Postfracture Period Research Articles

Who crashes their car following wrist fracture?

BackgroundWrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood. Purpose(1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture. Study DesignRetrospective cohort study. MethodsThree state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar’s tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period. ResultsData relating to 37,107 adults revealed a 3.3% (95% CI 3.0%–3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07–3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries. ConclusionsThese results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture.

Longitudinal Patterns of Postfracture Outpatient Physical Therapy and Occupational Therapy Use and Its Association With 3-Year Mortality Among Adults With Cerebral Palsy.

Fragility fractures are common among adults with cerebral palsy (CP), but clinical rehabilitation use after fracture and its effect on long-term health outcomes have not been sufficiently studied. The objectives of this study were to identify patterns of the use of physical therapy, occupational therapy, or both in the 6-month postfracture period and the association with 3-year mortality in adults with CP. This retrospective cohort study included adults who were ≥18years old, had CP, and had sustained an incident fragility fracture between January 1, 2014, and December 31, 2016, as identified from a random 20% Medicare fee-for-service dataset. Six-month outpatient physical therapy or occupational therapy use patterns after fracture were identified using group-based trajectory modeling. Cox regression determined the association between physical therapy or occupational therapy use trajectory patterns and mortality from 6months to 3years after fracture, adjusting for confounders. Effect modification by key characteristics was tested, including age, sex, and the modified Whitney Comorbidity Index (mWCI), which is a CP-specific comorbidity index that better captures overall medical complexity. Of the 2429 participants included, the majority (73.2%) were characterized as having little to no probability of physical therapy or occupational therapy use, whereas 16.0 and 10.7% were characterized as having early initiation and later initiation, respectively. Compared to the mortality rate for the little to no physical therapy or occupational therapy group, the mortality rates were 26% lower for the early physical therapy or occupational therapy initiation group (hazard ratio [HR] = 0.74; 95% CI = 0.55-1.00) and were 20% lower for the later initiation group (HR = 0.80; 95% CI = 0.57-1.12). There was effect modification by the mWCI. The mortality rate was lower when the early initiation and later initiation groups were compared to the little to no initiation group across all mWCI values examined (median and interquartile range), but the effect was stronger (ie, lower mortality rate) for lower mWCI values for both early initiation and later initiation groups. Most adults with CP underutilize outpatient physical therapy or occupational therapy services within 6months postfracture. Early or later initiation versus little to no physical therapy or occupational therapy use was associated with a lower HR of mortality, although the effect was stronger and statistically significant among those with less medical complexity. Throughout their lives, the use of rehabilitation services in individuals with CP, including physical therapy and occupational therapy, dramatically declines despite the need for continued rehabilitation across their lifespans. This study characterized longitudinal physical therapy or occupational therapy use patterns in the 6months following a fragility fracture among adults with CP and found that nearly 3 in 4 adults with CP had little to no physical therapy or occupational therapy use during this critical window to optimize postfracture health and function. Further, those who more regularly used physical therapy or occupational therapy services, regardless of the timing of initiation (early vs later), had significantly improved survival up to 3years after fracture, suggesting the need for greater access to and delivery of clinical rehabilitation services.

Post-Fracture Care Program: Pharmacological Treatment of Osteoporosis in Older Adults with Fragility Fractures.

To present and discuss the recently published scientific evidence on the approach, mode of action, and timing of osteoporosis therapy initiation after fragility fractures. A comprehensive management approach is required to reduce mortality and morbidity associated with fragility fractures. This will help to reduce the risk of missing the diagnosis of osteoporosis as the underlying disorder while at the same time promoting the timely treatment of osteoporosis. The target is to minimize the incidence of post-traumatic disability and to reduce the imminent fracture risk. This article will present a Bone-Care algorithm for the diagnosis and management of fragility fractures in patients presenting for trauma surgery. This algorithm has been developed based on recently published national as well as international guidelines for implementation in standard clinical practice. International figures revealed that only a small proportion of those patients at high risk of sustaining a fragility fracture receive osteoporosis therapy. Based on the best currently available evidence, it is safe to start osteoporosis therapy in the acute post-fracture period (the optimal therapeutic window of romosozumab is the late endochondral phase/throughout bone remodeling). The right Bone-Care pathway ensures the delivery of a comprehensive management approach that meets the global call to action. All parameters including risk, benefit, compliance, and cost should be considered on an individual base for all kinds of therapy.

Development and validation of a self-care scale for older adults undergoing hip fracture surgery: the HFS-SC

BackgroundThe ability to take care of oneself after hip fracture surgery is important for older adults. Various scales have been developed for evaluation of this ability, but a scale specifically focusing on hip fracture has not been developed. The aim of this study was to develop and validate a scale (Hip Fracture Surgery Self-Care Scale, HFS-SC) to evaluate self-care for older adults undergoing hip fracture surgery.MethodsThe scale was developed according to the guidelines by DeVellis. Initial items were derived from a literature review and individual interviews with 11 older adults who underwent hip fracture surgery. To confirm the suitability of the questions, a preliminary survey was conducted on 25 older adults. Psychometric testing was performed on 300 older adults 65 years old or over living at home after surgery for hip fracture. Psychometric properties of the scale were examined by content validity, construct validity, concurrent validity, internal consistency reliability, and test-retest reliability.ResultsExploratory factor analysis and confirmatory factor analysis demonstrated that the 18-item scale comprised five factors (functional independence, symptom recognition and management, positive mental health, participation and support in social activities, and a safe environment). The results of EFA showed that the factor loadings ranging from 0.51 to 0.87. The results of CFA were χ2=375.83, χ2/df=2.14, RMSEA 0.07, SRMR 0.05, GFI 0.88, TLI 0.91, and CFI 0.92 for the 18-item scale. The reliabilities of the scale were 0.91 for Cronbach’s alpha and 0.82 for test-retest reliability.ConclusionsThe HFS-SC has acceptable validity and reliability and is expected to be useful for evaluating the levels of self-care for older adults undergoing hip fracture surgery and adjusting at the post-fracture period at the community or out-patient department.

Timing of osteoporosis therapies following fracture: the current status.

In most patients, osteoporosis is diagnosed only after the occurrence of the first fragility fracture. It is of utmost importance to start osteoporosis medications immediately in these patients to prevent future fractures and also to reduce associated mortality and morbidity. There remains a hesitancy over initiating osteoporotic medications, specifically for antiresorptive agents like bisphosphonates following an acute fracture due to concern over their effect on fracture healing. The purpose of this review is to study the effect of the timing of initiation of different osteoporosis medications on healing after an acute fracture. Most of the human studies, including randomized control trials (RCTs), did not find any significant negative effect on fracture healing with early use of bisphosphonate after an acute fracture. Anabolic agents like teriparatide have shown either neutral or beneficial effects on fracture healing and thus can be started very early following any osteoporotic fracture. Although human studies on the early use of other osteoporosis medications like denosumab or strontium ranelate are very sparse in the literature, none of these medications have shown any evidence of delay in fracture healing. To summarize, among the commonly used anti-osteoporosis agents, both bisphosphonates and teriparatide are safe to be initiated in the early acute post-fracture period. Moreover, teriparatide has shown some evidence in favor of reducing fracture healing time.

Особенности показателей функциональной активности и риска остеопоротических переломов у больных с переломами бедренной кости и костей голени (результаты 12-месячного наблюдения)

Актуальность. На сегодняшний день переломы костей нижней конечности составляют от трети до половины переломов в их общей структуре, приводя к повышению показателей заболеваемости и смертности. Частота осложнений после этих переломов остается высокой, полное функциональное выздоровление отмечается не у всех больных. Актуальной остается надлежащая оценка функциональной активности пациентов в послепереломном периоде и риска последующих переломов. Цель — изучение показателей функциональной активности и риска остеопоротических переломов у больных старших возрастных групп с переломами костей нижней конечности различной локализации. Материалы и методы. Обследованы 72 человека с переломом проксимального отдела бедренной кости (ППОБК, n = 23) и костей голени (ПКГ, n = 49). Лонгитудинальное наблюдение за больными проводили в течение 12 мес. с оценкой показателей в канун перелома (ретроспективно) и через 6 и 12 мес. после него. Методы обследования: осмотр, опрос, общеклиническое, антропометрическое и ортопедическое обследование. Анкетирование проводили с использованием опросников Lower Extremity Functional Scale (LEFS) и Fracture Risk Assessment Tool (FRAX), которые пациенты заполняли самостоятельно под контролем врача. Результаты. Показатели анкеты LEFS у больных с ПКГ достоверно связаны с возрастом, полом, показателями роста, индекса массы тела, 10-летним риском основных остеопоротических переломов и переломов бедренной кости. У женщин с ППОБК показатели анкеты LEFS накануне перелома были достоверно ниже по сравнению с соответствующими у лиц с ПКГ и также были связаны с возрастом. Через 6 мес. после ПКГ и ППОБК показатели анкеты LEFS достоверно снижаются по сравнению с исходными данными, что свидетельствует об ухудшении функциональных возможностей больных. Через 12 мес. после ПКГ и ППОБК показатели анкеты LEFS достоверно возрастают и не отличаются от исходных у лиц с ППОБК, хотя не достигают исходного уровня у больных с ПКГ. Показатели 10-летнего риска основных остеопоротических переломов и переломов бедренной кости, по данным анкеты FRAX, достоверно не отличаются у обследованных в зависимости от локализации перелома, и они выше у женщин с ПКГ по сравнению с соответствующими параметрами у мужчин. Выводы. Все вышеперечисленное необходимо учитывать при планировании лечебно-профилактических и реабилитационных мероприятий у лиц старших возрастных групп с переломами костей нижних конечностей.

The Effect of Fracture Recency on Observed 10-Year Fracture Probability: A Registry-Based Cohort Study.

FRAX estimates 10-year fracture major osteoporotic fracture (MOF) and hip fracture probability from multiple risk factors. FRAX does not consider prior fracture site or time since fracture. Fracture risk is greater in the initial 2-year post-fracture period (imminent risk), implying that FRAX may underestimate risk in this setting. We used the population-based Manitoba Bone Mineral Density (BMD) Program registry to examine the effect of fracture recency and site on incident fracture risk predictions using FRAX. We identified women aged 40 years or older with baseline BMD and FRAX scores. Observed fracture outcomes to 10 years were compared with predicted 10-year fracture probability stratified by prior fracture status: none, recent (<2 years [median 0.3 years]), and remote (≥2 years [median 10.6 years]). For women with recent fractures, we also examined proposed multipliers to adjust FRAX for the effect of fracture recency and site. The cohort comprised 33,465 women aged 40 to 64 years (1897 recent fracture, 2120 remote fracture) and 33,806 women aged ≥65 years (2365 fracture, 4135 remote fracture). Observed fracture probability was consistent with predicted probability in most analyses. In women aged 40 to 64 years, there was a significant effect of recent vertebral and humerus fracture on MOF (observed to predicted 1.61 and 1.48, respectively), but these effects were still lower than the proposed multipliers (2.32 and 1.67, respectively). No significant effect of fracture recency was found after hip or forearm fracture in either age group. Our findings contribute to accumulating evidence of the importance of recent fracture. The effect of fracture recency was not consistent across fracture sites and with a lower magnitude than previously reported. Further quantification of effect size and specificity in additional independent cohorts is warranted to validate and refine recent-fracture multipliers in fracture risk assessment. © 2022 American Society for Bone and Mineral Research (ASBMR).

Secondary Fracture Prevention: Consensus Clinical Recommendations From a Multistakeholder Coalition.

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk offuture fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the riskfor second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring foradverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). (c) 2019 American Society for Bone and Mineral Research. (Less)

Timing of Bisphosphonate Initiation After Fracture: What Does the Data Really Say?

Introduction:Osteoporosis is often not clinically recognized until after a fracture occurs. Individuals who have 1 fracture are at increased risk of future fractures. Prompt initiation of osteoporosis treatment following fracture is critical to reducing the rate of future fractures. Antiresorptives are the most widely used class of medications for the prevention and treatment of osteoporosis. Many providers are hesitant to initiate antiresorptives in the acute post-fracture period. Concerns include interference with bone remodeling necessary for successful fracture healing, which would cause increased rates of non-union, malunion, and refracture. While such concerns should not extend to anabolic medications, physicians may also hesitate to initiate anabolic osteoporosis therapies due to high cost and/or lack of familiarity. This article aims to briefly review the available data and present a digestible narrative summary to familiarize practicing orthopaedic surgeons with the essential details of the published research on this topic.Results:The results of 20 clinical studies and key pre-clinical studies related to the effect of anti-resorptive medications for osteoporosis on fracture healing are summarized in the body of this narrative review.Discussion & Conclusions:While few level I studies have examined the impact of timing of initiation of osteoporosis medications in the acute post-fracture period, the few that have been published do not support these concerns. Specifically, data from level I clinical trials indicate that initiating bisphosphonates as early as 2 weeks post-fracture does not increase rates of non-union or malunion. By reviewing the available data, we hope to give clinicians the confidence to initiate osteoporosis treatment promptly post-fracture.

Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition.

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). © 2019 American Society for Bone and Mineral Research.

Incidence and Economic Burden of Intertrochanteric Fracture: A Medicare Claims Database Analysis.

Background:There is limited information on current cost estimates associated with intertrochanteric hip fractures in the United States. The purpose of the present study was to estimate the incidence and economic burden of both intertrochanteric and all hip fracture types in the Medicare patient population to the U.S. health-care system.Methods:This retrospective database analysis of the 2014 Medicare database involved Standard Analytic File (SAF) 5% sample claims and total enrollment files. Patients ≥65 years of age with a new principal diagnosis of hip fracture (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 820.xy) who were continuously enrolled for 18 months were included; those with intertrochanteric hip fracture were further identified with use of ICD-9-CM code 820.21. The total direct medical costs associated with hip fracture in the 90-day and 12-month post-fracture periods were estimated. The relevant costs were estimated on the basis of a propensity-score-matched analysis. The health-care services responsible for major expenses within the 90-day episode-of-care period were also identified.Results:The total annual direct medical costs associated with all hip fractures was $50,508 per patient, resulting in a yearly estimate of $5.96 billion to the U.S. health-care system. Intertrochanteric hip fractures accounted for an annual estimate of $52,512 per patient, corresponding to an overall annual economic burden of $2.63 billion to the U.S. health-care system and representing 44% of all hip fracture costs. Inpatient hospitalization and skilled nursing facility services jointly accounted for 76.3% of the $44,135 estimated cost per patient and 75.6% of the $42,388 estimated cost per patient within the 90-day post-acute care period for intertrochanteric and all hip fractures, respectively.Conclusions:Hip fracture represents a substantial economic burden to the U.S. health-care system, accounting for $5.96 billion per year, with intertrochanteric hip fracture accounting for 44% of total costs.Level of Evidence:Economic and decision analysis, Level IV. See Instructions for Authors for a complete description of levels of evidence.Clinical Relevance:The present study provides a comprehensive and updated annual estimate of the economic burden of all hip fracture types and estimates the economic burden of intertrochanteric hip fractures in the Medicare population; to our knowledge, prior availability of this information in the literature is limited.

Mortality After Osteoporotic Fractures: What Proportion Is Caused by Fracture and Is Preventable?

Mortality After Osteoporotic Fractures: What Proportion Is Caused by Fracture and Is Preventable?

Effect of calcitonin in the outcome of distal radial fractures in elderly patients

Background: Distal radial fractures are common and produce significant morbidity in elderly osteoporotic individuals. Calcitonin prevents bone resorption in osteoporotic individuals and hence can reduce morbidity in the immediate post fracture period. But scientific evidence regarding its efficacy in improving pain and functional abilities is lacking. Hence this study is being done to assess the clinical and radiological parameters after calcitonin usage in immediate post fracture period. Methods: 50 elderly patients with distal radial fractures treated conservatively with plaster application were randomly divided into two groups. One group received 400 IU of nasal salmon calcitonin daily for 6 months and the other group did not receive it. Demographic data of patients, co-morbid illnesses, and AO type were recorded. Patients were followed at 2, 4, 6, 8, 12 and 24 weeks post fracture. Their pain score (VAS), functional abilities with Mayo wrist score and radiological union were assessed. Statistical analysis was done with student t test and pearson correlation. Results: VAS score improved significantly from 9.57 to 2 in calcitonin group compared to 9.31 to 4.42 in non-calcitonin group. Mayo wrist score showed significant difference in calcitonin group. Fracture union and radiological parameters were comparable in both groups with no statistical significance. CRPS was less frequent in patients who took calcitonin. Conclusion: Calcitonin improves pain and functional outcome in elderly patients with distal radial fractures, reducing the incidence of CRPS. We recommend its routine usage in osteoporotic individuals with distal radial fractures predisposed for CRPS.

Diagnosis and Treatment of Osteoporosis Before and After Fracture: A Side-by-Side Analysis of Commercially Insured and Medicare Advantage Osteoporosis Patients.

Although treatment for osteoporosis is recommended by U.S. clinical guidelines, a lack of diagnosis and treatment is common among patients with osteoporotic fractures. To determine the rates of osteoporosis diagnosis and treatment before and after various types of fractures. This was a retrospective claims analysis using data from the Humana Medicare Advantage claims (Medicare group) and Optum Insight Clinformatics Data Mart commercial claims (Commercial group). Patients included in the study had a claim for a qualifying fracture occurring between January 2008 and December 2013 (the index fracture), were continuously enrolled in the health plan for ≥ 1 year before and after the index fracture, and were aged ≥ 65 years in the Medicare group or ≥ 50 years in the Commercial group at the time of the index fracture. Fragility fractures and osteoporosis diagnoses were identified from ICD-9-CM codes. Treatment for osteoporosis included oral and injectable therapies identified by National Drug Code numbers and Healthcare Common Procedure Coding System codes. Diagnosis and treatment rates were assessed during the 1-year periods before and after the index fracture. All analyses were conducted by fracture type (vertebral, hip, nonhip/nonvertebral [NHNV], and multiple), with stratification by age and sex. No comparisons were made between the Medicare and Commercial groups; rather, McNemar tests were used to compare prefracture versus postfracture diagnosis and treatment rates within each group. For inclusion in the Medicare group, 45,603 patients were identified, and 54,145 patients were identified for the Commercial group. In the prefracture period, the osteoporosis diagnosis rates ranged from 12.0% (NHNV) to 21.5% (vertebral) in the Medicare group and from 5.3% (NHNV) to 12.1% (vertebral) in the Commercial group. In the postfracture period, diagnosis rates significantly increased (P < 0.001)-and nearly doubled-for all fracture types but did not exceed 42.1% (vertebral) in the Medicare group and 27.7% (vertebral) in the Commercial group. Pre-index treatment rates were similarly low, ranging from 9.4% (hip) to 16.6% (vertebral) among Medicare patients, and 7.5% (NHNV) to 14.4% (vertebral) in Commercial patients. Osteoporosis treatment rates improved significantly in the postfracture year, ranging from 12.5% (NHNV) to 26.5% (vertebral) among Medicare patients, and 8.3% (NHNV) to 21.4% (vertebral) in Commercial patients. Larger increases in diagnosis rates and smaller increases in treatment rates were observed in stratified analyses of men and women and of different age groups, with women and older patients having higher overall rates of diagnosis and treatment before and after fracture. In men and women, osteoporosis diagnosis rates were low before the index fracture and improved substantially after the fracture, yet still remained low overall (under 50%). Osteoporosis treatment rates among patients experiencing a fracture were low before the index fracture and improved only minimally afterwards. This study was funded by Merck & Co. Other than through the employer relationship disclosed here, Merck & Co. did not have a role in the study design, data collection, interpretation of the data, in writing of the manuscript, or in the decision to submit the manuscript for publication. Weaver is an employee of Merck & Co. Sajjan was an employee of Merck & Co. and owned stock in the company at the time of the study. Lewiecki has received consulting and/or speaker honoraria from Merck & Co., AbbVie, AgNovos Healthcare, Alexion Pharmaceuticals, Amgen, Eli Lilly and Company, Radius Health, Shire, and TheraNova, along with research grant support from Merck & Co., Amgen, and Eli Lilly and Company, and serves as a board member for the National Osteoporosis Foundation, the International Society for Clinical Densitometry, and the Osteoporosis Foundation of New Mexico. Harris has received consulting honoraria from Merck & Co., Alexion Pharmaceuticals, Amgen, Eli Lilly and Company, Gilead Sciences, Primus Pharmaceuticals, and Radius Health. Study concept and design were contributed by Weaver and Sajjan. Sajjan collected the data, and data interpretation was performed by all the authors. The manuscript was written and revised by Weaver, Lewiecki, and Harris.

Estimating the long-term functional burden of osteoporosis-related fractures.

Although fractures are associated with short-term reductions in functional status and may have other short-term effects on healthcare utilization (hospitalization and follow-up care), there is limited information on long-term burden of fracture beyond 12 to 24months post-fracture. Analysis of the long-term health burden can inform policymakers, health care practitioners, and payers. We acquired a data set containing the 1992-2012 Health and Retirement Survey data linked to the same individuals' Medicare claims. Fracture cases (n=745) were matched to non-fracture controls using propensity scores matching. A regression-adjusted difference-in-difference (DD) approach was used to compare the change in functional status measures from baseline to two post-fracture periods for fracture cases relative to the change over the same time periods for matched controls. Self-reported measures of functional status were examined: limitations to activities of daily living (ADLs), limitations to instrumental activities of daily living (IADLs), a mobility index, a gross motor skills index, a fine motor skills index, and self-reported general health status. Fracture cases reported increases in limitations to ADLs, difficulties with mobility, difficulties with gross motor skills, and difficulties with fine motor skills in each HRS collection period (the survey is administered every 2years) following the fracture or index date (thus up to twoyears later) than matched controls (all p values<0.05). The magnitude of these effects diminished in the second post-fracture wave (two to fouryears after fracture/index date), but they were still statistically significant. Results suggest that fractures are associated with significant declines in some measures of functional activities up to twoyears following the fracture. The effects persist beyond twoyears but are smaller in magnitude.

Utilization of osteoporosis medication after a fragility fracture among elderly Medicare beneficiaries.

Osteoporosis medications are recommended for elderly patients after a fragility fracture, but under-treatment is common. We determined osteoporosis medication use after fragility fractures and examined associated factors. Our cohort included elderly (age ≥66years) Medicare-enrolled patients who sustained fragility fractures January 1, 2008-December 31, 2011. Osteoporosis medication prescriptions were determined in the 12months after the index fracture. Using multivariate logistic models, we examined the association between post-fracture osteoporosis medication use and predictors. Of 145,185 patients with fragility fractures (mean age 80.9±7.8years; 91.2% white; 81.3% female), 29.9% sustained hip, 31.8% vertebral, and 38.4% non-hip-non-vertebral fractures. Overall, 30.4% of the cohort received an osteoporosis medication in the 12-month post-fracture period. Of patients not receiving an osteoporosis medication in the pre-index period (n=108,344), 14.9% of all patients, 16.3% of women, and 10.3% of men received one in the post-fracture period. Corresponding values for patients receiving an osteoporosis medication in the pre-index period (n=36,841) were 76.2, 76.5, and 72.2%. Odds of post-fracture osteoporosis medication use were 68% higher for women than for men. Osteoporosis diagnosis (odds ratio, 1.55; P<0.0001) and bone-mineral-density tests before an index fracture (odds ratio, 1.24; P<0.001) were associated with post-fracture osteoporosis medication use. Less than one third of our cohort received an osteoporosis medication in the post-fracture year, when risk of a second fragility fracture is highest. In those not already previously treated with an osteoporosis medication, only about 1 in 7 patients received treatment.

Sensorimotor dysfunction after limb fracture - An exploratory study.

Chronic pain is often associated with sensorimotor dysfunction but little is known about the early impact of limb fracture on sensory and motor performance. This exploratory study sought to assess these changes in patients with recent wrist and ankle fractures. A secondary aim was to determine the incidence of Complex Regional Pain Syndrome (CRPS) and its clinical features. Fifty-three patients at a UK fracture centre underwent Quantitative Sensory Testing (QST), Motor Imagery (MI) and Body Perception Disturbance (BPD) assessments ≤5weeks post-fracture (Time 1). Subjective evaluation of recovery and clinical examination for CRPS was conducted 5weeks later (Time 2, 50 patients). Patient-reported outcomes of pain, psychological distress and limb function were collected at Times 1 and 2, and 6months after T1 (Time 3, 36 patients, postal questionnaire). Quantitative sensory testing at Time 1 demonstrated cold and pressure-pain hyperalgesia in the fractured limb compared to the non-fractured side (p<0.05). Imagined movements were reported as significantly more difficult to perform on the fractured side (p<0.001). There was evidence of BPD in the fractured limb, similar to that found in CRPS. The incidence of CRPS was 9.4%; however, individual signs and symptoms of the condition were commonly present (70% reported ≥ one symptom). Only 33% of patients reported to being 'back to normal' 6months after fracture with 34% reporting ongoing pain. Limb fracture is associated with changes in pain perceptions, motor planning, and disruption to body perception. Signs and symptoms of CRPS, ongoing pain and delayed recovery post-fracture are common. WHAT DOES THIS STUDY ADD?: In the immediate post-fracture period: Body perception disturbance is reported in the fractured limb. Imagined movements of the fractured limb are less vivid and associated with pain This study contributes to the incidence literature on CRPS.

Structural strength of cancellous specimens from bovine femur under cyclic compression

The incidence of osteoporotic fractures was estimated as nine million worldwide in 2000, with particular occurrence at the proximity of joints rich in cancellous bone. Although most of these fractures spontaneously heal, some fractures progressively collapse during the early post-fracture period. Prediction of bone fragility during progressive collapse following initial fracture is clinically important. However, the mechanism of collapse, especially the gradual loss of the height in the cancellous bone region, is not clearly proved. The strength of cancellous bone after yield stress is difficult to predict since structural and mechanical strength cannot be determined a priori. The purpose of this study was to identify whether the baseline structure and volume of cancellous bone contributed to the change in cancellous bone strength under cyclic loading. A total of fifteen cubic cancellous bone specimens were obtained from two 2-year-old bovines and divided into three groups by collection regions: femoral head, neck, and proximal metaphysis. Structural indices of each 5-mm cubic specimen were determined using micro-computed tomography. Specimens were then subjected to five cycles of uniaxial compressive loading at 0.05 mm/min with initial 20 N loading, 0.3 mm displacement, and then unloading to 0.2 mm with 0.1 mm displacement for five successive cycles. Elastic modulus and yield stress of cancellous bone decreased exponentially during five loading cycles. The decrease ratio of yield stress from baseline to fifth cycle was strongly correlated with bone volume fraction (BV/TV, r = 0.96, p < 0.01) and structural model index (SMI, r = − 0.81, p < 0.01). The decrease ratio of elastic modulus from baseline to fifth cycle was also correlated with BV/TV (r = 0.80, p < 0.01) and SMI (r = − 0.78, p < 0.01). These data indicate that structural deterioration of cancellous bone is associated with bone strength after yield stress. This study suggests that baseline cancellous bone structure estimated from adjacent non-fractured bone contributes to the cancellous bone strength during collapse.

Asymmetry in CT Scan Measures of Thigh Muscle 2 Months After Hip Fracture: The Baltimore Hip Studies.

Hip fracture is an important problem for older adults with significant functional consequences. After hip fracture, reduced muscle loading can result in muscle atrophy. We compared thigh muscle characteristics in the fractured leg to those in the nonfractured leg in participants from the Baltimore Hip Studies 7th cohort using computed tomography scan imaging. At 2 months postfracture, a single 10mm axial computed tomography scan was obtained at the midthigh level in 43 participants (23 men, 20 women) with a mean age of 79.9 years (range: 65-96 years), and thigh muscle cross-sectional area, cross-sectional area of intermuscular adipose tissue, and mean radiologic attenuation were measured. Total thigh muscle cross-sectional area was less on the side of the fracture by 9.46cm(2) (95% CI: 5.97cm(2), 12.95cm(2)) while the cross-sectional area of intermuscular adipose tissue was greater by 2.97cm(2) (95% CI: 1.94cm(2), 4.01cm(2)) on the fractured side. Mean muscle attenuation was lower on the side of the fracture by 3.66 Hounsfield Units (95% CI: 2.98 Hounsfield Units, 4.34 Hounsfield Units). The observed asymmetry is consistent with the effect of disuse and inflammation in the affected limb along with training effects in the unaffected limb due to the favoring of this leg with ambulation during the postfracture period.

Changes in quality of life associated with fragility fractures: Australian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (AusICUROS).

SummaryWe investigated change in health-related quality of life due to fracture in Australian adults aged over 50 years. Fractures reduce quality of life with the loss sustained at least over 12 months. At a population level, the loss was equivalent to 65 days in full health per fracture.PurposeWe aimed to quantify the change in health-related quality of life (HRQoL) that occurred as a consequence of a fracture using the EQ-5D-3 L questionnaire.MethodsAdults aged ≥50 years with a low to moderate energy fracture were recruited from eight study centres across Australia. This prospective study included an 18-month follow-up of participants recruited within 2 weeks of a fracture (hip, wrist, humerus, vertebral and ankle). Information collected at baseline and 4, 12 and 18 months included characteristics of participants such as income level, education and prior fracture status. At 12 months post-fracture, the cumulative loss of quality of life was estimated using multivariate regression analysis to identify the predictors of HRQoL loss.ResultsMean HRQoL for all participants before fracture was 0.86, with wrist fracture having the highest pre-fracture HRQoL (0.90), while vertebral fracture had the lowest (0.80). HRQoL declined to 0.42 in the immediate post-fracture period. Only participants with a wrist, humerus or ankle fracture returned to their pre-fracture HRQoL after 18 months. An increased loss of HRQoL over 12 months was associated with HRQoL prior to the fracture, hospitalisation, education and fracture site. The multiple regression explained 30 % of the variation in the cumulative HRQoL loss at 12 months post-fracture for all fractures.ConclusionLow to moderate energy fractures reduce HRQoL, and this loss is sustained for at least 12 months or, in the case of hip and spine fractures, at least 18 months. At a population level, this represents an average loss of 65 days in full health per fragility fracture. This significant burden reinforces the need for cost-effective fracture prevention strategies.Electronic supplementary materialThe online version of this article (doi:10.1007/s00198-015-3088-z) contains supplementary material, which is available to authorized users.