Recent Fragility Fracture Research Articles

Prevalence of Osteoporosis and Indications for Bone-Treatment In Older Adults Living with Frailty Enrolled in a Local Integrated Care Programme

Abstract Background Osteoporosis is estimated to affect more than 250,000 adults in Ireland, with 29.4% (€463.3 million) of the total healthcare cost attributable to osteoporosis-related fracture management, resulting in significant health and economic impact.(1,2) As such, early identification of osteoporosis and addressing associated risk factors are crucial steps in reducing osteoporosis-associated morbidity and mortality. This retrospective audit aims to assess the prevalence of osteoporosis and indications for initiating bone treatment among older adults living with frailty enrolled in the Limerick Integrated Care Programme for Older Persons (ICPOP). Methods All older adults attending ICPOP between 01/06/2023 to 29/02/2024 were included in the data collection. Data collected included patient age, gender, presence of vitamin D deficiency (<50), presence of osteopenia or osteoporosis via DEXA scan results, history of fragility fractures, and bone health treatment and its indication. Results A total of 310 patients (192 female, 118 male; age 70–98) attended ICPOP during the specified time period. DEXA scans identified osteopenia in 109 patients and osteoporosis in 69 patients. 86 patients experienced a history of fragility fractures, of which 30 were confirmed to have osteoporosis on DEXA. 93 patients (30.3%) displayed vitamin D deficiency, with the majority (81.7%) not previously receiving vitamin D supplementation. 151 patients were in receipt of bone treatment, of which 86 patients (56.9%) were newly commenced on bone treatment following interaction with ICPOP. The indications were osteoporosis on DEXA scan (44 patients), history of recent fragility fracture (20 patients), and high FRAX score (22 patients). Conclusion The increase in detection of risk factors and presence for osteoporosis, and initiating bone health treatment, achieved by way of an integrated care programme for older persons highlights the importance of proactive screening and timely initiation of treatment.

Study protocol for the ROLEX-DUO randomised placebo-controlled trial: ROmosozumab Loaded with EXercise – DUal effects on bone and muscle in postmenopausal Osteoporosis and Osteopenia

IntroductionNovel strategies are needed to address the rising burden of osteoporosis and fragility fractures. High-intensity resistance and impact (HiRIT) exercise has shown benefit in improving bone density in postmenopausal women...

Setrusumab for the treatment of osteogenesis imperfecta: 12-month results from the phase 2b asteroid study.

Osteogenesis imperfecta (OI) is a rare genetic disorder commonly caused by variants of the type I collagen genes COL1A1 and COL1A2. OI is associated with increased bone fragility, bone deformities, bone pain, and reduced growth. Setrusumab, a neutralizing antibody to sclerostin, increased areal bone mineral density (aBMD) in a 21-week phase 2a dose escalation study. The phase 2b Asteroid (NCT03118570) study evaluated the efficacy and safety of setrusumab in adults. Adults with a clinical diagnosis of OI type I, III, or IV, a pathogenic variant in COL1A1/A2, and a recent fragility fracture were randomized 1:1:1:1 to receive 2, 8, or 20mg/kg setrusumab doses or placebo by monthly intravenous infusion during a 12-mo treatment period. Participants initially randomized to the placebo group were subsequently reassigned to receive setrusumab 20mg/kg open label. Therefore, only results from the 2, 8, and 20mg/kg double-blind groups are presented herein. The primary endpoint of Asteroid was change in distal radial trabecular volumetric bone mineral density (vBMD) from baseline at month 12, supported by changes in high-resolution peripheral quantitative computed tomography micro-finite element (microFE)-derived bone strength. A total of 110 adults were enrolled with similar baseline characteristics across treatment groups. At 12mo, there was a significant increase in mean (SE) failure load in the 20mg/kg group (3.17% [1.26%]) and stiffness in the 8 (3.06% [1.70%]) and 20mg/kg (3.19% [1.29%]) groups from baseline. There were no changes in radial trabecula vBMD (p>05). Gains in failure load and stiffness were similar across OI types. There were no significant differences in annualized fracture rates between doses. Two adults in the 20mg/kg group experienced related serious adverse reactions. Asteroid demonstrated a beneficial effect of setrusumab on estimates of bone strength across the different types of OI and provides the basis for additional phase 3 evaluation.

Bone mineral density T-scores comparison between obese and non-obese individuals included in a Fracture Liaison Service following a recent fragility fracture.

This study aimed to compare the mean T-scores of obese and non-obese patients after recent fragility fractures. Over a period of 5 and a half years, from January 2016 to May 2021, patients from a fracture liaison service were identified and their demographic characteristics, osteoporosis risk factors, BMD T-scores, and fracture sites were compared between obese (BMI ≥ 30kg/m2) and non-obese (19kg/m2 < BMI < 30kg/m2) patients. A total of 712 patients were included (80.1% women; mean age 73.8 ± 11.3years). Sixteen % had type 2 diabetes mellitus and 80% had a major osteoporotic fracture (MOF). 135 patients were obese and 577 non-obese, with obese patients younger (p < 0.001) and more frequently female (p = 0.03). Obese patients presented with fewer hip fractures (10% vs. 21%, p = 0.003) and more proximal humerus fractures (16% vs. 7%, p < 0.001) than non-obese patients. After adjusting for age, sex, and diabetes mellitus, BMD T-score values were significantly higher at all measurement sites (lumbar spine, total hip, and femoral neck) in obese patients than in non-obese patients for all types of fractures, with a mean difference of 1 standard deviation (p < 0.001 for all comparisons). The same results were observed in the population limited to MOF. Given the crucial role of BMD T-score in determining the need for anti-osteoporotic medication following fragility fractures, it is reasonable to question the existing T-score thresholds in obese patients.

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)

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. Patients at least 50years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. Recent FF before TKA is associated with increased risk for additional FF and PPF within 8years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

E060 Testing a new prototype osteoporosis shared decision-making intervention in UK Fracture Liaison Services: patient and clinician perspectives of ‘iFraP’

Abstract Background/Aims Shared decision-making (SDM) is a joint process in which a person and healthcare professional work together to reach decisions about care. The Improving uptake of Fracture Prevention drug treatments (iFraP) study developed a prototype theoretically-informed intervention consisting of a computerised decision aid (DA) and Fracture Liaison Service (FLS) clinician training package to improve SDM about osteoporosis medicines. This abstract focuses on the early prototype iFraP in-practice testing phase that explored perceived acceptability of iFraP by those using it, barriers to, and facilitators of, implementation of the prototype iFraP in practice, and necessary changes required ahead of a full-scale randomised controlled trial (RCT). Methods In-practice testing was conducted at one FLS site. Participating FLS clinicians completed the prototype iFraP clinician training package, covering enhanced communication skills (e.g SDM, risk communication and health literacy techniques). Consenting patients with a recent fragility fracture referred for an FLS consultation were eligible to participate. Three cycles of iFraP in-practice testing were completed. Each cycle included observed iFraP consultations and post-consultation patient think-aloud interviews. After each complete cycle, the FLS clinician(s) was interviewed. Data were analysed using a framework approach. The Theoretical Framework of Acceptability and Theoretical Domains Framework facilitated understanding of iFraP acceptability and barriers to, and facilitators of, implementation. Results Four FLS clinicians (3 nurses, 1 allied health professional) completed the iFraP clinician training and delivered 10 iFraP consultations (8 face-to-face, 2 telephone) using the iFraP DA with participating patients (n = 3 cycle 1; n = 3 cycle 2; n = 4 cycle 3). In total, the four FLS clinicians completed 7 interviews, with all 10 patients completing a post-consultation interview. Findings demonstrate that patients and clinicians perceived the prototype iFraP DA as acceptable. Clinicians suggested that the iFraP DA supported them to elicit and address patient perceptions, increase patient involvement, and provide patients with sufficient and accessible information. Patients and clinicians expressed wanting to use iFraP in future FLS appointments, with some clinicians continuing to use the DA outside of iFraP in-practice testing. Identified barriers included: some clinicians questioned both the use of iFraP DA with patients not recommended first-line drug treatment; and, expressed concern that iFraP DA could extend the consultation length. Our findings demonstrated necessary updates to meet user needs and overcome identified barriers to iFraP intervention use, including presentation and structural changes to support integration of the iFraP DA into the consultation flow. Clinicians also provided feedback to improve the training package, including the need to demonstrate the DA in use, and increased allocated time to practice using the DA. Conclusion The iFraP intervention was perceived as acceptable, with the potential to support SDM about osteoporosis medicines. The iFraP RCT will now test our improved iFraP intervention across 3 FLS sites in England. Disclosure L. Bullock: None. N. Tyler: None. M. Thompson: None. S. Ryan: Grants/research support; the General Nursing Council for England and Wales Trust. J. Lefroy: None. S. Leyland: None. J. Fleming: None. E.M. Clark: None. S. Thomas: Other; owns Prescribing Decision Support Ltd that developed the iFraP decision aid. C. Gidlow: None. C.P. Iglesias-Urrutia: None. T.W. O'Neill: Grants/research support; supported by the NIHR Manchester Biomedical Research Centre. C.D. Mallen: Grants/research support; funded by the NIHR Applied Research Collaboration West Midlands, funded by the NIHR School for Primary Care Research. C. Jinks: Grants/research support; part funded by NIHR Applied Research Collaboration (ARC) West Midlands. Z. Paskins: Grants/research support; funded by the National Institute for Health Research (NIHR) [Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy].

The Association of Prior Fragility Fractures on 8-Year Periprosthetic Fracture Risk Following Total Hip Arthroplasty

BackgroundFragility fractures are often the initial clinical presentation of osteoporosis. Patients who have a history of fragility fractures undergoing total hip arthroplasty (THA) have an increased risk of 2-year postoperative complications. However, the association of recent fragility fractures with complications beyond 2 years following THA remains unknown. The purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision THA, periprosthetic fracture (PPF), and secondary fragility fracture. MethodsPatients aged 50 years and more who underwent THA for osteoarthritis were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to THA. There were 18,529 patients who had a prior fragility fracture and 408,753 who did not have a prior fragility fracture. Demographics and comorbidities were collected. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, PPF, and secondary fragility fracture within 8 years of index surgery. ResultsPatients who had recent fragility fracture had significantly higher risks of revision THA (Hazard Ratio [HR] 1.7; P < .001), PPF (HR 2.2; P < .001), and secondary fragility fracture (HR 4.9; P < .001). ConclusionPrior fragility fracture was shown to be a significant risk factor for revision THA, PPF, and secondary fragility fracture within 8 years of THA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

An Evaluation of the Implementation of the European Calcified Tissue Society Recommendations on the Prevention and Treatment of Osteoporosis Secondary to Bariatric Surgery.

The purpose of this study was to evaluate the implementation of the European Calcified Tissue Society (ECTS) 2022 recommendations on the prevention and treatment of osteoporosis secondary to bariatric surgery. The ECTS 2022 recommendations were applied in a retrospective cohort of postmenopausal women and men aged 50 years and older who were undergoing or had already undergone bariatric surgery. Osteoporosis medication was indicated if any of the following criteria were met: (i) history of recent (within 2 years) fragility fracture after the age of 40 years, (ii) BMD T score ≤ -2 at any of the sites of measurement, and (iii) FRAX® ≥ 20% for major osteoporotic fractures and/or ≥3% for hip fractures. Of the 170 patients (144 women, mean age 59 (55 to 63) years) included between February 2019 and March 2022, 33 were eligible for osteoporosis medication based on the ECTS 2022 recommendations, i.e., a prevalence of 19.6% [CI95%: 13.9%; 26.5%]. Most patients met the BMD T score ≤ -2 criterion (n = 25/170, 14.7% [CI95%: 9.7%; 20.9%]) and/or the history of recent fragility fracture criterion (n = 12/170, 7.1% [CI95%: 3.7%; 12.0%]). In this study, a fifth of our population was found to be eligible for osteoporosis medication after the application of the ECTS 2022 recommendations.

Fracture liaison service model: project design and accreditation

SummaryFrailty fractures place a significant socioeconomic burden on the health care system. The Italian Society of Orthopaedics and Traumatology (SIOT) is proceeding to fracture liaison service (FLS) model accreditation in several Italian Fracture Units (FUs), which provides a multidisciplinary approach for the management of the fragility fracture patient.IntroductionOsteoporosis and the resulting fragility fractures, particularly femoral fractures, place significant socioeconomic burdens on the health care system globally. In addition, there is a general lack of awareness of osteoporosis, resulting in underestimation of the associated risks and suboptimal treatment of the disease. The fracture liaison service (FLS) represents an exemplary model of post-fracture care that involves a multidisciplinary approach to the frail patient through the collaboration of multiple specialists. The purpose of this article is to highlight the path undertaken by the Italian Society of Orthopaedics and Traumatology (SIOT) for the purpose of certification of numerous FLS centers throughout Italy.MethodsSIOT is proceeding with international FLS accreditation in several Italian Fracture Units (FUs), following the creation of a model that provides specific operational and procedural steps for the management of fragility fractures throughout the country. FUs that decide to join the project and implement this model within their facility are then audited by an ACCREDIA-accredited medical certification body.ResultsThe drafted FLS model, thanks to the active involvement of a panel of experts appointed by SIOT, outlines a reference operational model that describes a fluid and articulated process that identifies the procedure of identification, description of diagnostic framing, and subsequent initiation of appropriate secondary prevention programs for fractures of individuals who have presented with a recent fragility fracture of the femur.ConclusionAccreditation of this prevention model will enable many facilities to take advantage of this dedicated diagnostic-therapeutic pathway for the purpose of fracture prevention and reduction of associated health and social costs.

Implementation of a clinical pathway for osteoporosis management within an Orthopaedic Fracture Clinic.

A fracture liaison service (FLS) is a multidisciplinary system approach to reducing subsequent fracture risk in patients with a recent fragility fracture. This study investigated the utility of an alternate model delivered by orthopaedic surgeons in increasing the investigation and treatment of osteoporosis within an orthopaedic fracture clinic in a tertiary hospital. We established a pathway of treatment (FLS) for women ≥50 years old with a minimal trauma fracture (MTF) in the orthopaedic fracture clinic using existing clinic resources to identify patients. All female patients ≥50 years old with upper limb MTFs during the study period were included and compared with historical controls prior to the intervention. The intervention and control groups were compared to assess the capacity of the new model of care to identify suitable patients and deliver best practice care. After the intervention the cumulative rate of osteoporosis screening increased from 52/173 to 201/318 (P < 0.001). Among the patients who were screened for osteoporosis the treatment rate increased from 25/52 to 126/201 (P < 0.001). The intervention resulted in a significant reduction in patients who were not screened after MTF from 87/173 to 40/318 (P < 0.001). We have developed a low-cost pathway developed by the orthogeriatric team integrated into an orthopaedic fracture clinic that leads to increased screening and treatment of osteoporosis. This model was implemented in a tertiary hospital with an integrated inpatient orthogeriatric service and highly engaged orthopaedic surgeons and may not be applicable in other settings.

Patients experience a need for informal care after a fragility fracture.

In individuals with fragility fractures, our objectives were to examine (1) the experience of receiving informal care post-fracture; and (2) how these care experiences influenced post-fracture recovery and subsequent management of bone health. A secondary analysis of six primary qualitative studies was conducted. Individuals in the primary studies were English-speaking women and men, 45years and older, who were living in the community and had sustained a recent fragility fracture or reported a history of previous fragility fractures. Participants who reported at least one instance of needing informal care were categorized as receiving "enough care", "insufficient care", or "no care". Of 145 participants in the primary studies, 109 (75%) described needing informal care after their fracture. Of those needing care, 62 (57%) were categorized as receiving enough care while 47 (43%) were categorized as receiving insufficient or no care. The care needed affected the management of participants' fracture and bone health, including access to health care services. Participants who received insufficient or no care, especially those living alone, devised strategies to care for themselves and often requested help from multiple individuals to minimize the burden to family and friends. Compared with men, women appeared to report needing help with personal daily activities, such as bathing, and transportation to appointments related to bone health. Informal care needs are an additional burden of fragility fractures. Post-fracture interventions should consider the broader context of patients' lives and potentially support the care needs of patients as part of their services.

Bariatric surgery and skeletal health: A narrative review and position statement for management by the European Calcified Tissue Society (ECTS).

Numerous studies have demonstrated detrimental skeletal consequences following bariatric surgery. A working group of the European Calcified Tissue Society (ECTS) performed an updated review of existing literature on changes of bone turnover markers (BTMs), bone mineral density (BMD), and fracture risk following bariatric surgery and provided advice on management based on expert opinion. Based on observational studies, bariatric surgery is associated with a 21-44% higher risk of all fractures. Fracture risk is time-dependent and increases approximately 3years after bariatric surgery. The bariatric procedures that have a malabsorptive component (including Roux-en-Y Gastric bypass (RYGB) and biliopancreatic diversion (BPD)) have clearly been associated with the highest risk of fracture. The extent of high-turnover bone loss suggests a severe skeletal insult. This is associated with diminished bone strength and compromised microarchitecture. RYGB was the most performed bariatric procedure worldwide until very recently, when sleeve gastrectomy (SG) became more prominent. There is growing evidence that RYGB is associated with greater reduction in BMD, greater increase in BTMs, and higher risk of fractures compared with SG but RCTs on optimal management are still lacking. In all patients, it is mandatory to treat vitamin D deficiency, to achieve adequate daily calcium and protein intake and to promote physical activity before and following bariatric surgery. In post-menopausal women and men older than 50years, osteoporosis treatment would be reasonable in the presence of any of the following criteria: i) history of recent fragility fracture after 40years of age, ii) BMD T-score≤-2 at hip or spine, iii) FRAX score with femoral neck BMD exceeding 20% for the 10-year major osteoporotic fracture probability or exceeding 3% for hip fracture. Zoledronate as first choice should be preferred due to intolerance of oral formulations and malabsorption. Zoledronate should be used with caution due to hypocemia risk. It is recommended to ensure adequate 25-OH vitamin D level and calcium supplementation before administering zoledronate. The bariatric procedures that have a malabsorptive component have been associated with the highest turnover bone loss and risk of fracture. There is a knowledge gap on osteoporosis treatment in patients undergoing bariatric surgery. More research is necessary to direct and support guidelines.

Evaluation of Environmental and Socioeconomic Factors Contri-buting to Fragility Fractures in Indians

Objective: Osteoporosis causes fragility fractures that also occur in patients with bone mineral density (BMD) in the normal or osteopenic range, suggesting role of risk factors that are unrelated or partially related to BMD. The study aims at highlighting the link between 3 conditions, that are environment and occupation related risk factors and that are widely prevalent in India, and development of fragility fractures. Methods: A Case Control study was done by rec-ruiting 110 Cases with history of recent fragility fractures and 84 Controls with no history of recent fractures. 3 study parameters, village dwelling, con-ventional farming, and poverty, were chosen the presence or absence of which were documented in participants. This was followed by an ODDS ratio analysis. Results: The Odds of village dwellers, conventional farmers, and socioeconomically poor individuals to develop fragility fractures were both significant and large. Conclusion: Urbanization is a risk in the dev-elopment of fragility fractures. However, this study points that village dwelling in India is associated with the development of fragility fractures. Similarly, Odds of farmers exposed to pesticides and agrochemicals to develop fragility fractures is large and significant. Pesticides and agrochemicals act as endocrine disruptors and bone health is closely linked to endocrine system. Fragility fractures among farmers may be due to endocrine disrupting properties of pesticides and agrochemicals. Socioeconomic deprivation is a known risk in the development of osteoporosis. This study too highlights that the odds of individuals living in poverty to develop fragility fractures is significant and large.

Evaluation of an Osteoporosis Outreach Program for Men With a Fragility Fracture and Their Physicians.

Many health plans have outreach programs aimed at appropriately screening, evaluating, and treating women experiencing fragility fractures; however, few programs exist for men. The objective of this study was to develop, implement, and evaluate an osteoporosis outreach program for men with a recent fragility fracture and their physicians. A total of 10,934 male patients enrolled in a Medicare Advantage with Prescription Drug Plan with a recent fragility fracture were randomized to a program or control group. Patients and their physicians received letters followed by phone calls on osteoporosis and the importance of screening and treatment. The evaluation compared bone mineral density (BMD) test utilization and osteoporosis medication treatment (OPT) among patients who received the outreach versus no outreach at 12 months. The effect of the program was estimated through univariate and multivariable logistic regressions. The program had a significant impact on BMD evaluation and OPT initiation. At 12 months, 10.7% of participants and 4.9% of nonparticipants received a BMD evaluation. The odds ratio (OR) (95% confidence interval) was 2.31 (1.94, 2.76), and the number needed to outreach to receive a BMD test was 18. OPT was initiated in 4.0% of participants and 2.5% of nonparticipants. The OR (95% confidence interval) of receiving OPT was 1.60 (1.24, 2.07), and the number needed to outreach was 69. Adjusted ORs were similar in magnitude and significance. The program was highly effective by more than doubling the rate of BMD evaluation; however, more intensive interventions may yield an even higher screening rate.

The use of 2-, 5-, and 10-year probabilities to characterize fracture risk after a recent sentinel fracture.

The recency of prior fractures affects subsequent fracture risk. The aim of this study was to quantify the effect of a recent sentinel fracture, by site, on the 2-, 5-, and 10-year probability of fracture. The study used data from the Reykjavik Study fracture register that documented prospectively all fractures at all skeletal sites in a large sample of the population of Iceland. Fracture probabilities were determined after a sentinel fracture (humeral, clinical vertebral, forearm and hip fracture) occurring within the previous 2years and probabilities for a prior osteoporotic fracture irrespective of recency. The probability ratios were used to adjust fracture probabilities over a 2-, 5-, and 10-year time horizon. As expected, probabilities decreased with decreasing time horizon. Probability ratios varied according to age and the site of sentinel fracture. Probability ratios to adjust for a prior fracture within the previous 2years were higher the shorter the time horizon, but the absolute increases in fracture probabilities were much reduced. Thus, fracture probabilities were substantially lower with time horizons less than 10years. The 10-year probability of fractures is the appropriate metric to capture the impact of the recency of sentinel fractures. The probability ratios provide adjustments to conventional FRAX estimates of fracture probability for recent sentinel fractures, adjustments which can readily inform clinical decision-making.

Identification of patients at high risk of fragility fractures in an Indian clinical setting using FRAX.

The Fracture Risk Assessment Tool (FRAX) appears useful to diagnose fragility fractures. The study aims to answer whether the FRAX tool has utility in India. One hundred ten cases with a history of recent fragility fractures and 84 controls with no fractures were included in the study. FRAX scores without bone mineral density (BMD), and also with it, of participants were calculated. Several cutoff FRAX scores were chosen around mean and median FRAX score of cases. The odds ratio was calculated along with sensitivity, specificity, positive predictive value, negative predictive value and Youden's index. The most ideal cutoff was chosen to construct a hypothetical model to detect individuals at high risk. The FRAX score with BMD and without BMD exhibited relatively high specificity and moderate to low sensitivity implying that FRAX scores above cutoff have diagnostic value. Cutoffs at which FRAX score without BMD exhibited high specificity (> 90%) were chosen to construct a hypothetical model. Patients with FRAX score without BMD in the intermediate range be advised dual-energy X-ray absorptiometry (DEXA) followed by recalculation of FRAX score with BMD. DEXA scan T score less than - 2.5 or FRAX score with BMD above the cutoff at which specificity was high (> 80%) were included to construct the hypothetical model. Patients with low FRAX score could be followed up. The hypothetical model was applied to the case group to analyse its detection potential. FRAX has utility in India. It cuts the cost of screening and limits the use of expensive investigation.

The risk of new fragility fractures in patients with chronic kidney disease and hip fracture\u2014a population-based cohort study in the UK

SummaryChronic kidney disease (CKD) is a risk factor for fractures. However, in hip fracture patients, CKD G3-G5 was associated with a higher mortality risk and not associated with a higher risk of subsequent non-hip fractures compared to eGFR > 60 ml/min. The higher mortality risk may, as competing risk, explain our findings.IntroductionChronic kidney disease (CKD) is a known risk factor for fragility fractures. Patients aged 50+ with a recent fragility fracture have an increased risk of subsequent fractures. Our aim was to evaluate the association between CKD stages G3–G5 versus estimated glomerular filtration rate (eGFR) > 60 ml/min and the risk of a new non-hip fracture or fragility fracture in patients with a first hip fracture.MethodsPopulation-based cohort study using the UK general practices in the Clinical Practice Research Datalink. Associations between CKD stage and first subsequent fracture were determined using Cox proportional hazard analyses to estimate hazard ratios (HRs). To explore the potential competing risk of mortality, cause-specific (cs) HRs for mortality were estimated.ResultsCKD G3–G5 was associated with a lower risk of any subsequent non-hip fracture (HR: 0.90, 95%CI: 0.83–0.97), but not with the risk of subsequent major non-hip fragility fracture. CKD G3-G5 was associated with a higher mortality risk (cs-HR: 1.05, 95%CI: 1.01–1.09). Mortality risk was 1.5- to 3-fold higher in patients with CKD G4 (cs-HR: 1.50, 95%CI: 1.38–1.62) and G5 (cs-HR: 2.93, 95%CI: 2.48–3.46) compared to eGFR > 60 ml/min.ConclusionsThe risk of a subsequent major non-hip fragility fractures following hip fracture was not increased in patients with CKD G3–G5 compared to eGFR > 60 ml/min. Mortality risk was higher in both hip fracture and non-hip fracture patients with CKD G4 and G5. The higher mortality risk may, as competing risk, explain our main finding of no increased or even decreased subsequent fracture risk after a hip fracture in patients with CKD G3–G5.

Adherence to fracture liaison service programs in patients over 70: the hidden part of the iceberg.

FLS programs are considered the most effective interventions for secondary prevention of osteoporotic fractures. Our objective was to identify risk factors for non-adherence to an FLS program set up specifically for patients over 70. Our multifaceted, intensive program included five appointments over a 2-year period. One hundred sixty-seven patients (mean age 83.5years) who presented with a recent fragility fracture were enrolled. Multivariable analysis was conducted to determine whether the demographic, clinical, frailty, and osteoporotic risk factors of the patients influenced their adherence to the program. About half of the patients did not attend the follow-up visits. According to the regression analysis, non-initiation of osteoporosis treatment was associated with poor adherence to the program (aHR 3.66). Demographic, clinical, dwelling, frailty factors, osteoporotic risk factors, fracture type, or densitometric scores were not associated with adherence. The first self-reported reason for withdrawal was the difficulty of attending several follow-up visits, and the second was the feeling of not being concerned. We observed that non-initiation of osteoporosis treatment was the only factor correlated with non-adherence to an FLS program. Thus, neither age nor frailty factors should result in patients not being included in FLS. Beyond the necessity of the osteoporosis treatment, good patient understanding of the relevance of all the interventions included in the program is the key.

Revised FRAX®-based intervention thresholds for the management of osteoporosis among postmenopausal women in Sri Lanka.

This study revised the Sri Lankan FRAX®-based intervention thresholds (ITs) previously published in 2013. Age-dependent ITs were estimated, from 50-80years with 5-year intervals, using a Sri Lankan FRAX® algorithm for a woman with a BMI of 24.8kg/m2 and history of prior fragility fracture without other clinical risk factors. Data of 653 postmenopausal women were used in estimating fixed, hybrid, and two-tier ITs. ITs were determined using the ROC curve and partial Youden index. New ITs were validated using data of 356 postmenopausal women who underwent DXA and 62 women who had a recent fragility fracture. Women in the two groups (n = 653 and n = 356) came from the Southern Province and had undergone DXA in our state-owned tertiary care hospital as a part of their routine clinical assessment. The mean (SD) age and BMI of the subjects (n = 653) were 62 (8)years and 24.8 (1.2)kg/m2, respectively. Age-dependent ITs of major osteoporotic fracture risk (MOFR) and hip fracture risk (HFR) ranged from 2.7 to 18% and from 0.4 to 7.1%. The best fixed ITs for women aged 50-80years were 9% for MOFR and 3% for HFR. In the hybrid method, MOFR of 6% and HFR of 2% were found appropriate for women aged < 70years. These were combined with age-dependent ITs for women aged 70years and above. In the two-tier system, two sets of ITs were calculated (ITs of MOFR/HFR for women aged < 70years and ≥ 70years were 6%/2% and 12%/5%, respectively). When age-dependent ITs were considered the reference standard, sensitivities of the fixed, hybrid, and two-tier ITs were 0.63, 0.73, and 0.74, respectively. The specificities were 0.76, 0.86, and 0.80 in the same order. Sensitivities of the age-dependent, fixed, hybrid, and two-tier ITs in identifying a woman with an incident fracture were 26%, 48%, 61%, and 61%, respectively. The new fixed MOFR is slightly lower than the previous value and hybrid and two-tier ITs perform better than age-dependent and fixed ITs.