We performed a retrospective review of all patients admitted to two large University Hospitals in the United Kingdom over a 24-month period from January 2008 to January 2010 to identify the incidence of atypical subtrochanteric and femoral shaft fractures and their relationship to bisphosphonate treatment. Of the 3515 patients with a fracture of the proximal femur, 156 fractures were in the subtrochanteric region. There were 251 femoral shaft fractures. The atypical fracture pattern was seen in 27 patients (7%) with 29 femoral shaft or subtrochanteric fractures. A total of 22 patients with 24 atypical fractures were receiving bisphosphonate treatment at the time of fracture. Prodromal pain was present in nine patients (11 fractures); 11 (50%) of the patients on bisphosphonates suffered 12 spontaneous fractures, and healing of these fractures was delayed in a number of patients. This large dual-centre review has established the incidence of atypical femoral fractures at 7% of the study population, 81% of whom had been on bisphosphonate treatment for a mean of 4.6 years (0.04 to 12.1).

This study does not advocate any change in the use of bisphosphonates to prevent fragility fractures but attempts to raise awareness of this possible problem so symptomatic patients will be appropriately investigated. However, more work is required to identify the true extent of this new and possibly increasing problem.

Abstract. Background. Atypical femur fracture (AFF) is a well known complication of Bisphosphonate therapy. Due to prolonged suppression of bone re-modelling in these fractures, surgical complications are difficult to manage. The aim of this study was to analyze the causes of surgical complications in AFF fixations and provide algorithm for management. Method. In this retrospective 10-year study (2010–2020), we identified patients surgically treated for AFF. We included patients who underwent revision surgery for any cause. Data collection included demographics, surgical complications, details of revision surgery and time to union. Result. Out of 57 patients who were operated for AFF, 17 underwent revision fixation. The average age was 69 with only 2 males. Around two-third (64%) were sub-trochanteric fractures and method of fixation in 64% cases was intra-medullary nail. The most common complication was non-union (12), followed by stress fracture and infection in 3 and 2 cases respectively. In most cases inadequate reduction and sub-optimal fixation was perceived as cause of failure except two cases which got infected. Revision fixation in all cases included improved bone contact (non-union site osteotomy), use of bone morphogenic proteins and improved fixation with augmentation device (either nail or plate). Follow up at 1 year showed fracture union in 12 cases, remaining 5 revision fixations failed, 3 of which were managed with proximal femur replacement. Conclusion. High rate of non-union after fixation in AFF. Optimizing the fixation construct results in union in most cases. However, arthroplasty should be considered in elderly patients with poor bone quality

Aims

This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model.

Septic arthritis is a medical emergency that can lead to significant morbidity and mortality arising from irreversible joint destruction and overwhelming sepsis. The purpose of this prospective study is to present epidemiological, clinical and laboratory findings in adult patients with septic arthritis. Adult patients treated for septic arthritis at the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia, from January 2012 to December 2014, qualified for the present report. The following data were analyzed: age, sex, underlying diseases, previous joint procedure, microbiological diagnostic examinations, causative agents, complications and therapy. During the study period of three years 94 episodes of septic arthritis were diagnosed. There were 49 (52.1%) females and 45 (47.9%) males, aged 64.5 (18 to 97) years. At the first visit elevated concentration of C-reactive protein was found in 93 (98.9%) patients. The most common affected joint was knee (48.9%), followed by shoulder (20.2%), wrist (12.8%), ankle (7.4%) and others. In 8 (8.5%) patients more than one joint was affected. Risk factors were found in 63 (67%) of study patients. The underlying joint disease (e.g. osteoarthritis, rheumatoid arthritis, gout) was found in 50.8% patients, following by malignancy and immunosuppressive therapy in 28.6%, diabetes mellitus in 14.9%, recent trauma in 12.8%, and prior joint procedure in 9.6% patients. In 65/94 (69.1%) patients the causative pathogen was demonstrated by blood culture in 35.6%, by synovial fluid culture in 48.8%, and by both methods in 13.8% patients. In patients with proven aetiology Staphylococcus aureus was the most frequent (44.6%) isolated pathogen (only one methicillin resistant), followed by gram-negative bacteria in 30.8%, and Streptococcus spp. in 23.1% patients. In 4/65 (6.2%) patients more than one pathogen was isolated. The patients were treated with antibiotics according to isolated pathogen. In 17 (70.8%) out of 24 patients with complications synovectomia was performed, and adjacent osteomyelitis was found in 9 (37.5%) patients. Our results show that the foremost risk factor in adult patients with septic arthritis is pre-existing joint disease, knee is the principal target of infection, and the most common isolated pathogen is S. aureus. It was established that prompt recognition, early appropriate antimicrobial and surgical treatment in these patients are critical to ensuring a good prognosis

Purpose. To analyse the effectiveness of using outpatient management of paediatric bone and joint infections with parenteral antibiotic therapy in terms of its efficacy, safety and cost-effectiveness compared to prolonged inpatient treatment. Method. Paediatric cases of septic arthritis or osteomyelitis were identified over a seven year (2004–2011) period in a regional teaching hospital. This included patients either treated as long-term inpatients or given outpatient parenteral antibiotic therapy. The outcome measures recorded included: whether treatment was successful, complications, and length of hospital stay. A cost analysis was also calculated. Results. A total of 41 paediatric patients diagnosed with osteomyelitis or septic arthritis were reviewed, of which 8 were treated as inpatients during the course of their IV antibiotic therapy, and 33 were treated with outpatient parenteral antibiotic therapy (requiring a PICC line to be in situ). The mean length of hospital stay for the inpatient group was 23 days, compared to 3.9 days for the outpatient group. The cost saving in terms of hospital stay is (19 × £464=) £8816. Treatment was effective in all groups. In terms of complications of therapy, there was 1 antibiotic-related case in the inpatient group, and 4 cases in the outpatient group of which 3 related to antibiotic side-effects and 1 related to the PICC line. Conclusion. Outpatient treatment of paediatric bone and joint infections is both clinically and cost effective when compared to long stay inpatient management. It is safe, well tolerated and we advocate its adoption, wherever resources allow

Aim. To assess the spread of foot infection and its impact on the outcomes of major amputations of lower extremities in diabetic patients. Method. In a multicentre retrospective and prospective cohort study, we included adult diabetic patients (≥ 18 years) who underwent a major amputation of a lower limb in 5 hospitals between 2000 and 2009, 2012 and 2014. A total of 51 patients were included (of which 27 (52.94%) were men and 24 (47.06%) were women) with the mean age of 65.51 years (SD=16.99). Concomitant section's osseous slice biopsy (BA) and percutaneous bone biopsy of the distal site (BD) were performed during limb amputation. A new surgical set-up and new instruments were used to try and reduce the likelihood of cross-contamination during surgery. A positive culture was defined as the identification of at least 1 species of bacteria not belonging to the skin flora or at least 2 bacteria belonging to the skin flora (CoNS (coagulase negative staphylococci), Corynebacterium spp, Propionibacterium acnes) with the same antibiotic susceptibility profiles. A doubtful culture was defined as the identification of 1 species of bacteria belonging to the skin flora. The patients were followed-up for 1 year. Stump outcomes were assessed on the delay of complete healing, equipment, need of re-intervention and antibiotics. Results. In total, 51 BA were performed during major lower limb amputations (17 above the knee and 34 below the knee) in diabetic patients. Nine (17.65%) bacterial culture results from BA specimens were positive, 7 (13.73%) doubtful and 35 (68.63%) sterile. Before amputation, 23 patients (45.1%) had not received any antibiotics, including 16 (31.37%) with an antibiotic-free interval of 15 days or more. Microorganisms identified in BA were also cultured from the distal site in 33.33% of the cases. Positive BA was associated with prolonged complete stump healing, delay of complete healing (more than 6 months), re-amputation and the need of antibiotics. Conclusions. The microorganisms identified from BA play a role in stump healing in diabetic patients. BA is useful during major limb amputation due to infectious complications and antibiotic therapy could be corrected on the basis of the BA culture results

Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases, anterior decompression (25), needle biopsy (13), incision and drainage 5 and 9 were treated non-operatively. Medication included ARV (72 patients) and anti-TB in all patients. Results. The mean follow-up was 21 months. Eleven (13.5%) patients developed wound infection and one child died. Complete recovery occurred in 23 patients (35%). The mean CD4 count was 341 cell/cumm. Conclusion. The short term results are encouraging. These patients are best managed by a multidisciplinary team to monitor potential complications from dual therapy, to ensure compliance and adequate nutrition

From 1987 to 1991, we treated 53 patients with 54 fractures of the acetabulum by reconstruction through a posterior or an extended iliofemoral surgical approach. For prophylaxis against heterotopic ossification we used perioperative irradiation and indomethacin. Indomethacin was given as daily doses of 25 mg started within 24 hours of operation and continued for four weeks. Irradiation was by either 1200 cGy in three daily doses or by a single 700 cGy dose on the first postoperative day. All patients were followed for at least one year postoperatively and the severity of heterotopic ossification was recorded using the Brooker classification and correlated with hip mobility. The combination therapy proved very effective; 44 fractures showed no heterotopic ossification and ten showed Brooker class I. The functional results were good and there were no complications of this therapy. Irradiation with 1200 cGy did not appear to offer any therapeutic advantage over the 700 cGy dose

Until recently, diaphyseal fractures in children aged 4–12 years were treated conservatively. Although Prof. Havránek recommended oblique bilateral skin traction in his monograph entitled Split Russell Traction, he is currently inclined to use skeletal traction through the proximal tibia (Goteborg traction). The author himself stresses that this therapy requires great expertise from the medical staff. In addition, patients are immobilised for several weeks in hospital. The Pediatric Traumatology School in Nancy, France prepared a method of intramedullar elastic ostheosynthesis according to Métaizeau and Prévote. After our experience with intramedullary fixation using Prévote’s nails in diaphyseal fractures of adults and diaphyseal forearm fractures, we also decided to use this ostheosynthesis in diaphyseal femoral fractures of children. Our group includes four patients (2 boys, 2 girls) with a mean age of 4.2 years (range 4–11). Average time from injury to operation was eight hours. The patient is in a supine position and given a general anaesthesia. After repositioning, two or more Prévot nails are inserted above the distal physis from the medial and lateral side towards the femoral diaphysis. The nails cross distally and proximally to the fracture line and are anchored in the intertrochanteric area. The operative procedure usually lasts approximately thirty minutes. The patient is hospitalised from two to five days. The child walks with crutches after discharge, and trains the operated lower extremity. According to the parents, these children began to load the extremity spontaneously after two weeks. After four weeks we perform a radiographic check and permit full loading. The bars are removed in eight weeks in children up to the age of seven years, and 12 weeks in older children. All of the children recovered without any problems. The schedule for follow-up is from nine to twelve months. The extremities do not appear to have a tendency to overgrow. The method of mini-invasive osteosynthesis of diaphyseal femoral fractures in children aged from four to twelve years is a modern alternative to conservative treatment. It is more comfortable for the patients, avoids the skin complications of traction therapy, and significantly shortens the time of treatment. This method will also be particularly useful in treating polytraumatised patients

The June 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.

We evaluated the efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 (E-BMP-2) in a mini-pig model of spinal anterior interbody fusion. A total of 14 male mini-pigs underwent three-level anterior lumbar interbody fusion using polyether etherketone (PEEK) cages containing porous hydroxyapatite (HA). Four groups of cages were prepared: 1) control (n = 10 segments); 2) 50 μg E-BMP-2 (n = 9); 3) 200 μg E-BMP-2 (n = 10); and 4) 800 μg E-BMP-2 (n = 9). At eight weeks after surgery the mini-pigs were killed and the specimens were evaluated by gross inspection and manual palpation, radiological evaluation including plain radiographs and micro-CT scans, and histological analysis. Rates of fusion within PEEK cages and overall union rates were calculated, and bone formation outside vertebrae was evaluated. One animal died post-operatively and was excluded, and one section was lost and also excluded, leaving 38 sites for assessment. This rate of fusion within cages was 30.0% (three of ten) in the control group, 44.4% (four of nine) in the 50 μg E-BMP-2 group, 60.0% (six of ten) in the 200 μg E-BMP-2 group, and 77.8% (seven of nine) in the 800 μg E-BMP-2 group. Fusion rate was significantly increased by the addition of E-BMP-2 and with increasing E-BMP-2 dose (p = 0.046). In a mini-pig spinal anterior interbody fusion model using porous HA as a carrier, the implantation of E-BMP-2-loaded PEEK cages improved the fusion rate compared with PEEK cages alone, an effect that was significantly increased with increasing E-BMP-2 dosage.

Cite this article: Bone Joint J 2013;95-B:217–23.

We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received aspirin only as chemical prophylaxis; 46 were mistakenly given low molecular weight heparin initially, which was stopped and changed to aspirin; 136 received no chemoprophylaxis and 11 patients received warfarin because of a previous history of pulmonary embolism. We identified the rate of clinical thromboembolism before and after discharge, and the mortality from pulmonary embolism at 90 days. The overall death rate was 0.31% (13 of 4253) and the rate of fatal pulmonary embolism was 0.07% (3 of 4253).

Our data suggest that fatal pulmonary embolism is not common following elective primary joint replacement, and with modern surgical practice elective hip and knee replacement should no longer be considered high-risk procedures.