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Hip Fractures (hip + fractures)
Selected AbstractsPrevention of Hip Fractures in Long-Term Care: Relevance of Community-Derived DataJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2010Richard G. Crilly MD Osteoporosis and falling are two major contributing factors to fractures in older persons; the relevant contribution of these may vary according to age, setting, and frailty. The purpose of this review was to examine the existing evidence on osteoporosis treatments to determine whether participants in clinical trials include or resemble the older and frailer adult population living in long-term care (LTC). The trials (N=50) used to support major Canadian guidelines for osteoporosis treatment were reviewed because these are used to recommend treatment for all older adults, and several more-recent studies were added. Trials conducted specifically with participants living in LTC were also reviewed (N=6). The majority of studies (96.0%) on osteoporosis treatments were conducted with community-dwelling participants, with many excluding participants resembling the LTC population. Mean ages ranged from 52 to 84, although for the majority of studies, the mean age was younger than 70. Similarly, 80.0% of studies conducted in LTC included only residents who were ambulatory, mobile, able to transfer independently, or not permanently bedridden. Mean ages in these studies ranged from 83 to 85. These findings suggest that frail older adults, particularly the oldest and frailest adults in LTC, are neglected in clinical trials of osteoporosis fracture prevention. There is little evidence to support the application of community-based guidelines to the LTC population, and studies directly involving this population are needed. The role of age, frailty, and the mechanics of falls in hip fracture are discussed. [source] Evaluating the Cost-Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010Kevin D. Frick PhD OBJECTIVES: To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature. SETTING: Model represents population level interventions. PARTICIPANTS: No human subjects were involved in the study. MEASUREMENS: The last Cochrane database review and meta-analyses of randomized controlled trials categorized effective fall-prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high-risk frail elderly people. Fall-related hip fracture incidence was obtained from the literature. Salary figures for health professionals were based on Bureau of Labor Statistics data. Using an integrated healthcare system perspective, healthcare costs were estimated based on practice and studies on falls in older adults. Base case incremental cost utility ratios were calculated, and probabilistic sensitivity analyses were conducted. RESULTS: Medical management of psychotropics and group tai chi were the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, most-effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality-adjusted life year (QALY) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more-studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls. [source] Hip Fractures and the Contribution of Cortical Versus Trabecular Bone to Femoral Neck Strength,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 3 2009Gerold Holzer Abstract Osteoporotic fractures are caused by both cortical thinning and trabecular bone loss. Both are seen to be important for bone fragility. The relative contributions of cortical versus trabecular bone have not been established. The aim of this study was to test the contribution of cortical versus trabecular bone to femoral neck stability in bone strength. In one femur from each pair of 18 human cadaver femurs (5 female; 4 male), trabecular bone was completely removed from the femoral neck, providing one bone with intact and the other without any trabecular structure in the femoral neck. Geometrical, X-ray, and DXA measurements were carried out before biomechanical testing (forces to fracture). Femoral necks were osteotomized, slices were analyzed for cross-sectional area (CSA) and cross-sectional moment of inertia (CSMI), and results were compared with biomechanical testing data. Differences between forces needed to fracture excavated and intact femurs (,F/F mean) was 7.0% on the average (range, 4.6,17.3%). CSA of removed spongiosa did not correlate with difference of fracture load (,F/F mean), nor did BMD. The relative contribution of trabecular versus cortical bone in respect to bone strength in the femoral neck seems to be marginal and seems to explain the subordinate role of trabecular bone and its changes in fracture risk and the effects of treatment options in preventing fractures. [source] Physical Performance and Risk of Hip Fractures in Older Men,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 7 2008Peggy Mannen Cawthon Abstract The aim of these analyses was to describe the association between physical performance and risk of hip fractures in older men. Performance on five physical function exams (leg power, grip strength, usual walking pace, narrow walk balance test, and five repeated chair stands) was assessed in 5902 men ,65 yr of age. Performance (time to complete or strength) was analyzed as quartiles, with an additional category for unable to complete the measure, in proportional hazards models. Follow-up averaged 5.3 yr; 77 incident hip fractures were confirmed by physician review of radiology reports. Poor physical performance was associated with an increased risk of hip fracture. In particular, repeated chair stand performance was strongly related to hip fracture risk. Men unable to complete this exam were much more likely to experience a hip fracture than men in the fastest quartile of this test (multivariate hazard ratio [MHR]: 8.15; 95% CI: 2.65, 25.03). Men with the worst performance (weakest/slowest quartile or unable) on at least three exams had an increased risk of hip fracture compared with men with higher functioning (MHR: 3.14, 95% CI: 1.46, 6.73). Nearly two thirds of the hip fractures (N = 49, 64%) occurred in men with poor performance on at least three exams. Poor physical function is independently associated with an increased risk of hip fracture in older men. The repeated chair stands exam should be considered in clinical settings for evaluation of hip fracture risk. Concurrent poor performance on multiple physical function exams is associated with an increased risk of hip fractures. [source] Geriatric Co-Management of Proximal Femur Fractures: Total Quality Management and Protocol-Driven Care Result in Better Outcomes for a Frail Patient PopulationJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2008Susan M. Friedman MD Hip fractures in older adults are a common event, leading to substantial morbidity and mortality. Hip fractures have been previously described as a "geriatric, rather than orthopedic disease." Patients with this condition have a high prevalence of comorbidity and a high risk of complications from surgery, and for this reason, geriatricians may be well suited to improve outcomes of care. Co-management of hip fracture patients by orthopedic surgeons and geriatricians has led to better outcomes in other countries but has rarely been described in the United States. This article describes a co-managed Geriatric Fracture Center program that has resulted in lower-than-predicted length of stay and readmission rates, with short time to surgery, low complication rates, and low mortality. This program is based on the principles of early evaluation of patients, ongoing co-management, protocol-driven geriatric-focused care, and early discharge planning. This is a potentially replicable model of care that uses the expertise of geriatricians to optimize the management of a common and serious condition. [source] Femoral Neck BMD Is a Strong Predictor of Hip Fracture Susceptibility in Elderly Men and Women Because It Detects Cortical Bone Instability: The Rotterdam Study,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 11 2007Fernando Rivadeneira Abstract We studied HSA measurements in relation to hip fracture risk in 4806 individuals (2740 women). Hip fractures (n = 147) occurred at the same absolute levels of bone instability in both sexes. Cortical instability (propensity of thinner cortices in wide diameters to buckle) explains why hip fracture risk at different BMD levels is the same across sexes. Introduction: Despite the sexual dimorphism of bone, hip fracture risk is very similar in men and women at the same absolute BMD. We aimed to elucidate the main structural properties of bone that underlie the measured BMD and that ultimately determines the risk of hip fracture in elderly men and women. Materials and Methods: This study is part of the Rotterdam Study (a large prospective population-based cohort) and included 147 incident hip fracture cases in 4806 participants with DXA-derived hip structural analysis (mean follow-up, 8.6 yr). Indices compared in relation to fracture included neck width, cortical thickness, section modulus (an index of bending strength), and buckling ratio (an index of cortical bone instability). We used a mathematical model to calculate the hip fracture distribution by femoral neck BMD, BMC, bone area, and hip structure analysis (HSA) parameters (cortical thickness, section modulus narrow neck width, and buckling ratio) and compared it with prospective data from the Rotterdam Study. Results: In the prospective data, hip fracture cases in both sexes had lower BMD, thinner cortices, greater bone width, lower strength, and higher instability at baseline. In fractured individuals, men had an average BMD that was 0.09 g/cm2 higher than women (p < 0.00001), whereas no significant difference in buckling ratios was seen. Modeled fracture distribution by BMD and buckling ratio levels were in concordance to the prospective data and showed that hip fractures seem to occur at the same absolute levels of bone instability (buckling ratio) in both men and women. No significant differences were observed between the areas under the ROC curves of BMD (0.8146 in women and 0.8048 in men) and the buckling ratio (0.8161 in women and 0.7759 in men). Conclusions: The buckling ratio (an index of bone instability) portrays in both sexes the critical balance between cortical thickness and bone width. Our findings suggest that extreme thinning of cortices in expanded bones plays a key role on local susceptibility to fracture. Even though the buckling ratio does not offer additional predictive value, these findings improve our understanding of why low BMD is a good predictor of fragility fractures. [source] Musculoskeletal Rehabilitation in Osteoporosis: A Review,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 8 2004Michael Pfeifer Abstract Measures of musculoskeletal rehabilitation play an integral part in the management of patients with increased fracture risk because of osteoporosis or extraskeletal risk factors. This article delineates current scientific evidence concerning nonpharmacologic approaches that are used in conjunction with pharmacotherapy for prevention and management of osteoporosis. Fractures caused by osteoporotic fragility may be prevented with multidisciplinary intervention programs, including education, environmental modifications, aids, and implementation of individually tailored exercise programs, which are proved to reduce falls and fall-related injuries. In addition, strengthening of the paraspinal muscles may not only maintain BMD but also reduce the risk of vertebral fractures. Given the strong interaction between osteoporosis and falls, selection of patients for prevention of fracture should be based on bone-related factors and on risk factors for falls. Rehabilitation after vertebral fracture includes proprioceptive dynamic posture training, which decreases kyphotic posturing through recruitment of back extensors and thus reduces pain, improves mobility, and leads to a better quality of life. A newly developed orthosis increases back extensor strength and decreases body sway as a risk factor for falls and fall-related fractures. Hip fractures may be prevented by hip protectors, and exercise programs can improve strength and mobility in patients with hip fracture. So far, there is no conclusive evidence that coordinated multidisciplinary inpatient rehabilitation is more effective than conventional hospital care with no rehabilitation professionals involved for older patients with hip fracture. Further studies are needed to evaluate the effect of combined bone- and fall-directed strategies in patients with osteoporosis and an increased propensity to falls. [source] Hip fractures and delay to surgeryANZ JOURNAL OF SURGERY, Issue 3 2003FA Orth A, Ian C. Hargreaves FRACS (Orth) No abstract is available for this article. [source] Effect of Evidence-Based Acute Pain Management Practices on Inpatient CostsHEALTH SERVICES RESEARCH, Issue 1 2009John M. Brooks Objectives. To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost. Data Sources/Study Setting. Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures. Study Design. Experimental design and observational "as-treated" and instrumental variable (IV) methods. Data Collection/Extraction Methods. Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts. Principal Findings. The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention. Conclusions. A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost. [source] How Much Is Postacute Care Use Affected by Its Availability?HEALTH SERVICES RESEARCH, Issue 2 2005Melinda Beeuwkes Buntin Objective. To assess the relative impact of clinical factors versus nonclinical factors,such as postacute care (PAC) supply,in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. Data Sources and Study Setting. Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. Study Design. We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. Data Collection/Extraction Methods. A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. Principal Findings. PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. Conclusions. We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes,or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes. [source] The role of depressive symptoms in recovery from injuries to the extremities in older persons.INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 1 2003A prospective study Abstract Background Previous research suggested that depressive symptoms play a role in recovery after hip fracture. However none of these studies were prospective and included only patients with hip fractures. Objective To examine the effect of depressive symptoms on the recovery of (instrumental) activities of daily living after fall-related injuries to the extremities in older persons. Design Prospective cohort study. Methods Data were collected from 168 older persons at baseline, prior to their injuries (hip fractures, other fractures or contortions and dislocations), and 8 weeks, 5 months and 12 months after their accident. Hierarchical multiple regression analysis was used to study the impact of depressive symptoms (as assessed with the Hospital Anxiety and Depression Scale; HADS) on disability (as assessed with the Groningen Activity Restriction Scale; GARS) after the injury while adjusting for several covariates. Results Depressive symptoms at baseline were not predictive for disability after the injury when covariates were taken into account. However, depressive symptoms 8 weeks after the fall were significantly related to disability at 8 weeks, 5 months and even 12 months after the injury. In addition, disability levels before the injury were highly predictive for recovery later on. Severity of injury was particularly predictive for disability at 8 weeks while age (which may generally represent the amount of physiological reserve) predicted disability at 5 and 12 months after the injury. Cognitive functioning 8 weeks post-injury was, in contrast to previous research, not predictive for recovery when covariates were taken into account. Conclusions Pre-injury levels of disability and post-injury depressive symptoms are associated with recovery and may warrant concern and special attention in clinical practice. Copyright © 2002 John Wiley & Sons, Ltd. [source] The development of pressure ulcers in patients with hip fractures: inadequate nursing documentation is still a problemJOURNAL OF ADVANCED NURSING, Issue 5 2000Lena Gunningberg MSC RN The aims of the study were to investigate, on a daily basis: (i] the development and progress of pressure ulcers, (ii) the documented nursing interventions for prevention and treatment of pressure ulcers, and (iii) when nursing interventions regarding prevention and treatment of pressure ulcers were documented, in relation to patient risk status and the development of pressure ulcers. The study design was prospective, comparative and descriptive. A total of 55 patients with hip fracture were included. To facilitate the nurse's assessment, a ,pressure ulcer card' was developed, consisting of the Modified Norton Scale (MNS) and descriptions of the four stages of pressure ulcers. The incidence of pressure ulcers was 55%. The mean rank of the lowest MNS score was significantly lower for patients who developed pressure ulcers than for patients without pressure ulcers. The majority of the pressure ulcers occurred between admission to the ward and the fourth day after surgery. Documented interventions regarding prevention and treatment were: repositioning, overlays, cushions, use of lotion and observation. The mean number of interventions per patient was 2·2 for patients who developed pressure ulcers during their hospital stay. The comprehensiveness and quality of the nursing record was unsatisfactory, and only three nursing records reached the level required by Swedish law. Preventive interventions such as repositioning were documented when the pressure ulcer had already occurred. The lack of nursing documentation regarding prevention and treatment of pressure ulcers may indicate that nurses did not identify pressure ulcers as a prioritized nursing problem for this patient group. The Modified Norton Scale could be a valuable tool for nurses, both identifying the patient at risk and acting as a guide for nursing interventions. The study was approved by the ethics committee of the Faculty of Medicine at Uppsala University. [source] Visual Field Loss and Risk of Fractures in Older WomenJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2009Anne L. Coleman MD OBJECTIVES: To evaluate the associations between visual field loss and nonspine fractures. DESIGN: Prospective cohort study. SETTING: Community. PARTICIPANTS: Four thousand seven hundred seventy-three community-dwelling white and African-American women aged 65 and older with no previous history of hip fracture at the time of recruitment. MEASUREMENTS: Radiographically confirmed hip and nonspine, nonhip fractures identified from September 1997 to April 2008. Visual field loss was measured using a Humphrey Field Analyzer suprathreshold screening test of the peripheral and central vision of each eye and was classified into an ordinal rating of no, mild, moderate, or severe binocular visual field (BVF) loss. RESULTS: For hip and nonspine, nonhip fractures and in unadjusted and covariate-adjusted analyses, the highest incidence of fractures was seen in women with the most-severe BVF loss. In covariate-adjusted analysis, women with mild, moderate, and severe BVF loss had a 49% (hazard ratio (HR)=1.49, 95% confidence interval (CI)=1.18,1.88), 25% (HR=1.25, 95% CI=0.87,1.80), and 66% (HR=1.66, 95% CI=1.19,2.32) greater risk, respectively, for hip fractures than women without BVF loss. Similarly, women with mild visual field loss had a 12% (HR=0.88, 95% CI=0.75,1.04) lower risk for nonspine, nonhip fractures, whereas women with moderate and severe visual field loss had a 18% (HR=1.18, 95% CI=0.92,1.52) and 59% (HR=1.59, 95% CI=1.24,2.03) greater risk of nonspine, nonhip fractures than women without BVF loss. CONCLUSION: BVF loss is independently associated with hip and nonspine, nonhip fractures in older female volunteers. [source] Self-Reported Sleep and Nap Habits and Risk of Falls and Fractures in Older Women: The Study of Osteoporotic FracturesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2006Katie L. Stone PhD OBJECTIVES: To test the association between self-reported sleep and nap habits and risk of falls and fractures in a large cohort of older women. DESIGN: Study of Osteoporotic Fractures prospective cohort study. SETTING: Clinical centers in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, near Pittsburgh, Pennsylvania. PARTICIPANTS: Eight thousand one hundred one community-dwelling Caucasian women aged 69 and older (mean 77.0). MEASUREMENTS: Sleep and nap habits were assessed using a questionnaire at the fourth clinic visit (1993/94). Fall frequency during the subsequent year was ascertained using tri-annual questionnaire. Incident hip and nonspinal fractures during 6 years of follow-up were confirmed using radiographic reports. RESULTS: Five hundred fifty-three women suffered hip fractures, and 1,938 suffered nonspinal fractures. In multivariate models, women who reported napping daily had significantly higher odds of suffering two or more falls during the subsequent year (odds ratio=1.32, 95% confidence interval (CI)=1.03,1.69) and were more likely to suffer a hip fracture (hazard ratio (HR)=1.33, 95% CI=0.99,1.78) than women who did not nap daily. Those sleeping at least 10 hours per 24 hours had a higher risk of nonspinal fracture than (HR=1.26, 95% CI=1.00,1.58) and a similar but nonsignificant increased risk of hip fracture to (HR=1.43, 95% CI=0.95,2.15) those who reported sleeping between 8 and 9 hours. CONCLUSION: Self-reported long sleep and daily napping are associated with greater risk of falls and fractures in older women. Interventions to improve sleep may reduce their risk of falls and fractures. Future research is needed to determine whether specific sleep disorders contribute to these relationships. [source] Estimating Hip Fracture Morbidity, Mortality and CostsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2003R. Scott Braithwaite MD OBJECTIVES: To estimate lifetime morbidity, mortality, and costs from hip fracture incorporating the effect of deficits in activities of daily living. DESIGN: Markov computer cohort simulation considering short- and long-term outcomes attributable to hip fractures. Data estimates were based on published literature, and costs were based primarily on Medicare reimbursement rates. SETTING: Postacute hospital facility. PARTICIPANTS: Eighty-year-old community dwellers with hip fractures. MEASUREMENTS: Life expectancy, nursing facility days, and costs. RESULTS: Hip fracture reduced life expectancy by 1.8 years or 25% compared with an age- and sex-matched general population. About 17% of remaining life was spent in a nursing facility. The lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. The development of deficits in ADLs after hip fracture resulted in substantial morbidity, mortality, and costs. CONCLUSION: Hip fractures result in significant mortality, morbidity, and costs. The estimated lifetime cost for all hip fractures in the United States in 1997 likely exceeded $20 billion. These results emphasize the importance of current and future interventions to decrease the incidence of hip fracture. [source] Risk of Hip Fracture in Disabled Community-Living Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2003Louise C. Walter MD OBJECTIVES: To determine the rate of hip fracture and risk factors associated with hip fractures in disabled older persons who enroll in the Program of All-Inclusive Care for the Elderly (PACE), a program providing comprehensive care to community-living nursing-home-eligible persons. DESIGN: Prospective cohort study between January 1990 and December 1997. SETTING: The twelve PACE demonstration sites: San Francisco, California; Columbia, South Carolina; Detroit, Michigan; Denver, Colorado; East Boston, Massachusetts; El Paso, Texas; Milwaukee, Wisconsin; Oakland, California; Portland, Oregon; Rochester, New York; Sacramento, California; and the Bronx, New York. PARTICIPANTS: Five thousand one hundred eighty-seven individuals in PACE; mean age 79, 71% female, 49% white, 47% with dementia. MEASUREMENTS: Functional status, cognitive status, demographics, and comorbid conditions were recorded on all the participants, who were tracked for occurrence of a hip fracture. The goals were to determine the rate of hip fracture and identify risk factors. RESULTS: Two hundred thirty-eight hip fractures (4.6%) occurred during follow-up. The rate of hip fracture was 2.2% per person-year. Four independent predictors of hip fracture were identified using Cox proportional hazard analysis: age of 75 and older (adjusted hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.4,2.8); white ethnicity (HR = 2.1, 95% CI = 1.6,2.8); ability to transfer independently to and from bed, chair, and toilet (HR = 3.0, 95% CI = 1.2,7.2); and five or more Short Portable Mental Status Questionnaire errors (HR = 1.6, 95% CI = 1.3,2.1). The incidence of hip fracture ranged from 0.5% per person-year in persons with zero to one independent risk factors to 4.7% per person-year in those with all four independent risk factors. CONCLUSIONS: The rate of hip fracture in this cohort of disabled community-living older adults was similar to that reported in nursing home cohorts. Older age, white race, ability to transfer independently, and cognitive impairment were independent predictors of hip fracture. Persons with these risk factors should be targeted for preventive interventions, which should include strategies for making transferring safer. [source] Evidence of a hypermineralised calcified fibrocartilage on the human femoral neck and lesser trochanterJOURNAL OF ANATOMY, Issue 2 2001J. E. SHEA Femoral neck fractures are a major cause of morbidity and mortality in elderly humans. In addition to the age-related loss of cancellous bone, changes to the microstructure and morphology of the metaphyseal cortex may be a contributing factor in osteoporotic hip fractures. Recent investigations have identified a hypermineralised tissue on the neck of the femur and trochanteric region that increases in fractional area with advancing age in both males (Boyce & Bloebaum, 1993) and females (Vajda & Bloebaum, 1999). The aim of this study was to determine if the hypermineralised tissue previously observed on the proximal femur is calcified fibrocartilage. Regional variations in the fractional area of hypermineralised tissue, cortical bone, and porosity of the cortical bone along the neck of the femur and lesser trochanter were also quantified. Comparison of back scattered electron and light microscope images of the same area show that regions of hypermineralised tissue correlate with the regions of calcified fibrocartilage from tendon and capsular insertions. The hypermineralised tissue and calcified fibrocartilage had similar morphological features such as the interdigitations of the calcified fibrocartilage into the bone, lacunar spaces, and distinctly shaped pores adjacent to the 2 tissues. Regions of the neck that did not contain insertions were covered with periosteum. There were no regional differences (P > 0.05) on the superior and inferior femoral neck in terms of the percentage area of hypermineralised calcified fibrocartilage, cortical bone, or cortical bone porosity. The lesser trochanter exhibited regional differences in the fractional area of hypermineralised calcified fibrocartilage (P = 0.007) and cortical bone (P = 0.007) but not porosity of the cortical bone (P > 0.05). The effects of calcified fibrocartilage on femoral neck periosteal expansion, repair, and mechanics are unknown, but may play a role in osteoporotic fractures and intracapsular fracture healing. [source] The FRAX tool in French women: How well does it describe the real incidence of fracture in the OFELY cohortJOURNAL OF BONE AND MINERAL RESEARCH, Issue 10 2010Elisabeth Sornay-Rendu Abstract The FRAX tool estimates an individual's fracture probability over 10 years from clinical risk factors with or without bone mineral density (BMD) measurement. The aim of our study was to compare the predicted fracture probabilities and the observed incidence of fracture in French women during a 10-year follow-up. The probabilities of fracture at four major sites (hip, clinical spine, shoulder, or wrist) and at the hip were calculated with the FRAX tool in 867 women aged 40 years and over from the Os des Femmes de Lyon (OFELY) cohort. The incidence of fracture was observed over 10 years. Thus 82 women sustained 95 incident major osteoporotic (OP) fractures including 17 fractures at the hip. In women aged at least 65 years (n,=,229), the 10-year predicted probabilities of fracture with BMD were 13% for major OP fractures and 5% for hip fractures, contrasting with 3.6% and 0.5% in women younger than 65 years (p,<,.0001). The predicted probabilities of both major OP and hip fractures were significantly higher in women with osteoporosis (n,=,77, 18% and 10%) and osteopenia (n= 390, 6% and 2%) compared with women with normal BMD (n,=,208, 3% and <1%; p,<,.0001. The predicted probabilities of fracture were two and five times higher in women who sustained an incident major OP fracture and a hip fracture compared with women who did not (p,<,.0001). Nevertheless, among women aged at least 65 years with low BMD values (T -score , ,1; n,=,199), the 10-year predicted probability of major OP fracture with BMD was 48% lower than the observed incidence of fractures (p,<,.01). A 10-year probability of major OP fracture higher than 12% identified more women with incident fractures than did BMD in the osteoporotic range (p,<,.05). In French women from the OFELY cohort, the observed incidence of fragility fractures over 10 years increased with age following a pattern similar to the predicted probabilities given by the FRAX tool. However, in women aged at least 65 years with low BMD, the observed incidence of fractures was substantially higher than the predicted probability. © 2010 American Society for Bone and Mineral Research. [source] Computed tomographic measurements of thigh muscle cross-sectional area and attenuation coefficient predict hip fracture: The health, aging, and body composition studyJOURNAL OF BONE AND MINERAL RESEARCH, Issue 3 2010Thomas Lang Abstract Fatty infiltration of muscle, myosteatosis, increases with age and results in reduced muscle strength and function and increased fall risk. However, it is unknown if increased fatty infiltration of muscle predisposes to hip fracture. We measured the mean Hounsfield unit (HU) of the lean tissue within the midthigh muscle bundle (thigh muscle HU, an indicator of intramuscular fat), its cross-sectional area (CSA, a measure of muscle mass) by computed tomography (CT), bone mineral density (BMD) of the hip and total-body percent fat by dual X-ray absorptiometry (DXA), isokinetic leg extensor strength, and the Short Physical Performance Battery (SPPB) in 2941 white and black women and men aged 70 to 79 years. Sixty-three hip fractures were validated during 6.6 years of follow-up. Proportional hazards regression analysis was used to assess the relative risk (RR) of hip fracture across variations in thigh muscle attenuation, CSA, muscle strength, and physical function for hip fracture. In models adjusted by age, race, gender, body mass index, and percentage fat, decreased thigh muscle HU resulted in increased risk of hip fracture [RR/SD,=,1.58; 95% confidence interval (CI) 1.10,1.99], an association that continued to be significant after further adjustment for BMD. In models additionally adjusted by CSA, muscle strength, and SPPB score, decreased thigh muscle HU but none of the other muscle parameters continued to be associated with an increased risk of hip fracture (RR/SD,=,1.42; 95% CI 1.03,1.97). Decreased thigh muscle HU, a measure of fatty infiltration of muscle, is associated with increased risk of hip fracture and appears to account for the association between reduced muscle strength, physical performance, and muscle mass and risk of hip fracture. This characteristic captures a physical characteristic of muscle tissue that may have importance in hip fracture etiology. © 2010 American Society for Bone and Mineral Research [source] Imputation of 10-year osteoporotic fracture rates from hip fractures: A clinical validation studyJOURNAL OF BONE AND MINERAL RESEARCH, Issue 2 2010William D Leslie Abstract The World Health Organization (WHO) fracture risk assessment system (FRAX) allows for calibration from country-specific fracture data. The objective of this study was to evaluate the method for imputation of osteoporotic fracture rates from hip fractures alone. A total of 38,784 women aged 47.5 years or older at the time of baseline femoral neck bone mineral density (BMD) measurement were identified in a database containing all clinical dual energy X-ray absorptiometry (DXA) results for the Province of Manitoba, Canada. Health service records were assessed for the presence of nontrauma osteoporotic fracture codes after BMD testing (431 hip, 787 forearm, 336 clinical vertebral, and 431 humerus fractures). Ten-year hip and osteoporotic fracture rates were estimated by the Kaplan-Meier method. The population was stratified by age (50 to 90 years, 5-year width strata) and again by femoral neck T -scores (,4.0 to 0.0, 0.5 SD width strata). Within each stratum, the ratio of hip to osteoporotic fractures was calculated and compared with the predicted ratio from FRAX. Increasing age was associated with greater predicted hip-to-osteoporotic ratios (youngest 0.07 versua oldest 0.41) and observed ratios (youngest 0.10 versus oldest 0.48). Lower T -scores were associated with greater predicted (highest 0.04 versus lowest 0.71) and observed ratios (highest 0.06 versus lowest 0.44). There was a strong positive correlation between predicted and observed ratios (Spearman r,=,0.90,0.97, p,<,.001). For 14 of the 18 strata, the predicted ratio was within the observed 95% confidence interval (CI). Since collection of population-based hip fracture data is considerably easier than collection of non,hip fracture data, this study supports the current emphasis on using hip fractures as the preferred site for FRAX model calibration. © 2010 American Society for Bone and Mineral Research [source] Bone turnover markers and prediction of fracture: A prospective follow-up study of 1040 elderly women for a mean of 9 yearsJOURNAL OF BONE AND MINERAL RESEARCH, Issue 2 2010Kaisa K Ivaska Abstract Osteoporosis is characterized by compromised bone mass and strength, predisposing to an increased risk of fracture. Increased bone metabolism has been suggested to be a risk factor for fracture. The aim of this study was to evaluate whether baseline bone turnover markers are associated with long-term incidence of fracture in a population-based sample of 1040 women who were 75 years old (Malmö OPRA study). Seven bone markers (S-TRACP5b, S-CTX-I, S-OC[1,49], S-TotalOC, S-cOC, S-boneALP, and urinary osteocalcin) were measured at baseline and 1-year follow-up visit. During the mean follow-up of 9.0 years (range 7.4,10.9), 363 women sustained at least one fracture of any type, including 116 hip fractures and 103 clinical vertebral fractures. High S-TRACP5b and S-CTX-I levels were associated with increased risk of any fracture with hazard ratios [HRs (95% confidence interval)] of 1.16 (1.04,1.29) and 1.13 (1.01,1.27) per SD increase, respectively. They also were associated with increased risk of clinical vertebral fracture with HRs of 1.22 (1.01,1.48) and 1.32 (1.05,1.67), respectively. Markers were not associated with risk for hip fracture. Results were similar when we used resorption markers, including urinary osteocalcin, measured at the 1-year visit or an average of the two measurements. The HRs were highest for any fracture in the beginning of the follow-up period, 2.5 years from baseline. For vertebral fractures, the association was more pronounced and lasted for a longer period of time, at least for 5 years. In conclusion, elevated levels of S-TRACP5b, S-CTX-I, and urinary osteocalcin are associated with increased fracture risk for up to a decade in elderly women. © 2010 American Society for Bone and Mineral Research [source] Biochemical Markers of Bone Turnover, Hip Bone Loss, and Fracture in Older Men: The MrOS Study,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 12 2009Douglas C Bauer Abstract We used data from the Osteoporotic Fractures in Men (MrOS) study to test the hypothesis that men with higher levels of bone turnover would have accelerated bone loss and an elevated risk of fracture. MrOS enrolled 5995 subjects >65 yr; hip BMD was measured at baseline and after a mean follow-up of 4.6 yr. Nonspine fractures were documented during a mean follow-up of 5.0 yr. Using fasting serum collected at baseline and stored at ,190°C, bone turnover measurements (type I collagen N-propeptide [PINP]; , C-terminal cross-linked telopeptide of type I collagen [,CTX]; and TRACP5b) were obtained on 384 men with nonspine fracture (including 72 hip fractures) and 947 men selected at random. Among randomly selected men, total hip bone loss was 0.5%/yr among those in the highest quartile of PINP (>44.3 ng/ml) and 0.3%/yr among those in the lower three quartiles (p = 0.01). Fracture risk was elevated among men in the highest quartile of PINP (hip fracture relative hazard = 2.13; 95% CI: 1.23, 3.68; nonspine relative hazard = 1.57, 95% CI: 1.21, 2.05) or ,CTX (hip fracture relative hazard = 1.76, 95 CI: 1.04, 2.98; nonspine relative hazard = 1.29, 95% CI: 0.99, 1.69) but not TRACP5b. Further adjustment for baseline hip BMD eliminated all associations between bone turnover and fracture. We conclude that higher levels of bone turnover are associated with greater hip bone loss in older men, but increased turnover is not independently associated with the risk of hip or nonspine fracture. [source] Antifracture Efficacy and Reduction of Mortality in Relation to Timing of the First Dose of Zoledronic Acid After Hip Fracture,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 7 2009Erik Fink Eriksen Abstract Annual infusions of zoledronic acid (5 mg) significantly reduced the risk of vertebral, hip, and nonvertebral fractures in a study of postmenopausal women with osteoporosis and significantly reduced clinical fractures and all-cause mortality in another study of women and men who had recently undergone surgical repair of hip fracture. In this analysis, we examined whether timing of the first infusion of zoledronic acid study drug after hip fracture repair influenced the antifracture efficacy and mortality benefit observed in the study. A total of 2127 patients (1065 on active treatment and 1062 on placebo; mean age, 75 yr; 76% women and 24% men) were administered zoledronic acid or placebo within 90 days after surgical repair of an osteoporotic hip fracture and annually thereafter, with a median follow-up time of 1.9 yr. Median time to first dose after the incident hip fracture surgery was ,6 wk. Posthoc analyses were performed by dividing the study population into 2-wk intervals (calculated from time of first infusion in relation to surgical repair) to examine effects on BMD, fracture, and mortality. Analysis by 2-wk intervals showed a significant total hip BMD response and a consistent reduction of overall clinical fractures and mortality in patients receiving the first dose 2-wk or later after surgical repair. Clinical fracture subgroups (vertebral, nonvertebral, and hip) were also reduced, albeit with more variation and 95% CIs crossing 1 at most time points. We concluded that administration of zoledronic acid to patients suffering a low-trauma hip fracture 2 wk or later after surgical repair increases hip BMD, induces significant reductions in the risk of subsequent clinical vertebral, nonvertebral, and hip fractures, and reduces mortality. [source] Risk Factors for Severity and Type of the Hip Fracture,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 5 2009Jane A Cauley Abstract More severe hip fractures such as displaced femoral neck (FN) fractures and unstable intertrochanteric (IT) fractures lead to poorer outcomes, but risk factors for severe fractures have not been studied. To identify risk factors for severe types of hip fracture, we performed a prospective cohort study and obtained preoperative hip radiographs from women who sustained an incident hip fracture (excluding traumatic fractures). A single radiologist scored the severity of FN fractures by the Garden System: grades I and II, undisplaced; grades III and IV, displaced. The severity of IT hip fractures was rated by the Kyle System: grades I and II, stable; grades III and IV, unstable. A total of 249 women had FN fractures: 75 (30%) were undisplaced. A total of 213 women had IT fractures: 59 (28%) were stable. Both types of hip fracture increased with age, but older age was even more strongly associated with more severe hip fractures. Low BMD was more strongly related to undisplaced FN fractures (p interaction BMD × FN type, p = 0.0008) and stable IT fractures (p interaction BMD × IT type, p = 0.04). Similar findings were observed for estimated volumetric BMD and hip geometric parameters. Corticosteroid use was only associated with displaced FN fractures, and Parkinson's disease was only associated with stable IT fractures. Little difference was reported in the self-reported circumstances surrounding each type of fracture. In conclusion, the lower the BMD, the greater the likelihood of experiencing a hip fracture that is less displaced and more stable. [source] Respiratory Function as a Marker of Bone Health and Fracture Risk in an Older Population,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 5 2009Alireza Moayyeri Abstract Identification of those at high risk of osteoporosis and fractures using clinically available tests beyond BMD measures is a major clinical challenge. We examined forced expiratory volume in 1 s (FEV1), an easily obtainable measure of respiratory function, as a clinical measure for fracture prediction. In the context of the European Prospective Investigation into Cancer-Norfolk Study, 8304 women and 6496 men 42,81 yr of age underwent a health check including spirometry and heel quantitative ultrasonography between 1997 and 2000 and were followed up for incident hip fractures until 2007. The main outcome measures were broadband ultrasound attenuation (BUA) of the heel (cross-sectional analysis) and hip fracture risk (prospective analysis). In multivariate regression models, a 1-liter increase in FEV1 was associated with a statistically significant 2.2-dB/MHz increase in BUA, independent of age, smoking, height, body mass index, history of fracture, and use of corticosteroids. Mean FEV1 was significantly lower among 84 women and 36 men with hip fracture compared with other participants. In multivariate proportional-hazard regression models, the relative risk (RR) of hip fracture associated with a 1-liter increase in FEV1 was 0.5 (95% CI, 0.3,0.9; p < 0.001) for both men and women. RR of hip fracture for a 1 SD increase in FEV1 was approximately equivalent to a 0.5 SD increase in BUA among women (1 SD among men) and an ,5-yr decrease in age among both men and women. Middle-aged and older people with low respiratory function are at increased risk of osteoporosis and hip fracture. FEV1, an easy, low-cost, and feasible clinical measure, may help improve the identification of high-risk groups. [source] Finite Element Analysis of the Proximal Femur and Hip Fracture Risk in Older Men,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 3 2009Eric S Orwoll Abstract Low areal BMD (aBMD) is associated with increased risk of hip fracture, but many hip fractures occur in persons without low aBMD. Finite element (FE) analysis of QCT scans provides a measure of hip strength. We studied the association of FE measures with risk of hip fracture in older men. A prospective case-cohort study of all first hip fractures (n = 40) and a random sample (n = 210) of nonfracture cases from 3549 community-dwelling men ,65 yr of age used baseline QCT scans of the hip (mean follow-up, 5.6 yr). Analyses included FE measures of strength and load-to-strength ratio and BMD by DXA. Hazard ratios (HRs) for hip fracture were estimated with proportional hazards regression. Both femoral strength (HR per SD change = 13.1; 95% CI: 3.9,43.5) and the load-to-strength ratio (HR = 4.0; 95% CI: 2.7,6.0) were strongly associated with hip fracture risk, as was aBMD as measured by DXA (HR = 5.1; 95% CI: 2.8,9.2). After adjusting for age, BMI, and study site, the associations remained significant (femoral strength HR = 6.5, 95% CI: 2.3,18.3; load-to-strength ratio HR = 4.3, 95% CI: 2.5,7.4; aBMD HR = 4.4, 95% CI: 2.1,9.1). When adjusted additionally for aBMD, the load-to-strength ratio remained significantly associated with fracture (HR = 3.1, 95% CI: 1.6,6.1). These results provide insight into hip fracture etiology and demonstrate the ability of FE-based biomechanical analysis of QCT scans to prospectively predict hip fractures in men. [source] Fracture Risk in Type 2 Diabetes: Update of a Population-Based Study,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 8 2008L Joseph Melton III Abstract We found no significant excess of fractures among Rochester, MN, residents with diabetes mellitus initially recognized in 1950,1969, but more recent studies elsewhere have documented an apparent increase in hip fracture risk. To explore potential explanations for any increase in fractures, we performed an historical cohort study among 1964 Rochester residents who first met glycemic criteria for diabetes in 1970,1994 (mean age, 61.7 ± 14.0 yr; 51% men). Fracture risk was estimated by standardized incidence ratios (SIRs), and risk factors were evaluated in Andersen-Gill time-to-fracture regression models. In 23,236 person-years of follow-up, 700 diabetic residents experienced 1369 fractures documented by medical record review. Overall fracture risk was elevated (SIR, 1.3; 95% CI, 1.2,1.4), but hip fractures were increased only in follow-up beyond 10 yr (SIR, 1.5; 95% CI, 1.1,1.9). As expected, fracture risk factors included age, prior fracture, secondary osteoporosis, and corticosteroid use, whereas higher physical activity and body mass index were protective. Additionally, fractures were increased among patients with neuropathy (hazard ratio [HR], 1.3; 95% CI, 1.1,1.6) and those on insulin (HR, 1.3; 95% CI, 1.1,1.5); risk was reduced among users of biquanides (HR, 0.7; 95% CI, 0.6,0.96), and no significant influence on fracture risk was seen with sulfonylurea or thiazolidinedione use. Thus, contrary to our earlier study, the risk of fractures overall (and hip fractures specifically) was increased among Rochester residents with diabetes, but there was no evidence that the rise was caused by greater levels of obesity or newer treatments for diabetes. [source] Physical Performance and Risk of Hip Fractures in Older Men,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 7 2008Peggy Mannen Cawthon Abstract The aim of these analyses was to describe the association between physical performance and risk of hip fractures in older men. Performance on five physical function exams (leg power, grip strength, usual walking pace, narrow walk balance test, and five repeated chair stands) was assessed in 5902 men ,65 yr of age. Performance (time to complete or strength) was analyzed as quartiles, with an additional category for unable to complete the measure, in proportional hazards models. Follow-up averaged 5.3 yr; 77 incident hip fractures were confirmed by physician review of radiology reports. Poor physical performance was associated with an increased risk of hip fracture. In particular, repeated chair stand performance was strongly related to hip fracture risk. Men unable to complete this exam were much more likely to experience a hip fracture than men in the fastest quartile of this test (multivariate hazard ratio [MHR]: 8.15; 95% CI: 2.65, 25.03). Men with the worst performance (weakest/slowest quartile or unable) on at least three exams had an increased risk of hip fracture compared with men with higher functioning (MHR: 3.14, 95% CI: 1.46, 6.73). Nearly two thirds of the hip fractures (N = 49, 64%) occurred in men with poor performance on at least three exams. Poor physical function is independently associated with an increased risk of hip fracture in older men. The repeated chair stands exam should be considered in clinical settings for evaluation of hip fracture risk. Concurrent poor performance on multiple physical function exams is associated with an increased risk of hip fractures. [source] Assessment of the 10-Year Probability of Osteoporotic Hip Fracture Combining Clinical Risk Factors and Heel Bone Ultrasound: The EPISEM Prospective Cohort of 12,958 Elderly Women,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 7 2008Didier Hans Abstract This study aimed to develop a hip screening tool that combines relevant clinical risk factors (CRFs) and quantitative ultrasound (QUS) at the heel to determine the 10-yr probability of hip fractures in elderly women. The EPISEM database, comprised of ,13,000 women ,70 yr of age, was derived from two population-based white European cohorts in France and Switzerland. All women had baseline data on CRFs and a baseline measurement of the stiffness index (SI) derived from QUS at the heel. Women were followed prospectively to identify incident fractures. Multivariate analysis was performed to determine the CRFs that contributed significantly to hip fracture risk, and these were used to generate a CRF score. Gradients of risk (GR; RR/SD change) and areas under receiver operating characteristic curves (AUC) were calculated for the CRF score, SI, and a score combining both. The 10-yr probability of hip fracture was computed for the combined model. Three hundred seven hip fractures were observed over a mean follow-up of 3.2 yr. In addition to SI, significant CRFs for hip fracture were body mass index (BMI), history of fracture, an impaired chair test, history of a recent fall, current cigarette smoking, and diabetes mellitus. The average GR for hip fracture was 2.10 per SD with the combined SI + CRF score compared with a GR of 1.77 with SI alone and of 1.52 with the CRF score alone. Thus, the use of CRFs enhanced the predictive value of SI alone. For example, in a woman 80 yr of age, the presence of two to four CRFs increased the probability of hip fracture from 16.9% to 26.6% and from 52.6% to 70.5% for SI Z-scores of +2 and ,3, respectively. The combined use of CRFs and QUS SI is a promising tool to assess hip fracture probability in elderly women, especially when access to DXA is limited. [source] Femoral Neck BMD Is a Strong Predictor of Hip Fracture Susceptibility in Elderly Men and Women Because It Detects Cortical Bone Instability: The Rotterdam Study,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 11 2007Fernando Rivadeneira Abstract We studied HSA measurements in relation to hip fracture risk in 4806 individuals (2740 women). Hip fractures (n = 147) occurred at the same absolute levels of bone instability in both sexes. Cortical instability (propensity of thinner cortices in wide diameters to buckle) explains why hip fracture risk at different BMD levels is the same across sexes. Introduction: Despite the sexual dimorphism of bone, hip fracture risk is very similar in men and women at the same absolute BMD. We aimed to elucidate the main structural properties of bone that underlie the measured BMD and that ultimately determines the risk of hip fracture in elderly men and women. Materials and Methods: This study is part of the Rotterdam Study (a large prospective population-based cohort) and included 147 incident hip fracture cases in 4806 participants with DXA-derived hip structural analysis (mean follow-up, 8.6 yr). Indices compared in relation to fracture included neck width, cortical thickness, section modulus (an index of bending strength), and buckling ratio (an index of cortical bone instability). We used a mathematical model to calculate the hip fracture distribution by femoral neck BMD, BMC, bone area, and hip structure analysis (HSA) parameters (cortical thickness, section modulus narrow neck width, and buckling ratio) and compared it with prospective data from the Rotterdam Study. Results: In the prospective data, hip fracture cases in both sexes had lower BMD, thinner cortices, greater bone width, lower strength, and higher instability at baseline. In fractured individuals, men had an average BMD that was 0.09 g/cm2 higher than women (p < 0.00001), whereas no significant difference in buckling ratios was seen. Modeled fracture distribution by BMD and buckling ratio levels were in concordance to the prospective data and showed that hip fractures seem to occur at the same absolute levels of bone instability (buckling ratio) in both men and women. No significant differences were observed between the areas under the ROC curves of BMD (0.8146 in women and 0.8048 in men) and the buckling ratio (0.8161 in women and 0.7759 in men). Conclusions: The buckling ratio (an index of bone instability) portrays in both sexes the critical balance between cortical thickness and bone width. Our findings suggest that extreme thinning of cortices in expanded bones plays a key role on local susceptibility to fracture. Even though the buckling ratio does not offer additional predictive value, these findings improve our understanding of why low BMD is a good predictor of fragility fractures. [source] | |||||||||||||||||||||||||