Incidence of fractures in patients with type 1 diabetes mellitus-a retrospective study with 4420 patients

New Evidence, Creative Insights, and Strategic Solutions: Advancing the Understanding and Practice of Diabetes Osteoporosis

BACKGROUND

Diabetes osteoporosis is a debilitating condition that significantly impacts human health. However, it is often underdiagnosed and not addressed in a timely or appropriate manner.

METHODS

Recent studies were reviewed to explore the roles of energy metabolism, sarcopeina, low-grade inflammation and gut microbiota in the development of diabetes osteoporosis.

RESULTS

Osteoporosis in diabetic patients differs from primary osteoporosis. Novel biomarkers and risk factors that are biologically, physiologically, and pathologically linked to the development of diabetes osteoporosis are emerging, necessitating a shift in strategies for diagnosis, risk stratification, and prevention of diabetes osteoporosis.

CONCLUSIONS

There is an urgent need to approach this disorder from a fresh perspective, initiating a range of basic research and clinical investigations.

Association between Chronic Hepatitis B/C and Incidence of Osteoporosis and Bone Fractures: Results from a Retrospective Cohort Study

Background: Osteoporosis and bone fractures affect health and quality of life. Since bone disease is multifactorial, identifying risk factors is key in prevention. There are multiple reports on how viral hepatitis, especially chronic hepatitis B (CHB) and chronic hepatitis C (CHC), are affecting bone disease, but results vary. Here, we analyzed the potential association between CHB/CHC and osteoporosis or bone fractures in a large outpatient cohort in Germany. Methods: We included 3136 outpatients with CHB and 15,608 matched non-hepatitis individuals as well as 2867 outpatients with CHC and 14,335 matched non-hepatitis individuals from the Disease Analyzer Database between 2005 and 2022. The main outcome was the 5-year cumulative incidence of osteoporosis and bone fractures as a function of either CHB or CHC. Results: Within 5 years of the index date, 2.9% vs. 1.6% of patients with and without CHB were diagnosed with osteoporosis (p = 0.001) and 1.0% vs. 0.4% were diagnosed with bone fractures (p < 0.001). Moreover, 3.3% of CHC patients and 2.2% of individuals without hepatitis C were diagnosed with osteoporosis (p = 0.002). In Cox regression analyses, CHB was significantly associated with an increased risk for osteoporosis (HR: 1.76) and fractures (HR:2.43) and CHC with osteoporosis (HR: 1.54). For both CHB and CHC, the association with osteoporosis was restricted to the female subgroup. Conclusions: CHB and CHC are associated with osteoporosis in women. CHB in male patients is associated with a higher risk of fractures. More research is needed to understand the underlying pathophysiological mechanisms.

Outcomes of surgical management of ankle fractures in patients with diabetes

Objective

Ankle fracture surgeries among diabetic are common and can have fatal consequences and serious adverse outcomes. A target hemoglobin A1c (HbA1c) level <8% in all elective surgeries for patients with diabetes is suggested to minimize poor outcomes. We investigated the postoperative outcomes and complications among patients who underwent ankle fracture surgery using HbA1c level as a predictor value.

Methods

This retrospective cohort study was conducted at King Abdulaziz Medical City between January 2016 and December 2022 on all patients with diabetes who underwent open reduction and internal fixation and who had a documented HbA1c level. Radiological outcomes and complications were noted along with the levels of HbA1c and analyzed statistically.

Results

A total of 44 patients were included in the study: 29 women (65.9%) and 15 (34.1%) men. The most frequent ankle fracture type was bimalleolar (54.5%). HbA1c was elevated (54.5%) in patients. A significantly higher proportion of patients who had <8% HbA1c level had radiological union compared to patients who had ≥8% HbA1c level (p = 0.036). Patients who had elevated HbA1c level had more complications although it did not reach statistical significance (p > 0.05). Multivariate regression analysis showed that age and HbA1c level were the significant factors for an uncomplicated and successful ankle surgery.

Conclusion

Poor postoperative outcomes and complications are more common among patients with elevated HbA1c. This suggests that an elevated HbA1c level is associated with a poor treatment outcome. Determination of HbA1c levels may predict potential problems post ankle fracture surgery and improve management outcomes.

Recent progress in bone-repair strategies in diabetic conditions

Bone regeneration following trauma, tumor resection, infection, or congenital disease is challenging. Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia. It can result in complications affecting multiple systems including the musculoskeletal system. The increased number of diabetes-related fractures poses a great challenge to clinical specialties, particularly orthopedics and dentistry. Various pathological factors underlying DM may directly impair the process of bone regeneration, leading to delayed or even non-union of fractures. This review summarizes the mechanisms by which DM hampers bone regeneration, including immune abnormalities, inflammation, reactive oxygen species (ROS) accumulation, vascular system damage, insulin/insulin-like growth factor (IGF) deficiency, hyperglycemia, and the production of advanced glycation end products (AGEs). Based on published data, it also summarizes bone repair strategies in diabetic conditions, which include immune regulation, inhibition of inflammation, reduction of oxidative stress, promotion of angiogenesis, restoration of stem cell mobilization, and promotion of osteogenic differentiation, in addition to the challenges and future prospects of such approaches.

Dual role of quercetin in enhancing the efficacy of cisplatin in chemotherapy and protection against its side effects: a review

Chemotherapy has opened a new window in cancer therapy. However, the resistance of cancer cells has dramatically reduced the efficacy of chemotherapy. Cisplatin is a chemotherapeutic agent and its potential in cancer therapy has been restricted by resistance of cancer cells. As a consequence, the scientists have attempted to find new strategies in elevating chemotherapy efficacy. Due to great anti-tumour activity, naturally occurring compounds are of interest in polychemotherapy. Quercetin is a flavonoid with high anti-tumour activity against different cancers that can be used with cisplatin to enhance its efficacy and also are seen to sensitise cancer cells into chemotherapy. Furthermore, cisplatin has side effects such as nephrotoxicity and ototoxicity. Administration of quercetin is advantageous in reducing the adverse effects of cisplatin without compromising its anti-tumour activity. In this review, we investigate the dual role of quercetin in enhancing anti-tumour activity of cisplatin and simultaneous reduction in its adverse effects.

Perceptions of fracture and fall risk and of the benefits and barriers to exercise in adults with diabetes

The increased risk of fractures and falls is under-appreciated by adults living with diabetes and by their healthcare providers. Strategies to overcome perceived exercise barriers and exercise programs optimized for bone health should be implemented.

PURPOSE

The purpose of the study was to assess the perceptions of fracture and fall risk, and the perceived benefits of and barriers to exercise in adults ≥ 50 years old living with type 1 (T1D) and type 2 diabetes (T2D).

METHODS

Participants were recruited through social media and from medical clinics and invited to complete a self-administered online survey, comprising 38 close-ended questions and 4 open-ended questions.

RESULTS

A total of 446 participants completed the survey: 38% T1D, 59% T2D, and 3% with unreported diabetes type. Most participants did not believe that having diabetes increased their risk of fractures (81%) nor falls (68%), and more than 90% reported having not been informed about diabetes-related fracture risk by their physicians. Among exercise types, participation in moderate aerobic exercise was most common (54%), while only 31%, 32%, and 37% of participants engaged in strenuous aerobic, resistance, and balance/flexibility exercise, respectively. The most prevalent barrier to exercise for both T1D and T2D was a lack of motivation, reported by 54% of participants. Lack of time and fear of hypoglycemia were common exercise barriers reported by participants with T1D. Most participants owned a smart phone (69%), tablet (60%), or computer (56%), and 46% expressed an interest in partaking in virtually delivered exercise programs.

CONCLUSIONS

Adults living with diabetes have limited awareness of increased fall and fracture risk. These risks are insufficiently highlighted by health care providers; strategies to overcome perceived exercise barriers and exercise programs optimized for bone health should be implemented.

Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes

Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.

Secondary Osteoporosis and Metabolic Bone Diseases

Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

Influence of glycemic control and hypoglycemia on the risk of fracture in patients with diabetes mellitus: a systematic review and meta-analysis of observational studies

Individuals with diabetes mellitus (DM) have an increased risk of fracture. Glycemic control is crucial to the management of DM, but there are concerns pertaining to hypoglycemia development in the course of glycemic control target achievement. The extent to which glycemic control may affect the risk of fracture remains less defined. Hypoglycemia-induced falls have been suggested to contribute to an elevated risk of fracture in DM patients. In this meta-analysis of observational studies, we aimed to investigate the relative contribution of glycemic control, as measured by glycated hemoglobin (HbA1c), and hypoglycemia to the risk of fracture in DM. The PubMed and Web of Science databases were searched for relevant studies. A random-effects model was used to generate summary relative risks (RRs) and 95% confidence intervals (CIs). Both increased HbA1c levels (RR _{per 1% increase} 1.08, 95% CI 1.03, 1.14; n_studies = 10) and hypoglycemia (RR 1.52, 95% CI 1.23, 1.88; n_studies = 8) were associated with an increased risk of fracture. The association between HbA1c levels and the risk of fracture was somewhat nonlinear, with a noticeably increased risk observed at an HbA1c level ≥ 8%. The positive associations of HbA1c levels and hypoglycemia with the risk of fracture did not reach statistical significance in the studies that adjusted for insulin use, hypoglycemia, or falls for the former and in those that adjusted for falls for the latter. In summary, both increased HbA1c levels and hypoglycemia may increase the risk of fracture in patients with DM. The positive association between HbA1c levels and the risk of fracture appears to be, in part, explained by hypoglycemia-induced falls, possibly due to insulin use. The avoidance of hypoglycemia in the course of achieving good glycemic control through the careful selection of glucose-lowering medications may contribute to fracture prevention by reducing the risk of falls related to treatment-induced hypoglycemia.

TLR4 knockout ameliorates streptozotocin-induced osteoporosis in a mouse model of diabetes

Type 1 diabetes mellitus (T1DM) is characterized by hyperglycemia manifesting as insufficient insulin. Toll-like receptor-4 (TLR4) has been implicated in diabetic osteoporosis. We established streptozotocin (STZ)-induced diabetic mouse model and examined the relevant osteoporosis factors in different experimental groups, the WT-CON group, WT-STZ group, KO-CON group and KO-STZ group, respectively. No obvious protection of TLR4 deletion was shown in mice with diabetes. There was no obvious difference in the body weight or blood glucose concentration between WT-STZ group and KO-STZ group. However, TLR4 deletion reduced the receptor activator of NF-κB ligand (RANKL)-induced osteoclast differentiation. Furthermore, TLR4 knockout attenuated STZ-induced diabetic osteoporosis via inhibiting osteoblasts and pre-inflammation factors mediated by the NF-κB pathway. TLR4 deletion ameliorated STZ-induced diabetic osteoporosis in mice, and TLR4 may be used as a potential therapeutic target for the treatment of diabetic osteoporosis.

Hip Structural Analysis Reveals Impaired Hip Geometry in Girls With Type 1 Diabetes

CONTEXT

Among patients with type 1 diabetes (T1D), the risk of hip fracture is up to 6-fold greater than that of the general population. However, the cause of this skeletal fragility remains poorly understood.

OBJECTIVE

To assess differences in hip geometry and imaging-based estimates of bone strength between youth with and without T1D using dual-energy x-ray absorptiometry (DXA)-based hip structural analysis.

DESIGN

Cross-sectional comparison.

PARTICIPANTS

Girls ages 10 to 16 years, including n = 62 with T1D and n = 61 controls.

RESULTS

The groups had similar age, bone age, pubertal stage, height, lean mass, and physical activity. Bone mineral density at the femoral neck and total hip did not differ in univariate comparisons but was lower at the femoral neck in T1D after adjusting for bone age, height, and lean mass. Subjects with T1D had significantly lower cross-sectional area, cross-sectional moment of inertia, section modulus, and cortical thickness at the narrow neck, with deficits of 5.7% to 10.3%. Cross-sectional area was also lower at the intertrochanteric region in girls with T1D. Among those T1D subjects with HbA1c greater than the cohort median of 8.5%, deficits in hip geometry and strength estimates were more pronounced.

CONCLUSIONS

DXA-based hip structural analysis revealed that girls with T1D have unfavorable geometry and lower estimates of bone strength at the hip, which may contribute to skeletal fragility and excess hip fracture risk in adulthood. Higher average glycemia may exacerbate effects of T1D on hip geometry.

Prophylaxis of Pain and Fractures within Feet in the Course of Osteoporosis: The Issue of Diagnosing

Background

Considering the enormous risk of fractures in the course of osteoporosis in the area of the feet, an important aspect of prophylaxis is periodic and, in special cases, ongoing monitoring of defects and deformations as well as pressure distribution. The purpose of this article is to indicate the role of the examination of posture and pressure distribution during standing, postural balance, and gait, in the prevention of fatigue fractures in the course of osteoporosis, based on the literature review and examples of patients.

Methods

The manuscript consists of two parts; it has a review-analytical character. The first part reviews the literature. The data were obtained using the MEDLINE (PubMed), as well as Cochrane and Embase databases. The database review was carried out focusing mainly on English-language publications, while taking into account the topicality of scientific and research works in the area of osteoporosis. The problem of multiaspects in the area of bone density was pointed out. Considering the above, in the second part, the authors analyzed 11 exemplary patients with osteoporosis, referring to the assessment of foot and lower limb defects using traditional posturological methods and including pedobarography to diagnostic procedures that are used in the assessment of pressure distribution, standing and moving, and an attempt to balance.

Results

Analysis of the research and scientific literature proved the lack of unambiguous diagnostic procedures of the locomotor system recommended for the prevention of fatigue fractures in the course of osteoporosis. The main diagnostic recommendations are imaging tests (most often X-ray), which are recommended in the case of specific clinical symptoms. The analysis of exemplary patients with osteoporosis showed numerous disorders in the distribution of pressure in the plantar part of the feet, which are related, among other things, with their individual defects and lower limbs.

Conclusions

Detailed posture diagnostics and gait estimation, along with the analysis of pressure distribution within the feet are a very important aspect of the prevention of structural degradation and fatigue fractures within the feet. An important postulate for further research and scientific work is the elaboration of the procedures that will serve the preventive diagnostics of the locomotor system, aimed at early detection of threats of fatigue fractures.

Membranes for Guided Bone Regeneration: A Road from Bench to Bedside

Bone resorption can negatively influence the osseointegration of dental implants. Barrier membranes for guided bone regeneration (GBR) are used to exclude nonosteogenic tissues from influencing the bone healing process. In addition to the existing barrier membranes available on the market, a growing variety of membranes for GBR with tailorable physicochemical properties are under preclinical evaluation. Hence, the aim of this review is to provide a comprehensive description of materials used for GBR and to report the main industrial and regulatory aspects allowing the commercialization of these medical devices (MDs). In particular, a summary of the main attributes defining a GBR membrane is reported along with a description of commercially available and under development membranes. Finally, strategies for the scaling-up of the manufacturing process and the regulatory framework of the main MD producers (USA, EU, Japan, China, and India) are presented. The description of the regulatory approval process of GBR membranes is representative of the typical path that medium- to high-risk MDs have to follow for an effective medical translation, which is of fundamental importance to increase the impact of biomedical research on public health.