Corticosteroid use has been implicated in the development of osteonecrosis of the femoral head (ONFH). The exact mechanism and predisposing factors such as age, gender, dosage, type and combination of steroid treatment remain controversial. Between March and July 2003, a total of 539 patients with severe acute respiratory syndrome (SARS) were treated with five different types of steroid. There were 129 men (24%) and 410 women (76%) with a mean age of 33.7 years (21 to 59). Routine screening was undertaken with radiographs, MRI and/or CT to determine the incidence of ONFH. Of the 129 male patients with SARS, 51 (39.5%) were diagnosed as suffering from ONFH, compared with only 79 of 410 female patients (19.3%). The incidence of ONFH in the patients aged between 20 and 49 years was much higher than that of the group aged between 50 and 59 years (25.9% (127 of 491) versus 6.3% (3 of 48); p = 0.018). The incidence of ONFH in patients receiving one type of steroid was 12.5% (21 of 168), which was much lower than patients receiving two different types (28.6%; 96 of 336) or three different types of steroid (37.1%; 13 of 35). Cite this article: Bone Joint J 2014;96-B:259–62

A total of 63 women who had an operation for a fracture of the hip was randomly allocated to one year of treatment either with anabolic steroids, vitamin D and calcium (anabolic group) or with calcium only (control group). The thigh muscle volume was measured by quantitative CT. The bone mineral density of the hip, femur and tibia was assessed by quantitative CT and dual-energy x-ray absorptiometry and of the heel by quantitative ultrasound. Quantitative CT showed that the anabolic group did not lose muscle volume during the first 12 months whereas the control group did (p< 0.01). There was less bone loss in the proximal tibia in the anabolic group than in the control group. The speed of gait and the Harris hip score were significantly better in the anabolic group after six and 12 months. Anabolic steroids, even in this moderate dose, given in combination with vitamin D and calcium had a beneficial effect on muscle volume, bone mineral density and clinical function in this group of elderly women

Aims. The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. Methods. A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively. Results. There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%). Conclusion. NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion. Cite this article: Bone Jt Open 2021;2(4):227–235

A Morton's neuroma is a painful forefoot disorder characterised by plantar pain and toe paraesthesia. Many treatments have been tried including modification of shoe wear, injections and surgery. The results from different treatment modalities are extremely variable in the scientific literature. We reviewed 79 patients who presented with an ultrasound proven Morton's Neuromata at an average of 60 months following treatment in a patient blind randomised trial. 35 had surgery with resection of the Morton's Neuromata. We compared the results of the patients who had had a steroid injection and surgery, a steroid injection alone, a placebo injection and then surgery and a placebo injection alone. We looked at the requirement for further consultations, pain scores, activity restrictions, footwear restriction, overall satisfaction with their treatment and overall quality of life scores. We found no significant difference between the groups. Overall 80% of the surgical patients had a good or excellent result and 67% of the non- operatively managed patients had a good or excellent result. There was no difference in their quality of life scores. Previous studies have shown little benefit in steroid injections in the treatment of Morton's Neuromata. We conclude at the five year mark there is no significant differences between operating on Morton's Neuromata and treating them conservatively. Further research should focus on comparing operative vs conservative treatment in the short to medium term. In order to justify the risks and costs of surgery

Aims

The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

Atypical femoral fractures (AFFs) are reported in patients taking bisphosphonates (BPs). This study aims to describe demographics, potential risk factors and outcome of fixation in AFFs. Forty-three patients with AFF were identified retrospectivity from all identified patients with subtrochanteric or diaphyseal fractures within NHS Grampian between 2008–2018. Patients were identified via hospital coding and electronic search of patients undergoing femoral fixation. AFFs were diagnosed by the 2014 American Society of Mineral and Bone Research diagnostic criteria by electronic patient record review by two investigators. Within this cohort, the incidence of AFF was 8.25% with male to female ratio of 10:1 and a mean of presentation age 73.3 years. 27.9% of AFFs occurred in the diaphysis. 22% of AFFs were bilateral. Mean follow-up was 11.5 months. 87.5% of patients had documented prodromal symptoms. 35% had proven radiological changes before fracture. All patients identified were on BPs. Duration of BPs before fracture was 5 months- 13.2 years (mean 6.3 years). Concurrent use of BPs with steroid and proton pump inhibitors was seen in 58.5%. All patients had intramedullary fixation with 8 (18.6%) requiring revision for non-union. For those that united radiologically it took on average 304 days (220–513). BPs were only stopped in 45% of patients after fixation. AFFs in this cohort appear to be associated with BP use, female sex, clinical and radiological prodrome. AFF remain a difficult clinical problem with a high revision rate. Further work is required to identify the temporal relationships and to raise awareness to improve surveillance/management

Introduction. Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure. Methods and materials. We identified 299 consecutive patients who underwent circular frame fixation for fracture or deformity correction in our unit from our prospective database. All 247 patients who followed the staged frame removal protocol were included in this study. We reviewed the electronic clinical record and radiographs of each patient to record demographics, risk factors for treatment failure and outcome following frame removal. We defined failure of the protocol as a re-fracture or change in bony alignment within 12 weeks of frame removal. Results underwent statistical analysis using Chi square analysis. Results. Of the 247 patients, 196 were trauma patients, of which 56 were open fractures and 48 were elective cases. There were 92 Ilizarov frames and 155 hexapods. 93 patients were smokers. The protocol failed to prevent mechanical failure after frame removal in 10 patients, of which four had refracture and six had an increase in deformity. The average increase in deformity was 7.7 in the frontal plane and 3.8 in the lateral plane. We identified risk factors for mechanical failure in eight of the ten; four were smokers, two were on steroids and two had hypophosphataemic rickets. Of the ten patients, four were for elective indications, six for trauma. Two of the six trauma patients had been treated for open fractures. ‘The type of frame and smoking history showed no statistical association with mechanical failure. Four patients went to have another frame, five were managed with plaster and one patient refused further treatment. Conclusion. Our staged reloading protocol may delay frame removal however it is a simple and effective way to confirm the timing of frame removal

Aims

The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years.

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity. The mean T-score for the distal radius was −2.97 (. sd. 1.56) compared with −1.61 (. sd. 1.62) for the lumbar spine and −1.78 (. sd. 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site. The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb

We present (with intra-operative imaging) 4 patients who sustained Pectoralis major ruptures on the same piece of equipment of the “Tarzan” assault course at the Commando Training Centre, Royal Marines (CTCRM). Recruits jump at running pace, carrying 21 pounds of equipment and a weapon (8 pounds) across a 6ft gap onto a vertical cargo-net. The recruits punch horizontally through the net, before adducting their arm to catch themselves, and all weight, on their axilla. All patients presented with immediate pain and reduced function. 2 had ruptures demonstrated on MRI, 1 on USS and one via clinical examination. All 4 patients were found, at operation, to have sustained type IIIE injuries. All patients underwent Pectoralis major repair using a uni-cortical button fixation and had an uneventful immediate post operative course. Patient 1 left Royal Marines training after the injury (out of choice, not because of failure to rehabilitate). All other patients are under active rehabilitation hoping to return to training. Review of 10 years of records at CTCRM reveal no documented Pectoralis major rupture prior to our first case in October 2013. There has been no change to the obstacle or technique used and all patients deny the use of steroids

Plantar fasciitis is thought to be a self limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and for some surgery may be indicated. Partial plantar fascial release is reported to have a short term success rate of up 80%, but anecdotally this was not thought to represent local experience. An audit of long term patient reported outcomes following surgery was performed. A total of 26 patients (29 feet) were identified retrospectively and case notes were reviewed for each patient. Patients were contacted by letter and invited to complete two validated patient reported outcome score questionnaires (foot and ankle visual analogue scale (VAS) and MOXFQ). The average age of the patients was 42.4(range 28–61) for males and 46.2 (range 33–60) for female patients, with a female:male ratio of 2.7:1. Preoperative treatments included orthotics (29), steroid injections (23), physiotherapy (21) and cast immobilisation (11). The average duration of treatment prior to surgical intervention was 3.1 years (range 1–5). All patients were reviewed post operatively and discharged from follow up at an average of 31 weeks, at which time 38% remained symptomatic. We conclude that the results from open partial plantar fascial release are poor and it is a technique of dubious clinical value

We report the largest series of periprosthetic fractures in the literature, describing the changing epidemiology and predictors of outcome. A retrospective search of prospectively compiled trauma and elective electronic databases identified 630 periprosthetic fractures presenting to the study centre between 1995 and 2010. Patient demographics, comorbidities, socioeconomic status, mechanism of injury, fracture type, classification, method of fixation, and outcome were recorded using the patients’ notes. The General Register Office for Scotland was used to obtain the mortality status of the patients. There were 276 total hip replacements (THR), 123 total knee replacements (TKR), 117 hemiarthroplasty, and 114 “other” implants. The incidence of periprosthetic fractures increased significantly during the study period for all implants: THR (p<0.001), TKR (p<0.001), hemiarthroplasty (p=0.002), and other (p=0.003). The majority of fractures were fixed by open reduction and internal fixation (72%). This failed in 14% of THR, 15% of TKR, 21% of hemiarthroplasties, and 18% of “other” implants. Isolated independent predictors of failure of fixation, after multivariate regression analysis, were increasing age, deprivation, a past medical history of asthma or chronic obstructive airways disease, osteoporosis, and steroid use (p<0.05). Failure of fixation was associated with a significantly increased one year mortality rate (OR 12.5, p=0.003). Periprosthetic fractures involving THR and TKR are becoming more prevalent. Patient demographics can be used to calculate the risk of failure of fixation, and those with an increased risk may benefit from revision of their implant, and avert the associate morbidity of failure of fixation

Aims

Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame.

Objectives. Juxtafacet cysts of the spine can cause radicular pain, neurological symptoms and are often associated with spinal degeneration. The mainstay of treatment of juxtafacet cysts is surgical resection with laminotomy and resection of the cyst. Other methods, including epidural steroid and facet injections are mostly temporarily effective. The aim of this study is the sufficient decompression with reduced traumatization and destabilization with the full-endoscopic interlaminar and transforaminal technique. Methods. 60 patients with unilateral, single-level juxtafacet cysts were included in this study. 30 Patients (group 1) were operated in full-endoscopic technique (22 interlaminar, 8 trans-/extraforaminal) and 30 Patients (group 2) with conventional microscopic-assisted technique. The full-endoscopic operation was performed with 6.9-mm endoscopes with 4.1-mm intra-endoscopic working canal. The follow-up was 18 months. 27 (91%) patients were followed. Additionally to general parameters validated scores were used. Results. No intraoperative complications occurred. 2 patient in group 1 and 4 patients in group 2 showed transient dysaesthesia. The mean operation time in group 1 was 32 minutes, in group 2 56 minutes. There was no measurable blood loss in group 1, and a mean blood loss of 85 ml in group 2. The follow-up showed satisfactory subjective results in 53 patients. There were no significant differences between the two groups or within group 1 between the transforaminal and interlaminar technique in the clinical results. Group 1 showed significant advantages in different clinical, technical and economical parameters. The maximum time in hospital for group 1 patients was 3 days and 6 days in group 2. No recurrence of the cyst was found in the follow up. Conclusion. The full-endoscopic operation of lumbar facet cysts with full-endoscopic technique is an alternative to the conventional microscopic-assisted procedure for sufficient decompression of juxtafacet cyst. It enables selective procedure with direct visualization, sufficient decompression and less traumatization of the access pathway and the spinal canal structures

Introduction. Following tear of its tendon, the muscle undergoes retraction, atrophy and fatty infiltration. These changes are inevitable and considered irreversible and limit the potential of successful repair of musculotendinous units. It was the purpose of this study to test the hypothesis that administration of anabolic steroids can prevent these muscular changes following experimental supraspinatus tendon release in the rabbit. Methods. The supraspinatus tendon was experimentally released in 20 New Zealand rabbits. Musculotendinous retraction was monitored over a period of 6 weeks. The seven animals in group I had no additional intervention, six animals in group II had local and seven animals in group III had systemic administration of nandrolone deconate during six weeks of retraction. At the time of sacrifice, in-vivo muscle performance as well as radiologic and histologic muscle changes were investigated. Results. Supraspinatus retraction was significantly higher in group I (1.8 ± 0.2cm) than in group II (1.5 ± 0.3cm, p = 0.044) or III (1.2 ± 0.3cm, p = 0.001). The reduction in radiological cross sectional area, as a measure for atrophy, was significant in groups I (p = 0.013) and II (p = 0.030) and insignificant in group III (p = 0.149). Histologically, there was no fatty infiltration in the treated groups II (p = 1.000) and III (p = 0.812), but in the untreated group I (p = 0.0312). The work of the respective muscle during one standardized contraction with supramaximal stimulation decreased markedly in groups I (p = 0.056) and II (p = 0.0528), and also but less in group III (p = 0.23). Conclusion. This is the first documentation of prevention of important muscle alterations after chronic retraction of the musculotendinous unit caused by rotator cuff tear. Nandrolone deconate administration in the post tendon release phase prevented fatty infiltration of the supraspinatus muscle and reduced functional muscle impairment caused by myo-tendinous retraction

BACKGROUND CONTEXT. Osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. PURPOSE. To identify the rate of recurrent fractures after vertebroplasty and after the conservative treatment for patients aged 50 years and older who sustained low impact vertebral compressions fractures over a 6-month period. STUDY DESIGNED/SETTING. Prospective study. PATIENT SAMPLE. The sample included patients 50 years or older who had a low-energy vertebral compression fracture. The patients were divided into two groups: first group (n=24) - patients teated by vertebroplasty and the second group (n=34) - patients treated conservatory. There was no significant difference among the groups in terms of the vertebral levels or BMD. METHODS. Patients records were reviewed for fracture recurrence and in the same time we examined medical records for osteoporotic medication prescriptions, refferals to endocrinology and to dual-energy X-ray absorptiometry (DEXA) scans. RESULTS. Confounding factors of age at the procedure, sex and chronic steroids use were considered and found to have no statistically significant difference between the two groups and between those with fracture recurrence and those without fracture recurrence. Four vertebroplasty procedure resulted in a recurrent fracture within the first 6 months. In the patient group treated conservatory 8 patients sustained recurrent fractures. Patients with recurrent vertebral fracture didn't receive active osteoporosis treatment. Within 6 months after the fracture only 21% of patients were receiving active osteoporosis treatment. CONCLUSIONS. The incidence of recurrent fracture after vertebroplasty or after conservative treatment is substantial but have no statistically significant difference between the two groups. We consider that the recurrence rate is not related with the surgical intervention but is the result of natural history of the patient's osteoporosis because the patients do not understand the importance of initiating active therapeutic intervention for osteoporosis recommended by physicians

Aims

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

Aims

Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment.

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

Aims

Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated.