Rehabilitation after surgery for hip fracture - the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study.

PURPOSE: To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. METHODS: A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. RESULTS: Of 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5-13) and 20 (IQR 8-38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2-3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2-3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02). CONCLUSION: Hip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.

Patient, surgical and hospital factors associated with the presence of a consultant surgeon during hip fracture surgery. Do we know the answer?

BACKGROUND: Provision of quality care can help to reduce adverse health outcomes following hip fracture. While surgical management by either a consultant or junior surgeon has shown inconclusive differences in patient outcomes, consultant presence is often recommended, yet little is known about the factors that influence whether a consultant surgeon is present during hip fracture surgery. The aim of this study is to examine patient, surgical and hospital factors associated with having a consultant surgeon present during hip fracture surgery. METHODS: An examination of hip fracture surgeries of adults aged ≥ 50 years admitted to hospitals in Australia and New Zealand between 1 January 2015 and 31 December 2018 using data from the Australia and New Zealand Hip Fracture Registry was conducted. Multivariable logistic regression was used to examine factors associated with the presence of a consultant surgeon during hip fracture surgery. RESULTS: There were 29 530 hip fracture surgeries 58.1% had a consultant surgeon present (range 8.5-100% by hospital). Patients were more likely to have a consultant surgeon present during surgery if they had private health insurance, were operated on after hours, required total hip replacements or were operated on in hospitals that conducted ≤150 surgeries per year. CONCLUSION: There is variation in the presence of consultant surgeons within Australia and New Zealand during hip fracture surgery, potentially associated with the complexity of surgery and hospital factors. However, further research is needed to determine the optimum level of supervision required based on patient factors and surgical complexity.

Orthopaedic surgeons' perceptions of frailty and frailty screening.

BACKGROUND: Over the past decade, there has been significant growth in the awareness and understanding of fragility among orthopaedic surgeons in the context of osteoporotic fractures and with it, improvements in the recognition and management of fragility fractures. Emerging as a major clinical and research focus in aged care is the concept of frailty and its associations with fragility, sarcopenia, falls and rehabilitation. Currently, research is lacking on how orthopaedic surgeons perceive frailty and the role of frailty screening. A baseline understanding of these perceptions is needed to inform integration of frailty identification and management for patient optimization in orthopaedic practices, as well as research and education efforts of patients and healthcare professionals in orthopaedic contexts. METHODS: We used an exploratory design guided by qualitative description to conduct 15 semi-structured telephone and in-person interviews across three orthopaedic surgeon subgroups (Registrars, Junior Consultants, and Senior Consultants). Data collection and analysis occurred iteratively and was guided by thematic saturation. RESULTS: Orthopaedic surgeons have a disparate understanding of frailty. Between colleagues, frailty is often referred to non-specifically to suggest a general state of risk to the patient. Frailty screening is regarded positively but its specific utility in orthopaedic environments is questioned. Easy-to-administer frailty screening tools that are not exclusive assessments of functional status are viewed most satisfactorily. However these tools are rarely used. CONCLUSIONS: There is little understanding among orthopaedic surgeons of frailty as a phenotype. Beliefs around modifiability of frailty were dissimilar as were the impact of related risk factors, such a cognitive status, chronic disease, social isolation, and environmental influences. This in turn may significantly impact on the occurrence and treatment outcomes of fragility fracture, a common orthopaedic problem in older populations. This study highlights need for knowledge translation efforts (e.g. education) to achieve cohesive understanding of frailty among health professionals.

Association between atrial fibrillation and hip fractures and the implications for hip fracture patients: a systematic review.

BACKGROUND: Atrial fibrillation (AF) and hip fractures are both prevalent in the elderly population. The aim of this study was to systematically review the literature regarding the association between AF and hip fractures, and the impact of AF on hip fracture prognosis. METHODS: The literature search was performed using PubMed, MEDLINE, Embase and Scopus. Inclusion was based upon the application of eligibility criteria in duplicate prior to data extraction with a standardized form. RESULTS: A total of 42 studies met the inclusion criteria. AF prevalence was found to vary between 6.5% and 35% in cohorts. Large studies with broad inclusion criteria found the prevalence of AF in hip fracture patients to be approximately 12-15%. There were conflicting results as to whether patients with AF have an increased rate of hip fractures, as compared to patients without AF. Several studies demonstrated that hip fracture patients with AF have increased rates of mortality, both as an inpatient and following discharge, and increased readmission rates. CONCLUSION: AF and hip fractures frequently coexist, and there is evidence to suggest AF is associated with increased readmission and mortality rates in hip fracture patients. Elements of the relationship between AF and hip fractures remain uncertain and further prospective studies on AF and hip fracture cohorts may clarify this relationship. Interventional studies targeting hip fracture patients with AF may be beneficial.

Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial.

OBJECTIVE: to determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care. DESIGN: parallel randomised controlled trial with integrated health economic study. SETTING: NCFs, in Adelaide South Australia. SUBJECTS: people aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture. MEASUREMENTS: primary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months. RESULTS: participants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference -1.9; 95% CI: -3.3, -0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = -7.4; 95% CI: -12.5 to -2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: -0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95% CI: $244 to $15,159) and $328,685 per QALY gained (95% CI: $82,654 to $75,007,056). CONCLUSIONS: the benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective. TRIAL REGISTRATION: ACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry. Trial protocol available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 361980.

Evaluation of the utility of teaching joint relocations using cadaveric specimens.

BACKGROUND: Like other procedural skills, the ability to relocate a joint is an important aspect of junior doctor education. Changes in the approach to teaching and learning from the traditional apprenticeship-style model have made the teaching of practical skills more difficult logistically. Workshops utilising cadaveric specimens offer a solution to this problem. METHODS: One hundred forty-six fourth year medical students were randomly divided into 5 groups. Each group received a different teaching intervention based on ankle, patella and hip relocation. The interventions consisted of online learning modules, instructional cards and workshops using skeleton models and cadaveric dislocation models. Following the intervention students were given a test containing multiple choice and true/false style questions. A 13-item 5-point Likert scale questionnaire was also delivered before and after the intervention. The data was analysed using one-way analysis of variance (ANOVA) and the Bonferroni post-hoc test. RESULTS: Compared to the instructional cards group, the other 4 groups showed a 10.8-19.2% improvement in total test score (p < 0.01) and an 18.4-25.3% improvement in self-reported understanding and confidence in performing joint relocations (P < 0.01). There was no significant difference in total test scores between groups exposed to cadaveric instruction on the relocation of one-, two- or all three- joints, nor any significant difference between all the cadaveric dislocation groups and the group receiving instruction on the skeleton model. CONCLUSION: The results of the present study suggest that workshops utilising cadaveric dislocation models are effective in teaching joint relocation. In addition, the finding that lower fidelity models may be of equal utility may provide institutions with flexibility of delivery needed to meet financial and resource constraints.

Testing the Hip Abductor Muscle Strength of Older Persons Using a Handheld Dynamometer.

OBJECTIVE: To investigate the reliability of a clinically applicable method of dynamometry to assess and monitor hip abductor muscle strength in older persons. DESIGN: Bilateral isometric hip abductor muscle strength measured with a handheld dynamometer, patients supine with the contralateral hip positioned directly against a wall for stabilization. Reliability determined by comparing intra-assessor and inter-assessor results and comparison to a criterion standard (stabilized dynamometer with patients in the standing position). SETTING: UniSA Nutritional Physiology Research Centre. PARTICIPANTS: Twenty-one patients older than 65 years were recruited from the Royal Adelaide Hospital. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs), bias, and limits of agreement calculated to determine reliability. RESULTS: Intra-assessor and inter-assessor ICCs were high (0.94 and 0.92-0.94, respectively). There was no intra-assessor bias and narrow limits of agreement (±2.4%). There was a small inter-assessor bias but narrow limits of agreement (0.6%-0.9% and ± 2.3%, respectively). There was a wide variation comparing results to the criterion standard (±5.0%-5.2% limits of agreement), highlighting problems attributed to difficulties that the test population had with the standing position used in the criterion standard test. CONCLUSIONS: Testing older persons' hip abductor muscle strength while in the supine position with optimal pelvic stabilization using a handheld dynamometer is highly reliable. While further studies must be done to assess patients with specific pathologies, this test has potential application to monitor and evaluate the effects of surgical interventions and/or rehabilitation protocols for a variety of conditions affecting hip abductor function such as hip fractures and arthritis.

A combined randomised and observational study of surgery for fractures in the distal radius in the elderly (CROSSFIRE)-a study protocol.

Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients. METHODS AND ANALYSIS: This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial. ETHICS AND DISSEMINATION: CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies. REGISTRATION: CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460).

Perspectives of Frailty and Frailty Screening: Protocol for a Collaborative Knowledge Translation Approach and Qualitative Study of Stakeholder Understandings and Experiences.

BACKGROUND: Accompanying the unprecedented growth in the older adult population worldwide is an increase in the prevalence of frailty, an age-related clinical state of increased vulnerability to stressor events. This increased vulnerability results in lower social engagement and quality of life, increased dependency, and higher rates of morbidity, health service utilization and mortality. Early identification of frailty is necessary to guide implementation of interventions to prevent associated functional decline. Consensus is lacking on how to clinically recognize and manage frailty. It is unknown how healthcare providers and healthcare consumers understand and perceive frailty, whether or not they regard frailty as a public health concern; and information on the indirect and direct experiences of consumer and healthcare provider groups towards frailty are markedly limited. METHODS: We will conduct a qualitative study of consumer, practice nurse, general practitioner, emergency department physician, and orthopedic surgeons' perspectives of frailty and frailty screening in metropolitan and non-metropolitan South Australia. We will use tailored combinations of semi-structured interviews and arts-based data collection methods depending on each stakeholder group, followed by inductive and iterative analysis of data using qualitative description. DISCUSSION: Using stakeholder driven approaches to understanding and addressing frailty and frailty screening in context is critical as the prevalence and burden of frailty is likely to increase worldwide. We will use the findings from the Perceptions of Frailty and Frailty Screening study to inform a context-driven identification, implementation and evaluation of a frailty-screening tool; drive awareness, knowledge, and skills development strategies across stakeholder groups; and guide future efforts to embed emerging knowledge about frailty and its management across diverse South Australian contexts using a collaborative knowledge translation approach. Study findings will help achieve a coordinated frailty and healthy ageing strategy with relevance to other jurisdictions in Australia and abroad, and application of the stakeholder driven approach will help illuminate how its applicability to other jurisdictions.

Outcomes between older adults with atypical and typical femoral fractures are comparable.

INTRODUCTION: Atypical femoral fractures (AFFs) are rare but a serious complication associated with prolonged use of bisphosphonates. However little is known about clinical outcomes of AFFs. The aim of this study is to compare the characteristics and postoperative outcomes between older patients with AFFs and typical femoral fractures (TFFs). METHODS: A retrospective matched cohort study (each AFF was age- and sex-matched with three TFFs) of patients aged 65 years or older who were admitted to The Queen Elizabeth Hospital, South Australia between January 2011 and December 2013 was undertaken. Baseline characteristics of both groups were compared. The primary outcomes evaluated were level of independence in mobility at discharge and 3 months after surgery. Secondary outcomes included length of hospital stay, post-operative complications, rate of surgical revision, discharge destination (after acute hospital stay or rehabilitation), 28-day hospital readmission and 12-month mortality. RESULTS: Ten patients (mean age: 78.1 years) with AFFs were compared with 30 matched TFFs. Patients with AFFs were predominantly female (90%) and 80% had been taking oral bisphosphonate. Nine of the AFFs had their fractures fixed with an intramedullary (IM) nail. The level of independent mobility at discharge (OR 0.31; 95%CI: 0.06-1.71; p=0.26) and at 3 months (OR 0.51; 95%CI: 0.10-2.53; p=0.47) were comparable between the two groups. Only one AFF patient treated with plate and screws required surgical revision, compared with none in the TFF group. Secondary outcomes were not significantly different between the two groups. CONCLUSION: Recovery of mobility and reoperation rates after surgery of patients with AFFs were favourable and did not differ significantly from TFFs. Further consideration should be given to using IM fixation in the management of AFFs in older people.

Influence of Fracture Stability on Early Patient Mortality and Reoperation After Pertrochanteric and Intertrochanteric Hip Fractures.

OBJECTIVES: To determine the influence of fracture stability on early patient mortality and complications requiring reoperation after trochanteric hip fracture. DESIGN: Prospective consecutive cohort study. SETTING: The orthopaedic unit of a public teaching hospital. PARTICIPANTS: Seven hundred twenty-eight patients with 743 consecutive stable (n = 446) pertrochanteric and unstable (n = 297) pertrochanteric or intertrochanteric fractures (median age: 84 years, 71% females) resulting from a low-impact injury and surgically managed. Mean follow-up of surviving patients was 4 years (range: 2-6 years). INTERVENTION: Fracture fixation by dynamic hip screw extramedullary device or intramedullary nail (Austofix or Gamma3) based on surgeon preference. MAIN OUTCOME MEASURES: Mortality within 6 and 12 months and surgical complications requiring device reoperation within 12 months of surgery (multivariate logistic regression and Kaplan-Meier survival analyses). RESULTS: Patients with unstable fractures were at 1.61 times (95% confidence interval: 1.18-2.21, P = 0.003) and 1.37 times (95% confidence interval: 1.02-1.83, P = 0.037) greater odds of dying within 6 and 12 months, respectively, than those with stable fractures. Older age, male gender, higher American Society of Anesthesiologists classification, in residential care, and inpatient-reported medical complications were also independent risk factors for early mortality. Increasing fracture instability and fixation using the Austofix nail were associated with early device reoperation. Comparable results were reported for the dynamic hip screw and Gamma3 nail, although the Gamma3 nail may offer advantages for more complex unstable fractures. CONCLUSIONS: Fracture instability influences early mortality after surgical fixation of trochanteric hip fracture. The Austofix double lag screw device had suboptimal results. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Common pitfalls in syndesmotic rupture management: a clinical audit.

BACKGROUND: Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes. MATERIALS AND METHODS: This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients' notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period. RESULTS: There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient. CONCLUSIONS: The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Operative management of common forefoot deformities: a representative survey of Australian orthopaedic surgeons.

BACKGROUND: Hallux valgus and hallux rigidus are common conditions for which numerous operative interventions have been described in the literature. Various clinical and radiological measurements have been used to help grade severity and to guide treatment. MATERIALS AND METHODS: A survey was e-mailed to all members of the Australian Orthopaedic Association. Questions were asked regarding respondents' demographics as well as their preferred treatment for 3 separate cases of hallux valgus and hallux rigidus of varying severity. They were specifically asked about type of deformity correction and type of fixation. The responses were collected and statistically analyzed. RESULTS: The authors collected the answers of 454 respondents with a response rate of 36%. There was a disproportionately large percentage of respondents who were members of the Australian Orthopaedic Foot and Ankle Society. Preferred treatments were different for the 3 different cases. Older surgeons were more likely to use Chevron osteotomies, and Australian Orthopaedic Foot and Ankle Society members were more likely to use a scarf. Scarf osteotomy was preferred by more than 50% for the cases of moderate and severe hallux valgus, whereas first metatarsophalangeal joint fusion was preferred for the case with significant arthritic changes. CONCLUSIONS: There are significant associations between the surgeons' age and expertise and their training and their preferred operative intervention. Considerable differences were found in the practice of the general orthopaedic surgeons and the foot and ankle specialists. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons. Although anecdotally aware that lesser deformity is treated with distal osteotomies and more severe deformity with a proximal osteotomy, the authors are unaware of any current literature that verifies this.

Current perspectives in the treatment of periprosthetic upper extremity fractures.

Periprosthetic fractures around the shoulder and elbow are rare and are often difficult to treat. Treatment options depend on the stability of the prosthesis, the location of the fracture, and the bone quality. The basic principles of treatment are that loose or unstable prostheses are removed and revised to a longer prosthesis with the possible addition of cortical struts and/or plate and screws. If the prosthesis is stable, nonoperative measures may be tried initially. In cases of nonunion, surgical treatment is recommended. This article describes the current literature related to periprosthetic fractures around the shoulder and the elbow.

Surgical education and training in Australia and New Zealand.

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate's specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees' progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.

Circulating RANKL is inversely related to RANKL mRNA levels in bone in osteoarthritic males.

INTRODUCTION: The relationship of circulating levels of receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) with the expression of these molecules in bone has not been established. The objective of this study was to measure, in humans, the serum levels of RANKL and OPG, and the corresponding levels in bone of mRNA encoding these proteins. METHODS: Fasting blood samples were obtained on the day of surgery from patients presenting for hip replacement surgery for primary osteoarthritis (OA). Intraoperatively, samples of intertrochanteric trabecular bone were collected for analysis of OPG and RANKL mRNA, using real time RT-PCR. Samples were obtained from 40 patients (15 men with age range 50 to 79 years, and 25 women with age range 47 to 87 years). Serum total RANKL and free OPG levels were measured using ELISA. RESULTS: Serum OPG levels increased over the age range of this cohort. In the men RANKL mRNA levels were positively related to age, whereas serum RANKL levels were negatively related to age. Again, in the men serum RANKL levels were inversely related (r = -0.70, P = 0.007) to RANKL mRNA levels. Also in the male group, RANKL mRNA levels were associated with a number of indices of bone structure (bone volume fraction relative to bone tissue volume, specific surface of bone relative to bone tissue volume, and trabecular thickness), bone remodelling (eroded surface and osteoid surface), and biochemical markers of bone turnover (serum alkaline phosphatase and osteocalcin, and urinary deoxypyridinoline). CONCLUSION: This is the first report to show a relationship between serum RANKL and the expression of RANKL mRNA in bone.