Abstract
ABSTRACTConflicting results exist about the relationship between bariatric surgery and fracture risk. Also, prediction of who is at increased risk of fracture after bariatric surgery is not currently available. Hence, we used a combination of a self‐controlled case series (SCCS) study to establish the association between bariatric surgery and fracture, and develop a prediction model for postoperative fracture risk estimation using a cohort study. Patients from UK Primary care records from the Clinical Practice Research Datalink GOLD linked to Hospital Episode Statistics undergoing bariatric surgery with body mass index (BMI) ≥30 kg/m2 between 1997 and 2018 were included in the cohort. Those sustaining one or more fractures in the 5 years before or after surgery were included in the SCCS. Fractures were considered in three categories: (i) any except skull and digits (primary outcome); (ii) major (hip, vertebrae, wrist/forearm, and humerus); and (iii) peripheral (forearm and lower leg). Of 5487 participants, 252 (4.6%) experienced 272 fractures (of which 80 were major and 135 peripheral) and were included in the SCCS analyses. Major fracture risk increased after surgery, incidence rate ratios (IRRs) and 95% confidence intervals (CIs): 2.77 (95% CI, 1.34–5.75) and 3.78 (95% CI, 1.42–10.08) at ≤3 years and 3.1 to 5 years postsurgery when compared to 5 years prior to surgery, respectively. Any fracture risk was higher only in the 2.1 to 5 years following surgery (IRR 1.73; 95% CI, 1.08–2.77) when compared to 5 years prior to surgery. No excess risk of peripheral fracture after surgery was identified. A prediction tool for major fracture was developed using 5487 participants included in the cohort study. It was also internally validated (area under the receiver‐operating characteristic curve [AUC ROC] 0.70) with use of anxiolytics/sedatives/hypnotics and female as major predictors. Hence, major fractures are nearly threefold more likely after bariatric surgery. A simple prediction tool with five variables identifies high risk patients for major fracture. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Highlights
Bariatric surgery has been proven to be a highly effective treatment for severe obesity with improvements in relevant clinical endpoints, such as a reduction in cardiovascular events and cardiovascular death.[1]
Of 16,493 patients identified with a code for bariatric surgery, 5487 patients were deemed suitable for study inclusion
Note: 3546 patients were excluded because their surgery occurred after they had left their Clinical Practice Research Datalink (CPRD) practice or their practice had stopped providing data to CPRD no information is available about the patients covariates or outcome
Summary
Bariatric surgery has been proven to be a highly effective treatment for severe obesity with improvements in relevant clinical endpoints, such as a reduction in cardiovascular events and cardiovascular death.[1]. The current NICE-recommended fracture prediction tools[8] are unlikely to be valid for the identification of patients undergoing bariatric surgery who might need further monitoring/testing (e.g., bone mineral density scans or serum measurement/s of vitamin D levels). Both the Fracture Risk Assessment Tool (FRAX)(9) and QFracture[10] tools assume a protective effect of obesity on fracture risk, demonstrating the need for a bespoke fracture prediction tool for the identification of patients undergoing bariatric surgery at need of further evaluation and/or treatment of their bone health postoperatively. We set out to identify key determinants of postoperative fracture risk, and to combine them to derive a prediction tool for the identification of patients at high risk of such fractures
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