Risk Of Further Fractures Research Articles

Geriatric traumatological management of osteoporosis : "Let the first fracture be the last"

In Germany more than 800,000 osteoporotic fractures occur every year, with severe medical, social and health economic consequences. Nevertheless, as in many other countries there is alarge gap in care. Fractures frequently occur in older geriatric patients, who are increasingly being (or should be) treated in geriatric trauma centers. This multidisciplinary approach offers the opportunity not only to restore the patient's mobility and independence but also to set the course for preventing further fractures. Diagnosing osteoporosis and initiating treatment early after afracture is particularly important as there is an imminently high risk of further fractures in the months and years following afracture. This review article describes apragmatic, guideline-based approach to osteoporosis management for geriatric trauma patients. It discusses fracture risk assessment, current treatment thresholds and treatment strategies as well as the individual osteoporosis drugs, the indications and contraindications. This review aims to show that the treatment of osteoporosis within the framework of ageriatric traumatology team is feasible in the majority of cases. It is suggested that atreatment decision can be systematically made based on afew questions or aflow chart.

Profile of Vertebral Fracture Cases in the First Full Year of an ANP led Fracture Liaison Service

Abstract Background A specialist osteoporosis and bone health service was founded in 2003 in our institution. It see’s a range of patients from providing DXA alone to giving specialist opinion on complex cases. The Irish Fracture Liaison Service Database (FLS-DB) commenced in 2020 and aims to target those who’ve just fractured with the aim of reducing risk of further imminent fracture by screening for osteoporosis and initiating bone protection measures. Methods Cases of vertebral fracture screened by our FLS ANP were extracted from the FLS database. Case finding for vertebral fracture remains dependent on referral to the service. Results We screened 53 patients with vertebral fractures through our FLS in 2023. 64% female, 36% male. Median age 81 years; range 56-99 yrs. Of these 32 (60%) were inpatients with 2 inpatient falls. 17 (32%) were on osteoporosis treatment. We noted 25 (47%) with previous fragility fracture including 9 (17%) with previous vertebral fracture – just over half of these i.e. 5 patients were on bone protection treatment. After FLS assessment of those on treatment 10 were changed to denosumab, 2 to teriparatide, one continued oral bisphosphonate by choice, rest changed to IV zoledronic acid. Those newly started on treatment a range of PO and IV Bisphosphonate, teriparatide and denosumab was recommended depending on patient factors. One declined. All were prescribed vitamin D +/- calcium supplements. Conclusion The UK FLS-DB estimated that the number of ‘clinical’ vertebral fractures roughly equates to that of hip fractures, so this denominator has been used for the Irish FLS-DB. This would correlate with our service assessing 29% of expected clinical vertebral fractures in 2023. Appointment of a dedicated ANP for fracture liaison has streamlined bone health assessment for acute fractures attending our hospital. Further work on case finding needed to ensure we are assessing all patients at increased risk of further fracture.

Hip Fracture and The Associated Risk Factors among Egyptian Males

Abstract Background Fragility fractures caused by osteoporosis are well-known to increase the risk of further fragility fractures; a history of the wrist, vertebral body, or hip fractures increases the risk of further fractures accordingly. Fragility fractures induce lower activities of daily living (ADL), and repeated fractures further reduce mobility. Studies found that persons who experienced at least one vertebral body fracture had a higher mortality rate than persons without vertebral body fractures. Also, the one year survival rate of patients with hip fractures was lower than that of the general population. The objective of this study was to find the proportion of concomitant hidden vertebral fractures among males with fragility hip fracture. Patients and Methods Observational analytical case control study, on 150 male cases of osteoporotic hip fractures with matching 150 controls, 40 years of age and older, presented to orthopedic emergency room in the period from Jan, 2019 to Jan, 2020. Cases and controls underwent structured interview questionnaire including all medical and socio- demographic characteristics. Cases in addition underwent plain x-ray for lumbosacral vertebra to assess for concomitant hidden vertebral fractures, in addition. Results We had 150 patients conforming to our inclusion criteria, visiting the orthopedic emergency department, of a total number 48000 patients, only 13000 of them are males during the study period, from Jan 2019 to Jan. 2020. The proportion of fragility hip fracture among males was 1.2%, with mean age 74.32 +/- 10.7. Cases also had a number of co- morbidities ranging from 4-7 chronic diseases. Of those cases, 26% had a concomitant hidden vertebral fracture. Conclusion Concomitant vertebral fracture is prevalent among males with other fragility fractures, especially hip fracture, which warrants identification and management to evade complications and mortality.

Improving patients’ experiences of diagnosis and treatment of vertebral fracture: co-production of knowledge sharing resources

BackgroundOsteoporosis involves changes to bones that makes them prone to fracture. The most common osteoporotic fracture is vertebral, in which one or more spinal vertebrae collapse. People with vertebral fracture are at high risk of further fractures, however around two-thirds remain undiagnosed. The National Institute for Health and Care Excellence (NICE) recommends bone protection therapies to reduce this risk. This study aimed to co-produce a range of knowledge sharing resources, for healthcare professionals in primary care and patients, to improve access to timely diagnosis and treatment.MethodsThis study comprised three stages: 1. In-depth interviews with primary care healthcare professionals (n = 21) and patients with vertebral fractures (n = 24) to identify barriers and facilitators to diagnosis and treatment. 2. A taxonomy of barriers and facilitators to diagnosis were presented to three stakeholder groups (n = 18), who suggested ways of identifying, diagnosing and treating vertebral fractures. Fourteen recommendations were identified using the nominal group technique. 3. Two workshops were held with stakeholders to co-produce and refine the prototype knowledge sharing resources (n = 12).ResultsStage 1: Factors included lack of patient information about symptoms and risk factors, prioritisation of other conditions and use of self-management. Healthcare professionals felt vertebral fractures were harder to identify in lower risk groups and mistook them for other conditions. Difficulties in communication between primary and secondary care meant that patients were not always informed of their diagnosis, or did not start treatment promptly. Stage 2: 14 recommendations to improve management of vertebral fractures were identified, including for primary care healthcare professionals (n = 9) and patients (n = 5). Stage 3: The need for allied health professionals in primary care to be informed about vertebral fractures was highlighted, along with ensuring that resources appealed to under-represented groups. Prototype resources were developed. Changes included help-seeking guidance and clear explanations of medical language.ConclusionsThe study used robust qualitative methods to co-produce knowledge sharing resources to improve diagnosis. A co-production approach enabled a focus on areas stakeholders thought to be beneficial to timely and accurate diagnosis and treatment. Dissemination of these resources to a range of stakeholders provides potential for substantial reach and spread.

POS1514-HPR UNDERSTANDING AND CHARACTERISING PATIENT PATHWAYS TO TREATMENT FOR VERTEBRAL FRACTURES: A QUALITATIVE STUDY

BackgroundOsteoporosis involves thinning of the bones, making them more prone to break. The most common osteoporotic fracture is a vertebral fracture (OVF). People with OVFs are at high risk of further fractures. To reduce this risk, guidelines recommend prescription of bone protection therapies to people who have experienced a fracture. However, many patients do not receive diagnosis. Understanding patient pathways to treatment for OVFs will provide information to improve practice and aid in effective identification and management.ObjectivesTo understand and characterise patient pathways to treatment for OVFs.MethodsTwenty-three semi-structured qualitative interviews were conducted with patients aged ≥50 years with diagnosis of OVF. Patients were recruited through two hospitals in England and were purposively sampled to capture variation in pathways to diagnosis, sex, age, comorbidities and other relevant characteristics. Interviews were audio-recorded, transcribed and analysed thematically, with themes transposed onto key stages of the patient pathway.ResultsSeveral factors influenced patient pathways to treatment:Patient appraisal and self-management: Characteristics and attitudes towards back pain impacted treatment-seeking behaviour. Patients who appraised their pain as ‘different’, severe or disruptive, or associated with an injury such as a fall, were more likely to seek help. Limited availability of information about OVFs and risk factors meant most patients did not associate symptoms with a potential OVF. Factors contributing to delayed consultation included the normalisation of back pain and prioritisation of comorbid conditions. Several misappraised their symptoms as a “pulled muscle” or other minor injury. Many adopted strategies to manage pain, including use of painkillers, lying flat or resting. For some, a lack of improvement in symptoms over time, combined with worsening pain, created a ‘tipping point’ in seeking care. There was a moral dimension for some patients who did not want to “bother” healthcare professionals.Healthcare professional appraisal: Differential diagnosis was a barrier to treatment and healthcare professionals interpreted OVF pain as broken ribs, muscular pain, kidney pain or sciatica. GPs tended to instigate watchful waiting, in which patients were asked to re-consult if pain did not improve. Feeling disbelieved caused some patients to become disillusioned and reluctant to re-consult and a small number of patients presented at Accident and Emergency. Those already having treatment for musculoskeletal conditions with access to specialist care, were more likely to receive timely diagnosis.Communication of diagnosis: Patients discussed multiple methods of communication, including written communication and clinical conversations. Several expressed confusion around the use of unfamiliar medical terminology, the implications of OVFs, how many OVFs they had experienced and how they had been identified.Treatment initiation: Bone protection therapies were not consistently prescribed after diagnosis. Patients who were familiar with these therapies were unsure whether treatment should be initiated in primary or secondary care. Patients described how they felt a need to be proactive by arranging appointments and asking for treatment.ConclusionThe study provides novel findings about patient pathways to treatment and will be used to identify targeted solutions to improve management of OVFs. This work addresses stages of the Model of Pathways to Treatment[1] and provides detailed understanding of patients’ experiences of these stages. Further work with healthcare professionals in primary care is underway to identify additional system-level factors that may impact patients’ journeys to treatment.

How to initiate and develop Fracture Liaison Services (FLS). Recommendations from the IOF Capture the Fracture® FLS Mentors in Brazil.

To create a guideline to show health professionals, hospital managers, and stakeholders in Brazil the importance of secondary fracture prevention and how to implement a Fracture Liaison Service. We review the cost-effectiveness for FLSs in Brazil. We describe the key components needed to set up an effective FLS including methods for identification, investigation, treatment indication, including bone drugs, supplementation, physical activity, fall prevention, and monitoring. The staffing of FLSs, value of regional clinical networks and quality improvement are also described as a guide for healthcare professionals and decision makers in Brazil. An FLS is a service dedicated to identifying, assessing, recommending treatment, and monitoring patient who present with a fragility fracture reducing the risk of another fracture. FLS has been implemented in Brazil since 2012 overcoming a large geography and a complex health system. Even the limitations, restrictions, differences, and characteristics of each region, it is possible for health institutions to initiate an FLS, adapted to own available resources and meet the stages of identification, investigation, treatment, and monitoring. The peculiarity of the Brazilian healthcare system means FLS implementation needs to be tailored to local reality. However, even with limitations, any attempt to capture patients who suffer a fracture due to bone fragility is effective and reduces the risk of further fractures.

Fracture liaison services in Ireland-how do we compare to international standards?

Fragility/low-trauma fractures are a global concern, whose incidence is rising as the population ages. Many are preventable, and people with a prior fragility fracture are at particularly high risk of further fractures. This patient group is the target of the International Osteoporosis Foundation (IOF) Capture the Fracture campaign, advocating global adoption of fracture liaison services (FLS), with the aim of preventing secondary fragility fractures. We wished to determine the current availability and standards of an FLS in Ireland, ahead of the launch of a National FLS database. We devised a questionnaire encompassing the thirteen IOF standards for an FLS and asked all 16 public hospitals with an orthopaedic trauma unit in Ireland, to complete for the calendar year 2019 in patients aged ≥ 50years. All sites returned the questionnaire, i.e. 100% response rate. Nine hospitals stated that they have an FLS, additionally one non-trauma hospital running a FLS responded, and were included. These 10 FLS had identified and managed 3444 non-hip fractures in the year 2019. This figure represents 19% of the expected non-hip fragility fracture numbers occurring annually in Ireland. Implementation of the IOF standards was very variable. All sites reported being inadequately resourced to provide a high-quality service necessary to be effective. The existence and functioning of FLS in Ireland are heterogeneous and suboptimal. A national policy to support the implementation of this programme in line with international standards of patient care is urgently needed.

Poor Attendance for bone densitometry in patients at high risk of subsequent fragility fractures

Fracture Liaison Services (FLS) are considered the most effective model for the prevention of subsequent fractures however, the uptake of these services has shown to be suboptimal. 6,528 patients were identified and referred on for bone densitometry assessment over a 6 yr period, however, 21% of these patients did not attend, with a trend towards a higher re-fracture rate in those that did not attend compared to those that did. The presence of a fragility fracture increases the risk of further fractures. Fracture Liaison Services (FLS) are considered the most effective model for the prevention of subsequent fractures, although the uptake amongst patients invited for bone densitometry assessment has shown to be suboptimal. The UK has one of the most comprehensive numbers of FLS, however the proportion and characteristics of patients identified through the FLS that do not respond to bone densitometry invitation, in the UK, remains unclear. We report the 6 yr. findings from the Nottingham FLS. The Nottingham Fracture Liaison Service (N-FLS) systematically identifies those adults aged 50 yr. and older with fragility fractures presenting to the fracture clinic and where appropriate, arranges referral for bone densitometry assessment. Routine clinical data is collected onto the N-FLS database. Patient characteristics, between January 2012 and December 2017, were examined of those referred for bone densitometry examination, comparing those that attended to those that did not attend (DNA). Deprivation scores for each patient were calculated using the English indices of deprivation 2015 (1–Most deprived; 5- Least deprived). Follow up data was available for those attending from 2016 onwards, which allowed an assessment of re-fracture. Over the 6 yr period, 6,528 patients as identified by the N-FLS were referred on for bone densitometry assessment. 1,386 patients (21%) did not attend (DNA) for bone densitometry assessment. The proportion was similar for each of the years. High prevalence of non-attendance was in females [1032 patients (74%)] and the most deprived individuals [398 patients (29%), which were significant when compared to those that did attend, p=0.042]. 826 patients were referred in 2016. Median follow-up time was 2.46 yr. (IQR 0.16–3.00 yr.). 52 (7%) patients, in this group, sustained a subsequent fracture (35 patients in the group that did not attend for bone density assessment and 17 in those that attend, p=0.092). Nottingham FLS have identified patients with fragility fractures that are at high-risk of further fractures. Despite a dedicated FLS, 21% of those invited for bone densitometry assessment, did not attend for their appointment, over the 6 yr. period, similar proportion each year. There was a significantly higher proportion of those identified as ‘most deprived’ not attending for a bone densitometry, compared to those who attended. Sub-analysis in those aged 75 yr. and over, showed a high non-attendance in this group. Further qualitative studies are necessary to explore this patient group in detail, who remain at high risk of re-fracture.

A Retrospective Analysis in 1347 Patients Undergoing Cement Augmentation for Osteoporotic Vertebral Compression Fracture: Is the Sandwich Vertebra at a Higher Risk of Further Fracture?

Chiu, Ping-Yeh MD; Kao, Fu-Cheng MD; Hsieh, Ming-Kai MD; Tsai, Tsung-Ting MD, PhD; Chen, Wen-Jer MD; Niu, Chi-Chien MD; Lai, Po-Liang MD, PhD

Osteoporotic fractures and subsequent fractures: imminent fracture risk from an analysis of German real-world claims data

PurposeIn osteoporosis, prior fracture is a strong predictor of subsequent fracture. This study aimed to assess the imminent risk of subsequent fracture following an initial fracture in osteoporosis patients in Germany, and to identify clinical and demographic characteristics that are independently associated with subsequent fracture risk.MethodsIn this retrospective, observational cohort study using German real-world claims data, male and female patients aged ≥ 50 years with osteoporosis who experienced an initial (“index”) hip/femur, vertebral, forearm/wrist/hand or shoulder/upper arm fracture between 2010 and 2014 were included. The incidence and timing of subsequent fractures during a 1-year follow-up period were analyzed. Independent risk factors for subsequent fracture were identified by multivariate regression analysis.ResultsA total of 18,354 patients (mean age: 77 years; standard deviation: 9.8) were included. Of these, 2918 (15.9%) suffered a subsequent fracture during the 1-year follow-up period. The incidence of subsequent fracture was higher following an index vertebral fracture (18.0%) than after an index forearm/wrist/hand fracture (14.1%) or index hip/femur fracture (12.1%). Subsequent 1-year fracture incidence was generally higher in older patients. Index fracture type, age, epilepsy/use of antiepileptics, and heart failure were all independently associated with subsequent fracture risk.ConclusionOsteoporosis patients in Germany are at imminent risk of subsequent fracture during the first year following an initial fracture. They should be targeted for immediate post-fracture treatment to reduce the risk of further fractures, especially in the presence of specific risk factors such as old age or index vertebral fracture.

In Reply: A Retrospective Analysis in 1347 Patients Undergoing Cement Augmentation for Osteoporotic Vertebral Compression Fracture: Is the Sandwich Vertebra at a Higher Risk of Further Fracture?

Background Multiple percutaneous vertebral cement augmentation may create sandwich vertebrae. Whether the sandwich vertebra is at higher risk of further fracture remains unknown. Objective To compare the incidence of further fractures of sandwich vertebrae and adjacent vertebrae and to identify potential risk factors for sandwich vertebral fractures. Methods Patients who underwent cement augmentation for osteoporotic vertebral compression fractures (OVCFs) in a single medical center between January 2012 and December 2015 were included. A sandwich vertebra was defined as an intact vertebra located between 2 previously cemented vertebrae. Demographic data and imaging findings were recorded. All patients were followed up for at least 24 mo postoperatively. During follow-up period, if the patient reported new-onset back pain with corresponding imaging findings, a diagnosis of sandwich vertebral fracture was made. Results Among the 1347 patients who underwent vertebroplasty/kyphoplasty for OVCFs, 127 patients with 128 fracture levels met the criteria for sandwich vertebrae (females/males 100/27, mean age 77.8 ± 7.7 yr old). The fracture location was most common in the thoraco-lumbar junction (T10-L2), 68.5% (87/127). The incidence of sandwich vertebral fracture was 21.3%, whereas the incidence of adjacent level fracture of those with no sandwich vertebra was 16.4% (196/1194), P = .1879. Conclusion The incidence of sandwich vertebral fracture is not higher than that at the adjacent levels. The factor associated with further sandwich vertebral fracture was male gender. Once sandwich vertebral fracture occurred, patients may seek more surgical intervention than those with only adjacent fractures.

411 EFFICACY OF CDSS IN IMPROVING ANTI-RESORPTIVE BONE PROTECTIVE THERAPY AMONGST ORTHOGERIATRIC INPATIENTS: A COMPARISON STUDY

Abstract Background Hip fractures have a mortality rate of 20% in the year following the fracture. Therefore, patients presenting with hip fractures should be assessed and prescribed anti-resorptive bone protective therapy (ABPT) to reduce the risk of further fractures. In our institution, this decision is undertaken by a specialist only. Purpose: The objective of this study is to compare the proportion of patients commenced on ABPT by surgical interns following the introduction of a Clinical Decision Support System (CDSS) in January 2020 to support appropriate ABPT prescribing amongst non-specialists. Methods The study compares the orthogeriatric patient cohort before and after CDSS introduction within the same time period (Jan 1st to June 30th) in 2019 and 2020. Data were extracted from the Irish Hip Fracture Database and statistically analyzed using SPSS. The Mann–Whitney two-tailed test was employed to calculate statistical significance. Results In 2019, 31% (55/178) of patients admitted during the study period (n = 178) did not receive orthogeriatric specialist input and only 27% (15/55) of these had ABPT prescribed during their admission. In 2020, 17% (32/185) of patients admitted during the study period (n = 185) did not receive specialist input; however, 44% (14/32) of these were commenced on ABPT. Overall, more patients were prescribed ABPT in 2020 (78%;146/185), as compared to 55% (98/178) in 2019 (z-score 6.57069; p-value <0.01). The number of patients awaiting specialist outpatient appointments before being prescribed ABPT also dropped from 40% (71/178) in 2019 to 13% (24/185) in 2020 (p-value <0.01). Conclusion This study highlighted the significance of a CDSS to improve inpatient ABPT prescribing by non-specialists and to reduce outpatient specialist appointments. This could have a major impact on the long-term reduction of mortality rates amongst orthogeriatric patients and the reduction of future healthcare costs.

A Retrospective Analysis in 1347 Patients Undergoing Cement Augmentation for Osteoporotic Vertebral Compression Fracture: Is the Sandwich Vertebra at a Higher Risk of Further Fracture?

Multiple percutaneous vertebral cement augmentation may create sandwich vertebrae. Whether the sandwich vertebra is at higher risk of further fracture remains unknown. To compare the incidence of further fractures of sandwich vertebrae and adjacent vertebrae and to identify potential risk factors for sandwich vertebral fractures. Patients who underwent cement augmentation for osteoporotic vertebral compression fractures (OVCFs) in a single medical center between January 2012 and December 2015 were included. A sandwich vertebra was defined as an intact vertebra located between 2 previously cemented vertebrae. Demographic data and imaging findings were recorded. All patients were followed up for at least 24 mo postoperatively. During follow-up period, if the patient reported new-onset back pain with corresponding imaging findings, a diagnosis of sandwich vertebral fracture was made. Among the 1347 patients who underwent vertebroplasty/kyphoplasty for OVCFs, 127 patients with 128 fracture levels met the criteria for sandwich vertebrae (females/males 100/27, mean age 77.8±7.7yr old). The fracture location was most common in the thoraco-lumbar junction (T10-L2), 68.5% (87/127). The incidence of sandwich vertebral fracture was 21.3%, whereas the incidence of adjacent level fracture of those with no sandwich vertebra was 16.4% (196/1194), P=.1879. The incidence of sandwich vertebral fracture is not higher than that at the adjacent levels. The factor associated with further sandwich vertebral fracture was male gender. Once sandwich vertebral fracture occurred, patients may seek more surgical intervention than those with only adjacent fractures.

Opportunistic diagnosis of osteoporotic vertebral fractures on standard imaging performed for alternative indications.

Osteoporotic vertebral fractures (VFs) are the most common type of osteoporotic fracture. Patients with VF are at increased risk of hip fractures or additional VFs, both of which contribute to patient morbidity and mortality. Early diagnosis of VFs is essential so patients can be prescribed appropriate medical therapy.Most patients with clinical suspicion for VF have an X-ray of the spine. Many VFs are invisible on X-ray and require further imaging. CT can provide excellent bony detail but uses high doses of ionising radiation. MRI provides excellent soft tissue detail and can distinguish old from new fractures in addition to differentiating osteoporotic VFs from other causes of back pain. Bone scans have a limited role due to poor specificity.The literature suggests that radiologists frequently miss or do not report VFs when imaging is requested for an alternative clinical indication and when there is no clinical suspicion of VF. Common examples include failure to identify VFs on lateral chest X-rays, sagittal reformats of CT thorax and abdomen, lateral localizers on MRI and scout views on CT.Failure to diagnose a VF is a missed opportunity to improve management of osteoporosis and reduce risk of further fractures. This article discusses the role of radiographs, CT, MRI and bone scintigraphy in the assessment and recognition of osteoporotic fractures. This article focuses on opportunistic diagnosis of VFs on imaging studies that are performed for other clinical indications. It does not discuss use of dual energy X-ray absorptiometry which is a specific imaging modality for osteoporosis.

Age-specific occurrence of pathological fractures in patients with spina bifida.

Pathological fractures (PFs) are common in patients with spina bifida. However, most previous studies refer to the overall fracture rate and largely neglecting putative age-dependent aspects. The aim of this retrospective study was to characterize patterns of fracture occurrence in childhood. In a retrospective study, we identified PF, all in the lower limbs, in 13% of 210 patients with spina bifida aperta. We further identified a bimodal frequency distribution of pathological fractures, with peaks at 1-5 and 10-12 years. We could thereby distinguish two groups of patients: (i) Children with a first fracture before an age of 6 years developed frequently multiple fractures within the following years, but fracture series typically stopped by 6 years-of-age. (ii) Children with a first fracture after the age of 6 years had fewer fractures, but these occurred also in adolescence. PF occurred rarely after the age of 13 years. The age at fracture correlated with the fracture site with 85% of the fractures occurring in the femur in the first five years of life and an increased frequency of tibia and foot fractures later in life. While, overall high lesion levels and preceding immobilizing events were risk factors for PF, femur fractures in children under 6 years-of-age occurred independent of their lesion level, and the age at verticalization did not correlate with PF rates.Conclusion: Based on these findings, standardized and effective preventive physiotherapeutic and/or pharmacological interventions to tackle PF in spina bifida need to consider age-specific differences in occurrence and reoccurrence of fractures.What is Known:• Pathological fractures are common in patients with spina bifida aperta, and associated risk factors include high lesion level, immobilization and low bone density.What is New:• We first report a bimodal frequency distribution of pathological fractures in childhood (first peak 1-5 years, second peak 10-12 years) and link early-onset fracture occurrence with the risk of multiple fractures arise in a short time period but a the chance of self-limitation of fracture series within a few years.• We show that femur fractures in children under 6 years-of-age occurred independent of their lesion level, and the age at verticalization did not correlate with PF rates.• We further link the age-dependent occurrence pattern with the risk of further fractures and with the chance of self-limitation of fracture series. The earlier a first fracture occurs, the more probable multiple fractures arise in a short time period. Nevertheless, early fracture series are often self-limiting within a few years.• Femur fractures in children under 6 years-of-age occurred independent of their lesion level, and the age at verticalization did not correlate with PF rates.• Based on these findings, physiotherapeutic and/or pharmaceutical concepts need to be developed in an age-adapted manner and in consideration of the potential self-limiting nature of fracture series.

Neglected bodily senses in women living with vertebral fracture: a focus group study.

Older women are at particular risk of osteoporosis. Among women with osteoporosis, fractures of the vertebra (vertebral fracture) are common, hard to detect and associated with risk of further fracture. Identifying vertebral fracture in a timely manner allows instigation of preventive measures to reduce the risk of further fracture. Although detection of vertebral fracture requires spinal radiograph, many women do not receive referral. To begin development of a screening tool to identify women in need of referral we undertook a qualitative study to characterize women's experiences of vertebral fracture, using Eccleston's 'Ten Neglected Bodily Senses'. Four qualitative focus groups were conducted with women who had been diagnosed with vertebral fracture (n = 19, age 60-91 years). Data were audio-recorded, transcribed and analysed thematically using the 'Ten Neglected Bodily Senses'. Women's experiences of vertebral fractures related to seven senses: pain, movement, fatigue, balance, pressure, appetite and breathing. Pain was the dominant sense and all participants explained how pain increased with activity, reaching a crescendo, and described strategies to minimize this disruption. Most participants had become physically shorter, making some feel 'squashed', putting pressure on other body parts. Some described appetite loss or a sense of restricted breathing. Participants experienced a sense of being 'pulled' forwards, impacting on balance and exacerbating fear of falling. The study found senses that have not been previously described in the experiences of women with vertebral fracture. These will be used to inform the design of a new screening tool for use in primary care.

An observational cohort study to produce and evaluate an improved tool to screen older women with back pain for osteoporotic vertebral fractures (Vfrac): study protocol

SummaryThe aim of this study is to produce an easy to use checklist for general practitioners to complete whenever a woman aged over 65 years with back pain seeks healthcare. This checklist will produce a binary output to determine if the patient should have a radiograph to diagnose vertebral fracture.PurposePeople with osteoporotic vertebral fractures are important to be identified as they are at relatively high risk of further fractures. Despite this, less than a third of people with osteoporotic vertebral fractures come to clinical attention due to various reasons including lack of clear triggers to identify who should have diagnostic spinal radiographs. This study aims to produce and evaluate a novel screening tool (Vfrac) for use in older women presenting with back pain in primary care based on clinical triggers and predictors identified previously. This tool will generate a binary output to determine if a radiograph is required.MethodsThe Vfrac study is a two-site, pragmatic, observational cohort study recruiting 1633 women aged over 65 years with self-reported back pain. Participants will be recruited from primary care in two sites. The Vfrac study will use data from two self-completed questionnaires, a simple physical examination, a lateral thoracic and lateral lumbar radiograph and information contained in medical records.ResultsThe primary objective is to develop an easy-to-use clinical screening tool for identifying older women who are likely to have vertebral fractures.ConclusionsThis article describes the protocol of the Vfrac study; ISRCTN16550671.

Vertebral Fragility Fractures (VFF)—Who, when and how to operate

Vertebral Fragility Fractures (VFF) are common and lead to pain, long term disability and increased mortality. Most patients will have mild to moderate pain symptoms and can be managed conservatively. However, patients with severe pain who have minimal or no pain relief with potent analgesia, or who only achieve adequate pain relief with high doses of morphine based analgesia which results in significant adverse events, should be considered for vertebral augmentation. Ideally, for vertebral augmentation, patients should present within four months of the fracture (onset of acute pain) and have at least 3 weeks of failure of conservative treatment although early intervention may be more appropriate for hospitalised patients, who tend to be older, more frail and likely to be less tolerant to the adverse effects of conservative treatment.The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) recommends Percutaneous Vertebroplasty as the first line surgical augmentation technique for VFF in older people, which has been shown to improve pain symptoms, allow early restoration of functional mobility and may reduce the risk of further vertebral collapse. CIRSE recommends percutaneous Balloon Kyphoplasty as second line treatment in VFF, although the optimal indication is for acute traumatic vertebral fractures (less than 7–10 days) in younger people. Assessment and treatment of underlying osteoporosis is important to reduce the risk of further fractures in older people with VFF.

Individualized fracture risk prediction

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

Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections.

Local release of antibiotic has advantages in the treatment of chronic osteomyelitis and infected fractures. The adequacy of surgical debridement is still key to successful clearance of infection but local antibiotic carriers seem to afford greater success rates by targeting the residual organisms present after debridement and delivering much higher local antibiotic concentrations compared with systemic antibiotics alone. Biodegradable ceramic carriers can be used to fill osseous defects, which reduces the dead space and provides the potential for subsequent repair of the osseous defect as they dissolve away. A dissolving ceramic antibiotic carrier also raises the possibility of single stage surgery with definitive closure and avoids the need for subsequent surgery for spacer removal.In this article we provide an overview of the properties of various biodegradable ceramics, including calcium sulphate, the calcium orthophosphate ceramics, calcium phosphate cement and polyphasic carriers. We summarise the antibiotic elution properties as investigated in previous animal studies as well as the clinical outcomes from clinical research investigating their use in the surgical management of chronic osteomyelitis.Calcium sulphate pellets have been shown to be effective in treating local infection, although newer polyphasic carriers may support greater osseous repair and reduce the risk of further fracture or the need for secondary reconstructive surgery. The use of ceramic biocomposites to deliver antibiotics together with BMPs, bisphosphonates, growth factors or living cells is under investigation and merits further study.We propose a treatment protocol, based on the Cierny-Mader classification, to help guide the appropriate selection of a suitable ceramic antibiotic carrier in the surgical treatment of chronic osteomyelitis.