in each group. Biomechanical testing and micro-computed tomography were performed. Results The formation and strength of the callus increased in all but the saline group. The mice treated with PTH(1-34) showed a significantly higher ultimate bending force, bending rigidity, bone mineral density, percent bone volume, and trabecular thickness than those treated with PTH(1-28). The PTH(1-34)+ZA group demonstrated the greatest improvements in the ultimate bending force, bending rigidity, bone mineral density, and relative bone volume. Conclusions PTH can promote fracture healing and callus hardness in ovariectomized mice by increasing callus formation and reconstructing trabecular bone via a PLC-independent pathway. PTH combined with ZA has a cumulative effect on the healing of fractures in ovariectomized mice. PMID:28534698
Based on biomechanical analysis, we present an until now unrecognised new view on pathological interactive relations in basic functional motor segments of the spine (vertebra - disc - vertebra), elevating the risk of osteoporotic vertebral fractures. They are classified as follows: 1. Degenerative alterations of intervertebral disc (chondrosis); 1a) decrease of intervertebral disc viscoelasticity; 1b) increase of compressive and tensile stress in the intervertebral disc. Loading the spine increases the compressive and tensile stress in the disc, afflicted by chondrosis, beyond physiological values. This increase conditions the non-physiological elevation of reaction compression forces in adjacent vertebrae, representing a fracture risk for endplates of these vertebrae. 2. Osteoporosis of vertebrae; 2a) decrease of vertebra elasticity and strength; 2b) phenomenon of local elevated compressive stress in the vertebra fracture site. In the vertebral body endplate infraction or fracture site develop a locus minoris of resistance and it contributes to the progression of breaking the vertebra and its whole compression by loading the spine with compressive force. With regard to the fact that above-mentioned risk factors are influenceable, we suggest preventive measures.
Macdonald, J.; Robinson, A.; Brown, I.
This case report involves a 56-year-old female (Mrs X) with a traumatic intertrochanteric hip fracture with subtrochanteric extension below a previous Birmingham hip resurfacing. Periprosthetic fractures following hip resurfacing are usually subcapital and treated with a revision or conservative management. We present an unusual surgical problem with an interesting solution stabilising the fracture using a proximal femoral locking compression plate (LCP). Eight months following surgery the patient is able to walk pain free and there is good fixation and stability. PMID:24995142
Peretz, Jeffrey I; Chuang, Michael J; Cerynik, Douglas L; Johanson, Norman A
Isolated greater trochanter fractures after total hip arthroplasty are associated with major comorbidities such as debilitating weakness, pain, and dislocation. No definitive standard of care has been established for these fracture. However, it is well known that reestablishing osseous union in these patients is strongly associated with return of functional status. We report a case of an elderly patient with multiple hip revision surgeries now presenting with unilateral greater trochanter fracture. Treatment incorporated the use of a trochanteric claw plate, cerclage wiring, and adjuvant demineralized bone matrix allograft to achieve successful osseous union. This is the first reported use of adjuvant demineralized bone matrix for fixing these fractures.
Guay, Joanne; Parker, Martyn J; Griffiths, Richard; Kopp, Sandra
Various nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017. This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards. For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles. We included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture. Two review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach. We included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I(2) = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR
Guay, Joanne; Parker, Martyn J; Gajendragadkar, Pushpaj R; Kopp, Sandra
The majority of people with hip fracture are treated surgically, requiring anaesthesia. The main focus of this review is the comparison of regional versus general anaesthesia for hip (proximal femoral) fracture repair in adults. We did not consider supplementary regional blocks in this review as they have been studied in another review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2014, Issue 3), MEDLINE (Ovid SP, 2003 to March 2014) and EMBASE (Ovid SP, 2003 to March 2014). We included randomized trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The main outcomes were mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, deep vein thrombosis and return of patient to their own home. Two reviewers independently assessed trial quality and extracted data. We analysed data with fixed-effect (I(2) < 25%) or random-effects models. We assessed the quality of the evidence according to the criteria developed by the GRADE working group. In total, we included 31 studies (with 3231 participants) in our review. Of those 31 studies, 28 (2976 participants) provided data for the meta-analyses. For the 28 studies, 24 were used for the comparison of neuraxial block versus general anaesthesia. Based on 11 studies that included 2152 participants, we did not find a difference between the two anaesthetic techniques for mortality at one month: risk ratio (RR) 0.78, 95% confidence interval (CI) 0.57 to 1.06; I(2) = 24% (fixed-effect model). Based on six studies that included 761 participants, we did not find a difference in the risk of pneumonia: RR 0.77, 95% CI 0.45 to 1.31; I(2) = 0%. Based on four studies that included 559 participants, we did
Man, L P; Ho, A Wh; Wong, S H
Geriatric hip fracture places an increasing burden to health care systems around the world. We studied the latest epidemiology trend of geriatric hip fracture in Hong Kong, as well as the excess mortality for patients who had undergone surgery for hip fracture. This descriptive epidemiology study was conducted in the public hospitals in Hong Kong. All patients who underwent surgery for geriatric hip fracture in public hospitals from January 2000 to December 2011 were studied. They were retrieved from the Clinical Management System of the Hospital Authority of Hong Kong. Relevant data were collected using the Clinical Data Analysis and Reporting System of the Hospital Authority. The actual and projected population size, and the age- and sex-specific mortality rates were obtained from the Census and Statistics Department of Hong Kong. The 30-day, 1-year and 5-year mortality, and excess mortality following surgery for geriatric hip fracture were calculated. There was a steady increase in the incidence of geriatric hip fracture in Hong Kong. The annual risk of geriatric hip fracture was decreasing in both sexes. Female patients aged 65 to 69 years had the lowest 1-year and 5-year mortality of 6.91% and 23.80%, respectively. Advancing age and male sex were associated with an increase in mortality and a higher excess mortality rate following surgery. The incidence of geriatric hip fracture is expected to increase in the future. The exact reason for a higher excess mortality rate in male patients remains unclear and should be the direction for future studies.
Woo, Dae Gon; Ko, Chang-Yong; Kim, Han Sung; Seo, Jong Bum; Lim, Dohyung
This study evaluated the possible clinical application of low-intensity ultrasound (LIUS) stimulation for preventing osteoporotic bone fracture. Eight virgin 14-week-old ICR mice (weight 24.0 +/- 0.7 g) were ovariectomized to induce osteoporosis. The right hind limbs (US limbs) were stimulated with LIUS, whereas the left hind limbs (CON limbs) were not stimulated. LIUS was applied for 20 min a day, 5 days a week over a 6-week period using the following parameters: 1.5 MHz frequency, 1.0 kHz pulse repetition, 30 mW/cm(2) intensity, and 200 mus pulse length. The effective structural modulus increased significantly (p < 0.05) in the US limbs over time with the increased bone quantity, whereas that in CON limbs remained statistically constant (p > 0.05). In addition, the elastic modulus in the US limbs was generally enhanced by an increased bone quality, compared with the CON limbs. Therefore, LIUS stimulation may effectively reduce the risk of osteoporotic bone fracture by increasing the mechanical characteristics of bone via improvements in both the effective structural and elastic modulus of the osteoporotic bone. In conclusion, LIUS may potentially prove very effective clinically for preventing osteoporotic bone fractures.
Kwon, Jin-Won; Park, Hae-Young; Kim, Ye Jee; Moon, Seong-Hwan
Background To assess the cost-effectiveness of drug therapy to prevent osteoporotic fractures in postmenopausal women with osteopenia in Korea. Methods A Markov cohort simulation was conducted for lifetime with a hypothetical cohort of postmenopausal women with osteopenia and without prior fractures. They were assumed to receive calcium/vitamin D supplements only or drug therapy (i.e., raloxifene or risedronate) along with calcium/vitamin D for 5 years. The Markov model includes fracture-specific and non-fracture specific health states (i.e. breast cancer and venous thromboembolism), and all-cause death. Published literature was used to determine the model parameters. Local data were used to estimate the baseline incidence rates of fracture in those with osteopenia and the costs associated with each health state. Results From a societal perspective, the estimated incremental cost-effectiveness ratios (ICERs) for the base cases that had T-scores between -2.0 and -2.4 and began drug therapy at the age of 55, 60, or 65 years were $16,472, $6,741, and -$13,982 per quality-adjusted life year (QALY) gained, respectively. Sensitivity analyses for medication compliance, risk of death following vertebral fracture, and relaxing definition of osteopenia resulted in ICERs reached to $24,227 per QALY gained. Conclusions ICERs for the base case and sensitivity analyses remained within the World Health Organization's willingness-to-pay threshold, which is less than per-capita gross domestic product in Korea (about $25,700). Thus, we conclude that drug therapy for osteopenia would be a cost-effective intervention, and we recommend that the Korean National Health Insurance expand its coverage to include drug therapy for osteopenia. PMID:27294078
Kang, Min-Soo; Shin, Yong-Hwan; Lee, Choon-Dae; Lee, Sang-Ho
A 79-year-old woman developed neurological deficits 6 weeks after the onset of a thoracic osteoporotic compression fracture. Magnetic resonance (MR) imaging of the thoracic spine revealed an epidural hematoma at the T10-L2 levels. Acute decompressive laminectomy and percutaneous vertebroplasty were performed. Following the surgery, the patient's neurologic deficits improved and follow-up MR imaging showed complete resolution of the hematoma. Spinal epidural hematomas are rare and associated delayed neurological deficits are extremely rare. Conservative treatment may be effective for epidural hematomas in neurologically intact patients, but epidural hematomas can be a cause of neural compression and symptomatic deterioration resulting in delayed neurological deficits during the follow-up period.
Ponzio, Danielle Y; Shahi, Alisina; Park, Andrew G; Purtill, James J
Intraoperative proximal femoral fracture is a complication of primary cementless total hip arthroplasty (THA) at rates of 2.95-27.8%. A retrospective review of 2423 consecutive primary cementless THA cases identified 102 hips (96 patients) with fracture. Multivariate analysis compared fracture incidences between implants, Accolade (Stryker Orthopaedics) and Tri-Lock (DePuy Orthopaedics, Inc.), and evaluated potential risk factors using a randomized control group of 1150 cases without fracture. The fracture incidence was 4.4% (102/2423), 3.7% (36/1019) using Accolade and 4.9% using Tri-Lock (66/1404) (P=0.18). Female gender (OR=1.96; 95% CI 1.19-3.23; P=0.008) and smaller stem size (OR=1.64; 95% CI 1.04-2.63; P=0.03) predicted increased odds of fracture. No revisions of the femoral component were required in the fracture cohort.
Jeon, Taek-Soo; Lee, Woo-Suk; Roh, Jae-Young; Kim, Jae-Young; Park, Won-Ki
Study Design A retrospective study. Purpose To compare the level of restoration of the vertebral height, improvement in the wedge and kyphotic angles, and the incidence of complications in osteoporotic compression fracture in patients treated with either kyphoplasty or lordoplasty. Overview of Literature Kyphoplasty involves recompression of the vertebral bodies. Recently, a more effective method known as lordoplasty was introduced. Methods Between 2004 and 2009, patients with osteoporotic thoracolumbar vertebral compression fractures were treated by either kyphoplasty (n = 24) or lordoplasty (n = 12) using polymethylmethacrylate (PMMA) cement, and the results of the two interventions were compared. A visual analogue scale was used to measure the pain status. Preoperative and postoperative radiographs were analyzed to quantify the anterior vertebral height restoration and the wedge and kyphotic alignment correction. Results All patients in both groups reported a significant decrease in pain. The anterior heights increased 24.2% and 17.5% after the lordoplasty and kyphoplasty procedures, respectively (p < 0.05). Three months after the procedures, there was a larger decrease in the loss of anterior vertebral height in the kyphoplasty group (12.8%) than in the lordoplasty group (6.3%, p < 0.05). The wedge angles decreased after both procedures. The wedge angle in the lordoplasty group maintained its value after 3 months (p < 0.05). The kyphotic angular correction was 11.4 and 7.0° in the lordoplasty and kyphoplasty groups, respectively (p < 0.05). Both kyphotic deformities worsened to a similar degree of 5° after 3 months. Conclusions Lordoplasty is more useful than kyphoplasty in terms of the improved anatomic restoration and postoperative maintenance. PMID:21165313
Jonas, S C; Young, A F; Curwen, C H; McCann, P A
Fragility fractures of the ankle are increasing in incidence. Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity. Ankle fractures in this age group are managed conservatively in plaster or by open reduction and internal fixation. Both modalities have shown high rates of failure in terms of delayed union or mal-union together with perioperative complications such as implant failure and wound breakdown. The optimal treatment of these patients remains controversial. We aimed to review the functional outcome of patients with ankle fragility fractures primarily managed using a tibio-talar-calcaneal nail (TTC). We retrospectively reviewed 31 consecutive patients primarily managed with a TCC nail for osteoporotic fragility fractures about the ankle. Data were collected via case notes, radiographic reviews and by clinical reviews at the outpatient clinic or a telephone follow-up. Information regarding patient characteristics, indication for operation, Arbeitsgemeinschaft für Osteosynthesefragen (AO) fracture classification, operative and postoperative complications, time to radiographic union and current clinical state including Olerud and Molander scores were recorded (as a measure of ankle function). Nine of 31 patients had died by the time of follow-up. Mean preoperative and postoperative Olerud and Molander scores were 56 and 45, respectively. There were no postoperative wound complications. Twenty-nine of 31 patients returned to the same level of mobility as pre-injury. There were three peri-prosthetic fractures managed successfully with nail removal and replacement or plaster cast. There were two nail failures, both in patients who mobilised using only a stick, which were managed by nail removal. Ten of 31 patients were not followed up radiographically due to either infirmity or death. Thirteen of 21 followed up radiographically had evidence of union and 8/21 had none. None, however, had clinical evidence