The relationship between chronic kidney disease and denosumab-induced hypocalcemia in high-age osteoporotic patients.

PURPOSE: A few studies have reported the safety of the treatment of elderly osteoporotic patients with chronic kidney disease (CKD) and the possibility of hypocalcemia. The aim of the present study was to examine the relationship between the incidence of hypocalcemia and the CKD stage in elderly osteoporotic patients treated with denosumab. MATERIALS AND METHODS: This study was designed as a parallel-group comparison study between the denosumab-associated hypocalcemia (DAH) groups: the concentration of serum calcium was under 8.6 mg/dl and the normal calcium (NC) groups: the concentration of serum calcium was over 8.6 mg/dl. Fifty-two subjects over 70 years old were enrolled in this study, with 16 patients classified into the DAH group and 36 patients assigned to the NC group. All patients were further classified into two subgroups according to their age, into an around 75 years group to clarify the relevance of old age and an around 85 years group and also into a mild CKD group and a moderate CKD group by based on estimated glomerular filtration (eGFR). Serum calcium concentration, tartrate-resistant acid phosphatase (TRACP-5b), and type 1 procollagen N terminal propeptide (P1NP) were measured, and adverse drug reactions were evaluated. RESULTS: The eGFR and serum calcium were significantly lower in the DAH group than in the NC group in the starting phase. Moreover, TRACP-5b was significantly higher in the DAH group than in the NC group in the starting phase. There were no significant differences in P1NP. The incidence of hypocalcemia was significantly higher in the around 85 groups than in the around 75 groups. The frequency of hypocalcemia was also significantly higher in the severe CKD group than in the mild CKD group. CONCLUSION: Advanced age combined with low eGFR and low serum Ca status appear to be associated with the incidence of hypocalcemia when using denosumab for the treatment of osteoporosis.

The Effects of Switch Therapy in Osteoporosis Treatment after Romosozumab after Comparing with Prior Treatment.

Rationale. Although romosozumab is one of the most effective treatments for osteoporosis by increasing bone mineral density in the lumbar spine and femur and recommended for denosumab as switch therapy, these effects regarding its prior treatment have not yet been evaluated clearly. This study focused on the effects of switch therapy from romosozumab to denosumab in regard to prior treatment of osteoporosis including bone mineral density and bone turnover marker and other related factors. Patient Concerns. 15 osteoporotic patients were assigned to the naïve group, 15 were assigned to the teriparatide group, and 10 were assigned to the bisphosphonate group. Interventions. Patients who were treated as outpatients for osteoporosis with romosozumab for 1 year and switched to denosumab between 2020 and 2022 at our hospital were examined. Our hospital registry included 40 osteoporotic patients who were over 65 years of age with bone mineral density (bone mineral density): T score <-2.5 standard deviations (SDs) and fracture assessment tool (FRAX) score >20%. Outcomes. The naïve group had the highest increase in LS BMD among these three groups during switch therapy from romosozumab to denosumab, while there were no significant differences about adverse drug events and serum Ca concentration among them. There was no incidence of fracture. Conclusion. These findings indicate that the effects of osteoporotic treatment of switch therapy from romosozumab to denosumab were likely to affect prior treatment of osteoporosis.

Comparison of the Effects on Rib Fracture between the Traditional Japanese Medicine Jidabokuippo and Nonsteroidal Anti-Inflammatory Drugs: A Randomized Controlled Trial.

Jidabokuippo is a traditional Japanese medicine used for contusion-induced swelling and pain. This open multicenter randomized study was designed to compare the efficacies of jidabokuippo and nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with rib fracture by analyzing the treatment duration. Our study involved 170 rib fracture patients capable of oral ingestion divided randomly into 2 groups: the jidabokuippo and NSAID groups. We compared the duration of treatment and healthcare expenditure between these 2 groups. Medication was continued in both groups until the visual analogue scale score decreased to less than 50% of the pretreatment score. We excluded the patients in whom medication was prematurely discontinued. We analyzed 81 patients belonging to the jidabokuippo and NSAIDs groups. No significant intergroup differences were observed in age, gender, severity (injury severity score), and presence/absence of underlying disease. The treatment duration was significantly shorter in the jidabokuippo group than in the NSAIDs group (P = 0.0003). Healthcare expenditure was significantly lower in the jidabokuippo group than in the NSAIDs group (P < 0.0001). Our results suggest that compared to NSAIDs, jidabokuippo can shorten the duration of treatment in patients with rib fracture and is a promising analgesic agent based on the medical economic viewpoint.

A prospective analysis of concentration of 25-OHD between northern and southern district in Japan in year-round study.

Although osteoporotic patients have already been recognized as having a low-volume vitamin D status, the concentration of active vitamin D precursor has not been studied in detail. This trial aimed to clarify the concentration of 25-hydroxyvitamin D (25-OHD), which is a natural type of vitamin D and compare between 2 separate areas in Japan. To compare and clarify the concentration of 25-OHD between 2 separate areas, Japanese patients who were diagnosed as having osteoporosis based on bone mineral density were studied. We analyzed 2 different hospitals' patients whose residence is separated into a northern district (Akita city: north latitude 39" 43') and a southern district (Shizuoka city: north latitude 34" 58'). Both of them have completely different daylight hours. Three-hundred sixty eight patients (174 in Akita, 194 in Shizuoka) were enrolled in this trial to compare the differences of concentration of 25-OHD by Welch's t t-test. There were significant differences in the concentration of 25-OHD and age between them. Akita patients were significantly higher than that of Shizuoka patients despite Shizuoka having much daylight hours of Akita. In conclusion, there might be no relationship between the concentration of 25 OHD and exposure to sunlight.

The Effects of Trends in Osteoporosis Treatment on the Incidence of Fractures.

OBJECTIVE: This study focused on the trends in antiosteoporosis drug preferences and compared the incidence of fractures between patients treated orally and those who were exposed to an awareness campaign and assigned to intravenous/subcutaneous treatment. METHODS: Our hospital registry included 1,716 osteoporotic women who were over 65 years of age without preexisting vertebral and nonvertebral fractures over 1 year before this study, with bone mineral density (BMD) < -2.5 standard deviation (SD) and fracture assessment tool (FRAX) score > 20%, who were given 1,337 oral and 379 intravenous/subcutaneous prescriptions to treat their osteoporosis. Self-administered surveys (2012, 2013, 2014, 2015, and 2016) collected data on trends of preferences among nine drugs and fracture prevention using relative risk reduction (RRR). RESULTS: The number of patients taking oral prescriptions decreased gradually from 2012 to 2016, while the number of patients treated with intravenous and subcutaneous injections increased. The incidence of fracture was lower in patients receiving intravenous and subcutaneous injections than in patients taking oral medications. CONCLUSION: These findings indicate a decrease in oral prescriptions for osteoporosis treatment and that treatment for osteoporosis using intravenous or subcutaneous injections of antiosteoporosis drugs is more effective for preventing fractures.

Treatment of spontaneous osteonecrosis of the knee by daily teriparatide: A report of 3 cases.

RATIONALE: Although the treatment of femoral head necrosis has already been established with the adoption of daily teriparatide, a clear consensus on the treatment of spontaneous osteonecrosis of the knee (SONK) has yet to be reached. Therefore, we focused on the treatment of SONK with daily teriparatide administration (20 µg, subcutaneous) and confirmed its effects to determine whether it is a valid option. PATIENTS' CONCERNS: Three osteoporotic patients who were diagnosed with SONK complained of knee pain. DIAGNOSIS: SONK was diagnosed on magnetic resonance imaging in all cases. INTERVENTIONS: All patients took daily teriparatide as a treatment for SONK. OUTCOMES: There was a significant and dramatic reduction in the visual analog scale score 1 month after treatment. After 6 months of treatment, the sizes of the affected SONK lesions were smaller than in the initial phase, and plain X-rays showed no further signs of progression. LESSONS: Daily teriparatide might be an effective treatment for SONK.

A prospective comparative study of intravenous alendronate and ibandronate for the treatment of osteoporosis.

RATIONALE: Few comparative studies have evaluated the differences between intravenous alendronate (ALN) and ibandronate (IBN) in patients with osteoporosis. This study was to compare the effects of these 2 drugs on bone mineral density (BMD), bone metabolic markers, and adverse events in patients with osteoporosis. PATIENT CONCERNS: Seventy-eight subjects were assigned to the ALN group and 66 to the IBN group. DIAGNOSES: The diagnosis of osteoporosis was based on BMD values of the femoral neck or lumbar spine less than -2.5 SD below the reference values. INTERVENTIONS: This study was designed as a 52-weeks, prospective, non-randomized study involving a parallel-group comparison between intravenous ALN and intravenous IBN in elderly women with osteoporosis. OUTCOMES: The non-switched-IBN subgroup showed significant decrease in serum collagen type I cross-linked telopeptide (NTX) at 6 and 12 months compared with baseline, and the decrease in NTX were significantly greater in the non-switched-IBN subgroup than in the non-swithed-ALN subgroup. BMD in the lumbar spine in the non-switched-IBN subgroup showed a significant increase at 12 months and the increase in BMD were significantly larger than in the non-switched-ALN subgroup. LESSONS: Intravenou IBN might result in a significantly greater increase of BMD and decrease in NTX, but it had a higher incidence of adverse drug reactions than ALN.

Spontaneous Osteonecrosis of the Knee: A Retrospective Analysis by Using MRI and DEXA.

OBJECTIVE: Although there are many etiology and prediction for prognosis of spontaneous osteonecrosis of the knee (SONK) by using radiological examinations, these issue have not been clarified yet. Furthermore, most of the studies evaluated them by only radiological examination such as magnetic resonance imaging (MRI), bone mineral density (BMD) in dual-energy X-ray abosorptiometry (DEXA) or plain X-ray. Therefore, we focused our investigation on the measurements of the affected área in MRI and BMD in DEXA, and whether these results were conected with the cause and prognosis of SONK or not. METHOD: A consecutive case series of two groups composed of ten osteoporotic patients who were suffering from SONK was considered. Based on the severity or duration of pain, one group was treated with surgical procedure which was unicompartmental knee arthroplasty (UKA), the other received conservative treatment. Both groups underwent DEXA in their distal fêmur and próximal tíbia and all patients who took MRI measured the affected lesion in low and high intensity área on T2 weighted images. This data was analyzed from these areas and units. RESULTS: Significant decrease in regional boné density of the affected femoral condyle compared to the unaffected side was observed. However, the boné mineral density in the affected side was similar in the non-operative and surgical group. The área of the lesion which showed in both low and high intensity indicated that the operation group was significantly larger than the conservative group on T2 weighted images. CONCLUSION: The cause and prognosis of SONK have a close relationship with the size of the affected lesion and decreased boné mineral density.

Nonsurgical Corrective Union of Osteoporotic Vertebral Fracture with Once-Weekly Teriparatide.

Osteoporotic vertebral fractures usually heal with kyphotic deformities with subsidence of the vertebral body when treated conservatively. Corrective vertebral union using only antiosteoporotic pharmacotherapy without surgical intervention has not been reported previously. An 81-year-old female with osteoporosis presented with symptomatic fresh L1 vertebral fracture with intravertebral cleft. Segmental vertebral kyphosis angle (VKA) at L1 was 20° at diagnosis. Once-weekly teriparatide administration, hospitalized rest, and application of a thoracolumbosacral orthosis alleviated symptoms within 2 months. Corrective union of the affected vertebra was obtained with these treatments. VKA at 2 months after injury was 8° (correction, 12°) and was maintained as of the latest follow-up at 7 months. Teriparatide has potent bone-forming effects and has thus been expected to enhance fracture healing. Based on the clinical experience of this case, teriparatide may have the potential to allow correction of unstable vertebral fractures without surgical intervention.

Comparison of clinical outcomes between total knee arthroplasty and unicompartmental knee arthroplasty for osteoarthritis of the knee: a retrospective analysis of preoperative and postoperative results.

BACKGROUND: Excellent results have recently been reported for both total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA), but there have been few reports about which has a better long-term outcome. The preoperative and postoperative results of TKA and UKA for osteoarthritis of the knee were thus compared. METHODS: The results of 48 patients who underwent TKA and 25 patients who underwent UKA were evaluated based on clinical scores and survivorship in the middle long-term period. Preoperative, latest postoperative, and changes in the femoro-tibial angle (FTA), range of motion (ROM), Japanese Orthopedic Association score (JOA score), and Japanese Knee Osteoarthritis Measure (JKOM) were compared. The patients' mean age was 73 years. The mean follow-up period was 9 years (TKA: mean, 10.5 years; range, 7-12 years; UKA: mean, 9 years; range, 6-11 years). RESULTS: Preoperative FTA and ROM were significantly higher in the UKA group than in the TKA group. Total changes in all scores were similar among the two groups, as were changes in scores for all JOA and JKOM domains. The cumulative revision rate was higher for UKA than for TKA (7 versus 4%). Kaplan-Meier survivorship at 10 years was 84% for UKA and 92% for TKA. CONCLUSIONS: This clinical study found no significant differences between TKA and UKA, except in long-term survivorship.

A comparative study between intravenous and oral alendronate administration for the treatment of osteoporosis.

It has recently been reported that bisphosphonates are the most common treatment for osteoporotic patients. However, they are many problems, including poor bioavailability and adherence, as well as adverse drug reactions. Therefore, intravenous administration of bisphosphonates has been developed to resolve these problems. In Japan today, alendronate and ibandronate have been approved for intravenous administration, and they have advantages, such as good adherence and better gastrointestinal tolerability, compared to oral administration. We attempted to confirm the effects of administration of intravenous alendronate, which is not inferior to oral administration, for osteoporotic patients in earlier research. 200 consecutive Japanese over 70 years-old postmenopausal women who visited the first author's orthopedic clinic and had femoral neck or lumbar spine bone mineral density (BMD) values more than 2.5 SD lower than the reference values were randomly enrolled in this study. 100 subjects were recruited for administration of intravenous alendronates because of their poor adherence, no respond of treatment status, and gastrointestinal adverse effects. Furthermore, 10 of these subjects were excluded due to discontinuation, and a total of 90 subjects were eligible for the intravenous group. The remaining 50 patients received oral alendronate. The present study also showed no significant difference between intravenous and oral administration with respect to BMD, biochemical bone turnover markers, and the incidence of fractures. These results show that intravenous administration of alendronate is not inferior to oral alendronate for the treatment of osteoporosis. Therefore, intravenous administration of alendronate can be recommended if patients do not tolerate or adhere to oral bisphosphonates.

Comparison of activities of daily living after osteoporotic hip fracture surgery in patients admitted from home and from geriatric health service facilities.

With the population and proportion of the elderly increasing each year, difficulties with postoperative treatment outcomes after osteoporotic hip fracture are increasing. This study focused on activities of daily living (ADL) in patients who underwent surgery for hip fracture through an investigation of living arrangements, the presence of dementia, and other complications of aging. Information from 99 patients who lived either at home or in geriatric health service facilities was collected for this trial. Most patients were over 65 years of age and female, and about half of them had dementia. The postoperative ADL score (focusing on patients' walking ability) was significant for those living at home than for those living in facilities. In addition, patients with dementia were divided into the following two categories: an early-rising group, comprising patients who were able to use a wheelchair within 48 hours of their operation; and a late-rising group, who did not start using a wheelchair until more than 48 hours after surgery. The ADL scores for the two groups were compared. Although the preoperative ADL scores were not significantly different between the two groups, postoperative ADL scores were significantly higher in the early-rising group than in the late-rising group, especially in patients who had undergone hemiarthroplasty. These data suggest that ADL in dementia patients following hip fracture depends on the surgical procedure performed and whether they are late or early risers after surgery.

The Relationship between Osteoporosis and Osteoarthritis of the Knee: A Report of 2 Cases with Suspected Osteonecrosis.

Knee specimens of two osteoporotic patients who underwent unilateral knee arthroplasty for suspected osteonecrosis of the knee were examined histologically. Preoperative findings of magnetic resonance images in both patients were consistent with the diagnosis of osteonecrosis of the medial femoral condyles, although plain X-rays showed minimal degenerative changes. In both patients, preoperative bone mineral densities of the femoral condyle and proximal tibia of the affected side were lower than those of the unaffected side. Pathological examination of the resected femoral condyle and proximal tibia showed almost intact joint cartilage, healing of the collapsed subchondral bone, and significant trabecular bone loss. Histologically, no evidence of osteonecrosis, including empty lacunae of the trabecular bone, was observed. These findings indicated that subchondral bone collapse caused by osteoporosis, but not osteonecrosis, initiated the osteoarthritic change of the affected knee. This report emphasizes that there may be cases of progressive local osteoarthritis caused by fracture of subchondral bone because of osteoporosis.

Recurrent dislocation of the patella accompanying hypotrochlea of the femur and malalignment of the patella.

This case report describes a rare case of recurrent dislocation of the patella which was accompanied with trochlear dysplasia and malalignment of the patella in a 15-year-old girl. She complained of hemoarthrosis and recurrent patellar dislocation in the early knee flexion phase. Plain radiography and computed tomography (CT) showed patellar malalignment (quadriceps angle 20°) and severe dysplasia of the trochlea of the femur (sulcus angle 170°). Surgery was performed, consisting of trochleoplasty in addition to proximal and distal realignment. Trochleoplasty was undertaken using a modified Dejour technique. After surgery, the patient complained of joint contracture. Arthroscopic release of fibrous tissue relieved symptoms and obtained normal range of motion without patellar dislocation. Postoperative radiography and CT demonstrated improvement of the quadriceps angle (10°) and sulcus angle (140°).

Insufficiency fracture of the sternum simulating myocardial infarction: case report and review of the literature.

Insufficiency fracture is a type of stress fracture that occurs when stress is applied to the bone with less than the normal elastic resistance, as in osteoporosis. Insufficiency fracture of the sternum is rare among all kinds of fractures. We describe two cases with insufficiency fractures of the sternum secondary to osteoporosis and thoracic kyphotic deformity. Both of the present cases, a 76-year-old woman and a 65-year-old woman, presented with severe anterior chest pain simulating myocardial infarction. However, cardiopulmonary examinations including chest radiographs, electrocardiograms, and laboratory tests were normal. Lateral radiographs of the sternum in both patients showed insufficiency fractures of the sternum. Conservative treatment with rib bandaging/bracing and analgesics relieved their symptoms. Clinical behavior, type of sternal insufficiency fractures, and mechanism of the fracture are reviewed from perusal of the literature. We emphasize that sternal insufficiency fracture should be considered in the differential diagnosis of acute chest pain in the elderly along with myocardial infarction or pulmonary embolism.