Difference in Bone Mineral Density Change at the Lateral Femoral Cortices according to Administration of Different Bisphosphonate Agents

BACKGROUND: To retrospectively assess whether the response of subtrochanteric lateral cortex (STLC) is different according to the bisphosphonate agents in terms of bone mineral density (BMD) change. METHODS: A total of 149 subjects, who had 2- to 4-year interval follow-up of BMD using dual energy X-ray absorptiometry (DXA), were included in this retrospective study divided into following 3 groups: control group (no consumption of any anti-osteoporotic drugs, n=38), alendronate group (naïve alendronate users, n=48), risedronate group (naïve risedronate users, n=63). BMD was measured at the STLC and subtrochanteric medial cortex (STMC) in each patient by drawing rectangular ROIs at the bone cortices. The percent change of BMD at the STLC were compared between the aforementioned 3 groups by using analysis of covariance model to control five independent variables of age, body mass index, percent change of STMC, hip axis length, time interval between DXA examinations. RESULTS: The least square mean values±standard deviation of the percent change of BMD in the control, alendronate, and risedronate groups were 1.46±1.50, 2.23±1.26, and 6.96±1.11, respectively. The risedronate group showed significantly higher change of BMD percentage compared with the control (adjusted P=0.012) or alendronate (adjusted P=0.016) groups. CONCLUSIONS: The percent change of BMD at the STLC in the risedronate user group was greater than the alendronate and control groups. The implication of these changes needs to be further verified.

Quality of Life in Patients with Osteochondromatosis / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to help predict the prognosis of multiple osteochondromatosis patients with the investigation of social function, pain, physical function and quality of life of patients. MATERIALS AND METHODS: Forty-five cases were diagnosed as multiple osteochondromatosis from March 1993 to June 2014. We performed a survey on pain, daily life, school or work life assessment of research and development-36. Forty-five people who responded to the survey completely were enrolled. Variable factors, including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health state were considered as elements related to quality of life. In addition, we investigated significant factors for multiple osteochondromatosis patients, and analyzed the survey by scoring. Related factors included age (over 18 years and under 18 years), gender, body mass index, operation, joint deformity, recurrence of disease, family history, the number of involved joints and the location of tumor. Statistical analyses were performed using SAS ver. 9.3 (SAS Inc., Cary, NC, USA). p-values of <0.05 were deemed statistically significant. RESULTS: Patients with a family history of multiple osteochondromatosis showed a significantly decreased result of assessment, physical function, vitality of life, social activities, and health state. In addition, there was a tendency of a poor influence in pain, emotional wellbeing, and general health. CONCLUSION: The results suggest that family history is a significant factor influencing and predicting the quality of life. In other words, the developed patients in the household including patients with severe enough for the rest of the family to know have poor prognosis. Through this study multiple osteochondromatosis is a chronic disease having a profound impact on quality of life.

Assessment of Denosumab in Korean Postmenopausal Women with Osteoporosis: Randomized, Double-Blind, Placebo-Controlled Trial with Open-Label Extension

PURPOSE: The efficacy and safety of denosumab was compared with placebo in Korean postmenopausal women with osteoporosis in this phase III study. MATERIALS AND METHODS: Women aged 60 to 90 years with a T-score of <-2.5 and ≥-4.0 at the lumbar spine or total hip were randomized to a single 60 mg subcutaneous dose of denosumab or placebo for the 6-month double-blind phase. Eligible subjects entered the 6-month open-label extension phase and received a single dose of denosumab 60 mg. RESULTS: Baseline demographics were similar in the 62 denosumab- and 64 placebo-treated subjects who completed the double-blind phase. Treatment favored denosumab over placebo for the primary endpoint {mean percent change from baseline in lumbar spine bone mineral density (BMD) at Month 6 [3.2% (95% confidence interval 2.1%, 4.4%; p<0.0001)]}; and secondary endpoints (mean percent change from baseline in lumbar spine BMD at Month 1, total hip, femoral neck, and trochanter BMD at Months 1 and 6, and median percent change from baseline in bone turnover markers at Months 1, 3, and 6). Endpoint improvements were sustained over 12 months in the open-label extension (n=119). There were no new or unexpected safety signals. CONCLUSION: Denosumab was well tolerated and effective in increasing BMD and decreasing bone turnover markers over a 12-month period in Korean postmenopausal women. The findings of this study demonstrate that denosumab has beneficial effects on the measures of osteoporosis in Korean postmenopausal women.

Vitamin D Repletion in Korean Postmenopausal Women with Osteoporosis

PURPOSE: Up to 71% of South Korean postmenopausal women have vitamin D deficiency {serum 25-hydroxyvitamin D [25(OH) D] level <50 nmol/L}. Data on vitamin D supplementation was collected during the screening phase of an efficacy/safety study of denosumab in Korean postmenopausal women with osteoporosis. This report describes the effect of vitamin D supplementation on repletion to 25(OH)D levels ≥50 nmol/L in Korean postmenopausal women with osteoporosis. MATERIALS AND METHODS: Vitamin D levels of Korean postmenopausal women (60-90 years old) were measured by extracting 25(OH)D2 and 25(OH)D3 from serum samples via protein precipitation and using liquid chromatography with tandem mass spectrometry detection. Calibration curves were constructed from the mass chromatograms to obtain total vitamin D levels. Subjects with serum 25(OH)D levels <50 nmol/L were supplemented with 1000 IU of vitamin D tablets during the 2.5-month-long screening period. Dose, frequency, and duration were determined by the investigator. If repletion was achieved (≥50 nmol/L) on retest, subjects were eligible to be rescreened for study entry. RESULTS: Of 371 subjects screened, 191 (52%) required vitamin D supplementation, and 88% (168 of 191) were successfully repleted. More than half of the subjects (58%) who were successfully repleted received doses of 2000 IU daily. The mean time to successful repletion was 31 days (standard deviation 8.4 days; range 11-48 days). CONCLUSION: Supplementation with daily median doses of 2000 IU vitamin D successfully repleted 88% of Korean postmenopausal women with osteoporosis within 48 days to a serum vitamin D level of 50 nmol/L.

An Experimental Study for Minimum Level of Decalcification to Detect the Osteolytic Bone Metastasis of Long Bone on Plain Radiography

BACKGROUND: In 1951, Ardran reported that metastatic bone lesions could be detectable on plain radiography with 30% to 50% of decalcification. Authors performed experimental study for minimum level of decalcification to detect the osteolytic bone metastasis of long bone with recent technique of radiographs. METHODS: One pair of fibula and humerus from two cadavers was cut into specimen 1 inch in length. Distal half of specimen was dipped into hydrochloride (HCl) with 15 min interval. All 16 specimens were checked by film-type radiography (FR), computed radiography (CR), digital radiography (DR). To exclude inter-observer's variance, 3 radiologists evaluated images. Calcium amount before and after decalcification was measured and expressed in percentage of decalcification. RESULTS: Osteolytic changes were detectable with 11% to 16% of decalcification for fibula and 3% to 8% for humerus on plain radiography with FR, CR, and DR. CONCLUSIONS: Our study showed that minimum of 3% and maximum of 16% of decalcification is necessary when osteolytic metastatic bone lesions of long bone could be detected on plain radiography.

Efficacy of Dual Energy X-ray Absorptiometry for Evaluation of Biomechanical Properties: Bone Mineral Density and Actual Bone Strength

INTRODUCTION: Bone mineral density (BMD) is an important index in diagnosis of osteoporosis and other metabolic bone diseases, prediction of fractures, and monitoring treatment. This study was to find a more feasible technique for prediction of osteoporotic fracture between dual energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) and to reveal the actual change of bone strength when BMD was changed. METHODS: Ten of these 20 specimens were used as the demineralized group and the other 10 as the control. Each specimen was immersed in HCl solution at for a period of at least 10 minutes, up to 100 minutes, at an interval of 10 minutes for different levels of demineralization. BMD was measured using DXA and QCT. Uniaxial compression tests were conducted to measure biomechanical parameters. Pearson correlation analysis was used respectively between BMD and biomechanical parameters and between DXA and QCT. RESULTS: Elastic modulus (r=0.87) and yield stress (r=0.84) showed a statistically significant correlation with DXA BMD. Through correlation analysis with QCT BMD and elastic modulus, correlation coefficient showed hemi-vertebra (r=0.80) and trabecular (r=0.68). In yield stress, there was a statistically significant correlation in hemi-vertebra (r=0.87) and trabecular bone (r=0.84). CONCLUSION: DXA is a current standard technique not only for diagnosis of osteoporosis but also for prediction of fracture risk compared to QCT. Actual decrease of bone strength was much greater than that of BMD by both DXA and QCT.

The Result of Bone Grafting for Fibrous Dysplasia / 대한골관절종양학회지

PURPOSE: Fibrous dysplasia is related to the mutation of gene encoding the alpha-subunit of a signal-transducing G-protein and has variable clinical course. Operation can be performed to prevent functional disorder or structural deformity. After curettage, autologous bone graft were used to fill the defects after curettage. The aim of this study is to compare the result of autogenous cancellous bone grafting and allogenic bone grafting for fibrous dysplasia. MATERIALS AND METHODS: Among the patients who visit our hospital during the period of April, 1997 to October, 2013, we selected 34 patients who diagnosed fibrous dysplasia and visited our clinic over 1 year. There were 13 males and 21 females. Average age was 26.4 (range 2 to 57) years old. Autogenous bone graft (group I) in 5 cases, Non-autogenous bone graft (group II) in 30 cases. Iliac bone is used in all cases of autogenous bone graft. There were no significant difference in age, follow-up period, preoperational laboratory finding between two groups. Radiographic image was done to evaluate the recurrence of fibrous dysplasia or secondary degeneration. RESULTS: There were four cases in recurrence (group I: 1 case, group II: 3 cases, p=0.554). In all recurrent cases, reoperations were done using curettage and autogenous iliac bone graft. There was no re-recurrence after reoperation. One case of secondary aneurysmal bone cyst was confirmed (group II) and 1 cases of pathologic fractures had developed (group I: 0 case, group II: 1 cases, p=0.559). No malignant change occurred. CONCLUSION: There were no significant difference between autogenous bone graft group and non-autogenous bone graft group. Our result suggested that autogenous bone graft seems to be good method to treat fibrous dysplasia, in the case of small volume of tumor lesion or non-weight bearing portion.

The Failure of Polyethylene Lock of MUTARS(R) Distal Femur Tumor Endoprostheses: A Case Report / 대한골관절종양학회지

The guidelines for the treatment of massive bone defects caused by bone resection due to tumors have changed from amputation to limb salvaging surgery. Limb salvaging surgery using endoprotheses is a well-established procedure. However, Aseptic loosening, infection, and mechanical defect remain significant problems. Among them, we experienced the case with a breakage of polyethylene lock of MUTARS(R) distal femur tumor Endoprostheses.

Neurilemmoma in the Digital Nerve: 8 cases

As a rare cause of tumor in hand, we report eight cases of neurilemmoma in the digital nerve. Enucleation of the neurilemmoma under the microscopy resulted in complete relief of the symptoms at the latest follow-up.

An Atypical Subtrochanteric Femoral Fracture in a Patient with Multiple Myeloma Received Zoledronic Acid: A Case Report / 대한골관절종양학회지

Little literature exists about the risk of atypical femoral fracture in patients received zoledronic acid for prevention of skeletal metastasis. We report an atypical subtrochanteric femoral fracture in a patient with multiple myeloma received zoledronic acid. The patient was treated by closed reduction and internal fixation with cephalomedullary nailing.

Could Prior Oral-bisphosphonate Administration Reduce the Acute Phase Reaction of Zoledronate?

OBJECTIVE: Bisphosphonates are the most commonly prescribed medications for the treatment of osteoporosis. This study was designed to analyze the rate of acute phase reaction (APR) following Zoledronate 5 mg administration in patients with osteoporosis who were treated with prior oral bisphosphonate for at least 2 weeks and to compare naive IV 5 mg Zoledronate. METHODS: Between July 2009 and October 2010, 27 patients with osteoporosis who were treated with prior oral bisphosphonate for at least 2 weeks, and maximum 52 weeks (average 18.5 weeks) and were between 42-and 85-year-old at the time of study participation. We prospectively evaluated APR, including fever, flu-like symptoms, headache, arthralgia, and myalgia, after 5 mg zoledronate by questionnaire. Additionally we assessed a visual analogue scale (VAS) by 4-point categorical scale. RESULTS: In this study of 27 patients with osteoporosis, the frequency of APR, flu-like symptom and myalgia were 14.8% and 7.4% and fever, arthralgia, and headache were 3.7% respectively. In VAS, all reactions were mild. The rate of APR rate in this study was statistically decreased compared to previous reports with zoledronate 5 mg IV in bisphosphonate-naive patients. CONCLUSION: Prior oral bisphosphonate administration for at least 2 weeks could significantly reduce the APR of IV zoledronate 5 mg.

Analysis of Osteoporosis Risk-factor for Women after Menopause; Through the Free Medical-examination Campaign / 대한골다공증학회지

OBJECTIVES: We performed research and analysis to determine the risk factors of osteoporosis for women after menopause by conducting a survey and measuring the bone density through a free program to diagnose osteoporosis. SUBJECTS AND METHODS: Kyungpook National University organized and then started the free osteoporosis diagnosis program on May 11 in 2005. One hundred forty six women whose age was between the early forties and late eighties took the survey. The risk factors for osteoporosis were analyzed according to the data which was obtained from the survey. The measurements of the bone mineral density (BMD) of right calcaneus area were recorded by the use of ultrasound equipment. RESULTS: Within the results, between the advancing age (P=0.000) of subjects, the lower BMI (P=0.002), the more children (P=0.004), the breast fed longer (P=0.047), the individuals who had a lower age when menopause began (P=0.037) and their BMD showed significant correlation. CONCLUSIONS: The results express that the osteoporosis risk-factors for Korean women, despite the advancing age and the lower BMI as absolute factors, that the more children, the longer breast feeding and the lower the age that menopause began, would result in a lower density of bone.

Treatment of Subtrochanteric Femoral Fractures Using Selfdynamisable Internal Fixator

BACKGROUND: Surgical treatment is the preferred method for treating subtrochanteric femoral fractures and the variety of extramedullary and intramedullary implants continues to evolve. The purpose of our study was to retrospectively evaluate the clinical and radiological results of subtrochanteric fractures that are treated with the Selfdynamisable internal fixator. METHODS: From January 2000 to January 2004, we treated 49 consecutive patients who had subtrochanteric fractures. According to the AO classification, 8 (16.3%) fractures were type 32-A, 16 (32.7%) were type 32-B and 25 (51%) fractures were type 32-C. The mean follow-up time was 22.3 months. RESULTS: The average operating time was 45 minutes (range, 32 to 90 minutes). The average blood loss was 250 mL (range, 125 to 350 mL). The average hospital stay was 10 days (range, 7 to 59 days). Implant failure was not observed and union was achieved in all the patients. Deep infection occurred in one (2%) patient in the early postoperative period. Fracture union was achieved at a mean of 14 weeks. Varus malalignment less then 10 degree was noted in three (6.1%) patients at the end of follow-up. Thirty-five patients were pain-free and 14 had mild pain. CONCLUSIONS: The selfdynamisable internal fixator was successfully used for subtrochanteric fracture. It provides a short operative time, low blood loss, spontaneous biaxial dynamisation and healing in an optimal period of time without the need for secondary intervention.

Analysis of Local Recurrence of Giant Cell Tumor / 대한골관절종양학회지

PURPOSE: This study was aimed to evaluate the recurrence rate of a giant cell tumor (GCT) of the bone. MATERIALS AND METHODS: The medical records of fifty four patients who were diagnosed with a giant cell tumor of the bone between March 1980 and December 2008 were analysed retrospectively. Among 54 patients, 27 were men, remaining 27 were women with the mean age of 33.1 years (range, 13-67 years). The mean duration of follow-up was 67.1 months. RESULTS: Twenty-one patients (38.9%) had a local recurrence. The mean time to recurrence was 21.5 months (range, 2-59 months). The local recurrence rate of the upper extremities was higher than that of lower extremities. According to Campanacci classification, patients with a grade I diseae had lower recurrence rate than those with grade II or III disease. There was no significant differences in the recurrence rates based on cryotherapy, the filling of bone cement or bone grafts and surgical margin. CONCLUSION: To prevent local recurrence of GCT of bone, curettage of the tumor and elimination of the remaining cells are more important than adjuvant therapy.

Minimally Invasive Plate Osteosynthesis to Prevent or Treat the Deformity after Distraction Osteogenesis / 대한정형외과학회잡지

PURPOSE: To determine the efficacy of minimally invasive plate osteosynthesis (MIPO) for distraction callus after a lengthening procedure with an external fixator. MATERIALS AND METHODS: Distraction osteogenesis were performed using an external fixator for growth arrest (7 cases), congenital pseudoarthrosis of tibia (2 cases), and congenital leg length discrepancy (2 cases). MIPO was performed using a locking compression plate over the distraction callus. The mean age of the index procedure was 11 years, and mean amount of distraction was 5.4 cm. Eight were treated earlier to remove the external fixator after achieving of the target length, and 3 were treated as a salvage operation of fractures after removal. RESULTS: In all patients, the distraction callus healed with its length or correction into the original alignment maintained. The mean external fixation index was 34.3 days/cm and the mean healing index was 52.6 days/cm. In 8 patients with the early removal of the external fixator, the mean external fixation index was 26.9 days/cm. No patient developed a deep infection or implant failure. All patients recovered their preoperative joint motion and were satisfied with their function. CONCLUSION: MIPO can prevent or correct a deformity after distraction osteogenesis, and allow patients to return to their daily life earlier.

Double Plating of Proximal Tibial Fractures Using Minimally Invasive Percutaneous Osteosynthesis Technique

OBJECTIVES: To evaluate the results and its efficacy of double plating for proximal tibial fractures using minimally invasive percutaneous osteosynthesis (MIPO) technique. MATERIAL & METHODS: Twenty-three fractures, followed-up more than 1 year, were included in this retrospective study. There were 18 men and 5 women, and the mean age was 53.5 years-old. According to the AO-OTA classification, five were 41A, 13 were 41C, and 5 were 42. There were four open fractures (grade I- three, grade III A-one case). The plates were fixed on the medial and lateral sides of tibia with MIPO technique. Functional and radiographic results were evaluated by the modified Rasmussen system. RESULTS: All fractures healed without bone graft, and the mean period for fracture healing was 19.3 weeks (range, 10~32 weeks). All other patients had excellent or good clinical or radiological results, except for two patients of a fair clinical result after a combined injury. Complications included one case of shortening (1 cm) and two cases of mal-alignments (varus less than 10 degrees). There was one case of superficial infection, but no patient showed deep infection. CONCLUSION: Double plating using MIPO technique can provide favorable results in the treatment of proximal tibial fractures.

Internal Bone Transport in the Management of Tibial Bone Defects

PURPOSE: To retrospectively review the results of internal bone transport in the management of tibial bone defect using ilizarov fixator. MATERIALS AND METHODS: We treated 39 cases of tibial bone defect (16 of traumatic bone loss, 23 after treatment of osteomyelitis). The mean age of index procedure was 33.8 years (range, 13~66 years), and all of them had follow-up study for a mean of 3.5 years (range, 1.6~8 years). The mean transported amount was 6.3 cm (range, 2.7~20 cm), and the external fixator was removed after 345 days (range, 120~700 days). The mean external fixation index was 60.3 days/cm (range, 13.1~121.3 days/cm). RESULTS: Primary union of distraction and docking site was achieved in all, but two patients had failure in union of docking site. Functional results showed 6 excellent, 19 good, 10 fair, and 4 fair. The patients under age 20 showed better functional outcomes than the others. Among 73 complications (incidence, 1.87 cases/ patient), 27 of major complications with residual sequelae occurred in 20 patients. The residual sequelae were more common in the patients who had the concomitant injuries in the same leg. CONCLUSION: Internal bone transport can solve the large amount of tibial bone defect. However, the complications are not uncommon, which might be related to the concomitant injures in the same leg.

Analysis of Bone Mineral Density and Biochemical Markers in Hip Fractures Injured by Low-energy Trauma / 대한정형외과학회잡지

PURPOSE: This study was conducted to compare bone mineral density (BMD) and biochemical markers of bone metabolism of an osteoporotic hip fracture group with those of a control group. MATERIALS AND METHODS: The fracture group included 76 patients with hip fractures who were injured by low energy trauma from November, 1999 to August, 2003. The control group consisted of 83 patients recruited over the same period. There were 22 men and 54 women in the fracture group, with an average age of 67.2 years for men and 71.1 years for women. In the control group, there were 22 men and 61 women, of average age 67.9 years for men and 70.1 years for women. There were no siginificant differences in age, height, weight, or body mass index. We analyzed BMD by a dual energy X-ray absorptiometry (DEXA). Bone specific alkaline phosphatase (B-ALP) and osteocalcin were used as markers of bone formation and urine-deoxypyridinoline (DPD) as a maker of bone resorption. RESULTS: B-ALP showed a significant decrease in the fracture group (p<0.05). Also, average serum osteocalcin showed a significant decrease in the fracture group (p<0.05). There was no significant difference in urine-DPD between the two groups. The mean values of BMD in men and women were significantly decreased in the fracture group. CONCLUSION: The results of this study suggest that a decreased BMD contributes to hip fractures in elderly people and that B-ALP and serum osteocalcin rather than urine-DPD are reliable biochemical markers of bone metabolism in osteoporotic hip fractures.

Femoral Lengthening with External Fixator over the Intramedullary Nail / 대한정형외과학회잡지

PURPOSE: The results and complications of femoral lengthening over an intramedullary nail with a external fixator in patients with limb length discrepancy were retrospectively reviewed. MATERIALS AND METHODS: After lengthening 22 femoral segments, all patients were followed-up for a mean of 3.2 years (range, 2 to 5.2 years). They ranged in age from 13 to 35 years (average age, 22.2 years) at the time of the index procedure. The mean lengthening was 5 cm (2.7 to 8.1 cm), and the external fixator was removed after a median 135.9 days (range, 59 to 210 days). The mean external fixation index was 23.8 days/cm of lengthening (range, 11.1 to 34.7 days/cm of lengthening). RESULTS: Nineteen patients achieved the length of their pre-operative goal. However, there were 3 failures with osteomyelitis and the removal of the nail, which had a past history of infection or open trauma. There were 4 knee joint complications when the lengthening was over 20%. These included three cases of a patella subluxation and one case of a posterior knee subluxation. In the other complications, there was one case of a collapse in the lengthened segment with a breakage of the locking screws. CONCLUSION: Although lengthening over a nail can reduce the duration of external fixation, caution is needed in order to prevent complications.

Grade III Tibia Open Fractures Treated with Unreamed Tibial Nailing

PURPOSE: This is a retrospective study to analyze the results of unreamed intramedullary nailing in grade III tibial open fracture. MATERIALS AND METHODS: Twenty-nine Gustilo-Anderson grade III tibial open fractures fixed with unreamed tibial nail were followed more than one year. Primary union rate, union time, infection, conversion to external fixation, ankle and knee function according to different grade of open, fracture level, AO classification, and muscle flap were evaluated. RESULTS: Primary union was achieved at sixteen fractures. There were three delayed union that achieved union twenty week after primary operation. And eight undergone secondary bone grafts which were done after inflammation sign subcided. Complications about infection were in five cases. Two cases were unable to maintain internal fixation due to deep infection, and three of superficial infection were treated with repeated debridement and antibiotics use. CONCLUSION: In grade III tibial open fracture, unreamed nailing with early soft tissue reconstruction and early prophylactic bone graft can be a good treatment.