Objectives. Osteoporosis has become an increasing concern for older people as it may potentially lead to osteoporotic fractures. This study is designed to assess the efficacy and safety of ten therapies for post-menopausal women using network meta-analysis. Methods. We conducted a systematic search in several databases, including PubMed and Embase. A random-effects model was employed and results were assessed by the odds ratio (OR) and corresponding 95% confidence intervals (CI). Furthermore, with respect to each outcome, each intervention was ranked according to the surface under the cumulative ranking curve (SUCRA) value. Results. With respect to preventing new vertebral fractures (NVF), all ten drugs outperformed placebo, and etidronate proved to be the most effective treatment (OR 0.24, 95% CI 0.14 to 0.39). In addition, zoledronic acid and parathyroid hormone ranked higher compared with the other drugs. With respect to preventing clinical vertebral fractures (CVF), zoledronic acid proved to be the most effective drug (OR = 0.25, 95% CI 0.08 to 0.92), with denosumab as a desirable second option (OR = 0.48, 95% CI 0.22 to 0.96), when both were compared with placebo. As for adverse events (AE) and severe adverse events (SAE), no significant difference was observed. According to SUCRA, etidronate ranked first in preventing CVF; parathyroid hormone and zoledronic acid ranked highly in preventing NVF and CVF. Raloxifene was safe with a high rank in preventing AEs and SAEs though performed unsatisfactorily in efficacy. Conclusions. This study suggests that, taking efficacy and safety into account, parathyroid hormone and zoledronic acid had the highest probability of satisfactory performance in preventing osteoporotic fractures. Cite this article: G. Wang, L. Sui, P. Gai, G. Li, X. Qi, X. Jiang. The efficacy and safety of vertebral fracture prevention therapies in post-menopausal osteoporosis treatment: Which therapies work best? a network meta-analysis. Bone Joint Res 2017;6:452–463. DOI: 10.1302/2046-3758.67.BJR-2016-0292.R1

The Cochrane Collaboration has produced five new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner These reviews are relevant to a wide range of musculoskeletal specialists, and include reviews in Morton’s neuroma, scoliosis, vertebral fractures, carpal tunnel syndrome, and lower limb arthroplasty

Introduction and Objective. Up to 30% of thoracolumbar (TL) fractures are missed in the emergency room. Failure to identify these fractures can result in neurological injuries up to 51% of the casesthis article aimed to clarify the incidence and risk factors of traumatic fractures in China. The China National Fracture Study (CNFS. Obtaining sagittal and anteroposterior radiographs of the TL spine are the first diagnostic step when suspecting a traumatic injury. In most cases, CT and/or MRI are needed to confirm the diagnosis. These are time and resource consuming. Thus, reliably detecting vertebral fractures in simple radiographic projections would have a significant impact. We aim to develop and validate a deep learning tool capable of detecting TL fractures on lateral radiographs of the spine. The clinical implementation of this tool is anticipated to reduce the rate of missed vertebral fractures in emergency rooms. Materials and Methods. We collected sagittal radiographs, CT and MRI scans of the TL spine of 362 patients exhibiting traumatic vertebral fractures. Cases were excluded when CT and/or MRI where not available. The reference standard was set by an expert group of three spine surgeons who conjointly annotated (fracture/no-fracture and AO Classification) the sagittal radiographs of 171 cases. CT and/or MRI were used confirm the presence and type of the fracture in all cases. 302 cropped vertebral images were labelled “fracture” and 328 “no fracture”. After augmentation, this dataset was then used to train, validate, and test deep learning classifiers based on the ResNet18 and VGG16 architectures. To ensure that the model's prediction was based on the correct identification of the fracture zone, an Activation Map analysis was conducted. Results. Vertebras T12 to L2 were the most frequently involved, accounting for 48% of the fractures. Accuracies of 88% and 84% were obtained with ResNet18 and VGG16 respectively. The sensitivity was 89% with both architectures but ResNet18 had a significantly higher specificity (88%) compared to VGG16 (79%). The fracture zone used was precisely identified in 81% of the heatmaps. Conclusions. Our AI model can accurately identify anomalies suggestive of TL vertebral fractures in sagittal radiographs precisely identifying the fracture zone within the vertebral body

The aim of our study is to investigate the relation between the intensity of pain in the thoracic and lumbar spine and morphometric parameters of vertebrae in postmenopausal women. Materials and methods. We have examined 250 postmenopausal women aged 50–79 years divided into two groups: 171 women without vertebral deformations and 79 women with confirmed vertebral fractures. The duration of pain syndrome after fracture was over 6 months. The presence and intensity of pain syndrome in the thoracic and lumbar spine were assessed using a visual analog scale (VAS). Morphometric analysis of the vertebral parameters was carried out using the VFA software of the dual-energy X-ray densitometer «Prodigy» (GE Medical systems, Lunar, model 8743, 2005). Results. The intensity of pain syndrome in the lumbar spine significantly correlates with L1 vertebral indices: A/P (r=−0.37, p=0.01) and M/P (r=−0.29, p=0.03) in women with normal BMD. The intensity of pain in the thoracic region correlates with Th10 vertebral indices: A/P (r=−0.45, p=0.0004) and M/P (r=−0.35, p=0.01) in women with osteopenia. We have not determined any significant relationship between the level of back pain and vertebral body size index in women with osteoporosis and without vertebral fractures. In 11% patients with confirmed wedge and compression vertebral fractures chronic pain syndrome is absent, and the presence of other fractures does not increase the frequency of back pain syndrome (14%). The presence of vertebral fractures significantly increases the risk of pain in the thoracic spine (RR=1.32; 95% CI: 1.09–1.60, p= 0.004). In patients with vertebral fractures the intensity of pain in the thoracic spine significantly correlates with indices of Th11-Th12vertebrae, and relates to the number and localisation of vertebral fractures. The level of pain in the lumbar region does not depend on the location and number of damaged vertebrae. Conclusion. In postmenopausal women without osteoporosis and vertebral fractures level of pain may be associated with initial vertebral deformation, limiting the spine transition zone. The presence of vertebral fractures increases the risk of pain syndrome in the thoracic region depending on the location and number of damaged vertebrae

Quantitative ultrasound (QUS) is a promising tool to estimate bone structure characteristics and predict fragile fracture. The aim of this pilot cross-sectional study was to evaluate the performance of a multi-channel residual network (MResNet) based on ultrasonic radiofrequency (RF) signal to discriminate fragile fractures retrospectively in postmenopausal women. Methods. RF signal and speed of sound (SOS) were obtained using an axial transmission QUS at one‐third distal radius for 246 postmenopausal women. Based on the involved RF signal, we conducted a MResNet, which combines multi-channel training with original ResNet, to classify the high risk of fragility fractures patients from all subjects. The bone mineral density (BMD) at lumber, hip and femoral neck acquired with DXA was recorded on the same day. The fracture history of all subjects in adulthood were collected. To assess the ability of the different methods in the discrimination of fragile fracture, the odds ratios (OR) calculated using binomial logistic regression analysis and the area under the receiver operator characteristic curves (AUC) were analyzed. Results. Among the 246 postmenopausal women, 170 belonged to the non-fracture group, 50 to the vertebral group, and 26 to the non-vertebral fracture group. MResNet was discriminant for all fragile fractures (OR = 2.64; AUC = 0.74), for Vertebral fracture (OR = 3.02; AUC = 0.77), for non-vertebral fracture (OR = 2.01; AUC = 0.69). MResNet showed comparable performance to that of BMD of hip and lumbar with all types of fractures, and significantly better performance than SOS all types of fractures. Conclusions. the MResNet model based on the ultrasonic RF signal can significantly improve the ability of QUS device to recognize previous fragile fractures. Moreover, the performance of the proposed model modified by age, weight, and height is further optimized. These results open perspectives to evaluate the risk of fragile fracture applying a deep learning model to analyze ultrasonic RF signal

Mechanical failure of spine posterior fixation in the lumbar region Is suspected to occur more frequently when the sagittal balance is not properly restored. While failures at the proximal extremity have been studied in the literature, the lumbar distal junctional pathology has received less attention. The aim of this work was to investigate if the spinopelvic parameters, which characterize the sagittal balance, could predict the mechanical failure of the posterior fixation in the distal lumbar region. All the spine surgeries performed in 2017-2019 at Rizzoli Institute were retrospectively analysed to extract all cases of lumbar distal junctional pathology. All the revision surgeries performed due to the pedicle screws pull-out, or the breakage of rods or screws, or the vertebral fracture, or the degenerative disc disease, in the distal extremity, were included in the junctional (JUNCT) group. A total of 83 cases were identified as JUNCT group. All the 241 fixation surgeries which to date have not failed were included in the control (CONTROL) group. Clinical data were extracted from both groups, and the main spinopelvic parameters were assessed from sagittal standing preoperative (pre-op) and postoperative (post-op) radiographs with the software Surgimap (Nemaris). In particular, pelvic incidence (PI), sagittal vertical axis (SVA), pelvic tilt (PT), T1 pelvic angle (TPA), sacral slope (SS) and lumbar lordosis (LL) have been measured. In JUNCT, the main failure cause was the screws pull-out (45%). Spine fixation with 7 or more levels were the most common in JUNCT (52%) in contrast to CONTROL (14%). In CONTROL, PT, TPA, SS and PI-LL were inside the recommended ranges of good sagittal balance. For these parameters, statistically significant differences were observed between pre-op and post-op (p<0.0001, p=0.01, p<0.0001, p=0.004, respectively, Wilcoxon test). In JUNCT, the spinopelvic parameters were out of the ranges of the good sagittal balance and the worsening of the balance was confirmed by the increase in PT, TPA, SVA, PI-LL and by the decrease of LL (p=0.002, p=0.003, p<0.0001, p=0.001, p=0.001, respectively, paired t-test) before the revision surgery. TPA (p=0.003, Kolmogorov-Smirnov test) and SS (p=0.03, unpaired t-test) differed significantly in pre-op between JUNCT and CONTROL. In post-op, PI-LL was significantly different between JUNCT and CONTROL (p=0.04, unpaired t-test). The regression model of PT vs PI was significantly different between JUNCT and CONTROL in pre-op (p=0.01, Z-test). These results showed that failure is most common in long fused segments, likely due to long lever arms leading to implant failure. If the sagittal balance is not properly restored, after the surgery the balance is expected to worsen, eventually leading to failure: this effect was confirmed by the worsening of all the spinopelvic parameters before the revision surgery in JUNCT. Conversely, a good sagittal balance seems to avoid a revision surgery, as it is visible is CONTROL. The mismatch PI-LL after the fixation seems to confirm a good sagittal balance and predict a good correction. The linear regression of PT vs PI suggests that the spine deformity and pelvic conformation could be a predictor for the failure after a fixation

Worldwide, osteoporosis, causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every 3 seconds, where 1 in every 3 women and 1 in every 5 men aged over 50 will experience osteoporotic fractures at least once in their lifetime. Vertebral fractures, estimated at 1.4 million/year are among the most common fractures, posing enormous health and socioeconomic challenges to the individual and society at large. Considering that the great majority of individuals at high risk (up to 80%), who have already had at least one osteoporotic fracture, are neither identified nor treated, prediction of the risk factors for vertebral fractures can be of great value for prevention/early diagnosis. Recent studies show that finite element analysis of computed tomography (CT) scans provides noninvasive means to assess fracture risk and has the potential to be clinically implemented upon proper validation. The objective of this study was to develop a voxel-based finite element model using quantitative computed tomography (QCT) images in conjunction with in-vitro experiments to evaluate the strength of the vertebral bodies and predict the fracture risk criteria. A total of 10 vertebrae were dissected from juvenile sheep lumbar spines. The attached soft tissues and posterior elements and facet joints were completely removed, and the upper and lower vertebral bodies were polished using glass paper to provide smooth surfaces. The specimens were wrapped in phosphate buffer saline (PBS) soaked gauze, sealed in plastic bags, and stored in a refrigerator at −22°C. QCT scans of the specimens were captured using a bone density calibration phantom (QRM Co., Moehrendorf, Germany) with three 18 mm cylindrical inserts, providing 0, 100 and 200 mg HA/ccm, respectively. All the specimens, preserved hydrated in PBS solution, were mechanically tested at room temperature using a mechanical testing apparatus (Zwick/Roell, Ulm-Germany). The QCT images were then used to reconstruct the voxel-based FE model employing a custom-developed heterogeneous material mapping code. Five different equations for the correlation of the density and the elastic modulus were used to validate the efficiency of the FE model as compared to the in-vitro experiments. The results of the voxel-based FE models matched well with the in-vitro experiments, with an average error of 11.38 (±4.09)% based on the power law equation. A failure criterion was embedded in the FE models and the initiation of fracture was successfully predicted for all specimens. Further, typical kyphoplasty treatment was simulated in the 5 models to evaluate the application of the validated algorithm in the estimation of the failure patterns. Our novel voxel-based FE model can be used in future studies to predict the outcome of different types of therapeutic modalities/surgeries and estimate fracture risk including postoperative fractures

Demographics changes and the increasing incidence of metastatic bone disease are driving the significant issues of vertebral body (VB) fractures as an important consideration in the quality of life of the elderly. Whilst osteoporotic vertebral fractures have been widely studies both clinically and biomechanically, those fractures arising from metastatic infiltration in the spine are relatively poorly understood. Biomechanical in-vitro assessment of these structurally weaker specimens is an important methodology for gaining an understanding of the mechanics of such fractures in which a key aspect is the development of methodologies for predicting the failure load. Here we report on a method to predict the vertebral strength by combining computed tomography assessment with an engineering beam theory as an alternative to more complex finite element analyses and its verification within a laboratory scenario. Ninety-two human vertebral bodies with 3 different pathologies: osteoporosis, multiple myeloma (MM) and specimens containing cancer metastases were loaded using a define protocol and the failure loads recorded. Analysis of the resulting data demonstrated that the mean difference between predicted and experimental failure loads was 0.25kN, 0.41kN and 0.79 kN, with adjunct correlation coefficients of 0.93, 0.64 and 0.79 for osteoporotic, metastatic and MM VBs, respectively. Issues in predicting vertebral fracture arise from extra-vertebral bony formations which add to vertebral strength in osteoporotic VB but are structurally incompetent in metastatic disease. The methodology is currently used in providing better experimental design/benchmarking within in-vitro investigations together with further exploration of its utility in the clinical arena

Background. Understanding vertebral fracture is important in order to reduce fracture risk. Previous studies have used FE to investigate mechanical behaviour, typically using a linear material response. This study aimed to establish a novel model that could represent the plastic behaviour leading to fracture. Method. Porcine vertebrae were mCT scanned and they were loaded to failure in a material test machine (Instron 5965). The specimens were then rescanned. From the first scan, specimen specific FE models were created (ScanIP, Simpleware, UK). Mesh convergence was studied and tetrahedral elements with an approximate element size of 0.7 were used for computational simulations. The relationship between greyscale values (GS) and Young's modulus (E) was optimised to match the experimental load displacement data using Ansys. Further, a plastic material response was modelled. Results. The experimental data showed an initial toe region followed by a linear response, which then displayed plastic deformation prior to failure. The following relationship was stablished for greyscale values of images and E: E=0.98GS+50.836 MPa. The following yield parameters, yield stress=2.2E/227.63 MPa and tangent=6.64E allowed FE prediction of the non-linear part of the experimental data. Conclusion. A mathematical relationship between E and greyscale values combined with plastic response allowed for the first time an FE model to fully represents the actual response of vertebral prior to failure. Level of Evidence. 3b: Individual case-control study

Multiple myeloma (MM) is a chronic, malignant B-cell disorder, with a less than 50% 5-year survival rate [1]. This disease is responsible for vertebral compression fractures (VCFs) in 34 to 64% of diagnosed patients [1], and at least 80% of MM patients experience pathological fractures [3]. Even though reduced DXA-derived bone mineral density (BMD) has been observed in MM patients with vertebral fractures [4], the current quantitative standard method is insufficient in MM due to the osteo-destructive bone changes. Finite-element (FE) analysis is a computational and non-destructive modeling and testing approach to determine bone strength using 3D bone models from CT images. Thus, this study aimed to assess the differences in FE-predicted critical fracture load in MM patients with and without VCFs in the thoracic and lumbar segments of the spine. Multi-detector CT (MDCT) images of two radiologically assessed MM patients (1 with VCFs and 1 without VCFs) were used to generate three-dimensional (3D) models of the whole spine. For each subject, the thoracic segments, 1 to 12 (T1-T12) and lumbar segments, 1 to 5 (L1-L5) were segmented and meshed. Heterogeneous, non-linear anisotropic material properties were applied by discretizing each vertebral segment into 10 distinct sets of materials. A compressive load was simulated by constraining the surface nodes on the inferior endplate in all directions, and a displacement load was applied on the surface nods on the superior endplate [2]. This analysis was performed using ABAQUS version 6.10 (Hibbitt, Karlsson, and Sorensen, Inc., Pawtucket, RI, USA). The MM subject with VCFs had originally experienced fractures in the T4, T5, T12, L1, and L5 segments whereas the MM subject without VCFs experienced none. The former displayed large and abrupt differences in fracture loads between adjacent vertebrae segments, unlike the latter, which exhibited progressive differences instead (no abrupt changes between adjacent vertebrae segments observed). Results from this preliminary study suggest that segments at high risk of fracture are collectively involved in an unstable network, which place the vertebral segments with high values of fracture loads (peaks) as well as the adjacent segments at risk of VCF. For instance, the high fracture load at T11 places T10, T11 and T12 at risk of fracture. Accordingly, T12 has already fractured, and T10 and T11 remain at risk. The relative changes between adjacent vertebrae segments that indicate instability (extremely high fracture load values) enables ease of identification of segments at high fracture risk. Clinicians would be able to work with pre-emptive treatment strategies in future as they can focus on more targeted therapy options at the high-risk vertebrae segments [3]

INTRODUCTION. Over 85% of patients with multiple myeloma (MM) have bone disease, mostly affecting thoraco-lumbar vertebrae. Vertebral fractures can lead to pain and large spinal deformities requiring application of vertebroplasty (PVP). PVP could be enhanced by use of Coblation technique to remove lesions from compromised MM vertebrae prior to cement injection (C-PVP). METHODS. 28 cadaveric MM vertebrae, were initially fractured (IF) up to 75% of its original height on a testing machine, with rate of 1mm/min. Loading point was located at 25% of AP-diameter, from anterior. Two augmentation procedure groups were investigated: PVP and C-PVP. All vertebrae were augmented with 15% of PMMA cement. At the end of each injection the perceived injection force (PIF) was graded on a 5-point scale (1 very easy to 5 almost impossible). Augmented MM vertebrae were re-fractured, following the same protocol as for IF. Failure load (FL) was defined as 0.1% offset evaluated from load displacement curves. RESULTS. Mean initial FL was 2.5kN (STD=1.8kN) and 2.7kN (STD=1.8kN) for PVP and C-PVP, respectively. Mean augmented FL was 3.5kN (STD=3.1kN) and 4.2kN (STD=2.3kN)for PVP and C-PVP, respectively. Only the effect of augmentation was significant(p=0.006). Median PIF on the RIGHT side of vertebrae was 3.0 in PVP group and 2.5 in C-PVP (p=0.054). On the LEFT side it was 3.5 in PVP group and 3.0 in C-PVP (p=0.028). DISCUSSION. Results suggest that Coblation did not compromise strength of augmented MM vertebrae. The PIF was lower for C-PVP, as compared to PVP group, probably due to removal of lesion tissue

Purpose. To compare the efficacy and safety of balloon kyphoplasty (BKP) to non-surgical management (NSM) over 24 months in patients with acute painful fractures by clinical outcomes and vertebral body kyphosis correction and surgical parameters. Material and Methods. Three hundred Adult patients with one to three VCF's were randomised within 3 months of the acute fracture; 149 to Balloon Kyphoplasty and 151 to Non-surgical management. Subjective QOL assessments and objective functional (Timed up and go [TUG]) and vertebral body kyphotic angulation (KA), were assessed over 24 months; we also report surgical parameters and adverse events temporally related to surgery (within 30-days). Results. Kyphoplasty was associated with greater improvements in SF-36 PCS scores when averaged across the 24-month follow-up period, compared with NSM (overall treatment effect 3.24points, 95% CI, 1.47–5.01; p=0.0004)., and TUG (overall treatment effect −3.00 seconds, 95% CI, −1.0 to −5.1; p<0.0043). At 24 months, the change from baseline in KA was statistically significantly improved in the kyphoplasty group (average 3.1°of correction for BKP versus 0.8°for NSM, p=0.003). On average IBT inflation volumes were consistent with cement volumes at 2.4 cc per side. The most common adverse events within 30-days were back pain, new vertebral fracture, nausea/vomiting and UTI. BKP is calculated to be cost-effective in the UK setting. Conclusions. Compared with NSM, BKP improves patient function and QOL when averaged over 24-months and results in better improvement of index vertebral body kyphotic angulation. Author potential conflicts of interest; JVM, LB; SB, DW and JR are consultants for Medtronic Spine LLC for the FREE study; JBT is currently employed by Medtronic, Inc

Low back pain admission to orthopaedics, aged >55, routinely received a myeloma screen (protein electrophoresis and urinary Bence Jones proteins). Myeloma association guidelines outline the symptoms that should trigger investigation. Acute admissions for back pain alone do not form part of this. We aimed to establish the number of emergency back pain admissions, >55, in our unit over two years. We wished to identify all patients who had protein electrophoresis and/or urinary Bence Jones proteins taken, the number of positive results and diagnoses of myeloma. From our database all patients >55 admitted with back pain in 2009 and 2010 were identified. Using the electronic laboratory reporting system we recorded FBC/ESR/Electrophoresis/Urinary Bence-Jones Proteins. There were 7682 admissions from January 2009–December 2010. 87 were for back pain (1.4%). 55 patients were aged >55 years. Within this group – 22 had protein electrophoresis and 23 had Bence-Jones Proteins. All were negative. 36 patients had an ESR taken, 9 were elevated. None were subsequently found to have haematological malignancy. 53 patients had an FBC taken (5 were anaemic, 8 had leucocytosis and 3 had thrombocytopenia). 20 patients had a vertebral fracture (36.4%). There were no documented cases of myeloma. The Information & Statistics Division of NHS Scotland published figures that demonstrate in 2006–2010, in patients > 55, there were 716 new cases of myeloma in the West of Scotland. Extrapolating this to our unit, on average, we would expect 24 new cases / year in this age group from all presentations. Performing myeloma screens on all back pains does not fulfil recognised screening criteria. We propose myeloma screens are not performed routinely in patients >55 admitted with back pain. It would be reasonable to do so where there is evidence of bone marrow failure, or plasmocytoma on Xray, associated with non-mechanical back pain

Summary Statement. It is now possible to diagnose osteoporosis using incidental CT scans; this approach has been used to objectively demonstrate the role of osteoporosis in fracture in ankylosing spondylitis patients. Background. In advanced disease, Ankylosing Spondylitis (AS) is frequently associated with a reduction in bone mineral density (BMD), this contributes to pain and predisposes to fractures. Quantifying this reduction in BMD is complicated by the simultaneous processes occurring, in which there is both an overgrowth of bone (syndesmophytes) and a concurrent loss of trabecular bone. Traditional methods such as dual-energy X-ray absorptiometry (DXA) struggle to generate accurate estimates for BMD in these patients. It has recently become possible to diagnose osteoporosis, with a high sensitivity and specificity, using incidental CT scans of the L1 vertebra. The purpose of this study was to evaluate the use of opportunistic CT screening in the diagnosis of osteoporosis in patients with AS who had sustained vertebral fractures. Patients & Methods. Following Institutional review board approval, patients with AS who presented, with acute fractures of the spine, to our facility between 2004 and 2013 were reviewed to assess whether or not they had a Computed Tomography (CT) scan of the abdomen on admission or in the 6 months before or after injury. In addition, patients were also required to have signs of advanced AS such as the presence of syndesmophytes and syndesmophyte bridging; patients with fractures through L1 were excluded. Of those fitting the criteria, a region of Interest (ROI) was generated over the body of L1, Hounsfield unit (HU) were then measured. Results. Of the 42 patients reviewed, a total of 17 AS patients fit the above criteria. 15 were male and 2 were female, mean age of the whole cohort was 69.9years (range 22–85; SD 15.9). Using a threshold balanced for sensitivity and specificity (<135 HU) which differentiates between osteopenia and osteporosis, 14 (82%) patients were found to have a BMD less than 135HU; a higher threshold (<160 HU) with 90 % sensitivity for differentiating osteoporosis from osteopenia was applied to the group, and 15 patients (88%) were found to be osteoporotic. Of note all the females in the study were osteoporotic. Discussion and Conclusion. This study demonstrates, for the first time, using opportunistic CT screening, that a high proportion of AS patients who sustain fractures have osteoporosis; this overcomes the difficulties that have been encountered with the use of DXA in this unique group of patients. This simple and accessible method saves on excess cost and exposure to radiation. With a high sensitivity, patients identified using this method can then be managed more proactively. We believe these data have the potential to significantly impact the day to day management of patients with spondyloarthropathies

Introduction. Osteoporotic vertebral fractures can cause severe vertebral wedging and kyphotic deformity. This study tested the hypothesis that kyphoplasty restores vertebral height, shape and mechanical function to a greater extent than vertebroplasty following severe wedge fractures. Methods. Pairs of thoracolumbar “motion segments” from seventeen cadavers (70–97 yrs) were compressed to failure in moderate flexion and then cyclically loaded to create severe wedge deformity. One of each pair underwent vertebroplasty and the other kyphoplasty. Specimens were then creep loaded at 1.0kN for 1 hour. At each stage of the experiment the following parameters were measured: vertebral height and wedge angle from radiographs, motion segment compressive stiffness, and stress distributions within the intervertebral discs. The latter indicated intra-discal pressure (IDP) and neural arch load-bearing (F. N. ). Results. Fracture and cyclic loading reduced anterior vertebral height by 34%, increased wedge angle from 5.0° to 11.4°, increased F. N. by 58% and reduced IDP and compressive stiffness by 96% and 44% respectively. Kyphoplasty restored anterior height to a greater extent than vertebroplasty (p<0.001), by 96% versus 59% immediately after augmentation, and by 79% versus 47% after subsequent creep loading. Wedge angle was also reduced to a greater extent following kyphoplasty than vertebroplasty (p<0.02) by 7.2° vs 4.2° after augmentation and 6.6° vs 4.0° after creep loading. IDP, F. N. and compressive stiffness were restored to a similar extent by both procedures. Conclusion. Kyphoplasty and vertebroplasty were equally effective in restoring mechanical function following severe wedge fractures, but kyphoplasty was better able to correct deformity by restoring vertebral height and reducing wedging. No conflicts of interest. Sources of funding: Funding was provided by a Royal College of Surgeons of England Research Fellowship and the Gloucestershire Arthritis Trust. Materials were provided by Medtronic and Depuy. This abstract has not been previously published in whole or substantial part nor has been presented previously at a national meeting

Background and objectives. The prevention of osteoporotic fractures is a global problem. Key to this strategy is efficient identification of ‘at risk’ patients in order to address the osteoporosis pandemic, including the identification of previously sustained fractures. GP practices are now integrating touch screens as a method of registering patients' attendance for an appointment, so all ages of patients are becoming familiar with this channel of communication. Our touch screen patient administered questionnaire system intends to provide an effective solution. Methods. The Virtual Research Integration Collaboration (VRIC) framework supports the integration of basic science and clinical research. It enables the management of research lifecycles by integrating scientific approaches with everyday work practice in a virtual research environment (VRE). ‘Catch Before a Fall’ (CBaF) is a clinical research project using VRIC, using a dedicated interface, co-designed by orthopaedic surgeons and basic scientists, adapted for sensory and IT impaired subjects to capture such information, since approximately 75% of registered over 65 year olds visit their GP each year. Results. Established in test sites across the UK, Data analysis is conducted via the VRIC ‘on-line’ portal. The conclusion of the research process is followed up within that tool. Using the validated osteoporosis risk questionnaire augmented by self reporting of height loss to identify missed vertebral fractures, we calculate the patients' risk factor of developing osteoporosis and of having an osteoporosis related fracture within the next 10 years. Patients' data are collected through CBaF (figure 1) and stored in data structures matching the VRIC architecture for automatic importing via a dedicated script and offering direct clinical service provider feedback. Conclusion. Patients recollect a previous fracture including other risk factors, so we are automating the secure data collection process to improve efficiency and save resources. We should see a ‘win’ for the patient who will receive better informed care. CBaF supports the practice who will streamline their pathway for effective osteoporosis management. The insight into personalised care management is a pathfinder, demonstrating improvement of services for our community, should reduce the greater silent population of osteoporosis sufferers worldwide, addressing the acute service burden ‘at source’

Background. Fracture of an osteoporotic vertebral body reduces vertebral stiffness and decompresses the nucleus in the adjacent intervertebral disc. This leads to high compressive stresses acting on the annulus and neural arch. Altered load-sharing at the fractured level may influence loading of neighbouring vertebrae, increasing the risk of a fracture ‘cascade’. Vertebroplasty has been shown to normalise load-bearing by fractured vertebrae but it may increase the risk of adjacent level fracture. The aim of this study was to determine the effects of fracture and subsequent vertebroplasty on the loading of neighbouring (non-augmented) vertebrae. Methods. Fourteen pairs of three-vertebra cadaver spine specimens (67-92 yr) were loaded to induce fracture. One of each pair underwent vertebroplasty with PMMA, the other with a resin (Cortoss). Specimens were then creep loaded at 1.0kN for 1hr. In 17 specimens where the upper or lower vertebra fractured, compressive stress distributions were measured in the disc between adjacent non-fractured vertebrae by pulling a pressure transducer through the disc whilst under 1.0kN load. These ‘stress profiles’ were obtained at each stage of the experiment (in flexion and extension) in order to quantify intradiscal pressure (IDP), the size of stress concentrations in the posterior annulus (SP) and compressive load-bearing by anterior (FA) and posterior (FP) halves of the vertebral body and by the neural arch (FN). Results. No differences were found between Cortoss and PMMA so all data were pooled. Following fracture, IDP fell by 26% in extension (P=0.004) and SP increased by more than 200% in flexion (P=0.01). FA decreased from 55% to 36% of the applied load in flexion (P=0.002) and from 36% to 27% in extension (P=0.002). FN increased from 17% to 31% in flexion (P=0.006) and from 22% to 37% in extension (P=0.008). Vertebroplasty reduced stress concentrations in the disc and restored load-bearing towards pre-fracture values. Conclusion. Vertebral fracture transfers compressive load from the anterior vertebral body to the posterior vertebral body and neural arch of adjacent (non-fractured) vertebrae. Vertebroplasty largely restores normal load-sharing at both the augmented and adjacent levels and in doing so may help reduce the risk of a spinal fracture cascade

Osteoporosis is a systemic skeletal disorder characterized by reduced bone mass and deterioration of bone microarchitecture, which results in increased bone fragility and fracture risk. Casein kinase 2-interacting protein-1 (CKIP-1) is a protein that plays an important role in regulation of bone formation. The effect of CKIP-1 on bone formation is mainly mediated through negative regulation of the bone morphogenetic protein pathway. In addition, CKIP-1 has an important role in the progression of osteoporosis. This review provides a summary of the recent studies on the role of CKIP-1 in osteoporosis development and treatment.

Cite this article: X. Peng, X. Wu, J. Zhang, G. Zhang, G. Li, X. Pan. The role of CKIP-1 in osteoporosis development and treatment. Bone Joint Res 2018;7:173–178. DOI: 10.1302/2046-3758.72.BJR-2017-0172.R1.

Intermittently administered parathyroid hormone (PTH 1-34) has been shown to promote bone formation in both human and animal studies. The hormone and its analogues stimulate both bone formation and resorption, and as such at low doses are now in clinical use for the treatment of severe osteoporosis. By varying the duration of exposure, parathyroid hormone can modulate genes leading to increased bone formation within a so-called ‘anabolic window’. The osteogenic mechanisms involved are multiple, affecting the stimulation of osteoprogenitor cells, osteoblasts, osteocytes and the stem cell niche, and ultimately leading to increased osteoblast activation, reduced osteoblast apoptosis, upregulation of Wnt/β-catenin signalling, increased stem cell mobilisation, and mediation of the RANKL/OPG pathway. Ongoing investigation into their effect on bone formation through ‘coupled’ and ‘uncoupled’ mechanisms further underlines the impact of intermittent PTH on both cortical and cancellous bone. Given the principally catabolic actions of continuous PTH, this article reviews the skeletal actions of intermittent PTH 1-34 and the mechanisms underlying its effect.

Cite this article: L. Osagie-Clouard, A. Sanghani, M. Coathup, T. Briggs, M. Bostrom, G. Blunn. Parathyroid hormone 1-34 and skeletal anabolic action: The use of parathyroid hormone in bone formation. Bone Joint Res 2017;6:14–21. DOI: 10.1302/2046-3758.61.BJR-2016-0085.R1.

The aim of this biomechanical study was to investigate the role of the dorsal vertebral cortex in transpedicular screw fixation. Moss transpedicular screws were introduced into both pedicles of each vertebra in 25 human cadaver vertebrae. The dorsal vertebral cortex and subcortical bone corresponding to the entrance site of the screw were removed on one side and preserved on the other. Biomechanical testing showed that the mean peak pull-out strength for the inserted screws, following removal of the dorsal cortex, was 956.16 N. If the dorsal cortex was preserved, the mean peak pullout strength was 1295.64 N. The mean increase was 339.48 N (26.13%; p = 0.033). The bone mineral density correlated positively with peak pull-out strength.

Preservation of the dorsal vertebral cortex at the site of insertion of the screw offers a significant increase in peak pull-out strength. This may result from engagement by the final screw threads in the denser bone of the dorsal cortex and the underlying subcortical area. Every effort should be made to preserve the dorsal vertebral cortex during insertion of transpedicular screws.