Publications by authors named "Kristyn Hare"

5 Publications

  • Page 1 of 1

Improving Secondary Fracture Prevention After Vertebroplasty: Implementation of a Fracture Liaison Service.

J Am Coll Radiol 2021 Sep 22;18(9):1235-1238. Epub 2021 Jun 22.

Director of Musculoskeletal Ultrasound and Fellowship Director for Musculoskeletal Imaging and Intervention, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Objective: The aim of our study was to evaluate a multidisciplinary fracture liaison service (FLS) to improve osteoporosis treatment and secondary fracture prevention for patients after vertebroplasty.

Methods: A retrospective chart review of consecutive vertebroplasty patients from January 2016 to January 2020. FLS began in December 2016 allowing for before-and-after comparison. Statistical analysis included patient demographics and procedure characteristics. Proportion of patients evaluated by the FLS clinic and treatment modification were evaluated. Opt-in versus opt-out referral strategies were compared. Dual energy x-ray absorptiometry scans or vitamin D levels within 3 months before or after vertebroplasty were assessed. Time to event analysis was used to evaluate secondary fracture occurrence.

Results: There were 137 vertebroplasty patients, 39 before FLS and 98 after FLS, included. Only 15% of all patients were already being treated in a bone health clinic. Of those referred and evaluated by the FLS, 73.0% had their osteoporosis treatment modified. Patients evaluated by the FLS were more likely to have a dual energy x-ray absorptiometry scan or a vitamin D level drawn (P < .001 for both). The opt-out referral was more effective with a 75.0% referral rate (P = .71). Secondary fracture of any kind occurred in 23.4% of all patients. Time to event analysis demonstrated a trend toward a reduced risk of secondary spinal fractures in the fracture prevention group with an adjusted hazard ratio of 0.39 (0.13-1.11, 95% confidence interval).

Discussion: A multidisciplinary FLS can be implemented for patients after vertebroplasty to evaluate osteoporotic risk factors and optimize osteoporosis therapy, both of which are important factors in preventing secondary vertebral fractures.
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September 2021

A probable atypical ulnar fracture in a man receiving denosumab.

Bone 2021 02 29;143:115726. Epub 2020 Oct 29.

University of Wisconsin, Madison, WI, USA.

Background: Atypical femur fractures are widely recognized and associated with anti-resorptive therapy, most commonly bisphosphonates. These fractures generally occur in the femoral shaft or subtrochanteric region. Cases of atypical fractures at non-femur sites, including the ulna, have been reported.

Case Report: Here we report a probable atypical ulnar fracture in a man receiving denosumab, who had been using his upper extremities for transfers and ambulation. Radiographs demonstrated a non-comminuted, transverse fracture somewhat similar to findings of atypical femur fractures. He was deemed a poor surgical candidate and treated with teriparatide. To our knowledge, this is the first reported probable atypical ulnar fracture potentially associated with denosumab use.

Conclusion: We believe it important that clinicians be aware of the association of anti-resorptive therapy with atypical fractures not only of the femur, but also at other skeletal sites. In patients on long-term anti-resorptive therapy, it is appropriate to consider that persistent "prodromal" pain might indicate an impending atypical fracture at an atypical skeletal site.
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February 2021

Preoperative bone health assessment and optimization in spine surgery.

Neurosurg Focus 2020 08;49(2):E2

2University of Wisconsin School of Medicine and Public Health, Osteoporosis Clinical Research Program, Madison, Wisconsin.

Objective: The purpose of this investigation was to characterize the bone health in preoperative spine surgery patients. This information will provide a framework to understand the needs and methods for providing bone health optimization in elective spine surgery patients.

Methods: A retrospective study of 104 patients undergoing bone health optimization was performed. Patients were selected based on risk factors identified by the surgeon and suspected compromised bone health. Evaluation included history and examination, laboratory investigations, and bone mineral density (BMD) at 3 sites (femoral neck, lumbar spine, and radius). Patients' bone status was classified using WHO criteria and expanded criteria recommended by the National Osteoporosis Foundation (NOF). The 10-year Fracture Risk Assessment Tool (FRAX) scores of the hip and major osteoporotic fracture (MOF) were calculated with and without femoral neck BMD, with spine BMD, and with the trabecular bone score (TBS). Antiresorptive and anabolic agents were provided in accordance with meeting NOF criteria for treatment of osteoporosis.

Results: The mean patient age was 69.0 years, and 81% of patients were female. The mean historical height loss was 5.6 cm, and 54% of patients had a history of fracture. Secondary osteoporosis due to chronic renal failure, inflammatory arthritis, diabetes, and steroid use was common (51%). The mean 25-hydroxy vitamin D was 42.4 ng/ml and was normal in 81% of patients, with only 4 patients being deficient. The mean T-scores were -2.09 (SD 0.71) of the femoral neck, -0.54 (1.71) of the lumbar spine, and -1.65 (1.38) of the distal radius. These were significantly different. The 10-year FRAX MOF score was 20.7%, and that for hip fracture was 6.9% using the femoral neck BMD and was not significantly different without the use of BMD. The FRAX risk-adjusted score using the lumbar spine BMD and TBS was significantly lower than that for the hip. Osteoporosis was present in 32.1% according to WHO criteria compared with 81.6% according to NOF criteria. Antiresorptive medications were recommended in 31 patients and anabolic medications in 44 patients.

Conclusions: Surgeons can reliably identify patients with poor bone health by using simple criteria, including historical height loss, history of fracture, comorbidities associated with osteoporosis, analysis of available imaging, and calculation of FRAX score without BMD. High-risk patients should have BMD testing and bone health assessment. In patients with osteoporosis, a comprehensive preoperative bone health assessment is recommended and, if warranted, pharmacological treatment should be started.
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August 2020

Do patients that fracture with normal DXA-measured BMD have normal bone?

Arch Osteoporos 2020 05 11;15(1):70. Epub 2020 May 11.

University of Wisconsin School of Medicine and Public Health, UW Health, 2870 University Avenue, Suite 100, Madison, WI, 53705, USA.

Patients that sustain "osteoporosis-related" fractures may have normal BMD at the hips and spine, but rarely have normal bone when other clinically available studies are considered. Such data often exist and can inform clinical decisions regarding osteoporosis therapy.

Purpose: Dual-energy X-ray absorptiometry (DXA) measured bone mineral density (BMD) at the hip and spine is widely used to diagnose osteoporosis. However, patients that sustain "osteoporosis-related" fractures often have normal BMD at these sites. The aim of this study was to explore whether older adults with fracture, but normal reported hip and spine BMD, also have normal bone using additional clinically available assessments.

Methods: This retrospective electronic medical record study included 387 patients evaluated by a university-based fracture liaison service with spine and hip DXA; 32 (8.3%) had normal spine/hip BMD reported. In this cohort, clinically available bone data including 0.3 and ultradistal radius T-scores, trochanteric T-scores, lumbar spine trabecular bone score (TBS), L1 opportunistic CT Hounsfield units (HU), and femoral cortical index (FCI) were assessed.

Results: One or more of the above noted studies were available in 30/32 patients. UD and 0.3 radius results were available in 21 patients, and 18 (85.7%) had T-scores < - 1.0. Trochanteric values were available in 16; T-scores were < - 1.0 in 18.8%. TBS data were available in 24; partially degraded or degraded values were present in 41.7%. L1 opportunistic CT was available in 25 patients, 80% were below normal, and < 150 HU. Finally, femoral cortical index (FCI) was measurable in 9 subjects; 66.7% were below < 0.4. When including all additional available data in the skeletal assessment, only 5/387 (1.3%) were identified with normal bone.

Conclusion: Patients with normal spine/hip BMD who sustain fracture rarely have normal bone when all available data are considered.
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May 2020

Bone Health Optimization in Orthopaedic Surgery.

J Bone Joint Surg Am 2020 Apr;102(7):574-581

Department of Orthopedics & Rehabilitation (A.K., K.J.H., and P.A.A.), and the Osteoporosis Clinical Research Program (N.B.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: Osteoporosis is associated with adverse orthopaedic surgical outcomes. Bone health optimization is a preoperative intervention intended to reduce the likelihood of postoperative complications. We aimed to characterize a patient cohort referred for bone health optimization to test the hypothesis that poor bone quality is common in orthopaedic surgery and that many such patients meet guidelines for osteoporosis treatment.

Methods: This retrospective study evaluated 124 patients referred for bone health optimization who were ≥50 years of age and candidates for arthroplasty or thoracolumbar surgery. The Fracture Risk Assessment Tool (FRAX) risk factors and dual x-ray absorptiometry (DXA) results were collected. When available, opportunistic computed tomographic (CT) imaging and the trabecular bone score were evaluated. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were applied.

Results: All patients were referred by their orthopaedic surgeon; their mean age was 69.2 years, 83% of patients were female, 97% were Caucasian, and 56% had sustained a previous fracture. The mean historical height loss (and standard deviation) was 5.3 ± 3.3 cm for women and 6.0 ± 3.6 cm for men. The mean lowest T-score of the hip, spine, or wrist was -2.43 ± 0.90 points in women and -2.04 ± 0.81 points in men (p < 0.08). Osteoporosis (T-score of ≤-2.5 points) was present in 45% of women and 20% of men; only 3% of women and 10% of men had normal bone mineral density. Opportunistic CT scans identified 60% of patients as likely having osteoporosis. The trabecular bone score identified 34% of patients with degraded bone microarchitecture and 30% of patients with partially degraded bone microarchitecture. The NOF threshold for osteoporosis treatment was met in 91% of patients. Treatment was prescribed in 75% of patients (45% anabolic therapy and 30% antiresorptive therapy).

Conclusions: Osteoporosis, degraded bone microarchitecture, prior fracture, and elevated fracture risk were common. Given the high prevalence of impaired bone health in this cohort, we believe that bone health screening, including FRAX assessment, should be considered in selected patients undergoing orthopaedic surgery as part of the preoperative optimization for all adults who are ≥50 years of age.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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April 2020