Showing papers on "Femoral neck published in 2014"
TL;DR: The goal of this study was to estimate the prevalence of osteoporosis and low bone mass based on bone mineral density (BMD) at the femoral neck and the lumbar spine in adults 50 years and older in the United States, and to note that a substantial number of men and women from other racial/ethnic groups also had osteoporeotic BMD orLow bone mass.
Abstract: The goal of our study was to estimate the prevalence of osteoporosis and low bone mass based on bone mineral density (BMD) at the femoral neck and the lumbar spine in adults 50 years and older in the United States (US). We applied prevalence estimates of osteoporosis or low bone mass at the femoral neck or lumbar spine (adjusted by age, sex, and race/ethnicity to the 2010 Census) for the noninstitutionalized population aged 50 years and older from the National Health and Nutrition Examination Survey 2005-2010 to 2010 US Census population counts to determine the total number of older US residents with osteoporosis and low bone mass. There were more than 99 million adults aged 50 years and older in the US in 2010. Based on an overall 10.3% prevalence of osteoporosis, we estimated that in 2010, 10.2 million older adults had osteoporosis. The overall low bone mass prevalence was 43.9%, from which we estimated that 43.4 million older adults had low bone mass. We estimated that 7.7 million non-Hispanic white, 0.5 million non-Hispanic black, and 0.6 million Mexican American adults had osteoporosis, and another 33.8, 2.9, and 2.0 million had low bone mass, respectively. When combined, osteoporosis and low bone mass at the femoral neck or lumbar spine affected an estimated 53.6 million older US adults in 2010. Although most of the individuals with osteoporosis or low bone mass were non-Hispanic white women, a substantial number of men and women from other racial/ethnic groups also had osteoporotic BMD or low bone mass.
1,265 citations
TL;DR: In postmenopausal women with low bone mass, romosozumab was associated with increased bone mineral density and bone formation and with decreased bone resorption.
Abstract: Background Sclerostin is an osteocyte-derived inhibitor of osteoblast activity. The monoclonal antibody romosozumab binds to sclerostin and increases bone formation. Methods In a phase 2, multicenter, international, randomized, placebo-controlled, parallel-group, eight-group study, we evaluated the efficacy and safety of romosozumab over a 12-month period in 419 postmenopausal women, 55 to 85 years of age, who had low bone mineral density (a T score of −2.0 or less at the lumbar spine, total hip, or femoral neck and −3.5 or more at each of the three sites). Participants were randomly assigned to receive subcutaneous romosozumab monthly (at a dose of 70 mg, 140 mg, or 210 mg) or every 3 months (140 mg or 210 mg), subcutaneous placebo, or an open-label active comparator — oral alendronate (70 mg weekly) or subcutaneous teriparatide (20 μg daily). The primary end point was the percentage change from baseline in bone mineral density at the lumbar spine at 12 months. Secondary end points included percentage ch...
946 citations
TL;DR: Continuing widespread use of vitamin D for osteoporosis prevention in community-dwelling adults without specific risk factors for vitamin D deficiency seems to be inappropriate.
500 citations
TL;DR: Evaluating the effect of single or combined risk factors as defined by the female athlete triad with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women suggested that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.
Abstract: Background:Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women.Purpose:To evaluate the effect of single or combined risk factors as defined by the female athlete triad—a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass—with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women.Study Design:Cohort study; Level of evidence, 3.Methods:At baseline, participants’ (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body com...
247 citations
TL;DR: LM exerts a greater effect on BMD than FM in men and women combined, which underlines the concept that physical activity is an important component in the prevention of bone loss and osteoporosis in the population.
Abstract: Context: Body weight is the most important anthropometric determinant of bone mineral density (BMD). Body weight is mainly made up of lean mass (LM) and fat mass (FM), and which component is more important to BMD has been a controversial issue. Objective: This study sought to compare the magnitude of association between LM, FM, and BMD by using a meta-analytic approach. Data Source: Using an electronic and manual search, we identified 44 studies that had examined the correlation between LM, FM, and BMD between 1989 and 2013. These studies involved 20 226 men and women (4966 men and 15 260 women) aged between 18 and 92 years. We extracted the correlations between LM, FM, and BMD at the lumbar spine, femoral neck, and whole body. The synthesis of correlation coefficients was done by the random-effects meta-analysis model. Results: The overall correlation between LM and femoral neck BMD (FNBMD) was 0.39 (95% confidence interval, 0.34 to 0.43), which was significantly higher than the correlation between FM an...
227 citations
TL;DR: For both sexes, the probabilities of spine and hip fractures were similarly high at the BMD‐based interventional thresholds for osteoporosis and at corresponding preestablished thresholds for “fragile bone strength”.
Abstract: Finite element analysis of computed tomography (CT) scans provides non-invasive estimates of bone strength at the spine and hip. To further validate such estimates clinically, we performed a five-year case-control study of 1110 women and men over age 65 from the AGES-Reykjavik cohort (case = incident spine or hip fracture; control = no incident spine or hip fracture, respectively). From the baseline CT scans, we measured femoral and vertebral strength, as well as bone mineral density (BMD) at the hip (areal BMD only) and lumbar spine (trabecular volumetric BMD only). We found that, for incident radiographically-confirmed spine fractures (n=167), the age-adjusted odds ratio for vertebral strength was significant for women (2.8, 95% CI: 1.8–4.3) and men (2.2, 95% CI: 1.5–3.2), and for men, remained significant (p=0.01) independent of vertebral trabecular volumetric BMD. For incident hip fractures (n=171), the age-adjusted odds ratio for femoral strength was significant for women (4.2, 95% CI: 2.6–6.9) and men (3.5, 95% CI: 2.3–5.3) and remained significant after adjusting for femoral neck areal BMD in women and for total hip areal BMD in both sexes; fracture classification improved for women by combining femoral strength with femoral neck areal BMD (p=0.002). For both sexes, the probabilities of spine and hip fractures were similarly high at the BMD-based interventional thresholds for osteoporosis and at corresponding pre-established thresholds for “fragile bone strength” (spine: women ≤ 4,500 N, men ≤ 6,500 N; hip: women ≤ 3,000 N, men ≤ 3,500 N). Since it is well established that individuals over age 65 who have osteoporosis at the hip or spine by BMD criteria should be considered at high risk of fracture, these results indicate that individuals who have “fragile bone strength” at the hip or spine should also be considered at high risk of fracture.
224 citations
TL;DR: In postmenopausal women who were suboptimally adherent to alendronate therapy, transitioning to denosumab was well tolerated and more effective than risedronate in increasing BMD and reducing bone turnover.
130 citations
TL;DR: It is concluded that moderate vertebral bone loss occurs in the first year after gastric bypass surgery, however, striking declines in DXA aBMD at the proximal femur were not confirmed with QCT vBMD measurements.
Abstract: Several studies, using dual-energy x-ray absorptiometry (DXA), have reported substantial bone loss after bariatric surgery. However, profound weight loss may cause artifactual changes in DXA areal bone mineral density (aBMD) results. Assessment of volumetric bone mineral density (vBMD) by quantitative computed tomography (QCT) may be less susceptible to such artifacts. We assessed changes in BMD of the lumbar spine and proximal femur prospectively for 1 year using DXA and QCT in 30 morbidly obese adults undergoing Roux-en-Y gastric bypass surgery and 20 obese non-surgical controls. At one year, subjects who underwent gastric bypass surgery lost 37 ± 2 kg compared with 3 ± 2 kg lost in the non-surgical controls (p<0.0001). Spine BMD declined more in the surgical group than in the non-surgical group whether assessed by DXA (−3.3 vs. −1.1%, p=0.034) or by QCT (−3.4 vs. 0.2%, p=0.010). Total hip and femoral neck aBMD declined significantly in the surgical group when assessed by DXA (−8.9 vs. −1.1%, p<0.0001 for the total hip and −6.1 vs. −2.0%, p=0.002 for the femoral neck), but no changes in hip vBMD were noted using QCT. Within the surgical group, serum P1NP and CTX levels increased by 82 ± 10% and by 220 ± 22%, respectively, by 6 months and remained elevated over 12 months (p<0.0001 for all). Serum calcium, vitamin D, and PTH levels remained stable in both groups. We conclude that moderate vertebral bone loss occurs in the first year after gastric bypass surgery. However, striking declines in DXA aBMD at the proximal femur were not confirmed with QCT vBMD measurements. These discordant results suggest that artifacts induced by large changes in body weight after bariatric surgery affect DXA and/or QCT measurements of bone, particularly at the hip.
129 citations
TL;DR: Patients aged 60 years and older sustaining a femoral neck fracture, with a higher modified frailty index, had increased 1- and 2-year mortality rates, and the ROC analysis suggests that this tool may be predictive of mortality.
Abstract: Background
Frailty, a multidimensional syndrome entailing loss of energy, physical ability, cognition, and health, plays a significant role in elderly morbidity and mortality. No study has examined frailty in relation to mortality after femoral neck fractures in elderly patients.
129 citations
TL;DR: In this paper, a systematic review and meta-analysis was performed to evaluate the relationship of Parkinson9s disease with osteoporosis, bone mineral density (BMD), and fracture risk.
Abstract: Objective Parkinson9s disease (PD) and osteoporosis are chronic diseases associated with increasing age. Single studies have reported associations between them and the major consequence, namely, increased risk of fractures. The aim of this systematic review and meta-analysis was to evaluate the relationship of PD with osteoporosis, bone mineral density (BMD) and fracture risk. Methods A literature search was undertaken on 4 September 2012 using multiple indexing databases and relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Results 23 studies were used in the final analysis. PD patients were at higher risk of osteoporosis (OR 2.61; 95% CI 1.69 to 4.03) compared with healthy controls. Male patients had a lower risk for osteoporosis and osteopenia than female patients (OR 0.45; 95% CI 0.29 to 0.68). PD patients had lower hip, lumbar spine and femoral neck BMD levels compared with healthy controls; mean difference, −0.08, 95% CI −0.13 to −0.02 for femoral neck; −0.09, 95% CI −0.15 to −0.03 for lumbar spine; and −0.05, 95% CI −0.07 to −0.03 for total hip. PD patients were also at increased risk of fractures (OR 2.28; 95% CI 1.83 to 2.83). Conclusions This systematic review and meta-analysis demonstrate that PD patients are at higher risk for both osteoporosis and osteopenia compared with healthy controls, and that female patients are at greater risk than male patients. Patients with PD also have lower BMD and are at increased risk of fractures.
111 citations
TL;DR: This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.
Abstract: Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young patients, preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.
TL;DR: The ABG II dual modular hip system is associated with a high rate of early failure secondary to fretting and corrosion at the femoral neck-stem taper and surgeons using modular hip systems with a titanium stem and cobalt-chromium neck should be vigilant about annual follow-up with radiographs, and use of MRIs as indicated.
Abstract: Background: During total hip arthroplasty, use of a modular femoral neck on a stemmed implant allows optimization of neck anteversion, length, and offset, resulting in more accurate balance We performed a retrospective analysis of a consecutive cohort of patients who had undergone total hip arthroplasty with a modular-neck hip system with ceramic-on-ceramic bearings
Methods: We reviewed the results in fifteen patients who had received an ABG II dual modular hip system (Stryker Orthopaedics, Mahwah, New Jersey) from May 2007 to August 2008 Anteroposterior radiographs of the pelvis were reviewed and scored with regard to medial calcar erosion Magnetic resonance imaging (MRI) was performed to assess for adverse local tissue reaction around the hip joint Calcar resorption was correlated with subsequent MRI findings Retrieval analysis was performed on the implants removed at revision
Results: The mean duration of follow-up for all patients was 423 months (range, thirty-three to sixty months) Cobalt-ion levels were elevated in all patients; chromium levels were within the normal range Medial femoral calcar erosion was noted in seven of the fifteen cases All patients with grade-2 or 3 calcar erosion on radiographs had positive MRI findings consistent with adverse local tissue reaction At the time of writing, seven patients had undergone revision arthroplasty Intraoperatively, tissue staining with tissue and bone necrosis and pseudotumor formation were observed in all revision cases Histological analysis confirmed the presence of metal-on-metal synovitis, with changes similar to those seen with metal-on-metal bearings
Conclusions: The ABG II dual modular hip system is associated with a high rate of early failure secondary to fretting and corrosion at the femoral neck-stem taper The component has subsequently been recalled and is no longer in use Surgeons using modular hip systems with a titanium stem and cobalt-chromium neck should be vigilant about annual follow-up with radiographs, and use of MRIs as indicated
Level of Evidence: Therapeutic Level IV See Instructions for Authors for a complete description of levels of evidence
TL;DR: Given this injury's characteristic findings, including fracture orientation, deformity, and comminution, surgeons should be cognizant of this pattern's innate instability and potential for treatment failure with typical implant constructs.
Abstract: Objective Management of vertical femoral neck fractures in young adults has been a challenging clinical problem, resulting in mixed clinical outcomes. A thorough understanding of the fracture morphology for this injury pattern is lacking, which may contribute to frequent failures of treatment. This study is designed to produce a detailed description of the pathoanatomy of these fractures, which may ultimately be helpful in developing more informed reduction and fixation strategies. Design Retrospective study of patient records, plain radiographs, and computed tomography scans to determine the morphology the Pauwels III femoral neck fractures (coronal angle >50 degrees) in young adults. Setting Two level I and 1 level II regional trauma centers. Patients All patients 18-49 years of age with a surgically repaired, high-energy high shear angle (>50 degrees) femoral neck fracture from January 1, 2007, to December 31, 2010. Methods One hundred thirty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 33 met all study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, comminution, deformity, characteristics of the inferomedial fracture spike, and the associated inferomedial calcar's cortical buttress. Results The vertical (coronal) fracture averaged 60 degrees and axial fracture obliquity averaged 24 degrees with relative deficiency of the posterior neck on the head-neck fragment. Major femoral neck comminution (>1.5 cm in any dimension) was identified in 96% of cases, mostly located in the inferior (94%) and posterior (82%) quadrants. The apical fracture spike of the head segment was found to be in line (within 10 degrees) of the neck-shaft axis on the proximal femur 63% of the time. Deformity in external rotation averaged 44 degrees (range, 10-68 degrees) and shortening of the femur averaged 1.8 cm (range, 0.9-4.4 cm). Conclusions This study investigated the fracture morphology of isolated, high shear angle femoral neck fractures in young adults, which may ultimately lead to improved operative reduction and fixation tactics. Given this injury's characteristic findings, including fracture orientation, deformity, and comminution, surgeons should be cognizant of this pattern's innate instability and potential for treatment failure with typical implant constructs.
TL;DR: Lumbar spine TBS is able to predict incident MOF independent of FRAX clinical risk factors and femoral neck BMD even after accounting for the increased death hazard.
Abstract: We found that lumbar spine texture analysis using trabecular bone score (TBS) is a risk factor for MOF and a risk factor for death in a retrospective cohort study from a large clinical registry for the province of Manitoba, Canada. FRAX® estimates the 10-year probability of major osteoporotic fracture (MOF) using clinical risk factors and femoral neck bone mineral density (BMD). Trabecular bone score (TBS), derived from texture in the spine dual X-ray absorptiometry (DXA) image, is related to bone microarchitecture and fracture risk independently of BMD. Our objective was to determine whether TBS provides information on MOF probability beyond that provided by the FRAX variables. We included 33,352 women aged 40–100 years (mean 63 years) with baseline DXA measurements of lumbar spine TBS and femoral neck BMD. The association between TBS, the FRAX variables, and the risk of MOF or death was examined using an extension of the Poisson regression model. During the mean of 4.7 years, 1,754 women died and 1,872 sustained one or more MOF. For each standard deviation reduction in TBS, there was a 36 % increase in MOF risk (HR 1.36, 95 % CI 1.30–1.42, p < 0.001) and a 32 % increase in death (HR 1.32, 95 % CI 1.26–1.39, p < 0.001). When adjusted for significant clinical risk factors and femoral neck BMD, lumbar spine TBS was still a significant predictor of MOF (HR 1.18, 95 % CI 1.12–1.23) and death (HR 1.20, 95 % CI 1.14–1.26). Models for estimating MOF probability, accounting for competing mortality, showed that low TBS (10th percentile) increased risk by 1.5–1.6-fold compared with high TBS (90th percentile) across a broad range of ages and femoral neck T-scores. Lumbar spine TBS is able to predict incident MOF independent of FRAX clinical risk factors and femoral neck BMD even after accounting for the increased death hazard.
TL;DR: The study confirms that greater insulin resistance is related to lower femoral neck strength relative to load, and suggests that hyperinsulinemia, rather than hyperglycemia, underlies this relationship.
Abstract: Although several studies have noted increased fracture risk in individuals with type 2 diabetes mellitus (T2DM), the pathophysiologic mechanisms underlying this association are not known. We hypothesize that insulin resistance (the key pathology in T2DM) negatively influences bone remodeling and leads to reduced bone strength. Data for this study came from 717 participants in the Biomarker Project of the Midlife in the United States Study (MIDUS II). The homeostasis model assessment of insulin resistance (HOMA-IR) was calculated from fasting morning blood glucose and insulin levels. Projected 2D (areal) bone mineral density (BMD) was measured in the lumbar spine and left hip using dual-energy X-ray absorptiometry (DXA). Femoral neck axis length and width were measured from the hip DXA scans, and combined with BMD and body weight and height to create composite indices of femoral neck strength relative to load in three different failure modes: compression, bending, and impact. We used multiple linear regressions to examine the relationship between HOMA-IR and bone strength, adjusted for age, gender, race/ethnicity, menopausal transition stage (in women), and study site. Greater HOMA-IR was associated with lower values of all three composite indices of femoral neck strength relative to load, but was not associated with BMD in the femoral neck. Every doubling of HOMA-IR was associated with a 0.34 to 0.40 SD decrement in the strength indices (p<0.001). On their own, higher levels of fasting insulin (but not of glucose) were independently associated with lower bone strength. Our study confirms that greater insulin resistance is related to lower femoral neck strength relative to load. Further, we note that hyperinsulinemia, rather than hyperglycemia, underlies this relationship. Although cross-sectional associations do not prove causality, our findings do suggest that insulin resistance and in particular, hyperinsulinemia, may negatively affect bone strength relative to load.
TL;DR: Impact + resistance training was a safe and acceptable form of exercise for older PCS on ADT and some evidence of skeletal adaptation to resistance + impact training in an androgen-deprived state was apparent.
Abstract: AB Introduction: Androgen deprivation therapy (ADT) is associated with significant bone loss and an increase in fracture risk among prostate cancer survivors (PCS). We investigated whether impact + resistance training could stop ADT-related declines in bone mineral density (BMD) among PCS on ADT. Methods: We randomized 51 PCS (mean age, 70.2 yr) currently prescribed ADT to participate in 1 yr of impact + resistance training (Prevent Osteoporosis with Impact + Resistance (POWIR)) or in an exercise placebo program of stretching exercise (FLEX). Outcomes were proximal femur (total hip, femoral neck, and greater trochanter) and spine (L1-L4) BMD (g[middle dot]cm-2) and bone turnover markers (serum osteocalcin (ng[middle dot]mL-1) and urinary deoxypyrodinoline cross-links (nmol[middle dot]mmol-1 Cr)). Results: Retention in the 1-yr study was 84% and median attendance to supervised classes was 84% in POWIR and 74% in FLEX. No study-related injuries were reported. There were no significant differences between groups for average L1-L4 BMD or for BMD at any hip site. When examining individual vertebrae, POWIR has a significant effect on preservation of BMD (-0.4%) at the L4 vertebrae compared with losses (-3.1%) in FLEX (P = 0.03). Conclusion: Impact + resistance training was a safe and acceptable form of exercise for older PCS on ADT. Among our limited sample, POWIR did not appear to have a clinically meaningful effect on hip or spine BMD, but some evidence of skeletal adaptation to resistance + impact training in an androgen-deprived state was apparent. Future studies need to be conducted on a larger sample of patients and should consider modifications to POWIR that could further enhance loading across the spine and at the hip to preserve BMD at these clinically relevant sites.
TL;DR: A smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care.
Abstract: Background: The purpose of this study was to investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification.
Methods: We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate.
Results: There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of “adult reconstruction” showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while “trauma” subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001).
Conclusions: The most substantial changes in treatment of femoral neck fractures were seen in the younger group of patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care.
TL;DR: In this paper, the femur failure is associated with failure of just a tiny proportion of the bone tissue, failure dominating in the very weakest femurs owing in part to a lack of structural redundancy.
Abstract: The etiology of hip fractures remains unclear but might be elucidated by an improved understanding of the microstructural failure mechanisms of the human proximal femur during a sideways fall impact. In this context, we biomechanically tested 12 cadaver proximal femurs (aged 76 ± 10 years; 8 female, 4 male) to directly measure strength for a sideways fall and also performed micro-computed tomography (CT)-based, nonlinear finite element analysis of the same bones (82-micron-sized elements, ∼120 million elements per model) to estimate the amount and location of internal tissue-level failure (by ductile yielding) at initial structural failure of the femur. We found that the correlation between the directly measured yield strength of the femur and the finite element prediction was high (R(2) = 0.94, p < 0.0001), supporting the validity of the finite element simulations of failure. In these simulations, the failure of just a tiny proportion of the bone tissue (1.5% to 6.4% across all bones) led to initial structural failure of the femur. The proportion of failed tissue, estimated by the finite element models, decreased with decreasing measured femoral strength (R(2) = 0.88, p < 0.0001) and was more highly correlated with measured strength than any measure of bone volume, mass, or density. Volume-wise, trabecular failure occurred earlier and was more prominent than cortical failure in all femurs and dominated in the very weakest femurs. Femurs with low measured strength relative to their areal bone mineral density (BMD) (by dual-energy X-ray absorptiometry [DXA]) had a low proportion of trabecular bone compared with cortical bone in the femoral neck (p < 0.001), less failed tissue (p < 0.05), and low structural redundancy (p < 0.005). We conclude that initial failure of the femur during a sideways fall is associated with failure of just a tiny proportion of the bone tissue, failure of the trabecular tissue dominating in the very weakest femurs owing in part to a lack of structural redundancy.
TL;DR: The survey demonstrates the diversity and disagreement among OTA member “expert” orthopaedic traumatologists for the “best” treatment choice for this important clinical scenario and highlights the need for further study of this problem.
Abstract: Objective To identify the current implant and diagnostic imaging preferences among orthopaedic trauma experts for the treatment of high-energy vertical femoral neck fractures in young adult patients. Design Web-based survey. Setting Not available. Participants Active members of the OTA. Methods A cross-sectional expert opinion survey was administered to the active members of the OTA to determine their preferences for implant use and imaging in the surgical treatment of a vertical femoral neck fracture in a young adult patient (e.g., 60-degree Pauwels angle fracture in a healthy 30-year-old patient). Questions were also asked regarding the reason why this implant was selected, whether the surgeon felt that their choice was supported by the literature, and what imaging studies are routinely obtained to guide decision making. Data were collected using simple multiple-choice questions and/or a 5-point Likert item. Results Two hundred seventy-two surgeons (47%) responded to the survey. The preferred constructs for a vertical femoral neck fracture in a healthy young patient were a sliding hip screw with or without an anti-rotation screw (47%), parallel cannulated screws with an off-axis screw (28%), and parallel cannulated screw constructs (15%). When asked if their designated construct "was clearly supported by the literature," 46% were either unsure or disagreed. Seventy percent of surgeons chose their preferred implant because it was "biomechanically most stable." Most surgeons required anteroposterior pelvis (70%) and standard hip (88%) radiographs; however only 29% of surgeons required a computed tomography (59% found computed tomography helpful but not required). Twenty-seven percent of surgeons have changed their implant choice intraoperatively. Conclusions Femoral neck fractures in young adult patients are a challenging problem with high rates of failed treatment. Many options for treatment exist and a consensus on the best method remains elusive. Our survey demonstrates the diversity and disagreement among OTA member "expert" orthopaedic traumatologists for the "best" treatment choice for this important clinical scenario. Our survey shows a divided level of confidence in the current literature and highlights the need for further study of this problem. Level of evidence Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: An acute/varus angle of the femoral neck, high BMI, and narrow center-edge angle were associated with development of atypical femur fracture in long-term bisphosphonate users.
TL;DR: A population-based study clarified the prevalence of radiographic OPLL in the Japanese population as well as its progression, and OPLL showed significant association with plasma pentosidine levels, BMD and DISH.
Abstract: Summary
The prevalence of radiographic cervical ossification of the posterior longitudinal ligament (OPLL) in 1,562 Japanese from a population-based cohort was 1.9 %. The presence of OPLL showed a significant association with the femoral neck bone mineral density (BMD), presence of diffuse idiopathic skeletal hyperostosis (DISH) and plasma pentosidine levels. Only one new case of radiographic OPLL was detected, but OPLL progressed in all affected subjects.
TL;DR: Denosumab is effective in restoring bone mass and reducing bone pain in patients on dialysis with secondary hyperparathyroidism and allows for a more aggressive use of calcitriol to control hyperparathiroidism.
Abstract: Context: Denosumab is widely used for bone diseases with increased bone resorption. Its effectiveness in patients with severe secondary hyperparathyroidism on dialysis is unclear. Objective: This study aimed to evaluate the efficacy and safety of denosumab in patients with severe secondary hyperparathyroidism who are on dialysis. Design: This 6-month prospective, open-labeled study evaluated 12 patients (five women, seven men; mean age 53.5±3.8 y). All had intact PTH (iPTH; > 1000 pg/mL), low bone mass (T-score < −1.0 SD), and bone pain and were poor surgical candidates. Serum calcium, phosphorus, alkaline phosphatase (AP), and iPTH levels were assessed at baseline and every month thereafter. Vertebral spine x-rays and bone mineral densities (BMDs) (lumbar spine and femoral neck) were assessed at the start and end of the study. All patients received denosumab (60 mg), calcitriol, phosphate binders, and dialysate calcium that were adjusted according to the biochemistry data. Results: The BMD increased in b...
TL;DR: Skeletal adaptation to increasing lean mass was positively associated with BMD but had no effect on femoral SI, whereas increasing fat mass hadNo effect on BMDbut adversely affected femoralSI, which should predict higher fracture risk.
Abstract: Although increasing body weight has been regarded as protective against osteoporosis and fractures, there is accumulating evidence that fat mass adversely affects skeletal health compared with lean mass We examined skeletal health as a function of estimated total body lean and fat mass in 40,050 women and 3600 men age ≥50 years at the time of baseline dual-energy X-ray absorptiometry (DXA) testing from a clinical registry from Manitoba, Canada Femoral neck bone mineral density (BMD), strength index (SI), cross-sectional area (CSA), and cross-sectional moment of inertia (CSMI) were derived from DXA Multivariable models showed that increasing lean mass was associated with near-linear increases in femoral BMD, CSA, and CSMI in both women and men, whereas increasing fat mass showed a small initial increase in these measurements followed by a plateau In contrast, femoral SI was relatively unaffected by increasing lean mass but was associated with a continuous linear decline with increasing fat mass, which should predict higher fracture risk During mean 5-year follow-up, incident major osteoporosis fractures and hip fractures were observed in 2505 women and 180 men (626 and 45 hip fractures, respectively) After adjustment for fracture risk assessment tool (FRAX) scores (with or without BMD), we found no evidence that lean mass, fat mass, or femoral SI affected prediction of major osteoporosis fractures or hip fractures Findings were similar in men and women, without significant interactions with sex or obesity In conclusion, skeletal adaptation to increasing lean mass was positively associated with BMD but had no effect on femoral SI, whereas increasing fat mass had no effect on BMD but adversely affected femoral SI Greater fat mass was not independently associated with a greater risk of fractures over 5-year follow-up FRAX robustly predicts fractures and was not affected by variations in body composition
TL;DR: Use of modular neck stems did not improve hip scores nor reduce the likelihood of complications or reoperations, and there is no clear indication for modularity with a primary THA, unless the hip center cannot be achieved with a nonmodular stem, which is rare.
Abstract: Background
Restoration of the hip center is considered important for a successful THA and requires achieving the right combination of offset, anteversion, and limb length. Modular femoral neck designs were introduced to make achieving this combination easier. No previous studies have compared these designs in primary THA, and there is increasing concern that modular designs may have a higher complication rate than their nonmodular counterparts.
TL;DR: The correlation between leptin and resistin are not inconclusive, and leptin did not have a significant correlation with BMD in either the osteoporosis or non-osteoporotic groups (P > 0.05).
Abstract: The purpose of this study was to investigate the relationship between fasting serum leptin, adiponectin and resistin levels and bone mineral density (BMD) in osteoporosis patients and a non-osteoporosis control group. We studied 81 non-diabetic osteoporosis patients (92 % female, 8 % male; mean age 54.5 ± 15.5 years and body mass index [BMI] 28.2 ± 4.6) and 120 non-diabetic individuals with normal BMD as controls (86 % female, 14 % male; mean age 39.7 ± 10.4 years and BMI 28.8 ± 4.4). BMD was studied by dual-energy X-ray absorptiometry from the lumbar spine (L1-L4) and femoral neck and fasting blood samples were taken for biochemical measurement of fasting blood glucose, leptin, adiponectin and resistin. Fasting levels of plasma adiponectin had a significant negative correlation with BMD of the femoral neck and lumbar spine in the osteoporosis group (r = -0.478, P = 0.003, r = -0.513, P = 0.023) but not in the non-osteoporosis group (r = -0.158, P = 0.057, r = -0.23, P = 0.465). Fasting plasma levels of resistin were significantly correlated only with femur BMD in the osteoporosis group, and not significantly correlated with lumbar spine BMD (r = -0.244, P = 0.048 vs r = 0.276, P = 0.56). Leptin did not have a significant correlation with BMD in either the osteoporosis or non-osteoporosis groups (P > 0.05). Adiponectin had a significant negative correlation with BMD of the lumbar spine and femoral neck. The correlation between leptin and resistin are not inconclusive.
TL;DR: Total hip replacement is superior to internal fixation in the treatment of a displaced femoral neck fracture and mental impairment for patients with mental impairment in both groups.
Abstract: Background: Prospective randomized studies comparing internal fixation and a cemented hip replacement in the treatment of displaced femoral neck fractures have shown favorable short-term results for prosthetic replacement. The present report compares the results after a minimum of fifteen years.
Methods: From 1994 to 1998, 143 patients (146 hips) were randomized to closed reduction and internal fixation with two screws (n = 78) or a cemented total hip replacement (n = 68). The average age of the patients was eighty-four years (range, seventy-five to 101 years), and 38% were classified as mentally impaired. Failure after internal fixation was defined as early redisplacement, nonunion, symptomatic segmental collapse, or deep infection. In the arthroplasty group, failure was defined as two dislocations or more, implant loosening, deep infection, or a periprosthetic fracture.
Results: For the lucid patients, the failure rate was 55% after internal fixation compared with 5% after total hip replacement. For patients with mental impairment, it was 16% in both groups.
Conclusions: Total hip replacement is superior to internal fixation in the treatment of a displaced femoral neck fracture.
Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: HIV is independently associated with lower BMD, and its effect is likely mediated, in part, by alterations in bone metabolism, as reported in HIV UPBEAT.
Abstract: INTRODUCTION Low bone mineral density (BMD) is common in HIV-positive patients, although the role played by HIV infection versus sociodemographic and metabolic factors remains unclear. METHODS Understanding the Pathology of Bone Disease in HIV-infected individuals (HIV UPBEAT) is a prospective cohort study, enrolled HIV-positive and HIV-negative participants from similar demographic backgrounds. Dual X-ray absorptiometry at femoral neck, total hip and lumbar spine and blood tests were performed. Associations between BMD and factors of interest were assessed using multivariable linear regression. RESULTS A total of 474 participants were recruited. Two hundred and ten were HIV-positive, of whom, 59% were male, 40% African and median (interquartile range) age was 39 (33, 46) years. HIV acquisition risks were heterosexual sex (46.9%), homosexual sex (25.4%) and intravenous drug use (18.7%). Of the HIV-negative participants, 44% were male, 25% were African and median (interquartile range) age was 42 (34-49) years. HIV infection was independently associated with a 0.062 (P < 0.0001), 0.078 (P < 0.0001) and 0.060 g/cm (P = 0.0002) lower BMD at femoral neck, total hip and lumbar spine, respectively, after adjustment for demographic/ lifestyle factors and BMI. After further adjustment for bone biomarkers, HIV remained independently associated with reduced BMD at each site, although effect sizes were reduced. The HIV-positive group had significantly higher bone turnover (all between-group P < 0.0001). Treatment variables and cumulative exposure to antiretroviral therapy were not associated with lower BMD at femoral neck or total hip, but acquisition of HIV infection via intravenous drug use and longer time since HIV diagnosis were independently associated with lower lumbar spine BMD. DISCUSSION HIV is independently associated with lower BMD, and its effect is likely mediated, in part, by alterations in bone metabolism.
TL;DR: In this paper, the authors examined the efficacy and safety of 24-month treatment with ONO-5334 and to assess the effect of treatment cessation over 2 months, concluding that the effect on biochemical markers was rapidly reversible on treatment cessation.
Abstract: Cathepsin K inhibitors, such as ONO-5334, are being developed for the treatment of postmenopausal osteoporosis. However, their relative effects on bone resorption and formation, and how quickly the effects resolve after treatment cessation, are uncertain. The aim of this study was to examine the efficacy and safety of 24-month treatment with ONO-5334 and to assess the effect of treatment cessation over 2 months. We studied 197 postmenopausal women with osteoporosis or osteopenia with one fragility fracture. Patients were randomized to ONO-5334 50 mg twice daily, 100 mg or 300 mg once daily, alendronate 70 mg once weekly (positive control), or placebo for 24 months. After 24 months, all ONO-5334 doses were associated with increased bone mineral density (BMD) for lumbar spine, total hip, and femoral neck (p < 0.001). ONO-5334 300 mg significantly suppressed the bone-resorption markers urinary (u) NTX and serum and uCTX-I throughout 24 months of treatment and to a similar extent as alendronate; other resorption marker levels remained similar to placebo (fDPD for ONO-5334 300 mg qd) or were increased (ICTP, TRAP5b, all ONO-5334 doses). Levels of B-ALP and PINP were suppressed in all groups (including placebo) for approximately 6 months but then increased for ONO-5334 to close to baseline levels by 12 to 24 months. On treatment cessation, there were increases above baseline in uCTX-I, uNTX, and TRAP5b, and decreases in ICTP and fDPD. There were no clinically relevant safety concerns. Cathepsin K inhibition with ONO-5334 resulted in decreases in most resorption markers over 2 years but did not decrease most bone formation markers. This was associated with an increase in BMD; the effect on biochemical markers was rapidly reversible on treatment cessation. © 2014 American Society for Bone and Mineral Research.
TL;DR: It is found that there are at least three major mechanisms by which obesity influences fracture risk: increased BMD in response to greater skeletal loading, increased impact forces, and greater absorption of impact forces by soft tissue padding.
Abstract: Some aspects of an obese body habitus may protect against fracture risk (higher bone mineral density [BMD] and greater tissue padding), while others may augment that risk (greater impact forces during a fall). To examine these competing pathways, we analyzed data from a multisite, multiethnic cohort of 1924 women, premenopausal or early perimenopausal at baseline. Obesity was defined as baseline body mass index (BMI) > 30 kg/m(2) . Composite indices of femoral neck strength relative to fall impact forces were constructed from DXA-derived bone size, BMD and body size. Incident fractures were ascertained annually during a median follow-up of 9 years. In multivariable linear regression adjusted for covariates, higher BMI was associated with higher BMD but with lower composite strength indices, suggesting that although BMD increases with greater skeletal loading, the increase is not sufficient to compensate for the increase in fall impact forces. During the follow-up, 201 women had fractures. In Cox proportional hazard analyses, obesity was associated with increased fracture hazard adjusted for BMD, consistent with greater fall impact forces in obese individuals. Adjusted for composite indices of femoral neck strength relative to fall impact forces, obesity was associated with decreased fracture hazard, consistent with a protective effect of soft tissue padding. Further adjustment for hip circumference, a surrogate marker of soft tissue padding, attenuated the obesity-fracture association. Our findings support that there are at least three major mechanisms by which obesity influences fracture risk: increased BMD in response to greater skeletal loading, increased impact forces, and greater absorption of impact forces by soft tissue padding.
TL;DR: Progressively implemented high‐impact training, which increased bone mass, did not affect the biochemical composition of cartilage and may be feasible in the prevention of osteoporosis and physical performance–related risk factors of falling in postmenopausal women.
Abstract: Osteoarthritis and osteoporosis often coexist in postmenopausal women. The simultaneous effect of bone-favorable high-impact training on these diseases is not well understood and is a topic of controversy. We evaluated the effects of high-impact exercise on bone mineral content (BMC) and the estimated biochemical composition of knee cartilage in postmenopausal women with mild knee osteoarthritis. Eighty women aged 50 to 66 years with mild knee osteoarthritis were randomly assigned to undergo supervised progressive exercise three times a week for 12 months (n = 40) or to a nonintervention control group (n = 40). BMC of the femoral neck, trochanter, and lumbar spine was measured by dual-energy X-ray absorptiometry (DXA). The biochemical composition of cartilage was estimated using delayed gadolinium-enhanced magnetic resonance imaging (MRI) cartilage (dGEMRIC), sensitive to cartilage glycosaminoglycan content, and transverse relaxation time (T2) mapping that is sensitive to the properties of the collagen network. In addition, we evaluated clinically important symptoms and physical performance–related risk factors of falling: cardiorespiratory fitness, dynamic balance, maximal isometric knee extension and flexion forces, and leg power. Thirty-six trainees and 40 controls completed the study. The mean gain in femoral neck BMC in the exercise group was 0.6% (95% CI, –0.2% to 1.4%) and the mean loss in the control group was –1.2% (95% CI, –2.1% to –0.4%). The change in baseline, body mass, and adjusted body mass change in BMC between the groups was significant (p = 0.005), whereas no changes occurred in the biochemical composition of the cartilage, as investigated by MRI. Balance, muscle force, and cardiorespiratory fitness improved significantly more (3% to 11%) in the exercise group than in the control group. Progressively implemented high-impact training, which increased bone mass, did not affect the biochemical composition of cartilage and may be feasible in the prevention of osteoporosis and physical performance–related risk factors of falling in postmenopausal women. © 2014 American Society for Bone and Mineral Research.