Search Results (45)

Background/Objectives: Paget’s disease of bone (PDB) and osteoporosis are chronic metabolic bone disorders characterized by disrupted bone remodeling and increased skeletal fragility; however, the underlying mechanism of PDB remains poorly understood. Artificial intelligence (AI) has emerged as a transformative tool in medical imaging, enabling automated feature extraction and improved diagnostic classification of skeletal disorders. This study aimed to investigate whether AI could distinguish subtle variations in bone morphology between PDB and osteoporotic bone. Methods: C57BL/6 mice femurs were scanned by µCT: 16 optineurin-knockout mice with a PDB phenotype (20–26 months), 25 genetically matched wild-type Aging mice (20–26 months), and 15 ovariectomized (OVX) mice with osteoporotic bone phenotype (4.5 months). Two AI algorithms were investigated: a machine learning (ML) model using 22 µCT-derived features trained with a Random Forest (RF) classifier, and a deep learning (DL) model using a 3D convolutional neural network (3D-CNN) trained on raw µCT images. Leave-one-out cross-validation was applied to evaluate model robustness. Results: Significant differences in volumetric, density, and morphological parameters of cortical and trabecular bone were observed between PDB and osteoporosis (p < 0.05). The RF algorithm achieved 90% accuracy in distinguishing PDB from both aging- and OVX-induced osteoporosis and provided feature importance rankings that improved model interpretability. The 3D-CNN achieved classification accuracies of 70% for PDB vs. OVX and 68% for PDB vs. aging, demonstrating the feasibility of an image-based DL approach. Conclusions: AI-based RF and 3D-CNN models demonstrated promising performance in differentiating PDB from osteoporosis using µCT-derived bone features. These findings suggest potential for using AI to assist with analyzing skeletal images in the diagnosis of metabolic bone disorders. Full article

Background and Objectives: This study aimed to investigate the biomechanical properties of different cephalomedullary fixation methods for osteoporotic femurs using a synthetic bone model. Materials and Methods: Lateral impact tests and axial cyclic loading tests were performed, and each test was divided into three groups: group 1 with one reconstruction screw, group 2 with two reconstruction screws, and group 3 without cephalomedullary fixation. To simulate a healed femoral shaft fracture, no osteotomy was performed on the specimens. Results: Groups 1 and 2 had significantly higher mean stiffness, ultimate failure load, and energy to failure in the lateral impact test compared to the native synthetic femur (p < 0.001 for all), while group 3 had significantly lower values in all outcomes (p < 0.05 for all). Groups 1 and 2 showed significantly higher average number of cycles, total load to failure, and initial axial stiffness in the axial cyclic incremental loading test compared to the native synthetic femur (p < 0.001 for all), whereas group 3 showed a significantly lower mean number of cycles and total load to failure (p < 0.001 for all). Conclusions: Under the specific test conditions of this intact synthetic bone model, cephalomedullary fixation with one or two reconstruction screws demonstrated superior relative mechanical stability compared to standard interlocking nails. Using two reconstruction screws provided the greatest biomechanical resistance to failure. In cases where inserting two reconstruction screws is technically challenging or infeasible, a single reconstruction screw may offer an acceptable biomechanical alternative to help prevent peri-implant fractures in healed or prophylactic settings. Intramedullary nailing without cephalomedullary fixation exhibited the lowest mechanical performance, suggesting a potential biomechanical vulnerability to peri-implant fractures under these test conditions. Full article

Proximal femoral fractures associated with osteoporosis are an important clinical problem, yet how bone quality independently influences stress distribution remains insufficiently understood. This study aimed to quantitatively compare surface stress distribution between normal and osteoporotic proximal femoral models using thermoelastic stress analysis (TSA). Fourth-generation composite femurs with identical external geometries were subjected to cyclic compressive loading at a 9° adduction angle, with different maximum loads applied to avoid structural failure (normal: 1900 N; osteoporotic: 1000 N). TSA was performed using an infrared lock-in system to obtain surface stress maps, and stress values were evaluated across key proximal regions and along the medial and lateral cortices. The osteoporotic group showed higher maximum stress values in the medial neck (−37.79 vs. −11.52 MPa), lateral neck (24.70 vs. 8.75 MPa), and intertrochanteric crest (−17.98 vs. −6.05 MPa), corresponding to approximately 1.8–3.5-fold increases compared with the normal model values normalized to 1000 N. Mean stress values were also higher by approximately 1.9–2.4-fold across regions. These results suggest that reduced bone quality is associated with increased proximal stress concentration. They may also help guide implant and fixation strategies, including stem selection and fixation configuration, by identifying regions susceptible to stress concentration under different bone quality conditions. Full article

Background: Distal femur fractures remain among the most challenging injuries in orthopedic trauma, particularly in elderly or osteoporotic patients and in cases involving periprosthetic or highly comminuted distal femur fracture patterns. Modern fixation strategies include retrograde intramedullary nails, locking plates, and, more recently, combined nail–plate constructs (NPC). However, the optimal fixation method remains debated, and high-quality comparative evidence is limited. This systematic review evaluates clinical outcomes, union rates, and complications associated with single versus combined fixation constructs in distal femur fractures. Materials and Methods: A systematic review was performed according to PRISMA guidelines using PubMed/MEDLINE, EMBASE, and the Cochrane Database up to June 2025. Original studies reporting surgical management of distal femur fractures, including periprosthetic distal femur fractures, with postoperative outcomes were included. Ten retrospective studies met the inclusion criteria, comprising 397 patients. Methodological quality was assessed using the Modified Coleman Methodology Score (mean: 56.5). Data collected included patient demographics, fracture type, surgical technique, union rates, complications, and follow-up duration. Descriptive statistics were used to summarize trends due to study heterogeneity. Results: Among the included fractures, 304 involved the distal femur and 55 were periprosthetic. Combined nail–plate fixation was used in 203 patients, while 185 received single-implant fixation. Across studies, union rates were consistently higher in the NPC group, with several reporting 100% union, compared with more variable results in single-construct cohorts (72–96.7%). The most frequent complication in the NPC group was infection (12 cases), whereas delayed union predominated in single-implant constructs (19 cases). Patient comorbidities, such as diabetes or smoking, were inconsistently reported but may have influenced complication patterns. Follow-up periods ranged from 5.15 to 20 months, and operative details were included in several studies. Due to heterogeneity and retrospective design, no meta-analysis was performed, but descriptive trends were consistently observed. Conclusions: Nail–plate constructs appear to offer mechanical advantages in complex or high-risk distal femur fractures, achieving superior union rates compared with single implants. However, this benefit is counterbalanced by a higher incidence of postoperative infections, likely related to greater surgical invasiveness. Single constructs remain appropriate for simpler fracture configurations or better-quality bone. High-quality prospective research with standardized radiographic and functional outcomes is needed to clarify indications and optimize fixation strategies for distal femur fractures. Full article

Objective: This study aimed to investigate the relationship between computed tomography (CT)-derived Hounsfield Unit (HU) measurements and dual-energy X-ray absorptiometry (DXA) and to evaluate the feasibility of using contrast-enhanced abdominal CT as a complementary tool in the assessment of bone health in liver transplant recipients. Methods: This retrospective descriptive and analytical study included adult liver transplant recipients who underwent both contrast-enhanced abdominal CT and DXA within a three-month interval. HU measurements were obtained from sagittal and axial reformatted images at the lumbar spine (L1–L4) and femoral neck. All CT examinations were performed using a standardized venous-phase protocol. DXA-derived T-scores from the lumbar spine and femur served as the reference standard. Correlation analyses and receiver operating characteristic (ROC) curves were used to evaluate associations between HU values and BMD, as well as the diagnostic performance of HU in identifying low bone density. Results: A total of 259 recipients (mean age 55.7 ± 14.4 years; 62.9% male) were included. Based on lumbar spine DXA, 17.8% had normal BMD, 36.7% were osteopenic, and 45.5% were osteoporotic. CT-derived HU values at both the lumbar spine and femoral neck were significantly lower in patients with reduced BMD and showed a graded decline across worsening DXA categories. HU values demonstrated positive correlations with corresponding T-scores. Diagnostic performance for detecting osteoporosis was fair, with AUCs of 0.700 (sagittal), 0.698 (axial), and 0.751 (femoral). Conclusion: Contrast-enhanced abdominal CT provides useful ancillary information for opportunistic bone health assessment. CT-derived HU values offer a rapid and cost-effective complementary tool but should not replace DXA in the diagnostic evaluation of osteoporosis Full article

Background/Objectives: This retrospective observational cohort examined whether opportunistic CT-derived Hounsfield units (HU) of the lumbar spine and proximal femur together with serum 25-OH-vitamin D can predict sacral insufficiency fractures (SIF) and osteoporosis. No interventional procedures were performed. Methods: Consecutive suspected SIF cases over 3 years (n = 253) were assigned to SIF (n = 98) or controls without SIF or spine/hip fractures (n = 155). HU were measured using ellipsoidal ROIs at L1–L3 and an irregular area ROI across the entire proximal femoral cancellous bone; vitamin D was quantified; ROC analyses assessed discrimination. HU cut-points were referenced via HU-to-QCT/CTXA conversions. Results: SIF patients had markedly lower HU than controls (lumbar 44.84 vs. 105.66 HU; femoral 47.0 vs. 148.0 HU). Diagnostic performance was excellent (AUC 0.98 for SIF discrimination using lumbar HU; AUC 0.98 for osteoporosis prediction using femoral HU). Vitamin D deficiency (<20 ng/mL) was highly prevalent (92.9%) with lower means in SIF (3.72 vs. 8.24 ng/mL). Within SIF, patients with hip fracture had femoral HU ≈ 14.2 vs. 70.6 without hip fracture; effect sizes were very large. Conclusions: Opportunistic HU assessment from routine CT provides a rapid, reproducible surrogate of bone density that distinguishes SIF with near-perfect accuracy and identifies osteoporosis. HU thresholds around ~96–98 are consistent with osteoporotic ranges and can be implemented to trigger metabolic evaluation and early osteoanabolic therapy where appropriate. Full article

Background/Objectives: Femoral neck and proximal femur fractures in the elderly can result from low-energy trauma due to osteoporotic changes and contribute significantly to increased morbidity and mortality. Despite various treatment options, closed reduction and internal fixation (CRIF) with intramedullary nails has become the predominant approach. While a minimally invasive approach reduces complications and speeds recovery, this outcome is not always feasible in practice. The primary surgical goal remains achieving a stable and precise fracture reduction, favoring CRIF when possible. Our study aims to evaluate the clinical, radiological, and functional outcomes of patients operated on using the Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique. Methods: Patients who underwent surgery for intertrochanteric femur fractures between June 2019 and June 2021 were analyzed. Patients who were between 75 and 90 years old and had undergone surgery with a proximal femoral nail (PFN) were included in the study. Patients were excluded if they required general anesthesia, if an acceptable reduction could not be achieved with the PFN, if they did not attend the last follow-up examination, or if the follow-up period was <4 years. Patients were functionally assessed using the Harris hip score at the 6th month and at the last follow-up and using the visual analog scale at the surgery, at the 4th hour after surgery, and at the time of discharge. For radiological assessment, the classification of reduction quality and the measurement of the tip–apex distance were used. Results: Forty patients (22F/18M) were included in the study. Their mean age was 83.0 ± 2.9 years. The mean time from trauma to surgery was 6.8 ± 2.3 h. Patients were mobilized on average 1.53 ± 0.8 h after surgery, and the mean hospitalization time was 27.4 ± 8.1 h. No statistically significant decrease in hemoglobin value was observed before or after surgery (p = 0.476). The Harris hip score was 73.3 ± 3.2 at the 6th month postoperatively and 74.9 ± 2.5 at the last follow-up (p = 0.296). The reduction quality was found to be poor in only two patients. Conclusions: The WALANT technique’s promising results in terms of pain management, blood loss control, and early mobilization show that it is a viable alternative to conventional anesthesia methods in geriatric hip fractures. Full article

The aim of this study was to evaluate structural and micro-architectural changes in the mandible, parietal bone, femur, and tibia in OVX rats at different time periods after ovariectomy. Forty-two 11-month-old female Wistar rats were used. Six rats without surgery were euthanized to serve as a baseline. Eighteen rats were ovariectomized and fed with a calcium-deficient diet, and eighteen animals were used as controls (Ctrls) and fed with a standard diet. Six OVX rats and six Ctrls were euthanized at 3, 6, and 9 months. Qualitative histology and dual-energy X-ray absorptiometry (DXA) were performed. Histological evaluation of bones harvested from the OVX groups revealed trabecular bone reduction, while no significant differences in the cortical bone of OVX and Ctrls were observed. DXA measurements of (1) femoral diaphysis showed a significant decrease in the OVX group compared to the Ctrl groups at 3 (p = 0.041), 6 (p < 0.001), and 9 months (p < 0.001); (2) the proximal tibia showed a significant decrease in the OVX group compared to the Ctrl groups (p < 0.001); (3) parietal bone showed a significant difference between OVX and Ctrls at 6 months (p = 0.012); and (4) the mandible showed no significant differences between the OVX and Ctrl groups. OVX aged rats might present reductions in the density of the femoral diaphysis, proximal tibia, parietal bone, and mandible at different time points. These findings contribute to the field of biomimetics by providing more details for the understanding of age- and hormone-related bone changes in the osteoporotic-like rat model. Such data are critical for the development of biomimetic materials and structures that attempt to simulate natural bone adaptation and deterioration, especially in the context of postmenopausal or osteoporotic conditions. Full article

Background: Patients awaiting total hip arthroplasty (THA), particularly those with hip osteoarthritis (OA), face an elevated risk of osteoporosis due to age and gender-related factors. Osteoporosis, indicated by low bone mineral density (BMD), can affect implant osteointegration, long-term stability, and increase the likelihood of periprosthetic fractures. Despite these risks, osteoporosis is often underdiagnosed and undertreated in THA candidates. While several studies have addressed this issue in Northern populations, data on Southern European cohorts, particularly Italian patients, remain limited. This study aims to evaluate the prevalence of osteoporosis and vitamin D deficiency, as well as the rates of related treatments, in patients with hip osteoarthritis scheduled for THA. Methods: This single-center, retrospective study was conducted at Policlinico Universitario di TorVergata, Italy, involving 66 hip OA patients (35 men, 31 women; mean age 67.5 years). BMD was assessed at the femoral neck, total femur, and lumbar spine via DEXA, alongside vitamin D and PTH levels. Demographic data, ongoing anti-osteoporotic therapies, Harris Hip Score (HHS), and handgrip strength were recorded. Statistical analysis included t-tests and Pearson’s correlation. Osteoporosis was defined per WHO criteria, with significance set at p < 0.05. Results: In this study of 66 patients with hip osteoarthritis (35 men, 31 women; mean age 67.5 years), women exhibited significantly lower bone mineral density (BMD) at the total femur (−0.98 ± 1.42 vs. −0.08 ± 1.04; p < 0.05) and lumbar spine (−0.66 ± 1.74 vs. 0.67 ± 1.59; p < 0.05) compared to men. Handgrip strength was also significantly reduced in females (17.1 ± 8.2 kg) versus males (27.3 ± 10.3 kg; p < 0.05). Vitamin D levels were below 30 ng/mL in 89.4% of patients, and 63.6% had levels below 20 ng/mL; PTH levels were elevated (>65 pg/mL) in 54.5% of cases, indicating frequent secondary hyperparathyroidism. Only 9 patients were receiving vitamin D supplementation and none were on anti-osteoporotic treatment. Conclusions: These findings highlight the frequent coexistence of low BMD, vitamin D deficiency, and reduced muscle strength in THA candidates, suggesting a pattern of musculoskeletal vulnerability that warrants clinical attention. Full article

Background/Objectives: Bisphosphonates are effective in preventing osteoporotic fractures. However, the risk of atypical femur fractures (AFFs) increases with long-term bisphosphonate use. There are few existing publications on the analysis of clinical outcomes of atypical femur fracture cases in Chinese patients. Our objective was to review the clinical outcomes of AFF cases managed in a tertiary center in Hong Kong, China. Methods: Cases of AFF managed in the Prince of Wales Hospital from 2010 to 2024 were included. Data on demographics, type and duration of bisphosphonate use prior to AFF, fixation method, and mobility 1 year post-operation were retrospectively retrieved. One-way ANOVA was used to compare the duration of use prior to the development of AFF between different types of bisphosphonates. Results: Sixty-nine cases of AFF were included, with a mean age of 73.8 ± 9.7 years. A total of 95.6% of patients had a history of bisphosphonate use, with a mean duration of usage of 6.8 ± 5.6 years prior to the occurrence of AFF. The duration of bisphosphonate use prior to the development of AFF was comparable between alendronate, ibandronate, and a history of using more than one type of anti-resorptive agent. A non-union rate of 5.8% was observed in the current cohort, with 48.2% returning to pre-morbid mobility 1 year post-operation. Conclusions: AFF is more commonly seen in female patients with a history of bisphosphonate use. Considering the high success rate demonstrated in the current cohort, treating AFF with closed reduction followed by fixation with a long cephalomedullary device in dynamic locking together with immediate full-weight-bearing rehabilitation post-operation may be effective. Full article

Managing periprosthetic femoral fractures is challenging, particularly in osteoporotic patients with fragile bones. Revision with a long stem is commonly considered but may fail to provide adequate fixation and stability in fragile bones. A novel approach using sandwiched strut allografts and controlled bone crushing with robust cable fixation can offer mechanical support and provide secondary stability to the loosened femoral stem and can be considered a treatment option for low-demand patients. A 73-year-old female with 23 years of hemodialysis experienced pain and instability in her right thigh following a slip. She had extremely low bone mineral density, and radiographs revealed a periprosthetic femoral fracture with a loosened femoral prosthesis, classified as Vancouver type B3. The patient underwent surgical fixation using a long anatomical plate augmented with dual strut allografts sandwiched anterior and posterior femur. Robust cable fixation was performed to partially crush the native cortical bone against the stem to enhance stability. Postoperative imaging at 18 months confirmed successful bone union and implant stability, and the patient regained preoperative functional capacity without pain. This case demonstrates that partially crushing native bone with dual strut allografts may provide stability to the loosened femoral stem and can be an effective alternative to long-stem revision surgery for patients with highly fragile bones. This approach may provide immediate mechanical stability and can be a potential treatment option for managing fragile periprosthetic femoral fractures. Full article

This study explores how select microRNAs (miRNAs) influence bone structure in humans and in transgenic mice. In trabecular bone biopsies from 84 postmenopausal women (healthy, osteopenic, and osteoporotic), we demonstrate that DLEU2 (deleted in lymphocytic leukemia 2)-encoded miR-15a-5p is strongly positively associated with bone mineral density (BMD) at different skeletal sites. In bone transcriptome analyses, miR-15a-5p levels correlated positively with the osteocyte characteristic transcripts SOST (encoding sclerostin) and MEPE (Matrix Extracellular Phosphoglycoprotein), while the related miR-15b-5p showed a negative association with BMD and osteoblast markers. The data imply that these miRNAs have opposite roles in bone remodeling with distinct actions on bone cells. Expression quantitative trait loci (eQTL) variants confirmed earlier DLEU2 associations. Furthermore, a novel variant (rs12585295) showed high localization with transcriptionally active chromatin states in osteoblast primary cell cultures. The supposition that DLEU2-encoded miRNAs have an important regulatory role in bone remodeling was further confirmed in a transgenic mice model showing that miR-15a/16-1-deleted mice had significantly higher percentage bone volume and trabecular number than the wild type, possibly due to prenatal actions. However, the three-point mechanical break force test of mice femurs showed a positive correlation between strength and miR-15a-5p/miR-16-5p levels, indicating differential effects on cortical and trabecular bone. Moreover, these miRNAs appear to have distinct and complex actions in mice prenatally and in adult humans, impacting BMD and microstructure by regulating bone cell transcription. However, detailed interactions between these miRNAs and their downstream mechanisms in health and disease need further clarification. Full article

Background and Objectives: Osteoporosis is becoming more prevalent with the rise in the aging population, leading to the increased use of bisphosphonates for treatment. While these medications are effective in preventing osteoporotic fractures, long-term use has been associated with atypical insufficiency fractures, primarily in the femur. However, atypical fractures in other weight-bearing bones, such as the tibia, have rarely been reported. This study aims to present a case of an atypical insufficiency fracture of the tibia in an elderly female who has been on long-term bisphosphonate therapy and to review treatment outcomes within the context of the current literature. Patient concerns: A 76-year-old female presented with pain in the proximal right tibia, developing two months prior without trauma. She had been receiving long-term bisphosphonate therapy for osteoporosis, initially taking sodium risedronate orally for 4 years, followed by intravenous ibandronate for 10 years. Physical examination revealed localized tenderness, and radiographs showed cortical thickening and a horizontal fracture line in the proximal right tibia. MRI confirmed these findings, along with surrounding edema. The laboratory results were mostly normal, but the bone formation marker osteocalcin was significantly reduced. The patient had a history of insufficiency fractures in the ipsilateral tibia and contralateral femur, previously treated conservatively with teriparatide. A similar conservative approach was attempted but failed, leading to surgical intervention with intramedullary nailing and supplementary plating. At the 8-month follow-up, the patient showed successful fracture union and resolution of symptoms. Conclusion: Long-term use of bisphosphonates, though effective for osteoporosis, can lead to atypical insufficiency fractures, primarily in the femur but also occasionally in the tibia. Clinicians should consider this possibility when patients present with pain in weight-bearing bones without a history of trauma. Prompt diagnosis through thorough history-taking, physical examination, and appropriate imaging is essential to ensure timely management. Full article

Background: A significant loss in bone density and strength occurs during the post-renal-transplant period with higher susceptibility to fracture. The study aims to compare the performance of the Radiofrequency Echographic Multi Spectrometry (REMS) in the bone mineral density assessment with the conventional dual-energy X-ray absorptiometry (DXA) in a cohort of kidney transplant recipients (KTR). Methods: A cohort of 40 patients underwent both DXA and REMS examinations on the lumbar spine and/or proximal femur. The paired t-test was used to compare DXA and REMS measurements; the chi-square test was used to compare the prevalence of osteoporosis/osteopenia. The agreement between the two techniques was assessed through Spearman’s correlation. Results: As expected, most KTR patients were osteopenic or osteoporotic with both REMS and DXA (86.5% and 81% for the femur; 88% and 65% for the lumbar spine p < 0.05). A modest correlation (r = 0.4, p < 0.01) was observed at the lumbar spine between the T-score measured by REMS and DXA. A strong correlation was defined between REMS and DXA in the femoral region (r = 0.7, p < 0.0001). Conclusions: The study demonstrates the exchangeability of the two techniques on the proximal femur in KTR and a higher diagnostic accuracy of REMS at the spine level than DXA. Full article

Background/Objectives: The increasing numbers of already endemic hip fractures in the elderly taking anticoagulants is a growing concern for daily surgical practice. Ample evidence demonstrates decreased morbidity and mortality in the general population when surgery is performed at the earliest possibility. Direct anticoagulants are relatively new drugs that can cause increased perioperative bleeding. Current guidelines propose stopping the drug to allow for elimination before performing elective surgery. Optimal management in urgent hip surgery is presently based on expert opinion with arbitrary cut-offs. In this study, we investigated whether patients taking direct anticoagulants would benefit from early surgical treatment, regardless of the timing since last intake. Methods: A total of 340 patients were included in the analysis, of which 59 took direct anticoagulants. The primary outcomes were time to surgery, postoperative transfusion rate, postoperative hemoglobin decrease, length of postoperative in-hospital stay (LOPS), revision rate, and complication rate (medical and surgical). Results: Our findings showed that the anticoagulated group was fit for discharge earlier when operated on within 24 h (p = 0.0167). Postoperative transfusion and medical complication rate tended to be lower when the operation was performed earlier. Revision rate due to hematomas were higher in the direct anticoagulant group without a relationship to time to surgery. Simple linear regression could not determine a relationship between postoperative hemoglobin change and time to surgery. Conclusions: We suggest that directly anticoagulated patients needing hip fracture surgery must be considered for early surgery. Full article