Jörn Bengt Seeger

The prevalence of vitamin D deficiency in patients with vertebral fragility fractures

Hypovitaminosis D has been identified as a common risk factor for fragility fractures and poor fracture healing. Epidemiological data on vitamin D deficiency have been gathered in various populations, but the association between vertebral fragility fractures and hypovitaminosis D, especially in males, remains unclear. The purpose of this study was to evaluate serum levels of 25-hydroxyvitamin D (25-OH D) in patients presenting with vertebral fragility fractures and to determine whether patients with a vertebral fracture were at greater risk of hypovitaminosis D than a control population. Furthermore, we studied the seasonal variations in the serum vitamin D levels of tested patients in order to clarify the relationship between other known risk factors for osteoporosis and vitamin D levels. We measured the serum 25-OH D levels of 246 patients admitted with vertebral fractures (105 men, 141 female, mean age 69 years, sd 8.5), and in 392 orthopaedic patients with back pain and no fractures (219 men, 173 female, mean age 63 years, sd 11) to evaluate the prevalence of vitamin D insufficiency. Statistical analysis found a significant difference in vitamin D levels between patients with vertebral fragility fracture and the control group (p = 0.036). In addition, there was a significant main effect of the tested variables: obesity (p < 0.001), nicotine abuse (p = 0.002) and diabetes mellitus (p < 0.001). No statistical difference was found between vitamin D levels and gender (p = 0.34). Vitamin D insufficiency was shown to be a risk factor for vertebral fragility fractures in both men and women.

Risk factors for pelvic insufficiency fractures and outcome after conservative therapy

PURPOSE The prevalence of osteoporosis has continuously increased over the past decades and it is set to increase substantially as life expectancy rises steadily. Fragility or osteoporotic fractures of the pelvis often occur after low energy falls e.g. from standing, however, some patients present with assumed insufficiency fractures of the pelvis without a previous trauma. Osteoporotic fractures impose a tremendous economic burden and these fractures deserve attention as they lead to a decrease in mobility with an increase in dependency and are associated with a high rate of mortality. To date, little is known about potential risk factors for pelvic insufficiency fractures. Furthermore, information on clinical outcome is scarce. In view of this rather limited knowledge, we aimed to identify potential risk factors for pelvic insufficiency fractures and to collect information on their short- and long-term outcomes. METHODS Files of all consecutive patients admitted between January 2010 and December 2013 for a pelvic insufficiency fracture were enrolled in this study. Pelvic fractures that occurred on tumorous bone or after high-energy trauma were excluded. Fractures of the pelvis included all pelvic bones except the coccyx. For all patients, we recorded clinical and biological parameters available from their medical history. For comparison, the same biological and clinical parameters were evaluated in an age matched control group of 1083 patients aged over 70 who were admitted to our orthopaedic department to undergo knee or hip arthroplasty. The statistical analyses used or Fisher test for percentages comparison, 2-tailed t-tests and Mann Whitney for mean comparison. To determine what factors are predictors and what factors are confounders of pelvic insufficiency fractures, multivariate linear regression analysis using the fracture as a continuous variable was performed. RESULTS Ninety-three patients with a pelvic insufficiency fracture were identified. Following the Rommens and Hofmann classification for fragility fractures of the pelvis (FFP), 51 were FFP Type Ia, 26 were FFP Type IIb lesions and 26 were FFP Type IIc. Osteoporosis was found to be significantly associated with pelvic insufficiency fractures (p=0.003), as was hypertension (p=0.036), diabetes (p=0.021), vitamin D deficiency (p=0.004), hypocalcaemia (p=0.002) and nicotine abuse (p=0.0012) after adjustment for possible confounders in the multivariate linear regression analysis. Comparing the autonomous state before and after pelvic fracture, a high loss of autonomy was observed. Patients needing daily assistance nearly doubled their number. Overall mortality was high (20%). CONCLUSIONS In conclusion, this study showed multiple risk factors for pelvic insufficiency fractures. Some, like vitamin D deficiency, can benefit easy preventive measures. Outcome of conservative therapy is poor, with loss of social and physical independence and autonomy. The mortality rate is high. Efforts should be made in preventing pelvic insufficiency fractures. All patients should be treated for the severe osteoporosis being associated with these fracture type.

The Heidelberg Sports Activity Score - A New Instrument to Evaluate Sports Activity

Objective: An appropriate measuring instrument for assessing if sports activity changes after a surgical treatment is not available yet. We hypothesised that the Heidelberg Sport Activity Score is a valid and adequate instrument for measuring sport activity in patients before and after operative treatment. Design: This retrospective study presents a new score (Heidelberg Sports Activity Score - HAS) for measuring the sport activity in 11 selected sports. Validity, sensitivity and test-retest-reliability have been assessed. Setting: The score includes importance of the sports for patients, impairment of the corresponding joint, and frequency and duration of the sporting activities undertaken. The HAS was validated using 3 criteria: external validation, internal comparison of groups and correlation with the Tegner Score. Patients: A total of 655 patients were recruited for this study. The inclusion criterion was a planned or already received reconstruction (such as a high tibial osteotomy or implantation of a hip or knee prosthesis). The sport activity of these patients was evaluated before and after treatment. Main Outcome Measurement: The mean HAS was 32.1 points preoperatively and 37.0 postoperatively (p=0.017). Results: A high correlation was found between the HAS and the Tegner Score (TS) (r=0.729; p=0.010). The Test-Retest- Reliability was performed within a time interval of 2 weeks and a significant correlation of r=0.752 was found (p<0.01). Sensitivity was analysed using a sample of patients before and after high tibial osteotomy. Conclusions: The HAS is a new, easy to use, effective and valid measuring instrument for the assessment of sports activity in patients before and after operative treatment.

Vitamin D and the Elderly Orthopedic Patient

Abstract Vitamin D is a key player in calcium homeostasis and bone health. Beyond these well-known effects, new data suggest that vitamin D deficiency potentiates a variety of chronic disease states, including diabetes, cancer, and depression. Extremely low vitamin D levels have been associated with osteomalacia and impaired muscle function, both core elements in the field of orthopedic surgery. Good muscle function and healthy bones are essential for fast rehabilitation and positive outcome after orthopedic surgery as well, especially for elderly patients seeking good physical function. Physical function is important for the preservation of independence in daily life and for the prevention of falls, which are associated with fractures and high mortality. This review focuses on the role of vitamin D deficiency in elderly orthopedic patients.

Vitamin D Deficiency: The Missing Etiological Factor in the Development of Juvenile Osteochondrosis Dissecans?

Background: Vitamin D deficiency can result in rickets and hypocalcemia during infant and childhood growth. There is an increasing interest in the role of vitamin D with regards to childhood bone health. Osteochondrosis dissecans (OD) is a common disease affecting different joints. To date, the exact etiology of OD still remains unclear. The aim of this study was to evaluate a possible association of vitamin D deficiency and juvenile OD. Methods: A retrospective chart review of the years 2010 to 2015 of all orthopaedic patients with an initial diagnosis of juvenile OD admitted to undergo operative treatment of the OD was performed. Patient demographics, medical history, information on sports activity (if available) and serum vitamin D (25-OH-D) level on admission date were obtained. For statistical comparison, we measured baseline prevalence of vitamin D insufficiency in age-matched orthopaedic patients presenting at the department of pediatric orthopaedics. Results: A total of 80 patients were included in this study. Overall, 97.5% (n=78) of tested patients in the OD group had serum vitamin D levels below the recommended threshold of 30 ng/mL (mean value of 10.1 ng/mL (±6.7 ng/mL)). Over 60% (n=49) were vitamin D deficient, 29 patients (37%) showed serum levels below 10 ng/mL corresponding to a severe vitamin D deficiency. Of note, only 2 patients (2.5%) reached serum vitamin D levels above the recommended threshold of 30 ng/mL. No statistical difference was found in respect to sports activity level before onset of the symptoms (P=0.09). Statistical analysis found a significant difference in vitamin D levels between patients with OD and patients without an OD (P=0.026). Conclusions: We found an unexpected high prevalence of vitamin D deficiency in juveniles diagnosed with OD presenting with significant lower mean 25-OH-D level compared with a control group. These results suggest that vitamin D deficiency is potentially associated with the development of OD. Thus, vitamin D deficiency might be an important cofactor in the multifactorial development of juvenile OD. For this reason, supplementation of vitamin D might not only be a potential additional therapy but also be a possible preventative factor in patients with juvenile OD. However, future prospective studies are needed to confirm this preliminary data. Level of Evidence: Level III—this is a case-control study.

Gluteal silicone injections and total hip arthroplasty: a case report

IntroductionSilicone injection is a common procedure in cosmetic surgery. Granuloma formation and migration are the most commonly observed complications.Case presentationWe report an unusual case of avascular necrosis of the hip in a 41-year-old woman from Thailand presenting with hip pain. Subcutaneous nodules were observed in the clinical examination. A pelvic X-ray revealed necrosis of the right femoral head and histological analysis of the punctuated nodules showed a reaction of foreign body granulomas. During surgical treatment with a hip replacement solitary silicone cysts were removed.ConclusionsThis case report emphasizes that orthopedic surgeons treating patients with necrosis of the hip joint in combination with palpable granulomas in the gluteal region have to be aware of silicone augmentation and its potential complications before planning a hip replacement.