Is Regional Bone Mineral Density the Differentiating Factor Between Femoral Neck and Femoral Trochanteric Fractures?

Background Osteoporosis is globally recognized as a prevalent bone disease, and proximal femoral fractures constitute a serious complication associated with it. In recent years, the frequency of hip fractures has increased rapidly, with ramifications that extend into the social and economic aspects of both patients' lives and healthcare systems. The primary goal of this study is to discover whether bone mineral density (BMD) in specific regions of the hip could be related to femoral neck or trochanteric fractures. Methodology This prospective cohort study employed dual-energy X-ray absorptiometry (DEXA) measurements on 70 individuals with proximal femoral fractures. The participants sought treatment at the emergency department of our unit for hip fractures and adhered to our predefined eligibility criteria. These criteria primarily included (i) age exceeding 60 years and (ii) a diagnosis of either femoral neck or trochanteric fracture attributed to (iii) a low-energy lateral fall and (iv) a previously established state of complete ambulation before the occurrence of the fracture. In this context, we recorded the BMD of the hip, as well as the BMD values of the upper and lower halves of the neck, trochanteric region, and diaphysis. For the comparison of the categorical variables, Pearson's χ2 criterion was used, whereas Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results No statistical differences were identified when comparing regional BMDs and T-scores with the fracture type. This conclusion was also reconfirmed concerning age, gender, and Tonnis classification. Only a moderate correlation was observed, demonstrating lower values of regional BMDs in women compared to men. Conclusions The inability of our study to establish a direct correlation between BMD measurements across diverse areas of the proximal femur underlines the imperative need for subsequent investigations. These studies should not only integrate more precise techniques for measuring and mapping the BMD of different hip regions but should also encompass a comprehensive examination that would consider both intrinsic and extrinsic characteristics of the proximal femur.

The lower Osteotomy Level is Associated With Decreased Revision Surgery Due to Mechanical Complications After Three-Column Osteotomy in Patients With Adult Spinal Deformity: A Multi-Institutional Retrospective Study

STUDY DESIGN

A multi-institutional retrospective study.

OBJECTIVES

To investigate risk factors of mechanical failure in three-column osteotomy (3COs) in patients with adult spinal deformity (ASD), focusing on the osteotomy level.

METHODS

We retrospectively reviewed 111 patients with ASD who underwent 3COs with at least 2 years of follow-up. Radiographic parameters, clinical data on early and late postoperative complications were collected. Surgical outcomes were compared between the low-level osteotomy group and the high-level osteotomy group: osteotomy level of L3 or lower group (LO group, n = 60) and osteotomy of L2 or higher group (HO group, n = 51).

RESULTS

Of the 111 patients, 25 needed revision surgery for mechanical complication (mechanical failure). A lower t-score (odds ratio [OR] .39 P = .002) and being in the HO group (OR 4.54, P = .03) were independently associated with mechanical failure. In the analysis divided by the osteotomy level (LO and HO), no difference in early complications or neurological complications was found between the two groups. The rates of overall mechanical complications, rod failure, and mechanical failure were significantly higher in the HO group than in the LO group. After propensity score matching, mechanical complications and failures were still significantly more observed in the HO group than in the LO group (P = .01 and .029, respectively).

CONCLUSIONS

A lower t-score and osteotomy of L2 or higher were associated with increased risks of mechanical failure. Lower osteotomy was associated with better correction of sagittal balance and a lower rate of mechanical complications.

Impact of Osteoporosis in Postmenopausal Women With Primary Knee Osteoarthritis

BACKGROUND

Although knee osteoarthritis (OA) and osteoporosis (OP) are common age-related bone disorders, the association between the two conditions remains indefinable. The aim of the present study is to investigate a possible relationship between the two conditions in post-menopausal women.

METHODOLOGY

A cross-sectional study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia, after obtaining IRB approval. The study included all post-menopausal female patients above 50 years of age, who underwent dual-energy X-ray absorptiometry (DXA) scans between January 2019 and July 2021 and have clear radiological data regarding knee OA. For our study, 487 ladies satisfied our inclusion criteria with an age range of 50-94 years (mean 64.67 ±8.4). The severity of knee OA was determined according to the Kellgren and Lawrence (KL) grading system.

RESULTS

The mean age and weight of all patients showed a significant association with knee OA. There was no significant association between bone quality and all parameters of bone mineral density (BMD) and T-score with the presence of knee OA. The mean age, height, weight, and BMI have a significant relationship with OP. Grade 3 of the KL classification system for knee OA is the only grade that showed a significant relationship with the presence of OP. The status of bone quality, BMD, and T-score parameters have no significant relationship with the severity subgrouping of knee OA. The BMD and the T-score of the right femoral neck have a significant correlation with BMI, which is linked to the presence of knee OA.

CONCLUSION

We didn't find a clear relationship between OP or BMD and the presence of knee OA. However, our findings demonstrated that BMD, T-score of the right femoral neck, and BMI can all be utilized as predictors for the development and progression of knee OA. We recommend considering the many potential confounding variations when describing a relationship between OP and OA.

Does Zoledronic Acid Provide a Good Clinical Outcome in Patients With Chronic Back Pain Associated With Vertebral Osteoporosis?

Background Osteoporosis is a chronic, progressive, systemic condition of the skeletal tissue that is characterized by reduced bone density, microarchitecture deterioration, and fragile bones, making osteoporotic fractures or fragility fractures more likely to occur. This condition often remains asymptomatic and undiagnosed until it presents with fragility fractures. The condition is associated with a significant socioeconomic burden with disability, morbidity, and mortality. Therefore, early diagnosis, as well as treatment, is needed to prevent fractures. Intravenous zoledronic is an effective bisphosphonate with high patient compliance due to once-yearly dosing. The present study aims to determine whether zoledronic acid effectively treats chronic back pain in people with osteoporosis. Materials and methods Seventy patients above the age of 60 years presented with complaints of chronic low back aches to the outpatient department of orthopedics, R L Jalappa Hospital & Research Centre attached to Sri Devaraj Urs Medical College. The study was conducted between November 2016 and November 2018. Results All the patients found excellent clinical improvement following zoledronic acid infusion in early and long-term follow-ups. Additionally, it was found that zoledronic acid's effectiveness was excellent, with significant improvement in bone mineral density (BMD), T-score, and Z-score. Conclusion Early diagnosis and treatment of vertebral osteoporosis is the most important factor in preventing fragility fractures. Zoledronic acid, an antiresorptive drug with better compliance, is very effective in controlling low back pain, improving bone mineral density, and preventing the occurrence of atraumatic fragility fractures. With all the above factors, zoledronic acid is a preferable bisphosphonate for the treatment and prevention of osteoporosis compared to other modalities of treatment of osteoporosis.

Osteoporosis: A Step-by-Step Case-Based Study

Osteoporosis is a common disease that affects our elderly population. This disease usually gets undiagnosed for an extended period. Osteoporosis increases the risk of fracture in our elderly population and increases morbidity. The cost associated with osteoporosis does carry a substantial burden in our society. Here, we present a case of osteoporosis with a fracture diagnosed in clinical settings. We discuss different etiology, pathophysiology, and treatment options available to treat this medical condition.

The Influence of DXA Hardware, Software, Reference Population and Software Analysis Settings on the Bone Mineral Density and T-Score Relationship

Different dual-energy x-ray absorptiometry (DXA) hardware can affect bone mineral density (BMD) measurements and different reference populations can affect t-scores. Long-term analyses describing differences in the relationship between BMD and t-scores are lacking. BMD-values were plotted against t-scores for 241 Lunar DXA scans on females obtained over 18 years from several centers in Sweden and Norway. The result of the plot was compared to hardware/software versions, reference populations and different software analysis settings (Basic vs Enhanced analysis for total body and Single Photon Absorptiometry (SPA) vs Lunar calibration for forearm). For the forearm compartments, we found different BMD-t-score relationships depending on the use of SPA or Lunar calibration (p<0.001). With Lunar calibration, BMD-values were 24% higher, but there was no effect on t-scores. Total body measurements with iDXA scanners and Enhanced analysis for Prodigy scanners (software version 14.10) resulted in a different BMD-t-score relationship compared to the other hardware/software versions (p<0.001), with the largest discrepancy for lower BMD-values. Switching from Basic to Enhanced analysis generally decreased BMD-values and often changed t-scores (both increased and decreased). For the femoral neck, there were two different BMD-t-score relationships caused by different reference populations (p<0.001). In contrast to total body, the difference for femoral neck was more pronounced for higher values, with little impact in the clinical decision-making area. Hardware, software, reference populations and software analysis settings can affect the BMD-t-score relationship, but do so differently for different compartments. The BMD-t-score-plot is a simple and effective tool to discover systematic differences. Longitudinal analyses of DXA scans should be performed based on raw data analyzed in "one run" with the same software version and settings, in order to avoid systematic differences.

Dual-Energy X-Ray Absorptiometry (DEXA) Scan Versus Computed Tomography for Bone Density Assessment

Rationale and objective Osteoporosis, a common non-pathological disease of bones, has been the cause of many disastrous consequences, in terms of physical, psychological, social, and economic loss. Therefore, it is crucial to diagnose it early for timely prevention and treatment of osteoporotic fractures. Dual-Energy X-Ray Absorptiometry (DEXA) is currently routinely used for determining bone mineral density. However, it has its limitations. Nowadays, CT technology has advanced so rapidly that the Hounsfield units (HU) values can be used in opportunistic screening for osteoporosis in patients during routine CT abdomen for other causes. Hence, there would be no need for additional study with DEXA and also reduce radiation exposure. The aim of our research is to determine whether there is a correlation between the bone mineral density and the T-score measured by DEXA and the HU values measured from the diagnostic CT images of L1-4 vertebrae. Also, to determine reference CT values that would help in screening the patients with osteoporosis. Materials and methods We conducted a retrospective study of 78 female patients who underwent CT lumbar spine, abdomen, and pelvis in our hospital between the years 2016-2020. We collected data of patients who performed DEXA and CT scans within an interval of up to two years. The final collected data was analyzed to find correlation values of HU with age group and with DEXA bone mineral density (BMD) and T-score using Pearson correlation coefficient. Results The mean of the 78 patients was 61.1 (range 37-88 years). Mean HU values decreased consistently with age, from 202.17 HU in the fifth decade to 71 HU in the ninth decade. Average L1-4 HU values ranged from 71 HU to 202.17 HU (mean with standard deviation), while their T-score ranged from -4.4 to +2.4 (mean was -1.7±1.41), and their BMD ranged from 0.62 to 1.465 g/cm2 (mean, 0.974±0.175 g/cm2). For each lumbar vertebra, the correlations of HU values with bone mineral density and T-score were calculated separately. For L1-4 vertebrae, the correlation coefficients (r2) for the HU value and T-score were 0.544, 0.600, 0.611, and 0.600, respectively. The correlation coefficients (r2) for the HU value and bone mineral density were 0.581, 0.623, 0.653,0.612, respectively. All the calculated correlations were significant (p<0.001). Therefore, it was concluded that there was a positive correlation between the HU values and the DEXA for the BMD and between the HU values and the T-score. Based on the WHO guidelines, the T-scores of the lumbar vertebrae were classified into three groups. The mean HU values for the subjects in the normal group were 174.05 (95% confidence interval, 153-194.49), in the osteopenia group were 120.45 HU (95% confidence interval, 106.98-133.91), and in the osteoporosis group were 115 HU (95% confidence interval, 104.60-125.40). The differences in the mean HU values between the groups were significant. Conclusion On analyzing the results of our study, we reached the conclusion that there is a positive correlation between the HU calculated from CT with automated exposure control and BMD calculated from the DEXA. Thus CT scans done for various reasons, for example, the abdomen, lumbar spine, etc. can provide us with information about the patient's bone density as well. CT is a very popular, easily accessible, reproducible, and reliable tool for measuring HU values and thereby in the opportunistic screening of osteoporosis.

Osteoporosis diagnosis in men: the T-score controversy revisited

Osteoporosis becomes common with aging in both sexes, but is often ignored in men. The 2013 International Society for Clinical Densitometry consensus conference endorsed a Caucasian female referent database for T-score calculation in men. This recommendation has generated controversy and concern. Accumulating data indicate that at the same DXA-measured body mineral density (BMD) (g/cm(2)), men and women are at approximately the same fracture risk. With this point in mind, using the same database to derive the T-score in men and women is reasonable. As a result, a greater proportion of men who sustain a fragility fracture will have T-scores that are higher than they would if a male database were used; in fact, many men will fracture at T-scores that are "normal." This highlights the importance of diagnosing osteoporosis not just by T-score, but also by the presence of fragility fracture and/or by estimations of fracture risk as generated by tools such as the FRAX calculator. The practical consequences of this change in densitometric definition of osteoporosis in men should be monitored, including the proportion of men at risk identified and treated as well as defining the response to treatment in those assessed by this more comprehensive approach.

Treatment of osteoporosis in men

SUMMARY

Aspects of osteoporosis in men, such as screening and identification strategies, definitions of diagnosis and intervention thresholds, and treatment options (both approved and in the pipeline) are discussed.

INTRODUCTION

Awareness of osteoporosis in men is improving, although it remains under-diagnosed and under-treated. A European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) workshop was convened to discuss osteoporosis in men and to provide a report by a panel of experts (the authors).

METHODS

A debate with an expert panel on preselected topics was conducted.

RESULTS AND CONCLUSIONS

Although additional fracture data are needed to endorse the clinical care of osteoporosis in men, consensus views were reached on diagnostic criteria and intervention thresholds. Empirical data in men display similarities with data acquired in women, despite pathophysiological differences, which may not be clinically relevant. Men should receive treatment at a similar 10-year fracture probability as in women. The design of mixed studies may reduce the lag between comparable treatments for osteoporosis in women becoming available in men.

Towards a diagnostic and therapeutic consensus in male osteoporosis

The consensus views on osteoporosis in men are reported.

INTRODUCTION

A workshop was convened within a meeting on osteoporosis in men to identify areas of consensus amongst the panel (the authors) and the participants of the meeting.

METHODS

A public debate with an expert panel on preselected topics was conducted.

RESULTS AND CONCLUSIONS

Consensus views were reached on diagnostic criteria and several aspects on the pathophysiology and treatment of osteoporosis in men.

Does using lower limit of normal values enhance the ability of a single bone mineral density measure to predict fractures?

Using a single bone mineral density (BMD) measure, we demonstrated that the lower limit of normal (LLN) method is more consistent in predicting osteoporosis fractures than the T-score in white menopausal women from the Study of Osteoporosis Fracture (SOF).

INTRODUCTION

In order to circumvent the inconsistencies and limitations with using the T-score when defining osteoporosis, we propose using 95% LLN values derived from centered polynomial models using the NHANES III BMD measures. The main aim of this study was to compare the two methods in prediction of fracture and agreement in osteoporosis classification using cohort data.

METHODS

We compared the fracture prediction ability of the two methods using a single BMD measurement in 4,948 white women aged 67-74 years in the SOF employing kappa statistics, sensitivity, and specificity.

RESULTS

The T-score provided inconsistent osteoporosis classification (46.6%) across the five hip regions of interest (ROIs) and this was significantly (p<0.0001) reduced when using the LLN method (36.5%). Kappa statistics of incident fracture during 12 years of follow-up related to the prevalence of osteoporosis at baseline was significantly improved using the LLN method compared to using T-score. Sensitivity and specificity for fracture based on a single BMD measurement of different hip ROIs were more consistent using the LLN method.

CONCLUSION

The LLN method provides a more consistent and efficient method for osteoporosis fracture prediction than the T-score in 67- to 74-year-old white women.