Diagnostic criteria for primary osteoporosis: year 2012 revision

In 1995, the Japanese Society for Bone and Mineral Metabolism (now the Japanese Society for Bone and Mineral Research) established the Osteoporosis Diagnostic Criteria Review Committee. Following discussion held at the 13th scientific meeting of the Society in 1996, the Committee, with the consensus of its members, proposed diagnostic criteria for primary osteoporosis. The Committee revised those criteria in 1998 and again in 2000. The Japanese Society for Bone and Mineral Research and Japan Osteoporosis Society Joint Review Committee for the Revision of the Diagnostic Criteria for Primary Osteoporosis aimed at obtaining international consistency and made a revised edition based on the new findings in 2012.

Bisphosphonate-related osteonecrosis of the jaw: position paper from the Allied Task Force Committee of Japanese Society for Bone and Mineral Research, Japan Osteoporosis Society, Japanese Society of Periodontology, Japanese Society for Oral and Maxillofacial Radiology, and Japanese Society of Oral and Maxillofacial Surgeons

Bisphosphonates (BPs) have been widely, efficiently, and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers, and multiple myeloma bone diseases. Accumulating recent reports describe that surgical dental treatments in patients with cancer or osteoporosis who have been receiving intravenous or oral BPs are associated with osteonecrosis of the jaw (bisphosphonate-related osteonecrosis of the jaw, BRONJ). The accurate incidence, clinical backgrounds, and pathogenesis of BRONJ have been unclear and appropriate approaches for prevention and treatment have not been established to date. To address the current situation of BRONJ in Japan, the "Allied Task Force Committee of Bisphosphonate-Related Osteonecrosis of the Jaw," consisting of physicians specializing in bone biology, orthopedic surgery, rheumatology, obstetrics/gynecology, and medical oncology and dentists specializing in oral surgery, periodontology, dental radiology, and oral pathology, was organized. The committee attempted to propose a standard position paper for the treatment of BRONJ. The committee expects that this proposal will provide objective and correct scientific information on BRONJ and will serve as a reference for conducting dental procedures for patients receiving BPs and in designing prevention and treatment of BRONJ. However, because this position paper is not based on direct clinical evidence, it should be used as a reference, and a decision on treatment in each case should be made after an extensive discussion among physicians, dentists/oral surgeons, and the patients.

Randomized Teriparatide [human parathyroid hormone (PTH) 1-34] Once-Weekly Efficacy Research (TOWER) trial for examining the reduction in new vertebral fractures in subjects with primary osteoporosis and high fracture risk

CONTEXT

Weekly teriparatide injection at a dose of 56.5 μg has been shown to increase bone mineral density.

OBJECTIVE

A phase 3 study was conducted to determine the efficacy of once-weekly teriparatide injection for reducing the incidence of vertebral fractures in patients with osteoporosis.

DESIGN AND SETTING

In this randomized, multicenter, double-blind, placebo-controlled trial conducted in Japan, the incidence of morphological vertebral fractures by radiographs was assessed.

PATIENTS

Subjects were 578 Japanese patients between the ages of 65 and 95 yr who had prevalent vertebral fracture.

INTERVENTION

Subjects were randomly assigned to receive once-weekly s.c. injections of teriparatide (56.5 μg) or placebo for 72 wk.

MAIN OUTCOME MEASURE

The primary endpoint was the incidence of new vertebral fracture.

RESULTS

Once-weekly injections of teriparatide reduced the risk of new vertebral fracture with a cumulative incidence of 3.1% in the teriparatide group, compared with 14.5% in the placebo group (P < 0.01), and a relative risk of 0.20 (95% confidence interval, 0.09 to 0.45). At 72 wk, teriparatide administration increased bone mineral density by 6.4, 3.0, and 2.3% at the lumbar spine, the total hip, and the femoral neck, respectively, compared with the placebo (P < 0.01). Adverse events (AE) and the dropout rates by AE were more frequently experienced in the teriparatide group, but AE were generally mild and tolerable.

CONCLUSION

Weekly s.c. administration of teriparatide at a dose of 56.5 μg may provide another option of anabolic treatments in patients with osteoporosis at higher fracture risk.

Antiresorptive agent-related osteonecrosis of the jaw: Position Paper 2017 of the Japanese Allied Committee on Osteonecrosis of the Jaw

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) is an intractable, though rare, complication in cancer patients with bone metastases and patients with osteoporosis who are treated with antiresorptive agents, including bisphosphonates and denosumab. Despite the more than 10 years that have passed since the first cases of bisphosphonate-related osteonecrosis of the jaw (BRONJ) were reported, our understanding of the epidemiology and pathophysiology of ARONJ remains limited, and data supported by evidence-based medicine are still sparse. However, the diagnosis and staging of ARONJ, identification of risk factors, and development of preventive and therapeutic approaches have advanced significantly over the past decade. The Position Paper 2017 is an updated version of the Position Paper 2010 of the Japanese Allied Committee on Osteonecrosis of the Jaw, which now comprises six Japanese academic societies. The Position Paper 2017 describes a new diagnostic definition for ARONJ, as proposed by the American Association of Oral and Maxillofacial Surgeons (AAOMS), summarizes our current understanding of the pathophysiology of ARONJ based on a literature search, and suggests methods for physicians and dentists/oral surgeons to manage the disease. In addition, the appropriateness of discontinuing antiresorptive medications (drug holiday) before, during, and after invasive dental treatments is discussed extensively. More importantly, the manuscript also proposes, for the first time, the importance of interactive communication and cooperation between physicians and dentists/oral surgeons for the successful treatment of ARONJ. The Position Paper 2017 is intended to serve as a guide for improving the management of ARONJ patients in Japan.

Dienogest is as effective as intranasal buserelin acetate for the relief of pain symptoms associated with endometriosis--a randomized, double-blind, multicenter, controlled trial

OBJECTIVE

To compare the efficacy and safety of dienogest (DNG) with intranasal buserelin acetate (BA) in patients with endometriosis.

DESIGN

Phase III, randomized, double-blind, multicenter, controlled trial.

SETTING

Twenty-four study centers in Japan.

PATIENT(S)

Two hundred seventy-one patients with endometriosis.

INTERVENTION(S)

Dienogest (2 mg/day, orally) or BA (900 microg/day, intranasally) for 24 weeks.

MAIN OUTCOME MEASURE(S)

The pre- to posttreatment changes in the scores of five subjective symptoms during nonmenstruation (lower abdominal pain, lumbago, defecation pain, dyspareunia, and pain on internal examination) and two objective findings (induration in the pouch of Douglas and limited uterine mobility).

RESULT(S)

Dienogest reduced the scores of all symptoms and findings at the end of treatment, and the mean changes in the scores of all symptoms and findings except induration in the pouch of Douglas were comparable to those obtained with BA. Compared with BA, DNG was associated with irregular genital bleeding more frequently and with fewer hot flushes. The reduction in bone mineral density (BMD) during DNG treatment was significantly lower than that during BA treatment.

CONCLUSION(S)

DNG is as effective as intranasal BA in alleviating endometriosis, and causes less BMD loss.

Changing incidence of hip, distal radius, and proximal humerus fractures in Tottori Prefecture, Japan

A survey of all fractures in patients > or =35 years of age for hip, distal radius, and proximal humerus was performed in Tottori Prefecture, Japan. Hip fracture survey was done for the years 1986-1988, and also 1992-1994. A distal radius and proximal humerus fracture survey was done for the years 1986-1988, 1992, and 1995. The age- and gender-specific incidence rates of these three types of fracture among Japanese were substantially lower than those of whites living in North America or northern Europe. The age-adjusted incidence rates of hip fracture (per 100,000 person-years) were 40.7 and 114.1 in 1986 and 57.1 and 145.2 in 1994 for men and women, respectively, showing a significant increase with time for women. Upon examination of individual fracture types, there was no significant increase in cervical fractures, whereas a significant increase was observed in trochanteric fractures for women. The age-adjusted incidence rates of distal radius fractures for women were 164.9 in 1986 and 211.4 in 1995, showing a significant increase with time; however, no increase was observed among men. Incidence of proximal humerus fractures was 10.3 and 42.0 in 1986 and 17.1 and 47.9 in 1995 for men and women, respectively, and these increases were significant for both genders.

Recent trends in the incidence and lifetime risk of hip fracture in Tottori, Japan

SUMMARY

Hip fracture incidence from 2004 to 2006 in the Tottori prefecture of Japan was investigated and compared with previously reported rates. The age- and gender-specific incidence of hip fracture in the Tottori prefecture has not plateaued, as has been reported for populations in Northern Europe or North America.

INTRODUCTION

Recent data from Northern Europe and North America indicate that the incidence of hip fracture has plateaued, whereas most reports from Asia indicate that the incidence is increasing. The aims of this study were to investigate the recent incidence of hip fracture in the Tottori prefecture, Japan, and to compare it with previous reports.

METHODS

All hip fractures in patients aged 35 years and older occurring between 2004 and 2006 were surveyed in all of the hospitals from the Tottori prefecture. The age- and gender-specific incidence rates were then calculated. Using these and previously reported data, the estimated number of hip fracture patients was determined using the age- and gender-specific incidence rates in each year from 1986 to 2006.

RESULTS

The survey identified 851, 906, and 1,059 patients aged 35 years and older, in 2004, 2005, and 2006 respectively. The residual lifetime risk of hip fracture for individuals at 50 years of age was estimated to be 5.6% for men and 20.0% for women. The estimated number of patients from 1986 to 2006 showed a significant increase over time for both genders.

CONCLUSIONS

The age- and gender-specific incidence of hip fracture in the Tottori prefecture, Japan has not plateaued for either gender.

A new active vitamin D, ED-71, increases bone mass in osteoporotic patients under vitamin D supplementation: a randomized, double-blind, placebo-controlled clinical trial

CONTEXT

ED-71 has been shown to increase lumbar bone mineral density (BMD) in osteoporotic subjects. However, vitamin D insufficiency might have influenced the effect of ED-71 on BMD.

OBJECTIVE

Our objective was to examine whether ED-71 can increase BMD in osteoporotic patients under vitamin D supplementation.

DESIGN, SETTING, AND PATIENTS

We conducted a randomized, double-blind, placebo-controlled clinical trial of 219 osteoporotic patients (49-87 yr of age).

INTERVENTIONS

Subjects were randomly assigned to receive placebo or 0.5, 0.75, or 1.0 microg/d ED-71 for 12 months. All the subjects received 200 or 400 IU/d vitamin D(3).

MAIN OUTCOME MEASURES

We assessed changes in lumbar and hip BMD and bone turnover markers from baseline.

RESULTS

Lumbar BMD increased with ED-71 treatment for 12 months (2.2, 2.6, and 3.1% from baseline and 2.9, 3.4, and 3.8% vs. placebo group in subjects receiving 0.5, 0.75, and 1.0 microg ED-71, respectively). Total hip BMD also increased with 0.75 and 1.0 microg ED-71 (-0.8, 0.6, and 0.9% from baseline and 0.1, 1.5, and 1.8% vs. placebo group in the 0.5, 0.75, and 1.0 microg ED-71 groups, respectively). Bone formation and resorption markers were suppressed by approximately 20% after 12 months of 0.75 and 1.0 microg ED-71 treatment. Transient hypercalcemia over 2.6 mmol/liter occurred in 7, 5, and 23% of subjects in the 0.5, 0.75, and 1.0 microg ED-71 groups, respectively, but none of them developed sustained hypercalcemia.

CONCLUSIONS

These results demonstrate that ED-71 treatment at around 0.75 microg/d can effectively and safely increase lumbar and hip BMD in osteoporotic patients with vitamin D supplementation.

The risk of a second hip fracture in patients after their first hip fracture

We investigated the incidence of additional fractures and the rate of prescription of osteoporotic pharmacotherapy after an initial hip fracture. We surveyed female patients aged 65 and over who sustained their first hip fracture between January 1, 2006, and December 31, 2007, treated at 25 hospitals in five geographic areas in Japan. Data for 1 year after the first hip fracture were collected from medical records, and questionnaires were mailed to all patients. In total, 2,663 patients were enrolled, and 335 patients were excluded based on exclusion criteria. The analysis was performed on 2,328 patients. During the 1-year follow-up period 160 fractures occurred in 153 patients and 77 subsequent hip fractures occurred in 77 patients. The incidence of all additional fractures among patients who sustained their first hip fracture was 70 (per 1,000 person-year) and that for second hip fracture was 34. In comparison to the general population, women ≥65 years of age who sustained an initial hip fracture were four times as likely to sustain an additional hip fracture. Antiosteoporosis pharmacotherapy was prescribed for 436 patients (18.7%), while 1,240 patients (53.3%) did not receive any treatment during the 1-year period. Patients who have sustained one hip fracture have a higher risk of a second hip fracture compared to the general population, and most of these women receive no pharmaceutical treatment for osteoporosis.

Guidelines for the use of bone metabolic markers in the diagnosis and treatment of osteoporosis (2012 edition)

Recently the clinical application of bone metabolic markers has achieved significant progress and the measurements of these indices give us a better understanding of the pathogenesis of osteoporosis. Bone metabolic markers were adapted to select drug treatment for osteoporosis and to evaluate drug efficacy. Therefore, the proper application and assessment of bone metabolic markers in clinical practice is very important. To achieve these aims, the committee on the guidelines for the use of biochemical markers of bone turnover in osteoporosis authorized by the Japan Osteoporosis Society has summarized recent progress in bone markers and proposed the proper utilization of bone markers. Although the use of bone metabolic markers now has an important role in the daily management of osteoporosis, their use in Japan is still insufficient because of insurance coverage limitations. Since the Japan Osteoporosis Society first created the 2001 guidelines, new bone metabolic markers have been introduced into clinical practice. The availability of new osteoporosis treatments that promote bone formation has changed the clinical application of bone metabolic markers in current practice. Therefore, revisions to the current clinical practice are needed which led to the proposal to create these new 2012 guidelines.

Role of subchondral bone in osteoarthritis development: a comparative study of two strains of guinea pigs with and without spontaneously occurring osteoarthritis

OBJECTIVE

To evaluate the relationships among cartilage and subchondral bone before and after the onset of cartilage degeneration in the Hartley guinea pig model of spontaneous osteoarthritis (OA) as compared with those in Weiser-Maple guinea pigs, which do not develop OA.

METHODS

Mice from each strain were used at ages 2, 3, 5, and 8 months (n = 7 at each time point). The region observed was the medial tibial plateau. Cartilage degeneration was evaluated histologically. Subchondral bone structure was evaluated based on subchondral bone plate thickness and subchondral cancellous bone trabecular parameters calculated from the microfocal computed tomography 3-dimensional reconstruction image. The bone mineral density (BMD) of the subchondral cancellous bone as well as levels of urinary N-telopeptide of type I collagen (NTX) and serum osteocalcin (OC) were measured.

RESULTS

In Hartley guinea pigs, the number of chondrocytes in the surface layer started to decrease at 3 months. At 8 months, fibrillation expanded to the radial zone. In Weiser-Maple guinea pigs, no cartilage degeneration was noted even at 8 months. Subchondral bone plate thickness was significantly lower in Hartley guinea pigs than in Weiser-Maple guinea pigs at 2 months. The subchondral bone had a rod-like and convex structure at 2 months in Hartley guinea pigs. BMD was significantly lower in Hartley guinea pigs than in Weiser-Maple guinea pigs at 2 months. The serum OC level was significantly higher in Hartley guinea pigs than in Weiser-Maple guinea pigs at 2 months and 3 months, whereas the urinary NTX level was significantly lower in Hartley guinea pigs at 3 months.

CONCLUSION

Subchondral bone is fragile, and bone formation may be promoted in subchondral bone before the onset of cartilage degeneration in Hartley guinea pigs. Subchondral bone may be involved in the development of OA.

Survey of hip fractures in Japan: Recent trends in prevalence and treatment

BACKGROUND

A nationwide survey of hip fractures by the Japanese Orthopaedic Association (JOA) from 1998 to 2008 found a drastic increase in incidence. The aims of this study were to elucidate the status of hip fractures from 2009 to 2014 and to survey the causes for delayed surgery.

METHODS

A tally of all hip fractures that occurred in patients from 2009 to 2014 was conducted in hospitals authorized by the JOA or in clinics with inpatient facilities of the Japanese Clinical Orthopaedic Association (JCOA). A survey of the causes for delay in surgery was conducted at 849 sites and 526 sites participated.

RESULTS

A total of 488,759 hip fractures were registered. Increases in incidence from 2009 to 2014 were prominent in the 90-94-year-old age group among women and the 85-89-year-old age group among men. More trochanteric fractures than neck fractures occurred; however, the neck/trochanter ratio increased over time. The mean duration of preoperative hospital stay was 4.8 and 4.5 days, and the mean duration of hospitalization was 40.5 and 36.8 days in 2009 and 2014, respectively. There were significant differences between patients who waited for surgery up to 3 days and those who waited longer than 3 days in date of hospitalization, fracture type, comorbidities, anticoagulant use, surgical procedure, type of physician who administered anesthesia, type of anesthesia, and operating room schedule. Physicians in charge of each patient who waited for surgery for more than 3 days most frequently cited difficulties in securing operating rooms as the cause for delayed surgery.

CONCLUSION

A drastic increase occurred in the number of patients with hip fractures with time in Japan. One problem in the treatment of hip fractures is the long waiting time from hospitalization to surgery resulting from difficulties in securing operating rooms.

Trifocal distraction osteogenesis for segmental mandibular defect: a technical innovation

Distraction osteogenesis in the mandible is a promising method, not only for correction of mandibular hypoplasia such as hemifacial microsomia, but also for reconstruction of segmental bone defects in the mandible. The authors report a case in which a mandibular segmental defect, about 60 mm in length, was reconstructed by distraction osteogenesis. The patient was a 45-year-old man who had been treated for an oral floor cancer. After preoperative chemotherapy and irradiation therapy, the mandible had been resected from the second incisor on the right side to the first molar on the left side, and had been reconstructed with a titanium plate and a vascularized rectus-abdominis compound flap. However, an infection developed around the titanium plate and this plate had to be removed. Therefore, trifocal distraction using an original three-dimensional distractor was performed, at the rate of 1 mm per day (0.5 mm in the morning and 0.5 mm in the evening). During the distraction period, the skin flap was pushed out from the bone defect. Although small free bone transplants were needed for complete continuity, the segmental bone defect was almost filled by the regenerated bone with the lengthened gingiva. Radiographic observation showed successful new bone formation in the lengthened area.

Increasing incidence of hip fracture in Tottori Prefecture, Japan: trend from 1986 to 2001

We conducted a survey of all hip fractures in patients 35 years old and over during 1998-2001 in Tottori Prefecture, Japan, and compared them with those reported previously. The survey found 604, 671, 710, 729 patients, in 1998, 1999, 2000, and 2001, respectively. The mean age- and gender-specific incidences (per 100,000 person-years) for men were 108.0, 209.0, 449.1, and 780.0 in the age groups of 70-74, 75-79, 80-84 and over 84, respectively, and those for women were 249.1, 505.8, 1,115.4, and 2,066.4, respectively. The expected numbers of patients in 1998 were 1.23 and 1.42 times those in 1986, and those in 2001 were 1.61 and 1.48 times those in 1986, for men and women, respectively, and the increases with time for both genders were significant. It was concluded that there was a significant increase in the incidence rates of hip fracture from 1986 to 2001.

Incidence and risk factors of falling in ambulatory patients with rheumatoid arthritis: a prospective 1-year study

A prospective 1-year study showed that fall incidence was 50% in women with rheumatoid arthritis. Multivariate analysis identified swollen joint count, use of antihypertensives or diuretics, one-leg standing time, and sway area measured by stabilometer as significant parameters associated with falls.

INTRODUCTION

Patients with rheumatoid arthritis (RA) may be at increased risk of falling because they frequently experience muscle weakness and stiff or painful joints. The aim of this study was to use a prospective design to determine the incidence of falls and their risk factors in women with RA.

METHODS

Eighty-four women aged 50 and over who had RA were enrolled. The mean age was 64.1 years. We evaluated postural stability, physical performance related to falls, disease activity, muscle volume, and bone density. The occurrence of falls was assessed every month for 1 year. Among 84 patients, 80 completed a 1-year observation.

RESULTS

Forty patients (50.0%) reported one or more falls, and two of them (5.0%) had fractures during the follow-up period. The fall group had more swollen joints and took more antihypertensives and/or diuretics. The fall group also had lower postural stability and tended to have reduced physical performance. The one-leg standing time was shorter, and the step-up-and-down test score was lower in the fall group. The sway area was larger in the fall group.

DISCUSSION

Multiple logistic regression analysis identified that number of swollen joints, use of antihypertensives or diuretics, shorter time standing on one foot, and the sway area were the most significant parameters associated with falls.

CONCLUSION

We concluded that fall rates in RA patients were higher than in the general population and that balance impairment or side effects of drugs may play a role in increasing the risk of falls.

Sequential change in quality of life for patients with incident clinical fractures: a prospective study

Health-related quality of life in elderly women with sustained incident fractures was assessed prospectively for 1 year, using the EuroQol standard. Loss of QOL was more severe in patients after hip or vertebral fractures than those with wrist fracture. QOL was not completely restored in patients suffering from hip fracture.

INTRODUCTION

Osteoporosis-related fractures decrease mobility, social interaction, and emotional well-being. All of these characteristics determine health-related quality of life (HR-QOL). In this study, we assessed HR-QOL in elderly women following incident clinical fractures.

METHODS

Thirty-seven patients with hip fractures (mean age 76.1 years), 35 with vertebral fractures (mean age 72.6 years), and 50 with wrist fractures (mean age 68.6 years) were enrolled. HR-QOL was prospectively measured using EuroQol (EQ-5D) before the fracture, 2 weeks, 3 months, 6 months, and 1 year after the fracture.

RESULTS

During the observation period, reduction of EQ-5D values was greatest in the hip fracture group. In the wrist fracture group, EQ-5D values at 6 months after the fracture showed recovery; however, in the hip and vertebral fracture groups, recovery was significantly lower than before the fracture. One year after the fracture, EQ-5D values were not significantly different from prefracture values in the vertebral and wrist fracture groups, but remained significantly lower in the hip fracture group.

CONCLUSIONS

Loss of QOL was more severe in patients after hip or vertebral fractures than in patients with wrist fracture. HR-QOL was not completely restored in patients suffering from hip fracture.

Effect of daily oral minodronate on vertebral fractures in Japanese postmenopausal women with established osteoporosis: a randomized placebo-controlled double-blind study

SUMMARY; A randomized placebo-controlled trial was conducted to examine the effect of daily oral 1 mg minodronate on vertebral fractures in 704 postmenopausal women with established osteoporosis for 24 months. Minodronate treatment reduced vertebral fractures by 59% without serious adverse events. Minodronate is a safe and effective bisphosphonate for osteoporosis treatment.

INTRODUCTION

Minodronate increases bone mineral density (BMD) in postmenopausal osteoporotic patients. However, its efficacy in reducing osteoporotic fractures has not been tested.

METHODS

To examine anti-fracture efficacy and safety of daily oral minodronate in postmenopausal women with established osteoporosis, a randomized, double-blind, placebo-controlled trial was conducted in 704 postmenopausal women (55 to 80 years) with one to five vertebral fractures and low BMD. Subjects were randomly assigned to receive daily oral 1 mg minodronate (n = 359) or placebo (n = 345) for 24 months, with daily supplements of 600 mg calcium and 200 IU vitamin D(3).

RESULTS

Daily 1 mg minodronate for 24 months reduced the risk of vertebral fractures by 59% (95% CI, 36.6-73.3%). Furthermore, when fractures during the first 6 months were eliminated, the risk of vertebral fractures from 6 to 24 months was reduced by 74% in minodronate-treated group. Minodronate treatment also reduced height loss. Bone turnover markers were suppressed by about 50% after 6 months of minodronate treatment and remained suppressed thereafter. The overall safety profile including gastrointestinal safety was similar between the two groups.

CONCLUSIONS

Daily oral minodronate is safe, well-tolerated, and is effective in reducing vertebral fracture risk in postmenopausal women with established osteoporosis.

Cross-sectional and longitudinal study of osteoporosis in patients with rheumatoid arthritis

To elucidate the pathology of osteoporosis associated with rheumatoid arthritis (RA), bone mass measurements were performed in 146 female patients with RA and compared with those in 150 age-matched female patients with osteoarthritis (OA) and postmenopausal osteoporosis (OP). Bone mineral density (BMD) was measured at the lumbar spine (L-BMD), the mid-radius (MR-BMD) and the calcaneus (C-BMD) by dual-energy X-ray absorptiometry (DXA), and at the distal radius by peripheral quantitative computed tomography (pQCT). The RA group showed significantly lower BMD at all sites, except L-BMD, than the OA group. Compared with the OP group, the RA group showed a significantly higher L-BMD but no difference at other sites. BMD in RA decreased with disease severity at all sites and lean body mass was highly correlated with L-BMD and C-BMD. Cross-sectional analysis revealed early bone loss at the distal radius and a decrease of L-BMD, MR-BMD, and C-BMD with disease duration. Longitudinal analysis showed that the annual loss of L-BMD, MR-BMD and C-BMD tended to be lower with increasing disease duration. Glucocorticoid administration had no influence on L-BMD, MR-BMD or C-BMD. We concluded that, unlike postmenopausal osteoporosis, osteoporosis associated with RA is characterised by relatively preserved bone mass in the axial bone and marked loss in the peripheral bone. The risk factors for generalised osteoporosis are a long disease duration, severity of disease, and decreased lean body mass.

Fall incidence and risk factors in patients after total knee arthroplasty

PURPOSE

To prospectively investigate the relationship between physical function and falls among elderly patients who underwent total knee arthroplasty (TKA) and to determine the incidence of falls as well as their risk factors.

METHODS

A total of 108 patients (17 male, 91 female) over 60 years of age who underwent TKA were enrolled and who were living independently in community. 75 patients fulfilled our inclusion criteria and 74 (8 male, 66 female) of them agreed to participate. Baseline assessment (physical examination, physical performance tests, and self-administered questionnaire) were conducted between 6 and 12 months after the last arthroplasty and the follow-up assessment was performed 6 months after the baseline assessment. Monthly pre-stamped postcards were sent to assess the incidence of falls.

RESULTS

Of the 74 patients enrolled, 70 (94.6%) completed a 6-month prospective observation. 23 of 70 patients (32.9%) fell during the observational period. Postoperative range of knee flexion, ranges of knee flexion and extension and ankle plantar flexion were significantly lower in fallers than in non-fallers (P = 0.016, P = 0.037, P = 0.014, respectively). In the multivariate analysis, postoperative range of knee flexion (OR 0.277, 95%CI 0.088-0.869, P = 0.028) and ankle plantar flexion (OR 0.594, 95%CI 0.374-0.945, P = 0.028) were determined to be significant risk factors.

CONCLUSION

Elderly people who underwent TKA are considered more likely to fall compared with healthy elderly people. For patients with limited knee flexion and ankle plantar flexion, improvement of ROM by exercise therapy and patient education regarding the prevention of falls and fractures are considered necessary.

Effects of unipedal standing balance exercise on the prevention of falls and hip fracture among clinically defined high-risk elderly individuals: a randomized controlled trial

BACKGROUND

The aim of this study was to assess the effectiveness of the unipedal standing balance exercise for 1 min to prevent falls and hip fractures in high-risk elderly individuals with a randomized controlled trial. This control study was designed as a 6-month intervention trial.

SUBJECTS

Subjects included 553 clinically defined high-risk adults who were living in residences or in the community. They were randomized to an exercise group and a control group.

METHODS

Randomization to the subjects was performed by a table of random numbers. A unipedal standing balance exercise with open eyes was performed by standing on each leg for 1 min three times per day. As a rule, subjects of the exercise group stood on one leg without holding onto any support, but unstable subjects were permitted to hold onto a bar during the exercise time. Falls and hip fractures were reported by nurses, physical therapists, or facility staff with a survey sheet every month. This survey sheet was required every month for both groups.

RESULTS

Registered subjects were 553 persons ranging in age from 37 to 102 years (average, 81.6 years of age). Twenty-six subjects dropped out. The number of falls and hip fractures for the 6-month period after the trial for 527 of the 553 subjects for whom related data were available were assessed. The exercise group comprised 315 subjects and the control group included 212 subjects. The cumulative number of falls of the exercise group, with 1 multiple faller omitted, was 118, and the control group recorded 121 falls. A significant intergroup difference was observed. However, the cumulative number of hip fractures was only 1 case in both groups. This difference was not statistically significant.

CONCLUSIONS

The unipedal standing balance exercise is effective to prevent falls but was not shown to be statistically significant in the prevention of hip fracture in this study.

Report on the Japanese Orthopaedic Association's 3-year project observing hip fractures at fixed-point hospitals

BACKGROUND

The aim of this study was to assess the disability and mortality of hip fractures 1 year after initial visit (postoperatively) at fixed-point hospitals selected by the Japanese Orthopaedic Association Committee on Osteoporosis.

METHOD

A total of 158 core orthopedic hospitals were selected for participation in this research. Subjects were all aged 65 years and older with hip fractures at the selected hospitals between January 1, 1999 and December 31, 2001. A prognostic survey of activities of daily living (ADL), assessed by the long-term care insurance criteria established by the Ministry of Health, Labour, and Welfare of Japan was performed 1 year after the initial visit.

RESULTS

A total of 1992 hip fractures in patients aged 65 to 111 years were treated over the 3 years from 1999 to 2001. Among the 1992 patients, 4537 had femoral neck fractures and 6217 had trochanteric fractures. Surgical treatment was chosen for 85.6% of the femoral neck fractures and 88.2% of the trochanteric fractures. The mean duration from fracture to admission was 3.1 days, and the mean duration from admission to surgery was 11.2 days. The mean duration from surgery to discharge over the 3-year period was 49.8 days. Before hip fracture, the ratio of patients with J1 ("able to go out freely utilizing public transportation") or J2 ("able to visit immediate neighbors independently") on the long-term care insurance criteria was 50.9%. At 1 year after the initial visit, that result represented a decrease of 24.1 percentage points before hip fracture. A total of 70 patients died before undergoing surgery. In the present study, the 1-year mortality rate for the entire patient population over the 3-year period was 10.1%.

CONCLUSIONS

Hip fracture patients show a decrease in the ADL score 1 year after the initial visit. Compared to other countries, the duration of hospitalization is longer in Japan, but the mortality rate is lower.

Epidemiology of fragility fractures in Sakaiminato, Japan: incidence, secular trends, and prognosis

We investigated the incidence of fragility fractures from 2010 to 2012 in Sakaiminato, Japan. The incidence rates of limb fractures in Sakaiminato were lower than in Caucasian populations but had increased relative to data obtained in Japan in the 1990s. Clinical vertebral fractures occurred at higher rates in Sakaiminato than in Caucasian populations.

INTRODUCTION

To elucidate the incidence and prognosis of fragility fractures in Sakaiminato, Japan.

METHODS

A survey of all hip, distal radius, proximal humerus, and clinical vertebral fractures was performed from 2010 to 2012 in patients aged 50 or older in Sakaiminato city, Tottori prefecture, Japan. The age- and gender-specific incidence rates (per 100,000 person-years) were calculated based on the population of Sakaiminato city each year. The incidence rates of hip, distal radius, and proximal humerus fractures were compared with previous reports. We conducted a follow-up study assessing patients within 1 year following their initial treatment at two Sakaiminato hospitals.

RESULTS

The age-adjusted incidence rates in population aged 50 years or older (per 100,000 person-years) of hip, distal radius, proximal humerus, and clinical vertebral fractures were, respectively, 217, 82, 26, and 412 in males and 567, 432, 96, and 1229 in females. Age-specific incidence rates of hip, distal radius, and proximal humerus fractures all increased since the 1990s. Our study also revealed that anti-osteoporotic pharmacotherapy was prescribed 1 year post-fracture at rates of 29, 20, 30, and 50 % for patients with hip, distal radius, proximal humerus, and clinical vertebral fractures, respectively.

CONCLUSIONS

The incidence rates of limb fractures in Sakaiminato were substantially lower than Caucasian populations in northern Europe but had increased relative to data obtained in Japan in the 1990s. Unlike upper and lower limb fractures, clinical vertebral fractures occurred at higher rates in our study population than in other Asian and North European countries.

Effect of ovariectomy on bone response to in vivo external loading

This study was undertaken to find whether the bone response to increased external loading (EL) of the tibia in rats is affected by estrogen depletion. Female Sprague-Dawley rats 6 months were randomly assigned to four groups of 10 each: sham ovariectomy without loading (Shm-XL), ovariectomy without loading (OVX-XL), sham ovariectomy with external loading (Shm-EL), and ovariectomy with external loading (OVX-EL). In vivo external loading by a four-point bending device was initiated 4 weeks after surgery. The right lower leg of each EL rat was loaded at 31.4 +/- 0.2 N for 36 cycles at 2 Hz every other day for 21 days (11 loading days). Mean in vivo induced strain was 1305 microstrain (mu epsilon) for Shm-EL rats and 1280 mu epsilon for OVX-EL rats. With external loading of the tibia, periosteal bone formation rose equally in Shm and OVX rats. Woven bone was present around the tibia or fibula in 60% of the loaded rats and none of the control rats. No loading response occurred either at the endocortical surface or in the cancellous bone of the proximal tibial metaphysis. After OVX, cancellous bone area in the proximal metaphysis declined and formation surface rose compared to Shm rats. Although periosteal and endocortical bone formation rose after OVX, no cortical bone loss occurred. We conclude that ovariectomy and attendant loss of endogenous estrogen do not change the cortical bone response to an external load of about 1300 mu epsilon in rats. However, these results may not predict the cortical bone response to loading in animals with Haversian remodeling that display estrogen-related loss of cortical bone.

Efficacy and safety of once-yearly zoledronic acid in Japanese patients with primary osteoporosis: two-year results from a randomized placebo-controlled double-blind study (ZOledroNate treatment in Efficacy to osteoporosis; ZONE study)

In a 2-year randomized, placebo-controlled study of 665 Japanese patients with primary osteoporosis, once-yearly administration of zoledronic acid (5 mg) reduced the risk of new morphometric vertebral fractures.

INTRODUCTION

The purpose of this study was to determine the efficacy and safety of once-yearly intravenous infusion of ZOL in Japanese patients with primary osteoporosis.

METHODS

This was a two-year multicenter, randomized, placebo-controlled, double-blind, parallel-group comparative study (ZONE Study). Subjects were 665 Japanese patients between the ages of 65 and 89 years who had prevalent vertebral fracture. Subjects were randomly assigned to receive once-yearly intravenous infusion of 5 mg of ZOL or placebo at baseline and 12 months.

RESULTS

The 2-year incidence of new morphometric vertebral fracture was 3.0 % (10/330 subjects) in the ZOL group and 8.9 % (29/327) in the placebo group (p = 0.0016). The 24-month cumulative incidence of new morphometric vertebral fracture was 3.3 % in the ZOL group versus 9.7 % in the placebo group (log-rank test: p = 0.0029; hazard ratio: 0.35; 95 % confidence interval: 0.17-0.72). The cumulative incidence of any clinical fracture, clinical vertebral fracture, and non-vertebral fracture was significantly reduced in the ZOL group by 54, 70, and 45 %, respectively, compared to the placebo group. At 24 months, ZOL administration increased bone mineral density in the lumbar spine, femoral neck, and total hip (t test: p < 0.0001). No new adverse events or osteonecrosis of the jaw were observed in this study.

CONCLUSIONS

Once-yearly administration of ZOL 5 mg to Japanese patients with primary osteoporosis reduced the risk of new morphometric vertebral fractures and was found to be safe.