Parathyroid hormone secretion after operative bone trauma

Serum intact-parathyroid hormone level following total knee arthroplasty

PURPOSE

To evaluate short-term parathyroid hormone (PTH) secretion following total knee arthroplasty (TKA).

METHODS

119 Caucasian postmenopausal women aged 49 to 81 (mean, 69.8) years who underwent TKA for end-stage knee osteoarthritis were included. Serum levels of intact-PTH, calcium, phosphorus, and creatinine were evaluated pre- and post-operatively (on days -1 and 7). Creatinine clearance was also calculated.

RESULTS

In 67 of the patients, serum intact-PTH levels decreased after TKA; this sample proportion was not significant (p=0.82). In 16 of the patients, such levels elevated abnormally (above normal range). In the remaining 36 patients, such levels elevated within the normal range. Therefore, the mean serum intact- PTH level of all patients increased slightly after TKA (45.4 vs. 45.3, p=0.162). The serum intact-PTH level did not correlate to body weight (r=-0.045, p=0.624), patient age (r=-0.061, p=0.508), serum creatinine level (r=0.084, p=0.366), and clearance of creatinine (r=-0.037, p=0.692).

CONCLUSION

In most postmenopausal women, the serum intact-PTH level decreased moderately following TKA, but in some, the level was abnormally elevated. This may interfere the prosthesis incorporation process.

Secondary hyperparathyroidism, vitamin D deficiency and hip fracture: importance of sampling times after fracture

There is controversy about how often elevated parathyroid hormone (PTH) levels are found in hip fracture patients. The aim of this study was to determine whether changes in PTH levels after fracture and surgery could explain some of the variation in published data. Blood samples were obtained from 24 elderly patients with hip fracture before surgery, immediately after surgery and at 2 weeks and 3 months after fracture. PTH levels were elevated (> 5.5 pmol) in 33% initially and then fell significantly at 2 weeks in virtually all subjects (P < 0.001) and remained significantly lower after 3 months (n = 17). Although 25-hydroxyvitamin D levels were low (< 30 nmol) in 44% of the patients, the fall in PTH was not explained by alterations in vitamin D metabolites or other measured parameters. The cause of the variation in PTH levels is unknown but measurements immediately after fracture could overestimate the incidence of secondary hyperparathyroidism. Vitamin D deficiency is common in our hip fracture population and is not influenced by hospitalisation.

Immobilization osteoporosis in paraplegia

The pathophysiology of osteoporosis as it relates to immobilization or disuse osteoporosis in paraplegics is briefly reviewed. The physiology of bone formation and resorption is discussed, and the influence of piezoelectric forces on bone integrity and the consequences of the loss of this effect in paraplegics is addressed. When bone is stressed, negative charges accumulate on the side from which the stress is applied and positive charges accumulate on the opposite side. Presumably the collagenous component of bone plays the major role in the generation of electrical potentials. Another mechanism important in the generation of electrical potentials is created by liquid planes streaming past solid planes. Diminished forces acting on bone, as in paraplegia, are translated into changes in the activity of bone remodeling units which can be assessed by histomorphic and histoenzymatic techniques. Other biochemical and endocrine consequences of immobilization involve increased serum calcium, decreased serum parathyroid hormone (PTH), and decreased dihydroxy-vitamin D synthesis. Urinary hydroxyproline and calcium excretion are increased, as is stool calcium. The bone loss that follows immobilization may produce an increased susceptibility to fractures involving long bones more than the spinal column, and is due more to decreased bone formation than to accelerated bone resorption. The treatment of immobilization osteoporosis primarily involves early remobilization, but other treatments, including the use of electrical fields and the administration of bisphosphonates, calcitonin, and a growth hormone are being actively investigated.

Immobilization osteoporosis: a review

Bone mass is not only subject to systemic hormonal homeostatic mechanisms, but also to local mechanical influences. The importance of the mechanical balance of bone has been more recently stressed by the research on the effect of weightlessness on bone, and by the introduction of the concept of "mechanostat" in the pathogenesis of osteoporotic conditions. Immobilization osteoporosis has clinical (fractures, sometimes hypercalcemia, urinary lithiasis) and radiological features. Immobilization has an effect on bone modeling and remodeling, through an increased activation of remodeling loci, and a decrease of the osteoblastic stimulus. This leads directly to a local reduction in bone mass, the increased activation multiplying the effect of the deficit in bone formation. The prevention is based on exercise if the load is applied intermittently for a daily period. It seems also that muscle weight is an important determinant of bone mass. There is a potential for recovery during the active early phase of immobilization osteoporosis that may disappear in the subsequent late (about six months) inactive phase. Permanent losses could be prevented by appropriate measures, pharmacology or exercises, applied during the first months of immobilization. No recovery has been demonstrated after the inactive phase has been reached, whatever the treatment. The cumulative effect of repeated periods of immobilization remains hypothetical.

Effects of 1,25-dihydroxycholecalciferol on fracture healing. Calcium, phosphate, and zinc in callus and serum

The incorporation of calcium, phosphate, and zinc into the callus of closed tibial fractures was studied in adult rats fed a standard diet. Low doses (60 ng/kg per day) of 1,25(OH)2D3 5 days a week greatly increased early callus mineralization. This was not related to an increased serum calcium-phosphate molar product but rather to a decreased ratio. The incorporation of zinc into callus seemed to be correlated to the mineralization process but not to the 1,25(OH)2D3 administration as such. The question of a direct, indirect, or a complex role of 1,25(OH)2D3 in bone formation and mineralization is discussed.

Secretion of parathyroid hormone after surgical trauma

Parathyroid hormone was measured in nine patients subjected to surgery under general anaesthesia not involving operative bone trauma. Total calcium concentration, ionized serum calcium and serum albumin was also analyzed pre- and post-operatively. An increase in serum parathyroid hormone was registered postoperatively without any accompanying decrease in ionized serum calcium. The measured changes are at present unexplained, but can be caused by other mechanisms than bone trauma.

Increase in plasma calcitonin following femoral fracture in rats

The secretion of calcitonin (CT) has been studied in male rats following a standardized, left femoral fracture after administration of subcutaneous fluanisone and fentanyl citrate anaesthesia. Twenty-five minutes after the fracture, the plasma concentrations of CT were increased by about 20 per cent in young and by about 60 per cent in adult rats compared to prefracture levels of the hormone. Three weeks later, plasma CT had decreased and was not significantly different from prefracture levels. Anaesthesia combined with femoral fracture did not influence plasma calcium significantly, whereas the plasma concentrations of calcium increased in young control rats during 35 minutes of anaesthesia alone. Plasma CT, however, remained unchanged in these control rats in the same period. In rats with a transplanted, CT-secreting, medullary thyroid carcinoma, femoral fracture did not alter the already high plasma concentrations of CT. It is suggested that increase in CT secretion is part of a general response to trauma.

The effect of scoliosis surgery on parathormone, calcitonin and calcium levels in serum and the urinary excretion of calcium

This study investigates mineral metabolism following scoliosis surgery in girls. During the first week there was a significant increase in the secretion of parathormone and a decrease in that of calcitonin. The serum calcium became significantly elevated from between the 3rd and 7th post-operative days. The serum phosphate decreased during the first week and increased significantly thereafter. The urinary excretion of calcium increased five-fold.