Percutaneous cement augmentation techniques for osteoporotic spinal fractures

Minimally invasive vertebral augmentation-based techniques have been used for the treatment of spinal fractures (osteoporotic and malignant) for approximately 25 years. In this review, we try to give an overview of the current spectrum of percutaneous augmentation techniques, safety aspects and indications. Crucial factors for success are careful patient selection, proper technique and choice of the ideal cement augmentation option. Most compression fractures present a favourable natural course, with reduction of pain and regainment of mobility after a few days to several weeks, whereas other patients experience a progressive collapse and persisting pain. In this situation, percutaneous cement augmentation is an effective treatment option with regards to pain and disability reduction, improvement of quality of life and ambulatory and pulmonary function.

Incidence and risk factors for early adjacent vertebral fractures after balloon kyphoplasty for osteoporotic fractures: analysis of the SWISSspine registry

PURPOSE The SWISSspine registry (SSR) was launched in 2005 to assess the safety and effectiveness of balloon kyphoplasty (BKP). In the meantime, repeated reports on high rates of adjacent vertebral fractures (ASF) after BKP of vertebral insufficiency fractures were published. The causes for ASF and their risk factors are still under debate. The purpose of this study was to report the incidence and potential risk factors of ASF within the SSR dataset. METHODS The SSR data points are collected perioperatively and during follow-ups, with surgeon- and patient-based information. All patients documented with a monosegmental osteoporotic vertebral insufficiency fracture between March 2005 and May 2012 were included in the study. The incidence of ASF, significant associations with co-variates (patient age, gender, fracture location, cement volume, preoperative segmental kyphosis, extent of kyphosis correction, and individual co-morbidities) and influence on quality of life (EQ-5D) and back pain (VAS) were analyzed. RESULTS A total of 375 patients with a mean follow-up of 3.6 months was included. ASF were found in 9.9 % (n = 37) and occurred on average 2.8 months postoperatively. Preoperative segmental kyphosis >30° (p = 0.026), and rheumatoid arthritis (p = 0.038) and cardiovascular disease (p = 0.047) were significantly associated with ASF. Furthermore, patients with ASF had significantly higher back pain at the final follow-up (p = 0.001). No further significant associations between the studied co-variates and ASF were seen in the adjusted analysis. CONCLUSIONS The findings suggest that patients with a preoperative segmental kyphosis >30° or patients with co-morbidities like rheumatoid arthritis and a cardiovascular disease are at high risk of ASF within 6 months after the index surgery. In case of an ASF event, back pain levels are significantly increased. LEVEL OF EVIDENCE IV.

Finite element analysis predicts experimental failure patterns in vertebral bodies loaded via intervertebral discs up to large deformation

Vertebral compression fracture is a common medical problem in osteoporotic individuals. The quantitative computed tomography (QCT)-based finite element (FE) method may be used to predict vertebral strength in vivo, but needs to be validated with experimental tests. The aim of this study was to validate a nonlinear anatomy specific QCT-based FE model by using a novel testing setup. Thirty-seven human thoracolumbar vertebral bone slices were prepared by removing cortical endplates and posterior elements. The slices were scanned with QCT and the volumetric bone mineral density (vBMD) was computed with the standard clinical approach. A novel experimental setup was designed to induce a realistic failure in the vertebral slices in vitro. Rotation of the loading plate was allowed by means of a ball joint. To minimize device compliance, the specimen deformation was measured directly on the loading plate with three sensors. A nonlinear FE model was generated from the calibrated QCT images and computed vertebral stiffness and strength were compared to those measured during the experiments. In agreement with clinical observations, most of the vertebrae underwent an anterior wedge-shape fracture. As expected, the FE method predicted both stiffness and strength better than vBMD (R2 improved from 0.27 to 0.49 and from 0.34 to 0.79, respectively). Despite the lack of fitting parameters, the linear regression of the FE prediction for strength was close to the 1:1 relation (slope and intercept close to one (0.86 kN) and to zero (0.72 kN), respectively). In conclusion, a nonlinear FE model was successfully validated through a novel experimental technique for generating wedge-shape fractures in human thoracolumbar vertebrae.

Vertebroplastia percutânea por fractura osteoporótica

A Vertebroplastia Percutânea é uma técnica minimamente invasiva relativamente recente, que tem reconhecidas vantagens e aplicações em fracturas compressivas dos corpos vertebrais. Basicamente, consiste na injecção de um Cimento Acrílico no interior do corpo vertebral, e desse modo, minimizar e estabilizar fracturas compressivas dos corpos vertebrais, que são frequentemente de etiologia osteoporótica. Fortemente indicada no tratamento de fracturas incapacitantes, possui como complicação principal o extravasamento do Cimento. Este artigo pretende abordar a técnica, expondo suas indicações, vantagens e complicações mais frequentes. Esta permite reduzir a elevada taxa de morbilidade e impacto económico-social associado à Osteoporose.

Les vertébroplasties: point de vue du rhumatologue [Vertebro-plasty: a rheumatologist's point of view]

Percutaneous vertebro-plasty is an efficient treatment of the symptomatic vertebral compression fracture refractory to optimal medical therapy. The procedure is used for neoplastic lesions, aggressive angioma, but also osteoporotic compression fractures. In order to adequately advice our patients, it is essential to know its indications and possible complications. However, to practice a vertebro-plasty for an osteoporotic compression fracture without any long term management of the osteoporotic disease is useless. Unfortunately, it still happens too often and it is essential that orthopedic surgeons, general practitioner, radiologist, rheumatologist, and any practitioners work together to guarantee the optimal management of our patients.

The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study

Percutaneous vertebroplasty, comprising of the injection of polymethylmethacrylate (PMMA) into vertebral bodies, is an efficient procedure to stabilize osteoporotic compression fractures as well as other weakening lesions. Besides fat embolism, cement leakage is considered to be one of the major and most severe complications during percutaneous vertebroplasty. The viscosity of the PMMA during injection plays a key role in this context. It was shown in vitro that the best way to lower the risk of cement leakage is to inject the cement at higher viscosity, which is requires high injection forces. Injection forces can be reduced by applying a newly developed lavage technique as it was shown in vitro using human cadaver vertebrae. The purpose of this study was to prove the in vitro results in an in vivo model. The investigation was incorporated in an animal study that was performed to evaluate the cardiovascular reaction on cement augmentation using the lavage technique. Injection forces were measured with instrumentation for 1 cc syringes, additionally acquiring plunger displacement. Averaged injection forces measured, ranged from 12 to 130 N and from 28 to 140 N for the lavage group and the control group, respectively. Normalized injection forces (by viscosity and injection speed) showed a trend to be lower for the lavage group in comparison to the control group (P = 0.073). In conclusion, the clinical relevance on the investigated lavage technique concerning lowering injection forces was only shown by trend in the performed animal study. However, it might well be that the effect is more pronounced for osteoporotic vertebral bodies.

Clinical investigations of polymethylmethacrylate cement viscosity during vertebroplasty and related in vitro measurements

Percutaneous vertebroplasty, comprising an injection of polymethylmethacrylate (PMMA) into vertebral bodies, is a practical procedure for the stabilization of osteoporotic compression fractures as well as other weakening lesions. Cement leakage is considered to be one of the major and most severe complications during percutaneous vertebroplasty. The viscosity of the material plays a key role in this context. In order to enhance the safety for the patient, a rheometer system was developed to measure the cement viscosity intraoperatively. For this development, it is of great importance to know the proper viscosity to start the procedure determined by experienced surgeons and the relation between the time period when different injection devices are used and the cement viscosity. The purpose of the study was to investigate the viscosity ranges for different injection systems during conventional vertebroplasty. Clinically observed viscosity values and related time periods showed high scattering. In order to get a better understanding of the clinical observations, cement viscosity during hardening at different ambient temperatures and by simulation of the body temperature was investigated in vitro. It could be concluded, that the direct viscosity assessment with a rheometer during vertebroplasty can help clinicians to define a lower threshold viscosity and thereby decrease the risk of leakage and make adjustments to their injection technique in real time. Secondly, the acceleration in hardening of PMMA-based cements at body temperature can be useful in minimizing leakages by addressing them with a short injection break.

Alterations of bone microarchitecture in young patients with inflammatory bowel diseases are associated with fracture risk during growth

Aims: Inflammatory bowel diseases (IBD) appearing during childhood and adolescence compromise peak bone mass acquisition and increase fracture risk. The structural determinants of bone fragility in IBD however remain unknown. Methods: We investigated volumetric bone mineral density (vBMD), trabecular and cortical bone microstructure at distal radius and tibia by high-resolution pQCT (XtremeCT, Scanco, Switzerland), aBMD at distal radius, hip and spine and vertebral fracture assessment (VFA) by DXA in 107 young patients (mean age 22.8 yrs, range 12.2-33.7 yrs; 62 females and 45 males) with Crohn's disease (n=75), ulcerative colitis (n=25), undetermined colitis (n=2), and no definitive diagnosis (n=5), and in 389 healthy young individuals. Results: Mean disease duration was 6.1 yrs, 89/107 IBD patients received corticosteroids, 83 other immunomodulators, and 59 vitamin D. Clinical fractures were reported by 38 patients (mean age at 1st fracture, 12.6 yrs), the vast majority of the forearm, arm or hand; 5 had vertebral crush fractures (Grade 1 or 2) and 11 had multiple fractures. As compared to healthy controls (matched 2:1 for age, sex, height and fracture history), the 102 patients with established IBD had similar weight but significantly lower aBMD at all sites, lower trabecular (Tb) BV/TV and number, and greater Tb separation and inhomogeneous Tb distribution (1/SD TbN) at both distal radius and tibia, lower tibia cortical thickness (CTh), but no differences in cortical vBMD nor bone perimeter. Among IBD's, aBMD was not associated with fractures (by logistic regression adjusted for age, age square, sex, height, weight and protein intake). However, radius and tibia Tb BV/TV, thickness and SD 1/TbN, as well as radius Tb separation and perimeter, were significantly associated with fracture risk (fully adjusted as above), whereas cortical vBMD and CTh were not. After adjustment for aBMD at radius, respectively at femur neck, radius SD 1/TbN and tibia BV/TV, TbTh and perimeter remained independently associated with fracture risk. Conclusions: Young subjects with IBD have low bone mass and poor bone microarchitecture compared to healthy controls. Alterations of bone microarchitecture, particularly in the trabecular bone compartment, are specifically associated with increased fracture risk during growth.

Behavioral and physiological methods for early quantitative assessment of spinal cord injury and prognosis in rats

Methods for reliable evaluation of spinal cord (SC) injury in rats at short periods (2 and 24 h) after lesion were tested to characterize the mechanisms implicated in primary SC damage. We measured the physiological changes occurring after several procedures for producing SC injury, with particular emphasis on sensorimotor functions. Segmental and suprasegmental reflexes were tested in 39 male Wistar rats weighing 250-300 g divided into three control groups that were subjected to a) anesthesia, b) dissection of soft prevertebral tissue, and c) laminectomy of the vertebral segments between T10 and L1. In the lesion group the SC was completely transected, hemisected or subjected to vertebral compression. All animals were evaluated 2 and 24 h after the experimental procedure by the hind limb motility index, Bohlman motor score, open-field, hot-plate, tail flick, and paw compression tests. The locomotion scale proved to be less sensitive than the sensorimotor tests. A reduction in exploratory movements was detected in the animals 24 h after the procedures. The hot-plate was the most sensitive test for detecting sensorimotor deficiencies following light, moderate or severe SC injury. The most sensitive and simplest test of reflex function was the hot-plate. The hemisection model promoted reproducible moderate SC injury which allowed us to quantify the resulting behavior and analyze the evolution of the lesion and its consequences during the first 24 h after injury. We conclude that hemisection permitted the quantitation of behavioral responses for evaluation of the development of deficits after lesions. Hind limb evaluation scores and spontaneous exploration events provided a sensitive index of immediate injury effects after SC lesion at 2 and 24 h. Taken together, locomotion scales, open-field, and hot-plate tests represent reproducible, quantitatively sensitive methods for detecting functional deficiencies within short periods of time, indicating their potential for the study of cellular mechanisms of primary injury and repair after traumatic SC injury.

Évolution de la gestion pharmacologique de la polyarthrite rhumatoïde et impact sur le risque de fracture ostéoporotique non vertébrale

Au cours des dernières années, le développement des connaissances au niveau de l’étiologie de la maladie ainsi que l’arrivée de nouveaux médicaments et de lignes directrices guidant la pratique clinique sont susceptibles d’avoir entraîné une meilleure gestion de la polyarthrite rhumatoïde (PAR) et de l’ostéoporose, une comorbidité fréquente chez ces patients. Dans cette thèse, trois questions de recherche sont étudiées à l’aide des banques de données administratives québécoises (RAMQ, MED-ÉCHO). Une première étude documente l’utilisation des médicaments pour la PAR au Québec. À ce jour, il s’agit de la seule étude canadienne à rapporter les tendances d’utilisation des DMARD (disease-modifying antirheumatic drug) biologiques depuis leur introduction dans la pratique clinique. Au cours de la période à l’étude (2002-2008), l’utilisation de DMARD (synthétiques et biologiques) a augmenté légèrement dans la population atteinte de PAR (1,9%, 95% CI : 1,1 - 2,8). Cependant, malgré la présence de recommandations cliniques soulignant l’importance de commencer un traitement rapidement, et la couverture de ces traitements par le régime général d’assurance médicaments, les résultats démontrent une initiation sous-optimale des DMARD chez les patients nouvellement diagnostiqués (probabilité d’initiation à 12 mois : 38,5%). L’initiation de DMARD était beaucoup plus fréquente lorsqu’un rhumatologue était impliqué dans la provision des soins (OR : 4,31, 95% CI : 3,73 - 4,97). Concernant les DMARD biologiques, le facteur le plus fortement associé avec leur initiation était l’année calendrier. Chez les sujets diagnostiqués en 2002, 1,2 sur 1 000 ont initié un DMARD biologique moins d’un an après leur diagnostic. Pour ceux qui ont été diagnostiqués en 2007, le taux était de 13 sur 1 000. Les résultats démontrent que si la gestion pharmacologique de la PAR s’est améliorée au cours de la période à l’étude, elle demeure tout de même sous-optimale. Assurer un meilleur accès aux rhumatologues pourrait, semble-t-il, être une stratégie efficace pour améliorer la qualité des soins chez les patients atteints de PAR. Dans une deuxième étude, l’association entre l’utilisation des DMARD biologiques et le risque de fractures ostéoporotiques non vertébrales chez des patients PAR âgés de 50 ans et plus a été rapportée. Puisque l’inflammation chronique résultant de la PAR interfère avec le remodelage osseux et que les DMARD biologiques, en plus de leur effet anti-inflammatoire et immunosuppresseur, sont des modulateurs de l’activité cellulaire des ostéoclastes et des ostéoblastes pouvant possiblement mener à la prévention des pertes de densité minérale osseuse (DMO), il était attendu que leur utilisation réduirait le risque de fracture. Une étude de cas-témoin intra-cohorte a été conduite. Bien qu’aucune réduction du risque de fracture suivant l’utilisation de DMARD biologiques n’ait pu être démontrée (OR : 1,03, 95% CI : 0,42 - 2,53), l’étude établit le taux d’incidence de fractures ostéoporotiques non vertébrales dans une population canadienne atteinte de PAR (11/1 000 personnes - années) et souligne le rôle d’importants facteurs de risque. La prévalence élevée de l’ostéoporose dans la population atteinte de PAR justifie que l’on accorde plus d’attention à la prévention des fractures. Finalement, une troisième étude explore l’impact de la dissémination massive, en 2002, des lignes directrices du traitement de l’ostéoporose au Canada sur la gestion pharmacologique de l’ostéoporose et sur les taux d’incidence de fractures ostéoporotiques non vertébrales chez une population de patients PAR âgés de 50 ans et plus entre 1998 et 2008. Étant donné la disponibilité des traitements efficaces pour l’ostéoporose depuis le milieu des années 1990 et l’évolution des lignes directrices de traitement, une réduction du taux de fractures était attendue. Quelques études canadiennes ont démontré une réduction des fractures suivant une utilisation étendue des médicaments contre l’ostéoporose et de l’ostéodensitométrie dans une population générale, mais aucune ne s’est attardée plus particulièrement sur une population adulte atteinte de PAR. Dans cette étude observationnelle utilisant une approche de série chronologique, aucune réduction du taux de fracture après 2002 (période suivant la dissémination des lignes directrices) n’a pu être démontrée. Cependant, l’utilisation des médicaments pour l’ostéoporose, le passage d’ostéodensitométrie, ainsi que la provision de soins pour l’ostéoporose en post-fracture ont augmenté. Cette étude démontre que malgré des années de disponibilité de traitements efficaces et d’investissement dans le développement et la promotion de lignes directrices de traitement, l’effet bénéfique au niveau de la réduction des fractures ne s’est toujours pas concrétisé dans la population atteinte de PAR, au cours de la période à l’étude. Ces travaux sont les premiers à examiner, à l’aide d’une banque de données administratives, des sujets atteints de PAR sur une période s’étalant sur 11 ans, permettant non seulement l’étude des changements de pratique clinique suivant l’apparition de nouveaux traitements ou bien de nouvelles lignes directrices, mais également de leur impact sur la santé. De plus, via l’étude des déterminants de traitement, les résultats offrent des pistes de solution afin de combler l’écart entre la pratique observée et les recommandations cliniques. Enfin, les résultats de ces études bonifient la littérature concernant la qualité des soins pharmacologiques chez les patients PAR et de la prévention des fractures.

Anterior approaches to the acetabulum

Since the 1960s the ilioinguinal approach by Letournel with the three anatomic windows has been successfully established for the treatment of acetabular fractures involving predominantly the anterior column. The previous standard approach, the iliofemoral approach by Smith-Petersen, is still used for the therapy of anterior wall or isolated femoral head fractures. The increase in acetabular fractures in the elderly with lateral compression fractures after lateral falls, characterized by medial displacement of the quadrilateral plate and superomedial dome impaction, led to the use of the intrapelvic modified Stoppa approach with or without the first window of the ilioinguinal approach in the 1990s. To combine the advantages of the second and third windows of the ilioinguinal approach and the medial view of the modified Stoppa approach the Berne research group recently introduced the pararectus approach in acetabular surgery, which can be used as a less invasive acetabular surgical (LIAS) technique especially in the elderly.

Estudio teórico-experimental sobre el deterioro en tableros de puentes de hormigón producido por la acción del hielo-deshielo con sales de fundentes

El deterioro del hormigón por ciclos de hielo-deshielo en presencia de sales fundentes es causa frecuente de problemas en los puentes e infraestructuras existentes en los países europeos. Los daños producidos por los ciclos de hielo-deshielo en el hormigón pueden ser internos, fundamentalmente la fisuración y/o externos como el descascarillamiento (desgaste superficial). La España peninsular presenta unas características geográficas y climáticas particulares. El 18% de la superficie tiene una altura superior a 1000mts y, además, la altura media geográfica con respecto al nivel del mar es de 660mts (siendo el segundo país más montañoso de toda Europa).Esto hace que la Red de Carreteras del Estado se vea afectada, durante determinados periodos, por fenómenos meteorológicos adversos, en particular por nevadas y heladas, que pueden comprometer las condiciones de vialidad para la circulación de vehículos. Por este motivo la Dirección General de Carreteras realiza trabajos anualmente (campañas de vialidad invernal, de 6 meses de duración) para el mantenimiento de la vialidad de las carreteras cuando éstas se ven afectadas por estos fenómenos. Existen protocolos y planes operativos que permiten sistematizar estos trabajos de mantenimiento que, además, se han intensificado en los últimos 10 años, y que se fundamentan en el empleo de sales fundentes, principalmente NaCl, con la misión de que no haya placas de hielo, ni nieve, en las carreteras. En zonas de fuerte oscilación térmica, que con frecuencia en España se localizan en la zona central del Pirineo, parte de la cornisa Cantábrica y Sistema Central, se producen importantes deterioros en las estructuras y paramentos de hormigón producidos por los ciclos de hielo- deshielo. Pero además el uso de fundentes de vialidad invernal acelera en gran medida la evolución de estos daños. Los tableros de hormigón de puentes de carretera de unos 40-50 años de antigüedad carecen, en general, de un sistema de impermeabilización, y están formados frecuentemente por un firme de mezcla asfáltica, una emulsión adherente y el hormigón de la losa. En la presente tesis se realiza una investigación que pretende reproducir en laboratorio los procesos que tienen lugar en el hormigón de tableros de puentes existentes de carreteras, de unos 40-50 años de antigüedad, que están expuestos durante largos periodos a sales fundentes, con objeto de facilitar la vialidad invernal, y a cambios drásticos de temperatura (hielo y deshielo). Por ello se realizaron cuatro campañas de investigación, teniendo en cuenta que, si bien nos basamos en la norma europea UNE-CEN/TS 12390-9 “Ensayos de hormigón endurecido. Resistencia al hielo-deshielo. Pérdida de masa”, se fabricaron probetas no estandarizadas para este ensayo, pensado en realidad para determinar la afección de los ciclos únicamente a la pérdida de masa. Las dimensiones de las probetas en nuestro caso fueron 150x300 mm, 75 x 150mm (cilíndricas normalizadas para roturas a compresión según la norma UNE-EN 12390-3) y 286x76x76 (prismáticas normalizadas para estudiar cambio de volumen según la norma ASTM C157), lo cual nos permitió realizar sobre las mismas probetas más ensayos, según se presentan en la tesis y, sobre todo, poder comparar los resultados con probetas extraídas de dimensiones similares en puentes existentes. En la primera campaña, por aplicación de la citada norma, se realizaron ciclos de H/D, con y sin contacto con sales de deshielo (NaCl en disolución del 3% según establece dicha norma). El hormigón fabricado en laboratorio, tratando de simular el de losas de tableros de puentes antiguos, presentó una fc de 22,6 MPa y relación agua/cemento de 0,65. Las probetas de hormigón fabricadas se sometieron a ciclos agresivos de hielo/deshielo (H/D), empleando una temperatura máxima de +20ºC y una temperatura mínima de -20ºC al objeto de poder determinar la sensibilidad de este ensayo tanto al tipo de hormigón elaborado como al tipo de probeta fabricado (cilíndrica y prismática). Esta campaña tuvo una segunda fase para profundizar más en el comportamiento de las probetas sometidas a ciclos H/D en presencia de sales. En la segunda campaña, realizada sobre probetas de hormigón fabricadas en laboratorio iguales a las anteriores, la temperaturas mínima del ensayo se subió a -14ºC, lo que nos permitió analizar el proceso de deterioro con más detalle. (Realizando una serie de ensayos de caracterización no destructivos y otros destructivos, y validando su aplicación a la detección de los deterioros causados tras los ensayos acelerados de hielodeshielo. También mediante aplicación de técnicas de microscopía electrónica.) La tercera campaña, se realizó sobre probetas de hormigón de laboratorio similares a las anteriores, fc de 29,3Mpa y relación a/c de 0,65, en las que se aplicó en una cara un revestimiento asfáltico de 2-4cms, según fueran prismáticas y cilíndricas respectivamente, compuesto por una mezcla asfáltica real (AC16), sobre una imprimación bituminosa. (Para simular el nivel de impermeabilización que produce un firme sobre el tablero de un puente) La cuarta campaña, se desarrolló tras una cuidadosa selección de dos puentes de hormigón de 40-50 años de antigüedad, expuestos y sensibles a deterioros de hielodeshielo, y en carreteras con aportación de fundentes. Una vez esto se extrajeron testigos de hormigón de zonas sanas (nervios del tablero), para realizar en laboratorio los mismos ensayos acelerados de hielo-deshielo y de caracterización, de la segunda campaña, basados en la misma norma. De los resultados obtenidos se concluye que cuando se emplean sales fundentes se acelera de forma significativa el deterioro, aumentando tanto el contenido de agua en los poros como el gradiente generado (mecanismo de deterioro físico). Las sales de deshielo aceleran claramente la aparición del daño, que se incrementa incluso en un factor de 5 según se constata en esta investigación para los hormigones ensayados. Pero además se produce un gradiente de cloruros que se ha detectado tanto en los hormigones diseñados en laboratorio como en los extraídos de puentes existentes. En casi todos los casos han aparecido cambios en la microestructura de la pasta de cemento (mecanismo de deterioro químico), confirmándose la formación de un compuesto en el gel CSH de la pasta de cemento, del tipo Ca2SiO3Cl2, que posiblemente está contribuyendo a la alteración de la pasta y a la aceleración de los daños en presencia de sales fundentes. Existe un periodo entre la aparición de fisuración y la pérdida de masa. Las fisuras progresan rápidamente desde la interfase de los áridos más pequeños y angulosos, facilitando así el deterioro del hormigón. Se puede deducir así que el tipo de árido afecta al deterioro. En el caso de los testigos con recubrimiento asfáltico, parece haberse demostrado que la precipitación de sales genera tensiones en las zonas de hormigón cercanas al recubrimiento, que terminan por fisurar el material. Y se constata que el mecanimo de deterioro químico, probablemente tenga más repercusión que el físico, por cuanto el recubrimiento asfáltico es capaz de retener suficiente agua, como para que el gradiente de contenido de agua en el hormigón sea mucho menor que sin el recubrimiento. Se constató, sin embargo, la importancia del gradiente de cloruros en el hormigon. Por lo que se deduce que si bien el recubrimiento asfáltico es ciertamente protector frente a los ciclos H/D, su protección disminuye en presencia de sales; es decir, los cloruros acabarán afectando al hormigón del tablero del puente. Finalmente, entre los hormigones recientes y los antiguos extraídos de puentes reales, se observa que existen diferencias significativas en cuanto a la resistencia a los ciclos H/D entre ellos. Los hormigones más recientes resultan, a igualdad de propiedades, más resistentes tanto a ciclos de H/D en agua como en sales. Posiblemente el hecho de que los hormigones de los puentes hayan estado expuestos a condiciones de temperaturas extremas durante largos periodos de tiempo les ha sensibilizado. La tesis realizada, junto con nuevos contrastes que se realicen en el futuro, nos permitirá implementar una metodología basada en la extracción de testigos de tableros de puente reales para someterlos a ensayos de hielo-deshielo, basados en la norma europea UNECEN/ TS 12390-9 aunque con probetas no normalizadas para el mismo, y, a su vez, realizar sobre estas probetas otros ensayos de caracterización destructivos, que posibilitarán evaluar los daños ocasionados por este fenómeno y su evolución temporal, para actuar consecuentemente priorizando intervenciones de impermeabilización y reparación en el parque de puentes de la RCE. Incluso será posible la elaboración de mapas de riesgo, en función de las zonas de climatología más desfavorable y de los tratamientos de vialidad invernal que se lleven a cabo. Concrete damage by freeze-thaw cycles in the presence of melting salts frequently causes problems on bridges and infrastructures in European countries. Damage caused by freeze-thaw cycles in the concrete can be internal, essentially cracking and / or external as flaking (surface weathering due to environmental action). The peninsular Spain presents specific climatic and geographical characteristics. 18% of the surface has a height greater than 1,000 m and the geographical average height from the sea level is 660 m (being the second most mountainous country in Europe). This makes the National Road Network affected during certain periods due to adverse weather, particularly snow and ice, which can compromise road conditions for vehicular traffic. For this reason the National Road Authority performs works annually (Winter Road Campaign, along 6 months) to maintain the viability of the roads when they are affected by these phenomena. There are protocols and operational plans that allow systematize these maintenance jobs, that also have intensified in the last 10 years, and which are based on the use of deicing salts, mainly NaCl, with the mission that no ice sheets, or snow appear on the roads. In areas of strong thermal cycling, which in Spain are located in the central area of the Pyrenees, part of the Cantabrian coast and Central System, significant deterioration take place in the structures and wall surfaces of concrete due to freeze-thaw. But also the use of deicing salts for winter maintenance greatly accelerated the development of such damages. The concrete decks for road bridges about 40-50 years old, lack generally a waterproofing system, and are often formed by a pavement of asphalt, an adhesive emulsion and concrete slab. In this thesis the research going on aims to reproduce in the laboratory the processes taking place in the concrete of an existing deck at road bridges, about 40-50 years old, they are exposed for long periods to icing salt, to be performed in order to facilitate winter maintenance, and drastic temperature changes (freezing and thawing). Therefore four campaigns of research were conducted, considering that while we rely on the European standard UNE-CEN/TS 12390-9 "Testing hardened concrete. Freezethaw resistance. Mass loss", nonstandard specimens were fabricated for this test, actually conceived to determine the affection of the cycles only to the mass loss. Dimensions of the samples were in our case 150x300 mm, 75 x 150mm (standard cylindrical specimens for compression fractures UNE-EN 12390-3) and 286x76x76 (standard prismatic specimens to study volume change ASTM C157), which allowed us to carry on same samples more trials, as presented in the thesis, and especially to compare the results with similar sized samples taken from real bridges. In the first campaign, by application of that European standard, freeze-thaw cycles, with and without contact with deicing salt (NaCl 3% solution in compliance with such standard) were performed. Concrete made in the laboratory, trying to simulate the old bridges, provided a compressive strength of 22.6 MPa and water/cement ratio of 0.65. In this activity, the concrete specimens produced were subjected to aggressive freeze/thaw using a maximum temperature of +20ºC and a minimum temperature of - 20°C in order to be able to determine the sensitivity of this test to the concrete and specimens fabricated. This campaign had a second phase to go deeper into the behavior of the specimens subjected to cycled freeze/thaw in the presence of salts. In the second campaign, conducted on similar concrete specimens manufactured in laboratory, temperatures of +20ºC and -14ºC were used in the tests, which allowed us to analyze the deterioration process in more detail (performing a series of non-destructive testing and other destructive characterization, validating its application to the detection of the damage caused after the accelerated freeze-thaw tests, and also by applying electron microscopy techniques). The third campaign was conducted on concrete specimens similar to the above manufactured in laboratory, both cylindrical and prismatic, which was applied on one side a 4 cm asphalt coating, consisting of a real asphalt mixture, on a bituminous primer (for simulate the level of waterproofing that produces a pavement on the bridge deck). The fourth campaign was developed after careful selection of two concrete bridges 40- 50 years old, exposed and sensitive to freeze-thaw damage, in roads with input of melting salts. Concrete cores were extracted from healthy areas, for the same accelerated laboratory freeze-thaw testing and characterization made for the second campaign, based on the same standard. From the results obtained it is concluded that when melting salts are employed deterioration accelerates significantly, thus increasing the water content in the pores, as the gradient. Besides, chloride gradient was detected both in the concrete designed in the laboratory and in the extracted in existing bridges. In all cases there have been changes in the microstructure of the cement paste, confirming the formation of a compound gel CSH of the cement paste, Ca2SiO3Cl2 type, which is possibly contributing to impair the cement paste and accelerating the damage in the presence of melting salts. The detailed study has demonstrated that the formation of new compounds can cause porosity at certain times of the cycles may decrease, paradoxically, as the new compound fills the pores, although this phenomenon does not stop the deterioration mechanism and impairments increase with the number of cycles. There is a period between the occurrence of cracking and mass loss. Cracks progress rapidly from the interface of the smallest and angular aggregate, thus facilitating the deterioration of concrete. It can be deduced so the aggregate type affects the deterioration. The presence of melting salts in the system clearly accelerates the onset of damage, which increases even by a factor of 5 as can be seen in this investigation for concrete tested. In the case of specimens with asphalt coating, it seems to have demonstrated that the precipitation of salts generate tensions in the areas close to the concrete coating that end up cracking the material. It follows that while the asphalt coating is certainly a protection against the freeze/thaw cycles, this protection decreases in the presence of salts; so the chlorides will finally affect the concrete bridge deck. Finally, among the recent concrete specimens and the old ones extracted from real bridges, it is observed that the mechanical strengths are very similar to each other, as well as the porosity values and the accumulation capacity after pore water saturation. However, there are significant differences in resistance to freeze/thaw cycles between them. More recent concrete are at equal properties more resistant both cycles freeze/thaw in water with or without salts. Possibly the fact that concrete bridges have been exposed to extreme temperatures for long periods of time has sensitized them. The study, along with new contrasts that occur in the future, allow us to implement a methodology based on the extraction of cores from the deck of real bridges for submission to freeze-thaw tests based on the European standard UNE-CEN/TS 12390-9 even with non-standard specimens for it, and in turn, performed on these samples other destructive characterization tests, which will enable to assess the damage caused by this phenomenon and its evolution, to act rightly prioritizing interventions improving the waterproofing and other repairs in the bridge stock of the National Road Network. It will even be possible to develop risk maps, depending on the worst weather areas and winter road treatments to be carried out.

A Randomized Trial of Sodium Fluoride (60 mg) ± Estrogen in Postmenopausal Osteoporotic Vertebral Fractures

Postmenopausal Caucasian women aged less than 80 years (n = 99) with one or more atraumatic vertebral fracture and no hip fractures, were treated by cyclical administration of enteric coated sodium fluoride (NaF) or no NaF for 27 months, with precautions to prevent excessive stimulation of bone turnover. In the first study 65 women, unexposed to estrogen (-E study), age 70.8 +/- 0.8 years (mean SEM) were all treated with calcium (Ca) 1.0-1.2 g daily and ergocalciferol (D) 0.25 mg per 25 kg once weekly and were randomly assigned to cyclical NaF (6 months on. 3 months off, initial dose 60 mg/day; group F CaD, n = 34) or no NaF (group CaD, n = 3 1). In the second study 34 patients. age 65.5 +/- 1.2 years, on hormone replacement therapy (E) at baseline, had this standardized, and were all treated with Ca and D and similarly randomized (FE CaD, n = 17, E CaD, n = 17) (+E study). The patients were stratified according to E status and subsequently assigned randomly to NaF. Seventy-five patients completed the trial. Both groups treated with NaF showed an increase in lumbar spinal density (by DXA) above baseline by 27 months: FE CaD + 16.2% and F CaD +9.3% (both p = 0.0001). In neither group CaD nor E CaD did lumbar spinal density increase. Peripheral bone loss occurred at most sites in the F CaD group at 27 months: tibia/fibula shaft -7.3% (p = 0.005); femoral shaft -7.1% (p = 0.004); distal forearm -4.0% (p = 0.004); total hip -4.1% (p = 0. 003); and femoral neck -3.5% (p = 0.006). No significant loss occurred in group FE CaD. Differences between the two NaF groups were greatest at the total hip at 27 months but were not significant [p < 0.05; in view of the multiple bone mineral density (BMD) sites, an alpha of 0.01 was employed to denote significance in BMD changes throughout this paper]. Using Cox's proportional hazards model, in the -E study there were significantly more patients with first fresh vertebral fractures in those treated with NaF than in those not so treated (RR = 24.2, p = 0.008, 95% CI 2.3-255). Patients developing first fresh fractures in the first 9 months were markedly different between groups: -23% of F CaD, 0 of CaD, 29% of FE CaD and 0 of E CaD. The incidence of incomplete (stress) fractures was similar in the two NaF-treated groups. Complete nonvertebral fractures did not occur in the two +E groups, there were no differences between groups F CaD and CaD. Baseline BMD (spine and femoral neck) was related to incident vertebral fractures in the control groups (no NaF), but not in the two NaF groups. Our results and a literature review indicate that fluoride salts. if used, should be at low dosage, with pretreatment and co-treatment with a bone resorption inhibitor.

A randomized trial comparing hormone replacement therapy (HRT) and HRT plus calcitriol in the treatment of postmenopausal osteoporosis with vertebral fractures: Benefit of the combination on total body and hip density

We report a prospective, randomized, multi-center, open-label 2-year trial of 81 postmenopausal women aged 53-79 years with at least one minimal-trauma vertebral fracture (VF) and low (T-score below 2) lumbar bone mineral density (BMD). Group HRT received piperazine estrone sulfate (PES) 0.625 - 1.25 mg/d +/- medroxyprogesterone acetate (MPA) 2.5 - 5 mg/d,- group HRT/D received HRT plus calcitriol 0.25 mug bd. All with a baseline dietary calcium (Ca) of < I g/d received Ca carbonate 0.6 g nocte. Final data were on 66 - 70 patients. On HRT/D, significant (P < 0.001) BNID increases from baseline by DXA were at total body - head, trochanter, Ward's, total hip, inter-trochanter and femoral shaft (% group mean Delta 4.2, 6.1, 9.3. 3.7. 3.3 and 3.3%, respectively). On HRT, at these significant Deltas were restricted to the trochanter and sites. si Wards. Significant advantages of HRT/D over HRT were in BMD of total body (- head), total hip and trochanter (all P = 0.01). The differences in mean Delta at these sites were 1.3, 2.6 and 3.9%. At the following, both groups Improved significantly -lumbar spine (AP and lateral), forearm shaft and ultradistal tibia/fibula. The weightbearing, site - specific benefits of the combination associated with significant suppression of parathyroid hormone-suggest a beneficial effect on cortical bone. Suppression of bone turnover was significantly greater on HRT/D (serum osteocalcin P = 0.024 and urinary hydroxyproline/creatinine ratio P = 0.035). There was no significant difference in the number of patients who developed fresh VFs during the trial (HRT 8/36, 22%; HRT/D 4/34, 12% - intention to treat); likewise in the number who developed incident nonvertebral fractures. This Is the first study comparing the 2 treatments in a fracture population. The results indicate a significant benefit of calcitriol combined with HRT on total body BMD and on BNID at the hip, the major site of osteoporotic fracture.

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.