Geographic differences in fractures among women

Subsequent fracture risk in Norwegians and immigrants with an index forearm fracture: a cohort study

The current study investigated subsequent fracture risk following a forearm fracture in three country of birth categories: Norway, Europe and North America, and other countries. Subsequent fracture risk was modestly higher in Norwegian-born individuals compared to the two other groups. Secondary fracture prevention should be recommended regardless of country background.

BACKGROUND

Fracture risk is higher in patients with a previous fracture, but whether subsequent fracture risk differs by origin of birth is unknown. This study explores subsequent fracture risk in patients with an index forearm fracture according to region of birth.

METHODS

Nationwide data on forearm fractures in patients ≥ 18 years in 2008-2019 were obtained from the Norwegian Patient Registry and Statistics Norway. Index fractures were identified by ICD-10 code S52, whereas subsequent fractures included any ICD-10 fracture code. Data on country of birth were from Statistics Norway and included three regional categories: (1) Norway, (2) other Europe and North America and (3) other countries. Direct age standardization and Cox proportional hazard regression were used to analyse the data.

RESULTS

Among 143,476 individuals with an index forearm fracture, 35,361 sustained a subsequent fracture. Norwegian-born forearm fracture patients had the highest subsequent fracture rates (516/10,000 person-years in women and 380 in men). People born outside Europe and North America had the lowest rates (278/10,000 person-years in women and 286 in men). Compared to Norwegian-born individuals, the hazard ratios (HRs) of subsequent fracture in individuals from Europe and North American were 0.93 (95% CI 0.88-0.98) in women and 0.85 (95% CI 0.79-0.92) in men. The corresponding HRs in individuals from other countries were 0.76 (95% CI 0.70-0.84) in women and 0.82 (95% CI 0.74-0.92) in men.

CONCLUSION

Individuals born outside Norway had a lower subsequent fracture risk than Norwegian-born individuals; however, subsequent fracture risk increased with age in all groups. Our results indicate that secondary fracture prevention should be recommended regardless of region of origin.

Considerations Regarding Vitamin D in Foot and Ankle Treatment and Surgery

Although the impact that vitamin D has on bone healing is uncertain in foot and ankle (F&A) surgery, there is support for vitamin D supplementation (2000 IU/day) with calcium (1 g/day) to promote bone healing. Although orthopedic F&A surgeons are frequently the first provider to detect the harbingers of osteoporosis by the occurrence of fragility fractures, this should trigger referral to the appropriate specialist for assessment and treatment. There is circumstantial evidence suggesting a role of hypovitaminosis D in bone marrow edema syndrome and possibly osteochondritis dissecans. There should be a low threshold for assessing vitamin D levels in such patients.

Geographic variation in bone mineral density and prevalent fractures in the Canadian longitudinal study on aging

Awareness of the prevalence of osteoporosis and fractures across jurisdictions can guide the development of local preventive programs and healthcare policies. We observed geographical variations in total hip bone mineral density and in the prevalence of major osteoporotic fractures across Canadian provinces, which persisted after adjusting for important covariates.

PURPOSE

We aimed to describe sex-specific total hip bone mineral density (aBMD) and prevalent major osteoporotic fractures (MOF) variation between Canadian provinces.

METHODS

We used baseline data from 21,227 Canadians (10,716 women, 10,511 men) aged 50-85 years in the Canadian Longitudinal Study on Aging (CLSA; baseline: 2012-2015). Linear and logistic regression models were used to examine associations between province of residence and total hip aBMD and self-reported MOF, stratified by sex. CLSA sampling weights were used to generate the prevalence and regression estimates.

RESULTS

The mean (SD) age of participants was 63.9 (9.1) years. The mean body mass index (kg/m2) was lowest in British Columbia (27.4 [5.0]) and highest in Newfoundland and Labrador (28.8 [5.3]). Women and men from British Columbia had the lowest mean total hip aBMD and the lowest prevalence of MOF. Alberta had the highest proportion of participants reporting recent falls (12.0%), and Manitoba (8.4%) the fewest (p-value=0.002). Linear regression analyses demonstrated significant differences in total hip aBMD: women and men from British Columbia and Alberta, and women from Manitoba and Nova Scotia had lower adjusted total hip aBMD than Ontario (p-values<0.02). Adjusted odds ratios (95% confidence intervals, CI) for prevalent MOF were significantly lower in women from British Columbia (0.47 [95% CI: 0.32; 0.69]) and Quebec (0.68 [95% CI: 0.48; 0.97]) and in men from British Columbia (0.40 [95% CI:0.22; 0.71]) compared to Ontario (p-values<0.03). Results were similar when adjusting for physical performance measures and when restricting the analyses to participants who reported White race/ethnicity.

CONCLUSION

Geographical variations in total hip aBMD and in the prevalence of MOF between provinces persisted after adjusting for important covariates which suggests an association with unmeasured individual and environmental factors.

Plant-derived natural medicines for the management of osteoporosis: A comprehensive review of clinical trials

Background

Osteoporosis is a chronic and systemic skeletal disease that is defined by low bone mineral density (BMD) along with an increase in bone fragility and susceptibility to fracture. This study aimed to overview clinical evidence on the use of herbal medicine for management of osteoporosis.

Methods

Electronic databases including Pubmed, Medline, Cochrane library, and Scopus were searched until November 2022 for any clinical studies on the efficacy and/or safety of plant-derived medicines in the management of osteoporosis.

Results

The search yielded 57 results: 19 on single herbs, 16 on multi-component herbal preparations, and 22 on plant-derived secondary metabolites. Risk of fracture, bone alkaline phosphatase, BMD, and specific bone biomarkers are investigated outcomes in these studies. Medicinal plants including Acanthopanax senticosus, Actaea racemosa, Allium cepa, Asparagus racemosus, Camellia sinensis, Cissus quadrangularis, Cornus mas, Nigella sativa, Olea europaea, Opuntia ficus-indica, Pinus pinaster, Trifolium pretense and phytochemicals including isoflavones, ginsenoside, Epimedium prenyl flavonoids, tocotrienols are among plant-derived medicines clinically investigated on osteoporosis. It seems that multi-component herbal preparations were more effective than single-component ones; because of the synergistic effects of their constituents. The investigated herbal medicines demonstrated their promising results in osteoporosis via targeting different pathways in bone metabolism, including balancing osteoblasts and osteoclasts, anti-inflammatory, immunomodulatory, antioxidant, and estrogen-like functions.

Conclusion

It seems that plant-derived medicines have beneficial effects on bone and may manage osteoporosis by affecting different targets and pathways involved in osteoporosis; However, Future studies are needed to confirm the effectiveness and safety of these preparations.

The Role of Estrogen Therapy as a Protective Factor for Alzheimer's Disease and Dementia in Postmenopausal Women: A Comprehensive Review of the Literature

The complete cessation of menstruation for 12 months with associated vasomotor symptoms is termed menopause. Apart from playing a role in reproduction, estrogen significantly affects the central nervous system (CNS). Population-based studies highlighted a substantial difference in the prevalence of dementia between men and women, with Alzheimer-associated dementia being more prevalent in women, indicating that estrogen deficiency might be a risk factor for neurodegenerative diseases. Patients with dementia experience a progressive decline in neurocognitive function, beginning with short-term memory loss that progresses to long-term memory loss and the inability to perform everyday activities, leading ultimately to death. There is currently no cure for dementia, so preventing or slowing the disease's progression is paramount. Accordingly, researchers have widely studied the role of estrogen as a neuroprotective agent. Estrogen prevents dementia by augmenting Hippocampal and prefrontal cortex function, reducing neuroinflammation, preventing degradation of estrogen receptors, decreasing oxidative damage to the brain, and increasing cholinergic and serotonergic function. According to the window phase hypothesis, estrogen's effect on preventing dementia is more pronounced if therapy is started early, during the first five years of menopause. Other studies like The Woman's Health Initiative Memory Study (WHIMS) showed unfavorable effects of estrogen on the brain. This review aims to establish an understanding of the currently available data on estrogen's effect on neurodegeneration, namely, dementia and Alzheimer's disease.

Oblique line contrast: A new radiomorphometric index for assessing bone quality in dental panoramic radiographs

The present study was carried out to assess the possible changes in mandibular bone density according to age and gender through dental panoramic radiographs (PAN). More specifically, the region of the mandibular oblique line.

Materials & methods

A group of 374 dental patients previously treated in the Ribeirão Preto Dental School (FORP/USP) was included in the study. The complete dental profiling of all the subjects (including PAN images) was previously available in the archive of the same institution. Those subjects were separated into four groups considering age and gender: Group 1-100 young adult men (21.48 ± 3.34 y. o.), Group 2-100 young adult women (20.66 ± 1.52 y. o.), Group 3-87 postmenopausal women (74.07 ± 9.82 y. o.), and Group 4-87 men over 70 years old (75.92 ± 8.71 y. o.). A new index called "W-index" (WI) was proposed for analyzing the possible difference in mandibular bone density. This new index is the ratio between the average pixel value of the image area of the mandibular ramus (AVMR) and the average pixel value of the image area of the mandibular oblique line (AVOL) (WI = AVMR/AVOL). WI was measured for each subject on each PAN and statistical analysis was performed to search how well WI can characterize each study group.

Results

The largest difference in WI is observed when we compare older subjects (WI 0.73 ± 0.11) with younger subjects (0.89 ± 0.05). WI also varies significantly with gender but in a smaller amount. Mean WI for old women (0.68 ± 0.11) was found lower than for old men (0.77 ± 0.09), and mean WI for young women (0.89 ± 0.05) was also inferior to young men (0.91 ± 0.05). The differences in WI observed in the subject group were tested for a significance level of α = 0,01. We speculate that WI refers to an aspect of bone mineral density. First, the sharp contrast of the mandibular oblique line may signify the loss of mandibular bone mass. And second, it showed to vary significantly with gender and age, but with higher intensity with age.

Clinical significance

WI might be used in the future for low bone mineral density risk assessment.

Prevalence and Predictors of Osteoporosis and Osteopenia in Postmenopausal Women of Punjab, India

The prevalence and predictors of osteoporosis and osteopenia remain to be examined in the postmenopausal women of Punjab, India. The present cross-sectional study screened 1628 postmenopausal women during September 2019 to March 2020. Osteoporosis and osteopenia were confirmed on the basis of T-scores using dual energy X-ray absorptiometry (DXA) at the hip (femoral neck) and lumbar spine regions (L1−L4 vertebrae). The prevalence of osteoporosis and osteopenia was observed to be 30.50% and 44.20%, respectively, in postmenopausal women of Punjab. In univariable and multivariable regression analysis, variables independently influencing the risk of osteoporosis and osteopenia were: higher systolic blood pressure (95%CI: 1.22−3.11 & 1.08−2.49), triglyceride levels (95%CI: 1.21−3.10 & 1.42−2.51), poor sleep quality (95%CI: 1.91−2.47 & 1.76−3.47) and C-reactive protein levels (95%CI: 2.18−3.56 & 1.03−2.18). Years since menopause >10 years was observed to be an independent predictor for the risk of osteopenia but not for osteoporosis. Higher body mass index (>30 kg·m−2) was observed to be a significant protective factor against the risk of osteoporosis (95%CI: 0.26−0.68) and osteopenia (95%CI: 0.19−0.52). The higher prevalence rates of osteoporosis and osteopenia in postmenopausal women of Punjab are alarming, which solicits awareness and earlier testing of those women who are approaching menopause.

The Effect of Teriparatide Treatment on the Risk of Fragility Fractures in Postmenopausal Women with Osteoporosis: Results from the Asian and Latin America Fracture Observational Study (ALAFOS)

The Asian and Latin America Fracture Observational Study (ALAFOS) is a prospective, observational, single-arm study conducted in 20 countries across Asia, Latin America and the Middle East. ALAFOS evaluated new clinical vertebral and non-vertebral fragility fractures in relation to time on teriparatide, in postmenopausal women with osteoporosis in real-life clinical practice. Clinical fragility fractures, back pain, and health-related quality of life (HRQoL) were recorded in 6-month intervals for ≤ 24 months during teriparatide treatment and up to 12-months post-treatment. Data were analysed with piecewise exponential regression with inverse probability weighting for time to event outcomes and mixed-model repeated measures for back pain and HRQoL. 3054 postmenopausal women started teriparatide and attended ≥ one follow-up visit (mean [SD] age 72.5 [10.4] years). The median (95% CI) time to treatment discontinuation was 22.0 months (21.2, 22.8). During the treatment period, 111 patients (3.6%) sustained 126 clinical fractures (2.98 fractures/100 patient-years). Rates of new clinical fragility fractures were significantly decreased during the > 6-12, > 12-18, and > 18-24-month periods, as compared with the first 6 months of treatment (hazard ratio [HR] 0.57; 95% CI 0.37, 0.88; p = 0.012; HR 0.35; 95% CI 0.19, 0.62; p < 0.001; HR 0.43; 95% CI 0.23, 0.83; p = 0.011; respectively). Patients also reported an improvement in back pain and HRQoL (p < 0.001). These results provide data on the real-world effectiveness of teriparatide in the ALAFOS regions and are consistent with other studies showing reduction of fractures after 6 months of teriparatide treatment. These results should be interpreted in the context of the noncontrolled design of this observational study.

The Global Burden of Osteoporosis, Low Bone Mass, and Its Related Fracture in 204 Countries and Territories, 1990-2019

BACKGROUND

Low bone mineral density (LBMD), including osteoporosis and low bone mass, has becoming a serious public health concern. We aimed to estimate the disease burden of LBMD and its related fractures in 204 countries and territories over the past 30 years.

METHODS

We collected detailed information and performed a secondary analysis for LBMD and its related fractures from the Global Burden of Disease Study 2019. Numbers and age-standardized rates related to LBMD of disability-adjusted life-years (DALYs) and deaths in 204 countries and territories were compared by age, gender, socio-demographic index (SDI), and location.

RESULTS

Global deaths and DALYs number attributable to LBMD increased from 207 367 and 8 588 936 in 1990 to 437 884 and 16 647 466 in 2019, with a raise of 111.16% and 93.82%, respectively. DALYs and deaths number of LBMD-related fractures increased 121.07% and 148.65% from 4 436 789 and 121248 in 1990 to 9 808 464 and 301 482 in 2019. In 2019, the five countries with the highest disease burden of DALYs number in LBMD-related fractures were India (2 510 288), China (1 839 375), United States of America (819 445), Japan (323 094), and Germany (297 944), accounting for 25.59%, 18.75%, 8.35%, 3.29%, and 3.04%. There was a quadratic correlation between socio-demographic index (SDI) and burden of LBMD-related fractures: DALYs rate was 179.985-420.435SDI+417.936SDI²(R^{2 =} 0.188, p<0.001); Deaths rate was 7.879-13.416SDI+8.839 SDI²(R^{2 =} 0.101, p<0.001).

CONCLUSIONS

The global burden of DALYs and deaths associated with LBMD and its related fractures has increased significantly since 1990. There were differences in disease burden between regions and countries. These estimations could be useful in priority setting, policy-making, and resource allocation in osteoporosis prevention and treatment.

Dynamic Simulation of Biomechanical Behaviour of the Pelvis in the Lateral Impact Loads

The objective of this study was to develop and validate a novel 3D dynamic model of a pelvic side-impactor system. The biomechanical responses of a pelvic flexible model (having .mnf file suffix) under the lateral impact load for predicting the bone fracture mechanism are investigated as well. The 3D solid model of the side-impactor system was imported into MSC/ADAMS software for analyzing the dynamic model, and the pelvic flexible model was extracted from the CT images of a Chinese female volunteer. The flexible model of the pelvis system was developed considering a wide range of mechanical properties in the bone complex and soft tissue to achieve a realistic biomechanical response during a lateral impact. Good agreements were achieved between the dynamic simulations and the experimental results of pelvic side impacts, in terms of the biomechanical criteria. The dynamic model of impactor system could be employed to investigate the hip protector effectiveness, improving the vehicle safety, and biomechanical response of the other human organs.

Fracture incidence and secular trends between 1989 and 2013 in a population based cohort: The Rotterdam Study

Fracture incidence needs to be evaluated over time to assess the impact of the enlarging population burden of fractures (due to increase in lifespan) and the efficacy of fracture prevention strategies. Therefore, we aimed to evaluate the association of femoral neck bone mineral density (FN-BMD) measured using dual-energy X-ray absorptiometry (DXA) at baseline with fracture risk over a long follow-up time period. Incident non-vertebral fractures were assessed in 14,613 individuals participating in the Rotterdam Study with up to 20 years of follow-up. During a mean follow-up of 10.7 ± 6.2 years, 2971 (20.3%) participants had at least one incident non-vertebral fracture. The risk for any non-vertebral fracture was 1.37 (95% Confidence Interval (CI): 1.25-1.49) and 1.42 (95%CI: 1.35-1.50) for men and women, respectively. The majority (79% in men and 75% in women) of all fractures occurred among participants a normal or osteopenic T-score. The incidence rates per 1000 person-years for the most common fractures were 5.3 [95%CI: 5.0-5.7] for hip, 4.9 [95%CI: 4.6-5.3] for wrist and 2.3 [95%CI: 2.0-2.5] for humerus. To examine the predictive ability of BMD through follow-up time we determined fracture hazard ratios (HR) per standard deviation decrease in femoral neck BMD across five year bins. No differences were observed, with a HR of 2.5 (95%CI: 2.0-3.1) after the first 5 years, and of 1.9 (95%CI: 1.1-3.3) after 20 years. To assess secular trends in fracture incidence at all skeletal sites we compared participants at an age of 70-80 years across two time periods: 1989-2001 (n = 2481, 60% women) and 2001-2013 (n = 2936, 58% women) and found no statistically significant difference (p < 0.05) between fracture incidence rates (i.e., incidence of non-vertebral fractures of 26.4 per 1000 PY [95%CI: 24.4-28.5]) between 1989 and 2001, and of 25.4 per 1000 PY [95%CI: 23.0-28.0] between 2001 and 2013. In conclusion, BMD is still predictive of future fracture over a long period of time. While no secular changes in fractures rates seem to be observed after a decade, the majority of fractures still occur above the osteoporosis threshold, emphasizing the need to improve the screening of osteopenic patients.

Fractures in Kidney Transplant Recipients: A Comparative Study Between England and New York State

OBJECTIVES

Fractures are associated with high morbidity and are a major concern for kidney transplant recipients. No comparative analysis has yet been conducted between countries in the contemporary era to inform future international prevention trials.

MATERIALS AND METHODS

Data were obtained from the Hospital Episode Statistics and the Statewide Planning and Research Cooperative databases on all adult kidney transplants performed in England and New York State from 2003 to 2013, respectively, and on posttransplant fracture-related hospitalization from 2003 to 2014.

RESULTS

Our analysis included 18 493 English and 11 602 New York State kidney transplant recipients. Overall, 637 English recipients (3.4%) and 398 New York State recipients (3.4%) sustained a fracture, giving an unadjusted event rate of 7.0 and 5.9 per 1000 years, respectively (P = .948). Of these, 147 English (0.8%) and 101 New York State recipients (0.9%) sustained a hip fracture, giving an unadjusted event rate of 1.6 and 1.5 per 1000 years, respectively (P = .480). There were no differences in the cumulative incidence of all fractures or hip fractures. One-year mortality rates after any fracture (9% and 11%) or after a hip fracture (15% and 17%) were not different between cohorts.

CONCLUSIONS

Contemporaneous English and New York State kidney transplant recipients have similar fracture rates and mortality rates postfracture.

Type 2 diabetes and risk of low-energy fractures in postmenopausal women: meta-analysis of observational studies

Background

Observational studies on osteoporotic fractures in patients with type 2 diabetes indicate their increased incidence compared to those without diabetes, but results are inconsistent. Currently, type 2 diabetes is not considered as an independent risk factor for low-energy fractures in elder subjects. The aim of the study was to assess the association between type 2 diabetes and risk for hip and vertebral fractures in postmenopausal women.

Materials and methods

We searched Medline, Web of Science and Cochrane databases for articles published before September 2013. Studies assessing fractures in women aged >50 diagnosed with type 2 diabetes, regardless of the diabetes treatment, were deemed eligible. To estimate fracture risk meta-analysis in a random effect model was performed. The results were shown by the odds ratio (OR) and 95 % confidence interval (CI). Heterogeneity was tested using a Q-Cochrane test (significance was analyzed with p < 0.10) and I² measure.

Results

A total of 15 observational studies (11 cohort and 4 cross-sectional, 263.006 diabetics and 502.115 controls) were included. Thirteen papers provided information on the incidence of hip fractures, and seven on vertebral ones. The meta-analysis revealed type 2 diabetes was associated with higher risk for hip fracture (OR 1.296, 95 % CI (1.069–1.571), but not vertebral fracture (OR = 1.134, 95 % CI (0.936–1.374). There was significant heterogeneity between hip fracture studies. American origin was identified as a potential source of such heterogeneity.

Conclusions

The results of our meta-analysis indicate there is an increased risk for hip fracture in postmenopausal women with type 2 diabetes.

Analysis of the hip fracture records of a central training and research hospital by selected characteristics

BACKGROUND/AIM

Despite the importance of hip fractures, very few studies have assessed their epidemiological characteristics in Turkey. The aim of this study was to evaluate the frequency and demography of hip fractures from the recent data of a central training and research hospital.

MATERIALS AND METHODS

In this descriptive study, we identified hip fracture cases between 2009 and 2013. The age, sex, region, injury pattern, and calendar year for all patients were evaluated.

RESULTS

Among the 687 patients (488 women, 199 men) described in our clinic's records, 122, 131, 144, 138, and 154 patients applied with hip fractures from the years 2009 to 2013, respectively. The mean ages of the women and men were 74.8 and 68.5 years, respectively. There were 220 patients who had femoral neck fracture (32%), 419 who had intertrochanteric fracture (61%), and 48 who had subtrochanteric fracture (7%).

CONCLUSION

The female geriatric population may have an increasing and distinct hip fracture risk, mainly in the trochanteric region. Furthermore, recent studies that show variations in the frequency and demography of hip fractures highlight the importance of meticulous recording of patients' information. A nationwide survey of different categories of hospitals and various geographic regions of Turkey is also needed to inform effective prevention strategies.

Identification of patient profile for treatment

The WHO clinical definition of osteoporosis, based on a measurement of bone mineral density (BMD) by Dual Energy X-ray Absorptiometry, has been used globally since the mid-1990s. However, although this definition identifies those at greatest individual risk of fracture, in the population overall a greater total number of fractures occur in individuals with BMD values above the osteoporosis threshold. The inclusion of clinical risk factors, with or without BMD, in fracture prediction algorithms can improve the identification of individuals at high fracture risk; thus a number of web-based tools have been developed, the most commonly used globally being FRAX(®). In this review, we will discuss the epidemiology of osteoporosis, clinical risk factors for fragility fracture, and how this knowledge is being used to aid risk stratification. Importantly, research is on-going to demonstrate the clinical efficacy and cost-effectiveness of such case-finding strategies.