Introduction. Atypical femoral fracture focused on relation of bisphosphonate use, frequently. However, the mechanism of atypical femoral fracture was not yet clarified. Atypical femoral fractures have been kept femoral shaft cortical thickness and BMD, practically. We hypothesized that atypical femoral fractures were associated with impaired bone quality and curvature of femoral shaft. Materials & Methods. We experienced four atypical femoral fractures. One was subtrochanteric and three were shaft fracture. Two cases received bisphosphonate therapy for 3–5 years. BMD, bone metabolic markers, and bone quality markers were evaluated. Histomorphometry and collagen cross-link analysis were performed. Curvature of femoral shaft and 3-D finite element analysis in one incomplete fracture case were assessed. Results. BMD values were either maintained or not severely decreased. Deterioration of bone quality were verified by the results of histomorphometry, collagen cross-link analysis, and bone quality maker. Especially, homocystine values, such as one of bone quality markers, were increased in all cases. All atypical femoral shaft fractures showed outward curvature of femoral bone. In one case of incomplete atypical femoral shaft fracture, stress was concentrated at the fracture region according 3-D finite element analysis. Conclusions. The results of this study suggest that atypical femoral fractures were estimated associated with deterioration of bone quality and curvature of femoral shaft

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. Patients and Methods. Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up. Results. In 100 patients (59 female, 41 male; mean age 57 years), 91 of the fractures (91%) remained stable. In five of nine patients (55%) with secondary displacement, surgery was recommended. Comminution, present in 23 patients (23%), was identified as a predictor of secondary displacement (p < 0.001). Patients’ age, sex, fracture configuration, and bone quality were not associated with secondary displacement (p ≥ 0.438). Nonoperative treatment resulted in a mean absolute Constant score (CS) of 80 (49 to 98), relative CS of 101% (63% to 138%), median subjective shoulder value of 95% (interquartile range (IQR) 90% to 100%), and median EuroQol five-dimensional questionnaire score of 0.89 (IQR 0.80 to 1.00) with bone union in all cases at one-year follow-up. Conclusion. Radiological re-evaluation was only necessary in patients presenting with comminution and may be redundant for 77% of patients with one-part proximal humerus fractures. Nonoperative treatment of one-part proximal humerus fractures remains the mainstay of treatment with a low rate of secondary surgery, a high union rate, and good clinical results. Cite this article: Bone Joint J 2019;101-B:1307–1312

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Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

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Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

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Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

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The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

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Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

Introduction. A review of the literature showed a discrepancy between biomechanical and clinical studies on fracture fixation failure in patients with poor bone quality. The objective of the present study is to assess the influence of local bone status on complications after surgical treatment of proximal humerus fractures. Methods. A prospective cohort study was initiated in 2007. The inclusion criteria were closed displaced fractures of the proximal humerus, primary fracture treatment with a Philos plate, patients aged 50 to 90, normal pre-trauma function of both shoulders in accordance to age, and monotrauma. There was active follow-up for one year with radiological assessment at clinical centers from four countries. Bone quality at the proximal humerus was determined preoperatively for the contralateral side of the fracture by CT scan, and at the contralateral radius within six weeks post-surgery by DXA. The occurrence of complications was monitored up to one year post-surgery. Independent x-ray evaluation and final classification of all complications will be performed at the end by a study review board using anonymous data and x-rays. Preliminary Results. 157 patients, 127 female (79%) met the inclusion criteria. Their mean age at time of surgery is 69 (range 50–89). 119 patients (100%) attended the 1-year follow-up assessment, 64 (96%) the one at 3 months, and 148 (99%) the 6 week follow-up examination. According to the WHO criteria, 107 patients (71%) suffered from either osteopenia or osteoporosis, while 43 patients (29%) had a normal T-score. The overall reported complication rate was 39%. However, the number of intraoperative complications was 0.6%, bone/fracture complications 19.1%, implant complications 15.3%, and general complications 14.6%. Discussion. Fixation of proximal humerus fractures with Philos plates in elderly people with osteoporotic bone is associated with a high rate of fixation failure. Final results will be reported after x-rays, local BMD (CT- based) and complications assessment have been conducted

Introduction. Osteoporosis (OP), osteoarthrosis (OA), and rheumatoid arthritis (RA) are the most common age-related degenerative bone diseases, and major public health problems in terms of enormous amount of economic cost. RA is considered as a major cause of secondary osteoporosis. At late stage, OP often leads to skeletal fractures, and OA and RA result in severe joint disability. Over the last a few decades, much significant research on the properties has been carried out on these diseases, however, a detailed comparison of the microarchitecture of cancellous bones of these diseases is not available. In this study, we investigated three-dimensional (3-D) microarchitectural properties of OP, OA and RA cancellous bone. We hypothesized that there were significant differences in microarchitecture among OP, OA and RA bone tissues that might lead to different bone quality. Materials and Method. Twenty OP, fifty OA, and twelve RA femur heads were harvested from patients undergone total hip replacement surgery. Cubic cancellous bone samples (8∗8∗8 mm3) were prepared and scanned with a high resolution microtomographic system (vivaCT 40, Scanco Medical AG., Brüttisellen, Switzerland). Then micro-CT images were segmented using individual thresholds to obtain accurate 3-D data sets. Detailed microarchitectural properties were evaluated based on novel unbiased, model-free 3-D methods. For statistical analysis, one-way ANOVA was used, and a p<0.05 was considered significant. Results. Significant differences in the microarchitecture of cancellous bone were observed among the OP, OA and RA groups. Compared with the other groups, OP cancellous bone had lowest density, thinner, typical rod-like structure and less connectivity (all p<0.01). Interestingly, there were no significant differences in the microarchitectural properties measured between the OA and RA cancellous bones. Both OA and RA cancellous bones had significant higher bone volume fraction and were thicker, typical plate-like structure compared with the OP group (all p<0.01), even though there was clearly bone erosion observed in RA cancellous bone. Discussion. Quantification of the alterations in bone properties and quality will help to gain more insights into the pathogenesis of degenerative bone diseases and to target and develop novel approaches for the intervention and treatment, and for the design, fixation and durability of total joint prosthesis. Our study demonstrated that there were significant differences in the microarchitecture of the OP, OA and RA femur head cancellous bone. The OA and RA cancellous bone had similar bone density and microarchitecture despite apparent bone erosion in the RA cancellous bone. These results from femur head did not support the traditional notion that RA and OP had similar low bone density. Thus, whether femur head bone tissues from these diseases have similar bone collagen, mineral and mechanical properties, more importantly bone quality, should be clarified in the future

The augmentation of fixation with bone cement is increasingly being used in the treatment of severe osteoporotic fractures. We investigated the influence of bone quality on the mechanics of augmentation of plate fixation in a distal femoral fracture model (AO 33 A3 type). Eight osteoporotic and eight non-osteoporotic femoral models were randomly assigned to either an augmented or a non-augmented group. Fixation was performed using a locking compression plate. In the augmented group additionally 1 ml of bone cement was injected into the screw hole before insertion of the screw. Biomechanical testing was performed in axial sinusoidal loading. Augmentation significantly reduced the cut-out distance in the osteoporotic models by about 67% (non-augmented mean 0.30 mm (. sd. 0.08) vs augmented 0.13 mm (. sd. 0.06); p = 0.017). There was no statistical reduction in this distance following augmentation in the non-osteoporotic models (non-augmented mean 0.15 mm (. sd. 0.02) vs augmented 0.15 mm (. sd. 0.07); p = 0.915). In the osteoporotic models, augmentation significantly increased stability (p = 0.017). Cite this article: Bone Joint J 2013;95-B:1406–9

Several low energy osteotomy techniques are described in the literature but there is limited evidence comparing healing indices. We present a retrospective review of two techniques to evaluate an optimum method. Method:. Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n=15) or DeBastiani corticotomy (n=12) technique. Indications for surgery included limb lengthening and bone transport for defect reconstruction with a minimal distraction of 2 cm. The patient radiographs were anonymised and the regenerate assessed by the two senior authors who were blinded to the osteotomy type. Bone quality was recorded along the anterior, posterior, medial and lateral cortices, graded 1–5 from absent to full consolidation over time in frame. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices were compared. Results:. The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the DeBastiani group 1.8 months/cm, This was not a significant difference. In both groups anterior bone formation was slower, and in 50% and 33% of the Gigli and DeBastiani groups respectively the anterior cortex did not fully heal by the time of frame removal. Discussion:. Both Gigli saw and DeBastiani corticotomy techniques result in good bone formation following distraction osteogenesis. The anterior tibial cortex consolidates more slowly than the other cortices in both groups. This is likely due to deficient soft tissue cover and direct periosteal damage at time of osteotomy

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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.

The relationship between advancing patient age, decreasing bone mineral density and increasing distal radial fracture incidence is well established. Biomechanical and clinical work has shown that the radiographic severity of distal radial fractures is greater in patients with poor bone quality. Between 1991 and 2007, the number of elderly Scots (aged 75 years or more) increased by 18%, and population projections predict a further 82% increase by 2035. This study was conducted to investigate the effect of recent changes in the demographics of our population on the pattern and radiographic severity of distal radial fractures encountered at our institution. The epidemiology of two distinct series of patients (1991–93; 2007–08) suffering distal radial fractures was compared. The patient and radiographic fracture characteristics known to be predictive of fracture instability and severity were compared using the MacKenney formulae, and a subgroup analysis of distal radial fragility fractures was performed. The life expectancy of our catchment population has improved since 1991, and we have encountered a larger number of distal radial fractures occurring in older, more active and functionally independent patients. We identified an increase in the proportion of AO type B fractures, particularly in the oldest patient groups. The radiographic severity of distal radial fractures, especially low energy metaphyseal injuries, has increased. If the current trend in population demographics continues, it seems likely that orthopaedic surgeons will encounter an increasing number of severe distal radial fractures deemed unsuitable for treatment by closed methods

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Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.

Introduction. Tunnelwidening in failed anterior cruciate ligament reconstruction (ACLR) can result in the staged revision procedures with a need for bone transplantation prior to revision reconstruction. Limited knowledge exist regarding to quality of different transplantation methods. The present study used CT-scanning to evaluate tunnel bone density after allogenic bone chips and bone cylinder transplantation. We hypothesized that bone chips transplantation resulted in higher bone density than bone cylinder transplantation due to possible voids between individual cylinders in the tunnels. Methods. The records of 24 patients operated for 1st stage revision ACLR from April 2003 to march 2010 were included in the study. twelve patients had their tunnels transplanted with bone chips and twelve patients with bone cylinders from allogenic femoral heads. Bone chips were created by fine bone milling and cylinders were extracted by 7–8 mm core drilling. Bone density 3–4 months after transplantation were evaluated by CT scanning reconstruction slides with 5 mm intervals throughout the tunnel length using histomorphometry. Results. There were 15 females and 9 males with an average age of 32 yrs. Using bone chips the bone density in the tibial tunnels was 55% and the femoral tunnels the bone density was 68% Using bone cylinders bone density was 60% in the tibial tunnels and 53% in the femoral tunnels. The femoral bone density in the bone chip group was significantly higher than the bone cylinders (p < 0.05). Conclusion. Transplantation with bone chips results in superior bone quality in the femoral tunnels where as no difference where demonstrated in the tibial tunnels

Background. Distal radial fractures in the elderly population have been traditionally managed by closed techniques, primarily due to their poor bone quality and low functional demands. Since the introduction of the volar locking plate (VLP), which provides a good fixation in osteoporotic bones, there maybe an increased use of open reduction and internal fixation (ORIF) in the elderly population. Aim. We aimed to determine the changes in the management of these fractures in Scotland, and whether this differs between specialist regional centres and district general centres. Patients and Methods. We retrospectively analysed distal radius fractures, in patients aged over 70 years in the period between 1989 and 2008. Data were obtained from the national statistical centre based on admission code and from discharge summaries. Data included patient demographics and treatment method; either open reduction and internal fixation (ORIF), Kirschner wire, or manipulation under anaesthetic (MUA). Results. Incidence of distal radius fractures has increased by 75% from 1989 to 2008. In 2003 there were 94 (13.6%) ORIF, 109 (15.1%) K-wire and 492 (71.3%) MUA. In 2008 there were 131 (22.5%) ORIF, 81 (14.2%) K-wire and 361 (63.3%) MUA. There has been a 34% increase in the number of ORIF and a 26% decrease in K-wire procedures. There is a difference in the proportion treated by ORIF in university hospital and district general hospital trusts; 11.8% more fractures are treated by ORIF in university hospitals (p<0.5). Conclusion. There has been an increasing tend to use VLP in the place of K wire fixation. However a vast majority of elderly patients are still treated primarily with MUA. There is an increased tendency to use VLP in university hospital trusts than in distict general hospitals. This may be a reflection of the availability and preferences of specialist orthopaedic hand surgeons

Title. 3D distribution of cortical bone thickness in the proximal humerus, implications for fracture management. Introduction. CT imaging is commonly used to gain a better understanding of proximal humerus fractures. the operating surgeon however has a limited capacity to evaluate the internal bone geometry from these clinical CT images. our aim was to use clinical CT in a novel way of accurately mapping cortical bone geometry in the proximal humerus. we planned to experimentally define the cortico-cancellous border in a cadaveric study and use CT imaging software to map out cortical thickness distribution in our specimens. Methodology. With ethical approval we used fifteen fresh frozen human proximal humeri. These were stripped of all soft tissue and transverse CT images taken with a GE VCT Lightspeed scanner. The humeral heads were then subsequently resected to allow access to the methaphyseal area. Using currettes, cancellous bone was removed down to hard cortical bone. Another set of CT images of the reamed specimen were then taken. Using Mimics imaging software[Materialise, Leuven] and a CAD interface, 3-matic [Materialise, Leuven], we built 3D model representations of our intact and reamed specimens. We first had to define an accurate CT density threshold for visualising cortical contours. We then analysed cortical thickness distribution based on that experimented threshold. Results. we were able to statistically determine the CT threshold, in Hounsfield Units, that represents the cortico-cancellous interface in the proximal humerus. Our 3D colour models provide an accurate depiction of the distribution of cortical thickness in the proximal humerus. Discussion/Conclusions. Our Hounsfield value for the cortico-cancellous interface in the proximal humerus agrees with a similar range of 400 to 800 HU reported in the literature for the proximal femur. Knowledge of regional variations in cortical bone thickness has direct implications for basic science studies on osteoporosis and its treatment, but is also important for the orthopaedic surgeon since our decision for treatment options is often guided by local bone quality

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Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

Introduction. Osteoporosis is a metabolic disease of the bone responsible for a loss of bone resistance and an increase in fracture risk. World Health Organization (WHO) estimations are about 6.3 millions of femoral neck fractures in the world by 2050. These estimations make osteoporosis a real problem in term of public health. Knowledge in biological tissues mechanical behaviour and its evolution with age are important for the design of diagnosis and therapeutic tools. From the mechanical aspect, bone resistance is dependent on bone density, bone architecture and bone tissue quality. If the importance of bone density and bone architecture has been well explored, the bone tissue quality still remains unstudied because of the lack of biomechanical tools suitable for testing bone at this microscopic dimension. Therefore the goal of this study is to estimate the osteoporotic cancellous bone tissue mechanical behaviour at its microscopic scale, using an approach coupling mechanical assays and digital reconstruction. Materials and methods. The experimental study is based on cancellous bone tissue extracted from human femoral head. Forty 8mm diameters bone cylinders have been removed from femoral head explanted after a femoral neck fracture treated by arthroplasty. These cylinders have been submitted to a digitally controlled compressive trial. Before and after the trials, microscanner analyses with an 8 μm spatial resolution have been realized in order to determine the micro structural parameters. The cylinders have been rebuilt with the digital model-building in order to estimate the mechanical behaviour and the bone quality. Results. The results will be presented from a macroscopic and microscopic point of view and will show the relationship between gender and age of the patients. At the macroscopic scale, we will look at that apparent young modulus heterogeneity and the cracking strength. At the microscopic scale, we will confirm that the cancellous bone tissue mechanical behaviour is close to the Haversian bone tissue mechanical behaviour. Finally, the parametric study will permit us to point out the main microstructural components influencing cancellous bone tissue quality. Conclusion. This study allows a precise estimation of the osteoporotic cancellous bone tissue mechanical behaviour. It seems to be a great step in the understanding of this disease and it could probably lead to great improvements in the diagnosis, prognostic, medical and surgical approaches of osteoporosis

Both posterior and anterior surgery have potential for complete scoliosis correction. Significant difference in judging the procedures still persists. Aim. To establish objective advantages and risks of the procedures, basing upon long term results. Method. From 1982–2007, 859 anterior(A) and 388 posterior(P) instrumentations were performed by the same surgeon. Single level thoracotomy used even in double curves. Spinal canal was never opened, rib heads left intact, ribs were fractured at the top of rib hump. Zielke rod was used for correction, and another rod added for aditional correction and stabilisation. Various posterior instrumentations were used. Results. CORRECTION (A)frontal 67-45-16(76%), sagital +6, (P)frontal 66-44-29(56%), sag+3; OP. TIME (A)140(50–300), (P)155(110–350); BLOOD REPL. (A)18%, (P)92%; HOSP STAY (A)10, (P)13; VC (A)-10%, (P)0%; SPORT ACT. (A)3mths, (P)12mths; MAJOR COMPLICATIONS: no deaths, (A)1 aorta rupture, 1 bronchus penetration, 0,7% haematothorax, 0,6% reinstrumentation, 0,7% infections demanding op, (P)2 paraplegia (0,5%), 3.9% infections, 4.9% reinstrumentation. Discussion. (A)required no neuromonitoring, no intensive care unit. Blood replacement was occasionally used only for double curves (11 segm), and in preop. anemia. Most of the complications were preventable. Hospitalisation was longer in (P) group due to wound problems. Pulmonary decrease was found only in curves greater than 100 °. Halo traction improved VC, but both instr. had no influence on further improv. In (A)VC recovered in 6 months. Conclusions. (A) can be performed in less radical and agressive way. Anterior release significantly mobilizes the spine and decreases necessary corrective forces. Infection was more frequent in (P) but consequences were more dramatic in (A). All major complications in (A) were preventable. There is temporary decrease in pulmonary function after (A). We could not find objectives for (A) to have more morbidity than (P). Due to superior results we still prefer (A) in surgery of AIS. Our indications for (P) is VC<40%, age, poor bone quality, surgery in upper thoracic spine