Hip fracture prognosis: could bioimpedance be an alternative to conventional nutritional assessment?

Background: Risk-factors for mortality in hip fractures encompass nutritional status, nominally body mass index, but not body composition. Given the difficulty of anthropometric assessment in bedridden patients a prospective study with bioimpedance analysis was designed. Methods: Elderly patients with hip fracture were consecutively recruited. Biochemical tests, primitive bioimpedance measurements (resistance, reactance and phase angle) and follow-up till one year were targeted. Results: Patients (N = 69, 81.2 +/- 8.1 years old, 72.5% females) stayed in the hospital for 15.5 +/- 17.1 days, and 18.8 %(13/69) required further hospitalization during the ensuing months. Mortality was 11.6% within 30 days, coinciding with hospital mortality, and an additional 11.6% till one year, thus reaching 23.2%. Anemia, hypoalbuminemia and low transferrin, along with elevated glucose and urea were frequent, suggesting undernutrition with metabolic derangements. Reactance, urea and creatinine were different in patients suffering both early and late demise. Resistance, white blood cell count and osteoporosis were risk factors for early mortality only, and anemia exclusively for late mortality. Conclusions: Primitive bioimpedance measurements, which had not been hitherto investigated, were prognostically related to early and late mortality. These markers of disease-related malnutrition and especially reactance should be further studied in patients unfit for anthropometric evaluation due to fracture and immobility.

Nutrient intakes related to osteoporotic fractures in men and women - The Brazilian Osteoporosis Study (BRAZOS)

Background: Adequate nutrition plays an important role in bone mass accrual and maintenance and has been demonstrated as a significant tool for the prevention of fractures in individuals with osteoporosis. Objective: The aim of the present study was to evaluate bone health-related nutrients intake and its association with osteoporotic fractures in a representative sample of 2344 individuals aged 40 years or older in Brazil. Methods: In a transversal population-based study, a total of 2420 individuals over 40 years old were evaluated from March to April 2006. Participants were men and women from all socioeconomic classes and education levels living around the Brazilian territory Individuals responded a questionnaire including self reported fractures as well a 24-hour food recall. Nutrient intakes were evaluated by Nutrition Data System for Research software (NDSR, University of Minnesota, 2007). Low trauma fracture was defined as that resulting of a fall from standing height or less. Nutrient intakes adequacies were performed by using the DRI's proposed values. Statistical analysis comprises Oneway ANCOVA adjusted by age and use of nutritional supplements and multiple logistic regression. SAS software was used for statistical analysis. Results: Fractures was reported by 13% of men and 15% of women. Women with fractures presented significantly higher calcium, phosphorus and magnesium intakes. However, in all regions and socio-economical levels mean intakes of bone related nutrients were below the recommended levels. It was demonstrated that for every 100 mg/phosphorus increase the risk of fractures by 9% (OR 1.09; IC95% 1.05-1.13, p < 0.001). Conclusion: The results demonstrated inadequacies in bone related nutrients in our population as well that an increase in phosphorus intake is related to bone fractures.

Transient effects of stretching exercises on gait parameters of elderly women

This study aimed to analyse the effects of a single stretching exercise session on a number of gait parameters ill elderly participants in all attempt to determine whether these exercises can influence the risk of fall. Fifteen healthy women living in the community Volunteered to participate in the study. A kinematic gait analysis was performed immediately before and after a session of static stretching exercises applied oil hip flexor/extensor muscles. Results showed a significant influence of stretching exercises on a number of gait parameters, which have previously been proposed as fall predictors. Participants showed increased gait velocity, greater step length and reduced double Support time during stance after performing stretching exercises, suggesting improved stability and mobility. Changes around the pelvis (increased anterior-posterior tilt and rotation range of motion) resulting from the stretching exercises were suggested to influence the gait parameters (velocity, step length and double support time). Therefore, stretching exercises were shown to be a promising strategy to facilitate changes in gait parameters related to the risk of fall. Some other gait variables related to the risk of fall remained Unaltered (e.g., toe clearance). The stable pattern of segmental angular velocities was proposed to explain the stability of these unchanged gait variables. The results indicate that stretching exercises, performed oil a regular (daily) basis, result in gait adaptations which can be considered as indicative of reduced fall risk. Other Studies to determine whether regular stretching routines are an effective strategy to reduce the risk of fall are required. (C) 2008 Elsevier Ltd. All rights reserved.

Vitamin D insufficiency: A risk factor to vertebral fractures in community-dwelling elderly women

Objective:To determine the risk factors for the presence of moderate/severe vertebral fracture, specifically 25-hydroxyvitamin D (25-OHD). Study design: Cross-sectional study conducted for 2 years in the city of Sao Paulo, Brazil including community-dwelling elderly women. Methods: Bone mineral density (BMD), serum 25-OHD, intact parathyroid hormone (iPTH), calcium and estimated glomerular filtration rate (eGFR) were examined in 226 women without vertebral fractures (NO FRACTURE group) and 189 women with at least one moderate/severe vertebral fracture (FRACTURE group). Vertebral fracture assessment (VFA) was evaluated using both the Genant semiquantitative (SQ) approach and morphometry. Results: Patients in the NO FRACTURE group had lower age, increased height, higher calcium intake, and higher BMD compared to those patients in the FRACTURE group (p < 0.05). Of interest, serum levels of 25-OHD in the NO FRACTURE group were higher than those observed in the FRACTURE group (51.73 nmol/L vs. 42.31 nmol/L, p < 0.001). Reinforcing this finding, vitamin D insufficiency (25-OHD < 75 nmol/L) was observed less in the NO FRACTURE group (82.3% vs. 93.65%, p = 0.001). After adjustment for significant variables within the patient population (age, height, race, calcium intake, 25-OHD, eGFR and sites BMD), the logistic-regression analyses revealed that age (OR = 1.09, 95% Cl 1.04-1.14, p < 0.001) femoral neck BMD (OR = 0.7, 95% CI 0.6-0.82, p < 0.001) and 25-OHD <75 nmol/L (OR = 2.38, 95% CI 1.17-4.8, p = 0.016) remains a significant factor for vertebral fracture. Conclusion: Vitamin D insufficiency is a contributing factor for moderate/severe vertebral fractures. This result emphasizes the importance of including this modifiable risk factor in the evaluation of elderly women. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Osteoporotic Fractures in the Brazilian Community-Dwelling Elderly: Prevalence and Risk Factors

The risk of osteoporotic fractures is known to vary among populations. There are no studies analyzing concomitantly clinical, densitometric, and lab risk factors in miscigenated community-dwelling population of Brazil. A total of 1007 elderly subjects (600 women and 407 men) from Sao Paulo, were evaluated using a questionnaire that included risk factors for osteoporotic fractures. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the hip and lumbar spine. Laboratory blood tests were also obtained. The prevalence of osteoporotic fractures was 13.2% (133 subjects), and the main fracture sites were distal forearm (6.0%), humerus (2.3%), femur (1.3%), and ribs (1.1%). Women had a higher prevalence (17.5%; 95% confidence interval [CI]: 14.6-20.6) than men (6.9%; 95% CI: 4.4-9.3) (p < 0.001). After adjusting for significant variables, logistic regression revealed that female gender (odds ratio [OR] = 2.7; 95% CI; 1.6-4.5; p < 0.001), current smoking (OR = 1.9; 95% CI: 1.2-3.3; p = 0.013), and the femoral neck T-score (OR = 0.7; 95% CI: 0.5-0.9; p = 0.001) remain significant risk factors for osteoporotic fractures in the community-dwelling elderly. Our findings identified that female gender, current smoking, and low hip BMD are independent risk factors for osteoporotic fractures.

Consequences of lifetime isolated growth hormone (GH) deficiency and effects of short-term GH treatment on bone in adults with a mutation in the GHRH-receptor gene

Growth hormone (GH) influences bone mass maintenance. However, the consequences of lifetime isolated GH deficiency (IGHD) on bone are not well established. We assessed the bone status and the effect of 6 months of GH replacement in GH-naive adults with IGHD due to a homozygous mutation of the GH-releasing hormone (GHRH)-receptor gene (GHRHR). We studied 20 individuals (10 men) with IGHD at baseline, after 6 months of depot GH treatment, and 6 and 12 months after discontinuation of GH. Quantitative ultrasound (QUS) of the heel was performed and serum osteocalcin (OC) and C-terminal cross-linking telopeptide of type I collagen (ICTP) were measured. QUS was also performed at baseline and 12 months later in a group of 20 normal control individuals (CO), who did not receive GH treatment. At baseline, the IGHD group had a lower T-score on QUS than CO (-1.15 +/- 0.9 vs. -0.07 +/- 0.9, P < 0.001). GH treatment improved this parameter, with improvement persisting for 12 months post-treatment (T-score for IGHD = -0.59 +/- 0.9, P < 0.05). GH also caused an increase in serum OC (baseline vs. pGH, P < 0.001) and ICTP (baseline vs. pGH, P < 0.01). The increase in OC was more marked during treatment and its reduction was slower after GH discontinuation than in ICTP. These data suggest that lifetime severe IGHD is associated with significant reduction in QUS parameters, which are partially reversed by short-term depot GH treatment. The treatment induces a biochemical pattern of bone anabolism that persists for at least 6 months after treatment discontinuation.

Clinical risk factors for osteoporotic fractures in Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS)

The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older. The prevalence of fragility fractures is about 15.1% in the women and 12.8% in the men. Moreover, advanced age, sedentarism, family history of hip fracture, current smoking, recurrent falls, diabetes mellitus and poor quality of life are the main clinical risk factors associated with fragility fractures. The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older with the purpose of identifying the prevalence and the main clinical risk factors (CRF) associated with osteoporotic fracture in our population. A total of 2,420 individuals (women, 70%) from 150 different cities in the five geographic regions in Brazil, and all different socio-economical classes were selected to participate in the present survey. Anthropometrical data as well as life habits, fracture history, food intake, physical activity, falls and quality of life were determined by individual quantitative interviews. The representative sampling was based on Brazilian National data provided by the 2000 and 2003 census. Low trauma fracture was defined as that resulting of a fall from standing height or less in individuals 50 years or older at specific skeletal sites: forearm, femur, ribs, vertebra and humerus. Sampling error was 2.2% with 95% confidence intervals. Logistic regression analysis models were designed having the fragility fracture as the dependent variable and all other parameters as the independent variable. Significance level was set as p < 0.05. The average of age, height and weight for men and women were 58.4 +/- 12.8 and 60.1 +/- 13.7 years, 1.67 +/- 0.08 and 1.56 +/- 0.07 m and 73.3 +/- 14.7 and 64.7 +/- 13.7 kg, respectively. About 15.1% of the women and 12.8% of the men reported fragility fractures. In the women, the main CRF associated with fractures were advanced age (OR = 1.6; 95% CI 1.06-2.4), family history of hip fracture (OR = 1.7; 95% CI 1.1-2.8), early menopause (OR = 1.7; 95% CI 1.02-2.9), sedentary lifestyle (OR = 1.6; 95% CI 1.02-2.7), poor quality of life (OR = 1.9; 95% CI 1.2-2.9), higher intake of phosphorus (OR = 1.9; 95% CI 1.2-2.9), diabetes mellitus (OR = 2.8; 95% CI 1.01-8.2), use of benzodiazepine drugs (OR = 2.0; 95% CI 1.1-3.6) and recurrent falls (OR = 2.4; 95% CI 1.2-5.0). In the men, the main CRF were poor quality of life (OR = 3.2; 95% CI 1.7-6.1), current smoking (OR = 3.5; 95% CI 1.28-9.77), diabetes mellitus (OR = 4.2; 95% CI 1.27-13.7) and sedentary lifestyle (OR = 6.3; 95% CI 1.1-36.1). Our findings suggest that CRF may contribute as an important tool to identify men and women with higher risk of osteoporotic fractures and that interventions aiming at specific risk factors (quit smoking, regular physical activity, prevention of falls) may help to manage patients to reduce their risk of fracture.

RESTORATION OF THE ROTATION CENTER IN MINIMALLY-INVASIVE TOTAL HIP REPLACEMENT

Objective: Our aim was to evaluate the challenges in obtaining a successful restoration of the rotation center as well as a good positioning of the acetabular component when using the minimally-invasive posterior approach for uncemented total hip replacement. Methods: In a comparative non-random prospective study, 64 adult patients underwent elective total hip arthroplasty using the minimally-invasive posterior approach performed by one single surgeon, All patients included in this study had a superior and lateral migration of the rotation center of the hip in comparison to the normal contralateral hip. Patients were excluded from the study if they presented the following: diagnosis of femoral neck fracture, displasic hip types 2, 3 and 4 (Crowe`s classification), osteoarthritis of the contralateral hip. Of the 64 patients in the study, 39 had a radiographic pre-op acetabular size planning equal or less than 50 mm and 25 patients had a radiographic pre-op acetabular size planning equal or more than 52 mm. We considered a good result the following goals: acetabular bend between 35 and 50 degrees, acetabular size according to the pre-op estimative with full contact in the three zones of DeLee-Charnley, a lower medial and vertical positioning of the rotation center in comparison with the pre-op values and a final limb discrepancy lower than 10 mm. Results: A better restoration of the rotation center, as well as, excellent acetabular positioning was found in patients with smaller acetabular size (equal or less than 50), p=0, 04. We must draw attention to two risks when using the minimally-invasive posterior approach: a vertical acetabular position and a lateral position of the acetabular component increasing the risk of a poor contact in the zone 1 due to an insufficient reaming of the medial acetabular host bone. Conclusion: We propose standard surgical approaches in patients with larger anatomical measurements (acetabular planning size more than 50).

SPONTANEOUS FRACTURE OF THE FEMORAL NECK FOLLOWING PFN REMOVAL

Femoral neck fracture without associated trauma following consolidation of a transtrochanteric fracture is a rare event. The authors report a case of transtrochanteric fracture that was treated with PFN and which presented fracturing of the femoral neck two weeks after removal of the device. This occurrence was treated with partial arthroplasty.

Prevalence and risk factors of radiographic vertebral fracture in Brazilian community-dwelling elderly

The prevalence and risk factors of radiographic vertebral fracture were determined among Brazilian community-dwelling elderly. Vertebral fractures were a common condition in this elderly population, and lower hip bone mineral density was a significant risk factor for vertebral fractures in both genders. The aim of the study was to estimate the prevalence of radiographic vertebral fracture and investigate factors associated with this condition in Brazilian community-dwelling elderly. This cross-sectional study included 943 elderly subjects (561 women and 382 men) living in So Paulo, Brazil. Thoracic and lumbar spine radiographs were obtained, and vertebral fractures were evaluated using Genant`s semiquantitative method. Bone mineral density (BMD) was measured by dual X-ray absorptiometry, and bone biochemical markers were also evaluated. Female and male subjects were analyzed independently, and each gender was divided into two groups based on whether vertebral fractures were present. The prevalence of vertebral fracture was 27.5% (95% CI 23.8-31.1) in women and 31.8% in men (95% CI 27.1-36.5) (P = 0.116). Cox regression analyses using variables that were significant in the univariate analysis showed that age (prevalence ratio = 1.03, 95% CI 1.01-1.06; p = 0.019) and total femur BMD (PR = 0.27, 95% CI 0.08-0.98; p = 0.048) were independent factors in predicting vertebral fracture for the female group. In the male group, Cox regression analyses demonstrated that femoral neck BMD (PR = 0.26, 95% CI 0.07-0.98; p = 0.046) was an independent parameter in predicting vertebral fractures. Our results suggest that radiographic vertebral fractures are common in Brazilian community-dwelling elderly and that a low hip BMD was an important risk factor for this condition in both genders. Age was also significantly correlated with the presence of vertebral fractures in women.

Influence of different catilever extensions and glass or polyamaramid reinforcement fibers on fracture strength of implant-supported temporary

In long-term oral rehabilitation treatments, resistance of provisional crowns is a very important factor, especially in cases of an extensive edentulous distal space. The aim of this laboratorial study was to evaluate an acrylic resin cantilever-type prosthesis regarding the flexural strength of its in-balance portion as a function of its extension variation and reinforcement by two types of fibers (glass and polyaramid), considering that literature is not conclusive on this subject. Each specimen was composed by 3 total crowns at its mesial portion, each one attached to an implant component (abutment), while the distal portion (cantilever) had two crowns. Each specimen was constructed by injecting acrylic resin into a two-part silicone matrix placed on a metallic base. In each specimen, the crowns were fabricated with either acrylic resin (control group) or acrylic resin reinforced by glass (Fibrante, Angelus) or polyaramide (Kevlar 49, Du Pont) fibers. Compression load was applied on the cantilever, in a point located 7, 14 or 21 mm from the distal surface of the nearest crown with abutment, to simulate different extensions. The specimen was fixed on the metallic base and the force was applied until fracture in a universal test machine. Each one of the 9 sub-groups was composed by 10 specimens. Flexural strength means (in kgf) for the distances of 7, 14 and 21 mm were, respectively, 28.07, 8.27 and 6.39 for control group, 31.89, 9.18 and 5.16 for Kevlar 49 and 30.90, 9.31 and 6.86 for Fibrante. Data analysis ANOVA showed statistically significant difference (p<0.05) only regarding cantilever extension. Tukey's test detected significantly higher flexural strength for the 7 mm-distance, followed by 14 and 21 mm. Fracture was complete only on specimens of non-reinforced groups.

Influence of intraradicular post and crown ferrule on the fracture strength of endodontically treated teeth

The aim of this study was to investigate the fracture strength of endodontically treated teeth restored with different posts and variable ferrule heights. Sixty freshly extracted human canines were treated endodontically and randomly assigned to 6 groups (n=10), being restored with custom-made cast post-and-core (CP0 and CP3 groups), prefabricated post and composite resin core (PF0 and PF3 groups), and composite resin (CR0 and CR3 groups). The CP0, PF0 and CR0 groups presented no ferrule and the CP3, PF3 and CR3 presented 3 mm of coronal structure. All teeth were restored with full metal crowns. The fracture strength was measured in a universal testing machine at 45o to the long axis of the tooth until failure. Data were analyzed statistically by 2-way ANOVA and Tukey's test (?=0.05). When the mean fracture strength values were compared (CP0 group - 820.20 N, CP3 group - 1179.12 N; PF0 group - 561.05 N; PF3 group - 906.79 N; CR0 group - 297.84 N; and CR3 group - 1135.15 N) there was statistically significant among the groups (p<0.05), except for the three groups with 3 mm of coronal remaining, which were similar to each other. The results of this study showed that the ferrule in crowns promoted significantly higher fracture strength in the endodontically treated teeth.

Fracture resistance of weakened roots restored with composite resin and glass fiber post

This study evaluated the fracture resistance of weakened roots restored with glass fiber posts, composite resin cores and complete metal crowns. Thirty maxillary canines were randomly divided into 3 groups of 10 teeth each: teeth without weakened roots (control); teeth with partially weakened roots (PWR) and teeth with and largely weakened roots (LWR). The control group was restored with glass fiber posts and a composite resin core. Teeth in the PWR and LWR groups were flared internally to standardized dimensions in order to simulate root weakness. Thereafter, the roots were partially filled with composite resin and restored in the same way as in the control group. The specimens were exposed to 250,000 cycles in a controlled chewing simulator. All intact specimens were subjected to a static load (N) in a universal testing machine at 45 degrees to the long axis of the tooth until failure. Data were analyzed by one-way ANOVA and Dunnett's test for multiple comparisons (p=0.05). There were statistically significant difference differences (p<0.01) among the groups (control group = 566.73 N; PWR = 409.64 N; and LWR = 410.91 N), with significantly higher fracture strength for the control group. There was no statistically significant difference (p>0.05) between the weakened groups. The results of this study showed that thicker root dentin walls significantly increase the fracture resistance of endodontically treated teeth.

Effect of different ferrule designs on the fracture resistance and failure pattern of endodontically treated teeth restored with fiber posts and all-ceramic crowns

OBJECTIVE: This study investigated the effect of different ferrule heights on endodontically treated premolars. MATERIAL AND METHODS: Fifty sound mandibular first premolars were endodontically treated and then restored with 7-mm fiber post (FRC Postec Plus #1 Ivoclar-Vivadent) luted with self-polymerized resin cement (Multilink, Ivoclar Vivadent) while the coronal section was restored with hybrid composite core build-up material (Tetric Ceram, Ivoclar-Vivadent), which received all-ceramic crown. Different ferrule heights were investigated: 1-mm circumferential ferrule without post and core (group 1 used as control), a circumferential 1-mm ferrule (group 2), non-uniform ferrule 2-mm buccally and 1-mm lingually (group 3), non-uniform ferrule 3-mm buccally and 2-mm lingually (group 4), and finally no ferrule preparation (group 5). The fracture load and failure pattern of the tested groups were investigated by applying axial load to the ceramic crowns (n=10). Data were analyzed statistically by one-way ANOVA and Tukey's post-hoc test was used for pair-wise comparisons (α=0.05). RESULTS: There were no significant differences among the failure load of all tested groups (P<0.780). The control group had the lowest fracture resistance (891.43±202.22 N) and the highest catastrophic failure rate (P<0.05). Compared to the control group, the use of fiber post reduced the percentage of catastrophic failure while increasing the ferrule height did not influence the fracture resistance of the restored specimens. CONCLUSIONS: Within the limitations of this study, increasing the ferrule length did not influence the fracture resistance of endodontically treated teeth restored with glass ceramic crowns. Insertion of a fiber post could reduce the percentage of catastrophic failure of these restorations under function.

Impact and fracture resistance of an experimental acrylic polymer with elastomer in different proportions

The purpose of this study was to evaluate the impact and fracture resistance of acrylic resins: a heat-polymerized resin, a high-impact resin and an experimental polymethyl methacrylate with elastomer in different proportions (10, 20, 40 and 60%). 120 specimens were fabricated and submitted to conventional heat-polymerization. For impact test, a Charpy-type impact tester was used. Fracture resistance was assessed with a 3-point bending test by using a mechanical testing machine. Ten specimens were used for each test. Fracture (MPa) and impact resistance values (J.m-1) were submitted to ANOVA - Bonferroni's test - 5% significance level. Materials with higher amount of elastomer had statistically significant differences regarding to impact resistance (p < 0.05). Fracture resistance was superior (p < 0.01) for high-resistance acrylic resin. The increase in elastomer concentration added to polymethyl methacrylate raised the impact resistance and decreased the fracture resistance. Processing the material by injection decreased its resistance to impact and fracture.