This report provides an overview and a comparison of the burden and management of fragility fractures in the largest five countries of the European Union plus Sweden (EU6). In 2017, new fragility fractures in the EU6 are estimated at 2.7 million with an associated annual cost of €37.5 billion and a loss of 1.0 million quality-adjusted life years. Introduction Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fractures, which in turn, represent the main consequence of the disease. This report provides an overview and a comparison of the burden and management of fragility fractures in the largest five EU countries and Sweden (designated the EU6). Methods A series of metrics describing the burden and management of fragility fractures were defined by a scientific steering committee. A working group performed the data collection and analysis. Data were collected from current literature, available retrospective data and public sources. Different methods were applied (e.g. standard statistics and health economic modelling), where appropriate, to perform the analysis for each metric. Results Total fragility fractures in the EU6 are estimated to increase from 2.7 million in 2017 to 3.3 million in 2030; a 23% increase. The resulting annual fracture-related costs (€37.5 billion in 2017) are expected to increase by 27%. An estimated 1.0 million quality-adjusted life years (QALYs) were lost in 2017 due to fragility fractures. The current disability-adjusted life years (DALYs) per 1000 individuals age 50 years or more were estimated at 21 years, which is higher than the estimates for stroke or chronic obstructive pulmonary disease. The treatment gap (percentage of eligible individuals not receiving treatment with osteoporosis drugs) in the EU6 is estimated to be 73% for women and 63% for men; an increase of 17% since 2010. If all patients who fracture in the EU6 were enrolled into fracture liaison services, at least 19,000 fractures every year might be avoided. Conclusions Fracture-related burden is expected to increase over the coming decades. Given the substantial treatment gap and proven cost-effectiveness of fracture prevention schemes such as fracture liaison services, urgent action is needed to ensure that all individuals at high risk of fragility fracture are appropriately assessed and treated.

This double blind, randomized, placebo-controlled study was undertaken at 14 hospitals in the United Kingdom in asymptomatic women who were at high risk of preterm birth because of risk factors such as previous midtrimester pregnancy loss or preterm delivery, uterine abnormality, cervical surgery, or cerclage. The criterion for entry into the study was the presence of fetal fibronectin (fFN) in vaginal secretions in the second trimester of pregnancy. This factor appears to be more predictive of preterm birth than bacterial vaginosis or other putative biochemical markers. A total of 900 pregnancies were screened at 24 and 27 weeks gestation. Women with positive results were assigned to receive either oral metronidazole (400 mg 3 times a day) or a placebo for 1 week. The primary outcome was delivery before 30 weeks gestation, and secondary outcomes included delivery before 37 weeks.The study was stopped at an early stage when 21% of 53 women given metronidazole and 11% of 46 placebo recipients delivered before 30 weeks gestation. The risk ratio (RR) was 1.9, with an 85% confidence interval (CI) of 0.72-5.09. Preterm delivery (earlier than 37 weeks gestation) took place in 62% of women given metronidazole and in 39% of the placebo group (RR, 1.6; 95% CI, 1.05-2.4). The positive and negative predictive values of fFN for early preterm birth, estimated at 24 weeks gestation for the risk of delivery before 30 weeks, were 26% and 99%, respectively. The fFN reverted to negative in approximately half of the actively treated and placebo groups. Birth weights averaged 366 g lower for infants whose mothers received metronidazole, and 56% more infants in this group were smaller than 2.5 kg at birth compared with those who mothers received placebo. The proportions of low 1-and 5-minute Apgar scores were comparable in the metronidazole and placebo groups. This is the first prospective trial showing that metronidazole is not an effective means of preventing preterm delivery in high-risk women and that it may have adverse effects on the newborn infant. The investigators do not recommend the continued use of this drug with the intent of preventing preterm delivery. EDITORIAL COMMENT(In the second half of pregnancy, increased concentrations of cervical and vaginal fetal fibronectin reflect choriodecidual basement membrane disruption and may herald preterm birth. In some women, intrauterine infection may be responsible for the disruption (Lockwood CJ, et al. N Engl J Med 1991;325:669; Goldenburg RL, et al. Obstet Gynecol 1996;87:656). This begs the question, then, as to whether antibiotics might reduce the rate of preterm birth in women with positive OBSTETRICS Volume 61, Number 5 OBSTETRICAL AND GYNECOLOGICAL SURVEY ABSTRACTWhen the fetal head remains in an occipitoposterior position during labor, the woman experiences continued back pain and is at increased risk of requiring operative delivery. Neonatal morbidity also is more likely. Some practitioners have proposed using the hands-and-knees position in the hope that gravitational...

Objectives To test whether bisphosphonate use is related to improved implant survival after total arthroplasty of the knee or hip.Design Population based retrospective cohort study. Setting Primary care data from the United Kingdom. Participants All patients undergoing primary total arthroplasty of the knee (n=18 726) or hip (n=23 269) in 1986-2006 within the United Kingdom’s General Practice Research Database. We excluded patients with a history of hip fracture before surgery or rheumatoid arthritis, and individuals younger than 40 years at surgery. Intervention Bisphosphonate users were classified as patients with at least six prescriptions of bisphosphonates or at least six months of prescribed bisphosphonate treatment with more than 80% adherence before revision surgery. Outcome measures Revision arthroplasties occurring after surgery, identified by READ and OXMIS codes. Parametric survival models were used to determine effects on implant survival with propensity score adjustment to account for confounding by indication. Results Of 41 995 patients undergoing primary hip or knee arthroplasty, we identified 1912 bisphosphonate users, who had a lower rate of revision at five years than non-users (0.93% (95% confidence interval 0.52% to 1.68%) v 1.96% (1.80% to 2.14%)). Implant survival was significantly longer in bisphosphonate users than in non-users in propensity adjusted models (hazard ratio 0.54 (0.29 to 0.99); P=0.047) and had an almost twofold increase in time to revision after hip or knee arthroplasty (time ratio 1.96 (1.01 to 3.82)). Assuming 2% failure over five years, we estimated that the number to treat to avoid one revision was 107 for oral bisphosphonates.Conclusions In patients undergoing lower limb arthroplasty, bisphosphonate use was associated with an almost twofold increase in implant survival time. These findings require replication and testing in experimental studies for confirmation.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear.

Summary Vertebral fractures are independent risk factors for vertebral and nonvertebral fractures. Since vertebral fractures are often missed, the relatively new introduction of vertebral fracture assessment (VFA) for imaging of the lateral spine during DXA-measurement of the spine and hips may contribute to detect vertebral fractures. We advocate performing a VFA in all patients with a recent fracture visiting a fracture liaison service (FLS). Fracture liaison services (FLS) are important service models for delivering secondary fracture prevention for older adults presenting with a fragility fracture. While commonly age, clinical risk factors (including fracture site and number of prior fracture) and BMD play a crucial role in determining fracture risk and indications for treatment with antiosteoporosis medications, prevalent vertebral fractures usually remain undetected. However, vertebral fractures are important independent risk factors for future vertebral and nonvertebral fractures. A development of the DXA technology, vertebral fracture assessment (VFA), allows for assessment of the lateral spine during the regular DXA bone mineral density measurement of the lumbar spine and hips. Recent approaches to the stratification of antiosteoporosis medication type according to baseline fracture risk, and differences by age in the indication for treatment by prior fracture mean that additional information from VFA may influence initiation and type of treatment. Furthermore, knowledge of baseline vertebral fractures allows reliable definition of incident vertebral fracture events during treatment, which may modify the approach to therapy. In this manuscript, we will discuss the epidemiology and clinical significance of vertebral fractures, the different methods of detecting vertebral fractures, and the rationale for, and implications of, use of VFA routinely in FLS. Summary points • Vertebral fracture assessment is a tool available on modern DXA instruments and has proven ability to detect vertebral fractures, the majority of which occur without a fall and without the signs and symptoms of an acute fracture. • Most osteoporosis guidelines internationally suggest that treatment with antiosteoporosis medications should be considered for older individuals (e.g., 65 years +) with a recent low trauma fracture without the need for DXA. • Younger individuals postfracture may be risk-assessed on the basis of FRAX® probability including DXA and associated treatment thresholds. • Future fracture risk is markedly influenced by both site, number, severity, and recency of prior fracture; awareness of baseline vertebral fractures facilitates definition of true incident vertebral fracture events occurring during antiosteoporosis treatment. • Detection of previously clinically silent vertebral fractures, defining site of prior fracture, might alter treatment...

The variability in service provision was not explained by local variations in care need. Further work is now needed to establish how the variability in service provision affects key patient, clinical and health economic outcomes.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear.

Purpose of review: This review sought to describe quality improvement initiatives in fragility fracture care and prevention. Recent findings: A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improvement their performance. Summary: Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.