25-Hydroxyvitamin-D and Bone Turnover Marker Levels in Patients with Distal Radial Fracture

Pre-existing osteoporosis and serum vitamin D levels in patients with distal radius fractures: are we missing something?

INTRODUCTION

Given the significant therapeutic gap for osteoporosis, this study aims to investigate the most common osteoporosis-related fracture. The analysis will also consider patients' serum vitamin D levels and the indications for basic osteoporosis diagnostic tests and osteoporosis therapy prior to fracture.

MATERIALS AND METHODS

This prospective clinical trial included patients with distal radius fractures who underwent surgery at our hospital between 1 April 2021 and 7 April 2022. Blood samples were taken from all participants and existing risk factors for osteoporosis were recorded. In addition, the indication for a guideline-based osteoporosis diagnosis was assessed and the risk of another future fracture with FRAX® was calculated. This information was used to decide whether there was an indication for specific osteoporosis therapy.

RESULTS

A diagnosis gap of 53% and a treatment gap of 84% were identified among the 102 patients investigated. The patients' ages ranged from 46 to 91 years, with an average vitamin D level of 57 nmol/l, which was below the recommended level of 75 nmol/l. It was noted on a monthly basis that the vitamin D level (without substitution) never exceeded the recommended value of 75 nmol/l in any month. Three-quarters of patients had indications for a baseline osteoporosis diagnosis, yet less than 50% received one. According to FRAX® data, 57% of patients had indications for specific osteoporosis treatment before experiencing the fracture.

CONCLUSION

Even without a previous distal radius fracture, many patients are in need of osteoporosis diagnosis or treatment. Our research suggests that patients with distal radius fractures should have their vitamin D levels checked via a blood test and be evaluated for osteoporosis. As endogenous vitamin D levels are often inadequate, year-round vitamin D supplementation should be considered for the prevention of osteomalacia and as a basis for the treatment of osteoporosis.

GERMAN CLINICAL TRIAL REGISTER ID

DRKS00028085.

Vitamin D status and its associations with bone mineral density, bone turnover markers, and parathyroid hormone in Chinese postmenopausal women with osteopenia and osteoporosis

Background

Vitamin D is a key factor in bone metabolism, yet vitamin D insufficiency and deficiency are prevalent among postmenopausal women, with potential repercussions on bone mineral density (BMD), bone turnover markers (BTMs), and parathyroid hormone (PTH). Nonetheless, the findings from existing studies exhibit inconsistency, and a notable gap exists in the availability of large-scale investigations.

Methods

In this real-world study, 8,532 postmenopausal women over 50 years old with a diagnosis of osteopenia (50.9%) and osteoporosis (49.1%) at the first visit were enrolled in this study. Serum 25(OH)D level, PTH, osteocalcin (OC) and Beta-CrossLaps of type 1 collagen containing cross-linked C-telopeptide (β-CTX), were measured. BMD at all sites, including the lumbar spine, femoral neck, and total hip were obtained by dual-energy X-ray absorptiometry (DXA). The associations of serum 25(OH)D level with BMDs and BTMs were investigated using spearman correlation analysis and analysis of general linear model adjusted by age and body mass index.

Results

The serum 25(OH)D level was 22.17 ± 9.75 ng/mL among all patients included in this study. For the osteopenia group, the serum 25(OH)D level was 22.40 ± 9.41 ng/mL, while for the osteoporosis group, it measured 21.93 ± 10.08 ng/mL. In the osteopenia group, the prevalence of vitamin D deficiency, insufficiency and sufficiency was 45.8, 34.6, and 19.6%, respectively, which was close to that of the osteoporosis group (47.4, 34.3, and 18.3%) (p = 0.202). Spearman correlation analysis unveiled negative associations between serum 25(OH)D concentrations and both BTMs and PTH within both the osteopenia and osteoporosis group. In the osteoporosis group, there were positive correlations between 25(OH)D levels and femoral neck BMD (r = 0.040, p = 0.010) and total hip BMD (r = 0.053, p = 0.001). Furthermore, we found that for the osteopenia group, greater vitamin D levels were associated with greater femoral neck BMD (p = 0.020) and total hip BMD (p = 0.008) and lower β-CTX (p < 0.001), OC (p < 0.001), and PTH (p < 0.001). The same trends were seen in osteoporosis patients (p < 0.05), and with greater lumbar spine BMD with higher levels of 25(OH)D (p = 0.009).

Conclusion

This study showed high prevalence of vitamin D deficiency and insufficiency in Chinese postmenopausal women with osteopenia and osteoporosis and the relationships between vitamin D and BMD, BTMs and PTH. The results contribute to a more comprehensive understanding of how vitamin D may impact bone health.

Osteoporosis and sarcopenia are associated with each other and reduced IGF1 levels are a risk for both diseases in the very old elderly

It is mandatory to manage musculoskeletal disorders in the elderly to prevent their becoming bed-ridden or requiring long-term care. However, the prevalence of musculoskeletal disorders such as osteoporosis and sarcopenia in otherwise healthy people over 85 years old is not completely known. Here we enrolled 1026 healthy subjects between 85 and 89 years old and evaluated them for the presence of osteoporosis, sarcopenia and fragility fracture(s), and how those conditions were related. We also evaluated biomarkers such as serum levels of insulin-like growth factor 1 (IGF1) and vitamin D status. The prevalence of osteoporosis, sarcopenia or fragility fracture(s) in these subjects was 22.4, 10.2 or 15.0 %, respectively. Serum IGF1 and 25(OH)D were significantly and negatively correlated with osteoporosis or sarcopenia. Osteoporosis and either sarcopenia or fragility fracture(s) were significantly related and shown to be risk factors for each other, even after adjustment for gender and BMI, while sarcopenia and fragility fracture(s) were not associated. Our data may provide a health platform for the very elderly and suggest strategies to prevent musculoskeletal disorders in this population.

Bone turnover markers as surrogates of fracture healing after intramedullary fixation of tibia and femur fractures

Aims

Bone turnover markers (BTMs) follow distinct trends after fractures and limited evidence suggests differential levels in BTMs in patients with delayed healing. The effect of vitamin D, and other factors that influence BTMs and fracture healing, is important to elucidate the use of BTMs as surrogates of fracture healing. We sought to determine whether BTMs can be used as early markers of delayed fracture healing, and the effect of vitamin D on BTM response after fracture.

Methods

A total of 102 participants aged 18 to 50 years (median 28 years (interquartile range 23 to 35)), receiving an intramedullary nail for a tibial or femoral shaft fracture, were enrolled in a randomized controlled trial comparing vitamin D₃ supplementation to placebo. Serum C-terminal telopeptide of type I collagen (CTX; bone resorption marker) and N-terminal propeptide of type I procollagen (P1NP; bone formation marker) were measured at baseline, six weeks, and 12 weeks post-injury. Clinical and radiological fracture healing was assessed at three months.

Results

CTX and P1NP concentrations peaked at six weeks in all groups. Elevated six-week CTX and P1NP were associated with radiological healing at 12 weeks post-injury (odds ratio (OR) 10.5; 95% confidence interval 2.71 to 53.5, p = 0.002). We found no association between CTX or P1NP and functional healing. Baseline serum 25(OH)D showed a weak inverse relationship with P1NP (p = 0.036) and CTX (p = 0.221) at 12 weeks, but we observed no association between vitamin D supplementation and either BTM.

Conclusion

Given the association between six-week BTM concentrations and three-month radiological fracture healing, CTX and P1NP appear to be potential surrogate markers of fracture healing.

Cite this article: Bone Joint Res 2022;11(4):239–250.

Relationship between distal radius fracture severity and 25-hydroxyvitamin-D level among perimenopausal and postmenopausal women

AIMS

Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency.

METHODS

This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared.

RESULTS

The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities.

CONCLUSION

Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D3 supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study. Cite this article: Bone Jt Open 2022;3(3):261-267.

The epidemiology of traumatic musculoskeletal injuries in Kuwait: Prevalence and associated risk factors

Objectives

Epidemiological explorations of traumatic injuries are essential to provide benchmarks for future planning to address multidimensional challenges. The study aimed to describe the epidemiology of traumatic musculoskeletal injuries in Kuwait, including their prevalence and associated risk factors.

Methods

The Orthopedic Admission Database of a level II trauma center in Kuwait was retrospectively reviewed from January 2018 to February 2020. Traumatic fractures of the spine and upper and lower limbs were explored.

Results

The study included 564 patients with 788 traumatic injuries who were 33.0 (23.0) years of age (median and interquartile range): 78.0% were male, and 43% were Kuwaitis. Spinal fractures were the most prevalent injury, at 21.7%, followed by tibial fractures, at 11.3%, and ankle fractures, at 10.2%. Road traffic accidents were the leading mechanism of injury, at 37.9%, followed by falling over and falling from height, at 29.3% and 16.8%, respectively. Risk factors included injury mechanism, nationality, and age (p < 0.05). Road traffic accidents were at risk for sustaining spinal, scapular, clavicle, humeral, pelvic, hip, tibial, and fibular fractures; those for falling over were radial, ulnar, femoral, and patellar fractures; and those for falling from height were foot and ankle fractures. Kuwaitis were found to be at risk of spinal, humeral, pelvic and femoral fractures, whereas non-Kuwaitis were found to be at risk of scapular, shoulder, elbow, ulnar, radial, hip, patellar, tibial, fibular, foot, and ankle fractures. The age range of 19–49 years was associated with the highest risk for all fracture sites.

Conclusion

Epidemiological characteristics of traumatic injuries in Kuwait have been determined to guide preventive strategies and healthcare planning.

The role of osteocalcin in regulation of glycolipid metabolism and muscle function in children with osteogenesis imperfecta

OBJECTIVE

Osteoblasts are discovered to secrete hormones with endocrine effects on metabolism, and osteocalcin (OC) is the most abundant non-collagenous protein in bone. We investigate the relationship between serum OC levels and glycolipid metabolism and muscle function in children with osteogenesis imperfecta (OI).

METHODS

A total of 225 children with OI and 80 healthy controls matched in age and gender were included in this single center study. Serum levels of fasting blood glucose (FBG), triglyceride (TG), total cholesterol (TC), low- and high-density lipoprotein cholesterol (LDL-C, HDL-C) were measured by automated analyzers. Serum levels of fasting insulin (FINS) were measured using an automated electrochemiluminescence system. Serum levels of OC and undercarboxylated osteocalcin (ucOC) were measured by enzyme-linked immunosorbent assay. Grip strength and timed-up-and-go (TUG) test were measured. Bone mineral density (BMD) and body composition were measured using dual-energy X-ray absorptiometry.

RESULTS

OI patients had significantly higher body mass index (BMI), FBG, and HOMA-IR, but lower HDL-C levels, lower grip strength and longer TUG than control group (all P<0.05). Serum OC, ucOC levels, and ucOC/OC in OI type III patients were significantly lower than those in OI patients with type I and IV. Serum levels of OC, ucOC, and ucOC/OC were negatively correlated to BMI, FBG, insulin levels, and HOMA-IR (all P<0.05). The ratio of ucOC/OC was positively correlated to grip strength (r=0.512, P=0.036), lean mass percentage (%LM) of the total body and limbs, and negatively correlated to fat mass percentage (%FM) of the total body, %FM and fat mass index (FMI) of the trunk (all P<0.05).

CONCLUSIONS

Obesity, glucolipid metabolic abnormalities, and reduced grip strength were common in children with OI. Circulating osteocalcin and ucOC may play an important role in the regulation of glucose metabolism, as well as the muscle function of children with OI.

Longitudinal Analysis of Circulating Markers of Bone Turnover Across Multiple Decades in Osteoporotic Women

PURPOSE

The objective of this study was to analyze changes in serum markers of bone turnover across multiple decades in osteoporotic women compared with nonosteoporotic controls, to determine their utility as potential predictors for osteoporosis. Early prediction of those at risk for osteoporosis can enable early intervention before the irreversible loss of critical bone mass.

METHODS

Serum samples were obtained from 20 women given the diagnosis of osteoporosis after age 46 years and 20 age-matched women with normal bone mineral density from 4 time points in their life (ages 25-31, 32-38, 39-45, and 46-60 years). Serum levels of bone turnover markers (propeptide of type I collagen, parathyroid hormone, bone-specific alkaline phosphatase, osteocalcin, C-terminal telopeptide of type I collagen, sclerostin, osteoprotegerin, osteopontin, and 25-OH vitamin D) were measured using commercially available arrays and kits. We used logistic regression to assess these individual serum markers as potential predictors of osteoporosis, and mixed-effects modeling to assess the change in bone turnover markers between osteoporotic and control groups over time, then performed fivefold cross-validation to assess the classification ability of the models.

RESULTS

Markers of bone turnover, bone-specific alkaline phosphatase, C-terminal telopeptide of type I collagen, sclerostin, and osteocalcin were all independent predictors at multiple time points; osteopontin was an independent predictor in the 39- to 45-year age group. Receiver operating characteristic analyses demonstrated moderately strong classification ability at all time points. Sclerostin levels among groups diverged over time and were higher in the control group than the osteoporotic group, with significant differences observed at time points 3 and 4.

CONCLUSIONS

Serum markers of bone turnover may be used to estimate the likelihood of osteoporosis development in individuals over time. Although prospective validation is necessary before recommending widespread clinical use, this information may be used to identify patients at risk for developing low bone mineral density long before traditional screening would ostensibly take place.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Serum Vitamin D Levels in Patients With Distal Radius Fractures Presenting to a Tertiary Care Hospital

Objective To compare the frequency of serum vitamin D levels in patients with and without distal radius fracture. Introduction Hypovitaminosis D is a common problem worldwide. Deficiency of vitamin D is not only associated with musculoskeletal problems, but also with chronic diseases like diabetes mellitus, cardiovascular disease and cancer. Vitamin D deficiency results in bone pain, aggravating osteoporosis and fragility fractures. Distal radius fractures are common upper limb fractures, mostly in the elderly population. Low serum levels of vitamin D have been reported to result in increased risk of distal radius fracture. Methodology This study was conducted at The Indus Hospital Karachi, from 1st March 2020 to 31st August 2020. Consecutive non-probability sampling was done. Patients aged between 20 to 80 years with and without distal radius fractures were enrolled and serum vitamin D levels were compared. Results A total of 130 patients were enrolled in this study, out of which 70 (53.8%) were males. The median (IQR) vitamin D, calcium, alkaline phosphate level, and albumin was 14.8 (9.5-23) ng/ml, 9.2 (8.9-9.5) ng/ml, 91 (77.3-111) U/L, and 4.2 (4-4.5) g/dl, respectively. No significant association between distal radius fracture and vitamin D levels was found in males, whereas a significantly higher proportion of females with no fracture had a mild-moderate deficiency in comparison to females with fracture. Conclusion No significant association was noted between patients with and without distal radius fracture and vitamin D levels, however, we recommend more studies on this topic so that more comprehensive results can be obtained.

Upper Extremity Fragility Fractures

The population of elderly patients is rapidly increasing in the United States and worldwide, leading to an increased prevalence of osteoporosis and a concurrent rise in fragility fractures. Fragility fractures are defined as fractures involving a low-energy mechanism, such as a fall from a standing height or less, and have been associated with a significant increase in the risk of a future fragility fracture. Distal radius fractures in the elderly often present earlier than hip and vertebral fractures and frequently involve underlying abnormalities in bone mass and microarchitecture. This affords a unique opportunity for upper extremity surgeons to aid in the diagnosis and treatment of osteoporosis and the prevention of secondary fractures. This review aims to outline current recommendations for orthopedic surgeons in the evaluation and treatment of upper extremity fragility fractures.

The relationship of 25-hydroxyvitamin D values and risk of fracture: a population-based retrospective cohort study

Our study investigates 25-hydroxyvitamin D levels and fracture risk using population-level data. 25-Hydroxyvitamin D values < 12, 12-19, and > 50 ng/mL were not associated with increased risk of fractures overall compared with values 20-50 ng/mL. Severely low levels may be associated with increased risk of osteoporotic fracture, particularly of the wrist.

INTRODUCTION

Studies of the relationship between serum 25-hydroxyvitamin D (25(OH)D) levels and fracture risk have been inconsistent. We hypothesized that high 25(OH)D concentrations (> 50 ng/mL) would be associated with increased risk of fracture.

METHODS

We identified all adult patients living in Olmsted County, Minnesota, between January 1, 2005 and December 31, 2011, who had at least one 25(OH)D measurement. Fracture outcomes were retrieved starting 30 days after 25(OH)D measurement and until patients' final clinical visit as an Olmsted County resident, December 31, 2014, or death. Data were analyzed using Cox proportional hazard regression.

RESULTS

Of 11,002 individuals with a 25(OH)D measurement, 5.8% had a 25(OH)D value ˂ 12 ng/mL, and 5.1% had a value > 50 ng/mL. Compared with subjects with 25(OH)D values 20-50 ng/mL (reference group), values < 12, 12-19, and > 50 ng/mL displayed no association with overall fracture risk. After adjusting for a prior diagnosis of osteoporosis/osteopenia, only individuals with values ˂ 12 ng/mL had increased risk of any osteoporotic fracture (aHR = 1.41; 95% CI 1.05-1.89) and wrist fracture (aHR = 2.11; 95% CI 1.27-3.48) compared with the reference group. Compared with the reference group, values ˂ 12 ng/mL were associated with increased risk of any fracture (aHR = 1.35; 95% CI 1.01-1.80), osteoporotic fracture (aHR = 2.18; 95% CI 1.44-3.31), and wrist fracture (aHR = 2.39; 95% CI 1.19-4.81) in subjects without a prior diagnosis of osteoporosis/osteopenia, but not in those with a prior diagnosis of osteoporosis/osteopenia.

CONCLUSION

Severely low 25(OH)D levels may be associated with increased risk of osteoporotic fracture, particularly of the wrist, but 25(OH)D values > 50 ng/mL were not associated with increased fracture risk.

Can Postural Instability in Individuals with Distal Radius Fractures Be Alleviated by Concurrent Cognitive Tasks?

BACKGROUND

Although impaired postural control may be a risk factor for distal radius fractures (wrist fractures), which often are caused by falls, little attention has been given thus far to the various performance and neurophysiologic aspects involved. Although studies suggest that external focus and cognitive tasks can improve postural control, it remains unclear whether these benefits are observed in individuals with a history of distal radius fracture and to what extent.

QUESTIONS/PURPOSES

(1) To compare patients with a history of distal radius fracture to age- and sex-matched controls in terms of postural stability while standing on stable and unstable support surfaces, using both postural sway and neurophysiological measures as endpoints; and (2) to determine whether internal- and external-focus strategies and cognitive tasks can improve postural stability in these patients.

METHODS

Forty patients with distal radius fracture (33 females and seven males with a mean ± SD age of 56 ± 4 years) and 40 sex- and age-matched control participants participated in the study. We recruited patients with a history of fall-induced distal radius fractures occurring between 6 and 24 months before the start of our study. We excluded patients who had any of the following: fear of falling, taking any medication that may affect balance, neurologic disorders, dizziness, vestibular problems, Type II diabetes, musculoskeletal disorders or recent history of lower extremity fracture, any recent surgical interventions in the spine or lower limbs, and/or cognitive impairment. Of 120 patients who were being treated for distal radius fracture over the 18-month period, 91 (76%) agreed to participate and 40 eligible patients were finally enrolled. The control group included sex- and age-matched (within 2-year intervals) individuals who had never had a wrist fracture. This group was selected from attendants/relatives of the patients attending the neurology and physical medicine and rehabilitation outpatient departments, as well as other volunteers with no history of balance problems or wrist fractures. To address our primary research question, we compared the postural control of individuals with a history of distal radius fracture with the control group while quietly standing on different support surfaces (rigid and foam surfaces) using both postural sway measures obtained by a force plate as well as neurophysiological measures (electromyography [EMG] activity of tibialis anterior and medial gastrocnemius). To address our secondary research question, we compared the postural sway measures and EMG activity of the ankle muscles between different experimental conditions (baseline, internal focus (mentally focusing on their feet without looking), external focus (mentally focusing on rectangular papers, placed on the force plate or foam, one under each foot), difficult cognitive task (recalling maximum backward digits plus one) and easy cognitive task (recalling half of the maximum backward digits).

RESULTS

Patients with distal radius fractures presented with greater postural sway (postural instability) and enhanced ankle muscle activity compared with their control counterparts, but only while standing on a foam surface (mean velocity: 5.4 ± 0.8 versus 4.80 ± 0.5 [mean difference = 0.59, 95% CI of difference, 0.44-0.73; p < 0.001]; EMG root mean square of the tibialis anterior: 52.2 ± 9.4 versus 39.30 ± 6 [mean difference = 12.9, 95% CI of difference, 11.4-14.5; p < 0.001]). Furthermore, a decrease in postural sway was observed while standing on both rigid and foam surfaces during the external focus, easy cognitive, and difficult cognitive conditions compared with the baseline (for example, mean velocity in the baseline condition compared with external focus, easy cognitive task and difficult cognitive task was: 4.9 ± 1.1 vs 4.7 ± 1 [mean difference = 0.14, 95% CI of difference, 0.11-0.17; p < 0.001], 4.6 ± 1 [mean difference = 0.25, 95% CI of difference, 0.21-0.29; p < 0.001], and 4.5 ± 1 [mean difference = 0.34, 95% CI of difference, 0.29-0.40; p < 0.001] in the wrist fracture group). The same result was obtained for muscle activity while standing on foam (EMG root mean square of tibialis anterior in the baseline condition compared with external focus, easy cognitive task and difficult cognitive task: 58.8 ± 7.2 versus 52.3 ± 6.6 [mean difference = 6.5, 95% CI of difference, 5.5-7.6; p < 0.001], 48.8 ± 7.1 [mean difference = 10.1, 95% CI of difference, 9-11.1; p < 0.001], 42.2 ± 5.3 [mean difference = 16.7 95% CI of difference, 15.1-18.2; p < 0.001] in the wrist fracture group).

CONCLUSIONS

The current results suggest that patients with a history of distal radius fractures have postural instability while standing on unstable support surfaces. This instability, which is associated with enhanced ankle muscle activity, conceivably signifying an inefficient cautious mode of postural control, is alleviated by external attention demands and concurrent cognitive tasks.

CLINICAL RELEVANCE

The findings of this study may serve as a basis for designing informed patient-specific balance rehabilitation programs and strategies to improve stability and minimize falls in patients with distal radius fractures. The integrative methodology presented in this work can be extended to postural control and balance assessment for various orthopaedic/neurological conditions.

Wrist Fractures and Osteoporosis

Distal radial fractures account for up to 18% of all fractures in patients over 65 years of age, and osteoporosis is a predominant factor in these fractures. Fracture treatment may include closed reduction and casting/splinting, external fixation, and open reduction and internal fixation.

Serum 25(OH)D is associated with an altered bone turnover marker response after a hip fracture

C-terminal telopeptide of type I collagen (CTX) and procollagen type 1 N-terminal propeptide (P1NP) are bone turnover markers (BTMs) that are promising surrogate measures of fracture healing; however, it is unknown if their response is affected by other bone healing metabolites. Since 70% of fracture patients are reported to have insufficient serum vitamin D, we sought to determine if serum 25(OH)D levels are associated with differential changes in CTX and P1NP concentrations after hip fracture. This prospective cohort included hip fracture patients 65 years of age or older admitted to one of eight Baltimore-area hospitals. Serum samples were collected at baseline, 2-, 6-, and 12-month post-fracture. A mixed-effects repeated-measures analysis was used to determine the longitudinal association between vitamin D deficiency (25(OH)D < 20 ng/ml) and CTX and P1NP. Baseline lab values were obtained for 296 participants (mean age, 80.8 years; 51% male; 55% 25(OH)D < 20 ng/ml). During the acute fracture healing period P1NP concentrations increased by 14% (95%CI: 7-21%, p < 0.01) while CTX levels did not change (p = 0.07). Both CTX and P1NP decreased below baseline at 6 and 12 months. CTX levels were higher in participants with baseline 25(OH)D < 20 ng/ml (p = 0.01). There was no association between 25(OH)D < 20 ng/ml and P1NP levels over the study duration (p = 0.33). Data from this large, longitudinal cohort support claims that CTX and P1NP concentrations change during fracture healing; however, the differential response of CTX among vitamin D deficient patients highlights important questions for its utility as a reliable surrogate marker of fracture healing. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Considerations in the Treatment of Osteoporotic Distal Radius Fractures in Elderly Patients

PURPOSE OF REVIEW

With the incidence of distal radius fractures increasing in the elderly population, we sought to summarize the current orthopedic and medical management of these fractures in the elderly osteoporotic population.

RECENT FINDINGS

The number of osteoporotic patients undergoing surgical fixation for distal radius fractures has increased in recent years. This is likely due to the improved outcomes seen with volar locking plates, as well as an increase in the number of fellowship-trained hand surgeons. Despite this potential improvement in acute fracture management, a majority of these patients are underdiagnosed and undertreated for their underlying osteoporosis or endocrinopathies. The implementation of fracture liaison services and the ability of the treating orthopedist to recognize this gap in patient care result in a higher number of patients initiating appropriate treatment. It is vital that when discussing acute fracture management, a thorough discussion is had with patients regarding functional outcome and the benefits of both surgical and non-operative management. As these fractures become more prevalent and a greater percentage undergo surgical intervention, the economic burden of distal radius fractures will continue to rise. It is imperative that the treating surgeon view these fractures as sentinel events that are predictive of future hip and vertebral fractures. While relatively new, the use of fracture liaison services to help aide in proper screening and treatment of osteoporotic patients is of great value. Non-pharmacologic therapy such as physical therapy, smoking and alcohol cessation programs, and dietary modifications are crucial in treating patients with osteoporosis. While bisphosphonates remain the first-line treatment in patients with osteoporosis, novel therapies show promise for future use.

Lower serum P1NP/βCTX ratio and hypoalbuminemia are independently associated with osteoporotic nonvertebral fractures in older adults

Purpose

To estimate the discriminative value of serum P1NP/βCTX ratio and albumin levels in hospitalized orthogeriatric patients with and without nonvertebral fractures.

Methods

In 1,239 orthogeriatric patients (mean age 78.1±9.52 years, 69.1% women) including 854 (68.9%) with osteoporotic nonvertebral fractures (455 [36.7%] with hip fracture [HF]) and 385 (31.1%) without fractures, markers of bone formation (procollagen type 1 N-terminal propeptide [P1NP], osteocalcin [OC], and bone resorption (beta-C-terminal cross-linking telopeptide of type 1 collagen [βCTX]), indices of mineral metabolism, and parameters of liver and renal functions were assessed; data on clinical and laboratory characteristics were collected prospectively.

Results

Both lower serum P1NP/βCTX ratio and albumin concentration (as continuous or categorical variables) were independently associated with fracture presence in multivariate logistic regressions. Compared with the highest P1NP/βCTX tertile, the prevalence of HF, after adjustment for multiple covariates, was 3-fold higher in the lowest tertile and 1.5 times higher in the middle tertile; presence of any fracture was 2.3- and 1.6-fold higher, respectively; patients with albumin levels in the lowest tertile had multivariate odds ratio (OR) of 4.6 for HF and 2.8 for any fracture, in the middle tertile the ORs were 2.2 and 1.3, respectively. The P1NP/βCTX <100.0 (median) and hypoalbuminemia (<33 g/L) demonstrated area under the curve values for HF of 0.802 and 0.806, respectively, and for any fractures of 0.711 and 0.706, respectively. When both characteristics were combined, the ORs for HF or any fracture, compared with the nonfractured group, were 7.8 and 3.2, respectively, with an accuracy of 79.6% and 71.6%, respectively.

Conclusions

In orthogeriatric patients, both serum P1NP/βCTX ratio and albumin levels demonstrated an inverse dose–effect relationship with the prevalence of nonvertebral fractures and independently indicated fracture presence with acceptable discriminatory power. Lower P1NP/βCTX (<100) and hypoalbuminemia could be useful simple additive prognostic tools for fracture risk stratification in the elderly.

Distal Radius Fractures in the Elderly

Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patient's bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

Elevated Bone Turnover Markers Are Associated With Distal Radius Fractures in Premenopausal Women

PURPOSE

To examine whether premenopausal women with distal radius fractures (DRF) have lower levels of 25-hydroxyvitamin D (25[OH]D) and increased levels of serum bone turnover markers (BTM) compared with control subjects without fracture.

METHODS

Premenopausal women with DRF (n = 20) were prospectively enrolled and compared with age-matched individuals without a fracture (n = 20). Outcome measures included serum levels of 25(OH)D, parathyroid hormone (PTH), markers of bone formation (osteocalcin [OC], N-terminal extension propeptide of type I collagen [P1NP], and bone-specific alkaline phosphatase [BSAP]), and markers of bone resorption (C-terminal telopeptide of type I collagen [CTX]). We assessed associations between BTM and DRF with conditional logistic regression and the utility of markers for fracture prediction with a receiver operator characteristic analysis.

RESULTS

The fracture group and control group were comparable in terms of age at menarche and BMI. Patients who had fractures had significantly greater levels of OC and P1NP, and demonstrated a nonsignificant increase in CTX. Levels of 25(OH)D, PTH, and BSAP were similar between groups. Conditional logistic regression revealed independent associations between DRF and increased levels of OC and CTX. Levels of 25(OH)D and PTH were not associated with DRF. Receiver operator characteristic analyses demonstrated moderate performance for OC, P1NP, BSAP, and CTX in predicting DRF.

CONCLUSIONS

Levels of 25(OH)D were not associated with DRF in premenopausal women. However, patients with DRF had increased levels of BTM of formation and resorption. Bone turnover markers may be helpful in predicting future fragility fractures in premenopausal women.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Postural Stability in Older Adults with a Distal Radial Fracture

BACKGROUND

The physical risk factors leading to distal radial fractures are poorly understood. The goal of this study was to compare postural stability between older adults with and without a prior distal radial fragility fracture.

METHODS

This case-control evaluation was performed at a single tertiary institution. The fracture cohort comprised 23 patients treated for a low-energy distal radial fracture within 6 to 24 months prior to this study. Twenty-three age and sex-matched control participants, without a prior fragility fracture, were selected from an outpatient clinic population. All participants completed a balance assessment with a computerized balance platform device. Dynamic motion analysis (DMA) scores ranging from 0 to 1,440 points are produced, with lower scores indicating better postural stability. Participants also completed validated questionnaires for general health quality (EuroQol-5D-3L [EQ-5D-3L]) and physical activity (Physical Activity Scale for the Elderly [PASE]) and comprehensive health and demographic information including treatment for compromised balance or osteoporosis. Statistical analysis compared data between cases and controls using either the Student t test or the Mann-Whitney U test.

RESULTS

There were no significant differences (p > 0.05) in age, sex, body mass index, physical activity score, or EQ-5D-3L general health visual analog scale score between participants with or without prior distal radial fracture. The fracture cohort demonstrated poorer balance, with higher DMA scores at 933 points compared with 790 points for the control cohort (p = 0.008). Nineteen patients (83%) in the fracture cohort reported having dual x-ray absorptiometry (DXA) scans within 5 years prior to this study, but only 2 patients (9%) had ever been referred for balance training with physical therapy.

CONCLUSIONS

Older adults who sustain low-energy distal radial fractures demonstrate impaired postural stability compared with individuals of a similar age who have not sustained such fractures. Following a distal radial fracture, these patients may benefit from interventions to improve postural stability.

LEVEL OF EVIDENCE

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