Prevalence and risk factors of radiographic vertebral fracture in Brazilian community-dwelling elderly

Summary

The prevalence and risk factors of radiographic vertebral fracture were determined among Brazilian community-dwelling elderly. Vertebral fractures were a common condition in this elderly population, and lower hip bone mineral density was a significant risk factor for vertebral fractures in both genders.

Introduction

The aim of the study was to estimate the prevalence of radiographic vertebral fracture and investigate factors associated with this condition in Brazilian community-dwelling elderly.

Methods

This cross-sectional study included 943 elderly subjects (561 women and 382 men) living in São Paulo, Brazil. Thoracic and lumbar spine radiographs were obtained, and vertebral fractures were evaluated using Genant's semiquantitative method. Bone mineral density (BMD) was measured by dual X-ray absorptiometry, and bone biochemical markers were also evaluated. Female and male subjects were analyzed independently, and each gender was divided into two groups based on whether vertebral fractures were present.

Results

The prevalence of vertebral fracture was 27.5% (95% CI 23.8–31.1) in women and 31.8% in men (95% CI 27.1–36.5) (P?=?0.116). Cox regression analyses using variables that were significant in the univariate analysis showed that age (prevalence ratio?=?1.03, 95% CI 1.01–1.06; p?=?0.019) and total femur BMD (PR?=?0.27, 95% CI 0.08–0.98; p?=?0.048) were independent factors in predicting vertebral fracture for the female group. In the male group, Cox regression analyses demonstrated that femoral neck BMD (PR?=?0.26, 95% CI 0.07–0.98; p?=?0.046) was an independent parameter in predicting vertebral fractures.

Conclusions

Our results suggest that radiographic vertebral fractures are common in Brazilian community-dwelling elderly and that a low hip BMD was an important risk factor for this condition in both genders. Age was also significantly correlated with the presence of vertebral fractures in women.     

The assessment of vertebral fractures in elderly women with recent hip fractures: the BREAK Study

Summary

This study aimed to evaluate the prevalence of vertebral fractures in elderly women with a recent hip fracture. The burden of vertebral fractures expressed by the Spinal Deformity Index (SDI) is more strictly associated with the trochanteric than the cervical localization of hip fracture and may influence short-term functional outcomes.

Introduction

This study aimed to determine the prevalence and severity of vertebral fractures in elderly women with recent hip fracture and to assess whether the burden of vertebral fractures may be differently associated with trochanteric hip fractures with respect to cervical hip fractures.

Methods

We studied 689 Italian women aged 60 years or over with a recent low trauma hip fracture and for whom an adequate X-ray evaluation of spine was available. All radiographs were examined centrally for the presence of any vertebral deformities and radiological morphometry was performed. The SDI, which integrates both the number and the severity of fractures, was also calculated.

Results

Prevalent vertebral fractures were present in 55.7 % of subjects and 95 women (13.7 %) had at least one severe fracture. The women with trochanteric hip fracture showed higher SDI and higher prevalence of diabetes with respect to those with cervical hip fracture, p?=?0.017 and p?=?0.001, respectively. SDI, surgical menopause, family history of fragility fracture, and type2 diabetes mellitus were independently associated with the risk of trochanteric hip fracture. Moreover, a higher SDI was associated with a higher percentage of post-surgery complications (p?=?0.05) and slower recovery (p?<?0.05).

Conclusions

Our study suggests that the burden of prevalent vertebral fractures is more strictly associated with the trochanteric than the cervical localisation of hip fracture and that elevated values of SDI negatively influence short term functional outcomes in women with hip fracture.     

Long-term fracture rates seen with continued ibandronate treatment: pooled analysis of DIVA and MOBILE long-term extension studies

Summary

Ibandronate reduces the risk of vertebral and non-vertebral fractures versus placebo in postmenopausal women with osteoporosis. This analysis, in which fractures were reported as safety events, showed that long-term use of ibandronate was associated with low fracture rates over 5 years of treatment.

Introduction

A previous post-hoc meta-analysis of 2–3 year studies found that ibandronate regimens with annual cumulative exposure (ACE) of ≥10.8 mg reduced the risk of vertebral and nonvertebral fractures (NVFs) versus placebo in postmenopausal women. This post-hoc analysis used individual patient data from the 2-year monthly oral ibandronate in ladies (MOBILE) and dosing intravenous administration (DIVA) studies, including the 3-year long-term extensions (LTEs), to assess fracture risk in patients treated with ibandronate for 5 years.

Methods

Patients treated for 2 years in MOBILE with monthly oral ibandronate 150 mg (n?=?176) and in DIVA with IV ibandronate every 2 months 2 mg (n?=?253) or quarterly 3 mg (n?=?263) who continued on the same regimens for 3 additional years in the LTEs were included. Three-year placebo data (n?=?1,924) were obtained from the ibandronate osteoporosis vertebral fracture trial in North America and Europe (BONE) and IV Fracture Prevention trials. The primary endpoint was clinical fracture rate; clinical fracture data were collected as adverse events. Time to fracture was analyzed using Kaplan–Meier and statistical analysis was conducted using the log-rank test. All clinical fractures included all NVFs and symptomatic vertebral fractures.

Results

For ibandronate regimens with ACE ≥10.8 mg, time to fracture was significantly longer for all clinical fractures, NVFs, and clinical vertebral fractures versus placebo (P?=?0.005). For all fracture types, the rate of fracture appeared stable during the 5-year treatment period.

Conclusion

In women with postmenopausal osteoporosis, continuous treatment with ibandronate over 5 years results in low sustained clinical fracture rate.     

Severity of aortic calcification is positively associated with vertebral fracture in older men—a densitometry study in the STRAMBO cohort

Summary

In older men, severe abdominal aortic calcification and vertebral fracture (both assessed using dual-energy X-ray absorptiometry) were positively associated after adjustment for confounders including bone mineral density.

Introduction

Abdominal aortic calcification (AAC) is associated with higher fracture risk, independently of low bone mineral density (BMD). Dual-energy X-ray absorptiometry (DXA) can be used to assess both vertebral fracture and AAC and requires less time, cost, and radiation exposure.

Methods

We conducted a cross-sectional study of the association between AAC and prevalent vertebral fractures in 901 men ≥50 years old. We used DXA (vertebral fracture assessment) to evaluate BMD, vertebral fracture, and AAC.

Results

Prevalence of vertebral fracture was 11 %. Median AAC score was 1 and 12 % of men had AAC score >6. After adjustment for age, weight, femoral neck BMD, smoking, ischemic heart disease, diabetes, and hypertension, AAC score >6 (vs ≤6) was associated with 2.5 (95 % CI, 1.4–4.5) higher odds of vertebral fracture. Odds of vertebral fracture for AAC score >6 increased with vertebral fracture severity (grade 1, OR?=?1.8; grade 2, OR?=?2.4; grade 3, OR?=?4.4; trend p?<?0.01) and with the number of vertebral fractures (1 fracture, OR?=?2.0, >1 fracture, OR?=?3.5). Prevalence of vertebral fracture was twice as high in men having both a T-score?<??2.0 and an AAC score?>?6 compared with men having only one of these characteristics.

Conclusions

Men with greater severity AAC had greater severity and greater number of vertebral fractures, independently of BMD and co-morbidities. DXA can be used to assess vertebral fracture and AAC. It can provide a rapid, safe, and less expensive alternative to radiography. DXA may be an important clinical tool to identify men at high risk of adverse outcomes from osteoporosis and cardiovascular disease.     

Effects of long-term strontium ranelate treatment on vertebral fracture risk in postmenopausal women with osteoporosis

Summary

Vertebral fractures are a major adverse consequence of osteoporosis. In a large placebo-controlled trial in postmenopausal women with osteoporosis, strontium ranelate reduced vertebral fracture risk by 33% over 4 years, confirming the role of strontium ranelate as an effective long-term treatment in osteoporosis.

Introduction

Osteoporotic vertebral fractures are associated with increased mortality, morbidity, and loss of quality-of-life (QoL). Strontium ranelate (2 g/day) was shown to prevent bone loss, increase bone strength, and reduce vertebral and peripheral fractures. The preplanned aim of this study was to evaluate long-term efficacy and safety of strontium ranelate.

Methods

A total of 1,649 postmenopausal osteoporotic women were randomized to strontium ranelate or placebo for 4 years, followed by a 1-year treatment-switch period for half of the patients. Primary efficacy criterion was incidence of patients with new vertebral fractures over 4 years. Lumbar bone mineral density (BMD) and QoL were also evaluated.

Results

Over 4 years, risk of vertebral fracture was reduced by 33% with strontium ranelate (risk reduction?=?0.67, p?<?0.001). Among patients with two or more prevalent vertebral fractures, risk reduction was 36% (p?<?0.001). QoL, assessed by the QUALIOST®, was significantly better (p?=?0.025), and patients without back pain were greater (p?=?0.005) with strontium ranelate than placebo over 4 years. Lumbar BMD increased over 5 years in patients who continued with strontium ranelate, while it decreased in patients who switched to placebo. Emergent adverse events were similar between groups.

Conclusion

In this 4- and 5-year study, strontium ranelate is an effective and safe treatment for long-term treatment of osteoporosis in postmenopausal women.     

Reliability of vertebral fracture assessment using multidetector CT lateral scout views: the Framingham Osteoporosis Study

Summary

Two radiologists evaluated images of the spine from computed tomography (CT) scans on two occasions to diagnose vertebral fracture in 100 individuals. Agreement was fair to good for mild fractures, and agreement was good to excellent for more severe fractures. CT scout views are useful to assess vertebral fracture.

Introduction

We investigated inter-reader agreement between two radiologists and intra-reader agreement between duplicate readings for each radiologist, in assessment of vertebral fracture using a semi-quantitative method from lateral scout views obtained by CT.

Methods

Participants included 50 women and 50 men (age 50-87?years, mean 70?years) in the Framingham Study. T4-L4 vertebrae were assessed independently by two radiologists on two occasions using a semi-quantitative scale as normal, mild, moderate, or severe fracture.

Results

Vertebra-specific prevalence of grade ??1 (mild) fracture ranged from 3% to 5%. We found fair (???=?56-59%) inter-reader agreement for grade ??1 vertebral fractures and good (???=?68-72%) inter-reader agreement for grade ??2 fractures. Intra-reader agreement for grade ??1 vertebral fracture was fair (???=?55%) for one reader and excellent for another reader (???=?77%), whereas intra-reader agreement for grade ??2 vertebral fracture was excellent for both readers (???=?76% and 98%). Thoracic vertebrae were more difficult to evaluate than the lumbar region, and agreement was lowest (inter-reader ???=?43%) for fracture at the upper (T4-T9) thoracic levels and highest (inter-reader ???=?76-78%) for the lumbar spine (L1-L4).

Conclusions

Based on a semi-quantitative method to classify vertebral fractures using CT scout views, agreement within and between readers was fair to good, with the greatest source of variation occurring for fractures of mild severity and for the upper thoracic region. Agreement was good to excellent for fractures of at least moderate severity. Lateral CT scout views can be useful in clinical research settings to assess vertebral fracture.     

Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening

Summary

We identified that use of VFA may be cost-effective in either selected women from primary care or women attending after a low trauma fracture.

Introduction

Lateral DXA scanning of the spine for vertebral fracture assessment (VFA) is used for research, but its wider role is unclear. We aimed to establish whether VFA is cost-effective in women based on two different scenarios: following a low-trauma fracture, and after screening of high-risk women identified in primary care.

Methods

The fracture cohort (FC) consisted of 377 women and the primary care cohort (PCC) of 251. Vertebral fractures were identified on VFA images by quantitative morphometry (QM). Outcome was cost-effectiveness of VFA, based on predicted change in clinical management defined as the identification of a vertebral fracture in a patient who otherwise falls below the threshold for treatment. FRAX treatment thresholds assessed were (1) 20/3 % thresholds and (2) National Osteoporosis Guidelines Group (NOGG) thresholds.

Results

As a result, 9.8 % from FC and 13.9 % from PCC were identified with vertebral fractures. Management was changed in 21 to 22/377 (5.6–5.8 %) in FC and 12 to 26/251 (4.8–10.4 %) from PCC depending on which thresholds were used. Sensitivity analyses identified medication adherence as the assumption which most influenced the model. The best-estimate cost-per-QALY for use of VFA in FC was £3,243 for 20/3 threshold and £2,130 for NOGG; for PCC, this was £7,831 for 20/3 and was cost-saving for NOGG. Further analyses to adjust for potential false-positive vertebral fracture identification with QM showed VFA was no longer cost-effective.

Conclusion

VFA appears to be cost-effective in routine clinical practise, particularly when relatively inaccurate methods of identification of vertebral fractures are used such as QM.     

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

Summary

Osteoporotic fracture risk depends on bone mineral density (BMD) and clinical risk factors (CRF). Five hundred and eighty-eight untreated female and male outpatient subjects were evaluated, 160 with vertebral fractures. BMD was measured both by using calcaneal dual X-ray and laser (DXL) and dual-energy X-ray absorptiometry (DXA), and CRF were evaluated. Detection frequencies for different BMD methods with or without CRF are presented.

Introduction

Osteoporotic fracture risk depends on bone mineral density and clinical risk factors. DXA of the spine/hip is considered a gold standard for BMD assessment, but due to degenerative conditions, particularly among the older population, assessment of BMD at the lumbar spine has been shown to be of limited significance. Portable calcaneal dual X-ray technology and laser can be an easily obtainable alternative.

Methods

Vertebral fractures were evaluated in a baseline analysis of 588 females and males (median age 64.4, range 17.6–93.1 years), comparing BMD measurements by using DXL and DXA and CRF with/without BMD. One hundred and sixty subjects had radiological verified vertebral fractures. Area under receiver-operating characteristic curves (AUROCC) and univariate and multiple logistic regressions were calculated.

Results

AUROCC for detection of vertebral fractures was comparable for DXL at calcaneus and DXA at femoral neck (DXL 0.665 and DXA 0.670). Odds ratio for prevalent vertebral fracture was generally weak for DXA femoral neck (0.613) and DXL (0.521). Univariate logistic regression among CRF without BMD revealed age, prevalent fragility fracture, and body mass index significantly associated with prevalent vertebral fracture (AUROCC?=?0.805). Combining BMD and CRF, a prognostic improvement in case of DXA at femoral neck (AUROCC 0.869, p?=?0.02), DXL at calcaneus (AUROCC 0.869, p?=?0.059), and DXA at total hip (AUROCC 0.861, p?=?0.06) was observed.

Conclusions

DXL was similarly sensitive compared with DXA for identification of subjects with vertebral fragility fractures, and combination of CRF with BMD by DXL or DXA further increased the discriminatory capacity for detection of patients susceptible to vertebral fracture.     

The prevalence of and risk factors for radiographic vertebral fractures in older Indian women and men: Delhi Vertebral Osteoporosis Study (DeVOS)

Summary

High prevalence of vertebral fractures (17.9?% over all; 18.8?% male and 17.1?% female) was observed in 808 free-living residents of Delhi, India, aged more than 50?years. The prevalence rates were comparable to that reported in Caucasian populations. While there was an increase in fracture prevalence with age in females, the same was not observed in males.

Introduction

The aim of this paper is to study the prevalence of and risk factors for morphometric vertebral fractures in elderly Indian men and women over 50?years of age.

Methods

We recruited 808 healthy subjects aged 50?years or more, residing in three residential colonies in Delhi, India who voluntarily agreed to participate in this study. All subjects underwent lateral X-rays of the lumbar and thoracic spine according to a standardized protocol. All X-rays were blindly evaluated by a single trained person using an advanced semi-automated software (Optasia Medical) based on Genant??s semiquantitative method. Recruited subjects underwent anthropometric, biochemical, and hormonal evaluation.

Results

With a mean age of 64.9 (±6.7) years, 345 males and 415 females were evaluated. Vertebral fractures were present in 17.9?% (95?% CI 15.2, 20.6) subjects [males, 18.8?% (95?% CI 14.6, 23), females 17.1?% (95?% CI 13.5, 20.8)]. Prevalence of vertebral fractures increased with age in females from 14.7?% in 50?C59?years age group to 22.4?% in those ??70?years, but not in men. Overweight subjects had significantly lower risk [OR, 0.63 (95?% CI 0.41, 0.97), p?=?0.035] of vertebral fractures. Serum 25 hydroxyvitamin D levels, intake of calcium and vitamin D, or history of previous fractures were not statistically different between patients with or without prevalent vertebral fractures.

Conclusions

The prevalence of vertebral fractures among older Indians was comparable to that reported in Caucasian populations. Prevalence of vertebral fractures increased with age in females, but not in males. Overweight individuals were protected against vertebral fractures.     

Reconsideration of the relevance of mild wedge or short vertebral height deformities across a broad age distribution

Summary

Based on an evaluation of vertebral fracture prevalence on lateral radiographs across all age groups in a large cohort, mild or wedge-shaped vertebral body changes identified among adults should be managed as osteoporosis or at least considered as a risk factor for osteoporotic fracture, since they are rare among young subjects.

Introduction

Radiographic assessment of vertebral fractures is limited by the inability to distinguish mild fractures from congenital mild wedge deformities or vertebrae of short vertebral height. We attempted to quantify the expected background prevalence of these deformities by measuring vertebral fracture prevalence across all age groups in a large hospital-based retrospective Chinese cohort.

Methods

We reviewed eligible lateral chest radiographs from patients admitted to Peking Union Medical College Hospital during 2011 using the Genant semiquantitative method for vertebral fracture assessment (T4–L2). We evaluated fracture prevalence among subjects by sex, 10-year age group, and fracture severity grades subjectively. We further analyzed characteristics of subjects with mild (grade I) fractures to estimate the relative contribution of congenital mild wedge deformities.

Results

A total of 10,720 subjects (5,396 men and 5,324 women) with lateral chest radiographs were evaluated. Subjects ranged in age from 0.5 to 97 years with a mean of 51.8?±?17.4 years (men 52.8?±?17.6 years; women 50.8?±?17.2 years). When stratified by 10-year age groups, the prevalence of vertebral fractures was relatively low until about 40 years of age, after which prevalence increased for both genders. Fractures (13 fractures for 9 males and 6 fractures for 5 females) seen in subjects younger than 40 years of age were almost exclusively mild grade fractures. No fractures were identified in subjects younger than 20 years of age.

Conclusions

Mild or wedge-shaped vertebral body changes on lateral radiographs are rare among young subjects, indicating that when mild vertebral deformities are found among adults, they are likely to be the product of aging and not congenital variation. Clinically, therefore, mild vertebral body changes should be managed as osteoporosis or at least considered as a risk factor for osteoporotic fracture.     

Prevalence of vertebral fractures and minor vertebral deformities evaluated by DXA-assisted vertebral fracture assessment (VFA) in a population-based study of postmenopausal women: the FRODOS study

Summary

Population-based studies performed with vertebral fracture assessment (VFA) morphometric technology are lacking in postmenopausal osteoporosis. In this study, we show a lower than expected prevalence of vertebral fractures, a high prevalence of minor vertebral deformities, and a clear association with clinical and densitometric parameters indicating the usefulness of this approach.

Introduction

Adequate epidemiological data on the prevalence of vertebral fractures (VF) is essential in studies of postmenopausal osteoporosis. Routine DXA-assisted VFA may be useful to determine the presence of VF. However, population-based studies performed with this technology are lacking. We aimed to assess the prevalence of VF and minor deformities in 2,968 postmenopausal women aged 59–70 years from a population-based cohort.

Methods

VFA and bone mineral density (BMD) measurements were conducted, and McCloskey criteria (vertebral heights under 3 SD from reference values) confirmed with the Genant method were used to define VF. Additionally, minor vertebral deformities (vertebral heights between ?2 and ?2.99 SD) were evaluated.

Results

The prevalence of VF was 4.3 %, and 17 % of the participants had minor vertebral deformities. Low BMD was frequently observed in women with VF, with 48 %, and 42 % of participants showing osteoporosis and osteopenia. Minor vertebral deformities were observed in nearly 40 % of women with VF. Multivariate logistic regression analysis showed that age, history of previous fracture, osteoporotic BMD, receiving anti-osteoporotic treatment, and current use of glucocorticoids were significantly associated with VF.

Conclusions

Although the VFA approach showed a lower than expected prevalence of VF in our cohort, its association with clinical and densitometric parameters may be useful to identify women at risk for developing fragility fractures and may therefore justify its use in longitudinal studies. The high prevalence of minor vertebral deformities detected in patients with VF indicates the need to evaluate this type of deformity as a risk factor for further skeletal fractures.     

Diffuse idiopathic skeletal hyperostosis (DISH): relation to vertebral fractures and bone density

Summary

Radiographs and spinal bone mineral density (BMD) were evaluated from 342 elderly men regarding possible effects of diffuse idiopathic skeletal hyperostosis (DISH) on vertebral fractures and densitometry measurements. Prevalent vertebral fractures were more frequent among men with DISH compared to men with no DISH even after fracture prevalence was adjusted for BMD. Paravertebral calcifications should be considered in patients with DISH when interpreting BMD measurements because both dual X-ray absorptiometry (DXA) and quantitative CT (QCT) densitometry may not be reliable.

Introduction

The purpose of this study is to evaluate the prevalence of DISH in older men and its association with vertebral fractures and with BMD determined by DXA and QCT.

Methods

Lateral radiographs of the spine were analyzed in a sample of 342 men aged ??65?years participating in the MrOS Study concerning the presence and grade of DISH and vertebral fractures. Lumbar BMD was measured by both DXA (areal, grams per square centimeter) and QCT (volumetric, grams per cubic centimeter). The association between DISH, BMD, and presence of fractures was studied using ?? ² and t tests.

Results

DISH was present in 52% (178/342) of the men. Men with DISH were older (mean, 75.1 vs 73.3, p?<?0.05) and more likely to have prevalent fractures (28% vs 20%, p?<?p?=?0.09). BMD assessed with DXA (1.08 vs 1.00?g/cm², p????0.0001), but not with QCT (0.11 vs 0.11?g/cm3, p?=?0.65), was significantly higher in men with DISH compared to men without DISH. Significantly lower BMD of men with both DISH and fractures compared to men with DISH but without fractures was only detected by QCT (?25%, 0.09 vs 0.12, p?<?0.05). Both DXA BMD and QCT BMD were significantly higher in severe lumbar DISH (+22% and +31%, p?<?0.0001), respectively.

Conclusion

DISH was associated with a higher prevalence of vertebral fractures in elderly men. Lumbar ossifications related to DISH should be considered when interpreting BMD measurements to predict their fracture risk.     

Quantitative ultrasound and fracture risk prediction in non-osteoporotic men and women as defined by WHO criteria

Summary

This study sought to determine the association between calcaneal quantitative ultrasound (QUS) and fracture risk in individuals without osteoporosis according to the World Health Organization criteria (i.e., BMD T-score?>??2.5). We found that calcaneal QUS is an independent predictor of fracture risk in women with non-osteoporotic bone mineral density (BMD).

Introduction

More than 50 % of women and 70 % of men who sustain a fragility fracture have BMD above the osteoporotic threshold (T-score?>??2.5). Calcaneal QUS is associated with fracture risk. This study aimed to test the hypothesis that low calcaneal QUS is associated with increased fracture risk in individuals with non-osteoporotic BMD.

Methods

We included 312 women and 390 men aged 62–90 years with BMD T-score?>??2.5 at femoral neck. QUS was measured in broadband ultrasound attenuation (BUA) at the calcaneus using a CUBA sonometer. BMD was measured at the femoral neck (FNBMD) by dual energy X-ray absorptiometry using GE Lunar DPX-L densitometer. The incidences of any fragility fracture were ascertained by X-ray reports during the follow-up period from 1994 to 2011.

Results

Of the 702 participants, 26 % of women (n?=?80/312) and 14 % of men (n?=?53/390) experienced at least one fragility fracture during the follow-up period. In women, after adjusting for covariates, increased risk of any fracture was significantly associated with decreased BUA (HR?=?1.50; 95 % CI, 1.13–1.99). Compared with that of FNBMD, the models with BUA, in women, had greater AUC (0.71, 0.85, 0.71 for any, hip and vertebral fracture, respectively), and yielded a net reclassification improvement of 16.4 % (P?=?0.009) when combined with FNBMD. In men, BUA was not significantly associated with fracture risk before and after adjustment.

Conclusion

These results suggest that calcaneal BUA is an independent predictor of fracture risk in women with non-osteoporotic BMD.     

Ethnic difference of clinical vertebral fracture risk

Summary

Vertebral fractures are the most common osteoporotic fractures. Data on the vertebral fracture risk in Asia remain sparse. This study observed that Hong Kong Chinese and Japanese populations have a less dramatic increase in hip fracture rates associated with age than Caucasians, but the vertebral fracture rates were higher, resulting in a high vertebral-to-hip fracture ratio. As a result, estimation of the absolute fracture risk for Asians may need to be readjusted for the higher clinical vertebral fracture rate.

Introduction

Vertebral fractures are the most common osteoporotic fractures. Data on the vertebral fracture risk in Asia remain sparse. The aim of this study was to report the incidence of clinical vertebral fractures among the Chinese and to compare the vertebral-to-hip fracture risk to other ethnic groups.

Methods

Four thousand, three hundred eighty-six community-dwelling Southern Chinese subjects (2,302 women and 1,810 men) aged 50 or above were recruited in the Hong Kong Osteoporosis Study since 1995. Baseline demographic characteristics and medical history were obtained. Subjects were followed annually for fracture outcomes with a structured questionnaire and verified by the computerized patient information system of the Hospital Authority of the Hong Kong Government. Only non-traumatic incident hip fractures and clinical vertebral fractures that received medical attention were included in the analysis. The incidence rates of clinical vertebral fractures and hip fractures were determined and compared to the published data of Swedish Caucasian and Japanese populations.

Results

The mean age at baseline was 62?±?8.2?years for women and 68?±?10.3?years for men. The average duration of follow-up was 4.0?±?2.8 (range, 1 to 14) years for a total of 14,733 person-years for the whole cohort. The incidence rate for vertebral fracture was 194/100,000 person-years in men and 508/100,000 person-years in women, respectively. For subjects above the age of 65, the clinical vertebral fracture and hip fracture rates were 299/100,000 and 332/100,000 person-years, respectively, in men, and 594/100,000 and 379/100,000 person-years, respectively, in women. Hong Kong Chinese and Japanese populations have a less dramatic increase in hip fracture rates associated with age than Caucasians. At the age of 65 or above, the hip fracture rates for Asian (Hong Kong Chinese and Japanese) men and women were less than half of that in Caucasians, but the vertebral fracture rate was higher in Asians, resulting in a high vertebral-to-hip fracture ratio.

Conclusions

The incidences of vertebral and hip fractures, as well as the vertebral-to-hip fracture ratios vary in Asians and Caucasians. Estimation of the absolute fracture risk for Asians may need to be readjusted for the higher clinical vertebral fracture rate.     

Mild morphometric vertebral fractures predict vertebral fractures but not non-vertebral fractures

Summary

In this meta-analysis of the control arms of four phase 3 trials, mild vertebral fractures were a significant risk factor for future vertebral fractures but not for non-vertebral fracture.

Introduction

A prior vertebral fracture is a risk factor for future fracture that is commonly used as an eligibility criterion for treatment and in the assessment of fracture probability. The aim of this study was to determine the prognostic significance of a morphometric fracture according to the severity of fracture.

Methods

We examined the control (placebo) treated arms of four phase 3 trials. Vertebral fracture status was graded at baseline in 7,623 women, and fracture outcomes were documented over the subsequent 20,000 patient-years. Fracture outcomes were characterised as a further vertebral fracture, a non-vertebral fracture or a clinical fracture (non-vertebral plus clinical vertebral fracture). The relative risk of fracture was computed from the merged β coefficients of each trial weighted according to the variance.

Results

Mild vertebral fractures were a significant risk factor for vertebral fractures [risk ratio (RR)?=?2.17; 95 % CI?=?1.70–2.76] but were not associated with an increased risk of non-vertebral fractures (RR?=?1.08; 95 % CI?=?0.86–1.36). Moderate/severe vertebral fractures were associated with a high risk of vertebral fractures (RR?=?4.23; 95 % CI?=?3.58–5.00) and a moderate though significant increase in non-vertebral fracture risk (RR?=?1.64; 95 % CI?=?1.38–1.94).

Conclusions

Prior moderate/severe morphometric vertebral fractures are a strong and significant risk factor for future fracture. The presence of a mild vertebral fracture is of no significant prognostic value for non-vertebral fractures. These findings should temper the use of morphometric fractures in the assessment of risk and the design of phase 3 studies.     

Thoracic kyphosis and rate of incident vertebral fractures: the Fracture Intervention Trial

Summary

Biomechanical analyses support the theory that thoracic spine hyperkyphosis may increase risk of new vertebral fractures. While greater kyphosis was associated with an increased rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.

Introduction

Biomechanical analyses suggest hyperkyphosis may increase risk of incident vertebral fracture by increasing the load on vertebral bodies during daily activities. We propose to assess the association of kyphosis with incident radiographic vertebral fracture.

Methods

We used data from the Fracture Intervention Trial among 3038 women 55–81 years of age with low bone mineral density (BMD). Baseline kyphosis angle was measured using a Debrunner kyphometer. Vertebral fractures were assessed at baseline and follow-up from lateral radiographs of the thoracic and lumbar spine. We used Poisson models to estimate the independent association of kyphosis with incident fracture, controlling for age and femoral neck BMD.

Results

Mean baseline kyphosis was 48° (SD?=?12) (range 7–83). At baseline, 962 (32 %) participants had a prevalent fracture. There were 221 incident fractures over a median of 4 years. At baseline, prevalent fracture was associated with 3.7° greater average kyphosis (95 % CI 2.8–4.6, p?<?0.0005), adjusting for age and femoral neck BMD. Before adjusting for prevalent fracture, each 10° greater kyphosis was associated with 22 % increase (95 % CI 8–38 %, p?=?0.001) in annualized rate of new radiographic vertebral fracture, adjusting for age and femoral neck BMD. After additional adjustment for prevalent fracture, estimated increased annualized rate was attenuated and no longer significant, 8 % per 10° kyphosis (95 % CI ?4 to 22 %, p?=?0.18).

Conclusions

While greater kyphosis increased the rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.

     

Low holotranscobalamin and cobalamins predict incident fractures in elderly men: the MrOS Sweden

Summary

In a population-based study on cobalamin status and incident fractures in elderly men (n?=?790) with an average follow-up of 5.9 years, we found that low levels of metabolically active and total cobalamins predict incident fractures, independently of body mass index (BMI), bone mineral density (BMD), plasma total homocysteine (tHcy), and cystatin C.

Introduction

Cobalamin deficiency in elderlies may affect bone metabolism. This study aims to determine whether serum cobalamins or holotranscobalamin (holoTC; the metabolic active cobalamin) predict incident fractures in old men.

Methods

Men participating in the Gothenburg part of the population-based Osteoporotic Fractures in Men (MrOS) Sweden cohort and without ongoing vitamin B medication were included in the present study (n?=?790; age range, 70–81 years).

Results

During an average follow-up of 5.9 years, 110 men sustained X-ray-verified fractures including 45 men with clinical vertebral fractures. The risk of fracture (adjusted for age, smoking, BMI, BMD, falls, prevalent fracture, tHcy, cystatin C, 25-OH-vitamin D, intake of calcium, and physical activity (fully adjusted)), increased per each standard deviation decrease in cobalamins (hazard ratio (HR), 1.38; 95 % confidence intervals (CI), 1.11–1.72) and holoTC (HR, 1.26; 95 % CI, 1.03–1.54), respectively. Men in the lowest quartile of cobalamins and holoTC (fully adjusted) had an increased risk of all fracture (cobalamins, HR?=?1.67 (95 % CI, 1.06–2.62); holoTC, HR?=?1.74 (95 % CI, 1.12–2.69)) compared with quartiles 2–4. No associations between folate or tHcy and incident fractures were seen.

Conclusions

We present novel data showing that low levels of holoTC and cobalamins predicting incident fracture in elderly men. This association remained after adjustment for BMI, BMD, tHcy, and cystatin C. However, any causal relationship between low cobalamin status and fractures should be explored in a prospective treatment study.     

Added value of trabecular bone score over bone mineral density for identification of vertebral fractures in patients with areal bone mineral density in the non-osteoporotic range

Summary

Detection of patients with vertebral fracture is similar for areal bone mineral density (aBMD) and trabecular bone score (TBS) in patients with non-vertebral fracture. In non-osteoporotic patients, TBS adds information to lumbar spine aBMD and is related to an index of spine deterioration.

Introduction

Vertebral fractures (VFs) are more predictive of future fracture than aBMD. The number and severity of VFs are related to microarchitecture deterioration. TBS has been shown to be related to microarchitecture. The study aimed at evaluating TBS in the prediction of the presence and severity of VFs.

Methods

Patients were selected from a Fracture Liaison Service (FLS): aBMD and vertebral fracture assessment (VFA) were assessed after the fracture, using dual-energy X-ray-absorptiometry (DXA). VFs were classified using Genant's semiquantitative method and severity, using the spinal deformity index (SDI). TBS was obtained after analysis of DXA scans. Performance of TBS and aBMD was assessed using areas under the curves (AUCs).

Results

A total of 362 patients (77.3 % women; mean age 74.3?±?11.7 years) were analysed. Prevalence of VFs was 36.7 %, and 189 patients (52.2 %) were osteoporotic. Performance of TBS was similar to lumbar spine (LS) aBMD and hip aBMD for the identification of patients with VFs. In the population with aBMD in the non-osteoporotic range (n?=?173), AUC of TBS for the discrimination of VFs was higher than the AUC of LS aBMD (0.670 vs 0.541, p?=?0.035) but not of hip aBMD; there was a negative correlation between TBS and SDI (r?=??0.31; p?<?0.0001).

Conclusion

Detection of patients with vertebral fracture is similar for aBMD and TBS in patients with non-vertebral fracture. In patients with aBMD in the non-osteoporotic range, TBS adds information to lumbar spine aBMD alone and is related to an index of spine deterioration.     

Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW)

Summary

We evaluated healthcare utilization associated with treating fracture types in >51,000 women aged ≥55 years. Over the course of 1 year, there were five times more non-hip, non-spine fractures than hip or spine fractures, resulting in twice as many days of hospitalization and rehabilitation/nursing home care for non-hip, non-spine fractures.

Introduction

The purpose of this study is to evaluate medical healthcare utilization associated with treating several types of fractures in women ≥55 years from various geographic regions.

Methods

Information from the Global Longitudinal Study of Osteoporosis in Women (GLOW) was collected via self-administered patient questionnaires at baseline and year 1 (n?=?51,491). Self-reported clinically recognized low-trauma fractures at year 1 were classified as incident spine, hip, wrist/hand, arm/shoulder, pelvis, rib, leg, and other fractures. Healthcare utilization data were self-reported and included whether the fracture was treated at a doctor’s office/clinic or at a hospital. Patients were asked if they had undergone surgery or been treated at a rehabilitation center or nursing home.

Results

During 1-year follow-up, there were 195 spine, 134 hip, and 1,654 non-hip, non-spine fractures. Clinical vertebral fractures resulted in 617 days of hospitalization and 512 days of rehabilitation/nursing home care; hip fractures accounted for 1,306 days of hospitalization and 1,650 days of rehabilitation/nursing home care. Non-hip, non-spine fractures resulted in 3,805 days in hospital and 5,186 days of rehabilitation/nursing home care.

Conclusions

While hip and vertebral fractures are well recognized for their associated increase in health resource utilization, non-hip, non-spine fractures, by virtue of their 5-fold greater number, require significantly more healthcare resources.     

An evaluation of the Fracture Risk Assessment Tool (FRAX®) as an indicator of treatment efficacy: the effects of bazedoxifene and raloxifene on vertebral, nonvertebral, and all clinical fractures as a function of baseline fracture risk assessed by FRAX®

Summary

The relationship between baseline Fracture Risk Assessment Tool (FRAX®) and treatment efficacy was evaluated using data from a pivotal phase 3 study. Relative risk of vertebral, nonvertebral, and all clinical fractures decreased with increasing probability of fracture for bazedoxifene (BZA) versus placebo but remained generally constant for raloxifene (RLX).

Introduction

To determine whether the FRAX® predicts osteoporosis treatment efficacy, we evaluated reductions in fracture incidence associated with BZA and RLX according to baseline fracture risk determined by FRAX® using data from a phase 3 osteoporosis treatment study.

Methods

Hazard ratios (HRs) for effects of BZA and RLX versus placebo on incidence of vertebral, nonvertebral, and all clinical fractures were calculated using a Cox regression model. Cox regression analyses were performed in subgroups at or above 10-year fracture probability thresholds determined by FRAX®.

Results

HRs for the risk of vertebral, nonvertebral, and all clinical fractures versus placebo decreased with increasing 10-year fracture probability for BZA, while those for RLX remained stable. In all 10-year fracture probability subgroups, all BZA doses significantly reduced vertebral fracture risk versus placebo (HR?=?0.22–0.66). BZA at 20, 40, and 20/40 mg significantly reduced risk of nonvertebral fractures (HR?=?0.45, 0.44, and 0.45, respectively) and all clinical fractures (HR?=?0.38, 0.41, and 0.40, respectively) for ≥20.0 % fracture probability. Vertebral fracture risk reductions for RLX 60 mg versus placebo were significant in subgroups at lower fracture probabilities (≥2.5–?≥?10.0 %), but not higher (≥12.5 %), and in no subgroups for nonvertebral or all clinical fractures.

Conclusion

The antifracture efficacy of BZA increased with increasing baseline FRAX® score, but there was no clear relationship between RLX and baseline FRAX®. These findings provide independent confirmation of current literature, suggesting that the relationship between FRAX® and treatment efficacy varies for different agents.