Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis

The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients

We examined the effect of a fracture clinic intervention in reducing previously documented undertreatment of osteoporosis (OP) in individuals with fragility fractures. Fragility fracture patients presenting to five community fracture clinics with no prior diagnosis of, or treatment for OP, and whose radiographic appearance was consistent with fragility fracture, were included. These individuals (intervention group) were informed of their OP risk, and advised to follow up with their physician for assessment. A standardized letter, intended for the physician and outlining the same was provided. Three months later, a telephone interview determined whether a physician visit had occurred, and if so, what investigation and treatment recommendations were made. These outcomes were compared with those for an equal number of age- and sex-matched fragility fracture "controls," selected from among fracture clinic attendees in the 6-9 months preceding the intervention. Logistic regression was used to examine the effect of having received the intervention on physician follow-up, bone density testing, and OP treatment recommendations. The mean age of the 278 participants (139 per group) was 66.0 years; 74% were female. Adjusting for age, sex, hospital, and perceived diagnosis of OP, those who received the intervention were more likely to follow up with a physician (adjusted OR 1.85, p=0.02) and to be recommended bone density testing (adjusted OR 5.22, p<0.0001), but were not more likely to receive an OP treatment recommendation (adjusted OR 2.07, p=0.07). It is concluded that a simple fracture clinic intervention increased follow-up and investigation, but not treatment for OP, in fragility fracture patients. Individuals recommended treatment for OP were more likely to perceive themselves as having OP and to have had a previous fragility fracture. Our findings suggest that future interventions should incorporate assessment of patients' OP health beliefs and education about risk factors for fracture, and should be coupled with physician education to achieve optimal results.

The menopause and HRT. Prevention and management of osteoporosis

Post-menopausal osteoporosis is characterized by increased fracture risk due to deficiencies in both the quantity and quality of bone. Assessing fracture risk involves combining clinical risk factors, including fall risks, with bone density testing. Treatment strategies are aimed at reducing fracture risk. General nutritional and lifestyle measures are appropriate for all women. Drug treatment is most clearly indicated in post-menopausal women at high current fracture risk. Treatment should also be considered for women at intermediate fracture risk, including those who have both low bone density and other risk factors for fracture. Whether there is practical clinical value in treating low-risk patients is much less clear. Non-pharmacological approaches addressing the consequences of fractures are integral parts of a comprehensive treatment programme. Reducing both the frequency and the effects of falls complements the efforts of treating osteoporosis to reduce the incidence of fractures and their important clinical consequences.

Risedronate prevents new vertebral fractures in postmenopausal women at high risk

Independent risk factors for fracture include advanced age, preexisting fractures, and low bone mineral density. Rised-ronate has been shown in several large trials to be safe and effective for patients with osteoporosis, but its effects in populations at high risk are not well characterized. To determine the effect of risedronate on vertebral fracture in high-risk subjects, we pooled data from two randomized, double-blind studies [Vertebral Efficacy with Risedronate Therapy (VERT) Multinational (VERT-MN) and VERT-North America (VERT-NA)] in 3684 postmenopausal osteoporotic women treated with placebo or risedronate 2.5 or 5 mg/d and analyzed fracture risk in subgroups of subjects at high risk for fracture due to greater age or more prevalent fractures (vs. median for overall study population), or lower bone mineral density (T-score, -2.5 or less). Fractures were diagnosed by quantitative and semiquantitative assessment of radiographs at baseline and 1 yr. In the overall population, treatment for 1 yr with risedronate 5 mg/d reduced the risk of new vertebral fractures by 62% vs. control (relative risk, 0.38; 95% confidence interval, 0.25, 0.56; P < 0.001) and of multiple new vertebral fractures by 90% vs. control (relative risk, 0.10; 95% confidence interval, 0.04, 0.26; P < 0.001). Consistent risk reductions were observed at 1 yr in the risedronate-treated high-risk subgroups. Significant reduction in fracture risk after 1 yr is an important benefit in patients at high risk for fracture because, without treatment, these patients are likely to sustain new fractures in the near term.

Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture

STUDY OBJECTIVE

To determine whether men and women admitted to a university teaching hospital for a low-trauma hip fracture were diagnosed, evaluated, or treated for osteoporosis during admission or for up to 1 year after admission.

DESIGN

Retrospective chart review.

SETTING

University of Colorado Hospital, Denver, Colorado.

PATIENTS

One hundred eighteen patients admitted with a low-trauma hip fracture from January 1993-December 1998.

MEASUREMENTS AND MAIN RESULTS

Demographics, medical and social history, prescribed drugs, clinical outcomes, and information regarding the diagnosis, evaluation, and treatment of osteoporosis were abstracted from inpatient medical records for the index hip fracture. Similar data for the first year after the index hip fracture were abstracted from outpatient medical records of patients who had follow-up visits within the hospital system. Mean +/- SD age at the time of fracture was 70 +/- 15 years; 43 patients were men and 75 were women. Eighteen percent of patients had experienced a previous hip fracture, 4% had a history of vertebral fracture, and 6% reported a previous wrist fracture. The diagnosis of osteoporosis was noted in the charts of 14% of the patients at discharge and 26% of patients at follow-up. Only 4% of patients during hospitalization and 9% during follow-up received any evaluative tests for osteoporosis, including bone densitometry. Subsequent fractures occurred in 12.5% of patients. Documented treatment of osteoporosis was uncommon, with approximately 75% of patients receiving no therapy for osteoporosis on discharge or during follow-up. Women were more likely than men to receive a diagnosis of osteoporosis, bone mineral density testing, and osteoporosis drug therapy.

CONCLUSION

In patients with hip fractures, osteoporosis is commonly not diagnosed or treated appropriately

Identification and treatment of osteoporosis in fractures

Patients who present with osteoporotic fracture are at highest risk of further fractures and their associated morbidity. Despite the availability of several evidence-based therapeutic options, which have the potential to reduce the incidence of fractures by up to 50%, it is paradoxical that these high-risk patients are seldom assessed for osteoporosis and offered treatment. Secondary prevention of osteoporotic fractures should now be the priority for osteoporosis services; the challenge that remains is to devise new models of patient care that can deliver strategies for the secondary prevention of osteoporotic fractures in different healthcare settings.

Treatment of osteoporotic fractures

Fractures are the most common problem associated with osteoporosis and despite advances in prevention and treatment of osteoporosis the number of fractures continue to increase. Along with the three classic locations hip, spine and wrist, there are several other fractures that commonly are related to osteoporosis. The weak bone makes it difficult to achieve a stable bone-implant construct and general weakness of the patient often prevents reduction of load on the injured extremity during healing. The main treatment goal should be preservation of function even at the expense of restoration of exact anatomy. By development of dynamic load-sharing implants and less invasive techniques the results following fixation of osteoporotic fractures has improved. A new strategy has also been to develop materials that will enhance the strength of the cancellous bone that surrounds the metal implant. By using bioactive cement in conjunction with metal implants improved strength has been shown in internally fixed metaphyseal fractures. Encouraging results have also been reported after cement injection into compressed vertebral fractures, so called vertebroplasty. The specific demands involved in the treatment of osteoporotic fractures calls for specific solutions. Apart from augmentation of the cancellous bone and development of new load-sharing devices, endoprosthetic replacement with specially designed fracture prosthesis has become more frequent.

A 6-mo home-based exercise program may slow vertebral height loss

Twenty-one of 46 postmenopausal women were assigned to a home-based exercise program consisting of 60 min of exercise, 3 d/wk. The 25 nonexercisers continued usual daily activities. Each woman had at least one prevalent vertebral fracture and suffered from osteoporosis as defined by the application of WHO criteria to lumbar spine bone mineral density. Vertebral heights were measured using bone densitometry at baseline and 12 mo later. Vertebrae T9 to L4 were all identified for each of the 46 subjects in both the baseline and end-of-study lateral scans. The change in mean vertebral height over the course of the study was -0.3 mm anteriorly, -0.7 mm at the mid-location, and -0.4 mm posteriorly for the nonexercisers. For the exercisers, the corresponding changes were +0.1 mm anteriorly, -0.3 mm at the mid-location, and +0.2 mm posteriorly. The benefit of exercise in preserving vertebral morphometry in patients with osteoporosis deserves further investigation.

Evaluation and management of osteoporosis following hospitalization for low-impact fracture

OBJECTIVE

To evaluate the pattern of osteoporosis evaluation and management in postmenopausal women who present with low-impact (minimal trauma) fracture.

DESIGN

Retrospective chart review of patients admitted with a fracture in the absence of trauma or bone disease. Telephone follow-up survey was conducted at 12 months after discharge to collect information on physician visits, pharmacological therapies for osteoporosis, functional status, and subsequent fractures.

PATIENTS/PARTICIPANTS

Postmenopausal women admitted to a hospital in St. Paul, Minnesota between June 1996 and December 1997 for low-impact fractures were identified. Low-impact fracture was defined as a fracture occurring spontaneously or from a fall no greater than standing height. Retrospective review of 301 patient medical records was conducted to obtain data on pre-admission risk factors for osteoporosis and/or fracture, and osteoporosis-related evaluation and management during the course of hospitalization. Follow-up 1 year after the incident fracture was obtained on 227 patients.

MEASUREMENTS AND MAIN RESULTS

Two hundred twenty-seven women were included in the study. Osteoporosis was documented in the medical record in 26% (59/227) of the patients at hospital discharge. Within 12 months of hospital discharge, 9.6% (22/227) had a bone mineral density test, and 26.4% (60/227) were prescribed osteoporosis treatment. Of those who were prescribed osteoporosis treatment, 86.6% (52/60) remained on therapy for 1 year. Nineteen women suffered an additional fracture. Compared to women without a prior fracture, women with at least 1 fracture prior to admission were more likely to have osteoporosis diagnosed and to receive osteoporosis-related medications.

CONCLUSION

Despite guidelines that recommend osteoporosis evaluation in adults experiencing a low-trauma fracture, we report that postmenopausal women hospitalized for low-impact fracture were not sufficiently evaluated or treated for osteoporosis during or after their hospital stay. There are substantial opportunities for improvement of care in this high-risk population to prevent subsequent fractures.

Vertebral morphometric X-ray absorptiometry in women with Colles' fracture

Colles' fracture (CF) in younger postmenopausal women is associated with low bone mineral density (BMD) and with an increased risk of other osteoporotic fractures; however, the prevalence of vertebral deformities has been not studied in CF patients. Vertebral morphometry (MXA) using dual-energy X-ray absorptiometry (DXA) is a research tool developed to evaluate the presence of vertebral deformities, but its clinical use is still limited. The goals of this work were to know the prevalence of vertebral deformities in women with CF, to study the morphometric characteristics of height ratios, and to determine the correlation between MXA findings and BMD. MXA was evaluated within an incident case-control study in which 58 women with a recent CF and 83 population-based control women were enrolled. Anterior (Ha), middle (Hm), and posterior (Hp) heights were measured, and wedge (Ha/Hp) and mid-wedge (Hm/Hp) ratios were calculated. A vertebral deformity was defined when at least one ratio fell 3 SD below the reference mean of that ratio at any vertebral level. The mean age of cases was 65.8 yr and in controls 58.7 (p < 0.05). Morphometric vertebral deformities were found in 19% of cases against 11% of controls (nonsignificant). The cases had a lower mid-wedge ratio than controls at each vertebral level (p < 0.05), while wedge ratio results did not show significant results. When the sample was stratified by age, CF showed a trend to be associated with vertebral deformity only in the younger (<65 yr) group. A low but significant coefficient of correlation was found between mid-wedge ratio and BMD, mainly at hip level. By using MXA we found that younger Colles' fracture cases were likely to have more vertebral deformities than healthy controls of the same age range.

Hip fracture patients are not treated for osteoporosis: a call to action

OBJECTIVE

To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis.

METHODS

Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment.

RESULTS

DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2-10% receiving a bisphosphonate.

CONCLUSION

Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.

The relationship between bone density and incident vertebral fracture in men and women

Bone mineral density (BMD) is an important predictor of future fracture risk in women; however, there are few prospective data in men. The aim of this analysis was to determine whether there are differences in the relationship between BMD and incident vertebral fracture in men and women. Men and women were recruited from population-based registers in 21 European centers. Those recruited were interviewed and had spinal radiographs performed. The radiographs were assessed morphometrically and prevalent vertebral deformity was defined using the McCloskey-Kanis method. Repeat spinal radiographs were performed at a mean of 3.8 years after the baseline radiographs. Incident fractures were defined using a combination of the point prevalence and 20% reduction in vertebral height (plus a 4-mm reduction in absolute height) criteria. BMD measurements were made in a subsample of those recruited. Poisson regression was used to explore the influence of gender, age, prevalent deformity, and BMD on the incidence of vertebral fracture. Thirty-four hundred sixty-one men and women had both paired spinal radiographs and bone density measurements performed. BMD at the spine and femoral neck was higher in men than in women. After adjusting for age, the risk of incident vertebral fracture was greater in women than in men (relative risk [RR] = 2.3; 95% CI, 1.5-3.6) and increased by a factor of 1.4 (95% CI, 1.2-1.8), 1.5 (95% CI, 1.2-1.8), and 1.6 (95% CI, 1.3-1.9) per decrease of 0.1 g/cm2 in BMD at the spine, femoral neck, and trochanter, respectively. After adjusting for BMD at the spine or trochanter, the gender difference in the predicted age-specific incidence of vertebral fracture was no longer significant (RR = 1.1 and 95% CI, 0.6-1.9 at the spine; RR = 1.5 and 95% CI, 0.8-2.7 at the trochanter), although it persisted after adjusting for femoral neck BMD (RR = 1.9; 95% CI, 1.1-3.3). The presence of a prevalent vertebral deformity was a strong risk factor for future vertebral fracture, although the strength of the association was reduced after adjustment for age, sex, and spine BMD. However, adjustment for the presence of a baseline vertebral deformity did not alter the main findings. In conclusion, at a given age and spine (although not femoral neck) bone density, the risk of incident vertebral fracture is similar in men and women. Incident vertebral fractures are more common in women than men because at any age their spine BMD is lower.

Alendronate in the prevention of bone loss after a fracture of the lower leg

Fracture of a leg and the consequent absence from weight-bearing lead to local bone loss. A 1-year, single-center, prospective, randomized, double-blind study was conducted, to determine whether bone loss would occur in the proximal femur and the calcaneus after a fracture of the lower leg and whether this loss could be prevented by the antiresorptive drug bisphosphonate alendronate. Twenty-three men and 18 women with a recent unstable fracture of the lower leg were randomized to receive either 10 mg of alendronate daily or placebo. Bone mineral density (BMD) of both hips and the lumbar spine was measured at baseline and 6 weeks and 3, 6, and 12 months after start of the treatment. Quantitative ultrasound (QUS) measurements of the calcaneus were performed at baseline on the noninjured side and at 6 weeks and 3, 6, and 12 months after start of treatment on both sides. After 1 year, in the placebo group, there was a significant decrease from baseline in BMD of the hip on the side of the fracture. In the alendronate group, there was no significant change from baseline. The differences in BMD between the two treatment groups on the side of the fracture were significant in all sites of the hip: 4.4% (p = 0.016) in the trochanter, 4.6% (p = 0.016) in the femoral neck, and 3.9% (p = 0.009) in the total hip. In the hip on the contralateral side, there were no significant changes from baseline in either treatment group and there was no difference between the two treatment groups. BMD in the lumbar spine increased in the alendronate group, and after 1 year there was a significant difference between the active treatment and placebo group of 3.4% (p = 0.04). One year after fracture, ultrasound parameters of the calcaneus in the placebo group were significantly lower on the fractured side compared with the contralateral side (p < 0.01). In the alendronate group, no significant difference between the two sides was observed. In conclusion, BMD of the proximal femur was still decreased 1 year after a fracture of the lower leg. Alendronate prevented this bone loss.

The association between iliocostal distance and the number of vertebral and non-vertebral fractures in women and men registered in the Canadian Database For Osteoporosis and Osteopenia (CANDOO)

BACKGROUND

The identification of new methods of evaluating patients with osteoporotic fracture should focus on their usefulness in clinical situations such that they are easily measured and applicable to all patients. Thus, the purpose of this study was to examine the association between iliocostal distance and vertebral and non-vertebral fractures in patients seen in a clinical setting.

METHODS

Patient data were obtained from the Canadian Database of Osteoporosis and Osteopenia (CANDOO). A total of 549 patients including 508 women and 41 men participated in this cross-sectional study. There were 142 women and 18 men with prevalent vertebral fractures, and 185 women and 21 men with prevalent non-vertebral fractures.

RESULTS

In women multivariable regression analysis showed that iliocostal distance was negatively associated with the number of vertebral fractures (-0.18, CI: -0.27, -0.09; adjusted for bone mineral density at the Ward's triangle, epilepsy, cerebrovascular disease, inflammatory bowel disease, etidronate use, and calcium supplement use) and for the number of non-vertebral fractures (-0.09, CI: -0.15, -0.03; adjusted for bone mineral density at the trochanter, cerebrovascular disease, inflammatory bowel disease, and etidronate use). However, in men, multivariable regression analysis did not demonstrate a significant association between iliocostal distance and the number of vertebral and non-vertebral fractures.

CONCLUSIONS

The examination of iliocostal distance may be a useful clinical tool for assessment of the possibility of vertebral fractures. The identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies.

Radius bone strength in bending, compression, and falling and its correlation with clinical densitometry at multiple sites

This study comprehensively analyzes the ability of site-specific and nonsite-specific clinical densitometric techniques for predicting mechanical strength of the distal radius in different loading configurations. DXA of the distal forearm, spine, femur, and total body and peripheral quantitative computed tomography (pQCT) measurements of the distal radius (4, 20, and 33%) were obtained in situ (with soft tissues) in 129 cadavers, aged 80.16 +/- 9.8 years. Spinal QCT and calcaneal quantitative ultrasound (QUS) were performed ex situ in degassed specimens. The left radius was tested in three-point bending and axial compression, and the right forearm was tested in a fall configuration, respectively. Correlation coefficients with radius DXA were r = 0.89, 0.84, and 0.70 for failure in three-point bending, axial compression, and the fall simulation, respectively. The correlation with pQCT (r = 0.75 for multiple regression models with the fall) was not significantly higher than for DXA. Nonsite-specific measurements and calcaneal QUS displayed significantly (p < 0.01) lower correlation coefficients, and QUS did only contribute to the prediction of axial failure stress but not of failure load. We conclude that a combination of pQCT parameters involves only marginal improvement in predicting mechanical strength of the distal radius, nonsite-specific measurements are less accurate for this purpose, and QUS adds only little independent information to site-specific bone mass. Therefore, the noninvasive diagnosis of loss of strength at the distal radius should rely on site-specific measurements with DXA or pQCT and may be the earliest chance to detect individuals at risk of osteoporotic fracture.

Risk factors for fractures in kidney transplantation

BACKGROUND

Risk factors for fracture after kidney transplantation need to be identified to target patients most likely to benefit from preventive measures.

METHODS

Medical records were reviewed for 1572 kidney transplants done at a single center between February, l963 and May, 2000 with 6.5+/-5.4 years of follow-up.

RESULTS

One or more fractures occurred in 300 (19.1%), with multiple fractures in 101 (6.4%). After excluding fractures of the foot or ankle (n=130 transplants, 8.3%), avascular necrosis (n=86, 5.5%), and vertebral fractures (n=28, 1.8%), there were one or more fractures in 196 (12.5%), with a cumulative incidence of 12.0%, 18.5%, and 23.0% at 5, 10, and 15 years, respectively. In multivariate Cox proportional hazards analysis, age had no effect on fractures in men. Compared with men and younger women, women 46-60 and >60 years old were, respectively, 2.11 (95% confidence interval 1.43-3.12, P=0.0002) and 3.47 (2.16-5.60, P<0.0001) times more likely to have fractures. Kidney failure from type 1 and 2 diabetes increased the risk by 2.08 (1.47-2.95, P<0.0001) and 1.92 (1.15-3.20, P=0.0131), respectively. A history of fracture pretransplant increased the risk by 2.15 (1.49-3.09, P<0.0001). Each year of pretransplant kidney failure increased the risk by 1.09 (1.05-1.14, P<0.0001). Obesity (body mass index >30 kg/m2) was associated with 55% (17-76%, P=0.0110) less risk. Different immunosuppressive medications, acute rejections, and multiple other factors were not independently associated with fractures.

CONCLUSIONS

The population of transplant patients at high risk for fracture can be identified using age/gender, pretransplant fracture history, diabetes, obesity, and years of pretransplant kidney failure.

Diagnosis and management of vertebral fractures in elderly adults

We reviewed the epidemiology, diagnosis, and treatment of vertebral fractures due to osteoporosis in the elderly. Vertebral fractures are underdiagnosed despite their high prevalence in both men and women. Clinical consequences of vertebral fractures include increased risk of future vertebral and hip fracture, acute and chronic back pain, decreased quality of life, and increased mortality. Patients with vertebral fractures have functional impairment and increased mortality similar to those with hip fractures. Asymptomatic fractures identified on radiograph also affect quality of life and mortality. A vertebral fracture is a clinical marker for a subsequent fracture and should trigger assessment and diagnosis of osteoporosis. The care of patients with vertebral fractures includes pain management, rehabilitation, and prevention of further fractures. There is evidence from randomized controlled trials that pharmacologic therapy can reduce the risk of future fractures by 40% to 50%. Vertebroplasty may be effective in the control of pain and in obtaining stability of the spine.

Is the predictive power of previous fractures for new spine and non-spine fractures associated with biochemical evidence of altered bone remodelling? The EPOS study. European Prospective Osteoporosis Study

BACKGROUND

In the European Prospective Osteoporosis Study (EPOS), a past spine fracture increased risk of an incident fracture 3.6 - 12-fold even after adjusting for BMD. We examined the possibility that biochemical marker levels were associated with this unexplained BMD-independent element of fracture risk.

METHODS

Each of 182 cases in EPOS of spine or non-spine fracture that occurred in 3.8 years of follow-up was matched by age, sex and study centre with two randomly assigned never-fractured controls and one case of past fracture. Analytes measured blind were: osteocalcin, bone-specific alkaline phosphatase, total alkaline phosphatase, serum creatinine, calcium, phosphate and albumin, together with the collagen cross-links degradation products serum CTS and urine CTX. Most subjects also had bone density measured by DXA.

RESULTS

Cases who had recent fractures did not differ in marker levels from cases who had their last fracture more than 3 years previously. No statistically significant effect of recent fracture was found for any marker except osteocalcin, which was 17.6% lower in recent peripheral cases compared to unfractured controls (p<0.05) and this was independent of BMD.

CONCLUSION

Past fracture as a risk indicator for future fracture is not strongly mediated through increased bone turnover.

Non-participants differ from participants as regards risk factors for vertebral deformities: a source of misinterpretation in the European Vertebral Osteoporosis Study

Interpretation of data in epidemiological cohort studies may be confounded if differences exist between non-participants and participants. In the Malmö part of the European Vertebral Osteoporosis Study (EVOS), which was designed to evaluate the prevalence of vertebral deformity in 50-80-year-old persons, we compared 74 men and 95 women who had been invited, but declined to participate with age- and gender-matched participants as regards alcohol abuse, previous fractures and subsequent mortality, factors known to affect the prevalence of vertebral deformity. We found more men with alcohol abuse, more men with a previous fragility fracture and a tendency to more men with a previous clinical vertebral fracture among the non-participants than in the male participants. In contrast, there were fewer female non-participants than female participants with a previous clinical vertebral fracture. The mortality rate during the decade after the baseline examination was higher among both male and female non-participants. The "true" prevalence of vertebral deformity in the whole male population at risk in Malmö seems to be underestimated in the EVOS study. In women, it is more difficult to estimate the combined result of the confounding factors. Conclusions based on the EVOS participants may not be applicable to the whole population at risk.

Practice pattern variation in the prevention and treatment of osteoporosis

Prevention and treatment of osteoporosis will be of increasing importance as the mean age of the world population rapidly increases in the coming decades. Nearly half of postmenopausal women not already diagnosed with osteoporosis have significantly low bone mineral density and are at increased risk of fracture, yet this risk is often unrecognized and untreated. Postmenopausal women who have experienced fractures of the hip, vertebra, and wrist and patients using glucocorticoids are at highest risk of fractures but often remain untested and untreated for osteoporosis. Because of the rising societal costs of osteoporosis anticipated in coming years, an improved understanding of the predictors of practice pattern variations and interventions designed to improve underutilization of appropriate care are important to clinicians, health services researchers, and policy makers.

Reduced bone mineral density in postmenopausal women self-reporting premenopausal wrist fractures

Postmenopausal fractures are associated with low bone mass; however, the role of low peak bone mass in young adults in determining subsequent osteoporosis suggests that premenopausal fractures may also be relevant. We therefore sought to determine whether a self-reported previous history of premenopausal wrist and nonwrist fractures could also be associated with bone density and therefore be used to predict osteoporosis. We recruited 453 volunteer women with a median age of 64 years (range 50-83 years), with no metabolic bone disease, previous femoral neck fracture, or prevalent vertebral fracture. Bone density at the femoral neck (FN) and lumbar spine (LS) was measured using a Lunar DPX-L. As expected, the 319 women who did not report any fracture had a higher T score at LS (-0.93 +/- 1.44) than the 134 women who reported a previous fracture at any site and at any age (T score -1.60 +/- 1.21, p < 0.001). The findings for the FN were similar. Compared with fracture-free women, the women who reported a first wrist fracture before menopause now had a lower LS T score (-1.77 +/- 1.20, n = 15, p < 0.05), whereas those who reported a nonwrist fracture showed no significant decrease in their LS T score (-1.26 +/- 1.00, n = 36). When both wrist and nonwrist fractures had occurred after menopause, the T score was significantly lower. Twenty percent of the fracture-free women were osteoporosis patients. After adjusting for body weight, age, hormonal replacement therapy (HRT), and hip fracture in the family, the relative risk (RR) of osteoporosis for premenopausal wrist fractures was 2.7 (95% confidence interval 1.4-4.3) vs. 1.2 (0.7-2.4) for women with premenopausal nonwrist fractures. We conclude that self-reported premenopausal wrist fractures, but no other fractures occurring before menopause, are likely to be associated with osteoporosis at 65 years of age, and therefore constitute strong grounds for screening.

Intervention thresholds for osteoporosis

The aim of this study was to determine the threshold of fracture probability at which interventions become cost-effective. We modeled the effects of a treatment costing $500/year, given for 5 years, that decreased the risk of all osteoporotic fractures by 35%, followed by a waning of effect for 5 years. Sensitivity analyses included a range of effectiveness (10%-50%) and a range of intervention costs (200-500 dollars/year). Data on costs and risks were from Sweden. Costs included direct costs and costs in added years of life, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of 60,000 dollars per quality-adjusted life-year (QALY) gained was used. Costs of added years were excluded in a sensitivity analysis for which a threshold value of 30,000 dollars per QALY was used. In the base case, intervention was cost-effective when treatment was targeted to women at average risk at age of >or=65 years. Irrespective of the efficacy modeled (10%-50%) or of cost of intervention (200-500 dollars/year) segments of the population at average risk could be targeted cost-effectively: The lower the intervention cost and the higher the effectiveness, the lower the age at which intervention was cost-effective. With the base case (500 dollars/year; 35% efficacy) treatment in women was cost-effective with a 10 year hip fracture probability that ranged from 1.4% at the age of 50 years to 4.4% at the age of 65 years. The exclusion of osteoporotic fractures other than hip fracture would increase the threshold to a 9%-11% 10 year probability because of the substantial morbidity from fractures other than hip fracture, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be cost-effectively targeted to individuals at moderately increased risk.

Performance of risk indices for identifying low bone density in postmenopausal women

OBJECTIVE

To examine the ability of 4 published osteoporosis risk indices to identify women with low bone density.

SUBJECTS AND METHODS

Subjects included postmenopausal women 45 years and older consecutively recruited from US clinics, women from general practice centers in The Netherlands (age range, 50-80 years), women in the Rotterdam Study (The Netherlands) 55 years and older, and women aged 55 to 81 years old screened for a clinical trial of alendronate. Bone mineral density (BMD) was measured at the femoral neck or lumbar spine; T scores represent the number of SDs below the mean for young healthy women. One risk index was calculated from age and weight; the other risk indices included up to 4 additional variables obtained by questionnaire. We calculated the sensitivity and specificity for identifying women with BMD T scores of -2.5 or less or -2.0 or less in the US clinic sample and created 3 risk categories, using each of the 4 indices.

RESULTS

Data were available for 1102 women from the US clinic sample, 3374 women in the Rotterdam Study, 23,833 women screened for a clinical trial of alendronate, and 4204 women from general practice centers in The Netherlands. Specificity for identifying BMD T scores of -2.5 or less ranged from 37% to 58% (depending on risk index) when sensitivity was approximately 90%. The prevalence of osteoporosis (defined as T scores < or = -2.5) differed widely across the 3 risk categories, ranging from 2% to 4% for the low-risk category to 47% to 61% for the high-risk category in the US clinic sample. For spine BMD in the US clinic sample, the prevalence of T scores of -2.5 or less ranged from 7% (low risk) to 38% (high risk). The large differences in prevalence across risk categories were consistent across the other 3 samples of postmenopausal women in the United States and The Netherlands for all 4 risk indices.

CONCLUSIONS

We recommend measuring BMD in women who are classified as having an increased risk of osteoporosis by using any of these risk indices because all 4 indices appear to predict low bone mass equally well. The Osteoporosis Self-assessment Tool index is easiest to calculate and therefore may be most useful in clinical practice.

Secondary osteoporosis and the risk of distal forearm fractures in men and women

Secondary osteoporosis plays an important role in the pathogenesis of hip and spine fractures, but relatively little is known about the potential impact of secondary osteoporosis and fall-related disorders on the risk of distal forearm fractures. To address this issue, we conducted a population-based, nested case-control study comparing 496 Rochester, Minnesota, residents with an initial distal forearm fracture to an equal number of age- and gender-matched controls. Potential risk factors were assessed by review of each subject's complete (inpatient and outpatient) medical records in the community (median duration >30 years) and analyzed using multiple logistic regression. Although history of diabetes mellitus in women (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.75) and long-term anticonvulsant use in both genders (OR 3.58, 95% CI 1.26-10) were independently associated with fracture risk in a multivariate analysis, the conditions linked with secondary osteoporosis had, in aggregate, no statistically significant association with distal forearm fractures. Fall-related conditions altogether were associated with a borderline increase in risk (OR 1.36, 95% CI 0.98-1.91) and might have accounted for 19% of forearm fracture occurrence in the community. Among women (OR 2.72, 95% CI 1.20-6.19), but not men, a history of prior osteoporotic fracture was also associated with an increase in distal forearm fractures. These factors do not appear to account for the discrepancy in forearm fracture incidence in women when compared with men.

Diagnosis of osteoporosis and assessment of fracture risk

The diagnosis of osteoporosis centres on the assessment of bone mineral density (BMD). Osteoporosis is defined as a BMD 2.5 SD or more below the average value for premenopausal women (T score < -2.5 SD). Severe osteoporosis denotes osteoporosis in the presence of one or more fragility fractures. The same absolute value for BMD used in women can be used in men. The recommended site for diagnosis is the proximal femur with dual energy X-ray absorptiometry (DXA). Other sites and validated techniques, however, can be used for fracture prediction. Although hip fracture prediction with BMD alone is at least as good as blood pressure readings to predict stroke, the predictive value of BMD can be enhanced by use of other factors, such as biochemical indices of bone resorption and clinical risk factors. Clinical risk factors that contribute to fracture risk independently of BMD include age, previous fragility fracture, premature menopause, a family history of hip fracture, and the use of oral corticosteroids. In the absence of validated population screening strategies, a case finding strategy is recommended based on the finding of risk factors. Treatment should be considered in individuals subsequently shown to have a high fracture risk. Because of the many techniques available for fracture risk assessment, the 10-year probability of fracture is the desirable measurement to determine intervention thresholds. Many treatments can be provided cost-effectively to men and women if hip fracture probability over 10 years ranges from 2% to 10% dependent on age.

Epidemiology and outcomes of osteoporotic fractures

Bone mass declines and the risk of fractures increases as people age, especially as women pass through the menopause. Hip fractures, the most serious outcome of osteoporosis, are becoming more frequent than before because the world's population is ageing and because the frequency of hip fractures is increasing by 1-3% per year in most areas of the world. Rates of hip fracture vary more widely from region to region than does the prevalence of vertebral fractures. Low bone density and previous fractures are risk factors for almost all types of fracture, but each type of fracture also has its own unique risk factors. Prevention of fractures with drugs could potentially be as expensive as medical treatment of fractures. Therefore, epidemiological research should be done and used to identify individuals at high-risk of disabling fractures, thereby allowing careful allocation of expensive treatments to individuals most in need.

The cost of osteoporosis in men: the French situation

The objective of this study was to estimate the annual direct medical costs of osteoporosis and osteoporotic fractures incurred by French men > or =50 years of age. Costs were assessed from a societal perspective for 1999 and expressed in Euros. An expert panel was consulted to identify fractures attributable to osteoporosis according to International Classification of Diseases (ICD)-10 codes. Available age- and gender-specific osteoporosis attribution probabilities (OAP) were used to derive the proportion of health-care utilization for fractures resulting from osteoporosis. Hospital and ambulatory care costs due to fractures were obtained from French databases. A total of 23,260 acute hospitalizations were found to be caused by osteoporosis, 52% of which are for hip fractures. Mean cost per stay varied widely according to the site of fracture, from 1300 (wrist fracture) to 5900 (hip fracture). Consequently, the total cost of acute hospitalization amounts to 97.6 million, with hip fractures accounting for 73.2% of the expenditures. Rehabilitation and convalescence costs were estimated to be 90.8 million, generating a total hospital cost of 188.4 million. The total outpatient costs were estimated to be 9.1 million. Thus, the total medical costs of male osteoporosis amount to 197.5 million. A sensitivity analysis was performed to test the robustness of this figure. We estimate the number of fractures by applying international incidence rates from the literature to the French male population aged > or =50 years, whereas the OAP and unit costs were kept constant. This approach yielded an estimate of 21,857 fractures, which is only 6% below the base case. When compared with values from other countries, our study results appear very conservative.

Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons

OBJECTIVE

To understand better the barriers among orthopedic surgeons and primary care physicians in identifying and treating possible osteoporosis in patients hospitalized with a fragility fracture sustained spontaneously or from a fall no greater than standing height.

METHODS

A 1-page, 7-question survey was sent to 35 admitting orthopedic surgeons and 75 primary care physicians at a midwestern managed care organization in March 2001. Returned surveys were collected until 30 days had passed since the mailing. Primary care physicians were board-certified family practitioners and internal medicine physicians. All orthopedists were admitting surgeons in the hospital system. Responders were anonymous, and posted surveys were returned to the Orthopaedic Collaborative Practice office. The surveys were color-coded to separate responses from orthopedic surgeons and primary care physicians.

RESULTS

Thirty-one surveys were returned: 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. Survey respondents agreed that the responsibility for postfracture attention to nutritional needs, including calcium and vitamin D, rested with the primary care provider. When asked about barriers to recommending bone mineral density testing with dual energy x-ray absorptiometry, 9 primary care physicians (39%) thought this type of testing was unnecessary for treatment, and 4 primary care physicians (17%) thought a barrier was caused by patient frailty. Primary care physicians indicated that potential adverse effects of medication (n=14 [61%]) and cost of therapy (n=13 [57%]) were the main factors limiting treatment. When asked to identify the single most important barrier in treatment, 14 physicians (61%) indicated cost was the greatest deterrent. Twenty-one primary care physicians (91%) reported they would be more likely to treat a patient with osteoporosis if a safe medication with proven fracture risk reduction were available. Primary care physicians indicated they were more likely to treat independently living adults (n=12 [52%]) and women compared with men (n=15 [65%]). All orthopedic surgeons (n=8) were willing for all patients to be evaluated in consultation with a nurse practitioner. Primary care respondents were less apt to agree with a nurse practitioner referral (n=5 [22%]). Both primary care physicians (n=16 [70%]) and orthopedic surgeons (n=4 [50%]) agreed that there is a need for increased primary care education about managing osteoporosis in patients hospitalized with low-impact fracture.

CONCLUSIONS

Orthopedic surgeons were consistent in their opinion that postfracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk postfracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects. Further education is needed to promote a standard of care for the postfracture patient that is directed toward the prevention of a subsequent fracture.

Alendronate reduces the risk of multiple symptomatic fractures: results from the fracture intervention trial

OBJECTIVES

To evaluate the effect of alendronate on the occurrence rate of multiple svmptomatic fractures and on the risk of multiple symptomatic fractures (likelihood of having more than one fracture diagnosed because of the symptoms the fractures caused over the study period) among women with osteoporosis.

DESIGN

Primary analysis of data from a randomized, placebo-controlled, double-blind trial.

SETTING

Eleven community-based clinical research centers.

PARTICIPANTS

Subset of women enrolled in the Fracture Intervention Trial: aged 55 to 81 and having at least one morphometric vertebral fracture at baseline (n=2,027) or having no vertebral fracture but meeting prevailing World Health Organization bone mineral density criteria for osteoporosis (T-score < or =2.5 at the femoral neck)(n = 1,631).

INTERVENTION

All participants reporting calcium intake of 1,000 mg/day or less received a supplement of 500 mg calcium and 250 IU cholecalciferol. Participants were randomly assigned to placebo or alendronate sodium (5 mg/day for 2 years and 10 mg/day for the remainder of the study). Average total follow-up was 4.3 years.

MEASUREMENTS

Symptomatic fractures were diagnosed by personal physicians and confirmed by review of radiological data by an expert committee blinded to treatment assignments.

RESULTS

Eighty-six of 1,817 women receiving placebo experienced multiple symptomatic fractures during the follow-up period, compared with 51 of 1,841 receiving alendronate. Reduction of risk for multiple symptomatic fractures combined was 42% (relative risk (RR) = 0.58, 95% confidence interval (CI) = 0.41, 0.81) and for multiple symptomatic vertebral fractures was 84% (RR = 0.16,95% Cl = 0.05, 0.42). Cumulative incidence curves showed divergence after as little as 3 months of treatment, with a statistically significant (P = .044) reduction at 6 months for multiple symptomatic vertebral fractures. When all fractures over the follow-up period were included, the occurrence rates of all symptomatic fractures and symptomatic vertebral fractures were 34% and 63% lower, respectively, with alendronate than with placebo. These reductions were sustained during the follow-up period. All reductions in risk were consistent across predefined subgroups: age (<75 vs > or =75), morphometric vertebral fracture(present vs absent), prior clinical fracture since age 45 (yes vs no), and whether the subject had fallen in the 12 months before randomization.

CONCLUSIONS

These data demonstrate that treatment with alendronate reduces the risk of multiple symptomatic fractures during a treatment period averaging 4.3 years. The reductions were consistent across prespecified sub-groups. This effect is evident early in treatment and is sustained.

Bone strength at clinically relevant sites displays substantial heterogeneity and is best predicted from site-specific bone densitometry

In this study we test the hypotheses that mechanical bone strength in elderly individuals displays substantial heterogeneity among clinically relevant skeletal sites, that ex situ dual-energy X-ray absorptiometry (DXA) provides better estimates of bone strength than in situ DXA, but that a site-specific approach of bone densitometry is nevertheless superior for optimal prediction of bone failure under in situ conditions. DXA measurements were obtained of the lumbar spine, the left femur, the left radius, and the total body in 110 human cadavers (age, 80.6 +/- 10.5 years; 72 female, 38 male), including the skin and soft tissues. The bones were then excised, spinal and femoral DXA being repeated ex situ. Mechanical failure tests were performed on thoracic vertebra 10 and lumbar vertebra 3 (compressive loading of a functional unit), the left and right femur (side impact and vertical loading configuration), and the left and right distal radius (fall configuration, axial compression, and 3-point-bending). The failure loads displayed only very moderate correlation among sites (r = 0.39 to 0.63). Ex situ DXA displayed slightly higher correlations with failure loads compared with those of in situ DXA, but the differences were not significant and relatively small. Under in situ conditions, DXA predicted 50-60% of the variability in bone failure loads at identical (or closely adjacent) sites, but only around 20-35% at distant sites, advocating a site-specific approach of densitometry. These data suggest that mechanical competence in the elderly is governed by strong regional variation, and that its loss in osteoporosis may not represent a strictly systemic process.

Densitometric diagnosis of osteoporosis in men: effect of measurement site and normative database

Controversy exists regarding which sites to measure, and the appropriate reference database to use, for densitometric diagnosis of osteoporosis in men. While hip and spine bone mineral density (BMD) measurement is routine, spinal osteoarthritis often elevates measured BMD in older men. Additionally, the use of male reference data is standard practice; however, recent reports suggest that a female database may be more appropriate. This study evaluated the effect of sites measured, and normative database utilized, on the densitometric diagnosis of osteoporosis in men. Spine, femur, and ultradistal radial BMD T-scores were determined in 595 male veterans using the GE Lunar male normative database. Subsequently, World Health Organization diagnostic criteria were applied, identifying 282 men with osteoporosis (T-score </= 2.5). The combination of femoral (lowest of neck or total) with the ultradistal radius site was more sensitive (p < 0.0001) for diagnosing osteoporosis than femur plus lumbar spine. When scans from 129 subjects with documented fractures were analyzed using female normative data, fewer (p < 0.0001) met an arbitrary threshold for receiving pharmacologic osteoporosis therapy. In conclusion, BMD measurement at only the spine and hip leads to underdiagnosis of osteoporosis in men. This situation will be exacerbated by utilization of a female normative database; more men with prior fracture may be categorized as not meeting a pharmaceutical intervention threshold.

Bone mineral density testing in healthy postmenopausal women. The role of clinical risk factor assessment in determining fracture risk

The ease of measurement and the quantitative nature of bone mineral densitometry (BMD) is clinically appealing. Despite BMD's proven capability to stratify fracture risk, data indicate that clinical risk factors provide complementary information on fracture susceptibility that is independent of BMD. Methods to quantify fracture risk using both clinical and BMD variables would have great appeal for clinical decision-making. We describe a procedure for quantifying hip fracture risk (5-yr and remaining lifetime) based on (1) the individual's age alone (base model, assuming average clinical risk factors and bone density), (2) incorporation of multiple patient-specific clinical risk factor data in the base model, and (3) incorporation of both patient-specific clinical risk factor data and BMD results.

Instant vertebral assessment: a noninvasive dual X-ray absorptiometry technique to avoid misclassification and clinical mismanagement of osteoporosis

The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.

Postmenopausal osteoporosis: fracture consequences and treatment efficacy vary by skeletal site

At least half of all postmenopausal women will experience fractures during their lifetime, and the consequences are often serious, but most women at risk are not receiving adequate treatment. The objective of this paper is to summarize the literature concerning the consequences of osteoporotic fractures, and the effectiveness of pharmacologic agents for preventing fractures and their consequences, emphasizing a systematic, evidence-based summary of treatment results from randomized, controlled trials that were published previously. Osteoporosis is associated with increased risk of fractures at most skeletal sites. Hip fractures have much greater prognostic significance in terms of health than any other single type of fracture. However, symptomatic vertebral fractures and other non-hip fractures also represent enormous morbidity and economic burdens, and signal increased risk of future fractures of all types, including the hip. There is convincing evidence that two bisphosphonates (alendronate and risedronate) reduce the risk of both spine and non-spine fractures. The evidence for reducing hip fracture risk is greater for alendronate, with a consistent approximately 50% reduction in hip fractures across studies. Alendronate has also been demonstrated to maintain quality of life by reducing outcomes such as hospitalization and bed rest related to back pain. Among other agents, raloxifene reduces the risk of vertebral fractures by approximately 30%; the published evidence for most other agents is inconclusive. Osteoporosis should be regarded as seriously as other important chronic disorders such as hypertension and hyperlipidemia. Postmenopausal patients with a high risk of fractures--such as those with prior fractures or osteoporosis as measured by BMD--need to be treated. Although other therapeutic modalities are available, the evidence is most convincing for the bisphosphonates, alendronate and risedronate.

Vertebral fracture prevalence among women screened for the Fracture Intervention Trial and a simple clinical tool to screen for undiagnosed vertebral fractures. Fracture Intervention Trial Research Group

OBJECTIVE

To evaluate the ability of self-reported risk factors to identify postmenopausal women likely to have extant vertebral fractures because approximately two thirds of women with radiographic evidence of vertebral fracture are unaware of the fracture.

PATIENTS AND METHODS

Questionnaire and spinal radiographic data were collected from postmenopausal women with a femoral neck bone mineral density T score of -1.6 or lower during screening for the Fracture Intervention Trial. Logistic regression was used to identify risk factors for extant vertebral fractures and to derive a final multivariable model.

RESULTS

Almost two thirds of 25,816 women 55 years and older met the bone density criterion, and 21% of those had an extant vertebral fracture. The final model consisted of 5 self-reported items: history of vertebral fracture, history of nonvertebral fracture, age, height loss, and diagnosis of osteoporosis. These were combined to yield a Prevalent Vertebral Fracture Index (PVFI). The prevalence of women with vertebral fracture varied from 3.8% to 62.3% over the range PVFI of 0 to greater than 5. Among the 13,051 women screened with spinal radiographs, a PVFI of 4 or greater identified 65.5% of women with vertebral fractures (sensitivity), with a specificity of 68.6%. Excluding 881 women who reported prior vertebral fractures reduced the sensitivity to 53.6 % and increased the specificity to 70.7% but did not alter the fracture prevalence at PVFI values less than 6.

CONCLUSION

In this population, 5 simple questions identified women who were likely to have undiagnosed vertebral fractures. Further research is needed to determine the validity of this index in other populations, including women without low bone mineral density.

Selection of individuals for prevention of fractures due to bone fragility

Most patients with fractures go untreated because of the lack of awareness of osteoporosis. Treatment is indicated for women and men with osteoporosis and women and men with fractures with either osteoporosis or osteopenia because (a) fractures increase morbidity and mortality, (b) the burden of fractures is increasing because longevity is increasing, and (c) bone loss accelerates, rather than decelerates in old age. The indication for drug therapy is less clear in women or men with osteopenia because drugs have not been proved to reduce fracture risk in this group. There is no evidence that treating individuals with only risk factors reduces the fracture rate. Screening has not been shown to reduce the burden of fractures. Altering the bone mineral density by a few percent in the population is likely to reduce the number of fractures, but how this can be achieved is unknown. The rigorously investigated drugs reducing the spine fracture rate are alendronate, raloxifene and risedronate. Calcium and vitamin D reduce hip fractures in nursing home residents but not community-dwellers. In the community, only alendronate and risedronate have been reported to reduce hip fractures in randomized trials. The evidence for hormone replacement therapy is less satisfactory. It is likely to reduce the number of spinal fractures, but its role in hip fracture prevention is uncertain. Only alendronate has been reported to reduce spine fractures in men with osteoporosis. Evidence for the use of other drugs (calcitonin, fluoride, anabolic steroids and active vitamin D metabolites) in women or men is insufficient to justify their use.

Change in bone mass after Colles' fracture: a case report on unique data collection and long-term implications

The cast immobilization of a fractured limb results in a loss of bone mass; however, the long-term implications of that effect with regard to bone mineral status, particularly in other skeletal sites, are less known. The purpose of this study was to describe changes in bone mass in different skeletal sites triggered by Colles' fracture. The case is unique regarding the existence of baseline measurements taken just a few days before the fracture on all measurable skeletal sites, including the fractured radius. Therefore, it was also possible to determine whether the injury caused long-term bone loss in the affected and unaffected skeletal sites. The patient was a healthy, premenopausal Caucasian woman, in her late forties, who fractured her nondominant wrist as a result of low-impact fall on ice. The arm and the metacarpals were immobilized to the elbow for 5 wk. Bone mass measurements were performed with DPX-MD densitometer (Lunar Corp. Madison, WI) at baseline and 5, 10, 13, 21, and 52 wk postinjury. At the 5-wk measurement (on plaster removal) there was a notable increase in bone mineral density (BMD) and bone mineral content (BMC) in all sites of ulna and radius of the injured forearm (from 10 to 73%), followed by the apparent decline to or below the baseline at 10, 13, 21 and 52 wk of follow-up. Other skeletal sites were measured at 10 wk when a substantial decrease in BMD and BMC in some of the hip regions and lumbar spine was noticed; most notably in L3-L4, Ward's triangle, and femoral neck (from 2 to 8%) and remained such after 1 yr. Although this patient had a normal bone mineral status and no osteopenia detected before fracture, the trauma of radial fracture caused long-standing bone loss in fracture-prone areas-hip and spine. Because about 70% of bone strength is explained by its mineral density, the patient might be at increased risk for fracture later in life. The changes in bone mass after injury should be monitored and interpreted carefully, and more elaborate treatment of patients presenting with wrist fractures are needed to prevent any potential risk for later osteoporotic fractures in spine and hip and possible refracture of the injured extremity.