Teriparatide Administration Increases Periprosthetic Bone Mineral Density After Total Knee Arthroplasty: A Prospective Study.

BACKGROUND: Teriparatide is a currently available therapeutic agent for osteoporosis. Previous studies have reported that teriparatide affects periprosthetic bone mineral density (BMD) after total knee arthroplasty (TKA). However, little agreement has been reached concerning the treatment of periprosthetic BMD after TKA with teriparatide. Moreover, BMD in the femoral and tibial sides of the joints together has never been examined. We investigated the efficacy of teriparatide to inhibit BMD loss in the femoral and tibial side and considered complications such as migration and periprosthetic fractures after TKA. METHODS: Twenty-two knees in 17 patients were included in this study, and a control group of patients who underwent TKA was identified according to their medical records. Dual-energy X-ray absorptiometry was performed for different locations (knee, hip, and lumbar spine), and regions of interest were measured to estimate BMD at initiation of the study as a baseline reference, followed by subsequent measurements at 6 and 12 months. RESULTS: As a result of adjusting the difference between the BMDs of the 2 groups at initiation, there was a significant increase in R3 (posterior condyle) and R4 (lateral) at 6 months. Furthermore, there was a significant increase in R2 (anterior condyle), R3 (posterior condyle), and R6 (tibial diaphysis) at 12 months. The study group had a higher adjusted mean BMD in all regions than did the control group at 6 and 12 months. CONCLUSION: Teriparatide may be a reasonable treatment option for osteoporotic patients to preserve or improve periprosthetic BMD after TKA.

A disintegrin and metalloproteinase (ADAM)-10 as a predictive factor for tocilizumab effectiveness in rheumatoid arthritis.

OBJECTIVES: A disintegrin and metalloproteinase (ADAM)-10 is expressed in rheumatoid arthritis (RA). In this study, we focused on ADAM-10 as a predictive factor for the treatment with biologics in RA. METHODS: The levels of ADAM-10 and fractalkine/CX3CL1 in RA and healthy controls serum were measured using enzyme-linked immunosorbent assays. Fifteen patients were treated with adalimumab (ADA), and 20 patients were treated with tocilizumab (TCZ). RESULTS: ADAM-10 positively correlated with fractalkine/CX3CL1 in the sera of RA patients and was presented at a significantly higher level compared to that in normal serum (487 ± 80 pg/ml and 85 ± 33 pg/ml, respectively, p < 0.05). ADAM-10 highly correlates with fractalkine/CX3CL1 in the sera of RA patients. The level of ADAM-10 decreased after the treatment with TCZ but not with ADA. In addition, we found that the level of ADAM-10 in TCZ responders was significantly higher than that of the TCZ nonresponders at 24 weeks (619 ± 134 pg/ml and 109 ± 25 pg/ml, respectively). Multiple regression analysis showed that ADAM-10 was only identified as independent predictive variable for the improvement of DAS28 (ESR) at 24 weeks. CONCLUSIONS: ADAM-10 may be a predictor of the effectiveness of TCZ in treating RA.

Assessment of malalignment at the metacarpophalangeal joint of the rheumatoid hand using three-dimensional computed tomogram.

OBJECTIVE: For the assessment of rheumatoid hand, three-dimensional (3D) malalignment including flexed or rotational deformities and dislocation at the finger joint is one of the important findings. The objective of this study is to prove usefulness of 3D computed tomography (3DCT) for the accurate measurement of palmoulnar flexion deformity at the metacarpophalangeal (MP) joint of the rheumatoid hand. METHODS: Swanson implant arthroplasty at the 2nd through the 5th MP joints was performed at 179 joints in 46 hands of 40 patients with rheumatoid arthritis. Pre-and postoperatively, evaluations included Larsen grade and ulnar flexion angle by an x-ray; and ulnar flexion angle, palmar flexion angle, and resected bone length by a 3DCT. RESULTS: With progression of Larsen grade and the joint dislocation, ulnar flexion angle increased. Average ulnar flexion angle was 18.7 ± 16.0° (mean ± SD) in grade III, 38.4 ± 21.2° in grade IV, and 40.1 ± 21.1° in grade V, 29.6 ± 16.0°in "subluxation," 24.8 ± 21.2° in "dislocation," and 41.1 ± 22.2° in "severe dislocation." There was no significant difference between grade of the MP joint dislocation and palmar flexion angle. With progression of the MP joint dislocation, resected bone length increased. CONCLUSION: A 3DCT gives accurate information about deformity of the rheumatoid hand. Also, an appropriate length of bone resection can be determined in the preoperative planning.

In Vivo Ultrasound Shear Wave Elastography Assessment of Acute Compartment Syndrome in a Turkey Model.

OBJECTIVE: The aim of the work described here was to evaluate the objectivity and reproducibility of non-invasive intra-compartment pressure (ICP) measurement using ultrasound shear wave elastography (SWE) in a turkey model in vivo and to determine the biological and histologic changes in acute compartment syndrome (ACS). METHODS: Twenty-four turkeys were randomly divided into four groups based on the duration and fasciotomy of ACS created by infusion of up to 50 mm Hg in the tibialis muscle: group 1, ACS 2 h; group 2, ACS 4 h; group 3, ACS 2 h + fasciotomy 2 h; group 4, ACS 4 h + fasciotomy 2 h. For each turkey, the contralateral limb was considered the control. Time-synchronized measures of SWE and ICP from each leg were collected. Then turkeys were euthanized for histology and quantitative reverse transcription polymerase chain reaction (qRT-PCR) examination. RESULTS: All models created reproducible increases in ICP and SWE, which had a strong linear relationship (r = 0.802, p < 0.0001) during phase 1. SWE remained stable (50.86 ± 9.64 kPa) when ICP remained at 50.28 ± 2.17 mm Hg in phase 2. After fasciotomy, SWE declined stepwise and then normalized (r = 0.737, p < 0.0001). Histologically, the myofiber diameter of group 2 (82.31 ± 22.92 µm) and group 4 (90.90 ± 20.48 µm) decreased significantly (p < 0.01) compared with that of the control group (103.1 ± 20.39 µm); the interstitial space of all groups increased significantly (p < 0.01). Multifocal muscle damage revealed neutrophilic infiltration, degeneration, hemorrhage and necrosis, especially in group 4. Quantitative RT-PCR verified that interleukin-6 and heparin-binding EGF-like growth factor were significantly increased in group 4. CONCLUSION: SWE provided sensitive measurements correlating to ICP in a clinically relevant ACS animal model. Once ACS time was exceeded, progression to irreversible necrosis continued spontaneously, even after fasciotomy. SWE may help surgeons in the early detection, monitoring, prognosis and decision making on fasciotomy for ACS.

Carpal Tunnel Volume after Basal Joint Arthroplasty in Postmenopausal Women.

Background: Carpal tunnel syndrome is occasionally associated with basal joint arthritis and is more common in postmenopausal women than in the general population. Currently, more evidence is needed to describe changes in the carpal tunnel after basal joint arthroplasty (BJA) of the thumb and to determine whether it is better to combine the release of the flexor retinaculum. The purpose of this study was to clarify the changes in the carpal tunnel cross-sectional area and carpal tunnel shape after complete removal of the trapezium during BJA of the thumb, according to computed tomography (CT) findings. Methods: We retrospectively investigated the carpal tunnel cross-sectional area with CT findings obtained pre- and postoperatively in 20 postmenopausal women who underwent BJA of the thumb. Results: The average horizontal plane area of the carpal tunnel was 1.11 ± 0.19 cm2 preoperatively and increased to 1.23 ± 0.2 cm2 at 3 months postoperatively (p = 0.0411). The ratio of the longitudinal diameter to the horizontal diameter was significantly increased from 0.6 ± 0.13 preoperatively to 1.23 ± 0.2 postoperatively (p = 0.0439). Conclusions: The increase in the carpal tunnel cross-sectional area was confirmed after BJA of the thumb. This increased carpal tunnel cross-sectional area changed as the longitudinal diameter increased, without changes in the horizontal diameter. Level of Evidence: Level IV (Therapeutic).

Adherence to methotrexate and associated factors considering social desirability in patients with rheumatoid arthritis: a multicenter cross-sectional study.

BACKGROUND: Assessing medication adherence in rheumatoid arthritis (RA) is clinically significant as low adherence is associated with high disease activity. Self-reported medication adherence surveys have been shown to have problems with overestimation of adherence due to social desirability bias. However, no MTX adherence studies adjusted for social desirability have been conducted to date. This study aimed to evaluate adherence to MTX and perform an investigatory search for factors associated with MTX adherence including social desirability. METHODS: This cross-sectional multicenter study was conducted among adult RA patients consuming oral MTX for ≥ 3 months. We examined the distribution of MTX adherence, according to the eight-item Morisky Medication Adherence Scale (MMAS-8). Social desirability was using the Social Desirability Scale (SDS). Furthermore, an exploratory factor analysis involving social desirability was examined to identify factors associated with MTX adherence using linear regression analysis. To deal with missing values, we used multiple imputations with chained equations methods. RESULTS: A total of 165 RA patients were enrolled. The median age was 64 years, and 86.1% were women. Based on the MMAS-8, low, medium, and high adherences were noted in 12.1%, 60.0%, and 27.9% of participants, respectively. High social desirability (coefficient, 0.14; 95% confidence interval [CI], 0.05-0.23; p < 0.05) and high age (coefficient per 10 years, 0.16; 95% CI, 0.01-0.03; p < 0.05) were associated with high MTX adherence, whereas full-time work was negatively associated with high MTX adherence (coefficient, -0.50; 95% CI, -0.95--0.05; p < 0.05). CONCLUSIONS: A large proportion of patients with RA do not take MTX as prescribed. High social desirability, high educational level, and non-full-time work may be associated with high MTX adherence. Physicians should confirm MTX adherence before switching or adding disease-modifying anti-rheumatic drugs in cases of uncontrolled disease activity.

Relationship between disease activity level and physical activity in rheumatoid arthritis using a triaxial accelerometer and self-reported questionnaire.

OBJECTIVE: This study evaluated the relationship between rheumatoid arthritis (RA) disease activity level and physical activity (PA) by using an accelerometer and self-reported questionnaire. RESULTS: The cross-sectional study was part of a cohort study designed to determine disease activity is associated with PA in RA patients. We classified patients with a Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) of less than and higher than 3.2 into the low-disease-activity (LDA) group and moderate/high-disease-activity (MHDA) group, respectively. We measured the wear time, time of vigorous-intensity PA, moderate-intensity PA, light-intensity PA, and sedentary behavior per day using a triaxial accelerometer. 34 patients were included in the study. The accelerometer-measured moderate-to-vigorous PA (MVPA) was 17.2 min/day and 10.6 min/day in the LDA group and MHDA group (p < 0.05), respectively. There was no significant association between RA disease activity level and accelerometer-measured PA with adjustment for age and Functional Assessment of Chronic Illness Therapy-Fatigue score. There was no correlation between accelerometer-measured MVPA and self-reported MVPA in the MHDA group, but these factors were correlated in the LDA group (rs = 0.57, p < 0.05). In conclusion, no significant association was noted between RA disease activity level and accelerometer-measured PA.

A non-invasive technique for evaluating carpal tunnel pressure with ultrasound vibro-elastography for patients with carpal tunnel syndrome: A pilot clinical study.

Carpal tunnel syndrome (CTS) is a disorder that affects the median nerve at the wrist sufficient to cause impairment of nerve function. Elevated carpal tunnel pressure (CTP) leads to median nerve pathology, sensory, and motor changes in CTS patient. The techniques to quantify CTP used in clinic are invasive. This study aimed to investigate the feasibility of a noninvasive ultrasound vibro-elastography (UVE) to predict CTP in CTS patients and healthy individuals. The magnitudes of shear wave speed ratio (rSWS) of the 10 CTS patients (10 hands) and 6 healthy individuals (12 hands), and 10 cadaveric hands were compared using UVE. The ratios of intra to extra-carpal tunnel SWS in CTS patients was significantly higher than those in the healthy individuals (p = 0.0008) and cadaveric hands (p = 0.0015) with 500-g tendon tension. We estimated the CTP in the carpal tunnel using the mean rSWS of each group obtained from the present study and the linear approximation obtain from cadaveric hands data with 500-g tendon tension (y = 0.0036x + 1.1413). These results indicated that the elevated pressure applied to the 3rd flexor digitorum superficialis tendon in the carpal tunnel of CTS patients resulted in faster shear wave propagation. These results show that UVE was useful to indirectly estimate the CTP by measuring the rSWS; thus, they are potentially useful for the early diagnosis and assessment of CTS.

Administration of Purified Exosome Product in a Rat Sciatic Serve Reverse Autograft Model.

BACKGROUND: The nerve autograft remains the gold standard when reconstructing peripheral nerve defects. However, although autograft repair can result in useful functional recovery, poor outcomes are common, and better treatments are needed. The purpose of this study was to evaluate the effect of purified exosome product on functional motor recovery and nerve-related gene expression in a rat sciatic nerve reverse autograft model. METHODS: Ninety-six Sprague-Dawley rats were divided into three experimental groups. In each group, a unilateral 10-mm sciatic nerve defect was created. The excised nerve was reversed and used to reconstruct the defect. Group I animals received the reversed autograft alone, group II animals received the reversed autograft with fibrin glue, and group III animals received the reversed autograft with purified exosome product suspended in the fibrin glue. The animals were killed at 3 and 7 days and 12 and 16 weeks after surgery. Evaluation included compound muscle action potentials, isometric tetanic force, tibialis anterior muscle wet weight, nerve regeneration-related gene expression, and nerve histomorphometry. RESULTS: At 16 weeks, isometric tetanic force was significantly better in group III (p = 0.03). The average axon diameter of the peroneal nerve was significantly larger in group III at both 12 and 16 weeks (p = 0.015 at 12 weeks; p < 0.01 at 16 weeks). GAP43 and S100b gene expression was significantly up-regulated by purified exosome product. CONCLUSIONS: Local administration of purified exosome product demonstrated improved nerve regeneration profiles in the reverse sciatic nerve autograft rat model. Thus, purified exosome product may have beneficial effects on nerve regeneration, gene profiles, and motor outcomes.

Long-term Use of Golimumab in Daily Practice for Patients with Rheumatoid Arthritis.

Objective To evaluate the effectiveness and drug retention rate of golimumab (GLM) for long-term use in daily practice for patients with rheumatoid arthritis (RA). Methods Patients with RA who started GLM therapy with a minimum follow-up period of 52 weeks were included. The patients were divided into a biologic-naïve group and switch group. The disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) (DAS28-ESR), grip power, and Japanese version of the health assessment questionnaire (J-HAQ) score were assessed. In addition, the treatment continuation rate was evaluated at the final follow-up. Patients Sixty-five patients [58 women and 7 men; median (range) age, 69 (61-74) years; median (range) disease duration, 9 (5-16) years] were included. Twenty-eight patients were biologic-naïve (naïve group), and 37 were switched to biologics (switch group). Results The median (range) follow-up period was 134 (58-162) weeks. The DAS28-ESR improved from a median (range) of 4.31 (3.52-5.25) to 2.65 (2.28-3.77) in the naïve group and from 4.27 (3.19-4.89) to 2.89 (2.49-3.88) in the switch group. The grip power improved in both groups (p<0.01); however, the J-HAQ score showed no marked improvement in either group. The continuation rates were 22/28 (78.6%) in the naïve group, and 26/37 (70.3%) in the switch group at the final follow-up. Conclusion We herein report for the first time that the long-term use of GLM improves the grip power. Improving the grip power may help prevent sarcopenia and frailty in the future. Given the efficacy and high continuation rate, we suggest that GLM would be a well-tolerated treatment option for RA.

Ultrasound shear wave elastography for measuring intracompartmental pressure of compartment syndrome using a turkey hind limb model.

Diagnosis and treatment of acute compartment syndrome are quite challenging. It is well known that compartment pressure is an important factor for diagnosing fasciotomy. However, the current technology to measure the pressure using a needle-catheter is invasive and painful. Recently ultrasound elastography has been used to measure soft tissue elasticity based on shear wave propagation speed. Because the muscle's elasticity is affected by the pressure within the compartment, ultrasound elastography might be a possible tool for the compartment pressure evaluation. Ultrasound shear wave elastography and pressure were simultaneously measured using a clinical ultrasound system and clinically used catheter in a turkey anterior-lateral and anterior-deep compartment under elevated pressures of baseline, 10, 20, 30, 40, and 50 mmHg using vascular infusion technique. Shear wave propagation speed increased linearly in proportion to the increase in intra-compartmental pressure. Strong correlation was observed between measured pressure and mean shear wave speed in each compartment (anterior-lateral compartment, mean R2 = 0.929, P < 0.001; anterior-deep compartment, mean R2 = 0.97, P < 0.001). Compared with anterolateral compartment pressure, anterior-deep compartment pressure was the same at the baseline; however, it was significantly higher at intended anterolateral compartment pressures of 20 and 30 mmHg (P = 0.008, P = 0.016). By using ultrasound shear wave elastography, the compartment pressure can be accurately measured. This noninvasive technology can potentially help surgeons for the early detection, monitoring, and prognosis of intra-compartmental pressure.

Therapeutic failure and eventual solution for skin necrosis and exposed tendon of the dorsum of the foot: A case report.

For the treatment of skin necrosis with exposed tendons in rheumatoid arthritis (RA) foot, we should perform microvascular free flap surgery at an early stage without conservative treatment considering the increased risk of infection and the decreased physical activity.

Metacarpophalangeal Joint Arthroplasty Using Flexible Hinge Toe Implant with Grommets for Boutonnière Deformity of Rheumatoid Thumb.

BACKGROUND: MP joint arthroplasty is one of the treatment options for the rheumatoid thumb with boutonniere deformity. The use of flexible hinge toe implant for MP joint reconstruction was introduced; however, the outcome of flexible toe implantation for the reconstruction of the MP joint has not as yet been reported in detail. Therefore, in this study, we retrospectively investigated the clinical outcome and radiological findings. METHODS: We assessed 56 Swanson implant arthroplasties that used flexible hinge toe implants with grommets to address boutonnière deformity of the thumb MP joint. The minimum follow-up period was 6 months. Pain, the range of motion, grip strength, pinch strength, General health Visual analogue scale and DASH (Disabilities of Hand, Shoulder and Hand) were assessed. RESULTS: For most of the patients, the procedure provided painless motion and stability to the thumb. In the radiological assessments, the preoperative flexion angles at the MP joint were 45° improved to 17°. The origin of arc was shifted toward the extended position and the average arc of motion was 21°, with a flexion arc from 23° to 44°. The severity of boutonniere deformity was improved in most cases. The average grip strength changed from 110 to 121 mmHg and the average side pinch power changed from 1.5 to 2.2 kgf. General health VAS improved from 40 to 29 (p = 0.019), and the DAS28-CRP decreased from 3.3 to 2.4 (p < 0.001). Infection occurred in one case, and there were no implant fractures. CONCLUSIONS: Swanson flexible hinge toe implant arthroplasty with grommets applied to the MP joint of the thumb was one of the recommended procedures for the reconstruction of boutonnière deformity of the thumb.

Clinical Characteristics of Rheumatoid Arthritis Patients Achieving Functional Remission after Six Months of Non-tumor Necrosis Factor Biological Disease-Modifying Antirheumatic Drugs (DMARDs) Treatment.

Objectives We aimed to identify the factors that predict the likelihood of remission based on a health assessment questionnaire (HAQ) in rheumatoid arthritis (RA) patients who received non-tumor necrosis factor (TNF) biologics for six months before they commenced definitive treatment. Methods The subjects consisted of 97 RA patients treated with tocilizumab or abatacept for 6 months. The following characteristics were investigated: age, gender, body mass index, steroid and methotrexate dosage, serum matrix metalloproteinase-3 levels, simplified disease activity index (SDAI) score, HAQ score (for assessing the activities of daily living [ADL]) and the short form (SF)-36 score (for assessing the quality of life [QOL]). Remission based on the HAQ score is defined as HAQ ≤0.5 after 6 months of treatment. The subjects were divided into two groups: patients with HAQ score ≤0.5 and HAQ score >0.5, and a retrospective study was conducted. Results The group of RA patients who entered remission based on the HAQ (53 patients) had a lower SDAI than the patients who did not enter remission (44 patients), and the RA patients had a lower tender joint count (TJC) and HAQ scores and a lower physician's global assessment (PGA) than those who did not enter remission. The physical component summary score (PCS) and role/social component summary score (RCS) of the SF-36 summary score were higher in the remission patients than in those without. Before the start of the treatment, the HAQ score, patients' global assessment (PtGA) and PCS and mental component summary score (MCS) of the SF-36 were determined based on a logistic regression analysis. Conclusion Our findings suggest that RA patients with lower HAQ scores and PtGA and higher PCS and MCS of the SF-36 at baseline are more likely to achieve HAQ remission with non-TNF biologic treatment than others.

Down-regulation of Irf8 by Lyz2-cre/loxP accelerates osteoclast differentiation in vitro.

Interferon regulatory factor 8 (Irf8) is a transcription factor that negatively regulates osteoclast differentiation and Irf8 global knockout (Irf8 -/-) mice have been shown to have reduced bone volume resulting from increased osteoclast numbers. However, detailed analysis of the functions of Irf8 in osteoclast precursors with a monocyte/macrophage linage is difficult, because the population and properties of hematopoietic cells in Irf8 -/- mice are severely altered. Therefore, to clearly elucidate the functions of Irf8 during osteoclastogenesis, we established myeloid cell-specific Irf8 conditional knockout (Irf8 fl/fl ;Lyz2 cre/+) mice. We found that trabecular bone volume in the Irf8 fl/fl ;Lyz2 cre/+ mice was not significantly affected, while exposure to M-CSF and RANKL significantly increased TRAP activity in vitro in osteoclasts that underwent osteoclastogenesis from bone marrow-derived macrophages (BMMs) induced from bone marrow cells (BMCs) of those mice by addition of M-CSF. Our results also showed that expression of Irf8 mRNA and protein in BMMs obtained from Irf8 fl/fl ;Lyz2 cre/+ mice and cultured with M-CSF was reduced. These findings predicted that Lyz2/Lyz2-cre expression is induced when BMCs differentiate into BMMs in cultures with M-CSF. In osteoclast differentiation cultures, Lyz2 was gradually increased by M-CSF during the first 3 days of culture, then rapidly decreased by the addition of RANKL with M-CSF during the next 3 days. Furthermore, BMCs differentiated into osteoclasts while maintaining a low level of Lyz2 expression when cultured simultaneously with both M-CSF and RANKL from the initiation of culture. These findings suggest that Lyz2-cre expression is induced along with differentiation to BMMs by BMCs obtained from Irf8 fl/fl ;Lyz2 cre/+ mice and cultured with M-CSF. In addition, Irf8 was down-regulated by activation of the cre/loxP recombination system in BMMs and osteoclastogenesis was accelerated. Based on our results, we propose the existence in vivo of a new lineage of osteoclast precursors among BMCs, which differentiate into osteoclasts without up-regulation of Lyz2 expression.

Clinical Characteristics of Rheumatoid Arthritis Patients Achieving Functional Remission with Six Months of Biological DMARDs Treatment.

Objective Although previous studies have reported the prognostic factors for functional remission, no reports have cited the predictive factors. Our aim was to study the predictive factors for functional remission, which is a treatment goal in rheumatoid arthritis (RA), after receiving biological disease-modifying antirheumatic drugs (bDMARDs) treatment for six months. Methods The study consisted of 333 RA patients treated with bDMARDs for six months. The following patient characteristics were investigated: age, gender, disease duration, type of bDMARDs, baseline steroid and methotrexate dosage, and levels of serum rheumatoid factor, matrix metalloprotease, anti-cyclic citrullinated peptides antibody, tumor necrosis factor-α, and interleukin-6. In our evaluation, we used the Simplified Disease Activity Index (SDAI) for RA disease activity, health assessment questionnaire disability index (HAQ-DI) for activity of daily living, Short Form (SF)-36 for quality of life, and Hamilton Depression Rating Scale (HAM-D) or Self-rating Depression Scale (SDS) to determine the patients' depression status. The subjects were divided into two groups: patients with HAQ-DI≤0.5 and HAQ-DI>0.5 at 6 months. Results A univariate analysis comparing a group of RA patients without functional remission (n=68) showed that the patients with functional remission (n=164) had the following in common compared with those without remission: younger age, shorter disease duration, lower baseline steroid dosage, lower SDAI, lower HAQ-DI, higher SF-36, and lower HAM-D. Only lower HAQ-DI scores and "mental health" score on the SF-36 were detected using a logistic regression analysis. Conclusion These findings suggested that RA patients with lower HAQ-DI and lower depression scores at baseline were more likely to achieve functional remission using bDMARDs treatment than those without these variables.

High bone turnover elevates the risk of denosumab-induced hypocalcemia in women with postmenopausal osteoporosis.

Hypocalcemia is the most common major adverse event in patients with osteoporosis receiving the bone resorption inhibitor denosumab; however, limited information is available regarding risk factors of hypocalcemia. Therefore, this study aimed to identify the risk factors of hypocalcemia induced by denosumab treatment for osteoporosis. We retrospectively reviewed the records of patients who had received initial denosumab supplemented with activated vitamin D for osteoporosis. Serum levels of the following bone turnover markers (BTMs) were measured at baseline: bone-specific alkaline phosphatase (BAP), total N-terminal propeptide of type 1 procollagen (P1NP), tartrate-resistant acid phosphatase 5b (TRACP-5b), and urinary cross-linked N-telopeptide of type 1 collagen (NTX). Of the 85 denosumab-treated patients with osteoporosis studied, 22 (25.9%) developed hypocalcemia. Baseline serum total P1NP, TRACP-5b, and urinary NTX were significantly higher in patients with hypocalcemia than in those with normocalcemia following denosumab administration (all P<0.01). Multivariate logistic regression analysis revealed that patients with total P1NP >76.5 µg/L, TRACP-5b >474 mU/dL, or urinary NTX >49.5 nmol bone collagen equivalent/mmol creatinine had a higher risk of hypocalcemia (P<0.01). Our study suggests that denosumab may have a greater impact on serum calcium levels in patients with postmenopausal osteoporosis with higher baseline bone turnover than in patients with postmenopausal osteoporosis with normal baseline bone turnover, because maintenance of normal serum calcium in this subgroup is more dependent on bone resorption. Close monitoring of serum calcium levels is strongly recommended for denosumab-treated patients with high bone turnover, despite supplementation with activated vitamin D and oral calcium.

Posterior Tibial Artery Perforator-Based Fascial Flap for Skin Necrosis and Exposed Extensor Tendon After Revision Total Ankle Replacement.

CASE: Delayed wound-healing of anterior ankle incisions can be problematic for patients who have undergone total ankle replacement. We describe the case of a patient in whom a posterior tibial artery perforator-based fascial flap was effectively used to cover skin necrosis and to repair the extensor retinaculum in a wound following revision total ankle replacement. CONCLUSION: When a tendon is exposed in the ankle, a skin flap is generally required. The creation of a perforator-based fascial flap is a useful technique for covering a wound with an exposed tendon and is an alternative to a musculocutaneous flap.

Posterior Tibial Artery Perforator-Based Fascial Flap for Skin Necrosis and Exposed Extensor Tendon After Revision Total Ankle Replacement: A Case Report.

CASE: Delayed wound-healing of anterior ankle incisions can be problematic for patients who have undergone total ankle replacement. We describe the case of a patient in whom a posterior tibial artery perforator-based fascial flap was effectively used to cover skin necrosis and to repair the extensor retinaculum in a wound following revision total ankle replacement. CONCLUSION: When a tendon is exposed in the ankle, a skin flap is generally required. The creation of a perforator-based fascial flap is a useful technique for covering a wound with an exposed tendon and is an alternative to a musculocutaneous flap.