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

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.

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.

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.

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.

Multi-Functional Small Molecule Alleviates Fracture Pain and Promotes Bone Healing

Bone injuries such as fractures are one major cause of morbidities worldwide. A considerable number of fractures suffer from delayed healing, and the unresolved acute pain may transition to chronic and maladaptive pain. Current management of pain involves treatment with NSAIDs and opioids with substantial adverse effects. Herein, we tested the hypothesis that the purine molecule, adenosine, can simultaneously alleviate pain and promote healing in a mouse model of tibial fracture by targeting distinctive adenosine receptor subtypes in different cell populations. To achieve this, a biomaterial-assisted delivery of adenosine is utilized to localize and prolong its therapeutic effect at the injury site. The results demonstrate that local delivery of adenosine inhibited the nociceptive activity of peripheral neurons through activation of adenosine A1 receptor (ADORA1) and mitigated pain as demonstrated by weight bearing and open field movement tests. Concurrently, local delivery of adenosine at the fracture site promoted osteogenic differentiation of mesenchymal stromal cells through adenosine A2B receptor (ADORA2B) resulting in improved bone healing as shown by histological analyses and microCT imaging. This study demonstrates the dual role of adenosine and its material-assisted local delivery as a feasible therapeutic approach to treat bone trauma and associated pain.

Age- and dose-dependent effect of statin use on the risk of osteoporotic fracture in older adults

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporosis-related measurement has shown controversial results. In this study, we found an age, dose andduration-dependent osteoprotective effect of statins in general older population.

PURPOSE

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporotic fractures has shown controversial results.

METHODS

In this study with Korean National Health Insurance Service-Senior cohort database, a total of 365,656 elderly without previous history of osteoporosis and who were started on statin since January 1 2004 were included and observed until December 31 2012. Hazard rations (HR) for major osteoporotic fractures were calculated using the weighted Cox proportional hazards model with inverse-probability of treatment weighting method.

RESULTS

During 6.27 years of follow-up period, 54,959 osteoporotic fractures occurred and the majority of fractures (69.5%) were vertebral fractures. Compared with non-users, statin use was associated with a decreased risk of all outcomes with adjusted HR (95% CI) of 0.77 (0.72-0.83; P < 0.001) for major osteoporotic fractures, 0.49 (0.38-0.62; P < 0.001) for hip fractures, and 0.70 (0.64-0.77; P < 0.001) for vertebral fractures. When outcomes were examined separately by sex, the results were broadly comparable in terms of patterns of risk reduction by statin use. The patients with statin initiated at age ≥ 80 years had the highest risk reduction for most outcomes relative to non-users. Higher cumulative dose of statin was negatively associated with the osteoporotic fracture risk; 0.97 (0.91-1.02) for 30-364 cumulative daily defined dose (cDDD), 0.45 (0.40-0.51) for 365-1,094 cDDD, and 0.22 (0.15-0.33) for ≥ 1,095 cDDD.

CONCLUSIONS

Our results showed that statin use was associated with significant reduction in the risk of osteoporotic fractures in general older population.

Bisphosphonates and Atypical Femur Fractures: Is the Relationship Causal or Casual?

Bisphosphonates (BPs) are a time-tested drug class with multivariate use cases. They are used in pathologies ranging from osteoporosis to Paget's disease, and also help in accelerated fracture healing. They have been used to treat both benign and malignant lesions of the skeletal system since a long time. However, there have been reports of increased incidences of atypical femoral fractures (AFFs) in patients exhibiting chronic use of bisphosphonates in the past years. This has led to the widespread dissuasion of physicians and practitioners from using the drug class. By means of this review of the literature, the authors aim to investigate the relationship between BP use and its association with AFFs. The review focuses on and elucidates the basic pharmacology of BPs and goes on to illustrate the indications of BPs in various pathologies of the musculoskeletal system, further exploring the effects of BPs on the healing of various bony fractures. The authors also explore the incidences of other pathologies, such as osteonecrosis of the jaw and nephropathies associated with BP use, and elaborate on their features. Through this review, the authors have tried to educate and induce critical thinking on the part of clinicians and medical professionals in regard to prescribing BPs to patients that need them, by keeping in mind the risk-reward relationship that accompanies their use.

Discordance in Secular Trends of Bone Mineral Density Measurements in Different Ages of Postmenopausal Women

BACKGROUND

Age-adjusted bone mineral density (BMD) in postmenopausal women decreases in developed countries whereas incidence of osteoporotic fracture decreases or remains stable. We investigated secular trends of bone density from 2008 to 2017 among different age groups of postmenopausal women.

METHODS

We analyzed BMD data obtained from health check-ups of 4,905 postmenopausal women during three survey cycles from 2008 to 2017. We divided them into 3 groups by age (50-59 years, 60-69 years, and 70 years or more) and observed the transition of lumbar and femoral BMD in each group, before and after adjusting for variables that may affect BMD.

RESULTS

Age-adjusted BMD, bone mineral content (BMC), and T-score demonstrated a declining trend over the survey period at lumbar spine (-2.8%), femur neck (-3.5%) and total femur (-4.3%), respectively. In the analysis for the age groups, the BMD, BMC, and T-score presented linear declining trend (-6.1%) in younger postmenopausal women while women aged over 70 or more showed linear increasing trends (+6.3%) at lumbar spine during the survey period. Femoral neck and total femur BMD demonstrated a declining linear trend only in the 50-59 and 60-69 years groups (-5.5%, -5.2%, respectively), but not in the 70 years or more group.

CONCLUSION

BMD in younger postmenopausal women has decreased considerably but has increased or plateaued in elderly women. This discordance of BMD trends among different age groups may contribute to decreased incidence of osteoporotic fracture despite a recent declining BMD trend in postmenopausal women.

Advances in Bioresorbable Triboelectric Nanogenerators

With the growing demand for next-generation health care, the integration of electronic components into implantable medical devices (IMDs) has become a vital factor in achieving sophisticated healthcare functionalities such as electrophysiological monitoring and electroceuticals worldwide. However, these devices confront technological challenges concerning a noninvasive power supply and biosafe device removal. Addressing these challenges is crucial to ensure continuous operation and patient comfort and minimize the physical and economic burden on the patient and the healthcare system. This Review highlights the promising capabilities of bioresorbable triboelectric nanogenerators (B-TENGs) as temporary self-clearing power sources and self-powered IMDs. First, we present an overview of and progress in bioresorbable triboelectric energy harvesting devices, focusing on their working principles, materials development, and biodegradation mechanisms. Next, we examine the current state of on-demand transient implants and their biomedical applications. Finally, we address the current challenges and future perspectives of B-TENGs, aimed at expanding their technological scope and developing innovative solutions. This Review discusses advancements in materials science, chemistry, and microfabrication that can advance the scope of energy solutions available for IMDs. These innovations can potentially change the current health paradigm, contribute to enhanced longevity, and reshape the healthcare landscape soon.

Risk factors and healthcare costs associated with long bone fracture non-union: a retrospective US claims database analysis

BACKGROUND

Few contemporary US-based long bone non-union analyses have recently been published. Our study was designed to provide a current understanding of non-union risks and costs, from the payers' perspective.

METHODS

The Merative™ MarketScan® Commercial Claims and Encounters database was used. Patients with surgically treated long bone (femur, tibia, or humerus) fractures in the inpatient setting, from Q4 2015 to most recent, were identified. Exclusion criteria included polytrauma and amputation at index. The primary outcome was a diagnosis of non-union in the 12 and 24 months post-index. Additional outcomes included concurrent infection, reoperation, and total healthcare costs. Age, gender, comorbidities, fracture characteristics, and severity were identified for all patients. Descriptive analyses were performed. Crude and adjusted rates of non-union (using Poisson regressions with log link) were calculated. Marginal incremental cost of care associated with non-union and infected non-union and reoperation were estimated using a generalized linear model with log link and gamma distribution.

RESULTS

A total of 12,770, 13,504, and 4,805 patients with femoral, tibial, or humeral surgically treated fractures were identified, 74-89% were displaced, and 18-27% were comminuted. Two-year rates of non-union reached 8.5% (8.0%-9.1%), 9.1% (8.6%-9.7%), and 7.2% (6.4%-8.1%) in the femoral, tibial, and humeral fracture cohorts, respectively. Shaft fractures were at increased risk of non-union versus fractures in other sites (risk ratio (RR) in shaft fractures of the femur: 2.36 (1.81-3.04); tibia: 1.95 (1.47-2.57); humerus: 2.02 (1.42-2.87)). Fractures with severe soft tissue trauma (open vs. closed, Gustilo III vs. Gustilo I-II) were also at increased risk for non-union (RR for Gustilo III fracture (vs. closed) for femur: R = 1.96 (1.45-2.58), for tibia: 3.33 (2.85-3.87), RR for open (vs. closed) for humerus: 1.74 (1.30-2.32)). For all fractures, younger patients had a reduced risk of non-union compared to older patients. For tibial fractures, increasing comorbidity (Elixhauser Index 5 or greater) was associated with an increased risk of non-union. The two-year marginal cost of non-union ranged from $33K-$45K. Non-union reoperation added $16K-$34K in incremental costs. Concurrent infection further increased costs by $46K-$86K.

CONCLUSIONS

Non-union affects 7-10% of surgically treated long bone fracture cases. Shaft and complex fractures were at increased risk for non-union.

Outcomes of young active patients with displaced clavicle fractures treated with Rockwood pin

PURPOSE

Various fixation techniques have been described for midshaft clavicle fractures in the literature. We hypothesized that use of the Rockwood pin for fixation of displaced midshaft clavicle fractures would result in favorable outcomes in a young active cohort.

METHODS

Patients aged 10-35 years who underwent Rockwood clavicle pin fixation at a single institution were identified. Preoperative and postoperative radiographs were reviewed and assessed for fracture characteristics, postoperative alignment, and radiographic union. Postoperative outcome scores were obtained.

RESULTS

A total of 39 patients (age 17.3 ± 3.9 years) with clavicle fracture treated with Rockwood pin were identified. Radiographic review demonstrated that 88% of fractures were 100%, or more, displaced, and surgery achieved near-anatomic reduction in 92% of cases. Average time to radiographic union was 2.3 ± 0.8 months, and average time to clinical union was 2.5 ± 0.3 months. One patient required revision for nonunion (3%). Complete outcome responses were obtained for 24 patients, with an average 40 ± 27.7 months of follow-up. Mean Total Clavicle Functional score was 2.75 ± 3.6 for minor patients. For adult patients, Nottingham Clavicle score was 90.7 ± 10.7, mean American Shoulder and Elbow Society score was 92.4 ± 11.2, and mean Single Assessment Numerical Evaluation score was 88.8 ± 21.5. 77% of adults reported no long-term functional limitation; 54% reported a bump at the prior fracture site, but 100% reported satisfaction with shoulder appearance.

CONCLUSIONS

In our cohort of young active patients, treatment with Rockwood pin allowed for anatomic reduction, healing with a low nonunion rate, and favorable patient reported outcomes.

Cost-effectiveness and willing-to-pay thresholds for vertebral augmentation of osteoporotic vertebral fractures, what are they based on: a systematic review

OBJECTIVE

Although there is substantial clinical evidence on the safety and effectiveness of vertebral augmentation for osteoporotic vertebral fractures, cost-effectiveness is less well known. The objective of this study is to provide a systematic review of cost-effectiveness studies and policy-based willingness-to-pay (WTP) thresholds for different vertebral augmentation (VA) procedures, vertebroplasty (VP) and balloon kyphoplasty (BK), for osteoporotic vertebral fractures (OVFs).

DESIGN

A systematic review targeting cost-effectiveness studies of VA procedures for OVFs.

DATA SOURCES

Six bibliographic databases were searched from inception up to May 2021.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Studies were eligible if meeting all predefined criteria: (1) VP or BK intervention, (2) OVFs and (3) cost-effectiveness study. Articles not written in English, abstracts, editorials, reviews and those reporting only cost data were excluded.

DATA EXTRACTION AND SYNTHESIS

Information was extracted on study characteristics, cost-effective estimates, summary decisions and payer WTP thresholds. Incremental cost-effective ratio (ICER) was the main outcome measure. Studies were summarised by a structured narrative synthesis organised by comparisons with conservative management (CM). Two independent reviewers assessed the quality (risk of bias) of the systematic review and cost-effectiveness studies by peer-reviewed checklists.

RESULTS

We identified 520 references through database searching and 501 were excluded as ineligible by titles and abstract. Ten reports were identified as eligible from 19 full-text reviews. ICER for VP versus CM evaluated as cost per quality-adjusted life-year (QALY) ranged from €22 685 (*US$33 395) in Netherlands to £-2240 (*US$-3273), a cost-saving in the UK. ICERs for BK versus CM ranged from £2706 (*US$3954) in UK to kr600 000 (*US$90 910) in Sweden. ICERs were within payer WTP thresholds for a QALY based on historical benchmarks.

CONCLUSIONS

Both VP and BK were judged cost-effective alternatives to CM for OVFs in economic studies and were within WTP thresholds in multiple healthcare settings.

The Effectiveness of Three-Dimensional Osteosynthesis Plates versus Conventional Plates for the Treatment of Skeletal Fractures: A Systematic Review and Meta-Analysis

PURPOSE

To assess the difference between preformed anatomically shaped osteosynthesis plates and patient-specific implants versus conventional flat plates for the treatment of skeletal fractures in terms of anatomical reduction, operation time, approach, patient outcomes, and complications.

MATERIAL AND METHODS

MEDLINE (1950 to February 2023), EMBASE (1966 to February 2023), and the Cochrane Central Register of Controlled Trials (inception to February 2023) databases were searched. Eligible studies were randomised clinical trials, prospective controlled clinical trials, and prospective and retrospective cohort studies (n ≥ 10). Inclusion criteria were studies reporting the outcomes of preformed anatomically shaped osteosynthesis plates and patient-specific implants versus conventional flat plates after treating skeletal fractures. Outcome measures included anatomical reduction, stability, operation time, hospitalisation days, patients' outcomes, and complications. Two independent reviewers assessed the abstracts and analysed the complete texts and methodologies of the included studies.

RESULTS

In total, 21 out of the 5181 primarily selected articles matched the inclusion criteria. A meta-analysis revealed a significant difference in operation time in favour of the preformed anatomical plates and patient-specific implants versus conventional plates. Significant differences in operation time were found for the orbital (95% CI: -50.70-7.49, p = 0.008), upper limb (95% CI: -17.91-6.13, p < 0.0001), and lower limb extremity groups (95% CI: -20.40-15.11, p < 0.00001). The mean difference in the rate of anatomical reduction in the lower limb extremity group (95% CI: 1.04-7.62, p = 0.04) was also in favour of using preformed anatomical plates and patient-specific implants versus conventional plates.

CONCLUSIONS

This systematic review showed a significant mean difference in surgery time favouring the use of preformed anatomical plates and patient-specific implants for orbital, upper, and lower limb extremity fractures. Additionally, preformed anatomical plates and patient-specific implants in the lower limb group result in a significantly higher rate of anatomical reduction versus conventional flat plates.

NMP4, an Arbiter of Bone Cell Secretory Capacity and Regulator of Skeletal Response to PTH Therapy

The skeleton is a secretory organ, and the goal of some osteoporosis therapies is to maximize bone matrix output. Nmp4 encodes a novel transcription factor that regulates bone cell secretion as part of its functional repertoire. Loss of Nmp4 enhances bone response to osteoanabolic therapy, in part, by increasing the production and delivery of bone matrix. Nmp4 shares traits with scaling factors, which are transcription factors that influence the expression of hundreds of genes to govern proteome allocation for establishing secretory cell infrastructure and capacity. Nmp4 is expressed in all tissues and while global loss of this gene leads to no overt baseline phenotype, deletion of Nmp4 has broad tissue effects in mice challenged with certain stressors. In addition to an enhanced response to osteoporosis therapies, Nmp4-deficient mice are less sensitive to high fat diet-induced weight gain and insulin resistance, exhibit a reduced disease severity in response to influenza A virus (IAV) infection, and resist the development of some forms of rheumatoid arthritis. In this review, we present the current understanding of the mechanisms underlying Nmp4 regulation of the skeletal response to osteoanabolics, and we discuss how this unique gene contributes to the diverse phenotypes among different tissues and stresses. An emerging theme is that Nmp4 is important for the infrastructure and capacity of secretory cells that are critical for health and disease.

Trends and Risk Factors for Surgical Site Infection after Treatment of the Ankle Fracture: National Cohort Study

Surgical site infection (SSI) is a major complication after the surgical treatment of ankle fractures that can result in catastrophic consequences. This study aimed to determine the incidence of SSI in several cohorts from national insurance databases over the past 12 years and identify its predictors. The claimed data for patients (n = 1,449,692) with ankle fractures between 2007 and 2019 were investigated, and a total of 41,071 patients were included in the final analysis. The covariates included were age, sex, season, fracture type (closed vs. open), type of surgical fixation procedure, and comorbidities of each patient. All subjects were divided into two groups according to the SSI after the surgical fixation of the ankle fracture (no infection group vs. infection group). The number of SSIs after the surgical treatment of ankle fractures was 874 (2.13%). Open fractures [odds ratio, (OR) = 4.220] showed the highest risk for SSI, followed by the male sex (OR = 1.841), an increasing number of comorbidities (3-5, OR = 1.484; ≥6, OR = 1.730), a history of dementia (OR = 1.720) or of myocardial infarction (OR = 1.628), and increasing age (OR = 1.010). The summer season (OR = 1.349) showed the highest risk among the four seasons for SSI after ankle fracture surgery.

Photoacoustic Imaging and Characterization of Bone in Medicine: Overview, Applications, and Outlook

Photoacoustic techniques have shown promise in identifying molecular changes in bone tissue and visualizing tissue microstructure. This capability represents significant advantages over gold standards (i.e., dual-energy X-ray absorptiometry) for bone evaluation without requiring ionizing radiation. Instead, photoacoustic imaging uses light to penetrate through bone, followed by acoustic pressure generation, resulting in highly sensitive optical absorption contrast in deep biological tissues. This review covers multiple bone-related photoacoustic imaging contributions to clinical applications, spanning bone cancer, joint pathologies, spinal disorders, osteoporosis, bone-related surgical guidance, consolidation monitoring, and transsphenoidal and transcranial imaging. We also present a summary of photoacoustic-based techniques for characterizing biomechanical properties of bone, including temperature, guided waves, spectral parameters, and spectroscopy. We conclude with a future outlook based on the current state of technological developments, recent achievements, and possible new directions.

Poly(3-hydroxybutyrate) (PHB) and Polycaprolactone (PCL) Based Blends for Tissue Engineering and Bone Medical Applications Processed by FDM 3D Printing

In the presented work, poly(3-hydroxybutyrate)-PHB-based composite blends for bone medical applications and tissue engineering are prepared and characterized. PHB used for the work was in two cases commercial and, in one case, was extracted by the chloroform-free route. PHB was then blended with poly(lactic acid) (PLA) or polycaprolactone (PCL) and plasticized by oligomeric adipate ester (Syncroflex, SN). Tricalcium phosphate (TCP) particles were used as a bioactive filler. Prepared polymer blends were processed into the form of 3D printing filaments. The samples for all the tests performed were prepared by FDM 3D printing or compression molding. Differential scanning calorimetry was conducted to evaluate the thermal properties, followed by optimization of printing temperature by temperature tower test and determination of warping coefficient. Tensile test, three-point flexural test, and compression test were performed to study the mechanical properties of materials. Optical contact angle measurement was conducted to determine the surface properties of these blends and their influence on cell adhesion. Cytotoxicity measurement of prepared blends was conducted to find out whether the prepared materials were non-cytotoxic. The best temperatures for 3D printing were 195/190, 195/175, and 195/165 °C for PHB-soap/PLA-SN, PHB/PCL-SN, and PHB/PCL-SN-TCP, respectively. Their mechanical properties (strengths ~40 MPa, moduli ~2.5 GPa) were comparable with human trabecular bone. The calculated surface energies of all blends were ~40 mN/m. Unfortunately, only two out of three materials were proven to be non-cytotoxic (both PHB/PCL blends).

Biomimetic Porous Magnesium Alloy Scaffolds Promote the Repair of Osteoporotic Bone Defects in Rats through Activating the Wnt/β-Catenin Signaling Pathway

In this study, biomimetic porous magnesium alloy scaffolds were prepared to repair femoral bone defects in ovariectomized osteoporotic rats. The purpose of the study was to investigate the effect of biomimetic porous magnesium alloy scaffolds on repairing osteoporotic bone defects and possible mechanisms. The animal model of osteoporosis was established in female SD rats. Three months later, a bone defect of 3 mm in diameter and 3 mm in depth was created in the lateral condyle of the right femur. The rats were then randomly divided into two groups: an experimental group and a control group. Four weeks after surgery, gross specimens were observed and micro-CT scans were performed. The repair of osteoporotic femoral defects in rats was studied histologically using HE staining, Masson staining, and Goldner staining. The expression of Wnt5a, β-catenin, and BMP-2 was measured between groups by immunohistochemical staining. The bone defect was repaired better after the application of biomimetic porous magnesium alloy scaffolds. Immunohistochemical results showed significantly higher expression of Wnt5a, β-catenin, and BMP-2. To conclude, the biomimetic porous magnesium alloy scaffolds proposed in this paper might promote the repair of osteoporotic femoral bone defects in rats possibly through activating the Wnt/β-catenin signaling pathway.

Efficacy and safety of odanacatib for osteoporosis treatment: a systematic review and meta-analysis

PURPOSE

Osteoporosis is a metabolic bone disease that commonly results in middle-aged and elderly people following fractures. Odanacatib (ODN), a potential osteoporosis medication, was stopped in the Long-term Odanacatib Fracture Trial (LOFT) phase III study because it increased the risk of stroke. Herein, we conducted a systematic review and meta-analysis to further assess the efficacy and safety of ODN in osteoporosis treatment.

METHODS

We searched the PubMed, EMBASE, Cochrane Library, and Web of Science, using the core search terms "osteoporosis" and "odanacatib." The primary outcomes were the percentage change in markers of bone turnover and bone formation as well as that in the bone mineral density (BMD) of the lumbar spine, hip, femoral neck, and greater trochanter. The secondary outcome was the risk of adverse events (AEs), used to explore the safety of ODN.

RESULTS

Ten articles-all double-blinded, randomized, placebo-controlled trials-were included. All trials were considered to be of high quality if they met the inclusion and exclusion criteria. We found that ODN increases BMD in the lumbar spine, total hip, and femoral neck, whereas it decreases the concentration of serum C-telopeptides of type I collagen (sCTx) and urinary N-telopeptide/creatinine ratio (uNTx/Cr). We found no significant differences in total, drug-related, serious, or skin AEs between the ODN and control groups. However, significant differences in fracture and stroke AEs were found between the ODN and control groups.

CONCLUSION

ODN is an appealing long-term osteoporosis treatment method; however, further research should focus on the potential increased risk of fracture and stroke.

Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes.

METHODS

Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI).

RESULTS

Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1 min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30 mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation.

CONCLUSION

Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.

Robocasting of Ceramic Fischer-Koch S Scaffolds for Bone Tissue Engineering

Triply Periodic Minimal Surfaces (TPMS) are promising structures for bone tissue engineering scaffolds due to their relatively high mechanical energy absorption, smoothly interconnected porous structure, scalable unit cell topology, and relatively high surface area per volume. Calcium phosphate-based materials, such as hydroxyapatite and tricalcium phosphate, are very popular scaffold biomaterials due to their biocompatibility, bioactivity, compositional similarities to bone mineral, non-immunogenicity, and tunable biodegradation. Their brittle nature can be partially mitigated by 3D printing them in TPMS topologies such as gyroids, which are widely studied for bone regeneration, as evidenced by their presence in popular 3D-printing slicers, modeling systems, and topology optimization tools. Although structural and flow simulations have predicted promising properties of other TPMS scaffolds, such as Fischer-Koch S (FKS), to the best of our knowledge, no one has explored these possibilities for bone regeneration in the laboratory. One reason for this is that fabrication of the FKS scaffolds, such as by 3D printing, is challenged by a lack of algorithms to model and slice this topology for use by low-cost biomaterial printers. This paper presents an open-source software algorithm that we developed to create 3D-printable FKS and gyroid scaffold cubes, with a framework that can accept any continuous differentiable implicit function. We also report on our successful 3D printing of hydroxyapatite FKS scaffolds using a low-cost method that combines robocasting with layer-wise photopolymerization. Dimensional accuracy, internal microstructure, and porosity characteristics are also presented, demonstrating promising potential for the 3D printing of TPMS ceramic scaffolds for bone regeneration.

Burden of disease of spinal muscular atrophy linked to chromosome 5q (5q-SMA) in Colombia

OBJECTIVE

This article estimates the disease burden of 5q-SMA in Colombia by using the Disability-Adjusted Life Years (DALYs) metric.

METHODS

Epidemiological data were obtained from local databases and medical literature and were adjusted in the DisMod II tool. DALYs were obtained by adding years of life lost due to premature death (YLL) and years lived with disability (YLD).

RESULTS

The modeled prevalence of 5q-SMA in Colombia was 0.74 per 100,000 population. The fatality rate for all types was 14.1%. The disease burden of 5q-SMA was estimated at 4,421 DALYs (8.6 DALYs/100,000), corresponding to 4,214 (95.3%) YLLs and 207 (4.7%) YLDs. Most of the DALYs were accounted in the 2-17 age group. Of the total burden, 78% correspond to SMA type 1, 18% to type 2, and 4% to type 3.

CONCLUSIONS

Although 5q-SMA is a rare disease, it is linked to a significant disease burden due to premature mortality and severe sequelae. The estimates shown in this article are important inputs to inform public policy decisions on how to ensure adequate health service provision for patients with 5q-SMA.

Bone Disease in Long-Term Lung Transplant Survivors

Background: During the first two years after lung transplantation (LTx), the incidence of fragility fractures (FX) is estimated to be 15–50% and it is lower in patients with cystic fibrosis (CF) as compared with other end-stage lung diseases (nCF). The aim of our study is to compare the skeletal outcomes, after the first 2 years post-LTx, in long-term survivors with CF and nCF. Materials and Methods: We evaluated the FX rate, the changes in bone mineral density (BMD) and trabecular bone score (TBS) in 68 patients (38 CF and 30 nCF) who underwent LTx in our center and with a follow-up after LTx longer than 5 years (7.3 ± 2.0 years). Results: After the second year post-LTx: (i) the FX rate was lower than during the first two years post-LTx (4.4 vs. 20.6%, p = 0.004), with no difference between CF and nCF patients (5.3 vs. 3.3%, p = 0.589); (ii) BMD at lumbar spine, femoral neck and total hip remained stable (−1.6 ± 1.0 vs. −1.4 ± 1.1, p = 0.431, −1.8 ± 0.9 vs. −1.9 ± 0.9, p = 0.683, −1.5 ± 0.9 vs. −1.4 ± 0.9, p = 0.678, respectively) as well as TBS (1.200 ± 0.124 vs. 1.199 ± 0.205, p = 0.166). Conclusions: After the second year post-LTx, the skeletal complications become less frequent and have similar incidence in patients with CF and nCF.

Deep Learning Assistance Closes the Accuracy Gap in Fracture Detection Across Clinician Types

BACKGROUND

Missed fractures are the most common diagnostic errors in musculoskeletal imaging and can result in treatment delays and preventable morbidity. Deep learning, a subfield of artificial intelligence, can be used to accurately detect fractures by training algorithms to emulate the judgments of expert clinicians. Deep learning systems that detect fractures are often limited to specific anatomic regions and require regulatory approval to be used in practice. Once these hurdles are overcome, deep learning systems have the potential to improve clinician diagnostic accuracy and patient care.

QUESTIONS/PURPOSES

This study aimed to evaluate whether a Food and Drug Administration-cleared deep learning system that identifies fractures in adult musculoskeletal radiographs would improve diagnostic accuracy for fracture detection across different types of clinicians. Specifically, this study asked: (1) What are the trends in musculoskeletal radiograph interpretation by different clinician types in the publicly available Medicare claims data? (2) Does the deep learning system improve clinician accuracy in diagnosing fractures on radiographs and, if so, is there a greater benefit for clinicians with limited training in musculoskeletal imaging?

METHODS

We used the publicly available Medicare Part B Physician/Supplier Procedure Summary data provided by the Centers for Medicare & Medicaid Services to determine the trends in musculoskeletal radiograph interpretation by clinician type. In addition, we conducted a multiple-reader, multiple-case study to assess whether clinician accuracy in diagnosing fractures on radiographs was superior when aided by the deep learning system compared with when unaided. Twenty-four clinicians (radiologists, orthopaedic surgeons, physician assistants, primary care physicians, and emergency medicine physicians) with a median (range) of 16 years (2 to 37) of experience postresidency each assessed 175 unique musculoskeletal radiographic cases under aided and unaided conditions (4200 total case-physician pairs per condition). These cases were comprised of radiographs from 12 different anatomic regions (ankle, clavicle, elbow, femur, forearm, hip, humerus, knee, pelvis, shoulder, tibia and fibula, and wrist) and were randomly selected from 12 hospitals and healthcare centers. The gold standard for fracture diagnosis was the majority opinion of three US board-certified orthopaedic surgeons or radiologists who independently interpreted the case. The clinicians' diagnostic accuracy was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, sensitivity, and specificity. Secondary analyses evaluated the fracture miss rate (1-sensitivity) by clinicians with and without extensive training in musculoskeletal imaging.

RESULTS

Medicare claims data revealed that physician assistants showed the greatest increase in interpretation of musculoskeletal radiographs within the analyzed time period (2012 to 2018), although clinicians with extensive training in imaging (radiologists and orthopaedic surgeons) still interpreted the majority of the musculoskeletal radiographs. Clinicians aided by the deep learning system had higher accuracy diagnosing fractures in radiographs compared with when unaided (unaided AUC: 0.90 [95% CI 0.89 to 0.92]; aided AUC: 0.94 [95% CI 0.93 to 0.95]; difference in least square mean per the Dorfman, Berbaum, Metz model AUC: 0.04 [95% CI 0.01 to 0.07]; p < 0.01). Clinician sensitivity increased when aided compared with when unaided (aided: 90% [95% CI 88% to 92%]; unaided: 82% [95% CI 79% to 84%]), and specificity increased when aided compared with when unaided (aided: 92% [95% CI 91% to 93%]; unaided: 89% [95% CI 88% to 90%]). Clinicians with limited training in musculoskeletal imaging missed a higher percentage of fractures when unaided compared with radiologists (miss rate for clinicians with limited imaging training: 20% [95% CI 17% to 24%]; miss rate for radiologists: 14% [95% CI 9% to 19%]). However, when assisted by the deep learning system, clinicians with limited training in musculoskeletal imaging reduced their fracture miss rate, resulting in a similar miss rate to radiologists (miss rate for clinicians with limited imaging training: 9% [95% CI 7% to 12%]; miss rate for radiologists: 10% [95% CI 6% to 15%]).

CONCLUSION

Clinicians were more accurate at diagnosing fractures when aided by the deep learning system, particularly those clinicians with limited training in musculoskeletal image interpretation. Reducing the number of missed fractures may allow for improved patient care and increased patient mobility.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Harnessing the potential of oxygen-generating materials and their utilization in organ-specific delivery of oxygen

The limited availability of transplantable organs hinders the success of patient treatment through organ transplantation. In addition, there are challenges with immune rejection and the risk of disease transmission when receiving organs from other individuals. Tissue engineering aims to overcome these challenges by generating functional three-dimensional (3D) tissue constructs. When developing tissues or organs of a particular shape, structure, and size as determined by the specific needs of the therapeutic intervention, a tissue specific oxygen supply to all parts of the tissue construct is an utmost requirement. Moreover, the lack of a functional vasculature in engineered tissues decreases cell survival upon implantation in the body. Oxygen-generating materials can alleviate this challenge in engineered tissue constructs by providing oxygen in a sustained and controlled manner. Oxygen-generating materials can be incorporated into 3D scaffolds allowing the cells to receive and utilize oxygen efficiently. In this review, we present an overview of the use of oxygen-generating materials in various tissue engineering applications in an organ specific manner as well as their potential use in the clinic.

Factors predictive of functional outcomes and quality of life in patients with fragility hip fracture: A retrospective cohort study

To determine the predictors of functional outcomes and quality of life (QoL) of patients who were surgically treated for fragility hip fracture. This was a retrospective cohort study performed in the 3 tertiary rehabilitation facilities. A total of 165 patients who had undergone surgery for fragility hip fracture were followed up to 6 months postoperatively. The factors expected to be related to the functional outcomes and QoL at 6 months post-surgery were as follows: baseline demographics, fracture site, operation type, fall characteristics including fall location and fall direction, comorbidities, and initial functional status. The following were comorbidities: hypertension, diabetes mellitus, dementia, cerebrovascular accident, and osteoporosis. Functional outcome and QoL measures were represented using the Koval grade, functional ambulatory category (FAC), Berg balance scale, 4-m walking speed test, the Korean version of Mini-Mental State Examination, EuroQol 5-dimension (EQ-5D) questionnaire, the Korean version of Modified Barthel Index, and the Korean version of instrumental activities of daily living (K-IADL). For all tests, each patient was assessed immediately after transfer and at 6 months post-surgery. Multivariable regression analyses adjusting for factors mentioned above were as follows. Old age led to a significantly less favorable outcome on FAC and K-IADL at 6 months. Intertrochanteric fracture had a significantly positive impact on Koval at 6 months compared to femur neck and intertrochanteric fractures. Total hip replacement arthroplasty and bipolar hemiarthroplasty had a significantly positive impact on EQ-5D and FAC at 6 months respectively compared to other operation types. Fall characteristics didn't reveal any significant impact on functional outcomes and QoL. Patients with hypertension and diabetes mellitus had a significantly negative outcome on EQ-5D and K-IADL respectively. Among initial assessments of function and QoL, initial 4-m walking speed test, Korean version of Mini-Mental State Examination, K-IADL, and Korean version of Modified Barthel Index were independent predictors of function and QoL at 6 months. This study confirmed that age, fracture site, operation type, comorbidities, and initial physical and cognitive function significantly influenced recovery of function and QoL at 6 months in patients with fragility hip fractures.

The Role of Bone Cell Energetics in Altering Bone Quality and Strength in Health and Disease

PURPOSE OF REVIEW

Bone quality and strength are diminished with age and disease but can be improved by clinical intervention. Energetic pathways are essential for cellular function and drive osteogenic signaling within bone cells. Altered bone quality is associated with changes in the energetic activity of bone cells following diet-based or therapeutic interventions. Energetic pathways may directly or indirectly contribute to changes in bone quality. The goal of this review is to highlight tissue-level and bioenergetic changes in bone health and disease.

RECENT FINDINGS

Bone cell energetics are an expanding field of research. Early literature primarily focused on defining energetic activation throughout the lifespan of bone cells. Recent studies have begun to connect bone energetic activity to health and disease. In this review, we highlight bone cell energetic demands, the effect of substrate availability on bone quality, altered bioenergetics associated with disease treatment and development, and additional biological factors influencing bone cell energetics. Bone cells use several energetic pathways during differentiation and maturity. The orchestration of bioenergetic pathways is critical for healthy cell function. Systemic changes in substrate availability alter bone quality, potentially due to the direct effects of altered bone cell bioenergetic activity. Bone cell bioenergetics may also contribute directly to the development and treatment of skeletal diseases. Understanding the role of energetic pathways in the cellular response to disease will improve patient treatment.

3D reconstruction of proximal femoral fracture from biplanar radiographs with fractural representative learning

A femoral fracture is a severe injury occurring in traumatic and pathologic causes. Diagnosis and Preoperative planning are indispensable procedures relying on preoperative radiographs such as X-ray and CT images. Nevertheless, CT imaging has a higher cost, radiation dose, and longer acquisition time than X-ray imaging. Thus, the fracture 3D reconstruction from X-ray images had been needed and remains a challenging problem, as well as a lack of dataset. This paper proposes a 3D proximal femoral fracture reconstruction from biplanar radiographs to improve the 3D visualization of bone fragments during preoperative planning. A novel Fracture Reconstruction Network (FracReconNet) is proposed to retrieve the femoral bone shape with fracture details, including the 3D Reconstruction Network (3DReconNet), novel Auxiliary class (AC), and Fractural augmentation (FA). The 3D reconstruction network applies a deep learning-based, fully Convolutional Network with Feature Pyramid Network architecture. Specifically, the auxiliary class is proposed, which refers to fracture representation. It encourages network learning to reconstruct the fracture. Since the samples are scarce to acquire, the fractural augmentation is invented to enlarge the fracture training samples and improve reconstruction accuracy. The evaluation of FracReconNet achieved a mIoU of 0.851 and mASSD of 0.906 mm. The proposed FracReconNet's results show fracture detail similar to the real fracture, while the 3DReconNet cannot offer.

Conditional Loss of Nmp4 in Mesenchymal Stem Progenitor Cells Enhances PTH-Induced Bone Formation

Activation of bone anabolic pathways is a fruitful approach for treating severe osteoporosis, yet FDA-approved osteoanabolics, eg, parathyroid hormone (PTH), have limited efficacy. Improving their potency is a promising strategy for maximizing bone anabolic output. Nmp4 (Nuclear Matrix Protein 4) global knockout mice exhibit enhanced PTH-induced increases in trabecular bone but display no overt baseline skeletal phenotype. Nmp4 is expressed in all tissues; therefore, to determine which cell type is responsible for driving the beneficial effects of Nmp4 inhibition, we conditionally removed this gene from cells at distinct stages of osteogenic differentiation. Nmp4-floxed (Nmp4fl/fl ) mice were crossed with mice bearing one of three Cre drivers including (i) Prx1Cre+  to remove Nmp4 from mesenchymal stem/progenitor cells (MSPCs) in long bones; (ii) BglapCre+  targeting mature osteoblasts, and (iii) Dmp1Cre+  to disable Nmp4 in osteocytes. Virgin female Cre+  and Cre- mice (10 weeks of age) were sorted into cohorts by weight and genotype. Mice were administered daily injections of either human PTH 1-34 at 30 μg/kg or vehicle for 4 weeks or 7 weeks. Skeletal response was assessed using dual-energy X-ray absorptiometry, micro-computed tomography, bone histomorphometry, and serum analysis for remodeling markers. Nmp4fl/fl ;Prx1Cre+  mice virtually phenocopied the global Nmp4-/- skeleton in the femur, ie, a mild baseline phenotype but significantly enhanced PTH-induced increase in femur trabecular bone volume/total volume (BV/TV) compared with their Nmp4fl/fl ;Prx1Cre- controls. This was not observed in the spine, where Prrx1 is not expressed. Heightened response to PTH was coincident with enhanced bone formation. Conditional loss of Nmp4 from the mature osteoblasts (Nmp4fl/fl ;BglapCre+ ) failed to increase BV/TV or enhance PTH response. However, conditional disabling of Nmp4 in osteocytes (Nmp4fl/fl ;Dmp1Cre+ ) increased BV/TV without boosting response to hormone under our experimental regimen. We conclude that Nmp4-/- Prx1-expressing MSPCs drive the improved response to PTH therapy and that this gene has stage-specific effects on osteoanabolism. © 2022 American Society for Bone and Mineral Research (ASBMR).

Epidemiology and the economic burden of traumatic fractures in China: A population-based study

OBJECTIVES

National data on the admission rate, distribution, in-hospital mortality, and economic burden of traumatic fractures in China is unclear. We aimed to conduct a cross-sectional population-based study to determine such above data at the national level in China.

METHODS

A national administrative database was used to review all traumatic fracture hospitalizations in China during 2020, from which a total of 2,025,169 inpatients with traumatic fractures was retrieved. Admission rates and in-hospital mortality rates stratified by age, sex, and region were calculated. The causes of traumatic fracture and economic burden were described.

RESULTS

The admission rate of traumatic fractures of all China population in 2020 was 1.437‰. The admission rate increased with age and varied with genders and causes of injuries. Falls are the leading cause of traumatic fracture hospitalization, followed by road traffic injuries. The most common diagnoses were femoral neck fractures, with a number of 138,377. The in-hospital mortality was 1.209‰. Road traffic injuries led to the highest in-hospital mortality. The median length of stay was 10 days, with the median hospitalization cost of ¥20,900 (about $3,056).

CONCLUSION

Traumatic fractures are concerning conditions with a high admission rate and in-hospital mortality in China, which are mainly caused by falls and road traffic injuries. The government should implement more public health policies to enhance the health of the elderly and improve transportation safety to prevent traumatic fractures.

Exosomes derived from human umbilical cord mesenchymal stem cells promote osteogenesis through the AKT signaling pathway in postmenopausal osteoporosis

Postmenopausal osteoporosis (PMO) is a relatively common disease characterized by low bone mass and microstructural changes of trabecular bone. The reduced bone strength is caused a variety of complications, including fragility fracture and sarcopenia. We used CCK-8 and EdU assays to evaluate cell proliferation rates. The osteogenesis effect was detected using ALP staining, alizarin red staining, and q-PCR. In vivo, the effects of exosomes derived from HUC-MSCs were evaluated using HE staining, IHC staining and Masson staining. In addition, we explored the mechanism of exosomes and found that the AKT signaling pathway played an important role in osteogenesis and cell proliferation. This paper mainly explored the function of exosomes derived from human umbilical cord mesenchymal stem cells (HUC-MSCs) and provided a new strategy for the treatment of postmenopausal osteoporosis. In conclusion, exogenous administration of exosomes can contribute to the treatment postmenopausal osteoporosis to a certain extent.

Quality of life after fracture-related infection of the foot

BACKGROUND

Fracture related infection (FRI) of the foot is a serious hazard. Despite successful therapy, the physiological and psychological involvement seems to be high. Therefore, we aim to analyze the impact of an FRI of the foot on the quality of life after successful surgical therapy and infect eradication.

METHODS

In total, 25 patients from two German hospitals treated for FRI of the foot between March 2011 to January 2020 were retrospectively included. Quality of life was assessed by the German Short Form 36 (SF-36) and the EuroQol five-dimension three-level questionnaire (EQ-5D) as well as the ICD-10 based psychological symptom rating (ISR), and compared to a norm obtained from the general population of Germany.

RESULTS

3.0 years (range 0.7-7.9 years) following final surgery after fracture-related infection of the foot, the mean physical health component score (PCS) of the SF-36 was 35.6 ± 12.3, and the mean mental health component score (MCS) of the SF-36 reached a value of 41.3 ± 12.9. Both values were significantly lower than in the general population of Germany (p< .019). The mean scores of the ISR of the cohort crossed the threshold of mild symptom burden in total, as well as for the subscales depression and somatization. The mean EQ-5D VAS rating (62.1 ± 18.6) and the EQ-5D index value (0.66 ± 0.27) were significantly lower in comparison to a score of 72.9 ± 1.0 and 0.88 obtained from an age-matched reference population (p < .01).

CONCLUSION

FRI of the foot represents a major burden for the patient. Physical and mental well-being of affected patients is restricted albeit successful treatment in terms of infect eradication and bone union has been achieved after a mean follow-up of 3.0 years. A patient-centered treatment approach focusing on improvement of quality of life during and after treatment is therefore warranted.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update

Osteoporosis constitutes a significant public health risk. An estimated 10.2 million adults in the United States >50 years of age have osteoporosis, a systemic condition that weakens the bones increasing the susceptibility for fractures. Approximately one-half of women and nearly one-third of men >50 years of age will sustain an osteoporotic fracture. These fractures are associated with a decrease in quality of life, diminished physical function, and reduced independence. Dual-energy X-ray absorptiometry (DXA) is the primary imaging modality used to screen for osteoporosis in women >65 years of age and men >70 years of age. DXA may be used in patients <65 years of age to evaluate bone mass density if there are additional risk factors. In certain situations, vertebral fracture assessment and trabecular bone score may further predict fracture risk, particularly in patients who are not yet osteoporotic but are in the range of osteopenia. Quantitative CT is useful in patients with advanced degenerative changes in the spine. Given the proven efficacy of pharmacologic therapy, the role of imaging to appropriately identify and monitor high-risk individuals is critical in substantially reducing osteoporosis-associated morbidity and mortality, and reducing the considerable cost to the health care system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Tibio-Talar-Calcaneal Nail Fixation for Ankle Fractures: A Systematic Review and Meta-Analysis

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multidatabase literature search was performed on December 14, 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36-104 weeks). Surgical site infection occurred in 11.2% (95% confidence interval [CI] 6.3%-19%) of patients, implant failure occurred in 8.1% (95% CI 5%-12.8%) of patients, and unplanned return to operating room occurred in 10.1% (95% CI 6.1%-16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7%-34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (95% CI: 67.4%-90.4%) of patients were able to return to similar preoperative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for nonoperative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. About 81.5% (95% CI 67.4%-90.4%) of patients were able to return to a similar preinjury mobility status after tibio-talar-calcaneal nailing.

How high-fat diet affects bone in mice: A systematic review and meta-analysis

High-fat diet (HFD) feeding for mice is commonly used to model obesity. However, conflicting results have been reported on the relationship between HFD and bone mass. In this systematic review and meta-analysis, we synthesized data from 80 articles to determine the alterations in cortical and trabecular bone mass of femur, tibia, and vertebrae in C57BL/6 mice after HFD. Overall, we detected decreased trabecular bone mass as well as deteriorated architecture, in femur and tibia of HFD treated mice. The vertebral trabecula was also impaired, possibly due to its reshaping into a more fragmentized pattern. In addition, pooled cortical thickness declined in femur, tibia, and vertebrae. Combined with changes in other cortical parameters, HFD could lead to a larger femoral bone marrow cavity, and a thinner and more fragile cortex. Moreover, we conducted subgroup analyses to explore the influence of mice's sex and age as well as HFD's ingredients and intervention period. Based on our data, male mice or mice aged 6-12 weeks old are relatively susceptible to HFD. HFD with > 50% of energy from fats and intervention time of 10 weeks to 5 months are more likely to induce skeletal alterations. Altogether, these findings supported HFD as an appropriate model for obesity-associated bone loss and can guide future studies.

Influence on Therapeutic Decision-Making of Supine and Standing Radiographs after Traumatic Thoracolumbar Fracture in the Elderly

Background A standing X-ray is recommended for decision-making relative to the therapy for a traumatic thoracolumbar fracture (TLF). However, standing X-ray management can be demanding in elderly patients because of pain. The goal of this study was to determine whether supine radiograph is sufficient for proper therapeutic decision-making in patients older than 65 years with acute stable traumatic TLF.

Methods Patients older than 65 years who came to the emergency department diagnosed with an acute and stable traumatic vertebral fracture between T10 and L3 (both included) were included in the study. Initially, all the patients were studied with a supine radiograph and computed tomography (CT) scan. If the TLF was stable, a standing radiograph was performed. Segmental kyphosis (SK) and visual analog scale (VAS) score were collected and compared in both the supine and standing X-ray projections.

Results Twenty-seven patients with a mean age of 76.39 (range: 65–93) years were included; most were females. The mean supine SK was 10.14degrees (SD±7.22degrees). It increased to 12.97 (SD±8.61degrees) in the standing projection (p<0.001). In 37.1% of the patients, the SK increased from 13.22degrees (SD±7.21degrees) in supine X-ray to 19.96degrees (SD±5.34degrees) in the standing position in this group. When the initial supine projection showed an SK of ≥10degrees, the mean SK observed in the standing X-ray increased to 20.5degrees (SD±5.30, p=0.321).

Conclusion Stable traumatic TLF in patients older than 65 years showing ≥10degrees of SK in supine radiography may benefit from a standing radiography to make a proper therapeutic decision.

Association of skin autofluorescence with low bone density/osteoporosis and osteoporotic fractures in type 2 diabetes mellitus

BACKGROUND

Advanced glycation end products (AGEs) that abnormally accumulate in diabetic patients have been reported to damage bone health. We aimed to investigate the association between skin autofluorescence (SAF)-AGE_age (SAF - AGEs × age/100) and low bone density (LBD)/osteoporosis or major osteoporotic fractures (MOFs) in patients with type 2 diabetes mellitus (T2DM).

METHODS

This study was nested in the prospective REACTION (Risk Evaluation of Cancers in Chinese Diabetic Individuals) study and included 1214 eligible participants. SAF was used to measure skin AGEs (SAF-AGEs). Fracture events were determined by an in-person clinical follow-up. Binary logistic regression analysis, linear regression analysis, and a restricted cubic spline nested in logistic models were used to test outcomes.

RESULTS

The overall prevalence of LBD/osteoporosis in middle-aged or elderly T2DM patients was 35.7% (n = 434), and the overall incidence of MOFs was 10.5% (n = 116). Logistic analysis showed a significantly positive relationship between quartiles of SAF-AGE_age and the risk of LBD/osteoporosis (odds ratio [OR] 2.02, 95% CI 1.34-3.03; OR 3.63, CI 2.44-5.39; and OR 6.51, CI 4.34-9.78) for the multivariate-adjusted models, respectively. SAF-AGE_age was associated with MOFs with a multivariate-adjusted OR of 1.02 (CI 0.52-2.02), 2.42 (CI 1.32-4.46), and 2.70 (CI 1.48-4.91), respectively. Stratified analyses showed that SAF-AGE_age was significantly associated with MOFs only in females, nonsmokers, nondrinkers, individuals with lower body mass index, and those without LBD/osteoporosis. Linear regression analyses showed that higher SAF-AGEs were associated with a higher level of serum N-terminal propeptide of type I procollagen (s-PINP) and serum carboxy-terminal cross-linking peptide of type I collagen (s-CTX), with a multivariate-adjusted OR of 1.02 (CI 0.24-1.80) and 6.30 (CI 1.77-10.83), respectively.

CONCLUSIONS

In conclusion, SAF-AGE_age was positively associated with the prevalence of LBD/osteoporosis or MOFs in patients with T2DM. A positive association between SAF-AGEs and the level of s-PINP and s-CTX was found.

Budesonide Maintenance in Microscopic Colitis: Clinical Outcomes and Safety Profile From a Population-Based Study

INTRODUCTION

Outcomes and safety of budesonide maintenance therapy in microscopic colitis (MC) are not well known.

METHODS

Adult residents of Olmsted County, Minnesota, diagnosed with MC (2002-2019) and treated with budesonide were identified using the Rochester Epidemiology Project. Response was assessed at 12 ± 4 weeks after initiation of therapy and defined as complete (resolution of diarrhea), partial (≥50% improvement in the number of bowel movements), nonresponse (&lt;50% improvement), and intolerance (discontinued because of side effects). For safety outcomes, cases (budesonide maintenance) and MC controls (no budesonide therapy) were matched by sex and age at diagnosis (±2 years).

RESULTS

A total of 450 patients were identified, of whom 162 (36.0%) were treated with budesonide for induction of clinical remission (median age 67 [23-91] years and 126 women [77.8%] ). Clinical outcomes for induction were as follows: 130 (80.2%) complete response, 22 (13.6%) partial response, 8 (4.9%) no response, and 2 (1.2%) intolerance. After induction, 96 (63.2%) had recurrence after discontinuation, of whom 27 (28.1%) required further budesonide induction treatment without maintenance, 56 (58.3%) required long-term budesonide maintenance, and 13 (13.5%) were treated with other therapies. Of those receiving budesonide maintenance, all responded (55 [98.2%] complete and 1 [1.8%] partial). No patient stopped maintenance from adverse events. The median duration of follow-up was 5.6 years (0.3-18.9). There was no significant difference between cases and controls in the incidence of osteopenia/osteoporosis, diabetes mellitus, hypertension, glaucoma, or cataracts.

DISCUSSION

The long-term use of budesonide in MC seems to be effective and generally well tolerated with limited adverse effects.

Cost-effectiveness studies of vertebral augmentation for osteoporotic vertebral fractures: a systematic review

BACKGROUND CONTEXT

Osteoporotic vertebral fractures (OVF) dramatically increase with age and are serious life altering adverse events for seniors resulting in increased rates of institutionalization, morbidity and mortality. Given the expanding population of the elderly and increasing prevalence of OVFs, cost-effective treatment strategies need to be considered. Percutaneous vertebral augmentation (VA) procedures such as vertebroplasty (VP) or balloon kyphoplasty (BK) are increasingly employed to treat painful vertebral fractures not responding to conservative management (CM) of bedrest and analgesia. Both VA procedures have been shown to be effective treatments for OVFs in multiple systematic reviews of randomized controlled trials. In this systematic review, analytical strategies, designs and results were compared for health economic studies evaluating cost-effectiveness of VA procedures, VP or BK for OVFs. Furthermore, assessments of quality (risk of bias) were conducted for the systematic review and the individual studies with peer-reviewed checklists recommended for cost-effectiveness studies.

PURPOSE

To provide an up-to-date systematic review of peer-reviewed studies evaluating cost-effectiveness of VA procedures, VP or KP for OVFs to support treatment and health care funding decisions.

STUDY DESIGN

This study is a systematic literature review and structured narrative synthesis.

STUDY SAMPLE

Peer reviewed health economic studies reporting cost-effectiveness for VA procedures, VP or BK for OVFs OUTCOME MEASURES: The following information extracted from the studies included: report country and year, study design, comparators, population, perspective, health valuations, costing sources and cost-effectiveness measures. For economic studies involving modeling, information was also extracted for model type, time horizon, key model drivers, and handling of uncertainty. Incremental cost-effectiveness ratio (ICER), the ratio of differences between comparator treatment groups in costs and health benefits, was considered the main cost-effectiveness measure.

METHODS

A systematic review was conducted of MEDLINE, EMBASE, CINAHL, ECONLIT, Cochrane Library and DARE databases up to the review date May 2021. Studies were reviewed for those reporting cost-effectiveness analyses on VA procedures including VP or BK for OVFs. Studies including only costs, abstracts, editorials, methodologies and reviews were not included. The selection of articles was reported in line with PRISMA guidance. A descriptive framework was developed to classify types of cost-effectiveness studies based on methodological differences and a structured narrative synthesis was used to summarize studies. Quality assessments were made with British Medical Journal checklist for individual cost-effectiveness studies and the CiCERO checklist for systematic reviews of cost-effectiveness studies.

RESULTS

In this systematic review, 520 references were identified through database searching and 501 were excluded as ineligible by titles and abstract based on prior eligibility criteria. From full-text reviews of 19 reports, ten were identified as eligible for the systematic review evaluating cost-effectiveness of VA procedures for OVFs. All references were published between 2008 and 2020. The ten cost-effectiveness studies, three for VP, three for BK and four for both VP and BK, all involved CM for OVFs as a treatment comparator. The studies involved different methods of economic analysis, modeling assumptions, cost and health valuations conducted in different health care setting over different time periods. A framework for the review outlines key features of cost-effectiveness study designs consisting of unmatched, matched, or randomized controls involving cost-effectiveness or cost-utility) analyses. Both VP and BK were cost-effective alternatives to CM for OVFs with earlier health gains and significantly shorter hospital stays. Cost-effectiveness estimates, ICERs, remained relatively stable and within willingness-to-pay thresholds under a range of sensitivity analyses. Comparisons between VP and BK were variable depending on modeling assumptions, but generally the procedures had similar health benefit gains with VP having lower acute procedural costs.

CONCLUSIONS

Both VP and BK, have been shown to be cost-effective alternatives to CM for osteoporotic vertebral fractures in diverse cost-effectiveness studies conducted in multiple health care settings. Trial-based cost-utility contributed the strongest evidence supporting cost-effectiveness determination for VP and BK for OVFs.

Incidence of Fracture Hospitalization and Surgery in Women Increases Steadily During the Puerperal and Lactation Period: A Retrospective Register-Based Cohort Study in Finland From 1999 to 2018

This retrospective cohort study assesses the incidences of major fractures and surgery in women during the puerperium and the lactation period in Finland between January 1, 1999, and December 31, 2018. Using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register, all women aged between 15 and 49 years with a fracture hospitalization within 12 months of delivery between 1999 and 2018 were included. During the study period, a total of 3140 fractures after delivery and 152,800 fractures of the female normal population of similar age were hospitalized. The incidence rate after delivery increased from 219/100,000 person-years during the first 4 months to 310 fractures/100,000 person-years during the latter 8 months of the first year after delivery. Altogether, 29% (n = 904/3140) of these fractures were treated operatively. The most common fractures were ankle and distal radius fractures, which made up one-third of all fractures. The incidence of pelvic fracture hospitalization was 15/100,000 person-years at 4 months after delivery, with an operation rate of 22%. Over half of all fractures occurred between 6 and 12 months after delivery (mean 6.6 months). The incidence of fracture hospitalization after delivery increased steadily during the puerperium and the lactation periods but remained lower than in the general population (age-adjusted incidence 554/100,000 person-years) with an incidence rate ratio of 0.51. However, a higher proportion of pelvic fractures were observed in the first months after delivery. Surgical rates were in line with the general population. Fractures of the wrist and ankle made up most of the fractures. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).