Does bisphosphonate-based anti-osteoporosis medication affect osteoporotic spinal fracture healing?

Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review

Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing.

BACKGROUND

Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing.

METHODS

Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).

RESULTS

Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans.

CONCLUSION

Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.

Multidisciplinary and Coordinated Management of Osteoporotic Vertebral Compression Fractures: Current State of the Art

Osteoporotic vertebral compression fractures (OVCFs) present a significant health concern, affecting a substantial portion of the older adult population worldwide. This narrative review explores the prevalence, diagnostic challenges and management strategies for OVCFs. Despite the increasing incidence and impact on morbidity and mortality, existing clinical guidelines lack consistency and clear diagnostic and therapeutic recommendations. The review addresses key questions faced by physicians dealing with older adult patients experiencing acute back pain, offering insights into triage, radiological assessments and classification systems. We propose a comprehensive algorithm for clearing OVCF, considering clinical presentation, radiological findings and morphological aspects. Emphasis is placed on the importance of medically treating osteoporosis alongside OVCF management. The review encompasses relevant literature from 1993 to 2023, provides a detailed discussion on triage issues and incorporates a clinically oriented classification system developed by the German Society for Orthopaedics and Trauma. The Material and Methods section outlines the extensive literature search carried out in PUBMED, encompassing clinical and experimental studies, systematic reviews and meta-analyses. The articles retained focused mainly on answering critical questions regarding radiological assessments, imaging modalities and the presence of a specific classification system for OVCFs. The review emphasises that the evaluation and management of OVCFs necessitates a multidisciplinary approach involving spine specialists and bone disease experts. It also addresses the role of conservative versus surgical treatments, with a focus on percutaneous vertebral augmentation. The conclusion summarises the algorithm derived for use in emergency departments and general practice, aiming to streamline OVCF management, reduce unnecessary examinations and ensure optimal patient care. The algorithm recommends primary diagnosis using computed tomography, with magnetic resonance imaging reserved for specific cases. The review advocates a holistic approach, integrating medical and surgical interventions to address the complex challenges posed by OVCFs in ageing populations.

Post-Fracture Care Program: Pharmacological Treatment of Osteoporosis in Older Adults with Fragility Fractures

PURPOSE OF REVIEW

To present and discuss the recently published scientific evidence on the approach, mode of action, and timing of osteoporosis therapy initiation after fragility fractures.

RECENT FINDINGS

A comprehensive management approach is required to reduce mortality and morbidity associated with fragility fractures. This will help to reduce the risk of missing the diagnosis of osteoporosis as the underlying disorder while at the same time promoting the timely treatment of osteoporosis. The target is to minimize the incidence of post-traumatic disability and to reduce the imminent fracture risk. This article will present a Bone-Care algorithm for the diagnosis and management of fragility fractures in patients presenting for trauma surgery. This algorithm has been developed based on recently published national as well as international guidelines for implementation in standard clinical practice. International figures revealed that only a small proportion of those patients at high risk of sustaining a fragility fracture receive osteoporosis therapy. Based on the best currently available evidence, it is safe to start osteoporosis therapy in the acute post-fracture period (the optimal therapeutic window of romosozumab is the late endochondral phase/throughout bone remodeling). The right Bone-Care pathway ensures the delivery of a comprehensive management approach that meets the global call to action. All parameters including risk, benefit, compliance, and cost should be considered on an individual base for all kinds of therapy.

Radiological Factors Associated with Bisphosphonate Treatment Failure and Their Impact on Fracture Healing in Postmenopausal Women with Osteoporotic Vertebral Fractures

(1) Background: Bisphosphonate treatment failure is one of the most difficult clinical problems for patients with osteoporosis. This study aimed to analyze the incidence of bisphosphonate treatment failure, associated radiological factors, and effect of fracture healing in postmenopausal women with osteoporotic vertebral fractures (OVFs). (2) Methods: A total of 300 postmenopausal patients with OVFs who were prescribed bisphosphonate were retrospectively analyzed and divided into two groups according to the treatment response: response (n = 116) and non-response (n = 184) groups. The radiological factors and the morphological patterns of OVFs were included in this study. (3) Results: The initial BMD values of the spine and femur in the non-response group were significantly lower than those in the response group (all Ps < 0.001). The initial BMD value of the spine (odd ratio = 1.962) and the fracture risk assessment tool (FRAX) hip (odd ratio = 1.32) showed statistical significance in logistic regression analysis, respectively (all Ps < 0.001). (4) Conclusions: The bisphosphonate non-responder group showed a greater decrease in BMD over time than the responder group. The initial BMD value of the spine and the FRAX hip could be considered radiological factors influencing bisphosphonate non-response in the postmenopausal patients with OVFs. The failure of bisphosphonate treatment for osteoporosis has a possible negative on the fracture healing process in OVFs.

Kummell's Disease is Becoming Increasingly Important in an Aging Society: A Review

Kummell's disease (KD) is referred to as delayed posttraumatic vertebral collapse, avascular necrosis of vertebrae, or ischemic vertebral collapse. KD is no longer rare in an aging society. It is mainly caused by minor trauma, and nonunion occurs secondary to avascular necrosis at the vertebral body fracture site, which can lead to vertebral kyphosis or intravertebral instability. Clinical symptoms of KD range from no symptoms to severe paralysis due to nerve injury. KD is considered a complication of osteoporotic vertebral compression fractures, and conservative treatment, including osteoporosis treatment, is important. Timely interventions such as vertebral augmentation or surgery, with active regular follow-up are necessary before the onset of neurological deficits due to osteonecrotic collapse in patients with suspected KD. In this study, we summarize the pathogenesis, diagnosis, and treatment of KD, which is showing increasing prevalence in an aging society. We have presented a literature review and discussed clinical guidelines and therapeutic strategies to reduce the morbidity and mortality associated with KD.

Zoledronic Acid Does Not Retard Bone Union: A Randomized Controlled Trial in Fragility Intertrochanteric Femur Fractures

BACKGROUND

Fragility hip fracture is a leading cause of death in the elderly and is common in postmenopausal women and elderly people. In the treatment of osteoporosis, bisphosphonates (BPs) are often considered first-line medications. Zoledronic acid is the most potent and long-acting BP in clinical use and is administered as an intravenous infusion. In the context of acute fractures, the use of BPs has been controversial due to conflicting reports of their positive and negative effects on fracture healing. The purpose of this study was to determine the effect of zoledronic acid on fracture healing in intertrochanteric (IT) fragility fractures.

METHODS

The study was conducted in a tertiary healthcare center after receiving scientific and ethical approval. The study included 136 patients of either gender over the age of 50 who presented with an IT femur fracture after minor trauma between November 2020 and November 2022. The total number of patients had been classified into two groups, and grouping involved random sampling: Group T (test group, n = 68; zoledronic acid injections were given on postoperative day 3) and Group C (control group, n = 68; interventions were given after fracture healing). Patients were evaluated using the Radiographic Union Score for Hip (RUSH) and Singh Index for radiological outcomes and the Harris Hip Score (HHS) for functional outcomes. The patients were followed for six months.

RESULTS

The overall mean age was 73.25 years; in Group T, it was 72.5 ± 11.9 years, and in Group C, it was 73.7 ± 11.8 years. Of 136 patients, 69 (51%) were males and 67 (49%) were females. The average fracture healing time in Group T was 12.2 ± 3.6 weeks, while it was 13.0 ± 2.8 weeks in Group C. Functional outcomes, including HHS, were found to be better in Group T than in Group C (p < 0.005). No significant difference was observed between the two groups with respect to the radiological union, the RUSH score, or Singh Index, implying no negative effect of zoledronic acid.

CONCLUSIONS

This study demonstrates that postoperative intravenous zoledronic acid therapy does not retard fracture healing. Osteoporosis management is frequently neglected because of a surgeon's fear of ZOL retarding fracture healing and a lack of awareness among patients, resulting in low compliance. Thus, opportunistic administration of zoledronic acid postoperatively can be beneficial and will increase compliance for osteoporosis management and fracture prevention to 100%.

Management of Osteoporosis Medication after Osteoporotic Fracture

The aim of this study was to provide helpful information for use in selection of an appropriate medication after osteoporotic fractures through conduct of a literature review. In addition, a review of the recommendations of several societies for prevention of subsequent fractures was performed and the appropriate choice of medication for treatment of atypical femur fractures was examined. Clinical perspective was obtained and an updated search of literature was conducted across PubMed and MEDLINE and relevant articles were selected. The articles were selected manually according to relevance, and the references for identified articles and reviews were also evaluated for relevance. The following areas are reviewed: Commonly prescribed osteoporosis medications: BPs (bisphosphonates), denosumab, and SERMs (selective estrogen receptor modulators) in antiresorptive medications and recombinant human parathyroid hormone teriparatide, recently approved Romosuzumab in anabolic agents, clinical practice guidelines for the management of osteoporosis, osteoporotic fracture, and atypical femur fracture. Most medications for treatment of osteoporosis do not delay fracture healing and the positive effect of teriparatide on fracture healing has been confirmed. In cases where an osteoporotic fracture is diagnosed, risk assessment should be performed for selection of very high-risk patients in order to prevent subsequent fractures, and administration of anabolic agents is recommended.

Therapeutic Effects of Conservative Treatment with 2-Week Bed Rest for Osteoporotic Vertebral Fractures: A Prospective Cohort Study

UPDATE

This article was updated on October 19, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1787, in the legend for Figure 2, the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (A/P) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." now reads "The vertebral collapse rate (in %) was defined as (1 - [A/P]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." On page 1788, in the section entitled "Data Collection," the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (anterior vertebral wall height/posterior vertebral wall height) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." now reads "The vertebral collapse rate (in %) was defined as (1 - [anterior vertebral wall height/posterior vertebral wall height]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." Finally, on page 1791, in Table IV, the footnote for the "Primary outcome" row that had read "N = 113 in the rest group and 99 in the no-rest group." now reads "N = 116 in the rest group and 108 in the no-rest group."

Risk Factors for Failure in Conservatively Treated Osteoporotic Vertebral Fractures: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Osteoporosis is one of the most common diseases of the elderly, whereby vertebral body fractures are in many cases the first manifestation. Even today, the consequences for patients are underestimated. Therefore, early identification of therapy failures is essential. In this context, the aim of the present systematic review was to evaluate the current literature with respect to clinical and radiographic findings that might predict treatment failure.

METHODS

We conducted a comprehensive, systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist and algorithm.

RESULTS

After the literature search, 724 potentially eligible investigations were identified. In total, 24 studies with 3044 participants and a mean follow-up of 11 months (range 6-27.5 months) were included. Patient-specific risk factors were age >73 years, bone mineral density with a t-score <-2.95, BMI >23 and a modified frailty index >2.5. The following radiological and fracture-specific risk factors could be identified: involvement of the posterior wall, initial height loss, midportion type fracture, development of an intravertebral cleft, fracture at the thoracolumbar junction, fracture involvement of both endplates, different morphological types of fractures, and specific MRI findings. Further, a correlation between sagittal spinal imbalance and treatment failure could be demonstrated.

CONCLUSION

In conclusion, this systematic review identified various factors that predict treatment failure in conservatively treated osteoporotic fractures. In these cases, additional treatment options and surgical treatment strategies should be considered in addition to follow-up examinations.

Treatment of Kümmell’s disease following the occurrence of osteoporotic vertebral compression fracture

Background: The incidence of osteoporotic vertebral compression fracture (OVCF) is increasing with the increase in the elderly population. Kümmell’s disease following OVCF occurrence is not a rare complication and is frequently associated with severe pain or neurologic deficit with progressive kyphotic deformity. Kümmell’s disease initially meant post-traumatic delayed vertebral collapse, but now it is also termed nonunion, osteonecrosis, or intravertebral vacuum cleft, all of which suggest the disruption of the healing process.Current Concepts: The major pathogenesis of Kümmell’s disease is a vascular compromise caused by mechanical stress or intravascular pathology. The key radiologic sign to diagnose Kümmell’s disease is the presence of intravertebral vacuum cleft, observed using simple X-ray, computed tomography, or magnetic resonance imaging. Magnetic resonance imaging is the most useful diagnostic tool showing gas or fluid signals. The risk factors for the progression of Kümmell’s disease after OVCF include middle-column injury, confined low signal intensity on T2-weighted image, posterior wall combined fracture, kyphotic angle >10°, and a height loss >15%. Its treatment can be broadly classified as conservative treatment, bone cement injection, and surgical treatment. The appropriate treatment method is selected based on the pain intensity, neurological symptoms, and the severity of the kyphotic deformity.Discussion and Conclusion: Kümmell’s disease usually develops along with osteoporosis. Therefore, the treatment should be focused on relief from symptoms associated with Kümmell’s disease and osteoporosis. It is recommended that an anabolic agent should be administered after the diagnosis of Kümmell’s disease, regardless of the treatment modality.

Increased Potential of Bone Formation with the Intravenous Injection of a Parathyroid Hormone-Related Protein Minicircle DNA Vector

Osteoporosis is commonly treated via the long-term usage of anti-osteoporotic agents; however, poor drug compliance and undesirable side effects limit their treatment efficacy. The parathyroid hormone-related protein (PTHrP) is essential for normal bone formation and remodeling; thus, may be used as an anti-osteoporotic agent. Here, we developed a platform for the delivery of a single peptide composed of two regions of the PTHrP protein (1–34 and 107–139); mcPTHrP 1–34+107–139 using a minicircle vector. We also transfected mcPTHrP 1–34+107–139 into human mesenchymal stem cells (MSCs) and generated Thru 1–34+107–139-producing engineered MSCs (eMSCs) as an alternative delivery system. Osteoporosis was induced in 12-week-old C57BL/6 female mice via ovariectomy. The ovariectomized (OVX) mice were then treated with the two systems; (1) mcPTHrP 1–34+107–139 was intravenously administered three times (once per week); (2) eMSCs were intraperitoneally administered twice (on weeks four and six). Compared with the control OVX mice, the mcPTHrP 1–34+107–139-treated group showed better trabecular bone structure quality, increased bone formation, and decreased bone resorption. Similar results were observed in the eMSCs-treated OVX mice. Altogether, these results provide experimental evidence to support the potential of delivering PTHrP 1–34+107–139 using the minicircle technology for the treatment of osteoporosis.

Restoration of the intravertebral stability in Kümmell's disease following the treatment of severe postmenopausal osteoporosis by 1-34PTH-a retrospective study

Following the 1-34PTH application for conservative treatment of Kümmell's disease, the intravertebral cleft was filled or bridged by the osseous tissue; the radiological evidence of further collapsing was absent. Pain and the neurological disorder were relieved; bone turnover markers, BMD as well as the health-related quality of life were improved.

INTRODUCTION

Kümmell's disease (KD) patients with severe osteoporosis were applied by the 1-34PTH; the fracture union and the increased bone mineral density (BMD) following this treatment were retrospectively reviewed.

METHODS

Twenty-one postmenopausal osteoporosis (PMOP) patients with KD received at least 6 months of 1-34PTH treatment. The medical records, including clinical evaluation symptoms, radiological evaluation for bone union and the stability of intravertebral vacuum cleft (IVC), BMD, and laboratory examination for osteoporosis recovery and health-related quality of life (HRQOL), were reviewed.

RESULTS

From baseline to month 12, visual analog scale decreased from 8.24 ± 0.54 to 1.71 ± 0.56 (P < 0.001) and the modified Japanese Orthopedic Association scores increased from 6.86 ± 1.77 to 10.43 ± 1.29 (P < 0.001). Sagittal CT demonstrated that the IVC was filled or bridged by the osseous tissue in all patients. Within the vertebra, the IVC area (IVCA) decreased from 4.50 ± 2.50 to 0 mm² (P = 0.001) and the mineralized bone area (MBA) increased from 170.91 ± 102.23 to 259.56 ± 98.60 mm² (P < 0.001). The area ratio of IVC to vertebra decreased from 0.97 ± 0.46 to 0% (P < 0.001), and the area ratio of mineral bone to vertebra was increased from 32.85 ± 14.51 to 54.97 ± 14.01% (P < 0.001). The kyphosis angle increment was 3.43 ± 1.80°, and the loss rate of anterior border height was 11.14 ± 4.82%. No differences were found in posterior border height and spinal canal diameter. The PINP, β-CTx, BMD, and Short Form-36 Health Survey scores markedly increased.

CONCLUSIONS

In KD patients with severe PMOP, 1-34PTH treatment could alleviate the clinical evaluation symptoms, facilitate the recovery of the intravertebral stability, ameliorate the BMD, and improve the HRQoL.

Psoralen, a natural phytoestrogen, improves diaphyseal fracture healing in ovariectomized mice: A preliminary study

Psoralen is an effective active component extracted from Psoraleacorylifolia, which can promote bone formation in osteoporotic animals. However, to the best of our knowledge, its effect on fracture healing has not yet been examined. In the present study, open femur fractures were created in ovariectomy (OVX)-induced osteoporotic mice. OVX mice were treated with psoralen (psoralen+OVX group) or physiological saline (OVX group) by oral gavage. Radiographic and histological results demonstrated progressed callus consolidation in the psoralen+OVX group compared with the OVX group after 10 and 21 days of treatment. Qualitative histological analysis showed that the number of osteoclasts was significantly reduced in the psoralen+OVX group after treatment. Moreover, reverse transcription-quantitative PCR analysis of callus samples showed increased expression of bone morphogenetic protein-2 (BMP-2) and osteoprotegerin (OPG), and decreased expression of receptor activator of nuclear factor-κB ligand (RANKL) at 10 and 21 days post injury in the psoralen+OVX group compared with the OVX group. Furthermore, western blot analysis showed that psoralen significantly increased the expression of estrogen receptor (ER)-α, but had no effect on ER-β expression; these results were further confirmed by immunohistochemistry. To conclude, these results indicated that psoralen may promote callus formation and inhibit osteoclast genesis by increasing BMP-2 and ER-α levels, and OPG/RANKL ratio. Consequently, psoralen could be a possible treatment for osteoporotic fracture-related complications.

Timing of Bisphosphonate Initiation After Fracture: What Does the Data Really Say?

Introduction:

Osteoporosis is often not clinically recognized until after a fracture occurs. Individuals who have 1 fracture are at increased risk of future fractures. Prompt initiation of osteoporosis treatment following fracture is critical to reducing the rate of future fractures. Antiresorptives are the most widely used class of medications for the prevention and treatment of osteoporosis. Many providers are hesitant to initiate antiresorptives in the acute post-fracture period. Concerns include interference with bone remodeling necessary for successful fracture healing, which would cause increased rates of non-union, malunion, and refracture. While such concerns should not extend to anabolic medications, physicians may also hesitate to initiate anabolic osteoporosis therapies due to high cost and/or lack of familiarity. This article aims to briefly review the available data and present a digestible narrative summary to familiarize practicing orthopaedic surgeons with the essential details of the published research on this topic.

Results:

The results of 20 clinical studies and key pre-clinical studies related to the effect of anti-resorptive medications for osteoporosis on fracture healing are summarized in the body of this narrative review.

Discussion & Conclusions:

While few level I studies have examined the impact of timing of initiation of osteoporosis medications in the acute post-fracture period, the few that have been published do not support these concerns. Specifically, data from level I clinical trials indicate that initiating bisphosphonates as early as 2 weeks post-fracture does not increase rates of non-union or malunion. By reviewing the available data, we hope to give clinicians the confidence to initiate osteoporosis treatment promptly post-fracture.

Zoledronic Acid Substantially Improves Bone Microarchitecture and Biomechanical Properties After Rotator Cuff Repair in a Rodent Chronic Defect Model

BACKGROUND

Bone mineral density at the humeral head is reduced in patients with chronic rotator cuff tears. Bone loss in the humeral head is associated with repair failure after rotator cuff reconstruction. Bisphosphonates (eg, zoledronic acid) increase bone mineral density.

HYPOTHESIS

Zoledronic acid improves bone mineral density of the humeral head and biomechanical properties of the enthesis after reconstruction of chronic rotator cuff tears in rats.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 32 male Sprague-Dawley rats underwent unilateral (left) supraspinatus tenotomy with delayed transosseous rotator cuff reconstruction after 3 weeks. All rats were sacrificed 8 weeks after rotator cuff repair. Animals were randomly assigned to 1 of 2 groups. At 1 day after rotator cuff reconstruction, the intervention group was treated with a single subcutaneous dose of zoledronic acid at 100 µg/kg bodyweight, and the control group received 1 mL of subcutaneous saline solution. In 12 animals of each group, micro-computed tomography scans of both shoulders were performed as well as biomechanical testing of the supraspinatus enthesis of both sides. In 4 animals of each group, histological analyses were conducted.

RESULTS

In the intervention group, bone volume fraction (bone volume/total volume [BV/TV]) of the operated side was higher at the lateral humeral head (P = .005) and the medial humeral head (P = .010) compared with the control group. Trabecular number on the operated side was higher at the lateral humeral head (P = .004) and the medial humeral head (P = .001) in the intervention group. Maximum load to failure rates on the operated side were higher in the intervention group (P < .001). Cortical thickness positively correlated with higher maximum load to failure rates in the intervention group (r = 0.69; P = .026). Histological assessment revealed increased bone formation in the intervention group.

CONCLUSION

Single-dose therapy of zoledronic acid provided an improvement of bone microarchitecture at the humeral head as well as an increase of maximum load to failure rates after transosseous reconstruction of chronic rotator cuff lesions in rats.

CLINICAL RELEVANCE

Zoledronic acid improves bone microarchitecture as well as biomechanical properties after reconstruction of chronic rotator cuff tears in rodents. These results need to be verified in clinical investigations.

Effect of Osteoporosis Medication on Fracture Healing: An Evidence Based Review

A systematic search was conducted and relevant studies that evaluated the influence of osteoporosis medications (bisphosphonates [BPs], denosumab, selective estrogen receptor modulators [SERMs], recombinant human parathyroid hormone teriparatide [TPTD], and strontium ranelate [SrR]) on wrist, hip, and spine fracture healing, were selected. BPs administration did not influence fracture healing and clinical outcomes after distal radius fracture (DRF). Similar results were observed in hip fracture, but evidence is lacking for spine fracture. Denosumab did not delay the non-vertebral fractures healing in one well-designed study. No studies evaluated the effect of SERMs on fracture healing in humans. One study reported shorter fracture healing times in TPTD treated DRF patients, which was not clinically meaningful. In hip fracture, recent studies reported better pain and functional outcomes in TPTD treated patients. However, in spine fracture, recent studies found no significant differences in fracture stability between TPTD treated patients and controls. Evidence is lacking for SrR, but it did not influence wrist fracture healing in one study. In comparisons between TPTD and BPs, fracture healing and physical scores were not significantly different in hip fracture by 1 study. In spine fracture, controversy exists for the role of each medication to the fracture stability, but several studies reported that fracture site pain was better in TPTD treated patients than BPs treated patients. Considering no clinical data of negative fracture healing of the antiresorptive medication and the danger of subsequent fracture after initial osteoporotic fracture, there is no evidence to delay initiation of osteoporosis medications after fracture.

Effects of anti-osteoporosis medications on radiological and clinical results after acute osteoporotic spinal fractures: a retrospective analysis of prospectively designed study

Effects of anti-osteoporosis medications such as anti-resorptive and anabolic agents on healing of osteoporotic spinal fracture were retrospectively investigated. The use of anabolic agent significantly enhanced fracture healing, reduced progressive collapse, and presented good pain relief. These findings suggest that proper selection of medication could improve initial management of acute osteoporotic spinal fractures (OSFs).

INTRODUCTION

Although anti-osteoporosis medications have beneficial effects on prevention of osteoporotic spinal fractures (OSFs), few studies have compared effects of medications on fracture healing following OSFs. Therefore, the purpose of this study was to elucidate the effects of different anti-osteoporosis medications on radiological and clinical outcomes after acute OSFs.

METHODS

A total of 132 patients diagnosed with acute OSFs were enrolled and allocated into three groups [group I (n = 39, no anti-osteoporosis medication), group II (n = 66, bisphosphonate), and group III (n = 27, parathyroid hormone (PTH)]. Radiological parameters including magnetic resonance (MR) classification, occurrence of intravertebral cleft (IVC), and clinical outcomes such as numerical rating scale (NRS) and Oswestry disability index were assessed. Risk analyses for IVC and progressive collapse were done along the related factors and medication type.

RESULTS

IVC sign was observed in 30 patients. The rate of IVC sign was lower in group III (7.4%) than that in group I (20.5%) or group II (30.3%), although the difference was not statistically significant. Moreover, the degree of NRS improvement was better in group III than that in group I or group II (5.7 vs. 3.1 vs. 3.5, p < 0.001). On multiple regression analysis, mid-portion type fracture in MR classification was a significant risk factor for progressive OSFs. The use of PTH showed significant lower incidences of occurrence of IVC (odds ratio (OR) = 0.160) and increase in height loss (OR = 0.325).

CONCLUSIONS

Different anti-osteoporosis medications presented different clinical and radiological results after acute OSFs. The use of anabolic agent significantly enhanced fracture healing, reduced progressive collapse, and presented better clinical outcomes. Proper selection of medication might improve initial management of acute OSFs.

The Association of Osteoporosis and Bisphosphonate Use With Revision Shoulder Surgery After Rotator Cuff Repair

PURPOSE

To examine any association between osteoporosis and the failure of arthroscopic rotator cuff repair (ARCR) leading to revision surgery and to investigate whether the use of bisphosphonates had any influence on the observed associations.

METHODS

Patients who underwent ARCR with a diagnosis of osteoporosis were identified from the PearlDiver database and stratified according to whether there was a filled prescription for a bisphosphonate in the perioperative period. Patients with osteoporosis who underwent ARCR with bisphosphonate use were compared with age- and sex-matched patients who underwent ARCR with osteoporosis without a prescription for a bisphosphonate within 1 year of surgery and patients who underwent ARCR without a diagnosis of osteoporosis and no bisphosphonate use. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair, debridement for a diagnosis of a rotator cuff tear, or reverse shoulder arthroplasty. A multivariable logistic regression analysis was used to control for patient demographic characteristics and comorbidities during comparisons.

RESULTS

We identified 2,706 patients, including 451 in the bisphosphonate study group; 902 in the osteoporosis, no-bisphosphonate control group; and 1,353 in the non-osteoporosis control group. Patients with osteoporosis, including those to whom bisphosphonates were prescribed, had a significantly higher rate of revision rotator cuff surgery (6.58%) than patients without osteoporosis (4.51%) (odds ratio, 1.60; 95% confidence interval, 1.30-1.97; P = .008). No significant difference in the rate of revision surgery was found between patients with osteoporosis using bisphosphonates (6.65%) and age- and sex-matched patients with osteoporosis not using bisphosphonates (6.54%, P = .718).

CONCLUSIONS

By using an administrative database, this study was able to show a substantial difference in the revision surgery rate after ARCR in patients with osteoporosis compared with matched controls.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Effect of Preoperative Bisphosphonate Treatment on Fracture Healing after Internal Fixation Treatment of Intertrochanteric Femoral Fractures

Purpose

There are concerns that administration of bisphosphonate (BP) can substantially suppress bone turnover, potentially interfering with fracture healing. We investigated the effects of preoperative BP administration before internal fixation of intertrochanteric femoral fractures using fracture healing and clinical outcomes.

Materials and Methods

We retrospectively analyzed data from 130 patients who underwent internal fixation for osteoporotic intertrochanteric femoral fractures between March 2012 and July 2016. Patients previously treated with BPs for at least 3 months (BP group; n=29) were compared with the remaining patients (BP-naïve group; n=101). Radiographs were used to assess and compare fracture healing 3 months and 1 year postsurgery. The primary clinical outcome measure assessed was change in Koval score.

Results

Fracture union at 3 months after surgery was verified in 72.4% of patients (21/29) in the BP group and 90.1% of patients (91/101) in the BP-naïve group (P=0.027). Fracture union at 1 year postsurgery (BP group, 93.1% [27/29] vs. BP-naïve group, 97.0% [98/101], P=0.310) and change in Koval score (1.1 vs. 1.0, P=0.694) were not significantly different between the groups. Multivariable logistic regression analysis revealed that a history of BP administration was associated with an increased risk of delayed union at 3 months postsurgery (P=0.014).

Conclusion

Preoperative administration of BP was associated with a decreased fracture healing rate 3 months after internal fixation, compared with BP-naïve patients. Therefore, patients previously treated with a BP should be carefully allowed to wean off walking aids and transition to full weight-bearing in the early postoperative period.

Clinical effect of early bisphosphonate treatment for pyogenic vertebral osteomyelitis with osteoporosis: An analysis by the Cox proportional hazard model

BACKGROUND CONTEXT

Patients with pyogenic vertebral osteomyelitis (PVO) are expected to have an increased risk of bone loss. Therefore, early bisphosphonate therapy would be clinically effective for PVO patients with osteoporosis.

PURPOSE

This study aimed to investigate the effect of bisphosphonate on clinical outcomes of PVO patients with osteoporosis.

STUDY DESIGN/SETTING

A retrospective comparative study.

PATIENT SAMPLE

PVO patients with osteoporosis.

OUTCOME MEASURES

Four events of interest for Cox proportional hazard model included surgical treatment, recurrence of infection, subsequent fracture of adjacent vertebral bodies, and death.

METHODS

PVO patients were divided into three groups: group A (initiation of bisphosphonate within 6 weeks after PVO diagnosis), group B (initiation of bisphosphonate between 6 weeks and 3 months after PVO diagnosis), and group C (no treatment for osteoporosis). Cox proportional hazard model was used for the four events of interest.

RESULTS

A total of 360 PVO patients with osteoporosis were investigated for the four events of interest. Group A had significantly lower hazard ratios for undergoing later (>6 weeks after diagnosis) surgery than group C (p = .014) despite similar occurrences of overall surgery. A significant difference was also observed in the occurrence of subsequent fractures at adjacent vertebral bodies (p = .001 for model 1 and p = .002 for model 2). Groups A and B had significantly lower hazard ratios for subsequent fracture than group C. No significant differences were observed in the hazard ratios of recurrence and death among the three groups.

CONCLUSIONS

Early bisphosphonate treatment in PVO patients with osteoporosis was associated with a significantly lower occurrence of subsequent vertebral fracture at adjacent vertebral bodies and lower occurrence of subsequent surgery.

Therapeutic effects of new-type hydraulic delivery vertebroplasty, balloon kyphoplasty and conventional pusher-type vertebroplasty on single segmental osteoporotic vertebral compression fracture

This study aims to evaluate safety and practicality in clinical application for better guidance of single segmental osteoporotic vertebral compression fractures treatment. From May 2012 to September 2013, a total of 188 cases of patients with fractures, who received different treatment, were incorporated in the study and then divided into: group A (n=59), conventional pusher-type vertebroplasty; group B (n=54), balloon kyphoplasty; group C (n=60), new-type hydraulic delivery vertebroplasty treatment. The overall follow-up rate was 92.02%. Postoperative visual analogue scale (VAS) and Oswestry disability index (ODI) scores were significantly improved more than those of the preoperative scores in the three groups. Bone cement injection volumes in group A were significantly lower than those in group B and group C. Vertebral height recovery rates among groups were obviously different, showing statistical significance. After a year of follow-up, the vertebral height recovery outcome in group A was obviously poorer than that in group B and group C. A poorer outcome in group B was also found when compared with group C. In addition, the vertebral height restoration had a certain degree of loss, with the loss rate of 20.5, 14.0 and 7.5% in the three groups, respectively. Three operation methods have equivalent effects in the improvement of symptoms and functional recovery. Therefore, the new-type hydraulic delivery vertebroplasty provides a relatively more concise operation and shorter operation time, displaying more outstanding performance of clinical efficacy in spinal reconstruction and reduction of complications risks by evaluating the diffusion of the bone cement, vertebral height restoration rate and postoperative complications.

Combination therapy with BMP-2 and psoralen enhances fracture healing in ovariectomized mice

The advantages of combining local delivery of bone morphogenetic protein (BMP)-2 with systemic or local anti-osteoporosis treatments have also been studied for enhancing osteoporotic fracture healing. The aim of the present study was to evaluate the effect of combination therapy with BMP-2 and psoralen on fracture repair in ovariectomized mice. At 6 weeks after bilateral ovariectomy, mice (n=30) underwent unilateral transverse osteotomy on the femur and were divided into 3 groups. In the model group (n=10), animals were implanted with an absorbable collagen sponge (ACS) alone and administered physiological saline intragastrically (i.g.). In the recombinant human (rh)BMP-2 group (n=10), animals were implanted with an ACS loaded with 2.5 µg rhBMP-2 and administered physiological saline i.g. In the psoralen + rhBMP-2 group (n=10) animals were implanted with an ACS loaded with 2.5 µg rhBMP-2 and administered psoralen i.g. The mice were euthanized after 21 days and their fractured femurs were assessed by micro computed tomography, histological analysis and biomechanical testing. Furthermore, the serum of the animals was analyzed. Psoralen + rhBMP-2 exerted more beneficial effects on callus consolidation and biomechanical strength. In addition, increased bone-specific alkaline phosphatase levels and decreased C-terminal telopeptide of type-1 collagen were observed in the Psoralen + rhBMP-2 group. However, no difference in estrogen levels was detected between the groups. In conclusion, the present study demonstrated that in ovariectomized mice, combination of locally delivered BMP-2 and systemically administered psoralen improved bone healing compared with BMP-2 alone.

Effect of risedronate on femoral periprosthetic bone loss following total hip replacement: A systematic review and meta-analysis

BACKGROUND

Recent study has reported that risedronate was effective in reducing periprosthesis bone loss after total hip arthroplasty (THA). The meta-analysis was performed to compare the clinical outcomes of THA with oral risedronate versus placebo.

METHODS

Electronic databases: PubMed (1950-March 2018), EMBASE (1974-March 2018), the Cochrane Central Register of Controlled Trials, Web of Science (1950-March 2018) were systematically searched. Two authors independently graded the methodological quality of each eligible study using the Cochrane Collaboration tool and extracted relevant data. Statistical heterogeneity among the trials were evaluated with chi-square and I-square tests. This meta-analysis was performed using STATA 14.0.

RESULTS

A total of 4 randomized controlled trials (RCTs) published between 2006 and 2015 were included in our study. The meta-analysis demonstrated that risedronate was associated with a significantly reduction of periprosthetic bone mineral density after THA. No increased postoperative complications were observed.

CONCLUSION

Oral risedronate might reduce the periprosthetic bone resorption after cementless THA. Additionally, no severe adverse effects were observed. High-quality RCTs with large sample size were still required.