Prevalence of Osteoporosis Confirmed by Dual-Energy X-Ray Absorptiometry in Patients with Bone Fracture
Mohammed Alghamdi *1, Emad Salawati 2, Abdullah Alghamdi 3, Asim Almalawi 4, Raed Alsulami 5,
Saad Alghamdi 6, Ali Al Dawais 7, Abdulrahman Al ghashmari 8, Ali Alhejji 9
*Correspondence to: Mohammed Saeed Alghamdi, MBBS, King Abdulaziz University Faculty of Medicine, Jeddah, 22345, Saudi Arabia.
© 2024 Mohammed Saeed Alghamdi. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 08 January 2024
Published: 30 January 2024
DOI: https://doi.org/10.5281/zenodo.10589002
Abstract
Background: Osteoporotic fractures are a significant cause of morbidity and mortality globally, and their incidence is increasing. This study aimed to investigate the prevalence of osteoporosis and its associated risk factors among patients with low-trauma fractures, and determine the percentage of underdiagnosed and undertreated patients with osteoporosis, in a tertiary care center in Jeddah, Saudi Arabia.
Methods: This retrospective record review study included 348 patients who had been present at the Emergency department or seen in the outpatient orthopedic clinic with fractures resulting from low-trauma incidents, such as falls from standing height or less. Data were collected from medical records, including demographic data, fracture types, previous history of fracture, and risk factors for osteoporosis. The Chi-squared test and Mann-Whitney test were used for data analysis.
Results: Femur fractures were the most common (80.2%), followed by vertebra (13.5%) and hip fractures (6.3%). Osteoporosis was diagnosed in 10.34% of patients. Vitamin D deficiency (41.4%) and corticosteroid use (28.7%) were prevalent risk factors. Low vitamin D levels were associated with an increased risk of fragility fractures, and previous fracture history and corticosteroid usage were associated with femur fractures.
Conclusion: This study highlights the underestimation of osteoporosis and the importance of its medical management. The majority of patients who are at risk for osteoporosis were not properly investigated and diagnosed using a Dual-Energy X-ray Absorptiometry (DEXA) scan, which could lead to increased morbidity and the burden of the disease. We recommend strict adherence to guidelines for diagnosing and managing osteoporosis and the implementation of regional initiatives to increase awareness and information.
Key word: Osteoporosis; Osteoporotic Fractures; Risk Factors; Prevalence; Femoral Fractures; DEXA Scan.
Introduction
Osteoporotic fractures also known as fragility fractures can lead to severe disability and an increase in morbidity and mortality rates. Osteoporosis is a prevalent, persistent,, and costly disease, with fractures being the primary clinical outcome.[1,2] It is estimated that almost 200 million women worldwide have osteoporosis, resulting in over 8.9 million fractures each year.[3] In terms of financial impact, a study conducted in Saudi Arabia found that the average direct medical cost for patients with osteoporotic fractures was 9,716.26 USD per person per year.[4] The universally accepted definition of osteoporosis is a systemic disease characterized by reduced bone mass and microarchitectural degeneration of bone tissue, resulting in increased bone fragility and fracture risk.[5]
Diagnosing osteoporosis requires evaluating bone mineral density (BMD), with Dual-Energy X-ray Absorptiometry (DEXA) being the gold standard technique for measuring BMD. [6,7] Patients with low BMD are at considerably higher risk of future fractures.[8]
Previous studies conducted in Saudi Arabia and Egypt have reported high prevalence rates of osteoporosis in hospitalized patients over the age of 50 years. [9,10] Factors associated with osteoporosis and fractures include old age, female gender, high or low body mass index (BMI), use of corticosteroids, vitamin D deficiency, and previous history of fracture. [4,5,10]
Despite the high prevalence rates and known risk factors, the association between BMD and the prevalence of fractures in Middle Eastern populations is understudied and limited. Additionally, many patients remain underdiagnosed and untreated. Therefore, our research aims to identify the prevalence of osteoporosis based on a DEXA scan among adult patients presenting with bone fractures at King Abdulaziz University Hospital. We also aim to investigate associated risk factors and determine the percentage of underdiagnosed and undertreated patients with osteoporosis.
Methods
Study design and setting
This retrospective record review study, which took place in April 2023, reviewed patients' medical records from Abdulaziz University Hospital (KAUH), a tertiary care center in Jeddah, Saudi Arabia. The study focused specifically on patients who had been present at the Emergency department or seen in the outpatient orthopedic clinic with fractures resulting from low-trauma incidents, such as falls from standing height or less. The research was conducted in the orthopedic department and obtained ethical approval from the Research Ethics Committee of KAUH Reference No. 401-23 [HA-02-J-008].
Study population and sample size
Medical records of (610) patients were reviewed and (348) patients who met the inclusion criteria were selected. The inclusion criteria were as follows: patients aged 18 or above with any fragility fractures of femur, hip, and spinal vertebral fractures only from 1/1/2012-31/12/2022, of both sexes and any ethnic origin. Fracture types not meeting this criterion were excluded. Only fractures resulting from low-energy trauma such as falls from standing height or less were included in this analysis. The exclusion criteria were pathological fractures due to malignant diseases or high-impact trauma (e.g. Motor vehicle accident, sports injury, or fall from above standing height), a treatment that may affect bone metabolism, inability to provide informed consent, death, and age less than 18 years. A total of 262 patients were excluded from the analysis. These exclusions were distributed as follows: 84 patients were deceased, 71 patients had a history of motor vehicle accidents, 61 patients had pathological fractures such as osteogenesis imperfecta and other malignancies, and 46 patients were below 18 years of age.
Data collection and definition of variables
Osteoporosis was defined as having a bone mineral density (BMD) with a T-score of less than -2.5 standard deviations. Traditionally, BMD was assessed using Dual-Energy X-ray Absorptiometry (DEXA), All incident fractures that occurred during the study period [2012-2020] were confirmed on radiographs and reviewed by qualified radiologists at hospitals. All data of patients admitted with fractures from 1/1/2012-31/12/2022 were abstracted by trained chart reviewers. We collected demographic data such as (MRN, age, gender, Hight, and weight) as well as information on fracture type (femur, hip, spinal vertebra), previous history of fracture, and risk factors for osteoporosis (uses of glucocorticoid or osteoporosis medication), Pre-existing medical conditions (vitamin D deficiency). The location of each fracture was evaluated on X-rays, surgery reports, and medical reports.
Data entry and data analysis
Data were analyzed using the SPSS application version 26. The Chi-squared test (χ2) was used to investigate the association between the qualitative data expressed as numbers and percentages. The Mann-Whitney test was used to examine the association between the quantitative non-parametric variables expressed as mean and standard deviation (Mean ± SD). A p-value of less than 0.05 was considered statistically significant, and the confidence interval was set at 95%.
Results
In our study, we included 348 patients with a mean age of 63.64 ± 19.88, (50.9%) of whom were female and (39.9%) were overweight. Most of the cases were femur fractures (80.2%) followed by vertebra (13.5%) and hip fractures (6.3%) (Table 1). Osteoporosis was not diagnosed in most cases (68.68%), and most of those diagnosed had no documented DEXA scan report (18.96%), the prevalence of osteoporosis confirmed by DEXA was (10.34%) (Table 2). Only (28.7%) of the total patients had a history of taking corticosteroids. (41.4%) of the patients were vitamin D deficient, and the majority of them were not prescribed to have a supplement (65.3%). Regarding other supplements, calcium was prescribed for (34.2%), calcitonin was used for (0.3%), and Bisphosphonates were used for (1.1%), further details are shown in (Table 1).
Furthermore, according to the results presented in (Table 3), we observe a positive statically correlation between femur fracture and having a previous history of fracture (66.7%) (p = 0.005), as well as having a history of vitamin D deficiency (72.2%) (p = 0.001), also with corticosteroid use (64%) (p = 0.000). However, BMI was not significantly correlated with femur fractures (p = 0.096).
Additionally, regarding fragility fractures results shown in (Table 4), patients presented at age (48.4 to 83.2) correlate significantly to these fractures (p = 0.024), as well as having (57.6%) of patients with fragility fractures had a history of vitamin D deficiency (p = 0.000), also with corticosteroid use (62%) (p = 0.000), and having a previous history of fracture (62.7%) (p = 0.000) and no significant correlation found with BMI (p = 0.541).
Table 1. Baseline characters
Table 2. Relationship between Osteoporosis Diagnosis and DEXA scan result
Table 3. Relationships between fracture site and previous fractures, vitamin D deficiency and history of corticosteroids use
Table 4. Relationships between fragility fractures and previous fractures, vitamin D deficiency and history of corticosteroids use.
Discussion
Our study shows a dominance of femur fractures. Considering the age of our population, a likely cause of this presentation may be the risk of falls and fragility.11 Moreover, we found that there are only 109 patients (31.32%) diagnosed with osteoporosis out of a total of 348 patients. On the other hand, another research in Egypt showed the prevalence of osteoporosis among admitted patients for proximal femur fracture is 74.9%.10 This decreased rate of diagnosis can be explained by the underestimation of the effect of osteoporosis and the importance of its medical management.[10,12]
Surprisingly our study found that most patients diagnosed with osteoporosis have not been investigated with a DEXA scan. In the literature, there was no similar finding noted. A possible explanation of this finding is that physicians in emergency settings make the diagnosis without doing proper investigations or referral to orthopedics, which may lead to increased morbidity, the burden of the disease, costs on the healthcare system, and the recurrence of fractures in the future.
Management strategies for the prevention and treatment of osteoporosis and osteoporotic fractures include calcium, vitamin D, and bisphosphonates supplements.[13,14] The findings of this study clarify a decreased prescribing rate of these supplements. In the same way, another study by Ha CW et al. shows low rates of pharmacologic osteoporosis treatment and prevention in patients awaiting total knee arthroplasty (TKA).[12] This suggests that physicians may not have paid as much attention to osteoporosis as they do to other chronic diseases.[12]
Fragility fractures are more common in people over the age of 48. This finding was also reported by Morin SN et al. and Dimai HP et al. who reported similar results.[1,15] Possible explanations for this finding, which is the higher prevalence of fragility fractures in older people, including age-related variables such as decreased bone density and muscular weakness, which lead to an increased vulnerability to fractures.
The results of this study show that low vitamin D levels are associated with an increased risk of fragility fractures, as confirmed by Tsuda T et al.[16] This could be explained by the impact of vitamin D deficiency on bone mineral density. Another finding that stands out from the results reported earlier is that vitamin D deficiency is a significant risk factor for femur fractures, which is consistent with findings from studies conducted by Kanis JA et al. found similar results in women, and Niikura T et al. found that Vitamin D level is a quadratic predictor of hip fractures respectively.[17,18] Vitamin D deficiency is associated with secondary hyperparathyroidism, which promotes bone turnover, accelerates bone loss and increases the risk of fractures.
Our results report a relationship between femur fractures and the consumption of glucocorticoids. Additionally, steroid use increases the risk of fragility fracture. These results reflect those of Van Staa T et al. also found that both daily and cumulative doses of oral corticosteroids are associated with an increased risk of fragility fractures.[19] As a result, steroids can alter the normal balance of bone creation and resorption, resulting in poor bone remodeling. It reduces osteoblast activity, which is responsible for bone production, while increasing osteoclast activity, which is responsible for bone resorption.[17]
One unanticipated result was that BMI shows no significant relation neither with fragility or femur fractures. These results corroborate the findings of Farouk O et al. who showed a similar result, the study suggests that several variables, including age, hormonal state, bone quality and density, and lifestyle elements like calcium consumption and physical exercise, may affect fragility fractures.[10] BMI may not adequately account for the complicated nature of these variables, which would explain the lack of association.[20]
Moreover, having a previous history of fracture is a risk factor for subsequent fractures, particularly fragility fractures. This finding is supported by Kanis JA et al. and Tsuda T et al. studies, which found that it is an independent factor for any fracture.[16,17] The remodeling process of the bone after a fracture can result in changes to its structure and density, making it more prone to future fractures.[21] Interestingly, our study found a significant positive correlation between femur fracture and previous fracture history. This finding suggests that the load and pattern of femoral fractures may be influenced by accumulative previous damage, highlighting the importance of considering a patient's fracture history in fracture risk assessment.[22]
Conclusion
This study has found that only a tenth of the patients presented with bone fractures diagnosed by osteoporosis using a DEXA scan. The research has also shown that osteoporotic fractures are associated with a previous history of fracture, corticosteroid usage, and vitamin D deficiency. In addition, we noticed that the majority of the patients who are at risk for osteoporosis were not properly investigated and diagnosed using a DEXA scan which could raise morbidity, the disease burden, the financial load on the healthcare system, and the likelihood of fracture recurrence. Our recommendation for medical physicians is to strictly follow the guidelines for diagnosing and managing osteoporosis. In addition, we advise the local healthcare authorities to implement regional initiatives to spread awareness and information.
Limitations
Our study involved some limitations, first is that the study included 348 patients, which is considered a small sample size. The second is that only fragility fractures of femur, hip and vertebra were included in our study, which can lead to selection bias. The third limitation is poor documentation in our health care facility that restricted further classification of femur fractures.
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