Proximal humerus fractures (PHFs) are a common injury experienced by elderly patients, however there is no consensus regarding the best treatment option. Recently, the use of reverse shoulder arthroplasty (RSA) in elderly patients with complex fractures is increasing. This systematic review and meta-analysis will compare the outcomes between RSA and non-operative treatment in 3- or 4-part PHFs in the elderly.

This study was conducted according to the PRISMA statement protocol and registered in PROSPERO (CRD42023439647). Searches on four databases (Medline, Embase, Web of Science, and Cochrane Library) were performed, and comparative studies which compared the outcomes of using RSA with conservative management were included. Demographic data, patient related outcome measures (PROMs), and complications rates were collected. Data were pooled using a random-effects model. Heterogeneity was determined using the I2 statistic and Cochran's Q test.

Six studies involving 439 patients (mean age 79.0 years old; 12.1 % male) were analysed. The average Charlson co-morbidity index (CCI) was 3.74 and follow-up time was 26.0 months. Compared to the non-operative cohort, the RSA cohort had better VAS scores (1.0 versus 0.575; p = 0.047), Constant-Murley scores (66.3 versus 71; p = 0.114), active forward flexion (121.5° versus 100°; p = 0.023; I2 = 35 %), external rotation (34.8° vs 23.1°; p = 0.020), and internal rotation (Constant score 5.44 versus 4.28; p = 0.169). There is no difference in the overall risk of complications (8.2 % versus 6.0 %; RR = 1.00; p = 0.993), but those treated by RSA have a higher risk of needing subsequent revision surgery (3.7 % versus 2.8 %; p = 0.640; I2 = 25 %).

In the short-term, elderly patients with complex PHFs treated with RSA may have decreased pain, increased Constant-Murley scores, and increased ROM compared with patients treated non-operatively, at the expense of a higher risk of needing subsequent surgery. However, moderate between-study heterogeneity in effect sizes and the retrospective nature of included studies may limit the clinical applications of conclusions obtained in this review.

III.

Persons with type 2 diabetes have increased fracture risk that existing fracture risk assessment tools underestimate.

Identify fracture predictors in persons with type 2 diabetes and overweight or obesity, considering traditional and diabetes-related risk factors.

This is a secondary analysis of a multicenter US study, the Look AHEAD: Action for Health in Diabetes randomized clinical trial, with randomization from 2001 to 2004 and fracture follow-up until 2015. Participants were men and women 45 to 75 years old with type 2 diabetes and body mass index ≥ 25 kg/m2. Potential fracture predictors ascertained at randomization included traditional and diabetes-related risk factors (diabetes duration, diabetic neuropathy, antidiabetic medication use, hemoglobin A1c, and renal function). Total hip bone mineral density (BMD) was measured in a subcohort. Primary outcome was all incident clinical fractures, ascertained by self-report and centrally adjudicated with medical records review.

Over a median 12.2-year follow-up, 649 of the 4703 participants experienced at least one clinical fracture. Thiazolidinedione use (hazard ratio [HR] 1.22; 95% CI, 1.02-1.46) and insulin use (HR 1.34, 95% CI, 1.08-1.66) were significant diabetes-related predictors of all clinical fractures. When measured in a subcohort (n = 1285), total hip BMD was the strongest modifiable predictor of all clinical fractures (per 1 SD = 0.1 g/cm2 increase, HR 0.47; 95% CI, 0.39-0.58).

Thiazolidinedione and insulin use predict clinical fracture in middle-aged and older persons with type 2 diabetes and overweight or obesity. Evaluating BMD is advisable if these medications are prescribed. Fracture risk prediction tools may consider including thiazolidinedione and insulin use to refine prediction in this population.

The prevalence of osteoporosis in individuals with type 1 diabetes (T1D) was investigated. Based on IOF/ADA recommendations, 36% had indications for anti-osteoporotic therapy. We propose that postmenopausal women and men with T1D and age > 50 years are screened for osteoporosis.

Type 1 diabetes is associated with an increased fracture risk and a lowering of the threshold for osteoporosis treatment has been recommended to be increased from a bone mineral density of a T-score ≤ - 2.5 to a T-score ≤ - 2.0. In this study, we aimed to investigate the prevalence and risk factors for osteoporosis in type 1 diabetes using the classic diagnostic criteria defined by WHO and the novel T-score cutoff of - 2.0 proposed by the ADA.

In a cross-sectional study, data were collected from the type 1 diabetes clinic at Steno Diabetes Center Aarhus, Aarhus University Hospital, where active attenders in the clinic were offered screening for osteoporosis using DXA of the lumbar spine and hip in the time period 2020-2022.

A total of 764 individuals with type 1 diabetes had a DXA and of these, 25.5% had osteoporosis based on a vertebral fracture or T-score ≤ - 2.5, and 36% met ADA-treatment criteria with a vertebral fracture or T-score ≤ - 2.0. In multivariate analysis increasing age (OR = 1.3, 95% CI 1.0; 1.7) and a family history of osteoporosis (OR = 1.9, 95% CI 1.2; 3.0) were associated with an increased risk of osteoporosis, whereas an increase in BMI was associated with a decreased risk of osteoporosis (OR = 0.87, 95% CI 0.82; 0.92).

The present study finds that a high proportion of individuals with type 1 diabetes have osteoporosis, and an even higher proportion meet the treatment criteria proposed by the ADA, and thus, early detection and treatment of osteoporosis may reduce the apparent increased fracture risk in type 1 diabetes.

This exploratory study developed and evaluated an artificial intelligence (AI)-based algorithm for quantitative morphometry to assess vertebral body deformities indicative of fractures. To achieve this, 709 radiographs from 355 cases were utilized for algorithm development and performance evaluation. The proposed algorithm integrates a first-stage AI model to identify the positions of thoracic and lumber vertebral bodies in lateral radiographs and a second-stage AI model to annotate 6 landmarks for calculating vertebral body height ratios (C/A, C/P, and A/P). The first-stage AI model achieved a sensitivity of 97.6%, a precision of 95.1%, and an average false-positive ratio of 0.43 per image for vertebral body detection. In the second stage, the algorithm's performance was evaluated using an independent dataset of vertebrae annotated by 2 spine surgeons and 1 radiologist. The average landmark errors ranged from 2.9% to 3.3% on the X-axis and 2.9% to 4.0% on the Y-axis, with errors increasing in more severely collapsed vertebrae, particularly at central landmarks. Spearman's correlation coefficients were 0.519-0.589 for C/A, 0.558-0.647 for C/P, and 0.735-0.770 for A/P, comparable with correlations observed among human evaluators. Bland-Altman analysis revealed systematic bias in some cases, indicating that the algorithm underestimated anterior and central height collapse in deformed vertebrae. However, the mean differences and limits of agreement between the algorithm and external evaluators were similar to those among the evaluators. Additionally, the algorithm processed each image within 10 s. These findings suggest that the algorithm performs comparably with human evaluators, demonstrating sufficient accuracy for clinical use. The proposed approach has the potential to enhance patient care by being widely adopted in clinical settings.

Hereditary neuromuscular disorders (NMD) are associated with compromised bone health and elevated fracture risk, though data are largely lacking.

This study aimed to assess the prevalence and risk factors of fractures in hereditary NMD.

We conducted a retrospective study in a cohort of adult patients with diverse hereditary NMD, using data from electronic medical records.

Among 469 patients, 505 fractures were recorded, with 5.5% of patients experiencing a fracture within the past year. In the 10 years preceding study inclusion, 31.1% of all patients sustained at least one fracture. The fracture rate was 47.3/1000 patient-years. Fracture incidence was highest in the second decade of life and the first five years after symptom onset. Fracture recurrence occurred in 25.6% over the next two years. Fractures were most prevalent in patients with Duchenne muscular dystrophy, myotonic dystrophy type 1/2, and spinal muscular atrophy. Patients with Vignos scale 5-6 had the highest fracture risk. Major osteoporotic fractures accounted for 28.6%, and 71.3% were caused by low-energy trauma. Long-term complications of a fracture were present in 44.2%, with 9.0% losing ambulation. Osteoporosis was confirmed in 47.5% of DXA scans. In patients with a normal DXA scan, 66.7% experienced a subsequent fracture. Hip T-scores declined with increasing Vignos scale (r = -0.27, p = 0.001). Fracture risk factors included glucocorticoid use, alcohol abuse, recent falls, and previous emergency visits for falls (all p < 0.05).

This cohort exhibited a high prevalence of fractures and osteoporosis, emphasizing the need for regular bone health assessment and fracture prevention in hereditary NMD patients.

Osteoporosis-related vertebral fractures are among the most frequent fracture entities in geriatric patients. They are associated with far-reaching individual and socioeconomic consequences. Adequate diagnostics and treatment are therefore essential. The osteoporotic fracture (OF) score is a central element in determining the right treatment. Although the majority of fractures can be healed with conservative treatment, a change of treatment should be considered in good time in cases of failure. Isolated cement augmentation procedures are particularly suitable for reducing pain in primarily stable osteoporotic vertebral fractures with a preserved framework structure (OF types 1-3) and a largely intact posterior edge. Dorsal cement-augmented stabilization with cementing of the fractured vertebral body leads to good results in unstable OF types 3 and 4 fractures. Dorsoventral procedures with cement-augmented internal fixator from the dorsal side and vertebral body replacement from the ventral side play a more subordinate role. Purely ventral procedures should be avoided in this patient group.

Multiple studies within the medical field have highlighted the remarkable effectiveness of using convolutional neural networks for predicting medical conditions, sometimes even surpassing that of medical professionals. Despite their great performance, convolutional neural networks operate as black boxes, potentially arriving at correct conclusions for incorrect reasons or areas of focus. Our work explores the possibility of mitigating this phenomenon by identifying and occluding confounding variables within images. Specifically, we focused on the prediction of osteopenia, a serious medical condition, using the publicly available GRAZPEDWRI-DX dataset. After detection of the confounding variables in the dataset, we generated masks that occlude regions of images associated with those variables. By doing so, models were forced to focus on different parts of the images for classification. Model evaluation using F1-score, precision, and recall showed that models trained on non-occluded images typically outperformed models trained on occluded images. However, a test where radiologists had to choose a model based on the focused regions extracted by the GRAD-CAM method showcased different outcomes. The radiologists' preference shifted towards models trained on the occluded images. These results suggest that while occluding confounding variables may degrade model performance, it enhances interpretability, providing more reliable insights into the reasoning behind predictions. The code to repeat our experiment is available on the following link: https://github.com/mikulicmateo/osteopenia .

To investigate the effects of surgical menopause on bone mineral density and bone quality because bilateral salpingo-oophorectomy for the treatment of gynecological malignancies is common even in premenopausal patients. This study is prospective one of bone mineral density and quality measurements after surgery for perimenopausal gynecologic malignancies.

In 50 women who underwent surgical menopause for a diagnosis of gynecological malignancies, bone mineral density (BMD), blood levels of tartrate-resistant acid phosphatase 5b (TRACP-5b) and bone-specific alkaline phosphatase (BAP) as bone metabolism markers, and urinary pentosidine level as bone quality marker were measured before surgery and at multiple points up to 24 months after surgery.

In a group of 22 patients who did not undergo hormone replacement therapy (HRT) (HRT- group), BMD of the lumbar spine and total hip continued to decrease significantly from 6 months postoperatively. Percentages of changes in BMD progressively increased over time after surgery. TRACP-5b and urinary pentosidine levels significantly increased 6 months postoperatively compared with preoperative levels. Comparisons between 10 patients who underwent HRT (HRT+ group) and the HRT- group revealed significant reductions in the percentage of change in lumbar spine BMD only and TRACP-5b and urinary pentosidine levels 12 months postoperatively in the former group.

In this pilot study, we showed that BMD and bone-related markers are altered in patients with surgical menopause. It also suggested that HRT may reduce these influences on bone metabolism.

Romosozumab is an anti-sclerostin antibody drug with potent bone formation-promoting and bone resorption-inhibiting properties. It enhances bone mineral density and has a novel effect in preventing fractures. However, there have been reports of non-responders to romosozumab.

If the least significant change is defined as 3%, only 2-12% of patients with spine osteoporosis are non-responders, and romosozumab is highly effective in this population. Low-type 1 amino-terminal propeptide (P1NP) levels during the early treatment phase are associated with non-responders early in treatment. The researchers found a cutoff value of 50.3 μg/L of P1NP in the first month of treatment. In contrast, hip osteoporosis does not respond (54-57% of the time). Low P1NP levels at the start of treatment increase the risk of non-responders. The cutoff value for P1NP was reported as 53.7 μg/L at the beginning of treatment. However, failure to meet these cutoff values does not necessarily indicate that the patient is a non-responder and does not justify a change in drug administration.

In spine osteoporosis, romosozumab demonstrates high effectiveness, with approximately 2-12% of patients showing no response. However, in hip osteoporosis, approximately 54-57% do not respond to the treatment with romosozumab.

Previous studies have demonstrated that in certain medical conditions, fragility fractures tend to occur even at bone mineral density (BMD) levels that are in the nonosteoporotic range. This warrants the assessment of other factors beyond BMD that might confer an increased propensity to fracture. Hip structural analysis (HSA) is also performed by the DXA scanner and evaluates different variables pertaining to proximal hip geometry. Bone Strain Index (BSI) is another novel DXA-based tool that was recently developed to further assess bone health. This has been based on a finite element analysis of grey scale images of density distribution of the femoral and lumbar spine scans obtained from a DXA scanner. Preliminary studies assessing the utility of BSI in predicting fragility fractures have been promising. This review will focus on the technical details and utility of the HSA and BSI beyond conventional BMD assessment.

The purpose of this review is to provide a background of osteoporosis and air pollution, discussing increasing incidence of the disease with exposure to pollutants and the role that inflammation may play in this process.

Osteoporosis-related fractures are one of the most pressing challenges for the ageing global population, with significant increases in mortality known to occur after major osteoporotic fractures in the elderly population. Recent studies have established a firm correlative link between areas of high air pollution and increased risk of osteoporosis, particularly alarming given the increasingly urban global population. While the culprit pollutants and molecular mechanisms underlying this phenomenon have not yet been elucidated, initial studies suggest a role for inflammatory cascades in this phenomenon. While much more research is required to identify the most damaging air pollutants and to delineate the specific inflammatory molecular mechanisms, it is clear from the literature that shedding light on these pathways would unveil potential therapeutic targets to treat bone diseases, including osteoporosis. Major deficiencies of current animal models highlight the need for complex human in vitro models such as organ-on-a-chip technology to better understand the impact of air pollution.

An Italian multidisciplinary working group discussed the current Italian scenario of osteoporosis management during a meeting and highlighted the essential role of calcium and vitamin D supplementation in the prevention of fragility fractures.

This paper aims to review and discuss data on calcium and vitamin D requirements and the role of combined calcium and vitamin D supplementation in the treatment of patients with osteoporosis.

The discussion of the experts covered literature data on calcium and vitamin D supplementation, gaps in the diagnosis and treatment of osteoporosis, and the role of the primary care physician in identifying and treating patients with osteoporosis. Articles for consideration were identified through PubMed searches using different combinations of pertinent keywords.

The discussion highlighted that insufficient calcium or vitamin D intake increases the risk of fragility fractures. The experts also drew attention to the essential role of calcium and vitamin D supplementation in achieving an anti-fracture effect and supporting the efficacy of anti-osteoporotic agents without increasing nephrolithiasis and cardiovascular risks. In addition, the discussion underlined the role of the primary care physician in the initial clinical approach to patients with osteoporosis.

The experts believe that efficient treatment for patients with osteoporosis should include calcium and vitamin D supplementation to achieve adequate levels that are able to inhibit the parathyroid hormone and bone resorption.

A history of fractures increases the likelihood of experiencing subsequent and secondary fractures. To prevent further fractures, global guidelines recommend aggressive proactive treatment with medication for patients at an imminent risk of osteoporotic fracture (OF), which is defined as a high likelihood of experiencing subsequent fractures in the near future. However, there is a lack of research focusing on patients with imminent risk of OFs in South Korea. Hence, this study aimed to evaluate the imminent risk of the first and second recurrent OFs among patients with OF in South Korea.

We conducted a retrospective analysis using the comprehensive Health Insurance Review and Assessment database, which encompasses the entire population of Korea from 2012 to 2017. The study focused on eligible patients aged 55 years and older who experienced an OF in 2013, including fractures in the hip/femur, vertebral, humerus, radius, tibia/fibula, and ankle regions. The first OF occurring in 2013 was considered the index OF. To ensure that the index fracture was the index OFs, we excluded patients who had any OF within 1 year before their index OF. We assessed the incidence of the first recurrent OF within 2 years after the index OF, and the second recurrent OF within 2 years after the occurrence of the first recurrent OF. Additionally, we estimated the risks of experiencing the first and second recurrent OFs according to age and sex using multi-variable Cox proportional hazard regression analysis.

Approximately 17 % of patients with an index OF had the first recurrent OF within 2 years after the index OF. Of those with a first recurrent OF, 28 % experienced a second recurrent OF within 2 years after the first recurrent OF. The two-year incidence rate of the first recurrent OF was 9.6 per 100 person-years (95 % confidence interval [CI], 9.6-9.7). The two-year incidence rate of the second recurrent OF was 22.0 per 100 person-years (95 % CI, 21.6-22.4), which is higher than that of the first recurrent OF. Females had a 31 % higher risk of the first recurrent OF (hazard ratio [HR] = 1.31; 95 % CI, 1.20-1.43) and a 43 % higher risk of the second recurrent OF than males (HR = 1.43; 95 % CI, 1.35-1.51).

In Korea, the imminent risk of a second recurrent OF was higher than that of a first recurrent OF. Consequently, given the elevated risk of subsequent fractures with the number of OFs experienced, a more targeted approach to treatment is recommended for patients with a first recurrent OF considering the risk of subsequent OF.

Malnutrition is common in patients with cirrhosis, eventually leading to sarcopenia and loss of bone mass.

The aims of this study was the assessment of body composition (BC) and bone mineral density (BMD) in patients with decompensated cirrhosis and the prognostic impact on survival after transjugular intrahepatic portosystemic shunt (TIPS) implantation.

BMD and BC of 107 patients with cirrhosis undergoing TIPS implantation were prospectively analyzed by dual-energy X-ray absorptiometry. The prevalence and predisposing risk factors for reduced BMD and sarcopenia were assessed. Impact on 12-month survival after TIPS implantation was evaluated.

Sarcopenia was diagnosed in 48.6 % of the patients with a predominance of male patients (58.7% vs. 25.0 %, p = 0.001). 67.2 % had reduced BMD. Low BMI was independently associated with sarcopenia (OR 0.751 (95 % CI: 0.662;0.852), p < 0.001) and reduced BMD (OR 0.851 (0.773;0.937), p = 0.001). Patients with reduced BMD, but not sarcopenia, had impaired 12-month survival after TIPS-implantation (61.2% vs. 82.9 %, p = 0.030). Subgroup analysis showed that this was especially valid for female patients.

Sarcopenia and reduced BMD are frequently observed in patients with decompensated cirrhosis. Reduced BMD negatively affects post-TIPS survival. Since malnutrition is a leading cause, assessment of nutritional status and specific treatment should be included in clinical practice.

Older women diagnosed with osteoporosis and referred to their general practitioners (GPs) exhibited significantly higher osteoporosis treatment rates and a reduced fracture risk compared to non-osteoporotic women who were not referred to their GPs.

The objective of this study was to investigate treatment rates and fracture outcomes in older women, from a population-based study, 1) diagnosed with osteoporosis, with subsequent referral to their general practitioner (GP), 2) women without osteoporosis, without referral to their GP.

In total, 3028 women, 75-80 years old were included in the SUPERB cohort. At inclusion, 443 women were diagnosed with osteoporosis (bone mineral density (BMD) T-score ≤ -2.5) at the lumbar spine or hip, did not have current or recent osteoporosis treatment, and were referred to their GP for evaluation (referral group). The remaining 2585 women without osteoporosis composed the control group. Sensitivity analysis was performed on subsets of the original groups. Adjusted Cox regression (hazard ratios (HR) and 95 % confidence intervals (CI)) analyses were performed to investigate the risk of incident fractures and the incidence of osteoporosis treatment.

Cox regression models, adjusted for age, sex, body mass index (BMI), smoking, alcohol, glucocorticoid use, previous fracture, parent hip fracture, secondary osteoporosis, rheumatoid arthritis, and BMD at the femoral neck, revealed that the risk of major osteoporotic fracture was significantly lower (HR = 0.81, 95 % CI [0.67-0.99]) in the referral group than in the controls. Similarly, the risk of hip fracture (HR = 0.69, [0.48-0.98]) and any fracture (HR = 0.84, [0.70-1.00]) were lower in the referral group. During follow-up, there was a 5-fold increase (HR = 5.00, [4.39-5.74]) in the prescription of osteoporosis medication in the referral group compared to the control group.

Screening older women for osteoporosis and referring those with osteoporosis diagnosis was associated with substantially increased treatment rates and reduced risk of any fracture, MOF, and hip fracture, compared to non-osteoporotic women.

The purpose of this study was to evaluate pre- and post-fracture medical management of osteoporosis among patients who underwent surgical fixation of femoral neck fractures (FNF) and vertebral compression fractures (VCF), and to investigate if there is a difference in treatment, management, and subsequent fractures between FNF and VCF patients.

Patients who underwent surgical fixation of FNF or VCF were retrospectively reviewed at a minimum 1 year follow up. Patients were excluded if their fracture was caused by high energy trauma or malignancy, <50 years-old, deceased, or lost to follow up. Patient demographics such as age, sex, BMI, American Society of Anesthesiology Physical Status Classification System and Charleston Comorbidity index were recorded. Management of osteoporosis, including medication regimen and dual-energy X-ray absorptiometry (DEXA) scans were assessed preoperatively and at minimum one year follow up. Subsequent fractures were also recorded.

In the analysis of 370 patients (74.7% FNF, 25.2% VCF), demographics showed a predominantly female population (mean age 78.1). Preoperatively, 21.6% were diagnosed with osteoporosis, consistent between FNF and VCF. Postoperatively, there were no significant differences in new osteoporosis diagnoses, bisphosphonate use, or subsequent fractures. VCF patients, however, were more likely to receive denosumab and post-operative DEXA scans (p < 0.05). Within a year, 6.2% experienced subsequent fractures, with no significant FNF-VCF difference. Only 12.7% received appropriate post-operative osteoporosis treatment, 27.1% had DEXA scans, and 25% had a recorded osteoporosis diagnosis. Multivariable analysis highlighted pre-fracture osteoporosis diagnosis as the sole predictor for post-operative DEXA scans and anti-osteoporotic medication (p < 0.001).

This study suggests that factors beyond the type of fragility fracture may influence subsequent fracture risk and anti-osteoporotic medication administration in elderly patients. These findings underscore the importance of a comprehensive approach to fracture risk assessment and treatment decisions in this population.

III.

Proximal humerus fractures (PHF) are common in the elderly, accounting for significant morbidity and mortality. Non-surgical treatment is a common option for low-demand elderly patients, but it can lead to unsatisfactory functional outcomes in some cases. The identification of predictive factors for poor prognosis in non-surgical management remains unclear. This study aimed to determine the predictive factors for poor prognosis in elderly patients treated non-surgically for displaced PHF and to assess associated complications.

A retrospective cohort study was conducted involving patients aged 60 years or older with displaced PHF treated non-surgically from May 2020 to January 2023 at a reference hospital for orthopedic trauma. The primary outcome was functional assessment using the American Shoulder and Elbow Surgeons (ASES) scale at 12 months. Predictive factors such as metaphyseal fracture comminution, Pain Catastrophizing Scale (PCS) scores, and radiographic criteria were analyzed. Multivariate regression analyses were performed to identify independent predictors of poor outcomes.

Out of 140 initially selected patients, 103 met the inclusion criteria and completed the follow-up. The mean ASES score was 71.3±25.4 points. Multivariate analysis identified metaphyseal comminution (p < 0.001) and PCS scores ≥ 30 (p < 0.001) as significant predictors of poorer functional outcomes. Complications were observed in 17.4% of patients, including osteonecrosis (6.7%), nonunion (4.9%), and persistent pain and stiffness (5.8%).

Metaphyseal comminution and high PCS scores are significant predictors of poor prognosis in elderly patients undergoing non-surgical treatment for displaced PHF. These findings highlight the importance of considering both biomechanical and psychological factors when managing proximal humerus fractures in this population. Further studies with larger sample sizes and prospective designs are needed to validate these findings and refine treatment strategies.

Osteoporotic vertebral compression fractures (OVCFs) are a highly prevalent source of morbidity and mortality, and preventive treatment has been demonstrated to be both effective and cost effective. To take advantage of the information available on existing chest and abdominal radiographs, the authors' study group has developed software to access these radiographs for OVCFs with high sensitivity and specificity using an established artificial intelligence deep learning algorithm. The aim of this analysis was to assess the potential cost-effectiveness of implementing this software.

A deterministic expected-value cost-utility model was created, combining a tree model and a Markov model, to compare the strategies of opportunistic screening for OVCFs against usual care. Total costs and total quality-adjusted life-years were calculated for each strategy. Screening and treatment costs were considered from a limited societal perspective, at 2022 prices.

In the base case, assuming a cost of software implantation of $10 per patient screened, the screening strategy dominated the nonscreening strategy: it resulted in lower cost and increased quality-adjusted life-years. The lower cost was due primarily to the decreased costs associated with fracture treatment and decreased probability of requiring long-term care in patients who received preventive treatment. The screening strategy was dominant up to a cost of $46 per patient screened.

Artificial intelligence-based opportunistic screening for OVCFs on existing radiographs can be cost effective from a societal perspective.

Enzyme insufficiency (EPI) is common in chronic pancreatitis (CP), pancreatic ductal adenocarcinoma (PDAC), and after pancreatic resection. 40%-50% of CP patients and 70%-80% of PDAC patients develop EPI. 1/3rd of these patients are prescribed Pancreatic enzyme replacement therapy (PERT), often at an inadequate dose, with evidence that this leads to increased morbidity and mortality. This study aimed to develop and implement an EPIC-based best practice alert (BPA) and smart set to improve the management of EPI.

A retrospective analysis of all patients with International Classification of Diseases codes for EPI, CP, and PDAC or CPT code for pancreatic resection from Feb-2018 to Feb-2021. Appropriate use of PERT was defined as ≥ 40,000 units of lipase with each meal. The BPA and smart set were implemented into the electronic medical record in Feb-2020. The BPA fired if the patient was already on PERT or if an order for PERT was placed and directed the clinician to the smart set which provided PERT formulations each prefilled to the minimum therapeutic dose of 40,000 units of lipase.

A significant increase in the proportion of patients on minimum therapeutic dose of PERT from 61.9% to 72.9% (P ≤ .001). Ordering of pancreatic elastase, A1c, vitamin D, and dual X-ray absorptiometry increased from 20.4% to 29.9% (P < .001), 54.7%-62.1% (P = .001), 30.9%-48.1% (P < .001) and 10%-18% (P < .001), respectively. The BPA triggered a total of 30,838 times resulting in the smart being opened a total of 624 (2.02%) times over 24 months.

The BPA and smart set were associated with an improvement in the diagnosis and management of EPI and related complications in CP, PDAC, and s/p pancreatic resection.

Osteoporotic vertebral compression fracture (OVCF) is a common complication in elderly patients with osteoporosis. Despite undergoing percutaneous kyphoplasty (PKP) treatment, a significant percentage of OVCF patients (1.8% to 31.9%) continue to experience residual low back pain. While acupuncture has shown promise in relieving this pain, there is currently no systematic review on its efficacy specifically for residual low back pain after PKP in OVCF patients. This project aims to evaluate the effectiveness and safety of acupuncture as a treatment for this condition.

A comprehensive search will be conducted, including manual and electronic searches of literature published. Various databases such as MEDLINE, PubMed, EMBASE, Web of Science, Cochrane Library, International Clinical Trial Registration Platform, China National Knowledge Network, China Biomedical Literature Database, China Scientific Journal Database and Wan-fang Database will be explored. Additional sources like bibliographies and meeting minutes will also be searched. All randomised controlled clinical trials related to acupuncture for treating residual low back pain after PKP in OVCF patients will be included. Two researchers will independently perform study selection, data extraction and quality assessment. The primary outcome measure will be pain relief assessed using a visual analogue scale (VAS) or other validated scales. Secondary outcomes include effectiveness, Oswestry dysfunction index (ODI), quality of life questionnaire (QUALEFFO-41), follow-up relapse rate and adverse events. If feasible, a meta-analysis using RevMan V.5.3 software will be conducted. Otherwise, descriptive or subgroup analyses will be performed. Database searches will commence after the publication of this agreement, with an estimated commencement date of 1 August 2024.

Ethical approval is not required since this review does not involve individual patient data. The findings will be disseminated through peer-reviewed journals or relevant conferences.

CRD42023478838.

Osteoporosis increases the risk of periprosthetic distal femoral fractures after TKA, especially in patients with a history of osteoporotic fractures. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized by the patients following primary TKA.

Osteoporosis is a risk factor for fractures, including those of the hip, vertebrae, and distal radius; however, the association between osteoporosis and periprosthetic fractures after total knee arthroplasty (TKA) has not been much investigated. Therefore, we aimed to investigate the association of the presence of systemic osteoporosis with periprosthetic fractures after TKA.

This study included 34 patients with periprosthetic fractures following primary TKA and 106 controls matched for age and sex. Bone mineral density was evaluated at the femoral neck, total hip, and lumbar spine using dual X-ray absorptiometry. Medical records were reviewed for age; sex; body mass index; smoking; rheumatoid arthritis, endocrine diseases, and cardiovascular diseases; history of glucocorticoid use; medication for osteoporosis; and history of previous osteoporotic fracture. In addition, anterior femoral notching after TKA was evaluated. Univariable and multivariable logistic regression analysis were used to determine factors associated with periprosthetic fracture.

The prevalence of osteoporosis in the fracture group was higher than that in the control group (61.8% vs. 40.6%, p=0.045). The rate of medication for osteoporosis was significantly low in the fracture group (47.6 % vs 76.7%, p=0.026). History of previous osteoporotic fracture (odds ratio [OR], 9.1; p=0.015) and osteoporosis (OR, 3.6; p=0.013) were significant risk factors for periprosthetic fractures after TKA. Medication for osteoporosis could decrease the risk of periprosthetic fracture (OR 0.3; p=0.020).

Osteoporosis is a major risk factor for periprosthetic distal femoral fractures after TKA. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized to the patients following primary TKA, especially in patients with a history of osteoporotic fracture.

Prognostic study, level III.

Osteoporotic fractures, prevalent in the elderly, pose a significant health and economic burden. Current methods for predicting fracture risk, primarily relying on bone mineral density, provide only modest accuracy. If better spatial resolution of trabecular bone in a clinical scan were available, a more complete assessment of fracture risk would be obtained using microarchitectural measures of bone (i.e. trabecular thickness, trabecular spacing, bone volume fraction, etc.). However, increased resolution comes at the cost of increased radiation or can only be applied at small volumes of distal skeletal locations. This study explores super-resolution (SR) technology to enhance clinical CT scans of proximal femurs and better reveal the trabecular microarchitecture of bone. Using a deep-learning-based (i.e. subset of artificial intelligence) SR approach, low-resolution clinical CT images were upscaled to higher resolution and compared to corresponding MicroCT-derived images. SR-derived 2-dimensional microarchitectural measurements, such as degree of anisotropy, bone volume fraction, trabecular spacing, and trabecular thickness were within 16 % error compared to MicroCT data, whereas connectivity density exhibited larger error (as high as 1094 %). SR-derived 3-dimensional microarchitectural metrics exhibited errors <18 %. This work showcases the potential of SR technology to enhance clinical bone imaging and holds promise for improving fracture risk assessments and osteoporosis detection. Further research, including larger datasets and refined techniques, can advance SR's clinical utility, enabling comprehensive microstructural assessment across whole bones, thereby improving fracture risk predictions and patient-specific treatment strategies.

Over the past few decades, early osteoporosis detection using ultrasonic bone quality evaluation has gained prominence. Specifically, various studies focused on axial transmission using ultrasonic guided waves and have highlighted this technique's sensitivity to intrinsic properties of long cortical bones. This work aims to demonstrate the potential of low-frequency ultrasonic guided waves to infer the properties of the bone inside which they are propagating. A proprietary ultrasonic transducer, tailored to transmit ultrasonic guided waves under 500 kHz, was used for the data collection. The gathered data underwent two-dimensional fast Fourier transform processing to extract experimental dispersion curves. The proposed inversion scheme compares experimental dispersion curves with simulated dispersion curves calculated through the semi-analytical iso-geometric analysis (SAIGA) method. The numerical model integrates a bone phantom plate coupled with a soft tissue layer on its top surface, mimicking the experimental bone phantom plates. Subsequently, the mechanical properties of the bone phantom plates were estimated by reducing the misfit between the experimental and simulated dispersion curves. This inversion leaned heavily on the dispersive trajectories and amplitudes of ultrasonic guided wave modes. Results indicate a marginal discrepancy under 5% between the mechanical properties ascertained using the SAIGA-based inversion and those measured using bulk wave pulse-echo measurements.

Prediction of bone fracture risk is clinically challenging. Computational modeling plays a vital role in understanding bone structure and diagnosing bone diseases, leading to novel therapies. The research objectives were to demonstrate the anisotropic structure of the bone at the micro-level taking into consideration the density and subject demography, such as age, gender, body mass index (BMI), height, weight, and their roles in damage accumulation. Out of 438 developed 3D bone models at the micro-level, 46.12% were female. The age distribution ranged from 23 to 95 years. The research unfolds in two phases: micro-morphological features examination and stress distribution investigation. Models were developed using Mimics 22.0 and SolidWorks. The anisotropic material properties were defined before importing into Ansys for simulation. Computational simulations further uncovered variations in maximum von-Misses stress, highlighting that young Black males experienced the highest stress at 127.852 ± 10.035 MPa, while elderly Caucasian females exhibited the least stress at 97.224 ± 14.504 MPa. Furthermore, age-related variations in stress levels for both normal and osteoporotic bone micro models were elucidated, emphasizing the intricate interplay of demographic factors in bone biomechanics. Additionally, a prediction equation for bone density incorporating demographic variables was proposed, offering a personalized modeling approach. In general, this study, which carefully examines the complexities of how bones behave at the micro-level, emphasizes the need for an enhanced approach in orthopedics. We suggest taking individual characteristics into account to make therapeutic interventions more precise and effective.

This study evaluated the cost-effectiveness of sequential treatment with romosozumab-to-alendronate compared to alendronate monotherapy and teriparatide-to-alendronate, in postmenopausal osteoporotic women from a Belgian healthcare perspective. Romosozumab-to-alendronate was found to be cost-effective compared to alendronate monotherapy and dominant compared to teriparatide-to-alendronate for osteoporotic women at high risk of fracture in Belgium.

This study aimed to evaluate the cost-effectiveness of sequential treatment with romosozumab followed by alendronate compared to alendronate monotherapy and teriparatide followed by alendronate, in postmenopausal osteoporotic women at high risk of fracture, from a Belgian healthcare perspective. Romosozumab is reimbursed in Belgium since December 2021.

A Markov microsimulation model was used to evaluate the cost-effectiveness of romosozumab-to-alendronate compared to alendronate monotherapy and to teriparatide-to-alendronate over a lifetime horizon. Patients transition between five different health states every 6 months based on fracture risks or death. The model was populated with Belgium-specific epidemiological and cost data, where available. The fracture risk reduction of romosozumab treatment was collated from the ARCH study, and from a published network meta-analysis. Costs were included from a healthcare perspective (NIHDI). Cost-effectiveness was reported in terms of costs per quality-adjusted life year (QALY), reported in Euro (€) 2022. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were performed.

Romosozumab-to-alendronate was associated with 0.12 additional QALYs at an additional cost of €2314 compared to alendronate monotherapy, resulting in an ICER of €19,978. Compared to teriparatide-to-alendronate, romosozumab-to-alendronate was found to be dominant, with higher QALYs and lower costs. The base-case results were robust to uncertainty in the input parameters when conducting the sensitivity analysis.

Sequential treatment with romosozumab followed by alendronate was found to be cost-effective compared to alendronate monotherapy and dominant compared to teriparatide followed by alendronate for postmenopausal women with osteoporosis at high risk of fracture in Belgium.

Osteoporotic fractures, also known as fragility fractures, are reflective of compromised bone strength and are associated with significant morbidity and mortality. Such fractures may be clinically silent, and others may present clinically with pain and deformity at the time of the injury. Unfortunately, and even at the time of detection, most individuals sustaining fragility fractures are not identified as having underlying metabolic bone disease and are not evaluated or treated to reduce the incidence of future fractures. A multidisciplinary international working group with representation from international societies dedicated to advancing the care of patients with metabolic bone disease has developed best practice recommendations for the diagnosis and evaluation of individuals with fragility fractures. A comprehensive narrative review was conducted to identify key articles on fragility fractures and their impact on the incidence of further fractures, morbidity, and mortality. This document represents consensus among the supporting societies and harmonizes best practice recommendations consistent with advances in research. A fragility fracture in an adult is an important predictor of future fractures and requires further evaluation and treatment of the underlying osteoporosis. It is important to recognize that most fragility fractures occur in patients with bone mineral density T scores higher than -2.5, and these fractures confirm the presence of skeletal fragility even in the presence of a well-maintained bone mineral density. Fragility fractures require further evaluation with exclusion of contributing factors for osteoporosis and assessment of clinical risk factors for fracture followed by appropriate pharmacological intervention designed to reduce the risk of future fracture. Because most low-trauma vertebral fractures do not present with pain, dedicated vertebral imaging and review of past imaging is useful in identifying fractures in patients at high risk for vertebral fractures. Given the importance of fractures in confirming skeletal fragility and predicting future events, it is recommended that an established classification system be used for fracture identification and reporting.

There is imminent refracture risk in elderly individuals for up to six years, with a decline thereafter except in women below 75 who face a constant elevated risk. Elderly men with fractures face the highest mortality risk, particularly those with hip and vertebral fractures. Targeted monitoring and treatment strategies are recommended.

Current management and interventions for osteoporotic fractures typically focus on bone mineral density loss, resulting in suboptimal evaluation of fracture risk. The aim of the study is to understand the progression of fractures to refractures and mortality in the elderly using multi-state models to better target those at risk.

This prospective, observational study analysed data from the AGES-Reykjavik cohort of Icelandic elderly, using multi-state models to analyse the evolution of fractures into refractures and mortality, and to estimate the probability of future events in subjects based on prognostic factors.

At baseline, 4778 older individuals aged 65 years and older were included. Elderly men, and elderly women above 80 years of age, had a distinct imminent refracture risk that lasted between 2-6 years, followed by a sharp decline. However, elderly women below 75 continued to maintain a nearly constant refracture risk profile for ten years. Hip (30-63%) and vertebral (24-55%) fractures carried the highest 5-year mortality burden for elderly men and women, regardless of age, and for elderly men over 80, lower leg fractures also posed a significant mortality risk.

The risk of refracture significantly increases in the first six years following the initial fracture. Elderly women, who experience fractures at a younger age, should be closely monitored to address their long-term elevated refracture risk. Elderly men, especially those with hip and vertebral fractures, face substantial mortality risk and require prioritized monitoring and treatment.

The role of recent fracture site in predicting the most detrimental subsequent fractures, hip and vertebral, is unclear. This study found that most recent fracture sites were associated with an increased risk of both hip and vertebral fracture, a finding that may impact the design of secondary prevention programs.

Hip and vertebral fractures are the most serious in terms of associated morbidity, mortality, and societal costs. There is limited evidence as to which fracture types are associated with the highest risk for subsequent hip and vertebral fractures. This study aims to explore the dependency of imminent hip and vertebral fracture risk on the site of the recent index fracture.

Conducted as a nationwide retrospective cohort study, we utilized Swedish national registers to assess the risk of hip and vertebral fractures based on the site of the recent (≤ 2 years) index fracture and an old (> 2 years) prevalent fracture. This risk was compared to that observed in individuals without any prevalent fractures. This study encompassed all Swedes aged 50 years and older between 2007 and 2010. Patients with a recent fracture were categorized into specific groups based on the type of their previous fracture and were followed until December 2017, with censoring for death and migration. The study assessed the risk of hip and vertebral fractures during the follow-up period.

The study included a total of 3,423,320 individuals, comprising 145,780 with a recent fracture, 293,051 with an old fracture, and 2,984,489 without a previous fracture. The median follow-up times for the three groups were 7.6 years (IQR 4.0-9.1), 7.9 years (5.8-9.2), and 8.5 years (7.4-9.7), respectively. Patients with a recent fracture at almost all sites exhibited a significantly increased risk of hip fracture and an elevated risk of vertebral fracture compared to controls. Patients with recent fractures had an increased risk of subsequent hip and vertebral fractures, regardless of the index fracture site. These results strengthen the notion that all patients with a recent fracture, regardless of fracture site, should be included in secondary prevention programs, to improve the prevention of the clinically most serious fractures.

With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself.

Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality.

The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was .44 (CI .18-.69, P < .01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was .96 (CI .78-1.14). The patients' ability to live independently in their own home had the highest impact on survival.

The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient.

The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient's ability and activity level.

Although physical activity (PA) is recognized as a key bone mass determinant across life, athlete studies suggest that it may be less effective in women and older individuals. This has not been explored within the general population. We aimed to address this knowledge gap using data from the UK Biobank Study, a large population-based study of middle-aged and older adults. Free-living PA data collected at 100 Hz for 7 d using wrist-worn accelerometers were classified as sedentary behavior (0-29 milligravities [mg]), light (30-124 mg), or moderate-to-vigorous PA (125 + mg). LS and FN-BMD were assessed using DXA. The associations between PA and BMD were assessed using linear regression models, with formal assessments of sex and age interactions undertaken and adjustments made for accelerometer wear time, height, body mass index, education, ethnicity, disability, and (in women only) menopausal status. In total, 15 133 UK Biobank participants (52% women) had complete PA, bone, and covariate data. In this sample, greater overall and moderate-to-vigorous PA was associated with higher LS BMD. In women, these associations were typically weaker in older individuals, for example, regression coefficients in women aged 70 yr or older were ~50% lower than at 45-54 yr (age-by-PA interactions P < .01 in all models). Similar associations were observed in basic but not full models for FN BMD. Greater sedentary time was associated with lower LS BMD in men only, and greater light PA and sedentary time were associated with higher and lower FN BMD, respectively, in both sexes. These results suggest that associations between PA and bone health at clinically-relevant sites are weaker in older than younger women. That positive associations are evident between overall and moderate-vigorous PA and FN BMD even in women ≥70 yr suggests that PA for bone health should still be promoted in older women.

Proinflammatory cytokines are implicated in the pathophysiology of postmenopausal bone loss. Clinical studies demonstrate that prunes prevent bone mineral density loss; however, the mechanism underlying this effect is unknown.

We investigated the effect of prune supplementation on immune, inflammatory, and oxidative stress markers.

A secondary analysis was conducted in the Prune Study, a single-center, parallel-arm, 12-mo randomized controlled trial of postmenopausal women (55-75 y old; n = 235 recruited; n = 183 completed) who were assigned to 1 of 3 groups: "no-prune" control, 50 g prune/d and 100 g prune/d groups. At baseline and after 12 mo of intervention, blood samples were collected to measure serum high-sensitivity C-reactive protein (hs-CRP), serum total antioxidant capacity (TAC), plasma 8-isoprostane, proinflammatory cytokines [interleukin (IL)-1β, IL-6, IL-8, monocyte chemoattractant protein-1, and tumor necrosis factor (TNF)-α] concentrations in plasma and lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMCs) culture supernatants, and the percentage and activation of circulating monocytes, as secondary outcomes.

Prune supplementation did not alter hs-CRP, TAC, 8-isoprostane, and plasma cytokine concentrations. However, percent change from baseline in circulating activated monocytes was lower in the 100 g prune/d group compared with the control group (mean ± SD, -1.8% ± 4.0% in 100 g prune/d compared with 0.1% ± 2.9% in control; P < 0.01). Furthermore, in LPS-stimulated PBMC supernatants, the percent change from baseline in TNF-α secretion was lower in the 50 g prune/d group compared with the control group (-4.4% ± 43.0% in 50 g prune/d compared with 24.3% ± 70.7% in control; P < 0.01), and the percent change from baseline in IL-1β, IL-6, and IL-8 secretion was lower in the 100 g prune/d group compared with the control group (-8.9% ± 61.6%, -4.3% ± 75.3%, -14.3% ± 60.8% in 100 g prune/d compared with 46.9% ± 107.4%, 16.9% ± 70.6%, 39.8% ± 90.8% in control for IL-1β, IL-6, and IL-8, respectively; all P < 0.05).

Dietary supplementation with 50-100 g prunes for 12 mo reduced proinflammatory cytokine secretion from PBMCs and suppressed the circulating levels of activated monocytes in postmenopausal women. This trial was registered at clinicaltrials.gov as NCT02822378.

In men and women with opportunistically identifiable vertebral fractures (VFs) on routine CT scans including the chest and/or abdomen, the risk of death is 51% higher than in those with no VF on the CT scan, and 325% higher than an age- and sex-matched general population cohort.

There is little knowledge about the risk of death in patients with VFs present on routine radiological imaging. We evaluated the risk of death in men and women aged 50 years or older with opportunistically identifiable VFs on routine CT scans and not treated with osteoporosis medications.

Thoracic and lumbar VFs were identified through a blinded, two-step approach on CT scans performed as part of normal clinical care in a Danish hospital in 2010 or later. Subjects with VF were matched on age and sex against those with no VF (1:2-ratio) and a general population cohort (1:3-ratio), respectively, and followed for up to 7 years through the national Danish registers. Subjects treated with an osteoporosis medication in the year prior to baseline were excluded.

Subjects with VF had a significantly higher risk of death during follow-up as compared to subjects with no VF on the CT scan (adjusted hazard ratio [HR] 1.51 [95% confidence interval 1.27-1.79; p < 0.001]) and even more so when compared to the general population cohort (HR 4.25 [3.53-5.12; p < 0.001]). In subjects with versus without VF on the CT scan, the risk was higher in those with moderate or severe VF, in those with no malignancy prior to baseline, and in those with a lower Charlson comorbidity index score.

Subjects with VF available for identification on routine CT scans face a substantially increased risk of death. Opportunistic identification and reporting of VF is important to identify these patients to allow intervention if indicated.

Periodontal disease and increased missing teeth were associated with incident vertebral fractures. In contrast, professional dental cleaning and frequent tooth brushing, was associated with a lower risk of vertebral fracture. Better oral hygiene care attenuated the risk associated with dental diseases.

To investigate the association between oral health and the risk of vertebral fractures.

We included 2,532,253 individuals aged ≥40 years who underwent the Korean National Health Insurance Service health examinations in 2008 and followed up until December 31, 2017. We performed multivariable Cox proportional hazard regression analyses to evaluate the association between dental diseases and oral hygiene care and the risk of vertebral fractures.

Over the 9.3-year median follow-up, 1.46% (n = 36,857) experienced vertebral fractures. Individuals with dental diseases had a higher risk of vertebral fracture than those without (hazard ratio [HR] 1.04, 95% confidence interval [CI]: 1.02-1.07 for periodontal diseases; 1.02, 1.00-1.05 for dental caries; 1.12, 1.05-1.20 for ≥15 missing teeth). Good oral hygiene care was associated with a lower vertebral fracture risk (HR 0.89, 95% CI: 0.86-0.91 for ≥1 time/year [vs. <1 time/year] of professional dental cleaning; 0.90, 0.87-0.93 for ≥2 times/day [vs. 0-1 time/day] of toothbrushing). The combined dental diseases was significantly associated with an increased vertebral fracture risk, whereas combined oral hygiene care was associated with further risk reduction. Better oral hygiene care reduced vertebral fracture risk associated with dental diseases (all P <0.001).

Periodontal disease, dental caries, and an increased number of missing teeth were independently associated with higher risks for vertebral fractures. Conversely, improved oral hygiene care, such as personal dental cleaning and frequent tooth brushing, may modify vertebral fracture risks associated with dental disease.

The incidence rate of olecranon fractures is highest in the elderly population. The aim of this study was to determine whether patients with olecranon fractures have similar demographic and risk characteristics compared to patients with osteoporotic upper extremity fractures.

A retrospective data analysis was performed with diagnoses for olecranon fracture, distal radius fracture and proximal humerus fracture between 2014 and 2016.

A total of 157 olecranon, 1022 distal radius and 451 proximal humerus fractures were identified. The risk of mortality after olecranon and distal radius fractures was comparable but statistically significantly higher after proximal humerus fractures (HR 1.97, 95% CI 1.19-3.27). The risk of subsequent osteoporotic fractures after an olecranon fracture was 10% at 1 year and 14% at 5 years and the risks did not differ statistically after a proximal humerus fracture, 6% and 11% (HR 0.65, 95% CI 0.40-1.06). After a distal radius fracture, the risks were statistically significantly lower: 2% and 5% (HR 0.35, 95% CI 0.22-0.56).

Patients with olecranon fractures have essentially similar demographic characteristics compared to patients with distal radius fractures, but the probability for a subsequent fracture is significantly higher and more comparable to patients with proximal humerus fractures.

Osteoporosis and cardiovascular disease (CVD) are highly prevalent in older women, with increasing evidence for shared risk factors and pathogenesis. Although FRAX was developed for the assessment of fracture risk, we hypothesized that it might also provide information on CVD risk. To test the ability of the FRAX tool and FRAX-defined risk factors to predict incident CVD in women undergoing osteoporosis screening with DXA, we performed a retrospective prognostic cohort study which included women aged 50 yr or older with a baseline DXA scan in the Manitoba Bone Mineral Density Registry between March 31, 1999 and March 31, 2018. FRAX scores for major osteoporotic fracture (MOF) were calculated on all participants. Incident MOF and major adverse CV events (MACE; hospitalized acute myocardial infarction [AMI], hospitalized non-hemorrhagic cerebrovascular disease [CVA], or all-cause death) were ascertained from linkage to population-based healthcare data. The study population comprised 59 696 women (mean age 65.7 ± 9.4 yr). Over mean 8.7 yr of observation, 6021 (10.1%) had MOF, 12 277 women (20.6%) had MACE, 2274 (3.8%) had AMI, 2061 (3.5%) had CVA, and 10 253 (17.2%) died. MACE rates per 1000 person-years by FRAX risk categories low (10-yr predicted MOF <10%), moderate (10%-19.9%) and high (≥20%) were 13.5, 34.0, and 64.6, respectively. Although weaker than the association with incident MOF, increasing FRAX quintile was associated with increasing risk for MACE (all P-trend <.001), even after excluding prior CVD and adjusting for age. HR for MACE per SD increase in FRAX was 1.99 (95%CI, 1.96-2.02). All FRAX-defined risk factors (except parental hip fracture and lower BMI) were independently associated with higher non-death CV events. Although FRAX is intended for fracture risk prediction, it has predictive value for cardiovascular risk.

The most prevalent type of fragility fractures is osteoporotic vertebral fractures (OVFs). However, only a few studies have examined the relationship between anti-osteoporosis treatments and malignancy-related mortality following an OVF. The goal of this study is to determine the effect of anti-osteoporosis therapy on mortality in OVF patients with and without cancer.

Data from older people over the age of 65 who were hospitalised for OVFs between 1 January 2003 and 31 December 2018 were analysed retrospectively. A total of 6139 persons getting osteoporosis treatment and 28,950 who did not receive treatment were analysed, together with 2 sets of patients, comprising cancer patients (794) and cancer-free patients (5342), using anti-osteoporosis medication or not, in 1:1 propensity score-matched analyses. The hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated.

In all, 35,089 patients with OVFs were included in the population; 29,931 people (85.3%) were women, and the mean (standard deviation) age was 78.13 (9.27) years. Overall survival was considerably higher in those undergoing osteoporosis therapy. This was true both for those without cancer (adjusted HR 0.55; 95% CI 0.51-0.59; P<.0001) as well as those with cancer (adjusted HR 0.72; 95% CI 0.62-0.84; P<.0001). Even among cancer patients, those who received anti-osteoporotic drugs had a lower mortality rate than those who did not.

Our findings suggest that anti-osteoporosis therapy should be initiated regardless of the presence of cancer in the elderly, as it increases survival following OVFs.

Fragility fractures occur because of low-impact trauma or even spontaneously in individuals with osteoporosis. Caring for older persons with fragility fractures can present several challenges due to the unique needs and vulnerabilities of this population. Older individuals commonly have multiple medical conditions, such as osteoporosis, arthritis, cardiovascular diseases, and diabetes. These comorbidities can complicate fracture management and increase the risk of complications. Fracture repair through surgery may be more complex in older patients due to poor bone quality, decreased tissue elasticity, and higher chances of anesthesia complications. In addition, mobility and functional limitations post-fracture are highly prevalent in this population, affecting their independence and increasing their risk of institutionalization. Addressing these challenges requires a multidisciplinary approach involving orthopedic surgeons, geriatricians, physical and rehabilitation physicians, physiotherapists, occupational therapists, dieticians, social workers, and caregivers. Preventive measures, such as fall prevention strategies and osteoporosis management, can also play a vital role in reducing the incidence of fragility fractures in older persons.