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We have evaluated the merits and scientific underpinning of two different forms of fracture prevention. The first is the fracture liaison service(FLS), in which persons aged 50 years or older who have suffered a fracture are assessed and treated. The second is a stepped screening program for women aged 65 years or older, utilizing questionnaires and bone densitometry to identify those with the highest fracture risk for treatment. The FLS approach is based on indirect evidence and has not been studied in randomised studies. There is a lack of evidence for effectiveness in the younger age group of 50-65 years. A meta-analysis of three randomised studies in older women showed a 20% risk reduction of hip fractures. We suggest that FLS should focus on the group >65 years and that an additional once in a life time fracture risk screening program in women of 75-80 year should be considered.

Hip fractures are a frequent cause of hospitalization in the elderly population and can lead to significant morbidity and mortality. As the population continues to age, the incidence of hip fractures is expected to increase. The internist/hospitalist plays a critical role in the care of this population as many patients have multiple medical comorbidities. Management of the fragility hip fracture patient requires knowledge of several perioperative topics including preoperative risk assessment, risk reduction strategies, the optimal timing of surgical repair, venous thromboembolism prevention, and postoperative care considerations such as early mobilization with physical therapy, and osteoporosis treatment., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Osteoporosis is characterized by loss of bone mineral density and increased fracture risk. Reduction of hip fracture incidence is of major clinical importance. Hip protectors aim to attenuate the impact force transmitted to the femur upon falling, however different conclusions on their efficacy have been reported; some authors suggest this may be due to differences in compliance. The aim of this study was to apply an In Silico trial methodology to predict the effectiveness of hip protectors and its dependence on compliance. A cohort of 1044 virtual patients (Finite Element models of proximal femur) were generated. A Markov chain process was implemented to predict fracture incidence with and without hip protectors, by simulating different levels of compliance. At each simulated follow-up year, a Poisson distribution was randomly sampled to determine the number of falls sustained by each patient. Impact direction and force were stochastically sampled from a range of possible scenarios. The effect of wearing a hip protector was simulated by applying attenuation coefficients to the impact force (12.9 %, 19 % and 33.8 %, as reported for available devices). A patient was considered fractured when impact force exceeded the femur strength. Without hip protector, virtual patients experienced 66 ± 5 fractures in 10 years. Wearing the three devices, fracture incidence was reduced to 43 ± 4, 35 ± 4 and 17 ± 2 respectively, at full compliance. As expected, effectiveness was dependent on compliance. This In Silico trial technology can be applied in the future to test multiple interventions, optimise intervention strategies, improve clinical trial design and drug development., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Context: Prolonged bisphosphonate (BP) treatment for osteoporosis prevents hip and other fractures but causes atypical femoral fractures (AFF)., Objective: To establish the relationship between patterns of BP use and the risk of AFF and hip fractures. Other potential risk factors for AFF were also examined., Methods: This population-based case-cohort study utilized data from the Danish National Healthcare system, including longitudinal records of medication use, healthcare utilization, and x-ray images. Among all 1.9 million Danish adults ≥50, those with subtrochanteric or femoral shaft fractures between 2010 and 2015 (n = 4973) were identified and compared to a random sample (n = 37 021). Bisphosphonate use was collected from 1995-2015. Fracture radiographs (n = 4769) were reviewed by blinded study radiologists to identify AFFs (n = 189) using established criteria. Traditional hip fractures in the random sample (n = 691) were identified by ICD-10., Results: Compared to <1 year of BP use, 5 to 7 years of use was associated with a 7-fold increase in AFF (adjusted HR = 7.29 [CI: 3.07, 17.30]); the risk of AFF fell quickly after discontinuation. The 5-year number needed to harm for one AFF was 1424, while the 5-year number needed to treat to prevent one hip fracture was 56. Glucocorticoid and proton pump inhibitor use were independently associated with increased AFF risk. Thirty-one percent of those with AFF had no BP exposure., Conclusion: The risk of AFF increases with duration of BP use but the beneficial effects of BP therapy in adults ≥50 dramatically exceed this increased risk. Nearly one-third of those with AFF have no BP exposure., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives: With the global aging trend, the incidence of falls and hip fractures is projected to rise, leading to an increased associated burden. Over 90% of hip fractures result from falls, yet not all falls cause fractures, suggesting specific fall characteristics may contribute to hip fractures. This review provides insights into fragility hip fracture-related falls among the older adults, aiding in understanding and developing effective fall prevention strategies for this population., Methods: Searches encompassed PubMed, OVID, EMBASE, Cochrane Library, and Web of Science, supplemented by citation checks. We included non-randomized studies detailing characteristics of fragility hip fracture-related falls in the older individuals, with or without a non-hip fracture control. Evaluated fall characteristics included height, location, direction, time, mechanism, activity during the fall, hip impact, protective responses, walking aid use, and impact surface. Results were analyzed using a narrative synthesis approach. The quality of these studies was assessed using the revised Risk of Bias Assessment tool for Non-randomized Studies 2 (RoBANS2)., Results: A total of 30 articles were reviewed, comprising 23 non-case control and 7 case-control studies, with a mean age of 75.6 years. Studies presented varied details on fall characteristics. Hip-fracture related falls typically occur indoors at or around standing height during daytime, often involving sideways or backward motions with inadequate protective responses. Slipping is predominant, yet lost balance and weakness/collapse are notable. Walking precedes many falls, but stationary activities (lack of forward motion, changing positions, sitting or standing still, transfer) also contribute. Low usage of walking aids and impact on hard surfaces are common features of these falls., Conclusions: This review underscores fall characteristics associated with fragility hip fractures in older adults, highlighting features more aligned with age-related physical frailty than general falls. Such insights can guide healthcare providers in implementing tailored interventions to reduce hip fractures and related challenges., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

We found that a standardized order set after hip fracture increased initiation of anti-osteoporosis medication and increased persistence at 1 year, but did not reduce secondary fractures., Background: A treatment gap exists after osteoporosis-related fractures. Introducing standardized care can improve treatment. We evaluated the impact of a hip fracture order set (OS) on anti-osteoporosis medication (AOM) initiation, persistence, and secondary fracture prevention., Methods: In 2015, one hospital in Manitoba, Canada, introduced a hip fracture OS including recommendations for the initiation of AOM (OS group). A control group was identified from the other hospitals in the same region. A retrospective cohort study was conducted using linked administrative health data. All individuals 50 + years with surgical treatment for low-energy hip fracture between 2010 and 2019 were included and followed for AOM initiation, medication persistence at 1 year, and secondary fractures. Between-group differences for each year were assessed using chi-square tests. Logistic regression models tested the impact of socio-demographic and clinical factors on initiation, persistence of AOM. Cox regression tested the risk of secondary fracture., Results: No baseline differences between OS group (813 patients) and control group (2150 patients) were observed in demographics, socioeconomic factors, or comorbidities. An increase in post-fracture AOM initiation was seen with OS introduction (OS group year before 16.7% versus year after 48.6%, p < 0.001). No change was seen in the control group. Persistence on AOM also increased (OS group year before 17.7% versus year after 28.4%, p < 0.001). No difference in secondary fractures was observed (OS group 19.8% versus control group 18.8%, p = 0.38)., Conclusion: Introduction of a hip fracture OS significantly increased AOM initiation and persistence at 1-year post-fracture. There was no significant difference in secondary fractures., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

There is a strong association between total hip bone mineral density (THBMD) changes after 24 mo of treatment and reduced fracture risk. We examined whether changes in THBMD after 12 and 18 mo of treatment are also associated with fracture risk reduction. We used individual patient data (n = 122 235 participants) from 22 randomized, placebo-controlled, double-blind trials of osteoporosis medications. We calculated the difference in mean percent change in THBMD (active-placebo) at 12, 18, and 24 mo using data available for each trial. We determined the treatment-related fracture reductions for the entire follow-up period, using logistic regression for radiologic vertebral fractures and Cox regression for hip, non-vertebral, "all" (combination of non-vertebral, clinical vertebral, and radiologic vertebral) fractures and all clinical fractures (combination of non-vertebral and clinical vertebral). We performed meta-regression to estimate the study-level association (r2 and 95% confidence interval) between treatment-related differences in THBMD changes for each BMD measurement interval and fracture risk reduction. The meta-regression revealed that for vertebral fractures, the r2 (95% confidence interval) was 0.59 (0.19, 0.75), 0.69 (0.32, 0.82), and 0.73 (0.33, 0.84) for 12, 18, and 24 mo, respectively. Similar patterns were observed for hip: r2 = 0.27 (0.00, 0.54), 0.39 (0.02, 0.63), and 0.41 (0.02, 0.65); non-vertebral: r2 = 0.27 (0.01, 0.52), 0.49 (0.10, 0.69), and 0.53 (0.11, 0.72); all fractures: r2 = 0.44 (0.10, 0.64), 0.63 (0.24, 0.77), and 0.66 (0.25, 0.80); and all clinical fractures: r2 = 0.46 (0.11, 0.65), 0.64 (0.26, 0.78), and 0.71 (0.32, 0.83), for 12-, 18-, and 24-mo changes in THBMD, respectively. These findings demonstrate that treatment-related THBMD changes at 12, 18, and 24 mo are associated with fracture risk reductions across trials. We conclude that BMD measurement intervals as short as 12 mo could be used to assess fracture efficacy, but the association is stronger with longer BMD measurement intervals., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Society for Bone and Mineral Research.)

Randomized trials have not been performed, and may never be, to determine if osteoporosis treatment prevents hip fracture in men. Addressing that evidence gap, we analyzed data from an observational study of new hip fractures in a large integrated healthcare system to compare the reduction in hip fractures associated with standard-of-care osteoporosis treatment in men versus women. Sampling from 271,389 patients aged ≥ 65 who had a hip-containing CT scan during care between 2005 and 2018, we selected all who subsequently had a first hip fracture (cases) after the CT scan (start of observation) and a sex-matched equal number of randomly selected patients. From those, we analyzed all who tested positive for osteoporosis (DXA-equivalent hip BMD T-score ≤ -2.5, measured from the CT scan using VirtuOst). We defined "treated" as at least six months of any osteoporosis medication by prescription fill data during follow-up; "not-treated" was no prescription fill. Sex-specific odds ratios of hip fracture for treated vs not-treated patients were calculated by logistic regression; adjustments included age, BMD T-score, BMD-treatment interaction, BMD, race/ethnicity, and seven baseline clinical risk factors. At two-year follow-up, 33.9% of the women (750/2,211 patients) and 24.0% of the men (175/728 patients) were treated primarily with alendronate; 51.3% and 66.3%, respectively, were not-treated; and 721 and 269, respectively, had a first hip fracture since the CT scan. Odds ratio of hip fracture for treated vs not-treated was 0.26 (95% confidence interval: 0.21-0.33) for women and 0.21 (0.13-0.34) for men; the ratio of these odds ratios (men:women) was 0.81 (0.47-1.37), indicating no significant sex effect. Various sensitivity and stratified analyses confirmed these trends, including results at five-year follow-up. Given these results and considering the relevant literature, we conclude that osteoporosis treatment prevents hip fracture similarly in both sexes., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Society for Bone and Mineral Research.)

Falls among the elderly cause a huge number of hip fractures worldwide. Energy absorbing floors (EAFs) represent a promising strategy to decrease impact force and hip fracture risk during falls. Femoral neck force is an effective predictor of hip injury. However, the biomechanical effectiveness of EAFs in terms of mitigating femoral neck force remains largely unknown. To address this, a whole-body computational model representing a small-size elderly woman with a biofidelic representation of the soft tissue near the hip region was employed in this study, to measure the attenuation in femoral neck force provided by four commercially available EAFs (Igelkott, Kradal, SmartCells, and OmniSports). The body was positioned with the highest hip force with a -10 ∘ trunk angle and +10 ∘ anterior pelvis rotation. At a pelvis impact velocity of 3 m/s, the peak force attenuation provided by four EAFs ranged from 5% to 19%. The risk of hip fractures also demonstrates a similar attenuation range. The results also exhibited that floors had more energy transferred to their internal energy demonstrated greater force attenuation during sideways falls. By comparing the biomechanical effectiveness of existing EAFs, these results can improve the floor design that offers better protection performance in high-fall-risk environments for the elderly., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Svein Kleiven reports financial support was provided by Sweden’s Innovation Agency. Svein Kleiven reports a relationship with Igelkott Golv AB that includes: board membership. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

This study compared the effectiveness and cardiovascular safety of romosozumab and teriparatide. The main finding was that there were no significant differences between the two drugs in fracture prevention and risk of major adverse cardiac events. This suggests that romosozumab and teriparatide are comparable options for treating osteoporosis., Purpose: This study aimed to determine the preventive effects of romosozumab versus teriparatide on fractures and the risk of cardiovascular events in patients initiating these drugs., Methods: We conducted an active comparator, a new user cohort design, with confounding controlled by inverse probability of treatment weighting using a Japanese administrative claims database (March 2019 to October 2022). This cohort study included 49,104 patients aged 50 years or older who initiated romosozumab (n = 16,125) or teriparatide (n = 32,979) for osteoporosis. The study exposure was the initiation of romosozumab or teriparatide. Effectiveness outcomes were nonvertebral fracture and hip fracture. The safety outcome was major adverse cardiac events (MACE). Follow-up period was 365 days., Results: The weighted incidence rate difference (IRD) for nonvertebral fracture between romosozumab versus teriparatide was -0.08 (95% confidence interval [CI], -0.34 to 0.17) events per 100 person-years (weighted hazard ratio [HR], 0.95 [95% CI, 0.81 to 1.12]); weighted IRD for hip fracture was 0.00 (95% CI, -0.16 to 0.16) events per 100 person-years (weighted HR, 0.99 [95% CI, 0.76 to 1.29]); and weighted IRD for MACE was -0.06 (95% CI, -0.20 to 0.09) events per 100 person-years (weighted HR, 0.90 [95% CI, 0.68 to 1.19])., Conclusion: In patients with osteoporosis, there was no significant difference in the prevention of nonvertebral fracture and hip fracture between romosozumab and teriparatide. In addition, the risk of MACE was comparable between the two drugs., Competing Interests: Declarations. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required. Informed consent: Informed consent was not required, in accordance with ethical guidelines in Japan. Conflict of interest: Toshiki Fukasawa has been employed by the Department of Digital Health and Epidemiology with support from Eisai Co., Ltd. and Kyowa Kirin Co., Ltd.; and has received consulting fees from Real World Data Co., Ltd. and honoraria from EPS Corporation and Research Institute of Healthcare Data Science (RIHDS). Koji Kawakami has received consulting fees from Advanced Medical Care Inc., JMDC Inc., LEBER Inc., and Shin Nippon Biomedical Laboratories Ltd.; executive compensation from Cancer Intelligence Care Systems, Inc.; honoraria from Shionogi Pharma Co., Ltd., Taisho Pharmaceutical Co., Ltd., Kaken Pharmaceutical Co., Ltd., and Pharma Business Academy; and grants from Eisai Co., Ltd., Kyowa Kirin Co., Ltd., OMRON Corporation, and Toppan Inc. All other authors declare no potential conflicts of interest., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Patients who sustain a hip fracture are known to be at imminent refracture risk. Their complex multidisciplinary rehabilitation needs to include falls prevention and anti-osteoporosis medication (AOM) to prevent such fractures. This study aimed to determine which hospital-level organizational factors predict prescription of post-hip fracture AOM and refracture risk. A cohort of 178 757 patients aged ≥60 yr who sustained a hip fracture in England and Wales (2016-2019) was examined and followed for 1 yr. Patient-level hospital admission datasets from 172 hospitals, the National Hip Fracture Database, and mortality data were linked to 71 metrics extracted from 18 hospital-level organizational reports. Multilevel models determined organizational factors, independent of patient case-mix, associated with (1) AOM prescription and (2) refracture (by ICD10 coding). Patients were mean (SD) 82.7 (8.6) yr old, 71% female, with 18% admitted from care homes. Overall, 101 735 (57%) were prescribed AOM during admission, while 50 354 (28%) died during 1-yr follow-up, 12 240 (7%) refractured. Twelve organizational factors were associated with AOM prescription, for example, orthogeriatrician-led care compared to traditional care models (odds ratio [OR] 4.65 [95% CI, 2.25-9.59]); AOM was 9% (95% CI, 6%-13%) more likely to be prescribed in hospitals providing routine bone health assessment to all patients. Refracture occurred at median 126 d (IQR 59-234). Eight organizational factors were associated with refracture risk; hospitals providing orthogeriatrician assessment to all patients within 72 h of admission had an 18% (95% CI, 2%-31%) lower refracture risk, weekend physiotherapy provision had an 8% (95% CI, 3%-14%) lower risk, and where occupational therapists attended clinical governance meetings, a 7% (95% CI, 2%-12%) lower risk. Delays initiating post-discharge community rehabilitation were associated with a 15% (95% CI, 3%-29%) greater refracture risk. These novel, national findings highlight the importance of orthogeriatrician, physiotherapist, and occupational therapist involvement in secondary fracture prevention post hip fracture; notably, fracture risk reductions were seen within 12 mo of hip fracture., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Society for Bone and Mineral Research.)

This study aimed to explore the views of healthcare professionals regarding the barriers and facilitators for a Fracture Liaison Service (FLS) in Malaysia. The qualitative study was conducted from February to December 2021 at a tertiary hospital in Malaysia. Doctors, nurses, pharmacists, and policymakers were recruited via purposive sampling. Semi-structured in-depth interviews were conducted until thematic saturation was achieved. Data were transcribed verbatim and analysed using thematic analysis. Thirty participants [doctors (n = 13), nurses (n = 8), pharmacists (n = 8), and policymakers (n = 1)] with 2-28 years of working experience were recruited. Three themes emerged: 1) Current delivery of secondary fracture prevention; 2) Importance of secondary fracture prevention, and 3) FLS sustainability. Some participants reported that the current post-hip fracture care was adequate, whilst some expressed concerns about the lack of coordination and continuity of care, especially in non-hip fragility fracture care. Most participants recognised the importance of secondary fracture prevention as fracture begets fracture, highlighting the need for a FLS to address this care gap. However, some were concerned about competing priorities. To ensure the sustainability of a FLS, cost-effectiveness data, support from relevant stakeholders, increased FLS awareness among patients and healthcare professionals, and a FLS coordinator were required. Training and financial incentives may help address the issue of low confidence and encourage the nurses to take on the FLS coordinator role. Overall, all participants believed that there was a need for a FLS to improve the delivery of secondary fracture prevention. Addressing concerns such as lack of confidence among nurses and lack of awareness can help improve FLS sustainability., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Cheah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Hip fractures are associated with a high burden of morbidity and mortality. Diet is essential for preventing fragility fractures, but the role of dietary fatty acids on the risk of hip fracture is uncertain. The aim was to investigate how intake of different dietary fatty acids relates to the risk of hip fracture. A relative validation of the long-term intake of dietary fatty acids estimated from food frequency questionnaires (FFQs) was also performed., Design, Settings and Participants: We used data collected in two population-based cohorts, the Swedish Mammography Cohort and the Cohort of Swedish men (n = 83,603, 54% men, aged 45-82 years). Data from the repeated investigations in the cohorts and cross-sectional data from their clinical sub-cohorts were used., Measurements: Diet data was collected in FFQs. Incident hip fractures were gathered by individual linkage to national registers. We performed Cox regression analysis to investigate associations between dietary fatty acids and hip fracture. Follow-up time was between January 1st, 1998 and December 31st, 2020. The validation was performed using correlation analyses, comparing fatty acids measured in adipose tissue with estimated fatty acid intakes from FFQs., Results: During up to 23 years of follow-up (mean 18 years) and 1,538,627 person-years at risk, 7345 participants (2840 men) experienced a hip fracture. A low linoleic acid (LA) and high intakes of long-chain n-3 fatty acids were associated with higher hip fracture risk in a non-linear way. In quartile 4 compared to quartile 1 of LA, the multivariable-adjusted hazard ratio of hip fracture was 0.89 (95% Confidence Interval: 0.81, 0.97). The study confirmed the validity of FFQs to capture the intake of the specific dietary long-chain n-3 fatty acids. The estimated intake of LA, α-linolenic acid, and myristic acid were also adequately captured by the FFQs. Validity was confirmed in both women and men., Conclusion: A low to moderate intake of linoleic acid and a higher intake of long-chain n-3 fatty acids were associated with a higher risk of hip fractures. The results indicate that attention should be paid to dietary fatty acid composition for the optimal prevention of fragility fractures., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

This study investigates the effects of fall configurations on hip fracture risk with a focus on pelvic soft tissue shape. This was done by employing a whole-body finite element (FE) model. Soft tissue thickness around the pelvis was measured using a standing CT system, revealing a trend of increased trochanteric soft tissue thickness with higher BMI and younger age. In the lateroposterior region from the greater trochanter, the soft tissues of elderly females were thin with a concave shape. Based on the THUMS 5F model, an elderly female FE model with a low BMI was developed by morphing the soft tissue shape around the pelvis based on the CT data. FE simulation results indicated that the lateroposterior fall led to a higher femoral neck force for the elderly female model compared to the lateral fall. One reason may be related to the thin soft tissue of the pelvis in the lateroposterior region. Additionally, the effectiveness of interventions that can help mitigating hip fractures in lateroposterior falls on the thigh-hip and hip region was assessed using the elderly female model. The attenuation rate of the femoral neck force by the hip protector was close to zero in the thigh-hip fall and high in the hip fall, whereas the attenuation rate of the compliant floor was high in both falls. This study highlights age-related changes in the soft tissue shape of the pelvis in females, particularly in the lateroposterior regions, which may influence force mitigation for the hip joint during lateroposterior falls., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Masahiro Jinzaki received a grant from Canon Medical Systems, which loaned an upright CT device to Keio University. The funder was not involved in the design of the study; collection, analysis, interpretation of data; or writing of the manuscript. The remaining authors have no conflicts of interest to declare]., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Wearing hip protectors is a measure used to prevent hip fractures caused by falls. However, its protective effect has remained controversial in previous studies. This study provides a rationale for the use of hip protectors by pooling all the current meta-analysis evidence., Methods: We conducted an umbrella review of all the current meta-analysis articles about the efficacy of hip protectors to reduce hip fractures and falls in communities and/or institutions. Major databases including EMBASE, Cochrane Library, PubMed and Web of Science, were searched up to June 2022. Two reviewers screened the studies, extracted the data, and conducted the methodological quality assessment independently. The primary outcome was the association statistic (odds ratio (OR), relative risk (RR), etc.) reported in the meta-analysis that quantified the influence of the intervention on hip fractures and falls compared to that of the control group. Narrative synthesis was also conducted. Forest plots and the AMSTAR score were used to describe the results and quality of the pooled literature, respectively., Results: A total of six meta-analysis articles were included in the study. Hip protectors were effective at reducing hip fractures in older individuals who were in institutions (nursing or residential care settings) but not in communities (RR = 0.70, 95% CI 0.58 to 0.85, I 2  = 42%, P < 0.001) (RR = 1.12, 95% CI 0.94 to 1.34, I 2  = 0%, P = 0.20), and they did not reduce falls (RR = 1.01, 95% CI 0.90 to 1.13, I 2  = 0%, P = 0.89)., Conclusions: Hip protectors are effective at preventing hip fractures in institutionalized older adults but not in community-dwelling older adults., Trial Registration: This study has been registered in PROSPERO (PROSPERO ID: CRD42022351773)., (© 2024. The Author(s).)

Hip fractures are a major health issue considerably impacting patients' quality of life and well-being. This is particularly evident in elderly subjects, in which the decline in bone and muscle mass coexists and predisposes individuals to fall and fracture. Among interventions to be implemented in hip fractured patients, the assessment and management of nutritional status is pivotal, particularly in subjects older than 65. Nutrition plays a central role in both primary and secondary preventions of fracture. An adequate protein intake improves muscle mass and strength and the intestinal absorption of calcium. Other nutrients with recognized beneficial effects on bone health are calcium, vitamins D, K, and C, potassium, magnesium, folate, and carotenoids. With reference to calcium, results from longitudinal studies showed that the consumption of dairy foods has a protective role against fractures. Moreover, the most recent systematic reviews and meta-analyses and one umbrella review demonstrated that the combination of calcium and vitamin D supplementation significantly reduces hip fracture risk, with presumed higher efficacy in older and institutionalized subjects. Owing to these reasons, the adequate intake of calcium, vitamin D, protein, and other macro and micronutrients has been successfully implemented in the Fracture Liaison Services (FLSs) that represent the most reliable model of management for hip fracture patients. In this narrative review, papers (randomized controlled trials, prospective and intervention studies, and systematic reviews) retrieved by records from three different databases (PubMed, Embase, and Medline) have been analyzed, and the available information on the screening, assessment, and management of nutritional and vitamin D status and calcium intake in patients with hip fractures is presented along with specific prevention and treatment measures.

With the analysis of nationwide health claim data, treatment with the composite agent of SERMs and vitamin D reduces the risk of osteoporotic fracture and hip fracture better compared to SERMs treatment in women with osteoporosis aged ≥ 50 years., Purpose: This study compared the potential of the composite agent of selective estrogen receptor modulators (SERMs) and vitamin D (SERM + VitD) with that of SERMs-only for fracture prevention and mortality reduction in women aged ≥ 50 years., Methods: The incidence of osteoporotic fracture (fractures of the vertebrae, hip, wrist, or humerus) and all-cause death after treatment with SERM + VitD and SERMs were characterized using the Korean National Health Insurance Service database 2017-2019. The participants were divided into two groups (SERM + VitD vs SERMs). After exclusion and propensity score matching, 2,885 patients from each group were included in the analysis. Fracture incidence was compared between groups. Kaplan-Meier curves were used to compare mortality. Cox proportional hazards regression analysis was used to compare the risks of fracture occurrence and mortality between the groups., Results: The incidence rate (138.6/10,000 vs. 192.4/10,000 person-years), and risk of osteoporotic fractures (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.61-0.97; p = 0.024) were lower in the SERM + VitD group than in the SERMs group. Analysis for specific fractures showed a lower hazard of hip fracture in the SERM + VitD group (HR, 0.25; 95% CI, 0.09-0.71; p = 0.009). No difference was observed between the groups regarding mortality., Conclusion: The risk of osteoporotic fractures, especially hip fractures, was lower in the SERM + VitD group than in the SERMs group. Therefore, the composite agent of SERMs and vitamin D can be considered as a viable option for postmenopausal women with a relatively low fracture risk., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Background: In 2018, a grant was provided for an evidence-based guideline on osteoporosis and fracture prevention based on 10 clinically relevant questions., Methods: A multidisciplinary working group was formed with delegates from Dutch scientific and professional societies, including representatives from the patient's organization and the Dutch Institute for Medical Knowledge. The purpose was to obtain a broad consensus among all participating societies to facilitate the implementation of the updated guideline., Results: Novel recommendations in our guideline are as follows: - In patients with an indication for DXA of the lumbar spine and hips, there is also an indication for VFA. - Directly starting with anabolic drugs (teriparatide or romosozumab) in patients with a very high fracture risk; - Directly starting with zoledronic acid in patients 75 years and over with a hip fracture (independent of DXA); - Directly starting with parenteral drugs (denosumab, teriparatide, zoledronic acid) in glucocorticoid-induced osteoporosis with very high fracture risk; - A lifelong fracture risk management, including lifestyle, is indicated from the start of the first treatment., Conclusion: In our new multidisciplinary guideline osteoporosis and fracture prevention, we developed 5 "relatively new statements" that are all a crucial step forward in the optimization of diagnosis and treatment for fracture prevention. We also developed 5 flowcharts, and we suppose that this may be helpful for individual doctors and their patients in daily practice and may facilitate implementation., (© 2024. The Author(s).)

Background: Although calcium and vitamin D (CaD) supplementation may affect chronic disease in older women, evidence of long-term effects on health outcomes is limited., Objective: To evaluate long-term health outcomes among postmenopausal women in the Women's Health Initiative CaD trial., Design: Post hoc analysis of long-term postintervention follow-up of the 7-year randomized intervention trial of CaD. (ClinicalTrials.gov: NCT00000611)., Setting: A multicenter ( n = 40) trial across the United States., Participants: 36 282 postmenopausal women with no history of breast or colorectal cancer., Intervention: Random 1:1 assignment to 1000 mg of calcium carbonate (400 mg of elemental calcium) with 400 IU of vitamin D 3 daily or placebo., Measurements: Incidence of colorectal, invasive breast, and total cancer; disease-specific and all-cause mortality; total cardiovascular disease (CVD); and hip fracture by randomization assignment (through December 2020). Analyses were stratified on personal supplement use., Results: For women randomly assigned to CaD versus placebo, a 7% reduction in cancer mortality was observed after a median cumulative follow-up of 22.3 years (1817 vs. 1943 deaths; hazard ratio [HR], 0.93 [95% CI, 0.87 to 0.99]), along with a 6% increase in CVD mortality (2621 vs. 2420 deaths; HR, 1.06 [CI, 1.01 to 1.12]). There was no overall effect on other measures, including all-cause mortality (7834 vs. 7748 deaths; HR, 1.00 [CI, 0.97 to 1.03]). Estimates for cancer incidence varied widely when stratified by whether participants reported supplement use before randomization, whereas estimates on mortality did not vary, except for CVD mortality., Limitation: Hip fracture and CVD outcomes were available on only a subset of participants, and effects of calcium versus vitamin D versus joint supplementation could not be disentangled., Conclusion: Calcium and vitamin D supplements seemed to reduce cancer mortality and increase CVD mortality after more than 20 years of follow-up among postmenopausal women, with no effect on all-cause mortality., Primary Funding Source: National Heart, Lung, and Blood Institute of the National Institutes of Health., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2598.

Bisphosphonates prevent future hip fractures. However, we found that one in six patients with hip fractures had a delay in bisphosphonate initiation and another one-sixth discontinued treatment within 12 months after discharge. Our results highlight the need to address hesitancy in treatment initiation and continuous monitoring., Purpose: Suboptimal antiresorptive use is not well understood. This study investigated trajectories of oral bisphosphonate use following first hip fractures and factors associated with different adherence and persistence trajectories., Methods: We conducted a retrospective study of all patients aged ≥ 50 years dispensed two or more bisphosphonate prescriptions following first hip fracture in Victoria, Australia, from 2012 to 2017. Twelve-month trajectories of bisphosphonate use were categorized using group-based trajectory modeling. Factors associated with different trajectories compared to the persistent adherence trajectory were assessed using multivariate multinomial logistic regression., Results: We identified four patterns of oral bisphosphonate use in 1811 patients: persistent adherence (66%); delayed dispensing (17%); early discontinuation (9%); and late discontinuation (9%). Pre-admission bisphosphonate use was associated with a lower risk of delayed dispensing in both sexes (relative risk [RR] 0.28, 95% confidence interval [CI] 0.21-0.39). Older patients ( ≥ 85 years old versus 50-64 years old, RR 0.38, 95% CI 0.22-0.64) had a lower risk of delayed dispensing. Males with anxiety (RR 9.80, 95% CI 2.24-42.9) and females with previous falls had increased risk of early discontinuation (RR 1.80, 95% CI 1.16-2.78)., Conclusion: Two-thirds of patients demonstrated good adherence to oral bisphosphonates over 12 months following hip fracture. Efforts to further increase post-discharge antiresorptive use should be sex-specific and address possible persistent uncertainty around delaying treatment initiation., (© 2024. The Author(s).)

Purpose: This study aimed to develop and validate clinical prediction models using machine learning (ML) algorithms for reliable prediction of subsequent hip fractures in older individuals, who had previously sustained a first hip fracture, and facilitate early prevention and diagnosis, therefore effectively managing rapidly rising healthcare costs in China., Methods: Data were obtained from Grade A Tertiary hospitals for older patients (age ≥ 60 years) diagnosed with hip fractures in southwest China between 1 January 2009 and 1 April 2020. The database was built by collecting clinical and administrative data from outpatients and inpatients nationwide. Data were randomly split into training (80%) and testing datasets (20%), followed by six ML-based prediction models using 19 variables for hip fracture patients within 2 years of the first fracture., Results: A total of 40,237 patients with a median age of 66.0 years, who were admitted to acute-care hospitals for hip fractures, were randomly split into a training dataset (32,189 patients) and a testing dataset (8,048 patients). Our results indicated that three of our ML-based models delivered an excellent prediction of subsequent hip fracture outcomes (the area under the receiver operating characteristics curve: 0.92 (0.91-0.92), 0.92 (0·92-0·93), 0.92 (0·92-0·93)), outperforming previous prediction models based on claims and cohort data., Conclusions: Our prediction models identify Chinese older people at high risk of subsequent hip fractures with specific baseline clinical and demographic variables such as length of hospital stay. These models might guide future targeted preventative treatments., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Context: Although physical activity (PA) is recognized to reduce fracture risk, whether its benefits differ according to glycemic status remains unknown., Objective: We investigated the effect of PA on incident hip fracture (HF) according to glycemic status., Methods: We studied 3 723 097 patients older than 50 without type 1 diabetes mellitus (DM) or past fractures. HF risks were calculated using Cox proportional hazard regression. Participants were categorized by glycemic status into 5 groups: normal glucose tolerance, impaired fasting glucose, new-onset type 2 DM, type 2 DM less than 5 years, and type 2 DM of 5 years or greater. PA was evaluated using the Korean adaptation of the International Physical Activity Questionnaire Short Form., Results: The highest HF risk were associated with the lowest PA level (<500 metabolic equivalent task [MET]-min/wk). While similar risks emerged across MET 500 to 1000, 1000 to 1500, and greater than 1500 categories, the relationship showed variations in different glycemic status groups. Exceptions were particularly noted in women with normoglycemia. However, a consistent inverse pattern, with few exceptions, was observed both in men and women with type 2 DM of 5 years or greater. Furthermore, the benefit of PA in the prevention of HFs was most evident in participants with type 2 DM of 5 years or greater. Compared to the reference group (lowest physical activity level <500 MET-min/wk within type 2 DM ≥5 years), the adjusted hazard ratios were 0.74 (0.62-0.88) in men and 0.74 (0.62-0.89) in women, suggesting a significant reduction in risk., Conclusion: Higher PA levels are associated with a lower risk of HF. This protective effect of PA on fracture risk is greatest in patients with DM, particularly in those with DM of 5 years or greater., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Previous research has found that vegetarian diets are associated with lower bone mineral density and higher risk of fractures, but these studies did not differentiate the quality of the plant-based foods., Objective: To examine the association between the quality of plant-based diets (not necessarily vegan but also omnivorous) and hip fracture risk among postmenopausal women in the Nurses' Health Study., Design, Setting, and Participants: This cohort study analyzed data from 70 285 postmenopausal women who participated in the US Nurses' Health Study from 1984 through 2014. Data were analyzed from January 1 to July 31, 2023., Main Outcomes and Measures: Hip fractures were self-reported on biennial questionnaires. Diet was assessed every 4 years using a validated semiquantitative food frequency questionnaire. Plant-based diet quality was assessed using 2 previously established indices: the healthful Plant-Based Diet Index (hPDI), for which healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea or coffee) received positive scores, whereas less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, and sweets or desserts) and animal foods received reversed scores; and the unhealthful Plant-Based Diet Index (uPDI), for which positive scores were given to less healthy plant foods and reversed scores to healthy plant and animal foods. Quintile scores of 18 food groups were summed, with a theoretical range for both indices of 18 to 90 (highest adherence). Cox proportional hazards regression with time-varying covariates was used to compute hazard ratios (HRs) and 95% CIs for hip fracture., Results: In total, 70 285 participants (mean [SD] age, 54.92 [4.48] years; 100% White women) were included, and 2038 cases of hip fracture were ascertained during the study and for up to 30 years of follow-up. Neither the hPDI (HR for highest vs lowest quintile, 0.97 [95% CI, 0.83-1.14]) nor the uPDI (HR for highest vs lowest quintile, 1.02 [95% CI, 0.87-1.20]) for long-term diet adherence was associated with hip fracture risk. However, when examining recent intake for the highest vs lowest quintiles, the hPDI was associated with 21% lower risk of hip fracture (HR, 0.79 [95% CI, 0.68-0.92]; P = .02 for trend), and the uPDI was associated with 28% higher risk (1.28 [95% CI, 1.09-1.51]; P = .008 for trend)., Conclusions and Relevance: Findings of this cohort study indicated that long-term adherence to healthful or unhealthful plant-based diets as assessed by hPDI and uPDI scores was not associated with hip fracture risk. Future research should clarify whether the associations observed with recent dietary intake are due to short-term effects of these dietary patterns, reverse causality, or both.

Introduction: Secondary fracture prevention is an essential part of hip fracture treatment. Despite this, many patients are discharged without the appropriate anti-osteoporotic medication. The aim of this study is to report the outcomes of the application of an in-hospital, surgeon-led anti-osteoporotic medication algorithm to patients with hip fractures., Materials and Methods: This prospective cohort study followed patients with hip fractures who were treated at a tertiary referral hospital between 2020 and 2022. At discharge, anti-osteoporotic medication according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Foundation algorithm was prescribed to all patients. Multivariate Cox regression analysis was used to investigate the risks of non-persistence to medication and of secondary fracture., Results: Two hundred thirteen consecutive patients were prospectively followed. Mean follow-up was 17.2 ± 7.1 months. Persistence to medication at 2 years was 58% (95%CI 51-65%). A secondary osteoporotic fracture occurred in 1/126 (0.8%) persistent patients and 9/87 (11.4%) non-persistent patients. Multivariable Cox regression analysis confirmed that persistence to medication was significantly associated with a lower risk of secondary fracture (cause-specific hazard ratio [csHR] 0.05; 95%CI 0.01-0.45; p = 0.007)., Conclusion: The application of the surgeon-led AO Foundation algorithm enables the in-hospital initiation of anti-osteoporotic treatment, leading to better persistence to medication and decreased incidence of secondary osteoporotic fractures., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In Sweden, secondary prevention of fragility fractures through osteoporosis medication is directed by national guidelines. According to these, postmenopausal women and men who have suffered a fragility fracture should be assessed and pharmaceutical treatment of osteoporosis should always be considered. For the most serious fractures (hip and vertebral fractures), treatment can be initiated immediately. Despite this, previous studies have shown that the level of pharmaceutical treatment is low. In Sweden, osteoporosis drugs are predominantly administered by prescription, but about one-third of drugs are nowadays administered on-site in the health care system, which is not recorded in national registers. We have estimated the total amount of osteoporosis drugs through aggregated sales statistics. Our results show that medical treatment with osteoporosis drugs is still at low levels, covering approximately 5 percent of the population aged 70 or older, with clear differences between regions.

Previous cohort studies have indicated that consumption of total and animal proteins are related to fracture risk; however, results were inconclusive. This dose-dependent review sought to summarize the earlier evidence regarding the relation between total and animal proteins and fracture risk. We searched Scopus, PubMed, and Web of Science until July 2023 for original research articles examining the association of certain types of proteins and the incidence of all fractures in general adults. Summary relative risks (RRs) were calculated using random effects analysis to examine the relation between each certain amount (g/day) increment of total and animal protein and fracture risk. Twenty cohort studies with serious to moderate risk of bias involving 780,322 individuals were included. There was a non-statistically significant relation between intake of animal proteins and dairy products and all fracture risk. However, 43% and 5% decreased incidence of fracture was obtained with total protein (RR, 0.57; 95%CI, 0.36 to 0.93; per 100 g/day) and fish (RR, 0.95; 95%CI, 0.91 to 0.99; per 15 g/day) intake. Every 100 g/day total and animal protein consumption and every 15 g/day fish consumption were linked to 48%, 50%, and 5% lower hip fracture risk. Greater dietary animal protein intake might reduce risk of hip but not fracture at any site. We obtained a lower risk of any or hip fracture with greater total protein (per 100 g/day) and fish (per 15 g/day) intake. No evidence was obtained that higher intake of dairy could decrease risk of fracture., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Purpose of Review: Recent findings in the influence of dietary patterns, dairy products, beverages and microbiota composition and function on bone health are reviewed and discussed., Recent Findings: Evidence is accumulating on the increased risk of fracture in individuals following a vegan diet. Meta-analysis of randomized controlled trials indicates a favourable, though of low amplitude, effect of dairy products on bone mass accrual during childhood and adolescence. Though mostly based on results from observational studies, it seems that dairy product consumption, particularly fermented dairy products, is associated with a lower risk of hip fracture. Regular green tea drinkers may have a lower fracture risk than tea abstainers. Magnesium intake is beneficial for bone health. Prune supplements prevents bone loss in untreated postmenopausal women. This seems to be associated with modification of gut microbiota., Summary: This information should help the medical practitioners facing questions from their patients on how to protect bone health through nutrition., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Goeffrey Rose postulated that a population-based measure bringing a small benefit to each individual can yield large benefits to the community. We aimed to test this axiom by quantifying the relationship between change in bone mineral density (BMD) and hip fracture incidence between two prospective cohorts separated by ~10 years. In this prospective population-based Dubbo Osteoporosis Epidemiology Study (DOES), the participants aged 60+ were recruited in two waves: the initial cohort (1311 women, 842 men) in 1989 to 1992 and the second cohort (974 women, 544 men) in 1999 to 2001. The incident hip fracture was radiologically ascertained. Femoral neck BMD was measured biannually. Multivariable-adjusted Cox's proportional hazards models were adjusted for the predefined covariates such as age, BMI, lifestyle factors, falls, and prior fracture. Compared with the initial cohort, the second cohort had a higher femoral neck BMD by ~0.04 g/cm 2 in women and 0.03 g/cm 2 in men. However, the prevalence of osteoporosis in the second cohort was halved (prevalence ratio 0.51, 95% CI 0.36 to 0.73 in women; 0.45, 0.24 to 0.84 in men), and its hip fracture incidence was significantly reduced (hazard ratio 0.54, 95% CI, 0.38 to 0.78 in women; 0.39, 0.19 to 0.80 in men). Sensitivity analyses indicated that the "effect" was unlikely due to unmeasured confounders. These findings suggest that a population-wide strategy aimed at enhancing BMD across the entire population could lead to a substantial decrease in the incidence of hip fractures. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR)., (© 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).)

Milk and milk products have been known as important for bone health. Can ingestion of milk and milk products lower hip fracture risk for older adults? In this study, older Icelandic adults who were ingesting higher milk had a lower risk of hip fractures., Introduction: This study describes associations between milk intake and hip fracture risk in older Icelanders. The data indicate that no/low milk consumption is related to greater hip fracture risk. Hip fracture can have a severe effect on the life of older adults. Health authorities recommend milk intake for better bone health. However, previous studies addressing this association have been divergent., Methods: This prospective study included 4614 subjects (mean age 76 years) recruited between 2002 and 2006 into the Age, Gene/Environment Susceptibility-Reykjavik (AGES-Reykjavik) study. Information on hip fractures occurring between recruitment and end of follow-up in 2012 was extracted from hospital records., Results: A total of 14% of participants reported milk intake < 0.5 times/day (the lowest category) and 22% of the participants consumed at least milk two times/day (highest category). Milk consumption was positively related to the volumetric bone mineral density at baseline with a sex- and age-adjusted difference of 8.95 ± 2.5 mg/cm 3 between the highest compared to lowest milk intake categories (P < 0.001). During the follow-up, 7.4% of participants had a hip fracture, and we observed a decreased risk of incident hip fractures in the highest compared to the lowest milk intake category with a hazard ratio of 0.69 (95% CI: 0.47-0.99) in adjusted model. Further analysis indicated a linear relationship between milk intake and fracture risk (P-value for linear trend < 0.001)., Conclusion: Milk intake is associated with a lower risk of incident hip fracture in a linear way in Icelandic community-dwelling older adults., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Hip fractures are common in the elderly, particularly due to an increased susceptibility to falls and greater bone frailty, especially in women. The consequences of such events are potentially serious. Early management (< 48 hours) significantly reduces the mortality and postoperative complications. Because of their comorbidities, older people are often on antiplatelet therapy, anticoagulant therapy, or both. However, there are no definitive recommendations for the perioperative management of antiplatelet and anticoagulant treatment in the early surgery of hip fractures. The purpose of this article is to review the management of these patients., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporosis-related measurement has shown controversial results. In this study, we found an age, dose andduration-dependent osteoprotective effect of statins in general older population., Purpose: Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporotic fractures has shown controversial results., Methods: In this study with Korean National Health Insurance Service-Senior cohort database, a total of 365,656 elderly without previous history of osteoporosis and who were started on statin since January 1 2004 were included and observed until December 31 2012. Hazard rations (HR) for major osteoporotic fractures were calculated using the weighted Cox proportional hazards model with inverse-probability of treatment weighting method., Results: During 6.27 years of follow-up period, 54,959 osteoporotic fractures occurred and the majority of fractures (69.5%) were vertebral fractures. Compared with non-users, statin use was associated with a decreased risk of all outcomes with adjusted HR (95% CI) of 0.77 (0.72-0.83; P < 0.001) for major osteoporotic fractures, 0.49 (0.38-0.62; P < 0.001) for hip fractures, and 0.70 (0.64-0.77; P < 0.001) for vertebral fractures. When outcomes were examined separately by sex, the results were broadly comparable in terms of patterns of risk reduction by statin use. The patients with statin initiated at age ≥ 80 years had the highest risk reduction for most outcomes relative to non-users. Higher cumulative dose of statin was negatively associated with the osteoporotic fracture risk; 0.97 (0.91-1.02) for 30-364 cumulative daily defined dose (cDDD), 0.45 (0.40-0.51) for 365-1,094 cDDD, and 0.22 (0.15-0.33) for ≥ 1,095 cDDD., Conclusions: Our results showed that statin use was associated with significant reduction in the risk of osteoporotic fractures in general older population., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Purpose: Although the Mediterranean diet has been associated with a lower risk of hip fracture, the effect of other dietary patterns on bone density and risk of fracture is unknown. This scoping review aims to investigate the association between adherence to alternative dietary patterns (other than the traditional Mediterranean diet) and osteoporosis or osteoporotic fracture risk in older people., Methods: A systematic search was carried out on three electronic databases (Medline, EMBASE, and Scopus) to identify original papers studying the association between alternative dietary patterns (e.g., Baltic Sea Diet (BSD), modified/alternative Mediterranean diet in non-Mediterranean populations, Dietary Approaches to Stop Hypertension (DASH)) assessed using 'prior' methods (validated scores) and the risk of osteoporotic fracture or Bone Mineral Density (BMD) in people aged ≥50 (or reported average age of participants ≥ 60). Results from the included studies were presented in a narrative way., Results: Six observational (four prospective cohort and two cross-sectional) studies were included. There was no significant association between BMD and BSD or DASH scores. Higher adherence to DASH was associated with a lower risk of lumbar spine osteoporosis in women in one study, although it was not associated with the risk of hip fracture in another study with men and women. Higher adherence to aMED (alternative Mediterranean diet) was associated with a lower risk of hip fracture in one study, whereas higher adherence to mMED (modified Mediterranean diet) was associated with a lower risk of hip fracture in one study and had no significant result in another study. However, diet scores were heterogeneous across cohort studies., Conclusions: There is some evidence that a modified and alternative Mediterranean diet may reduce the risk of hip fracture, and DASH may improve lumbar spine BMD. Larger cohort studies are needed to validate these findings.

Objective: Fracture liaison services (FLSs) have proven to be effective for secondary fracture prevention. In this study, we evaluated the essential factors in determining whether the FLS saves or loses more than it costs., Methods: A randomized controlled trial was performed in patients with hip fragility fractures using a hospital-based FLS program in parallel with a cost analysis. Data were generated from a cohort of patients using actual data for FLS effectiveness, individual costs of hip fracture treatment, and medication costs based on an accepted treatment algorithm., Results: A total of 200 patients were randomized, and 180 were analyzed for costs. The FLS program had an overall cost despite the savings in reducing secondary fractures. Medication was 89% of the costs and was the main factor for the FLS costs exceeding the savings. Specifically, using the medication algorithm in this study, the overall cost per patient enrolled in the FLS was $1189 for a 2-year period. If intravenous zoledronic acid had been used, then the overall cost would have been $489. If only oral bisphosphonates had been used, then the FLS would have cost $159 per patient for a 2-year period., Conclusion: The present analysis shows that medication cost is the critical component in cost-effectiveness of an FLS program. The FLS program costs would be significantly lower if patients are prescribed less expensive drugs to treat osteoporosis. Additional work needs to be performed refining the medication algorithm considering medication costs but individualized to patient needs based on fracture risk., Competing Interests: Disclosure The authors have no multiplicity of interest to disclose., (Copyright © 2023 AACE. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults., Recent Findings: Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Various femoral augmentation designs have been investigated over the past decade for the prevention of geriatric hip fracture. The experimental methods used to evaluate the efficacy of these augmentations have not been critically evaluated or compared in terms of biofidelity, robustness, or ease of application. Such parameters have significant relevance in characterizing future clinical success. In this study we aimed to use a scoping review to summarize the experimental studies that evaluate femoral augmentation approaches, and critically evaluate commonly applied protocols and identify areas for concordance with the clinical situation. We conducted a literature search targeting studies that used experimental test methods to evaluate femoral augmentation to prevent geriatric fragility fracture. A total of 25 studies met the eligibility criteria. The most commonly investigated augmentation to date is the injection of bone cement or another material that cured in situ, and a popular subsequent method for biomechanical evaluation was to load the augmented proximal femur until fracture in a sideways fall configuration. We noted limitations in the clinical relevance of sideways fall scenarios being modeled and large variance in the concordance of many of the studies identified. Our review brings about recommendations for enhancing the fidelity of experimental methods modeling clinical sideways falls, which include an improved representation of soft tissue effects, using outcome metrics beyond load-to-failure, and applying loads inertially. Effective augmentations are encouraging for their potential to reduce the burden of hip fracture; however, the likelihood of this success is only as strong as the methods used in their evaluation., (© 2023 Orthopaedic Research Society.)

Patients with osteoporosis are prone to fragility fractures. Evidence of the effects of active forms of vitamin D on hip fracture prevention is insufficient. We examined the association between vitamin D prescription and incidence of new fractures using the data of osteoporotic patients from the nationwide health insurance claims database of Japan. The follow-up period was 3 years after entry. The untreated patients were never prescribed vitamin D during follow-up (n = 422,454), and the treated patients had a vitamin D medication possession ratio of ≥ 0.5 at all time points (n = 169,774). Propensity score matching was implemented on these groups, yielding 105,041 pairs, and subsequently, the control and treatment groups were established and analyzed. The incidence of new fractures was significantly lower in the treatment group compared with the control group (6.25% vs. 5.69%, hazard ratio 0.936 [95% confidence interval 0.904-0.970], p < 0.001*). By site, hip fractures significantly decreased (0.89% vs. 0.42%, p < 0.001), but not vertebral and radial fractures. Subgroup analysis by vitamin D type showed a significantly lower incidence of total fractures only in alfacalcidol (hazard ratio 0.676 [95% confidence interval 0.628-0.728], p < 0.001*). The results suggest that vitamin D prescription was associated with a reduced incidence of hip fractures., (© 2023. Springer Nature Limited.)

We investigated the association between bisphosphonate and denosumab use and risk of hip fracture in Norway. These drugs protect against fractures in clinical trials, but their population-level effect is unknown. Our results showed lowered risk of hip fracture for treated women. Treatment of high-risk individuals could prevent future hip fractures., Purpose: To investigate whether bisphosphonates and denosumab reduced the risk of first-time hip fracture in Norwegian women when adjusting for a medication-based comorbidity index., Methods: Norwegian women aged 50-89 in 2005-2016 were included. The Norwegian prescription database (NorPD) supplied data on exposures to bisphosphonates, denosumab, and other drugs for the calculation of the Rx-Risk Comorbidity Index. Information on all hip fractures treated in hospitals in Norway was available. Flexible parametric survival analysis was used with age as time scale and with time-varying exposure to bisphosphonates and denosumab. Individuals were followed until hip fracture or censoring (death, emigration, age 90 years), or 31 December 2016, whichever occurred first. Rx-Risk score was included as a time-varying covariate. Other covariates were marital status, education, and time-varying use of bisphosphonates or denosumab with other indications than osteoporosis., Results: Of 1,044,661 women 77,755 (7.2%) were ever-exposed to bisphosphonate and 4483 (0.4%) to denosumab. The fully adjusted hazard ratios (HR) were 0.95 (95% confidence interval (CI): 0.91-0.99) for bisphosphonate use and 0.60 (95% CI: 0.47-0.76) for denosumab use. Bisphosphonate treatment gave a significantly reduced risk of hip fracture compared with the population after 3 years and denosumab after 6 months. Fracture risk was lowest in denosumab users who had previously used bisphosphonate: HR 0.42 (95% CI: 0.29-0.61) compared with the unexposed population., Conclusions: In population-wide real-world data, women exposed to bisphosphonates and denosumab had a lower hip fracture risk than the unexposed population after adjusting for comorbidity. Treatment duration and treatment history impacted fracture risk., (© 2023. The Author(s).)

Objectives: Levothyroxine suppressive therapy following thyroidectomy for thyroid cancer patients is considered as a risk factor for osteoporosis and fragility fractures. We evaluated the association of regular exercise and exercise habit change with fracture risk in adults older than 40 years who underwent thyroidectomy for thyroid cancer., Methods: We enrolled the patients who underwent thyroidectomy for thyroid cancer older than 40 years between 2010 and 2016 from the Korean National Health Insurance Service data, and they were followed through 2019. Based on the questionnaire of health examination within 2 years before and after surgery, whether regular exercise once a week was evaluated. The reference group for the statistical analysis was the continuing lack of physical activity group that did not exercise before or after surgery. For fractures newly diagnosed during the follow-up period, univariate and multivariate Cox regression analyses were performed for risk evaluation., Results: We evaluated 74,774 subjects, of whom 2,924 (3.9%) experienced any fractures during a median follow-up of 4.5 years. Compared with the group consistently lack of physical activity, the group that exercised before and after surgery showed a significant decrease in the risk of any fracture, vertebral fracture, and hip fracture: adjusted hazard ratio 0.848 (95% Confidence Interval 0.771-0.932), 0.703 (0.591-0.836), and 0.405 (0.224-0.732), respectively. For vertebral fracture, a significant reduction in fracture risk was confirmed even in patients who started their regular exercise after surgery: adjusted hazard ratio 0.779 (0.648-0.936). The risk reduction for vertebral fractures upon the initiation of exercise was found to be significant in the high-risk groups of patients: women and total thyroidectomy patients., Conclusion: We suggest that maintaining or starting regular exercise after surgery may help prevent fractures in thyroid cancer patients older than 40 years who have undergone thyroidectomy., 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 © 2023 Kim, Han, Jung, Ha, Jeong, Heu, Lee, Lee, Lim, Kim, Kwon, Song and Baek.)

Hip fractures are strong risk factors for further fractures. However, using the National Hip Fracture Database, we observed that in England and Wales, 64% of patients admitted on oral bisphosphonates were discharged on the same and injectable drug use varies from 0-67% and 0.2%-83.6% were deemed "inappropriate" for bone protection. This variability requires further investigation., Introduction: A key aim for the National Hip Fracture Database (NHFD) is to encourage secondary fracture prevention of the 75,000 patients who break their hip annually in the UK, through bone health assessment and appropriate provision of anti-osteoporosis medication (AOM). We set out to describe trends in anti-osteoporosis medication prescription and examine the types of oral and injectable AOMs being prescribed both before and after a hip fracture., Methods: We used data freely available from the NHFD  www.nhfd.co.uk  to analyse trends in oral and injectable AOM prescription across a quarter of a million patients presenting between 2016 and 2020, and more detailed information on the individual type of AOM prescribed for 63,705 patients from 171 hospitals in England and Wales who presented in 2020., Results: Most patients (88.3%) are not taking any AOM when they present with a hip fracture. Half of all patients (50.8%) were prescribed AOM treatment by the time of discharge, but the proportion deemed 'inappropriate for AOM' varied hugely (0.2-83.6%) in different hospitals. Nearly two-thirds (64.2%) of those previously taking an oral bisphosphonate were simply discharged on the same type of medication. The total number of patients discharged on oral medication fell by over a quarter in these five years. The number discharged on injectables increased by nearly three-quarters to 14.2% over the same period, but remains hugely variable across the country, with rates ranging from 0-67% across different units., Conclusion: A recent hip fracture is a strong risk factor for future fractures. The huge variability in approaches, and in particular the use of injectables, in different trauma units across England and Wales requires further investigation., (© 2023. Crown.)

Background: older adults in aged care account for 30% of the population burden of hip fractures. Nutritional interventions to correct under nutrition reduce these debilitating fractures, perhaps partly by reducing falls and slowing deterioration in bone morphology., Objective: to determine whether a nutritional approach to fracture risk reduction in aged care homes is cost-effective., Design: cost-effectiveness was estimated based on results from a prospective 2-year cluster-randomised controlled trial and secondary data. Intervention residents consumed a total of 3.5 daily servings of milk, yoghurt and/or cheese, resulting in 1,142 mg of calcium and 69 g of protein compared with the daily intakes of 700 mg of calcium and 58 g of protein consumed by the control group., Setting: fifty-six aged care homes., Participants: residents for 27 intervention (n = 3,313) and 29 control (n = 3,911) homes., Methods: ambulance, hospital, rehabilitation and residential care costs incurred by fracture were estimated. The incremental cost-effectiveness ratios per fracture averted within a 2-year time horizon were estimated from the Australian healthcare perspective applying a 5% discount rate on costs after the first year., Results: intervention providing high-protein and high-calcium foods reduced fractures at a daily cost of AU$0.66 per resident. The base-case results showed that the intervention was cost-saving per fracture averted, with robust results in a variety of sensitivity and scenario analyses. Scaling the benefits of intervention equates to a saving of AU$66,780,000 annually in Australia and remained cost-saving up to a daily food expenditure of AU$1.07 per resident., Conclusions: averting hip and other non-vertebral fractures in aged care residents by restoring nutritional inadequacy of protein and calcium is cost-saving., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Our imminent model was less sensitive but more selective than FRAX® in the choice of treatment to prevent imminent fractures. This new model decreased NNT by 30%, which could reduce the treatment costs. In the Belgian FRISBEE cohort, the effect of recency further decreased the selectivity of FRAX®., Purpose: We analyzed the selection for treatment of patients at high risk of fracture by the Belgian FRISBEE imminent model and the FRAX® tool., Methods: We identified in the FRISBEE cohort subjects who sustained an incident MOF (mean age 76.5 ± 6.8 years). We calculated their estimated 10-year risk of fracture using FRAX® before and after adjustment for recency and the 2-year probability of fracture using the FRISBEE model., Results: After 6.8 years of follow-up, we validated 480 incident and 54 imminent MOFs. Of the subjects who had an imminent fracture, 94.0% had a fracture risk estimated above 20% by the FRAX® before correction for recency and 98.1% after adjustment, with a specificity of 20.2% and 5.9%, respectively. The sensitivity and specificity of the FRISBEE model at 2 years were 72.2% and 55.4%, respectively, for a threshold of 10%. For these thresholds, 47.3% of the patients were identified at high risk in both models before the correction, and 17.2% of them had an imminent MOF. The adjustment for recency did not change this selection. Before the correction, 34.2% of patients were selected for treatment by FRAX® only, and 18.8% would have had an imminent MOF. This percentage increased to 47% after the adjustment for recency, but only 6% of those would suffer a MOF within 2 years., Conclusion: In our Belgian FRISBEE cohort, the imminent model was less sensitive but more selective in the selection of subjects in whom an imminent fracture should be prevented, resulting in a lower NNT. The correction for recency in this elderly population further decreased the selectivity of FRAX®. These data should be validated in additional cohorts before using them in everyday practice., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Background: There is well-established evidence to understand the characteristics of falls among the older patients with hip fracture in many countries, but very little knowledge existed in China. This study described the characteristics of falls in older patients with hip fractures from six Chinese hospitals., Methods: This cross-sectional study is a post-hoc descriptive analysis of a recently completed trial. Eligible patients were aged 65 years and older, with confirmed hip fractures due to falls, and were admitted to the hospital within 21 days of the fracture. All patients were consecutively enrolled and screened within one year (November 15, 2018, to November 14, 2019). The collected data included patient demographics and fall-related information., Results: A total of 1,892 patients' fall-related information were described. Most patients with hip fractures caused by falls were in the oldest old age group (60.4% in age group ≥ 80), with an overall average age of 80.7 (7.6) years. There were more females (n = 1,325, 70.0%) than males (n = 567, 30.0%). The majority lived in urban (n = 1,409, 74.5%). Most falls (n = 1,237, 67.3%) occurred during the daytime (6:01-18:00). There were 1,451 patients had their falls occurring at home (76.7%). Lost balance (n = 1,031, 54.5%) was reported as the primary reason to cause falls. The most common activity during a fall was walking (n = 1,079, 57.0%)., Conclusions: Although the incidence of fall-related hip fractures in China is unclear, preventing falls and fall-related hip fractures in older people remains an urgent health concern as the ageing society increases. Studies with larger sample size and diverse population are needed to robustly understand this growing epidemic., (© 2023. The Author(s).)

This scoping review described the use, effectiveness, and cost-effectiveness of clinical fracture-risk assessment tools to prevent future osteoporotic fractures among older adults. Results show that the screening was not superior in preventing all osteoporosis-related fractures to usual care. However, it positively influenced participants' perspectives on osteoporosis, may have reduced hip fractures, and seemed cost-effective., Purpose: We aim to provide a synopsis of the evidence about the use of clinical fracture-risk assessment tools to influence health outcomes, including reducing future osteoporotic fractures and their cost-effectiveness., Methods: We followed the guidelines of Arksey and O'Malley and their modifications. A comprehensive search strategy was created to search CINAHL, Medline, and Embase databases until June 29, 2021, with no restrictions. We critically appraised the quality of all included studies., Results: Fourteen studies were included in the review after screening 2484 titles and 68 full-text articles. Four randomized controlled trials investigated the effectiveness of clinical fracture-risk assessment tools in reducing all fractures among older women. Using those assessment tools did not show a statistically significant reduction in osteoporotic fracture risk compared to usual care; however, additional analyses of two of these trials showed a trend toward reducing hip fractures, and the results might be clinically significant. Four studies tested the impact of screening programs on other health outcomes, and participants reported positive results. Eight simulation studies estimated the cost-effectiveness of using these tools to screen for fractures, with the majority showing significant potential savings., Conclusion: According to the available evidence to date, using clinical fracture-risk assessment screening tools was not more effective than usual care in preventing all osteoporosis-related fractures. However, using those screening tools positively influenced women's perspectives on osteoporosis, may have reduced hip fracture risk, and could potentially be cost-effective. This is a relatively new research area where additional studies are needed., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Introduction: A significant treatment gap has been observed in patients with osteoporosis. Our previous audit found a 31.5% rate of anti-osteoporosis medication initiation after fragility fractures at one year. We piloted the use of telecarers to monitor osteoporosis treatment and compliance., Methods: From January 2017 to January 2018, all hip fracture patients at Changi General Hospital, Singapore, were automatically enrolled into the Health Management Unit valued care hip fracture programme. Telecarer calls were scheduled at discharge, 3, 6 and 12 months. We assessed the acceptability, completion and treatment rates of patients enrolled in this programme., Results: A total of 537 patients with a hip fracture were enrolled in the telecarer programme over one year. Their average age was 79.8 ± 8.23 years, and 63.1% of them were female. A total of 341 patients completed 12 months of follow-up, of which 251 (73.6%) patients were on treatment at 12 months. The most common cause of lack of initiation of secondary osteoporosis treatment was patient or family rejection (34.4%), followed by physician failure to prescribe (24.4%) and renal impairment (24.4%). 16.7% of patients were deemed to have advanced dementia with a life-limiting illness and were, thus, deemed unsuitable for treatment., Conclusion: Telecarers may be a useful adjunct in the monitoring of osteoporosis treatment after hip fractures in an elderly population. The main limitations are patient or family rejection and physician inertia. Further studies should focus on a combination of interventions for both patients and physicians to increase awareness of secondary fracture prevention., Competing Interests: None

Hip fracture is the most devastating type of osteoporosis-related fracture, and is a major worldwide public health problem with a high socioeconomic burden, morbidity rate, and mortality rate. Thus, it is crucial to uncover the risk factors and protective factors to create a hip fracture prevention strategy. In addition to a briefly review of some well accepted risk and protective factors of hip fracture, this review mainly summarized the recent advances in the identification of emerging risk or protective factors for hip fracture, in terms of regional differences in medical services, diseases, drugs, mechanical load, neuromuscular mass, genes, blood types, cultural differences. This review provides a comprehensive review of the associated factors and effective prevention measures for hip fracture, and discusses issues that need further investigation. These issues include the determination of the influencing mechanism of risk factors triggering hip fracture and their interlinked correlation with other factors, as well as the confirmation or correction of emerging factors associated with hip fracture, particularly those that are still controversial. These recent findings will aid in optimizing the strategy for preventing hip fracture., 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 © 2023 Yu, Wang, Hou and Tian.)

Aims: Type 2 diabetes mellitus (T2DM) frequently co-exists with osteoporosis and dyslipidemia. Statins have been commonly used in the treatment of dyslipidemia. Recent studies have indicated a therapeutic role of statins in decreasing the risk of osteoporosis and fractures, but conflicting results have been reported. This study investigated the association between statin use and hip fracture (HFx) risk among T2DM patients., Materials and Methods: A retrospective Taiwan population-based propensity-matched cohort study was performed using the Diabetes Mellitus Health Database from Taiwan National Health Insurance Research Database. Patients with newly diagnosed with T2DM between 2010 and 2014 were identified. Patients who previously used statins and had ever suffered HFx before the index date were excluded. HFx that occurred from 2010 to 2019 was collected to compute the cumulative rate of HFx. Hazard ratios (HRs) were calculated for the HFx risk according to the use or non-use of statins. To evaluate the dose-effect relationship of statins, sensitivity analyses were conducted., Results: After propensity score matching for age and sex, 188,588 patients were identified as statin users and non-statin users. Statin use after T2DM diagnosis was associated with a decreased HFx risk with an adjusted HR (aHR) of 0.69 (P < 0.001). A dose-effect relationship was identified. The aHRs for developing HFx were 1.29, 0.67, and 0.36 for patients who used 28-174, 175-447, and >447 cumulative defined daily doses of statins, respectively (P < 0.001)., Conclusions: Statin use in adults with T2DM showed a lower risk of HFx by demonstrating a dose-response relationship., (© 2022 John Wiley & Sons Ltd.)

Introduction: The most successful programme for secondary fracture prevention is the FLS (fracture liaison service) model. Our orthopaedic department carried out a prospective randomised study to measure the effectiveness of a 4-step intervention programme. The findings in this study reveal important additional clinical benefits to having an orthopaedic-based FLS programme and evaluates the usefulness of fracture risk tools., Methods: We carried out a prospective study to evaluate patients with a fragility fracture of the hip. There were 2 groups, intervention and control (each 100 patients). Of these, 20 were either removed from the study or dropped out, leaving 180 for analysis. In addition to routine preoperative blood tests, albumin and thyroid function levels were obtained and PTH (parathyroid hormone) levels when indicated.The intervention group (83 patients) had a dual-energy x-ray absorptiometry (DEXA) scan performed and fracture risk (FRAX) was calculated., Results: 12 patients (6.7%) had blood results which showed a potentially treatable cause for osteoporosis and 36 (20%) had blood results that changed their medical care.FRAX scores (180 patients) showed that the major osteoporotic fracture score correctly predicted the hip fracture in only 49%. The hip fracture score correctly predicted the hip fracture in 83%.DEXA scores (65 patients) showed osteoporosis in only 46% of hips and in only 26% of spines.An abnormal FRAX score or DEXA scan would have predicted a fragility fracture 93% of the time., Conclusions: In addition to reducing secondary fractures, FLS programmes can provide fundamental benefits to the health of the patient. The intervention programme in this study identified patients with underlying treatable causes, correctable clinical conditions and patients with an unusually low bone density. When used together, FRAX and DEXA are more sensitive predictors for hip fracture risk than either are individually., Trial Registry: 201497CTIL (https://clinicaltrials.gov/ct2/show/NCT02239523).