Aasis Unnanuntana

The Assessment of Fracture Risk

Bone mineral density is considered to be the standard measure for the diagnosis of osteoporosis and the assessment of fracture risk. The majority of fragility fractures occur in patients with bone mineral density in the osteopenic range. The Fracture Risk Assessment Tool (FRAX) can be used as an assessment modality for the prediction of fractures on the basis of clinical risk factors, with or without the use of femoral neck bone mineral density. Treatment of osteoporosis should be considered for patients with low bone mineral density (a T-score of between -1.0 and -2.5) as well as a ten-year risk of hip fracture of > or = 3% or a ten-year risk of a major osteoporosis-related fracture of > or = 20% as assessed with the FRAX. Biochemical bone markers are useful for monitoring the efficacy of antiresorptive or anabolic therapy and may aid in identifying patients who have a high risk of fracture. An approach combining the assessment of bone mineral density, clinical risk factors for fracture with use of the FRAX, and bone turnover markers will improve the prediction of fracture risk and enhance the evaluation of patients with osteoporosis.

The Effect of Long-term Alendronate Treatment on Cortical Thickness of the Proximal Femur

BackgroundOne of the radiographic hallmarks in patients with atypical femoral insufficiency fractures after prolonged bisphosphonate treatment is generalized cortical hypertrophy. Whether cortical thickening in the proximal femur is caused by long-term alendronate therapy, however, remains unknown.Questions/purposesWe asked whether long-term alendronate use of 5 years or more results in progressive thickening of the subtrochanteric femoral cortices.Patients and MethodsWe retrospectively evaluated changes in cortical thickness and cortical thickness ratio (ratio of cortical to femoral shaft diameter) at the subtrochanteric region of the proximal femur in baseline and latest hip dual-energy xray absorptiometry (DXA) scans of 131 patients. The mean followup was 7.3 years. Patients were divided into two groups: control (no history of alendronate, 45 patients) and alendronate (history of alendronate ≥ 5 years, 86 patients). We determined cortical thickness and cortical thickness ratio at 3.5 and 4.0 cm below the tip of the greater trochanter, representing the subtrochanteric region.ResultsAfter a minimum of 5 years followup, mean cortical thickness decreased approximately 3% in the alendronate and control groups. The cortical thickness at the subtrochanteric femoral region changed less than 1 mm in greater than 90% of the patients with long-term alendronate treatment. We observed no differences in mean changes of cortical thickness and percent changes of cortical thickness between the two groups.ConclusionsLong-term alendronate treatment did not appear to cause thickened femoral cortices within the detection limits of our method. This finding contrasts with the notion that long-term alendronate treatment leads to generalized cortical thickening.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Diseases Affecting Bone Quality: Beyond Osteoporosis

BackgroundBone quantity, quality, and turnover contribute to whole bone strength. Although bone mineral density, or bone quantity, is associated with increased fracture risk, less is known about bone quality. Various conditions, including disorders of mineral homeostasis, disorders in bone remodeling, collagen disorders, and drugs, affect bone quality.Questions/purposesThe objectives of this review are to (1) identify the conditions and diseases that could adversely affect bone quality besides osteoporosis, and (2) evaluate how these conditions influence bone quality.MethodsWe searched PubMed using the keywords “causes” combined with “secondary osteoporosis” or “fragility fracture.” After identifying 20 disorders/conditions, we subsequently searched each condition to evaluate its effect on bone quality.ResultsMany disorders or conditions have an effect on bone metabolism, leading to fragility fractures. These disorders include abnormalities that disrupt mineral homeostasis, lead to an alteration of the mineralization process, and ultimately reduce bone strength. The balance between bone formation and resorption is also essential to prevent microdamage accumulation and maintain proper material and structural integrity of the bone. As a result, diseases that alter the bone turnover process lead to a reduction of bone strength. Because Type I collagen is the most abundant protein found in bone, defects in Type I collagen can result in alterations of material property, ultimately leading to fragility fractures. Additionally, some medications can adversely affect bone.ConclusionsRecognizing these conditions and diseases and understanding their etiology and pathogenesis is crucial for patient care and maintaining overall bone health.

Performance-Based Tests and Self-Reported Questionnaires Provide Distinct Information for the Preoperative Evaluation of Total Hip Arthroplasty Patients

Our objectives were to assess relationships between self-reported questionnaires and 2-minute walk test (2MWT) and timed get-up-and-go test (TUG) in preoperative total hip arthroplasty patients. A total of 162 patients completed the Western Ontario and McMaster Universities Osteoarthritis Index and Short Form 36 and performed 2MWT and TUG. Correlations between self-reported questionnaires and 2MWT and TUG were mild to moderate, indicating that the 2MWT and TUG capture additional dimensions of preoperative total hip arthroplasty function not measured by the Western Ontario and McMaster Universities Osteoarthritis Index and Short Form 36. Use of walking aids, female sex, and presence of other painful joints were significantly associated with 2MWT, whereas older age and additional painful joints were significantly associated with TUG. These 2 tests are easy to perform in clinical practice and contribute to a comprehensive assessment of preoperative status.

Atypical Femoral Fractures: Epidemiology, Etiology, and Patient Management

Purpose of reviewTo review the definition, epidemiology, and putative pathophysiology of atypical femoral fractures and propose strategies for the management of patients with atypical fractures as well as patients on long-term bisphosphonates without atypical fractures. Recent findingsRecent epidemiologic evidence shows that the absolute incidence of atypical femoral fractures is small compared with the incidence of typical hip fractures. However, long-term bisphosphonate use may be an important risk factor for atypical fractures, and minimal additional antifracture benefit has been demonstrated for treatment durations longer than 5 years for patients with postmenopausal osteoporosis. This review gives advice to aid clinicians in the management of patients with incipient or complete atypical fractures. SummaryExtremely limited evidence is available for how best to manage patients with atypical fractures. A comprehensive metabolic approach for the management of patients on long-term bisphosphonates will help to prevent oversuppression of bone remodeling that is implicated in the pathogenesis of these fractures.

Does Vitamin D Status Affect the Attainment of In-Hospital Functional Milestones After Total Hip Arthroplasty?

Our study aims to identify the prevalence of low vitamin D status in patients undergoing total hip arthroplasty (THA) and to evaluate the association between serum vitamin D level and the attainment of in-hospital functional milestones. We collected data from patients who underwent THA and had preoperative serum vitamin D (serum 25-hydroxy vitamin D) levels measured. From 200 patients, 79 (39.5%) had low serum vitamin D (serum 25-hydroxy vitamin D <32 ng/mL). There were no associations between serum vitamin D level and the attainment of in-hospital functional milestones as well as length of hospital stay or perioperative complications after THA. Because low vitamin D status did not compromise the short-term functional outcomes after THA, surgery need not be delayed, but low vitamin D levels should be corrected once identified.

Low Vitamin D Status Does Not Adversely Affect Short-Term Functional Outcome After Total Hip Arthroplasty

We prospectively measured functional performances (Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-36, 2-minute walk test, and timed get-up-and-go test) of patients who underwent total hip arthroplasty (THA) and had serum vitamin D levels tested during the preoperative evaluation. Of 219 patients, 102 (46.6%) had low vitamin D levels (25-hydroxyvitamin D<30 ng/mL). Low vitamin D status did not adversely affect short-term function at 6 weeks after THA. In addition, there was no association between serum vitamin D levels and the within-patient changes of scores of each outcome measurement. Because this 6-week period is generally adequate to correct vitamin D deficiency, orthopedic surgeons can safely perform THA without delay. Nevertheless, because vitamin D deficiency impairs bone quality, patients with low vitamin D levels should be treated once identified.

A Comprehensive Approach to Fragility Fractures

To address the cause of fragility fractures, an understanding of the determinants of bone strength is needed. Identifying patients at increased fracture risk should take into account bone quantity, quality, and turnover. Postmenopausal osteoporosis remains the most common derangement of bone strength; however, decreased bone strength can also result from secondary causes of osteoporosis. In order to properly manage patients with fragility fractures, assessment should include a focused medical history and physical examination, proper laboratory investigation, dual-energy x-ray absorptiometry screening, and, if necessary, use of the fracture risk assessment tool (FRAX). Treatment options will include nonpharmacologic treatment such as calcium and vitamin D and pharmacologic treatment with antiresorptive or anabolic agents to prevent future fractures. Bisphosphonates remain the standard treatment for osteoporosis. Concerns of oversuppression of bone turnover on long-term bisphosphonate treatment can be addressed with a drug holiday depending on the patients fracture risk. An anabolic agent such as teriparatide is a powerful tool for the prevention of fragility fractures and should be reserved for patients at high risk for fracture, such as those with declining bone mineral density despite bisphosphonate treatment. Careful evaluation of all patients with a fragility fracture will enable the orthopaedic surgeon to identify the cause of fracture and implement a treatment plan that can prevent subsequent fractures in this vulnerable population.

The Role of Vitamin D in Orthopedic Surgery

Publisher Summary Vitamin D status is a critical factor for maintaining musculoskeletal health, and remains an important consideration in patients undergoing orthopedic surgery. While vitamin D deficiency has emerged as a global health issue, the prevalence of vitamin D deficiency is also significant in the orthopedic population. This chapter defines normal vitamin D status as serum 25(OH)D level>32 ng/ml. Low serum vitamin D levels can be subcategorized to insufficiency and deficiency based on 25(OH) D levels—insufficiency (25(OH)D=20–31 ng/ml) and deficiency (25(OH)D

Multifocal Osteomyelitis with Streptococcus pneumoniae in a Patient with Waldenström Macroglobulinemia

Waldenstrom macroglobulinemia is a rare hematologic disorder in which a neoplastic clonal proliferation of terminally differentiated B lymphocytes produces excessive immunoglobulin M (IgM)1,2. This condition typically presents with constitutional symptoms including generalized fatigue and weakness, weight loss, and mucosal bleeding3. The known complications of this disorder, first described in 19444, include hyperviscosity, conversion to non-Hodgkin lymphoma, anemia, and hypofibrinogenemia1,2. Additionally, monoclonal proliferation of IgM leads to low concentrations of other immunoglobulins, such as IgG. This impaired antibody response5 renders patients vulnerable to encapsulated organisms such as Haemophilus influenzae type B , Neisseria meningitidis, and Streptococcus pneumoniae, as would be the case in an asplenic patient6. Although the rate of infection with encapsulated organisms in patients with Waldenstrom macroglobulinemia is increased compared with the general population, musculoskeletal infections in these patients are still uncommon. Case reports of septic arthritis are rare in the literature7-9, and we know of only one case of osteomyelitis of a lumbar vertebral body that has been published10. To our knowledge, this is the first report of multifocal pneumococcal osteomyelitis in a patient with Waldenstrom macroglobulinemia. The patient was informed that data concerning the case would be submitted for publication, and she consented. A sixty-eight-year-old woman presented to our orthopaedic office with severe pain in the right shoulder and mild pain in the right knee. She had been diagnosed as having Waldenstrom macroglobulinemia seventeen years earlier during a workup for osteoporosis. She was treated with chemotherapy (rituximab), and the disease remained well controlled. Her medical history was notable only for mild mitral valve prolapse, for which she usually took oral antibiotics before dental procedures. She had not, however, taken antibiotics prior to her most recent dental …