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Geriatr Gerontol Int 2016; 16: 35 2–357
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Prevalence and burden of vertebral fractures in older men and women with hip fracture: A cross-sectional study Marco Di Monaco,1 Carlotta Castiglioni,1 Roberto Di Monaco2 and Rosa Tappero1 1 Osteoporosis Research Center, Division of Physical and Rehabilitation Medicine, Presidio Sanitario San Camillo, Fondazione Opera San Camillo, and 2Department of Culture, Politics, and Society, University, Torino, Italy
Aim: To investigate the prevalence and burden (combination of number and severity) of vertebral fractures in men and women with hip fracture. Methods: We investigated 458 of 490 hip-fracture patients admitted consecutively to a rehabilitation hospital. Lateral radiographs of the spine were taken 19.2 ± 5.5 days (mean ± SD) after hip-fracture occurrence. To obtain a summary measure of vertebral fracture burden, we calculated the spinal deformity index (SDI) by summing the fracture grades assessed using Genant’s method of all vertebrae (T4 to L4). Results: The median SDI score was 2 in both the 411 women and the 47 men (interquartile range 0–4 in both groups), and no significant between-sex differences were found (P = 0.52). A total of 69% of the women (95% CI 65–74%), and 60% of the men (95% CI 45–74%) had at least one mild vertebral fracture (SDI score ≥1), 41% of the women (95% CI 36–46%) and 38% of the men (95% CI 24–53%) had a SDI score ≥3, whereas 16% of the women (95% CI 12% 19%) and 17% of the men (95%CI 6−28%) had at least one severe vertebral fracture. Sex was not significantly associated with a SDI score ≥1, or ≥3 or with the presence of at least one severe vertebral fracture after adjustment for age, hip-fracture type, cognitive impairment, pressure ulcers, neurological impairment, comorbidities, number of medications in use and Barthel index scores. Conclusions: The prevalence of vertebral fractures was high after hip fracture in both men and women. We found no significant between-sex differences in the prevalence and burden of vertebral fractures. Geriatr Gerontol Int 2015; 16: 352–357. Keywords: hip fracture, osteoporosis, sex, spine, vertebral fracture.
Introduction Accepted for publication 31 January 2015. Correspondence: Dr Marco Di Monaco MD, Osteoporosis Research Center, Division of Physical and Rehabilitation Medicine, Presidio Sanitario San Camillo, Strada Santa Margherita 136, 10131, Torino, Italy. Email [email protected]; [email protected] Marco Di Monaco conceived the first idea of the study and planned it. He interpreted data, and wrote the first draft of the manuscript and its final version. Carlotta Castiglioni co-conceived the idea of the study. She was implicated with the management of the patients and collected clinical data. She helped to write the first draft of the manuscript. Roberto Di Monaco contributed to planning and carrying out the study. He was the statistical advisor. Rosa Tappero contributed to collecting clinical data. She commented on the first draft of the manuscript and on the successive versions. She contributed to writing the final paper. All the authors approvedthe final version of the manuscript.
352 |
doi: 10.1111/ggi.12479
Osteoporosis is characterized by low bone mass, deterioration of bone tissue, disruption of bone architecture and compromised bone strength.1–3 Fragility fractures result when weakened bone is overloaded, often by falls or certain activities of daily living.1–3 The most relevant fragility fractures are those of the vertebrae (spine) and proximal femur (hip), given both their high incidence rate and their devastating consequences, including excess mortality and permanent restriction in activity and participation.4–8 The presence of one fragility fracture is a major risk factor for future fractures, because osteoporosis is a systemic condition of the skeleton, and the first osteoporosis-related fracture is the hallmark of the disease.9–11 Furthermore, sarcopenia and falls are strictly associated with osteoporosis, and falls often © 2015 Japan Geriatrics Society
. patients Spine fractures in hip-fracture
recur in the same subject, thus contributing to increasing the individual risk of new fractures after the first one.12–16 Several prospective studies have consistently shown that previous vertebral fractures enhance the risk of subsequent hip fractures, and the proportion of hip-fracture women with at least one prevalent spine fracture is high, ranging from 55% to 74%, as shown by the few cross-sectional studies that addressed this issue.17–22 Although osteoporosis is often considered a women’s disease, between 30 and 40% of fragility fractures occur in men, and the lifetime risk of fracture for men aged 50 years or older is between 13 and 30%.23 Furthermore, the clinical consequences of the most relevant fragility fractures are worse in men than in women, with higher mortality rates, higher morbidity and lower functional recovery.23–27 Despite high incidence rates and severe outcomes, fragility fractures in men are often overlooked, and the vast majority of the available epidemiological data regards women. In particular, the prevalence of vertebral fractures in men with hip fracture has scarcely been investigated. Our aim was to investigate the prevalence and burden of vertebral fractures in patients with hip fracture, comparing women and men. We hypothesized that the number and severity of prevalent spine fractures could be similar in hip-fracture women and men.
Methods Patients We evaluated 490 white patients with hip fracture admitted consecutively to our Physical Medicine and Rehabilitation division during a 26-month period. We focused on white patients because few non-white, elderly people live in our country. All the patients were referred for acute inpatient rehabilitation by the consultant physiatrists of the orthopedic wards. The criteria agreed on for selecting patients with hip fractures to undergo acute inpatient rehabilitation were as follows: (i) health conditions allowing a total of 3 h of physical therapy and/or occupational therapy daily; (ii) weightbearing to tolerance on the fractured hip; and (iii) a potential high increase in ability to function in activities of daily living as a result of an intensive rehabilitation regimen. A total of 26 of the 490 patients were excluded from the study, because their hip fracture was caused by either major trauma or cancer affecting the bone. All the 464 remaining patients suffered from fractures that either were spontaneous or caused by minimal trauma (trauma equal to or less than a fall from a standing position). Six of these patients were excluded from the study, because they either refused to undergo X-ray assessment or suffered from acute concomitant diseases. The final study sample included 458 patients who © 2015 Japan Geriatrics Society
gave their written informed consent to participate in the study. Institutional review board approval was obtained for the study protocol.
Outcome measures Lateral radiographs of the spine were taken 19.2 ± 5.5 days (mean ± SD) after fracture occurrence. The presence of spinal fractures and their grade were recorded independently by a single radiologist and a single physician skilled in metabolic bone diseases. In cases of divergent opinions, consensus was reached by discussion. For each vertebra, the extent of fracture deformation was graded by the semi-quantitative method presented by Genant et al.: normal (grade 0), mildly deformed (grade 1, 20–25% reduction in anterior, middle and/or posterior height), moderately deformed (grade 2, 25–40% reduction in any height) and severely deformed (grade 3, 40% or greater reduction in any height).28 To obtain a summary measure of the vertebral fracture status of the spine, we calculated the spinal deformity index (SDI) by summing the fracture grades of all vertebrae (T4 to L4).29 In each patient we recorded nine further variables: age, hip fracture type (cervical or trochanteric by radiographic and surgical findings), cognitive impairment (Mini-Mental State Examination
Geriatr Gerontol Int 2016; 16: 35 2–357
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Prevalence and burden of vertebral fractures in older men and women with hip fracture: A cross-sectional study Marco Di Monaco,1 Carlotta Castiglioni,1 Roberto Di Monaco2 and Rosa Tappero1 1 Osteoporosis Research Center, Division of Physical and Rehabilitation Medicine, Presidio Sanitario San Camillo, Fondazione Opera San Camillo, and 2Department of Culture, Politics, and Society, University, Torino, Italy
Aim: To investigate the prevalence and burden (combination of number and severity) of vertebral fractures in men and women with hip fracture. Methods: We investigated 458 of 490 hip-fracture patients admitted consecutively to a rehabilitation hospital. Lateral radiographs of the spine were taken 19.2 ± 5.5 days (mean ± SD) after hip-fracture occurrence. To obtain a summary measure of vertebral fracture burden, we calculated the spinal deformity index (SDI) by summing the fracture grades assessed using Genant’s method of all vertebrae (T4 to L4). Results: The median SDI score was 2 in both the 411 women and the 47 men (interquartile range 0–4 in both groups), and no significant between-sex differences were found (P = 0.52). A total of 69% of the women (95% CI 65–74%), and 60% of the men (95% CI 45–74%) had at least one mild vertebral fracture (SDI score ≥1), 41% of the women (95% CI 36–46%) and 38% of the men (95% CI 24–53%) had a SDI score ≥3, whereas 16% of the women (95% CI 12% 19%) and 17% of the men (95%CI 6−28%) had at least one severe vertebral fracture. Sex was not significantly associated with a SDI score ≥1, or ≥3 or with the presence of at least one severe vertebral fracture after adjustment for age, hip-fracture type, cognitive impairment, pressure ulcers, neurological impairment, comorbidities, number of medications in use and Barthel index scores. Conclusions: The prevalence of vertebral fractures was high after hip fracture in both men and women. We found no significant between-sex differences in the prevalence and burden of vertebral fractures. Geriatr Gerontol Int 2015; 16: 352–357. Keywords: hip fracture, osteoporosis, sex, spine, vertebral fracture.
Introduction Accepted for publication 31 January 2015. Correspondence: Dr Marco Di Monaco MD, Osteoporosis Research Center, Division of Physical and Rehabilitation Medicine, Presidio Sanitario San Camillo, Strada Santa Margherita 136, 10131, Torino, Italy. Email [email protected]; [email protected] Marco Di Monaco conceived the first idea of the study and planned it. He interpreted data, and wrote the first draft of the manuscript and its final version. Carlotta Castiglioni co-conceived the idea of the study. She was implicated with the management of the patients and collected clinical data. She helped to write the first draft of the manuscript. Roberto Di Monaco contributed to planning and carrying out the study. He was the statistical advisor. Rosa Tappero contributed to collecting clinical data. She commented on the first draft of the manuscript and on the successive versions. She contributed to writing the final paper. All the authors approvedthe final version of the manuscript.
352 |
doi: 10.1111/ggi.12479
Osteoporosis is characterized by low bone mass, deterioration of bone tissue, disruption of bone architecture and compromised bone strength.1–3 Fragility fractures result when weakened bone is overloaded, often by falls or certain activities of daily living.1–3 The most relevant fragility fractures are those of the vertebrae (spine) and proximal femur (hip), given both their high incidence rate and their devastating consequences, including excess mortality and permanent restriction in activity and participation.4–8 The presence of one fragility fracture is a major risk factor for future fractures, because osteoporosis is a systemic condition of the skeleton, and the first osteoporosis-related fracture is the hallmark of the disease.9–11 Furthermore, sarcopenia and falls are strictly associated with osteoporosis, and falls often © 2015 Japan Geriatrics Society
. patients Spine fractures in hip-fracture
recur in the same subject, thus contributing to increasing the individual risk of new fractures after the first one.12–16 Several prospective studies have consistently shown that previous vertebral fractures enhance the risk of subsequent hip fractures, and the proportion of hip-fracture women with at least one prevalent spine fracture is high, ranging from 55% to 74%, as shown by the few cross-sectional studies that addressed this issue.17–22 Although osteoporosis is often considered a women’s disease, between 30 and 40% of fragility fractures occur in men, and the lifetime risk of fracture for men aged 50 years or older is between 13 and 30%.23 Furthermore, the clinical consequences of the most relevant fragility fractures are worse in men than in women, with higher mortality rates, higher morbidity and lower functional recovery.23–27 Despite high incidence rates and severe outcomes, fragility fractures in men are often overlooked, and the vast majority of the available epidemiological data regards women. In particular, the prevalence of vertebral fractures in men with hip fracture has scarcely been investigated. Our aim was to investigate the prevalence and burden of vertebral fractures in patients with hip fracture, comparing women and men. We hypothesized that the number and severity of prevalent spine fractures could be similar in hip-fracture women and men.
Methods Patients We evaluated 490 white patients with hip fracture admitted consecutively to our Physical Medicine and Rehabilitation division during a 26-month period. We focused on white patients because few non-white, elderly people live in our country. All the patients were referred for acute inpatient rehabilitation by the consultant physiatrists of the orthopedic wards. The criteria agreed on for selecting patients with hip fractures to undergo acute inpatient rehabilitation were as follows: (i) health conditions allowing a total of 3 h of physical therapy and/or occupational therapy daily; (ii) weightbearing to tolerance on the fractured hip; and (iii) a potential high increase in ability to function in activities of daily living as a result of an intensive rehabilitation regimen. A total of 26 of the 490 patients were excluded from the study, because their hip fracture was caused by either major trauma or cancer affecting the bone. All the 464 remaining patients suffered from fractures that either were spontaneous or caused by minimal trauma (trauma equal to or less than a fall from a standing position). Six of these patients were excluded from the study, because they either refused to undergo X-ray assessment or suffered from acute concomitant diseases. The final study sample included 458 patients who © 2015 Japan Geriatrics Society
gave their written informed consent to participate in the study. Institutional review board approval was obtained for the study protocol.
Outcome measures Lateral radiographs of the spine were taken 19.2 ± 5.5 days (mean ± SD) after fracture occurrence. The presence of spinal fractures and their grade were recorded independently by a single radiologist and a single physician skilled in metabolic bone diseases. In cases of divergent opinions, consensus was reached by discussion. For each vertebra, the extent of fracture deformation was graded by the semi-quantitative method presented by Genant et al.: normal (grade 0), mildly deformed (grade 1, 20–25% reduction in anterior, middle and/or posterior height), moderately deformed (grade 2, 25–40% reduction in any height) and severely deformed (grade 3, 40% or greater reduction in any height).28 To obtain a summary measure of the vertebral fracture status of the spine, we calculated the spinal deformity index (SDI) by summing the fracture grades of all vertebrae (T4 to L4).29 In each patient we recorded nine further variables: age, hip fracture type (cervical or trochanteric by radiographic and surgical findings), cognitive impairment (Mini-Mental State Examination
