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Summary: Sequential romosozumab-to-alendronate or sequential teriparatide-to-alendronate can be a cost-effective treatment option for postmenopausal women at very high risk of fracture. Purpose: To estimate the 10-year probability of a major osteoporotic fracture (MOF) at which sequential treatment with romosozumab or teriparatide followed by alendronate, compared with alendronate alone, becomes cost-effective in a UK setting. Methods: A microsimulation model with a Markov structure was used to simulate fractures, costs, and quality-adjusted life years (QALYs), in women receiving sequential treatment with either romosozumab or teriparatide followed by alendronate, compared with alendronate alone. Patients aged 50 to 90 years with a recent MOF, hip or spine fracture were followed from the start of a 5-year treatment until the age of 100 years or death. The analysis had a healthcare perspective. Efficacy of romosozumab, teriparatide and alendronate was derived from phase III randomised controlled trials. Resource use and unit costs were derived from the literature. Cost-effectiveness intervention threshold (CEIT), defined as the 10-year probability of a major osteoporotic fracture at which treatment becomes cost-effective, was compared with clinically appropriate intervention thresholds for bone-forming treatment in women with very high fracture risk as recommended by the UK National Osteoporosis Guideline Group (NOGG). Results: The base case analysis showed that sequential romosozumab-to-alendronate treatment was cost-effective from a 10-year MOF probability of 18–35% and above depending on age and site of sentinel fracture at a willingness to pay (WTP) of £30,000. For teriparatide-to-alendronate, treatment was cost-effective at a 10-year MOF probability of 27–57%. The results were sensitive to pricing of the drugs but relatively insensitive to treatment duration, romosozumab persistence assumptions, and site of sentinel fracture. The CEITs for romosozumab-to-alendronate treatment were lower than the clinical thresholds from the age of 70 years meaning that treatment could be considered both cost-effective and aligned with the NOGG treatment guidelines. By contrast, for teriparatide-to-alendronate the CEITs were higher than the clinical thresholds irrespective of age. However, cost-effective scenarios were found in the presence of strong clinical risk factors in addition to a recent sentinel fracture. Conclusion: The results of this study indicate that sequential romosozumab-to-alendronate or teriparatide-to-alendronate treatment can be a cost-effective treatment option for postmenopausal women at very high risk of fracture. [ABSTRACT FROM AUTHOR]

Purpose Osteoporosis (OP) is characterized by a gradual onset and an increased susceptibility to osteoporotic fractures. Previous retrospective studies have suggested that hemoglobin (HGB) levels could be a potential diagnostic marker for OP. However, the relationship between OP and anemia remains uncertain. This prospective study aimed to investigate the association between HGB levels and OP. Methods Leveraging data from the UK Biobank, a cohort of 452 778 individuals was analyzed. Employing a modified Cox proportional hazards model that accounted for sociodemographic factors, lifestyle, and health-related factors, we examined the links between incident OP and sex. Moreover, we investigated the impact of OP with or without a pathological fracture. Results Following a median follow-up period of 5.85 years, 4294 participants were diagnosed with OP. After adjusting for a comprehensive range of pertinent confounders, individuals with anemia exhibited a 2.15-fold higher risk of OP in males and a 1.41-fold higher risk in females. Moreover, each unit increase in HGB concentration corresponded to a 0.83-fold decrease in OP risk for men and a 0.94-fold decrease for women. Perspectives Our findings reveal a significant correlation between HGB levels or anemia and OP, with males demonstrating a greater susceptibility compared to females. The risk of OP decreased with higher HGB concentrations in both sexes, although this effect was more pronounced in males. It is recommended to conduct longitudinal studies to investigate the causality of the observed connections and experimental studies to understand the underlying mechanisms. Key messages What is already known on this topic Cross-sectional studies have shown that anemia are associated with osteoporosis, and gender differences present in both diseases, but their role in this association is rarely studied at present. What this study adds There is a significant correlation between hemoglobin levels and osteoporosis, with male gender demonstrating a greater susceptibility compared to females. The risk of osteoporosis decreased with higher hemoglobin levels in both genders, although this effect was more pronounced in males. How this study might affect research, practice or policy Regular screening of bone health and elevating hemoglobin levels are recommended for anemic patients to proactively prevent osteoporosis, especially in male gender. Large-scale, multicenter, longitudinal studies are encouraged to investigate the association, and experimental studies are necessary to comprehend the underlying mechanisms. [ABSTRACT FROM AUTHOR]

Summary: We studied the association between non-osteoporotic fractures and future major osteoporotic fractures, using UK health records. Non-osteoporotic fractures were found to increase the risk of major osteoporotic fractures, although to a lesser extent than osteoporotic fractures. This highlights the importance of considering all previous fractures in assessing future fracture risk. Purpose: Previous studies demonstrated that osteoporotic fractures—minor and major—increase the risk for future major osteoporotic fractures; we test whether non-osteoporotic fractures are also associated with such increased risk. Methods: The study is a retrospective cohort study using UK primary care electronic health records. Exposure groups were defined according to fracture location prior to the year 2011 (index date): major, minor, and non-osteoporotic. The outcome of incident major osteoporotic fractures following the index date was compared between the exposure groups and the general population. Results: The general study population included 1,951,388 patients. The exposure groups included 39,931 patients with a prior major osteoporotic fracture, 19,397 with a prior minor osteoporotic fracture, and 50,115 patients with a prior non-osteoporotic fracture. The standardized Incidence Rate Ratio for future major osteoporotic fractures was 2.73 (95% confidence interval: 2.64–2.82), 2.43 (2.32–2.54), and 1.83 (1.74–1.92), respectively. Conclusion: Non-osteoporotic fractures are significantly associated with increased risk for future major osteoporotic fractures relative to the general population, yet to a lesser extent compared to major and minor osteoporotic fractures. [ABSTRACT FROM AUTHOR]

Summary: The effect of deprivation on total bone health status has not been well defined. We examined the relationship between socioeconomic deprivation and poor bone health and falls and we found a significant association. The finding could be beneficial for current public health strategies to minimise disparities in bone health. Purpose: Socioeconomic deprivation is associated with many illnesses including increased fracture incidence in older people. However, the effect of deprivation on total bone health status has not been well defined. To examine the relationship between socioeconomic deprivation and poor bone health and falls, we conducted a cross-sectional study using baseline measures from the United Kingdom (UK) Biobank cohort comprising 502,682 participants aged 40–69 years at recruitment during 2006–2010. Method: We examined four outcomes: 1) low bone mineral density/osteopenia, 2) fall in last year, 3) fracture in the last five years, and 4) fracture from a simple fall in the last five years. To measure socioeconomic deprivation, we used the Townsend index of the participant's residential postcode. Results: At baseline, 29% of participants had low bone density (T-score of heel < -1 standard deviation), 20% reported a fall in the previous year, and 10% reported a fracture in the previous five years. Among participants experiencing a fracture, 60% reported the cause as a simple fall. In the multivariable logistic regression model after controlling for other covariates, the odds of a fall, fracture in the last five years, fractures from simple fall, and osteopenia were respectively 1.46 times (95% confidence interval [CI] 1.42–1.49), 1.26 times (95% CI 1.22–1.30), 1.31 times (95% CI 1.26–1.36) and 1.16 times (95% CI 1.13–1.19) higher for the most deprived compared with the least deprived quantile. Conclusion: Socioeconomic deprivation was significantly associated with poor bone health and falls. This research could be beneficial to minimise social disparities in bone health. [ABSTRACT FROM AUTHOR]

Purpose: The epidemiology of paediatric fractures has been previously described, however there is limited data available on open fractures in this population. The purpose of this study was to investigate trends, mechanism of injury (MOI) and severity of paediatric open fractures and undertake an epidemiological study. Methods: All children ≤ 16.0 years presenting with open fractures were identified between 01/04/2013 and 01/04/2023. Those with craniofacial, thoracic and distal phalangeal fractures were excluded. Incidence was calculated based on those presenting within the local geographical region. Social deprivation was measured using the Index of Multiple Deprivation (IMD). Results: There were 208 open fractures with a median age of 11.0(q1 7.4-q3 13.4) years, and 153(74.6%) were in males. The MOIs were road traffic collisions 73(35.1%), sports/play 45(21.6%), fall > 2m 29(13.9%), simple fall 25(12.0%), crush 16(7.7%), bites 8(3.8%), assault 6(2.9%), and other 6(2.9%). Nineteen children (9.1%) presented with polytrauma. Gustilo-Anderson grade for long bone fractures were I-61(29.3%), II-24(11.5%), IIIa-36(17.3%), IIIb-30(14.4%) and IIIc-7(3.4%). There were 129 children presenting within the local geographical region providing an annual incidence of 8.0/100,000. Radius and ulna were the most frequently injured 49(38.0%) followed by tibia and fibula 44(34.1%). There were 69(53.5%) children presenting from an IMD quintile 1 with open fractures. Conclusion: Paediatric open fractures are commonly seen in the adolescent male and affect those who are from a more socially deprived background. These injuries account for 3.2% of fractures admitted to a MTC. Data suggests children principally sustain open fractures through two distinct injury patterns and ten-year trends suggests that there is a gradual decline in the annual incidence. [ABSTRACT FROM AUTHOR]

Massive genetic compendiums such as the UK Biobank have become an invaluable resource for identifying genetic variants that are associated with complex diseases. Due to the difficulties of massive data collection, a common practice of these compendiums is to collect interval‐censored data. One challenge in analyzing such data is the lack of methodology available for genetic association studies with interval‐censored data. Genetic effects are difficult to detect because of their rare and weak nature, and often the time‐to‐event outcomes are transformed to binary phenotypes for access to more powerful signal detection approaches. However transforming the data to binary outcomes can result in loss of valuable information. To alleviate such challenges, this work develops methodology to associate genetic variant sets with multiple interval‐censored outcomes. Testing sets of variants such as genes or pathways is a common approach in genetic association settings to lower the multiple testing burden, aggregate small effects, and improve interpretations of results. Instead of performing inference with only a single outcome, utilizing multiple outcomes can increase statistical power by aggregating information across multiple correlated phenotypes. Simulations show that the proposed strategy can offer significant power gains over a single outcome approach. We apply the proposed test to the investigation that motivated this study, a search for the genes that perturb risks of bone fractures and falls in the UK Biobank. [ABSTRACT FROM AUTHOR]

Background: Lifetime risk of fragility fractures is 50% in post-menopausal women and 20% in men aged >50 years. Identifying people at high risk facilitates early intervention and reduction of biopsychosocial morbidity associated with these fractures. Aim: To explore if bone health assessment (BHA) rates differ between women and men aged =50 years with fragility fracture risk factors. Design & setting: A primary care-based cohort study in North Staffordshire, UK. Method: Patients were identified from the Consultations in Primary Care Archive (CiPCA) database between 2002 and 2014 with one or more fragility fracture risk factors (previous fractures, falls, and prolonged steroid use). Evaluation of BHA within 12 months of presentation of the first risk factor was carried out by searching for codes for fracture risk assessment tools (FRAX and QFracture), bone density measurement, specialist service referral, or if bone-protection medication was started. Results: A total of 15 581 patients with risk factors were identified; men represented 40.4% of the cohort. The study found 1172 (7.5%) had BHA performed within 1 year of presentation, and 8.9% of women and 5.5% of men had BHAs, which was found with strong statistical evidence (χ2 = 59.88, P = 1 × 10-14). This relationship prevailed after adjusting for other covariates, such as comorbidity and number of consultations, with an odds ratio of 1.25 (95% confidence interval [CI] = 1.08 to 1.43). Conclusion: This study has shown that rates of BHA were generally low and even lower in men compared with women. Primary care clinicians should be alert to fragility fracture risk factors in both men and women to enable early assessment and intervention. [ABSTRACT FROM AUTHOR]

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Summary: Bone mineral density (BMD) is an essential predictor of osteoporosis and fracture. We conducted a genome-wide trajectory analysis of BMD and analyzed the BMD change. Purpose: This study aimed to identify the genetic architecture and potential biomarkers of BMD. Methods: Our analysis included 141,261 white participants from the UK Biobank with heel BMD phenotype data. We used a genome-wide trajectory analysis tool, TrajGWAS, to conduct a genome-wide association study (GWAS) of BMD. Then, we validated our findings in previously reported BMD genetic associations and performed replication analysis in the Asian participants. Finally, gene-set enrichment analysis (GSEA) of the identified candidate genes was conducted using the FUMA platform. Results: A total of 52 genes associated with BMD trajectory mean were identified, of which the top three significant genes were WNT16 (P = 1.31 × 10−126), FAM3C (P = 4.18 × 10−108), and CPED1 (P = 8.48 × 10−106). In addition, 114 genes associated with BMD within-subject variability were also identified, such as AC092079.1 (P = 2.72 × 10−13) and RGS7 (P = 4.72 × 10−10). The associations for these candidate genes were confirmed in the previous GWASs and replicated successfully in the Asian participants. GSEA results of BMD change identified multiple GO terms related to skeletal development, such as SKELETAL SYSTEM DEVELOPMENT (Padjusted = 2.45 × 10−3) and REGULATION OF OSSIFICATION (Padjusted = 2.45 × 10−3). KEGG enrichment analysis showed that these genes were mainly enriched in WNT SIGNALING PATHWAY. Conclusions: Our findings indicated that the CPED1-WNT16-FAM3C locus plays a significant role in BMD mean trajectories and identified several novel candidate genes contributing to BMD within-subject variability, facilitating the understanding of the genetic architecture of BMD. [ABSTRACT FROM AUTHOR]

The UK Bone and Joint Infection Registry (BAJIR) is a national project established in 2018 with the aim of collecting information about demographics, co-morbidities, pathogens, treatment strategies and outcomes on all patients who are diagnosed with, and treated for, a bone or joint infection in the UK with the objective of providing an understanding of the burden of disease. In time these data will be used to inform best practice, direct research and provide information for commissioners of healthcare. In this fracture-related infection special edition article, we discuss the registry's development, relevance and how we see it directing our practice in the future. Equally, we have highlighted some potential limitations and lessons learned. [ABSTRACT FROM AUTHOR]

The Diabetes UK Professional Conference, held this year in Liverpool, featured presentations on pharmacological treatment across the spectrum of diabetes care, promoting safe and effective use of medications to optimise outcomes. Dr Katherine Bishop reports on some key prescribing topics. [ABSTRACT FROM AUTHOR]

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population. [ABSTRACT FROM AUTHOR]

Objective: Gout is associated with a higher risk of fracture; however, findings on the associations of hyperuricemia and urate‐lowering therapy (ULT) with the risk of fracture have been inconsistent. We examined whether lowering serum urate (SU) levels with ULT to a target level (i.e., <360 μmoles/liter) reduces the risk of fracture among individuals with gout. Methods: We emulated analyses of a hypothetical target trial using a "cloning, censoring, and weighting" approach to examine the association between lowering SU with ULT to the target levels and the risk of fracture using data from The Health Improvement Network, a UK primary care database. Individuals with gout who were age 40 years or older and for whom ULT was initiated were included in the study. Results: Among 28,554 people with gout, the 5‐year risk of hip fracture was 0.5% for the "achieving the target SU level" arm and 0.8% for the "not achieving the target SU level" arm. The risk difference and hazard ratio for the "achieving the target SU level" arm was –0.3% (95% confidence interval [95% CI] –0.5%, –0.1%) and 0.66 (95% CI 0.46, 0.93), respectively, compared with the "not achieving the target SU level" arm. Similar results were observed when the associations between lowering SU level with ULT to the target levels and the risk of composite fracture, major osteoporotic fracture, vertebral fracture, and nonvertebral fracture were assessed. Conclusion: In this population‐based study, lowering the SU level with ULT to the guideline‐based target level was associated with a lower risk of incident fracture in people with gout. [ABSTRACT FROM AUTHOR]

Summary: This study used primary care data to estimate the incidence of recorded diagnosis of osteoporosis, osteopenia, and fragility fracture in the UK during 2000–2018 accounting for age, sex, calendar year and social deprivation. More than 3 million people aged 50–99 years were included. We found that men living in the most deprived areas had a 45% higher risk of being diagnosed with osteoporosis and 50% higher risk of fragility fracture compared to men living in the least deprived areas. Purpose: a) To estimate the incidence trends of a recorded diagnosis of osteoporosis, osteopenia, and fragility fracture in the UK over time; b) to describe differences according to age, sex, and social deprivation. Methods: This is a longitudinal population-based cohort study using routinely collected primary care data obtained via IQVIA Medical Research Database (IMRD). All patients aged 50–99 years registered with a practice participating in THIN (The Health Improvement Network) between 2000–2018 were included. The first recorded diagnosis of osteoporosis, osteopenia, or fragility fracture was used to estimate incidence rates (IR) per 10,000 person-years at risk. Poisson regression was used to provide Incidence Rate Ratios (IRR) adjusted by age, sex, social deprivation, calendar year, and practice effect. Results: The year-specific adjusted IRR of recorded osteoporosis was highest in 2009 in women [IRR 1.44(95%CI 1.38–1.50)], whereas in men it was highest in 2013–2014 [IRR 1.94(95%CI 1.72–2.18)] compared to 2000. The year-specific adjusted IRR of fragility fracture was highest in 2012 in women [IRR 1.77(95%CI 1.69–1.85)], whereas in men it was highest in 2013 [IRR 1.64(95%CI 1.51–1.78)] compared to 2000. Men in the most deprived areas had a higher risk of being diagnosed with osteoporosis [IRR 1.45(95%CI 1.38–1.53)], osteopenia [IRR 1.17(95%CI 1.09–1.26)], and fragility fracture [IRR 1.50(95%CI 1.44–1.56)] compared to those living in the least deprived areas, but smaller differences were seen in women. Conclusion: Use of fracture risk assessment tools may enhance the detection of osteoporosis cases in primary care. Further research is needed on the effect of social deprivation on diagnosis of osteoporosis and fractures. [ABSTRACT FROM AUTHOR]

Summary: The potential of bone mineral density (BMD)-related genome-wide polygenic score (PGS) in identifying individuals with a high risk of fractures remains unclear. This study suggests that an efficient PGS enables the identification of strata with up to a 1.5-fold difference in fracture incidence. Incorporating PGS into clinical diagnosis is anticipated to increase the population-level screening benefits. Purpose: This study sought to construct genome-wide polygenic scores for femoral neck and total body BMD and to estimate their potential in identifying individuals with a high risk of osteoporotic fractures. Methods: Genome-wide polygenic scores were developed and validated for femoral neck and total body BMD. We externally tested the PGSs, both by themselves and in combination with available clinical risk factors, in 455,663 European ancestry individuals from the UK Biobank. The predictive accuracy of the developed genome-wide PGS was also compared with previously published restricted PGS employed in fracture risk assessment. Results: For each unit decrease in PGSs, the genome-wide PGSs were associated with up to 1.17-fold increased fracture risk. Out of four studied PGSs, P G S _ T B B M D 81 (HR: 1.03; 95%CI 1.01–1.05, p = 0.001) had the weakest and the P G S _ T B B M D l d p r e d (HR: 1.17; 95%CI 1.15–1.19, p < 0.0001) had the strongest association with an incident fracture. In the reclassification analysis, compared to the FRAX base model, the models with P G S _ F N B M D 63 , P G S _ T B B M D 81 , P G S _ F N B M D l d p r e d , and P G S _ T B B M D l d p r e d improved the reclassification of fracture by 1.2% (95% CI, 1.0 to 1.3%), 0.2% (95% CI, 0.1 to 0.3%), 1.4% (95% CI, 1.3 to 1.5%), and 2.2% (95% CI, 2.1 to 2.4%), respectively. Conclusions: Our findings suggested that an efficient PGS estimate enables the identification of strata with up to a 1.7-fold difference in fracture incidence. Incorporating PGS information into clinical diagnosis is anticipated to increase the benefits of screening programs at the population level. [ABSTRACT FROM AUTHOR]

Background: Self-perceived risk of fracture (SPR) is associated with fracture independent of FRAX calculated risk. To understand this better we considered whether lifestyle factors not included in the FRAX algorithm and psychosocial factors (social isolation, self-efficacy, or mental health status) explain the relationship between SPR and fracture. Methods: We studied 146 UK community-dwelling older adults from the Hertfordshire Cohort Study. SPR ranked as 'lower', 'similar' and 'higher' relative to others of the same age, was assessed by questionnaire. Social isolation was assessed using the six-item Lubben Social Network Scale; self-efficacy was assessed using a shortened General Self-Efficacy Scale (GSE); mental health status was assessed using the anxiety/depression item from the EuroQoL questionnaire. SPR in relation to previous self-reported fracture was examined using logistic regression. Results: Among participants of median age 83.4 (IQR 81.5–85.5) years, SPR was lower for 54.1% of participants, similar for 30.8%, and higher for 15.1%; 74.7% reported no previous fractures. Greater SPR was associated with increased odds of previous fractures when adjusting for sex and age only (OR 1.72, 95% CI 1.03–2.87, per higher band of SPR). While further individual adjustment for social isolation (1.73, 1.04–2.89), self-efficacy (1.71, 1.02–2.85), or mental health (1.77, 1.06–2.97) did not attenuate the relationship, individual adjustment for diet quality and number of comorbidities did. Conclusions: Adjustment for social isolation, self-efficacy or mental health status did not attenuate the relationship between SPR and fracture. By contrast, lifestyle factors not included in FRAX, such as diet quality, did attenuate relationships, suggesting a possible future area of investigation. [ABSTRACT FROM AUTHOR]

Introduction: Low-intensity pulsed ultrasound (LIPUS) is a non-invasive treatment modality for delayed union or non-union of acute fractures. We aimed to assess the current use of LIPUS at a national level in the United Kingdom, why and how clinicians use it, what treatment protocols are followed, and what the current perceptions are on this technology.Methodology: Using a detailed online survey compromised of 20 questions delivered to known LIPUS users, we were able to collect qualitative data on indication of use, type of machine used, personal views on the technology, frequency of usage, and treatment protocols. Each question was peer-reviewed to exclude bias.Results: A total of 70 respondents completed the survey. LIPUS was used by most clinicians for cases of non-union (N = 55, 78.5%) and delayed union (N = 51, 72.8%). The majority of respondents personally used a LIPUS device between 1 and 5 times in 12 months (N = 38, 54.3%). Most considered LIPUS a failure after three to six months of treatment without clinical improvement (N = 39, 55.7%). A total of 32 respondents (45.7%) mentioned the need for funding approval before accessing LIPUS technology. Poor revision surgery candidates (N = 48, 68.6%) and atrophic non-union (N = 46, 65.7%) were the most frequently cited reasons for using LIPUS technology as treatment. Most participants (N = 48, 68.6%) considered LIPUS to be cost-effective. Despite most clinicians being comfortable with the use of LIPUS, some respondents did not understand the basic science underpinning the technology nor could explain the need for LIPUS to patients comfortably.Conclusion: LIPUS technology may have a significant role to play in the treatment of orthopaedic fracture related pathology. Regular users perceived the technology to be cost-effective and efficacious. Further research should standardize treatment protocols and aim to establish a national LIPUS registry. [ABSTRACT FROM AUTHOR]

Background: There is an emerging interest in using automated approaches to enable the incidental identification of vertebral fragility fractures (VFFs) on existing medical images visualising the spine. Aim: To quantify values, and the degree of uncertainty associated with them, for the incidental identification of VFFs from computed tomography (CT) scans in current practice. Methods: An expert elicitation exercise was conducted to generate point estimates and measures of uncertainty for four values representing the probability of: VFF being correctly reported by the radiologist; the absence of VFF being correctly assessed by the radiologist; being referred for management when a VFF is identified; having a dual-energy X-ray absorptiometry (DXA) scan after general practitioner (GP) referral. Data from a sample of seven experts in the diagnosis and management of people with VFFs were pooled using mathematical aggregation. Results: The estimated mean values for each probability parameter were: VFF being correctly reported by the radiologist = 0.25 (standard deviation (SD): 0.21); absence of VFF being correctly assessed by the radiologist = 0.89 (0.10); being referred for management when a VFF is identified by the radiologist = 0.15 (0.12); having a DXA scan after GP referral = 0.66 (0.28). Discussion: These estimates could be used to facilitate the subsequent early economic evaluation of potential new approaches to improve the health outcomes of people with VFFs. Conclusion: In the absence of epidemiological studies, this study produced point estimates and measures of uncertainty for key parameters needed to describe current pathways for the incidental diagnosis of VFFs. [ABSTRACT FROM AUTHOR]

Background: The associations between visceral adipose tissue (VAT) and bone mineral density (BMD) or fracture have been controversial and the causality of the associations remains to be assessed. This study aimed to explore the associations of VAT^ (predicted value of VAT mass) with BMD and fracture risk in men and women, and to examine their potential causation by two-sample Mendelian randomization (MR) analyses. Methods: UK Biobank is a large, population-based prospective cohort study that recruited more than 500,000 participants aged 40–69 in the United Kingdom from 2006 to 2010. In this study, we used a validated and reliable prediction model to estimate the VAT amount of the participants. On this basis, linear and nonlinear multivariable statistical models were used to explore the association of VAT^ with BMD and fracture risk in different groups of sex and BMI. In observational analyses, the multivariable linear regression model and Cox proportional-hazards model were used to assess VAT^ association with BMD and fracture risk, respectively. Inverse variance weighting was used as the main result of MR analysis. Results: In 190,836 men, an inverted U-shaped association was observed between VAT^ and heel BMD (P for nonlinearity < 0.001), with a turning point of VAT^ = 1.25 kg. Per kg increase in VAT^ was associated with a 0.13 standard deviation (SD) increase in heel BMD (P = 1.5 × 10−16) among men with lower amounts of VAT^, and associated with a 0.05 SD decrease in heel BMD (P = 1.3 × 10−15) among men with higher amounts of VAT^. In 193,592 women, per kg increase in VAT^ was monotonically associated with a 0.16 SD increase in heel BMD (P = 1.2 × 10−136, P for VAT^-sex interaction = 8.4 × 10−51). During a median follow-up of 8.2 years, VAT^ was associated with lower risks of hip fractures in the overall men and women (P for VAT^-sex interaction = 1.9 × 10−4 for total fractures; 1.5 × 10−4 for other fractures). There were significant interactions of VAT^ and BMI on heel BMD and fracture risks in men only (P for VAT^-BMI interaction = 5.9 × 10−31 for heel BMD; 2.7 × 10−4 for total fractures; 5.7 × 10−3 for hip fractures; 6.8 × 10−3 for other fractures). In two-sample MR analyses, evidence of causality was not observed between VAT^ and DXA-derived BMD or fractures. Conclusions: These novel findings demonstrated gender-dependent associations of VAT^ with BMD and fracture risk, with the association in men being modified by adiposity. Evidence of causality was not observed, suggesting that the observational association of VAT^ with BMD and fracture risk could be the result of confounding. [ABSTRACT FROM AUTHOR]

Transthyretin (TTR) is the precursor of the fibrils that compromise organ function in hereditary and sporadic systemic amyloidoses (ATTR). RNA-interference and anti-sense therapeutics targeting TTR hepatic transcription have been shown to reduce TTR amyloid formation. In the present study, we leveraged genetic and phenotypic information from the UK Biobank and transcriptomic profiles from the Genotype-Tissue Expression project to test the association of genetically regulated TTR gene expression with 7149 traits assessed in 420,531 individuals. We conducted a multi-tissue analysis of TTR transcription and identified an association with a operational procedure related to bone fracture (p = 5.46×10−6). Using tissue-specific TTR expression information, we demonstrated that the association is driven by the genetic regulation of TTR hepatic expression (odds ratio [OR] = 3.46, p = 9.51×10−5). Using the UK Biobank electronic health records (EHRs), we investigated the comorbidities affecting individuals undergoing this surgical procedure. Excluding bone fracture EHRs, we identified a pattern of health outcomes previously associated with ATTR manifestations. These included osteoarthritis (OR = 3.18, p = 9.18×10−8), carpal tunnel syndrome (OR = 2.15, p =.002), and a history of gastrointestinal diseases (OR = 2.01, p = 8.07×10−4). In conclusion, our study supports that TTR hepatic expression can affect health outcomes linked to physiological and pathological processes presumably related to the encoded protein. [ABSTRACT FROM AUTHOR]

Introduction: Osteoporotic acetabular fractures are common and pose a difficult technical challenge for the trauma surgeon. Acute total hip arthroplasty (THA) using a Burch-Schneider antiprotrusio cage with immediate postoperative weight-bearing is a method to approach these injuries. This case series reports our outcomes of acute THA using Burch-Schneider cages for acetabular fractures from a UK major trauma centre based on length of stay, radiological outcome, complications and outcome scores. Methods: Data were collected from all patients who underwent acute THA with a Burch-Schneider cage for acetabular fractures between June 2006 and August 2015. Patients were followed up clinically, radiologically, and using Oxford Hip Scores (OHS). Results: 20 patients with a median age of 73 (range 60–90 years) were identified. All patients were independent walkers at follow-up, and had achieved radiological union. There were no dislocations, subsidence, revision or deep infections. Significant complications include 1 perioperative death as a result of complications arising from pre-existing pulmonary fibrosis; 1 deep vein thrombosis; 1 intraoperative arterial injury to the superior gluteal artery; and 1 leg-length discrepancy. Mean length of stay was 10 days. The mean OHS was 37/48 at a mean follow-up of 26 months. Conclusions: This case series further validates the use of Burch-Schneider cages with primary THA in acute acetabular fractures. [ABSTRACT FROM AUTHOR]

The recent update to the NICE guideline on type 2 diabetes management has given the sodium--glucose cotransporter 2 (SGLT2) inhibitor class a high prominence among the potential glucose-lowering therapies, with their early use recommended in a wide range of people with type 2 diabetes. This article updates a previous review of the SGLT2 inhibitors and covers the latest evidence of their cardiovascular and renoprotective effects, their place within treatment guidelines, and how to use them safely and effectively. [ABSTRACT FROM AUTHOR]

As with any other healthcare professional in today's medicolegal climate, the Occupational Therapist is at a risk of litigious claims being made against them. Through a Freedom of Information request, litigation claims data between 2000 and 2020 against National Health Service Occupational Therapists in the United Kingdom were obtained from National Health Service (NHS) Resolution. We perform a descriptive analysis of the results and review the literature around litigation involving Occupational Therapists. 79 claims were registered over this period, of which 37 were settled with damages. The most common primary injury for successful claims was fracture. The most common primary causes for successful claims were equipment malfunction and lack of assistance/care. The total cost for successful claims was £1,655,771. These data demonstrate that Occupational Therapy is a trusted profession, with a low rate of claims. We frame these findings in context and discuss lessons behind the data. [ABSTRACT FROM AUTHOR]

Introduction: Weight-bearing (WB) status following a fracture or surgical fixation is an important determinant of the mechanical environment for healing. In order for healthcare professionals to communicate and understand the extent of bearing weight through a limb, clear terminology must be used. There is widespread variation in the usage and definitions of WB terminology in the literature and clinical practice. This study sought to define the understanding and extent of variation across the United Kingdom.Methods: A nationwide online survey of UK-based Trauma & Orthopaedic (T&O) multidisciplinary healthcare professionals was conducted. Participants answered seven questions assessing their usage and understanding of various WB terminology.Results: A total of 707 responses were received: 48% by doctors, 32% by physiotherapists, 13% by occupational therapists and 7% from other healthcare professionals. In terms of understanding of WB terminology with respect to percentage body weight (BW), 89% of respondents interpret 'full WB' as 100% BW, 97% interpret 'non WB' as 0% BW, 80% interpret 'partial WB' as 50% BW, and 89% interpret 'touch/toe-touch WB' as 10% or 20% BW. There were statistically significant differences between the responses of doctors and therapists for these four terms, with doctors tending to give higher %BW values. 'Protected WB' and 'WB as tolerated' had less consensus and more variability in responses. The majority (68%) of respondents do not usually quantify terminology such as 'partial WB' with a value, and 94% agreed that standardisation of WB terminology would improve communication amongst professionals.Conclusion: This study provides evidence of the substantial variation in the understanding of WB terminology amongst healthcare professionals, which likely results in ambiguous rehabilitation advice. Existing literature has shown that patients struggle to comply with terms such as 'partial weight-bearing'. We recommend consensus within the T&O multidisciplinary community to standardise and define common weight-bearing terminology. [ABSTRACT FROM AUTHOR]

Summary: We estimated and characterized the imminent fracture risk (1–2 years) of high-risk fracture patients through a multinational (UK, Spain, Denmark) cohort study. Older individuals with newly diagnosed osteoporosis and individuals who had a fracture while on treatment with a bisphosphonate were at a high risk of imminent fracture. Purpose: To characterize and estimate 1- to 2-year fracture risk in high-risk fracture patients. Methods: Multi-cohort study in (database/study period) UK (CPRD/1995–2017), Spain (SIDIAP/2006–2016) and Denmark (DHR/1995–2016) including individuals ≥ 50 years old in NDO (newly diagnosed osteoporosis), OFx (incident osteoporotic fracture), BP (incident oral bisphosphonates use) or FWOT (fracture while on treatment with bisphosphonates). Outcomes (ICD-10/READ): hip, clinical spine, non-hip, non-spine and hip/humerus/distal forearm fracture. Follow-up: from cohort entry until death, migration/transfer or end of the study. Statistics: baseline characteristics and incidence rate (IR per 1000 persons). Results (1-year IR): NDO included 69,899 (UK), 37,901 (Spain) and 158,191 (Denmark) individuals. Spanish-IR was lowest for hip (4.7), clinical spine (2.5) and major osteoporotic fracture (MOF) (17.3) and highest in Denmark (74.2, 26.0 and 120.1, respectively). OFx included 83,514 (UK), 51,044 (Spain) and 509,551 (Denmark) individuals. IR in Denmark was highest for hip (24.1) and MOF (47.2), in Spain was highest for the clinical spine (9.4) and lowest for hip (9.5) and in the UK was lowest for the clinical spine (2.8) and MOF (20.7). BP included 148,507 (UK), 52,037 (Spain) and 204,010 (Denmark) individuals. Spanish-IR was lowest for hip (5.0) and MOF (21.1) and highest in Denmark (20.3 and 48.6, respectively). FWOT included 28,930 (UK), 1,865 (Spain) and 31,882 (Denmark) individuals. Clinical spine-IR was highest for Spain (12.0). Hip-IR was lowest for Spain (7.6) and highest for Denmark (33.6). Comparing young subjects, those who have FWOT started with an increased fracture rate. Conclusion: OFx and FWOT individuals experience higher re-fracture incidence rates than those with osteoporosis with or without treatment. [ABSTRACT FROM AUTHOR]

Background: Treatment for hypertension improves cardiovascular outcomes. Frailty may be present in older people treated for hypertension, but associates with adverse drug effects, potentially including falls resulting in fractures. We aimed to determine the association between baseline frailty and fractures in patients initiated on antihypertensive treatment. Methods: We conducted a retrospective cohort study using United Kingdom primary care data, including new users of first-line antihypertensives aged 65 years or over. We reported degree of frailty (fit, mild, moderate, severe) at antihypertensive initiation using the Electronic Frailty Index. We examined the association of frailty with fractures using multivariable Poisson regression, and assessed for interaction between antihypertensive class and frailty. Results: Of 113,779 patients aged 65 years or over who initiated on first-line antihypertensives, 49,634 patients (44%) were mildly or more frail. Over 4.1 years mean follow-up, 6567 (5.8%) experienced a fracture, with 3832 (58%) of these fractures occurring in frail people. Among those with severe frailty, doubling of fracture risk was observed after antihypertensive initiation, compared with fit people [adjusted rate ratio 2.26, 95% confidence interval (CI) 1.93–2.65]. Secondary analyses indicate this pattern was replicated for hip and arm fractures, and strongest for spine fractures, and the association between different types of antihypertensives and fractures varied by frailty (p = 0.004), being lower in moderately frail users of renin-angiotensin blockers compared with calcium channel blockers [rate ratio 0.81, 95% CI 0.71–0.94]. Conclusions: Frailty is common among older patients initiating first-line antihypertensive treatment, and was associated with an increased fracture rate. Awareness of this is important to encourage clinicians to consider risk of falls and fractures when treating hypertension. [ABSTRACT FROM AUTHOR]

Geriatric medicine is the clinical specialty that focuses upon the care of older people—especially those with frailty (a state of increased vulnerability). In hospital, older people living with frailty are at high risk of developing a range of unpleasant outcomes such as delirium, falls, fractures, pressure sores and death. Comprehensive geriatric assessment is a form of holistic care that incorporates a specific set of clinical competencies that are able to reduce these adverse outcomes. Over the years, geriatric medicine has moved from being more of a community-based service towards a more acute specialty—encroaching now upon emergency department care. The challenge now is to work out how best to deliver geriatric care across the whole hospital (older people with frailty are not just cared for in geriatric wards!). The themed collection published on the Age & Ageing journal website outlines key articles that are attempting to develop solutions to this challenging conundrum. We hope that you enjoy reading them. [ABSTRACT FROM AUTHOR]

Background: The associations of physical pre-frailty and frailty with bone fractures and the modified effect of sedentary lifestyle remain uncertain. This study was performed to explore the association of physical pre-frailty and frailty with risk of incident bone fractures, and test the modification effects of sedentary lifestyle and other risk factors., Methods: This cohort study included 413 630 participants without bone fractures at baseline in the UK Biobank study between 2006 and 2010 and followed up to 2021. The mean age of the participants was 56.5 years. A total of 224 351 (54.2%) enrolled participants were female and 376 053 (90.9%) included participants were White. Three Cox regression models were constructed to analyze the association of pre-frailty and frailty with total fractures, hip fractures, vertebrae fractures, and other fractures., Results: As compared with the physical nonfrailty group, the multivariate-adjusted hazard ratios were 1.17 (95% confidence interval [CI]: 1.14-1.21) and 1.63 (95% CI: 1.53-1.74) for the physical pre-frailty group and frailty group, respectively (p-trend < .001). In addition, we found that sedentary behavior time significantly accentuated the associations of physical pre-frailty and frailty with total fractures (p-interaction <.001), hip fractures (p-interaction = .013), and other fractures (p-interaction <.001)., Conclusions: Our results indicate that physical pre-frailty and frailty are related to higher risks of bone fractures; such association was more pronounced among those with longer sedentary behavior time., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Summary: Less is known about the risk of fracture in people with rheumatoid arthritis aged under 50 than those in older age groups. The study shows that the risk of fracture before age 50 remains significantly higher in those with rheumatoid arthritis than matched controls. This has implications for fracture risk management. Introduction: To determine the risk of first and subsequent fracture occurring before age 50 in people diagnosed with rheumatoid arthritis (RA) before age 50. Methods: A retrospective observational cohort study of RA cases with matched controls using data from Clinical Practice Research Datalink (CPRD) of adults ≥ 18 years with diagnosis of RA recorded from 1992 to 2016 in the UK. Patients were followed from index date to the first fracture and subsequent fracture. A total of 36,858 cases were each matched to 3 controls. Incidence rates (IR) and incidence rate ratios (IRR) of first and subsequent fractures were calculated. A multivariate Cox's proportional hazards model was used to calculate the risk of first fracture and of subsequent fracture in the presence of different risk factors. Results: The IR of first and subsequent fractures at any age is significantly higher in cases than controls for patients with onset of RA at any age. This includes first fractures occurring before age 50 for those diagnosed with RA before this age. In women, the rate of first fracture before age 50 are significantly higher than matched controls (IRR 1.29 CI 1.12–1.49), the IRR for subsequent fracture is higher but not significantly so. For men, the IRRs of first and subsequent fractures below age 50 are also higher but not significantly so. Gender, previous fracture, glucocorticoid prescription, osteoporosis diagnosis, alcohol, smoking, and bisphosphonate prescription have a significant effect on the risk of first fracture at any age for RA patients; all these variables except osteoporosis diagnosis and alcohol have a significant effect on the risk of subsequent fracture and first fractures before age 50. Conclusions: These results indicate an increased risk of first fracture before age 50 in people with RA diagnosed before this age. It is important that patients with RA of all ages are given timely support from the time of diagnosis to protect their bone health. [ABSTRACT FROM AUTHOR]

Sports-related injuries are the third commonest cause of spine fractures. Spinal fractures incurred as a result of partaking in sport by their nature are different from those associated with frailty and road traffic accidents. The patient demographics and nature of fractures associated with sports activities are not well documented. We aim to describe the management and outcome of patients with a sports-related spine fracture in a single U.K. major trauma center in a 6-year time period. Patients with sports-related spinal fractures were identified from the Trauma Audit and Research Network database at a U.K. major trauma center between January 2011 and December 2016. Patient notes were retrospectively reviewed for demographics, injury severity score, treatment, complications, and outcomes. In the study period, 122 patients were admitted with a sports-related spinal fracture, sustaining a total of 230 fractures. Of these, 48 (20.9%) were in the cervical, 79 (34.3%) in the thoracic, and 103 (44.8%) in the lumbar regions. The sports most commonly associated with spinal fractures were horse riding (n = 55), cycling (n = 36), and boating (n = 10). Of the 230 fractures, 32 (13.9%) were associated with neurologic injury. Forty-five of the 230 fractures (19.6%) were managed surgically, and the remainder were managed conservatively. Within our population, sports most commonly associated with spinal fractures were horse riding, cycling, and boating. The majority of cases were managed nonoperatively. Further research is required to establish evidence-based guidelines on the management of sports-related spinal fractures. [ABSTRACT FROM AUTHOR]

Introduction: Proximal humeral fractures (PHF) are a common injury in the older population but there is limited research evaluating rehabilitation following PHF. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following PHF as a platform for conducting future research. Methods: Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following PHF, for example, duration of immobilisation. One reviewer extracted data and a second reviewer verified this. Results: Seventeen PIS from 17 different NHS trusts were identified. All provided some information on the method of immobilisation but only six provided guidance on duration of immobilisation with the median time being 2 weeks (range 0–6). The median time to commencement of passive exercise was 2 weeks (range 0–4) and 9 weeks (range 6–12) for active exercise. Only one PIS reported on the time for commencement of resisted exercises and this was reported as 6 weeks. The median time recommended return to work was 7.5 weeks (range 6–12). Conclusion: This study found limited publicly available information for rehabilitation following PHF in the NHS but offers some insight into current approaches. Our results will facilitate development of relevant information for patients and evaluation of rehabilitation strategies in future research. [ABSTRACT FROM AUTHOR]

Introduction Acute vertebral fragility fracture requiring hospital admission is common, painful and disabling. No comprehensive clinical guideline for their care exists. To support the development of such a guideline, we sought the views of experts in the field. Methods A modified Delphi study was used. A total of 70 statements were presented, using an online platform, over three consensus-seeking rounds, to participants with experience in the hospital care of patients with acute vertebral fragility fractures from UK-based specialist societies. Participants rated the level of their agreement with each statement on a 5-point Likert scale. Consensus was defined at 70% of respondents choosing either agree/strongly agree or disagree/strong disagree. Over the first two rounds, statements not reaching consensus were modified in subsequent rounds, and new statements proposed by participants and agreed by the research team could be added. Results There were 71 participants in the first round, 37 in the second round and 28 (most of whom were geriatricians) in the third round. Consensus was reached in 52 statements covering fracture diagnosis, second-line imaging, organisation of hospital care, pain management and falls and bone health assessment. Consensus was not achieved for whether vertebral fragility fractures should be managed in a specific clinical area. Discussion These findings provide the basis for the development of clinical guidelines and quality improvement initiatives. They also help to justify research into the merits of managing acute vertebral fragility fracture patients in a specific clinical area. [ABSTRACT FROM AUTHOR]

Summary: Osteoporosis and fractures are common features of alkaptonuria. Introduction: A large cohort of alkaptonuria (AKU) patients was studied to better recognise and characterise osteoporosis and fractures in AKU. Methods: Assessments including questionnaire analysis, DEXA and CT densitometry at the neck of femur (FN), total hip (TH) and lumbar spine (LS) were performed on patients at baseline when 2 mg nitisinone was commenced, and yearly thereafter. Blood and urine samples were collected for chemical measurement. CT BMD Z-scores were generated. Results: Between June 2007 and March 2020, 87 AKU patients attended the NAC. At baseline, there were 48 fractures in 39 patients. Prevalence of osteoporosis was 3.1 at FN, 10.8 at TH and 24.7% at LS respectively. Prevalence of fragility fractures was greatly increased at 44.8%. The group with fractures showed increased ochronosis scores (p < 0.05). CT LS showed an inverse relationship with fractures (R = − 0.28; p < 0.05). CT LS was significantly lower in the fracture group (p < 0.002). Following nitisinone only, CT FN and CT TH decreased significantly (p < 0.05 and 0.01 respectively). Following nitisinone plus antiresorptive therapy, CT FN, CT TH and CT LS all increased significantly (p < 0.05, 0.05 and 0.001 respectively). However, patients on nitisinone plus antiresorptive had more fractures than nitisinone and no-treatment groups (p < 0.05). Conclusions: Osteopenia and fragility fractures are common in AKU.. Anti-resorptive therapy increased BMD in AKU without decreasing fragility fractures. Bone densitometry measurements by DXA are less reliable than quantitative CT at the LS in AKU. [ABSTRACT FROM AUTHOR]

Objective To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30 days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death. Method We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between 1 January 2014 and 31 December 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36 h of surgery) and those mobilised late, accounting for potential confounders and the competing risk of in-hospital death. Results A total of 106,722 (79%) of patients first mobilised early. The average rate of discharge was 39.2 (95% CI 38.9–39.5) per 1,000 patient days, varying from 43.1 (95% CI 42.8–43.5) among those who mobilised early to 27.0 (95% CI 26.6–27.5) among those who mobilised late, accounting for the competing risk of death. By 30-day postoperatively, the crude and adjusted odds ratios of discharge were 2.36 (95% CI 2.29–2.43) and 2.08 (95% CI 2.00–2.16), respectively, among those who first mobilised early compared with those who mobilised late, accounting for the competing risk of death. Conclusion Early mobilisation led to a 2-fold increase in the adjusted odds of discharge by 30-day postoperatively. We recommend inclusion of mobilisation within 36 h of surgery as a new UK Best Practice Tariff to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture. [ABSTRACT FROM AUTHOR]

Background/aims: Given the extent of osteoporosis in people with Duchenne muscular dystrophy treated with glucocorticoids and the limited evidence of bone-protective therapies, clinical trials are needed. We conducted surveys to obtain the opinion of young people with Duchenne muscular dystrophy, parents/guardians and neuromuscular clinicians on the feasibility of osteoporosis clinical trials in this population. Methods: Online surveys were sent to three groups: (a) people with a confirmed diagnosis of Duchenne muscular dystrophy (≥14 years), (b) parents and guardians and (c) neuromuscular clinicians in the UK NorthStar Clinical Network. Surveys (a) and (b) were distributed via the UK Duchenne muscular dystrophy Registry. Results: Survey respondents included 52 people with Duchenne muscular dystrophy with a median age of 17 years (range: 14, 40) and 183 parents/guardians. Fourteen out of 23 (61%) NorthStar centres responded. Of the 52 people with Duchenne muscular dystrophy, 13 (25%) were very concerned about their bone health and 21 (40%) were slightly concerned. Of the 183 parents/guardians, 75 (41%) were very concerned about their son's bone health and 90 (49%) were slightly concerned. Fractures and quality of life were the top two main outcome measures identified by people with Duchenne muscular dystrophy. Fractures and bone density were the top two main outcome measures identified by parents/guardians and neuromuscular clinicians. Thirty percent of people with Duchenne muscular dystrophy and 40% of parents/guardians would not take part if an osteoporosis trial involved a placebo that was administered parenterally. Only 2 of the 14 NorthStar centres (14%) would enrol people with Duchenne muscular dystrophy if a parenteral placebo was used in an osteoporosis trial in Duchenne muscular dystrophy. Conclusion: There is great awareness of bone health and the need for bone-protective trials among people with Duchenne muscular dystrophy and their carers. However, a proportion of people with Duchenne muscular dystrophy and parents are reluctant to participate in a placebo-controlled osteoporosis trial that included a parenteral therapy. A larger proportion of health care experts are unwilling to enrol their patients in such a trial. Our finding is relevant for the design of bone-protective studies in Duchenne muscular dystrophy. [ABSTRACT FROM AUTHOR]

Introduction: The novel coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organisation on 11 March 2020. The aim of this study is to assess the impact of COVID-19 on orthopaedic practice and training in the UK. Methods: Surgeons throughout UK hospitals were asked to complete an electronic survey relating to orthopaedic practice and training in their hospital. The nationwide survey was conducted during the first peak of COVID-19 cases in the UK between 20 March 2020 and 20 April 2020. Results: All 202 UK participants reported disruption to their daily practice. 91% reported all elective operating had been cancelled and trauma continued as normal in only 24% of cases. 70% reported disruption to trauma operating. Elective clinic capacity significantly reduced with no elective clinics running as normal. 55% reported their elective clinics completely cancelled, whilst 38% reported elective clinics running at a reduced capacity, with non-urgent appointments postponed. Only 9% of fracture clinics ran as normal, and 69% had a reduced service. 67% reported teaching and study leave cancelled. Significantly, 69% of participants felt the pandemic would result in a delay to completion of registrar training programmes. Conclusion: This is the first nationwide survey assessing the impact of the coronavirus disease 2019 on UK orthopaedic practice and training, during the peak of the pandemic. It highlights the scale of the challenge ahead for the specialty, including during the recovery phase and post-recovery phase of the pandemic. [ABSTRACT FROM AUTHOR]

Objective: To estimate risk of fracture in men and women with recent diagnosis of type 2 diabetes compared with individuals without diabetes.Research Design and Methods: In this cohort study, we used routinely collected U.K. primary care data from The Health Improvement Network. In adults (>35 years) diagnosed with type 2 diabetes between 2004 and 2013, fractures sustained until 2019 were identified and compared with fractures sustained in individuals without diabetes. Multivariable models estimated time to first fracture following diagnosis of diabetes. Annual prevalence rates included at least one fracture in a given year.Results: Among 174,244 individuals with incident type 2 diabetes and 747,290 without diabetes, there was no increased risk of fracture among males with diabetes (adjusted hazard ratio [aHR] 0.97 [95% CI 0.94, 1.00]) and a small reduced risk among females (aHR 0.94 [95% CI 0.92, 0.96]). In those aged ≥85 years, those in the diabetes cohort were at significantly lower risk of incident fracture (males: aHR 0.85 [95% CI 0.71, 1.00]; females: aHR 0.85 [95% CI 0.78, 0.94]). For those in the most deprived areas, aHRs were 0.90 (95% CI 0.83, 0.98) for males and 0.91 (95% CI 0.85, 0.97) for females. Annual fracture prevalence rates, by sex, were similar for those with and without type 2 diabetes.Conclusions: We found no evidence to suggest a higher risk of fracture following diagnosis of type 2 diabetes. After a diagnosis of type 2 diabetes, individuals should be encouraged to make positive lifestyle changes, including undertaking weight-bearing physical activities that improve bone health. [ABSTRACT FROM AUTHOR]

Context: Dietary fiber intake may relate to bone health.Objective: To investigate whether dietary fiber intake is associated with bone mineral density (BMD), and the modification effect of genetic variations related to gut microbiota-derived short-chain fatty acids (SCFAs).Design: The associations of dietary fiber intake with estimated BMD derived from heel ultrasound and fractures were assessed in 224 630 and 384 134 participants from the UK Biobank.Setting: UK Biobank.Main Outcome Measures: Estimated BMD derived from heel ultrasound.Results: Higher dietary fiber intake (per standard deviation) was significantly associated with higher heel-BMD (β [standard error] = 0.0047 [0.0003], P = 1.10 × 10-54). Similarly significant associations were observed for all the fiber subtypes including cereal, fruit (dried and raw), and vegetable (cooked and raw) (all P < .05). A positive association was found in both women and men but more marked among men except for dietary fiber in cooked vegetables (all Pinteraction < .05). A protective association was found between dietary fiber intake and hip fracture (hazard ratio, 95% confidence interval: 0.94, 0.89-0.99; P = 3.0 × 10-2). In addition, the association between dietary fiber and heel BMD was modified by genetically determined SCFA propionate production (Pinteraction = 5.1 × 10-3). The protective association between dietary fiber and heel BMD was more pronounced among participants with lower genetically determined propionate production.Conclusions: Our results indicate that greater intakes of total dietary fiber and subtypes from various food sources are associated with higher heel-BMD. Participants with lower genetically determined propionate production may benefit more from taking more dietary fiber. [ABSTRACT FROM AUTHOR]

Aim: This UK based multi-centre study reports clinical characteristics, early outcomes and predictors of mortality in 34 consecutive COVID-19-positive hip fractures so that the lessons learnt could be utilised in other parts of World who are at a different phase of the pandemic. Methods: This study analysed patient admitted with hip fractures with COVID positive swabs, between March and May'2020 in three large hospitals covering a population of nearly two million. Data was collected on demographic profile, peri-operative variables, post-operative complications and mortality. The specific aim was to identify any variables, which could predict high 30-day mortality. Results: Overall, 12% of hip fractures were COVID positive with the mortality rate of 41.2%. The higher age (p = 0.036) and male gender (p = 0.025) was significantly associated with mortality and most of the deaths were between American Society of Anaesthesiologists (ASA) grade 3 and 4 patients. The patients having intramedullary (IM) nailing were more likely to die (p = 0.02). There was no difference in laboratory parameters but there was significant difference in findings on chest radiographs (p < 0.001), post-operative oxygen requirements (p = 0.006) and early respiratory complications (p = 0.006). Conclusion: This study suggests that the mortality following surgery for a hip fracture in COVID-positive patients is strikingly high and is associated with higher age and male gender. Higher mortality has been observed for extracapsular fracture operated with intramedullary nailing. In the immediate post-operative period, rapid deterioration of chest imaging, higher oxygen requirement and early pulmonary complications can serve as warning signs and predicting factors for higher mortality. [ABSTRACT FROM AUTHOR]

Summary: Aiming to identify pleiotropic genomic loci for bone mineral density and bone size, we performed a bivariate GWAS in five discovery samples and replicated in two large-scale samples. We identified 2 novel loci at 2q37.1 and 6q26. Our findings provide insight into common genetic architecture underlying both traits. Introduction: Bone mineral density (BMD) and bone size (BS) are two important factors that contribute to the development of osteoporosis and osteoporotic fracture. Both BMD and BS are highly heritable and they are genetically correlated. In this study, we aim to identify pleiotropic loci associated with BMD and BS. Methods: We conducted a bivariate genome-wide association (GWA) analysis of hip BMD and hip BS in 6180 participants from 5 samples, followed by in silico replication in the UK Biobank study of BMD (N = 426,824) and the deCODE study of BS (N = 28,954), respectively. Results: SNPs from 2 genomic loci were significant at the genome-wide significance (GWS) level (p lt; 5 × 10−8) in the discovery samples and were successfully replicated in the replication samples (2q37.1, lead SNP rs7575512, discovery p = 1.49 × 10−10, replication p = 0.05; 6q26, lead SNP rs1040724, discovery p = 1.95 × 10−8, replication p = 0.03). Functional annotations suggested functional relevance of the identified variants to bone development. Conclusion: Our findings provide insight into the common genetic architecture underlying BMD and BS, and enhance our understanding of the potential mechanism of osteoporosis fracture. [ABSTRACT FROM AUTHOR]

Summary: Chronic kidney disease (CKD) is a risk factor for fractures. However, in hip fracture patients, CKD G3-G5 was associated with a higher mortality risk and not associated with a higher risk of subsequent non-hip fractures compared to eGFR > 60 ml/min. The higher mortality risk may, as competing risk, explain our findings. Introduction: Chronic kidney disease (CKD) is a known risk factor for fragility fractures. Patients aged 50+ with a recent fragility fracture have an increased risk of subsequent fractures. Our aim was to evaluate the association between CKD stages G3–G5 versus estimated glomerular filtration rate (eGFR) > 60 ml/min and the risk of a new non-hip fracture or fragility fracture in patients with a first hip fracture. Methods: Population-based cohort study using the UK general practices in the Clinical Practice Research Datalink. Associations between CKD stage and first subsequent fracture were determined using Cox proportional hazard analyses to estimate hazard ratios (HRs). To explore the potential competing risk of mortality, cause-specific (cs) HRs for mortality were estimated. Results: CKD G3–G5 was associated with a lower risk of any subsequent non-hip fracture (HR: 0.90, 95%CI: 0.83–0.97), but not with the risk of subsequent major non-hip fragility fracture. CKD G3-G5 was associated with a higher mortality risk (cs-HR: 1.05, 95%CI: 1.01–1.09). Mortality risk was 1.5- to 3-fold higher in patients with CKD G4 (cs-HR: 1.50, 95%CI: 1.38–1.62) and G5 (cs-HR: 2.93, 95%CI: 2.48–3.46) compared to eGFR > 60 ml/min. Conclusions: The risk of a subsequent major non-hip fragility fractures following hip fracture was not increased in patients with CKD G3–G5 compared to eGFR > 60 ml/min. Mortality risk was higher in both hip fracture and non-hip fracture patients with CKD G4 and G5. The higher mortality risk may, as competing risk, explain our main finding of no increased or even decreased subsequent fracture risk after a hip fracture in patients with CKD G3–G5. [ABSTRACT FROM AUTHOR]

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalized anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. A quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation. Since patients admitted with fragility fractures are often frail, elderly and at risk of deterioration post-operatively, we focused on improving ReSPECT in the orthopaedic department with medical departments used for comparison post-intervention. Interventions included teaching sessions for consultants and junior doctors, increased senior orthogeriatrician input, and electronic documentation of ReSPECT forms. Post-intervention results revealed an improved engagement with the ReSPECT process with orthopaedic patients with frailty or life-limiting co-morbid conditions more likely to receive early anticipatory care planning as part of their admission process compared to medical inpatients. Senior consultant engagement was key to providing a cultural shift in early anticipatory care planning which helped to foster an environment of open communication among the team, allowing for more effective recognition of frail or co-morbid patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Antidepressants increase the risk of falls and fracture in older adults. However, risk estimates vary considerably even in comparable populations, limiting the usefulness of current evidence for clinical decision making. Our aim was to apply a common protocol to cohorts of older antidepressant users in multiple jurisdictions to estimate fracture risk associated with different antidepressant classes, drugs, doses, and potential treatment indications. DESIGN: Retrospective (2009–2014) cohort study. SETTING: Five jurisdictions in the United States, Canada, United Kingdom, and Taiwan. PARTICIPANTS: Older antidepressant users—subjects were followed from first antidepressant prescription or dispensation to first fracture or until the end of follow‐up. MEASUREMENTS: The risk of fractures with antidepressants was estimated by multivariable Cox proportional hazards models using time‐varying measures of antidepressant dose and use vs nonuse, adjusting for patient characteristics. RESULTS: Between 42.9% and 55.6% of study cohorts were 75 years and older, and 29.3% to 45.4% were men. Selective serotonin reuptake inhibitors (SSRIs) (48.4%‐60.0%) were the predominant class used in North America compared with tricyclic antidepressants (TCAs) in the United Kingdom and Taiwan (49.6%‐53.6%). Fracture rates varied from 37.67 to 107.18 per 1,000. The SSRIs citalopram (hazard ratio [HR] = 1.23; 95% confidence interval [CI] = 1.11‐1.36 to HR = 1.43; 95% CI = 1.11‐1.84) and sertraline (HR = 1.36; 95% CI = 1.10‐1.68), the SNRI duloxetine (HR = 1.41; 95% CI = 1.06‐1.88), TCAs doxepin (HR = 1.36; 95% CI = 1.00‐1.86) and imipramine (HR = 1.16; 95% CI = 1.05‐1.28), and atypicals (HR = 1.34; 95% CI = 1.14‐1.58) increased fracture risk in some but not all jurisdictions. In the United States and the United Kingdom, fracture risk with all classes was higher when prescribed for depression than chronic pain, a trend that is likely explained by drug choice. CONCLUSION: The fracture risk for patients may be reduced by selecting paroxetine, an SSRI with lower risk than citalopram, the SNRI venlafaxine over duloxetine, and the TCA amitriptyline over imipramine or doxepin. There is uncertainty about the risk associated with the atypical antidepressants. J Am Geriatr Soc 68:1494‐1503, 2020. [ABSTRACT FROM AUTHOR]

This study aimed to compare the treatment pathway and 30-day outcomes of hip fracture patients admitted during the COVID-19 pandemic with the pre-pandemic period. Three periods were retrospectively analysed: period C = 23/03/2020–11/05/2020, period A = 23/03/2018–11/05/2018, period B = 23/03/2019–11/05/2019. No statistically significant differences in time to surgery, type of treatment, complications, and mortality rates were noted. A significant reduction (p = 0.021) in the time to orthogeriatric assessment and length of inpatient stay (p < 0.001) was found in period C. Institutional adaptions to facilitate prompt treatment in hip fractures during the pandemic resulted in favourable outcomes. [ABSTRACT FROM AUTHOR]

Bisphosphonates (BPs) might have extra benefits in reducing mortality because of their anti-atherosclerotic effects, but studies reported conflicting results. We investigated the association between oral BP use and mortality risk following a major osteoporotic fracture (MOF) in the United Kingdom. This was a population-based cohort study. In total, 163,273 adults aged 50 years and older with an MOF between 2000 and 2018 from the Clinical Practice Research Datalink in the United Kingdom. Cox proportional hazards models were used to estimate the risk of all-cause mortality in current (0‒6 months), recent (7‒12 months), and past (>1 year) exposures to oral BPs after nonhip MOF and hip fracture. In addition, stratification by sex, BP type, and duration of follow-up was performed. Compared with never users of oral BPs, current BP use was associated with a 7% higher all-cause mortality risk after nonhip MOF, whereas a 28% lower all-cause mortality risk was observed after hip fracture. Past BP exposure was associated with a 14% and 42% lower risk after nonhip MOF and hip fracture, respectively. When considering only the first 5 years of follow-up, mortality risk associated with current BP use was significantly lower for both fracture groups, and the greatest reduction in mortality risk was observed within the first year. Women had slightly lower risk compared with men. We found a slight increased risk of all-cause mortality with current BP exposure after a nonhip MOF; however, a protective effect was observed following a hip fracture. Both the timing and the effect size of an association based on the anti-atherosclerotic hypothesis of BPs are not supported by our results. The decreasing trend of the mortality risk with shorter durations of follow-up suggests that the observed association is likely due to unknown distortion or unknown pleiotropic properties of BPs. [ABSTRACT FROM AUTHOR]

We aimed to identify the incidence and types of neonatal birth fractures in a single tertiary maternity hospital in the United Kingdom and to find possible associated factors, including all live births born between 2000 and 2016. We reviewed hospital records and imaging of all neonates who had any imaging done to identify birth fractures. We identified 87,461 consecutive live births. Sixty-six sustained a fracture during delivery: 46 clavicle-, 13 humerus-, four skull-, one femoral-, one rib- and one tibial fracture. Five neonates with a clavicle or humeral fracture had an Erb's palsy. Sixty-five fractures were in singletons. Twenty-five fractures were diagnosed after discharge. Binary logistic regression analysis with R-Studio showed a significant association between 'Fracture' and 'Birthweight' (p < .0005), 'Delivery Mode' (Forceps: p < .001, Ventouse: p < .0004) and 'Gestation' (p < .0005) but not with 'Sex', 'Day' and 'Time' of delivery, 'Number of deliveries per day', 'Singleton/Multiple Births' and 'Breech'. The incidence of birth fractures (0.075%) was low with 24 hours obstetrician support on site in comparison to published data. We recommend to include data on neonatal birth injuries in addition to the existing clinical safety markers for delivery units.Impact statementWhat is already known on this subject? Most birth fractures affect the clavicle with a large variation in published incidences from 0.035% to 3.2%. High birthweight is the most frequently identified risk factor. An increased risk for out of hours deliveries (16.00-8.00) and inverse association between fracture rate and level of experience and academic qualification have also been reported. Between 14% and 39% of fractures are diagnosed after discharge but many studies are based on birth certificate and discharge diagnoses coding only.What the results of this study add? This is the first study on neonatal birth fractures from the United Kingdom and the only study for which radiological investigations of all neonates were reviewed. Our fracture rate of 0.075% for all fractures is therefore most likely the most accurate, showing no significant difference in the fracture risk between our six defined time intervals and days of the week, with experienced midwifes managing many high risk pregnancies and an obstetrician being present on site all the time.What the implications are of these findings for clinical practice and/or further research? Our findings support to use data on neonatal birth injuries as one indicator to assess the quality and safety of maternity units. [ABSTRACT FROM AUTHOR]

Age is one of the most important parameters influencing the occurrence of hip fractures in patients over the age of 65 but also their mental state is a decisive factor. In the first three months, older adults have eight times higher risk of dying of a hip fracture if compared with people who have not suffered such type of injury. In the last 10 years, several studies showed considerable increase in the well-being of patients who have both pathologies but for the caregivers it proved to be a very hard task. The management of hospitalization costs of dementia and hip fracture patients cannot include only the period of hospitalization, but should also include the 1-year period of recovery. In UK, the annual incidence of hip fracture is 79,243, accident and emergency costs per hip fracture is 297 pounds and hospitalization costs per hip fracture is 13,765 pounds. Health and social care for hip bone fractures in one year amounts to 2 billion euros but specialists expect the number of hip fractures to increase reaching 104,000 cases by 2025. [ABSTRACT FROM AUTHOR]

Hip fractures are the most common cause for admission to an acute orthopaedic ward in the UK, and typically affect elderly, frail individuals with extensive co-morbidity. As such, they are associated with a high burden of morbidity and mortality as well as significant financial cost. Standards have therefore been developed to improve care and outcomes for hip fracture patients, including through the introduction of the 'best practice tariff' payment system in English hospitals. These emphasize a multidisciplinary team approach with early involvement of appropriately trained healthcare professionals including anaesthetists, orthopaedic surgeons and orthogeriatricians. Key elements of the perioperative optimization of patients following admission with a hip fracture include prompt and effective analgesia, including the use of regional nerve blockade, the rapid identification and correction of acute medical problems, particularly cardiac arrhythmias, electrolyte abnormalities and anaemia, and careful management of fluid balance. In addition, medication review is of critical importance, particularly with respect to antiplatelet agents and anticoagulants. In all cases, early surgery, ideally within 36 hours of admission, should be considered a key aim given evidence supporting a reduction in complication and mortality rates when this is achieved. Similarly, patients should be mobilized as soon as possible in the postoperative period in order to maximize their rehabilitation potential. [ABSTRACT FROM AUTHOR]

Background: A thoracolumbar fracture is the most common fracture of the spinal column. Where the fracture is not obviously stable or unstable, the optimal management is uncertain. There are variations between surgeons, treating centres and within the evidence base as to whether surgical or non-surgical approaches should be used. In addition, the boundaries of this zone of uncertainty for stability are unclear. This study has been designed in response to an NIHR HTA commissioning brief to assess the feasibility of undertaking a large-scale trial to evaluate the effectiveness of surgical and non-surgical treatments for thoracolumbar fractures without neurological deficit. Methods: Assessment of feasibility will be addressed through three elements: a randomised external feasibility study, a national survey of surgeons and a qualitative study. The external feasibility study is a pragmatic, parallel-group, randomised controlled trial comparing surgical fixation (intervention) versus non-surgical management (control). Recruitment will take place in three secondary care centres in the UK. The primary outcome is recruitment rate, defined as the proportion of eligible participants who are randomised. Further outcomes related to recruitment, randomisation, drop-out, cross-over, loss to follow-up, completeness of outcome data, study processes and details of the interventions delivered will be collected. The survey of surgeons and qualitative study of clinicians, recruiting staff and patients will enhance the feasibility study, enabling a broad overview of current practice in the field in addition to perceived facilitators and barriers to running a full-scale trial. Discussion: PRESTO is a feasibility study which aims to inform methodology for a definitive trial comparing surgical fixation with non-surgical management for patients with stable thoracolumbar fractures. Trial registration: The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN12094890). Date of registration was 22/02/2018 (http://www.isrctn.com/ISRCTN12094890). [ABSTRACT FROM AUTHOR]

Summary: Patients hospitalised with vertebral fragility fractures were elderly, multimorbid and frail and lead to poor outcomes. Their hospital treatment needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes. Purpose: Patients admitted to hospital with vertebral fragility fractures are elderly and have complex care needs who may benefit from specialist multidisciplinary input. To date, their characteristics and outcomes have not been reported sufficiently. This study aims to justify such a service. Methods: Patients admitted with an acute vertebral fragility fracture over 12 months were prospectively recruited from a university hospital in England. Data were collected soon after their admission, at discharge from hospital and 6 months after their hospital discharge on their characteristics, pain, physical functioning, and clinical outcomes. Results: Data from 90 participants were analysed. They were mainly elderly (mean age 79.7 years), multimorbid (69% had ≥ 3 comorbid condition), frail (56% had a Clinical Frailty Scale score ≥ 5), cognitively impaired (54% had a MoCA score of < 23) and at high risk of falls (65% had fallen ≥ 2 in the previous year). Eighteen percent died at 6 months. At 6 months post-hospital discharge, 12% required a new care home admission, 37% still reported their pain to be severe and physical functioning was worse compared with their preadmission state. Conclusion: Patients hospitalised with vertebral fragility fractures were elderly, multimorbid, frail and are susceptible to persistent pain and disability. Their treatment in hospital needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes. [ABSTRACT FROM AUTHOR]