Osteoporosis Diagnosis, Management, and Referral Practice After Fragility Fractures

Biomechanical Study of Porcine Osteoporotic Vertebral Compression Fracture Model Strengthened by Trajectory-Adjustable Bone Cement Filling Device

OBJECTIVE

To establish a porcine osteoporotic vertebral compression fracture model and compare the impact of unilateral vertebroplasty using trajectory-adjustable bone cement filling device to traditional surgical tools on vertebral biomechanics.

METHODS

Twenty-four fresh adult porcine vertebrae were used to establish an osteoporotic vertebral compression fracture model. The specimens were divided into 4 groups (A, B, C, and D), each consisting of 6 vertebrae. Group A served as the control group without vertebral augmentation (percutaneous vertebroplasty [PVP]). Patients in Group B underwent unilateral PVP using conventional surgical tools, while patients in Group C underwent bilateral PVP using the same tools. In Group D, patients underwent unilateral PVP with a trajectory-adjustable bone cement filling device. Postoperative X-ray examinations were performed to assess cement distribution and leakage. The compressive stiffness and strength of each spinal unit were evaluated using an electronic mechanical testing machine.

RESULTS

In Groups B, C, and D, the percentages of total cement distribution area were 32.83 ± 3.64%, 45.73 ± 2.27%, and 47.43 ± 3.51%, respectively. The values were significantly greater in Groups C and D than in Group B (P < 0.05), but there was no significant difference between Groups C and D (P > 0.05). The stiffness after vertebral augmentation in Groups B, C, and D was 1.04 ± 0.23 kN/mm, 1.11 ± 0.16 KN/mm, and 1.15 ± 0.13 KN/mm, respectively, which were significantly greater than that in Group A (0.46 ± 0.06 kN/mm; P < 0.05). The ultimate compressive strengths in Groups B, C, and D were 2.53 ± 0.21 MPa, 4.09 ± 0.30 MPa, and 3.99 ± 0.29 MPa, respectively, all surpassing Group A's strength of 1.41 ± 0.31 MPa. Additionally, both Groups C and D demonstrated significantly greater ultimate compressive strengths than Group B did (P < 0.05).

CONCLUSIONS

A trajectory-adjustable bone cement filling device was proven to be an effective approach for unilateral vertebroplasty, restoring the biomechanical properties of fractured vertebrae. Compared to traditional surgical tools, this approach is superior to unilateral puncture and yields outcomes comparable to those of bilateral puncture. Additionally, the device ensures a centrally symmetrical distribution pattern of bone cement, leading to improved morphology.

Low screening rates and high prevalence of osteoporosis in cirrhosis: A real-world retrospective analysis

BACKGROUND

Patients with cirrhosis are at increased risk for osteoporosis, and those who suffer a fracture are at high risk for mortality. Despite this, osteoporosis is often overlooked and undertreated. This study aimed to evaluate osteoporosis screening, management, and adverse osteoporosis medication events in patients with cirrhosis.

METHODS

We performed a retrospective chart review of adult outpatients with compensated and decompensated cirrhosis seen in single health system over a 6-year period. Patient demographics, liver and bone health comorbidities, DEXA scan results, and medications were abstracted.

RESULTS

In total, 5398 patients met criteria. The cohort was predominately white (79.1%) and older (age 59). 44.4% were female. 64.6% had decompensated cirrhosis. Median MELD-Na score was 12.8. 23.5% had a DEXA scan ordered, approximately 50% completed this test. Patients who were older, female, white, with more severe liver disease, and other osteoporosis risk factors were more likely to have a DEXA scan ordered. 48.5% of patients had osteopenia and 30.2% had osteoporosis on DEXA scan. Only 22.6% of patients with osteoporosis received treatment, most commonly oral bisphosphonates. Oral bisphosphonate prescription was not associated with variceal bleeding (8.4% without vs. 4.8% with, p = 0.487).

CONCLUSION

A minority of patients with cirrhosis were screened for osteoporosis. The majority screened had osteopenia or osteoporosis on DEXA scan. Less than a quarter of patients with osteoporosis were started on treatment. Real-world experience of oral bisphosphonate use did not reveal higher rates of gastrointestinal bleeding. There is room for improvement in all aspects of bone health care in cirrhosis.

Bone mineral density estimation from a plain X-ray image by learning decomposition into projections of bone-segmented computed tomography

Osteoporosis is a prevalent bone disease that causes fractures in fragile bones, leading to a decline in daily living activities. Dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) are highly accurate for diagnosing osteoporosis; however, these modalities require special equipment and scan protocols. To frequently monitor bone health, low-cost, low-dose, and ubiquitously available diagnostic methods are highly anticipated. In this study, we aim to perform bone mineral density (BMD) estimation from a plain X-ray image for opportunistic screening, which is potentially useful for early diagnosis. Existing methods have used multi-stage approaches consisting of extraction of the region of interest and simple regression to estimate BMD, which require a large amount of training data. Therefore, we propose an efficient method that learns decomposition into projections of bone-segmented QCT for BMD estimation under limited datasets. The proposed method achieved high accuracy in BMD estimation, where Pearson correlation coefficients of 0.880 and 0.920 were observed for DXA-measured BMD and QCT-measured BMD estimation tasks, respectively, and the root mean square of the coefficient of variation values were 3.27 to 3.79% for four measurements with different poses. Furthermore, we conducted extensive validation experiments, including multi-pose, uncalibrated-CT, and compression experiments toward actual application in routine clinical practice.

Micheliolide prevents estrogen deficiency-induced bone loss via inhibiting osteoclast bone resorption

Osteoporosis is one of the major health problems characterized by decreased bone density and increased risk of fractures. Nowadays, the treating strategies against osteoporosis are efficient, but still have some drawbacks. Micheliolide, a guaianolide sesquiterpene lactone isolated from Michelia compressa and Michelia champac, has been reported to have anti-inflammatory effects. Here, our data suggest that Micheliolide could protect mice from ovariectomy induced bone loss. According to the Micro-CT scan and histomorphometry quantification data, Micheliolide treatment inhibits excessive osteoclast bone resorption without affecting bone formation in estrogen deficiency mice. Consistently, our data suggest that Micheliolide could inhibit osteoclastogenesis in vitro. Additionally, we confirmed that Micheliolide inhibits osteoclasts formation via inhibiting P38 MAPK signaling pathway, and P79350 (a P38 agonist) could rescue this effect. In summary, our data suggest that Micheliolide could ameliorate estrogen deficiency-induced bone loss via attenuating osteoclastogenesis. Hence, Micheliolide could be used as a novel anti-resorptive agent against osteoporosis.

Bone mineral density and its influential factors in Chinese patients with newly diagnosed Crohn's disease

OBJECTIVES

Bone loss is a common morbidity in patients with inflammatory bowel disease (IBD). Bone mineral density (BMD) measurement is recommended for IBD patients at a high risk of osteoporosis. However, there is a lack of evidence in the need of BMD measurement in patients who are young at the first disease onset. In this study we aimed to investigate the prevalence of low BMD in patients with newly diagnosed Crohn's disease (CD) at 20-50 years of age and the potential risk factors.

METHODS

A single-center, retrospective cross-sectional study was conducted. Medical records of the patients were reviewed and their demographics, clinical characteristics and laboratory test results were collected. Dual energy X-ray absorptiometry (DEXA) scan was performed for BMD measurements; low BMD was defined as Z-score or T-score <-1.0 standard deviation (SD). Univariate and multivariate logistic regression analyses were used to determine the risk factors for low BMD.

RESULTS

A total of 221 patients with CD were included; osteopenia and osteoporosis were identified in 23.1% and 8.6%, and 39.4% and 7.2% of the patients using Z-score and T-score, respectively. Female gender and a higher BMI at diagnosis were protective factors for low BMD.

CONCLUSIONS

Low BMD is common in patients with newly diagnosed CD aged 20-50 years. Female gender and a higher BMI at diagnosis might protect CD patients from bone loss. Therefore, BMD measurement and early intervention with calcium and vitamin D are recommended for these patients.

Advanced applications of strontium-containing biomaterials in bone tissue engineering

Strontium (Sr) and strontium ranelate (SR) are commonly used therapeutic drugs for patients suffering from osteoporosis. Researches have showed that Sr can significantly improve the biological activity and physicochemical properties of materials in vitro and in vivo. Therefore, a large number of strontium containing biomaterials have been developed for repairing bone defects and promoting osseointegration. In this review, we provide a comprehensive overview of Sr-containing biomaterials along with the current state of their clinical use. For this purpose, the different types of biomaterials including calcium phosphate, bioactive glass, and polymers are discussed and provided future outlook on the fabrication of the next-generation multifunctional and smart biomaterials.

The genetically predicted causal relationship of inflammatory bowel disease with bone mineral density and osteoporosis: evidence from two-sample Mendelian randomization

Background

Many existing studies indicated that patients with inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), tend to have the risk of low total body bone mineral density (BMD), and are more likely to have osteoporosis (OS). To determine the causal relationship between IBD and bone metabolic disorders, we herein performed a two-sample Mendelian randomization analysis (TSMR) using publicly available summary statistics.

Methods

Summary statistics of total body BMD, OS and IBD were downloaded from the Open Genome-Wide Association Study (GWAS), FinnGen consortium and International Inflammatory Bowel Disease Genetics Consortium (IIBDGC). The European and East Asian populations have consisted in this Mendelian Randomization (MR) work. A range of quality control procedures were taken to select eligible instrument SNPs closely associated with total body BMD, OS and IBD. To make the conclusions more reliable, we applied five robust analytical methods, among which the inverse variance weighting (IVW) method acted as the major method. Besides, heterogeneity, pleiotropy and sensitivity were evaluated.

Results

In the European population, the genetic association of UC on total body BMD (OR=0.97, 95%CI=0.96,0.99, P<0.001) and overall IBD on total body BMD (OR=0.98, 95%CI=0.97,1.00, P=0.013) were significant, while the effect of CD on total body BMD was not significant enough (OR=0.99, 95%CI=0.98,1.00, P=0.085). All of UC, CD and overall IBD can be the genetic risk factor of having OS with pathological fracture (UC: OR=1.13, 95%CI=1.02,1.26, P=0.024, CD: OR=1.14, 95%CI=1.05,1.25, P=0.003, overall IBD: OR=1.13, 95%CI=1.02,1.24, P=0.015). In East Asian groups, only CD had a causal relationship with OS (OR=1.04, 95% CI=1.01,1.07, P=0.019).

Conclusion

Our study revealed genetically predicted associations between IBD on total body BMD and OS in European and East Asian populations. This work supplemented the results of previous retrospective studies and demonstrated the necessity of BMD monitoring in patients with IBD.

Exercise to Prevent and Manage Frailty and Fragility Fractures

PURPOSE OF REVIEW

This review identifies exercise-based recommendations to prevent and manage frailty and fragility fractures from current clinical practice guidelines. We also critically assess recently published literature in relation to exercise interventions to mitigate frailty and fragility fractures.

RECENT FINDINGS

Most guidelines presented similar recommendations that included the prescription of individually tailored, multicomponent exercise programs, discouragement of prolonged sitting and inactivity, and combining exercise with optimal nutrition. To target frailty, guidelines recommend supervised progressive resistance training (PRT). For osteoporosis and fragility fractures, exercise should include weight-bearing impact activities and PRT to target bone mineral density (BMD) at the hip and spine, and also incorporate balance and mobility training, posture exercises, and functional exercise relevant to activities of daily living to reduce falls risk. Walking as a singular intervention has limited benefits for frailty and fragility fracture prevention and management. Current evidence-based clinical practice guidelines for frailty, osteoporosis, and fracture prevention recommend a multifaceted and targeted approach to optimise muscle mass, strength, power, and functional mobility as well as BMD.

Innovative minimally invasive implants for osteoporosis vertebral compression fractures

With increasing population aging, osteoporosis vertebral compression fractures (OVCFs), resulting in severe back pain and functional impairment, have become progressively common. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) as minimally invasive procedures have revolutionized OVCFs treatment. However, PVP- and PKP-related complications, such as symptomatic cement leakage and adjacent vertebral fractures, continue to plague physicians. Consequently, progressively more implants for OVCFs have been developed recently to overcome the shortcomings of traditional procedures. Therefore, we conducted a literature review on several new implants for OVCFs, including StaXx FX, Vertebral Body Stenting, Vesselplasty, Sky Bone Expander, Kiva, Spine Jack, Osseofix, Optimesh, Jack, and V-strut. Additionally, this review highlights the individualized applications of these implants for OVCFs. Nevertheless, current clinical studies on these innovative implants remain limited. Future prospective, randomized, and controlled studies are needed to elucidate the effectiveness and indications of these new implants for OVCFs.

Sarcopenic obesity predicts negative health outcomes among older patients with type 2 diabetes: The Ageing and Body Composition of Diabetes (ABCD) cohort study

BACKGROUND AND AIMS

The definition of and diagnostic criteria for sarcopenic obesity (SO) remain unclear, hindering the assessment of its prevalence as well as its clinical relevance to negative health outcomes, especially in diabetic patients, who are more prone to body composition changes. The aim of this study was to investigate the prevalence of SO and its impact on negative health outcomes among elderly patients with type 2 diabetes (T2DM) from the Ageing and Body Composition of Diabetes (ABCD) cohort.

METHODS

This retrospective cohort study included 386 elderly patients with T2DM (177 males and 209 females, mean age of 67.91 ± 6.10 years). SO was defined as the coexistence of sarcopenia defined by the 2019 Asian Working Group for Sarcopenia up-to-date consensus and obesity identified by five alternative measurements as follows: body mass index (BMI)≥28 kg/m² (BMI28), BMI≥25 kg/m² (BMI25), body fat percentage (BF%)≥25% for men or 35% for women, visceral fat area (VFA)≥100 cm², or android fat mass (AF) higher than the sex-specific median. The primary endpoint was all-cause death or fragility fracture, and the secondary endpoint was a composite of cardiovascular diseases (CVDs). Cox proportional hazards regression analysis was used to estimate the association between SO and negative health outcomes.

RESULTS

The prevalence of SO was 0.2% (BMI28), 2.5% (BMI25), 9.8% (AF), and 18.7% (BF% or VFA) among elderly patients with T2DM, according to the different obesity surrogate markers. During a mean follow-up period of 3.46 ± 1.15 years, 50 patients reached the primary endpoint, and 33 patients had incident CVD. SO classified using BF% was significantly associated with the primary endpoint [hazard ratio (HR) = 2.94, 95% CI = 1.25-6.92] and incident CVD (HR = 6.02, 95% CI = 1.56-23.15), even after comprehensive adjustment for bone-, comorbidity-, and diabetes-specific confounding variables. When SO was classified using BMI25, VFA and AF, similar results were found for adverse outcomes. However, SO classified using BMI25 resulted in misclassification of SO for 61 participants, 19 of whom experienced adverse events during follow-up, and SO classified using VFA or AF was not significantly associated with incident CVD.

CONCLUSIONS

SO is not uncommon in geriatric patients with T2DM, and its prevalence varies widely depending on the diverse surrogate indices of body fat excess. Furthermore, SO may be a better independent risk factor for negative health outcomes when classified using BF%.

Living alone decreased calcaneus ultrasound T-score in a large Taiwanese population follow-up study

Background

Osteoporosis is associated with many serious health conditions that have a severely negative impact on quality of life, as well as higher rates of morbidity and mortality. Due to the aging society and low birth rate in Taiwan, an increasing number of people are living alone. This longitudinal study was aimed to assess the relationship between living alone and calcaneus ultrasound T-score in a large cohort in Taiwan.

Methods

A total of 118,853 participants enrolled in the Taiwan Biobank since 2008 to 2016, who had complete calcaneus ultrasound examinations were collected in the baseline study. Of these participants, 26,850 received complete follow-up measurements after a median of 4 years. The T-score (g/cm²) of the calcaneus in the non-dominant foot was measured using ultrasound. Changes in the calcaneus ultrasound T-score (ΔT-score) were calculated as follow-up T-score minus baseline T-score. We analyzed these data in 2022. We used multivariable linear regression analysis to investigate correlation between living alone with baseline T-score and ΔT-score. We also carried out separate analyses for men and women.

Results

The mean age of the participants was 49.89 ± 10.95 years, and multivariable analysis showed that living alone was significantly correlated to low baseline T-score in whole cohort (β = -0.040; p = 0.012) and women (β = -0.055; p = 0.023). Furthermore, living alone (coefficient β = -0.049; p = 0.048) was significantly correlated to a low ΔT-score after 4 years of follow-up.

Conclusion

In this large population-based longitudinal study, living alone may be related to low baseline calcaneus ultrasound T-score and ΔT-score. Adopting long-term community-based care policies to increase the activity of people living alone may help to prevent osteoporosis and decrease the risk of fractures in Taiwan.

The Anion Gap and Mortality in Critically Ill Patients with Hip Fractures

Objectives

Epidemiological evidence suggests that anion gap (AG) has been reported to serve as an independent predictor for mortality in different diseases. We studied the effect of AG on both short and long-term mortalities in critically ill patients with hip fracture.

Methods

A large clinical database was utilized to perform retrospective cohort analysis. AG was subdivided into three groups. The Cox proportional hazards regression model was employed to approximate the hazard ratio (HR) with a confidence interval (CI) of 95% for the link between AG and mortality. 30-day mortality is the primary outcome, while 90-day and 1-year mortalities represented our secondary outcomes for this study.

Results

The participants in this study were that who provided essential data on AG and the number of patients with hip fractures was 395, and they were all aged ≥16 years. The participants comprised 199 (50.4%) females as well as 196 (49.6%) males with an average age of 71.9 ± 19.4 years, and a mean AG of 12.4 ± 3.3 gmEq/L. According to an unadjusted model for 30-day all-cause mortality, the HR (95% CI) of AG ≥ 12.5 gmEq/L was 1.82 (1.11, 2.99), correspondingly, compared to the reference group (AG < 12.5 gmEq/L). This correlation was still remarkable after adjustment for r age, sex, race, SBP, DBP, WBC, heart failure, and serum chloride (HR = 1.70, 95% CI: 1.02–2.02; 2.82). For 90-day all-cause mortality, a similar correlation was observed.

Conclusions

We noted that AG was an independent indicator of both short and long-term mortalities among hip fractures individuals in this retrospective single-center cohort study. AG is a simple, readily available, and inexpensive laboratory variable that can serve as a possible risk stratification tool for hip fracture.