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Jacob G, Shimomura K, Nakamura N. Biologic therapies in stress fractures: Current concepts. J ISAKOS 2024:S2059-7754(24)00078-6. [PMID: 38631518 DOI: 10.1016/j.jisako.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
Stress fractures, a common overuse injury in physically active individuals, present a significant challenge for athletes and military personnel. Patients who sustain stress fractures have demanding training regimes where periods of rest and immobilisation have unacceptable negative consequences on sports goals and finances. Aside from being an overuse injury, there are various contributing risk factors that put certain individuals at risk of a stress fracture. The main two being nutritional deficiencies and hormonal variations, which have significant effects on bone metabolism and turnover. Historically, treatment of stress fractures focused on conservative strategies such as rest and immobilisation. Calcium and vitamin D deficiencies have been closely linked to stress fractures and so over time supplementation has also played a role in treatment. With the introduction of biologics into orthopaedics, newer treatment strategies have been applied to accelerate fracture healing and perhaps improve fracture callus quality. If such therapies can reduce time spent away from sport and activity, it would be ideal for treating stress fractures. This article aims to offer insights into the evolving landscape of stress fracture management. It investigates the pre-clinical evidence and available published clinical applications. Though fracture healing is well understood, the role of biologics for fracture healing is still indeterminate. Available literature for the use of biologic therapies in stress fractures are restricted and most reports have used biologics as a supplement to surgical fixation in subjects in studies that lack control groups. Randomised control trials have been proposed and registered by a few groups, with results awaited. Assessing individuals for risk factors, addressing hormonal imbalances and nutritional deficiencies seems like an effective approach to addressing the burden of stress fractures. We await better designed trials and studies to accurately determine the clinical benefit of adding biologics to the management of these injuries.
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Affiliation(s)
- George Jacob
- Department of Orthopaedic Surgery, Lakeshore Hospital, Cochin, India
| | - Kazunori Shimomura
- Department of Rehabilitation, Kansai University of Welfare Sciences, Osaka, Japan; Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Norimasa Nakamura
- Institute for Medical Science in Sports, Osaka Health Science University, Osaka, Japan; Global Centre for Medical Engineering and Informatics, Osaka University, Osaka, Japan.
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2
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Nam EY, Choi SH, Hwang JH. Therapeutic Efficacy of Chinese Patent Medicine Containing Pyrite for Fractures: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:76. [PMID: 38256337 PMCID: PMC10818888 DOI: 10.3390/medicina60010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Korean and traditional Chinese medicine state that pyrite is effective for fracture treatment, but supporting clinical data are limited. This systematic review aimed to investigate the therapeutic role of Chinese patent medicine containing pyrite (CPMP) in clinical treatment for fractures. Materials and Methods: Seven electronic databases were searched using the keywords "pyrite", "pyritum", and "zirantong" between inception and December 2022, yielding 29 published clinical studies. Randomized controlled trials that included CPMP were considered eligible regardless of the fracture type. Quality assessment and meta-analysis of the included RCTs were also performed. Results: Most studies showed high heterogeneity (I2 > 50%) and significant results (p < 0.05). Compared to the results of the control group, CPMP was more effective in terms of the primary outcome related to the efficacy rate, including the total effective rate, callus growth rate, bone union, and edema disappearance time (all p < 0.00001) and in terms of secondary outcomes related to pain reduction, namely pain intensity and pain disappearance time, than the control group (both p < 0.01). CPMP was more effective than the control group in terms of erythrocyte sedimentation rate (p < 0.01), hematocrit (p < 0.01), erythrocyte aggregation (p < 0.05), and plasma viscosity (p < 0.05). CPMP did not cause serious side effects, and the incidence of complications was significantly less than that in the control group. Conclusions: CPMP may be a safe and effective alternative treatment for fractures and may be beneficial in preventing postoperative complications, reducing pain, relieving symptoms, and accelerating healing.
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Affiliation(s)
- Eun-Young Nam
- Mimi Korean Medicine Clinic, Seoul 05616, Republic of Korea;
| | - Su Hyun Choi
- College of Korean Medicine, Gachon University, Seongnam 13120, Republic of Korea;
| | - Ji Hye Hwang
- Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Gachon University, Seongnam 13120, Republic of Korea
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3
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Landi L, Leali PT, Barbato L, Carrassi AM, Discepoli N, Muti PCM, Oteri G, Rigoni M, Romanini E, Ruggiero C, Tarantino U, Varoni E, Sforza NM, Brandi ML. Anti-resorptive therapy in the osteometabolic patient affected by periodontitis. A joint position paper of the Italian Society of Orthopaedics and Traumatology (SIOT) and the Italian Society of Periodontology and Implantology (SIdP). J Orthop Traumatol 2023; 24:36. [PMID: 37453950 DOI: 10.1186/s10195-023-00713-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
This joint report from the Italian Society of Orthopaedics and Traumatology (SIOT) and the Italian Society of Periodontology and Implantology (SIdP) aims for a consensus around the scientific rationale and clinical strategy for the management of osteoporotic patients affected by periodontitis who are undergoing anti-resorptive (AR) therapy to manage the risk of the occurrence of a medication-related osteonecrosis of the jaws (MRONJ). Osteoporosis and periodontitis are chronic diseases with a high prevalence in aging patients, and they share some of the same pathogenetic mechanisms based upon inflammation. Available evidence shows the relationship among osteoporosis, AR agents, periodontitis and implant therapy in relation to the incidence of MRONJ. Uncontrolled periodontitis may lead to tooth loss and to the need to replace teeth with dental implants. Tooth extraction and surgical dental procedures are recognized as the main risk factors for developing MRONJ in individuals taking AR therapy for osteometabolic conditions. Although the incidence of MRONJ in osteometabolic patients taking AR therapy may be as low as 0.9%, the increasing prevalence of osteoporosis and the high prevalence of periodontitis suggest that this potential complication should not be overlooked. Good clinical practice (GCP) guidelines are proposed that aim at a more integrated approach (prescriber, dentist, periodontist and dental hygienist) in the management of periodontitis patients undergoing AR therapy for osteometabolic disorders to reduce the risk of MRONJ. Dental professional and prescribers should educate patients regarding the potential risk associated with the long-term use of AR therapy and oral health behavior.
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Affiliation(s)
- L Landi
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy.
- Private Practice Verona and Roma, Verona, Italy.
| | - P Tranquilli Leali
- SIOT Panel, Rome, Italy
- Department of Orthopedic Diseases, University of Sassari, Sassari, Italy
| | - L Barbato
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Department of Experimental and Clinical Medicine, Research Unit in Periodontology and Periodontal Medicine, University of Florence, Florence, Italy
| | - A M Carrassi
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - N Discepoli
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Department of Medical Biotechnologies, Unit of Periodontology, University of Siena, Siena, Italy
| | - P C M Muti
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Maxillo-Facial Surgery and Dental Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Oteri
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - M Rigoni
- SIOT Panel, Rome, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - E Romanini
- SIOT Panel, Rome, Italy
- RomaPro, Polo Sanitario San Feliciano, Rome, Italy
| | - C Ruggiero
- SIOT Panel, Rome, Italy
- Department of Medicine and Surgery, Gerontology and Geriatric Section, University of Perugia, Perugia, Italy
| | - U Tarantino
- SIOT Panel, Rome, Italy
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Rome, Italy
| | - E Varoni
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - N M Sforza
- SIdP Panel, Via della Balduina 114, 00136, Rome, Italy
- Private Practice Bologna, Bologna, Italy
| | - M L Brandi
- SIOT Panel, Rome, Italy.
- Osservatorio Fratture da Fragilità, Via San Gallo 123, 50100, Florence, Italy.
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Ebrahimi S, Navabazam A, Salemi F, Khaleghi F, Barzegar M, Saghafi F, Fallahzadeh H. The efficacy of teriparatide (Cinnopar®) on bone repair in mandibular fractures: A single blinded randomized clinical trial. J Craniomaxillofac Surg 2022; 50:923-928. [PMID: 36646571 DOI: 10.1016/j.jcms.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 12/12/2022] [Accepted: 12/27/2022] [Indexed: 01/07/2023] Open
Abstract
This study focused on the effects of teriparatide (CinnoPar) on healing and postoperative complications in mandibular bone fractures. In this single-blind randomized controlled trial, 30 patients with a mandibular fracture hospitalized for open reduction internal fixation were randomly assigned to the intervention (I) (n = 15) and control (C) (n = 15) groups. Both groups received daily acetaminophen and cephalexin for 1 week. For 1 month, Group I received daily subcutaneous teriparatide injections. The Radiographic Union Scale of the Mandible (RUSM) was used to assess mandibular bone fusion subjectively, and the Hounsfield unit (HU) was used to objectively assess radiodensity in a computed tomography (CT) scan. In both groups, the visual analog scale (VAS) score was used to assess postoperative complications such as pain, swelling, wound opening, pus secretion, and bitter taste. There was no significant difference in bone repair between the two groups in this study (P > 0.05). Teriparatide also had no effect on the postoperative complication rate in the control group (P > 0.05). Within the limitations of the study it seems that in mandibular fractures, teriparatide did not affect bone fusion or postoperative complications, so its use is not recommended for better bone fusion and fewer postoperative complications of mandibular fracture during the first month.
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Affiliation(s)
- Somayyeh Ebrahimi
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, 8914815667, Iran.
| | - Alireza Navabazam
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, 8914815667, Iran.
| | - Fateme Salemi
- Islamic Azad University of Medical Sciences, School of Medicine, Yazd, 19395/1495, Iran.
| | - Fatemeh Khaleghi
- Department of Radiology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, 8916978477, Iran
| | - Mohsen Barzegar
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, 8914815667, Iran.
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, 8915173149, Iran.
| | - Hossien Fallahzadeh
- Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, 8915173160, Iran
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de Sire A, Lippi L, Aprile V, Calafiore D, Folli A, D’Abrosca F, Moalli S, Lucchi M, Ammendolia A, Invernizzi M. Pharmacological, Nutritional, and Rehabilitative Interventions to Improve the Complex Management of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease: A Narrative Review. J Pers Med 2022; 12:1626. [PMID: 36294765 PMCID: PMC9604650 DOI: 10.3390/jpm12101626] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022] Open
Abstract
Osteoporosis is a highly prevalent condition affecting a growing number of patients affected by chronic obstructive pulmonary disease (COPD), with crucial implications for risk of fragility fractures, hospitalization, and mortality. Several risk factors have been identified to have a role in osteoporosis development in COPD patients, including corticosteroid therapy, systemic inflammation, smoke, physical activity levels, malnutrition, and sarcopenia. In this scenario, a personalized multitarget intervention focusing on the pathological mechanisms underpinning osteoporosis is mandatory to improve bone health in these frail patients. Specifically, physical exercise, nutritional approach, dietary supplements, and smoke cessation are the cornerstone of the lifestyle approach to osteoporosis in COPD patients, improving not only bone health but also physical performance and balance. On the other hand, pharmacological treatment should be considered for both the prevention and treatment of osteoporosis in patients at higher risk of fragility fractures. Despite these considerations, several barriers still affect the integration of a personalized approach to managing osteoporosis in COPD patients. However, digital innovation solutions and telemedicine might have a role in optimizing sustainable networking between hospital assistance and community settings to improve bone health and reduce sanitary costs of the long-term management of COPD patients with osteoporosis.
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Affiliation(s)
- Alessandro de Sire
- Physical and Rehabilitative Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, Viale Europa, 88100 Catanzaro, Italy
| | - Lorenzo Lippi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy
- Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Translational Medicine, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Vittorio Aprile
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56122 Pisa, Italy
| | - Dario Calafiore
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, ASST Carlo Poma, 46100 Mantua, Italy
| | - Arianna Folli
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy
| | - Francesco D’Abrosca
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy
| | - Stefano Moalli
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy
| | - Marco Lucchi
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56122 Pisa, Italy
| | - Antonio Ammendolia
- Physical and Rehabilitative Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, Viale Europa, 88100 Catanzaro, Italy
| | - Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy
- Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Translational Medicine, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
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6
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Han MS, Lee GJ, Lee SK, Lee JK, Moon BJ. Clinical application of bone turnover markers in treating osteoporotic vertebral compression fractures and their role in predicting fracture progression. Medicine (Baltimore) 2022; 101:e29983. [PMID: 35960080 PMCID: PMC9371513 DOI: 10.1097/md.0000000000029983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
This study aimed to investigate whether changes in the bone turnover markers (BTMs) during teriparatide therapy for osteoporotic vertebral compression fractures could reflect therapeutic effects by analyzing the relationship between clinical and radiological features and BTMs. A total of 33 patients with 51 osteoporotic vertebral compression fracture segments were included. Plain radiographs and BTM levels were evaluated at the pretreatment and at 3 months after teriparatide treatment. Based on serial vertebral compression ratio analysis, the progression of fracture was defined as a vertebral compression ratio decrease of ≥10%, relative to the pretreatment values. All segments were divided into 2 groups: the "maintain" group with 32 (62.7%) segments and the "progression" group with 19 (37.3%) segments. After the teriparatide treatment, serum osteocalcin and serum C-terminal telopeptide of type I collagen levels (P = .028 and .008, respectively), and change amounts of them were significantly larger, increasing (P = .001) in the progression group. The vitamin D (25OH-D) levels were significantly lower (P = .038) in the progression group; however, the relative changes in the 25OH-D levels between the 2 groups, before and after the treatment, were not significantly different (P = .077). The parathyroid hormone (PTH) levels were reduced by the teriparatide treatment in both groups, while the decrease in PTH concentration after the treatment was significantly more pronounced in the progression group (P = .006). Significant increase in the osteocalcin and serum C-terminal telopeptide of type I collagen levels and a simultaneous decrease in the PTH levels during the teriparatide treatment suggest that clinicians should assume the progression of fracture.
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Affiliation(s)
- Moon-Soo Han
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Gwang-Jun Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Seul-Kee Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Bong Ju Moon
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
- *Correspondence: Bong Ju Moon, Department of Neurosurgery, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju 61469, Republic of Korea (e-mail: )
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7
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Zhang J, Pi C, Cui C, Zhou Y, Liu B, Liu J, Xu X, Zhou X, Zheng L. PTHrP promotes subchondral bone formation in TMJ-OA. Int J Oral Sci 2022; 14:37. [PMID: 35853862 PMCID: PMC9296483 DOI: 10.1038/s41368-022-00189-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 02/08/2023] Open
Abstract
PTH-related peptide (PTHrP) improves the bone marrow micro-environment to activate the bone-remodelling, but the coordinated regulation of PTHrP and transforming growth factor-β (TGFβ) signalling in TMJ-OA remains incompletely understood. We used disordered occlusion to establish model animals that recapitulate the ordinary clinical aetiology of TMJ-OA. Immunohistochemical and histological analyses revealed condylar fibrocartilage degeneration in model animals following disordered occlusion. TMJ-OA model animals administered intermittent PTHrP (iPTH) exhibited significantly decreased condylar cartilage degeneration. Micro-CT, histomorphometry, and Western Blot analyses disclosed that iPTH promoted subchondral bone formation in the TMJ-OA model animals. In addition, iPTH increased the number of osterix (OSX)-positive cells and osteocalcin (OCN)-positive cells in the subchondral bone marrow cavity. However, the number of osteoclasts was also increased by iPTH, indicating that subchondral bone volume increase was mainly due to the iPTH-mediated increase in the bone-formation ability of condylar subchondral bone. In vitro, PTHrP treatment increased condylar subchondral bone marrow-derived mesenchymal stem cell (SMSC) osteoblastic differentiation potential and upregulated the gene and protein expression of key regulators of osteogenesis. Furthermore, we found that PTHrP-PTH1R signalling inhibits TGFβ signalling during osteoblastic differentiation. Collectively, these data suggested that iPTH improves OA lesions by enhancing osteoblastic differentiation in subchondral bone and suppressing aberrant active TGFβ signalling. These findings indicated that PTHrP, which targets the TGFβ signalling pathway, may be an effective biological reagent to prevent and treat TMJ-OA in the clinic.
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Affiliation(s)
- Jun Zhang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Yunnan Key Laboratory of Stomatology, Kunming, China.,Department of, Affiliated Stomatological Hospital, Kunming Medical University, Kunming, China
| | - Caixia Pi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Chen Cui
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yang Zhou
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bo Liu
- Yunnan Key Laboratory of Stomatology, Kunming, China
| | - Juan Liu
- Yunnan Key Laboratory of Stomatology, Kunming, China
| | - Xin Xu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xuedong Zhou
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Liwei Zheng
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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Garg B, Mehta N. Acute Neurological Deficit Due to Sacral Insufficiency Fracture With Coexistent Severe Lumbar Canal Stenosis: A Case Report. HSS J 2022; 18:307-311. [PMID: 35645643 PMCID: PMC9097004 DOI: 10.1177/15563316211006665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India
Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, Jai Prakash
Narayan Apex Trauma Center, New Delhi, India,Nishank Mehta, MS, Department of Orthopaedics, Jai
Prakash Narayan Apex Trauma Center, New Delhi 110029, India.
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9
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Ma C, Liu H, Wei Y, Li H, Miao D, Ren Y. Exogenous PTH 1-34 Attenuates Impaired Fracture Healing in Endogenous PTH Deficiency Mice via Activating Indian Hedgehog Signaling Pathway and Accelerating Endochondral Ossification. Front Cell Dev Biol 2022; 9:750878. [PMID: 35071224 PMCID: PMC8766796 DOI: 10.3389/fcell.2021.750878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Fracture healing is a complicated, long-term, and multistage repair process. Intermittent administration of parathyroid hormone (PTH) has been proven effective on intramembranous and endochondral bone formation during the fracture healing process, however, the mechanism is unclear. In this study, we investigated the role of exogenous PTH and endogenous PTH deficiency in bone fracture healing and explored the mechanism by using PTH knockout (PTH-/-) mice and ATDC5 cells. In a mouse femur fracture model, endogenous PTH deficiency could delay endochondral ossification whereas exogenous PTH promotes accumulation of endochondral bone, accelerates cartilaginous callus conversion to bony callus, enhances maturity of bony callus, and attenuates impaired fracture healing resulting from endogenous PTH deficiency. In fracture callus tissue, endogenous PTH deficiency could inhibit chondrocyte proliferation and differentiation whereas exogenous PTH could activate the IHH signaling pathway to accelerate endochondral ossification and rescue impaired fracture healing resulting from endogenous PTH deficiency. In vitro, exogenous PTH promotes cell proliferation by activating IHH signaling pathway on ATDC5 cells. In mechanistic studies, by using ChIP and luciferase reporter assays, we showed that PTH could phosphorylate CREB, and subsequently bind to the promoter of IHH, causing the activation of IHH gene expression. Therefore, results from this study support the concept that exogenous PTH 1-34 attenuates impaired fracture healing in endogenous PTH deficiency mice via activating the IHH pathway and accelerating endochondral ossification. Hence, the investigation of the mechanism underlying the effects of PTH treatment on fracture repair might guide the exploration of effective therapeutic targets for fracture.
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Affiliation(s)
- Cheng Ma
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huan Liu
- Department of Orthopaedics, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Yifan Wei
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - He Li
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dengshun Miao
- Nanjing Medical University, Affiliated Friendship Plastic Surgery Hospital, Nanjing, China
| | - Yongxin Ren
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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10
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Gamada H, Yanagisawa Y, Teruya S, Eda Y, Nakagawa T, Yamazaki M. Clinical Outcome of Sacroiliac Rod Fixation for Fragility Fracture of the Pelvis Rommens and Hoffman Classification Type IVb: Case Series. Geriatr Orthop Surg Rehabil 2022; 13:21514593221141358. [DOI: 10.1177/21514593221141358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 11/07/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Fragility fracture of the pelvis (FFP), generally involving Rommens and Hoffman classification type IVb (H-shaped) requires spinopelvic fixation (SPF). We report the clinical outcome of sacroiliac rod fixation (SIRF) for FFP type IVb in a case series. Materials and Methods In this retrospective observational study, six patients (mean age, 80.3 years; range, 74-85 years) with FFP type IVb who underwent SIRF since October 2019 and could be followed up for ≥1 year postoperatively were included. All patients were injured in low-energy falls, a patient had a femoral neck fracture, and other had a humeral neck fracture and distal radius fracture. Results The mean (range) operative time was 135 (98-200) min, and mean blood loss was 103 (80-130) g. All patients achieved bone union in an average of 4.3 months. No implant failure or surgical site infection requiring reoperation occurred. No patient complained of iliac screw irritation or requested removal. One patient developed a T12 vertebral fracture at 3 weeks postoperatively. The mean final follow-up period was 17.8 months (13-22 months) and mean final modified Majeed Score (maximum 76 points as the items “work” and “sexual intercourse” were omitted for this study) was 71.7 (56-76). Conclusions SIRF is a less invasive surgical technique than SPF that uses only an S1 pedicle screw and iliac screw. SIRF using the “within ring” concept showed good clinical outcome in FFP type IVb.
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Affiliation(s)
- Hisanori Gamada
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, Chikusei, Japan
| | - Yohei Yanagisawa
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shotaro Teruya
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yusuke Eda
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, Chikusei, Japan
| | - Tsukasa Nakagawa
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, Chikusei, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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11
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Yi H, Wang Y, Liang Q, Mao X. Preclinical and Clinical Amelioration of Bone Fractures with Mesenchymal Stromal Cells: a Systematic Review and Meta-Analysis. Cell Transplant 2022; 31:9636897211051743. [PMID: 35916286 PMCID: PMC9350497 DOI: 10.1177/09636897211051743] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Even though reunion of bone fracture confronts clinicians, mesenchymal stromal
cells (MSCs) are investigated to be curative in bone fracture. This study aimed
to explore the application potential of MSCs for healing bone fractures. By
inputting search terms and retrieving studies published up to March 2021,
multiple databases, including PubMed, EMBASE, Web of Science, and Cochrane
Library, were searched to identify eligible studies. The mean difference (MD)
and 95% confidence interval (95% CI) were calculated to analyze the main results
in the meta-analysis. Data analysis was performed using Engauge Digitizer 10.8
and R Software. Of the 31 articles, 26 were preclinical studies
(n = 913), and 5 were clinical trials (n =
335). Preclinically, MSCs therapy significantly augmented the progress of bone
regeneration [(bone volume over tissue volume (MD7.35, p <
0.01)], despite some non-significant effects (on the callus index, bone
strength, work to failure, and stiffness). Clinically, the MSC group had a
significantly reduced incidence of poor recovery (odds ratio (OR) 0.30,
p < 0.01); however, a significant decrease in healing
time was not observed in the MSC group (MD 2.47, p = 0.26). In
summary, our data suggest that patients with bone fractures benefited from MSC
administration and that MSCs are a potentially useful agent for bone
regeneration. Despite these satisfactory outcomes, larger randomised clinical
trials (RCTs) are necessary to confirm these findings.
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Affiliation(s)
- Hanxiao Yi
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Qunying Liang
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoqun Mao
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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12
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Osagie-Clouard L, Meeson R, Sanghani-Kerai A, Bostrom M, Briggs T, Blunn G. The role of intermittent PTH administration in conjunction with allogenic stem cell treatment to stimulate fracture healing. Bone Joint Res 2021; 10:659-667. [PMID: 34634923 PMCID: PMC8559967 DOI: 10.1302/2046-3758.1010.bjr-2019-0371.r2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aims A growing number of fractures progress to delayed or nonunion, causing significant morbidity and socioeconomic impact. Localized delivery of stem cells and subcutaneous parathyroid hormone (PTH) has been shown individually to accelerate bony regeneration. This study aimed to combine the therapies with the aim of upregulating fracture healing. Methods A 1.5 mm femoral osteotomy (delayed union model) was created in 48 female juvenile Wistar rats, aged six to nine months, and stabilized using an external fixator. At day 0, animals were treated with intrafracture injections of 1 × 106 cells/kg bone marrow mesenchymal stem cells (MSCs) suspended in fibrin, daily subcutaneous injections of high (100 μg/kg) or low (25 μg/kg) dose PTH 1-34, or a combination of PTH and MSCs. A group with an empty gap served as a control. Five weeks post-surgery, the femur was excised for radiological, histomorphometric, micro-CT, and mechanical analysis. Results Combination therapy treatment led to increased callus formation compared to controls. In the high-dose combination group there was significantly greater mineralized tissue volume and trabecular parameters compared to controls (p = 0.039). This translated to significantly improved stiffness (and ultimate load to failure (p = 0.049). The high-dose combination therapy group had the most significant improvement in mean modified Radiographic Union Score for Tibia fractures (RUST) compared to controls (13.8 (SD 1.3) vs 5.8 (SD 0.5)). All groups demonstrated significant increases in the radiological scores – RUST and Allen score – histologically compared to controls. Conclusion We demonstrate the beneficial effect of localized MSC injections on fracture healing combined with low- or high-dose teriparatide, with efficacy dependent on PTH dose. Cite this article: Bone Joint Res 2021;10(10):659–667.
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Affiliation(s)
| | | | | | | | | | - Gorden Blunn
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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13
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Systemic Administration of PTH Supports Vascularization in Segmental Bone Defects Filled with Ceramic-Based Bone Graft Substitute. Cells 2021; 10:cells10082058. [PMID: 34440827 PMCID: PMC8392660 DOI: 10.3390/cells10082058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/29/2021] [Accepted: 08/07/2021] [Indexed: 12/19/2022] Open
Abstract
Non-unions continue to present a challenge to trauma surgeons, as current treatment options are limited, duration of treatment is long, and the outcome often unsatisfactory. Additionally, standard treatment with autologous bone grafts is associated with comorbidity at the donor site. Therefore, alternatives to autologous bone grafts and further therapeutic strategies to improve on the outcome and reduce cost for care providers are desirable. In this study in Sprague–Dawley rats we employed a recently established sequential defect model, which provides a platform to test new potential therapeutic strategies on non-unions while gaining mechanistic insight into their actions. The effects of a combinatorial treatment of a bone graft substitute (HACaS+G) implantation and systemic PTH administration was assessed by µ-CT, histological analysis, and bio-mechanical testing and compared to monotreatment and controls. Although neither PTH alone nor the combination of a bone graft substitute and PTH led to the formation of a stable union, our data demonstrate a clear osteoinductive and osteoconductive effect of the bone graft substitute. Additionally, PTH administration was shown to induce vascularization, both as a single adjuvant treatment and in combination with the bone graft substitute. Thus, systemic PTH administration is a potential synergistic co-treatment to bone graft substitutes.
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14
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Eastman K, Gerlach M, Piec I, Greeves J, Fraser W. Effectiveness of parathyroid hormone (PTH) analogues on fracture healing: a meta-analysis. Osteoporos Int 2021; 32:1531-1546. [PMID: 33559713 DOI: 10.1007/s00198-021-05847-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 01/12/2021] [Indexed: 12/21/2022]
Abstract
UNLABELLED This meta-analysis evaluated the evidence for the use of parathyroid hormone (PTH) analogues to improve fracture healing. Eligible studies were prospective randomised controlled trials of adults with acute fractures treated with a PTH analogue. PTH improved functional outcomes but did not affect fracture healing rate or reduce pain. PURPOSE This meta-analysis evaluated the evidence of parathyroid hormone (PTH) analogues in fracture healing. The use of PTH analogues to prevent osteoporotic fractures is well investigated, and studies are emerging on extended indications. One such indication receiving increasing attention is the effect of PTH in fracture healing; however, the overall degree of efficacy remains inconclusive. METHODS A systematic electronic database search of MEDLINE, EMBASE and the Cochrane Library was conducted for relevant articles in August 2019 with no date restrictions. Randomised controlled trials of adults with acute fractures treated with a PTH analogue were included. PTH was compared with a comparator intervention, placebo or no treatment. RESULTS PTH analogue treatment improved functional outcomes in a range of fracture types but did not affect the fracture healing rate or reduce pain. Most trials included in this review were in elderly patients with osteoporosis. There was no evidence that PTH treatment caused harm or impeded fracture healing. CONCLUSIONS Meta-analysis of published data supports the use of PTH analogues to improve functional outcomes but not fracture healing rate or pain for different fracture types. The evidence for PTH analogue use in fracture healing is less clear in younger, non-osteoporotic patient populations. Trial design was heterogeneous and of limited quality, justifying further original trials.
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Affiliation(s)
- K Eastman
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - M Gerlach
- Norfolk and Norwich University Hospital, Norwich, UK
| | - I Piec
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J Greeves
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Army Health and Performance Research, Andover, Hampshire, UK
| | - W Fraser
- Norwich Medical School, University of East Anglia, Norwich, UK
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15
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Coelho AR, Cardoso G, Brito ME, Gomes IN, Cascais MJ. The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S). REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:395-402. [PMID: 34077990 PMCID: PMC10304901 DOI: 10.1055/s-0041-1730289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
In a healthy athlete, the caloric intake is sufficient for sports energy needs and body physiological functions, allowing a balance between energy availability, bone metabolism, and menstrual cycle. On the other hand, an imbalance caused by low energy availability due to a restrictive diet, eating disorders or long periods of energy expenditure leads to multisystemic deregulation favoring the essential functions of the body. This phenomenon, described as the female athlete triad, occurs in a considerable percentage of high-performance athletes, with harmful consequences for their future. The present review was carried out based on a critical analysis of the most recent publications available and aims to provide a global perception of the topic relative energy deficit in sport (RED-S). The objective is to promote the acquisition of more consolidated knowledge on an undervalued theme, enabling the acquisition of preventive strategies, early diagnosis and/or appropriate treatment.
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Affiliation(s)
| | - Gonçalo Cardoso
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário, Lisboa, Portugal
| | - Marta Espanhol Brito
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário, Lisboa, Portugal
| | | | - Maria João Cascais
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário, Lisboa, Portugal
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16
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Evaluation and management of atypical femoral fractures: an update of current knowledge. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:825-840. [PMID: 33590316 DOI: 10.1007/s00590-021-02896-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.
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17
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Bovbjerg P, Høgh D, Froberg L, Schmal H, Kassem M. Effect of PTH treatment on bone healing in insufficiency fractures of the pelvis: a systematic review. EFORT Open Rev 2021; 6:9-14. [PMID: 33532082 PMCID: PMC7845562 DOI: 10.1302/2058-5241.6.200029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The aging of our society is associated with an increasing number of insufficiency fractures of the pelvis and the current standard of care is pain control and early mobilization. The aim of this study was to explore whether parathyroid hormone (PTH) treatment can support bone healing in these patients. We conducted a systematic review searching the databases PubMed, Embase and Cochrane. Our primary outcome was fracture healing, secondary outcome measures comprised pain, mobility and patient-reported outcome measures (PROMs). Eight articles were included in the qualitative synthesis, of which two were included in a meta-analysis. However, only three studies were comparative including one randomized controlled trial. Fracture healing and reported pain were assessed after eight weeks, and were significantly improved in the group being treated with PTH (p < 0.01) in the meta-analysis. All articles described a positive effect for PTH on fracture healing and pain. Our systematic review indicates that there is a positive effect of PTH treatment on healing and pain in patients with insufficiency fracture in the pelvic ring, but further research is necessary.
Cite this article: EFORT Open Rev 2021;6:9-14. DOI: 10.1302/2058-5241.6.200029
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Affiliation(s)
- Pernille Bovbjerg
- Department of Orthopedic Surgery, Odense University Hospital, Odense, Denmark
| | - Ditte Høgh
- Department of Orthopedic Surgery, Hospital of Southern Denmark, Odense, Denmark
| | - Lonnie Froberg
- Department of Orthopedic Surgery, Odense University Hospital, Odense, Denmark
| | - Hagen Schmal
- Department of Orthopedic Surgery, Odense University Hospital, Odense, Denmark.,Clinic of Orthopaedic Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moustapha Kassem
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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18
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Yu D, Kim S, Jeon I. Therapeutic Effect of Teriparatide for Osteoporotic Thoracolumbar Burst Fracture in Elderly Female Patients. J Korean Neurosurg Soc 2020; 63:794-805. [PMID: 33105532 PMCID: PMC7671788 DOI: 10.3340/jkns.2020.0110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/02/2020] [Indexed: 12/14/2022] Open
Abstract
Objective Teriparatide is known as an effective anabolic agent not only for severe osteoporosis but also for bone healing and union. We explored the possibility of teriparatide as an alternative treatment option for osteoporotic thoracolumbar (TL) burst fracture.
Methods This retrospective study enrolled 35 female patients with mean age of 73.77±6.71 years (61–88) diagnosed as osteoporotic TL burst fracture with ≥4 of thoracolumbar injury classification and severity (TLICS) score and no neurological deficits. All patients were treated by teriparatide only (12 of group A), teriparatide plus vertebroplasty (12 of group B), or surgical fixation with fusion (11 of group C), and followed up for 12 months. Radiological outcomes were evaluated using radiological parameters including kyphotic angle (KA), segmental vertebral kyphotic angle (SVKA), compression ratio (CR), and vertebral body height (anterior [AH], middle [MH], posterior [PH]). Functional outcomes were evaluated using visual analog scale (VAS) and Macnab classification (MC).
Results There were no statistical significant differences in age, bone mineral density (-3.36±0.73), and TLICS score (4.34±0.48) among the three groups (p>0.05). Teriparatide was administered during 8.63±2.32 months in group A and B. In 12-month radiological outcomes, there were significant restoration in SVKA, CR, AH, and MH of group B and KA, SVKA, CR, AH, and MH of group C compared to group A with no radiological changes (p<0.05). All groups showed similar significant improvements in 12-month functional outcomes, although group B and C showed a better 1-month VAS, 1-month MC, 3-month MC compared to group A (p<0.05).
Conclusion Non-surgical treatment with teriparatide showed similar 12-month functional outcomes compared to surgical fixation with fusion. The additional vertebroplasty to teriparatide and surgical fixation with fusion were more helpful to improve short-term functional outcomes with structural restoration compared to teriparatide only.
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Affiliation(s)
- Dongwoo Yu
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
| | - Sungho Kim
- Department of Neurosurgery, Bogang Hospital, Daegu, Korea
| | - Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
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Halloran D, Durbano HW, Nohe A. Bone Morphogenetic Protein-2 in Development and Bone Homeostasis. J Dev Biol 2020; 8:E19. [PMID: 32933207 PMCID: PMC7557435 DOI: 10.3390/jdb8030019] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/01/2020] [Accepted: 09/11/2020] [Indexed: 12/11/2022] Open
Abstract
Bone morphogenetic proteins (BMPs) are multi-functional growth factors belonging to the Transforming Growth Factor-Beta (TGF-β) superfamily. These proteins are essential to many developmental processes, including cardiogenesis, neurogenesis, and osteogenesis. Specifically, within the BMP family, Bone Morphogenetic Protein-2 (BMP-2) was the first BMP to be characterized and has been well-studied. BMP-2 has important roles during embryonic development, as well as bone remodeling and homeostasis in adulthood. Some of its specific functions include digit formation and activating osteogenic genes, such as Runt-Related Transcription Factor 2 (RUNX2). Because of its diverse functions and osteogenic potential, the Food and Drug Administration (FDA) approved usage of recombinant human BMP-2 (rhBMP-2) during spinal fusion surgery, tibial shaft repair, and maxillary sinus reconstructive surgery. However, shortly after initial injections of rhBMP-2, several adverse complications were reported, and alternative therapeutics have been developed to limit these side-effects. As the clinical application of BMP-2 is largely implicated in bone, we focus primarily on its role in bone. However, we also describe briefly the role of BMP-2 in development. We then focus on the structure of BMP-2, its activation and regulation signaling pathways, BMP-2 clinical applications, and limitations of using BMP-2 as a therapeutic. Further, this review explores other potential treatments that may be useful in treating bone disorders.
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Affiliation(s)
| | | | - Anja Nohe
- Department of Biological Sciences, University of Delaware, Newark, DE 19716, USA; (D.H.); (H.W.D.)
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20
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The Efficacy of Teriparatide in Improving Fracture Healing in Hip Fractures: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5914502. [PMID: 32904518 PMCID: PMC7456478 DOI: 10.1155/2020/5914502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/09/2020] [Accepted: 08/06/2020] [Indexed: 12/28/2022]
Abstract
Background This systematic review and meta-analysis assessed the role of teriparatide in improving hip fracture healing and function to provide a clinical guide. Methods The systematic literature review identified randomized controlled trials (RCTs) and controlled studies evaluating teriparatide for elderly hip fractures. A meta-analysis was performed using RevMan version 5.3. Results This study included two RCTs and four retrospective studies comprising 607 patients, with 269 and 338 patients in the teriparatide and control groups, respectively. The quality of these six studies was moderate. Compared to the control group, teriparatide reduced the time to union (weighted mean difference (WMD) = −1.95; 95% confidence interval (CI): -3.23–-0.68; P = 0.003) but did not improve the rate of fracture union at 3 months (odds ratio (OR) = 1.46; 95% CI: 0.50–4.24; P = 0.49) or 6 months (OR = 0.89; 95% CI: 0.44–1.81; P = 0.75). In addition, teriparatide did not decrease the complications, need for reoperation, mortality, rate of deformity after fracture healing, and subsequent fracture or improve hip function. Conclusions The current limited evidence did not support that teriparatide improves fracture healing in hip fractures, due to study heterogeneity and various sources of biases. Further high-quality, large-sample trials are needed. This trial is registered with PROSPERO with registration number CRD42020152205.
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21
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Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O. Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management. Curr Pain Headache Rep 2020; 24:10. [PMID: 32067155 DOI: 10.1007/s11916-020-0848-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF THE REVIEW Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management. RECENT FINDINGS Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jessica Callan
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Nishita V Maganty
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Sara Pousti
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Thomas Simopoulos
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Cyrus Yazdi
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | | | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Abstract
In an era of continual single-sport specialization and year-round training, overuse injuries, including stress injuries of bone, are increasingly common. These injuries can be season- or even career-ending. For many elite and professional athletes, the traditional treatment strategy of immobilization and extended rest from sports participation is often not practical or acceptable. An understanding of modern strategies for evaluating and treating stress fractures is paramount for maintaining athletic participation and optimal athletic performance. This begins with the ability to categorize and stratify bony stress injuries by both severity and risk of fracture progression. Surgical procedures such as open reduction and internal fixation or intramedullary fixation with possible bone grafting remain the standard of care for chronic or severe stress fractures. However, emerging techniques to augment the biologic environment are a minimally invasive adjunct for stimulating and supporting bone healing in elite-level athletes to optimize bone health, expedite recovery, and decrease the risk of nonunion or catastrophic fracture.
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23
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Iolascon G, Paoletta M, Liguori S, Curci C, Moretti A. Neuromuscular Diseases and Bone. Front Endocrinol (Lausanne) 2019; 10:794. [PMID: 31824418 PMCID: PMC6886381 DOI: 10.3389/fendo.2019.00794] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/30/2019] [Indexed: 02/05/2023] Open
Abstract
Neuromuscular diseases (NMDs) are inherited or acquired conditions affecting skeletal muscles, motor nerves, or neuromuscular junctions. Most of them are characterized by a progressive damage of muscle fibers with reduced muscle strength, disability, and poor health-related quality of life of affected patients. In this scenario, skeletal health is usually compromised as a consequence of modified bone-muscle cross-talk including biomechanical and bio-humoral issues, resulting in increased risk of bone fragility and fractures. In addition, NMD patients frequently face nutritional issues, including malnutrition due to feeding disorders and swallowing problems that might affect bone health. Moreover, in these patients, low levels of physical activity or immobility are common and might lead to overweight or obesity that can also interfere with bone strength features. Also, vitamin D deficiency could play a critical role both in the pathogenesis and in the clinical scenario of many NMDs, suggesting that its correction could be useful in maintaining or enhancing bone health, especially in the early phases of NMDs. Last but not least, specific disease-modifying drugs, available for some NMDs, are frequently burdened with adverse effects on bone tissue. For example, glucocorticoid therapy, standard of care for many muscular dystrophies, prolongs long-term survival in treated patients; nevertheless, high dose and/or chronic use of these drugs are a common cause of secondary osteoporosis. This review addresses the current state of knowledge about the factors that play a role in determining bone alterations reported in NMDs, how these factors can modify the biological pathways underlying bone health, and which are the available interventions to manage bone involvement in patients affected by NMDs. Considering the complexity of care of these patients, an interdisciplinary and multimodal management strategy based on both pharmacological and non-pharmacological interventions is recommended, particularly targeting musculoskeletal issues that are closely related to functional independence as well as social implications.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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24
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Kim SJ, Park HS, Lee DW, Lee JW. Does short-term weekly teriparatide improve healing in unstable intertrochanteric fractures? J Orthop Surg (Hong Kong) 2019; 26:2309499018802485. [PMID: 30296889 DOI: 10.1177/2309499018802485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Slow recovery after hip fracture has been associated with negative consequences. Thus, there is medical need to improve healing and functional recovery after intertrochanteric fracture. The aim of this study was to measure whether short-term teriparatide would improve healing in intertrochanteric fractures after internal fixation as measured by (1) clinical scores, (2) radiographic fracture healing, and (3) complication rates. We retrospectively reviewed 96 patients (average age, 82 years) who underwent closed reduction and internal fixation with proximal femoral nail (PFN) for unstable intertrochanteric fractures between 2014 and 2016. Of the 96 patients, 56 patients were treated with a PFN alone (group 1). These patients were compared with 46 patients for whom the same device was used and a weekly subcutaneous injection of PTH 1-34 (teriparatide) was prescribed postoperatively (group 2). Questionnaire surveys or telephone interviews were conducted, and patients completed a self-report Harris hip score and visual analog scale scores. The radiological time to fracture healing was assessed as the primary end point. Postoperative complication rates were compared. Functional outcomes at 6 months after surgery were similar in both groups. There were no differences between groups in the proportion of patients achieving radiographic fracture healing. The frequency of patients reporting adverse events was 20% (10 of 50) in group 1 versus 17% (8 of 46) in group 2 ( p = 0.744). Short-term teriparatide did not improve radiographic signs of fracture healing of an intertrochanteric fracture and reduce the incidence of complications. The effect of teriparatide on fracture healing remains uncertain. Further multicenter prospective studies are needed to demonstrate objective long-term results of parathyroid hormone therapy in patient with hip fracture. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Seung-Ju Kim
- Department of Orthopaedics, Hanil General Hospital, Seoul, Korea
| | - Hyun-Soo Park
- Department of Orthopaedics, Hanil General Hospital, Seoul, Korea
| | - Dong-Woo Lee
- Department of Orthopaedics, Hanil General Hospital, Seoul, Korea
| | - Jae-Won Lee
- Department of Orthopaedics, Hanil General Hospital, Seoul, Korea
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Kim SJ, Park HS, Lee DW, Lee JW. Short-term daily teriparatide improve postoperative functional outcome and fracture healing in unstable intertrochanteric fractures. Injury 2019; 50:1364-1370. [PMID: 31182230 DOI: 10.1016/j.injury.2019.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/25/2019] [Accepted: 06/02/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND There has been heightened interest in the effect of osteoanabolic agents on acceleration of fracture healing. OBJECTIVES The purpose of this study was to identify whether short-term daily teriparatide prescribed for osteoporosis treatment would improve postoperative outcomes including clinical scores, radiographic healing, and complication rates. METHODS Between 2014 and 2017, we retrospectively assessed 112 patients who underwent closed reduction and internal fixation with proximal femoral nail (PFN) for unstable intertrochanteric fractures. In 60 of 112 patients, patients were treated with a PFN alone (group I). These patients were compared with 52 patients for whom the same device was used and a daily subcutaneous injection of teriparatide (1-34 PTH, Forsteo®) was prescribed postoperatively (group II). Teriparatide was administered by nurses during a hospital stay and then self-injection was monitored by follow-up visits to the outpatient clinic after discharge. Questionnaire surveys were conducted and patients completed a self-report Harris hip score (HHS) and visual analog scale (VAS) scores. RESULTS Teriparatide therapy significantly increased HHS (p = 0.02) and decreased VAS pain scores (p = 0.008). The mean time to fracture healing post-operatively was 14.8 weeks (SD 7.1) and 12.1 weeks (SD 6.4) in group I and II, respectively (p = 0.002). The frequency of patients reporting postoperative complications was also markedly reduced in the teriparatide-treated groups (p = 0.028). CONCLUSIONS Short-term daily teriparatide used for osteoporosis treatment improved radiographic fracture healing of a hip fracture and reduced complication rates. However, because of the limited power of the study, additional randomized placebo-controlled trials are needed to determine the potential benefit of PTH as an adjunct to enhance fracture healing and its efficacy in broader populations with varying comorbidities and fracture types.
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Affiliation(s)
- Seung-Ju Kim
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul 132-703, South Korea.
| | - Hyun-Soo Park
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul 132-703, South Korea.
| | - Dong-Woo Lee
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul 132-703, South Korea.
| | - Jae-Won Lee
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul 132-703, South Korea.
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Kang JH, Yang SM, Im SB, Jeong JH. Can Three Months of Teriparatide Be One of Treatment Options for Osteoporotic Vertebral Compression Fracture Patients? Korean J Neurotrauma 2019; 15:19-27. [PMID: 31098345 PMCID: PMC6495587 DOI: 10.13004/kjnt.2019.15.e13] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 12/15/2022] Open
Abstract
Objective Osteoporosis is one of the most common causes of vertebral compression fractures (VCFs). Teriparatide, a recombinant human parathyroid hormone, is the first anabolic agent for the treatment of osteoporosis. The aim of this study was to determine whether 3 months of teriparatide could be effective for patients with osteoporotic VCF at the thoracolumbar spine. Methods We reviewed 25 patients with thoracolumbar osteoporotic compression fractures between July 2012 and October 2016 who could be followed up for more than 1 year. Patients were divided into 2 groups depending on the use of teriparatide: 14 patients received teriparatide through subcutaneous injection (group I) and 11 patients did not receive teriparatide (group II). Demographic data, bone mineral density, hospitalization period, changes in the visual analogue scale (VAS) score, body mass index, and medical history such as smoking, alcohol, diabetes, and steroid usage were reviewed. Radiographs were also reviewed to evaluate vertebral body compression percentages and kyphotic angles. Results Overall changes of VAS score between injury and follow-up were statistically improved in both groups at 2 to 3 weeks post-injury. However, difference in VAS improvement at a specific time between the 2 groups was not statistically significant. Overall kyphotic angle and compression percentage between injury and follow-up time were increased in group II than those in group I, although the difference between the 2 groups was not statistically significant. Conclusion Three-month of teriparatide did not show protective effects on progression of fractured vertebral body collapse or kyphotic changes in patients with osteoporosis.
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Affiliation(s)
- Jung Hoon Kang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang Mi Yang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Soo Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Lumbopelvic Fixation for Sacral Insufficiency Fracture Presenting with Sphincter Dysfunction. Case Rep Orthop 2019; 2019:9097876. [PMID: 31093401 PMCID: PMC6476123 DOI: 10.1155/2019/9097876] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 03/05/2019] [Accepted: 03/25/2019] [Indexed: 11/17/2022] Open
Abstract
Sacral insufficiency fractures (SIFs) are common in the elderly. In patients with SIF, objective neurological abnormalities such as sphincter dysfunction or leg paresthesia are uncommon. We present a case of SIF accompanied by spinopelvic dissociation with late neurological compromise treated by spinopelvic fixation. A 61-year-old woman presented to our hospital with low back pain without obvious trauma history. She had a past history of eosinophilic granulomatosis with polyangiitis and treatment with steroids. Her low back pain became worse, and she started to have radiating left posterior thigh pain and motor weakness in the left ankle and both great toes with symptoms of stress urinary incontinence, constipation, and loss of anal sensation. Magnetic resonance imaging revealed an H-shaped sacrum fracture. We attributed the neurological symptoms to unstable SIF and performed lumbopelvic fixation. After the surgery, her leg pain and symptoms of stress urinary incontinence improved markedly, as did anal sensation. At a 6-month follow-up, the patient reported no low back pain and she was walking independently without pelvic complaints. CT showed bone union was achieved. Even minimally displaced SIF in patients with osteoporosis can be a cause of bowel and bladder disturbance. Lumbopelvic fixation is a treatment option for SIF with spinopelvic dissociation presenting neurological deficit.
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Abstract
A history of prior fracture is the most reliable indicator of prospective fracture risk. Increased fracture risk is not confined to the region of the prior fracture, but is operant at all skeletal sites, providing strong evidence of systemic bone loss after fracture. Animal and human studies suggest that systemic bone loss begins shortly after fracture and persists for several years in humans. In fact, bone quantity and bone quality may never fully return to their pre-fracture levels, especially in older subjects, demonstrating a need for improved understanding of the mechanisms leading to systemic bone loss after fracture in order to reduce subsequent fracture risk. Although the process remains incompletely understood, mechanical unloading (disuse), systemic inflammation, and hormones that control calcium homeostasis may all contribute to systemic bone loss. Additionally, individual factors can potentially affect the magnitude and time course of systemic bone loss and recovery. The magnitude of systemic bone loss correlates positively with injury severity and age. Men may also experience greater bone loss or less recovery than women after fracture. This review details the current understanding of systemic bone loss following fracture, including possible underlying mechanisms and individual factors that may affect this injury response.
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Abstract
A substantial proportion of fractures can present with nonunion, and the management of nonunion continues to present a challenge for orthopaedic surgeons. A variety of biological, mechanical, patient, and injury factors can contribute to the occurrence of nonunion, and often the cause of nonunion may be multifactorial. Successful management often requires assessment and treatment of more than one of these factors. This article reviews common factors that may contribute to nonunion including infection, impaired biology, and metabolic disorders. In addition, new and evolving strategies for diagnosing the cause and effectively treating nonunion including the diagnosis of infection, metabolic workup, bone grafting, cell-based therapies, and biological adjuvants are reviewed and discussed.
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Kumabe Y, Lee SY, Waki T, Iwakura T, Takahara S, Arakura M, Kuroiwa Y, Fukui T, Matsumoto T, Matsushita T, Nishida K, Kuroda R, Niikura T. Triweekly administration of parathyroid hormone (1-34) accelerates bone healing in a rat refractory fracture model. BMC Musculoskelet Disord 2017; 18:545. [PMID: 29268728 PMCID: PMC5740882 DOI: 10.1186/s12891-017-1917-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 12/14/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Some reports have shown that intermittent parathyroid hormone (PTH) (1-34) treatment for patients with delayed union or nonunion have led to successful healing. In this study, we investigated whether systemic intermittent administration of PTH (1-34) has a beneficial effect on bone healing in a rat refractory fracture model. METHODS We created a refractory femoral fracture model in 32 rats with periosteal cauterization that leads to atrophic nonunion at 8 weeks after surgery. Half the rats received subcutaneous intermittent human PTH (1-34) injections at a dosage of 100 μg/kg, thrice a week for 8 weeks. The other half received the vehicle only. At 8 weeks after fracture, radiographic, histological and mechanical assessments were performed. RESULTS Radiographic assessments showed that the union rate was significantly higher in the PTH group than in the control group (P < 0.05). The degree of fracture repair as scored using the Allen grading system in histological assessment was significantly greater in the PTH group than in the control group (P < 0.05). The ultimate stress and stiffness measurements were significantly greater in the PTH group than in the control group (p < 0.05). CONCLUSIONS We demonstrated that triweekly administration of PTH (1-34) increased union rate and accelerated bone healing in a rat refractory fracture model, suggesting that systemic administration of PTH (1-34) could become a novel and useful therapy for accelerating fracture healing in patients at high risk of delayed union or nonunion.
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Affiliation(s)
- Yohei Kumabe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Sang Yang Lee
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.,Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Takahiro Waki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takashi Iwakura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shunsuke Takahara
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Michio Arakura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yu Kuroiwa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Kotaro Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
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Tarantino U, Iolascon G, Cianferotti L, Masi L, Marcucci G, Giusti F, Marini F, Parri S, Feola M, Rao C, Piccirilli E, Zanetti EB, Cittadini N, Alvaro R, Moretti A, Calafiore D, Toro G, Gimigliano F, Resmini G, Brandi ML. Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology. J Orthop Traumatol 2017; 18:3-36. [PMID: 29058226 PMCID: PMC5688964 DOI: 10.1007/s10195-017-0474-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Italian Society for Orthopaedics and Traumatology conceived this guidance-which is primarily addressed to Italian orthopedic surgeons, but should also prove useful to other bone specialists and to general practitioners-in order to improve the diagnosis, prevention, and treatment of osteoporosis and its consequences. MATERIALS AND METHODS Literature reviews by a multidisciplinary team. RESULTS The following topics are covered: the role of instrumental, metabolic, and genetic evaluations in the diagnosis of osteoporosis; appraisal of the risk of fracture and thresholds for intervention; general strategies for the prevention and treatment of osteoporosis (primary and secondary prevention); the pharmacologic treatment of osteoporosis; the setting and implementation of fracture liaison services for tertiary prevention. Grade A, B, and C recommendations are provided based on the main levels of evidence (1-3). Toolboxes for everyday clinical practice are provided. CONCLUSIONS The first up-to-date Italian guidelines for the primary, secondary, and tertiary prevention of osteoporosis and osteoporotic fractures are presented.
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Affiliation(s)
- Umberto Tarantino
- Policlinico Tor Vergata Foundation, Orthopaedics and Traumatology, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Naples, Italy
| | - Luisella Cianferotti
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Laura Masi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Gemma Marcucci
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Francesca Giusti
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Francesca Marini
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Simone Parri
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Maurizio Feola
- Policlinico Tor Vergata Foundation, Orthopaedics and Traumatology, University of Rome Tor Vergata, Rome, Italy
| | - Cecilia Rao
- Policlinico Tor Vergata Foundation, Orthopaedics and Traumatology, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Piccirilli
- Policlinico Tor Vergata Foundation, Orthopaedics and Traumatology, University of Rome Tor Vergata, Rome, Italy
| | - Emanuela Basilici Zanetti
- Nursing Science, Center of Excellence for Culture and Nursing Research-IPASVI, University of Rome Tor Vergata, Rome, Italy
| | - Noemi Cittadini
- Nursing Science, Center of Excellence for Culture and Nursing Research-IPASVI, University of Rome Tor Vergata, Rome, Italy
| | - Rosaria Alvaro
- Nursing Science, Center of Excellence for Culture and Nursing Research-IPASVI, University of Rome Tor Vergata, Rome, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Naples, Italy
| | - Dario Calafiore
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Naples, Italy
| | - Francesca Gimigliano
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Naples, Italy
| | - Giuseppina Resmini
- Section of Orthopaedics and Traumatology, Centre for the Study of Osteoporosis and Metabolic Bone Disease, Treviglio-Caravaggio Hospital, Bergamo, Italy
| | - Maria Luisa Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
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Kasukawa Y, Miyakoshi N, Ebina T, Hongo M, Ishikawa Y, Kudo D, Nozaka K, Shimada Y. Enhanced bone healing and decreased pain in sacral insufficiency fractures after teriparatide treatment: retrospective clinical-based observational study. ACTA ACUST UNITED AC 2017; 14:140-145. [PMID: 29263722 DOI: 10.11138/ccmbm/2017.14.1.140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The purpose of this retrospective clinical-based observational study was to evaluate the effects of teriparatide (TPTD) on clinical outcomes and radiologic findings of sacral insufficiency fractures (SIFs). Seven elderly women with SIFs received TPTD for at least 6 months. We evaluated the symptoms, pain, and radiological findings. At their initial clinic visit, 86% patients could not walk or sit. Computed tomography (CT) images revealed sacral wing fracture in 6 patients, and bone scintigram showed H-shaped uptake over the bilateral sacral wings in 1 patient. After the treatment, 5 patients could walk. Mean visual analog scale score was significantly lower after (12.9 mm) than before (87.4 mm) TPTD treatment (p < 0.0001). CT images revealed bone union (four patients) and sclerotic changes (three patients) at the fracture sites. Seven elderly women with SIFs had significant improvement in pain and demonstrated bone union or sclerotic changes at fracture sites by TPTD.
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Affiliation(s)
- Yuji Kasukawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
| | - Toshihito Ebina
- Department of Orthopedic Surgery, Kakunodate General Hospital, Senboku, Japan
| | - Michio Hongo
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
| | - Yoshinori Ishikawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
| | - Daisuke Kudo
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
| | - Koji Nozaka
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan.,Akita Bone and Osteoporosis Network (A-BONE)
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Nishitani K, Mietus Z, Beck CA, Ito H, Matsuda S, Awad HA, Ehrhart N, Schwarz EM. High dose teriparatide (rPTH1-34) therapy increases callus volume and enhances radiographic healing at 8-weeks in a massive canine femoral allograft model. PLoS One 2017; 12:e0185446. [PMID: 29020057 PMCID: PMC5636088 DOI: 10.1371/journal.pone.0185446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/12/2017] [Indexed: 01/15/2023] Open
Abstract
Small animal studies have demonstrated significant high-dose recombinant parathyroid hormone1-34 (rPTH1-34) effects on intercalary allograft healing. Towards a human adjuvant therapy to decrease non-unions, we evaluated rPTH1-34 safety and efficacy in a clinically relevant canine femoral allograft model. Adult female mongrel hounds (n = 20) received a 5cm mid-diaphyseal osteotomy reconstructed with a plated allograft, and were randomized to: 1) Placebo (n = 5; daily saline), 2) Continuous rPTH1-34 (n = 7; 5 μg/kg/day s.c. from day 1-55 post-op), or 3) Delayed rPTH1-34 (n = 8; 5 μg/kg/day s.c. from day 14-28 post-op). Safety was assessed by physical behavior and blood calcium monitoring. Cone beam CT (CB-CT) was performed on days 14, 28 and 56 post-op to assess 2D cortical healing, 3D bone volume, and Union Ratio. Biomechanical testing and dynamic histomorphometry were also performed. The high drug dose was poorly tolerated, as most dogs receiving rPTH1-34 had to be given intravenous saline, and one dog died from hypercalcemia. Continuous rPTH1-34 significantly increased 2D healing and callus volumes at 4-weeks versus Placebo, and sustained the significant increase in cortical union at 8-week (p<0.05). These rPTH1-34 effects were confirmed by histomorphometry, revealing significant increases in mineral apposition rates (MAR) on host bone and graft-host junctions (p<0.05). Delayed rPTH1-34 significantly increased callus volume and MAR at 8 weeks (p<0.05). Although no biomechanical differences were observed, as expected for early healing, the results demonstrated that 2D RUST scoring significantly correlated with torsional biomechanics (p<0.01). In conclusion, 8-weeks of intermittent high-dose rPTH1-34 treatment significantly increases callus formation and accelerates bony union of intercalary massive allografts in a clinically relevant canine model, but with serious side-effects from hypercalcemia.
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Affiliation(s)
- Kohei Nishitani
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Orthopaedics Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Zachary Mietus
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States of America
| | - Christopher A. Beck
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Hiromu Ito
- Department of Orthopaedics Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedics Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hani A. Awad
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States of America
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Nicole Ehrhart
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States of America
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States of America
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY, United States of America
- * E-mail:
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34
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Zhang H, Kot A, Lay YAE, Fierro FA, Chen H, Lane NE, Yao W. Acceleration of Fracture Healing by Overexpression of Basic Fibroblast Growth Factor in the Mesenchymal Stromal Cells. Stem Cells Transl Med 2017; 6:1880-1893. [PMID: 28792122 PMCID: PMC6430058 DOI: 10.1002/sctm.17-0039] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/20/2017] [Indexed: 12/29/2022] Open
Abstract
In this study, we engineered mesenchymal stem cells (MSCs) to over‐express basic fibroblast growth factor (bFGF) and evaluated its effects on fracture healing. Adipose‐derived mouse MSCs were transduced to express bFGF and green fluorescence protein (ADSCbFGF‐GFP). Closed‐femoral fractures were performed with osterix‐mCherry reporter mice of both sexes. The mice received 3 × 105 ADSCs transfected with control vector or bFGF via intramuscular injection within or around the fracture sites. Mice were euthanized at days 7, 14, and 35 to monitor MSC engraftment, osteogenic differentiation, callus formation, and bone strength. Compared to ADSC culture alone, ADSCbFGF increased bFGF expression and higher levels of bFGF and vascular endothelial growth factor (VEGF) in the culture supernatant for up to 14 days. ADSCbFGF treatment increased GFP‐labeled MSCs at the fracture gaps and these cells were incorporated into the newly formed callus. quantitative reverse transcription polymerase chain reaction (qRT‐PCR) from the callus revealed a 2‐ to 12‐fold increase in the expression of genes associated with nervous system regeneration, angiogenesis, and matrix formation. Compared to the control, ADSCbFGF treatment increased VEGF expression at the periosteal region of the callus, remodeling of collagen into mineralized callus and bone strength. In summary, MSCbFGF accelerated fracture healing by increasing the production of growth factors that stimulated angiogenesis and differentiation of MSCs to osteoblasts that formed new bone and accelerated fracture repair. This novel treatment may reduce the time required for fracture healing. Stem Cells Translational Medicine2017;6:1880–1893
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Affiliation(s)
- Hongliang Zhang
- Center for Musculoskeletal Health, Department of Internal Medicine, Sacramento, California, USA.,Department of Emergency Medicine, Center for Difficult Diagnoses and Rare Diseases, Second Xiangya Hospital of the Central-South University, Hunan, Changsha, People's Republic of China
| | - Alexander Kot
- Center for Musculoskeletal Health, Department of Internal Medicine, Sacramento, California, USA
| | - Yu-An E Lay
- Center for Musculoskeletal Health, Department of Internal Medicine, Sacramento, California, USA
| | - Fernando A Fierro
- Stem Cell Program, UC Davis Health System, Institute for Regenerative Cures, University of California Davis Medical Center, Sacramento, California, USA
| | - Haiyan Chen
- Center for Musculoskeletal Health, Department of Internal Medicine, Sacramento, California, USA.,Adult Programs Division, California Department of Social Services, Sacramento, California, USA
| | - Nancy E Lane
- Center for Musculoskeletal Health, Department of Internal Medicine, Sacramento, California, USA
| | - Wei Yao
- Center for Musculoskeletal Health, Department of Internal Medicine, Sacramento, California, USA
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Emanuele C, Leonardo P, Gianfilippo C, Matteo A, Doria C. Peri-prosthetic humeral non-union: Where biology meets bio-mechanic. A case report. Int J Surg Case Rep 2017; 39:102-105. [PMID: 28826070 PMCID: PMC5565746 DOI: 10.1016/j.ijscr.2017.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The worldwide incidence of traumatic fractures has been growing over the last years due to the progressive aging of the population. Today, the increase of arthroplasty procedures in orthopaedic surgery is related to a high rate of peri-prosthetic fractures. Healing of the fracture is a multifactorial metabolic process; if these factors are impaired, healing process could be interrupted resulting in non-union. PRESENTATION OF CASE We report our experience about a case of a humeral diaphysis non-union secondary to peri-prosthetic fracture (reverse shoulder arthroplasty) treated by conservative approach. DISCUSSION We treated this patient using a multilevel approach, consisting of revision surgery and drug therapy. CONCLUSION We assume that an aggressive revision surgery done with bone autograft implant and a bone healing therapy administering teriparatide off-label can reduce the convalescence in non-unions and can improve prognosis.
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Affiliation(s)
- Ciurlia Emanuele
- Orthopaedic Department - Medical School of Sassari, Viale San Pietro 47, 07100 Sassari, Italy.
| | - Puddu Leonardo
- Orthopaedic Department - Medical School of Sassari, Viale San Pietro 47, 07100 Sassari, Italy.
| | - Caggiari Gianfilippo
- Orthopaedic Department - Medical School of Sassari, Viale San Pietro 47, 07100 Sassari, Italy.
| | - Andreozzi Matteo
- Orthopaedic Department - Medical School of Sassari, Viale San Pietro 47, 07100 Sassari, Italy.
| | - Carlo Doria
- Orthopaedic Department - Medical School of Sassari, Viale San Pietro 47, 07100 Sassari, Italy.
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Malouf-Sierra J, Tarantino U, García-Hernández PA, Corradini C, Overgaard S, Stepan JJ, Borris L, Lespessailles E, Frihagen F, Papavasiliou K, Petto H, Aspenberg P, Caeiro JR, Marin F. Effect of Teriparatide or Risedronate in Elderly Patients With a Recent Pertrochanteric Hip Fracture: Final Results of a 78-Week Randomized Clinical Trial. J Bone Miner Res 2017; 32:1040-1051. [PMID: 28019683 DOI: 10.1002/jbmr.3067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/19/2016] [Accepted: 12/21/2016] [Indexed: 12/14/2022]
Abstract
We present final results of a study comparing teriparatide 20 μg every day (QD) with risedronate 35 mg once per week (QW) started within 2 weeks after surgery for a pertrochanteric hip fracture. Patients with BMD T-score ≤ -2.0 and 25OHD ≥9.2 ng/mL were randomized to receive 26-week double-dummy treatment plus calcium and vitamin D, followed by 52-week open-label treatment with the same assigned active drug. Primary endpoint was change from baseline in lumbar spine (LS) BMD at 78 weeks. Secondary and exploratory endpoints were change in BMD at the proximal femur, function, hip pain (Charnley score and 100 mm Visual Analog Scale [VAS]), quality of life (Short Form-36), radiology outcomes, and safety. Data were analyzed with mixed models for repeated measures (MMRM) and logistic regression. Totally, 224 patients were randomized; 171 (teriparatide: 86) contributed to the efficacy analyses (mean ± SD age: 77 ± 7.7 years, 77% females). Mean baseline LS, femoral neck (FN), and total hip (TH) T-scores were -2.16, -2.63, and -2.51, respectively. At 78 weeks, BMD increased significantly more with teriparatide compared to risedronate at the LS (+11.08% versus +6.45%; p < 0.001) and FN (+1.96% versus -1.19%; p = 0.003), with no significant between-group difference in TH BMD. Timed up-and-go (TUG) test was significantly faster with teriparatide at 6, 12, 18, and 26 weeks (differences: -3.2 to -5.9 s; p = 0.045 for overall difference). Hip pain during TUG test by 100 mm VAS was significantly lower with teriparatide at 18 weeks (adjusted difference: -11.3 mm, p = 0.033; -10.0 and -9.3 mm at 12 and 26 weeks, respectively; p = 0.079 for overall difference). Other secondary and exploratory outcomes were not different. Teriparatide group showed two new hip fractures versus seven with risedronate (p = 0.171) and more frequent hypercalcemia and hyperuricemia. In conclusion, 78-week treatment with teriparatide showed significantly greater increases in LS and FN BMD, less pain, and a faster TUG test versus risedronate. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
| | | | | | - Costantino Corradini
- Department of Biomedical Surgical and Dental Sciences, University of Milan, c/o 1st University Division of Orthopaedy and Traumatology, ASST Gaetano Pini, Milan, Italy
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan J Stepan
- Institute of Rheumatology and Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lars Borris
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Eric Lespessailles
- Institut de prévention et de recherche sur l'ostéoporose (IPROS), Department of Rheumatology, Centre Hospitalier Régional (CHR) d'Orléans, Orléans, France.,Imagerie Multimodale Multiéchelle et Modélisation du Tissu Osseux (I3MTO), EA 4708, Orléans University, Orléans, France
| | - Frede Frihagen
- Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Kyriakos Papavasiliou
- 3rd Orthopaedic Department, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | | | - Per Aspenberg
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - José Ramón Caeiro
- Department of Orthopaedic Surgery and Traumatology, Santiago de Compostela University Hospital, Health Research Institute, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Fernando Marin
- Eli Lilly Research Centre Ltd, Erl Wood Manor, Surrey, UK
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Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:1413-1439. [PMID: 28368518 DOI: 10.1210/jc.2017-00131] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/23/2017] [Indexed: 02/04/2023]
Abstract
COSPONSORING ASSOCIATIONS The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society. OBJECTIVE To formulate clinical practice guidelines for the diagnosis and treatment of functional hypothalamic amenorrhea (FHA). PARTICIPANTS The participants include an Endocrine Society-appointed task force of eight experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and cosponsoring organizations reviewed and commented on preliminary drafts of this guideline. CONCLUSIONS FHA is a form of chronic anovulation, not due to identifiable organic causes, but often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.
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Affiliation(s)
| | - Kathryn E Ackerman
- Boston Children's Hospital, Boston, Massachusetts 02115
- Massachusetts General Hospital, Boston, Massachusetts 02114
| | - Sarah L Berga
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Jay R Kaplan
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - George Mastorakos
- Areteio Hospital, Medical School, National and Capodistrian University of Athens, Athens, Greece 10674
| | | | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | | | - Michelle P Warren
- Center for Menopause, Hormonal Disorders, and Women's Health, Columbia University Medical Center, New York, New York 10021
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Koh A, Guerado E, Giannoudis PV. Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management. Bone Joint J 2017; 99-B:295-302. [PMID: 28249967 DOI: 10.1302/0301-620x.99b3.bjj-2016-0276.r2] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
Abstract
AIMS Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures. MATERIALS AND METHODS Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified. RESULTS For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing. CONCLUSION Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295-302.
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Affiliation(s)
- A Koh
- Kobe Rosai Hospital, 4-1-23 Kagoike-dori, Chuo-ku, Kobe, 651-0053, Japan
| | - E Guerado
- University of Malaga, Autovia A-7 K, 187 29603, Marbella, Malaga, Spain
| | - P V Giannoudis
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, Leeds, UK
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Effectiveness of Teriparatide on Fracture Healing: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0168691. [PMID: 27997614 PMCID: PMC5173248 DOI: 10.1371/journal.pone.0168691] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/05/2016] [Indexed: 01/15/2023] Open
Abstract
Purpose Nowadays, the efficacy of teriparatide in treating osteoporosis was widely accepted, but the discussion about using teriparatide to enhance fracture healing hasn’t come to an agreement. This meta-analysis was conducted to evaluate the effectiveness of teriparatide for fracture healing. Methods We searched PubMed, the Cochrane Library, and Embase in August 2016 for randomized controlled trials (RCTs) which concerned the treatment of teriparatide for fracture healing. Results Finally, a total of 380 patients were randomly assigned in the 5 trials included in this meta-analysis. There was a significant effectiveness with regards to function improvement in patients following fracture, however, there was no significant effectiveness with regards to time of radiographic fracture healing, fracture healing rate and reduction in pain. Conclusions This analysis showed that administration of teriparatide following fracture lacked the effectiveness for fracture healing. Moreover, teriparatide administration had no apparent adverse effects. These results should be interpreted with caution because of some clear limitations. If we want to confirm whether teriparatide improves fracture healing, more high-quality randomized controlled trials are needed.
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Aspenberg P, Malouf J, Tarantino U, García-Hernández PA, Corradini C, Overgaard S, Stepan JJ, Borris L, Lespessailles E, Frihagen F, Papavasiliou K, Petto H, Caeiro JR, Marin F. Effects of Teriparatide Compared with Risedronate on Recovery After Pertrochanteric Hip Fracture: Results of a Randomized, Active-Controlled, Double-Blind Clinical Trial at 26 Weeks. J Bone Joint Surg Am 2016; 98:1868-1878. [PMID: 27852903 PMCID: PMC5551693 DOI: 10.2106/jbjs.15.01217] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteoporosis drugs might affect fracture-healing. We therefore studied the effects of teriparatide in comparison with risedronate on recovery after pertrochanteric hip fractures. METHODS The study was a randomized, multicenter, active-controlled, 78-week trial comparing teriparatide (20 μg/day) with risedronate (35 mg/week) initiated within 2 weeks after fixation of a low-trauma pertrochanteric hip fracture (AO/OTA 31-A1 or 31-A2). The main inclusion criteria were a bone mineral density T-score of ≤-2.0 and 25-OH-vitamin D of ≥9.2 ng/mL. During the first 26 weeks, patients received study medication with oral or injectable placebo plus calcium and vitamin D in a double-blinded fashion. Secondary (Timed Up-and-Go [TUG] test, hip pain, Short Form [SF]-36 health status, and safety) and exploratory (radiographic outcomes and ability to walk) 26-week end points are reported. RESULTS Of the 224 patients who were randomized, 171 (86 teriparatide, 85 risedronate) were included in the analysis. The mean age was 77 ± 8 years, 77% were female, and 26% had a prior history of low-trauma fracture. The teriparatide group completed the TUG test in a shorter time at 6, 12, 18, and 26 weeks (differences of -5.7, -4.4, -3.1, and -3.1 seconds, respectively; p = 0.021 for the overall difference). They also reported less pain on a visual analog scale immediately after the TUG test at 12 and 18 weeks (adjusted absolute differences of 10.6 and 11.9 mm, respectively; p < 0.05). There were no significant between-group differences in the SF-36 score, Charnley hip pain score, ability to walk, or use of walking aids during follow-up. Radiographic healing at 6, 12, and 26 weeks, mechanical failure of the implant (teriparatide, 7; risedronate, 8), loss of reduction (teriparatide, 2; risedronate, 4), and nonunion (0 cases) were not significantly different. Mild hypercalcemia and hyperuricemia were more frequent with teriparatide. CONCLUSIONS Teriparatide was associated with less pain and a shorter time to complete the TUG test between 6 and 26 weeks compared with risedronate. Other fracture-recovery outcomes were similar. The results should be interpreted with caution as these were secondary end points. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Per Aspenberg
- Department of Clinical and Experimental Medicine,
Linköping University, Linköping, Sweden,E-mail address for P. Aspenberg:
| | - Jorge Malouf
- Internal Medicine, Hospital San Pablo, Barcelona,
Spain,E-mail address for J. Malouf:
| | - Umberto Tarantino
- Orthopaedic Surgery, University Tor Vergata, Rome,
Italy,E-mail address for U. Tarantino:
| | - Pedro A. García-Hernández
- Osteoporosis Center, University Hospital, Monterrey,
Mexico,E-mail address for P.A.
García-Hernández:
| | - Costantino Corradini
- Department of Biomedical Surgical and Dental
Sciences, University of Milan, c/o I Division of Orthopaedics and Traumatology,
A.O. Orthopaedic Institute, Milan, Italy,E-mail address for C. Corradini:
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology,
Odense University Hospital, Odense, Denmark,Institute of Clinical Research, University of
Southern Denmark, Odense, Denmark,E-mail address for S. Overgaard:
| | - Jan J. Stepan
- Institute of Rheumatology and Faculty of Medicine 1,
Charles University, Prague, Czech Republic,E-mail address for J.J. Stepan:
| | - Lars Borris
- Orthopaedic Surgery, University Hospital, Aarhus,
Denmark,E-mail address for L. Borris:
| | - Eric Lespessailles
- IPROS, Department of Rheumatology, C.H.R
Orléans, Orléans, France,I3MTO, Orléans University, Orléans,
France,E-mail address for E. Lespessailles:
| | - Frede Frihagen
- Orthopaedic Surgery, Oslo University Hospital,
Oslo, Norway,E-mail address for F. Frihagen:
| | - Kyriakos Papavasiliou
- 3rd Orthopaedic Department, Aristotle University of
Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece,E-mail address for K. Papavasiliou:
| | - Helmut Petto
- Eli Lilly, Vienna, Austria,E-mail address for H. Petto:
| | - José Ramón Caeiro
- Department of Orthopaedic Surgery and Traumatology,
Santiago de Compostela University Hospital, Health Research Institute,
University of Santiago de Compostela, Santiago de Compostela, Spain,E-mail address for J. Ramón Caeiro:
| | - Fernando Marin
- Eli Lilly Research Centre, Windlesham, United
Kingdom,E-mail address for F. Marin:
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Duchman KR, Goetz JE, Uribe BU, Amendola AM, Barber JA, Malandra AE, Fredericks DC, Hettrich CM. Delayed administration of recombinant human parathyroid hormone improves early biomechanical strength in a rat rotator cuff repair model. J Shoulder Elbow Surg 2016; 25:1280-7. [PMID: 26948004 DOI: 10.1016/j.jse.2015.12.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/10/2015] [Accepted: 12/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite advances in intraoperative techniques, rotator cuff repairs frequently do not heal. Recombinant human parathyroid hormone (rhPTH) has been shown to improve healing at the tendon-to-bone interface in an established acute rat rotator cuff repair model. We hypothesized that administration of rhPTH beginning on postoperative day 7 would result in improved early load to failure after acute rotator cuff repair in an established rat model. METHODS Acute rotator cuff repairs were performed in 108 male Sprague-Dawley rats. Fifty-four rats received daily injections of rhPTH beginning on postoperative day 7 until euthanasia or a maximum of 12 weeks postoperatively. The remaining 54 rats received no injections and served as the control group. Animals were euthanized at 2 and 16 weeks postoperatively and evaluated by gross inspection, biomechanical testing, and histologic analysis. RESULTS At 2 weeks postoperatively, rats treated with rhPTH demonstrated significantly higher load to failure than controls (10.9 vs. 5.2 N; P = .003). No difference in load to failure was found between the 2 groups at 16 weeks postoperatively, although control repairs more frequently failed at the tendon-to-bone interface (45.5% vs. 22.7%; P = .111). Blood vessel density appeared equivalent between the 2 groups at both time points, but increased intracellular and extracellular vascular endothelial growth factor expression was noted in the rhPTH-treated group at 2 weeks. CONCLUSIONS Delayed daily administration of rhPTH resulted in increased early load to failure and equivalent blood vessel density in an acute rotator cuff repair model.
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Affiliation(s)
- Kyle R Duchman
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Jessica E Goetz
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bastian U Uribe
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Andrew M Amendola
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Joshua A Barber
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Allison E Malandra
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Douglas C Fredericks
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Carolyn M Hettrich
- Department of Orthopaedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Huang TW, Huang KC, Lin SJ, Chuang PY, Shih HN, Lee MS, Hsu RWW, Shen WJ. Effects of teriparatide on cementless bipolar hemiarthroplasty in patients with osteoporotic femoral neck fractures. BMC Musculoskelet Disord 2016; 17:300. [PMID: 27435235 PMCID: PMC4952237 DOI: 10.1186/s12891-016-1149-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/23/2016] [Indexed: 01/02/2023] Open
Abstract
Background For osteoporotic femoral neck fractures, suitable bone-implant stability is critical for pain relief, early return to daily activities and reduction of complications. Teriparatide (parathyroid hormone [PTH1-34]) can improve bone-implant stability in some basic studies. However it’s use in osteoporotic femoral neck fractures treated by cementless hemiarthroplasties for the beneficial effects on bone-implant stability is sparse in the literature. The aim of this study was to determine if post-operative teriparatide administration can reduce femoral stem migration and improve early functional recovery and health-related quality of life (HRQoL). Methods Between 2010 and 2014, patients with osteoporotic femoral neck fracture who underwent cementless bipolar hemiarthroplasty were included into this retrospective cohort study. Group A included patients treated with cementless bipolar hemiarthroplasty only; Group B patients had additional teriparatide. Demographic data, complications, radiographic and functional outcomes as well as health-related quality of life (HRQoL) were compared. Results There were 52 hips in group A (no teriparatide) and 40 hips in group B (patient who received teriparatide). The subsidence of the femoral stem tended to be significantly decreased in the teriparatide group at 6 and 12 weeks post-operatively (p = 0.003 and p = 0.008, respectively). The Harris Hip Score (HHS) increased significantly from pre-operation to 6 weeks post-operatively and thereafter up to one year in both groups. However, there were no significant differences in terms of subsequent fracture, mortality, HHS, and HRQoL between two groups during the entire study period. Conclusions Teriparatide significantly reduces the subsidence of the cementless femoral stem in elderly patients in the early post-operative period, but this benefit does not reflect better functional outcomes and HRQoL. Further prospective randomized large-scale cohort study is warranted for evidence-based recommendations.
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Affiliation(s)
- Tsan-Wen Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan No. 6, West Section, Chia-Pu Road, Pu-Tz City, Chia-Yi Hsien, 613, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan No. 6, West Section, Chia-Pu Road, Pu-Tz City, Chia-Yi Hsien, 613, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Shih-Jie Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan No. 6, West Section, Chia-Pu Road, Pu-Tz City, Chia-Yi Hsien, 613, Taiwan
| | - Po-Yao Chuang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan No. 6, West Section, Chia-Pu Road, Pu-Tz City, Chia-Yi Hsien, 613, Taiwan
| | - Hsin-Nung Shih
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Mel S Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Dapi Road, Niaosong Dist., Kaohsiung City, 83301, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
| | - Robert Wen-Wei Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan No. 6, West Section, Chia-Pu Road, Pu-Tz City, Chia-Yi Hsien, 613, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
| | - Wun-Jer Shen
- PO CHENG Orthopedic Institute, 100 Bo-ai 2nd Road Zuoying District, Kaohsiung, Taiwan
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Yao W, Lay YAE, Kot A, Liu R, Zhang H, Chen H, Lam K, Lane NE. Improved Mobilization of Exogenous Mesenchymal Stem Cells to Bone for Fracture Healing and Sex Difference. Stem Cells 2016; 34:2587-2600. [PMID: 27334693 DOI: 10.1002/stem.2433] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/15/2016] [Accepted: 05/06/2016] [Indexed: 01/05/2023]
Abstract
Mesenchymal stem cell (MSC) transplantation has been tested in animal and clinical fracture studies. We have developed a bone-seeking compound, LLP2A-Alendronate (LLP2A-Ale) that augments MSC homing to bone. The purpose of this study was to determine whether treatment with LLP2A-Ale or a combination of LLP2A-Ale and MSCs would accelerate bone healing in a mouse closed fracture model and if the effects are sex dependent. A right mid-femur fracture was induced in two-month-old osterix-mCherry (Osx-mCherry) male and female reporter mice. The mice were subsequently treated with placebo, LLP2A-Ale (500 μg/kg, IV), MSCs derived from wild-type female Osx-mCherry adipose tissue (ADSC, 3 x 105 , IV) or ADSC + LLP2A-Ale. In phosphate buffered saline-treated mice, females had higher systemic and surface-based bone formation than males. However, male mice formed a larger callus and had higher volumetric bone mineral density and bone strength than females. LLP2A-Ale treatment increased exogenous MSC homing to the fracture gaps, enhanced incorporation of these cells into callus formation, and stimulated endochondral bone formation. Additionally, higher engraftment of exogenous MSCs in fracture gaps seemed to contribute to overall fracture healing and improved bone strength. These effects were sex-independent. There was a sex-difference in the rate of fracture healing. ADSC and LLP2A-Ale combination treatment was superior to on callus formation, which was independent of sex. Increased mobilization of exogenous MSCs to fracture sites accelerated endochondral bone formation and enhanced bone tissue regeneration. Stem Cells 2016;34:2587-2600.
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Affiliation(s)
- Wei Yao
- Department of Internal Medicine, Center for Musculoskeletal Health, University of California at Davis Medical Center, Sacramento, California, USA.
| | - Yu-An Evan Lay
- Department of Internal Medicine, Center for Musculoskeletal Health, University of California at Davis Medical Center, Sacramento, California, USA
| | - Alexander Kot
- Department of Internal Medicine, Center for Musculoskeletal Health, University of California at Davis Medical Center, Sacramento, California, USA
| | - Ruiwu Liu
- Department of Biochemistry and Molecular Medicine, University of California at Davis Medical Center, Sacramento, California, USA
| | - Hongliang Zhang
- Department of Internal Medicine, Center for Musculoskeletal Health, University of California at Davis Medical Center, Sacramento, California, USA
| | - Haiyan Chen
- Department of Internal Medicine, Center for Musculoskeletal Health, University of California at Davis Medical Center, Sacramento, California, USA
| | - Kit Lam
- Department of Biochemistry and Molecular Medicine, University of California at Davis Medical Center, Sacramento, California, USA
| | - Nancy E Lane
- Department of Internal Medicine, Center for Musculoskeletal Health, University of California at Davis Medical Center, Sacramento, California, USA
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44
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Silverman SL, Kupperman ES, Bukata SV. Fracture healing: a consensus report from the International Osteoporosis Foundation Fracture Working Group. Osteoporos Int 2016; 27:2197-2206. [PMID: 27112766 DOI: 10.1007/s00198-016-3513-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 02/02/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED We used the RAND UCLA appropriateness method to decide appropriateness of use of osteoporosis medication after incident fracture and potential for fracture healing and make suggestions for trial design for clinical and preclinical research. PURPOSE To develop appropriateness criteria to assist in the use and study of osteoporosis medications in patients with recent fracture and in the potential use of osteoporosis medications to enhance delayed fracture healing. To promote further research by suggesting preclinical and clinical trial design for studies where fracture healing is the endpoint. DESIGN RAND/UCLA appropriateness method (RUAM). PARTICIPANTS A panel of experts, both members and non-members of the International Osteoporosis Foundation Fracture Working Group, were identified consisting of geriatricians, rheumatologists, orthopedists, endocrinologists, and internists. This resulted in a round 1 panel of 15 panelists, round 2 panel of 15 members, and a round 3 panel of 14 members. MAIN OUTCOME MEASURE Agreement on statements and scenarios using RUAM. Three rounds of voting by panelists took place. Agreement in a third round was reached for 111 statements and scenarios, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range. RESULTS An expert panel validated a set of statements and scenarios about the use of osteoporosis medications after incident fracture and use of these medications to enhance delayed fracture healing and made recommendations for study designs to investigate the effect of osteoporosis medications on fracture healing. CONCLUSIONS The result of this exercise is intended to assist in improving patient care by identifying the appropriateness of use of osteoporosis medications after fracture and in fracture healing and to make suggestions for further preclinical and clinical research.
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Affiliation(s)
- S L Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
| | - E S Kupperman
- UCLA Department of Orthopedics, Santa Monica, CA, USA
| | - S V Bukata
- UCLA Department of Orthopedics, Santa Monica, CA, USA
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Bhandari M, Jin L, See K, Burge R, Gilchrist N, Witvrouw R, Krohn KD, Warner MR, Ahmad QI, Mitlak B. Does Teriparatide Improve Femoral Neck Fracture Healing: Results From A Randomized Placebo-controlled Trial. Clin Orthop Relat Res 2016; 474:1234-44. [PMID: 26932738 PMCID: PMC4814417 DOI: 10.1007/s11999-015-4669-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/02/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a medical need for therapies that improve hip fracture healing. Teriparatide (Forteo(®)/ Forsteo(®), recombinant human parathyroid hormone) is a bone anabolic drug that is approved for treatment of osteoporosis and glucocorticoid-induced osteoporosis in men and postmenopausal women at high fracture risk. Preclinical and preliminary clinical data also suggest that teriparatide may enhance bone healing. QUESTIONS/PURPOSES We wished to test the hypotheses that treatment with teriparatide versus placebo would improve femoral neck fracture healing after internal fixation as measured by (1) frequency of revision surgery, (2) radiographic fracture healing, and (3) other outcomes including pain control, gait speed, and safety. METHODS We initiated two separate, but identically designed, clinical trials to meet FDA requirements to provide substantial evidence to support approval of a new indication. The two prospective, randomized double-blind, placebo-controlled Phase III studies were designed to evaluate the effect of subcutaneous teriparatide (20 μg/day) for 6 months versus placebo on fracture healing at 24 months. The trials were conducted concurrently with a planned enrollment of 1220 patients per trial. However, enrollment was stopped owing to very slow patient accrual, and an a priori decision was made to pool the results of those studies for statistical analyses before study completion; pooling was specified in both protocols. Randomization was stratified by fixation (sliding hip screw or multiple cancellous screws) and fracture type (displaced or nondisplaced). An independent Central Adjudication Committee reviewed revision surgical procedures and radiographs. A total of 159 patients were randomized in the two trials (81 placebo, 78 teriparatide). The combined program had very low power to detect the originally expected treatment effect but had approximately 80% power to detect a larger difference of 12% between treatment groups for risk of revision surgery. RESULTS The proportion of patients undergoing revision surgery at 12 months was 14% (11 of 81) in the placebo group versus 17% (13 of 78) in the teriparatide group. Central Adjudication Committee review excluded two of these patients treated with placebo from the primary analysis. After exclusions, the proportion of patients who did not undergo revision surgery at 12 months (primary endpoint) was not different between the study and placebo groups, at 88% in the placebo group (90% CI, 0.79-0.93) versus 84% in the teriparatide group (90% CI, 0.75-0.90; p = 0.743). There also were no differences between groups in the proportion of patients achieving radiographic fracture healing at 12 months (75% [61 of 81] placebo versus 73% [57 of 78] teriparatide; odds ratio, 0.89; 90% CI, 0.46-1.72; p = 0.692) or in measures of pain control (such as pain during ambulation, 92% [55 of 62] placebo versus 91% [52 of 57] teriparatide; odds ratio, 0.91; 90% CI, 0.25-3.37; p = 0.681). The frequency of patients reporting adverse events was 49% [40 of 81] in the placebo group versus 45% [35 of 78] in the teriparatide group (p = 0.634) during the 6-month treatment period. CONCLUSIONS The small sample size limited this study's power to detect potential differences, and the results are exploratory. With the patients available, teriparatide did not decrease the risk of revision surgery, improve radiographic signs of fracture healing, or decrease pain compared with the placebo. The adverse event data observed were consistent with the teriparatide safety profile. Functional and health outcome data from the studies may help improve our understanding of patients recovering from femoral neck fractures. Further large controlled studies are required to determine the effect of teriparatide on fracture healing. LEVEL OF EVIDENCE Level II, prospective study.
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Affiliation(s)
- Mohit Bhandari
- Department of Surgery, McMaster University, 293 Wellington Street N, Suite 110, Hamilton, ON L8L8E7 Canada
| | - Ling Jin
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Kyoungah See
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Russel Burge
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Nigel Gilchrist
- Canterbury District Health Board and Canterbury Geriatric Medical Research Trust Research, The Princess Margaret Hospital, Christchurch, New Zealand
| | - Richard Witvrouw
- Department of Traumatology and Orthopaedics, Sint Jan Hospital, Genk, Belgium
| | - Kelly D. Krohn
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Margaret R. Warner
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Qasim I. Ahmad
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Bruce Mitlak
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
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Huang TW, Chuang PY, Lin SJ, Lee CY, Huang KC, Shih HN, Lee MS, Hsu RWW, Shen WJ. Teriparatide Improves Fracture Healing and Early Functional Recovery in Treatment of Osteoporotic Intertrochanteric Fractures. Medicine (Baltimore) 2016; 95:e3626. [PMID: 27175673 PMCID: PMC4902515 DOI: 10.1097/md.0000000000003626] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing.Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared.A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications and mortality were also markedly reduced in the teriparatide-treated groups.Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures. However, because of the limited power of the study, a prospective, randomized, large-scale cohort study is still required for determining the efficacy of teriparatide.
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Affiliation(s)
- Tsan-Wen Huang
- From the Department of Orthopedic Surgery (T-WH, P-YC, S-JL, C-YL, K-CH, RW-WH) and Sports Medicine Center (RW-WH), Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan (MSL); Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan (H-NS); Chang Gung University, Taoyuan, Taiwan (T-WH, K-CH, H-NS, MSL, RW-WH); and Po-Cheng Orthopedic Institute, Kaohsiung (W-JS), Taiwan
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47
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Favinger JL, Hippe D, Ha AS. Long-term radiographic follow-up of bisphosphonate-associated atypical femur fractures. Skeletal Radiol 2016; 45:627-33. [PMID: 26880003 DOI: 10.1007/s00256-016-2346-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/21/2016] [Accepted: 02/01/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the appearance of bisphosphonate-related femur insufficiency fractures on long-term follow-up radiographic studies and to describe the rate of fracture line obscuration and cortical beak healing over time. MATERIALS AND METHODS In this retrospective study, bisphosphonate-related femur fracture radiographs were reviewed by two radiologists for the presence of a fracture line, callus, and the characteristic cortical beak. Kaplan-Meier curves were used to analyze the time to first indication of healing. Femurs were also subdivided into those who underwent early versus late surgical fixation and those who underwent early versus late discontinuation of bisphosphonate. Clinical data including pain level and medication history were collected. RESULTS Forty-seven femurs with a bisphosphonate-related femur fracture were identified in 28 women. Eighty-five percent took a bisphosphonate for greater than 5 years and 59 % for greater than 10 years. The median time to beak healing was 265 weeks and the median time to fracture line healing was 56 weeks in the 31 femurs with a baseline fracture. No statistically significant difference was identified between surgical fixation and conservative management. CONCLUSIONS Bisphosphonate-related fractures demonstrate notably prolonged healing time on long-term follow-up.
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Affiliation(s)
- Jennifer L Favinger
- Department of Radiology, University of Washington, 1959 N.E. Pacific Street, Box 357115, Seattle, WA, 98195, USA
| | - Daniel Hippe
- Department of Radiology, University of Washington, 850 Republication St, Seattle, WA, 98109, USA
| | - Alice S Ha
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA.
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Abstract
PTH and Vitamin D are two major regulators of mineral metabolism. They play critical roles in the maintenance of calcium and phosphate homeostasis as well as the development and maintenance of bone health. PTH and Vitamin D form a tightly controlled feedback cycle, PTH being a major stimulator of vitamin D synthesis in the kidney while vitamin D exerts negative feedback on PTH secretion. The major function of PTH and major physiologic regulator is circulating ionized calcium. The effects of PTH on gut, kidney, and bone serve to maintain serum calcium within a tight range. PTH has a reciprocal effect on phosphate metabolism. In contrast, vitamin D has a stimulatory effect on both calcium and phosphate homeostasis, playing a key role in providing adequate mineral for normal bone formation. Both hormones act in concert with the more recently discovered FGF23 and klotho, hormones involved predominantly in phosphate metabolism, which also participate in this closely knit feedback circuit. Of great interest are recent studies demonstrating effects of both PTH and vitamin D on the cardiovascular system. Hyperparathyroidism and vitamin D deficiency have been implicated in a variety of cardiovascular disorders including hypertension, atherosclerosis, vascular calcification, and kidney failure. Both hormones have direct effects on the endothelium, heart, and other vascular structures. How these effects of PTH and vitamin D interface with the regulation of bone formation are the subject of intense investigation.
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Affiliation(s)
- Syed Jalal Khundmiri
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
- Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA
| | - Rebecca D. Murray
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
- Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA
| | - Eleanor Lederer
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
- Department of Physiology and Biophysics, University of Louisville, Louisville, Kentucky, USA
- Robley Rex VA Medical Center, University of Louisville, Louisville, Kentucky, USA
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Nakatoh S. The importance of assessing the rate of bone turnover and the balance between bone formation and bone resorption during daily teriparatide administration for osteoporosis: a pilot study. J Bone Miner Metab 2016; 34:216-24. [PMID: 26031934 DOI: 10.1007/s00774-015-0665-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 02/23/2015] [Indexed: 11/25/2022]
Abstract
This study aimed to examine the importance of simultaneously measuring bone formation and resorption markers during daily teriparatide administration. In 135 women with osteoporosis, bone mineral density (BMD) was measured at 0, 24, and 48 weeks after teriparatide administration. Bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b were measured at 0, 4, 12, 24, 36, and 48 weeks. Subanalyses were performed in groups divided according to the BMD change at 48 weeks (increased and decreased groups), history of fragility fracture (acute and chronic groups), and treatment prior to teriparatide administration (alendronate, raloxifene, and naïve groups). The scatter diagram of multiple of median formation (MoMf) and multiple of median resorption (MoMr) showed that the distribution gradually spread to a high turnover by week 24. A significant correlation was observed between the rate of change in BMD at week 48 and the turnover rate [√(MoMf(2) + MoMr(2))] at week 0. Significant differences were observed in the turnover rate between the acute and chronic groups at weeks 0 and 4 and between the groups divided according to prior treatment from week 0 to 24. Because the assessment of either bone formation markers or bone resorption markers may result in erroneous data, it is necessary to assess them together during teriparatide treatment. The turnover rate at treatment initiation is a useful indicator to predict changes in BMD. When evaluating the turnover rate and balance (MoMf/MoMr), one should consider patient characteristics, including history of fragility fracture and prior treatment.
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Affiliation(s)
- Shinichi Nakatoh
- Department of Orthopedic Surgery, Asahi General Hospital, 477 Tomari, Asahimachi, Toyama, 939-0741, Japan.
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50
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Etxebarria-Foronda I, Carpintero P. An atypical fracture in male patient with osteogenesis imperfecta. CLINICAL CASES IN MINERAL AND BONE METABOLISM 2015; 12:278-81. [PMID: 26811713 DOI: 10.11138/ccmbm/2015.12.3.278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
So-called atypical fractures have been related to prolonged treatment with bisphosphonates. Although there remain unanswered questions with respect to their etiology and physiopathology, it does appear to be a causal relationship. There are many references in the literature about this problem in patients in whom these drugs have been used to treat osteoporosis, but few reports in patients who have received this therapy for the management of osteogenesis imperfecta. The Authors describe a case of a young male patient with osteogenesis imperfecta with a number of historical fractures, and who received treatment with these drugs, initially parenterally and subsequently orally, presenting as a complication of the treatment, an atypical diaphyseal femoral fracture. The characteristics of the fracture are consistent with the updated diagnostic criteria of the American Society for Bone and Mineral Research. The clinical case, its treatment, both surgically and metabolically with teriparatide, and its development over a year, are analysed. The case is notable for, on the one hand, the significance of the presence of this type of fracture in a young patient with this disease, and on the other, because of the administration of teriparatide outside its established clinical indications, with twin objectives: to improve the bone structure of the patient's underlying disease, and to counteract the harmful effects which bisphosphonates may have on this bone.
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Affiliation(s)
| | - Pedro Carpintero
- Orthopaedic Surgery and Traumatology Department, Reina Sofia University Hospital, Córdoba, Spain
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