The impact of magnetic resonance imaging in the diagnostic and classification process of osteoporotic vertebral fractures

[Osteoporotic vertebral fractures of the thoracic and lumbar spine]

The frequency of osteoporotic vertebral fractures in the clinical routine is increasing due to the demographic change. They are the most frequent fractures associated with osteoporosis and affect an especially morbid and vulnerable group of patients. These fractures often occur after minor trauma or spontaneously. Pain is the predominant symptom, whereas mechanical stability is mostly sufficient, in comparison to vertebral fractures after high-energy trauma, and is not a predominant indication for surgery. These fractures can be described using the classification for fractures associated with osteoporosis and the corresponding treatment recommendations are guided by them. Besides the specific treatment of osteoporotic vertebral fractures, a holistic treatment of patients taking pre-existing comorbidities into consideration is decisive. A mobilization as quickly as possible and treatment of the underlying osteoporosis are important to prevent further fractures.

A Deep Learning-Based Model for Classifying Osteoporotic Lumbar Vertebral Fractures on Radiographs: A Retrospective Model Development and Validation Study

Early diagnosis and initiation of treatment for fresh osteoporotic lumbar vertebral fractures (OLVF) are crucial. Magnetic resonance imaging (MRI) is generally performed to differentiate between fresh and old OLVF. However, MRIs can be intolerable for patients with severe back pain. Furthermore, it is difficult to perform in an emergency. MRI should therefore only be performed in appropriately selected patients with a high suspicion of fresh fractures. As radiography is the first-choice imaging examination for the diagnosis of OLVF, improving screening accuracy with radiographs will optimize the decision of whether an MRI is necessary. This study aimed to develop a method to automatically classify lumbar vertebrae (LV) conditions such as normal, old, or fresh OLVF using deep learning methods with radiography. A total of 3481 LV images for training, validation, and testing and 662 LV images for external validation were collected. Visual evaluation by two radiologists determined the ground truth of LV diagnoses. Three convolutional neural networks were ensembled. The accuracy, sensitivity, and specificity were 0.89, 0.83, and 0.92 in the test and 0.84, 0.76, and 0.89 in the external validation, respectively. The results suggest that the proposed method can contribute to the accurate automatic classification of LV conditions on radiography.

Imaging of pelvic ring fractures in older adults and its clinical implications-a systematic review

Identifying the full scope of pelvic fracture patterns in older adults has gained clinical importance since the last decennium. CT is recommended as the golden standard; however, MRI has even greater diagnostic accuracy. Dual energy computed tomography (DECT) is a new and promising imaging technique, but the diagnostic accuracy in the context of pelvic fragility fractures (FFPs) has not been widely established. The aim was to provide insight into the diagnostic accuracy of different imaging techniques and the relevance for clinical practice. A systematic search was performed in the PubMed database. All studies that reported on CT, MRI or DECT imaging techniques in older adults who suffered a pelvic fracture were reviewed and, if relevant, included. Eight articles were included. In up to 54% of the patients, additional fractures were found on MRI compared to CT, and in up to 57% of the patients on DECT. The sensitivity of DECT for posterior pelvic fracture detection was similar to MRI. All patients without fractures on CT appeared to have posterior fractures on MRI. After additional MRI, 40% of the patients had a change of classification. DECT and MRI showed very similar results in terms of diagnostic accuracy. Over a third of all patients appear to have a more severe fracture classification after MRI, the majority changing to Rommens type 4. However, in only a few patients who changed of fracture classification, a change of therapy was advised. This review suggests that MRI and DECT scans are superior in diagnosing FFPs.

Red flags to screen for vertebral fracture in people presenting with low back pain

BACKGROUND

Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.

OBJECTIVES

To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.

SELECTION CRITERIA

We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.

MAIN RESULTS

This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).

AUTHORS' CONCLUSIONS

The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.

Radiographic assessment of acute vs chronic vertebral compression fractures

PURPOSE

Distinguishing between acute and chronic vertebral compression fractures typically requires advanced imaging techniques such as magnetic resonance imaging (MRI). Recognizing specific radiographic findings associated with fracture acuity may improve the accuracy of radiographic assessment.

METHODS

Patients with compression fractures that had both radiographic and MRI studies of the lumbar spine within a 30-day time frame were retrospectively reviewed. MRI studies were used to determine compression fracture acuity. Radiographs were interpreted by a separate group of radiologists blinded to the MRI results. Radiographic findings of endplate osteophyte, subendplate density, subendplate cleft, and subendplate cyst were recorded as was the overall impression of fracture acuity.

RESULTS

Sensitivity and specificity for radiographic reporting of acute fracture were 0.52 (95% CI: 0.42, 0.61) and 0.95 (95% CI: 0.93, 0.97) respectively. For chronic fractures, the sensitivity and specificity were 0.52 (95% CI: 0.41, 0.63) and 0.94 (95% CI: 0.92, 0.96). The radiographic presence of a subendplate cleft increased the odds of a fracture being acute by a factor of 1.75 (95% CI: 1.09, 2.81; P = 0.0202). The radiographic presence of subendplate density increased the odds of a fracture being acute by a factor of 1.78 (95% CI: 1.21, 2.63; P = 0.0037). The presence of an endplate osteophyte or subendplate cyst was not significantly associated with fracture acuity.

CONCLUSION

Radiographs are relatively insensitive in distinguishing between acute and chronic lumbar compression fractures but the presence of a subendplate cleft or subendplate density increases the likelihood that a given fracture is acute.

Therapeutic Effects of Conservative Treatment with 2-Week Bed Rest for Osteoporotic Vertebral Fractures: A Prospective Cohort Study

UPDATE

This article was updated on October 19, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1787, in the legend for Figure 2, the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (A/P) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." now reads "The vertebral collapse rate (in %) was defined as (1 - [A/P]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." On page 1788, in the section entitled "Data Collection," the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (anterior vertebral wall height/posterior vertebral wall height) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." now reads "The vertebral collapse rate (in %) was defined as (1 - [anterior vertebral wall height/posterior vertebral wall height]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." Finally, on page 1791, in Table IV, the footnote for the "Primary outcome" row that had read "N = 113 in the rest group and 99 in the no-rest group." now reads "N = 116 in the rest group and 108 in the no-rest group."

Efficacy of Recombinant Human Parathyroid Hormone versus Vertebral Augmentation Procedure on Patients with Acute Osteoporotic Vertebral Compression Fracture

OBJECTIVE

Although widely used in clinical practice, vertebral augmentation procedure (VAP) for osteoporotic vertebral compression fracture (OVCF) is not supported. Recently, the effect of recombinant human parathyroid hormone (1-34) (rhPTH) has been paid great attention for its efficacy in anti-osteoporosis and bone union. This study aims to explore the outcome of rhPTH on acute OVCF and compare it with VAP to clarify its therapeutic advantages.

METHODS

The retrospective study comprised 71 acute OVCF patients from January 2015 to March 2020: 22 received rhPTH treatment (rhPTH group) and 49 underwent VAP (VAP group). The rhPTH group was 15 women and seven men with an average of 76.18 years, and the VAP group were 35 women and 14 men with an average of 73.63 years. The thoracic/lumbar vertebrae were 14/8 in the rhPTH group and 29/20 in the VAP group. The average follow-up period was 14.05 months in the rhPTH group and 13.82 months in the VAP group. The two groups were assessed regarding the visual analog score (VAS), Oswestry Disability Index (ODI), OVCF bone union, bone mineral density (BMD), kyphotic angle (KA), anterior and posterior border height (ABH and PBH, respectively), adverse events and the health-related quality of life assessed by short form-36 health survey scores (SF-36). Categorical variables were analyzed by chi-square test and continuous variables between groups were analyzed by independent samples t-test or Mann-Whitney U test according to the normality.

RESULTS

During the follow-up, the VAS was significantly lower in the rhPTH group than in the VAP group at month 3 (0.39 ± 0.6 vs 0.68 ± 0.651) (p = 0.047), month 6 (0.45 ± 0.60 vs 2.18 ± 1.22) (p < 0.001), and month 12 (0.45 ± 0.60 vs 2.43 ± 1.49) (p < 0.001). At month 12, the ODI was significantly lower in the rhPTH group (18.59 ± 3.33%) than in the VAP group (28.93 ± 16.71%) (p < 0.001). Bone bridge was detected on sagittal computed tomography images of all fractured vertebrae in the rhPTH group. The BMD was significantly higher in the rhPTH group (87.66 ± 5.91 Hounsfield units [HU]) than in the VAP group (68.15 ± 11.32HU) (p < 0.001). There were no significant differences in the changes in KA, ABH, and PBH between groups (all p > 0.05). The incidence of new OVCF was significantly lower in the rhPTH group than in the VAP group (p = 0.042). All scores of SF-36 were significantly higher in the rhPTH group than in the VAP group (all p < 0.05).

CONCLUSION

In acute OVCF patients, rhPTH was better than VAP in increasing spinal BMD to promote OVCF healing, reduce new OVCF, and improve back pain, physical ability, and health-related quality of life.

Reliability Evaluation of the New AO Spine-DGOU Classification for Osteoporotic Thoracolumbar Fractures

OBJECTIVES

To perform an interobserver and intraobserver agreement evaluation of the new AO Spine-DGOU classification system for osteoporotic thoracolumbar fractures (OFc).

METHODS

Complete imaging studies of 97 patients (radiographs, computed tomography scans, and magnetic resonance imaging) with osteoporotic thoracolumbar fractures were selected and classified using the OFc by 6 spine surgeons (3 senior surgeons with more than 15 years of experience and 3 surgeons with less than 15 years). After a 4-week interval, the same cases were presented to the same evaluators in a random sequence for a new classification assessment. The weighted kappa coefficient (wκ) was used to determine the interobserver and intraobserver agreement.

RESULTS

The interobserver agreement was moderate, wκ = 0.59 (95% confidence interval 0.54-0.64). The intraobserver agreement was fair, wκ = 0.35 (95% confidence interval 0.29-0.40). Interobserver agreement slightly improved for junior staff between first and second evaluation, suggesting a learning effect. Better agreement was obtained by senior staff at the interobserver and intraobserver agreement.

CONCLUSIONS

This independent assessment demonstrated that new OFc allows moderate interobserver agreement and fair intraobserver agreement. Further studies are necessary prior to its widespread adoption.

A Rare Presentation of a Compression Fracture or a Typical Presentation of Lateral Cutaneous Nerve Entrapment Syndrome: A Diagnostic Error?

A 78-year-old woman complained of severe pain in the left costal region. Her body mass index was 23.1 kg/m2. Lateral cutaneous nerve entrapment syndrome (LACNES) was the suspected diagnosis because the affected area was 2×2 cm and positive for pinch sign. Seventeen days later, the patient again presented with complaints of lower back pain accompanied by back pain upon extending the spine. Magnetic resonance imaging of the spine showed a fracture of the vertebral body of T11. We herein discuss our errors in the diagnostic process and critical tactics for avoiding such errors in the future.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment

BACKGROUND

The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

METHODS

A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

RESULTS

The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

CONCLUSION

It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

Osteoporotic vertebral fractures: A diagnostic challenge in the 21ST century

Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients' quality of life.

Artificial intelligence for the detection of vertebral fractures on plain spinal radiography

Vertebral fractures (VFs) cause serious problems, such as substantial functional loss and a high mortality rate, and a delayed diagnosis may further worsen the prognosis. Plain thoracolumbar radiography (PTLR) is an essential method for the evaluation of VFs. Therefore, minimizing the diagnostic errors of VFs on PTLR is crucial. Image identification based on a deep convolutional neural network (DCNN) has been recognized to be potentially effective as a diagnostic strategy; however, the accuracy for detecting VFs has not been fully investigated. A DCNN was trained with PTLR images of 300 patients (150 patients with and 150 without VFs). The accuracy, sensitivity, and specificity of diagnosis of the model were calculated and compared with those of orthopedic residents, orthopedic surgeons, and spine surgeons. The DCNN achieved accuracy, sensitivity, and specificity rates of 86.0% [95% confidence interval (CI) 82.0-90.0%], 84.7% (95% CI 78.8-90.5%), and 87.3% (95% CI 81.9-92.7%), respectively. Both the accuracy and sensitivity of the model were suggested to be noninferior to those of orthopedic surgeons. The DCNN can assist clinicians in the early identification of VFs and in managing patients, to prevent further invasive interventions and a decreased quality of life.

Magnetic resonance imaging has an advantage over conventional spine X-rays in the evaluation of rebound-associated vertebral fractures following denosumab discontinuation

INTRODUCTION

Patients discontinuing or neglecting denosumab treatment are at risk of sustaining rebound-associated vertebral fractures (RAVFs). In everyday clinical practice, conventional X-rays are used to diagnose such events in patients reporting acute back pain.

PATIENTS

Herein we report the cases of two patients, in whom magnetic resonance imaging (MRI) depicted more RAVFs or allowed earlier detection of RAVFs compared with conventional X-rays.

CONCLUSION

It seems that, in the setting of RAVFs following denosumab discontinuation, MRI imaging provides better accuracy in the diagnostic process and in the classification assessment compared to conventional X-rays, thus allowing an earlier and clearer picture of the magnitude of spinal damage. This could have an impact on clinical decisions and improve patient's management.

Back pain from painful osteoporotic vertebral fractures: discrepancy between the actual fracture location and the location suggested by patient-reported pain or physical examination findings

Caution is necessary when using symptom or physical examination findings to localize the osteoporotic vertebral fractures (VFs) attributable to the discrepant colocalized relationship.

INTRODUCTION

Whether the location of symptoms or physical examination findings delineates the appropriate spinal range for imaging has not been thoroughly investigated for VFs. The present study aims to analyze the consistency between the fractural vertebrae location and the location suggested by patient-reported pain or physical examination findings.

METHODS

This observational study, following a prospective design, enrolled 358 patients with VFs. The locations of two symptoms (patient-reported back pain [P-RBP], radiating pain [RP]) and findings from two physical examinations (spinal palpation tenderness [SPT], axial spinal percussion pain [ASPP]) were used to locate the VF segments identified using whole-spine magnetic resonance imaging (MRI). The percentage of agreements and kappa coefficient were calculated.

RESULTS

In 20.7% (74/358), the P-RBP site and VF segments were in the same location (kappa = 0.153); 21.2% (76/358) presented with concomitant RP in 93.4% (71/76) of whom the RP dermatome was colocalized with the VF segments (kappa = 0.924); 55.0% (197/358) and 23.2% (83/358) of patients presented with positive SPT and ASPP, respectively; and in 49.2% (97/197) and 96.4% (80/83) of patients with positive SPT (kappa = 0.435) and ASPP (kappa = 0.963), the positive finding and the VF segments were consistently colocalized.

CONCLUSIONS

The positive finding of RP or ASPP is useful in determining the spinal range for imaging tests, while an MRI scan covering the whole thoracic and lumbar spine is necessary in VF-suspected patients with P-RBP or positive SPT, indicating that caution is necessary when using symptoms or physical examination findings to localize VFs.

Traumatic vertebral fractures involve the anterior end plate more than the posterior end plate: A retrospective study

Traumatic end plate fractures (EPFs) refers to the EPF caused by trauma, rather than the pathological status of the end plate (EP). However, some old traumatic EPFs may be mistaken as osteoporotic in the elderly. The objective of this study is to describe the radiological features of traumatic EPF in different traumatic fracture type patients presenting in the Emergency department setting. And to compare the result with osteoporotic vertebral fracture (VF).This study retrospectively analyzed the anatomical location of acute thoracolumbar vertebral traumatic EPFs in males (age≤55 years) and females (age≤50 years). The anatomic distribution of EPFs, the anterior and posterior wall fracture were analyzed in patients, who were scanned with 1 or more of the following methods: radiography, CT, and magnetic resonance imaging.There were 194 cases of acute spine trauma involving at least 1 EPF, including 118 males and 76 females. The involved vertebra was mostly at L1 (29.7%), followed by T12 (18.3%), and then by L2 (12.9%). Excluding those with both upper and lower EP involvements, the ratio of superior EPF to inferior EPF was 33.5 for males and 45.5 for females. With the EP divided into 5 segments of equal length in the anteroposterior direction in different fracture types, fractures occurred mostly at a2 segment (71.48% for superior EPs and 7.60% for inferior EPs), followed by a1 segment (66.16% for superior EPs). The upper third of the anterior and posterior walls were most prone to fracture in traumatic vertebral fracture.Traumatic EPFs more likely involve the anterior EP more than the posterior EP and is correlated with fracture type. These characteristics may help radiologist differential diagnosis between traumatic and osteoporotic EPF.

The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

Osteoporotic vertebral fractures: A diagnostic challenge in the 21st century

Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients' quality of life.

Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems

Background

The classification systems for proximal humeral fractures routinely used in clinical practice include the Neer and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 2007 systems. Currently used systems have low inter- and intraobserver reliability. In 2018, AO/OTA introduced a new classification system with the aim of simplifying the coding process, in which the Neer four-part classification was integrated into the fracture description. The aim of the present work is to assess the inter- and intraobserver agreement of the new AO/OTA 2018 compared with the Neer and AO/OTA 2007 classifications.

Materials and methods

A total of 116 radiographs of consecutive patients with proximal humeral fracture were selected and classified by three observers with different levels of experience. All three observers independently reviewed and classified the images according to the Neer, AO/OTA 2007, and new AO/OTA 2018 systems. To determine the intraobserver agreement, the observers reviewed the same set of radiographs after an interval of 8 weeks. The inter- and intraobserver agreement were determined through Cohen’s kappa coefficient analysis.

Results

The new AO/OTA 2018 classification showed substantial mean inter- (k = 0.67) and intraobserver (k = 0.75) agreement. These results are similar to the reliability observed for the Neer classification (interobserver, k = 0.67; intraobserver, k = 0.85) but better than those found for the AO/OTA 2007 system, which showed only moderate inter- (k = 0.57) and intraobserver (k = 0.58) agreement. The two more experienced observers showed better overall agreement, but no statistically significant difference was found. No differences were found between surgical experience and agreement regarding specific fracture types or groups.

Conclusions

The results showed that the Neer system still represents the more reliable and reproducible classification. However, the new AO/OTA 2018 classification improved the agreement among observers compared with the AO/OTA 2007 system, while still maintaining substantial descriptive power and simplifying the coding process. The universal modifiers and qualifications, despite their possible complexity, allowed a more comprehensive fracture definition without negatively affecting the reliability or reproducibility of the classification system.

Level of evidence: Level III, diagnostic studies

Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study

To detect painful vertebral fractures (VFs) in back pain populations at risk of osteoporosis, we designed a physical examination test (the Back Pain-Inducing Test [BPIT]) that included three movements: lying supine, rolling over, and sitting up. If back pain is induced during any of these movements, the result is defined as positive, thereby establishing a presumptive diagnosis of painful VFs. Pain severity is quantified using a self-reported numerical rating scale (NRS). The presence or absence of painful VFs is verified by whole-spine magnetic resonance imaging (MRI), the gold standard for final diagnosis. According to the standards for reporting diagnostic accuracy, a real-world, prospective, and observational study was performed on 510 back pain patients (enrolled from a single institute) at risk of osteoporosis. The sensitivity, specificity, and accuracy of the BPIT for identifying painful VFs were 99.1% (95% CI, 97.5% to 99.8%), 67.9% (95% CI, 60.4% to 74.5%), and 89.0%, respectively. The positive and negative predictive values were 86.6% (95% CI, 82.9% to 89.6%) and 97.4% (95% CI, 92.6% to 99.3%), respectively. Cutoff NRS scores for lying supine, rolling over, and sitting up were 3, 0, and 2, respectively. The corresponding area under the receiver operating characteristic curves (AUROCs) of each movement was 0.898 (95% CI, 0.868 to 0.922), 0.884 (95% CI, 0.854 to 0.911), and 0.910 (95% CI, 0.882 to 0.933), respectively. Although the high prevalence of VFs in the enrolled cohort partially limits the external validity of the predictive value in the general population, we conclude that the BPIT is potentially effective for detecting painful VFs in back pain populations at risk of osteoporosis. This test may be used as a stratification tool in decision-making on subsequent imaging procedures: a negative BPIT rules out painful VFs and indicates that an MRI should be spared, whereas a positive BPIT means that an MRI is necessary and is likely to identify painful VFs. © 2019 American Society for Bone and Mineral Research.

The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence

BACKGROUND

The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures.

METHODS

A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide".

RESULTS

The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old.

CONCLUSIONS

General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.

Risk factors of adjacent segmental fractures when percutaneous vertebroplasty is performed for the treatment of osteoporotic thoracolumbar fractures

The study aimed to analyze the radiographic and magnetic resonance imaging (MRI) findings that might predict the risk for adjacent segmental fractures (ASFs) when percutaneous vertebroplasty (PV) is used for the treatment of osteoporotic thoracolumbar fractures (OTFs). A total of 92 OTFs patients who underwent PV between January 2013 and January 2015 were retrospectively reviewed. The visual analog scale (VAS), Oswestry-Disability Index (ODI) and radiolographic measurements were assessed. The VAS and ODI scores improved significantly at the final follow-up (FU) compared with the preoperation scores. Compared with the preoperative values, the fractured body alignment (FBA) significantly improved at the 3-month FU and the final FU, but the adjacent segment alignment (ASA) and thoracolumbar alignment (TLA) did not improve. According to the correlation analysis, the final FU TLA and the final FU ASA were correlated with the preoperative FBA, ASA, and TLA on plain radiography and were highly correlated on MRI. However, the final FU FBA was not correlated with the preoperative FBA, ASA, or TLA on plain radiography or MRI (P > 0.05). The ASFs were correlated with the 3-month FU TLA (r = 0.6044, P = 0.0037) and the final FU TLA (r = 0.5699, P = 0.007) on plain radiography, and the final TLA was more correlated with the preoperative FBA, ASA, and TLA on MRI than on plain radiography. In conclusion, the preoperative ASA and TLA on MRI were risk factors associated with ASFs in OTFs treated with PV.