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Chang E, Binkley N, Krueger D, Illgen R, Nickel B, Hennessy D, Bernatz J, Winzenried A, Anderson PA. Proposed bone health screening protocol to identify total knee arthroplasty patients for preoperative DXA. Osteoporos Int 2023; 34:171-177. [PMID: 36326846 DOI: 10.1007/s00198-022-06585-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
UNLABELLED This study evaluates a novel, simple bone health screening protocol composed of patient sex, age, fracture history, and FRAX risk to identify total knee arthroplasty patients for preoperative DXA. Findings supported effectiveness, with sensitivity of 1.00 (CI 0.92-1.00) and specificity of 0.54 (CI 0.41-0.68) when evaluating for clinical osteoporosis. PURPOSE Bone health optimization is a process where osteoporotic patients are identified, evaluated via modalities such as dual-energy X-ray absorptiometry (DXA), and treated when indicated. There are currently no established guidelines to determine who needs presurgical DXA. This study evaluates the effectiveness of a simple screening protocol to identify TKA patients for preoperative DXA. METHODS This prospective cohort study began on September 1, 2019, and included 100 elective TKA patients. Inclusion criteria were ≥ 50 years and primary TKA. All patients obtained routine clinical DXA. The screening protocol defining who should obtain DXA included meeting any of the following: female ≥ 65, male ≥ 70, fracture history after age 50, or FRAX major osteoporotic fracture risk without bone mineral density (BMD) adjustments ≥ 8.4%. Osteoporosis was defined by the World Health Organization (WHO) criteria (T-score ≤ - 2.5) or clinically (T-score ≤ - 2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture). Sensitivity and specificity were calculated. RESULTS The study included 68 females and 32 males, mean age 67.2 ± 7.7. T-score osteoporosis was observed in 16 patients while 43 had clinical osteoporosis. Screening criteria recommending DXA was met by 69 patients. Screening sensitivity was 1.00 (CI 0.79-1.00) and specificity was 0.37 (CI 0.27-0.48) for identifying patients with T-score osteoporosis. Similar sensitivity of 1.00 (CI 0.92-1.00) and specificity of 0.54 (CI 0.41-0.68) were found for clinical osteoporosis. CONCLUSIONS A simple screening protocol identifies TKA patients with T-score and clinical osteoporosis for preoperative DXA with high sensitivity in this prospective cohort study.
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Affiliation(s)
- Elliot Chang
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA.
| | - Neil Binkley
- School of Medicine and Public Health Osteoporosis Clinical Research Program, University of Wisconsin, 2870 University Ave, Suite 100, Madison, WI, 53705, USA
| | - Diane Krueger
- School of Medicine and Public Health Osteoporosis Clinical Research Program, University of Wisconsin, 2870 University Ave, Suite 100, Madison, WI, 53705, USA
| | - Richard Illgen
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA
| | - Brian Nickel
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA
| | - David Hennessy
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA
| | - James Bernatz
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA
| | - Alec Winzenried
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA
| | - Paul A Anderson
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin, UWMF Centennial Bldg, 1685 Highland Ave, 6Th Floor, Madison, WI, 53705-2281, USA.
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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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Kim D, Pirshahid AA, Li Y, Varghese T, Pope JE. Prevalence of osteoporosis in osteoarthritis: a systematic review and meta-analysis. Osteoporos Int 2022; 33:1687-1693. [PMID: 35380214 DOI: 10.1007/s00198-022-06376-0] [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] [Received: 07/18/2021] [Accepted: 03/10/2022] [Indexed: 12/24/2022]
Abstract
Data are contradictory regarding the relationship between osteoarthritis (OA) and osteoporosis (OP) with some studies showing the increased risk of OP in OA. The study was conducted to determine whether OP prevalence is increased in patients with OA, compared to age and sex-matched population. MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library (inception-2019) were searched for studies reporting the frequency, rate, prevalence, incidence, risk, or excess risk of OP in patients with OA compared to age and sex-matched population. Estimates were combined using a random effects model. Consistency was evaluated using the I2 statistic. Articles with fewer than 200 participants were excluded. Of 2772 articles, 49 had full article screening, and 8 articles met the inclusion criteria. Other articles reporting mean BMD and not OP were excluded. In women, 998 participants with OA were compared with 1903 controls. The pooled estimate of the odds ratio for prevalence of OP vs general matched population was not statistically different. In men, 136 participants with OA were compared with 682 controls. The results did not show a statistically significant difference in the frequency of OP in OA in men. According to the site of bone mineral density measurement, a higher prevalence of OP at lumbar spine was found in both men and women. The frequency of OP overall in participants with OA was not different, except for a higher prevalence of OP in lumbar spine in both men and women compared to the matched controls.
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Affiliation(s)
- Dongkeun Kim
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Ali Ahmadi Pirshahid
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Yueyang Li
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Timothy Varghese
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Janet E Pope
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
- Division of Rheumatology, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON, N6A 4V2, Canada.
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Dave D, Bhattacharjee SK, Shah DD, Mascerhans A, Dey PC, Arumugan S, Mehra V, Agarwal V, Garg S, Gore SC, Choudhry RR, Mahajan M, Bharat S. Osteoporosis in Indian Patients Undergoing Elective Arthroplasty and Spinal Procedures: An Observational Study. Cureus 2022; 14:e27275. [PMID: 35910701 PMCID: PMC9329657 DOI: 10.7759/cureus.27275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background This is an observational study conducted to determine the prevalence of osteoporosis and osteopenia in patients undergoing elective arthroplasty and spinal procedures in India. Methods This observational, multicentre study included both male and female patients. Their bone mineral density and fracture risk were measured using dual-energy x-ray absorptiometry (DEXA) and Fracture Risk Assessment Tool (FRAX®: Centre for Metabolic Bone Diseases, University of Sheffield, UK), respectively, in compliance with the guidelines for Good Epidemiological Practice (ISRCTN: 14543098). Results The study revealed that majority (76.4%; 97/127) of the patients had low BMD; over one-third had osteoporosis (39.4%; 50/127) or osteopenia (37%; 47/127). Among those undergoing total knee replacement (TKR)/total hip replacement (THR), majority (75.6%; 59/78) had low BMD (osteoporosis: 38.5% {30/78}; osteopenia: 37.2% {29/78}). Among the patients undergoing spinal procedures, all except two (93.10%; 27/29) had low BMD, two-thirds had osteoporosis (65.5%; 19/29), and around one-fourth had osteopenia (27.6%; 8/29). Radial BMD measurements showed higher prevalence of osteoporosis and osteopenia. Based on FRAX score, nearly 30% of patients were at a high risk of hip fracture in the next 10 years. As per National Osteoporosis Foundation (NOF) guidelines, most (59.79%; 58/97) patients with osteoporosis/osteopenia met criteria for pharmacological treatment. Conclusions Regular preoperative bone health evaluation should be adopted and osteoporosis/osteopenia patients should be adequately managed pharmacologically in India.
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Prevalence and treatment rate of osteoporosis in patients undergoing total knee and hip arthroplasty: a systematic review and meta-analysis. Arch Osteoporos 2022; 17:16. [PMID: 35029750 DOI: 10.1007/s11657-021-01055-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/21/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Due to age and gender, patients awaiting total knee or hip arthroplasty (TKA/THA) are at a higher risk of osteoporosis. In joint arthroplasty, low bone mineral density (BMD) is a risk factor for implant osseointegration, durability, and prosthesis complications. This study aims to investigate the prevalence and treatment rate of osteoporosis in patients undergoing total joint arthroplasty (TJA). METHODS We applied a comprehensive literature search through PubMed, Cochrane Library, and EMBASE from inception to July 10, 2021, for studies investigating the prevalence and treatment rate of osteoporosis in TJA patients. The aggregated prevalence was calculated with the random-effects model, and the heterogeneity between studies was checked by Cochran's Q test and quantified by the I2 statistic. We performed subgroup analyses and meta-regression analyses to determine the source of heterogeneity. Publication bias was assessed by a funnel plot and verified by Egger's test. Anti-osteoporosis treatment for TJA patients was described qualitatively and quantitatively. RESULTS Of 4561 citations identified by the search strategy, 11 studies including 3462 patients were eligible for inclusion. The pooled prevalence of osteoporosis and osteopenia in TJA patients was 24.8% (95%CI: 14.1-37.2%) and 38.5% (95%CI: 29.3-48.0%), respectively. The prevalence of osteoporosis/osteopenia in TJA patients was 64.0% (95%CI: 45.8-80.3%). In terms of gender, the pooled prevalence of osteoporosis in males, females, and postmenopausal females were 5.5% (95%CI: 1.5-11.4%), 29.0% (95%CI: 18.3-41.1%), and 38.3% (95%CI: 13.2-67.1%), respectively. The treatment rate of osteoporosis in TJA patients was 32.9% (95%CI: 15.2-53.1%) by a random-effects model. CONCLUSIONS Osteoporosis is highly prevalent in patients undergoing TJA, especially in postmenopausal females. However, the treatment rate of osteoporosis is low. Considering the possibility of surgical complications, clinicians should strengthen their awareness of pre-operative BMD assessment and manage osteoporosis in high-risk patients.
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Fischer LT, Heinecke M, Röhner E, Schlattmann P, Matziolis G. Cones and sleeves present good survival and clinical outcome in revision total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:2824-2837. [PMID: 34389876 PMCID: PMC9309140 DOI: 10.1007/s00167-021-06670-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The fixation of revision total knee arthroplasties (rTKA) tends to be difficult, leading to a reduction in implant survival. One option for achieving a more stable anchorage is to use metaphyseal cones and sleeves. The objective of the present paper is to provide a current comparative meta-analysis on survival and clinical results of cones vs. sleeves, with a differentiation between the short- and long-term outcome. METHODS A search of the literature was conducted systematically to include original papers from 2010 to June 2021. The following parameters were taken into account: revision for aseptic loosening, revision for any reason, periprosthetic joint infections (PJI), KSS as well as KSFS. Studies with a mean follow-up of at least 60 months were defined to be long-term follow-up studies (LT). All other studies were included in the short-term (ST) study analysis. A pooled incidence was used as a summary statistic using a random intercept logistic regression model. RESULTS The present meta-analysis included 43 publications with 3008 rTKA. Of these, 23 publications with 1911 cases were allocated to the sleeve group (SG) and 20 papers with 1097 cases to the cone group (CG). CG showed overall numerically higher complication rates in short- and long-term follow-up, compared with SG. Aseptic loosening occurred at a rate of 0.4% in SG (LT) and 4.1% in CG (LT) (p = 0.09). Periprosthetic joint infection (PJI) was more frequent in the cone group (7% in ST and 11.7% in LT) than in the sleeve group (3.4% in ST and 4.9% in LT, p = 0.02 both). The total revision rate was 5.5% in SG (LT) and 14.4% in CG (LT) (p = 0.12). The clinical scores were also comparable between the two groups. Hinged prothesis were used more frequent in the cone group (ST p < 0.001; LT p = 0.10), whereas CC type protheses were used more frequently in the sleeve group (ST p < 0.001; LT p < 0.11). CONCLUSIONS This meta-analysis takes into account the longest follow-up periods covered to date. Both cones and sleeves represent a reliable fixation method in the case of severe bone loss in rTKA, although the higher rate of PJI after cone fixation remains a source of concern. A metaphyseal fixation of hinged implants should be taken into account. LEVEL OF EVIDENCE II (meta-analysis).
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Affiliation(s)
- Laura Theresa Fischer
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany.
| | - Markus Heinecke
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Eric Röhner
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Peter Schlattmann
- Department of Medical Statistics, Informatics and Data Science, Jena University Hospital Jena, Bach Str. 18, 07743, Jena, Germany
| | - Georg Matziolis
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
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Ishii Y, Noguchi H, Sato J, Takahashi I, Ishii H, Ishii R, Ishii K, Toyabe SI. Preoperative bone assessment by bone mineral density and bone turnover in patients undergoing total knee arthroplasty. J Orthop 2021; 28:121-125. [PMID: 34924727 DOI: 10.1016/j.jor.2021.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022] Open
Abstract
Background The preoperative overall bone quality in patients undergoing total knee arthroplasty (TKA) might influence the development of postoperative bone-derived complications. This study was performed to simultaneously evaluate the baseline bone mineral density (BMD) and bone turnover in these patients. Methods We prospectively measured the lumbar spine, total hip, and femoral neck BMD using dual-energy X-ray absorptiometry (DXA) in 214 patients (239 knees; women, 199 knees; men, 40 knees) 1 day preoperatively. Women were stratified into three age groups: <70 years (60s), <80 years (70s), and ≥80 years (80s). We assessed bone turnover using the urinary level of N-telopeptide (NTx) normalized to creatinine (NTx/Cre). Results The prevalence of osteoporosis as assessed by DXA (T-score of ≤ -2.5) was 22% in women and 5% in men. A decline in BMD with aging was found in the hip but not in the lumbar spine with significant differences among ages. Women showed a higher NTx/Cre level than men (p = 0.033). An NTx/Cre level suggesting a high fracture risk (>56.5 mmol BCE/mmol Cre) was present in 54% of women and 35% of men (p = 0.037). No significant differences were found in this prevalence among age groups in women. Seventeen percent of women and 0% of men had both osteoporosis and a high fracture risk simultaneously (p = 0.002). The proportion of women in this category was lower in the 60s than 70s age group (p = 0.019). Conclusions Preoperative bone health screening before TKA might be necessary for women aged ≥70 years to prevent complications caused by perioperative poor bone condition.
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Affiliation(s)
- Yoshinori Ishii
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Hideo Noguchi
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Junko Sato
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Ikuko Takahashi
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Hana Ishii
- Kanazawa Medical University, School of Plastic Surgery, 1-1 Daigaku Uchinada, Ishikawa 920-0253, Japan
| | - Ryo Ishii
- Shinshu University Hospital, 3-1-1 Asahi Matsumoto, Nagano 390-8621, Japan
| | - Kei Ishii
- Iwate Prefectural Ninohe Hospital, 38 Horino, Ninohe, Iwate 028-6193, Japan
| | - Shin-Ichi Toyabe
- Niigata University Crisis Management Office, Niigata University Hospital, Niigata University Graduate School of Medical and Dental Sciences, 1 Asahimachi Dori Niigata, Niigata 951-8520, Japan
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Mohler SA, Stambough JB, Mears SC, Barnes CL, Stronach BM. A Review of Periprosthetic Tibial Fractures: Diagnosis and Treatment. Orthop Clin North Am 2021; 52:357-368. [PMID: 34538348 DOI: 10.1016/j.ocl.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Periprosthetic fracture occurring during or after total knee arthroplasty is a rare injury. Literature concerning periprosthetic tibial factures is sparse, and there is limited guidance for evidence-based management. This review aims to provide readers with an overview of the epidemiology, risk factors, and classification of these fractures. Management includes nonoperative treatment of nondisplaced fractures, fixation for those with stable implants, and revision for those with loose implants.
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Affiliation(s)
- Samantha A Mohler
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot # 531, Little Rock, AR 72205, USA
| | - Jeffery B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot # 531, Little Rock, AR 72205, USA
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot # 531, Little Rock, AR 72205, USA
| | - Charles Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot # 531, Little Rock, AR 72205, USA
| | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot # 531, Little Rock, AR 72205, USA.
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The predictive significance of bone mineral density on postoperative pain relief in knee osteoarthritis patients after total knee arthroplasty: A prediction model. J Orthop Sci 2021; 26:622-628. [PMID: 32732146 DOI: 10.1016/j.jos.2020.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/01/2020] [Accepted: 05/15/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Bone mineral density (BMD) may be an important factor affecting the clinical outcomes after total knee arthroplasty (TKA). However, further information regarding BMD in postoperative pain relief is not present yet. This study aims to gain further insight into the predictive significance of BMD in postoperative pain relief in knee osteoarthritis (KOA) patients after TKA. METHODS 156 KOA patients treated by TKA were included in this study. Visual analogue scale (VAS) was used to measure the pain intensity in patients within one year after TKA. The patients were divided into good pain relief group (the improvement of VAS ≥ 3) and poor pain relief group (the improvement of VAS < 3). BMD and other clinical characteristics were also collected. Logistic regression analysis and receiver operating characteristic curve (ROC curve) were used to evaluate the predictive significance of BMD. Subgroup analysis was used to compare the difference of postoperative pain between High BMD group and Low BMD group extra. RESULTS 34 (21.8%) patients had poor pain relief after TKA. Logistic regression analysis indicated that age, BMD, preoperative hospital for special surgery (HSS) scores, preoperative VAS score and postoperative posterior slope angles (PSA) were the risk factors of poor pain relief (P < 0.05). Using BMD as a predictor, the optimum cut-off value of poor pain relief was T-level = -3.0 SD in the ROC curve, where sensitivity and specificity were 73.5% and 83.7%, respectively. Based on this cut-off value, obvious pain relief was observed in the High BMD group compared with Low BMD group from the 6th month after TKA in the subgroup analysis (P < 0.05). CONCLUSIONS BMD is an effective predictor for postoperative pain relief in KOA patients after TKA, and the poor pain relief should be fully considered especially when BMD T-level ≤ -3.0 SD.
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Tao Y, Tang S, Huang X, Wang H, Zhou A, Zhang J. Prevalence and Risk Factors of Osteoporosis in Chinese Postmenopausal Women Awaiting Total Knee Arthroplasty. Clin Interv Aging 2021; 16:379-387. [PMID: 33664569 PMCID: PMC7924246 DOI: 10.2147/cia.s297947] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/10/2021] [Indexed: 01/01/2023] Open
Abstract
Background Total knee arthroplasty (TKA) complications associated with low bone quality are challenging for orthopaedic surgeons to treat, but little is known about bone quality in Chinese postmenopausal women awaiting TKA. This study investigated the incidence of osteoporosis (OP) and explored the preoperative risk factors for OP in this population. Methods We retrospectively reviewed the data of Chinese postmenopausal women who were indicated for TKA between May 2017 and June 2020. The bone mineral density (BMD) of the hip and lumbar spine and multiple preoperative parameters were collected and analyzed. Binary logistic regression analysis was performed to identify independent risk factors for OP in this population. Results A total of 204 postmenopausal women with advanced knee OA were included in the study (age: 69.7±8.5 years; body mass index [BMI]: 25.5±4.0 kg/m2). The OP prevalence among all participants was 59.8%, and the patients aged 60–80 years had a significantly lower BMD than did the age/ethnicity-adjusted population. An age ≥60 years, a BMI<25, and the presence of a varus knee deformity were independent risk factors for preoperative OP in the postmenopausal women awaiting TKA. Conclusion The prevalence of OP in Chinese postmenopausal women awaiting TKA is higher than that in the age/ethnicity-adjusted normal population. An age ≥60 years, a BMI<25, and the presence of a varus knee deformity are independent risk factors that can be used to predict preoperative OP in this population.
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Affiliation(s)
- Yuzhang Tao
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Siying Tang
- Department of Clinical Nutrition, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Xiao Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Hongwei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Aiguo Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Jian Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
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Zafeiris EP, Babis GC, Zafeiris CP, Chronopoulos E. Association of vitamin D, BMD and knee osteoarthritis in postmenopausal women. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2021; 21:509-516. [PMID: 34854390 PMCID: PMC8672405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to analyze the association of knee OA with bone mineral density (BMD) and vitamin D serum levels in postmenopausal women. METHODS A cross-sectional study including 240 postmenopausal women with knee OA was conducted. Demographic data were recorded along with balance and functionality scores. Knee OA severity was assessed by the radiological Kellgren & Lawrence scale. BMD and T-scores were calculated in hips and lumbar spine. Serum levels of vitamin D were also measured. RESULTS High BMI (p<0.005), high number of children (p=0.022) and family history of hip fracture (p=0.011) are significantly associated with knee OA severity. Lumbar spine OP is negatively associated with knee OA (p<0.005). A significant difference was detected between vitamin D deficiency and severe knee OA, adjusted for BMD [OR (95%CI); 3.1 (1.6-6.1), p=0.001]. BMD does not affect the relationship of vitamin D levels in relation to OA and vitamin D levels do not affect the relationship of BMD with OA. CONCLUSIONS Low BMD has a protective role against knee OA while vitamin D deficiency contributes significantly to knee OA severity. However, the association between OA and OP is not affected by vitamin D deficiency and the association of OA and vitamin D serum levels is not affected by BMD.
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Affiliation(s)
- Evangelos P. Zafeiris
- 2nd Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece;,Corresponding author: Evangelos P. Zafeiris, 2nd Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Agias Olgas 3-5, 14233, Athens, Greece E-mail:
| | - George C. Babis
- 2nd Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Christos P. Zafeiris
- Orthopaedics and Spine Surgery, Metropolitan General Hospital, Athens, Greece,Laboratory for Research of the Musculoskeletal System, School of Medicine University of Athens, Greece
| | - Efstathios Chronopoulos
- 2nd Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece;,Laboratory for Research of the Musculoskeletal System, School of Medicine University of Athens, Greece
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White R, Krueger D, De Guio F, Michelet F, Hans D, Anderson P, Binkley N. An Exploratory Study of the Texture Research Investigational Platform (TRIP) to Evaluate Bone Texture Score of Distal Femur DXA Scans - A TBS-Based Approach. J Clin Densitom 2021; 24:112-117. [PMID: 31358359 DOI: 10.1016/j.jocd.2019.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 11/21/2022]
Abstract
Poor bone status is associated with increased complications following orthopedic surgery. Therefore, assessing site-specific skeletal status prior to or after orthopedic surgery to optimize outcomes is appealing. The trabecular bone score (TBS) approach, a surrogate for microarchitecture, was adapted to the Texture Research Investigational Platform (TRIP), which allows assessment of many skeletal sites imaged by various modalities. TRIP generates a bone texture score (TBS ORTHO), which could potentially guide surgical decision-making and offer insight into postsurgical fracture risk. As distal femur bone loss occurs following total knee arthroplasty (TKA), we hypothesized that TBS ORTHO after TKA would identify poorer texture in the operated femur compared to the nonoperated. We evaluated 30 subjects (15 M/15 F) with unilateral TKA 2-5 yr previously, mean age 67.9 yr and body mass index 30 kg/m2. Using a Lunar iDXA, lumbar spine and entire femur scans were obtained, the latter using the atypical femur fracture feature. Distal femur bone mineral density (BMD) and TBS ORTHO were obtained using manual regions of interest (ROI) at 15% and 25% of leg length from the intercondylar notch. TBS ORTHO was determined using distal femur DICOM images and TRIP v1.0 (Medimaps, France). Differences in operated vs nonoperated femur were evaluated by paired t test. As previously reported, operated leg BMD was approx 10% lower at 15% and 25% ROIs. Similarly, TBS ORTHO values in the operated leg were approx 5% lower (p < 0.05) at these same ROIs. Distal femur TBS ORTHO and BMD were largely unrelated. TBS ORTHO reproducibility at these ROIs was approx 3.5%. In conclusion, this pilot study documents the feasibility of reproducibly obtaining distal femur TBS ORTHO values. Lower values were observed in the surgical leg, consistent with the bone loss that follows TKA. Further work is indicated to refine TRIP use and evaluate whether such data provides guidance for surgical decision-making and improves periprosthetic fracture prediction.
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Affiliation(s)
- R White
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA.
| | - D Krueger
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
| | - F De Guio
- Research and Development Department, Medimaps, Bordeaux, France
| | - F Michelet
- Research and Development Department, Medimaps, Bordeaux, France
| | - D Hans
- Research and Development Department, Medimaps, Bordeaux, France; Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - P Anderson
- University of Wisconsin, Department of Orthopedics and Rehabilitation, Madison, WI, USA
| | - N Binkley
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
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13
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Prevalence and Treatment of Osteoporosis Prior to Elective Shoulder Arthroplasty. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00204. [PMID: 33986217 PMCID: PMC7722598 DOI: 10.5435/jaaosglobal-d-20-00204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 11/18/2022]
Abstract
Introduction: The rate of preoperative osteoporosis in lower extremity arthroplasty is 33%. The prevalence of osteoporosis in shoulder arthroplasty patients is inadequately studied. The purpose of this study was to (1) determine the prevalence of osteoporosis in patients undergoing elective shoulder arthroplasty, (2) report the percentage of patients having dual-energy x-ray absorptiometry (DEXA) testing before surgery, and (3) determine the percentage of patients who have been prescribed osteoporosis medications within 6 months before or after surgery. Methods: This retrospective case series included all adults aged 50 years and older who underwent elective shoulder arthroplasty at a single tertiary care center over an 8-year period. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Results: Two hundred fifty-one patients met the inclusion criteria; 171 (68%) met the criteria for DEXA testing, but only 31 (12%) had this testing within 2 years preoperatively. Eighty patients (32%) met the NOF criteria for receipt of pharmacologic osteoporosis treatment, and 17/80 (21%) received a prescription for pharmacotherapy. Discussion: Two-thirds of elective shoulder arthroplasty patients meet the criteria to have bone mineral density measurement done, but less than 20% have this done. One in three elective shoulder arthroplasty patients meet the criteria to receive osteoporosis medications, but only 20% of these patients receive therapy.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to critically evaluate the current literature regarding implant fixation in osteoporotic bone. RECENT FINDINGS Clinical studies have not only demonstrated the growing prevalence of osteoporosis in patients undergoing total joint replacement (TJR) but may also indicate a significant gap in screening and treatment of this comorbidity. Osteoporosis negatively impacts bone in multiple ways beyond the mere loss of bone mass, including compromising skeletal regenerative capacity, architectural deterioration, and bone matrix quality, all of which could diminish implant fixation. Recent findings both in preclinical animal models and in clinical studies indicate encouraging results for the use of osteoporosis drugs to promote implant fixation. Implant fixation in osteoporotic bone presents an increasing clinical challenge that may be benefitted by increased screening and usage of osteoporosis drugs.
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Affiliation(s)
- Kyle D Anderson
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Frank C Ko
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, 60612, USA
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Amarjit S Virdi
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, 60612, USA
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - D Rick Sumner
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, 60612, USA
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Ryan D Ross
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, 60612, USA.
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, 60612, USA.
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15
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Carlson BB, Salzmann SN, Shirahata T, Ortiz Miller C, Carrino JA, Yang J, Reisener MJ, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Prevalence of osteoporosis and osteopenia diagnosed using quantitative CT in 296 consecutive lumbar fusion patients. Neurosurg Focus 2020; 49:E5. [PMID: 32738803 DOI: 10.3171/2020.5.focus20241] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Osteoporosis is a metabolic bone disease that increases the risk for fragility fractures. Screening and diagnosis can be achieved by measuring bone mineral density (BMD) using quantitative CT tomography (QCT) in the lumbar spine. QCT-derived BMD measurements can be used to diagnose osteopenia or osteoporosis based on American College of Radiology (ACR) thresholds. Many reports exist regarding the disease prevalence in asymptomatic and disease-specific populations; however, osteoporosis/osteopenia prevalence rates in lumbar spine fusion patients without fracture have not been reported. The purpose of this study was to define osteoporosis and osteopenia prevalence in lumbar fusion patients using QCT. METHODS A retrospective review of prospective data was performed. All patients undergoing lumbar fusion surgery who had preoperative fine-cut CT scans were eligible. QCT-derived BMD measurements were performed at L1 and L2. The L1-2 average BMD was used to classify patients as having normal findings, osteopenia, or osteoporosis based on ACR criteria. Disease prevalence was calculated. Subgroup analyses based on age, sex, ethnicity, and history of abnormal BMD were performed. Differences between categorical groups were calculated with Fisher's exact test. RESULTS Overall, 296 consecutive patients (55.4% female) were studied. The mean age was 63 years (range 21-89 years). There were 248 (83.8%) patients with ages ≥ 50 years. No previous clinical history of abnormal BMD was seen in 212 (71.6%) patients. Osteopenia was present in 129 (43.6%) patients and osteoporosis in 44 (14.9%). There were no prevalence differences between sex or race. Patients ≥ 50 years of age had a significantly higher frequency of osteopenia/osteoporosis than those who were < 50 years of age. CONCLUSIONS In 296 consecutive patients undergoing lumbar fusion surgery, the prevalence of osteoporosis was 14.9% and that for osteopenia was 43.6% diagnosed by QCT. This is the first report of osteoporosis disease prevalence in lumbar fusion patients without vertebral fragility fractures diagnosed by QCT.
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Affiliation(s)
- Brandon B Carlson
- 1Marc A. Asher, MD, Comprehensive Spine Center, University of Kansas Medical Center, Kansas City, Kansas
| | | | | | | | - John A Carrino
- 3Department of Radiology and Imaging, Hospital for Special Surgery, New York; and
| | - Jingyan Yang
- 2Spine Care Institute and.,4Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Ha CW, Park YB. Underestimation and undertreatment of osteoporosis in patients awaiting primary total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:1109-1114. [PMID: 32358659 DOI: 10.1007/s00402-020-03462-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Osteoporosis is generally regarded as a risk factor for periprosthetic fracture during or after primary total knee arthroplasty (TKA). Despite this, little is known about osteoporosis in patients undergoing elective primary TKA Therefore, we sought to investigate the prevalence of osteoporosis and rates of pharmacologic osteoporosis treatment prior to primary TKA. We hypothesized that preoperative osteoporosis is underestimated and undertreated in the primary TKA population. MATERIALS AND METHODS This retrospective study included consecutive 1972 patients scheduled for elective primary TKA at a single tertiary hospital (age, 50-89 years). Charts were reviewed for patient demographics, prior pharmacologic osteoporosis treatment and Knee Society (KS) scoring system and WOMAC score. Dual energy X-ray absorptiometry (DEXA) measurement of the lumbar vertebrae and proximal femur was performed in all patients on the day before surgery. The associations of BMD with age, sex, body mass index (BMI), and clinical outcome were analyzed. RESULTS The prevalence of osteoporosis was 50.0% (53.4% in women and 7.0% in men). Among patients with osteoporosis, only 15.1% (149/986) of patients (15.0% in women and 30.0% in men) had pharmacological osteoporosis treatment prior to primary TKA. Age, sex and WOMAC stiffness showed association with osteoporosis. Sex (odds ratio (OR): 20.83, p < 0.001) was the most significant factor associated with osteoporosis. CONCLUSION Osteoporosis was highly prevalent in patients awaiting TKA, but the rates of diagnosis and pharmacologic osteoporosis treatment were low. Therefore, more attention needs to estimate and treat osteoporosis in patients awaiting primary TKA, especially in female patients.
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Affiliation(s)
- Chul-Won Ha
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea.
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17
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Miller AM, Beyer DT, Starring HM, Leonardi C, Bronstone AB, Dasa V. Importance of Routine Bone Mineral Density Screening Prior to Elective Total Joint Replacement. Orthopedics 2019; 42:310-312. [PMID: 31751487 DOI: 10.3928/01477447-20191022-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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18
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Anderson PA, Morgan SL, Krueger D, Zapalowski C, Tanner B, Jeray KJ, Krohn KD, Lane JP, Yeap SS, Shuhart CR, Shepherd J. Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position. J Clin Densitom 2019; 22:517-543. [PMID: 31519473 DOI: 10.1016/j.jocd.2019.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin UWMF Centennial Building, Madison, WI, USA.
| | - Sarah L Morgan
- UAB Osteoporosis Prevention and Treatment Clinic, University of Alabama Birmingham, Birmingham, AL, USA
| | - Diane Krueger
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
| | | | - Bobo Tanner
- Division Rheumatology, Vanderbilt University, Nashville, TN, USA
| | - Kyle J Jeray
- Greenville Health System, Deparment of Orthopaedic Surgery, Greenville, SC, USA
| | | | - Joseph P Lane
- Department of Orthopedic Surgery, Hospital for Special surgery, New York, USA
| | | | | | - John Shepherd
- University of Hawaii Cancer Center, University of Hawaii, Honolulu, HI, USA
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Anderson PA, Jeray KJ, Lane JM, Binkley NC. Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues. J Bone Joint Surg Am 2019; 101:1413-1419. [PMID: 31393435 DOI: 10.2106/jbjs.18.01229] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Kyle J Jeray
- Department of Orthopaedic Surgery, Greenville Health System, Greenville, South Carolina
| | | | - Neil C Binkley
- University of Wisconsin Osteoporosis Clinical Research Program, Madison, Wisconsin
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20
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Kim BY, Kim HA, Jung JY, Choi ST, Kim JM, Kim SH, Kwon SR, Suh CH, Kim SS. Clinical Impact of the Fracture Risk Assessment Tool on the Treatment Decision for Osteoporosis in Patients with Knee Osteoarthritis: A Multicenter Comparative Study of the Fracture Risk Assessment Tool and World Health Organization Criteria. J Clin Med 2019; 8:jcm8070918. [PMID: 31248035 PMCID: PMC6678257 DOI: 10.3390/jcm8070918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 11/23/2022] Open
Abstract
Background: To compare the frequency of high-risk osteoporotic fracture in patients with knee OA (OA) using the fracture risk assessment tool (FRAX) and the bone mineral density (BMD). Methods: We retrospectively assessed 282 Korean patients with knee OA who visited five medical centers and 1165 healthy controls (HCs) aged ≥50 years without knee OA. After matching for age, sex, and body mass index, 478 subjects (239 patients with knee OA and 239 HCs) were included. Results: Based on the BMD, the frequency of osteoporosis was 40.2% in patients with knee OA and 36.4% in HCs. The predicted mean FRAX major osteoporotic fracture probabilities calculated with or without femur neck BMD differed significantly between the knee OA and HCs (6.9 ± 3.8% versus 6.1 ± 2.8%, p = 0.000 and 8 ± 3.6% versus 6.8 ± 2.3%, p < 0.001, respectively). The mean FRAX hip fracture probabilities calculated with or without femur neck BMD differed significantly in the knee OA and HCs (2.1 ± 2.4% versus 1.7 ± 1.8%, p = 0.006 and 3 ± 2.3% versus 2.4 ± 1.6%, p < 0.001, respectively). Conclusion: Our study suggests that FRAX may have a clinical impact on treatment decisions to reduce osteoporotic facture in patients with knee OA.
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Affiliation(s)
- Bo Young Kim
- Division of Rheumatology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung 25440, Korea.
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon 16449, Korea.
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon 16449, Korea.
| | - Sang Tae Choi
- Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul 06973, Korea.
| | - Ji-Min Kim
- Division of Rheumatology, Department of Internal Medicine, Keimyung University School of Medicine, Dongsan Medical Center, Daegu 42601, Korea.
| | - Sang Hyon Kim
- Division of Rheumatology, Department of Internal Medicine, Keimyung University School of Medicine, Dongsan Medical Center, Daegu 42601, Korea.
| | - Seong-Ryul Kwon
- Division of Rheumatology, Department of Internal Medicine, Rheumatism Center, Inha University Hospital, Incheon 22332, Korea.
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon 16449, Korea.
| | - Sung-Soo Kim
- Division of Rheumatology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung 25440, Korea.
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Prince JM, Bernatz JT, Binkley N, Abdel MP, Anderson PA. Changes in femoral bone mineral density after total knee arthroplasty: a systematic review and meta-analysis. Arch Osteoporos 2019; 14:23. [PMID: 30798359 DOI: 10.1007/s11657-019-0572-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Bone loss after total knee arthroplasty (TKA) may lead to periprosthetic fractures that are associated with significant costs (morbidity, economic, etc.) and pose a challenge to operative fixation. This meta-analysis quantifies the change in bone mineral density (BMD) of the distal femur after primary TKA. METHODS A systematic review of six databases was performed by two independent reviewers. Studies that reported bone density after knee arthroplasty were identified and inclusion/exclusion criteria was applied. Data were extracted and analyzed using the Comprehensive Meta-Analysis Software. RESULTS Fourteen studies were included in the analysis. The average decrease in BMD was 0.09 [0.05, 0.13], 0.14 [0.08, 0.20], 0.16 [0.10, 0.23], and 0.16 [0.12, 0.20] g/cm2 at 3, 6, 12, and 24 months, respectively, corresponding to a 9.3%, 13.2%, 15.8%, and 15.4% BMD loss. A high degree of heterogeneity existed between the studies (I2 > 90% at most time points). CONCLUSION In summary, there is a rapid and significant 15% decrease in BMD in the first 6 months after TKA that is sustained to 24 months. Better understanding regarding how perioperative optimization of bone health may affect BMD loss and the incidence of periprosthetic fracture is essential. LEVEL OF EVIDENCE Therapeutic Level II.
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Affiliation(s)
- Joel M Prince
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI, 53705, USA
| | - James T Bernatz
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI, 53705, USA
| | - Neil Binkley
- University of Wisconsin Osteoporosis Clinical Research Program, Madison, WI, 53705, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 65905-53705, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI, 53705, USA.
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22
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Blaty T, Krueger D, Illgen R, Squire M, Heiderscheit B, Binkley N, Anderson P. DXA evaluation of femoral bone mineral density and cortical width in patients with prior total knee arthroplasty. Osteoporos Int 2019; 30:383-390. [PMID: 30171301 DOI: 10.1007/s00198-018-4682-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
Abstract
UNLABELLED Periprosthetic fractures after total knee arthroplasty (TKA) have devastating consequences. Osteoporosis increases periprosthetic fracture risk, but distal femur bone mineral density (BMD) is not measured post-TKA. This study measured distal femur BMD and cortical width; both were lower in the TKA compared to the non-operated leg. BMD measurement reproducibility was good. Standardized DXA regions of interest are proposed. INTRODUCTION Periprosthetic fractures following total knee arthroplasty (TKA) are not rare. We hypothesized that TKA is associated with low BMD, potentially increasing periprosthetic fracture risk. However, distal femur dual energy x-ray (DXA) measurement is virtually never performed after TKA due to lack of standardized approaches. Thus, this study's aims were to develop standard DXA femur regions of interest (ROIs), assess cortical width, and determine measurement reproducibility in TKA patients. METHODS Thirty adults (15 M/15 F) age 59-80 years with unilateral, primary TKA within 2-5 years had femoral DXA scans performed in duplicate using a Lunar iDXA densitometer. In prior work, we established that femur BMD was lowest in the distal metaphysis and highest in mid-shaft. Thus, BMD and cortical width were measured at 15%, 25%, and 60% of the femur length measured from the distal notch. Femur BMD and cortical width were compared between limbs (TKA vs. non-operated side) by paired t test. RESULTS BMD was 3.2-9.9% lower (p < 0.001) in the operated femur at all custom ROIs; substantial between individual differences existed with some up to 30% lower. Cortical width was lower (p < 0.05) at the 25% ROI on the TKA side. BMD reproducibility was excellent; CV 0.85-1.33%. CONCLUSIONS Distal femur BMD can be reproducibly measured using DXA and is ~ 10% lower on the TKA leg. Similarly, medial and lateral cortices are thinner at the 25% ROI. These bone changes likely increase periprosthetic fracture risk. Further work to define and mitigate periprosthetic fracture risk after TKA is needed.
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Affiliation(s)
- T Blaty
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, 2870 University Ave. Ste. 100, Madison, WI, 53705, USA
| | - D Krueger
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, 2870 University Ave. Ste. 100, Madison, WI, 53705, USA
| | - R Illgen
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - M Squire
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - B Heiderscheit
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - N Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, 2870 University Ave. Ste. 100, Madison, WI, 53705, USA.
| | - P Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Thomas B, Binkley N, Anderson PA, Krueger D. DXA Measured Distal Femur Bone Mineral Density in Patients After Total Knee Arthroplasty: Method Development and Reproducibility. J Clin Densitom 2019; 22:67-73. [PMID: 30228047 DOI: 10.1016/j.jocd.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is increasingly being performed. Distal femur periprosthetic fracture is a potentially catastrophic complication following TKA and existing data document substantial distal femur bone mineral density (BMD) loss following TKA. However, distal femur BMD is virtually never measured clinically as no consensus approach exists. This pilot study's purpose was to define regional BMD variation throughout the femur, suggest standard dual-energy X-ray absorptiometry (DXA) regions of interest (ROIs) and evaluate BMD reproducibility at these ROIs. METHODS Thirty volunteers 2-5 yr post TKA had both entire femurs imaged twice using a Lunar iDXA with subject repositioning between scans; the atypical femur fracture feature of enCORE software was utilized. To define femoral BMD distribution, custom 1 cm ROIs were stacked one atop the other starting at the intercondylar notch and continuing to the base of the lesser trochanter. Femur length was measured with the ruler tool to calculate distance at 5% increments. ROIs encompassing each 5% increment were utilized to measure BMD at each location. Descriptive statistics were used to determine mean BMD at each ROI and reproducibility at the 15%, 25%, 45%, 60%, and 80% ROIs. RESULTS The 5 and 10% ROIs included prosthetic and/or patella, causing high BMD values. Distal femur BMD was lowest at the 15% ROI and was higher (p < 0.05) at each more proximal ROI to 45%, then plateaued from 45% to 75%. BMD reproducibility at these regions was excellent; coefficient of variation (CV) from ∼1% to 3.5%. As periprosthetic fractures generally occur in the distal femur, we propose measuring femur BMD using ROIs placed at 15% and 25%. A 60% region could also be used as a highly cortical site. CONCLUSION Existing DXA capabilities allow distal femur BMD measurement with good reproducibility. Further research using standardized ROIs to assess distal femur BMD loss after TKA, and interventions to mitigate this loss, is indicated.
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Affiliation(s)
- B Thomas
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA;.
| | - N Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA
| | - P A Anderson
- Department of Orthopedic Surgery and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA
| | - D Krueger
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, USA
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Fakler JKM, Pönick C, Edel M, Möbius R, Brand AG, Roth A, Josten C, Zajonz D. A new classification of TKA periprosthetic femur fractures considering the implant type. BMC Musculoskelet Disord 2017; 18:490. [PMID: 29178860 PMCID: PMC5702181 DOI: 10.1186/s12891-017-1855-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 11/16/2017] [Indexed: 12/16/2022] Open
Abstract
Background The treatment aims of periprosthetic fractures (PPF) of the distal femur are a gentle stabilization, an early load-bearing capacity and a rapid postoperative mobilization of the affected patients. For the therapy planning of PPF a standardized classification is necessary which leads to a clear and safe therapy recommendation. Despite different established classifications, there is none that includes the types of prosthesis used in the assessment. For this purpose, the objective of this work is to create a new more extensive fracture and implant-related classification of periprosthetic fractures of the distal femur based on available classifications which allows distinct therapeutic recommendations. Methods In a retrospective analysis all patients who were treated in the University Hospital Leipzig from 2010 to 2016 due to a distal femur fracture with total knee arthroplasty (TKA) were established. To create an implant-associated classification the cases were discussed in a panel of experienced orthopaedists and well-practiced traumatologists with a great knowledge in the field of endoprosthetics and fracture care. In this context, two experienced surgeons classified 55 consecutive fractures according to Su et al., Lewis and Rorabeck and by the new created classification. In this regard, the interobserver reliability was determined for two independent raters in terms of Cohen Kappa. Results On the basis of the most widely recognized classifications of Su et al. as well as Lewis and Rorabeck, we established an implant-dependent classification for PPF of the distal femur. In accordance with the two stated classifications four fracture types were created and defined. Moreover, the four most frequent prosthesis types were integrated. Finally, a new classification with 16 subtypes was generated based on four types of fracture and four types of prosthesis. Considering all cases the presented implant-associated classification (κ = 0.74) showed a considerably higher interobserver reliability compared to the other classifications of Su et al. (κ = 0.39) as well as Lewis and Rorabeck (κ = 0.31). Excluding the cases which were only assessable by the new classification, it still shows a higher interobserver reliability (κ = 0.70) than the other ones (κ = 0.63 or κ = 0.45). Conclusions The new classification system for PPF of the distal femur following TKA considers fracture location and implant type. It is easy to use, shows agood interobserver reliability and allows conclusions to be drawn on treatment recommendations. Moreover, further studies on the evaluation of the classification are necessary and planned.
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Affiliation(s)
- Johannes K M Fakler
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany.
| | - Cathleen Pönick
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany
| | - Melanie Edel
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany.,ZESBO - Center for Research on Musculoskeletal Systems, University of Leipzig, Semmelweisstrasse 14, D-04103, Leipzig, Germany
| | - Robert Möbius
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany.,ZESBO - Center for Research on Musculoskeletal Systems, University of Leipzig, Semmelweisstrasse 14, D-04103, Leipzig, Germany
| | - Alexander Giselher Brand
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany
| | - Andreas Roth
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany.,ZESBO - Center for Research on Musculoskeletal Systems, University of Leipzig, Semmelweisstrasse 14, D-04103, Leipzig, Germany
| | - Dirk Zajonz
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, D-04103, Leipzig, Germany.,ZESBO - Center for Research on Musculoskeletal Systems, University of Leipzig, Semmelweisstrasse 14, D-04103, Leipzig, Germany
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Loures FB, Motta JRW, Albuquerque RSPE, Barretto JM, Cavanellas NT. Bilateral distal femoral fracture after total knee arthroplasty. Rev Bras Ortop 2016; 51:606-609. [PMID: 27818985 PMCID: PMC5091021 DOI: 10.1016/j.rboe.2016.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 10/20/2015] [Indexed: 11/17/2022] Open
Abstract
The number of total knee arthroplasties has increased exponentially and their indications have been expanded. This procedure presents challenging complications for orthopedic surgeons that are potentially catastrophic for patients. Here, a rare case of simultaneous bilateral periprosthetic fracture of the knee is reported, with discussion of the causal factors, possible management and prophylaxis.
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Affiliation(s)
- Fabrício Bolpato Loures
- Instituto Nacional de Traumatologia e Ortopedia (Into), Centro de Cirurgia do Joelho, Rio de Janeiro, RJ, Brazil
| | - Jorge Rafael Wenck Motta
- Instituto Nacional de Traumatologia e Ortopedia (Into), Centro de Cirurgia do Joelho, Rio de Janeiro, RJ, Brazil
| | | | - João Maurício Barretto
- Instituto Nacional de Traumatologia e Ortopedia (Into), Centro de Cirurgia do Joelho, Rio de Janeiro, RJ, Brazil
| | - Naason Trindade Cavanellas
- Instituto Nacional de Traumatologia e Ortopedia (Into), Centro de Cirurgia do Joelho, Rio de Janeiro, RJ, Brazil
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Ishii Y, Noguchi H, Sato J, Takayama S, Toyabe SI. Preoperative Bone Mineral Density and Bone Turnover in Women Before Primary Knee Arthroplasty. Open Orthop J 2016; 10:382-388. [PMID: 28523079 PMCID: PMC5434765 DOI: 10.2174/1874325001610010382] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The preoperative prevalence of osteoporosis and/or osteopenia and overall bone quality in prospective total knee arthroplasty (TKA) patients may affect the postoperative outcome after prosthetic insertion into the bone. The purpose of this study is to determine the baseline bone mineral density (BMD) and bone turnover in preoperative, female, primary TKA patients. METHODS We prospectively measured the lumbar spine and hip BMDs using dual-energy X-ray absorptiometry (DEXA) scans in a cohort of 119 knees (107 patients) one day before surgery. We also assessed bone turnover using urinary levels of N-telopeptide (NTX), a type I collagen crosslinker, normalized to creatinine. RESULTS The prevalence of osteoporosis by DEXA scan (T-score ≤ -2.5) among the TKAs was 12% in the spine and 10% in the hip. Eighty-three knees (70%) had osteopenia or osteoporosis of either the spine or hip. The mean T-score of the spine was -0.7 (SD 1.6), which is within normal limits, and of the hip was -1.2 (SD 1.0), which is defined as osteopenia. The mean Z-scores of 0.9 (SD 1.4) in the spine and 0.6 (SD 0.9) in the hip were positive. The median urinary NTX/creatinine ratio was elevated at 58.1 (interquartile range: 13.7 to 188.4). CONCLUSION Based on Z-scores, the TKA patients had higher spine and hip BMDs than the age-matched general population. Elevated NTX levels may suggest a systemic or local abnormal bone turnover. Further study is needed to determine whether such turnover, as a type of patient-related medical systemic disorder, affects postoperative clinical outcomes.
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Affiliation(s)
- Yoshinori Ishii
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Hideo Noguchi
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Junko Sato
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Satoshi Takayama
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan
| | - Shin-Ichi Toyabe
- Division of Information Science and Biostatistics, Niigata University Graduate School of Medical and Dental Sciences, 1 Asahimachi Dori Niigata, Niigata 951-8520 Japan
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