Bilateral Total Hip Research Articles

Osteoporosis should be evaluated by bone mineral density at the combination of the lumbar spine and ipsilateral femoral neck in female patients with knee osteoarthritis scheduled for knee arthroplasty: A retrospective observational study

BackgroundKnee arthroplasty is a well-established surgery with good clinical outcomes. However, periprosthetic fractures and aseptic loosening negatively impact clinical outcomes, and osteoporosis is one of the causes of such complication. Osteoporosis is usually evaluated by bone mineral density of the lumbar spine and hip using dual-energy X-ray absorptiometry (DXA). However, the prevalence of this disease in patients with knee osteoarthritis scheduled for knee arthroplasty may be underestimated due to differences in the measurement sites. This study aimed to determine the appropriate measurement site for DXA that would not miss osteoporosis in female patients with knee osteoarthritis undergoing knee arthroplasty. MethodsWe measured bone mineral density preoperatively in the consecutive 50 female patients with knee osteoarthritis scheduled for knee arthroplasty by dual-energy X-ray absorptiometry at five sites: the lumbar spine, bilateral-total hip, and femoral neck. We then compared the prevalence of osteoporosis among the four combinations of the lumbar spine and single hip site (ipsilateral or contralateral total hip or femoral neck). ResultsOsteoporosis prevalence in the combination of the lumbar spine and ipsilateral or contralateral total hip was 32%, and that in the combination of the lumbar spine and contralateral femoral neck was 44%. Notably, the disease's prevalence in the combination of the lumbar spine and ipsilateral femoral neck was 50%, which was significantly higher than that in the other combinations. ConclusionOsteoporosis should be evaluated by bone mineral density in the combination of the lumbar spine and ipsilateral femoral neck in female patients with knee osteoarthritis scheduled for knee arthroplasty.

INDISCRIMINATE COAGULATION TESTING FOR BLEEDING RISK ASSESSMENT PRIOR TO ORTHOPEDIC SURGERY. IS IT A RATIONAL APPROACH?

Abstract Objective: Indiscriminative preoperative coagulation testing to identify patients at risk of bleeding is commonly practiced. However, this practice is no longer supported by current recommendations. We conducted this study with an aim to evaluate the advantage of doing screening testing for coagulation and hemostasis in unselected patients prior to elective orthopedic surgeries in our setting. Material and Methods: It was a retrospective, cross sectional study carried out at Medicare Cardiac and General Hospital, Jinnah Medical and Dental College, Karachi. All the patients admitted for elective orthopedic bilateral total knee replacement and Hip replacement surgeries from March 2016 to December 2018 were included in the study. Electronic data of patients’ pre-operative test results for Prothrombin time, activated partial Thromboplastin time was retrieved. Frequency of patients with deranged coagulation screening was calculated. Results: A total of 367 patients underwent pre-surgical coagulation testing. Male to female ratio was 1:3. Median age of patients was 61±5 years. A total of 2.9% (n=11) patients were found to have deranged coagulation profile. Out of which 3 patients did not undergo surgery and were loss to follow up. Out of total 0.54% (n=2) patients had both prolonged PT and APTT, 1.6% (n=6) patients had prolonged APTT and 0.3% (n=1) patient experienced intraoperative bleeding requiring one unit of packed cell transfusion. Only 0.3% (n=1) patient experienced post-operative bleeding and dropped her Hemoglobin and received transfusion. Conclusion: The overall results of the study suggest that indiscriminate coagulation screening does not provide any additional information unless further detailed hemostatic evaluation is carried out. It is suggested that routine screening tests should not be performed unless a medical history is indicative of bleeding tendency. Key Words: Coagulation screening, Bleeding risk, Orthopedic surgery.

Inverse Relationship between Mean Corpuscular Volume and T-Score in Chronic Dialysis Patients

Background and Objectives: Osteoporosis and anemia are prevalent among chronic kidney disease stage 5D (CKD stage 5D) patients. Osteoblasts are known as the niche cells of hematopoietic stem cells (HSCs) and stimulate HSCs to form blood-cell lineages within bone marrow microenvironments. We hypothesized that an inverse correlation may exist between mean corpuscular volume (MCV), a surrogate for ineffective hematopoiesis, and bone mineral density (BMD) in the CKD stage 5D population. Materials and Methods: This is a cross-sectional designed cohort study evaluating CKD stage 5D patients who have received dialysis therapy for over three months. Baseline clinical characteristics and laboratory data were prospectively collected. The dual-energy X-ray absorptiometry (DXA) method was used to measure BMD at five sites, which were bilateral femoral neck, total hip, and lumbar spine 1–4. The Pearson correlation test was initially adopted, and a multivariate linear regression model was further applied for potential confounder adjustments. Results: From September 2020 to January 2021, a total of 123 CKD stage 5D patients were enrolled. The Pearson correlation test revealed a significant inverse association between MCV and BMD at bilateral femoral neck and lumbar spine. The lowest T-score of the five body sites was determined as the recorded T-score. After adjustments for several potential confounding factors, the multivariate linear regression model found consistent negative associations between T-score and MCV. Conclusions: The present study found significant inverse correlations between MCV and BMD at specific body locations in patients on dialysis. A decreased T-score was also found to be associated with macrocytosis after adjustments for confounding variables. However, direct evidence for the causative etiology was lacking.

Neglected reactive arthritis complicated by bilateral hip and temporomandibular joints ankylosis after a suspected tetanus infection: a case report

BackgroundReactive arthritis had been reported to occur after various vaccinations, including the tetanus toxoid vaccine; here, we report a case of ankylosing arthropathy suggested to be a complication of missed neglected reactive arthritis after tetanus infection.Case presentationA healthy 20-year-old woman presented with subtrochanteric right femoral fracture; imaging studies showed bilateral ankylosed hip, kyphoscoliosis, bilateral fused temporomandibular joints, and normal sacroiliac joints bilaterally. Laboratory investigations for a rheumatic or autoimmune disease were all within normal ranges. Detailed history revealed admission of the patient to an ICU unit (1 year before the trauma) for a month as she was diagnosed as having tetanus infection, after which she was unable to walk or feed herself. At the final follow-up, the patient started walking with a moderate limb after having a series of surgeries including femoral fracture fixation, temporomandibular joint excision arthroplasty, and bilateral total hip arthroplasty.ConclusionUnusual complications after tetanus infection can occur in the form of joint ankylosis, which could be presented after prolonged immobilization possibly due to improper management of reactive arthritis.

Mid-term results of bilateral synchronous total hip arthroplasty for bony ankylosis in patients with ankylosing spondylitis

BackgroundTotal hip arthroplasty (THA) for bony ankylosis is technically challenging in patients with ankylosing spondylitis (AS). This study aimed to determine the mid-term results of bilateral synchronous THA for bony ankylosis in patients with AS.MethodsNineteen cases of bony ankylosis in patients with AS who received bilateral synchronous THA were included in this study (17 males and 2 females, mean age 49.2 years). Disease duration was 5–38 years (mean 18 years and 6 months). All patients received cementless THA. Intraoperative blood loss, visual analog scale (VAS) score, and complications were assessed. Harris hip scores evaluated the clinical effect.ResultsPatients were followed up for 62–98 months (mean 82.5 months). VAS score decreased from 7.42 ± 0.92 to 2.42 ± 0.83, Harris hip score improved from 21.8 ± 7.2 to 80.3 ± 6.5, and the flexion-extension range of the hip improved from 0 to 142.3 ± 6.2°. One patient with septum bronchiale had a fracture intraoperatively and was treated with wire strapping. One patient had a traction injury of the femoral nerve postoperatively and recovered 1 year after the operation. Loosening and subsidence were not observed in all patients. Heterotopic bone formation was noted in 3 patients. No complications such as joint dislocation, acute infection, and deep vein thrombosis were found.ConclusionBilateral synchronous THA was effective for bony ankylosis of the hip in patients with AS because it improved patients’ quality of life and had satisfactory mid-term outcomes.

Trabecular and cortical bone involvement in rheumatoid arthritis by DXA and DXA-based 3D modelling.

To evaluate cortical and trabecular bone involvement of the hip in RA patients by dual-energy X-ray absorptiometry (DXA) and 3D analysis. The secondary end-point was to evaluate bone involvement in patients treated with classic (c-DMARD) or biological (b-DMARD) disease-modifying antirheumatic drug therapies and the effect of the duration of the disease and corticosteroid therapy on 3D parameters. A cross-sectional study of 105 RA patients and 100 subjects as a control group (CG) matched by age, sex, and BMI was carried out. BMD was measured by DXA of the bilateral femoral neck (FN) and total hip (TH). The 3D analyses including trabecular and cortical BMD were performed on hip scans with the 3D-Shaper software. FN and TH BMD and trabecular and cortical vBMD were significantly lower in RA patients. The c-DMARD (n = 75) group showed significantly lower trabecular and cortical vBMD than the CG. Despite the lower values, the b-DMARD group (n = 30) showed no significant differences in most parameters compared with the CG. The trabecular and cortical 3D parameters were significantly lower in the group with an RA disease duration of 1 to 5years than in the CG, and the trabecular vBMD was significantly lower in the group with a duration of corticosteroid therapy of 1 to 5years than in the CG, while no significant differences were found by standard DXA in the same period. RA patients had a higher risk of developing low BMD or osteoporosis than controls. RA patients receiving c-DMARD therapy showed significantly lower BMD than controls, while no significant differences in most parameters were found between RA patients receiving b-DMARDs and controls. 3D-DXA allowed us to find changes in trabecular and cortical bone compartments in RA patients.

Effects of monthly minodronate with or without eldecalcitol addition in osteoporosis patients with rheumatoid arthritis: An 18-month prospective study

ObjectivesIncreasing bone mineral density (BMD) to reduce fracture risk is a primary goal of osteoporosis treatment. This prospective, observational study evaluates the effects of monthly minodronate (MIN; 50 mg) with or without eldecalcitol (ELD) addition in osteoporosis patients with rheumatoid arthritis (RA) during 18 months. MethodsThe cohort was prospectively and randomly split into the MIN monotherapy group (14 cases) and MIN plus ELD group (combination group; 14 cases) due to no reports on the effectiveness and safety of MIN therapy in relation to ELD addition for comparisons of serum tartrate-resistant acid phosphatase (TRACP)-5b, bone alkaline phosphatase (BAP), and BMD of the lumbar 1–4 vertebrae (L-BMD), bilateral total hips (H-BMD; the mean value of the right and left hips), and bilateral femoral necks (FN-BMD) at baseline and at 6, 12, and 18 months of treatment. ResultsBaseline values were comparable between the groups apart from a tendency for higher TRACP-5b in the combination group. Seven of 14 patients in the combination group had received previous bisphosphonate treatment. BAP was significantly more reduced in the monotherapy group at 6 months, with no other remarkable differences for TRACP5b, L-BMD, H-BMD, or FN-BMD during the observation period. ConclusionsThe above findings suggest that regardless of ELD addition, MIN potentially improves BMD during 18 months in osteoporosis patients with RA.

Bone Mineral Density as a Predictor of Atherogenic Indexes of Cardiovascular Disease, Especially in Nonobese Adults.

Purpose This study is aimed at determining whether bone mineral density (BMD) values are related to atherogenic indexes (AIs) and could predict the risk of cardiovascular disease (CVD) in southern Taiwanese adults. Methods Medical records of 3249 adults who underwent health examinations between June 2014 and February 2018 at a regional hospital in southern Taiwan were reviewed. Data collected included health history, anthropomorphic characteristics, exercise habits, diets (vegetarian or nonvegetarian), clinical laboratory results (lipid profile, systemic blood pressure (SBP), glucose level, creatinine (Cre) level, and hemoglobin (Hb) level), and bone mineral density (BMD), which were used to identify the associations of these parameters, especially BMD, with lipid profile and calculated AIs through simple and multiple linear regressions. Results The mean age of the patients was 58.0 years, and 71.4% were male. Body mass index (BMI), SBP, glucose level, Cre level, Hb level, and all BMD values were positively correlated with triglyceride (TG) level and AIs and were negatively correlated with high-density lipoprotein cholesterol (HDL-C) level. The significant positive correlations of BMD at all the measured sites with AIs remained after adjusting for age, sex, SBP, glucose level, Cre level, Hb level, smoking, exercise habits, and vegetarian state. The expanded adjusting model for TG/HDL-C remained significant at all the BMD measured sites in nonobese men, at bilateral femoral neck and total hips in nonobese women, and at the bilateral total hips in obese women. Conclusions AIs are predictive markers for CVD, and BMD values are predictors of AIs, especially the novel AI, i.e., TG/HDL-C ratio, in nonobese adult men and women after dividing the patients into subgroups to eliminate the effect of BMI as a confounding factor. Thus, BMD values could predict AIs of CVD, especially in nonobese adults.

Bilateral hip joint arthroplasty in dysplastic hip arthritis in patients with osteopenia and osteoporosis

In severe forms of dysplastic hip arthritis (DA) total hip arthroplasty is the most effective method of treatment. Objective: to investigate the results of bilateral hip arthroplasty in patients with dysplastic hip arthritis combined with osteopenia and osteoporosis. Methods: we examined 72 women with DA after bilateral total hip. The main group included 45 patients, who had DA combined with signs of osteopenia and osteoporosis. The control group consisted of 27 patients without signs of decreased mineral bone density. The mean age of patients in the main group was (51.5 ± 2.06) years, in the control group — (43.5 ± 2.25) years. Before surgery we assessed indexes: cortical, Singh, morpho-cortical, Noble, Spotorno. We analyzed the type of the femoral canal according to Spotorno and Dorr, type of dysplastic acetabulum. Results: 90 surgeries were made in the main group of patients, of which in 86 cases (95.6 %) cementless implants were used, in 3 cases (3.3 %) — hybrid fixation, in 1 case (1.1 %) — reverse hybrid fixation was used. The patients of the control group were undergone 54 operations of cementless hip replacement. The average evaluationof the results of treatment according to Harris hip score was 88.2 in the main group, in the control group — 89.1 points. Conclusions: during the planning of hip arthroplasty in patients with bilateral DA, it is necessary to take into account the x-ray anthropometric characteristics of the proximal femur, which allow to choose the design of the femoral component of the endoprosthesis and the type of its fixation, depending on the two-planeshape of the medullary canal. The use of threaded cementless cups allow to achieve a primary stable fixation of the acetabular component of the endoprosthesis in case of dysplastic deformation of the acetabulum even at decreased bone density.

Calcium and vitamin D supplementation with 3-year denosumab treatment is beneficial to enhance bone mineral density in postmenopausal patients with osteoporosis and rheumatoid arthritis.

BackgroundThis 3-year retrospective study compared the outcomes of bisphosphonate-pretreated denosumab therapy with or without vitamin D and calcium supplementation in postmenopausal osteoporosis (OP) patients with rheumatoid arthritis (RA).Materials and methodsFifty-eight patients under long-term denosumab treatment were divided into groups without (denosumab group; 31 cases) or with (combination group; 27 cases) vitamin D and calcium supplementation. The bone markers of BAP, TRACP-5b, and urinary NTX were measured at baseline and every year for 3 years. We also evaluated bone mineral density (BMD) of the lumbar 1–4 vertebrae (L-BMD) and bilateral total hips (H-BMD) at the same time points.ResultsThere were no significant differences in the percent changes of serum albumin-corrected calcium between the groups. The percent change in TRACP-5b was significantly higher in the combination group at 2 years. Serum 25-hydroxyvitamin D status was persistently high during therapy in both groups, with significant percent increases over baseline at 2 and 6 months in both groups and at 24 months in the combination group. The percent increase from baseline of serum zinc was significantly higher at 3 years in the combination group over the denosumab group. L-BMD and H-BMD were significantly increased at every time point for 3 years vs pretreatment levels in both groups and were significantly higher in the combination group at all time points.ConclusionCompared with denosumab monotherapy, the combination group displayed significantly increased serum zinc, L-BMD, and H-BMD at 3 years in OP patients with RA. Thus, calcium and vitamin D supplementation may be beneficial to enhance BMD gains, but not necessarily 25-hydroxyvitamin D status, in patients with OP and RA under denosumab.

Efficacy of 4-year denosumab treatment alone or in combination with teriparatide in Japanese postmenopausal osteoporotic women

Purpose: This extended randomized prospective study aimed to compare the 4-year clinical outcomes of denosumab treatment alone or in combination with teriparatide in treatment-naïve postmenopausal Japanese patients with osteoporosis.Methods: Between July 2013 and December 2016, 30 eligible women from our previous study were enrolled. After newly adding 17 randomly assigned patients, 47 patients were classified into the denosumab alone group (denosumab group, n = 22) or denosumab plus teriparatide group (combination group, n = 25). Serum bone-specific alkaline phosphatase (BAP), serum tartrate-resistant acid phosphatase (TRACP)-5b, urinary cross-linked N-terminal telopeptide of type I collagen (NTX), and bone mineral density (BMD) of the lumbar 1–4 vertebrae (L-BMD) and bilateral total hips (H-BMD) were determined at the first visit and at regular time points up to 48 months of treatment to determine percentage changes.Results: BAP was significantly decreased from baseline in both groups from 24 to 48 months, with significant differences at all time points between the groups. TRACP-5b and urinary NTX were comparably decreased at every time point in both groups versus pretreatment levels. L-BMD was significantly more increased by combination therapy over denosumab alone at 24 and 30 months (21.1% increase vs. 14.2% increase at 48 months). There were no significant differences in H-BMD between the groups, although levels tended to be higher in the combination group throughout the study period (9.7% increase vs. 6.8% increase at 48 months).Conclusion: Long-term denosumab and teriparatide combination therapy represents an effective treatment option for primary osteoporosis patients with low L-BMD.

Establishing thresholds for metal ion levels in patients with bilateral Articular Surface Replacement hip arthroplasty.

The primary aim of the current study was to determine whether metal ion levels could identify well- from poorly-functioning implants in patients after undergoing bilateral Articular Surface Replacement (ASR) Hip System. The secondary aim was to establish threshold values for Co and Cr that could be used to predict clinical problems in these patients. The study included 125 patients treated with bilateral ASR hip resurfacing (HRA) and 93 patients treated with bilateral ASR XL total hip arthroplasty (THA) at a mean follow-up of 7.1 years post-surgery. Patients were labelled as well- or poorly-functioning based on strict criteria. We calculated the Co and Cr safe upper ion limits (SUL) for ASR HRA and ASR XL THA separately and assessed these cutoffs ability to predict clinical problems. In patients with bilateral ASR HRA, the well-functioning group had lower ions than the poorly-functioning. In ASR THA patients, there was no difference in blood Co or Cr levels between well- and poorly-functioning implant groups (p = 0.118 and p = 0.379, respectively). Both Co and Cr could effectively discriminate between well-functioning and poorly-functioning ASR HRA implants (p < 0.001 and p < 0.001, respectively), but not for ASR THA implants (p = 0.118 and p = 0.564, respectively). SULs of 4.0 ppb for Co and 4.0 ppb for Cr could differentiate between well- and poorly-functioning implants with high specificity. Metal ion levels are a more reliable tool in MoM HRA than THA when discriminating well- from poorly-functioning implants in bilateral patients. For patients treated with bilateral ASR HRA, ion levels above 4.0 ppb are highly specific for the detection of clinical problems.

Pretreatment of daily teriparatide enhances the increase of bone mineral density in cortical bones by denosumab therapy.

BackgroundWhile it is well known that teriparatide (TPTD) increases bone mineral density (BMD) in osteoporotic patients, it is unknown whether TPTD pretreatment affects BMD after denosumab (DMAb) therapy.MethodsFifty-seven patients in TPTD-pretreated group and 35 patients in DMAb-alone group had been further analyzed, all of whom were treated by DMAb for 1.5 years. Vitamin D (400 IU) and Ca (600 mg) supplementation was used in all patients. The BMD of lumbar 1–4 vertebrae (L-BMD), bilateral total hips (H-BMD), and bilateral femoral neck (FN-BMD) was quantified at first visit, and at 4, 8, 12, and 18 months after daily TPTD treatment following four times DMAb treatment.ResultsThere were significant differences in L-BMD (p=0.004) and H-BMD (p=0.026) at baseline between TPTD-pretreated and DMAb-alone groups, although there was no significant difference in FN-BMD between the two groups. The increase of L-BMD by DMAb therapy was less in TPTD-pretreated group than in DMAb-alone group. There was no significant difference in H-BMD, although percent changes of H-BMD tended to be higher in the TPTD-pretreated group than those in the DMAb-alone group. Percent change in FN-BMD at 4 months (p=0.067) and 12 months (p=0.057) tended to be higher in TPTD-pretreated group than in DMAb-alone group. Percent change in FN-BMD at 18 months was significantly higher in TPTD-pretreated group (p=0.004) than in DMAb-alone group.ConclusionThese findings suggest that the pretreatment of TPTD might have enhanced the increase of BMD in cortical bones treated by DMAb. Thus, it is favorable that TPTD can be used for osteoporotic patients who have high fracture risks with cortical bones.

Significant improvement of bone mineral density by denosumab treatment in Japanese osteoporotic patients following breast cancer treatment.

BackgroundThe aim of this study was to evaluate the effects of denosumab in patients with osteoporosis (OP) and non-metastatic breast cancer following treatment of 1) surgery, 2) surgery and aromatase inhibitors, and 3) surgery, aromatase inhibitors, and anti-cancer agents, compared with those in primary OP patients.Patients and methodsIn this retrospective 24-month study, patients were divided into the primary OP group (34 cases) or OP receiving breast cancer treatment group (breast cancer group; 17 cases). We measured serum calcium, whole parathyroid hormone (PTH), 1,25OH2D3, bone alkaline phosphatase (BAP), tartrate-resistant acid phosphatase-5b (TRACP-5b), and bone mineral density (BMD) of the lumbar 1–4 vertebrae (L-BMD) and bilateral total hips (H-BMD) for 24 months.ResultsThe percent changes of serum calcium in the breast cancer group were significantly lower than those in the primary OP group at 1 week, 1 and 12 months. The percent changes of whole PTH in the primary OP group were significantly lower than those in the breast cancer group at 2 and 4 months. Significant differences were found between the groups at 18 months (−34.5% in the primary OP group and −52.6% in the breast cancer group, respectively) for the percent changes of BAP. Significant differences were found between the groups at 12, 18, and 24 months (−39.7% in the primary OP group and −64.0% in the breast cancer group at 24 months, respectively) for the percent changes of TRACP-5b. The percent changes of L-BMD and H-BMD were significantly increased at 12, 18, and 24 months in both the primary OP group (7.0% and 4.7% at 24 months, respectively) and breast cancer group (8.0% and 5.4% at 24 months, respectively), compared with pre-treatment levels. Significant differences were not found between the groups for the percent changes of L-BMD and H-BMD.ConclusionDenosumab significantly increased L-BMD and H-BMD to comparable degrees in both groups; therefore, it represents a good therapeutic option for OP receiving breast cancer treatment as well as primary OP. Also, vitamin D supplementation is required due to the potential hypocalcemia, and estrogen may be responsible for the decrease of serum calcium in the breast cancer patients.

Two-year clinical outcome of denosumab treatment alone and in combination with teriparatide in Japanese treatment-naive postmenopausal osteoporotic women

This randomized prospective study aimed to evaluate the clinical outcome of denosumab treatment alone and in combination with teriparatide in treatment-naive postmenopausal Japanese female patients with osteoporosis. Thirty patients were randomly assigned to two groups: (1) denosumab group (denosumab alone, n=13); and (2) combination group (denosumab+teriparatide, n=17). Serum bone-specific alkaline phosphatase (BAP), serum tartrate-resistant acid phosphatase (TRACP)-5b, urinary cross-linked N-terminal telopeptides of type I collagen (NTX), and bone mineral density (BMD) of L1–4 lumbar vertebrae (L-BMD) and bilateral total hips (H-BMD) were determined at the first visit and at various time points up to 24 months post-treatment to determine percentage changes. Serum TRACP-5b and urinary NTX were equally suppressed in both groups and maintained at low levels, with slight increases at 12, 18 and 24 months. BAP was significantly decreased in both groups from 4 to 24 months, with significant differences between the groups at 4, 8 and 15 months (P<0.05). L-BMD was significantly increased at most time points in both groups, with a significant difference between the combination group and denosumab group at 24 months (17.2% increase versus 9.6% increase; P<0.05). There was no significant difference in H-BMD between the two groups, although the levels tended to be higher in the combination group than in the denosumab group (9.5% increase versus 5.6% increase). These findings suggest that denosumab+teriparatide combination therapy may represent an important treatment for primary osteoporotic patients at high risk of vertebral fracture.

Bilateral Total Hip and Knee Arthroplasties: Average 10-Year Follow-Up

BackgroundThe present study investigates the clinical and radiographic outcomes in patients with all 4 major lower extremity joints replaced. MethodsA retrospective review of our institution's database identified 125 patients in whom both hips and both knees were replaced. The mean time between the first and last arthroplasty was 6.6 years. Preoperative diagnoses included osteoarthritis in 80% and rheumatoid arthritis in 20%. The average age at the time of the first arthroplasty was 63.7 years. The mean follow-up for all arthroplasties was 10.5 years (range 2-31 years). Patients were then matched according to age, gender, diagnosis, prosthesis, and follow-up, to patients with single or bilateral total hip or total knee arthroplasty. ResultsThere were 11 aseptic hip revisions (4.4%) and 3 aseptic knee revisions (1.2%). At final follow-up, 86% of hips and 83% of knees were rated with no or mild pain, 68% of patients rated walking as unlimited, and 98% of patients were able to satisfactorily negotiate stairs. Aseptic survivorship for all joint arthroplasties was 93.8% at 15 years. No statistical differences were noted in pain, function, stair, and walking scores between the matched groups. ConclusionThis report demonstrated excellent clinical, functional, and radiographic outcomes in patients with all 4 major lower extremity joints replaced. Walking aids were needed in 15% of patients, however. At final follow-up, this selected group of patients appears to fare just as well as patients with single or bilateral hip or knee arthroplasty with respect to pain and function.

Vitamin D and Calcium Are Required during Denosumab Treatment in Osteoporosis with Rheumatoid Arthritis

The aim of this 12-month retrospective study was to evaluate differences in the outcomes of denosumab alone or denosumab combined with vitamin D and calcium supplementation in patients having osteoporosis (OP) with rheumatoid arthritis (RA). Patients were divided into the denosumab monotherapy group (denosumab group, 22 cases) or denosumab plus vitamin D supplementation group (combination group, 21 cases). We measured serum bone alkaline phosphatase (BAP), N-terminal propeptide of type 1 collagen (P1NP), tartrate-resistant acid phosphatase (TRACP)-5b, and urinary N-terminal telopeptide of type-I collagen (NTX) at baseline, 1 week, and 1, 2, 4, 6, 8, and 12 months. We also assessed bone mineral density (BMD) of the lumbar 1-4 vertebrae (L-BMD) and bilateral total hips (H-BMD) at baseline and 4, 8, and 12 months. Matrix metalloprotanase-3 (MMP-3), Disease Activity Score-28 C-reactive protein (DAS28-CRP), Simplified Disease Activity Index (SDAI), and Health Assessment Questionnaire-Disability Index (HAQ-DI) were assessed before treatment and at 12 months to evaluate RA conditions. The study results showed that BAP, TRACP-5b, and NTX were significantly decreased, but tended to return to pre-treatment levels around 6 and 12 months in both groups. While L-BMD and H-BMD substantially increased in both groups, H-BMD had become significantly higher in the combination group at 12 months (p < 0.01) as compared with the denosumab group. There were no significant differences between the groups regarding MMP-3, DAS28-CRP, SDAI, or HAQ-DI. Compared with denosumab monotherapy, combination therapy of denosumab with vitamin D and calcium significantly increased H-BMD in patients having OP with RA.

Spontaneous Bilateral Femoral Neck Fracture Rare Presentation of a Metabolic Bone Disease

A 50 year old woman was observed at the emergency department after falling from her own height after sudden failure of the lower limbs, which led to bilateral femoral neck fracture. She has had multiple repeated urinary tract infections, nephrolithiasis with several admissions in urology department and extracorporeal lithotripsy episodes with shock waves. She also had history of surgical removal of kidney stones. The Laboratory tests revealed high calcemia (13.2 mg/dl) and alkaline phosphatase (445); normal phosphate and magnesium, normal Calcitonin; high parathyroid hormone(> 2500 pg / ml). Hyperparathyroidism caused by a parathyroid adenoma was diagnosed after ultrasound, biopsy and scintigraphy were performed. Radiographs revealed classic and severe bone findings in PHPT, features which were common in the past but are thought to be rare at this modern age. Parathyroidectomy was performed at the same time as a bilateral cemented total hip arthroplasty. She developed the hungry-?bone syndrome 5 days postoperatively, which resolved with administration of bisphosphonates, calcium and D vitamin.

Post-operative Rehabilitation of a Bilateral Uncemented Total Hip Replacement Rheumatoid Arthritis Patient. A Case Study

Background and Purpose: Total hip replacement (THR) is one of the most frequently performed orthopedic surgery in India and worldwide. Thousands of people undergo THR every year in hopes of improving their functional abilities and reducing their disability levels. The purpose of this case report is to document acute care outcome measures in Rheumatoid arthritis patient who had undergone bilateral THR and to assess the possible implications that a short staging period might have on the patient’s ability to recover. Case Presentation: A 44 years old rheumatoid arthritis patient with severe restriction in mobility had undergone bilateral Uncemented total hip replacement following which patient was rehabilitated for strength, gait and functional abilities. Outcomes: Modified Harris Hip Score was taken preoperatively, Post-operative day 6, 3 weeks, 6 weeks for both the hips. Discussion: Many studies support an early and intensive Physiotherapy following THR but there are limited literature on rehabilitation in case of rheumatic arthritis patient who had undergone bilateral THR. This study includes an early acute care Physiotherapy from day 1 up to 6 weeks which helped the patient in resuming his daily activities early.

Bisphosphonate Pre-Treatment Diminishes the Therapeutic Benefits of Teriparatide in Japanese Osteoporotic Patients.

Osteoporosis (OP) is the most common multifactorial metabolic bone disorder worldwide. It remains unclear whether bisphosphonate (BP) pre-treatment affects the anabolic bone metabolism in OP patients treated with teriparatide (TPTD), a recombinant form of parathyroid hormone 1-34. This study is the first to evaluate the clinical outcomes of daily TPTD administration in Japanese OP patients and aimed to clarify how BP pre-treatment influences the efficacy of TPTD. We enrolled 112 patients diagnosed as primary OP who received TPTD. Subjects were classified as OP treatment-naïve patients (TPTD alone group) or patients previously treated with BP (BP pre-treated group). We measured serum bone-specific alkaline phosphatase (BAP) as a bone formation marker, urinary cross-linked N-terminal telopeptide of type I collagen (NTX) as a bone resorption marker, and bone mineral density (BMD) of lumbar vertebrae (L-BMD) and bilateral total hips (H-BMD). In both groups, BAP and NTX increased until 6 months and then decreased thereafter. The percent changes of both markers in BP pre-treated group were more increased than those in TPTD alone group. L-BMD increased significantly in both groups. The percent increase of L-BMD in the TPTD alone group was significantly higher than that in the BP pre-treated group. H-BMD rose significantly in the TPTD alone group, but not in BP pre-treated group. BP pre-treatment appears to diminish the degree of the TPTD-mediated increase in BMD. Thus, it is preferable to administer TPTD ahead of BP treatment in patients with severe OP.