Osteoarthritis

Major Finding: People who developed osteoarthritis in both knees during 30 months of follow-up had a twofold increased rate of vitamin K deficiency at baseline, compared with people who did not develop osteoarthritis, and a nearly threefold increased risk of vitamin K deficiency compared with those who developed osteoarthritis in one knee.

Data Source: The 1,180 people enrolled in the MOST study who did not have osteoarthritis at baseline.

Disclosures: Dr. Neogi had no disclosures.

BRUSSELS – Vitamin K deficiency may increase the risk for developing knee osteoarthritis and for forming knee cartilage lesions, judging from the findings of a 30-month study of nearly 1,200 people at risk for knee osteoarthritis.

This apparent role of low vitamin K levels in susceptibility to knee pathology raised the question whether vitamin K supplementation for deficient individuals might be a “simple, effective preventive agent,” Dr. Tuhina Neogi said at the congress.

“The next step is an intervention trial,” said Dr. Neogi, a rheumatologist at Boston University. “Taken together, there is enough biological plausibility that vitamin K could play a role. Osteoarthritis is multifactorial, but this could be one component. If [dietary supplementation] proves effective, it would be something easy for people to do.”

Vitamin K works as a cofactor in the carboxylation of several proteins that are involved in bone and cartilage formation and maintenance. Prior studies have shownethat low vitamin K intake and low blood levels weare linked to prevalent radiographic features of hand and knee osteoarthritis.

The investigators examined data that were collected from people enrolled in the Multicenter Osteoarthritis (MOST) study who had an elevated risk for knee osteoarthritis at entry but had not yet developed the disease. MOST enrolled more than 3,000 people who had osteoarthritis or were at risk for it starting in 2003 at two U.S. sites. The 1,180 people who were included in the study averaged 62 years of age; 62% were women, and their average body mass index was about 30 kg/m

Dr. Neogi and her associates defined vitamin K deficiency as a plasma level of phylloquinone less than 0.5 nmol/L. (Normal is 0.5-1.2 nmol/L.) At baseline, 9% of the study participants without osteoarthritis had vitamin K deficiency.

The researchers made incidence osteoarthritis the primary end point, defined as development of a knee Kellgren-Lawrence (KL) grade of 2 or higher (including knee replacement). All people included in the analysis had a KL grade less than 2 at baseline. During 30 months of follow-up, 15% of the participants developed osteoarthritis.

Analysis revealed that participants with vitamin K deficiency at baseline had a 43% increased risk, after adjustment for age, sex, BMI, bone mineral density, and vitamin D level at baseline. This increased risk just missed reaching significance. Dr. Neogi suggested that this may have been a power issue, with too few vitamin K–deficient participants in the database.

Analysis also showed a link between the extent of knee osteoarthritis and vitamin K deficiency. Those with osteoarthritis in both knees had a significant, nearly threefold increased risk of vitamin K deficiency at baseline, compared with those who developed osteoarthritis in one knee during follow-up. Those who had both knees affected had a significant, twofold increased risk of vitamin deficiency, compared with people who did not develop any knee osteoarthritis, she reported at the congress, which was organized by the Osteoarthritis Research Society International.

Vitamin K–deficient participants also had a significant, nearly threefold increased risk of new cartilage lesions on their knee MRI scans that were consistent with osteoarthritis.

Major Finding: People who developed osteoarthritis in both knees during 30 months of follow-up had a twofold increased rate of vitamin K deficiency at baseline, compared with people who did not develop osteoarthritis, and a nearly threefold increased risk of vitamin K deficiency compared with those who developed osteoarthritis in one knee.

Data Source: The 1,180 people enrolled in the MOST study who did not have osteoarthritis at baseline.

Disclosures: Dr. Neogi had no disclosures.

BRUSSELS – Vitamin K deficiency may increase the risk for developing knee osteoarthritis and for forming knee cartilage lesions, judging from the findings of a 30-month study of nearly 1,200 people at risk for knee osteoarthritis.

This apparent role of low vitamin K levels in susceptibility to knee pathology raised the question whether vitamin K supplementation for deficient individuals might be a “simple, effective preventive agent,” Dr. Tuhina Neogi said at the congress.

“The next step is an intervention trial,” said Dr. Neogi, a rheumatologist at Boston University. “Taken together, there is enough biological plausibility that vitamin K could play a role. Osteoarthritis is multifactorial, but this could be one component. If [dietary supplementation] proves effective, it would be something easy for people to do.”

Vitamin K works as a cofactor in the carboxylation of several proteins that are involved in bone and cartilage formation and maintenance. Prior studies have shownethat low vitamin K intake and low blood levels weare linked to prevalent radiographic features of hand and knee osteoarthritis.

The investigators examined data that were collected from people enrolled in the Multicenter Osteoarthritis (MOST) study who had an elevated risk for knee osteoarthritis at entry but had not yet developed the disease. MOST enrolled more than 3,000 people who had osteoarthritis or were at risk for it starting in 2003 at two U.S. sites. The 1,180 people who were included in the study averaged 62 years of age; 62% were women, and their average body mass index was about 30 kg/m

Dr. Neogi and her associates defined vitamin K deficiency as a plasma level of phylloquinone less than 0.5 nmol/L. (Normal is 0.5-1.2 nmol/L.) At baseline, 9% of the study participants without osteoarthritis had vitamin K deficiency.

The researchers made incidence osteoarthritis the primary end point, defined as development of a knee Kellgren-Lawrence (KL) grade of 2 or higher (including knee replacement). All people included in the analysis had a KL grade less than 2 at baseline. During 30 months of follow-up, 15% of the participants developed osteoarthritis.

Analysis revealed that participants with vitamin K deficiency at baseline had a 43% increased risk, after adjustment for age, sex, BMI, bone mineral density, and vitamin D level at baseline. This increased risk just missed reaching significance. Dr. Neogi suggested that this may have been a power issue, with too few vitamin K–deficient participants in the database.

Analysis also showed a link between the extent of knee osteoarthritis and vitamin K deficiency. Those with osteoarthritis in both knees had a significant, nearly threefold increased risk of vitamin K deficiency at baseline, compared with those who developed osteoarthritis in one knee during follow-up. Those who had both knees affected had a significant, twofold increased risk of vitamin deficiency, compared with people who did not develop any knee osteoarthritis, she reported at the congress, which was organized by the Osteoarthritis Research Society International.

Vitamin K–deficient participants also had a significant, nearly threefold increased risk of new cartilage lesions on their knee MRI scans that were consistent with osteoarthritis.

Major Finding: People who developed osteoarthritis in both knees during 30 months of follow-up had a twofold increased rate of vitamin K deficiency at baseline, compared with people who did not develop osteoarthritis, and a nearly threefold increased risk of vitamin K deficiency compared with those who developed osteoarthritis in one knee.

Data Source: The 1,180 people enrolled in the MOST study who did not have osteoarthritis at baseline.

Disclosures: Dr. Neogi had no disclosures.

BRUSSELS – Vitamin K deficiency may increase the risk for developing knee osteoarthritis and for forming knee cartilage lesions, judging from the findings of a 30-month study of nearly 1,200 people at risk for knee osteoarthritis.

This apparent role of low vitamin K levels in susceptibility to knee pathology raised the question whether vitamin K supplementation for deficient individuals might be a “simple, effective preventive agent,” Dr. Tuhina Neogi said at the congress.

“The next step is an intervention trial,” said Dr. Neogi, a rheumatologist at Boston University. “Taken together, there is enough biological plausibility that vitamin K could play a role. Osteoarthritis is multifactorial, but this could be one component. If [dietary supplementation] proves effective, it would be something easy for people to do.”

Vitamin K works as a cofactor in the carboxylation of several proteins that are involved in bone and cartilage formation and maintenance. Prior studies have shownethat low vitamin K intake and low blood levels weare linked to prevalent radiographic features of hand and knee osteoarthritis.

The investigators examined data that were collected from people enrolled in the Multicenter Osteoarthritis (MOST) study who had an elevated risk for knee osteoarthritis at entry but had not yet developed the disease. MOST enrolled more than 3,000 people who had osteoarthritis or were at risk for it starting in 2003 at two U.S. sites. The 1,180 people who were included in the study averaged 62 years of age; 62% were women, and their average body mass index was about 30 kg/m

Dr. Neogi and her associates defined vitamin K deficiency as a plasma level of phylloquinone less than 0.5 nmol/L. (Normal is 0.5-1.2 nmol/L.) At baseline, 9% of the study participants without osteoarthritis had vitamin K deficiency.

The researchers made incidence osteoarthritis the primary end point, defined as development of a knee Kellgren-Lawrence (KL) grade of 2 or higher (including knee replacement). All people included in the analysis had a KL grade less than 2 at baseline. During 30 months of follow-up, 15% of the participants developed osteoarthritis.

Analysis revealed that participants with vitamin K deficiency at baseline had a 43% increased risk, after adjustment for age, sex, BMI, bone mineral density, and vitamin D level at baseline. This increased risk just missed reaching significance. Dr. Neogi suggested that this may have been a power issue, with too few vitamin K–deficient participants in the database.

Analysis also showed a link between the extent of knee osteoarthritis and vitamin K deficiency. Those with osteoarthritis in both knees had a significant, nearly threefold increased risk of vitamin K deficiency at baseline, compared with those who developed osteoarthritis in one knee during follow-up. Those who had both knees affected had a significant, twofold increased risk of vitamin deficiency, compared with people who did not develop any knee osteoarthritis, she reported at the congress, which was organized by the Osteoarthritis Research Society International.

Vitamin K–deficient participants also had a significant, nearly threefold increased risk of new cartilage lesions on their knee MRI scans that were consistent with osteoarthritis.

After knee injury, do physicians have a rare opportunity to intervene and perhaps prevent the development of osteoarthritis? Dr. Amanda Nelson discusses the possibilities. See related story at http://tinyurl.com/23ps2sl

View Video Now.

After knee injury, do physicians have a rare opportunity to intervene and perhaps prevent the development of osteoarthritis? Dr. Amanda Nelson discusses the possibilities. See related story at http://tinyurl.com/23ps2sl

View Video Now.

After knee injury, do physicians have a rare opportunity to intervene and perhaps prevent the development of osteoarthritis? Dr. Amanda Nelson discusses the possibilities. See related story at http://tinyurl.com/23ps2sl

View Video Now.

The U.K. National Institute for Health and Clinical Excellence said in September that it would recommend the osteoporosis drug denosumab for older women at risk of fractures who cannot take oral bisphosphonates.

NICE's standard treatment recommendation for this patient group is alendronate and either risedronate or etidronate.

All of these agents are oral medications associated with adverse upper-GI effects if not taken according to instructions. Patients must take the medicines before meals and should not lie down for at least half an hour afterward. Denosumab, by contrast, is an injection administered twice annually.

Denosumab (Prolia, Amgen) is a monoclonal antibody that reduces osteoclast activity, limiting bone breakdown.

The NICE reviewers, in deciding to recommend denosumab, considered results from a manufacturer-sponsored phase III randomized controlled trial of denosumab 60 mg subcutaneously every 6 months in 7,868 osteoporotic women aged 60–90 years.

After 3 years, 7.2% of the placebo patients sustained a new vertebral fracture, compared with 2.3% of those who were taking denosumab, a 68% reduction. Nonvertebral fractures were 6.5% with denosumab versus 8% with placebo, and hip fractures were reduced by 40% to 2.3% in the treatment arm.

The drug was also shown to increase bone mineral density at the lumbar spine by 9% over the 3 years compared with placebo, and by 6% at the hip.

The NICE reviewers, while acknowledging denosumab's effectiveness, nonetheless noted that it was not being considered as a replacement for the cheap and widely available oral bisphosphonates, but as an alternative only where these were unsuitable.

Denosumab costs approximately $290.00 for a 1-mL prefilled syringe (60 mg per mL solution), and about $580.00 for 1 year of treatment.

Women eligible for treatment with denosumab must be intolerant of, have contraindications to, or be unable to comply with manufacturer instructions for taking alendronate and risedronate or etidronate.

They must also have bone density scores indicative of fracture risk. Other clinical risk factors for fracture that may be considered are alcohol consumption of more than 4 units per day, parental history of hip fracture, and rheumatoid arthritis.

NICE's guidance on denosumab, which is in final appraisal stage, mirrors its guidance on strontium ranelate, another treatment option for postmenopausal women at risk of fracture who cannot take bisphosphonates.

The U.K. National Institute for Health and Clinical Excellence said in September that it would recommend the osteoporosis drug denosumab for older women at risk of fractures who cannot take oral bisphosphonates.

NICE's standard treatment recommendation for this patient group is alendronate and either risedronate or etidronate.

All of these agents are oral medications associated with adverse upper-GI effects if not taken according to instructions. Patients must take the medicines before meals and should not lie down for at least half an hour afterward. Denosumab, by contrast, is an injection administered twice annually.

Denosumab (Prolia, Amgen) is a monoclonal antibody that reduces osteoclast activity, limiting bone breakdown.

The NICE reviewers, in deciding to recommend denosumab, considered results from a manufacturer-sponsored phase III randomized controlled trial of denosumab 60 mg subcutaneously every 6 months in 7,868 osteoporotic women aged 60–90 years.

After 3 years, 7.2% of the placebo patients sustained a new vertebral fracture, compared with 2.3% of those who were taking denosumab, a 68% reduction. Nonvertebral fractures were 6.5% with denosumab versus 8% with placebo, and hip fractures were reduced by 40% to 2.3% in the treatment arm.

The drug was also shown to increase bone mineral density at the lumbar spine by 9% over the 3 years compared with placebo, and by 6% at the hip.

The NICE reviewers, while acknowledging denosumab's effectiveness, nonetheless noted that it was not being considered as a replacement for the cheap and widely available oral bisphosphonates, but as an alternative only where these were unsuitable.

Denosumab costs approximately $290.00 for a 1-mL prefilled syringe (60 mg per mL solution), and about $580.00 for 1 year of treatment.

Women eligible for treatment with denosumab must be intolerant of, have contraindications to, or be unable to comply with manufacturer instructions for taking alendronate and risedronate or etidronate.

They must also have bone density scores indicative of fracture risk. Other clinical risk factors for fracture that may be considered are alcohol consumption of more than 4 units per day, parental history of hip fracture, and rheumatoid arthritis.

NICE's guidance on denosumab, which is in final appraisal stage, mirrors its guidance on strontium ranelate, another treatment option for postmenopausal women at risk of fracture who cannot take bisphosphonates.

The U.K. National Institute for Health and Clinical Excellence said in September that it would recommend the osteoporosis drug denosumab for older women at risk of fractures who cannot take oral bisphosphonates.

NICE's standard treatment recommendation for this patient group is alendronate and either risedronate or etidronate.

All of these agents are oral medications associated with adverse upper-GI effects if not taken according to instructions. Patients must take the medicines before meals and should not lie down for at least half an hour afterward. Denosumab, by contrast, is an injection administered twice annually.

Denosumab (Prolia, Amgen) is a monoclonal antibody that reduces osteoclast activity, limiting bone breakdown.

The NICE reviewers, in deciding to recommend denosumab, considered results from a manufacturer-sponsored phase III randomized controlled trial of denosumab 60 mg subcutaneously every 6 months in 7,868 osteoporotic women aged 60–90 years.

After 3 years, 7.2% of the placebo patients sustained a new vertebral fracture, compared with 2.3% of those who were taking denosumab, a 68% reduction. Nonvertebral fractures were 6.5% with denosumab versus 8% with placebo, and hip fractures were reduced by 40% to 2.3% in the treatment arm.

The drug was also shown to increase bone mineral density at the lumbar spine by 9% over the 3 years compared with placebo, and by 6% at the hip.

The NICE reviewers, while acknowledging denosumab's effectiveness, nonetheless noted that it was not being considered as a replacement for the cheap and widely available oral bisphosphonates, but as an alternative only where these were unsuitable.

Denosumab costs approximately $290.00 for a 1-mL prefilled syringe (60 mg per mL solution), and about $580.00 for 1 year of treatment.

Women eligible for treatment with denosumab must be intolerant of, have contraindications to, or be unable to comply with manufacturer instructions for taking alendronate and risedronate or etidronate.

They must also have bone density scores indicative of fracture risk. Other clinical risk factors for fracture that may be considered are alcohol consumption of more than 4 units per day, parental history of hip fracture, and rheumatoid arthritis.

NICE's guidance on denosumab, which is in final appraisal stage, mirrors its guidance on strontium ranelate, another treatment option for postmenopausal women at risk of fracture who cannot take bisphosphonates.

TORONTO — Women aged 67 years or older with a bone mineral density T score higher than −1.50 on dual-energy x-ray absorptiometry can have their next DXA examination deferred for at least 10 years with a low risk that they'll progress to osteoporosis in the interim, according to an analysis of data from more than 5,000 U.S. women.

“Fewer than 10% of women with a BMD [bone mineral density] T score of more than −1.50 were estimated to transition to osteoporosis if followed for 15 years,” Dr. Margaret L. Gourlay said.

For these women, “repeat testing before 10 years is unlikely to show osteoporosis,” she said, and for women with a T score of −1.50 to −1.99, “a 5-year interval could be considered.”

The results provide the first evidence-based guidance available on the appropriate interval for osteoporosis screening in elderly women.

“The value of these results is that we can be less concerned about women with good BMD,” Dr. Gourlay said in an interview. “We don't need to go on autopilot and screen [all women] every 2 years.”

Medicare reimburses for screening women aged 65 years or older with dual-energy x-ray absorptiometry (DXA) every 2 years, she noted, and hence U.S. physicians often recommend this screening interval.

Earlier this year, however, an updated review of osteoporosis screening by the U.S. Preventive Services Task Force (USPSTF) noted that no evidence existed to support any screening interval (Ann. Intern. Med. 2010;153:99–111).

The results “were a surprise in a good way,” said Dr. Gourlay, a family physician at the University of North Carolina in Chapel Hill. “This is good news for women with good BMD. For women with higher bone density, we're probably doing some unnecessary testing.”

The new results also showed that the T score exerted the strongest influence on the osteoporosis screening interval, more so than clinical risk factors for fracture. Adjustment for “risk factors did not make too much of a difference, so physicians do not need to make a FRAX calculation” to decide a screening interval, she said. “They can just go by the BMD.”

“With FRAX [the World Health Organization's Fracture Risk Assessment Tool] you don't just look at BMD, but primary care physicians can't stop [in the middle of a patient consultation] to calculate a FRAX score,” Dr. Gourlay said.

“When a patient has a BMD result in the good range, the main value of the new results is that we can be less concerned about these women” and the need for rescreening in the near future, she noted.

“The importance [of the new findings] is not the absolute time estimates we found; it's the magnitude of the difference.

A 16-year interval [for 10% of women to develop osteoporosis] for women in the top two T score groups, and a 5-year interval [for women with a baseline T score of −1.50 to −1.99] is quite different” from the way most physicians practice today, she said.

She cautioned that the finding needs confirmation from similar analyses using different data sets, and that it remains up to health policy-setting groups, such as the USPSTF, to consider the findings and use them to formulate updated screening recommendations. But, she added, the findings have already influenced her own approach to handling screening intervals.

“If I have a patient who missed a test and her prior T score was more than −1.50, I'm not nearly as worried now,” said Dr. Gourlay.

The analysis used data collected in the Study of Osteoporotic Fractures (SOF), which enrolled women aged 65 years or older in four U.S. cities starting in 1986 and has followed them since then.

Dr. Gourlay and her associates focused on 5,036 women in the study who underwent at least two serial BMD measures over a total of 15 years. Patients were excluded from analysis if they had osteoporosis at any hip site at baseline, had an incident hip fracture, or were treated with a bisphosphonate or calcitonin. Patients also were excluded if they died or dropped out of the study.

The analysis included 1,275 women who had at least one normal baseline BMD value (a T score of −1.00 or greater) and 4,279 women with at least one T score that identified them as having osteopenia (−1.01 to −2.49).

Some women fell into both categories if they underwent at least three DXA examinations starting with at least one normal T score followed by at least one osteopenic score.

At baseline, the rate of estrogen use ran 25% in women with a normal T score at baseline and 16% in women with osteopenia – relatively high rates by today's standards but typical for practice in the 1980s.

During follow-up, full transition to osteoporosis occurred in fewer than 1% of the participants with a T score of at least −1.00 at baseline, fewer than 5% of those with a T score of −1.01 to −1.49 at baseline, and 22% of women with a score of −1.50 to −1.99 at baseline. Transition to osteoporosis took place in 65% of women who had a T score of −2.00 to −2.49 at baseline.

After Dr. Gourlay and her associates adjusted for the covariates of age and continuous bone mineral density, they found that it took an estimated 16 years for 10% of women with a T score of −1.00 or higher at baseline to transition to osteoporosis.

The other three T score subgroups that were analyzed underwent covariate adjustment for age, body mass index, current estrogen use, any fracture after age 50, current smoking, and oral glucocorticoid use.

After adjustment, the average time for 10% of women to transition to osteoporosis was found to be 15.5 years in women following a T score measure of −1.01 to −1.49, 4.5 years in women with a T score of −1.50 to −1.99, and 1.2 years in women with a T score of −2.00 to −2.49.

The investigators performed an additional analysis that stratified women by their age at the baseline DXA examination.

Even among women who were 85 years old, it took an average of nearly 11 years for 10% to develop osteoporosis following a baseline T score of −1.01 to −1.49.

Dr. Gourlay said that she had no disclosures relevant to this study.

Source Elsevier Global Medical News

X-ray of the hip shows a fracture due to osteoporosis in an elderly woman. Less frequent screening may be indicated.

Source ©2010 Science Photo Library

TORONTO — Women aged 67 years or older with a bone mineral density T score higher than −1.50 on dual-energy x-ray absorptiometry can have their next DXA examination deferred for at least 10 years with a low risk that they'll progress to osteoporosis in the interim, according to an analysis of data from more than 5,000 U.S. women.

“Fewer than 10% of women with a BMD [bone mineral density] T score of more than −1.50 were estimated to transition to osteoporosis if followed for 15 years,” Dr. Margaret L. Gourlay said.

For these women, “repeat testing before 10 years is unlikely to show osteoporosis,” she said, and for women with a T score of −1.50 to −1.99, “a 5-year interval could be considered.”

The results provide the first evidence-based guidance available on the appropriate interval for osteoporosis screening in elderly women.

“The value of these results is that we can be less concerned about women with good BMD,” Dr. Gourlay said in an interview. “We don't need to go on autopilot and screen [all women] every 2 years.”

Medicare reimburses for screening women aged 65 years or older with dual-energy x-ray absorptiometry (DXA) every 2 years, she noted, and hence U.S. physicians often recommend this screening interval.

Earlier this year, however, an updated review of osteoporosis screening by the U.S. Preventive Services Task Force (USPSTF) noted that no evidence existed to support any screening interval (Ann. Intern. Med. 2010;153:99–111).

The results “were a surprise in a good way,” said Dr. Gourlay, a family physician at the University of North Carolina in Chapel Hill. “This is good news for women with good BMD. For women with higher bone density, we're probably doing some unnecessary testing.”

The new results also showed that the T score exerted the strongest influence on the osteoporosis screening interval, more so than clinical risk factors for fracture. Adjustment for “risk factors did not make too much of a difference, so physicians do not need to make a FRAX calculation” to decide a screening interval, she said. “They can just go by the BMD.”

“With FRAX [the World Health Organization's Fracture Risk Assessment Tool] you don't just look at BMD, but primary care physicians can't stop [in the middle of a patient consultation] to calculate a FRAX score,” Dr. Gourlay said.

“When a patient has a BMD result in the good range, the main value of the new results is that we can be less concerned about these women” and the need for rescreening in the near future, she noted.

“The importance [of the new findings] is not the absolute time estimates we found; it's the magnitude of the difference.

A 16-year interval [for 10% of women to develop osteoporosis] for women in the top two T score groups, and a 5-year interval [for women with a baseline T score of −1.50 to −1.99] is quite different” from the way most physicians practice today, she said.

She cautioned that the finding needs confirmation from similar analyses using different data sets, and that it remains up to health policy-setting groups, such as the USPSTF, to consider the findings and use them to formulate updated screening recommendations. But, she added, the findings have already influenced her own approach to handling screening intervals.

“If I have a patient who missed a test and her prior T score was more than −1.50, I'm not nearly as worried now,” said Dr. Gourlay.

The analysis used data collected in the Study of Osteoporotic Fractures (SOF), which enrolled women aged 65 years or older in four U.S. cities starting in 1986 and has followed them since then.

Dr. Gourlay and her associates focused on 5,036 women in the study who underwent at least two serial BMD measures over a total of 15 years. Patients were excluded from analysis if they had osteoporosis at any hip site at baseline, had an incident hip fracture, or were treated with a bisphosphonate or calcitonin. Patients also were excluded if they died or dropped out of the study.

The analysis included 1,275 women who had at least one normal baseline BMD value (a T score of −1.00 or greater) and 4,279 women with at least one T score that identified them as having osteopenia (−1.01 to −2.49).

Some women fell into both categories if they underwent at least three DXA examinations starting with at least one normal T score followed by at least one osteopenic score.

At baseline, the rate of estrogen use ran 25% in women with a normal T score at baseline and 16% in women with osteopenia – relatively high rates by today's standards but typical for practice in the 1980s.

During follow-up, full transition to osteoporosis occurred in fewer than 1% of the participants with a T score of at least −1.00 at baseline, fewer than 5% of those with a T score of −1.01 to −1.49 at baseline, and 22% of women with a score of −1.50 to −1.99 at baseline. Transition to osteoporosis took place in 65% of women who had a T score of −2.00 to −2.49 at baseline.

After Dr. Gourlay and her associates adjusted for the covariates of age and continuous bone mineral density, they found that it took an estimated 16 years for 10% of women with a T score of −1.00 or higher at baseline to transition to osteoporosis.

The other three T score subgroups that were analyzed underwent covariate adjustment for age, body mass index, current estrogen use, any fracture after age 50, current smoking, and oral glucocorticoid use.

After adjustment, the average time for 10% of women to transition to osteoporosis was found to be 15.5 years in women following a T score measure of −1.01 to −1.49, 4.5 years in women with a T score of −1.50 to −1.99, and 1.2 years in women with a T score of −2.00 to −2.49.

The investigators performed an additional analysis that stratified women by their age at the baseline DXA examination.

Even among women who were 85 years old, it took an average of nearly 11 years for 10% to develop osteoporosis following a baseline T score of −1.01 to −1.49.

Dr. Gourlay said that she had no disclosures relevant to this study.

Source Elsevier Global Medical News

X-ray of the hip shows a fracture due to osteoporosis in an elderly woman. Less frequent screening may be indicated.

Source ©2010 Science Photo Library

TORONTO — Women aged 67 years or older with a bone mineral density T score higher than −1.50 on dual-energy x-ray absorptiometry can have their next DXA examination deferred for at least 10 years with a low risk that they'll progress to osteoporosis in the interim, according to an analysis of data from more than 5,000 U.S. women.

“Fewer than 10% of women with a BMD [bone mineral density] T score of more than −1.50 were estimated to transition to osteoporosis if followed for 15 years,” Dr. Margaret L. Gourlay said.

For these women, “repeat testing before 10 years is unlikely to show osteoporosis,” she said, and for women with a T score of −1.50 to −1.99, “a 5-year interval could be considered.”

The results provide the first evidence-based guidance available on the appropriate interval for osteoporosis screening in elderly women.

“The value of these results is that we can be less concerned about women with good BMD,” Dr. Gourlay said in an interview. “We don't need to go on autopilot and screen [all women] every 2 years.”

Medicare reimburses for screening women aged 65 years or older with dual-energy x-ray absorptiometry (DXA) every 2 years, she noted, and hence U.S. physicians often recommend this screening interval.

Earlier this year, however, an updated review of osteoporosis screening by the U.S. Preventive Services Task Force (USPSTF) noted that no evidence existed to support any screening interval (Ann. Intern. Med. 2010;153:99–111).

The results “were a surprise in a good way,” said Dr. Gourlay, a family physician at the University of North Carolina in Chapel Hill. “This is good news for women with good BMD. For women with higher bone density, we're probably doing some unnecessary testing.”

The new results also showed that the T score exerted the strongest influence on the osteoporosis screening interval, more so than clinical risk factors for fracture. Adjustment for “risk factors did not make too much of a difference, so physicians do not need to make a FRAX calculation” to decide a screening interval, she said. “They can just go by the BMD.”

“With FRAX [the World Health Organization's Fracture Risk Assessment Tool] you don't just look at BMD, but primary care physicians can't stop [in the middle of a patient consultation] to calculate a FRAX score,” Dr. Gourlay said.

“When a patient has a BMD result in the good range, the main value of the new results is that we can be less concerned about these women” and the need for rescreening in the near future, she noted.

“The importance [of the new findings] is not the absolute time estimates we found; it's the magnitude of the difference.

A 16-year interval [for 10% of women to develop osteoporosis] for women in the top two T score groups, and a 5-year interval [for women with a baseline T score of −1.50 to −1.99] is quite different” from the way most physicians practice today, she said.

She cautioned that the finding needs confirmation from similar analyses using different data sets, and that it remains up to health policy-setting groups, such as the USPSTF, to consider the findings and use them to formulate updated screening recommendations. But, she added, the findings have already influenced her own approach to handling screening intervals.

“If I have a patient who missed a test and her prior T score was more than −1.50, I'm not nearly as worried now,” said Dr. Gourlay.

The analysis used data collected in the Study of Osteoporotic Fractures (SOF), which enrolled women aged 65 years or older in four U.S. cities starting in 1986 and has followed them since then.

Dr. Gourlay and her associates focused on 5,036 women in the study who underwent at least two serial BMD measures over a total of 15 years. Patients were excluded from analysis if they had osteoporosis at any hip site at baseline, had an incident hip fracture, or were treated with a bisphosphonate or calcitonin. Patients also were excluded if they died or dropped out of the study.

The analysis included 1,275 women who had at least one normal baseline BMD value (a T score of −1.00 or greater) and 4,279 women with at least one T score that identified them as having osteopenia (−1.01 to −2.49).

Some women fell into both categories if they underwent at least three DXA examinations starting with at least one normal T score followed by at least one osteopenic score.

At baseline, the rate of estrogen use ran 25% in women with a normal T score at baseline and 16% in women with osteopenia – relatively high rates by today's standards but typical for practice in the 1980s.

During follow-up, full transition to osteoporosis occurred in fewer than 1% of the participants with a T score of at least −1.00 at baseline, fewer than 5% of those with a T score of −1.01 to −1.49 at baseline, and 22% of women with a score of −1.50 to −1.99 at baseline. Transition to osteoporosis took place in 65% of women who had a T score of −2.00 to −2.49 at baseline.

After Dr. Gourlay and her associates adjusted for the covariates of age and continuous bone mineral density, they found that it took an estimated 16 years for 10% of women with a T score of −1.00 or higher at baseline to transition to osteoporosis.

The other three T score subgroups that were analyzed underwent covariate adjustment for age, body mass index, current estrogen use, any fracture after age 50, current smoking, and oral glucocorticoid use.

After adjustment, the average time for 10% of women to transition to osteoporosis was found to be 15.5 years in women following a T score measure of −1.01 to −1.49, 4.5 years in women with a T score of −1.50 to −1.99, and 1.2 years in women with a T score of −2.00 to −2.49.

The investigators performed an additional analysis that stratified women by their age at the baseline DXA examination.

Even among women who were 85 years old, it took an average of nearly 11 years for 10% to develop osteoporosis following a baseline T score of −1.01 to −1.49.

Dr. Gourlay said that she had no disclosures relevant to this study.

Source Elsevier Global Medical News

X-ray of the hip shows a fracture due to osteoporosis in an elderly woman. Less frequent screening may be indicated.

Source ©2010 Science Photo Library

Major Finding: In patients undergoing periodontal surgery, daily 20-mcg injections of teriparatide for 6 weeks led to an average 29% bone gain at the surgery site after 1 year, compared with an average 3% gain in the placebo group.

Data Source: A randomized, single-center pilot study of 40 patients with severe periodontal disease.

Disclosures: The investigator-initiated study received partial funding from Eli Lilly & Co., the company that markets teriparatide (Forteo). Dr. McCauley has received research grants and transportation support from Lilly. She has also received research grants and has been a consultant to Amgen, but has not received any honoraria or consulting fees. Dr. Bashutski said she has received travel expenses from the Colgate-Palmolive Co. Dr. Grey said that he has received travel expenses from Merck Sharp & Dohme (NZ) Ltd.

Treatment for 6 weeks with teriparatide, a U.S.-approved drug that stimulates bone remodeling, led to significant, 1-year improvements in alveolar bone formation and clinical outcomes in a controlled pilot study of 40 patients undergoing periodontal surgery.

Bone gain in the osseous defects of the 20 patients who were randomized to receive daily teriparatide injections became detectable early after treatment began and continued to improve during 12 months of follow-up, leading to a highly significant improvement in overall alveolar bone gain, compared with the 20 patients on placebo, Jill D. Bashutski, D.D.S., and her associates reported online (N. Engl. J. Med. 2010 Oct. 16 [doi:10.1056/NEJMoa1005361]).

The patients who were treated with teriparatide also demonstrated significantly better 1-year improvements in periodontal probing depth and clinical attachment, reported Dr. Bashutski, a periodontist at the University of Michigan in Ann Arbor.

The article's online publication was timed to coincide with Dr. Bashutski's presentation of the study findings at the annual meeting of the American Society for Bone and Mineral Research in Toronto.

She and her coinvestigators used teriparatide, a recombinant agent that contains the first 34 amino acids of parathyroid hormone, because of its activity as an anabolic agent and evidence from prior studies that it enhances bone remodeling and wound healing in areas of high bone turnover, such as fractures and surgical sites.

“We know that parathyroid hormone stimulates formation of preosteoblast cells, and these cells go on to eventually form bone,” said Dr. Bashutski.

The 6-week regimen consists of daily teriparatide injections, which produce “an initial incentive for bone formation to occur” during subsequent months, said Dr. Laurie K. McCauley, the principal investigator of the study and professor and chair of periodontics and oral medicine at the University of Michigan, in an interview.

The positive effects that teriparatide treatment had on the study outcomes of bone gain, probing depth, and clinical attachment were also all clinically significant, according to Dr. McCauley. Teriparatide increased 1-year bone gain at a rate that was 10-fold higher than placebo.

“That's huge,” she said.

The long-term sequence of events that teriparatide triggers likely explains how a 6-week course produced significant differences after 1 year, she said.

“We know that most connective tissue healing goes on during the first 6 weeks,” according to Dr. McCauley. “The thought was to augment that healing with this agent.”

The outcome from “this small trial provides preliminary evidence that an agent that stimulates bone formation might confer additional benefit over that achieved with standard care in patients with periodontitis,” commented Dr. Andrew Grey in an editorial that accompanied the article (N. Engl. J. Med. 2010 Oct. 16 [doi:10.1056/NEJMe1010459]).

But many questions about this treatment remain, he said. “How durable is the effect of teriparatide? What is the optimal dosing regimen? Does teriparatide alter important end points] such as tooth loss or the need for further operative intervention? Do antiresorptive agents, which cost considerably less than teriparatide, confer similar benefits?” asked Dr. Grey, an endocrinologist at the University of Auckland (New Zealand).

The study enrolled patients (aged 30–65 years) with severe periodontal disease at the University of Michigan from January 2005 to June 2009. All patients in the study had normal levels of calcium and parathyroid hormone, a minimum vitamin D level of 16 ng/mL, and no osteoporosis.

All patients underwent conventional surgery on an osseous defect. Starting 3 days before surgery, patients began daily treatment with either 20 mcg of teriparatide or placebo, administered daily by subcutaneous injection, for 6 weeks. All patients also received a daily supplement of calcium and vitamin D.

Patients who were treated with teriparatide had significantly better resolution of their periodontal bone defects at 6, 9, and 12 months following baseline, compared with the placebo patients.

At 12 months, the teriparatide-treated patients averaged a bone gain of 1.86 mm (29%), compared with baseline, whereas the placebo patients averaged a 0.16-mm (3%) gain from baseline.

Teriparatide treatment was also associated with a 2.42-mm (33%) average reduction in probing depth at the surgical site after a period of 12 months, compared with baseline. The placebo group averaged a 1.32-mm (20%) reduction in probing depth from baseline, a statistically significant difference.

Clinical attachment improved by an average of 1.58 mm (22%) at 1-year follow-up, compared with baseline, in the teriparatide patients, significantly better than the average value of 0.42 mm (7%) for attachment improvement in the placebo group.

No improvements in probing depth occurred in the teriparatide and placebo patients in areas of severe, chronic periodontitis that did not undergo surgery.

At entry to the study, five patients in the teriparatide arm and nine in the placebo group had osteopenia on dual x-ray absorptiometry examinations. At the 12-month follow-up, patients in both of the study arms showed no significant changes in bone density scores or in quality of life scores.

Teriparatide treatment was not associated with any pattern of adverse events that differed from the placebo group.

Although teriparatide is available in the United States for treating osteoporosis, its widespread use in patients who are undergoing periodontal surgery should await results from studies involving larger numbers of patients, Dr. McCauley said. She also cautioned against extrapolating the results to other types of bone surgery.

Dr. McCauley said she would like to run studies on a delayed-release, topical formulation of teriparatide that would be implanted during surgery and would then release over the subsequent 6 weeks. Such a mode of delivery would precludeithe necessity of administering daily injections. Teriparatide formulations of this type now exist, but they have not reached the clinical-testing stage.

Parathyroid hormone stimulates formation of preosteoblast cells and bone.

Source DR. BASHUTSKI

Teriparatide increased 1-year bone gain at a rate that was 10-fold higher than placebo.

Source DR. MCCAULEY

Major Finding: In patients undergoing periodontal surgery, daily 20-mcg injections of teriparatide for 6 weeks led to an average 29% bone gain at the surgery site after 1 year, compared with an average 3% gain in the placebo group.

Data Source: A randomized, single-center pilot study of 40 patients with severe periodontal disease.

Disclosures: The investigator-initiated study received partial funding from Eli Lilly & Co., the company that markets teriparatide (Forteo). Dr. McCauley has received research grants and transportation support from Lilly. She has also received research grants and has been a consultant to Amgen, but has not received any honoraria or consulting fees. Dr. Bashutski said she has received travel expenses from the Colgate-Palmolive Co. Dr. Grey said that he has received travel expenses from Merck Sharp & Dohme (NZ) Ltd.

Treatment for 6 weeks with teriparatide, a U.S.-approved drug that stimulates bone remodeling, led to significant, 1-year improvements in alveolar bone formation and clinical outcomes in a controlled pilot study of 40 patients undergoing periodontal surgery.

Bone gain in the osseous defects of the 20 patients who were randomized to receive daily teriparatide injections became detectable early after treatment began and continued to improve during 12 months of follow-up, leading to a highly significant improvement in overall alveolar bone gain, compared with the 20 patients on placebo, Jill D. Bashutski, D.D.S., and her associates reported online (N. Engl. J. Med. 2010 Oct. 16 [doi:10.1056/NEJMoa1005361]).

The patients who were treated with teriparatide also demonstrated significantly better 1-year improvements in periodontal probing depth and clinical attachment, reported Dr. Bashutski, a periodontist at the University of Michigan in Ann Arbor.

The article's online publication was timed to coincide with Dr. Bashutski's presentation of the study findings at the annual meeting of the American Society for Bone and Mineral Research in Toronto.

She and her coinvestigators used teriparatide, a recombinant agent that contains the first 34 amino acids of parathyroid hormone, because of its activity as an anabolic agent and evidence from prior studies that it enhances bone remodeling and wound healing in areas of high bone turnover, such as fractures and surgical sites.

“We know that parathyroid hormone stimulates formation of preosteoblast cells, and these cells go on to eventually form bone,” said Dr. Bashutski.

The 6-week regimen consists of daily teriparatide injections, which produce “an initial incentive for bone formation to occur” during subsequent months, said Dr. Laurie K. McCauley, the principal investigator of the study and professor and chair of periodontics and oral medicine at the University of Michigan, in an interview.

The positive effects that teriparatide treatment had on the study outcomes of bone gain, probing depth, and clinical attachment were also all clinically significant, according to Dr. McCauley. Teriparatide increased 1-year bone gain at a rate that was 10-fold higher than placebo.

“That's huge,” she said.

The long-term sequence of events that teriparatide triggers likely explains how a 6-week course produced significant differences after 1 year, she said.

“We know that most connective tissue healing goes on during the first 6 weeks,” according to Dr. McCauley. “The thought was to augment that healing with this agent.”

The outcome from “this small trial provides preliminary evidence that an agent that stimulates bone formation might confer additional benefit over that achieved with standard care in patients with periodontitis,” commented Dr. Andrew Grey in an editorial that accompanied the article (N. Engl. J. Med. 2010 Oct. 16 [doi:10.1056/NEJMe1010459]).

But many questions about this treatment remain, he said. “How durable is the effect of teriparatide? What is the optimal dosing regimen? Does teriparatide alter important end points] such as tooth loss or the need for further operative intervention? Do antiresorptive agents, which cost considerably less than teriparatide, confer similar benefits?” asked Dr. Grey, an endocrinologist at the University of Auckland (New Zealand).

The study enrolled patients (aged 30–65 years) with severe periodontal disease at the University of Michigan from January 2005 to June 2009. All patients in the study had normal levels of calcium and parathyroid hormone, a minimum vitamin D level of 16 ng/mL, and no osteoporosis.

All patients underwent conventional surgery on an osseous defect. Starting 3 days before surgery, patients began daily treatment with either 20 mcg of teriparatide or placebo, administered daily by subcutaneous injection, for 6 weeks. All patients also received a daily supplement of calcium and vitamin D.

Patients who were treated with teriparatide had significantly better resolution of their periodontal bone defects at 6, 9, and 12 months following baseline, compared with the placebo patients.

At 12 months, the teriparatide-treated patients averaged a bone gain of 1.86 mm (29%), compared with baseline, whereas the placebo patients averaged a 0.16-mm (3%) gain from baseline.

Teriparatide treatment was also associated with a 2.42-mm (33%) average reduction in probing depth at the surgical site after a period of 12 months, compared with baseline. The placebo group averaged a 1.32-mm (20%) reduction in probing depth from baseline, a statistically significant difference.

Clinical attachment improved by an average of 1.58 mm (22%) at 1-year follow-up, compared with baseline, in the teriparatide patients, significantly better than the average value of 0.42 mm (7%) for attachment improvement in the placebo group.

No improvements in probing depth occurred in the teriparatide and placebo patients in areas of severe, chronic periodontitis that did not undergo surgery.

At entry to the study, five patients in the teriparatide arm and nine in the placebo group had osteopenia on dual x-ray absorptiometry examinations. At the 12-month follow-up, patients in both of the study arms showed no significant changes in bone density scores or in quality of life scores.

Teriparatide treatment was not associated with any pattern of adverse events that differed from the placebo group.

Although teriparatide is available in the United States for treating osteoporosis, its widespread use in patients who are undergoing periodontal surgery should await results from studies involving larger numbers of patients, Dr. McCauley said. She also cautioned against extrapolating the results to other types of bone surgery.

Dr. McCauley said she would like to run studies on a delayed-release, topical formulation of teriparatide that would be implanted during surgery and would then release over the subsequent 6 weeks. Such a mode of delivery would precludeithe necessity of administering daily injections. Teriparatide formulations of this type now exist, but they have not reached the clinical-testing stage.

Parathyroid hormone stimulates formation of preosteoblast cells and bone.

Source DR. BASHUTSKI

Teriparatide increased 1-year bone gain at a rate that was 10-fold higher than placebo.

Source DR. MCCAULEY

Major Finding: In patients undergoing periodontal surgery, daily 20-mcg injections of teriparatide for 6 weeks led to an average 29% bone gain at the surgery site after 1 year, compared with an average 3% gain in the placebo group.

Data Source: A randomized, single-center pilot study of 40 patients with severe periodontal disease.

Disclosures: The investigator-initiated study received partial funding from Eli Lilly & Co., the company that markets teriparatide (Forteo). Dr. McCauley has received research grants and transportation support from Lilly. She has also received research grants and has been a consultant to Amgen, but has not received any honoraria or consulting fees. Dr. Bashutski said she has received travel expenses from the Colgate-Palmolive Co. Dr. Grey said that he has received travel expenses from Merck Sharp & Dohme (NZ) Ltd.

Treatment for 6 weeks with teriparatide, a U.S.-approved drug that stimulates bone remodeling, led to significant, 1-year improvements in alveolar bone formation and clinical outcomes in a controlled pilot study of 40 patients undergoing periodontal surgery.

Bone gain in the osseous defects of the 20 patients who were randomized to receive daily teriparatide injections became detectable early after treatment began and continued to improve during 12 months of follow-up, leading to a highly significant improvement in overall alveolar bone gain, compared with the 20 patients on placebo, Jill D. Bashutski, D.D.S., and her associates reported online (N. Engl. J. Med. 2010 Oct. 16 [doi:10.1056/NEJMoa1005361]).

The patients who were treated with teriparatide also demonstrated significantly better 1-year improvements in periodontal probing depth and clinical attachment, reported Dr. Bashutski, a periodontist at the University of Michigan in Ann Arbor.

The article's online publication was timed to coincide with Dr. Bashutski's presentation of the study findings at the annual meeting of the American Society for Bone and Mineral Research in Toronto.

She and her coinvestigators used teriparatide, a recombinant agent that contains the first 34 amino acids of parathyroid hormone, because of its activity as an anabolic agent and evidence from prior studies that it enhances bone remodeling and wound healing in areas of high bone turnover, such as fractures and surgical sites.

“We know that parathyroid hormone stimulates formation of preosteoblast cells, and these cells go on to eventually form bone,” said Dr. Bashutski.

The 6-week regimen consists of daily teriparatide injections, which produce “an initial incentive for bone formation to occur” during subsequent months, said Dr. Laurie K. McCauley, the principal investigator of the study and professor and chair of periodontics and oral medicine at the University of Michigan, in an interview.

The positive effects that teriparatide treatment had on the study outcomes of bone gain, probing depth, and clinical attachment were also all clinically significant, according to Dr. McCauley. Teriparatide increased 1-year bone gain at a rate that was 10-fold higher than placebo.

“That's huge,” she said.

The long-term sequence of events that teriparatide triggers likely explains how a 6-week course produced significant differences after 1 year, she said.

“We know that most connective tissue healing goes on during the first 6 weeks,” according to Dr. McCauley. “The thought was to augment that healing with this agent.”

The outcome from “this small trial provides preliminary evidence that an agent that stimulates bone formation might confer additional benefit over that achieved with standard care in patients with periodontitis,” commented Dr. Andrew Grey in an editorial that accompanied the article (N. Engl. J. Med. 2010 Oct. 16 [doi:10.1056/NEJMe1010459]).

But many questions about this treatment remain, he said. “How durable is the effect of teriparatide? What is the optimal dosing regimen? Does teriparatide alter important end points] such as tooth loss or the need for further operative intervention? Do antiresorptive agents, which cost considerably less than teriparatide, confer similar benefits?” asked Dr. Grey, an endocrinologist at the University of Auckland (New Zealand).

The study enrolled patients (aged 30–65 years) with severe periodontal disease at the University of Michigan from January 2005 to June 2009. All patients in the study had normal levels of calcium and parathyroid hormone, a minimum vitamin D level of 16 ng/mL, and no osteoporosis.

All patients underwent conventional surgery on an osseous defect. Starting 3 days before surgery, patients began daily treatment with either 20 mcg of teriparatide or placebo, administered daily by subcutaneous injection, for 6 weeks. All patients also received a daily supplement of calcium and vitamin D.

Patients who were treated with teriparatide had significantly better resolution of their periodontal bone defects at 6, 9, and 12 months following baseline, compared with the placebo patients.

At 12 months, the teriparatide-treated patients averaged a bone gain of 1.86 mm (29%), compared with baseline, whereas the placebo patients averaged a 0.16-mm (3%) gain from baseline.

Teriparatide treatment was also associated with a 2.42-mm (33%) average reduction in probing depth at the surgical site after a period of 12 months, compared with baseline. The placebo group averaged a 1.32-mm (20%) reduction in probing depth from baseline, a statistically significant difference.

Clinical attachment improved by an average of 1.58 mm (22%) at 1-year follow-up, compared with baseline, in the teriparatide patients, significantly better than the average value of 0.42 mm (7%) for attachment improvement in the placebo group.

No improvements in probing depth occurred in the teriparatide and placebo patients in areas of severe, chronic periodontitis that did not undergo surgery.

At entry to the study, five patients in the teriparatide arm and nine in the placebo group had osteopenia on dual x-ray absorptiometry examinations. At the 12-month follow-up, patients in both of the study arms showed no significant changes in bone density scores or in quality of life scores.

Teriparatide treatment was not associated with any pattern of adverse events that differed from the placebo group.

Although teriparatide is available in the United States for treating osteoporosis, its widespread use in patients who are undergoing periodontal surgery should await results from studies involving larger numbers of patients, Dr. McCauley said. She also cautioned against extrapolating the results to other types of bone surgery.

Dr. McCauley said she would like to run studies on a delayed-release, topical formulation of teriparatide that would be implanted during surgery and would then release over the subsequent 6 weeks. Such a mode of delivery would precludeithe necessity of administering daily injections. Teriparatide formulations of this type now exist, but they have not reached the clinical-testing stage.

Parathyroid hormone stimulates formation of preosteoblast cells and bone.

Source DR. BASHUTSKI

Teriparatide increased 1-year bone gain at a rate that was 10-fold higher than placebo.

Source DR. MCCAULEY

BRUSSELS – Use of high-tibial osteotomy as surgical treatment for knee osteoarthritis dwindled during the decade ending in 2007, according to data collected on nearly 2,900 Swedish patients during the 10-year period.

During the same decade, use of total-knee arthroplasty (TKA) for knee osteoarthritis increased, especially in patients younger than 55 years, Annette W-Dahl, Ph.D., said at the annual World Congress on Osteoarthritis.

Despite diminished use, the revision rate following high-tibial osteotomy (HTO) remained modest, with a 29% rate after 10 years. That performance record for HTO suggests that using it first has the potential to delay significantly the need for TKA in patients with severe knee osteoarthritis, making HTO an attractive option for younger patients, said Dr. W-Dahl, a researcher in the department of orthopedics at Lund (Sweden) University.

During 1998-2007, HTO use in Sweden fell from about 5% of primary knee reconstructions for osteoarthritis in 1998 to abut 2% 10 years later. In contrast, use of TKR rose from 78% in 1998 to about 90% in 2007. Use of a third surgical option, unicompartmental knee arthroplasty, also dropped during the decade studied, from 17% in 1998 to 8% in 2007. The low rate of HTO use throughout the decade contrasts with a roughly 30% share of all Swedish primary knee reconstructions about 30 years ago.

Use of HTO also lags today in the United States, with an annual rate probably similar to Sweden’s, commented Dr. Jeffrey N. Katz, professor of medicine at Harvard Medical School in Boston and director of the orthopedics and arthritis center for outcomes research at Brigham and Women’s Hospital in that city. It remains unclear whether use of HTO actually delays the time when a patient with severe osteoarthritis needs TKA, he added.

The new analysis used data collected by the Swedish National Board of Health and Welfare. During the decade reviewed, surgeons performed 3,196 HTOs in 2,893 patients. Two-thirds were men, and their average age was 52 years, with 62% of the patients being younger than 55 years, and 97% aged 65 years or younger. The annual tally of HTOs fell from nearly 400 in 1998 to about 260 in 2007.

Analysis of the surgery done on patients younger than 55 years showed that use of TKA in this age group jumped fivefold, from about 100 in 1998 to more than 500 in 2007. Concurrently, use of HTO dropped, from about 230 in 1998 to about 180 in 2007; use of unicompartmental knee arthroplasty remained relatively stable throughout the decade, with about 100 cases done each year, said Dr. W-Dahl at the congress, which was organized by the Osteoarthritis Research Society International.

The cumulative need for revision surgery in patients who initially underwent HTO surgery ran 29% during the period studied, with women having a statistically significant 30% higher revision rate, compared with men, after adjustment for age and year of surgery.

Among patients younger than 65 years, cumulative revision rates for the three types of surgery during the 10 years studied showed clear differences, with 27% of HTO patients requiring a revision, compared with 16% of patients undergoing unicompartmental knee arthroplasty, and 8% with a TKA.

Dr. W-Dahl had no disclosures.

BRUSSELS – Use of high-tibial osteotomy as surgical treatment for knee osteoarthritis dwindled during the decade ending in 2007, according to data collected on nearly 2,900 Swedish patients during the 10-year period.

During the same decade, use of total-knee arthroplasty (TKA) for knee osteoarthritis increased, especially in patients younger than 55 years, Annette W-Dahl, Ph.D., said at the annual World Congress on Osteoarthritis.

Despite diminished use, the revision rate following high-tibial osteotomy (HTO) remained modest, with a 29% rate after 10 years. That performance record for HTO suggests that using it first has the potential to delay significantly the need for TKA in patients with severe knee osteoarthritis, making HTO an attractive option for younger patients, said Dr. W-Dahl, a researcher in the department of orthopedics at Lund (Sweden) University.

During 1998-2007, HTO use in Sweden fell from about 5% of primary knee reconstructions for osteoarthritis in 1998 to abut 2% 10 years later. In contrast, use of TKR rose from 78% in 1998 to about 90% in 2007. Use of a third surgical option, unicompartmental knee arthroplasty, also dropped during the decade studied, from 17% in 1998 to 8% in 2007. The low rate of HTO use throughout the decade contrasts with a roughly 30% share of all Swedish primary knee reconstructions about 30 years ago.

Use of HTO also lags today in the United States, with an annual rate probably similar to Sweden’s, commented Dr. Jeffrey N. Katz, professor of medicine at Harvard Medical School in Boston and director of the orthopedics and arthritis center for outcomes research at Brigham and Women’s Hospital in that city. It remains unclear whether use of HTO actually delays the time when a patient with severe osteoarthritis needs TKA, he added.

The new analysis used data collected by the Swedish National Board of Health and Welfare. During the decade reviewed, surgeons performed 3,196 HTOs in 2,893 patients. Two-thirds were men, and their average age was 52 years, with 62% of the patients being younger than 55 years, and 97% aged 65 years or younger. The annual tally of HTOs fell from nearly 400 in 1998 to about 260 in 2007.

Analysis of the surgery done on patients younger than 55 years showed that use of TKA in this age group jumped fivefold, from about 100 in 1998 to more than 500 in 2007. Concurrently, use of HTO dropped, from about 230 in 1998 to about 180 in 2007; use of unicompartmental knee arthroplasty remained relatively stable throughout the decade, with about 100 cases done each year, said Dr. W-Dahl at the congress, which was organized by the Osteoarthritis Research Society International.

The cumulative need for revision surgery in patients who initially underwent HTO surgery ran 29% during the period studied, with women having a statistically significant 30% higher revision rate, compared with men, after adjustment for age and year of surgery.

Among patients younger than 65 years, cumulative revision rates for the three types of surgery during the 10 years studied showed clear differences, with 27% of HTO patients requiring a revision, compared with 16% of patients undergoing unicompartmental knee arthroplasty, and 8% with a TKA.

Dr. W-Dahl had no disclosures.

BRUSSELS – Use of high-tibial osteotomy as surgical treatment for knee osteoarthritis dwindled during the decade ending in 2007, according to data collected on nearly 2,900 Swedish patients during the 10-year period.

During the same decade, use of total-knee arthroplasty (TKA) for knee osteoarthritis increased, especially in patients younger than 55 years, Annette W-Dahl, Ph.D., said at the annual World Congress on Osteoarthritis.

Despite diminished use, the revision rate following high-tibial osteotomy (HTO) remained modest, with a 29% rate after 10 years. That performance record for HTO suggests that using it first has the potential to delay significantly the need for TKA in patients with severe knee osteoarthritis, making HTO an attractive option for younger patients, said Dr. W-Dahl, a researcher in the department of orthopedics at Lund (Sweden) University.

During 1998-2007, HTO use in Sweden fell from about 5% of primary knee reconstructions for osteoarthritis in 1998 to abut 2% 10 years later. In contrast, use of TKR rose from 78% in 1998 to about 90% in 2007. Use of a third surgical option, unicompartmental knee arthroplasty, also dropped during the decade studied, from 17% in 1998 to 8% in 2007. The low rate of HTO use throughout the decade contrasts with a roughly 30% share of all Swedish primary knee reconstructions about 30 years ago.

Use of HTO also lags today in the United States, with an annual rate probably similar to Sweden’s, commented Dr. Jeffrey N. Katz, professor of medicine at Harvard Medical School in Boston and director of the orthopedics and arthritis center for outcomes research at Brigham and Women’s Hospital in that city. It remains unclear whether use of HTO actually delays the time when a patient with severe osteoarthritis needs TKA, he added.

The new analysis used data collected by the Swedish National Board of Health and Welfare. During the decade reviewed, surgeons performed 3,196 HTOs in 2,893 patients. Two-thirds were men, and their average age was 52 years, with 62% of the patients being younger than 55 years, and 97% aged 65 years or younger. The annual tally of HTOs fell from nearly 400 in 1998 to about 260 in 2007.

Analysis of the surgery done on patients younger than 55 years showed that use of TKA in this age group jumped fivefold, from about 100 in 1998 to more than 500 in 2007. Concurrently, use of HTO dropped, from about 230 in 1998 to about 180 in 2007; use of unicompartmental knee arthroplasty remained relatively stable throughout the decade, with about 100 cases done each year, said Dr. W-Dahl at the congress, which was organized by the Osteoarthritis Research Society International.

The cumulative need for revision surgery in patients who initially underwent HTO surgery ran 29% during the period studied, with women having a statistically significant 30% higher revision rate, compared with men, after adjustment for age and year of surgery.

Among patients younger than 65 years, cumulative revision rates for the three types of surgery during the 10 years studied showed clear differences, with 27% of HTO patients requiring a revision, compared with 16% of patients undergoing unicompartmental knee arthroplasty, and 8% with a TKA.

Dr. W-Dahl had no disclosures.

BRUSSELS – The use of magnetic resonance imaging may enable earlier recognition of knee osteoarthritis, and should be incorporated into recommended diagnostic criteria, a panel of 16 osteoarthritis experts concluded.

Using MRI to define knee osteoarthritis (OA) may allow detection of the disease before radiographic changes occur. But despite a growing body of literature on the role of MRI in OA, little uniformity exists for its diagnostic application, perhaps because of the absence of criteria for an MRI-based structural diagnosis of OA, the group said.

The Osteoarthritis Research Society International (OARSI) organized the 16-member panel, the OA Imaging Working Group, to develop an MRI-based definition of structural OA. The working group sought to identify structural changes on MRI that defined a structural diagnosis of knee OA, Dr. David J. Hunter and the other members of the working group wrote in a poster presented at the World Congress on Osteoarthritis, which was organized by OARSI.

The working group began with a literature review through April 2009, a process that yielded 25 studies that met the group’s inclusion criteria and evaluated MRI diagnostic performance. The 16 members also contributed candidate propositions dealing with key aspects of MRI diagnosis of knee OA.

Through a multiphase process of discussion and voting, the group agreed on the following set of nine propositions based on MRI criteria of knee OA:

1. MRI changes of OA may occur in the absence of radiographic findings of OA.

2. MRI may add to the diagnosis of OA and should be incorporated into the ACR diagnostic criteria including x-ray, clinical, and laboratory parameters.

3. MRI may be used for inclusion in clinical studies according to the criteria detailed above, but should not be a primary diagnostic tool in a clinical setting.

4. Certain MRI changes that occur in isolation are not diagnostic of OA. These include cartilage loss, change in cartilage composition, cystic change and development of bone marrow lesions, ligamentous and tendinous damage, meniscal damage, and effusion and synovitis.

5. No single finding is diagnostic of knee OA.

6. MRI findings indicative of knee OA may include abnormalities in all tissues of the joint (bone, cartilage, meniscus, synovium, ligament, and capsule).

7. Given the multiple tissue abnormalities detected by MRI in OA, diagnostic criteria are likely to involve several possible combinations of features.

8. Definite osteophyte production is indicative of OA.

9. Joint space narrowing as assessed by (nonweight bearing) MRI cannot be used as a diagnostic criterion.

Similarly, the working group agreed on the following two definitions for MRI findings that were diagnostic of knee OA:

1. Tibiofemoral OA should have either both features from group A (below), or one feature from group A and at least two features from group B. Examination of the patient must also rule out joint trauma within the last 6 months (by history) as well as inflammatory arthritis (diagnosed by radiographs, history, and laboratory findings).

• Group A features: Definite osteophyte formation; full thickness cartilage loss.

• Group B features: Subchondral bone marrow lesion or cyst not associated with meniscal or ligamentous attachments; meniscal subluxation, maceration, or degenerative (horizontal) tear; partial-thickness cartilage loss (without full thickness loss).

2. Patellofemoral OA requires both of the following features involving the patella or the anterior femur or both:

• Definite osteophyte formation.

• Partial- or full-thickness cartilage loss.

These constitute “statements of preamble and context setting.” The two definitions “offer an opportunity for formal testing against other diagnostic constructs,” said Dr. Hunter, a rheumatologist and professor of medicine at the University of Sydney and his associates in the working group.

The working group noted that the American College of Rheumatology in 1986 first released the current standard criteria for diagnosing OA, which deal only with radiographic imaging (Arthritis Rheum. 1986;29:1039-49). The European League Against Rheumatism published more current recommendations this year, but focused on a clinical diagnosis that did not involve imaging (Ann. Rheum. Dis. 2010;69:483-9).

The working group aimed to “include MRI as a means to define the disease with the intent that one may be able to identify early, pre-radiographic disease, thus enabling recruitment of study populations where structure modification (or structure maintenance) may be realistic in a more preventive manner.”

The group cautioned that prior to using the definitions, “it is important that their validity and diagnostic performance be adequately tested.” They also stressed that “the propositions have been developed for structural OA, not for a clinical diagnosis, not for early OA, and not to facilitate staging of the disease.” The propositions “are not to detract from, nor to discourage the use of traditional means for diagnosing OA.”

An osteoarthritis specialist who was not involved with the working group cautioned that waiting for MRI structural changes that are specific for OA may still miss a truly early diagnosis, before irreversible pathology occurred.

“It’s too early to know the definition of OA on MRI. We know what features of OA are on MRI, but that doesn’t mean we can make a diagnosis based on MRI,” commented Dr. Tuhina Neogi, a rheumatologist at Boston University. “There are early changes [seen with MRI] that are not picked up on radiographs, but we don’t yet have a standardized, validated definition of an earlier stage” on MRI, Dr. Neogi said in an interview.

Dr. Hunter said that he has received research support from AstraZeneca, DJO Inc. (DonJoy), Eli Lilly & Co., Merck & Co., Pfizer Inc., Stryker Corp., and Wyeth. Eight of the other members of the working group also provided disclosures, whereas the remaining seven members said they had no disclosures. Dr. Neogi had no disclosures.

BRUSSELS – The use of magnetic resonance imaging may enable earlier recognition of knee osteoarthritis, and should be incorporated into recommended diagnostic criteria, a panel of 16 osteoarthritis experts concluded.

Using MRI to define knee osteoarthritis (OA) may allow detection of the disease before radiographic changes occur. But despite a growing body of literature on the role of MRI in OA, little uniformity exists for its diagnostic application, perhaps because of the absence of criteria for an MRI-based structural diagnosis of OA, the group said.

The Osteoarthritis Research Society International (OARSI) organized the 16-member panel, the OA Imaging Working Group, to develop an MRI-based definition of structural OA. The working group sought to identify structural changes on MRI that defined a structural diagnosis of knee OA, Dr. David J. Hunter and the other members of the working group wrote in a poster presented at the World Congress on Osteoarthritis, which was organized by OARSI.

The working group began with a literature review through April 2009, a process that yielded 25 studies that met the group’s inclusion criteria and evaluated MRI diagnostic performance. The 16 members also contributed candidate propositions dealing with key aspects of MRI diagnosis of knee OA.

Through a multiphase process of discussion and voting, the group agreed on the following set of nine propositions based on MRI criteria of knee OA:

1. MRI changes of OA may occur in the absence of radiographic findings of OA.

2. MRI may add to the diagnosis of OA and should be incorporated into the ACR diagnostic criteria including x-ray, clinical, and laboratory parameters.

3. MRI may be used for inclusion in clinical studies according to the criteria detailed above, but should not be a primary diagnostic tool in a clinical setting.

4. Certain MRI changes that occur in isolation are not diagnostic of OA. These include cartilage loss, change in cartilage composition, cystic change and development of bone marrow lesions, ligamentous and tendinous damage, meniscal damage, and effusion and synovitis.

5. No single finding is diagnostic of knee OA.

6. MRI findings indicative of knee OA may include abnormalities in all tissues of the joint (bone, cartilage, meniscus, synovium, ligament, and capsule).

7. Given the multiple tissue abnormalities detected by MRI in OA, diagnostic criteria are likely to involve several possible combinations of features.

8. Definite osteophyte production is indicative of OA.

9. Joint space narrowing as assessed by (nonweight bearing) MRI cannot be used as a diagnostic criterion.

Similarly, the working group agreed on the following two definitions for MRI findings that were diagnostic of knee OA:

1. Tibiofemoral OA should have either both features from group A (below), or one feature from group A and at least two features from group B. Examination of the patient must also rule out joint trauma within the last 6 months (by history) as well as inflammatory arthritis (diagnosed by radiographs, history, and laboratory findings).

• Group A features: Definite osteophyte formation; full thickness cartilage loss.

• Group B features: Subchondral bone marrow lesion or cyst not associated with meniscal or ligamentous attachments; meniscal subluxation, maceration, or degenerative (horizontal) tear; partial-thickness cartilage loss (without full thickness loss).

2. Patellofemoral OA requires both of the following features involving the patella or the anterior femur or both:

• Definite osteophyte formation.

• Partial- or full-thickness cartilage loss.

These constitute “statements of preamble and context setting.” The two definitions “offer an opportunity for formal testing against other diagnostic constructs,” said Dr. Hunter, a rheumatologist and professor of medicine at the University of Sydney and his associates in the working group.

The working group noted that the American College of Rheumatology in 1986 first released the current standard criteria for diagnosing OA, which deal only with radiographic imaging (Arthritis Rheum. 1986;29:1039-49). The European League Against Rheumatism published more current recommendations this year, but focused on a clinical diagnosis that did not involve imaging (Ann. Rheum. Dis. 2010;69:483-9).

The working group aimed to “include MRI as a means to define the disease with the intent that one may be able to identify early, pre-radiographic disease, thus enabling recruitment of study populations where structure modification (or structure maintenance) may be realistic in a more preventive manner.”

The group cautioned that prior to using the definitions, “it is important that their validity and diagnostic performance be adequately tested.” They also stressed that “the propositions have been developed for structural OA, not for a clinical diagnosis, not for early OA, and not to facilitate staging of the disease.” The propositions “are not to detract from, nor to discourage the use of traditional means for diagnosing OA.”

An osteoarthritis specialist who was not involved with the working group cautioned that waiting for MRI structural changes that are specific for OA may still miss a truly early diagnosis, before irreversible pathology occurred.

“It’s too early to know the definition of OA on MRI. We know what features of OA are on MRI, but that doesn’t mean we can make a diagnosis based on MRI,” commented Dr. Tuhina Neogi, a rheumatologist at Boston University. “There are early changes [seen with MRI] that are not picked up on radiographs, but we don’t yet have a standardized, validated definition of an earlier stage” on MRI, Dr. Neogi said in an interview.

Dr. Hunter said that he has received research support from AstraZeneca, DJO Inc. (DonJoy), Eli Lilly & Co., Merck & Co., Pfizer Inc., Stryker Corp., and Wyeth. Eight of the other members of the working group also provided disclosures, whereas the remaining seven members said they had no disclosures. Dr. Neogi had no disclosures.

BRUSSELS – The use of magnetic resonance imaging may enable earlier recognition of knee osteoarthritis, and should be incorporated into recommended diagnostic criteria, a panel of 16 osteoarthritis experts concluded.

Using MRI to define knee osteoarthritis (OA) may allow detection of the disease before radiographic changes occur. But despite a growing body of literature on the role of MRI in OA, little uniformity exists for its diagnostic application, perhaps because of the absence of criteria for an MRI-based structural diagnosis of OA, the group said.

The Osteoarthritis Research Society International (OARSI) organized the 16-member panel, the OA Imaging Working Group, to develop an MRI-based definition of structural OA. The working group sought to identify structural changes on MRI that defined a structural diagnosis of knee OA, Dr. David J. Hunter and the other members of the working group wrote in a poster presented at the World Congress on Osteoarthritis, which was organized by OARSI.

The working group began with a literature review through April 2009, a process that yielded 25 studies that met the group’s inclusion criteria and evaluated MRI diagnostic performance. The 16 members also contributed candidate propositions dealing with key aspects of MRI diagnosis of knee OA.

Through a multiphase process of discussion and voting, the group agreed on the following set of nine propositions based on MRI criteria of knee OA:

1. MRI changes of OA may occur in the absence of radiographic findings of OA.

2. MRI may add to the diagnosis of OA and should be incorporated into the ACR diagnostic criteria including x-ray, clinical, and laboratory parameters.

3. MRI may be used for inclusion in clinical studies according to the criteria detailed above, but should not be a primary diagnostic tool in a clinical setting.

4. Certain MRI changes that occur in isolation are not diagnostic of OA. These include cartilage loss, change in cartilage composition, cystic change and development of bone marrow lesions, ligamentous and tendinous damage, meniscal damage, and effusion and synovitis.

5. No single finding is diagnostic of knee OA.

6. MRI findings indicative of knee OA may include abnormalities in all tissues of the joint (bone, cartilage, meniscus, synovium, ligament, and capsule).

7. Given the multiple tissue abnormalities detected by MRI in OA, diagnostic criteria are likely to involve several possible combinations of features.

8. Definite osteophyte production is indicative of OA.

9. Joint space narrowing as assessed by (nonweight bearing) MRI cannot be used as a diagnostic criterion.

Similarly, the working group agreed on the following two definitions for MRI findings that were diagnostic of knee OA:

1. Tibiofemoral OA should have either both features from group A (below), or one feature from group A and at least two features from group B. Examination of the patient must also rule out joint trauma within the last 6 months (by history) as well as inflammatory arthritis (diagnosed by radiographs, history, and laboratory findings).

• Group A features: Definite osteophyte formation; full thickness cartilage loss.

• Group B features: Subchondral bone marrow lesion or cyst not associated with meniscal or ligamentous attachments; meniscal subluxation, maceration, or degenerative (horizontal) tear; partial-thickness cartilage loss (without full thickness loss).

2. Patellofemoral OA requires both of the following features involving the patella or the anterior femur or both:

• Definite osteophyte formation.

• Partial- or full-thickness cartilage loss.

These constitute “statements of preamble and context setting.” The two definitions “offer an opportunity for formal testing against other diagnostic constructs,” said Dr. Hunter, a rheumatologist and professor of medicine at the University of Sydney and his associates in the working group.

The working group noted that the American College of Rheumatology in 1986 first released the current standard criteria for diagnosing OA, which deal only with radiographic imaging (Arthritis Rheum. 1986;29:1039-49). The European League Against Rheumatism published more current recommendations this year, but focused on a clinical diagnosis that did not involve imaging (Ann. Rheum. Dis. 2010;69:483-9).

The working group aimed to “include MRI as a means to define the disease with the intent that one may be able to identify early, pre-radiographic disease, thus enabling recruitment of study populations where structure modification (or structure maintenance) may be realistic in a more preventive manner.”

The group cautioned that prior to using the definitions, “it is important that their validity and diagnostic performance be adequately tested.” They also stressed that “the propositions have been developed for structural OA, not for a clinical diagnosis, not for early OA, and not to facilitate staging of the disease.” The propositions “are not to detract from, nor to discourage the use of traditional means for diagnosing OA.”

An osteoarthritis specialist who was not involved with the working group cautioned that waiting for MRI structural changes that are specific for OA may still miss a truly early diagnosis, before irreversible pathology occurred.

“It’s too early to know the definition of OA on MRI. We know what features of OA are on MRI, but that doesn’t mean we can make a diagnosis based on MRI,” commented Dr. Tuhina Neogi, a rheumatologist at Boston University. “There are early changes [seen with MRI] that are not picked up on radiographs, but we don’t yet have a standardized, validated definition of an earlier stage” on MRI, Dr. Neogi said in an interview.

Dr. Hunter said that he has received research support from AstraZeneca, DJO Inc. (DonJoy), Eli Lilly & Co., Merck & Co., Pfizer Inc., Stryker Corp., and Wyeth. Eight of the other members of the working group also provided disclosures, whereas the remaining seven members said they had no disclosures. Dr. Neogi had no disclosures.

BRUSSELS – Analysis of plain x-ray images of knee joints from 60 patients with osteoarthritis confirmed that a novel method for assessing bone trabecular structure adjacent to knee joints provides a reliable prediction of future disease progression.

Assessment of bone trabecular integrity by fractal signature analysis “provides an osteoarthritis imaging biomarker that is a prognostic marker of knee osteoarthritis progression,” Dr. Virginia Byers Kraus said at the annual World Congress on Osteoarthritis.

Baseline bone trabecular integrity predicted roughly 85% of the change in joint space area during 2 years of follow-up in patients with osteoarthritis (OA). The new study, which used x-rays from 60 patients with OA and 67 controls, is the second report to document the prognostic accuracy of fractal signature analysis of bone trabecular integrity in OA patients. The first report, also from Dr. Kraus and her associates, came out last year, and involved 138 OA patients who were followed for 3 years (Arthritis Rheum. 2009;60:3711-22).

“The next step is to compare fractal signature analysis head to head with MRI and look at its ability to predict MRI changes” in OA patients, and “its ability to identify OA in the preradiographic stage,” Dr. Kraus said in an interview.

Fractal signature analysis of bone trabecular integrity using x-ray images “gives you the ability to more fully phenotype patients than we’ve been able to, and it is less costly than MRI,” said Dr. Kraus, a rheumatologist and professor of medicine at Duke University in Durham, N.C. “It’s very promising for identifying patients at high risk for progression in [an intervention] trial, and possibly to screen patients in the clinic.”

Fractal signature analysis evaluates the complexity of detail of a two-dimensional image. Researchers first reported using fractal signature analysis in 1991 to assess bone architecture in radiographs of OA joints. Past studies also successfully used the method to assess osteoporosis and arthritis of the spine, hip, wrists, hands, and knees before and after surgery. Fractal signature analysis has the major advantage of not being very sensitive to image-acquisition quality.

Although fractal signature analysis involves a complex statistical analysis of x-ray image data of bone structure adjacent to a patient’s knee joint, Dr. Kraus and her associates incorporated that analysis into “KneeAnalyzer” software developed by Optasia Medical, a British company. Now that the software exists, “it is easy to use. It’s just a tool to get at bone trabecular integrity. I think it can easily be widely adopted,” she said.

The new study used data collected in a non–therapeutic methods trial sponsored by Pfizer Inc. The data set included 60 women with knee OA, an average age of 58 years, and an average body mass index of 35.6 kg/m2. (All participants in this arm of the study had a BMI of at least 30.) The 67 women controls had an average age of 55 years, all had a BMI of 28 or less, and all had no knee symptoms, no radiographic signs of knee OA, and no history of knee fracture, surgery, or disease.

The researchers assessed bone trabecular integrity using fractal signature analysis on radiographs taken at baseline, and after 12 and 24 months. The results showed that baseline measurements in the vertical dimension of bone trabecular integrity predicted changes in joint space area at 12 and 24 months, and in joint space width at 24 months. Baseline measures in the horizontal dimension were not predictive. The predicted changes based on baseline bone trabecular integrity accounted for 85%-87% of the actual change in joint space area over 24 months, Dr. Kraus reported at the congress, which was organized by the Osteoarthritis Research Society International.

Analysis of baseline and follow-up measures in the control subjects allowed the researchers to attribute progression in patients to an OA-specific process and not as the result of aging.

Dr. Kraus said that she had no relevant disclosures. One coauthor is an employee of Optasia Medical, and Optasia provided the software used for the radiograph analyses. Another coauthor is an employee of Pfizer, and Pfizer supplied the database used in the study.

BRUSSELS – Analysis of plain x-ray images of knee joints from 60 patients with osteoarthritis confirmed that a novel method for assessing bone trabecular structure adjacent to knee joints provides a reliable prediction of future disease progression.

Assessment of bone trabecular integrity by fractal signature analysis “provides an osteoarthritis imaging biomarker that is a prognostic marker of knee osteoarthritis progression,” Dr. Virginia Byers Kraus said at the annual World Congress on Osteoarthritis.

Baseline bone trabecular integrity predicted roughly 85% of the change in joint space area during 2 years of follow-up in patients with osteoarthritis (OA). The new study, which used x-rays from 60 patients with OA and 67 controls, is the second report to document the prognostic accuracy of fractal signature analysis of bone trabecular integrity in OA patients. The first report, also from Dr. Kraus and her associates, came out last year, and involved 138 OA patients who were followed for 3 years (Arthritis Rheum. 2009;60:3711-22).

“The next step is to compare fractal signature analysis head to head with MRI and look at its ability to predict MRI changes” in OA patients, and “its ability to identify OA in the preradiographic stage,” Dr. Kraus said in an interview.

Fractal signature analysis of bone trabecular integrity using x-ray images “gives you the ability to more fully phenotype patients than we’ve been able to, and it is less costly than MRI,” said Dr. Kraus, a rheumatologist and professor of medicine at Duke University in Durham, N.C. “It’s very promising for identifying patients at high risk for progression in [an intervention] trial, and possibly to screen patients in the clinic.”

Fractal signature analysis evaluates the complexity of detail of a two-dimensional image. Researchers first reported using fractal signature analysis in 1991 to assess bone architecture in radiographs of OA joints. Past studies also successfully used the method to assess osteoporosis and arthritis of the spine, hip, wrists, hands, and knees before and after surgery. Fractal signature analysis has the major advantage of not being very sensitive to image-acquisition quality.

Although fractal signature analysis involves a complex statistical analysis of x-ray image data of bone structure adjacent to a patient’s knee joint, Dr. Kraus and her associates incorporated that analysis into “KneeAnalyzer” software developed by Optasia Medical, a British company. Now that the software exists, “it is easy to use. It’s just a tool to get at bone trabecular integrity. I think it can easily be widely adopted,” she said.

The new study used data collected in a non–therapeutic methods trial sponsored by Pfizer Inc. The data set included 60 women with knee OA, an average age of 58 years, and an average body mass index of 35.6 kg/m2. (All participants in this arm of the study had a BMI of at least 30.) The 67 women controls had an average age of 55 years, all had a BMI of 28 or less, and all had no knee symptoms, no radiographic signs of knee OA, and no history of knee fracture, surgery, or disease.

The researchers assessed bone trabecular integrity using fractal signature analysis on radiographs taken at baseline, and after 12 and 24 months. The results showed that baseline measurements in the vertical dimension of bone trabecular integrity predicted changes in joint space area at 12 and 24 months, and in joint space width at 24 months. Baseline measures in the horizontal dimension were not predictive. The predicted changes based on baseline bone trabecular integrity accounted for 85%-87% of the actual change in joint space area over 24 months, Dr. Kraus reported at the congress, which was organized by the Osteoarthritis Research Society International.

Analysis of baseline and follow-up measures in the control subjects allowed the researchers to attribute progression in patients to an OA-specific process and not as the result of aging.

Dr. Kraus said that she had no relevant disclosures. One coauthor is an employee of Optasia Medical, and Optasia provided the software used for the radiograph analyses. Another coauthor is an employee of Pfizer, and Pfizer supplied the database used in the study.

BRUSSELS – Analysis of plain x-ray images of knee joints from 60 patients with osteoarthritis confirmed that a novel method for assessing bone trabecular structure adjacent to knee joints provides a reliable prediction of future disease progression.

Assessment of bone trabecular integrity by fractal signature analysis “provides an osteoarthritis imaging biomarker that is a prognostic marker of knee osteoarthritis progression,” Dr. Virginia Byers Kraus said at the annual World Congress on Osteoarthritis.

Baseline bone trabecular integrity predicted roughly 85% of the change in joint space area during 2 years of follow-up in patients with osteoarthritis (OA). The new study, which used x-rays from 60 patients with OA and 67 controls, is the second report to document the prognostic accuracy of fractal signature analysis of bone trabecular integrity in OA patients. The first report, also from Dr. Kraus and her associates, came out last year, and involved 138 OA patients who were followed for 3 years (Arthritis Rheum. 2009;60:3711-22).

“The next step is to compare fractal signature analysis head to head with MRI and look at its ability to predict MRI changes” in OA patients, and “its ability to identify OA in the preradiographic stage,” Dr. Kraus said in an interview.

Fractal signature analysis of bone trabecular integrity using x-ray images “gives you the ability to more fully phenotype patients than we’ve been able to, and it is less costly than MRI,” said Dr. Kraus, a rheumatologist and professor of medicine at Duke University in Durham, N.C. “It’s very promising for identifying patients at high risk for progression in [an intervention] trial, and possibly to screen patients in the clinic.”

Fractal signature analysis evaluates the complexity of detail of a two-dimensional image. Researchers first reported using fractal signature analysis in 1991 to assess bone architecture in radiographs of OA joints. Past studies also successfully used the method to assess osteoporosis and arthritis of the spine, hip, wrists, hands, and knees before and after surgery. Fractal signature analysis has the major advantage of not being very sensitive to image-acquisition quality.

Although fractal signature analysis involves a complex statistical analysis of x-ray image data of bone structure adjacent to a patient’s knee joint, Dr. Kraus and her associates incorporated that analysis into “KneeAnalyzer” software developed by Optasia Medical, a British company. Now that the software exists, “it is easy to use. It’s just a tool to get at bone trabecular integrity. I think it can easily be widely adopted,” she said.

The new study used data collected in a non–therapeutic methods trial sponsored by Pfizer Inc. The data set included 60 women with knee OA, an average age of 58 years, and an average body mass index of 35.6 kg/m2. (All participants in this arm of the study had a BMI of at least 30.) The 67 women controls had an average age of 55 years, all had a BMI of 28 or less, and all had no knee symptoms, no radiographic signs of knee OA, and no history of knee fracture, surgery, or disease.

The researchers assessed bone trabecular integrity using fractal signature analysis on radiographs taken at baseline, and after 12 and 24 months. The results showed that baseline measurements in the vertical dimension of bone trabecular integrity predicted changes in joint space area at 12 and 24 months, and in joint space width at 24 months. Baseline measures in the horizontal dimension were not predictive. The predicted changes based on baseline bone trabecular integrity accounted for 85%-87% of the actual change in joint space area over 24 months, Dr. Kraus reported at the congress, which was organized by the Osteoarthritis Research Society International.

Analysis of baseline and follow-up measures in the control subjects allowed the researchers to attribute progression in patients to an OA-specific process and not as the result of aging.

Dr. Kraus said that she had no relevant disclosures. One coauthor is an employee of Optasia Medical, and Optasia provided the software used for the radiograph analyses. Another coauthor is an employee of Pfizer, and Pfizer supplied the database used in the study.

BRUSSELS – When younger patients receive a total hip replacement, they are more likely to eventually need revision surgery, compared with older patients, according to findings from a 12-year follow-up study of more than 58,000 Medicare patients.

The finding makes sense and comes as no surprise, but the documentation of a link between younger age and increased revision rates has important implications for prosthesis design.

“As total hip replacement indications extend to increasingly younger populations, [the patients’] mortality risk will diminish, and a vast majority will remain at risk for revision for decades,” Dr. Jeffrey N. Katz said at the annual World Congress on Osteoarthritis.

“Research evaluating technical innovations to increase prosthesis longevity should recognize the competing risk of mortality. In a 75- or 80-year old, revision is a rather infrequent event; their implant will likely outsurvive them. The older a patient is, the more likely the patient is to die with their original prosthesis intact,” said Dr. Katz of the department of medicine at Harvard Medical School, Boston, and director of the orthopedic and arthritis center for outcomes research at Brigham and Women’s Hospital in that city.

“If a prosthesis manufacturer wants to increase the longevity of a prosthesis, the patients to target are those younger than 65. For patients who gets through the perioperative period, the real issue is biomaterials: How likely are the biomaterials to wear out over time?” he noted.

Currently, about 280,000 total hip replacements are performed in the United States annually (more than 90% because of osteoarthritis), along with 40,000 revision hip surgeries each year. Revisions alone cost more than $1 billion annually.

Dr. Katz and his associates studied the 58,521 Medicare beneficiaries who underwent a total hip replacement during July 1995–June 1996. Two-thirds were women, and 60% were aged 65-75 years, with the remaining patients older than 75 years. The researchers had complete follow-up records for all patients for the subsequent 12 years, through 2008. They presumed that all patients in this group with subsequent hip surgery had revisions, although it’s also possible that the second surgery involved the contralateral hip.

During follow-up, 60% of the patients who were older than 75 years at the time of surgery died; during the 12-year follow-up, the survivors had a revision rate of 9%. Among patients aged 65-75 years at the time of their initial hip surgery, 30% died during follow-up, with the survivors having a 13% revision rate. In both age groups, men had a higher revision rate than did women.

“Younger patients are more active and heavier,” Dr. Katz explained in an interview at the congress, which was organized by the Osteoarthritis Research Society International. “Younger patients probably wear their [prosthetic] joints out faster, and – given the same amount of wear – they are offered [revision] surgery more frequently and they accept surgery more frequently.

“We don’t have data for 45- to 65-year-olds, but by extension, their mortality is unlikely over the following 20 years, while a revision is likely. The younger age group has a very real risk of facing a revision in their lifetime. If a manufacturer could improve the longevity of their prosthesis, it would potentially save them an operation,” Dr. Katz said.

Dr. Katz said that he had no disclosures.

BRUSSELS – When younger patients receive a total hip replacement, they are more likely to eventually need revision surgery, compared with older patients, according to findings from a 12-year follow-up study of more than 58,000 Medicare patients.

The finding makes sense and comes as no surprise, but the documentation of a link between younger age and increased revision rates has important implications for prosthesis design.

“As total hip replacement indications extend to increasingly younger populations, [the patients’] mortality risk will diminish, and a vast majority will remain at risk for revision for decades,” Dr. Jeffrey N. Katz said at the annual World Congress on Osteoarthritis.

“Research evaluating technical innovations to increase prosthesis longevity should recognize the competing risk of mortality. In a 75- or 80-year old, revision is a rather infrequent event; their implant will likely outsurvive them. The older a patient is, the more likely the patient is to die with their original prosthesis intact,” said Dr. Katz of the department of medicine at Harvard Medical School, Boston, and director of the orthopedic and arthritis center for outcomes research at Brigham and Women’s Hospital in that city.

“If a prosthesis manufacturer wants to increase the longevity of a prosthesis, the patients to target are those younger than 65. For patients who gets through the perioperative period, the real issue is biomaterials: How likely are the biomaterials to wear out over time?” he noted.

Currently, about 280,000 total hip replacements are performed in the United States annually (more than 90% because of osteoarthritis), along with 40,000 revision hip surgeries each year. Revisions alone cost more than $1 billion annually.

Dr. Katz and his associates studied the 58,521 Medicare beneficiaries who underwent a total hip replacement during July 1995–June 1996. Two-thirds were women, and 60% were aged 65-75 years, with the remaining patients older than 75 years. The researchers had complete follow-up records for all patients for the subsequent 12 years, through 2008. They presumed that all patients in this group with subsequent hip surgery had revisions, although it’s also possible that the second surgery involved the contralateral hip.

During follow-up, 60% of the patients who were older than 75 years at the time of surgery died; during the 12-year follow-up, the survivors had a revision rate of 9%. Among patients aged 65-75 years at the time of their initial hip surgery, 30% died during follow-up, with the survivors having a 13% revision rate. In both age groups, men had a higher revision rate than did women.

“Younger patients are more active and heavier,” Dr. Katz explained in an interview at the congress, which was organized by the Osteoarthritis Research Society International. “Younger patients probably wear their [prosthetic] joints out faster, and – given the same amount of wear – they are offered [revision] surgery more frequently and they accept surgery more frequently.

“We don’t have data for 45- to 65-year-olds, but by extension, their mortality is unlikely over the following 20 years, while a revision is likely. The younger age group has a very real risk of facing a revision in their lifetime. If a manufacturer could improve the longevity of their prosthesis, it would potentially save them an operation,” Dr. Katz said.

Dr. Katz said that he had no disclosures.

BRUSSELS – When younger patients receive a total hip replacement, they are more likely to eventually need revision surgery, compared with older patients, according to findings from a 12-year follow-up study of more than 58,000 Medicare patients.

The finding makes sense and comes as no surprise, but the documentation of a link between younger age and increased revision rates has important implications for prosthesis design.

“As total hip replacement indications extend to increasingly younger populations, [the patients’] mortality risk will diminish, and a vast majority will remain at risk for revision for decades,” Dr. Jeffrey N. Katz said at the annual World Congress on Osteoarthritis.

“Research evaluating technical innovations to increase prosthesis longevity should recognize the competing risk of mortality. In a 75- or 80-year old, revision is a rather infrequent event; their implant will likely outsurvive them. The older a patient is, the more likely the patient is to die with their original prosthesis intact,” said Dr. Katz of the department of medicine at Harvard Medical School, Boston, and director of the orthopedic and arthritis center for outcomes research at Brigham and Women’s Hospital in that city.

“If a prosthesis manufacturer wants to increase the longevity of a prosthesis, the patients to target are those younger than 65. For patients who gets through the perioperative period, the real issue is biomaterials: How likely are the biomaterials to wear out over time?” he noted.

Currently, about 280,000 total hip replacements are performed in the United States annually (more than 90% because of osteoarthritis), along with 40,000 revision hip surgeries each year. Revisions alone cost more than $1 billion annually.

Dr. Katz and his associates studied the 58,521 Medicare beneficiaries who underwent a total hip replacement during July 1995–June 1996. Two-thirds were women, and 60% were aged 65-75 years, with the remaining patients older than 75 years. The researchers had complete follow-up records for all patients for the subsequent 12 years, through 2008. They presumed that all patients in this group with subsequent hip surgery had revisions, although it’s also possible that the second surgery involved the contralateral hip.

During follow-up, 60% of the patients who were older than 75 years at the time of surgery died; during the 12-year follow-up, the survivors had a revision rate of 9%. Among patients aged 65-75 years at the time of their initial hip surgery, 30% died during follow-up, with the survivors having a 13% revision rate. In both age groups, men had a higher revision rate than did women.

“Younger patients are more active and heavier,” Dr. Katz explained in an interview at the congress, which was organized by the Osteoarthritis Research Society International. “Younger patients probably wear their [prosthetic] joints out faster, and – given the same amount of wear – they are offered [revision] surgery more frequently and they accept surgery more frequently.

“We don’t have data for 45- to 65-year-olds, but by extension, their mortality is unlikely over the following 20 years, while a revision is likely. The younger age group has a very real risk of facing a revision in their lifetime. If a manufacturer could improve the longevity of their prosthesis, it would potentially save them an operation,” Dr. Katz said.

Dr. Katz said that he had no disclosures.

Source Elsevier Global Medical News

Source Elsevier Global Medical News

Source Elsevier Global Medical News