Epidemiology of hip fracture in Qatar and development of a country specific FRAX model

Update on fracture risk assessment in osteoporosis

PURPOSE OF REVIEW

The assessment of fracture risk is playing an ever-increasing role in osteoporosis clinical management and informing international guidelines for osteoporosis. FRAX, a fracture risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used since 2008. In this review, we recap the development and limitations of intervention thresholds and the role of absolute fracture risk.

RECENT FINDINGS

There is an increasing awareness of disparities and inequities in the setting of intervention thresholds in osteoporosis. The limitations of the simple use of prior fracture or the DXA-derived BMD T -score threshold are increasingly being discussed; one solution is to use fracture risk or probabilities in the setting of such thresholds. This approach also permits more objective assessment of high and very high fracture risk to enable physicians to make choices not just about the need to treat but what agents to use in individual patients.

SUMMARY

Like all clinical tools, FRAX has limitations that need to be considered, but the use of fracture risk in deciding who to treat, when to treat and what agent to use is a mechanism to target treatment equitably to those at an increased risk of fracture.

Postoperative pneumonia after femoral fracture surgery: an in-depth retrospective analysis

BACKGROUND

Femoral fractures significantly contribute to disability, predominantly in the elderly. Despite this, data on postoperative pneumonia following femoral fracture surgeries remains sparse. Our study sought to explore the incidence and impact of postoperative pneumonia on outcomes following such surgeries.

METHODS

A retrospective study analyzed femoral fracture patients hospitalized from 2016 to 2022. We scrutinized postoperative outcomes, including pneumonia, hospital stay duration, intensive care unit (ICU) admissions, and in-hospital mortality. We established stringent diagnostic criteria for postoperative pneumonia, incorporating both clinical signs and radiological evidence, excluding patients with prior infections or those discharged within 24 h post-surgery. Statistical analyses involved Chi-square and t-tests, linear regression, and logestic regression using SPSS.

RESULTS

Out of 636 patients, 10.8% were diagnosed with postoperative pneumonia. The average age was 79.55 ± 8.57 years, with a male prevalence of 47.8%. Common comorbidities were hypertension (78.3%), diabetes (60.9%), and cardiovascular diseases (40.6%). Surgical interventions were categorized as intramedullary nailing (40.6%), partial hip replacement (37.7%), and dynamic hip screw (21.7%). Postoperative pneumonia was associated with older age (AOR = 1.053, 95% CI 1.020 to 1.087, p = 0.002), ICU admission (AOR = 2.283, 95% CI 1.256 to 4.148, p = 0.007), and longer length of hospital stay (AOR = 1.079, 95% CI 1.030 to 1.130, p = 0.001). The presence of pneumonia was associated with a 2.621-day increase in hospitalization after adjusting for other variables (p < 0.001, 95% CI: 1.454 to 3.789).

CONCLUSION

This study accentuates the clinical significance of postoperative pneumonia in femoral fracture patients, with a noted incidence of 10.8%. A notable association with older age, prolonged hospital stays, and ICU admissions was observed, underscoring the necessity of addressing this complication to improve patient outcomes and healthcare resource allocation.

FRAX-derived intervention and assessment thresholds for osteoporosis in ten Middle Eastern countries

This study established FRAX-based age-specific assessment and intervention thresholds for ten Middle Eastern countries where FRAX is currently available, but the lack of specific thresholds has limited its usefulness. The intervention thresholds ranged from 0.6 (Saudi Arabia) to 36.0% (Syria) at the ages of 40 and 90 years, respectively.

INTRODUCTION

Developing fracture risk assessment tools allows physicians to select patients for therapy based on their absolute fracture risk instead of relying solely on bone mineral density (BMD). The most widely used tool is FRAX, currently available in ten Middle Eastern countries. This study aimed to set FRAX-derived assessment and intervention thresholds for individuals aged 40 or above in ten Middle Eastern countries.

METHODS

The age-specific 10-year probabilities of a major osteoporotic fracture (MOF) for a woman with a BMI of 25.0 kg/m2, without BMD and clinical risk factors except for prior fracture, were calculated as intervention Threshold (IT). The upper and lower assessment thresholds were set at 1.2 times the IT and an age-specific 10-year probability of a MOF in a woman with a BMI of 25.0 kg/m2, without BMD, prior fracture, and other clinical risk factors, respectively. IT is utilized to determine treatment or reassurance when BMD facilities are unavailable. However, with BMD facilities, assessment thresholds can offer treatment, reassurance, or bone densitometry based on MOF probability.

RESULTS

The age-specific IT varied from 0.9 to 11.0% in Abu Dhabi, 2.9 to 10% in Egypt, 2.7 to 14.0% in Iran, 1.0 to 28.0% in Jordan, 2.7 to 27.0% in Kuwait, 0.9 to 35.0% in Lebanon, 1.0 to 16.0% in Palestine, 4.1 to 14% in Qatar, 0.6 to 3.7% in Saudi Arabia, and 0.9 to 36.0% in Syria at the age of 40 and 90 years, respectively.

CONCLUSIONS

FRAX-based IT in Middle Eastern countries provides an opportunity to identify individuals with high fracture risk.

Guidelines for fracture risk assessment and management of osteoporosis in postmenopausal women and men above the age of 50 in Qatar

We present comprehensive guidelines for osteoporosis management in Qatar. Formulated by the Qatar Osteoporosis Association, the guidelines recommend the age-dependent Qatar fracture risk assessment tool for screening, emphasizing risk-based treatment strategies and discouraging routine dual-energy X-ray scans. They offer a vital resource for physicians managing osteoporosis and fragility fractures nationwide.

PURPOSE

Osteoporosis and related fragility fractures are a growing public health issue with an impact on individuals and the healthcare system. We aimed to present guidelines providing unified guidance to all healthcare professionals in Qatar regarding the management of osteoporosis.

METHODS

The Qatar Osteoporosis Association formulated guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men above the age of 50. A panel of six local rheumatologists who are experts in the field of osteoporosis met together and conducted an extensive review of published articles and local and international guidelines to formulate guidance for the screening and management of postmenopausal women and men older than 50 years in Qatar.

RESULTS

The guidelines emphasize the use of the age-dependent hybrid model of the Qatar fracture risk assessment tool for screening osteoporosis and risk categorization. The guidelines include screening, risk stratification, investigations, treatment, and monitoring of patients with osteoporosis. The use of a dual-energy X-ray absorptiometry scan without any risk factors is discouraged. Treatment options are recommended based on risk stratification.

CONCLUSION

Guidance is provided to all physicians across the country who are involved in the care of patients with osteoporosis and fragility fractures.

Diagnosis and management of osteoporosis in Saudi Arabia: 2023 key updates from the Saudi Osteoporosis Society

The Saudi Osteoporosis Society (SOS) has updated its guidelines for the diagnosis and management of osteoporosis in Saudi Arabia (SA), with emphasis on postmenopausal women. This document is relevant to all healthcare professionals in SA involved in the care of patients with osteoporosis and osteoporosis-related fractures.

INTRODUCTION

The SOS launched the first national osteoporosis guidelines in 2015 and spearheaded the Gulf Cooperation Council Countries (GCC) osteoporosis consensus report in 2020 which was under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO). This paper highlights a major update of the guidelines in the SA setting.

METHODS

This guideline is an adaptation of the current guidelines derived from ESCEO, the American Association of Clinical Endocrinologists (AACE), and the GCC osteoporosis consensus report and studies on osteoporosis done in SA. Where accessible, the timeliest systematic review, meta-analysis, and randomized controlled trials were used as evidence.

RESULTS

The present update includes new recommendations for the assessment of osteoporosis taking into consideration the Saudi model of FRAX for fracture probabilities, appropriate doses for the maintenance of vitamin D status and calcium, the use of representative blood analytes for therapy monitoring, the use of romosozumab and sequential therapy in the pharmacological management strategies, and the establishment of fracture liaison services to prevent secondary fractures.

CONCLUSION

This updated guideline is for all healthcare professionals involved in osteoporosis and post-fracture care and management in SA and harmonized the most up-to-date changes in the field based on evidence-based medicine for use in the local setting.

The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis

This position paper of the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) addresses the rationale for separate diagnostic and intervention thresholds in osteoporosis. We conclude that the current BMD-based diagnostic criteria for osteoporosis be retained whilst clarity is brought to bear on the distinction between diagnostic and intervention thresholds.

Characteristics of Elderly Hip Fracture Patients in Jordan: A Multicenter Epidemiological Study

Background

Elderly hip fractures represent a global health care burden. Several reports expected a massive increase in the incidence of hip fractures by the next few decades. Knowing the epidemiology of hip fractures is crucial for planning health care policies. The purpose of this study is to provide a nationwide epidemiological overview of hip ‎fractures in Jordan and to report the perioperative outcomes that may help to improve the delivered healthcare. ‎.

Methods

We conducted ‎ a retrospective study at 2 university hospitals and 2 major ‎governmental hospitals in Jordan.‎ We reviewed the records for all patients (age >55 years) who were diagnosed with hip fractures ‎over a 3 years duration (2019–2021). ‎We documented the patient’s characteristics and the perioperative data (including preoperative, intraoperative, and postoperative details including the 1-year mortality).‎

Results

The total number of included patients was 1268; more than half (53.7%) were females.‎ The mean age is ‎75 years (SD 9.7). ‎ The most common fracture type was trochanteric (66.2%)‎. ‎7% of patients had a prior contralateral hip fracture‎. The average time from admission to surgery was 2.96 days (SD 2.63). The surgery was done within 48 ‎hours for ‎56.7%‎ of patients.‎ Approximately, one-third of all patients (34.5%) received a blood transfusion.‎ The average length of hospital stay is 7.44 days (SD 5). The overall rate of postoperative thromboembolic events, readmission within 1 month, and revision ‎for the same surgery are 2.4%‎, 10.7%‎, and 3% respectively.‎ The 1-month, 6-month, and 12-month mortality rates are 4.5%, 9.1%, and 12.8% respectively.

Conclusion

The annual incidence of elderly hip fractures in Jordan is approximately 96 per 100,000 individuals. The 1-year mortality rate of hip fractures in Jordan ‎is ‎12.8%‎.‎ Both findings are ‎in the lower range of nearby Arab countries.

Incidence of hip fracture in Saudi Arabia and the development of a FRAX model

A prospective hospital-based survey in representative regions of Saudi Arabia determined the incidence of fractures at the hip. The hip fracture rates were used to create a FRAX® model to facilitate fracture risk assessment in Saudi Arabia.

OBJECTIVE

This paper describes the incidence of hip fracture in the Kingdom of Saudi Arabia that was used to characterize the current and future burden of hip fracture, to develop a country-specific FRAX® tool for fracture prediction and to compare fracture probabilities with neighbouring countries.

METHODS

During a 2-year (2017/2018) prospective survey in 15 hospitals with a defined catchment population, hip fractures in Saudi citizens were prospectively identified from hospital registers. The number of hip fractures and future burden was determined from national demography. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Saudi Arabia. Fracture probabilities were compared with those from Kuwait and Abu Dhabi.

RESULTS

The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 2,949 and is predicted to increase nearly sevenfold to 20,328 in 2050. Hip fracture rates were comparable with estimates from Abu Dhabi and Kuwait. By contrast, probabilities of a major osteoporotic fracture or hip fracture from the age of 70 years were much lower than those seen in Abu Dhabi and Kuwait due to higher mortality estimates for Saudi Arabia.

CONCLUSION

A country-specific FRAX tool for fracture prediction has been developed for Saudi Arabia which is expected to help guide decisions about treatment.