Diabetes and fractures:​ new evidence of atypical femoral fractures?

Rasmussen, N. H.<sup>1</sup>; Dal, J.<sup>2</sup>; de Vries, F.<sup>3,4</sup>; van den Bergh, J. P.<sup>5,6,7</sup>; Jensen, M. H.<sup>1</sup>; Vestergaard, P.<sup>1</sup>

Affiliations

¹Steno Diabetes Center North, Aalborg University Hospital, Aalborg, Denmark

²Department of Endocrinology, Aalborg University Hospitall, Aalborg, Denmark

³Department of Clinical Pharmacy & Toxicology, Maastricht UMC+, Maastricht, The Netherlands

⁴Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands

⁵Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands

⁶Department of Internal Medicine, Maastricht UMC+, Maastricht, The Netherlands

⁷Faculty of Medicine and Life Sciences, University Hasselt, Hasselt, Belgium

Abstract and keywords

Summary: Patients with diabetes have an increased risk of fractures. In this study, subtrochanteric and femoral shaft fractures were increased in patients with type 1 diabetes compared with the general population. In the light of this, more evidence points towards an association between diabetes and atypical femoral fractures.

Introduction: Patients with diabetes have an increased risk of femoral fractures, but little is known about the risk of atypical femoral fractures (AFFs). The aim of this study was to identify the risk of subtrochanteric and femoral shaft (ST/FS) fractures and estimate the risk of AFFs in patients with type 1 (T1D) and type 2 diabetes (T2D).

Methods: From the nationwide Danish National Patient Register, we identified patients with T1D (n = 19,896), T2D (n = 312,188), and sex- and aged-matched controls without diabetes (n = 996,252) from the general population and all ST/FS fractures (n = 7509). Data were analyzed using a Cox proportional-hazards model and the incidence rate and rate ratio of ST/FS fractures were estimated.

Results: The incidence rate of ST/FS fractures in T1D was 52.14 events per 100,000 person years and 73.21 per 100,000 person years in T2D. T1D was associated with an increased risk of ST/FS (HR 2.07 (95% CI 1.68–2.56)), whereas T2D was not (HR 0.99 (95% CI 0.94–1.10)). Previous ST/FS fractures were associated with an increased risk of subsequent ST/FS fractures (HR 6.95 (95% CI 6.00–8.05)) and the use of bisphosphonates with an increased risk of ST/FS fractures (HR 1.72 (95% CI 1.54–1.91)).

Conclusion: Patients with T1D have a higher risk of ST/FS fractures compared with sex- and age-matched controls. Since a proportion of ST/FS fractures are classified as AFFs, this could point towards the fact that AFFs also are increased in patients with T1D, but not T2D.

Keywords: Atypical femoral fractures; Diabetes type 1; Diabetes type 2; Femoral shaft fracture; Fractures; Subtrochanteric fracture

Links

DOI: 10.1007/s00198-019-05224-y

PubMed: 31838553

WoS: 000519860900005

History

Received: 2019-07-20

Accepted: 2019-11-05

Online: 2019-12-14

Cited Works (10)

Year	Entry
2007	Vestergaard P. Discrepancies in bone mineral density and fracture risk in patients with type 1 and type 2 diabetes: a meta-analysis. Osteoporos Int. April 2007;18(4):427-444.
2016	Farlay D, Armas LAG, Gineyts E, Akhter MP, Recker RR, Boivin G. Nonenzymatic glycation and degree of mineralization are higher in bone from fractured patients with type 1 diabetes mellitus. J Bone Miner Res. January 2016;31(1):190-195.
2005	Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A. Alcohol intake as a risk factor for fracture. Osteoporos Int. July 2005;16(7):737-742.
2007	Center JR, Bliuc D, Nguyen TV, Eisman JA. Risk of subsequent fracture after low-trauma fracture in men and women. JAMA. January 24, 2007;297(4):387-394.
2011	Schilcher J, Michaëlsson K, Aspenberg P. Bisphosphonate use and atypical fractures of the femoral shaft. NEJM. May 5, 2011;364(18):1728-1737.
2007	Janghorbani M, Van Dam RM, Willett WC, Hu FB. Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture. Am J Epidemiol. September 1, 2007;166(5):495-505.
2015	Shanbhogue VV, Hansen S, Frost M, Jørgensen NR, Hermann AP, Henriksen JE, Brixen K. Bone geometry, volumetric density, microarchitecture, and estimated bone strength assessed by HR-pQCT in adult patients with type 1 diabetes mellitus. J Bone Miner Res. December 2015;30(12):2188-2199.
2014	Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Ebeling PR, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O’Keefe R, Papapoulos S, Howe TS, van der Meulen MCH, Weinstein RS, Whyte MP. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. January 2014;29(1):1-23.
2017	Hygum K, Starup-Linde J, Harsløf1 T, Vestergaard P, Langdahl BL. Diabetes mellitus, a state of low bone turnover: a systematic review and meta-analysis. Eur J Endocrinol. March 2017;176(3):R137-R157.
2018	Samelson EJ, Demissie S, Cupples LA, Zhang X, Xu H, Liu C-T, Boyd SK, McLean RR, Broe KE, Kiel DP, Bouxsein ML. Diabetes and deficits in cortical bone density, microarchitecture, and bone size: Framingham HR-pQCT study. J Bone Miner Res. January 2018;33(1):54-62.

Cited By (1)

Year	Entry
2021	Tsuchie H, Miyakoshi N, Kasukawa Y, Nozaka K, Saito K, Kinoshita H, Kobatyashi M, Suzuki N, Aizawa T, Abe H, Maekawa S, Tomite T, Ono Y, Ouchi K, Shibata N, Nagahata I, Takeshima M, Akagawa M, Yuasa Y, Sato C, Shimada Y. Evaluation of factors affecting the occurrence of second atypical fracture after bone union of the first atypical fracture. Bone. February 2021;143:115671.