Increased Bone Formation and Accelerated Bone Mass Accrual in a Man Presenting with Diffuse Osteosclerosis/High Bone Mass Phenotype and Adenocarcinoma of Unknown Primary.

A 71-year-old man was referred for evaluation of incidental generalized osteosclerosis. He was found to have a high bone mass (HBM) with an elevated lumbar spine bone mineral density (BMD) Z-score of +5.3. Over an 18-month period, his lumbar spine BMD measured by dual energy X-ray absorptiometry (DXA) had increased by +64% from 1.09 to 1.79 g/cm2 and femoral neck by +21% from 0.83 to 1.01 g/cm2. Biochemical markers of bone turnover were markedly increased (serum propeptide of type 1 collagen and urine telopeptides greater than 10-times normal). The high bone formation and increased skeletal calcium acquisition resulted in profound hypocalcemia (low serum calcium 1.88 mmol/L) and hypocalciuria (low urinary calcium <0.2 mmol/day). Positron emission tomography (PET) with 2-deoxy-2-[fluorine-18] fluoro-D-glucose (FDG) confirmed diffuse osteosclerosis without focal areas of abnormal FDG uptake in the skeleton or elsewhere to suggest either an underlying primary malignancy or metastatic disease. Bone biopsy showed markedly sclerotic woven and lamellar bone. The marrow space was devoid of typical bone cells and adipocytes and instead was filled by fibromyxoid stroma, infiltrated by small clusters of tumor cells. Bone histomorphometry and micro-computed tomography demonstrated an elevated trabecular bone volume and trabecular plate thickness. The bone disorder in this case is unique and raises the possibility of a new yet undefined novel anabolic paracrine factor (or factors) secreted by an adenocarcinoma of unknown primary that resulted in dramatic increases in BMD, HBM, and radiological osteosclerosis. The differential diagnosis and potential mechanisms responsible for the HBM are discussed. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: We hypothesised that vertebroplasty provides effective analgesia for patients with poorly controlled pain and osteoporotic spinal fractures of less than 6 weeks' duration. The effectiveness of vertebroplasty, using an adequate vertebral fill technique, in fractures of less than 6 weeks' duration has not been specifically assessed by previously published masked trials. METHODS: This was a multicentre, randomised, double-blind, placebo-controlled trial of vertebroplasty in four hospitals in Sydney, Australia. We recruited patients with one or two osteoporotic vertebral fractures of less than 6 weeks' duration and Numeric Rated Scale (NRS) back pain greater than or equal to 7 out of 10. We used an automated telephone randomisation service provided by the National Health and Medical Research Council to assign patients (1:1; stratified according to age, degree of vertebral compression, trauma, corticosteroid use, and hospital) to either vertebroplasty or placebo, immediately before the procedure. Patients received conscious sedation. Vertebroplasty was done with the adequate vertebral fill technique and the placebo procedure with simulated vertebroplasty. Follow-up was for 6 months. Outcome assessors and patients were masked to treatment allocation. The primary outcome was the proportion of patients with NRS pain below 4 out of 10 at 14 days post-intervention in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT01482793. FINDINGS: Between Nov 4, 2011, and Dec 5, 2014, 120 patients were enrolled. 61 patients were randomly assigned to vertebroplasty and 59 to placebo. 24 (44%) patients in the vertebroplasty group and 12 (21%) in the control group had an NRS pain score below 4 out of 10 at 14 days (between-group difference 23 percentage points, 95% CI 6-39; p=0·011). Three patients in each group died from causes judged unrelated to the procedure. There were two serious adverse events in each group, related to the procedure (vertebroplasty group) and the fracture (control group). INTERPRETATION: Vertebroplasty is superior to placebo intervention for pain reduction in patients with acute osteoporotic spinal fractures of less than 6 weeks' in duration. These findings will allow patients with acute painful fractures to have an additional means of pain management that is known to be effective. FUNDING: Education grant from CareFusion Corporation.

A multi-planar CT-based comparative analysis of patient-specific cutting guides with conventional instrumentation in total knee arthroplasty.

Patient specific guides (PSGs) are postulated to improve the alignment of components in total knee arthroplasty. Three hundred consecutive total knee arthroplasties performed with either conventional (CON) (n = 185) or Visionaire PSG (n = 115) were evaluated with a CT protocol for coronal limb alignment, coronal and sagittal alignment of individual components and femoral component rotation. There was no statistically significant difference between the two groups in any of the above parameters. In addition, no difference was found in total operative time. PSGs do not offer any benefit over conventional guides in terms improving the coronal alignment of the limb or alignment of individual components.

A comparison of alignment using patient specific guides, computer navigation and conventional instrumentation in total knee arthroplasty.

BACKGROUND: Patient specific guides (PSG) have been introduced as a tool in total knee arthroplasty (TKA) in an attempt to improve limb alignment and reduce operative time compared to other established surgical techniques. The purpose of this study was to compare the post-operative radiographic alignment and operative time in patients who underwent TKA surgery with PSG, conventional instrumentation or computer-assisted navigation surgery using fully cemented components. METHODS: A cohort of 260 patients who underwent TKA surgery using PSG (PSG group, n=115) was compared to patients who underwent TKA using either conventional instrumentation (CON group, n=92) or computer-assisted navigation (CAS group, n=53). Post-operative CT imaging using the Perth CT protocol was used to compare alignment between the three groups. RESULTS: In the PSG and CAS groups, the post-operative hip-knee angle (HKA) was within 3° of neutral alignment in 91.3% and 90.7% of patients, respectively. This compared to 80.4% of patients in the CON group (p=0.02). There were no significant differences with respect to alignment when comparing individual component positioning between the PSG and CAS groups apart from tibial slope (Table 3). Total operative time was found to be significantly reduced in the PSG group (80.2 min) compared to both the CON group (86 min, p=0.002) and the CAS group (110.2 min, p<0.0001). CONCLUSIONS: The use of PSG resulted in similar alignment accuracy to CAS and superior alignment to CON with significantly shorter operative times.

Clinical outcomes after acute osteoporotic vertebral fractures: a 2-year non-randomised trial comparing percutaneous vertebroplasty with conservative therapy.

OBJECTIVE: To assess the safety and efficacy of percutaneous vertebroplasty for the treatment of acute osteoporotic vertebral fractures. DESIGN: A prospective, non-randomised, "intention-to-treat" 2-year study. PATIENTS AND SETTING: 126 consecutive patients (39 men and 87 women, aged 51-95 years) with acute osteoporotic vertebral fractures presenting to St George Hospital from November 2000 to December 2002. They comprised 88 patients treated by percutaneous vertebroplasty and 38 by conservative therapy. MAIN OUTCOME MEASURES: Primary outcomes--changes in patients' pain score and level of function recorded at 24 hours, 6 weeks, 6-12 months and 24 months after therapy. Secondary outcomes--occurrence of new clinical or radiological vertebral fractures and survival at 2 years. RESULTS: Three minor complications (fractured pedicle and psoas muscle haemorrhage) occurred in the vertebroplasty group during the first year of the study. Outcomes in vertebroplasty-treated patients (60% reduction in visual analogue pain scores from 20 to 8; P < 0.001), a rapid return to normal function (29% improvement in physical functioning from 14 to 18; P < 0.001) and lower rates of hospitalisation (43% reduction in the mean number of hospital bed-days occupied) were better than those treated conservatively (P < 0.001 for the comparison of all variables at 24 hours). Lower pain scores persisted in the vertebroplasty-treated group at 6 weeks (P < 0.001), but no differences between the two groups were evident at 12 and 24 months. In the vertebroplasty-treated group compared with the control group, the rates of new vertebral fractures (clinically and by radiographic assessment) (hazard ratio, 1.13; 95% CI, 0.52-2.46; P = 0.76) and death (hazard ratio, 1.07; 95% CI, 0.42-2.76; P = 0.89) showed no significant difference. CONCLUSION: The analgesic benefit of percutaneous vertebroplasty and the low complication rates suggest that it is a useful therapy for acute painful osteoporotic vertebral fractures.

Osteoporosis and spinal fractures in men with prostate cancer: risk factors and effects of androgen deprivation therapy.

PURPOSE: We determined the risk factors for osteoporosis and spinal fractures in men with prostate cancer receiving androgen deprivation therapy. MATERIALS AND METHODS: We performed a retrospective analysis of 87 consecutive men with prostate cancer receiving androgen deprivation therapy referred for evaluation of osteoporosis. Data were comprised of lateral thoracolumbar radiographs, bone densitometry, serum biochemistry and a detailed assessment of osteoporotic risk factors. Multivariate regression analysis was used to determine the major risk factors for osteoporosis and spinal fractures. RESULTS: There were 38 (44%) men who were 74.5 years old with radiographic evidence of spinal fractures. They had an initial mean prostate specific antigen of 52.8 ng/ml and had received androgen deprivation therapy for a mean of 39.6 months (95% confidence interval 28.7 to 50.4). Mean spinal (quantitative computerized tomography t-score -4.2) and femoral neck bone mineral densities (dual energy x-ray absorptiometry t-score -2.1) were significantly lower than in men without spinal fractures (p < 0.001 for all measurements). In the regression analysis the duration of androgen deprivation therapy (p = 0.002), serum 25-hydroxyvitamin D levels (p = 0.003) and a history of alcohol excess (defined as more than 4 standard drinks daily, p = 0.04) were the main determinants of spinal fractures. CONCLUSIONS: Prolonged androgen deprivation therapy, low serum 25-hydroxyvitamin D levels and a history of alcohol excess are important risk factors for osteoporosis and spinal fractures in men with prostate cancer.

Diagnostic values of tests for acromioclavicular joint pain.

BACKGROUND: This prospective study was performed to determine which clinical and imaging tests were most helpful for diagnosing acromioclavicular joint pain. METHODS: Of 1037 patients with shoulder pain, 113 who mapped pain within an area bounded by the midpart of the clavicle and the deltoid insertion were eligible for inclusion in the study. Forty-two subjects agreed to participate, and four of them were lost to follow-up. Twenty clinical tests, radiography, bone-scanning, magnetic resonance imaging, and an acromioclavicular joint injection test were performed on all patients. The patients were divided into two groups according to whether they had a > or =50% decrease in pain following the acromioclavicular joint injection. Statistical analysis, including multivariate regression analysis, was performed in order to evaluate the diagnostic effectiveness of the various tests. RESULTS: Acromioclavicular joint pain was confirmed in twenty-eight of the thirty-eight patients. The most sensitive tests were examination for acromioclavicular tenderness (96% sensitivity), the Paxinos test (79%), magnetic resonance imaging (85%), and bone-scanning (82%), but these studies had low specificity. In the stepwise regression model, with the response to the injection used as the dependent variable, bone-scanning and the Paxinos test were the only independent variables retained. Patients with a positive Paxinos test as well as a positive bone scan had high post-test odds (55:1) and a 99% post-test probability of having pain due to pathological changes in the acromioclavicular joint. The likelihood ratio for patients with one negative test and one positive test was indeterminate (0.4:1). Patients with both a negative Paxinos test and a negative bone scan had a likelihood ratio of 0.03:1 for having acromioclavicular joint pain, which basically rules out the disorder. CONCLUSIONS: The highly sensitive tests had low specificity, and the highly specific tests had low sensitivity. However, the combination of a positive Paxinos test and a positive bone scan predicted damage to the acromioclavicular joint as the cause of shoulder pain with a high degree of confidence.

A comparison of clinical estimation, ultrasonography, magnetic resonance imaging, and arthroscopy in determining the size of rotator cuff tears.

This prospective study was undertaken to compare the ability of clinical estimation, diagnostic ultrasonography, magnetic resonance imaging, and arthroscopy to estimate the size of rotator cuff tears. Estimates of rotator cuff tear size were compared with the findings at open operation in 33 consecutive patients with a presumptive diagnosis of rotator cuff tear. Arthroscopy estimates of rotator cuff tear size correlated best with actual tear size (Pearson correlation coefficient r = 0.92; P <.001). Magnetic resonance imaging (r = 0.74; P <.001) was similar to ultrasonography (r = 0.73; P <.001). Estimates of rotator cuff tear size after clinical assessment alone had weaker correlation coefficients (r = 0.41; P =.02) than the other methods. Each method underestimated rotator cuff tear size by 12%, 30%, 33%, and 38%, respectively. No method was able to determine the size of partial-thickness rotator cuff tears (r < 0.02).