Fractures of the distal forearm are widely regarded as the result of “fragility”. We have examined the extent to which patients with Colles’ fractures have osteopenia. We measured the bone mineral density (BMD) in the contralateral radius of 235 women presenting with Colles’ fractures over a period of two years. While women of all ages had low values for ultra-distal BMD, the values, in age-matched terms, were particularly low among premenopausal women aged less than 45 years. This result was not due to the presence of women with an early menopause. This large survey confirms and extends the findings from earlier small studies. We consider that it is particularly important to investigate young patients with fractures of the distal forearm to identify those with osteoporosis, to seek an underlying cause and to consider treatment

Introduction. The risk factors for new adjacent vertebral compression fracture (NAVCF) after Vertebroplasty (VP) or Kyphoplasty (KP) for osteoporotic vertebral compression fractures (VCFs) were investigated. Materials and methods. The authors retrospectively analyzed the incidence of NAVCFs in 135 patients treated with VP or KP for osteoporotic VCFs. Study period was from 2004 to 2008 with minimum follow-up of 2 years. Possible risk factors were documented: age, gender, body mass index, bone mineral density (BMD), co-morbidities, location of treated vertebra, treatment modality and amount of bone cement injected. Anterior-posterior vertebral body height ratio, intra-discal cement leakage into the disc space and pattern of cement distribution of the initial VCF and adjacent vertebral bodies were assessed on lateral thoracolumbar radiographs by 2 independent assessors. Results. 21 patients (15.6%) had subsequent symptomatic NAVCFs with a median time to new fracture was of 125 days. There was no difference in incidence of NAVCF between VP and KP groups (P>0.05). Significant differences were found between patients with and without NAVCF in terms of age, BMD, and the proportion of cement leakage into the disc space (P < 0.05). Greater age, intra-discal cement leakage and low BMD were found in patients with NAVCF. Conclusion. The most important risk factors affecting NAVCFs were age, osteoporosis and intra-discal cement leakage

Background. The treatment of femoral neck fracture with internal fixation (IF) is recommended in younger patients and has compared to arthroplasty the advantage of retaining the femoral head. A big problem with osteosynthesis is though failure. Finding predictors for fixation failure is still an ongoing process and osteoporosis has been suggested as a predictor. Aim. To correlate bone mineral density (BMD) in regard to failure of IF in osteosynthesized femoral neck fractures. Material and method. In a health technology assessment study from 2005–2006 at Odense University Hospital, Department of Orthopaedic Surgery and Traumatology, 175 patients with femoral neck fractures accepted DEXA - scanning of the hip and lumbar spine assessing BMD. Final follow-up were 01.08.2010 and 141 patients with IF comprised the final cohort. The cohort consisted of 105 females and 36 males with a mean (CI) age of 77,2 (75,4–79,0). Failure is defined as revision surgery or new fracture. Results. 69 patients had a t-score (total hip) below −2,5 SD as defined for osteoporosis. At 1 year the overall (dislocated) failure rate was 34,5 % (44,7 %), at 2 years 45,4 % (60,0 %) and at end of follow-up 49,6 % (62,8 %). In the cox regression analysis the following factors for failure were significant: dislocated fracture, osteosynthesis placement and prior fracture. There were no associations for total hip BMD, neck BMD, age, sex, quality of fracture reduction, walking disability, independent living, alcohol or smoking. A cox regression sub analysis of the undisplaced fractures showed significant result only for osteosynthesis placement. Conclusion. There is no association between BMD and failure of internal fixation in osteosynthesized femoral neck fractures

Introduction. Metal-on-metal hip resurfacing (MOMHR) is a good surgical indication for young active patients. However, it cannot be used in patients with an excessively short femoral head/neck. To address these cases, a new surgical technique has been developed comprising femoral head augmentation using impacted morcellized bone grafts. Methods. 32 osteoarthritis patients who had severe congenital insufficiency of the femoral head/neck were treated with MOMHR combined with femoral head augmentation. Mean patient age was 49 ± 9 years (18–66). The required amount of augmentation was calculated on preoperative X-rays and confirmed during surgery. Using specially designed instrumentation, bone chips produced while reaming the socket and trimming the head were impacted onto the head to achieve the desired reconstruction and lengthening. Finally, the femoral component was cemented. Results. Mean head lengthening was 12 ± 2mm. Mean follow-up was 4.2 years (3–6). Mean preoperative Harris hip score was 58, increasing to 95 at follow-up (p<0.05). Mean leg lengthening was 2.2cm (p=0.001). In all Gruen zones, bone mineral density (BMD) decreased during the first 3 months. At 2 years, in zone 1, mean BMD increased to 96.8% (p=0.009) and to 102.1% in zone 7 (p=0.05). A correlation was found between valgus positioning of the femoral components and increased BMD (p=0.005). To date, only 1 patient has been revised due to socket loosening. Discussion and conclusions. This bone grafting technique expands the use of MOMHR to patients with severe deficiencies of the femoral head, thereby leading to a more anatomical reconstruction with a full recovery of function and BMD of the proximal femur

Objective. To compare regional body composition, bone mineral density (BMD), and clinical outcome in patients with two different shoulder arthroplasty designs. Materials and Methods. This cross-sectional study included 54 patients with a total of 63 shoulder arthroplasties. There were 18 men and 45 women with a mean age of 68.9 years SD ± 10.5. Mean follow-up time was 39.2 months SD ± 14.4. The patients were divided into three groups according to their history: 22 patients were diagnosed with a proximal humeral fracture and treated with a stemmed hemi arthroplasty, 11 patients were diagnosed with osteoarthritis and treated with a stemmed hemi arthroplasty, and 30 patients were diagnosed with osteoarthritis and treated with a resurfacing arthroplasty. All patients underwent a one-day protocol: Regional Dual X-ray Absorptiometri (DXA) was used to measure BMD of the distal third of humerus and regional body composition of the upper arm. The clinical outcome was measured using Western Ontario Osteoarthritis of the Shoulder index (WOOS) and Constant-Murley score. Results. All three groups were comparable regarding demographic data. Mean BMD of the distal third of humerus was 1.029 g/cm2 SD ± 0.204, mean tissue mass of the upper arm was 2.6 kg SD ± 0.7 and mean muscle mass was 1.4 kg SD ± 0.6. BMD of the distal third of humerus, tissue mass and muscle mass were significantly higher in the group diagnosed with osteoarthritis and treated with a resurfacing arthroplasty compared to the group diagnosed with a proximal humeral fracture and treated with a stemmed hemi arthroplasty, P = 0.03, P = 0.01 and P = 0.02 respectively. Median Constant score was 45.0, range 6–89, median WOOS 633, range 28–1824, and median strength 7.0 units, range 0–25. There were no significant differences between the three groups. Nevertheless, there was a trend towards a higher Constant-Murley score and muscle strength in the group of patients diagnosed with osteoarthritis and treated with a resurfacing arthroplasty compared to the group of patients diagnosed with a proximal humeral fracture and treated with a stemmed hemi arthroplasty. Conclusion. After shoulder arthroplasty BMD of the distal third of humerus and body composition are apparently more dependent on diagnosis rather than arthroplasty design. However, a larger number of patients diagnosed with osteoarthritis and treated with a stemmed hemi arthroplasty are needed to support this

Despite proven advantages, pulsatile lavage seems to be used infrequently during preparation in cemented total knee arthroplasty. This remains irritating, as the technique has been suggested to improve radiological survival in cemented TKA, where aseptic loosening of the tibial component represents the main reason for revision. Furthermore, there may be a potential improvement of fixation strength for the tibial tray achieved by increased cement penetration. In this study, the influence of pulsed lavage on mechanical stability of the tibial component and bone cement penetration was analyzed in a cadaveric setting. Six pairs of cadaveric, proximal tibia specimen underwent computed tomography (CT) for assessment of bone mineral density (BMD) and exclusion of osseous lesions. Following surgical preparation, in one side of a pair, the tibial surface was irrigated using 1800ml normal saline and pulsatile lavage, while in the other side syringe lavage using the identical amount of fluid was applied. After careful drying, bone cement was hand-pressurized on the bone surface, tibial components were inserted and impacted in an identical way. After curing of cement, specimen underwent a postimplantation CT analysis). Cement distrubution was then assessed using a three-dimenionsional visualization software. Trabecular bone, cement and implant were segmented based on an automatic thresholding algorithm, which had been validated in a previous study. This allowed to determine median cement penetration for the entire cemented area. Furthermore, fixation strength of the tibial trays was determined by a vertical pull-out test using a servohydraulic material testing machine. Testing was performed under displacement control at a rate of 0,5mm/sec until implant failure. Data was described by median and range. Results were compared by a Wilcoxon matched pairs signed rank test with a type 1 error probability of 5 %. Median pull-out forces in the pulsed lavage group were 1275N (range 864–1391) and 568N (range 243–683) in the syringe lavage group (p=0.031). Cement penetration was likewise increased (p=0.031) in the pulsed lavage group (1.32mm; range 0.86–1.94), when compared to the syringe irrigated group (0.79mm; range 0.51–1.66). Failure occurred in the pulsatile lavage group at the implant-cement interface and in the syringe lavage group at the bone-cement interface, which indicates the weakness of the latter. Altogether, improved mechanical stability of the tibial implant and likewise increased bone cement interdigitation could be demonstrated in the current study, when pulsed lavage is implemented. Enhanced fixation strength was suggested being a key to improved survival of the implant. If this is the case, pulsatile lavage should be considered being a mandatory preparation step when cementing tibial components in TKA

Introduction. Several short femoral stems have been introduced in primary total hip arthroplasty, supposedly in order to save proximal bone stock. We intended to analyse primary stability, changes in periprosthetic bone mineral density (BMD), and clinical outcome after insertion of the uncemented collum femoris preserving (CFP)-femoral device. Methods. A prospective cohort study on 30 patients scheduled for receiving the CFP-stem combined with an uncemented cup was carried out. Stem migration was analysed by radiostereometry (RSA). Preoperative total hip BMD and postoperative periprosthetic BMD in Gruen zones 1–7 was investigated by DXA, and the Harris hips score (HHS) was determined. The patients were followed up to 12 months. Results. 2 patients were intraoperatively excluded because their proximal femur was found to be unsuitable for insertion of the studied implant, 1 patient was later revised due to a deep infection. This left 27 patients for final analysis. RSA showed that only very little migration of the implant occurred, with the largest amplitude found in rotation around the y-axis (1.8°, SD 0.6, after 12 mths), representing minimal stem retroversion. DXA after 12 mths demonstrated substantial BMD loss in Gruen zones 7 (−30.8%), 6 (−19.1%) and 2 (−13.3%, p-values for all described changes <0.001 when comparing with baseline BMD determined immediately postoperatively). There was a moderate correlation of low preoperative total hip BMD with a higher amount of bone loss in Gruen zones 2 (Pearson correlation coefficient r = 0.6, p = 0.001), 6 (r = 0.5, p = 0.005) and 7 (r = 0.6, p = 0.003). In contrast, we found no correlation of periprosthetic bone loss in any of the Gruen zones 1–7 with logarithmically transformed maximal total point translation (MTPT) of the stem (p > 0.05 for all regions), neither after 3 nor after 12 mths. The mean HHS increased from 49 (SD 15) preoperatively to 99 (SD 2) after 12 mths. Interpretation. Based on these short-term data, we conclude that i) the studied implant seems to be stable within the first year, ii) substantial loss in periprosthetic BMD - with a predominance in the calcar region - occurs, iii) low preoperative total hip BMD predisposes towards greater loss of periprosthetic BMD after 12 months, iv) postoperative loss in periprosthetic BMD does not correlate with increased stem migration. Clinical results are excellent so far. Continuing follow-up will reveal whether this novel stem remains stable in the medium and long term, and whether the loss in BMD in the regions mentioned above can be recovered with time or whether it continues

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.

Aims

Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS).

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Aims

Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants.

Aims

In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck.

We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years.

Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D.

Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years.

The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.

Aims

The aim of this study was to investigate the effect of a posterior malleolar fragment (PMF), with < 25% ankle joint surface, on pressure distribution and joint-stability. There is still little scientific evidence available to advise on the size of PMF, which is essential to provide treatment. To date, studies show inconsistent results and recommendations for surgical treatment date from 1940.

It is becoming increasingly common for a patient to have ipsilateral hip and knee replacements. The inter-prosthetic (IP) distance, the distance between the tips of hip and knee prostheses, has been thought to be associated with an increased risk of IP fracture. Small gap distances are generally assumed to act as stress risers, although there is no real biomechanical evidence to support this.

The purpose of this study was to evaluate the influence of IP distance, cortical thickness and bone mineral density on the likelihood of an IP femoral fracture.

A total of 18 human femur specimens were randomised into three groups by bone density and cortical thickness. For each group, a defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing the appropriate lengths of component. The maximum fracture strength was determined using a four-point bending test.

The fracture force of all three groups was similar (p = 0.498). There was a highly significant correlation between the cortical area and the fracture strength (r = 0.804, p <  0.001), whereas bone density showed no influence.

This study suggests that the IP distance has little influence on fracture strength in IP femoral fractures: the thickness of the cortex seems to be the decisive factor.

Cite this article: Bone Joint J 2014;96-B:1378–84.

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

We carried out a retrospective review over ten months of patients who had presented with a low-energy subtrochanteric fracture. We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active. The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.

Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis.

Osteoporosis and fragility fractures in men constitute a considerable burden in healthcare. We have reviewed 2035 men aged over 50 years with 2142 fractures to clarify the epidemiology of these injuries and their underlying risk factors. The prevalence of osteoporosis ranged between 17.5% in fractures of the ankle and 57.8% in those of the hip. The main risk factors associated with osteoporosis were smoking (47.4%), alcohol excess (36.2%), body mass index < 21 (12.8%) and a family history of osteoporosis (8.4%). Immobility, smoking, self-reported alcohol excess, a low body mass index, age ≥72 and loss in height were significantly more common among men with fractures of the hip than in those with fractures elsewhere.

Epidemiological studies enhance clinical practice in a number of ways. However, there are many methodological difficulties that need to be addressed in designing a study aimed at the collection and analysis of data concerning fractures and other injuries. Most can be managed and errors minimised if careful attention is given to the design and implementation of the research.

Cite this article: Bone Joint J 2014;96-B:863–7.

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of greater than 5º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union.

This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes.

Cite this article: Bone Joint J 2014;96-B:956–62.