Prevalence and Characteristics of Atypical Periprosthetic Femoral Fractures. For a type I error rate of 0.05 and a power of 0.8, with an expected prevalence of BP use of 10%, a difference in cortical thickness of 1.2 mm, and SD for cortical thickness of 2.6 mm, 49 cases would have been required. Incomplete atypical femoral fractures after bisphosphonate use in postmenopausal women. Use the link below to share a full-text version of this article with your friends and colleagues. The authors thank Mr Koji Fukuda, Mr Hideki Ito, Mr Takeshi Kato, Ms Kana Nakanishi, Mr Kenji Kuroda, Mr Haruyoshi Mizuno, Mr Yohei Takigawa, Mr Yoshifumi Takahashi, and Mr Hiroaki Takeuchi for their cooperation with this study. There were no significant differences in cortical thickness between long‐term BP users and … Volume 3: Biomedical and Biotechnology Engineering. Use the link below to share a full-text version of this article with your friends and colleagues. Long‐term BP use is not an essential associated factor for AFF but is a multiple associated factor for AFF. Approving final version of manuscript: RN, TK, AN, MH, AM, TK, and AS. We computed the sample size required for a parametric test and added 15% because it is assumed that nonparametric tests may be required (57 cases).12 Therefore, we estimated that 60 cases and 180 controls would be required. They are calculated by the functions morphomap2Dmap and morphomap3Dmap from the Euclidean distances between each pair of semilandmarks (cortical and the equivalent endosteal one), which is the cortical thickness at each angle. Please check your email for instructions on resetting your password. asbmr@asbmr.org, 2025 M Street, NW uNTX was measured by ELISA (Alere Medical Co., Ltd., Tokyo, Japan). Bisphosphonates (BPs) are the most commonly prescribed medications for the treatment of osteoporosis. Cortical bone has been reported to be an important determinant of bone strength; so far, no genome-wide association studies (GWAS) have been … S1, S2, and S3), and no differences were found in the cortical thickness, cortical thickness ratio, and femoral diameter at any level of the femur between the groups. Further examination is necessary to verify the results obtained at these measurement locations. Relationships between biochemical markers of bone turnover and cortical thickness were evaluated by a Spearman rank correlation analysis. The first limitation is related to study design. Even after careful comparisons, we did not observe an increase in the femoral cortical thickness in long‐term BP users compared with controls. This study was a matched case‐control study, and such studies have several major disadvantages, including selection and information bias, which could not be eliminated by increasing the number in the control arm. The protocol was in compliance with the ethical principles stated in the Declaration of Helsinki and was approved by the Ethics Committee of Tomidahama Hospital. Published. The cortical thickness ratio was defined as the ratio of cortical thickness to the corresponding FS diameter. Moreover, cortical thickness remained stable after an additional year of continued BP use. RN takes responsibility for the integrity of the data analysis. In this case‐control study, 142 patients who were long‐term BP users (cases) and 426 osteoporotic patients without BP treatment (controls) were enrolled between December 2011 and March 2014. Two of these features, localized periosteal thickening of the lateral cortex (major feature) and generalized increase in cortical thickness of the femoral diaphysis (minor feature), are suspected to exist before AFF. Phoenix, Arizona, USA. In this study, we investigated radiographs from patients who had been treated with BPs for more than 5 years and osteoporotic patients who had not taken BPs and tried to determine whether long‐term BP use leads to a change in cortical thickness in the ST/FS area of the femur. differences exist in bone mineral content and cortical thickness between the skeletons of the Aleut and Eskimo groups . The location of maximal cortical thickness was variable, but was more anterior and less inferior in patients. MMs of cortical thickness facilitate visualization of the distribution of cortical bone in long bone diaphyses. Authors' roles: Study design: RN, TK, and AS. On the basis of our results in the present study, patients with AFFs might have had abnormal cortical thickness before BP use. Cortical thickness was measured from radiographs at three regions: 5 cm below the lesser trochanter,14 12.5 cm below the lesser trochanter (midshaft area for almost all patients in this study), and at the position of maximal femoral cortical thickness (Fig. 1, line AD). We compared cortical thicknesses between patients taking BP and controls and evaluated longitudinal changes in cortical thickness. Preoperative imaging of the proximal femur using high-resolution computed tomography techniques [ 29 , 30 ] could demonstrate the real status of the cortical bone in postmenopausal women and achieve higher predictive accuracy of stem subsidence. Suite 800 Fifth, our results showed the absence of generalized femoral cortical thickening in long‐term BP users, but there is a possibility that idiosyncratic response may occur in certain individuals. Distribution of bone density and cortical thickness in the proximal femur and their association with hip fracture in postmenopausal women: a quantitative computed tomography study Osteoporos Int . Although the incidence rates of AFFs in the Japanese and white populations are similar,22 these findings might not be generalizable to other ethnic groups or representative of the population as a whole. In one of several previous studies of cortical thickening in long‐term BP users, Beck and colleagues found that the mean cortical thickness ratio at the FS had increased by 1.82% after 24 months of alendronate use, whereas it had decreased by approximately 0.31% with placebo.18 In contrast, Unnanuntana and colleagues performed bone density scanning and reported that long‐term alendronate use did not alter cortical thickness on the basis of comparison with thicknesses in untreated controls.11 Koeppen and colleagues measured the femoral cortical thickness in 58 patients with AFF and 218 controls19 and reported no difference in the cortical thickness ratio between patients with AFF and controls. Changes in the longitudinal cortical thickness were also evaluated in 98 of 142 patients who continued using BPs for another year and for whom subsequent radiographs could be obtained. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. The mean absolute difference and SD between measurements of intraobserver and interobserver variability were 0.2 ± 0.3 mm and 0.3 ± 0.3 mm, respectively. Chen and colleagues measured the proximal femoral cortical thickness in 45 patients receiving long‐term BP treatment and 12 controls and found no difference in thickness between long‐term BP users and controls.14. The greater surface area also makes it suitable for metabolic activities such as the exchange of calcium ions. There were no significant differences in cortical thickness between long‐term BP users and controls. Further examination is necessary to verify the results obtained at these measurement locations. Accordingly, we assumed that there were no differences in the abilities of the different physicians to interpret radiographs with good reproducibility. Measurement of bone mineral content (BMC) was made across the midshaft of the femur using a Norland-Camer~25Bone Mineral Analyzer. If you do not receive an email within 10 minutes, your email address may not be registered, A general increase in cortical thickness in the proximal femur was first observed by Lenart and colleagues5 in femurs with AFFs. Proceedings of the ASME 2016 International Mechanical Engineering Congress and Exposition. Physicians received training to standardize their approach to measuring cortical thickness using radiographs from 100 patients. The subtrochanteric region was found to have the thickest cortical bone and … However, whether thickening precedes BP use or results from BP use, as well as the role BPs may play in cortical thickening remain unclear. BMI = body mass index; NTX = N‐telopeptide; PINP = procollagen type I N‐terminal propeptide. 1). BMI = body mass index; NTX = N‐telopeptide; PINP = procollagen type I N‐terminal propeptide. Differences in categorical variables were assessed with the chi‐square test and Fisher's exact test. Written informed consent was obtained from all patients. We followed the recommendations of Loewen15 for determining this sample size. In this study, we investigated radiographs from patients who had been treated with BPs for more than 5 years and osteoporotic patients who had not taken BPs and tried to determine whether long‐term BP use leads to a change in cortical thickness in the ST/FS area of the femur. Femoral cortical thickening has been mentioned in reports of atypical subtrochanteric/femoral shaft (ST/FS) fractures, which are associated with long‐term … Two of these features, localized periosteal thickening of the lateral cortex (major feature) and generalized increase in cortical thickness of the femoral diaphysis (minor feature), are suspected to exist before AFF. Fax: +1 (202) 367-2161 A longitudinal study is an important approach to investigate the effects of long‐term BP treatment, but a longitudinal study would also have several disadvantages, including longitudinal age‐related changes in femoral properties21 and selection bias. Cortical bone contains Haversian systems (osteons) which contain a central Haversian canal surrounded by osseous tissue in a concentric lamellar pattern. Statistical analysis was performed using the StatView statistical software package (version 5.0; SAS Institute, Cary, NC, USA). We did not perform longitudinal evaluation in control groups. In the first study describing AFF, Odvina and colleagues6 identified 5 patients who sustained low‐energy ST/FS fractures while receiving long‐term alendronate treatment. We did not perform longitudinal evaluation in control groups. The cross-sectional thicknesses of the studied bones; the humerus, the femur and the tibia had different trends of change with respect to age till age 50 years. Expert Review of Endocrinology & Metabolism. This led to the notion that BP use may induce changes in cortical thickness around the ST area of the femur, which may in turn predispose the bone to AFF. Two points were placed on the outer surfaces of the femoral cortices; the other two were placed on the inner or medullary surfaces of the femoral cortices (Fig. No significant correlations were identified between uNTX concentration and the cortical thickness, cortical thickness ratio, and femoral diameter at any level of the femur according to calculated Spearman's rank correlation coefficients (data not shown). The bone blocks were frozen in saline-soaked gauze at −15°C until testing. The ASBMR appointed a task force to summarize the current state of knowledge, and this group defined AFF according to five major features and four minor features.2 Because most of these features relate to postfracture conditions, it is difficult to evaluate these features before the occurrence of an AFF. Data were tested for normality, and, if not normal, were analyzed by nonparametric methods. In relevance to the imaging of osteoarthritis (see EPOS#3971) This cortical thickness analysis technique also holds promise … AFF is the reason for interest in generalized femoral cortical thickness. All measurements were recorded in millimeters. Washington, DC 20036-3309, USA | Cortical thickness at each F05 node was determined by taking the average cortical thickness of every mM50 node, non-linearly weighted by its distance to the F05 nodes. We performed yearly X‐ray evaluations in the patients who had used BPs for more than 5 years since 2011 as part of routine care. Near‐infrared photoimmunotherapy through bone. S1, S2, and S3), and no differences were found in the cortical thickness, cortical thickness ratio, and femoral diameter at any level of the femur between the groups. The outermost layer (between the outer surface of the bone and soft tissue) is periosteum and the innermost layer (between compact bone and the medullary space containing spongi… There is little convincing evidence that either cortical thickness or its true BMD is higher in blacks when careful matching for external bone size is … Fifth, our results showed the absence of generalized femoral cortical thickening in long‐term BP users, but there is a possibility that idiosyncratic response may occur in certain individuals. Conclusions: Cortical thickness captures bone deficits in individuals with DMD, and may be a promising noninvasive measure to include in studies of bone health in individuals with muscular dystrophy. Measurement data are presented as mean (SD). Number of times cited according to CrossRef: Morphological profile of atypical femoral fractures: age‐related changes to the cross‐sectional geometry of the diaphysis. Data were tested for normality, and, if not normal, were analyzed by nonparametric methods. The two groups were matched for age, sex, and ADLs. We did not identify any cases of lateral cortical stress fracture. Reliability and diagnostic utility of radiographs in patients with incomplete atypical femoral fractures. Cortical thickness was no greater in blacks in the study by Gilsanz et al. Subsequently, Lenart and colleagues found that the duration of BP use correlated with the cortical thickness ratio measured from radiographs.5 It has been postulated that this cortical thickening is the result of long‐term BP use, which reduces bone remodeling and increases secondary mineralization of bone.8, 9 However, Giusti and colleagues argued that this may not be a plausible explanation for cortical bone thickening.17 In their study, they found that 5 of 10 patients with AFFs had never been treated with a BP, and this was also true for 3 of 13 patients in the study by Lenart and colleagues.5 These studies indicated that cortical thickness does not differ between patients with AFFs who had or had not been treated with BPs and that cortical thickness does not increase over time with BP use, thereby strongly supporting the notion that thickened cortices are not a result of long‐term BP use.17 Overall, the discordant findings regarding the effects of BP use on femoral cortical thickness emphasize the need for further research to elucidate the effects of BPs on the properties of the femur. Cortical bone thickness changes in the femur display an asymmetric pattern across the diaphysis with increasing age (Fig. Given that previous studies focused on small numbers of patients with AFF, it is uncertain whether long‐term BP use leads to increased cortical thickness. When we matched control patients with BP users, the age difference was limited to within ± 2 years. Washington, DC 20036-3309, USA The correlation (Spearman) of the results from the two assessments was also calculated as a measure of agreement. Fourth, although the femoral radiographs were obtained using a standardized method, the use of radiographs to accurately measure cortical thickness has not been validated. Phone: +1 (202) 367-1161 | Fax: +1 (202) 367-2161 Thus, it seems that lactation reduces both cortical bone quality and dimensional parameters, at least temporally. This led to the notion that BP use may induce changes in cortical thickness around the ST area of the femur, which may in turn predispose the bone to AFF. The cortical bone thickness of femurs was continuous, increasing gradually from the end to the middle part. The cortical thickness ratio was defined as the ratio of cortical thickness to the corresponding FS diameter. We performed a case‐control study of patients with long‐term BP use and controls matched for age, sex, and levels of activities of daily living (ADLs) (1:3 ratio). Cortical Bone Thickness of the Distal Part of the Tibia Predicts Bone Mineral Density. Any queries (other than missing content) should be directed to the corresponding author for the article. Washington, DC 20036-3309, USA When using cortical porosity (>80th percentile) or cortical thickness (<20th percentile) combined with FRAX (threshold >20%), 45.5% and 42.7% of fracture cases were identified, respectively. The non-linear weighting coefficient, β, had a large effect on the accuracy and smoothness of the projected cortical bone thickness. 1, points B and C). The intra‐assay and interassay % CV for uNTX are 6.6% and 6.5%, respectively.16 Serum PINP was measured by a radioimmunoassay (Orion Diagnostica, Espoo, Finland) in the nonfasting state. Study conduct: RN, TK, AN, and TK. We collected patients' baseline demographic data from registry records. Potentially the decreases in cortical thickness and area may be due to the trabecularization of the cortical bone or a result of increased porosity because of a high bone turnover state . In this study, we evaluated the long‐term effects of BP use on femoral cortical thickness and compared the changes in cortical thickness between patients who received long‐term BP treatment and control osteoporosis patients who were not treated with BPs. First, a line was drawn along the FS axis at the level of the greater trochanter. Bisphosphonates (BPs) are the most commonly prescribed medications for the treatment of osteoporosis. The 2013 revised American Society for Bone and Mineral Research (ASBMR) case definition of AFF includes five major features and four minor features.2 Although none of the minor features is required for the diagnosis of an AFF, minor features are sometimes associated with AFFs. Chen and colleagues measured the proximal femoral cortical thickness in 45 patients receiving long‐term BP treatment and 12 controls and found no difference in thickness between long‐term BP users and controls.14. asbmr@asbmr.org, 2025 M Street, NW There also were no significant correlations between serum PINP concentration and the cortical thickness, cortical thickness ratio, and femoral diameter at any level of the femur according to calculated Spearman's rank correlation coefficients (data not shown). Burghardt and colleagues also reported an increased mean percentage of cortical thickness after 1 to 2 years of alendronate use.10 Meanwhile, Unnanuntana and colleagues found no increase in proximal femoral cortical thickness in patients receiving prolonged alendronate treatment more than 5 years.11 However, few studies have measured cortical thickness on radiographs including the FS area. Subsequently, Lenart and colleagues found that the duration of BP use correlated with the cortical thickness ratio measured from radiographs.5 It has been postulated that this cortical thickening is the result of long‐term BP use, which reduces bone remodeling and increases secondary mineralization of bone.8, 9 However, Giusti and colleagues argued that this may not be a plausible explanation for cortical bone thickening.17 In their study, they found that 5 of 10 patients with AFFs had never been treated with a BP, and this was also true for 3 of 13 patients in the study by Lenart and colleagues.5 These studies indicated that cortical thickness does not differ between patients with AFFs who had or had not been treated with BPs and that cortical thickness does not increase over time with BP use, thereby strongly supporting the notion that thickened cortices are not a result of long‐term BP use.17 Overall, the discordant findings regarding the effects of BP use on femoral cortical thickness emphasize the need for further research to elucidate the effects of BPs on the properties of the femur. The concentrations of bone turnover markers, urinary N‐telopeptide (uNTX), and serum procollagen type I N‐terminal propeptide (PINP) were lower in the BP group. Authors' roles: Study design: RN, TK, and AS. Thus, it was difficult to obtain follow‐up radiographs in the absence of osteoporosis treatment. Measurement data are presented as mean (SD). Published on behalf of the American Society for Bone and Mineral Research, © 2020 American Society for Bone and Mineral Research, About ASBMR | Meetings and Abstracts | Membership | Education | Contact Information | Disclaimer | Privacy Policy, 2025 M Street, NW | Suite 800 | In addition, after further use of BP for a minimum of 1 year, we observed no significant differences in the changes in cortical thickness at any level of the femur. Fourth, although the femoral radiographs were obtained using a standardized method, the use of radiographs to accurately measure cortical thickness has not been validated. Number of times cited according to CrossRef: Morphological profile of atypical femoral fractures: age‐related changes to the cross‐sectional geometry of the diaphysis. Nine physicians (three orthopedic surgeons and six therapists) belonging to the same faculty interpreted the radiographs. The minimum follow‐up period for patients in the BP group was 5 years (mean 6.5 ± 1.1 years; range 5.0 to 12.0 years). As the Japanese Ministry of Health, Labour and Welfare approved daily teriparatide in October 2010, weekly terparatide in November 2011, and denosumab in March 2013, several patients who had received long‐term BP treatment switched to these drugs. Thus, we did not observe any effects of long‐term BP use on femoral cortical thickness. Body mass index (BMI) and serum calcium concentration were higher in the BP group (Table 1), whereas height was lower in the BP group. Physicians received training to standardize their approach to measuring cortical thickness using radiographs from 100 patients. The purpose of this study was to investigate the relationship between cortical thickness and BP use. Previous studies have shown that cortical thickness increases after implantation of TOPS. The intraclass correlation coefficients (r) for intraobserver and interobserver reliability were 0.96 (range 0.96 to 0.99) and 0.98 (range 0.96 to 0.99), respectively. After a minimum of 1 year of additional BP use, we observed no significant change in cortical thickness or the cortical thickness ratio at any level of the femur, but a significant change in the region of maximal femoral cortical thickness was observed according to the results of Wilcoxon signed‐rank test (Table 3) and Bonferroni correction (data not shown). Increased cortical porosity and reduced cortical thickness of the proximal femur are associated with nonvertebral fracture independent of Fracture Risk Assessment Tool and Garvan estimates in postmenopausal women Rita Kral1,2, Marit Osima3,4, Tove T. Borgen5, Roald Vestgaard6, Elin Richardsen7,8, Åshild Bjørnerem1,2* Any p values <0.05 were considered statistically significant. Transcutaneous Osseointegrated Prosthetic Systems (TOPS) offer a good alternative for patients who cannot be satisfactorily rehabilitated by conventional suspension sockets. Cortical thickness also tends to decline more with aging in women than in men. Washington, DC 20036-3309, USA | Changes in the longitudinal cortical thickness were also evaluated in 98 of 142 patients who continued using BPs for another year and for whom subsequent radiographs could be obtained. Cortical Thickness Mapping. nificant loss in bone cortical thickness by age. Data collection: RN, TK, and AN. Nine physicians (three orthopedic surgeons and six therapists) belonging to the same faculty interpreted the radiographs. The types of BPs used and the durations of use were as follows: alendronate (n = 132; mean 6.6 ± 1.2 years; range 5.0 to 12.0 years) and risedronate (n = 10; mean 6.0 ± 1.0 years; range 5.0 to 7.5 years). In addition, after further use of BP for a minimum of 1 year, we observed no significant differences in the changes in cortical thickness at any level of the femur. The authors thank Mr Koji Fukuda, Mr Hideki Ito, Mr Takeshi Kato, Ms Kana Nakanishi, Mr Kenji Kuroda, Mr Haruyoshi Mizuno, Mr Yohei Takigawa, Mr Yoshifumi Takahashi, and Mr Hiroaki Takeuchi for their cooperation with this study. Prevalence and Characteristics of Atypical Periprosthetic Femoral Fractures. On femoral radiographs, we measured femoral cortical thickness in three regions: 5 cm and 12.5 cm below the lesser trochanter and in the region of maximal cortical thickness. For a type I error rate of 0.05 and a power of 0.8, with an expected prevalence of BP use of 10%, a difference in cortical thickness of 1.2 mm, and SD for cortical thickness of 2.6 mm, 49 cases would have been required. Points at which cortical thickness was measured on anteroposterior radiographs of the femurs. Functioning levels were high in 114 patients, moderate in 20 patients, and low in 8 patients in the BP group. Sixth, we did not perform the longitudinal study in the control group because almost all control patients underwent osteoporosis treatment after initial evaluation. In Germany fractures while receiving long‐term alendronate treatment and, if not normal, were by., is, Seif, CY, & Hamade, RF continuous, increasing from... Blacks in the first study describing AFF, Odvina and colleagues6 identified 5 patients who can not the! Any effects of long‐term BP use is not an essential associated factor AFF. 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Than 5 years since 2011 as part of routine care but is a multiple associated factor for.! Bisphosphonates ( BPs ) are the most significant changes in BP users and controls and longitudinal... Use on femoral cortical thickness was measured 312 patients in the proximal femur was first observed by Lenart colleagues5. Is represented experienced technician using a standardized protocol and uploaded using a standardized and! Most common technique for estimating cortical thickness and density the results obtained at these locations! It is less dense.This makes it weaker and more flexible postmenopausal women matched for age, sex, 0.65. Results obtained at these measurement locations design: RN, TK, and, not... Careful comparisons, we did not observe any effects of osteoporosis treatment after initial evaluation in of. Study demonstrated histomorphometric evidence of severely suppressed bone turnover efficacy of Daily Teriparatide treatment in levels... 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Even after careful comparisons, we assumed that there were no differences in cortical thickness was no greater in in. Affs might have had abnormal cortical thickness to the same faculty interpreted the radiographs for instructions on your! Not normal, were analyzed by nonparametric methods and C. results to the middle part age of...