Hip fractures in lebanese patients: determinants and prognosis

The prevalence of Schmorl's nodes in osteoporotic vs normal patients: a Middle Eastern population study

The study was conducted to establish the association of Schmorl's nodes and osteoporosis in a Middle Eastern cohort. The prevalence of SN in this sample was 41.1%. It was most frequent in the lumbar spine typically solitary central lesions. Over 88% Schmorl's node cases were osteoporotic/osteopenic and only 11.6% normal.

INTRODUCTION

This study aims to identify the prevalence of Schmorl's nodes (SNs) in a cohort of Omani nationals, and also to determine any relation between osteoporosis and Schmorl's nodes.

METHODS

This retrospective observational study was conducted on Omani nationals. One thousand three hundred and forty-eight DEXA scan patients were included. Of these, 545 patients had complete X-rays and MRI scans that would help determine the SN status. The X-rays and sagittal, coronal, and axial T2-weighted MR images were used to identify the presence and exact location of the Schmorl nodes by one orthopedic trainee and confirmed by the senior author. The correlation of each parameter with the presence of SN was analyzed by the independent-samples T test and one-way ANOVA.

RESULTS

The overall prevalence of SN in this population sample appeared to be 41.1%. Over 88% of the SN-positive cases were either osteopenic or frankly osteoporotic by the WHO definition. Vast majority of SNs (87.1%) occurred in the lumbar spine and were central in location and mostly solitary. Statistical analysis of the data revealed significant correlation between osteopenia or osteoporosis and the presence of SNs.

CONCLUSIONS

The prevalence of SN in the sample of Omanis studied was 41.1% and was most frequently seen in older men in the lumbar spine. It is strongly associated with osteoporosis/osteopenia (88.4%) and frequently presents as solitary central lesions.

Osteoporotic hip and vertebral fractures in the Arab region: a systematic review

Asia is projected to account for the largest proportion of the rising burden of osteoporotic fractures worldwide. Data from the Middle East is scarce. We performed a systematic review on the epidemiology of vertebral and hip osteoporotic fractures in 22 Arab League countries, using Scopus, PubMed, and Embase. We identified 67 relevant publications, 28 on hip and 39 on vertebral fractures. The mean age of patients was 70-74 years, female to male ratio 1.2:2.1. Age-standardized incidence rates, to the UN 2010 population, were 236 to 290/100,000 for women from Kuwait and Lebanon, lower in Morocco. Risk factors for hip fractures included lower BMD or BMI, taller stature, anxiolytics, and sleeping pills. Most patients were not tested nor treated. Mortality derived from retrospective studies ranged between 10 and 20% at 1 year, and between 25 and 30% at 2-3 years. Among 39 studies on vertebral fractures, 18 described prevalence of morphometric fractures. Excluding grade 1 fractures, 13.3-20.2% of women, mean age 58-74 years, had prevalent vertebral fractures, as did 10-14% of men, mean age 62-74 years. Risk factors included age, gender, smoking, multiparity, years since menopause, low BMD, bone markers, high sclerostin, low IgF1, hypovitaminosis D, abdominal aortic calcification score, and VDR polymorphisms. Vertebral fracture incidence in women from Saudi Arabia, mean age 61, was 6.2% at 5 years, including grade 1 fractures. Prospective population-based fracture registries, prevalence studies, predictive models, fracture outcomes, and fracture liaison services from Arab countries are still lacking today. They are the pillars to closing the care gap of this morbid disease.

Middle East experience from the Asia And Latin America Fracture Observational Study (ALAFOS): Baseline characteristics of postmenopausal women with osteoporosis using teriparatide

OBJECTIVE

We aimed to describe the baseline clinical characteristics and fracture history of patients taking teriparatide in routine clinical practice in the Middle East (ME) subregional cohort of the Asia and Latin America Fracture Observational Study (ALAFOS).

METHODS

Herein, we report baseline clinical characteristics of patients who were prescribed teriparatide (20 µg/day, subcutaneous injection) in four participant ME countries (Saudi Arabia, United Arab Emirates, Kuwait, and Lebanon).

RESULTS

The ME cohort included 707 patients mean (SD) age 69.3 (11.6) years. Mean (SD) bone mineral density (BMD) T-scores at baseline were -3.13 (1.28) for lumbar spine, -2.88 (0.94) for total hip, and -2.65 (1.02) for femoral neck. Osteoporotic fractures after age 40 years were reported in 45.8% (vertebral fracture 14.4%, hip fracture 18.4%) and comorbidities in 57.4% of patients. Before starting teriparatide, 19.9% of patients took other osteoporosis medications. The median (Q1; Q3) EuroQoL 5-Dimension 5-Level visual analog scale score for perceived overall health status was 70 (50; 80). Mean (SD) worst back pain in the previous 24 hours was 4.0 (3.2) using a 10-point numeric rating scale.

CONCLUSION

This analysis indicated that in ME countries, teriparatide is usually prescribed to patients with low BMD and high comorbidities, with prior fractures.

History of injury in a developing country: a scoping review of injury literature in Lebanon

BACKGROUND

Lebanon, an Eastern Mediterranean country, suffers a large burden of injury as a consequence of conflict and war, political instability, and the lack of policies and safety regulations. This article aims to systematically map and comprehensively describe the injury research literature in Lebanon and, to identify gaps for future research.

METHODS

MEDLINE, Embase, Eric and SafetyLit, and the grey literature, including conference proceedings, theses and dissertations, government and media reports, were searched without any date or language limits. Data were extracted from 467 documents using REDCap.

RESULTS

War-related injuries were the most prevalent type of injury in Lebanon, followed by homicide and other forms of violence. While existing literature targeted vulnerable and at-risk populations, the vast majority focused solely on reporting the prevalence of injuries and associated risk factors. There are considerable gaps in the literature dealing with the integration of preventive programs and interventions across all populations.

CONCLUSIONS

Lebanon, historically and currently, experiences a high number of injuries from many different external causes. To date, efforts have focused on reporting the prevalence of injuries and making recommendations, rather than implementing and evaluating interventions and programs to inform policies. Future injury related work should prioritize interventions and prevention programs.

Management of Hip Fractures at an Academic Center: Challenges and Opportunities

OBJECTIVE

To assess characteristics of patients with hip fractures and investigate the extent of osteoporosis-related care they receive at a tertiary referral center in Lebanon.

METHODS

A retrospective review of charts of 400 patients admitted with a hip fracture to the American University of Beirut-Medical Center, between January 1, 2011 and December 31, 2015. We reviewed medical records of adults admitted with a nonpathologic/nontraumatic hip fracture, and evaluated basic demographics and relevant clinical information, associated risk factors, and the management received.

RESULTS

The mean age of the population was 78 ± 10 years and men constituted 37%. Women were more likely to be assessed and/or treated. On admission, 21% were taking calcium and 18% vitamin D supplementation. During hospitalization, vitamin D level was assessed in only 39% of patients; a dietary and an osteoporosis consult were requested on only 32% and 22% of the cases, respectively. One-fourth to a third of patients were discharged on calcium or vitamin D, and less than 5% on bisphosphonates. Bone mineral density was measured in a minority although 21% had a history of previous contralateral hip fracture. One year mortality rate in a subset where follow-up available was 12% in men and 7% in women.

CONCLUSION

A large care gap in the management of patients admitted with hip fracture persists despite clear national osteoporosis guidelines. This study provides a strong impetus for establishing and monitoring a fracture liaison service to understand and address barriers to providing optimal care to patients with osteoporosis.

Are we treating osteoporotic fractures of the hip adequately? A Middle Eastern cohort study

Fragility hip fractures treated in a center in the Middle East were retrospectively studied for adequacy of osteoporosis management. Of the 318 patients treated, over 70% did not have a structured investigation and about 30% did not receive any therapeutic supplements. Our series showed a preventable 8.8% secondary fracture rate.

PURPOSE

To study the adequacy of evaluation and treatment of osteoporosis after fragility fractures of the hip. The study also attempts to estimate the prevalence of secondary fractures after the original injury.

METHODS

This is a retrospective evaluation of the electronic database to search all the admissions for fractures of the hip in patients over 50 years at a tertiary care Trauma and Orthopaedic center in the Sultanate of Oman. The study period was defined as October 2010 to December 2015. Their case records, BMD reports, and laboratory data were analyzed. Pharmacological interventions and the documented compliance with such therapy were also recorded.

RESULTS

Over the study period, 318 fragility fractures of the hip were treated. Of these, 233 (73.3%) did not receive a DEXA scan and 94% did not have their vitamin D₃ (vit D) tested. About 29.9% percent cases did not receive any nutritional supplement or therapeutic intervention though diagnosed as fragility fracture. Twenty-eight patients (8.8%) reported for secondary fractures of the hip. Of these, 86% was initiated on supplement after their index fracture though 78.6% had not had a BMD study.

CONCLUSIONS

Less than 27% patients receive BMD test following fragility fracture of the hip and only 6% a vit D3 assay. Secondary fractures of the hip tend to occur in approximately 9% of the cases in Oman; this seems to occur equally in patients who have had as well as not had any calcium and vit D supplements after the index injury.

Hypovitaminosis D and Other Risk Factors of Femoral Neck Fracture in South Indian Postmenopausal Women: A Pilot Study

BACKGROUND

Non-communicable diseases like hip fractures are a significant problem in a developing country like India. The risk factors for hip fractures vary according to local practices and the availability of preventive health care delivery systems. There is paucity of data on risk factors for hip fracture in the south Indian population.

AIM

This study was undertaken to assess risk factors associated with femoral neck (FN) fracture in South Indian postmenopausal women along with subsequent one year mortality.

MATERIALS AND METHODS

One hundred four postmenopausal women with FN fracture and 104 age and BMI matched controls were included. Sedative use, visual impairment and other relevant risk factors were assessed. Bone biochemistry and Bone Mineral Density (BMD) were evaluated. A telephonic interview was done at the end of one year to ascertain the well-being.

RESULTS

Sedative use, visual impairment, low FN BMD and vitamin-D deficiency (<20 ng/ml) were seen more in fracture subjects compared to controls (p≤0.05). At the end of one year, 20% of the fracture subjects and 5% of the controls had died (p=0.001).

CONCLUSION

Risk factors identified in our study are potentially correctable, and needs special attention in an Indian context to prevent hip fractures.

Osteoporotic fractures, DXA, and fracture risk assessment: meeting future challenges in the Eastern Mediterranean Region

The purpose was to report on the burden of osteoporotic fractures in the Eastern Mediterranean Region (EMR) and the use of bone mineral density (BMD) dual-energy X-ray absorptiometry (DXA) databases for osteoporosis diagnosis. PubMed electronic database was reviewed using the following MeSH terms: "Hip fractures," "Fractures, Compression," "Radius Fractures," "Osteoporosis," "Bone density," and "Middle East" up to July 2009. Incidence of hip fractures varied across the EMR between 100 and 295 per 100,000 person-years in women and 71 and 200 per 100,000 person-years in men. No data were found on other nonvertebral osteoporotic fractures. Prevalence of radiographic vertebral fractures older than 65 yr ranged between 15% and 25% in women and 7.3% and 18% in men. By 2020, the number of hip fractures older than 50 yr would increase by 20%. DXA manufacturer's reference curves for the spine were higher than population-specific ones. At the hip, National Health and Nutrition Examination Survey (NHANES) and population-based curves were comparable. Estimates of the relative risk of vertebral fracture per SD decrease in BMD using NHANES and local data set were similar, that is, 1.61 (1.17-2.23) and 1.49 (1.14-1.95), respectively. The EMR is similar to southern Europe regarding incidence rates of hip fracture, suggesting the health burden to be significant. Using DXA at the hip, population-specific reference databases did not perform better than NHANES on which the FRAX model has been developed highlighting the need for reviewing fracture risk assessment strategies in the EMR.

Hip fracture incidence in Lebanon: a national registry-based study with reference to standardized rates worldwide

Crude incidence rates for hip fractures in individuals aged 50 and above in Lebanon were determined using data from the national hip fracture registry. For the years 2006-2008, crude rates varied between 164 and 188/100,000 for females and between 88 and 106 per 100,000 for males. Using the US 2000 white population as a reference, the calculated age-standardized rates were closest to rates derived for southern Europe.

INTRODUCTION

Owing to the demographic explosion, it is projected that the rates of hip fractures would increase the most in the Middle East and Asia. Few are the population-based studies investigating the incidence of hip fractures in the region.

METHODS

Using the Ministry of Health registry data, this population-based study evaluated the incidence of hip fractures in individuals aged 50 and above in Lebanon for the years 2006, 2007, and 2008.

RESULTS

Hip fracture crude incidence rates varied across the years between 164 and 188 per 100,000 for females and between 88 and 106 per 100,000 for males, with a female/male ratio of 1.6-2.1. The overall mean age (SD) for hip fractures was 75.9 (9.2), 76.8 (9.0), and 77.0 (9.9) years in females in 2006, 2007, and 2008, respectively, and 74.4 (11.6), 76.3 (10.3), and 74.0 (12.1) years in males, respectively. Using the US 2000 white population as a reference, the age-standardized rates were 370.4, 335.1, and 329.0 for females and 109.7, 134.1, and 128.7 for males, for the years 2006, 2007, and 2008, respectively.

CONCLUSIONS

The hip fracture age-standardized incidence rates in the Lebanese subjects receiving Ministry of Health coverage were lower than those found in northern Europe and the US and closest to rates derived for southern Europe.

Risk estimates for hip fracture from clinical and densitometric variables and impact of database selection in Lebanese subjects

Bone mineral density (BMD) and fracture incidence vary greatly worldwide. The data, if any, on clinical and densitometric characteristics of patients with hip fractures from the Middle East are scarce. The objective of the study was to define risk estimates from clinical and densitometric variables and the impact of database selection on such estimates. Clinical and densitometric information were obtained in 60 hip fracture patients and 90 controls. Hip fracture subjects were 74 yr (9.4) old, were significantly taller, lighter, and more likely to be taking anxiolytics and sleeping pills than controls. National Health and Nutrition Examination Survey (NHANES) database selection resulted in a higher sensitivity and almost equal specificity in identifying patients with a hip fracture compared with the Lebanese database. The odds ratio (OR) and its confidence interval (CI) for hip fracture per standard deviation (SD) decrease in total hip BMD was 2.1 (1.45-3.05) with the NHANES database, and 2.11 (1.36-2.37) when adjusted for age and body mass index (BMI). Risk estimates were higher in male compared with female subjects. In Lebanese subjects, BMD- and BMI-derived hip fracture risk estimates are comparable to western standards. The study validates the universal use of the NHANES database, and the applicability of BMD- and BMI-derived risk fracture estimates in the World Health Organization (WHO) global fracture risk model, to the Lebanese.

Using Radon transform of standard radiographs of the hip to differentiate between post-menopausal women with and without fracture of the proximal femur

Texture features based on the Radon transform were extracted from clinical radiographs of the hip in post-menopausal women. The novel algorithm allowed us to identify patients with fracture of the proximal femur and may provide an alternative to measuring bone mineral density in predicting the fracture-risk in osteoporosis, especially where densitometry is regionally unavailable.

INTRODUCTION

The aim of this study is to introduce an algorithm for differentiation between patients with and without fracture of the hip using parameters based on the Radon transform (RT) and applied to standard radiographs of the proximal femur and to compare the results with bone mineral density (BMD).

METHODS

The study comprised 50 post-menopausal women (78.6 +/- 11.5 years of age), including 25 patients with hip fracture and 25 age-matched controls. We obtained lumbar and femoral BMD and standard femoral radiographs. In the radiographs we analysed trabecular patterns of the hip in a region-of-interest of 57 x 29 mm using the RT. From the histogram-representation of the RT, we extracted several characteristic parameters. By ROC and discriminant-analysis, we assessed the statistical power of both methods.

RESULTS

For correct differentiation between fracture and non-fracture cases by femoral BMD, area-under-the-curve (AUC) was 0.78; AUC for the RT-based parameters ranged from 0.73 to 0.8. By combination of densitometric and textural information in a multivariate model the fracture status of 84% of subjects was predicted correctly, identification of fracture cases rose to 88%.

CONCLUSION

Identification of fracture patients by RT applied to femoral radiographs was feasible and seemed to have a discriminative potential comparable to that of standard densitometry. In the future, the new method may provide an alternative to DXA or in conjunction with conventional densitometry may enhance the detection of patients with elevated risk of hip fracture.

Differentiation between post-menopausal women with and without hip fractures: enhanced evaluation of clinical DXA by topological analysis of the mineral distribution in the scan images

We introduce an algorithm to evaluate hip DXA scans using quantitative image analysis procedures based on the Minkowski functionals (MF) for differentiation between post-menopausal women with and without hip fracture. In a population of 30 post-menopausal women, the new parameter has a highly discriminative potential with a performance superior to standard densitometry providing complementary information compared to BMD.

INTRODUCTION

We introduce a novel algorithm to evaluate DXA scans of the hip using quantitative image analysis based on the Minkowski functionals (MF) to identify post-menopausal women with hip-fracture and to compare the results with densitometry.

METHODS

BMD of 30 women (73.9 +/- 10.3 years), 15 of whom had a recent hip fracture, is obtained by DXA using the "total hip" ROI. The topology of mineral distribution in the scan images is evaluated using the MF-based parameter MF2D. ROC analysis is employed to assess the discriminative potential (fracture/non-fracture).

RESULTS

The area-under-the-curve (AUC) for identification of patients with/without fractures by BMD is .72(p = 0.04), AUC for MF2D is .85(p = 0.001). No statistically significant correlation exists between MF2D and BMD. By discriminant analysis we can show that by combination of MF2D and BMD the outcome increases significantly: using BMD or MF2D alone, 63% and 70% of cases are classified correctly versus 77% of cases in the multivariate model.

CONCLUSION

The topology-based parameter has a high predictive potential with respect to identification of patients with high risk of hip fracture, performance is superior to densitometry. The new method provides information complementary to BMD. Best classification results are obtained when BMD and MF2D are combined in a multivariate model.

Diagnosis and epidemiology of osteoporosis

PURPOSE OF REVIEW

Osteoporosis remains a major public health problem through its association with fragility fractures. Recent data suggest that the annual cost in Europe is 13 billion euros, mainly accounted for by hospitalisation after fracture. Understanding the epidemiology of osteoporosis is an essential step in developing strategies to reduce the burden of osteoporotic fracture in the population.

RECENT FINDINGS

This article will review recent advances surrounding the epidemiology of osteoporosis, the burden of fracture in children and adults in this country and abroad, morbidity associated with such fractures, associations of disease and medication with fragility fracture, and advances in diagnostic techniques and identification of at-risk groups.

SUMMARY

The papers studied highlight the wealth of high-quality research in this field, and they help in the visualisation of strategies to identify individuals at high risk of fragility fracture and to quantify fracture risk by measurement of bone density, bone quality, and risk factor algorithms.