Long-term denosumab treatment restores cortical bone loss and reduces fracture risk at the forearm and humerus: analyses from the FREEDOM Extension cross-over group.

Upper limb fractures (including wrist, forearm, and humerus) represent a significant burden among postmenopausal women with osteoporosis. Up to 7 years of treatment with denosumab resulted in an increase in bone mineral density and decrease in fractures in upper limb sites. INTRODUCTION: Upper limb (wrist, forearm, and humerus) fractures are a significant burden in osteoporosis, associated with significant morbidity and mortality. Denosumab, a monoclonal antibody against RANK ligand, increases bone mineral density (BMD) and decreases vertebral, nonvertebral, and hip fractures. Here, we evaluated the long-term effect of denosumab treatment on upper limb fracture risk and BMD. METHODS: In the FREEDOM trial, subjects were randomized 1:1 to receive every-6-month denosumab 60 mg or placebo subcutaneously for 3 years, after which all subjects could receive denosumab for up to 7 years (Extension). Among placebo subjects who completed FREEDOM and enrolled in the Extension, wrist, forearm, humerus, and upper limb fracture rates and rate ratios between different time periods (FREEDOM years 1-3, Extension years 1-3, and Extension years 4-7) were computed. BMD at the ultradistal radius, 1/3 radius, and total radius was analyzed in a subset of subjects in a BMD substudy. RESULTS: This analysis included 2207 subjects (116 in the BMD substudy). Fracture rates decreased over the 7-year Extension; fracture rate ratios between Extension years 4-7 (denosumab) and FREEDOM years 1-3 (placebo) reduced significantly for the wrist (0.57), forearm (0.57), humerus (0.42), and upper limb (0.52; p < 0.05 for all). Percentage increase in BMD from Extension baseline at the ultradistal radius, 1/3 radius, and total radius was significant by Extension year 7 (p < 0.05 for all). CONCLUSIONS: Long-term treatment with denosumab decreases upper limb fracture risk and increases forearm BMD, suggesting beneficial effects on both cortical and trabecular bone accruing over time.

Size of greater tuberosity fragment: a risk of iatrogenic injury during shoulder dislocation reduction.

PURPOSE: Shoulder dislocation with greater tuberosity fractures (GTF) is becoming increasingly common, as is the number of cases of iatrogenic humeral neck fractures (IHNF) during reduction. This study investigated the relationship between size of greater tuberosity fragment and occurrence of IHNF in patients with shoulder dislocation and GTF. METHODS: A retrospective study was made to identify all patients presenting with shoulder dislocation with GTF between September 2014 and July 2016. There were 74 patients with an average age of 52.4 years (range 18-84 years) representing 76 cases of shoulder dislocation associated with GTF. Patient age, injury mechanism and location, treatment waiting time, and reduction method were noted. Using conventional anterior-posterior view radiographs, three points were identified as A, B, and C. Distance ratios between AC and AB were calculated, then the resulting ratio was compared to a critical value of 0.4. RESULTS: More iatrogenic fractures occurred in cases where the AC/AB ratio exceeded 0.4. Most (13) occurred during emergency Hippocratic manual reduction. Only five of 18 iatrogenic fractures (27.78%) occurred during surgery while under traction. Women ran a higher risk of iatrogenic fracture than men (female/male ratio 8:1). On average, women were older than men at the time of fracture (59.75 years for women vs. 42 years for men). CONCLUSIONS: A statistically significant relationship exists between size of greater tuberosity fragment and occurrence of iatrogenic humeral neck fractures during the reduction of shoulder dislocation. The larger the greater tuberosity fragment, the higher the incidence of iatrogenic humeral neck fractures. For such fracture dislocations, we recommend open reduction with internal fixation directly and using a Kirschner wire in advance to reinforce the proximal humerus before reduction of the shoulder.

Fragility fractures in the upper limb: proximal and distal humerus.

The incidence of fragility fractures of the humerus is increasing worldwide. Although clinicians are aware of fractures of hips and wrists, fractures of the shoulder and elbow do not receive much attention. A considerable proportion of the elderly population (estimated at 10-24%) is dependent on walking aids. A well-functioning and pain-free shoulder and elbow is essential for use of these aids. The impact of loss of mobility in the elderly is well known, hence the overall impact of these fractures on the individual can be considerable. This article increases the awareness of these fractures among non-orthopaedic colleagues and provides a brief outline of their management. In the elderly population using walking aids, the shoulder and elbow are effectively weight-bearing joints. Fractures of the shoulder or elbow in the elderly require extra attention to maintain their mobility during this period by physiotherapy to the lower limbs and chest. In patients who mobilize using a frame, the use of a stick on the opposite side of the injury may have to be considered while recovery is in progress.

The prevalence of the complications and their associated factors in humeral lengthening for achondroplasia: retrospective study of 54 cases.

The aim of this study is to evaluate the complications of humeral lengthening and their associated factors. Fifty-four achondroplastic patients were treated by bilateral humeral lengthening. Our original shoulder sling was sufficient to prevent shoulder dislocation. Pre-existing radial head dislocation was observed in 18 patients. Lengthening was accomplished in all cases without a decrease in the elbow function. Seven humeri fractured after the fixator removal. The risk factors for postoperative fracture were a waiting period of less than 5 days, a healing index less than 25, and the concave shape of the callus. There was no radial nerve palsy.

Flexible intramedullary nailing in simple bone cysts of the proximal humerus: prospective study for high-risk cases of pathologic fracture.

UNLABELLED: We designed and evaluated a modified cyst index using the Picture Archiving and Communication System software for treating simple bone cysts of the proximal humerus by preventive intramedullary flexible nail insertion in symptomatic children or adolescents. From January 2007 to December 2009, cases with a cyst index of at least 4 were enrolled in the study. Of 20 total cases, 19 were prospectively followed-up for at least 2 years. The mean patient age was 10.6 years (range, 7-15 years) and the mean modified cyst index was 6.56 (range, 4.95-8.25). The mean cyst healing period was 8.7 months (range, 4-30 months) and the mean follow-up period was 31.05 months (range, 24-42 months). Seventeen lesions (89%) were classified as completely healed and two (11%) were classified as healed with residual radiolucency. In all cases, no angular deformity was found on the final follow-up radiograph. Therefore, preventive flexible intramedullary nail insertion before the occurrence of a pathologic fracture because of simple bone cysts with a modified cyst index of at least 4 in the proximal humerus is an excellent treatment option. LEVEL OF EVIDENCE: Therapeutic Level IV.

Prophylactic stabilization for bone metastases, myeloma, or lymphoma: do we need to protect the entire bone?

BACKGROUND: The current operative standard of care for disseminated malignant bone disease suggests stabilizing the entire bone to avoid the need for subsequent operative intervention but risks of doing so include complications related to embolic phenomena. QUESTIONS/PURPOSES: We questioned whether progression and reoperation occur with enough frequency to justify additional risks of longer intramedullary devices. METHODS: A retrospective chart review was done for 96 patients with metastases, myeloma, or lymphoma who had undergone stabilization or arthroplasty of impending or actual femoral or humeral pathologic fractures using an approach favoring intramedullary fixation devices and long-stem arthroplasty. Incidence of progressive bone disease, reoperation, and complications associated with fixation and arthroplasty devices in instrumented femurs or humeri was determined. RESULTS: At minimum 0 months followup (mean, 11 months; range, 0-72 months), 80% of patients had died. Eleven of 96 patients (12%) experienced local bony disease progression; eight had local progression at the original site, two had progression at originally recognized discretely separate lesions, and one had a new lesion develop in the bone that originally was surgically treated. Six subjects (6.3%) required repeat operative intervention for symptomatic failure. Twelve (12.5%) patients experienced physiologic nonfatal complications potentially attributable to embolic phenomena from long intramedullary implants. CONCLUSIONS: Because most patients in this series were treated with the intent to protect the bone with long intramedullary implants when possible, the reoperation rate may be lower than if the entire bone had not been protected. However, the low incidence of disease progression apart from originally identified lesions (one of 96) was considerably lower than the physiologic complication rate (12 of 96) potentially attributable to long intramedullary implants. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Direct and indirect costs of fractures due to osteoporosis in Austria]. / Direkte und indirekte Kosten von osteoporotisch bedingten Frakturen in Österreich.

OBJECTIVES: We examined the financial burden of osteoporosis in Austria. METHODS: We took both direct and indirect costs into consideration. Direct costs encompass medical costs such as expenses for pharmaceuticals, inpatient and outpatient medical care costs, as well as other medical services (e.g., occupational therapies). Non-medical direct costs include transportation costs and medical devices (e.g., wheel chairs or crutches). Indirect costs refer to costs of productivity losses due to absence of work. Moreover, we included costs for early retirement and opportunity costs of informal care provided by family members. While there exist similar studies for other countries, this is the first comprehensive study for Austria. For our analysis, we combined data of official statistics, expert estimates as well as unique patient surveys that are currently conducted in the course of an international osteoporotic fracture study in Austria. RESULTS: Our estimation of the total annual costs in the year 2008 imposed by osteoporosis in Austria is 707.4 million €. The largest fraction of this amount is incurred by acute hospital treatment. Another significant figure, accounting for 29% of total costs, is the opportunity cost of informal care. CONCLUSIONS: The financial burden of osteoporosis in Austria is substantial. Economic evaluations of preventive and therapeutic interventions for the specific context of Austria are needed to inform health policy decision makers.

Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision.

SUMMARY: The cost-effectiveness of Fracture Liaison Services (FLSs) for prevention of secondary fracture in osteoporosis patients in the United Kingdom (UK), and the cost associated with their widespread adoption, were evaluated. An estimated 18 fractures were prevented and £21,000 saved per 1,000 patients. Setup across the UK would cost an estimated £9.7 million. INTRODUCTION: Only 11% to 28% of patients with a fragility fracture receive osteoporosis treatment in the UK. FLSs provide an efficient means to identify patients and are endorsed by the Department of Health but have not been widely adopted. The objective of this study was to evaluate the cost-effectiveness of FLSs in the UK and the cost associated with their widespread adoption. METHODS: A cost-effectiveness and budget-impact model was developed, utilising detailed audit data collected by the West Glasgow FLS. RESULTS: For a hypothetical cohort of 1,000 fragility-fracture patients (740 requiring treatment), 686 received treatment in the FLS compared with 193 in usual care. Assessments and osteoporosis treatments cost an additional £83,598 and £206,544, respectively, in the FLS; 18 fractures (including 11 hip fractures) were prevented, giving an overall saving of £21,000. Setup costs for widespread adoption of FLSs across the UK were estimated at £9.7 million. CONCLUSIONS: FLSs are cost-effective for the prevention of further fractures in fragility-fracture patients. The cost of widespread adoption of FLS across the UK is small in comparison with other service provision and would be expected to result in important benefits in fractures avoided and reduced hospital bed occupancy.

Fracture risk before and after total hip replacement in patients with osteoarthritis: potential benefits of bisphosphonate use.

OBJECTIVE: The association between osteoarthritis (OA) and fractures remains unclear. OA patients have increased bone mass, but no corresponding decrease in fracture rate. This study was undertaken to determine the fracture rates in patients with hip OA undergoing a total hip replacement (THR), as compared with disease-free controls, and to assess the association between bisphosphonate use and postsurgery fracture risk. METHODS: We conducted a population-based parallel-cohorts study. All patients in the UK General Practice Research Database undergoing a THR for hip OA between 1986 and 2006 constituted the exposed cohort (n = 14,133). Five disease-free controls were matched with each patient by age, sex, and practice site. Subjects were followed up for 5 years before and after surgery. Fracture rates and rate ratios (RRs) were estimated using Poisson regression. In addition, bisphosphonate use was identified among patients undergoing THR, and the data, stratified by the presence or absence of a previous fracture and by treatment propensity score, were assessed using fitted Cox models to study the effect of bisphosphonate use on the risk of fracture postsurgery. RESULTS: Patients undergoing a THR had a similar fracture risk as that in controls in the 5 years before THR, but had higher rates postsurgery, which peaked at years 2.5-5 (adjusted RR 1.24, 95% confidence interval [95% CI] 1.02-1.52). Use of bisphosphonates lowered the fracture risk among THR patients who received bisphosphonates as primary prevention (hazard ratio [HR] 0.56, 95% CI 0.38-0.82) and also among THR patients who had experienced a previous osteoporotic fracture (HR 0.48, 95% CI 0.23-0.99). CONCLUSION: This study identified a 25% increase in fracture risk at 2.5-5 years postsurgery among patients undergoing a THR. Bisphosphonate use reduced the post-THR risk of fracture when administered both as primary prevention and as secondary prevention, by 44% and 52%, respectively. This must be further confirmed in randomized controlled trials.

Osteoporosis in patients with a low-energy fracture: 3 years of screening in an osteoporosis outpatient clinic.

BACKGROUND: The prevalence of osteoporosis in the Netherlands is 52 per 1,000 men and 166 per 1,000 women (age >55 years). Previous results of an osteoporosis screening program showed that 55%, 41%, and 37.1% had osteoporosis. This study aims to evaluate the incidence of osteoporosis after low-energy fractures and to describe the care program for osteoporosis screening. The second endpoint was to investigate the incidence of risk factors in the whole study population and a subgroup analysis from the three major groups with osteoporotic fractures. METHODS: All female and male patients older than 50 years with a low-energy fracture were included for the osteoporosis screening program. Patients with a fracture of the vertebrae were also included if the age was less than 50 years. All patients underwent a bone mineral density measurement by means of dual-energy X-ray film absorptiometry. All obtained data were registered by a nurse specialist in osteoporosis, in a computerized database. RESULTS: The incidence of osteoporosis in patients with low-energy fractures is high, 46.4%. At the time of fracture presentation, there were 33.2% of the patients with a low body weight (<67 kg), almost all osteoporotic patients (96%) had a low-energy fracture occurred after their 50th year. In patients diagnosed with osteoporosis, the hip fracture is the most common fracture site (34%), followed by the humerus (20.1%). CONCLUSIONS: In conclusion, a screening program for osteoporosis is necessary and should be a tool in the armamentarium of every traumatology department.

Underutilization of antiosteoporotic drugs by orthopedic surgeons for prevention of a secondary osteoporotic fracture.

BACKGROUND: Despite the availability of effective treatment and well-publicized treatment guidelines for preventing osteoporotic fractures, there are significant gaps in implementing the recommendations, and it is unknown how many patients are treated for prevention of secondary osteoporotic fractures. In this study, we investigate what percentage of osteoporosis patients were treated with antiosteoporotic drugs after osteoporotic fractures of the hip, wrist, and proximal humerus, and we discuss here the need for improvement in the treatment of osteoporosis following fracture. METHODS: We studied 422 patients with osteoporotic fractures, 91 men and 331 women, with an average age of 77.1 years (range, 52-102 years). The 422 cases consisted of 299 hip fractures, 97 distal radius fractures, and 26 proximal humerus fractures. All patients underwent surgical intervention. The variables were examined to ascertain whether osteoporosis patients were medicated with antiosteoporotic drugs at postfracture. RESULTS: Fifty-five (13%) of the 422 patients received antiosteoporotic medication at postfracture. Pharmaceutical treatment was given in 44 cases (14.7%) of hip fractures, 8 cases (8.2%) of distal radius fractures, and 3 cases (11.5%) of proximal humerus fractures. Thirty-one (7.3% of total) of the 55 patients were taking the same medication pre- and postfracture. Seven (1.7%) of the 55 were administered a different drug compared to before the fracture, and 17 (4%) started to take an antiosteoporotic drug for the first time subsequent to the fracture. CONCLUSIONS: The present rate of treatment is insufficient given the high risk of secondary fractures and the availability of appropriate drugs that would reduce that risk.

One fracture is enough! Experience with a prospective and consecutive osteoporosis screening program with 239 fracture patients.

BACKGROUND: Fracture and low bone mineral density both have strong predictive value for future fractures. The risk of future fractures can be reduced by medi-cal treatment if patients with osteoporosis are identified, for example by screening fracture patients for low bone mineral density. We suggest that these screening routines be organized at orthopedics departments and we report our experience with such a screening system. PATIENTS AND METHODS: We screened all patients between 50-75 years of age with a wrist, vertebral, proximal humerus, or hip fracture visiting our orthopedics department by measuring bone mineral density (BMD) using DEXA scans. After diagnosis, the patients were referred to their primary care physician for treatment. RESULTS: Between November 1, 2002, and October 31, 2003, 239 patients were investigated and only 13% had normal BMD values. 45% of the patients were diagnosed with osteopenia and 42% with osteoporosis. INTERPRETATION: Screening of fracture patients who visit an orthopedics department appears to be an effective way of identifying individuals with low bone mineral density. The screening routines can be organized as an osteoporosis team consisting of a doctor, a nurse and a secretary at each department. Today, these patients are largely undetected and untreated--at least in our region. In our series, only 13 patients had been DEXA-scanned and were treated by antiresorptive drugs at the time of fracture.

Osteoporosis risk assessment and treatment intervention after hip or shoulder fracture. A comparison of two centres in the United Kingdom.

This study compares the investigation of and treatment for osteoporosis in two groups of fracture patients at two orthopaedic centres in the UK. One centre had a formal fracture liaison service (FLS) responsible for screening fracture patients for osteoporosis. The other centre relied upon individual clinicians to initiate investigation or treatment for osteoporosis in patients following fracture. Patients who had been treated in either centre for a proximal humeral or hip fracture during a 6-month period were followed up 6 months later to identify how many had received screening or treatment for osteoporosis. Information was retrieved from a prospectively compiled database or by postal questionnaire. The study revealed that in the centre with an FLS 85% of patients with a proximal humeral fracture and 20% with a hip fracture had been offered a dual-energy X-ray absorptiometry (DEXA) scan. Approximately 50% and 85%, respectively, were receiving treatment for osteoporosis 6 months following their fracture. This compared with DEXA being offered to only 6% and 9.7% of humeral and hip fracture patients, respectively, and 20% (hip) and 27% (proximal humerus) receiving osteoporosis treatment in the other centre. The presence of an FLS resulted in a considerably higher proportion of patients receiving investigation and treatment for osteoporosis following a hip or proximal humeral fracture.

Are current playground safety standards adequate for preventing arm fractures?

OBJECTIVE: To assess compliance with current standards of playgrounds where children have sustained a fall-related arm fracture. DESIGN, SETTING AND PARTICIPANTS: Between October 2000 and December 2002, a consecutive prospective series of 402 children aged under 13 years who fell from playground equipment and sustained an arm fracture was identified by emergency department staff in five Victorian hospitals. Trained field testers measured playground equipment height, surface type and depth, and surface impact attenuation factors to determine compliance with safety standards. MAIN OUTCOME MEASURES: Playground compliance with current Australian safety standards. RESULTS: Ninety-eight percent of playgrounds had a recommended type of surface material. The mean surface depth was 11.1 cm (SD, 5.0 cm) and the mean equipment height was 2.04 m (SD, 0.43 m). Although over 85% of playgrounds complied with recommended maximum equipment height and surface impact attenuation characteristics, only 4.7% complied with recommended surface depth. CONCLUSION: Playgrounds where children have sustained an arm fracture generally comply with all important safety recommendations except surface depth. Playground fall-related arm fracture requires specific countermeasures for prevention, distinct from head injury prevention guidelines.

Treatment of pathological fractures of the humerus with a locked intramedullary nail.

OBJECTIVE: The humerus is a common site for metastasis. Intramedullary nail fixation has been reported to be the best form of fixation for this disease but complications occur. This study aimed to assess the use of a new humeral nail to treat pathological fractures and impending pathological fractures of the humerus. METHODS: 29 patients received 31 Austofix locked intramedullary humeral nails: 25 for pathological fractures and 6 for impending fractures; 24 nails were inserted anterograde and 7 retrograde. Cement augmentation was applied in 4 patients, and adjuvant therapy was used in 28 patients. Complications occurred in 12 patients. RESULTS: Fixation failed in 6 patients: 2 due to intraoperative fractures during retrograde nailing, one due to a fracture through screw holes postoperatively, and 3 due to local progression of disease. Difficulty in distal locking of the nail was encountered in 4 patients. Locked intramedullary nailing resulted in a stable humerus in 80% of patients. CONCLUSION: Retrograde insertion of the nail is associated with an increased risk of intra-operative fracture, and disease progression can occur, despite the administration of adjuvant therapy.

Biomechanical analysis of prophylactic fixation for middle third humeral impending pathologic fractures.

For determination of the most biomechanically desirable construction for prophylactic fixation of impending central 1/3 humeral fractures, 24 matched pairs of fresh frozen skeletonized human cadaveric humeri were divided randomly into four groups. Group 1 compared intact humeri with matched humeri that had a 50% hemicylindrical cortical central 1/3 defect to show reproducible failure at the defect with significant reduction in strength. Groups 2 through 4 compared prophylactic fixation of the defect combined with cementation and dynamic compression plating, Rush rodding, or locked intramedullary nailing. Each specimen was tested in external rotation torsion to failure by fracture. In Group 1, test specimens with defects failed with significantly lower rotation to failure, peak torque, stiffness, and total energy absorbed to failure. In Groups 2 through 4, intramedullary nailing provided statistically significantly better total energy absorbed to failure and stiffness than did dynamic compression plating. The proximally and distally locked intramedullary nail seems to have biomechanical advantages in the prophylactic stabilization of an impending pathologic fracture of the central 1/3 of the humerus. These biomechanical findings must be considered in light of the clinical context when a means of fixation is selected.

Periprosthetic fractures of the humerus and scapula: management and prevention.

The management of humerus fractures is complicated by the presence of a prosthesis. Vigilance in addressing the mechanisms and predisposing factors for periprosthetic fracture may prevent their occurrence. In the event of a periprosthetic fracture, attention to prosthetic stability, fracture location and stability, and bone quality will help guide treatment decisions. Treatment should be commensurate with the goals of fracture stability, early rehabilitation, and maintaining a well-functioning prosthesis.