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This study was conducted to investigate the effects of depression and antidepressant medications on hip fracture. The database of the Taiwan National Health Insurance with medical records of more than 1,000,000 individuals was searched for patients who had hip fracture with or without depression from 1998 to 2009. Patients with the following conditions were excluded: hip fracture due to cancer or traffic accidents, hip fracture that occurred before the diagnosis of depression, and use of antidepressants before the diagnosis of depression. A matched cohort of 139,110 patients was investigated, including 27,822 (17,309 females; 10,513 males) with depression and 111,288 (69,236 females; 42,052 males) without depression (1:4 randomly matched with age, sex, and index date). Among these patients, 232 (158 females and 74 males) had both hip fracture and depression, and 690 (473 females and 217 males) had hip fracture only. The Cox proportional-hazards regression method was used to determine the effect of depression on hip fracture. The hazard ratio (HR) for each clinical parameter was calculated after adjusting for confounders including sex, age, Charlson comorbidity index, urbanization, osteoporosis, and antidepressants. Results showed that patients with major depressive disorder had a 61% higher incidence of hip fracture than those without depression (HR 1.61, 95% confidence interval [CI] 1.19-2.18, P = 0.002). The risk of hip fracture for patients with less severe depressive disorder (dysthymia or depressive disorder, not otherwise specified) was not statistically higher than that of patients with no depression (HR 1.10, 95% CI = 0.91-1.34, P = 0.327). Among the patients with depression, females had a 49% higher incidence for hip fracture than males (HR 1.49, 95% CI 1.30-1.72, P < 0.001). The incidence of hip fracture also increased with age and Charlson comorbidity index scores. Analyses of both all (139,110) patients and only patients (27,822) with depression revealed that antidepressants had no negative impact on the incidence of hip fracture. In conclusion, major depression was found to be a risk factor for hip fracture and that use of antidepressants had no adverse effect on hip fracture in the Taiwanese population., Competing Interests: The authors have no conflicts of interest to disclose.

Several factors impede the implementation of effective strategies for fall and fracture prevention. The Centre of Expertise for Fall & Fracture prevention Flanders organized a symposium, "Implementation of fall en fracture prevention in older people", with the aim to elaborate on the facilitation of effective strategies for falls and fall-related injuries in community-dwelling older people in Flanders. This article summarizes the main bottlenecks for implementation and provides recommendations for optimizing dissemination and implementation.

Background: Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge., Methods: The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates., Results: At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point., Conclusions: A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care., Trial Registration: Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.

Historically, treatment decisions for osteoporosis were based on bone mineral density. However, many fractures occur in patients with T-scores outside the osteoporotic range, emphasizing the importance of multi-factorial risk assessments. The World Health Organization Fracture Risk Assessment Tool (FRAX) predicts 10-year risk of osteoporotic fracture. We hypothesized that physicians' clinical estimates of osteoporotic fracture risk would differ significantly from that calculated by FRAX. Thus, treatment decisions would differ depending whether or not physicians used FRAX. A survey consisting of five clinical scenarios was administered to 76 endocrinologists, family physicians, internists, and internal medicine residents. They were asked to estimate the osteoporotic fracture risk and decide whether they would offer preventative treatment. Their estimates were compared to the risk predicted by FRAX and national treatment threshold guidelines. The primary outcome was the difference between the participant's estimate and the FRAX-based estimate of the 10-year risk of osteoporotic fracture for each scenario. In each scenario, physicians statistically significantly over-estimated fracture risk compared to that predicted by FRAX. Estimates for hip fracture risk were 2-4 times higher than FRAX estimates. The major osteoporotic fracture risk at which participants would offer treatment varied with physician group, with endocrinologists, family physicians, and residents requiring a 10-20 % 10-year risk, while internal medicine physician thresholds ranged from 2 to 20 %. Physicians greatly over-estimated the risk of hip fracture based on clinical information. FRAX is necessary to accurately quantify risk, but because physicians varied in the level of risk required before they would offer treatment, uniform approaches to risk estimation may still not result in uniform clinical treatment decisions.

The incidence of second hip fractures occurring within a year of initial fractures is 20%-45%. The high incidence of second hip fractures in this period can be attributed to the rapid bone loss that occurs during this time. Restoring bone mass at an early stage after hip fractures is critical for preventing subsequent fractures. The aim of this study was to investigate the efficacy of monthly minodronate therapy (50 mg/4 wk) for preventing bone loss over a 9-mo period following hip fractures. Minodronate was administered monthly to 51 patients (44 females), beginning within 3 mo after hip fracture surgery. The mean (±standard deviation) age of the patients was 82.0 ± 0.9 yr. Demographics, mobility status, bone turnover makers, and bone mineral density (BMD) in the lumbar spine and proximal femur (including femoral neck and total hip BMD) were examined prior to and after 9 mo of treatment. Lumbar BMD was increased by 2.7% ± 4.4% (p < 0.001) compared to the baseline values. However, femoral neck and total hip BMD did not significantly change. Bone formation and resorption markers both decreased by approximately 70% during treatment. Monthly treatment with minodronate did not adversely affect the healing process on the fracture site or the patients' laboratory results. The patients who were independently mobile prior to injury exhibited greater recovery of BMD in the femoral neck during the 9-mo treatment period. Monthly minodronate therapy during the early stages after hip fractures has favorable effects on restoring overall lumbar BMD and contralateral femoral neck BMD in patients with independent mobility prior to fractures., (Copyright © 2016 International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: In the 8 years since the launch of the FRAX tool, it has continued to grow with the addition of new country or territory models. Although the core of the fracture risk algorithm remains unchanged, there is growing evidence of possible additional independent clinical variables that might modulate the interpretation of the FRAX outputs. There is also an expanding number of international guidelines that incorporate FRAX assessments, leading to discussions on the use of FRAX in treated patients and the determination of intervention thresholds., Recent Findings: This review encompasses recent information on the use of FRAX in immigrant populations and the potential influence of skeletal and extraskeletal risk factors on FRAX estimations. For example, trabecular bone score and falls risk appear to be promising additional factors in individual risk assessment. FRAX appears to remain accurate in those on osteoporosis treatments, but FRAX is not a suitable tool for use in treat-to-target strategies., Summary: The assessment of fracture risk in immigrants is probably more accurate with the use of the FRAX tool for the country of origin, if available. The impact of additional risk variables will need evaluation of the impact of these on recharacterizing patients by moving them across intervention thresholds.

Low serum 25-hydroxyvitamin D (25(OH)D) levels are implicated as a risk factor for hip and spine fractures. Studies of the relation between 25(OH)D levels and fractures have primarily involved elderly osteoporosis patients or patients with fractures; however, the serum 25(OH)D and parathyroid hormone (PTH) status in younger adult populations remains largely unknown. We evaluated serum 25(OH)D and intact PTH levels in 411 women aged 39-64 years who were not receiving medication for osteoporosis or other bone diseases. Serum 25(OH)D levels were positively correlated with age (P = 0.019), whereas intact PTH levels were inversely correlated with 25(OH)D levels (P < 0.001). Thus, low vitamin D levels with high intact PTH levels were more common in younger than in older women. Our data show that serum 25(OH)D insufficiency could be a more serious concern in the younger population than had been previously anticipated. Because serum 25(OH)D insufficiency is reportedly a risk factor for hip and spine fracture, the number of fracture patients could increase in the future, suggesting that we may need to correct the serum vitamin D/intact PTH status to prevent future osteoporosis.

As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: Fall-related injuries among the elderly, specifically hip fractures, cause significant morbidity and mortality as well as imposing a substantial financial cost on the health care system. Impact-absorbing flooring has been advocated as an effective method for preventing hip fractures resulting from falls. This study identifies the cost-effectiveness of impact-absorbing flooring compared to standard flooring in residential care facilities for the elderly in a Swedish setting., Method: An incremental cost-effectiveness analysis was performed comparing impact-absorbing flooring to standard flooring using a Markov decision model. A societal perspective was adopted and incremental costs were compared to incremental gains in quality-adjusted life years (QALYs). Data on costs, probability transitions and health-related quality of life measures were retrieved from the published literature and from Swedish register data. Probabilistic sensitivity analysis was performed through a Monte Carlo simulation., Results: The base-case analysis indicates that the impact-absorbing flooring reduces costs and increases QALYs. When allowing for uncertainty we find that 60% of the simulations indicate that impact-absorbing flooring is cost-saving compared to standard flooring and an additional 20% that it has a cost per QALY below a commonly used threshold value, Conclusions: : Using a modelling approach, we find that impact-absorbing flooring is a dominant strategy at the societal level considering that it can save resources and improve health in a vulnerable population., (© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Chronic bisphosphonate therapy is associated with atypical fractures of the subtrochanteric and proximal femoral diaphyseal regions. Various radiologic imaging signs can identify bisphosphonate-associated stress fractures before they progress to complete fractures. Identifying patients who are at risk and modifying treatment can prevent these fractures from occurring. We present a case study of a patient taking bisphosphonate with 2 years of chronic pain, and characteristic clinical signs of bisphosphonate-associated incomplete stress fractures that went untreated until the patient suffered from a right subtrochanteric complete fracture. Our goal is to make physicians aware of the signs of insufficiency fractures associated with chronic bisphosphonate therapy such that appropriate clinical decisions are made to optimize the quality of patient care., (© Copyright 2016 by the American Board of Family Medicine.)

Importance: Considerable efforts have been undertaken to relate single nutrients to bone health. To this point, results are inconsistent. Suboptimal single nutrient intake does not occur in isolation but rather reflects a poor diet quality., Objective: To assess the association between adherence to a diet quality index constructed on the basis of dietary recommendations or existing healthy dietary patterns and fractures in postmenopausal women., Design, Setting, and Participants: Post hoc analysis was conducted of longitudinal data from 40 clinical centers throughout the United States included in the Women's Health Initiative (WHI) observational study. Participants in the prospective cohort included 93 676 women who were eligible for the WHI if they were aged 50 to 79 years. Recruitment was conducted from October 1, 1993, to December 31, 1998, with the study ending August 29, 2014. The WHI food frequency questionnaire was used to derive nutrient and food intake at baseline. Diet quality and adherence were assessed by scores on the alternate Mediterranean Diet (aMED), a 9-category measure of adherence to a Mediterranean dietary pattern; the Healthy Eating Index 2010 (HEI-2010), a 100-point measure of 12 food components; the 11-item Alternate Healthy Eating Index 2010 (AHEI-2010); or the 8-component Dietary Approaches to Stop Hypertension (DASH) diet score., Main Outcomes and Measures: Outcome measures included incident total and hip fractures. Hazard ratios (HRs) by quintiles of dietary index scores were estimated using Cox proportional hazards regression analyses., Results: Of the 93 676 participants, 90 014 were included in the analysis (mean [SD] age, 63.6 [7.4]) years. During a median follow-up time of 15.9 years, there were 2121 cases of hip fractures and 28 718 cases of total fractures. Women scoring in the highest quintile (Q5) of the aMED index had a lower risk for hip fractures (HR, 0.80; 95% CI, 0.66-0.97), with an absolute risk reduction of 0.29% and a number needed to treat of 342 (95% CI, 249-502). No association between the aMED score and total fractures was observed (Q5 HR, 1.01; 95% CI, 0.95-1.07). Higher HEI-2010 or DASH scores tended to be inversely related to hip fracture risk, but the results were nonsignificant (Q5 HR, 0.87; 95% CI, 0.75-1.02; and Q5 HR, 0.89; 95% CI, 0.75-1.06, respectively). The AHEI-2010 score was associated with neither hip nor total fractures., Conclusions and Relevance: Higher adherence to a Mediterranean diet is associated with a lower risk for hip fractures. These results support that a healthy dietary pattern may play a role in maintaining bone health in postmenopausal women.

Unlabelled: There is variation in how services to prevent secondary fractures after hip fracture are delivered and no consensus on best models of care. This study identifies healthcare professionals' views on effective care for the prevention of these fractures. It is hoped this will provide information on how to develop services., Introduction: Hip fracture patients are at high risk of subsequent osteoporotic fractures. Whilst fracture prevention services are recommended, there is variation in delivery and no consensus on best models of care. This study aims to identify healthcare professionals' views on effective care for prevention of secondary fracture after hip fracture., Methods: Forty-three semi-structured interviews were undertaken with healthcare professionals involved in delivering fracture prevention across 11 hospitals in one English region. Interviews explored views on four components of care: (1) case finding, (2) osteoporosis assessment, (3) treatment initiation, and (4) monitoring and coordination. Interviews were audio-recorded, transcribed, anonymised and coded using NVivo software., Results: Case finding: a number of approaches were discussed. Multiple methods ensured there was a 'backstop' if patients were overlooked. Osteoporosis assessment: there was no consensus on who should conduct this. The location of the dual energy X-ray absorptiometry (DXA) scanner influenced the likelihood of patients receiving a scan. Treatment initiation: it was felt this was best done in inpatients rather request initiation in the post-discharge/outpatients period. Monitoring (adherence): adherence was a major concern, and participants felt more monitoring could be conducted by secondary care. Coordination of care: participants advocated using dedicated coordinators and formal and informal methods of communication. A gap between primary and secondary care was identified and strategies suggested for addressing this., Conclusions: A number of ways of organising effective fracture prevention services after hip fracture were identified. It is hoped that this will help professionals identify gaps in care and provide information on how to develop services.

Objective: The aim of this study was to investigate the association between hormone therapy (HT) use and the development of bone fractures., Methods: Using terms related to HT and fractures, we searched PubMed, Embase, and the Cochrane library for randomized controlled trials on HT and the associated risk of fractures published before August 2014. Two evaluators independently selected studies on the basis of predetermined selection criteria, and 28 studies were included in the meta-analysis. Summary estimates were obtained using fixed- or random-effects models as appropriate., Results: A total of 28 studies included 33,426 participants and 2,516 fractures cases. The overall relative risk of HT was 0.74 (95% confidence interval [CI] 0.69-0.80) for total fractures, 0.72 (95% CI 0.53-0.98) for hip fractures, and 0.63 (95% CI 0.44-0.91) for vertebral fractures. In subgroup analyses, women of an age less than 60 years had lower risk of total fractures compared with women of an age more than 60 years (P = 0.003). Estradiol led to greater decrease in the risk of total fractures compared with conjugated equine estrogens (P =  .01). There is greater reduction in total fracture risk in trials of follow-up less than 36 months than that of follow-up more than 36 months (P = 0.003). No increase in the incidence of total cancer events but an increase in the incidence of thrombus was found to be associated with HT., Conclusions: HT is associated with a reduced risk of total, hip, and vertebral fractures, with a possible attenuation of this protection effect after it is stopped or when it is begun after 60 years. However, there may be an increase in the incidence of thrombus formation associated with HT.

Introduction: Osteoporosis predisposes for a higher risk of hip fracture and its treatment is frequently underprescribed. Our purpose was to assess the relation between having a second hip fracture and receiving osteoporosis treatment. Also to assess the relation between this second fracture and using central nervous system drugs or being institutionalised., Patients and Methods: We reviewed all the patients that were admitted to our hospital with an osteoporotic proximal femoral fracture between September 2009 and February 2011. We identified 685 patients, 74 of which presented a contralateral fracture. We evaluated if they were receiving osteoporosis treatment or taking any medication that could affect the central nervous system and if they were institutionalised., Results: A 10.8% of patients had a second fracture and the mean time between the two of them was 20 months (1-122). There was a clear female predominance (76.35%). The mean age at occurrence of the primary fracture was 83.02 years and 85 for the second. A 90.8% did not follow any type of osteoporosis medication before the first fracture. A 50.9% did not receive central nervous system drugs and 79.1% lived at home at the time of the first fracture. 12.8% of the patients that did not follow the osteoporosis treatment, had a contralateral fracture, 3% more than those that did follow some kind of treatment, but this difference was not significant (p=0.2)., Discussion: We identified a similar number of patients undergoing osteoporotic treatment as registered in literature. There was no significant difference between suffering a second hip fracture and following osteoporosis treatment, using psychotropic drugs or being institutionalised., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

We carried out the study to investigate and quantitatively assess the potential association between current level of physical activity and the risk of osteoporosis hip fracture in older women. Relevant publications before October 2015 were identified using the PubMed and Ovid searching tools. A dose-response meta-analysis was carried out to combine and analysis results. Fourteen prospective studies were included in the meta-analysis. A general analysis of 9 studies showed a significant inverse relationship between increasing level of physical activity and risk of hip fracture in older women [relative risk (RR) = 0.93, 95% confidence interval (95% CI): 0.91-0.96]. The result of a sensitivity analysis was consistent with the general analysis (RR = 0.94, 95% CI: 0.93-0.96). The association between increasing level of physical activity and risk of wrist fracture was not statistically significant in a general analysis of three studies (RR = 1.004, 95% CI: 0.98-1.03). A potential direct association between increasing level of physical activity and risk of wrist fracture was observed after removing 1 study with the greatest weight (RR = 1.01, 95% CI: 1.00-1.03). No significant publication bias was observed in our analysis. Our results show that increasing level of physical activity within an appropriate range may reduce the risk of hip fracture but not the risk of wrist fracture in older women.

Aim: Fracture risk assessment tool® calculations can be performed with or without addition of bone mineral density; however, the impact of this addition on fracture risk assessment tool® scores has not been studied in Indian women. Given the limited availability and high cost of bone mineral density testing in India, it is important to know the influence of bone mineral density on fracture risk assessment tool® scores in Indian women. Therefore, our aim was to assess the contribution of bone mineral density in fracture risk assessment tool® outcome in Indian women., Methods: Apparently healthy postmenopausal Indian women (n = 506), aged 40-72 years, without clinical risk factors for bone disease, were retrospectively selected, and their fracture risk assessment tool® scores calculated with and without bone mineral density were compared., Results: Based on WHO criteria, 30% women were osteoporotic, 42.9% were osteopenic and 27.1% had normal bone mineral density. Fracture risk assessment tool® scores for risk of both major osteoporotic fracture and hip fracture significantly increased on including bone mineral density (P < 0.0001). When criteria of National Osteoporosis Foundation, US was applied number of participants eligible for medical therapy increased upon inclusion of bone mineral density, (for major osteoporotic fracture risk number of women eligible without bone mineral density was 0 and with bone mineral density was 1, P > 0.05, whereas, for hip fracture risk number of women eligible without bone mineral density was 2 and with bone mineral density was 17, P < 0.0001)., Conclusion: Until the establishment of country-specific medication intervention thresholds, bone mineral density should be included while calculating fracture risk assessment tool® scores in Indian women., (© The Author(s) 2016.)

Summary: In patients in the Direct Assessment of Nonvertebral Fractures in Community Experience (DANCE) observational study with and without a prior vertebral or hip fracture, the incidence of nonvertebral fractures was lower with >6 months of teriparatide treatment than during the first 6 months., Introduction: Clinical evidence on the effect of teriparatide in patients with prior fracture is limited. In the DANCE observational study, the incidence of nonvertebral fragility fractures (NVFX) decreased significantly in patients receiving teriparatide for >6 months (6-24 months) versus >0 to ≤6 months (reference period)., Methods: We performed a post hoc analysis to assess the effect of teriparatide 20 μg/day in patients who entered DANCE with prior vertebral or hip fractures. The incidence of patients experiencing a NVFX for four 6-month intervals during and after treatment was compared with the reference period., Results: Overall, 4085 patients received ≥1 dose of teriparatide. Of 3720 with sufficient data for efficacy analysis, 692 had prior vertebral fracture, including 179 with previous kyphoplasty/vertebroplasty; 290 had prior hip fracture. These patients were older, and those with prior vertebral fractures had more comorbid conditions at baseline than those without prior vertebral fractures. The incidence of patients experiencing NVFX declined over time in all patient groups. The fracture incidence rate declined 49 and 46%, respectively, in patients with and without prior vertebral fracture and was 63 and 46% lower in patients with previous kyphoplasty/vertebroplasty and without prior vertebral fracture. NVFX declined 43 and 48% in patients with and without prior hip fracture. The reduced incidence over time was consistent in the subgroups (all interaction p values >0.05). Patients with prior fracture were more likely to experience serious adverse events., Conclusion: The incidence of NVFX decreased over time in patients receiving teriparatide in DANCE regardless of prior fracture status.

Unlabelled: Hip fracture risk is increased by landing on the hip. We examined factors that contribute to hip impact during real-life falls in long-term care facilities. Our results indicate that hip impact is equally likely in falls initially directed forward as sideways and more common among individuals with dependent Activities of Daily Living (ADL) performance., Introduction: The risk for hip fracture in older adults increases 30-fold by impacting the hip during a fall. This study examined biomechanical and health status factors that contribute to hip impact through the analysis of real-life falls captured on video in long-term care (LTC) facilities., Methods: Over a 7-year period, we captured 520 falls experienced by 160 residents who provided consent for releasing their health records. Each video was analyzed by a three-member team using a validated questionnaire to determine whether impact occurred to the hip or hand, the initial fall direction and landing configuration, attempts of stepping responses, and use of mobility aids. We also collected information related to resident physical and cognitive function, disease diagnoses, and use of medications from the Minimum Data Set., Results: Hip impact occurred in 40 % of falls. Falling forward or sideways was significantly associated with higher odds of hip impact, compared to falling backward (OR 4.2, 95 % CI 2.4-7.1) and straight down (7.9, 4.1-15.6). In 32 % of sideways falls, individuals rotated to land backward. This substantially reduced the odds for hip impact (0.1, 0.03-0.4). Tendency for body rotation was decreased for individuals with dependent ADL performance (0.43, 0.2-1.0)., Conclusions: Hip impact was equally likely in falls initially directed forward as sideways, due to the tendency for axial body rotation during descent. A rotation from sideways to backward decreased the odds of hip impact 10-fold. Our results may contribute to improvements in risk assessment and strategies to reduce risk for hip fracture in older adults.

Unlabelled: We analyzed the association of bisphosphonate therapy with mortality and hip refracture incidence among osteoporosis-related hip fracture patients in Austria. Mortality was lower in primarily female bisphosphonate users, while hip refracture incidence was generally elevated relative to controls, indicating beneficial effects of bisphosphonates other than on bone., Introduction: The purpose of this study was to analyze mortality and hip refracture risk in osteoporotic hip fracture patients with and without antiosteoporotic medication., Methods: We retrospectively analyzed data on 31,668 Austrian patients ≥50 years with a hip fracture between July 2008 and December 2010 for antiosteoporotic drug treatment with respect to outcome parameters all-cause mortality, hip refracture incidence, and hip refracture-free days. Outcomes when bisphosphonate (BP) treatment was begun before or after fracture were compared with an age- and sex-matched hip fracture control without antiosteoporotic medication., Results: 27.69 % of patients (33.01 % of women, 13.13 % of men) were prescribed antiosteoporotic medication, primarily BPs. Females having initiated BP treatment before first fracture had lower odds for mortality 1 and 3 year(s) post-fracture, whereas hip refracture incidence under pre-fracture BP initiation was generally higher. Treatment that was started after fracture, however, entailed significantly lower mortality hazards for both genders (HR 0.43, 95 %CI 0.36-0.52, p < 0.0001 after 1 year) but significantly higher hip refracture incidence except for patients aged 50-69 years and more hip refracture free days for females. Hip refractures overall amounted to 29.22/1000 patient years differing significantly between women and men (31.03 vs. 23.89, respectively, p < 0.0001), and longer hip refracture free survival was observed for women than for men (499 vs. 466 median days, respectively, p < 0.0001)., Conclusions: Although BP use is associated with reduced mortality after hip fracture, notably among women, hip refracture incidences are likewise elevated, which is most likely accounted for by a high probability of BP prescription to more comorbid patients suffering from more severe osteoporosis. Concomitantly, through possible effects other than on bone, BPs might be able to curtail mortality. Male hip fracture patients' low treatment frequency in particular reflects underdiagnosis and undertreatment of osteoporosis in Austria.

Purpose: To evaluate the efficiency of a clinical pathway in the management of elderly patients with fragility hip fracture in a second level hospital in terms of length of stay time to surgery, morbidity, hospital mortality, and improved functional outcome., Material and Methods: A comparative and prospective study was carried out between two groups of patients with hip fracture aged 75 and older prior to 2010 (n=216), and after a quality improvement intervention in 2013 (n=196). A clinical pathway based on recent scientific evidence was implemented. The degree of compliance with the implemented measures was quantified., Results: The characteristics of the patients in both groups were similar in age, gender, functional status (Barthel Index) and comorbidity (Charlson Index). Median length of stay was reduced by more than 45% in 2013 (16.61 vs. 9.08 days, p=.000). Also, time to surgery decreased 29.4% in the multidisciplinary intervention group (6.23 vs. 4.4 days, p=.000). Patients assigned to the clinical pathway group showed higher medical complications rate (delirium, malnutrition, anaemia and electrolyte disorders), but a lower hospital mortality (5.10 vs. 2.87%, p>.005). The incidence of surgical wound infection (p=.031) and functional efficiency (p=.001) also improved in 2013. An increased number of patients started treatment for osteoporosis (14.80 vs. 76.09%, p=.001) after implementing the clinical pathway., Conclusion: The implementation of a clinical pathway in the care process of elderly patients with hip fracture reduced length of stay and time to surgery, without a negative impact on associated clinical and functional outcomes., (Copyright © 2015 SECOT. Published by Elsevier Espana. All rights reserved.)

Unlabelled: The present dose-response meta-analysis shows linearly decreased hip fracture (HF) risk and nonlinearly decreased osteoporotic fracture (OF) risk associated with increasing number of parity of up to five live births among postmenopausal women., Introduction: Epidemiological reports suggest that parity is associated with reduced OF risk among women. However, these findings are controversial. Here, we present a meta-analysis of prospective studies of parity in relation to OF risk., Methods: We performed systematic searches using Medline and Embase from January 1, 1966, to December 31, 2014, with limits of language in English and prospective study design. Relative risks (RRs) and confidence intervals (CIs) were derived mainly using random-effects models. Categorical, dose-response, heterogeneity, publication bias, and subgroup analyses were conducted., Results: We analyzed 10 articles of 19 independent reports from 1966 to 2014, comprising a total of 217,295 participants and 26,525 cases of OF. Compared to nulliparous women, the OF and HF risks of parous women with at least one live birth were reduced by 11 % (95 % confidence interval (CI) 3-19 %; I (2) = 77.1 %, p < 0.001) and 26 % (95 % CI 17-35 %; I (2) = 19.5 %, p = 0.287), respectively. Representative nonlinearly and linearly inverse dose-response associations were found between parity (range of 0-6) and OF risk (p nonlinearity = 0.0163; I (2) = 79.7 %, p < 0.001), and between parity (range of 0-5) and HF risk (p nonlinearity = 0.054; I (2) = 76.5 %, p < 0.001), respectively. The lowest risk reduction for OF of 25 % (95 % CI 16-33 %) was observed for five live births. And, the summary risk reduction for HF was 12 % (95 % CI 9-15 %) for each one increased live birth., Conclusions: We found that increasing number of parity is associated with linearly reduced HF risks among women. The association between parity of six or more live births and HF risks should be studied further in future.

Denosumab is an anti-RANK ligand (RANKL) monoclonal antibody approved for the treatment of postmenopausal osteoporosis and prevention of skeletal metastasis complications. Administered subcutaneously every 6 months, it reduces the risk of vertebral fracture by 70% and of hip fracture by 40%. Its safety profile is acceptable. Denosumab may be used to treat patients with moderate to severe renal insufficiency. It has anti-fracture activity equivalent to that of zoledronic acid, but no residual effect, and no action at all beyond 6 months. In France, denosumab is reimbursed as a second-line treatment after a first attempt with bisphosphonate., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: The Norwegian population has among the highest hip fracture rates in the world. The incidence varies geographically, also within Norway. Calcium in drinking water has been found to be beneficially associated with bone health in some studies, but not in all. In most previous studies, other minerals in water have not been taken into account. Trace minerals, for which drinking water can be an important source and even fulfill the daily nutritional requirement, could act as effect-modifiers in the association between calcium and hip fracture risk. The aim of the present study was to investigate the association between calcium in drinking water and hip fracture, and whether other water minerals modified this association., Materials and Methods: A survey of trace metals in 429 waterworks, supplying 64% of the population in Norway, was linked geographically to the home addresses of patients with incident hip fractures (1994-2000). Drinking water mineral concentrations were divided into "low" (below and equal waterworks average) and "high" (above waterworks average). Poisson regression models were fitted, and all incidence rate ratios (IRRs) were adjusted for age, geographic region, urbanization degree, type of water source, and pH of the water. Effect modifications were examined by stratification, and interactions between calcium and magnesium, copper, zinc, iron and manganese were tested both on the multiplicative and the additive scale. Analyses were stratified on gender., Results: Among those supplied from the 429 waterworks (2,110,916 person-years in men and 2,397,217 person-years in women), 5433 men and 13,493 women aged 50-85 years suffered a hip fracture during 1994-2000. Compared to low calcium in drinking water, a high level was associated with a 15% lower hip fracture risk in men (IRR=0.85, 95% CI: 0.78, 0.91) but no significant difference was found in women (IRR=0.98, 95%CI: 0.93-1.02). There was interaction between calcium and copper on hip fracture risk in men (p=0.051); the association between calcium and hip fracture risk was stronger when the copper concentration in water was high (IRR=0.52, 95% CI: 0.35, 0.78) as opposed to when it was low (IRR=0.88, 95% CI: 0.81, 0.94). This pattern persisted also after including potential confounding factors and other minerals in the model. No similar variation in risk was found in women., Conclusion: In this large, prospective population study covering two thirds of the Norwegian population and comprising 19,000 hip fractures, we found an inverse association between calcium in drinking water and hip fracture risk in men. The association was stronger when the copper concentration in the water was high., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Vitamin C sufficiency may help prevent osteoporosis and fractures by mediating osteoclastogenesis, osteoblastogenesis, and bone collagen synthesis., Objective: We determined whether dietary intakes and plasma concentrations of vitamin C were associated with a heel ultrasound and hip and spine fracture risks in older men and women., Design: Participants were recruited from the European Prospective Investigation into Cancer in Norfolk study with 7-d diet diary estimates of vitamin C intake and plasma concentrations. A random subset (4000 of 25,639 subjects) was available for the cross-sectional (ultrasound) study of broadband ultrasound attenuation (BUA) and velocity of sound (VOS), which were determined during the second health examination. The prospective (fracture) study was a case-cohort sample of all participants with a fracture up to March 2009 and the random subset (n = 5319). ANCOVA-determined associations between quintiles of vitamin C intake and plasma status with adjusted BUA and VOS and adjusted Prentice-weighted Cox proportional HRs were calculated for fracture risk., Results: Women were 58% of the population (39-79 y old), and the median follow-up was 12.6 y (range: 0-16 y). Positive associations across all quintiles of vitamin C intake but not plasma status were significant for VOS in men (β = 2.47 m/s, P = 0.008) and BUA in women (β = 0.82 dB/MHz, P = 0.004). Vitamin C intake was not associated with fracture risk, but there was an inverse association with plasma concentrations in men, with quintile 4 having significantly lower risks of hip fractures (HR: 0.35; 95% CI: 0.16, 0.80) and spine fractures (HR: 0.26; 95% CI: 0.10, 0.69) than quintile 1., Conclusions: Higher vitamin C intake was significantly associated with higher heel ultrasound measures in men and women, and higher plasma vitamin C concentrations were significantly associated with reduced fracture risk in men only. Our findings that vitamin C intake and status were inconsistently associated with bone health variables suggest that additional research is warranted., (© 2015 American Society for Nutrition.)

Hip fracture affects more than 250,000 people in the US and 1.6 million worldwide per year. With an aging population, the development of reliable fracture risk models is therefore of prime importance. Due to the complexity of the hip fracture phenomenon, the use of clinical data only, as it is done traditionally, might not be sufficient to ensure an accurate and robust hip fracture prediction model. In order to increase the predictive ability of the risk model, the authors propose to supplement the clinical data with computational data from finite element models. The fusion of the two types of data is performed using deterministic and stochastic computational data. In the latter case, uncertainties in loading and material properties of the femur are accounted for and propagated through the finite element model. The predictive capability of a support vector machine (SVM) risk model constructed by combining clinical and finite element data was assessed using a Women׳s Health Initiative (WHI) dataset. The dataset includes common factors such as age and BMD as well as geometric factors obtained from DXA imaging. The fusion of computational and clinical data systematically leads to an increase in predictive ability of the SVM risk model as measured by the AUC metric. It is concluded that the largest gains in AUC are obtained by the stochastic approach. This gain decreases as the dimensionality of the problem increases: a 5.3% AUC improvement was achieved for a 9 dimensional problem involving geometric factors and weight while a 1.3% increase was obtained for a 20 dimensional case including geometric and conventional factors., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Purpose: To estimate the association between hydroxymethylglutaryl-CoA inhibitor (statin) use and hip fracture., Methods: We conducted a population-based case-control study. Cases were 6774 male enrollees in a large managed care organization, aged 45 or more years, with an incident hip fracture from 1997 to 2006. Controls without fracture (n = 6774) were matched to cases on age, race, and medical center. Electronic information on pharmaceutical use was used to identify the dispensing of statins from 1991 forward., Results: Overall, 1884 (27.8%) cases and 2150 controls (31.7%) used a statin before index date (matched odds ratio [mOR] = 0.81, 95% confidence interval [CI] = 0.74-0.87). Adjustment for comorbidity burden strengthened the magnitude of the overall association (mOR = 0.68, CI = 0.62-0.74). The adjusted association was similar across age groups but was strongest among men aged 80 years or more (mOR = 0.62, CI = 0.54-0.71) and was most pronounced in African Americans (mOR = 0.43, CI = 0.28-0.64). Greater duration of statin use did not alter the odds ratios., Conclusions: These data add to the growing evidence of a potential protective effect of statin use on bone health. However, these results need to be replicated in a prospective study that can account for confounding by indication which may explain these findings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Unlabelled: Fracture Liaison Services are the best model to prevent secondary fractures. The International Osteoporosis Foundation developed a Best Practice Framework to provide a quality benchmark. After a year of implementation, we confirmed that a single framework with set criteria is able to benchmark services across healthcare systems worldwide., Introduction: Despite evidence for the clinical effectiveness of secondary fracture prevention, translation in the real-world setting remains disappointing. Where implemented, a wide variety of service models are used to deliver effective secondary fracture prevention. To support use of effective models of care across the globe, the International Osteoporosis Foundation's Capture the Fracture® programme developed a Best Practice Framework (BPF) tool of criteria and standards to provide a quality benchmark. We now report findings after the first 12 months of implementation., Methods: A questionnaire for the BPF was created and made available to institutions on the Capture the Fracture website. Responses from institutions were used to assign gold, silver, bronze or black (insufficient) level of achievements mapped across five domains. Through an interactive process with the institution, a final score was determined and published on the Capture the Fracture website Fracture Liaison Service (FLS) map., Results: Sixty hospitals across six continents submitted their questionnaires. The hospitals served populations from 20,000 to 15 million and were a mix of private and publicly funded. Each FLS managed 146 to 6200 fragility fracture patients per year with a total of 55,160 patients across all sites. Overall, 27 hospitals scored gold, 23 silver and 10 bronze. The pathway for the hip fracture patients had the highest proportion of gold grading while vertebral fracture the lowest., Conclusion: In the first 12 months, we have successfully tested the BPF tool in a range of health settings across the globe. Initial findings confirm a significant heterogeneity in service provision and highlight the importance of a global approach to ensure high quality secondary fracture prevention services.

Unlabelled: Daily teriparatide injections have been shown to reduce vertebral and non-vertebral fractures. Here, we demonstrate that the magnitude of fracture risk reduction is independent of baseline fracture probability assessed by FRAX., Introduction: Daily administration of 20 or 40 μg teriparatide has been shown to significantly decrease the risk of vertebral and non-vertebral fracture compared with placebo. The aim of the present study was to evaluate fracture risk assessed at baseline using the FRAX® tool and to determine the efficacy of teriparatide as a function of baseline fracture risk., Methods: One thousand six hundred thirty-seven postmenopausal women in the pivotal phase three trial, randomly assigned to receive placebo (n = 544), teriparatide 20 μg per day (n = 541) or teriparatide 40 μg per day (n = 552), were studied. Baseline clinical risk factors were entered into country-specific FRAX models to compute the 10-year probability of major osteoporotic fractures with or without input of femoral neck BMD. Because there was no difference in effect of 20 and 40 μg teriparatide daily on fracture occurrence, the two active groups were merged. The interaction between probability of a major fracture and treatment efficacy was examined by Poisson regression., Results: The 10-year probability of major osteoporotic fractures (with BMD) ranged from 2.2-67.2 %. Treatment with teriparatide was associated with a 37 % decrease in all non-vertebral fractures (95 % CI 10-56 %) and a 56 % decrease in low-energy non-vertebral fractures (95 % CI 24-75 %) compared with placebo. The risk of morphometric vertebral fractures decreased significantly by 66 % (95 % CI 50-77 %). Hazard ratios for the effect of teriparatide on the fracture outcome did not change significantly with increasing fracture probability (p > 0.30). Similar findings were noted for the interaction when BMD was excluded from the FRAX model, or when probability of hip fracture was used as the marker of baseline risk., Conclusion: We conclude that teriparatide significantly decreases the risk of non-vertebral and morphometric vertebral fractures in women by a similar extent, irrespective of baseline fracture probability.

Background: Osteoporosis is a common disease in elderly, characterized by poor bone quality as a result of alterations affecting trabecular bone. However, recent studies have described also an important role of alterations of cortical bone in the physiopathology of osteoporosis. Although dual-energy X-ray absorptiometry (DXA) is a valid method to assess bone mineral density, in the presence of comorbidities real bone fragility is unable to be evaluated. The number of hip fractures is rising, especially in people over 85 years old., Aims: The aim is to evaluate an alternative method so that it can indicate fracture risk, independent of bone mineral density (BMD). Femoral cortical index (FCI) assesses cortical bone stock using femur X-ray., Methods: A retrospective study has been conducted on 152 patients with hip fragility fractures. FCI has been calculated on fractured femur and on the opposite side. The presence of comorbidities, osteoporosis risk factors, vitamin D levels, and BMD have been analyzed for each patient., Results: Average values of FCI have been 0.42 for fractured femurs and 0.48 at the opposite side with a statistically significant difference (p = 0.002). Patients with severe hypovitaminosis D had a minor FCI compared to those with moderate deficiency (0.41 vs. 0.46, p < 0.011). 42 patients (27.6%) with osteopenic or normal BMD have presented low values of FCI., Discussion and Conclusion: A significant correlation among low values of FCI, comorbidities, severe hypovitaminosis D. and BMD in patients with hip fractures has been found. FCI could be a useful tool to evaluate bone fragility and to predict fracture risk even in the normal and osteopenic BMD patients.

Background: Sideways fall-induced hip fracture is a major worldwide health problem among the elderly population. However, all existing biomechanical models for predicting hip fracture mainly consider the femur related parameters. Their accuracy is limited as hip fracture is significantly affected by loading conditions as well. The objective of this study was to develop a biomechanical model for improving assessment of hip fracture risk by subject-specific prediction of fall-induced loading conditions., Method: All information required to construct the models was extracted from the subject's whole-body and hip medical image in order to make the models subject-specific. Fall-induced hip fracture risk for eighty clinical cases was calculated under two sets of loading conditions: subject-specific determined by the proposed model, and non-subject-specific obtained from empirical functions. The predicted hip fracture risk indices were then compared with clinical observations., Findings: It was found that the subject-specific prediction of fall-induced loading conditions significantly improves the hip fracture risk assessment. Consistent to the clinical observations, the fracture risk predicted by the proposed model suggested that obesity is a protective factor for hip fracture and underweight subjects are more likely to experience a hip fracture., Interpretations: This study shows that hip fracture risk is affected by a number of factors, including body weight, body height, impact force, body mass index, hip soft tissue thickness, and bone quality. The proposed model provides a comprehensive, fast, accurate, and non-expensive method for prediction of hip fracture risk which should lead to more effective prevention of hip fractures., (Copyright © 2015. Published by Elsevier Ltd.)

Osteoporosis is nowadays big burden for aging societies. However, low treatment rate even after first hip fracture results in the increase of second hip fracture in both developed and developing countries. Fracture liaison services, commonly known as FLS, are coordinator-based, secondary fracture prevention services implemented by health care systems for the treatment of osteoporotic patients. Osteoporosis liaison service (OLS) in Japan includes not only FLS but also educational program, medical check-up for bone fragility and risk assessment for primary fracture in osteoporotic subjects. Japan Osteoporosis Society gives coordinators and medical doctors the certificates as a specialist for OLS since 2015. OLS in Japan should facilitate better performance of the treatment of osteoporosis and should contribute the reduction of clinical fractures.

Proximal femoral fractures represent an increasing major healthcare problem due to the demographic changes in this aging population and are associated with the highest mortality among fractures in elderly patients after suffering insufficiency injuries (so-called fragility fractures). The main aim in the treatment of orthogeriatric patients who suffered from a proximal femoral fracture is the preservation of function and independency. Given the high prevalence of comorbidities in these patients, interdisciplinary and interprofessional approaches are required. The use of modern osteosynthesis procedures can provide an improved, individualized surgical treatment with early full weight bearing of the affected extremity. Another aspect is the accompanying geriatric treatment which is associated with a significant reduction of perioperative and postoperative complications. In addition to acute treatment, the organization of secondary fracture prevention is a crucial pillar of treatment. This article provides an overview of the essential elements of orthogeriatric trauma surgery in elderly patients following proximal femoral fractures.

Introduction: Hip fracture poses a significant global challenge both to healthcare systems and to patients themselves. We outline the management of this injury, highlight areas where the evidence is deficient and discuss research efforts towards improving the quality of the evidence base., Sources of Data: We searched MEDLINE, PubMed and the Cochrane Library, using the core search terms 'hip fracture' and 'proximal femoral fracture'. In addition we reviewed national treatment guidelines for hip fracture care and references from relevant articles. Only articles published in English from inception to March 2015 were included., Areas of Agreement: Modern hip fracture management should consist of a coordinated multidisciplinary approach with orthogeriatrician input, early surgery, adequate analgesia and liaison with related services to facilitate safe supported discharge., Areas of Controversy: The optimum thromboprophylaxis to reduce venous thromboembolism remains a topic for debate. The use of bone cement has received much attention recently with concerns about its safety in the frailest of hip fracture patients., Growing Points: An increasing understanding of the severity and impact of sustaining a hip fracture upon quality of life., Areas Timely for Developing Research: Strategies to improve postoperative mobility, postoperative nutrition and the role of home-based rehabilitation. There is a need to identify the optimum analgesic regimes and assessment tools for hip fracture patients with cognitive impairment., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Unlabelled: We investigated the incidence of fragility fractures from 2010 to 2012 in Sakaiminato, Japan. The incidence rates of limb fractures in Sakaiminato were lower than in Caucasian populations but had increased relative to data obtained in Japan in the 1990s. Clinical vertebral fractures occurred at higher rates in Sakaiminato than in Caucasian populations., Introduction: To elucidate the incidence and prognosis of fragility fractures in Sakaiminato, Japan., Methods: A survey of all hip, distal radius, proximal humerus, and clinical vertebral fractures was performed from 2010 to 2012 in patients aged 50 or older in Sakaiminato city, Tottori prefecture, Japan. The age- and gender-specific incidence rates (per 100,000 person-years) were calculated based on the population of Sakaiminato city each year. The incidence rates of hip, distal radius, and proximal humerus fractures were compared with previous reports. We conducted a follow-up study assessing patients within 1 year following their initial treatment at two Sakaiminato hospitals., Results: The age-adjusted incidence rates in population aged 50 years or older (per 100,000 person-years) of hip, distal radius, proximal humerus, and clinical vertebral fractures were, respectively, 217, 82, 26, and 412 in males and 567, 432, 96, and 1229 in females. Age-specific incidence rates of hip, distal radius, and proximal humerus fractures all increased since the 1990s. Our study also revealed that anti-osteoporotic pharmacotherapy was prescribed 1 year post-fracture at rates of 29, 20, 30, and 50 % for patients with hip, distal radius, proximal humerus, and clinical vertebral fractures, respectively., Conclusions: The incidence rates of limb fractures in Sakaiminato were substantially lower than Caucasian populations in northern Europe but had increased relative to data obtained in Japan in the 1990s. Unlike upper and lower limb fractures, clinical vertebral fractures occurred at higher rates in our study population than in other Asian and North European countries.

Unlabelled: The aim of this study was to determine the efficacy of once-weekly teriparatide as a function of baseline fracture risk. Treatment with once-weekly teriparatide was associated with a statistically significant 79 % decrease in vertebral fractures, and in the cohort as a whole, efficacy was not related to baseline fracture risk., Introduction: Previous studies have suggested that the efficacy of some interventions may be greater in the segment of the population at highest fracture risk as assessed by the FRAX® algorithms. The aim of the present study was to determine whether the antifracture efficacy of weekly teriparatide was dependent on the magnitude of fracture risk., Methods: Baseline fracture probabilities (using FRAX) were computed from the primary data of a phase 3 study (TOWER) of the effects of weekly teriparatide in 542 men and postmenopausal women with osteoporosis. The outcome variable comprised morphometric vertebral fractures. Interactions between fracture probability and efficacy were explored by Poisson regression., Results: The 10-year probability of major osteoporotic fractures (without BMD) ranged from 7.2 to 42.2 %. FRAX-based hip fracture probabilities ranged from 0.9 to 29.3 %. Treatment with teriparatide was associated with a 79 % (95 % CI 52-91 %) decrease in vertebral fractures assessed by semiquantitative morphometry. Relative risk reductions for the effect of teriparatide on the fracture outcome did not change significantly across the range of fracture probabilities (p = 0.28). In a subgroup analysis of 346 (64 %) participants who had FRAX probabilities calculated with the inclusion of BMD, there was a small but significant interaction (p = 0.028) between efficacy and baseline fracture probability such that high fracture probabilities were associated with lower efficacy., Conclusion: Weekly teriparatide significantly decreased the risk of morphometric vertebral fractures in men and postmenopausal women with osteoporosis. Overall, the efficacy of teriparatide was not dependent on the level of fracture risk assessed by FRAX in the cohort as a whole.

Pycnodysostosis is a rare autosomal recessive disease due to a mutation in the gene for the enzyme Cathepsin K. It is characterized by short stature, craniofacial dysmorphias, osteosclerosis, and brittle bones. There are only a few reports in the literature describing surgical interventions for long bone fractures in pycnodysostosis patients, most of which describe intramedullary nail treatment of isolated long bone fractures. We describe a case in which a pregnant female with pycnodysostosis presented with a shaft fracture of the left femur following minor trauma and a history of increasing thigh pain. Radiographs obtained in the emergency room also revealed an impending subtrochanteric fracture of the contralateral side. The acute left femoral shaft fracture was treated with an adolescent-sized intramedullary nail; it was decided to defer surgery on the contralateral side until after pregnancy. Three months later, the patient had the contralateral femur prophylactically fixated with a plate and screws. One year after the index surgery, both methods demonstrated satisfactory healing both clinically and radiographically. Although we recommend use of an intramedullary nail for long bone fractures in patients with pycnodysostosis, a plate can be utilized if health conditions or skeletal morphology precludes use of a nail.

Background: In our aging population, maintenance of bone health is critical to reduce the risk of osteoporosis and potentially debilitating consequences of fractures in older individuals. Among modifiable lifestyle and dietary factors, dietary magnesium and potassium intakes are postulated to influence bone quality and osteoporosis, principally via calcium-dependent alteration of bone structure and turnover., Objective: We investigated the influence of dietary magnesium and potassium intakes, as well as circulating magnesium, on bone density status and fracture risk in an adult population in the United Kingdom., Design: A random subset of 4000 individuals from the European Prospective Investigation into Cancer and Nutrition-Norfolk cohort of 25,639 men and women with baseline data was used for bone density cross-sectional analyses and combined with fracture cases (n = 1502) for fracture case-cohort longitudinal analyses (mean follow-up 13.4 y). Relevant biological, lifestyle, and dietary covariates were used in multivariate regression analyses to determine associations between dietary magnesium and potassium intakes and calcaneal broadband ultrasound attenuation (BUA), as well as in Prentice-weighted Cox regression to determine associated risk of fracture. Separate analyses, excluding dietary covariates, investigated associations of BUA and fractures with serum magnesium concentration., Results: Statistically significant positive trends in calcaneal BUA for women (n = 1360) but not men (n = 968) were apparent across increasing quintiles of magnesium plus potassium (Mg+K) z score intake (P = 0.03) or potassium intake alone (P = 0.04). Reduced hip fracture risk in both men (n = 1958) and women (n = 2755) was evident for individuals in specific Mg+K z score intake quintiles compared with the lowest. Statistically significant trends in fracture risk in men across serum magnesium concentration groups were apparent for spine fractures (P = 0.02) and total hip, spine, and wrist fractures (P = 0.02). None of these individual statistically significant associations remained after adjustment for multiple testing., Conclusions: These findings enhance the limited literature studying the association of magnesium and potassium with bone density and demonstrate that further investigation is warranted into the mechanisms involved and the potential protective role against osteoporosis., (© 2015 American Society for Nutrition.)

Objectives: To compare retrograde versus antegrade femoral bone graft harvesting using the reamer-irrigator-aspirator system to determine whether there was any difference in intraoperative, postoperative, or patient outcome variables., Design: Retrospective cohort study., Setting: Urban Level I Trauma Center., Patients/participants: Ninety-four (62 antegrade and 32 retrograde procedures) consecutive adult patients who underwent femoral autologous bone graft harvesting using the Synthes reamer-irrigator-aspirator system between April 2008 and March 2013., Main Outcome Measurements: Amount of bone graft, perioperative fractures or other complications, and postoperative hip and/or knee pain., Results: There was no significant difference between demographic or medical comorbidities between the groups. There was no significant difference in the side of the graft harvest, graft volume, hospital length of stay, or the ability to ambulate on postoperative day 1. There was a significantly increased incidence of iatrogenic fracture or prophylactic nailing with antegrade reaming (4 vs. 0, P = 0.01). Average length of follow-up was 500 (range, 20-1477) days for the antegrade group and 378 (range, 19-706) days for the retrograde group. The antegrade group had a nonsignificant increased incidence of hip pain (8.1% vs. 3.1%, P = 0.66), and the retrograde group had a significantly higher incidence of knee pain (15.6% vs. 1.6%, P = 0.02) at 6-month follow-up. Neither hip nor knee complaints were present at final follow-up. No cases of delayed femur fracture, infection, or abductor and/or antalgic gait involving the donor extremity were seen at final follow-up., Conclusions: This study provides support to the safety of femoral bone graft harvesting using both antegrade and retrograde techniques. Both techniques provide reliable, high-volume, nonstructural autologous bone graft with minimal associated morbidity., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Addison's disease is associated with low bone mineral density and increased risk of hip fractures. Causes are multifactorial, contributed by underlying adrenocortical hormonal deficiency, associated autoimmune endocrinopathies, electrolyte disturbances and, in some patients, supraphysiologic glucocorticoid replacement. Recent realization of physiologic cortisol production rate has revised downwards glucocorticoid replacement dosages. Meanwhile, new research has emerged suggesting complex interplay between sodium and calcium homoeostasis under the influence of mineralocorticoid and parathyroid hormone that may impact bone health. As the prevalence of Addison's disease is rising, and osteoporosis and fractures are associated with significant morbidity and increased mortality, attention to bone preservation in Addison's disease is of clinical relevance and importance. We suggest an approach to bone health in Addison's disease integrating physiologic adrenocortical hormonal replacement with electrolyte and mineral homoeostasis optimization., (© 2015 John Wiley & Sons Ltd.)

Enhancement of healing of osteoporotic fractures remains a significant objective of contemporary clinical care. Aiming to produce preliminary clinical evidence on the effect of antiosteoporotic drugs on the process of fragility fracture healing, a pilot prospective randomized assessor-blinded trial was performed. The tested hypothesis was that it is possible to accelerate the healing of hip fractures in the presence of osteoporosis with the administration of therapeutic agents. However, significant difficulties of recruitment and completion of follow up did not allow the researchers to produce the preliminary evidence testing the study hypothesis, highlighting the challenges that contemporary clinical investigators face when conducting studies focusing on elderly patients, with high proportion of coinciding factors affecting patients' eligibility, compliance, and overall outcome. Nevertheless, the significance of enhancing bone healing in this specific patient population, dictates further clinical efforts and future well designed and funded trials of adequate power and level of evidence are desirable to allow the effective and safer management of the consequences of the modern epidemic of osteoporosis., (Copyright © 2015. Published by Elsevier Ltd.)