骨质疏松性骨折围手术期的药物治疗

骨质疏松性骨折是一个全球性的骨骼健康问题,患病人群广泛且早期症状隐伏,严重危害老年人群的健康,骨折是其最严重的并发症。骨质疏松性骨折手术治疗难度大,疗效常不令人满意,因此,在积极手术治疗骨折的同时,一定要重视骨质疏松的药物治疗。骨质疏松性骨折围手术期使用抗骨吸收,以及补充活性维生素D3和钙剂,可以为骨质疏松性骨折进行各种手术准备较好的骨质基础,同时促进骨愈合,预防再次骨折的发生。本文针对骨质疏松性骨折围手术期的药物治疗进行讨论。     

骨质疏松与骨折的关系

骨质疏松症主要危险是脊椎压缩性骨折、髋部骨折和桡骨远端骨折。这种骨质疏松性骨折可加重原发性骨质疏松，易发生再骨折。创伤性骨折，治疗过程中多发生局部或全身性骨质疏松。预防和治疗骨质疏松、骨质疏松性骨折、骨折后骨质疏松及再骨折具有重要意义。本文对骨质疏松与骨折相互影响、病理机理、诊断及预防和治疗作一综述。     

住院骨质疏松性骨折患者危险因素与干预措施

目的 探讨住院老年骨质疏松骨折发生的危险因素,为指导骨质疏松性骨折的预防提出干预措施。方法 选择2010年5月～2012年 5 月在我院住院的203例老年骨质疏松症患者为研究对象,根据患者是否出现骨折分为老年骨质疏松性骨折组和老年骨质疏松症无骨折组,采用自编问卷的方法收集符合条件的患者的临床资料。采用多因素 Logistic回归分析骨质疏松性骨折患者的危险因素。结果 骨密度是骨质疏松症并发骨折的保护因素,而年龄、低钙饮食、跌倒、脆性骨折史及骨折家族史是发生老年骨质疏松性骨折的危险因素。结论 老年骨质疏松症并发骨折受多种因素影响,可从饮食、体育锻炼及药物等多方面进行干预。     

骨质疏松性骨折预测方法的研究进展

骨质疏松症的最大危害是骨折的发生。骨质疏松性骨折特别是髋部骨折会导致死亡率、致残率、致畸率和医疗费用的增加。因此进行骨折风险评估、预防骨质疏松性骨折的发生是骨质疏松诊治过程的关键内容。骨质疏松性骨折除了与骨密度的下降有关,还与年龄、体重指数、既往骨折史、父母骨折史、长期应用糖皮质激素、维生素D不足等危险因素相关。跌倒是骨折发生的重要诱因,因此防跌倒是预防骨折的重要内容。骨密度、FRAX巳经被证实可用于预测骨折风险,而QUS、QCT及骨转换生化标志物也可能用于骨折风险预测,但目前尚未得到肯定。本文试从DXA、FRAX、骨转换生化标志物、定量超声、定量CT、跌倒等方面来阐述对骨质疏松性骨折预测的研究进展,其目的是为了早期发现骨折的高危人群,通过相应干预措施降低骨折的发生。     

骨质疏松症营养干预研究进展

随着人口老龄化加剧,骨质疏松症及骨质疏松性骨折的发生率和死亡率明显升高,给家庭和社会带来沉重负担。如何有效干预骨质疏松症的发生,减少骨质疏松症及其并发症带来的不良后果,不仅是有效提高骨质疏松症患者生活质量的关键,还可以减轻家庭和社会的经济负担。目前研究发现,饮食营养及营养素补充与骨质疏松症密切相关,早期营养及营养素补充改变有助于避免骨质疏松症的发生发展。在本文中,我们阐述了蛋白质、钙、维生素D及其他维生素和矿物质等营养素补充在预防骨质疏松症、维持骨骼健康中的作用,重点关注以骨密度或骨折作为结果的营养干预研究,探讨了近期关注的营养干预预防骨质疏松症的可能机制,强调了营养补充对预防骨质疏松和维持骨骼健康的重要性。     

老年性骨质疏松性骨折的发生与预防

骨质疏松性骨折是一项在老年人中极为常见和严重的健康问题。随着人口的老龄化,骨量丢失在变成一个日益严重的临床问题。然而老年人骨量丢失这个情况很少被人们发觉,因而不能得到很好的治疗。除了骨矿物含量密度(骨密度)的下降,导致骨质疏松性骨折的因素常与影响姿势稳定性的神经肌肉失调有关。骨质疏松性骨折的预防围绕充足的矿物营养,包括每日钙和维生素D的供应以及抗骨吸收药物的应用,两者都可以降低骨折发生风险。预防骨折还需要预防跌倒,并减少跌倒产生的冲击力。因此,药物和非药物干预同样重要。本综述也探讨了骨折风险预测工具(FRAX)的使用,它可以通过使用患者的特定数据来预测特定时间内骨折的风险。当前,老年性骨质疏松症仍缺乏诊断和治疗,但年龄并不能成为骨质疏松性骨折干预的障碍。     

重视骨质疏松性骨折后再骨折的防治管理

随着社会老龄化到来, 骨质疏松症发生率越来越高。骨质疏松性骨折与骨质疏松症直接相关, 在骨质疏松症逐渐增加的背景下, 发生骨质疏松性骨折的数量不断增多, 相应地骨折后再骨折发生率也在逐年增加。骨质疏松性骨折后再骨折指初次骨折后, 由于骨骼的密度及质量没有改善, 骨骼受到低能量外力作用再次发生新的骨折。再骨折发生对患者的治疗方案、骨折愈合、康复训练、自理能力、心理预期及依从性等临床指标均有很多危害, 因此骨质疏松性骨折后防治再骨折管理逐渐成为国内国外关注的热点。目前, 在这一防治领域, 临床医生、社区医生都存在认识程度不足、临床管理存在短板的问题, 如再骨折防治管理规范不明确、各级各类医生分工不明确、提高患者依从性措施不明确。对此围绕骨质疏松性骨折、骨折后再骨折、再骨折防治管理等特点, 提出和阐述再骨折防治管理核心要点, 需明确防治管理的相应内容、固定团队、专有数据库或专有台账等, 为进一步完善骨质疏松性骨折后再骨折防治临床管理提供借鉴和参考。     

探讨骨质疏松性骨折的相关影响因素及预防

目的对98例骨质疏松性骨折患者进行相关危险因素分析,旨在早期采取恰当的预防措施防止骨折并发症的发生,进而提高生活质量。方法对我院收治的98例50~89岁老年骨质疏松性骨折患者根据年龄、骨折发生时的状态及相关危险因素进行总结分析。结果股骨颈、椎体、桡骨远端较其他部位容易发生骨质疏松性骨折。女性骨折占63.27%,男性占36.73%,意外跌倒是造成老年人骨质疏松性骨折的主要危险因素。结论骨质疏松患者由于骨骼脆性增加,当受到轻微的外力撞击或震动时,即可发生骨折。因此,针对老年骨质疏松性骨折的危险因素,采取有效的预防措施,以降低骨质疏松性骨折的发生率。     

中国脆性骨折术后规范化抗骨质疏松治疗指南(2021)

骨质疏松症是一种全身性的骨骼系统疾病,其特征是骨量减少和骨组织显微结构退化,导致骨骼脆性增加,骨折风险增高。根据其发病原因可分为原发性骨质疏松和继发性骨质疏松两大类。本指南仅针对原发性骨质疏松症引起的脆性骨折所制定。脆性骨折亦称为骨质疏松性骨折,是骨质疏松症的最严重后果.     

锁定加压钢板治疗骨质疏松性骨折的疗效分析

[目的]探讨应用锁定加压钢板(locking compression plate,LCP)治疗骨质疏松性骨折的临床疗效.[方法]2007年6月～2009年12月应用锁定加压钢板(LCP)治疗老年骨质疏松性骨折58例,有效随访53例;男15例,女38例,年龄64～86岁,平均72.1岁;骨折均为不慎滑倒低能量微创伤所致,符合骨质疏松性骨折的诊断.骨折采用闭合或切开的方式复位,使用锁定加压钢板(LCP)进行内固定手术治疗.[结果]本组53例获得随防,随访时间12～18个月,平均14.6个月.骨折愈合时间3～5个月,平均3.6个月;髋、肩和腕关节功能的优良率分别为84.6％,81.3％和81.8％;无骨折不愈合,无钢板螺钉断裂等并发症;随访中出现3例再发骨折病例.[结论]锁定接骨板通过角稳定作用对骨折端进行稳定,在骨质疏松性骨折的内固定治疗中具有优势,可以提高治疗骨质疏松性骨折疗效;评估骨质疏松性骨折后再骨折的风险,积极药物干预对预防再骨折的发生具有积极意义.     

The cost-effectiveness of alendronate in the management of osteoporosis

The National Institute for Health and Clinical Excellence (NICE) in the UK has recently issued health economic appraisals for the primary and secondary prevention of osteoporotic fracture that are more restrictive than previous guidelines for the management of osteoporosis despite a marked reduction of the cost of intervention. The aim of the present study was to examine the cost-effectiveness of the bisphosphonate, alendronate for the prevention and treatment of fractures associated with osteoporosis. A second aim was to investigate reasons for any disparities in cost-effectiveness between our findings and the NICE appraisals. We compared the effects of alendronate 70 mg weekly by mouth for 5 years with no treatment in postmenopausal women with clinical risk factors for fracture and computed the incremental cost-effectiveness ratio (ICER) using a lifetime simulation model based on Markov cohort methodology. A sensitivity analysis examined other common interventions. Using a threshold of pound sterling 30,000 and pound sterling 20,000 per quality of life-year (QALY) gained to determine cost-effectiveness, alendronate was cost-effective for the primary prevention of fracture in women with osteoporosis irrespective of age as was treatment of women with a prior fragility fracture irrespective of BMD. Cost-effective scenarios were also found in women with strong risk factors for fracture with a bone mineral density value above the threshold for osteoporosis. The results were robust over reasonable assumptions in sensitivity analysis. We conclude that alendronate is a cost-effective agent for the prevention and treatment of fractures associated with osteoporosis. These findings, suitable for informing practice guidance, contrast with recent appraisals from NICE.     

The Challenges of Peripheral Bone Density Testing: Which Patients Need Additional Central Density Skeletal Measurements?

Lower cost, portable, peripheral bone mass measurement devices are being increasingly utilized for widespread bone mass testing. These devices are being placed in traditional medical settings as well as nontraditional settings, such as pharmacies and grocery stores. Increased bone mass testing is appropriate at menopause in women who are undecided whether to begin systemic estrogen replacement. Women may decide to begin estrogen replacement if they are aware they have low bone mass and understand that bone mass will predictably decline after the menopause (1). With the approval of alendronate and raloxifene for the prevention of osteoporosis, even women who cannot or will not utilize estrogen replacement may be offered preventive interventions if they are identified as having low bone mass. More accessible bone mass measurements and more approved pharmacologic interventions will shift the focus of osteoporosis management to strategies that emphasize the reduction of lifetime fracture risk as well as current fracture risk. It will also be an impetus to focus on earlier identification and intervention (2-4).     

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial

Summary

We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management.

Introduction

To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control).

Methods

A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40?years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was ??appropriate?? management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications.

Results

Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65?±?12?years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6?months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3?C4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0?C7.0).

Conclusions

A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.     

Chronic kidney disease and fragility fracture

Osteoporosis is defined simply as “a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Thus, any bone lesion that causes fragility fracture is osteoporosis, which has quite heterogeneous backgrounds. Chronic kidney disease-related bone and mineral disease (CKD-MBD) is defined as “a systemic disorder of mineral and bone metabolism due to CKD, which is manifested by abnormalities in bone and mineral metabolism and/or extra-skeletal calcification”. Although CKD-MBD is one of the possible causes of osteoporosis, we do not have evidences that CKD-MBD is the only or crucial determinant of bone mechanical strength in CKD patients. The risk of hip fracture is considerably high in CKD patients. Drugs that intervene in systemic mineral metabolism, indeed, lead to the improvement on bone histology in CKD patients. However, it remains unclear whether the intervention in systemic mineral metabolism also improves bone strength, today. Thus, the use of drugs that directly act on bone and the introduction of fracture liaison concept are promising strategies for fragility fracture prevention among CKD patients, as well as treatment for CKD-MBD.     

FRAX评分在中老年人骨质疏松性骨折风险评估中的研究进展

骨质疏松症(osteoporosis)是一种以骨密度降低、骨小梁及其他组织结构损坏,造成骨脆性以及骨折风险增加为特征的全身性骨病。FRAX评分是2008年世界卫生组织推荐的骨折风险预测简易诊断工具,可用于计算10年发生髋部骨折及任何重要的骨质疏松性骨折的发生概率。目前FRAX评分的应用才刚刚起步,评价标准还不完善,使用过程存在一定的局限性。但是长远来看,FRAX评分在骨质疏松性骨折预测方面应用前景广阔,将会成为预防骨质疏松性骨折的有力工具。本文将近年来FRAX评分的应用以及研究进展进行综述。以期在骨质疏松性骨折预防、管理、诊断和治疗方面提供新思路、新视角。     

Assessment of Fracture Risk

Osteoporosis-related fractures (low-trauma, fragility fractures) are associated with significant morbidity, mortality, and health care expenditure worldwide. In the absence of a defining fracture, the diagnosis of osteoporosis is based on the World Health Organization’s T-score criteria using central dual-energy x-ray absorptiometry (DXA). Paradoxically, the majority of those patients who will sustain a low-trauma fracture do not meet the T-score definition of osteoporosis. Conversely, younger individuals with bone density in the osteoporotic range but no other risk factors have relatively low fracture rates and yet are frequently considered candidates for osteoporosis therapies. The limited accuracy of bone density testing alone to predict fractures has led to the development of a variety of fracture assessment tools that utilize the combination of bone density and clinical risk factors to improve the prediction of low-trauma fractures. These fracture assessment tools quantitatively predict the 10-year fracture probability of hip and major osteoporosis-related fractures, and can be used to define cost-effective intervention strategies for primary and secondary fracture prevention.     

Hip fracture prevention with a multifactorial educational program in elderly community-dwelling Finnish women

Summary

Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy. However, most women who sustain a hip fracture do not have osteoporosis in terms of bone density. The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention.

Introduction

Hip fractures are expensive for society and cause disability for those who sustain them. We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women.

Methods

A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken. A random sample was drawn from the Population Information System and assigned into the intervention group (IG) and control group (CG). Of the 2,547 women who were invited to the IG, 1,004 (39 %) and of the 2,120 invited to the CG, 1,174 (55 %) participated. The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice. The CG received no intervention. During the 10-year follow-up, both groups participated in survey questionnaire by mail. Outcome of interest was occurrence of hip fractures and changes in bone–health-related lifestyle.

Results

During the follow-up, 12 (1.2 %) women in the IG and 29 (2.5 %) in the CG sustained a hip fracture (P?=?0.039). The determinants of hip fractures by stepwise logistic regression were baseline smoking (odds ratio (OR) 4.32 (95 % confidence interval [CI] 2.14–8.71), age OR 1.15/year (95 % CI 1.03–1.28), fall history OR 2.7 (95 % CI 1.24–5.9), stroke history OR 2.99 (95 % CI 1.19–7.54) and participating in this program OR 0.45 (95 % CI 0.22–0.93). Starting vitamin D and calcium supplement use was more common in the IG compared with the CG.

Conclusions

The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women.     

Age-associated endocrine deficiencies as potential determinants of femoral neck (type II) osteoporotic fracture occurrence in elderly men

Osteoporotic fractures, and especially hip fractures, are a leading cause of morbidity and mortality among elderly men. Among other factors, a decline in bone mass has been identified as the major determinant of the age-related reduction in bone strength and therefore of osteoporotic fracture risk. Recent evidence suggests that age-associated endocrine deficiencies may contribute to femoral bone loss and hip fracture occurrence in elderly men. The decline in circulating androgen levels and the decreased activity of the growth hormone–insulin-like growth factor-I axis may result in a reduction in bone formation that contributes to the age-related increase in bone fragility in men. Vitamin D deficiency-induced secondary hyperparathyroidism, on the other hand, may further enhance bone loss by activating bone turnover and so increasing the number of bone remodelling units with impaired bone formation. On the basis of these pathophysiological models, guidelines can be developed for the prevention of age-related bone loss in men, but these approaches lack validation. The results of controlled intervention trials will have to be awaited to answer the question of whether hormone replacement therapy attenuates bone loss and reduces fracture incidence in elderly men.     

Proceedings of the Eighth Annual Santa Fe Bone Symposium, August 3–4, 2007

The Eighth Annual Santa Fe Bone Symposium convened August 3–4, 2007, in Santa Fe, New Mexico, USA, immediately preceded by the Research Symposium in Metabolic Bone Disease and Osteoporosis Update for Endocrine Fellows, and followed by the International Society for Clinical Densitometry (ISCD) Bone Densitometry Course. The symposium faculty consists of internationally recognized experts in osteoporosis and metabolic bone disease who presented state-of-the-art research data and late-breaking developments in the fields of osteoporosis, metabolic bone disease, and assessment of skeletal health. The presentations and numerous interactive discussions that followed focused on applying what is known from clinical trials, knowledge of bone pathophysiology, and the mechanisms of action of therapeutic interventions, to making real-world patient management decisions. Topics included an update on reimbursement issues for bone density testing in the United States, a report on the 2007 ISCD Pediatric and Adult Position Development Conferences, present and future therapeutic concepts, new paradigms for fracture risk assessment and intervention thresholds, evaluation for secondary causes of osteoporosis, nonvertebral fracture risk reduction-medical evidence and clinical practice, epidemiological insights into the prevention of osteoporotic fractures, osteonecrosis of the jaw facts and fictions, and osteomalacia. Presented here are short essays based on the key clinical presentations of the 2007 Santa Fe Bone Symposium.