Bone Health ECHO (Extension of Community Healthcare Outcomes) is a virtual community of practice that has been connecting healthcare professionals online once weekly for the past 10 years. A key component of each ECHO session is presentation and discussion of patient cases with diagnostic and treatment dilemmas. Here we present two wheelchair-bound female patients aged 47 years (Patient 1) and 34 years (Patient 2), both with type 1 diabetes mellitus (T1DM). They were admitted to our hospital due to multiple fractures and muscle weakness. Since age 8 years, both women suffered from T1DM. Patient 1 had extremely poor glycemic control over the whole period of diabetes with frequent cases of ketoacidosis (glycated hemoglobin [HbA1c] varied 10.0-14.2 %), with multiple end-stage complications of DM including anuria requiring hemodialysis from age 37 years. Patient 2 had minimal DM complications and maintained HbA1c within an individual goal (5.0-6.1 %). Both patients had low fasting phosphate and elevated alkaline phosphatase on laboratory evaluation. In the patient with anuria (Patient 1), after careful evaluation of all possible causes of hypophosphatemia, we found the most likely cause to be the effects of constantly repeated intracellular phosphate depletion due to poorly compensated T1DM. While achieving stable glucose control in hospital care, her phosphate levels gradually returned within the reference range. In the younger patient (Patient 2), tumor-induced osteomalacia (TIO) was diagnosed. After tumor removal her symptoms and laboratory results normalized. These cases illustrate two different causes of hypophosphatemia in patients with similar skeletal presentations in association with T1DM.

INTRODUCTION. The development of an interdisciplinary consensus on the care of elderly and elderly patients with proximal femoral fractures is an urgent problem of modern medicine. The provisions of this Consensus will help to establish effective interaction between physicians of different specialties on the basis of their better understanding, which will contribute to the improvement of specialized medical care, saving lives and reducing disability of elderly patients with hip fractures through. MAIN CONSENSUS CONTENT. Hip fractures through are one of the most frequent and severe complications of osteoporosis. Difficulties in the management of elderly and elderly patients with hip fractures through are due to both the severity of the injury itself and comorbidity, which is accompanied by high mortality and extremely poor quality of life of survivors. Effective management of such patients is possible only with the joint participation of doctors and nurses of surgical and therapeutic profiles within the framework of the so-called orthogeriatric approach. Experts in the field of traumatology and orthopedics, anesthesiology and resuscitation, geriatrics, regenerative medicine, clinical pharmacology, therapy, rheumatology and endocrinology on the basis of available clinical recommendations and orders of the Ministry of Health of the Russian Federation, literature data, scientific studies and general discussion have formulated the main provisions of the Consensus, interdisciplinary management of elderly and elderly people with hip fractures through. CONCLUSION. The introduction of the Consensus provisions developed by experts into the practical work of specialized medical organizations in Russia will improve the quality of medical care for a complex category of elderly patients with hip fractures through, save many of their lives and reduce the level of disability, which will undoubtedly have positive social and economic consequences.

Osteoporosis is a metabolic skeletal disease characterized by reduced bone mass, impaired microarchitecture, and an increased risk of fractures. Low-energy fractures resulting from osteoporosis lead to severe complications and patient mortality, diminish quality of life, and represent a serious medical, social, and economic burden for society. Timely diagnosis of the disease and prediction of fracture risk remain largely unresolved issues, requiring the development and implementation of new technologies. Radiofrequency echographic multispectrometry is an innovative ultrasound-based technique for diagnosing osteoporosis and assessing fracture risk. Its main advantage over other ultrasound densitometry methods is the assessment of bone status not in peripheral skeletal sites, but in the principal regions used for diagnosing the disease—the lumbar vertebrae and the proximal femur. Unlike dual-energy X-ray absorptiometry, considered the gold standard, radiofrequency echographic multispectrometry does not measure bone mineral density but instead assesses integral parameters of bone status by comparing the spectra of ultrasound signals reflected from the bone surface in patients with osteoporosis, healthy individuals, and individuals with a history of low-energy fractures. An important advantage of radiofrequency echographic multispectrometry is the portability of its equipment, which increases accessibility in remote regions and for less mobile patient groups. International studies have demonstrated a high level of concordance between radiofrequency echographic multispectrometry and dual-energy X-ray absorptiometry findings, providing the basis for recommending this new technique for clinical use in patients with osteoporosis in several countries. At the same time, the different underlying principle of the method offers potential benefits that still require further validation. This article reviews the potential applications and unresolved issues of radiofrequency echographic multispectrometry based on analysis of the current scientific data. The authors also present several clinical examples of radiofrequency echographic multispectrometry application in patients with osteoporosis and hereditary systemic diseases and discuss the outcomes of its use.

Tumor-induced osteomalacia (TIO) is a rare disorder caused by a phosphaturic mesenchymal tumor (PMT) secreting fibroblast growth factor 23 (FGF23). The aim of this study was to analyze PMTs for their transcriptomic characteristics. We performed single-cell RNA (n = 3) alongside bulk RNA sequencing of PMTs (n = 5) and surrounding bone tissue (n = 4) obtained during tumor removal in 10 patients (age 44 (41;64), serum phosphate (Pi)- 0.54 (0.43; 0.59) mM/L, FGF23-113 (40; 205) pg/ml). We revealed a total of 22,449 cells divided into 13 different categories. We identified the heterogeneity of the PMT cell cluster and subsequently divided it into two tumor clusters 1 and 2 characterized by the deeper epithelial-mesenchymal phenotype transition, higher FGF23 expression as well as various SNP and CNV. We further identified tumor cell differentiation driving regulons ERG and EGR3, based on scoring by allele expression and velocity based pseudotime on a trajectory that may play a critical role in the tumorigenesis of PMTs. In both single-cell and bulk transcriptome analysis we found upregulation of vesicle-specific and exocytosis associated genes (SLC30A3, SYT1, STX1A and SNAP25) which most likely represent molecular mechanisms of active secretion in all PMT samples. We report transmembrane protein coding genes expressed in all PMTs specifically in tumor cell clusters (PHEX, ERBB4, PCDH7, LRRFIP2) which are suggested as potential diagnostic targets. We confirmed the presence of FN1-FGFR1 fusion genes and Klotho expression in most PMTs (6 out of 8). Conclusion: specific SNARE proteins gene upregulation along with transcriptional signatures of PMT offer new insights into its pathogenesis which may be further studied for diagnostic and therapeutic interventions.

BACKGROUND:Aneurysmal bone cysts (ABCs) are usually treated with curettage or various minimally invasive percutaneous procedures. Patient refractory to these treatments, as well as those with locally advanced or unresectable tumors, present a challenge for orthopedic surgeons and require new treatment approaches. Anti-resorptive drugs inhibit osteoclastic resorption and increase intralesional osteogenesis. Denosumab induces tumor ossification, but this effect may disappear after drug withdrawal due to limited impact on neoplastic cells. Bisphosphonates (BPs) may induce apoptosis of tumor cells and allow for long-term local control. We hypothesized that after denosumab treatment, BPs would better accumulate in the tumor and exert an irreversible antitumor effect. AIM:To test the hypothesis that the sequential use of BPs after denosumab induction improves treatment outcomes in surgically unsalvageable ABCs. METHODS:Using data from five electronic databases (Scopus, MEDLINE, EMBASE, PubMed, Web of Science), we aimed to identify all patients who received denosumab therapy (DT) for unresectable ABCs. Among published case reports and case series, we identified patients who discontinued denosumab for various reasons and divided them into two groups: Group 1 included 31 patients without further anti-resorptive therapy and Group 2 included 12 patients who received BPs in the context of rebound hypercalcemia. Local control rates in both groups were analyzed. RESULTS:As of December 2024, 43 patients have been reported in the literature who received DT for locally advanced/unresectable ABCs. There were 27 males and 16 females with a mean age of 15.8 years. At a median follow-up time of 15.5 months, there were 10 confirmed and two pathologically unconfirmed relapses after denosumab discontinuation. All 10 relapses occurred in patients in Group 1 at a median time of 13.5 months. Among patients in Group 2, with a median follow-up time of 12.5 months after completion of therapy, no local relapses were observed. The difference between local recurrence rates (32% vs 0%) is statistically significant (P value = 0.02). Kaplan-Meier estimates show the same trend with marginal statistical significance (P value = 0.085). Here we put forward a novel treatment algorithm. CONCLUSION:BPs used in post-denosumab ossifying ABCs appear to improve treatment outcomes, presumably by targeting residual tumor cells. Prospective clinical studies are warranted to validate this promising two-stage conceptual strategy in difficult-to-treat ABC.

INTRODUCTION: Bone marrow edema (a radiological term used in MR diagnosis) is characterized by low-intensity infiltration on T1-weighted sequences and high-intensity signal on T2-weighted short-tau inversion recovery (T2w-STIR) images. CLINICAL CASE DESCRIPTION: The paper presents a case series in patients with knee pain, with subchondral bone lesions on MRI, characterized by bone marrow edema with no previous injury. The following diagnoses were made based on the type of bone edema and medical history: aseptic necrosis of the condyle, subchondral fracture, osteochondritis, secondary osteonecrosis, osteoarthritis, septic arthritis, and others. The paper describes the approach to differential diagnosis based on MRI findings. CONCLUSION: An assessment of bone marrow edema found on MRI in patients with knee pain allows for timely diagnosis clarification and treatment initiation in some cases.

BACKGROUND: Age and comorbidities are considered independent preoperative predictors of mortality in proximal femoral fractures; however, their contribution remains debatable. AIM: To assess the prognostic significance of age and Charlson Comorbidity Index (CCI) of the survival of older people with proximal femoral fractures. MATERIALS AND METHODS: This retrospective prospective study included all cases of proximal femoral fractures that occurred between January 1, 2019, and December 31, 2019, in individuals over 50 years of age from the cities of Tver, Torzhok, Rzhev, VyshnyVolochek, and Kashin. ICD-10 codes: S72.0, S72.1, and S72.2. The CCI of each patient was calculated using an online calculator and clinical data obtained from patient and outpatient records. Statistical analysis. Survival was estimated using Kaplan–Meier curves and the average number of deaths per day per 1000 people. The follow-up interval was obtained in days from the time of injury to the event of death or last contact with the patient. The minimum observation period was 876 days, and the maximum was 1492 days. RESULTS: The survival rate of patients decreased from younger to older age groups, both among those operated on and those who were not. Patients aged ≥85 years were at greatest risk (median survival: 257 days; 95% CI: 36.6–478.3). CCI was significantly associated with survival: the risk of death with CCI 3 was 3–6 times higher than that with CCI 2–3, depending on the follow-up interval. CCI reflected health status more than age: within the same age group, there were patients with different CCIs. CONCLUSION: Using age and CCI simultaneously as predictors of mortality and more accurate indicators of health status will enable the planning of the utilization of additional medical and social resources in the preoperative and postoperative periods, thereby increasing survival.

Background. Studying structural changes in bone tissue after arthroscopic meniscectomy is an urgent problem in traumatology and orthopedics. This is due to the fact that despite the large number of surgical interventions performed, a number of patients after surgical treatment have such a complication as postmeniscatomic syndrome. The purpose of the study is to improve the results of treatment of patients with meniscus injury and systematization of data from literary sources. Materials and methods. A literature review was performed in the PubMed, eLibrary, Spriger Link system and in the Russian-language literature with the keywords “Postmeniscectomy Syndrome”, “bone marrow edema”, “Postmeniscectomy osteonecrosis”, “Subchondral fracture following arthroscopic knee surgery”, “Complications of arthroscopy and arthroscopic surgery”, “Postarthroscopic osteonecrosis of the femoral condyles and the tibia”. According to these keywords, 45 publications devoted to postmeniscectomy syndrome were selected. Results and conclusions. A review of the literature has demonstrated that the topic is relevant in arthroscopic surgery, however, the number of studies conducted does not currently allow us to draw unambiguous conclusions, which requires further research to clarify the etiological causes of postmeniscectomy syndrome and ways to prevent it.

The article presents historical information about the creation of the school of traumatology and orthopedics in Arkhangelsk, in memory of its founder V.F. Tsel (1898–1974), who made a huge contribution to the formation and development of the Northern Medical Institute itself, as well as his students and followers.

Background. Avascular necrosis of the femoral head (ANFH) is a disabling disease that often leads to hip replacement. Due to the increasing incidence among the young population, various methods of organ-preserving treatment aimed at slowing down the progression of ANFH and preserving the functions of the hip joint have been proposed. Today, there is a lot of controversy and disagreement over the procedure of introducing bone marrow-derived multipotent mesenchymal stromal cells (MMSCs) into the site of osteonecrosis. The aim of the study — a systematic analysis of the accumulated literature data on the effectiveness, safety, advantages and disadvantages of treating patients with aseptic necrosis of the femoral head by the tunneling method using bone marrow-derived MMSCs, as well as their impact on reducing the risk of disease progression and long-term treatment results. Methods. A 10-year literature search (2013-2023) was performed in the PubMed, Scopus and eLIBRARY databases. According to our inclusion criteria, the review included 8 high-quality studies that examined the use of MMSCs as part of bone marrow concentrate for the treatment of ANFH. Results. The surgical outcomes of 368 patients (548 hips) from 8 studies were analyzed. The mean follow-up period was from 24 to 360 months. In most cases, functional indicators improved. In the main group, where mesenchymal stromal cells were used, X-ray progression to the next stage occurred in 31.25% of cases and the need for endoprosthetics was 30.6%; in the comparison group, the progression occurred in 68.75% of cases and the need for endoprosthetics was 69.4 %. Conclusion. The use of multipotent mesenchymal stromal cells in the complex treatment of ANFH in the early (ARCO I, II, IIIA) stages of the disease can improve the hip joint function, slow down the progression of the disease and reduce the need for endoprosthetics.

BACKGROUND: In Russia, according to official statistics, a high level of conservative treatment of fractures of the proximal femur remains, especially in older age groups. In this regard, assessing the effects of predictors of mortality at the stage of providing trauma care to such patients remains relevant. Тhere is ongoing debate regarding the timing of the effect of surgical treatment on mortality associated with the fracture event itself.AIM: To assess the effect on mortality of hip fractures in people 50 years of age and older of the type of treatment (operative or conservative) and the duration of the preoperative period.MATERIALS AND METHODS: A cross-sectional retrospective study with a prospective component was conducted on fractures of the proximal femur that occurred from January 1, 2019 to December 31, 2019 in people over 50 years of age living in the urban district of Armavir. The Kaplan-Meier method was used to analyze mortality.RESULTS: Significantly longer survival after surgical treatment compared with conservative treatment was due to lower patient mortality in the interval up to 240 days (Breslow criterion (Generalized Wilcoxon, p<0.007) from the moment of injury Mortality by this period was, respectively, 11.7% versus 32.7%, the average mortality per day per 1000 patients is 0.489 among those operated on and 1.37 among those not operated on. In groups stratified by age and Charlson index, significant differences were noted only for persons 80 years of age and older. A delay in surgical intervention of more than 72 hours significantly increased mortality (Pearson chi-square test, log-rank test, p=0.012.CONCLUSION: Surgical treatment performed within 72 hours of the hip fracture reduces or minimizes the risk of death associated directly with the fracture event itself, including in persons over 80 years of age. The effect of surgical intervention on mortality is maximally manifested in the time interval of 6-8 months after the fracture.

Revision interventions due to aseptic instability show a marked upward trend, and one of the reasons is an increase in the number of people with osteoporosis in the population. The impaired bone metabolism in these cases persist even after re-endoprosthetics. The authors aim to draw attention of trauma orthopaedists to the need to treat osteoporosis either before or immediately after the re-endoprosthetic surgery. A clinical case is presented. A 65-year-old patient T., 5 months after surgery, complained of persistent pain in the left hip joint radiating to the left knee joint, which intensified when walking, lameness, inability to move without additional support (two crutches), limited range of motion within the left hip joint that had undergone surgery (endoprosthesis). The patient had a history of femoral neck fracture associated with a low energy fall. The left hip joint re-endoprosthetics was performed due to aseptic instability of the femoral and acetabular components of the prosthetic implant. The diagnosed diseases included secondary osteoporosis, D-deficiency, hypocalcemia, and periprosthetic osteolysis. Given the increased intensity of resorption and the fact that the femoral neck fracture occurred with underlying secondary osteoporosis, it was decided to prescribe antiresorptive therapy with denosumab 60 mg once every 6 months combined with alfacalcidol and calcium supplement. Despite an objective 3-month delay in antiresorptive therapy initiation, the treatment result was achieved in the observed patient. In summary, denosumab 60 mg increases the effectiveness of re-endoprosthetics with underlying osteoporosis by reducing activity of the periprosthetic bone osteolysis.

Taking into account the increasing number of patients with osteoporosis and, accordingly, related fractures, mortality, as a possible outcome of a fracture, is an extremely urgent problem for both the patient and healthcare system. The mortality rate after a proximal femoral fracture, especially in the first 6 months, includes deaths directly, or indirectly associated with the fracture and deaths due to concomitant diseases. The influence of these two components of mortality remains a subject of discussion. This review aimed to analyze the influence of factors directly or indirectly associated with a fracture of the proximal femur and mortality.

Key statements of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis are summarized. They were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis and approved by the Russian Ministry of Health.PURPOSE:To summarize key statements of the Russian clinical practice guidelines for the diagnosis and treatment of osteoporosis.METHODS:The Russian clinical guidelines on the diagnosis and treatment of osteoporosis were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis: These comprised the Russian Association of Endocrinologists, the Russian Association for Osteoporosis, the Association of Rheumatologists of Russia, the Association of Orthopedic surgeons and Traumatologists of Russia, the Russian Association of Gynecologists-Endocrinologists, and the Russian Association of Gerontologists and Geriatrics. The guidelines are based on a systematic literature review and principles of evidence-based medicine and were compiled in accordance with the requirements for clinical recommendations developed by the Ministry of Health of the Russian Federation.RESULTS:Key statements included in the Russian guidelines of osteoporosis approved by the Russian Ministry of Health in 2021 are summarized. The statements are graded based on levels of evidence and supported by short comments. The guidelines are focused on the current approach to screening, diagnosis, differential diagnosis, and treatment of osteoporosis.CONCLUSION:These guidelines are a practical tool for general practitioners, as well as medical specialists, primarily endocrinologists, rheumatologists, orthopedic surgeons, and other physicians who are involved in the management of patients with osteoporosis.

Abstract Disclosure: S. Gronskaia: None. Z. Belaya: None. L. Rozhinskaya: None. T. Dubovitskaya: None. E. Mamedova: None. E.A. Pigarova: None. M. Degtyarev: None. S. Rodionova: None. Y. Buklemishev: None. D. Babaeva: None. V. Vladimirova: None. N. Tarbaeva: None. S. Serzhenko: None. A. Grigoriev: None. L. Dzeranova: None. V. Karpenko: None. A. Karasev: None. R. Fedotov: None. I. Ulyanova: None. D. Trukhina: None. N. Toroptsova: None. O. Lesnyak: None. N.G. Mokrysheva: None. G.A. Melnichenko: None. I. Dedov: None. Introduction: Tumor-induced osteomalacia is an acquired rare disease manifested by hypophosphatemic osteomalacia due to excessive secretion of fibroblast growth factor 23 (FGF23). FGF 23 is a non-classical hormone secreted by bone tissue (osteocytes) and regulates phosphorus metabolism.The aim of this work is to present clinical experience in the diagnosis, treatment and rehabilitation of patients with tumor-induced osteomalacia. Materials and methods: 40 patients with clinically-confirmed tumor-induced osteomalacia were included in the study, 34 of whom had the tumor localized, 27 underwent surgical treatment and 21 achieved stable remission. Results: The average age was 48 +/- 14 years, 43% were men, the time left from the the onset of the disease was 8 +/- 6 years. Biochemical fundings were hypophosphatemia 0.47 [0.4 ; 0.53] mmol/l, a decrease in the tubular reabsorption phosphate 62 [52 ; 67]%, and an increase in alkaline phosphatase of 183 [112 ; 294] units/l. At the time of diagnosis, 100% had multiple pathological fractures, only 10% could move independently, and 76.3% classified the pain as unbearable (8-10 points according to the 10-point pain syndrome scale ). Among the methods used to detect tumors, the most sensitive were scintigraphy with tectrotide with SPECT/CT 71.4% (20/28) and MRI 90% (18/20). In 55% of cases, the tumor was localized in soft tissues and in 45% in bone tissue; The tumor was most often detected in the lower extremities, followed by the head in frequency of localization. 18 patients currently have no remission and they receive conservative treatment (phosphorus and alfacalcidol n=15 and burozumab n=3). In case of achieving remission (n=21), regression of clinical symptoms and restoration of bone and muscle mass was observed. Extensive excision of the tumor without prior biopsy resulted in the best percentage of remission - 87%. Conclusion: Tumor-induced osteomalacia is most common in the middle age people. It is characterized by severe damage to bone and muscle tissue with the development of multiple fractures, muscle weakness and severe pain syndrome. In laboratory diagnostics, attention should be paid to hypophosphatemia, a decrease in the tubutar reabsorption phosphate index and increased alkaline phosphatase. The use of functional diagnostic methods with a labeled somatostatin analogue to the subtype 2 receptor and MRI with contrast enhancement are the most accurate methods of topical diagnostics. In case of localization of the tumor, a wide excision without a preliminary biopsy is recommended. Presentation: Thursday, June 15, 2023

Bone marrow edema is MR images is defined by the presence of hypointense infiltration on T1-weighted images and clear high signal intensity on fat-saturated T2-weighted sequences (T2 FSE FAT SATURATED, T2-weighted short-tau inversion recovery (T2w-STIR)).Aim: To demonstrate the features of manifestation of “bone marrow edema” at different severity and character of traumatic injury of the knee.Materials and Methods. A series of clinical cases with subchondral bone involvement in the form of “bone marrow edema” resulting from trauma is presented using the example of the knee joint as the most common area of MRI for differential diagnosis.Results. The features of “marrow edema” of the femoral and tibial condyles were analyzed using clinical examples. It was shown that the severity and nature of injury can be judged by the nature of the edema, presence of linear hypointensities, articular surface deforms and the bone defects.Conclusion. Evaluation of “bone marrow edema” revealed on MRI examination in case of pain syndrome after a knee joint injury allows timely clarification of the diagnosis and adequate treatment.

Introduction The low detection rate of osteoporosis and the lack of treatment in the elderly can contribute to a higher rate of low-energy fractures, poor results of surgical treatment and mortality. The purpose of the work was to evaluate the frequency of detection and treatment of osteoporosis before the fracture and during specialized trauma and orthopaedic care provided for a low-energy fracture of the proximal femur in the elderly. Material and methods A retrospective analysis of 209 medical histories of individuals aged 60 years and older who received treatment for a low-energy fracture of the proximal femur in 2 randomly selected trauma departments and a telephone survey of the patients performed at 3-8 months were produced. Availability of the diagnosed osteoporosis and the treatment before and during fracture repair were identified. Results The diagnosed osteoporosis was established in 5.2 % prior to fracture occurrence and in 16.7 % after the fracture occurrence. In both cases, the condition was treated with colcalciferol, calcium and pathogenetic therapy used in some cases. Discussion Diagnosis and treatment of osteoporosis in the elderly remained low before a lowenergy fracture of the proximal femur and during trauma and orthopaedic treatment. Conclusion The initiation and treatment of osteoporosis during the trauma and orthopaedic management of a low-energy fracture should be considered as a component of the high-quality specialized care.