Aims

Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery’s outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis.

Aims

The Patient-Reported Outcomes Measurement Information System (PROMIS) has demonstrated faster administration, lower burden of data capture and reduced floor and ceiling effects compared to traditional Patient Reported Outcomes Measurements (PROMs). We investigated the suitability of PROMIS Mobility score in assessing physical function in the sequelae of childhood hip disease.

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity. The mean T-score for the distal radius was −2.97 (. sd. 1.56) compared with −1.61 (. sd. 1.62) for the lumbar spine and −1.78 (. sd. 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site. The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb

Objectives. The Oxford Hip and Knee Scores (OHS, OKS) have been demonstrated to vary according to age and gender, making it difficult to compare results in cohorts with different demographics. The aim of this paper was to calculate reference values for different patient groups and highlight the concept of normative reference data to contextualise an individual’s outcome. Methods. We accessed prospectively collected OHS and OKS data for patients undergoing lower limb joint arthroplasty at a single orthopaedic teaching hospital during a five-year period. T-scores were calculated based on the OHS and OKS distributions. . Results. Data were obtained from 3203 total hip arthroplasty (THA) patients and 2742 total knee arthroplasty (TKA) patients. The mean age of the patient was 68.0 years (. sd. 11.3, 58.4% women) in the THA group and in 70.2 (. sd. 9.4; 57.5% women) in the TKA group. T-scores were calculated for age and gender subgroups by operation. Different T-score thresholds are seen at different time points pre and post surgery. Values are further stratified by operation (THA/TKA) age and gender. Conclusions. Normative data interpretation requires a fundamental shift in the thinking as to the use of the Oxford Scores. Instead of reporting actual score points, the patient is rated by their relative position within the group of all patients undergoing the same procedure. It is proposed that this form of transformation is beneficial (a) for more appropriately comparing different patient cohorts and (b) informing an individual patient how they are progressing compared with others of their age and gender. Cite this article: Bone Joint Res 2015;4:137–144

Introduction. The aim of this study was to compare patient reported outcomes, radiographic measurements, and survival free from total hip arthroplasty (THA) in patients who underwent periacetabular osteotomy (PAO) for mild, moderate, or severe developmental dysplasia of the hip (DDH). Methods. We performed a retrospective cohort study on all patients (n=223, n=274 hips) who underwent a PAO procedure between May 1996 and May 2016, by a single surgeon at one academic center. Cases with a history of retroversion (n=64), Perthes (n=5), and those with <2 years of follow-up (n=63) were excluded. Patients were evaluated based on severity of dysplasia using the preoperative lateral center edge angle (LCEA): 18° – 25° was considered mild dysplasia (n=19), 10° – 17° moderate (n=62), and <10° severe (n=61). There was no difference in patient characteristics (age, sex, body mass index, or ASA score) between then cohorts (all, p>0.05). NIH PROMIS outcome measures included the physical function computerized adaptive test (PF CAT) and the Global 10 health assessment. Generalized estimating equations were used for all comparisons and missing data was imputed using the multivariate imputation by chained equations method. A Kaplan-Meier analysis was used to assess survival. Failure was defined as conversion to THA and follow-up was ended at time of failure or at the time of last follow-up. Mean follow-up was five years (1 – 19). Results. Using the mild group as a reference, there was no difference in the PF CAT T-scores for moderate (p=0.167) or severe (p=0.910) dysplasia. These findings were similar for the Global physical and Mental Health T-scores (all, p>0.05). These outcomes were all within ½ of the standard deviation of the US general population (T-Score 50, SD 10) and demonstrate an average level of function or health. There was no difference in the numeric pain scores at last follow-up (all, p>0.05), with scores of approximately 2 – 3 units. There was no difference (all, p>0.05) in the proportion of patients achieving the correction goal for the LCEA (20° – 40°) where 95% (95% CI, 85% – 105%) of the mild group, 95% (95% CI, 90% – 100%) of the moderate group, and 76% (95% CI, 65% – 87%) in the severe group achieved this goal. The average amount of correction was roughly 12° (9° – 15°) in the mild, 15° (13° – 16°) in the moderate (p=0.185), and 23° (21° – 25°) in the severe group (p<0.001). The post-operative anterior center edge angle was in goal in approximately 70% – 80% of the cases for all groups (all, p>0.05). The post-operative acetabular index was within goal in roughly 65% – 75% of the cases in each group (all, p>0.05). Survival free from THA at five years was 100% for the mildly dysplastic, 92% (77% – 98%) for moderately dysplastic, and 96% (85% – 99%) for severely dysplastic hips (p=0.696). Conclusion. Although requiring less correction than hips with moderate or severe dysplasia, we found PAO for mild dysplasia to be associated with promising patient reported outcomes, consistent with that of the general US population, and excellent survivorship at 5 years. Future studies should compare these results to hip arthroscopy in the setting of mild hip dysplasia

Vitamin D is vital for bone health because it assists in the absorption and utilisation of calcium. Vitamin D deficiency may predispose individuals to developing osteoporosis and subsequent osteoporotic fracture. There are various studies in elderly females with hip fractures correlating the low bone mineral density (BMD) with vitamin D levels. But very few studies have evaluated the influence on elderly males. Therefore this study was conducted. All male patients aged more than 50 years presenting to orthopaedic department, in JIPMER, Puducherry, with either fracture neck of femur or intertrochanteric fracture were included. Serum vitamin D level was assessed in them and BMD of both the hips was evaluated by DEXA scan. The vitamin D levels, T-scores, Z-scores were then analysed and correlated. Of the total 41 patients evaluated 21 (51%) had fracture neck of the femur and 20 (49%) patients had intertrochanteric fractures. We found that 11 (26.8%) patients had osteoporosis, 17 (41.5%) had osteopenia, and 13 (31.7%) had normal values. The mean value of total T-scores on fracture side was −1.55 and on no fracture side was −1.88. Among them 9 (22%) patients had vitamin D level <20 ng /mL, 15 (36%) had levels between 20ng–30ng/mL and 17 (41%) had >30ng/mL. Total T-score and Z-score on fracture side and no fracture side showed no correlation with vitamin D (p value >0.05) in these patients. We found significant osteoporosis in both neck and trochanteric regions on both fracture and no fracture sides, yet we had some patients with trochanteric fracture and some with neck fracture on only one side. In view of this other factors like mode of injury, velocity of injury, muscle wasting might have contributed significantly to the type of fracture and side involved. The BMD was found to be lower in patients with neck of femur fracture compared to intertrochanteric fracture, but no correlation was found between vitamin D and BMD scores at neck and trochanteric region. From this study it appears that there is no direct relationship between the vitamin D level and BMD in elderly males with hip fractures. It may emphasise that in male patients with hip fractures vitamin D may not have critical role in development of osteoporosis. The treatment of such patients with vitamin D supplements to prevent hip fractures is still debatable. However further studies in very large groups and controls may bring more light on this subject

Objectives: The aim of this study was to explore the relationship between stress fractures, bone density and factors related to bone metabolism in a comparative group matched study including male military personnel beyond basic training. Materials and Methods: Thirty two patients with stress fractures were matched with 32 uninjured-healthy volunteers (controls), by gender, age, height, body weight and level of physical performance. A questionnaire concerning the calcium intake, alcohol consumption and smoking was completed, the values of several biochemical markers related to bone metabolism were measured from blood samples, and calcaneal quantitative ultrasound was measured by heel ultrasound for each one of the 64 patients and healthy volunteers. Results: Statistically significant lower levels of serum Osteocalcin (p=0.012) and higher levels of Albumin (p=0.006) were found among patients compared to controls. The levels of serum Total Protein, Ca, intact Parathormone and 25-hydroxy Vitamin D were lower among patients compared to controls, but none of these differences was statistically significant (all p> 0.10). Moreover, mean values of T-scores and Z-scores were statistically significantly lower in patients than in controls (p=0.018 for T-scores; p=0.016 for Z-scores). Conclusions: Decreased bone turnover and low calcaneal bone density may increase the incidence of lower extremity stress fractures among men military personnel

Aims: The objective of this study was to establish the validity of biochemical markers in osteoporosis evaluation by comparing the biochemical marker indices with that of T-scores values, considered to be the gold standard of osteoporosis assessment. Methods: Sixty osteoporotic postmenopausal Indian women were recruited in the study on the basis of DEXA T-scores. The biochemical markers estimated were Crosslaps (bone degradation marker), Osteocalcin (bone formation marker), and intact PTH and vitamin D (associated markers). Serum Osteocalcin and 25-OH Vitamin D were estimated by Radioimmunoassay. Intact PTH in the plasma was estimated by Chemiluminescence. Crosslaps was estimated in the second morning void by Enzyme Linked Immuno Sorbent Assay and expressed in terms of mmol creatinine. Results: The results of the present study showed that Crosslaps, the resorption marker was signiþcantly higher (signiþcant at P< 0.5) in osteoporotic patients as compared to that of the controls (n=27). The other three markers were comparable in both the groups and were within the normal range. The most significant þnding of this study was that the resorption marker and DEXA results showed a signiþcant correlation (R=0.82). Conclusions: Of the four biochemical markers assayed, Crosslaps turned out to be the best predictor of the metabolic turnover changes and the values signiþcantly correlated with that of the DEXA scores

Aim: Urinary C-terminal telopeptide of type I collagen (u-CTx) has been reported to be a sensitive biochemical marker of bone turnover. There have been two assays for urinary CTx, which are u-aCTx and u-BCTx. A newly developed immunoassay for serum CTx (s-CTx) is now available for assessment of bone resorption. We have both evaluated the effects of menopause, and osteoporosis on the measurements of serum CTx and compared them to urinary CTx assays. Subjects: 79 premenopausal healthy women, 80 post-menopausal healthy women, 61 osteoporotic patients with vertebral fractures and 34 osteoporotic patients with hip fractures. Results: Bone resorption markers were increased after menopause. There was no significant difference among s-CTx, u-aCTx and u-BCTx in the T-scores of post-menopausal group over premenopausal group (T -score; s-CTx:2.3, u-aCTx:1.8, u-BCTx:2.1). Patients with vertebral fractures and patients with hip fracture had elevated levels of bone resorption markers compared to age-matched healthy postmenopousal women. There was no significant difference among s-CTx, u-aCTx and u-BCTx in the T-scores against postmenopausal group in vertebral fracture group (T -score; s-CTx:0.8, u-aCTx:0.9, u-BCTx:0.7) and in hip fracture group women (T-score; s-CTx:1.1, u-aCTx: 1.3 u-BCTx: 1.3). Conclusions: These findings indicate that s-CTx reflects the increase of bone resorption associated with menopause and osteoporosis with vertebral fractures and hip fractures

Objectives. Researchers continue to seek easier ways to evaluate the quality of bone and screen for osteoporosis and osteopenia. Until recently, radiographic images of various parts of the body, except the distal femur, have been reappraised in the light of dual-energy X-ray absorptiometry (DXA) findings. The incidence of osteoporotic fractures around the knee joint in the elderly continues to increase. The aim of this study was to propose two new radiographic parameters of the distal femur for the assessment of bone quality. Methods. Anteroposterior radiographs of the knee and bone mineral density (BMD) and T-scores from DXA scans of 361 healthy patients were prospectively analyzed. The mean cortical bone thickness (CBTavg) and the distal femoral cortex index (DFCI) were the two parameters that were proposed and measured. Intra- and interobserver reliabilities were assessed. Correlations between the BMD and T-score and these parameters were investigated and their value in the diagnosis of osteoporosis and osteopenia was evaluated. Results. The DFCI, as a ratio, had higher reliability than the CBTavg. Both showed significant correlation with BMD and T-score. When compared with DFCI, CBTavg showed better correlation and was better for predicting osteoporosis and osteopenia. Conclusion. The CBTavg and DFCI are simple and reliable screening tools for the prediction of osteoporosis and osteopenia. The CBTavg is more accurate but the DFCI is easier to use in clinical practice. Cite this article: Q-F. He, H. Sun, L-Y. Shu, Y. Zhu, X-T. Xie, Y. Zhan, C-F. Luo. Radiographic predictors for bone mineral loss: Cortical thickness and index of the distal femur. Bone Joint Res 2018;7:468–475. DOI: 10.1302/2046-3758.77.BJR-2017-0332.R1

Aims

Osteoporosis can determine surgical strategy for total hip arthroplasty (THA), and perioperative fracture risk. The aims of this study were to use hip CT to measure femoral bone mineral density (BMD) using CT X-ray absorptiometry (CTXA), determine if systematic evaluation of preoperative femoral BMD with CTXA would improve identification of osteopenia and osteoporosis compared with available preoperative dual-energy X-ray absorptiometry (DXA) analysis, and determine if improved recognition of low BMD would affect the use of cemented stem fixation.

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The management of periprosthetic joint infection (PJI) remains a major challenge in orthopaedic surgery. In this study, we aimed to characterize the local bone microstructure and metabolism in a clinical cohort of patients with chronic PJI.

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The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

The primary purpose of this study was to evaluate the appropriate use of Dual Energy X-ray absorptiometry (DEXA) scanning in the follow-up of osteoporosis. The secondary aim was to ascertain the correlation between body mass index (BMI) and osteoporosis in the study population. Six hundred and sixty six patients were sent for DEXA scanning from the Osteoporosis clinic at 1-Military Hospital from June 1998 to February 2004. A descriptive expost facto study of primary data was undertaken, consisting of patient records, test results and post treatment test results. Patients were classified according to their World Health Organization (WHO) classification of bone density. Each of the categories was then followed-up to determine an improvement or deterioration in a specific category. A total number of 307 (46.1%) follow-up DEXA scans were done over a period of five years. The majority of patients’ bone mineral density (BMD) remained in the same WHO category while a significant number improved to a higher category. The biggest improvement was in elevating patients from an osteoporosis category to an osteopenic category. Only a small number of patients’ BMD deteriorated. A significant positive correlation between BMI and T-scores for all the patients who received DEXA scans was found. It is therefore apparent that it is safe to follow-up patients with osteoporosis by means of DEXA scanning only once every four to five years. The correlation between BMI and bone mineral density, might serve as a useful guide to identify patients qualifying for more frequent follow up scans

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The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition.

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This study aimed to develop and validate a fully automated system that quantifies proximal femoral bone mineral density (BMD) from CT images.

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Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, postoperative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA and identify the patient characteristics linked to suboptimal trajectories.

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To map the Oxford Knee Score (OKS) and High Activity Arthroplasty Score (HAAS) items to a common scale, and to investigate the psychometric properties of this new scale for the measurement of knee health.

The triple taper polished cemented stem (C-stem, DePuy) was developed to promote calcar loading, and reduce proximal femoral bone resorption and aseptic loosening. We aimed to evaluate the changes in peri-prosthetic bone mineral density using Dual Energy X-ray Absorbtiometry (DEXA) after total hip arthroplasty (THA) using the C-stem prosthesis. One hundred and three patients were recruited voluntarily through and single institution for THA. The prosthesis used was the triple-taper polished cemented C-Stem (De Puy, Warsaw, Indiana, USA). DEXA scans were performed pre- operatively, then at day for, three months, nine months, 18 months and 24 months post-operativley. Scans were analysed with specialised software (Lunar DPX) to measure bone mineral density (BMD) in all seven Gruen zones at each time interval. Changes in calcar BMD were also correlated with patient age, sex, surgical approach, pre-operative BMD and post-operative mobility to identify risk factors for periprosthetic bone resorption. One hundred and three patients underwent 103 primary THA over a five-year period (98 osteoarthritis; 5 AVN). No femoral components were loose at the two year review and none were revised. The most marked bone resorption occured in Gruen zones 1 and 7, and was best preserved in zone 5. BMD decreased rapidly in all zones in the first three months post-operatively, after which the rate of decline slowed substantially. BMD was better preserved medially (zones 6 and 5) than laterally (zones 2 and 3) at 24 months. There was delayed recovery of BMD in all zones except zones 4 and 5. High pre-operative T-scores (>2.0) in the spine, ipsilateral and contralateral femoral neck were associated with the higher post-operative BMD and less bone resorption at all time intervals in Gruen zone 7. Pre-operative osteopenia and osteoporosis were associated with low BMD and accelerated post-operative bone resorption in zone 7. Patients whose mobility rendered them housebound had lower post-operative BMD, and accelerated post-operative BMD loss in zone 7 when compared to non-housebound patients. Females had a lower post-operative BMD and greater loss of BMD in zone 7. Patient age and surgical approach did not effect post-operative BMD or rate of bone resorption in zone 7. The triple-taper femoral stem design did not show an increase in periprosthetic bone density at the proximal femur at two years post-operative. Calcar bone resorption is accelerated by low pre-operative BMD, poor post-operative mobility, and in females. Age and surgical approach do not have significant effects on calcar bone remodelling

Introduction: Osteoporosis is a disease characterized by a low bone mass and the development of nontraumatic fractures. Approximately 700,000 elderly women in the US are newly diagnosed with osteoporotic vertebral fractures every year. Noninvasive measurements of bone mineral density (BMD) are central to the diagnosis and management of osteoporosis. However, BMD alone is not completely satisfactory in vertebral fracture risk assessment. The aim of this study was to identify clinical and laboratoristic factors associated with an increased risk of vertebral fractures in osteoporotic Caucasian women and to define a new clinically relevant scale of risk. Methods: 475 patients consecutively admitted at our ambulatory for the treatment of vertebral osteoporosis were included in the study. All patients were affected by post-menopausal osteoporosis according to the WHO classification criteria. Exclusion criteria were major infectious diseases, tumors and major diseases of sense organs. We attempted to determine whether parameters such as age, body mass index, smoking and alcohol habitudes, femoral and lumbar T-scores, femoral and lumbar Z-scores, femoral and lumbar BMD, total and bone alkaline phosphatase and L3 and T7 vertebral volumes were associated with the risk of vertebral fractures. Results: 173 patients of the entire population presented at least one vertebral fracture for a total of 488 fractures (238 thoracic and 250 lumbar collapses). When considered alone, age (> 65 years-p=0,0001), lumbar T-score (≤-3,5-p=0,0001), lumbar Z-score (≤-2,5-p=0,0050), lumbar BMD (≤0,800-p=0,0017), femoral T-score (≤-3,5-p=0,0090), femoral Z-score (≤-2,5-p=0,0127), L3 volume (≤-2,0SD–p=0,0023) and T7 volume (≤-2,0SD–p=0,0075) were significantly associated with an increased risk of vertebral fractures. Considering only the patients with two fractures or more, the same parameters with the exception of the femoral T-score resulted strongly associated with the risk of new vertebral fractures. Moreover, there was a significantly increased risk of vertebral fractures when two or more of these parameters were present together (p = 0.02). On the base of the obtained data we have then defined a new scale of risk (from grade I-low risk to grade IV-very high risk-p=0.0123) confirmed in a prospective study conducted on 71 osteoporotic patients followed for 30 months. Conclusion: We propose a new clinical scale to easily identify the osteoporotic patient at risk of new vertebral fractures