Longitudinal Analysis of Circulating Markers of Bone Turnover Across Multiple Decades in Osteoporotic Women.

PURPOSE: The objective of this study was to analyze changes in serum markers of bone turnover across multiple decades in osteoporotic women compared with nonosteoporotic controls, to determine their utility as potential predictors for osteoporosis. Early prediction of those at risk for osteoporosis can enable early intervention before the irreversible loss of critical bone mass. METHODS: Serum samples were obtained from 20 women given the diagnosis of osteoporosis after age 46 years and 20 age-matched women with normal bone mineral density from 4 time points in their life (ages 25-31, 32-38, 39-45, and 46-60 years). Serum levels of bone turnover markers (propeptide of type I collagen, parathyroid hormone, bone-specific alkaline phosphatase, osteocalcin, C-terminal telopeptide of type I collagen, sclerostin, osteoprotegerin, osteopontin, and 25-OH vitamin D) were measured using commercially available arrays and kits. We used logistic regression to assess these individual serum markers as potential predictors of osteoporosis, and mixed-effects modeling to assess the change in bone turnover markers between osteoporotic and control groups over time, then performed fivefold cross-validation to assess the classification ability of the models. RESULTS: Markers of bone turnover, bone-specific alkaline phosphatase, C-terminal telopeptide of type I collagen, sclerostin, and osteocalcin were all independent predictors at multiple time points; osteopontin was an independent predictor in the 39- to 45-year age group. Receiver operating characteristic analyses demonstrated moderately strong classification ability at all time points. Sclerostin levels among groups diverged over time and were higher in the control group than the osteoporotic group, with significant differences observed at time points 3 and 4. CONCLUSIONS: Serum markers of bone turnover may be used to estimate the likelihood of osteoporosis development in individuals over time. Although prospective validation is necessary before recommending widespread clinical use, this information may be used to identify patients at risk for developing low bone mineral density long before traditional screening would ostensibly take place. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Risk Factors for Failure of Nonoperative Treatment of Posterior Shoulder Labral Tears on Magnetic Resonance Imaging.

INTRODUCTION: There are no reports in the literature describing risk factors for failure of nonoperative treatment of patients with posterior labral tears on magnetic resonance imaging (MRI). The purpose of this study is to identify risk factors for failure of nonoperative treatment in patients with an isolated posterior glenoid labral tear identified on MRI only. Patients with posterior labral tears on MRI who fail to improve with nonoperative treatment likely share a constellation of clinical history, physical exam, and radiographic findings. METHODS: One hundred and fifty-nine active duty military service members under the age of 40 with a posterior labral tear seen on MRI and who were clinically evaluated by a musculoskeletal trained physician were identified. We retrospectively evaluated their records ensuring a minimum of 2 years follow-up after MRI to identify surgical intervention for the posterior labral tear during this time period. Patients were stratified into two groups, those treated with any combination of nonoperative modalities and those treated with posterior labral repair surgery during the 2 years after the MRI. The electronic medical records were reviewed for clinical presentation and physical exam results. We measured multiple radiographic parameters, including glenoid version, size of the tear, and bone loss on MRI. Qualitative and quantitative data were compared between groups using Fisher's exact test and Student's t-test, respectively. This study was conducted under institutional review board approval. RESULTS: Of the 157 patients' shoulders in our study, 52% (n = 82) of patients with posterior labral tears underwent nonoperative treatment while 48% (n = 75) underwent surgery. The significant risk factors associated with surgery were a history of a specific injury, primary presenting complaint of instability, patient reported history of subluxation, inability to trust their shoulder with overhead activity, decreased strength with weight lifting, positive posterior load/shift exam, positive anterior apprehension, increased osseous glenoid retroversion, increased humeral head subluxation ratio, and anterior labral height (P < 0.05). Patients with a chief complaint of pain were much more likely to succeed with nonoperative treatment while those with instability underwent surgery more often. Ten (12.5%) of the surgical procedures included an anterior and posterior labral repair/stabilization procedure. CONCLUSION: Patients with an MRI confirmed posterior labral tear, which present with subjective complaints and physical exam maneuvers consistent with instability, appear less likely to be treated nonoperatively. Increased glenoid retroversion and posterior humeral head subluxation may also predispose patients toward surgical treatment. Additionally, posterior labral tears may extend into the anterior labrum more frequently than is recognized on MRI.

Repeated Noise Exposure Does Not Reach Hazardous Levels During Total Joint Arthroplasty.

INTRODUCTION: Noise exposure is an occupational health concern for certain professions, especially military servicemembers and those using power tools on a regular basis. The purpose of this study was to quantify noise exposure during total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases compared to the recommended standard for occupational noise exposure. MATERIALS AND METHODS: A sound level meter was used to record cumulative and peak noise exposure levels in 10 primary THA and 10 primary TKA surgeries, as well as 10 arthroscopy cases as controls. Measurements at the distance of the surgeon were taken in all cases. In TKA cases, measurements were taken at 3 feet and 8 feet from the surgeon, to simulate the position of the anesthetist and circulating nurse, respectively. RESULTS: Time-weighted average was significantly higher in THA (64.7 ± 5.2 dB) and TKA (64.5 ± 6.8 dB) as compared to arthroscopic cases (51.1 ± 7.5 dB, P < 0.001) and higher at the distance of the surgeon (64.5 ± 6.8 dB) compared to the anesthetist (52.9 ± 3.8 dB) and the circulating nurse (54.8 ± 11.2 dB, P = 0.006). However, time-weighted average was below the recommended exposure level of 85 dB for all arthroplasty cases. Peak levels did not differ significantly between surgery type or staff role, and no values above the ceiling limit of 140 dB were recorded. Surgeon's daily noise dose percentage per case was 1.78% for THA and 2.04% for TKA. CONCLUSION: Noise exposure in THA and TKA was higher than arthroscopic cases but did not exceed occupational standards. A daily dose percentage of approximately 2% per case indicates that repeated noise exposure likely does not reach hazardous levels in modern arthroplasty practice.

Fascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial.

PURPOSE: To determine in a prospective, randomized fashion whether liposomal bupivacaine extends the effectiveness of decreased pain scores and reduces narcotic requirements following hip arthroscopy when used in addition to a fascia iliaca blockade with plain bupivacaine alone. METHODS: Double-blinded prospective randomized controlled trial of participants undergoing hip arthroscopy. Randomized to receive a fascia iliaca blockade with 40 mL 0.25% plain bupivacaine (100 mg; control group) or 20 mL 0.5% plain bupivacaine (100 mg) plus 20 mL liposomal bupivacaine (266 mg; study group). The primary outcome was Defense and Veterans Pain Rating Scale (DVPRS) scores in the postanesthesia care unit and on postoperative days (POD) 1, 2, 3, and 14. Secondary outcomes included postoperative opioid consumption and subjective loss of anterior thigh sensation. RESULTS: Seventy-four patients were enrolled, and 70 completed the study; 37 were randomized to the control group and 33 to the study group. There was no significant difference in postoperative DVPRS scores at any time point. There was no significant difference in total postoperative opioid use during any postoperative time points. While most patients reported anterior thigh numbness at discharge, significantly more patients in the study group reported anterior thigh numbness at POD2 (control, 19/37 numb vs study, 32/33 numb; P < .0001) and at POD3 (control, 8/37 numb vs study, 26/33 numb; P < .0001). CONCLUSIONS: In this prospective evaluation comparing plain bupivacaine versus the liposomal formulation administered via a fascia iliaca blockade there were no significant differences in postoperative pain scores and narcotic pill usage. Given the highly significant findings of prolonged anterior thigh numbness out to POD3 in patients who received liposomal bupivacaine, this formulation did exhibit prolonged effects; however, it did not provide improved pain control when used in this surgical population, likely due to the innervation of the hip capsule from differential nerve plexi. Given the 6-fold increased cost of using the liposomal formulation, we are unable to recommend its use via a fascia iliaca blockade for hip arthroscopy. LEVEL OF EVIDENCE: Level I, therapeutic study.

Proximal Femur Hounsfield Units on CT Colonoscopy Correlate With Dual-energy X-ray Absorptiometry.

BACKGROUND: Quantifying bone mineral density (BMD) on CT using commercial software demonstrates good-to-excellent correlations with dual-energy x-ray absorptiometry (DEXA) results. However, previous techniques to measure Hounsfield units (HUs) within the proximal femur demonstrate less successful correlation with DEXA results. An effective method of measuring HUs of the proximal femur from CT colonoscopy might allow for opportunistic osteoporosis screening. QUESTIONS/PURPOSES: (1) Do proximal femur HU measurements from CT colonoscopy correlate with proximal femur DEXA results? (2) How effective is our single HU measurement technique in estimating the likelihood of overall low BMD? (3) Does the relationship between our comprehensive HU measurement and DEXA results change based on age, sex, or time between studies? METHODS: This retrospective study investigated the measurement of HU of the femur obtained on CT colonoscopy studies compared with DEXA results. Between 2010 and 2017, five centers performed 9085 CT colonoscopy studies; of those, 277 (3%) also had available DEXA results and were included in this study, whereas 8809 (97%) were excluded for inadequate CT imaging, lack of DEXA screening, or lack of proximal femur DEXA results. The median number of days between CT colonoscopy and DEXA scan was 595 days; no patient was excluded based on time between scans because bone remodeling is a long-term process and this allowed subgroup analysis based on time between scans. Two reviewers performed HU measurements at four points within the proximal femur on the CT colonoscopy imaging and intraclass correlation coefficients were used to evaluate interrater reliability. We used Pearson correlation coefficients to compare the comprehensive (average of eight measurements) and a single HU measurement with each DEXA result-proximal femur BMD, proximal femur T-score, femoral neck BMD, and femoral neck T-score-to identify the best measurement technique within this study. Based on their lowest DEXA T-score, we stratified patients to a diagnosis of osteoporosis, osteopenia, or normal BMD. We then calculated the area under the receiver operator characteristic curves (AUCs) to evaluate the classification ability of a single HU value to identify possible threshold(s) for detecting low BMD. For each subgroup analysis, we calculated Pearson correlation coefficients between DEXA and HUs and evaluated each subgroup's contribution to the overall predictive model using an interaction test in a linear regression model. RESULTS: The Pearson correlation coefficient between both the comprehensive and single HU measurements was highest compared with the proximal femur T-score at 0.75 (95% confidence interval [CI], 0.69-0.80) and 0.74 (95% CI, 0.68-0.79), respectively. Interobserver reliability, measured with intraclass correlation coefficients, for the comprehensive and single HU measurements was 0.97 (95% CI, 0.72-0.99) and 0.96 (95% CI, 0.89-0.98), respectively. Based on DEXA results, 20 patients were osteoporotic, 167 had osteopenia, and 90 patients had normal BMD. The mean comprehensive HU for patients with osteoporosis was 70 ± 30 HUs; for patients with osteopenia, it was 110 ± 36 HUs; and for patients with normal BMD, it was 158 ± 43 HUs (p < 0.001). The AUC of the single HU model was 0.82 (95% CI, 0.77-0.87). A threshold of 214 HUs is 100% sensitive and 59 HUs is 100% specific to identify low BMD; a threshold of 113 HUs provided 73% sensitivity and 76% specificity. When stratified by decade age groups, each decade age group demonstrated a positive correlation between the comprehensive HU and proximal femur T-score, ranging between 0.71 and 0.83 (95% CI, 0.59-0.91). Further subgroup analysis similarly demonstrated a positive correlation between the comprehensive HU and proximal femur T-score when stratified by > 6 months or < 6 months between CT and DEXA (0.75; 95% CI, 0.62-0.84) as well as when stratified by sex (0.70-0.76; 95% CI, 0.48-0.81). The linear regression model demonstrated that the overall positive correlation coefficient between HUs and the proximal femur T-score is not influenced by any subgroup. CONCLUSIONS: Our measurement technique provides a reproducible measurement of HUs within the proximal femur HUs on CT colonoscopy. Hounsfield units of the proximal femur based on this technique can predict low BMD. These CT scans are frequently performed before initial DEXA scans are done and therefore may lead to earlier recognition of low BMD. Future research is needed to validate these results in larger studies and to determine if these results can anticipate future fracture risk. LEVEL OF EVIDENCE: Level III, diagnostic study.

Effect of NSAIDs on Bone Healing Rates: A Meta-analysis.

INTRODUCTION: NSAIDs inhibit osteogenesis and may result in delayed union or nonunion. The purpose of this meta-analysis was to determine whether their use leads to delayed union or nonunion. METHODS: We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included studies of pediatric and adult patients NSAID exposure and healing bone. The outcomes of interest were delayed union, nonunion, or pseudarthrosis with at least six months of follow-up. A maximum likelihood random-effects model was used to conduct meta-analysis and meta-regression. RESULTS: NSAID exposure increased delayed union or nonunion (odds ratio [OR], 2.07; confidence interval [CI], 1.19 to 3.61). No effect was noted in pediatrics (OR, 0.58; CI, 0.27 to 1.21) or low dose/short duration of exposure (OR, 1.68; CI, 0.63 to 4.46). CONCLUSION: Analysis of the literature indicates a negative effect of NSAIDs on bone healing. In pediatric patients, NSAIDs did not have a significant effect. The effect may be dose or time dependent because low-dose/short-duration exposure did not affect union rates.

Primary Circumferential Acetabular Labral Reconstruction: Achieving Outcomes Similar to Primary Labral Repair Despite More Challenging Patient Characteristics.

BACKGROUND: Treatment of acetabular labral tears with moderate or severe intrasubstance damage or segmental defects remains a substantial challenge. Circumferential labral reconstruction with iliotibial band allograft is a relatively new technique that has been proposed to restore stability and eliminate high-stress junction points. PURPOSE: To compare outcomes between hips treated with primary allograft circumferential labral reconstruction and primary labral repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All consecutive hips between 2014 and 2015 that underwent primary reconstruction or primary repair by the senior surgeon were included and compared. Hips that had a prior intra-articular procedure were excluded. Patient-reported outcome (PRO) scores and visual analog scales were completed by patients within 1 week before surgery and between 22 and 26 months postoperatively. PROs included the modified Harris Hip Score, the International Hip Outcome Tool, and the 12-Item Short Form Health Survey for physical health. Pain and satisfaction were assessed with visual analog scales. Crude and inverse probability of treatment weighting comparisons of PROs between groups were performed. RESULTS: A total of 162 hips met the inclusion criteria for this study, including 99 labral repairs and 63 complete labral reconstructions. Patients who underwent labral reconstruction were, on average, older (43.4 vs 29.5 years; P < .01), had a slightly higher body mass index (24.6 vs 23.0; P < .01), had hips with a higher Tönnis grade (grade 1 or 2: 25% vs 9%; P < .01), had higher preoperative pain scores (49.9 vs 41.5; P = .01), and had hips with more severe pathology (68% vs 5%; P < .01) as compared with patients with labral repair hips. Five (5%) labral repair hips and 5 (8%) labral reconstruction hips failed treatment ( P = .48). Among hips that did not fail (n = 94 repairs, n = 58 reconstructions), all demonstrated statistically significant improvements in PROs, and there was no statistical difference in PROs between groups after weighting ( P > .05). CONCLUSION: Primary circumferential labral reconstruction is a viable treatment option with promising short-term outcomes for hips that demonstrate moderate or severe labral damage. Despite less favorable preoperative characteristics, labral reconstruction offers similar outcomes when compared with labral repair in hips with less severe pathology.

A History of Shoulder Instability in the Military: Where We Have Been and What We Have Learned.

Introduction: Shoulder instability is one of the most common pathologies seen by the orthopedic sports medicine surgeon. With a uniquely young, high-demand patient population in the U.S. Military, the incidence of shoulder instability is remarkably more common than the civilian population. As such, military orthopedic surgeons and sports medicine and shoulder specialists have developed a unique understanding and experience of shoulder instability. The historical advances of shoulder instability in the military have been instrumental in understanding the epidemiology, evaluation, pathology, treatment of first-time shoulder subluxations and dislocations, operative and non-operative treatment options, arthroscopic and open stabilization methods, management of the in-season athlete, treatment of combined and circumferential labral pathology, and associated pathology. Methods: The purpose of this article is to chronicle the experience of military orthopedic surgeons in treating shoulder instability. We discuss how this unique experience has led to a better understanding of the epidemiology and pathology of this condition and how we have adapted our clinical practice to improve patient outcomes. Results: The historical contribution of U.S. Military orthopedics to the understanding of shoulder instability has been monumental. This article reviews the evolution of shoulder instability treatment and the understanding as it has evolved in the U.S. Military. It further elaborates on our understanding of the epidemiology of shoulder instability in the U.S. Military, with attention given to our incidence of 1.69 per 1000 person-years, approximately 20 times higher incidence than the general population. We discuss known risk factors for dislocation that contribute to this incidence, which are specific to military service. We address pathologic changes seen following a first-time instability event, including an analysis of labral injury and the role of these pathologic changes in recurrent instability. We also review our results from arthroscopic evaluation of first-time dislocations and compare the pathologic changes with those following a first-time subluxation. Evaluation of treatment outcomes is discussed, comparing operative and non-operative results as well as open and arthroscopic stabilization in the U.S. Military population and contact/collision athletes. Finally, we address how these results drive our current treatment algorithm. Discussion and Conclusion: The physical demands of military service result in a high rate of shoulder instability relative to the general population. For years military orthopedic surgeons have sought to better understand this pathology and learn how to optimally manage it so as to reduce this heavy burden of disease. This article discusses our experience with treating shoulder instability, provides an overview of the lessons learned, and provides a historical perspective for the evolution of shoulder instability understanding in the U.S. Military.

Glenoid neck Hounsfield units on computed tomography can accurately identify patients with low bone mineral density.

BACKGROUND: Osteoporosis is a costly and morbid disease with the first presentation often with a fragility fracture. The purpose of this study was to assess whether Hounsfield unit (HU) measurements on shoulder computed tomography could identify patients at risk of osteoporosis and aid in its diagnosis. METHODS: We identified patients who had both a computed tomography scan of the glenoid and a dual-energy x-ray absorptiometry scan. Dual-energy x-ray absorptiometry results and HU measurements of the patients' glenoid were recorded. Differences in HU measurements between patients with normal and abnormal central bone mineral density (BMD) were assessed. Correlations were calculated, and receiver operating characteristics were examined. RESULTS: A total of 51 glenoids met the criteria. The mean glenoid HU measurement was 140.6 (95% confidence interval [CI], 120.1-161.1) in the osteoporotic group, 168.1 (95% CI, 152.7-183.5) in the osteopenic group, and 233.2 (95% CI, 210.1-256.4) in the normal BMD group (P < .001). There was a significant correlation between mean glenoid HU measurement and patients' t scores in the femoral neck (r = 0.581), total hip (r = 0.524), and lumbar spine (r = 0.345). The area under the receiver operating characteristic curve was 0.918. With 197 HUs used as the cutoff for diagnosis of abnormal BMD, the positive predictive value was 96.6%. With 257.1 HUs used as the cutoff, the negative predictive value was 100%. CONCLUSION: A patient with an HU measurement below 197 has a 97% chance of having low BMD, and a patient with a measurement over 257 likely has normal BMD. In patients with measurements between these values, a definitive diagnosis should be aggressively pursued. Opportunistic screening for a modifiable disease that has significant morbidity and mortality rates at no additional cost, radiation, or time is of great value.

Frequency of Bone Health Presentations at National Hand Meetings.

PURPOSE: The purpose of this study was to determine the frequency with which osteoporosis topics (screening, medical treatment, and fracture prevention) are presented at national hand surgery meetings. This was compared with the frequency of the same topics presented at the Orthopaedic Trauma Association (OTA) annual meetings. METHODS: The annual meeting programs for the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the OTA from the previous 10 years (2007-2016) were searched for presentations that covered bone health at each of these meetings. We categorized the presentations as either instructional or research. RESULTS: There were 2 bone health instructional presentations at hand surgery meetings in contrast to 13 presentations at OTA meetings over the last 10 years. For the last 9 years, the OTA has featured at least 1 instructional presentation on bone health every year. We identified 11 research presentations at the hand surgery meetings compared with 16 at the OTA meetings. CONCLUSIONS: Osteoporosis and bone health are infrequently presented instructional topics at national hand meetings compared with OTA meetings. The cause of the difference is unclear and likely multifactorial, varying each year with different program chairs and committees. The level of involvement of hand surgeons in osteoporosis management is controversial; however, incorporation of this topic may stimulate discussion and help identify solutions for this controversy. CLINICAL RELEVANCE: It may benefit hand surgeons to place more importance on osteoporosis screening and treatment. We believe that there should be an annual instructional course on this topic at the ASSH and AAHS meetings.