Majority Of Fragility Fractures Research Articles

Usefulness of DXA-based bone strain index in postmenopausal women with type 2 diabetes mellitus

SummaryBone Strain Index (BSI) is a new dual-energy x-ray absorptiometry (DXA)-based index. We retrospectively evaluated data from 153 postmenopausal women with a history of type 2 diabetes mellitus (T2DM). Lumbar spine and femoral Bone Strain Index (BSI) were sensitive to skeletal impairment in postmenopausal women suffering from T2DM.PurposeBone Strain Index (BSI) is a new dual-energy X-ray absorptiometry (DXA)-based measurement. We evaluated the performance of BSI in predicting the presence of fragility fractures in type 2 diabetes mellitus (T2DM) postmenopausal women.MethodsWe retrospectively evaluated data from a case–control study of 153 postmenopausal women with a history of at least 5 years of T2DM (age from 40 to 90 years). For each subject, we assessed the personal or familiar history of previous fragility fractures and menopause age, and we collected data about bone mineral density (BMD), BSI, and Trabecular Bone Score (TBS) measurements. Statistical analysis was performed having as outcome the history of fragility fractures.ResultsOut of a total of 153 subjects, n = 22 (14.4%) presented at least one major fragility fracture. A negative correlation was found between lumbar BSI and lumbar BMD (r = − 0.49, p < 0.001) and between total femur BSI and total femur BMD (r = − 0.49, p < 0.001). A negative correlation was found between femoral neck BSI and femoral neck BMD (r = − 0.22, p < 0.001). Most DXA-based variables were individually able to discriminate between fractured and non-fractured subjects (p < 0.05), and lumbar BSI was the index with the most relative difference between the two populations, followed by femoral BSI.ConclusionLumbar spine and femoral BSI are sensitive to skeletal impairment in postmenopausal women suffering from T2DM. The use of BSI in conjunction with BMD and TBS can improve fracture risk assessment.

OA37 Regional variations in adiposity is a strong predictor of fragility fractures in a large cohort: a cross sectional study

Abstract Background/Aims BMI is a core component of fracture risk estimation tools; however, it does not consider the body composition of patients. Emerging research is highlighting that total body fat percentage (TBF%) may be a superior predictor of fracture. Increases in TBF% is thought to be protective of hip fracture while associated with major fragility fractures. However, we have yet to see whether regional variations (abdominal vs hip) in fat deposition is even still a better predictor of fracture. Methods Patients were referred to a DEXA scanner in the northwest of England from 2004-2019. A multivariate logistic regression analysis reporting odds ratios was conducted looking at the fat percentage at the left and right hip (FPLH% and FPRH%), as well as abdominally (FPA%), as predictors of fracture. Results were adjusted for smoking, gender, BMI, steroid use and left femoral t-score. Statistical significance was set at p &amp;lt; 0.05 with STATA V12 used as the statistical package. Results 31,547 patients (5,390 males and 26,156 females) were included in our analysis. The mean age was 64.9 (95% CI 64.8-65.1), BMI 27.1 (95% CI 27.0-27.2), weight 71.1kg (95% CI 70.9-71.3) and height 162cm (95% CI 162.0 cm-162.1cm). 11,875 fractures were reported with 1,375 (11.6%) hip fractures. Table 1 demonstrates the results of our analysis. Conclusion The FPLH% was associated with both hip and all major fragility fractures, while FPA% and FPRH% was only associated with major fragility fractures. We would have expected to see a protective effect for hip fractures, considering our patients were clinically overweight; however, this was not observed. Hence, we report in the literature for the first time that FPLH% is predictive for both hip and major fragility fractures even in patients who are clinically overweight. Our approach of considering regional variations in body fat seems to be superior to methods currently used. Hence, we make the recommendation to conduct further research to validate our findings, as well as investigating ways to incorporate such methods into future iterations of fracture risk calculators. Disclosure H. Amin: None. A. Khan: None. Z. Sultan: None. M. Bukhari: None.

Osteoporosis and major fragility fractures (MOF) in sarcoidosis patients: association with disease severity

BackgroundThe reports on bone mineral loss or major osteoporosis fracture (MOF) in sarcoidosis are scarce and have conflicting outcomes. This study aimed to evaluate the prevalence and risk factors of MOF in sarcoidosis patients.MethodsIn a single-center cohort of 382 patients with sarcoidosis (55.8 ± 11.6 years) we evaluated bone mineral density at lumbar spine, at femoral neck and at total hip and the presence of MOF. Lung function measurements including diffusion capacity for carbon monoxide (DLCO) were assessed. Chest X-rays were performed and radiological staging was done by Scadding score.ResultsNinety patients (23.6%) with sarcoidosis have history of a MOF. BMD T-scores were lower in sarcoidosis with MOF with respect to those without MOF, but the difference was statistically significant only for BMD at femoral neck (p < 0.05). Moreover, BMD values at total hip was positively correlated with DLCO (%) (p < 0.001). Prevalence of MOF was higher in patients with sarcoidosis with lung parenchymal involvement (radiological stages 2–4) than in patients with sarcoidosis in chest X-ray stages 0 and 1 (28.3 vs 19.2% respectively, p < 0.05). Moreover, multiple regression analyses showed that X-ray Scadding score was positively associated with MOF.ConclusionsThis study shows that MOF represent a common and important complication in patients with moderate/severe sarcoidosis. The chest X-ray evaluation and the pulmonary function test could allow to define the risk of MOF in sarcoidosis patients.

Long-term fracture risk in rheumatoid arthritis: impact of early sustained DAS28-remission and restored function, progressive erosive disease, body mass index, autoantibody positivity and glucocorticoids. A cohort study over 10 years

BackgroundRisk of fragility fractures in patients with rheumatoid arthritis (RA) is increased. Disease-related inflammation in RA is associated with low Bone Mineral Density (BMD). However, effects of specific disease factors on fracture occurrence and whether or not such disease effects are independent of BMD are unknown.MethodsAnalysis of fracture outcome in the prospective cohort of 2557 patients with early RA (67% women, mean age 58.1 ± 15.6 years) during an observation period of 10.6 ± 4.7 years. In 602 patients BMD was measured at baseline. The first major fragility fractures were considered. Kaplan-Meier and Cox regression analysis, adjusted for traditional factors, prior fracture, disease activity and period of inclusion, were used to estimate the risk of the outcome.ResultsDuring follow-up fracture occurred in 352 patients (13.8%), a rate of 13/1000 p-y. A proportional risk reduction for the outcome was associated with Body Mass Index (BMI) at baseline, BMI ≥ 30 kg/m2, and over the first two years sustained Disease Activity Score (DAS28)-remission, DAS28-low disease activity and Health Assessment Questionnaire (HAQ) ≤ 0.5. The proportional risk elevation for fractures was associated with BMI ≤ 20 kg/m2, DAS28 at baseline, 6-month and at 1-year, cumulative DAS28 over the two years, RF, erosion score progression at 2-year, HAQ score and HAQ ≥ 1 at 6-month and 1-year and showed a trend for ACPA positivity. The estimated fracture risk was increased in users of glucocorticoids (GC), associated with a higher GC-dosage at follow-ups and a higher cumulative dosage over two years, independently of disease activity. With adjustment for BMD, there was no difference in fracture outcome by exposure to GC. The effects of a higher BMI, DAS28-remission and low HAQ ≤ 0.5 attained at 6-month of treatment initiation and sustained up to 2 years, RF, ACPA, and erosion score progression at 2-year were independent of low BMD.ConclusionsThis analysis supports importance of RA-specific risk factors in early RA for future major fragility fractures. Treat-to-target strategy and restored functional capacity in early RA-disease are important to prevent fractures. Autoantibody positivity, progressively erosive disease, and low weight could have additional value for personalized fracture preventive strategies in early RA.

The total number of patients with any of four major fragility fractures decreased during the first wave of the COVID-19 epidemic in Japan, commencing before the state of emergency declaration, which was not as enforceable as lockdown.

This study aimed to investigate the impact of public health measures in the first wave of the COVID-19 epidemic on the occurrence of major fragility fractures (MFFs). Patients aged 50years or older who were hospitalized or had an initial visit as an outpatient for an MFF, defined as a proximal femoral fracture (PFF), vertebral fragility fracture (VFF), distal radius fracture (DRF), or a proximal humeral fracture (PHF), were included in this study. Three-phase interrupted time-series analyses were performed to evaluate the impact of the voluntary event cancellation request in late February 2020 and the emergency declaration in early April 2020 on changes in the total number of patients, including inpatients and first-visit outpatients. A total of 166,560 patients with MFFs were included (92,767 PFFs, 26,158 VFFs, 33,869 DRFs, and 13,766 PHFs). From the end of February, in seven prefectures with high proportions of urbanization, decreasing trends were estimated for level changes and slope changes in the total number of patients with any of the four MFFs (level change: PFF; point estimate; - 13.5 (95% CI; - 43.4, 16.5), VFF; - 15.3 (- 32.2, 1.5), DRF; - 16.1 (- 39.9, 7.6), PHF; - 1.9 (- 13.6, 9.8), slope change: PFF; - 4.8 (- 14.0, 4.4), VFF; - 3.0 (- 8.1, 2.2), DRF; - 0.6 (- 7.9, 6.7), PHF; - 2.4 (- 6.0, 1.2)). The findings suggested that the total number of patients with any of the four MFFs did not begin to decline from early April 2020 after the state of emergency was declared but earlier, in late February 2020.

Evolution of bone densitometry parameters and risk of fracture in coeliac disease: a 10-year perspective

BackgroundMetabolic bone disease is frequently found in patients with coeliac disease (CD). Despite its high prevalence, international guidelines are partially discordant about its management due to the lack of long-term data.MethodsWe retrospectively evaluated a large dataset of prospectively collected data of CD patients assessing the variation of DXA parameters and estimated fracture risk according to the FRAX® score in a 10-year follow-up. Incident fractures are reported, and the predictive ability of the FRAX® score is verified.ResultsWe identified 107 patients with low bone density (BMD) at the diagnosis of CD and a 10-year follow-up. After improving at the first follow-up, T-scores slowly reduced over time but with no clinically relevant differences between the first and last examination (lumbar spine: from − 2.07 to − 2.07, p = 1.000; femoral neck: from − 1.37 to − 1.55, p = 0.006). Patients with osteoporosis at the index measurement had more marked fluctuations than those with osteopenia; the latter group also showed minimal modifications of the FRAX® score over time. Six incident major fragility fractures occurred, with a good predictive ability of the FRAX® (AUC 0.826).ConclusionAdult CD patients with osteopenia and no risk factors had substantially stable DXA parameters and fracture risk during a 10-year follow-up. A dilated interval between follow-up DXA for these patients could be considered to reduce diagnosis-related time and costs, maintaining a 2-year interval for patients with osteoporosis or risk factors.

Bone fragility during the COVID-19 pandemic: the role of macro- and micronutrients.

Bone fragility is the susceptibility to fracture due to poor bone strength. This condition is usually associated with aging, comorbidities, disability, poor quality of life, and increased mortality. International guidelines for the management of patients with bone fragility include a nutritional approach, mainly aiming at optimal protein, calcium, and vitamin D intakes. Several biomechanical features of the skeleton, such as bone mineral density (BMD), trabecular and cortical microarchitecture, seem to be positively influenced by micro- and macronutrient intake. Patients with major fragility fractures are usually poor consumers of dairy products, fruit, and vegetables as well as of nutrients modulating gut microbiota. The COVID-19 pandemic has further aggravated the health status of patients with skeletal fragility, also in terms of unhealthy dietary patterns that might adversely affect bone health. In this narrative review, we discuss the role of macro- and micronutrients in patients with bone fragility during the COVID-19 pandemic.

Comparison between real-world practice and application of the FRAX algorithm in the treatment of osteoporosis

Background and aimsThe most recent guidelines suggest treating patients whose FRAX 10-year fracture risk scores are ≥ 20%. However, this method of evaluation does not take into account parameters that are nonetheless relevant to the therapeutic choice. Our aim was to compare the therapeutic choices for treatment based on a wider assessment (real-world practice) with those based on FRAX scores, taking 20% as the cut-off score.MethodsWe obtained the medical history, bone mineral density (BMD) values, and the presence of major fragility fractures in a sample of 856 postmenopausal women. The 10-year FRAX risk of major osteoporotic fracture was calculated, and patients were grouped into risk classes (“FRAX < 20%” = low, “FRAX ≥ 20%” = high); we then compared the treated and untreated patients in each class. After an average interval of 2.5 years, changes in lumbar and femoral BMD and appearances of new fragility fractures were recorded.Results83% of high-risk patients and 57% of low-risk patients were treated. The therapeutic decision was based mainly on densitometric values and the presence of vertebral fractures. At the 2.5 year follow-up, lumbar spine and femur BMD had decreased in the untreated group; 9.9% of the treated patients developed new vertebral fragility fractures, compared with 5.3% of the untreated patients.Discussion and conclusionsOur wider assessment designated as at high fracture risk a group of patients who had not been identified by the FRAX assessment. FRAX could underestimate the risk of fracture in older people, for which the therapeutic choice should consider a broader approach, also based on individual patient’s needs.

Effects of prior osteoporosis treatment on the treatment response of romosozumab followed by denosumab in patients with postmenopausal osteoporosis.

To investigate the effects of prior osteoporosis treatment on the response to treatment with romosozumab (ROMO) followed by denosumab (DMAb) in patients with postmenopausal osteoporosis. In this prospective, observational, multicenter study, treatment-naïve patients (Naïve; n = 55) or patients previously treated with bisphosphonates (BP; n = 37), DMAb (DMAb; n = 45) or teriparatide (TPTD; n = 17) (mean age, 74.6years; T-scores of the lumbar spine [LS] - 3.2 and total hip [TH] - 2.6) were switched to ROMO for 12months, followed by DMAb for 12months. Bone mineral density (BMD) and serum bone turnover markers were evaluated for 24months. A BMD increase was observed at 12 and 24months in the following patients: Naïve (18.2% and 22.0%), BP (10.2% and 12.1%), DMAb (6.6% and 9.7%), and TPTD (10.8% and 15.0%) (P < 0.001 between the groups at both 12 and 24months) in LS and Naïve (5.5% and 8.3%), BP (2.9% and 4.1%), DMAb (0.6% and 2.2%), and TPTD (4.3% and 5.4%) (P < 0.01 between the groups at 12months and P < 0.001 at 24months) in TH, respectively. The BMD increase in LS from 12 to 24months was negatively associated with the levels of bone resorption marker at 24months. Incidences of major fragility fractures for the respective groups were as follows: Naïve (5.5%), BP (16.2%), DMAb (11.1%), and TPTD (5.9%). Previous treatment affected the BMD increase of following treatment with ROMO, although it did not affect that of following treatment with DMAb after ROMO.

Dietary calcium intake in a cohort of individuals evaluated for low bone mineral density: a multicenter Italian study

BackgroundA low calcium intake is a well-known factor that influences the bone mineral density (BMD) maintenance. In the presence of inadequate calcium intake, secondary hyperparathyroidism develops, leading to an increased bone turnover and fracture risk.AimsTo assess the dietary calcium intake in relation with osteoporosis and fragility fracture in a cohort of Italian individuals evaluated for low BMD.MethodsA 7-day food-frequency questionnaire was administered to 1793 individuals, who were consecutively referred at the Centers of the Italian Society for Osteoporosis, Mineral Metabolism and Skeletal Diseases (SIOMMMS) for low BMD.ResultsIn 30.3% and 20.9% of subjects, the calcium intake was inadequate (< 700 mg/day) and adequate (> 1200 mg/day), respectively. As compared with patients with adequate calcium intake, those with inadequate calcium intake were younger (65.5 ± 10.8 vs 63.9 ± 11.5 years, p = 0.03) and they more frequently reported adverse reactions to food (3.2% vs 7.2% p = 0.01) and previous major fragility fractures (20.8% vs 27.0%, p = 0.03). Patients with calcium intake < 700 mg/day showed a higher prevalence of diabetes mellitus, idiopathic hypercalciuria and food allergy/intolerance (8.1%, 5.1%, 7.2%, respectively) than patients with calcium intake > 700 mg/day (5.3%, 3.0%, 4.1%, respectively, p < 0.04 for all comparisons), also after adjusting for age, gender and body mass index. In 30.3% of fractured subjects, the calcium intake was < 700 mg/day.DiscussionIn Italy, a low calcium intake is highly prevalent in individuals at risk for low BMD. Importantly, an inadequate calcium intake is highly prevalent even in patients with history of fragility fractures.ConclusionsOnly about a fifth of patients being assessed for low BMD in an Italian SIOMMMS referral Centre have an adequate calcium intake.

Prediction of femoral osteoporosis using machine-learning analysis with radiomics features and abdomen-pelvic CT: A retrospective single center preliminary study.

Osteoporosis has increased and developed into a serious public health concern worldwide. Despite the high prevalence, osteoporosis is silent before major fragility fracture and the osteoporosis screening rate is low. Abdomen-pelvic CT (APCT) is one of the most widely conducted medical tests. Artificial intelligence and radiomics analysis have recently been spotlighted. This is the first study to evaluate the prediction performance of femoral osteoporosis using machine-learning analysis with radiomics features and APCT. 500 patients (M: F = 70:430; mean age, 66.5 ± 11.8yrs; range, 50-96 years) underwent both dual-energy X-ray absorptiometry and APCT within 1 month. The volume of interest of the left proximal femur was extracted and 41 radiomics features were calculated using 3D volume of interest analysis. Top 10 importance radiomic features were selected by the intraclass correlation coefficient and random forest feature selection. Study cohort was randomly divided into 70% of the samples as the training cohort and the remaining 30% of the sample as the validation cohort. Prediction performance of machine-learning analysis was calculated using diagnostic test and comparison of area under the curve (AUC) of receiver operating characteristic curve analysis was performed between training and validation cohorts. The osteoporosis prevalence of this study cohort was 20.8%. The prediction performance of the machine-learning analysis to diagnose osteoporosis in the training and validation cohorts were as follows; accuracy, 92.9% vs. 92.7%; sensitivity, 86.6% vs. 80.0%; specificity, 94.5% vs. 95.8%; positive predictive value, 78.4% vs. 82.8%; and negative predictive value, 96.7% vs. 95.0%. The AUC to predict osteoporosis in the training and validation cohorts were 95.9% [95% confidence interval (CI), 93.7%-98.1%] and 96.0% [95% CI, 93.2%-98.8%], respectively, without significant differences (P = 0.962). Prediction performance of femoral osteoporosis using machine-learning analysis with radiomics features and APCT showed high validity with more than 93% accuracy, specificity, and negative predictive value.

Racial Disparities Exist in Outcomes After Major Fragility Fractures.

Fractures associated with postmenopausal osteoporosis (PMO) are associated with pain, disability, and increased mortality. A recent, nationwide evaluation of racial difference in outcomes after fracture has not been performed. To determine if 1-year death, debility, and destitution rates differ by race. Observational cohort study. US Medicare data from 2010 to 2016. Non-Hispanic black and white women with PMO who have sustained a fragility fracture of interest: hip, pelvis, femur, radius, ulna, humerus, and clinical vertebral. Outcomes included 1-year: (1) mortality, identified by date of death in Medicare vital status information, (2) debility, identified as new placement in long-term nursing facilities, and (3) destitution, identified as becoming newly eligible for Medicaid. Among black and white women with PMO (n = 4,523,112), we identified 399,000 (8.8%) women who sustained a major fragility fracture. Black women had a higher prevalence of femur (9.0% vs 3.9%; P < .001) and hip (30.7% vs 28.0%; P < .001) fractures and lower prevalence of radius/ulna (14.7% vs 17.0%; P < .001) and clinical vertebral fractures (28.8% vs 33.5%; P < .001) compared with white women. We observed racial differences in the incidence of 1-year outcomes after fracture. After adjusting for age, black women had significantly higher risk of mortality 1 year after femur, hip, humerus, and radius/ulna fractures; significantly higher risk of debility 1 year after femur and hip fractures; and significantly higher risk of destitution for all fractures types. In a sample of Medicare data from 2010 to 2016, black women with PMO had significantly higher rates of mortality, debility, and destitution after fracture than white women. These findings are a first step toward understanding and reducing disparities in PMO management, fracture prevention, and clinical outcomes after fracture. J Am Geriatr Soc 68:1803-1810, 2020.

MAKING OLD BONES: QUALITY IMPROVEMENT IN OSTEOPOROSIS MANAGEMENT IN A GERIATRIC PRIMARY CARE CLINIC

Osteoporotic fractures and their sequelae are a leading cause of morbidity and mortality in older adults. In the United States, nearly 50% of white women and 20% of black women and white men will suffer a fragility fracture in his or her lifetime. Osteoporosis medications reduce the risk of major fragility fracture by 31-62%, but numerous care gaps exist, including screening rates as low as 1-47% and treatment rates as low as 16-30% even after a fracture has already occurred. From January to August 2019, we conducted a multi-faceted quality improvement project at a university hospital-based geriatric primary care clinic, with a goal of improving our rates of osteoporosis screening and treatment. We designed and tested electronic health record-based registries of eligible patients, and developed patient outreach workflows and physician “inreach” workflows. We piloted a bone health clinic. While we did not meaningfully affect the rate of osteoporosis screening, our efforts resulted in an increase in treatment of osteoporosis from 49% to 53%. Documentation of osteoporosis decision making among eligible patients improved from 66% to 80%. In our clinic, ongoing barriers to evidence-based osteoporosis management include competition for time with other medical issues, patient mistrust of medications, and the complexity of decision making around osteoporosis in older adults with polypharmacy and limited life expectancy. Future work must balance the broad application of treatment guidelines via population health tools with the need to individualize treatment decisions for each patient’s overall health and goals of care.

Fragility fractures and imminent fracture risk in Hong Kong: one of the cities with longest life expectancies.

Imminent fracture risk, or fractures within 2years of an initial fracture, is a pressing issue worldwide. Hong Kong is a city with one of the longest life expectancies. The concern of fragility fractures and the imminent risk of a subsequent fracture is becoming a top priority. The objective of this study was to present the epidemiology of incident fragility fractures of all public acute hospitals and the imminent risk of a subsequent fracture in Hong Kong. This was a retrospective population-based analysis. Patient records from all acute hospitals in Hong Kong from 1 January 2004 to 31 December 2018 were retrieved for patients ≥ 50years of age with hip, distal radius, or proximal humerus fractures. Secondary fractures and falls were identified in the subsequent 5years. Post hoc analysis in recent 2013-2018 period was performed. Overall survival (re-fracture incidence) on age subgroups using Kaplan survival analysis and variables was compared using the log-rank test. Cox proportional hazard regressions, obtaining the hazard ratios (HR) and their respective 95% confidence intervals (CI), were used. There is an overall increasing trend of fragility fractures (hip, distal radius, proximal humerus) from 5596 in 2004 to 8465 in 2018. The average cumulative imminent risk of fractures from recent 5years is 3.87% at 1year and 6.50% at 2years. 49.5% of the patients with a secondary fracture occurred within 2years since the initial major fragility fracture. Post hoc analysis in recent 2013-2018 period (N = 7039) showed male patients were 1.21 times more likely to have further fractures with time (HR = 1.21 (1.02, 1.45), p = 0.03) compared with female patients. Patients over age 95 were 2.01 times higher than patients of age under 75 to have further fracture over time. Following an initial fracture, prompt treatment strategies should be adopted to avoid imminent risk of fractures. This window of opportunity in the first 2years is a golden period to treat osteoporosis and prevent falls. Our post hoc analysis has shown that male patients and patients older than 95 are at even higher risk. Clinicians and allied healthcare professionals should be alert on these patients.

Russian federal clinical guidelines on the diagnostics, treatment, and prevention of osteoporosis

Screening using the Fracture Risk Assessment Tool (FRAX) is recommended in all postmenopausal woman and mеn over 50 (A1) in order to identify individuals with high probability of fractures. It is recommended to diagnose osteoporosis and start treatment in patients with fragility fracture of large bones of the skeleton and/or high individual probability of major fragility fractures (FRAX) and/or detected decrease in bone mineral density (BMD) up to –2.5 T-score as assessed by DXA in the femoral neck and/or lumbar vertebrae (A1). Patients with back pain, lifetime height loss of 4 cm or height loss of 2 cm since a previous medical examination, those who receive glucocorticoids, patients with long lasting decompensated type 2 diabetes mellitus, or those receiving insulin therapy, as well as patients who were previously diagnosed with fragility fractures at the other sites are advised to underwent standard lateral X-ray imaging of the spine (Th4—L5) in order to verify the presence of compression vertebral fractures (B1).&#x0D; Dual-energy X-ray absorptiometry (DXA) is recommended for individuals whose 10-year probability of major osteoporotic fracture (FRAX) falls within the medium risk group (B1). It is recommended to include the trabecular bone score (TBS) the FRAX algorithm in order to improve the sensitivity of this method (B1).&#x0D; Laboratory testing is recommended for the differential diagnosis with other causes of increased skeletal fragility in all patients with newly diagnosed osteoporosis and when previously prescribed antiosteoporostic treatment was ineffective (B1).&#x0D; Bisphosphonates (BPs), antibodies to receptor activator of nuclear factor kappa-beta ligand (RANKL) (denosumab), or parathyroid hormone analogue (teriparatide) are equally recommended to prevent fragility fractures and increase BMD in patients with osteoporosis (A1). Denosumab is also recommended to prevent BMD loss and fractures in females receiving aromatase inhibitors therapy for breast cancer and males with prostate cancer receiving hormone-deprivation therapy and having no bone metastases (A1). Since teriparatide has the anabolic effect, it is recommended as the first line treatment in patients with severe osteoporosis having history of vertebral fractures, in the individuals with very high risk of fragility fractures, or in the cases when antiresorptive treatment was ineffective (B1). All medications for treatment of osteoporosis are recommended in combination with calcium and vitamin D supplements (A1).

Parity and Lactation Are Not Associated with BMD Loss or Incident Major Fragility Fractures Over 15 Years: Canadian Multicentre Osteoporosis Study (CaMos)

Background: Pregnancy and especially lactation cause loss of bone mass and microarchitecture that may not be completely restored. Although cross-sectional studies in older women have reported that parity and lactation are neutral or protective against fragility fractures, longitudinal data are lacking. CaMos is a randomly selected cohort of >6000 women who have been followed for up to 15 years, with annual, verified incident fractures, and 5-yearly bone density assessments.

Individualized fracture risk prediction

Fractures are a growing problem today and an urgent public health challenge due to the increasing proportion of older people and the increasing incidence of fractures. Osteoporotic fragility fractures are common in men as well as women. More than 50% of women and more than 25% of men aged older than 50 years will sustain a fragility fracture in their remaining lifetime. Moreover, it is clear that initial fragility fractures signal much increased risk of further fractures, and several studies support the relationship between major (proximal) fragility fractures and premature mortality. Subsequent fracture risk is highest in the first years after the initial fracture. Therefore, it is important to identify patients at high risk for fractures and subsequent fractures for whom treatment would be most effective.

Low-trauma fractures without osteoporosis.

In clinical practice, areal bone mineral density (aBMD) is usually measured using dual-energy X-ray absorptiometry (DXA) to assess bone status in patients with or without osteoporotic fracture. As BMD has a Gaussian distribution, it is difficult to define a cutoff for osteoporosis diagnosis. Based on epidemiological considerations, WHO defined a DXA-based osteoporosis diagnosis with a T-score <-2.5. However, the majority of individuals who have low-trauma fractures do not have osteoporosis with DXA (i.e., T-score <-2.5), and some of them have no decreased BMD at all. Some medical conditions (spondyloarthropathies, chronic kidney disease and mineral bone disorder, diabetes, obesity) or drugs (glucocorticoids, aromatase inhibitors) are more prone to cause fractures with subnormal BMD. In the situation of fragility fractures with subnormal or normal BMD, clinicians face a difficulty as almost all the pharmacologic treatments have proved their efficacy in patients with low BMD. However, some data are available in post hoc analyses in patients with T score >-2. Overall, in patients with a previous fragility fracture (especially vertebra or hip), treatments appear to be effective. Thus, the authors recommend treating some patients with a major fragility fracture even if areal BMD T score is above -2.5.

Recommendations on hip fractures.

Hip fractures among the elderly are one of the major fragility fractures in terms of quality of life, health outcomes and medical costs [1]. Since mortality and morbidity are high, hip fractures have a direct impact on public health [2] and are one of the main reasons for disability [3]. Increases in age-adjusted incidence of falls with accompanying deterioration in age-adjusted bone quality may explain the reason for osteoporotic hip fractures among the elderly [2]. According to United Nations records from 2009, the average lifetime of human beings was 56 years in 1970; by 2000 it rose to 65 and by the year 2050 it is expected to be 75.5 years (73.3 for men and 77.9 for women) [4]. According to some epidemiological studies, there were 1.66 million hip fractures worldwide in 1990. Epidemiological projections estimate these annual figures to rise to 6.25 million by 2050 [2]. In another epidemiological study, the total number of hip fractures in 1990 was found to be 1.26 million; this is estimated to approximately double to 2.6 million by 2025 and to 4.5 million by 2050 [5]. As advances in medicine and healthcare awareness increase, life expectancy at birth and lifetime spans will rise exponentially. Management of hip fractures requires a wide spectrum of approaches, from prevention to postoperative care [6]. The socioeconomic impact of hip fractures is increasing on a worldwide scale, and there is a need to develop preventive strategies [5] as well as evidence-based treatment protocols to minimise the enormous social burden of these fractures. Given that hip fractures are common, costly injuries with a complex treatment journey that is complicated by comorbidities in the elderly patient group, building clinical recommendations is an important and challenging topic if one considers that infrastructures do vary among European countries. These recommendations are therefore proposals for medical treatment in typical situations, and do not constitute legally committing rules to be observed. ESTES study group, proximal femur Cem Copuroglu Turkey Dominik Heim Switzerland Christoph Josten Germany Richard Kdolsky Austria Radko Komadina Slovenia Hans-Jorg Oestern Germany Henrik Palm Denmark Jan Bernard Sintenie The Netherlands Klaus Wendt The Netherlands Open in a separate window The European Society for Trauma and Emergency Surgery (ESTES) Study Group was formed in 2014 with the aim of developing ESTES recommendations on proximal hip fractures. After a review of the recent literature and already existing guidelines in several European countries the members of the study group wrote a concept of the different parts of the recommendations. On a consensus meeting in September 2014 in Frankfurt a definitive version of the recommendations was formulated and agreed by all study group members. The recommendations on hip fractures are approved by the ESTES board.

FES-rowing attenuates bone loss following spinal cord injury as assessed by HR-pQCT.

Neurologically motor complete spinal cord injury (SCI) presents a unique model of bone loss whereby specific regional sites are exposed to a complete loss of voluntary muscle-induced skeletal loading against gravity. This results in a high rate of bone loss, especially in the lower limbs where trabecular bone mass decreases by ~50-60% and cortical bone mass decreases by 25-34% before the rate of bone loss slows. These SCI-induced losses that are likely superimposed on continual age-related bone losses, increase the risk of low-impact fragility fracture. The fracture incidence 20 years post SCI is reported to be 4.6% per year. An intervention that effectively prevents, attenuates, or reverses bone loss is therefore highly desirable. We present a case study of an individual with chronic complete SCI, where bone loss has been attenuated following long-term functional electrical stimulation (FES)-rowing training. In this case study, we characterize the ultradistal tibia and ultradistal radius of the FES-rower with chronic complete SCI using high-resolution-peripheral quantitative computed tomography. These data are compared with a group of FES-untrained individuals with chronic complete SCI and to a normative non-SCI cohort. The evidence suggests, albeit from a single individual, that long-term FES-rowing training can attenuate bone loss secondary to chronic complete SCI. Indeed, key FES-rower's bone metrics for the ultradistal tibia more closely resemble normative age-matched values, which may have clinical significance since the majority of fragility fractures in chronic SCI occur in the lower extremities.