We compared cortical thicknesses between patients taking BP and controls and evaluated longitudinal changes in cortical thickness. There were 129 female and 13 male patients in the BP group. Femoral cortical thickening has been mentioned in reports of atypical subtrochanteric/femoral shaft (ST/FS) fractures, which are associated with long‐term bisphosphonate (BP) use. BPs significantly increase bone mineral density (BMD) and reduce the risk of vertebral, hip, and other nonvertebral fractures.1 Recent studies have suggested a possible link between long‐term BP use and atypical femoral fractures (AFFs) in the subtrochanteric/femoral shaft (ST/FS) areas.2-6 Several reports have suggested that the decreased rate of bone turnover associated with the reduction in osteoclastic resorption leads to increased bone mineralization and causes the bone to become brittle.7-9 These changes, combined with unrepaired microdamage, may lead to a long‐term increase in the risk of fracture. cortical bone thickness in the proximal femur. The intraassay and interassay % coefficient of variation (CV) for PINP are 3.5% and 4.2%, respectively.16 uNTX levels were measured in 132 patients (10 patients had difficulty providing samples for urine tests), and serum PINP levels were measured in all 142 patients of the BP group. Statistical analysis was performed using the StatView statistical software package (version 5.0; SAS Institute, Cary, NC, USA). All measurements were recorded in millimeters. Data interpretation: RN, TK, MH, AM, and AS. V003T04A071. The measurement of cortical-bone thickness is a challenge , and pulse-echo ultrasonometry gives only a rough estimate of cortical-bone thickness. Fax: +1 (202) 367-2161 We computed the sample size required for a parametric test and added 15% because it is assumed that nonparametric tests may be required (57 cases).12 Therefore, we estimated that 60 cases and 180 controls would be required. Femoral cortical thickening has been mentioned in reports of atypical subtrochanteric/femoral shaft (ST/FS) fractures, which are associated with long‐term … The Endo-Exo-Prothesis (EEP, ESKA Orthopaedic Handels GmbH®, Deutschland) is the most implanted TOPS in Germany. A total of 620 potential control individuals were seen during the study period. The primary measures of cortical thickness included in the analysis were medial cortical thickness, lateral cortical thickness, total cortical thickness (medial plus lateral thickness), and the cortical thickness ratio. Increased cortical porosity and reduced cortical thickness of the proximal femur are associated with nonvertebral fracture independent of Fracture Risk Assessment Tool and Garvan estimates in postmenopausal women Rita Kral1,2, Marit Osima3,4, Tove T. Borgen5, Roald Vestgaard6, Elin Richardsen7,8, Åshild Bjørnerem1,2* Reliability and diagnostic utility of radiographs in patients with incomplete atypical femoral fractures. Femoral diameter was defined as the distance between the outer surfaces of the femoral cortices (Fig. Please check your email for instructions on resetting your password. The ASBMR appointed a task force to summarize the current state of knowledge, and this group defined AFF according to five major features and four minor features.2 Because most of these features relate to postfracture conditions, it is difficult to evaluate these features before the occurrence of an AFF. Femoral cortical thickening has been mentioned in reports of atypical subtrochanteric/femoral shaft (ST/FS) fractures, which are associated with long‐term bisphosphonate (BP) use. Sixth, we did not perform the longitudinal study in the control group because almost all control patients underwent osteoporosis treatment after initial evaluation. The change in bone cortical bone thicknesses for the humerus, femur and tibia in males and females is represented. Published on behalf of the American Society for Bone and Mineral Research, © 2020 American Society for Bone and Mineral Research, About ASBMR | Meetings and Abstracts | Membership | Education | Contact Information | Disclaimer | Privacy Policy, 2025 M Street, NW | Suite 800 | Sixth, we did not perform the longitudinal study in the control group because almost all control patients underwent osteoporosis treatment after initial evaluation. Chen and colleagues measured the proximal femoral cortical thickness in 45 patients receiving long‐term BP treatment and 12 controls and found no difference in thickness between long‐term BP users and controls.14. We compared cortical thicknesses between patients taking BP and controls and evaluated longitudinal changes in cortical thickness. The outermost layer (between the outer surface of the bone and soft tissue) is periosteum and the innermost layer (between compact bone and the medullary space containing spongi… All measurements were recorded in millimeters. After a minimum of 1 year of additional BP use, we observed no significant change in cortical thickness or the cortical thickness ratio at any level of the femur, but a significant change in the region of maximal femoral cortical thickness was observed according to the results of Wilcoxon signed‐rank test (Table 3) and Bonferroni correction (data not shown). Second, almost all participants enrolled in this study were Japanese. The concentrations of bone turnover markers, urinary N‐telopeptide (uNTX), and serum procollagen type I N‐terminal propeptide (PINP) were lower in the BP group. The first limitation is related to study design. Baseline femoral measurements were compared between the BP and control groups (Table 2, Supporting Figs. Body mass index (BMI) and serum calcium concentration were higher in the BP group (Table 1), whereas height was lower in the BP group. Measurement data are presented as mean (SD). Third, we measure cortical thickness at three points on radiographs. On the basis of our results in the present study, patients with AFFs might have had abnormal cortical thickness before BP use. On femoral radiographs, we measured femoral cortical thickness in three regions: 5 cm and 12.5 cm below the lesser trochanter and in the region of maximal cortical thickness. Thereafter, two pairs of four points were plotted on the FS at each level of measurement. It will be essential for future analysis of bone in this region to take these effects into account. As a result, we could perform this case‐control study with a patient/control ratio of 1:3. Fourth, although the femoral radiographs were obtained using a standardized method, the use of radiographs to accurately measure cortical thickness has not been validated. Because radiographs are two‐dimensional projections of a three‐dimensional structure, the inner edge of cortical bone cannot be precisely determined. Cortical thickness at each F05 node was determined by taking the average cortical thickness of every mM50 node, non-linearly weighted by its distance to the F05 nodes. Bisphosphonates (BPs) are the most commonly prescribed medications for the treatment of osteoporosis. We did not identify any cases of lateral cortical stress fracture. However, two features, localized periosteal thickening of the lateral cortex (major feature) and generalized increase in cortical thickness of the femoral diaphysis (minor feature), are present before AFF. The purpose of this study was to investigate the relationship between cortical thickness and BP use. In a small number of nonambulatory participants, cortical thickness was lower than ambulatory individuals (0.27 ± 0.04 vs 0.32 ± 0.06). The mean absolute difference and SD between measurements of intraobserver and interobserver variability were 0.2 ± 0.3 mm and 0.3 ± 0.3 mm, respectively. Additional Supporting Information may be found in the online version of this article. Longitudinal cortical thickness changes in BP users were assessed with paired t tests. Although the incidence rates of AFFs in the Japanese and white populations are similar,22 these findings might not be generalizable to other ethnic groups or representative of the population as a whole. Thresholding is the most common technique for estimating cortical thickness and density. The authors thank Dr Hideki Yamamoto and Dr Takahito Saito for their contributions to osteoporosis treatment. 1). 28 patients were excluded. The relationship between CBT in the distal part of the tibia and DXA findings in the hip, proximal part of the femur, and lumbar spine was assessed with Pearson correlations. We performed yearly X‐ray evaluations in the patients who had used BPs for more than 5 years since 2011 as part of routine care. Baseline anteroposterior femoral radiographs were obtained for all patients. All radiographs were obtained by an experienced technician using a standardized protocol and uploaded using a computerized imaging system linked to PACS. The cortical bone thickness of femurs was continuous, increasing gradually from the end to the middle part. The patients were stratified into low‐, moderate‐, and high‐functioning levels according to the following criteria in reference to a previous report:13 low functioning: requires assistance with all ADLs, lives with caregiver, and needs frame to mobilize or uses a wheelchair; moderate functioning: requires some assistance with ADLs, mobilizes with a handcart; and high functioning: requires no assistance with ADLs, functions independently, and able to mobilize a significant distance (ie, walks for exercise or can walk around supermarket). The subtrochanteric region was found to have the thickest cortical bone and … may elicit bone remodeling at the proximal femur, causing increases in cortical bone thickness. Conclusions: Cortical thickness captures bone deficits in individuals with DMD, and may be a promising noninvasive measure to include in studies of bone health in individuals with muscular dystrophy. Thickness of cortical bone at mid shaft level, thickness of individual trabeculae were measured using a calibrated ocular micrometer. Bisphosphonates in the treatment of osteoporosis: a review of skeletal safety concerns. Comparison of Baumgaertner and Chang reduction quality criteria for the assessment of trochanteric fractures. Because AFF does not likely occur without cortical thickening, Koeppen and colleagues proposed two hypotheses regarding cortical thickness in the context of AFFs.19 The first hypothesis is that cortical thickening is caused by BPs, and the second hypothesis states that increased cortical thickness is a risk factor for AFF regardless of BP use. Cortical bone thickness in this region of the femur, as well as over the proximal surface, was significantly greater in patients with cam FAI than control subjects. Thus, it was difficult to obtain follow‐up radiographs in the absence of osteoporosis treatment. We did not perform longitudinal evaluation in control groups. The 142 long‐term BP users were all patients who were under follow‐up at our institution. To avoid selection bias, which is a major disadvantage of a matched case‐control study, we evaluated the maximum number of controls registered during the study period. It has been postulated that this cortical thickening is the result of long‐term BP use. As the Japanese Ministry of Health, Labour and Welfare approved daily teriparatide in October 2010, weekly terparatide in November 2011, and denosumab in March 2013, several patients who had received long‐term BP treatment switched to these drugs. Transcutaneous Osseointegrated Prosthetic Systems (TOPS) offer a good alternative for patients who cannot be satisfactorily rehabilitated by conventional suspension sockets. The 142 long‐term BP users were all patients who were under follow‐up at our institution. The non-linear weighting coefficient, β, had a large effect on the accuracy and smoothness of the projected cortical bone thickness. Burghardt and colleagues also reported an increased mean percentage of cortical thickness after 1 to 2 years of alendronate use.10 Meanwhile, Unnanuntana and colleagues found no increase in proximal femoral cortical thickness in patients receiving prolonged alendronate treatment more than 5 years.11 However, few studies have measured cortical thickness on radiographs including the FS area. The Bonferroni correction results in very few significant differences between age groups. We performed yearly X‐ray evaluations in the patients who had used BPs for more than 5 years since 2011 as part of routine care. Phone: +1 (202) 367-1161 The study of osteoporotic fractures, The incidence of and risk factors for developing atypical femoral fractures in Japan, Correlation of plain radiographic indices of the hip with quantitative bone mineral density. Data collection: RN, TK, and AN. Bisphosphonates in the treatment of osteoporosis: a review of skeletal safety concerns. We observed no significant increase in cortical thickness in either of the two groups. The most significant changes in thickness are between age groups of 1 and 2, in nearly all sectors including the midshaft. Learn about our remote access options, Department of Orthopaedic Surgery, Tomidahama Hospital, Yokkaichi City, Japan, Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan. Cortical Thickness Mapping. Differences in the FS diameter, cortical thickness, and cortical thickness ratio in the BP and control groups were assessed with the Mann–Whitney U‐test. Longitudinal cortical thickness changes in BP users were assessed with paired t tests. The intra‐assay and interassay % CV for uNTX are 6.6% and 6.5%, respectively.16 Serum PINP was measured by a radioimmunoassay (Orion Diagnostica, Espoo, Finland) in the nonfasting state. Effects of osteoporosis drug treatments on cortical and trabecular bone in the femur using DXA-based 3D modeling. There is little convincing evidence that either cortical thickness or its true BMD is higher in blacks when careful matching for external bone size is … However, because we wanted to perform the analysis for lateral cortical stress fracture, we included all eligible patients with long‐term BP use. To date, numerous genetic loci for bone mineral density (BMD) and only one locus for osteoporotic fracture have been previously identified to be genome-wide significant. Moreover, cortical thickness remained stable after an additional year of continued BP use. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. If the femur cannot be correctly remodeled, a reduced cortical bone thickness plays an important role in the bone strength of the proximal diaphysis. This study was a matched case‐control study, and such studies have several major disadvantages, including selection and information bias, which could not be eliminated by increasing the number in the control arm. The Dorr proximal femur morphology was classified into types A, B, and C. Results. First, a line was drawn along the FS axis at the level of the greater trochanter. Additional Supporting Information may be found in the online version of this article. On the other hand, the slopes of strains and strain energy density showed markedly higher values in zone 1 (p < 0.01) and small changes in cortical bone thickness resulted in large differences. Any queries (other than missing content) should be directed to the corresponding author for the article. 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