Trends in fracture incidence: a population-based study over 20 years

Global, regional, and national burden of vertebral fractures due to falls from 1990 to 2021 and predictions for the next 15 years: A systematic analysis of the global burden of disease 2021 study

OBJECTIVES

This study utilized the latest data from the 2021 Global Burden of Disease Study to analyze the incidence, prevalence, and years lived with disability due to vertebral fractures from 1990 to 2021, providing information for effective management and prevention strategies.

METHODS

This study describes the trends in incidence, prevalence, and years lived with disability (YLDs) due to vertebral fractures caused by falls. It employs methods such as the Age-Period-Cohort (APC) model, joinpoint regression analysis, and decomposition analysis for further investigation, and calculates the ASIR, ASPR, and ASYR. Finally, it predicts the incidence trend for the next 15 years using the Autoregressive Integrated Moving Average (ARIMA) model.

RESULTS

In 2021, the number of new cases of vertebral fractures due to falls globally reached 4.7 million, with a total prevalence of 3.67 million cases, and years lived with disability (YLDs) amounted to 370,000. Compared to 1990, the estimated annual percentage change (EAPC) was -0.37 (-0.41, -0.32), -0.35 (-0.39, -0.31), and -0.37 (-0.41, -0.33) respectively, indicating a declining trend. There are significant differences in the disease burden among different countries and regions. The APC model, Joinpoint model, and ARIMA forecasting model indicate a global declining trend in the disease burden of vertebral fractures.

CONCLUSIONS

Although the burden of vertebral fractures is on a downward trend, it continues to increase in low and middle SDI regions, as well as among the elderly population. Therefore, targeted preventive measures are still necessary to address the health outcomes related to vertebral fractures.

Associations of preoperative hematocrit and platelet count with morbidity after pathologic fracture fixation

Background

Anemia and abnormal platelet count are common among patients with cancer and are associated with complications after orthopaedic procedures. We studied associations between these conditions and morbidity within 30 days after surgery for pathologic femur or humerus fracture.

Methods

We retrospectively reviewed data from the National Surgery Quality Improvement Project database for 145,030 adults following surgical fixation of a pathologic femur or humerus fracture from 2010 to 2020. Multivariable logistic regressions compared 30-day complications between patients with mild or severe anemia versus those with normal hematocrit and between patients with thrombocytopenia or thrombocytosis versus those with normal platelet count.

Results

Likelihood of extended hospitalization (≥6 days) was higher in patients with mild anemia (odds ratio [OR]: 1.47; 95 % confidence interval [CI]: 1.44, 1.51) and severe anemia (OR: 2.14; 95 % CI: 2.06, 2.23). Likelihood of all-cause morbidity was also higher among those with mild anemia (OR: 1.17; 95 % CI: 1.13, 1.21) and severe anemia (OR: 1.35; 95 % CI: 1.28, 1.42). Similarly, likelihood of extended hospitalization was higher in patients with thrombocytopenia (OR: 1.25; 95 % CI: 1.22, 1.29) and thrombocytosis (OR: 1.24; 95 % CI: 1.13, 1.36). Likelihood of all-cause morbidity was also higher for those with thrombocytopenia (OR: 1.12; 95 % CI: 1.07, 1.16) and thrombocytosis (OR: 1.21; 95 % CI: 1.07, 1.37).

Conclusion

Preoperative anemia and platelet abnormalities were potentially modifiable risk factors associated with postoperative complications following surgery for pathologic fracture.

Bioenergetic programs of cancellous and cortical bone are distinct and differ with age and mechanical loading

Mechanical loading induces bone formation in young rodents, but mechanoresponsiveness is reduced with age. Glycolytic activity and mitochondrial dysfunction increase with age and may change bone mechanotransduction. To evaluate load-induced changes to bioenergetic activity in young and adult animals, we loaded the tibia of 10-wk and 26-wk female C57BL/6J mice and examined transcriptomic responses at the mid-diaphysis, and metaphyseal cortical shell and cancellous core. Across all biological processes, oxidative phosphorylation and mitochondrial pathways were most often enriched with loading and had contrasting enrichment in young and adult animals. Following loading, young animals had temporally-coordinated differential expression of mitochondrial-associated genes, with greatest expression at the mid-diaphysis. In adults, bioenergetic gene expression was lower compared to young animals. To assess individual contributions of glycolysis and pyruvate-mediated oxidative phosphorylation to load-induced bone formation in vivo, we inhibited each pathway therapeutically and loaded the tibia of young and adult female mice for 2 weeks. In both young and adult mice, loading increased cortical bone mass, but inhibition of oxidative phosphorylation reduced cortical area and moment of inertia in both loaded and control limbs. Conversely, load-induced improvements of adult cancellous bone depended on glycolysis. In summary, mechanical loading transcriptionally activated mitochondrial pathways in an age-specific manner and bioenergetic inhibition revealed unique metabolic programs for cortical and cancellous bone.

The Use of Percutaneous Stent-Kyphoplasty (SpineJack®) in Osteoporotic and Non-Osteoporotic Vertebral Fractures: A Retrospective Analysis of 310 Implants From a Level-1 Trauma Center in Switzerland

Study DesignRetrospective cohort study.ObjectivesThe SpineJack®-system represents a new generation of kyphoplasty for the treatment of traumatic and osteoporotic fractures. The aim of this study was to analyze the usage, safety and efficacy of the SpineJack®-system, in both osteoporotic and non-osteoporotic fractures.Methods310 patients with vertebral fractures treated with the SpineJack®-system between November 2014 and December 2022 were analyzed. Demographics, intraoperative parameters and outcomes were assessed. A subgroup analysis was performed for traumatic vertebral fractures (tVCFs) and osteoporotic vertebral fractures (oVCFs).ResultsSpineJack®-kyphoplasty was performed for 157 (47.4%) oVCFs and 153 (46.2%) tVCFs. Stand-alone SpineJack®-kyphoplasty was performed in 128 patients, while 182 patients underwent combined procedures. The mean pain reduction from admission to discharge was 3.8 (range 3-10, SD 2.7). Opioids were administered for an average of 4.6 days (range 0-72 days, SD 7.2 days). The overall mean hospital length of stay was 6.1 days, significantly shorter for patients undergoing stand-alone SpineJack® procedures at 4.8 days (SD 6.9 days). The most common complication observed was cement extravasation in 29 patients (8.8%), followed by neurological symptoms in 8 patients (2.4%) and surgical site infections in 4 patients (1.2%). Notably, no surgical site infections were recorded in the stand-alone SpineJack®-group.ConclusionPercutaneous stent-kyphoplasty (SpineJack®-system) appears to be a safe and effective therapeutic option, whether used as a stand-alone procedure or in combination with other interventions, for osteoporotic and non-osteoporotic vertebral fractures.

Evaluation of causal links of gut microbiota and inflammatory cytokines with 10 fracture locations: A Mendelian randomization study

Recent investigations have revealed an association of variations in gut microbiota (GM) composition and inflammatory cytokine (IC) levels with fracture risk; however, the causal relationship of GM or inflammatory factors with fracture risk remains unelucidated. The study utilized Mendelian randomization (MR) analyses, utilizing aggregated data from the genome-wide association study of GM, ICs, and 10 fracture locations. The primary aim was to examine the causal associations between GM, ICs, and 10 fracture locations. Furthermore, mediational analyses and multivariate MR were conducted to explore the potential mediating role of ICs in this relationship. MR analysis identified 35 positive and 53 negative causal associations between GM and 10 fracture locations. ICs showed 22 positive and 24 negative correlations with 10 fracture locations. However, after false discovery rate correction, most associations lost significance, leaving only 1 IC significant for foot fractures. Moreover, our findings suggest that the ICs may be act as a mediating factor in the pathway from GM to 10 fracture locations. GM and ICs exhibited a significant causal relationship with the 10 fracture locations; furthermore, ICs may function as mediators in the pathway from GM to fracture risk.

Uncemented versus cemented humeral fixation during reverse total shoulder arthroplasty for proximal humerus fracture

Introduction

Over time, the use of reverse total shoulder arthroplasty (RTSA) treating proximal humerus fractures (PHFs) and fracture sequelae has grown significantly due to its demonstrated effectiveness over open reduction internal fixation (ORIF) and hemiarthroplasty (HA). Cemented humeral stems have been widely utilized in RTSA for PHF, however cementless alternatives have become increasingly popular. This study seeks to analyze outcomes and complications in patients undergoing RTSA for fracture with uncemented and cemented stems at mid-term follow-up.

Methods

Patient records were queried for all patients who underwent reverse total shoulder arthroplasty for fracture with between January 7, 2009 and January 10, 2019 and completed a minimum follow-up of 2 years. Demographics characteristics, post-operative functional measurements, complications, and radiographs were assessed. A 5-year Kaplan-Meier survival analysis was performed.

Results

A total of 23 patients encompassing 11 cemented and 12 uncemented stems met the inclusion criteria. The mean age of the uncemented cohort was 70.0 ± 9.8 years with a mean follow-up of 2.6 ± 1.3 years while the mean age of the cemented cohort was 68.9 ± 9.2 years with a mean follow-up of 2.9 ± 1.1 years. No differences in strength, range of motion, or survival between groups were observed. Two patients in the cemented cohort demonstrated humeral component loosening on follow-up radiographs.

Discussion

Uncemented and cemented humeral fixation during RTSA for proximal humerus fracture leads to similar outcomes, and thus both are safe and effective methods of achieving humeral fixation in fracture patients.

Excess subsequent fracture and mortality risk after ankle fractures: a relative survival analysis of the 45 and Up Study

Ankle fractures are one of the common fractures that account for hospitalization. Ankle fractures were often thought of inconsequential as limited data on their long-term consequences. After accounting for age, sex, and time, ankle fractures were associated with increased risk of subsequent fracture and mortality.

BACKGROUND

Ankle fractures are common but it is uncertain whether they are indicative of poor bone health. There are limited data about subsequent fracture and mortality risk following ankle fractures.

OBJECTIVE

To determine if there is increased subsequent fracture and mortality risk after ankle fractures.

METHODS

A prospective population-based cohort of 143,070 women and 123,818 men in the 45 and Up Study (NSW, Australia) had baseline questionnaire responses that were linked to Emergency Department Data Collection (EDDC), the Admitted Patient Data Collection (APDC), and the NSW Registry of Births Deaths & Marriages death registrations from 2006 to 2017. Secure data access was provided through the Sax Institute's Secure Unified Research Environment (SURE). Sex-specific excess risks of subsequent fracture and mortality following ankle fractures were quantified using relative survival analysis.

RESULTS

During 1,490,651 person-years, women and men experienced 1379 and 579 ankle fractures and 78 deaths and 76 deaths, respectively. Ankle fractures were associated with a 5-year 5% (95% CI 3-8%) excess risk of subsequent fracture in both women and men, compared to subjects' risk of an incident fracture in the study. There was a 5-year cumulative excess mortality of 10% (95% CI 6-13%) following ankle fractures in men but no excess mortality in women compared to the overall cohort. Participants with ankle fractures who died were older (P < 0.001), more likely to have had a second fracture (P < 0.001), have had a prior fracture (P < 0.001), and have more comorbidities (P < 0.001).

CONCLUSION

In the 45 and Up cohort, there was a modest but significant increased risk of fracture following ankle fracture seen in both women and men. In men, but not women, ankle fractures were associated with 10% excess mortality. Ankle fractures should be considered for secondary fracture prevention in those who are older and have more comorbidities.

Fractures in Hereditary Neuromuscular Disorders: Frequency, Risk Factors, and Implications

BACKGROUND

Hereditary neuromuscular disorders (NMD) are associated with compromised bone health and elevated fracture risk, though data are largely lacking.

OBJECTIVE

This study aimed to assess the prevalence and risk factors of fractures in hereditary NMD.

METHODS

We conducted a retrospective study in a cohort of adult patients with diverse hereditary NMD, using data from electronic medical records.

RESULTS

Among 469 patients, 505 fractures were recorded, with 5.5% of patients experiencing a fracture within the past year. In the 10 years preceding study inclusion, 31.1% of all patients sustained at least one fracture. The fracture rate was 47.3/1000 patient-years. Fracture incidence was highest in the second decade of life and the first five years after symptom onset. Fracture recurrence occurred in 25.6% over the next two years. Fractures were most prevalent in patients with Duchenne muscular dystrophy, myotonic dystrophy type 1/2, and spinal muscular atrophy. Patients with Vignos scale 5-6 had the highest fracture risk. Major osteoporotic fractures accounted for 28.6%, and 71.3% were caused by low-energy trauma. Long-term complications of a fracture were present in 44.2%, with 9.0% losing ambulation. Osteoporosis was confirmed in 47.5% of DXA scans. In patients with a normal DXA scan, 66.7% experienced a subsequent fracture. Hip T-scores declined with increasing Vignos scale (r = -0.27, p = 0.001). Fracture risk factors included glucocorticoid use, alcohol abuse, recent falls, and previous emergency visits for falls (all p < 0.05).

CONCLUSION

This cohort exhibited a high prevalence of fractures and osteoporosis, emphasizing the need for regular bone health assessment and fracture prevention in hereditary NMD patients.

Accelerated bone loss in late reproductive-aged and perimenopausal women with vitamin D insufficiency

INTRODUCTION

The association between serum vitamin D levels and bone mineral density (BMD) varies by race and gender. This study aimed to evaluate this relationship between serum vitamin D levels and BMD, and changes of BMD over time in Korean women.

MATERIALS AND METHODS

We analyzed data from 586 generally healthy Korean women aged 29-79 who underwent health check-ups at Seoul National University Gangnam Center between 2010 and 2011 (baseline measurement) and 2015-2016 (follow-up). Dual energy X-ray absorptiometry (DEXA) and serum 25-hydroxyvitamin D (25OH-D) level measurements were conducted. We assessed the association between serum 25OH-D levels and BMD, as well as changes in BMD over time.

RESULTS

The mean age of participants was 51.3 ± 7.9 years, with a mean follow-up interval of 4.6 ± 0.7 years, and mean serum 25OH-D level of 20.6 ± 8.5 ng/ml. Baseline serum 25OH-D levels did not correlate with BMD values at the lumbar spine, femoral neck, or total femur, nor with changes in BMD over time. A significant negative association was found between perimenopausal status and BMD changes at all sites, and between premenopausal status and lumbar bone mass, compared to postmenopausal status in the 25OH-D < 20 ng/ml group. This association was not observed in women with higher serum 25OH-D levels.

CONCLUSIONS

Serum 25OH-D levels did not correlate with BMD levels or changes in BMD overall. However, in late reproductive-aged and perimenopausal women with serum 25OH-D insufficiency, there was a significant association with accelerated bone loss.

Hypoalbuminemia increases risks for complications after surgical repair of nonunions and malunions

OBJECTIVE

The purpose of this study was to determine the association of hypoalbuminemia with adverse outcomes in patients undergoing surgical repair of nonunions or malunions of upper and lower extremity long bones.

METHODS

DESIGN: Retrospective.

SETTING

Hospitals participating in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005 to 2019.

PATIENTS

Patients in the ACS-NSQIP database with upper extremity and lower extremity fractures who underwent nonunion or malunion repairs and had preoperative serum albumin levels. Outcome Measures and Comparisons: Demographic variables, comorbidities and postoperative complications were collected and compared using t tests and chi squared tests. Multivariate linear regression models were used to assess complications, adjusting for variables such as age, sex, BMI, hospital length of stay, and operation time.

RESULTS

Univariate analysis of 1640 total patients (338 [20.6%] with hypoalbuminemia and 1302 [79.4%] with normal albumin) showed patients with hypoalbuminemia had significantly increased 30-day mortality rates, increased lengths of stay, and returns to the operating room. Multivariate analysis showed patients with hypoalbuminemia had significantly greater odds for any complication (OR: 2.62; 95% CI [1.77, 3.84]; p < 0.001), surgical site infections (OR: 2.62; 95% CI [1.34, 4.99]; p = 0.004) and transfusions (OR: 2.77; 95% CI: [1.62, 4.69]; p < 0.001) compared to the normal albumin group.

CONCLUSIONS

There was a significant difference in 30-day postoperative complications between patients with normal albumin levels and those who were hypoalbuminemic after surgical repairs of nonunions or malunions. Albumin level is a risk factor that should be monitored and counseled upon prior to surgical intervention for nonunion or malunion correction.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

Hydrogels in Oral Disease Management: A Review of Innovations in Drug Delivery and Tissue Regeneration

The oral cavity is an open and complicated structure with a variety of factors affecting topical oral medications. The complicated physical and chemical surroundings of the oral cavity can influence the action of free drugs. Thus, the drug delivery system can serve as a support structure or carrier. Hydrogels are prospective tissue engineering biomaterials that demonstrate immense potential for oral tissue regeneration and drug delivery. Hydrogels are crosslinked polymer chains with a 3-dimensional network structure that can take up larger volumes of liquid and have a soft, porous structure that closely resembles living tissue. Hydrogels protect the active drug from systemic and topical elimination, increase the bioavailability and absorption into cells, and release or modify the therapeutic drug release immediately after dosing. In this review, we introduce the classification of hydrogels, introduce the application of hydrogels in oral diseases (periodontal disease, endodontics, oral mucosal disease, alveolar surgery, oral cancer, maxillofacial bone defects, and oral implantation), summarize the synthesis methods and the applications of hydrogels, and discuss the possible directions of the future development of hydrogels, which will provide a new idea for the formulation and production of a more advantageous and efficient topical oral drug delivery system.

Personalised 3D-printed bioactive peek bone plate scaffold for treating femoral defects

Fractures affect millions of individuals worldwide, particularly those with osteoporosis, and often require rigid fixation for proper healing. Although traditional metal bone plates are effective, they are limited by their stiffness and inability to conform precisely to anatomical structures, leading to complications such as stress shielding and delayed healing. In this study, we utilized computer-aided design (CAD) combined with reverse engineering to develop a 3D bone plate scaffold model that perfectly matches the contours of the rabbit femur. Additionally, we employed fused deposition modeling (FDM) 3D printing to fabricate a customized polyetheretherketone (PEEK) bone plate scaffold based on the model, designed to match individual bone structures and reduce rigidity-related issues. To enhance the bioactivity of the PEEK scaffold surface, we applied plasma spraying technology to coat it with bioactive materials, including nanohydroxyapatite (HA), tantalum (Ta), and titanium (Ti). The results showed that the HA coating contained 48.06% calcium (Ca) and 16.47% phosphorus (P) and the Ti coating contained 82.32% Ti. In vitro studies showed that the bioactive scaffold effectively promoted the proliferation and differentiation of osteogenic mesenchymal stem cells, with a cell survival rate greater than 93.86%. Moreover, in vivo results from the rabbit femoral defect model showed that the bioactive scaffolds significantly accelerated bone tissue healing, with HA-coated PEEK scaffolds exhibiting exceptional bone regeneration potential. This study proposes a comprehensive strategy for customizing bone plate scaffolds, which holds significant promise for personalized precision medicine.

The Impact of Diabetes on Outcomes for Tibiotalocalcaneal Arthrodesis: A Systematic Review of Available Comparative Studies

Background/Objectives: Tibiotalocalcaneal (TTC) arthrodesis is commonly used in salvage situations involving the ankle and subtalar joint, often in patients with concomitant diabetes mellitus (DM). Across orthopedics, DM presents an overall increased risk of developing complications post-surgically. In this systematic review, the primary aim was to summarize the outcomes and complications of patients undergoing TTC arthrodesis with DM. Methods: A qualitative systematic review was conducted, with an initial search performed on 30 August 2023, using PubMed, SPORTDiscus, CINAHL, and MEDLINE. The search algorithm "tibiotalocalcaneal" AND (nail OR nails) AND (fusion OR arthrodesis) was applied, following PRISMA guidelines. Inclusion criteria encompassed articles examining the impact of diabetes on TTC arthrodesis outcomes. Data extraction involved patient demographics, complication rates, and surgical outcomes. Due to data heterogeneity, a narrative approach was utilized to describe results across studies. Results: Four articles met the inclusion criteria. These observational comparative studies were of moderate quality, with a mean MINORS score of 20.5 ± 1.9 points. The combined patient cohort included 162 patients, evenly split between diabetic and non-diabetic groups, with a mean age of 58.2 ± 2.7 years and a follow-up duration of 35.0 ± 7.4 months. Diabetic patients exhibited higher rates of superficial infection, though functional outcomes and fusion rates were generally favorable. Conclusions: TTC arthrodesis in diabetic patients was associated with an increased risk of superficial infections and various other complications. Despite these risks, functional outcomes and rates of successful fusion were comparable to non-diabetic patients undergoing TTC arthrodesis. This review highlights the need for standardized definitions of surgical success.

Twenty-Year Trends in Osteoporosis Treatment and Post-Fracture Care in South Korea: A Nationwide Study

BACKGROUND

Osteoporosis is a significant public health issue in aging populations. Despite advances in pharmacotherapy, underdiagnosis and undertreatment remain prevalent even in patients with recent fractures. This study examined 20-year trends (2002- 2022) in anti-osteoporotic medication (AOM) usage in South Korea.

METHODS

Data from the Korean National Health Information Database were retrospectively analyzed. The study included individuals aged ≥50 years and analyzed prescription trends, medication adherence, measured by the medication possession ratio (MPR), and treatment initiation rates post-fracture. The AOMs examined included bisphosphonates, selective estrogen receptor modulators, denosumab (DMAB), teriparatide (TPTD), and romosozumab (ROMO).

RESULTS

Over two decades, AOM use has shifted significantly from oral to injectable formulations, with injectables surpassing oral medications in 2020; from 397,440 prescriptions in 2016 to 1,162,779 in 2022. Prescriptions for DMAB surged following its approval as a first-line therapy in 2019, increasing 2.65 times from 217,606 in 2019 to 575,595 in 2022. The MPR improved from 35.4% in 2003 to 73.2% in 2021, with females demonstrating higher adherence than males. Post-fracture treatment rates increased from 31.1% in 2006 to 39.9% in 2021 but remained below 50%. Vertebral fractures had the highest treatment initiation rates, while anabolic agents, such as TPTD and ROMO were underprescribed despite their efficacy.

CONCLUSIONS

This 20-year analysis highlights significant progress in osteoporosis management in South Korea, including a shift towards injectable therapies and improved adherence. However, the persistent undertreatment of high-risk patients underscores the requirement for enhanced access to anabolic agents, clinician education, and policy reforms to optimize post-fracture care.

Updates in non-neoplastic orthopaedic pathology: what you don't know can hurt you!

Even though the average surgical pathologist reviews far more non-neoplastic orthopaedic pathology on a daily basis, most current research focuses on rare tumours and their even less frequent molecular events. Our experiences among consults and focused conferences strongly suggest that there remains a practice gap regarding knowledge and diagnosing specific non-neoplastic orthopaedic conditions. One of the most frequent intraoperative consultations performed in the USA, among both academic and private institutions, relates to revision arthroplasty and the determination of infection in periprosthetic joints. Pathologists play a critical role in this algorithm, helping determine intraoperatively whether patients require antibiotic spacers prior to reimplantation. Many pathology departments have abandoned the examination of arthroplasty specimens because they (and their surgeons) mistakenly believe there is little clinically relevant information to be gained by thorough pathological examination. However, recent literature has challenged this concept, emphasising the importance of distinguishing avascular necrosis (from osteoarthritis/degenerative joint disease with secondary osteonecrosis), subchondral insufficiency fracture, septic arthritis (from so-called 'sterile' osteomyelitis/pseudoabscesses), underlying crystalline diseases and incidental/occult neoplasia. Histological evaluation of historically insignificant orthopaedic specimens, such as tenosynovium from carpal tunnel syndrome/trigger finger, is now seen as valuable in early diagnosis of cardiac amyloidosis. Not infrequently, orthopaedic conditions like haemosiderotic synovitis, osteocartilaginous loose bodies or rheumatoid nodules, may histologically mimic bona fide neoplasms, notably diffuse tenosynovial giant cell tumour, synovial chondromatosis and epithelioid sarcoma, respectively. Here is a review of the more common non-neoplastic orthopaedic conditions, those likely to be examined by the practising surgical pathologist, with updates and guidelines for establishing clinically relevant diagnoses.

First fracture in rheumatoid arthritis: analysis by fracture site, gender, age, and comorbidities

Rheumatoid arthritis (RA) is a potentially devastating disorder associated with increased risk of fractures, but current studies do not completely evaluate the RA fracture risk profile. This study estimates fracture incidence by site of fracture and makes comparisons between RA and controls using the key variables gender, age, and comorbidities.

BACKGROUND

Rheumatoid arthritis RA is a potentially devastating osteoimmunological disorder, predisposing to osteoporosis (OP), fragility fracture (FF), and major osteoporotic fractures (MOF). As few studies incorporate statistical matching, comorbidity and non-MOF sites, we compared the incidence of first FF, MOF, and non-MOF in RA patients with a matched control cohort adjusting for comorbidities.

METHODS

This longitudinal cohort study uses routinely collected administrative data from the West Australian Rheumatic Disease Epidemiological Registry (WARDER) between 1980 and 2015. RA patients, as defined using International Classification of Disease (ICD) codes, were compared to hospitalised patients free of rheumatic disease. Case-control matching adjusted for age, gender, and comorbidities (Charlson Comorbidity Index). Incidence rates (IR) per 1000 person years (PY) with 95% confidence intervals (CI) were compared by incidence rate ratios (IRR).

FINDINGS

In RA patients from 2000 to 2010, the first fracture IR was 18.3 (15.7-21.2) for an IRR of 1.32 (1.10-1.60). Upper limb, lower limb, and axial IR were 5.56 (95% CI 4.18-7.26), 10.60 (95% CI 8.66-12.87), and 2.47 (95% CI 2.58-3.68) with IRR of 1.18 (95% CI 0.84-1.65), 1.44 (95% CI 1.19-1.86), and 1.01 (95% CI 0.61-1.63) respectively. The first fracture IR increased 6 years before first RA hospital record (RR 1.58, CI 1.05-2.39).

CONCLUSIONS

After age, gender, and comorbidity adjustment, RA is associated with a 32% higher incidence of first fracture, increased MOF, and a fracture incidence that is already increased before a first recorded RA diagnosis. This suggests a need for early attention to prevention of all fractures in RA patients.

Comparative study between unilateral and bilateral extrapedicular approaches for osteoporotic vertebral compression fractures: A retrospective study

OBJECTIVE

Percutaneous vertebroplasty (PVP) is a primary treatment for osteoporotic vertebral compression fractures (OVCF). Historically, surgeons preferred a bilateral approach for PVP; however, this approach may impose greater financial strain on patients. This retrospective study examines the efficacy of the unilateral approach compared to the bilateral approach.

METHODS

A total of193 patients were categorized into Group A (unilaterally extrapedicular approach) and Group B (bilateral approach) based on the operative method. Efficacy was evaluated using perioperative indicators, follow-up results, and imaging evaluation results.

RESULTS

Out of the 193 patients involved, 169 were eligible for analysis. All patients completed follow-up visits lasting 49-70 months. Compared to Group B, Group A exhibited significantly shorter operation time, puncture duration, amount of bone cement injected, and number of X-ray fluoroscopies (P < 0.05). While initial pain reduction, as measured by the visual analog scale and Oswestry Disability Index scores, was lower in Group A, the difference between the groups narrowed by the final follow-up. At the final imaging follow-up, no statistically significant differences were observed between the two groups regarding the relative height of the injured vertebral bodies and local Cobb angle measurements.

CONCLUSIONS

This technique holds the potential for accelerated patient rehabilitation and reduced hospitalization expenses, presenting a promising treatment option for OVCF patients.

New Challenges: Use and Interpretation of Radius Bone Mineral Density

CONTEXT

It is unknown if isolated low bone mineral density (BMD) "osteoporosis" at the radius is associated with increased fracture risk, not only at the wrist but elsewhere, and whether it reflects more generalized skeletal fragility.

OBJECTIVE

This work aimed to review the association of radius BMD and fracture risk, the epidemiology of wrist fractures, isolated osteoporosis at the radius, and the concordance between radial BMD and femoral neck BMD.

METHODS

We completed a narrative literature review on radius BMD and fracture risk and current recommendations for measurement of radial BMD. We updated results of radial BMD and fracture results from the Study of Osteoporotic Fractures over 20 years and examined the concordance of BMD at the distal and proximal radius with femoral neck BMD T scores.

RESULTS

Radius BMD is a robust predictor of all types of fractures including hip and wrist but there is insufficient evidence to suggest that radius BMD predicts wrist fractures better than fractures at other sites. Fractures of the wrist tend to occur in younger, healthier women compared with hip and spine fractures. Nevertheless, wrist fractures are associated with an increased risk of future fractures and represent a missed opportunity for intervention. On a population level, the discordance between radius BMD and femoral neck BMD is small. But women with isolated osteoporosis at the radius had biochemical and microarchitecture deterioration that were similar to women with hip osteoporosis.

CONCLUSION

Future research should address the clinical implications of isolated osteoporosis at the radius and whether treatment is warranted.

Patella fractures are associated with bone fragility - a retrospective study

Patella fractures are not typically considered osteoporotic fractures. We compared bone mineral density (BMD) and microstructure in elderly women from a multiethnic population-based study in New York City with any history of a patella fracture (n = 27) to those without historical fracture (n = 384) and those with an adult fragility forearm fracture (n = 28) using dual energy x-ray absorptiometry (DXA) and high resolution peripheral quantitative computed tomography (HR-pQCT). Compared to those without fracture, women with patella fracture had 6.5% lower areal BMD (aBMD) by DXA only at the total hip (p=.007), while women with forearm fracture had lower aBMD at multiple sites and lower trabecular bone score (TBS), adjusted for age, body mass index, race and ethnicity (all p<.05). By HR-pQCT, adjusted radial total and trabecular (Tb) volumetric BMD (vBMD) and Tb number were 10%-24% lower while Tb spacing was 12-23% higher (all p<.05) in the fracture groups versus women without fracture. Women with a forearm, but not a patella, fracture also had lower adjusted radial cortical (Ct) area and vBMD and 21.8% (p<.0001) lower stiffness vs. women without fracture. At the tibia, the fracture groups had 9.3%-15.7% lower total and Tb vBMD (all p<.05) compared to the non-fracture group. Women with a forearm fracture also had 10.9, and 14.7% lower tibial Ct area and thickness versus those without fracture. Compared to women without fracture, tibial stiffness was 9.9% and 12% lower in the patella and forearm fracture groups, respectively (all p<.05). By HR-pQCT, the patella vs. forearm fracture group had 36% higher radial Tb heterogeneity (p<.05). In summary, women with patella fracture had Tb deterioration by HR-pQCT associated with lower tibial mechanical competence that was similar to those with fragility forearm fracture, a more universally accepted "osteoporotic" fracture. These data suggest patella fractures are associated with skeletal fragility and warrant skeletal evaluation.

Amorphous Calcium Carbonate Enhances Fracture Healing in a Rat Fracture Model

Background: Delayed and failed fracture repair and bone healing remain significant public health issues. Dietary supplements serve as a safe, inexpensive, and non-surgical means to aid in different stages of fracture repair. Studies have shown that amorphous calcium carbonate (ACC) is absorbed 2 to 4.6 times more than crystalline calcium carbonate in humans. Objectives: In the present study, we assessed the efficacy of ACC on femoral fracture healing in a male Wistar rat model. Methods: Eighty male Wistar rats were randomly divided into five groups (n = six per group): sham, fracture + water, fracture + 0.5× (206 mg/kg) ACC, fracture + 1× ACC (412 mg/kg), and fracture + 1.5× (618 mg/kg) ACC, where ACC refers to the equivalent supplemental dose of ACC for humans. A 21-gauge needle was placed in the left femoral shaft, and we then waited for three weeks. After three weeks, the sham group of rats was left without fractures, while the remaining animals had their left mid-femur fractured with an impactor, followed by treatment with different doses of oral ACC for three weeks. Weight-bearing capacity, microcomputed tomography, and serum biomarkers were evaluated weekly. After three weeks, the rats were sacrificed, and their femur bones were isolated to conduct an evaluation of biomechanical strength and histological analysis. Results: Weight-bearing tests showed that treatment with ACC at all the tested doses led to a significant increase in weight-bearing capacity compared to the controls. In addition, microcomputed tomography and histological studies revealed that ACC treatment improved callus formation dose-dependently. Moreover, biomechanical strength was improved in a dose-dependent fashion in ACC-treated rats compared to the controls. In addition, supplementation with ACC significantly lowered bone formation and resorption marker levels two-three weeks post-fracture induction, indicating accelerated fracture recovery. Conclusions: Our preliminary data demonstrate that ACC supplementation improves fracture healing, with ACC-supplemented rats healing in a shorter time than control rats.

Osteoporosis incidence and its associated factors in the older Korean population: findings from a population-based cohort study

In South Korea, osteoporosis incidence among the elderly was unclear. Our study revealed an incidence of 18.4 per 1000 person-years, with higher rates in females and those with lower education. The findings indicate a need for targeted prevention strategies to guide health policy for improved osteoporosis care for the elderly.

BACKGROUND

Although osteoporosis significantly affects morbidity and mortality among the older population in South Korea, the incidence of osteoporosis and its associated factors within this demographic group remains unclear.

METHOD

We analyzed data from the Korean National Health Panel Survey, a nationally representative, population-based panel survey covering 2008 to 2018, to compute the incidence of osteoporosis among South Koreans aged 50 and older. Using the stepwise Cox Proportional Hazard model, we then identified and determined the associated factors of osteoporosis.

RESULT

Out of the 7304 study participants in our analysis, we identified 792 osteoporosis events, resulting in an overall cumulative incidence rate of 18.4 per 1000 person-years. The incidence of osteoporosis increased steadily with age and was higher among those with lower levels of education. We also found that female study participants were at a statistically significant 7.2-fold higher risk (aHR = 7.2, 95% CI = 5.8-8.8) of developing osteoporosis compared to males. At the same time, those with hyperlipidemia had a statistically significant 1.3-fold increased risk (aHR = 1.3, 95% CI = 1.1-1.4) of developing osteoporosis.

CONCLUSION

Our study highlights a significant proportion of the older South Korean population developed osteoporosis, especially among those who are older, females, and who have hyperlipidemia. This indicates the pressing need for the government's and healthcare systems' consideration of osteoporosis diagnosis and prevention strategies to ensure the health and well-being of the older South Korean population.

Stress fracture of bone under physiological multiaxial cyclic loading: Activity-based predictive models

While it is known that excessive accumulation of fatigue damage from daily activities contributes to fracture, a model of bone failure under physiologically relevant multiaxial cyclic loading needs to be developed in order to develop effective management strategies for stress or fatigue fractures. The role of strain-induced damage from repetitive loading is a strong candidate for such a model, as cycles of mechanical loading leading to failure can be measured directly. However, this approach has been limited by the restrictions of uniaxial loading models, which often overestimates the fatigue life of bone and suggests that bone will only break well beyond the realistic limits of exercise. To address this gap and develop a physiologically relevant model, our study leverages the power of four commonly used engineering failure criteria as a model for multiaxial loading using a cohort of human tibiae from cadaveric donors (age range 21-85 years old). Four failure criteria (Von Mises, Tsai-Wu, Findley critical plane, and maximum shear strain) were found to be effective in vitro models of tibial fracture when age groups of donors were combined (r2 > 0.84) and stratified (younger: 21-52-years-old versus older: 57-85-years-old) (r2 > 0.83) (p < 0.001). Each failure criterion displayed distinctly lower fatigue curves for the older age group. The maximum shear strain model was used to determine the efficacy of this approach to predict fatigue fractures in humans using published in vivo data from human volunteers. Consistent with in vivo observations in general population, the model demonstrated failure at 5000 to 200,000 loading cycles depending on activities such as jumping, sprinting, and walking, with a 3-fold reduction of fatigue life in older donors. These findings dramatically improve estimates of fatigue life under repetitive loading and demonstrate how age-related changes in bone significantly increase its propensity for fatigue-induced fractures.

Epidemiology of Lumbar Spine Fractures: Twenty-Year Assessment of Nationwide Emergency Department Visit Data

BACKGROUND

Lumbar spine fractures are common injuries associated with substantial morbidity for patients and socioeconomic burden. This study sought to epidemiologically analyze lumbar spine fractures by mechanism of injury and identify temporal trends in patient demographics and disposition, which few studies have previously evaluated.

MATERIALS AND METHODS

A retrospective analysis was done of the US National Electronic Injury Surveillance System (NEISS) database between 2003 and 2022. The sample contained all patients 2 to 101 years old with product-related lumbar fractures presenting to participating institutions' emergency departments. A total of 15,196 unweighted injuries (642,979 weighted injuries) were recorded.

RESULTS

Overall, there was a 20-year incidence rate of 10.14 cases per 100,000 person-years with a 2-fold increase in fracture incidence. Females were more prone to lumbar fracture than males (P=.032). Injuries primarily stemmed from a fall (76.6%). The incidence of lumbar fracture increased most significantly in older patients, with patients 80 years and older showing the greatest annual increase (β=8.771, R2=0.7439, P<.001) and patients 60 to 69 years showing the greatest percent increase with a 3.24-fold increase in incidence. Most (58.9%) of the fractures occurred at home. Females were more often injured at home compared with males (P<.001), who more often sustained lumbar fractures during recreational or athletic activity (P<.001). All patients older than 40 years showed at least a doubling in incidence rate of lumbar fracture between 2003 and 2022.

CONCLUSION

These data demonstrate the pressing need to address poor bone health in the aging population, shown here to have an increasing fracture burden. [Orthopedics. 202x;4x(x):xx-xx.].

Teriparatide in postmenopausal osteoporosis: uncovering novel insights into efficacy and safety compared to other treatments - a systematic review and meta-analysis

Objective

The aim of the study was to evaluate the efficacy and safety of teriparatide compared to other treatments for postmenopausal osteoporosis.

Methods

A review of studies from 2000 to January 2023 analyzed randomized controlled trials on postmenopausal women treated with teriparatide (PTH 1-34), comparing it to placebo or other osteoporosis treatments. The analysis focused on bone mineral density (BMD), bone turnover markers, and clinical outcomes, employing Review Manager 5.4.1 and the RoB 2 tool for bias assessment.

Results

Our analysis of 23 randomized controlled trials (RCTs) found that PTH (134) treatment significantly increased lumbar spine BMD (mean difference (MD) = 0.02, 95% CI: 0.01-0.03) and femoral neck BMD (MD = 0.01, 95% CI: 0.00-0.01). However, there were no significant changes in total hip and radial bone BMD among the 3536 and 2046 participants, respectively. We also found that PTH (1-34) increased P1NP in a larger cohort (n = 1415) when compared to osteocalcin (n = 206). Although the risk of adverse events increased (relative risk (RR) = 1.65, 95% CI: 1.32-2.07), the incidence of fractures decreased significantly (RR = 0.57, 95% CI: 0.45-0.072), with no significant difference observed in mortality rates between treatment and control groups.

Conclusion

Teriparatide improves lumbar spine and femoral neck BMD in postmenopausal women. Particularly notable is the novel finding regarding its effect on radius BMD, an area less explored in previous research. Despite an uptick in adverse events, the marked decrease in fracture incidence confirms its clinical utility for high-risk osteoporosis patients, highlighting the necessity for ongoing investigations into its full skeletal effects.

Evaluation of treatment planning discrepancies: CT versus plain radiographic findings in patients with foot and ankle trauma

This study aimed to compare the findings of plain radiography and computed tomography (CT) of foot and ankle in patients submitted to the emergency department with high-energy foot and ankle trauma, to demonstrate if missing fractures on plain radiographs will significantly alter the treatment plan considered for each patient based on the findings of each imaging modality. We retrospectively observed standard radiological foot and ankle x-rays and CT scans in patients who presented to our center from April 2019 to June 2020 with a history of foot and ankle trauma with either loss of consciousness, a history of high-energy trauma, or clinical presentation disproportionate to plain radiographic findings. We investigated the number of fractures of each bone detected on plain radiographs and CT scans and the treatments based on each modality's findings in patients admitted to our center. Sixty-five out of 163 (39.87%) included in our study had at least one missed fracture on plain radiography that was detected on CT. Thirty-one (19%) patients had normal radiography despite actually having fractures. In 38 (23.31%) patients CT changed the treatment plan decided by our surgeons (P < 0.001). The two imaging modalities had a moderate agreement for detecting foot and ankle fractures overall (κ = 0.432). The failure to detect fractures in patients with high-energy trauma can significantly impact treatment effectiveness. Integrating CT scans into the diagnostic process can lead to changes in treatment planning and ultimately improve patient outcomes. LEVEL OF CLINICAL EVIDENCE: IV.

B7-1 and PlGF-1 are two possible new biomarkers to identify fracture-associated trauma patients at higher risk of developing complications: a cohort study

BACKGROUND

Around 10% of fractures lead to complications. With increasing fracture incidences in recent years, this poses a serious burden on the healthcare system, with increasing costs for treatment. In the present study, we aimed to identify potential 'new' blood markers to predict the development of post-surgical complications in trauma patients following a fracture.

METHODS

A total of 292 trauma patients with a complete three-month follow-up were included in this cohort study. Blood samples were obtained from 244 of these patients. Two complication groups were distinguished based on the Clavien-Dindo (CD) classification: CD grade I and CD grade III groups were compared to the controls (CD 0). The Mann-Whitney U test was used to compare the complication groups to the control group.

RESULTS

Analysis of the patients' data revealed that risk factors are dependent on sex. Both, males and females who developed a CD III complication showed elevated blood levels of B7-1 (p = 0.015 and p = 0.018, respectively) and PlGF-1 (p = 0.009 and p = 0.031, respectively), with B7-1 demonstrating greater sensitivity (B7-1: 0.706 (male) and 0.692 (female), PlGF-1: 0.647 (male) and 0.615 (female)). Further analysis of the questionnaires and medical data revealed the importance of additional risk factors. For males (CD 0: 133; CD I: 12; CD III: 18 patients) alcohol consumption was significantly increased for CD I and CD III compared to control with p = 0.009 and p = 0.007, respectively. For females (CD 0: 107; CD I: 10; CD III: 12 patients) a significantly increased average BMI [kg/m2] from 25.5 to 29.7 with CD III was observed, as well as an elevation from one to three comorbidities (p = 0.003).

CONCLUSIONS

These two potential new blood markers hold promise for predicting complication development in trauma patients. Nevertheless, further studies are necessary to evaluate the diagnostic utility of B7-1 and PlGF-1 in predicting complications in trauma patients and consider sex differences before their possible use as routine clinical screening tools.

Unchanged incidence of major adverse events amidst rising surgical interventions for osteoporotic vertebral fractures, 2015-2021

This study investigated treatment trends and major adverse events in patients hospitalized for osteoporotic vertebral fracture (OVF). The frequency of surgical interventions for OVF increased significantly, but this did not decrease major adverse events. The findings underscore the necessity for reevaluating OVF management strategies.

PURPOSE

Osteoporotic vertebral fracture (OVF) is a common condition in the aging population, often leading to increased morbidity and mortality. Here, we analyzed treatment trends and incidence of major adverse events in patients hospitalized for OVF.

METHODS

We conducted a cross-sectional descriptive study, using a large Japanese hospital administrative database. The cohort included hospitalized patients aged 65 years or older, admitted for OVF from January 2015 to December 2021. The primary outcomes were the trend in the proportion of the patients undergoing surgery for OVF and the incidence of major adverse events within 30 days of admission. As a secondary outcome, we evaluated the trend in hospitalization costs.

RESULTS

The study cohort consisted of 14,714 patients, with a mean age of 82.4 years. There was a significant increase in surgical interventions for OVF, from 3.7% of patients in 2015 to 9.8% in 2021 (p < 0.001). The incidence of major adverse events remained unchanged, with a risk ratio of 1.09 (95% confidence interval, 0.88 to 1.35) in 2021 compared to 2015. Average hospitalization costs increased significantly, from $7,570.6 (SD 6,047.0) in 2015 to $9,502.9 (SD 7,231.5) in 2021 (p < 0.001).

CONCLUSION

Despite a significant increase in the proportion of surgical intervention for OVF, no reduction in the risk of major adverse events was observed between 2015 and 2021. Surgeons and policy makers need to interpret these findings and work towards an optimized approach to the management of OVF in the aging population.

Teriparatide alone versus vertebroplasty on pain control and radiographic outcomes after osteoporotic vertebral compression fracture

PURPOSE

To investigate efficacy of 3-month teriparatide(TPD) and compare this treatment with vertebroplasty in terms of clinical and radiographic outcomes after osteoporotic vertebral compression fractures (OVCFs).

METHODS

This is a retrospective matched cohort study. Patients who received conservative treatment with at least 3-month TPD treatment for acute OVCF with at least 6 months follow-up were included. Each enrolled TPD case was matched with 2 vertebroplasty cases using age and gender. 30 TPD cases and 60 vertebroplasty cases were enrolled. Patient-reported pain scores were obtained at diagnosis and 1, 3, 6 months after diagnosis. Radiographic parameters including middle body height, posterior body height, wedge angle and kyphotic angle were measured at diagnosis and 6 months after diagnosis. Fracture non-union and subsequent vertebral fracture were evaluated.

RESULTS

TPD treatment showed inferior pain relief to vertebroplasty group at 1 month, but did not show difference at 3 and 6 months after diagnosis. In TPD cases, progression of vertebral body collapse was noted in terms of middle body height and wedge angle at final follow up. Instead, both middle body height and wedge angle increased significantly after operation in the vertebroplasty group. Fracture non-union was confirmed via MRI and 4 TPD patients were diagnosed with non-union (4/30, 13.3%). Subsequent compression fracture within 6 months was significant higher in vertebroplasty group (12/60, 20%) than in TPD group (1/30, 3.3%).

CONCLUSION

In acute OVCFs, 3-month TPD treatment alone showed comparable pain improvement and less subsequent spine fracture than vertebroplasty.

Bone Fracture Healing under the Intervention of a Stretchable Ultrasound Array

Ultrasound treatment has been recognized as an effective and noninvasive approach to promote fracture healing. However, traditional rigid ultrasound probe is bulky, requiring cumbersome manual operations and inducing unfavorable side effects when functioning, which precludes the wide application of ultrasound in bone fracture healing. Here, we report a stretchable ultrasound array for bone fracture healing, which features high-performance 1-3 piezoelectric composites as transducers, stretchable multilayered serpentine metal films in a bridge-island pattern as electrical interconnects, soft elastomeric membranes as encapsulations, and polydimethylsiloxane (PDMS) with low curing agent ratio as adhesive layers. The resulting ultrasound array offers the benefits of large stretchability for easy skin integration and effective affecting region for simple skin alignment with good electromechanical performance. Experimental investigations of the stretchable ultrasound array on the delayed union model in femoral shafts of rats show that the callus growth is more active in the second week of treatment and the fracture site is completely osseous healed in the sixth week of treatment. Various bone quality indicators (e.g., bone modulus, bone mineral density, bone tissue/total tissue volume, and trabecular bone thickness) could be enhanced with the intervention of a stretchable ultrasound array. Histological and immunohistochemical examinations indicate that ultrasound promotes osteoblast differentiation, bone formation, and remodeling by promoting the expression of osteopontin (OPN) and runt-related transcription factor 2 (RUNX2). This work provides an effective tool for bone fracture healing in a simple and convenient manner and creates engineering opportunities for applying ultrasound in medical applications.

Performance of the Brazilian Fracture Assessment Risk Tool (FRAX) model and the age-dependent intervention thresholds according to National Osteoporosis Guideline Group (NOGG) guidelines on fracture prediction in community-dwelling older adults: the São Paulo Ageing and Health (SPAH) Study

The SPAH study is a population-based prospective cohort of Brazilian community-dwelling elderlies with higher fracture risk than observed in the studies used to construct the Brazilian FRAX model. In this study, the FRAX tool was a good fracture predictor within this high-risk elderly cohort, especially when calculated without bone density.

PURPOSE

To determine the performances of FRAX and age-dependent intervention thresholds according to National Osteoporosis Guideline Group (NOGG) guidelines with and without bone mineral density (BMD) regarding fracture prediction in community-dwelling elderly Brazilians.

METHODS

Seven hundred and five older adults (447 women; 258 men) were followed for 4.3 ± 0.8 years. FRAX risk for hip and major osteoporotic fractures with and without BMD was calculated at baseline. The bivariate analysis investigated the associations between the absolute probability of fracture (FRAX), as well as the age-dependent intervention thresholds (NOGG), and the incidence of vertebral fracture (VF), non-vertebral fracture (NVF), and major osteoporotic fractures (MOF), segregated by sex. Age-adjusted Poisson's multiple regression and ROC curves were constructed to determine FRAX and NOGG's accuracies as fracture predictors.

RESULTS

Fractures occurred in 22% of women and 15% of men. FRAX with and without BMD was higher in women with all types of fractures (p < 0.001). Only NOGG risk classification without BMD was associated with NVF (p = 0.047) and MOF (p = 0.024). FRAX was associated with NVF in the multiple regression, regardless of BMD. ROC curves of FRAX with and without BMD had AUCs of 0.74, 0.64, and 0.61 for NVF, VF, and MOF, respectively. The most accurate risk cutoffs for FRAX were 8% for MOF and 3% for hip fractures. No statistically significant associations were found in men.

CONCLUSION

FRAX predicted NVF more accurately than VF or MOF in elderlies, regardless of BMD. These results reiterate that FRAX may be used without BMD, even considering that Brazilian elderlies have known higher fracture risk.

Effects of tetrahedral DNA nanostructures on the treatment of osteoporosis

Osteoporosis (OP) is a common disease characterized by bone loss and bone tissue microstructure degradation. Drug treatment is a common clinical treatment that aims to increase bone mass and bone density. Tetrahedral DNA nanostructures (TDNs) are three-dimensional tetrahedral frames formed by folding four single-stranded DNA molecules, which have good biological safety and can promote bone regeneration. In this study, a mouse model of OP was established by ovariectomy (OVX) and TDN was injected into the tail vein for 8 weeks. We found that ovariectomized mice could simulate some physiological changes in OP. After treatment with TDNs, some of this destruction in mice was significantly improved, including an increase in the bone volume fraction (BV/TV) and bone trabecular number (Tb. N), decrease in bone separation (Tb. SP), reduction in the damage to the mouse cartilage layer, reduction in osteoclast lacunae in bone trabecula, and reduction in the damage to the bone dense part. We also found that the expression of ALP, β-Catenin, Runx2, Osterix, and bone morphogenetic protein (BMP)2 significantly decreased in OVX mice but increased after TDN treatment. Therefore, this study suggests that TDNs may regulate the Wnt/β-Catenin and BMP signalling pathways to improve the levels of some specific markers of osteogenic differentiation, such as Runx2, ALP, and Osterix, to promote osteogenesis, thus showing a therapeutic effect on OP mice.

Geographic Variation in Osteoporosis Treatment in Postmenopausal Women: A 15-Year Longitudinal Analysis

Context

Osteoporosis affects more than half of older women, but many are not treated. Whether treatment differs between rural and urban areas is unknown.

Objective

To examine differences in osteoporosis treatment among postmenopausal women living in urban and rural areas of Australia.

Methods

Women participating in the Australian Longitudinal Study on Women's Health, a prospective longitudinal cohort study, born between 1946-1951, and with osteoporosis or fractures, were included. Surveys from 2004 to 2019 were linked to the Pharmaceutical Benefits Scheme (government-subsidized medications) to assess osteoporosis treatment and adherence, comparing geographical areas.

Results

Of the 4259 women included (mean age, 55.6 years), 1703 lived in major cities, 1629 inner regional, 794 outer regional, and 133 remote areas. Over the 15-year follow-up, 1401 (32.9%) women received treatment, including 47.4% of women with osteoporosis and 29.9% with fractures. Women in outer regional and remote areas were less likely to use antiosteoporosis treatment than those in major cities on univariable analysis (outer regional odds ratio, 0.83; 95% CI, 0.72-0.95; remote, 0.65; 0.49-0.86), but this did not remain significant on multivariable analysis. Median duration of use was 10 to 36 months, adherence varied by treatment type (34%-100%) but was not related to incident fractures, and of the women who stopped denosumab, 85% did not receive another consolidating treatment.

Conclusions

One-third of women with osteoporosis/fractures received treatment, and adherence was low. There was no difference in treatment use between urban and rural areas after adjusting for risk factors, although the specific treatment used, and adherence, differed.

Stem Cells and Acellular Preparations in Bone Regeneration/Fracture Healing: Current Therapies and Future Directions

Bone/fracture healing is a complex process with different steps and four basic tissue layers being affected: cortical bone, periosteum, fascial tissue surrounding the fracture, and bone marrow. Stem cells and their derivatives, including embryonic stem cells, induced pluripotent stem cells, mesenchymal stem cells, hematopoietic stem cells, skeletal stem cells, and multipotent stem cells, can function to artificially introduce highly regenerative cells into decrepit biological tissues and augment the healing process at the tissue level. Stem cells are molecularly and functionally indistinguishable from standard human tissues. The widespread appeal of stem cell therapy lies in its potential benefits as a therapeutic technology that, if harnessed, can be applied in clinical settings. This review aims to establish the molecular pathophysiology of bone healing and the current stem cell interventions that disrupt or augment the bone healing process and, finally, considers the future direction/therapeutic options related to stem cells and bone healing.

The effect of green mussel ( Perna viridis) shells' hydroxyapatite application on alkaline phosphatase levels in rabbit femur bone defect

Background

Non-union fractures can be prevented with bone grafts, such as hydroxyapatite made from green mussel shells. Green mussel shells contain a high percentage of HA, making them a promising alternative for bone healing. This research aims to reveal the effectiveness of green mussel shell HA as a bone substitute material and to provide knowledge for further research.

Methods

This research was conducted for four months using a true experimental research method with a post-test-only control group design. This study used 36 New Zealand rabbits ( Oryctolagus cuniculus) which were divided into 9 groups: positive control, negative control, and intervention at weeks 2, 4 and 6 after the intervention. All groups were subjected to three general procedures: pre-surgery, surgery, and post-surgery. This study utilized histological evaluation and biochemical assessment, specifically measuring serum alkaline phosphatase (ALP) levels, to investigate the effects of hydroxyapatite (HA) from green mussel shells on bone healing in rabbits.

Results

The findings demonstrated that green mussel shell HA hashad efficacy in accelerating bone healing, better than HA bovine HA i.e. green mussel shell hydroxyapatite showed superior efficacy compared to bovine hydroxyapatite in accelerating and maximizing fracture healing, as compared to the 6-week negative control group and demonstrated a significant difference ( p < 0.05).

Conclusions

Green mussel hydroxyapatite is proven to be able to fasten and maximize the bone healing process as fast as bovine HA, and even has higher efficacy than bovine HA.

Natural linear coumarin-heterocyclic conjugates: A review of their roles in phytotherapy

Heterocycle conjugates provide a fresh investigative scope to find novel molecules with enhanced phytotherapeutic characteristics. Coumarin-based products are widely used in the synthesis of several compounds with biological and medicinal properties since they are naturally occurring heterocycles with a broad dispersion. The investigation of coumarin-based phytochemicals with annulated heterocyclic rings is a promising approach to discovering novel conjugates with significant phytotherapeutic attributes. Due to the applicable coumarin extraction processes, a range of linear coumarin-heterocyclic conjugates were isolated from different natural resources and exhibited remarkable therapeutic efficacy. This review highlights the phytotherapeutic potential and origins of various natural linear coumarin-heterocyclic conjugates. We searched several databases, including Science Direct, Web of Science, Springer, Google Scholar, and PubMed. After sieving, we ultimately identified and included 118 pertinent studies published between 2000 and the middle of 2023. This will inspire medicinal chemists with extremely insightful ideas for designing and synthesizing therapeutically active lead compounds in the future that are built on the pharmacophores of coumarin-heterocyclic conjugates and have significant therapeutic attributes.

Technology Behind Cell Therapy Augmentation of Fracture Healing: Concentrated Bone Marrow Aspirate

With an aging population, and an anticipated increase in overall fracture incidence, a sound understanding of bone healing and how technology can optimize this process is crucial. Concentrated bone marrow aspirate (cBMA) is a technology that capitalizes on skeletal stem and progenitor cells (SSPCs) to enhance the regenerative capacity of bone. This overview highlights the science behind cBMA, discusses the role of SSPCs in bone homeostasis and fracture repair, and briefly details the clinical evidence supporting the use of cBMA in fracture healing. Despite promising early clinical results, a lack of standardization in harvest and processing techniques, coupled with patient variability, presents challenges in optimizing the use of cBMA. However, cBMA remains an emerging technology that may certainly play a crucial role in the future of fracture healing augmentation.

Compliant substrates mitigate the senescence associated phenotype of stress induced mesenchymal stromal cells

Mesenchymal stromal cells (MSCs) are a promising cell population for musculoskeletal cell-based therapies due to their multipotent differentiation capacity and complex secretome. Cells from younger donors are mechanosensitive, evidenced by changes in cell morphology, adhesivity, and differentiation as a function of substrate stiffness in both two- and three-dimensional culture. However, MSCs from older individuals exhibit reduced differentiation potential and increased senescence, limiting their potential for autologous use. While substrate stiffness is known to modulate cell phenotype, the influence of the mechanical environment on senescent MSCs is poorly described. To address this question, we cultured irradiation induced premature senescent MSCs on polyacrylamide hydrogels and assessed expression of senescent markers, cell morphology, and secretion of inflammatory cytokines. Compared to cells on tissue culture plastic, senescent MSCs exhibited decreased markers of the senescence associated secretory phenotype (SASP) when cultured on 50 kPa gels, yet common markers of senescence (e.g., p21, CDKN2A, CDKN1A) were unaffected. These effects were muted in a physiologically relevant heterotypic mix of healthy and senescent MSCs. Conditioned media from senescent MSCs on compliant substrates increased osteoblast mineralization compared to conditioned media from cells on TCP. Mixed populations of senescent and healthy cells induced similar levels of osteoblast mineralization compared to healthy MSCs, further indicating an attenuation of the senescent phenotype in heterotypic populations. These data indicate that senescent MSCs exhibit a decrease in senescent phenotype when cultured on compliant substrates, which may be leveraged to improve autologous cell therapies for older donors.

Balancing fracture risk versus risk of mortality before fracture among women aged 80 years or older

BACKGROUND

Most fractures occur in women aged ≥80 years but competing mortality unrelated to fracture may limit the benefit of osteoporosis drug therapy for some women in late life. Our primary aim was to develop separate prediction models for non-spine fracture (NSF) and mortality before fracture to identify subsets of women with varying fracture versus mortality risks.

METHODS

Separate prediction models were developed for NSF and mortality before NSF for 4895 women aged ≥80 years enrolled in the Study of Osteoporotic Fractures (SOF) or the Health Aging and Body Composition (HABC) study. Proportional hazards models modified to account for competing mortality were used to identify candidate risk factors for each outcome. Predictors associated with NSF or mortality (p < 0.2) were included in separate competing risk models to estimate the cumulative incidence of NSF and mortality before NSF during 5 years of follow-up. This process was repeated to develop separate prediction models for hip fracture and mortality before hip fracture.

RESULTS

Significant predictors of NSF (race, total hip BMD, grip strength, prior fracture, falls, and use of selective serotonin reuptake inhibitors, benzodiazepines, or oral/transdermal estrogen) differed from predictors of mortality before NSF (age, walking speed, multimorbidity, weight change, shrinking, smoking, self-rated health, dementia, and use of warfarin). Within nine subsets of women defined by tertiles of risk, 5-year outcomes varied from 28% NSF and 8% mortality in the high-risk NSF/low-risk mortality subset, to 9% NSF and 22% mortality in the low-risk NSF/high-risk mortality subset. Similar results were seen for predictors of hip fracture and mortality before hip fracture.

CONCLUSION

Considerable variation in 5-year competing mortality risk is present among women in late life with similar 5-year NSF risk. Both fracture risk and life expectancy should inform shared clinical decision-making regarding initiation or continuation of osteoporosis drug therapy for women aged ≥80 years.

Diagnostic power of ChatGPT 4 in distal radius fracture detection through wrist radiographs

Distal radius fractures rank among the most prevalent fractures in humans, necessitating accurate radiological imaging and interpretation for optimal diagnosis and treatment. In addition to human radiologists, artificial intelligence systems are increasingly employed for radiological assessments. Since 2023, ChatGPT 4 has offered image analysis capabilities, which can also be used for the analysis of wrist radiographs. This study evaluates the diagnostic power of ChatGPT 4 in identifying distal radius fractures, comparing it with a board-certified radiologist, a hand surgery resident, a medical student, and the well-established AI Gleamer BoneView™. Results demonstrate ChatGPT 4's good diagnostic accuracy (sensitivity 0.88, specificity 0.98, diagnostic power (AUC) 0.93), surpassing the medical student (sensitivity 0.98, specificity 0.72, diagnostic power (AUC) 0.85; p = 0.04) significantly. Nevertheless, the diagnostic power of ChatGPT 4 lags behind the hand surgery resident (sensitivity 0.99, specificity 0.98, diagnostic power (AUC) 0.985; p = 0.014) and Gleamer BoneView™(sensitivity 1.00, specificity 0.98, diagnostic power (AUC) 0.99; p = 0.006). This study highlights the utility and potential applications of artificial intelligence in modern medicine, emphasizing ChatGPT 4 as a valuable tool for enhancing diagnostic capabilities in the field of medical imaging.

Opportunistically identifiable vertebral fractures on routine radiological imaging predict mortality: observational cohort study

In men and women with opportunistically identifiable vertebral fractures (VFs) on routine CT scans including the chest and/or abdomen, the risk of death is 51% higher than in those with no VF on the CT scan, and 325% higher than an age- and sex-matched general population cohort.

PURPOSE

There is little knowledge about the risk of death in patients with VFs present on routine radiological imaging. We evaluated the risk of death in men and women aged 50 years or older with opportunistically identifiable VFs on routine CT scans and not treated with osteoporosis medications.

METHODS

Thoracic and lumbar VFs were identified through a blinded, two-step approach on CT scans performed as part of normal clinical care in a Danish hospital in 2010 or later. Subjects with VF were matched on age and sex against those with no VF (1:2-ratio) and a general population cohort (1:3-ratio), respectively, and followed for up to 7 years through the national Danish registers. Subjects treated with an osteoporosis medication in the year prior to baseline were excluded.

RESULTS

Subjects with VF had a significantly higher risk of death during follow-up as compared to subjects with no VF on the CT scan (adjusted hazard ratio [HR] 1.51 [95% confidence interval 1.27-1.79; p < 0.001]) and even more so when compared to the general population cohort (HR 4.25 [3.53-5.12; p < 0.001]). In subjects with versus without VF on the CT scan, the risk was higher in those with moderate or severe VF, in those with no malignancy prior to baseline, and in those with a lower Charlson comorbidity index score.

CONCLUSION

Subjects with VF available for identification on routine CT scans face a substantially increased risk of death. Opportunistic identification and reporting of VF is important to identify these patients to allow intervention if indicated.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma

Introduction

As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase.

Research question

To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care.

Materials and methods

We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition.

Results

A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility.

Discussion and conclusions

Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

Revision ratio after Femoral Neck System implantation for hip fracture treatment: a retrospective cohort analysis

The aim of the study is to determine the revision ratio after implantation of the femoral neck system (FNS) for the treatment of femoral neck fractures. A retrospective single center cohort analysis with a total of 71 patients who underwent the implantation of the FNS between December 2019 and December 2021, was performed. 31 males and 40 females were included. There was no exclusion based on BMI, ASA score, Garden classification or Pauwels classification. Primary outcome was the revision rate after FNS implantation. Secondary outcomes comprise the reason for revision surgery as well as the time toward revision surgery and the 30-day mortality. The revision ratio was 11 out of 71 patients (15.5%) with an average time to revision surgery of 10 months. Most common reason for revision was avascular necrosis (AVN) in 45.5%. Other reasons for revision surgery were implant failure due to a secondary fall on to the hip with the FNS implant in place, cut-out, cut-through and malunion in respectively 27.3%, 9%, 9% and 9% of the revision patients. The one- hole plate was used in 72% of the patients. Mean follow-up was 18.07 months (range 6-30 months). Full weight bearing instruction was given to 85.9% of the patients. Partial weight bearing in 14.1% of the patients. In conclusion, the FNS has similar revision ratio when used for femoral neck fractures compared to cannulated screw fixation in literature. The predominant reason for revision is AVN and implant failure with no difference between the use of the one- or-two-hole plate in this study.

East Asians' T-scores for the diagnosis of osteoporosis should be calculated using ethnicity- and gender-specific BMD reference ranges: justifications

The 2013 ISCD consensus recommended a Caucasian female reference database for T-score calculation in men, which says "A uniform Caucasian (non-race adjusted) female reference database should be used to calculate T-scores for men of all ethnic groups." However, this statement was recommended for the US population, and no position was taken with respect to BMD reference data or ethnicity matching outside of the USA. In East Asia, currently, a Japanese BMD reference database is universally adopted in Japan for clinical DXA diagnosis, while both local BMD and Caucasian BMD reference databases are in use in Mainland China, South Korea, Taiwan, and Singapore. In this article, we argue that an ethnicity- and gender-specific BMD database should be used for T-score calculations for East Asians, and we list the justifications why we advocate so. Use of a Caucasian BMD reference database leads to systematically lower T-scores for East Asians and an overestimation of the prevalence of osteoporosis. Using a female BMD reference database to calculate T-scores for male patients leads to higher T-score values and an underestimation of the prevalence of osteoporosis. Epidemiological evidence does not support using a female BMD reference database to calculate T-scores for men. We also note that BMD reference databases collected in Asia should be critically evaluated for their quality.

Development of guar gum reinforced calcium magnesium phosphate-based bone biocement

This study aims at developing a calcium magnesium phosphate-based bone biocement that combines a natural polymer and regenerative properties of bone bonding materials. The formulation of this biocement consists of oxidized guar gum, polydopamine, and calcium magnesium phosphate. The oxidized guar gum is easily soluble in water and has a slightly basic pH, unlike unmodified guar gum, thus allowing a homogenous paste to form in the alkaline environment of calcium magnesium phosphate. Three different oxidized degrees of guar gum were made, and the impact on the biocement properties was studied. The modified guar gum-reinforced biocement (OGG C2) displayed higher mechanical strength and lower degradation rates than OGG B1 and OGG A0. Furthermore, samples with polydopamine exhibited better results, thus, improving the already reinforced biocement. Morphological studies of the biocement displayed a highly porous structure with porosity varying among biocement containing different oxidized guar gum and polydopamine levels.

Epidemiology of distal radius fractures in Germany - incidence rates and trends based on inpatient and outpatient data

We examined incidence rates (IR) for all distal radius fracture (DRF) events based on inpatient and outpatient data from a large statutory health insurance in Germany. Of all DRF, 56% were treated as inpatients, and thus, 44% treated as outpatients. IR were higher in women than in men.

PURPOSE

Although a distal radius fracture (DRF) is one of the most common fractures in the elderly population, epidemiological data are limited. Many studies examine only hospitalized patients, do not analyze time trends, or include only small populations. In this retrospective population-based observational study, routine data on inpatient and outpatient care of persons aged ≥ 60 years insured by a large statutory health insurance in Germany were analyzed from 2014 to 2018.

METHODS

DRF were identified by ICD-10 codes. All DRF events of an individual were considered with a corresponding individual washout period. Incidence rates (IR) and time trends were estimated assuming a Poisson distribution per 100,000 person-years, with 95% confidence intervals [95% CI] and age-sex standardization to the German population in 2018. Associations of calendar year, age, sex, and comorbidity with IR were examined using Poisson regression estimating incidence rate ratios (IRR) with CI.

RESULTS

The study population consists of 974,332 insured individuals, with 16,557 experiencing one or more DRF events during the observation period. A total of 17,705 DRF events occurred, of which 9961 (56.3%) were hospitalized. Standardized IR were 439 [424-453] (inpatient: 240 [230-251], outpatient: 199 [189-209]) in 2014 and 438 [423-452] (inpatient: 238 [227-249], outpatient: 200 [190-210]) in 2018. Female sex, older age, and comorbidity were associated with higher IR and adjusted Poisson regression showed no significant time trend (IRR overall 0.994 [0.983-1.006]).

CONCLUSION

A relevant proportion of DRF were treated in outpatient settings, so both inpatient and outpatient data are necessary for a valid estimate.

Expanding the therapeutic potential of Salvia miltiorrhiza: a review of its pharmacological applications in musculoskeletal diseases

Salvia miltiorrhiz, commonly known as "Danshen" in Chinese medicine, has longstanding history of application in cardiovascular and cerebrovascular diseases. Renowned for its diverse therapeutic properties, including promoting blood circulation, removing blood stasis, calming the mind, tonifying the blood, and benefiting the "Qi", recent studies have revealed its significant positive effects on bone metabolism. This potential has garnered attention for its promising role in treating musculoskeletal disorders. Consequently, there is a high anticipation for a comprehensive review of the potential of Salvia miltiorrhiza in the treatment of various musculoskeletal diseases, effectively introducing an established traditional Chinese medicine into a burgeoning field.

AIM OF THE REVIEW

Musculoskeletal diseases (MSDs) present significant challenges to healthcare systems worldwide. Previous studies have demonstrated the high efficacy and prospects of Salvia miltiorrhiza and its active ingredients for treatment of MSDs. This review aims to illuminate the newfound applications of Salvia miltiorrhiza and its active ingredients in the treatment of various MSDs, effectively bridging the gap between an established medicine and an emerging field.

METHODS

In this review, previous studies related to Salvia miltiorrhiza and its active ingredients on the treatment of MSD were collected, the specific active ingredients of Salvia miltiorrhiza were summarized, the effects of Salvia miltiorrhiza and its active ingredients for the treatment of MSDs, as well as their potential molecular mechanisms were reviewed and discussed.

RESULTS

Based on previous publications, Salvianolic acid A, salvianolic acid B, tanshinone IIA are the representative active ingredients of Salvia miltiorrhiza. Their application has shown significant beneficial outcomes in osteoporosis, fractures, and arthritis. Salvia miltiorrhiza and its active ingredients protect against MSDs by regulating different signaling pathways, including ROS, Wnt, MAPK, and NF-κB signaling.

CONCLUSION

Salvia miltiorrhiza and its active ingredients demonstrate promising potential for bone diseases and have been explored across a wide variety of MSDs. Further exploration of Salvia miltiorrhiza's pharmacological applications in MSDs holds great promise for advancing therapeutic interventions and improving the lives of patients suffering from these diseases.

Utilization of Vertebroplasty/Kyphoplasty in the Management of Compression Fractures: National Trends and Predictors of Vertebroplasty/Kyphoplasty

OBJECTIVE

The purpose of this study is to examine the utilization of kyphoplasty/vertebroplasty procedures in the management of compression fractures. With the growing elderly population and the associated increase in rates of osteoporosis, vertebral compression fractures have become a daily encounter for spine surgeons. However, there remains a lack of consensus on the optimal management of this patient population.

METHODS

A retrospective analysis of 91 million longitudinally followed patients from 2016 to 2019 was performed using the PearlDiver Patient Claims Database. Patients with compression fractures were identified using International Classification of Disease, 10th Revision codes, and a subset of patients who received kyphoplasty/vertebroplasty were identified using Common Procedural Terminology codes. Baseline demographic and clinical data between groups were acquired. Multivariable regression analysis was performed to determine predictors of receiving kyphoplasty/vertebroplasty.

RESULTS

A total of 348,457 patients with compression fractures were identified with 9.2% of patients receiving kyphoplasty/vertebroplasty as their initial treatment. Of these patients, 43.5% underwent additional kyphoplasty/vertebroplasty 30 days after initial intervention. Patients receiving kyphoplasty/vertebroplasty were significantly older (72.2 vs. 67.9, p < 0.05), female, obese, had active smoking status and had higher Elixhauser Comorbidity Index scores. Multivariable analysis demonstrated that female sex, smoking status, and obesity were the 3 strongest predictors of receiving kyphoplasty/vertebroplasty (odds ratio, 1.27, 1.24, and 1.14, respectively). The annual rate of kyphoplasty/vertebroplasty did not change significantly (range, 8%-11%).

CONCLUSION

The majority of vertebral compression fractures are managed nonoperatively. However, certain patient factors such as smoking status, obesity, female sex, older age, osteoporosis, and greater comorbidities are predictors of undergoing kyphoplasty/vertebroplasty.