Vertebral fractures are the most common osteoporotic fracture, and patients with prevalent vertebral fractures have a greater risk of future fractures. However, radiographically determined vertebral fractures are not identified as a distinct risk factor in the World Health Organization (WHO) fracture risk assessment tool. The objective of this study [1] was to evaluate and compare potential risk factors including morphometric spine fracture status and the WHO risk factors for predicting 5-y fracture risk. It was hypothesized that spine fracture status provides prognostic information in addition to consideration of the WHO risk factors alone. A randomly selected, population-based community cohort of 2761 noninstitutionalized men and women > 50 y of age living within 50 km of one of nine regional centers was enrolled in the Canadian Multicentre Osteoporosis Study (CaMOS), a prospective and longitudinal cohort study following subjects for 5 y. Prevalent and incident spine fractures were identified from lateral spine radiographs. Incident nonvertebral fragility fractures were determined by an annual, mailed fracture questionnaire with validation, and nonvertebral fragility fracture was defined by investigators as a fracture with minimal trauma.A model considering the WHO risk factors plus spine fracture status provided greater prognostic information regarding future fracture risk than a model considering the WHO risk factors alone. In univariate analyses, age, BMD, and spine fracture status had the highest gradient of risk. A model considering these three risk factors captured almost all of the predictive information provided by a model considering spine fracture status plus the WHO risk factors and provided greater predictive information than a model considering the WHO risk factors alone.
The use of spine fracture status along with age and BMD predicted future fracture risk with greater simplicity and higher prognostic accuracy than consideration of the risk factors included in the WHO tool.

1. Chen P et al. J Bone Miner Res. 2009; 24: 495–502.

Vertebroplasty is commonly used to treat painful, osteoporotic vertebral compression fractures. Two recent studies [1,2] evaluated the efficiency of this procedure. In a multicenter trial [1], the authors randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement (control group). The primary outcomes were scores on the modified Roland–Morris Disability Questionnaire (RDQ) (on a scale of 0 to 23, with higher scores indicating greater disability) and patients’ ratings of average pain intensity during the preceding 24 hours at 1 month (on a scale of 0 to 10, with higher scores indicating more severe pain). Patients were allowed to cross over to the other study group after 1 month.

All patients underwent the assigned intervention (68 vertebroplasties and 63 simulated procedures). The baseline characteristics were similar in the two groups. At 1 month, there was no significant difference between the vertebroplasty group and the control group in either the RDQ score or the pain rating. Both groups had immediate improvement in disability and pain scores after the intervention. Although the two groups did not differ significantly on any secondary outcome measure at 1 month, there was a trend toward a higher rate of clinically meaningful improvement in pain (a 30% decrease from baseline) in the vertebroplasty group (64% vs. 48%, P=0.06). At 3 months, there was a higher crossover rate in the control group than in the vertebroplasty group (43% vs 12%, P<0.001). There was one serious adverse event in each group.

The second study [2] was also a multicenter, randomized, double-blind, placebo-controlled trial in which 78 participants with one or two painful osteoporotic vertebral fractures that were of less than 12 months’ duration and unhealed, as confirmed by magnetic resonance imaging, were randomly assigned to undergo vertebroplasty or a sham procedure. Similar improvements were seen in both groups with respect to pain at night and at rest, physical functioning, quality of life, and perceived improvement.

In conclusion, improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group. These studies found no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures, up to 6 months after treatment.

1. Kallmes DF et al. N Engl J Med. 2009; 361:569-579.
2. Buchbinder R et al. N Engl J Med. 2009; 361:557-568.

Smoking is associated with lower areal bone mineral density and higher fracture risk, although most evidence has been derived from studies in elderly subjects. This study [1] investigates smoking habits in relation to areal and volumetric bone parameters and fracture prevalence in young, healthy males at peak bone mass. Healthy male siblings (n=677) at the age of peak bone mass (25 to 45 years) were recruited in a cross-sectional population-based study. Trabecular and cortical bone parameters of the radius and cortical bone parameters of the tibia were assessed using peripheral quantitative computed tomography (pQCT). Areal bone mass was determined using dual energy X-ray absorptiometry (DXA). Sex steroids and bone markers were determined using immunoassays. Prevalent fractures and smoking habits were assessed using questionnaires.

Self-reported fractures were more prevalent in the current and early smokers than in the never smokers (P<.05), with a fracture prevalence odds ratio for early smokers of 1.96 after adjustment for age, weight, educational level, and alcohol use and exclusion of childhood fractures. Current smoking was associated with a significantly larger endosteal circumference and a decreased cortical thickness at the tibia.
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Fragility fractures cause significant morbidity and mortality. Effective osteoporosis treatment can reduce fracture incidence, but it is not clear whether it reduces mortality. The aim of this meta-analysis study [1] was to determine whether effective osteoporosis treatment reduces mortality. The authors searched Medline and the Cochrane Central Register of Trials prior to September 2008, as well as 2000–2008 American Society for Bone and Mineral Research conference abstracts. Eligible studies were randomized placebo-controlled trials of approved doses of medications with proven efficacy in preventing both vertebral and nonvertebral fractures, in which the study duration was longer than 12 months and there were more than 10 deaths. Trials of estrogen and selective estrogen receptor modulators were specifically excluded. Data were extracted from the text of the retrieved articles, published meta-analyses, or the Food and Drug Administration web site.

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The objective of this study [1] was to develop and validate two new fracture risk algorithms (QFractureScores) for estimating the individual risk of osteoporotic fracture or hip fracture over 10 years. For this purpose, the authors used a prospective open cohort study with routinely collected data from 357 general practices to develop the scores and from 178 practices to validate the scores, in England and Wales. Participants were 1 183 663 women and 1 174 232 men aged 30 to 85 in the derivation cohort, who contributed 7 898 208 and 8 049 306 person years of observation, respectively. There were 24 350 incident diagnoses of osteoporotic fracture in women and 7934 in men, and 9302 incident diagnoses of hip fracture in women and 5424 in men. The main outcome measures were first (incident) diagnosis of osteoporotic fracture (vertebral, distal radius, or hip) and incident hip fracture recorded in general practice records.

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Poor vitamin D status is common in the elderly and is associated with bone loss and fractures. The aim of this study [1] was to assess worldwide vitamin D status in postmenopausal women with osteoporosis according to latitude and economic status, in relation to parathyroid function, bone turnover markers, and BMD. The study was performed in 7441 postmenopausal women from 29 countries participating in a clinical trial, with BMD T-score at the femoral neck or lumbar spine < -2.5 or one to five mild or moderate vertebral fractures. Serum 25(OH)D, PTH, alkaline phosphatase (ALP), bone turnover markers osteocalcin (OC) and C-terminal cross-linked telopeptides of type I collagen (CTX), and BMD of the lumbar spine, total hip, femoral neck, and trochanter were measured.

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The B cell lymphoma 2 (Bcl-2) family member Bcl-xL has a well-characterized antiapoptotic function in lymphoid cells. However, its functions in other cells - including osteoclasts, which are of hematopoietic origin - and other cellular processes remain unknown. The authors of a recent study [1] report an unexpected function of Bcl-xL in attenuating the bone-resorbing activity of osteoclasts in mice. To investigate the role of Bcl-xL in osteoclasts, they generated mice with osteoclast-specific conditional deletion of Bcl-x.

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Childhood fractures are common. Their clinical relevance to osteoporosis and fractures in later life is unclear. The aim of this study [1] was to determine the predictive risk of childhood fracture on the risk of fracture in later life. Men and women >50 y of age were recruited from population registers for participation in the European Prospective Osteoporosis Study (EPOS). Subjects completed an interviewer-administered questionnaire that included questions about previous fractures and the age at which the first of these fractures occurred. Lateral spine radiographs were performed to ascertain prevalent vertebral deformities. Subjects were followed prospectively by postal questionnaire to determine the occurrence of clinical fractures. A subsample of subjects had BMD measurements performed. A cox proportional hazards model was used to determine the predictive risk of childhood fracture between the ages of 8 and 18 y on the risk of future limb fracture and logistic regression was used to determine the association between reported childhood fractures and prevalent vertebral deformity.

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Bone mineral density is known to decrease rapidly after the menopause. There is limited evidence about the separate contributions of a woman’s age, menopausal status and age at menopause to the incidence of hip fracture. Over one million middle-aged women joined the UK Million Women Study in 1996–2001 providing information on their menopausal status, age at menopause, and other factors, which was updated, where possible, 3 y later. All women were registered with the UK National Health Service (NHS) and were routinely linked to information on cause-specific admissions to NHS hospitals. 561,609 women who had never used hormone replacement therapy and who provided complete information on menopausal variables (at baseline 25% were pre/perimenopausal and 75% postmenopausal) were followed up for a total of 3.4 million woman-years (an average 6.2 y per woman).

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Osteoporosis in men is an increasingly important concern and, compared with women, the pathophysiology of bone loss and fragility fractures in men is less well studied. Although sex hormones, cytokines, and other biological determinants likely play an important role, it is probable that these factors impact the male skeleton at least in part by their effects on bone turnover. In a recent study [1], the authors 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.

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