Surgical Treatment Options in Patients With Impaired Bone Quality (original) (raw)
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Bone Quality: From Bench to Bedside: Opening Editorial Comment
Clinical Orthopaedics and Related Research
Fig. 1Adele L. Boskey, PhD, is shown.Fig. 2Eve Donnelly, PhD, is shown.Fig. 3J. Gregory Kinnett, MD, is shown.The term “bone quality” is frequently used by clinicians, basic scientists, and engineers. However, do they mean the same thing? In this symposium, we asked the authors what they meant by “bone quality,” and as the reader will discover, there are many aspects of bone quality that vary in importance and scope with the person providing the definition. In recent years, numerous reviews have explored and described bone quality (eg, [2–25, 29]) and some have discussed therapies for fragility fractures [13], but none has emphasized the transition from the bench to the bedside (and the operating room). In fact, the majority of these reviews of bone quality are either engineering or basic bone biology articles [3–6, 10, 11, 16], including imaging techniques [3, 8, 12, 17, 20, 25], or papers on how to treat osteoporosis [5, 7, 9, 15, 18, 19, 21, 23, 24]. Here too we review those topics
Methods for Assessing Bone Quality: A Review
Clinical Orthopaedics and Related Research
Background Bone mass, geometry, and tissue material properties contribute to bone structural integrity. Thus, bone strength arises from both bone quantity and quality. Bone quality encompasses the geometric and material factors that contribute to fracture resistance. Questions/purposes This review presents an overview of the methods for assessing bone quality across multiple length scales, their outcomes, and their relative advantages and disadvantages. Methods A PubMed search was conducted to identify methods related to bone mechanical testing, imaging, and compositional analysis. Using various exclusion criteria, articles were selected for inclusion. Results Methods for assessing mechanical properties include whole-bone, bulk tissue, microbeam, and micro- and nanoindentation testing techniques. Outcomes include structural strength and material modulus. Advantages include direct assessment of bone strength; disadvantages include specimen destruction during testing. Methods for characterizing bone geometry and microarchitecture include quantitative CT, high-resolution peripheral quantitative CT, high-resolution MRI, and micro-CT. Outcomes include three-dimensional whole-bone geometry, trabecular morphology, and tissue mineral density. The primary advantage is the ability to image noninvasively; disadvantages include the lack of a direct measure of bone strength. Methods for measuring tissue composition include scanning electron microscopy, vibrational spectroscopy, nuclear magnetic resonance imaging, and chemical and physical analytical techniques. Outcomes include mineral density and crystallinity, elemental composition, and collagen crosslink composition. Advantages include the detailed material characterization; disadvantages include the need for a biopsy. Conclusions Although no single method can completely characterize bone quality, current noninvasive imaging techniques can be combined with ex vivo mechanical and compositional techniques to provide a comprehensive understanding of bone quality.
Use of Bone Health Evaluation in Orthopedic Surgery: the 2019 ISCD Official Positions
Journal of Clinical Densitometry, 2019
This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability
Bone Quality: Educational Tools for Patients, Physicians, and Educators
Clinical Orthopaedics and Related Research®, 2011
Background Defining bone quality remains elusive. From a patient perspective bone quality can best be defined as an individual's likelihood of sustaining a fracture. Fracture risk indicators and performance measures can help clinicians better understand individual fracture risk. Educational resources such as the Web can help clinicians and patients better understand fracture risk, communicate effectively, and make decisions concerning diagnosis and treatment. Questions/purposes We examined four questions: What tools can be used to identify individuals at high risk for fracture? What clinical performance measures are available? What strategies can help ensure that patients at risk for fracture are identified? What are some authoritative Web sites for educating providers and patients about bone quality? Methods Using Google, PUBMED, and trademark names, we reviewed the literature using the terms ''bone quality'' and ''osteoporosis education.'' Web site legitimacy was evaluated using specific criteria. Educational Web sites were limited to English-language sites sponsored by nonprofit organizations Results The Fracture Risk Assessment Tool1 (FRAX1) and the Fracture Risk Calculator (FRC) are reliable means of assessing fracture risk. Performance measures relating to bone health were developed by the AMA convened Physician Consortium for Performance Improvement1 and are included in the Physician Quality Reporting Initiative. In addition, quality measures have been developed by the Joint Commission. Strategies for identifying individuals at risk include designating responsibility for case finding and intervention, evaluating secondary causes of osteoporosis, educating patients and providers, performing cost-effectiveness evaluation, and using information technology. An abundance of authoritative educational Web sites exists for providers and patients. Conclusions Effective clinical indicators, performance measures, and educational tools to better understand and identify fracture risk are now available. The next challenge is to encourage broader use of these resources so that individuals at high risk for fracture will not just be identified but will also adhere to therapy.
The International journal of oral & maxillofacial implants
To investigate the relationship between bone mineral density (BMD) before implant placement, implant stability measures at implant placement, and marginal bone loss of immediately loaded implants after 1 year in situ. Consecutively recruited patients received Straumann SLActive implants loaded with fixed provisional prostheses within 24 hours. BMD was measured from computed tomographic images before implant placement. Alveolar bone quality was assessed during surgery. Implant stability-both rotational and as measured with resonance frequency analysis-and marginal bone height were assessed at implant placement and after 1 year. The Pearson correlation coefficient was used to calculate correlations, and significance was considered when P < .05. Twenty-one patients received 137 implants (87 in maxillae and 50 in mandibles). BMD was significantly correlated with bone quality classification in both arches (P < .001). Mean BMD was also significantly correlated with stability values ...
Research perspectives: The 2013 AAOS/ORS research symposium on Bone Quality and Fracture Prevention
Journal of Orthopaedic Research, 2014
Bone fracture resistance is determined by the amount of bone present ("bone quantity") and by a number of other geometric and material factors grouped under the term "bone quality." In May 2013, a workshop was convened among a group of clinicians and basic science investigators to review the current state of the art in Bone Quality and Fracture Prevention and to make recommendations for future directions for research. The AAOS/ORS/OREF workshop was attended by 64 participants, including two representatives of the National Institutes of Arthritis and Musculoskeletal and Skin Diseases and 13 new investigators whose posters stimulated additional interest. A key outcome of the workshop was a set of recommendations regarding clinically relevant aspects of both bone quality and quantity that clinicians can use to inform decisions about patient care and management. The common theme of these recommendations was the need for more education of clinicians in areas of bone quality and for basic science studies to address specific topics of pathophysiology, diagnosis, prevention, and treatment of altered bone quality. In this report, the organizers with the assistance of the speakers and other attendees highlight the major findings of the meeting that justify the recommendations and needs for this field.
A paradigm shift for bone quality in dentistry: A literature review
Journal of Prosthodontic Research, 2017
The aim of this study was to present the current concept of bone quality based on the proposal by the National Institutes of Health (NIH) and some of the cellular and molecular factors that affect bone quality. Study selection: This is a literature review which focuses on collagen, biological apatite (BAp), and bone cells such as osteoblasts and osteocytes. Results: In dentistry, the term "bone quality" has long been considered to be synonymous with bone mineral density (BMD) based on radiographic and sensible evaluations. In 2000, the NIH proposed the concept of bone quality as "the sum of all characteristics of bone that influence the bone's resistance to fracture," which is completely independent of BMD. The NIH defines bone quality as comprising bone architecture, bone turnover, bone mineralization, and micro-damage accumulation. Moreover, our investigations have demonstrated that BAp, collagen, and bone cells such as osteoblasts and osteocytes play essential roles in controlling the current concept of bone quality in bone around hip and dental implants. Conclusion: The current concept of bone quality is crucial for understanding bone mechanical functions. BAp, collagen and osteocytes are the main factors affecting bone quality. Moreover, mechanical loading dynamically adapts bone quality. Understanding the current concept of bone quality is required in dentistry.
Prevalence of Poor Bone Quality in Patients Undergoing Spine Surgery: A Comprehensive Approach
Global Spine Journal, 2021
Study Design: A cross-sectional study. Objectives: To investigate the prevalence of poor bone quality in patients requiring spine surgery through comprehensive evaluation with bone mass density (BMD), trabecular bone score (TBS), FRAX, and vitamin D status. Methods: we prospectively recruited patients of > 50 years old candidates for lumbar or cervical spine fusion surgery at our institution. Recorded data were: demographic, body mass index (BMI), risk factors for osteoporosis, daily calcium intake, FRAX score, disability index for lumbar and cervical spine, and VAS for pain. Serum 25 OH vitamin D, BMD using DXA, and TBS was also evaluated. Results: A total of 104 patients were recruited, osteoporosis by BMD was detected in 9.6%, and osteopenia in 34.6% of patients. 69.4% of patients with osteopenia had a degraded or partially degraded bone microarchitecture by TBS. Low levels of vitamin D were detected in 79.8% of patients. Increased pain was associated with low BMD levels. Adding TBS to BMD for the determination of bone strength resulted in 33.7% of patients with poor bone quality. Lastly, the combination of BMD, TBS, and FRAX revealed 37,5% of patients with poor bone quality. Conclusions: Poor bone quality and low vitamin D levels are quite common among patients aged ! 50 years undergoing spine surgery. DXA alone seems not enough for preoperative identification of impaired bone quality cases. FRAX is useful for identifying high-risk patients and TBS is a valuable complement to DXA by adding the dimension of bone quality.