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DeClercq MG, Eberhardt L, Zakko P, Keeley J, Audet M, Park D. Equivalence in osteoporosis workup and management after femoral neck fracture fixation and vertebral compression fracture cement augmentation: A single-center retrospective study highlighting persistent Underdiagnosis and Undertreatment. J Orthop 2024; 56:133-140. [PMID: 38854776 PMCID: PMC11153879 DOI: 10.1016/j.jor.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 06/11/2024] Open
Abstract
Background The purpose of this study was to evaluate pre- and post-fracture medical management of osteoporosis among patients who underwent surgical fixation of femoral neck fractures (FNF) and vertebral compression fractures (VCF), and to investigate if there is a difference in treatment, management, and subsequent fractures between FNF and VCF patients. Methods Patients who underwent surgical fixation of FNF or VCF were retrospectively reviewed at a minimum 1 year follow up. Patients were excluded if their fracture was caused by high energy trauma or malignancy, <50 years-old, deceased, or lost to follow up. Patient demographics such as age, sex, BMI, American Society of Anesthesiology Physical Status Classification System and Charleston Comorbidity index were recorded. Management of osteoporosis, including medication regimen and dual-energy X-ray absorptiometry (DEXA) scans were assessed preoperatively and at minimum one year follow up. Subsequent fractures were also recorded. Results In the analysis of 370 patients (74.7% FNF, 25.2% VCF), demographics showed a predominantly female population (mean age 78.1). Preoperatively, 21.6% were diagnosed with osteoporosis, consistent between FNF and VCF. Postoperatively, there were no significant differences in new osteoporosis diagnoses, bisphosphonate use, or subsequent fractures. VCF patients, however, were more likely to receive denosumab and post-operative DEXA scans (p < 0.05). Within a year, 6.2% experienced subsequent fractures, with no significant FNF-VCF difference. Only 12.7% received appropriate post-operative osteoporosis treatment, 27.1% had DEXA scans, and 25% had a recorded osteoporosis diagnosis. Multivariable analysis highlighted pre-fracture osteoporosis diagnosis as the sole predictor for post-operative DEXA scans and anti-osteoporotic medication (p < 0.001). Conclusions This study suggests that factors beyond the type of fragility fracture may influence subsequent fracture risk and anti-osteoporotic medication administration in elderly patients. These findings underscore the importance of a comprehensive approach to fracture risk assessment and treatment decisions in this population. Level of evidence III.
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Affiliation(s)
- Madeleine Grace DeClercq
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Lauren Eberhardt
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Philip Zakko
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
| | - Jacob Keeley
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Megan Audet
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
| | - Daniel Park
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
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Sheth NP, Smith JR, Winzenrieth R, Humbert L, Wang Y, Boxberger JI, Bostrom MP. Effects of Abaloparatide on Bone Mineral Density in Proximal Femoral Regions Corresponding to Arthroplasty Gruen Zones: A Study of Postmenopausal Women with Osteoporosis. J Bone Joint Surg Am 2024; 106:1162-1170. [PMID: 38691582 DOI: 10.2106/jbjs.23.01334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND Low hip bone mineral density (BMD) in patients who undergo total hip arthroplasty (THA) increases the risk of periprosthetic fractures, implant instability, and other complications. Recently, emphasis has been placed on bone health optimization: treating low BMD prior to a planned orthopaedic implant procedure in an effort to normalize BMD and reduce the potential risk of future complications. Abaloparatide is a U.S. Food and Drug Administration-approved osteoanabolic agent for men and postmenopausal women with osteoporosis and a candidate drug for bone health optimization that, in addition to benefits at the spine, increases hip BMD and reduces nonvertebral fracture risk. We hypothesized that abaloparatide would improve BMD in proximal femoral regions surrounding a virtual THA stem. METHODS This post hoc analysis obtained dual x-ray absorptiometry (DXA) hip scans from 500 randomly selected postmenopausal women with osteoporosis from the Phase-3 Abaloparatide Comparator Trial in Vertebral Endpoints (ACTIVE, NCT01343004) study after 0, 6, and 18 months of abaloparatide (250 patients) or placebo (250 patients). Hip DXA scans underwent 3-dimensional (3D) modeling via 3D-Shaper, followed by virtual resection of the proximal femur and simulated placement of a tapered, flat-wedge hip stem that guided delineation of the Gruen zones that were fully (zones 1 and 7) or largely (zones 2 and 6) captured in the scanning region. Integral, cortical, and trabecular volumetric BMD, cortical thickness, and cortical surface BMD (the product of cortical volumetric BMD and cortical thickness) were determined for each zone. RESULTS Compared with placebo, the abaloparatide group showed greater increases in integral volumetric BMD in all zones at months 6 and 18; cortical surface BMD in zones 1, 6, and 7 at month 6; cortical thickness, cortical volumetric BMD, and cortical surface BMD in all zones at month 18; and trabecular volumetric BMD in zones 1 and 7 at months 6 and 18. CONCLUSIONS Abaloparatide increases BMD in proximal femoral regions that interact with and support femoral stems, suggesting that abaloparatide may have value for preoperative or potentially perioperative bone health optimization in patients with osteoporosis undergoing THA. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Yamei Wang
- Radius Health, Inc., Boston, Massachusetts
| | | | - Mathias P Bostrom
- Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, New York, NY
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Kumar RP, Adida S, Lavadi RS, Mitha R, Legarreta AD, Hudson JS, Shah M, Diebo B, Fields DP, Buell TJ, Hamilton DK, Daniels AH, Agarwal N. A guide to selecting upper thoracic versus lower thoracic uppermost instrumented vertebra in adult spinal deformity correction. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2742-2750. [PMID: 38522054 DOI: 10.1007/s00586-024-08206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/26/2024] [Accepted: 02/24/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Operative treatment of adult spinal deformity (ASD) has been shown to improve patient health-related quality of life (HRQOL). Selection of the uppermost instrumented vertebra (UIV) in either the upper thoracic (UT) or lower thoracic (LT) spine is a pivotal decision with effects on operative and postoperative outcomes. This review overviews the multifaceted decision-making process for UIV selection in ASD correction. METHODS PubMed was queried for articles using the keywords "uppermost instrumented vertebra", "upper thoracic", "lower thoracic", and "adult spinal deformity". RESULTS Optimization of UIV selection may lead to superior deformity correction, better patient-reported outcomes, and lower risk of proximal junctional kyphosis (PJK) and failure (PJF). Patient alignment characteristics, including preoperative thoracic kyphosis, coronal deformity, and the magnitude of sagittal correction influence surgical decision-making when selecting a UIV, while comorbidities such as poor body mass index, osteoporosis, and neuromuscular pathology should also be taken in to account. Additionally, surgeon experience and resources available to the hospital may also play a role in this decision. Currently, it is incompletely understood whether postoperative HRQOLs, functional and radiographic outcomes, and complications after surgery differ between selection of the UIV in either the UT or LT spine. CONCLUSION The correct selection of the UIV in surgical planning is a challenging task, which requires attention to preoperative alignment, patient comorbidities, clinical characteristics, available resources, and surgeon-specific factors such as experience.
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Affiliation(s)
- Rohit Prem Kumar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samuel Adida
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rida Mitha
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Manan Shah
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Daryl P Fields
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
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Seward MW, Hannon CP, Yuan BJ, Kearns AE, Anderson PA, Berry DJ, Abdel MP. Systemic Osteoporosis and Osteopenia Among Periprosthetic Fractures After Total Hip Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00577-1. [PMID: 38852691 DOI: 10.1016/j.arth.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Most periprosthetic fractures following total hip arthroplasty (THA) are fragility fractures that qualify patients for osteoporosis diagnoses. However, it remains unknown how many patients were diagnosed who had osteoporosis before injury or received the proper evaluation, diagnosis, and treatment after injury. METHODS We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femur fractures treated with a modular fluted tapered stem from 2000 to 2018 at 1 institution. The mean patient age was 75 years (range, 35 to 94), 50% were women, and the mean body mass index was 29 (range, 17 to 60). We identified patients who had osteoporosis or osteopenia diagnoses, a fracture risk assessment tool (FRAX), bone mineral density (BMD) testing, an endocrinology consult, and osteoporosis medications. Age-appropriate BMD testing was defined as no later than 1 year after the recommended ages of 65 (women) or 70 years (men). The mean follow-up was 11 years (range, 4 to 21). RESULTS Falls from standing height caused 94% of fractures and thus, by definition, qualified as osteoporosis-defining events. The prevalence of osteoporosis diagnosis increased from 20% before periprosthetic fracture to 39% after (P < .001). The prevalence of osteopenia diagnosis increased from 13% before the fracture to 24% after (P < .001). The prevalence of either diagnosis increased from 24% before fracture to 44% after (P < .001). No patients had documented FRAX scores before fracture, and only 2% had scores after. The prevalence of BMD testing was 21% before fracture and 22% after (P = .88). By the end of the final follow-up, only 16% had received age-appropriate BMD testing. The proportion of patients who had endocrinology consults increased from 6% before the fracture to 25% after (P < .001). The proportion on bisphosphonate therapy was 19% before fracture and 25% after (P = .08). CONCLUSIONS Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. Like nonarthroplasty fragility fractures, a systematic approach is needed after periprosthetic fractures. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Michael W Seward
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Charles P Hannon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ann E Kearns
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Paul A Anderson
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Pu HY, Chen Q, Huang K, Wei P. Correlation between Forearm Bone Mineral Density Measured by Dual Energy X-ray Absorptiometry and Hounsfield Units Value Measured by CT in Lumbar Spine. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:247-253. [PMID: 36720241 DOI: 10.1055/a-1984-0466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Our aim was to determine if the dual-energy X-ray absorptiometry (DXA)-measured forearm bone mineral density (BMD) correlates with the Hounsfield unit (HU) values obtained from computed tomography (CT). METHODS A retrospective analysis of 164 patients with degenerative diseases of the lumbar spine was performed. DXA was used to measure the BMD and T-scores of each patient's forearm. Lumbar CT was used to measure the CT HU values in three axial images of the L1-L4 vertebral bodies, and the average was calculated. According to the preoperative DXA T-score, they were divided into a normal group, an osteopenia group, and an osteoporosis group. Pearson's correlation coefficient was used to analyze the correlations of CT HU values in L1-L4 with BMD and T-scores in the corresponding vertebral body. The receiver operating characteristic curve (ROC) was used to determine the CT HU thresholds between osteoporosis and non-osteoporosis groups. RESULTS Forearm BMD was moderately correlated with L1-L4 CT HU values (0.4 < R2 < 0.6), and the correlation coefficients (R2) were 0.552, 0.578, 0.582, and 0.577, respectively (all p < 0.001). Forearm T-scores were moderately correlated with L1-L4 CT HU values (0.4 < R2 < 0.6), and the correlation coefficients (R2) were 0.595, 0.609, 0.605, and 0.605, respectively (all p < 0.001). The thresholds of L1-L4 between the osteoporosis group (t ≤ -2.5) and the non-osteoporosis group (t > -2.5) were 110.0 HU (sensitivity 74% and specificity 76%), 112.5 HU (sensitivity 67% and 83% specificity), 92.4 HU (81% sensitivity and 70% specificity), and 98.7 HU (74% sensitivity and 78% specificity), respectively. CONCLUSIONS Based on the moderate positive correlation between forearm DXA-measured BMD and HU values, forearm DXA provides a theoretical basis for evaluating lumbar vertebral bone mass. Preoperative forearm DXA may be useful in the formulation of surgical plans and the prevention of postoperative complications in patients with lumbar degenerative diseases.
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Affiliation(s)
- Hong Yu Pu
- Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Qian Chen
- Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Kun Huang
- Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Peng Wei
- Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Pflug EM, Lott A, Konda SR, Leucht P, Tejwani N, Egol KA. Bone Health Evaluations and Secondary Fragility Fractures in Hip Fracture Patients. Hip Pelvis 2024; 36:55-61. [PMID: 38420738 DOI: 10.5371/hp.2024.36.1.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 03/02/2024] Open
Abstract
Purpose This study sought to examine the utilization of bone health evaluations in geriatric hip fracture patients and identify risk factors for the development of future fragility fractures. Materials and Methods A consecutive series of patients ≥55 years who underwent surgical management of a hip fracture between September 2015 and July 2019 were identified. Chart review was performed to evaluate post-injury follow-up, performance of a bone health evaluation, and use of osteoporosis-related diagnostic and pharmacologic treatment. Results A total of 832 patients were included. The mean age of the patients was 81.2±9.9 years. Approximately 21% of patients underwent a comprehensive bone health evaluation. Of this cohort, 64.7% were started on pharmacologic therapy, and 73 patients underwent bone mineral density testing. Following discharge from the hospital, 70.3% of the patients followed-up on an outpatient basis with 95.7% seeing orthopedic surgery for post-fracture care. Overall, 102 patients (12.3%) sustained additional fragility fractures within two years, and 31 of these patients (3.7%) sustained a second hip fracture. There was no difference in the rate of second hip fractures or other additional fragility fractures based on the use of osteoporosis medications. Conclusion Management of osteoporosis in geriatric hip fracture patients could be improved. Outpatient follow-up post-hip fracture is almost 70%, yet a minority of patients were started on osteoporosis medications and many sustained additional fragility fractures. The findings of this study indicate that orthopedic surgeons have an opportunity to lead the charge in treatment of osteoporosis in the post-fracture setting.
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Affiliation(s)
- Emily M Pflug
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ariana Lott
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Nirmal Tejwani
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Pasqualini I, Huffman N, Keller SF, McLaughlin JP, Molloy RM, Deren ME, Piuzzi NS. Team Approach: Bone Health Optimization in Orthopaedic Surgery. JBJS Rev 2023; 11:01874474-202312000-00007. [PMID: 38100611 DOI: 10.2106/jbjs.rvw.23.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
» Bone health optimization (BHO) has become an increasingly important consideration in orthopaedic surgery because deterioration of bone tissue and low bone density are associated with poor outcomes after orthopaedic surgeries.» Management of patients with compromised bone health requires numerous healthcare professionals including orthopaedic surgeons, primary care physicians, nutritionists, and metabolic bone specialists in endocrinology, rheumatology, or obstetrics and gynecology. Therefore, achieving optimal bone health before orthopaedic surgery necessitates a collaborative and synchronized effort among healthcare professionals.» Patients with poor bone health are often asymptomatic and may present to the orthopaedic surgeon for reasons other than poor bone health. Therefore, it is imperative to recognize risk factors such as old age, female sex, and low body mass index, which predispose to decreased bone density.» Workup of suspected poor bone health entails bone density evaluation. For patients without dual-energy x-ray absorptiometry (DXA) scan results within the past 2 years, perform DXA scan in all women aged 65 years and older, all men aged 70 years and older, and women younger than 65 years or men younger than 70 years with concurrent risk factors for poor bone health. All women and men presenting with a fracture secondary to low-energy trauma should receive DXA scan and bone health workup; for fractures secondary to high-energy trauma, perform DXA scan and further workup in women aged 65 years and older and men aged 70 years and older.» Failure to recognize and treat poor bone health can result in poor surgical outcomes including implant failure, periprosthetic infection, and nonunion after fracture fixation. However, collaborative healthcare teams can create personalized care plans involving nutritional supplements, antiresorptive or anabolic treatment, and weight-bearing exercise programs, resulting in BHO before surgery. Ultimately, this coordinated approach can enhance the success rate of surgical interventions, minimize complications, and improve patients' overall quality of life.
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Affiliation(s)
| | - Nickelas Huffman
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sarah F Keller
- Department of Rheumatology and Immunology, Cleveland Clinic, Cleveland, Ohio
| | | | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Matthew E Deren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
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Reider L, Owen EC, Dreyer HC, Fitton LS, Willey MC. Loss of Muscle Mass and Strength After Hip Fracture: an Intervention Target for Nutrition Supplementation. Curr Osteoporos Rep 2023; 21:710-718. [PMID: 38019345 DOI: 10.1007/s11914-023-00836-0] [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] [Accepted: 11/03/2023] [Indexed: 11/30/2023]
Abstract
PURPOSEOF REVIEW To summarize what is known about the deleterious effect of hip fracture on muscle mass and strength as well as the scientific evidence for post-surgical nutrition supplementation to maintain muscle and improve function. RECENT FINDINGS This review provides a discussion of the relationship between muscle mass, strength, and physical function following hip fracture, briefly describes the approaches to measuring lean mass, discusses prevalence of sarcopenia and malnutrition among older men and women with hip fracture, and reviews the effects of essential amino acids on muscle. Loss of muscle mass and strength following hip fracture is substantial with consequences for recovery of functional independence. EAA-based nutrition supplementation, which directly effects muscle, has potential to improve outcomes.
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Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Street, Room 648, Baltimore, MD, 21205, USA.
| | | | - Hans C Dreyer
- Department of Human Physiology, University of Oregon, Eugene, OR, 97403, USA
| | - Lori S Fitton
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Michael C Willey
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Willey MC, Owen EC, Miller A, Glass N, Kirkpatrick T, Fitzpatrick D, Wilken J, Marsh JL, Reider L. Substantial Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture. J Bone Joint Surg Am 2023; 105:1777-1785. [PMID: 37738373 DOI: 10.2106/jbjs.23.00353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
BACKGROUND Femoral fragility fractures in older adults can result in devastating loss of physical function and independence. Skeletal muscle atrophy likely contributes to disability. The purpose of this study was to characterize the change in skeletal muscle mass, investigate the relationship with malnutrition and physical function, and identify risk factors for skeletal muscle loss. METHODS Adults ≥65 years of age who were treated with operative fixation of an isolated femoral fragility fracture were enrolled in this multicenter, prospective observational study. Skeletal muscle mass was assessed within 72 hours of admission using multifrequency bioelectrical impedance analysis, which was repeated at 6 weeks, 3 months, and 6 months. Sarcopenia was defined by sex-specific cutoffs for the appendicular skeletal muscle mass index. The Mini Nutritional Assessment was used to measure nutritional status at the time of injury. Physical function was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function domain. Linear mixed models were used to evaluate changes in skeletal muscle mass and PROMIS Physical Function scores over time and to evaluate factors associated with skeletal muscle mass changes. RESULTS Ninety participants (74% female) with a mean age of 77.6 ± 9.0 years were enrolled. At the time of injury, 30 (33%) were sarcopenic and 44 (49%) were at risk for malnutrition or had malnutrition. Older age was associated with lower skeletal muscle mass (age of ≥75 versus <75 years: least squares mean [and standard error], -3.3 ± 1.6 kg; p = 0.042). From the time of injury to 6 weeks, participants lost an average of 2.4 kg (9%) of skeletal muscle mass (95% confidence interval [CI] = ‒3.0 to ‒1.8 kg; p < 0.001). This early loss did not recover by 6 months (1.8 kg persistent loss compared with baseline [95% CI = ‒2.5 to ‒1.1 kg]; p < 0.001). Participants with normal nutritional status lost more skeletal muscle mass from baseline to 6 weeks after injury compared with those with malnutrition (1.3 kg more loss [standard error, 0.6 kg]; p = 0.036). A 1-kg decrease in skeletal muscle mass was associated with an 8-point decrease in the PROMIS Physical Function (model parameter estimate, 0.12 [standard error, 0.04]; p = 0.002). CONCLUSIONS We found that older adults with femoral fragility fractures lost substantial skeletal muscle mass and physical function. Participants with adequate baseline nutrition actually lost more muscle mass than those who were malnourished, indicating that future investigations of interventions to prevent muscle loss should focus on older adults regardless of nutritional status. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael C Willey
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Erin C Owen
- Slocum Research and Education Foundation, Eugene, Oregon
| | - Aspen Miller
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Natalie Glass
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | | | - Jason Wilken
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - J Lawrence Marsh
- Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Shapiro LM, Bolognesi MP, Bozic K, Kamal RN. Preoperative Optimization for Orthopaedic Surgery: Steps to Reduce Complications. J Am Acad Orthop Surg 2023; 31:e949-e960. [PMID: 37769027 DOI: 10.5435/jaaos-d-22-00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/28/2023] [Indexed: 09/30/2023] Open
Abstract
As the population ages and patients maintain higher levels of activity, the incidence of major and minor orthopaedic procedures continues to rise. At the same time, health policies are incentivizing efforts to improve the quality and value of musculoskeletal health services. As such, orthopaedic surgeons play a key role in directing the optimization of patients before surgery by assessing patient risk factors to inform risk/benefit discussions during shared decision-making and designing optimization programs to address modifiable risks. These efforts can lead to improved health outcomes, reduced costs, and preference-congruent treatment decisions. In this review, we (1) summarize the evidence on factors known to affect outcomes after common orthopaedic procedures, (2) identify which factors are considered modifiable and amenable to preoperative intervention, and (3) provide guidance for preoperative optimization.
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Affiliation(s)
- Lauren M Shapiro
- From the Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA (Shapiro), the Department of Orthopaedic Surgery, Duke University, Morrisville, NC (Bolognesi), the Department of Orthopaedic Surgery, University of Texas-Austin, Austin, TX (Bozic), and the VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Kamal)
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11
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Vignolles-Jeong J, Weber MD, Xu DS, Elder JB, Chakravarthy VB. Letter: Global Spinal Alignment Considerations in the Oncological Spine Population. Neurosurgery 2023; 93:e105-e106. [PMID: 37489901 DOI: 10.1227/neu.0000000000002615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/06/2023] [Indexed: 07/26/2023] Open
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Leopold SS. Editor's Spotlight/Take 5: Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic? Clin Orthop Relat Res 2023; 481:1657-1659. [PMID: 37486781 PMCID: PMC10427072 DOI: 10.1097/corr.0000000000002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Seth S Leopold
- Editor-in-Chief, Clinical Orthopaedics and Related Research® , Park Ridge, IL60068, USA
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13
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Zuelzer DA, Weaver D, Zuelzer AP, Hessel EA. Current Strategies in Medical Management of the Geriatric Hip Fracture Patient. J Am Acad Orthop Surg 2023:00124635-990000000-00694. [PMID: 37184459 DOI: 10.5435/jaaos-d-22-00815] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/01/2023] [Indexed: 05/16/2023] Open
Abstract
Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.
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Affiliation(s)
- David A Zuelzer
- From the Department of Orthopaedic and Sports Medicine (Zuelzer), Department of Internal Medicine (Weaver), Department of Anesthesiology (Zuelzer and Hessel), University of Kentucky, Lexington, KY
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14
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Bian Y, Hu T, Lv Z, Xu Y, Wang Y, Wang H, Zhu W, Feng B, Liang R, Tan C, Weng X. Bone tissue engineering for treating osteonecrosis of the femoral head. EXPLORATION (BEIJING, CHINA) 2023; 3:20210105. [PMID: 37324030 PMCID: PMC10190954 DOI: 10.1002/exp.20210105] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/12/2022] [Indexed: 06/16/2023]
Abstract
Osteonecrosis of the femoral head (ONFH) is a devastating and complicated disease with an unclear etiology. Femoral head-preserving surgeries have been devoted to delaying and hindering the collapse of the femoral head since their introduction in the last century. However, the isolated femoral head-preserving surgeries cannot prevent the natural progression of ONFH, and the combination of autogenous or allogeneic bone grafting often leads to many undesired complications. To tackle this dilemma, bone tissue engineering has been widely developed to compensate for the deficiencies of these surgeries. During the last decades, great progress has been made in ingenious bone tissue engineering for ONFH treatment. Herein, we comprehensively summarize the state-of-the-art progress made in bone tissue engineering for ONFH treatment. The definition, classification, etiology, diagnosis, and current treatments of ONFH are first described. Then, the recent progress in the development of various bone-repairing biomaterials, including bioceramics, natural polymers, synthetic polymers, and metals, for treating ONFH is presented. Thereafter, regenerative therapies for ONFH treatment are also discussed. Finally, we give some personal insights on the current challenges of these therapeutic strategies in the clinic and the future development of bone tissue engineering for ONFH treatment.
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Affiliation(s)
- Yixin Bian
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Tingting Hu
- State Key Laboratory of Chemical Resource EngineeringBeijing Advanced Innovation Center for Soft Matter Science and EngineeringBeijing University of Chemical TechnologyBeijingChina
| | - Zehui Lv
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Yiming Xu
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Yingjie Wang
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Han Wang
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Wei Zhu
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Bin Feng
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Ruizheng Liang
- State Key Laboratory of Chemical Resource EngineeringBeijing Advanced Innovation Center for Soft Matter Science and EngineeringBeijing University of Chemical TechnologyBeijingChina
| | - Chaoliang Tan
- Department of ChemistryCity University of Hong KongKowloonHong Kong SARChina
| | - Xisheng Weng
- Department of Orthopedic SurgeryState Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
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15
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Nickel B, Krueger D, Borchardt G, Andersen L, Illgen R, Hennessy D, Hetzel S, Binkley N, Anderson PA. Intraoperative physician assessment of bone: correlation to bone mineral density. Osteoporos Int 2023; 34:1093-1099. [PMID: 37000208 DOI: 10.1007/s00198-023-06729-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
This study evaluated the intraoperative physician assessment (IPA) of bone status at time of total knee arthroplasty. IPA was highly correlated with distal femur and overall bone mineral density. When IPA identifies poor bone status, formal bone health assessment is indicated. PURPOSE Intuitively, intraoperative physician assessment (IPA) would be an excellent measure of bone status gained through haptic feedback during bone preparation. However, no studies have evaluated the orthopedic surgeon's ability to do so. This study's purpose, in patients undergoing total knee arthroplasty (TKA), was to relate IPA with (1) the lowest bone mineral density (BMD) T-score at routine clinical sites; and (2) with distal femur BMD. METHODS Seventy patients undergoing TKA by 3 surgeons received pre-operative DXA. Intraoperatively, bone quality was assessed on a 5-point scale (1 excellent to 5 poor) based on tactile feedback to preparation. Demographic data, DXA results, and IPA score between surgeons were compared by factorial ANOVA. Lowest T-score and distal femur BMD were associated with IPA using Spearman's correlation. RESULTS The mean (SD) age and BMI were 65.8 (7.6) years and 31.4 (5.1) kg/m2, respectively. Patient demographic data, BMD, and IPA (mean [SD] = 2.74 [1.2]) did not differ between surgeons. IPA correlated with the lowest T-score (R = 0.511) and distal femur BMD (R = 0.603-0.661). Based on the lowest T-score, no osteoporotic patients had an IPA above average, and none with normal BMD was classified as having poor bone. CONCLUSIONS IPA is highly correlated with local (distal femur) and overall BMD. This study supports the International Society for Clinical Densitometry position that surgeon concern regarding bone quality should lead to bone health assessment. As IPA is comparable between surgeons, it is logical this can be widely applied by experienced orthopedic surgeons. Future studies evaluating IPA at other anatomic sites are indicated.
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Affiliation(s)
- Brian Nickel
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 4602 Eastpark Blvd, MCAC06, Madison, WI, 53718, USA.
| | - Diane Krueger
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Gretta Borchardt
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Lucas Andersen
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Richard Illgen
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 4602 Eastpark Blvd, MCAC06, Madison, WI, 53718, USA
| | - David Hennessy
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 4602 Eastpark Blvd, MCAC06, Madison, WI, 53718, USA
| | - Scott Hetzel
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 4602 Eastpark Blvd, MCAC06, Madison, WI, 53718, USA
| | - Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 4602 Eastpark Blvd, MCAC06, Madison, WI, 53718, USA
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16
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Binkley N, Nickel B, Anderson PA. Periprosthetic fractures: an unrecognized osteoporosis crisis. Osteoporos Int 2023; 34:1055-1064. [PMID: 36939852 DOI: 10.1007/s00198-023-06695-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/02/2023] [Indexed: 03/21/2023]
Abstract
Total joint replacement is common and increasing. Many of these patients have low bone mineral density preoperatively, and arthroplasty leads to bone loss. As falls are common before and after arthroplasty, it is unsurprising that periprosthetic fractures, defined as those associated with an orthopedic device, whether a joint replacement or other internal fixation devices, are not rare. These fractures engender morbidity and mortality comparable to osteoporosis-related hip fractures but remain largely unrecognized and untreated by osteoporosis/metabolic bone disease clinicians. Indeed, recent osteoporosis guidelines are silent regarding periprosthetic fractures. The purposes of this clinical review are to briefly describe the epidemiology of arthroplasty procedures and periprosthetic fractures, raise awareness that these fractures are osteoporosis-related, and suggest approaches likely to reduce their occurrence. Notably, bone health evaluation is essential following the occurrence of a periprosthetic fracture to reduce subsequent fracture risk. Importantly, in addition to such secondary fracture prevention, primary prevention, i.e., bone health assessment and optimization prior to elective orthopedic procedures, is appropriate.
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Affiliation(s)
- Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, 2870 University Avenue, Suite 100, Madison, WI, 53705, USA.
| | - Brian Nickel
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, USA
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17
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Kadri A, Binkley N, Daffner SD, Anderson PA. Fracture in Patients with Normal Bone Mineral Density: An Evaluation of the American Orthopaedic Association's Own the Bone Registry. J Bone Joint Surg Am 2023; 105:128-136. [PMID: 36575157 DOI: 10.2106/jbjs.22.00012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fractures often occur in patients with normal dual x-ray absorptiometry (DXA)-measured bone mineral density (BMD). DXA does not consider clinical fracture risk factors or bone quality. We hypothesized that patients with normal BMD who sustain a fracture have other characteristics suggesting abnormal bone and an elevated fracture risk requiring additional bone health evaluation and potential anti-osteoporotic treatment. METHODS A total of 7,219 patients who were ≥50 years of age, had sustained a fracture from July 2016 to July 2021, and had DXA data in the American Orthopaedic Association's Own the Bone (AOA OTB) registry were included in this study. The index and prior fracture site data were obtained. BMD status was classified by the World Health Organization T-score criteria. The Fracture Risk Assessment Tool (FRAX) scores with and without BMD were calculated in patients with normal BMD. An elevated risk was defined as a major osteoporotic fracture risk of ≥20% or a hip fracture risk of ≥3%. RESULTS The mean patient age (and standard deviation) was 70.8 ± 9.71 years, 84% of patients were female, and 92% of patients were Caucasian. Normal BMD was present in 8.6% of patients. The index fracture was a major osteoporotic fracture in 68.6% of patients with normal BMD and 75.6% of patients with osteoporosis. The most common site for index and prior fractures other than major osteoporotic fractures was the foot and ankle; of patients with normal BMD, 13.9% had this as the most common index site and 17.4% had this as the most common prior site. The FRAX risk calculated without BMD was elevated in 72.9% of patients with normal BMD, and the FRAX risk calculated with BMD was elevated in 12.0% of patients. CONCLUSIONS Most patients with a fracture and normal BMD met indications, including a prior fracture or elevated FRAX risk, for anti-osteoporotic therapies. Most patients were Caucasian and therefore potentially had a higher baseline fracture risk. The FRAX risk calculated without BMD was elevated more often than the FRAX risk with BMD, implying that clinical risk factors, which highlight multiple opportunities for non-pharmacologic secondary fracture prevention, should be considered along with DXA. Fractures other than major osteoporotic fractures were more common in patients with normal BMD, suggesting that minor fractures in adults who are ≥50 years of age should be considered sentinel events warranting further evaluation. Surgeons must recognize that other important risk factors apart from BMD may help to guide further bone health evaluation. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aamir Kadri
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Scott D Daffner
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Paul A Anderson
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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18
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San C, Xu Y, Lee M, Pu L, Wang T, Shi X, Lu S, Cheng Q. A modified surgical method for the treatment of ONFH: quadratus femoris muscle pedicle bone grafting with preservation of the posterior superior retinacular artery. BMC Surg 2022; 22:437. [PMID: 36550517 PMCID: PMC9773483 DOI: 10.1186/s12893-022-01834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/01/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Osteonecrosis of the femoral head (ONFH) can lead to pain and loss of function of the hip joint, which places a great burden on patients and society. Surgery is the main treatment for osteonecrosis of the femoral head, and quadratus femoris muscle pedicle bone grafting has a definite therapeutic effect as one method of surgery for the treatment of ONFH. However, the posterior superior retinacular artery is often injured during quadratus femoris muscle pedicle bone graft surgery. There is evidence that this artery is extremely important to the femoral head, as injury to this artery will seriously affect the blood supply of the femoral head. Therefore, this situation restricts the clinical application of quadratus femoris muscle pedicle bone grafts. We aimed to explore a new surgical method of quadratus femoris muscle pedicle bone grafting that can preserve the integrity of the posterior superior retinacular artery. METHODS We modified the traditional quadratus femoris muscle pedicle bone graft and preserved the integrity of the posterior superior retinacular artery. To explore the safety and feasibility of the operation, we simulated the operation on 6 fresh frozen cadavers (12 hips) and measured the related data. We also tried this modified surgical method in the clinic and collected detailed data from the patients. RESULTS By simulating the modified quadratus femoris muscle pedicle bone graft on the hip joints of fresh frozen cadavers, we found that the posterior superior retinacular artery existed in all cadaver specimens and that the sources may be different (MFCA or IGA). In the modified operation, the joint capsule did not need to be cut during the operation; therefore, the integrity of the posterior superior retinacular artery was preserved. The quadratus femoris muscle was exposed via the posterior approach of the hip joint, and then the quadratus femoris muscle pedicle bone flap was chiseled. After the pedicle of the quadratus femoris muscle was loosened properly, the migration distance of the quadratus femoris muscle pedicle bone flap reached 5.89 ± 0.45 (χ ± s) cm. The bone flap was trimmed properly and placed on one side. Next, we drilled a bone tunnel from the external intertrochanteric aspect of the capsule of the hip joint, and the bone tunnel broke through the sclerosing zone and proceeded straight to the necrotic area of the femoral head. Next, the necrotic bone was removed with a ring saw and arc bone knife, autogenous bone or allogeneic bone was filled into the bone groove according to the situation, and the cancellous bone in the bone groove was tamped by percussion. Then, the bone flap was inserted into the bone groove, and appropriate pressurization was performed. The depth of the bone groove was determined by the location of ONFH. We found that the furthest distance between the bone groove and the femoral head was 4.76 ± 0.07 (χ ± s) cm and that the length of the bone flap was (4.91 ± 0.23) (χ ± s) cm. This means that when the depth of the bone groove reached the area of ONFH, the quadratus femoris muscle pedicle bone flap had a sufficient length and migration distance to be embedded in the area of ONFH and firmly fixed, and the quadratus femoris did not have much tension. The closest distance between the posterior superior retinacular artery and the bone groove was (1.11 ± 0.96) (χ ± s) cm. When the bone groove was created in this area, the edge of the bone groove had a safe distance of at least 1 cm from the posterior superior retinacular artery of the femoral head. We attempted to implement this modified operation clinically. During the procedure, the quadratus femoris muscle pedicle bone flap was embedded into the drilled bone groove and fixed with a magnesium nail. There was no sliding of the bone flap after the operation, and the posterior superior retinacular artery was intact. We followed the patient for 3 months and found that the patient recovered well with no weight-bearing by the affected limb. The duration of the modified operation was shorter than that of the traditional quadratus femoris muscle pedicle bone graft, the amount of bleeding was significantly reduced, the postoperative pain was lessened, and no special discomfort was reported. Postoperative imaging examination showed that the collapse of the femoral head had been partially corrected and that the bone flap had gradually fused with the surrounding bone. CONCLUSIONS Through this experimental study, we confirmed the feasibility of the modified method for quadratus femoris muscle pedicle bone grafting with preservation of the posterior superior retinacular artery. This modified operation not only retains the integrity of the posterior superior retinacular artery of the femoral head but also reduces the difficulty of the operation and shortens the surgical time, which is of great clinical significance.
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Affiliation(s)
- Changmeng San
- grid.285847.40000 0000 9588 0960Kunming Medical University, Kunming, China
| | - Yongqing Xu
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force, Kunming, China
| | - Mingjun Lee
- grid.285847.40000 0000 9588 0960Kunming Medical University, Kunming, China
| | - Luqiao Pu
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force, Kunming, China
| | - Teng Wang
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force, Kunming, China
| | - Xiangwen Shi
- grid.285847.40000 0000 9588 0960Kunming Medical University, Kunming, China
| | - Siyu Lu
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force, Kunming, China
| | - Qi Cheng
- grid.285847.40000 0000 9588 0960Kunming Medical University, Kunming, China
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19
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Kuo CC, Soliman MAR, Aguirre AO, Ruggiero N, Kruk M, Khan A, Ghannam MM, Almeida ND, Jowdy PK, Smolar DE, Pollina J, Mullin JP. Vertebral Bone Quality Score Independently Predicts Proximal Junctional Kyphosis and/or Failure After Adult Spinal Deformity Surgery. Neurosurgery 2022; 92:945-954. [PMID: 36700747 DOI: 10.1227/neu.0000000000002291] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) can be catastrophic complications associated with adult spinal deformity (ASD) surgery. These complications are markedly influenced by osteoporosis, leading to additional vertebral fracture and pedicle screw loosening. The MRI-based vertebral bone quality score (VBQ) is a newly developed tool that can be used to assess bone quality. OBJECTIVE To investigate the utility of the VBQ score in predicting PJK and/or PJF (PJF/PJK) after ASD correction. METHODS We conducted a retrospective chart review to identify patients age ≥50 years who had received ASD surgery of 5 or more thoracolumbar levels. Demographic, spinopelvic parameters, and procedure-related variables were collected. Each patient's VBQ score was calculated using preoperative T1-weighted MRI. Univariate analysis and multivariate logistic regression were performed to determine potential risk factors of PJK/PJF. Receiver operating characteristic analysis and area-under-the-curve values were generated for prediction of PJK/PJF. RESULTS A total of 116 patients were included (mean age, 64.1 ± 6.8 years). Among them, 34 patients (29.3%) developed PJK/PJF. Mean VBQ scores were 3.13 ± 0.46 for patients with PJK/PJF and 2.46 ± 0.49 for patients without, which was significantly different between the 2 groups ( P < .001). On multivariate analysis, VBQ score was the only significant predictor of PJK/PJF (odds ratio = 1.745, 95% CI = 1.558-1.953, P < .001), with a predictive accuracy of 94.3%. CONCLUSION In patients undergoing ASD correction, higher VBQ was independently associated with PJK/PJF occurrence. Measurement of VBQ score on preoperative MRI may be a useful adjunct to ASD surgery planning.
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Affiliation(s)
- Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.,Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Marissa Kruk
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Neil D Almeida
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Patrick K Jowdy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - David E Smolar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
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20
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Kang L. CORR Insights®: Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries. Clin Orthop Relat Res 2022; 480:2120-2121. [PMID: 35976168 PMCID: PMC9556015 DOI: 10.1097/corr.0000000000002352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Lana Kang
- Assistant Attending Orthopaedic Surgeon, Orthopaedic Surgery Hand Surgery Division, Hospital for Special Surgery, New York, NY, USA
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21
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Mikula AL, Lakomkin N, Pennington Z, Pinter ZW, Nassr A, Freedman B, Sebastian AS, Abode-Iyamah K, Bydon M, Ames CP, Fogelson JL, Elder BD. Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine. J Neurosurg Spine 2022; 37:694-702. [PMID: 35561697 DOI: 10.3171/2022.3.spine22197] [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: 02/11/2022] [Accepted: 03/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to analyze risk factors and avoidance techniques for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in the upper thoracic spine with an emphasis on bone mineral density (BMD) as estimated by Hounsfield units (HU). METHODS A retrospective chart review identified patients at least 50 years of age who underwent instrumented fusion extending from the pelvis to an upper instrumented vertebra (UIV) between T1 and T6 and had a preoperative CT, pre- and postoperative radiographs, and a minimum follow-up of 12 months. HU were measured in the UIV, the vertebral body cephalad to the UIV (UIV+1), and the L3 and L4 vertebral bodies. Numerous perioperative variables were collected, including basic demographics, smoking and steroid use, preoperative osteoporosis treatment, multiple frailty indices, use of a proximal junctional tether, UIV soft landing, preoperative dual-energy x-ray absorptiometry, spinopelvic parameters, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, lumbar lordosis distribution, and postoperative spinopelvic parameters compared with age-adjusted normal values. RESULTS Eighty-one patients were included in the study (21 men and 60 women) with a mean (SD) age of 66 years (6.9 years), BMI of 29 (5.5), and follow-up of 38 months (25 months). Spinal fusion constructs at the time of surgery extended from the pelvis to a UIV of T1 (5%), T2 (15%), T3 (25%), T4 (33%), T5 (21%), and T6 (1%). Twenty-seven patients (33%) developed PJK and/or PJF; 21 (26%) had PJK and 15 (19%) had PJF. Variables associated with PJK/PJF with p < 0.05 were included in the multivariable analysis, including HU at the UIV/UIV+1, HU at L3/L4, DXA femoral neck T-score, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, and postoperative lumbar lordosis distribution. Multivariable analysis (area under the curve = 0.77) demonstrated HU at the UIV/UIV+1 to be the only independent predictor of PJK and PJF with an OR of 0.96 (p = 0.005). Patients with < 147 HU (n = 27), 147-195 HU (n = 27), and > 195 HU (n = 27) at the UIV/UIV+1 had PJK/PJF rates of 59%, 33%, and 7%, respectively. CONCLUSIONS In patients with upper thoracic-to-pelvis spinal reconstruction, lower HU at the UIV and UIV+1 were independently associated with PJK and PJF, with an optimal cutoff of 159 HU that maximizes sensitivity and specificity.
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Affiliation(s)
| | | | | | | | - Ahmad Nassr
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brett Freedman
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arjun S Sebastian
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- 1Department of Neurological Surgery, Mayo Clinic, Rochester
| | - Christopher P Ames
- 4Department of Neurological Surgery, University of California, San Francisco, California
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22
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Mills ES, Hah RJ, Fresquez Z, Mertz K, Buser Z, Alluri RK, Anderson PA. Secondary Fracture Rate After Vertebral Osteoporotic Compression Fracture Is Decreased by Anti-Osteoporotic Medication but Not Increased by Cement Augmentation. J Bone Joint Surg Am 2022; 104:2178-2185. [PMID: 36223482 DOI: 10.2106/jbjs.22.00469] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Painful vertebral osteoporotic compression fractures (OCFs) are often treated with cement augmentation, although controversies exist as to whether or not this increases the secondary fracture risk. Prevention of secondary fracture includes treatment of underlying osteoporosis. The purposes of this study were to determine (1) whether cement augmentation increases the rate of secondary fracture compared with nonoperative management, (2) whether anti-osteoporotic medications reduce the rate of secondary fracture, and (3) the rate of osteoporosis treatment with medications following vertebral OCF. METHODS The PearlDiver database was queried for all patients with a diagnosis of OCF from 2015 to 2019. Patients were excluded if they were <50 years old, had a diagnosis of spinal neoplasm or infection, or underwent lumbar fusion in the perioperative period. Secondary fracture risk was assessed using univariate and multivariate logistic regression analysis, with kyphoplasty, vertebroplasty, anti-osteoporotic medications, age, gender, and Elixhauser Comorbidity Index as variables. RESULTS A total of 36,145 patients were diagnosed with an OCF during the study period. Of those, 25,904 (71.7%) underwent nonoperative management and 10,241 (28.3%) underwent cement augmentation, including 1,556 who underwent vertebroplasty and 8,833 who underwent kyphoplasty. Patients who underwent nonoperative management had a secondary fracture rate of 21.8% following the initial OCF, compared with 14.5% in the vertebroplasty cohort and 18.5% in the kyphoplasty cohort, which was not a significant difference on multivariate analysis. In the entire cohort, 2,833 (7.8%) received anti-osteoporotic medications and 33,312 (92.2%) did not. The rate of secondary fracture was 10.1% in patients who received medications and 21.9% in those who did not, which was a significant difference on multivariate analysis (odds ratio = 1.23, p < 0.001). CONCLUSIONS Cement augmentation did not alter the rate of secondary fracture, whereas anti-osteoporotic medications significantly decreased the risk of subsequent OCF by 19%. Only 7.8% of patients received a prescription for an anti-osteoporotic medication following the initial OCF. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emily S Mills
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Raymond J Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Zoe Fresquez
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kevin Mertz
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ram K Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Paul A Anderson
- Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin
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Moafian F, Sharifan P, Assaran Darban R, Khorasanchi Z, Amiri Z, Roohi S, Mohseni Nik F, Mohammadi Bajgiran M, Saffar Soflaei S, Darroudi S, Ghazizadeh H, Tayefi M, Rafiee M, Ebrahimi Dabagh A, Shojasiahi M, Yaghoobinezhad M, Talkhi N, Esmaily H, Ferns GA, Dabbagh VR, Sadeghi R, Ghayour-Mobarhan M. Factors Associated With Trabecular Bone Score and Bone Mineral Density; A Machine Learning Approach. J Clin Densitom 2022; 25:518-527. [PMID: 35999152 DOI: 10.1016/j.jocd.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/05/2022] [Accepted: 06/24/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Bone indexes including trabecular bone score (TBS) and bone mineral density (BMD) have been shown to be associated with wide spectrum of variables including physical activity, vitamin D, liver enzymes, biochemical measurements, mental and sleep disorders, and quality of life. Here we aimed to determine the most important factors related to TBS and BMD in SUVINA dataset. METHODS Data were extracted from the Survey of Ultraviolet Intake by Nutritional Approach (SUVINA study) including all 306 subjects entered this survey. All the available parameters in the SUVINA database were included the analysis. XGBoost modeler software was used to define the most important features associated with bone indexes including TBS and BMD in various sites. RESULTS Applying XGBoost modeling for 4 bone indexes indicated that this algorithm could identify the most important variables in relation to bone indexes with an accuracy of 92%, 93%, 90% and 90% respectively for TBS T-score, lumbar Z-score, neck of femur Z-score and Radius Z-score. Serum vitamin D, pro-oxidant-oxidant balance (PAB) and physical activity level (PAL) were the most important factors related to bone indices in different sites of the body. CONCLUSIONS Our findings indicated that XGBoost could identify the most important variables with an accuracy of >90% for TBS and BMD. The most important features associated with bone indexes were serum vitamin D, PAB and PAL.
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Affiliation(s)
- Fahimeh Moafian
- Department of Pure Mathematics, Center of Excellence in Analysis on Algebraic Structures (CEAAS), Ferdowsi University of Mashhad, P.O. Box 1159, Mashhad 91775, Iran; International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Payam Sharifan
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Assaran Darban
- Department of Biology, Faculty of Sciences, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Zahra Khorasanchi
- Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Amiri
- Department of Pure Mathematics, Center of Excellence in Analysis on Algebraic Structures (CEAAS), Ferdowsi University of Mashhad, P.O. Box 1159, Mashhad 91775, Iran; International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Roohi
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Mohseni Nik
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Mohammadi Bajgiran
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sara Saffar Soflaei
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Susan Darroudi
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamideh Ghazizadeh
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran; Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Tayefi
- Norwegian Center for e-health Research, University hospital of North Norway, Tromsø, Norway
| | - Mahdi Rafiee
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Ebrahimi Dabagh
- Department of Nutrition Sciences, Varastegan Institute for Medical Sciences, Mashhad, Iran
| | - Maryam Shojasiahi
- Department of Nutrition Sciences, Varastegan Institute for Medical Sciences, Mashhad, Iran
| | - Mahdiye Yaghoobinezhad
- Department of Nutrition Sciences, Varastegan Institute for Medical Sciences, Mashhad, Iran
| | - Nasrin Talkhi
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Habibollah Esmaily
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Division of Medical Education, Brighton & Sussex Medical School, Falmer, Brighton, Sussex, UK
| | - Vahid Reza Dabbagh
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ramin Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Majid Ghayour-Mobarhan
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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Wang Z, Levin JE, Amen TB, Arzani A, Manzi JE, Lane JM. Total Joint Arthroplasty and Osteoporosis: Looking Beyond the Joint to Bone Health. J Arthroplasty 2022; 37:1719-1725.e1. [PMID: 35447275 DOI: 10.1016/j.arth.2022.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/22/2022] [Accepted: 04/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Metabolic bone diseases in the total joint arthroplasty (TJA) population are undertested and undertreated, leading to increased risk of adverse outcomes such as periprosthetic fractures. This study aims to better characterize the current state of bone care in TJA patients using Fracture Risk Assessment Tool (FRAX) score risk stratifications. METHODS In total, 505 consecutive TJA patients who meet the Endocrine Society guidelines for osteoporosis screening were included for review. They were divided into a high risk or low risk group depending on FRAX scores and were compared based on screening, diagnosis, and treatment of metabolic bone disease. Logistic regression models were used to analyze factors influencing screening and treatment. A population analysis involving 2,000 TJA patients, and a complication analysis involving 40 periprosthetic fracture patients were conducted. RESULTS Among high risk patients undergoing TJA, 90% did not receive any pharmacological treatment for osteoporosis, 45% were not treated with vitamin D or calcium, and 88% did not receive bone density testing in the routine care period. Among patients with pre-existing osteoporosis undergoing TJA, 80% were not treated with any osteoporosis medications and 33% of these patients were not taking vitamin D or calcium. Female gender and past fracture history contributed to whether patients received screening and treatment. Patients with periprosthetic hip fractures have significantly higher FRAX scores compared to control THA patients. CONCLUSION There are significant gaps in metabolic bone care of the geriatric TJA population regarding both screening and treatment. Metabolic bone care and risk identification with FRAX should be highly considered for TJA patients.
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Affiliation(s)
- Zhaorui Wang
- Weill Cornell Medical College, New York, New York
| | - Justin E Levin
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Troy B Amen
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | | | - Joseph M Lane
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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25
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Chang E, Nickel B, Binkley N, Bernatz J, Krueger D, Winzenried A, Anderson PA. A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization. Geriatr Orthop Surg Rehabil 2022; 13:21514593221116413. [PMID: 35967749 PMCID: PMC9364193 DOI: 10.1177/21514593221116413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Osteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA. Materials/Methods This retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ -2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ -2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD]. Results The study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.). Discussion/Conclusion A simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.
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Affiliation(s)
- Elliot Chang
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Bldg, Madison, WI, USA
| | - Brian Nickel
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Bldg, Madison, WI, USA
| | - Neil Binkley
- University of Wisconsin School of Medicine and Public Health Osteoporosis Clinical Research Program, Madison, WI, USA
| | - James Bernatz
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Bldg, Madison, WI, USA
| | - Diane Krueger
- University of Wisconsin School of Medicine and Public Health Osteoporosis Clinical Research Program, Madison, WI, USA
| | - Alec Winzenried
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Bldg, Madison, WI, USA
| | - Paul A Anderson
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Bldg, Madison, WI, USA
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Cong T, Hall AJ, Jia Z, Christiano A, Elsevier HCK, Cheung ZB, Wellman D, Forsh D, Lane JM. Conceptualizing Biological Aging and Frailty in Orthopaedics: A Framework for Clinical Practice. J Bone Joint Surg Am 2022; 104:1212-1222. [PMID: 35275895 DOI: 10.2106/jbjs.21.01053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Biological aging can best be conceptualized clinically as a combination of 3 components: frailty, comorbidity, and disability. ➤ Despite advancements in the understanding of senescence, chronological age remains the best estimate of biological age. However, a useful exercise for practitioners is to look beyond chronological age in clinical and surgical decision-making. ➤ A chronologically aging person does not age biologically at the same rate. ➤ The best way to understand frailty is to consider it as a physical phenotype. ➤ Physical optimization should parallel medical optimization before elective surgery. ➤ The poorer the host (both in terms of bone quality and propensity for healing), the more robust the implant construct must be to minimize reliance on host biology.
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Affiliation(s)
- Ting Cong
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Arielle J Hall
- Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Zhimeng Jia
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anthony Christiano
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, Minnesota
| | - Hannah C K Elsevier
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, University of California Davis, Davis, California
| | - David Wellman
- Department of Orthopaedic Surgery, Westchester Medical Center, Westchester, New York
| | - David Forsh
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Joseph M Lane
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
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Snodgrass P, Zou A, Gruntmanis U, Gitajn IL. Osteoporosis Diagnosis, Management, and Referral Practice After Fragility Fractures. Curr Osteoporos Rep 2022; 20:163-169. [PMID: 35442009 DOI: 10.1007/s11914-022-00730-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The purpose of this manuscript is to review the current diagnosis, management, and referral practices of patients with osteoporosis after a fragility fracture from the orthopedic surgeon's perspective. RECENT FINDINGS Effective treatments are available for osteoporosis that significantly decrease the risk of additional fractures. Despite recommendations for improved post-fragility fracture osteoporosis management, the rate of diagnosis and treatment is still unacceptably low. Patients sustaining a low-energy fracture should be evaluated for osteoporosis with discussion of beginning pharmacological treatment. Antiresorptive and anabolic agents are available treatment options. Fracture Liaison Services can help to coordinate the care of these patients and improve the rate of diagnosis and initiation of therapy. Dartmouth-Hitchcock is working to improve the bone health for our patients utilizing a multidisciplinary team-based approach. This process is intended to lead to increased recognition of osteoporosis within our institution and close the capture gap between hospital discharge and initiation of osteoporosis pharmacotherapy.
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Affiliation(s)
- Phillip Snodgrass
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA.
| | - Anthony Zou
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
| | - Ugis Gruntmanis
- Department of Medicine, Division of Endocrinology, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
| | - Ida Leah Gitajn
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
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Effect of Bone Health Optimization on Osteoporosis Screening and Treatment Before Thoracolumbar Fusion. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202203000-00014. [PMID: 35290252 PMCID: PMC8926033 DOI: 10.5435/jaaosglobal-d-21-00253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
Abstract
Objective: Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized, and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population. Methods: This retrospective case series includes adults older than 30 years who underwent elective thoracolumbar spine fusion at a single tertiary care center before and after creation of a BHO referral clinic. Data collected included preoperative osteoporosis risk factors, prior dual-energy radiograph absorptiometry testing, and prior osteoporosis pharmacotherapy. Fracture risk was estimated using the fracture risk assessment tool with and without bone mineral density (BMD), and the US National Osteoporosis Foundation criteria for screening and treatment were applied. Results: Ninety patients were included in the pre-BHO group; 53 patients met criteria for BMD measurement, but only 10 were tested within 2 years preoperatively. Sixteen patients (18%) met criteria for osteoporosis pharmacotherapy, but only 5 of the 16 (31%) received osteoporosis medication within 6 months of surgery. There were 87 patients in the post-BHO group, and 19 were referred to the BHO clinic. BMD measurement was done in 17 of the patients (89%) referred to the BHO clinic compared with 10% for those not referred. All patients (n = 7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of the patients not referred received treatment. Discussion: Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13% to 18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment.
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Lewiecki EM, Anderson PA, Bilezikian JP, Binkley N, Cheung AM, Imel EA, Krueger D, McClung MR, Miller PD, Rothman MS. Proceedings of the 2021 Santa Fe Bone Symposium: Advances in the Management of Osteoporosis and Metabolic Bone Diseases. J Clin Densitom 2022; 25:3-19. [PMID: 34785102 DOI: 10.1016/j.jocd.2021.10.001] [Citation(s) in RCA: 6] [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: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
The 2021 Virtual Santa Fe Bone Symposium was held August 5-8, with over 300 registered attendees from throughout the USA, and at least 18 other countries. This annual meeting focuses on applying advances in basic science and clinical research to the care of patients with osteoporosis and those with inherited and acquired disorders of bone metabolism. Participants represented a broad range of medical disciplines with an interest in skeletal diseases. These included physicians of many specialties and practice settings, fellows, advanced practice providers, fracture liaison service (FLS) coordinators, clinical researchers, and bone density technologists. There were lectures, case presentations, and panel discussions, all followed by interactive discussions. Breakout sessions included an FLS workshop, Bone Health TeleECHO workshop, special interest groups, meet-and-greet the faculty, and satellite symposia. The agenda covered topics of interest such as strategies for the use of osteoanabolic therapy, prevention of periprosthetic fractures, management of atypical femur fractures, what we know and don't know about vitamin D, advances in the use of dual-energy X-ray absorptiometry in the assessment of skeletal health, controversies and conundrums in osteoporosis care, skeletal health in transgender patients, management of patients with hypophosphatasia and hypophosphatemia, and treat-to-target approaches for managing patients with osteoporosis. The Proceedings of the 2021 Virtual Santa Fe Bone Symposium consists of highlights of each presentation with current strategies for optimizing the care of patients with skeletal disorders.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - Paul A Anderson
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John P Bilezikian
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Neil Binkley
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Erik A Imel
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Diane Krueger
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA, and Mary MacKillop Center for Health Research, Australian Catholic University, Melbourne, Australia
| | | | - Micol S Rothman
- University of Colorado Health School of Medicine, Aurora, CO, USA
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Marchenkova LA. [Topical issues of rehabilitation of patients with osteoporotic vertebral fractures]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2022; 99:69-79. [PMID: 35236069 DOI: 10.17116/kurort20229901169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The literature review analyzed 20 Russian and 69 foreign publications on the rehabilitation of elderly patients with osteoporotic vertebral fractures. The article deals in detail with the prevalence, medical and social significance of pathological osteoporotic fractures, including vertebral deformities. The data confirming the importance of osteoporosis for physical and rehabilitation medicine specialists are presented. Changes in the quality of life, functional and gate disorders associated with osteoporotic vertebral fractures are described. Based on the available literature data, the principles of rehabilitation of patients with osteoporotic vertebral compression fractures are formulated, including the effectiveness of various methods of physical therapy, mechanotherapy and apparatus physiotherapy. From the standpoint of evidence-based medicine, the role of orthotics in the complex rehabilitation of such patients is described. Based on the analysis of literature data, it was concluded that the problem of osteoporosis is relevant for physicians working in the field of rehabilitation medicine; osteoporotic vertebral fractures are characterized by a high prevalence over the age of 50 years and are associated with a decrease in the quality of life, motor and functional limitations, and an increased risk of death, and well-planned medical rehabilitation programs including physical exercises, physiotherapy and orthotics can significantly improve patient functionality.
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Affiliation(s)
- L A Marchenkova
- National Medical Research Center of Rehabilitation and Balneology of Ministry of Health of Russian Federation, Moscow, Russia
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Kelly BJ, Williams BR, Gravely AA, Schwanz K, Sechriest VF. Femoral head collapse after hip intra-articular corticosteroid injection: An institutional response to improve practice and increase patient safety. PLoS One 2021; 16:e0259242. [PMID: 34727125 PMCID: PMC8562809 DOI: 10.1371/journal.pone.0259242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Femoral head collapse (FHC) is a rarely reported complication of hip intra-articular corticosteroid injection (IACSI). Upon observing a high rate of FHC after hip IACSI, we sought to (1) describe how we addressed the problem through a systematic evaluation of clinical data and institutional care practices followed by process improvement efforts; and (2) report our results. METHODS Patients receiving hip IACSI during a 27-month period underwent retrospective review to determine the rate of FHC and to identify associated patient factors or practice shortfalls. Findings led to institution-wide interventions: (1) to improve patient/provider awareness of this association; and (2) to develop/implement practice guidelines. Rates of FHC after hip IACSI and practice patterns among providers before and after intervention were compared. RESULTS Initial FHC rate after hip IACSI was 20.4%. Patient-related factors included body mass index (p = 0.025), history of cancer therapy (p = 0.012), Vitamin D level (p = 0.030), and multiple injections (p = 0.004). Volume/dose of injectate and post-injection surveillance methods varied widely. Quality improvement (QI) intervention resulted in fewer treatment referrals (from 851 to 436), fewer repeat injections (mean = 1.61 to 1.37; p = 0.0006), and a 5% lower FHC rate (p = 0.1292). Variation in practice patterns persisted, so a systems-based Clinical Pathway was established. DISCUSSION When a high rate of FHC after hip IACSI was found to be associated with certain patient and practice factors, introduction of education materials and treatment guidelines decreased number of referrals, number of injections per patient, and FHC rate. In the absence of the systems-based Pathway, the type, dose, and volume of injectate and post-procedure follow-up remained variable.
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Affiliation(s)
- Brandon J. Kelly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Benjamin R. Williams
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Amy A. Gravely
- Department of Research Service, Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America
| | - Kersten Schwanz
- Department of Physical Medicine/Rehabilitation, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - V. Franklin Sechriest
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
- Department of Orthopaedic Surgery, Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America
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Abstract
Falls are the most common cause of injury to older patients, resulting in >3 million emergency room visits per year and 290,000 hip fractures annually in the United States. Orthopaedic surgeons care for the majority of these patients; however, they are rarely involved in the assessment of fall risk and providing prevention strategies. Falls also occur perioperatively (e.g., in patients with arthritis and those undergoing arthroplasty). Preoperatively, up to 40% of patients awaiting joint arthroplasty sustain a fall, and 20% to 40% have a fall postoperatively. Risk factors for falls include intrinsic factors such as age and comorbidities that are not modifiable as well as extrinsic factors, including medication reconciliation, improvement in the environment, and the management of modifiable comorbidities that can be optimized. Simple in-office fall assessment tools are available that can be adapted for the orthopaedic practice and be used to identify patients who would benefit from rehabilitation. Orthopaedic surgeons should incorporate these strategies to improve care and to reduce fall risk and associated adverse events.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics & Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Jay S Magaziner
- Department of Epidemiology and Public Health, and Center for Research on Aging, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Julie A Switzer
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota.,Geriatric Orthopedics-The Masters Orthopedic Program, HealthPartners Care Group, and Department of Orthopedic Surgery, Park Nicollet Methodist Hospital, Bloomington, Minnesota
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Levitt EB, Patch DA, Ponce BA, Razi AE, Kates SL, Patt JC. Barriers and Resources to Optimize Bone Health in Orthopaedic Education: Own the Bone (OTB): Bone Health Education in Residency. JB JS Open Access 2021; 6:JBJSOA-D-21-00026. [PMID: 34646973 PMCID: PMC8500628 DOI: 10.2106/jbjs.oa.21.00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Osteoporosis is a critical public health issue with substantial morbidity and healthcare costs. Resident education on osteoporosis is not standardized. Little is known about the barriers to osteoporosis treatment and the usefulness of educational programming from the perspective of orthopaedic residency program directors (PDs).
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Affiliation(s)
- Eli B Levitt
- University of Alabama at Birmingham, Birmingham, Alabama
| | - David A Patch
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Joshua C Patt
- Atrium Health - Musculoskeletal Institute, Levine Cancer Institute, Carolinas Medical Center Charlotte, North Carolina
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von Vopelius E, Oheim R, Amling M, Rolvien T, Beil FT. Skeletal characterization in a patient with Hajdu-Cheney syndrome undergoing total knee arthroplasty. Osteoporos Int 2021; 32:1899-1904. [PMID: 33742215 PMCID: PMC8387270 DOI: 10.1007/s00198-021-05914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/05/2021] [Indexed: 11/19/2022]
Abstract
Hajdu-Cheney syndrome (HCS) is a rare genetic connective tissue disorder caused by gain-of-function mutations in the NOTCH2 gene. We report a 38-year-old male HCS patient with a history of multiple pathologic fractures, poor bone stock under intermittent antiresorptive therapy, and secondary osteoarthritis (OA) of the knee, in which we successfully performed total knee arthroplasty (TKA). Next to a detailed skeletal assessment including laboratory bone metabolism markers, dual energy X-ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT), undecalcified histologic and histomorphometric analysis was performed on intraoperatively obtained tibial cut sections. This multiscale assessment revealed a severe, combined trabecular-cortical microarchitectural deterioration, increased bone turnover indices, and advanced cartilage degeneration, thus demonstrating the crucial role of Notch2 in skeletal and cartilage homeostasis, which is in line with the findings of previous mouse models.
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Affiliation(s)
- E von Vopelius
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - R Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- National Bone Board, Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Rolvien
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - F T Beil
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Mikula AL, St Jeor JD, Naylor RM, Bernatz JT, Patel NP, Fogelson JL, Larson AN, Nassr A, Sebastian AS, Freedman B, Currier BL, Bydon M, Kennel KA, Yaszemski MJ, Anderson PA, Elder BD. Teriparatide Treatment Increases Hounsfield Units in the Thoracic Spine, Lumbar Spine, Sacrum, and Ilium Out of Proportion to the Cervical Spine. Clin Spine Surg 2021; 34:E370-E376. [PMID: 34029261 DOI: 10.1097/bsd.0000000000001203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective chart review. OBJECTIVE The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). SUMMARY OF BACKGROUND DATA HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA. MATERIALS AND METHODS A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available. RESULTS One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA. CONCLUSIONS Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA.
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Affiliation(s)
| | | | | | - James T Bernatz
- Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | | | | | | | | | | | | | - Kurt A Kennel
- Endocrinology, Diabetes, and Metabolism, Mayo Clinic, Rochester, MN
| | | | - Paul A Anderson
- Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Diebo BG, Sheikh B, Freilich M, Shah NV, Redfern JAI, Tarabichi S, Shepherd EM, Lafage R, Passias PG, Najjar S, Schwab FJ, Lafage V, Paulino CB. Osteoporosis and Spine Surgery: A Critical Analysis Review. JBJS Rev 2021; 8:e0160. [PMID: 33006455 DOI: 10.2106/jbjs.rvw.19.00160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite being part of the aging process, early and adequate management of osteoporosis mitigates adverse outcomes associated with low bone mineral density. Although the health-care burden of osteoporosis is on the rise, screening and management of osteoporosis are not yet an integral part of preoperative patient evaluation in spine surgery. Patients with osteoporosis should undergo multidisciplinary evaluation and management, including lifestyle modifications and initiation of multiple therapeutic modalities. Integrating osteoporosis in preoperative optimization and surgical planning for patients undergoing spine surgery has the potential to mitigate osteoporosis-related postoperative complications.
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Affiliation(s)
- Bassel G Diebo
- 1Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York 2Royal College of Surgeons in Ireland (RCSI)-Bahrain, Al Sayh, Bahrain 3Division of Spine Surgery, Methodist Hospitals, Merrillville, Indiana 4Spine Service, Hospital for Special Surgery, New York, NY 5Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 6Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Abstract
➤ Our ability to accurately identify high fracture risk in individuals has improved as the volume of clinical data has expanded and fracture risk assessment tools have been developed. ➤ Given its accessibility, affordability, and low radiation exposure, dual x-ray absorptiometry (DXA) remains the standard for osteoporosis screening and monitoring response to treatment. ➤ The trabecular bone score (TBS) is a DXA software add-on that uses lumbar spine DXA imaging to produce an output that correlates with bone microarchitecture. It has been identified as an independent fracture risk factor and may prove useful in further stratifying fracture risk among those with a bone mineral density (BMD) in the osteopenic range (-1.0 to -2.4 standard deviations), in those with low-energy fractures but normal or only mildly low BMD, or in those with conditions known to impair bone microarchitecture. ➤ Fracture risk assessment tools, including the Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator, and QFracture, evaluate the impact of multiple clinical factors on fracture risk, even in the absence of BMD data. Each produces an absolute fracture risk output over a defined interval of time. When used appropriately, these enhance our ability to identify high-risk patients and allow us to differentiate fracture risk among patients who present with similar BMDs. ➤ For challenging clinical cases, a combined approach is likely to improve accuracy in the identification of high-risk patients who would benefit from the available osteoporosis therapies.
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Affiliation(s)
| | - Lisa K Schroder
- University of Minnesota, Minneapolis, Minnesota.,Park Nicollet Methodist Hospital, St. Louis Park, Minnesota
| | - Julie A Switzer
- University of Minnesota, Minneapolis, Minnesota.,Park Nicollet Methodist Hospital, St. Louis Park, Minnesota
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Mikula AL, Fogelson JL, Lakomkin N, Flanigan PM, Pinter ZW, Doan MK, Bydon M, Nassr A, Freedman B, Sebastian AS, Abode-Iyamah K, Anderson PA, Elder BD. Lower Hounsfield Units at the Upper Instrumented Vertebrae are Significantly Associated With Proximal Junctional Kyphosis and Failure Near the Thoracolumbar Junction. Oper Neurosurg (Hagerstown) 2021; 21:270-275. [PMID: 34171907 DOI: 10.1093/ons/opab236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Low bone mineral density (BMD) on dual energy x-ray absorptiometry (DXA) is likely a risk factor for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). However, prior instrumentation and degenerative changes can preclude a lumbar BMD measurement. Hounsfield units (HU) represent an alternative method to estimate BMD via targeted measurements at the intended operative levels. OBJECTIVE To determine if patients with lower HU at the upper instrumented vertebrae (UIV) and vertebral body superior to the UIV (UIV + 1) are at greater risk for PJK and PJF. METHODS A retrospective chart review identified patients at least 50 yr of age who underwent instrumented lumbar fusion with pelvic fixation, a UIV from T10 to L2, and a preoperative computed tomography (CT) encompassing the UIV. HU were measured at the UIV, UIV + 1, and the L3-L4 vertebral bodies. RESULTS A total of 150 patients (80 women and 70 men) were included with an average age of 66 yr and average follow-up of 32 mo. Multivariable logistic regression analysis with an area under the curve (AUC) of 0.89 demonstrated HU at the UIV/UIV + 1 as the only independent predictor of PJK/PJF with an odds ratio of 0.94 (P-value = .031) for a change in a single HU. Patients with HU at UIV/UIV + 1 of <110 (n = 35), 110 to 160 (n = 73), and >160 (n = 42) had a rate of PJK/PJF of 63%, 27%, and 12%, respectively (P-value < .001). CONCLUSION Patients with lower HU at the UIV and UIV + 1 were significantly associated with PJK and PJF, with an optimal cutoff of 122 HU that maximizes sensitivity and specificity.
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Affiliation(s)
- Anthony L Mikula
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy L Fogelson
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikita Lakomkin
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick M Flanigan
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachariah W Pinter
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Paul A Anderson
- Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Benjamin D Elder
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Ghodasra JH, Yousaf IS, Sanghavi KK, Rozental TD, Means KR, Giladi AM. Assessing the Relationship Between Bone Density and Loss of Reduction in Nonsurgical Distal Radius Fracture Treatment. J Hand Surg Am 2021; 46:377-385.e2. [PMID: 33741214 DOI: 10.1016/j.jhsa.2021.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Whether low bone mineral density affects loss of reduction for distal radius fractures (DRFs) managed without surgery is unknown. Our purpose was to understand how bone mineral density, based on second metacarpal cortical percentage (2MCP) measurement, affects DRF healing after nonsurgical treatment. METHODS We retrospectively reviewed 304 patients from 2 health systems with DRFs treated without surgery. The AO classification, 2MCP (<50% indicating osteoporosis), and fracture stability based on Lafontaine criteria were determined from prereduction radiographs. Radial inclination, radial height, volar tilt, ulnar variance, and intra-articular stepoff were measured on initial and 6-week final follow-up radiographs and compared. Bivariate analysis was used to evaluate the association between Lafontaine criteria or 2MCP and changes in radiographic parameters. Radiographic parameters with significant associations in bivariate analysis were evaluated in multivariable models adjusted for age, sex, initial radiographic parameters, reduction status, and AO fracture type. RESULTS Across all patients, after 6 weeks of nonsurgical treatment, ulnar variance (shortening of the radius) increased by an average of 1.4 mm. Bivariate analysis showed that lower 2MCP and unstable fractures per Lafontaine criteria were each significantly associated with an increase in ulnar variance (P < .05). In adjusted multivariable models, having both 2MCP less than 50% and an unstable fracture together was associated with an additional 1.2-mm increase in ulnar variance (P < .05). CONCLUSIONS A 2MCP in the osteoporosis range and unstable fractures by Lafontaine criteria were each associated with a significant increase in ulnar variance after nonsurgical treatment for DRFs. Patients with unstable fractures and 2MCP less than 50% are likely to have an additional increase of greater than 1 mm in ulnar variance at the end of nonsurgical fracture treatment than patients with similar injuries, but without these features. Using initial radiographs to identify patients with low bone mineral density that may be at risk for more substantial loss of reduction can assist with decision making for managing DRFs. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Jason H Ghodasra
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore
| | - Imran S Yousaf
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore
| | - Kavya K Sanghavi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore; MedStar Health Research Institute, Hyattsville, MD
| | - Tamara D Rozental
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kenneth R Means
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore.
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Anderson PA, Freedman BA, Brox WT, Shaffer WO. Osteoporosis: Recent Recommendations and Positions of the American Society for Bone and Mineral Research and the International Society for Clinical Densitometry. J Bone Joint Surg Am 2021; 103:741-747. [PMID: 33587517 DOI: 10.2106/jbjs.20.01248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Osteoporosis is common in orthopaedic patients, not only in those sustaining fragility fractures but also in patients ≥50 years old who are having elective orthopaedic surgery. ➤ The American Society for Bone and Mineral Research (ASBMR) has developed consensus-based recommendations for secondary fracture prevention for all patients who are ≥65 years old with a hip or spine fracture. ➤ The ASBMR encourages orthopaedic surgeons to "Own the Bone," by beginning prevention of a secondary fracture during hospitalization for a fragility fracture, if practicable, and arranging follow-up for continued bone health care after discharge. ➤ The International Society for Clinical Densitometry (ISCD) recognized that many poor outcomes and complications of elective orthopaedic surgery are related to osteoporosis. ➤ The ISCD used an evidence-based approach to create official positions to identify which patients ≥50 years old who are having elective orthopaedic surgery should undergo assessment of bone health and how this should be performed.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Brett A Freedman
- Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - W Timothy Brox
- Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - William O Shaffer
- Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin
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41
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Gosch M, Kammerlander C, Fantin E, Jensen TG, Salazar AML, Olarte C, Bavatonavarech S, Medina C, Link BC, Cunningham M. Design and Evaluation of a Hospital-Based Educational Event on Fracture Care for Older Adult. Geriatr Orthop Surg Rehabil 2021; 12:21514593211003857. [PMID: 33868767 PMCID: PMC8020218 DOI: 10.1177/21514593211003857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Surgeons, internal medicine physicians, nurses, and other members of the
healthcare team managing older adults with a fracture all have barriers to
attending educational courses, including time away from practice and cost.
Our planning group decided to create and evaluate a hospital-based
educational event to address, meet, and improve the care of older adults
with a fracture. Materials and Methods: A committee of surgeons and geriatricians defined 3 learning objectives to
improve knowledge and attitudes in co-managed care. They designed a 1-day
educational event consisting of a departmental visit, a review of cases, a
planning session to identify gaps and plan changes, and presentations on
selected topics. Thirteen hospitals worldwide completed an 8-question online
application form, and 7 sites were selected for delivery over 3 years in
Denmark, Colombia, Thailand, Paraguay, Switzerland, and the Dominican
Republic. Results: Each event was conducted by 1 or more visiting surgeons and geriatricians,
and the local team leaders. The most common challenges reported in the
applications were preoperative assessment or optimization, delayed surgery,
lack of protocols, access to a geriatrician, teamwork, and specific aspects
of perioperative and postoperative care. In each department, 4 or 5 goals
and targets for implementation were agreed. The presentations section was
customized and attended by 20 to 50 team members. Discussion: Topics selected by a majority of departments were principles of co-managed
care (7), preoperative optimization (7), and management of delirium (4).
Follow up was conducted after 3 and 12 months to review the degree of
achievement of each planned change and to identify any barriers to complete
implementation. Conclusions: Hospital-based events with visiting and local faculty were effective to
engage a broader audience that might not attend external courses. A
performance improvement component with goal setting and follow up was
acceptable to all host departments.
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Affiliation(s)
| | | | - Emilio Fantin
- IMC Instituto Modelo de Cardiologia Cordoba, Argentina
| | | | | | | | | | - Claudia Medina
- IPS Universitaria Clínica León XIII, Envigado, Antioquia, Colombia
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Hwang J, Simon V, Rojas D, Mauffrey C, Parry JA. Bilateral subtrochanteric stress riser fractures following percutaneous screw fixation of femoral neck stress fractures: a literature review and case report. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:371-376. [PMID: 33783628 DOI: 10.1007/s00590-021-02950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 03/21/2021] [Indexed: 12/01/2022]
Abstract
Hip and groin pain in patients at-risk for femoral neck stress fracture demand a careful workup including advanced imaging in the setting of normal radiographs. A delay in diagnosis can lead to fracture displacement, which negatively impacts outcomes. Non-displaced tension-sided fractures and displaced fractures warrant operative fixation, while non-displaced compression-side fractures can be managed conservatively. Fixation with a sliding hip screw or cephalomedullary nail is recommended over cannulated screws. In addition, all patients should undergo a metabolic workup to identify correctable parameters. We present a rare case of bilateral compression-sided basicervical femoral neck stress fractures in a non-compliant osteoporotic patient who was treated with cannulated screws. The postoperative course was complicated by bilateral subtrochanteric stress riser fractures requiring revision fixation, which could have been prevented with use of a different implant.
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Affiliation(s)
- Jihyo Hwang
- Department of Orthopaedics, Gangnam Sacred Heart Hospital, University of Hallym School of Medicine, Seoul, Republic of Korea
| | - Violette Simon
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, Colorado, 80204, USA
| | - David Rojas
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, Colorado, 80204, USA
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, Colorado, 80204, USA
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, Colorado, 80204, USA.
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Cotter EJ, Klosterman EL, Winzenried AE, Greiner JJ, Grogan BF. Osteoporosis Screening Is Often Indicated but Overlooked Prior to Rotator Cuff Repair. Arthrosc Sports Med Rehabil 2021; 3:e659-e665. [PMID: 34195629 PMCID: PMC8220567 DOI: 10.1016/j.asmr.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/05/2021] [Indexed: 02/06/2023] Open
Abstract
Purpose To (1) report the percentage of patients undergoing rotator cuff repair (RCR) who were appropriately screened with dual-energy X-ray absorptiometry testing prior to surgery, if indicated, and (2) determine the percentage of patients properly prescribed osteoporosis medications within 6 months of surgery. Methods Consecutive patients aged 50 years or older who underwent elective RCR at a single tertiary-care center over a 1-year period were reviewed. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density. The U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Patients with acute fractures or revision surgery were excluded. Results Of the 218 patients included, 129 were women (58.1%). The mean age was 61.5 ± 7.2 years. One hundred thirty-one RCRs (60.1%) occurred within 3 months of injury. A total of 69 patients (31.7%) met the NOF criteria for bone mineral density screening. Of these patients, 23 (33.3%) were appropriately screened with a dual-energy X-ray absorptiometry scan. Primary care providers initiated bone health assessment in 18 of the 23 appropriately screened patients, with orthopaedic providers initiating the workup in 3 patients (13.0%). Thirty-two patients (14.7%) met the NOF criteria for pharmacologic management of osteoporosis. Of these patients, 5 (15.6%) were treated. Patients meeting the medication criteria were older (69.1 ± 7.7 years vs 60.2 ± 6.3 years, P < .001), had a lower body mass index (28.8 ± 6.1 vs 31.5 ± 6.5, P = .028), and had chronic rotator cuff tears (P = .015). Conclusions Patients aged 50 years or older undergoing RCR are often not appropriately screened for osteoporosis. Even when appropriately screened, only 15.6% of patients meeting the indications for pharmacologic intervention for bone health optimization were prescribed appropriate medications. Although bone health optimization may or may not affect surgical timing, patient encounters related to rotator cuff tears can be used as an opportunity for providers to initiate osteoporosis screening and treatment protocols. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Eric J Cotter
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Emma L Klosterman
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Alec E Winzenried
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Justin J Greiner
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Brian F Grogan
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
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Anderson PA, Freedman BA. Editorial. Bisphosphonates do not impair spinal fusion. Neurosurg Focus 2020; 49:E13. [PMID: 32738797 DOI: 10.3171/2020.5.focus20413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paul A Anderson
- 1Department of Orthopedics & Rehabilitation, University of Wisconsin, Madison, Wisconsin; and
| | - Brett A Freedman
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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45
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Anderson PA, Kadri A, Hare KJ, Binkley N. Preoperative bone health assessment and optimization in spine surgery. Neurosurg Focus 2020; 49:E2. [PMID: 32738805 DOI: 10.3171/2020.5.focus20255] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this investigation was to characterize the bone health in preoperative spine surgery patients. This information will provide a framework to understand the needs and methods for providing bone health optimization in elective spine surgery patients. METHODS A retrospective study of 104 patients undergoing bone health optimization was performed. Patients were selected based on risk factors identified by the surgeon and suspected compromised bone health. Evaluation included history and examination, laboratory investigations, and bone mineral density (BMD) at 3 sites (femoral neck, lumbar spine, and radius). Patients' bone status was classified using WHO criteria and expanded criteria recommended by the National Osteoporosis Foundation (NOF). The 10-year Fracture Risk Assessment Tool (FRAX) scores of the hip and major osteoporotic fracture (MOF) were calculated with and without femoral neck BMD, with spine BMD, and with the trabecular bone score (TBS). Antiresorptive and anabolic agents were provided in accordance with meeting NOF criteria for treatment of osteoporosis. RESULTS The mean patient age was 69.0 years, and 81% of patients were female. The mean historical height loss was 5.6 cm, and 54% of patients had a history of fracture. Secondary osteoporosis due to chronic renal failure, inflammatory arthritis, diabetes, and steroid use was common (51%). The mean 25-hydroxy vitamin D was 42.4 ng/ml and was normal in 81% of patients, with only 4 patients being deficient. The mean T-scores were -2.09 (SD 0.71) of the femoral neck, -0.54 (1.71) of the lumbar spine, and -1.65 (1.38) of the distal radius. These were significantly different. The 10-year FRAX MOF score was 20.7%, and that for hip fracture was 6.9% using the femoral neck BMD and was not significantly different without the use of BMD. The FRAX risk-adjusted score using the lumbar spine BMD and TBS was significantly lower than that for the hip. Osteoporosis was present in 32.1% according to WHO criteria compared with 81.6% according to NOF criteria. Antiresorptive medications were recommended in 31 patients and anabolic medications in 44 patients. CONCLUSIONS Surgeons can reliably identify patients with poor bone health by using simple criteria, including historical height loss, history of fracture, comorbidities associated with osteoporosis, analysis of available imaging, and calculation of FRAX score without BMD. High-risk patients should have BMD testing and bone health assessment. In patients with osteoporosis, a comprehensive preoperative bone health assessment is recommended and, if warranted, pharmacological treatment should be started.
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Affiliation(s)
- Paul A Anderson
- 1Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison; and
| | - Aamir Kadri
- 1Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison; and
| | - Kristyn J Hare
- 1Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison; and
| | - Neil Binkley
- 2University of Wisconsin School of Medicine and Public Health, Osteoporosis Clinical Research Program, Madison, Wisconsin
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Flanigan PM, Mikula AL, Peters PA, Oushy S, Fogelson JL, Bydon M, Freedman BA, Sebastian AS, Currier BL, Nassr A, Kennel KA, Anderson PA, Polly DW, Elder BD. Regional improvements in lumbosacropelvic Hounsfield units following teriparatide treatment. Neurosurg Focus 2020; 49:E11. [DOI: 10.3171/2020.5.focus20273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEOpportunistic Hounsfield unit (HU) determination from CT imaging has been increasingly used to estimate bone mineral density (BMD) in conjunction with assessments from dual energy x-ray absorptiometry (DXA). The authors sought to compare the effect of teriparatide on HUs across different regions in the pelvis, sacrum, and lumbar spine, as a surrogate measure for the effects of teriparatide on lumbosacropelvic instrumentation.METHODSA single-institution retrospective review of patients who had been treated with at least 6 months of teriparatide was performed. All patients had at least baseline DXA as well as pre- and post-teriparatide CT imaging. HUs were measured in the pedicle, lamina, and vertebral body of the lumbar spine, in the sciatic notch, and at the S1 and S2 levels at three different points (ilium, sacral body, and sacral ala).RESULTSForty patients with an average age of 67 years underwent a mean of 20 months of teriparatide therapy. Mean HUs of the lumbar lamina, pedicles, and vertebral body were significantly different from each other before teriparatide treatment: 343 ± 114, 219 ± 89.2, and 111 ± 48.1, respectively (p < 0.001). Mean HUs at the S1 level for the ilium, sacral ala, and sacral body were also significantly different from each other: 124 ± 90.1, −10.7 ± 61.9, and 99.1 ± 72.1, respectively (p < 0.001). The mean HUs at the S2 level for the ilium and sacral body were not significantly different from each other, although the mean HU at the sacral ala (−11.9 ± 52.6) was significantly lower than those at the ilium and sacral body (p = 0.003 and 0.006, respectively). HU improvement occurred in most regions following teriparatide treatment. In the lumbar spine, the mean lamina HU increased from 343 to 400 (p < 0.001), the mean pedicle HU increased from 219 to 242 (p = 0.04), and the mean vertebral body HU increased from 111 to 134 (p < 0.001). There were also significant increases in the S1 sacral body (99.1 to 130, p < 0.05), S1 ilium (124 vs 165, p = 0.01), S1 sacral ala (−10.7 vs 3.68, p = 0.04), and S2 sacral body (168 vs 189, p < 0.05).CONCLUSIONSThere was significant regional variation in lumbar and sacropelvic HUs, with most regions significantly increasing following teriparatide treatment. The sacropelvic area had lower HU values than the lumbar spine, more regional variation, and a higher degree of correlation with BMD as measured on DXA. While teriparatide treatment resulted in HUs > 110 in the majority of the lumbosacral spine, the HUs in the sacral ala remained suggestive of severe osteoporosis, which may limit the effectiveness of fixation in this region.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Kurt A. Kennel
- 3Division of Endocrinology, Department of Internal Medicine, Mayo Clinic, Rochester
| | - Paul A. Anderson
- 4Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David W. Polly
- 5Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota; and
| | - Benjamin D. Elder
- Departments of 1Neurologic Surgery,
- 2Orthopedic Surgery, and
- 6Biomedical Engineering, Mayo Clinic, Rochester
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Mont MA, Salem HS, Piuzzi NS, Goodman SB, Jones LC. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update. J Bone Joint Surg Am 2020; 102:1084-1099. [PMID: 32282421 PMCID: PMC7508290 DOI: 10.2106/jbjs.19.01271] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➢. Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. ➢. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. ➢. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. ➢. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. ➢. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.
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Affiliation(s)
- Michael A. Mont
- Lenox Hill Hospital, New York, NY,Cleveland Clinic, Cleveland, Ohio,Email address for M.A. Mont:
| | | | | | | | - Lynne C. Jones
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Jayaraj JM, Reteti E, Kesavan C, Muthusamy K. Structural insights on vitamin D receptor and screening of new potent agonist molecules: structure and ligand-based approach. J Biomol Struct Dyn 2020; 39:4148-4159. [DOI: 10.1080/07391102.2020.1775122] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - Everlyne Reteti
- Department of Bioinformatics, Alagappa University, Karaikudi, India
| | - Chandrasekhar Kesavan
- Department of Medicine, Musculoskeletal Disease Center, JLP VA Medical Center, Loma Linda University, Loma Linda, CA, USA
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Kadri A, Binkley N, Hare KJ, Anderson PA. Bone Health Optimization in Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:574-581. [PMID: 31977823 DOI: 10.2106/jbjs.19.00999] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteoporosis is associated with adverse orthopaedic surgical outcomes. Bone health optimization is a preoperative intervention intended to reduce the likelihood of postoperative complications. We aimed to characterize a patient cohort referred for bone health optimization to test the hypothesis that poor bone quality is common in orthopaedic surgery and that many such patients meet guidelines for osteoporosis treatment. METHODS This retrospective study evaluated 124 patients referred for bone health optimization who were ≥50 years of age and candidates for arthroplasty or thoracolumbar surgery. The Fracture Risk Assessment Tool (FRAX) risk factors and dual x-ray absorptiometry (DXA) results were collected. When available, opportunistic computed tomographic (CT) imaging and the trabecular bone score were evaluated. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were applied. RESULTS All patients were referred by their orthopaedic surgeon; their mean age was 69.2 years, 83% of patients were female, 97% were Caucasian, and 56% had sustained a previous fracture. The mean historical height loss (and standard deviation) was 5.3 ± 3.3 cm for women and 6.0 ± 3.6 cm for men. The mean lowest T-score of the hip, spine, or wrist was -2.43 ± 0.90 points in women and -2.04 ± 0.81 points in men (p < 0.08). Osteoporosis (T-score of ≤-2.5 points) was present in 45% of women and 20% of men; only 3% of women and 10% of men had normal bone mineral density. Opportunistic CT scans identified 60% of patients as likely having osteoporosis. The trabecular bone score identified 34% of patients with degraded bone microarchitecture and 30% of patients with partially degraded bone microarchitecture. The NOF threshold for osteoporosis treatment was met in 91% of patients. Treatment was prescribed in 75% of patients (45% anabolic therapy and 30% antiresorptive therapy). CONCLUSIONS Osteoporosis, degraded bone microarchitecture, prior fracture, and elevated fracture risk were common. Given the high prevalence of impaired bone health in this cohort, we believe that bone health screening, including FRAX assessment, should be considered in selected patients undergoing orthopaedic surgery as part of the preoperative optimization for all adults who are ≥50 years of age. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aamir Kadri
- Department of Orthopedics & Rehabilitation (A.K., K.J.H., and P.A.A.), and the Osteoporosis Clinical Research Program (N.B.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Schubert MF, Sidhu R, Getgood AM, Sherman SL. Failures of Realignment Osteotomy. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2019.150714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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