Objectives. Insufficient protein ingestion may affect muscle and bone mass, increasing the risk of osteoporotic fractures in the elderly, and especially in postmenopausal women. We evaluated how a low-protein diet affects bone parameters under gonadal hormone deficiency and the improvement led by hormone replacement therapy (HRT) with 17β-oestradiol. Methods. Female Wistar rats were divided into control (C), ovariectomized (OVX), and 17β-oestradiol-treated ovariectomized (OVX-HRT) groups, which were fed a control or an isocaloric low-protein diet (LP; 6.6% protein; seven animals per group). Morphometric, serum, and body composition parameters were assessed, as well as bone parameters, mechanical resistance, and mineralogy. Results. The results showed that protein restriction negatively affected body chemical composition and bone metabolism by the sex hormone deficiency condition in the OVX group. The association between undernutrition and hormone deficiency led to bone and muscle mass loss and increased the fragility of the bone (as well as decreasing relative femoral weight, bone mineral density, femoral elasticity, peak stress, and stress at offset yield). Although protein restriction induced more severe adverse effects compared with the controls, the combination with HRT showed an improvement in minimizing these damaging effects, as it was seen that HRT had some efficacy in maintaining muscle and bone mass, preserving the bone resistance and minimizing some deleterious processes during the menopause. Conclusion. Protein restriction has adverse effects on metabolism, leading to more severe menopausal symptoms, and HRT could minimize these effects. Therefore, special attention should be given to a balanced diet during menopause and HRT. Cite this article: Bone Joint Res 2019;8:573–581

Background: Relatively little is known about the risk factors for carpal tunnel syndrome (CTS) in the community. Previous studies have generally assessed smaller numbers of patients in specialist clinics, or in particular occupations. Therefore, we have performed a case-control study using the West Midlands General Practice Research Database. Methods: Our cases were all patients with a recorded diagnosis of CTS; four controls per case were individually matched by age, sex and general practice. Information on constitutional, hormonal and musculoskeletal factors was extracted and analysed by conditional logistic regression. Results: Our dataset included 3,391 cases; 2,444 (72%) were female, mean age at diagnosis was 45.8 years: and 13,564 matched controls. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR = 2.29, 95% CI: 1.67–3.12), rheumatoid arthritis (OR = 2.23, 95% CI: 1.57–3.17), osteoarthritis (OR = 1.89, 95% CI: 1.65–2.17), BMI (BMI 30–40, OR = 2.06, 95% CI: 1.79–2.38), diabetes (OR = 1.51, 95% CI: 1.24–1.84), the use of insulin (OR = 1.52, 95% CI: 1.06–2.18), sulphonylureas (OR = 1.45, 95% CI: 1.07–1.97), metformin (OR = 1.20, 95% CI: 0.84–1.72) and thyroxine (OR = 1.36, 95% CI: 1.08–1.70). Smoking habit, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS. Conclusions: Rheumatoid arthritis, wrist fracture, osteoarthritis, and an increased Body Mass Index were the most important risk factors for CTS that we identiþed. The combined oral contraceptive, hormone replacement therapy, prednisolone and smoking are not associated with CTS

An increased prevalence of osteoarthritis (OA) in post-menopausal women has led to the suggestion that hormonal factors may play a role in the pathogenesis. This study aims to examine if undergoing a hysterectomy, both with retention and removal of ovaries, predisposes women to OA and secondly if the development is influenced by hormone replacement therapy (HRT). Statistical shape modelling (SSM) is a method of image analysis allowing for detection of subtle shape variation described by landmark points. Through the generation of linearly independent modes of variation, each image can be described in terms of numerical scores. 149 radiographs from female participants of the Osteoarthritis Initiative (OAI) were examined to compare hip morphology in those who had undergone hysterectomies compared to controls. No differences were observed in BMI, age, height or weight between groups. ANOVA and Games-Howell post-hoc analysis showed that modes 3 and 5 were statistically significant. Lower mode 3 scores were associated with hysterectomy (p=0.019), with narrowing of the femoral neck and increased acetabular coverage. Lower mode 5 scores were associated with hysterectomy and oophorectomy (p=0.049), displaying reduced coverage of the femoral head, superolateral migration of the femoral head and larger greater trochanter. No associations were observed between HRT use and OA. The subtle morphologic features of hip OA present in only hysterectomised women suggests undergoing a hysterectomy may be a predisposing factor and a clinical consideration. The use of HRT was not observed to influence the development of OA and thus cannot be suggested as a protective measure

Introduction. Venous thromboembolism (VTE) is an uncommon complication of foot and ankle surgery but has the potential for significant morbidity and mortality. The incidence, risk factors and prevention of VTE in foot and ankle surgery is not clear. Materials and methods. We conducted a systematic review of the literature using MEDLINE, EMBASE, CINAHL, the Cochrane library and reference lists of retrieved articles without language or date restriction upto 31st July 2010. The Coleman methodology score was used to evaluate the quality of studies. From 985 citations, 38 full text articles fulfilled the inclusion criteria. Conclusions were drawn on the incidence, risk factors and prevention of VTE in foot and ankle surgery. Results. The incidence of symptomatic VTE in foot and ankle surgery in general is low; higher incidence has been reported in tendoachilles surgery. There is some evidence that history of prior VTE, immobilisation, non-weight bearing, obesity, hormone replacement therapy and oral contraceptives predispose to VTE in foot and ankle surgery. The evidence on the efficacy of different thromboprophylaxis agents and the optimum duration of treatment is unclear. Conclusion. The current evidence on VTE prophylaxis in foot and ankle surgery is insufficient to draw any firm conclusions. Long term effects of VTE in foot and ankle surgery need to be investigated further. Further large scale, multicentre studies are needed to delineate the role of VTE prophylaxis in foot and ankle surgery

Aims: Hormone replacement therapy (HRT) reverses the menopausal decline in bone mineral density (BMD).We investigate if part of this response is through modulation of Interleukin-6 (IL-6) activity, which is known to be reduced by HRT. Methods: We have examined the association of the -174 G/C functional promoter polymorphism of the IL-6 gene with the BMD response to HRT (Prempak C: 0.625mg oestrogen per day and 0.15mg norgestrel). 65 women were genotyped for the IL-6 polymorphism, and differences in genotype related to changes in BMD over a one year follow up period. Results: Baseline BMD (0.75 g/cm. 2. ) was independent of IL-6 genotype. The rise in BMD with HRT (5% ± 3%, p < 0.00005 by paired t-test) was genotype-dependent, with BMD rising least amongst those of GG genotype (6% ± 3% for ≥1 C allele vs 4% ± 2% GG, p=0.03). In the HRT group, BMD rose most amongst those with the putatively ‘lowest IL-6’ genotype combination- namely ≥ 1 ACE I allele and ≥ 1 IL-6 C allele (n=14) (7% ± 3%), when compared with other genotype combinations (4% ± 2%) (n=16) (p=0.003). Conclusion: These are the first data to demonstrate an influence for IL-6 genotype in influencing response to oestrogen therapy, rather than its physiological withdrawal

Purpose: Hormone replacement therapy for the menopause seems to be associated with a decrease in the prevalence of symptoms and radiological alterations related to hip and knee osteoarthritis. However, little is known on the effects of estrogen in articular cartilage and intervertebral disc (IVD). The aim of this study was to evaluate the developmental changes in mouse articular cartilage and intervertebral discs under estrogen deficiency. Method: Experimental studies used 6- to 7-month-old adult female wild-type or bilaterally ovariectomized (OVX) C57Bl/6 mice. All animals were sacrificed at the same age interval (8- to 9-months) and stored at −20°C. Prior to dissection, posterior-anterior and lateral x-rays of whole mice were done. Right knee joint and cervical to lumbar spine were stained with hematoxylineosin (H& E), Safranin-O/Fast green, and Weigert’s hematoxylin/alcian blue/picrosirius red for histological analysis. Bone mineral density (BMD) was measured using a PIXImus Bone Densitometer System. Micro computed tomography (CT) data were acquired on a SkyScan T1072 X-ray Microscope-Microtomograph. Results: Degeneration, including the loss of notochordal cells, was observed in the nucleus pulposus (NP) of the IVD of OVX mice. The annulus fibrosus (AF) showed marked thinning as compared to the wild type. Furthermore, the OVX group showed decreased IVD heights and trend of endplate ossification. Knee joints of OVX mice showed a trend towards having more gross degenerative changes, like areas of cartilage erosion. A decrease in articular cartilage thickness was also observed. Certain layers of cartilage were more affected than others, suggesting a specific role of estrogens in the developing cartilage. Also, the BMD was reduced in both the femur and lumbar vertebrae of the OVX group. Finally, MicroCT results showed a decrease in percent bone volume, trabecular thickness, trabecular number, and an increase in trabecular separation. Conclusion: The present study showed AF thinning, decreased IVD height, NP degeneration, and loss of cellular components in the NP in ovariectomized mice. Likewise, the articular cartilage revealed more degenerative changes, including a decrease in articular thickness. Results suggest that estrogens play a role in maintaining healthy cartilage and IVD

Introduction: Large numbers of women are taking hormone replacement therapy (HRT) or an oestrogen containing contraceptive pill. They are being advised that these medications can increase their risk of developing deep vein thrombosis (DVT) and there has been considerable recent publicity. Aim: To determine the practice of New Zealand orthopaedic surgeons when women taking such medications present for major surgery. Method: A postal survey was sent to all New Zealand orthopaedic surgeons. The current practice was compared with recently revised national guidelines and manufacturers advice. Results: The response rate was 80% (118/148). There was wide variation in the beliefs surrounding the peri-operative use of both of these medications. Of the surgeons who replied, 44% indicated that they would routinely advise discontinuing the combined oral contraceptive pill peri-operatively for major surgery, 24% indicated that they would routinely advise discontinuing HRT peri-operatively. The mean duration that surgeons would discontinue the medication pre-operatively was 13 days for the contraceptive pill and nine days for HRT. The mean time for re-starting medication post-operatively was 18 days for the contraceptive pill and 13 days for HRT. Recently released New Zealand guidelines recommend that HRT should be stopped for at least 30 days prior to elective surgery and withheld for 90 days following surgery. Less than 3% of surgeons appeared to be routinely following this recommendation. Most manufacturers of combined oral contraceptive pills recommend stopping the medication for at least four weeks prior to elective surgery. Only 25% of surgeons routinely practice in accordance with these recommendations. Discussion: This survey demonstrated substantial differences between actual clinical practice, recently revised national guidelines and manufacturers’ advice. These differences need to be brought to the attention of surgeons and guideline producers alike. A review of international literature and recommendations revealed that these guidelines are very conservative and that strong evidence for them is lacking. Issues to be considered include the practicalities of implementing such recommendations; the associated risks of discontinuing medication; the presence of other risk factors; the type of surgery; the use of thromboprophylaxis and not least the wishes of the patient. The possible medico-legal implications are uncertain and caution in this area is advised

Aims

As the first wave of the COVID-19 pandemic began to dip, restarting elective orthopaedics became a challenge. Protocols including surgery at ‘green’ sites, self-isolation for 14 days, and COVID-19 testing were developed to minimize the risk of transmission. In this study, we look at risk effects of 14-day self-isolation on the incidence of venous thromboembolism (VTE) in our green site hospital among patients undergoing total joint replacement (TJR).

Aims

The aim of this study was to investigate the effects of preoperative bisphosphonate treatment on the intra- and postoperative outcomes of arthroplasty of the shoulder. The hypothesis was that previous bisphosphonate treatment would adversely affect both intra- and postoperative outcomes.

Aims

Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing orthopaedic surgery. There remains a lack of prospective evidence for the use of TXA in patients undergoing periacetabular osteotomy (PAO). The purpose of this study was to determine if intravenous (IV) TXA is effective in reducing calculated blood loss and transfusions after PAO.

Objectives

The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular.

Aims

Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation.

Objectives

Osteoporosis is a metabolic disease resulting in progressive loss of bone mass as measured by bone mineral density (BMD). Physical exercise has a positive effect on increasing or maintaining BMD in postmenopausal women. The contribution of exercise to the regulation of osteogenesis in osteoblasts remains unclear. We therefore investigated the effect of exercise on osteoblasts in ovariectomized mice.

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement.

Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively.

In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors.

We have investigated the effect of using tranexamic acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative blood loss and blood transfusion requirements. In addition we analysed whether the use of TXA was associated with an increased risk of venous thromboembolism (VTE) following this procedure.

A consecutive series of 96 PAOs, performed by a single surgeon, were reviewed. A total of 48 patients received TXA and 48 did not. The TXA group received a continuous infusion of TXA at a rate of 10 mg/kg/h. The primary outcome measure was the requirement for blood transfusion. Secondary outcomes included total blood loss, the decrease in the level of haemoglobin in the blood, the length of hospital stay, and the complications of this treatment.

The mean rate of transfusion was significantly lower in the TXA group (62.5% vs 12.5%, p < 0.001). The mean blood loss was also significantly reduced in the TXA group (1.9 L (standard deviation (sd) 0.9) vs 1.5 L (sd 0.7), p < 0.01). No post-operative episodes of VTE were identified in either group.

The use of TXA reduced the blood loss and the rate of transfusion after PAO significantly, without adverse effects such as an increased rate of VTE.

Cite this article: Bone Joint J 2015;97-B:1604–7.

Recent recommendations by the National Institute for Health and Care Excellence (NICE) suggest that all patients undergoing elective orthopaedic surgery should be assessed for the risk of venous thromboembolism (VTE).

Little is known about the incidence of symptomatic VTE after elective external fixation. We studied a consecutive series of adult patients who had undergone elective Ilizarov surgery without routine pharmacological prophylaxis to establish the incidence of symptomatic VTE.

A review of a prospectively maintained database of consecutive patients who were treated between October 1998 and February 2011 identified 457 frames in 442 adults whose mean age was 42.6 years (16.0 to 84.6). There were 425 lower limb and 32 upper limb frames. The mean duration of treatment was 25.7 weeks (1.6 to 85.3).

According to NICE guidelines all the patients had at least one risk factor for VTE, 246 had two, 172 had three and 31 had four or more.

One patient (0.23%) developed a pulmonary embolus after surgery and was later found to have an inherited thrombophilia. There were 27 deaths, all unrelated to VTE.

The cost of providing VTE prophylaxis according to NICE guidelines in this group of patients would be £89 493.40 (£195.80 per patient) even if the cheapest recommended medication was used.

The rate of symptomatic VTE after Ilizarov surgery was low despite using no pharmacological prophylaxis. This study leads us to question whether NICE guidelines are applicable to these patients.

Cite this article: Bone Joint J 2014;96-B:426–30.

The October 2012 Hip & Pelvis Roundup³⁶⁰ looks at: diagnosing the infected hip replacement; whether tranexamic acid has a low complication rate; the relationship between poor cementing technique and early failure of resurfacing; debridement and retention for the infected replacement; triple-tapered stems and bone mineral density; how early discharge can be bad for your sleep; an updated QFracture algorithm to predict the risk of an osteoporotic fracture; and local infiltration analgesia and total hip replacement.