How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women

A Comparison of Ankle Fractures Relative to Other Fragility Fractures: A Review and Analysis of the American Orthopaedic Association's Own the Bone Database

BACKGROUND

Ankle fragility fractures (AFX) continue to increase in the elderly population. There is limited knowledge of AFX characteristics compared to nonankle fragility fractures (NAFX). The American Orthopaedic Association's Own the Bone (OTB) is a fragility fracture initiative. This robust data set was used to examine and compare characteristics of patients presenting with AFX to those with NAFX.

METHODS

The OTB database contained 72,617 fragility fractures between January 2009 and March of 2022 and were reviewed in our secondary cohort comparative analysis. After exclusions, AFX accounted for 3229 patients and 54,772 patients were in the NAFX cohort. Bivariate analysis and logistic regression compared the AFX and NAFX groups concerning demographics, bone health factors, medication use, and prior fragility fracture.

RESULTS

AFX patients were found to have a higher likelihood to be younger (67.6 years old), female (81.4%), non-Caucasian (11.7%) and have a higher BMI (30.6) compared to NAFX. Prior AFX predicted the risk of a future AFX. The probability of an AFX increased with increased age and BMI.

CONCLUSION

A prior AFX is independently predictive of subsequent AFX. Therefore, these fractures should be considered a sentinel event. These patients are more likely to have higher BMI, to be of female gender, non-Caucasian race, and are younger compared to patients with NAFX.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Risk factor analysis of fragility fractures in rheumatoid arthritis: A 3-year longitudinal, real-world, observational, cohort study

Objectives

To explore the risk factors for fragility fractures in rheumatoid arthritis (RA) patients using a 3-year longitudinal, observational cohort study.

Methods

This RA registry study included consecutive RA patients in the outpatient clinic of Chang Gung Memorial Hospital since September 1, 2014. The demographics, clinical characteristics, lifestyle, evidence of previous fracture, risk factors according to the Fracture Risk Assessment Tool (FRAX^®), and the FRAX score of each participant were recorded. The participants were categorized into the new incident fracture (group A) and no incident fracture (group B) groups based on evidence or absence of new incident fractures and propensity score matching (age and gender, 1:2).

Results

Overall, 477 participants completed the 3-year observation period. After matching, 103 and 206 participants were allocated to groups A and B, respectively. The non-adjusted model revealed, presented as hazard ratio (HR) (95% confidence interval [CI]), that the presence of co-morbidity (1.80 [1.17–2.78], p = 0.008), Health Assessment Questionnaire Disability Index (1.35 [1.07–1.69], p = 0.010), lower baseline hip bone mineral density (0.11 [0.02–0.48], p = 0.004), longer disease duration (1.02 [1.00–1.04], p = 0.026), higher FRAX score of major fracture (1.03 [1.02–1.04], p<0.001) or hip fracture (1.03 [1.02–1.04], p<0.001), and previous fracture history (2.65 [1.79–3.94], p<0.001) were associated with new incident fracture. After adjustment, it was disclosed that a previous fracture is an independent risk factor for fragility fractures in RA patients (2.17 [1.20–3.90], p = 0.010).

Conclusions

In addition to aging and disease-related factors, previous fracture history is the most important risk factor for fragility fractures in RA patients.

The effect on subsequent fracture risk of age, sex, and prior fracture site by recency of prior fracture

The risk of a recurrent fragility fracture varies by age and sex, as by site and recency of sentinel fracture.

INTRODUCTION

The recency of prior fractures affects subsequent fracture risk. Variable recency may obscure other factors that affect subsequent fracture risk. The aim of this study was to quantify the effect of a sentinel fracture by site, age, and sex where the recency was held constant.

METHODS

The study used data from the Reykjavik Study fracture register that documented prospectively all fractures at all skeletal sites in a large sample of the population of Iceland. Fracture incidence was compared to that of the general population determined at fixed times after a sentinel fracture (humeral, clinical vertebral, forearm, hip, and minor fractures). Outcome fractures comprised a major osteoporotic fracture and hip fracture.

RESULTS

Sentinel osteoporotic fractures were identified in 9504 men and women. Of these, 3616 individuals sustained a major osteoporotic fracture as the first subsequent fracture, of whom 1799 sustained a hip fracture. Hazard ratios for prior fracture were consistently higher in men than in women and decreased progressively with age. Hazard ratios varied according to the site of sentinel fracture with higher ratios for hip and vertebral fracture than for humerus, forearm, or minor osteoporotic fracture.

CONCLUSION

The risk of a recurrent fragility fracture varies by age, sex, and site of sentinel fracture when recency is held constant.

High Risk of Hip and Spinal Fractures after Distal Radius Fracture: A Longitudinal Follow-Up Study Using a National Sample Cohort

The purpose of the present study was to estimate the risk of hip and spinal fracture after distal radius fracture. Data from the Korean National Health Insurance Service—National Sample Cohort were collected between 2002 and 2013. A total of 8013 distal radius fracture participants who were 50 years of age or older were selected. The distal radius fracture participants were matched for age, sex, income, region of residence, and past medical history in a 1:4 ratio with control participants. In the subgroup analysis, participants were stratified according to age group (50–59, 60–69, or ≥70 years) and sex (male or female). Distal radius fracture patients had a 1.51-fold and 1.40-fold higher incidence of hip fracture and spinal fracture in the adjusted models, respectively. Among males, patients of all ages had a significantly higher incidence of hip fracture, and those who were 50 to 69 years of age had a significantly higher incidence of spinal fracture. Among females, those older than 70 years had a significantly higher incidence of hip fracture, and patients of all ages had a significantly higher incidence of spinal fracture. Previous distal radius fracture has a significant impact on the risk of subsequent hip and spinal fractures.

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I² = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I² = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

[Ankle fractures in older patients : What should we do differently?]

As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.

Vertebral fracture assessment (VFA) for osteoporosis screening in US postmenopausal women: is it cost-effective?

Vertebral fracture assessment (VFA) is cost-effective when it was incorporated in the routine screening for osteoporosis in community-dwelling women aged ≥ 65 years, which support guidelines, such as the National Osteoporosis Foundation (NOF) for the diagnostic use of VFA as an important addition to fracture risk assessment.

INTRODUCTION

To evaluate the cost-effectiveness of VFA as a screening tool to reduce future fracture risk in US community-dwelling women aged ≥ 65 years.

METHODS

An individual-level state-transition cost-effectiveness model from a healthcare perspective was constructed using derived data from published literature. The time horizon was lifetime. Five screening strategies were compared, including no screening at all, central dual-energy X-ray absorptiometry (DXA) only, VFA only, central DXA followed by VFA if the femoral neck T-score (FN-T) ≤ - 1.5, or if the FN-T ≤ - 1.0. Various initiation ages and rescreening intervals were evaluated. Oral bisphosphonate treatment for 5-year periods was assumed. Incremental cost-effectiveness ratios (2017 US dollars per quality-adjusted life-year (QALY) gained) were used as the outcome measure.

RESULTS

The incorporation of VFA slightly increased life expectancy by 0.1 years and reduced the number of subsequent osteoporotic fractures by 3.7% and 7.7% compared with using DXA alone and no screening, respectively, leading to approximately 30 billion dollars saved. Regardless of initiation ages and rescreening intervals, central DXA followed by VFA if the FN-T ≤ - 1.0 was most cost-effective ($40,792 per QALY when the screening is initiated at age 65 years and with rescreening every 5 years). Results were robust to change in VF incidence and medication costs.

CONCLUSION

In women aged ≥ 65 years, VFA is cost-effective when it was incorporated in routine screening for osteoporosis. Our findings support the National Osteoporosis Foundation (NOF) guidelines for the diagnostic use of VFA as an important addition to fracture risk assessment.

Changes in physical activity and risk of fracture: a Korean nationwide population-based cohort study

Physical activity (PA) is one of the most important modifiable factors associated with fracture risk. However, the association between interval changes in PA and the risk of fracture remains unknown. We investigated the risk of fracture development according to interval changes in PA in middle aged and older individuals. In this nationwide cohort study of adults aged ≥ 40 years, more than 4.9 million individuals without fractures within the last year who underwent two consecutive national health screenings in Korea from 2009 to 2012 were identified. The risk of fracture between 2013 and 2016 according to interval changes in regular PA was prospectively analyzed. Compared to individuals with a continuous lack of PA, those with a decrease in PA (0.41/1000 person-years (PY) decrease in incidence rate (IR); adjusted hazard ratio (aHR) 0.975; 95% confidence interval (CI) 0.964–0.987), increase in PA (1.8/1000 PY decrease in IR; aHR 0.948; 95% CI 0.937–0.959), and continuous PA (3.58/1000 PY decrease in IR; aHR 0.888; 95% CI 0.875–0.901) had a significantly reduced risk of fracture. Interval changes in regular PA were associated with risk of fracture. Individuals who engaged in continuous regular PA exhibited the maximum protective benefit against fracture.

Grade 1 Vertebral Fractures Identified by Densitometric Lateral Spine Imaging Predict Incident Major Osteoporotic Fracture Independently of Clinical Risk Factors and Bone Mineral Density in Older Women

Because prevalent vertebral fracture (VF) is a strong predictor of future fractures, they are important to identify in clinical practice as osteoporosis medications are effective and can be used to reduce fracture risk in postmenopausal women with VF. Lateral spine imaging (LSI) with dual-energy X-ray absorptiometry (DXA) can be used to diagnose VFs accurately but is not widespread in clinical practice. The prognostic value of grade 1 (20% to 25% compression) VFs diagnosed by LSI with DXA has been insufficiently studied. The aim of this study was to determine if grade 1 VF is associated with incident fracture in older women. Sahlgrenska University Hospital Prospective Evaluation of Risk of Bone Fractures (SUPERB) is a population-based study of 3028 older women from Gothenburg, Sweden. Included women were 75 to 80 years of age at baseline, answered questionnaires, and were scanned with DXA (Discovery A, Hologic, Waltham, MA, USA). LSI was used to diagnose VFs, which were classified using the Genant semiquantitative method. Cox regression models were used to estimate the association between VFs at baseline and X-ray-verified incident fractures, with adjustment for confounders. Women with a grade 1 VF (n = 264) or a grade 2-3 VF (n = 349) were compared with women without any fracture (n = 1482). During 3.6 years (median, interquartile range [IQR] 1.5 years) of follow-up, 260 women had any incident fracture and 213 a major osteoporotic fracture (MOF). Women with only grade 1 VF had increased risk of any fracture (hazard ratio [HR] = 1.67; 95% confidence interval [CI] 1.18-2.36) and MOF (HR = 1.86; 95% CI 1.28-2.72). For MOF, this association remained after adjustment for clinical risk factors and femoral neck bone mineral density (BMD). In conclusion, grade 1 VFs were associated with incident MOF, also after adjustment for clinical risk factors and BMD, indicating that all VF identified by DXA should be considered in the evaluation of fracture risk in older women. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research..

Recurrent Fragility Fractures: A Cross-sectional Analysis

INTRODUCTION

Despite growing rates of fragility fractures, there has been a lack of research investigating the risk and characteristics of recurrent fragility fractures.

METHODS

The Medicare Standard Analytic Files database was used to identify patients from 2005 to 2009 who were older than 65 years, had a diagnosis of osteoporosis or osteopenia, and sustained a fragility fracture of the proximal humerus, distal radius, hip, ankle, or vertebral column. The incidence and type of recurrent fragility fracture were tracked over a 36-month period.

RESULTS

A total of 1,059,212 patients had an initial fragility fracture from 2005 to 2009. Of these patients, 5.8% had a subsequent fragility fracture within 1 year for their initial fracture, 8.8% within 2 years, and 11.3% within 3 years. At 3-year follow-up, hip fractures were the most common type of subsequent fracture, regardless of the initial fracture type (6.5%, P < 0.001). Vertebral compression and proximal humerus fractures (13.8% and 13.2%, respectively) were most likely to be associated with a recurrent fragility fracture.

CONCLUSION

Patients who have any type of fragility fracture have a notable risk of subsequent fractures within 3 years, especially hip fractures. These patients should be evaluated and treated for underlying risks factors, including osteoporosis and/or osteopenia.

LEVEL OF EVIDENCE

Retrospective, level III.

Epidemiology of Adult Ankle Fractures: 1756 cases identified in Norrbotten County during 2009-2013 and classified according to AO/OTA

Background

The ankle fracture is one of the most common fractures, increasing in an ageing population, but not generally seen as an osteoporotic fracture. The aim of this study was to examine the relationship between different AO/OTA classes of ankle fractures, age, sex and type of trauma.

Methods

Ankle fractures, treated at any of the hospitals in Norrbotten County in Sweden between 2009 and 2013, were retrospectively identified and classified according to the AO/OTA-classification system. Information about the trauma mechanism was also obtained.

Results

In Norrbotten County, 1756 ankle fractures in 1735 patients aged 20 years or older were identified. This gave an incidence in the county of 179 per 100,000 person-years. Of these patients, 34.6% were 65 years or older, 58.4% were women and 68.2% of the trauma leading to a fracture was defined as low-energy. In 1.5% of the cases the fractures were open. Incidences of type B fractures increased substantially with age, from 62 (95% CI 50–77) at 30–39 years of age to 158 (95% CI 131–190) in patients older than 80 years of age per 100,000 person-years. Type B fractures showed a slightly higher proportion of low-energy trauma while type C showed a lower mean age and proportion of women.

Conclusions

This study shows an incidence of 179 adult ankle fractures annually per 100,000 persons. More than two thirds of the fractures were caused by a low-energy trauma and ankle fractures are more frequent among females. Females generally have an increased incidence during their life, mainly between the ages of 30 and 60. This is in contrast to men who have more of an even distribution throughout their life. Classification according to AO/OTA reveals some heterogeneity among the classes of ankle fractures in age and gender as well as the energy involved in the trauma.

Demographic and socioeconomic factors influencing the incidence of ankle fractures, a national population-based survey of 512187 individuals

This study aimed to investigate the population-based incidence rate of ankle fracture and associated risk factors in China. All the data on ankle fractures were available from the China National Fracture Survey (CNFS) conducted between January and May in 2015. All eligible household members were sampled from 8 provinces, 24 urban cities and 24 rural counties in China, using stratified random sampling and the probability proportional to size method. Questionnaires were sent to every participant for data collection and quality control was accomplished by our quality control team members. A total of 512187 valid questionnaires were collected and relevant data were abstracted and analyzed. One hundred and ninety patients sustained 193 ankle fractures in 2014, indicating the incidence rate was 37.1 (95% CI, 31.8–42.4)/100,000 person-year. Alcohol consumption, living alone and average sleep time <7 h/d were identified as independent risk factors for ankle fracture in both males and females. Previous history of fracture was identified as significant risk factor of ankle fracture in females but not in males. Therefore, specific public health policies focusing on decreasing alcohol consumption and encouraging individuals to obtain sufficient sleep should be implemented. Individuals living alone should focus more on healthcare, especially in those with previous fracture.

Risk of Subsequent Fragility Fractures Observed After Low-Trauma Ankle Fractures

While fragility fractures (FFs) are one of the strongest predictors of subsequent osteoporotic fractures, it remains unclear whether low-trauma ankle fractures have this ability. The aim of the study was to identify the characteristics of patients with low-trauma ankle FFs who develop subsequent FFs. The OPTIMUS initiative is a strategy to improve osteoporosis treatment post-FF in orthopedic clinics. FRAX scores without BMD (FRAX-BMI) were calculated at time of inclusion. Recurrent FFs were recorded over a 48-month follow-up. All FFs were X-ray-confirmed. A total of 265 patients with initial ankle FF were included (190 women; mean age 62.8 ± 9.6 years), of whom 15 developed new FFs. Patients with ankle FFs had longer time until recurrence and lower 2-year incidence of recurrent FFs (3.2%) compared with those having wrist FFs (9.0%) or other initial FFs (9.6%), and 4-year incidence rates of 6.2, 13.4, and 15.3%, respectively (log-rank test, p = 0.001). With an ankle FF at inclusion, recurrent FFs were more frequent in patients with previous FF (6.2 per 100 patient-years; p < 0.01) or high-risk FRAX-BMI scores pre- or post-FF (2.4 or 2.0 per 100 patient-years, respectively; ns), compared to patients without any of these conditions (0.7 per 100 patient-years). Ankle FFs represent a clinical opportunity for identifying at-risk patients who should be targeted for treatment (previous FFs and/or high-risk FRAX). Because of mechanical factors and other contributors involved, ankle FFs themselves do not predict subsequent FFs overall, and their inclusion in FRAX-BMI risk calculation may thus not be warranted.

Socioeconomic factors and individual lifestyles influencing the incidence of patella fractures: a national population-based survey in China

BACKGROUND

We aimed to do a national survey on the population-based incidence of patella fractures and related risk factors fracture in China.

METHODS

All the data on patella fractures were available from the China National Fracture Survey (CNFS) between January and May in 2015. And in the CNFS, all eligible household members were selected from 24 urban cities and 24 rural counties of eight provinces of China, with stratified random sampling and the probability proportional to size method used. Questionnaire was sent to every participant for data collection and quality control was accomplished by our research team members.

RESULTS

A total of 512,187 valid questionnaires were collected, and relevant data were abstracted. There were a total of 69 patients with 69 patella fractures that occurred in 2014, indicating that the incidence was 13.5 (95% CI, 10.3-16.7))/100,000 person-years. Slip, trip, or fall from standing height was the most common cause, leading to 69.6% (48/69) of patella factures, followed by traffic accidents (18.8%, 13/69). Home and road were the first two most common places, where 86.9% of the overall injuries occurred. Age of 45-64 and 65-74 years, alcohol consumption and previous history of fractures were identified as independent risk factors for patella fracture.

CONCLUSIONS

Specific public health policies focusing on decreasing alcohol consumption should be implemented. Individuals aged 45-64 and 65-74 should pay more attention to bone mass density and prevention of falls, especially those with previous history of fracture.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture

The human body undergoes several physiological adaptations as a result of the aging process. Amongst other organs, the skeleton is also affected and when bone fragility is present, an increase in both morbidity and mortality has been reported. Identification of risk factors to calculate the probability for a given patient to develop a fragility fracture it is therefore of paramount importance. Moreover, the existence of an in house protocol for diagnostic work up using biochemical tests and imaging investigations is essential. In the herein study we discuss a diagnostic protocol that has been developed in our clinic based on knowledge from the literature and our clinical experience.

Ankle fractures in the elderly: Treatment and results in 477 patients

INTRODUCTION

In the elderly, ankle fractures are likely to cause specific complications and have a major impact on their autonomy. The goal of this multicentre study was to assess these outcomes in a geriatric population treated operatively.

MATERIAL AND METHODS

This retrospective study included 477 patients with ankle fractures treated surgically between 2008 and 2014. The minimum age was 60years for women and 70 for men. Patients with a tibial pilon fracture or less than 3months' follow-up were excluded. Functional (autonomy and comorbidities) and radiological assessments were performed before surgery and at the review.

RESULTS

The cohort was 81% female (384 women, 93 men) and had median age of 74years. The preoperative autonomy was 7.8 points on average using the Parker score. Most of the fractures were either Weber type B (n=336) or type C (n=114). At the follow-up, the mean autonomy score was 7.3 points. The fibula was fixed with a plate and screws in 69% of cases (n=325), with additional internal malleolar fixation was carried out in some cases. A satisfactory result, defined as 2 points or less reduction in the Parker score, was found in 89.9% of patients; 71.8% had not lost any autonomy. The main risk factors for loss of autonomy were being more than 80years of age (OR=2.93, P<0.001), poor surgical reduction (OR=2.8, P<0.01), the presence of two or more comorbidities (OR=2.71, P<0.001), being female (OR=2.19, P<0.043) or having a Weber type C fracture (OR=2.05, P=0.023).

DISCUSSION

The functional results are satisfactory overall following standard surgical treatment consisting of internal malleolar and fibular fixation for ankle fractures in the elderly. We identified five factors that greatly impact functional recovery.

LEVEL OF EVIDENCE

IV.

Prior ankle fractures in postmenopausal women are associated with low areal bone mineral density and bone microstructure alterations

In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility.

INTRODUCTION

Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin.

METHODS

In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography.

RESULTS

Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude.

CONCLUSION

Women with ankle fractures have lower aBMD and vBMD and trabecular bone alterations, suggesting that ankle fractures are another manifestation of bone fragility.

Correlation between distal radial cortical thickness and bone mineral density

PURPOSE

To determine interobserver reliability in measuring the cortical thickness of distal radiuses on posteroanterior radiographs obtained at the time of injury and to determine whether there is a correlation between distal radius cortical thickness and hip and lumbar spine scores on dual-energy x-ray absorptiometry (DXA).

METHODS

Four orthopedic surgeons at 2 academic institutions who were blinded to the study protocol reviewed standard posteroanterior wrist radiographs of 80 women over age 50 years with distal radius fractures with DXA data obtained within the past 2 years. Radial bicortical widths were measured at 50 and 70 mm proximal to the distal ulnar articular surface, and mean bicortical thickness was calculated from radiographs of the injured wrist. Average bicortical width was compared with each patient's femoral and lumbar spine bone density measures. Data were analyzed using Pearson correlation coefficients and simple linear regression. Inter-rater reliability was evaluated using intra-class correlation coefficients.

RESULTS

The inter-rater reliability for average bicortical thickness had a high intra-class correlation coefficient value of 0.91. Average bicortical thickness showed a statistically significant positive relationship with femoral bone density. Average bicortical thickness was statistically correlated with femoral bone density values, with a 1-mm increase in average bicortical thickness associated with a 0.05 g/cm(2)-increase in femoral density. Average bicortical thickness was not associated with lumbar bone density.

CONCLUSIONS

Bicortical thickness of the distal radius was positively correlated with femoral bone density but not with lumbar spine density. This may reflect similarity in quality and loading properties of the femur and radius as appendicular bones, compared with the axial spine. Identification of thinned distal radial cortices in association with distal radius fracture is a simple qualitative observation that should prompt further evaluation with DXA and medical management of bone insufficiency.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Subsequent fracture rates in a nationwide population-based cohort study with a 10-year perspective

SUMMARY

Fractures after the age of 50 are frequently observed in Denmark, and many of these may be osteoporotic. This study examined the incidence of all and subsequent fractures in a 10-year period from 2001 to 2011. The incidence of subsequent fractures was high, especially following hip fracture.

INTRODUCTION

The purpose of this study is to examine patterns of subsequent fractures and mortality rates over a 10-year period in patients already suffering from fracture.

METHODS

The study was designed as a nationwide, register-based follow-up study. Patients were included if diagnosed with an index fracture (ICD-10 codes: S22.x, S32.x, S42.x, S52.x, S62.x, S72.x, S82.x, S92.x, T02.x, T08.x, T10.x and T12.x) between January 1st, 2001 and December 31st, 2001 and if older than 50 years at time of fracture. The patients were investigated for future subsequent fractures from January 1st, 2002 to December 31st, 2011.

RESULTS

In this study, we demonstrated that patients with fractures (especially hip fractures) have a high risk of subsequent fractures, especially hip fracture. Other fractures, which are not commonly considered as osteoporotic fractures, such as lower leg, were frequently observed in the 10 years following index fracture. The cumulative incidence proportion (CIP) of subsequent fractures during the 10-year follow-up period was high for all recurrent fractures (9-46 %). Subsequent hip fracture, regardless of index fracture, had the highest CIP across the study period, ranging from 9 to 40 %. Appendicular fractures were often followed by a recurrent fracture, or subsequent fractures at a more proximal location in the same limb, i.e. forearm fractures were followed by humerus fractures. These results have not been previously demonstrated to this extent, and according to our knowledge, no previous studies have estimated cumulative 10-year subsequent fracture incidences for any non-hip fractures.

CONCLUSION

Patients suffering a fracture (and especially a hip fracture) have a high incidence of subsequent fracture. Fractures after the age of 50 may be considered an early warning of increased risk for future fractures in many patients.

Osteoporosis and fragility fractures: Vertebral fractures

The incidence of vertebral fragility fractures and deformity increase steeply with age. Every sixth woman and every twelfth man will sustain a symptomatic vertebral fracture. Vertebral fractures result in pain, functional disability and decreased quality of life, which may last for several years, and may also affect mortality. The patient with an acute fracture should be examined with radiology for diagnosis. In case of a low-energy fracture, osteoporosis should be suspected and investigated. If the pain management fails, vertebroplasty or kyphoplasty could be considered. Braces may be used, but evidence for its effect is lacking. In the rare event of neurological compromise, or unstable fractures, surgical treatment should be considered. After vertebral fragility fractures, the risk for new fractures is high and secondary preventive measures advocated. The best evidence for secondary prevention is currently on medical treatment of osteoporosis.

Mild morphometric vertebral fractures predict vertebral fractures but not non-vertebral fractures

In this meta-analysis of the control arms of four phase 3 trials, mild vertebral fractures were a significant risk factor for future vertebral fractures but not for non-vertebral fracture.

INTRODUCTION

A prior vertebral fracture is a risk factor for future fracture that is commonly used as an eligibility criterion for treatment and in the assessment of fracture probability. The aim of this study was to determine the prognostic significance of a morphometric fracture according to the severity of fracture.

METHODS

We examined the control (placebo) treated arms of four phase 3 trials. Vertebral fracture status was graded at baseline in 7,623 women, and fracture outcomes were documented over the subsequent 20,000 patient-years. Fracture outcomes were characterised as a further vertebral fracture, a non-vertebral fracture or a clinical fracture (non-vertebral plus clinical vertebral fracture). The relative risk of fracture was computed from the merged β coefficients of each trial weighted according to the variance.

RESULTS

Mild vertebral fractures were a significant risk factor for vertebral fractures [risk ratio (RR) = 2.17; 95% CI = 1.70-2.76] but were not associated with an increased risk of non-vertebral fractures (RR = 1.08; 95% CI = 0.86-1.36). Moderate/severe vertebral fractures were associated with a high risk of vertebral fractures (RR = 4.23; 95% CI = 3.58-5.00) and a moderate though significant increase in non-vertebral fracture risk (RR = 1.64; 95% CI = 1.38-1.94).

CONCLUSIONS

Prior moderate/severe morphometric vertebral fractures are a strong and significant risk factor for future fracture. The presence of a mild vertebral fracture is of no significant prognostic value for non-vertebral fractures. These findings should temper the use of morphometric fractures in the assessment of risk and the design of phase 3 studies.

Do the hospitalized patients with osteoporotic fractures require endocrinologists' help?

AIM

Osteoporotic fractures are a crucial cause of morbidity and mortality in patients with fragility fractures and impose huge economic burden on health care services. Orthopedic surgeons are often the only clinicians seen by the patients with osteoporotic fractures. The improvement in osteoporosis management is an urgent require; therefore, the aim of this study was to determine the efficacy of consultation with an endocrinologist in osteoporosis management of patients with a fragility fracture.

METHODS

This survey was undertaken in three phases that focused on patients with osteoporotic fractures who were admitted to five tertiary care, level-I, trauma hospital. Patients were evaluated through a questionnaire which was designed to determine whether physicians manage underlying osteoporosis.

RESULTS

The number of patients who underwent a bone mineral density test increased from a rate of 3.6% to 91% after the intervention, as calcium and vitamin D supplementation from 18% to 92%, bisphosphonate prescription from 0.5% to 83%. Also, the overall medication usage increased from 9% to 87%. A small number of patients (3%) were followed up in contrast to a rate of 73% in the third phase.

CONCLUSION

Orthopedic surgeons are not completely engaged in osteoporosis care for patients with a fragility fracture; therefore, a consultation with an endocrinologist is required to enable orhopedic surgeons to provide an effective osteoporosis care for their patients with an osteoporotic fracture.

Social determinants of bone densitometry uptake for osteoporosis risk in patients aged 50yr and older: a systematic review

The World Health Organization identifies that osteoporosis is one of the leading health problems in the Western world. An increased risk of fragility fracture is observed in more socially disadvantaged individuals in most Western countries. Dual-energy X-ray absorptiometry (DXA) is currently the procedure of choice to diagnose osteoporosis and assess fracture risk. We systematically reviewed the literature regarding social determinants of DXA utilization for osteoporosis detection in patients aged 50yr and older using a computer-aided search of MEDLINE, EMBASE, CINAHL, and PsychINFO from January 1994 to December 2010. Five cross-sectional studies, incorporating 16 separate analyses, were identified for inclusion in this review. The best evidence analysis identified limited evidence for a positive association between either income or education with DXA utilization; furthermore, the best evidence analysis found no evidence for an association between either marital status or working status and DXA utilization. Further research is required to identify whether a relationship exists and elucidate reasons for disparities in DXA utilization between different social groups, such as choice and referral processes, as a necessary precursor in identifying modifiable determinants and appropriate strategies to promote preventive screening to identify fracture risk.

Ankle fractures do not predict osteoporotic fractures in women with or without diabetes

It is not clear whether ankle fractures predict future osteoporotic fractures in women, and whether diabetes influences this relationship. We found that a prior ankle fracture does not predict subsequent osteoporotic fractures in women with or without diabetes.

INTRODUCTION

We aimed to determine: (1) whether a prior ankle fracture was a risk factor for a subsequent major osteoporotic fracture in older women; (2) whether this risk was modified by the presence of diabetes; (3) the risk factors for ankle fracture in older women.

METHODS

We identified 3,054 women age 50 years and older with diabetes and 9,151 matched controls using the Manitoba Bone Density Program database. Multivariable regression models were used to examine factors associated with prior ankle fracture, and the importance of prior ankle fracture as a predictor of subsequent major osteoporotic fracture during a mean 4.8 years of observation.

RESULTS

A prior ankle fracture was not a significant predictor of subsequent major osteoporotic fracture for women with diabetes (hazard ratio [HR] 1.13; 95% confidence interval [CI], 0.68-1.83; p = 0.623) or women without diabetes (HR 1.16; 95% CI, 0.79-1.71; p = 0.460), and there was no interaction between diabetes and ankle fracture after pooling all women in the cohort (p = 0.971). The presence of diabetes was not independently associated with prior ankle fracture (adjusted odds ratio [OR] 1.14 [95% CI, 0.93-1.38], p = 0.200), whereas higher body mass index (adjusted OR 1.04 per standard deviation increase [95% CI, 1.03-1.06], p < 0.001), previous major osteoporotic fracture (adjusted OR 1.40 [95% CI, 1.13-1.75], p = 0.002), and multiple comorbidities (>6 ambulatory diagnostic groups) (adjusted OR 1.81 [95% CI, 1.40-2.36], p < 0.001) were related to prior ankle fracture.

CONCLUSIONS

Ankle fracture was not a significant predictor of major osteoporotic fracture in women, and a diagnosis of diabetes did not influence the relationship.

Bone mineral density (BMD) and osteoporosis risk factor in Egyptian male and female battery manufacturing workers

The study was conducted to estimate the relation between lead exposure and the risk of various symptoms of osteoporosis in male and female battery manufacturing workers by using dual energy X-ray absorptiometry. A total of 18 female and 24 male workers were chosen with the same age range, duty hours per day, work history and weight. A total of 15 healthy controls were chosen with no previous history of bone illness and normal blood lead concentration. Blood lead concentration was measured in all workers and controls. Non-lead elevated subjects were excluded. Bone mineral density was measured by X-ray-based dual-energy X-ray absorptiometry scan machine. Spine, femur neck and radius sites were studied. Results showed that both male and female workers recorded significant elevated levels of lead concentration accompanied by osteoporosis when compared with control. Interestingly, the data revealed that fracture risk in female was significantly higher than male workers. It was concluded that lead poisoning may act as osteoporosis risk factor or co-factor in female workers by activating the conversion of osteopenia to osteoporosis.

Clinical fractures cluster in time after initial fracture

A history of fractures is a well recognised risk factor for a new clinical fracture. However, this subsequent fracture risk is not constant, but fluctuates over time, with the greatest increase in the years immediately after the initial fracture, followed by a gradual waning of risk toward the population risk. The clustering of fractures occurred regardless of age, gender and initial fracture location. It is therefore likely that fracture risk models, which take into account this fluctuation of fracture risk over time, will be more relevant in predicting an individual's subsequent fracture risk. Regardless of the cause of this clustering, these studies all strongly support the need for early action after an initial fracture to reduce the preventable risk of subsequent fractures with medical interventions that have been shown to immediately decrease the risk of fractures.

Treatment of distal radius fractures

The clinical practice guideline is based on a systematic review of published studies on the treatment of distal radius fractures in adults. None of the 29 recommendations made by the work group was graded as strong; most are graded as inconclusive or consensus; seven are graded as weak. The remaining five moderate-strength recommendations include surgical fixation, rather than cast fixation, for fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees , or intra-articular displacement or step-off >2 mm; use of rigid immobilization rather than removable splints for nonsurgical treatment; making a postreduction true lateral radiograph of the carpus to assess dorsal radial ulnar joint alignment; beginning early wrist motion following stable fixation; and recommending adjuvant treatment with vitamin C to prevent disproportionate pain.

Is prophylactic fixation a cost-effective method to prevent a future contralateral fragility hip fracture?

OBJECTIVE

: A previous hip fracture more than doubles the risk of a contralateral hip fracture. Pharmacologic and environmental interventions to prevent hip fracture have documented poor compliance. The purpose of this study was to examine the cost-effectiveness of prophylactic fixation of the uninjured hip to prevent contralateral hip fracture.

METHODS

: A Markov state-transition model was used to evaluate the cost and quality-adjusted life-years (QALYs) for unilateral fixation of hip fracture alone (including internal fixation or arthroplasty) compared with unilateral fixation and contralateral prophylactic hip fixation performed at the time of hip fracture or unilateral fixation and bilateral hip pad protection. Prophylactic fixation involved placement of a cephalomedullary nail in the uninjured hip and was initially assumed to have a relative risk of a contralateral fracture of 1%. Health states included good health, surgery-related complications requiring a second operation (infection, osteonecrosis, nonunion, and malunion), fracture of the uninjured hip, and death. The primary outcome measure was the incremental cost-effectiveness ratio estimated as cost per QALY gained in 2006 US dollars with incremental cost-effectiveness ratios below $50,000 per QALY gained considered cost-effective. Sensitivity analyses evaluated the impact of patient age, annual mortality and complication rates, intervention effectiveness, utilities, and costs on the value of prophylactic fixation.

RESULTS

: In the baseline analysis, in a 79-year-old woman, prophylactic fixation was not found to be cost-effective (incremental cost-effectiveness ratio = $142,795/QALY). However, prophylactic fixation was found to be a cost-effective method to prevent contralateral hip fracture in: 1) women 71 to 75 years old who had 30% greater relative risk for a contralateral fracture; and 2) women younger than age 70 years. Cost-effectiveness was greater when the additional costs of prophylaxis were less than $6000. However, for most analyses, the success of prophylactic fixation was highly sensitive to the effectiveness and the relative morbidity and mortality of the additional procedure.

CONCLUSION

: Prophylactic fixation with a cephalomedullary nail was not found to be cost-effective for the average older woman who sustained a hip fracture. However, it may be appropriate for select patient populations. The study supports the need for basic science and clinical trials investigating the effectiveness of prophylactic fixation for patient populations at higher lifetime risk for contralateral hip fracture.

Management of osteoporosis in primary care in Australia

This study reviewed factors influencing osteoporosis management in primary care settings in Australia and examined risk profiles of patients (n = 37,957) for osteoporosis. Only 29.7% of patients with a prior fracture were currently on specific medication for osteoporosis. The results highlight the need for further exploration of barriers to osteoporosis management.

INTRODUCTION

Osteoporosis management in primary care is suboptimal even for high-risk people with a history of prior fracture.

METHODS

This study reviewed factors influencing the management of individuals at risk for osteoporosis in primary care settings in Australia and examined risk profiles of patients for osteoporosis. Patients (n = 37,957, mean age 71) were recruited over a 12-month period (February 2006-Jan 2007) and interviewed.

RESULTS

With regard to risk factors for osteoporosis, 12.6% of patients reported a history of prior minimal trauma fracture, 7.5% reported a family history of osteoporosis, 7.4% reported they were current smokers, 11.4% reported low dietary calcium intake, 31.8% reported no regular weekly physical exercise and 10.3% reported current use of glucocorticoids. Of those with a prior fracture, only 29.7% were currently on specific medication for osteoporosis. Radiography (n = 17,754) demonstrated a prior vertebral fracture in 30.1%, but only 3.8% of the 17,754 patients reported current use of specific osteoporosis medication.

CONCLUSIONS

This study has confirmed low rates of treatment in primary care even in individuals who have already suffered a prior fracture or have other risk factors. This study highlights the need for further exploration of barriers to osteoporosis management in the primary care setting.

Role of quantitative ultrasound to predict fracture among institutionalised older people with a history of fracture

The fracture predictive value of quantitative ultrasound (QUS) may be modified by previous fracture status. Non-significant associations between QUS parameters and fracture risk were observed among frail older people with a history of fracture. These findings suggest that QUS measurements for frail older people might be more useful in those without a fracture history.

INTRODUCTION

Quantitative ultrasound has been shown to predict risk of fracture in various populations. However, this ability may be modified by the presence of previous fracture in very frail older people.

METHODS

We assessed bone strength by QUS and clinical risk factors at baseline for 1,982 institutionalised older people. Fractures were ascertained for 2 years from baseline and validated by X-ray reports.

RESULTS

Study participants were very old (mean age = 85.7 +/- 7.1 years) and frail (70% using walking aids). Forty-five percent reported a history of fracture. During a mean follow-up period of 1.64 years, 335 participants suffered a fracture or fractures. Fracture rates were significantly higher in participants with a history of fracture compared with those without a history of fracture (16.0 vs 9.2 per 100 person years, p < 0.001). Significant associations between fracture risk and QUS parameters (broadband ultrasound attenuation and velocity of sound) were observed among participants without a history of fracture (both p < 0.01), but not among those who had a fracture history (both p >/= 0.7).

CONCLUSIONS

In very frail older people, QUS measurements may be more useful for assessing fracture risk in those without a history of fracture after age 50.

A Markov model simulation of the impact of treatment persistence in postmenopausal osteoporosis

BACKGROUND

The Markov model followed a cohort of patients over 10 years to estimate the total number of incident osteoporotic fractures by age for the overall population of women with diagnosed postmenopausal osteoporosis in France (mean age, 71.1 years +/-9.6; range, 50-96 years). The impact of clinical efficacy, persistence, and residual treatment effects data on predicted fracture risk was also estimated in the model.

RESULTS

Predicted numbers of incident fractures appeared consistent with published data. Compared with no treatment, the relative risk of fracture over 10 years was 0.831 for weekly bisphosphonate treatment with an assumed persistence rate of 51% after 1 year (absolute risk reduction = 11.4%). This relative risk decreased to 0.731 (absolute risk reduction=18.1%) if hypothetical full-treatment persistence was achieved. In terms of public health, improving persistence with bisphosphonate treatment by only 20% could have the same impact as a 20.2% increase in clinical efficacy. The benefit associated with improved persistence declines as full persistence is approached.

CONCLUSION

Improving persistence can increase treatment effectiveness. Giving greater priority to persistence interventions might have a greater impact on the health of osteoporotic women than advances in treatment efficacy.

Characteristics of males over 50 years who present with a fracture: epidemiology and underlying risk factors

Osteoporosis and fragility fractures in men constitute a considerable burden in healthcare. We have reviewed 2035 men aged over 50 years with 2142 fractures to clarify the epidemiology of these injuries and their underlying risk factors. The prevalence of osteoporosis ranged between 17.5% in fractures of the ankle and 57.8% in those of the hip. The main risk factors associated with osteoporosis were smoking (47.4%), alcohol excess (36.2%), body mass index < 21 (12.8%) and a family history of osteoporosis (8.4%). Immobility, smoking, self-reported alcohol excess, a low body mass index, age >/=72 and loss in height were significantly more common among men with fractures of the hip than in those with fractures elsewhere.

Clinical risk factors for fracture in postmenopausal osteoporotic women: a review of the recent literature

OBJECTIVE

To review recent literature regarding relationships among age, weight or body mass index (BMI), bone mineral density (BMD), maternal history of fracture, or personal prior history of fracture and fragility fractures in women with postmenopausal osteoporosis (PMO).

DATA SOURCES

A MEDLINE database search (1995-June 30, 2007) was conducted to identify literature related to risk factors of interest for PMO-related fractures.

STUDY SELECTION AND DATA EXTRACTION

Cohort studies, case-control studies, and meta-analyses that reported fracture outcomes were included if they provided an estimate of relative risk for at least 1 of the 5 selected clinical risk factors (CRFs) and studied women with PMO or stratified risk estimates by age and sex. Of 313 identified studies that evaluated fractures as an endpoint, 245 did not report risk estimates for a CRF of interest and/or did not report data for a PMO population.

DATA SYNTHESIS

In the 68 included articles, the risks associated with the evaluated CRFs were high and significant. Prior fracture was a strong predictor of fracture and increased risk up to 18 times. Each standard deviation below the referent mean for BMD was associated with an increased fracture risk of up to 4.0 times; maternal fracture history increased risk 1.3-2.9 times. Age (per 5 year increment) increased risk by 1.2-5.0 times; low weight or BMI inconsistently showed a 0.5-3.0 times greater risk.

CONCLUSIONS

Low BMD is widely used as a diagnostic indicator for osteoporosis; however, other CRFs play an important role in determining fracture risk among women with PMO.

[Prevalence of vertebral fractures in hip fracture patients]

BACKGROUND

Fractures are the clinical complication of osteoporosis. There are no previous studies that describe the prevalence of vertebral fractures (VF) in patients admitted into a hospital due to a hip fracture (HF).

OBJECTIVE

To study the prevalence of vertebral fractures in elderly women in the moment of their admission to the hospital due to a hip fracture.

METHOD

This is a cooperative, multicentric, case-control study, performed in 21 different hospitals of Spain by the Working Group on Osteoporosis of the Spanish Society of Internal Medicine. A total of 143 elderly women with hip fractures comprised the case group. The control group consists of 138 elderly women admitted into other wards of the hospital due to other diseases with no relationship with osteoporosis. A questionnaire was administered and a lateral thoracic and lumbar X-ray was performed to assess vertebral fractures applying Genant's criteria.

RESULTS

The mean age of the patients with HF was 79.8 +/- 6.9 years and the mean age of the controls was 77.7 +/- 8.9 years. Patients suffering from HF had less weight than controls (BMI: 25.9 +/- 4.4 g/m2 vs 27.7 +/- 5.2 kg/m2, p = 0.002). Prevalence of VF was 62.6% in patients with HF, and 50% in controls (p = 0.039).

CONCLUSIONS

Elderly women admitted to a hospital due to hip fracture have a very high prevalence of previously undiagnosed VF. Indeed, elderly women admitted into the hospital because of other diseases also have a high prevalence of VF. These facts must be taken into account due to the morbidity and mortality of VF, that increases the HF morbidity and mortality.

Relationship between arm span and height in postmenopausal osteoporotic women

Osteoporosis is a progressive systemic skeletal disease characterized by low bone density and microarchitectural deterioration of the bone. A minimum 3-cm difference between arm span and height makes up one of the criteria for suspecting osteoporosis. Therefore, it is easy to determine osteoporotic women by measuring the proportion of height to the arm span. The purposes of this study are to assess the relationship between arm span and height and to compare them in postmenopausal and young healthy women. This was a randomized-controlled, prospective study. There were two groups in this study. Group I included 70 postmenopausal osteoporotic women and group II had 70 healthy young women. Height, weight and arm span of the individuals were measured in all subjects. Bone mineral density and radiological examination of spine were also evaluated. Mean age of postmenopausal women was 64.4 +/- 8.6 years and it was 27.3 +/- 3.5 years in young healthy women. Mean height was 152 +/- 5.1 and 161.5 +/- 5.9 cm in group I and II, respectively. Mean arm span length was 159.6 +/- 6.3 cm in postmenopausal women and 163.5 +/- 6 cm in young healthy women. Mean arm span-height difference was significantly higher in postmenopausal women when compared to healthy young women (7.7 +/- 3.6 and 2 +/- 2.9 cm, respectively, P < 0.001). We suggest that arm span measurements can be used in the estimation of youth height and age-related loss in stature in postmenopausal women.

Validation of a 4-item score predicting hip fracture and mortality risk among elderly women

PURPOSE

One in 4 Swedish women experiences a hip fracture, an event that has high concomitant morbidity and mortality. We developed and validated a clinical predictor of fracture and mortality risk, the Fracture and Mortality (FRAMO) Index.

METHODS

This was a population-based prospective cohort study with a baseline questionnaire and 2-year outcomes of hip fracture, fragility fracture, and death. The questionnaire was sent to 1,498 women aged 70 years or older in 3 rural populations, asking them about their age, weight, height, mobility, previous fractures, smoking, medication use, and housing. Some women were also asked about previous vertebral radiographs. We defined 2 risk models before outcome data collection and subsequently renamed 1 model (age =80 years, weight <60 kg, previous fragility fracture, and the need to use arms to rise from the sitting position) the FRAMO Index. We used logistic regression analysis to study the association between the FRAMO Index and outcomes in all participants.

RESULTS

The participation rate was 83% in this elderly female population (N = 1,248). The 63% of women with 0 to 1 risk factor had a 2-year hip fracture risk of 0.8% and mortality risk of 3.2%. In contrast, women with 2 to 4 risk factors had a 2-year hip fracture risk of 5.4% (odds ratio = 7.5; 95% confidence interval, 3.0-18.4) and mortality risk of 23.7% (odds ratio = 9.5; 95% confidence interval, 6.0-14.9). These differences remained significant after adjustment for age as a continuous variable. Mortality increased with the number of risk factors. The proportion of women reporting previous vertebral fractures was higher among the group specifically questioned about vertebral radiographs (P <.001).

CONCLUSIONS

The FRAMO Index identified the majority of women who experienced hip fractures during a 2-year follow-up, who might have been candidates for intensified preventive measures. The FRAMO Index, based on 4 binary risk factors, would be practical for routine use in primary care.

Hip fracture risk among community-dwelling elderly people in the United States: a prospective study of physical, cognitive, and socioeconomic indicators

OBJECTIVES

We determined risks of short-term (2-year) hip fracture in a nationally representative, prospective cohort of community-dwelling elderly people 70 years or older.

METHODS

We used self-report data from 2 waves of the Asset and Health Dynamics Survey (n = 5630). Sample-weighted logistic regression analyses were conducted to determine risk of hip fracture in relation to several demographic, cognitive, physical, and socioeconomic indicators.

RESULTS

During the 2-year study period, 102 participants reported a new hip fracture. Several indicators of physical functioning and cognitive status, including incorrect delayed word recall and inability to lift 10 lbs (4.5 kg), were significantly associated with hip fracture risk. In the final model, mobile home residents, individuals without Medicare part B insurance, and those without a high-school diploma were at more than a 2-fold risk of hip fracture. Educational level, physical functioning, and insurance status were the top 3 contributors to hip fracture risk.

CONCLUSIONS

In addition to functional status measures, health insurance status, educational level, and type of residence appear to be independent predictors of hip fracture.

Rehabilitation of the Older Adult with an Osteoporosis-Related Fracture

Osteoporosis is the most common metabolic bone disease and is clinically silent until it manifests in the form of fracture. When this occurs, significant deformity and disability can result. Appropriate rehabilitation of fracture includes antiosteoporotic medication; exercise programs; fall prevention; orthoses, such as bracing and hip protectors; and the minimally invasive procedures vertebroplasty and kyphoplasty.

Rib fractures predict incident limb fractures: results from the European prospective osteoporosis study

Population studies suggest that rib fractures are associated with a reduction in bone mass. While much is known about the predictive risk of hip, spine and distal forearm fracture on the risk of future fracture, little is known about the impact of rib fracture. The aim of this study was to determine whether a recalled history of rib fracture was associated with an increased risk of future limb fracture. Men and women aged 50 years and over were recruited from population registers in 31 European centres for participation in a screening survey of osteoporosis (European Prospective Osteoporosis Study). Subjects were invited to complete an interviewer-administered questionnaire that included questions about previous fractures including rib fracture, the age of their first fracture and also the level of trauma. Lateral spine radiographs were performed and the presence of vertebral deformity was determined morphometrically. Following the baseline survey, subjects were followed prospectively by annual postal questionnaire to determine the occurrence of clinical fractures. The subjects included 6,344 men, with a mean age of 64.2 years, and 6,788 women, with a mean age of 63.6 years, who were followed for a median of 3 years (range 0.4-5.9 years), of whom 135 men (2.3%) and 101 women (1.6%) reported a previous low trauma rib fracture. In total, 138 men and 391 women sustained a limb fracture during follow-up. In women, after age adjustment, those with a recalled history of low trauma rib fracture had an increased risk of sustaining 'any' limb fracture [relative hazard (RH)=2.3; 95% CI 1.3, 4.0]. When stratified by fracture type the predictive risk was more marked for hip (RH=7.7; 95% CI 2.3, 25.9) and humerus fracture (RH=4.5; 95% CI 1.4, 14.6) than other sites (RH=1.6; 95% CI 0.6, 4.3). Additional adjustment for prevalent vertebral deformity and previous (non-rib) low trauma fractures at other sites slightly reduced the strength of the association between rib fracture and subsequent limb fracture. In men, after age adjustment, there was a small though non-significant association between recalled history of rib fracture and future limb fracture. Our data highlight the importance of rib fracture as a marker of bone fragility in women.

The discriminative ability of peripheral and axial bone measurements to identify proximal femoral, vertebral, distal forearm and proximal humeral fractures: a case control study

Previous studies evaluating peripheral bone measurement devices have often used discontinued technologies, compared single devices, only evaluated a single fracture syndrome or failed to make a comparison with central densitometry, which is currently the gold standard for fracture discrimination. We have used a case control study to evaluate the ability of different peripheral and central bone techniques to discriminate between fracture cases and controls, determine the impact of different measurement sites, evaluate the role of measuring the cortical or trabecular envelopes using quantitative computed tomography (QCT) and determine the impact of using combinations of sites and techniques on fracture discrimination. We recruited postmenopausal women with proximal femoral (n=53), vertebral (n=73), distal forearm (n=78) or proximal humeral (n=75) fractures, and 500 population-based women (age 55-80 years). All subjects had measurements of the spine, total hip and distal forearm with dual-energy X-ray absorptiometry (DXA), distal forearm QCT and quantitative ultrasound (QUS) of the heel (four devices), finger (two devices), radius and metatarsal. The association of each device with fracture was expressed as the age-adjusted standardized odds ratios (sOR) per 1-SD decrease of population variance. The association of bone measurements with fracture was site-specific. We found the hip (sOR up to 3.40) and vertebral (sOR up to 4.67) fractures were more closely associated with central bone measurements than upper limb fractures (sOR 1.96 and 2.05). The performance of heel broadband ultrasound attenuation (sOR 2.09-2.41), heel speed of sound (sOR 1.79-2.28) and peripheral BMD (sOR 2.07 and 2.24) was comparable with total hip (sOR 2.46) and lumbar spine DXA (sOR 2.31) in discriminating all types of osteoporotic fracture. In general, measuring cortical or trabecular envelopes did not increase sOR. However, combining different measurement sites or technologies provided additional information, which was independent of total hip BMD. The ability of different bone measurements to discriminate between fracture cases and controls is device- and site-specific, with additional information obtained by combining measurement sites and technologies.

Osteoporotic fractures of the proximal humerus, pelvis, and ankle: epidemiology and diagnosis

Although fractures involving the wrist, spine, and proximal femur are known to be strongly associated with osteoporosis, the underlying bone insufficiency often receives insufficient diagnostic and therapeutic attention. Osteoporosis also increases the risk of fractures at other sites. Low-energy fractures in patients older than 50 years should lead to investigations for osteoporosis, the only exceptions being fractures of the skull, cervical spine, fingers, and toes. The incidence rates of fractures of the proximal humerus, pelvis, and ankle are climbing relentlessly. Whereas fractures of the proximal humerus and pelvis are undoubtedly related to osteoporosis, the link is less well established for fractures of the ankle. Mortality and morbidity rates associated with pelvic fractures are similar to those seen with fractures of the proximal femur, in keeping with the fact that both fractures occur in elderly individuals.

Improving osteoporosis management in patients with fractures

A history of fracture is an independent risk factor for future fractures, but patients who have sustained a fracture are rarely evaluated for osteoporosis (OP). The objective of this study was to determine if a simple intervention in a general orthopedic clinic would lead to more fracture patients receiving evaluation and treatment for OP. Patients with a history of fracture visiting a weekly orthopedic clinic during a 6-month intervention period were educated about OP, and a bone mineral density (BMD) test was offered. The number of BMD tests performed and other OP-specific actions taken as a result of the intervention were compared with a 6-month pre-intervention period. The prevalence of OP in those who underwent BMD testing was examined. In the pre-intervention period, only 12.7% (16 of 126) had a BMD test as compared with 62.5% of the 136 intervention-period subjects (odds ratio [OR] 11.5, 95% confidence interval [CI] 6.1, 21.4). Based on BMD test results, 11.9% of the pre-intervention patients, and 41.9% of the intervention patients received OP-specific recommendations (OR 5.3, 95% CI 2.8, 10.1). The intervention led to more patients being treated for low bone mass (9.5% vs 23.5%); OR 2.9, 95% CI 1.4, 5.9. Low bone mass was common among all types of fracture patients: 20% had osteoporosis and 41%, osteopenia. BMD testing in patients with fractures should identify those at risk for future fractures, leading to appropriate treatment.

Alcohol intake as a risk factor for fracture

High intakes of alcohol have adverse effects on skeletal health, but evidence for the effects of moderate consumption are less secure. The aim of this study was to quantify this risk on an international basis and explore the relationship of this risk with age, sex, and bone mineral density (BMD). We studied 5,939 men and 11,032 women from three prospectively studied cohorts comprising CaMos, DOES, and the Rotterdam Study. Cohorts were followed for a total of 75,433 person-years. The effect of reported alcohol intake on the risk of any fracture, any osteoporotic fracture, and hip fracture alone was examined using a Poisson model for each sex from each cohort. Covariates examined included age and BMD. The results of the different studies were merged using weighted beta-coefficients. Alcohol intake was associated with a significant increase in osteoporotic and hip fracture risk, but the effect was nonlinear. No significant increase in risk was observed at intakes of 2 units or less daily. Above this threshold, alcohol intake was associated with an increased risk of any fracture (risk ratio [RR] = 1.23; 95% CI, 1.06-1.43), any osteoporotic fracture (RR = 1.38; 95% CI, 1.16-1.65), or hip fracture (RR = 1.68; 95% CI, 1.19-2.36). There was no significant interaction with age, BMD, or time since baseline assessment. Risk ratios were moderately but not significantly higher in men than in women, and there was no evidence for a different threshold for effect by gender. We conclude that reported intake of alcohol confers a risk of some importance beyond that explained by BMD. The validation of this risk factor on an international basis permits its use in case-finding strategies.

Bone mineral density measurement and osteoporosis treatment after a fragility fracture in older adults: regional variation and determinants of use in Quebec

Background

Osteoporosis (OP) is a skeletal disorder characterized by reduced bone strength and predisposition to increased risk of fracture, with consequent increased risk of morbidity and mortality. It is therefore an important public health problem. International and Canadian associations have issued clinical guidelines for the diagnosis and treatment of OP. In this study, we identified potential predictors of bone mineral density (BMD) testing and OP treatment, which include place of residence.

Methods

Our study was a retrospective population-based cohort study using data from the Quebec Health Insurance Board. The studied population consisted of all individuals 65 years and older for whom a physician claimed a consultation for a low velocity vertebral, hip, wrist, or humerus fracture in 1999 and 2000. Individuals were considered to have undergone BMD testing if there was a claim for such a procedure within two years following a fracture. They were considered to have received an OP treatment if there was at least one claim to Quebec's health insurance plan (RAMQ) for OP treatment within one year following a fracture. We performed descriptive analyses and logistic regressions by gender. Predictors included age, site of fracture, social status, comorbidity index, prior BMD testing, prior OP treatment, long-term glucocorticoid use, and physical distance to BMD device.

Results

The cohort, 77% of which was female, consisted of 25,852 individuals with fragility fractures. BMD testing and OP treatment rates were low and gender dependent (BMD: men 4.6%; women 13.1%; OP treatment: men 9.9%; women 29.7%). There was an obvious regional variation, particularly in BMD testing, ranging from 0 to 16%. Logistic regressions demonstrate that individuals living in long term care facilities received less BMD testing. Patients who had suffered from vertebral fractures, or who had received prior OP treatment or BMD testing, regardless of gender, subsequently received more BMD testing and OP treatments. Furthermore, increasing the distance between a patient's residence and BMD facility precluded likelihood of BMD testing.

Conclusion

BMD testing rate was extremely low but not completely explained by reduced physical access; gender, age, social status, prior BMD testing and OP treatment were all important predictors for future BMD testing and OP treatment.