Guidelines for diagnosis and treatment of glucocorticoid-induced osteoporosis / 中华内科杂志

Glucocorticoid-induced osteoporosis (GIOP) is a skeletal disease characterized by decreased bone strength and increased fracture risk associated with long-term glucocorticoid use. GIOP is the most common secondary osteoporosis that critically affects the quality of life of patients. Currently, the incidence of GIOP in China remains high, with insufficient awareness and lack of prevention and treatment norms. Therefore, the Chinese Rheumatology Association has established this standard based on domestic and international experience, with the aim of raising awareness of prevention and treatment among clinicians, guiding the standardized diagnosis and treatment of this disease, and improving the overall prognosis of patients with GIOP.

Atypical femur fractures associated with chronic bisphosphonates use: A case series with 66 patients / Fraturas atípicas do fêmur associadas ao uso crônico de bisfosfonatos: Uma série de casos de 66 pacientes

Abstract Objective The present study aims to describe outcomes from a series of surgically treated patients with atypical femoral fracture due to bisphosphonates use, in addition to correlate the time of previous medication use with fracture consolidation time, and to compare the consolidation time of complete and incomplete fractures. Methods This is an observational, retrospective study with 66 patients diagnosed with atypical femur fractures associated with chronic bisphosphonates use. The patients underwent orthopedic surgical treatment at a referral hospital from January 2018 to March 2020. Results All patients were females, with two bilateral cases. Fracture consolidation occurred in all cases, with an average time of 2.3 months and a follow-up time of 5.8 months. The average time of bisphosphonates use was 7.8 years. There was no correlation between the time of previous bisphosphonates use and the time for fracture consolidation. Consolidation time differed in complete and incomplete fractures. Conclusion Surgical treatment with a long cephalomedullary nail resulted in consolidation in all patients. The consolidation time was longer in complete fractures when compared with incomplete lesions, and there was no correlation between the time of previous bisphosphonates use and the consolidation time . Level of evidenceLevel IV, case series

Resumo Objetivo Descrever os resultados de uma série de pacientes tratados cirurgicamente com diagnóstico de fratura femoral atípica associada ao uso de bisfosfonatos, assim como correlacionar o tempo de uso prévio da medicação com o tempo de consolidação da fratura e comparar o tempo de consolidação das fraturas completas e incompletas. Métodos Trata-se de um estudo observacional e retrospectivo de 66 pacientes com diagnóstico de fratura atípica do fêmur associada ao uso crônico de bisfosfonatos. Os pacientes foram submetidos ao tratamento cirúrgico ortopédico em hospital de referência no período de janeiro de 2018 a março de 2020. Resultados Os pacientes incluídos no estudo eram todos do sexo feminino, com dois casos bilaterais. A consolidação da fratura ocorreu em todos os casos com tempo médio de 2,3 meses e seguimento de 5,8 meses. O tempo médio de uso de bisfosfonatos foi de 7,8 anos. Não houve correlação do tempo de uso prévio de bisfosfonatos com o tempo de consolidação das fraturas. Houve uma diferença do tempo de consolidação entre as fraturas completas e incompletas. Conclusão Houve consolidação após tratamento cirúrgico com haste cefalomedular longa em todos os pacientes do presente estudo, sendo o tempo de consolidação maior nas fraturas completas em relação às incompletas, e não houve correlação entre o tempo de uso prévio de bisfosfonatos e o tempo de consolidação. Nível de evidênciaNível IV, série de casos

Influencia de diferentes materiales de relleno en alvéolos post exodoncia de ratas ovariectomizadas (OVX) / Influence of different graft materials on post extraction sockets of ovariectomized rats (OVX)

RESUMEN: El objetivo del presente estudio fue establecer la influencia de diferentes materiales en el proceso de regeneración ósea de alveolos post exodoncia de ratas hembra adultas ovariectomizadas (OVX). Para ello, se utilizaron 40 ratas sprague dawley, divididas en grupo experimental (OVX) (n=20) y grupo control (Sin ovariectomía) (n=20). Todas las ratas del grupo experimental fueron sometidas a ovariectomía bilateral para simular un estado de osteoporosis inducida por déficit de estrógeno. Posterior a 12 semanas post OVX, las ratas de ambos grupos fueron divididas en 4 subgrupos, en los cuales fue extraído el primer molar superior derecho de cada rata. Posteriormente, las terapias realizadas en los alveolos post-exodoncia fueron: A: (N=5) Alveolo no rellenado para ser utilizado como control negativo. B: (N=5) Aplicación de injerto bifásico (HA+BTCP). C: (N=5) Aplicación de PRF. D: Aplicación de una combinación de injerto bifásico + PRF. Luego de tres semanas se realizó la eutanasia de los animales y obtención de las muestras para los análisis respectivos. Todos los animales sobrevivieron al final del estudio sin ninguna complicación postoperatoria. Los resultados cuantitativos del área ósea interradicular del segundo molar superior, mostraron diferencias estadísticamente significativas entre grupo control y grupo OVX. Mientras que no se observaron diferencias en la descripción histológica ni en el análisis cuantitativo de fibras colágenas tipo I y III. Es posible concluir que el modelo de osteoporosis inducida por déficit de estrógeno modificaría también la microarquitectura ósea de la Maxila. No obstante, nuevos estudios son necesarios para continuar con el estudio de biomateriales para regeneración ósea en modelos de osteoporosis inducida.

SUMMARY: The aim of the present study was to establish the influence of different materials on the process of bone regeneration in post-extraction sockets of ovariectomized (OVX) adult female rats. For this, 40 Sprague Dawley rats were used, divided into an experimental group (OVX) (n=20) and a control group (without ovariectomy) (n=20). All rats in the experimental group underwent bilateral ovariectomy to simulate a state of estrogen deficiency osteoporosis. After 12 weeks post OVX, rats from both groups were divided into 4 subgroups, in which the upper right first molar of each rat was extracted. Subsequently, the therapies performed in the post-extraction sockets were A: (N=5) Unfilled alveolus to be used as a negative control. B: (N=5) Biphasic graft application (HA+BTCP). C: (N=5) PRF application. D: Application of a combination of biphasic graft + PRF. After three weeks, the animals were euthanized, and the samples were obtained for the respective analyses. All animals survived to the end of the study without any postoperative complications. The quantitative results of the interradicular bone area of ??the upper second molar showed significant differences between the control group and the OVX group. While no differences were observed in the histological description or in the quantitative analysis of collagen fibers type I and III. It is possible to conclude that the model of osteoporosis induced by estrogen deficiency would modify the bone microarchitecture of the Maxilla. However, new studies are necessary to continue with the study of biomaterials for bone regeneration in models of induced osteoporosis.

Performance of the Fracture Risk Assessment Tool Associated with Muscle Mass Measurements and Handgrip to Screen for the Risk of Osteoporosis in Young Postmenopausal Women / Desempenho da ferramenta de avaliação de risco de fraturas associada à medida de massa muscular e à preensão manual no rastreio de risco de osteoporose em mulheres jovens pós-menopáusicas

Abstract Objective To evaluate the improvement in screening accuracy of the Fracture Risk Assessment Tool (FRAX) for the risk of developing osteoporosis among young postmenopausal women by associating with it clinical muscle mass measures. Methods A sample of postmenopausal women was submitted to calcaneal quantitative ultrasound (QUS), application of the FRAX questionnaire, and screening for the risk of developing sarcopenia at a health fair held in the city of São Bernardo do Campo in 2019. The sample also underwent anthropometric measurements, muscle mass, walking speed and handgrip tests. A major osteoporotic fracture (MOF) risk ≥ 8.5% on the FRAX, a classification of medium risk on the clinical guideline of the National Osteoporosis Guideline Group (NOGG), and a QUS T-score ≤ -1.8 sd were considered risks of having low bone mass, and QUS T-score ≤ -2.5sd, risk of having fractures. Results In total, 198 women were evaluated, with a median age of 64±7.7 years, median body mass index (BMI) of 27.3±5.3 kg/m2 and median QUS T-score of -1.3±1.3 sd. The accuracy of the FRAX with a MOF risk ≥ 8.5% to identify women with T-scores ≤ -1.8 sd was poor, with an area under the curve (AUC) of 0.604 (95% confidence interval [95%CI]: 0.509-0.694) for women under 65 years of age, and of 0.642 (95%CI: 0.571-0.709) when age was not considered. Including data on muscle mass in the statistical analysis led to a significant improvement for the group of women under 65 years of age, with an AUC of 0,705 (95%CI: 0.612-0.786). The ability of the high-risk NOGG tool to identify T-scores ≤ -1.8 sd was limited. Conclusion Clinical muscle mass measurements increased the accuracy of the FRAX to screen for osteoporosis in women aged under 65 years.

Resumo Objetivo Avaliar a melhora da precisão da Fracture Risk Assessment Tool (Ferramenta de Avaliação do Risco de Fraturas, FRAX, em inglês) no rastreio do risco de desenvolver osteoporose em mulheres jovens pós-menopáusicas com a associação de medidas clínicas de massa muscular e preensão manual. Métodos Uma amostra de mulheres pós-menopáusicas foi submetida a ultrassom quantitativo (USQ) de calcâneo, à aplicação do questionário FRAX, e rastreadas quanto ao risco de desenvolver sarcopenia em uma feira de saúde realizada em 2019 em São Bernardo do Campo. Alémdisso, a amostra tambémfoi submetida a antropometria, e a testes de massa muscular, velocidade de marcha, e preensão manual. Um risco de grandes fraturas osteoporóticas (GFOs) ≥ 8,5% no FRAX, classificação de médio risco nas diretrizes clínicas do National Osteoporosis Guideline Group (NOGG), e T-score no USQ ≤ -1,8 dp foram considerados riscos de ter baixa massa óssea, e T-score no QUS ≤ -2,5 sd, risco de ter fraturas. Resultados Ao todo, 198 mulheres foram avaliadas, com idade média de 64±7,7 anos, índice de massa corporal (IMC) médio de 27,3±5,3 kg/m2, e T-score médio no USQ de -1,3±1,3 sd. A precisão do FRAX comumrisco de GFO≥ 8,5% para identificar mulheres com T-score ≤ -1,8 dp foi precária, com uma área sob a curva (ASC) de 0,604 (intervalo de confiança de 95% [IC95%]: 0,509-0,694), para mulheres menores de 65 anos de idade, e de 0,642 (IC95%: 0,571-0,709) quando a idade não foi considerada. A inclusão de dados da massa muscular na análise estatística levou a uma melhora significativa no grupo menor de 65 anos de idade, com uma ASC de 0,705 (IC95%: 0,612-0,786). A habilidade da ferramenta NOGG de alto risco para identificar T-scores ≤ -1,8 dp foi limitada. Conclusão As medidas clínicas da massa muscular aumentaram a precisão do FRAX no rastreio de osteoporose em mulheres menores de 65 anos de idade.

Electroacupuncture on motor function in patients with primary osteoporosis: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the effect of electroacupuncture on motor function and muscle state in patients with primary osteoporosis (POP).@*METHODS@#A total of 60 female patients with POP were randomized into an observation group (30 cases, 1 case dropped off) and a control group (30 cases, 1 case dropped off). On the basis of adjusting lifestyle, caltrate was given orally in the control group, 2 pills a day for 4 weeks. On the basis of the treatment in the control group, electroacupuncture was applied at Zusanli (ST 36), Yanglingquan (GB 34), Ganshu (BL 18), Pishu (BL 20), Shenshu (BL 23), etc. in the observation group, with disperse-dense wave of 2 Hz/10 Hz in frequency, once every other day, 3 times a week for 4 weeks. The time of timed up-and-go test (TUGT) and the value of 10 m maximal walking speed (10 m MWS) before and after treatment were compared in the two groups, and the Young's modulus values of bilateral multifidus muscles in prone position and sitting position before and after treatment were compared by real-time shear wave elastography (SWE) in the two groups.@*RESULTS@#After treatment, the TUGT time was decreased compared before treatment in the observation group (P<0.01), and that in the observation group was shorter than the control group (P<0.01). After treatment, the value of 10 m MWS test was increased compared before treatment in the observation group (P<0.05). After treatment, the Young's modulus values of bilateral multifidus muscles in prone position and sitting position were increased compared before treatment in the observation group (P<0.01); except for the left side in sitting position, the Young's modulus values of multifidus muscles in the observation group were higher than those in the control group (P<0.01, P<0.05).@*CONCLUSION@#On the basis of oral caltrate, electroacupuncture can improve the motor function and muscle state in patients with POP.

Osteoporosis, un problema de salud de estos tiempos / Osteoporosis, a health problem of our times

RESUMEN En los adultos mayores existen múltiples enfermedades que afectan su calidad de vida y el logro de una longevidad satisfactoria. Una de ellas es la osteoporosis, enfermedad de elevada incidencia a nivel mundial, lo cual también se refleja en Cuba. Siendo una afección que conlleva a un alto grado de discapacidad, constituye un problema en el campo de la salud y de magnitud epidémica, más aún cuando la supervivencia de la humanidad tiende al aumento. Con el objetivo de estructurar los referentes teóricos sobre la osteoporosis, que contribuyan a la capacitación de médicos y estudiantes de Medicina como promotores de salud en prevención primaria de esta enfermedad, se realizó el siguiente artículo científico. Los factores que predisponen la aparición de la enfermedad son diversos, algunos modificables. Se señaló la importancia de su prevención, diagnóstico y tratamiento, así como formas de actuar sobre la misma, para modificar estilos de vida en la comunidad (AU).

ABSTRACT There are many diseases affecting life quality and the achievement of a satisfactory longevity in elder people; osteoporosis, a disease of high incidence around the world that also strikes in Cuba, is found among them. It is an affection leading to a high disability level, being a problem in the health field with an epidemic magnitude, even more when the human kind survival tends to increase. The current scientific article was written with the objective of structuring the theoretical referents on osteoporosis contributing to train Medicine doctors and students as health promoters in the primary prevention of this disease. The factors predisposing the disease's appearance are different, some of them modifiable. It is also stated the importance of its prevention, diagnosis and treatment, and also forms and ways of working on it to modify life styles in the community (AU).

The therapeutic potential of mesenchymal stem cells in treating osteoporosis

Osteoporosis (OP), a common systemic metabolic bone disease, is characterized by low bone mass, increasing bone fragility and a high risk of fracture. At present, the clinical treatment of OP mainly involves anti-bone resorption drugs and anabolic agents for bone, but their long-term use can cause serious side effects. The development of stem cell therapy and regenerative medicine has provided a new approach to the clinical treatment of various diseases, even with a hope for cure. Recently, the therapeutic advantages of the therapy have been shown for a variety of orthopedic diseases. However, these stem cell-based researches are currently limited to animal models; the uncertainty regarding the post-transplantation fate of stem cells and their safety in recipients has largely restricted the development of human clinical trials. Nevertheless, the feasibility of mesenchymal stem cells to treat osteoporotic mice has drawn a growing amount of intriguing attention from clinicians to its potential of applying the stem cell-based therapy as a new therapeutic approach to OP in the future clinic. In the current review, therefore, we explored the potential use of mesenchymal stem cells in human OP treatment.

Osteoporosis grave secundaria a enfermedad de Gaucher: reporte de caso / Severe osteoporosis secondary to Gaucher disease: case report

La enfermedad de Gaucher (EG) es un trastorno genético lisosomal autosómico recesivo infrecuente, que conduce a la acumulación de lípidos y disfunción en múltiples órganos. La afectación del esqueleto es uno de los hallazgos más frecuentes de la EG y una de las principales causas de dolor y reducción de calidad de vida. El compromiso esquelético incluye anomalías en el remodelado óseo con pérdida mineral ósea, adelgazamiento cortical, lesiones líticas, fracturas por fragilidad y deformidades articulares. A continuación presentamos el caso de una paciente 61 años con osteoporosis grave secundaria a EG diagnosticada en la vida adulta, con antecedente de dos hermanas con EG. La paciente refería dolores óseos y lumbago crónico desde los 53 años. El 2012 fue evaluada en policlínico de hematología por trombocitopenia y debido a sus antecedentes familiares se le solicitaron exámenes que fueron compatibles con EG. El año 2016 la densitometría ósea (DXA) de columna lumbar y cuello femoral izquierdo, que mostró una osteoporosis. Se inició tratamiento con Alendronato, Calcio y Vitamina D, pero la paciente tuvo escasa adherencia. El 2018 se inició tratamiento de su EG con Taliglucerasa α. Al año siguiente se le realizó nueva DXA que evidenció persistencia de la osteoporosis y por mantención del lumbago se le solicitó una TAC de columna lumbar que mostró fracturas por aplastamiento de cuerpos vertebrales dorsales bajos. Se derivó a endocrinología para manejo de su osteoporosis grave. A su ingreso a endocrinología la paciente persitía con dolor lumbar alto y destacaba una marcada cifosis. Se decidió retomar tratamiento con Alendronato, calcio y vitamina D, además, se le solicitó una nueva evaluación densitométrica junto a una radiografía de columna total y evaluación dental. Durante el seguimiento la paciente mantuvo niveles de vitamina D adecuados con funciones renal, hepática y tiroidea normales.

Gaucher disease (GD) is a rare autosomal recessive lysosomal genetic disorder, leading to the accumulation and dysfunction of lipids in multiple organs. Skeletal involvement is one of the most prevalent aspects of GD and one of the main causes of pain and reduced quality of life. Abnormalities of bones, which cause changes in the development and loss of bone mineral, cortical thinning, lytic lesions,fragility fractures and deformities. We present a case of a patient diagnosed with severe osteoporosis, secondary to GD diagnosed in adult life. The patient presents a disease pattern composed of bone pain and chronic low back pain since the age of 53. In 2012, she was evaluated at the hematology for thrombocytopenia and due to her family history, tests were performed to diagnose GD, which were compatible with it. In 2016 Bone Densitometry (DXA) of the lumbar spine and left femoral neck was requested, being consistent with osteoporosis. Treatment with Alendronate, Calcium and Vitamin D was started, however, there is little adherence. In 2018, treatment for Gaucher's disease was started with Taliglucerase α. The following year, DXA was performed with few changes and a CT scan of the lumbar spine was performed diagnosing crush fractures of the low dorsal vertebral bodies. She was referred to endocrinology. Upon admission to Endocrinology, it was decided to resume initial osteoporosis treatment and to perform skeletal evaluation with DXA of the lumbar spine and hips, total spine X-ray and dental evaluation. During follow-up, it maintains vitamin D at adequate levels and normal kidney, liver and thyroid functions.

Acciones óseas de las hormonas de la neurohipófisis / Bone actions of neuro hypophyseal hormones

La oxitocina (OXT) como la arginina-vasopresina (AVP) son dos hormonas primitivas secretadas por la hipófisis posterior. Sus receptores están mucho más ampliamente distribuidos en el organismo de lo que se pensaba originalmente, incluido el hueso. En los estudios preclínicos, la OXT ha mostrado ser anabólica para el hueso, promoviendo la osteogénesis sobre la adipogénesis y favoreciendo la actividad osteoblástica sobre la osteoclástica. Tanto los osteoblastos como los osteoclastos tienen receptores para la OXT, y los efectos de los estrógenos sobre la masa ósea en ratones está mediada por lo menos en parte por la OXT. El mecanismo preciso por el cual la activación de los receptores de oxitocina (OXTR) se traduce en un incremento de la formación ósea permanece poco claro. La AVP también podría afectar el esqueleto en forma directa. Dos de los receptores de la AVP, V1a y V2 están expresados en osteoblastos y osteoclastos. La inyección de AVP en ratones de tipo salvaje aumenta la formación osteoclastos que producen resorción y reduce los osteoblastos formadores de hueso. En forma opuesta, la exposición de precursores osteoblásticos a antagonistas de los receptores V1a o V2, incrementan la osteoblastogénesis, como también lo hace la deleción genética del receptor V1a. (AU)

Both oxytocin (OXT) and argininevasopressin (AVP) are primitive hormones secreted by the posterior pituitary gland. OXT receptors are much more widely distributed in the body than originally thought, including in bone. In preclinical studies, OXT has been shown to be anabolic for bone, promoting osteogenesis over adipogenesis and favoring osteoblastic over osteoclastic activity. Both osteoblasts and osteoclasts have receptors for OXT, and the effects of estrogen on bone mass in mice is mediated at least in part by OXT. The precise mechanism by which the activation of oxytocin receptors (OXTRs) results in an increase in bone formation remains unclear. AVP could also have direct actions on the skeleton. The two AVP receptors, V1a and V2, are expressed in osteoblasts and osteoclasts. Injection of AVP in wild-type mice increases the formation of osteoclasts increasing bone resorption, and reduces bone-forming osteoblasts. On the contrary, the exposure of osteoblastic precursors to V1a and V2 antagonists increase osteoblastogenesis, the same as the genetic deletion of the V1a receptor. (AU)

Lo que debe conocer un traumatólogo sobre osteoporosis y fracturas por fragilidad ósea / What an Orthopedic Surgeon Should Know of Osteoporosis and Bone Fragility Fractures

RESUMEN Introducción: La osteoporosis es la enfermedad ósea más común de los adultos mayores y constituye un importante problema de salud pública en todo el mundo. Objetivo: Actualizar algunos conceptos sobre osteoporosis y su tratamiento. Métodos: Se realizó una revisión de publicaciones entre 2010-2020 en inglés, con los términos: "osteoporosis", "tratamiento de la osteoporosis", "fracturas por osteoporosis". Resultados: La osteoporosis tiene gran impacto no solamente desde el ámbito clínico, sino también económico y social. Su tratamiento incluye medidas generales y el empleo de diversos grupos de fármacos. La posibilidad de fracturas por fragilidad en muñeca, columna y cadera es considerable lo que determina morbilidad y mortalidad elevadas(AU)

ABSTRACT Introduction: Osteoporosis is the most common bone disease in aged adults and it constitutes a major public health problem throughout the world. Objective: To update concepts on osteoporosis and treatment. Methods: A review of publications from 2010 to 2020 in English was carried out, using the terms "osteoporosis", "treatment of osteoporosis", "osteoporosis fractures". Results: Osteoporosis has great impact not only clinically, but economically and socially as well. Its treatment includes general measures and the use of various groups of drugs. The possibility of fragility fractures in the wrist, spine and hip is significant, which determines high morbidity and mortality(AU)

Síndrome de osteoporosis-pseudoglioma: a propósito de un caso pediátrico de osteoporosis primaria / Osteoporosis-pseudoglioma Syndrome: a pediatric case of primary osteoporosis

La osteoporosis es un trastorno para tener en cuenta en niños con patologías crónicas graves o con algunas enfermedades genéticas que predisponen al incremento de la fragilidad ósea. La osteoporosis primaria es una entidad con etiologías emergentes y puede ocurrir en forma sindrómica. La asociación con pliegues retinianos congénitos debe orientar al diagnóstico de osteoporosis-pseudoglioma (OMIM 259770), síndrome poco frecuente (prevalencia de 1/2000000), que se origina por la pérdida de función de la proteína LRP5 (low-density lipoprotein receptor-related protein 5) y compromete la vía de señalización de Wnt/ß-catenina. Se presenta el caso de un niño con pliegues retinianos congénitos, ceguera progresiva y múltiples fracturas cuyo estudio clínico, bioquímico y genético confirmó el diagnóstico de osteoporosis primaria debido a una nueva variante inactivante en el gen LRP5 en homocigosis

Osteoporosis should be considered in children with severe chronic diseases or in association with some genetic diseases that bear an increased risk of bone fragility. Primary osteoporosis is an entity in which emerging aetiologies are being recognized. Its association with congenital retinal folds should guide the diagnosis to the Osteoporosis-Pseudoglioma syndrome (OMIM 259770), a rare disease (prevalence of 1/2000000), caused by the loss of function of the protein LRP5 (low-density lipoprotein receptor-related protein 5) resulting in the alteration of the Wnt/ß-catenin signalling pathway. We report the case of a child with congenital retinal folds, progressive loss of vision and multiple fractures whose clinical, biochemical and genetic studies confirmed the diagnosis of primary osteoporosis due to a novel homozygous inactivating variant in LRP5

¿A qué pregunta responde "el hueso"?: una cuestión de direccionalidad estructural y organización biológica (hueso y huesos, del big-bang a la osteoporosis) / To which question is 'bone' the answer?: a matter of structural directionality and biological organization (bone and bones, from the big bang to osteoporosis)

La "razón de ser" de nuestros huesos y esqueletos constituye un dilema centralizado en los conceptos biológicos de "estructura" y "organización", cuya solución necesitamos comprender para interpretar, diagnosticar, tratar y monitorear correctamente las osteopatías fragilizantes. Últimamente se ha reunido conocimiento suficiente para proponer aproximaciones razonables a ese objetivo. La que exponemos aquí requiere la aplicación de no menos de 6 criterios congruentes: 1) Un criterio cosmológico, que propone un origen común para todas las cosas; 2) Un criterio biológico, que explica el origen común de todos los huesos; 3) Un enfoque epistemológico, que desafía nuestra capacidad de comprensión del concepto concreto de estructura y del concepto abstracto de organización, focalizada en la noción rectora de direccionalidad espacial; 4) Una visión ecológica, que destaca la importancia del entorno mecánico de cada organismo para la adecuación de la calidad mecánica de sus huesos a las "funciones de sostén" que les adjudicamos; 5) Una correlación entre todo ese conocimiento y el necesario para optimizar nuestra aptitud para resolver los problemas clínicos implicados y 6) Una jerarquización del papel celular en el manejo de las interacciones genético-ambientales necesario para asimilar todo el problema a una simple cuestión de organización direccional de la estructura de cada hueso. Solo aplicando estos 6 criterios estaríamos en condiciones de responder a la incógnita planteada por el título. La conclusión de esta interpretación de la conducta y función de los huesos debería afectar el fundamento de la mayoría de las indicaciones farmacológicas destinadas al tratamiento de la fragilidad ósea. (AU)

The nature of the general behavior of our bones as weight-bearing structures is a matter of two biological concepts, namely, structure and organization, which are relevant to properly interpret, diagnose, treat, and monitor all boneweakening diseases. Different approaches can be proposed to trace the corresponding relationships. The one we present here involves six congruent criteria, namely, 1) a cosmological proposal of a common origin for everything; 2) a biological acknowledgement of a common origin for all bones; 3) the epistemological questioning of our understanding of the concrete concept of structure and the abstract notion of organization, focused on the lead idea of directionality; 4) the ecological insight that emphasizes the relevance of the mechanical environment of every organism to the naturally-selected adjustment of the mechanical properties of their mobile bones to act as struts or levers; 5) The clinical aspects of all the alluded associations; 6) The central role of bone cells to control the genetics/ environment interactions of any individual as needed to optimize the directionality of the structure of each of his/her bones to keep their mechanical ability within physiological limits. From our point of view, we could only solve the riddle posed by the title by addressing all of these six criteria. The striking conclusion of our analysis suggests that the structure (not the mass) of every bone would be controlled not only to take care of its mechanical ability, but also to cope with other properties which show a higher priority concerning natural selection. The matter would be that this interpretation of bone behavior and 'function' should affect the rationales for most pharmacological indications currently made to take care of bone fragility. (AU)

Osteoactivos en insuficiencia renal crónica avanzada: a propósito de un caso / Osteoactive in advanced chronic renal failure: a case report

El propósito de la terapia en el desorden del metabolismo óseo mineral asociado a la enfermedad renal crónica (IRC) consiste en restaurar el balance mineral, y, en la osteoporosis, mantener o aumentar la masa ósea. Ambas terapias tratan de evitar la fractura ósea. La mayoría de los osteoactivos están contraindicados en la insuficiencia renal crónica avanzada (estadios 4 y 5), y las terapias son empíricas. Algunos autores opinan que sin anomalías bioquímicas del desorden del metabolismo óseo mineral asociado a la enfermedad renal crónica avanzada se podría intentar el tratamiento estándar para la osteoporosis. Antes de intentar la terapia osteoactiva se debe corregir el desorden mineral óseo que pudiera presentarse asociado a la IRC, y en la indicación del tipo de osteoactivo se sugiere seleccionar al paciente según su estado óseo. Se aconseja que la administración de los antirresortivos se realice a dosis menores con respecto a los que tienen mejor función renal junto con aportes adecuados de calcio y vitamina D, antes y durante el tratamiento para prevenir el riesgo de severas hipocalcemias y un efecto óseo excesivo. Se presenta el caso clínico de una mujer de 65 años, con diagnóstico de osteoporosis de etiología multifactorial, fractura de pelvis, múltiples fracturas vertebrales e insuficiencia renal crónica avanzada, entre otras comorbilidades, y probable enfermedad ósea adinámica. Recibió inicialmente terapia con teriparatide y luego con denosumab, complicándose con hipocalcemia asintomática. (AU)

The purpose of therapy for the bone mineral metabolism disorder associated with chronic kidney disease is to restore the mineral balance; and to maintain or increase bone mass in osteoporosis. The goal of both types of therapy is to avoid bone fractures. Most antiosteoporotic drugs are contraindicated in advanced chronic renal failure (CRF) stages 4 and 5, and the therapies are empirical. Some authors believe that without biochemical abnormalities of the mineral bone metabolism disorder associated with advanced chronic kidney disease, standard treatment for osteoporosis could be attempted. Before attempting antiosteoporotic therapy, the bone mineral disorder that may be associated with CRF must be corrected, and in the indication of the type drug it is suggested that the patient be selected according to their bone status. It is advised that the administration of anti-resorptives be performed at lower doses in individuals with poor renal function compared to those with better renal function together with adequate calcium and vitamin D, before and during treatment to prevent the risk of severe hypocalcemia, and an excessive bone effect. We present the clinical case of a 65-year-old woman with a diagnosis of osteoporosis of multifactorial etiology, pelvic fracture, multiple vertebral fractures and advanced chronic renal failure, among other comorbidities and probable adynamic bone disease. The patient received initial therapy with teriparatide and followed by denosumab administration and exhibited asymptomatic hypocalcemia. (AU)

Guía para el diagnóstico y tratamiento de la osteoporosis, 2018 / Guidelines for the diagnosis and treatment of osteoporosis, 2018

Cinco años después de la primera reunión de consenso para la propuesta de una Guía cubana para el diagnóstico y tratamiento de la osteoporosis se produce en La Habana (15 de mayo de 2017), esta segunda reunión con el propósito de actualizarla. De manera general se mantienen iguales objetivos que en la anterior. En esta versión se incorporan nuevos grupos de riesgo para osteoporosis, se exponen resultados nacionales relacionados con la frecuencia de esta enfermedad, así como el resultado del estudio multicentro (Instituto Nacional de Endocrinología, Hospital Ginecobstétrico "Ramón González Coro", Hospital Provincial Universitario "Arnaldo Milián Castro" y Hospital Provincial Universitario "Camilo Cienfuegos Gorriarán") con alendronato de sodio genérico, relacionado con la prevención de fractura, y un resumen actualizado de los fármacos aprobados para el tratamiento de la osteoporosis. Se reafirman los criterios para diagnóstico y opciones terapéuticas, así como para evaluar la utilidad de la guía(AU)

Controversias en el manejo de la fractura de cadera en el adulto mayor. Encuesta nacional a Traumatólogos especialistas en cirugía de cadera / Management of hip fractures in the elderly. A national survey among Chilean orthopaedic surgeons

Background: As the population ages, patients exposed to osteoporotic fractures increase, especially hip fracture, which is the most severe and costly. Aim: To characterize surgical practices in the management of hip fractures in older patients through a nationwide survey of specialized hip surgeons dedicated to the care of these patients. Material and Methods: A survey composed of 32 questions was formulated, including demographic factors, preoperative evaluation, definitive treatment, and postoperative management. It was sent to 140 specialists. 84 of them replied (61%), and 71 answers were included. Results: Eighty six percent of respondents agreed that orthogeriatric management is fundamental in the outcome of these patients, but only 73% had the collaboration of an internist or a geriatrician. Although 97% considered 72 hours or less the ideal time to perform surgery, only 52% of the respondents declared performing surgery within that timeframe, with differences between private and public system. Regarding surgical treatment, 94-98% of femoral neck fractures are treated with an arthroplasty and 98-99% of per-subtrochanteric fractures are treated with internal fixation and osteosynthesis. Osteoporosis treatment is only carried out by 51% of the respondents and with significant variation. Conclusions: This survey shows that there is agreement in surgical practice between specialists treating these patients, but clear differences in preoperative optimization, treatment timeframe, and post fracture medical treatment.

Effect of stem cells combined with a polymer/ceramic membrane on osteoporotic bone repair

Abstract Cell therapy associated with guided bone regeneration (GBR) can be used to treat bone defects under challenging conditions such as osteoporosis. This study aimed to evaluate the effect of mesenchymal stem cells (MSCs) in combination with a poly(vinylidene-trifluoroethylene)/barium titanate (PVDF-TrFE/BT) membrane on bone repair in osteoporotic rats. Osteoporosis was induced in female rats by bilateral removal of the ovaries (OVX) or sham surgery (SHAM), and the osteoporotic condition was characterized after 5 months by microtomographic and morphometric analyses. Calvarial defects were created in osteoporotic rats that immediately received the PVDF-TrFE/BT membrane. After 2 weeks, bone marrow-derived MSCs from healthy rats, characterized by the expression of surface markers using flow cytometry, or phosphate-buffered saline (PBS) (Control) were injected into the defects and bone formation was evaluated 4 weeks post-injection by microtomographic, morphometric, and histological analyses. A reduction in the amount of bone tissue in the femurs of OVX compared with SHAM rats confirmed the osteoporotic condition of the experimental model. More bone formation was observed when the defects were injected with MSCs compared to that with PBS. The modification that we are proposing in this study for the classical GBR approach where cells are locally injected after a membrane implantation may be a promising therapeutic strategy to increase bone formation under osteoporotic condition.

Efectos del ranelato de estroncio sobre la densidad mineral ósea en hombres / Effect of strontium ranelate on bone mineral density in men

La osteoporosis afecta al 6-7% de la poblaciónmasculina. Es alta la proporción de pacientes confractura osteoporótica sin diagnóstico previo de estaenfermedad. La mortalidad luego de una fracturaes mayor en hombres que en población femenina;a pesar de esto, la mayoría de los pacientes no reciben tratamiento. Los fármacos aprobados, en nuestro medio, para tratar la osteoporosis masculina son:bifosfonatos, teriparatida y ranelato de estroncio. Elobjetivo de este estudio fue evaluar el efecto del ranelato de estroncio sobre la densidad mineral ósea enhombres después de 1 año de tratamiento. Se incluyeron los registros de 20 hombres de 67.8±3.0 años,tratados con ranelato de estroncio (2 g/día) durante 1año. Todos los pacientes presentaban un T-score inferior a -2.5 en cadera o columna vertebral o un T-scoreinferior a -2.0 y factores de riesgo de fractura. Nohubo modificación de parámetros de laboratorio luego del tratamiento (calcemia, calciuria, fósforo sérico,parathormona, 25(OH)vitamina D, fosfatasa alcalinay desoxipiridinolina). Luego de 1 año de tratamiento con ranelato de estroncio se observó incrementode la densidad mineral ósea en columna lumbar:0.953±0.029 versus 0.997±0.030 g/cm2 (p=0.0068),cuello femoral: 0.734±0.013 versus 0.764±0.016 g/cm2 (p=0.0084) y cadera total: 0.821±0.02 versus0.834±0.02 g/cm2 (p=0.0419). Conclusión: luego de1 año de tratamiento el ranelato de estroncio produjoun incremento significativo de la densidad mineralósea en columna lumbar y fémur proximal en hombres con osteoporosis (AU)

Osteoporosis affects 6-7% of the male population. The proportion of patients with fragility fractures but without diagnosis of the disease is high. Mortality after hip fracture is higherin men than in women; in spite of this, mostpatients are left without treatment for osteoporosis. Drugs approved, for the treatment ofosteoporosis in our country are bisphosphonates, teriparatide, and strontium ranelate (SrR).The objective of this study was to evaluate theeffect of SrR on axial BMD in men after one yearof treatment. We obtained pertinent data frommedical registries of 20 men aged 67,8±3,0 years,treated with oral SrR (2 g/day) for 12 months. All patients had a T-score below -2,5 at the hipor the lumbar spine, or a T-score below -2,0and one or more risk factors for fracture. Thelevels of serum calcium, phosphate, alkalinephosphatase, 25-hydroxyvitamin D, or PTH,or urinary calcium and desoxipyridinoline remained unchanged following SrR administration. After treatment with SrR there weresignificant increases in BMD at the lumbarspine: 0,953±0,029 versus 0,997±0,030 g/cm2(p=0,0068), femoral neck: 0,734±0,013 versus 0,764±0,016 g/cm2 (p=0.0084), and total hip: 0,821±0,02 versus 0,834±0,02 g/cm2(p=0,0419). Conclusion: in osteoporotic men,treatment with SrR significantly increases BMDin the lumbar spine and the proximal femur (AU)