Abstract. Objectives. Non-technical skills including teamwork play a pivotal role in surgical outcomes. Virtual reality is effective at improving technical skills, however there is a paucity of evidence on team-based virtual reality (VR) training. This study aimed to assess if multiplayer virtual reality training was superior to solo training for acquisition of both technical and non-technical skills in learning the complex anterior approach total hip arthroplasty operation. Methods. 10 novice surgeons and 10 novice scrub nurses, were randomised to solo or team virtual reality training to perform anterior approach total hip arthroplasty. Solo participants trained with virtual avatar counterparts, whilst teams trained in pairs (surgeon and scrub nurse). Both groups underwent 5 VR training sessions over 6 weeks. Then, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and solo participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. Outcomes were procedure time, procedural errors from an expert pre-defined protocol and acetabular component positioning. Non-technical skills were assessed using the NOTECHs II and NOTSS scores. Results. Teams were 28.11% faster than solos in the real world assessment (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), with 34.91% less errors (−15.25 errors ±3.09 vs −23.43 ±1.84, p=0.04). Teams had significantly higher NOTSS and NOTECHS II scores when compared to solos (p<0.001). 8/10 surgeons placed the acetabular component within the target safe zone. Conclusions. Multiplayer training appears to lead to faster surgery with fewer technical errors and the development of superior non-technical skills. VR learnt skills appear to translate to the physical world. This supports the application of multidisciplinary learning to create a more integrated approach to surgical team training

Anterior approach total hip arthroplasty (AA-THA) has a steep learning curve, with higher complication rates in initial cases. Proper surgical case selection during the learning curve can reduce early risk. This study aims to identify patient and radiographic factors associated with AA-THA difficulty using Machine Learning (ML). Consecutive primary AA-THA patients from two centres, operated by two expert surgeons, were enrolled (excluding patients with prior hip surgery and first 100 cases per surgeon). K- means prototype clustering – an unsupervised ML algorithm – was used with two variables - operative duration and surgical complications within 6 weeks - to cluster operations into difficult or standard groups. Radiographic measurements (neck shaft angle, offset, LCEA, inter-teardrop distance, Tonnis grade) were measured by two independent observers. These factors, alongside patient factors (BMI, age, sex, laterality) were employed in a multivariate logistic regression analysis and used for k-means clustering. Significant continuous variables were investigated for predictive accuracy using Receiver Operator Characteristics (ROC). Out of 328 THAs analyzed, 130 (40%) were classified as difficult and 198 (60%) as standard. Difficult group had a mean operative time of 106mins (range 99–116) with 2 complications, while standard group had a mean operative time of 77mins (range 69–86) with 0 complications. Decreasing inter-teardrop distance (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95–0.99, p = 0.03) and right-sided operations (OR 1.73, 95% CI 1.10–2.72, p = 0.02) were associated with operative difficulty. However, ROC analysis showed poor predictive accuracy for these factors alone, with area under the curve of 0.56. Inter-observer reliability was reported as excellent (ICC >0.7). Right-sided hips (for right-hand dominant surgeons) and decreasing inter-teardrop distance were associated with case difficulty in AA-THA. These data could guide case selection during the learning phase. A larger dataset with more complications may reveal further factors

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined. In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur. There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle

Evidence supporting the use of virtual reality (VR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. We aimed to investigate whether spaced VR training is more effective than massed VR training. 24 medical students with no hip arthroplasty experience were randomised to learning the direct anterior approach total hip arthroplasty using the same VR simulation, training either once-weekly or once-daily for four sessions. Participants underwent a baseline physical world assessment on a saw bone pelvis. The VR program recorded procedural errors, time, assistive prompts required and hand path length across four sessions. The VR and physical world assessments were repeated at one-week, one-month, and 3 months after the last training session. Baseline characteristics between the groups were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the median ± IQR number of procedural errors from 68 ± 67.05 (session one) to 7 ± 9.75 (session four), compared to the weekly group's improvement from 63 ± 27 (session one) to 13 ± 15.75 (session four), p < 0.001. The weekly group error count plateaued remaining at 14 ± 6.75 at one-week, 16.50 ± 16.25 at one-month and 26.45 ± 22 at 3-months, p < 0.05. However, the daily group showed poorer retention with error counts rising to 16 ± 12.25 at one-week, 17.50 ± 23 at one-month and 41.45 ± 26 at 3-months, p<0.01. A similar effect was noted for the number of assistive prompts required, procedural time and hand path length. In the real-world assessment, both groups significantly improved their acetabular component positioning accuracy, and these improvements were equally maintained (p<0.01). Daily VR training facilitates faster skills acquisition; however weekly practice has superior skills retention

Current evidence suggests that superior surgical team performance is linked to fewer intra-operative errors, reductions in mortality and even improved patient outcomes. Virtual reality has demonstrated excellent efficacy in training surgeons and scrub nurses individually, however its impact on training teams is currently unknown. This study aimed to assess if training together (scrub nurse and surgeon) in an innovative multiplayer virtual reality program was superior to single player training for novices learning anterior approach total hip arthroplasty (AA-THA). 40 participants (20 novice surgeons (CT1-ST3 level) and 20 novice scrub nurses) were enrolled in this study and randomised to individual or team virtual reality training. Individually-trained participants played with virtual avatar counterparts, whilst teams trained live in pairs (surgeon and scrub nurse). Both groups underwent 5 VR training sessions over 6 weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and individually-trained participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. The primary outcome was team performance as graded by the validated NOTECHs II score. Secondary outcomes were procedure time and number of technical errors from an expert pre-defined protocol. Teams outperformed individually-trained participants for non-technical skills in the real-world assessment (NOTECHS-II score 50.3 ± 6.04 vs 43.90 ± 5.90, p=0.0275). They completed the assessment 28.1% faster (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), and made close to half the number of technical errors when compared to the individual group (12.9 ± 8.3 vs 25.6 ± 6.1, p=0.001). Multiplayer, team training appears to lead to faster surgery with fewer technical errors and the development of superior non-technical skills

Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

Introduction and Objective. Interest for direct anterior approach (DAA) in hip hemiarthroplasty (HHA) has greatly increased in recent years, however which is the best surgical approach in hip replacement treating femoral neck fractures (FNFs) is already unclear. The aim of this study is to perform a radiographic and perioperative complications analysis by comparing the direct anterior approach (DAA) with the direct lateral approach (DLA) in patients treated with hemiarthroplasty for FNFs. Materials and Methods. Patients with FNFs surgically treated between 2016–2020 with HHA were enrolled. The radiographical outcomes of DAA and DLA are compared. Several peri-operative and post-operative variables were evaluated: mean surgery time, complications as periprosthetic fractures or episodes of dislocation, the average of post-operative diaphyseal filling of the stem (Canal Fill Index, CFI), the extent of heterotopic ossification (HO) (simplified Broker classification) and metadiaphiseal bone loss (Paprosky classification) within one year from surgery. Results. 86 patients underwent HHA by DAA and 80 patients by DLA. The two groups are qualitatively comparable. No statistically significate differences were showed in all variables analyzed (p>0.05). The average of surgical time of DAA were 61 minutes compared to 67 of DLA. No differences were showed in the post-operative CFI (DAA 0.71 ± 6.1; DLA 0.76 ± 13.5), the extent of the HO (DAA 79.07% low; DLA 75% low) and metadiaphiseal bone loss (DAA Grade I 91.86%; DLA Grade I 93.75%). Regarding perioperative complications, we have discovered only one periprosthetic fracture each group. Although there was no statistically significant difference, we highlighted a higher number of dislocations in the group of DLA (2 episodes vs no one). Conclusions. In this study we have shown that the DAA is an adequate surgical choice comparing with the classical DLA for FNFs treated with HHA. The analysis of our radiographic parameters and perioperative complications have not shown a significant difference between the two surgical approach. This study is limited by a purely radiographic analysis without addition of clinical parameters

Range of Motion (ROM) assessments are routinely used during joint replacement to evaluate joint stability before, during and after surgery to ensure the effective restoration of patient biomechanics. This study aimed to quantify axial torque in the femur during ROM assessment in total hip arthroplasty to define performance criteria against which hip instruments can be verified. Longer term, this information may provide the ability to quantitatively assess joint stability, extending to quantitation of bone preparation and quality. Joint loads measured with strain-gaged instruments in five cadaveric femurs prepared using posterior approach were analysed. Variables such as surgeon-evaluator, trial offset and specimen leg and weight were used to define 13 individual setups and paired with surgeon appraisal of joint tension for each setup. Peak torque loads were then identified for specific motions within the ROM assessment. The largest torque measured in most setups was observed during maximum extension and external rotation of the joint, with a peak torque of 13Nm recorded in a specimen weighing 98kg. The largest torque range (19.4Nm) was also recorded in this specimen. Other motions within the trial reduction showed clear peaks in applied torque but with lower magnitude. Relationships between peak torque, torque range and specimen weight produced an R2 value greater than 0.65. The data indicated that key influencers of torsional loads during ROM were patient weight, joint tension and limb motion. This correlation with patient weight should be further investigated and highlights the need for population representation during cadaveric evaluation. Although this study considered a small sample size, consistent patterns were seen across several users and specimens. Follow-up studies should aim to increase the number of surgeon-evaluators and further vary specimen size and weight. Consideration should also be given to alternative surgical approaches such as the Direct Anterior Approach

There is controversy regarding the effect of different approaches on recovery after THR. Collecting detailed relevant data with satisfactory compliance is difficult. Our retrospective observational multi-center study aimed to find out if the data collected via a remote coaching app can be used to monitor the speed of recovery after THR using the anterolateral (ALA), posterior (PA) and the direct anterior approach (DAA). 771 patients undergoing THR from 13 centers using the moveUP platform were identified. 239 had ALA, 345 DAA and 42 PA. There was no significant difference between the groups in the sex of patients or in preoperative HOOS Scores. There was however a significantly lower age in the DAA (64,1y) compared to ALA (66,9y), and a significantly lower Oxford Hip Score in the DAA (23,9) compared to PA(27,7). Step count measured by an activity tracker, pain killer and NSAID use was monitored via the app. We recorded when patients started driving following surgery, stopped using crutches, and their HOOS and Oxford hip scores at 6 weeks. Overall compliance with data request was 80%. Patients achieved their preoperative activity level after 25.8, 17,7 and 23.3 days, started driving a car after 33.6, 30.3 and 31.7 days, stopped painkillers after 27.5, 20.2 and 22.5 days, NSAID after 30.3, 25.7, and 24.7 days for ALA, DAA and PA respectively. Painkillers were stopped and preoperative activity levels were achieved significantly earlier favoring DAA over ALA. Similarly, crutches were abandoned significantly earlier (39.9, 29.7 and 24.4 days for ALA, DAA and PA respectively) favoring DAA and PA over ALA. HOOS scores and Oxford Hip scores improved significantly in all 3 groups at 6 weeks, without any statistically significant difference between groups in either Oxford Hip or HOOS subscores. No final conclusion can be drawn as to the superiority of either approach in this study but the remote coaching platform allowed the collection of detailed data which can be used to advise patients individually, manage expectations, improve outcomes and identify areas for further research

Talar neck fractures are associated with high complication rates with significant associated morbidity. Adequate exposure and stable internal fixation remains challenging. We investigated the anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compared the quality and quantity of exposure of the talar neck obtained by this approach, with the classically described medial/lateral approaches. An anterior approach to the talus between the tibialis anterior and the extensor hallucis tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscribe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven talar neck fractures underwent operative fixation using the anterior approach with parallel cannulated screws inserted through the talo-navicular joint. 3D mapping demonstrated that the talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination. Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients were reviewed. All had anatomical articular restoration, and no wound problems. None developed non union or AVN. The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. We argue that this approach is safe, adequate and causes less vascular disruption

Dual mobility (DM) bearing implants reduce the incidence of dislocation following total hip arthroplasty (THA) and as such they are used for the treatment of hip instability in both primary and revision cases. The aim of this study was to compare lower limb muscle activity of patients who underwent a total hip arthroplasty (THA) with a dual mobility (DM) or a common cup (CC) bearing compared to healthy controls (CON) during a sit to stand task. A total of 21 patients (12 DM, 9 CC) and 12 CON were recruited from the local Hospital. The patients who volunteered for the study were randomly assigned to either a DM or a CC cementless THA after receiving informed consent. All surgeries were performed by the same surgeon using the direct anterior approach. Participants underwent electromyography (EMG) and motion analysis while completing a sit-to-stand task. Portable wireless surface EMG probes were placed on the vastus lateralis, rectus femoris, biceps femoris, semitendinosus (ST), gluteus medius and tensor fasciae latae muscles of the affected limb in the surgical groups and the dominant limb in the CON group. Motion capture was used to record lower limb kinematics and kinetics. Muscle strength was recorded using a hand-held dynamometer during maximal voluntary isometric contraction (MVIC) testing. Peak linear envelope (peakLE) and total muscle activity (iEMG) were extrapolated and normalized to the MVIC and time cycle for the sit to stand task. Using iEMG, quadriceps-hamstrings muscle co-activation index was calculated for the task. Nonparametric Kruskal Wallace ANOVA tests and Wilcoxon rank sum tests were used to identify where significant (p < 0.05) differences occurred. The DM group had greater iEMG of the ST muscle compared to the CC (p=0.045) and the CON (p=0.015) groups. The CC group had lower iEMG for hamstring muscles compared to the DM (p=0.041) group. The DM group showed lower quadriceps-hamstrings co-activation index compared to the CON group and it approached significance (p=0.054). The CC group had greater anterior pelvis tilt compared to both DM (p=0.043) and the CON (p=0.047) groups. The DM also had larger knee varus angles and less knee internal rotation compared to both groups, however this never reached significance. No significant differences in muscle strength existed between the groups. Higher ST muscle activity in the DM group is explained by the reduction in internal rotation at the knee joint as the ST muscle was more active to resist the varus forces during the sit-to-stand task. Reduced quadriceps activity in the CC group is explained by increased pelvic anterior tilt as this would shorten the moment arm and muscle length in the quadriceps, ultimately reducing quadriceps muscle activity. The reduced co-activation between quadriceps and hamstrings activity in the DM group compared to the CC and CON groups is related to better hip function and stability. Combining lower co-activation and larger range of motion for the DM group without impingement, this implant seems to offer better prevention against THA subluxation and less wear of the implant

Fusion is the main goal in the surgical management of the injured and unstable spine. A wide variety of implants is available to enhance this. Our study was performed to evaluate the stabilising characteristics of several anterior, posterior and combined systems of fixation. Six thoracolumbar (T11 to L2) spines from 13-week-old calves were first tested intact. Then the vertebral body of T13 was removed and the defect replaced and supported by a wooden block to simulate bone grafting. Dorsal implants consisting of a Universal Spine System (USS) fracture system and an AO Fixateur interne (AOFI), and ventral implants comprising of a Kaneda Classic, a Kaneda SR, a prototype of the VentroFix single clamp/single rod construct (SC/SR) and the VentroFix single clamp/double rod construct (SC/DR) were first implanted individually to stabilise the removal of the vertebral body. Simulating the combined anteroposterior stabilisations, all ventral implants were combined with the AOFI. The range of motion (ROM) was measured under loads of up to 7.5 Nm. The load was applied in a custom-made spine tester in the three primary directions while measuring the intervertebral movements using a goniometric linkage system. The dorsal systems limited ROM in flexion below 0.9° and in extension between 3.3° and 3.6° (median values). The improved Kaneda System SR yielded a mean ROM of 1.8° in flexion and in extension. The median rotation found with the VentroFix (SC/DR) was 3.2° for flexion and 2.8° for extension. Reinforcement of the ventral constructs with a dorsal system reduced the ROM in flexion and extension in all cases to 0.4° and lower. In rotation, the median ROM of the anterior systems ranged from 2.7° to 5.1° and for the posterior systems from 3.9° to 5.7°, while the combinations provided a ROM of 1.2° to 1.9°. In lateral bending, the posterior implants restricted movement to 1.1°, whereas the anterior implants allowed up to 5.2°. The combined systems provided the highest stability at less than 0.6°. Our study revealed distinct differences between posterior and anterior approaches in all primary directions. Also, different stabilisation characteristics were found within the anterior and posterior groups. Combinations of these two approaches provided the highest stability in all directions

Objectives

We studied subchondral intraosseous pressure (IOP) in an animal model during loading, and with vascular occlusion. We explored bone compartmentalization by saline injection.

Using the transverse processes of fresh porcine lumbar spines as an experimental model we evaluated the heat generated by a rotating burr of a high-speed drill in cutting the bone. The temperature at the drilled site reached 174°C with a diamond burr and 77°C with a steel burr. With water irrigation at a flow rate of 540 ml/hr an effective reduction in the temperature was achieved whereas irrigation with water at 180 ml/hr was much less effective. There was a significant negative correlation between the thickness of the residual bone and the temperature measured at its undersurface adjacent to the drilling site (p < 0.001).

Our data suggest that tissues neighbouring the drilled bone, especially nerve roots, can be damaged by the heat generated from the tip of a high-speed drill. Nerve-root palsy, one of the most common complications of cervical spinal surgery, may be caused by thermal damage to nerve roots arising in this manner.

In order to determine the potential for an internervous safe zone, 20 hips from human cadavers were dissected to map out the precise pattern of innervation of the hip capsule. The results were illustrated in the form of a clock face. The reference point for measurement was the inferior acetabular notch, representing six o’clock. Capsular branches from between five and seven nerves contributed to each hip joint, and were found to innervate the capsule in a relatively constant pattern. An internervous safe zone was identified anterosuperiorly in an arc of 45° between the positions of one o’clock and half past two.

Our study shows that there is an internervous zone that could be safely used in a capsule-retaining anterior, anterolateral or lateral approach to the hip, or during portal placement in hip arthroscopy.

We describe a lateral approach to the distal humerus based on initial location of the superficial branches of the radial nerve, the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm. In 18 upper limbs the superficial branches of the radial nerve were located in the subcutaneous tissue between the triceps and brachioradialis muscles and dissected proximally to their origin from the radial nerve, exposing the shaft of the humerus. The inferior lateral cutaneous nerve of the arm arose from the radial nerve at the lower part of the spiral groove, at a mean of 14.2 cm proximal to the lateral epicondyle. The posterior cutaneous nerve of the forearm arose from the inferior lateral cutaneous nerve at a mean of 6.9 cm (6.0 to 8.1) proximal to the lateral epicondyle and descended vertically along the dorsal aspect of the forearm. The size and constant site of emergence between the triceps and brachioradialis muscles constitute a readily identifiable landmark to explore the radial nerve and expose the humeral shaft.

Although success has been achieved with implantation of bone marrow mesenchymal stem cells (bMSCs) in degenerative discs, its full potential may not be achieved if the harsh environment of the degenerative disc remains. Axial distraction has been shown to increase hydration and nutrition. Combining both therapies may have a synergistic effect in reversing degenerative disc disease. In order to evaluate the effect of bMSC implantation, axial distraction and combination therapy in stimulating regeneration and retarding degeneration in degenerative discs, we first induced disc degeneration by axial loading in a rabbit model.

The rabbits in the intervention groups performed better with respect to disc height, morphological grading, histological scoring and average dead cell count. The groups with distraction performed better than those without on all criteria except the average dead cell count.

Our findings suggest that bMSC implantation and distraction stimulate regenerative changes in degenerative discs in a rabbit model.

We studied the effect of vitamin C on fracture healing in the elderly. A total of 80 elderly Osteogenic Disorder Shionogi rats were divided into four groups with different rates of vitamin C intake. A closed bilateral fracture was made in the middle third of the femur of each rat. Five weeks after fracture the femora were analysed by mechanical and histological testing. The groups with the lower vitamin C intake demonstrated a lower mechanical resistance of the healing callus and a lower histological grade. The vitamin C levels in blood during healing correlated with the torque resistance of the callus formed (r = 0.525). Therefore, the supplementary vitamin C improved the mechanical resistance of the fracture callus in elderly rats. If these results are similar in humans, vitamin C supplementation should be recommended during fracture healing in the elderly.