Maroun Rizkallah

Bone Variables in Active Overweight/Obese Men and Sedentary Overweight/Obese Men

The aim of this study was to compare bone variables in active overweight/obese men and sedentary overweight/obese men. Thirty-seven active overweight/obese men and 45 sedentary overweight/obese men participated in this study. Weight and height were measured, and body mass index was calculated. Body composition and bone variables (bone mineral content [BMC], bone mineral density [BMD], geometric indices of hip bone strength, and trabecular bone score) were measured by DXA. Physical activity level, daily calcium intake, daily protein intake, and sleep duration were measured by validated questionnaires. Maximum oxygen consumption (VO2 max) was determined by direct measurement while exercising on a medical treadmill. One-repetition-maximum half-squat of the lower limbs was measured using a validated protocol. Body weight and body mass index were higher in sedentary overweight/obese men than in active overweight/obese men. In the whole population (n = 82), VO2 max (in liter per minute), lean mass, and one-repetition-maximum half-squat were positively correlated to BMC, BMD, and geometric indices of hip bone strength (cross-sectional area and section modulus [Z] of the femoral neck [FN]). After adjusting for body weight using a 1-way analysis of covariance, active overweight/obese men displayed higher whole-body BMC, lumbar spine BMD, total hip BMD, FN BMD, FN cross-sectional area, and FN Z values than sedentary overweight/obese men. In conclusion, the current study suggests that physical activity level positively affects bone variables in overweight/obese men. Optimizing lean mass and muscular strength of the lower limbs can help to prevent osteoporosis in overweight and obese men.

Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients’ clinical history (observing “red flags”), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.

Percutaneous cement augmentation for osteoporotic vertebral fractures

Thoracolumbar vertebral fracture incidents usually occur secondary to a high velocity trauma in young patients and to minor trauma or spontaneously in older people. Osteoporotic vertebral fractures are the most common osteoporotic fractures and affect one-fifth of the osteoporotic population. Percutaneous fixation by ‘vertebroplasty’ is a tempting alternative for open surgical management of these fractures. Despite discouraging initial results of early trials for vertebroplasty, cement augmentation proved its superiority for the treatment of symptomatic osteoporotic vertebral fracture when compared with optimal medical treatment. Early intervention is also gaining ground recently. Kyphoplasty has the advantage over vertebroplasty of reducing kyphosis and cement leak. Stentoplasty, a new variant of cement augmentation, is also showing promising outcomes. In this review, we describe the additional techniques of cement augmentation, stressing the important aspects for success, and recommend a thorough evaluation of thoracolumbar fractures in osteoporotic patients to select eligible patients that will benefit the most from percutaneous augmentation. A detailed treatment algorithm is then proposed. Cite this article: EFORT Open Rev 2017;2:293–299. DOI: 10.1302/2058-5241.2.160057

Commentary: Where are we from the Implementation of Fragility FractureGuidelines in Lebanon?

Abstract: After the publication of our report that established the guidelines for the management of fragility fractures in Lebanon four years ago, many major hospitals adhered to the recommendations and witnessed an important reduction in fragility fracture morbidity and mortality as well as an increased awareness of the secondary prevention of fractures. However, this adherence was not noted on all the Lebanese territories and there is still much work to do, especially to establish a Lebanese fragility fracture registry and a Lebanese National Hip Fracture Database, and to diffuse the guidelines nationwide by making the Lebanese Ministry of Health, the Lebanese Order of Physicians and the Lebanese Orthopedic Society adopt them.

Vitamin D Level and Composite Indices of Femoral Neck Strength in a Group of Young Lebanese Women

Low serum vitamin D is associated with low bone mineral density (BMD), which is an important predictor of fracture risk (1–6). However, hypovitaminosis D is a prevalent disorder in the Lebanese population (7–13). BMD is generally considered as the best determinant of bone strength and can therefore practically predict fracture risk (14). However, only 50%–70% of bone strength variability can be explained by BMD (15). Hip bone strength is also influenced by other factors such as femoral neck (FN) width and bending strength (16). Karlamangla et al (17) have examined the prediction of incident hip fracture risk by composite indices of FN strength (compression strength index [CSI], bending strength index [BSI], and impact strength index [ISI]) constructed from dualenergy X-ray absorptiometry (DXA) scans of the hip. These indices integrate FN size and body size with bone density (17). CSI, BSI, and ISI reflect the ability of the FN to withstand axial compressive and bending forces and to absorb energy from an impact (17). These indices have been shown to improve hip fracture risk and bone strength assessments in the elderly (17–19). In children and young adults, physical activity practice positively influences these indices (20–23). In a recent study, we have shown that obesity is associated with low composite indices of FN strength in young obese men (24). The aim of the present study was to explore the relationships between serum vitamin D and composite indices of FN strength in a group of young Lebanese men. A total of 116 young Lebanese men (43 obese, 51 overweight, and 22 normal weight) whose ages ranged from 18 to 35 yr participated in the current study. Normal weight, overweight, and obesity are defined by a body mass index (BMI) between 20.0 and 24.9 kg/m, between 25.0 and 29.9 kg/m, and 30 kg/m or more, respectively. The participants were recruited from 3 private universities located in North Lebanon. All participants were nonsmokers and had no history of major orthopedic problems or other disorders known to affect bone metabolism or physical tests of the study. Other inclusion criteria included no diagnosis of comorbidities and no history of fracture. An informed written consent was obtained from the participants. The study was approved by the University of Balamand Ethics Committee. Bone mineral content and BMD were determined for each individual by DXA at whole body, lumbar spine (L1–L4), total hip, and FN (GE Healthcare, Madison,WI). Body composition and trabecular bone score were also evaluated by DXA. Composite indices of FN strength (CSI, BSI, and ISI) were calculated as previously described (17–19). Serum 25-hydroxyvitamin D level was measured by the Nichols Advantage competitive binding chemiluminescence immunoassay (25). Vitamin D insufficiency is defined as a 25(OH)D concentration of <30 ng/mL (26). The mean serum vitamin D level of the studied population was 27.3 ± 12.4 ng/mL. Overall, 65.6% of the subjects were vitamin D insufficient (serum vitamin D < 30 ng/mL). In the whole population (n = 116), serum vitamin D was negatively correlated to body weight (r = −0.33, p < 0.01), BMI (r = −0.30, p < 0.01), fat mass (r = −0.31, p < 0.01), and fat mass percentage (r = −0.26, p < 0.05), but positively correlated to CSI (r = 0.28,p < 0.01), BSI (r = 0.22, p < 0.05), and ISI (r = 0.19, p < 0.05). Serum vitamin D was not significantly correlated to bone mineral content, BMD, or trabecular bone score values. Vitamin D-sufficient men (n = 40) had a significantly higher CSI than vitamin D-insufficient men (n = 76). Our results are in accordance with those reported by Kim et al (27) in Korean women aged ≥50 years. Given that our study sample included obese, overweight, and normal-weight subjects, future larger studies are necessary to confirm whether the relation between serum vitamin D and CSI is independent of or dependent on BMI. Our study suggests that serum vitamin D is a positive but weak determinant of composite indices of FN strength in young men. To our knowledge, this is the first study to find positive correlations between serum vitamin D and composite indices of FN strength in young men. Optimization of serum vitamin D levels may be associated with greater composite indices of FN strength in young Lebanese men. Our study provides an additional evidence of vitamin D on bone health.

Influence of the Level of Pedicle Subtraction Osteotomy on Pelvic Tilt Change in Adult Spinal Deformity

Background Spine osteotomy is used for patients with rigid severe spinal deformity. Pedicle Subtraction Osteotomy (PSO) is performed by removing the posterior elements and both pedicles, removing a wedge from the vertebral body, and closure of the osteotomy by hinging on the anterior cortex. This technique is demanding and have very steep learning curve. We analyze the effect of the level of PSO on the change of pelvic tilt Methods this is a retrospective study of 35 patients (mean age, 60.7 years; range, 45–81 years) undergoing thoracolumbar PSO at a single institution in the past 4 years. One patient underwent PSO at T11, two patient underwent PSO at L2, and 16 patients underwent PSO at L3 and 16 at the L4 level. Seventy percent of the patients had undergone at least one previous spine surgery in the region of the PSO. Results the mean pelvic incidence in the cohort was 54.5. There was no change in the pelvic tilt between the preoperative and postoperative state (24.8 vs 22; p > 0.05). On the other hand, lumbar lordosis (26 vs 44), thoracic kyphosis (27 vs 38.8) and T1 pelvic angle (26.6 vs 14.7) had all significant improvement. Mean PSO resection was 35°. With subgroup analysis, mean pelvic tilt change -3.3° at the L3 level and -8.6 ° at the L4 level. Conclusions The degree of PSO resection correlates greatly with spinopelvic parameters (lumbar lordosis, thoracic kyphosis, and T1PA). More importantly, PSO level impacts postoperative PT correction; L4 level PSO have shown a better correction of the pelvic tilt than L3 PSO.

Decreased Composite Indices of Femoral Neck Strength in Young Obese Women

The aim of the current study was to compare compression strength index (CSI), bending strength index (BSI) and impact strength index (ISI) among obese, overweight and normal-weight young women. 117 young women (20 obese, 36 overweight and 61 normal-weight) whose ages range from 18 to 35 years participated in this study. Body composition and BMD were evaluated by dual-energy X-ray absorptiometry (DXA). CSI, BSI and ISI values were significantly lower in obese and overweight women compared to normal-weight women (p < 0.001). In the whole population (n = 117), body mass index (BMI) was negatively correlated to CSI (r = −0.66; p < 0.001), BSI (r = −0.56; p < 0.001) and ISI (r = −0.54; p < 0.001). This study suggests that obesity is associated with lower CSI, BSI and ISI values in young women.

Vitamin D and Trabecular Bone Score in a Group of Young Lebanese Adults

The relationship between vitamin D and trabecular bone score (TBS) in young adults remains unclear. The aim of this study was to explore the relationship between 25-hydroxyvitamin D [25(OH)D] serum levels and TBS in a healthy adult population. A total of 54 men and 61 women whose ages range from 18 to 35 participated in the present study. Participants with 25(OH)D insufficiency (between 21 and 29 ng/mL) were 55.7%, and those with 25(OH)D deficiency (≤20 ng/mL) were 11.4%. TBS positively correlated with 25(OH)D in men (r = 0.393; p <0.05) and women (r = 0.324; p < 0.05). In both genders, TBS was significantly higher in 25(OH)D-sufficient participants (≥30 ng/mL). The present study provides evidence that vitamin D positively affects bone health and suggests that maintaining adequate vitamin D status may be essential for optimal TBS values.

Muscular Maximal Strength Indices and Bone Variables in a Group of Elderly Women

The aim of the present study was to explore the relations between muscular maximal strength indices and bone parameters (bone mineral density [BMD], hip geometry indices, and trabecular bone score [TBS]) in a group of elderly women. This study included 35 healthy elderly women whose ages range between 65 and 75 yr (68.1 ± 3.1 yr). BMD (in gram per square centimeter) was determined for each individual by dual-energy X-ray absorptiometry at the whole body, lumbar spine (L1-L4), total hip (TH), and femoral neck (FN). L1-L4 TBS and hip geometry indices were also evaluated by dual-energy X-ray absorptiometry. Maximal muscle strength of bench press (1-repetition maximum [RM] bench press), maximal muscle strength of leg press (1-RM leg press), and handgrip were measured using validated methods. 1-RM bench press was positively correlated to TH BMD (r = 0.40; p < 0.05), FN BMD (r = 0.41; p < 0.05), FN section modulus (r = 0.33; p < 0.05), and FN cross-sectional moment of inertia (r = 0.35; p < 0.05). 1-RM leg press was positively correlated to TH BMD (r = 0.50; p < 0.01), FN BMD (r = 0.35; p < 0.05), FN cross-sectional area (r = 0.38; p < 0.05), and TBS (r = 0.37; p < 0.05). Handgrip was correlated only to FN cross-sectional moment of inertia (r = 0.43; p < 0.01). This study suggests that 1-RM bench press and 1-RM leg press are positive determinants of BMD in elderly women.

Positive Correlations between Free Vitamin D and Bone Variables in a Group of Young Lebanese Men

Abstract Optimizing bone mass in adulthood is of great importance to prevent the occurrence of osteoporosis in later age. Vitamin D is an essential component of bone health. Low-serum vitamin D is associated with low bone mineral density (BMD), which is an important predictor of fracture risk. However, most cells, apart from renal tubular cells, are exposed to free rather than to total 25-hydroxyvitamin D. Whether free vitamin D would be a better marker than total vitamin D is still under debate. The aim of the present study was to explore the relationships between serum total vitamin D, vitamin D-binding protein (BP), free vitamin D, and bone parameters in a group of young Lebanese women. This study included 88 young female adults aged between 18 and 35 yr. Body composition and BMD were assessed by dual-energy X-ray absorptiometry, and the lumbar spine trabecular bone score was derived. Bone mineral content (BMC) and BMD were measured at the whole body (WB), the lumbar spine (L1–L4), the total hip (TH), and the femoral neck (FN). To evaluate hip bone geometry, dual-energy X-ray absorptiometry scans were analyzed at the FN, the intertrochanteric region, and the femoral shaft by the Hip Structure Analysis program. The cross-sectional area, the index of axial compression strength, and the section modulus ( Z ), as well as index of bending strength, were measured from bone mass profiles. Composite indices of FN strength (compressive strength index [CSI], bending strength index, and impact strength index [ISI]) were calculated as previously described. Direct measurement of free 25-hydroxyvitamin D concentrations was performed by immunoassay, which detects free vitamin D by ELISA on a microtiter plate. Serum vitamin D BP was measured using a Quantikine ELISA kit, which employed the quantitative sandwich enzyme immunoassay technique. Serum free vitamin D was positively correlated with WB BMC ( r  = 0.26, p r  = 0.29, p r  = 0.28, p r  = 0.34, p r  = 0.29, p r  = 0.24, p r  = 0.28, p