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Background: Clinical studies indicate that strength-balance training for active fall prevention can prevent fractures in older people. The present modelling study evaluates the cost-effectiveness of fall prevention exercise (FPE) provided to independently living older people compared to no intervention in Germany., Method: We designed a Markov model to evaluate the cost-effectiveness of a group-based FPE-program provided to independently living people ≥75 years from the perspective of the German statutory health insurance (SHI). Input data was obtained from public databases, clinical trials and official statistics. The incremental cost-effectiveness ratio (ICER) was presented as costs per avoided hip fracture. Additionally, we performed deterministic and probabilistic sensitivity analyses and, estimated monetary consequences for the SHI in a budget impact analysis (BIA)., Results: For women, the costs per hip fracture avoided amounted to €52,864 (men: €169,805). Results of deterministic and probabilistic sensitivity analyses confirmed the robustness of the results. According to the BIA, for the reimbursement of FPE additional costs of €3.0 million (women) and €7.8 million (men) are expected for the SHI., Conclusions: Group-based FPE appears to be no cost-effective option to prevent fall-related hip fractures in independently living elderly. To allow a more comprehensive statement on the cost effectiveness of FPE fracture types other than hip should be increasingly evaluated in clinical trials., (© 2021. The Author(s).)

Background: The Fracture Screening and Prevention Program (FSPP), a fracture liaison service (FLS), was implemented in the province of Ontario, Canada, in 2007 to prevent recurrent fragility fractures and to improve post-fracture care. The objective of this analysis was to determine the cost-effectiveness of the current model of the FSPP compared with usual care (no program) from the perspective of the universal public health-care payer (Ontario Ministry of Health and Long-Term Care [MOHLTC]), over the lifetime of older adults who presented with a fragility fracture of the proximal part of the femur, the proximal part of the humerus, or the distal part of the radius and were not taking medications to prevent or slow bone loss and reduce the risk of fracture (bone active medications)., Methods: We developed a state-transition (Markov) model to conduct a cost-effectiveness analysis of the FSPP in comparison with usual care. The model simulated a cohort of patients with a fragility fracture starting at 71 years of age. Model parameters were obtained from published literature and from the FSPP. Quality-adjusted life-years (QALYs) and costs in 2018 Canadian dollars were predicted over a lifetime horizon using a 1.5% annual discount rate. Health outcomes included subsequent proximal femoral, vertebral, proximal humeral, and distal radial fractures. Scenario and subgroup analyses were reported., Results: The FSPP had lower expected costs ($277 less) and higher expected effectiveness (by 0.018 QALY) than usual care over the lifetime horizon. Ninety-four percent of the 10,000 Monte Carlo simulated incremental cost-effectiveness ratios (ICERs) demonstrated lower costs and higher effectiveness of the FSPP., Conclusions: The FSPP appears to be cost-effective compared with usual care over a lifetime for patients with fragility fracture. This information may help to quantify the value of the FSPP and to assist policy-makers in deciding whether to expand the FSPP to additional hospitals or to initiate similar programs where none exist., Level of Evidence: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: Funding for this study was provided by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The funding source did not play a role in the investigation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G427)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Bisphosphonates reduce fractures in randomized controlled trials (RCT); however, there is less information from real life. In our population including 14,990 women and 13,239 men, use of bisphosphonates reduced risk of fractures in hip and forearm in women. The magnitude of the effect was comparable to results from RCT., Introduction: The objective was to examine if treatment with bisphosphonates (BPs) was associated with reduced risk of fractures in the hip and forearm in women and men in the general population., Methods: In a cohort study based on data from the third wave of the population-based HUNT Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, 14,990 women and 13,239 men 50-85 years were followed from the date of participating in HUNT3 (2006-2008) until the date of first fracture in the hip or forearm, death, or end of study (31 December 2012). Hazard ratios with 95% confidence intervals for hip and forearm fracture according to use of BPs were estimated using Cox proportional hazards models with time-dependent exposure. Adjustment for individual FRAX® fracture risk assessment scores was included., Results: BPs, predominantly alendronate, were used by 9.4% of the women and 1.5% of the men. During a median of 5.2 years of follow-up, 265 women and 133 men had a hip fracture, and 662 women and 127 men had a forearm fracture. Compared with non-users of BPs, the hazard ratios with 95% confidence interval for a fracture among users of BPs adjusted for age and FRAX® were 0.67 (0.52-0.86) for women and 1.13 (0.50-2.57) for men. Among users of glucocorticoids, the corresponding figures were 0.35 (0.19-0.66) and 1.16 (0.33-4.09), respectively., Conclusions: Use of BPs was associated with reduced risk of fractures in hip and forearm in women, and the magnitude of effect is comparable to results from RCTs.

In patients with surgical repair of a low-trauma hip fracture, zoledronic acid (ZA) reduced the risk of subsequent fractures regardless of pretreatment femoral neck and total hip bone mineral density (BMD)., Introduction: Zoledronic acid reduces the risk of subsequent fractures after repair of a hip fracture. It is still unclear whether the benefits in fracture reduction with ZA depend upon hip bone mineral density at the time of fracture., Methods: We preformed additional post hoc analyses of data from the HORIZON Recurrent Fracture Trial to determine if ZA treatment reduced the risk of new clinical fractures regardless of pretreatment BMD. We modeled femoral neck and total hip BMD as both continuous and dichotomous variables (BMD T-score above and below -2.5)., Results: There are no evidence that baseline femoral neck and total hip BMD modified the anti-fracture efficacy of ZA when pretreatment BMD was analyzed as a continuous or a dichotomous variable (interaction p-values > 0.20). The clinical fracture efficacy of ZA was similar among patients with pretreatment femoral neck BMD values above and below -2.5 (relative hazards = 0.60 and 0.67, respectively, interaction p-value = 0.95). A similar result was obtained using pretreatment total hip BMD values (relative hazards = 0.72 and 0.57, respectively, interaction p-value = 0.41)., Conclusion: There data should provide more comfort in prescribing ZA after surgical repair of a hip fracture, regardless of pretreatment BMD.

Fragility fractures (FFs) are low-energy trauma fractures that occur at or below standing height. Among FFs, hip fractures are associated with the greatest morbidity, mortality and cost to Canadian health care systems. This review highlights the current state of medical care for hip fractures in Canada, with specific focus on the role of the multidisciplinary team. Gaps in care exist, as FFs represent a unique challenge requiring both acute and chronic management. Furthermore, there is a lack of ownership of FFs by a medical specialty. These gaps can be addressed through the use of multidisciplinary teams, which have been shown to be efficacious and cost-effective. This model of care also addresses numerous patient-identified barriers to treatment, including inadequate patient counselling. However, there is still room for improvement in both the identification of patients at risk for hip fracture and patient adherence to therapy., Competing Interests: None declared., (© 2021 CMA Joule Inc. or its licensors)

Background: Hip structural analysis (HSA) is a method for evaluating bone geometry reflecting bone structural and biomechanical properties. However, tissue-selective estrogen complex (TSEC) treatment effects on HSA have not been investigated., Objective: This study was performed to evaluate the effect of TSEC treatment on hip geometry in postmenopausal Korean women. The treatment was given for 12 months, and hip geometry was measured by HSA., Materials and Methods: A total of 40 postmenopausal women who received TSEC containing conjugated estrogen 0.45 mg and bazedoxifene 20 mg for treating vasomotor symptoms were included in this retrospective cohort study. The changes in bone mineral density and parameters of HSA including the outer diameter, cross-sectional area, cross-sectional moment of inertia, cortical thickness, section modulus, and buckling ratio as determined by dual-energy X-ray absorptiometry were compared before and after 12 months of TSEC treatment., Results: Mean age and years since menopause were 55.1 and 4.5 years, respectively. Total hip bone mineral density significantly increased by 0.74% after treatment (P=0.011). The changes in HSA were mainly demonstrated in the narrow femoral neck: cross-sectional area (P=0.003) and cortical thickness (P<0.001) increased significantly. For the shaft region, only SM decreased significantly after treatment (P=0.009). However, most parameters did not change significantly with TSEC treatment in the intertrochanteric and shaft regions., Conclusions: Our findings demonstrate that 12 months of TSEC treatment could improve bone geometry as measured by HSA. The findings suggest that TSEC might be an interesting option for the prevention of fracture as well as osteoporosis in postmenopausal women., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kim, Kim, Lee and Choi.)

Understanding the hip loading environment for daily activities is useful for hip fracture prevention, rehabilitation, and the design of osteogenic exercises. Seventeen older adults (50-70 yrs) and twenty young adults (18-30 yrs) were recruited. A rigid body model combined with a musculoskeletal model was used to estimate lower extremity loading. An elliptical cross-section model of the femoral neck was used to estimate femoral neck stress during stair ascent and descent. Two peaks were identified in the stress curves, corresponding to the peaks in the vertical ground reaction force. During stair ascent, significantly higher tension on the superior femoral neck was found for the young group at peak 1 (young: 13.5±6.1 MPa, older: 4.2±6.5 MPa, p<0.001). Also during stair ascent, significantly higher compression on the posterior femoral neck was found for the older group at peak 2 (young: -11.4±4.9 MPa, old: -18.1±8.6 MPa, p = 0.006). No significant difference was found for stair descent. Components of stress (muscle vs. reaction forces; axial forces vs. bending moments) were also examined for each trial of stair ascent and descent. The stresses and their components provided loading magnitude and locations of higher stress on the femoral neck during stair ascent and descent. Understanding femoral neck stresses may be used to help prevent hip fractures, reduce pain, improve rehabilitation, and design osteogenic exercises., Competing Interests: The authors have declared that no competing interests exist.

Calcium supplementation and fortification are strategies widely used to prevent adverse outcome in population with low-calcium intake which is highly frequent in low-income settings. We aimed to determine the effectiveness and cost-effectiveness of calcium fortified foods on calcium intake and related health, or economic outcomes. We performed a systematic review and meta-analysis involving participants of any age or gender, drawn from the general population. We searched PubMed, Agricola, EMBASE, CINAHL, Global Health, EconLit, the FAO website and Google until June 2019, without language restrictions. Pair of reviewers independently selected, extracted data and assessed the risk of bias of included studies using Covidence software. Disagreements were resolved by consensus. We performed meta-analyses using RevMan 5.4 and subgroup analyses by study design, age group, and fortification levels. We included 20 studies of which 15 were randomized controlled trials (RCTs), three were non-randomised studies and two were economic evaluations. Most RCTs had high risk of bias on randomization or blinding. Most represented groups were women and children from 1 to 72 months, most common intervention vehicles were milk and bakery products with a fortification levels between 96 and 1200 mg per 100 g of food. Calcium intake increased in the intervention groups between 460 mg (children) and 1200 mg (postmenopausal women). Most marked effects were seen in children. Compared to controls, height increased 0.83 cm (95% CI 0.00; 1.65), plasma parathyroid hormone decreased -1.51 pmol/L, (-2.37; -0.65), urine:calcium creatinine ratio decreased -0.05, (-0.07; -0.03), femoral neck and hip bone mineral density increased 0.02 g/cm 2 (0.01; 0.04) and 0.03 g/cm 2 (0.00; 0.06), respectively. The largest cost savings (43%) reported from calcium fortification programs came from prevented hip fractures in older women from Germany. Our study highlights that calcium fortification leads to a higher calcium intake, small benefits in children's height and bone health and also important evidence gaps for other outcomes and populations that could be solved with high quality experimental or quasi-experimental studies in relevant groups, especially as some evidence of calcium supplementation show controversial results on the bone health benefit on older adults.

Importance: Clinical trials have demonstrated the antifracture efficacy of bisphosphonate drugs for the first 3 to 5 years of therapy. However, the efficacy of continuing bisphosphonate for as long as 10 years is uncertain., Objective: To examine the association of discontinuing bisphosphonate at study entry, discontinuing at 2 years, and continuing for 5 additional years with the risk of hip fracture among women who had completed 5 years of bisphosphonate treatment at study entry., Design, Setting, and Participants: This cohort study included women who were members of Kaiser Permanente Northern and Southern California, 2 integrated health care delivery systems, and who had initiated oral bisphosphonate and completed 5 years of treatment by January 1, 2002, to September 30, 2014. Data analysis was conducted from January 2018 to August 2020., Exposure: Discontinuation of bisphosphonate at study entry (within a 6-month grace period), discontinuation at 2 years (within a 6-month grace period), and continuation for 5 additional years., Main Outcomes and Measures: The outcome was hip fracture determined by principal hospital discharge diagnoses. Demographic, clinical, and pharmacological data were ascertained from electronic health records., Results: Among 29 685 women (median [interquartile range] age, 71 [64-77] years; 17 778 [60%] non-Hispanic White individuals), 507 incident hip fractures were identified. Compared with bisphosphonate discontinuation at study entry, there were no differences in the cumulative incidence (ie, risk) of hip fracture if women remained on therapy for 2 additional years (5-year risk difference [RD], -2.2 per 1000 individuals; 95% CI, -20.3 to 15.9 per 1000 individuals) or if women continued therapy for 5 additional years (5-year RD, 3.8 per 1000 individuals; 95% CI, -7.4 to 15.0 per 1000 individuals). While 5-year differences in hip fracture risk comparing continuation for 5 additional years with discontinuation at 2 additional years were not statistically significant (5-year RD, 6.0 per 1000 individuals; 95% CI, -9.9 to 22.0 per 1000 individuals), interim hip fracture risk appeared lower if women discontinued after 2 additional years (3-year RD, 2.8 per 1000 individuals; 95% CI, 1.3 to 4.3 per 1000 individuals; 4-year RD, 9.3 per 1000 individuals; 95% CI, 6.3 to 12.3 per 1000 individuals) but not without a 6-month grace period to define discontinuation., Conclusions and Relevance: In this study of women treated with bisphosphonate for 5 years, hip fracture risk did not differ if they discontinued treatment compared with continuing treatment for 5 additional years. If women continued for 2 additional years and then discontinued, their risk appeared lower than continuing for 5 additional years. Discontinuation at other times and fracture rates during intervening years should be further studied.

Introduction: High protein diet is essential for the healthy state of bones. Low protein diet is often recommended to patients with chronic kidney disease (CKD). Risk factors for femoral neck fractures are clear, but trochanteric and intertrochanteric fractures may have different risk factors. In this study, we determined the association between bone density at different femoral areas and a number of protein diets in patients with and without CKD., Methods: We extracted information from the database of the National Health and Nutrition Examination Survey (NHANES), 2005-2010. We have basic variables, metabolic diseases, and bone density of different femoral areas and separated them according to different protein diets (<0.8 g/kg/day, 0.8-1.0 g/kg/day, 1.0-1.2 g/kg/day, and ≥1.2 g/kg/day). The differences of differential femoral areas were analyzed according to different protein intakes in subjects with and without CKD., Results: A total 12,812 subjects were analyzed. Among all four subgroups of protein diets, we found statistically significant differences over bone mineral density (BMD) or T scores (p < 0.0001) among all femoral areas. For total femoral BMD and T scores, the higher the protein intake, and the higher the bone BMD and T scores were noticed (p < 0.0001). We found similar relationship in the trochanter and intertrochanteric bone areas, but not in the femoral neck area. For the femoral BMD, higher protein diets led to higher BMD in the femoral neck, trochanter, intertrochanteric, and total femoral areas (p = 0.032, 0.0036, 0.008, and 0.0039, respectively). Such increased BMD benefits of higher protein diet were not found in CKD patients., Conclusions: Higher protein diets led to higher femoral BMD only in subjects without CKD. CKD patients did not benefit in developing higher femoral BMD and those with Low protein diet did not reduce their femoral BMD. CKD was found to be a risk factor for low BMD in the intertrochanteric bone region., Competing Interests: Conflict of interest Authors declared no competing interests., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Asia Pacific Consortium on Osteoporosis (APCO) comprises of clinical experts from across the Asia Pacific region, uniting to develop solutions to problems facing osteoporosis management and care. The vision of APCO is to reduce the burden of osteoporosis and fragility fractures in the Asia Pacific region., Introduction: The Asia Pacific (AP) region comprises 71 countries with vastly different healthcare systems. It is predicted that by 2050, more than half the world's hip fractures will occur in this region. The Asia Pacific Consortium on Osteoporosis (APCO) was set up in May 2019 with the vision of reducing the burden of osteoporosis and fragility fractures in the AP region., Methods: APCO has so far brought together 39 clinical experts from countries and regions across the AP to develop solutions to challenges facing osteoporosis management and fracture prevention in this highly populous region of the world. APCO aims to achieve its vision by engaging with relevant stakeholders including healthcare providers, policy makers and the public. The initial APCO project is to develop and implement a Framework of pan-AP minimum clinical standards for the screening, diagnosis and management of osteoporosis., Results and Conclusions: The Framework will serve as a platform upon which new national clinical guidelines can be developed or existing guidelines be revised, in a standardised fashion. The Framework will also facilitate benchmarking for provision of quality of care. It is hoped that the principles underlying the formation and functioning of APCO can be adopted by other regions and that every health care facility and progressively every country in the world can follow our aspirational path and progress towards best practice.

This systematic review and meta-analysis found low-quality evidence that orthogeriatric care is positively associated with diagnosis of osteoporosis, prescription of calcium and vitamin D supplements and bisphosphonates in older hip fracture patients. Evidence on fall and fracture prevention was scarce and inconclusive. Orthogeriatrics may reduce the treatment gap following hip fractures., Introduction: Hip fracture patients are at imminent risk of additional fractures and falls. Orthogeriatric care might reduce the osteoporosis treatment gap and improve outcomes in these patients. However, the optimal orthogeriatric care model (geriatric liaison service, co-management, or geriatrician-led care) remains unclear., Purpose: To summarize the association of different orthogeriatric care models for older hip fracture patients, compared to usual orthopaedic care, with fall prevention measures, diagnosis and treatment of osteoporosis and future falls and fractures., Methods: Two independent reviewers retrieved randomized controlled trials (RCTs) or controlled observational studies. Random effects meta-analysis was applied (PROSPERO ID: 165914)., Results: One RCT and twelve controlled observational studies were included, encompassing 20,078 participants (68% women, median ages between 75 and 85 years). Orthogeriatric care was associated with higher odds of diagnosing osteoporosis (odds ratio [OR] 11.36; 95% confidence interval [CI] 7.26-17.77), initiation of calcium and vitamin D supplements (OR 41.44; 95% CI 7.07-242.91) and discharge on anti-osteoporosis medication (OR 7.06; 95% CI 2.87-17.34). However, there was substantial heterogeneity in these findings. Evidence on fall prevention and subsequent fractures was scarce and inconclusive. Almost all studies were at high risk of bias. Evidence was insufficient to compare different care models directly against each other., Conclusions: Low-quality evidence suggests that orthogeriatric care is associated with higher rates of diagnosing osteoporosis, initiation of calcium and vitamin D supplements and anti-osteoporosis medication. Whether orthogeriatric care prevents subsequent falls and fractures in older hip fracture patients remains unclear.

Background: Epidemiological studies examining the association between β-carotene intake and risk of fracture have reported inconsistent findings. We conducted a meta-analysis to investigate the association between β-carotene intake and risk of fracture., Methods: We systematically searched PubMed, EMBASE and Cochrane library databases for relevant articles that were published until December 2019. We also identified studies from reference lists of articles identified from the clinical databases. The frequentist and Bayesian random-effects model was used to synthesize data., Results: Nine studies with a total of 190,545 men and women, with an average age of 59.8 years, were included in this meta-analysis. For β-carotene intake (1.76-14.30 mg/day), the pooled risk ratio (RR) of any fracture was 0.67 (95% Credible Interval (CrI): 0.51-0.82; heterogeneity: P = 0.66, I 2  = 0.00%) and 0.63 (95%CrI: 0.44-0. 82) for hip fracture. By study design, the pooled RRs were 0.55 (95% CrI: 0.14-0.96) for case-control studies and 0.82 (95% CrI: 0.58-0.99) for cohort studies. By geographic region, the pooled RRs were 0.58 (95% CrI: 0.28-0.89), 0.86 (95% CrI: 0.35-0.1.37), and 0.91(95% CrI: 0.75-1.00) for studies conducted in China, the United States, and Europe, respectively. By sex, the pooled RRs were 0.88 (95% CrI: 0.73-0.99) for males and 0.76 (95% CrI, 0.44-1.07) for females. There was a 95% probability that β-carotene intake reduces risk of hip fracture and any type of fracture by more than 20%., Conclusions: The present meta-analysis suggests that β-carotene intake was inversely associated with fracture risk, which was consistently observed for case-control and cohort studies. Randomized controlled trials are warranted to confirm this relationship.

Background: What affects the efficacy of alendronate for prevention of glucocorticoid-induced (GI) fractures remains unclear. We aimed to explore the factors affecting alendronate's efficacy, and further identify subgroup effects of alendronate in preventing GI fractures., Methods: We searched 3 databases. Random-effects meta-analysis was conducted to synthesize risk ratio (RR) and 95% confidence interval (CI) for each endpoint. Meta-regression analysis was used to explore sources of heterogeneity, and subgroup analysis was used to address heterogeneity and evaluate subgroup effects. We detected publication bias using funnel plots and Egger tests., Results: We included 13 papers from 12 unique studies involving 46431 participants. Glucocorticoid (GC) dosage (P = .053) and proportion of previous vertebral fracture (PVF) (P = .047) were probably 2 sources of heterogeneity in meta-analysis for vertebral fractures, while GC duration (P = .020) was probably 1 for nonvertebral fractures. Alendronate reduced vertebral fractures in the high dosage subgroup (RR 0.61, 95% CI 0.44-0.86), but didn't in the low dosage subgroup (RR 1.56, 95% CI 0.20-12.02). Alendronate reduced vertebral fractures (RR 0.53, 95% CI 0.40-0.68) in the subgroup of PVF proportion <5%, but didn't (RR 0.76, 95% CI 0.42-1.37) in the subgroup of this proportion ≥5%. Alendronate reduced nonvertebral and hip fractures, whether in primary or in secondary prevention subgroup., Conclusions: The findings in our study support that alendronate is used for the primary and secondary prevention of GI fractures, but do not support that alendronate is recommended as a first-line agent for patients receiving a low dose of GCs or patients with PVF.

Background: Falls may lead to hip fractures, which have a detrimental effect on the prognosis of patients as well as a considerable impact on healthcare expenditures. Since a secondary hip fracture (SHF) may lead to even higher costs than primary fractures, the development of innovative services is crucial to limit falls and curb costs in high-risk patients. An early economic evaluation assessed which patients with a second hip fracture could benefit most from an exoskeleton preventing falls and whether its development is feasible., Methods: The life-course of hip fractured patients presenting with dementia or cardiovascular diseases was simulated using a Markov model relying on the United Kingdom administrative data and complemented by published literature. A group of experts provided the exoskeleton parameters. Secondary analyses included a threshold analysis to identify the exoskeleton requirements (e.g. minimum impact of the exoskeleton on patients' quality of life) leading to a reimbursable incremental cost-effectiveness ratio. Similarly, the uncertainty around these requirements was modelled by varying their standard errors and represented alongside population Expected Value of Perfect Information (EVPI)., Results: Our base-case found the exoskeleton cost-effective when providing a statistically significant reduction in SHF risk. The secondary analyses identified 286 cost-effective combinations of the exoskeleton requirements. The uncertainty around these requirements was explored producing further 22,880 scenarios, which showed that this significant reduction in SHF risk was not necessary to support the exoskeleton adoption in clinical practice. Conversely, a significant improvement in women quality of life was crucial to obtain an acceptable population EVPI regardless of the cost of the exoskeleton., Conclusions: Our study identified the exoskeleton requisites to be cost-effective and the value of future research. Decision-makers could use our analyses to assess not only whether the exoskeleton could be cost-effective but also how much further research and development of the exoskeleton is worth to be pursued.

Results indicating that a high milk intake is associated with both higher and lower risks of fragility fractures, or that indicate no association, can all be presented in the same meta-analysis, depending on how it is performed. In this narrative review, we discuss the available studies examining milk intake in relation to fragility fractures, highlight potential problems with meta-analyses of such studies, and discuss potential mechanisms and biases underlying the different results. We conclude that studies examining milk and dairy intakes in relation to fragility fracture risk need to study the different milk products separately. Meta-analyses should consider the doses in the individual studies. Additional studies in populations with a large range of intake of fermented milk are warranted.

The aim of this study was to investigate the effect of bisphosphonates on preventing osteoporotic hip fracture in patients with or without prior major osteoporotic fracture. Randomized controlled trials (RCTs) and observational studies (OSs) based on electronic health records were used to assess bisphosphonate efficacy and were searched using PubMed, Scopus, and the Cochrane Library databases. Eight RCT studies and 14 OSs were extracted from the studies and quantitatively combined by random-effects meta-analysis. The odds ratio (OR) for all hip fractures in RCTs of 0.66, with a 95% confidence interval (CI) of 0.55-0.79, was lower than that in the OSs (OR 0.83; CI 0.74-0.94). The OR in patients with prior fracture was significantly reduced by bisphosphonates in both RCTs and OSs. Conversely, significant fracture reduction was not apparent in patients without prior fracture. A moderate relationship between prior major fracture rates and OR in hip fractures was defined. In patients with an average age of over 80 years, similar results were confirmed. In this meta-analysis, the efficacy of bisphosphonates was significant in patients with prior major fracture, recommending to prescribe for such patients. Their effect in patients without prior fracture, in contrast, remains unclear.

Background: This study aimed to provide reliable estimates for dietary antioxidant vitamin (vitamins A, C, and E) intake and their effect on fracture risk at various sites., Methods: The PubMed, EMBASE, and Cochrane Library databases were searched to identify prospective cohort studies published throughout October 2019. The pooled relative risk (RR) with its 95% confidence interval (CI) was calculated using a random-effects model., Results: In total, 13 prospective cohort studies involving 384,464 individuals were selected for this meta-analysis. The summary RR indicated that increased antioxidant vitamin intake was associated with a reduced fracture risk (RR: 0.92; 95% CI: 0.86-0.98; P = .015). When stratified by the vitamin types, increased vitamin E intake was found to be associated with a reduced fracture risk (RR: 0.66; 95% CI: 0.46-0.95; P = .025), whereas increased vitamin A and C intake did not affect this risk. Increased antioxidant vitamin intake was associated with a reduced fracture risk, irrespective of fracture sites (HR: 0.90; 95% CI: 0.86-0.94; P < .001); however, it did not affect hip fracture risk. Furthermore, increased antioxidant vitamin intake was associated with a reduced fracture risk in men (RR: 0.81; 95% CI: 0.68-0.96; P = .017) and combined men and women (RR: 0.83; 95%CI: 0.73-0.93; P = .002); however, it did not affect fracture risk in women., Conclusion: Fracture risk at any site is significantly reduced with increased antioxidant vitamin intake, especially vitamin E intake and in men.

Background: Bisphosphonates are effective in reducing hip and osteoporotic fractures. However, concerns about atypical femur fractures have contributed to substantially decreased bisphosphonate use, and the incidence of hip fractures may be increasing. Important uncertainties remain regarding the association between atypical femur fractures and bisphosphonates and other risk factors., Methods: We studied women 50 years of age or older who were receiving bisphosphonates and who were enrolled in the Kaiser Permanente Southern California health care system; women were followed from January 1, 2007, to November 30, 2017. The primary outcome was atypical femur fracture. Data on risk factors, including bisphosphonate use, were obtained from electronic health records. Fractures were radiographically adjudicated. Multivariable Cox models were used. The risk-benefit profile was modeled for 1 to 10 years of bisphosphonate use to compare associated atypical fractures with other fractures prevented., Results: Among 196,129 women, 277 atypical femur fractures occurred. After multivariable adjustment, the risk of atypical fracture increased with longer duration of bisphosphonate use: the hazard ratio as compared with less than 3 months increased from 8.86 (95% confidence interval [CI], 2.79 to 28.20) for 3 years to less than 5 years to 43.51 (95% CI, 13.70 to 138.15) for 8 years or more. Other risk factors included race (hazard ratio for Asians vs. Whites, 4.84; 95% CI, 3.57 to 6.56), height, weight, and glucocorticoid use. Bisphosphonate discontinuation was associated with a rapid decrease in the risk of atypical fracture. Decreases in the risk of osteoporotic and hip fractures during 1 to 10 years of bisphosphonate use far outweighed the increased risk of atypical fracture among Whites but less so among Asians. After 3 years, 149 hip fractures were prevented and 2 bisphosphonate-associated atypical fractures occurred in Whites, as compared with 91 and 8, respectively, in Asians., Conclusions: The risk of atypical femur fracture increased with longer duration of bisphosphonate use and rapidly decreased after bisphosphonate discontinuation. Asians had a higher risk than Whites. The absolute risk of atypical femur fracture remained very low as compared with reductions in the risk of hip and other fractures with bisphosphonate treatment. (Funded by Kaiser Permanente and others.)., (Copyright © 2020 Massachusetts Medical Society.)

The aim of this study was to gain insight into the nutritional status, dietary intake and muscle health of older Dutch hip fracture patients to prevent recurrent fractures and to underpin rehabilitation programs. This cross-sectional study enrolled 40 hip fracture patients (mean ± SD age 82 ± 8.0 years) from geriatric rehabilitation wards of two nursing homes in the Netherlands. Assessments included nutritional status (Mini Nutritional Assessment), dietary intake on three non-consecutive days which were compared with Dietary Reference Intake values, and handgrip strength. Muscle mass was measured using Bioelectrical Impedance Analysis and ultrasound scans of the rectus femoris. Malnutrition or risk of malnutrition was present in 73% of participants. Mean energy, protein, fibre and polyunsaturated fat intakes were significantly below the recommendations, while saturated fat was significantly above the UL. Protein intake was <0.8 in 46% and <1.2 g/(kg·day) in 92%. Regarding micronutrients, mean intakes of calcium, vitamin D, potassium, magnesium and selenium were significantly below the recommendations. The prevalence of low muscle mass, low handgrip strength and sarcopenia were 35%, 27% and 10%, respectively. In conclusion, a poor nutritional status, dietary intake and muscle health are common in older hip fracture patients in geriatric rehabilitation wards.

Rationale: Autosomal dominant type II (AD II) osteopetrosis is a rare inheritable metabolic bone disease characterized by hard but brittle bone and a narrow medullary canal. Intramedullary nailing (IMN) is a difficult but attractive option for the treatment of subtrochanteric fractures in patients with AD II osteopetrosis., Patient Concerns and Diagnosis: Two patients with AD II osteopetrosis sustained subtrochanteric fractures after a fall., Interventions: IMN was performed through the sequential use of instruments such as a 4.9-mm drill bit, small reamer, and larger reamer for over-reaming., Outcomes: In the first case, IMN left some gap at the fracture site. Dynamization was performed to treat the delayed union at 6 months postoperatively. The fracture healed at 10 months after the dynamization. In the second case, IMN was successful without a gap, and the fracture healed at 8 months., Lessons: Although IMN is difficult to perform owing to partial obliteration of the medullary canal in AD II osteopetrosis, it can be performed with sequential widening of the medullary canal using various instruments. In addition, the fracture gap should not be left uncorrected during IMN to attain fracture union.

Background and objectives : Hip fracture is a major public health issue. Those fractures lead to high costs and a decrease in quality of life. A national French survey was conducted, with the objectives to firstly assess the current management of hip fracture and its prevention, both in the osteoporotic and cancer settings, and secondly to evaluate the opinions of physicians on the potential use of minimally invasive implantable devices to prevent hip fracture in alternative of surgery. Materials and methods : This national survey was conducted in France between April and July 2017. Questionnaires were sent to orthopedic surgeons, interventional radiologists, oncologists, and rheumatologists. Completed questionnaires were analyzed and compared according to two indications: orthopedics-traumatology and oncology. Factors associated with these responses were assessed using univariable analyses, based on chi-square tests or an exact Fisher test, as appropriate. Results : A total of 182 questionnaires were completed and further analyzed. Physicians have highlighted the need for a low re-fracture rate and to improve life expectancy for more than 1 year (50% for responders of the orthopedics-traumatology questionnaire and 80% for the responders interested in both indications), as well as quality of life (12.5% and 31%, respectively), but with no significant differences in the oncologic indication. Most of the experts were willing to use or prescribe implantable devices for prevention (63% in orthopedics-traumatology and 93% in oncology), although limited clinical experience (54 and 58%) and surgical risk (around 30% in each indication) were considered as limits. Conclusions: Prevention of hip fracture remains a concern for physicians. More clinical experience with implantable devices, in particular in cancer patients, is needed, but implemented in a strategy to maximize patient recovery while reducing costs.

Alendronate is effective in preventing second hip fracture in osteoporotic patients. However, no consensus exists on the duration that is effective in preventing a second hip fracture. Our study demonstrated that risk can be reduced when the prescription is ≥ 6 months for the year following the index hip fracture., Introduction: Alendronate is effective in preventing second hip fracture in osteoporotic patients. However, no consensus exists on the accurate medication possession ratio (MPR) that is effective in preventing a second hip fracture. Our objective was to compare the risk of second hip fracture in patients treated with different MPR of alendronate., Methods: In this population-based cohort study, data from National Health Insurance Research Database of Taiwan were analyzed. Patients 50 years and older who had an index hip fracture and were not receiving any osteoporotic medications before their fracture during 2000-2010 were included. The cohort consisted of 88,320 patients who were new alendronate users (n = 9278) and non-users (n = 79,042). Those without alendronate were matched 4:1 as the control group. Patients were subdivided into those with no medication, MPR < 25%, MPR 25-50%, MPR 50-75%, and MPR 75-100%. Cox proportional hazard models were used to calculate the adjusted hazard ratios for different MPRs of alendronate., Results: After matching, 38,675 patients were included in this study; 20,363 (52.7%) were women, and 30,940 (80%) patients were without medication of alendronate. During follow-up on December 31, 2012, 2392 patients had a second hip fracture, for an incidence of 1449/100,000 person-years. Patients with alendronate MPR 50-75% had a lower risk of a second hip fracture compared to non-users (hazard ratio 0.66). When the MPR increased to 75-100%, the hazard ratio decreased to 0.61., Conclusions: In this population-based cohort study, risk of a second hip fracture can be reduced when the alendronate MPR is ≥ 50% for the year following the index hip fracture. As the MPR increases, the risk of a second hip fracture decreases.

We evaluated whether active osteoporosis care in patients experiencing their first distal radius fracture (DRF) reduces subsequent hip or spine fractures by comparing two cohorts. The incidence of subsequent fractures was significantly lower in the active care cohort than the other cohort in 4-year follow-up., Purpose: Studies show that osteoporosis care in patients with osteoporotic fracture reduces subsequent fractures, but the impact of such active care in patients with distal radius fracture (DRF) has not been well studied. We evaluated how much osteoporosis care in patients experiencing their first DRF can reduce subsequent hip or spine fractures at 4-year follow-up., Methods: Active osteoporosis care by orthopedic surgeons for patients with DRF started from September 2009 at our institution, thus we had a unique opportunity to compare the two cohorts: pre-involvement (PreI) group (DRF before September 2009) and post-involvement (PostI) group (DRF from September 2009). We compared the two cohorts for subsequent hip or spine fracture incidence in the 4 years following DRF., Results: Overall, 1057 patients with a DRF (85% women; mean age, 70 years) were studied, of whom 205 patients were in PreI group and 852 in PostI group. Subsequent fractures occurred in 27 patients (2.6%), with a mean interval of 29 months after DRF. The incidence was significantly lower in the PostI group than in the PreI group (1.9% vs. 5.4%, p = 0.004), especially in hip fractures (0.4% vs. 2.9%, p = 0.002). The relative risk reduction was 65% for all subsequent fractures and 86% for hip fractures., Conclusion: This study demonstrates that active osteoporosis care in patients with DRF significantly reduces subsequent fracture incidence even for the 4-year follow-up period. These findings add an evidence for the current proactive osteoporosis care programs such as fracture liaison services., Level of Evidence: Therapeutic level III.

In the present meta-analysis, reductions in the risk of hip fracture with milk consumption were only observed among American adults, but not among Scandinavian adults, possibly because milk products are more commonly fortified with vitamin D in the former population than in Scandinavian countries. The reduction in the risk of hip fracture was also observed with yogurt consumption, which is often associated with healthy lifestyles and dietary patterns that contribute to improved bone health., Introduction: Although dairy products contain bone-beneficial nutrients, the association between dairy consumption and the risk of hip fracture remains equivocal. Fueling this uncertainty, the elevated risk of hip fracture in association with milk consumption was observed in a cohort of Swedish women. A systematic review and meta-analysis of prospective cohort studies was performed to critically evaluate the association, or lack thereof, between dairy consumption (milk, yogurt, and cheese) and the risk of hip fracture., Methods: A random effects model was used to generate the summary relative risks (RRs) with their 95% confidence intervals (CIs) for the associations of interest., Results: In the meta-analysis of the highest versus lowest category of consumption, higher consumption of yogurt (RR 0.78, 95% CI 0.68, 0.90), but not milk (RR 0.86, 95% CI 0.73, 1.02) or cheese (RR 0.85, 95% CI 0.66, 1.08), was associated with a lower risk of hip fracture. For milk, the reduced risk of fracture with higher milk consumption was observed in the USA (RR 0.75, 95% CI 0.65, 0.87), but not in Scandinavian countries (RR 1.00, 95% CI 0.85, 1.17). These findings were further supported by the fact that American studies (RR 0.93, 95% CI 0.88, 0.98; per 1 glass/day), but not Scandinavian studies (RR 1.01, 95% CI 0.95, 1.07; per 1 glass/day), demonstrated a linear association between milk consumption and the risk of hip fracture., Conclusions: The cumulative evidence from prospective cohort studies reassuringly suggests that the risk of hip fracture may not be elevated among people who consume milk, yogurt, and cheese, and that a greater consumption of milk or yogurt may even be associated with a lower risk of hip fracture depending on the factors that may differ across the population of interest.

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture., Purpose/introduction: To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice., Methods: The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses., Results: One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%)., Conclusion: A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.

Mobile fracture prevention services, with DXA, significantly improved access to care for those at high risk of fracture living in rural areas. Introduction of mobile services facilitated access to fracture liaison services and development of integrated of care pathways across community- and secondary-based care., Introduction: The ageing population is growing faster in rural areas, yet most fracture prevention services are located in urban areas. As part of a wider study, evaluating the introduction of mobile fracture prevention services, we focus on whether mobile services improve access to care for those at highest risk of fracture., Methods: Services outcomes were assessed against the Royal Osteoporosis Society clinical standards for fracture liaison services. This included standardised, age-specific referral rates, FRAX 10-year probability of major osteoporotic and hip fracture of referrals, pre- and post-introduction of the mobile service across two island and one rural mainland sites. This was compared with referrals from a similar rural mainland region with local access to a comprehensive service., Results: Greatest impact occurred in areas with most limited service provision at baseline. Mean age of patients referred increased from 59 to 68 years (CI 6.8-10.1, p < 0.001). Referral rates increased from 2.8 to 5.4 per 1000 population between 2011 and 2018, with a 5-fold rise in those ≥ 75 years (0.4 to 2.0 per 1000). Mean FRAX 10-year risk of major osteoporotic fracture increased from 12.7 to 17.7% (CI 3.2-5.7, p < 0.001). Mean hip fracture risk probability increased from 3.0 to 5.7% (CI 2.0-3.4, p < 0.001). However, referral rates from the mobile sites remained lower than the comparator site., Conclusions: Mobile fracture prevention services, including DXA, greatly improved uptake amongst high-risk individuals. Mobile services facilitated development of integrated of care pathways, including fracture liaison services, across community- and secondary-based care.

This study was carried out to describe the profile of prescription of antiosteoporotic treatment at discharge after a hip fracture in the Spanish National Hip Fracture Registry. Prescription rates among hospitals ranged from 0 to 94% of patients discharged. The prescription rate was higher among patients with better cognitive and functional baseline status., Purpose: National hip fracture registries are useful for assessing current care processes. The goals of this study were as follows: first, to know the rate of antiosteoporotic prescription at discharge among hip fracture patients in hospitals participating in the Spanish National Hip Fracture Registry (RNFC); second, to compare the differences between treated and non-treated patients; third, to analyze patients' characteristics associated with antiosteoporotic prescription at discharge; and fourth, to evaluate whether there were differences in the profile of patients discharged from hospitals with high and low prescription rates., Method: Patients discharged after a fragility hip fracture in 2017 and participating in the RNFC were included. Demographic variables, cognitive and functional status, prefracture osteoporosis treatment, fracture type, anesthetic risk, hospital volume, and antiosteoporotic prescription at discharge were analyzed. Given that patients were clustered within hospitals, intraclass correlation was calculated and generalized estimating equations were fitted., Results: A total of 6701 patients from 54 hospitals were included. Antiosteoporotic prescription at discharge was prescribed to 36.5% (CI95% 35.8-37.2%), with a wide inter-hospital variability (range 0-94%). The intraclass correlation due of clustering of patients within hospitals was 47.9%. Antiosteoporotic prescription was more likely in patients who were younger, lived at home, previously treated for osteoporosis, had better baseline functional and cognitive status, lower anesthetic risk, and were discharged from high-volume hospitals, all with p < 0.001. The general profile of patients discharged from hospitals with high and low rate of prescription was similar., Conclusions: There is a wide variability between hospitals regarding antiosteoporotic prescription after hip fracture. This is more likely to be initiated in patients with better clinical, functional, and mental status and in those discharged from hospitals with larger volumes of patients. These results offer insights regarding the selection of patients receiving secondary prevention and raises questions on who and how many should be treated.

Cost-effective preventive interventions are necessary for tackling the increasing number of hip fractures, which are frequently occuring as a serious consequence of osteoporosis. Several interventions have been available for preventing and treating osteoporosis. The aim of this study was to systematically review and critically appraise studies that assessed cost-effectiveness of hip protectors for the prevention of hip fractures and to investigate the effects of age, gender and residence situation on cost-effectiveness. A systematic review was conducted in order to identify economic evaluation studies examining the hip protector solely or compared to no treatment according to the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Synthesis of results was performed to observe trends between the studies. Methodological quality of the studies was assessed by the use of the Quality of Health Economic Studies (QHES) instrument. A total of 15 economic evaluation studies were included for analysis. The methodological quality was high in most studies (13/15). The hip protector was solely evaluated in three studies and within 12 other studies compared with no intervention. All studies that investigated the cost-effectiveness in long-term care facilities revealed that hip protector use is a cost-effective strategy for the prevention of hip fractures in elderly. Cost-effectiveness was also observed in two studies that provided hip protectors in a geriatric hospital ward. Four studies included both community-dwelling residents and residents living in a long-term care facility in their study. These studies showed more variability regarding cost-effectiveness. One study did not report information regarding the residence situation of their cohort, but also observed cost-effectiveness. In conclusion, this review suggests that hip protectors are a cost-effective approach in the prevention of hip fractures in populations with high risk of hip fractures especially in long-term care facilities and a geriatric ward in a hospital.

Background/aim: β1-selective beta-blockers (BBs) are sympatholytic agents, and discerning their effects on bone health would be of great importance. This study aimed to investigate the influence of β1-selective BBs on bone mineral density (BMD) and fracture risk., Materials and Methods: This study included postmenopausal women who used β1-selective BBs (BB group) and control group. Sociodemographic characteristics, BMD and previous fragility fractures were recorded. Additionally, the 10-year probability of a major osteoporotic and hip fracture was calculated using the fracture risk assessment tool (FRAX)., Results: A total of 60 participants were included in the study. L1-4 and L2-4 BMD values were significantly higher in BB group than control group (P = 0.015 and P = 0.025, respectively). Moreover, T-scores of lumbar and femur total were significantly higher in the BB group. Two patients in BB and 6 patients in control group had previous fragility fracture. No statistically significant intergroup difference was noted regarding FRAX., Conclusion: Based on our results, β1-selective BB usage was associated with higher BMD at the lumbar region in postmenopausal women., Competing Interests: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

This qualitative study identified the barriers to the implementation of a multidisciplinary co-management program for older hip fracture patients and provided evidence for future intervention improvement and scale-up., Introduction: Multidisciplinary co-management has been recommended as an effective intervention for hip fracture management in older people. This study is a process evaluation of a multidisciplinary co-management program in an orthopaedic hospital in Beijing, China, to better understand the barriers to implementation., Methods: Data collection involved semi-structured interviews with key implementers of the co-management intervention (surgeon, geriatrician, physician, nurse, physiotherapist and anaesthetist) and observations of patients' journey to map the care processes were conducted in Beijing Jishuitan Hospital. Data were transcribed, qualitatively coded and analysed using normalization process theory to understand the intervention process from four constructs: coherence, cognitive participation, collective action and reflexive monitoring., Results: Ten stakeholder interviews were conducted. Despite multidisciplinary co-management intervention was meaningful and valued by participants, barriers to its implementation were identified. These included unmatched investment and benefit (cognitive participation), challenges of facing increased workload (collective action), deficient training and supervision system (collective action), limited accommodating capacity of hospital (collective action) and difficulties in accessing information about the effect of the intervention (reflexive monitoring)., Conclusions: Multiple barriers to the effective implementation of the multidisciplinary co-management program in China were identified. The process evaluation highlights key aspects in less willingness to fully invest in the program, inappropriate workload allocation and lack of training and supervision which need to be addressed before scaling up.

Introduction The number of fragility hip fractures (>60 years) are estimated to triple/quadruple by 2050. It is estimated that the prevalence of patient's contralateral hip fractures (HF2s) will increase also. Methods Single hospital, Retrospective review, 2013-2017, Radiograph review, n = 822. Results Management of patient's 2nd hip fractures accounted for 10.5% of all hip fracture surgeries. ~50% occurred within 3 years of the 1st hip fracture. There was no statistically significant difference in discharge destination, length-of-stay or mortality between the HF1 and HF2 cohorts. Discussion Patients with HF2s comprised a significant and stable proportion of all hip fractures treated. We advocate for the provision of a Fracture Liaison Service in each of the 16 hip fracture operating hospitals in Ireland to optimise the secondary prevention of hip fractures., Competing Interests: The authors have no conflicts of interest to disclose.

Background: Vitamin D and calcium are important dietary compounds that affect bone mass, even if other minerals (potassium, zinc, etc.) and vitamins (A, C and K) are also involved. Vitamin D and certain minerals, in fact, play an important role in calcium homeostasis and calcium absorption. Hip fracture incidence is higher in Europe and the United States, where calcium is frequently included in the human diet; while the occurrence of these fractures is lower in developing countries, where diets are often poor in calcium. This condition is named the "calcium paradox", and may be partially explained by phosphate toxicity, which can negatively affect mineral metabolism. It is important to maintain correct dietary calcium-phosphate balance in order to have a healthy life, reducing the risk of osteoporotic fractures in older people. Vitamin D can also act as a hormone; vitamin D2 (ergocalciferol) is derived from the UV-B radiation of ergosterol, the natural vitamin D precursor detected in plants, fungi, and invertebrates. Vitamin D3 (cholecalciferol) is synthesized by sunlight exposure from 7-dehydrocholesterol, a precursor of cholesterol that can also act as provitamin D3. Dietary intake of vitamin D3 is essential when the skin is exposed for short periods to ultraviolet B light (UV-B), a category of invisible light rays such as UV-A and UV-C. This can be considered the usual situation in northern latitudes during the winter season, or the typical lifestyle for older people and/or for people with very white delicate skin. The actual recommended daily intake of dietary vitamin D is strictly correlated with age, ranging from 5 μg for infants, children, teenagers, and adults-including pregnant and lactating women-to 15 μg for people over 65 years.

Vitamin D deficiency is widespread in geriatric patients. While vitamin D deficiency is prevalent in about 50% of healthy older adults, the prevalence in geriatric patients with hip fracture increases to over 80%. This is partly due to the fact that sunlight is unreliable as the main source of vitamin D. In addition to insufficient sun intensity from November to April, skin aging plays an important role; it causes a 4-fold reduction in the skin's own vitamin D production during sunshine exposure in older adults compared with younger people. Immobility and institutionalization are additional risk factors for vitamin D deficiency in geriatric patients. At the same time, vitamin D deficiency (< 20 ng/ml) increases parathyroid hormone levels and thus promotes bone loss and the risk of fracture. Severe vitamin D deficiency (< 10 ng/ml) may also lead to reversible muscle weakness resulting in an increased risk of falling. Since falls affect at least every second geriatric patient and hip fractures increase exponentially after the age of 75, the correction of vitamin D deficiency is an important medical and public health effort in these patients. Several randomized intervention trials, comparing 800-1000 IU vitamin D/day versus placebo or calcium, showed a significant reduction in falls and hip fractures in adults ≥65 years of age who had an increased risk of vitamin D deficiency and of falls or fractures. In geriatric patients, implementing vitamin D supplementation at this dosage is currently preferred. A bolus dose of over 24,000 IU/month should be avoided due to the increased risk of falls and fractures. These recommendations remain relevant after a critical review of the four most recent meta-analyses.

Osteoporosis is highly prevalent but underdiagnosed and undertreated in Hong Kong. Fragility fractures associated with osteoporosis often result in loss of independence and increased mortality for home-dwelling patients, imposing a high socio-economic burden on society. This issue requires urgent attention given the rapid growth of the elderly population in Hong Kong by approximately 4.3% each year. To address this situation, a group of experts convened to discuss practical ways to reduce the burden of fractures and formulated three recommendations: first, all men (aged ≥70 years) and women (aged ≥65 years) should receive universal dual-energy X-ray absorptiometry assessment for osteoporosis. Second, all men (aged ≥70 years) and women (aged ≥65 years) with a fracture-risk assessment-derived 10-year risk (hip fracture with bone mineral density) ≥3% should receive ≥3 years of anti-osteoporotic treatment. Third, comprehensive structured assessment (including dual-energy X-ray absorptiometry) should be conducted in older patients with a history of falling. By implementing these recommendations, we estimate that we could prevent 5234 hip fractures in 10 years, an annual incidence reduction of approximately 7%, and save HK$425 million in direct medical costs plus substantial indirect savings. Ample clinical and cost-effectiveness data support these recommendations, and studies in Hong Kong and abroad could serve as models on how to implement them. We are confident that by applying these recommendations rigorously and systematically, a significant reduction in hip fractures in Hong Kong is achievable., Competing Interests: This publication is funded by a supportive grant from Amgen Asia Holding Limited to the Hong Kong Osteoporosis Foundation (HKOF) and the Osteoporosis Society of Hong Kong (OSHK) Consensus Group on Prevention of Fractures in Older People. All authors declare that they have no additional conflicts of interest.

Purpose of Review: We review the literature on hip fracture mechanics and models of hip strain during exercise to postulate the exercise regimen for best promoting hip strength., Recent Findings: The superior neck is a common location for hip fracture and a relevant exercise target for osteoporosis. Current modelling studies showed that fast walking and stair ambulation, but not necessarily running, optimally load the femoral neck and therefore theoretically would mitigate the natural age-related bone decline, being easily integrated into routine daily activity. High intensity jumps and hopping have been shown to promote anabolic response by inducing high strain in the superior anterior neck. Multidirectional exercises may cause beneficial non-habitual strain patterns across the entire femoral neck. Resistance knee flexion and hip extension exercises can induce high strain in the superior neck when performed using maximal resistance loadings in the average population. Exercise can stimulate an anabolic response of the femoral neck either by causing higher than normal bone strain over the entire hip region or by causing bending of the neck and localized strain in the superior cortex. Digital technologies have enabled studying interdependences between anatomy, bone distribution, exercise, strain and metabolism and may soon enable personalized prescription of exercise for optimal hip strength.

Hip fractures in the elderly account for more than half of osteoporotic fractures and represent a substantial economic and social burden. Novel coronavirus pneumonia (COVID-19), which began to spread in December 2019, has created challenges in the management of elderly hip fracture patients, not only by influencing the choice of operation and postoperative rehabilitation methods, but also by generating new risks for the medical staff. During this period, our infection and orthopedic treatment unit in the center of the epidemic area effectively treated 82 elderly patients with hip fracture, and no cross-infection occurred. Therefore, our experience in prevention and treatment is worth recommending to frontline anti-epidemic personnel.

We assessed the context in which a hip Fracture Liaison Service was implemented. We conducted semi-structured interviews with 21 key informants at two time points to understand organizational readiness, facilitators, and barriers to change. We identified strategies important to successful implementation, particularly in the context of change fatigue., Purpose: Fracture Liaison Service (FLS) is effective for secondary fracture prevention. Two hospital sites implemented FLS for hip fracture patients, 50 + years, in Alberta, Canada. We assessed organizational readiness, facilitators, and barriers to change to better understand the context in which the FLS was implemented to inform its potential spread provincially., Methods: We recruited individuals involved in FLS implementation at provincial and site levels to participate in telephone interviews at baseline and 16 months post-implementation. Interviews were transcribed and analyzed using thematic content analysis. In addition, site-level participants were invited to complete the Organizational Readiness to Implement Change tool at baseline., Results: We conducted 33 semi-structured interviews (20 at baseline; 13 at post-implementation) with 21 key informants. Participants included managers (24%), FLS physicians/clinical nurses (19%), operational/leadership roles (19%), physicians/surgeons (14%), pharmacists (10%), nurse practitioners (10%), and social work (5%). Seventeen site-level participants completed the ORIC tool at baseline; all participants scored high (71%) or neutral (29%). We found that the use of several strategies, including demonstrating value, providing resources, and selecting appropriate sites, were important to implementation, particularly in the context of change fatigue. Participants perceived the FLS as acceptable and there was evidence of facilitated learning rather than simply monitoring implementation as intended., Conclusions: An effective change management approach neutralized change fatigue. This approach, if maintained, bodes well for the potential spread of the FLS provincially if proven effective and cost effective. Change readiness assessment tools could be used strategically to inform the spread of the FLS to early adopter sites.

A reduction in hip fracture incidence following population screening might reflect the effectiveness of anti-osteoporosis therapy, behaviour change to reduce falls, or both. This post hoc analysis demonstrates that identifying high hip fracture risk by FRAX was not associated with any alteration in falls risk., Introduction: To investigate whether effectiveness of an osteoporosis screening programme to reduce hip fractures was mediated by modification of falls risk in the screening arm., Methods: The SCOOP study recruited 12,483 women aged 70-85 years, individually randomised to a control (n = 6250) or screening (n = 6233) arm; in the latter, osteoporosis treatment was recommended to women at high risk of hip fracture, while the control arm received usual care. Falls were captured by self-reported questionnaire. We determined the influence of baseline risk factors on future falls, and then examined for differences in falls risk between the randomisation groups, particularly in those at high fracture risk., Results: Women sustaining one or more falls were slightly older at baseline than those remaining falls free during follow-up (mean difference 0.70 years, 95%CI 0.55-0.85, p < 0.001). A higher FRAX 10-year probability of hip fracture was associated with increased likelihood of falling, with fall risk increasing by 1-2% for every 1% increase in hip fracture probability. However, falls risk factors were well balanced between the study arms and, importantly, there was no evidence of a difference in falls occurrence. In particular, there was no evidence of interaction (p = 0.18) between baseline FRAX hip fracture probabilities and falls risk in the two arms, consistent with no impact of screening on falls in women informed to be at high risk of hip fracture., Conclusion: Effectiveness of screening for high FRAX hip fracture probability to reduce hip fracture risk was not mediated by a reduction in falls.

Background: Osteoporosis is the most common condition contributing to 95% of fractures in older patients hospitalized for fracture treatment. Despite the significant impact of fragility fractures on patient morbidity and mortality, efforts in optimizing osteoporotic treatment and prevention remain inadequate. In contrast, in patients with limited life expectancy, withholding specific osteoporosis drug treatment appears reasonable. The threshold between under- and overtreatment is still unclear., Methods: In 2016, we implemented a fracture liaison service (FLS) for 18 months to improve the quality of osteoporosis care. We collected prospectively the patient's history, current treatment for osteoporosis, and risk factors for fragility fractures using a standardized protocol. Recommendations for drug therapy are discussed during the interdisciplinary ward round. The primary outcome parameter was a recommendation for specific osteoporosis drug treatment. We included 681 patients (mean age 82.5 years, 502 (73.7%) females). The inclusion criteria were the following: age of 70 years or older, admission to geriatric fracture center between April 2016 and December 2018., Results: Based on our data, specific osteoporosis drug therapy was recommended in 467 (68.6%) patients. Six hundred fifty-one (95.6%) patients received vitamin D3, and 546 (80.2%) calcium. After adjustment, only age (every 5 years, OR 0.57; 95% CI 0.45-0.72; p < 0.0001), cognitive impairment (OR 0.41; 95% CI 0.23-0.74; p = 0.003), pre-fracture mobility (OR 1.54; 95% CI 1.34-1.75; p < 0.0001), and living in a nursing home (OR 0.52; 95% CI 0.27-0.99; p = 0.049) remained as independent predictors for an indication of specific osteoporosis drug therapy., Conclusion: We found a higher rate of recommendations for specific osteoporosis drug therapy compared with usual treatment rates in literature. Though in some cases withholding of specific osteoporosis drug therapy seems reasonable, the main proportion of fragility fracture patients is undertreated. Our results could be a benchmark for the quality of osteoporosis care in older fragility fracture patients treated in a geriatric fracture center.

This systematic review and meta-analysis showed a significant reduction of (major) osteoporotic fractures and hip fractures after screening using fracture risk assessment and bone densitometry compared with usual care. The results indicate that screening is effective for fracture risk reduction, especially hip fractures. To perform a systematic review and meta-analysis of population screening for high fracture risk on fracture prevention compared with usual care. MEDLINE and Embase were searched for studies published until June 20th 2019. Randomized studies were selected that screened for high fracture risk using at least bone densitometry, screened in a general population, provided subsequent treatment with anti-osteoporosis medication, had a usual care group as comparator, and had at least one fracture-related outcome (all fractures, (major) osteoporotic fractures, or hip fractures). The primary assessment was the hazard ratio (HR) for fracture-related outcomes. All-cause mortality was a secondary outcome. Random-effects models were used to estimate pooled HRs. We identified 1186 potentially eligible articles and included three randomized studies: the ROSE study, the SCOOP study, and the SOS with a total number of N = 42,009 participants. Respectively, 11%, 15%, and 18% of the participants in the intervention group started medication. Meta-analysis showed a statistically significant and clinically relevant reduction of osteoporotic fractures (HR = 0.95, 95% confidence interval (CI) = 0.89-1.00), major osteoporotic fractures (HR = 0.91; 95%CI = 0.84-0.98), and hip fractures (HR = 0.80; 95%CI = 0.71-0.91), but no reduction of all fractures (HR = 0.95; 95%CI = 0.89-1.02). The pooled HR for the secondary outcome all-cause mortality was 1.04 (95% CI = 0.95-1.14). Numbers needed to screen to prevent one fracture were 247 and 272 for osteoporotic fractures and hip fractures, respectively (corresponding to 113 and 124 performed bone densitometry examinations, and 25 and 28 persons being treated). This meta-analysis showed that population screening is effective to reduce osteoporotic fractures and hip fractures. Implementation of screening in older women should be considered as serious option to prevent osteoporotic fractures, especially hip fractures.

Periosteal expansion and bone loss have opposite effects on femur strength. Their combined effect has not been fully understood. Our investigation using a recently developed beam model suggested that periosteal expansion may maintain femur bending stiffness among elderly women, but not help preserve femoral strength and reduce hip fracture risk., Introduction: Periosteal expansion and bone loss are two accompanying biological phenomena in old population. Their combined effect on bone stiffness, strength, and fracture risk is still not clear, because previous studies have reported contradictory results., Methods: A recently developed DXA (dual-energy X-ray absorptiometry)-based beam model was applied to study the effect at the femoral neck. We first made a theoretical analysis. Then, a clinical cohort consisting of 961 women (316 hip fractures and 645 controls, age of 75.9 ± 7.1) was used to investigate the associations quantitatively. We investigated (1) correlations of femoral-neck width and bone mineral density with femoral stiffness and strength; (2) correlations of femoral stiffness, strength, and hip fracture risk index with age; (3) associations of femoral stiffness, strength and fracture risk index with actual fracture status, measured by the area under the curve (AUC) and odds ratio (OR)., Results: The investigation results showed that (i) femoral-neck width had stronger correlation with femoral bending stiffness (r = 0.61-0.82, p < 0.001) than with the other stiffness components, while bone mineral density had stronger correlation with axial/shearing stiffness (r = 0.84-0.97, p < 0.001), strength (r = 0.85-0.92, p < 0.001), and fracture risk index (r = -0.61-0.62, p < 0.001) than with bending stiffness. (ii) The association between femoral bending stiffness and age was insignificant (r = - 0.06-0.05, r > 0.05); The associations of axial/shearing stiffness (r = - 0.27--0.20, p < 0.001), strength (r = - 0.28, p < 0.001), and fracture risk index (r = 0.38, p < 0.001) with age were significant. (iii) Fracture risk index had the strongest association with actual fracture status (AUC = 0.75, OR = 3.19), followed by strength (AUC = 0.74, OR = 2.84) and axial/shearing stiffness (AUC = 0.56-0.65, OR = 2.39-2.49). Femoral bending stiffness had the weakest association (AUC = 0.48-0.69, OR = 1.42-2.09)., Conclusion: We concluded that periosteal expansion may be adequate to maintain femoral bending stiffness among elderly women, but it may not help preserve strength and reduce hip fracture risk.

Objectives: Bisphosphonates are effective at preventing hip fractures among older adults, yet many patients still fracture while on treatment and may benefit from additional preventive interventions. Little data are specifically available to target such efforts among bisphosphonate users. We aimed to identify predictors of hip fracture unique to frail older adults initiating pharmacologic treatment for osteoporosis., Design: Retrospective cohort using 2008-2013 linked national Minimum Data Set assessments, Medicare claims, and nursing home (NH) facility data., Setting: NHs in the United States., Participants: Long-stay NH residents 65 years or older who initiated treatment with a bisphosphonate (N = 17 753). Estimates for bisphosphonate initiators were contrasted with those for calcitonin initiators (control group; N = 5348)., Measurements: Hospitalized hip fracture outcomes were measured using Part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for 36 a priori selected potential predictors., Results: The mean (SD) age of the study population was 84 (8) years, 85% were women, and 51% had moderate to severe cognitive impairment. Predictors associated with a higher risk of hip fracture despite bisphosphonate use included age 75 years or older to 85 years (vs ≥65 to <75 y; HR = 1.25; 95% CI = 1.02-1.55), female sex (HR = 1.33; 95% CI = 1.06-1.67), white race (vs black race (HR = 1.87; 95% CI = 1.36-2.58), and body mass index = 18.5-24.9 (vs ≥30; HR = 1.93; 95% CI = 1.53-2.42). Independent ability to transfer (vs total dependence; HR = 3.11; 95% CI = 1.83-5.30) and occasional urinary incontinence (vs frequent; HR = 1.45; 95% CI = 1.18-1.78) were also important predictors. Dementia, diabetes, psychoactive drug use, and other characteristics were not associated with post-prescribing hip fracture. Predictors did not differ between bisphosphonate and calcitonin users., Conclusion: Predictors of hip fracture among frail older adults did not differ between those who were new users of bisphosphonates vs calcitonin. Given the absence of risk factors unique to bisphosphonate users, targeting of fracture prevention efforts should extend beyond pharmacologic therapy to include existing nonpharmacologic therapies, particularly fall prevention strategies. J Am Geriatr Soc 68:256-260, 2020., (© 2019 The American Geriatrics Society.)

Introduction: We present the second implementation of a fracture liaison service (FLS) at a national level in Greece., Methods: This was a multicenter prospective study, organized by the Hellenic Society for the Study of Bone Metabolism, aiming to investigate the tracking and outcome of patients with low-trauma fractures visiting four university orthopedic departments across the country. The primary endpoint was the participation rate of eligible patients with low-trauma fractures in the program within a time frame of 1 year. Secondary outcomes included the percentage of patients initiating osteoporosis treatment, adherence to treatment, and the percentage of patients experiencing subsequent fractures. A major difference with previous reports was the designed implication of the orthopedic surgeon managing the fracture., Results: Among the 1350 eligible patients with major osteoporotic fractures, only 396 (29.3%; mean age 78.1 ± 11.6 years; female/male ratio: 4.4) agreed to participate, nearly all of the latter (n = 392) completing the study. With the exception of seven patients, all participants were receiving anti-osteoporotic treatment at the end of the study. Twelve new fractures were recorded at completion of the 12-month follow-up, which were all sustained in patients who either declined to receive anti-osteoporotic treatment or who discontinued treatment despite advice to the contrary., Conclusion: The participation rate remains low and needs improvement. However, we report herein that whenever the treating physician is involved in the FLS structure, patients are more easily convinced to complete the program, to receive anti-osteoporotic treatment, and to stay connected throughout with the outpatient clinic.

Various mechanical and biomechanical test systems to evaluate the effectiveness of hip protectors designed to prevent hip fracture as a result of falls were examined in this review. The articles considered were selected systematically. The effect of differences in design criteria was demonstrated, and it was observed that the impact energy employed during testing dramatically affects the performance of the hip protector. Over the past three decades, researchers have continuously experimented with various systems to determine the efficacy of various hip protectors. The primary aim has been to make informed decisions in optimizing hip protector design. This article provides a systematic review of various test systems employed in the determination of the biomechanical efficacy of hip protectors. A systematic literature search was carried out, and 28 relevant articles were included to demonstrate the effect of test systems in the evaluation of the biomechanical effectiveness of hip protectors. Methodological studies illustrated the appropriate use of impact testing systems for the simulation of hip anatomy and fall dynamics in evaluating the effectiveness of hip protectors in preventing a hip fracture. This systematic review has demonstrated the effect of the variability of test systems on the evaluation of impact attenuation by various hip protectors. The lack of standardized test systems accounts for the inconsistencies in the test results of the efficacy of hip protectors. This has been a major challenge in the efforts of researchers to optimize the interventions. The standardization of test systems may require needed improvements immediately as opposed to the development of new interventions in order to ensure that only hip protectors with adequately proven efficacies are deployed for clinical trials or for the protection of the hips of vulnerable individuals from sideways impact.

Purpose : Antiresorptive agents, such as bisphosphonates, are useful for the prevention of the recurrence of hip fractures. However, their administration has a risk of antiresorptive agent-related osteonecrosis of the jaw (ARONJ), and risk factors include poor oral hygiene. It is difficult for an orthopedic surgeon to examine a patient's oral condition thoroughly. This study evaluated the relationship between risk factors for ARONJ and intraoral findings in hip fracture patients. Materials and Methods : We evaluated 79 patients (average age of 82.2 years) with hip fracture surgery who underwent an oral assessment by dentists. The risk assessments of the intraoral findings were classified into four levels (levels 0-3), with levels 2 and 3 requiring dental treatment intervention. Data that could be extracted as risk factors of ARONJ were also examined. Results : Level 1 was found most frequently (54.4%), followed by level 0 (35.4%), level 2 (8.9%), level 3 (1.3%). The area under the receiver operating characteristic curve for the number of risk factors for the two groups (dental treatment intervention required and unnecessary) and oral findings were 0.732. When the cut-off value was set to two risk factors, the specificity and sensitivity was 53.5% and 87.5%. Conclusions : For hip fracture patients with a more than 2 risk factors, dental visits are recommended to prevent ARONJ. This is a useful evaluation method that can be used to screen for ONJ from data obtained from other risk factors, even if it is difficult to evaluate the oral condition in hospitals where dentists are absent. J. Med. Invest. 67 : 328-331, August, 2020.

Background: Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values., Objective: We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds., Design and Participants: This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center., Intervention: A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated 1 their 10-year MOF and hip fracture risk using FRAX and 2 their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation., Main Measures: We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%)., Key Results: Among 85 women (median [IQR] age 62 [58-67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9-22.0]; hip fracture risk, 3.3% [1.3-5.3]), 46% declined (MOF risk, 9.5% [6.5-11.6]; hip fracture risk, 1.8% [0.6-2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8-20.2]; hip fracture risk, 4.4% [1.7-4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9-15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4-9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0-8.5; p = 0.105)., Conclusions: Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.