History Of Previous Fracture Research Articles

Determination of Bone Fracture Risk in Kidney Transplant Recipients With FRAX Score

Background:It is thought that the Fracture Risk Assessment Tool(FRAX) score of the World Health Organization determines a 10-year fracture risk.The study aimed to investigate the major osteoporotic fracture(MOF) and hip fracture(HF) values determined with the FRAX score and practicality of the FRAX score in kidney transplant recipients(KTRs).Methods:The study was conducted with 44 female and 59 male KTRs and 100 healty control group.Bone mineral density(BMD) was measured by dual-energy X-ray absorptiometry.FRAX scores were calculated from baseline information (age, height, weight, BMD femur neck T score,previous fracture history, glucocorticoid use, smoking status, alcohol consumption,and presence of rheumatoid arthritis).Results:In KTRs, FRAX score MOF, and FRAX score HF were found to be significantly elevated, while BMD femur T score was determined to be significantly low. No significant relationship was found between FRAX score MOF and HF and kidney function tests and bone parameters. In the ROC analysis performed based on the determination of the FRAX score the cutoff point was determined as≥3.4 for MOF and≥0.4 for HF.Conclusion:In KTRs, increased FRAX score MOF and HF compared to healthy individuals were determined.FRAX score MOF≥3.4 and HF≥0.4 values indicate high-risk patients for increased fracture risk.The high accuracy rates determined suggest that the use of the FRAX score in KTRs is a valuable method for determining fracture risk.

Use of Routine Dual-Energy X-Ray Absorptiometry-Based Bone Mineral Density Measurement in Individuals with Self-Reported Falls within 1 Year as a Warning Sign of Sarcopenia Assessment

This study evaluated the association between self-reported falls within 1 year and fragility fracture among patients who underwent dual-energy X-ray absorptiometry (DXA)-based bone mineral density (BMD) measurement. This retrospective cross-sectional analytic study included 1,283 women and men aged 40–90 years who underwent BMD measurement using DXA. The variables assesses were age, sex, body mass index, self-reported falls within 1 year, fragility fractures and bone site, parental hip fracture, current history of daily smoking and daily excess alcohol consumption, long-term steroid use, rheumatoid arthritis, secondary osteoporosis, BMD and BMD T-scores of the lumbar spine and hip, vertebral fracture assessment results, and diagnostic classifications of osteoporosis. The participants were divided into the faller group (those with at least one fall incident within 1 year) and the non-faller group. Overall, 375 (29.2%) patients reported history of falls within 1 year. A previous history of hip fracture (aOR = 7.674, 95% CI: 3.96– 14.86, P = 0.000), previous non-vertebral fracture (aOR = 6.305, 95% CI: 3.41–11.66, P = 0.000), previous vertebral fracture (aOR = 2.466, 95% CI: 1.61–3.78, P = 0.000), and parental hip fracture (aOR = 2.354, 95% CI: 1.46–3.80, P = 0.000) was associated with self-reported falls within 1 year. In conclusion, self-reported falls within 1 year were strongly associated with fragility fracture. The simultaneous testing of DXA- based appendicular skeletal mass and hand grip strength is recommended for diagnosing coincident sarcopenia on routine DXA- based BMD measurement.

Total knee arthroplasty and periprosthetic distal femoral fracture: looking beyond the osteoporosis to previous osteoporotic fracture.

Osteoporosis is a risk factor for fractures, including those of the hip, vertebrae, and distal radius; however, the association between osteoporosis and periprosthetic fractures after total knee arthroplasty (TKA) has not been much investigated. Therefore, we aimed to investigate the association of the presence of systemic osteoporosis with periprosthetic fractures after TKA. This study included 34 patients with periprosthetic fractures following primary TKA and 106 controls matched for age and sex. Bone mineral density was evaluated at the femoral neck, total hip, and lumbar spine using dual X-ray absorptiometry. Medical records were reviewed for age; sex; body mass index; smoking; rheumatoid arthritis, endocrine diseases, and cardiovascular diseases; history of glucocorticoid use; medication for osteoporosis; and history of previous osteoporotic fracture. In addition, anterior femoral notching after TKA was evaluated. Univariable and multivariable logistic regression analysis were used to determine factors associated with periprosthetic fracture. The prevalence of osteoporosis in the fracture group was higher than that in the control group (61.8% vs. 40.6%, p=0.045). The rate of medication for osteoporosis was significantly low in the fracture group (47.6 % vs 76.7%, p=0.026). History of previous osteoporotic fracture (odds ratio [OR], 9.1; p=0.015) and osteoporosis (OR, 3.6; p=0.013) were significant risk factors for periprosthetic fractures after TKA. Medication for osteoporosis could decrease the risk of periprosthetic fracture (OR 0.3; p=0.020). Osteoporosis is a major risk factor for periprosthetic distal femoral fractures after TKA. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized to the patients following primary TKA, especially in patients with a history of osteoporotic fracture. Prognostic study, level III.

The influence of tibial length on radiographic posterior tibial slope measurement: How much tibia do we need?

PurposeThe purpose of this study was to determine whether significant differences exist when comparing posterior tibial slope (PTS) measured using increasing lengths of the tibia to determine the anatomical axis. MethodsPatients with full-length weight-bearing tibial radiographs were retrospectively identified from 2014 to 2022 at a single institution. Patients were excluded if there was any previous history of lower extremity fracture or osteotomy. The anatomical axis of the tibia was determined using the full length of tibial radiographs, and the “reference PTS” was measured using this axis. Using the same radiograph, the PTS was measured using four different anatomical axes at standardized tibial lengths. While the center of the proximal circle remained constant at 5-cm below the tibial plateau, the center of the distal circle was drawn at four points: a) overlapping circles; b) 10-cm distal to the tibial plateau; c) 15-cm distal to the tibial plateau; d) half the length of the tibia, measured from the tibial plateau to the tibial plafond. Bivariate correlation and frequency distribution analysis (measurements >2-degrees from reference PTS) were performed between the reference PTS and PTS measured at each of the four other lengths. ResultsA total of 154 patients (39.8 ± 17.4 years old, 44.2% male) were included in the final analysis. Measurements at each of the four tibial lengths were all significantly different from the reference PTS (p < 0.001). The correlation strength improved with increasing tibial length (overlapping: R = 0.681, 10-cm: R = 0.821, 15-cm: R = 0.937, and half-tibia: R = 0.963). The number of PTS measurements >2-degree absolute difference from the reference PTS decreased with increasing tibial length (overlapping: 40.3%, 10-cm: 24.0%, 15-cm: 26.0%, and half-tibia: 18.8%). ConclusionAssessment of PTS is dependent on the length of the tibia utilized to obtain the anatomical axis. Accuracy and precision of PTS measurements improved with increasing length of tibia used to determine the anatomical axis. Study designCase series.

Poster 109: Association of Anti-hypertensive and Statin Medication Usage With Post-Operative Stiffness After Arthroscopic Rotator Cuff Repair: A Retrospective Cohort Study

Objectives: Postoperative stiffness following arthroscopic rotator cuff repair (aRCR) is a major cause of morbidity reported in up to 23% of patients. Angiotensive converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB), medications commonly used to treat hypertension, affect TGF-β, an essential regulator of both the inflammatory process and tissue healing that has been linked to the development of tissue fibrosis. Statins, a class of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, have downstream cytokine effects thought to impact bone formation and resorption. The purpose of this study is to: determine if there is an association between ACEi, ARB, or statin usage and post-operative range of motion (ROM) following aRCR, determine if ACEi, ARB, or statin usage has any association with post-operative patient-reported outcome measures (PROMs) following aRCR, and to determine if ACEi, ARB, or statin usage has any association with the need for follow-up shoulder procedures following primary repair. Methods: This was an IRB approved retrospective cohort study examining all patients at a single institution undergoing primary aRCR from 1/1/2016 – 12/31/2019. Patients were identified by CPT codes and included if they had a minimum of 1-year postoperative follow-up and documented ROM outcomes. Patients with concomitant adhesive capsulitis, calcific tendinosis, glenohumeral arthritis, labral tears, prior history of shoulder surgery, previous history of humeral fractures, workman’s compensation claims, age under 18, irreparable rotator cuff tear, history of substance abuse, or on dialysis were excluded. Patients were then separated into four groups based on usage of ACEi, ARBs, statins, or control. Demographic information, medication usage, concurrent diagnoses, and follow-up procedures were collected via chart review. Physician and physiotherapy notes were examined to determine ROM (flexion, abduction, internal rotation (IR), and external rotation (ER)) (Figure 1). PROMs were assessed through the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE) and Simple Shoulder Test (SST). Results: After applying inclusion/exclusion criteria, 125 patients were included in the case group (ACEi 45 patients, ARB 27 patients, statins 53 patients) and 217 controls. No significant differences were found between groups with regard to demographics. Preoperatively, patients on ACEi or ARBs had significantly decreased active flexion (p=.022), IR (p=.002), and abduction (p&lt;.001). Patients on statins had significantly decreased active abduction (85° vs. 130°, p=0.015), ER (40° vs. 50°, p=0.008), and IR (4 vs. 5, p=0.011). Postoperatively, patients on ACEi or ARBs had significantly decreased 6-month active ER (p=.015) that resolved by 12 months, and 6-month active abduction (p=.047) that also resolved by 12 months. Patients on statin medication had significantly increased 6-week active abduction (95° vs. 58°, p=0.017) that normalized to the control group by 3 month. All other ROM measurements at different time points were not significant. There was a significant decrease in postoperative SST scores in those taking ACEi or ARBs (p=.004), with no significance found in the other PROM scores at the 1-year mark. No significant differences were found in complications or reoperation rates between groups. Conclusions: Patients on ACEi or ARB medications are at an increased risk of decreased ROM before and 6 months after aRCR. Sub-analyses revealed that this effect was more pronounced with ACEi than with ARBs. Patients on statin medications are at an increased risk of decreased ROM before arthroscopic rotator cuff repair but increased ROM in the early postoperative period, especially abduction. Surgeons should use this information to guide patient education and rehabilitation perioperatively after arthroscopic rotator cuff repair.

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.

Finite element analysis of modified Slongo's external fixation in the treatment of supracondylar humeral fractures in older children.

Older children over 8 years old are at higher risk of elbow joint stiffness after treatment of supracondylar humeral fractures. The objective of this study was to improve the Slongo's external fixation system for treating supracondylar humeral fractures in older children. This would be achieved by increasing fixation strength and providing a theoretical basis through finite element analysis and mechanical testing. A 13-year-old female patient with a history of previous fracture was selected for CT data processing to create a three-dimensional model of the distal humerus fracture. Two internal fixation models were established, using the Slongo's external fixation method with Kirschner wire (Group A) and modifying the Slongo's external fixation (Kirschner wire tail fixation) (Group B). The fracture models were then subjected to mechanical loading analysis using Finite Element Analysis Abaqus 6.14 software to simulate separation, internal rotation, and torsion loads. A PVC humeral bone model was used to create a supracondylar fracture model, and the A and B internal fixation methods were applied separately. The anterior-posterior and torsional stresses were measured using the Bose Electroforce3510 testing system, followed by a comparative analysis. The finite element simulation results showed that under the same tensile, torsion, and inversion forces, the osteotomy model fixed with Kirschner wire at the distal end in Group B exhibited smaller tensile stress and deformation compared to the unfixed osteotomy model in Group A. This indicated that the fixation strength of Group B was superior to that of Group A. According to the test results of the Bose Electroforce3510 testing system, a simple linear regression analysis was conducted using SPSS software. The K values of rotation angle-torque tests and front and rear displacement-stress tests were calculated for Groups A and B, with Group B showing higher values than Group A. The results of this study supported the significantly enhanced biomechanical reliability and stability of fracture fixation in Group B, which utilized the modified Slongo's external fixation (Kirschner wire tail fixation). This optimized method provides a new choice for the clinical treatment of supracondylar humeral fractures in older children, backed by both clinical evidence and theoretical basis.

Evaluation of the potential implications of following a vegan diet on bone health

Cow’s milk is the primary source of calcium in the NZ diet(1). The absence of dietary planning in a vegan diet can result in the individual unknowingly obtaining low intakes of calcium. Prolonged low calcium intakes can result in negative implications on bone mineral density by increasing the risk of osteoporosis later in life. The measurement of bone health parameters in NZ vegan adults have not been investigated. Therefore, we measured bone mineral density, markers of calcium homeostasis and assessed intake of essential nutrients for optimal bone health in vegans. This cross-sectional study included adults (&gt;18yrs), who followed a vegan diet for 2 years minimum. Demographic and lifestyle information was obtained from questionnaires including previous history of bone fractures and background of familial osteoporosis. A 4-day food record was completed for analysis of calcium, zinc, protein, magnesium, phosphorus and vitamin C intake and compared to the Estimated Average Requirement (EAR)(2). Weight, height and BMI were obtained, bone mineral density was measured at the hip and spine via dual x-ray absorptiometry (DXA) and reported as Z and T scores. Plasma calcium concentrations were corrected for albumin. All values are presented as mean and standard deviation. The study included 212 participants, aged 39 ± 12.38 years, 71% female. T scores at the lumbar spine and femoral neck were −0.63 ± 1.22 (Z score: −0.29 ± 1.12) and −0.66 ± 1.00 (Z score: −0.24 ± 0.89), respectively. Nine participants had a Z-score of &lt;-2.0 at the lumbar spine, and three at the femoral neck. Corrected calcium concentrations were 2.21 ± 0.33 mmol/L. Calcium intake was 917 ± 347.23 (range 195 to 2,429 mg/day) in all participants, which exceeded the EAR of 840 mg/day for adults aged 19-50 years. Men had higher intakes of calcium than women, 1,051 ± 363.7 mg/day (range 382 to 2,267 mg/day) vs. 867 ± 328.04 mg/day (range 194 to 2,428 mg/day), P-value &lt;0.001. The main source of calcium in the vegan diet was tofu. The intake of protein (77 ± 27.80) g/day, magnesium (569 ± 181.05) mg/day, and vitamin C (145 ± 96.94) mg/day met the EAR, excluding vitamin and mineral supplements. However, the intake of phosphorus (1,472 ± 459.98) mg/day and zinc (10.6 ± 4.01) mg/day were below the EAR. The findings of this study suggest that bone health of vegans are not negatively affected by the exclusion of dairy in the diet, provided that appropriate dietary planning is included to avoid nutrient deficiencies associated with poor bone health. Despite mean intake of calcium exceeding the EAR, very low intakes demonstrated significant variations between participants.

Radiological Differences Following Proximal Femoral Nail Antirotation (PFNA) Compared to the Contralateral Side and Its Correlation with Harris Hip Score (HHS) in Intertrochanteric Femoral Fracture After Three Months

Introduction: The incidence of intertrochanteric femoral fractures, which account for 50% of all hip fractures, is increasing as a result of the aging population. While PFNA surgery typically enhances outcomes, certain individuals continue to have pain, stiffness, and difficulties with their gait. This study aims to determine whether there is a correlation between post-surgical complications and changes in hip joint angles assessed three months following PFNA to lead future advances in PFNA surgery for older persons by comparing impacted and unaffected hips and correlating angles with patients' hip ratings. Methods: This study included 42 individuals who underwent surgery for intertrochanteric fractures aged 50 and above. Eligible participants must possess the ability to walk before to the study, have no history of previous leg fractures, and be capable of participating in rehabilitation. Individuals having comorbidities impacting these aspects or those unable to partake were not included. Result : This study looked at hip angles in 42 people who had surgery intertrochanteric fracture. While the participants varied in age and gender, the surgery itself didn't seem to significantly change the angles of their hip bones or their ability to walk. This suggests that PFNA may not directly affect hip mechanics on its own. Conclusion: This study indicates that attaining acceptable hip angles during the procedure could enhance patients' mobility and post-operative condition. Further investigation involving bigger cohorts and extended periods of observation is necessary to validate these findings and ascertain whether modifying these angles during surgery will result in improved outcomes following PFNA. Keywords: Intertrochanteric fracture; Hip fracture; PFNA

The role of the psychological attributes of parents and children, and fracture history in upper extremity fractures in school-age and adolescents: A case-control study.

This study aims to investigate the influence of parents and children's psychological attributes and previous fracture history on upper extremity fractures in school-aged and adolescent children. Between January 2022 and January 2023, a total of 194 participants consisting of 97 cases with upper extremity fractures (23 males, 74 females; median age: 10 years; range, 6 to 16 years) and 97 age-matched controls suffering from growing pains (47 males, 50 females; median age: 10 years; range, 6 to 16 years) were included in this case-control study. Both cases and controls were of school-age or over. The parents of the children were interviewed face-to-face using psychological scales including the Adult Attention Deficit Hyperactivity Disorder Self-Report Scale (ASRS), the Autism-Spectrum Quotient (AQ), the Short Form of the Conners' Parent Rating Scale-Revised (CPRS-R:S), and the Developmental Coordination Disorder Questionnaire 2007 (DCDQ'07). The results derived from these scales and the demographics of the participants were evaluated in terms of their association with the risk of upper extremity fractures. A household income below the official minimum monthly wage (MMW) and a previous fracture history showed a higher risk for upper extremity fractures (odds ratio [OR]=2.38, 95% confidence interval [CI]: 1.07-5.26 and OR=24.93, 95% CI: 3.27-189.98, respectively). In the univariate analyses, elevated scores on the hyperactivity subscale of CPRS-R:S (CPRS-R:SHS) were associated with a higher fracture risk (OR=1.14, 95% CI: 1.05-1.24). Furthermore, both a household income below MMW, a previous fracture history, and higher CPRS-R:S-HS scores were found as independent risk factors for upper extremity fractures in the multivariate regression analysis (OR=2.78, 95% CI: 1.13-6.86, OR=21.79, 95% CI: 2.73-174.03), and OR=1.11, 95% CI: 1.02-1.22, respectively). Our study results highlight the importance of known risk factors for upper extremity fractures such as lower monthly wage and the presence of previous fractures. The psychological states of parents and children should be evaluated together.

Risk of fracture in patients with myasthenia gravis: a nationwide cohort study in Korea.

Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junctions, resulting in muscle weakness and fatigue. Muscle weakness, restricted mobility, and frequent use of corticosteroids in patients with MG may predispose them to a higher risk of fractures. However, studies on the impact of MG on bone health and the associated fracture risk are scarce. Utilizing claim database of the Korean National Health Insurance Service collected between 2002 and 2020, we compared the risk of major osteoporotic fracture between 23 118 patients with MG and 115 590 individuals as an age- and sex-matched control group using multivariable Cox proportional hazard models. Over a median follow-up duration of 5.58years, the MG group (mean age 53.7years; 55% women) had higher risk of major osteoporotic fracture compared with controls (incidence rate 13.59 versus 9.74 per 10 000 person-years), which remained independent of age, sex, comorbidities, drug use including anti-osteoporotic agents, and previous fracture history (adjusted hazard ratio [aHR] 1.19, P < 0.001; subdistributed HR 1.14, P < 0.001 adjusted for mortality as competing risk). Subgroup analyses showed a greater association between MG and major osteoporotic fracture risk in younger (age 50 or younger) than older individuals (aHR 1.34 vs. 1.17) and in men compared with women (aHR 1.32 vs. 1.15; P for interaction < 0.05 for all). An imminent divergence of the fracture risk curve between MG and controls was observed for vertebral fracture, while there was time delay for non-vertebral sites, showing site-specific association. Factors associated with higher fracture risk in patients with MG were older age, female gender, high dose glucocorticoid use (>7.5mg/day), immunosuppressant use, and previous history of fracture. In summary, patients with MG had higher risk of major osteoporotic fracture compared with controls, which calls further preventive actions in this patient group.

The experience of feeling old after a fragility fracture

BackgroundThere has been little exploration of the effect of fragility fractures on patient perceptions of their age. The common assumption is that fractures “happen to old people”. In individuals with a fragility fracture, our objective was to explore the experience of feeling old after sustaining a fragility fracture.MethodsA secondary analysis of data from 145 community-dwelling women and men participating in six qualitative primary studies was conducted relying on a phenomenological approach. Participants were English-speaking, 45 years and older, who had sustained a recent fragility fracture or reported a history of previous fragility fractures. Data for the analysis included direct statements about feeling old as well any discussions relevant to age post-fracture.ResultsWe highlight two interpretations based on how individuals with a history of fragility fracture talked about age: (1) Participants described feeling old post-fracture. Several participants made explicit statements about being “old”. However, the majority of participants discussed experiences post-fracture that implied that they felt old and had resigned themselves to being old. This appeared to entail a shift in thinking and perception of self that was permanent and had become a part of their identity; and (2) Perceptions of increasing age after sustaining a fracture were reinforced by health care providers, family, and friends.ConclusionsOur findings challenge the notion that fractures “happen to old people” and suggest that fractures can make people feel old. Careful consideration of how bone health messages are communicated to patients post-fracture by health care providers is warranted. (Word Count: 248)

Predicting Non-traumatic Incident Fractures on Rheumatic Disease Patients on Long-term Glucocorticoids

Background: To identify contributors to non-traumatic incident fractures on rheumatic disease patients who are on long term glucocorticoids (LTGC) Methods: Two hundred and twenty patients on LTGC (110 with vertebral fracture and 110 without vertebral fracture) who participated in a cross-sectional study in 2014-2015 were invited to have repeated assessments on 1) aBMD using dual-energy X-ray absorptiometry (DXA), 2) volumetric BMD (vBMD), microstructure and bone strength assessment of the wrist and tibia using high-resolution peripheral quantitative computed tomography (HR-pQCT) and 3) spine radiographs in the 5th year. Clinical covariates were recorded on questionnaires, and Fracture Risk Assessment Tool (FRAX) score was calculated accordingly. Non-traumatic incident fracture over the 5-year were documented. Receiver operating characteristic curve (ROC) analysis was performed to compare the strength of fracture prediction tools. Results: Out of the 140 patients who completed the 5th year assessments, 47 (33.6%) developed incident fractures. History of previous fracture, aBMD at hip and lumbar spine, T-score, trabecular vBMD, trabecular bone volume fraction and estimated bone strength at the tibia at baseline remained significantly different after adjusting for age between the group with and without incident fractures. The area under curve (AUC) of a prediction model comprised of age, history of previous fracture and average trabecular vBMD at tibia was comparable with that of the FRAX score (0.710 vs 0.679-0.702), and slightly outperformed than the AUC of DXA aBMD at hip and lumbar spine (0.628-0.668) under ROC analysis. Conclusion: Age, history of previous fracture and average trabecular vBMD at tibia could be the main contributors in building a prediction model for non-traumatic incident fracture in rheumatic disease patients on LTGC.

Frequency of Re-Fracture in Osteoporotic Patients

Aim: To determine the frequency of re-fracture in osteoporotic patients presenting @ SMBBMU Larkana Subject and Methods: This is Descriptive Cross-sectional study, accompanied at Department of Orthopedics, SMBBMU and Civil hospital Karachi, for period of 6 months from 19-07-2018 to 19-01-2019. Total of 130 osteoporotic patients with previous fracture were included in this study. Brief histories for the duration of present complain and history of previous fracture was taken. Presence of pain, tenderness and mobility at the site of trauma was noted. X rays Anterio-posterior/Lateral of the effected site was done and presence of fracture with break in the continuity of the bone was considered as re-fracture. Data was collected on structured proforma. Results: A total of 130 osteoporotic patients with previous fracture were selected in our study. The average age of the patients was 58.77±4.27 years. Average duration of presenting complains and previous fractures were 3.93 ± 0.87 days and 7.11±1.23 months. There were 1:1 male to female ratio. Out of 130 patients, 68.46% were type II diabetic, 83.85% were hypertension. Frequency of re-fracture in osteoporotic patients was observed in 8.46% (11/130) Conclusion: Fracture is common presentation in osteoporotic bones. Our study showed that rates of re-fracture range up to 8.46% in patients with an initial osteoporotic fracture, depending on the type of initial fracture. Keywords: Osteoporosis, Osteoporotic fractures, fracture and Re-fracture.

Position Statement: Postmenopausal Osteoporosis Treatment Strategies in Korea

Classifying patients with osteoporosis according to fracture risk and establishing adequate treatment strategies is crucial to effectively treat osteoporosis. The Korean Society for Bone and Mineral Research has issued a position statement regarding appropriate treatment strategies for postmenopausal osteoporosis. According to previous fragility fracture history, bone mineral density (BMD) test results, fracture risk assessment tool, and several clinical risk factors, fracture risk groups are classified into low, moderate, high, and very-high-risk groups. In high-risk groups, bisphosphonates (BPs) and denosumab are recommended as first-line therapies. Sequential BP treatment after denosumab discontinuation is required to prevent the rebound phenomenon. In the very high-risk group, anabolic drugs (teriparatide or romosozumab) are recommended as a first-line therapy; sequential therapy with antiresorptive agents is required to maintain BMD gain and reduce fracture risk. Fracture risk was reassessed annually, and the treatment plan was determined based on the results, according to the osteoporosis treatment algorithm for fracture risk.

Clinical Characteristics of Spinal versus General Anaesthesia in Older Patients Undergoing Hip Fracture Repair Surgery in Jordan: A Multicentre Study.

The primary aim of this study was to examine the clinical characteristics and outcomes of older patients who underwent hip fracture repair surgery. The secondary aims were to assess the predictors of the choice of spinal or general anaesthesia and to explore the risk factors for all-cause mortality. This three-tertiary centres study was conducted at a tertiary care centre in Jordan. Clinical data include previous fracture history; medication details; comorbidities; surgical approach; and postoperative pain management. Overall, 1084 patients who underwent hip fracture repair were included in this study. The mean age of patients was 78 years, and 55.2% were women. Twenty-four were treated with bisphosphonates before the fracture, whereas 30 were in steroid therapy. Overall, 61.8% of patients underwent spinal anaesthesia, whereas 38.2% underwent general anaesthesia. Spinal anaesthesia group had a lower prevalence of cardiovascular accidents (16.3% vs. 22.3%, p = 0.014) and Alzheimer's (3.4% vs. 1.4%, p = 0.049) than the general anaesthesia group. In the spinal anaesthesia group, postoperative opioid administration (p = 0.025) and postoperative blood transfusion (p = 0.011) occurred more frequently than general anaesthesia group. In hospital, 30-day and all-cause mortality were comparable between both groups. Diabetes mellitus (HR = 2.6; 95%CI = 1.5-4.4; p = 0.001); cemented hip hemiarthroplasty (HR = 2.4; 95%CI = 1.1-5.1; p = 0.025); deep venous thrombosis/pulmonary embolism (HR = 5.0; 95%CI = 1.2-12.9; p = 0.001); and readmission within 1 month from surgery (HR = 3.6; 95%CI = 2.0-6.3; p < 0.001) were all significant predictors of mortality. This study provides insights into the outcomes and factors associated with different anaesthesia types in hip fracture repair surgery. The anaesthesia type does not affect all-cause mortality in patients undergoing hip fracture repair.

Exploring new balance and gait factors that are associated with osteosarcopenia in patients with a previous fall and/or fracture history

Osteosarcopenic individuals have poor muscle function and increased bone fragility, which results in a severe detriment to health outcomes. Hence, there is a necessity to discover easily accessible factors associated with osteosarcopenia to develop timely interventions. This study aimed to determine new sensitive balance and/or gait variables that are associated with osteosarcopenia in a population of older people with a history of falls and/or fractures. In a cross-sectional cohort study, 306 men and women aged ≥65 years completed a series of questionnaires, clinical assessments and muscle strength and function tests. Subsequently, participants were separated into osteopenia, osteoporosis and osteosarcopenia, groups for comparison and further analysis. Osteosarcopenia performed worse than osteopenia and osteoporosis in grip strength, gait speed, physical function scores and in multiple gait and balance indices (p<0.001). During posturography testing, there were larger elliptical areas with eyes open (p = 0.003), and eyes closed (p = 0.043) and increased sway velocity on a firm platform (p = 0.007) in the osteosarcopenia group, compared to osteoporosis. Limits of stability and eyes open ellipse area significantly contributed to the multivariable model (p = 0.029 and p = 0.038, respectively), suggesting that these balance parameters, along with grip strength, may be useful in identifying older adults with osteosarcopenia from those with only osteopenia/osteoporosis. Older adults with osteosarcopenia and a history of falls and/or fractures demonstrated inferior strength, function, and gait characteristics. This study identified indices of balance that were sensitive discriminators for osteosarcopenia and could be easily implemented into routine assessment.

THU438 A Case Of Pregnancy Associated Osteoporosis

Abstract Disclosure: S. Maradana: None. F. Iqbal: None. M. Safran: None. Background: Pregnancy associated osteoporosis (PAO) is a rare form of osteoporosis that is seen in late pregnancy and early post-partum period. Hip and vertebral body are most involved in PAO. Common clinical manifestation is back pain, and many patients suffer from vertebral fractures and kyphosis causing great physiologic burden and negative impact on quality of life. We report a case of PAO with good response to teriparatide. Clinical case: A 27-year-old female with no significant past medical history presented with severe acute back pain two months after delivery of her second child, whilst still breast feeding. Imaging studies demonstrated acute compression fractures of T12, L1, L2 and L3 vertebrae. She had regular monthly menstrual cycles prior to pregnancy with no previous history of fractures. Her pre pregnancy weight was 135 lbs and she had been physically active, while caring for her older son. Family history is notable for osteoporosis in multiple paternal aunts and maternal grandmother with no family history of fractures. There were no other identifiable risk factors. Evaluation for secondary causes of osteoporosis showed 25-OH vitamin D levels of 23 ng/mL (NL 30-100 ng/mL), TSH 1.72 uIU/mL (NL 0.28-3.8 uIU/mL), PTH 19 pg/mL (NL 14-64 pg/mL), calcium 9.7 mg/dL (NL 8.7-10.7 mg/dL), phosphorus 4 mg/dL (NL 2.5-4.5 mg/dL), tryptase 4 mcg/L (NL &amp;lt;11 mcg/L), alkaline phosphatase 111 U/L (NL 30-115 U/L) and 24-hour urine calcium 168 mg (NL 100-300 mg). Urine immune electrophoresis and serum immunofixation did not show any evidence of monoclonal gammopathy. DEXA scan showed low BMD with Z-score of −4.4 SD in lumbar spine -3.1 in femoral neck. She was diagnosed with PAO. She stopped breast feeding after the diagnosis. As the bone mineral density was very low, she was started on teriparatide along with calcium and vitamin D supplementation. One year after treatment initiation, her DEXA scan showed improved bone mineral density with Z-score of −3.5 in lumbar spine and −1.9 in femoral neck. Her osteoporosis is currently being managed with teriparatide with plan to continue for a total duration of 24 months. Conclusion: PAO is under-recognized and under-reported, with limited available evidence on the management. Spontaneous improvement in BMD is known to occur in 6-12 months after pregnancy and lactation have been completed, although, the addition of anti-resorptive treatment in this setting may result in superior BMD gain compared with calcium and vitamin D supplementation alone. Use of teriparatide has shown to have significant increase in BMD and help with pain relief in PAO. Teriparatide has helped with improving the BMD in our patient. Nevertheless, controlled trials are lacking, and the optimal timing of teriparatide use in these women remains uncertain. Presentation: Thursday, June 15, 2023

OA08 Atypical femoral fracture secondary to long term bisphosphonate use; are we doing enough to prevent it?

Abstract Introduction Atypical femoral fractures (AFF) are low energy subtrochanteric or femoral shaft fracture associated with long term use of bisphosphonates (BP). Although the absolute risk of AFF is low and ranges between 3.2-50 cases/100,000 person-years, this risk is said to double with prolonged use (&amp;gt;5 years). ROS and American Society for Bone and Mineral Research (ASBMR) recommends regular review of patient at 5 years for oral BP and 3 years for intravenous BP. We would like to share our experience with two AFF which was seen in our bone clinic over the last one year resulting from prolonged bisphosphonates use. Case description Case 1 A 76-year-old Caucasian lady was reviewed for follow-up appointment in bone clinic for the management of steroid induced osteoporosis. She was on AA for 13 years for primary prophylaxis. It was noted that she was experiencing discomfort in her right thigh for the last 8 months. Her initial femoral X-ray showed incomplete AFF of the right femur and she was referred to orthopaedics who suggested conservative management. 6 months later, she unfortunately had a fall resulting in right femur fracture which required intramedullary nailing. X-ray of the contralateral side shows periosteal thickening and she is waiting for prophylactic nailing. Case 2 79 year old white Caucasian presented to the hospital with a fall. She has been on long term steroids for PMR and was on alendronate for 20 years for primary prophylaxis. X-ray showed complete AFF of proximal right femur shaft which required intramedullary nailing, subsequently developed pain in left hip during physiotherapy and X-ray showed incomplete AFF of mid left femur which needed prophylactic nailing. She was then referred to our clinic for further risk stratification. Both the patients had their bisphosphonates stopped and was advised reduced weight bearing along with calcium and vitamin D supplementation. The table summarises the background history and investigations post presentation with AFF: Discussion Bisphosphonates are one of the mainstays for managing steroid induced osteoporosis and for patients with high risk fragility fractures. Despite the increasing awareness of long term complication, we still see patients with AFF who have missed the opportunity for review in primary and secondary care particularly among patients with primary prophylaxis with satisfactory DEXA scan. ROS and ASBMR recommends review of patients who are on oral bisphosphonates at 5 years and for patients on intravenous bisphosphonates at 3 years for further risk stratification to reduce the incidence of AFFs. It also recommends close monitoring in patients with prodromal pain in the hip, groin or thigh especially in those who have high risk factors such as long term glucocorticoid use, Asian race and femoral bowing. Cessation of bisphosphonates can result in 70% reduction of developing AFF. Hence a break in the treatment for approximately 18-24 months needs to be considered for patients who are at lower levels of risk for fragility fracture such as age &amp;lt;75years, no previous history of fragility fracture, DEXA T score more than −2.5 and low FRAX score. Yet, this is not happening in routine clinical practice both in primary and secondary care and patients fall out of safety netting resulting in AFF. We need robust pathway and safety netting for patients who are on long term treatment. This situation could have also been exacerbated by the COVID pandemic which has increased the waiting lists and cancelled appointments. Resulting in many elderly patients having no follow ups and DEXA assessments for risk stratification. Key learning points Following the COVID pandemic there has been a huge impact on the waiting list, which has further pushed follow-up review for patients on long term bisphosphonates. This has resulted in a missed opportunity to identify patients with low risk to have a break in the BPs treatment. We feel that with appropriate treatment pathways needs to be set at primary care and secondary care level to capture these patients on long bisphosphonates after 3 to 5 years of BP use; especially patients who are at higher AFF risk, including patients on glucocorticoids and patients of Asian ancestry. Steps must be put in place to ensure counselling and education is given to patients about risk of AFF and prodromal symptoms such as thigh or groin pain which are initial symptoms, so that they can seek appropriate review at primary care level. ROS and ASBMR Task Force 2013 need to be implemented locally to capture patients with long term BPs treatment. Also, if patients has AFF fracture, imaging of the other leg has to be considered for further evaluation as more than one fourth of the cases have contralateral lesion.

Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX.

The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD). We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted β-coefficients. A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72-2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69-2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63-2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62-2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination. A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.