Publications by authors named "Paul A Anderson"

260 Publications

A Multicenter Evaluation of the Feasibility, Patient/Provider Satisfaction, and Value of Virtual Spine Consultation During the COVID-19 Pandemic.

World Neurosurg 2021 Aug 10. Epub 2021 Aug 10.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Objective: To assess the feasibility, patient/provider satisfaction, and perceived value of telehealth spine consultation after rapid conversion from traditional in-office visits during the COVID-19 pandemic.

Methods: Data were obtained for patients undergoing telehealth visits with spine surgeons in the first 3 weeks after government restriction of elective surgical care at 4 sites (March 23, 2020, to April 17, 2020). Demographic factors, technique-specific elements of the telehealth experience, provider confidence in diagnostic and therapeutic assessment, patient/surgeon satisfaction, and perceived value were collected.

Results: A total of 128 unique visits were analyzed. New (74 [58%]), preoperative (26 [20%]), and postoperative (28 [22%]) patients were assessed. A total of 116 (91%) visits had successful connection on the first attempt. Surgeons felt very confident 101 times (79%) when assessing diagnosis and 107 times (84%) when assessing treatment plan. The mean and median patient satisfaction was 89% and 94%, respectively. Patient satisfaction was significantly higher for video over audio-only visits (P < 0.05). Patient satisfaction was not significantly different with patient age, location of chief complaint (cervical or thoracolumbar), or visit type (new, preoperative, or postoperative). Providers reported that 76% of the time they would choose to perform the visit again in telehealth format. Sixty percent of patients valued the visit cost as the same or slightly less than an in-office consultation.

Conclusions: This is the first study to demonstrate the feasibility and high patient/provider satisfaction of virtual spine surgical consultation, and appropriate reimbursement and balanced regulation for spine telehealth care is essential to continue this existing work.
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http://dx.doi.org/10.1016/j.wneu.2021.08.004DOI Listing
August 2021

Own the Fall: AOA Critical Issues.

J Bone Joint Surg Am 2021 Jun 30. Epub 2021 Jun 30.

Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota.

Abstract: Falls are the most common cause of injury to older patients, resulting in >3 million emergency room visits per year and 290,000 hip fractures annually in the United States. Orthopaedic surgeons care for the majority of these patients; however, they are rarely involved in the assessment of fall risk and providing prevention strategies. Falls also occur perioperatively (e.g., in patients with arthritis and those undergoing arthroplasty). Preoperatively, up to 40% of patients awaiting joint arthroplasty sustain a fall, and 20% to 40% have a fall postoperatively. Risk factors for falls include intrinsic factors such as age and comorbidities that are not modifiable as well as extrinsic factors, including medication reconciliation, improvement in the environment, and the management of modifiable comorbidities that can be optimized. Simple in-office fall assessment tools are available that can be adapted for the orthopaedic practice and be used to identify patients who would benefit from rehabilitation. Orthopaedic surgeons should incorporate these strategies to improve care and to reduce fall risk and associated adverse events.
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http://dx.doi.org/10.2106/JBJS.20.02254DOI Listing
June 2021

Lower Hounsfield Units at the Upper Instrumented Vertebrae are Significantly Associated With Proximal Junctional Kyphosis and Failure Near the Thoracolumbar Junction.

Oper Neurosurg (Hagerstown) 2021 Sep;21(4):270-275

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: Low bone mineral density (BMD) on dual energy x-ray absorptiometry (DXA) is likely a risk factor for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). However, prior instrumentation and degenerative changes can preclude a lumbar BMD measurement. Hounsfield units (HU) represent an alternative method to estimate BMD via targeted measurements at the intended operative levels.

Objective: To determine if patients with lower HU at the upper instrumented vertebrae (UIV) and vertebral body superior to the UIV (UIV + 1) are at greater risk for PJK and PJF.

Methods: A retrospective chart review identified patients at least 50 yr of age who underwent instrumented lumbar fusion with pelvic fixation, a UIV from T10 to L2, and a preoperative computed tomography (CT) encompassing the UIV. HU were measured at the UIV, UIV + 1, and the L3-L4 vertebral bodies.

Results: A total of 150 patients (80 women and 70 men) were included with an average age of 66 yr and average follow-up of 32 mo. Multivariable logistic regression analysis with an area under the curve (AUC) of 0.89 demonstrated HU at the UIV/UIV + 1 as the only independent predictor of PJK/PJF with an odds ratio of 0.94 (P-value = .031) for a change in a single HU. Patients with HU at UIV/UIV + 1 of <110 (n = 35), 110 to 160 (n = 73), and >160 (n = 42) had a rate of PJK/PJF of 63%, 27%, and 12%, respectively (P-value < .001).

Conclusion: Patients with lower HU at the UIV and UIV + 1 were significantly associated with PJK and PJF, with an optimal cutoff of 122 HU that maximizes sensitivity and specificity.
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http://dx.doi.org/10.1093/ons/opab236DOI Listing
September 2021

Improving Secondary Fracture Prevention After Vertebroplasty: Implementation of a Fracture Liaison Service.

J Am Coll Radiol 2021 Sep 22;18(9):1235-1238. Epub 2021 Jun 22.

Director of Musculoskeletal Ultrasound and Fellowship Director for Musculoskeletal Imaging and Intervention, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Objective: The aim of our study was to evaluate a multidisciplinary fracture liaison service (FLS) to improve osteoporosis treatment and secondary fracture prevention for patients after vertebroplasty.

Methods: A retrospective chart review of consecutive vertebroplasty patients from January 2016 to January 2020. FLS began in December 2016 allowing for before-and-after comparison. Statistical analysis included patient demographics and procedure characteristics. Proportion of patients evaluated by the FLS clinic and treatment modification were evaluated. Opt-in versus opt-out referral strategies were compared. Dual energy x-ray absorptiometry scans or vitamin D levels within 3 months before or after vertebroplasty were assessed. Time to event analysis was used to evaluate secondary fracture occurrence.

Results: There were 137 vertebroplasty patients, 39 before FLS and 98 after FLS, included. Only 15% of all patients were already being treated in a bone health clinic. Of those referred and evaluated by the FLS, 73.0% had their osteoporosis treatment modified. Patients evaluated by the FLS were more likely to have a dual energy x-ray absorptiometry scan or a vitamin D level drawn (P < .001 for both). The opt-out referral was more effective with a 75.0% referral rate (P = .71). Secondary fracture of any kind occurred in 23.4% of all patients. Time to event analysis demonstrated a trend toward a reduced risk of secondary spinal fractures in the fracture prevention group with an adjusted hazard ratio of 0.39 (0.13-1.11, 95% confidence interval).

Discussion: A multidisciplinary FLS can be implemented for patients after vertebroplasty to evaluate osteoporotic risk factors and optimize osteoporosis therapy, both of which are important factors in preventing secondary vertebral fractures.
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http://dx.doi.org/10.1016/j.jacr.2021.06.004DOI Listing
September 2021

Cervical fusion for treatment of degenerative conditions: development of appropriate use criteria.

Spine J 2021 Sep 1;21(9):1460-1472. Epub 2021 Jun 1.

Department of Neurosurgery, Lahey Hospital & Medical Center, 41 Mall Road Charles A, Tufts University School of Medicine, Burlington, MA 01805-0105, USA.

Background Context: High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking.

Purpose: Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine.

Study Design/setting: Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations.

Outcome Measures: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters.

Methods: Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed.

Results: Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance.

Conclusions: Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."
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http://dx.doi.org/10.1016/j.spinee.2021.05.023DOI Listing
September 2021

Teriparatide Treatment Increases Hounsfield Units in the Thoracic Spine, Lumbar Spine, Sacrum, and Ilium Out of Proportion to the Cervical Spine.

Clin Spine Surg 2021 Aug;34(7):E370-E376

Department of Neurological Surgery, Mayo Clinic.

Study Design: This was a retrospective chart review.

Objective: The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA).

Summary Of Background Data: HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA.

Materials And Methods: A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available.

Results: One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA.

Conclusions: Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA.
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http://dx.doi.org/10.1097/BSD.0000000000001203DOI Listing
August 2021

Prevalence and Treatment of Osteoporosis Prior to Elective Shoulder Arthroplasty.

J Am Acad Orthop Surg Glob Res Rev 2020 12 7;4(12):e20.00204. Epub 2020 Dec 7.

From the Department of Orthopedics & Rehabilitation (Dr. Bernatz, Dr. Brooks, Mr. Nguyen, Mr. Shin, Dr. Anderson, and Dr. Grogan), and the Divisions of Endocrinology and Geriatrics, Department of Medicine (Dr. Binkley), University of Wisconsin School of Medicine and Public Health, Madison.

Introduction: The rate of preoperative osteoporosis in lower extremity arthroplasty is 33%. The prevalence of osteoporosis in shoulder arthroplasty patients is inadequately studied. The purpose of this study was to (1) determine the prevalence of osteoporosis in patients undergoing elective shoulder arthroplasty, (2) report the percentage of patients having dual-energy x-ray absorptiometry (DEXA) testing before surgery, and (3) determine the percentage of patients who have been prescribed osteoporosis medications within 6 months before or after surgery.

Methods: This retrospective case series included all adults aged 50 years and older who underwent elective shoulder arthroplasty at a single tertiary care center over an 8-year period. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied.

Results: Two hundred fifty-one patients met the inclusion criteria; 171 (68%) met the criteria for DEXA testing, but only 31 (12%) had this testing within 2 years preoperatively. Eighty patients (32%) met the NOF criteria for receipt of pharmacologic osteoporosis treatment, and 17/80 (21%) received a prescription for pharmacotherapy.

Discussion: Two-thirds of elective shoulder arthroplasty patients meet the criteria to have bone mineral density measurement done, but less than 20% have this done. One in three elective shoulder arthroplasty patients meet the criteria to receive osteoporosis medications, but only 20% of these patients receive therapy.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722598PMC
December 2020

Opportunistic use of dual-energy X-ray absorptiometry to evaluate lumbar scoliosis.

Arch Osteoporos 2021 02 23;16(1):38. Epub 2021 Feb 23.

Department of Orthopedics and Rehabilitation, Medical Foundation Centennial Building, University of Wisconsin, 1685 Highland Ave, 6th floor, Madison, WI, 53705-2281, USA.

Low bone mineral density is associated with spinal deformity. Dual-energy X-ray absorptiometry (DXA), a modality that assesses bone density, portends a theoretical means to also assess spinal deformity. We found that DXA can reliably assess spine alignment. DXA may permit surveillance of spine alignment, i.e., scoliosis in the clinical setting.

Purpose: Osteoporosis and scoliosis are interrelated disease processes. Dual-energy X-ray absorptiometry (DXA), used to assess bone density, can also be used to evaluate spinal deformity since it captures a posteroanterior (PA) image of the lumbar spine. We assessed the use of DXA to evaluate lumbar spine alignment.

Methods: A lumbar spine DXA phantom was used to assess the effects of axial and sagittal plane rotation on lumbar bone mineral content (BMC), density (BMD), and L1-L4 Cobb angle measurements. Using two subject cohorts, intra- and inter-observer reliability and validity of using DXA for L1-L4 Cobb angle measurements in the coronal and sagittal planes were assessed.

Results: Axial and sagittal plane rotation greater than 15° and 10°, respectively, significantly reduced measured BMD and BMC; there was minimal effect on Cobb angle measurement reliability. In human subjects, excellent intra- and inter-observer reliability was observed using lumbar PA DXA images for Cobb angle measurements. Agreement between Cobb angles derived from lumbar PA DXA images and AP lumbar radiographs ranged from good to excellent. The mean difference in Cobb angles between supine lumbar PA DXA images and upright AP lumbar radiographs was 2.8° in all subjects and 5.8° in those with scoliosis.

Conclusions: Lumbar spine rotation does not significantly affect BMD and BMC within 15° and 10° of axial and sagittal plane rotation, respectively, and minimally affects Cobb angle measurement. Spine alignment in the coronal plane can be reliably assessed using lumbar PA DXA images.
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http://dx.doi.org/10.1007/s11657-021-00898-6DOI Listing
February 2021

Osteoporosis: Recent Recommendations and Positions of the American Society for Bone and Mineral Research and the International Society for Clinical Densitometry.

J Bone Joint Surg Am 2021 Apr;103(8):741-747

Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin.

: Osteoporosis is common in orthopaedic patients, not only in those sustaining fragility fractures but also in patients ≥50 years old who are having elective orthopaedic surgery.

: The American Society for Bone and Mineral Research (ASBMR) has developed consensus-based recommendations for secondary fracture prevention for all patients who are ≥65 years old with a hip or spine fracture.

: The ASBMR encourages orthopaedic surgeons to "Own the Bone," by beginning prevention of a secondary fracture during hospitalization for a fragility fracture, if practicable, and arranging follow-up for continued bone health care after discharge.

: The International Society for Clinical Densitometry (ISCD) recognized that many poor outcomes and complications of elective orthopaedic surgery are related to osteoporosis.

: The ISCD used an evidence-based approach to create official positions to identify which patients ≥50 years old who are having elective orthopaedic surgery should undergo assessment of bone health and how this should be performed.
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http://dx.doi.org/10.2106/JBJS.20.01248DOI Listing
April 2021

Undertreatment After Pelvic Fragility Fractures: Commentary on an article by Christian T. Smith, MS, et al.: "Pelvic Fragility Fractures. An Opportunity to Improve the Undertreatment of Osteoporosis".

Authors:
Paul A Anderson

J Bone Joint Surg Am 2021 02;103(3):e11

Department of Orthopedic Surgery & Rehabilitation, University of Wisconsin, Madison, Wisconsin.

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http://dx.doi.org/10.2106/JBJS.20.01913DOI Listing
February 2021

The Basics of Bone Physiology, Healing, and Osteoporosis.

Instr Course Lect 2021 ;70:527-536

Osteoporosis is a skeletal condition characterized by decreased bone mineral density and poor bone quality with resultant greater fracture risk. There has been a focus on bone mineral density deficiency, which is easily measured with dual-energy x-ray absorptiometry and managed with pharmaceutic medications. More recently, impaired bone quality independent of bone mineral density has been recognized as a potential cause of fragility fracture and poor bone healing. Many conditions lead to poor bone quality; the most common is vitamin D deficiency and others are genetic causes and other nutritional deficits. In addition, the cellular and molecular changes associated with osteoporosis are being investigated and are potential targets for treatment. Treatment of patients with poor bone health include nutritional supplementation with vitamin D and calcium, weight-bearing exercises, and antiosteoporotic medications when warranted. Antiosteoporotic medications include antiresorptive drugs such as diphosphonate and denosumab that inhibit osteoclastic bone resorption. Anabolic agents such as teriparatide, abaloparatide, and romosozumab stimulate osteoblastic differentiation and bone formation. All these agents are effective in reducing fracture risk.
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January 2021

Rationale for Bone Health Optimization in Patients Undergoing Orthopaedic Surgery.

Instr Course Lect 2021 ;70:355-366

Osteoporosis is common, affecting more than 40 million people, and is associated with increased fracture risk, loss of independence, chronic pain, and disability. Osteoporosis is underdiagnosed and undertreated even after fracture where secondary fracture prevention has been shown to be cost effective in reducing further fracture risk and mortality. Osteoporosis is also undiagnosed in patients undergoing orthopaedic and spine surgery in up to one-third of cases and negatively affects outcomes, need for revision surgery, and risk of complications. The diagnosis of osteoporosis was previously based on bone mineral density; however, recent clinical definitions include T-scores less than -2.5, the presence of hip and spine fractures, and high fracture risk. Surgeons should adopt bone health optimization for elective surgery. This program screens patients to determine whether a bone mineral density test is indicated and provides counseling for nutritional supplements, elimination of toxins, fall risk assessment, and education regarding bone health. Following assessment, patients meeting the criteria for osteoporosis are referred to a bone health specialist or a fracture liaison program. Both antiresorptive and anabolic antiosteoporotic medications appear effective at improving outcomes and reducing complications of orthopaedic and spine surgery, although a delay in surgery may be required.
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January 2021

Biomechanical Analysis of an Anterior Cervical Discectomy and Fusion Pseudarthrosis Model Revised With Machined Interfacet Allograft Spacers.

Global Spine J 2020 Dec 22;10(8):973-981. Epub 2019 Oct 22.

5228University of Wisconsin, Madison, WI, USA.

Study Design: Biomechanics study.

Objectives: To evaluate the biomechanical advantage of interfacet allograft spacers in an unstable single-level and 2-level anterior cervical discectomy and fusion (ACDF) pseudoarthrosis model.

Methods: Nine single-level and 8 two-level ACDF constructs were tested. Range of motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) at 1.5 N m were collected in 4 testing configurations: (1) intact spine, (2) ACDF with interbody graft and plate/screw, (3) ACDF with interbody graft and plate/loosened screws (loose condition), and (4) ACDF with interbody graft and plate/loosened screws supplemented with interfacet allograft spacers (rescue condition).

Results: All fixation configurations resulted in statistically significant decreases in range of motion in all bending planes compared with the intact spine ( < .05). Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 60.0%, 64.9%, and 72.9%, respectively. Loosening the ACDF screws decreased these reductions to 40.9%, 44.6%, and 52.1%. The addition of interfacet allograft spacers to the loose condition increased these reductions to 74.0%, 84.1%, and 82.1%. . Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 72.0%, 71.1%, and 71.2%, respectively. Loosening the ACDF screws decreased these reductions to 55.4%, 55.3%, and 51.3%. The addition of interfacet allograft spacers to the loose condition significantly increased these reductions to 82.6%, 91.2%, and 89.3% ( < .05).

Conclusions: Supplementation of a loose ACDF construct (pseudarthrosis model) with interfacet allograft spacers significantly increases stability and has potential applications in treating cervical pseudarthrosis.
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http://dx.doi.org/10.1177/2192568219884265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645080PMC
December 2020

Preoperative bone health assessment and optimization in spine surgery.

Neurosurg Focus 2020 08;49(2):E2

2University of Wisconsin School of Medicine and Public Health, Osteoporosis Clinical Research Program, Madison, Wisconsin.

Objective: The purpose of this investigation was to characterize the bone health in preoperative spine surgery patients. This information will provide a framework to understand the needs and methods for providing bone health optimization in elective spine surgery patients.

Methods: A retrospective study of 104 patients undergoing bone health optimization was performed. Patients were selected based on risk factors identified by the surgeon and suspected compromised bone health. Evaluation included history and examination, laboratory investigations, and bone mineral density (BMD) at 3 sites (femoral neck, lumbar spine, and radius). Patients' bone status was classified using WHO criteria and expanded criteria recommended by the National Osteoporosis Foundation (NOF). The 10-year Fracture Risk Assessment Tool (FRAX) scores of the hip and major osteoporotic fracture (MOF) were calculated with and without femoral neck BMD, with spine BMD, and with the trabecular bone score (TBS). Antiresorptive and anabolic agents were provided in accordance with meeting NOF criteria for treatment of osteoporosis.

Results: The mean patient age was 69.0 years, and 81% of patients were female. The mean historical height loss was 5.6 cm, and 54% of patients had a history of fracture. Secondary osteoporosis due to chronic renal failure, inflammatory arthritis, diabetes, and steroid use was common (51%). The mean 25-hydroxy vitamin D was 42.4 ng/ml and was normal in 81% of patients, with only 4 patients being deficient. The mean T-scores were -2.09 (SD 0.71) of the femoral neck, -0.54 (1.71) of the lumbar spine, and -1.65 (1.38) of the distal radius. These were significantly different. The 10-year FRAX MOF score was 20.7%, and that for hip fracture was 6.9% using the femoral neck BMD and was not significantly different without the use of BMD. The FRAX risk-adjusted score using the lumbar spine BMD and TBS was significantly lower than that for the hip. Osteoporosis was present in 32.1% according to WHO criteria compared with 81.6% according to NOF criteria. Antiresorptive medications were recommended in 31 patients and anabolic medications in 44 patients.

Conclusions: Surgeons can reliably identify patients with poor bone health by using simple criteria, including historical height loss, history of fracture, comorbidities associated with osteoporosis, analysis of available imaging, and calculation of FRAX score without BMD. High-risk patients should have BMD testing and bone health assessment. In patients with osteoporosis, a comprehensive preoperative bone health assessment is recommended and, if warranted, pharmacological treatment should be started.
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http://dx.doi.org/10.3171/2020.5.FOCUS20255DOI Listing
August 2020

Osteoporosis in spine surgery patients: what is the best way to diagnose osteoporosis in this population?

Neurosurg Focus 2020 08;49(2):E4

2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization.

Methods: A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit.

Results: Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors' proposed "expanded spine" criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools.

Conclusions: Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.
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http://dx.doi.org/10.3171/2020.5.FOCUS20277DOI Listing
August 2020

Introduction. Lumbar spinal osteoporosis.

Neurosurg Focus 2020 08;49(2):E1

4Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.3171/2020.5.FOCUS20412DOI Listing
August 2020

Editorial. Bisphosphonates do not impair spinal fusion.

Neurosurg Focus 2020 08;49(2):E13

2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.3171/2020.5.FOCUS20413DOI Listing
August 2020

Regional improvements in lumbosacropelvic Hounsfield units following teriparatide treatment.

Neurosurg Focus 2020 08;49(2):E11

Departments of1Neurologic Surgery.

Objective: Opportunistic Hounsfield unit (HU) determination from CT imaging has been increasingly used to estimate bone mineral density (BMD) in conjunction with assessments from dual energy x-ray absorptiometry (DXA). The authors sought to compare the effect of teriparatide on HUs across different regions in the pelvis, sacrum, and lumbar spine, as a surrogate measure for the effects of teriparatide on lumbosacropelvic instrumentation.

Methods: A single-institution retrospective review of patients who had been treated with at least 6 months of teriparatide was performed. All patients had at least baseline DXA as well as pre- and post-teriparatide CT imaging. HUs were measured in the pedicle, lamina, and vertebral body of the lumbar spine, in the sciatic notch, and at the S1 and S2 levels at three different points (ilium, sacral body, and sacral ala).

Results: Forty patients with an average age of 67 years underwent a mean of 20 months of teriparatide therapy. Mean HUs of the lumbar lamina, pedicles, and vertebral body were significantly different from each other before teriparatide treatment: 343 ± 114, 219 ± 89.2, and 111 ± 48.1, respectively (p < 0.001). Mean HUs at the S1 level for the ilium, sacral ala, and sacral body were also significantly different from each other: 124 ± 90.1, -10.7 ± 61.9, and 99.1 ± 72.1, respectively (p < 0.001). The mean HUs at the S2 level for the ilium and sacral body were not significantly different from each other, although the mean HU at the sacral ala (-11.9 ± 52.6) was significantly lower than those at the ilium and sacral body (p = 0.003 and 0.006, respectively). HU improvement occurred in most regions following teriparatide treatment. In the lumbar spine, the mean lamina HU increased from 343 to 400 (p < 0.001), the mean pedicle HU increased from 219 to 242 (p = 0.04), and the mean vertebral body HU increased from 111 to 134 (p < 0.001). There were also significant increases in the S1 sacral body (99.1 to 130, p < 0.05), S1 ilium (124 vs 165, p = 0.01), S1 sacral ala (-10.7 vs 3.68, p = 0.04), and S2 sacral body (168 vs 189, p < 0.05).

Conclusions: There was significant regional variation in lumbar and sacropelvic HUs, with most regions significantly increasing following teriparatide treatment. The sacropelvic area had lower HU values than the lumbar spine, more regional variation, and a higher degree of correlation with BMD as measured on DXA. While teriparatide treatment resulted in HUs > 110 in the majority of the lumbosacral spine, the HUs in the sacral ala remained suggestive of severe osteoporosis, which may limit the effectiveness of fixation in this region.
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http://dx.doi.org/10.3171/2020.5.FOCUS20273DOI Listing
August 2020

Appropriate Management of Vertebral Fragility Fractures: Development of a Pathway Based on a Vertebral Compression Fracture Registry.

Pain Physician 2020 07;23(4):E343-E352

Department of Radiology, Summit Medical Center, Edmond, OK.

Background: The BenchMarket Medical (BMM) Vertebral Compression Fracture (VCF) Registry, now known as Talosix, is a collaborative effort between Talosix (the authorized registry vendor), Noridian Healthcare Solutions, and clinicians to gather outcomes evidence for cement augmentation treatments in patients with acute painful osteoporotic VCFs. The VCF Registry was designed to provide outcomes evidence to inform the Medicare payer's "coverage with evidence development" decision to authorize reimbursement for cement augmentation treatments.

Objectives: The purpose of this article was to present a pathway for appropriate use of vertebral augmentation based on the findings of the VCF Registry.

Study Design: Prospective observational data, including patient characteristics, diagnosis, process of care, and patient-reported outcomes (PROs) for pain and function, were collected from patients undergoing cement augmentation treatment. The PROs were collected at baseline, 1, 3, and 6 months following the procedure.

Setting: The VCF Registry is a national ongoing registry with no specified end time or designated sample size.

Methods: Primary outcomes were pain improvement measured using the Numeric Rating Scale and function improvement, measured using the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes included cement leakage, new neurologic deficits, adverse events, readmissions, and death.

Results: The VCF Registry delivered outcomes data to support Noridian's "coverage with evidence development" decision. A total of 732 patients were included in this study. Registry outcomes confirmed postmarket evidence of highly significant pain relief with mean pain score improvement of 6.5/10 points at 6 months. Function also improved significantly with mean RMDQ score change of 11.4/24 points 6 months after surgery. Results also showed the safety and reliability of cement augmentation.

Limitations: The nature of the registry data is that it contains nonrandomized, nonplacebo controlled data and should not be perceived as such. The real-world setting and the large number of patients within the dataset should increase the external validity of the findings.

Conclusions: Cement augmentation treatments of patients with acute painful VCFs reliably results in highly significant benefits of pain decrease and functional improvement for this Medicare population.

Key Words: Vertebral compression fractures, osteoporosis, kyphoplasty, back pain, registry.
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July 2020

Cervical Kyphosis in Spinal Muscular Atrophy: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e1900341

1Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 2Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska.

Case: A 12-year-old boy with spinal muscular atrophy (SMA) Type II presented 5 years after undergoing spinal growing rod placement with cervical kyphosis at C2-3. He underwent anterior cervical discectomy and fusion but 6 years later developed significant kyphosis at the adjacent C3-4 level.

Conclusion: We describe a rare adjacent segment kyphotic condition in a young man with SMA Type II. Clinicians should be cognizant of the risk of cervical kyphosis in adolescent patients with SMA.
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http://dx.doi.org/10.2106/JBJS.CC.19.00341DOI Listing
February 2021

Abaloparatide and the Spine: A Narrative Review.

Clin Interv Aging 2020 29;15:1023-1033. Epub 2020 Jun 29.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.

Osteoporosis is a common and debilitating condition characterized by diminished bone mass and architecture leading to bone fragility. Antiresorptive medicines like bisphosphonates (and less commonly denosumab) are the typical first-line agents for the medical treatment of osteoporosis. However, newer anabolic agents have been shown to improve bone mass and architecture, as well as reduce fracture risk, to a greater degree than traditional antiresorptive therapies. Teriparatide (human recombinant parathyroid hormone (PTH) 1-34, Forteo, Ely Lilly, Indianapolis, IN), which was the first in class to be approved in the United States, is the most widely used anabolic osteoporosis medicine and has shown significant benefit over traditional antiresorptive therapies. However, abaloparatide (synthetic parathyroid-related peptide (PTHrP), Tymlos, Radius Health, Waltham, MA), the second drug in this family, has recently become available for use. In this narrative review, we review the mechanism, effects, and benefits of abaloparatide compared to alternative treatments as well as discuss the current literature in regard to its effect on osteoporosis-related complications in the spine.
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http://dx.doi.org/10.2147/CIA.S227611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334019PMC
October 2020

Secondary fracture prevention: review of recent American Society for Bone and Mineral Research multidisciplinary stakeholder consensus recommendations.

Spine J 2020 07;20(7):1044-1047

Center for Medical Technology Policy, 401 E Pratt St, Suite 631, Baltimore, MD, 21202, USA. Electronic address:

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http://dx.doi.org/10.1016/j.spinee.2020.03.012DOI Listing
July 2020

Association of Perioperative Computed Tomography Hounsfield Units and Failure of Femoral Neck Fracture Fixation.

J Orthop Trauma 2020 12;34(12):632-638

Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI.

Objectives: To determine whether Hounsfield units (HUs) measured on perioperative computed tomographic scans are associated with radiographic outcomes and reoperations after femoral neck fracture fixation.

Design: Retrospective cohort study.

Setting: Level I trauma center.

Patients: One hundred fourteen patients age ≥18 years, who presented to a Level I trauma center, and who underwent surgical fixation of intracapsular femoral neck fracture and had perioperative computed tomographic scans and adequate follow-up.

Intervention: None.

Main Outcome Measurements: Screw penetration, femoral neck shortening >5 mm, and revision surgery.

Results: A median follow-up was 23 months. An HU measurement of the femoral head was significantly associated with screw penetration and femoral neck shortening but not revision surgery. Patients with middle femoral head HU measurements <146 had 17 times (95% confidence interval: 4.32-78.9, P < 0.001) increased odds of screw penetration. Greater than 5 mm shortening was seen in patients with HUs <212.5 in the low head section by an odds ratio of 7.8 (95% confidence interval: 2.15-33.0, P = 0.014).

Conclusion: Outcome differences regarding screw penetration and femoral neck shortening related to the HU or densities of femoral head and neck at the time of fracture are significant. These findings can help the clinician with developing a treatment plan for either arthroplasty or fixation of a femoral neck fracture based on objective bone quality measurements rather than relying on an arbitrary age recommendation.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001843DOI Listing
December 2020

Bone Health Optimization in Orthopaedic Surgery.

J Bone Joint Surg Am 2020 Apr;102(7):574-581

Department of Orthopedics & Rehabilitation (A.K., K.J.H., and P.A.A.), and the Osteoporosis Clinical Research Program (N.B.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: Osteoporosis is associated with adverse orthopaedic surgical outcomes. Bone health optimization is a preoperative intervention intended to reduce the likelihood of postoperative complications. We aimed to characterize a patient cohort referred for bone health optimization to test the hypothesis that poor bone quality is common in orthopaedic surgery and that many such patients meet guidelines for osteoporosis treatment.

Methods: This retrospective study evaluated 124 patients referred for bone health optimization who were ≥50 years of age and candidates for arthroplasty or thoracolumbar surgery. The Fracture Risk Assessment Tool (FRAX) risk factors and dual x-ray absorptiometry (DXA) results were collected. When available, opportunistic computed tomographic (CT) imaging and the trabecular bone score were evaluated. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were applied.

Results: All patients were referred by their orthopaedic surgeon; their mean age was 69.2 years, 83% of patients were female, 97% were Caucasian, and 56% had sustained a previous fracture. The mean historical height loss (and standard deviation) was 5.3 ± 3.3 cm for women and 6.0 ± 3.6 cm for men. The mean lowest T-score of the hip, spine, or wrist was -2.43 ± 0.90 points in women and -2.04 ± 0.81 points in men (p < 0.08). Osteoporosis (T-score of ≤-2.5 points) was present in 45% of women and 20% of men; only 3% of women and 10% of men had normal bone mineral density. Opportunistic CT scans identified 60% of patients as likely having osteoporosis. The trabecular bone score identified 34% of patients with degraded bone microarchitecture and 30% of patients with partially degraded bone microarchitecture. The NOF threshold for osteoporosis treatment was met in 91% of patients. Treatment was prescribed in 75% of patients (45% anabolic therapy and 30% antiresorptive therapy).

Conclusions: Osteoporosis, degraded bone microarchitecture, prior fracture, and elevated fracture risk were common. Given the high prevalence of impaired bone health in this cohort, we believe that bone health screening, including FRAX assessment, should be considered in selected patients undergoing orthopaedic surgery as part of the preoperative optimization for all adults who are ≥50 years of age.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.00999DOI Listing
April 2020

Osteoporosis-related Vertebral Fragility Fractures: A Review and Analysis of the American Orthopaedic Association's Own the Bone Database.

Spine (Phila Pa 1976) 2020 Apr;45(8):E430-E438

Mayo Clinic, Rochester, MN.

Study Design: Retrospective cohort study of the Own the Bone database which is a fracture liaison service designed to improve recognition and treatment of osteoporosis.

Objective: To use the Own the Bone (OTB) database to 1) examine the specific demographics of patients presenting with a low-energy clinical vertebral fracture (VFX) and 2) compare demographic and fracture-specific risk factors between patients with clinical VFX versus patients with nonvertebral low-energy fracture (NVFX).

Summary Of Background Data: Large database studies have described risk factors for developing VFX. It is well described that a history of previous VFX portends an increased risk of future VFX. Few studies have reported cohorts from a fracture liaison service such as the OTB initiative.

Methods: 35,039 unique cases of fragility fracture occurred between 2009 and 2016 and were included in analysis. VFX accounted for 3395 (9.9%) of the presenting fractures at OTB enrollment. The demographics, lifestyle factors, medication use, and fracture-specific data for patients in the OTB registry with vertebral fractures were summarized and then statistically compared to those with nonvertebral fragility fractures.

Results: The majority of VFX patients were Caucasian, postmenopausal women (74.4%). There was an increased likelihood of presenting with a vertebral fracture in patients who sustained a previous VFX after the age of 50, while patients who sustained a prior nonvertebral fracture (NVFX) were more likely to present with a subsequent NVFX. After controlling for patients with a history of fracture after the age of 50, VFX patients (vs. NVFX) were more likely to be age 70-79, class 1 obesity, with a history of taking anti-osteoporotic prescription medications.

Conclusions: Multiple factors were associated with a significantly increased risk of VFX compared with NVFX. Understanding the risk factors unique to fragility VFX is a critical component for targeting "at-risk" patients and preventing future osteoporosis-related fractures and their consequences.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003324DOI Listing
April 2020

Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes.

J Neurosurg Spine 2019 Oct 18:1-6. Epub 2019 Oct 18.

1Department of Neurological Surgery, Mayo Clinic, Rochester.

Objective: The authors sought to assess whether Hounsfield units (HU) increase following teriparatide treatment and to compare HU increases with changes in bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DEXA).

Methods: A retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. The authors identified patients who had been treated with at least 6 months of teriparatide and compared HU and BMD as measured on DEXA scans before and after treatment.

Results: Fifty-two patients were identified for analysis (46 women and 6 men, average age 67 years) who underwent an average of 20.9 ± 6.5 months of teriparatide therapy. The mean ± standard deviation HU increase throughout the lumbar spine (L1-4) was from 109.8 ± 53 to 133.9 ± 61 HU (+22%, 95% CI 1.2-46, p value = 0.039). Based on DEXA results, lumbar spine BMD increased from 0.85 to 0.93 g/cm2 (+9%, p value = 0.044). Lumbar spine T-scores improved from -2.4 ± 1.5 to -1.7 ± 1.5 (p value = 0.03). Average femoral neck T-scores improved from -2.5 ± 1.1 to -2.3 ± 1.0 (p value = 0.31).

Conclusions: Teriparatide treatment increased both HU and BMD on DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the 9% improvement determined with DEXA. These results support some surgeons' subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. To the authors' knowledge, this is the first study demonstrating an increase in HU with teriparatide treatment.
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http://dx.doi.org/10.3171/2019.7.SPINE19654DOI Listing
October 2019

Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position.

J Clin Densitom 2019 Oct - Dec;22(4):517-543. Epub 2019 Aug 16.

University of Hawaii Cancer Center, University of Hawaii, Honolulu, HI, USA.

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 throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.
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http://dx.doi.org/10.1016/j.jocd.2019.07.013DOI Listing
July 2020

An Ion-Exchangeable MOF with Reversible Dehydration and Dynamic Structural Behavior (NH ) [Zn (O PCH CH COO) ]⋅5 H O (BIRM-1).

Chemistry 2019 Nov 9;25(61):13865-13868. Epub 2019 Oct 9.

School of Chemistry, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.

(NH ) [Zn (O PCH CH COO) ]⋅5 H O (BIRM-1) is a new metal phosphonate material, synthesized through a simple hydrothermal reaction between zinc nitrate and 3-phosphonopropionic acid, using urea and tetraethylammonium bromide as the reaction medium. In common with other metal-organic framework materials, BIRM-1 has a large three-dimensional porous structure providing potential access to a high internal surface area. Unlike most others, it has the advantage of containing ammonium cations within the pores and has the ability to undergo cation exchange. Additionally, BIRM-1 also exhibits a reversible dehydration behavior involving an amorphization-recrystallization cycle. The ability to undergo ion exchange and dynamic structural behavior are of interest in their own right, but also increase the range of potential applications for this material. Here the crystal structure of this new metal phosphonate and its ion exchange behavior with K as an exemplar are studied in detail, and its unusual structure-reviving property reported.
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http://dx.doi.org/10.1002/chem.201903230DOI Listing
November 2019

Executive Summary of the 2019 ISCD Position Development Conference on Monitoring Treatment, DXA Cross-calibration and Least Significant Change, Spinal Cord Injury, Peri-prosthetic and Orthopedic Bone Health, Transgender Medicine, and Pediatrics.

J Clin Densitom 2019 Oct - Dec;22(4):453-471. Epub 2019 Jul 5.

Population Sciences in the Pacific Program, University of Hawai'i Cancer Center, Honolulu, Hawai'i, USA.

To answer important questions in the fields of monitoring with densitometry, dual-energy X-ray absorptiometry machine cross-calibration, monitoring, spinal cord injury, periprosthetic and orthopedic bone health, transgender medicine, and pediatric bone health, the International Society for Clinical Densitometry (ISCD) held a Position Development Conference from March 20 to 23, 2019. Potential topics requiring guidance were solicited from ISCD members in 2017. Following that, a steering committee selected, prioritized, and grouped topics into Task Forces. Chairs for each Task Force were appointed and the members were co-opted from suggestions by the Steering Committee and Task Force Chairs. The Task Forces developed key questions, performed literature searches, and came up with proposed initial positions with substantiating draft publications, with support from the Steering Committee. An invited Panel of Experts first performed a review of draft positions using a modified RAND Appropriateness Method with voting for appropriateness. Draft positions deemed appropriate were further edited and presented at the Position Development Conference meeting in an open forum. A second round of voting occurred after discussions to approve or reject the positions. Finally, a face-to-face closed session with experts and Task Force Chairs, and subsequent electronic follow-up resulted in 34 Official Positions of the ISCD approved by the ISCD Board on May 28, 2019. The Official Positions and the supporting evidence were submitted for publication on July 1, 2019. This paper provides a summary of the all the ISCD Adult and Pediatric Official Positions, with the new 2019 positions highlighted in bold.
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http://dx.doi.org/10.1016/j.jocd.2019.07.001DOI Listing
July 2020

Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues.

J Bone Joint Surg Am 2019 Aug;101(15):1413-1419

University of Wisconsin Osteoporosis Clinical Research Program, Madison, Wisconsin.

Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.
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http://dx.doi.org/10.2106/JBJS.18.01229DOI Listing
August 2019
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