Neighborhood Socioeconomic Status Affects Patient-Reported Outcome 2 Years After ACL Reconstruction.

BACKGROUND: Lower socioeconomic status (SES) is associated with worse patient-reported outcome (PRO) after orthopaedic procedures. In patients with anterior cruciate ligament (ACL) reconstruction, evaluating SES by use of traditional measures such as years of education or occupation is problematic because this group has a large proportion of younger patients. We hypothesized that lower education level and lower values for SES would predict worse PRO at 2 years after ACL reconstruction and that the effect of education level would vary with patient age. PURPOSE: To compare the performance of multivariable models that use traditional measures of SES with models that use an index of neighborhood SES derived from United States (US) Census data. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A cohort of 675 patients (45% female; median age, 20 years), were prospectively enrolled and evaluated 2 years after ACL reconstruction with questionnaires including the International Knee Documentation Committee (IKDC) questionnaire, the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Marx activity rating scale (Marx). In addition, a new variable was generated for this study, the SES index, which used geocoding performed retrospectively to identify the census tract of residence for each participant at the time of enrollment and extract neighborhood SES measures from the 2000 US Census Descriptive Statistics. Multivariable models were constructed that included traditional measures of SES as well as the SES index, and the quality of models was compared through use of the likelihood ratio test. RESULTS: Lower SES index was associated with worse PRO for all measures. Models that included the SES index explained more variability than models with traditional SES. In addition, a statistically significant variation was found regarding the impact of education on PRO based on patient age for the IKDC score, the Marx scale, and 4 of the 5 KOOS subscales. CONCLUSION: This study demonstrates that lower neighborhood SES is associated with worse PRO after ACL reconstruction and that age and education have a significant interaction in this patient population. Future studies in patients who have undergone ACL reconstruction should attempt to account for neighborhood SES when adjusting for confounding factors; further, targeting patients from areas with lower neighborhood SES with special interventions may offer an opportunity to improve their outcomes.

The Effect of Capsulotomy and Capsular Repair on Hip Distraction: A Cadaveric Investigation.

PURPOSE: To quantify how increasing interportal capsulotomy size affects the force required to distract the hip and to biomechanically compare simple side-to-side suture repair to acetabular-based suture anchors as capsular repair techniques. METHODS: Twelve fresh-frozen cadaveric hip specimens were dissected to the capsuloligamentous complex of the hip joint and fixed in a material testing system, such that a pure axial distraction of the iliofemoral ligament could be achieved. After each hip in was tested an intact state, sequential distraction was tested with 2, 4, 6, and 8 cm capsulotomies. Specimens were assigned randomly to be repaired with either 4 side-to-side suture repair (n = 6) or 2 double-loaded all-suture anchors (n = 6). The distraction force as well as the relative distraction force percentage normalized to the intact capsule were compared between suture repair and suture anchor repair groups. RESULTS: Increasing the size of the capsulotomy resulted in less force required to distract the hip to 6 mm. The force decreased as the capsulotomy was extended with statistical significance in distraction force seen between the intact state and the 4 cm (P = .003), 6 cm (P < .001), and 8 cm (P ≤ .001) capsulotomy but not for the intact state compared to the 2 cm capsulotomy (P = .28). Statistical significance in relative distraction force was seen for each of the capsulotomy conditions (P < .001 for all conditions compared with the intact state). The side-to-side suture repair construct (104.3% of intact force) required greater force to distraction to 6 mm compared with the suture anchor repair (87.1% of intact force) (P = .008). CONCLUSIONS: An interportal capsulotomy significantly affected the force required to distract the hip in a cadaveric model, with the larger the size of capsulotomy resulting in less force required to distract the hip. When we performed an interportal capsulotomy, the iliofemoral ligament strength was altered significantly but capsular repair with either side-to-side sutures or suture anchor-based repair was able to restore the capsular strength to a native intact hip. We found, however, that the side-to-side suture repair was better able to restore the distraction force compared with suture anchor repair. CLINICAL RELEVANCE: Capsular management during hip arthroscopy remains a debated topic, with multiple techniques involving both capsulotomy and capsular closure published in the literature. This study provides insight into capsular stability against axial stress under capsulotomy and capsular repair conditions.

Axon Counts Yield Multiple Options for Triceps Fascicular Nerve to Axillary Nerve Transfer.

PURPOSE: To evaluate the relative axonal match between potential donor and recipient nerves, so that maximal reinnervation potential may be reached with the least chance of donor site morbidity. METHODS: In 10 fresh-frozen cadaveric specimens, the main trunk and anterior, posterior, sensory and teres minor branches of the axillary nerve were identified, as were the radial nerve branches to the long, medial, and lateral heads of the triceps. The swing distances of the triceps fascicular nerve branches and the axillary nerve branches relative to the inferior border of the teres major muscle were recorded. Histomorphological analysis and axon counts were performed on sections of each branch. RESULTS: The median number of axons in the main axillary trunk was 7,887, with 4,052, 1,242, and 1,161 axons in the anterior, posterior, and teres minor branches, respectively. All specimens had a single long head triceps branch (median, 2,302 axons), a range of 1 to 3 branches to the medial head of the triceps (composite axon count, 2,198 axons), and 1 to 3 branches to the lateral head of the triceps (composite average, 1,462 axons). The medial and lateral head branches had sufficient swing distance to reach the anterior branch of the axillary nerve in all 10 specimens, with only 4 specimens having adequate long head branch swing distances. CONCLUSIONS: It is anatomically feasible to transfer multiple branches of the radial nerve supplying the medial, lateral, and sometimes, long head of the triceps to all branches of the axillary nerve in an attempt to reinnervate the deltoid and teres minor muscles. CLINICAL RELEVANCE: Understanding the axon counts of the different possible transfer combinations will improve operative flexibility and enable peripheral nerve surgeons to reinnervate for both abduction and external rotation with the highest donor/recipient axon count ratios.

A Systematic Review of Preoperative Fatty Infiltration and Rotator Cuff Outcomes.

BACKGROUND: Fatty infiltration (FI) of the muscle as graded by the Goutallier classification (GC) is a well-known sequela following rotator cuff injury. The degree to which this predicts the success of rotator cuff repair is unknown. QUESTIONS/PURPOSES: We conducted a systematic review to address the following questions: (1) Does the grade of FI of the rotator cuff muscles present preoperatively predict retear rates postoperatively? (2) Are amounts of preoperative FI predictive of functional outcomes following repair? METHODS: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials online databases were searched for all literature published between January 1966 and March 2015. Keywords were chosen to achieve a broad search category. All articles were reviewed by three of the authors, and those meeting the study inclusion criteria were selected for data abstraction. RESULTS: The systematic literature review yielded 11 studies reporting on a total of 925 shoulders. Rotator cuffs with moderate or significant FI preoperatively (grades 2-4) had a significantly higher retear rate than those with no or minimal FI (grades 0-1) (59 vs. 25%, p = 0.045). Four studies reported postoperative Constant scores and preoperative GC scores. One study found that lower GC scores were associated with higher Constant scores postoperatively, one found no association, and the data was inconclusive in the other two. CONCLUSIONS: While lower preoperative GC scores are associated with lower rates of rotator cuff retear following repair, there is insufficient data to make conclusions on the effects of FI on functional outcomes following repair.

Primary Repair of the Anterior Cruciate Ligament: A Systematic Review.

PURPOSE: To describe the clinical and preclinical research conducted on primary repair of the anterior cruciate ligament (ACL) during the past 10 years. METHODS: A systematic search of PubMed, the Cochrane Central Register of Controlled Trials, and Embase was performed for all English-language studies published between 2003 and April 2014 on primary repair of the ACL. RESULTS: Twenty-six studies met the inclusion and exclusion criteria. In the clinical research group, 8 studies (166 patients; age range, 10 to 71 years) met the inclusion and exclusion criteria and were largely long-term clinical outcome studies, based on the original cohorts from the 1970s and 1980s, and suggested high failure rates, additional surgery, and revision for instability. A subset of patients, however, achieved good to excellent subjective and objective long-term outcomes. In the preclinical research group, 18 studies met the inclusion and exclusion criteria and were based on an ACL transection model; they suggested that (1) stabilization of the knee with an internal suture strut improved the healing and biomechanical properties of the repaired ACL, (2) "enhancing" the repair with biological collagen-platelet composite augmentation improved healing and mechanical strength, (3) younger age and skeletal immaturity seem to correlate with improved histologic healing and biomechanical properties, (4) enhanced primary repair of the ACL may reduce post-traumatic osteoarthritis, and (5) the native ACL biomechanically outperformed the repaired ACL. CONCLUSIONS: Although long-term human studies suggest collectively unacceptable outcomes for open primary repair of the ACL, a subset of patients achieved acceptable long-term results. ACL transection model animal studies showed improved healing and biomechanics with primary suture repair stabilization, early intervention, biological augmentation techniques, and younger age. Primary repair of the ACL may be an effective treatment modality for an appropriately selected subset of patients. LEVEL OF EVIDENCE: Level IV, systematic review of preclinical and clinical Level IV studies.

Sex Differences in Patients With CAM Deformities With Femoroacetabular Impingement: 3-Dimensional Computed Tomographic Quantification.

PURPOSE: To determine if significant differences exist between male and female CAM deformities using quantitative 3-dimensional (3D) volume and location analysis. METHODS: Retrospective analysis of preoperative computed tomographic (CT) scans for 138 femurs (69 from male patients and 69 from female patients) diagnosed with impingement from November 2009 to November 2011 was completed. Those patients who presented with hip complaints and had a history, physical examination (limited range of motion, positive impingement signs), plain radiographs (anteroposterior pelvis, 90° Dunn view, false profile view), and magnetic resonance images consistent with femoroacetabular impingement (FAI) and in whom a minimum of 6 months of conservative therapy (oral anti-inflammatory agents, physical therapy, and activity modification) had failed were indicated for arthroscopic surgery and had a preoperative CT scan. Scans were segmented, converted to point cloud data, and analyzed with a custom-written computer program. Analysis included mean CAM height and volume, head radius, and femoral version. Differences were analyzed using an unpaired t test with significance set at P < .05. RESULTS: Female patients had greater femoral anteversion compared with male patients (female patients, 15.5° ± 8.3°; male patients, 11.3° ± 9.0°; P = .06). Male femoral head radii were significantly larger than female femoral heads (female patients, 22.0 ± 1.3 mm; male patients, 25.4 ± 1.3 mm; P < .001). Male CAM height was significantly larger than that in female patients (female patients, 0.66 ± 0.61 mm; male patients, 1.51 ± 0.75 mm; P < .001). Male CAM volume was significantly larger as well (male patients, 433 ± 471 mm(3); female patients, 89 ± 124 mm(3); P < .001). These differences persisted after normalizing height (P < .001) and volume (P < .001) to femoral head radius. Average clock face distribution was from the 1:09 o'clock position ± the 2:51 o'clock position to the 3:28 o'clock position ± the 1:59 o'clock position, with an average span from the 3:06 o'clock position ± the 1:29 o'clock position (male patients, the 11:23 o'clock position ± the 0:46 o'clock position to the 3:05 o'clock position ± the 1:20 o'clock position; female patients, the 11:33 o'clock position ± the 0:37 o'clock position to the 2:27 o'clock position ± the 0:45 o'clock position). There were no differences in the posterior (P = .60) or anterior (P = .14) extent of CAM deformities. However, the span on the clock face of the CAM deformities varied when comparing men with women (male patients, the 3:43 o'clock position ± the 1:29 o'clock position; female patients, the 2:54 o'clock position ± the 1:09 o'clock position; P = .02). CONCLUSIONS: Our data show that female CAM deformities are shallower and of smaller volume than male lesions. Further studies will allow further characterization of the 3D geometry of the proximal femur and provide more precise guidance for femoral osteochondroplasty for the treatment of CAM deformities. CLINICAL RELEVANCE: Female CAM deformities may not be detectable using current 2D nonquantitative methods. These findings should raise the clinician's index of suspicion when diagnosing a symptomatic CAM lesion in female patients.

Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior Outcomes Compared With Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review of Overlapping Meta-analyses.

PURPOSE: The aims of this study were (1) to perform a systematic review of meta-analyses evaluating platelet-rich plasma (PRP) injection in the treatment of knee joint cartilage degenerative pathology, (2) to provide a framework for analysis and interpretation of the best available evidence to provide recommendations for use (or lack thereof) of PRP in the setting of knee osteoarthritis (OA), and (3) to identify literature gaps where continued investigation would be suggested. METHODS: Literature searches were performed for meta-analyses examining use of PRP versus corticosteroids, hyaluronic acid, oral nonsteroidal anti-inflammatory drugs, or placebo. Clinical data were extracted, and meta-analysis quality was assessed. The Jadad algorithm was applied to determine meta-analyses that provided the highest level of evidence. RESULTS: Three meta-analyses met the eligibility criteria and ranged in quality from Level II to Level IV evidence. All studies compared outcomes of treatment with intra-articular platelet-rich plasma (IA-PRP) versus control (intra-articular hyaluronic acid or intra-articular placebo). Use of PRP led to significant improvements in patient outcomes at 6 months after injection, and these improvements were seen starting at 2 months and were maintained for up to 12 months. It is unclear if the use of multiple PRP injections, the double-spinning technique, or activating agents leads to better outcomes. Patients with less radiographic evidence of arthritis benefit more from PRP treatment. The use of multiple PRP injections may increase the risk of self-limited local adverse reactions. After application of the Jadad algorithm, 3 concordant high-quality meta-analyses were selected and all showed that IA-PRP provided clinically relevant improvements in pain and function compared with the control treatment. CONCLUSIONS: IA-PRP is a viable treatment for knee OA and has the potential to lead to symptomatic relief for up to 12 months. There appears to be an increased risk of local adverse reactions after multiple PRP injections. IA-PRP offers better symptomatic relief to patients with early knee degenerative changes, and its use should be considered in patients with knee OA. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Shoulder arthroplasty: return to sport.

CONTEXT: Increasingly, total shoulder arthroplasty is being performed not only to treat the pain associated with glenohumeral arthritis but also to return patients to the level of activity and function they enjoyed prior to the development of arthritis. While return to sport and activity have been studied in the total knee and total hip replacement literature, it is only relatively recently that the same focus has been placed on total shoulder replacements. EVIDENCE ACQUISITION: PubMed database from the years 2000 to 2014. All studies relevant to shoulder arthroplasty and return to sport were included in the review. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: An increasing number of patients seeking total shoulder arthroplasty are doing so with the expectation of not only decreased symptoms of glenohumeral arthritis but also of return to a high level of activity. The majority of patients are able to return to their prior level of activity within 6 months of surgery. In some series, patients saw an improvement in their ability to perform their chosen activity. CONCLUSION: Patients should be counseled that there is a high probability that they will be able to return to their preoperative activity level after total shoulder arthroplasty and, in some cases, see an improvement in their abilities to participate in sport. STRENGTH-OF-RECOMMENDATION TAXONOMY SORT: C.

Arthroscopic Repair of a Glenoid Avulsion of the Glenohumeral Ligament.

Injury to the glenohumeral capsulolabral complex is the critical lesion in anterior shoulder instability. Various injury patterns have been described including the classic Bankart lesion, the bony Bankart lesion, and humeral avulsion of the glenohumeral ligament. A rare injury variant is a glenoid avulsion of the glenohumeral ligament (GAGL lesion). Careful patient setup and surgical technique are required to identify and arthroscopically repair these lesions. We describe a suture anchor-based arthroscopic GAGL repair performed with the patient in the lateral decubitus position through standard anterior and posterior portals and an accessory posterolateral 7-o'clock portal.

The anatomy and histology of the bicipital tunnel of the shoulder.

BACKGROUND: The bicipital tunnel is the extra-articular, fibro-osseous structure that encloses the long head of the biceps tendon. METHODS: Twelve cadaveric shoulder specimens underwent in situ casting of the bicipital tunnel with methyl methacrylate cement to demonstrate structural competence (n = 6) and en bloc harvest with gross and histologic evaluation (n = 6). The percentage of empty tunnel was calculated histologically by subtracting the proportion of cross-sectional area of the long head of the biceps tendon from that of the bicipital tunnel for each zone. RESULTS: Cement casting demonstrated that the bicipital tunnel was a closed space. Zone 1 extended from the articular margin to the distal margin of the subscapularis tendon. Zone 2 extended from the distal margin of the subscapularis tendon to the proximal margin of the pectoralis major tendon. Zone 3 was the subpectoral region. Zones 1 and 2 were both enclosed by a dense connective tissue sheath and demonstrated the presence of synovium. Zone 3 had significantly greater percentage of empty tunnel than zones 1 and 2 did (P < .01). CONCLUSION: The bicipital tunnel is a closed space with 3 distinct zones. Zones 1 and 2 have similar features, including the presence of synovium, but differ from zone 3. A significant bottleneck occurs between zone 2 and zone 3, most likely at the proximal margin of the pectoralis major tendon. The bicipital tunnel is a closed space where space-occupying lesions may produce a bicipital tunnel syndrome. Careful consideration should be given to surgical techniques that decompress both zones 1 and 2 of the bicipital tunnel.

Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex.

PURPOSE: The purpose of this study was to define the limits of diagnostic glenohumeral arthroscopy and determine the prevalence and frequency of hidden extra-articular "bicipital tunnel" lesions among chronically symptomatic patients. METHODS: Eight fresh-frozen cadaveric specimens underwent diagnostic glenohumeral arthroscopy with percutaneous tagging of the long head of the biceps tendon (LHBT) during maximal tendon excursion. The percentage of visualized LHBT was calculated relative to the distal margin of subscapularis tendon and the proximal margin of the pectoralis major tendon. Then, a retrospective review of 277 patients who underwent subdeltoid transfer of the LHBT to the conjoint tendon were retrospectively analyzed for lesions of the biceps-labral complex. Lesions were categorized by anatomic location (inside, junctional, or bicipital tunnel). Inside lesions were labral tears. Junctional lesions were LHBT tears visualized during glenohumeral arthroscopy. Bicipital tunnel lesions were extra-articular lesions hidden from view during standard glenohumeral arthroscopy. RESULTS: Seventy-eight percent of LHBT were visualized relative to the distal margin of the subscapularis tendon and only 55% relative to the proximal margin of the pectoralis major tendon. No portion of the LHBT inferior to the subscapularis tendon was visualized. Forty-seven percent of patients had hidden bicipital tunnel lesions. Scarring was most common and accounted for 48% of all such lesions. Thirty-seven percent of patients had multiple lesion locations. Forty-five percent of patients with junctional lesions also had hidden bicipital tunnel lesions. The only offending lesion was in the bicipital tunnel for 18% of patients. CONCLUSIONS: Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex because it visualizes only 55% of the LHBT relative to the proximal margin of the pectoralis major tendon and did not identify extra-articular bicipital tunnel lesions present in 47% of chronically symptomatic patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series and cadaveric study.

Aseptic lymphocyte dominated vasculitis-associated lesion resulting from trunnion corrosion in a cobalt-chrome unipolar hemiarthroplasty.

Most of the published descriptions of adverse soft tissue reactions that have been reported in the context of a metal-on-metal articulation have been in cases of total hip arthroplasty or resurfacing arthroplasty. Recently, several case reports have been published describing aseptic lymphocyte dominated vasculitis-associated lesions (ALVAL) in metal-on-polyethylene. To our knowledge, there has not been a description of a similar, aggressive reaction secondary to metal debris from the head-neck junction of a unipolar hemiarthroplasty component. In this case report, we describe a patient with a catastrophic failure of a unipolar hip hemiarthroplasty, secondary to aggressive osteolysis and an inflammatory mediated immunological reaction to metal debris.

Suture number determines strength of rotator cuff repair.

BACKGROUND: Failure of surgical repair of a rotator cuff tear continues to be a clinical problem. For other tendon repairs, increasing the number of sutures improves both biomechanical performance and clinical outcomes. Several investigators have shown biomechanical advantages of double-row techniques but have used many more sutures than were used with the single-row techniques with which the double-row techniques were compared. The purposes of our study were to establish whether using a greater number of sutures would improve the biomechanical properties of a rotator cuff repair model, and whether using equal numbers of sutures would lead to equivalent results between single and double-row configurations. METHODS: Fresh-frozen sheep infraspinatus tendons underwent single-row repair with two, four, or six mattress sutures and double-row repair with use of four mattress sutures. Specimens were pretensioned at 10 N for one minute, then cycled from 10 to 180 N for 200 cycles at 0.2 Hz; this was followed by load to failure. Cyclic gap formation, failure load, and failure type were recorded. RESULTS: The four-suture single-row and four-suture double-row repairs had similar gap formation during cyclic testing, with no significant differences between them. Cyclic gap formation in the two-suture single-row group was 6.7 and 7.1 mm (97% and 109%) greater than that in the four and six-suture single-row groups after 200 cycles (p < 0.001). The average loads to failure of the two, four, and six-suture single-row groups were 274, 362, and 572 N (p < 0.0001). The average load to failure of the four-suture double-row group was 386 N, which was similar to the value in the four-suture single-row group (p = 0.58). CONCLUSIONS: In an ovine rotator cuff tendon repair model, increasing the number of sutures decreased cyclic gap formation and increased load to failure. Single and double-row repairs are biomechanically equivalent when the number of sutures is kept constant. CLINICAL RELEVANCE: The results of this study support the use of greater numbers of sutures in rotator cuff repair and disagree with the assertion that double-row repairs are biomechanically superior to single-row repairs.

A review of synthetic playing surfaces, the shoe-surface interface, and lower extremity injuries in athletes.

The evolution of synthetic playing surfaces began in the 1960s and has had an impact on field use, shoe-surface dynamics, and the incidence of sports-related injuries. Modern third-generation turfs are being installed in recreational facilities and professional stadiums worldwide. Currently, > two-thirds of National Football League teams, > 100 National Collegiate Athletic Association Division I football teams, and > 1000 high schools in the United States have installed synthetic playing surfaces. Those in favor of such playing surfaces note their unique combination of versatility and durability; they can be used in both ideal and inclement weather conditions. However, the more widespread installation and use of these surfaces have raised questions and concerns regarding the impact of artificial turf on the type and severity of sports-related injuries. There appears to be no question that the shoe-surface interface has a significant impact on such injuries. Independent variables such as weather conditions, contact versus noncontact sport, shoe design, and field wear complicate many of the results reported in the literature, thereby preventing an accurate assessment of the true risk(s) associated with certain shoe-surface combinations. Historically, studies suggest that artificial turf is associated with a higher incidence of injury. Furthermore, reliable biomechanical data suggest that both the torque and strain experienced by lower extremity joints generated by artificial surfaces may be more than those generated by natural grass fields. Recent data from the National Football League support this theory and suggest that elite athletes may sustain more injuries, even when playing on the newer artificial surfaces. By contrast, some reports based on data collected from lower-level athletes suggest that artificial turf may protect against injury. This review discusses the history of artificial surfaces, the biomechanics of the shoe-surface interface, and some common turf-related lower extremity injuries.

Treatment of irreparable rotator cuff tears.

Irreparable rotator cuff tears are a challenging problem for patients and surgeons. There are several treatment options, but deciding the correct one for each patient can be difficult. Treatment options include physical therapy, arthroscopy, muscle transfers, reverse shoulder arthroplasty, and hemiarthroplasty. An understanding of the patient's chief complaint and their functional ability to elevate their arm above horizontal should guide the treatment. This article reviews the current literature on various treatment options for irreparable rotator cuff tears, then outlines an algorithm for determining treatment.

Diseases affecting bone quality: beyond osteoporosis.

BACKGROUND: Bone quantity, quality, and turnover contribute to whole bone strength. Although bone mineral density, or bone quantity, is associated with increased fracture risk, less is known about bone quality. Various conditions, including disorders of mineral homeostasis, disorders in bone remodeling, collagen disorders, and drugs, affect bone quality. QUESTIONS/PURPOSES: The objectives of this review are to (1) identify the conditions and diseases that could adversely affect bone quality besides osteoporosis, and (2) evaluate how these conditions influence bone quality. METHODS: We searched PubMed using the keywords "causes" combined with "secondary osteoporosis" or "fragility fracture." After identifying 20 disorders/conditions, we subsequently searched each condition to evaluate its effect on bone quality. RESULTS: Many disorders or conditions have an effect on bone metabolism, leading to fragility fractures. These disorders include abnormalities that disrupt mineral homeostasis, lead to an alteration of the mineralization process, and ultimately reduce bone strength. The balance between bone formation and resorption is also essential to prevent microdamage accumulation and maintain proper material and structural integrity of the bone. As a result, diseases that alter the bone turnover process lead to a reduction of bone strength. Because Type I collagen is the most abundant protein found in bone, defects in Type I collagen can result in alterations of material property, ultimately leading to fragility fractures. Additionally, some medications can adversely affect bone. CONCLUSIONS: Recognizing these conditions and diseases and understanding their etiology and pathogenesis is crucial for patient care and maintaining overall bone health.