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Asian Spine Journal Jun 2024A retrospective cohort study using the Kaplan-Meier method with propensity-score matching.
Prevalent morphometric vertebral fractures as a risk factor for subsequent clinical vertebral fractures after shortfusion surgery in older Japanese women with degenerative spondylolisthesis.
STUDY DESIGN
A retrospective cohort study using the Kaplan-Meier method with propensity-score matching.
PURPOSE
To evaluate whether the presence of prevalent morphometric vertebral fractures (VFs) poses a risk for subsequent clinical VFs after short-fusion surgery in women aged ≥60 years with degenerative spondylolisthesis.
OVERVIEW OF LITERATURE
VFs are common osteoporotic fractures and are associated with a low quality of life. Subsequent VFs are a complication of instrumented fusion in patients with degenerative lumbar disorders. Thus, risk factors for subsequent VFs after fusion surgery must be analyzed. Population-based studies have suggested that prevalent morphometric VFs led to a higher incidence of subsequent VFs in postmenopausal women; however, no studies have investigated whether prevalent morphometric VFs are a risk factor for subsequent VFs after fusion surgery in patients with degenerative spondylolisthesis.
METHODS
The study enrolled a total of 237 older female patients: 50 and 187 patients had prevalent morphometric VFs (VF [+] group) and nonprevalent morphometric VFs (VF [-] group), respectively. The time to subsequent clinical VFs after fusion surgery was compared between the two groups using the Kaplan-Meier method. Moreover, 40 and 80 patients in the VF (+) and VF (-) groups, respectively, were analyzed and matched by propensity scores for age, follow-up duration, surgical procedure, number of fused segments, body mass index, and number of patients treated for osteoporosis.
RESULTS
Kaplan-Meier analysis indicated that the VF (+) group had a higher incidence of subsequent clinical VFs than the VF (-) group, and Cox regression analysis showed that the presence of prevalent morphometric VFs was an independent risk factor for subsequent clinical VFs before matching. Kaplan-Meier analysis demonstrated comparable results after matching.
CONCLUSIONS
The presence of prevalent morphometric VFs may be a risk factor for subsequent clinical VFs in older women with degenerative spondylolisthesis who underwent short-fusion surgery.
PubMed: 38917857
DOI: 10.31616/asj.2023.0327 -
Reumatismo Jun 2024Fragility fractures (FF) resulting from osteoporosis pose a significant public health challenge in Italy, with considerable socio-health and economic implications....
OBJECTIVE
Fragility fractures (FF) resulting from osteoporosis pose a significant public health challenge in Italy, with considerable socio-health and economic implications. Despite the availability of safe and effective drugs, osteoporosis remains underdiagnosed and undertreated, leaving over 2 million high-risk Italian women without treatment. This paper aims to identify and propose key improvements in the management of osteoporosis, focusing particularly on the critical issues related to the use of anabolic drugs in secondary prevention, according to the current Italian Medicines Agency (AIFA) Note 79.
METHODS
The Expert Panel, composed of nine recognized Italian experts in rheumatology, analyzed current practices, prescribing criteria, and the most recent literature. Three main reasons for revising the indications on pharmacological treatment of osteoporosis were identified: inadequate treatment of osteoporosis, new evidence regarding frontline placement of anabolics in high-risk conditions, and emerging sequential or combined strategies.
RESULTS
The proposed improvements include the adoption of the Derived Fracture Risk Assessment algorithm for accurate fracture risk assessment, revision of AIFA Note 79 to reflect current evidence, improved prescribing appropriateness, broader access to anabolic agents, and the provision of sequential therapies with antiresorptives for teriparatide. These changes aim to enhance patient outcomes, streamline healthcare processes, and address the high percentage of undertreated individuals.
CONCLUSIONS
This expert opinion emphasizes the importance of the appropriate use of anabolic drugs to reduce FF and associated costs while ensuring the sustainability of the National Health Service. The proposed recommendations are in line with the latest scientific evidence, providing a comprehensive strategy to optimize the management of osteoporosis in Italy. On behalf of the Study Group on Osteoporosis and Skeletal Metabolic Diseases of the Italian Society of Rheumatology.
Topics: Humans; Italy; Anabolic Agents; Osteoporosis; Bone Density Conservation Agents; Osteoporotic Fractures; Female; Teriparatide; Risk Assessment; Secondary Prevention; Expert Testimony
PubMed: 38916162
DOI: 10.4081/reumatismo.2024.1696 -
Chiropractic & Manual Therapies Jun 2024Osteoporosis is significantly associated with fractures and burdens the health of especially older people. Osteoporotic fractures cause pain, disability, and increased... (Review)
Review
BACKGROUND
Osteoporosis is significantly associated with fractures and burdens the health of especially older people. Osteoporotic fractures cause pain, disability, and increased mortality. Early diagnosis of osteoporosis allows earlier initiation of treatment, thereby reducing the risk of osteoporotic fractures. Chiropractors encounter potential osteoporotic patients daily, and perform radiological evaluation of these and other patients, including evaluation of X-rays done for other purposes than osteoporosis. Therefore, chiropractors may identify vertebral fractures, vertebral deformity or osteopenia not otherwise suspected or recorded.
METHODS
This study examines procedures available to the chiropractor to describe conventional X-rays with the focus of osteoporosis related findings. We review the indications for radiological examination in chiropractic practice, and in the realm of osteoporosis we describe radiological methods available for examination of conventional radiographs, and the necessity of inter-disciplinary communication.
RESULTS
National guidelines are available regarding referral for X-rays in chiropractic practice. Standardized protocols ensure image acquisition of the highest quality in the chiropractors' radiological department. Conventional X-ray examination is not indicated on clinical suspicion of osteoporosis alone, as bone mineral density testing is the diagnostic test. Radiological assessment of all available X-rays of patients above the age of 50 years should include evaluation of the bone quality, and hip and vertebral fracture assessment. The Singh index, Genant Semi-Quantitative tool (GSQ), and Algorithm-Based Qualitative method (ABQ) should be used consistently during interpretation. Referral for additional imaging and evaluation should be prompt and systematic when needed.
CONCLUSIONS
This article presents an overview of evidence-based radiological procedures for the purpose of promoting early diagnosis of osteoporosis. We present recommendations to the clinicians where we propose an opportunistic evaluation of X-rays, done for any reason, which include systematic evaluation of bone quality, presence of hip and vertebral fractures, and vertebral deformation of all patients above the age of 50 years. Detailed referral to healthcare professionals for further diagnostic evaluation is performed when needed. Consistent, high-quality radiological procedures in chiropractic practices could feasibly contribute to the timely diagnosis of osteoporosis, ultimately minimizing the impact of osteoporosis-related complications on patients' health.
Topics: Humans; Osteoporosis; Chiropractic; Radiography; Female; Bone Density
PubMed: 38915085
DOI: 10.1186/s12998-024-00545-0 -
EClinicalMedicine Jul 2024Mobile health (mHealth) systems are a promising alternative for rehabilitation of hip fracture, addressing constrained healthcare resources. Half of older adults fails...
Effects of the ActiveHip+ mHealth intervention on the recovery of older adults with hip fracture and their family caregivers: a multicentre open-label randomised controlled trial.
BACKGROUND
Mobile health (mHealth) systems are a promising alternative for rehabilitation of hip fracture, addressing constrained healthcare resources. Half of older adults fails to recover their pre-fracture routines, which imposes a burden on caregivers. We aimed to test the effectiveness of the 3-month ActiveHip + mHealth intervention on physical and psychological outcomes of older adults with hip fracture and their family caregivers.
METHODS
In a multicentre open-label randomised controlled trial conducted across 3 hospitals in Andalusia (Spain), patients older than 65 with a hip fracture, who were previously independent and lacked cognitive impairment were recruited alongside with their caregivers. Participants were randomly allocated (1:1) to the intervention group (ActiveHip+) or control (usual care) group. The intervention group underwent a 12-week health education and tele-rehabilitation programme through the ActiveHip + mHealth intervention. The primary outcome, physical performance, was assessed using the Short Physical Performance Battery at three time points: at hospital discharge (baseline), 3-month after surgery (post intervention) and 1-year after surgery follow-up. Primary analyses of primary outcomes and safety data followed an intention-to-treat approach. This study is registered at ClinicalTrials.gov, NCT04859309.
FINDINGS
Between June 1st, 2021 and June 30th, 2022 data from 105 patients and their caregivers were analysed. Patients engaged in the ActiveHip + mHealth intervention (mean 7.11 points, SE 0.33) showed higher physical performance compared with patients allocated in the control group (mean 5.71 points, SE 0.32) at 3 months after surgery (mean difference in change from baseline 1.40 points, SE 0.36; puncorrected = 0.00011). These benefits were not maintained at 1-year after surgery follow-up (mean difference in change from baseline 0.19 points, SE 0.47; puncorrected = 0.68). No adverse events, including falls and refractures, were reported during the tele-rehabilitation sessions. At 3-months, the intervention group had 2 falls, compared to 4 in the control group, with no observed refractures. At the 1-year follow-up, the intervention group experienced 7 falls and 1 refracture, while the control group had 13 falls and 2 refractures.
INTERPRETATION
This study suggests that the ActiveHip + mHealth intervention may be effective for recovering physical performance in older adults with hip fracture. Importantly, the implementation of ActiveHip + into daily clinical practice may be feasible and has already been adopted in 18 hospitals, mostly in Spain but also in Belgium and Portugal. Thus, ActiveHip + could offer a promising solution when rehabilitation resources are limited. However, its dependence on caregiver support and the exclusion of participants with cognitive impairment makes it necessary to be cautious about its applicability. In addition, the non-maintenance of the effectiveness at 1-year follow-up highlights the need of refinement the ActiveHip + intervention to promote long-lasting behavioural changes.
FUNDING
EIT Health and the Ramón y Cajal 2021 Excellence Research Grant action from the Spanish Ministry of Science and Innovation.
PubMed: 38911836
DOI: 10.1016/j.eclinm.2024.102677 -
Frontiers in Genetics 2024Osteoporosis (OP) is typically diagnosed by evaluating bone mineral density (BMD), and it frequently results in fractures. Here, we investigated the causal relationships...
BACKGROUND
Osteoporosis (OP) is typically diagnosed by evaluating bone mineral density (BMD), and it frequently results in fractures. Here, we investigated the causal relationships between diet-derived circulating antioxidants and the risk of OP using Mendelian randomization (MR).
METHODS
Published studies were used to identify instrumental variables related to absolute levels of circulating antioxidants like lycopene, retinol, ascorbate, and β-carotene, as well as antioxidant metabolites such as ascorbate, retinol, α-tocopherol, and γ-tocopherol. Outcome variables included BMD (in femoral neck, lumbar spine, forearm, heel, total body, total body (age over 60), total body (age 45-60), total body (age 30-45), total body (age 15-30), and total body (age 0-15)), fractures (in arm, spine, leg, heel, and osteoporotic fractures), and OP. Inverse variance weighted or Wald ratio was chosen as the main method for MR analysis based on the number of single nucleotide polymorphisms (SNPs). Furthermore, we performed sensitivity analyses to confirm the reliability of the findings.
RESULTS
We found a causal relationship between absolute retinol levels and heel BMD ( = 7.6E-05). The results of fixed effects IVW showed a protective effect of absolute retinol levels against heel BMD, with per 0.1 ln-transformed retinol being associated with a 28% increase in heel BMD (OR: 1.28, 95% CI: 1.13-1.44). In addition, a sex-specific effect of the absolute circulating retinol levels on the heel BMD has been observed in men. No other significant causal relationship was found.
CONCLUSION
There is a positive causal relationship between absolute retinol levels and heel BMD. The implications of our results should be taken into account in future studies and in the creation of public health policies and OP prevention tactics.
PubMed: 38911297
DOI: 10.3389/fgene.2024.1346367 -
JOR Spine Jun 2024We analyzed the influence of the location of the upper and lower cement on the sandwich vertebrae (SV) by computer finite element analysis.
Static study and numerical simulation of the influence of cement distribution in the upper and lower adjacent vertebrae on sandwich vertebrae in osteoporotic patients: Finite element analysis.
OBJECTIVE
We analyzed the influence of the location of the upper and lower cement on the sandwich vertebrae (SV) by computer finite element analysis.
MATERIALS AND METHODS
A finite element model of the spinal segment of T11-L1 was constructed and 6 mL of cement was built into T11 and L1 simultaneously. According to the various distributions of bone cement at T11 and L1, the following four groups were formed: (i) Group B-B: bilateral bone cement reinforcement in both T11 and L1 vertebral bodies; (ii) Group L-B: left unilateral reinforcement in T11 and bilateral reinforcement in L1; (iii) Group L-R: unilateral cement reinforcement in both T11 and L1 (cross); (iv) Group L-L: unilateral cement reinforcement in both T11 and L1 (ipsilateral side). The maximum von Mises stress (VMS) and maximum displacement of the SV and intervertebral discs were compared and analyzed.
RESULTS
The maximum VMS of T12 was in the order of size: group B-B < L-B < L-R < L-L. Group B-B showed the lowest maximum VMS values for T12: 19.13, 18.86, 25.17, 25.01, 19.24, and 20.08 MPa in six directions of load flexion, extension, left and right lateral bending, and left and right rotation, respectively, while group L-L was the largest VMS in each group, with the maximum VMS in six directions of 21.55, 21.54, 30.17, 28.33, 19.88, and 25.27 MPa, respectively.
CONCLUSION
Compared with the uneven distribution of bone cement in the upper and lower adjacent vertebrae (ULAV), the uniform distribution of bone cement in the ULAV reduced and uniformed the stress load on the SV and intervertebral disc. Theoretically, it can lead to the lowest incidence of sandwich vertebral fracture and the slowest rate of intervertebral disc degeneration.
PubMed: 38911099
DOI: 10.1002/jsp2.1343 -
Cureus May 2024Background Hip fractures are one of the most common serious injuries seen today and constitute one of the most serious healthcare problems affecting the elderly...
Background Hip fractures are one of the most common serious injuries seen today and constitute one of the most serious healthcare problems affecting the elderly worldwide. Due to the elderly population, associated falls and osteoporosis increase the incidence of hip fractures. Patients may remain hospitalized for several weeks, leading to one and a half million hospital bed days used each year. The reported incidence of a concurrent upper limb and a lower limb fracture is between 3% and 5%. It has been shown in the literature that patients who sustain both a hip fracture and an upper limb fracture have difficulties with rehabilitation which causes prolonged stays. The available literature on concomitant hip fracture and upper extremity fracture is limited. This study aimed to review patients with concurrent upper limb injury and hip fractures and to analyse the pattern of associated upper limb fractures, management of these fractures, length of hospital stay, mortality rates, and complications. Methodology We performed a retrospective data collection of all patients with a concomitant upper limb fracture and hip fracture from January 2017 to December 2020 at the University Hospital of Wales, Cardiff, United Kingdom. Patients were identified from the registers maintained in the ward. All patients aged over 60 years with a fragility hip fracture (managed operatively) and a concurrent upper limb fracture were included in the study. Patients aged less than 60 years were excluded. The local research department registered and approved this study as a service evaluation and therefore did not need ethical committee approval. The anatomical location of the upper limb and hip fractures was confirmed using the imaging database (Synapse). Results Of the 760 patients admitted with neck of femur fractures during this period, 39 (5.1%) patients had concomitant upper limb fractures. Only one upper limb fracture was managed with fixation, and for this study, that patient was excluded. Our retrospective search identified 38 patients, of whom 11 were men and 27 were women. Distal radius fractures were the most commonly associated upper limb fractures (55%). There was a significant increase in length of stay (43.6 days vs. 16.6 days) and delay in mobilization (58.9% vs. 81%) compared to an isolated hip fracture. There was no difference in the 30-day mortality rates. We were unable to collect the data for the Key Performance Indicator (KPI) of the National Institute for Health and Care Excellence compliant surgery, and this KPI was excluded from our study. Of the remaining five KPIs, our group of patients displayed better averages in three of the five categories, including prompt orthogeriatric review (92%), not delirious postoperatively (87%), and return to original residence (79%). Conclusions Due to the ageing population, hip fractures are increasing, and within one year of operation, have shown higher mortality rates. Annually, reports show that the worldwide incidence of fractures in the adult population ranges between 9.0 and 22.8 per 1,000. These fractures are more frequent in osteoporotic patients with weak bone quality. Following hip fractures, upper extremity fractures are the second most common among the osteoporotic, elderly population, with distal radius fractures being the most common. With the length of stay almost tripled (from 16.6 to 44.4 days), one can see this has a very big effect on costs in the National Health Service system.
PubMed: 38910742
DOI: 10.7759/cureus.60862 -
Global Spine Journal Jun 2024Retrospective Cohort Study.
STUDY DESIGN
Retrospective Cohort Study.
OBJECTIVE
The primary objective of this study is to evaluate the efficacy of early administration of Teriparatide in preventing the necessity of surgical intervention in individuals with osteoporotic vertebral compression fractures.
METHODS
In a 24-month follow-up retrospective analysis, 191 OVCF patients from January 2016 to October 2020 were randomly assigned to Non teriparatide Group A (n = 104) or Group B teriparatide (n = 87). At baseline, 6 months, 1 year, and 2 years following treatment, demographic data and need of surgical intervention, VAS, ODI, union rates, and kyphosis development, were examined.
RESULTS
Our study found that non-teriparatide group individuals had an 11.53% higher risk of non-union formation that required surgery. Only 8.63% of teriparatide group patients needed surgery. Both groups had significant VAS score reductions. Non-teriparatide group scores declined from 8.38 ± 0.74 to 3.15 ± 1.40, while teriparatide group scores decreased from 8.49 ± 0.73 to 1.11 ± 0.31. The 2-year follow-up ODI scores significantly decreased, with values of 25.02 ± 13.94 for non-teriparatide patients and 15.11 ± 2.17 for teriparatide patients. The kyphosis progression angles in the teriparatide group were considerably lower (4.97 ± 0.78°) compared to the other group (8.09 ± 1.25°).
CONCLUSION
With increasing elderly populations, it is necessary to take measures to prevent surgical intervention in osteoporotic spinal compression fractures. Teriparatide can be employed as an early medication in the management of these fractures to avert non-union and the minimise the progression of kyphosis.
PubMed: 38910440
DOI: 10.1177/21925682241265327 -
Revista Espanola de Cirugia Ortopedica... Jun 2024Low socioeconomic status (SES) is associated with a higher risk of fragility fractures, as well as higher mortality in the first year post-fracture. The SES variables...
Low socioeconomic status (SES) is associated with a higher risk of fragility fractures, as well as higher mortality in the first year post-fracture. The SES variables that have the greatest impact are educational level, income level, and cohabitation status. Significant disparities exist among racial and ethnic minorities in access to osteoporosis screening and treatment.In Spain, a higher risk of fractures has been described in people with a low income level, residence in rural areas during childhood and low educational level. The Civil War cohort effect is a significant risk factor for hip fracture. There is significant geographic variability in hip fracture care, although the possible impact of socioeconomic factors has not been analyzed. It would be desirable to act on socioeconomic inequalities to improve the prevention and treatment of osteoporotic fractures.
PubMed: 38909956
DOI: 10.1016/j.recot.2024.06.010 -
JBJS Essential Surgical Techniques 2024Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and...
BACKGROUND
Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.
DESCRIPTION
Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.
ALTERNATIVES
Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.
RATIONALE
Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone. Adjunctive use of a medial plate also has been suggested to prevent varus collapse, particularly with metaphyseal comminution and poor bone quality. Finally, in the periprosthetic fracture population, dual plating also removes the concern of incompatibility with a retrograde nail.
EXPECTED OUTCOMES
The outcomes of dual plating are promising, given the severity of the injury. When comparing operative to nonoperative treatment outcomes, nonoperatively managed patients had worse functional outcomes and higher rates of complications related to immobility. Dual plating of supracondylar fractures and intra-articular distal femoral fractures yields nonunion rates ranging from 0% to 12.5%, lower than the 18% to 20% reported with lateral locking plates. This reduction in nonunions has been shown to lead to fewer revisions when compared with single-plating techniques. In prior studies, 95% of nonunions treated with the dual-plating technique achieved union postoperatively. One concern when utilizing the medial approach is critical damage to medial vascularity; however, this result has not been reported in the literature, and there is a safe operating window. Despite the benefits of dual plating, there are relatively high rates of infection following dual plating (0% to 16.7%) compared with lateral plating alone (3.6% to 8.5%). However, many of these studies are small case series, highlighting that a surgeon's comfort and skill with these procedures is paramount to patient outcomes.
IMPORTANT TIPS
Meticulous placement and contouring of lateral and medial plates are required to prevent malreduction of the articular block that creates a "golf-club deformity."During the medial approach, be aware of descending geniculate artery-particularly its muscular branch, which is ∼5 cm from the adductor tubercle/medial epicondyle, and its root, which enters the compartment at the adductor hiatus at ∼16 cm.
PubMed: 38903606
DOI: 10.2106/JBJS.ST.23.00018