Changes in Testing and Treatment Methods in Osteoporosis Care.

Osteoporosis treatment plays a crucial role in preventing fractures, particularly in bedridden patients. We conducted a questionnaire survey presenting hypothetical clinical cases in 2015 and 2020 to investigate trends over a 5-year period. The target population included physicians working in clinics and hospitals within our neighbourhood. The cases were presented, and the questionnaire was administered in a confidential format. The orthopaedic surgeons were matched for age and practice, resulting in 74 cases being included in the analysis. Comparing the 2015 and 2020 results, we observed a notable increase in physicians who would perform "bone mineral density measurements of the lumbar spine and hip." Furthermore, there was a significant rise in the percentage of respondents willing to test for bone metabolic markers, such as serum type I collagen cross-linked N-telopeptide (NTX), procollagen I N-terminal propeptide (P1NP), and tartrate-resistant acid phosphatase 5b (TRACP-5b). Regarding therapeutic agents, bisphosphonates decreased in usage, whereas parathyroid hormone and romosozumab witnessed an increase. In conclusion, the percentage of physicians requesting bone mineral density measurements of the lumbar spine and hip increased over the five-year period. In addition, more physicians chose to utilise bone metabolic markers due to their ease of measurement through blood tests and reduced diurnal variation. Finally, there was a marked trend towards the administration of drugs capable of rapidly and effectively increasing bone mineral density at an early stage of treatment.

Relationship between sacral-abdominal wall distance, movement performance, and spinal alignment in osteoporosis: a retrospective study.

BACKGROUND: Aging is associated with muscle atrophy, as typified by sarcopenia. Loss of abdominal muscle strength can cause abdominal wall laxity. The purpose of this study was to investigate the relationship between the sacral vertebra-abdominal wall distance (SAD) and movement performance using a simple lateral spine X-ray image for measuring the SAD. METHODS: In this retrospective study, we included women aged ≥ 65 years who were attending the outpatient clinic for osteoporosis at our hospital. A total of 287 patients (mean age ± SD, 76.8 ± 7.1 years) with measured SAD were included in the analysis. Patients were divided into two groups based on SAD cutoff (160 mm) and age (75 years), respectively. The patients were examined using the two-foot 20 cm rise test, 3 m Timed Up and Go (TUG) test, two-step test, open-eyed one-leg standing time, and spinal alignment. Normally distributed data are expressed as means (standard deviations) and non-normally distributed data as medians (interquartile range), depending on the results of the Kolmogorov-Smirnov test. Student's t-test and χ2 test were used for between-group comparisons. Regression analysis was performed with SAD as the objective variable. A two-sided p < 0.05 was considered statistically significant. RESULTS: The shorter SAD group performed better in the two-step test, TUG test, and open-eyed one-leg standing time (p < 0.001) as well as in the two-foot 20 cm rise test (p < 0.01) compared to the longer SAD group. Spinal alignment was better in the shorter SAD group than in the longer SAD group, with a shorter sagittal vertical axis (p < 0.001), smaller pelvic tilt (p < 0.001), and greater sacral slope (p < 0.05). CONCLUSION: SAD was associated with posterior pelvic tilt and movement performance parameters. In addition to testing for osteoporosis, movement performance parameters should be evaluated in women with osteoporosis who are aged ≥ 65 and have greater SAD (≥ 160 mm in this study). The SAD is a new assessment method, and further research is required to verify its validity and reproducibility. This is the first attempt to determine how age and SAD affect movement performance in older adults.

Pregnancy- and lactation-associated osteoporosis in the mother after the first and second children: A case report.

INTRODUCTION: This study reports an unusual experience of a mother who may have developed birth-related osteoporosis after each of the births of her two children. PRESENTATION OF CASE: A 31-year-old woman presented with lumbar back pain. She had given birth to her first child through vaginal delivery 4 months prior and was breastfeeding. Magnetic resonance imaging showed multiple fresh vertebral fractures, but continued breastfeeding resulted in further loss of bone density. The bone mineral density recovered after weaning. The patient gave birth to a second child three years after the first child's birth. She opted to discontinue breastfeeding after the detection of repeated instances of significant bone loss. No new vertebral fractures have occurred in the 9 years since the patient's initial visit to our clinic. DISCUSSION: We describe a case where a mother experienced multiple episodes of rapid bone loss following childbirth. Bone health evaluation at an early stage following childbirth may be effective for preventing future bone fractures. CONCLUSION: It is desirable to develop a team and guidelines for treating osteoporosis associated with pregnancy and lactation and for the next pregnancy and delivery.

Association of Spinal Alignment and Abdominal Circumference with Sarcopenia Status and Fall Risk in Patients with Osteoporosis: A Retrospective Study.

Since vertebral kyphosis and abdominal circumference are thought to influence sarcopenia and fall risk in osteoporosis, we evaluated sarcopenia and fall risk in patients with different measurements of abdominal circumference and sagittal longitudinal axis (SVA). In this post hoc study, 227 patients aged 65 years or more who visited an outpatient osteoporosis clinic were included in the analysis. Sarcopenia was determined from lean body mass, grip strength, and walking speed by dual energy X-ray absorptiometry; SVA (median 40 mm) and abdominal circumference (median 80 cm) were compared between the four groups, each divided into two groups. Nutritional management, falls, and fall anxiety scores were also examined. The incidence of sarcopenia was significantly increased in those with abdominal circumference < 80 cm in both the SVA < 40 mm and SVA ≥ 40 mm groups (p < 0.05). Nonetheless, the fall scores of those with SVA < 40 mm were lower than those of individuals with SVA ≥ 40 mm (p < 0.01). Based on the results of this study, SVA and abdominal circumference values may predict the risk of sarcopenia and falls. More research is needed before our results can be translated into clinical practice.

The serum 25(OH)D level and hand grip strength for fall risk assessment among osteoporotic elderly Japanese women.

We investigated the relationship between serum 25(OH)D levels, grip strength, and fall score in elderly osteoporotic women for fall risk assessment. Both low serum 25(OH)D and low grip strength were independently associated with increased fall risk. The serum 25(OH)D cutoff specific to increased fall risk was 14 mg/dL (35 nmol/L). PURPOSE: This study aimed to establish a cutoff value of serum 25-hydroxyvitamin D (25(OH)D) for fall assessment and investigate the relationship between serum 25(OH)D, grip strength, and fall score adjusted for age in osteoporotic elderly Japanese women. METHODS: This is a cross-sectional study utilizing collected data of osteoporotic elderly (age ≥65 years) female patients. A questionnaire for fall risk assessment was used, in which a score ≥ 6 was determined as increased fall risk. Serum 25(OH)D levels and grip strength were measured, and the cutoff points were calculated by receiver operating curve (ROC) analysis. Logistic regression analysis with age adjustment was conducted for potential risk factors for fall. RESULTS: After applying eligibility criteria, finally, 349 patients were enrolled. The median patient age was 77.0 years, and the mean serum 25(OH)D level was 15.6 ng/mL (36 nmol/L). Based on the ROC analysis, we defined the cutoff values of serum 25(OH)D level and grip strength as 14 ng/mL (35 nmol/L) and 15 kg, respectively. A multivariate analysis adjusted for age was conducted. Low serum 25(OH)D level and grip strength were independent risk factors for ≥6 fall risk scores. CONCLUSION: Both low serum 25(OH)D level and low grip strength were independently associated with increased fall risk score in osteoporotic elderly women. The appropriate serum 25(OH)D cutoff specific to the increased fall risk group in this population was 14 mg/dL (35 nmol/L). These findings might be used for the identification of patients with high fall risks. These results should be confirmed in other patient groups.

[New methods for the evaluation of bone quality. Relationship between bone resorption inhibitors and bony quality.]

Bone resorption inhibitors used in Japan are bisphosphonate, selective estrogen receptor modulators(SERMs), denosumab, eldecalcitol, and calcitonin. The structural and material properties of bone quality are important factors in osteoporosis treatment. In contrast to improvements in bone density, those in bone quality are difficult to clinically determine as no simple test is available and changes are difficult to detect. Numerous reports have been published on the mechanisms by which bone resorption inhibitors increase bone density and suppress bone fractures. This paper describes the effects of each bone resorption inhibitor and focusses on burr holes, trabeculae, microdamage, collagen cross-links, and microstructures.

High bone turnover elevates the risk of denosumab-induced hypocalcemia in women with postmenopausal osteoporosis.

Hypocalcemia is the most common major adverse event in patients with osteoporosis receiving the bone resorption inhibitor denosumab; however, limited information is available regarding risk factors of hypocalcemia. Therefore, this study aimed to identify the risk factors of hypocalcemia induced by denosumab treatment for osteoporosis. We retrospectively reviewed the records of patients who had received initial denosumab supplemented with activated vitamin D for osteoporosis. Serum levels of the following bone turnover markers (BTMs) were measured at baseline: bone-specific alkaline phosphatase (BAP), total N-terminal propeptide of type 1 procollagen (P1NP), tartrate-resistant acid phosphatase 5b (TRACP-5b), and urinary cross-linked N-telopeptide of type 1 collagen (NTX). Of the 85 denosumab-treated patients with osteoporosis studied, 22 (25.9%) developed hypocalcemia. Baseline serum total P1NP, TRACP-5b, and urinary NTX were significantly higher in patients with hypocalcemia than in those with normocalcemia following denosumab administration (all P<0.01). Multivariate logistic regression analysis revealed that patients with total P1NP >76.5 µg/L, TRACP-5b >474 mU/dL, or urinary NTX >49.5 nmol bone collagen equivalent/mmol creatinine had a higher risk of hypocalcemia (P<0.01). Our study suggests that denosumab may have a greater impact on serum calcium levels in patients with postmenopausal osteoporosis with higher baseline bone turnover than in patients with postmenopausal osteoporosis with normal baseline bone turnover, because maintenance of normal serum calcium in this subgroup is more dependent on bone resorption. Close monitoring of serum calcium levels is strongly recommended for denosumab-treated patients with high bone turnover, despite supplementation with activated vitamin D and oral calcium.

Case of femoral diaphyseal stress fracture after long-term risedronate administration diagnosed by iliac bone biopsy.

Bisphosphonate excessively inhibits bone resorption and results in pathological fracture of the femur or ilium. The subject of this study was administered risedronate for 7 years; we suspected an easy fracture of the femoral diaphysis. In this study, we report the results of this patient's bone biopsy and bone morphometric analysis. A 76-year-old female patient presented with right femoral pain. Bone mineral density of the anteroposterior surface of the 2nd to 4th lumbar vertebrae (L2-L4) was decreased and levels of bone turnover markers were high. Therefore, we initiated treatment with risedronate. As she continued the medication, urinary levels of cross-linked N-terminal telopeptides of type I collagen and alkaline phosphatase (bone-type isozyme) were found to be within the normal ranges. After 7 years of administration, the patient experienced pain when she put weight on the right femur and right femoral pain while walking. Plain radiographic examination revealed polypoid stress fracture-like lesions on the right femoral diaphysis and on the slightly distal-lateral cortical bone. Similar lesions were observed on magnetic resonance imaging and bone scintigraphy. We suspected severely suppressed bone turnover. Bone biopsy was obtained after labeling with tetracycline, and bone morphometric analysis was performed. On microscopic examination, slight double tetracycline labeling was observed. The trabeculae were narrow, and the numbers of osteoblasts and osteoclasts were decreased. Further, rates of bone calcification and bone formation were slow. Hence, we diagnosed fracture as a result of low turnover osteopathy. Risedronate was withdrawn, and Vitamin D3 was administered to improve the bone turnover. At 6 months, abnormal signals on magnetic resonance imaging had decreased and her pain while walking or undergoing the stress test disappeared as well. Thus, long-term administration of bisphosphonates may lead to easy fracture, although bone turnover markers were observed to be within the normal range. During bisphosphonate administration, physicians need to monitor closely and treat their patients for any pain experienced in the femoral region while walking or undergoing a stress test.

Why not use your own body weight to prevent falls? A randomized, controlled trial of balance therapy to prevent falls and fractures for elderly people who can stand on one leg for ≤15 s.

BACKGROUND: Maintaining or improving motor (balance) ability is essential to extending the healthy lifespan of elderly people, and developing effective and efficient strategies to prevent falls of elderly people is an urgent. The purpose of this study was to determine the effects of balance exercise on fall and fracture prevention for elderly people with poor balance. METHODS: A 6-month, randomized controlled trial was conducted to verify whether one-leg standing with eyes open for a total of 1 min, three times a day (dynamic flamingo exercise) prevents falls and fractures. Setting and participants were elderly people ≥75 years of age and one-leg standing time ≤15.0 s living in their own home. They were visiting orthopaedic clinics for orthopaedic handicaps. Subjects with poor balance were allowed to hold on to something. If a subject's lifted leg touched the ground during the exercise, they were allowed to lift it again and continue so that they stood on one leg for a total of 60 s. RESULTS: The dynamic flamingo exercise group (410 people; 86 men, 324 women) and the no exercise group (455 people; 78 men, 377 women) were compared. After dynamic flamingo exercise for 6 months, significant differences were seen in the increase in one-leg standing time with eyes open (men right/left, women right/left), in the improvement in independence in daily living (women), number of people who fell during the 6 months (women), and adverse events (women). The number of fractures was not significantly different for men or women. CONCLUSIONS: Dynamic flamingo exercise prevents falls but no significant difference was demonstrated in fracture prevention in elderly women with poor balance.

Nationwide one-decade survey of hip fractures in Japan.

BACKGROUND: To elucidate the characteristics of hip fractures and the current status of their treatment in Japan, the Japanese Orthopaedic Association (JOA) conducted a nationwide hip fracture survey from 1998 to the present. The aim of the current report was to present the changes in patient distribution by age and fracture type, cause of fracture, treatment selection, and duration of hospitalization for a study period of one decade. METHODS: A tally of all hip fractures that occurred in patients between 2001 and 2008 was conducted in JOA-authorized hospitals and in Japanese Clinical Orthopaedic Association (JCOA) hospitals. Registration forms were sent to these hospitals each year, and registration was performed based on their hospital records. RESULTS: The mean response rate was 51.8%, and the total number of patients aged ≥35 with new hip fractures between 2001 and 2008 was 402 760. A drastic increase in the number of patients, especially those aged ≥90 was observed over the course of the decade. More trochanteric fractures occurred than neck fractures during the observational period; however, the neck/trochanter ratio increased over time. Simple falls were the most common cause of fracture. About 94% patients were treated surgically with about a 5-day presurgical hospital stay, and the mean hospitalization period was 40.7 days in 2008. CONCLUSIONS: This one-decade survey demonstrated a drastic increase in the number of patients over the course of the decade in Japan. Appropriate treatment and prevention of hip fractures, including the treatment of osteoporosis and more effective interventions for preventing falls, are important issues to address to reduce the burden of this fracture.

[Dynamic flamingo therapy].

A long follow up study of one minute unipedal standing therapy 3 times in a day to prevent femoral neck osteoporosis that have started from 1993 was reported. The registration from July 1993 to March 2004 were 86 cases which measured the femoral neck bone mineral density (BMD) according to dual energy x-ray absorptiometry (DXA) (Hologic QDR 1000 and 2000) in a follow-up period. Average age at starting exercise was 67.9 years old. All cases were female who were registered in our university hospital. The result of unipedal exercise evaluated by the femoral neck BMD was described as follows : The increased cases of BMD were 15/24 (62.5%) post exercise 3 months, 15/37 (40.5%) post 6 months, and 12/21 (57.1%) post one year, 8/25 (32%) post 3 years, 7/13 (53.8%) post 5 years and 1/3 (33.3%) post 10 years. We have no fracture cases in which continued exercise in follow-up period. According to a randomized controlled study of unipedal standing balance therapy to clinically defined high-risk elderly individuals a therapy group reduced fall times by a significant difference than non-therapy group. We conclude that unipedal standing therapy is efficacious against femoral neck osteoporosis and fractures.

Surgical results and related factors for ossification of posterior longitudinal ligament of the thoracic spine: a multi-institutional retrospective study.

STUDY DESIGN: Retrospective multi-institutional study OBJECTIVE: To describe the surgical outcomes in patients with ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL) and to clarify factors related to the surgical outcomes. SUMMARY OF BACKGROUND DATA: Detailed analyses of surgical outcomes of T-OPLL have been difficult because of the rarity of this disease. METHODS: The subjects were 154 patients with T-OPLL who were surgically treated at 34 institutions between 1998 and 2002. The surgical procedures were laminectomy in 36, laminoplasty in 51, anterior decompression via anterior approach in 25 and via posterior approach in 29, combined anterior and posterior fusion in 8, and sternum splitting approach in 5 patients. Instrumentation was conducted in 52 patients. Assessments were made on (1) The Japanese Orthopedic Association (JOA) scores (full score, 11 points), its recovery rates, (2) factors related to surgical results, and (3) complications and their consequences. RESULTS: (1) The mean JOA score before surgery was 4.6 +/- 2.0 and, 7.1 +/- 2.5 after surgery. The mean recovery rate was 36.8% +/- 47.4%. (2) The recovery rate was 50% or higher in 72 patients (46.8%). Factors significantly related to this were location of the maximum ossification (T1-T4) (odds ratio, 2.43-4.17) and the use of instrumentation (odds ratio, 3.37). (3) The frequent complications were deterioration of myelopathy immediately after surgery in 18 (11.7%) and dural injury in 34 (22.1%) patients. CONCLUSION: The factors significantly associated with favorable surgical results were maximum ossification located at the upper thoracic spine and use of instrumentation. T-OPLL at the nonkyphotic upper thoracic spine can be treated by laminoplasty that is relatively a safe surgical procedure for neural elements. The use of instrumentation allows correction of kyphosis or prevention of progression of kyphosis, thereby, enhancing and maintaining decompression effect, and its use should be considered with posterior decompression.

Characterization of synovial cell clones isolated from rheumatoid arthritis patients: possible involvement of TNF-alpha in reduction of osteoprotegerin in synovium.

To elucidate the role of the synovium in bone destruction by osteoclasts in rheumatoid arthritis (RA), primary synovial cells isolated from RA patients were cultured and characterized. The cultured primary cells did not produce RANKL (TRANCE/ODF/OPGL/TNFSF11/CD254), an inducer of osteoclast differentiation, but constitutively produced its inhibitor, osteoprotegerin (OPG). Addition of TNF-alpha to the primary cultures of synovial cells reduced the cell viability and strongly suppressed OPG production. We then established nine synovial cell clones, including SYM-1, responsible for OPG production from primary synovial cell cultures. TNF-alpha induced apoptosis of SYM-1 cells within 24h and decreased OPG levels, while infliximab, a chimerical form of the anti-TNF-alpha antibody drug, suppressed the apoptosis and restored OPG levels. These results suggest the existence of fibroblastic cells producing OPG in the synovium, while TNF-alpha suppresses OPG production by inducing apoptosis in those cells. Further, infliximab is considered to inhibit bone destruction through restoration of OPG levels in RA.

[Effects of unipedal standing balance exercise on the prevention of falls and hip fracture].

To prevent hip fracture there are three methods: 1) falls prevention, 2) treatment of osteoporosis and 3) hip protectors. The improvement of the osteoporosis of the proximal hip demands nutrition involved medication as bisphosphonate and mechanical stress. Unipedal standing captures the 2.75 times weight load to the femoral head. Unipedal standing for one minute is equivalent to the amount of integral load gained through walking for approximately 53 minutes. Unipedal standing balance exercise in one minute 3 times per one day is useful to create the proximal femoral bone density and to prevent falls but is not statistically definition to prevent hip fracture. We believe daily unipedal standing balance exercise should contribute toward overcoming prevention of hip fractures.

Effects of unipedal standing balance exercise on the prevention of falls and hip fracture among clinically defined high-risk elderly individuals: a randomized controlled trial.

BACKGROUND: The aim of this study was to assess the effectiveness of the unipedal standing balance exercise for 1 min to prevent falls and hip fractures in high-risk elderly individuals with a randomized controlled trial. This control study was designed as a 6-month intervention trial. SUBJECTS: Subjects included 553 clinically defined high-risk adults who were living in residences or in the community. They were randomized to an exercise group and a control group. METHODS: Randomization to the subjects was performed by a table of random numbers. A unipedal standing balance exercise with open eyes was performed by standing on each leg for 1 min three times per day. As a rule, subjects of the exercise group stood on one leg without holding onto any support, but unstable subjects were permitted to hold onto a bar during the exercise time. Falls and hip fractures were reported by nurses, physical therapists, or facility staff with a survey sheet every month. This survey sheet was required every month for both groups. RESULTS: Registered subjects were 553 persons ranging in age from 37 to 102 years (average, 81.6 years of age). Twenty-six subjects dropped out. The number of falls and hip fractures for the 6-month period after the trial for 527 of the 553 subjects for whom related data were available were assessed. The exercise group comprised 315 subjects and the control group included 212 subjects. The cumulative number of falls of the exercise group, with 1 multiple faller omitted, was 118, and the control group recorded 121 falls. A significant intergroup difference was observed. However, the cumulative number of hip fractures was only 1 case in both groups. This difference was not statistically significant. CONCLUSIONS: The unipedal standing balance exercise is effective to prevent falls but was not shown to be statistically significant in the prevention of hip fracture in this study.

Report on the Japanese Orthopaedic Association's 3-year project observing hip fractures at fixed-point hospitals.

BACKGROUND: The aim of this study was to assess the disability and mortality of hip fractures 1 year after initial visit (postoperatively) at fixed-point hospitals selected by the Japanese Orthopaedic Association Committee on Osteoporosis. METHOD: A total of 158 core orthopedic hospitals were selected for participation in this research. Subjects were all aged 65 years and older with hip fractures at the selected hospitals between January 1, 1999 and December 31, 2001. A prognostic survey of activities of daily living (ADL), assessed by the long-term care insurance criteria established by the Ministry of Health, Labour, and Welfare of Japan was performed 1 year after the initial visit. RESULTS: A total of 1992 hip fractures in patients aged 65 to 111 years were treated over the 3 years from 1999 to 2001. Among the 1992 patients, 4537 had femoral neck fractures and 6217 had trochanteric fractures. Surgical treatment was chosen for 85.6% of the femoral neck fractures and 88.2% of the trochanteric fractures. The mean duration from fracture to admission was 3.1 days, and the mean duration from admission to surgery was 11.2 days. The mean duration from surgery to discharge over the 3-year period was 49.8 days. Before hip fracture, the ratio of patients with J1 ("able to go out freely utilizing public transportation") or J2 ("able to visit immediate neighbors independently") on the long-term care insurance criteria was 50.9%. At 1 year after the initial visit, that result represented a decrease of 24.1 percentage points before hip fracture. A total of 70 patients died before undergoing surgery. In the present study, the 1-year mortality rate for the entire patient population over the 3-year period was 10.1%. CONCLUSIONS: Hip fracture patients show a decrease in the ADL score 1 year after the initial visit. Compared to other countries, the duration of hospitalization is longer in Japan, but the mortality rate is lower.

[Prevention of the trauma and accident in exercise of elderly people with osteoporosis].

It is the important thing that osteoporotic patient is checked by internal and orthopaedic medical check before starting exercise. If a patient with mal-alignment you may reduce the alignment by foot insole. To count unilateral foot standing time is available the motor assessment. The falling school or unilateral standing of one minute is useful to prevent the accident like a fracture in exercise for osteoporosis.