{'fraction_non_alphanumeric': 0.0419523704195237, 'fraction_numerical': 0.030450490304504904, 'mean_word_length': 5.017746228926353, 'pattern_counts': {'":': 0, '<': 6, '<?xml version=': 0, '>': 1, 'https://': 1, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 1, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A description of bone density of osteoporosis patients with femoral neck fracture

DOI: 10.4328/ACAM.20104 Received: 2020-01-03 Accepted: 2020-01-17 Published Online: 2020-01-20 Printed: 2020-09-01 Ann Clin Anal Med 2020;11(5):390-394 Corresponding Author: Quang Tri Le, Director of 7A MILITARY HOSPITAL, Head of Department of Orthopedics, 7A MILITARY HOSPITAL, 466 Nguyen Trai Street, Ward 8, District 5, Ho Chi Minh City, 72706, Vietnam. E-mail: lqtri@ntt.edu.vn P: (+084)0839241868 / (+084)0913126229 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2777-0828 Abstract Aim: In this study, we aimed to describe clinical traits and bone density of osteoporosis patients with femoral proximal fractures on the Vietnamese elderly. Materials and Methods: This cross-sectional descriptive study included 152 patients over 65-year-olds with femoral neck fracture treated. Results: Male/female ratio was 0.88, average age was 77.25 ± 8.64 years. Common clinical symptoms were pain or irritation across long bones (69.1%), reduced height at more than 3cm compared with earlier ages (38.2%). Radiographs show that 64.5% of patients had intertrochanteric fractures, 63.2% of patients had Grade 3 femoral neck condition according to Singh Index. Average bone density measured by the DEXA scan of the femoral neck was -2.87 ± 0.39 and of the lumbar spine was -3.74 ± 0.71. Bone density results of the Singh Index and DEXA scan had a rigid, positive correlation (p < 0.05). Discussion: Aspects of gender, age, BMI index, lifestyles, menopause time and the number of children were discussed to show a correlation with results from Vietnam and others. Some initial clinical symptoms suggesting osteoporosis risks and types of hip fractures were assessed. Singh Index and DEXA scan measurements were compared and evaluated, showing a rigid correlation. Conclusion: Osteoporosis and osteoporosis-related femoral neck fractures occurred more in female than in male patients. Risk factors included a sedentary lifestyle, long menopause and many children in female and unhealthy lifestyles in males. Some clinical symptoms might early suggest osteoporosis conditions. There was a correlation between bone density measured using the Singh Index and DEXA scan, implying that the Singh Index still a valuable tool for initial diagnostic of osteoporosis and bone fracture prevention.


Introduction
Osteoporosis is a bone disease with reducing bone mass and bone structure degeneration, which leads to an increase of bone fragility, i.e., fracture rate. Osteoporosis progresses naturally and silently with atypical clinical symptoms usually underestimated by the patients -30% of the bone mass had already been lost when apparent symptoms or fractures occur. Risk factors of Osteoporosis include old age, gender (menopause in women increases bone loss), lifestyles (alcoholism, too little exercising, smoking), and some diseases and medication intake (hyperthyroidism, kidney disease, ovaries removal, corticoid, chemotherapy, etc.) [1][2][3]. In 1999 there were 1.7 million femoral neck fracture patients worldwide, and this number may reach 6.3 million in 2050, half of which occurred in Asia. Bone fractures due to osteoporosis were seen in 150000 patients annually in France, 70000 of them had femoral proximal fractures. Amongst patients, 80% did not fully recover after treatment, 40% required assistance in travel, and 25% died within one year. Treatment costs reached 1 billion euros. In America annually, there were 1.5 million bone fracture cases due to osteoporosis, 20% of whom got repeated fracture, 50% retain walking ability, 3 -10% died in hospital, 14 -36% died after one year. In Vietnam, it is estimated that 2.8 million people suffered from osteoporosis, accounted for 30% of women aged over 50 [5]. According to the initial survey data of the National Institute of Nutrition, osteoporosis affects about 1/3 of women and 1/8 of men over 50 years old. It is estimated that by 2030, the number of people with femoral neck fracture due to osteoporosis will be 41,000 cases (Bulletin of Ministry of Health, Mar 09, 2018, in Vietnamese). Diseases should be prevented from the beginning, and for osteoporosis prevention, risk factors identification, early detection, and effective preventive care to avoid complications are considered critical. This study was carried out with the aim of a description of clinical traits and bone density of osteoporosis patients with femoral proximal fractures at the 7A Military Hospital, Hochiminh City, Vietnam.

Material and Methods
One hundred fifty-two patients diagnosed with osteoporosis according to WHO criteria (T-score ≤ -2,5) and femoral proximal fractures on radiographs in the 7A Military Hospital (Ho Chi Minh City, Viet Nam) from July 2015 to July 2019 were included in the study. Participation in the study was voluntary. Criteria for rejection included cancer patients, patients unable to attend interviews. Research methods included description, study design, crosssection, case-by-case analysis, and total sample size. Clinical history, clinical examinations, and tests, bone density, were recorded for all patients with intertrochanteric fractures, data were collected using a unified form.
Research clinical criteria were as follows: 1. Interview: disease history, careers, lifestyles (sedentary or active), habits (smoking, drinking), menstruation (for females), fracture history, parental fracture history, drug-taking history, diabetes history (duration, treatment, complications). 2. Organs and full-body checkups, examinations of accompanying injuries. Measurements of blood pressure, height (low: < 1.47m for women, < 1.57m for men), weight (low: < 42kg for women, < 50kg for men), BMI calculation, detection of accompanying secondary fracture factors. Research sub-clinical criteria were as follows: 1. Radiographs of hip joints from both sides in the supine position were recorded. Fractures were recorded and evaluated osteoporosis using Singh Index [4]. The Singh Index assesses bone condition based on gradual trabeculae losses shown on radiographs. Bone quality was classified into six grades in which grade 6 was the reasonable condition, and level 1 was severe osteoporotic bones. a) Grade 6: All visible normal trabecular groups and fully occupied cancellous bone at the femoral proximal end. b) Grade 5: Clear, prominent principal tensile and principal compressive trabeculae and Ward's triangle. c) Grade 4: Significantly reduced principal tensile trabeculae but traceable from the lateral cortex to the femoral neck upper part. d) Grade 3: Discontinuity of the principal tensile trabeculae opposite the greater trochanter. Indication of osteoporosis. e) Grade 2: Only principal compressive trabeculae remain strongly visible; others have essentially vanished. f) Grade 1: Principal compressive trabeculae are significantly reduced in number and are no longer prominent. 2. Bone density was measured by Dual-energy X-ray absorptiometry (DEXA) scan using MEDIX DR equipment (France) at femoral head, neck, greater and lesser trochanters, intertrochanteric line, Ward triangle, and lumbar spine (L1, L2, L3, L4). The final value was the averaged sum of all measured parameters. 3. Osteoporosis was diagnosed according to WHO criteria (Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser. 1994;843:1-129) based on bone density: a) Normal: ≥-1 SD; b) Osteopenia: -1 SD to -2.5 SD; c) Osteoporosis: ≤-2.5SD; d) Severe osteoporosis: ≤-2.5SD in the presence of one or more fractures. Data analysis: The data were processed by the medical statistical method using SPSS software 16.0, and the hypothesis test was done by the Chi-squared method.

Parameters
Results (X ± SD) DEXA scan results of bone density were collected, analysis, and presented in Table 2. In general, the measured average bone density at the femoral neck was higher than that at the lumbar spine (-2.87 ± 0.39 and -3.74 ± 0.71, respectively).
Correlation between bone density measured by the DEXA scan and osteoporosis conditions based on the Singh Index (p < 0.05) is shown in Table 3 and Figure 2.
There was a strong, positive correlation between the lumbar spine and femoral neck bone density measured by the DEXA scan with radiographic osteoporosis conditions based on Singh Index.    Effect of lifestyle on bone loss. Regular exercises are essential for the elderly since, after retirement, most of them choose to rest, stay at home more, and work lightly. Doing exercises at least five days a week, 30 minutes a day can promote health, increase bone density, improve circulation, reduce blood sugar; it also maintains muscular quality and reduces the chance of falling, thus more or less prevent osteoporosis and fractures in senior citizens [7,8]. In this study, 79% of the patients had a sedentary lifestyle making it the most frequently encountered risk factor. Other lifestyle risk factors for bone loss are smoking and alcoholism [2]. Most of the male patients in our study smoked (59.2%) and frequently consumed alcohol (78.9%) (n=71). Effect of menopause on the loss of bone mass. Menopause is a natural physiological phenomenon in women. Postmenopausal estrogen level drastically decreases. Rapid bone loss occurs during the first 5 -15 years after menopause, followed by a slow loss due to a lack of estrogen and old age. That means a higher period equal to longer postmenopausal time, which leads to more significant bone loss and higher risks for osteoporosis and osteoporotic bone fracture in women [7,9]. In this study, most female patients (n=81) menopause lasted over 30 years, accounted for 70.4% comparing to only 14 female patients who were in their early menopause (17.3%). The number of offsprings is one essential trait of female reproduction. Reginster and colleagues (2005) [10] observed that mothers of many children had higher osteoporosis risks than mother of few since many births affected mother's calcium metabolism due to transfer from mother to child during pregnancy and breastfeeding; without adequate calcium re-supplement in these periods, women with many births will suffer from high osteoporosis risks. Also, Vietnamese women tend to refrain from movement and eating during several first months after birth. Women with more than three children were also a majority in this study (67.9%).

Clinical traits and bone density
Osteoporosis is a silent disease without apparent symptoms. As a result of many patients, especially men, were not aware of their illness until bone fractures occurred. However, the senior patients in this study showed several symptoms such as pain or irritation across long bones (105 patients, 69.1%), decreasing in height >3cm comparing to previous younger height (58 patients, 38.2%), and kyphosis and lordosis (46 patients, 30.3%). Although no symptoms do not mean healthy or such signs always mean osteoporosis, the above mentioned signs, albeit not specific for this disease, may remind the clinicians of osteoporosis risks as such risks are very high in patients with these symptoms [11,12]. Senior people have a reduced bone quality, which, even in the case of simple falling with small impact, quickly leads to femoral proximal fractures [2]. In this study, intertrochanteric fractures were seen in 64.5% of cases, and other fractures accounted for 35.5% cases, compatible with the significant researches of Guyton (2003) [13] and Lorich (2004) [14]. Classification of intertrochanteric fractures may help in the selection of treatment equipment and methods. Our study showed that bone density at the femoral neck was higher than that at the lumbar spine (-2.87 ± 0.39 and -3.74 ± 0.71, respectively), which is compatible with the literature since the lumbar vertebrae (L1 to L4) are spongy bones with higher annual bone loss than compact ones. Therefore osteoporosis in the lumbar spine took place earlier than in the femoral neck [12]. Osteoporosis levels, according to the Singh Index in this study, were mostly in Grade 3 (63.2%). There was a rigid, positive correlation between bone density measured by DEXA scan and osteoporosis assessment using the Singh Index. Some other authors otherwise reported that there was little to no correlation between Singh Index and DEXA scan bone density measuring [15]. Vietnam is still a developing country and expensive diagnostic tools as DEXA might not be readily available in many hospitals and be a financial burden to many patients. Based on our result, the Singh Index is still a valuable way to initially assess osteoporosis and give a useful hint about the patients' bone conditions for further examination and treatment.

Conclusion
Osteoporosis and osteoporosis-related femoral neck fractures occurred more in female than in male patients. The most frequently encountered risk factor, in general, was the sedentary lifestyle. Most female patients had long menopause and many children, while most male patients had unhealthy lifestyles such as smoking and alcoholism.
Although not significantly specific to osteoporosis, some clinical symptoms such as pain and irritation across long bones or highly decreasing in height might early suggest osteoporosis conditions. There was a rigid, positive correlation between bone density measured using the Singh Index and DEXA scan, implying that the Singh Index is still a valuable tool for initial diagnostic of osteoporosis and bone fracture prevention.