Progressive Hemiosteoporosis on the Paretic Side and Increased Bone Mineral Density in the Nonparetic Arm the First Year after Severe Stroke

Fractures are a common and serious complication after stroke and the risk of hip fractures among stroke patients is 2 to 4 times greater than among other elderly people. The aim of this study was to investigate prospectively the change in bone mineral density (BMD) after severe stroke and to study the association between motor impairment, disability and the development of hemiosteoporosis. The study comprised 24 stroke patients, with no persistent paresis from previous strokes or previous osteoporotic fractures, included 1 month after stroke onset. BMD, motor function, ambulation and activities of daily living (ADL) were assessed at 1, 4, 7 and 12 months after stroke onset. At inclusion, the patients’ BMD was normal for their age. During the study, there was a significant loss of BMD in the total body (−2.0%; p<0.05), but not in the head or spine. BMD differed significantly between the paretic and the non-paretic arm at inclusion (−4.8%; p<0.001). Decrease in BMD was most pronounced in the affected humerus (−17.4%; p<0.001) and proximal femur (−12.2%; p<0.01). BMD decreased significantly in both lower extremities during follow-up, but the losses were more pronounced on the paretic side (p<0.01). In the nonaffected ultradistal radius there was a significant increase in BMD from inclusion to the end of the study (+5.8%; p<0.01). There was no pattern in the bone losses correlating with presumptive risk factors for hemiosteoporosis such as motor function, ability to perform ADL or ambulation. Two patients had fractures at follow-up, both on the paretic side. Loss of bone mineral density in the paretic extremities is thus pronounced and progressive during the first year after stroke, indicating that loss of BMD is probably an important risk factor for post-stroke fractures. Surprisingly, BMD in the nonaffected arm increased significantly during the first year after stroke, most likely due to increased physical activity, and perhaps a redistribution of bone minerals from the paretic extremities. Received: 13 January 1998 / Accepted: 24 July 1998     

Walking after Stroke: Does It Matter? Changes in Bone Mineral Density Within the First 12 Months after Stroke. A Longitudinal Study

Stroke patients have increased risk of hip fractures. Nearly all fractures occur on the hemiplegic side, and reduced bone mineral density (BMD) may be an important predisposing factor. The aim of this study was to investigate the degree of demineralization within the first year after stroke, and to elucidate a possible difference in patients with high versus low ambulatory levels. Forty acute stroke patients were followed (17 initially wheelchair-bound and 23 initially ambulatory). BMD was measured in the proximal femur bilaterally at a mean 6 days, 7 months and 1 year after stroke onset using dual-energy X-ray absorptiometry. Ambulatory status was independently associated with changes in BMD (p≤0.005) 1 year after stroke. The 17 initially wheelchair-bound patients had a significant 10% reduction in BMD at the paretic side and 5% reduction at the non-paretic side (p<0.001), while the 23 patients initially able to walk had a significant loss (3%) only at the paretic side (p = 0.01). The analysis also indicated that the major reduction in BMD took place within the first 7 months. Two months after stroke 12 of the wheelchair-bound patients had relearned to walk. At the paretic side the 1 year changes in BMD in the patients who stayed wheelchair-bound, the patients who relearned to walk within the first 2 months and the patients who were able to walk throughout the study were 13%, 8% and 3%, respectively, and a statistically significant trend with ambulatory level was found (p = 0.007). This study provides clear evidence that lack of mobility and weight-bearing early after stroke is an important factor for the greater bone loss in the paretic leg, but that relearning to walk within the first 2 months after stroke, even with the support of another person, may reduce the bone loss after immobilization. Received: 24 August 1999 / Accepted: 25 October 1999     

Rate and circumstances of clinical vertebral fractures in older men

Summary We examined the rate of clinical vertebral fractures, and the circumstances associated with the fractures, in a cohort of 5,995 US older men. Fractures were more common in the most elderly men, and were usually associated with falls and other low-energy trauma. Introduction Little is known about clinical vertebral fractures in older men. We postulated that clinical vertebral fractures occur with falls, affect men with osteoporosis, and are more common as age increases. Methods Five thousand nine hundred and ninety-five men aged ≥65 years were followed prospectively for an average of 4.7 years. Men with incident clinical vertebral fractures were compared to controls. Results One percent (n = 61) sustained incident clinical vertebral fractures (2.2/1,000 person-years). The rate of fracture rose with age (0.7% in men 65–69 years and 5% ≥85 years). Fractured men were more likely frail (8.2% vs. 2.2%), more often fell (36.1% vs. 21%) and had lower total hip and lumbar spine BMD (all p values ≤0.002). In 73.8% of cases fractures were precipitated by no known trauma or by low-energy trauma, including falls in 57.3% Fractures were thoracic in 33% and lumbar in 56%. Men with an incident vertebral fracture were more likely to be osteoporotic (13% vs. 2%, p < 0.0001), but most men with incident fractures did not have osteoporosis. Conclusions Incident clinical vertebral fractures were relatively common in older men and the rate increased after age 80 years. Fractures were usually associated with minimal trauma, most commonly a fall. The Osteoporotic Fractures in Men (MrOS) is supported by the National Institutes of Health. The following Institutes provide support: the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), the National Institute on Aging (NIA), and the National Cancer Institute (NCI), under the following grant numbers: UO1 AR45580, UO1 AR45614, UO1 AR45632, UO1 AR45647, UO1 AR45654, UO1 AR45583, UO1 AG18197 and M01 RR000334.     

Reduced hip bone mineral density is related to physical fitness and leg lean mass in ambulatory individuals with chronic stroke

Following a stroke, the reduced level of physical activity and functional use of the paretic leg may lead to bone loss and muscle atrophy. These factors and the high incidence of falls may contribute to hip fractures in the stroke population. This study was the first to examine total proximal femur bone mineral content (BMC) and bone mineral density (BMD) and their relationship to stroke-specific impairments in ambulatory individuals with chronic stroke (onset >1 year). We utilized dual-energy X-ray absorptiometry (DXA) to acquire proximal femur and total body scans on 58 (23 women) community-dwelling individuals with chronic stroke. We reported total proximal femur BMC (g) and BMD (g/cm²) derived from the proximal femur scans, and lean mass (g) and fat mass (g) for each leg derived from the total body scans. Each subject was evaluated for ambulatory capacity (Six-Minute Walk Test), knee extension strength (hand-held dynamometry), physical fitness [maximal oxygen uptake (VO₂max)] and spasticity (Modified Ashworth Scale). Results showed that the paretic leg had significantly lower proximal femur BMD, lean mass and percent lean mass, but higher fat mass than the non-paretic leg for both men and women. Proximal femur BMD of the paretic leg was significantly related to ambulatory capacity ( r =0.33, P =0.011), muscle strength ( r =0.39, P =0.002), physical fitness ( r =0.57, P <0.001), but not related to spasticity ( r =–0.23, P =0.080). Multiple regression analysis showed that lean mass in the paretic leg was a major predictor ( r ²=0.371, P <0.001) of the paretic proximal femur BMD. VO₂max was a significant predictor of both paretic proximal femur BMD ( r ²=0.325, P <0.001) and lean mass in the paretic leg ( r ²=0.700, P <0.001). Further study is required to determine whether increasing physical fitness and lean mass are important to improve hip bone health in chronic stroke.     

Symptomatic Fracture Incidence in Southern Tasmania: Does Living in the Country Reduce Your Fracture Risk?

There are limited data describing urban–rural differences in fracture incidence and the overall effect remains controversial. The aim of this study was to compare symptomatic fracture incidence occurring in geographically defined rural (n= 34 619) and urban (n = 194 974) populations of Southern Tasmania from July 1, 1997 to June 30, 1999. Fractures were ascertained by reviewing reports from all the radiology providers within the area. In the 2-year study time frame there were 3644 fractures in males and 2657 fractures in females. Fracture incidence was significantly higher in urban compared with rural populations in both sexes (male: RR 1.60, 95% CI 1.47–1.75; female: RR 1.77, 95% CI 1.58–1.98). This higher urban fracture incidence was present across all age groups and all fracture types with the exception of knee and pelvis fractures in males (although not all were statistically significant). In addition, urban men >50 years old had a higher fracture incidence than rural women >50 years old (RR 1.25, 95% CI 1.05–1.50), suggesting that in later life the factors responsible for the urban–rural difference are able to offset completely the effect of gender. While some of the reduced fracture incidence in the rural population may be explained by urban drift and underreporting of minor fractures such as foot fractures, the overall pattern of higher fracture risk was very consistent, suggesting a real difference in whole-of-life symptomatic fracture incidence. Further research at an individual level is required to determine what factors account for these large urban–rural differences, as they imply a substantial potential for fracture prevention. Received: 28 November 2001 / Accepted: 5 April 2001     

Long-Term Fracture Risk Following Ischemic Stroke: A Population-Based Study

The overall risk of fracture following stroke has not been well quantified. We addressed this issue in a population-based retrospective cohort study among the 387 Rochester, Minnesota residents who survived for 90 days following their first cerebral infarction during the 10-year period, 1960–69. Cases were matched by age and sex to controls from the general population of Rochester, and subsequent fractures were assessed through review of each subject’s complete (inpatient and outpatient) medical records in the community. With comparable follow-up, the 128 fractures observed among cases were little more than the 118 seen among controls, and the cumulative incidence of any fracture after 25 years was not significantly different (71% versus 66%; p=0.464). Using stratified Cox analysis, there was no increase in the risk of fractures generally (hazard ratio (HR), 1.1; 95% CI, 0.8–1.6) or hip fractures specifically (HR, 1.1; 95% CI, 0.6–2.1) compared with controls. Among the stroke patients with hemiparesis or hemiplegia, the majority of fractures occurred on the impaired side. In a multivariate analysis, fracture risk increased with age (HR per 10 years, 1.6; 95% CI, 1.4–2.0), with hospitalization at onset of stroke (HR, 2.0; 95% CI, 1.3–3.2) and with moderate functional impairment (HR, 1.6; 95% CI, 1.02–2.5) but not severe disability (HR, 0.8; 95% CI, 0.4–1.6). No other characteristic of the stroke or its treatment was an independent predictor of overall fracture risk. Patients and their caretakers need to be aware of the risk of fracture from falls, particularly when moderate impairment permits the patient to be independently mobile. Received: 29 September 2000 / Accepted: 26 April 2001     

Evaluation of the Age-Adjusted Incidence of Hip Fractures Between Urban and Rural Areas: The Difference Is Not Related to the Prevalence of Institutions for the Elderly

As many as 40% of hip fractures occur in institutions for the elderly. Several studies have demonstrated a higher age-adjusted incidence of hip fractures in urban areas compared with rural areas. To assess whether this difference could be due to a preferential location of institutions for the elderly in urban areas, we compared the incidence of hip fractures over a 5-year period in urban versus rural areas, as defined according to the population density (urban >15 inhabitants/ha²). We then determined the age-adjusted incidence of hip fractures in institutional-dwelling elderly and home-dwelling elderly. Hip fracture incidence was 100.0/100 000 (150.5 in women and 43.8 in men) in urban areas, and 71.0/100 000 (107.2 in women and 32.8 in men) in rural areas (p<0.001). When only those patients living in their own homes were analyzed, the incidence was 66.7/100 000 (94.6 in women and 35.7 in men) in urban regions and 36.8/100 000 (49.6 in women and 23.4 in men) in rural areas (p<0.001), a difference of even greater magnitude than when both home-dwelling and institutional-dwelling residents were considered together. In a logistic regression model including age class, gender, urban or rural areas and institutionalization for inhabitants 65 years of age and older, urban residents have a 31% significantly (p<0.001) higher incidence of hip fracture compared with rural residents; women have a 79% significantly (p<0.001) higher incidence of hip fracture compared with men; and institutional-dwelling elderly have a 351% significantly (p<0.001) higher incidence of hip fracture compared with home-dwelling elderly. These results confirm the existence of a higher age-adjusted incidence of hip fractures in urban compared with rural areas. Since this difference is increased when patients living at home were analyzed separately, it indicates that the difference between urban and rural areas is not due to a preferential urban location of institutions for the elderly. Received: 7 November 2000 / Accepted: 9 July 2001     

Do Both Areal BMD and Injurious Falls Explain the Higher Incidence of Fractures in Women than in Men?

The higher incidence of fractures in women than in men is generally attributed to the lower areal bone mineral density (areal BMD, g/cm²) of the former. The purpose of the present study was to investigate both areal BMD and injurious falls as risk factors for fractures. In a first cohort, areal BMD was measured in 5,131 men and women (age range 40–95 years). In a second cohort, consisting of 26,565 men and women (age range 40–69 years), a health survey was conducted including questions about lifestyle and medication. Main outcome measures included validated prospective injurious falls and fractures in both cohorts. The higher areal BMD and femoral neck BMD in men compared to women (P < 0.001) were explained by a higher diameter of the femoral neck. Importantly, the diameter of the femoral neck was not associated with fractures in either sex (hazard ratio [HR] 0.94–1.04, P > 0.05 for all), suggesting that a higher areal BMD and lower incidence of osteoporosis in men do not explain their lower incidence of fractures. In contrast, women were more prone to sustain injurious falls than men in both cohorts investigated (HR for women = 1.61 and 1.84, P < 0.001 for both), resulting in a higher incidence of fractures (HR for women = 2.24 and 2.36, P < 0.001 for both). The number of injurious falls and fractures occurring each month during the study period showed a very strong correlation in both women (r = 0.95, P < 0.00001) and men (r = 0.97, P < 0.00001). In summary, low areal BMD, and thus osteoporosis, may not explain the higher fracture incidence in women than in men. Instead, a higher incidence of injurious falls in women was strongly associated with the higher fracture risk.     

Secular trends in hip fracture incidence and recurrence

Summary  The decline in hip fracture incidence is now accompanied by a further reduction in the likelihood of a recurrent hip fracture among survivors of the first fracture. Introduction  Hip fracture incidence is declining in North America, but trends in hip fracture recurrence have not been described. Methods  All hip fracture events among Olmsted County, Minnesota residents in 1980–2006 were identified. Secular trends were assessed using Poisson regression, and predictors of recurrence were evaluated with Andersen–Gill time-to-fracture regression models. Results  Altogether, 2,752 hip fractures (median age, 83 years; 76% female) were observed, including 311 recurrences. Between 1980 and 2006, the incidence of a first-ever hip fracture declined by 1.37%/year for women (p < 0.001) and 0.06%/year for men (p = 0.917). Among 2,434 residents with a first-ever hip fracture, the cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men with death treated as a competing risk. Age and calendar year of fracture were independently associated with hip fracture recurrence. Accounting for the reduction in first-ever hip fracture rates over time, hip fracture recurrence appeared to decline after 1997. Conclusion  A recent reduction in hip fracture recurrence is somewhat greater than expected from the declining incidence of hip fractures generally. Additional research is needed to determine the extent to which this can be attributed to improved patient management.     

Refracture following Fracture Liaison Service Assessment Illustrates the Requirement for Integrated Falls and Fracture Services

The Fracture Liaison Service (FLS) allows appropriate antiosteoporosis therapy to be targeted to potentially reduce future fracture risk. A proportion of these treated patients will still experience a further fracture. This work reviews the characteristics of these patients. Data were collated for patients >65 years old presenting to the South Glasgow FLS between January 2001 and August 2004. There were 2,489 patients who presented (incident fracture group), and 129 (5.2%) sustained an additional fracture (refracture group). Median age of the incident fracture group was 77.8 years vs. 80.6 years for the refracture group (P = nonsignificant). The refracture group was determined according to whether their incident fracture was hip (n = 47) or nonhip (n = 82). When the incident fracture was hip, a refracture was more likely to be a further hip fracture (χ² = 14.4, P = 0.002) and patients refractured sooner (median time to refracture 194 [range 10–1,134] days vs. 258 [range 6–1,081] days [nonhip]) (P = nonsignificant). In the refracture group, 76% of patients were already on osteoporosis treatment after their incident fracture. Patients over 65 years of age presenting to FLS who sustain an additional fracture are older; are likely to sustain another hip fracture after an incident hip fracture; often refracture early, particularly when the incident fracture is of the hip; and are often already on antiosteoporosis treatment. Therefore, it is important to identify these high-risk patients and offer a combined approach of prompt drug treatment through a systematic and specialist osteoporosis management team along with reducing any reversible falls risk factors.     

Risk of new clinical fractures within 2 years following a fracture

Introduction:Clinical fractures are associated with an increased relative risk of future fractures, but the absolute risk and timing of new clinical fractures immediately after a clinical fracture have not been reported extensively. The study objective was to determine the absolute risk of subsequent clinical fractures within 2 years after a clinical fracture. Methods:We analyzed clinical fracture data from a university hospital recruiting all fractures in the area between January 1999 and December 2001. Subjects were 2,419 male and female patients aged 50 years and older, with a total of 2,575 fractures. There were 139 patients with more than one simultaneous fracture. Mean age was 66 years for males and 72 for females. Results:The cumulative incidence of patients with new clinical fractures over 2 years was 10.8% (262/2,419). In the 262 patients with subsequent fractures, we observed a higher mean age, more females and more often multiple baseline fractures compared with the 2,157 patients without subsequent fractures. Kaplan-Meier analysis indicated that age, gender and having multiple baseline fractures contributed significantly to cumulative new fracture incidence. Cox regression showed that these variables independently contributed to a higher subsequent fracture incidence. New fracture incidence was higher with increasing age ( p <0.001; hazard ratio [HR] 1.2 per decade; confidence interval [CI] 1.1–1.3). Females had a new fracture incidence of 12.2% compared with 7.4% in males ( p =0.015; HR 1.5; CI 1.1–2.0). Patients with multiple baseline fractures had a new fracture incidence of 17.3% compared with 10.4% for subjects with one baseline fracture ( p =0.006; HR 1.8; CI 1.2–2.7). Of all clinical fractures occurring within 2 years after a clinical fracture, 60% occurred during the first year and 40% during the second year ( p =0.005). The absolute risk to develop an incident clinical fracture within 2 years after any clinical fracture was 10.8%. Increased age, female gender and the presence of multiple simultaneous fractures at baseline each independently increased the risk of incident fracture. Significantly more fractures occurred in the first year following the index fracture than in the second year. Conclusion: Altogether, these data support the need for early prevention of future fracture among individuals with a fracture after age 50, using interventions which have been shown to have a rapid anti-fracture benefit.     

The Injury Mechanisms of Osteoporotic Upper Extremity Fractures Among Older Adults: A Controlled Study of 287 Consecutive Patients and Their 108 Controls

The risk factors for falls in older adults are well known but knowledge on the direct injury mechanisms that result in various osteoporotic fractures has been very sparse. The purpose of this study was therefore to clarify the injury mechanisms of osteoporotic upper extremity fractures of older adults and to compare these mechanisms with those of the control fallers, and in this way to obtain reliable insight into the etiology and pathogenesis of upper extremity fractures and thus to enable fracture prevention. One hundred and twelve patients with a fresh fracture of the proximal humerus, 65 patients with an elbow fracture, 110 patients with a wrist fracture and 108 controls (no fracture, or a fracture other than the case fracture) were interviewed and examined between September 1995 and December 1997. The inclusion criteria of the subjects were that the patient was 50 years of age or older at the time of the accident, and that the fracture/injury had occurred as a result of low-energy trauma (typically a fall from standing height or less) within a week before the interview and examination. In 97% of patients with a proximal humerus or elbow fracture, and in all patients (100%) with a wrist fracture, the fracture was a result of a fall. In the control group this figure was 93%. In a polychotomous logistic regression analysis the intergroup differences in the fall directions (adjusted by gender, age and functional capacity) were statistically highly significant (χ²= 43.6, d.f. = 15, p<0.001). Most of the patients with a proximal humerus fracture or elbow fracture reported that they had fallen “obliquely forward” (43% and 38%) or “to the side” (29% and 26%), whereas in the wrist fracture group the main fall direction was also “obliquely forward” (34%) but the other fall directions (i.e., “forward”, “to the side”, “obliquely backward” and “backward”) were quite equally represented (13–19%). The odds ratio (OR) for an obliquely forward fall resulting in a proximal humerus fracture was 3.5 [95% confidence interval (CI) 1.4–9.2), as compared with the fall directions of the controls and the “obliquely backward” fall direction. In a logistic regression analysis the patients with a wrist fracture managed to break their fall (e.g., with an outstretched arm) more frequently than the patients in the other groups (OR 3.9; 95% CI 2.0–7.3). The patients with a proximal humerus fracture, in turn, managed to break their fall less frequently than the controls (OR 0.33; 95% CI 0.14–0.80). The same was true of the patients with an elbow fracture, although the difference was not significant (OR 0.49%; 95% CI 0.19–1.3). As objective evidence for a direct fall-induced impact on the fracture site, 68% of patients with a proximal humerus fracture revealed a fresh subcutaneous hematoma on the shoulder/upper arm, while such a hematoma was rare in the controls (2%) (p<0.001). Correspondingly, 62% of patients with an elbow fracture showed a similar hematoma on the elbow area, while this was seen in none of the controls (p<0.001). In patients with a wrist fracture a hand/wrist hematoma was seen in 58% of the victims, as compared with 18% of the controls (p<0.001). The study shows that the most typical osteoporotic upper extremity fractures of older adults have their specific injury mechanisms. A great majority of these fractures occur as a result of a fall and a subsequent direct impact of the fractured site. Effective fracture prevention could be achieved by minimizing the obvious risk factors of falling and reducing the fall-induced impact force with injury site protection. Received: 13 January 2000 / Accepted: 11 April 2000     

Calcaneal Ultrasound but Not Bone Turnover Predicts Fractures in Vitamin D Deficient Frail Elderly at High Risk of Falls

Background Biochemical markers of bone turnover have been reported to predict fracture risk independent of bone mass in postmenopausal women. We investigated their use in predicting fractures in the frail elderly. Methods Cases were 151 low trauma fractures. For each case, a control was selected marched for sex, age, institution type and follow-up period. We measured two bone resorption markers (serum ICTP and serum CTX-I) and two bone formation markers (serum PINP and serum BAP). Quantitative Ultrasound (QUS) was measured in the calcaneus. Fractures were ascertained by x-ray reports. Results The mean age of subjects was 86.8 years (± 5.8 SD) and 86% were female. 76% had hypovitaminosis D (a serum 25 hydroxy vitamin D (25OHD) level < 39 nmol/L) and 81% had BUA < 67.4 dB/MHz (corresponding to a BMD T-score < −2.5). No significant differences in bone turnover markers were detected between fracture cases and their matched controls. In contrast, there was a significant difference between cases and controls for both broadband ultrasound attenuation (BUA) and velocity of sound (VOS) (both P < 0.05). These results remained the same after adjusting for weight, lower leg length and walking aids as well as the higher falls incidence in cases than controls (average 2.7 vs 0.9 falls respectively; P < 0.001) during the follow-up period. Conclusion In the frail elderly with vitamin D deficiency and high falls risk, calcaneal ultrasound but not markers of bone turnover were associated with fractures.     

Decreasing incidence and changing pattern of childhood fractures: A population‐based study

Fractures are common in children, and some studies suggest an increasing incidence. Data on population‐based long‐term trends are scarce. In order to establish fracture incidence and epidemiologic patterns, we carried out a population‐based study in Helsinki, Finland. All fractures in children aged 0 to 15 years were recorded from public health care institutions during a 12‐month period in 2005. Details regarding patient demographics, fracture site, and trauma mechanism were collected. All fractures were confirmed from radiographs. Similar data from 1967, 1978, and 1983 were used for comparison. In 2005, altogether 1396 fractures were recorded, 63% in boys. The overall fracture incidence was 163 per 10,000. Causative injuries consisted of mainly falls when running or walking or from heights less than 1.5 m. Fracture incidence peaked at 10 years in girls and 14 years in boys. An increase in fracture incidence was seen from 1967 to 1983 (24%, p < .0001), but a significant decrease (18%, p < .0001) was seen from 1983 to 2005. This reduction was largest in children between the ages of 10 and 13 years. Despite the overall decrease and marked decrease in hand (?39%, p < .0001) and foot (?48%, p < .0001) fractures, the incidence of forearm and upper arm fractures increased significantly by 31% (p < .0001) and 39% (p = .021), respectively. Based on these findings, the overall incidence of childhood fractures has decreased significantly during the last two decades. Concurrently, the incidence of forearm and upper arm fractures has increased by one‐third. The reasons for these epidemiologic changes remain to be elucidated in future studies. © 2010 American Society for Bone and Mineral Research.     

Musculoskeletal rehabilitation in osteoporosis: a review.

Measures of musculoskeletal rehabilitation play an integral part in the management of patients with increased fracture risk because of osteoporosis or extraskeletal risk factors. This article delineates current scientific evidence concerning nonpharmacologic approaches that are used in conjunction with pharmacotherapy for prevention and management of osteoporosis. Fractures caused by osteoporotic fragility may be prevented with multidisciplinary intervention programs, including education, environmental modifications, aids, and implementation of individually tailored exercise programs, which are proved to reduce falls and fall-related injuries. In addition, strengthening of the paraspinal muscles may not only maintain BMD but also reduce the risk of vertebral fractures. Given the strong interaction between osteoporosis and falls, selection of patients for prevention of fracture should be based on bone-related factors and on risk factors for falls. Rehabilitation after vertebral fracture includes proprioceptive dynamic posture training, which decreases kyphotic posturing through recruitment of back extensors and thus reduces pain, improves mobility, and leads to a better quality of life. A newly developed orthosis increases back extensor strength and decreases body sway as a risk factor for falls and fall-related fractures. Hip fractures may be prevented by hip protectors, and exercise programs can improve strength and mobility in patients with hip fracture. So far, there is no conclusive evidence that coordinated multidisciplinary inpatient rehabilitation is more effective than conventional hospital care with no rehabilitation professionals involved for older patients with hip fracture. Further studies are needed to evaluate the effect of combined bone- and fall-directed strategies in patients with osteoporosis and an increased propensity to falls.     

Hip Fracture Epidemiology in Greece During 1977–1992

Hip fracture, the most dramatic complication of osteoporosis, constitutes a serious health problem of the elderly, with great socioeconomic consequences. Hip fracture epidemiology has been studied by many investigators. Until now, reported studies in Greece include either data from only one region, or they do not include all the epidemiological parameters concerning hip fractures. We studied hip fractures that occurred in Greece in 1992 and compared the findings with those of previous years (1977, 1982, 1987), in order to identify age and sex incidence and increase rate during 1977–1992. There has been an average annual increase of 7.6%, thus total hip fractures in Greece increased from 5,100 in 1977 (54.75 fractures/100,000 inhabitants) to 10,953 in 1992 (107.30 fractures/100,000 inhabitants). In 1992, 70% of the patients were women. During the 1977–1992 period, age-adjusted incidence for people aged over 50 increased in both sexes (from 173.54 fractures/100,000 inhabitants in 1977 to 314.07 fractures/100,000 inhabitants in 1992, an increase of age-adjusted incidence of 80.97%). Approximately 50% of the patients in 1992 were aged 80 and over, whereas in 1977 there were only 22.49% patients of the same age. The increase in hip fracture numbers is greater than expected due to population aging, suggesting the existence of other factors influencing this increase. The most affected age group is 80 and over. Received: 3 June 1997 / Accepted: 9 October 1997     

Susceptibility to Osteoporotic Fracture is Determined by Allelic Variation at the Sp1 Site, Rather than Other Polymorphic Sites at the COL1A1 Locus

Previous studies have identified an association between osteoporotic fracture and a polymorphism affecting a Sp1 binding site in the first intron of the collagen type I alpha 1 gene (COL1A1). It is currently unclear, however, whether this association is direct or the result of linkage disequilibrium with other polymorphisms situated nearby. In this study we analyzed the relationship between four well-characterized single-nucleotide polymorphisms at the COL1A1 locus and osteoporotic fracture in 93 patients with vertebral fracture and 88 age-matched controls randomly selected from the community. We studied a Msp I polymorphism 26 kb upstream of the COLIA1 gene, the Sp1 binding site polymorphism in intron 1, a Rsa I polymorphism in intron 5 and a Mnl I polymorphism in exon 52. The Sp1 and Rsa I polymorphisms were in strong linkage disequilibrium (χ²=77.87, p<0.001) and weaker linkage disequilibrium was detected between the Sp1 and Mnl I polymorphisms (χ²=5.54, p<0.025). There was a significant association between COL1A1 haplotypes that included the Sp1 and Rsa I polymorphisms and fracture (p<0.05–0.001), but no association with haplotypes that included only the Msp I and Mnl I polymorphisms. This association with fracture was strongest when haplotypes were grouped by Sp1 alleles (χ²=11.15, d.f. = 1; p= 0.001). Furthermore, logistic regression analysis showed that of all the polymorphisms tested, only the Sp1 binding site polymorphism acted as an independent predictor of fracture: odds ratio [95% CI] = 2.26 [1.09–4.69]. These data suggest that it is the Sp1 polymorphism rather than other polymorphisms at the COL1A1 locus which act as a marker for osteoporotic fractures. Received: 1 July 1999 / Accepted: 28 September 1999     

Utility of fragility fracture prediction tools in a group of postmenopausal women

ObjectivesFractures are a common complication of osteoporosis. The main aim of our study was to assess the relation between fractures identified as low energy fractures (fragility), bone mineral density (BMD), trabecular bone score (TBS), and handgrip in a group of postmenopausal women. An additional aim was to determine the relation between fragility fractures and age, height loss, and falls (reported in the last 12 months and 5 years).Material and methodsThe study was conducted in a group of 120 (mean age 69 years; 59–81, SD 5.3) postmenopausal patients who were referred to the Medical Centre for an osteoporosis screening appointment by their general practitioner. All patients were interviewed (with a questionnaire containing questions on fracture risk factors and highest height), had their anthropometric measures taken (current height and weight) as well as TBS analysis following their DXA (dual-energy X-ray absorptiometry) scan and handgrip measure.ResultsSixty patients from the study group had a history of fractures (with a total of 92 fractures), of whom 39 women (76 fractures) were identified as those with a low-energy fracture. Fragility fractures were more likely to be reported in older patients (Me 71 vs. 68 years, p < 0.05). Differences observed between TBS, handgrip and BMD in reference to fragility fractures were not statistically significant. Analysis showed significant correlations between BMD (neck and L1–L4) and TBS fracture risk categories. Falls reported in the last 5 years and height loss were factors which correlated with fragility fractures (p < 0.05).ConclusionsRisk of fragility fractures increases with age. Bone mineral density is insufficient as a fracture risk assessment tool. Information on falls and height loss may provide additional data on fracture risk assessment.     

Hip fractures in end-stage renal disease patients: incidence, risk factors, and prevention

Hip fractures are an important problem for end-stage renal disease (ESRD) patients treated with dialysis. The incidence of hip fractures in the dialysis population is approximately four times that of the general population. Even more concerning is the associated 1 year mortality, which is twice that of other dialysis patients. Management of this problem is complicated by the heterogeneous nature of renal osteodystrophy and the inadequate methods of diagnosis currently available. Fall prevention has been shown to reduce the incidence of hip fracture and associated decline in functional ability in the general population. Because falls occur frequently in the dialysis population, simple fall prevention may be one important way of protecting dialysis patients from the morbidity and mortality of hip fracture.     

Longitudinal change in hip fracture incidence after starting risedronate or raloxifene: an observational study

This study examined patients’ risk profiles and adherence to treatment in relation to the effect of risedronate and raloxifene on hip fracture incidence. Administrative billing data were used to follow two cohorts of women aged 65 and older after starting therapy with either risedronate (n = 86,735) or raloxifene (n = 37,726). The fracture risk profile was described using a 6-month history period before starting therapy. Effectiveness of each therapy was evaluated by comparing the incidence of hip fractures during the first 3 months with the subsequent 12 months among women adherent (medication possession ratio >80%) compared with those non-adherent to treatment. At the start of therapy, the raloxifene cohort was younger than the risedronate cohort (median age 73 vs. 76 years) and had fewer prior fractures (p < 0.01 for both). In the first 3 months of therapy, hip fracture incidence was lower in the raloxifene group (0.51 per 100 person-years) compared with the risedronate group (0.94 per 100 person-years). In the subsequent 12 months, the incidence of hip fractures decreased among patients adherent to the risedronate regimen [relative risk (RR) 0.70, 95% CI 0.59–0.84, p < 0.01] and did not change significantly among patients adherent to the raloxifene regimen (RR 1.02, 95% CI 0.73–1.44). In poorly adherent patients, neither drug decreased hip fracture risk. Risedronate treatment in adherent patients rapidly decreased the risk of hip fractures, whereas raloxifene treatment did not.