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Osteoporotic fracture introduce enormous societal and economic burden, especially for long-term care residents (LTCRs). Although osteoporosis prevention for LTCRs is urgently needed, obstacles such as frail status and inconvenient hospital visits hurdled them from necessary examinations and diagnoses. We aimed to test 10 existing osteoporosis screening tools (OSTs), which can be easily used in institutions and serve as a prediction, for accurately determining the outcome of a Taiwan's National Health Insurance (NHI)-reimbursed anti-osteoporosis medications (AOMs) application for LTCRs.This prospective analysis recruited 444 patients from LTC institutions between October 2018 and November 2019. Predictions of whether the NHI-reimbursed AOMs criteria was met were tested for 10 OSTs. The results of OSTs categorized into self-reported or validated based on previous fracture history were self-reported by LTCRs or validated by imaging data and medical records, respectively. The receiver operating characteristic curve and the optimal cut-off points for LTCRs based on Youden's index were explored.Overall, the validated OSTs had a higher positive predictive value (PPV) and negative predictive value (NPV) summation than the corresponding reported OSTs. The validated FRAX-Major was the best OST (PPV = 63.6%, NPV = 82.4% for the male group and, PPV = 78.8%, NPV = 90.0% for the female group). After applying the optimum cut-off derived from Youden's index, the validated FRAX-Major (PPV = 75.4%, NPV = 92.0%)) remained performed best for men. In female population, validated FRAX-Major (PPV = 87.2%, NPV = 84.1%) and validated osteoporosis prescreening risk assessment (OPERA; PPV = 96.1%, NPV = 79.7%)) both provided good prediction results.FRAX-Major and OPERA have better prediction ability for LTCRs to acquire NHI-reimbursed AOMs. The validated fracture history and adjusted cut-off points could prominently increase the PPV during prediction.

Background To compare the risks of major osteoporotic, vertebral, and non-vertebral fractures between patients who discontinued anti-osteoporosis medications. Methods We conducted a comparative effectiveness study with a nationwide population-based cohort study design. Patients aged ≥50 years admitted between 2012 and 2015 for incident hip fractures and receiving denosumab or bisphosphonates with sufficient compliance for at least one year were included. Patients were categorized into persistent or non-persistent denosumab or bisphosphonates users based on their subsequent use pattern. The main outcomes were subsequent hospitalizations for a major osteoporotic, vertebral or non-vertebral fracture. Multivariate, time-varying Cox proportional hazards model was used to evaluate the risk of major outcomes. Results Compared with persistent denosumab users, non-persistent denosumab users had a significantly higher risk of major osteoporotic fractures (Hazard ratio (HR) = 1.60; 95% confidence interval (CI), 1.20 to 2.14),vertebral fractures (HR = 2.18; 95% CI, 1.46 to 3.24) and death (HR = 3.57; 95%CI, 2.63-4.84). However, the increased risk of fracture was not found in both persistent and non-persistent bisphosphonates users. Noteworthy, the increased risk of vertebral fractures in non-persistent denosumab users was more pronounced within one-year post discontinuation (HR = 2.90, 95% CI, 1.77 to 4.74) and among patients who discontinued from 2-year denosumab therapy (HR = 3.58; 95% CI, 1.74 to7.40). Discussion Discontinuation of denosumab resulted in an increased risk of major osteoporotic fractures, especially vertebral fractures. The increased risk tends to reveal within one-year post discontinuation and be greater after a longer treatment duration. Notably, only fracture with hospitalization was identified as our research outcome, the real risk of osteoporotic fracture post discontinuation is believed to be higher, especially for vertebral fracture. This article is protected by copyright. All rights reserved.

As aging populations increase worldwide, many governments have introduced the concept of paratransit services to assist individuals with limited mobility with transportation. A successful paratransit service must be able to satisfy most requests to the system; this success is typically related to the allocation of vehicles to dispatch stations. A suitable configuration can reduce unnecessary travel time and thus serve more people. This resembles the classic Dial-a-Ride problem, which previous studies have solved using heuristic algorithms. Most of these algorithms, however, incur heavy computational costs and, therefore, cannot be operated online, especially when there are many conditions to consider, many configuration requirements, or many vehicles requested. Therefore, this paper proposes an approach based on the generative adversary network (GAN), which can reduce computation significantly. In online environments, this approach can be implemented in just a few seconds. Furthermore, the amount of computation is not affected by the number of conditions, configuration requirements, or vehicles requested. This approach is based on three important concepts: (1) designing a GAN to solve the target problem; (2) using an improved Voronoi diagram to divide the overall service area to generate the input of the GAN generator; (3) using well-known system simulation software Arena to swiftly generate many conditions for the target problem and their corresponding best solutions to train the GAN. The efficiency of the proposed approach was verified using a case study of paratransit services in Yunlin, Taiwan.

Purpose The objective of this study was to investigate the association between the administration of dipeptidyl peptidase-4 (DPP-4) inhibitors (cumulative duration, timing, and individual substance) and the risk of arthralgia by using a nationwide database with two methodological approaches including cohort and nested case-control study designs. Methods Using Taiwan's National Health Insurance Research Database, we identified patients who were newly prescribed with DPP-4 inhibitors, thiazolidinediones (TZDs), or acarbose between 1 March 2009 and 31 December 2012. The exposure of studied drugs was categorized into five exclusive categories: DPP-4 inhibitor, TZD, acarbose, combined use, or non-use, and assessed in a time-varying manner. Time-dependent Cox proportional hazard models were used to estimate the association between DPP-4 inhibitors and the risk of arthralgia. Particularly, we tested the impact of different cumulative duration, timing, and individual substance of DPP-4 inhibitors use on risk of arthralgia. A corresponding nested case-control study using conditional logistic regression was conducted to verify this association. Results An increased risk of arthralgia was observed during the first year after initiating DPP-4 inhibitors (adjusted Hazard Ratio = 1.35; 95% confidence interval [CI], 1.04-1.75) but the risk declined with cumulative use. This duration-response relation was not found in TZDs use and acarbose use. In the nested case-control study, there was a slightly increased risk of arthralgia (aOR = 1.08; 95% CI, 1.04-1.12) associated with current DPP-4 inhibitor use. Conclusion A relatively higher risk of arthralgia was associated with the initial administration of DPP-4 inhibitors, however, the risk declined among long-term users.

BackgroundAlthough the pros and cons of prone and decubitus positioning methods, for posterior approaches to acetabular fractures, have been widely discussed, it remains inconclusive whether a particular patient position is superior to the other. Here we present our preliminary experience with placing the patient in the semiprone position for posterior approaches to the acetabulum as a potentially advantageous alternative.MethodsTechnical notes were provided as well as the preoperative, intraoperative and postoperative images of the demonstrative cases. From July 2018 to April 2020, eight selected patients with complex acetabular fractures were surgically treated through posterior approaches in semiprone position. Patient demographics, fracture pattern, poor prognostic factors and associated conditions were recorded. The quality of fracture reduction was assessed by Modified Matta’s criteria. The operative hip’s function was evaluated by the Modified Merle d’Aubigné-Postel score if follow-up was more than 3 months.Result:The Median age of our cohort was 48.55 years (24.3–70.6). The median body mass index was 23.90 kg/ m2 (17.6–26.4). Satisfactory reduction was achieved in 6 of the 8 patients. Intraoperative radiographs obtained by the standard vertical and horizontal projection of the C-arm machine resembled the classic Judet views. Trochanteric flip osteotomy and surgical hip dislocation were feasible. One hip was converted to total hip replacement 5 months after primary fracture surgery due to femoral head osteonecrosis.Conclusion:The preliminary radiographic and reduction quality of our cohort were comparable to those reported in the literature. The advantages of semiprone position include intuitive intraoperative radiographic acquisition, making gravity as a aid for reduction and feasibility of surgical hip dislocation. Long-term follow-up and further case-controlled or randomized controlled studies are necessary to uphold its value.

Background: Since 2011, Taiwan’s National Health Insurance Administration (NHIA) issued a regulation on the reimbursement to anti-osteoporosis medications (AOMs). This study aimed to evaluate the impact of this regulation in reimbursement on the utilization of AOMs, clinical outcomes and associated medical expenditures of patients with incident hip fractures. Methods: By using the National Health Insurance Research Database (NHIRD), patients with incident hip fracture from 2006 to 2015 were identified as our study cohort. Patients younger than 50 years old or prescribed with AOMs within one year prior to incident fracture were excluded. Outcomes of interest were quarterly estimates of the proportion of patients who received bone mineral density (BMD) examination, who were prescribed AOMs, as well as who encountered subsequent osteoporotic fracture-related visits and associated medical expenditures. Particularly, age- and gender specific estimates were reported. An interrupted time series study design with segmented regression model was used to quantitatively explore the impact of the changes of the reimbursement criteria on the level (immediate) and trend (long-term) changes of these outcomes. Results: Our study enrolled 118 493 patients with incident hip fracture with those patients aged older than 80 years old accounting for the largest proportion. A significantly decreased trend of AOMs prescription rates was observed immediately post regulation except for female aged between 65 and 80, while the long-term pattern showed no significant difference. However, the percentage of patients encountered subsequent osteoporotic fracture-related visit was not statistically different between pre- and post-regulation periods. Noteworthy, the policy regulation was associated with an increasing trend of osteoporotic fracture associated medical expenditures, especially for patients older than 80 years old. Conclusion: The regulation on the reimbursement for AOMs decreased the prescribing rate of AOMs immediately although the effect did not sustain thereafter. However, higher subsequent osteoporotic fracture-related medical expenditures were introduced, especially among those very old population.

Background Staple removal from surgical wounds is painful. Only a few articles have provided expert opinions using anesthetic cream for such a problem; however, direct application of the anesthetic cream to a wound may cause infection. A safe alternative can be an anesthetic patch without wound contact. Materials and methods This was a prospective, double-blind, randomized clinical trial. Sixty patients who underwent primary total knee replacement were assigned to an experimental group or control group. One lidocaine patch was applied around the surgical wound for each patient in the experimental group. Alternatively, the adhesive sides of the lidocaine patches were shielded with waterproof films in the control group. A resident peeled off the patch before a single nursing practitioner removed the staples. Pain was assessed with the 10-cm visual analog scale, and a face pain scale-revised was performed. The patients and the nursing practitioner were blind to the management. Results Mean visual analog scale and face pain scale-revised scores were significantly lower in the experimental group. The mean pain score was significantly lower in the experimental group if the application time was >47 min; for patients with application time of 47 min or shorter, the score was comparable with the mean pain scores of the control group ( P = 0.215). Conclusions Removal of the metal skin staples after total knee arthroplasty is associated with moderate-to-severe pain. The lidocaine patch applied topically around the surgical wound could effectively reduce the pain during the procedure, without remarkable complications such as systemic adverse effects or wound contamination.

Objective The optimal time after hip fracture to start prophylactic anti-osteoporosis medications (AOMs) remains uncertain, especially in real-world practice. Therefore, we investigated how timing of AOMs initiation affects the risk of subsequent osteoporotic fractures, and what factors influence timing of AOMs prescription. Method Patients ≥50 years old with diagnostic codes indicating hospitalization for hip fracture (n = 77,930) were identified from the Taiwan National Health Insurance Research Database; 9986 who were prescribed AOMs ≤1 year after a newly-diagnosed hip fracture were grouped into those who started AOMs from: ≤14 days (very early); 15–84 days (early); 85–252 days (late); and 253–365 days (very late). Associations with fracture-related hospitalizations after an index fracture were analyzed using a multivariate, time-dependent Cox proportional hazards model, and between-group differences compared by log-rank testing. Factors influencing timing of AOMs initiation were elucidated using multivariate logistic regression analyses. Results Compared to AOMs initiation from 15 to 84 days, initiation after 252 days was associated with significantly increased risk of fracture-related hospitalization (HR = 1.93, 95% CI 1.29–2.89). Both sensitivity and pre-specified subgroup analyses yield similar results. Among patients with high adherence to AOMs, the increased risk of subsequent fracture-related hospitalization among very late users was profound (HR = 2.56, 95% CI 1.41–4.64). Conclusion Timing of AOMs initiation was significantly associated with age, index year, index hospital length of stay as well as the accreditation level and geographic region of index hospital. After adjusting factors associated with timing of AOMs initiation and patients' adherence, the anti-fracture benefit of AOMs still depends crucially on the timely initiation of AOMs.

This nationwide cohort study examined the potential disease-modifying effect of anti-osteoporosis medication on hip osteoarthritis. The results revealed that the usage of anti-osteoporosis medication is not associated with decreased risk in undergoing total hip arthroplasty in patient with hip osteoarthritis. This study aimed to assess the association between use of anti-osteoporosis medications (AOMs) and the risk of undergoing total hip arthroplasty (THA) in patients with hip osteoarthritis (OA). Using the 2008–2013 National Health Insurance Research Database, we identified patients who were first diagnosed as having hip OA. All identified patients were followed until THA, death of any cause, or December 31, 2013, whichever occurred first. All AOM exposures were divided into three categories: bisphosphonates use, non-bisphosphonates use, and no use of AOMs and assessed in a time-varying manners. The primary outcome was THA. The secondary outcome was the differences in the longitudinal utilization of NSAIDs between AOM users and non-users. Time-dependent Cox proportional hazards models were used to investigate the effect of AOM use on the risk of THA. We identified 35,870 patients who were first diagnosed as having hip OA and had no history of AOM use between 2009 and 2012. Among them, 3162 and 1667 patients had their first prescription of bisphosphonates and other non-bisphosphonates AOMs during the follow-up period. Mean age of bisphosphonates users, non-bisphosphonates users, and non-users was 75.62, 76.84, and 67.39 years, respectively. Bisphosphonates or non-bisphosphonates users did not show significant change when compared to non-users in terms of risk of undergoing THA [adjusted hazard ratio (aHR) 0.972, 95% confidence interval (CI) 0.743–1.273; aHR 0.926, 95% CI 0.672–1.277]. Our results showed that the use of AOMs is not associated with decreased risk of THA in patients with hip OA.

Summary: Objective: Femoral neck shortening is a common complication after surgical treatment for intracapsular femoral neck fractures. This study investigated whether fully-threaded Headless Compression Screw (FTHCS) can be a more length-stable implant than partially-threaded cannulated screw (PTCS) in reducing femoral neck shortening. Methods: A total of 50 patients with undisplaced femoral neck fractures (17 treated by internal fixation with three FTHCS, and 33 treated by three PTCS) from 2011 to 2014 were enrolled in this study. The radiography of the hips and medical records were reviewed for proximal femur geometry and complications. Results: Significant shortening of the femoral neck length until union were noted in both group (FTHCS group: −2.5 mm, p = 0.045; PTCS group: −2.4 mm, p = 0.011). There was no significant difference in the length of femoral neck shortening between groups (p = 0.855). Age was the only significant risk factor for >5 mm of femoral neck shortening (p = 0.041). The femoral neck-shaft angle tended to reduce and become more varus in both groups (FTHCS: −2.7°, SD = 4.5, p = 0.028; PTCS: −5.0°, SD = 8.3, p = 0.002), but the differences between groups were nonsignificant (p = 0.577). The complication rates were similar between FTHCS and PTCS (17.6% and 21.2%, p > 0.999). Conclusion: The FTHCSs may be a substitute for PTCSs, but it cannot prevent femoral neck shortening and varus collapse after fracture fixation. Future studies should focus on how to preserve femoral neck length and hip function after femoral neck fractures. Keywords: Cannulated screw, Femoral neck shortening, Femoral neck fractures, Headless compression screw, Thread

This nationwide study investigated the epidemiology, treatment patterns, and economic burden of osteoporosis and associated fracture in Taiwan. The treatment of osteoporosis is alarmingly suboptimal, considering the significantly increased economic burden of major osteoporotic fracture. Osteoporosis men received lesser anti-osteoporosis drugs but had higher incremental costs attributable to osteoporotic fractures. This nationwide study investigated the epidemiology, treatment patterns, and economic burden of osteoporosis and associated fracture between 2009 and 2013 in Taiwan. We used the National Health Insurance Research Database as our data source. The prevalence of diagnosed osteoporosis and major osteoporotic fractures was calculated annually from 2009 to 2013, stratified by age and gender. Osteoporosis patients who received any prescription of anti-osteoporosis drugs during each fiscal year were defined as osteoporosis patients under treatment. Healthcare utilization and associated direct medical costs were used to quantify the economic burden of osteoporosis. For patients who encountered major osteoporotic fracture, the incremental changes of direct medical costs attributable to fracture using a pre- and post-quasi-experimental design were estimated. Furthermore, we compared the annual direct medical costs of patients who encountered major osteoporotic fracture with those diagnosed osteoporosis only and with the general population. The prevalence of diagnosed osteoporosis increased with age, with the highest rate among those aged 80 and older. Overall, less than one-third of women and only 10% of men received anti-osteoporosis drugs among osteoporosis patients. The annual direct medical costs for osteoporosis patients increased steadily from 2009 to 2013. The total medical costs and incremental change of direct medical costs were higher in men than those in women. We found the treatment of osteoporosis to be alarmingly suboptimal, considering the significantly increased economic burden of major osteoporotic fracture also identified in this study. Osteoporosis men received lesser anti-osteoporosis drugs but had higher incremental costs attributable to major osteoporotic fractures.

BACKGROUND The use of bisphosphonates has been reported to have potential beneficial effects on knee osteoarthritis, but existing studies have limitations. The purpose of this study was to examine the association of bisphosphonate use with the risk of undergoing total knee arthroplasty and with the consumption of pain medication among osteoporotic patients with knee osteoarthritis. METHODS We identified patients who were newly diagnosed with knee osteoarthritis among a cohort of patients with osteoporosis from 2009 to 2012 in the National Health Insurance Research Database in Taiwan. We further categorized these patients into 2 groups: those who were treated with bisphosphonates (bisphosphonate users) and those who were not treated with any anti-osteoporosis drug (nonusers). Bisphosphonate treatment adherence was calculated by the medication possession ratio (MPR) as the proportion of days of bisphosphonate treatment within a fixed duration; an MPR of ≥80% was considered high adherence. The primary and secondary outcomes of interest were undergoing total knee arthroplasty and the use of pain medication, respectively. Analyses using Cox proportional hazard models with propensity-score adjustment were performed to estimate the association between bisphosphonate use and the risk of undergoing total knee arthroplasty. The incremental change in the mean accumulated defined daily doses of pain medications among both bisphosphonate users and nonusers was calculated. RESULTS We identified 16,276 bisphosphonate users and 123,791 nonusers of any anti-osteoporosis drug among the patients with osteoporosis who were newly diagnosed with osteoarthritis. Bisphosphonate use was significantly associated with a decreased risk of total knee arthroplasty (adjusted hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.69 to 0.83; p < 0.001). In patients with a follow-up period of ≥24 months and an MPR of ≥80%, the effect size was significantly greater (adjusted HR, 0.66; p = 0.048). Over the 5 years of follow-up, we found a significantly greater decrease in the use of pain medication among bisphosphonate users than among nonusers (p < 0.001; Chow test). CONCLUSIONS Among patients with osteoporosis and osteoarthritis, bisphosphonate use was associated with a significantly lower risk of total knee arthroplasty, especially in patients with high adherence and longer treatment duration. A lower consumption of pain medication was also found for bisphosphonate users among the patients with osteoporosis and osteoarthritis. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

AIMS Recent clinical guidelines have suggested that patients experience an osteoporotic fracture should initiate anti-osteoporosis medications (AOMs). However, whether clinical guidelines translate well in "real-world" practices remain questioned. This study aimed to evaluate the "real-world" prescription pattern of AOMs and visualise the unmet treatment needs in different geographical areas in Taiwan. METHODS Using Taiwan's National Health Insurance Research Database, we identified patients diagnosed with a hip or vertebral fracture between 2009 and 2012. The treatment rate was defined as the proportion of patients receiving AOMs within 1 year after their index fracture. The qualitative geographical information systems approach was adopted to visualise the treatment needs of postfracture patients in different geographical areas. RESULTS Our study included 276,492 patients diagnosed with a hip or vertebral fracture between 2009 and 2012. The proportion of patients who received AOMs within 1 year after their index fracture increased with age and differed with fracture types and sex. For patients with hip fractures, the treatment rate ranged from 3.43% to 20.88% for female patients and from 0.69% to 10.04% for male patients in different age groups. For patients with vertebral fractures, the treatment rate ranged from 3.23% to 37.08% for female patients and from 1.85% to 23.05% for male patients. Cities in the mid-northern and southern areas of Taiwan had the highest unmet treatment need, with a treatment rate of less than 15%. CONCLUSION The treatment rate of osteoporotic fractures with AOMs was diverse and suboptimal in Taiwan, especially among male patients. This study used a visualisation technique to display information about the treatment status in different geographical areas and help policymakers allocate resource appropriately.

This is the first study to investigate the association between the use of selective serotonin reuptake inhibitor (SSRI)/serotonin–norepinephrine reuptake inhibitor (SNRI) and the risk of fractures using a nationwide representative cohort of ethnic Chinese. Current use of SSRI/SNRI and the co-morbidity, especially osteoporosis and history of falling, play an important role in the increased risk of fractures. This nested case–control study examines the association between the timing, intensity, and individual components of serotonergic antidepressant (including SSRIs and SNRIs) use and the risk of all-cause fracture. Using the 2002–2011 Taiwan National Health Insurance Research Database, we identified patients who received at least three prescriptions of antidepressants between January 1st 2002 and December 31st 2010 as our study cohort. In the study cohort, we identify 8250 patients who had first admission for fracture and 33,000 matched controls (1:4, matched by age, sex, and cohort entry date). Multivariate conditional logistic regression was used to estimate the association between the use of serotonergic antidepressants and the risk of fracture. Current users of serotonergic antidepressants were associated with an increased risk of fracture (adjusted odds ratio (aOR) 1.16 [95 % confidence interval 1.07–1.25]). Furthermore, a higher risk of fractures was found in patients with osteoporosis (aOR 3.05 [2.73–3.42]) or a history of falling (aOR 6.13 [3.41–11.0]). The risks of fracture between SSRI and SNRI users were comparable. Current use of SSRI/SNRI is associated with an increased risk of all caused fractures. Additionally, the co-morbidity, especially osteoporosis and a history of falling, plays an important role in the risk of fractures.

Musculoskeletal allografts are now commonly used. To decrease the potential risks of transmission of pathogenic bacteria, fungi, or viruses to the transplant recipients, certain issues regarding the management of patients who receive contaminated allografts need to be addressed. We aimed to clarify the incidence and extent of disease transmission from allografts by analyzing the allografting procedures performed in the bone bank of our hospital over the past 20 years. We retrospectively reviewed the data from our allograft registry center on 3979 allografts that were implanted in 3193 recipients throughout a period of two decades, from July 1991 to June 2011. The source of the allografts, results of all screening tests, dates of harvesting and implantation, and recipients of all allografts were checked. With the help of the Center for Infection Control of our hospital, a strict prospective, hospital-wide, on-site surveillance was conducted, and every patient with healthcare-associated infection was identified. Fisher’s exact test was used to compare the infection rate between recipients with sterile allografts and those with contaminated allografts. The overall discard and infection rates were, respectively, 23% and 1.3% in the first decade (1991–2001); and 18.4% and 1.25% in the second decade (2001–2011). The infection rate of contaminated allograft recipients was significantly higher than that of sterile allograft recipients (10% vs. 1.15%, P < 0.01) in the second decade. Both infection and discard rates of our bone bank are comparable with those of international bone banks. Strict allograft processing and adequate prophylactic use of antibiotics are critical to prevent infection and disease transmission in such cases.