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Zebaze R, Ebeling PR. Disorganization and Musculoskeletal Diseases: Novel Insights into the Enigma of Unexplained Bone Abnormalities and Fragility Fractures. Curr Osteoporos Rep 2022; 21:154-166. [PMID: 36494594 DOI: 10.1007/s11914-022-00759-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Describe the potential contribution of disorganized tissue to the pathogenesis of bone abnormalities and fractures. Especially, fractures that are unexplained by bone loss (osteoporosis) or structural deterioration. RECENT FINDINGS Currently, bone fragility is primarily viewed as due to loss, or decay (osteoporosis). However, it is also acknowledged that this view is limited because it does not explain many fractures or abnormalities such as necrosis, sclerosis, or infarcts. Atypical femoral fractures (AFFs) during antiresorptive therapy are an example. Hence, it is proposed that another distinct mechanism is responsible for bone diseases. A remarkable bone property distinct from mass and decay is the organization (arrangement) of its components. Components must be perfectly assembled or well-stacked to ensure "the right amount of bone, at the right place". Disorganization is an aberration that is conspicuous in many diseases, more so in conditions poorly associated with bone mass and decay such as osteogenesis imperfecta, hypophosphatasia, and AFFs. However, despite the likely critical role of disorganization, this feature has received limited clinical attention. This review focuses on the potential contribution of disorganization to bone in health and diseases. Particularly, we propose that disorganization, by causing ineffective transfer of loads, may produce not only bone abnormalities (pain, necrosis, infarct, sclerosis, delayed healing) but also fractures, especially AFFs or stress fractures. A disorganized element is one that is where it shouldn't be (improperly stacked elements). Hence, disorganization can be measured by quantifying the extent to which a tissue (pixel within an image) is at an incorrect location.
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Affiliation(s)
- Roger Zebaze
- Department of Medicine, School of Clinical Sciences, Monash University, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria, 3168, Australia.
| | - Peter Robert Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria, 3168, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
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Cho Y, Shin JU. Bilateral Subtrochanteric Complete Atypical Femoral Fracture in a Patient With Rheumatoid Arthritis: A Case Report. Cureus 2022; 14:e30692. [PMID: 36439599 PMCID: PMC9692201 DOI: 10.7759/cureus.30692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/05/2022] Open
Abstract
Antiresorptive drugs such as bisphosphonates (BPs) or denosumab, used for the treatment of osteoporosis over the past decades, have improved bone mineral density and reduced the incidence of fractures. However, there are increasing evidence that atypical femoral fractures (AFFs) are related to long-term use of these medications. We had experienced bilateral simultaneous subtrochanteric complete AFFs in having rheumatoid arthritis (RA) for 15 years. She just had been taking risedronate for three months prior to this event. Fractures were treated with long cephalomedullary nails. We could get a bone union for the right side at 15 months after index surgery. However, two more surgeries were needed to get bone union for the left side. This study aimed to share our treatment strategy and review of the literature on the correlation between RA and AFFs.
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Griffin LV, Warner E, Palnitkar S, Qiu S, Honasoge M, Griffin SG, Divine G, Rao SD. Bone Nanomechanical Properties and Relationship to Bone Turnover and Architecture in Patients With Atypical Femur Fractures: A Prospective Nested Case-Control Study. JBMR Plus 2021; 5:e10523. [PMID: 34532612 PMCID: PMC8441274 DOI: 10.1002/jbm4.10523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 11/20/2022] Open
Abstract
Atypical femur fractures (AFFs) are well‐established serious complication of long‐term bisphosphonate and denosumab therapy in patients with osteopenia or osteoporosis. To elucidate underlying mechanism(s) for the development of AFF, we performed a nested case‐control study to investigate bone tissue nanomechanical properties and prevailing bone microstructure and tissue‐level remodeling status as assessed by bone histomorphometry. We hypothesized that there would be differences in nanomechanical properties between patients with and without AFF and that bone microstructure and remodeling would be related to nanomechanical properties. Thirty‐two full‐thickness transiliac bone biopsies were obtained from age‐ and sex‐matched patients on long‐term bisphosphonate therapy with (n = 16) and without an AFF (n = 16). Standard histomorphometric measurements were made in each sample on three different bone envelopes (cancellous, intracortical, and endosteal). Iliac bone wall thickness was significantly lower on all three bone surfaces in patients with AFF than in those without AFF. Surface‐based bone formation rate was suppressed similarly in both groups in comparison to healthy premenopausal and postmenopausal women, with no significant difference between the two groups. Nanoindentation was used to assess material properties of cortical and cancellous bone separately. Elastic modulus was higher in cortical than in cancellous bone in patients with AFF as well as compared to the elastic modulus of cortical bone from non‐AFF patients. However, the elastic modulus of the cancellous bone was not different between AFF and non‐AFF groups or between cortical and cancellous bone of non‐AFF patients. Resistance to plastic deformation was decreased in cortical bone in both AFF and non‐AFF groups compared to cancellous bone, but to a greater extent in AFF patients. We conclude that long‐term bisphosphonate therapy is associated with prolonged suppression of bone turnover resulting in altered cortical remodeling and tissue nanomechanical properties leading to AFF. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Lanny V Griffin
- California Polytechnic State University (Cal Poly) San Luis Obispo CA USA
| | - Elizabeth Warner
- Bone & Mineral Research Laboratory Henry Ford Health System/Wayne State University Integrative Biosciences (IBio) Research Facility Detroit MI USA
| | - Saroj Palnitkar
- Bone & Mineral Research Laboratory Henry Ford Health System/Wayne State University Integrative Biosciences (IBio) Research Facility Detroit MI USA
| | - Shijing Qiu
- Bone & Mineral Research Laboratory Henry Ford Health System/Wayne State University Integrative Biosciences (IBio) Research Facility Detroit MI USA
| | - Mahalakshmi Honasoge
- Division of Endocrinology, Diabetes, and Bone & Mineral Disorders Henry Ford Health System Detroit MI USA
| | - Shawna G Griffin
- California Polytechnic State University (Cal Poly) San Luis Obispo CA USA
| | - George Divine
- Department of Public Health Sciences Henry Ford Health System Detroit MI USA
| | - Sudhaker D Rao
- Bone & Mineral Research Laboratory Henry Ford Health System/Wayne State University Integrative Biosciences (IBio) Research Facility Detroit MI USA.,Division of Endocrinology, Diabetes, and Bone & Mineral Disorders Henry Ford Health System Detroit MI USA
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Sato H, Takai C, Kondo N, Kurosawa Y, Hasegawa E, Wakamatsu A, Kobayashi D, Nakatsue T, Abe A, Ito S, Ishikawa H, Kazama JJ, Kuroda T, Suzuki Y, Endo N, Narita I. Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patients with rheumatoid arthritis. Osteoporos Int 2021; 32:363-375. [PMID: 32885317 DOI: 10.1007/s00198-020-05601-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
UNLABELLED The incidence of localized periosteal thickening (LPT, also termed beaking) of the lateral cortex that often precedes an atypical femoral fracture (AFF) was not high in patients with rheumatoid arthritis (RA) but incomplete AFFs developed in two patients. Higher-dose prednisolone was a significant risk factor for LPT in patients with RA. INTRODUCTION Atypical femoral fractures (AFFs) are stress fractures; bisphosphonate (BP) use is a major risk factor for the development of such fractures. Localized periosteal thickening (LPT, also termed beaking) of the lateral cortex often precedes a complete or incomplete AFF. We evaluated the incidence of latent LPT in patients with rheumatoid arthritis (RA), to evaluate LPT progression, and to define LPT risk factors. METHODS A total of 254 patients with RA were included; all underwent annual X-ray evaluation, dual-energy X-ray absorptiometry, and analyses of serum and bone metabolic markers for 2-3 years. LPT of the lateral cortex was sought in femoral X-rays. RESULTS The incidence of LPT was 2.4% (6/254). Among patients on both BP and prednisolone (PSL) at enrollment, the incidence was 2.3% (3/131). Two femurs of two patients with LPT developed incomplete AFFs; LPT was extensive and associated with endosteal thickening. One patient had been on BP and PSL and microscopic polyangiitis was comorbidity. The other was on a selective estrogen receptor modulator and PSL. A daily PSL dose >5 mg (OR 11.4; 95%CI 2.15-60.2; p = 0.004) and higher-dose methotrexate (OR 1.22; 95%CI 1.01-1.49; p = 0.043) were significant risk factors for LPT. CONCLUSIONS The incidence of latent LPT was not high (2.4%) but incomplete AFFs developed in two RA patients. Higher-dose PSL because of a comorbid disease requiring glucocorticoid treatment other than RA or refractory RA were risk factors for LPT; X-ray screening for latent LPT would usefully prevent complete AFFs.
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Affiliation(s)
- H Sato
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan.
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan.
| | - C Takai
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - N Kondo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Y Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - E Hasegawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - A Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - D Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - T Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - A Abe
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - S Ito
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - H Ishikawa
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - J J Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, 960-1295, Japan
| | - T Kuroda
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan
| | - Y Suzuki
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan
| | - N Endo
- Division of Orthopedic Surgery, Tsubame Rosai Hospital, 633, Sawatari, Tsubame City, 959-1228, Japan
| | - I Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
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Xie J, Li S, Xiao L, Ouyang G, Zheng L, Gu Y, Gao C, Han X. Zoledronic acid ameliorates the effects of secondary osteoporosis in rheumatoid arthritis patients. J Orthop Surg Res 2019; 14:421. [PMID: 31823822 PMCID: PMC6902494 DOI: 10.1186/s13018-019-1492-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/27/2019] [Indexed: 01/16/2023] Open
Abstract
Background Secondary osteoporosis may occur in patients with rheumatoid arthritis (RA), causing irreversible joint damage and disability. Bisphosphonates, the recently developed bone resorption inhibitors, have demonstrated significant therapeutic effects on senile and postmenopausal osteoporosis. This study evaluated the efficacy and safety of zoledronic acid (ZOL), with or without methotrexate (MTX), for the prevention and treatment of bone destruction in RA patients. Methods We recruited 66 RA patients with symptoms of secondary osteoporosis. They were randomized into three treatment groups—combined treatment with MTX and ZOL, ZOL monotherapy, or MTX monotherapy—in two consecutive 6-month periods. The participants were followed for 12 months. At the end of each treatment period, improvement in disease activity, bone destruction, and fracture risk were evaluated. Results Combined treatment with ZOL and MTX had significantly better clinical efficacy compared with either ZOL or MTX monotherapy (P < 0.05). The combination significantly improved the lumbar spine and hip BMD and reduced FRAX scores, suggesting that ZOL combined with MTX reduces bone loss and risk of hip fracture in RA patients with secondary osteoporosis. Conclusion ZOL has a synergistic effect when combined with MTX, inhibiting RA disease activity, reducing fracture risk, and improving quality of life in RA patients with secondary osteoporosis. Trial registration Chinese Clinical Trial Registry, ChiCTR1800019290. Registered 3 November 2018–Retrospective registered, http://www.chictr.org.cn/showproj.aspx?proj = 31758
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Affiliation(s)
- Jun Xie
- Department of Orthopedics, The Tenth People's Hospital Affiliated to Nanjing Medical University, No. 301 Yanchangzhong Road, Shanghai, 200000, China.,Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China
| | - Shaohua Li
- Department of Orthopedics, The Tenth People's Hospital Affiliated to Nanjing Medical University, No. 301 Yanchangzhong Road, Shanghai, 200000, China.
| | - Lianbo Xiao
- Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China.
| | - Guilin Ouyang
- Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China
| | - Lin Zheng
- Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China
| | - Yubiao Gu
- Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China
| | - Chengxin Gao
- Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China
| | - Xiuwei Han
- Department of Joint Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 504 Xinhua Road, Shanghai, 200052, China
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Peris P, González-Roca E, Rodríguez-García SC, Del Mar López-Cobo M, Monegal A, Guañabens N. Incidence of Mutations in the ALPL, GGPS1, and CYP1A1 Genes in Patients With Atypical Femoral Fractures. JBMR Plus 2018; 3:29-36. [PMID: 30680361 PMCID: PMC6339546 DOI: 10.1002/jbm4.10064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/26/2018] [Accepted: 05/23/2018] [Indexed: 12/22/2022] Open
Abstract
Atypical femoral fractures (AFFs) are uncommon and often related to prolonged bisphosphonate (BP) treatment. Isolated cases have been linked to mutations of tissue nonspecific alkaline phosphatase (ALPL). Moreover, mutations in the geranylgeranyl pyrophosphate synthase (GGPPS) gene, which can be inhibited by BPs, and in the enzyme of the cytochrome P450 superfamily (CYP1A1), related to the metabolism of several drugs, have also been associated with AFF development. Our aim was to analyze the incidence of ALPL, GGPS1, and CYP1A1 gene mutations in patients with AFFs and their clinical characteristics. Seventeen women with AAFs were included. All patients underwent Sanger sequencing of the ALPL, GGPS1, and CYP1A1 genes, analyzing the presence of mutations and polymorphisms in these genes. The clinical characteristics of the patients, previous treatments, ALP substrates (vitamin B6 and phosphoethanolamine), bone turnover markers, and bone mass were also analyzed. Three of 17 patients (17.6%) presented heterozygous mutations in the ALPL (p.Gly288Ala) or CYP1A1 (p.Arg136His, p.Val409Ile) genes. Only the patient with the ALPL mutation presented increased ALP substrates. Patients with CYP1A1 variants had glucocorticoid-induced osteoporosis. All patients were previously treated with BPs during 85.5 ± 38 months, and nearly 50% were also treated with glucocorticoids. The AFF was bilateral in 35% of cases. In conclusion, ALPL and CYP1A1 mutations may be related to the development of AFF in patients treated with BPs. The evaluation of ALP substrates in patients with low ALPL levels allows the identification of patients with hypophosphatasia. The role of CYP1A1 mutations in AFF needs further study. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Pilar Peris
- Rheumatology Department Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd) Clínic Foundation for Biomedical Research (FCRB) Hospital Clínic University of Barcelona Barcelona Spain
| | - Eva González-Roca
- Immunology Department IDIBAPS CIBERehd FCRB Hospital Clínic University of Barcelona Barcelona Spain
| | - Sebastian C Rodríguez-García
- Rheumatology Department Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd) Clínic Foundation for Biomedical Research (FCRB) Hospital Clínic University of Barcelona Barcelona Spain
| | - María Del Mar López-Cobo
- Molecular Biology Core Laboratory IDIBAPS CIBERehd FCRB Hospital Clínic University of Barcelona Barcelona Spain
| | - Ana Monegal
- Rheumatology Department Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd) Clínic Foundation for Biomedical Research (FCRB) Hospital Clínic University of Barcelona Barcelona Spain
| | - Núria Guañabens
- Rheumatology Department Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd) Clínic Foundation for Biomedical Research (FCRB) Hospital Clínic University of Barcelona Barcelona Spain
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Koh JH, Myong JP, Yoo J, Lim YW, Lee J, Kwok SK, Park SH, Ju JH. Predisposing factors associated with atypical femur fracture among postmenopausal Korean women receiving bisphosphonate therapy: 8 years' experience in a single center. Osteoporos Int 2017; 28:3251-3259. [PMID: 28748389 DOI: 10.1007/s00198-017-4169-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023]
Abstract
UNLABELLED The risk factors for atypical femur fracture in patients exposed to bisphosphonates for at least 1 year were examined. Prolonged and continuous use of bisphosphonates, long-term use of glucocorticoids, and a higher body mass index were associated with increased risk of atypical femur fracture. INTRODUCTION The purpose of the present study is to determine whether rheumatoid arthritis (RA) and other clinical factors are associated with an increased risk of bisphosphonate (BP)-related atypical femur fracture (AFF). METHODS A retrospective nested case-control study of patients who had taken BPs for at least 1 year was conducted. Patients with AFF were identified by reviewing surgical and radiographic records. Three controls with no history of AFFs were randomly selected and age- and sex-matched to each patient with AFFs. Cox proportional hazard models were used to analyze the independent contribution of risk factors to BP-related AFF. RESULTS Among the 35,104 patients prescribed BPs for at least 1 year, 43 females (mean age, 68 years) suffered AFFs (0.12%). Patients with AFFs were exposed to BPs for a mean of 7.3 years. Patients with AFFs were exposed to BPs for longer than those without AFFs and continued treatment without a drug holiday. More patients with AFF than controls had taken glucocorticoids and disease-modifying anti-rheumatic drugs. Multivariate Cox regression analyses estimated that long-term use of glucocorticoids, prolonged exposure to BP without cessation, and every 1 kg/m2 increase in the body mass index (BMI) increased the hazard ratio for AFFs by 3.0, 5.2, and 1.2, respectively. CONCLUSIONS Prolonged and continuous use of BPs, long-term use of glucocorticoids, and a higher BMI increase the risk of AFFs. Switching long-term BP and glucocorticoid users to other bone-protective agents should be considered.
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Affiliation(s)
- J H Koh
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - J P Myong
- Department of Occupational & Environmental Medicine, Center for Occupational & Environmental Medicine (WHO Collaboratory Center), Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Yoo
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - Y-W Lim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea.
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