Click here to watch a video clip showing hysteroscopic intrauterine morcellation of submucosal fibroids

Submucosal fibroids are a common cause of heavy menstrual bleeding.1 Traditionally, conventional hysteroscopic monopolar loop resection of such fibroids represents the surgical treatment of choice (Fig 1a). Hysteroscopic management of such fibroids using the intrauterine morcellation (IUM) technique (eg MyoSure, Hologic, Bedford, US; Truclear, Smith & Nephew Inc, Andover, US; Fig 1b), however, is increasingly being used worldwide but no literature concerning its safety and efficacy is available within our local population.

Our hospital is one of the first to introduce the use of the hysteroscopic IUM device in Hong Kong. This preliminary review looks at the safety, satisfaction, and efficiency of such technique when performed within our hospital and within a Chinese population. Comparisons were made between the conventional hysteroscopic monopolar loop resection technique and IUM technique with the aim of identifying the potential benefits that have been described by previous studies worldwide.

All cases of hysteroscopic resection of submucosal fibroids performed at Queen Elizabeth Hospital, Hong Kong, between 1 January 2011 and 31 December 2014, either by IUM (MyoSure) or conventional hysteroscopic monopolar loop resection, were selected and the case notes were reviewed. Choice of method was dependant on the operator but all cases using the IUM method were performed between the years 2013 and 2014 after its introduction in our department. Patients were identified from the Clinical Data Analysis and Reporting System through specialised coding. Detailed technical aspects of both operations were collected using a self-designed proforma with information collected via the Clinical Management System computerised record system. Analysis and comparison of technical details such as fibroid size, operating time, fluid deficit, operative complications, and patient satisfaction were made between the IUM and the conventional groups. Fibroid size was measured via preoperative abdominal and/or vaginal fluid–infused sonography, and confirmed during diagnostic hysteroscopy prior to resection. Those cases with prolonged operating time due to multiple operations for other indications or complications were excluded from final analysis. In our hospital, monopolar energy was used during conventional loop resection, hence glycine was used as the distending medium. With the IUM technique, since no energy source was required during morcellation, normal saline was used as the distending medium. Operating time was measured from the time the patient was anaesthetised to completion of the operation. Hence operating time included the time required to position the patient, cleaning, draping, and the time for setting up equipment. In the IUM system, fluid deficit calculations were accurately measured by the Aquilex Fluid Control System (Hologic, Bedford, US). With the conventional method, deficit calculations were based on the amount of fluid entered minus the amount of fluid suctioned and retrieved intra-operatively. Postoperatively, a satisfactory outcome was considered when the patient subjectively reported reduced menstrual bleeding and considered the operation to have improved menstrual symptoms at 3 months’ follow-up. Pre- and post-operative haemoglobin levels within 3 months of follow-up and differences between them were also investigated. All results were statistically analysed using the Statistical Package for the Social Sciences (Windows version 22.0; SPSS Inc, Chicago [IL], US). Statistical significance was represented by P values that were calculated using the Chi squared test for patient satisfaction and Mann-Whitney test for the remaining tests. P values of <0.05 were considered statistically significant for all of the data.

The research protocol was approved by the Ethics Committee of the study hospital. The patients were not required to undergo additional tests or visits, and therefore consent from the patients was not required.

During the study period, 29 patients with submucosal fibroids were treated with hysteroscopic surgery at Queen Elizabeth Hospital, Hong Kong. Conventional hysteroscopic monopolar loop resection was performed in 14 patients and IUM with the MyoSure device in 15.

Among those who underwent surgery using the conventional technique, one patient experienced a uterine perforation that required surgical repair and was excluded from data analysis. No complications occurred in any patient in the IUM group. Two patients from the IUM group and one from the conventional group were excluded due to the need for multiple procedures including endometrial ablation or laparoscopic ovarian cystectomy during the same operation. The remaining patients were all well and discharged the day after their operation regardless of the hysteroscopic technique used.

The mean size of fibroids resected was 3.3 cm (range, 2-5 cm; median, 3 cm) for the conventional technique and 3.5 (range, 1.5-6 cm; median, 3 cm) for the IUM group, although they were not significantly different (P=0.470). The operating time was significantly shorter using the IUM technique (mean, 36.6 mins; range, 17-72 mins) compared with the conventional technique (mean, 53.6 mins; range, 39-102 mins) [P=0.005]. Total fluid deficit, however, was significantly greater when using the IUM technique (1005 mL; range, 40-2600 mL) compared with the conventional technique (225 mL; range, 0-1000 mL) [P=0.003; Table 1]. No patient in either group developed any complication associated with excessive fluid absorption.

At 3 months’ follow-up, there was no significant difference in the overall outcome between the two groups: 84.6% of patients who underwent the conventional method versus 93.3% of those who underwent IUM were pleased with their overall outcome (P=0.841). Within the conventional group, the mean preoperative haemoglobin level was 95.4 g/L (range, 81-121 g/L). The mean postoperative haemoglobin level of nine patients who returned with blood results was 119 g/L (range, 91-137 g/L). The difference between pre- and post-haemoglobin level in the conventional resection group was +21.5 g/L (range, +1 to +44 g/L). In the IUM group, two patients were excluded from this part of the analysis as the indication for surgery was post-menopausal bleeding, not menorrhagia. For the remaining 11 patients, the mean preoperative haemoglobin level was 99.1 g/L (range, 62-120 g/L). The mean postoperative haemoglobin level among the nine patients in the IUM group who returned with results was 108.8 g/L (range, 90-124 g/L). The mean improvement in haemoglobin level was +17.0 g/L (range, -4 to +40 g/L). There was no significant difference between the change in haemoglobin level pre- and post-operatively between the IUM and conventional groups (P=0.235, Mann-Whitney test; Fig 2).

For both techniques, each group had two patients in whom fibroid protrusion was <60% within the uterine cavity, with the remaining patients all having >60% protrusion. Of those with <60% protrusion, each group had one (50%) of two patients who was satisfied with the procedure. In those with >60%, 100% of patients were satisfied (n=10 for conventional group and n=11 for IUM group; Table 1).

The data were further divided into groups of small and large fibroids with the cut-off of 3.0 cm to differentiate the two groups. With regard to small fibroids of ≤3.0 cm, the mean duration of procedure was significantly reduced among those using the IUM system (mean, 27.6 mins vs 53.4 mins; P=0.019), but fluid deficit was significantly greater (mean, 634.4 mL using IUM vs 80 mL using conventional technique; P=0.019; Table 2). There was no statistical difference in overall satisfaction for the two methods. When the procedure involved larger fibroids (>3.0 cm), there was no difference in operating time (P=0.527) or patient satisfaction (P=0.788) between the two methods but considerably more fluid deficit was again generated using the IUM system (mean, 328.6 mL using conventional technique vs 1839 mL using IUM; P=0.024; Table 2).

When we reviewed the data for all patients who underwent submucosal fibroid resection using the IUM technique, the procedural time was significantly reduced, while fluid deficit had a lowering trend with smaller fibroids compared with larger fibroids. Regardless of fibroid size, however, there was no significant difference in overall patient satisfaction (P=0.710; Table 3).

Hysteroscopic surgery using hysteroscopic monopolar loop resection has always been the conventional method to resect submucosal fibroids. Recently, hysteroscopic intrauterine morcellators such as MyoSure have been increasingly used as an alternative. Reports have suggested that such techniques to remove submucosal fibroids and polyps are as effective as the conventional hysteroscopic resection while fibroid symptom–related quality of life is improved and the recurrence of endometrial polyp reduced.2 3 Reports have suggested that IUM may be associated with adverse complications such as bowel damage, hysterectomy, uterine perforation, and pelvic infection, but an adverse event complication rate of <1% for hysteroscopic morcellation technique is lower than that for conventional electrocautery.4 Other reports have suggested additional benefits such as reduction in instances of uterine perforation, cervical dilation, thermal bowel injury, and intrauterine adhesions when comparing the use of such a device with conventional methods. Operating time, fluid absorption, and the need for a second operation may also be reduced.5 6 7

Despite its increasing popularity worldwide, the IUM technique remains a relatively new concept within the Chinese population. In this retrospective review, among the 13 patients who underwent IUM for the management of submucosal fibroids, none developed intra-operative complications or postoperative complications that could lead to an extended hospital stay.

Excessive fluid deficit and subsequent fluid absorption remains a concern with hysteroscopic surgery. Electrolyte imbalance as well as cardiac collapse and death can occur in severe cases. This is more likely if hypotonic glycine is used as the uterine distention medium: normal saline reduces such risks.8 In our study, the IUM technique was associated with significantly higher fluid deficit regardless of fibroid size being morcellated. One explanation of this is the fast fluid pumping device that is used with the IUM. High fluid flow within the cavity is important to maintain a clear view during the morcellation procedure and to maintain a high intrauterine pressure to prevent bleeding during the myoma morcellation process. Normal saline was used in the IUM technique instead of glycine (which was used in conventional technique). Despite its significantly higher fluid deficit, no patients experienced any associated complications.9 In both techniques and regardless of the size of the submucosal fibroids, the total amount of fluid deficit remained within or just above the maximum limit of 2500 mL of saline or 1000 mL glycine set by AAGL (American Association of Gynecologic Laparoscopists).10 One patient who underwent IUM had 100 mL (2600 mL) above the recommended maximum fluid deficit limit. This was due to the additional time required to completely resect a large 6-cm fibroid and avoided a second operation. This patient recovered well and did not have any complications. Hence despite the excessive fluid deficit, IUM remains a safe procedure.

When the technicalities of both techniques were compared, the total time required for the operation was significantly reduced when the IUM technique was used. This was particularly significant if the fibroid size was ≤3 cm but not if the fibroid was >3 cm; 3 cm was chosen as the cut-off between small and large fibroid as previous studies have already shown morcellation of submucosal fibroids of ≤3.0 cm to be safe and effective.11 12 One of the main reasons for the reduced operating time was the constant suction mechanism at the morcellator blade of the IUM device. This suction constantly removes resected material to maintain a clear view of the uterine cavity. The material is collected directly into the Aquilex Fluid Control System that is required for the MyoSure IUM device. As a result, unlike the conventional method, the need to constantly remove fibroid chips during the procedure is avoided and hence operating time is reduced. With the larger-sized fibroids, the time needed to morcellate the large fibroid will still be considerable so there is a smaller difference compared with conventional methods. One may suggest that the reduced time difference may be due to the experience of the operator, as the IUM is a new technique within our department. Previous study has suggested that both experienced operators and training doctors favour the morcellation technique and the learning curve is minimal.12 Familiarisation with the setup of the system, the technique of hysteroscopic morcellation, management of a loose cervix that can cause fluid leakage as well as fluid control to maintain haemostasis versus a clear visual field remain a challenge. Given more experience with the IUM system, reduced operating times will become more significant. This proposed reduction in operating time will benefit both patient (eg anaesthetic exposure) and the institution (reduced waiting time for operation). Other potential benefits described by other studies such as reduced uterine perforation, cervical dilation, thermal bowel injury, and intrauterine adhesions5 6 7 cannot be determined given the small number of cases performed so far. Nonetheless, there has been one case of uterine and subsequent bowel perforation with the conventional technique and none with the IUM technique in this study.

Patient satisfaction in terms of reduced or improved menstrual symptoms showed no significant difference at 3 months’ follow-up when the IUM technique was compared with the conventional technique. Haemoglobin levels improved following hysteroscopic resection of fibroid regardless of the technique used, with no significant difference in improvement between the two groups. Patient satisfaction again showed no statistically significant difference regardless of the size of the submucosal fibroids, suggesting that the IUM technique can be applied to large fibroids. If cases were carefully selected and only submucous fibroids with less than 50% of the contents intramural were surgically resected as suggested by Di Spiezio Sardo et al,7 the satisfaction rate would remain the same between the two techniques, that is both achieved 100% satisfaction.

Although results regarding safety, effectiveness, and benefits of the IUM technique appear to be promising, this study remains a preliminary overview as the strength of the evidence is limited by the small number of cases. The limited sample may not be representative of the general population and the two groups using different techniques may not be comparable. As a result of the small numbers, this in itself and the non-parametric test used due to the lack of numbers reduce its statistical power. Limitations also arise when the skill of the surgeon varies and the total operating time incorporates the time for preparation and setting up for the procedure. The latter may cause discrepancy in the actual total operating time. Further prospective studies or randomised controlled trials with more subjects, a limited number of surgeons with similar hysteroscopic skills, and a more accurate surgical time measurement would be more beneficial. More standardised outcome measures using a combination of haemoglobin improvement, menstrual chart, and/or patient satisfaction surveys may also improve the strength of future studies.

This retrospective review suggests that hysteroscopic IUM is a safe and effective technique for management of menorrhagia secondary to submucosal fibroid. Preliminary data suggest the technique to be as safe and effective as, and less time-consuming than, conventional techniques. Maximum benefit would be achieved if submucosal fibroid cases for IUM resection were carefully selected, with particular reference to patients in whom >50% of the fibroid protrudes into the uterine cavity and where maximum diameter is ≤3 cm.

No conflicts of interest were declared by authors.

1. Puri K, Famuyide AO, Erwin PJ, Stewart EA, Laughlin-Tommaso SK. Submucosal fibroids and the relation to heavy menstrual bleeding and anemia. Am J Obstet Gynecol 2014;210:38.e1-7. Crossref

2. Rubino RJ, Lukes AS. Twelve-month outcomes for patients undergoing hysteroscopic morcellation of uterine polyps and myomas in an office or ambulatory surgical center. J Minim Invasive Gynecol 2015;22:285-90. Crossref

3. AlHilli MM, Nixon KE, Hopkins MR, Weaver AL, Laughlin-Tommaso SK, Famuyide AO. Long-term outcomes after intrauterine morcellation vs hysteroscopic resection of endometrial polyps. J Minim Invasive Gynecol 2013;20:215-21. Crossref

4. Haber K, Hawkins E, Levie M, Chudnoff S. Hysteroscopic morcellation: review of the manufacturer and user facility device experience (MAUDE) database. J Minim Invasive Gynecol 2015;22:110-4. Crossref

5. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993;8:736-40.

6. Stamatellos I, Apostolides A, Tantis A, Stamatopoulos P, Bontis J. Fertility rates after hysteroscopic treatment of submucous fibroids depending on their type. Gynecol Surg 2006;3:206-10. Crossref

7. Di Spiezio Sardo A, Mazzon I, Bramante S, et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update 2008;14:101-19. Crossref

8. Tarneja P, Tarneja VK, Duggal BS. Complications of hysteroscopy surgery. Medical Journal Armed Forces India 2002;58:331-4. Crossref

9. Isaacson KB, Olive DL. Operative hysteroscopy in physiologic distention media. J Am Assoc Gynecol Laparosc 1999;6:113-8. Crossref

10. AAGL Advancing Minimally Invasive Gynecology Worldwide, Munro MG, Storz K, Abbott JA, et al. AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media: (Replaces Hysteroscopic Fluid Monitoring Guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.). J Minim Invasive Gynecol 2013;20:137-48. Crossref

11. Hamerlynck TWO, Dietz V, Schoot BC. Clinical implementation of the hysteroscopic morcellator for the removal of intrauterine myomas and polyps. A retrospective descriptive study. Gynecol Surg 2011;8:193-6. Crossref

12. Emanuel MH, Wamsteker K. The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas. J Minim Invasive Gynecol 2005;12:62-6. Crossref

With the widespread use of advanced imaging such as computed tomography (CT), many renal tumours are now incidentally discovered before the patient becomes symptomatic. These tumours are often of small size. This has led to the emerging practice of partial nephrectomy (PN) rather than radical nephrectomy (RN) that has been the gold-standard treatment for localised renal tumours for over 40 years.1 Studies have shown that cancer control can be achieved by PN in patients with T1a tumours,2 3 4 5 and some studies also supported the extended use of PN for T1b tumours.6 7 8 9 In addition, patients who undergo PN have been shown to be at decreased risk of renal impairment.10

Nonetheless, many surgeons in Hong Kong continue to perform RN for all renal tumours, regardless of their size. The major concerns are the technical difficulty of PN and the associated major postoperative complications.

The aim of this study was to compare the oncological outcome, survival, and changes in renal function in patients who underwent RN or PN for T1 renal cancer in our centre. Patients were predominantly of Chinese ethnicity.

We retrospectively reviewed the data of patients who underwent RN or PN at our centre between January 2005 and December 2010. Patients with a solitary tumour of 7 cm or less in diameter and a normal contralateral kidney were included. The decision to perform PN was based on tumour characteristics (size, proximity to collecting system and major vessels) and the surgeon’s preference. Exclusion criteria were: end-stage renal failure (glomerular filtration rate [GFR] <15 mL/min/1.73 m²), history of renal transplantation, known hereditary renal cancer, known poor or non-functioning contralateral kidney, history of nephrectomy, and preoperative evidence of tumour metastases.

Preoperative parameters including age, gender, serum creatinine, and estimated GFR were studied. We used the modified Charlson-Romano index to compare patient co-morbidity.11 We also compared postoperative outcome for the RN and PN groups, including length of hospital stay, complications, and 90-day mortality. Severity of complications was graded using the Clavien-Dindo classification system.12

Our study outcome included 5-year overall survival, cancer-free survival, change in renal function in terms of estimated GFR (eGFR), and new onset of chronic kidney disease (CKD)—GFR was calculated with the four-variable Modification of Diet in Renal Disease formula: eGFR = 32 788 x serum creatinine (µmol/L)^-1.154 x age^-0.203 x [1.212 if black] x [0.742 if female]13; CKD was defined as GFR of <60 mL/min/1.73 m². Patients were followed up according to international guidelines, with slight variation in timing of imaging due to examination waiting time issues. In general, follow-up was scheduled every 3 months within the first year of operation with measurement of serum creatinine and GFR, and CT scan was performed approximately 12 months following surgery. Patients were subsequently followed up every 6 months, with renal function checked at each visit, and imaging studies (ultrasonography or CT) performed annually for the first 5 years and thereafter once every 2 years.

For preoperative characteristics and postoperative outcome, P value was determined by the Chi squared test and Mann-Whitney U test for categorical and continuous variables, respectively. Kaplan-Meier model was used for 5-year overall and cancer-free survival, and the postulated 5-year probability of freedom from CKD. Risk of new onset of CKD was calculated with Cox proportional hazards regression, adjusted for age, Charlson Comorbidity Index (CCI), preoperative GFR, gender, and tumour size; with time to CKD development as dependent variable; death, loss to follow-up, or last follow-up date before 31 December 2012 were censored in the analysis. Overall survival was analysed by Cox proportional hazards regression adjusted with Fuhrman grade of tumour, in addition to the above factors. We did not include diabetes mellitus as it was included in the CCI. We considered a 2-sided P value of <0.05 as statistically significant. All statistical analyses were performed with the Statistical Package for the Social Sciences (Windows version 20.0; SPSS Inc, Chicago [IL], US).

A total of 86 patients were reviewed, with a mean (± standard deviation) follow-up time of 43.5 ± 22.4 months. Four (5%) patients were lost to follow-up with their status unknown by the end of our study. Overall, RN was performed in 38 patients and PN in 48. Age, gender, and preoperative serum creatinine level and GFR were similar between the two groups. The mean age of RN and PN groups was 61 years and 63 years, respectively (P=0.48), with a respective mean preoperative GFR of 80.8 mL/min/1.73 m² and 75.0 mL/min/1.73 m² (P=0.38). Six (16%) patients in the RN group and 11 (23%) in the PN group had a preoperative GFR of <60 mL/min/1.73 m²; one patient in the PN group had a preoperative GFR of <30 mL/min/1.73m². Most patients in the RN and PN groups had a CCI of <2 (84% vs 85%; P=0.87). The respective mean follow-up time was 42.1 ± 24.0 and 44.5 ± 21.3 months (P=0.62) [Table 1].

Tumours were more complex in the RN group in terms of the R.E.N.A.L. score14 derived from preoperative CT (8.4 vs 6.7, P<0.001). The mean tumour size, based on final pathological examination, was also larger in the RN group (4.8 cm vs 2.5 cm, P<0.001). In the RN group, 24 (63%) patients had a T1b tumour compared with three (6%) in the PN group (P<0.001). Comparison of the first half of our study period (2005-2008) with the second half (2009-2010) revealed that tumour characteristics were similar in the PN group, in terms of both size (2.4 cm vs 2.5 cm; P=0.93) and R.E.N.A.L. score (6.2 vs 7.0; P=0.32). Most tumours in both groups were of the clear cell type. The RN group had more Fuhrman grade 3 tumours but the difference was not significant (Table 1). All resections enjoyed clear resection margins on final pathological examination.

All RNs were performed via a laparoscopic approach. An open procedure was performed for 29 (60%) of the PNs, eight (17%) were performed via a laparoscopic approach, and 11 (23%) with robotic assistance. Of the latter, conversion to an open procedure was required in two cases. Operating time was significantly longer in the PN group (250 mins vs 345 mins; P<0.001). None of the PNs were converted to RN.

All PNs were performed with vascular control achieved by hilar clamping. Overall, 28 (58%) PNs were performed with cold ischaemia using ice slush, with a mean cold ischaemia time of 70 minutes; among these, 23 (82%) were an open procedure and two were conversion of robotic-assisted laparoscopic PN to open procedure. Of the PNs, 20 (42%) were performed with warm ischaemia, and the mean warm ischaemia time was 32 minutes; all laparoscopic PNs were performed with warm ischaemia. The complexity of tumour in terms of R.E.N.A.L. score was significantly lower in the warm ischaemia group (5.7 vs 7.5; P=0.01).

Patients in the PN group had a longer postoperative hospital stay (6 vs 13 days; P<0.001); one of whom died within 90 days of surgery of cholecystitis and septic complications unrelated to the renal cancer.

Postoperative complication rates were similar between the two groups (P=0.19), although the PN group had more Clavien grade III or above complications (0% vs 10%; Table 2). Four patients had persistent urine leakage that was successfully treated with retrograde injection of surgical adhesive glue; one patient developed pseudoaneurysm of the segmental branch of the renal artery, which was treated by angiographic embolisation. No long-term morbidity or mortality occurred. Complication rate was not associated with patient age, CCI, R.E.N.A.L. score of tumour, or operative parameters (operative approach, operating time, and ischaemia time).

An overall excellent oncological outcome was achieved by both groups. Extensive metastases were evident 3 months after operation in one patient in the RN group but these were not apparent before operation. By 31 December 2012, 32 (84%) RN and 43 (90%) PN patients were alive. The overall 5-year survival for the RN and PN groups was 84.2% and 89.6% (P=0.29) respectively, and the cancer-free survival was 97% and 100% (P=0.29) respectively. Both RN and PN did not affect overall survival (hazard ratio=0.84; 95% confidence interval [CI], 0.17-4.02; P=0.82), after adjustment for age, CCI, preoperative GFR, gender, tumour size, and Fuhrman grade (Table 3).

Patients who underwent RN had a greater median reduction in GFR than PN patients (35.4% vs 12.6%; P<0.001), and the degree of reduction was most distinctive in the first year after operation (Fig 1). In the PN group, one patient with a preoperative GFR of 30 mL/min/1.73 m² developed stage 5 CKD 4 years after surgery and required renal replacement therapy. Preoperative GFR was >60 mL/min/1.73 m² in 32 patients in the RN group and in 36 patients in the PN group. At their last follow-up, CKD was developed in 18 (56%) patients who underwent RN but new-onset CKD was evident in only five (14%) of the PN group (P<0.001). The majority of the CKD cases were stage 3 (94% in RN group and 80% in PN group); none was in stage 5. Cox proportional hazards regression model showed that RN was the most significant factor contributing to the development of CKD (RN vs PN, hazard ratio=5.44; 95% CI, 1.26-23.55; P=0.02; Table 4). The postulated probability of freedom from new-onset CKD in 5 years, by Kaplan-Meier model, was 33% and 81% in the RN and PN groups, respectively (P<0.001; Fig 2).

Many surgeons have underestimated the impact of renal impairment after RN for renal cancer, on the basis that organ donors who undergo nephrectomy are not at increased risk of renal failure or death.15 16 17 Nonetheless, donors represent a different population as they are often young and fit. Patients with renal cancer are often older and have co-morbidities such as hypertension and diabetes mellitus. In our study, 21% of our patients had a GFR of <60 mL/min/1.73 m² prior to surgery and 15% had a CCI of ≥2. Therefore it is logical that this cohort of patients may benefit from a surgical technique that preserves more of their renal function.

Our study showed that PN resulted in less renal deterioration in terms of GFR, with RN having a hazard ratio of 5.44 for development of CKD, after taking into consideration the patient co-morbidities, gender, age, and tumour size. The postulated probability of freedom from new onset of CKD in 5 years in our series was 33% following RN and 81% following PN. This echoes the finding of Huang et al10 who reported the 3-year probability of freedom from new onset of CKD as 35% after RN and 80% after PN; RN remained an independent risk factor for development of new-onset CKD with a hazard ratio of 3.82.

A community-based study showed that CKD was an independent risk factor for the development of cardiovascular events, hospitalisation, and death.18 In a population-based cohort of 7769 patients, RN was associated with a 1.23-fold increase in overall mortality compared with PN (P=0.001), and a higher rate of non–cancer-related mortality.19 Huang et al10 also demonstrated that RN was associated with a 1.46-fold increased risk of overall mortality, although the risk of a cardiovascular event was not increased in the RN group. Evidence that PN decreases overall mortality remains contradictory. A randomised controlled trial showed that RN had comparable overall survival with PN after a median follow-up of 9.3 years.20 In our study we did not show a significant difference in overall survival between PN and RN groups.

Another concern of PN is its cancer control, since the prevention of local recurrence is of paramount importance. The extent of resection is affected by tumour size, proximity to the collecting system, and location and degree of exophytic growth. It is generally accepted that PN can achieve excellent oncological outcome for tumours smaller than 4 cm, with a long-term 5-year and 10-year cancer-free survival rates of 92% to 100%.2 21 22 23 Studies have demonstrated the feasibility of PN for tumours larger than 4 cm without compromising the oncological outcome, although there was a higher risk of peri-operative bleeding and other complications.23 24 In our cohort, we achieved a 100% clear surgical resection margin with PN, and no local recurrence was found after 5 years.

Increased peri-operative morbidity is traditionally a concern in PN. There were more Clavien grade III complications and a longer hospital stay for patients who underwent PN in our cohort. The most common complication in an open PN series was urine leakage, with a mean incidence of 6.5% (range, 2.1%-17%).25 26 In a multicentre review of 51 laparoscopic PNs, postoperative urine leakage was observed in three (6%) patients.27 The results of a previous series by Gill et al,28 supported by our results, suggested that both tumour location and diameter were not related to the occurrence of urine leakage. In contrast to the logical thinking that calyceal entry was not observed during renorrhaphy, it has been suggested that central coagulation necrosis with electrocautery is responsible for fistula formation.27 The use of a ureteral catheter and retrograde dye injection after haemostasis has been advocated to help identify any calyceal opening, but this was not supported in a retrospective series by Bove et al29 that involved 54 patients with and 49 patients without ureteral catheter placement. We believe that the adoption of cold cutting and elevation of the tumour from the tumour bed by the suction cannula, which also simultaneously aspirates the blood, can avoid coagulation necrosis and a clear operative field can be maintained so that any breaching of calyceal integrity can be identified. The use of a ureteral catheter can be an adjunct measure in equivocal cases when the tumour is abutting the calyceal lining on preoperative imaging.

Our study have some limitations. Since it was a retrospective study, patients were not randomised and there was a selection of smaller and less complex tumours in the PN group. There were also other confounding factors such as patient’s smoking status that were not included, hence the two groups were not totally comparable, although other patient demographics were similar. As a proportion of preoperative imaging could not be retrieved, the R.E.N.A.L. score could not be calculated for every patient included, and this contributed another confounding factor. Only three patients had T1b renal cancer in the PN group, thus the oncological outcome may be more certain in T1a renal cancer. Our stratified analysis in T1a renal cancer had a similar result with PN having an equivalent oncological outcome and superior renal function preservation, although the result is not shown here. In addition, the risk of tumour recurrence, negative effect of CKD and their effect on survival might not be truly reflected in our relatively short follow-up time. Nonetheless with experience, renal tumours of 4 cm or more in diameter may be amenable to safe PN with equivalent oncological outcome and a lower chance of progression to CKD. This may translate into improved overall survival.30

Partial nephrectomy can preserve more renal function and reduce the risk of development of CKD compared with RN. Excellent cancer control and a low local recurrence rate can still be achieved with PN for T1 tumours, in particular T1a tumours and tumours with a low R.E.N.A.L. score. Although RN continues to constitute a significant proportion of surgical procedures for T1 renal cancer in our locality, we recommend that, if technically feasible, PN should be performed for all T1a and selected T1b renal cancers.

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2. Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol 2000;163:442-5. Crossref

3. Lee CT, Katz J, Shi W, Thaler HT, Reuter VE, Russo P. Surgical management of renal tumors 4 cm or less in a contemporary cohort. J Urol 2000;163:730-6. Crossref

4. Touijer K, Jacqmin D, Kavoussi LR, et al. The expanding role of partial nephrectomy: a critical analysis of indications, results, and complications. Eur Urol 2010;57:214-22. Crossref

5. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2007;51:1606-15. Crossref

6. Patard JJ, Shvarts O, Lam JS, et al. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urol 2004;171:2181-5. Crossref

7. Leibovich BC, Blute M, Cheville JC, Lohse CM, Weaver AL, Zincke H. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004;171:1066-70. Crossref

8. Dash A, Vickers AJ, Schachter LR, Bach AM, Snyder ME, Russo P. Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm. BJU Int 2006;97:939-45. Crossref

9. Antonelli A, Cozzoli A, Nicolai M, et al. Nephron-sparing surgery versus radical nephrectomy in the treatment of intracapsular renal cell carcinoma up to 7 cm. Eur Urol 2008;53:803-9. Crossref

10. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006;7:735-40. Crossref

11. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. Crossref

12. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13. Crossref

13. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461-70. Crossref

14. Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 2009;182:844-53. Crossref

15. Najarian JS, Chavers BM, McHugh LE, Matas AJ. 20 Years or more of follow-up of living kidney donors. Lancet 1992;340:807-10. Crossref

16. Fehrman-Ekholm I, Dunér F, Brink B, Tydén G, Elinder CG. No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up. Transplantation 2001;72:444-9. Crossref

17. Fehrman-Ekholm I, Elinder CG, Stenbeck M, Tydén G, Groth CG. Kidney donors live longer. Transplantation 1997;64:976-8. Crossref

18. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296-305. Crossref

19. Zini L, Perrotte P, Capitanio U, et al. Radical versus partial nephrectomy: effect on overall and noncancer mortality. Cancer 2009;115:1465-71. Crossref

20. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011;59:543-52. Crossref

21. Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol 2001;166:6-18. Crossref

22. Herr HW. Partial nephrectomy for unilateral renal carcinoma and a normal contralateral kidney: 10-year followup. J Urol 1999;161:33-4; discussion 34-5. Crossref

23. Becker F, Siemer S, Humke U, Hack M, Ziegler M, Stöckle M. Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: long-term survival data of 216 patients. Eur Urol 2006;49:308-13. Crossref

24. Patard JJ, Pantuck AJ, Crepel M, et al. Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication. Eur Urol 2007;52:148-54. Crossref

25. Campbell SC, Novick AC, Streem SB, Klein E, Licht M. Complications of nephron sparing surgery for renal tumors. J Urol 1994;151:1177-80.

26. Kim FJ, Rha KH, Hernandez F, Jarrett TW, Pinto PA, Kavoussi LR. Laparoscopic radical versus partial nephrectomy: assessment of complications. J Urol 2003;170:408-11. Crossref

27. Jeschke K, Peschel R, Wakonig J, Schellander L, Bartsch G, Henning K. Laparoscopic nephron-sparing surgery for renal tumors. Urology 2001;58:688-92. Crossref

28. Gill IS, Desai MM, Kaouk JH, et al. Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol 2002;167:469-76. Crossref

29. Bove P, Bhayani SB, Rha KH, Allaf ME, Jarrett TW, Kavoussi LR. Necessity of ureteral catheter during laparoscopic partial nephrectomy. J Urol 2004;172:458-60. Crossref

30. Weight CJ, Larson BT, Gao T, et al. Elective partial nephrectomy in patients with clinical T1b renal tumors is associated with improved overall survival. Urology 2010;76:631-7. Crossref

Ageing is associated with changes in all body organs including body composition, skeletal muscle, and bone mass. Muscle mass decreases by 3% to 8% per decade after the age of 30 years and the rate of decline is even higher after the age of 60 years.1 2 3 Rosenberg4 first referred to this involuntary age-related loss of muscle mass as ‘sarcopeny’ in 1989. The term sarcopenia derives from the Greek words sarks (flesh) and penia (loss) and is equivalent to a process that occurs during osteoporosis. Sarcopenic individuals have a greater than 3-fold increase in falls,5 6 7 higher earlier mortality,8 9 10 and poor mobility and instrumental activity in daily living.11 Sarcopenia imposes significant costs on the health care system each year.12 It is the underlying cause of frailty, the debilitating syndrome in ageing. Functional impairment and physical disability are 2 to 3 times more likely in sarcopenic people.13 In the United States, costs related to complications of sarcopenia were estimated to be more than 18.5 billion dollars in 2000.12

Since 1989, several definitions of sarcopenia have been presented based on the method of measuring body composition including bio-impedance analysis, dual-energy X-ray absorptiometry (DXA), computed tomography,14 and magnetic resonance imaging.15 In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) developed a new definition for sarcopenia using the presence of both low muscle mass and low muscle function (strength or performance).16 The Working Group suggests three stages of sarcopenia: pre-sarcopenia stage, characterised by low muscle mass without change in muscle strength or performance; sarcopenia, low muscle mass plus low muscle strength or low physical performance; and severe sarcopenia, with a decrease in all three components: muscle mass, strength, and performance.

Inadequate protein intake is one of the main risk factors for sarcopenia.17 One study showed that the dietary intake of patients undergoing orthopaedic surgery was insufficient in terms of energy, proteins, and micronutrients.18 This situation is often due to a hypermetabolic state secondary to inflammation, to a reduced food intake due to lack of appetite and to patients being confined to bed. For all these reasons, the European Society for Parenteral and Enteral Nutrition recommends the use of nutritional supplements in older people who have experienced a hip fracture.19 A daily intake of 1.2 to 1.5 g/kg of protein has been reported to prevent sarcopenia, which is much more than the currently recommended daily dietary protein intake for adults of 0.8 g/kg/day.20 There is general agreement that the essential amino acid leucine increases protein anabolism and decreases protein breakdown.21 Vitamin D has recently received recognition as another potential intervention strategy for sarcopenia.22 23 Three registered clinical trials are currently being conducted across France, Belgium, and the United States to investigate protein nutritional supplements and sarcopenia. All trials include nutritional supplements and resistance training as interventions.

There is growing evidence that physical activity can slow down the loss of skeletal muscle and function.24 Exercise also reduces the likelihood of falls and fall-related injuries.24 25 While progressive resistance exercises can increase muscle strength and power exercises can increase strength and power, both have been recommended to revert sarcopenia.26 27 28

In Taiwan, the prevalence of sarcopenia has been reported to be 10.8% in male and 3.7% in female community-dwelling older Chinese adults aged 65 years or above using EWGSOP criteria.29 The impact of sarcopenia on osteoporotic fractures has rarely been reported, however. One study from Japan reported a lower relative skeletal muscle mass index and higher prevalence of sarcopenia in hip fracture patients.30 No data are available for Chinese patients.

In this study, we report the prevalence of sarcopenia in Chinese geriatric patients with hip fracture, and its correlation with different factors.

This was an observational study to determine the prevalence of sarcopenia, which was conducted among geriatric hip fracture patients admitted to Kowloon West Cluster Orthopaedic Rehabilitation Centre in Hong Kong. All patients aged 60 years or above admitted from June to December 2014 to Kowloon West Cluster Orthopaedic Rehabilitation Centre with operated hip fracture were recruited. All study subjects were assessed by a clinician and therapist within 3 weeks of admission. Basic demographics and anthropometric measurement data were collected.

Dual-energy X-ray absorptiometry was adopted to assess sarcopenia. We used the criteria recommended by the Asian Working Group for Sarcopenia (AWGS) based on DXA study. Appendicular and whole lean body mass was measured. Appendicular skeletal muscle mass was normalised by size (sum of lean muscle mass in upper and lower limb divided by square of body height). Relative appendicular skeletal muscle mass index (RASM) was used with a cut-off value of 7 kg/m² in men, and 5.4 kg/m² in women according to the consensus report of the AWGS.31

Isometric grip strength, the maximal hand grip strength, was measured using a JAMAR hand dynamometer (Sammons Preston, US). Patients were seated with the shoulders in an anatomical position and elbows in 90° flexion. The patients were shown how to use the dynamometer and then asked to press for 3 to 5 seconds on the grip using the greatest possible force. The measurement was repeated after a 30-second rest. Both hands were measured separately and the highest score was registered. In order to reduce variability, measurement was taken in a standardised manner. We used <26 kg for men and <18 kg for women according to the cut-off values recommended by AWGS.31

The prevalence of sarcopenia was reported as the mean of RASM and hand grip strength. To find a significant relationship between RASM and other factors (age, hand grip strength, body weight, body height, hip bone mineral density [BMD], and total fat mass), Pearson’s correlation was performed in each group. A P value of <0.05 was considered statistically significant. Analysis was performed using the Statistical Package for the Social Sciences (Windows version 20.0; SPSS Inc, Chicago [IL], US).

There were 239 patients (72 men and 167 women) in this study. Their mean age was 82 years, with 81.5 years for males and 82.2 years for females. By stratifying individuals as male or female, the mean (± standard deviation) body weight was 54.1 ± 9.8 kg and 48.9 ± 9.9 kg, respectively. Respective mean hand grip strength was 20.6 ± 7.3 kg and 13.6 ± 4.5 kg. Dual-energy X-ray absorptiometry was performed 14 days (mean; range, 3-28 days) after fall. Using the cut-off value recommended by AWGS, the 95% centile was lower than the cut-off value (Fig 1). The mean hip BMD for males and females was 0.696 ± 0.13 g/cm² and 0.622 ± 0.12 g/cm², mean hip T-score was -2.23 and -2.67, and the mean RASM was 5.72 ± 0.83 kg/m² and 4.87 ± 0.83 kg/m², respectively (Table 1). Age- and sex-specific RASM are shown in Figure 2. For males, RASM declined as age increased. For females, a lower RASM was observed in the youngest and the oldest patients. The prevalence of sarcopenia based on AWGS definition (RASM <7 kg/m² for men and <5.4 kg/m² for women, together with hand grip strength <26 kg for men and <18 kg for women) was 73.6% in males and 67.7% in females. According to EWGSOP, the prevalence of pre-sarcopenia was 20.8% in males and 12.4% in females. The prevalence of femoral neck osteoporosis based on hip T-score of <–2.5 was 47.8% in males and 59.1% in females.

The relationship between RASM and hand grip strength, body weight, hip BMD, body mass index (BMI), and total fat mass in males is shown in Figure 3 (P value from Pearson’s test). There was a positive correlation between RASM and the above parameters and all were statistically significant. In females, the relationship between RASM and hand grip strength, body weight, body height, BMI, and total fat mass is shown in Figure 4. There was a positive and statistically significant correlation between RASM and all the above parameters except body height.

The prevalence of sarcopenia was 10.8% in male and 3.7% in female community-dwelling older Chinese adults aged ≥65 years based on AWGS criteria.31 Few papers have reported the prevalence of sarcopenia in hip fracture patients, and have used different definitions of sarcopenia. Table 230 32 summarises the findings.

Hida et al30 reported the prevalence of sarcopenia in hip fracture patients based on Japanese criterion (appendicular skeletal muscle mass index <5.46 kg/m² in women and <6.87 kg/m² in men): the figures being 44.7% in males and 81.1% in females. Di Monaco et al32 reported a sarcopenia prevalence of 64% in female hip fracture patients and 95% in male hip fracture patients, based on height-adjusted appendicular lean mass (aLM/height²). Sarcopenia was defined according to normative data from the New Mexico Elder Health Survey33 where aLM was less than 2 standard deviations below the mean of a young reference group. They showed a significant positive correlation between aLM/height² and BMD.32

In our study, there was a higher prevalence of sarcopenia in both male and female patients with hip fracture, and even higher than that for community-dwelling older Chinese adults. This reveals that the problem of sarcopenia in geriatric hip fracture patients is very serious. Our study is the only one to adopt the definition proposed by the AWGS and currently accepted in literature for an Asian population. In addition, the interval between fracture and DXA assessment is important: a significant decrease in total body mass, lean mass, and BMD has been reported from 10 days to 2 months post-fracture.34 As we performed DXA on an average of 14 days following fall, the potential effect of deterioration in muscle mass after immobilisation was minimised.

In our study, the mean RASM in females was the lowest in the 60-64 years’ age-group. Sarcopenia may be a risk factor in this group of relatively young geriatric hip fracture patients. Further study should assess this particular group of patients to determine the correlation of sarcopenia and fracture risk.

The prevalence of femoral neck osteoporosis based on hip T-score of <–2.5 was 47.8% in males and 59.1% in females. For male patients the RASM was correlated with hip BMD, although a similar result was not significant in female patients (R=0.15, P=0.07). The prevalence of both osteoporosis and sarcopenia is high in geriatric hip fracture patients, and the prevalence of sarcopenia is even higher. Based on the high prevalence of both osteoporosis and sarcopenia, screening and treatment of both diseases should be targeted to geriatric patients with hip fracture.

Our study also showed that RASM was correlated with hand grip strength, body weight, and BMI (and total fat mass). Hence, they may be applied to screen for high-risk patients where a whole-body DXA machine or bio-impedance assessment is not available.

There are few potential limitations of our study. First, we only included patients with operated hip fracture. The number of non-operated hip fractures was unknown. Second, the time interval between fall and DXA measurement varied from 3 to 28 days. The period of immobilisation commencement from the date of fracture also varied. As the period of immobilisation lengthens, there will be a drop in RASM, although in our study a non-significant negative correlation between RASM and time interval between fall and DXA measurement was shown. Third, this was an unblinded study, and assessment involved several assessors. Nonetheless, these issues could be minimised by standardising the approach, and providing briefing instructions to the patient being assessed. The use of the DXA machine will not be biased since lean muscle mass is an objective measure.

Our study showed a high prevalence of osteoporosis and sarcopenia in geriatric patients with hip fracture. With an expanding elderly population, the number of such patients will increase. In addition to surgical treatment of hip fracture, a well-structured screening and treatment programme of osteoporosis and sarcopenia should be implemented in order to reduce subsequent fall, subsequent fracture, and the fracture-related complications and economic burden to Hong Kong.

1. Volpi E, Nazemi R, Fujita S. Muscle tissue changes with aging. Curr Opin Clin Nutr Metab Care 2004;7:405-10. Crossref

2. Doherty TJ. Invited review: Aging and sarcopenia. J Appl Physiol (1985) 2003;95:1717-27. Crossref

3. Hughes VA, Frontera WR, Roubenoff R, Evans WJ, Singh MA. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr 2002;76:473-81.

4. Rosenberg IH. Summary comments. Am J Clin Nutr 1989;50:1231-3.

5. Wu IC, Lin CC, Hsiung CA, et al. Epidemiology of sarcopenia among community-dwelling older adults in Taiwan: a pooled analysis for a broader adoption of sarcopenia assessments. Geriatr Gerontol Int 2014;14 Suppl 1:52-60. Crossref

6. Tanimoto Y, Watanabe M, Sun W, et al. Sarcopenia and falls in community-dwelling elderly subjects in Japan: Defining sarcopenia according to criteria of the European Working Group on Sarcopenia in Older People. Arch Gerontol Geriatr 2014;59:295-9. Crossref

7. Landi F, Liperoti R, Russo A, et al. Sarcopenia as a risk factor for falls in elderly individuals: results from the ilSIRENTE study. Clin Nutr 2012;31:652-8. Crossref

8. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older nursing home residents. J Am Med Dir Assoc 2012;13:121-6. Crossref

9. Kim JH, Lim S, Choi SH, et al. Sarcopenia: an independent predictor of mortality in community-dwelling older Korean men. J Gerontol A Biol Sci Med Sci 2014;69:1244-52. Crossref

10. Vetrano DL, Landi F, Volpato S, et al. Association of sarcopenia with short- and long-term mortality in older adults admitted to acute care wards: results from the CRIME study. J Gerontol A Biol Sci Med Sci 2014;69:1154-61. Crossref

11. da Silva Alexandre T, de Oliveira Duarte YA, Ferreira Santos JL, Wong R, Lebrão ML. Sarcopenia according to the European Working Group on Sarcopenia in Older People (EWGSOP) versus dynapenia as a risk factor for disability in the elderly. J Nutr Health Aging 2014;18:547-53. Crossref

12. Janssen I, Shepard DS, Katzmarzyk PT, Roubenoff R. The healthcare costs of sarcopenia in the United States. J Am Geriatr Soc 2004;52:80-5. Crossref

13. Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc 2002;50:889-96. Crossref

14. Heymsfield SB, Gallagher D, Visser M, Nuñez C, Wang ZM. Measurement of skeletal muscle: laboratory and epidemiological methods. J Gerontol A Biol Sci Med Sci 1995;50 Spec No:23-9.

15. Baumgartner RN, Rhyne RL, Troup C, Wayne S, Garry PJ. Appendicular skeletal muscle areas assessed by magnetic resonance imaging in older persons. J Gerontol 1992;47:M67-72. Crossref

16. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412-23. Crossref

17. Paillaud E, Bories PN, Le Parco JC, Campillo B. Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up. Br J Nutr 2000;83:97-103.

18. Wyers CE, Breedveld-Peters JJ, Reijven PL, et al. Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial. BMC Public Health 2010;10:212. Crossref

19. Volkert D, Berner YN, Berry E, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006;25:330-60. Crossref

20. Masanes F, Culla A, Navarro-Gonzalez M, et al. Prevalence of sarcopenia in healthy community-dwelling elderly in an urban area of Barcelona (Spain). J Nutr Health Aging 2012;16:184-7. Crossref

21. Paddon-Jones D, Rasmussen BB. Dietary protein recommendations and the prevention of sarcopenia. Curr Opin Clin Nutr Metab Care 2009;12:86-90. Crossref

22. Morley JE. Sarcopenia: diagnosis and treatment. J Nutr Health Aging 2008;12:452-6. Crossref

23. Dawson-Hughes B. Serum 25-hydroxyvitamin D and functional outcomes in the elderly. Am J Clin Nutr 2008;88:537S-540S.

24. Harber MP, Konopka AR, Douglass MD, et al. Aerobic exercise training improves whole muscle and single myofiber size and function in older women. Am J Physiol Regul Integr Comp Physiol 2009;297:R1452-9. Crossref

25. Kim HK, Suzuki T, Saito K, et al. Effect of exercise and amino acid supplementation on body composition and physical function in community-dwelling elderly Japanese sarcopenic women: a randomized controlled trial. J Am Geriatr Soc 2012;60:16-23. Crossref

26. Waters DL, Baumgartner RN, Garry PJ, Vellas B. Advantages of dietary, exercise-related, and therapeutic interventions to prevent and treat sarcopenia in adult patients: an update. Clin Interv Aging 2010;5:259-70. Crossref

27. McCartney N, Hicks AL, Martin J, Webber CE. Long-term resistance training in the elderly: effects on dynamic strength, exercise capacity, muscle, and bone. J Gerontol A Biol Sci Med Sci 1995;50:B97-104. Crossref

28. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009;(3):CD002759. Crossref

29. Lee WJ, Liu LK, Peng LN, Lin MH, Chen LK; ILAS Research Group. Comparisons of sarcopenia defined by IWGS and EWGSOP criteria among older people: results from the I-Lan longitudinal aging study. J Am Med Dir Assoc 2013;14:528.e1-7. Crossref

30. Hida T, Ishiguro N, Shimokata H, et al. High prevalence of sarcopenia and reduced leg muscle mass in Japanese patients immediately after a hip fracture. Geriatr Gerontol Int 2013;13:413-20. Crossref

31. Chen LK, Liu LK, Assantachai P, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc 2014;15:95-101. Crossref

32. Di Monaco M, Castiglioni C, Vallero F, Di Monaco R, Tappero R. Sarcopenia is more prevalent in men than in women after hip fracture: a cross-sectional study of 591 inpatients. Arch Gerontol Geriatr 2012;55:e48-52. Crossref

33. Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 1998;147:755-63. Crossref

34. D’Adamo CR, Hawkes WG, Miller RR, et al. Short-term changes in body composition after surgical repair of hip fracture. Age Ageing 2014;43:275-80. Crossref

Arthritis is a common clinical condition and its prevalence is increasing worldwide.1 2 3 4 More than 20% of the United States population suffer from arthritis, and it is estimated that one in four may develop symptomatic hip osteoarthritis in their lifetime.1 5 It is an important clinical problem and a major burden on the health care system. Total hip replacement (THR) significantly improves quality of life and functional disability.6 7 8 The number of THR surgeries has been increasing all around the world over the past 10 years.9 10 11 12

Osteoarthritis is the most common indication for THR in Caucasian populations. According to the Annual Report 2013 of the National Joint Registry for England, Wales and Northern Ireland, osteoarthritis was the most common cause of primary THR across all age-groups, accounting for more than 90% of those aged 50 years and above.10 Overall, 79.2% of primary THRs from 1992 to 2011 in the Swedish population were due to primary osteoarthritis, with a decreasing trend observed in THR for inflammatory arthritis.11 As the prevalence of hip osteoarthritis is lower in Asians,13 the disease pattern for THR would also be expected to differ. A review of primary total hip arthroplasty (THA) in the Hong Kong Chinese population from 1972 to 1997 showed that osteonecrosis was the most common cause, accounting for 45.6% of cases, while primary osteoarthritis contributed to 10.2% only.14 Singh et al15 found that in Singapore, 42% of THRs from 2004 to 2006 were due to osteonecrosis. There are no other recent updates, however.

In view of our ageing population and rising number of primary THRs, study of the epidemiology in our locality is important to further plan and budget our health care resources. This study reviewed the demographics and disease spectrum leading to primary THR in the Chinese population from 1998 to 2010, and attempted to identify any changes since 1997.

All patients who underwent primary THR at Queen Mary Hospital (QMH), a university teaching hospital in Hong Kong, from January 1998 to December 2010 were reviewed. Diagnosis was made according to clinical, radiological, and intra-operative findings and entered by the surgeon. Non-Chinese patients were excluded from further analysis. Patients’ age and sex, diagnosis, preoperative and latest Harris Hip Scores16 at follow-up were analysed. All patients had clinical follow-up for at least 2 years. The causes of THR were then compared with the data from 1972 to 1997.14 Chi squared test and Student’s t test were used for statistical analysis.

A total of 512 THR surgeries were performed on 419 Chinese patients at QMH from January 1998 to December 2010. Of the cases, 43.4% were males and 48.4% were left hips. The mean (± standard deviation) age at the time of operation was 57.6 ± 16.6 years. The mean Harris Hip Score at the last follow-up increased significantly compared with that preoperatively (89.7 ± 13.0 vs 43.9 ± 18.3; paired t test, P<0.05) [Table 1].

Osteonecrosis was the most common cause of primary THR in both males and females in our study population, accounting for 50.9% and 33.0%, respectively. The second most common cause was ankylosing spondylitis in males (19.5%) and osteoarthritis in females (18.8%). Post-traumatic arthritis was the third most common cause in both males (8.5%) and females (15.8%). Rheumatoid arthritis accounted for 2.5% of primary THRs in males and 9.4% in females. Dysplasia contributed to 4.1% and 8.0% of primary THRs in males and females, respectively (Table 2).

The underlying causes of osteonecrosis in females and males were further analysed. The cause of osteonecrosis was entered by the operating surgeon based on medical records, as well as clinical, radiological, and intra-operative findings. The most common cause of osteonecrosis was alcoholism in males (52.5%) and idiopathic osteonecrosis in females (40.7%). Steroid-induced and idiopathic osteonecrosis was the second and third most common causes in males, accounting for 26.7% and 15.0%, respectively. In females, steroid-induced and post-traumatic osteonecrosis was the second and third most common causes, accounting for 29.7% and 23.1%, respectively (Table 3).

Our data were compared with the results from a previous study from 1972 to 1997 of primary THR in the Chinese patients.14 We concluded that osteonecrosis remains the most common cause of primary THR in the Chinese population. Other common causes, such as post-traumatic arthritis, ankylosing spondylitis and osteoarthritis, showed no statistically significant changes. The percentage of primary THR in the Chinese population due to rheumatoid arthritis, however, has increased significantly from 3.3% to 6.3% (P=0.025; Table 414).

Total hip replacement is a well-established surgical procedure for end-stage arthritis. The number of THR surgeries is increasing worldwide in parallel with the rising number of patients with advanced arthritis. This will place a huge socio-economic burden on our health care system in the future. Study of the epidemiology and diseases underlying the need for THR might help reduce the number of patients who progress to advanced arthritis, and in so doing, reduce the burden on our health care system. In our local community, osteonecrosis was the most common cause of primary THA from 1972 to 2010.14 Alcoholism was the most common underlying aetiology of osteonecrosis in men, accounting for more than 50% of cases. It is evident that alcoholism remains a major social and health issue in Hong Kong. The World Health Organization defines alcoholism as chronic and continual drinking or periodic consumption of alcohol, characterised by impaired self-control, frequent intoxication, and use of alcohol despite adverse consequences. There is no exact alcohol level that defines alcoholism. Alcoholism was identified as the cause of osteonecrosis in our studied patients according to the clinical context and patient’s social history. The importance of alcoholism in Hong Kong is further echoed by a publication by the Department of Health stating that alcohol consumption per capita has risen from 2004 to 2010.17 The prevalence of adult and underage drinking also increased between 2005 and 2010.17 More than 15% of drinkers in Hong Kong drank beyond the recommended daily limit in 2010.17 Local and global strategies are needed to tackle alcoholism and its associated health problems.

Although alcohol is a well-known risk factor for development of osteonecrosis, the pathogenesis and dose-response relationship are less established. Pathological studies in rabbits show that marrow fat cell hypertrophy and proliferation, thinning of trabecular, and increased empty osteocyte lacunae are observed in alcohol-induced osteonecrosis.18 Previous studies proposed that the alcohol exposure threshold for osteonecrosis in humans is 150 L of 100% ethanol, consumed at a rate of 400 mL of absolute ethanol weekly.19 20 More studies, however, are needed to understand the dose and duration effect of alcohol-induced osteonecrosis.

The Swedish Hip Arthroplasty Register, one of the earliest registries, is an excellent resource to study the demographic pattern of joint replacement in Caucasians. According to their Annual Report 2011, the number of primary THRs steadily increased from 14 312 in 2007 to 15 945 in 2011.11 Primary osteoarthritis of the hip has been the most common cause of THA in Sweden for more than 20 years, accounting for 83% in 2011, while idiopathic osteonecrosis only contributed to 3.2% in 2011.11 On the contrary, our study showed that osteonecrosis is the most common cause of THR in the Chinese population and osteoarthritis accounts for only 12.5%. Such discrepancy is also observed in other studies in Asian populations. A recent publication in India found that osteonecrosis was the most common indication for THR, accounting for 49% of those performed from 2006 to 2012.21 In Singapore, 42% of THRs were due to osteonecrosis from 2004 to 2006.15 Although the exact underlying mechanism is unclear, the prevalence of hip osteoarthritis has been shown to be lower in Orientals than Caucasians.13

The proportion of primary THR performed in Sweden for inflammatory arthritis decreased over a period of 5 years, from 2.08% in 2007 to 1.51% in 2011.11 In the Hong Kong population, however, the proportion of THR performed for rheumatoid arthritis increased between 1972-1997 and 1998-2010. We postulate that such discrepancy is due to our delay in adopting an early strict treatment strategy for rheumatoid arthritis. It has been shown by various studies that joint destruction occurs early in the course of rheumatoid arthritis.22 23 24 Early disease control is essential to prevent joint destruction and hence, need for joint replacement surgery. Such a concept had been incorporated in the European League Against Rheumatism treatment guideline of 2007.22 Despite this, it is only recently that the Hong Kong Society of Rheumatology has modified the local treatment guidelines on rheumatoid arthritis.25 Future epidemiological study might be needed to observe any changes in primary THR requirement for rheumatoid patients.

In this study, the disease leading to THR was entered by the operating surgeon based on clinical, radiological, and intra-operative assessments. Nonetheless, the underlying aetiology is sometimes difficult to determine in patients with end-stage arthritis and those with multiple risk factors. This causes possible information bias, and is a limitation of this study.

All data within the study period were pooled for analysis. Hence, any significant changes within the period from 1998 to 2010 might have been missed. In addition, data from this study were limited to a regional hospital in Hong Kong and generalisation of the results to the present Chinese population might not be accurate. A total of 15 hospitals were performing THR within the study period, and QMH accounted for 15% of surgeries. As a university teaching hospital, QMH also serves as a tertiary and quaternary referral centre in Hong Kong, and may therefore encounter a different disease spectrum compared with peripheral hospitals in Hong Kong. We believe a territory or nationwide joint registry, such as the Swedish Hip Arthroplasty Register or National Joint Registry (for England, Wales, Northern Ireland), is needed for more representative results. In view of the rising number of patients who suffer from advanced arthritis and hence, the rising number of joint replacement surgeries, the setting up of a joint registry is important for further research and budgeting of our health care resources.

1. Centers for Disease Control and Prevention (CDC). Prevalence of doctor-diagnosed arthritis-attributable activity limitation—United states, 2003-2005. MMWR Morb Mortal Wkly Rep 2006;55:1089-92.

2. Centers for Disease Control and Prevention (CDC). Prevalence of disabilities and associated health conditions among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:120-5.

3. Stoddard S, Jans L, Ripple J, Kraus L. Chartbook on work and disability in the United States, 1998: an InfoUse report. Washington DC: US National Institute on Disability and Rehabilitation Research; 1998.

4. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum 2006;54:226-9. Crossref

5. Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic hip osteoarthritis in his or her lifetime. Osteoarthritis Cartilage 2010;18:1372-9. Crossref

6. Ibrahim SA. Racial variations in the utilization of knee and hip joint replacement: an introduction and review of the most recent literature. Curr Orthop Pract 2010;21:126-31. Crossref

7. Chang RW, Pellisier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA 1996;275:858-65. Crossref

8. Emejuaiwe N, Jones AC, Ibrahim SA, Kwoh CK. Disparities in joint replacement utilization: a quality of care issue. Clin Exp Rheumatol 2007;25(6 Suppl 47):44-9.

9. Singh JA, Vessely MB, Harmsen WS, et al. A population-based study of trends in the use of total hip and total knee arthroplasty, 1969-2008. Mayo Clinic Proc 2010;85:898-904. Crossref

10. National Joint Registry for England, Wales and Northern Ireland 10th Annual Report; 2013.

11. The Swedish Hip Arthroplasty Register Annual Report 2011; 2012.

12. Lai YS, Wei HW, Cheng CK. Incidence of hip replacement among national health insurance enrollees in Taiwan. J Orthop Surg Res 2008;3:42. Crossref

13. Lau EM, Symmons DP, Croft P. The epidemiology of hip osteoarthritis and rheumatoid arthritis in the Orient. Clin Orthop Relat Res 1996;(323):81-90. Crossref

14. Chiu KY, Ng TP, Poon KC, Ho WY, Yau WP. Primary total hip replacement in Hong Kong Chinese—a review of 647 hips. Hong Kong J Orthop Surg 1998;2:114-9.

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16. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737-55.

17. Alcohol and health: Hong Kong situation. Hong Kong SAR: Department of Health. Available from: http://www.dh.gov.hk/english/pub_rec/pub_rec_ar/pdf/ncd_ap2/action_plan_2_alcohol%20and%20health%20HK%20situation_e.pdf. Accessed Sep 2015.

18. Wang Y, Yin L, Li Y, Liu P, Cui Q. Preventive effects of puerarin on alcohol-induced osteonecrosis. Clin Orthop Related Res 2008;466:1059-67. Crossref

19. Cruess RL. Osteonecrosis of bone. Current concepts as to etiology and pathogenesis. Clin Orthop Related Res 1986;(208):30-9.

20. Jones JP Jr. Concepts of etiology and early pathogenesis of osteonecrosis. Instr Course Lect 1994;43:499-512.

21. Pachore JA, Vaidya SV, Thakkar CJ, Bhalodia HK, Wakankar HM. ISHKS joint registry: A preliminary report. Indian J Ortho 2013;47:505-9. Crossref

22. Combe B, Landewe R, Lukas C, et al. EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007;66:34-45. Crossref

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Osteoporosis is a major health problem in the elderly causing significant morbidity, mortality, and socio-economic burden. Women are more vulnerable to osteoporosis than men because they have smaller and thinner bones. In addition, the sudden drop in ovarian oestrogen production around menopause causes women to lose bone rapidly. Accelerated bone loss begins about 2 to 3 years before the last menses and continues until 3 to 4 years after menopause. There is 2% bone loss annually around menopause, slowing to 1% to 1.5% annually thereafter.1 2 Bone mineral density (BMD) measurement by central dual-energy X-ray absorptiometry (DXA) is the gold standard for diagnosing osteoporosis. Bone mineral density is compared with the mean peak BMD for young adults of the same sex and ethnicity to calculate a T-score. The World Health Organization (WHO) defines osteoporosis as a BMD 2.5 standard deviations (SDs) below that of young-adult BMD and osteopenia as a BMD 1.0 to 2.5 SD below.3 A meta-analysis of prospective and case-control studies of BMD and fracture risk showed that the predictive value of BMD for fracture is at least as good as that of blood pressure for stroke.4 In a recent prospective study of postmenopausal Chinese women, the relative risk of fracture increased 2-fold (95% confidence interval [CI], 1.6-2.5) for each decrease in SD of mean femoral-neck BMD.5

With urbanisation and adoption of a more sedentary lifestyle, the age-specific incidence of hip fracture in Hong Kong women increased by 300% between 1966 and 1985.6 The incidence levelled off between 1985 and 1995.7 Between 1995 and 2004, the incidence declined by 50% in those aged 50 to 59 years but remained stable for other age-groups.8 Although the age-specific incidence rates stabilise, the absolute number of hip fractures will continue to increase because of the ageing population. It has been estimated that in Hong Kong, 5293 women will have a hip fracture in the year 2015.9 The local prevalence of vertebral fracture in women has been estimated to be 30%.10 Osteoporotic fractures increase the morbidity and mortality of individuals and are a considerable burden on the health-care system. After the first fracture, the risk of subsequent fracture of an individual is 2.2 times higher than that of an individual without a prior fragility fracture (95% CI, 1.9-2.6).11 Primary care physicians play a pivotal role in preventing this fracture cascade in postmenopausal women. They can help postmenopausal women improve bone health by encouraging them to adopt primary prevention strategies for osteoporosis and fall that may cause fracture; increasing their awareness of their personal risk for osteoporosis and taking action to minimise those risks; providing DXA assessment when indicated; and treating women who are diagnosed with osteoporosis.12 Pharmacological treatment can reduce the risk of osteoporotic fractures by 30% to 70%. Treatment failure is partly due to poor drug compliance with treatment. In a systematic review of osteoporosis treatment with bisphosphonates, the yearly drug compliance rate was only 42.5% to 54.8%.13

The objectives of this study were to evaluate the prevalence of osteoporosis in treatment-naïve postmenopausal Chinese women, and determine the risk factors associated with osteoporosis and treatment compliance in those diagnosed with osteoporosis. These results will help physicians understand the bone health status of postmenopausal Chinese women.

Postmenopausal women who attend the Women’s Health Service in Hong Kong for menopause assessment are offered DXA testing of the spine and hip. Since a charge is made for the test, it is not universally accepted. The number of women who refused DXA was not captured. Prior to undergoing DXA, women completed a checklist of risk factors that included a history of parental osteoporosis or hip fracture, personal low trauma fracture, smoking habit, drinking habit, calcium intake, exercise habit, sun exposure, use of medication or presence of disease that causes bone loss, number of falls in the past 12 months, previous use of hormone replacement therapy, previous use of osteoporosis drugs, and current osteoporosis treatment. The BMD at the postero-anterior lumbar spine (L1-L4) and left femur (total hip, trochanter, Ward’s triangle, and femoral neck) was measured using a Hologic QDR4000 machine (Hologic Inc, Bedford [MA], US) and performed by a single operator. The DXA report provided data on age, menopause age, body mass index (BMI), BMD, T-score, and Z-score. The checklist and DXA report were filed together by date.

This analysis was conducted by searching through paper records completed between January 2008 and December 2011. The research protocol was approved by the Ethics Panel of the Family Planning Association of Hong Kong. Non-Chinese women and those previously or currently prescribed hormone replacement therapy or osteoporosis treatment were excluded. The computerised consultation records of those with osteoporosis were searched to obtain treatment history. Our clinic only provides oral osteoporotic drugs (raloxifene, weekly alendronate, monthly ibandronate and strontium ranelate). The treatment plan, risks, and benefits of each drug, specific prescription required of each drug, and contra-indications are discussed with the patient before deciding the drug therapy. Patients are involved in decision making and must pay for treatment.

Descriptive statistics for basic demographic factors, risk factors for osteoporosis, T-score distribution, and treatment adherence were presented. Women were categorised into three subgroups according to their T-score and based on WHO recommendations3: normal BMD (T-score ≥-1.0 at either the hip or spine), osteopenia (T-score between <-1.0 and -2.5), and osteoporosis (T-score <-2.5). The Chi squared test was used to test for a significant association between categorical risk factors and osteoporosis. Stepwise binomial logistic regression analysis using factors found to have a significant correlation with BMD of T-score of <-2.5 was performed to identify risk factors that best predict osteoporosis. Analysis of variance was used to analyse the difference between group means. Level of significance was set at alpha = 0.05 for the two-tailed tests. Data analyses were performed using the Statistical Package for the Social Sciences (version 23.0; IBM, New York, US).

Between January 2008 and December 2011, 1507 DXA scans were performed for eligible women. Their mean (± SD) age was 58.2 ± 6.4 years and the mean age at menopause was 49.9 ± 4.0 years. The median duration of menopause (years from menopause to date of DXA) was 7 years (interquartile range, 3-11 years). The number of women with risk factors for osteoporosis in the whole group and subgroups are listed in Table 1. Only 1% of participants were unable to recall whether or not there was a parental history of osteoporosis or hip fracture.

Osteoporosis was diagnosed in 25.7% of women and osteopenia in 51.6%. The mean age of women with normal BMD, osteopenia, and osteoporosis was 57.0 ± 5.6 years, 58.0 ± 6.4 years, and 59.7 ± 6.8 years, respectively (P<0.001). The mean age at menopause for each subgroup was the same: 50.0 years (P=0.441). Apart from age, BMI of <18.5 kg/m² (P<0.001), duration of menopause (P<0.001), parental history of osteoporosis or hip fracture (P=0.024), and not doing 20 minutes of weight-bearing exercise daily (P=0.033) were significant risk factors for osteoporosis. Although smoking is a significant risk factor for low bone mass, there were too few smokers in this group to make any meaningful comparison. The other risk factors did not show a significant association with osteoporosis (Table 1). The proportion of women who had risk factors and who had spine osteoporosis and hip osteoporosis is listed in Table 2. The results of the stepwise logistic regression analysis are shown in Table 3—only older age, low BMI, longer duration of menopause, and parental history remained significant.

Among the 387 women with osteoporosis, 166 (42.9%) refused treatment because they feared of the side-effects of drugs, 119 (30.7%) complied with the treatment provided, 45 (11.6%) discontinued treatment due to side-effects or worry about side-effects, and 57 (14.7%) has defaulted from follow-up by March 2015. The common side-effects that concerned patients included hot flushes with raloxifene, gastric and musculoskeletal pain with bisphosphonates, and loose stools and diarrhoea with strontium ranelate. For major adverse events, patients were concerned about atypical fracture and osteonecrosis of the jaw with bisphosphonates and increased cardiac risk with strontium ranelate. Among the 119 women who complied with treatment, 20 were still on treatment in March 2015 and 99 were taking a drug holiday after 2 to 6 years’ treatment that brought BMD to the osteopenic range. Those who refused treatment were significantly older with a mean age of 61.2 ± 7.8 years (P<0.001).