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Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis

      ABSTRACT

      Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

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      References

        • Salai M
        • Dudkiewicz I
        • Novikov I
        • Amit Y
        • Chechick A
        The epidemic of ankle fractures in the elderly: is surgical treatment warranted?.
        Arch Orthop Trauma Surg. 2000; 120: 511-513
        • Koval KJ
        • Lurie J
        • Zhou W
        • Sparks MB
        • Cantu RV
        • Sporer SM
        • Weinstein J
        Ankle fractures in the elderly: what you get depends on where you live and who you see.
        J Orthop Trauma. 2005; 19: 635-639
        • King CM
        • Hamilton GA
        • Cobb M
        • Carpenter D
        • Ford L
        Association between ankle fractures and obesity.
        J Foot Ankle Surg. 2012; 51: 543-547
        • Schwartz AV
        • Sellmeyer DE
        • Ensrud KE
        • Cauley JA
        • Tabor HK
        • Schreiner PJ
        • Jamal SA
        • Black DM
        • Cummings SR
        • Study of Osteoporotic Features Research Group
        Older women with diabetes have an increased risk of fracture: a prospective study.
        J Clin Endocrinol Metab. 2001; 86: 32-38
        • Vestergaard P
        • Mosekilde L
        Fracture risk associated with smoking: a meta-analysis.
        J Intern Med. 2003; 254: 572-583
        • Ward KD
        • Klesges RC
        A meta-analysis of effects of cigarette smoking on bone mineral density.
        Calcif Tissue Int. 2001; 68: 259-270
        • Bauer M
        • Bengner U
        • Johnell O
        • Redlund-Johnell I
        Supination-eversion fractures of the ankle joint: changes in incidence over 30 years.
        Foot Ankle. 1987; 8: 26-28
        • Patsch JM
        • Burghardt Yap SP
        • Baum T
        • Schwartz A
        • Joseph GB
        • Link TM
        Increased cortical porosity in type-2 diabetic postmenopausal women with fragility fractures.
        J Bone Miner Res. 2013; 28: 313-324
        • Hasselman CT
        • Vogt MT
        • Stone KL
        • Cauley JA
        • Conti SF
        Foot and ankle fractures in elderly white women.
        J Bone Joint Surg Am. 2003; 85-A: 820-824
        • Sharma S
        • Fraser M
        • Lovell F
        • Reece A
        • McLellan AR
        Characteristics of males over 50 years who present with a fracture: epidemiology and underlying risk factors.
        J Bone Joint Surg Br. 2008; 90: 72-77
        • Kannus P
        • Palvanen M
        • Niemi S
        • Parkkari J
        • J ¨arvinen M
        Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future.
        Bone. 2002; 31: 430-433
        • Ensrud KE
        Epidemiology of fracture risk with advancing age.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 1236-1242
        • Lee KM
        • Chung CY
        • Kwon SS
        • Won SH
        • Lee SY
        • Chung MK
        • Park MS
        Ankle fractures have features of an osteoporotic fractures.
        Osteoporosis Int. 2013; 24: 2819-2825
        • Valtola A
        • Honkanen R
        • Kroger H
        • Tuppurainen M
        • Saarikoski S
        • Alhava E
        Lifestyle and other factors predict ankle fractures in perimenopausal women: a population-based prospective cohort study.
        Bone. 2002; 30: 238-242
        • Stein EM
        • Liu XS
        • Nickolas TL
        • Cohen A
        • Thomas V
        • McMahon DJ
        • Zhang C
        • Cosman F
        • Nieves J
        • Greisberg J
        • Guo XE
        • Shane E
        Abnormal microarchitecture and stiffness in postmenopausal women with ankle fractures.
        J Clin Endocrinol Metab. 2011; 96: 2041-2048
        • Lauritzen JB
        • Lund B
        Risk of hip fracture after osteoporosis fractures. 451 women with fracture of lumbar spine, olecranon, knee or ankle.
        Acta Orthop Scand. 1993; 64: 297-300
        • Center JR
        • Bliuc D
        • Nguyen TV
        • Eisman JA
        Risk of subsequent fracture after low-trauma fracture in men and women.
        JAMA. 2007; 297: 387-394
        • Pritchard JM
        • Giangregorio LM
        • Ioannidis G
        • Papaioannou A
        • Adachi JD
        Leslie WD ankle fractures do not predict osteoporotic fractures in women with or without diabetes.
        Osteoporos Int. 2012; 23: 957-962
        • Seeley DG
        • Kelsey J
        • Jergas M
        • Nevitt MC
        Predictors of ankle and foot fractures in older women. The Study of Osteoporotic Fractures Research Group.
        J Bone Miner Res. 1996; 11: 1347-1355
        • Greenfield DM
        Eastell R. Risk factors for ankle fracture.
        Osteoporos Int. 2001; 12: 97-103
        • Seeley DG
        • Browner WS
        • Nevitt MC
        • Genant HK
        • Scott JC
        Cummings SR. Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group.
        Ann Intern Med. 1991; 115: 837-842
        • Biver E
        • Durosier C
        • Chevalley T
        • Herrmann FR
        • Ferrari S
        • Rizzoli R
        Prior ankle fractures in postmenopausal women are associated with low areal bone mineral density and bone microstructure alterations.
        Osteoporos Int. 2015; 26: 2147-2155
        • Honkanen R
        • Kroger H
        • Tuppurainen M
        • Alhava E
        Saarikoski S. Fractures and low axial bone density in perimenopausal women.
        J Clin Epidemiol. 1995; 48: 881-888
        • Warner SJ
        • Garner M
        • Fabricant P
        • Lorich D
        Bone density correlates with clinical outcomes after ankle fracture fixation.
        Arch Orthop Trauma Surg. 2018; 138: 1653-1657
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Borenstein M
        • Hedges LV
        • Higgins JPT
        • Rothstein HR
        Introduction to Meta-Analysis.
        John Wiley & Sons, Ltd, West Sussex, United Kingdom2009: 21-291
        • Cohen J
        Statistical Power Analysis for the Behavioral Sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale, NJ1988: 20-26
        • Higgins JP
        • Thompson SG
        Quantifying heterogeneity in a metaanalysis.
        Stat Med. 2002; 21: 1539-1558
        • Downs SH
        • Black N
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Roux S
        • Cabana F
        • Carrier N
        • Beaulieu MC
        • Boire G
        Risk of subsequent fragility fractures observed after low-trauma ankle fractures.
        Calcif Tissue Int. 2018; 103: 62-70
        • Taylor AJ
        • Gary LC
        • Arora T
        • Becker DJ
        • Curtis JR
        • Kilgore ML
        • Morrisey MA
        • Saag KG
        • Matthews R
        • Yun H
        • Smith W
        • Delzell E
        Clinical and demographic factors associated with fractures among older Americans.
        Osteoporos Int. 2011; 22: 1263-1274
        • Gunnes M
        • Mellstrom D
        Johnell O. How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women.
        Acta Orthop Scand. 1998; 69: 508-512
        • Kanis JA
        • Johnell O
        • Oden A
        • Johansson H
        • McCloskey E
        FRAX and the assessment of fracture probability in men and women from the UK.
        Osteoporos Int. 2008; 19: 385-397
        • Hippisley-Cox J
        Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study.
        BMJ. 2012; 344: e3427
        • Boguch ER
        • Elliot-Gibson V
        • Beaton D
        • Sale J
        • Josse RG
        Fracture prevention in the orthopaedic environment: outcomes of a coordinator-based fracture liaison service.
        J Bone Joint Surg Am. 2017; 99: 820-831
        • Rosen CJ
        Clinical practice. Postmenopausal osteoporosis.
        N Engl J Med. 2005; 353: 595-603
        • Schreiber JJ
        • Hughes AP
        • Taher F
        • Girardi FP
        An association can be found between Hounsfield units and success of lumbar spine fusion.
        HSS J. 2014; 10: 25-29
        • Ali AM
        • Saleh M
        • Eastell R
        • Wigderowitz CA
        • Rigby AS
        • Yang L
        Influence of bone quality on the strength of internal and external fixation of tibial plateau fractures.
        J Orthop Res. 2006; 24: 2080-2086
        • Cummings SR
        • Melton LJ
        Epidemiology and outcomes of osteoporotic fractures.
        Lancet. 2002; 359: 1761-1767
        • Eckel TT
        • Glisson RR
        • Anand P
        • Parekh SG
        Biomechanical comparison of 4 different lateral plate constructs for distal fibula fractures.
        Foot Ankle Int. 2013; 34: 1588-1595
        • Minihane KP
        • Lee C
        • Ahn C
        • Zhang LQ
        • Merk BR
        Comparison of lateral locking plate and antiglide plate for fixation of distal fibular fractures in osteoporotic bone: a biomechanical study.
        J Orthop Trauma. 2006; 20: 562-566
        • Johnson BA
        • Fallat LM
        Comparison of tension band wire and cancellous bone screw fixation for medial malleolar fractures.
        J Foot Ankle Surg. 1997; 36: 284-289
        • Ramasamy PR
        • Sherry P
        The role of a fibular nail in the management of Weber type B ankle fractures in elderly patients with osteoporotic bone: a preliminary report.
        Injury. 2001; 32: 477-485
        • Lemon M
        • Somayaji HS
        • Khaleel A
        • et al.
        Fragility fractures of the ankle: stabilisation with an expandable calcaneotalotibial nail.
        J Bone Joint Surg Br. 2005; 87: 809-813
        • Houshian S
        • Bajaj SK
        • Mohammed AM
        Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis.
        Injury. 2006; 37: 791-794
        • Collinge C
        • Merk B
        • Lautenschlager EP
        Mechanical evaluation of fracture fixation augmented with tricalcium phosphate bone cement in a porous osteoporotic cancellous bone model.
        J Orthop Trauma. 2007; 21: 124-128