Epidemiology and economic burden of fragility fractures in Austria.

Fragility fractures are a frequent and costly event. In Austria, 92,835 fragility fractures occurred in patients aged ≥ 50 years in 2018, accruing direct costs of > 157 million €. Due to demographic aging, the number of fragility fractures and their associated costs are expected to increase even further. INTRODUCTION: Fragility fractures are frequently associated with long hospital stays, loss of independence, and increased need for care in the elderly, with consequences often leading to premature death. The aim of this study was to estimate the number of fragility fractures and associated healthcare costs in Austria in 2018. METHODS: The number of in-patient cases with relevant ICD-10 diagnoses in all Austrian public hospitals was derived from discharge documentation of diagnoses and procedures covering all public hospitals in Austria. Fractures resulting from falls from standing height in patients aged ≥ 50 years were used as a proxy for fragility fractures, and the number of in-patient and out-patient cases was estimated. The direct costs of these cases were calculated using the average cost of the corresponding in-patient hospital stay and the average cost for the out-patient stay. RESULTS: The present study estimated the number of fragility fractures (pelvis, thoracic and lumbar vertebra, hip, humerus, rib, forearm, and tibia) for 2018 at 92,835 or just over half of all fractures in patients aged ≥ 50 years, corresponding to a prevalence of 2,600 per 100,000 inhabitants of this age group. A constant increase in the proportion of fragility fractures among all fractures was observed with increasing age in both men and women. These fractures amounted to direct costs of > 157 million €. CONCLUSION: Fragility fractures are a frequent and costly event in Austria. Due to the aging of the population, the number of fragility fractures and their associated costs is expected to increase even further.

Bone microstructure and volumetric bone mineral density in patients with hyperuricemia with and without psoriasis.

We analyzed volumetric bone mineral density (vBMD) and bone microstructure using HR-pQCT in subjects with normouricemia (NU) and subjects with hyperuricemia (HU) with and without psoriasis (PSO). HU was associated with higher cortical vBMD and thickness. Differences in average and trabecular vBMD were found between patients with PSO + HU and NU. INTRODUCTION: Hyperuricemia (HU) and gout are co-conditions of psoriasis and psoriatic arthritis. Current data suggest a positive association between HU and areal bone mineral density (BMD) and a negative influence of psoriasis on local bone, even in the absence of arthritis. However, the influence of the combination of HU and psoriasis on bone is still unclear. The aim of this study was to assess the impact of HU with and without psoriasis on bone microstructure and volumetric BMD (vBMD). METHODS: Healthy individuals with uric acid levels within the normal range (NU), with hyperuricemia (HU), patients with hyperuricemia and psoriasis (PSO + HU), and patients with uric acid within the normal range and psoriasis (PSO + NU) were included in our study. Psoriasis patients had no current or past symptoms of arthritis. Average, trabecular, and cortical vBMD (mgHA/cm3); trabecular number (Tb.N, 1/mm) and thickness (Tb.Th, mm); inhomogeneity of the network (1/N.SD, mm); and cortical thickness (Ct.Th., mm) were carried out at the ultradistal radius using high-resolution peripheral quantitative computed tomography. In addition, bone turnover markers such as DKK-1, sclerostin, and P1NP were analyzed. RESULTS: In total, 130 individuals were included (44 NU participants (34% female), 50 HU (24%), 16 PSO + HU (6%), 20 PSO + NU (60%)). Subjects were aged: NU 54.5 (42.8, 62.1), HU 57.5 (18.6, 65.1), PSO + HU 52.0 (42.3, 57.8), and PSO + NU 42.5 (34.8, 56.8), respectively. After adjusting for age, sex, BMI, and diabetes, patients in the HU group revealed significantly higher values of cortical vBMD (p < 0.001) as well as cortical thickness (p = 0.04) compared to the NU group. PSO + NU showed no differences to NU, but PSO + HU demonstrated both lower average (p = 0.03) and trabecular vBMD (p = 0.02). P1NP was associated with average, cortical, and trabecular vBMD as well as cortical thickness while sclerostin levels were related to trabecular vBMD. CONCLUSION: Hyperuricemia in otherwise healthy subjects was associated with a better cortical vBMD and higher cortical thickness. However, patients with both psoriasis and hyperuricemia revealed a lower vBMD.

Bone microarchitecture and bone turnover in hepatic cirrhosis.

Liver cirrhosis leads to bone loss. To date, information on bone quality (three-dimensional microarchitecture) and, thus, bone strength is scarce. We observed decreased bone quality at both assessed sites, independent of disease severity. Therefore, all patients should undergo early-stage screening for osteoporosis. INTRODUCTION: Recent studies found low bone mineral density in cirrhosis, but data on bone microstructure are scarce. This study assessed weight-bearing and non-weight-bearing bones in patients with cirrhosis and healthy controls. The primary objective was to evaluate trabecular and cortical microarchitecture. METHODS: This was a single-center study in patients with recently diagnosed hepatic cirrhosis. Thirty-two patients and 32 controls participated in this study. After determining the type of cirrhosis, the parameters of bone microarchitecture were assessed by high-resolution peripheral quantitative computed tomography. RESULTS: Both cortical and trabecular microarchitectures showed significant alterations. At the radius, trabecular bone volume fraction was 17% lower (corrected p = 0.028), and, at the tibia, differences were slightly more pronounced. Trabecular bone volume fraction was 19% lower (p = 0.024), cortical bone mineral density 7% (p = 0.007), and cortical thickness 28% (p = 0.001), while cortical porosity was 32% higher (p = 0.023), compared to controls. Areal bone mineral density was lower (lumbar spine - 13%, total hip - 11%, total body - 9%, radius - 17%, and calcaneus - 26%). There was no correlation between disease severity and microarchitecture. Areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA) correlated well with parameters of cortical and trabecular microarchitecture. CONCLUSIONS: Hepatic cirrhosis deteriorates both trabecular and cortical microarchitecture, regardless of disease severity. Areal bone mineral density is diminished at all sites as a sign of generalized affection. In patients with hepatic cirrhosis, regardless of its origin or disease severity, aBMD measurements are an appropriate tool for osteologic screening.

Preceding and subsequent high- and low-trauma fracture patterns-a 13-year epidemiological study in females and males in Austria.

This study investigated the implication of a preceding high-trauma fracture on subsequent high- and low-trauma fractures at different skeletal sites in postmenopausal women and similarly aged men at an age range of 54 to 70 years. A preceding high-trauma fracture increases the risk of future low-trauma non-vertebral fractures including hip. INTRODUCTION: Little is known about the impact of the skeletal fracture site in conjunction with the severity of a past fracture (high- or low-trauma preceding fracture) and its effect on future fracture risk. METHODS: Patients with de novo high- and low-trauma fractures admitted to seven large trauma centers across Austria between 2000 and 2012 were stratified into sex and different age groups. Kaplan-Meier estimates, Cox proportional hazards regression models (HR), and likelihood calculations estimated effects of age, sex, and the anatomic region on the probability of a subsequent fracture in the same patient. RESULTS: Included in the study were 433,499 female and male patients at an age range of 0 to 100 years with 575,772 de novo high- and low-trauma fractures. In the age range of 54-70 years, subsequent fractures were observed in 16% of females and 12.1% of males. A preceding high-trauma fracture was associated with 12.9% of subsequent fractures, thereof 6.5% of high- and 6.4% of low-trauma in origin, usually at the hip, humerus, or pelvis. The highest effect sizes were observed for femur, humerus, and thorax fractures with hazard ratios (HR) of 1.26, 1.18, and 1.14. After splitting into high-trauma preceding and subsequent low-trauma fractures, the femoral neck (HR = 1.59), the female sex (HR = 2.02), and age (HR = 1.03) were discriminators for increased future fracture risk. CONCLUSIONS: Preceding high-trauma fractures increase the risk of future low-trauma non-vertebral fractures including hip. For each patient with a fracture, regardless of the severity of the trauma, osteoporosis should be taken into clinical consideration.

Bone structure assessed by HR-pQCT, TBS and DXL in adult patients with different types of osteogenesis imperfecta.

UNLABELLED: Bone microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT) was assessed in adult patients with mild, moderate, and severe osteogenesis imperfecta (OI). The trabecular bone score (TBS), bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), and dual X-ray and laser (DXL) at the calcaneus were likewise assessed in patients with OI. Trabecular microstructure and BMD in particular were severely altered in patients with OI. INTRODUCTION: OI is characterized by high fracture risk but not necessarily by low BMD. The main purpose of this study was to assess bone microarchitecture and BMD at different skeletal sites in different types of OI. METHODS: HR-pQCT was performed in 30 patients with OI (mild OI-I, n = 18 (41.8 [34.7, 55.7] years) and moderate to severe OI-III-IV, n = 12 (47.6 [35.3, 58.4] years)) and 30 healthy age-matched controls. TBS, BMD by DXA at the lumbar spine and hip, as well as BMD by DXL at the calcaneus were likewise assessed in patients with OI only. RESULTS: At the radius, significantly lower trabecular parameters including BV/TV (p = 0.01 and p < 0.0001, respectively) and trabecular number (p < 0.0001 and p < 0.0001, respectively) as well as an increased inhomogeneity of the trabecular network (p < 0.0001 and p < 0.0001, respectively) were observed in OI-I and OI-III-IV in comparison to the control group. Similar results for trabecular parameters were found at the tibia. Microstructural parameters were worse in OI-III-IV than in OI-I. No significant differences were found in cortical thickness and cortical porosity between the three subgroups at the radius. The cortical thickness of the tibia was thinner in OI-I (p < 0.001), but not OI-III-IV, when compared to controls. CONCLUSIONS: Trabecular BMD and trabecular bone microstructure in particular are severely altered in patients with clinical OI-I and OI-III-IV. Low TBS and DXL and their significant associations to HR-pQCT parameters of trabecular bone support this conclusion.

Epidemiology of distal forearm fractures in Austria between 1989 and 2010.

UNLABELLED: Only few studies have been published hitherto on country-specific incidence of distal forearm fracture. In the prevailing study, incidences were estimated, and trend analyses were performed for the entire Austrian population aged ≥50á. Incidence decreased significantly in women, but not in men, over the past 12 years of observation. INTRODUCTION: To estimate incidence of distal forearm fracture and assess incidence trends in the entire Austrian population aged ≥50á from 1989-2010 for inpatient fractures and from 1999 to 2010 for all fractures. METHODS: The number of inpatient forearm fractures was obtained from the Austrian Hospital Discharge Register (AHDR) for the entire population aged ≥50á from 1989 to 2010. Total number of distal forearm fractures was modeled using patient-level data on 36,327 patients with distal forearm fractures. Crude and age-standardized incidence rates (cases per 100,000) were estimated in 5-year age intervals. To analyze the change in incidence over time, average annual changes expressed as incidence rate ratios (IRR) were calculated. RESULTS: For all distal forearm fractures, age-standardized incidence in women in 1999 and 2009 were estimated at 709 (95 % CI 675-743) and 607 (578-637), respectively. The age-standardized incidences in men the same years were estimated at 171 (156-185) and 162 (151-174), respectively. IRR analyses showed a significant decrease in women (-1.1 %, p < 0.01) but not in men (-0.8 %, p > 0.05) over the last 12 years (1999-2010). CONCLUSION: Incidence of distal forearm fracture in the entire Austrian population is comparable to hip fracture incidence which is known to be among the highest worldwide. However, trend analyses reveal a significant decrease for all distal forearm fractures in women, but not in men, over the last 12 years.

The discriminatory capacity of BMD measurements by DXA and dual X-ray and laser (DXL) at the calcaneus including clinical risk factors for detecting patients with vertebral fractures.

UNLABELLED: Osteoporotic fracture risk depends on bone mineral density (BMD) and clinical risk factors (CRF). Five hundred and eighty-eight untreated female and male outpatient subjects were evaluated, 160 with vertebral fractures. BMD was measured both by using calcaneal dual X-ray and laser (DXL) and dual-energy X-ray absorptiometry (DXA), and CRF were evaluated. Detection frequencies for different BMD methods with or without CRF are presented. INTRODUCTION: Osteoporotic fracture risk depends on bone mineral density and clinical risk factors. DXA of the spine/hip is considered a gold standard for BMD assessment, but due to degenerative conditions, particularly among the older population, assessment of BMD at the lumbar spine has been shown to be of limited significance. Portable calcaneal dual X-ray technology and laser can be an easily obtainable alternative. METHODS: Vertebral fractures were evaluated in a baseline analysis of 588 females and males (median age 64.4, range 17.6-93.1 years), comparing BMD measurements by using DXL and DXA and CRF with/without BMD. One hundred and sixty subjects had radiological verified vertebral fractures. Area under receiver-operating characteristic curves (AUROCC) and univariate and multiple logistic regressions were calculated. RESULTS: AUROCC for detection of vertebral fractures was comparable for DXL at calcaneus and DXA at femoral neck (DXL 0.665 and DXA 0.670). Odds ratio for prevalent vertebral fracture was generally weak for DXA femoral neck (0.613) and DXL (0.521). Univariate logistic regression among CRF without BMD revealed age, prevalent fragility fracture, and body mass index significantly associated with prevalent vertebral fracture (AUROCC = 0.805). Combining BMD and CRF, a prognostic improvement in case of DXA at femoral neck (AUROCC 0.869, p = 0.02), DXL at calcaneus (AUROCC 0.869, p = 0.059), and DXA at total hip (AUROCC 0.861, p = 0.06) was observed. CONCLUSIONS: DXL was similarly sensitive compared with DXA for identification of subjects with vertebral fragility fractures, and combination of CRF with BMD by DXL or DXA further increased the discriminatory capacity for detection of patients susceptible to vertebral fracture.

The effect of PTH(1-84) or strontium ranelate on bone formation markers in postmenopausal women with primary osteoporosis: results of a randomized, open-label clinical trial.

UNLABELLED: We explored the effects of PTH(1-84) compared with strontium ranelate on bone remodeling as measured by bone remodeling markers in postmenopausal women with osteoporosis. Biochemical markers of bone formation were significantly increased after treatment with PTH(1-84) but not strontium ranelate, indicating a different mechanism of action between these agents. INTRODUCTION: PTH(1-84) and strontium ranelate (SR) are both known to reduce fracture risk in osteoporosis. Measuring changes in biochemical markers of bone turnover induced by these agents can help in characterizing the action of PTH(1-84) and SR on bone remodeling. METHODS: A 24-week, randomized, open-label, parallel group, phase IV trial was conducted in 81 postmenopausal women with primary osteoporosis (≥50 years of age, lumbar spine, or total hip T-score ≤-2.5 SD) to assess the effect of SR as compared to PTH(1-84) on bone formation markers P1NP and BSAP. The bone resorption marker CTX was also measured. Subjects were randomly assigned to receive daily either 100 µg PTH(1-84) (n = 41) (subcutaneous injection) or oral 2 g SR (n = 40) for 24 weeks with daily supplements of 800 IU vitamin D(3) and 1,000 mg calcium. Patient-reported outcomes were collected to investigate the effect of treatment on quality of life (QoL). RESULTS: Percentage changes from baseline in P1NP and BSAP were significantly increased for PTH(1-84) by week 24 compared with SR (p < 0.0001). Significant changes from baseline in P1NP and BSAP were noted for PTH(1-84) from week 4 onwards; no significant changes were noted for SR. A trend towards a positive impact on QoL was seen with PTH(1-84) treatment. Safety profiles concur with previous analyses. CONCLUSIONS: PTH(1-84) had a more rapid and higher effect on bone formation markers compared to SR, indicating that SR has a different mode of action on bone remodeling than the bone building agent PTH(1-84) in postmenopausal women with osteoporosis.