Evaluation of bone mineral density and metabolic abnormalities associated with low-energy hip fractures

Background: Low-energy hip fractures are markers for osteoporosis. Despite a recent call for better evaluation of this issue, there is a lack of data regarding the metabolic abnormalities found in these patients and how it relates to their bone density. Additionally, no clear guidelines have been published for the evaluation of osteoporosis in these patients. We characterize the metabolic abnormalities seen in this patient population and suggest an effective screening protocol. Methods: Thirty-one patients with low-energy hip fractures not receiving osteoporosis treatment were evaluated with bone density scans and a serum metabolic evaluation consisting of a 25-hydroxyvitamin D level, parathyroid hormone level, and calcium level. The relationship of metabolic abnormalities to bone density values was evaluated. Results: Most of the patients presenting with low-energy hip fractures had metabolic abnormalities associated with low bone density. The femoral neck T-scores averaged-2.3. Fifty-three percent (16/30) of patients had low levels of vitamin D and 83% (25/30) of patients had evidence of secondary hyperparathyroidism (PTH \u3e25 nleq/ml). We also found relatively poor correlations of bone density T-scores to parathyroid hormone and vitamin D levels (r=-0.38 and-0.05). Conclusion: Most patients presenting with low energy hip fractures have severe metabolic abnormalities associated with low bone density. Due to the poor correlation between bone density T-scores and the serum levels of parathyroid hormone and vitamin D, appropriate osteoporosis evaluation of this patient population requires both bone density evaluation and serum metabolic evaluation of 25-hydroxyvitamin D, PTH, and calcium levels. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Core needle biopsies of musculoskeletal tumors: Potential pitfalls

Core needle biopsy is a powerful tool used to diagnose and develop a treatment strategy for musculoskeletal tumors. With accuracy rates reported between 69% and 99%, it is evident that errors in diagnosis occur, and they can lead to devastating consequences. We reviewed pathology reports of preoperative core needle biopsies in an attempt to determine factors associated with false negative diagnoses for the purpose of improving surgical planning. We retrospectively reviewed all office-based core needle biopsies accomplished in our practice over a 6-year period. One hundred nineteen biopsies were identified, of which 82 fulfilled criteria to be included in the study population. The pathologist\u27s report of each biopsy was reviewed and categorized based on the findings into 1 of 2 diagnostic groups: neoplastic or nonneoplastic. The results of the biopsies were then compared to the pathology results of the final surgical resection, and the rates and nature of false negative biopsy results (unrecognized malignant pathology) were compared for each group. Seventy-one biopsies were categorized as neoplastic based on the pathology report. No false negative results were found in this group when compared to the final surgical resection pathology. Eleven biopsies were categorized as nonneoplastic, of which 6 were found to be false negatives when compared to the final surgical pathologic diagnosis. The rate of false negative results significantly increased in biopsies whose reports were categorized as nonneoplastic compared to biopsies categorized as neoplastic (P\u3c.0001). We found core needle biopsies of musculoskeletal lesions to be safe and effective in diagnosing pathologic processes. In cases in which analysis of the biopsy specimen did not identify a specific neoplastic process, we found a high incidence of undiagnosed malignancy upon definitive surgical resection. Pathology reports of core needle biopsies that specify only normal, inflammatory, or other nonspecific tissue descriptions should alert the clinician to the increased possibility of a false negative result, and require further tissue analysis. Copyright © 2009 SLACK Incorporated. All rights reserved

Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture a randomized clinical trial

Background: Although osteoporosis is strongly associated with hip fractures, the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5% and 30%. Currently, most patients receiving treatment have been referred back to their primary care physician for osteoporosis management. The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months. Methods: A prospective randomized trial was conducted to assess the difference in the rate of osteoporosis treatment when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and usual care. Results: Sixty-two patients were enrolled in the study. Thirty-one patients each were in the control and intervention groups. The percentage of patients who were on pharmacologic treatment for osteoporosis at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic (58%) than when treatment was managed by a primary care physician (29%) (p = 0.04). Conclusions: An active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2008 by The Journal of Bone and Joint Surgery, Incorporated

Bone marrow adiposity: basic and clinical implications.

The presence of adipocytes in mammalian bone marrow (BM) has been recognized histologically for decades, yet, until recently, these cells have received little attention from the research community. Advancements in mouse transgenics and imaging methods, particularly in the last 10 years, have permitted more detailed examinations of marrow adipocytes than ever before and yielded data that show these cells are critical regulators of the BM microenvironment and whole-body metabolism. Indeed, marrow adipocytes are anatomically and functionally separate from brown, beige, and classic white adipocytes. Thus, areas of BM space populated by adipocytes can be considered distinct fat depots and are collectively referred to as marrow adipose tissue (MAT) in this review. In the proceeding text, we focus on the developmental origin and physiologic functions of MAT. We also discuss the signals that cause the accumulation and loss of marrow adipocytes and the ability of these cells to regulate other cell lineages in the BM. Last, we consider roles for MAT in human physiology and disease

Bone marrow adipocytes.

Adipocytes were identified in human bone marrow more than a century ago, yet until recently little has been known about their origin, development, function or interactions with other cells in the bone marrow. Little functional significance has been attributed to these cells, a paradigm that still persists today. However, we now know that marrow adipose tissue increases with age and in response to a variety of physiologic induction signals. Bone marrow adipocytes have recently been shown to influence other cell populations within the marrow and can affect whole body metabolism by the secretion of a defined set of adipokines. Recent research shows that marrow adipocytes are distinct from white, brown and beige adipocytes, indicating that the bone marrow is a distinct adipose depot. This review will highlight recent data regarding these areas and the interactions of marrow adipose tissue (MAT) with cells within and outside of the bone marrow

NCCN Guidelines (R) Insights Bone Cancer, Version 2.2017 Featured Updates to the NCCN Guidelines

The NCCN Guidelines for Bone Cancer provide interdisciplinary recommendations for treating chordoma, chondrosarcoma, giant cell tumor of bone, Ewing sarcoma, and osteosarcoma. These NCCN Guidelines Insights summarize the NCCN Bone Cancer Panel's guideline recommendations for treating Ewing sarcoma. The data underlying these treatment recommendations are also discussed