Locking plate fixation in proximal humeral fractures has demonstrated good results tempered by a significant rate of loss of fixation. Reported rates of failure are typically around 10% of cases but can be 20% or higher. In addition large series are often made up of a diverse patient population, so we have chosen to focus solely on patients confirmed to have significantly reduced BMD who can be considered a subset at high risk of fixation failure. Twenty-three patients (5 male, 18 female) with a proximal humeral fracture treated by locking plate fixation were confirmed on DEXA scanning to be osteopaenic (17), osteoporotic (4) or severely osteoporotic (2). Patients early in the series were reviewed retrospectively and recalled for an updated assessment where appropriate, and the remainder were followed prospectively. The average age was 66 years (range 49 to 82). Follow up was for an average of nine months following surgery (range 2 and a half to 28 months). 17 patients underwent surgery for acute injuries and 6 for established surgical neck non-unions. Seven injuries were 2-part fractures, 12 3-part, 3 were 4-part and one a 2-part surgical neck non-union.1 plate failed due to complete loss of fixation within 2 months in a patient with severe osteoporosis and was treated with removal of metalwork. This was the only injury that failed to unite. Avascular necrosis occurred in three patients with two revised to a hemiarthroplasty. 1 patient had ongoing pain and underwent removal of the plate. Our series demonstrated that locking plate fixation of proximal humeral fractures is associated with a low rate of fixation failure and satisfactory outcomes in patients with significantly reduced bone mineral density

Treatment of simple and complex patella fractures represents a challenging clinical problem. Controversy exists regarding the most appropriate fixation method. Tension band wiring, aiming to convert the pulling forces on the anterior aspect of the patella into compression forces across the fracture site, is the standard of care, however, it is associated with high complication rates. Recently, anterior variable-angle locking plates have been developed for treatment of simple and comminuted patella fractures. The aim of this study was to investigate the biomechanical performance of the novel anterior variable-angle locking plates versus tension band wiring used for fixation of simple and complex patella fractures.

Sixteen pairs of human cadaveric knees were used to simulate either two-part transverse simple AO/OTA 34-C1 or five-part complex AO/OTA 34-C3 patella fractures by means of osteotomies, with each fracture model created in eight pairs. The complex fracture pattern was characterized with a medial and a lateral proximal fragment, together with an inferomedial, an inferolateral and an inferior fragment mimicking comminution around the distal patellar pole. The specimens with simple fractures were pairwise assigned for fixation with either tension band wiring through two parallel cannulated screws, or an anterior variable-angle locking core plate. The knees with complex fractures were pairwise treated with either tension band wiring through two parallel cannulated screws plus circumferential cerclage wiring, or an anterior variable-angle locking three-hole plate. Each specimen was tested over 5000 cycles by pulling on the quadriceps tendon, simulating active knee extension and passive knee flexion within the range from 90° flexion to full knee extension. Interfragmentary movements were captured by motion tracking.

For both fracture types, the articular displacements, measured between the proximal and distal fragments at the central aspect of the patella between 1000 and 5000 cycles, together with the relative rotations of these fragments around the mediolateral axis were all significantly smaller following the anterior variable-angle locked plating compared with the tension band wiring, p < 0.01

From a biomechanical perspective, anterior locked plating of both simple and complex patella fractures provides superior construct stability versus tension band wiring.

This study aims to compare the outcomes of Volar locking plating (VLP) versus percutaneous Kirschner wires (K-wire) fixation for surgical management of distal radius fractures.

We systematically searched multiple databases, including MEDLINE for randomized controlled trials (RCTs) comparing outcomes of VLP fixation and K-wire for treatment of distal radius fracture in adults. The methodological quality of each study was assessed by the Cochrane Risk of Bias tool. Patient-reported outcomes, functional outcomes, and complications at 1 year follow up were evaluated. Meta-analysis was performed using random-effects models and results presented as risk ratios (RRs) or mean differences (MDs) with 95% confidence interval (CI).

13 RCTs with 1336 participants met the inclusion criteria. Disabilities of the Arm, Shoulder and Hand (DASH) scores were significantly better for VLP fixation (MD= 2.15; 95% CI, 0.56-3.74; P = 0.01; I2=23%). No significant difference between the two procedures for grip strength measured in kilograms (MD= −3.84; 95% CI,-8.42-0.74; P = 0.10; I2=52%) and Patient-Rated Wrist Evaluation (PRWE) scores (MD= −0.06; 95% CI,-0.87-0.75; P = 0.89; I2=0%). K-wire treatment yielded significantly improved extension (MD= −4.30; P=0.04) but with no differences in flexion, pronation, supination, and radial deviation (P >0.05). The risk of complications and rate of reoperation were similar for the two procedures (P >0.05).

This meta-analysis suggests that VLP fixation improves DASH score at 12 months follow up, however, the difference is small and unlikely to be clinically important. Existing literature does not provide sufficient evidence to demonstrate the superiority of either VLP or K-wire treatment in terms of patient-reported outcomes, functional outcomes, and complications.

Treatment of both simple and complex patella fractures is a challenging clinical problem. The aim of this study was to investigate the biomechanical performance of recently developed lateral rim variable angle locking plates versus tension band wiring used for fixation of simple and complex patella fractures.

Twelve pairs of human anatomical knees were used to simulate either two-part transverse simple AO/OTA 34C1 or five-part complex AO/OTA 34C3 patella fractures by means of osteotomies, with each fracture model created in six pairs. The complex fracture pattern was characterized by a medial and a lateral proximal fragment, together with an inferomedial, an inferolateral, and an inferior fragment mimicking comminution around the distal patellar pole. The specimens with simple fractures were pairwise assigned for fixation with either tension band wiring through two parallel cannulated screws, or a lateral rim variable angle locking plate. The knees with complex fractures were pairwise treated with either tension band wiring through two parallel cannulated screws plus circumferential cerclage wiring, or a lateral rim variable angle locking plate.

Each specimen was tested over 5000 cycles by pulling on the quadriceps tendon, simulating active knee extension and passive knee flexion within the range of 90° flexion to full knee extension. Interfragmentary movements were captured via motion tracking.

For both fracture types, the longitudinal and shear articular displacements measured between the proximal and distal fragments at the central patella aspect between 1000 and 5000 cycles, together with the relative rotations of these fragments around the mediolateral axis were all significantly smaller following the lateral rim variable angle locked plating compared with tension band wiring, p<0.01.

Lateral rim locked plating of both simple and complex patella fractures provides superior construct stability versus tension band wiring under dynamic loading.

Proximal humerus fractures (PHF) are the third most common fractures in the elderly. Treatment of complex PHF has remained challenging with mechanical failure rates ranging up to 35% even when state-of-the-art locked plates are used. Secondary (post-operative) screw perforation through the articular surface of the humeral head is the most frequent mechanical failure mode, with rates up to 23%. Besides other known risk factors, such as non-anatomical reduction and lack of medial cortical support, in-adverse intraoperative perforation of the articular surfaces during pilot hole drilling (overdrilling) may increase the risk of secondary screw perforation. Overdrilling often occurs during surgical treatment of osteoporotic PHF due to minimal tactile feedback; however, the awareness in the surgical community is low and the consequences on the fixation stability have remained unproved. Therefore, the aim of this study was to evaluate biomechanically whether overdrilling would increase the risk of cyclic screw perforation failure in unstable PHF.

A highly unstable malreduced 3-part fracture was simulated by osteotomizing 9 pairs of fresh-frozen human cadaveric proximal humeri from elderly donors (73.7 ± 13.0 ys, f/m: 3/6). The fragments were fixed with a locking plate (PHILOS, DePuy Synthes, Switzerland) using six proximal screws, with their lengths selected to ensure 6 mm tip-to-joint distance. The pairs were randomized into two treatment groups, one with all pilot holes accurately predrilled (APD) and another one with the boreholes of the two calcar screws overdrilled (COD). The constructs were tested under progressively increasing cyclic loading to failure at 4 Hz using a previously developed setup and protocol. Starting from 50 N, the peak load was increased by 0.05 N/cycle. The event of initial screw loosening was defined by the abrupt increase of the displacement at valley load, following its initial linear behavior. Perforation failure was defined by the first screw penetrating the joint surface, touching the artificial glenoid component and stopping the test via electrical contact.

Bone mineral density (range: 63.8 – 196.2 mgHA/cm3) was not significantly different between the groups. Initial screw loosening occurred at a significantly lower number of cycles in the COD group (10,310 ± 3,575) compared to the APD group (12,409 ± 4,569), p = 0.006. Number of cycles to screw perforation was significantly lower for the COD versus APD specimens (20,173 ± 5,851 and 24,311 ± 6,318, respectively), p = 0.019. Failure mode was varus collapse combined with lateral-inferior translation of the humeral head. The first screw perforating the articular surface was one of the calcar screws in all but one specimen.

Besides risk factors such as fracture complexity and osteoporosis, inadequate surgical technique is a crucial contributor to high failure rates in locked plating of complex PHF. This study shows for the first time that overdrilling of pilot holes can significantly increase the risk of secondary screw perforation. Study limitations include the fracture model and loading method. While the findings require clinical corroboration, raising the awareness of the surgical community towards this largely neglected risk source, together with development of devices to avoid overdrilling, are expected to help improve the treatment outcomes.

Treatment of comminuted intraarticular calcaneal fractures remains controversial and challenging. Anatomic reduction with stable fixation has demonstrated better outcomes than nonoperative treatment of displaced intraarticular fractures involving the posterior facet and anterior calcaneocuboid joint (CCJ) articulating surface of the calcaneus. The aim of this study was to investigate the biomechanical performance of three different methods for fixation of comminuted intraarticular calcaneal fractures.

Comminuted calcaneal fractures, including Sanders III-AB fracture of the posterior facet and Kinner II-B fracture of the CCJ articulating calcaneal surface, were simulated in 18 fresh-frozen human cadaveric lower legs by means of osteotomies. The ankle joint, medial soft tissues and midtarsal bones along with the ligaments were preserved. The specimens were randomized according to their bone mineral density to 3 groups for fixation with either (1) 2.7 mm variable-angle locking anterolateral calcaneal plate in combination with one 4.5 mm and one 6.5 mm cannulated screw (Group 1), (2) 2.7 mm variable-angle locking lateral calcaneal plate (Group 2), or (3) interlocking calcaneal nail with 3.5 mm screws in combination with 3 separate 4.0 mm cannulated screws (Group 3). All specimens were biomechanically tested until failure under axial loading with the foot in simulated midstance position. Each test commenced with an initial quasi-static compression ramp from 50 N to 200 N, followed by progressively increasing cyclic loading at 2Hz. Starting from 200 N, the peak load of each cycle increased at a rate of 0.2 N/cycle. Interfragmentary movements were captured by means of optical motion tracking. In addition, mediolateral X-rays were taken every 250 cycles with a triggered C-arm. Varus deformation between the tuber calcanei and lateral calcaneal fragments, plantar gapping between the anterior process and tuber fragments, displacement at the plantar aspect of the CCJ articular calcaneal surface, and Böhler angle were evaluated.

Varus deformation of 10° was reached at significantly lower number of cycles in Group 2 compared to Group 1 and Group 3 (P ≤ 0.017). Both cycles to 10° plantar gapping and 2 mm displacement at the CCJ articular calcaneal surface revealed no significant differences between the groups (P ≥ 0.773). Böhler angle after 5000 cycles (1200 N peak load) had significantly bigger decrease in Group 2 compared to both other groups (P ≤ 0.020).

From biomechanical perspective, treatment of comminuted intraarticular calcaneal fractures using variable-angle locked plate with additional longitudinal screws or interlocked nail in combination with separate transversal screws seems to provide superior stability as opposed to variable-angle locked plating only.

Introduction

Being challenging, multifragmentary proximal tibial fractures in patients with severe soft tissue injuries and/or short stature can be treated using externalized locked plating. A recent finite element study, investigating the fixation stability of plated unstable tibial fractures with 2-mm, 22-mm and 32-mm plate elevation under partial and full weight-bearing, reported that from a virtual biomechanical point of view, externalized plating seems to provide appropriate relative stability for secondary bone healing under partial weight-bearing during the early postoperative phase. The aim of the current study was to evaluate the clinical outcomes of using a LISS plate as a definitive external fixator for the treatment of multifragmentary proximal tibial fractures.

Introduction

The incidence of distal femoral fractures in the geriatric population is growing and represents the second most common insufficiency fracture of the femur following fractures around the hip joint. Fixation of fractures in patients with poor bone stock and early mobilisation in feeble and polymorbide patients is challenging. Development of a fixation approach for augmentation of conventional LISS (less invasive stabilization system) plating may result in superior long-term clinical outcomes and enhance safe weight bearing.

Purpose of the study: We report our experience with the LCP DRP 2.4 plate with a locking screw for the treatment of distal factures of the radius.

Material and methods: Between 2003 and June 2004, 67 displaced fractures of the distal radius were treated with a LCP DRP 2.4 system. Patients were subsequently immobilized in a removable anatomic orthesis for three weeks. The Fernandez, Castaign and AO classifications were used. Clinical evaluation was based on the DASH test, the Green and O’Brien score and the PWRE.

Results: Clinical assessment was available for 59 patients who also responded to the questionnaires. Mean follow-up was eight months. Healing was achieved in six weeks. There were no cases of secondary displacement nor of lost reduction. The mean Green and O’Brien assessment was 85% good and very good outcome, the mean DASH score was 20.6 and the mean PWRE was 32.8.

Discussion: Appropriate fixation for fractures of the distal radius remains a controversial issue, as illustrated by the variety of treatments used, the different materials proposed for fixation, and the large number of publications. The primary stability achieved with the locking screw in the LCP plate enables early rehabilitation. The absence of secondary displacement, irrespective of the quality of the bone, enables equivalent results in osteoporotic patients as in younger patients. No other material has enabled equivalent results to date. This is a major advance in osteosynthesis.

Periarticular metastasis may be treated with endoprosthetic reconstruction. The extensive surgery required may not, however, be appropriate for all patients. Our aim was to establish if the outcome of locking plate fixation in selected patients with periarticular metastases.

Prospective data collection was performed. Twenty one patients underwent surgery for periarticular metastatic tumours. The median duration of follow-up for surviving patients was one year. There have been no cases of implant failure and no requirement for revision surgery. Pain relief was excellent or good in the majority of patients. Patients who had sustained a fracture prior to fixation had restoration of their WHO performance status. All patients had a dramatic improvement in their MSTS scores. The median pre-operative score was 15% (0%-37%) improving to a median score of 80% (75% -96%) post operatively.

Locking plates provide reliable fixation and excellent functional restoration in selected patients suffering from periarticular metastatic bone disease.

Objective: To evaluate the outcome of open reduction and internal fixation of displaced proximal humerus fractures using a new locking plate.

Design: Prospective.

Setting: Level I university center.

Patients: Twenty-eight women and 22 men (mean age, 62.9 ± 19.l years). Twenty-nine patients were 65 years of age or older (mean age, 76.8 years). Fractures were classified according to AO/OTA as 11-A2 (n=3), A3 (n=12), B1 (n=4), B2 (n=18), B3 (n=1), C1 (n=1), and C2 (n=11). Mean follow-up was 19.8 months (range, 12 to 39 months).

Intervention: Open reduction and internal fixation with a proximal humerus locking plate.

Main Outcome Measurements: Raw and adjusted (sex and age) Constant score.

Results: Forty patients were available for follow-up. The mean raw Constant score was 66.6 (adjusted, 82.0). In patients under 65, the raw Constant score was 78.2 (adjusted score, 86.7). In patients over 65, the raw Constant score was 56.1 (adjusted score, 77.8). An excellent or good result was found in 72.5% overall. There was no secondary loss of position or implant cut-out. Seven patients (17.5%) developed avascular necrosis (AVN), 6 in C2 fractures in the older group. Their mean adjusted score was 60.7, as compared to 86.6 ± in those without AVN (p = 0.001).

Conclusions: The outcome was equally good in the younger and older age groups of patients, except in those who developed avascular necrosis. While the latter might be due to the nature of the fracture, it is also possible that surgical technique plays a role.

Osteosynthesis of high-energy metaphyseal proximal tibia fractures is still challenging, especially in patients with severe soft tissue injuries and/or short stature. Although the use of external fixators is the traditional treatment of choice for open comminuted fractures, patients' acceptance is low due to the high profile and therefore the physical burden of the devices. Recently, clinical case reports have shown that supercutaneous locked plating used as definite external fixation could be an efficient alternative. Therefore, the aim of this study was to evaluate the effect of implant configuration on stability and interfragmentary motions of unstable proximal tibia fractures fixed by means of externalized locked plating. Based on a right tibia CT scan of a 48 years-old male donor, a finite element model of an unstable proximal tibia fracture was developed to compare the stability of one internal and two different externalized plate fixations. A 2-cm osteotomy gap, located 5 cm distally to the articular surface and replicating an AO/OTA 41-C2.2 fracture, was virtually fixed with a medial stainless steel LISS-DF plate. Three implant configurations (IC) with different plate elevations were modelled and virtually tested biomechanically: IC-1 with 2-mm elevation (internal locked plate fixation), IC-2 with 22-mm elevation (externalized locked plate fixation with thin soft tissue simulation) and IC-3 with 32-mm elevation (externalized locked plate fixation with thick soft tissue simulation). Axial loads of 25 kg (partial weightbearing) and 80 kg (full weightbearing) were applied to the proximal tibia end and distributed at a ratio of 80%/20% on the medial/lateral condyles. A hinge joint was simulated at the distal end of the tibia. Parameters of interest were construct stiffness, as well as interfragmentary motion and longitudinal strain at the most lateral aspect of the fracture. Construct stiffness was 655 N/mm (IC-1), 197 N/mm (IC-2) and 128 N/mm (IC-3). Interfragmentary motions under partial weightbearing were 0.31 mm (IC-1), 1.09 mm (IC-2) and 1.74 mm (IC-3), whereas under full weightbearing they were 0.97 mm (IC-1), 3.50 mm (IC-2) and 5.56 mm (IC-3). The corresponding longitudinal strains at the fracture site under partial weightbearing were 1.55% (IC-1), 5.45% (IC-2) and 8.70% (IC-3).

From virtual biomechanics point of view, externalized locked plating of unstable proximal tibia fractures with simulated thin and thick soft tissue environment seems to ensure favorable conditions for callus formation with longitudinal strains at the fracture site not exceeding 10%, thus providing appropriate relative stability for secondary bone healing under partial weightbearing during the early postoperative phase.

Purpose: Non-union and secondary reduction loss complicate open distal femur fractures with bone loss. We hypothesize that locking plates decrease subsequent bone grafting in these injuries, yet maintain alignment; immediate post-fixation radiographic features predict primary union.

Method: From 2001 to 2004 inclusive, 34 adults with 36 open AO/OTA C-type distal femur fractures were reviewed. All were treated with locking plates and 3-month minimum follow-up. Union required radiographic bridging callus on 2/4 cortices combined with lack of symptoms. Alignment was assessed on initial and united radiographs. Antibiotic beads within a metaphyseal defect defined clinically important bone loss.

Results: Eleven of 20 fractures with bone loss (55%) underwent staged bone grafting to achieve union, versus two of 16 fractures without bone loss (13%). The presence of antibiotic beads was significantly associated with staged bone grafting (p< 0.01). Of those with bone loss and staged grafting, three had posterior cortical bone loss, and only three had medial and posterior cortical bone loss, and five had segmental defects. Of nine fractures with bone loss not requiring grafting, all had radiographic posterior cortical contact; seven had radiographic medial cortical contact. Posterior (p< 0.001) and medial (p< 0.025) cortical continuity were associated with injuries not requiring bone graft. Thirty-four had accurate frontal plane reductions; thirty-five had accurate sagittal plane reductions. Complications included two non-unions, and one reduction loss.

Conclusion: Despite metaphyseal bone loss, locking plates obviate the need for routine bone grafting of some open distal femur fractures. Those with radiographic posterior cortical contact and/or medial cortical contact are strongly correlated with primary union.

Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes.

From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient axillary nerve palsy and deep infection. Both of these patients recovered with delayed union observed in the infection case (52 weeks). Time to union range was 8–52 weeks (mean 17.1).

The literature shows a high failure rate of up to 45% with intramedullary nail fixation and limited predominantly to 2 part fractures with risk of damage to the rotator cuff. This study shows a satisfactory union rate using the Philos of 90% with only 3 (15%) requiring further surgery for non-union, plate fracture and infection. 3 and 4 part fractures composed 65% of case load. Early results indicate satisfactory outcomes compared to current published literature.

Endoprosthetic replacement is often the preferred treatment for neoplastic lesions as internal fixation has been shown to have a high failure rate. Due to anatomical location, disease factors and patient factors internal fixation may be the treatment of choice. No reports exist in the literature regarding the use of locking plates in the management of neoplastic long bone lesions.

Data was collected prospectively on the first 10 patients who underwent locking plate fixation of neoplastic long bone lesions. Data was collected on the nature of the lesion, surgery performed, complications and outcome.

The patients mean age was 56.6 (15–88). Six lesions were metastatic, one haematological (myeloma) and 3 were primary bone lesions (lymphoma, Giant cell tumour, simple bone cyst). In nine cases a fracture through the lesion had occurred. Anatomical locations of the lesions were; proximal humerus (four), proximal tibia (three), distal femur (two) and distal tibia (one). Cement augmentation of significant bone defects was necessary in seven cases.

The mean hospital stay was 8 days (3–20). There were no inpatient complications. Five patients received adjuvant radiotherapy and one patient received neo-adjuvant radiotherapy to the lesion. There have been 3 deaths. All were due to metastatic disease and occurred between 6 and 12 months after surgery. The mean follow up in the surviving patients is currently 9 months (5–16). There have been no fixation related complications. Patients who had suffered a fracture had restoration of their WHO performance status. At last follow up the mean MSTS was 78% (57–90) for lower limb surgery and 70% (63–76) for upper limb surgery. These figures compare favourably with the results of endoprosthetic replacement.

The early results of locking plate fixation for neoplastic long bone lesions are excellent. Follow up continues to observe how these devices perform in the long term.

Objectives

We aimed to further evaluate the biomechanical characteristics of two locking screws versus three standard bicortical screws in synthetic models of normal and osteoporotic bone.

Introduction

Getting the distal locking screw lengths right in volar locking plate fixation of distal radius is crucial. Long screws can lead to extensor tendon ruptures whereas short screws can lead to failure of fixation, especially if there is dorsal comminution of the fracture. The aim of our study was to determine the distal radius anatomy in relation to sagittal lengths and distance between dorsal bone edge and extensor tendons based on MRI scan.

Controversy exists whether a single proximal lateral tibia (PLT) locked plate is adequate for bicondylar fractures and whether the use of integral raft screws makes the use of bone graft less important.

57 consecutive patients who underwent reconstruction with a locked PLT plate were retrospectively reviewed. Radiographs were examined for operative reduction and subsequent loss of reduction.

55 patients were followed-up for an average of 27 weeks. Fractures were divided into unicondylar (Group 1, n=33) and bicondylar (Group 2, n=22). Union occurred in all patients, with no revisions or removal of metalwork at final follow-up. In 50 patients (88%), the fracture was reduced to within 2mm of anatomical. Articular surface collapse of >2mm occurred in three patients. Nine patients underwent bone grafting with no difference in outcome. A supplementary medial plate was used in three patients with a separate posteromedial fragment.

Except for a separate posteromedial fragment, the use of a single locked PLT plate for bicondylar fractures allows union to occur without failure. With the use of integral raft screws, the need for bone graft is questionable. The short-term radiological results and complication rate of PLT locked plating is excellent.

Statement of Purpose

To compare the functional outcome of Distal Tibial Metaphyseal fracture treated with Circular frame compared vs. Locking Plate

Introduction

Several clinical and radiological studies have confirmed the benefits of using Volar Locking Plates (VLPs) to treat unstable distal radius fractures. The “theoretical” advantage of VLPs compared to standard plate fixation is that VLPs, through their design, intrinsically provide angular stability for most fracture configurations including comminuted fractures and, quite possibly, osteoporotic fractures. However few studies have compared the clinical results of patients of different ages who have been treated using VLPs.