Sex differences in hemoglobin levels and five-year refracture risk in patients with osteoporotic fractures: a retrospective cohort analysis.

We conducted a retrospective cohort analysis to examine the association between hemoglobin (Hb) levels and refracture risk in elderly patients with osteoporotic fractures (OPFs). Our findings suggest a nonlinear relationship exists in females, and females with Hb levels below 10.7 g/dL may be at a higher risk of refracture. INTRODUCTION: Hematopoiesis and bone health have a reciprocal influence on each other. Nevertheless, there is a scarcity of in-depth research on the association between Hb levels and the occurrence of fractures. The present research aimed to investigate the correlation between Hb levels and the rate of refracture within 5 years among individuals with OPFs. METHODS: A retrospective cohort analysis was undertaken between 2017 and 2022. The study included 1906 individuals who were inhabitants of Kunshan and were over 60 years old. These individuals had experienced an OPF between January 1, 2017, and July 27, 2022, resulting in their hospitalization. Cox proportional hazard regression models were used to evaluate the risk of refracture within 5 years based on the Hb levels acquired during the admission examination, with consideration for sex differences. A nonlinear relationship was identified using smoothed curve fitting and threshold analysis. Kaplan-Meier curves were used to compare refracture rates between patients with low and high Hb levels. RESULTS: Elderly female patients with OPFs and lower Hb levels exhibited a significantly higher risk of a 5-year refracture. Conversely, no significant associations were observed between the two variables in male patients. A nonlinear correlation was found between Hb levels and the probability of refracture in females, with a turning point identified at 10.7 g/dL of Hb levels. A strong negative association was observed with the five-year refracture rate when Hb levels fell below 10.7 g/dL (hazard ratio (HR) = 0.63; 95% confidence interval (CI) 0.48 to 0.83; P-value = 0.0008). This finding suggests that for every 1 g/dL increase in Hb below 10.7 g/dL, the risk of refracture reduced by 37%. However, no statistically significant association was observed when Hb levels were above 10.7 g/dL. CONCLUSIONS: The findings demonstrated a significant negative correlation between Hb levels and the likelihood of refracture in elderly female patients with OPFs and suggested that elderly females with recent OPFs and Hb levels below 10.7 g/dL may be at a higher risk of refracture. Additionally, the Hb levels can serve as an indicator of bone fragility in elderly female patients with OPFs. These findings highlight the importance of monitoring Hb levels as a part of comprehensive management strategies to both assess skeletal health and prevent refractures in this population.

Should major trauma fractures be part of a fracture liaison service's remit: a cost-benefit estimate.

The refracture rate after major trauma is approximately half (57%) the refracture rate after a minimal trauma injury. Extending Fracture Liaison Service activity to include major trauma patients creates significant additional direct cost, but remains essentially cost neutral if notional savings through refracture risk reduction are taken into account. PURPOSE: To compare the 3-year refracture rate following minimal trauma (MT) and non-minimal trauma (non-MT) injuries and evaluate the cost of extending fracture liaison service (FLS) operations to non-MT presentations. METHODS: Patients aged 50, or above presenting to the John Hunter Hospital with a fracture in calendar year 2018 were identified through the Integrated Patient Management System (IPMS) of the Hunter New England Health Service's (HNEHS), and re-presentation to any HNEHS facility over the following 3 years monitored. The refracture rate of MT and non-MT presentations was compared and analysed using Cox proportional hazards regression models. The cost of including non-MT patients was estimated through the use of a previously conducted micro-costing analysis. The operational fidelity of the FLS to the previous estimate was confirmed by comparing the 3-year refracture rate of MT presentations in the two studies. RESULTS: The 3-year refracture rate following a MT injury was 8% and after non-MT injury 4.5%. Extension of FLS activities to include non-MT patients in 2022 would have cost an additional $198,326 AUD with a notional loss/saving of $ - 26,625/ + 26,913 AUD through refracture risk reduction. No clinically available characteristic at presentation predictive of increased refracture risk was identified. CONCLUSION: The 3-year refracture after a non-MT injury is about half (57%) that of the refracture rate after a MT injury. Extending FLS activity to non-MT patients incurs a significant additional direct cost but remains cost neutral if notional savings gained through reduction in refracture risk are taken into account.

The predictive value of albumin to alkaline phosphatase ratio for vertebral refractures in postmenopausal women.

INTRODUCTION: To investigate the clinical value of serum albumin to alkaline phosphatase ratio (AAPR) in predicting the risk of osteoporotic vertebral refractures group (OVRFs) after percutaneous vertebral augmentation (PVA) in postmenopausal women. MATERIALS AND METHODS: This is a retrospective case-control study including a series of postmenopausal women patients with osteoporotic vertebral fracture (OVF) and underwent PVA. Patients were divided into OVRFs and non-OVRFs. COX model was used to evaluate the correlation between preoperative AAPR and OVRFs after PVA. The receiver operating characteristic (ROC) curve and Kaplan-Meier method were used to analyze the predictive value of AAPR for the incidence of OVRFs. RESULTS: A total of 305 patients were included in the final study, and the incidence of postoperative OVRFs was 28.9%. Multivariate COX analysis showed that advanced age (HRs = 1.062, p = 0.002), low BMI (HRs = 0.923, p = 0.036), low AAPR (HRs = 0.019, p = 0.001), previous fall history (HRs = 3.503, p = 0.001), denosumab treatment (HRs = 0.409, p = 0.007), low L3 BMD (HRs = 0.977, p = 0.001) and low L3 paravertebral muscle density (PMD)value (HRs = 0.929, p = 0.001)) were closely related to the incidence of OVRFs. The area under the curve (AUC) of AAPR for predicting OVRFs was 0.740 (p < 0.001), and the optimal diagnostic cut-off value was 0.49. Kaplan-Meier curve analysis showed that low AAPR group (< 0.49) was significantly associated with lower OVRFs-free survival (p = 0.001; log-rank test). CONCLUSION: AAPR is an independent risk factor for OVRFs after PVA in postmenopausal women, and it can be used as an effective index to predict OVRFs.

Refracture following vertebral fragility fracture when bone fragility is not recognized: summarizing findings from comparator arms of randomized clinical trials.

PURPOSE: Since vertebral fragility fractures (VFFs) might increase the risk of subsequent fractures, we evaluated the incidence rate and the refracture risk of subsequent vertebral and non-vertebral fragility fractures (nVFFs) in untreated patients with a previous VFF. METHODS: We systematically searched PubMed, Embase, and Cochrane Library up to February 2022 for randomized clinical trials (RCTs) that analyzed the occurrence of subsequent fractures in untreated patients with prior VFFs. Two authors independently extracted data and appraised the risk of bias in the selected studies. Primary outcomes were subsequent VFFs, while secondary outcomes were further nVFFs. The outcome of refracture within ≥ 2 years after the index fracture was measured as (i) rate, expressed per 100 person-years (PYs), and (ii) risk, expressed in percentage. RESULTS: Forty RCTs met our inclusion criteria, ranging from medium to high quality. Among untreated patients with prior VFFs, the rate of subsequent VFFs and nVFFs was 12 [95% confidence interval (CI) 9-16] and 6 (95% CI 5-8%) per 100 PYs, respectively. The higher the number of previous VFFs, the higher the incidence. Moreover, the risk of VFFs and nVFFs increased within 2 (16.6% and 8%) and 4 years (35.1% and 17.4%) based on the index VFF. CONCLUSION: The highest risk of subsequent VFFs or nVFFs was already detected within 2 years following the initial VFF. Thus, prompt interventions should be designed to improve the detection and treatment of VFFs, aiming to reduce the risk of future FFs and properly implement secondary preventive measures.

Mortality and re-fracture rates in low trauma hip fracture.

OBJECTIVES: This study aimed to estimate the incidence rate of re-fracture and all-cause mortality rate in patients with hip fractures caused by minor trauma in the first year following the event. MATERIALS AND METHODS: This is a retrospective cohort study of patients over 50 years of age conducted in a referral hospital located in Tehran (Shafa-Yahyaian). Using the hospital information system (HIS), all patients hospitalized due to hip fractures caused by minor trauma during 2013-2019 were included in the study. We investigated the occurrence of death and re-fracture in all patients one year after the primary hip fracture. RESULTS: A total of 945 patients with hip fractures during a 307,595 person-days of follow-up, were included. The mean age of the participants was 71 years (SD = 11.19), and 533 (59%) of them were women. One hundred forty-nine deaths were identified during the first year after hip fracture, resulting in a one-year mortality rate of 17.69% (95% CI: 15.06-20.77). The one-year mortality rate was 20.06% in men and 15.88% in women. Out of all the participants, 667 answered the phone call, of which 29 cases had experienced a re-fracture in the first year (incidence rate = 5.03%, 95% CI: 3.50-7.24). The incidence rates in women and men were 6.07% and 3.65%, respectively. CONCLUSION: Patients with low-trauma hip fractures have shown a high rate of mortality in the first year. Considering the increase in the incidence of hip fractures with age, comprehensive strategies are needed to prevent fractures caused by minor trauma in the elderly population.

Secondary osteoporosis prevention: three-year outcomes from a Fracture Liaison Service in elderly hip fracture patients.

BACKGROUND: Hip fractures are the most serious fragility fractures due to their associated disability, higher hospitalization costs and high mortality rates. Fracture Liaison Service (FLS) programs have enhanced the management of osteoporosis-related fractures and have shown their clinical effectiveness. AIMS: To analyze the effect of the implementation of a FLS model of care over the survival and mortality rates following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture before and after the implementation of the FLS in our center (between January 2016 and December 2019). Patients were followed for three years after the index date. Mortality, complications and refracture rates were compared between the two groups using a Multivariate Cox proportional hazard model. RESULTS: A total of 1366 patients were included in this study (353 before FLS implementation and 1013 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (79.3% vs 12.5%; p < 0.01) and there was an increase in adherence to treatment (51.7% vs 30.2%; p < 0.01). A total of 413 (40.8%) patients after FLS implementation and 141 (39.9%) individuals before (p = 0.47) died during the three-years follow-up period. A second fracture occurred in 101 (10.0%) patients after FLS implementation and 37 (10.5%) individuals before (p = 0.78). Patients after the implementation of the FLS protocol had a lower all cause one-year mortality [adjusted Hazard Ratio (HR) 0.74 (0.57-0.94)] and a decreased risk of suffering a second osteoporotic fracture [adjusted HR 0.54 (0.39-0.75) in males and adjusted HR 0.46 (0.30-0.71) in females]. CONCLUSIONS: The implementation of a FLS protocol was associated with a lower all-cause one-year mortality rate and a higher survivorship in elderly hip fracture patients. However, no three-year mortality rate differences were observed between the two groups. We also found a reduction in the complication and second-fracture rates.

Effect of sarcopenia on refractures of adjacent vertebra after percutaneous kyphoplasty.

PURPOSE: To explore the effect of sarcopenia on recurrent fractures of adjacent vertebra after percutaneous kyphoplasty (PKP). METHODS: A total of 376 osteoporotic vertebral compression fractures (OVCFs) patients over 55 years old who were admitted to the Hospital from August 2020 to January 2021 were selected. Among them, 38 patients with recurrent fractures in adjacent vertebra after PKP were selected as the refracture group (RG), and the remaining 338 patients were selected as the non-refracture group (NRG). The age, gender, grip strength, body mass index (BMI), bone mineral density (BMD), visual analogue scale (VAS) of pain before and one month after surgery, Oswestry disability index (ODI) before and one month after surgery and the occurrence of sarcopenia were compared between the two groups. Logistic regression analysis was used to evaluate the effect of related risk factors on refracture after vertebral PKP. RESULTS: The results of t-test and Chi-square test showed that there were no obvious differences in gender, BMI, preoperative VAS score (t=-0.996, P = 0.320) and ODI (t=-0.424, P = 0.671), one month postoperative VAS score (t=-0.934, P = 0.355) and ODI score (t=-0.461, P = 0.645). while the age and grip strength showed significant differences between the two groups. Logistic regression analysis showed that BMI and gender had no significant effect on refracture after PKP, while sarcopenia and advanced age were independent risk factors for refracture after PKP. Also, increased BMD was a protective factor for refracture after PKP. CONCLUSION: Sarcopenia is an independent risk factor for recurrent fractures after PKP in OVCF patients. The screening and diagnosis of sarcopenia should be strengthened. At the same time, anti-sarcopenia treatment should be actively performed after surgery.

Causal impact of DNA methylation on refracture in elderly individuals with osteoporosis - a prospective cohort study.

BACKGROUND: Osteoporotic vertebral compression fractures (OVCF) in the elderly increase refracture risk post-surgery, leading to higher mortality rates. Genome-wide association studies (GWAS) have identified susceptibility genes for osteoporosis, but the phenotypic variance explained by these genes has been limited, indicating the need to explore additional causal factors. Epigenetic modifications, such as DNA methylation, may influence osteoporosis and refracture risk. However, prospective cohorts for assessing epigenetic alterations in Chinese elderly patients are lacking. Here, we propose to conduct a prospective cohort study to investigate the causal network of DNA polymorphisms, DNA methylation, and environmental factors on the development of osteoporosis and the risk of refracture. METHODS: We will collect vertebral and peripheral blood from 500 elderly OVCF patients undergoing surgery, extract DNA, and generate whole genome genotype data and DNA methylation data. Observation indicators will be collected and combined with one-year follow-up data. A healthy control group will be selected from a natural population cohort. Epigenome-wide association studies (EWAS) of osteoporosis and bone mineral density will be conducted. Differential methylation analysis will compare candidate gene methylation patterns in patients with and without refracture. Multi-omics prediction models using genetic variants and DNA methylation sites will be built to predict OVCF risk. DISCUSSION: This study will be the first large-scale population-based study of osteoporosis and bone mineral density phenotypes based on genome-wide data, multi-time point methylation data, and phenotype data. By analyzing methylation changes related to osteoporosis and bone mineral density in OVCF patients, the study will explore the feasibility of DNA methylation in evaluating postoperative osteoporosis intervention effects. The findings may identify new molecular markers for effective anti-osteoporosis treatment and inform individualized prevention and treatment strategies. TRIAL REGISTRATION: chictr.org.cn ChiCTR2200065316, 02/11/2022.

Lumbar localized fat distribution parameters are independent predictors of osteoporotic vertebral compression re-fractures (OVCRFs) following Percutaneous Kyphoplasty (PKP): a retrospective matched case-control study.

OBJECTIVE: To investigate potential risk factors for osteoporotic vertebral compression re-fractures (OVCRFs) following percutaneous kyphoplasty (PKP). MATERIALS AND METHODS: Patients who underwent PKP from January 2012 to January 2020 were included in this study within the same institution. Cases were defined as patients who experienced OVCRFs, while controls were matched based on corresponding clinical characteristics from those patients without OVCRFs. The lumbar localized fat distribution parameters, including the fat infiltration ratio (FIR) in muscles [multifidus (MF), erector spinae (ES), paravertebral muscles (PVM), and psoas major (PS)] and subcutaneous fat thickness (SFT), were compared between the two groups through radiological data. And other clinical data that may be relevant were also compared. Independent risk factors for OVCRFs after PKP were identified through a binary logistic regression analysis. RESULT: A total of 1391 patients who underwent PKP were included in this study. 51 patients were categorized into the re-fracture group, and 102 patients were selected as matched controls from the remaining cohort. There were statistically significant differences between the two groups in metrics including MF-FIR, ES-FIR, PVM-FIR, PS-FIR, bone mineral density (BMD), body-mass index (BMI), SFT, hemoglobin (Hb), albumin (ALB), alkaline phosphatase (ALP), and triglycerides (TG) (P < 0.05). Binary logistic regression analysis demonstrated that PVM-FIR (P = 0.003), SFT (P < 0.001), BMD (P = 0.011), and ALP (P = 0.005) were independent predictors for the occurrence of OVCRFs. CONCLUSION: This study discovered that lumbar localized fat distribution parameters including PVM-FIR and SFT are independent predictors of OVCRFs. Additionally, BMD and ALP were found to be independent predictors of OVCRFs.

Refracture-related bone transport of tibia: technical notes and preliminary clinical results in nineteen cases.

PURPOSE: Refracture is one of the main complications of bone transport, which brings additional physical and mental burden to surgeries and patients. We aimed to raise a new classification system of refracture-related bone transport based on the Simpson classification and to present our experience on treatment. METHODS: This retrospective analysis included 19 patients with refracture-related bone transport (average age of 37.7 years; 18 men). We developed a modified Simpson classification system to assist decision-making (conservative versus surgical). The ASAMI criteria were used to assess the outcomes at last follow-up. RESULTS: The mean follow-up was 12.3 ± 3.2 months. Complete union was achieved in all patients, with no reinfection. Based on the modified Simpson classification, refracture was Ia type (within regeneration area) in three cases, Ib (collapsed fracture at the regeneration area) in one case, Ic (stress fracture) in three cases, II (at the junction between the regenerate and original bone) in one case, III (at the docking site) in nine cases, and V (at distant site) in two cases. Refracture was managed conservatively in six cases and surgically in 13 cases. Average time to bone union was 2.8 ± 1.2 months in the conservative group versus 4.4 ± 1.4 months in the surgery group. Assessment at the final follow-up using the ASAMI criteria revealed excellent bone result in all patients, excellent functional results in six patients (31.6%), and good functional results in 13 patients. CONCLUSIONS: The modified Simpson classification could include refracture at the docking site and stress fracture in the regeneration zone and provide some guidance in determining the appropriate treatment strategy.

Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study.

BACKGROUND: Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes. METHODS: This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure. RESULTS: Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46). CONCLUSIONS: Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same. LEVEL OF EVIDENCE: III.

The Association of nutritional status and physical activity on osteoporotic refractures among older adults.

BACKGROUND: This paper focuses on revealing the relationship between the Geriatric Nutritional Risk Index (GNRI) and Activity of Daily Living (ADL) with osteoporotic refracture. METHODS: Data from 1068 inpatients with osteoporotic fractures were analyzed. Binary logistic regression, Cox proportional hazard regression and Kaplan-Meier curves were performed for osteoporosis characteristics and its risk factors. Receiver operating characteristic (ROC) curve was developed to predict the cut-off value. RESULTS: The study showed that older age, lower ADL and lower GNRI were independent risk factors for osteoporotic fracture with OR of 1.039, 0.946, 0.892 and HR of 1.033, 0.967, 0.947 respectively. According to the results of ROC, the predictive accuracy of GNRI was high with an area under ROC (AUC) of 0.715, sensitivity of 76.6%, specificity of 53.5% and a threshold value of 99.65. CONCLUSION: Older age, lower ADL and lower GNRI were independent risk factors for osteoporotic refracture.

The impact of acute-phase reaction on mortality and re-fracture after zoledronic acid in hospitalized elderly osteoporotic fracture patients.

This study involving 674 elderly osteoporotic fracture (OPF) patients undergoing orthopedic surgery investigated the long-term outcomes of acute phase reaction (APR) after initial zoledronic acid (ZOL). Those who had an APR had a 97% higher risk of mortality and a 73% lower rate of re-fracture than patients who did not. INTRODUCTION: Annual infusion of ZOL efficiently decreases the risk of fracture. A temporary APR, consisting of flu-like symptoms, myalgia, and fever, is frequently observed within 3 days after the first dose. This work aimed to identify whether the occurrence of APR after initial ZOL infusion is a reliable indicator of drug efficacy for mortality and re-fracture in elderly OPF patients undergoing orthopedic surgery. METHODS: This retrospectively observed work was constructed on a database prospectively collected from the Osteoporotic Fracture Registry System of a tertiary level A hospital in China. Six hundred seventy-four patients 50 years old or older with newly identified hip/morphological vertebral OPF who received ZOL for the first time after orthopedic surgery were included in the final analysis. APR was identified as a maximum axillary body temperature greater than 37.3 °C for the first 3 days after ZOL infusion. We utilized models of multivariate Cox proportional hazards to compare the risk of all-cause mortality in OPF patients with APR (APR+) and without APR (APR-). Competing risks regression analysis was used to examine the association between the occurrence of APR and re-fracture when mortality was taken into account. RESULTS: In a fully adjusted Cox proportional hazards model, APR+ patients had a significantly higher risk of death than APR- patients with a hazard ratio [HR] 1.97 (95% CI, 1.09-3.56; P-value = 0.02). Furthermore, in an adjusted competing risk regression analysis, APR+ patients had a significantly reduced risk of re-fracture compared with APR- patients with a sub-distribution HR, 0.27 (95% CI, 0.11-0.70; P-value = 0.007). CONCLUSIONS: Our findings suggested a potential association between the occurrence of APR and increased mortality risk. An initial dose of ZOL following orthopedic surgery was found to be protective against re-fracture in older patients with OPFs.

A nomogram prediction model for refracture in elderly patients with osteoporotic vertebral compression fractures after percutaneous vertebroplasty.

BACKGROUND: This study aims to evaluate the risk factors of refracture in elderly patients with osteoporotic vertebral compression fracture (OVCF) patients after percutaneous vertebroplasty (PVP) and construct a predictive nomogram model. METHODS: Elderly symptomatic OVCF patients undergoing PVP were enrolled and grouped based on the development of refracture within 1 year postoperatively. Univariate and multivariate logistic regression analyses were performed to identify risk factors. Subsequently, a nomogram prediction model was constructed and evaluated based on these risk factors. RESULTS: A total of 264 elderly OVCF patients were enrolled in the final cohort. Among these, 48 (18.2%) patients had suffered refracture within 1 year after surgery. Older age, lower mean spinal BMD, multiple vertebral fracture, lower albumin/fibrinogen ratio (AFR), no postoperative regular anti-osteoporosis, and exercise were six independent risk factors identified for postoperative refracture. The AUC of the constructed nomogram model based on these six factors was 0.812 with a specificity and sensitivity of 0.787 and 0.750, respectively. CONCLUSIONS: In summary, the nomogram model based on the six risk factors had clinical efficacy for refracture prediction.

Sequential treatment of teriparatide and alendronate versus alendronate alone for elevation of bone mineral density and prevention of refracture after percutaneous vertebroplasty in osteoporosis: a prospective study.

BACKGROUND: Percutaneous vertebroplasty was the most common strategy for osteoporotic vertebral compression fracture. However, refracture after vertebroplasty also occurred and bone mineral density (BMD) was one of the main factors associated with refracture after percutaneous vertebroplasty. AIMS: To investigate the efficacy of a short-sequential treatment of teriparatide followed by alendronate on prevention of refracture after percutaneous vertebroplasty in osteoporotic patients, and compare it with the therapy of alendronate alone. METHODS: From January 2018 to January 2020, we recruited 165 female osteoporosis patients after percutaneous vertebroplasty who were assigned into sequential treatment of teriparatide followed by alendronate group (TPTD + ALN group) and alendronate alone group (ALN group). The vertebral fracture occurred during this process was also recorded in both the groups. A total of 105 participants completed the 1-year follow-up. Furthermore, BMD and serum procollagen type I N-terminal propeptide (PINP) and C-terminal cross-linking telopeptide of type I collagen (CTX) were compared between the two groups during 1-year follow-up. RESULTS: The 105 patients were finally included, with 59 in ALN group and 46 in TPTD + ALN group. During 1-year follow-up, the vertebral refracture rate in TPTD + ALN group was much lower than that in ALN group (2.2% vs. 13.6%, p < 0.05). At 12 months, the BMDs at lumbar in TPTD + ALN group were significantly elevated when compared to the ALN group (0.65 ± 0.10 vs. 0.57 ± 0.07, p < 0.001). DISCUSSION AND CONCLUSION: A short-sequential administration of teriparatide followed by alendronate was more effective in elevating the BMD and decreasing the refracture rate at 12-month follow-up, compared to the counterpart with alendronate alone.

Development of a nomogram model for prediction of new adjacent vertebral compression fractures after vertebroplasty.

BACKGROUND: Vertebroplasty is the main minimally invasive operation for osteoporotic vertebral compression fracture (OVCF), which has the advantages of rapid pain relief and shorter recovery time. However, new adjacent vertebral compression fracture (AVCF) occurs frequently after vertebroplasty. The purpose of this study was to investigate the risk factors of AVCF and establish a clinical prediction model. METHODS: We retrospectively collected the clinical data of patients who underwent vertebroplasty in our hospital from June 2018 to December 2019. The patients were divided into a non-refracture group (289 cases) and a refracture group (43 cases) according to the occurrence of AVCF. The independent predictive factors for postoperative new AVCF were determined by univariate analysis, least absolute shrinkage and selection operator (LASSO) logistic regression, and multivariable logistic regression analysis. A nomogram clinical prediction model was established based on relevant risk factors, and the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA) were used to evaluate the prediction effect and clinical value of the model. After internal validation, patients who underwent vertebroplasty in our hospital from January 2020 to December 2020, including a non-refracture group (156 cases) and a refracture group (21 cases), were included as the validation cohort to evaluate the prediction model again. RESULTS: Three independent risk factors of low bone mass density (BMD), leakage of bone cement and "O" shaped distribution of bone cement were screened out by LASSO regression and logistic regression analysis. The area under the curve (AUC) of the model in the training cohort and the validation cohort was 0.848 (95%CI: 0.786-0.909) and 0.867 (95%CI: 0.796-0.939), respectively, showing good predictive ability. The calibration curves showed the correlation between prediction and actual status. The DCA showed that the prediction model was clinically useful within the whole threshold range. CONCLUSION: Low BMD, leakage of bone cement and "O" shaped distribution of bone cement are independent risk factors for AVCF after vertebroplasty. The nomogram prediction model has good predictive ability and clinical benefit.

A 2-year follow-up of a novel Fracture Liaison Service: can we reduce the mortality in elderly hip fracture patients? A prospective cohort study.

Osteoporosis is an underdiagnosed disease that results in bone fragility and risk of fractures. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of a FLS protocol showed an increase of anti-osteoporotic drug prescription and significant reduction of all-cause mortality. INTRODUCTION: Hip fractures are the most severe osteoporotic fracture due to their associated disability and elevated risk of mortality. FLS programs have enhanced the management of osteoporosis-related fractures. Our objective is to analyze the effect of the FLS model over survival and 2-year mortality rate following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during 3 consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2018). Patients' information was withdrawn from our local computerized database. Patients were followed for 2 years after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model. RESULTS: A total of 1101 patients were included in this study (i.e., 357 before FLS implementation and 744 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (583 (78.4%) vs 44 (12.3%); p < 0.01). There was an increase of adherence to treatment after FLS implementation (227 (38.9%) vs 12 (3.3%); p = 0.03). A total of 222 (29.8%) patients after FLS implementation and 114 (31.9%) individuals before FLS implementation (p = 0.44) died during the follow-up period. A second fracture occurred in 49 (6.6%) patients after FLS implementation and in 26 (7.3%) individuals before FLS implementation (p = 0.65). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower all-cause 1-year and 2-year mortality compared with patients managed before the implementation of the FLS protocol (adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59-0.96; HR 0.87, 95% CI 0.69-1.09, respectively). CONCLUSIONS: The implementation of a FLS protocol was associated with an increase of anti-osteoporotic treatment, higher adherence, and greater survival in elderly hip fracture patients. There was a significant reduction of all-cause mortality in the FLS patients treated with anti-osteoporotic. However, the application of the FLS did not affect the risk of suffering a second fragility fracture.

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.

Assessment of clinical, imaging, surgical risk factors for subsequent fracture following vertebral augmentation in osteoporotic patients.

INTRODUCTION: Currently, the risk factors for subsequent fracture following vertebral augmentation remain incomplete and controversial. To provide clinicians with accurate information for developing a preventive strategy, we carried out a comprehensive evaluation of previously controversial and unexplored risk factors. METHODS: We retrospectively reviewed patients with osteoporotic vertebral compression fracture in lumbar spine who received vertebral augmentation between January 2019 and December 2020. Based on whether refracture occurred, patients were assigned to refracture and non-refracture group. The clinical characteristics, imaging parameters (severity of vertebral compression, spinal sagittal alignment, degeneration of paraspinal muscles), and surgical indicators (cement distribution and leakage, correction of spinal sagittal alignment) were collected and analyzed. RESULTS: There were 128 patients and 16 patients in non-refracture and refracture group. The incidence of previous fracture, multiple fractures, and cement leakage were notably higher, relative cross-sectional area of psoas (r-CSAPS) was significantly smaller, CSA ratio, fatty infiltration of erector spinae plus multifidus (FIES+MF), FIPS, postoperative lumbar lordosis (post-LL), correction of body angel (BA), and LL were significantly greater in refracture group. Binary logistic regression analysis revealed previous fracture, cement leakage, post-LL, and correction of BA were independent risk factors. According to the ROC curve, correction of BA showed the highest prediction accuracy, and the critical value was 3.45°. CONCLUSIONS: The occurrence of subsequent fracture might be the consequence of multiple factors. Previous fracture, cement leakage, post-LL, and correction of BA were identified as independent risk factors. Furthermore, the correction of BA should not exceed 3.45°, especially in patients with risk factors.

Prediction Criteria for the Formation of Refracture after Union of a Long Bone Fracture on the Basis of Hemodynamic Changes in the Tissues of the Area of Damage.

We studied hemodynamic changes in the area of leg bone fracture and determined the prognostic criteria for refracture formation after achieved union. In Wistar rats (n=18), shin bone fracture with external fixation of the fragments was modeled. The union was formed 35 days after osteosynthesis, the device was removed at this term. In 5 cases, a refracture was formed after the termination of fixation. Hemodynamics and local temperature in the tissues in the area of injury were recorded before the start of the experiment and on days 21 and 35 of fixation. In rats with refracture after union, the blood circulation in the area of damage was characterized by a pronounced hypertonicity of the arteries of both large and small diameters, obstruction of venous outflow, and local hyperthermia. This hemodynamics in tissues in the area of damage can serve as an informative criterion for predicting the course of reparative osteogenesis.