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Trends in fractures in patients with spondyloarthritis: a nationwide population-based study (TREND-EspA study)



Our aim was to analyze trends in fracture rates in SpA patients over an extended time period. Only an increase of axial fractures, more specifically vertebral fractures, is observed in SpA.


To analyze fracture incidence and trend in patients with spondyloarthritis (SpA) over an extended time period.


Retrospective observational population-based study with matched cohorts. Data from the Minimum Basic Data Set (MBDS) of Spain were reviewed. All SpA patient hospitalizations reported from 1999 to 2015 (SpA cohort) were analyzed. A control cohort (non-SpA cohort) matched by age, sex, region, and year of hospitalization was recruited. The age and sex-adjusted crude incidence rate was calculated for any fractures (axial and peripheral). Generalized linear models (GLM) were used for trend analysis. Association between fracture type and SpA (and its subtypes) was assessed using unconditional logistic regression models.


In the SpA cohort, the age and sex-adjusted rates per 100,000 inhabitants/year of total fracture and different types of fracture were 45.72 any fractures, 17.64 axial, and 28.02 peripheral; 29.42 osteoporotic (12.67 vertebra, 12.29 hip, 1.50 pelvis, 1.82 humerus and 2.09 radius). In the non-SpA cohort, they were 65.79 any, 12.08 axial, 51.52 peripheral; 31.17 osteoporotic (4.94 vertebra, 16.15 hip, 2.29 pelvis, 3.64 humerus, 5.38 radius). Between 1999 and 2015, the trend in incidence rate for total fracture and different types of fracture increased similarly for both cohorts. In the SpA cohort, an increase of axial fractures was found (AOR 1.444; 95%CI 1.297–1.609), and specifically of vertebral fractures (AOR 2.440; 95%CI 2.097–2.839). Other types of fractures did not increase.


Only an increase of axial fractures, more specifically vertebral fractures, is observed in SpA. Trend in incidence is similar in both cohorts.

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Data availability

The databases used for this study can be made available for review upon request to


  1. 1.

    Moltó A, Etcheto A, van der Heijde D et al (2016) Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study. Ann Rheum Dis 75:1016–1023.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    López-Medina C, Moltó A (2020) Comorbid pain in axial spondyloarthritis, including fibromyalgia. Ther Adv Musculoskelet Dis 12:1759720X20966123.

  3. 3.

    Vosse D, Landewe R, van der Heijde D et al (2009) Ankylosing spondylitis and the risk of fracture: results from a large primary care-based nested case-control study. Ann Rheum Dis 68:1839–1842.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Prieto-Alhambra D, Muñoz-Ortego J, De Vries F et al (2015) Ankylosing spondylitis confers substantially increased risk of clinical spine fractures: a nationwide case-control study. Osteoporos Int 26:85–91.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Kang KY, Ju JH, Park S-H, Hong YS (2020) Longitudinal association between trabecular bone loss and disease activity in axial spondyloarthritis: a 4-year prospective study. J Rheumatol 47:1330–1337.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Kang KY, Jung J-Y, Hong YS et al (2017) Positive correlation between inflammation on sacroiliac joint MRI and serum. Clin Exp Rheumatol 35:415–422

    PubMed  Google Scholar 

  7. 7.

    Adami F, Rossini, et al (2019) Osteoporosis in rheumatic diseases. IJMS 20:5867.

    CAS  Article  PubMed Central  Google Scholar 

  8. 8.

    Fitzgerald GE, O’Dwyer T, Mockler D et al (2020) Pharmacological treatment for managing bone health in axial spondyloarthropathy: systematic review and meta-analysis. Rheumatol Int 40:1369–1384.

    Article  PubMed  Google Scholar 

  9. 9.

    Bernal-Delgado E, García-Armesto S, Peiró S, Atlas VPM Group (2014) Atlas of Variations in Medical Practice in Spain: the Spanish National Health Service under scrutiny. Health Policy 114:15–30.

    Article  Google Scholar 

  10. 10.

    Ministerio de Sanidad, Consumo y Bienestar Social - Estadísticas / Estudios - Sistema de Información Sanitaria del SNS. Accessed 2 Mar 2021

  11. 11.

    Simard M, Sirois C, Candas B (2018) Response to precision on the scope on the combined Comorbidity Index published in: Validation of the combined Comorbidity Index of Charlson and Elixhauser to predict 30-day mortality across ICD-9 and ICD-10. Med Care 56(5):114–447.

    Article  Google Scholar 

  12. 12.

    Seoane-Mato D, Sánchez-Piedra C, Silva-Fernández L et al (2019) Prevalence of rheumatic diseases in adult population in Spain (EPISER 2016 study): aims and methodology. Reumatol Clin 15:90–96.

    Article  PubMed  Google Scholar 

  13. 13.

    Altman DG, Bland JM (2003) Interaction revisited: the difference between two estimates. BMJ 326:219.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Smith E, Hoy DG, Cross M et al (2014) The global burden of other musculoskeletal disorders: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 73:1462.

    Article  PubMed  Google Scholar 

  15. 15.

    Dougados M, Baeten D (2011) Spondyloarthritis Lancet 377:2127–2137.

    Article  PubMed  Google Scholar 

  16. 16.

    Machado P, Landewé R, Braun J et al (2010) Both structural damage and inflammation of the spine contribute to impairment of spinal mobility in patients with ankylosing spondylitis. Ann Rheum Dis 69:1465.

    Article  PubMed  Google Scholar 

  17. 17.

    Maas F, Spoorenberg A, van der Slik BPG et al (2017) Clinical risk factors for the presence and development of vertebral fractures in patients with ankylosing spondylitis: vertebral fractures in AS. Arthritis Care Res 69:694–702.

    Article  Google Scholar 

  18. 18.

    Briot K, Durnez A, Paternotte S et al (2013) Bone oedema on MRI is highly associated with low bone mineral density in patients with early inflammatory back pain: results from the DESIR cohort. Ann Rheum Dis 72:1914.

    Article  PubMed  Google Scholar 

  19. 19.

    Weiss RJ, Wick MC, Ackermann PW, Montgomery SM (2010) Increased fracture risk in patients with rheumatic disorders and other inflammatory diseases—a case-control study with 53,108 patients with fracture: Table 1. J Rheumatol 37:2247–2250.

    Article  PubMed  Google Scholar 

  20. 20.

    Roux C (2011) Osteoporosis in inflammatory joint diseases. Osteoporos Int 22:421–433.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Zhang M, Li X-M, Wang G-S et al (2017) The association between ankylosing spondylitis and the risk of any, hip, or vertebral fracture: a meta-analysis. Medicine 96:e8458.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Muñoz-Ortego J, Vestergaard P, Rubio JB et al (2014) Ankylosing spondylitis is associated with an increased risk of vertebral and nonvertebral clinical fractures: a population-based cohort study: as and increased risk of vertebral and nonvertebral clinical fractures. J Bone Miner Res 29:1770–1776.

    Article  PubMed  Google Scholar 

  23. 23.

    Geusens P, Vosse D, van der Linden S (2007) Osteoporosis and vertebral fractures in ankylosing spondylitis. Curr Opin Rheumatol 19:335–339.

    Article  PubMed  Google Scholar 

  24. 24.

    Maillefert JF, Aho LS, El Maghraoui A et al (2001) Changes in bone density in patients with ankylosing spondylitis: a two-year follow-up study. Osteoporos Int 12:605–609.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Montala N, Juanola X, Collantes E et al (2011) Prevalence of vertebral fractures by semiautomated morphometry in patients with ankylosing spondylitis. J Rheumatol 38:893–897.

    Article  PubMed  Google Scholar 

  26. 26.

    Beek KJ, Rusman T, van der Weijden MAC et al (2019) Long-term treatment with TNF-alpha inhibitors improves bone mineral density but not vertebral fracture progression in ankylosing spondylitis. J Bone Miner Res 34:1041–1048

    CAS  Article  Google Scholar 

  27. 27.

    Ramírez J, Nieto-González JC, Curbelo Rodríguez R et al (2018) Prevalence and risk factors for osteoporosis and fractures in axial spondyloarthritis: a systematic review and meta-analysis. Semin Arthritis Rheum 48:44–52.

    Article  PubMed  Google Scholar 

  28. 28.

    Ognjenovic M, Raymond WD, Inderjeeth CA et al (2020) The risk and consequences of vertebral fracture in patients with ankylosing spondylitis: a population-based data linkage study. J Rheumatol 47:1629–1636.

    Article  PubMed  Google Scholar 

  29. 29.

    Ogdie A, Harter L, Shin D et al (2017) The risk of fracture among patients with psoriatic arthritis and psoriasis: a population-based study. Ann Rheum Dis 76:882–885.

    Article  PubMed  Google Scholar 

  30. 30.

    Kathuria P, Gordon KB, Silverberg JI (2017) Association of psoriasis and psoriatic arthritis with osteoporosis and pathological fractures. J Am Acad Dermatol 76:1045-1053.e3.

    Article  PubMed  Google Scholar 

  31. 31.

    Chen T-L, Lu J-W, Huang Y-W et al (2020) Bone mineral density, osteoporosis, and fracture risk in adult patients with psoriasis or psoriatic arthritis: a systematic review and meta-analysis of observational studies. J Clin Med 9(11):3712.

    CAS  Article  PubMed Central  Google Scholar 

  32. 32.

    Xia J, Xie S-Y, Liu K-Q et al (2020) Systemic evaluation of the relationship between psoriasis, psoriatic arthritis and osteoporosis: observational and Mendelian randomisation study. Ann Rheum Dis 79:1460–1467.

    Article  PubMed  Google Scholar 

  33. 33.

    Mazzucchelli R, Crespi Villarias N, Perez Fernandez E et al (2018) Short-term association between outdoor air pollution and osteoporotic hip fracture. Osteoporos Int 29:2231–2241.

    CAS  Article  PubMed  Google Scholar 

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The authors thank the staff of the Research Unit of the Spanish Society of Rheumatology (SER) for their support in the translation of this manuscript.

To my good friend Caligula who faithfully accompanies me in my research work.


This study was supported by a research grant from Pfizer (Pfizer 61029829) to RM.

Author information




RM and NCV designed the research. EPF, RM and NCV. RM, NCV, EDC, RA, and AGV wrote the paper.

Corresponding author

Correspondence to Ramon Mazzucchelli.

Ethics declarations

Ethics approval

The Hospital Fundación Alcorcon’s Ethics Committee (ref 18/135) evaluated the present project and approved it on December 18th, 2018.

Conflicts of interest

Ramón Mazzucchelli received research grants from Pfizer, Roche, and Amgen due to different projects in the past. The rest of authors have no conflicts of interest to declare. The study is based on data obtained from the Minimum Basic Data Set (MBDS) of Spain provided by its Ministry of Health and Welfare. The interpretation and conclusions do not necessarily represent those of this Ministry.

Statement of human and animal rights

This article does not contain any studies involving human participants or animals that were performed by the authors. For this type of study, formal consent was therefore not required.

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Mazzucchelli, R., Almodovar, R., Dieguez-Costa, E. et al. Trends in fractures in patients with spondyloarthritis: a nationwide population-based study (TREND-EspA study) . Osteoporos Int (2021).

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  • Fractures
  • Hip fracture
  • Vertebral fracture
  • Spondyloarthritis
  • Trend