Letter from Deputy Editor-in-Chief Prof. H. Resch

No abstract

POS0314 IDENTIFICATION OF CIRCULATING microRNA SIGNATURES IN PATIENTS WITH PSORIASIS WITH SUBCLINICAL JOINT DISEASE AND PATIENTS WITH PSORIATIC ARTHRITIS

Background

MicroRNAs (miRNAs) are small non-coding RNAs that control gene expression. Specific miRNA signatures have been identified in numerous diseases and may serve as potential biomarkers or new drug targets. Whether certain miRNA signatures are associated with psoriatic joint disease is currently unknown.

Objectives

To search for circulating miRNA signatures in psoriasis patients with subclinical joint disease and in patients with psoriatic arthritis (PsA).

Methods

Analyses of serum miRNA were done in three groups: (1) PsA patients fulfilling CASPAR criteria (PsA), (2) healthy controls without past or present signs of musculoskeletal disease (HC) and (3) psoriasis patients with musculoskeletal pain but no signs of clinical PsA (PsO). PsO and PsA patients received a hand MRI, which was scored according to PsAMRIS method. miRNA analysis of serum samples was performed stepwise using RT-qPCR (TAmiRNA Vienna). In the discovery phase 192 miRNA assays were analyzed in 48 samples (N=16 each group). In the validation phase 17 miRNAs (Table 1) were selected and analyzed in 94 samples (N=35 PsA, N=24 PsO, N=35 HC) based on results of discovery phase and previous reports in literature. Results presented as mean±SD/median (IQR), p-values are adjusted for multiple testing.

Table 1.miRNAsPsA vs HCPsO vs HCPsA vs PsODiscovery PhaseValidation PhaseDiscovery PhaseValidation PhaseDiscovery PhaseValidation Phasep-adj.p-adj.p-adj.p-adj.p-adj.p-adj.miR-93-5p0.0001<0.0010.0080.0050.0390.947miR-29b-3p0.0001<0.00010.0040.00020.1910.522miR-19b-3p0.0070.7080.00020.0200.1380.147miR-320d0.0010.619<0.00010.1350.9410.247miR-144-5p0.0030.0060.00010.1690.3500.444miR-188-5p0.0140.9900.9750.6470.0530.839let-7b-5p0.0250.00030.8890.0260.00030.472miR-92a-3p0.0430.0010.0050.773<0.00010.0005miR-324-3p0.1381.0000.2570.3920.8140.518miR-126-3p0.0140.1690.0130.5980.9220.654miR-223-3p0.1690.8720.6170.7460.5191.000miR-130a-3p0.0390.0350.5560.0090.0060.724miR-140-3p0.3500.0530.0020.0060.1180.683miR-155-5p0.1590.9950.1690.5490.9220.604miR-21-5p0.2970.9900.0030.1160.080.014miR-146a-5p0.7060.0040.8360.0380.9050.941miR-122-5p0.9600.7340.6950.7990.9050.444

Results

51 PsA patients (age: 51.3±11.4 years; 56.9% females), 40 PsO patients (51.4±11.0; 37.5%) and 50 HC (51.0±10.5; 52.9%) were assessed. Duration of psoriasis was 12(25) years in PsA and 15(22.8) years in PsO. Duration of joint disease in PsA was 1.0(4.8) year. 51% of PsA and 5% of PsO patients were on biological disease modifying drugs (bDMARDs), 49% vs. 10% on conventional DMARDs. The most frequent findings in the MRI were erosions (PsA 59.6%; PsO 40%) and synovitis (PsA 48.9%; PsO 42.5%). PsA patients had higher number of tenosynovitis compared to PsO (p=0.04). In discovery phase 51 miRNAs in PsO and 64 miRNAs in PsA were down- or upregulated compared to HC, with an overlap of 33 miRNAs changed in PsA and PsO (p<0.05). Results of the selected 17 miRNAs are presented in Table 1. The top candidates to differentiate PsA and HC were miR-29b-3p (AUC=0.87), miR-93-5p (AUC=0.83) and let-7b-5p (AUC=0.79). For differentiating PsO and HC, they were miR-29b-3p (AUC=0.82), miR-140-3p (AUC=0.81) and miR-19b-3p (AUC=0.80) and for PsO vs. PsA miR-92a-3p (AUC=0.87), let-7b-5p (AUC=0.72) and miR-21-5p (AUC=0.70). miR-93-5p was lower in patients with erosions (p=0.01). miR-92a-3p, let-7b-5p and miR-21-5p were lower in patients with tenosynovitis, bone proliferations or erosions.

Conclusion

PsA and PsO patients show miRNA signatures different from HC. Top candidate miRNAs differentially regulated in PsA and PsO have been previously reported in alteration of bone metabolism and osteoarthritis indicating the intimate association of psoriatic inflammation with bone and cartilage changes.

References

[1]Faustini F et al. Ann Rheum Dis 2016 Dec;75(12):2068-2074

[2]Hackl, M et al. Molecular and Cellular Endocrinology Elsevier Ireland Ltd 432, pp 83–95

[3]Feichtinger X et al. Sci Rep 2018 Mar 20;8(1):4867

Disclosure of Interests

None declared

Bone microstructure and volumetric bone mineral density in patients with hyperuricemia with and without psoriasis

We analyzed volumetric bone mineral density (vBMD) and bone microstructure using HR-pQCT in subjects with normouricemia (NU) and subjects with hyperuricemia (HU) with and without psoriasis (PSO). HU was associated with higher cortical vBMD and thickness. Differences in average and trabecular vBMD were found between patients with PSO + HU and NU.

INTRODUCTION

Hyperuricemia (HU) and gout are co-conditions of psoriasis and psoriatic arthritis. Current data suggest a positive association between HU and areal bone mineral density (BMD) and a negative influence of psoriasis on local bone, even in the absence of arthritis. However, the influence of the combination of HU and psoriasis on bone is still unclear. The aim of this study was to assess the impact of HU with and without psoriasis on bone microstructure and volumetric BMD (vBMD).

METHODS

Healthy individuals with uric acid levels within the normal range (NU), with hyperuricemia (HU), patients with hyperuricemia and psoriasis (PSO + HU), and patients with uric acid within the normal range and psoriasis (PSO + NU) were included in our study. Psoriasis patients had no current or past symptoms of arthritis. Average, trabecular, and cortical vBMD (mgHA/cm³); trabecular number (Tb.N, 1/mm) and thickness (Tb.Th, mm); inhomogeneity of the network (1/N.SD, mm); and cortical thickness (Ct.Th., mm) were carried out at the ultradistal radius using high-resolution peripheral quantitative computed tomography. In addition, bone turnover markers such as DKK-1, sclerostin, and P1NP were analyzed.

RESULTS

In total, 130 individuals were included (44 NU participants (34% female), 50 HU (24%), 16 PSO + HU (6%), 20 PSO + NU (60%)). Subjects were aged: NU 54.5 (42.8, 62.1), HU 57.5 (18.6, 65.1), PSO + HU 52.0 (42.3, 57.8), and PSO + NU 42.5 (34.8, 56.8), respectively. After adjusting for age, sex, BMI, and diabetes, patients in the HU group revealed significantly higher values of cortical vBMD (p < 0.001) as well as cortical thickness (p = 0.04) compared to the NU group. PSO + NU showed no differences to NU, but PSO + HU demonstrated both lower average (p = 0.03) and trabecular vBMD (p = 0.02). P1NP was associated with average, cortical, and trabecular vBMD as well as cortical thickness while sclerostin levels were related to trabecular vBMD.

CONCLUSION

Hyperuricemia in otherwise healthy subjects was associated with a better cortical vBMD and higher cortical thickness. However, patients with both psoriasis and hyperuricemia revealed a lower vBMD.

Comparison of two reinforcement rings for primary total hip arthroplasty addressing displaced acetabular fractures: a biomechanical analysis

INTRODUCTION

Aim of this study was to biomechanically compare two different acetabular cup fixation constructs in terms of fracture fixation for displaced acetabular fractures involving the anterior column with hemitransverse fracture under partial and full weight-bearing conditions.

METHODS

Two different reinforcement rings designed as cages for primary THA were biomechanically tested in terms of managing a complex acetabular fracture. Single-leg stance cyclic loading was performed to assess fracture gap movement and fragment rotation. Twelve hemi pelvis Sawbones were divided into two groups: primary THA with acetabulum roof reinforcement plate (ARRP) (n = 6) and primary THA with Burch-Schneider reinforcement cage (BSRC) (n = 6).

RESULTS

During loading under partial weight-bearing (250 N) fracture gap movement tended to be larger in the BSRC group as compared to the ARRP group. Under full weight-bearing conditions, the ARRP showed 60% significantly less motion (p = 0.035) of the os ilium to os ischii gap compared to BSRC. Fracture gap movements between the os ilium and spina iliaca fragments were significantly reduced by 76% (p = 0.048) for ARRP in contrast to BSRC. The ARRP group also demonstrated significantly less movement in the fracture gaps os ischii to quadrilateral plate (62% reduction, p = 0.009) and quadrilateral plate to spina iliaca (87% reduction, p < 0.001). Significantly less rotational movement of the quadrilateral plate to the os ilium was exhibited by the ARRP group (p = 0.015).

CONCLUSIONS

The presented acetabulum roof-reinforcement plate (ARRP) provides stable conditions at the acetabular component with adequate stabilization of a displaced acetabular fracture.

Correction to: Comparison of two reinforcement rings for primary total hip arthroplasty addressing displaced acetabular fractures: a biomechanical analysis

The original version of this article unfortunately contained a mistake.

Bone microarchitecture and bone turnover in hepatic cirrhosis

Liver cirrhosis leads to bone loss. To date, information on bone quality (three-dimensional microarchitecture) and, thus, bone strength is scarce. We observed decreased bone quality at both assessed sites, independent of disease severity. Therefore, all patients should undergo early-stage screening for osteoporosis.

INTRODUCTION

Recent studies found low bone mineral density in cirrhosis, but data on bone microstructure are scarce. This study assessed weight-bearing and non-weight-bearing bones in patients with cirrhosis and healthy controls. The primary objective was to evaluate trabecular and cortical microarchitecture.

METHODS

This was a single-center study in patients with recently diagnosed hepatic cirrhosis. Thirty-two patients and 32 controls participated in this study. After determining the type of cirrhosis, the parameters of bone microarchitecture were assessed by high-resolution peripheral quantitative computed tomography.

RESULTS

Both cortical and trabecular microarchitectures showed significant alterations. At the radius, trabecular bone volume fraction was 17% lower (corrected p = 0.028), and, at the tibia, differences were slightly more pronounced. Trabecular bone volume fraction was 19% lower (p = 0.024), cortical bone mineral density 7% (p = 0.007), and cortical thickness 28% (p = 0.001), while cortical porosity was 32% higher (p = 0.023), compared to controls. Areal bone mineral density was lower (lumbar spine - 13%, total hip - 11%, total body - 9%, radius - 17%, and calcaneus - 26%). There was no correlation between disease severity and microarchitecture. Areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA) correlated well with parameters of cortical and trabecular microarchitecture.

CONCLUSIONS

Hepatic cirrhosis deteriorates both trabecular and cortical microarchitecture, regardless of disease severity. Areal bone mineral density is diminished at all sites as a sign of generalized affection. In patients with hepatic cirrhosis, regardless of its origin or disease severity, aBMD measurements are an appropriate tool for osteologic screening.

Diagnostic guidelines for the histological particle algorithm in the periprosthetic neo-synovial tissue

BACKGROUND

The identification of implant wear particles and non-implant related particles and the characterization of the inflammatory responses in the periprosthetic neo-synovial membrane, bone, and the synovial-like interface membrane (SLIM) play an important role for the evaluation of clinical outcome, correlation with radiological and implant retrieval studies, and understanding of the biological pathways contributing to implant failures in joint arthroplasty. The purpose of this study is to present a comprehensive histological particle algorithm (HPA) as a practical guide to particle identification at routine light microscopy examination.

METHODS

The cases used for particle analysis were selected retrospectively from the archives of two institutions and were representative of the implant wear and non-implant related particle spectrum. All particle categories were described according to their size, shape, colour and properties observed at light microscopy, under polarized light, and after histochemical stains when necessary. A unified range of particle size, defined as a measure of length only, is proposed for the wear particles with five classes for polyethylene (PE) particles and four classes for conventional and corrosion metallic particles and ceramic particles.

RESULTS

All implant wear and non-implant related particles were described and illustrated in detail by category. A particle scoring system for the periprosthetic tissue/SLIM is proposed as follows: 1) Wear particle identification at light microscopy with a two-step analysis at low (× 25, × 40, and × 100) and high magnification (× 200 and × 400); 2) Identification of the predominant wear particle type with size determination; 3) The presence of non-implant related endogenous and/or foreign particles. A guide for a comprehensive pathology report is also provided with sections for macroscopic and microscopic description, and diagnosis.

CONCLUSIONS

The HPA should be considered a standard for the histological analysis of periprosthetic neo-synovial membrane, bone, and SLIM. It provides a basic, standardized tool for the identification of implant wear and non-implant related particles at routine light microscopy examination and aims at reducing intra-observer and inter-observer variability to provide a common platform for multicentric implant retrieval/radiological/histological studies and valuable data for the risk assessment of implant performance for regional and national implant registries and government agencies.

Patterns in the Diagnosis and Treatment of Osteoporosis in Men: A Questionnaire-based Survey in Central and Eastern European Countries

To assess the current practice patterns in the diagnosis and treatment of male osteoporosis based on questionnaires. Questionnaires were presented and filled out by osteoporosis experts from Austria, Bulgaria, the Czech Republic, Hungary, Poland, Romania, Slovakia, Slovenia and Russia. The questions included focused on the proportion of male referrals to DXA, the main reasons for referral, the preferred measurement sites and reference database, the definition of male osteoporosis, needed laboratory investigations, data on calcium and vitamin D supplementation as well as on treatment modalities and their reimbursement rate. Men comprised 5 to 10% of all DXA referrals. The main reasons for referral were low back pain and fractures. Most of the respondents used the International male reference database. The diagnosis of osteoporosis was based mainly on a T-score below −2.5 after the age of 50, but a few respondents added fractures as a necessary condition. Only 1/3 of men visiting DXA sites are expected to have normal BMD. A consensus for the use of laboratory investigations in male osteoporosis is practically lacking. Treatment modalities include alendronate, risedronate, zoledronate, denosumab, rhPTH and strontium (with some restrictions for the latter three). Data on treatment adherence and persistence are generally lacking except for Austria, Romania and Slovakia. The levels of reimbursement vary a lot across countries. Osteoporosis in men is an under-recognized problem in CEE countries, leading to a tremendous gap in the diagnosis and treatment.

Reverse shoulder arthroplasty combined with latissimus dorsi transfer: A systemic review

Reverse shoulder arthroplasty (RSA) combined with latissimus dorsi transfer (LDT) is described for patients with cuff arthropathy and a combined loss of abduction and external rotation. The purpose of this systemic review was to present clinical and radiological outcomes following RSA combined with LDT. A comprehensive literature review was performed to identify studies reporting clinical and radiological results of RSA combined with LDT. Seven articles that describe the treatment of 116 patients were selected. Functional scores, range of motion, radiological outcome, complications, rehabilitation regime, surgical technique, patient demographics and indication were analyzed and discussed. All studies reported significant improvement in functional scores and abduction and external rotation. Complications occurred in 26% of patients. Although high-level studies are lacking, this systemic review shows that RSA combined with LDT is a reliable surgical method with which to treat patients with loss of active abduction and loss of external rotation. The available data are insufficient to draw conclusions regarding the long-term outcomes of this procedure.

LEVEL OF EVIDENCE

IV.

Preceding and subsequent high- and low-trauma fracture patterns-a 13-year epidemiological study in females and males in Austria

This study investigated the implication of a preceding high-trauma fracture on subsequent high- and low-trauma fractures at different skeletal sites in postmenopausal women and similarly aged men at an age range of 54 to 70 years. A preceding high-trauma fracture increases the risk of future low-trauma non-vertebral fractures including hip.

INTRODUCTION

Little is known about the impact of the skeletal fracture site in conjunction with the severity of a past fracture (high- or low-trauma preceding fracture) and its effect on future fracture risk.

METHODS

Patients with de novo high- and low-trauma fractures admitted to seven large trauma centers across Austria between 2000 and 2012 were stratified into sex and different age groups. Kaplan-Meier estimates, Cox proportional hazards regression models (HR), and likelihood calculations estimated effects of age, sex, and the anatomic region on the probability of a subsequent fracture in the same patient.

RESULTS

Included in the study were 433,499 female and male patients at an age range of 0 to 100 years with 575,772 de novo high- and low-trauma fractures. In the age range of 54-70 years, subsequent fractures were observed in 16% of females and 12.1% of males. A preceding high-trauma fracture was associated with 12.9% of subsequent fractures, thereof 6.5% of high- and 6.4% of low-trauma in origin, usually at the hip, humerus, or pelvis. The highest effect sizes were observed for femur, humerus, and thorax fractures with hazard ratios (HR) of 1.26, 1.18, and 1.14. After splitting into high-trauma preceding and subsequent low-trauma fractures, the femoral neck (HR = 1.59), the female sex (HR = 2.02), and age (HR = 1.03) were discriminators for increased future fracture risk.

CONCLUSIONS

Preceding high-trauma fractures increase the risk of future low-trauma non-vertebral fractures including hip. For each patient with a fracture, regardless of the severity of the trauma, osteoporosis should be taken into clinical consideration.

Factors associated with high 24-month persistence with denosumab: results of a real-world, non-interventional study of women with postmenopausal osteoporosis in Germany, Austria, Greece, and Belgium

Persistence with osteoporosis therapy is vital for fracture prevention. This non-interventional study of postmenopausal women receiving denosumab in Germany, Austria, Greece, and Belgium found that persistence with denosumab remains consistently high after 24 months in patients at high risk of fracture.

PURPOSE

Continued persistence with osteoporosis therapy is vital for fracture prevention. This non-interventional study of clinical practice evaluated medication-taking behavior of postmenopausal women receiving denosumab in Germany, Austria, Greece, and Belgium and factors influencing persistence.

METHODS

Subcutaneous denosumab (60 mg every 6 months) was assigned according to prescribing information and local guidelines before and independently of enrollment; outcomes were recorded during routine practice for up to 24 months. Persistence was defined as receiving the subsequent injection within 6 months + 8 weeks of the previous injection and adherence as administration of subsequent injections within 6 months ± 4 weeks of the previous injection. Medication coverage ratio (MCR) was calculated as the proportion of time a patient was covered by denosumab. Associations between pre-specified baseline covariates and 24-month persistence were assessed using multivariable logistic regression.

RESULTS

The 24-month analyses included 1479 women (mean age 66.3-72.5 years) from 140 sites; persistence with denosumab was 75.1-86.0%, adherence 62.9-70.1%, and mean MCR 87.4-92.4%. No covariate had a significant effect on persistence across all four countries. For three countries, a recent fall decreased persistence; patients were generally older with chronic medical conditions. In some countries, other covariates (e.g., older age, comorbidity, immobility, and prescribing reasons) decreased persistence. Adverse drug reactions were reported in 2.3-6.9% patients.

CONCLUSIONS

Twenty-four-month persistence with denosumab is consistently high among postmenopausal women in Europe and may be influenced by patient characteristics. Further studies are needed to identify determinants of low persistence.

Biomechanical analysis of the effect of congruence, depth and radius on the stability ratio of a simplistic 'ball-and-socket' joint model

Objectives

The bony shoulder stability ratio (BSSR) allows for quantification of the bony stabilisers in vivo. We aimed to biomechanically validate the BSSR, determine whether joint incongruence affects the stability ratio (SR) of a shoulder model, and determine the correct parameters (glenoid concavity versus humeral head radius) for calculation of the BSSR in vivo.

Methods

Four polyethylene balls (radii: 19.1 mm to 38.1 mm) were used to mould four fitting sockets in four different depths (3.2 mm to 19.1mm). The SR was measured in biomechanical congruent and incongruent experimental series. The experimental SR of a congruent system was compared with the calculated SR based on the BSSR approach. Differences in SR between congruent and incongruent experimental conditions were quantified. Finally, the experimental SR was compared with either calculated SR based on the socket concavity or plastic ball radius.

Results

The experimental SR is comparable with the calculated SR (mean difference 10%, sd 8%; relative values). The experimental incongruence study observed almost no differences (2%, sd 2%). The calculated SR on the basis of the socket concavity radius is superior in predicting the experimental SR (mean difference 10%, sd 9%) compared with the calculated SR based on the plastic ball radius (mean difference 42%, sd 55%).

Conclusion

The present biomechanical investigation confirmed the validity of the BSSR. Incongruence has no significant effect on the SR of a shoulder model. In the event of an incongruent system, the calculation of the BSSR on the basis of the glenoid concavity radius is recommended.

Cite this article: L. Ernstbrunner, J-D. Werthel, T. Hatta, A. R. Thoreson, H. Resch, K-N. An, P. Moroder. Biomechanical analysis of the effect of congruence, depth and radius on the stability ratio of a simplistic ‘ball-and-socket’ joint model. Bone Joint Res 2016;5:453–460. DOI: 10.1302/2046-3758.510.BJR-2016-0078.R1.

Relationship Between Medial Meniscal Extrusion and Cartilage Loss in Specific Femorotibial Subregions: Data From the Osteoarthritis Initiative

OBJECTIVE

Medial meniscal extrusion is known to be related to structural progression of knee osteoarthritis. However, it is unclear whether medial meniscal extrusion is more strongly associated with cartilage loss in certain medial femorotibial subregions than in others.

METHODS

Segmentation of the medial tibial and femoral cartilage (baseline; 1-year followup) and the medial meniscus (baseline) was performed in 60 participants with frequent knee pain (mean ± SD ages 61.3 ± 9.2 years, body mass index 31.3 ± 3.9 kg/m(2) ) and with unilateral medial radiographic joint space narrowing (JSN) grades 1-3, using double-echo steady-state magnetic resonance images. Medial meniscal extrusion distance and extrusion area (percentage) between the external meniscal and tibial margin at baseline, and longitudinal medial cartilage loss in 8 anatomic subregions were determined.

RESULTS

A significant association (Pearson's correlation coefficient) was seen between medial meniscal extrusion area in JSN knees and cartilage loss over 1 year throughout the entire medial femorotibial compartment. The strongest correlation was with cartilage loss in the external medial tibia (r =-0.34, P < 0.01 in JSN; r =-0.30, P = 0.02 in knees without JSN).

CONCLUSION

Medial meniscal extrusion was associated with subsequent medial cartilage loss. The external medial tibial cartilage may be particularly vulnerable to thinning once the meniscus extrudes and its surface is exposed to direct, nonphysiological, cartilage-to-cartilage contact.

[Injuries in Freestyle Motocross (FMX): A Retrospective Study]

INTRODUCTION

Freestyle Motocross (FMX) is an emerging extreme sport in which motocross riders perform risky jumps and tricks, which are graded by judges for their degree of difficulty, originality, and style. To this date, injury, patterns and causes in Freestyle Motocross have not been determined.

METHODS

Over the time period from January 2006 to December 2012, 19 professional FMX riders of an internationally active FMX team were retrospectively surveyed by means of a questionnaire and questionnaire-based interviews regarding injuries sustained during training, shows, or competition. The questionnaire collected information regarding injury type, circumstances, causes, and treatment. In addition, general information was obtained on body dimensions, experience, training, and equipment used.

RESULTS

A total of 54 accidents resulting in 78 severe injuries were registered. The most common types of injuries were fractures (66.6 %), ligament ruptures (7.7 %), and contusions (6.4 %). Most frequently affected body regions were foot/ankle (20.5 %), shoulder (12.8 %), and back (10.3 %). The Backflip was the trick during which most of the injuries occurred (35.2 %). Incorrect execution of jumps (25.9 %) was the leading cause of accidents.

CONCLUSION

Based on our data, FMX is a high-risk sport. To avoid injuries, ramps, motorcycles, and equipment should be in the best possible shape and the athletes themselves in good physical and mental condition. Attendance of medical staff during FMX activity is advised at all time.

Bone structure assessed by HR-pQCT, TBS and DXL in adult patients with different types of osteogenesis imperfecta

Bone microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT) was assessed in adult patients with mild, moderate, and severe osteogenesis imperfecta (OI). The trabecular bone score (TBS), bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), and dual X-ray and laser (DXL) at the calcaneus were likewise assessed in patients with OI. Trabecular microstructure and BMD in particular were severely altered in patients with OI.

INTRODUCTION

OI is characterized by high fracture risk but not necessarily by low BMD. The main purpose of this study was to assess bone microarchitecture and BMD at different skeletal sites in different types of OI.

METHODS

HR-pQCT was performed in 30 patients with OI (mild OI-I, n = 18 (41.8 [34.7, 55.7] years) and moderate to severe OI-III-IV, n = 12 (47.6 [35.3, 58.4] years)) and 30 healthy age-matched controls. TBS, BMD by DXA at the lumbar spine and hip, as well as BMD by DXL at the calcaneus were likewise assessed in patients with OI only.

RESULTS

At the radius, significantly lower trabecular parameters including BV/TV (p = 0.01 and p < 0.0001, respectively) and trabecular number (p < 0.0001 and p < 0.0001, respectively) as well as an increased inhomogeneity of the trabecular network (p < 0.0001 and p < 0.0001, respectively) were observed in OI-I and OI-III-IV in comparison to the control group. Similar results for trabecular parameters were found at the tibia. Microstructural parameters were worse in OI-III-IV than in OI-I. No significant differences were found in cortical thickness and cortical porosity between the three subgroups at the radius. The cortical thickness of the tibia was thinner in OI-I (p < 0.001), but not OI-III-IV, when compared to controls.

CONCLUSIONS

Trabecular BMD and trabecular bone microstructure in particular are severely altered in patients with clinical OI-I and OI-III-IV. Low TBS and DXL and their significant associations to HR-pQCT parameters of trabecular bone support this conclusion.

Persistence, adherence, and medication-taking behavior in women with postmenopausal osteoporosis receiving denosumab in routine practice in Germany, Austria, Greece, and Belgium: 12-month results from a European non-interventional study

Persistence with and adherence to osteoporosis therapy are critical for fracture reduction. This non-interventional study is evaluating medication-taking behavior of women with postmenopausal osteoporosis (PMO) receiving denosumab in Germany, Austria, Greece, and Belgium. Patients were representative of the PMO population and highly persistent with and adherent to denosumab at 12 months.

INTRODUCTION

Persistence with and adherence to osteoporosis therapy are important for optimal treatment efficacy, namely fracture reduction. This ongoing, non-interventional study will evaluate medication-taking behavior of women with postmenopausal osteoporosis (PMO) receiving denosumab in routine practice in four European countries.

METHODS

The study enrolled women who had been prescribed subcutaneous denosumab (60 mg every 6 months) in accordance with prescribing information and local guidelines. Persistence was defined as receiving the subsequent injection within 6 months + 8 weeks of the previous injection. Adherence was defined as receiving two consecutive injections within 6 months ± 4 weeks of each other. Medication coverage ratio (MCR) was calculated using the time a patient was covered with denosumab, as assessed from prescription records. Treatment was assigned prior to and independently of enrollment; outcomes are recorded during routine practice.

RESULTS

These planned 12-month interim analyses included data from 1500 patients from 141 sites. Mean age was 66.4-72.4 years, mean baseline total hip T-scores ranged from -2.0 to -2.1 and femoral neck T-scores from -2.2 to -2.6, and 30.7-62.1% of patients had prior osteoporotic fracture. Persistence was 87.0-95.3%, adherence 82.7-89.3%, and MCR 91.3-95.4%. In a univariate analysis, increased age, decreased mobility, and increased distance to the clinic were associated with significantly decreased persistence; parental history of hip fracture was associated with significantly increased persistence.

CONCLUSIONS

These data extend the real-world evidence regarding persistence with and adherence to denosumab, both of which are critical for favorable clinical outcomes, including fracture risk reduction.

Treatment with denosumab reduces secondary fracture risk in women with postmenopausal osteoporosis

OBJECTIVES

A history of prior fracture is one of the strongest predictors of a future fragility fracture. In FREEDOM, denosumab significantly reduced the risk of new vertebral, non-vertebral, and hip fractures. We carried out a post-hoc analysis of FREEDOM to characterize the efficacy of denosumab in preventing secondary fragility fractures in subjects with a prior fracture.

METHODS

A total of 7808 women aged 60-90 years with a bone mineral density T-score of less than - 2.5 but not less than - 4.0 at either the lumbar spine or total hip were randomized to subcutaneous denosumab 60 mg or placebo every 6 months for 36 months. The anti-fracture efficacy of denosumab was analyzed by prior fracture status, to assess secondary fragility fracture, and by subject age, prior fracture site and history of prior osteoporosis medication use.

RESULTS

A prior fragility fracture was reported for 45% of the overall study population. Compared with placebo, denosumab significantly reduced the risk of a secondary fragility fracture by 39% (incidence, 17.3% vs. 10.5%; p < 0.0001). Similar results were observed regardless of age or prior fracture site. In the overall population, denosumab significantly reduced the risk of a fragility fracture by 40% (13.3% vs. 8.0%; p < 0.0001), with similar results observed regardless of history of prior osteoporotic medication use.

CONCLUSIONS

Denosumab reduced the risk of fragility fractures to a similar degree in all risk subgroups examined, including those with prior fragility fractures. Identifying and treating high-risk individuals could help to close the current care gap in secondary fracture prevention.

[Posttraumatic arthrosis of the glenohumeral joint. From partial resurfacing to reverse shoulder arthroplasty]

BACKGROUND

Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.

OBJECTIVE

Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.

METHODS

Selective literature review and description of personal experience.

RESULTS

The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.

CONCLUSION

Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

Epidemiology of distal forearm fractures in Austria between 1989 and 2010

Only few studies have been published hitherto on country-specific incidence of distal forearm fracture. In the prevailing study, incidences were estimated, and trend analyses were performed for the entire Austrian population aged ≥50á. Incidence decreased significantly in women, but not in men, over the past 12 years of observation.

INTRODUCTION

To estimate incidence of distal forearm fracture and assess incidence trends in the entire Austrian population aged ≥50á from 1989-2010 for inpatient fractures and from 1999 to 2010 for all fractures.

METHODS

The number of inpatient forearm fractures was obtained from the Austrian Hospital Discharge Register (AHDR) for the entire population aged ≥50á from 1989 to 2010. Total number of distal forearm fractures was modeled using patient-level data on 36,327 patients with distal forearm fractures. Crude and age-standardized incidence rates (cases per 100,000) were estimated in 5-year age intervals. To analyze the change in incidence over time, average annual changes expressed as incidence rate ratios (IRR) were calculated.

RESULTS

For all distal forearm fractures, age-standardized incidence in women in 1999 and 2009 were estimated at 709 (95 % CI 675-743) and 607 (578-637), respectively. The age-standardized incidences in men the same years were estimated at 171 (156-185) and 162 (151-174), respectively. IRR analyses showed a significant decrease in women (-1.1 %, p < 0.01) but not in men (-0.8 %, p > 0.05) over the last 12 years (1999-2010).

CONCLUSION

Incidence of distal forearm fracture in the entire Austrian population is comparable to hip fracture incidence which is known to be among the highest worldwide. However, trend analyses reveal a significant decrease for all distal forearm fractures in women, but not in men, over the last 12 years.

Hidden discoligamentous instability in cervical spine injuries: can quantitative motion analysis improve detection?

PURPOSE

Recent literature shows that occult discoligamentous injuries still remain difficult to diagnose in the first instance. Thresholds as indicators for discoligamentous segmental instability were previously defined. But, since supine radiodiagnostic is prone to spontaneous reduction of a displaced injury, and even some highly unstable injuries reveal only slight radiographic displacement, these criteria might mislead in the traumatized patient. A highly accurate radiographic instrument to assess segmental motion is the computer-assisted quantitative motion analysis (QMA). The aim was to evaluate the applicability of the QMA in the setting of a traumatized patient.

METHODS

Review of 154 patients with unstable cervical injuries C3-7. Seventeen patients (male/female: 1:5, age: 44.6 years) had history of initially hidden discoligamentous injuries without signs of neurologic impairment. Initial radiographs did not fulfill instability criteria by conventional analysis. Instability was identified by late subluxation/dislocation, persisting/increasing neck pain, and/or scheduled follow-up. For 16 patients plain lateral radiographs were subjected to QMA. QMA data derived were compared with normative data of 140 asymptomatic volunteers from an institutional database.

RESULTS

Data analysis of measurements revealed mean spondylolisthesis of -1.0 mm (-3.7 to +3.4 mm), for segmental rotational angle mean angulation of -0.9° (-11.1° to +17.7°). Analysis of these figures indicated positive instability thresholds in 5 patients (31.3 %). Analysis of center of rotation (COR)-shifts was only accomplishable completely in 3/16 patients due to limited motion or inadequacy of radiographs. Two of these patients (12.5 %) showed a suspect shift of the COR.

CONCLUSIONS

Our data show a high rate of false negative results in cases of hidden discoligamentous injuries by using conventional radiographic analysis as well as QMA in plain lateral radiographs in a trauma setting. Despite the technical possibilities in a modern trauma center, our data and recent literature indicate a thorough clinical and radiographic follow-up of patients with cervical symptoms to avoid secondary complications from missed cervical spine injuries.

Contribution of regional 3D meniscus and cartilage morphometry by MRI to joint space width in fixed flexion knee radiography--a between-knee comparison in subjects with unilateral joint space narrowing

BACKGROUND

Radiographic joint space width (JSW) is considered the reference standard for demonstrating structural therapeutic benefits in knee osteoarthritis. Our objective was to determine the proportion by which 3D (regional) meniscus and cartilage measures explain between-knee differences of JSW in the fixed flexion radiographs.

METHODS

Segmentation of the medial meniscus and tibial and femoral cartilage was performed in double echo steady state (DESS) images. Quantitative measures of meniscus size and position, femorotibial cartilage thickness, and radiographic JSW (minimum, and fixed locations) were compared between both knees of 60 participants of the Osteoarthritis Initiative, with strictly unilateral medial joint space narrowing (JSN). Statistical analyses (between-knee, within-person comparison) were performed using regression analysis.

RESULTS

A strong relationship with side-differences in minimum and a central fixed location JSW was observed for percent tibial plateau coverage by the meniscus (r = .59 and .47; p<.01) and central femoral cartilage thickness (r = .69 and .75; p<.01); other meniscus and cartilage measures displayed lower coefficients. The correlation of central femoral cartilage thickness with JSW (but not that of meniscus measures) was greater (r = .78 and .85; p<.01) when excluding knees with non-optimal alignment between the tibia and X-ray beam.

CONCLUSION

3D measures of meniscus and cartilage provide significant, independent information in explaining side-differences in radiographic JSW in fixed flexion radiographs. Tibial coverage by the meniscus and central femoral cartilage explained two thirds of the variability in minimum and fixed location JSW. JSW provides a better representation of (central) femorotibial cartilage thickness, when optimal positioning of the fixed flexion radiographs is achieved.

Epidemiology of proximal humeral fractures in Austria between 1989 and 2008

Incidence rates of proximal humeral fractures in Austria over a period of twenty years (1989-2008) were estimated. Age standardized incidence rates increased until 2008, primarily driven by an increase in incidence rates in women.

INTRODUCTION

The aim of the prevailing study was to estimate incidence rates of proximal humeral fractures and to assess changes in trend in the Austrian population aged 50 years and above, over a period of 20 years (1989-2008).

METHODS

Number of proximal humeral fractures were obtained from the Austrian Hospital Discharge Register for the entire population >50 years of age. Adjustment factors were determined for multiple registrations of the same diagnosis, and for the fact that not all patients with proximal humeral fractures are treated in an inpatient setting. To analyze the overall change in this type of fracture for the period, average annual changes expressed as incidence rate ratios were calculated.

RESULTS

The estimated age-standardized incidence (fractures per 100,000 individuals) of proximal humeral fractures among Austrians >50 years of age increased in men from 112 (95% CI, 99-124) to 141 (129-153) and in women from 222 (202-241) to 383 (360-406). The increase appeared to be linear with no leveling off towards the end of the study period.

CONCLUSION

While some caution is necessary when interpreting the results given the use of adjustment factors, there appears to have been a rise in the incidence of proximal humeral fractures in Austria in both men and women, with no leveling off in recent years. The reasons for this are not clear, but in the light of previously reported leveling off in the increase in the incidence of hip fractures, a change in the patterns of falls cannot be ruled out.

How long should women with postmenopausal osteoporosis be treated with a bisphosphonate?

Bisphosphonates are very frequently prescribed to women suffering from postmenopausal osteoporosis with or without fragility fractures. The present review was aimed to update the available information on the most efficient treatment duration. Studies on bisphosphonate treatment duration were identified by Medline up to January 2013. Bisphosphonates are very effective in the short as well as in the medium-term. However, the optimal duration of use has not been determined yet. Therefore, this review summarizes the long-term effects of bisphosphonates on surrogate parameters of fracture prevention, bone mineral density measurements, and bone turnover markers. An initial treatment period of 3-5 years is recommended. Then, the patient has to be re-evaluated for fracture risk, which depends on fracture status as well as on other health issues. Beyond that, life style factors such as regular physical activity as well as a sufficient intake of calcium and vitamin D or, if necessary supplementation of calcium and/or vitamin D play an essential part in fracture prevention.

The discriminatory capacity of BMD measurements by DXA and dual X-ray and laser (DXL) at the calcaneus including clinical risk factors for detecting patients with vertebral fractures

Osteoporotic fracture risk depends on bone mineral density (BMD) and clinical risk factors (CRF). Five hundred and eighty-eight untreated female and male outpatient subjects were evaluated, 160 with vertebral fractures. BMD was measured both by using calcaneal dual X-ray and laser (DXL) and dual-energy X-ray absorptiometry (DXA), and CRF were evaluated. Detection frequencies for different BMD methods with or without CRF are presented.

INTRODUCTION

Osteoporotic fracture risk depends on bone mineral density and clinical risk factors. DXA of the spine/hip is considered a gold standard for BMD assessment, but due to degenerative conditions, particularly among the older population, assessment of BMD at the lumbar spine has been shown to be of limited significance. Portable calcaneal dual X-ray technology and laser can be an easily obtainable alternative.

METHODS

Vertebral fractures were evaluated in a baseline analysis of 588 females and males (median age 64.4, range 17.6-93.1 years), comparing BMD measurements by using DXL and DXA and CRF with/without BMD. One hundred and sixty subjects had radiological verified vertebral fractures. Area under receiver-operating characteristic curves (AUROCC) and univariate and multiple logistic regressions were calculated.

RESULTS

AUROCC for detection of vertebral fractures was comparable for DXL at calcaneus and DXA at femoral neck (DXL 0.665 and DXA 0.670). Odds ratio for prevalent vertebral fracture was generally weak for DXA femoral neck (0.613) and DXL (0.521). Univariate logistic regression among CRF without BMD revealed age, prevalent fragility fracture, and body mass index significantly associated with prevalent vertebral fracture (AUROCC = 0.805). Combining BMD and CRF, a prognostic improvement in case of DXA at femoral neck (AUROCC 0.869, p = 0.02), DXL at calcaneus (AUROCC 0.869, p = 0.059), and DXA at total hip (AUROCC 0.861, p = 0.06) was observed.

CONCLUSIONS

DXL was similarly sensitive compared with DXA for identification of subjects with vertebral fragility fractures, and combination of CRF with BMD by DXL or DXA further increased the discriminatory capacity for detection of patients susceptible to vertebral fracture.

Tibial coverage, meniscus position, size and damage in knees discordant for joint space narrowing - data from the Osteoarthritis Initiative

INTRODUCTION

Meniscal extrusion is thought to be associated with less meniscus coverage of the tibial surface, but the association of radiographic disease stage with quantitative measures of tibial plateau coverage is unknown. We therefore compared quantitative and semi-quantitative measures of meniscus position and morphology in individuals with bilateral painful knees discordant on medial joint space narrowing (mJSN).

METHODS

A sample of 60 participants from the first half (2,678 cases) of the Osteoarthritis Initiative cohort fulfilled the inclusion criteria: bilateral frequent pain, Osteoarthritis Research Society International (OARSI) mJSN grades 1-3 in one, no-JSN in the contra-lateral (CL), and no lateral JSN in either knee (43 unilateral mJSN1; 17 mJSN2/3; 22 men, 38 women, body mass index (BMI) 31.3 ± 3.9 kg/m(2)). Segmentation and three-dimensional quantitative analysis of the tibial plateau and meniscus, and semi-quantitative evaluation of meniscus damage (magnetic resonance imaging (MRI) osteoarthritis knee score = MOAKS) was performed using coronal 3T MR images (MPR DESSwe and intermediate-weighted turbo spin echo (IW-TSE) images). CL knees were compared using paired t-tests (between-knee, within-person design).

RESULTS

Medial tibial plateau coverage was 36 ± 9% in mJSN1 vs 45 ± 8% in CL no-JSN knees, and was 31 ± 9% in mJSN2/3 vs 46 ± 6% in no-JSN knees (both P < 0.001). mJSN knees showed greater meniscus extrusion and damage (MOAKS), but no significant difference in meniscus volume. No significant differences in lateral tibial coverage, lateral meniscus morphology or position were observed.

CONCLUSIONS

Knees with medial JSN showed substantially less medial tibial plateau coverage by the meniscus. We suggest that the less meniscal coverage, i.e., less mechanical protection may be a reason for greater rates of cartilage loss observed in JSN knees.

Tendons from non-diabetic humans and rats harbor a population of insulin-producing, pancreatic beta cell-like cells

Diabetes mellitus is a risk factor for various types of tendon disorders. The mechanisms underlying diabetes associated tendinopathies remain unclear, but typically, systemic factors related to high blood glucose levels are thought to be causally involved. We hypothesize that tendon immanent cells might be directly involved in diabetic tendinopathy. We therefore analyzed human and rat tendons by immunohistochemistry, laser capture microdissection, and single cell PCR for pancreatic β-cell associated markers. Moreover, we examined the short term effects of a single injection of streptozotocin, a toxin for GLUT2 expressing cells, in rats on insulin expression of tendon cells, and on the biomechanical properties of Achilles tendons. Tendon cells, both in the perivascular area and in the dense collagenous tissue express insulin and Glut2 on both protein and mRNA levels. In addition, glucagon and PDX-1 are present in tendon cells. Intraperitoneal injection of streptozotocin caused a loss of insulin and insulin mRNA in rat Achilles tendons after only 5 days, accompanied by a 40% reduction of mechanical strength. In summary, a so far unrecognized, extrapancreatic, insulin-producing cell type, possibly playing a major role in the pathophysiology of diabetic tendinopathy is described. In view of these data, novel strategies in tendon repair may be considered. The potential of the described cells as a tool for treating diabetes needs to be addressed by further studies.

OPG-Fc treatment in growing pigs leads to rapid reductions in bone resorption markers, serum calcium, and bone formation markers

Inhibition of the receptor activator of NF-κB ligand (RANKL) is a novel therapeutic option in the treatment of osteoporosis and related diseases. The aim of this study was to evaluate bone metabolism and structure in pigs after RANKL inhibition. 12 growing pigs were assigned to 2 groups with 6 animals each. The OPG group received recombinant human OPG-Fc (5 mg/kg IV) at day 0, the control group was given 0.9% NaCl solution. Serum levels of OPG-Fc, calcium (Ca), phosphorus (P), and bone turnover markers were evaluated every 5 days, and pigs were euthanized on day 20. Serum OPG-Fc concentration peaked at day 5 and coincided with significantly decreased Ca, P, and bone turnover markers. By day 15, measureable OPG-Fc serum levels could only be detected in 2/6 animals. With OPG-Fc clearance starting at day 10, serum Ca and P concentrations were not different between the 2 groups. TRACP5b, P1CP, and BAP levels significantly decreased by 40-70% relative to vehicle controls in the OPG-Fc group between days 5 and 10, indicating that pharmacologic concentration of OPG-Fc led to systemic concomitant inhibition of bone formation and resorption in young growing pigs. Dual X-ray absorptiometry data derived from the proximal femur did not differ between the 2 groups. μCT analysis of selected bone sites demonstrated an OPG-Fc-induced improvement of specific bone architectural indices and bone mineralization.

Radiological evaluation of cartilage after microfracture treatment: a long-term follow-up study

INTRODUCTION

Recent literature revealed good short-term results after microfracturing (MFX) of isolated focal cartilage defects in the knee joint. Study purpose was a long-term evaluation of patients who received MFX through a multimodal approach, correlating clinical scores and morphological pre- and postoperative MRI-scans.

MATERIALS AND METHODS

Between 2000 and 2007 158 patients were treated with MFX for focal femoral or tibial defects at our department. Patients with instabilities, secondary surgical intervention, patellofemoral lesions, a plica mediopatellaris or more than one cartilage defect site and age >55 were excluded. 15 patients were included. Minimum postoperative follow-up (FU) was 18 months (18-78 m). Mean age at surgery was 45 years (27-54), mean FU-interval 48 months (18-78 m). Male to female ratio was 9:6. For clinical assessment the Knee Osteoarthritis Ou tcome Score (KOOS) and Lysholm Score were used, radiological evaluation was performed with radiographs and 3Tesla-MRI.

RESULTS

Clinical knee function was rated good to excellent in 1 patient, fair in 2 and poor in 10 patients. 2/15 patients received full knee replacement due to insufficient cartilage repair through MFX during FU period. Evaluation of pre- and postoperative MRI showed good cartilage repair tissue in 1 (7.7%), moderate repair in 2 (15.4%) and poor fill in 10 patients (76.9%). In these 10 patients the defect size increased. Average defect size preoperatively was 187 mm(2) (range 12-800 mm(2)) and postoperatively 294 mm(2) (40-800 mm(2)). The KOOS-Pain averaged 60 (39-94), KOOS-Symptoms 60.6 (21-100), KOOS-ADL 69 (21-91), KOOS-Sports 35.7 (5-60) and KOOS-QUL 37.2 (6-81). The average Lysholm Score was 73.9 (58-94). 10 patients showed a varus leg axis deviation (Ø 5.9°), 3 had a neutral alignment. The alignment correlated positively with KOOS and especially with the Lysholm Score.

CONCLUSION

Our study demonstrated that MFX as a treatment option for cartilage defect in the knee did not show the anticipated clinical and radiological long-term results. In 12 of 15 patients the cartilage defect size had increased after MFX, in 2 patients indicating full-knee replacement. Especially those with a leg malalignment >5° in varus were more prone to suffer from an increase in defect size. In our cohort the clinical scores correlated with the radiological findings.

Bone and cellular immune system of multiparous sows are insensitive to ovariectomy and nutritive calcium shortage

Research in osteoporosis, which is a complex systemic disease, demands suitable large animal models. In pigs, most research has been done in growing minipigs, which probably are not ideal models for postmenopausal osteoporosis. Therefore, our aim was to analyze the effects of ovariectomy (OVX) and nutritive calcium shortage on multiparous Large White sows. 32 animals were randomly assigned to 4 groups in a cross design with OVX vs. sham and physiological calcium supplementation (0.75% calcium) vs. dietary calcium shortage (0.3% calcium). The observation period was 10 months with blood sampling every 2 months for hematological, immunological, and biochemical bone marker measurements. At the termination of the experiment, animals were sacrificed. Samples of trabecular bone of distal radius, proximal tibia, and sixth lumbar vertebra were subjected to micro-computed tomography imaging and ashed afterwards. Dual X-ray absorptiometry scans of the proximal femora were performed with prepared bones being placed in a water bath for mimicking soft tissue. Analyses of bone marker and cytokine profile kinetics, distribution of leukocyte subpopulations, and morphometrical and densitometrical analyses showed no evidence of any impact of OVX or calcium shortage. In conclusion, the skeleton of adult sows of a conventional breed is seemingly protected from effects of OVX and calcium shortage.

Epidemiology of hip fractures in Austria: evidence for a change in the secular trend

Hip fracture incidence rates in Austria over a period of 20 years (1989-2008) were assessed. Age-standardized incidence rates increased until 2005 but decreased thereafter. This change in the secular trend was primarily driven by a decrease in hip fracture incidence in women.

INTRODUCTION

The aim of the prevailing study was to assess the incidence rates of hip fractures including changes in trend in the Austrian population over a period of 20 years (1989-2008).

METHODS

The number of hip fractures was obtained from the Austrian Hospital Discharge Register for the entire population ≥ 50 years of age. A correction factor for multiple registrations of the same diagnosis was determined. Incidence rates (cases per 100,000) of hip fracture were calculated in 5-year age intervals. To analyze the overall change in hip fracture for the period, average annual change expressed as incidence rate ratios (IRRs) was calculated.

RESULTS

The age-standardized incidence in women increased until 2005, from 493 to 642, and decreased thereafter. In men, it increased at a measured pace until 2006, from 192 to 280, and decreased thereafter with a slight rebound in 2008. The age-standardized incidence in the entire population increased until 2005, from 376 to 496, and decreased thereafter. The IRR for the last 3 years (2006-2008) was significantly below the IRR for the first 17 years (0.94, ρ < 0.01), driven by a lower IRR in women (0.91, ρ < 0.01) and to a lesser extent by a lower IRR (not statistically significant) in men (0.96, ρ < 0.15).

CONCLUSION

The present study indicates that since 2006, age-standardized incidence of hip fractures has been declining in the Austrian population aged 50 years and above. This reversal in the secular trend has primarily been driven by a decrease in hip fracture incidence in women.

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

Clinical studies reported frequent failure with anterior instrumented multilevel cervical corpectomies. Hence, posterior augmentation was recommended but necessitates a second approach. Thus, an author group evaluated the feasibility, pull-out characteristics, and accuracy of anterior transpedicular screw (ATPS) fixation. Although first success with clinical application of ATPS has already been reported, no data exist on biomechanical characteristics of an ATPS-plate system enabling transpedicular end-level fixation in advanced instabilities. Therefore, we evaluated biomechanical qualities of an ATPS prototype C4-C7 for reduction of range of motion (ROM) and primary stability in a non-destructive setup among five constructs: anterior plate, posterior all-lateral mass screw construct, posterior construct with lateral mass screws C5 + C6 and end-level fixation using pedicle screws unilaterally or bilaterally, and a 360° construct. 12 human spines C3-T1 were divided into two groups. Four constructs were tested in group 1 and three in group 2; the ATPS prototypes were tested in both groups. Specimens were subjected to flexibility test in a spine motion tester at intact state and after 2-level corpectomy C5-C6 with subsequent reconstruction using a distractable cage and one of the osteosynthesis mentioned above. ROM in flexion-extension, axial rotation, and lateral bending was reported as normalized values. All instrumentations but the anterior plate showed significant reduction of ROM for all directions compared to the intact state. The 360° construct outperformed all others in terms of reducing ROM. While there were no significant differences between the 360° and posterior constructs in flexion-extension and lateral bending, the 360° constructs were significantly more stable in axial rotation. Concerning primary stability of ATPS prototypes, there were no significant differences compared to posterior-only constructs in flexion-extension and axial rotation. The 360° construct showed significant differences to the ATPS prototypes in flexion-extension, while no significant differences existed in axial rotation. But in lateral bending, the ATPS prototype and the anterior plate performed significantly worse than the posterior constructs. ATPS was shown to confer increased primary stability compared to the anterior plate in flexion-extension and axial rotation with the latter yielding significance. We showed that primary stability after 2-level corpectomy reconstruction using ATPS prototypes compared favorably to posterior systems and superior to anterior plates. From the biomechanical point, the 360° instrumentation was shown the most efficient for reconstruction of 2-level corpectomies. Further studies will elucidate whether fatigue testing will enhance the benefit of transpedicular anchorage with posterior constructs and ATPS.

Effects of rotator cuff ruptures on the cellular and intracellular composition of the human supraspinatus muscle

Ruptures of the rotator cuff tendons of the human shoulder are a common incidence and lead to functional impairment of the four muscles connected to the cuff, entailing profound changes of their cellular tissue composition. Most importantly, such tendon tears lead to atrophy, fatty degeneration and fibrosis of the corresponding muscles. The muscle most commonly affected with such changes is the M. supraspinatus. The present study uses biopsy samples from the supraspinatus muscle of 12 elderly patients and 6 controls to examine the rupture-induced muscle change at both the cellular and the intracellular (ultrastructural) levels. Amounts of fatty tissue, connective tissue and muscle were assessed by light microscopy-based morphometry and stereology. Stereology of electron micrographs was employed to determine volume densities of muscle fibre mitochondria, myofibrils and intracellular lipid. Results demonstrate that the supraspinatus muscles of patients with a massive rupture contain significantly higher amounts not only of fatty tissue but also of intracellular lipid than those of control subjects. These patients further exhibit a major decrease in relative amounts of myofibrils, thus confirming that change of intracellular composition is a major component of the observed muscle degeneration. The results contribute to establish the true spectrum of supraspinatus muscle damage in humans induced by tendon rupture.

Perivascular cells of the supraspinatus tendon express both tendon- and stem cell-related markers

Tendons and ligaments are often affected by mechanical injuries or chronic impairment but other than muscle or bone they possess a low healing capacity. So far, little is known about regeneration of tendons and the role of tendon precursor cells in that process. We hypothesize that perivascular cells of tendon capillaries are progenitors for functional tendon cells and are characterized by expression of marker genes and proteins typical for mesenchymal stem cells and functional tendon cells. Immunohistochemical characterization of biopsies derived from intact human supraspinatus tendons was performed. From these biopsies perivascular cells were isolated, cultured, and characterized using RT-PCR and Western blotting. We have shown for the first time that perivascular cells within tendon tissue express both tendon- and stem/precursor cell-like characteristics. These findings were confirmed by results from in vitro studies focusing on cultured perivascular cells isolated from human supraspinatus tendon biopsies. The results suggest that the perivascular niche may be considered a source for tendon precursor cells. This study provides further information about the molecular nature and localization of tendon precursor cells, which is the basis for developing novel strategies towards tendon healing and facilitated regeneration.

Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock.

A displacement of the tuberosity of > 5 mm and an angulation of > 30° of the head fragment were the indications for surgery.

Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing.

The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm.

The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.

Pectoralis major inverse plasty for functional reconstruction in patients with anterolateral deltoid deficiency

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

[Fractures of the femoral head. A multicenter study]

BACKGROUND

Dislocated fractures of the femoral head are highly infrequent injuries. In line with this multicenter study, a follow-up examination of patients with Pipkin fractures was performed in Austrian trauma centers. The aim of this study was to evaluate the types of fractures, the kind of treatment, and the long-term results.

PATIENTS AND METHODS

In sum 46 patients were included in our study. A personal and radiological follow-up examination was carried out. The fractures were classified according to Pipkin.

RESULTS

Patients with type I fractures had the best functional outcome according to the Harris Hip Score, followed by patients with type II fractures, type IV fractures, and finally type III fractures. The result of the radiological follow-up examination showed that patients who were treated conservatively or with extirpation of the fragment had a lower grade of arthrosis. The poorest radiological outcome was seen in patients who underwent surgical treatment with open reduction and internal fixation. The implantation of a total hip prosthesis was necessary in 24% of the patients. A relevant soft tissue calcification was not recorded.

CONCLUSION

The size and location of the fractured fragment has a huge influence on the outcome. An exact anatomical reconstruction of the femoral head, especially of the weight-bearing part, is absolutely necessary.

Rockwood type III acromioclavicular dislocation: surgical versus conservative treatment

The best treatment for Rockwood type III injuries is still controversial. During a retrospective study, 24 patients who were treated surgically with a hook plate and 17 conservatively treated patients were examined with a mean follow-up of 34 months. The Oxford Shoulder Score, Simple Shoulder Test, and Constant score were assessed at the follow-up examination. Stress radiographs of both shoulders were taken, and the coracoclavicular distance, as well as the width of the acromioclavicular joint, was measured. The mean Constant score was 80.7 in the conservatively treated group and 90.4 in the group that underwent surgery. The mean coracoclavicular distance was 15.9 mm in the conservatively treated group and 12.1 mm in the surgically treated group. These differences were significant (P < .05, Mann-Whitney U test and Student t test). In this study, better results were achieved by surgical treatment with the hook plate than by conservative treatment.

Physician and patient perceptions on the use of vitamin D and calcium in osteoporosis treatment: a European and Latin American perspective

OBJECTIVE

Although osteoporosis treatment guidelines include recommendations for calcium and vitamin D intake, routine use of adequate supplementation often is low. This study explored the attitudes of physicians and patients towards vitamin D and calcium and patient use of both supplements.

METHODS

A survey of randomly selected physicians in the United Kingdom, Mexico, and Austria, and the first seven eligible women with osteoporosis from each of their practices, was conducted. Physicians were asked to rate the importance of vitamin D and calcium in osteoporosis management on a scale of 1 to 10 (1 = not important at all, 10 = extremely important) and to estimate use of calcium and vitamin D supplements by their patients. Patients were asked about their own use of vitamin D and calcium, and their perceptions regarding these supplements.

RESULTS

Altogether 151 physicians (50 in Austria, 51 in the UK, and 50 in Mexico), and 910 osteoporosis patients (350 in Austria, 212 in UK, and 348 in Mexico) completed telephone surveys. Approximately, 86%, 28%, and 46% of physicians rated importance of vitamin D and calcium as being 9 or 10 in Austria, UK, and Mexico, respectively. Overall, 50% of patients reported taking calcium and vitamin D supplements (47% of these on a daily basis and 46% on a regular basis), and 19% of patients reported that they had no discussions with their physicians about calcium, while 39% reported no discussion about vitamin D.

CONCLUSIONS

Despite the recognition by physicians and patients that vitamin D and calcium are important for bone health, only a small proportion of patients regularly take supplements. This is the case even when vitamin D and calcium supplements are provided free with osteoporosis drug prescriptions, as occurs in Austria. However, these results rely on patient self-report of compliance which can lead to overestimation. In addition this study's participants may not be representative of other patient populations. This study provides additional evidence that compliance with treatment guidelines is suboptimal, and highlights the need for further study to explore the discrepancy between the highly perceived importance of vitamin D and calcium and the low use of both supplements, and to improve use among osteoporosis patients.