Bone mineral density is considered to be the standard measure for the diagnosis of osteoporosis and the assessment of fracture risk. The majority of fragility fractures occur in patients with bone mineral density in the osteopenic range.ä The Fracture Risk Assessment Tool (FRAX) can be used as an assessment modality for the prediction of fractures on the basis of clinical risk factors, with or without the use of femoral neck bone mineral density. Treatment of osteoporosis should be considered for patients with low bone mineral density (a T-score of between 21.0 and 22.5) as well as a ten-year risk of hip fracture of ‡3% or a ten-year risk of a major osteoporosis-related fracture of ‡20% as assessed with the FRAX.ä Biochemical bone markers are useful for monitoring the efficacy of antiresorptive or anabolic therapy and may aid in identifying patients who have a high risk of fracture.ä An approach combining the assessment of bone mineral density, clinical risk factors for fracture with use of the FRAX, and bone turnover markers will improve the prediction of fracture risk and enhance the evaluation of patients with osteoporosis.

Reduction of bone turnover with bisphosphonate treatment alters bone mineral and matrix properties. Our objective was to investigate the effect of bisphosphonate treatment on bone tissue properties near fragility fracture sites in the proximal femur in postmenopausal women with osteoporosis. The mineral and collagen properties of cortico-cancellous biopsies from the proximal femur were compared in bisphosphonate-naive (-BIS, n=20) and bisphosphonate-treated (+BIS, n=20, duration 7 ± 5 y) patients with intertrochanteric (IT) and subtrochanteric (ST) fractures using Fourier transform infrared imaging (FTIRI). The mean values of the FTIRI parameter distributions were similar across groups, but the widths of the parameter distributions tended to be reduced in the +BIS group relative to the -BIS group. Specifically, the distribution widths of the cortical collagen maturity and crystallinity were reduced in the +BIS group relative to those of the -BIS group by 28% (+BIS 0.45 ± 0.18 vs. -BIS 0.63 ± 0.28, p=0.03) and 17% (+BIS 0.087 ± 0.012 vs. -BIS 0.104 ± 0.036, p=0.05), respectively. When the tissue properties were examined as a function of fracture morphology within the +BIS group, the FTIR parameters were generally similar regardless of fracture morphology. However, the cortical mineral:matrix ratio was 8% greater in tissue from patients with atypical ST fractures (n =6) than that of patients with typical (IT or spiral ST) fractures (n=14) (Atypical 5.6 ± 0.3 vs. Typical 5.2 ± 0.5, p=0.03). Thus, although the mean values of the FTIR properties were similar in both groups, the tissue in bisphosphonate-treated patients had a more uniform composition than that of bisphosphonate-naïve patients. The observed reductions in mineral and matrix heterogeneity may diminish tissue-level toughening mechanisms.

Recent studies suggest the ‘Lewinnek safe zone’ for acetabular component position is outdated. We used a large prospective institutional registry to determine if there is a ‘safe zone’ exists for acetabular component position within which the risk of hip dislocation is low and if other patient and implant factors affect the risk of hip dislocation. Patients who reported a dislocation event within six months after hip replacement surgery were identified, and acetabular component position was measured with anteroposterior radiographs. The frequency of dislocation was 2.1% (147 of 7040 patients). No significant difference was found in the number of dislocated hips among the zones. Dislocators <50 years old were less active preoperatively than nondislocators (p=0.006). Acetabular component position alone is not protective against instability.

This is a prospective randomised study comparing the clinical and radiological outcomes of uni- and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. A total of 44 patients were randomised to undergo either uni- or bipedicular balloon kyphoplasty. Self-reported clinical assessment using the Oswestry Disability Index, the Roland-Morris Disability questionnaire and a visual analogue score for pain was undertaken pre-operatively, and at three and twelve months post-operatively. The vertebral height and kyphotic angle were measured from pre- and post-operative radiographs. Total operating time and the incidence of cement leakage was recorded for each group. Both uni- and bipedicular kyphoplasty groups showed significant within-group improvements in all clinical outcomes at three months and twelve months after surgery. However, there were no significant differences between the groups in all clinical and radiological outcomes. Operating time was longer in the bipedicular group (p < 0.001). The incidence of cement leakage was not significantly different in the two groups (p = 0.09). A unipedicular technique yielded similar clinical and radiological outcomes as bipedicular balloon kyphoplasty, while reducing the length of the operation. We therefore encourage the use of a unipedicular approach as the preferred surgical technique for the treatment of osteoporotic vertebral compression fractures.

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