Delayed wound healing after tooth extraction and self-reported kyphosis in Japanese men and women.

It is unclear whether osteoporosis itself is a main risk factor for delayed wound healing after tooth extraction in humans. In this study, we evaluated the association between experience of delayed wound healing after last tooth extraction and self-reported kyphosis, with the possibility of having vertebral fractures, in Japanese patients. Among the 1,504 patients who responded to the structured questionnaire survey, 518 patients (134 men and 384 women) aged 55-97 years finally participated in this study. Patients who self-reported mild-moderate kyphosis were more likely to have problematic delayed wound healing after last tooth extraction than those who reported severe kyphosis (odds ratio [OR] 4.98; 95% confidence interval [CI], 1.86-13.38 and OR 2.30; 95% CI, 0.52-10.22, respectively) (p for trend = 0.005). Japanese patients with vertebral fractures may have a higher risk of having problematic delayed wound healing after tooth extraction.

Risk factors of adjacent vertebral collapse after percutaneous vertebroplasty for osteoporotic vertebral fracture in postmenopausal women.

BACKGROUND: Recently percutaneous vertebroplasty (PVP) was frequently performed for treatment of osteoporotic vertebral fractures (VFs). It is widely accepted that new compression fractures tend to occur adjacent to the vertebral bodies, typically within a month after PVP. To determine the risk factors among several potential predictors for de novo VFs following PVP in patients with osteoporosis. METHODS: We retrospectively screened the clinical results of 88 patients who had been treated by PVP. Fifteen cases were excluded due to non-union. Of the remaining 73 patients, 19 (26.0%) later returned with pain due to a new vertebral compression fracture. One patient with a non-adjacent fracture and 2 patients with adjacent factures occurring 3 months later were excluded from the study. The 9 male patients were excluded to avoid gender bias. Ultimately, we divided the 61 remaining postmenopausal female patients (mean age: 78.9 years) into the collapse group (14 patients) who had experienced adjacent vertebral collapse after PVP and the non-collapse group (47 patients) who had not. Logistic regression analysis was performed to identify the risk factors for new VFs after PVP. RESULTS: All 14 cases of adjacent VF occurred within the first month after surgery. The collapse group had significantly advanced age, higher urinary N-terminal cross-linking telopeptide of type I collagen, and lower lumbar and hip bone mineral density (BMD) scores as compared with the non-collapse group. The odds ratios for age, lumbar, total hip, femoral neck, and trochanteric BMD were 4.5, 8.2, 4.5, 7.2, and 9.6, respectively. Positive likelihood ratios suggested that age more than 85 years, lumbar BMD less than 0.700 [-2.6SD], total hip BMD less than 0.700 [-1.8SD], neck BMD less than 0.600 [-2.1], and trochanter BMD less than 0.600 conferred an elevated risk of adjacent VF. CONCLUSIONS: Our study revealed that advanced age and decreased lumbar and hip BMD scores most strongly indicated a risk of adjacent VF following PVP.

The effect of a prostaglandin E1 derivative on the symptoms and quality of life of patients with lumbar spinal stenosis.

BACKGROUND: Quality of life (QOL) is a concern for patients with lumbar spinal stenosis (LSS). In this study, QOL was examined using the 5-item EuroQol (EQ-5D). METHODS: QOL and activities of daily living (ADL) were surveyed for 91 patients who visited 18 medical institutions in our prefecture and were diagnosed with LSS-associated intermittent claudication. A second survey was performed after ≥6 weeks for 79 of the subjects to evaluate therapy with limaprost (an oral prostaglandin E1 derivative) or etodolac (an NSAID). Symptoms, maximum walking time, QOL, ADL items, and relationships among these variables were investigated for all 91 patients. Leg pain, leg numbness, and low back pain while walking were surveyed by use of VAS scores (0-100). RESULTS: Leg pain, leg numbness, and low back pain while walking (VAS ≥25) were present in 83.5, 62.6, and 54.9 % of the patients in the first survey, and approximately half of the patients had a maximum walking time <15 min. The mean EQ-5D utility value for QOL was 0.59 ± 0.12. This value was significantly associated with maximum walking time (p = 0.030) based on classification of patients into groups with walking times <7.5, 7.5-15, 15-30, and >30 min, showing that maximum walking time affected health-related QOL. Of the 79 patients who completed the second survey, 56 had taken limaprost and 23 (control group) had received etodolac. Limaprost improved possible walking time, reduced ADL interference, and significantly increased the EQ-5D utility score, whereas no significant changes occurred in the control group. Maximum walking time was prolonged by ≥10 min and the EQ-5D utility value was improved by ≥0.1 points in significantly more patients in the limaprost group than in the control group. CONCLUSION: According to the findings of this survey, at an average of 8 weeks after administration limaprost improved symptoms, QOL, and ADL in LSS patients whereas treatment with an NSAID reduced pain but did not have any other effects.

Early changes in bone specific turnover markers during the healing process after vertebral fracture.

BACKGROUND: The present study measured longitudinal changes in bone turnover markers in elderly patients with vertebral fracture and investigated the relationship among bone turnover markers, duration of bed rest and bone mineral density (BMD). METHODS: Criteria for patient selection were 50 years in age and older, and presence of VF. Serum bone-specific alkaline phosphatase (BAP) was measured as a marker of bone formation. Urinary crosslinked N-terminal telopeptides of type I collagen (NTX) was measured as a marker of bone resorption. In principle, samples were collected just after injury, within 24 h, and 1, 2, 3, 5 and 8 weeks after. We also measured duration of bed rest and BMD. RESULTS: The study population consisted of 42 cases. The average BMD of the lumbar vertebrae was 0.670 ± 0.174 g/cm2. Bed rest period was 17.9 ± 8.8 days. BAP showed significantly higher values at 2 and 3 weeks compared with the baseline value. Thereafter, BAP progressively decreased until 8 weeks. Urinary NTX was increased soon after the onset of pain with the same patterns in BAP. Urinary NTX values reached a peak at 3 weeks, and then they kept significantly higher values until 8 weeks. The peak value of serum BAP was affected by the duration of bed rest, although that of the urinary NTX was not. The peak values of serum BAP and urinary NTX showed negative correlations with the initial BMD values. CONCLUSIONS: Bone turnover markers remained higher at 8 weeks, even patients symptom was healed after VF. Bone turnover markers were affected on physical activity and BMD.

Anti-nociceptive effects of elcatonin injection for postmenopausal women with back pain: a randomized controlled trial.

BACKGROUND: Eel calcitonin (elcatonin) injection is widely used for elderly patients suffering from somatic pain in Japan. However, there have been few reports on the analgesic effects of elcatonin injection. The purpose of this study was to examine the analgesic effects of elcatonin injection in postmenopausal women with lower back pain. METHODS: This study was designed as a double-blind, randomized, placebo-controlled study. Thirty-six women aged >/=50 years with acute lower back pain participated in this study. They were randomly divided into two treatment groups according to whether they received a placebo or a weekly trigger point injection of elcatonin (20 units). They were observed for 5 weeks and the extent of pain at motion and at rest according to the visual analog scale (VAS) was evaluated. The mean VAS scores for the elcatonin group were then compared with those of the placebo group. RESULTS: There were no statistically significant differences in the mean VAS scores for pain at rest between the two groups during the 5-week treatment course. However, the mean VAS scores for motion pain in the elcatonin group were significantly lower than those in the placebo group at the third, fifth and sixth weeks. CONCLUSIONS: Elcatonin injection (20 units) significantly relieved motion pain in the lower back in postmenopausal women after three weeks of treatment. This analgesic effect continued for the subsequent 3 weeks.

Bone mineral density measurement at both spine and hip for diagnosing osteoporosis in Japanese patients.

In Japan, spinal dual-energy X-ray absorptiometry (DXA) has been commonly performed for diagnosing osteoporosis but scanning the proximal femur is not done widely. The latest Japanese guidelines for prevention and treatment of osteoporosis, revised in 2006, recommend bone mineral density (BMD) measurement at both spine and hip for diagnosing osteoporosis, although there have been no reports that proved the necessity of those measurements. One thousand forty-one women and 485 men with clinical suspicion of osteoporosis were enrolled in this study, and DXA was performed at both spine and hip. The proportions of the patients who had inconsistency between diagnosis of osteoporosis from spinal DXA and that of hip were estimated. As a result, 22% of women and 15% of men had an inconsistency with the diagnosis of osteoporosis using DXA at each measurement site. There was inconsistency in diagnosing osteoporosis using DXA at the spine and proximal femur measurement sites. Because spine and femoral DXA measurements complement each other in the diagnosis of osteoporosis, BMD measurement at both spine and hip should be performed for all Japanese patients who are suspected osteoporosis, regardless of age and sex.

Comparison in bone turnover markers during early healing of femoral neck fracture and trochanteric fracture in elderly patients.

Healing of fractures is different for each bone and bone turnover markers may reflect the fracture healing process. The purpose of this study was to determine the characteristic changes in bone turnover markers during the fracture healing process. The subjects were consecutive patients with femoral neck or trochanteric fracture who underwent surgery and achieved bone union. There were a total of 39 patients, including 33 women and 6 men. There were 18 patients (16 women and 2 men) with femoral neck fracture and 21 patients (17 women and 4 men) with trochanteric fracture. Serum bone-specific alkaline phosphatase (BAP) was measured as a bone formation marker. Urine and serum levels of N-terminal telopeptide of type I collagen (NTX), as well as urine levels of C-terminal telopeptide of type I collagen (CTX) and deoxypyridinoline (DPD), were measured as markers of bone resorption. All bone turnover markers showed similar changes in patients with either type of fracture, but significantly higher levels of both bone formation and resorption markers were observed in trochanteric fracture patients than in neck fracture patients. BAP showed similar levels at one week after surgery and then increased. Bone resorption markers were increased after surgery in patients with either fracture. The markers reached their peak values at three weeks (BAP and urinary NTX), five weeks (serum NTX and DPD), and 2-3 weeks (CTX) after surgery. The increase in bone turnover markers after hip fracture surgery and the subsequent decrease may reflect increased bone formation and remodeling during the healing process. Both fractures had a similar bone turnover marker profile, but the extent of the changes differed between femoral neck and trochanteric fractures.

Surgery for thoracic myelopathy caused by ossification of the ligamentum flavum.

BACKGROUND: Ossification of the ligamentum flavum overlying the lower thoracic spine frequently produces myelopathy. This study analyzed the postoperative outcomes after decompressive laminectomy for thoracic OLF. METHODS: We retrospectively studied 13 patients (10 male, 3 female; mean age, 58 years; range, 39-69). The mean follow-up duration was 66 months (range, 21-107). All patients had undergone decompressive laminectomy and excision of the OLF. The clinical course was evaluated according to the Frankel grading system and JOA scores. The number of vertebral segments demonstrating OLF, the most frequent level of thoracic cord involvement, and spine lesions coexisting with OLF were determined by MR imaging. RESULTS: By the Frankel system, 7 of 13 patients improved by one grade, whereas the others, classified as grade D, were unchanged after surgery. Using the JOA score, the functional improvement was excellent in 3 patients, good in 4, fair in 2, and unchanged in 4. The number of vertebral segments demonstrating OLF included 4 levels in 2 patients, 3 levels in 2 patients, 2 levels in 5 patients, and 1 level in 4 patients. Ossification of the ligamentum flavum occurred most frequently at the T10/T11 level. Tandem cervical and lumbar lesions were present in 6 patients. CONCLUSIONS: Decompressive laminectomy for excision of OLF resulted in clinical improvement using the Frankel grading system in 7 of 13 patients. In myelopathy patients with OLF, preoperative MR imaging of the entire spine is necessary because other coexisting spinal lesions may be present.

Change of cross-linked telopeptide of type I collagen (ICTP) and other bone resorption markers in patients with bone fragility fractures.

BACKGROUND: The serum concentration of cross-linked telopeptide of type I collagen (ICTP) has been reported to be a useful marker and for both diagnosis and monitoring of bone metastasis. This study was performed to clarify the changes in various bone turnover markers, including ICTP, after bone fragility fracture. METHODS: Seventy-six bone fragility fracture patients (14 men and 62 postmenopausal women; mean age, 77.0 years) were evaluated for bone resorption markers, including serum ICTP. We measured urinary N-terminal telopeptides of type I collagen (NTX) several times after fracture. Furthermore, serum ICTP, serum NTX, urinary deoxypyridinoline (DPD), and urinary C-telopeptide-cross-linked type I collagen (CTX) were measured at the times of both minimum and maximum urinary NTX. RESULTS: Urinary NTX was increased significantly from 86.4 +/- 57.9 to 214.3 +/- 137.2 nmol BCE/mmol Cr following fracture. Serum ICTP showed a similar significant increase from 7.6 +/- 4.7 to 10.4 +/- 5.5 ng/ml in bone fragility fracture patients. Furthermore, other markers also showed similar increases. The level of increase in urinary NTX (148.0%) was especially high compared with other bone resorption markers. On the other hand, the level of increase in serum ICTP (36.8%) was similar to that in serum NTX (39.8%). Serum ICTP levels were significantly correlated with other bone resorption markers, with an especially strong correlation between serum ICTP and serum NTX (r = 0.647, P < 0.001). The percentage of cases in which ICTP exceeded the cutoff value for suspected bone metastasis in postmenopausal women was 73.6%. CONCLUSIONS: The value of ICTP increases with bone fragility fracture and is correlated with other bone resorption markers, and ICTP obviously exceeded the reference value as compared with other bone resorption markers.

Insufficiency fracture of the acetabulum without apparent trauma.

A 76-year-old woman presented history of left hip joint pain on walking, which occurred after she bent to move a planter. Plain radiographs showed no fracture. Bone scintigraphy revealed accumulation, and magnetic resonance imaging showed a low signal area on T1-weighted images. We diagnosed an insufficiency fracture and pain decreased naturally on conservative treatment. Insufficiency fracture of the acetabulum should be considered when elderly patients have hip joint pain. Magnetic resonance imaging and bone scintigraphy is most useful for the diagnosis.

Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation.

Six hundred and six clinical records of patients who were admitted to the Department of Orthopaedic Surgery, Suwa Red Cross Hospital, Nagano, Japan, due to lumbar disc herniation (LDH) between 1991 and 2002 were reviewed to determine the ideal conservative treatment period in relation to different types of LDH: contained and non-contained. Since 1997, we have prolonged in-hospital conservative treatment over a few weeks, which resulted in a decrease in the number of surgeries for non-contained LDH, especially of surgeries performed within 1 month. The number of surgeries for contained LDH did not decrease. The preoperative period of non-contained LDH was significantly shorter than that of contained LDH. These results indicate that for patients who have non-contained LDH, intensive conservative treatment may avoid a surgical procedure. For those patients who have contained LDH, conservative treatment should not be prolonged. We believe that the optimal duration of intensive conservative therapy should be less than 1 month.

Radiographic evaluation of vertebral fractures in osteoporotic patients.

Vertebral fractures, are a serious clinical problem for elderly osteoporotic patients, have been increasingly recognized and are now common. On the assumption that it is difficult to diagnose osteoporotic vertebral fractures on plain radiographs, we studied 78 consecutive patients aged over 50 years with severe back pain with or without minor trauma. All patients had been admitted to our department and had undergone radiographic examinations including plain radiography, magnetic resonance imaging (MRI) and bone scintigraphy. Surprisingly, 74 of the patients (94.9%) with severe back pain had vertebral fractures. Low intensity on T1-weighted MRI indicated that the severe back pain was a symptom of vertebral fracture. The patients were divided into two groups: those with total, and those with partial T1-weighted hypointensity of the vertebral body on MRI. Thirty-five of the vertebral fractures (47.3%) were not detectable on plain radiographs, and patients without trauma showed vertebral deformity more frequently than those with trauma. The patients were treated conservatively with bed rest until the severe back pain had subsided, after which they were evaluated clinically. The average period of bed rest was 22.3 days, which did not differ significantly in relation to the occurrence of trauma, the extent of the signal change in the vertebral body on MRI or the presence of vertebral deformity. Even without vertebral deformity or trauma, vertebral fractures required long periods of bed rest for pain relief and entailed serious clinical problems.

Changes in total alkaline phosphatase level after hip fracture: comparison between femoral neck and trochanter fractures.

BACKGROUND: Biochemical bone metabolic markers are affected by fractures, and total alkaline phosphatase (ALP) is considered one of the bone formation markers. Only a few reports have dealt with changes in bone formation markers during the healing process of bone fragility hip fractures. Despite the difference in the amount of callus formation and bone fusion rate, no significant differences in longitudinal change of total ALP between femoral neck and trochanter fracture have been reported. METHODS: A total of 69 osteoporotic patients with femoral neck or trochanter fracture whose serum concentrations of total ALP were examined at least four times at six periodic examination points (1, 2, 3, 4, 6, and 8 weeks after surgery) and whose state of bone union was obtained within 24 weeks after surgery were selected for this retrospective study. The characteristic longitudinal change of total ALP during the healing process was shown, and the possibility of total ALP as a predictive factor for the state of osteosynthesis of hip fractures is discussed. RESULTS: Changes in the total ALP level according to the healing process were similar for femoral neck and trochanter fractures. The concentration of total ALP rose to a maximum at 3 weeks after surgery and then gradually decreased for both fractures. However, the range of change was significantly greater for trochanter fractures than for femoral neck fractures. For trochanter fractures, total ALP decreased from 3 to 6 weeks after surgery in all but one patient. CONCLUSIONS: Increases in the concentration of total ALP after surgery and the subsequent decreases may reflect the normal healing process. A significant difference in the changes of total ALP after surgery between femoral trochanter and neck fractures was shown. Periodic measurement of total ALP might be useful for obtaining information on the osteosynthesis state.

Pseudoarthrosis of vertebral fracture: radiographic and characteristic clinical features and natural history.

BACKGROUND: We examined mobility based on radiographic appearance, clinical appearance, and the natural course of osteoporotic vertebral pseudoarthrosis (VPA) in a prospective study in 34 consecutive cases of VPA in 27 patients with osteoporosis. METHODS: Conventional lateral, lateral flexion, and extension stress radiography (XP) and supine cross-table lateral XP were performed. Anterior vertebral body height and vertebral kyphotic angle were measured to assess vertebral mobility. If vertebral cleft or vertebral instability, which means a difference in vertebral body height between conventional and supine cross-table lateral XP, was present, VPA was diagnosed. Back pain was classified into five grades. RESULTS: The average anterior vertebral height was 9.9 +/- 5.6 mm on conventional lateral XP; it increased to 11.4 +/- 6.5 mm on extension stress XP (not significant) and 18.3 +/- 5.7 mm on cross-table lateral XP (significant). The vertebral kyphotic angle was 24.1 degrees +/- 9.7 degrees on conventional lateral XP; it decreased to 21.6 degrees +/- 9.8 degrees on extension stress XP (not significant) and 11.8 degrees +/- 8.5 degrees on cross-table lateral XP (significant). Intravertebral clefts were detected by conventional lateral XP, extension stress XP, and supine cross-table XP in 3 of 34 (8.8%), 7 of 21 (33.3%), and 28 of 34 (82.4%) vertebral compression fractures (VCFs), respectively. Surgical treatment was performed in seven patients (two because of severe pain and five because of neurological deficits) and in one patient who died. Except in these eight patients, back pain decreased by at least one grade with time in 18 of 19 patients (95%) in whom the clinical course was analyzed. Radiographic follow-up using supine cross-table XP was performed in 15 of 19 patients. Although 11 of these 15 patients (73%) showed vertebral instability on supine cross-table lateral XP, 10 of 11 patients (91%) did not complain of intolerable back pain during daily activity at the final follow-up. CONCLUSIONS: VPA is often detected on supine cross-table lateral XP but not usually on extension stress XP. Despite the presence of vertebral instability, many patients did not complain of intolerable back pain during their daily activity. Surgical treatment to alleviate back pain should be performed for painful VPA after conservative treatment for about 4 months.

Urinary excretion of type I collagen cross-linked N-telopeptide and serum bone-specific alkaline phosphatase analysis to determine the correlation of age and back-pain related changes in elderly women.

We evaluated bone turnover using biochemical markers in 273 women over 60 years of age with suspected osteoporosis. Their age range was 60-96 years, with an average of 72.7 years. Patients with disorders that might affect bone metabolism were excluded. Those complaining of back pain within 6 months before or after examination were assigned to the back-pain group. Serum bone-specific alkaline phosphatase (BAP) was measured as a bone formation marker, and the urinary N-terminal telopeptide of type I collagen (NTX) was measured as a bone resorption marker. Both BAP and NTX levels increased in individuals over 60 years of age; moreover, these markers were significantly higher in subjects aged over 80 years. Among elderly patients, both BAP and NTX levels were significantly higher in those with back pain than in those without, and in a similar way were observed to increase in parallel with age from the 60-year point. We found that both NTX and BAP increased with aging, and that the increase in these bone turnover markers was closely related to back pain. We also showed that NTX and BAP levels increased significantly in women over 80 years, and specifically in patients with back pain.

Changes in biochemical markers of bone in patients with insufficiency fractures.

Twelve patients presented at our department with low back or buttock pain and were diagnosed as suffering from insufficiency fracture. All patients were evaluated with plain radiographs, magnetic resonance imaging, and/or bone scintigraphy. We also measured biochemical markers of bone turnover in these patients. Bone scintigraphy revealed a high uptake in the fracture site in all patients with insufficiency fracture. Biochemical markers of bone turnover were significantly increased in all patients, but decreased after the fracture healed and the pain was resolved. In those patients who complained of pain again, the biochemical markers of bone turnover had increased once more, and bone scintigraphy showed a new fracture at a different site. Because the changes in bone turnover markers were closely related to clinical symptoms of insufficiency fracture, we speculated that repeated measurements of bone turnover markers may be informative for discriminating insufficiency fracture from bone metastasis.

Snapping wrist after surgery for carpal tunnel syndrome and trigger digit: a case report.

We present a case of snapping dislocation of the flexor digitorum superficialis tendon to the small finger over the hook of the hamate that was noted after carpal tunnel release and trigger digit release.

Progressive symptomatic kyphotic deformity after decompressive surgery for lumbar destructive spondyloarthropathy.

Destructive spondyloarthropathy (DSA) is a serious complication of haemodialysis for end stage renal failure. We present a case of a patient who complained of back pain and cruralgia due to L2-3 disc degeneration with instability, and was treated with posterior decompression and bone grafting. Soon after surgery, the kyphotic deformity progressed and the symptoms deteriorated. A correction of the deformity and posterior fusion was required six years after initial surgery. Pathological findings showed characteristic findings of DSA. Our findings indicate that in some cases with unstable DSA, spinal decompression as well as spinal fixation may be necessary.