Disability after clinical fracture in postmenopausal women with low bone density: the fracture intervention trial (FIT)

Association between dental diseases and oral hygiene care and the risk of vertebral fracture: a nationwide cohort study

Periodontal disease and increased missing teeth were associated with incident vertebral fractures. In contrast, professional dental cleaning and frequent tooth brushing, was associated with a lower risk of vertebral fracture. Better oral hygiene care attenuated the risk associated with dental diseases.

PURPOSE

To investigate the association between oral health and the risk of vertebral fractures.

METHODS

We included 2,532,253 individuals aged ≥40 years who underwent the Korean National Health Insurance Service health examinations in 2008 and followed up until December 31, 2017. We performed multivariable Cox proportional hazard regression analyses to evaluate the association between dental diseases and oral hygiene care and the risk of vertebral fractures.

RESULTS

Over the 9.3-year median follow-up, 1.46% (n = 36,857) experienced vertebral fractures. Individuals with dental diseases had a higher risk of vertebral fracture than those without (hazard ratio [HR] 1.04, 95% confidence interval [CI]: 1.02-1.07 for periodontal diseases; 1.02, 1.00-1.05 for dental caries; 1.12, 1.05-1.20 for ≥15 missing teeth). Good oral hygiene care was associated with a lower vertebral fracture risk (HR 0.89, 95% CI: 0.86-0.91 for ≥1 time/year [vs. <1 time/year] of professional dental cleaning; 0.90, 0.87-0.93 for ≥2 times/day [vs. 0-1 time/day] of toothbrushing). The combined dental diseases was significantly associated with an increased vertebral fracture risk, whereas combined oral hygiene care was associated with further risk reduction. Better oral hygiene care reduced vertebral fracture risk associated with dental diseases (all P <0.001).

CONCLUSION

Periodontal disease, dental caries, and an increased number of missing teeth were independently associated with higher risks for vertebral fractures. Conversely, improved oral hygiene care, such as personal dental cleaning and frequent tooth brushing, may modify vertebral fracture risks associated with dental disease.

Performance of Fracture Risk Assessment Tools by Race and Ethnicity: A Systematic Review for the ASBMR Task Force on Clinical Algorithms for Fracture Risk

The American Society of Bone and Mineral Research (ASBMR) Professional Practice Committee charged an ASBMR Task Force on Clinical Algorithms for Fracture Risk to review the evidence on whether current approaches for differentiating fracture risk based on race and ethnicity are necessary and valid. To help address these charges, we performed a systematic literature review investigating performance of calculators for predicting incident fractures within and across race and ethnicity groups in middle-aged and older US adults. We included English-language, controlled or prospective cohort studies that enrolled US adults aged >40 years and reported tool performance predicting incident fractures within individual race and ethnicity groups for up to 10 years. From 4838 identified references, six reports met eligibility criteria, all in women. Just three, all from one study, included results in non-white individuals. In these three reports, non-white women experienced relatively few major osteoporotic fractures (MOFs), especially hip fractures, and risk thresholds for predicting fractures in non-white women were derived from risks in the overall, predominantly white study population. One report suggested the Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) overestimated hip fracture similarly across race and ethnicity groups (black, Hispanic, American Indian, Asian, white) but overestimated MOF more in non-white than White women. However, these three reports were inconclusive regarding whether discrimination of FRAX or the Garvan calculator without BMD or of FRAX with BMD for MOF or hip fracture differed between white versus black women. This uncertainty was at least partly due to imprecise hip fracture estimates in black women. No reports examined whether ratios of observed to predicted hip fracture risks within each race or ethnicity group varied across levels of predicted hip fracture risk. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Sex- and Age Group-Specific Fracture Incidence Rates Trends for Type 1 and 2 Diabetes Mellitus

The incidence of major osteoporotic fractures has declined in men and women in Western countries over the last two decades. Although fracture risk is higher in persons with diabetes mellitus, trends of fractures remain unknown in men and women with diabetes. We investigated the trends in fracture incidence rates (IRs) in men and women with type 1 diabetes mellitus (T1D) and type 2 diabetes mellitus (T2D) in Denmark between 1997 and 2017. We identified men and women aged 18+ years who sustained a fracture (excluding skull and facial fractures) between 1997 and 2017 using the Danish National Patient Registry. We calculated sex-specific IRs of fractures per 10,000 person-years separately in persons with T1D, T2D, or without diabetes. Furthermore, we compared median IRs of the first 5 years (1997-2002) to the median IRs of the last 5 years (2012-2017). We identified 1,235,628 persons with fractures including 4863 (43.6% women) with T1D, 65,366 (57.5% women) with T2D, and 1,165,399 (54.1% women) without diabetes. The median IRs of fractures declined 20.2%, 19.9%, and 7.8% in men with T1D, T2D, and without diabetes, respectively (p-trend <0.05). The median IRs decreased 6.4% in women with T1D (p-trend = 0.35) and 25.6% in women with T2D (p-trend <0.05) but increased 2.3% in women without diabetes (p-trend = 0.08). Fracture IRs decreased in men with both diabetes types and only in women with T2D, highlighting the need for further attention behind the stable trend observed in women with T1D. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures - a propensity score matched comparison

BACKGROUND

Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF).

METHODS

All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared.

RESULTS

Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant.

CONCLUSION

rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.

Characteristics Associated With 5-Year Fracture Risk Versus 5-Year Mortality Risk Among Late-Life Men

BACKGROUND

Identifying late-life men who might benefit from treatment to prevent fracture is challenging given high mortality. Our objective was to evaluate risks of clinical fracture, hip fracture, and mortality prior to fracture among men aged at least 80 years.

METHODS

Study participants included 3 145 community-dwelling men (mean [standard deviation] age 83 [2.8] years) from the Osteoporotic Fractures in Men (MrOS) Study. We used separate multivariable Fine-Gray competing risk models with prespecified risk factors (age, hip bone mineral density [BMD], recent fracture [<5 years], fall history [previous year], and multimorbidity [# conditions]) to estimate subdistribution hazard ratios and absolute 5-year risks of any clinical fracture and mortality prior to clinical fracture. Secondary analysis considered a hip fracture.

RESULTS

There were 414 incident clinical fractures and 595 deaths without prior fracture within 5 years. BMD, fall history, and recent fracture were strong predictors of clinical fracture. Age and multimorbidity were strong predictors of mortality before fracture. After accounting for competing risks, age, BMD, and fall history were each associated with both risks of hip fracture and mortality before hip fracture. Model discrimination varied from 0.65 (mortality before fracture) to 0.79 (hip fracture). Estimated mortality differed substantially among men with similar clinical fracture risk due to a modest correlation between fracture risk and competing mortality risk = 0.37.

CONCLUSION

In late-life men, strong risk factors for clinical fracture and hip fracture include fall history, BMD, and recent fracture. Osteoporosis drug treatment decisions may be further enhanced by consideration of fracture risk versus overall life expectancy.

International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures

We identified a knowledge gap in the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.

MAIN RESULTS

This international consensus process established multidisciplinary biopsychosocial recommendations on pain, nutrition, safe movement, and exercise for individuals with acute and chronic vertebral fractures.

SIGNIFICANCE

These recommendations will guide clinical practice and inform interventions for future research.

PURPOSE

To establish international consensus on recommendations for the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.

METHODS

We adopted a five-step modified Delphi consensus process: (1) literature search and content analysis, (2) creation of the survey, (3) selection of the expert panel, (4) first round of the rating process, and (5) second round of the rating process. The first round included 49 statements and eight open-ended questions; the second round included 30 statements. Panelists were asked to rate their agreement with each of the statements using a 9-point scale, with the option to provide further comments. Consensus for each statement was determined by counting the number of panelists whose rating was outside the 3-point region containing the median.

RESULTS

We invited 76 people with degree in medicine, physiotherapy, kinesiology, and experience in the management of osteoporotic vertebral; 31 (41%) and 27 (36%) experts agreed to participate to the first and the second round, respectively. The mean percentage agreement after the first and second rounds was 76.6% ± 16.0% and 90.7% ± 6.5%, respectively. We established consensus on recommendations on pain, early satiety, weight loss, bracing, safe movement, and exercise for individuals with acute and chronic vertebral fractures.

CONCLUSION

Our international consensus provides multidisciplinary biopsychosocial recommendations to guide the management of osteoporotic vertebral fractures and inform interventions for future research.

A cost-effectiveness analysis of reverse total shoulder arthroplasty compared with locking plates in the management of displaced proximal humerus fractures in the elderly: the DelPhi trial

AIM

To evaluate the cost-effectiveness of surgical treatment with reverse total shoulder arthroplasty (RTSA) compared with open reduction and internal fixation (ORIF) with a locking plate for patients 65-85 years old with a displaced proximal humerus fracture.

METHODS

A cost-utility analysis was conducted alongside a multicenter randomized controlled trial, taking a health care perspective. A total of 124 patients with displaced proximal humerus fractures were randomized to treatment with RTSA (n = 64) or ORIF (n = 60) during a 2-year period. The outcome measure was quality-adjusted life years derived from the generic questionnaire 15D in an intention to treat population. The results were expressed as incremental cost-effectiveness ratios, and a probabilistic sensitivity analysis was performed to account for uncertainty in the analysis.

RESULTS

At 2 years, 104 patients were eligible for analyses. The mean quality-adjusted life year was 1.24 (95% confidence interval: 1.21-1.28) in the RTSA group and 1.26 (95% confidence interval: 1.22-1.30) in the ORIF group. The mean cost in the RTSA group (€36.755 [€17,654-€55,855]) was higher than that in the ORIF group (€31.953 [€16,226-€47,279]). Using incremental cost-effectiveness ratio, ORIF was the dominant treatment. When using a probabilistic sensitivity analysis with 1000 replications, the plots were centered around origo. This indicates that there is no significant difference in cost or effect.

CONCLUSION

In the cost-utility analysis of treatment of displaced proximal humeral fractures, there were no differences between RTSA and ORIF.

Pharmacological options for pain control in patients with vertebral fragility fractures

This review considers the evidence base and current knowledge for pharmacological treatment options that are available for pain control in patients with vertebral fractures sustained after a low trauma incident. Due care needs to be taken when considering prescribed options for pain control. The decision should be based on first establishing whether the presentation is one of acute severe pain at the time of a new vertebral fragility fracture incident or whether the complaint is one of the debilitating, longer term chronic back pain syndrome, accompanied by a clinical suspicion of a possible new fracture. The article also presents currently debated questions in this important area of clinical and patient care and will be of interest to the readership worldwide.

Implementing and Evaluating the Impact of BoneRx: A Healthy Bone Prescription for Men with Prostate Cancer Initiating Androgen Deprivation Therapy

Background: The initiation of Androgen Deprivation Therapy (ADT) results in rapid and profound hypogonadism, resulting in significant bone and muscle loss, increasing the risk for osteoporosis (OP), falls, and fractures. Despite this, there exist very low rates of guideline adherent care regarding bone health in this population. We developed and implemented a healthy bone prescription tool entitled BoneRx to facilitate the uptake of guideline-concordant bone health care into practice and increase patient awareness and promote the uptake of health bone behaviours (HBBs). Methods: We conducted a cross-sectional pre-BoneRx implementation (n = 143) vs. post-implementation (n = 149) cohort study to evaluate the impact on (i) bone health care, patient engagement in HBB, and patient knowledge and health beliefs regarding OP. Results: There was a significant difference pre- vs. post BoneRx implementation on receipt of baseline BMD (34.7% vs. 59.5%, p < 0.0001) and bone health counselling (32.4% vs. 59.9%, p < 0.0001). More participants in the post-BoneRx implementation cohort reported taking vitamin D supplements 57% vs. 81% (p < 0.001) and calcium supplements 39% vs. 61% (p < 0.001). Physical activity levels also significantly increased (p = 0.021). No differences were detected in OP knowledge or feelings of OP susceptibility, seriousness, or health motivation. Conclusion: BoneRx is a simple, cost-effective, and acceptable strategy that could improve the care of PCa survivors receiving ADT.

Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient

BACKGROUND

Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly.

METHODS

We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up.

RESULTS

Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%.

CONCLUSION

In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.

Reverse total shoulder arthroplasty (RTSA) versus open reduction and internal fixation (ORIF) for displaced three-part or four-part proximal humeral fractures: a systematic review and meta-analysis

Despite rapid medical technology development, various challenges exist in three- and four-part proximal humeral fracture (PHF) management. This condition has led to a notably increased use of the reverse total shoulder arthroplasty (RTSA); however, open reduction and internal fixation (ORIF) is still the most widely performed procedure. Thus, these two modalities are crucial and require further discussion. We aim to compare the outcomes of three- or four-part PHF surgeries using ORIF and RTSA based on direct/head-to-head comparative studies.We conducted a systematic review and meta-analysis based on the Cochrane handbook and PRISMA guidelines. We searched MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Library) from inception to October 2020. Our protocol was registered at PROSPERO (registration number CRD42020214681). We assessed the individual study risk of bias using ROB 2 and ROBINS-I tools, then appraised our evidence using the GRADE approach.Six head-to-head comparative studies were included, comprising one RCT and five retrospective case-control studies. We found that RTSA significantly improved forward flexion but was comparable to ORIF in abduction (p = 0.03 and p = 0.47, respectively) and more inferior in external rotation (p < 0.0001). Moreover, RTSA improved the overall Constant-Murley score, but the difference was not significant (p = 0.22). Interestingly, RTSA increased complications (by 42%) but reduced the revision surgery rates (by 63%) compared to ORIF (p = 0.04 and p = 0.02, respectively).RTSA is recommended to treat patients aged 65 years or older with a three- or four-part PHF. Compared to ORIF, RTSA resulted in better forward flexion and Constant-Murley score, equal abduction, less external rotation, increased complications but fewer revision surgeries. Cite this article: EFORT Open Rev 2021;6:941-955. DOI: 10.1302/2058-5241.6.210049.

Feasibility of a generalized convolutional neural network for automated identification of vertebral compression fractures: The Manitoba Bone Mineral Density Registry

BACKGROUND

Vertebral fracture assessment (VFA) images are acquired in dual-energy (DE) or single-energy (SE) scan modes. Automated identification of vertebral compression fractures, from VFA images acquired using GE Healthcare scanners in DE mode, has achieved high accuracy through the use of convolutional neural networks (CNNs). Due to differences between DE and SE images, it is uncertain whether CNNs trained on one scan mode will generalize to the other.

PURPOSE

To evaluate the ability of CNNs to generalize between GE DE and GE SE VFA scan modes.

METHODS

12,742 GE VFA images from the Manitoba Bone Mineral Density Program, obtained between 2010 and 2017, were exported in both DE and SE modes. VFAs were classified by imaging specialists as fracture present or absent using the modified algorithm-based qualitative (mABQ) method. VFA scans were randomly divided into independent training (60%), validation (10%), and test (30%) sets. Three CNN models were constructed by training separately on DE only, SE only, and a composite dataset comprised of both SE and DE VFAs. All three trained CNN models were separately evaluated against both SE and DE test datasets.

RESULTS

Good performance was seen for CNNs trained and evaluated on the same scan mode. DE scans used for both training and evaluation (DE/DE) achieved 87.9% sensitivity, 87.4% specificity, and an area under the receiver operating characteristic curve (AUC) of 0.94. SE scans used for both training and evaluation (SE/SE) achieved 78.6% sensitivity, 90.6% specificity, AUC = 0.92. Conversely, CNNs performed poorly when evaluated on scan modes that differed from their training sets (AUC = 0.58). However, a composite CNN trained simultaneously on both SE and DE VFAs gave performance comparable to DE/DE (82.4% sensitivity, 94.3% specificity, AUC = 0.95); and provided improved performance over SE/SE (82.2% sensitivity, 92.3% specificity, AUC = 0.94). Positive predictive value was higher with the composite CNN compared with models trained solely on DE (74.5% vs. 58.7%) or SE VFAs (68.6% vs. 62.9%).

CONCLUSION

CNNs for vertebral fracture identification are highly sensitive to scan mode. Training CNNs on a composite dataset, comprised of both GE DE and GE SE VFAs, allows CNNs to generalize to both scan modes and may facilitate the development of manufacturer-independent machine learning models for vertebral fracture detection.

Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society

OBJECTIVE

To review evidence regarding osteoporosis screening, prevention, diagnosis, and management in the past decade and update the position statement published by The North American Menopause Society (NAMS) in 2010 regarding the management of osteoporosis in postmenopausal women as new therapies and paradigms have become available.

DESIGN

NAMS enlisted a panel of clinician experts in the field of metabolic bone diseases and/or women's health to review and update the 2010 NAMS position statement and recommendations on the basis of new evidence and clinical judgement. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, especially prevalent in older postmenopausal women, increases the risk of fractures that can be associated with significant morbidity and mortality. Postmenopausal bone loss, related to estrogen deficiency, is the primary contributor to osteoporosis. Other important risk factors for postmenopausal osteoporosis include advanced age, genetics, smoking, thinness, and many diseases and drugs that impair bone health. An evaluation of these risk factors to identify candidates for osteoporosis screening and recommending nonpharmacologic measures such as good nutrition (especially adequate intake of protein, calcium, and vitamin D), regular physical activity, and avoiding smoking and excessive alcohol consumption are appropriate for all postmenopausal women. For women at high risk for osteoporosis, especially perimenopausal women with low bone density and other risk factors, estrogen or other therapies are available to prevent bone loss. For women with osteoporosis and/or other risk factors for fracture, including advanced age and previous fractures, the primary goal of therapy is to prevent new fractures. This is accomplished by combining nonpharmacologic measures, drugs to increase bone density and to improve bone strength, and strategies to reduce fall risk. If pharmacologic therapy is indicated, government-approved options include estrogen agonists/antagonists, bisphosphonates, RANK ligand inhibitors, parathyroid hormone-receptor agonists, and inhibitors of sclerostin.

CONCLUSIONS

Osteoporosis is a common disorder in postmenopausal women. Management of skeletal health in postmenopausal women involves assessing risk factors for fracture, reducing modifiable risk factors through dietary and lifestyle changes, and the use of pharmacologic therapy for patients at significant risk of osteoporosis or fracture. For women with osteoporosis, lifelong management is necessary. Treatment decisions occur continuously over the lifespan of a postmenopausal woman. Decisions must be individualized and should include the patient in the process of shared decision-making.

External validity in a multicenter randomized clinical trial of proximal humeral fractures: the DelPhi trial

Background

Randomized controlled trials (RCT) are regarded as the gold standard for effect evaluation in clinical interventions. However, RCTs may not produce relevant results to all patient groups. We aimed to assess the external validity of a multicenter RCT (DelPhi trial).

Methods

The DelPhi RCT investigated whether elderly patients with displaced proximal humeral fractures (PHFs) receiving reversed total shoulder prosthetic replacement (RTSA) gained better functional outcomes compared to open reduction and internal fixation (ORIF) using an proximal humerus locking plate (PHILOS). Eligible patients were between 65 and 85 years old with severely displaced 11-B2 or 11-C2 fractures (AO/OTA-classification, 2007). We compared baseline and follow-up data of patients for two of the seven hospitals that were included in the DelPhi trial (n = 54) with non-included patients (n = 69). Comparisons were made based on reviewing medical records regarding demographic, health and fracture parameters.

Results

Forty-four percent of the eligible patients were included in the DelPhi trial. Comparing included and non-included patients indicated higher incidences of serious heart disease (P = 0.044) and a tendency toward higher tobacco intake (P = 0.067) in non-included patients. Furthermore, non-included patients were older (P = 0.040) and had higher ASA classification (P < 0.001) and were in more need for resident aid (in-home assistance) (P = 0.022) than included patients. The cause of PHF was more frequently related to fall indoors in non-included vs. included patients (P = 0.018) and non-included patients were more prone to other concomitant fractures (P = 0.004). Having concomitant fractures was associated with osteoporosis (P = 0.014). We observed no significant differences in rates of complications or deaths between included and non-included patients within 3 months after treatment. In descending order, non-included patients were treated conservatively, with PHILOS, RTSA, anatomic hemi-prothesis or an alternative type of ORIF. RTSA was the preferred treatment choice for C2-type fractures (P < 0.001).

Conclusions

Results from the DelPhi RCT may not directly apply to older PHFs patients with lower health status or concomitant fractures.

Level of evidence

Level 4.

Measures of physical performance as a predictor of fracture risk independent of BMD: The Chungju metabolic disease cohort study

BACKGROUND

Bone mineral density (BMD) assessments alone might not be sufficient for assessing fracture risk in the whole population, and decreased balance is an important risk factor for fracture. The aim of this study was to evaluate the association between baseline physical performance and fracture risk.

METHODS

This community-based cohort study was conducted in rural areas. The follow-up examination was performed in 4015 subjects for approximately 4 years. We used the one-leg standing time (OLST) to assess static balance and the timed up-and-go test (TUGT) to assess dynamic balance. Fractures were assessed during the medical interview.

RESULTS

The participants were divided into quartile groups according to their performance level, and the lowest baseline OLST performance was associated with a 2.1-fold increased risk of major osteoporotic fracture (MOF) independent of age, gender, hip BMD, fall incidence, and lifestyle factors. The participants in the low performance quartile of baseline OLST or TUGT performance had an increased incidence of osteoporosis and falling compared to that in the participants in the highest baseline performance quartile after adjusting for covariates. Among the participants with a femoral neck T-score above -2.5, the participants with an OLST below 14 s had a 1.7-fold higher risk of MOF than the participants with an OLST of 14 s or more.

CONCLUSIONS

The measurement of static balance by the OLST predicted the risk of fracture in Korean adults independent of BMD and fall history. Our results suggest that the OLST may have clinical utility in identifying individuals at risk of fracture, especially those who might not be adequately identified by BMD measurements alone.

One Approach Anterior Decompression and Fixation with Posterior Unilateral Pedicle Screw Fixation for Thoracolumbar Osteoporotic Vertebral Compression Fractures

Objective

The objective of the present paper was to explore the clinical effect of one approach anterior decompression and fixation with posterior unilateral pedicle screw fixation for thoracolumbar osteoporosis vertebral compression fractures (OVCF).

Methods

This is a single‐center retrospective analysis. A total of six thoracolumbar OVCF patients (four women and two men) with an average age of 65.2 years (58–72 years) who were treated between June 2016 and May 2018 were enrolled in the present study. The lesion segments included: 1 case at T11, 1 case at T12, 3 cases at L1, and 1 case at L2. The six thoracolumbar OVCF patients were treated with one approach anterior decompression and fixation with posterior unilateral pedicle screw fixation. After general anesthesia, patients were placed in the right lateral decubitus position, an approximately 10–15‐cm oblique incision was made along corresponding ribs, and the conventional left retroperitoneal and/or the extrapleural approach was performed for anterior lateral exposure. First, anterior decompression and fixation were performed, and then through the unilateral paraspinal muscle approach, posterior pedicle screw fixation was performed under the same incision. The back pain visual analogue scale (VAS), the Oswestry disability index (ODI), and the MacNab criteria were used to evaluate the clinical outcome. The radiographic analysis included the regional kyphosis angle and the fusion rate. Neurological status, operation time, intraoperative bleeding, the time of ambulation, hospital stay, and surgical complications were also assessed.

Results

Surgery was successful in all six patients, who were followed up for 31.6 months (range, 23–46 months). The operation time was 125–163 min, with a median of 135 min. The preoperative blood loss was 580–1230 mL, with a median of 760 mL. The time of ambulation was 3–5 days, with a median of 4.2 days. The hospital stay was 8–15 days, with the median of 10.5 days. According to the Frankel classification of neurological deficits, of two patients with grade C preoperatively, one had improved to grade D and one had improved to grade E at final follow up; among four patients with grade D preoperatively, at the final follow up one remained the same and three had improved to grade E. The postoperative back pain VAS score decreased significantly, from 6.17 ± 0.75 preoperatively to 0.83 ± 0.41 postoperatively (P < 0.05). The mean ODI score was 73.7 ± 5.86 preoperatively and reduced to 21.85 ± 3.27 postoperatively (P < 0.05). According to the MacNab criteria, at the final follow up, two patients rated their satisfaction as excellent, three patients as good, and one patient as fair. The mean regional kyphosis angle was 22.17° ± 6.01°before surgery, which improved to 9.33° ± 3.88° at the final follow up (P < 0.05). At the final follow up, there were two patients who had achieved a grade 2 bony fusion (33.3%), three patients grade 3 (50.0%), and one patient grade 4 (16.7%). No incision infections, internal fixation failures or other complications were found during the perioperative and the follow‐up period.

Conclusion

One approach anterior decompression and fixation with posterior unilateral pedicle screw fixation provides a novel method for thoracolumbar OVCF disease, with a satisfactory clinical outcome.

Obstructive Sleep Apnea and Risk for Incident Vertebral and Hip Fracture in Women

Recent studies suggest a positive association between obstructive sleep apnea (OSA), a disorder associated with intermittent hypoxia and sleep fragmentation, and derangements in bone metabolism. However, no prospective study to date has investigated the association between OSA and fracture risk in women. We conducted a prospective study examining the relation between OSA and risk of incident vertebral fracture (VF) and hip fracture (HF) in the Nurses' Health Study. History of physician-diagnosed OSA was assessed by self-reported questionnaires. A previous validation study demonstrated high concordance between self-reports and medical record identification of OSA. OSA severity was further categorized according to the presence or absence of self-reported sleepiness. Self-reports of VF were confirmed by medical record review. Self-reported HF was assessed by biennial questionnaires. Cox proportional-hazards models estimated the hazard ratio for fracture according to OSA status, adjusted for potential confounders, including BMI, physical activity, calcium intake, history of osteoporosis, and falls, and use of sleep medications. Among 55,264 women without prior history of fracture, physician-diagnosed OSA was self-reported in 1.3% in 2002 and increased to 3.3% by 2012. Between 2002 and 2014, 461 incident VF cases and 921 incident HF cases were documented. The multivariable-adjusted hazard ratio (HR) for confirmed VF for women with history of OSA was 2.00 (95% CI, 1.29-3.12) compared with no OSA history, with the strongest association observed for OSA with daytime sleepiness (HR 2.86; 95% CI, 1.31-6.21). No association was observed between OSA history and self-reported HF risk (HR 0.83; 95% CI, 0.49-1.43). History of OSA is independently associated with higher risk of confirmed VF but did not have a statistically significant association with self-reported HF in women. Further research is warranted in understanding the role of OSA and intermittent hypoxia in bone metabolism and health that may differ by fracture site. © 2020 American Society for Bone and Mineral Research (ASBMR).

Comorbid pain in axial spondyloarthritis, including fibromyalgia

The main symptom in patients with axial spondyloarthritis (axSpA) is inflammatory back pain, caused principally by inflammation of the sacroiliac joints and the spine. However, not all back pain in patients with axSpA is related to active inflammation: other types of pain can occur in these patients, and may be related to structural damage (e.g. ankylosis), degenerative changes, vertebral fractures or comorbid fibromyalgia, which are not uncommon in these patients. Structural damage and ankylosis may lead to a biomechanical stress, which can lead to chronic mechanical pain; and degenerative changes of the spine may also exist in patients with axSpA also leading to mechanical pain. Osteoporosis is more prevalent in axSpA patients than in the general population, and vertebral fractures may result in acute bone pain, which can persist for several months. Fibromyalgia, which is also more prevalent in patients with chronic inflammatory diseases (including axSpA), presents with widespread pain which can mimic entheseal pain. A correct diagnosis of the origin of the pain is crucial, since treatments and management may differ considerably. Recognizing these causes of pain may be a challenge in clinical practice, especially for fibromyalgia, which can coexist with axSpA and may have a significant impact on biologic drug response.

In this review, we provide an update of the most common causes of pain other than inflammatory back pain in axSpA patients, and we discuss the latest management options for such causes.

Back pain from painful osteoporotic vertebral fractures: discrepancy between the actual fracture location and the location suggested by patient-reported pain or physical examination findings

Caution is necessary when using symptom or physical examination findings to localize the osteoporotic vertebral fractures (VFs) attributable to the discrepant colocalized relationship.

INTRODUCTION

Whether the location of symptoms or physical examination findings delineates the appropriate spinal range for imaging has not been thoroughly investigated for VFs. The present study aims to analyze the consistency between the fractural vertebrae location and the location suggested by patient-reported pain or physical examination findings.

METHODS

This observational study, following a prospective design, enrolled 358 patients with VFs. The locations of two symptoms (patient-reported back pain [P-RBP], radiating pain [RP]) and findings from two physical examinations (spinal palpation tenderness [SPT], axial spinal percussion pain [ASPP]) were used to locate the VF segments identified using whole-spine magnetic resonance imaging (MRI). The percentage of agreements and kappa coefficient were calculated.

RESULTS

In 20.7% (74/358), the P-RBP site and VF segments were in the same location (kappa = 0.153); 21.2% (76/358) presented with concomitant RP in 93.4% (71/76) of whom the RP dermatome was colocalized with the VF segments (kappa = 0.924); 55.0% (197/358) and 23.2% (83/358) of patients presented with positive SPT and ASPP, respectively; and in 49.2% (97/197) and 96.4% (80/83) of patients with positive SPT (kappa = 0.435) and ASPP (kappa = 0.963), the positive finding and the VF segments were consistently colocalized.

CONCLUSIONS

The positive finding of RP or ASPP is useful in determining the spinal range for imaging tests, while an MRI scan covering the whole thoracic and lumbar spine is necessary in VF-suspected patients with P-RBP or positive SPT, indicating that caution is necessary when using symptoms or physical examination findings to localize VFs.

Uptrend of cervical and sacral fractures underlie increase in spinal fractures in the elderly, 2003-2017: analysis of a state-wide population database

BACKGROUND

Traumatic spinal injuries can be life-threatening conditions. Despite numerous epidemiological studies, reports on specific spinal regions affected are lacking.

HYPOTHESIS

We hypothesized that fractures at specific regions, such as the cervical spine (including the axis segment), have been affected to a greater degree. We also hypothesized that advanced age may be a significant contributing factor.

OBJECTIVE

To longitudinally analyze trend of spine fractures and specific fracture subtypes.

STUDY DESIGN

Longitudinal trend analysis of discharged patient state database.

PATIENT SAMPLE

Discharged patient's data from 15 years (2003-2017) METHODS: We retrieved pertinent ICD-9 and 10 codes depicting fractures involving the entire spine and specific subtypes. To assess possible association with age, we analyzed the trend of the average age in patients discharged with and without spinal fractures as well as in specific fracture subtypes. Similar analysis was performed for other common fragility fractures. FDA device/drug status: The manuscript submitted does not contain information about medical device(s) or drug(s).

RESULTS

We found that within 15 years, the overall proportion of spinal fractures has increased by 64% (from 0.47 to 0.77% of all discharged patients) with the greatest increase noted in fractures of the cervical spine (123%) and specifically of the second cervical vertebra (84%). Age was found to have increased more in patients with spinal fractures than in the general discharged population. Surprisingly, other non-spinal fractures among patients above 60 remained relatively stable, demonstrating a spine-specific effect.

CONCLUSIONS

Our findings confirm a recent increase in all spinal fractures and in the cervical and sacral regions in particular. Advanced age may be an important underlying factor.

Corrigendum to how to define an osteoporotic vertebral fracture

[This corrects the article DOI: 10.21037/qims.2019.09.10.].

Post-fracture Risk Assessment: Target the Centrally Sited Fractures First! A Substudy of NoFRACT

The location of osteoporotic fragility fractures adds crucial information to post-fracture risk estimation. Triaging patients according to fracture site for secondary fracture prevention can therefore be of interest to prioritize patients considering the high imminent fracture risk. The objectives of this cross-sectional study were therefore to explore potential differences between central (vertebral, hip, proximal humerus, pelvis) and peripheral (forearm, ankle, other) fractures. This substudy of the Norwegian Capture the Fracture Initiative (NoFRACT) included 495 women and 119 men ≥50 years with fragility fractures. They had bone mineral density (BMD) of the femoral neck, total hip, and lumbar spine assessed using dual-energy X-ray absorptiometry (DXA), trabecular bone score (TBS) calculated, concomitantly vertebral fracture assessment (VFA) with semiquantitative grading of vertebral fractures (SQ1-SQ3), and a questionnaire concerning risk factors for fractures was answered. Patients with central fractures exhibited lower BMD of the femoral neck (765 versus 827 mg/cm² ), total hip (800 versus 876 mg/cm² ), and lumbar spine (1024 versus 1062 mg/cm² ); lower mean TBS (1.24 versus 1.28); and a higher proportion of SQ1-SQ3 fractures (52.0% versus 27.7%), SQ2-SQ3 fractures (36.8% versus 13.4%), and SQ3 fractures (21.5% versus 2.2%) than patients with peripheral fractures (all p < 0.05). All analyses were adjusted for sex, age, and body mass index (BMI); and the analyses of TBS and SQ1-SQ3 fracture prevalence was additionally adjusted for BMD). In conclusion, patients with central fragility fractures revealed lower femoral neck BMD, lower TBS, and higher prevalence of vertebral fractures on VFA than the patients with peripheral fractures. This suggests that patients with central fragility fractures exhibit more severe deterioration of bone structure, translating into a higher risk of subsequent fragility fractures and therefore they should get the highest priority in secondary fracture prevention, although attention to peripheral fractures should still not be diminished. © 2019 American Society for Bone and Mineral Research. © 2019 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Association Between Abdominal Aortic Calcification, Bone Mineral Density, and Fracture in Older Women

Although a relationship between vascular disease and osteoporosis has been recognized, its clinical importance for fracture risk evaluation remains uncertain. Abdominal aortic calcification (AAC), a recognized measure of vascular disease detected on single-energy images performed for vertebral fracture assessment, may also identify increased osteoporosis risk. In a prospective 10-year study of 1024 older predominantly white women (mean age 75.0 ± 2.6 years) from the Perth Longitudinal Study of Aging cohort, we evaluated the association between AAC, skeletal structure, and fractures. AAC and spine fracture were assessed at the time of hip densitometry and heel quantitative ultrasound. AAC was scored 0 to 24 (AAC24) and categorized into low AAC (score 0 and 1, n = 459), moderate AAC (score 2 to 5, n = 373), and severe AAC (score >6, n = 192). Prevalent vertebral fractures were calculated using the Genant semiquantitative method. AAC24 scores were inversely related to hip BMD ( r _s = -0.077, p = 0.013), heel broadband ultrasound attenuation ( r _s = -0.074, p = 0.020), and the Stiffness Index ( r _s = -0.073, p = 0.022). In cross-sectional analyses, women with moderate to severe AAC were more likely to have prevalent fracture and lumbar spine imaging-detected lumbar spine fractures, but not thoracic spine fractures (Mantel-Haenszel test of trend p < 0.05). For 10-year incident clinical fractures and fracture-related hospitalizations, women with moderate to severe AAC (AAC24 score >1) had increased fracture risk (HR 1.48; 95% CI, 1.15 to 1.91; p = 0.002; HR 1.46; 95% CI, 1.07 to 1.99; p = 0.019, respectively) compared with women with low AAC. This relationship remained significant after adjusting for age and hip BMD for clinical fractures (HR 1.40; 95% CI, 1.08 to 1.81; p = 0.010), but was attenuated for fracture-related hospitalizations (HR 1.33; 95% CI, 0.98 to 1.83; p = 0.073). In conclusion, older women with more marked AAC are at higher risk of fracture, not completely captured by bone structural predictors. These findings further support the concept that vascular calcification and bone pathology may share similar mechanisms of causation that remain to be fully elucidated © 2019 American Society for Bone and Mineral Research.

How to define an osteoporotic vertebral fracture?

A vertebral deformity (VD) is not always a vertebral fracture (VF). Because of lack of a completely satisfactory "gold standard", there is no consensus on the exact definition of a VF. Therefore, it may sometimes be difficult, especially in mild cases, to discriminate the prevalent VF from a non-fracture deformity or short vertebral height (SVH). A combined standardized approach based on qualitative and semiquantitative (SQ) vertebral assessment may be the most option to correctly identify a VD as a VF. However this visual approach for VF identification is subjective, therefore it is mandatory an adequate training and experience of radiologist to reach a good sensitivity and specificity. Vertebral morphometry, objective and reproducible method, could be used only to evaluate the severity of VFs but requires the availability of reference values of vertebral height ratios. There is actually an evidentiary basis for suggesting that a qualitative approach by expert radiologists to morphological vertebral assessment, combined SQ and morphometric methods seem to be the preferred option for the correct diagnosis of VF as endplate or/and cortex fracture (ECF) or severe vertebral height loss.

High prevalence of vertebral fractures and low trabecular bone score in patients with fragility fractures: A cross-sectional sub-study of NoFRACT

PURPOSE

Norway has among the highest incidence rates of fractures in the world. Vertebral fracture assessment (VFA) and trabecular bone score (TBS) provide information about fracture risk, but their importance have not been studied in Norwegian patients with fragility fractures. The objectives of this study were to examine the clinical characteristics of a cohort of women and men with fragility fractures, their prevalence of vertebral fractures using VFA and prevalence of low TBS, and explore the differences between the sexes and patients with and without vertebral fractures.

METHODS

This cross-sectional sub-study of the Norwegian Capture the Fracture Initiative (NoFRACT) included 839 patients with fragility fractures. Of these, 804 patients had bone mineral density (BMD) of the total hip, femoral neck and/or spine assessed using dual energy x-ray absorptiometry, 679 underwent concomitant VFA, 771 had TBS calculated and 696 responded to a questionnaire.

RESULTS

Mean age was 65.8 (SD 8.8) years and 80.5% were women. VFA revealed vertebral fractures in 34.8% of the patients and 34.0% had low TBS (≤ 1.23), with no differences between the sexes. In all patients with valid measures of both VFA and TBS, 53.8% had either vertebral fractures, low TBS, or both. In the patients with osteopenia at the femoral neck, 53.6% had either vertebral fractures, low TBS, or both. Femoral neck BMD T-score ≤ -2.5 was found in 13.8% of all patients, whereas the corresponding figure was 27.4% using the skeletal site with lowest T-score. Women exhibited lower BMD at all sites and lower TBS than men (1.27 vs. 1.29), (all p < 0.05). Patients with prevalent vertebral fractures were older (69.4 vs. 64.0 years), exhibited lower BMD at all sites and lower TBS (1.25 vs.1.29) than those without vertebral fractures (all p < 0.05). Before assessment, 8.2% were taking anti-osteoporotic drugs (AOD), and after assessment, the prescription rate increased to 56.2%.

CONCLUSIONS

More than half of the patients with fragility fractures had vertebral fractures, low TBS or both. The prescription of AOD increased seven fold from before assessment to after assessment, emphasizing the importance of risk assessment after a fragility fracture.

Adding Lateral Spine Imaging for Vertebral Fractures to Densitometric Screening: Improving Ascertainment of Patients at High Risk of Incident Osteoporotic Fractures

The current diagnosis of osteoporosis is limited to a T-score ≤-2.5. However, asymptomatic vertebral fractures (VF) are known to predict a high risk of subsequent fractures and pharmaceutical intervention is known to reduce future fracture risk in these individuals. In a prospective, population-based cohort of ambulant older women, we sought to evaluate the role of VF detection by screening densitometric lateral spine imaging (LSI) for VF at time of bone density testing to the effect on the magnitude of fracture risk. A total of 1084 women (mean age 75 years ± SD 3 years) had baseline LSI that identified 100 (9%) women with VFs and 89 (8%) with femoral neck (FN) T-score osteoporosis ≤-2.5. Follow-up identified incident clinical spine fracture in 73 (7%), 305 (28%) with any fracture-related hospitalization, and 121 (11%) with a hip fracture-related hospitalization. Compared with those without baseline VF, in those with baseline VF, relative risk (RR) for incident clinical spine, hip, and any fracture were 3.46 (95% confidence interval [CI] 2.14-5.60, p < 0.001); 1.72 (95% CI 1.09-2.71, p = 0.02), and 1.4 (95% CI 1.07-1.84, p = 0.02), respectively. In 675 (62%) of women with femoral neck osteopenia (T-score <-1 to >-2.5), 61 (9%) also had a VF. Compared with those without baseline VF, RR for any incident fragility fractures and fractures at spine and hip in those with baseline VF were 1.6 (95% CI 1.2-2.1, p < 0.01), 3.9 (95% CI 2.2-6.9, p < 0.01), and 1.6 (95% CI 0.9-2.8, p = 0.10), respectively. On basis of the prognosis, older women with LSI VF with osteopenia should be diagnosed with osteoporosis and should be considered for pharmaceutical intervention. © 2018 American Society for Bone and Mineral Research.

Musculoskeletal problems in diabetes mellitus

Diabetic patients may suffer from a wide range of musculoskeletal disorders that can cause pain and some dysfunctions in the patient and affect the treatment negatively or reduce the quality of life by causing problems in the implementation of exercise programs, which are very important in the treatment of patients with Diabetes Mellitus. Although most of these problems are also seen in non-diabetics, they are more frequently observed but are not specific to diabetics. Their physiopathology is not fully understood; there is some evidence suggesting that macro- and microvascular complications of diabetes are responsible. A diagnosis of musculoskeletal dysfunctions in diabetic patients is made by clinical findings, and there is currently no specific treatment. If the treatment of problems requires corticosteroid use, diabetes can be hard to manage. In this review, we summarized the general features, diagnosis, and treatment modalities of frequent and important musculoskeletal disorders in diabetic patients.

Fracture incidence and secular trends between 1989 and 2013 in a population based cohort: The Rotterdam Study

Fracture incidence needs to be evaluated over time to assess the impact of the enlarging population burden of fractures (due to increase in lifespan) and the efficacy of fracture prevention strategies. Therefore, we aimed to evaluate the association of femoral neck bone mineral density (FN-BMD) measured using dual-energy X-ray absorptiometry (DXA) at baseline with fracture risk over a long follow-up time period. Incident non-vertebral fractures were assessed in 14,613 individuals participating in the Rotterdam Study with up to 20 years of follow-up. During a mean follow-up of 10.7 ± 6.2 years, 2971 (20.3%) participants had at least one incident non-vertebral fracture. The risk for any non-vertebral fracture was 1.37 (95% Confidence Interval (CI): 1.25-1.49) and 1.42 (95%CI: 1.35-1.50) for men and women, respectively. The majority (79% in men and 75% in women) of all fractures occurred among participants a normal or osteopenic T-score. The incidence rates per 1000 person-years for the most common fractures were 5.3 [95%CI: 5.0-5.7] for hip, 4.9 [95%CI: 4.6-5.3] for wrist and 2.3 [95%CI: 2.0-2.5] for humerus. To examine the predictive ability of BMD through follow-up time we determined fracture hazard ratios (HR) per standard deviation decrease in femoral neck BMD across five year bins. No differences were observed, with a HR of 2.5 (95%CI: 2.0-3.1) after the first 5 years, and of 1.9 (95%CI: 1.1-3.3) after 20 years. To assess secular trends in fracture incidence at all skeletal sites we compared participants at an age of 70-80 years across two time periods: 1989-2001 (n = 2481, 60% women) and 2001-2013 (n = 2936, 58% women) and found no statistically significant difference (p < 0.05) between fracture incidence rates (i.e., incidence of non-vertebral fractures of 26.4 per 1000 PY [95%CI: 24.4-28.5]) between 1989 and 2001, and of 25.4 per 1000 PY [95%CI: 23.0-28.0] between 2001 and 2013. In conclusion, BMD is still predictive of future fracture over a long period of time. While no secular changes in fractures rates seem to be observed after a decade, the majority of fractures still occur above the osteoporosis threshold, emphasizing the need to improve the screening of osteopenic patients.

Bone marrow edema in traumatic vertebral compression fractures: Diagnostic accuracy of dual-layer detector CT using calcium suppressed images

PURPOSE

To evaluate calcium suppressed images (CaSupp) in dual-layer detector computed tomography (DLCT) for the detection of bone marrow edema (BME) in vertebral fractures.

MATERIALS AND METHODS

The retrospective study was approved by the institutional review board. 34 patients with synchronous DLCT and MRI, who were diagnosed with one or more acute vertebral fractures, were included. MRI were systematically analyzed as reference standard. Two blinded and independent readers evaluated CaSupp for vertebral BME. Additionally, both readers determined the optimal calcium suppression indices (CaSupp-I) for visualization of BME in consensus and correlated the CaSupp-I with parallel measurement of trabecular density as surrogate parameter for bone mineral density. ROI-based measurements of the contrast-to-noise ratios (CNR) were also conducted. Interrater agreement was determined by kappa-statistics. CNR were analyzed using Wilcoxon signed rank test.

RESULTS

Fifty-seven acute fractured vertebrae out of 383 vertebrae (14.9%) were found. CaSupp yielded an average sensitivity of 87% and specificity of 99%, a positive predictive value of 95%, a negative predictive value of 98% and an accuracy of 97% for the detection of fracture-associated edema. Interrater agreement was excellent (kappa 0.91). Increase in CNR of BME correlated with increasing CaSupp-I. Edema adjacent to the cortical endplates was better visualized using CaSupp-I of 70 and 80, while extensive edema was better visualized using a CaSupp-I of 90 and 100 (chi2 < 0.0001). No correlation between optimal CaSupp-I and trabecular density was found (p > 0.2).

CONCLUSION

CaSupp reconstructed from DLCT enable visualization and detection of BME in traumatic fractured vertebrae with high diagnostic accuracy using CaSupp-I of 70-100.

Comparative Analysis of the Radiology of Osteoporotic Vertebral Fractures in Women and Men: Cross-Sectional and Longitudinal Observations from the Canadian Multicentre Osteoporosis Study (CaMos)

We compared two methods for osteoporotic vertebral fracture (VF) assessment on lateral spine radiographs, the Genant semiquantitative (GSQ) technique and a modified algorithm-based qualitative (mABQ) approach. We evaluated 4465 women and 1771 men aged ≥50 years from the Canadian Multicentre Osteoporosis Study with available X-ray images at baseline. Observer agreement was lowest for grade 1 VFs determined by GSQ. Among physician readers, agreement was greater for VFs diagnosed by mABQ (ranging from 0.62 [95% confidence interval (CI) 0.00-1.00] to 0.88 [0.76-1.00]) than by GSQ (ranging from 0.38 [0.17-0.60] to 0.69 [0.54-0.85]). GSQ VF prevalence (16.4% [95% CI 15.4-17.4]) and incidence (10.2/1000 person-years [9.2; 11.2]) were higher than with the mABQ method (prevalence 6.7% [6.1-7.4] and incidence 6.3/1000 person-years [5.5-7.1]). Women had more prevalent and incident VFs relative to men as defined by mABQ but not as defined by GSQ. Prevalent GSQ VFs were predominantly found in the mid-thoracic spine, whereas prevalent mABQ and incident VFs by both methods co-localized to the junction of the thoracic and lumbar spine. Prevalent mABQ VFs compared with GSQ VFs were more highly associated with reduced adjusted L₁ to L₄ bone mineral density (BMD) (-0.065 g/cm² [-0.087 to -0.042]), femoral neck BMD (-0.051 g/cm² [-0.065 to -0.036]), and total hip BMD (-0.059 g/cm² [-0.076 to -0.041]). Prevalent mABQ VFs compared with prevalent GSQ were also more highly associated with incident VF by GSQ (odds ratio [OR] = 3.3 [2.2-5.0]), incident VF by mABQ (9.0 [5.3-15.3]), and incident non-vertebral major osteoporotic fractures (1.9 [1.2-3.0]). Grade 1 mABQ VFs, but not grade 1 GSQ VFs, were associated with incident non-vertebral major osteoporotic fractures (OR = 3.0 [1.4-6.5]). We conclude that defining VF by mABQ is preferred to the use of GSQ for clinical assessments. © 2017 American Society for Bone and Mineral Research.

Surgical options for osteoporotic vertebral compression fractures complicated with spinal deformity and neurologic deficit

INTRODUCTION

This paper describes surgical options for Osteoporotic vertebral compression fracture (OVCF) with acute flexible or chronic rigid kyphosis, and pseudarthrosis complicated with pain and neurologic deficit.

METHODS

This study has two components. a) A prospective clinical study of surgical treatment of 31 patients (age: 69±11 years) with either acute flexible or progressive pseudarthrotic kyphosis manifested with severe pain or neurological deficit between 2010 and 2014. Eleven patients exhibited neurocompression (Frankel B, C, D). Surgery consisted in indirect reduction, kyphoplasty, and short posterior instrumentation in 28 patients and multilevel instrumentation in three. b) The second component involved a literature search of OVCF complicated with acute or painful chronic deformities and neurologic deficit, managed with open surgical approach.

RESULTS

Indirect reduction, kyphoplasty and short posterior stabilization can restore satisfactory anatomic alignment and neurological deficit. Multilevel instrumentation was used for rigid long kyphosis. Complications were related to a) screw pull out and junctional kyphosis (4 patients) one of the patients also developed anterior migration of cement, b) cement leakage (4 patients). L5 radiculopathy occurred in one patient. The others remained asymptomatic. The literature review concluded that corpectomy with anterior, posterior or combined instrumentations is indicated for burst fractures, or rigid kyphosis with neurocompression. Prompt decompression with anatomical alignment may restore paraplegia. Complications were germane to osteoporotic bone predisposing to hardware loosening or cut out and dislodgement of instrumentation.

DISCUSSION

Neurologic deficit associated with fractures or progressive pseudarthrotic kyphosis effectively may respond to indirect postural reduction, kyphoplasty and posterior percutaneous short segment transpedicle instrumentation. For burst fractures and rigid chronic kyphosis corpectomy reconstructed with cages and anterior, or posterior or combined instrumentations can restore and maintain normal anatomy. The following guidelines for optimal surgical instrumentation have been established: To prevent screw loosening and junctional kyphosis the instrumentation should not end within the kyphotic segment. Screws for anterior instrumentation should penetrate the contralateral cortex. Multiple site of fixation or combined anterior and posterior instrumentations dissipate stresses at any one site. Augmentation of transpedicle screw fixation with cement is a sound technical principle. Cement should inserted in a doughy state with minimal pressure to prevent cement complications.

Association of Incident, Clinically Undiagnosed Radiographic Vertebral Fractures With Follow-Up Back Pain Symptoms in Older Men: the Osteoporotic Fractures in Men (MrOS) Study

Prior data in women suggest that incident clinically undiagnosed radiographic vertebral fractures (VFs) often are symptomatic, but misclassification of incident clinical VF may have biased these estimates. There are no comparable data in men. To evaluate the association of incident clinically undiagnosed radiographic VF with back pain symptoms and associated activity limitations, we used data from the Osteoporotic Fractures in Men (MrOS) Study, a prospective cohort study of community-dwelling men aged ≥65 years. A total of 4396 men completed spine X-rays and symptom questionnaires at baseline and visit 2, about 4.6 years later. Incident clinical VFs during this interval were defined by self-reported clinical diagnosis plus community imaging showing a centrally adjudicated ≥1 increase in semiquantitative (SQ) grade in any thoracic or lumbar vertebra versus baseline study X-rays. Incident radiographic VFs (≥1 increase in SQ grade between baseline and visit 2 study X-rays) were categorized as radiographic-only (not clinically diagnosed) or radiographic plus clinical (also clinically diagnosed). Multivariable-adjusted log binomial regression was used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). Men with incident radiographic plus clinical VF were most likely to have back pain symptoms and associated activity limitation at follow-up. However, versus men without incident VF, those with incident radiographic-only VF also were significantly more likely at follow-up to report any back pain (70% versus 59%; PR, 1.2 [95% CI, 1.1 to 1.3]), severe back pain (8% versus 4%; PR, 1.9 [95% CI, 1.1 to 3.3]), bother from back pain most/all the time (22% versus 13%; PR, 1.7 [95% CI, 1.3 to 2.2]), and limited usual activity from back pain (34% versus 18%; PR, 1.9 [95% CI, 1.5 to 2.4]). Clinically undiagnosed, incident radiographic VFs were associated with an increased likelihood of back pain symptoms and associated activity limitation. Results suggest incident radiographic-only VFs often were symptomatic, and were associated with both new and worsening back pain. Preventing these fractures may reduce back pain and related disability in older men. © 2017 American Society for Bone and Mineral Research.

Characterizing the course of back pain after osteoporotic vertebral fracture: a hierarchical cluster analysis of a prospective cohort study

This study demonstrated four distinct patterns in the course of back pain after osteoporotic vertebral fracture (OVF). Greater angular instability in the first 6 months after the baseline was one factor affecting back pain after OVF.

PURPOSE

Understanding the natural course of symptomatic acute OVF is important in deciding the optimal treatment strategy. We used latent class analysis to classify the course of back pain after OVF and identify the risk factors associated with persistent pain.

METHODS

This multicenter cohort study included 218 consecutive patients with ≤ 2-week-old OVFs who were enrolled at 11 institutions. Dynamic x-rays and back pain assessment with a visual analog scale (VAS) were obtained at enrollment and at 1-, 3-, and 6-month follow-ups. The VAS scores were used to characterize patient groups, using hierarchical cluster analysis.

RESULTS

VAS for 128 patients was used for hierarchical cluster analysis. Analysis yielded four clusters representing different patterns of back pain progression. Cluster 1 patients (50.8%) had stable, mild pain. Cluster 2 patients (21.1%) started with moderate pain and progressed quickly to very low pain. Patients in cluster 3 (10.9%) had moderate pain that initially improved but worsened after 3 months. Cluster 4 patients (17.2%) had persistent severe pain. Patients in cluster 4 showed significant high baseline pain intensity, higher degree of angular instability, and higher number of previous OVFs, and tended to lack regular exercise. In contrast, patients in cluster 2 had significantly lower baseline VAS and less angular instability.

CONCLUSIONS

We identified four distinct groups of OVF patients with different patterns of back pain progression. Understanding the course of back pain after OVF may help in its management and contribute to future treatment trials.

Reverse total shoulder versus angular stable plate treatment for proximal humeral fractures in over 65 years old patients

Background

Treatment for displaced proximal humeral fractures is still under debate. Poor rotator cuff status and non-union of the tubercles in elderly patients has caused reversed total shoulder prosthesis growing popularity and showed promising results, even in comparison to angular stable plates fixation.The purpose of this study is to report clinical and radiological results of proximal humerus fractures treated with rTSA or ORIF in elderly.

Materials and methods

The study has investigated retrospectively a consecutive series of 73 patients over 65 years old (range 65-91) with proximal humeral three- and four- parts fractures, operated from January 2009 to June 2014 with a reversed total shoulder prosthetic replacement or open reduction and internal fixation using an angular stable plate, with at least 1 year follow-up. Participants are admitted in our hospital with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2.The primary outcomes are active ROM and shoulder function (Constant score). Secondary outcomes have been patient self-assessment form (Simple shoulder test) and radiographical details. Follow-up takes place at the moment of clinical observation with rx control.

Results

We analyzed a group of 23 patients treated by plate and screws and 21 patients treated by rTSA with these average results. ORIF: Flexion 112.8°, Abduction 99.6°, External rotation at 90° 47.4°, modal Internal rotation hand at Sacroiliac joint, Constant Score 52.9 and Simple Shoulder Test 8.0. RSA: Flexion 133.3°, Abduction 101.4°, External rotation at 90° of abduction 35.5°, modal Internal rotation hand at waist (L3), Constant Score 65.9 and Simple Shoulder Test 9.2. No nerve injuries were reported. No cases of pseudoarthrosis or plate fractures. No arthroplasty implant loosening, infection or dislocation was documented and revision required.

Conclusion

Our study shows good clinical outcomes and fewer complications in both treatment options. Better clinical and daily living results are reported in RSA compared with ORIF, confirming that rTSA is one of the best treatment in proximal humeral fractures in the elderly patients, which rotator cuff status frequently is poor and degenerating. The few radiological complications do not seem to have influence on active ROM and Constant Score, both the first and the second group of patients.

Level of evidence

Level IV, Case Series, Surgical.

Total and Visceral Adiposity Are Associated With Prevalent Vertebral Fracture in Women but Not Men at Age 62 Years: The Newcastle Thousand Families Study

Low body weight is an established risk factor for osteoporosis and fracture, but the skeletal risks of higher adiposity are unclear and appear sex-specific and site-dependent. The aim of this study was to investigate associations of total fat mass (TFM), visceral adipose tissue (VAT), and C-reactive protein (CRP) with bone mineral density (BMD) and prevalent vertebral fracture (VF) in men and women aged 62 years. A total of 352 men and women aged 62.5 ± 0.5 years from the Newcastle Thousand Families Study cohort received dual-energy X-ray absorptiometry (DXA) evaluations of femoral neck and lumbar spine BMD, of the lateral spine for vertebral fracture assessment, and of the whole body for TFM and VAT (GE Lunar CoreScan, Madison, WI, USA). Plasma CRP, FRAX scores, falls in the last 12 months, and occupation at age 50 years were also included in the analysis. Vertebral fractures were less prevalent in women than in men (odds ratio [OR] = 0.33, p < 0.001) and BMD or FRAX scores did not differ between participants with and without VF. Women with VF were heavier and had higher TFM, VAT, and CRP than women without (p < 0.001). In women, greater (+1 SD) TFM and VAT increased the odds of any grade VF (TFM: OR = 1.06, p = 0.001; VAT: OR = 2.50, p = 0.002), and greater VAT mass increased the odds of prevalent mild VF (OR = 2.60, p = 0.002). In contrast, there were no associations in men. In both sexes, after controlling for body weight, neither VAT nor CRP were associated with BMD. In conclusion, irrespective of BMD, total and visceral adiposity were associated with prevalent VF in women but not in men. High fat mass, particularly if visceral, should be considered when assessing VF risk in women. Risk factors for VF in men require further investigation, particularly given their high prevalence. © 2017 American Society for Bone and Mineral Research.

Effects of acupuncture on quality of life and pain in patients with osteoporosis-a pilot randomized controlled trial

In this sham-controlled study, 53 patients received 10 sessions of acupuncture treatment over 5 weeks to investigate the effects of acupuncture on the pain and quality of life of patients with osteoporosis. The results showed significant favorable effects of verum acupuncture on quality of life. Both interventions showed sustained and clinically relevant effects on pain.

PURPOSE

Standard analgesic treatment is associated with adverse events in patients with osteoporosis, especially elderly and/or comorbid patients. As acupuncture has gained widespread acceptance as a complementary treatment modality with few side effects, the aim of this study was to evaluate the effects of acupuncture on the pain and quality of life of patients with osteoporosis.

METHODS

In total, 53 patients with vertebral compression fractures, osteoporosis-associated spinal deformities, and resultant pain were randomly allocated to the verum acupuncture with deep needling of specific points following the principles of traditional Chinese medicine (n = 29) or control acupuncture group with superficial needling of non-acupuncture points (n = 24). All patients received 10 sessions of standardized verum or control acupuncture treatment over 5 weeks. Pain (VAS score 1-100) and quality of life (QUALEFFO-41) were measured at the start of treatment (T0), before each acupuncture session (T1), and at 1 (T2) and 3 months (T3) post-treatment.

RESULTS

Both acupuncture treatments significantly reduced activity-related pain and pain at rest over time. The verum acupuncture group experienced a significantly greater reduction in mean pain intensity at rest than the control group. In the control group, quality of life improved only temporarily post-treatment (T2) and slightly declined at the end of the follow-up period (T3). In contrast, patients in the verum acupuncture group experienced continuous and significant improvements in quality of life up to 3 months after treatment (T3).

CONCLUSIONS

Both types of acupuncture were equally effective in producing sustained, clinically relevant pain relief in patients with osteoporosis. Verum acupuncture had stronger and longer-lasting effects on quality of life and pain at rest. The possible reasons for these findings include the specificity of acupuncture point selection and the performance of needle stimulation.

Vertebral Fractures: Clinical Importance and Management

Vertebral fractures are common and can result in acute and chronic pain, decreases in quality of life, and diminished lifespan. The identification of vertebral fractures is important because they are robust predictors of future fractures. The majority of vertebral fractures do not come to clinical attention. Numerous modalities exist for visualizing suspected vertebral fracture. Although differing definitions of vertebral fracture may present challenges in comparing data between different investigations, at least 1 in 5 men and women aged >50 years have one or more vertebral fractures. There is clinical guidance to target spine imaging to individuals with a high probability of vertebral fracture. Radiology reports of vertebral fracture need to clearly state that the patient has a "fracture," with further pertinent details such as the number, recency, and severity of vertebral fracture, each of which is associated with risk of future fractures. Patients with vertebral fracture should be considered for antifracture therapy. Physical and pharmacologic modalities of pain control and exercises or physiotherapy to maintain spinal movement and strength are important components in the care of vertebral fracture patients.

The Radiology of Osteoporotic Vertebral Fractures Redux

When a low-energy fracture occurs, then osteoporosis has progressed to the point of bony structural failure. Because vertebral fractures are the commonest type of osteoporotic fracture, the correct identification of them becomes important for diagnosis, risk estimation, and management. However, there are no uniformly agreed criteria for their diagnosis. The purpose of this review was to examine the diagnostic radiological strategies available and suggest a coherent approach to diagnosis. Diagnosis had come to focus on comparative changes in vertebral dimensions. However, it has become apparent that mild reductions in vertebral height are of uncertain implication. The importance of structural damage in diagnosis has become recognized in parallel. Relative reductions in vertebral height may not be a necessary nor sufficient criterion by which to diagnose a fracture.

The effect of vitamin D and bisphosphonate on fracture healing: An experimental study

BACKGROUND

The aim of the study was to evaluate the effects of the using bisphosphonate, vitamin D, and a combination of bisphosphonate and vitamin D on fracture healing, by comparison of radiological and histological findings of the study groups and a control group.

METHODS

A total of 24 rats were randomly divided into 4 groups. A mid-third fracture was created in the femur of all rats. Saline was administered to Group A, bisphosphonate (Alendronate) to Group B, bisphosphonate (Alendronate) + vitamin D (Calcitriol) to Group C and vitamin D (Calcitriol) to Group D. All preparations were administered orally for 28 days.

RESULTS

No statistically significant difference was determined between the groups in respect of the effect on fracture healing according to radiological findings. The histological findings of fracture healing showed Groups B and C to be significantly more advanced than Group A (p = 0.017, p = 0.009). However no significant difference was found in Group D comparison with Group A (p = 0.224).

CONCLUSION

According to the histological findings, advanced fracture healing was seen in the groups administered with bisphosphonate or combined bisphosphonate and vitamin D compared to the use of vitamin D alone and the control group. It was concluded that bisphosphonate treatment combined with vitamin D can be used safely without any negative effect on fracture healing.

Epidemiology of Vertebral Fractures

Vertebral fractures are one of the most common fractures associated with skeletal fragility and can cause as much morbidity as hip fractures. However, the epidemiology of vertebral fractures differs from that of osteoporotic fractures at other skeletal sites in important ways, largely because only one quarter to one-third of vertebral fractures are recognized clinically at the time of their occurrence and otherwise require lateral spine imaging to be recognized. This article first reviews the prevalence and incidence of clinical and radiographic vertebral fractures in populations across the globe and secular trends in the incidence of vertebral fracture over time. Next, associations of vertebral fractures with measures of bone mineral density and bone microarchitecture are reviewed followed by associations of vertebral fracture with various textural measures of trabecular bone, including trabecular bone score. Finally, the article reviews clinical risk factors for vertebral fracture and the association of vertebral fractures with morbidity, mortality, and other subsequent adverse health outcomes.

Epidemiology of fractures in type 2 diabetes

Type 2 diabetes affects an increasing proportion of older adults, the population that is also at elevated risk of fracture. Type 2 diabetes itself increases the risk of fracture, particularly in African-American and Latino populations. In Western countries, overweight and obesity, associated with reduced fracture risk, are highly prevalent in diabetic patients. Studies in East Asian countries that have a lower prevalence of obesity with diabetes may help to disentangle the effects of diabetes and obesity on the skeleton. Type 2 diabetes is also associated with higher bone density, and as a result standard tools for fracture prediction tend to underestimate fracture risk in this population, an important challenge for risk assessment in the clinical setting. Contributing factors to the increased fracture risk in type 2 diabetes include more frequent falls and deficits in diabetic bone, not captured by dual X-ray absorptiometry (DXA), that are as yet not clearly understood. Recent epidemiological studies indicate that poor glycemic control contributes to increased fracture risk although intensive lowering of A1C is not effective in preventing fracture. This article is part of a Special Issue entitled "Bone and diabetes".

Concomitant upper limb fractures and short-term functional recovery in hip fracture patients: does the site of upper limb injury matter?

OBJECTIVE

The aim of this study was to evaluate functional recovery in a subgroup of hip fracture patients who sustained a simultaneous fracture at the upper limb, taking into account the site of upper limb injury.

DESIGN

Of 760 patients admitted consecutively to the authors' rehabilitation hospital because of a fall-related hip fracture, 700 were retrospectively investigated. Functional outcome was assessed using Barthel Index scores.

RESULTS

In 49 of the 700 patients, a single fall resulted in both a hip fracture and a fracture of either wrist (n = 34) or proximal humerus (n = 15). The patients with concomitant shoulder fractures had lower median Barthel Index scores after rehabilitation (70 vs. 90, P = 0.003), lower median Barthel Index effectiveness (57.1 vs. 76.9, P = 0.018), and prolonged median length of stay (42 vs. 36 days, P = 0.011) than did the patients with isolated hip fractures. Significant differences persisted after adjustment for six potential confounders. The adjusted odds ratio for achieving a Barthel Index score lower than 85 was 6.71 (95% confidence interval, 1.68-26.81; P = 0.007) for the patients with concomitant shoulder fractures. Conversely, no prognostic disadvantages were associated with concomitant wrist fractures.

CONCLUSIONS

Data show a worse functional recovery and a prolonged length of stay in the subgroup of hip fracture patients who sustained a concomitant fracture at the proximal humerus, but not at the wrist.

Osteoporosis: the evolution of a diagnosis

The global trend towards increased longevity has resulted in ageing populations and a rise in diseases or conditions that primarily affect older persons. One such condition is osteoporosis (fragile or porous bones), which causes an increased fracture risk. Vertebral and hip fractures lead to increased morbidity and mortality and result in enormous healthcare costs. Here, we review the evolution of the diagnosis of osteoporosis. In an attempt to separate patients with normal bones from those with osteoporosis and to define the osteoporosis diagnosis, multiple factors and characteristics have been considered. These include pathology and histology of the disease, the endocrine regulation of bone metabolism, bone mineral density (BMD), fracture type or trauma severity, risk models for fracture prediction, and thresholds for pharmacological intervention. The femoral neck BMD -2.5 SDs cut-off for the diagnosis of osteoporosis is arbitrarily chosen, and there is no evidence to support the notion that fracture location (except vertebral fractures) or severity is useful to discriminate osteoporotic from normal bones. Fracture risk models (including factors unrelated to bone) dissociate bone strength from the diagnosis, and treatment thresholds are often based on health-economic considerations rather than bone properties. Vertebral fractures are a primary feature of osteoporosis, characterized by decreased bone mass, strength and quality, and a high risk of another such fracture that can be considerably reduced by treatment. We believe that the 2001 definition of osteoporosis by the National Institutes of Health Consensus Development Panel on Osteoporosis is still valid and useful: 'Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture'.

Low clinical relevance of a prevalent vertebral fracture in elderly men--the MrOs Sweden study

BACKGROUND CONTEXT

The epidemiology, the fracture pattern, and the clinical relevance of prevalent vertebral fractures in old men are debated wherefore we set out to clarify these issues.

METHODS

Mister Osteoporosis (MrOs) Sweden is a population-based cohort of community-living men aged 69-81 years that includes 3,014 men. Out of these, 1,453 men underwent a lateral radiograph of the thoracic and lumbar spine of which 1,427 were readable and classified by a radiologist, that is the sample size in this study. The men also answered a questionnaire evaluating back pain and limitation in activities of daily living (ADLs) because of back pain during the preceding 12 months in addition with fracture history and life style.

RESULTS

Fifteen percentage of the men had at least one prevalent vertebral fracture, but only 1/10th of these were aware of their fracture. Among the men with a fracture, 58% had one, 21% two, 9% three, and 11% four or more fractures. In men with only one fracture, 70% of the fractures were located in the thoracic and 30% in the lumbar spine, 85% had a wedge, 13% a biconcave, and 2% a crush-type configuration; one-quarter had a maximum vertebral body compression degree of less than 24% and one-quarter of more than 38%. Among the men with one or several vertebral fracture, 57% reported back pain compared with 55% in those without a fracture (p=.53). Most ADL functions were similar in the men with or without a prevalent vertebral fracture. In the men with one fracture, there was no difference in the occurrence of back pain depending on the fractured region (p=.49), type of the fracture (p=.77), or degree of compression (p=.85). In men with one or several fractures, there were no significant differences in the presence of back pain in any ages (p=.08), nor there were differences in presence of back pain regarding type (p=.08) or number of fractures (p=.21).

CONCLUSIONS

A prevalent vertebral fracture is common in old men but has low clinical relevance. There does not seem to be a specific fracture pattern that predisposes for back pain.

Clinical investigation for displaced proximal humeral fractures in the elderly: a randomized study of two surgical treatments: reverse total prosthetic replacement versus angular stable plate Philos (The DELPHI-trial)

BACKGROUND

Treatment for displaced proximal humeral fractures is still under debate. Few studies exist at the highest level of evidence. Although reversed total shoulder prosthesis has gained popularity and showed promising results in the treatment for proximal humeral fractures in the elderly patients, no randomized controlled trials exist to the authors' knowledge.

METHODS/DESIGN

This study is a randomized semi-blinded controlled multicenter trial designed according to the Consort statement and the recommendations given by the Cochrane reviewers for proximal humeral fractures. The study will investigate whether a reversed total shoulder prosthetic replacement gain better functional outcome compared to open reduction and internal fixation using an angular stable plate in displaced three- and four parts proximal humeral fractures after two and five years follow-up.Participants are aged 65-85 admitted in seven different hospitals with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2. The intervention group is surgical treatment using a reversed total shoulder prosthesis (Delta X-tend) compared to open reduction and internal fixation with an angular stable plate (Philos) and thread cerclage in the control group. 60 patients will be randomized to each group.The primary outcome is shoulder function (Constant score). Secondary outcomes will be patient self-assessment form (Oxford shoulder score), a quality of life questionnaire (15D score) and resource implications (cost-effectiveness). Follow-ups take place at 3, 6, 12 and 24 months, and five years. The trial design is semi-blinded with blinded physiotherapists performing the functional testing of patients at all follow-ups.Randomization to treatment groups is electronic online, by independent supervisor (web-CRF). The recruitment of patients started at January 1.st 2013. Inclusion of 120 patients during three years is expected.

DISCUSSION

This semiblinded trial include a high number of patients compared to existing randomized trials in this field. To our knowledge and according to ClinicalTrials.gov, this is the first study that compare these two treatments for a displaced proximal humeral fracture in elderly patients. This may provide important information to help the surgeon to decide the best treatment in the future.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01737060.

Physical performance and radiographic and clinical vertebral fractures in older men

In men, the association between poor physical performance and likelihood of incident vertebral fractures is unknown. Using data from the MrOS study (N = 5958), we describe the association between baseline physical performance (walking speed, grip strength, leg power, repeat chair stands, narrow walk [dynamic balance]) and incidence of radiographic and clinical vertebral fractures. At baseline and follow-up an average of 4.6 years later, radiographic vertebral fractures were assessed using semiquantitative (SQ) scoring on lateral thoracic and lumbar radiographs. Logistic regression modeled the association between physical performance and incident radiographic vertebral fractures (change in SQ grade ≥1 from baseline to follow-up). Every 4 months after baseline, participants self-reported fractures; clinical vertebral fractures were confirmed by centralized radiologist review of the baseline study radiograph and community-acquired spine images. Proportional hazards regression modeled the association between physical performance with incident clinical vertebral fractures. Multivariate models were adjusted for age, bone mineral density (BMD, by dual-energy X-ray absorptiometry [DXA]), clinical center, race, smoking, height, weight, history of falls, activity level, and comorbid medical conditions; physical performance was analyzed as quartiles. Of 4332 men with baseline and repeat radiographs, 192 (4.4%) had an incident radiographic vertebral fracture. With the exception of walking speed, poorer performance on repeat chair stands, leg power, narrow walk, and grip strength were each associated in a graded manner with an increased risk of incident radiographic vertebral fracture (p for trend across quartiles <0.001). In addition, men with performance in the worst quartile on three or more exams had an increased risk of radiographic fracture (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.33-2.45) compared with men with better performance on all exams. Clinical vertebral fracture (n =149 of 5813, 2.6%) was not consistently associated with physical performance. We conclude that poorer physical performance is associated with an increased risk of incident radiographic (but not clinical) vertebral fracture in older men.