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Holloway-Kew KL, Betson AG, Anderson KB, Kotowicz MA, Pasco JA. Associations between ultra-distal forearm bone mineral density and incident fracture in women. Osteoporos Int 2024; 35:1019-1027. [PMID: 38448781 PMCID: PMC11136831 DOI: 10.1007/s00198-024-07041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024]
Abstract
Bone mineral density measured at the ultra-distal forearm site was associated with any fracture, as well as distal radius fracture in women from a longitudinal cohort study. PURPOSE Femoral neck (BMDhip) and lumbar spine (BMDspine) bone mineral density (BMD) are routinely used to assess fracture risk. More data are needed to understand how ultra-distal forearm BMD (BMDUDforearm) may assist fracture prediction. METHODS Using a Lunar DPX-L, Geelong Osteoporosis Study women (n = 1026), aged 40-90 years, had BMD measured. Incident low-trauma fractures were radiologically verified. Using Cox proportional hazard models, hazard ratios (HR) were calculated for BMDUDforearm as a continuous variable (expressed as a one-unit decrease in T-score) and a categorical variable (normal/osteopenia/osteoporosis). Areas under receiver operating characteristics (AUROC) curves were calculated. Analyses were conducted for any fracture and distal radius fractures. RESULTS During 14,270 person-years of follow-up, there were 318 fractures (85 distal radius). In adjusted models, continuous BMDUDforearm was associated with any (HR 1.26;95%CI 1.15-1.39) and distal radius fractures (HR 1.59;95%CI 1.38-1.83). AUROCs for continuous BMDUDforearm, 33% forearm(BMD33%forearm), BMDhip, BMDspine, and FRAX without BMD were similar for any fracture (p > 0.05). For distal radius fracture, the AUROC for BMDUDforearm was higher than other sites and FRAX (p < 0.05). In adjusted models, those with osteoporosis had a higher likelihood of any fracture (HR 2.12; 95%CI 1.50-2.98). For distal radius fractures, both osteopenia and osteoporosis had a higher risk (HR 4.31; 95%CI 2.59-7.15 and 4.81; 95%CI 2.70-8.58). AUROCs for any fracture were similar for categorical BMD at all sites but lower for FRAX (p < 0.05). For distal radius fractures, the AUROC for BMDUDforearm, was higher than other sites and FRAX (p < 0.05). CONCLUSION Ultra-distal forearm BMD may aid risk assessments for any distal radius fractures.
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Affiliation(s)
- Kara L Holloway-Kew
- Deakin University, Institute for Mental and Physical Health and Clinical Translation - IMPACT, Geelong, Australia.
| | - Amelia G Betson
- Deakin University, Institute for Mental and Physical Health and Clinical Translation - IMPACT, Geelong, Australia
| | - Kara B Anderson
- Deakin University, Institute for Mental and Physical Health and Clinical Translation - IMPACT, Geelong, Australia
| | - Mark A Kotowicz
- Deakin University, Institute for Mental and Physical Health and Clinical Translation - IMPACT, Geelong, Australia
- Department of Medicine - Western Health, The University of Melbourne, St Albans, Australia
- University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Julie A Pasco
- Deakin University, Institute for Mental and Physical Health and Clinical Translation - IMPACT, Geelong, Australia
- Department of Medicine - Western Health, The University of Melbourne, St Albans, Australia
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Australia
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O'Mara A, Kerkhof F, Kenney D, Segovia N, Asbell P, Ladd AL. Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study. BMC Musculoskelet Disord 2024; 25:159. [PMID: 38378510 PMCID: PMC10877789 DOI: 10.1186/s12891-023-07127-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/16/2023] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD). METHODS We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves. RESULTS 2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores. CONCLUSIONS These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.
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Affiliation(s)
- Alana O'Mara
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA.
| | - Faes Kerkhof
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Deborah Kenney
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Nicole Segovia
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Paige Asbell
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Amy L Ladd
- Department of Orthopaedic Surgery, Robert A. Chase Hand & Upper Limb Center, Stanford University, Stanford, CA, USA
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Miura K, Tanaka SM, Chotipanich C, Chobpenthai T, Jantarato A, Khantachawana A. Osteoporosis Prediction Using Machine-Learned Optical Bone Densitometry Data. Ann Biomed Eng 2024; 52:396-405. [PMID: 37882922 PMCID: PMC10808164 DOI: 10.1007/s10439-023-03387-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
Optical bone densitometry (OBD) has been developed for the early detection of osteoporosis. In recent years, machine learning (ML) techniques have been actively implemented for the areas of medical diagnosis and screening with the goal of improving diagnostic accuracy. The purpose of this study was to verify the feasibility of using the combination of OBD and ML techniques as a screening tool for osteoporosis. Dual energy X-ray absorptiometry (DXA) and OBD measurements were performed on 203 Thai subjects. From the OBD measurements and readily available demographic data, machine learning techniques were used to predict the T-score measured by the DXA. The T-score predicted using the Ridge regressor had a correlation of r = 0.512 with respect to the reference value. The predicted T-score also showed an AUC of 0.853 for discriminating individuals with osteoporosis. The results obtained suggest that the developed model is reliable enough to be used for screening for osteoporosis.
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Affiliation(s)
- Kaname Miura
- Biological Engineering Program, King Mongkut's University of Technology Thonburi, Bangkok, 10140, Thailand
- Graduate School of Natural Science and Technology, Kanazawa University, Kanazawa, 920-1192, Japan
| | - Shigeo M Tanaka
- Institute of Science and Engineering, Kanazawa University, Kanazawa, 920-1192, Japan
| | - Chanisa Chotipanich
- National Cyclotron and PET Center, Chulabhorn Hospital, Bangkok, 10140, Thailand
| | - Thanapon Chobpenthai
- Faculty of Medicine and Public Health, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, 10140, Thailand
| | - Attapon Jantarato
- National Cyclotron and PET Center, Chulabhorn Hospital, Bangkok, 10140, Thailand
| | - Anak Khantachawana
- Department of Mechanical Engineering, King Mongkut's University of Technology Thonburi, Bangkok, 10140, Thailand.
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Uemura K, Miyamura S, Otake Y, Mae H, Takashima K, Hamada H, Ebina K, Murase T, Sato Y, Okada S. The effect of forearm rotation on the bone mineral density measurements of the distal radius. J Bone Miner Metab 2024; 42:37-46. [PMID: 38057601 DOI: 10.1007/s00774-023-01473-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Forearm dual-energy X-ray absorptiometry (DXA) is often performed in clinics where central DXA is unavailable. Accurate bone mineral density (BMD) measurement is crucial for clinical assessment. Forearm rotation can affect BMD measurements, but this effect remains uncertain. Thus, we aimed to conduct a simulation study using CT images to clarify the effect of forearm rotation on BMD measurements. MATERIALS AND METHODS Forearm CT images of 60 women were analyzed. BMD was measured at the total, ultra-distal (UD), mid-distal (MD), and distal 33% radius regions with the radius located at the neutral position using digitally reconstructed radiographs generated from CT images. Then, the rotation was altered from - 30° to 30° (supination set as positive) with a one-degree increment, and the percent BMD changes from the neutral position were quantified for all regions at each angle for each patient. RESULTS The maximum mean BMD changes were 5.8%, 7.0%, 6.2%, and 7.2% for the total, UD, MD, and distal 33% radius regions, respectively. The analysis of the absolute values of the percent BMD changes from the neutral position showed that BMD changes of all patients remained within 2% when the rotation was between - 5° and 7° for the total region, between - 3° and 2° for the UD region, between - 4° and 3° for the MD region, and between - 3° and 1° for the distal 33% radius region. CONCLUSION Subtle rotational changes affected the BMD measurement of each region. The results showed the importance of forearm positioning when measuring the distal radius BMD.
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Affiliation(s)
- Keisuke Uemura
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Satoshi Miyamura
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshito Otake
- Division of Information Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Hirokazu Mae
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuma Takashima
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hidetoshi Hamada
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kosuke Ebina
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tsuyoshi Murase
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshinobu Sato
- Division of Information Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Seiji Okada
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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De-Levie TK, Schiffenbauer YS, Druckmann I, Rouach V, Stern N, Binderman I, Nevo U. Quantitative MR Analysis of Changes in the Radius Bone Marrow in Osteoporosis. J Osteoporos 2023; 2023:7861495. [PMID: 38179189 PMCID: PMC10764646 DOI: 10.1155/2023/7861495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
Purpose This pilot study aimed to explore the feasibility of scanning the human distal radius bone marrow in vivo to detect osteoporosis-related changes using magnetic resonance and evaluate whether the radius may serve as an accessible probing site for osteoporosis. This may lead in the future to the use of affordable means such as low-field MRI scanners for the monitoring of disease progression. Methods A clinical trial was performed using a 3T MR scanner, including 26 women assigned into three study groups: healthy-premenopausal (n = 7; mean age 48.6 ± 3.5 years), healthy-postmenopausal (n = 10; mean age 54.5 ± 5.6 years), and osteoporotic-postmenopausal (n = 9; mean age 61.3 ± 5.6 years). Marrow fat composition was evaluated using T2 maps, a two-compartment model of T1, and a Dixon pulse sequence. Results The osteoporotic group exhibited higher fat content than the other two groups and lower T2 values than the healthy-premenopausal group. Conclusions Osteoporosis-related changes in the composition of the distal radius bone marrow may be detected in vivo using MRI protocols. The scanning protocols chosen here can later be repeated using low-field MRI scanners, thus offering the potential for early detection and treatment monitoring, using an accessible, affordable means that may be applied in small clinics. This trial is registered with MOH_2018-05-23_002247, NCT03742362.
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Affiliation(s)
- Tamar K. De-Levie
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Ido Druckmann
- Skeletal Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Vanessa Rouach
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Naftali Stern
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- The Sagol Center for Epigenetics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- The Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Itzhak Binderman
- Department of Oral Biology, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Nevo
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
- The Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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Banks KP, Farrell MB, Gunther RS, McWhorter NE, Byerly DW, Peacock JG. Improving DXA Quality by Avoiding Common Technical and Diagnostic Pitfalls: Part 1. J Nucl Med Technol 2023; 51:167-175. [PMID: 36195442 DOI: 10.2967/jnmt.122.264885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
Dual-energy x-ray absorptiometry (DXA) is an accurate means to assess bone mineral density, determine the risk of a fragility fracture, and monitor response to therapy. Despite its seemingly straightforward nature-the review of 2-to-3 nondiagnostic images and a few automatically generated numbers-the proper performance and interpretation of DXA can often be complex. It is complex because it is highly dependent on many factors, such as image acquisition, processing, analysis, and subsequent examination interpretation. Each step is subject to potential errors, artifacts, and diagnostic pitfalls; hence, meticulous attention must be paid to the technique by both the technologist and the interpreting physician to provide high-quality results and, in turn, maximize the examination's clinical utility. This article is part 1 of a 2-part series. Part 1 will begin with a review of bone physiology and osteoporosis etiology, followed by a discussion of the principles underlying DXA and the technical procedure. Part 2 will focus on DXA interpretation and discuss scanning pitfalls and clues to recognizing issues and improving scan quality.
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Affiliation(s)
- Kevin P Banks
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
- Department of Radiology, Uniformed Services University, Bethesda, Maryland; and
| | | | - Rutger S Gunther
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
| | - Nathan E McWhorter
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
- Department of Radiology, Uniformed Services University, Bethesda, Maryland; and
| | - Doug W Byerly
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
- Department of Radiology, Uniformed Services University, Bethesda, Maryland; and
| | - Justin G Peacock
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
- Department of Radiology, Uniformed Services University, Bethesda, Maryland; and
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Farzad M, MacDermid J, Hemmati M, Farhoud AR. Occupational Performance 1 Year After a Distal Radius Fracture From the Perspective of the International Classification of Functioning, Disability and Health. Am J Occup Ther 2023; 77:7705205040. [PMID: 37793017 DOI: 10.5014/ajot.2023.050180] [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: 10/06/2023] Open
Abstract
IMPORTANCE Distal radius fractures (DRFs) frequently compromise independent functioning. OBJECTIVE To analyze occupational performance post-DRF using the Canadian Occupational Performance Measure (COPM) and related interviews, guided by the International Classification of Functioning, Disability and Health (ICF). COPM score was compared with standard metrics: Patient-Reported Wrist Evaluation (PRWE) and Participation Behavior Questionnaire (PBQ). METHOD Through a semistructured COPM interview, participants highlighted self-care, productivity, and leisure. They completed the PRWE and PBQ, linking results to ICF sets. DESIGN Prospective cohort. SETTING Outpatient hand surgery clinic at a trauma center. PARTICIPANTS Patients (N = 120), 1 yr post-DRF. OUTCOMES AND MEASURES Incorporated COPM, PRWE, and PBQ, linked to ICF. RESULTS Analysis identified 73 codes, aligning with 30 ICF Hand Conditions codes. Main concerns related to self-care (15.21%), leisure (12.16%), and productivity (16.22%). Major challenges pertained to domestic (67.00%) and civic life (64.53%) within ICF. Occupational performance was positively correlated with participation (r = .62) and inversely with disability (r = -.62). CONCLUSIONS AND RELEVANCE DRFs result in varied occupational challenges that are not always reflected in standard measures. The COPM offers a comprehensive insight into post-DRF patient challenges, emphasizing the value of diverse clinical assessment approaches. What This Article Adds: This study highlights the importance of a holistic approach in occupational therapy for DRF patients, revealing that standard measurements might overlook key challenges that they face. By adopting broader evaluative methods, occupational therapists can better address patient-specific needs and enhance their rehabilitation outcomes.
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Affiliation(s)
- Maryam Farzad
- Maryam Farzad, PhD, MSc, BSc, is Postdoctoral Associate, School of Physical Therapy, Department of Health and Rehabilitation Sciences, University of Western Ontario, London, Ontario, Canada, and Assistant Professor, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran;
| | - Joy MacDermid
- Joy MacDermid, PhD, MSc, BSc, is Professor, Department of Physical Therapy and Surgery, Western University, London, Ontario, Canada; Codirector, Clinical Research Laboratory, Hand and Upper Limb Center, St. Joseph's Health Center, London, Ontario, Canada; and Professor, Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Motahar Hemmati
- Motahar Hemmati, BSc OT, is Master's Student, Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Amir Reza Farhoud
- Amir Reza Farhoud, MD, is Assistant Professor, Department of Orthopedic Surgery, Imam Hospital Complex, Tehran University of Medical Sciences, Joint Reconstruction Research Center, Tehran, Iran
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Ma SB, Lee SK, An YS, Kim WS, Choy WS. The clinical necessity of a distal forearm DEXA scan for predicting distal radius fracture in elderly females: a retrospective case-control study. BMC Musculoskelet Disord 2023; 24:177. [PMID: 36894929 PMCID: PMC9996865 DOI: 10.1186/s12891-023-06265-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Recent studies have demonstrated that the distal forearm dual-energy X-ray absorptiometry (DEXA) scan might be a better method for screening bone mineral density (BMD) and the risk of a distal forearm fracture, compared with a central DEXA scan. Therefore, the purpose of this study was to determine the effectiveness of a distal forearm DEXA scan for predicting the occurrence of a distal radius fracture (DRF) in elderly females who were not initially diagnosed with osteoporosis after a central DEXA scan. METHODS Among the female patients who visited our institutes and who were over 50 years old and underwent DEXA scans at 3 sites (lumbar spine, proximal femur, and distal forearm), 228 patients with DRF (group 1) and 228 propensity score-matched patients without fractures (group 2) were included in this study. The patients' general characteristics, BMD, and T-scores were compared. The odds ratios (OR) of each measurement and correlation ratio among BMD values of the different sites were evaluated. RESULTS The distal forearm T-score of the elderly females with DRF (group 1) was significantly lower than that of the control group (group 2) (p < 0.001 for the one-third radius and ultradistal radius measurements). BMD measured during the distal forearm DEXA scan was a better predictor of DRF risk than BMD measured during the central DEXA (OR = 2.33; p = 0.031 for the one-third radius, and OR = 3.98; p < 0.001 for the ultradistal radius). The distal one-third radius BMD was correlated with hip BMD, rather than lumbar BMD (p < 0.05 in each group). CONCLUSION Performing a distal forearm DEXA scan in addition to a central DEXA scan appears to be clinically significant for detecting the low BMD in the distal radius, which is associated with osteoporotic DRF in elderly females. LEVEL OF EVIDENCE III; case-control study.
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Affiliation(s)
- Sang Beom Ma
- Department of Orthopedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon, 35233, South Korea
| | - Sang Ki Lee
- Department of Orthopedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon, 35233, South Korea.
| | - Young Sun An
- Department of Orthopedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon, 35233, South Korea
| | - Woo-Suk Kim
- Department of Orthopedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon, 35233, South Korea
| | - Won Sik Choy
- Department of Orthopedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon, 35233, South Korea
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Schwarz Y, Goldshtein I, Friedman YE, Peltz-Sinvani N, Brodavka M, Kowal D, Vered I, Tripto-Shkolnik L. Bone mineral density of the ultra-distal radius: are we ignoring valuable information? Arch Osteoporos 2023; 18:28. [PMID: 36725758 DOI: 10.1007/s11657-023-01218-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
The current study explored the possible utilization in dual-X-ray-absorptiometry scanning (DXA) of the ultra-distal radius (UDR). This region of interest is currently unused and mostly unstudied in this context. The study findings suggest UDR as potential useful region of interest in DXA scanning and warrant further study of the site. PURPOSE Bone mineral density (BMD) measurement of a non-dominant arm is not routinely performed during dual-X-ray-absorptiometry (DXA) test, and the possible utility of ultra-distal (UDR) radius BMD is not well-studied. We evaluated in women, correlations of UDR BMD with fracture prevalence, fracture risk prediction by the fracture risk assessment tool (FRAX), and osteoporosis diagnosed by traditional sites. METHODS Women who underwent a routine DXA (including their non-dominant forearm and including UDR BMD) in a tertiary medical center were included. Risk factors relevant to FRAX calculation were assessed via a self-administered questionnaire. Spearman correlations of UDR BMD to 10-year risks of major osteoporotic and hip fractures (assessed by FRAX) were explored. The possible added value of UDR BMD in explaining prevalent osteoporotic fractures was assessed using a multivariable regression model incorporating age and traditional osteoporosis diagnosis. RESULTS The study included 1245 women with a median age of 66 years (interquartile range: 59-73), of whom 298 (24%) had UDR T-score ≤ - 2.5 and 154 (12%) reported prior fractures. UDR BMD was significantly negatively correlated with FRAX risk score for hip and major osteoporotic fractures (R = - 0.5 and R = - 0.41, respectively; P < 0.001). UDR T-score ≤ - 2.5 was associated with higher fracture prevalence (19% vs 10%; P < 0.001) and remained significant after adjusting for traditional BMD and age (OR 1.49, 1.01-2.19; P = 0.043). CONCLUSION UDR BMD correlates both with prior fractures and with predicted fracture risks and might pose added value over traditional DXA sites.
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Affiliation(s)
- Yair Schwarz
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Inbal Goldshtein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yehudit Eden Friedman
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Peltz-Sinvani
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Brodavka
- Rheumatology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - David Kowal
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
| | - Iris Vered
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cho ST, Kim JH, Lee SS, Lee YJ, Lee HI. Forearm bone mineral density as a predictor of reduction loss in distal radius fractures treated with cast immobilization. Front Surg 2022; 9:1043002. [DOI: 10.3389/fsurg.2022.1043002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/09/2022] [Indexed: 11/29/2022] Open
Abstract
ObjectiveMany potential predictors have been identified and proposed for predicting late reduction loss in distal radius fractures. However, no report exists on whether the bone mineral density (BMD) of the forearm correlates with the loss of reduction in distal radius fractures. This study aimed to investigate whether forearm BMD can be used as a predictor of reduction loss in distal radius fractures treated with cast immobilization.MethodsNinety patients with distal radius fractures were divided into two groups according to the maintenance or loss of reduction evaluated from radiographs taken at least 6 weeks after their injury. Lumbar and forearm BMD (total and metaphysis) T-scores were measured and compared between the maintenance of reduction (MOR) group and the loss of reduction (LOR) group. Additionally, serologic markers (C-terminal telopeptide, osteocalcin, vitamin D) and radiologic risk factors (intra-articular fracture, ulnar fracture, dorsal comminuted fracture, volar hook) were evaluated and a logistic multiple regression analysis was performed to know the main risk factors of reduction loss.ResultsReduction loss was observed in 38 patients (42.2%). The total and metaphyseal BMD of the forearm was less in the LOR group than in the MOR group. However, the difference was not statistically significant [−2.9 vs. −2.5 for total (p = 0.18), −2.3 vs. −2.0 for metaphysis (p = 0.17)]. Multiple logistic regression analysis showed initial dorsal comminution (p = 0.008) and ulnar variance (p = 0.01) were the main risk factors for reduction loss.ConclusionsForearm BMD was not a valuable prognostic factor for reduction loss in distal radius fractures. Initial dorsal comminution and ulnar variance rather than forearm BMD should be considered preferentially when predicting which patients are at high risk of reduction loss in distal radius fractures.
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Abstract
PURPOSE OF REVIEW Bone fragility is a complication of type 2 diabetes (T2D), and insulin resistance is suspected to contribute to diabetes-related bone deficits. This article provides an overview of emerging clinical research involving insulin resistance and bone health by summarizing recent publications, identifying existing knowledge gaps, and suggesting 'next steps' for this evolving field of research. RECENT FINDINGS Clinical studies in children and adults report greater bone density in people with increased insulin resistance, but these associations are often attenuated when adjusting for body size. Advancements in bone imaging methods allow for assessment of nuanced characteristics of bone quality and strength that extend beyond standard bone mineral density assessment methods. For example, several recent studies focusing on lumbar spine trabecular bone score, a relatively new measure of trabecular bone quality from dual-energy X-ray absorptiometry, have reported generally consistent inverse associations with insulin resistance. Longitudinal studies using advanced imaging methods capable of evaluating trabecular bone microstructure and strength, such as high-resolution peripheral quantitative computed tomography, are lacking. Studies in younger individuals are sparse, but emerging data suggest that peak bone mass attainment might be threatened by diabetes progression, and increased visceral fat, suppressed muscle-bone unit, advanced glycation end-products, sedentary lifestyle, and poor diet quality might contribute to diabetes effects on bone. Prospective studies during the transition from adolescence to young adulthood are required. SUMMARY Insulin resistance is a main feature of T2D, which is suspected to contribute to subclinical diabetes-related threats to bone health. Future clinical studies should focus on the critical years surrounding peak bone mass and peak bone strength attainment using contemporary imaging techniques.
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Affiliation(s)
- Wang Shin Lei
- Department of Nutritional Sciences, The University of Georgia, Athens, GA, USA
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12
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Chukir T, Haseltine K, Do H, McMahon DJ, Russell L, Stein EM. Clinical Characteristics and Fracture Patterns Among Postmenopausal Women with Isolated Osteoporosis at the Forearm. J Clin Densitom 2022; 25:208-214. [PMID: 34511326 DOI: 10.1016/j.jocd.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 11/28/2022]
Abstract
Patients found to have isolated osteoporosis at the 1/3 radius (1/3RO) represent a therapeutic dilemma. It is unknown whether 1/3RO is associated with an increased risk of fragility fractures, and is therefore unclear whether these patients should be treated similarly to those with osteoporosis at central sites. This retrospective study investigated the clinical significance of 1/3RO by comparing medical history, fracture prevalence, areal BMD, and Trabecular Bone Score in postmenopausal women with 1/3RO (n = 107) to age-matched women with osteoporosis at the hip and/or spine (PMO, n = 214), and to controls without osteoporosis at any site (n = 214). We then compared the clinical and densitometric characteristics among women with 1/3RO according to fracture history. The mean age of the 535 women included in the study was 71 ± 8 yr. Women with 1/3RO had BMD in the osteopenic range at all other sites (mean spine T-score = -1.0, total hip = -1.4, femoral neck = -1.7). Women with 1/3RO reported similar calcium and vitamin D intake, prevalence of primary hyperparathyroidism, chronic kidney disease, and other comorbidities compared to the other groups. The prevalence of an osteoporotic fracture of the spine, hip, wrist, or humerus tended to be higher among women with PMO compared to 1/3RO or controls (PMO: 31%, 1/3RO: 21%, Controls: 23%, p = 0.07). Among women with 1/3RO, fracture prevalence was related to older age. No other clinical characteristic distinguished women with and without fracture. Neither BMD at other sites nor TBS differed according to fracture history. Among postmenopausal women with 1/3RO, those who are older are at an increased risk of fracture, even when T-scores at other sites are well above the osteoporosis threshold. Additional research is needed to confirm our results, and to assess whether treatment should be considered to reduce fracture risk in older women with 1/3RO.
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Affiliation(s)
| | - Katherine Haseltine
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, USA.
| | - Huong Do
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Donald J McMahon
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, USA
| | - Linda Russell
- Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, USA
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13
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The Impact of Diabetes on Osteoporosis Management and Secondary Fracture Risk After Primary Fragility Fractures: A Propensity Score-Matched Cohort Study. J Am Acad Orthop Surg 2022; 30:e204-e212. [PMID: 34543247 DOI: 10.5435/jaaos-d-21-00185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/22/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Rates of osteoporosis evaluation and management after primary fragility fractures have remained low in recent years. The extent to which this treatment gap affects patients with diabetes is unclear. This study aimed to compare the risk of secondary fractures and rates of osteoporosis diagnosis and management after sentinel fractures in patients with and without diabetes. METHODS A propensity score-matched cohort study was conducted using the PearlDiver database. Patients aged 50 years and older with primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other locations were identified. Rates of secondary fractures, dual radiograph absorptiometry (DXA) scans, charted osteoporosis diagnoses (International Classification of Diseases, Ninth and Tenth Revisions), and osteoporosis pharmacotherapy within 2 years were compared for patients with and without diabetes using multivariable logistic regression. RESULTS Matching yielded 27,052 patients in each cohort. Index humerus fractures were more common in the diabetic cohort (15.0% versus 11.6%, P < 0.001), whereas wrist fractures were more prevalent among the nondiabetic cohort (15.2% versus 19.3%, P < 0.001). Incidence of secondary fractures at 2 years was higher for diabetic patients than nondiabetic patients (5.2% versus 4.7%; odds ratio [OR] 1.08; 95% confidence interval [CI], 0.99 to 1.17). Diabetic patients were significantly less likely to receive a DXA scan (13.2% versus 13.5%; OR 0.93; 95% CI, 0.88 to 0.98), be diagnosed with osteoporosis (9.3% versus 11.9%; OR 0.77; 95% CI, 0.73 to 0.82), or start pharmacotherapy (8.1% versus 8.7; OR 0.93; 95% CI, 0.87 to 0.99). CONCLUSION Despite diabetes being a well-established risk factor for fragility fractures, diabetic patients were significantly less likely to receive DXA scan evaluation, be formally diagnosed with osteoporosis, or be treated with osteoporosis pharmacotherapy after a sentinel fragility fracture. Incidence of secondary fractures within 2 years was also higher among diabetic patients.
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Cheung WH, Hung VWY, Cheuk KY, Chau WW, Tsoi KKF, Wong RMY, Chow SKH, Lam TP, Yung PSH, Law SW, Qin L. Best Performance Parameters of HR-pQCT to Predict Fragility Fracture: Systematic Review and Meta-Analysis. J Bone Miner Res 2021; 36:2381-2398. [PMID: 34585784 PMCID: PMC9298023 DOI: 10.1002/jbmr.4449] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/30/2021] [Accepted: 09/24/2021] [Indexed: 01/11/2023]
Abstract
Osteoporosis is a systemic skeletal disease characterized by low bone mass and bone structural deterioration that may result in fragility fractures. Use of bone imaging modalities to accurately predict fragility fractures is always an important issue, yet the current gold standard of dual-energy X-ray absorptiometry (DXA) for diagnosis of osteoporosis cannot fully satisfy this purpose. The latest high-resolution peripheral quantitative computed tomography (HR-pQCT) is a three-dimensional (3D) imaging device to measure not only volumetric bone density, but also the bone microarchitecture in a noninvasive manner that may provide a better fracture prediction power. This systematic review and meta-analysis was designed to investigate which HR-pQCT parameters at the distal radius and/or distal tibia could best predict fragility fractures. A systematic literature search was conducted in Embase, PubMed, and Web of Science with relevant keywords by two independent reviewers. Original clinical studies using HR-pQCT to predict fragility fractures with available full text in English were included. Information was extracted from the included studies for further review. In total, 25 articles were included for the systematic review, and 16 articles for meta-analysis. HR-pQCT was shown to significantly predict incident fractures and/or major osteoporotic fractures (MOFs). Of all the HR-pQCT parameters, our meta-analysis revealed that cortical volumetric bone mineral density (Ct.vBMD), trabecular thickness (Tb.Th), and stiffness were better predictors. Meanwhile, HR-pQCT parameters indicated better performance in predicting MOFs than incident fractures. Between the two standard measurement sites of HR-pQCT, the non-weight-bearing distal radius was a more preferable site than distal tibia for fracture prediction. Furthermore, most of the included studies were white-based, whereas very few studies were from Asia or South America. These regions should build up their densitometric databases and conduct related prediction studies. It is expected that HR-pQCT can be used widely for the diagnosis of osteoporosis and prediction of future fragility fractures. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Wing-Hoi Cheung
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Vivian Wing-Yin Hung
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Ka-Yee Cheuk
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai-Wang Chau
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Kelvin Kam-Fai Tsoi
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Ronald Man-Yeung Wong
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Simon Kwoon-Ho Chow
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Tsz-Ping Lam
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Patrick Shu-Hang Yung
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sheung-Wai Law
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Ling Qin
- Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Miyamura S, Lans J, Min KS, Waryasz GR, Murase T, Chen NC. Bone resorption of the greater tuberosity after open reduction and internal fixation of complex proximal humeral fractures: fragment characteristics and intraoperative risk factors. J Shoulder Elbow Surg 2021; 30:1626-1635. [PMID: 33038499 DOI: 10.1016/j.jse.2020.09.014] [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: 02/27/2020] [Revised: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND In complex proximal humeral fractures, bone resorption of the greater tuberosity is sometimes observed after open reduction and internal fixation (ORIF). However, this has not been well characterized, and risk factors for resorption are not completely understood. We aimed (1) to identify the risk factors associated with bone resorption of the greater tuberosity and (2) to quantify the geometric and bone density characteristics associated with bone resorption using 3-dimensional computed tomography models in complex proximal humeral fractures treated with ORIF. METHODS We identified a retrospective cohort of 136 patients who underwent ORIF of 3- or 4-part proximal humeral fractures; greater tuberosity resorption developed after ORIF in 30 of these patients. We collected demographic, fracture-related, and surgery-related characteristics and performed multivariable logistic regression analysis to identify factors independently associated with the development of greater tuberosity resorption. Furthermore, we identified 30 age- and sex-matched patients by use of propensity score matching to perform quantitative fragment-specific analysis using 3-dimensional computed tomography models. After the fragment of the greater tuberosity was identified, the number of fragments, the relative fragment volume to the humeral head, and the relative bone density to the coracoid process were calculated. Measurements were compared between matched case-control groups. RESULTS We found that an unreduced greater tuberosity (odds ratio [OR], 10.9; P < .001), inadequate medial support at the calcar (OR, 15.0; P < .001), and the use of an intramedullary fibular strut (OR, 4.5; P = .018) were independently associated with a higher risk of bone resorption. Quantitative fragment-specific analysis showed that greater tuberosities with a larger number of fragments (5 ± 2 vs. 3 ± 2, P = .021), smaller fragments (9.9% ± 3.8% vs. 18.6% ± 4.7%, P < .001), and fragments with a lower bone density (66.4% ± 14.3% vs. 88.0% ± 18.4%, P = .001) had higher rates of resorption. DISCUSSION AND CONCLUSION An unreduced greater tuberosity or inadequate medial support increases the risk of greater tuberosity resorption, as do a larger number of fracture fragments, smaller fragments, and lower bone density. Additionally, fibular strut grafting is an independent risk factor for tuberosity resorption. Further study is needed, but alternatives to strut grafting such as femoral head allograft may warrant serious consideration.
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Affiliation(s)
- Satoshi Miyamura
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
| | - Jonathan Lans
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyong S Min
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Gregory R Waryasz
- Department of Orthopaedic Surgery, Foot and Ankle Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsuyoshi Murase
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Neal C Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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16
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Ross BJ, Lee OC, Harris MB, Dowd TC, Savoie FH, Sherman WF. Rates of Osteoporosis Management and Secondary Preventative Treatment After Primary Fragility Fractures. JB JS Open Access 2021; 6:JBJSOA-D-20-00142. [PMID: 34136740 PMCID: PMC8202643 DOI: 10.2106/jbjs.oa.20.00142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Fragility fractures are often sentinel events in documenting new cases of osteoporosis. Numerous analyses have demonstrated low rates of adequate osteoporosis evaluation and treatment following primary fragility fractures. The purpose of this study was to quantify the incidence of primary fragility fractures in America and the rates of osteoporosis screening and management before and after fracture.
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Affiliation(s)
- Bailey J Ross
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas C Dowd
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium Orthopaedic Residency Program, Fort Sam Houston, Texas
| | - Felix H Savoie
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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