In Brazil number of hip fractures expected to increase 32 percent by 2050

A new Audit report on fragility fractures, issued today by the International Osteoporosis Foundation (IOF), predicts that Brazil will experience an explosion in the number of fragility fractures due to osteoporosis in the coming decades.

Osteoporosis, a disease which weakens bones and makes them more likely to fracture, is thought to affect around 33% of postmenopausal women in Brazil. Fractures due to osteoporosis mostly affect older adults, with fractures at the spine and hip causing the most suffering, disability and healthcare expenditure.
Currently, about 20% of Brazil's population is 50 years of age or over and 4.3% is aged 70 or over. With average life expectancy projected to rise to 80 years in 2050, it is estimated that the total population will increase to 260 million. Around 37% will then be over 50 years of age, and 14% (around 36 million people) aged 70 years or over.
These projections serve as a dire warning to health authorities as well as to social institutions which care for the aged. In Brazil, around 153 to 343 hip fractures occur among every 100,000 people aged 50 and over. While today there are an estimated 121, 700 annual hip fractures, these numbers are predicted to increase by 16% in 2020, and by 32% in 2050.
Hip fractures are a major cause of suffering, disability, and early death in seniors. Various international studies show that around 20% of hip fracture sufferers will die within the year of fracture, but one study examining patients in various hospitals in Rio de Janeiro showed that as many as 35% died either in hospital or soon after discharge. Surviving hip fracture patients often remain disabled, and lose the inability to live productive and independent lives, thus becoming a burden on family or transferring to institutional care.
Dr. Bruno Muzzi Camargos, President of the Associação Brasileira da Avaliação da Saúde Óssea e Osteometabolismo (ABrASSO), stated, "Given the future projections, osteoporosis and fragility fractures have become a health issue of immediate concern. We must implement nation-wide measures for early prevention, while ensuring that people at risk –and especially people who have already suffered a fracture – are appropriately diagnosed and treated to prevent future fractures. This is the only way that we can slow the rising tide of costly fractures. "
The 'Latin America Audit: Epidemiology, Costs, and Burden of Osteoporosis 2012' was prepared by IOF in cooperation with IOF member societies . It includes data from 14 countries throughout Latin America, and reveals the following key findings in Brazil:

• A 2010 study of more than 4,300 women aged 50 and over found that 11.5% had sustained some kind of osteoporotic fracture and that 33% were osteoporotic.
• An estimated 2.9 million Brazilian women over the age of 50 may be living with vertebral fractures, mostly undiagnosed and untreated. Vertebral fractures cause pain and disability, often resulting in a stooped back.
• Vitamin D, made in the skin upon exposure to sunlight, is essential for bone and muscle strength. Yet despite Brazil's sunny climate, vitamin D deficiency is widespread throughout the population. In a recent study 60% of the healthy adolescent participants did not have adequate amounts of vitamin D.
• The cost of treating fractures is enormous and growing. The approximate direct cost of treating a hip fracture in Brazil ranges from 3900 to 12,000 USD in private hospitals, with an average 11 days spent in hospital. This does not include the indirect costs associated with post-fracture care, rehabilitation, loss of productivity and long-term need for nursing assistance.
• As in other countries around the world, there is a widespread problem of under diagnosis and under-treatment, even after fracture. A fragility fracture indicates a high risk of further fractures and should immediately trigger an assessment for osteoporosis. However, one study showed that, of 123 hospitalized hip fracture sufferers, not a single patient was discharged from the hospital with a referral for bone density testing or osteoporosis treatment.
• The urban- rural divide is reflected in both incidence of fractures and in accessibility to diagnosis and treatment. There is a higher incidence of fractures among women living in cities than in rural areas. On the other hand, people living in rural areas often have no access to bone densitometry for diagnostic testing.

On the positive side, Brazil is one of the few Latin American countries which has declared osteoporosis as a national health priority. Professor Christiano Zerbini, IOF Board Member and Director of the Paulista Clinical Research Center in Sao Paulo, commented, "Brazilian researchers and health professionals are working to find answers to the problem of osteoporosis and related musculoskeletal diseases. For example, an important new multicentre prospective study, BRAVOS (Brazilian Vertebral Osteoporosis Study), will gather much-needed epidemiological data from six research centres across the country. We hope this data will lead to the development of a WHO Fracture Risk Assessment model (FRAX) for Brazil – a tool to facilitate the identification of people at high risk of fracture. Among other necessary steps, this would be an important achievement in our efforts to reduce the burden of future fractures." The authors of the Audit report call for more public awareness campaigns, osteoporosis training programmes for doctors, better accessibility to low cost testing and treatment, and more epidemiological research.
IOF President John A. Kanis stated, "IOF joins concerned Brazilian doctors and patient societies to call for the channelling of health care resources towards the prevention and care of age-related musculoskeletal diseases and fragility fractures. This is an important investment in Brazil's future."
More information: Information about the Latin American Audit is available in English, Portuguese and Spanish at http://www.osteopo … namerica.com
The report can also be downloaded from the IOF website at http://www.iofbone … ional-audits
Provided by International Osteoporosis Foundation

99-year-old woman regains mobility following spinal procedures

Scans of Elizabeth DiGennaro's spine show the compression fracture, above, and the results, below, after doctors at University of Rochester Medical Center performed kyphoplasty to repair the bone.

27 dec 2011-- A 99-year-old woman has returned to her daily routine after doctors repaired three separate compression fractures in her spine three times in a month. Specialists at the University of Rochester Medical Center repaired the brittle vertebra using bone glue while the patient was under sedation, which is easier for elderly patients.

Elizabeth DiGennaro of Scottsville is the oldest person to undergo the procedure at URMC exemplifying doctors’ commitment to providing comprehensive care for the fast-growing elderly population. She believes the injury occurred during routine chores that may have been too much for her aging, osteoporotic bones.

She will celebrate her 100th birthday Jan. 3.

“Looking at the scans, you can see that bone had crumbled into pieces,” said Per-Lennart Westesson, M.D., D.D.S., Ph.D., a neuroradiologist who collaborated with Orthopedic surgeon Susan V. Bukata, M.D., and Freda B. Hannafon, FNP-C,MSN, of The Center for Bone Health, to care for DiGennaro.

After several weeks of being bedridden with back pain, DiGennaro’s family worried that she would never recover. They sought help from Bukata, who suggested balloon kyphoplasty. The procedure involves injecting bone cement directly into the compression fracture and using balloons to shift the vertebrae back into place to relieve pain and hasten healing.

This procedure has been used for decades by doctors in Orthopedics, Neurosurgery and Interventional Radiology. Bukata recognized that traditional surgery under general anesthesia may not be best for DiGennaro, because it can elevate a risk of stroke in elderly patients. Bukata suggested Westesson perform kyphoplasty using sedation in an interventional radiology suite, rather than an operating room.

“This was a better option for Mrs. DiGennaro and other elderly patients who suffer these types of injuries,” said Westesson, professor of Imaging Sciences.

The near-centenarian has always been an active, strong-willed woman, according to her daughter, Barbara Galbraith. And the spinal fracture was very painful and the medications to control the pain made her confused and exhausted, and as a result, she was bedridden

“We were really worried that she’d never be able to enjoy her life again,” Galbraith said. “That was no way for her to live.”

“The pain went away immediately and she was back to her normal self again. Two days later she was in pain again, and it was a break, but not the same place. And then there was a third one. Each time we went back and had the second and third procedures she did really well.”

DiGennaro had the first surgery on Sept. 30, followed by a second on Oct. 12, and the third on Nov. 23. Each procedure was a success; the pain was gone and she was able to resume her normal life.

URMC doctors perform more than 100 kyphoplasty procedures each year, providing much needed relief for aging adults with compression fractures.

“This is something we’ll do more and more often with sedation as we see the baby boomer generation age further,” Westesson said.

Provided by University of Rochester Medical Center

Calcium With or Without Vitamin D May Help Prevent Osteoporosis

August 28, 2007 — Calcium, or calcium in combination with vitamin D, may prevent osteoporosis in people aged 50 years and older, according to the results of a systematic review and meta-analysis in the August 25 issue of The Lancet.
"Calcium alone, or in combination with vitamin D, has been suggested as an inexpensive treatment to prevent osteoporotic bone loss and fractures, costing as little as €0.41 per day in one European study," write Benjamin M.P. Tang, MD, from the University of Western Sydney in New South Wales, Australia, and colleagues. "However, there has been substantial uncertainty about its efficacy in lowering the fracture rate.... We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss."
Using electronic databases, as well as a hand-search of reference lists, review articles, and conference abstracts, the study authors identified 29 randomized trials enrolling a total of 63,897 subjects. Average duration of treatment with calcium, or calcium in combination with vitamin D, was 3.5 years.
Eligibility criteria were randomized design and recruitment of people aged 50 years or older. Primary endpoints were all types of fractures and the percentage change of bone mineral density (BMD) from baseline. A random-effect model allowed pooling of data.
There were 17 trials that reported fracture as an outcome, enrolling a total of 52,625 subjects. In these trials, treatment with calcium, or calcium in combination with vitamin D, was associated with a 12% risk reduction in fractures of all types (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.83 - 0.95; P = .0004).
There were 23 trials, enrolling a total of 41,419 subjects, that reported BMD as an outcome. In these trials, treatment was associated with a decrease in the rate of bone loss of 0.54% (95% CI, 0.35 - 0.73; P < .0001) at the hip and 1.19% (95% CI, 0.76 - 1.61%; P < .0001) at the spine.
In trials with high rates of compliance, the reduction in the risk for fractures was significantly greater (24%; P < .0001). Calcium doses of 1200 mg or more were associated with a greater treatment effect than were doses of less than 1200 mg (0.80 vs 0.94; P = .006), and vitamin D doses of 800 IU or more were associated with a greater treatment effect than were doses of less than 800 IU (0.84 vs 0.87; P = .03).
Subjects who were elderly, lived in institutions, had a low body weight and low calcium intake or were at a high baseline risk had a greater reduction in fracture risk than did others. The treatment effect was consistent regardless of sex, fracture sites, or history of previous fractures.
"Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older," the study authors write. "For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation)."
Limitations of the study include the scarcity of data for vitamin D doses of more than 800 IU, probable underestimation of the treatment efficacy because of poor compliance in some trials, exclusion of trials that studied calcium as part of a dietary intake or nutritional supplementation regimen, exclusion of observational studies, absence of men-only trials, and inability to determine the interaction of physical exercise on the treatment effect.
The Australian Government supported this study. The study authors have disclosed no relevant financial relationships.
In an accompanying editorial, Jean-Yves Reginster, MD, PhD, from the Bone and Cartilage Metabolism Unit, CHU Centre Ville in Liege, Belgium, notes that this study does not fully address the cost-conscious use of calcium or calcium with vitamin D supplementation.
"Tang and colleagues' contribution is important because it paves the way for future research aiming at the best clinical, pharmacological, and economic use of calcium and vitamin D in patients at increased risk of osteoporotic fractures," Dr. Reginster writes. "Various treatment options have been advocated, including systematic supplementation at the onset of menopause and restriction of calcium with or without vitamin D to patients receiving other anti-osteoporotic drugs. Tang suggests that the number needed to treat (NTT) (63 patients over 3.5 years) with calcium or calcium and vitamin D to prevent one osteoporotic fracture compares favourably with similar calculations from the cardiovascular field."
Dr. Reginster has disclosed various financial relationships with Servier, Novartis, Negma, Lilly, Wyeth, Amgen, GlaxoSmithKline, Roche, Merckle, Nycomed, NPS, Theramex, Merck Sharp and Dohme, Rottapharm, IBSA, Genevrier, Teijin, Teva, Ebewee Pharma, Zodiac, Analis, Theramex, Nycomed, and Novo-Nordisk.
Lancet. 2007;370:632-633, 657-666.

Regular Exercise May Reduce Risk for Osteoporotic Fracture in Older Men

June 25, 2007 — Regular exercise reduces the risk for osteoporotic fracture in older men, according to the results of a longitudinal, population-based study published in the June issue of PLoS Medicine.
"Data from previous studies are inconsistent, and it is therefore uncertain whether, to what extent, and at what level leisure physical activity influences the risk of osteoporotic fractures in men," write Karl Michaëlsson from the University Hospital in Uppsala, Sweden, and colleagues. "We therefore investigated the impact of physical activity on the risk of fracture in a population-based cohort of men followed over a 35-y period."
The study cohort consisted of 2205 men, aged 49 to 51 years at enrollment, who were followed up for 35 years. Leisure physical activity and other lifestyle habits were determined at enrollment and at ages 60, 70, 77, and 82 years. The investigators used Cox's proportional hazards regression to determine hazard ratios (HRs) of fracture associated with time-dependent physical activity habits and covariates.
During follow-up, 482 men had at least 1 fracture. Compared with men who participated in regular sports activities for at least 3 hours/week, men with a sedentary lifestyle or men who walked or bicycled only for pleasure had an increased adjusted risk for hip fracture (HR, 2.56; 95% confidence interval [CI], 1.55 - 4.24; and HR, 1.61; 95% CI, 1.10 - 2.36, respectively).
At the end of follow-up, hip fracture had occurred in 8.4% of men with a high level of physical activity, 13.3% of men with a medium level of physical activity, and 20.5% of men with a low level of physical activity. Based on estimates of population-attributable risk, one third of all hip fractures could be prevented by participation in regular sports activities. High level of activity was also associated with decreased overall fracture risk.
"Our data indicate that regular sports activities can reduce the risk of fractures in older men," the authors write. "As expected, those who maintained a high physical activity level had the lowest risk of hip fracture, but there was also a tendency towards a lower risk of fracture for those who increased their level of activity compared with those who reduced their level of activity, or compared with those who reported constant low activity."
The Swedish Research Council supported this study. The authors have disclosed no relevant financial relationships.
In an accompanying perspective article, Harri Sievänen and Pekka Kannus from the UKK Institute in Tampere, Finland, note that the best way to prove that physical activity prevents fragility fractures would be to conduct several adequately powered randomized controlled trials. However, such trials are almost impossible to perform for methodologic reasons.
"In Michaëlsson and colleagues' study, the effective 'dose' of exercise for reducing the risk of hip fracture was readily attained by recreational sports, heavy gardening, or other activities with similar intensity performed for at least three hours per week," Sievänen and Kannus write. "This volume of exercise is relatively easy to incorporate into everyday life. It is also fortunate that it is never too late to start exercising."
Sievänen and Kannus received no specific funding for this article and have disclosed no relevant financial relationships.
PLoS Med. 2007;4:e199, e222.