Intertrochanteric Region Research Articles

Association of estrogen receptor alpha and vitamin D receptor gene polymorphisms with bone mineral density in Chinese males.

Osteoporosis is a common health problem not only in females but also in males, however, studies of osteoporosis in males are relatively rare compared to those in females. This is especially true in genetics studies. We evaluated the effects of PvuII and XbaI polymorphisms in the estrogen receptor alpha (ER-alpha) gene and ApaI polymorphism in the vitamin D receptor (VDR) gene on BMD variation in a random sample of 352 unrelated males from 401 Chinese nuclear families. BMD was measured at the lumbar spine (L1-L4) and hip (femoral neck, trochanter, intertrochanteric region). Raw BMD values were adjusted by age, age(2), height, and weight as covariates. We found no significant results for the 3 individual markers on BMD variation, however, ER-alpha haplotype analyses yielded some interesting results. Carriers of haplotype pX had a 4.98% lower BMD at the trochanter (P = 0.02) and 3.55% lower BMD at the lumbar spine (P = 0.09) than non-carriers. PX subjects had a 3.42% higher BMD at the trochanter and 3.26% higher BMD at the lumbar spine than others (P = 0.07 and P = 0.10, respectively). Such results were highly comparable with the significant or nearly significant interactions between ER-PvuII and ER-XbaI on BMD values at the trochanter (P = 0.03) and spine (P = 0.11). No significant results were observed for the interactions between ER-PvuII and VDR-ApaI, between ER-XbaI and VDR-ApaI, and between any of ER-alpha haplotypes and VDR-ApaI locus. Our results suggest that the ER-alpha haplotypes, not individual markers, may be associated with BMD variation at some skeletal sites in our Chinese male samples.

MR imaging of bone marrow edema and joint effusion in patients with osteonecrosis of the femoral head: relationship to pain.

Our aim was to determine the occurrence of bone marrow edema and joint effusion and their relationship to pain in patients with osteonecrosis of the femoral head on the basis of MR imaging. There were 71 patients with osteonecrosis of the femoral head based on characteristic radiographic and MR imaging findings. All patients had surgical confirmation of the disease. Both hips were affected with osteonecrosis in 39 patients, whereas only one hip was involved in 31 patients. The last patient underwent an arthroplasty of one hip during the study and had only one hip imaged. We evaluated a total of 110 hips in this study, of which 98 were painful. We staged osteonecrosis of the femoral head, using the classification of Steinberg et al. The 31 unaffected hips served as controls. Bone marrow edema and joint fluid were evaluated on MR images. Bone marrow edema was defined as an ill-defined area of low signal intensity on T1-weighted images with corresponding high signal intensity on T2-weighted or inversion recovery images localizing to the femoral head, neck, and intertrochanteric region. The amount of joint fluid was graded from 0 to 3. The peak of bone marrow edema occurred in stage III disease (72%); its odds ratio was seven times greater than that for stage I osteonecrotic hips. Effusions of a grade greater than or equal to 2 were seen most often in stage III disease (92%), compared with 10% in the control hips. With an effusion, bone marrow edema was 12.6 times greater when the hip was painful than when it was not. Both bone marrow edema and joint effusions existed with a peak occurrence in stage III disease. Bone marrow edema seems to have a stronger association with pain than does joint effusion in osteonecrosis of the femoral head.

Innovations in the management of hip fractures.

Hip fractures include fractures of the head, neck, intertrochanteric, and subtrochanteric regions. Head fractures commonly accompany dislocations. Neck fractures and intertrochanteric fractures occur with greatest frequency in elderly patients with a low bone mineral density and are produced by low-energy mechanisms. Subtrochanteric fractures occur in a predominantly strong cortical osseous region that is exposed to large compressive stresses. Implants used to address these fractures must accommodate significant loads while the fractures consolidate. Complications secondary to hip fractures produce significant morbidity and include infection, nonunion, malunion, decubitus ulcers, fat emboli, deep venous thrombosis, pulmonary embolus, pneumonia, myocardial infarction, stroke, and death.

Tests of linkage and association of the COL1A2 gene with bone phenotypes’ variation in Chinese nuclear families

In the present study, we simultaneously test linkage and/or association of the collagen type I α 2 (COL1A2) gene with bone mineral density (BMD) and bone area. A total of 1280 subjects from 407 Chinese nuclear families (including both parents and their daughters) were genotyped for an intragenic marker MspI in the COL1A2 gene. BMD and bone area at the lumbar spine and hip were measured by dual-energy X-ray absorptiometry. Applying the QTDT (quantitative transmission disequilibrium test) program, we performed tests for population stratification, within-family association (via transmission disequilibrium test), total association, linkage, and linkage while modeling association. Significant or marginal within-family associations were found with BMD at the lumbar spine (P = 0.013), trochanter (P = 0.004), and total hip (P = 0.053) and with bone area at the intertrochanteric region (P = 0.024) and total hip (P = 0.048). The positive associations were confirmed in permutations except for bone area at total hip (P > 0.10). A small proportion (<1%) of the population variance of bone phenotypes can be explained by the MspI polymorphism; however, it may be underestimated given the significant population stratification detected in our sample. Due to the limited number of sib pairs in this sample, we did not find evidence of linkage. In summary, the MspI polymorphism is likely to be in linkage disequilibrium with a nearby functional mutation affecting BMD and bone area.

Estrogen receptor alpha gene polymorphisms and peak bone density in Chinese nuclear families.

PBD is an important determinant of osteoporotic fractures. Few studies were performed to search for genes underlying PBD variation in Chinese populations. We tested linkage and/or association of the estrogen receptor alpha gene polymorphism with PBD in 401 Chinese nuclear families. This study suggests the ER-alpha gene may have some minor effects on PBM variation in the Chinese population. Low peak bone density (PBD) in adulthood is an important determinant of osteoporotic fractures in the elderly. PBD variation is mainly regulated by genetic factors. Extensive molecular genetics studies have been performed to search for genes underlying PBD variation, largely in whites. Few studies were performed in Chinese populations. In this study, we simultaneously test linkage and/or association of the estrogen receptor alpha (ER-alpha) gene polymorphism with PBD in 401 Chinese nuclear families (both parents plus their female children) of 1260 subjects, with the 458 children generally between 20 and 40 years of age. All the subjects were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) at polymorphic PvuII and XbaI sites inside the ER-alpha gene. Bone mineral density was measured at the lumbar spine (L1-L4) and hip (femoral neck, trochanter, and intertrochanteric region). Raw bone mineral density values were adjusted by age, height, and weight as covariates. We detected marginally significant results for within-family association (transmission disequilibrium; p = 0.054) between the spine bone mineral density variation and the ER-alpha XbaI genotypes. For the hip bone mineral density variation, significant (p < 0.05) linkage results were generally found for the two intragenic markers. Analyses of the haplotypes defined by the two markers confer further evidence for linkage of the ER-alpha with the hip PBD variation. In conclusion, this study suggests that the ER-alpha gene may have minor effects on PBD variation in our Chinese population.

HIP PAIN IN A MIDDLE AGED MALE

HISTORY A 50 year old white male presented to the office with a 3 month history of progressive right hip pain. He first noticed the pain when he was playing volleyball in a pool. The pain was located in the right lateral hip with radiation to the lateral thigh, anterior hip, and groin. These symptoms initially improved slightly, but worsened slightly with white water rafting and substantially after playing basketball. He denied any falls or direct trauma to the hip. He denied low back pain, paresthesias, weakness, and loss of bowel or bladder function. The pain was increased with cough and sneeze. He had no fevers, chills, night sweats, or weight loss. He had mild night pain associated with movement, but the pain did not awake him. No other joint problems. He had previously been diagnosed with referred pain secondary to lumbar radiculopathy. He had no relief with PT and Prednisone. An MRI of the lumbar spine was normal. He had no personal or family history of gout, lupus, or symptoms suggestive of inflammatory arthropathies. PHYSICAL EXAMINATION He ambulated with a marked limp. Flexion was to within four inches of the floor with restricted extension. Neurological exam, including straight leg raise, motor, sensation, and reflexes, was normal. Hip exam revealed marked pain with log rolling. Quadrant test was significantly positive. His ROM showed reduced flexion, internal and external rotation associated with marked pain. DIFFERENTIAL DIAGNOSIS Hip osteoarthritis Avascular necrosis Septic arthritis of the hip Trochanteric bursitis Occult hip fracture Malignancy TESTS AND RESULTS X-ray of the hip showed no acute bony abnormality or joint space narrowing. MRI showed a uniformly abnormal appearance of the bone marrow in the right femoral head, femoral neck, and inter-trochanteric region. This was a homogenous abnormality with diminished signal on T1 weighted images and increased signal on T2 images. There were no focal areas of marrow abnormality. Trace effusion. No fracture. Hip joint spaces were relatively well maintained. The left femoral head was normal in appearance. Adjacent soft tissues were normal. FINAL/WORKING DIAGNOSIS Idiopathic Transient Osteoporosis of the Hip TREATMENT AND OUTCOME Treatment is supportive with pain control and avoidance of provoking factors. The patient's symptoms are improving with indomethacin. Expect spontaneous resolution over a period of months.

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Unreamed Nailing of Diaphyseal and Metaphyseal Fractures of the Femur

Background: Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. Patients and Methods: A prospective series of 63 patients were treated with three different unreamed nailing and interlocking techniques selected according to the predominant fracture location. Median age of the 30 women and 33 men was 39 (17–97) years. High-energy injuries had occurred in 37 patients. Antegrade nailing and interlocking with standard technique was used in 29 diaphyseal fractures, antegrade nailing and placement of the proximal locking device to the femoral head was performed in eleven proximal fractures with involvement of the intertrochanteric region, and retrograde nailing and standard interlocking was done in 23 mainly distal fractures. Results: We encountered two types of major mechanical complications: angular malalignment and protrusion of the nail into the knee joint following compression in the fracture. Angular malalignment was found in four fractures. One midshaft fracture was fixed in a valgus reduction. Varus malalignment and loss of fixation occurred in two high subtrochanteric fractures after proximal locking with a spiral blade. In another midshaft fracture redisplacement in varus occurred. Compression in the fracture with protrusion of the nail by 2–10 mm into the knee joint following retrograde nailing was observed in six osteoporotic patients. Only two of these patients had significant knee problems. The median time to union – 4 months – did not differ significantly between the fixation groups. Conclusions: Thus, there are still problems after nailing very proximal and distal fractures. Most postoperative complications were seen after retrograde nailing of distal fractures, but the consequences of fixation failure in very proximal fractures were worse. Nevertheless, a protocol that takes advantage of the different options for nail introduction and locking depending on the fracture location seems promising.

Soft tissue uptake of Tc99m-MDP in acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is associated rarely with hypercalcemia. This may be due to elevated levels of parathyroid hormone-related peptide (PTHrP). We report a case of an 18-year-old female patient who was presented with a pathological fracture of left intertrochanteric region. Bone scintigraphy was consistent with features of hypercalcemia associated with metastatic calcification. A bone marrow biopsy led to the diagnosis of ALL. The mechanism of hypercalcemia in ALL, metastatic calcification and soft tissue uptake of bone seeking agents in this case are discussed in detail.

Operative treatment of intertrochanteric hip fractures: an overview of modern advances and techniques

Hip fractures have been one of the most studied injury pattern in adults. The number of hip fractures is increasing exponentially; furthermore, the cost of treatment places great economic strain on society. There have been recent developments in hip-fracture treatment, particularly involving the intertrochanteric region, with emphasis on deformity prevention to try to optimize patient functional outcomes. In this article, we outline some of these developments with an emphasis on changes in implant design.

The possible role of locally produced cytokines in the pathogenesis of peritrochanteric fractures in the elderly.

Sixteen patients with intertrochanteric femoral fractures were studied for possible involvement of the cytokines interleukin-6 (IL-6), interleukin-1 beta (IL-1beta), tumor necrosis factor-alpha, and the disease activity factors C-reactive protein and alpha1-antitrypsin as local bone-resorbing agents. Cytokine and disease activity factor levels were measured in gluteus medius muscle and serum samples and were compared to sera obtained from age- and sex-matched healthy controls. Interleukin-6 and IL-1beta levels were significantly higher (P=.0024 and P=.036, respectively) in the muscle samples from the fractured side than in the samples from the contralateral unaffected side. Levels of IL-6 and IL-1beta also were significantly higher in patients' sera than in the sera of healthy controls. These results support a new hypothesis that may contribute to the pathogenesis of fractures in the elderly: unilaterally locally over-produced IL-6 and IL-1beta may lead to local bone resorption in the intertrochanteric region, which subsequently weakens the femoral bone and increases the risk of unilateral peritrochanteric fractures.

Genetic loci influencing natural variations in femoral bone morphometry in mice

This study identifies genetic loci affecting femoral bone length and width measures in mature mice. Sixteen month old female F2 progeny of a C57BL/6J and DBA/2J intercross were examined for femur length and width of the femoral head, intertrochanteric region and three locations of the diaphysis using digitized images of femur radiographs obtained in the anterior–posterior and lateral projections. A genome wide linkage map was constructed using microsatellite markers at an average density of 20 cM, and quantitative trait locus analysis used to identify regions of the genome showing linkage with the traits measured. Femur length showed significant linkage with loci on proximal chromosome 3 (lod 6.1), and suggestive linkage with a locus on chromosome 14. A major locus on mid-chromosome 7 controlled width of the diaphysis (lod 6.8). Other loci were identified on chromosomes 2 and 4. Width at the intertrochanteric region had suggestive linkage with loci on chromosomes 6 and 19. No loci were found with linkage for width of the femoral head. Candidate genes related to bone development or metabolism are present at most of these loci. These findings show that genetic regulation of femoral bone morphology is complex, and are consistent with the distinct biologic processes that control longitudinal and lateral growth of the femur.

Coronary Artery Calcification is Inversely Related to Bone Mineral Density in Young Women:

0003 Coronary artery calcification (CAC), a marker of subclinical atherosclerosis, is related to low bone mineral density (BMD) in postmenopausal women, potentially due to age or declining estrogen levels. Little is known about this association in premenopausal women. During the Year 10 CARDIA Study, BMD was measured by dual energy X-ray absorptiometry at the hip (pelvis, femoral neck, intertrochanteric (IT) region, Ward’s triangle) and the lumbar spine in a subgroup; CAC was measured in a different subgroup by electron beam tomography within the same year. A calcium score was calculated as the product of an area of potential calcification covered by 6 adjacent pixels and the peak CT number within that region; a calcium score &gt;0 indicates the presence of any CAC. Data for both measures were available for 75 women, ages 29-41 years (mean age 35 years). CAC was present in 14.7% of these young women. Mean weight was 75.2±19.1 kg, range 48.6 to 124.4 kg. Mean areal BMD was consistent with the age and reproductive status of these women: 1.18, 0.89, 1.15, and 0.83 g/cm 2 for the pelvis, femoral neck, IT region and Ward’s triangle, respectively; and 1.09 g/cm 2 for the lumbar spine. Cross-sectional logistic regression was performed to determine the crude association between BMD and CAC. BMD was not related to CAC at any site. Weight, however, was strongly associated with CAC, with a prevalence odds ratio (pOR) of 2.53 (95% CI 1.43, 4.49) for a 1-sd increment in weight. When weight was considered as a confounder to the association between BMD and CAC, BMD in the IT region was inversely related to CAC, with a 1-sd (0.17 g/cm 2 ) decrement in the IT region BMD associated with a 233% increase in the odds of CAC (pOR=3.33, 95% CI 1.08, 10.4). This association was not materially affected by adjustment for age, ethnicity, or height. Nearly identical results were seen for CARDIA men, with an inverse association between IT region BMD and CAC after adjustment for weight. These data suggest that in a population-based group of young women with low prevalence of either osteopenia or osteoporosis, lower BMD may be a marker of subclinical atherosclerosis, comparable to findings in postmenopausal women.

Predictive value of bone mineral density and morphology determined by peripheral quantitative computed tomography for cancellous bone strength of the proximal femur

Peripheral quantitative computed tomography (pQCT) is an established diagnostic method for assessment of bone mineral density in the diagnosis of osteoporosis. However, the capacity of structural parameters of cancellous bone measured by high-resolution computed tomography remains to be explored. In 33 patients, bone mineral density (BMD) of the proximal femur was measured in vitro by pQCT using cylindrical biopsies from the intertrochanteric region harvested before the implantation of an artificial hip joint. By digital image analysis of CT scans, parameters derived from histomorphometry describing the microarchitecture of cancellous bone were measured. The biopsies were also loaded to failure by an uniaxial compression test to determine the biomechanical parameters, Young’s modulus, strength, and maximum energy absorption (E max). Strong correlations were found for BMD vs. mechanical parameters ( r = 0.73 for Young’s modulus, r = 0.82 for strength, and r = 0.79 for E max; p < 0.001, n = 29). The morphological parameters, bone volume per trabecular volume (BV/TV), apparent trabecular thickness (app.Tb.Th), apparent trabecular separation (app.Tb.Sp), and trabecular number (Tb.N), correlated significantly with all mechanical parameters. The combination of morphological parameters with BMD in a multivariate regression model led to an overall, but only moderate, increase in R 2 in all cases. Our data confirm the high predictive value of BMD for the mechanical competence of cancellous bone of the intertrochanteric region. However, quantification of cancellous bone structure by image analysis of CT scans may provide additional qualitative information for the analysis of bone strength.

The role of subchondral insufficiency fracture in rapid destruction of the hip joint: a preliminary report.

The pathophysiology of rapidly destructive arthrosis of the hip joint (RDA) is unknown. The purpose of this study was to document cases of subchondral insufficiency fracture of the femoral head, which has similar clinicoradiologic features to those of early-stage RDA. This study was based on a retrospective review of 11 cases of subchondral insufficiency fracture of the femoral head that were confirmed histopathologically and for which radiographs both at the onset of hip pain and at the time of surgery were available. All patients were > 60 years of age (range 61-78 years, mean age 69), and 9 were women. On plain radiographs, the normal joint space had undergone rapid narrowing and/or disappeared within 9 months (mean 5.8 months). Magnetic resonance imaging, available in 2 cases, showed a pattern of bone marrow edema from the upper portion of the femoral head to the intertrochanteric region, with an associated focal low-intensity band on T1 paralleling the articular surface. In all cases, evidence of subchondral insufficiency fracture was confirmed histopathologically. In addition, in the marrow space, there were several round-to-oval granulomatous foci, which consisted of amorphous debris, fragmented bone, and articular cartilage surrounded by reactive histiocytes and giant cells. All 11 patients were osteopenic, as shown both radiologically and histopathologically. Subchondral insufficiency fracture resulting from osteopenia may lead to a rapid breakdown of the hip joint.

Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging.

To demonstrate the MR depiction of the intertrochanteric or femoral neck extension of fractures of the greater trochanter, when standard radiographs show only a fracture of the greater trochanter. A retrospective review was performed of the MR and radiographic findings in 13 consecutive patients (10 men, 3 women; ages 24-86 years) with radiographic evidence of fracture of the greater trochanter who were examined with MR imaging. The MR study displayed the fracture of the greater trochanter in all cases. In all but three patients, MR examinations displayed an extension of the fracture into the intertrochanteric region, and in one, also an extension into the femoral neck, although the cortex at this level was not interrupted. When there is radiographic evidence of an isolated fracture of the greater trochanter, MR often shows an intertrochanteric or femoral neck extension of the fracture in both young and older adults. This finding may be a factor in determining the need for surgical intervention.

Polymorphisms in the vitamin D receptor gene and bone mass, bone turnover and osteoporotic fractures.

Vitamin D is essential for normal bone metabolism. Polymorphisms in exon 2, intron 8 and exon 9 of the vitamin D receptor (VDR) gene have previously been found to be associated with bone mass and bone turnover. We examined the effect of these polymorphisms, separately and in combination, on bone mineral density (BMD), bone turnover, and the prevalence of osteoporotic fractures in 192 osteoporotic patients and 207 normal controls. The four polymorphisms were determined by RFLP using Fok I (T2-C), Bsm I (intron 8), Apa I (intron 8) and Taq I (T1055-C) after PCR. We did not find any association between the Fok I polymorphism and bone mass, bone turnover or prevalence of osteoporotic fractures. We found that BB + Bb-genotypes were more frequent in patients with osteoporotic fractures (chi2 = 3.50, P = 0. 06). Furthermore, BMD of the intertrochanteric region (P < 0.0001, ANOVA) as well as the total hip (P < 0.01, ANOVA) were higher in individuals with the bb-genotype. The Apa I and the Taq I polymorphisms were not distributed differently among osteoporotic patients and normal controls. Apa I was not associated with differences in BMD. BMD of the intertrochanteric region was higher in individuals with the TT-genotype compared with individuals with the Tt- or tt-genotypes (P < 0.01, ANOVA), while no differences could be demonstrated in BMD of the lumbar spine, femoral neck, trochanter or Wards triangle. Combining the genotypes generally reflected the differences caused by the Bsm I polymorphism. We have found that the B-allele of the Bsm I polymorphism in the 3' untranslated region of the VDR was associated with low BMD at the hip, and tended to be associated with osteoporotic fractures. The translation initiation polymorphism in the VDR does not affect BMD and is not associated with osteoporotic fractures in men or women.

Prevalence Of Osteoporosis In Women: Variation With Skeletal Site Of Measurement Of Bone Mineral Density

ObjectiveTo determine retrospectively the prevalence of osteoporosis in a referral population of female patients and to compare the sensitivity for diagnosing osteoporosis by dual-energy x-ray absorptiometry (DXA) measurements of bone mineral density (BMD) at multiple skeletal sites. MethodsWe studied the data from 625 consecutive women (mean age, 57.3 ± 13.9 years), who had been referred to our center for lumbar spine (anteroposterior [AP] and lateral region) and hip (femoral neck [FN], Ward’s triangle [WT], trochanter, intertrochanteric region, and total hip) BMD measurements with use of DXA (Hologic QDR-2000) between June 1994 and July 1998. ResultsOsteoporosis (based on the World Health Organization definition—T-score of -2.5 or lower for BMD) was diagnosed by DXA at the following sites: AP spine in 21.7%, lateral spine in 43.2%, FN in 33.6%, WT in 49.1%, trochanter in 26.1%, intertrochanteric region in 25.9%, and total hip in 28.4% of study patients. Significant site differences were found in the prevalence of osteoporosis between the lateral and AP spine (P<0.001), as well as between WT and the FN, trochanter, intertrochanteric region, and total hip (P<0.001). In a subgroup of 71 women, forearm (ultradistal radius and radius 1/3 region) BMD results indicated low sensitivity for diagnosing osteoporosis, similar to that seen at the AP spine, trochanter, and intertrochanteric region. Not surprisingly, the prevalence of osteoporosis increased with advancing age (15.5% in patients younger than 50 years, in comparison with 59.6% in those older than 69 years of age). The frequency of misclassification of patients (osteoporosis at one site and normal BMD at another) with use of the seven measurement sites was 16.6% (104 of the 625 patients). ConclusionFor diagnosis of osteoporosis, DXA BMD measurements are significantly more sensitive at the lateral spine than at the AP spine, as well as at WT than at the FN, trochanter, intertrochanteric region, and total hip sites. (Endocr Pract. 2000;6:127-131)

Hip and femur trauma.

Fractures that involve the acetabulum and proximal femur are common. These injuries frequently occur due to high-energy trauma and may result in significant morbidity and long-standing disability, or high mortality when associated with other injuries, particularly to vascular structures. In this article, classifications pertinent to fractures of the acetabulum, hip dislocations, and fractures of the femoral neck, intertrochanteric region, and subtrochanteric region of the femur are discussed in detail with emphasis on their radiographic features.