Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review.

Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem. PURPOSE: Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries. METHODS: We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures. RESULTS: All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women. CONCLUSION: Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.

The risk of osteoporotic fracture in gastric cancer survivors: total gastrectomy versus subtotal gastrectomy versus endoscopic treatment.

PURPOSES: Previous studies have suggested that there is an increased risk of osteoporotic fracture in gastric cancer survivors. However, the data was not classified according to surgery type. This study investigated the cumulative incidence osteoporotic fracture (OF) in gastric cancer survivors according to treatment modality. METHODS: A total of 85,124 gastric cancer survivors during 2008-2016 were included. The type of surgery was classified as total gastrectomy (TG, n = 14,428)/subtotal gastrectomy (SG, n = 52,572)/endoscopic mucosal dissection and endoscopic mucosal resection (ESD/EMR, n = 18,125). The site of osteoporotic fractures included the spine, hip, wrist, and humerus. We examined cumulative incidence using Kaplan-Meier survivor analysis and cox proportional hazards regression analysis to determine the risk factor of OF. RESULTS: The incidence of OF per 100,000 patient year was 2.6, 2.1, 1.8 in TG, SG, ESD/EMR group. The cumulative incidence rate was 2.3% at 3 years, 4.0% at 5 years, and 5.8% at 7 years in gastrectomy group, and 1.8% at 3 years, 3.3% at 5 years in the SG group, and 4.9% at 7 years postoperatively in ESD/EMR group. TG increased the risk of OF compared to patients who underwent SG (HR 1.75, 95% confidence interval [CI] 1.57-1.94), and ESD/EMR (hazard ratio [HR] 2.23, 95% CI 2.14-2.32). CONCLUSION: Gastric cancer survivors who underwent TG had an increased osteoporotic fracture risk than did SG or ESD/EMR in these patients. The amount of gastric resection and accompanying metabolic changes seemed to mediate such risk. Additional research is needed to establish an optimal strategy for each type of surgery.

The Korean hip fracture registry study.

BACKGROUND: The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model. METHODS: The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey. DISCUSSION: KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants. TRIAL REGISTRATION: Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).

Hip Magnetic Resonance Arthrography Using Normal Saline Is Less Accurate Than Using a Gadolinium-Based Contrast Agent.

PURPOSE: To evaluate the diagnostic performance of hip magnetic resonance (MR) arthrography with a gadolinium-based contrast agent (GBCA) or normal saline (NS) for intra-articular pathologies. METHODS: This retrospective study was approved by the institutional review board of our hospital, and the requirement for informed consent was waived. The study included 37 consecutive patients (38 hips; 21 right hips; 24 males; mean age, 33 years) who underwent GBCA-hip MR arthrography from July 2011 to January 2020 and 30 consecutive patients (30 hips; 20 right hips; 21 males; mean age, 40 years) who underwent NS-hip MR arthrography from January 2018 to June 2020. All images were evaluated twice independently by two radiologists blinded to the arthroscopic findings for the presence of labral tears, cartilage abnormalities, or ligamentum teres tears. Intrareader and interreader reliabilities were determined by kappa values (k) using the chi-squared test, and diagnostic performance was evaluated based on the arthroscopic findings. A P value less than .05 was considered to indicate statistical significance. RESULTS: Intra-reader reliability in the detection of intra-articular pathologies ranged from moderate to almost perfect (k = 0.510-0.840) and inter-reader reliability ranged from moderate to substantial (k = 0.441-0.695) for GBCA- and NS-hip MR arthrography. The diagnostic accuracy of GBCA- and NS-hip MR arthrography was as follows: 81.6-92.1% and 66.7-73.3% for labral tears, respectively; 68.4-86.8% and 63.3-70.0% for cartilage abnormality, respectively; and 68.4-76.3% and 50.0-56.7% for ligamentum teres tears, respectively. CONCLUSION: NS-hip MR arthrography may be less accurate than GBCA-hip MR arthrography. LEVEL OF EVIDENCE: Level II of development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding).

A 10- to 12-year follow-up study of delta ceramic-on-ceramic total hip arthroplasty.

BACKGROUND: We previously reported five-to-seven-year results of total hip arthroplasty (THA) with the use of delta ceramic-on-ceramic (CoC) bearing. We conducted an extension study with a CT scan at a minimum of 10 years after surgery. METHODS: From March 2009 to March 2011, 273 patients (310 hips) received cementless THA with delta CoC bearing, porous-coated cup and hydroxyapatite-coated stem. In this extended study, 252 patients (144 men and 108 women) (288 hips) with a mean age of 49.7 years (16-83) at surgery were followed for a mean of 10.4 years (10-12) with CT scans in 133 hips (46.2%, 133/288). Clinical and radiographic evaluations were made at each follow-up and Kaplan-Meier survival analysis was performed with revision and reoperation as endpoints. RESULTS: There were no more ceramic fractures. Compared to mid-term results, the incidence of squeaking and RLLs increased to 3.1% (9/288) and 19.4% (56/288), respectively. The RLL progressed to focal osteolysis in 3 hips (5.4%, 3/56). No hip had detectable wear or prosthetic loosening. Two hips were reoperated due to periprosthetic joint infection and periprosthetic femoral fracture in each. The survivorship decreased to 98.3% (96.7-99.9%) at 12 years. CONCLUSION: During the extended follow-up, no additional ceramic fracture occurred, and the incidence of squeak increased by 0.7%. The long-term survivorship of Delta CoC THA was encouraging. However, focal osteolysis occurred around the hydroxyapatite-coated stem in 1% (3/288). LEVEL OF EVIDENCE: II (Prospective cohort study).

The Potential Economic Benefits of an Alarm Service in Order Communication Systems in Korea: a Cost-Effectiveness Analysis of Less-Intensive Fracture Liaison Services Based on a Prospective Cohort Study.

An alarm service in an order communication system (OCS) was found to be effective at increasing the rate of dual-energy X-ray absorptiometry (DXA) testing and treatment in South Korea, but its cost-effectiveness remains unknown. We used a Markov model to determine the cost-effectiveness of the alarm service in the OCS compared to no alarm service for the post-fracture management of subjects aged 50 years and older with fragility fractures. DXA testing and treatment data were collected from a prospective cohort study. The prevalence of osteoporotic fractures, the subsequent risk of hip fracture, and healthcare costs were obtained using Korea National Health Insurance claims data. The lifetime cost and quality-adjusted life-years (QALYs) gained were estimated from a healthcare perspective. A probabilistic sensitivity analysis was performed to examine the uncertainty of the results. The alarm service increased treatment by 125 per 1000 patients and prevented 3 hip fractures per 1000 patients. The alarm service cost an additional 249,393 KRW and resulted in an increase of 0.008 QALYs per patient compared to no alarm service. The incremental cost-effectiveness ratio was 31,174,125 KRW (26,843 USD) per QALY gained. The alarm service was cost-effective than no alarm service if the willingness to pay setting as 1GDP per capita (29,288 USD) per QALY gained. This study shows that less-intensive fracture liaison services, such as an alarm service, are cost-effective for patients aged 50 years and older with osteoporotic fractures in Korea. An intensive model, including enhanced identification and education, could further prevent the risk of refracture and improve cost-effectiveness.

Sarcopenia: an unsolved problem after hip fracture.

INTRODUCTION: Sarcopenia, loss of muscle mass and strength, leads to functional dependence and disability. To date, no study reported the postoperative change of sarcopenia prevalence after hip fractures. Thus, we assessed postoperative changes in the prevalence of osteoporosis and sarcopenia in hip fracture patients. MATERIALS AND METHODS: Among 1159 patients, who underwent surgery for low-energy hip fractures between May 2012 and December 2019, 224 patients (38 men and 186 women with a mean age of 76.8 ± 8.7 years) were studied with preoperative and follow-up dual-energy X-ray absorptiometry (DXA). Bone mineral density (BMD) and skeletal muscle mass were measured on DXA scans. The postoperative changes in the prevalence of osteoporosis and that of the sarcopenia were evaluated as well as Koval grade of the hip fracture patients. RESULTS: While there was no significant change in BMD, SMI significantly decreased postoperatively. Mean decrease of the SMI was 0.53 kg/m2 in men and 0.38 kg/m2 in women. Prevalence of sarcopenia increased from 63 to 89% (p = 0.014) in men and from 45 to 57% (p = 0.006) in women. Lower BMI (Odds ratio (OR) 0.85 (95% confidence interval (CI) 0.76-0.96), p = 0.008) and prior sarcopenia (OR 14.47 (95% CI 5.29-35.39), p < 0.001) were the risk factors for the decrease of SMI after hip fracture. CONCLUSIONS: After hip fracture, osteoporosis seemed to be well managed and the prevalence of osteoporosis did not increase. However, SMI decreased and the prevalence of sarcopenia increased. More active measures are warranted to prevent sarcopenia in elderly hip fracture patients.

High Risk of Neck-liner Impingement and Notching Observed with Thick Femoral Neck Implants in Ceramic-on-ceramic THA.

BACKGROUND: Recently, impingement between the femoral stem and ceramic liner, which appears as a notch in the stem neck on radiographs, has emerged as a new complication. However, the proportion of impingement, potential risk factors, and related complications are poorly elucidated. QUESTION/PURPOSES: In patients who underwent ceramic-on-ceramic (CoC) THA and had at least 10 years of follow-up, we asked: (1) What proportion had radiographic evidence of stem neck-ceramic liner impingement (notching of the stem), and what implant design, implantation factors, or complications such as ceramic fracture or metallosis are associated with impingement? (2) How common are the complications of noise and ceramic fracture? (3) What are the radiologic changes (including fixation of femoral and acetabular components, osteolysis, and heterotopic ossification) and clinical outcomes as determined by the modified Harris hip score (mHHS) for this cohort? (4) What is the survivorship with implant revision as the endpoint and with reoperation for any reason as the endpoint after CoC THA using a thick-neck stem design? METHODS: Between May 2003 and April 2010, 643 patients underwent primary THA at a tertiary referral hospital. After excluding patients with metal-on-polyethylene and with ceramic-on-polyethylene implants, 621 patients were considered eligible for this study. All patients received the same hemispherical titanium cup, a standard-length tapered titanium stem, and a CoC bearing. Of those, 19% (115) were lost to follow-up before 10 years, and 8% (50) were excluded because they died before the minimum follow-up duration of 10 years, leaving 73% (456) for analysis. Patients had a mean age of 50 ± 14 years and were followed for a median (range) of 13 years (10 to 17). The mean cup abduction was 38° ± 5°, and the mean cup anteversion was 26° ± 7°. To determine the proportion of patients with the neck-liner impingement, we analyzed the plain radiographs of every patient during follow-up to detect notches around the stem. The detection of stem neck notches on the radiographs was reliable (intraobserver reliability: κ = 0.963; p < 0.001 and interobserver reliability: κ = 0.975; p < 0.001). To evaluate factors related to notching, we compared the possible confounding factors including gender, age, BMI, implant position, neck length, and head diameter. Complications such as ceramic fracture, noise, dislocation, and periprosthetic joint infection were recorded. Noise was evaluated via interview and with the Hip Noise Assessment Questionnaire, which assessed the noise qualitatively. For clinical outcome, we assessed the mHHS, which includes pain and function scales (0 [worst] to 100 [best]), every visit. Tilting of at least 4° or migration of at least 4 mm was the criteria for cup loosening; subsidence more than 3 mm, any change in position, or a continuous radiolucent line greater than 2 mm was the criteria for stem loosening. To evaluate osteolysis, we performed CT scans in 57% (262 of 456) of patients. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from implant revision and survivorship free from reoperation for any cause. RESULTS: The proportion of stem neck notching was 11% (49 of 456). There were no differences in cup abduction and anteversion between hips with notches and those without notches. Notched hips were more likely to have 28-mm than 32-mm heads (90% [44 of 49] versus 70% [285 of 407]; odds ratio 3.77 [95% CI 1.46 to 9.73]; p = 0.004). None of the 49 notched hips had a ceramic head or liner fracture or evidence of metallosis. A ceramic head fracture was reported in 2% (9 of 456); all fractures occurred in 28-mm short neck heads. A ceramic liner fracture occurred in 0.2% (1 of 456), and noise was noted in 6% (27 of 456). Acetabular osteolysis developed in 2% (7 of 456). The mHHS was 91 ± 12 points at the final follow-up. The survivorship free from implant revision was 97% (95% CI 96% to 99%), and the survivorship free from reoperation for any cause was 96% (95% CI 95% to 98%) at 13 years. CONCLUSION: The proportion of stems with neck-ceramic liner impingement and ceramic component fracture were unacceptably high after the use of a thick-neck stem design, especially when a 28-mm head was used. We have discontinued the use of this stem design and we recommend that such stems should not be used when CoC bearings are used. As these findings might be generalized to other bearing couples, further studies focused on polyethylene liner wear and local metallosis due to thick stem neck are warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.

Do Cementless Short Tapered Stems Reduce the Incidence of Thigh Pain After Hip Arthroplasty? Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this study was to determine whether short tapered stems reduce the rate of thigh pain through a systematic review and meta-analysis of comparative studies between short tapered stems and standard-length tapered stems. METHODS: We conducted a meta-analysis of comparative studies: 1) retrospective studies and 2) randomized controlled trials (RCTs), on 2 stem designs: short tapered stem versus standard-length tapered stem. Studies were selected by means of the following criteria: 1) study design: retrospective comparative studies, prospective comparative studies, RCTs; 2) study population: patients with total hip arthroplasty or hemiarthroplasty for hip disease or hip fracture; 3) intervention: short tapered stem and standard tapered stem; and 4) outcomes; thigh pain, other clinical results. RESULTS: Among the 250 articles that were identified at the initial search, 6 studies, 4 RCTs and 2 retrospective comparative studies, were included in this meta-analysis. In the analysis of retrospective studies, the short tapered stem reduced the risk of thigh pain compared to the standard tapered stem (risk ratio [RR] = 0.13; 95% confidence interval [CI], 0.02-0.09; Z = -2.07; P = 0.039). However, in the analysis of RCTs, the incidence of thigh pain was similar between the two stem designs (RR = 1.21; 95% CI, 0.76-1.93; Z = 0.82; P = 0.410). Overall meta-analysis including all studies showed that the short tapered stem did not reduce the incidence of thigh pain compared to the standard-length tapered stem (RR = 0.91; 95% CI, 0.59-1.40; Z = -0.44, P = 0.663). CONCLUSIONS: We did not find a significant difference in the incidence of thigh pain between short tapered stem and standard tapered stem in hip arthroplasty. TRIAL REGISTRATION: PROSPERO Identifier: CRD42021231240.

Operational Definition Identifying Osteoporotic Vertebral Fractures in the Claims Database.

BACKGROUND: We analyzed the International Classification of Diseases, 10th edition (ICD-10) diagnostic codes, procedure codes, and radiographic image codes for vertebral fracture (VF) used in the database of Health Insurance Review and Assessment Service (HIRA) of Korea to establish a validated operational definition for identifying patients with osteoporotic VF in claims data. METHODS: We developed three operational definitions for detecting VFs using 9 diagnostic codes, 5 procedure codes and 4 imaging codes. Medical records and radiographs of 2,819 patients, who had primary and subordinated codes of VF between January 2016 and December 2016 at two institutions, were reviewed to detect true vertebral fractures. We evaluated the sensitivity and positive predictive value (PPV) of the operational definition in detecting true osteoporotic VF and obtained the receiver operating characteristic (ROC) curve. RESULTS: Among the 2,819 patients who had primary or secondary diagnosis codes for VF, 995 patients satisfied at least one of the criteria for the operational definition of osteoporotic VF. Of these patients, 594 were judged as having true fractures based on medical records and radiographic examinations. The sensitivity and PPV were 62.5 (95% confidence interval [CI], 59.4-65.6) and 59.7(95% CI, 56.6-62.8) respectively. In the receiver operating characteristic analysis, area under the curve (AUC) was 0.706 (95% CI, 0.688-0.724). CONCLUSION: Our findings demonstrate the validity of our operational definitions to identify VFs more accurately using claims data. This algorithm to identify VF is likely to be useful in future studies for diagnosing osteoporotic VF.

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study.

BACKGROUND: The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications. METHODS: In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH. RESULTS: In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10-5). CONCLUSION: This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH. LEVEL OF EVIDENCE: Level III, diagnostic study.

Translation and validation of the Korean version of the Sarcopenia Quality of Life (SarQoL-K®) questionnaire and applicability with the SARC-F screening tool.

PURPOSE: The purpose of this paper was to translate and validate into the Korea language and setting the Sarcopenia Quality of Life (SarQoL®) questionnaire. METHODS: The participants consisted of 450 individuals in Namgaram-2 cohort who were followed up in 2019-2020. The study participants were divided into four groups: (1) SARC-F < 4, (2) SARC-F ≥ 4 and robust grip strength, (3) SARC-F ≥ 4, low grip strength, robust muscle mass, (4) SARC-F ≥ 4, low grip strength, and low muscle mass. To assess construct validity, population with sarcopenia-associated symptoms (SARC-F ≥ 4) apart from the Korean SarQoL (SarQoL-K®) completed the Korean versions of two generic questionnaires, the Short Form-36 and the EuroQoL 5-dimension. To validate the Korean SarQoL®, we assessed its validity (discriminative power, construct validity), reliability (internal consistency, test-retest reliability), and floor/ceiling effects. RESULTS: The SarQoL-K® questionnaire was translated without major difficulties. The mean SarQoL-K scores were 72.9 (95%, CI; 71.2-74.6) in SARC-F < 4, 54.6 (95%, CI; 50.7-58.3) in SARC-F ≥ 4 and robust grip strength, 47.0 (95%, CI; 43.8-50.1) in SARC-F ≥ 4, low grip strength, robust muscle mass, 46.6 (95%, CI; 43.0-50.1) in SARC-F ≥ 4, low grip strength, and low muscle mass. The results indicated good discriminative power across each four groups (p < 0.001), high internal consistency (Cronbach's alpha of 0.866), and excellent test-retest reliability (ICC = 0.977, 95% CI 0.975-0.979). No floor- or ceiling-effects were observed. CONCLUSIONS: This is the first study to confirm the reliability and validity of the Korean version of the SarQoL®. We demonstrated that the population with sarcopenia-associated symptoms (determined using the SARC-F questionnaire) has a lower quality of life.

No Clinically Important Differences in Thigh Pain or Bone Loss Between Short Stems and Conventional-length Stems in THA: A Randomized Clinical Trial.

BACKGROUND: Short-length stems were developed to reduce bone loss of the proximal femur and potentially decrease the incidence of thigh pain after cementless THA. However, it remains unknown whether short stems indeed reduce bone loss or the frequency of thigh pain. QUESTIONS/PURPOSES: Is there a difference between short- and standard-length stems in terms of: (1) the frequency or severity of thigh pain, (2) modified Harris hip scores, (3) implant loosening, or (4) bone mineral density as measured by dual-energy x-ray absorptiometry? METHODS: Between March 2013 and January 2014, three surgeons performed 205 primary THAs. To be eligible, patients needed to be at least 20 years of age, have not undergone previous history of hip surgery, and have no metabolic bone disease. A total of 100 patients were randomized to receive THA either with a short stem (n = 56) or with a standard-length stem (n = 44). Both stems were proximally coated, tapered, cementless stems. Compared with standard stems, short stems typically were 30- to 35-mm shorter. A total of 73% (41 of 56) and 77% (34 of 44) of those groups, respectively, were accounted for at a minimum of 5 years and were analyzed. The presence of thigh pain during activity was evaluated using a 10-point VAS, and the modified Harris hip score was calculated by research assistants who were blinded to the treatment groups. Plain radiographs were taken at 6 weeks, 6 months, and 12 months postoperatively, and every 1 year thereafter; loosening was defined as subsidence > 3 mm or a position change > 3° on serial radiographs. Radiological assessment was performed by two researchers who did not participate in the surgery and follow-up evaluations. Bone mineral density of the proximal femur was measured using dual-energy x-ray absorptiometry at 4 days, 1 year, 2 years, and 5 years postoperatively. The primary endpoint of our study was the incidence of thigh pain during 5-year follow-up. Our study was powered at 80% to detect a 10% difference in the proportion of patients reporting thigh pain at the level of 0.05. RESULTS: With the numbers available, we found no difference between the groups in the proportion of patients with thigh pain; 16% (9 of 56) of patients in the short-stem group and 14% (6 of 44) of patients in the standard-stem group experienced thigh pain during the follow-up period (p = 0.79). In all patients, the pain was mild or moderate (VAS score of 4 or 6 points). Among the 15 available patients who reported thigh pain, there was no difference between the implant groups in mean severity of thigh pain (4.3 ± 0.8 versus 4.2 ± 0.7; p = 0.78). There were no between-group differences in the short versus standard-length stem groups in terms of mean modified Harris hip score by 5 years after surgery (89 ± 13 versus 95 ± 7 points; p = 0.06). No implant was loose and no hip underwent revision in either group. Patients in the short-stem group showed a slightly smaller decrease in bone mineral density in Gruen Zones 2, 3, and 5 than those in the standard-stem group did; the magnitude of the difference seems unlikely to be clinically important. CONCLUSION: We found no clinically important differences (and few differences overall) between short and standard-length THA stems 5 years after surgery in a randomized trial. Consequently, we recommend that clinicians use standard-length stems in general practice because standard-length stems have a much longer published track record in other studies, and short stems can expose patients to the uncertainty associated with novelty, without any apparent offsetting benefit. LEVEL OF EVIDENCE: Level I, therapeutic study.

Burden and future projection of revision Total hip Arthroplasty in South Korea.

BACKGROUND: The annual number of hip arthroplasties is increasing combined with the aging population worldwide. In accordance with the increasing number of primary hip arthroplasties, the number of revision total hip arthroplasties (THAs) is expected to increase. The incidence and burden of revision THAs in the United States and have been reported by registry studies. To identify potential differences according to ethnics and regional practice, it is important to obtain data from East Asia. Nevertheless, there has been a lack of studies on the burden and future projection of revision THA based on a large-scale database in East Asia. The purpose of this study was to evaluate annual incidence and burden of revision THAs and to project the future burden in South Korea. METHODS: We identified primary THAs, primary hemiarthroplasties (HAs) and revision THAs, which were performed from 2010 to 2018, using database of Health Insurance and Review and Assessment (HIRA); nation-wide medical claim system of South Korea. The annual incidence rates (per 100,000) of primary THA, primary HA and revision THA, and the annual burden of revision THA; the number of revision THAs divided by the sum of primary hip arthroplasties and revision THAs, were calculated. The future burden of revision THAs were projected through 2030 using generalized linear model with Quasi-poisson regression. RESULTS: During the 9-year period, the annual incidences of primary THA, primary HA and revision THA increased by 47, 29 and 3%, respectively, while the revision burden decreased from 0.13 to 0.10. Compared to 2018, the annual incidences of primary THA, HA, and revision THA were projected to increase by 7.2, 2.3 and 1.1% per year, respectively, whereas the burden of revision THA was projected to decrease to 0.07 in 2030. CONCLUSION: Trends of revision THA in South Korea were similar with those of national registry studies from the United States. The annual incidence of revision THA has steadily increased, whereas its burden has decreased. Findings of our study could be used for epidemiological comparison between Western countries and East Asia as well as for the establishment of medical policies of revision THA in East Asian countries.

Effect of Dementia on Postoperative Mortality in Elderly Patients with Hip Fracture.

BACKGROUND: The aim of this study was to assess the prevalence of dementia as an underlying disease in elderly patients with hip fracture, to investigate the effect of dementia on postoperative mortality after surgery of hip fracture, and to analyze the differences in postoperative mortalities according to the severity of dementia through subgroup analysis. METHODS: This study selected 2,346 elderly patients who were diagnosed with unilateral intertrochanteric or femoral neck fractures who underwent surgery between January 2004 and December 2018. The patients were classified into the non-dementia group (2,196 patients) and dementia group (150 patients; no-medication [66 patients] and medication [84 patients] subgroups). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the groups. A univariate regression test was performed using age, sex, diagnosis, surgery type, and Charlson's comorbidity index (CCI), as these variables had P values of < 0.10. Multivariate regression analysis was performed to identify independent risk factors associated with mortality. RESULTS: The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.8%, 3.8%, 5.6%, 8.9%, and 13.6%, respectively, in the non-dementia group, and 2%, 7.3%, 14%, 19.3%, and 24%, respectively, in the dementia group (P = 0.748, P = 0.048, P < 0.001, P < 0.001, and P = 0.001). The factors that affected the 1-year mortality were age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.08; P < 0.001), sex (OR, 2.68; 95% CI, 2.07-3.47; P < 0.001), CCI (OR, 1.34; 95% CI, 1.23-1.47; P < 0.001), and dementia (OR, 1.70; 95% CI, 1.46-1.08; P = 0.016). In subgroup analysis, severity of dementia influenced the 6-month mortality (OR, 1.41; 95% CI, 1.70-2.01; P = 0.018), and 1-year mortality (OR, 1.30; 95% CI, 1.17-1.90; P = 0.027). CONCLUSION: In elderly hip fracture patients, the comparison between patients with and without dementia revealed that dementia was an independent risk factor for mortality at a minimum of 1 year of follow-up, and the severity of dementia in hip fracture patients was a risk factor for mortality within 6 months and 1 year, postoperatively.

Incidence and Risk of Venous Thromboembolism in Bisphosphonates and Selective Estrogen Receptor Modulators Treatment in Korea.

BACKGROUND: Selective estrogen receptor modulators (SERMs) were associated with an increased risk of venous thromboembolism (VTE) due to the estrogen effect. In this study, we investigated the effect of SERMs on VTE compared to bisphosphonates (BPs) using the Korean National Health Insurance claims database. METHODS: This was a retrospective cohort study. Women over 50 years old who were first prescribed BPs or SERMs for osteoporosis treatment in 2012 were included. The difference in VTE incidence between the SERMs and BP groups was compared. Both groups were followed up for VTE or PE occurrence, death, or until December 2016. The study population was analyzed by 3:1 matching according to age using a multivariate Cox model. RESULTS: The hazard ratio (HR) for VTE was 0.72 (95% confidence interval [CI], 0.40-1.28) in the SERMs group compared to BP group. Older age (60-69 vs. 50-59 years: HR, 3.77; 95% CI, 2.07-6.86 and 70-79 vs. 50-59 years: HR, 5.88; 95% CI, 3.14-11.02), major osteoporotic fracture (HR, 1.77; 95% CI, 1.16- 2.70), atrial fibrillation (HR, 3.31; 95% CI, 1.35-8.11), and estrogen replacement (HR, 3.40; 95% CI, 2.01-5.73) all increased VTE risk. In subgroup analysis of the SERMs group, past hospitalization (HR, 2.24; 95% CI, 1.02-4.92), estrogen replacement (HR, 5.75; 95% CI, 2.29-14.39), and glucocorticoid replacement (HR, 2.71; 95% CI, 1.05-7.0) increased VTE risk. CONCLUSION: SERMs did not increase the risk of VTE compared to BPs in Koreans with osteoporosis. However, old age and estrogen replacement both increased VTE risk.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment.

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

Validation of an Operational Definition to Identify Distal Radius Fractures in a National Health Insurance Database.

PURPOSE: To develop and validate identification criteria for distal radius fractures (DRFs) and their treatment using a national health insurance database. METHODS: Patients who had at least 1 wrist radiograph taken in 2018 were recruited from a single academic referral hospital. After excluding patients who lacked immobilization code for wrist pathology, we collected data on the overall population. Because some patients might have undergone wrist radiography at another institution or had DRFs without an immobilization code, we additionally included patients who had a DRF diagnosis code at our institution. Reviews of medical records and wrist radiographs were considered for the diagnosis of DRF. We evaluated the sensitivity, specificity, and positive predictive value (PPV) of 3 operational definitions of fractures that were based on a single primary or secondary diagnosis code; all diagnosis codes, including primary and secondary codes; and all diagnosis and procedure codes. RESULTS: Among 768 patients included in the study, true DRFs were confirmed in 305. The sensitivity, specificity, and PPV for definition 1 were 91.5% (95% CI, 88.3%-94.6%), 97.5% (95% CI, 95.9%-99.1%), and 96.9% (95% CI, 94.9%-98.9%), respectively. Although the sensitivity of definition 2 was higher (92.1%; 95% CI, 89.1%-95.2%), its specificity and PPV were lower (96.4% [95% CI, 94.4%-98.3%] and 95.6% [95% CI, 93.2%-97.9%], respectively). The sensitivity of definition 3 was the lowest (88.2%; 95% CI, 84.6%-91.8%), but its specificity and PPV were the highest among the 3 definitions (98.6% [95% CI, 97.4%-98.8%] and 98.2% [95% CI, 96.6%-99.8%], respectively). CONCLUSIONS: Patients with DRFs can be identified from claims databases with high accuracy using an operational definition based on DRF diagnosis and procedure codes, including codes for surgical and nonoperative methods. CLINICAL RELEVANCE: Verified operational definitions will increase the consistency of results in future national health insurance database studies related to DRFs.

Diagnosis and Treatment of Femoral Head Osteonecrosis: A Protocol for Development of Evidence-Based Clinical Practice Guidelines.

INTRODUCTION: There are many treatment options for patients who have osteonecrosis of the femoral head (ONFH) and management strategies vary widely both among and within individual countries. Although many researchers have attempted to elucidate the optimal strategies for managing this disease, the lack of large-scale randomized control trials and the lack of agreement on disease staging have curtailed the development of clear-cut guidelines. MATERIALS AND METHODS: The Association Research Circulation Osseous (ARCO) group sought to address three questions for the management of patients who have ONFH: 1) What imaging studies are most sensitive and specific for the diagnostic evaluation of patients who have ONFH?; 2) What is the best treatment strategy for preventing disease progression in patients who have pre-collapse lesions?; and 3) What is the best treatment strategy for patients who have post-collapse disease? The Patient, Intervention, Comparison, and Outcome (PICO) format was used to formulate the search strategy for each research question. A systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ARCO participants have been allocated to three groups, each representing one of the PICO questions. After qualitative and quantitative analysis of the data extracted from studies pertaining to each of the three research questions, a set of evidence-based clinical practice guidelines will be proposed for the management of patients who have ONFH. DISCUSSION: It is not always clear which treatment method is optimal for the management of ONFH. Thus, many surgeons have developed and performed various procedures based on patient-specific factors. As there is no consensus on the optimal treatment for various stages of disease, it was clear that developing evidence-based clinical practice guidelines would provide more structure and uniformity to management of these patients. Therefore, the results of this systematic review will lead to the development guidelines that may improve patient-care strategies and result in better outcomes for patients who have ONFH.