Future Fracture Risk Research Articles

Oral Contraceptive Use and Bone Density Change in Adolescent and Young Adult Women: A Prospective Study of Age, Hormone Dose, and Discontinuation

Oral contraceptive (OC) use is common, but bone changes associated with use of contemporary OC remain unclear. The objective of the study was to compare bone mineral density (BMD) change in adolescent and young adult OC users and discontinuers of two estrogen doses, relative to nonusers. This was a prospective cohort study, Group Health Cooperative. Participants included 606 women aged 14-30 yr (50% adolescents aged 14-18 yr): 389 OC users [62% 30-35 μg ethinyl estradiol (EE)] and 217 age-similar nonusers; there were 172 OC discontinuers. The 24-month retention was 78%. The main outcome measure was BMD measured at 6-month intervals for 24-36 months. After 24 months, adolescents using 30-35 μg EE OCs, but not those using lower-dose OCs, had significantly smaller adjusted mean percentage BMD gains than nonusers at the spine [group means (95% confidence interval for between group differences) 1.32 vs. 2.26% (-1.89, -0.13%)] and whole body [1.45 vs. 2.03% (-1.29%, -0.13%)]. Adolescents who discontinued 30-35 μg EE OC showed significantly smaller gains than nonusers at the spine after 12 months [0.51 vs. 1.72% (-2.38%, -0.30%)]. Young adult OC users did not differ from nonusers. However, OC discontinuers of both doses differed significantly from nonusers at the spine 12 months after discontinuation [-1.32% < 30 μg EE, -0.92% 30-35 μg EE vs. +0.27% nonusers (-2.48, -0.54, and -1.94%, -0.55%, respectively)]. Results were similar for mean absolute BMD change (grams per square centimeter). Both OC use and discontinuation were associated with BMD losses/smaller gains relative to nonusers (differences < 2% after 12-24 months for all skeletal sites). The clinical significance of these results regarding future fracture risk is unknown. Study of longer-term trends after discontinuation is needed.

A prospective study of mandibular trabecular bone to predict fracture incidence in women: A low-cost screening tool in the dental clinic

Bone structure is the key to the understanding of fracture risk. The hypothesis tested in this prospective study is that dense mandibular trabeculation predicts low fracture risk, whereas sparse trabeculation is predictive of high fracture risk. Out of 731 women from the Prospective Population Study of Women in Gothenburg with dental examinations at baseline 1968, 222 had their first fracture in the follow-up period until 2006. Mandibular trabeculation was defined as dense, mixed dense plus sparse, and sparse based on panoramic radiographs from 1968 and/or 1980. Time to fracture was ascertained and used as the dependent variable in three Cox proportional hazards regression analyses. The first analysis covered 12 years of follow-up with self-reported endpoints; the second covered 26 years of follow-up with hospital verified endpoints; and the third combined the two follow-up periods, totaling 38 years. Mandibular trabeculation was the main independent variable predicting incident fractures, with age, physical activity, alcohol consumption and body mass index as covariates. The Kaplan-Meier curve indicated a graded association between trabecular density and fracture risk. During the whole period covered, the hazard ratio of future fracture for sparse trabeculation compared to mixed trabeculation was 2.9 (95% CI: 2.2-3.8, p<0.0001), and for dense versus mixed trabeculation was 0.21 (95% CI: 0.1-0.4, p<0.0001). The trabecular pattern was a highly significant predictor of future fracture risk. Our findings imply that dentists, using ordinary dental radiographs, can identify women at high risk for future fractures at 38-54 years of age, often long before the first fracture occurs.

Official Positions for FRAX ® Clinical Regarding Prior Fractures : From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX ®

The 2010 Position Development Conference addressed four questions related to the impact of previous fractures on 10-year fracture risk as calculated by FRAX ®. • Does the number of past fractures affect future fracture risk? • Does the severity of past vertebral fractures affect future fracture risk? • Does the site of past fractures affect future fracture risk? • Should the family history of fracture be expanded to include additional sites, additional family members, or account for age at fracture? To address these questions, PubMed was searched on the keywords “fracture, epidemiology, osteoporosis.” Titles of retrieved articles were reviewed for an indication that risk for future fracture was discussed. Abstracts of these articles were reviewed for an indication that one or more of the questions listed above was discussed. For those that did, the articles were reviewed in greater detail to extract the findings and to find additional past work and citing works that also bore on the questions. The official positions and the supporting literature review are presented here. FRAX ® underestimates fracture probability in persons with a history of multiple fractures (good, A, W). FRAX ® may underestimate fracture probability in individuals with prevalent severe vertebral fractures (good, A, W). While there is evidence that hip, vertebral, and humeral fractures appear to confer greater risk of subsequent fracture than fractures at other sites, quantification of this incremental risk in FRAX ® is not possible (fair, B, W). FRAX ® may underestimate fracture probability in individuals with a parental history of non-hip fragility fracture (fair, B, W). Limitations of the methodology include performance by a single reviewer, preliminary review of the literature being confined to titles, and secondary review being limited to abstracts. Limitations of the evidence base include publication bias, overrepresentation of persons of European descent in the published studies, and technical differences in the methods used to identify prevalent and incident fractures. Emerging topics for future research include fracture epidemiology in non-European populations and men, the impact of fractures in family members other than parents, and the genetic contribution to fracture risk.

Clinical characteristics and incidence of first fracture in a consecutive sample of post-menopausal women attending osteoporosis centers: The PROTEO-1 study

Osteoporosis is a highly prevalent disease and fractures are a major cause of disability and morbidity. The purpose of this study was to characterize post-menopausal women attending osteoporosis centers in Italy, to evaluate physician management, and to determine the incidence of first osteoporotic fracture. PROTEO-1 was an observational longitudinal study with a 12-month follow-up. Data were collected from women attending osteoporosis centers. Women without prevalent fracture were eligible to enter the 1-yr follow-up phase: the clinical approach to patients according to their fracture risk profile and the incidence of fracture were recorded. 4269 patients were enrolled in 80 centers in the cross-sectional phase; 34.2% had an osteoporotic fracture at baseline. Patients with prevalent fractures were older and more likely to be treated compared with non-fractured patients. The incidence of vertebral or hip fracture after 1 yr was 3.84%, regardless of the calculated risk factor profile, and was significantly higher in patients with back pain at baseline (4.2%) compared with those without back pain (2.2%; p=0.023). Generally, physicians prescribed more blood exams and drugs to patients at higher risk of fracture. Among fractured patients only 24% were properly treated; the rate of non-responders to treatment was about 4%. In a large, unselected sample of post-menopausal women attending osteoporosis centers, those without previous fracture were at substantial risk of future fracture, regardless of their theoretical low 10-yr fracture risk. The presence of back pain in women without previous fracture warrants close attention.

Treatment of osteopenia.

The majority of osteoporotic fractures happen in individuals with BMD t-scores in the osteopenic range (−2, 5< t-score <−1). However, widespread use of anti-osteoporotic medication in this group based on t-score alone is not advisable because: 1) the number needed to treat is much higher (NNT > 100) than in patients with fractured and t-score below −2,5 (NNT 10–20); 2)while specific osteoporosis treatments have demonstrated significant reductions of the fracture risk in patients with t-score <−2, 5, the efficacy in patients in the osteopenic range is less well established. Therefore, an osteopenic t-score does not in itself constitute a treatment imperative. Generally, osteopenia has to be associated with either low energy fracture(s) or very high risk for future fracture as assessed with risk calculators like FRAX to warrant specific osteoporosis therapy. Vertebral fractures are now conveniently assessed using lateral x-rays from DXA machines. In the vast majority of cases antiresorptive treatments (mainly hormone replacement therapy and SERMS in younger and bisphosphonates or Denosumab in older women) are the treatments of choice in this group of patients,—only rarely is anabolic therapy indicated.

Minor, Major, Low-Trauma, and High-Trauma Fractures: What Are the Subsequent Fracture Risks and How Do They Vary?

Osteoporosis is a leading health problem worldwide due to the morbidity and mortality associated with fractures. However, a large number of fractures occur in persons without osteoporosis, when defined by bone mineral density alone. Numerous studies have shown that the risk of subsequent fracture is increased following fractures at most sites, and the increased risk is not limited to prior hip and vertebral fractures only. In addition, the amount of trauma present at the time of a fracture event appears to have limited impact on future fracture risk. Thus, even fractures that occur in the presence of high trauma should be recognized as evidence of possible bone fragility. Further methods to better identify persons at risk of future fracture are needed, such as through evaluation of other indicators of bone strength or recognition of modifiable, non-bone factors. Any initial fracture event is important for patients and caregivers to recognize as an implication for future fracture risk.

Imaging of Insufficiency Fractures

This review article focuses on occurrence, imaging, and differential diagnosis of insufficiency fractures. Prevalence and the most common sites of insufficiency fractures and their clinical implications are discussed. Insufficiency fractures are due to normal stress exerted on weakened bone. Most commonly postmenopausal osteoporosis is the cause for insufficiency fractures. Additional conditions affecting bone turnover include osteomalacia, chronic renal failure, and high-dose corticosteroid therapy. It is a challenge for the radiologist to detect and diagnose insufficiency fractures as well as to differentiate them from malignant fractures. Radiographs are the basic modality used for screening of insufficiency fractures, yet depending on the location of the fractures, sensitivity is limited. Magnetic resonance imaging is a very sensitive tool to visualize bone marrow abnormalities associated with insufficiency fractures and allows differentiation of benign versus malignant fractures. Thin section multidetector computed tomography (CT) depicts subtle fracture lines allowing direct visualization of cortical and trabecular bone. Dedicated Mikro-CTs (Xtreme-CT) can detect subtle fractures reaching an in-plane resolution of 80 μm. Bone scintigraphy still plays a role in detecting fractures, with good sensitivity but unsatisfactory specificity. Positron emission tomography-CT with hybrid-scanners has been the upcoming modality for the differentiation of benign from malignant fractures. Bone densitometry and clinical fracture history may determine the future risk of possible insufficiency fractures.

Vertebral fracture status and the World Health Organization risk factors for predicting osteoporotic fracture risk in Japan

Vertebral fractures are the most common osteoporotic fracture and the prevalence of vertebral fracture is commonly assessed in clinical practice in Japan. The objective of this study was to evaluate potential risk factors for osteoporotic fractures, including morphometric spine fracture status and the WHO risk factors for predicting 4-year fracture risk. A population-based community cohort, the Adult Health Study, consisting of 2613 men and women with mean age of 65 enrolled in Hiroshima was followed prospectively for 4 years. The prevalence and incidence of spine fractures were identified from lateral and posterior-anterior spine radiographs using a semiquantitative method. Information on incident nonvertebral fragility fractures (hip, proximal humeral, and forearm) was collected at interviews by trained nurses and physicians during biennial health examinations. A model, including spine fracture status in addition to the WHO risk factors, appeared to provide greater prognostic information regarding future fracture risk (gradient of risk/standard deviation: GR/SD=2.73) than a model with the WHO risk factors alone (GR/SD=2.54). In univariate analyses, age, bone mineral density (BMD), prior clinical fracture, and spine fracture status had the highest gradient of risk. The presence of multiple prevalent spine or non-spine fractures significantly increased fracture risk, but, their contributions to the gradient of risk were similar to those when fracture status was categorized as a binary variable. A model considering those four risk factors yielded GR/SD=2.67, indicating that it could capture most of the predictive information provided by the model with spine fracture status plus the WHO risk factors. The use of age, BMD, prior clinical fracture and spine fracture predicted future fracture risk with greater simplicity and higher prognostic accuracy than consideration of the risk factors included in the WHO tool.

Breaking the fragility fracture cycle

Fracture begets fracture. This phenomenon has been wellcharacterised in many prospective studies and summarised by meta-analyses [1, 2]; a prior fracture at least doubles a patient’s future fracture risk. Elevated fracture risk persists for up to 10 years after the initial fracture event [3] and is greatest during the first year after this [4]. Several studies have explored this phenomenon from the obverse view of fracture history in patients presenting to hospital with a hip fracture. In 1980, Gallagher and colleagues reported prior fracture history amongst patients presenting with hip fracture in Rochester, USA for the period 1965–1974 [5]. Sixty-eight percent of women and 59% of men had suffered at least one other fracture besides their hip fracture. More recent studies from the UK [6], USA [7] and Australia [8] have consistently reported that 45% or more of today’s hip fracture patients have a prior fracture history. These epidemiological data reveal a stark truth; almost half of hip fracture patients provide us with an obvious opportunity for preventive intervention. Tragically, numerous studies from across the world have found that healthcare systems are failing to respond to the first fracture to prevent the second [9, 10]. This special issue of Osteoporosis International focuses on post-fracture coordinatorbased models that have been shown to close the secondary prevention management gap. The systematic review conducted by Sale and colleagues [11] considered published models of case-finding systems in the orthopaedic environment. The reviewers sought to evaluate the structure, protocols, staffing and outcomes of different models and categorise them by the key elements present in each program. Sixty-five percent formally described the role of a dedicated coordinator who identified patients, facilitated BMD testing and the initiation of osteoporosis treatment. A clear message is that coordinator-based models circumvent the challenge of where clinical responsibility resides for osteoporosis care of the fragility fracture patient. The Glasgow Fracture Liaison Service (FLS) has provided clinically effective post-fracture osteoporosis care for the one million residents of Glasgow, Scotland for the last decade [12]. McLellan and colleagues’ formal costeffectiveness analysis of the Glasgow FLS [13] provides crucial health economic information in the prevailing austere economic climes. An estimated 18 fractures were prevented, including 11 hip fractures, and £21,000 (€23,350, US$34,700) was saved per 1,000 patients managed by the FLS versus “usual care” for the United Kingdom. To date, approximately one third of the UK’s 61 million residents are served by an FLS. McLellan has Related articles can be found at doi:10.1007/s00198-011-1534-0, doi:10.1007/s00198-011-1544-y, doi:10.1007/s00198-011-1638-6 and doi:10.1007/s00198-011-1642-x.

Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study

The incidence of hip fractures in Turkey increased markedly from that reported in 1988/1989 so that FRAX® models for Turkey should be revised. The MEDOS study in 1988/1989 reported that men and women from Turkey had exceptionally low rates of hip fracture. The aim of the FRACTURK study was to estimate current and future hip fracture risks and the prevalence of osteoporosis in Turkey. Hip fracture cases in 2009 were identified from interviews of a population-based sample of 26,424 residents aged 50 years or more in 12 different regions of Turkey and in two hospital surveys. Bone mineral density was evaluated by DXA in an age-stratified sample of 1,965 men and women. Hip fracture incidence in the community-based survey was similar to that in the hospital survey. The age-specific incidence in men and women was substantially higher than that reported for 1988/1989. At the age of 50 years, the remaining lifetime probability of a hip fracture was 3.5% in men and 14.6% in women. In 2009, there were approximately 24,000 hip fractures estimated in Turkey, 73% of which were found in women. Assuming no change in the age- and sex-specific incidence, the number of hip fractures was expected to increase to nearly 64,000 in 2035. The prevalence of osteoporosis at the femoral neck was 7.5% and 33.3% in men and women, respectively, aged 50 years or more. Although Turkey is still among the countries with low hip fracture rates in Europe, the incidence has increased markedly in the last 20 years. This finding can be used to recalibrate fracture risk assessment models for Turkey.

Decision to take osteoporosis medication in patients who have had a fracture and are 'high' risk for future fracture: A qualitative study

BackgroundPatients' values and preferences are fundamental tenets of evidence-based practice, yet current osteoporosis (OP) clinical guidelines pay little attention to these issues in therapeutic decision making. This may be in part due to the fact that few studies have examined the factors that influence the initial decision to take OP medication. The purpose of our study was to examine patients' experiences with the decision to take OP medication after they sustained a fracture.MethodsA phenomenological qualitative study was conducted with outpatients identified in a university teaching hospital fracture clinic OP program. Individuals aged 65+ who had sustained a fragility fracture within 5 years, were 'high risk' for future fracture, and were prescribed OP medication were eligible. Analysis of interview data was guided by Giorgi's methodology.Results21 patients (6 males, 15 females) aged 65-88 years participated. All participants had low bone mass; 9 had OP. Fourteen patients were taking a bisphosphonate while 7 patients were taking no OP medications. For 12 participants, the decision to take OP medication occurred at the time of prescription and involved minimal contemplation (10/12 were on medication). These patients made their decision because they liked/trusted their health care provider. However, 4/10 participants in this group indicated their OP medication-taking status might change. For the remaining 9 patients, the decision was more difficult (4/9 were on medication). These patients were unconvinced by their health care provider, engaged in risk-benefit analyses using other information sources, and were concerned about side effects; 7/9 patients indicated that their OP medication-taking status might change at a later date.ConclusionsAlmost half of our older patients who had sustained a fracture found the decision to take OP medication a difficult one. In general, the decision was not considered permanent. Health care providers should be aware of their potential role in patients' decisions and monitor patients' decisions over time.

Outpatient Management of the Elderly Patient Following Fragility Hip Fracture

Hip fractures associated with underlying osteoporosis result in significant morbidity and mortality in elderly patients and increase the risk for future fractures. Several underlying modifiable contributors may be identified, while osteoporosis itself is amenable to a number of effective treatments. Other interventions can further reduce the risk of falls and second fractures. This paper reviews evaluation and management options after fragility (low trauma) hip fractures in the geriatric population.

Male and Non-English-Speaking Patients with Fracture Have Poorer Knowledge of Osteoporosis

Prior fracture is a strong independent risk factor for subsequent fracture. To date, few studies have examined the level of osteoporosis knowledge specifically in the population of patients who have sustained a fracture. This study was designed to assess the knowledge of osteoporosis among patients who sustained a fracture and who were forty years of age or older, as well as to identify what social factors and health and fracture characteristics determine the level of osteoporosis knowledge in this population. Patients who had sustained a fracture and were attending fracture clinics at two Toronto hospitals were identified and invited to fill out a questionnaire during their visit. This questionnaire included questions that could be answered by checking "true," "false," or "don't know" and that were designed to assess the patient's knowledge of osteoporosis. The questionnaire also included questions about the respondent's background. Of 259 patients identified as eligible for the study, 204 (78.8%) agreed to participate. The mean number of correct responses was 16.5 (55%) out of thirty responses. Variables significantly associated with greater numbers of correct responses were female sex, English as a first language, being currently employed, exercising regularly, and having received information from a health-care provider or from a newspaper or magazine. The level of osteoporosis knowledge was fairly low among the surveyed patients, indicating that more education is needed. This study also highlighted certain characteristics (i.e., male sex, English as a second language, being unemployed, and not exercising) that are associated with a lower level of knowledge. Our results can help target certain groups for osteoporosis educational initiatives, especially ethnic groups whose first language is not English, so as to appropriately reduce the risk of future fractures in this high-risk population.

Evaluation and Management of Proximal Humerus Fractures

Fractures of the proximal humerus occur frequently, and are primarily insufficiency fractures that occur in the elderly. Thorough clinical evaluation is essential in identifying associated neurovascular injury, which warrants emergent surgical referral. Good quality radiographs remain a necessary diagnostic tool in the evaluation of proximal humerus injuries. An appreciation of the relevant anatomy and predictable patterns of deformation aid in understanding the basic classification of proximal humerus fractures. Most of these fractures are minimally displaced and can be treated nonoperatively with acceptable clinical outcomes. Familiarity with the basic surgical treatment modalities is helpful to physicians involved in the pre- and postoperative management. Significantly displaced proximal humerus fractures are typically treated with surgical reduction and internal fixation. Complex fractures in the elderly and fracture dislocations are indications for humeral head prosthetic replacement. Proximal humerus fractures are strongly associated with decreased bone mineral density and future fracture risk, and should prompt a referral for medical management of osteoporosis.

If you don't take it &amp;ndash; it can't work: the consequences of not being treated or nonadherence to osteoporosis therapy

Osteoporosis is a growing problem worldwide, linked to an increasingly aging population. Despite the availability of a wide variety of treatments for osteoporosis, a significant number of patients are either not being prescribed treatment or discontinue therapy as early as 6 months after initiation. The reasons for a lack of adherence are many but poor adherence increases the risk of fracture and, therefore, the disease burden to the patient and society. Results from large-scale, randomized clinical studies have shown that different osteoporosis treatments are efficacious in reducing the risk of fracture. Studies assessing the effects of discontinuing osteoporosis therapies show that some treatments appear to continue to protect patients from the risk of future fracture even when treatment is stopped. However, these trials involve patients who have been compliant with treatment for between 2 and 5 years, a situation not reflective of real-world clinical practice. In reality, patients who discontinue therapy within the first 6 months may never achieve the optimum protection from fracture regardless of which treatment they have been prescribed. Clinicians need to develop management strategies to enable patients to adhere to their treatment. This will ultimately result in better prevention of fracture and a lower burden of disease to society and patients.

Objective measures of physical capability and subsequent health: a systematic review

Background: measures of physical capability may be predictive of subsequent health, but existing published studies have not been systematically reviewed. We hypothesised that weaker grip strength, slower walking speed and chair rising and shorter standing balance time, in community-dwelling populations, would be associated with higher subsequent risk of fracture, cognitive outcomes, cardiovascular disease, hospitalisation and institutionalisation.Methods: studies were identified through systematic searches of the electronic databases MEDLINE and EMBASE (to May 2009). Reference lists of eligible papers were also manually searched.Results: twenty-four papers had examined the associations between at least one physical capability measure and one of the outcomes. As the physical capability measures and outcomes had been assessed and categorised in different ways in different studies, and there were differences in the potential confounding factors taken into account, this made it impossible to pool results. There were more studies examining fractures than other outcomes, and grip strength and walking speed were the most commonly examined capability measures. Most studies found that weaker grip strength and slower walking speed were associated with increased risk of future fractures and cognitive decline, but residual confounding may explain results in some studies. Associations between physical capability levels and the other specified outcomes have not been tested widely.Conclusions: there is some evidence to suggest that objective measures of physical capability may be predictors of subsequent health in older community-dwelling populations. Most hypothesised associations have not been studied sufficiently to draw definitive conclusions suggesting the need for further research.

Bones in pediatric Crohnʼs disease

There is evidence to suggest that the inflammation associated with Crohn's disease (CD) impacts the bone health of patients, predisposing them to early onset osteoporosis and increasing their risk of fracture. Fractures have been documented in patients with CD, with a high proportion of these being found during young adulthood, which suggests that these patients are not simply fracturing as a result of the normal aging process but rather due to the presence of CD. In population terms, patients with CD have increased risk of fracture compared with the general population. Studies in children suggest that, irrespective of time on corticosteroid therapy, the underlying systemic inflammation associated with CD is an independent detrimental influence on the bone health of children with CD. This poses the question as to whether the onset of disease in childhood predisposes the individual to increased risk of future fractures later in life, as a result of decreased peak bone mass during the growing years. It is generally believed that dual energy x-ray absorptiometry-assessed areal bone mineral density is a good indicator of fracture risk; however, several studies have shown this may not be the case. New research, utilizing peripheral quantitative computed tomography, which provides a true volumetric assessment of bone, suggests altered bone geometry in patients with CD, which poses a structural threat by being more brittle and susceptible to damage accumulation.

Another chapter for vertebral compression fractures

Every year, 1·4 million patients present with vertebral compression fractures worldwide. 1 Johnell O Kanis JA An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006; 17: 1726-1733 Crossref PubMed Scopus (2858) Google Scholar These fractures cause pain, disability, and diminished quality of life, 2 Borgstrom F Zethraeus N Johnell O et al. Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int. 2006; 17: 637-650 Crossref PubMed Scopus (244) Google Scholar , 3 Silverman SL Minshall ME Shen W Harper KD Xie S on behalf of the Health-Related Quality of Life Subgroup of the Multiple Outcomes of Raloxifene Evaluation StudyThe relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis: results from the Multiple Outcomes of Raloxifene Evaluation Study. Arthritis Rheum. 2001; 44: 2611-2619 Crossref PubMed Scopus (294) Google Scholar and are associated with an increased risk of future vertebral fractures. 4 Lindsay R Silverman SL Cooper C et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001; 285: 320-323 Crossref PubMed Scopus (1447) Google Scholar Most of these fractures are due to osteoporosis and occur spontaneously or with minimum trauma, and the vertebrae heal in a deformed state with non-surgical management that includes analgesia, bed rest, physiotherapy, and back bracing. Pain can resolve slowly and persist. 5 Lyritis GP Mayasis B Tsakalakos N et al. The natural history of the osteoporotic vertebral fracture. Clin Rheumatol. 1989; 8: 66-69 Crossref PubMed Scopus (106) Google Scholar Further fractures result in vertebral deformity, height loss, kyphosis, decreased pulmonary function, and mobility and balance impairment. 5 Lyritis GP Mayasis B Tsakalakos N et al. The natural history of the osteoporotic vertebral fracture. Clin Rheumatol. 1989; 8: 66-69 Crossref PubMed Scopus (106) Google Scholar , 6 Schlaich C Minne HW Bruckner T et al. Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int. 1998; 8: 261-267 Crossref PubMed Scopus (417) Google Scholar , 7 Lyles KW Gold DT Shipp KM Pieper CF Martinez S Mulhausen PL Association of osteoporotic vertebral compression fractures with impaired functional status. Am J Med. 1993; 94: 595-601 Summary Full Text PDF PubMed Scopus (358) Google Scholar What is the point of surgery?On an individual level, surgery relieves pain, restores function, improves quality of life, and saves lives. In what manner and to what end do these services engage in broader terms with the health of populations? 1 year ago, The Lancet published a surgery-themed issue that introduced the IDEAL recommendations to improve surgical research. In that issue, Ara Darzi and colleagues challenged surgeons to transform their specialty into a word-class discipline. Today's Lancet returns to the theme of surgery to assess what progress has been made. Full-Text PDF Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trialIn a subgroup of patients with acute osteoporotic vertebral compression fractures and persistent pain, percutaneous vertebroplasty is effective and safe. Pain relief after vertebroplasty is immediate, is sustained for at least a year, and is significantly greater than that achieved with conservative treatment, at an acceptable cost. Full-Text PDF

Reporting of frequent alcohol intake and its influence on fracture risk based on FRAX®

To assess the fracture risk in a cohort of Egyptian systemic lupus erythematosus (SLE) females in correlation to some disease variables.Seventy female SLE patients ≥40 years old were enrolled with detailed history taking, assessment of disease activity and damage index. Measurement of Serum calcium, phosphorus and alkaline phosphatase, bone mineral density (BMD) by dual emission X-ray absorptiometry (DEXA) at lumbar spine (LS) and femoral neck (FN), serum osteocalcin level and World Health Organization (WHO) fracture risk assessment tool (FRAX®).20% of the patients had LS osteoporosis, 35.7% LS osteopenia, 8.6% FN osteoporosis, and 42.9% FN osteopenia. Ten-year risk of major and hip fractures was high in SLE patients evidenced by FRAX-Major ≥20% in 10% of patients, and FRAX-Hip ≥3% in 27.1% of patients. Serum osteocalcin level was significantly decreased in SLE patients with lower BMD than those with normal BMD, and significantly decreased in patients with osteoporosis than those with osteopenia. A significant negative correlation was found between osteocalcin level and age of patients, disease duration, disease activity and damage index scores, current intravenous pulse and cumulative steroids, immunosuppressants, anticoagulants, but there was a positive correlation with antimalarials and calcium supplements.Ten-year risk of major and hip fractures was high in SLE patients. Increasing age, disease duration, high anti-DNA titres, higher disease activity and damage index were associated with a higher fracture risk. FRAX predicted fractures among SLE patients with normal and low bone mass not just those with frank osteoporosis. Physicians should be alerted to the higher risk of future fractures in SLE patients for periodic monitoring.

Time since prior fracture is a risk modifier for 10-year osteoporotic fractures

The objective of this study was to assess the importance of time since prior fracture as a risk factor for future osteoporotic fractures and how it affects 10-year fracture rates. We identified 39,991 women 45 years of age or older undergoing baseline bone mineral density (BMD) testing (1990-2007) from a regional database that contains dual-energy X-ray absorptiometry (DXA) results for Manitoba, Canada. Health service records were used to identify nontrauma ICD-9-CM fracture codes preceding DXA, grouped as "major" fractures (n = 5178; hip, spine, forearm, and humerus) or "minor" fractures (n = 3479; ribs, sternum, pelvis, trunk, clavicle, scapula, patella, tibia/fibula, and ankle). Time since prior fracture was coded in years as less than 1, 1 to 5, 5 to 10, and more than 10. Incident fractures (ie, hip, spine, forearm, and humerus) after BMD testing were identified (mean follow-up 4.2 years, maximum 10 years) and studied in Cox proportional-hazards models adjusted for age, BMD T-score, and other covariates. After BMD testing, n = 1749 (4.4%) women experienced an incident fracture. Prior major fracture was a strong risk factor for incident fracture, greatest risk in the first year [hazard ratio (HR) 1.90, 95% confidence interval (CI) 1.60-2.25], declining by more than 10 years (HR 1.62, 95% CI 1.25-2.10). Prior minor fracture was a weaker risk factor, greatest in the first year (HR 1.45, 95% CI 1.13-1.87) and no longer significant by 1 to 5 years. Major and minor fractures both showed a time-dependent decline in importance as risk factors. In conclusion, time since prior fracture modifies future fracture risk, but prior fractures of the hip, spine, forearm, and humerus remain strong risk factors even 10 years later. Fracture risk assessment should emphasize the importance of prior fractures at these sites.