Fragility fractures in Europe: burden, management and opportunities

Using network pharmacology and molecular docking technology, proteomics and experiments were used to verify the effect of Yigu decoction (YGD) on the expression of key genes in osteoporotic mice

BACKGROUND

Yigu decoction (YGD) is a traditional Chinese medicine prescription for the treatment of osteoporosis, although many clinical studies have confirmed its anti-OP effect, but the specific mechanism is still not completely clear.

METHODS

In this study, through the methods of network pharmacology and molecular docking, the material basis and action target of YGD in preventing and treating OP were analyzed, and the potential target and mechanism of YGD in preventing and treating OP were clarified by TMT quantitative protein and experiment.

RESULTS

Network pharmacology and molecular docking revealed that the active components of YGD were mainly stigmasterol and flavonoids. Molecular docking mainly studied the strong binding ability of stigmasterol to the target. Animal proteomics verified the related mechanism of YGD in preventing and treating OP. Based on the KEGG enrichment of network pharmacology and histology, our animal experiments in vivo verified that YGD may play a role in the treatment of OP by mediating hif1- α/vegf/glut1 signal pathway.

CONCLUSIONS

YGD prevention and treatment of OP may be achieved by interfering with multiple targets. This study confirmed that it may promote osteoblast proliferation and protect osteoblast function by up-regulating the expression of proteins related to HIF signal pathway.

Pre-fracture functional status and 30-day recovery predict 5-year survival in patients with hip fracture: findings from a prospective real-world study

Disability overcomes mortality burden in older adults with hip fracture, expanding unhealthy lifespan. Building comprehensive assessment, pre-fracture functional status and 30-day post-surgical recovery are the most powerful predictors of 5-years survival. A tool supporting estimation of long-term survival may optimize the appropriate delivery of targeted interventions.

BACKGROUND

Older people with hip fractures are highly heterogeneous patients, impacting health and economic systems. The availability of tools to estimate survival may help optimize patients' outcomes and treatment management decisions.

METHODS

A prospective observational study was conducted on older patients with hip fractures who received baseline and 30-day comprehensive assessment from discharge, focusing on functional status based on Basic Activity of Daily Living (BADL). The primary outcome was to identify predictors of 5-year survival and develop nomograms to be adopted at admission or 30 days after discharge.

RESULT

Among 231 hip fracture patients, 5-year survival was 38.3% in men and 61.9% in women; women experienced a 1.8 higher likelihood of survival than men. Pre-fracture functional status predicted mortality as a function of age. At hospital admission, pre-fracture BADL level was a protective factor (HR 0.742; 95% CI 0.668-0.825), while male gender (HR 1.840; 95% CI 1.192-2.841), age (HR 1.070; 95% CI 1.037-1.105), and multimorbidity (HR 1.096; 95% CI 1.007-1.193) were independent mortality risk factors. At the 30-day follow-up visit, the BADL recovery gap was an independent predictor of 5-year survival (HR 1.439; 95% CI 1.158-1.789), in addition to male gender (HR 1.773; 95% CI 1.146-2.744), age (HR 1.046; 95% CI 1.010-1.083), and pre-fracture BADL (HR 0.621; 95% CI 0.528-0.730), while comorbidity disappeared (HR 1.083; 95% CI 0.994-1.179).

CONCLUSION

More than half of hip fracture patients are still alive 5 years after surgical repair. Pre-fracture functional status and a 30-day functional recovery gap are the main predictors of survival. Nomograms may help to define prognosis and suitable interventions.

Osteoporosis management in patients presenting to the emergency department with fragility fractures: A retrospective observational study

Objectives

This study aimed to determine the rate of anti-osteoporotic treatment (AOT) within one year in patients presenting to the emergency department with fragility fractures and to investigate the effects of physiatrist visit, secondary cause of osteoporosis, and previous fracture history on the rate of AOT.

Methods

This study included patients aged 50 years and older who presented to the emergency department between January 1, 2019, and June 1, 2023, with fragility fractures. Demographic characteristics of the patients, a history of fragility fractures, causes of secondary osteoporosis, and clinical features of AOT within one year were recorded using the hospital information system. The effects of physiatrist visit, secondary cause of osteoporosis and previous fracture history on the rate of AOT were examined by chi-square analysis.

Results

The study included a total of 357 patients, with a mean age of 73.5 + 10.1 (range: 51-100) years. The rate of patients receiving AOT was 8.4%. It was observed that 63.3% of the patients receiving AOT had a physiatrist visit, and 70% had secondary osteoporosis. Physiatrist visit and the presence of secondary osteoporosis cause affected the AOT rate statistically significantly (p = .000, p = .003, respectively), while the previous fracture history did not affect the treatment rate (p = .147).

Conclusions

Patients presenting to the emergency department with fragility fractures had a low rate of receiving AOT within one year. Physiatrist visits and finding a secondary cause of osteoporosis increase the detection rate of fragility fractures.

Global, regional, and national burdens of hip fractures in elderly individuals from 1990 to 2021 and predictions up to 2050: A systematic analysis of the Global Burden of Disease Study 2021

PURPOSE

We aimed to analyse the global, regional, and national burdens of hip fractures in older adults from 1990 to 2021, with projections to 2050, on the basis of data from the GBD 2021 study.

METHODS

We employed a joinpoint model to analyse trends in the burden of hip fractures from 1990‒2021. The estimated annual percentage change (EAPC) was used to quantify temporal trends over this period. We evaluated the relationship between the social development index and the burden of hip fracture in elderly people and conducted a health inequality analysis. Additionally, we applied Long-short Term Memory (LSTM) networks to forecast burden trends of hip fractures up to 2050.

RESULTS

The global age-standardized incidence rate (ASIR) for hip fractures in older adults rose from 781.56 per 100,000 in 1990 to 948.81 in 2021. The 2021 age-standardized prevalence rate (ASPR) was 1,894.07, and the age-standardized YLD rate (ASDR) was 173.52. From 1990 to 2021, the incidence and prevalence increased by 168.71 % and 173.07 %, respectively, while the burden of DALYs decreased. Future trends were projected via the LSTM. The burden and risk factors for hip fractures varied significantly by sex, country, and region. Population and aging are primary contributors to the rising incidence of elderly hip fractures, with falls being the leading direct cause.

CONCLUSION

From 1990 to 2021, the global burden of hip fractures in the elderly population, especially among older women, steadily increased. Population ageing highlights the urgent need for targeted public health interventions and resource allocation, including early diagnosis, effective prevention strategies, and region-specific management approaches.

Could point-of-care bioimpedance analysis be another tool in the prevention of osteoporotic fractures?

A treatment gap exists in osteoporosis, with people at risk of fracture often not identified. Dual X-Ray Absorptiometry is the gold standard technique for the identification of low bone mass, but it is not always easily accessible. Bioimpedance analysis (BIA) is a non-invasive, safe and portable technology, which can provide a calculated estimate of bone mass. However, the validity of using BIA in the assessment of bone health is largely unknown. The objective of this study was to examine BIA-derived bone mass (BBM) data from a local population, with the aim of exploring its potential for use as a preliminary osteoporosis screening tool. A convenience sample of 124 participants (40 males, 84 females) was recruited from the local population. BIA was performed on participants according to standard procedures. BBM data was analysed in relation to weight, height, sex, age and BMI. Data was analysed using ANOVA, hierarchial regression, and bivariate correlation as appropriate. Weight was strongly associated with BBM (R2 = 0.637, p < 0.001), providing the greatest contribution to variance, of the factors examined. BBM was also positively associated with height, in a model that included weight (ΔR2 = 0.218, p < 0.001). Females had a significantly lower bone mass than males, independent of weight and height (ΔR2 = 0.055, p < 0.001). There was a small negative association of BBM with age, in a model that included weight and sex (ΔR2 = 0.011; p = 0.002). A positive correlation between BMI and BBM was found in both males (r s (38) = 0.482, p = 0.002), and females (r s (82) = 0.565, p < 0.001). The finding that BBM values are associated with factors known to be relevant to fracture risk, provides a rationale to perform further studies to investigate if BBM values could have validity for point-of-care assessment of bone health.

Association between sarcopenia on residual back pain after percutaneous kyphoplasty for osteoporotic vertebral compression fractures

OBJECTIVE

This study aimed to investigate whether sarcopenia affects residual back pain (RBP) after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures (OVCF).

METHODS

We retrospectively analyzed the clinical data of 231 patients with single-segment OVCF treated with PKP between January 2023 and December 2023. Postoperative RBP was assessed at 1 month using the visual analogue scale (VAS). Patients with a VAS score ≥ 4 were classified as the RBP group, while those with a score < 4 served as controls. Sarcopenia was diagnosed using the skeletal muscle mass index (SMI), calculated by dividing the cross-sectional muscle area at the T12 vertebral level (measured via chest CT) by height squared. Univariate analysis compared clinical and imaging data between groups, and binary logistic regression identified risk factors.

RESULT

No significant differences were observed between groups in gender, BMI, surgical segment, hypertension, diabetes, or coronary heart disease (P > 0.05). However, age, BMD, SMI, bone cement usage, and sarcopenia prevalence differed significantly (P < 0.05). Binary logistic regression identified BMD and sarcopenia as independent risk factors for RBP after PKP.

CONCLUSION

OVCF patients with sarcopenia have a higher likelihood of postoperative RBP, with an incidence approximately twice that of non-sarcopenic patients. Preoperative sarcopenia screening should be prioritized, and postoperative anti-muscular atrophy therapy actively implemented.

Secular trend of humeral fractures incidence rates in patients ≥ 50 years requiring hospitalization: a retrospective analysis of the public health system data in Brazil from 2004 to 2013

This study examined the incidence trend of humeral fragility fractures among Brazilian adults over age 50 admitted to public hospitals from 2004 to 2013. The findings revealed significant increases in annual rates of humeral fractures, especially among elderly women and patients from the Southeast region. It is essential for the implementation of effective public health policies.

PURPOSE

Humeral fragility fractures are associated with a significant health care burden, especially those requiring surgeries. With limited epidemiological data, the present study aimed to determine the annual rate of humeral fractures requiring hospitalization in the public health system among Brazilian adults ≥ 50 years-old between 2004 and 2013. A secular trend analysis of the humeral fracture rate was also investigated.

METHODS

This was a retrospective, observational study of admissions in the Brazilian public hospitals from 2004 to 2013, including patients 50 years and older admitted for primary treatment with a primary diagnosis of humerus fractures (ICD-10 S-42.2, S-42.3 and S-42.4) associated with low-trauma events. The annual rates of humeral fractures were calculated according to sex, age, and geographic region, and a linear regression analysis was used to determine secular trends.

RESULTS

Most of the total of 34,071 humeral fractures occurred in women (59.21%), among the age group 50-59 years (33.14%) and in residents from the Southeast region (60%). The average annual rate of humeral fractures for the overall population, women and men was 12.56, 14.11 and 10.85 per 100,000 inhabitants-years, respectively. Secular trend analysis showed a 21.18% significant increase in the crude humeral fracture rate among women (P = 0.024). There was a reduction in humeral fracture rate between 2004 and 2008 followed by an increase from 2009 to 2013. The Southeast region had the highest fracture rates with a significant 11.95% increase in secular trend for women (P = 0.031).

CONCLUSION

Hospitalizations for humeral fractures in Brazil increased significantly from 2004 to 2013, particularly among elderly women and those living in the most densely populated Southeast region. As osteoporotic humeral fractures are often associated with an increased risk of subsequent major osteoporotic fractures, especially hip fractures, understanding this trend is essential for implementing effective public health policies.

LEVEL OF EVIDENCE

Level III-Retrospective Design Using a Large Database. Prognosis Study.

CT- and MRI-based endplate osteoporosis status assessment for predicting adjacent vertebral fractures after thoracolumbar percutaneous kyphoplasty: a matched comparison study

PURPOSE

This study aimed to investigate the predictive value of adjacent vertebral endplate osteoporotic status for adjacent vertebral fracture (AVF) after percutaneous kyphoplasty (PKP) for treating osteoporotic vertebral compression fracture (OVCF) and compared it with vertebral cancellous bone.

METHODS

This study retrospectively analyzed consecutive patients with OVCF who underwent PKP. Participants were categorized into the study group (49 patients with AVF) and the control group (49 matched patients without AVF). The vertebral Hounsfield units (VHU), endplate HU (EHU), vertebral bone quality (VBQ), and endplate bone quality (EBQ) scores were calculated using preoperative CT and MRI. To identify the predictive ability of the HU and EBQ scores, multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were conducted.

RESULTS

VHU (p = 0.006), EHU proximal to the fracture segment (pEHU) (p = 0.001), average level of EHUs (aEHU) (p = 0.001), and EBQ score proximal to the fracture segment (pEBQ score) (p = 0.034) of the adjacent fractured vertebrae (AFV) in the study group were significantly different from the control study. The lower VHU (OR = 0.981, p = 0.007), pEHU (OR = 0.984, p < 0.001), lower aEHU (OR = 0.986, p = 0.002), and higher pEBQ score (OR = 1.002, p = 0.050) of the AFV were determined as the independent predictors for AVF. The ROC curve analysis revealed that the adjusted area under the curve (AUC) for the pEHU was 0.756 and the most suitable threshold was 254.87 (sensitivity: 69.4% and specificity: 77.6%), indicating that the predictive performance of pEHU was relatively higher. Further, the adjusted AUCs for the VHU, aEHU, and pEBQ scores were 0.703, 0.699, and 0.666, respectively.

CONCLUSION

This study revealed that the endplate osteoporosis status predicted AVF better than the vertebral cancellous bone and the predictive performance of pEHU was relatively higher.

Profile and risk stratification for sarcopenia in postmenopausal women

OBJECTIVE

This study aimed to assess the risk factors associated with sarcopenia and identify risk profiles through cluster analysis in postmenopausal women treated at specialized outpatient clinics.

METHODS

A retrospective cross-sectional study evaluated data from 287 postmenopausal women. Sarcopenia was determined by handgrip and gait speed testing. Cluster analysis was applied to identify risk subgroups, and logistic regression to identify factors associated with sarcopenia.

RESULTS

Sarcopenia was identified in 18.50% of women. Advanced age (odds ratio [OR] = 1.12; 95% confidence interval [CI]: 1.07-1.16; p < 0.01), number of pregnancies (OR = 1.14; 95% CI: 1.00-1.29; p = 0.04), hip Fracture Risk Assessment Tool (FRAX) (OR = 1.29; 95% CI: 1.12-1.49; p < 0.01), systemic arterial hypertension (OR = 3.20; 95% CI: 1.66-6.17; p < 0.01) and multiple comorbidities (OR = 2.46; 95% CI: 1.19-5.09, p = 0.01) were associated with higher risk for sarcopenia. Cluster analysis revealed an increased risk profile for women who were aged over 70 years, multiparous, hypertensive, with hip FRAX greater than 3% and with major fractures greater than 6%.

CONCLUSION

Postmenopausal women with sarcopenia are more likely to have fragility fractures at 10 years, to be older, multiparous and hypertensive, and to have multiple comorbidities.

Primary care follow-up of patients after attending a fracture liaison service: an integrative review

Based on a small number of predominantly low-to-moderate quality studies with moderate-to-high risk of bias, the FLS-to-primary care transition is portrayed as a challenging time for patients, GPs, and FLS clinicians, who experience numerous barriers to care continuation and coordination at this care juncture.

PURPOSE

Continuity and coordination of care between fracture liaison services (FLS) and primary care is required for optimal long-term osteoporosis care. This study aims to explore (1) how patients and healthcare providers (HCPs) experience the FLS to primary care transition, (2) the barriers and facilitators to primary care follow-up after FLS, and (3) interventions that enhance integration of FLS with primary care.

METHODS

An integrative review was performed and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) Statement 2020. Online bibliographic databases were searched using the terms "osteoporosis", "primary care", and "fracture liaison services" and related terms for original English-language studies conducted between January 1, 2003 and December 29, 2023. Manuscripts were assessed for relevance using pre-defined criteria, and for quality and bias using validated instruments. Thematic analysis was used to extract key themes relevant to each research question.

RESULTS

Overall, 14 relevant manuscripts were identified. Among the four studies that addressed patient and HCP experience of the FLS-to-primary care transition, five key themes emerged: (1) time and workload pressures, (2) limited confidence in primary care follow-up, (3) GP knowledge gaps, (4) siloed or disconnected care, and (5) communication issues. Twelve studies addressed barriers and facilitators to primary care follow-up after FLS, which fell into five themes: (1) patient knowledge and understanding (2) miscommunication and misinformation, (3) understanding roles and responsibilities, (4) GP engagement, and (5) GP-patient relationship. Additionally, single studies suggested healthcare policies and funding, accessing primary care from residential facilities, and GP gender influenced primary care follow-up. Five studies detailed interventions to enhance FLS-to-primary care integration. GP education and patient reminders, delivered as part of a multifaceted intervention, appeared to improve integration of acute and primary post-fracture care; however, the contribution of these individual interventions to outcomes remains unclear. While telephone coaching and bone marker monitoring were identified as potential interventions, there was insufficient evidence to conclude they are effective.

CONCLUSION

Available evidence was generally low-to-moderate quality with moderate-to-high risk of bias. Integration of the available evidence portrays the FLS-to-primary care transition as a challenging time for patients, GPs, and FLS clinicians, who experience a multitude of barriers to care continuation and coordination. There is insufficient data to support any single intervention as effective for enhancing care coordination beyond those considered standard components of FLS models. Knowledge gaps exist regarding the patient experience of the FLS-to-primary care transition, facilitators to primary care follow-up, interventions to support FLS integration with primary care, and how such information may be integrated to optimise care for patients with osteoporosis.

Cost-effectiveness of opportunistic osteoporosis screening using chest radiographs with deep learning in Germany

BACKGROUND

Osteoporosis is often underdiagnosed due to limitations in traditional screening methods, leading to missed early intervention opportunities. AI-driven screening using chest radiographs could improve early detection, reduce fracture risk, and improve public health outcomes.

AIMS

To assess the cost-effectiveness of deep learning models (hereafter referred to as AI-driven) applied to chest radiographs for opportunistic osteoporosis screening in German women aged 50 and older.

METHODS

A decision tree and microsimulation Markov model were used to calculate the cost per quality-adjusted life year (QALY) gained (€2024) for screening with AI-driven chest radiographs followed by treatment, compared to no screening and treatment. Patient pathways were based on AI model accuracy and German osteoporosis guidelines. Women with a fracture risk below 5% received no treatment, those with 5-10% risk received alendronate, and women 65 + with a risk above 10% received sequential treatment starting with romosozumab. Data was validated by a German clinical expert, incorporating real-world treatment persistence, DXA follow-up rates, and treatment initiation. Sensitivity analyses assessed parameter uncertainty.

RESULTS

The cost per QALY gained from screening was €13,340, far below the typical cost-effectiveness threshold of €60,000. Optimizing follow-up, treatment initiation, and medication adherence further improved cost-effectiveness, with dominance achievable by halving medication non-persistence, and in women aged 50-64.

CONCLUSION

AI-driven chest radiographs for opportunistic osteoporosis screening is a cost-effective strategy for German women aged 50+, with the potential to significantly improve public health outcomes, reduce fracture burdens and address healthcare disparities. Policymakers and clinicians should consider implementing this scalable and cost-effective screening strategy.

Comparison of the time-dependent discriminatory accuracy of femoral strength and bone mineral density for predicting future hip and major osteoporotic fractures: a 16-year follow-up of the AGES-Reykjavik cohort

The discriminative accuracy of femoral strength was significantly higher than that of aBMD over 16 years of follow-up for classifying hip fractures and major osteoporotic fractures. The use of accurate thresholds, whether for aBMD or other imaging-based biomarkers, is crucial to improve sensitivity and identify high-risk older adults.

BACKGROUND

Areal bone mineral density (aBMD) is a surrogate for bone strength but has limited prognostic value. Finite element (FE)-derived femoral strength offers a biomechanical alternative to aBMD for fracture risk assessment, but its long-term predictive value remains unclear. This study compared the discriminatory accuracy of aBMD and femoral strength for hip (HFs) and major osteoporotic fractures (MOFs) over 16 years, accounting for mortality risk.

METHODS

In the prospective Age Gene/Environment Susceptibility-Reykjavik (AGES-Reykjavik) Study, elderly participants underwent CT scans at entry and automated algorithms were used to compute aBMD and femoral strength. Time-dependent area under the receiver operating characteristic curves (AUC) was used to compare the predictive abilities of aBMD and femoral strength. Optimal cutoffs at the Youden's index were compared with the World Health Organization (WHO)-defined aBMD cutoffs at various time points.

RESULTS

The cohort comprised 4621 older adults (mean age 76 ± 5 years). Femoral strength had a significantly higher AUC than aBMD in identifying HFs (p < 0.05) from the 6th year in males and females, while their AUCs in predicting MOFs were similar. WHO-defined aBMD showed low sensitivity (17-52%) but high specificity (78-94%) for both HFs and MOFs. The sensitivity of optimal femoral strength was significantly higher than that of aBMD at comparable specificity by 5-19% for HFs and 2-10% for MOFs (p < 0.05).

CONCLUSIONS

Both image-based markers predict long-term fracture risk and enable opportunistic screening with existing CT scans. However, femoral strength demonstrates better discriminatory accuracy than aBMD. The low sensitivity of the WHO-defined aBMD demonstrates the necessity to revise current risk assessment criteria.

Examining Romosozumab Adherence and Side Effects in Osteoporotic Patients After Surgical Fracture Fixation: A Comparative, Descriptive, and Hypothesis-Generating Study with Non-Fractured Controls

OBJECTIVES

The study aims to evaluate adherence to Romosozumab treatment in osteoporotic patients after surgical fracture fixation and compare side effects with non-fractured controls on the same therapy.

METHODS

This retrospective case-control study was conducted at the Orthopaedic Department of Policlinico Universitario di Roma "Tor Vergata", following the principles of the Declaration of Helsinki. It included postmenopausal women aged over 60, with the case group receiving Romosozumab after fracture fixation, and the control group consisting of women on Romosozumab therapy without fracture fixation. Exclusion criteria included psychiatric conditions, contraindications to Romosozumab, high-energy trauma, or other bone metabolism disorders. Data on fractures, surgeries, FRAX (Fracture Risk Assessment Tool) scores, BMD (Bone Mineral Densit) values, and follow-up details were collected. Side effects, including nasopharyngitis and severe events like hypocalcemia, stroke, and myocardial infarction, were recorded. Adherence was assessed via pharmacy records and patient interviews during routine clinical follow-up visits. Statistical analysis was performed using descriptive statistics, t-tests, and chi-square tests.

RESULTS

The study included 25 patients, with 12 in the surgical group and 13 in the conservative treatment group. The surgical group had a mean age of 67.3 years and a follow-up of 374 days, while the conservative group had a mean age of 76.4 years and a follow-up of 287 days. The surgical group underwent various fracture treatments, including femoral, humeral, and distal radius fractures, while the conservative group was treated with immobilization. There were no significant differences in FRAX scores or BMD values between the two groups. Vitamin D levels increased significantly in both groups after supplementation, but parathyroid hormone levels showed no difference. No new fractures occurred, and surgical patients had no delayed union or nonunion, though two had superficial wound infections.

CONCLUSIONS

Both groups adhered well to Romosozumab therapy, with no severe side effects; minor side effects included myalgia in the surgical group and shoulder arthralgia in the conservative group. Romosozumab is well-tolerated and adherent in osteoporotic patients after osteosynthesis surgery, with adverse events similar to non-fractured individuals. While the study design is appropriate, multicenter trials would improve the sample size and allow for subgroup analysis based on fracture type and demographics.

A Modeling Study for Hip Fracture Rates in Romania

Background and Objectives: As the population ages, the number of hip fractures is expected to increase. Developing prevention policies requires knowledge of the factors that lead to the incidence of hip fractures. In this study, we aimed to quantify how much variation in hip fracture incidence can be explained by osteoporosis treatment and temporal trends in the main risk factors. Methods: We used the HIP-IMPACT method for a national study in Romania. This method has been validated nationally in Norway, based on the validated IMPACT models for coronary heart disease. The model uses numerical data from 2008 to 2018 on fractures stratified by sex, the prevalence of pharmacological treatments, and risk and prevention factors. Results: The HIP-IMPACT model explained 90.1% (4287/4760) of the variation in hip fracture rates recorded during the period of 2008-2018. The increase in the number of fractures was explained by the increase in body mass index (1750/4760; 36.8%), the decrease in the intensity of physical activities (1396/4760; 29.3%), the increase in the prevalence of smoking (1387/4760; 29.1%), the increased prevalence of type 2 diabetes (334/4760; 7.0%), and users of z-drugs (381/4760; 8.0%), glucorticoids (491/4760; 10.3%), and opioids (331/4760; 7.0%). These effects were partially compensated by change over time in the uptake of osteoporosis medication (733/4760; 15.4%), increased prevalence of total hip replacements (491/4760; 10.2%), and reduced benzodiazepine use (559/4760; 11.8%). Conclusions: From 2008 to 2018, osteoporosis medication contributed to a decrease in hip fractures by one-eighth, while changes in risk factors and prevention contributed to an increase in hip fractures by three-quarters. There is high potential for fracture prevention through pharmacological treatments but also through national policies to increase physical activity, reduce smoking, and lower body mass index (BMI).

AGN1 local osteo-enhancement procedure increases proximal femur volumetric bone mineral density of women with post-menopausal osteoporosis as assessed by quantitative computed tomography analysis

In this study, QCT was used to analyze the AGN1 Local Osteo-Enhancement Procedure (LOEP) as a treatment to form bone in the proximal femurs of patients with osteoporosis. Using this minimally invasive procedure, a resorbable triphasic AGN1 implant material was injected into the left femurs of 12 women with post-menopausal osteoporosis. Computed tomography scans were taken before treatment (baseline) and at 12 wk, 24 wk, and 5-7 yr after treatment. Quantitative computed tomography was used to investigate the resorption of AGN1 within the treated proximal femurs and to analyze the treatment's impact on integral, trabecular, and cortical bone. The untreated right femurs were used as controls. Data illustrated an increase in trabecular volumetric BMD (trab vBMD) of treated hips at all timepoints (baseline: 22 ± 21 mg/cm3 vs 217 ± 56 mg/cm3, 161 ± 18 mg/cm3, and 121 ± 37 mg/cm3 at 12-wk, 24-wk, and 5- to 7-yr timepoints, respectively), and an increase in integral vBMD of 65% at the 12-wk timepoint and 34% at the 5- to 7-yr timepoint. The increase in trab vBMD was observed in the location where the AGN1 implant material bolus was injected, and at the 5- to 7-yr timepoint, no significant BMD change was observed in the trabecular regions surrounding the original implantation zone (treated: 32 ± 16 mg/cm3, control: 31 ± 16 mg/cm3). This QCT study provides a more detailed understanding of the resorption and transformation of the AGN1 implant material into bone and supports, with some limitations, that the AGN1 LOEP treatment can locally increase trabecular bone density in weakened areas of the proximal femur where strength increase is most needed to reduce the risk of hip fragility fracture.

Increased prevalence of osteopenia and osteoporosis in systemic sclerosis patients, including in men and young women-a case-control study

OBJECTIVES

To investigate bone mineral density (BMD), osteoporosis prevalence and SSc-specific associations of BMD in SSc patients compared with background population.

METHODS

In total, 211 SSc patients (182 women, 29 men; mean age 61.3 and 62.2 years, respectively) and 505 age- and sex-matched controls from the same geographic area participated. BMD and T-score at total hip and lumbar spine was measured by dual-energy X-ray absorptiometry. Osteopenia was defined as T-score -1.0 to -2.5, and osteoporosis as T-score ≤-2.5. Associates of low BMD were identified by multiple regression analysis.

RESULTS

Women with SSc had lower BMD for total hip (P < 0.001) and spine (P = 0.011), equivalent to ΔT-score -0.56 and -0.35 compared with controls. Osteopenia was present in 51.6% and 16.5% had osteoporosis (P = 0.001, compared with controls). Already in women below age 45 years, differences in hip BMD were apparent (ΔT-score -0.93, P = 0.005). In addition to expected risk factors for osteoporosis (older age, lower BMI and menopause), finger ulcers (P = 0.009) and diffuse skin involvement (P = 0.027) were associated with lower hip BMD in women. In men with SSc, more than half displayed osteopenia or osteoporosis and had numerically lower hip BMD than their age-matched counterparts.

CONCLUSION

SSc patients, including men and younger women, have lower BMD than the background population. Finger ulcers and diffuse skin involvement, in addition to older age, lower BMI and being post-menopausal, are associated with lower BMD in women. The data emphasize the importance of performing bone health assessment of all SSc patients, including men and young subjects.

Orthogeriatric co-management and incident nursing home admissions in older patients with fragility fractures other than the hip-a retrospective cohort study using insurance claims data from Germany

BACKGROUND

Orthogeriatric co-management (OGCM) has been proposed as care model for geriatric patients with fragility fractures. However, its impact on nursing home (NH) admissions following non-hip fractures is unclear. This study aims to assess the association between OGCM and the probability of NH admissions within 6 months in older patients with fragility fractures other than the hip.

METHODS

This retrospective cohort study utilized nationwide insurance claims data from Germany (from years 2014-2018), covering individuals aged 80 years or older with fractures of the humerus, forearm, pelvis, or vertebrae. Based on the number of OGCM claims per year, hospitals were categorized as either OGCM or no OGCM. The primary outcome was the incidence of NH admissions within 6 months of the index fracture. Quasi-Poisson regression models were used to calculate incidence rate ratios (IRRs) with 95% confidence intervals (CI), adjusted for age, sex, prior care needs, comorbidity score, and rehabilitation transfer rates.

RESULTS

A total of 106,217 patients were included in the analysis. The incidence of NH admissions varied by fracture site, ranging from 11.1% for pelvic to 24.7% for vertebrae fractures, respectively. OGCM was associated with a reduced probability of NH admissions for humerus fractures (IRR 0.94, 95% CI 0.88-1.00) and vertebral fractures (IRR 0.92, 95% CI 0.87-0.97). No statistically significant associations were found for forearm (IRR 1.06, 95% CI 0.97-1.15) or pelvic fractures (IRR 1.02, 95% CI 0.96-1.09).

CONCLUSIONS

OGCM went along with a reduced probability of NH admissions in geriatric patients with humerus and vertebral fractures but showed no statistically significant benefit for forearm or pelvic fractures. The results highlight the need for targeted OGCM strategies based on fracture type and patient demographics to optimize outcomes in this vulnerable population.

Construction of Fracture Liaison Service Scheme Under Medical Alliance Framework in China: A Modified Delphi Method Study

Purpose

To devise an implementation blueprint for the fracture liaison service (FLS) model within the context of a medical consortium. The FLS is an integrated system designed to identify, register, assess, treat, and monitor patients with osteoporotic fractures. The FLS constitutes a structured intervention strategy to administer standardized care to osteoporotic fracture patients. Its efficacy has been validated through extensive implementation across various countries. However, large-scale intervention research on this model within China is lacking. This investigation endeavors to construct a comprehensive FLS framework and to establish its core performance indicators within the Chinese medical alliance structure.

Patients and Methods

The research methodology encompassed focus group interviews and a two-phase Delphi process. An initial inventory of FLS implementation elements was compiled through a systematic literature review and focus group discussions. This was followed by a two-step Delphi survey, wherein experts refined the key indicators. The study calculated metrics such as response rate, composite reliability (CR), coefficient of variation, and the Kendall coefficient of concordance to evaluate the indicators.

Results

The study involved 17 experts who completed 2 rounds of the Delphi consultation, culminating in a consensus on 2 primary and 8 secondary indicators, encompassing 34 specific indicators. The response rate for the first and second round was 100%, with CR values of 0.871 and 0.882, and Kendall's coefficients of 0.161 and 0.179, respectively (P < 0.05).

Conclusion

This work delineated a robust set of indicators specifically tailored for the FLS schema under the medical alliance framework in China. The rigorous application of the Delphi technique led to a consensus on 34 pivotal indicators, elucidating their relative significance.

Proximal Hip Fracture: Does Canal Width Matter?

Background/Objectives: Proximal femur fractures are common in the older population and are related to bone quality. Our work evaluates bone parameters from pelvic anteroposterior (AP) radiographs in patients with trochanteric and sub-capital fractures to determine if there are predictive morphology parameters for each fracture type. Methods: Data from 237 medical records were extracted from patients who arrived at our hospital with trochanteric and sub-capital femoral fractures. Descriptive data and radiological evaluation of the calcar-to-canal ratio (CCR), cortical thickness index (CTI), and Dorr classification were measured by two observers and statistically evaluated. Results: A total of 202 patients were found to be eligible for the study. The mean patient age was 81.41 ± 7.27 years old. The mean age of the trochanteric group was significantly higher than that of the sub-capital group (p = 0.005). There were no statistically significant differences in gender and comorbidities. The CCR showed significance, but the CTI and Dorr classification did not show a significant difference (p = 0.001, p = 0.78, and p = 0.98). A high degree of reliability was shown for all measurements. The ICC for CTI and CCR was p = 0.791 and p = 0.770 (p < 0.001), and Cronbach's alpha was 0.815 and 0.796, respectively. Logistic regression was found to be significant in predicting 60.4% of correct forecasts with an odds ratio of 0.011 and 95% confidence interval (p = 0.001). For CTI, the correct forecasting rate was 48%, with an odds ratio of 0.615 (p = 0.78). Conclusions: We found that, out of the measured parameters, the CCR stood out as important, showing that higher CCR levels are linked to an increased likelihood of trochanteric fractures.

Advancing care: optimizing osteoporosis treatment in the older and oldest old population

Osteoporosis is a critical public health issue, particularly in the "older" (those aged over 75) and "oldest old" population (those aged 85 and above), who are at a heightened risk for fractures and related complications. This article reviews current osteoporosis treatments tailored for these age groups, emphasizing the balance between efficacy and safety, while considering cost/benefit aspects. We discuss pharmacological therapies available nowadays and their respective benefits and risks in the old population, based on the available literature on the subject. Special attention is given to specific features of this age category, like challenges of polypharmacy, physiological changes associated with age, comorbidities and patient adherence. This paper highlights the need for individualised treatment plans that consider the patient's overall health status, life expectancy and quality of life and the importance of continued innovation and personalized care in managing osteoporosis especially among the "older" population.

Exercise for Postmenopausal Bone Health - Can We Raise the Bar?

PURPOSE OF REVIEW

This review summarises the latest evidence on effects of exercise on falls prevention, bone mineral density (BMD) and fragility fracture risk in postmenopausal women, explores hypotheses underpinning exercise-mediated effects on BMD and sheds light on innovative concepts to better understand and harness the skeletal benefits of exercise.

RECENT FINDINGS

Multimodal exercise programs incorporating challenging balance exercises can prevent falls. Emerging clinical trial evidence indicates supervised progressive high-intensity resistance and impact training (HiRIT) is efficacious in increasing lumbar spine BMD and is safe and well-tolerated in postmenopausal women with osteoporosis/osteopenia. There remains uncertainty regarding durability of this load-induced osteogenic response and safety in patients with recent fractures. Muscle-derived myokines and small circulating extracellular vesicles have emerged as potential sources of exercise-induced muscle-bone crosstalk but require validation in postmenopausal women. Exercise has the potential for multi-modal skeletal benefits with i) HiRIT to build bone, and ii) challenging balance exercises to prevent falls, and ultimately fractures. The therapeutic effect of such exercise in combination with osteoporosis pharmacotherapy should be considered in future trials.

Risk factors for non-vertebral fractures in community-dwelling elderly: a 10-year follow-up study in New Zealand

This 10-year study of 5000 + adults aged 50-84 found 20% experienced non-vertebral fractures. Higher risk was linked to female sex, older age, European ethnicity, lower education, living alone, alcohol use, prior falls/fractures, osteoporosis, arthritis, and antidepressants. Targeting modifiable factors (living arrangements, alcohol, antidepressants) could reduce fracture burden cost-effectively in older adults.

BACKGROUND

Although there has been extensive research on non-vertebral fractures, their risk factors remain incompletely understood. This study aimed to examine risk factors associated with non-vertebral fractures through a longitudinal examination of a community-dwelling cohort.

METHODS

This was a follow-up of participants recruited from family practices into a randomized trial of vitamin D supplementation and interviewed between 2011 and 2012, with follow-up until 2022. The outcome was the first non-vertebral fracture during the follow-up period, as identified from hospital events and insurance claims for fractures. Candidate risk factors were selected using a domain-based approach, and Cox models were employed to estimate adjusted hazard ratios (HRs).

RESULTS

The analysis comprised 5108 participants aged 50-84 years. Of these, 83% were of European/other ethnicity. A substantial proportion reported living with non-family members or living alone (20.5%), engaging in daily drinking (21.6%), or using antidepressants (11.9%). Over a median 10-year follow-up, 1016 participants (20%) experienced non-vertebral fractures. In the multivariable model, several factors were related to higher risk of non-vertebral fracture, including females (HR = 1.53), aged 80-84 years (HR = 1.47), European/other ethnicity, primary school education (HR = 1.65), living with non-family members (HR = 1.47) or living alone (HR = 1.29), daily alcohol drinking (HR = 1.51), history of falls (HR = 1.59) or fractures (HR = 1.43), osteoporosis (HR = 1.95), and arthritis (HR = 1.20), and dispensing of antidepressants (HR = 1.52) and antiarrhythmic medications (HR = 1.51).

CONCLUSION

Non-vertebral fractures are prevalent among older adults, with several prevalent and potentially modifiable risk factors identified, such as living situation, drinking habits, and antidepressant dispensing. Further exploration of these factors' causality and the implementation of public health interventions targeting them, could yield significant benefits and cost-effectively reduce the burden of fractures.

TRIAL REGISTRATION

This study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000402943).

Global, regional, and national burden of fracture of sternum and/or fracture of one or more ribs: a systematic analysis of incidence, YLDs with projections to 2030

Background

Sternal and/or rib fractures represent a growing global health challenge. Despite their significant clinical and public health implications, epidemiological studies on these injuries remain limited. Utilizing the Global Burden of Disease 2019 (GBD2019) database, this study evaluates the worldwide burden of sternal and/or rib fractures and projects trends through 2030 to inform policy development.

Methods

We analyzed global incidence, age-standardized incidence rate (ASIR), years lived with disability (YLDs), age-standardized YLD rate (ASYR) and estimated annual percentage change (EAPC) of sternal and/or rib fractures across geographic regions, nations, age-sex groups, and socio-demographic index (SDI) quintiles using GBD2019 data. The Bayesian age-period-cohort (BAPC) model was employed to forecast trends until 2030.

Results

In 2019, global incident cases of sternal/rib fractures reached 4.1 million (44% increase since 1990), with YLDs at 190,000 (62% rise since 1990). While ASIR and ASYR showed modest declines, the absolute burden remained substantial. East Asia and high-income North America both exhibited the highest incident cases and YLDs. Central Latin America and Western Saharan Africa demonstrated the steepest incidence growth, whereas the Caribbean experienced the most pronounced YLD increases. Nationally, China reported the highest absolute burden, while Greenland had the highest ASIR and ASYR. Males carried over 60% of the burden. Also, there was a negative correlation between EAPC and national SDI. Projections indicate that the global burden of disease will continue to rise by 2030.

Conclusion

The escalating burden of sternal/rib fractures demands targeted interventions. Prioritizing injury prevention in high-burden regions (e.g., East Asia), addressing male-dominated occupational/behavioral risks, and optimizing infrastructure such as medical transport in low-SDI settings are critical policy priorities. Sustained surveillance through standardized reporting systems is essential for monitoring progress.

A Hip New Standard: Improving Osteoporosis Care with Inpatient Administration of IV Zoledronate

BACKGROUND

Osteoporosis continues to be underdiagnosed and inadequately treated in older hip-fracture patients. Our aim was to improve the rate of osteoporosis treatment with IV bisphosphonate therapy in eligible patients admitted for hip-fracture surgery.

METHODS

The present study was designed as a quality improvement initiative using Plan-Do-Study-Act (PDSA) cycles at an academic medical center in Portland, Oregon, over 2.5 years. A protocol was developed (1) to administer IV zoledronate on postoperative day 2 to inpatients aged ≥50 years who underwent surgery for a low-energy hip fracture and (2) to formally diagnose osteoporosis during admission. The protocol was introduced across 3 care settings in a stepped-wedge manner. Outcome measures were the percentage of inpatient zoledronate administered to eligible patients and formal documented diagnosis of osteoporosis. Balance measures included fever after administration and hospital length of stay (LOS). Measures were assessed through quarterly chart review and tracked via control charts.

RESULTS

The rate of zoledronate administration significantly increased from 34.5% (29 of 84) to 74.6% (53 of 71) following the second PDSA cycle (p < 0.001). Documented osteoporosis diagnosis also significantly improved from 51.0% (53 of 104) to 85.7% (96 of 112) following the second PDSA cycle (p < 0.001). No significant differences were shown for hospital LOS, and 1 of 82 patients had medical work-up for post-infusion acute phase reaction after administration.

CONCLUSIONS

This initiative was effective at improving osteoporosis diagnosis and treatment among older hip-fracture patients at our institution. Protocol development for administrating inpatient zoledronate after hip fracture is a reliable way to predictably offer bone health care and secondary-fracture prevention to hip-fracture patients and can be adapted and implemented at other institutions.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Preventing Falls in Older Adults After Upper Limb Fractures: A Scoping Review

OBJECTIVE

The objective was to identify and describe fall prevention strategies in upper limb fracture rehabilitation for older people using recent fall prevention guidelines as a standard.

METHODS

A systematic search was conducted in 9 electronic databases (PubMed/MEDLINE, EBSCOhost, Cochrane Library, Lilacs, SPORTDiscus, CINAHL, Web of Science, AgeLine, and SciELO), gray literature, and in bibliographic and citation searching of selected articles between May and December 2022 and updated between February and March 2024. Two independent reviewers screened citations for inclusion. Data extraction was performed by 1 reviewer and verified by a second reviewer. A frequency of strategies and content analysis syntheses were conducted.

RESULTS

A broad search strategy was used, initially identifying 25,945 articles and including 6 randomized clinical trials. The gray literature search identified 18 records. Five studies included forearm fractures, 1 upper limb fracture, and no study exclusively on rehabilitation after humerus fractures. None of the studies provided comprehensive multifactorial fall risk assessments to guide tailored interventions. Assessments mainly focused on gait and balance. Exercise was the most offered intervention alone or in combination with education. Exercise programs were aligned with recommendations to include progressive balance and functional exercises overall. However, the frequency of ≥3 times weekly was less frequently offered. The gray literature showed a lack of fall prevention-specific information after upper limb fractures and mostly called attention to fall prevention after hip fractures.

CONCLUSION

Upper limb fracture rehabilitation in older adults, considered at high risk of falling, did not include comprehensive and tailored multifactorial fall assessment and intervention. Unequivocally, exercise programs were overall aligned with recent recommendations and were the most frequent intervention. There is a crucial gap for humerus fractures. This study can help align the treatment of upper limb fractures with updated fall prevention recommendations and impact future research, guiding and influencing implementation in clinical practice.

IMPACT

There is an urgent need to implement comprehensive and tailored multifactorial fall assessments and interventions in rehabilitation programs for older adults recovering from upper limb fractures. Guidelines should direct this work to enhance clinical practice.

Real-World Osteoporosis Treatment Gap and Costs in Spain: Data from Women with a First Fragility Fracture or Diagnosis of Postmenopausal Osteoporosis

INTRODUCTION

Postmenopausal osteoporosis (PMO) increases the risk of fragility fractures (FF), leading to disability, higher mortality, and elevated healthcare costs. Despite available treatments, osteoporosis (OP) remains undertreated, especially in women over 50 years at high risk for FF. Real-world data on OP care in Spain are limited. This study aims to assess the OP treatment gap, healthcare resource utilisation (HCRU), and costs among Spanish women following a first FF or PMO diagnosis.

METHODS

This retrospective study used data from the BIG-PAC® administrative database on women aged ≥ 50 years with a first FF (cohort 1) or newly diagnosed PMO (cohort 2) between 2014 and 2018. Patients were followed for 2 years after the index event. The primary outcome was the proportion of women not prescribed OP medication within 6 months after the index event (treatment gap). Secondary outcomes included fracture incidence, mortality, HCRU, and costs.

RESULTS

The study included 22,142 women: 3190 in cohort 1 and 18,952 in cohort 2. The OP treatment gap was higher in cohort 1 vs cohort 2 (41.5% vs 23.6%). In cohort 1, 59.2% were diagnosed with PMO after the first FF, with 88% experiencing subsequent fracture(s). OP treatment persistence decreased over time in both cohorts. Fracture rates were lower in women prescribed OP treatment vs those who were not (8.35 vs 13.8 per 1000 patient-years) and in those who showed 24-month-persistence and 12-month adherence to treatment vs those who did not (8.98 and 7.66 vs 10.79 and 10.76). The 2-year mean cost per patient was higher in cohort 1 (€10,601) than in cohort 2 (€1659), with the highest costs incurred for hip (€15,833) and vertebral (€10,593) fractures.

CONCLUSION

This study highlights a significant treatment gap in Spanish women aged ≥ 50 with a first FF or newly diagnosed PMO. Costs are particularly high for those with a first FF, especially for hip or vertebral fractures. Improving treatment adherence could reduce fracture risk, healthcare costs, and resource utilisation.

Effects of combined protein and exercise interventions on bone health in middle-aged and older adults - A systematic literature review and meta-analysis of randomized controlled trials

PURPOSE

Osteoporosis has become a global public health concern making prevention and treatment essential to reduce severe consequences for individuals and health systems. This systematic review with meta-analysis aimed to determine the effects of combined protein and exercise interventions compared to (a) exercise alone and (b) protein alone on bone mineral content (BMC) or density (BMD) in middle-aged and older adults.

METHODS

We systematically searched Medline, CINAHL, CENTRAL, Web of Science, and SPORTDiscus until 24th January 2023. Pairwise random-effects meta-analyses were performed to calculate weighted mean differences (WMD) with 95% confidence intervals (95% CI). We evaluated risk of bias (Cochrane RoB2) and certainty of evidence (CoE; GRADE). If pooling was not possible, the results were summarized descriptively.

RESULTS

For the comparison of combined protein supplementation and exercise vs. exercise alone, no meta-analysis for BMD (2 RCTs) was possible. For BMC, little to no intervention effect was found (WMD 0.03 kg; 95% CI - 0.00 to 0.05; 4 RCTs; IG = 97/CG = 98; I2 = 58.4%). In a sensitivity analysis, restricted to combined milk-protein supplementation and exercise, the result remained similar (0.01 kg; 95% CI - 0.01 to 0.03; 4 RCTs; IG = 71/CG = 71; I2 = 0.0%; low CoE). For the comparison of combined protein and exercise interventions vs. protein alone, no RCT on BMC was identified; the results on total or regional BMD (2 RCTs) were inconclusive.

CONCLUSION

Based on our findings, no robust conclusions can be drawn on whether combining protein and exercise interventions is more beneficial for bone health than one component alone. Sufficiently powered studies with longer duration are required to clarify these questions (CRD42022334026).

Mechanisms of mitochondrial reactive oxygen species action in bone mesenchymal cells

Mitochondrial (mt)ROS, insufficient NAD+, and cellular senescence all contribute to the decrease in bone formation with aging. ROS can cause senescence and decrease NAD+, but it remains unknown whether these mechanisms mediate the effects of ROS in vivo. Here, we generated mice lacking the mitochondrial antioxidant enzyme Sod2 in osteoblast lineage cells targeted by Osx1-Cre and showed that Sod2ΔOsx1 mice had low bone mass. Osteoblastic cells from these mice had impaired mitochondrial respiration and attenuated NAD+ levels. Administration of an NAD+ precursor improved mitochondrial function in vitro but failed to rescue the low bone mass of Sod2ΔOsx1 mice. Single-cell RNA-sequencing of bone mesenchymal cells indicated that ROS had no significant effects on markers of senescence but disrupted parathyroid hormone signaling, iron metabolism, and proteostasis. Our data supports the rationale that treatment combinations aimed at decreasing mtROS and senescent cells and increasing NAD+ should confer additive effects in delaying age-associated osteoporosis.

CT-based vertebral three-dimensional Hounsfield unit can predict the new vertebral fracture after percutaneous vertebral augmentation in postmenopausal women: a retrospective study

BACKGROUND

Vertebral Hounsfield unit (HU) were regarded as a new way to predict fragility fracture. However, HU values were measured in a single plane, which is not accurate for the entire vertebral body. This study aimed to create a new CT-based metric for assessing bone mineral density, three-dimensional Hounsfield unit value (3D-HU), and to evaluate its effect in independently predicting new vertebral fracture (NVF) after percutaneous vertebral augmentation (PVA) in postmenopausal women.

METHODS

This study reviewed female patients with osteoporotic vertebral compression fracture (OVCF) who were treated at our hospital. Patients were divided into NVF and control groups according to whether they had NVF. 3D-HU of the L1-4 vertebrae was measured using preoperative computed tomography (CT) scanning of the lumbar spine. Demographics, procedure-related data, and radiological data were collected. Pearson correlation test was used to determine the correlation between 3D-HU and BMD T-score. The independent risk factors of NVF were determined by multivariate logistic regression analyses. Receiver operating characteristic curve (ROC) was used to evaluate the predictive performance of 3D-HU.

RESULTS

This study involved 349 postmenopausal women who were treated with PVA between January 2017 and August 2022. Among them, 61 people suffered the NVF following PVA. The mean 3D-HU was 40.64 ± 22.43 in the NVF group and 79.93 ± 25.69 in the without NVF group (p < 0.001). Multivariate analysis showed that lower 3D-HU (OR = 0.927; 95%CI = 0.906-0.945; p < 0.001) was the only independent predictor of NVF following PVA. The predictive accuracy of 3D-HU was 87.7%, which was higher than that of the HU value (82.3%), and it was highly positively correlated with BMD T-score (r = 0.628, p < 0.001).

CONCLUSIONS

Lower 3D-HU was significantly associated with NVF following PVA in postmenopausal women. In addition, vertebral 3D-HU had better predictive power than HU values. 3D-HU assessment prior to PVA may provide insight into a patient' s risk for NVF.

Biomechanical perspectives on image-based hip fracture risk assessment: advances and challenges

Hip fractures pose a significant health challenge, particularly in aging populations, leading to substantial morbidity and economic burden. Most hip fractures result from a combination of osteoporosis and falls. Accurate assessment of hip fracture risk is essential for identifying high-risk individuals and implementing effective preventive strategies. Current clinical tools, such as the Fracture Risk Assessment Tool (FRAX), primarily rely on statistical models of clinical risk factors derived from large population studies. However, these tools often lack specificity in capturing the individual biomechanical factors that directly influence fracture susceptibility. Consequently, image-based biomechanical approaches, primarily leveraging dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT), have garnered attention for their potential to provide a more precise evaluation of bone strength and the impact forces involved in falls, thereby enhancing risk prediction accuracy. Biomechanical approaches rely on two fundamental components: assessing bone strength and predicting fall-induced impact forces. While significant advancements have been made in image-based finite element (FE) modeling for bone strength analysis and dynamic simulations of fall-induced impact forces, substantial challenges remain. In this review, we examine recent progress in these areas and highlight the key challenges that must be addressed to advance the field and improve fracture risk prediction.

Longitudinal assessment of changes in muscle composition using proton density fat fraction and T2* in patients with and without incidental vertebral compression fractures

Objective

Chemical shift encoded-based water-fat separation magnetic resonance imaging (CSE-MRI) is an emerging noninvasive tool for the assessment of bone and muscle composition. This study aims to examine both the predictive value and the longitudinal change of proton density fat fraction (PDFF) and T2* in the paraspinal muscles (PSM) in patients with and without the development of an incidental vertebral compression fracture (VCFs) after 6 months of follow-up.

Methods

Patients (N=56) with CT and 3T CSE-MRI of the lumbar spine at baseline and CSE-MRI at 6 months follow-up were included in this retrospective study. Patients who, on average, developed an incidental VCF one year after baseline MRI (VCF: N=14, 9 males, 66.8 ± 7.9 years) were frequency matched by age and sex to patients without VCFs (non-VCF) at baseline and follow-up (non-VCF: N=42, 27 males, 64.6 ± 13.3 years). Mean PDFF, T2*, and cross-sectional area (CSA) values from the autochthonous PSM of the thoracolumbar spine (T11-L4) and opportunistic CT-based bone mineral density (BMD) measurements were obtained for each individual. The associations between baseline measurements, longitudinal changes in PDFF, T2*, CSA of the PSM and the occurrence of VCFs at follow-up were evaluated using linear and logistic multivariable regression models. ROC analyses were used to assess cutoff values for predicting the development of VCFs.

Results

No significant difference in PDFF of the PSM was found between the VCF and non-VCF group at baseline (VCF/non-VCF 8.5 ± 13.8% vs. 5.0 ± 4.6%; p=0.53). In multivariable linear regression models adjusted for sex, age and baseline BMD, PDFF values of the PSM increased significantly over 6 months in the VCF group (2.4 ± 2.8% vs. -1.0 ± 2.3%, p<0.001), while T2* values of the PSM showed a significant decrease (p ≤ 0.01). ROC analyses identified a PDFF increase of 0.2% in the PSM as the optimal cutoff value to distinguish between patients with and without VCF (AUC 0.86, 95% CI [0.74-0.98], p<0.001).

Conclusion

Longitudinal PDFF-based assessment of the PSM composition may be a useful indicator for the prediction of the development of vertebral compression fractures.

Marrow Adiposity Content and Composition Are Not Associated With Incident Fragility Fractures in Postmenopausal Women: The ADIMOS Fracture Study

Context

Noninvasive measurement of bone marrow adipose tissue using magnetic resonance imaging and proton density fat fraction (PDFF) may enhance clinical fractures prediction in postmenopausal women.

Objective

This study aimed to assess the association between PDFF measurements and clinical fracture incidence.

Methods

A longitudinal study was conducted. Postmenopausal women with recent osteoporotic fractures (<12 months) and with osteoarthritis without fractures were included. Lumbar spine and proximal femur PDFFs were measured at baseline using water-fat imaging (WFI) and dual-energy x-ray absorptiometry scans. Clinical fractures were recorded during follow-up.

Results

Among 195 participants (mean age 67.4 ± 10.0 years, body mass index 27.2 ± 5.9 kg/m²), the PDFF (WFI-based) was higher at the proximal femur, particularly at the femoral head (90.0% ± 4.9%), compared to the lumbar spine (57.8% ± 9.6%). Over a mean follow-up period of 37.2 ± 11.6 months, 7 participants died, 29 (14.9%) experienced incident clinical fractures, and 1 was lost to follow-up. The lack of an association between WFI-based PDFFs and the incidence of clinical fractures was demonstrated regardless of the region of measurement (hazard ratio [HR] = 0.95 [95% CI 0.67-1.35], P = 0.77 at the lumbar spine, HR = 1.07 [95% CI 0.71-1.63], P = 0.74 at the femoral neck). Stepwise regression analysis did not alter these findings, and the variable "recent osteoporotic fractures" was found to be significantly associated with incident clinical fractures.

Conclusion

This study found no evidence of a relationship between PDFF and clinical fracture incidence in postmenopausal women. Further studies are necessary involving larger cohorts and longer follow-up periods.

Improving readability in AI-generated medical information on fragility fractures: the role of prompt wording on ChatGPT's responses

Understanding how the questions used when interacting with chatbots impact the readability of the generated text is essential for effective health communication. Using descriptive queries instead of just keywords during interaction with ChatGPT results in more readable and understandable answers about fragility fractures.

PURPOSE

Large language models like ChatGPT can enhance patients' understanding of medical information, making health decisions more accessible. Complex terms, such as "fragility fracture," can confuse patients, so presenting its medical content in plain language is crucial. This study explored whether conversational prompts improve readability and understanding compared to keyword-based prompts when generating patient-centered health information on fragility fractures.

METHODS

The 32 most frequently searched keywords related to "fragility fracture" and "osteoporotic fracture" were identified using Google Trends. From this set, 24 keywords were selected based on relevance and entered sequentially into ChatGPT. Each keyword was tested with two prompt types: (1) plain language with keywords embedded and (2) keywords alone. The readability and comprehensibility of the AI-generated responses were assessed using the Flesch-Kincaid reading ease (FKRE) and Flesch-Kincaid grade level (FKGL), respectively. The scores of the responses were compared using the Mann-Whitney U test.

RESULTS

The FKRE scores indicated significantly higher readability with plain language prompts (median 34.35) compared to keyword-only prompts (median 23.60). Similarly, the FKGL indicated a lower grade level for plain language prompts (median 12.05) versus keyword-only (median 14.50), with both differences achieving statistical significance.

CONCLUSION

Our findings suggest that using conversational prompts can enhance the readability of AI-generated medical information on fragility fractures. Clinicians and content creators should consider this approach when using AI for patient education to optimize comprehension.

Development and implementation of a physiotherapy exercise intervention with tailored support for exercise adherence for people with vertebral fragility fractures (OPTIN trial)

OBJECTIVES

The OsteoPorosis Tailored exercise adherence INtervention (OPTIN) trial is a two-arm, multi-centre randomised controlled trial. It compares the effectiveness of physiotherapy exercise rehabilitation with integrated support for exercise adherence, to physiotherapy exercise rehabilitation alone, for people with vertebral fragility fracture (VFF) and back pain. This paper describes the development of the physiotherapist-led adherence enhanced intervention.

METHODS

We used an intervention mapping approach and followed Medical Research Council guidelines for developing complex interventions. We co-created the intervention involving expert clinicians, service managers, researchers, and adults with long-term musculoskeletal conditions, including osteoporosis. We identified a theoretical framework, reviewed the evidence, used a feasibility study, and considered clinical practice and deliverability within UK National Health Service (NHS) outpatient physiotherapy secondary care. Through a collaborative workshop, we refined the intervention, involved patients again and re-tested the intervention. Finally, we manualised the intervention, produced patient and physiotherapist materials and trained physiotherapists for delivery.

RESULTS

The OPTIN intervention uses a motivational interviewing approach and captures information about patient goals, barriers, and facilitators to exercise. Physiotherapists assess exercise capability, opportunities and motivation and utilise at least three behaviour change approaches, selecting from an intervention toolkit of nine approaches to support exercise behaviour. Ninety minutes of additional physiotherapy are provided to deliver the intervention, integrated within the assessment and six follow-up visits.

CONCLUSIONS

A theory-informed intervention to support exercise adherence was developed and delivered by physiotherapists trained in the intervention to older adults with VFF and back pain in the intervention arm (n = 63) of the OPTIN trial.

TRIAL REGISTRATION NUMBER

ISRCTN 14465704. CONTRIBUTION OF PAPER.

In Silico Clinical Trial for Osteoporosis Treatments to Prevent Hip Fractures: Simulation of the Placebo Arm

Osteoporosis represents a major healthcare concern. The development of novel treatments presents challenges due to the limited cost-effectiveness of clinical trials and ethical concerns associated with placebo-controlled trials. Computational models for the design and assessment of biomedical products (In Silico Trials) are emerging as a promising alternative. In this study, a novel In Silico Trial technology (BoneStrength) was applied to replicate the placebo arms of two concluded clinical trials and its accuracy in predicting hip fracture incidence was evaluated. Two virtual cohorts (N = 1238 and 1226, respectively) were generated by sampling a statistical anatomy atlas based on CT scans of proximal femurs. Baseline characteristics were equivalent to those reported for the clinical cohorts. Fall events were sampled from a Poisson distribution. A multiscale stochastic model was implemented to estimate the impact force associated to each fall. Finite Element models were used to predict femur strength. Fracture incidence in 3 years follow-up was computed with a Markov chain approach; a patient was considered fractured if the impact force associated with a fall exceeded femur strength. Ten realizations of the stochastic process were run to reach convergence. Each realization required approximately 2500 FE simulations, solved using High-Performance Computing infrastructures. Predicted number of fractures was 12 ± 2 and 18 ± 4 for the two cohorts, respectively. The predicted incidence range consistently included the reported clinical data, although on average fracture incidence was overestimated. These findings highlight the potential of BoneStrength for future applications in drug development and assessment.

Radiofrequency Echographic Multi Spectrometry-A Novel Tool in the Diagnosis of Osteoporosis and Prediction of Fragility Fractures: A Systematic Review

Background/Objectives: Given the significant economic and social burden of osteoporosis, there is growing interest in developing an efficient alternative to the traditional dual-energy X-ray absorptiometry (DXA). Radiofrequency Echographic Multi Spectrometry (REMS) is an innovative, non-ionizing imaging technique that recently emerged as a viable tool to diagnose osteoporosis and estimate the fragility fracture risk. Nevertheless, its clinical use is still limited due to its novelty and continuing uncertainty of long-term performance. Methods: In order to evaluate the accuracy of the REMS, a systematic review of the English-language literature was conducted. Three databases were searched for relevant publications from 1 January 2015 until 1 December 2024 using the keyword combinations "(radiofrequency echographic multi spectrometry OR REMS) AND (dual-energy X-ray absorptiometry OR DXA)". The initial search yielded 602 candidate articles. After screening the titles and abstracts following the eligibility criteria, 17 publications remained for full-text evaluation. Results: The reviewed studies demonstrated strong diagnostic agreement between REMS and DXA. Additionally, REMS showed enhanced diagnostic capabilities in cases where lumbar bone mineral density measurements by DXA were impaired by artifacts such as vertebral fractures, deformities, osteoarthritis, or vascular calcifications. REMS exhibited excellent intra-operator repeatability and precision, comparable to or exceeding the reported performance of DXA. The fragility score (FS), a parameter reflecting bone quality and structural integrity, effectively discriminated between fractured and non-fractured patients. Moreover, REMS proved to be a radiation-free option for bone health monitoring in radiation-sensitive populations or patients requiring frequent imaging to assess fracture risk. Conclusions: This current study underscores the robustness of REMS as a reliable method for diagnosing and monitoring osteoporosis and evaluating bone fragility via the FS. It also identifies critical knowledge gaps and emphasizes the need for further prospective studies to validate and expand the clinical applications of REMS across diverse patient populations.

Falling rates but projected rising numbers of fractures in elderly Norwegians: a study of fracture rates in the Norwegian patient registry from 2010 to 2021, extrapolated to 2041

PURPOSE

 Our aim was to calculate rates of major fractures by fracture location in elderly Norwegians over the years 2010 to 2021 and thereby estimate the volume of fractures in this population by 2041.

METHODS

 We identified fractures in persons aged 65 years and over from the Norwegian Patient Registry. We summarized age- and sex-specific numbers of fractures and incidence rates by fracture location. Extrapolating adjusted incidence rates combined with population projections from Statistics Norway, we estimated the expected numbers of fracture cases for the following 20 years.

RESULTS

 The total number of major fractures rose from 22,581 in 2010 to 27,596 in 2021. While the number of hip fractures was relatively stable (8,164 to 8,194 over the period), there were substantial increases in the number of fractures in the upper extremities, spine and pelvis, and lower extremities. Annual changes in incidence rates adjusted for age and sex were 0.6% (95% confidence interval [CI] 0.4-0.7), 1.2% (CI 0.9-1.4), 0.4% (CI 0.1-0.7), and -1.9% (CI -2.0 to -1.7) for upper extremity, spine and pelvis, lower extremity, and hip respectively. Extrapolating trends in incidence rates, we estimate a 64% (95% prediction interval 48-70) overall increase in the number of major fractures by 2041 compared with 2021, primarily due to the aging of the population.

CONCLUSION

 Incidence rates of hip fractures decreased over the period, while rates of other major fractures increased. We can expect a substantial increase in the number of fractures over the coming years, primarily due to the expected aging of the population.

Postoperative outcomes in patients operated for extra- and intracapsular hip fractures - a secondary analysis of two randomized controlled trials

BACKGROUND

Hip fractures are among the most common and serious injuries in older adults. There has been a perception that extracapsular hip fractures have worse outcome than intracapsular hip fractures. We aimed to examine postoperative outcomes in patients operated for extra- and intracapsular hip fractures.

METHODS

This is a secondary analysis of data from two randomized controlled trials evaluating the effect of orthogeriatric care. Bivariate analyses were conducted, comparing patients with extracapsular fracture to patients with intracapsular fracture. Mortality, length of hospital stay (LOS), new nursing home admissions, operative data and measures of functional and cognitive performance were assessed as endpoints.

RESULTS

The primary analysis included 711 patients; 283 patients had an extracapsular fracture and 428 an intracapsular fracture. At four months follow-up, the intracapsular fracture group had significantly better Short Physical Performance Battery (SPPB) (5.0 vs. 4.0, p = 0.007), personal Activities of Daily Living (p-ADL) (17.0 vs. 16.0, p = 0.007) and instrumental ADL (i-ADL) (32.5 vs. 28.0, p = 0.049). There were no statistically significant differences between the groups at 12 months.

CONCLUSIONS

Patients with an extracapsular fracture had worse mobility and ADL levels four months postoperatively, but there were no clinically relevant differences at 12 months postoperatively.

Performance of the Nottingham hip fracture score (NHFS) as a predictor of 30-day mortality after proximal femur fracture in an older people Brazilian cohort

Perioperative risk assessment helps inform clinical practice for older people with hip fractures. This is a cohort study, where perioperative risk screening, including NHFS, was performed at admission, followed by an evaluation of 30-day outcomes. 503 patients were included, 73% female, 79.4 ± 9.3 years old; 58% presented extracapsular and 42% intracapsular fractures, with a 30-day mortality of 9%. The NHFS was higher in the patients who died at 5.6 ± 1.1 compared to survivals at 4.3 ± 1.5 (p-value < 0.001). NHFS > 4 was associated with 30-day mortality observed by Cox regression adjusted by fracture type: HR 4.55 (95% CI 2.10-9.82) (p-value < 0.001) and Kaplan-Meyer Curve (HR 3.94; 95% CI 2.19-7.07; p-value < 0.001). ROC curve showed the accuracy of NHFS in explaining 30-day mortality (AUC 0.74; 95% CI 0.67-0.81). Complications were higher among patients with NHFS > 4. The performance of NHFS was better than the traditional perioperative risk ASA score. Therefore, NHFS can be implemented in real-world clinical practice to estimate the 30-day mortality risk for hip fracture in older patients in Brazil. NHFS > 4 is critical for 30-day mortality and complications; this cutoff helps inform clinical practice. The present study might motivate other centers to consider NHFS in their perioperative risk assessment routine.

Exploring the potential cost-effectiveness and societal burden implications of screening for fracture risk in a UK general radiography setting

BACKGROUND

Fragility fractures lead to considerable societal costs and individual suffering. Despite the availability of cost-effective treatments for high-risk patients, a significant treatment gap exists, with many high-risk individuals remaining unidentified and untreated. The aim of this study was to explore the potential cost-effectiveness and societal impact of opportunistic screening for fracture risk with IBEX Bone Health (BH), a software solution that provides bone mineral density from wrist radiographs, in a UK general radiography setting.

METHODS

The study used a health economic model that compared the health outcomes and costs of screening with IBEX BH versus usual care for men and women aged 50 and older who had a forearm radiograph for any reason. The model incorporated data on fracture incidence, fracture risk reduction, mortality, quality of life, and fracture and treatment costs from published sources and Royal Cornwall Hospitals NHS Trust. Costs and health outcomes in terms of quality-adjusted life years (QALYs) were simulated over the remaining lifetime of patients. The analysis took the perspective of the National Health Service (NHS) and Personal Social Services in the UK.

RESULTS

The results showed that screening with IBEX BH was associated with a gain of 0.013 QALYs and a cost saving of £109 per patient compared with usual care, making it a dominant (cost-saving) strategy. Sensitivity analyses confirmed the robustness of the results under various assumptions. Widespread adoption of IBEX BH in the NHS was estimated to save 8,066 QALYs and £65,930,555 in healthcare costs over the lifetime of patients visiting hospitals for wrist radiographs each year.

CONCLUSIONS

IBEX BH could be a cost-effective tool for early identification and prevention of fragility fractures in the UK, addressing the current challenges of low provision and access to fracture risk assessment and treatment.

Sentinel fracture: the necessity of improved post-fracture care

Fragility fractures caused by osteoporosis, the most common metabolic bone disease, place a significant burden on affected individuals and impose substantial economic costs. A fragility fracture implies an imminent elevated risk for subsequent fractures, particularly in the short term. Therefore, osteoporosis must be addressed in the event of a sentinel fracture, if not already previously treated. Regardless of whether the fracture is treated conservatively or surgically, post-fracture care is particularly important. Early mobilization followed by fall risk assessment and the initiation of adequate bone-specific medication are essential milestones in preventing subsequent fractures. Monitoring patients increases adherence to bone-specific medication and fall prevention strategies. Comprehensive post-fracture care is important and should be performed by a multidisciplinary team. Coordinated care models, such as the fracture liaison service (FLS), have shown enhancements in the initiation of and adherence to secondary prevention of fragility fractures. Despite recommendations by several guidelines including that published by the Austrian Society for Bone and Mineral Research, only one fracture liaison service has been implemented in Austria.

The Impact of Hospital Volume and Region on Mortality, Medical Costs, and Length of Hospital Stay in Elderly Patients Following Hip Fracture: A Nationwide Claims Database Analysis

Backgroud

The purpose of our study was to analyze the effects of hospital volume and region on in-hospital and long-term mortality, direct medical costs (DMCs), and length of hospital stay (LOS) in elderly patients following hip fracture, utilizing nationwide claims data.

Methods

This retrospective nationwide study sourced its subjects from the Korean National Health Insurance Review and Assessment Service database spanning from January 2011 to December 2018. A generalized estimating equation model with a Poisson distribution and logarithmic link function was used to estimate adjusted odds ratios (aORs) and 95% CIs to assess the association of hospital volume with in-hospital and 1-year mortality, DMCs, and LOS.

Results

A total of 172,144 patients were included. Comparing the risk of in-hospital death between high-volume and low-volume hospitals, the risk of in-hospital death was 1.2 times higher at low-volume hospitals (aOR, 1.20; 95% CI, 1.07-1.33; p = 0.002). Additionally, the risk of death at 1 year was 1.05 times higher at low-volume hospitals (aOR, 1.05; 95% CI, 1.01-1.09; p = 0.008) compared to high-volume hospitals. DMCs were 0.84 times lower at low-volume hospitals for in-hospital period (aOR, 0.84; 95% CI, 0.84-0.85; p < 0.001) and 0.87 times lower for 1 year (aOR, 0.87; 95% CI, 0.86-0.88; p < 0.001) compared to high-volume hospitals. In-hospital LOS was 1.21 times longer at low-volume hospitals (aOR, 1.21; 95% CI, 1.20-1.22; p < 0.001) than at high-volume hospitals. In addition, the risk of in-hospital death was 1.22 times higher (aOR, 1.22; 95% CI, 1.12-1.33; p < 0.001) and the risk of 1-year death was 1.07 times higher (aOR, 1.07; 95% CI, 1.04-1.10; p < 0.001) at rural hospitals compared to urban hospitals.

Conclusions

Clinicians should focus on improving clinical outcomes for hip fracture patients in low-volume and rural hospital settings, with a specific emphasis on reducing mortality rates.

The association of lipids and novel non-statin lipid-lowering drug target with osteoporosis: evidence from genetic correlations and Mendelian randomization

BACKGROUND

It remains controversial whether lipids affect osteoporosis (OP) or bone mineral density (BMD), and causality has not been established. This study aimed to investigate the genetic associations between lipids, novel non-statin lipid-lowering drug target genes, and OP and BMD.

METHODS

Mendelian randomization (MR) method was used to explore the genetic associations between 179 lipid species and OP, BMD. Drug-target MR analysis was used to explore the causal associations between angiopoietin-like protein 3 (ANGPTL3) and apolipoprotein C3 (APOC3) inhibitors on BMD.

RESULTS

The IVW results with Bonferroni correction indicated that triglyceride (TG) (51:3) (OR = 1.0029; 95% CI: 1.0014-1.0045; P = 0.0002) and TG (56:6) (OR = 1.0021; 95% CI: 1.0008-1.0033; P = 0.0011) were associated with an increased risk of OP; TG (51:2) (OR = 0.9543; 95% CI: 0.9148-0.9954; P = 0.0298) was associated with decreased BMD; and ANGPTL3 inhibitor (OR = 1.1342; 95% CI: 1.0393-1.2290; P = 0.0093) and APOC3 inhibitor (OR = 1.0506; 95% CI: 1.0155-1.0857; P = 0.0058) was associated with increased BMD.

CONCLUSIONS

MR analysis indicated causal associations between genetically predicted TGs and OP and BMD. Drug-target MR analysis showed that ANGPTL3 and APOC3 have the potential to serve as novel non-statin lipid-lowering drug targets to treat or prevent OP.

Health-Related Quality of Life in Men with Fractures and Fear of Falling in General Population: A Cross-Sectional Study

Purpose: This study aims to assess how fractures and fear of falling affect health-related quality of life (HRQoL) in men (≥50 years) across different domains. Methods: Design: Observational study.

SETTING

Primary care.

SUBJECTS

237 men aged 50-90 years.

OUTCOME MEASURES

Age, frac-tures, fear of falling, EQ-5D. Results: A total of 122 men (51.47% of the male cohort) participated, the mean age was 69 ± 5 (≥65-74 years 26.2%, ≥75-84 years 21.3%, ≥85 years 9.8%). Poorer EQ-5D scores were observed in men ≥ 65 years with fractures in the pain domain (p = 0.04), while men < 65 showed better scores in mobility (p = 0.04), self-care (p = 0.04), daily activities (p = 0.04), and anxiety/depression (p = 0.01). Fear of falling significantly impacted HRQoL across all ages, with men ≥ 65 reporting worse mobility (p = 0.02) and higher anxiety/depression (p = 0.01), while men < 65 experienced less pain (p = 0.00). Conclusions: This study shows a relationship between frac-tures, fear of falling, and the perception of the various dimensions of HRQoL in older men. It highlights the need for targeted interventions and follow-up systems to monitor recovery and address fears of falling in men aged 65 and above post-fracture.

d-limonene suppresses RANKL-induced osteoclast differentiation and promotes osteoblast activity in vitro

Treatments for osteoporosis are typically given postfracture. Therefore, identifying safe prophylactic interventions to reduce fracture risk would be beneficial. One approach is to utilize the bioactive properties of natural compounds to modify osteoclast and osteoblast activity. d-limonene a well-tolerated, anti-inflammatory monoterpene found in citrus fruits holds promise due to its suppressive effect on NFκB, a key regulator of bone cell activity. We found that limonene promoted osteoblast differentiation and bone nodule formation and inhibited RANKL-induced osteoclast formation and bone resorption in vitro. Limonene also reduced the proresorptive signal provided by osteoblast, augmenting markers of osteoblast differentiation (alkaline phosphatase, osterix, and osteocalcin) and significantly decreasing osteoclastogenic cytokine production (PTHrP, IL-1β, and TNF-α). Therefore, limonene supplementation represents a potential route in combination with current interventions to optimize bone cell activity to maintain or enhance bone mass.

Osteoporosis in Older Men: Informing Patient Management and Improving Health-Related Outcomes

Osteoporosis has been usually considered a female disease, generally causing more fracture risk and complications in adult and older women compared to older men. While vertebral fractures occur in a small proportion of men during middle age, men generally fracture about 10 years later than women, with significant increases in fracture risk after about age 75. Independent of age, men experiencing fragility fractures have a higher risk of life-threatening events compared to women, but the risk of secondary fragility fracture overlaps between men and women. Often, male osteoporosis recognizes the overlap between secondary causes and primary osteoporosis risk factors. Assessment through physical examination, history, and laboratory tests is recommended, with dual-energy X-ray absorptiometry of bone density being the preferred diagnostic test for osteoporosis in men. A treatment program should include awareness of diet and vitamin D status, fall risk reduction, and pharmaceutical therapy. Medications that are fracture-reducing in older women should also achieve fewer fractures in older men; however, there is a paucity of studies in men with the primary outcome of fracture risk reduction. Most older men with osteoporosis should be treated with oral or intravenous bisphosphonates, denosumab especially when on androgen deprivation therapy, and initial anabolic treatment should be considered for men at very high risk of fracture. This review summarizes the main features of osteoporosis and fragility fractures in men and reports findings from the available pharmacological and non-pharmacological studies conducted in men.

Osteoporosis in older patients with idiopathic normal pressure hydrocephalus

Both osteoporosis and idiopathic normal pressure hydrocephalus may increase the risk of falls and fractures. This study showed that osteoporosis is more common in older patients with iNPH. It is important to raise awareness of osteoporosis in older patients with iNPH to prevent adverse health consequences.

PURPOSE

Idiopathic normal pressure hydrocephalus (iNPH), a potentially reversible condition with timely intervention, may cause cognitive impairment, balance and gait disturbance, and urinary incontinence in advanced age. Osteoporosis is a progressive metabolic bone disease that increases bone fragility in older adults. Both conditions may lead to falls and fractures. Therefore, this study aims to investigate osteoporosis in older adults with iNPH.

METHODS

A total of 64 patients diagnosed with iNPH and 458 participants in the control group were included in the study. Demographic and clinical characteristics, including age, sex, comorbidities, laboratory findings, and comprehensive geriatric assessment parameters, were recorded. Osteoporosis was defined according to the WHO classification. The relationship between osteoporosis and iNPH was assessed with regression analysis.

RESULTS

The mean age was higher in the iNPH group than in the control group (79.91 ± 6.36 vs 75.86 ± 6.51 years, p < 0.001). The frequency of female patients was higher in the control group than in the iNPH group (81% vs 70.3%, p = 0.046). The osteoporosis frequency was higher in the iNPH group than in the controls (51.6% vs 32.1%, p = 0.002). Adjusted for age and gender, iNPH was associated with osteoporosis (odds ratio (OR), 1.750; confidence interval (CI) 95%, 1.002-3.054; p = 0.049).

CONCLUSIONS

This study showed that osteoporosis is more common in older patients with iNPH. Therefore, screening and treatment of osteoporosis in these individuals is crucial to avoid adverse health outcomes such as fractures.

Trends in Orthopaedic Surgery on Patients 90 Years Old and Older 2014-2023

Objectives

The United States (US) population is aging with an increasing number of older adults over 90 years old. The primary purpose of this study is to evaluate trends in orthopaedic surgeries in patients 90 years old and greater over the past decade from 2014-2023.

Methods

Patients ≥90 years old at the time of surgery at a single orthopaedic specialty practice from 2014 through 2023 were identified. All patients that underwent nonsurgical treatment were excluded. Surgeries were categorized by musculoskeletal area and procedure type by CPT codes. Musculoskeletal areas include Shoulder, Humerus/Elbow, Forearm/Wrist, Hand/Fingers, Pelvis/Hip, Femur/Knee, Leg/Ankle, Foot/Toes, Spine, Integumentary, Nervous System, and Other.

Results

Over the last decade, 5,291 orthopaedic surgeries were performed on 4,807 patients 90 years old and older (age range 90-107 years old; 75% female). Of these patients, 91% underwent only one surgery while ≥90 years old, while the remaining underwent between two to five surgeries. The number of surgeries each year ranged from 180 to 680 with a positive correlation between year and number of surgeries and a greater than threefold increase in surgeries 2014-2023. The Pelvis and Hip were the primary musculoskeletal areas of surgery, accounting for 69% of surgeries overall, followed by femur and knee (11%) and nervous system (which includes carpal tunnel release, 5.2%). Most surgeries (69%) were for a fracture or dislocation.

Conclusion

There is an increase in volume of orthopaedic surgery on patients ≥90 years old over the last decade between 2014-2023, the majority of which were performed on the hip and pelvis and for fractures or dislocations. As older adults ≥90 years old continue to increase in the population, we project the surgical volume will continue to grow and place a large financial burden on the US healthcare system.

A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures

BACKGROUND

Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment.

METHODS

Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios.

RESULTS

In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay.

CONCLUSION

Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.

Taking care of inpatients with fragility hip fractures: the hip-padua osteosarcopenia (Hip-POS) fracture liaison service model

PURPOSE

Osteoporotic fragility fractures (FF), particularly those affecting the hip, represent a major clinical and socio-economic concern. These fractures can lead to various adverse outcomes, which may be exacerbated by the presence of sarcopenia, especially among older and frail patients. Early identification of patients with FF is crucial for implementing effective diagnostic and therapeutic strategies to prevent subsequent fractures and their associated consequences.

METHODS

The Hip-POS program, implemented at Azienda Ospedale-Università Padova, is a Fracture Liaison Service (FLS) program to evaluate patients aged > 50 years old admitted with fragility hip fractures, involving an interdisciplinary team. After the identification of patients with hip fractures in the Emergency Department, a comprehensive evaluation is conducted to identify risk factors for further fractures, and to assess the main domains of multidimensional geriatric assessment, including muscle status. Patients are then prescribed with anti-fracture therapy, finally undergoing periodic follow-up visits.

RESULTS

During the first five months, a total of 250 patients were evaluated (70.4% women, median age 85 years). Following assessment by the Hip-POS team, compared to pre-hospitalization, the proportion of patients not receiving antifracture therapy decreased significantly from 60 to 21%. The prescription rates of vitamin D and calcium increased markedly from 29.6% to 81%.

CONCLUSIONS

We introduced the Hip-POS program for the care of older adults with hip fractures. We aspire that our model will represent a promising approach to enhancing post-fracture care by addressing the multifactorial nature of osteoporosis and its consequences, bridging the gap in secondary fracture prevention, and improving patient outcomes.