Prospective evaluation of risk of vertebral fractures using quantitative ultrasound measurements and bone mineral density in a population-based sample of postmenopausal women: results of the Basel Osteoporosis Study.

OBJECTIVE: Prospective studies have shown that quantitative ultrasound (QUS) techniques predict the risk of fracture of the proximal femur with similar standardised risk ratios to dual-energy x-ray absorptiometry (DXA). Few studies have investigated these devices for the prediction of vertebral fractures. The Basel Osteoporosis Study (BOS) is a population-based prospective study to assess the performance of QUS devices and DXA in predicting incident vertebral fractures. METHODS: 432 women aged 60-80 years were followed-up for 3 years. Incident vertebral fractures were assessed radiologically. Bone measurements using DXA (spine and hip) and QUS measurements (calcaneus and proximal phalanges) were performed. Measurements were assessed for their value in predicting incident vertebral fractures using logistic regression. RESULTS: QUS measurements at the calcaneus and DXA measurements discriminated between women with and without incident vertebral fracture, (20% height reduction). The relative risks (RRs) for vertebral fracture, adjusted for age, were 2.3 for the Stiffness Index (SI) and 2.8 for the Quantitative Ultrasound Index (QUI) at the calcaneus and 2.0 for bone mineral density at the lumbar spine. The predictive value (AUC (95% CI)) of QUS measurements at the calcaneus remained highly significant (0.70 for SI, 0.72 for the QUI, and 0.67 for DXA at the lumbar spine) even after adjustment for other confounding variables. CONCLUSIONS: QUS of the calcaneus and bone mineral density measurements were shown to be significant predictors of incident vertebral fracture. The RRs for QUS measurements at the calcaneus are of similar magnitude as for DXA measurements.

Gastric banding induces negative bone remodelling in the absence of secondary hyperparathyroidism: potential role of serum C telopeptides for follow-up.

OBJECTIVE: Data about the consequences of laparoscopic adjustable gastric banding (LAGB) on phospho-calcic and bone metabolism remain scarce. SUBJECTS: We studied a group of 37 obese premenopausal women (age: 24-52 y; mean BMI = 43.7 kg/m2) who underwent LAGB. METHODS: Serum calcium, phosphate, alkaline phosphatase, parathormone (PTH), vitamin D3, serum C-telopeptides, IGFBP-3 and IGF-1 were measured at baseline, 6, 12, 18 and 24 months after surgery. Body composition, bone mineral content (BMC) and density (BMD) were measured using dual-X-ray absorptiometry (DXA) at baseline, 6, 12 and 24 months after surgery. RESULTS: There was no clinically significant decrease of calcemia; PTH remained stable. Serum telopeptides increased by 100% (P < 0.001) and serum IGFBP-3 decreased by 16% (P < 0.001) during the first 6 months, and then stabilized, whereas IGF-1 remained stable over the 2 y. BMC and BMD decreased, especially at the femoral neck; this decrease was significantly correlated with the decrease of waist and hip circumference. CONCLUSIONS: We concluded that there was no evidence of secondary hyperparathyroidism 24 months after LAGB. The observed bone resorption could be linked to the decrease of IGFBP-3, although this decrease could be attributable to other confounding factors. Serum telopeptides seem to be a reliable marker of bone metabolism after gastric banding. DXA must be interpreted cautiously during major weight loss, because of the artefacts caused by the important variation of fat tissue after LAGB.

Variability of indication criteria in knee and hip replacement: an observational study

BACKGROUND. Total knee (TKR) and hip (THR) replacement (arthroplasty) are effective surgical procedures that relieve pain, improve patients' quality of life and increase functional capacity. Studies on variations in medical practice usually place the indications for performing these procedures to be highly variable, because surgeons appear to follow different criteria when recommending surgery in patients with different severity levels. We therefore proposed a study to evaluate inter-hospital variability in arthroplasty indication. METHODS. The pre-surgical condition of 1603 patients included was compared by their personal characteristics, clinical situation and self-perceived health status. Patients were asked to complete two health-related quality of life questionnaires: the generic SF-12 (Short Form) and the specific WOMAC (Western Ontario and Mcmaster Universities) scale. The type of patient undergoing primary arthroplasty was similar in the 15 different hospitals evaluated.The variability in baseline WOMAC score between hospitals in THR and TKR indication was described by range, mean and standard deviation (SD), mean and standard deviation weighted by the number of procedures at each hospital, high/low ratio or extremal quotient (EQ5-95), variation coefficient (CV5-95) and weighted variation coefficient (WCV5-95) for 5-95 percentile range. The variability in subjective and objective signs was evaluated using median, range and WCV5-95. The appropriateness of the procedures performed was calculated using a specific threshold proposed by Quintana et al for assessing pain and functional capacity. RESULTS. The variability expressed as WCV5-95 was very low, between 0.05 and 0.11 for all three dimensions on WOMAC scale for both types of procedure in all participating hospitals. The variability in the physical and mental SF-12 components was very low for both types of procedure (0.08 and 0.07 for hip and 0.03 and 0.07 for knee surgery patients). However, a moderate-high variability was detected in subjective-objective signs. Among all the surgeries performed, approximately a quarter of them could be considered to be inappropriate. CONCLUSIONS. A greater inter-hospital variability was observed for objective than for subjective signs for both procedures, suggesting that the differences in clinical criteria followed by surgeons when indicating arthroplasty are the main responsible factors for the variation in surgery rates.

The long and painful path towards arthroplasty: A qualitative study

Hip or knee arthroplasty is proposed after osteoarthritis or an accident. It is decided after a long path of pain and decrease in the quality of life. This research explores the period of illness until surgery. Twenty-four semi-structured interviews were conducted one month before surgery and a thematic discourse analysis performed. The diversity and complexity of the patient experience, in a commonly performed surgical intervention underlines important topics, requiring attention in order to improve patient preparations and information prior to arthroplasty: information adapted to individual concerns, needs and representations. Psychological and physical acceptance is necessary for integration of the prosthesis.

Effect of a general school-based physical activity intervention on bone mineral content and density: A cluster-randomized controlled trial.

Background: Specific physical loading leads to enhanced bone development during childhood. A general physical activity program mimicking a real-life situation was successful at increasing general physical health in children. Yet, it is not clear whether it can equally increase bone mineral mass. We performed a cluster-randomized controlled trial in children of both gender and different pubertal stages to determine whether a school-based physical activity (PA) program during one school-year influences bone mineral content (BMC) and density (BMD), irrespective of gender.Methods: Twenty-eight 1st and 5th grade (6-7 and 11-12 year-old) classes were cluster randomized to an intervention (INT, 16 classes, n = 297) and control (CON; 12 classes, n = 205) group. The intervention consisted of a multi-component PA intervention including daily physical education with at least 10 min of jumping or strength training exercises of various intensities. Measurements included anthropometry, and BMC and BMD of total body, femoral neck, total hip and lumbar spine using dual-energy X-ray absorptiometry (DXA). PA was assessed by accelerometers and Tanner stages by questionnaires. Analyses were performed by a regression model adjusted for gender, baseline height and weight, baseline PA, post-intervention pubertal stage, baseline BMC, and cluster.Results: 275 (72%) of 380 children who initially agreed to have DXA measurements had also post-intervention DXA and PA data. Mean age of prepubertal and pubertal children at baseline was 8.7 +/- 2.1 and 11.1 +/- 0.6 years, respectively. Compared to CON, children in INT showed statistically significant increases in BMC of total body, femoral neck, and lumbar spine by 5.5%, 5.4% and 4.7% (all p < 0.05), respectively, and BMD of total body and lumbar spine by 8.4% and 7.3% (both p < 0.01), respectively. There was no gender*group, but a pubertal stage*group interaction consistently favoring prepubertal children.Conclusion: A general school-based PA intervention can increase bone health in elementary school children of both genders, particularly before puberty. (C) 2010 Elsevier Inc. All rights reserved.

Reversed shoulder arthroplasty baseplate fixed according to the major columns principle

Purpose Cadaveric study at our institution has demonstrated that optimal basaplate fixation of a reversed shoulder arthroplasty (RSA) could be achieved with screws in three major columns. Our aim was to review our early rate of aseptic glenoid loosening in a series of baseplate fixed according to this principle. Material and Methods Between 2005 and 2008, 48 RSA (Aequalis Reversed) were implanted in 48 patients with an average age of 74.4 years (range, 56 to 86 years). There were 37 women and 11 men. Twenty-seven primary RSAs were performed for cuff tear arthropathy, 3 after failed rotator cuff surgery, 6 for failed arthroplasties, 7 for acute fractures and 5 after failed ORIF. All baseplate fixation were done using a nonlocking posterior screw in the spine, a nonlocking anterior screw in the glenoid body, a locking superior screw in the coracoid and a locking inferior screw in the pillar. All patients were reviewed with standardized radiographs. The number of screws were reported. We measured the position of the screws in relation to the scapular spine and the coracoid process in two different views. We defined screw positions as totally, partially or out of the target. Finally we reported glenoid aseptic loosening which was defined as implant subsidence. Results Four patients were lost to follow-up. Thus, 44 shoulders could be reviewed after a mean follow-up of 13 months (range, 6 to 32 months). All baseplates were fixed with 4 screws. Thirty-seven (84%) screws were either partially or totally in the spine. Thus, 7 (16%) scapular spine screws were out of the target. No coracoid screw was out the target. Two (4.5%) patients had glenoid loosening. Both had a scapular spine and a coracoid screw partially in the bone. Conclusion Early aseptic glenoid loosening occurred before the two years follow-up and is most of time related to technical problems and/or insufficient bone stock and bone quality. Our study demonstrate that baseplate fixation according to the three columns principle is a reproducible technique and a valuable way to prevent early glenoid loosening.

Long gamma nail in the treatment of subtrochanteric fractures.

INTRODUCTION: The purpose of our study was to retrospectively evaluate the clinical and radiological results of subtrochanteric fractures treated with a long gamma nail (LGN). The LGN has been the implant of choice at our level-1 trauma center since 1992. MATERIALS AND METHODS: Over a period of 7 years, we have treated 90 consecutive patients with subtrochanteric fractures. In order to evaluate the clinical and radiological outcomes, we reviewed the clinical and radiographic charts of these patients followed for a mean time of 2 years (range 13-36 months). RESULTS: We found no intra- or perioperative complications nor early or late infection. Clinical and radiological union was achieved at a mean of 4.3 months in all of the patients (range 3-9 months); in 24 cases (30%) the distal locking bolts were retrieved in order to enhance callus formation and remodeling as a planned secondary surgery. Three patients (3.3%) needed unplanned secondary surgery for problems related to the nailing technique. Two mechanical failures with breakage of the nail were encountered due to proximal varus malalignment, of which one was treated with exchange nailing and grafting and the other one by removal of the broken hardware, blade-plating, and bone grafting. One fracture below a short LGN was treated by exchange nailing. CONCLUSIONS: The minimally invasive technique and simple application of the LGN lead to a low percentage of complications in these difficult fractures after a relatively short learning curve. The biomechanical properties of this implant allow early mobilization and partial weight-bearing even in patients with advanced osteoporosis.

The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women.

SUMMARY: BMD and clinical risk factors predict hip and other osteoporotic fractures. The combination of clinical risk factors and BMD provide higher specificity and sensitivity than either alone. INTRODUCTION AND HYPOTHESES: To develop a risk assessment tool based on clinical risk factors (CRFs) with and without BMD. METHODS: Nine population-based studies were studied in which BMD and CRFs were documented at baseline. Poisson regression models were developed for hip fracture and other osteoporotic fractures, with and without hip BMD. Fracture risk was expressed as gradient of risk (GR, risk ratio/SD change in risk score). RESULTS: CRFs alone predicted hip fracture with a GR of 2.1/SD at the age of 50 years and decreased with age. The use of BMD alone provided a higher GR (3.7/SD), and was improved further with the combined use of CRFs and BMD (4.2/SD). For other osteoporotic fractures, the GRs were lower than for hip fracture. The GR with CRFs alone was 1.4/SD at the age of 50 years, similar to that provided by BMD (GR = 1.4/SD) and was not markedly increased by the combination (GR = 1.4/SD). The performance characteristics of clinical risk factors with and without BMD were validated in eleven independent population-based cohorts. CONCLUSIONS: The models developed provide the basis for the integrated use of validated clinical risk factors in men and women to aid in fracture risk prediction.

Quantitative ultrasound of bone in institutionalized elderly women: a cross-sectional and longitudinal study.

Quantitative ultrasound of bone is a promising method for bone assessment: radiation-free, portable and predictive of hip fracture. Its portability allowed us to study the relationships between ultrasonic parameters of bone with age and with non-vertebral fractures in elderly women living in 19 nursing homes. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) of the calcaneus were measured (and the stiffness index calculated) in a sample of 270 institutionalized women, aged 85 +/- 7 years, using an Achilles bone densitometer (Lunar). The effects of age, history of non-vertebral and non-traumatic fractures, body mass index, triceps skinfold and arm circumference were assessed on BUA, SOS and stiffness index. Furthermore, to evaluate longitudinally the influence of aging on the ultrasound parameters of bone, 60 subjects from the same group had a second ultrasound measurement after 1 year. The cross-sectional analysis of the data on all 270 women showed a significant decrease (p < 0.001) with age in BUA, SOS and stiffness index (-0.47%, -0.06%, and -1.01% respectively per year). In the 94 women, (35%) with a history of previous non-vertebral fractures, ultrasound parameters were significantly lower (p < 0.0001) than in the 176 women with no history of fracture (-8.3% for BUA, -1.3% for SOS, -18.9% for stiffness index). In contrast, there was no significant difference in anthropometric measurements between the groups with and without previous non-vertebral fractures, although the measurements decreased significantly with age. In the longitudinal study, repeated quantitative ultrasound after 11.4 +/- 0.8 months showed no significant decrease in BUA (-1%) but a significant decrease in SOS (-0.3%, p < 0.0001) and in stiffness index (-3.6%, p < 0.0002). In conclusion, quantitative ultrasound of the calcaneus measures properties of bone which continue to decline in institutionalized elderly women, and is able to discriminate women with previous non-vertebral fractures.

Acetylcholinesterase inhibitors and healing of hip fracture in Alzheimer's disease patients: a retrospective cohort study.

OBJECTIVES This study was designed to assess effects of cholinergic stimulation using acetylcholinesterase inhibitors (AChEIs), a group of drugs that stimulate cholinergic receptors and are used to treat Alzheimer's disease (AD), on healing of hip fractures. METHODS A retrospective cohort study was performed using 46-female AD patients, aged above 75 years, who sustained hip fractures. Study analyses included the first 6-months after hip fracture fixation procedure. Presence of AChEIs was used as predictor variable. Other variables that could affect study outcomes: age, body mass index (BMI), mental state or type of hip fracture, were also included. Radiographic union at fracture site (Hammer index), bone quality (Singh index) and fracture healing complications were recorded as study outcomes. The collected data was analyzed by student's-t, Mann-Whitney-U and chi-square tests. RESULTS No significant differences in age, BMI, mental state or type of hip fracture were observed between AChEIs-users and nonusers. However, AChEIs-users had better radiographic union at the fracture site (relative risk (RR),2.7; 95%confidence interval (CI),0.9-7.8), better bone quality (RR,2.0; 95%CI,1.2-3.3) and fewer healing complications (RR,0.8; 95%CI,0.7-1.0) than nonusers. CONCLUSION In elderly female patients with AD, the use of AChEIs might be associated with an enhanced fracture healing and minimized complications.

Fracturas femorales periprotésicas de rodilla tratadas con clavo intramedular retrógrado y osteosíntesis con placa: comparación de resultados a medio-largo plazo

INTRODUCTION: The femoral periprosthetic fracture of the knee is one of the most feared complications because of its repercussions. Incidence are more and more likely due to the increase of total implanted arthroplasty of the knee, due to the increasing lifespan among the general population. The objective of this study is to analyze some of the perioperative aspects of the treatment of these fractures, comparing the use of osteosynthesis with plates and the retrograde nailing in those patients with femoral periprosthetic knee fractures with a stable implant. MATERIAL AND METODS: The study retrospectively examines 18 cases treated consecutively in our hospital (3 men and 15 women, average age of 72.7 years) between the years of 2000 and 2009. All fractures were located in the distal femur and on a stable implant. Eight were treated through retrograde nailing (Group I) and ten with plates (Group II). The cases are analyzed through the tests of the University of Mann-Withney and the exact Fischer test, with significant values of p≤0.05, the variables of median hospital stay, necessity of transfusion indicated with values of hemoglobin less than 8 mg/ml, preoperative radiological alignment and postoperative alignment of the total knee prosthesis (TKR), measured following the anatomical tibiofemoral axis, time of consolidation and incidence of localized complications in both groups. RESULTS: We did not find any statistically significant differences between the two groups in any of the variables analyzed. Localized complications are more frequent in Group I (62.5 percent of patients) than in Group II (10 percent of patients). The need for transfusion is greater in Group II (40 percent) than in Group I (12.5 percent). CONCLUSIONS: The type of implant used in treatment of femoral periprosthetic knee fracture does not significantly influence perioperative factors. The treatment for this type of fractures should be individually chosen in relation to the type of fracture, characteristics of the patient and stability and prosthesis model of the primary knee.

Role of mental disorders in nosocomial infections after hip fracture treatment.

The association between mental disorders (MDs) and iatrogenic complications after hip fracture surgery has been poorly studied. Among iatrogenic complications, nosocomial infections (NIs) are a major factor in hip fracture surgery. The aim of this paper was to determine whether patients with a MD and a hip fracture develop more NIs after hip surgery than patients with no MD. We studied 912 patients who underwent surgery for a hip fracture (223 patients with a MD who underwent surgery for a hip fracture and 689 control patients without a MD who also underwent surgery for a hip fracture) and followed them after surgery. Univariable and multivariable analyses were performed using simple and multiple logistic regression analysis (confidence interval, crude and adjusted odds ratios, and P value). We found that MDs, gender, and comorbidities were not associated with a higher risk of developing a NI after surgery for a hip fracture. Only age increases the risk of a NI.

Recambios en un solo tiempo de prótesis de cadera y rodilla sobre terreno contaminado: nuestra experiencia

Objective: Evaluate the results obtained in the simultaneous replacement of a septic arthroplasty or a second septic replacement (implanting the prosthesis in a contaminated eld). Material and method: Series of 17 cases, with a mean age of 66.8 years and average follow-up of 49 months. The exclusion criteria were serious immunological depression and unknown germ or not sensitive to at least three antibiotics. After the intervention, the corresponding antibiotics were administered between six weeks and three months. Recovery was established as the normality for infection indicator variables at least nine months after the replacement. Results: 14 patients developed towards total recovery (follow-up at least 9 months and maximum 84 months). 3 cases presented relapse, all three carriers of Staphylococcus epidermidis (at 1, 3 and 7 months of follow-up respectively). The success percentage is 82.41% (average follow-up of 49 months). Conclusions: Simultaneous replacements is an interesting option for patients with plural pathologies as it o"ers a single operation, less morbidity, quicker return to activities to restore normal function and less associated costs

Synthesis of bone-like structured foams

Here we present a processing route to produce multi-structured ceramic foams based on the combination of particle-stabilized foams with polymeric sponges to produce positive and negative templating structures. Polyester sponges are infiltrated with freshly produced calcium aluminate alumina foams and upon sintering either positive templating structures are produced when wetting the sponges, or negative templating foams with a percolating pore network are obtained when completely filling the sponges. Additionally, by combining different layers of these particle-stabilized foam infiltrated sponges, various different structures can be produced, including sandwich structures, pore size gradients, and ceramic bone-like structures applying to different types of bone. The particle-stabilized foams used were in situ self-hardening calcium aluminate cement enriched alumina foams to obtain crack-free samples with pore interconnections and tailorable pore sizes.

Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma.

Painful total hip replacement remains a challenging problem because of the large amount of possible diagnoses. We report about a 64-year-old female patient who was misdiagnosed during 4 years as psychiatric. She suffered of excruciating left retrotrochanteric pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations. Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI was obtained to visualize the retrotrochanteric soft tissues and showed a tight scar surrounding the sciatic nerve, which was also compressed by an adjacent lipoma. Therefore, she was reoperated on to remove the lipoma and the scar tissue around the sciatic nerve. To decrease the risk of recurrent scarring around the sciatic nerve, an adhesion barrier was applied before closure. One year after the operation, the patient has no neurologic deficit, no more pain and is able to walk unlimited distances without crutches. Scar tissue around the sciatic nerve is frequently observed during revision surgery. However, we feel that sciatic nerve entrapment by scar tissue should be a part of the differential diagnosis of painful THR. MRI may be a useful tool to achieve this diagnosis.