Lower Fracture Incidence Research Articles

Associations between body composition and vertebral fracture risk in postmenopausal women.

Osteoporosis is a metabolic bone disease with low bone mineral density (BMD) and high incidence of vertebral fractures (VFs). Postmenopausal women with osteoporosis have decreased total fat and lean mass. This study aimed to investigate the associations between body composition and VF risk and explore the potential predictor of VF risk in postmenopausal women. Enrolled 731 postmenopausal women were referred by various departments and outpatient clinics to assess vertebral status between October 2016 and November 2017. The main measures were total body lean mass, fat mass, and BMD. Patients were divided into osteopenia, osteoporosis, and normal groups based on T-scores. Logistic regression analyses were performed to evaluate associations between body composition parameters and VF. VF was significantly associated with increased age, lower height, and lighter weight in all participants, and higher BMI was observed in VF participants. Participants in the osteoporosis group were older and had lower height, weight, and BMD than those in normal and osteopenia groups. Femoral and total hip T-scores as well as T-scores for lumbar spine were significantly lower in participants with VF than in non-VF participants. Percentage of bone mass was also significantly lower in VF participants compared to that of non-VF participants. Women with increased BMD and lower bone mass had reduced odds for VF occurrence. Bone mass was significantly able to identify VF occurrence. Body composition analysis discerns differences in the bone status of postmenopausal women with and without VF. The cutoff value of the bone mass might be used effectively as an indicator of risk for VF occurrence.

РАСПРОСТРАНЕННОСТЬ И ЭТИОЛОГИЯ ПЕРЕЛОМОВ НИЖНЕЙ ЧЕЛЮСТИ

Subject. A review of the literature on the topical problem of maxillofacial surgery and dental surgery — the prevalence and etiology of mandibular fractures is presented. The aim of the study was to study the materials of publications on the prevalence and etiology of mandibular fractures. 
 Methodology. The publications of domestic and foreign authors, testifying to the prevalence and etiology of mandibular fractures, were studied. 
 Results. The publications confirm the tendency of an increase in the number of mandibular fractures. Fractures of the mandible are of polyfactorial origin. 
 The research results demonstrate the presence of a specific connection between fractures of the lower jaw and social (region of residence, socio-economic state, cultural characteristics, lifestyle, etc.), age and gender factors. 
 Conclusions. Fractures of the lower jaw prevail in the structure of fractures of the bones of the facial skeleton. The majority of patients are urban residents. One-sided fractures are most common. 
 The greatest number of mandibular fractures is recorded in the age group 21-30 years. At the same time, the youth age group is dominant here. A low incidence of fractures was noted in the elderly group. 
 Mandibular fractures are more common in men than in women in a ratio of ~ 4: 1, but the proportion of women with fractures of the mandible has recently been increasing. 
 Mandibular fractures are most common in the summer months, with Sunday dominating the days of the week. 
 Mandibular fractures can be caused by a variety of factors. In recent years, there has been an upward trend in the number of fractures caused by road traffic accidents in many countries. Female patients indicate a high incidence of violence against them. Falls are the most common cause of fractures in older people. 
 There is a definite relationship between the incidence of fractures and the use of alcohol and other psychoactive substances.

Management and Outcome of Hindfoot Trauma With Concomitant Talar Head Injury.

Background:Talar head fractures account for 2.6% to 10% of all talar fractures and are often associated with concomitant musculoskeletal injuries. The current literature only describes a total of 14 patients with talar head fractures and, with that, guidelines for management are lacking. The aim of the current study was to evaluate the management and long-term outcome of patients who have hindfoot trauma with concomitant talar head fractures.Methods:This study includes a retrospective cohort of patients with talar head fractures. Patient characteristics, trauma mechanism, fracture characteristics, treatment, follow-up, and complications were reported. Functional outcome was assessed using the Foot Function Index (FFI) and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Quality of life was measured by the EuroQol-5D (EQ-5D). Twenty-one patients with acute fractures of the talar head were identified. The mean follow-up time was 4.9 years.Results:All patients sustained additional ipsilateral foot and/or ankle injuries. Fifteen patients had operative management of their talar head fracture. There were no postoperative wound infections and no cases of avascular necrosis. All fractures united, and 29% of patients developed posttraumatic osteoarthritis. The overall mean FFI score index was 34.2, and the mean AOFAS score was 70.7. The mean EQ-5D index score was 0.74.Conclusion:Talar head fractures always coincided with other (foot) fractures. Management and long-term functional outcome were affected by the extent of associated injuries. Due to the low incidence and high complexity of talar head fractures, early referral to dedicated foot surgeons and centralization of complex foot surgery is recommended.Level of Evidence:Level IV, retrospective case series.

Fracture incidence of Reciproc instruments during root canal retreatment performed by postgraduate students: a cross-sectional retrospective clinical study.

ObjectivesTo evaluate the fracture incidence of Reciproc R25 instruments (VDW) used during non-surgical root canal retreatments performed by students in a postgraduate endodontic program.Materials and MethodsFrom the analysis of clinical record cards and periapical radiographs of root canal retreatments performed by postgraduate students using the Reciproc R25, a total of 1,016 teeth (2,544 root canals) were selected. The instruments were discarded after a single use. The general incidence of instrument fractures and its frequency was analyzed considering the group of teeth and the root thirds where the fractures occurred. Statistical analysis was performed using the χ2 test (p < 0.01).ResultsSeven instruments were separated during the procedures. The percentage of fracture in relation to the number of instrumented canals was 0.27% and 0.68% in relation to the number of instrumented teeth. Four fractures occurred in maxillary molars, 1 in a mandibular molar, 1 in a mandibular premolar and 1 in a maxillary incisor. A greater number of fractures was observed in molars when compared with the number of fractures observed in the other dental groups (p < 0.01). Considering all of the instrument fractures, 71.43% were located in the apical third and 28.57% in the middle third (p < 0.01). One instrument fragment was removed, one bypassed, while in 5 cases, the instrument fragment remained inside the root canal.ConclusionsThe use of Reciproc R25 instruments in root canal retreatments carried out by postgraduate students was associated with a low incidence of fractures.

Denosumab Safety and Efficacy Among Participants in the FREEDOM Extension Study With Mild to Moderate Chronic Kidney Disease.

ContextThe effects of long-term exposure to denosumab in individuals with renal insufficiency are unknown.ObjectiveThis post hoc analysis evaluates the long-term safety and efficacy of denosumab in individuals with mild-to-moderate chronic kidney disease (CKD) (stages 2 and 3) using data from the pivotal phase 3, double-blind, 3-year FREEDOM (NCT00089791) and open-label, 7-year extension (NCT00523341) studies.Participants and MethodsWomen age 60 to 90 years with a bone mineral density (BMD) T-score of less than –2.5 to greater than –4.0 at the total hip or lumbar spine were randomly assigned 1:1 to receive denosumab 60 mg subcutaneously every 6 months (long-term arm) or placebo (cross-over arm) in FREEDOM; eligible participants could enroll in the extension to receive denosumab 60 mg subcutaneously every 6 months. Change in estimated glomerular filtration rate (eGFR) from study baseline and annualized rates of fracture and adverse events (AEs) were the main outcome measures.ResultsMost participants (1259/1969 [64%] long-term arm; 1173/1781 [66%] crossover arm) with baseline CKD stage 2 or 3 remained within the same CKD subgroup at study completion; less than 3% progressed to CKD stage 4. Participants in all eGFR subgroups showed similar, persistent BMD gains over time and a low incidence of fractures. The percentage of participants reporting serious AEs was similar among renal subgroups (normal, CKD stage 2, CKD stage 3a, CKD stage 3b) both for the long-term (54% vs 52% vs 57% vs 58%) and crossover (43% vs 42% vs 43% vs 68%) arms, except CKD stage 3b subgroup, crossover arm.ConclusionThe safety and efficacy of denosumab did not differ among participants with mild to moderate CKD.

Safety And Clinical Outcomes Of Radium-223 With Concomitant Radiotherapy Or Subsequent Treatment With The Investigational Agent 177Lu-PSMA In Patients With Metastatic Castration-Resistant Prostate Cancer: An Interim Analysis Of The REASSURE Study

Radium-223 (Ra-223) improved overall survival (OS) and demonstrated a favorable safety profile in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC) in the phase 3 ALSYMPCA trial. REASSURE (NCT02141438) is a global, prospective, single-arm, observational study investigating the safety of Ra-223 in routine clinical practice in pts with mCRPC over 7 years. The objective of this investigation, using data from the second prespecified interim analysis, was to assess safety and clinical outcomes in pts from REASSURE, including the subgroups who received radiotherapy concomitant with Ra-223, or investigational 177Lu-PSMA subsequent to Ra-223. Results of this analysis may help to inform future treatment decisions in pts with mCRPC. This analysis (data cut-off: March 20, 2019) was conducted for the entire cohort and two subsets of pts treated with either concomitant radiotherapy or with subsequent 177Lu-PSMA. Incidence of second primary malignancy (SPM), pain response, incidence of adverse events (AEs), and OS are described. In total, 1465 pts with mCRPC were included. Median follow-up was 11.5 months, and a median of 6 Ra-223 injections was received. Overall, 14 pts (1%) developed a SPM. At Cycle 6, 222/657 pts (34%) had a clinically meaningful pain response (decrease ≥2 points from baseline) in the Brief Pain Inventory worst pain item. Overall, median OS was 15.6 months (95% CI 14.6, 16.5). The most frequent treatment-emergent serious AEs (any grade; ≤30 days after Ra-223) were anemia (n = 27; 2%), physical health deterioration (n = 14; 1%), and pneumonia (n = 13; 1%). Grade 3–4 hematologic AEs occurred in 214 pts (15%); 70 pts (5%) had fractures. 160/1465 pts (11%) had concomitant radiotherapy, mainly external beam radiation therapy (n = 117; 73%), brachytherapy (n = 14; 9%), and gamma knife or stereotactic therapy (n = 8; 5% for each). Of these 160 pts, 1 (<1%) developed a SPM. Safety, including hematologic toxicity fracture rate, and pain response in this pt group was acceptable and will be presented. 26/1465 pts (2%) received 177Lu-PSMA treatment after Ra-223. Median duration of 177Lu-PSMA was 3.5 months. 3/26 pts (12%) had drug-related serious AEs; 9/26 pts (35%) had grade 3–4 hematologic AEs. 2/26 pts (8%) had fractures. Median OS was 28.0 months (95% CI 19.5, 32.7) from start of Ra-223 and 13.2 months (8.4, 16.2) from start of 177Lu-PSMA. There was a low incidence of SPM, low rate of grade 3–4 hematologic AEs, and low incidence of fractures in this second interim analysis of REASSURE, in a real-life clinical practice setting. A pain response was observed in about one-third of pts. Treatment with 177Lu-PSMA in pts who had prior Ra-223 may be feasible in selected pts based on the subset analyzed.

Small, Short, Oblique Patellar Tunnels for Patellar Fixation Do Not Increase Fracture Risk or Complications in MPFL Reconstruction: A Retrospective Cohort Study.

Background:Large (4.5 mm) and/or transpatellar bone tunnels have been associated with patellar fracture after medial patellofemoral ligament (MPFL) reconstruction. To avoid this outcome, many surgeons now employ suture anchors to affix the MPFL graft to the patella.Purpose:To evaluate the risk of patellar fracture and other outcomes associated with smaller (3.2-mm), short, oblique patellar tunnels as compared with suture anchor fixation in MPFL reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:A single institution’s electronic medical record was queried for all patients undergoing MPFL reconstruction between March 2010 and December 2018. A chart review of operative reports was utilized to identify those who had undergone MPFL reconstruction. Patients undergoing revision MPFL reconstruction or reconstruction with fully transpatellar bone tunnels were excluded. The incidence of patellar fracture and outcomes were evaluated from chart review. The mean duration of follow-up was >2 years.Results:A total of 384 knees in 352 patients undergoing primary MPFL reconstruction were identified. Small (3.2-mm), short, oblique tunnels were used for patellar fixation in 215 cases, and suture anchors were utilized in 169 cases. The small, oblique tunnels and suture anchor techniques both resulted in a low incidence of patellar fracture, with rates of 0.47% and 0%, respectively. The use of suture anchors was associated with an increased risk of subluxation or dislocation compared with small, oblique tunnels (odds ratio, 3.98; P = .028). No significant difference was found in the need for revision MPFL reconstruction surgery with suture anchors (odds ratio, 1.925; P = .66).Conclusion:The use of small, oblique tunnels with hamstring autograft is a safe means of patellar fixation in MPFL reconstruction. The use of small, oblique tunnels for patellar fixation versus 2 suture anchors can result in material cost savings with no significantly increased risk for fracture as well as an overall reduction in complication rates.

Complications d’une ostéotomie autocentrée coulissante de la tubérosité tibiale antérieure pour pathologie fémoro-patellaire : faible incidence de pseudarthrose et de fracture

BackgroundA tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center. HypothesisWe hypothesize that nonunion or fracture occurs in less than 1% of the procedures. Patients and methodsFive hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy nonunion, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor. ResultsThe major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total, 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thromboembolism (VTE). ConclusionA self-centering TTO is a relatively safe technique with a low number of nonunion and fracture. Level of evidenceLevel IV, retrospective cohort study.

Complications of a self-centering sliding tibial tubercle osteotomy for patellofemoral complaints; low incidence of non-union and fracture

BackgroundA tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center. HypothesisWe hypothesize that non-union or fracture occurs in less than 1% of the procedures. Patients and methodsFive hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow-up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy non-union, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor. ResultsThe major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thrombo-embolism (VTE). ConclusionA self-centering TTO is a relatively safe technique with a low number of non-union and fracture. Level of evidenceLevel IV, retrospective cohort study.

Implementation of a fracture liaison service and its effects on osteoporosis treatment adherence and secondary fracture at a tertiary care academic health system.

To assess the effects of implementation of a fracture liaison service at a tertiary care academic medical center on osteoporosis treatment adherence and secondary fracture rates. We retrospectively reviewed over 6000 patients age 50years or greater during a 5-year time period (2013-2018). Patients were identified as having a fragility fracture on presentation to the emergency department at the Wake Forest Baptist Medical Center and referred to our osteoporosis clinic using the electronic medical record. Data were collected regarding those patients who were recommended treatment, started treatment, maintained adherent to treatment, and those who sustained a secondary fracture. 6178 patients were identified as having a fragility fracture and referred to the osteoporosis clinic. 2631 of these patients successfully had a scheduled outpatient appointment at the osteoporosis clinic, of which 1937 attended their initial appointment and 1840 of these patients were prescribed treatment. Of the 1840 patients who were initially prescribed medication, 1416 (76.96%) initiated their treatment, and 1156 (81.64%) remained adherent to treatment. Fifteen patients (1.05%) on treatment sustained a secondary fracture after initiation of therapy. Implementation of a fracture liaison service at a tertiary care academic medical center is feasible and is associated with high rates of treatment implementation/adherence and low incidence of secondary fracture.

Sacral fractures: issues, challenges, solutions

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures.Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064

How Physical Activity across the Lifespan Can Reduce the Impact of Bone Ageing: A Literature Review.

Bone remodeling is a lifelong process, due to the balanced activity of the osteoblasts (OBs), the bone-forming cells, and osteoclasts (OCs), the bone-resorbing cells. This equilibrium is mainly regulated by the WNT-ß-cathenin pathway and the RANK-RANKL/OPG system, respectively. Bone ageing is a process which normally occurs during life due to the imbalance between bone formation and bone resorption, potentially leading to osteoporosis. Bone loss associated with bone ageing is determined by oxidative stress, the result of the increasing production of reactive oxygen species (ROS). The promotion of physical exercise during growth increases the chances of accruing bone and delaying the onset of osteoporosis. Several studies demonstrate that physical exercise is associated with higher bone mineral density and lower fracture incidence, and the resulting bone mineral gain is maintained with ageing, despite a reduction of physical activity in adulthood. The benefits of exercise are widely recognized, thus physical activity is considered the best non-pharmacologic treatment for pathologies such as osteoporosis, obesity, diabetes and cardiovascular disease. We reviewed the physiological mechanisms which control bone remodeling, the effects of physical activity on bone health, and studies on the impact of exercise in reducing bone ageing.

Estimation of Long‐Term Efficacy of Denosumab Treatment in Postmenopausal Women With Osteoporosis: A FRAX‐ and Virtual Twin‐Based Post Hoc Analysis From the FREEDOM and FREEDOM Extension Trials

ABSTRACTThe 3‐year placebo‐controlled FREEDOM (Fracture REduction Evaluation of Denosumab in Osteoporosis Every 6 Months) trial established the antifracture efficacy of denosumab in postmenopausal women with osteoporosis. The 7‐year open‐label extension demonstrated that denosumab treatment for up to 10 years was associated with low rates of adverse events and low fracture incidence. The extension lacked a long‐term control group, thus limiting the ability to fully evaluate long‐term efficacy. This analysis provides a quantitative estimate of the long‐term antifracture efficacy of denosumab based on two approaches: comparison with FRAX®‐ (Fracture Risk Assessment Tool‐) and virtual twin‐estimated 10‐year fracture rates. Subjects who were randomized to denosumab in the FREEDOM trial, continued into the Extension study, completed the 10‐year visit, and missed ≤1 dose in the FREEDOM trial and ≤1 dose in the Extension (n = 1278) were included in the analysis. The 10‐year observed cumulative incidence of major osteoporotic fracture (MOF) and hip fractures was compared with the 10‐year fracture probability predicted at baseline by FRAX, a computer‐based fracture risk algorithm, and with that estimated for a hypothetical cohort of 10‐year placebo controls (virtual twins). The observed 10‐year fracture incidence was lower than the 10‐year probability predicted by FRAX for both MOF (10.75% [95% CI, 9.05 to 12.46] versus 15.63% [95% CI, 15.08 to 16.18], respectively), and hip fractures (1.17% [95% CI, 0.58 to 1.76] versus 5.62% [95% CI, 5.28 to 5.97], respectively). The observed fracture incidence was also lower than the fracture rate estimated in a hypothetical cohort of 10‐year placebo controls for MOF (23.13% [95% CI, 17.76 to 28.87]; relative risk 0.49 [95% CI, 0.36 to 0.64]). These data support the long‐term efficacy of denosumab in reducing MOF and hip fractures in postmenopausal women with osteoporosis. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Clinical outcomes and patient (pt) profiles in REASSURE: An observational study of radium-223 (Ra-223) in metastatic castration-resistant prostate cancer (mCRPC).

32 Background: Ra-223 is a targeted alpha therapy that showed a survival advantage and favorable safety profile in the phase 3 ALSYMPCA trial in pts with mCRPC. REASSURE (NCT02141438) is evaluating the long-term safety of Ra-223 in routine clinical practice in pts with mCRPC over a 7-year follow-up period. Methods: In this global, prospective, single-arm, observational study, the second prespecified interim analysis (data cut-off March 2019) evaluated safety and clinical outcomes of Ra-223 in pts with mCRPC. Primary outcome measures were incidence of second primary malignancies (SPM), bone marrow suppression and short- and long-term safety in pts who had ≥1 Ra-223 dose. Secondary outcomes included overall survival (OS). Results: For 1465 pts in the safety analysis, median follow up was 11.5 months. Median PSA (n=1053), ALP (n=1048), and LDH (n=555) levels at baseline were 59 ng/mL, 135 U/L, and 269 U/L, respectively. 81% of pts had bone metastases only at baseline; 19% of pts had other metastatic sites, mostly in the lymph nodes. 19% of pts had &lt;6 metastatic sites, 47% had 6–20 sites, 20% had &gt;20 lesions but not a superscan, and 6% had a superscan. 45%, 38%, 37%, 9%, and 8% of pts received prior abiraterone, docetaxel, enzalutamide, cabazitaxel, or sipuleucel-T as prior therapies, respectively. Median number of Ra-223 doses received was 6; 67% of pts had ≥5 doses. SPM occurred in 1% of pts. The most common treatment-emergent drug-related adverse event (AE) of any grade was diarrhea (11%). 10% of pts had a bone-associated event, 5% had fractures, and 15% had a hematological AE. Median OS was 15.6 months (95% CI 14.6–16.5). Conclusions: In REASSURE, there was a low incidence of SPM, bone fractures, and bone marrow suppression after Ra-223 treatment, with no new AEs identified. This study confirms that in routine clinical practice, Ra-223 AE rates were low, and pts generally received ≥5 doses. Clinical trial information: NCT02141438. [Table: see text]

Denosumab in postmenopausal women with osteoporosis and diabetes: Subgroup analysis of FREEDOM and FREEDOM extension.

Diabetes and osteoporosis occur frequently in older adults and are both associated with increased fracture risk. Denosumab treatment reduced new vertebral, nonvertebral, and hip fractures over 3years, with continued low fracture incidence for up to 10years in postmenopausal women with osteoporosis. However, its effects in diabetic subjects with osteoporosis have not yet been investigated. Post hoc analysis of the 3-year, placebo-controlled FREEDOM study and 7-year Extension included postmenopausal women with osteoporosis and diabetes. Effects on BMD, vertebral, and nonvertebral fracture incidence were evaluated. Of 7808 subjects in FREEDOM, 508 with diabetes received denosumab (n=266) or placebo (n=242). Among those, BMD increased significantly with denosumab versus placebo in FREEDOM, and continued to increase during the Extension in long-term (continuing denosumab) and crossover (placebo to denosumab) denosumab subjects. In FREEDOM, denosumab-treated subjects with diabetes had significantly lower new vertebral fracture rates (1.6%) versus placebo (8.0%) (RR: 0.20 [95% CI 0.07-0.61]; p=.001). Nonvertebral fracture incidence was higher with denosumab (11.7%) versus placebo (5.9%) (HR: 1.94 [95% CI 1.00-3.77]; p=.046), although there were fewer hip fractures with denosumab (World Health Organization, 2017 [1]) than placebo (4; nonsignificant). During the first 3years in FREEDOM Extension, new vertebral and nonvertebral fracture incidences were low in long-term and crossover denosumab diabetic groups (≤6%), consistent with the overall Extension population; yearly nonvertebral fracture incidence was comparable to the FREEDOM placebo group. Denosumab significantly increased BMD and decreased vertebral fracture risk in subjects with osteoporosis and diabetes. No reduction in nonvertebral fractures was observed.

Correlations of lipid metabolism with bone remodeling

Introduction. Both dyslipidemia and osteoporosis are chro­nic medical problems, and the relationship between these two pathologies is based on common risk factors and patho­genic mechanisms which favour the development of both diseases. Dyslipidemia can be a risk factor for osteoporosis, therefore it is important to understand the me­cha­nisms underlying the relation between these two pathologies. The link between dyslipidemia and osteoporosis. Lipo­pro­tein oxidation products suppress the differentiation of osteoblasts while stimulating the differentiation of adi­po­cytes and their proliferation, a mechanisms that can con­tri­bute to the reduction of bone mineralization and the oc­cur­rence of inflammatory events. A number of clinical and ex­pe­ri­men­tal studies have been performed, these studies sug­ges­ting an inverse correlation between the adipose con­tent of the bone marrow and the density of the bone tis­sue, in other words, in parallel with the osteoporotic bone loss there is an increase of the adipocyte content in the bone marrow. The role of plasma lipids on bone me­ta­bo­lism. Because in clinic patients with dyslipidemia are often diagnosed with osteoporosis, we can say that serum levels of plasma lipids influence both osteoblastic and osteoclastic activity. Cholesterol correlates with low bone mineral density, while triglycerides are associated with a low incidence of vertebral fractures in osteoporotic wo­men. Effects of lipid-lowering medication on bone tis­sue. Statins, first introduced to treat patients with hyper­li­pi­de­mia and hypercholesterolemia, have also been shown to be beneficial for osteoporotic patients and have recently been introduced to prevent fractures and treat osteoporosis through their ability to enhance osteogenesis and inhibit os­teo­clas­to­ge­ne­sis. Conclusions.There is a wide range of studies that have shown that statins, widely used as lipid-lowering agents, could also be utilized in the treatment of osteo­po­rosis, through the beneficial effects they have on bone metabolism, effects with a positive impact on bone mineral density.

Adherence to Teriparatide Treatment and Risk of Fracture: A Systematic Review and Meta-Analysis.

To conduct a retrospective systematic review and meta-analysis of studies investigating the fracture risk among adherence versus non-adherence patients to treatment for osteoporosis. Cohort studies involving adherence to specifically Teriparatide treatment and the risk of fracture, published from inception to June 10 2019, were identified through PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Scopus database of Systematic Reviews. Five eligible cohort studies were included for analysis. Overall, adherence, compared with nonadherence, had a significant 28% reduction in the risk of all fractures, an 49% reduction in the risk of hip fracture and an 26% reduction in the risk of non-vertebral fracture. Subgroup analyses showed that treatment compliant North American patients had a lower incidence of fracture than treatment compliant Asian patients. The effect size associated with adherence showed no difference with non-adherence when the analysis was limited to a small sample size (<10 000 patients). The findings of this retrospective review indicate that high compliance of Teriparatide treatment result in a decreased risk of fracture, particularly in North American treatment adherence, compared with Asian treatment adherence. Improvement of treatment adherence in patients with osteoporosis should be considered through various means in clinical practice.

Comparison of rod fracture rates in long spinal deformity constructs after transforaminal versus anterior lumbar interbody fusions: a single-institution analysis.

Pseudarthrosis is a common complication of long-segment fusions after surgery for correction of adult spinal deformity (ASD). Interbody fusions are frequently used at the caudal levels of long-segment spinal deformity constructs as adjuncts for anterior column support. There is a paucity of literature comparing rod fracture rates (proxy for pseudarthrosis) in patients undergoing transforaminal lumbar interbody fusion (TLIF) versus anterior lumbar interbody fusion (ALIF) at the caudal levels of the long spinal deformity construct. In this study the authors sought to compare rod fracture rates in patients undergoing surgery for correction of ASD with TLIF versus ALIF at the caudal levels of long spinal deformity constructs. We reviewed clinical records of patients who underwent surgery for correction of ASD between 2008 and 2014 at a single institution. Data including demographics, comorbidities, and indications for surgery, as well as postoperative variables, were collected for each patient. All patients had a minimum 2-year follow-up. Patients were dichotomized into two groups for comparison on the basis of undergoing a TLIF versus an ALIF procedure at the caudal levels of long spinal deformity constructs. The primary outcome of interest was the rate of rod fractures. A total of 198 patients (TLIF 133 patients; ALIF 65 patients) underwent a long-segment fusion to the sacrum with iliac fixation. The mean ± standard deviation follow-up period was 62.23 ± 29.26 months. Baseline demographic variables were similar in both patient groups. There were no significant differences between groups in the severity of the baseline sagittal plane deformity (i.e., baseline lumbar-pelvic parameters) or the final deformity correction achieved. Mean total recombinant human bone morphogenetic protein 2 (rhBMP-2) dose for L1-sacrum fusion was significantly higher in the ALIF (100 mg) than in the TLIF (62 mg) group. The overall rod failure rate (cases with rod fracture/total cases) within this case series was 19.19% (38/198); 10.60% (21/198) were unilateral rod fractures and 8.58% (17/198) were bilateral rod fractures. At last clinical follow-up, there were no statistically significant differences in bilateral rod fracture rates between the group of patients who had a TLIF procedure and the group who had an ALIF procedure at the caudal levels of the long spinal deformity constructs (TLIF 10.52% vs ALIF 4.61%, p = 0.11). However, the incidence rate (cases per patient follow-up years) for bilateral rod fractures was significantly higher in the TLIF than in the ALIF cohort (TLIF 2.20% vs ALIF 0.70%, p < 0.0001). The reoperation rate for rod fractures was similar between the patient groups (p = 0.40). Although both ALIF and TLIF procedures at the caudal levels of long spinal deformity constructs achieved similar and satisfactory deformity correction, ALIFs were associated with a lower rod fracture incidence rate. There were no differences between groups in the prevalence of rod fracture or revision surgery, however, and both groups had low bilateral rod fracture prevalence and incidence rates. One technique is not clearly superior to the other.

Results of Medium-Term Survival of the Non-Cemented Logical Femoral Stem.

Objective The main objective of the present study was to evaluate the clinical and radiographic results of the Logical (Baumer, Mogi Mirim, SP, Brasil) cementless femoral stem in primary total hip arthroplasties (THAs). Methods A retrospective cohort study of 632 patients submitted to primary THA with the Logical cementless femoral stem. The study period was between January 2004 and January 2015. The outcome defined to evaluate the survival of the stem was the clinical and radiographic indication of the revision hip arthroplasty or the actual revision of the femoral stem for any cause. Results Kaplan-Meier survival curves were estimated at > 95%, with a follow-up ranging from 2 to 13 years. There was a low incidence of transoperative periprosthetic fractures (0.02%). No axial migration or cortical bone atrophy was observed in the radiographic sample evaluated. Conclusions In the intermediate follow-up, there was excellent survival of the Logical cementless femoral stem. Although long-term studies are still awaited, this implant appears to be safe and promising to be used for primary THAs.

Fracture liaison programs.

In view of the high imminent risk of having subsequent fractures after a fracture, early evaluation and treatment decisions to prevent subsequent fractures are advocated. After a hip fracture, the fracture liaison service (FLS) and orthogeriatric care are considered the most appropriate organisational approaches for secondary fracture prevention following a recent fracture. Their introduction and implementation have been shown to increase evaluation and treatment of patients at high risk for subsequent fracture. Of real-world cohort studies, most, but not all studies, indicate a lower incidence of fracture and longer survival after treatment with nitrogen-containing bisphosphonates.