David Rawlings

Case-Control Study of the Pathogenesis and Sequelae of Symptomatic Vertebral Fractures in Men

Abstract: To investigate the pathogenesis and sequelae of symptomatic vertebral fractures (VF) in men, we have performed a case–control study, comparing 91 men with VF (median age 64 years, range 27–79 years) with 91 age-matched control subjects. Medical history, clinical examination and investigations were performed in all patients and control subjects, to identify potential causes of secondary osteoporosis, together with bone mineral density (BMD) measurements. BMD was lower at the lumbar spine and all sites in the hip in patients with VF than in control subjects (p<0.001). Potential underlying causes of secondary osteoporosis were found in 41% of men with VF, compared with 9% of control subjects (OR 7.1; 95% CI 3.1–16.4). Oral corticosteroid and anticonvulsant treatment were both associated with a significantly increased risk of VF (OR 6.1; 95% CI 1.3–28.4). Although hypogonadism was not associated with an increased risk of fracture, the level of sex hormone binding globulin was higher (p<0.001) and the free androgen index lower (p<0.001) in men with VF than control subjects. Other factors associated with a significantly increased risk of VF were family history of bone disease (OR 6.1; 95% CI 1.3–28.4), current smoking (OR 2.8; 95% CI 1.2–6.7) and alcohol consumption of more than 250 g/week (OR 3.8; 95% CI 1.7–8.7). Men with VF were more likely to complain of back pain (p<0.001) and greater loss of height (p<0.001) than control subjects, and had poorer (p<0.001) scores for the energy, pain, emotion, sleep and physical mobility domains of the Nottingham Health Profile. We conclude that symptomatic VF in men are associated with reduced BMD, underlying causes of secondary osteoporosis such as corticosteroid and anticonvulsant treatment, family history of bone disease, current smoking and high alcohol consumption, and that they impair the perceived health of the individual.

A randomized controlled trial of calcium with vitamin D, alone or in combination with intravenous pamidronate, for the treatment of low bone mineral density associated with Crohn's disease

Background : Osteoporosis is a common complication of Crohns disease.

The prevalence of osteoporosis in patients with severe hip and knee osteoarthritis awaiting joint arthroplasty

BACKGROUND the presence of osteoporosis in patients with hip and knee osteoarthritis (OA) has important implications for understanding disease progression and providing optimal surgical and medical management. OBJECTIVE to determine the prevalence of osteoporosis among patients with osteoarthritis awaiting total knee arthroplasty or total hip arthroplasty aged between 65 and 80 years. DESIGN cross-sectional observational study. SETTING tertiary referral centre in Newcastle upon Tyne, UK. SUBJECTS patients with osteoarthritis awaiting total knee hip arthroplasty aged between 65 and 80 years. METHODS lumbar spine, bilateral femoral and forearm bone mineral density (BMD) measurements were obtained using dual-energy X-ray absorptiometry. RESULTS the cohort consisted of 199 patients with a mean age of 72 years (SD 4), and 113 (57%) were women. The overall rate of osteoporosis at any site was 23% (46/199) and a further 43% (85/199) of patients would have been classified as osteopaenic according to World Health Organization criteria. Osteoporosis was more commonly detected in the forearm (14%) than the lumbar spine (8.5%) and proximal femur of the index side (8.2%). CONCLUSIONS in summary, a significant proportion of patients with end-stage OA have osteoporosis but this diagnosis may be missed unless BMD measurements are performed at sites distant from joints affected by OA.

Lifecourse study of bone health at age 49–51 years: the Newcastle thousand families cohort study

Objective: To quantify the direct and indirect effects of fetal (position in family, weight, and social class at birth), childhood (breast feeding, growth, infections, and social class in childhood, age at menarche), and adult life (social class, alcohol consumption, smoking, diet, reproductive history, exercise, hormone replacement therapy use), and adult size (height, weight) on bone health at age 49–51 years, as measured by bone mineral density, total scanned bone area of the hip and lumbar spine, and femoral neck shaft angle. Design: Follow up study of the Newcastle thousand families birth cohort established in 1947. Participants: 171 men and 218 women who attended for dual energy x ray absorptiometry scanning. Main results: Fetal life explained around 6% of variation in adult bone mineral density for men, but accounted for less than 1% for women. Adult lifestyle, including effects mediated through adult weight accounted for over 10% of variation in density for men and around 6% for women. Almost half of variation in bone area for men was explained by early life. However, most of this was mediated through achieved adult height and weight. In women, less than 5% of variation in bone area was accounted for by early life, after adjusting for adult size. Most of the variation in each of the indicators for both sexes was contributed either directly or indirectly by adult lifestyle and achieved adult height and weight. Conclusions: The effect of fetal life on bone health in adulthood seems to be mediated through achieved adult height.

Bone density of the femoral neck following Birmingham hip resurfacing: A 2-year prospective study in 27 hips

Background Resurfacing is a popular alternative to a standard hip replacement in young arthritic patients. Despite bone preservation around the femoral component, there is little information regarding the bone quality. Patients and methods 32 patients underwent consecutive Birmingham hip resurfacing. The bone density of the femoral neck was measured preoperatively and then at 6 weeks, 3 months, 1 year, and 2 years. The femoral neck was divided into regions of interest. Results were available for 27 hips in 26 patients. Results The overall femoral neck bone density showed a trend towards a decrease at 6 weeks and 3 months but returned to the preoperative level at 1 year, and was maintained at 2 years. The combined superior regions of the neck showed a statistically significant decrease in bone density at 6 weeks and 3 months. This returned to preoperative levels at 1 year and was maintained at 2 years. Interpretation Bone density appears to decrease at 6 weeks and 3 months, suggesting that care is necessary until bone density begins to recover.

Bone Health in Adult Men and Women with a History of Juvenile Idiopathic Arthritis

Objective. Our aim was to determine areal bone mineral density (BMDa) and disease-related factors linked with BMDa in adults with a history of juvenile idiopathic arthritis (JIA). Methods. Men and women with a history of JIA attending a young adult rheumatology clinic in Newcastle, UK, underwent dual energy x-ray absorptiometry (DEXA) of the lumbar spine and total hip. Information was obtained about disease duration and subtype, previous treatment including corticosteroid and methotrexate therapy, and large-joint replacement. Subjects completed the modified Health Assessment Questionnaire (HAQ). Blood was taken for assessment of C-reactive protein, erythrocyte sedimentation rate, and rheumatoid factor (RF). Results. Seventy-one women and 16 men, mean age 28.7 and 31.4 years, and mean disease duration 20.6 and 24.0 years, respectively, were studied. Mean BMDa was 0.982 (Z-score = −0.328; 95% CI −0.657, 0.001) and 1.028 g/cm2 (Z-score = −0.251; 95% CI −1.266, 0.764) in women and men, respectively, at the spine and 0.817 (Z-score = −0.542; 95% CI −0.975, −0.109) and 0.857 g/cm2 (Z-score = −0.176; 95% CI −2.323, 1.971) at the hip. After adjusting for age and sex, increasing HAQ score was associated with both lower spine BMDa and hip BMDa. Compared with patients with oligoarticular disease, those with enthesitis-related arthritis had higher BMDa at the spine, while those with extended oligoarticular and polyarticular RF-negative disease had lower hip BMDa. Oral corticosteroids and the presence of a large-joint replacement were associated with lower BMDa at both the spine and hip. Conclusion. There was a trend toward low BMDa in women with a history of JIA. These patients may be at risk of the complications of osteoporosis including fragility fractures and should be considered for targeted preventive measures.

A reliable DEXA measurement technique for metal- on-metal hip resurfacing

Introduction Dual energy X-ray absorptiometry (DEXA) has been used to measure bone mineral density (BMD) around total hip prostheses. With the recent increase in the use of metal-on-metal hip resurfacing, such as the Birmingham hip resurfacing (BHR), we aimed to produce a reliable method of measuring bone density around a metal-on-metal hip resurfacing. Methods We performed DEXA scans on 5 patients (7 BHRs), who had undergone resurfacing with the BHR within the past 2 years. A zonal reporting technique was devised and evaluated. Results The intraclass correlation (i.e. the correlation between any two assessments of one region of interest) was 0.997, with an overall coefficient of variation of 5%. Interpretation We have designed and demonstrated a safe, noninvasive and highly reproducible method for interpreting and reporting the results of DEXA scanning of BHR implants in vivo. We will now use this method to prospectively study our BHR population to assess the changes in bone density following BHR within the femoral neck. This method may add to the current techniques available for detection of impending failure.

Prophylactic oral bisphosphonate therapy in duchenne muscular dystrophy.

We assessed prophylactic use of bisphosphonate (BP) in Duchenne muscular dystrophy (DMD) patients on glucocorticoid (GC) therapy.

Femoral Neck Shaft Angle in Men with Fragility Fractures

Introduction. Femoral neck shaft angle (NSA) has been reported to be an independent predictor of hip fracture risk in men. We aimed to assess the role of NSA in UK men. Methods. The NSA was measured manually from the DXA scan printout in men with hip (62, 31 femoral neck and 31 trochanteric), symptomatic vertebral (91), and distal forearm (67) fractures and 389 age-matched control subjects. Age, height, weight, and BMD (g/cm2: lumbar spine, femoral neck, and total femur) measurements were performed. Results. There was no significant difference in mean NSA between men with femoral neck and trochanteric hip fractures, so all further analyses of hip fractures utilised the combined data. There was no difference in NSA between those with hip fractures and those without (either using the combined data or analysing trochanteric and femoral neck shaft fractures separately), nor between fracture subjects as a whole and controls. Mean NSA was smaller in those with vertebral fractures (129.2° versus 131°: P = 0.001), but larger in those with distal forearm fractures (129.8° versus 128.5°: P = 0.01). Conclusions. The conflicting results suggest that femoral NSA is not an important determinant of hip fracture risk in UK men.

Bisphosphonate use in Duchenne Muscular Dystrophy – why, when to start and when to stop?

ABSTRACT Introduction: Long term use of glucocorticoids has dramatically improved the disease course in Duchenne Muscular Dystrophy (DMD) and patients are now frequently surviving into their thirties. However, there are significant side-effects associated with chronic glucocorticoid administration, including a reduction in bone mineral content. The resultant osteoporosis, which predisposes to fragility fractures of both long bones and vertebrae, is a major cause for concern. There is a wide variation in clinical practice regarding the use of bisphosphonates (BP) as a means of preserving skeletal integrity in this patient group. Areas covered: This review describes the rationale and evidence for use of BP in DMD, and discusses the main side-effects and limitations of their use. It will introduce the controversial concept of a bisphosphonate holiday (a break in BP therapy after a prolonged period of use) and then summarise the potential strategies for monitoring bone health when BP is stopped. It will highlight evidence from adult studies and discuss the paucity of knowledge relating to the growing skeleton. Expert Opinion: Bisphosphonates are currently the most effective therapy for steroid-induced osteoporosis in DMD but the side-effects and consequences of their long term use remain a concern. The impact of a BP holiday on the developing skeleton is unknown and further controlled studies in children are required.