Ipsilateral femoral neck and shaft fracture in children: Two case reports

Rationale:Pediatric femoral shaft combined with ipsilateral femoral neck fractures are very rare but challenging injuries fraught with the development of avascular necrosis, coxa vara, and leg length discrepancy. Majority of the previous reports indicated the neck femur fracture was fixed with cannulated screws or/and pins, femoral shaft fracture was stabilized with a plate and screws. However, we used cannulated screws combined with elastic stable intramedullary nails to minimally invasive procedures treat this type of injury and achieved good follow-up results.Patient concerns:A 7-year-old boy (Case 1) was hospitalized due to a traffic accident resulting in swelling and deformity of the right thigh accompanied by limited mobility of hip and knee. A 5-year-old male child (Case 2) presented with pain and swelling in the bilateral lower limb after fall from approximately 12 feet.Diagnoses:Physical examination, X-ray film, and computed tomography were performed. Both patients were diagnosed with ipsilateral femoral neck and shaft fracture.Interventions:The fractures were reduced closed by image-intensifier imaging. Two partially threaded cancellous screws were used to fix femoral neck fracture, and elastic intramedullary nails were performed to stable the femoral shaft fracture. Postoperatively, the patients were immobilized in a one-and-a-half hip spica cast for six weeks. The internal fixations were removed after one year.Outcomes:Case one was follow-up at 14 months and the other one was followed up for 3 years. And at the last follow-up showed a normal and painless hip function. No clinical complications were found during follow-up visit, including head penetration, implant failure, fracture nonunion, avascular necrosis and hip varus deformity.Lessons:Clinician should carefully check and read relevant imaging data to avoid missed diagnosis. And the internal fixation method described in this paper may be more minimally invasive.     

Dual-construct fixation is recommended in ipsilateral femoral neck fractures with infra-isthmus shaft fracture: A STROBE compliant study

The aim of this study was to evaluate the risk factors related to osteosynthesis failure in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age; smoking habit; comminuted fragments; infra-isthmus fracture; angular malreduction; unsatisfactory reduction (fracture gap >5 mm); and treatment with single construct.Patients over the age of 20 with concomitant ipsilateral femoral neck and shaft fractures diagnosed at a level one medical center between 2003 and 2019 were included. Treatment modalities included single construct with/without an antirotational screw for the neck and dual constructs. Radiographic outcomes were assessed from anteroposterior and lateral hip radiographs at follow-up. Fisher exact test was used to analyze categorical variables. The presence of avascular necrosis of the femoral head, delayed union, atrophic or hypertrophic nonunion of the femoral shaft fracture, and loss of reduction were identified as factors related to treatment failure.A total of 22 patients were included in this study. The average age was 58.5 years, and the majority was male (68.2%). The minimum radiographic follow-up duration was 12 months, and the median follow-up time was 12 (interquartile range 12–24) months.Femoral neck osteosynthesis failed in 3 patients, whereas femoral shaft osteosynthesis failed in 12 patients. Fisher exact test demonstrated the failure of femoral shaft osteosynthesis was significantly more frequent in the single-construct cohort in 16 infra-isthmus femoral fracture cases (P = .034).In ipsilateral femoral neck and infra-isthmus shaft fractures, it is better to treat the neck and shaft fractures with separate implants (dual constructs).In a dual-construct cohort, separate plate fixation of the femoral shaft achieved a better result in terms of bone union than retrograde nailing of the shaft (bone union rate: 4/8 vs 0/2).     

2枚空心钉内固定治疗股骨颈骨折GardenⅠ Ⅱ Ⅲ型临床疗效分析

目的分析2枚空心钉内固定治疗股骨颈骨折GardenⅠ、Ⅱ、Ⅲ型闭合复位的临床疗效。方法收集该院2013-01~2017-08收治股骨颈骨折患者85例,均为新鲜性非病理性股骨颈骨折,Garden分型分别为Ⅰ、Ⅱ、Ⅲ型,行2枚空心钉内固定组(简称2枚组)45例:GardenⅠ型18例,Ⅱ型11例,Ⅲ型16例;行3枚空心钉内固定组(简称3枚组)40例:GardenⅠ型13例,Ⅱ型9例,Ⅲ型18例。同时收集相关临床资料,85例随访12~24(20.26±2.68)个月。评估骨折愈合及股骨头坏死情况,采用髋关节功能Harris评分评估术后临床功能疗效。结果2枚组有42例获得愈合,愈合率为93.33%,15例术后因骨性愈合已取出内固定钉,3例出现股骨头缺血性坏死。3枚组有38例获得愈合,愈合率为95.00%,2例出现股骨头缺血性坏死。两组愈合率差异无统计学意义(P>0.05)。髋关节功能Harris评分结果2枚组(89.70±8.82)分,36例为优,4例为良,2例为可,3例为差,优良率为88.89%;3枚组(91.53±8.38)分,35例为优,2例为良,1例为可,2例为差,优良率为92.50%。两组Harris评分和优良率差异无统计学意义(P>0.05)。结论股骨颈骨折GardenⅠ、Ⅱ、Ⅲ型闭合复位2枚空心钉内固定治疗可获得满意的临床疗效。     

Intertrochanteric valgus osteotomy for post-traumatic coxa vara after proximal femur fractures: A retrospective study

To investigate the clinical effects of a new intertrochanteric valgus osteotomy technique designed by the authors for treatment of post-traumatic coxa varus after proximal femur fractures. Retrospectively analyzed 11 patients who developed coxa vara after sustaining proximal femoral fractures were treated with intertrochanteric valgus osteotomy from December 2005 to December 2018 in our hospital. This study included 6 cases of intertrochanteric fracture deformity union, 3 cases of subtrochanteric fracture nonunion and 2 cases of femoral neck fracture nonunion. Measured the degree of coxa varus, the differences in the lower limb length and force line in all patients. Evaluated hip function with the Harris hip score. All injuries were treated with the authors’ intertrochanteric valgus osteotomy technique. The average follow-up period was 3 years and evaluated the clinical effects by radiological examination and the Harris hip score. The average neck–shaft angle increased 35.0° (99.1°–134.1°) and the average limb shortening lengthened 1.9 cm (2.9–1.0 cm) after surgery. The average operating time was 67.2 minutes and blood loss was 237.7 ml. The osteotomy position healed in all patients 3 months later. Union of the 2 old femoral neck fractures was achieved 4 and 6 months after surgery, respectively, and no femoral head necrosis occurred during follow-up. The Harris hip score increased an average of 49 points (44.1–93.1 points) at 1 year postoperatively. Our self-designed intertrochanteric valgus osteotomy technique showed a favorable clinical effect to treatment coxa vara and can be used in the clinical setting.     

微创内固定治疗偏瘫合并髋部骨折35例分析

目的 分析经皮空心加压螺纹钉内固定治疗偏瘫合并髋部骨折的临床疗效.方法 回顾性总结35例偏瘫合并髋部骨折患者采用经皮空心加压螺纹钉内固定的治疗效果,其中股骨颈骨折24例,转子间骨折11例,在C型臂X光机透视下闭合复位,经皮置入2～3枚空心加压螺纹钉固定,观察手术创伤、住院时间、围手术期并发症、早期活动、早期并发症、死亡率等指标.结果 35例手术顺利完成,手术切口1.5～2 cm、平均住院时间12 d,围手术期并发症5例,早期并发症6例,随访期内死亡5例.结论 选择合适的适应证,微创内固定治疗偏瘫合并髋部骨折可获得良好的临床效果.     

Cortical strut allografting in reconstructive orthopaedic surgery

Many approaches are used in the repair of skeletal defects in reconstructive orthopaedic surgery, and bone grafting is involved in virtually every procedure. Autografting remains the gold standard for replacing bone loss. However, the limited amount of bone that can be harvested and the morbidity associated with that procedure are major constraints to the clinical use of autografts. In contrast, bone allografts can be used in any kind of surgery, whether involving minor defects or major bone loss. Cortical strut allografts unite to host bone through callus formation, restoring bone stock and can be used as an onlay biological plate. These struts can be made from hemicylinders of tibia being fixed to host bone by circumferential metallic cables or by screws. The purpose of this study was to analyze the radiographic outcomes of twelve cryopreserved cortical onlay strut allografts, used in a group of nine patients, for revision hip arthroplasty of the femoral side, to stabilize femoral periprosthetic fractures, to reinforce poor cortical bone and to treat one atrophic femoral nonunion. The average follow-up period was 4.3 years (range, 1.6 to 9 years). No fractures, nonunions or progressive resorption of the bone allografts were observed. All struts were incorporated to the native femur with minimal resorption, within the first year after surgery. There was no failure of any of the allograft reconstructions.The results obtained show that cortical onlay strut allografts, either alone or in conjunction with metallic plate or cancellous bone allografts, are a valuable adjunct for reconstructive surgery of the hip and to treat atrophic femoral nonunion.     

老年人移位股骨颈骨折内固定术中对股骨头血供观察的临床意义

目的 探讨老年移位股骨颈骨折术中对股骨头血供肉眼观察的临床意义.方法 2007年2月-2012年9月,对96例移位股骨颈骨折患者,年龄60～85岁,作髋关节前方和外侧双切口,在直视下将骨折解剖复位,以空心螺钉内固定,同时利用克氏针在股骨头上复位时留下的钻孔,观察孔内的渗血情况,了解股骨头真实的血液供应.并随访治疗结果.结果 所观察到的股骨头渗血情况：65岁以下年龄组和65岁及以上年龄组之间差异无统计学意义（P=0.376）.受伤至手术时间2～7d组与7d以上组之间差异有统计学意义（P=0.000）.不同骨折类型组之间差异没有统计学意义（P=0.294）.有或无股骨头缺血性坏死组之间差异有统计学意义（P=0.000）.结论 使用髋关节前方和外侧双切口将骨折解剖复位,以三枚空心螺钉内固定治疗老年人移位股骨颈骨折术中对股骨头血供的直接肉眼观察有临床意义.观察结果支持对股骨颈骨折早期手术的观点,加深了骨折移位对股骨头血液供应影响程度的认识,有利于评估术后的预后.对65岁及以上的有移位股骨颈骨折患者的治疗方案,仍然可以在人工髋关节置换和切开解剖复位内固定两者之间选择.     

The role of internal fixation in the treatment of femoral head necrosis with ipsilateral hip fracture

Whether internal fixation or hip arthroplasty is the most appropriate initial treatment for patients with ipsilateral hip fracture and osteonecrosis of the femoral head remains unknown. In this study, the prognoses of patients who underwent internal fixation or hip arthroplasty were analyzed and compared to explore the role of internal fixation in treating such patients.We retrospectively reviewed 69 patients diagnosed with osteonecrosis of the femoral head and ipsilateral hip fracture from 1999 to 2018. They were divided into the hip arthroplasty or internal fixation group. The visual analog scale and Harris score were used. The incidence of complications and the conversion to arthroplasty were also investigated to further explore the role of internal fixation.Male patients (male/female: 25/31 vs 20/38, P = .015), younger patients (average age: 46.80 ± 13.14 vs 61.07 ± 15.61, P < .001), and patients with femoral neck fractures (fracture type, femoral neck/trochanter: 21/31 vs 12/38, P = .003) were more likely to receive 1-stage hip arthroplasty. Of 38 patients undergoing internal fixation, fracture nonunion was identified in 9, and progression of osteonecrosis was identified in 16. Meanwhile, conversion to secondary hip arthroplasty occurred in 13 patients. Four independent risk factors for conversion to secondary hip arthroplasty were identified: age of ≤60 years (odds ratio [OR] = 9.786, 95% confidence interval [CI] = 2.735–35.015), male sex (OR = 6.790, 95% CI = 1.718–26.831), collapse of the femoral head before injury (OR = 7.170, 95% CI = 2.004–25.651), and femoral neck fracture (OR = 8.072, 95% CI = 2.153–30.261). A new scoring system was constructed for predicting conversion to hip arthroplasty in patients undergoing internal fixation treatment. A cutoff of ≤2 points indicated low risk for conversion, 3 to 4 points indicated moderate risk, and ≥5 points indicated high risk.Patients who underwent internal fixation had worse prognoses than those who underwent 1-stage hip arthroplasty. However, in this study, hip arthroplasty conversion did not occur in most patients who received internal fixation. Using the new scoring system to identify patients who may require conversion to replacement may help make appropriate patient management and clinical decisions.     

Intertrochanteric versus femoral neck hip fractures: differential characteristics, treatment, and sequelae

BACKGROUND: More than 220,000 persons 65 years and older fracture a hip every year in the United States. Although hip fractures have been considered as a single, homogeneous condition, there are two major anatomic types of proximal femoral fractures: intertrochanteric and femoral neck. The present study's objective was to determine if the two types of hip fracture have different patient characteristics and sequelae. METHODS: A prospective study of 923 elderly patients admitted to seven Baltimore hospitals for a hip fracture between 1984 and 1986. RESULTS: Patients with intertrochanteric fractures were slightly older, sicker on hospital admission, had longer hospital stays, and were less likely at 2 months postfracture to have recovered activities of daily living than femoral neck fracture patients. Intertrochanteric fracture patients also had higher mortality rates at 2 and 6 months after fracturing. Long-term recovery (1 year) did not differ between fracture type. CONCLUSIONS: It appears that intertrochanteric fracture patients have intrinsic factors (older age, poor health) impacting upon their risk of fracture and ability to recover. Differences in patient characteristics and sequelae do exist between femoral neck and intertrochanteric hip fracture patients that impact upon recovery.     

回顾性分析72例老年股骨颈囊内移位骨折患者关节置换术

目的 探讨老年股骨颈囊内移位骨折患者行人工髋关节置换术的方法及其疗效.方法 回顾性分析72例老年股骨颈囊内移位骨折患者的病例资料,其中Garden Ⅲ型35例,Garden Ⅳ型37例;按手术方法分4组：骨水泥全髋置换术11例,非骨水泥拿髋置换术12例,骨水泥半髋置换术30例,非骨水泥半髋置换术19例.术后定期随访X线片及Hams评分.结果 随访时间25-114个月,中位随访时间93个月,行人工髋关节置换术者Harris评分优良率为92.19%.结论 老年股骨颈骨折患者应尽可能接受手术治疗;老年股骨颈囊内移位骨折、Garden Ⅲ和Garden Ⅳ型患者宜行人工髋关节置换术;不同手术方法中期效果及并发症比较,差异无统计学意义.     

Long-term clinical and radiographic results of cementless total hip arthroplasty for patients with rheumatoid arthritis: minimal 10-year follow-up

Abstract

Objectives. The aim of this study was to clarify the long-term clinical and radiographic results of cementless total hip arthroplasty (THA) for patients with rheumatoid arthritis (RA).

Methods. Twenty-eight total hip arthroplasties in 24 patients with a diagnosis of RA were performed from October 1992 to October 1996. All components were titanium alloy with a circumferential porous coating. Six patients (six hips) died before the 10-year follow-up, and one patient (one hip) was lost to follow-up, leaving 21 joints of 17 patients for review at a minimum 10-year follow-up after surgery. There were 3 men and 14 women with an average age of 55.0 years. The average duration of RA at the time of the operation was 12.6 years, and the average follow-up period was 12.2 years. We evaluated the Japanese Orthopaedic Association (JOA) hip scores, radiographic changes and survivor rates of components.

Results. Compared with the preoperative JOA hip scores, there was significant improvement in the postoperative scores. Spot welds consistent with bone ingrowth were identified in 95.0% of the femoral components. No femoral components showed radiographic loosening or required revision for aseptic loosening, but two acetabular revisions were performed because of aseptic loosening. The 14-year survivor rates of the stem and cup with the end point of loosening were 100% and 88.2%, respectively.

Conclusions. Cementless THA with this component design in patients with RA appears to be a promising treatment.     

Raised serum albumin in hip osteoarthrosis: a comparative study in women of some blood chemical parameters in aging and in cases of femoral neck fractures, osteoporotic vertebral crush fractures, and hip osteoarthrosis.

Twelve blood parameters were studied in five groups of women totalling 120 subjects--group I: 26 blood donors (average age 45.2 years, range 23-66); group II: 18 patients with various cerebral, cardiovascular, or infectious illnesses (average age 79.9 years, range 66-92); group III: 28 patients with femoral neck fractures (average age 79.4 years, range 56-95); group IV: 12 patients with hip osteoarthrosis (average age 71.7 years, range 60-87); group V: 36 patients with vertebral crush fractures associated with postmenopausal and involutional osteoporosis (average age 63.0 years, range 51-75). The parameters measured were total proteins, albumin, total, alpha 1, alpha 2, beta, and gamma globulins, total calcium, phosphates, alkaline phosphatase, bilirubin, and haemoglobin. Statistical analysis showed that each group differed from the others even with adjustment for age. Among the discriminant parameters, serum albumin had a distinctive position. Significantly high concentrations of serum albumin in the group with osteoarthrosis raise the question of the possible existence of a population prone to osteoarthrosis in whom the serum albumin level may reflect a special nutritional state associated with the well known bone density in subjects with hip osteoarthrosis. Albumin values in patients with femoral neck fractures are lower than normal but non-significantly. The difference between the group with vertebral crush fractures and that with femoral neck fractures seems to be due to age.     

老年人髋部骨折的相关因素观察

目的　观察老年人髋部骨折的骨密度 (BMD)值 ,探讨老年人股骨颈骨折和转子间骨折与骨密度的相关性。　方法　将 496例老年髋部骨折住院患者按年龄、性别及骨折类型分组 ,选择性行骨密度检查。对检查结果进行统计学处理 ,并对临床髋部骨折患者分布情况进行分析。　结果　骨折组的骨密度值均低于同性别正常人骨峰值的 2 5s;同性别、同年龄组股骨颈骨折和转子间骨折患者的骨密度间差异无显著性 (P <0 0 1) ;老年人髋部骨折主要集中在 6 0～ 79岁之间 ,占同期髋部骨折的 73 %。　结论　老年人骨量低于同性别骨峰值应视为髋部骨折的危险人群。骨量降低是老年人髋部骨折的前提条件 ,但老年骨质疏松患者发生股骨颈骨折或发生转子间骨折 ,主要决定于受伤时的暴力大小和方向。     

Nonspherical femoral head shape (pistol grip deformity), neck shaft angle, and risk of hip osteoarthritis: a case-control study

OBJECTIVE: To determine whether 2-dimensional measures of femoral head shape and angle are associated with hip osteoarthritis (OA). METHODS: We compared cases with symptomatic radiographic hip OA with asymptomatic controls with no radiographic hip OA. On anteroposterior pelvis radiographs, we measured "pistol grip deformity" for each hip (visually categorized as nonspherical, indeterminate, or spherical), the femoral head-to-femoral neck ratio as an interval measure of femoral head shape, and the femoral neck shaft angle. The relative risk of hip OA associated with each feature was estimated using odds ratios (ORs) and 95% confidence intervals (95% CIs), adjusted for possible confounders using a logistic regression model. RESULTS: Of 1,007 cases, 965 had definite radiographic hip OA; of 1,123 controls, 1,111 had no radiographic OA. The prevalence of pistol grip deformity in at least 1 hip was 3.61% in controls and 17.71% in cases (OR 6.95 [95% CI 4.64-10.41]), and the prevalence of abnormal femoral head-to-femoral neck ratio in at least 1 hip was 3.70% in controls and 24.27% in cases (OR 12.08 [95% CI 8.05-18.15]). The risk of hip OA increased as the femoral head-to-femoral neck ratio decreased (P for trend<0.001) and with each extreme of neck shaft angle (P<0.05). In cases with unilateral hip OA, the prevalence of abnormal femoral head-to-femoral neck ratio in the unaffected hip was 2 times greater than that in controls (OR 1.82 [95% CI 1.07-3.07]); in contrast, an abnormally low, but not abnormally high, neck shaft angle was more common in unaffected hips than in controls (OR 1.79 [95% CI 1.03-3.14]). CONCLUSION: Our findings indicate that pistol grip deformity is associated with hip OA. The increased prevalence of pistol grip deformity and an abnormally low neck shaft angle in unaffected hips of cases with unilateral OA suggests that they are risk factors for development of hip OA. However, both a nonspherical head shape and an increase in neck shaft angle may occur as a consequence of OA.     

老年人骨质疏松性髋部骨折100例治疗探讨

目的探讨老年人骨质疏松性髋部骨折的临床诊治方法及疗效。方法对70～96岁的骨质疏松性髋部骨折100例实施不同的方法治疗的(其中股骨粗隆间骨折29例中,DHS内固定20例,保守治疗8例,人工股骨头置换1例;股骨颈骨折71例中,人工股骨头置换33例,全髋置换38例)的同时,配合抗骨质疏松药物治疗。结果 100例均获得随访。随访时间6～28个月,平均14.2个月。术后股骨头缺血坏死4例;内固定物松动滑脱5例,断裂2例;人工股骨头下沉致疼痛5例;84例恢复行走功能。结论老年骨质疏松性髋部骨折需要采取积极的以手术为主的综合治疗。     

Fractures of the proximal femur in patients over 70 years--choice of procedure and results

From 1978 till oct. 1981 110 patients between 70 and 99 years old were operated upon fractures of the proximal femur. Out of those 43 presented with fractures of the femoral neck, 46 with pertrochanteric, and 17 with subtrochanteric. In fractures of the femoral neck we generally perform alloplastic replacement of the femoral head or total hip arthroplasty. By means of a 24 hour preparing period (volume and electrolyte replacement, digitalis) and intraoperative administration of dopamine the systemic reaction to bone cement could be avoided. Pertrochanteric fractures are treated by Ender- rods immediately. Subtrochanteric fractures are the greatest technical problem. We now use long-stem-prosthesis as compound-osteosynthesis. Physiotherapy is applied aggressively. The patients are trained to walk from the second day p.op. on. Perioperative lethality rated 17%. Within the group of age 70 till age 80 only four died (7,5%), over 80 years 15 (30% of this group). Following hip-replacement there were 13 deaths, after Ender-rods only 4 lethalities. 83% of all patients could be discharged after a mean of 19 days, 86% of those ambulatory.     

后外侧微创入路与后外侧常规入路全髋关节置换术在治疗老年股骨颈骨折中的疗效比较

目的对比后外侧微创入路与后外侧常规入路行全髋关节置换术治疗老年股骨颈骨折的效果。方法将2016年1月1日-2019年10月31日于南京中医药大学附属姜堰医院骨伤科就诊的107例老年股骨颈骨折患者作为研究对象,对所有患者的临床及随访资料进行回顾性分析,按照治疗方式的不同将其分为微创组(53例)及常规组(54例)。微创组采用后外侧微创入路行全髋关节置换术,常规组则采用后外侧常规入路行全髋关节置换术。对比2组患者围术期相关指标(手术时间、术中出血量、术后15 d柄假体颈干角及髋臼外展角角度)及手术前后的疼痛视觉模拟评分(VAS)、髋关节(Harris)评分和并发症的发生率。结果微创组手术中出血量少于常规组(P<0.05),常规组住院时间长于微创组(P<0.05);手术后微创组VAS评分低于常规组,Harris评分高于常规组(P<0.05);治疗后常规组并发症总发生率(16.67%)高于微创组(5.66%)(P<0.05)。结论后外侧微创入路行全髋关节置换术治疗老年股骨颈骨折,能有效减少患者术中出血量,缓解患者的疼痛感,改善其髋关节功能,且术后并发症发生率较低。     

长柄人工股骨头置换治疗高龄股骨转子间骨折的疗效分析

目的探讨长柄骨水泥型双极人工股骨头置换治疗高龄不稳定性股骨转子间骨折的临床疗效。方法对2005-01-2010-06采用长柄骨水泥型双极人工股骨头置换治疗75岁以上不稳定性股骨转子间骨折62例,平均随访15个月,观察术后并发症、骨折愈合时间、关节功能情况。结果术后53例患者获得随访,无一例死亡;有1例出现下肢深静脉栓塞,经治疗后痊愈出院;无褥疮、肺部感染、髋关节脱位等常见并发症发生。根据Harris评定标准评价：优43例（81．1％）,良7例（13．2％）,可3例（5．6％）,差0例,优良率达94．3％。结论长柄骨水泥型双极人工股骨头置换治疗高龄不稳定性股骨转子间骨折具有创伤小、手术时间短、下地活动早、并发症少、髋关节功能恢复好等优点,是一种较理想的治疗方法。     

The prevalence of vertebral fractures in mild ankylosing spondylitis and their relationship to bone mineral density

OBJECTIVE: To determine bone mineral density (BMD) in patients with mild ankylosing spondylitis (AS), to establish the prevalence of vertebral fractures and fracture risk in these patients, and to determine the relationship between BMD and vertebral fractures. METHODS: Sixty-six men with mild AS were studied. BMD of the lumbar spine and femoral neck was measured by dual X-ray absorptiometry (DXA) and radiographs of the thoracic and lumbar spine were obtained in all subjects. From the radiographs, vertebral fractures were characterized by a morphometric technique using established criteria. Thirty-nine healthy male subjects aged 50-60 yr, recruited from primary care registers, had spinal radiographs performed and served as controls for vertebral fractures. RESULTS: In patients with AS, BMD was reduced in both the lumbar spine 0.97 (0.1) g/cm(2) [T score -1.10 (1.3), 95% confidence interval (CI) -0.50, +0.14] and femoral neck 0.82 (0.1) g/cm(2) [T score -1.40 (1.2), 95% CI -0.51, +0.09]. There was no correlation between BMD of either the lumbar spine or femoral neck and duration of disease in patients with AS. Eleven of 66 (16.7%) patients with AS had a vertebral fracture, compared with one of 39 (2.6%) controls; odds ratio 5.92 (95% CI 1.4, 23.8). AS patients with fractures were not significantly older (mean age 41.4 vs 37.8 yr, P=0.17), but had significantly longer disease duration (12.4 vs 9.3 yr, P<0.05) than patients without fractures. No significant difference was found in the visual analogue scores for pain in AS patients with fractures compared with those without. No significant correlation was observed between BMD of the lumbar spine or femoral neck and vertebral fractures in patients with AS. In addition, there was no significant difference in the lumbar spine or femoral neck BMD in AS patients with fractures compared with those without. CONCLUSIONS: Spinal and hip osteopenia and vertebral fractures are a feature of mild AS. However, there was no correlation between BMD and vertebral fractures in these patients. AS patients with mild disease had a higher risk of fractures compared with the normal population and this increased with the duration of disease.     

Meta-analyses of therapies for postmenopausal osteoporosis. III. Meta-analysis of risedronate for the treatment of postmenopausal osteoporosis

OBJECTIVE: To review the effect of risedronate on bone density and fractures in postmenopausal women. DATA SOURCES: We searched MEDLINE from 1966 to the end of 2000 and examined citations of relevant articles and the proceedings of international osteoporosis meetings. STUDY SELECTION: We included eight randomized, placebo-controlled trials of postmenopausal women receiving risedronate or placebo with a follow-up of at least one year and providing data on bone density or fracture rate. DATA EXTRACTION: For each trial, two independent reviewers assessed the methodological quality and abstracted data. DATA SYNTHESIS: The major methodological limitation of the trials was the loss to follow-up, which was over 20% in most trials and over 35% in the largest study. However, the magnitude of the treatment effect was unrelated to loss to follow-up, and in one of the largest trials, more high-risk patients were lost to follow-up in the control than in the treatment group. The pooled relative risk (RR) for vertebral fractures in women given 2.5 mg or more of risedronate was 0.64 [95% confidence interval (CI) 0.54, 0.77]. The pooled RR of nonvertebral fractures in patients given 2.5 mg or more of risedronate was 0.73 (95% CI 0.61, 0.87). Risedronate produced positive effects on the percentage change in bone density of the lumbar spine, combined forearm, and femoral neck that were generally larger with the 5-mg daily dose than with cyclical administration or the 2.5-mg dose. The pooled estimate of the difference in percentage change between 5 mg risedronate and placebo after the final year of treatment (1.5-3 yr) was 4.54% (95% CI 4.12, 4.97) for the lumbar spine, and 2.75% (95% CI 2.32, 3.17) at the femoral neck. CONCLUSIONS: Risedronate substantially reduces the risk of both vertebral and nonvertebral fractures. This fracture reduction is accompanied by an increase in bone density of the lumbar spine and femoral neck in both early postmenopausal women and those with established osteoporosis.