Aims. In this study, we aimed to explore surgical variations in the Femoral Neck System (FNS) used for stable fixation of Pauwels type III femoral neck fractures. Methods. Finite element models were established with surgical variations in the distance between the implant tip and subchondral bone, the gap between the plate and lateral femoral cortex, and inferior implant positioning. The models were subjected to physiological load. Results. Under a load of single-leg stance, Pauwels type III femoral neck fractures fixed with 10 mm shorter bolts revealed a 7% increase of the interfragmentary gap. The interfragmentary sliding, compressive, and shear stress remained similar to models with bolt tips positioned close to the subchondral bone. Inferior positioning of FNS provided a similar interfragmentary distance, but with 6% increase of the interfragmentary sliding distance compared to central positioning of bolts. Inferior positioning resulted in a one-third increase in interfragmentary compressive and shear stress. A 5 mm gap placed between the diaphysis and plate provided stability comparable to standard fixation, with a 7% decrease of interfragmentary gap and sliding distance, but similar compressive and shear stress. Conclusion. Finite element analysis with FNS on Pauwels type III femoral neck fractures revealed that placement of the bolt tip close to subchondral bone provides increased stability. Inferior positioning of FNS bolt increased interfragmentary sliding distance, compressive, and shear stress. The comparable stability of the fixation model with the standard model suggests that a 5 mm gap placed between the plate and diaphysis could viably adjust the depth of the bolt. Cite this article: Bone Joint Res 2022;11(2):102–111

Aims. Distal femoral resection in conventional total knee arthroplasty (TKA) utilizes an intramedullary guide to determine coronal alignment, commonly planned for 5° of valgus. However, a standard 5° resection angle may contribute to malalignment in patients with variability in the femoral anatomical and mechanical axis angle. The purpose of the study was to leverage deep learning (DL) to measure the femoral mechanical-anatomical axis angle (FMAA) in a heterogeneous cohort. Methods. Patients with full-limb radiographs from the Osteoarthritis Initiative were included. A DL workflow was created to measure the FMAA and validated against human measurements. To reflect potential intramedullary guide placement during manual TKA, two different FMAAs were calculated either using a line approximating the entire diaphyseal shaft, and a line connecting the apex of the femoral intercondylar sulcus to the centre of the diaphysis. The proportion of FMAAs outside a range of 5.0° (SD 2.0°) was calculated for both definitions, and FMAA was compared using univariate analyses across sex, BMI, knee alignment, and femur length. Results. The algorithm measured 1,078 radiographs at a rate of 12.6 s/image (2,156 unique measurements in 3.8 hours). There was no significant difference or bias between reader and algorithm measurements for the FMAA (p = 0.130 to 0.563). The FMAA was 6.3° (SD 1.0°; 25% outside range of 5.0° (SD 2.0°)) using definition one and 4.6° (SD 1.3°; 13% outside range of 5.0° (SD 2.0°)) using definition two. Differences between males and females were observed using definition two (males more valgus; p < 0.001). Conclusion. We developed a rapid and accurate DL tool to quantify the FMAA. Considerable variation with different measurement approaches for the FMAA supports that patient-specific anatomy and surgeon-dependent technique must be accounted for when correcting for the FMAA using an intramedullary guide. The angle between the mechanical and anatomical axes of the femur fell outside the range of 5.0° (SD 2.0°) for nearly a quarter of patients. Cite this article: Bone Jt Open 2024;5(2):101–108

Hip fractures are associated with poor outcomes and high mortality rates of 30%. The current gold standard to measure bone fragility is a Dual-Energy X-ray Absorptiometry (DEXA) scan measuring bone mineral density. Yet DEXA under-diagnoses bone fragility by 50% (1). To combat the burden of bone fragility, this experimental study combined ultrasound (US) with a sophisticated computational algorithm, namely full wave inversion (FWI), to evaluate femoral bone structure. The aims were to assess the association of bone structure between the proximal femoral diaphysis and femoral neck; secondly to evaluate whether transverse ultrasound could assess bone structure of the proximal femoral diaphysis. Bone structure of 19 ex vivo human femora was assessed by micro-CT analysis (mean age 88.11 years, male:female 13:6)(Nikon HMXST 225). Using ImageJ/BoneJ, three 10.2mm subsections of proximal diaphysis and femoral neck underwent analysis: the total bone volume fraction, cortical parameters (bone volume fraction, porosity, thickness) and trabecular parameters (porosity, thickness, spacing and connectivity). A unique US prototype was developed to analyse fifteen femoral diaphyseal subsections using two P4-1 transducers with a novel tomography sequence (Verasonics, Matlab ver R2019a, FWI TRUST protocol). Comparative quantitative analysis of US and Micro-CT measurements was assessed (Graphpad Prism 8.3.1). Micro-CT analysis of the proximal femoral diaphysis demonstrated low correlation to the femoral neck (Pearson r −0.54 to 0.55). US was able to capture cortical structure, though a wide limit of agreement seen when compared to micro-CT analysis (Bland-Altman range 36–59% difference). This novel US technique was able to capture cortical bone structure. Improvements in methodology and technology are required to improve the analysis of trabecular bone and overall accuracy. Further evaluation of US and FWI is required to develop the technique and determine its role in clinical practice

Aims. Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures. Methods. The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive. Discussion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England – Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024. Cite this article: Bone Jt Open 2024;5(4):343–349

Aims. Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods. This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination. This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(5):411–418

Recent researches indicate that both M1 and M2 macrophages play vital roles in tissue repair and foreign body reaction processes. In this study, we investigated the dynamics of M1 macrophages in the induced membrane using a mouse femur critical-sized bone defect model. The Masquelet method (M) and control (C) groups were established using C57BL/6J male mice (n=24). A 3mm-bone defect was created in the right femoral diaphysis followed by a Kirschner wire fixation, and a cement spacer was inserted into the defect in group M. In group C, the bone defect was left uninserted. Tissues around the defect were harvested at 1, 2, 4, and 6 weeks after surgery (n=3 in each group at each time point). Following Hematoxylin and eosin (HE) staining, immunohistochemical staining (IHC) was used to evaluate the CD68 expression as a marker of M1 macrophage. Iron staining was performed additionally to distinguish them from hemosiderin-phagocytosed macrophages. In group M, HE staining revealed a hematoma-like structure, and CD68-positive cells were observed between the spacer and fibroblast layer at 1 week. The number of CD68-positive cells decreased at 2 weeks, while they were observed around the new bone at 4 and 6 weeks. In group C, fibroblast infiltration and fewer CD68-positive cells were observed in the bone defect without hematoma-like structure until 2 weeks, and no CD68-positive cells were observed at 4 and 6 weeks. Iron staining showed hemosiderin deposition in the surrounding area of the new bone in both groups at 4 and 6 weeks. The location of hemosiderin deposition was different from that of macrophage aggregation. This study suggests that M1 macrophage aggregation is involved in the formation of induced membranes and osteogenesis and may be facilitated by the presence of spacers

Renal Osteodystrophy is a type of metabolic bone disease characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities. Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. Treatment involves medical management to resolve the etiology of the underlying renal condition, as well as management (and prevention) of pathological fractures. A 66-year-old female patient, with severe osteoporosis and chronic kidney disease undergoing haemodialysis, has presented with multiple fractures along the years. She was submitted to bilateral proximal femoral nailing as fracture treatment on the left and prophylactically due to pathological bone injury on the right, followed by revision of the left nail with a longer one after varus angulation and fracture distal to the nail extremity. Meanwhile, the patient suffered a pathological fracture of the radial and cubital diaphysis and was submitted to conservative treatment with cast, with consolidation of the fracture. Posteriorly, she re-fractured these bones after a fall and repeated the conservative treatment. Clinical management: There is a multidisciplinary approach to manage the chronic illness of the patient, including medical management to resolve the etiology and consequences of her chronic kidney disease, pain control, conservative or surgical fracture management and prevention of falls. The incidence of chronic renal disease is increasing and the patients with this condition live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Their quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. A multidisciplinary approach is required to treat these patients, controlling their chronic diseases, managing fractures and preventing falls

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery. We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip. Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially. The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller. By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm)

Open tibia fractures are common injuries in our paediatric population and are often associated with high-energy trauma such as pedestrian-vehicle accidents. At our institution, these injuries are routinely treated with debridement and mono-lateral external fixation. The purpose of this study was to determine the outcome of open tibia fractures treated according to this protocol, as well as the complication rate and factors contributing to the development of complications. We performed a retrospective folder review of all patients with open tibia fractures that were treated according to our protocol from 2015–2019. Patients treated by other means, who received primary treatment elsewhere, and with insufficient data, were excluded. Data was collected on presenting demographics, injury characteristics, management, and clinical course. Complications were defined as pin tract infections, delayed- or non-union, malunion, growth arrest, and neurovascular injury. Appropriate statistical analysis was performed. One-hundred-and-fifteen fractures in 114 children (82 males) with a median age of 7 years (IQR 6–9) were included in the analysis. Pedestrian vehicle accidents (PVA's) accounted for 101 (88%) of fractures, and the tibial diaphysis was affected in 74 cases (64%). Fracture severity was equally distributed among the Gustillo-Anderson grades. The median Abbreviated Injury Score was 4 (IQR 4;5). Ninety-five fractures (83%) progressed to uneventful union within 7 weeks. Twenty patients (17%) developed complications, with delayed union and fracture site infections being the most common complications. Gustillo-Anderson Grade 3 fractures, an increased Abbreviated Injury Score, and the need for advanced wound closure techniques were risk factors for developing complications. Surgical debridement and external fixation in a simple mono-lateral frame is an effective treatment for open tibia fractures in children and good outcomes were seen in 83% of patients. More severe injuries requiring advanced wound closure were associated with the development of complications

Introduction. We aimed to study the rates of both surgical and medical complications associated with femoral diaphysis fracture fixation with intramedullary nailing including all fracture mechanisms. Additionally, we investigated whether the trauma energy has an impact on the complication risk. Method. In this retrospective cohort study, the health records of 491 patients with 503 femoral fractures, who underwent surgery between May 2007 and May 2022 in Tampere University Hospital, were reviewed. Patients who underwent a primary operation with a reamed rigid intramedullary nail for a diaphyseal femoral fracture and whose follow-ups were organized at the same hospital district, were included. Based on those criteria, 57.5% were included for analysis (279 patients with 289 fractures). The complications were then recorded by chart review. To investigate the impact of trauma energy on complication risk, we compared complication proportions in high- and low-energy groups and calculated odds ratios. Result. The crude percentage of 30-day mortality was 2.1% (6 of 289) based on information obtained from the patients’ records. The overall proportion of complications was 22.5%. The risk of any medical complication was 2.8%, whereas the risk of surgical complication was 19.8%. The risk of complications was nearly twice as high in high-energy fractures compared to low-energy fractures, with an odds ratio (OR) of 1.92, 95% CI 1.03-3.75. The risk of reoperations was significantly increased in high-energy traumas (OR 2.46, CI 1.25-5.24). Conclusion. This study reveals a 2.1% risk of thirdy-day mortality and a 22.5% risk of overall complications, predominantly of a surgical type. The complication risk, especially the risk of surgical complications, is higher among the patients with fractures caused by high-energy injury compared to low-energy fractures, highlighting the importance of timely identification of those complications for providing better postoperative care

Introduction. Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasties (TKAs). However, if the diaphysis has been previously violated (as in revision of a failed stemmed implant), the resultant sclerotic canal can impair cemented stem fixation, which is vital for cone ingrowth and long-term fixation. We report the outcomes of our novel solution to this problem, in which impaction grafting and a cemented stem in the diaphysis was combined with an uncemented metaphyseal cone for revision TKAs with severely compromised bone. Methods. A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems in a novel fashion for 35 revision TKAs. Mean age at revision TKA was 70 years, with 63% being male. Patients had a mean of 4 prior knee arthroplasty procedures. Indications for the revision with this construct were aseptic loosening (80%) and two-stage re-implantation for periprosthetic infection (PJI; 20%). Mean follow-up was 3 years. Results. Survivorship free from revision of the cone/impaction grafting construct due to aseptic loosening was 100% at 5 years. Survivorships free from any revision of the cone/impaction grafting construct and free from any reoperation were 92% and 73% at 5 years, respectively. Six knees (17%) required a reoperation (4 for infection/wound issues and 2 for periprosthetic fractures). Radiographically, 97% of cones were ingrown (1 loose cone in setting of PJI). In all but one case, impacted diaphyseal bone graft appeared to have incorporated radiographically. Conclusions. When presented with a sclerotic diaphysis and substantial metaphyseal bone loss, this innovative technique combining diaphyseal impaction grafting with a metaphyseal cone provided near universal success in regards to implant fixation. Moreover, radiographs revealed incorporation of the bone graft, and ingrowth of the cones. While long-term follow-up is required, this novel technique provides an excellent option in the most difficult of revision TKAs. For figures, tables, or references, please contact authors directly

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Shoulder arthroplasty is effective at restoring function and relieving pain in patients suffering from glenohumeral arthritis; however, cortex thinning has been significantly associated with larger press-fit stems (fill ratio = 0.57 vs 0.48; P = 0.013)1. Additionally, excessively stiff implant-bone constructs are considered undesirable, as high initial stiffness of rigid fracture fixation implants has been related to premature loosening and an ultimate failure of the implant-bone interface2. Consequently, one objective which has driven the evolution of humeral stem design has been the reduction of stress-shielding induced bone resorption; this in-part has led to the introduction of short stems, which rely on metaphyseal fixation. However, the selection of short stem diametral (i.e., thickness) sizing remains subjective, and its impact on the resulting stem-bone construct stiffness has yet to be quantified. Eight paired cadaveric humeri (age = 75±15 years) were reconstructed with surgeon selected ‘standard’ sized and 2mm ‘oversized’ short-stemmed implants. Standard stem sizing was based on a haptic assessment of stem and broach stability per typical surgical practice. Anteroposterior radiographs were taken, and the metaphyseal and diaphyseal fill ratios were quantified. Each humerus was then potted in polymethyl methacrylate bone cement and subjected to 2000 cycles of compressive loading representing 90º forward flexion to simulate postoperative seating. Following this, a custom 3D printed metal implant adapter was affixed to the stem, which allowed for compressive loading in-line with the stem axis (Fig.1). Each stem was then forced to subside by 5mm at a rate of 1mm/min, from which the compressive stiffness of the stem-bone construct was assessed. The bone-implant construct stiffness was quantified as the slope of the linear portion of the resulting force-displacement curves. The metaphyseal and diaphyseal fill ratios were 0.50±0.10 and 0.45±0.07 for the standard sized stems and 0.50±0.06 and 0.52±0.06 for the oversized stems, respectively. Neither was found to correlate significantly with the stem-bone construct stiffness measure (metaphysis: P = 0.259, diaphysis: P = 0.529); however, the diaphyseal fill ratio was significantly different between standard and oversized stems (P < 0.001, Power = 1.0). Increasing the stem size by 2mm had a significant impact on the stiffness of the stem-bone construct (P = 0.003, Power = 0.971; Fig.2). Stem oversizing yielded a construct stiffness of −741±243N/mm; more than double that of the standard stems, which was −334±120N/mm. The fill ratios reported in the present investigation match well with those of a finite element assessment of oversizing short humeral stems3. This work complements that investigation's conclusion, that small reductions in diaphyseal fill ratio may reduce the likelihood of stress shielding, by also demonstrating that oversizing stems by 2mm dramatically increases the stiffness of the resulting implant-bone construct, as stiffer implants have been associated with decreased bone stimulus4 and premature loosening2. The present findings suggest that even a small, 2mm, variation in the thickness of short stem humeral components can have a marked influence on the resulting stiffness of the implant-bone construct. This highlights the need for more objective intraoperative methods for selecting stem size to provide guidelines for appropriate diametral sizing. For any figures or tables, please contact the authors directly

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Introduction. Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small, woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occationally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique. The management of tibial fibrous dysplasia in children are curettage or subperiosteal resection to extra periosteal wide resection followed by bone transport. Materials and Methods. A total of 18 patients were treated between 2010 – 2020; 12 patients came with pain and 6 with pain and deformity. All patients were treated by Ilizarov technique. Age ranges from 4–14 years. 12 patients by enbloc excision and bone transportation and 6 patients were treated by osteotomy at the true apex of the deformity by introducing the k/wires in the medullary cavity with stable fixation by Ilizarov device. The longest duration for bone transport was 16 weeks (14–20 weeks) for application, after deformity correction was 20 weeks. We have never used any kind of bone grafts. Results. All the 18 patients were treated successfully by Ilizarov compression distraction device. The patients with localized tibial pathology with deformity had the shortest period on the Ilizarov apparatus, 14 weeks. Conclusions. Preservation and bone regeneration by distraction histogenesis constitutes a highly conservative limb saving surgery. Patients with bone defects of <10 cm, a great deal of preserved healthy tissue and good prognosis are good candidates for these methods

Most of researches related to osteoporosis emphasized on trabecular bone loss. However, cortical bone has a prominent role on bone strength determined by bone quality, such as 2D or 3D geometry and microstructure of bone, not only density.[1] The focal thinning of cortical bone associated with aging in post-menopausal osteoporotic bone in the proximal femur may predispose a hip to fracture.[2, 3] As the trabecular bone is lost with progression of osteoporosis, the remaining cortical bone take more predominant role on bone strength.[4] To date, no effective osteoporotic agent was demonstrated to enhance both cortical geometric change and bone strength. Herein, we investigate the effect of Teriparatide (rhPTH(1–34)) on cortical bone at femoral diaphysis in OVX rat model. Twenty 12-week-old, female Sprague Dawley rats were used in this study. Bilateral ovariectomies were performed in 16 animals and randomly divided to three groups as control (N=6), OVX (N=6) and treatment group after OVX (OVX+F) by teriparatide (N=8). After twelve weeks of intervention, all rats were euthanized and right femurs and L5 vertebrae were extracted for further tests. All bone specimens were subjected to dual-energy X-ray absorptiometer (DXA) to evaluate areal bone mineral density (aBMD) of L5 vertebrae and femurs, micro-computed tomography (micro-CT) to analyze cortical bone parameters of femoral diaphysis, including cortical cross section area (CSA), cortical thickness and cross-sectional moment of inertia (CSMI). A three-point bending test was applied to determine fracture load of each femurs. Compare to OVX group, increase of aBMD by 14.6 % at L5 vertebrae and 13.3% at femoral diahpysis in treatment group. The cortical parameters of femoral diaphysis, CSA and cortical thickness, analyzed by micro-CT were significantly increased but the increasing tendency of CSMI did not have significant changes statistically after teriparatide intervention for 3 months duration. The increase of cortical bone strength (OVX vs OVX+F group, 120.72±2.72 vs 137.93±5.02, p < 0.05) at femoral diaphysis after treatment were also noticed. This study has point out a deeper look at geometric change of cortical bone after teriparatide treatment. This finding imply teirparatide has the ability to change the geometry of cortical bone and increase bone strength at femoral diaphysis

Objectives. This investigation sought to advance the work published in our prior biomechanical study (Journal of Orthopaedic Research, 2016). We specifically sought to determine whether there are additional easy-to-measure parameters on plain radiographs of the proximal humerus that correlate more strongly with ultimate fracture load, and whether a parameter resembling the Dorr strength/quality characterisation of proximal femurs can be applied to humeri. Materials and Methods. A total of 33 adult humeri were used from a previous study where we quantified bone mineral density of the proximal humerus using radiographs and dual-energy x-ray absorptiometry (DEXA), and regional mean cortical thickness and cortical index using radiographs. The bones were fractured in a simulated backwards fall with the humeral head loaded at 2 mm/second via a frustum angled at 30° from the long axis of the bone. Correlations were assessed with ultimate fracture load and these new parameters: cortical index expressed in areas (“areal cortical index”) of larger regions of the diaphysis; the canal-to-calcar ratio used analogous to its application in proximal femurs; and the recently described medial cortical ratio. Results. The three new parameters showed the following correlations with ultimate fracture load: areal cortical index (r = 0.56, p < 0.001); canal-to-calcar ratio (r = 0.38, p = 0.03); and medial cortical ratio (r = 0.49, p < 0.005). These correlations were weaker when compared with those that we previously reported: mean cortical thickness of the proximal diaphysis versus ultimate fracture load (r = 0.71; p < 0.001); and mean density in the central humeral head versus ultimate fracture load (r = 0.70; p < 0.001). Conclusion. Simple-to-measure radiographic parameters of the proximal humerus reported previously are more useful in predicting ultimate fracture load than are areal cortical index, canal-to-calcar ratio, and medial cortical ratio. Cite this article: J. G. Skedros, C. S. Mears, W. Z. Burkhead. Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio. Bone Joint Res 2017;6:1–7. DOI: 10.1302/2046-3758.61.BJR-2016-0145.R1

Aims. With the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI). Methods. A total of 120 six-month-old Sprague-Dawley (SD) rats were randomized to six groups: Sham, sham + infection (Sham-Inf), sham with infection + antibiotics (Sham-Inf-A), ovariectomized (OVX), OVX + infection (OVX-Inf), and OVX + infection + antibiotics (OVX-Inf-A). Open femoral diaphysis fractures with Kirschner wire fixation were performed. Staphylococcus aureus at 4 × 10. 4. colony-forming units (CFU)/ml was inoculated. Rats were euthanized at four and eight weeks post-surgery. Radiography, micro-CT, haematoxylin-eosin, mechanical testing, immunohistochemistry (IHC), gram staining, agar plating, crystal violet staining, and scanning electron microscopy were performed. Results. Agar plating analysis revealed a higher bacterial load in bone (p = 0.002), and gram staining showed higher cortical bone colonization (p = 0.039) in OVX-Inf compared to Sham-Inf. OVX-Inf showed significantly increased callus area (p = 0.013), but decreased high-density bone volume (p = 0.023) compared to Sham-Inf. IHC staining showed a significantly increased expression of TNF-α in OVX-Inf compared to OVX (p = 0.049). Significantly reduced bacterial load on bone (p = 0.001), enhanced ultimate load (p = 0.001), and energy to failure were observed in Sham-Inf-A compared to Sham-Inf (p = 0.028), but not in OVX-Inf-A compared to OVX-Inf. Conclusion. In osteoporotic bone with FRI, infection was more severe with more bone lysis and higher bacterial load, and fracture-healing was further delayed. Systemic antibiotics significantly reduced bacterial load and enhanced callus quality and strength in normal bone with FRI, but not in osteoporotic bone. Cite this article: Bone Joint Res 2022;11(2):49–60

Femoral revision after cemented total hip arthroplasty (THA) might include technical difficulties, following essential cement removal, which might lead to further loss of bone and consequently inadequate fixation of the subsequent revision stem. Bone loss may occur because of implant loosening or polyethylene wear, and should be addressed at time of revision surgery. Stem revision can be performed with modular cementless reconstruction stems involving the diaphysis for fixation, or alternatively with restoration of the bone stock of the proximal femur with the use of allografts. Impaction bone grafting (IBG) has been widely used in revision surgery for the acetabulum, and subsequently for the femur in Paprosky defects Type 1 or 2. In combination with a regular length cemented stem, impaction grafting allows for restoration of femoral bone stock through incorporation and remodeling of the proximal femur. Cavitary bone defects affecting the metaphysis and partly the diaphysis leading to a wide femoral canal are ideal indications for this technique. In case of combined segmental-cavitary defects a metal mesh is used to contain the defect which is then filled and impacted with bone grafts. Cancellous allograft bone chips of 2 to 4 mm size are used, and tapered into the canal with rods of increasing diameters. To impact the bone chips into the femoral canal a dummy of the dimensions of the definitive cemented stem is inserted and tapped into the femur to ensure that the chips are firmly impacted. Finally, a standard stem is implanted into the newly created medullary canal using bone cement. To date several studies from Europe have shown favorable results with this technique, with some excellent long-term results reported. Advantages of IBG include the restoration of the bone stock in the proximal femur, the use of standard length cemented stems and preserving the diaphysis for re-revision. As disadvantages of the technique: longer surgical time, increased blood loss and the necessity of a bone bank can be mentioned

Background. Systemically administered vancomycin may provide insufficient target-site concentrations. Intraosseous vancomycin administration has the potential to overcome this concern by providing high target-site concentrations. Aim. To evaluate the local bone and tissue concentrations following tibial intraosseous vancomycin administration in a porcine model. Method. Eight female pigs were assigned to receive 500 mg diluted vancomycin (50 mg/mL) through an intraosseous cannula into the proximal tibial cancellous bone. Microdialysis was applied for sampling of vancomycin concentrations in tibial cancellous bone adjacent to the intraosseous cannula, in cortical bone, in the intramedullary canal of the diaphysis, in the synovial fluid of the knee joint, and in the subcutaneous tissue. Plasma samples were obtained. Samples were collected for 12 hours. Results. High vancomycin concentrations were found in the tibial cancellous bone with a mean peak drug concentration of 1,236 (range 28–5,295) µg/mL, which remained high throughout the sampling period with a mean end concentration of 278 (range 2.7–1,362.7) µg/mL after 690 min. The mean (standard derivation (SD)) peak drug concentration in plasma was 19 (2) µg/mL, which was obtained immediately after administration. For the intramedullary canal, in the synovial fluid of the knee joint, and subcutaneous tissue, comparable mean peak drug concentration and mean time to peak drug concentration were found in the range of 7.5–8.2 µg/mL and 45–70 min, respectively. Conclusions. Tibial intraosseous administration of vancomycin provided high mean concentrations in tibial cancellous bone throughout a 12-hour period, but with an immediate and high systemic absorption. The concentrations in cancellous bone had an unpredictable and wide range of peak concentration. Low mean concentrations were found in all the remaining compartments. Our findings suggest that intraosseous vancomycin administration in proximal tibial cancellous bone only is relevant as treatment in cases requiring high local concentrations nearby the intraosseous cannula