The Effect of Denosumab in Elderly Patients Regarding Bone Density and Fracture Risk

Background@#With an aging population, the importance of treating and diagnosing osteoporosis is increasing. Osteoporosis, previously known as a resorptive change primarily related to endocrinological mechanisms, is also being approached as a phenomenon of senile change. Denosumab is gaining popularity among osteoporosis medications due to its ability to increase bone mineral density (BMD) and the economic benefit arising from the 6-month cycle. In line with previous literature, this study aimed to examine the BMD-augmenting effect of denosumab through which it reduces fracture risk in individuals aged over 80 years. @*Methods@#We reviewed patients who received denosumab between 2018 and 2022 with a minimum clinical observation period of 12 months. BMD was measured every 12 months, and patients were classified per their period of denosumab use. Fracture risk was evaluated using the fracture risk assessment tool (FRAX) and fracture incidence during the observation period were assessed. @*Results@#Among 155 patients, a significant increase in BMD was observed at 3 sites: the lumbar spine, femoral neck, and total hip (p<0.001, p<0.001, and p=0.001, respectively). The patients were divided according to the length of clinical follow-up they received, and similar results were found in all subgroups. Fracture risk assessment was performed using FRAX and the incidence of fracture events during follow-up. FRAX significantly decreased in all subgroups except those who received 24 months of follow-up (p=0.003, p=0.41, p=0.001 in the 12, 24, and ≥36 months groups, respectively). @*Conclusions@#Denosumab use resulted in long-term BMD increase and reduced fracture risk in individuals aged 80 and above.

Hip Fractures in Centenarians: Functional Outcomes, Mortality, and Risk Factors from a Multicenter Cohort Study

Background@#Increasing longevity has caused the very old population to become the fastest-growing segment. The number of centenarians (over 100 years old) is increasing rapidly. Fractures in the elderly lead to excessive medical costs and decreased quality of life with socioeconomic burdens. However, little research has thoroughly examined the functional outcomes and mortality of hip fractures in centenarians. @*Methods@#This is a retrospective observational study. Sixty-eight centenarian hip fracture patients were admitted to the 10 institutions from February 2004 to December 2019. Fifty-six patients with 1-year follow-up were finally included. The following data were obtained: sex, age, body mass index, Charlson comorbidity index value on the operation day, Koval’s classification for ambulatory ability, type of fracture, the time interval from trauma to surgery, American Society of Anesthesiologists grade, surgery-related complications, and duration of hospital stay. Postoperative Koval’s classification (at 1 year after surgery) and information about death were also collected. Multivariate analysis was performed to analyze the risk factors affecting mortality 1 year after surgery. @*Results@#Mortality rates were 26.8% at 6 months and 39.3% at 1 year. The 90-day mortality was 19.6%, and one of them (2.1%) died in the hospital. The 1-year mortality rates for the community ambulatory and non-community ambulatory groups were 29% and 52%, respectively. Only 9 (16.1%) were able to walk outdoors 1 year after surgery. The remaining 47 patients (83.9%) had to stay indoors after surgery. Multivariate analysis demonstrated that the pre-injury ambulatory level (adjusted hazard ratio, 2.884; p = 0.034) was associated with the risk of mortality. @*Conclusions@#We report a 1-year mortality rate of 39.3% in centenarian patients with hip fractures. The risk factor for mortality was the pre-injury ambulatory status. This could be an important consideration in the planning of treatment for centenarian hip fracture patients.

The Efficacy of Suture Fixation of the Greater Trochanter in Unstable Intertrochanteric Fractures

Background@#Intertrochanteric fractures are one of the most common fractures in the elderly, especially those having osteoporosis. Stable intertrochanteric fractures may be fixed with implants including the dynamic hip screw and proximal femoral nail antirotation; however, this method is difficult to apply to unstable fractures. Bipolar hemiarthroplasty can be applied to unstable fractures and it prevents complications by facilitating early ambulation in the elderly. Many studies reported on how to fix the greater trochanter in unstable fractures during arthroplasty. We suggest that suture fixation alone can be a useful, effective, and affordable method. @*Methods@#We retrospectively enrolled 294 patients who underwent hemiarthroplasty for an unstable intertrochanteric fracture, and 225 patients were included in this study after excluding 69 patients who had not been available for follow-up until 1 year after surgery or died. The patients were divided into suture fixation and wiring fixation groups. Relationships of operation time, estimated blood loss, tip-to-stem distance, union rate, and physical performance in the groups of suture fixation and wiring were analyzed respectively. @*Results@#Changes in the tip-to-stem distance between the initial assessment at 1 year after surgery were statistically significantly different between the suture fixation group and wiring group (p < 0.001). There was no significant difference in change of the Koval score between the suture fixation and wiring groups (p = 0.362). The operation time and estimated intraoperative blood loss were statistically significantly lower in the suture group than in the wiring group (p < 0.001). There was no significant difference in the union rate between the groups (p = 0.470). @*Conclusions@#Compared to tension-band wiring, the suture fixation technique demonstrated an effective fixing force. In addition to the clinical results, it had an advantage of preventing complications due to shortening of the operation time and estimated intraoperative blood loss. Suture fixation of the greater trochanter is recommended for elderly patients with unstable intertrochanteric fractures.

Clinical Study on Safety, Clinical Indicators of Polydioxanone Sutures Inserted into Vastus Medialis Muscle in Degenerative Knee Osteoarthritis

Objective@#Physiologically, the vastus medialis muscle is the first muscle to undergo muscle atrophy, and it was thought that pain in patients with knee osteoarthritis could be reduced if this muscle could be strengthened and stabilized. The purpose of this study was to prove the effectiveness in knee osteoarthritis using polydioxanone sutures that have been tried in other musculoskeletal areas. Method: Forty knee osteoarthritis patients voluntarily participated in the study, and divided into 30 polydioxanone suture needle (MEST-B2375 produced by Ovmedi Co.) and 10 sham needle (without suture). And the needles were inserted into the vastus medialis muscle. In all patients, safety evaluation including blood tests and ultrasonography as well as efficacy evaluation including isometric maximal contractile strength of quadriceps muscle, weight bearing pain, impression of change, quadriceps angle, rescue drug intake were evaluated up to 30 weeks after the procedure. @*Results@#Isometric maximal contractile strength showed a significant improvement at 4 weeks after the procedure in the polydioxanone suture group, and the weight-bearing pain showed a significant improvement at every visit in the polydioxanone suture group compared with baseline values. Patient global impression of change score showed significant improvement at 20 and 30 weeks, and clinical score showed improvement at every visit. @*Conclusion@#Insertion of polydioxanone sutures showed improvement in muscle strength and knee pain by supporting and fixation of the vastus medialis muscle in patients with degenerative knee osteoarthritis. Insertion of polydioxanone sutures is considered to have a therapeutic effect in knee osteoarthritis patients.

Does Teriparatide Improve Fracture Union?:A Systematic Review

We conducted an updated review of the evidence of teriparatide (TPTD) for fracture healing for the following questions. (1) Does it decrease fracture healing time?; (2) Can it be an alternative treatment for nonunion?; (3) Does it aid the union of atypical femoral fracture (AFF)? We searched PubMed, EMBASE, and Cochrane Library including “Fracture” AND “nonunion” AND “Teriparatide”. In total, 57 publications met our inclusion criteria were summarized. This systemic review of the available literature revealed that TPTD works positively with regard to enhancing fracture healing time and union of AFF. There are also many case studies on the use of TPTD could be a potential new safe treatment for nonunion with no side effects. However, level 1 studies on the evidence of TPTD are still lacking so far. Over the last decade, a growing body of evidence has accumulated suggesting that TPTD can be an adjunct to enhance fracture healing or a therapeutic option to treat nonunion, but greater evidences from large volume prospective trials are needed.

Assessing Low Skeletal Mass in Patients Undergoing Hip Surgery: The Role of Sonoelastography / 대한고관절학회지

Purpose@#To analyze the utility of sonoelastography–a radiation-free procedure to characterize muscle properties–as an instrument to qualitatively and quantitatively assess the rectus femoris muscle. @*Materials and Methods@#Fifty-one consecutive patients who underwent a pelvic computed tomography (CT) exam were enrolled prospectively. The final analysis was conducted using data from 39 patients after 12 were removed due to exclusion criteria (muscle strength could not be measured due to poor cognition [n=11]; too young [n=1]). The potential correlation between average Hounsfield unit (HFU) at the rectus femoris muscle (measured by CT) and muscle quality grade (determined by sonoelastography) was assessed along with a retrospective analysis of the relationship between hand grip strength, knee extensor power, history of intensive care unit stay, length of hospital day and sonoelastographic grade. @*Results@#There was a significant correlation between sonoelastographic grade and the average HFU (P<0.001).Furthermore, hand grip strength (P<0.001) and knee extensor power (P<0.001) decreased significantly as the sonoelastographic grade increased. The likelihood of an intensive care unit stay and prevalence of low skeletal mass increased significantly with an increase in sonoelastography grade (P=0.037, P<0.001, respectively). The sensitivity, specificity, and accuracy of sonoelastographic images for predicting low skeletal mass were 77.3%, 100%, and 87.5%, respectively. @*Conclusion@#Sonoelastography advantages, including the lack of radiation and greater accessibility, may make it a valuable alternative to qualitatively and quantitatively identify sarcopenia and low skeletal mass.

Assessing Low Skeletal Mass in Patients Undergoing Hip Surgery: The Role of Sonoelastography / 대한고관절학회지

Purpose@#To analyze the utility of sonoelastography–a radiation-free procedure to characterize muscle properties–as an instrument to qualitatively and quantitatively assess the rectus femoris muscle. @*Materials and Methods@#Fifty-one consecutive patients who underwent a pelvic computed tomography (CT) exam were enrolled prospectively. The final analysis was conducted using data from 39 patients after 12 were removed due to exclusion criteria (muscle strength could not be measured due to poor cognition [n=11]; too young [n=1]). The potential correlation between average Hounsfield unit (HFU) at the rectus femoris muscle (measured by CT) and muscle quality grade (determined by sonoelastography) was assessed along with a retrospective analysis of the relationship between hand grip strength, knee extensor power, history of intensive care unit stay, length of hospital day and sonoelastographic grade. @*Results@#There was a significant correlation between sonoelastographic grade and the average HFU (P<0.001).Furthermore, hand grip strength (P<0.001) and knee extensor power (P<0.001) decreased significantly as the sonoelastographic grade increased. The likelihood of an intensive care unit stay and prevalence of low skeletal mass increased significantly with an increase in sonoelastography grade (P=0.037, P<0.001, respectively). The sensitivity, specificity, and accuracy of sonoelastographic images for predicting low skeletal mass were 77.3%, 100%, and 87.5%, respectively. @*Conclusion@#Sonoelastography advantages, including the lack of radiation and greater accessibility, may make it a valuable alternative to qualitatively and quantitatively identify sarcopenia and low skeletal mass.

Diagnosis and Treatment of Inflammatory Joint Disease / 대한고관절학회지

Arthritis damages the cartilage within joints, resulting in degenerative changes, including loss of function and joint instability. Ankylosing spondylitis (AS) is a chronic inflammatory condition affecting the spine and bone-to-tendon attachment area within the sacroiliac joint leading to back pain and progressive spinal stiffness. In the final stages, AS causes hyperkyphosis-a condition closely tied to the human leukocyte antigen-B27 gene. Rheumatoid arthritis is a chronic, systemic autoimmune disease characterized by the simultaneous inflammation of the synovium of multiple joints, leading to joint damage (e.g., destruction, deformation and disability). In the past, nonsteroidal anti-inflammatory drugs or conventional disease-modifying antirheumatic drug (DMARDs) have been used for the treatment of these autoimmune diseases, but biologic DMARDs have recently been introduced with excellent results. Gout is a chronic inflammatory disease that causes an alteration of joints resulting in severe pain. Specifically, gout is associated with an accumulation of uric acid within the body resulting from dysregulated purine metabolism, causing recurrent paroxysmal inflammation in the joints. Allopurinol and febuxostat are the primary treatment options for individuals with gout. It is necessary to have an accurate understanding of the pathogenesis, pathological ecology and treatment of AS, rheumatoid arthritis, and gouty arthritis, which are the representative diseases that may cause inflammatory arthritis.

The Role of Arthroscopy of Acute and Chronic Painful Thumb Metacarpophalangeal Joint

PURPOSE: There has been few published on arthroscopy of metacarpophalangeal joint (MCPJ) despite increasingly being used worldwide. The purpose of this study was to investigate the effectiveness of arthroscopy for pathologies around MCPJ of the thumb. METHODS: Between September 2007 and June 2015, 56 patients (56 thumb) who underwent arthroscopy of the MCPJ were retrospectively studied. Preoperative diagnoses, which were made through physical examination, plain radiograph, stress radiography, ultrasound, and magnetic resonance images (MRI), were compared with arthroscopic findings. Therapeutic arthroscopic surgeries were performed according to the needs of each patient. Functional outcomes were assessed with physical examination as well as disabilities of the arm, shoulder and hand (DASH) score and Michigan Hand outcomes Questionnaire (MHQ) score at an average 7.3 months follow-up. RESULTS: Six patients who suspected with collateral ligament injuries in MRI confirmed different diagnoses under arthroscopy. At final follow-up, the mean range of flexion contracture of the MCPJ was 5°, and the mean range of further flexion was 52.7°. Grip and pinch strength averaged 87.2% and 79.3% of contralateral side. Mean DASH and MHQ score were improved from 48.1 and 44.6, preoperatively to 14.9 and 26.3, postoperatively (p<0.001, p=0.012, respectively). All patients were satisfied with their outcomes at final follow-up, except 4 patients who noted joint stiffness or chronic pain around the thumb. CONCLUSION: Our results revealed that arthroscopy is helpful for both diagnostic and therapeutic purposes of acute and chronic painful MCPJ of the thumb. However, further studies are needed to expand the applications of arthroscopy of MCPJ of the thumb.

Utilization of Hyaluronate and Incidence of Septic Knee Arthritis in Adults: Results from the Korean National Claim Registry

BACKGROUND: Septic arthritis of the knee has been reported recently in adult patients who were administered hyaluronate. We evaluated the incidence of septic knees and the utilization of hyaluronate in the Korean adult population using nationwide data from the Health Insurance Review and Assessment Service (HIRA). METHODS: All new admissions to the clinics or hospitals for septic knees were recorded in the HIRA database which was established by the Korean government and covers the Korean population using the International Classification of Diseases-10 revision code. We evaluated the incidence of septic arthritis of the knees in the population above 50 years of age. Hyaluronate prescription data was also collected from the HIRA database. RESULTS: In 2012, the incidence of septic knees was 2.7 per 100,000 persons in men and 4.2 per 100,000 persons in women, respectively. The age-adjusted incidence of septic knees increased by 6.7% per year (95% confidence interval, 3.3 to 10.1), and the annual number of prescriptions of hyaluronate increased about 1.5-fold during the study period. CONCLUSIONS: Cautious aseptic technique is required when hyaluronate is administered in adult patients with osteoarthritis of the knee due to the concerns of the risk of septic arthritis.

Patient Satisfaction after Arthroscopic Repair of Acetabular Labral Tears

BACKGROUND: Acetabular labral tear is a main cause of hip pain and disability, often requiring surgical treatment. Improvements of hip arthroscopic technique have produced positive outcomes after labral repair with arthroscopy. The purpose of this study was to determine clinical outcomes and patient satisfaction after arthroscopic repair of acetabular labral tear. METHODS: We interviewed 21 patients (10 men and 11 women; mean age, 36 years [range, 22 to 57 years]) with acetabular labral tears that had been repaired arthroscopically in terms of satisfaction of the procedure. In addition, clinical outcome was assessed using visual analog scale (VAS) score, University of California, Los Angeles (UCLA) activity, Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, and Harris hip score, and radiologic outcome was assessed using serial radiography. The patients were followed for 24-50 months. RESULTS: The mean Harris hip score was 73 points (range, 64 to 84 points) preoperatively and 83 points (range, 66 to 95 points) postoperatively. Fifteen hips (71%) were rated excellent and good. The mean WOMAC osteoarthritis index and VAS scores were improved at final follow-up. UCLA activity at the latest follow-up improved in 16 patients. The Tonnis grade of osteoarthritis at the latest follow-up did not change in all patients. Eighteen of the patients (86%) were satisfied with the procedure. CONCLUSIONS: High rate of satisfaction after arthroscopic repair of acetabular labral tears is an encouraging outcome. Arthroscopic treatment of labral tears might be a useful technique in patients with hip pathologies, such as femoroacetabular impingement with labral tears.

Current Trends of Stem Use in Hemiarthroplasty for Femoral Neck Fracture in South Korea

BACKGROUND: Hemiarthroplasty is a common operation to treat femoral neck fracture in elderly patients. The choice of whether to use cemented stem or cementless stem in hemiarthroplasty has been controversial in clinical practice. However, recent trends regarding stem choice in South Korea are not known or documented. In this study, we assessed the trends of stem fixation in hemiarthroplasty for femoral neck fractures in South Korea. METHODS: Data of patients with femoral neck fractures, who were operated on between the years of 2007 and 2011 and were > or = 50 years old at the time of operation, were obtained from the Health Insurance Review and Assessment Service. All new visits or admissions to clinics or hospitals for femoral neck fractures were identified using the International Classification of Disease Tenth Revision diagnostic code (S720). The trends in the utilization of cemented and cementless hemiarthroplasty were then analyzed. RESULTS: The proportion of cementless hemiarthroplasty increased from 42.7% of all surgical procedures in 2007 to 61.4% of all surgical procedures in 2011 (p < 0.001), while the use of cemented hemiarthroplasty demonstrated a corresponding decrease. CONCLUSIONS: There was a current trends towards using cementless stems in hemiarthroplasty for femoral neck fractures in South Korea.

Bone Health and Clinical Results after Hip Fracture Surgery in Patients with Subclinical Hypothyroidism

BACKGROUND: Subclinical thyroid dysfunction might influence a bone health. We evaluated whether subclinical hypothyroidism adversely affects bone health including bone mineral density (BMD), level of vitamin D, and bone turnover status in patients with hip fracture. METHODS: We evaluated 471 patients aged 50 years or older, who underwent hip fracture surgeries. BMD, level of vitamin D, bone turnover status, and one-year mortality were compared between subclinical hypothyroidism group and control group. RESULTS: BMD of femur and the level of 25-hydroxy-vitamin D (25-[OH]D) were similar in the two groups. There were no significant differences in bone turnover markers according to thyroid function. No significant differences were observed between the groups in utilization of intensive care unit (ICU), length of hospital stay, mobility, and one-year mortality. CONCLUSIONS: Subclinical hypothyroidism was not associated with reduced bone health, including BMD, the level of 25-(OH)D, and bone turnover marker.

Intravenous Zoledronate for a Patient with Paget's Disease

Paget's disease (PD) of bone is characterized by increase of bone resorption by atypical osteoclasts, followed by rapid new bone formation resulting in a disorganized mosaic bone. Although the pathophysiology is not fully understood, bisphosphonate, which is a potent anti-resorptive agent for treatment of osteoporosis, have been the most effective agents available for the treatment of PD. We report a case of PD of bone in a 49-year-old woman patient, who was treated with intravenous zoledronate.

Domestic Characteristics and Trends of Publications on Bone Metabolism in South Korea between 1998 and 2012

BACKGROUND: This study was undertaken to investigate the trends in domestic publications on bone metabolism during the last decade, and to document the characteristics of articles in South Korea. METHODS: Articles on bone metabolism including osteoporosis published between 1998 and 2012 were evaluated, in terms of title, type of articles, subspecialty, and authors' affiliations. We used descriptive statistics for presenting the characteristics of domestic publication on bone metabolism. RESULTS: Total of 247 articles, published articles between 1998 and 2012, were reviewed. Over a total study period of 14 years, the number of articles which was initially 109 in the first half term increased to 247 during the period of second half. Of these 247 articles, 52 were on basic research, and 195 were on clinical research. Although the types of article were added in the later 7 years were much diverse than that of the earlier 7 years, the proportion of original articles has decreased. CONCLUSIONS: Our findings presented the characteristics and trends of domestic publication on bone metabolism in South Korea, and concerns for editorial boards in future.

Influence of Oral and Intravenous Bisphosphonate for the Patients Treated Surgically in Osteoporotic Distal Radius Fracture / 대한골다공증학회지

OBJECTIVES: Purpose of this study is investigation the influence of intravenous and oral bisphosphonate to bone union and clinical results in patient treated with plate fixation in an osteoporotic distal radius fracture. MATERIALS AND METHODS: The medical records of 160 patients with an osteoporotic distal radius fracture treated with plate fixation in our hospital between January 2008 and April 2012 were reviewed retrospectively. The patients were classified by 3 groups; who did not administrate bisphosphonate after surgery as Group I (n=69), administrated oral bisphosphonate after surgery as Group II (n=44), and administrated intravenous bisphosphonate as Group III (n=47). After surgery, bone union, radiologic parameters, disabilities of the DASH score and range of motion of wrist were assessed. RESULTS: Mean time of bone union was 6.7 weeks in Group I, 6.8 weeks in Group II, and 7.1 weeks in Group III. There was no significant difference between three groups (P=0.571). Bone union rate on 6weeks shows no significant differences between three groups (P=0.16). Three groups also have no significant differences in all radiologic and clinical parameters. CONCLUSION: This study shows that early initiation of oral and Intravenous bisphosphonate did not affect bone union and clinical results compared to group who did not administrate bisphosphonate result in patient treated with plate fixation in an osteoporotic distal radius fracture.

National Trends of Surgical Treatment for Intertrochanteric Fractures in Korea

Intramedullary nailing has been reported to have better outcome compared with traditional plate fixation in surgical treatment of intertrochanteric fractures. We evaluated the trends of surgical treatment of intertrochanteric fracture in Korea. Data of patients with intertrochanteric fractures, who were operated between the years of 2006 and 2011, was obtained from the Health Insurance Review and Assessment Service. The ratio of intramedullary nailing increased from 27.9% in 2006 to 64.3% in 2011 (P < 0.001), while the ratio of plate fixation decreased. During recent 5 yr, the utilization of intramedullary nailing doubled in clinical practice of intertrochanteric fractures in Korea.

Acute Calcific Tendinitis of the Abductor Pollicis Brevis in the Hand / 대한정형외과학회잡지

Acute calcific tendinitis in the hand is a very rare disease. We experienced two cases of acute calcific tendinitis of the abductor pollicis brevis in the hand. Both of the patients experienced pain, edema and erythema on radial side of metacarpophalangeal joint of thumb. We successfully treated the condition with aspiration and steroid injection under the ultrasonographic examination and subsequently, applied the casts. An improvement of the symptoms was observed with good results. In the present work, we report these cases with appropriate review of literatures.

Little Impact of Antiplatelet Agents on Venous Thromboembolism after Hip Fracture Surgery

Since the late 1980s, low dose aspirin has been used to prevent stroke and ischemic heart disease. However, prophylactic effect of antiplatelets against venous thromboembolism (VTE), in patients who undergo hip fracture surgery (HFS) is controversial. Our purpose was to determine the incidence of symptomatic VTE after HFS and to evaluate whether antiplatelets reduce the development of symptomatic VTE following HFS. We retrospectively reviewed 858 HFS in 824 consecutive patients which were performed from May 2003 to April 2010 at an East Asian institute. We compared the incidence of symptomatic VTE in antiplatelet users and non-users using multivariate logistic regression analyses. Overall incidences of symptomatic pulmonary embolism including fatal pulmonary embolism, and symptomatic deep vein thrombosis in this study were 2.4% (21/858), and 3.5% (30/858), respectively. The incidence of symptomatic VTE was 4.8% (12/250) in antiplatelet users and 4.3% (26/608) in non-users (P = 0.718). It is suggested that antiplatelet agents are not effective in prevention of symptomatic VTE after HFS.

Joint Preserving Operations for Femoral Head Osteonecrosis

Osteonecrosis of the femoral head mainly occurs in young patients, and the hip joint with osteonecrosis of the femoral head can be preserved by adequate joint-preserving surgery. This review article includes the information, surgical technique, pitfalls and results of several types of joint preserving surgeries.