Publications by authors named "Aasis Unnanuntana"

42 Publications

Midterm functional recovery of Total knee arthroplasty patients compared between the ATTUNE knee system and the press fit condylar (PFC) SIGMA knee system.

BMC Musculoskelet Disord 2021 Jul 13;22(1):620. Epub 2021 Jul 13.

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

Background: The ATTUNE Knee System is a new prosthetic design that has theoretical advantages over the Press Fit Condylar (PFC) Sigma Knee System specific to improved knee kinematics and patellofemoral joint tracking. This study aimed to evaluate functional outcomes compared between the ATTUNE and PFC Sigma designs at a minimum follow-up of 5 years.

Methods: We retrospectively reviewed data from total knee arthroplasty (TKA) patients who received either the ATTUNE or PFC Sigma system during November 2013 to February 2015 at Siriraj Hospital (Bangkok, Thailand). Functional outcomes were evaluated using Timed Up and Go (TUG) test, 2-min walk test (2MWT), modified knee score, numerical rating scale-pain, range of motion (ROM), and rate of anterior knee pain and crepitation at preoperation, 3-months, 1-year, and 5-years postoperatively.

Results: Of 113 patients, 59 and 54 received the PFC Sigma and ATTUNE systems, respectively. At a minimum of 5-years follow-up, all functional outcomes improved significantly from the preoperative period although TUG test and 2MWT declined significantly from 1- to 5-years postoperatively only in the PFC Sigma group. The mean ROM at 5-years postoperatively was significantly higher in ATTUNE than in PFC Sigma; however, the difference was small (116° vs. 110°, respectively; p = 0.041). There were no significant differences in any of the other outcome measurements, including anterior knee pain, clunking, and crepitation, between groups at any study time point.

Conclusions: ​Our results revealed no major differences in functional outcomes between the PFC Sigma and ATTUNE TKA designs at an intermediate-term follow-up of at least 5 years. Longer-term follow-up study is needed to evaluate the benefits of the ATTUNE design relative to polyethylene wear and the rate of aseptic loosening.
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http://dx.doi.org/10.1186/s12891-021-04464-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278715PMC
July 2021

Stress Fracture of the Femoral Shaft in Paget's Disease of Bone: A Case Report.

J Bone Metab 2021 May 31;28(2):171-178. Epub 2021 May 31.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Paget's disease of bone (PDB) is a progressive bone disorder characterized by increased osteoclast-mediated bone resorption and abnormal bone formation. Incomplete atypical femoral fracture, appearing radiographically as a stress fracture at the lateral aspect of the femur, is an uncommon low-trauma fracture frequently seen in association with long-term bisphosphonate therapy. We describe the case of a 61-year-old female patient with PDB who developed a stress fracture at the lateral femoral cortex after 5 doses of intravenous bisphosphonate. The conservative treatment plan included discontinuation of bisphosphonate, a continuation of calcium and vitamin D supplementation, and limited weight-bearing for 3 months. The patient's pain level gradually improved after switching to the new treatment plan. At the latest follow-up, approximately 5 years after the initiation of conservative treatment, the patient remained pain-free, and her PDB was well-controlled. However, the fracture line was still visible on the most recent radiograph. Although it remains unclear whether a stress fracture at the lateral femoral cortex occurred due to bisphosphonate therapy or PDB, this case highlights the importance of careful evaluation of any lesion that appears in PDB patients receiving bisphosphonate therapy.
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http://dx.doi.org/10.11005/jbm.2021.28.2.171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206614PMC
May 2021

Osteitis Fibrosa Cystica and pathological fractures-the classic but neglected skeletal manifestation of primary hyperparathyroidism: a case report.

BMC Musculoskelet Disord 2021 May 14;22(1):443. Epub 2021 May 14.

Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Osteitis fibrosa cystica is the classic manifestation of primary hyperparathyroidism (PHPT), occurs after prolonged exposure of bone to high serum parathyroid hormone (PTH) level. It has become increasingly rare due to early detection of PHPT.

Case Presentation: A 37-year-old woman was referred to our institution for fixation of multiple fractures of upper and lower extremities that had been reoccurring in the past 5 years. Her medical history showed right-shoulder, left-elbow, and right-femur fractures after a fall 5 years previously. One month ago, she sustained fractures of the right distal humerus, left tibia, and left femur without history of trauma. Upon arrival to our hospital, a thorough review of her plain radiographs demonstrated brown tumors at multiple sites, along with a salt-and-pepper appearance of the skull and a rugger-jersey spine, compatible with osteitis fibrosa cystica. Patient was diagnosed with PHPT, confirmed by high-corrected serum calcium (13.6 [8.6-10.0] mg/dl), low serum phosphate (2.2 [2.5-4.5] mg/dL), high serum alkaline phosphatase (1482 [35-105] U/L), and significantly elevated parathyroid hormone (PTH 3850 [15-65] pg/mL). A histologically confirmed, 2.5-cm parathyroid adenoma was removed by parathyroidectomy. Ten days later, closed reduction and internal fixation of the left proximal femoral shaft was performed. Pain and ambulation were significantly improved 6 months postoperatively. At the 1.5-year follow-up, fracture unions and complete mineralization of brown tumors were noted; the patient could ambulate with neither pain nor an assistive device.

Conclusions: PHPT has become more asymptomatic in countries where routine calcium screening is performed. Nevertheless, the classic skeletal involvement, osteitis fibrosa cystica, should not be overlooked, particularly in young patients who present with a low-energy fracture.
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http://dx.doi.org/10.1186/s12891-021-04326-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122575PMC
May 2021

High-dose versus low-dose ergocalciferol for correcting hypovitaminosis D after fragility hip fracture: a randomized controlled trial.

BMC Geriatr 2021 01 21;21(1):72. Epub 2021 Jan 21.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand.

Background: Hypovitaminosis D can be observed in most fragility hip fracture patients. However, measurement of 25-hydroxyvitamin D (25(OH)D) level is costly and may not be available in some centers. Without the baseline serum 25(OH)D level, the appropriate dose of vitamin D supplementation is not known. The aim of this study was to evaluate the effectiveness and safety of vitamin D supplementation in fragility hip fracture patients compared between high- and low-dose vitamin D supplementation.

Methods: A total of 140 patients diagnosed with fragility hip fracture were randomly allocated to either the high-dose (60,000 IU/week) or low-dose (20,000 IU/week) vitamin D2 supplementation group for 12 weeks. The number of patients who achieved optimal vitamin D level (serum 25(OH)D > 30 ng/mL), the proportion of patients who developed hypercalcemia, and the functional outcome were compared between groups.

Results: Of the 140 patients who were enrolled, 21 patients were lost to follow-up during the study period. The remaining 119 patients (58 and 61 in the high- and low-dose groups, respectively) were included in the final analysis. The high-dose group had a higher rate of serum 25(OH)D restoration to optimal level than the low-dose group (82.8% vs 52.5%, respectively; p < 0.001). Approximately 3.4 and 1.6% of patients in the high- and low-dose groups, respectively, had mild transient hypercalcemia, but none developed moderate, severe, or symptomatic hypercalcemia. There were no differences in functional outcome scores between groups.

Conclusions: In treatment settings where baseline serum 25(OH)D level can't be evaluated in older adults with fragility hip fracture, we recommend high-dose vitamin D2 of approximately 60,000 IU/week for 12 weeks, with subsequent switch to a maintenance dose. This regimen effectively restored serum vitamin D to an optimal level in 82.8% of patients without causing symptomatic hypercalcemia.

Trial Registration: The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database no. TCTR20180302007 on 20 February 2018.
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http://dx.doi.org/10.1186/s12877-021-02023-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818778PMC
January 2021

Validity and reliability of the self-rated fall risk questionnaire in older adults with osteoporosis.

BMC Musculoskelet Disord 2020 Nov 18;21(1):757. Epub 2020 Nov 18.

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

Background: Several risk assessments have been developed to evaluate fall risk in older adults, but it has not been conclusively established which of these tools is most effective for assessing fall risk in this vulnerable population. Recently, the U.S. Centers for Disease Control and Prevention (CDC) developed the self-rated Fall Risk Questionnaire (self-rated FRQ), a 12-item questionnaire designed to screen older adults who are at risk of falling and has been widely used in many centers. This study aimed to determine the validity and reliability of the self-rated FRQ in older adults with osteoporosis.

Methods: This prospective study was conducted at the Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from December 2019 to March 2020. Sixty-eight men or postmenopausal women aged > 65 years who were diagnosed with osteoporosis either by bone mineral density T-score or by occurrence of fragility fracture were evaluated with the self-rated FRQ, the Thai falls risk assessment test (Thai-FRAT), the timed get-up-and-go test (TUG test), the Berg Balance Scale (BBS), and the 5 times sit-to-stand test (5TSTS test). Validity of the self-rated FRQ was assessed by evaluating the correlations (r) between the self-rated FRQ score and the scores from the other four assessments. Reliability of the self-rated FRQ was evaluated by measuring test-retest reliability and internal consistency.

Results: The self-rated FRQ was moderately strongly correlated with the BBS, TUG test, and 5TSTS test (r = 0.535 to 0.690; p < 0.001), and fairly correlated with the Thai-FRAT (r = 0.487; p < 0.001). Test-retest reliability of the self-rated FRQ was high, with a Kappa of 1. Internal consistency of the self-rated FRQ was excellent (Cronbach's alpha: 0.936).

Conclusions: The self-rated FRQ was found to be a valid and reliable tool for evaluating fall risk in older adults with osteoporosis. Since assessment of fall risk requires a multifaceted measurement tool, the self-rated FRQ is an appropriate tool that can be integrated into the fall risk assessment algorithm in older adults with osteoporosis.
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http://dx.doi.org/10.1186/s12891-020-03788-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677850PMC
November 2020

Cosmetic outcomes and patient satisfaction compared between staples and subcuticular suture technique for wound closure after primary total knee arthroplasty: a randomized controlled trial.

Arch Orthop Trauma Surg 2020 Sep 18;140(9):1255-1263. Epub 2020 May 18.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand.

Introduction: Staples and subcuticular suture are commonly used wound closure techniques after total knee arthroplasty (TKA). To date, only a few studies have investigated the differences between these two wound closure methods in TKA. Accordingly, this study aimed to compare cosmetic outcome and patient satisfaction between staples and subcuticular suture for post-TKA wound closure.

Materials And Methods: This prospective randomized controlled trial included patients scheduled to undergo TKA at the Department of Orthopaedic Surgery of Siriraj Hospital (Bangkok, Thailand) during June 2018-March 2019. Patients were randomized into the staples or subcuticular suture groups. Hollander Wound Evaluation Scale (HWES), cosmetic-visual analogue scale (VAS), and patient satisfaction-VAS were evaluated at the 6-week and 3-month follow-ups. Functional outcome by the modified Knee Society Knee Scoring System and wound complications were also assessed.

Results: Sixty-two patients (31 per group) were included. There were no significant differences in the HWES, cosmetic-VAS, patient satisfaction-VAS, or wound complication rate between groups at the 6-week or 3-month follow-ups. Wound closure time was significantly shorter in the staples group (p < 0.001), but the total operative time was not significantly different between groups. Modified knee score was significantly better in the suture group at 6 weeks (p = 0.024), but there was no significant difference between groups at 3 months. Significant association was observed between patient satisfaction-VAS and cosmetic-VAS at the 6-week (p = 0.03) and 3-month (p = 0.021) follow-ups.

Conclusion: Subcuticular suture and staples were found to be comparable wound-closure options after TKA relative to cosmetic outcome, patient satisfaction, functional outcome, and wound complication rate at 3-months post-operation.
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http://dx.doi.org/10.1007/s00402-020-03479-3DOI Listing
September 2020

Video-based learning versus traditional lecture-based learning for osteoporosis education: a randomized controlled trial.

Aging Clin Exp Res 2021 Jan 6;33(1):125-131. Epub 2020 Mar 6.

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi district, Bangkok, 10700, Thailand.

Background: Patient education about osteoporosis is an important component of osteoporosis treatment.

Aim: To compare the effectiveness of osteoporosis education between video-based learning and traditional lecture-based learning.

Methods: Participants who attended the Outpatient Department of Siriraj Hospital during June 2017 to November 2017 were recruited. Ten-question pre- and post-tests were used to evaluate participant osteoporosis knowledge. After finishing the pre-test, patients were randomized to receive osteoporosis education via either traditional lecture-based or video-based learning for 25 min. After the training, patient questions about the subject matter were answered, and then the post-test was administered. Change in score was compared between groups using non-inferiority test at a non-inferiority margin of - 1.

Results: Of 413 participants, 207 and 206 people were allocated to the lecture-based group and the video-based group, respectively. There were no significant differences in baseline characteristics, change in score between pre-test and post-test, or change in score between pre-test and retention test between groups. Non-inferiority test revealed the change in score after video-based learning to be non-inferior to traditional lecture-based learning at a difference of > - 1, α = 0.05 (p < 0.001).

Discussion: Video-based osteoporosis education can be used as part of a fracture liaison service to provide essential information about osteoporosis to both patients and caregivers. Video-based education is an efficient and effective tool that will reduce dependency on clinicians to provide lecture-based osteoporosis instruction.

Conclusions: Since video- and lecture-based education were found to be equally effective, a standard package for both education techniques should be developed and implemented for all patients.
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http://dx.doi.org/10.1007/s40520-020-01514-2DOI Listing
January 2021

Cost-effectiveness of denosumab for high-risk postmenopausal women with osteoporosis in Thailand.

J Med Econ 2020 Jul 28;23(7):776-785. Epub 2020 Feb 28.

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand.

This study assessed the cost-effectiveness of denosumab for treating postmenopausal women with osteoporosis (PMO) at high risk of fracture in Thailand. A published Markov cohort cost-effectiveness model was populated with country-specific data as available and other published data as needed. The model used a societal perspective, lifetime horizon, efficacy data from network meta-analysis of trials, and included costs for direct medical and non-medical care, informal care, and osteoporosis treatments to compare denosumab to no pharmacologic treatment (calcium and vitamin D supplements only) and to oral weekly alendronate. The base case (high-risk population) included postmenopausal women with femoral neck T-score ≤-2.5, mean age 65 years at entry, and history of vertebral fracture. High-risk women with osteoporosis using denosumab had the greatest number of life years and quality-adjusted life-years (QALYs) with higher reductions in hip and vertebral fracture incidence compared with patients with no pharmacologic treatment. The incremental cost-effectiveness ratio (ICER) was 119,575 Thai Baht (THB) per QALY for denosumab versus no pharmacologic treatment and 199,186 THB per QALY for denosumab versus alendronate. Among Thai postmenopausal women with high-risk of fractures, denosumab was cost-effective compared with no pharmacologic treatment at a willingness-to-pay threshold of 160,000 THB per QALY. One-way sensitivity analysis showed models were most sensitive to changes in denosumab pricing. Data from other countries used when country-specific data were unavailable may not accurately reflect the true experience in Thailand. The model focused explicitly on hip, vertebral, and wrist fractures, and therefore provides a conservative estimate of the overall potential impact of osteoporosis-related fracture. The fracture risk was not adjusted to reflect potential changes in risk after denosumab treatment discontinuation. In Thailand, denosumab offers a cost-effective osteoporosis treatment option versus no pharmacologic treatment in postmenopausal women at high risk of fracture.
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http://dx.doi.org/10.1080/13696998.2020.1730381DOI Listing
July 2020

Outcomes of cerclage wiring to manage intra-operative femoral fracture occurring during cementless hemiarthroplasty in older patients with femoral neck fractures.

Int Orthop 2019 11 9;43(11):2637-2647. Epub 2019 Apr 9.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

Background: Cementless hemiarthroplasty is a widely used treatment for femoral neck fractures. Intra-operative femoral fracture occasionally occurs during the procedure, and the use of cerclage wire has been proposed to stabilize both the prosthesis and the bone. This study aimed to investigate the outcomes of cerclage wiring to manage intra-operative fractures occurring during cementless hemiarthroplasty in older patients with a femoral neck fracture.

Methods: Medical records and radiographs of older patients with femoral neck fractures who underwent hemiarthroplasty during 2009 to 2015 were retrospectively reviewed. Patients who received cerclage wiring were matched with a demographically matched control group that did not. Patients were followed for at least 12 months. Functional outcomes and health-related quality of life were evaluated by determining the distance of distal stem migration, Barthel Index, EuroQol-visual analog scale (VAS), and pain-VAS.

Results: Eighty-one patients were included, comprising 27 study group and 54 control group patients. A tapered wedge-shaped femoral prosthesis was implanted in all cases. No significant differences in distance of distal stem migration or rate of stem subsidence > 2 mm were observed between the case and control groups (subsidence rate 11.1 vs. 14.8%, respectively). There was also no significant difference in functional outcomes between groups.

Conclusion: Our results revealed a low mean distance of distal stem migration and a low subsidence rate. Functional outcomes and quality of life were similar between the two groups. Cerclage wiring technique is safe, and it should be routinely performed when intra-operative femoral fracture occurs during cementless hemiarthroplasty.
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http://dx.doi.org/10.1007/s00264-019-04327-9DOI Listing
November 2019

Validity and responsiveness of Barthel index for measuring functional recovery after hemiarthroplasty for femoral neck fracture.

Arch Orthop Trauma Surg 2018 Dec 9;138(12):1671-1677. Epub 2018 Aug 9.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand.

Introduction: To investigate the validity of Barthel Index (BI) compared with de Morton Mobility Index (DEMMI), EuroQol-visual analog scale (EQ-VAS), 2-min walk test (2MWT), and timed get-up-and-go test (TUG), and to evaluate the responsiveness of all outcome measures for assessing functional recovery in older patients who underwent hemiarthroplasty after femoral neck fracture.

Material And Method: Eighty-one femoral neck fracture patients who were enrolled in a study evaluating functional recovery after bisphosphonate therapy during 2013 to 2015, and who had data available at both baseline and 12 months after surgery were included in this study.

Results: All scores improved significantly from baseline to the 1-year follow-up. BI had moderate to strong correlation with DEMMI, 2MWT, and TUG (r-value: 0.490-0.843), and mild to moderate correlation with EQ-VAS (r-value: 0.278-0.323). All outcome measurements had high effect estimates. The minimal clinically important difference (MCID) of BI at 12 months was 9.8 points.

Conclusion: Since BI was shown to have good validity (moderate to strong correlation with DEMMI and performance-based tests, and mild to moderate correlation with EQ-VAS), BI can be used to accurately assess functional recovery in patients who undergo hemiarthroplasty after femoral neck fracture.
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http://dx.doi.org/10.1007/s00402-018-3020-zDOI Listing
December 2018

Validity and Responsiveness of the Two-Minute Walk Test for Measuring Functional Recovery After Total Knee Arthroplasty.

J Arthroplasty 2018 06 31;33(6):1737-1744. Epub 2018 Jan 31.

Department of Orthopaedics, Rayong Hospital, Rayong, Thailand.

Background: The 2-minute walk test (2mwt) is a performance-based test that evaluates functional recovery after total knee arthroplasty (TKA). This study evaluated its validity compared with the modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), modified Knee Score, Numerical Pain Rating Scale, and Timed Up and Go test, and its responsiveness in assessing functional recovery in TKA patients.

Methods: This prospective cohort study included 162 patients undergoing primary TKA between 2013 and 2015. We used patient-reported outcome measures (modified WOMAC, OKS, modified Knee Score, Numerical Pain Rating Scale) and performance-based tests (2mwt and Timed Up and Go test) at baseline and 3, 6, and 12 months postoperatively. The construct validity of 2mwt was determined between the 2mwt distances walked and other outcome measurements. To assess responsiveness, effect size and standardized response mean were analyzed. Minimal clinically important difference of 2mwt at 12 months after TKA was also calculated.

Results: All outcome measurements improved significantly from baseline to 3, 6, and 12 months postoperatively. Bivariate analysis revealed mild to moderate associations between the 2mwt and modified WOMAC function subscales, and moderate to strong associations with OKS. Mild to moderate correlations were found for pain and stiffness between 2mwt and other outcome measurements. The effect size and standardized response mean at 12 months were large, with a minimal clinically important difference of 12.7 m.

Conclusion: 2mwt is a validated performance-based test with responsiveness properties. Being simple and easy to perform, it can be used routinely in clinical practice to evaluate functional recovery after TKA.
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http://dx.doi.org/10.1016/j.arth.2018.01.015DOI Listing
June 2018

PREVALENCE OF OSTEOPOROSIS AND HYPOVITAMINOSIS D AT SIRIRAJ METABOLIC BONE DISEASE CLINIC.

Acta Ortop Bras 2017 Nov-Dec;25(6):262-265

. Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Objective: To identify the prevalence of osteoporosis and hypovitaminosis D among patients at the Siriraj Metabolic Bone Disease (MBD) Clinic, and to compare initial vitamin D levels in patients with and without a history of fragility fractures.

Methods: Medical records of patients who attended our MBD clinic between 2012 and 2015 were retrospectively reviewed. Patient baseline demographic, clinical, bone mineral density (BMD), and laboratory data were collected and analyzed. Osteoporosis was diagnosed when patients had a BMD T-score <-2.5 or presented with fragility fractures.

Results: There were 761 patients included in this study. Of these, 627 patients (82.4%) were diagnosed with osteoporosis and 508 patients (66.8%) had fragility fractures. Baseline serum 25-hydroxyvitamin D (25(OH)D) levels were available in 685 patients. Of these, 391 patients (57.1%) were diagnosed with hypovitaminosis D. When evaluated only in patients with fragility fractures, the average initial 25(OH)D level was 28.2±11.6 ng/mL, and the prevalence of hypovitaminosis D was 57.6%.

Conclusion: A high prevalence of osteoporosis and hypovitaminosis D was found among patients at our clinic; two-thirds of patients had a history of fragility fractures, and no difference in initial 25(OH)D levels was seen between patients with and without fragility fractures.
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http://dx.doi.org/10.1590/1413-785220172506174133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5782860PMC
January 2018

Randomized clinical trial comparing efficacy and safety of brand versus generic alendronate (Bonmax®) for osteoporosis treatment.

PLoS One 2017 5;12(7):e0180325. Epub 2017 Jul 5.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Introduction: Although the same efficacy and tolerability are anticipated due to both drugs containing the same active ingredients, comparative studies between brand and generic alendronate are limited. Accordingly, the objective of this study was to compare efficacy and safety between brand alendronate and a recently introduced generic alendronate drug.

Methods: A total of 140 postmenopausal women or men aged older than 50 years who met the indications for osteoporosis treatment were randomized to receive either generic (Bonmax®) or brand alendronate (Fosamax®) 70 mg/week over a 12-month period during the May 2014 to June 2015 study period. Endpoints included bone mineral density (BMD) changes at the lumbar spine, total hip, and femoral neck; percentage of patients with predefined levels of change in total hip and lumbar spine BMD at 12 months; and, changes in biochemical bone markers at 3, 6, and 12 months. Tolerability was evaluated by patient self-reporting of adverse experiences.

Results: At 12 months post-treatment, BMD significantly increased at all sites in both groups. There were no differences in BMD percentage changes or the number of patients with stable or increased BMD after 1 year between groups. No significant differences in the amount of biochemical bone marker reduction or incidence of adverse events were observed between groups.

Conclusions: Generic and brand alendronate produced similar gains in BMD and reduction in bone turnover markers. Both medicadoitions were also equally well-tolerated. Based on these findings, generic alendronate (Bonmax®) is a viable alternative to the original brand of alendronate.

Trial Registration: ClinicalTrials.gov NCT02371252.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0180325PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5498028PMC
October 2017

Effect of bisphosphonate initiation at week 2 versus week 12 on short-term functional recovery after femoral neck fracture: a randomized controlled trial.

Arch Osteoporos 2017 Dec 10;12(1):27. Epub 2017 Mar 10.

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.

The appropriate time to initiate bisphosphonate treatment after a fragility fracture has not yet been established. In this study, we found no significant differences in short-term functional recovery between femoral neck fracture patients who received bisphosphonate treatment at 2 versus 12 weeks after hemiarthroplasty.

Introduction: Bisphosphonate is the mainstay therapy for prevention and treatment of osteoporosis. The aim of this study was to investigate the effect of bisphosphonate initiation on short-term functional recovery in femoral neck fracture patients at 2 versus 12 weeks after hemiarthroplasty.

Methods: One hundred patients were randomly allocated into two groups in a parallel group designed, randomized, controlled trial. Both groups received risedronate 35 mg/week at either 2 or 12 weeks after hemiarthroplasty. All patients received calcium and vitamin D supplementation. Functional recovery was assessed by de Morton Mobility Index, Barthel Index, EuroQol 5D, visual analog scale, 2-min walk test, and timed get-up-and-go test at 2 weeks, 3 months, and 1 year after surgery.

Results: At the 3-month follow-up, all functional outcome measures showed significant improvement in both groups. There were no statistically significant differences in any of the functional outcomes between groups at both the 3-month and 1-year follow-ups. Although patients who received bisphosphonate initiation at week 2 had lower serum calcium level at 3 months and more overall adverse events than patients in the week 12 group, no patients in either group discontinued their prescribed medications.

Conclusions: While underpowered, the findings of this study suggest that there were no significant differences in short-term functional recovery or significant adverse events between the two bisphosphonate groups. Thus, the initiation of bisphosphonate therapy may be considered as early as 2 weeks after femoral neck fracture. It is important that low serum calcium and vitamin D status must be corrected with calcium and vitamin D supplementation prior to or at the time of bisphosphonate initiation.

Clinical Trial Registration Number: This study was registered in the database via the Protocol Registration and Results System (PRS) (NCT02148848).
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http://dx.doi.org/10.1007/s11657-017-0321-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346124PMC
December 2017

The Prevalence of Hypovitaminosis D in Patient with Fragility Hip Fracture at a Single Institution in Thailand.

J Med Assoc Thai 2016 Nov;99(11):1233-8

Background: The proportion of people aged 65 years or older continues to increase in Thailand. Consistent with that trend, the number of fragility fracture patients is increasing. Hypovitaminosis D is one of the important factors associated with fragility fracture.

Objective: To evaluate serum 25-hydroxyvitamin D (25(OH)D) level and prevalence of hypovitaminosis D in patients with fragility hip fracture in Thailand.

Material And Method: This study retrospectively reviewed 25(OH)D level in fragility hip fracture patients treated at Siriraj Hospital between January 2012 and December 2015.

Results: Three hundred seventy nine fragility hip fractures were included in this study. Two hundred sixty eight of those patients had serum 25(OH)D level available within one month after fracture. Mean age of patients was 80.8±8.3 years and 74.6% were women. One hundred twenty four patients (46.3%) had vitamin D deficiency (<20 ng/mL) and 86 patients (32.1%) had vitamin D insufficiency (20 to 30 ng/mL). Parathyroid hormone level was available in 159 of 268 patients, and 31.5% of those had hyperparathyroidism (PTH level >65 pg/mL).

Conclusion: Orthopedists who treat fragility hip fracture should always include treatment of vitamin D deficiency in their patient management plan. Future studies should establish treatment guidelines regarding dose and duration of vitamin D supplementation in fragility hip fracture patients.
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November 2016

Prevalence of atypical femoral fractures in Thai patients at a single institution.

J Med Assoc Thai 2014 Jun;97(6):635-43

Objective: Evaluate the prevalence of atypical femoral fracture (AFF) in Thai patients at a single institution based on the 2010 and 2013 American Society of Bone and Mineral Research (ASBMR) criteria and the sensitivity and specificity of each radiographic feature of AFF to identify bisphosphonate treatment.

Material And Method: The authors retrospectively reviewed plain radiographs of 856 patients who were diagnosed with subtrochanteric or femoral shaft fractures between 2002 and 2013. Only those who had major radiographic features of AFF according to the 2010 ASBMR criteria were included. Next, the prevalence of atypical fracture was recalculated based on the revised 2013 ASBMR criteria. Furthermore, the specificity and sensitivity of each radiological finding to detect bisphosphonate treatment were calculated.

Results: The prevalence of atypical femoral fracture based on 2010 ASBMR criteria at this institution was 5.7%. Two patients had all radiographic features of AFF but sustained a high-energy trauma and could be diagnosed with AFF based on the 2013 ASBMR criteria. Among all of the radiographic features to define AFF, a localized periosteal thickening of the lateral femoral cortex was the most specific sign to detect bisphosphonate treatment (0.98; 95% CI 0.96-0.99).

Conclusion: The prevalence of AFF in Thai patients at a single institution was approximately 6%. Although the prevalence of AFF did not dramatically change after applying the 2013 revised ASBMR criteria, this reflected some gap in the diagnosis criteria, which should require further refinement. The authors suggested that the ASBMR criteria should be used only with those having acute fractures.
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June 2014

Extra-articular knee lesion with high fluorodeoxyglucose-uptake on positron emission tomography.

Bull Hosp Jt Dis (2013) 2013 ;71(2):170-4

Pigmented villonodular synovitis (PVNS) is an uncommon musculoskeletal tumor that is typically benign and often diagnosed radiologically by magnetic resonance imaging (MRI). Fluorodeoxyglucose (FDG)-uptake positron emission tomography (PET) is an imaging tool primarily used in oncology to evaluate malignancy. FDG measures metabolic activity with standardized uptake value (SUV). A high SUV is suggestive of malignancy. We report a case of PVNS detected incidentally by FDG-PET as an extracapsular mass adherent to vastus medialis tendon with a high SUV of 15.1. Given the patient's history of cancer and the high SUV, the lesion was initially considered a malignancy. The objective of this case report is to illustrate that even a high-SUV mass detected with PET imaging does not necessarily indicate malignancy, and thus a benign lesion can also demonstrate such elevated signal.
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May 2014

Minimally invasive and standard total knee arthroplasty result in similar clinical outcomes at a minimum of five-year follow-up.

J Med Assoc Thai 2012 Sep;95 Suppl 9:S29-35

Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Although a minimally invasive total knee arthroplasty (MIS-TKA)fails to show superior short-term clinical results over a standard technique, the longer-term outcomes remain unknown.

Objective: Evaluate the intermediate clinical outcomes of MIS-TKA, comparing to those of standard technique.

Material And Method: The authors retrospectively collected data from the patients who underwent uncomplicated total knee arthroplasty between March 2004 and December 2005. Patients with a body mass index (BMI) over 30 kg/m2 or with severe deformity and those who required a complex surgical procedure were excluded. Patients were divided into 2 groups based on the surgical approach: 27patients (31 knees) and 26 patients (33 knees) for the MIS-TKA and standard TKA, respectively. Pre- and perioperative data were collected. Clinical and functional outcomes were followed-up to a minimum of 5 years.

Results: The means follow-up in the MIS- and standard TKA groups were 73 and 74 months, respectively. Pre- and perioperative data did not show any differences between the two groups except for more females and lower BMI in the MIS-TKA group. At 2- and 5-year post-operative follow-up, the knee society pain and functional scores improved significantly in both groups (p < 0.001). There were no differences in the postoperative alignment, range of motion and the knee society scores between MIS- and standard TKA. In addition, post-operative complications were similar in both groups (2 manipulations under anesthesia and 1 traumatic rupture of patellar tendon in each group).

Conclusion: The present study showed that there were no differences in the intermediate-term post-operative function between MIS-TKA and standard TKA in a well-selected patient population. Thus, orthopedic surgeons should not compromise their surgical exposure by using small and unfamiliar surgical technique. Since MIS-technique may increase the postoperative complication rate, a long-term study to evaluate the results of MIS-TKA is still needed.
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September 2012

Atypical femoral fractures: what do we know about them?: AAOS Exhibit Selection.

J Bone Joint Surg Am 2013 Jan;95(2):e8 1-13

Department of Orthopaedic Surgery, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi District, Bangkok, Thailand.

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http://dx.doi.org/10.2106/JBJS.L.00568DOI Listing
January 2013

Low vitamin D status does not adversely affect short-term functional outcome after total hip arthroplasty.

J Arthroplasty 2013 Feb 13;28(2):315-322.e2. Epub 2012 Jul 13.

Department of Orthopaedic Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand.

We prospectively measured functional performances (Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-36, 2-minute walk test, and timed get-up-and-go test) of patients who underwent total hip arthroplasty (THA) and had serum vitamin D levels tested during the preoperative evaluation. Of 219 patients, 102 (46.6%) had low vitamin D levels (25-hydroxyvitamin D<30 ng/mL). Low vitamin D status did not adversely affect short-term function at 6 weeks after THA. In addition, there was no association between serum vitamin D levels and the within-patient changes of scores of each outcome measurement. Because this 6-week period is generally adequate to correct vitamin D deficiency, orthopedic surgeons can safely perform THA without delay. Nevertheless, because vitamin D deficiency impairs bone quality, patients with low vitamin D levels should be treated once identified.
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http://dx.doi.org/10.1016/j.arth.2012.04.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037853PMC
February 2013

The effect of therapies for osteoporosis on spine fusion: a systematic review.

Spine J 2013 Feb 1;13(2):190-9. Epub 2012 Jun 1.

Department of Orthopaedic Surgery, University of Miami/Jackson Health System, PO Box 016960 (D-27), Miami, FL 33101, USA.

Background Context: Fusion of the spine requires de novo bone formation and remodeling, processes that rely heavily on the action of the osteoblast and osteoclast. Bisphosphonate drugs and intermittent parathyroid hormone (PTH) therapy are widely prescribed to treat osteoporosis and act on the osteoblast/osteoclast complex. The impact of these medications on spine fusion is not known.

Purpose: To evaluate the available evidence on the potential impact of bisphosphonates and PTH on fusion rate and fusion quality in spinal arthrodesis.

Study Design: A systematic review of the literature.

Patient Sample: All available literature regarding the impact of bisphosphonates and PTH on spinal fusion.

Outcome Measures: Fusion rate and histologic, microstructural, or biomechanical measures of fusion quality.

Methods: A systematic review of the literature published between 1980 and 2011 was conducted using major electronic databases. The results of studies meeting criteria for inclusion were then aggregated and examined for consensus on the effect of these medications on spine fusion.

Results: The literature contained 18 animal studies and one clinical trial investigating the impact of these medications on spine fusion. Most animal studies evaluating the impact of bisphosphonates on fusion rate have not found statistically significant changes with treatment, although this fact may be attributable to low statistical power. The animal literature does suggest that bisphosphonate therapy results in a less histologically mature fusion mass; however, the impact of these changes on fusion mass biomechanics is unclear. The only available human study suggests that these bisphosphonates may increase the radiographically defined fusion rate but did not demonstrate an impact on clinical outcome. In animals, PTH improves the fusion rate and fusion mass microstructure, but data on its effect on fusion mass biomechanics are lacking. No studies have evaluated the impact of PTH on spine fusion in humans.

Conclusions: In animals, bisphosphonate therapy appears to impede maturation of the fusion mass, with an unclear effect on mechanical strength. This effect was not seen in the lone human study, which suggested that these medications improved the radiographically defined fusion rate. The available animal studies on intermittent PTH treatment suggest that it may improve fusion rate and fusion mass microstructure. Given the widespread use of these agents, further investigation into their impact on human spine fusion is necessary to inform the care of patients with osteoporosis who are undergoing spine surgery.
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http://dx.doi.org/10.1016/j.spinee.2012.03.035DOI Listing
February 2013

Atypical femoral fractures: epidemiology, etiology, and patient management.

Curr Opin Support Palliat Care 2012 Sep;6(3):348-54

Materials Science and Engineering, Cornell University, Ithaca, New York, USA.

Purpose Of Review: To review the definition, epidemiology, and putative pathophysiology of atypical femoral fractures and propose strategies for the management of patients with atypical fractures as well as patients on long-term bisphosphonates without atypical fractures.

Recent Findings: Recent epidemiologic evidence shows that the absolute incidence of atypical femoral fractures is small compared with the incidence of typical hip fractures. However, long-term bisphosphonate use may be an important risk factor for atypical fractures, and minimal additional antifracture benefit has been demonstrated for treatment durations longer than 5 years for patients with postmenopausal osteoporosis. This review gives advice to aid clinicians in the management of patients with incipient or complete atypical fractures.

Summary: Extremely limited evidence is available for how best to manage patients with atypical fractures. A comprehensive metabolic approach for the management of patients on long-term bisphosphonates will help to prevent oversuppression of bone remodeling that is implicated in the pathogenesis of these fractures.
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http://dx.doi.org/10.1097/SPC.0b013e3283552d7dDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556525PMC
September 2012

Multimodality treatment of a multifocal osteoblastoma-like tumor of the lower extremity.

Skeletal Radiol 2012 Sep 13;41(9):1153-61. Epub 2012 Feb 13.

Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA.

Osteoblastoma-like tumor is a rare condition with limited information on its orthopedic management in the current medical literature. The tumor histologically resembles an osteoblastoma, although the radiographic features are similar to those observed in primary vascular lesions. The treatment in the previously reported cases involved aggressive procedures including amputation, en bloc resection, and chemotherapy because of the uncertainty regarding the biological behavior of the tumor. We present a case of this entity that was successfully treated by a combination therapy including intralesional curettage with adjuvant cryotherapy, in situ and intravenous administration of bisphosphonates and radioablation.
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http://dx.doi.org/10.1007/s00256-011-1345-6DOI Listing
September 2012

Performance-based tests and self-reported questionnaires provide distinct information for the preoperative evaluation of total hip arthroplasty patients.

J Arthroplasty 2012 May 29;27(5):770-5.e1. Epub 2011 Sep 29.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, USA.

Our objectives were to assess relationships between self-reported questionnaires and 2-minute walk test (2MWT) and timed get-up-and-go test (TUG) in preoperative total hip arthroplasty patients. A total of 162 patients completed the Western Ontario and McMaster Universities Osteoarthritis Index and Short Form 36 and performed 2MWT and TUG. Correlations between self-reported questionnaires and 2MWT and TUG were mild to moderate, indicating that the 2MWT and TUG capture additional dimensions of preoperative total hip arthroplasty function not measured by the Western Ontario and McMaster Universities Osteoarthritis Index and Short Form 36. Use of walking aids, female sex, and presence of other painful joints were significantly associated with 2MWT, whereas older age and additional painful joints were significantly associated with TUG. These 2 tests are easy to perform in clinical practice and contribute to a comprehensive assessment of preoperative status.
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http://dx.doi.org/10.1016/j.arth.2011.08.005DOI Listing
May 2012

A fracture does not adversely affect bone mineral density responses after teriparatide treatment.

Clin Orthop Relat Res 2012 Mar 24;470(3):927-36. Epub 2011 Aug 24.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.

Background: Fracture leads to local and systemic catabolic physiologic changes. As teriparatide is an agent used to treat osteoporosis in patients with fragility fractures, it is unclear whether teriparatide treatment alters bone mineral density (BMD) and bone markers when given to patients with fractures.

Questions/purposes: We asked whether BMD and bone marker responses would be blunted in patients with fractures placed on teriparatide after fracture compared with patients without fractures on teriparatide.

Patients And Methods: We retrospectively collected data from 141 patients treated with teriparatide for osteoporosis. Seventy-seven patients received teriparatide after fractures (fracture group), whereas 64 were treated for other indications (nonfracture group). We determined BMD at the lumbar spine and at the proximal femur before and 12 and 24 months posttreatment. Bone markers (urine N-telopeptide [urine NTX], bone-specific alkaline phosphatase [BALP]) were measured at baseline and 3, 12, and 24 months posttreatment.

Results: Mean lumbar spine and hip BMDs at last followup increased from baseline with no differences between groups to approximately 9% and 4% at 24 months, respectively. Both bone markers increased from baseline in the nonfracture group, peaking at 12 months. For the fracture group, only urine NTX increased at 3 and 12 months posttreatment. Although the peak levels of both bone markers in the nonfracture group were greater, there was no difference between the two groups.

Conclusions: Fracture does not have a negative effect on the BMD and bone marker responses to teriparatide treatment. Clinicians should anticipate comparable BMD responses when treating patients with teriparatide for osteoporotic fractures and for other indications.

Level Of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1007/s11999-011-2029-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3270178PMC
March 2012

Bilateral pathologic hip fractures associated with antiretroviral therapy: a case report.

J Bone Joint Surg Am 2011 Jul;93(14):e78

Weill Cornell Medical College, Cornell University, 1300 East 70th Street, New York, NY 10021, USA.

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http://dx.doi.org/10.2106/JBJS.J.00885DOI Listing
July 2011

The effect of long-term alendronate treatment on cortical thickness of the proximal femur.

Clin Orthop Relat Res 2012 Jan 20;470(1):291-8. Epub 2011 Jul 20.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.

Background: One of the radiographic hallmarks in patients with atypical femoral insufficiency fractures after prolonged bisphosphonate treatment is generalized cortical hypertrophy. Whether cortical thickening in the proximal femur is caused by long-term alendronate therapy, however, remains unknown.

Questions/purposes: We asked whether long-term alendronate use of 5 years or more results in progressive thickening of the subtrochanteric femoral cortices.

Patients And Methods: We retrospectively evaluated changes in cortical thickness and cortical thickness ratio (ratio of cortical to femoral shaft diameter) at the subtrochanteric region of the proximal femur in baseline and latest hip dual-energy xray absorptiometry (DXA) scans of 131 patients. The mean followup was 7.3 years. Patients were divided into two groups: control (no history of alendronate, 45 patients) and alendronate (history of alendronate ≥ 5 years, 86 patients). We determined cortical thickness and cortical thickness ratio at 3.5 and 4.0 cm below the tip of the greater trochanter, representing the subtrochanteric region.

Results: After a minimum of 5 years followup, mean cortical thickness decreased approximately 3% in the alendronate and control groups. The cortical thickness at the subtrochanteric femoral region changed less than 1 mm in greater than 90% of the patients with long-term alendronate treatment. We observed no differences in mean changes of cortical thickness and percent changes of cortical thickness between the two groups.

Conclusions: Long-term alendronate treatment did not appear to cause thickened femoral cortices within the detection limits of our method. This finding contrasts with the notion that long-term alendronate treatment leads to generalized cortical thickening.
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http://dx.doi.org/10.1007/s11999-011-1985-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237985PMC
January 2012

Does vitamin D status affect the attainment of in-hospital functional milestones after total hip arthroplasty?

J Arthroplasty 2012 Mar 12;27(3):482-9. Epub 2011 Jul 12.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Our study aims to identify the prevalence of low vitamin D status in patients undergoing total hip arthroplasty (THA) and to evaluate the association between serum vitamin D level and the attainment of in-hospital functional milestones. We collected data from patients who underwent THA and had preoperative serum vitamin D (serum 25-hydroxy vitamin D) levels measured. From 200 patients, 79 (39.5%) had low serum vitamin D (serum 25-hydroxy vitamin D <32 ng/mL). There were no associations between serum vitamin D level and the attainment of in-hospital functional milestones as well as length of hospital stay or perioperative complications after THA. Because low vitamin D status did not compromise the short-term functional outcomes after THA, surgery need not be delayed, but low vitamin D levels should be corrected once identified.
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http://dx.doi.org/10.1016/j.arth.2011.05.023DOI Listing
March 2012

A comprehensive approach to fragility fractures.

J Orthop Trauma 2011 Sep;25(9):566-73

Weill Cornell Medical College, Cornell University, New York, NY, USA.

To address the cause of fragility fractures, an understanding of the determinants of bone strength is needed. Identifying patients at increased fracture risk should take into account bone quantity, quality, and turnover. Postmenopausal osteoporosis remains the most common derangement of bone strength; however, decreased bone strength can also result from secondary causes of osteoporosis. In order to properly manage patients with fragility fractures, assessment should include a focused medical history and physical examination, proper laboratory investigation, dual-energy x-ray absorptiometry screening, and, if necessary, use of the fracture risk assessment tool (FRAX). Treatment options will include nonpharmacologic treatment such as calcium and vitamin D and pharmacologic treatment with antiresorptive or anabolic agents to prevent future fractures. Bisphosphonates remain the standard treatment for osteoporosis. Concerns of oversuppression of bone turnover on long-term bisphosphonate treatment can be addressed with a drug holiday depending on the patient's fracture risk. An anabolic agent such as teriparatide is a powerful tool for the prevention of fragility fractures and should be reserved for patients at high risk for fracture, such as those with declining bone mineral density despite bisphosphonate treatment. Careful evaluation of all patients with a fragility fracture will enable the orthopaedic surgeon to identify the cause of fracture and implement a treatment plan that can prevent subsequent fractures in this vulnerable population.
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http://dx.doi.org/10.1097/BOT.0b013e3181f9b389DOI Listing
September 2011

Multifocal osteomyelitis with Streptococcus pneumoniae in a patient with Waldenström macroglobulinemia: a case report.

J Bone Joint Surg Am 2011 May;93(9):e46

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.

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http://dx.doi.org/10.2106/JBJS.J.00695DOI Listing
May 2011
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