Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomised controlled trial at a minimum follow-up of ten years.

AIMS: Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy. PATIENTS AND METHODS: This randomised controlled trial of 140 patients (52 men, 88 women, mean age 47.1 years; 18 to 60) with rotator cuff tendinopathy extended previous work up to a maximum of 13 years. The patients were randomised into two treatment groups: arthroscopic acromioplasty and a supervised exercise treatment and a similar supervised exercise treatment alone. Self-reported pain on a visual analogue scale (VAS) was the primary outcome measure. Secondary measures were disability, working ability, pain at night, Shoulder Disability Questionnaire score and the number of painful days during the three months preceding the final assessment. RESULTS: A total of 90 patients (64%) returned questionnaires at a mean 12 years after randomisation. On an intention-to-treat basis, both treatment groups reached statistically significant improvement compared with the initial VAS for pain, but there was no significant difference between groups. The same was true in the secondary outcome measures. Due to group changes, the results were also analysed per protocol: operated or not. No significant differences between the groups were found. CONCLUSION: The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results. In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy. Cite this article: Bone Joint J 2017;99-B:799-805.

No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial.

OBJECTIVES: To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. METHODS: A total of 140 patients were randomly divided into two groups: 1) supervised exercise programme (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). RESULTS: The main outcome measure was self-reported pain as measured on a visual analogue scale. At the five-year assessment a total of 109 patients were examined (52 in the exercise group and 57 in the combined treatment group). There was a significant decrease in mean self-reported pain on the VAS between baseline and the five-year follow-up in both the exercise group (from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) and the combined treatment group (from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). The same trend was seen in the secondary outcome measures (disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days). An intention-to-treat analysis showed statistically significant improvements in both groups at five years compared with baseline. Further, improvement continued between the two- and five-year timepoints. No statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. CONCLUSIONS: Differences in the patient-centred primary and secondary parameters between the two treatment groups were not statistically significant, suggesting that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome.

Salmon calcitonin (Miacalcic ns 200 IU) in prevention of bone loss after hip replacement.

BACKGROUND AND AIMS: Loosening of a hip prosthesis after total arthroplasty is related to periprosthetic bone loss. Calcitonin has been used in the treatment of bone loss in osteoporosis and prevention of fractures. The main purposes of the study were firstly to evaluate the effect of calcitonin on periprosthetic bone after total hip arthroplasty, secondly investigate possible loosening of the prosthesis and thirdly examine further clinical outcome. PATIENTS AND METHODS: 60 patients who underwent total hip arthroplasty using cemented Exeter prosthesis were randomized in the treatment group (salmon calcitonin 200 IU nasal spray daily + calcium 500 mg) and the placebo group (inactive nasal spray + calcium 500 mg) for six months. Bone mineral density (BMD) was measured from different locations at the time of discharge and after six and 12 months. Dynamic histomorphometry on bone biopsies taken from femoral collum was performed. Serum bone-specific alkaline phosphatase (BAP), serum osteocalcine (OC) and cross-linked N-telopeptides (NTX) were measured after one week, one month, three months and 12 months. Clinical manifestations and the incidence of fractures and loosening of the prosthesis were followed up to eight years. RESULTS: Statistically there was not significant difference in bone histomorphometry between the groups. In both groups there was a significant BMD decrease in periprosthetic bone. However, the difference between the groups was not statistically significant. In the biochemical analysis NTX increased more in the Miacalcic group than in the placebo group (p = 0.013). There were no significant differences between the groups in serum BAP or OC even though the changes within the groups were statistically significant. No loosening of the prosthesis was seen during the follow-up and there was no need for revision of any reason. Four fractures were recorded in three patients. One patient sustained a periprosthetic fracture. All the patients with fractures were allocated in the placebo group. CONCLUSIONS: Nasal salmon calcitonin 200 IU on a daily basis does not promote any additional value on calcium substitution to prevent bone loss after hip replacement. The durability of the Exeter prosthesis was good.

Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial.

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven.

Hipotermia tras el consumo de ibuprofeno. A propósito de dos casos / No disponible

La hipotermia en relación con el consumo de fármacos es un fenómeno poco frecuente.Existen sólo seis casos documentados de hipotermia relacionados con el consumo de ibuprofenoen la base de datos de reacciones adversas medicamentosas de la OrganizaciónMundial de la Salud (OMS). Se plantea la sospecha de dos casos de hipotermia tras el consumode dicho fármaco. Ante la existencia de hipotermia grave serán necesarias la realizaciónde pruebas complementarias para descartar previamente otras causas más frecuentes,así como la notificación de la sospecha de reacción adversa al centro de farmacovigilanciacorrespondiente

Hypothermia due to medicaments is an infrequent idiosyncratic reaction. There are onlysix similar cases related to the consumption of ibuprofen reported in the WHO adverse drugreactions database. Two of the cases of hypothermia attended in our unit seem to be due tothe consumption of the mentioned medicament. The existence of hypothermia makes necessarysome complementary tests to discard other more frequent aetiologies, as well as the notificationof the adverse reaction to the corresponding Drugs and Therapeutics Centre

No long-term effects of ultrasound therapy on bioabsorbable screw-fixed lateral malleolar fracture.

BACKGROUND AND AIMS: The present study was initiated to evaluate the long-term effects of low-intensity ultrasound therapy on bioabsorbable screw-fixed lateral malleolar fractures, which has not been studied earlier. PATIENTS AND METHODS: The study design was prospective, randomized, double-blinded, and placebo-controlled. Sixteen dislocated lateral malleolar fractures were fixed with one bioabsorbable self-reinforced poly-L-lactide screw. The patients used an ultrasound device 20 minutes daily for six weeks without knowing it was active (eight patients) or inactive (eight patients). The follow-up time was 18 months. The radiological bone morphology was assessed by multidetector computed tomography (MDCT) scans, the bone mineral density by dual-energy X-ray absorptiometry scans, and the clinical outcome by Olerud-Molander scoring and clinical examination of the ankle. RESULTS: The MDCT scans revealed that all fractures were fully healed, and no differences were observed in radiological bone morphology at the fracture site. The bone mineral density of the fractured lateral malleolus tended to increase slightly during the 18-month follow-up, the increase being symmetrical in both groups. No differences were observed in the clinical outcome or Olerud-Molander scores. CONCLUSIONS: The six-week low-intensity ultrasound therapy had no effect on radiological bone morphology, bone mineral density or clinical outcome in bioabsorbable screw-fixed lateral malleolar fractures 18 months after the injury.

Bone histomorphometry in celiac disease.

BACKGROUND AND AIMS: Bone metabolism in celiac patients is not well understood and there are no previous histomorphometric studies on bone of patients with celiac disease. The aim of the study was to investigate bone metabolism in celiac patients using bone histomorphometry, measurement of bone mineral density (BMD) and biochemical parameters. MATERIAL AND METHODS: The patient groups included 19 men and 23 women with previously diagnosed celiac disease in remission (group I), 7 women not in remission (group II) and 19 women and 9 men with newly diagnosed celiac disease (group III). Static and dynamic parameters of bone structure, formation and resorption were measured using undecalcified sections. The following parameters were obtained: bone volume (BV/TV; %), osteoid volume (OV/BV; %), osteoid surface (OS/BS; %), resoprtion surface (ES/BS; %), osteoid thickness(Oth; microm), mineral apposition rate (MAR; microm/day), and mineralization lag time (MinLag; day). BMD was measured at the spine (L2-4) and left femoral neck, trochanter and Ward's triangle. Serum calcium (S-Ca; mmol/L), alkaline phosphatase (AP; U/L), intact parathyroid hormone (S-PTH; ng/L), 25-hydroxyvitamin D (S-25(OH)D; nmol/L), cross-linked carboxyterminal telopeptide of human type I collagen (S-ICTP; microg/L) and C-terminal extension peptide of type I procollagen (S-PICP; microg/L) were analysed. RESULTS: In the histomorphometric analysis there were no significant differences in static or dynamic parameters between the groups. Very low bone mass (< 10%) was found in one patient in every group. OV/BV was increased (> 3.5%) in all groups (31% in group I, 13% in group II and 29% in group III). OS/BS was increased (> 36.5%) in groups I and III (17% and 29% respectively). In group II OS/BS was normal in all patients. Mineralization defect was found in four patients in group I and in two patients in group III with otherwise normal histomorphometric results. ES/BS was increased in three patients in group I and III and in one patient in group II. One female patient in group III had increased osteoid parameters, resorption surface, S-PTH and low concentration of vitamin D reflecting hyperparathyroid changes in bone. S-PTH was increased (66-87 ng/L) in four patients in group III and one of these patients had hyperparathyroid histological changes in bone. CONCLUSIONS: Static and dynamic histomorphometry of iliac crest bone biopsy are useful tools to evaluate bone metabolism in celiac disease especially if hyperparathyroidism or mineralization defect are suspected. Hyperparathyroidism may be a problem in the patients before introducing gluten-free diet. Mineralization defect and osteomalacic changes are common later on irrespective of whether the patients are in remission or not.

Alendronate influences bending force of femoral diaphysis after orchidectomy in rats.

BACKGROUND AND AIMS: We examined the effect of alendronate on bone following orchidectomy-induced osteoporosis. MATERIAL AND METHODS: Eighty male rats were used. Group I (C) served as the untreated control. In group II (ALN), alendronate was administered subcutaneously (18 microg/kg). In group III (ORC), rats were castrated only. In group IV (ORC+ALN), administration of alendronate (18 microg/kg) was started immediately after castration, and in group V (ORC + ALN-21) medication was started 21 days after castration. Alendronate was given twice a week for eight weeks in the treatment groups. Bone mineral density (BMD) of the proximal femur, ultimate bending forces of femoral diaphyses, ash weights of femurs (AWcc) and the calcium content (Ca) of femoral ash were determined. Histomorphometric analysis was performed on trabecular bone of proximal tibiae. RESULTS: BMD of the proximal femur was significantly decreased by orchidectomy compared with C and ALN. However, no statistical difference was observed between alendronate-treated groups (ORC + ALN and ORC + ALN-21) and the ORC group. Histologically, alendronate reduced the trabecular bone turnover. Ultimate bending force increased significantly in the ORC+ALN-21 group compared with group C, and had a good correlation with the cortical width of tibia (r = 0.53, p < 0.001). Ash weight per bone volume (AWcc) was lowest in the ORC group, whilst alendronate maintained AWcc after orchidectomy. CONCLUSION: Alendronate increased the ultimate bending force of the femoral diaphysis after orchidectomy. On the other hand, ALN treatment was not able to maintain the BMD of the proximal femur at the pre-orchidectomy level. Our results suggest that the remodelling and modelling of bone may influence the response to ALN treatment.

Pamidronate increases trabecular bone mineral density in immobilization osteopenia in male rats.

BACKGROUND AND AIMS: Osteopenia is a common consequence of immobilization. We investigated the effects of pamidronate on immobilized bone in male rats. MATERIAL AND METHODS: Eighty male Wistar rats (5 months old) were divided in five groups (control (C); pamidronate at 0.5 mg/kg per dose (Pam0.5); immobilization (N); pamidronate at 0.05 mg/kg per dose + immobilization (N + Pam0.05); and pamidronate at 0.5 mg/kg per dose + immobilization (N + Pam0.5). The rats were immobilized on their right side by sciatic neurectomy. Pamidronate was given subcutaneously three times a week for three weeks. Trabecular bone mineral density (TBMD) of the upper femur, ultimate failure load of the femoral diaphysis, ash weight of femur, calcium content of femoral ash, and ash weight corrected with bone volume (AWcc [g/cm3]) were determined. Histomorphometry of proximal tibiae was performed by a semiautomatic method. RESULTS: TBMD was higher on both sides in Pam0.5 and N + Pam0.5 groups than in C or N groups. Ultimate failure load was not altered significantly with treatment. AWcc of the immobilized femur was lower (p < 0.001) than in the contralateral limb in N, N + Pam0.05 and N + Pam0.5 groups. Both resorption and formation parameters were suppressed by pamidronate. CONCLUSION: Pamidronate treatment seemed to increase trabecular bone density, although it was not effective in maintaining the AWcc of the operated extremity. Pamidronate did not seem to affect the ultimate failure load of cortical bone.

Intermittent and continuous administration of the bisphosphonate ibandronate in ovariohysterectomized beagle dogs: effects on bone morphometry and mineral properties.

Bisphosphonates have emerged as a valuable treatment for postmenopausal osteoporosis. Bisphosphonate treatment is usually accompanied by a 3-6% gain in bone mineral density (BMD) during the first year of treatment and by a decrease in bone turnover. Despite low bone turnover, BMD continues to increase slowly beyond the first year of treatment. There is evidence that bisphosphonates not only increase bone volume but also enhance secondary mineralization. The present study was conducted to address this issue and to compare the effects of continuous and intermittent bisphosphonate therapy on static and dynamic parameters of bone structure, formation, and resorption and on mineral properties of bone. Sixty dogs were ovariohysterectomized (OHX) and 10 animals were sham-operated (Sham). Four months after surgery, OHX dogs were divided in six groups (n = 10 each). They received for 1 year ibandronate daily (5 out of 7 days) at a dose of 0, 0.8, 1.2, 4.1, and 14 microg/kg/day or intermittently (65 microg/kg/day, 2 weeks on, 11 weeks off). Sham dogs received vehicle daily. At month 4, there was a significant decrease in bone volume in OHX animals (p < 0.05). Doses of ibandronate >/= 4.1 microg/kg/day stopped or completely reversed bone loss. Bone turnover (activation frequency) was significantly depressed in OHX dogs given ibandronate at the dose of 14 microg/kg/day. This was accompanied by significantly higher crystal size, a higher mineral-to-matrix ratio, and a more uniformly mineralized bone matrix than in control dogs. This finding lends support to the hypothesis that an increase in secondary mineralization plays a role in gain in BMD associated with bisphosphonate treatment. Moreover, intermittent and continuous therapies had a similar effect on bone volume. However, intermittent therapy was more sparing on bone turnover and bone mineral properties. Intermittent therapy could therefore represent an attractive alternative approach to continuous therapy.

Bone recovery after a gluten-free diet: a 5-year follow-up study.

The purpose of our study was to investigate the recovery of bone disease in celiac patients during 5 years of a gluten-free diet. The study group consisted of 28 newly diagnosed celiac patients (9 men, 19 women) recruited between 1990 and 1991. Six patients withdrew from the 5-year follow-up. Compliance with the gluten-free diet was good: 96% at 1 year and 82% at 5 years. During the follow-up period, the body mass index increased significantly (8%). Both in men and women, bone mineral density (BMD) values determined by dual X-ray absorptiometry (DXA) increased at the lumbar spine (2%), the femoral neck (1%), the trochanter (6%), and the Wards' area (3%) during the follow-up. The increase in BMD was found already during the first year of follow-up. After 1 year, BMD increased or remained the same in 69% of the patients at the lumbar spine and in 67% of the patients at the femoral neck, 89% of patients at the throchanter, and 67% of patients at the Wards' area. During the 5-year follow-up, these figures were 52%, 46%, 68%, and 59%, respectively. At the baseline, 19 out of 28 patients, after 1 year, 14 out of 26 patients, and after 5 years, 2 out of 26 patients had low serum 25(OH)D vitamin values (p = 0.0001). A high serum parathormone value was noticed in 6 out of 25 patients at the baseline, but after 1 year, 5 of them showed normalized values (p = 0.03). According to our results, bone disease in celiac patients is cured in most patients during 5 years on a gluten-free diet. The improvement in BMD mostly occurred already within the first year after the establishment of a gluten-free diet.

Characteristics of male hip fracture patients.

BACKGROUND AND AIMS: Among men, hip fracture is the most common outcome of osteoporosis. The aim of this study was to investigate the clinical characteristics, treatment, complications, short-term outcome and mortality of male hip fracture patients. MATERIAL AND METHODS: Operation theatre logs of all hip fracture patients operated on (1124 patients) at Kuopio University Hospital in 1989-1993 were reviewed. Medical records of the 276 male patients who underwent surgery (25 % of all patients) were studied. RESULTS AND CONCLUSIONS: 233 hip fractures (86 %) in men were due to low energy trauma. Of these cases, 61 % of the fractures occurred at the femoral neck, 31 % were pertrochanteric and 8 % subtrochanteric. The vast majority (90 %) of these patients had some chronic medical condition, and in 66 % the condition influenced motory or sensory functions. Hemiarthroplasty was most often used for femoral neck fractures (64 %). Internal fixation was used for pertrochanteric (97 %) and subtrochanteric (94 %) fractures. 20 % of the men had post-operative complications during the 1.5 year follow-up. During primary hospitalisation mortality was 3 %. Within 1.5 years of the fracture 40 % of the men had died, resulting in a mortality three times higher than age matched Finnish male population.

Urinary bone resorption markers in monitoring treatment of symptomatic osteoporosis.

We have studied the clinical usefulness of urinary bone resorption markers in postmenopausal women with symptomatic osteoporosis. The study design is a randomised double-blind placebo controlled study, in which the subjects were daily treated for 24 months either with a hormone analogue (2.5 mg Livial, generic name Tibolone, Organon, Amsterdam, Holland) plus 800 mg calcium (n = 14, age 63+/-5 years, range 52-68 years), or with placebo plus 800 mg calcium (n = 19, age 66+/-7 years, range 50-75 years). The laboratory methods for urinary bone resorption markers were enzyme immunoassays (EIA) for urinary pyridoline (PYD) and deoxypyridoline crosslinks (DPD), and for cross-linked N-telopeptides of Type I Collagen (NTx), and an HPLC assay for urinary hydroxyproline (HOP). All the urine assay results were calculated per mmol creatinine. All the resorption markers decreased during the two-year study period in both groups. The Z scores (discriminating power, i.e. ability of the different tests to distinguish the hormone treated subjects from the placebo treated subjects) for HOP and PYD were rather low: 0.06-1.52 for HOP and 0.68-1.47 for PYD. The differences between the two treatment groups were statistically significant for DPD at 12 and 24 months of treatment (P = 0.0471 and P = 0.0466, respectively), the Z scores ranging 0.45-1.90. NTx showed the most prominent decrease from the beginning of the study especially in the hormone treatment group: the differences between the two treatment groups were statistically highly significant for NTx already at 6 months of treatment (P = 0.0015), and the Z scores remained high ranging 2.11-3.82 throughout the two-year study period. Dual X-ray absorptiometry (DXA) of the lumbar spine and femoral neck did not show statistically significant differences between the two treatment groups throughout the two-year study period. After 2 years there was, however, a significant increase in bone density both in the spine (+ 6.6%, P = 0.0002) and in the femoral neck (+ 3.4%, P = 0.0389) in the women with hormone treatment. In the control group a significant increase (+ 5.1%, P = 0.0012) in the spine, whereas a non-significant decrease (-1.5%, n.s.) in the femoral neck was observed. We suggest that measurement of urinary cross-linked peptides derived from Type I collagen (NTx and DPD) might be a useful biochemical method of observing the positive clinical effect (i.e. reduction in bone resorption) following hormone replacement therapy in postmenopausal fracture patients.

Osteoporosis in adult patients with celiac disease.

We investigated the bone mineral density (BMD) and prevalence of osteopenia and osteoporosis in adult celiac patients with varying disease states. In this cross-sectional study the data on the severity of celiac disease and BMD were collected from 77 celiac patients (28 newly diagnosed and 49 previously diagnosed celiac patients), and BMD results were compared with those of 157 control subjects matched for age, gender, and menopausal status. The celiac patients had significantly lower BMD than the control subjects at the lumbar spine (-6%) and femoral neck (-5%). The mean BMD did not differ significantly among celiac patients classified by severity of disease. Based on Z scores, 35% of the celiac patients and 17% of the control subjects had low BMDs for age at the lumbar spine (p = 0.005), whereas 31% of celiac patients and 16% of control subjects had Z scores of < or =-1 at the femoral neck (p = 0.01). Altogether, 26% of all celiac patients, but only 5% of control subjects, were classified as having osteoporosis (T score < or =-2.5 SD) at the lumbar spine (p = 0.03), whereas osteoporosis was rare at the femoral neck in both groups (3% vs. 1%, p = 1.00). Prevalence of osteopenia and osteoporosis was highest in newly diagnosed celiac patients and in patients with disease not in remission. A low 25-(OH)D vitamin concentration was a typical biochemical abnormality in our patients (64% of men and 71% of women). The main associated variables of low BMD were age (men), low serum vitamin D level, low body weight, and postmenopausal status (women). The present study suggests that celiac disease constitutes a risk factor for osteoporosis. This finding applies particularly to untreated and poorly treated patients.

A randomized study of tibolone on bone mineral density in osteoporotic postmenopausal women with previous fractures.

OBJECTIVE: To investigate the effects of tibolone on trabecular and cortical bone mineral density and on indices of calcium metabolism in postmenopausal women with previous fractures. METHODS: In a 2-year, randomized, double-blind, placebo-controlled, bicenter study, 45 women were treated with tibolone and 43 with placebo. All subjects received 800 mg of calcium daily. Trabecular bone mineral density of lumbar spine (L1 to L4) and cortical bone mass at the femoral neck were assessed by dual energy x-ray absorptiometry at baseline and at 6-month intervals. Serum and urinary bone biochemistry variables were also assessed. RESULTS: After 2 years, subjects in the tibolone group gained 6.9% bone mass at lumbar spine and 4.5% at femoral neck, and respective increases from baseline in the placebo group were 2.7% and 1.4%. Tibolone-treated patients gained statistically significantly more bone mass than placebo-treated patients in the spine and femur. Urinary calcium: creatinine and hydroxyproline:creatinine ratios, as well as serum alkaline phosphatase and phosphate levels, were significantly reduced with tibolone compared with placebo. CONCLUSION: Tibolone induced a significant increase in trabecular (lumbar spine) and cortical (femoral neck) bone mass in postmenopausal osteoporotic women compared to placebo, suggesting its potential to treat postmenopausal osteoporosis.

Subchondral bone remodeling increases in early experimental osteoarthrosis in young beagle dogs.

We evaluated subchondral bone remodeling and structure in the condyles of the femur and the patellar surface of the femur in early experimental osteoarthrosis of young female beagle dogs. 14 littermate (twin) dogs were divided into operation (n 7) and control groups (n 7). The dogs in the operation group underwent surgically a 30 degrees valgus angulation of the right tibia to induce osteoarthrotic articular cartilage lesions in the knee (stifle) joint. 7 months postoperatively, bone samples were harvested from both condyles and the patellar surface of the femur and evaluated by histomorphometry of subchondral bone. Cartilage samples from the same areas were taken for histology. In the operated dogs, subchondral bone remodeling increased strikingly in the patellar surface of the femur; osteoid thickness and osteoblast surface/bone surface increased up to 42% and 94% (p < 0.05), as compared to controls. Total and active erosion depths increased by 14% and 30% in the same area (p < 0.05). However, in bone structural parameters no significant difference could be observed between the groups. In the medial condyle of the femur, the trabecular number decreased in operated dogs, as compared to controls (p < 0.05). The lateral condyle of the femur in operated animals did not differ from controls in the parameters tested. In the operated dogs, histology from cartilage samples showed initial osteoarthrotic changes in the patellar surface and the medial condyle of the femur. Histologic changes were greatest in the patellar surface of the femur, as assessed by the Mankin scores. At the very onset of osteoarthrosis, subchondral bone remodeling increases, but the bone structural changes are indistinct. It seems that in this osteoarthrosis model, cartilage lesions precede major subchondral changes in the structure of the bone.

Short-term intravenous bisphosphonates in prevention of postmenopausal bone loss.

This study was performed to test the efficacy of short-term intravenous clodronate and etidronate in the prevention of postmenopausal bone loss. Healthy postmenopausal women, exhibiting a decreasing trend in bone mineral density, were randomized to five groups (clodronate at doses of 150, 300, and 600 mg; etidronate at a dose of 300 mg; and a placebo group) of 21-22 subjects. The drugs were administered intravenously three times with 1-week intervals, followed by regular evaluation for up to 24 months. During the first year, 300 mg of clodronate retarded bone loss significantly in the lumbar spine and femoral neck, where significant protection still persisted after 24 months. Other doses of clodronate (150 and 600 mg) were not bone protective. Etidronate (300 mg) retarded bone loss significantly in the lumbar spine up to 24 months, relative to placebo. Serum concentrations of procollagen I carboxy-terminal propeptide and urinary Ca2+ and hydroxyproline excretion decreased in all bisphosphonate groups during the first month after treatment, but the values returned later toward baseline. In the etidronate-group, serum osteocalcin concentrations also decreased significantly during the first 3 months of the study. Otherwise, no uniform serum responses to bisphosphonate-treatment were detected in circulating markers of bone formation, alkaline phosphatase, or osteocalcin. No significant differences in the serum concentrations of cross-linked carboxy-terminal telopeptide of type I collagen were detected between the groups. Patient acceptance of both bisphosphonates was excellent, and no drug-related adverse side effects were detected. These results suggest that infrequently repeated intravenous treatment with bisphosphonates may effectively counteract postmenopausal bone loss.

Analysis of 245 consecutive hip fracture patients with special reference to bone metabolism.

BACKGROUND AND AIMS: The number of hip fractures in industrialised countries is increasing rapidly, being a major socio-economic burden for the health care system. The aims of this study were to evaluate fracture treatment, complications, recovery and especially bone metabolism of the hip fracture patients. MATERIAL AND METHODS: 245 consecutive hip fracture patients were examined. Information on the type of the fracture, surgical methods and outcome, previous chronic diseases and mortality were obtained from the hospital records. Bone biopsy of the iliac crest was performed on 105 patients at the time of the operation for histomorphometric evaluation. Later questionnaires were sent to the biopsy patients. A subgroup (n = 13) of fracture patients with osteomalacia were further evaluated for bone mineral density (BMD) and biochemistry. RESULTS AND CONCLUSIONS: The overall condition of the patients deteriorated in 72.1%. Only 58% of the patients were able to return to their previous place of residence. Only 20% of the patients had normal histomorphometry of trabecular bone. Osteomalacia was found in 24% and hyperparathyroid histological changes in 3% of the cases. To prevent hip fractures, not only adjustments in daily environment but also proper therapy of chronic diseases as well as diagnosis and treatment of metabolic bone diseases are needed. Also, accurate surgical methods and good rehabilitation are necessary to ensure optimal recovery of the patients with proximal femoral fractures.

Evaluation of periprosthetic bone using dual-energy x-ray absorptiometry: precision of the method and effect of operation on bone mineral density.

To assess the perioperative bone loss of femur during total hip arthroplasty (THA), periprosthetic bone mineral density (BMD) of the seven regions of interests (Gruen zones) was determined with dual-energy x-ray absorptiometry (DXA) preoperatively in both proximal femurs and postoperatively in the involved side in 53 patients with degenerative hip osteoarthrosis. The mean (standard deviation, SD) precision error (coefficient of variation percent, CV%) in various regions of interest (ROIs) based on two consecutive measurements (n = 16) were 2.3 (0.8)%, 2.5 (1.5)%, and 2.8 (1.6)% for uncemented stems, cemented stems, and control sides, respectively. Furthermore, the mean variability caused by the rotation of femur was 3.5 (1.4)%. The most significant perioperative bone loss (13.5-19.2%) was found in the calcar area (zone 7) after noncemented THA. Zone 4, representing the bone below the prosthesis, also showed BMD decreases. These decreases suggest perioperative bone loss owing to rasping and reaming the calcar and bone canal. However, after cemented THA, highly significant BMD increases were found in all the lateral zones. The calcar area was the only site where significant perioperative bone loss was detected (12.8%). In conclusion, DXA is a precise method for quantifying bone mass and density changes in the follow-up of THA. However, when interpreting the results, the preoperative BMD, differences between the femurs and the effect of operation on bone mass should be taken into account. We suggest that the best reference for BMD follow-up is the periprosthetic BMD of the involved side measured soon after the THA.

Salmon calcitonin in the prevention of bone loss at perimenopause.

The objective of this study was to determine whether intranasal salmon calcitonin prevents physiological bone loss at perimenopause. A double-blind study of 120 perimenopausal women without present or past disease or medication that could affect bone metabolism were studied. The subjects were randomized in two groups and provided with nasal spray bottles containing either placebo (excipient only) or active compound (excipient plus 50 international units (IU) salmon calcitonin per dose). Subjects took one puff from the nasal spray in each nostril every morning. All subjects took one soluble tablet of calcium (1000 mg) per day. Serum biochemistry, dual-energy X-ray absorptiometry of lumbar spine and proximal femur, quantitative computed tomography of lumbar spine, and single photon attenuation of forearm were used to evaluate bone mineral density (BMD). There were no differences in demographic characteristics or hormone status at entry. No fractures were recorded during the study period. Serum calcium increased and serum dihydroxyvitamin D and osteocalcin decreased in both groups. There was no difference in biochemical parameters between the groups. The BMD of upper femur did not change during the study, but it was decreased in the lumbar spine in both groups. The mineral content of distal radius increased in both groups. In conclusion, nasal salmon calcitonin, 100 IU daily, has no protective effect on bone mass and does not modify bone metabolism at perimenopause.