Introduction. Spinal aBMD only explains 50–80% of vertebral strength, and the application of aBMD measurements in isolation cannot accurately identify individuals who are likely to eventually experience bone fracture, due to the low sensitivity of the test. For appropriate treatment intervention, a more sensitive test of bone strength is needed. Such a test should include not only bone mineral density, but also bone quality. Quantitative computed tomography-based finite element methods (QCT/FEM) may allow structural analyses taking these factors into consideration to accurately predict bone strength (PBS). To date, however, basic data have not been reported regarding the prediction of bone strength by QCT/FEM with reference to age in a normal population. The purpose of this study was thus to create a database on PBS in a normal population as a preliminary trial. With these data, parameters that affect PBS were also analyzed. Methods. Participants in this study comprised individuals who participated in a health checkup program with CT at our hospital in 2009. Participants included 217 men and 120 women (age range, 40–89 years). Exclusion criteria were provided. Scan data of the second lumber vertebra (L2) were isolated and taken from overall CT data for each participant obtained with simultaneous scans of a calibration phantom containing hydroxyapatite rods. A FE model was constructed from the isolated data using Mechanical Finder software. For each of the FE models, A uniaxial compressive load with a uniform distribution and uniform load increment was applied. For each participant, height and weight were measured, BMI was calculated. Simple linear regression analysis was used to estimate correlations between age and PBS as analyzed by QCT/FEM. Changes in PBS with age were also evaluated by grouping participants into 5-year age brackets. One-way analysis of variance was used to compare average PBS for participants in each age range. Mean PBS in the 40–44 year age range was taken as the young adult mean (YAM). The ratio of mean PBS in each age group to YAM was calculated as a percentage. A multivariate statistical technique was used to determine how PBS was affected by age, height, weight, and BMI. Result/Discussion. Mean PBS was lower in women than in men for all age ranges. PBS in men and women significantly decreased with age. Simple linear regression between age and PBS showed the annual rate of decline in PBS was 55 N/year in men and 164 N/year in women. Mean PBS in the 75–79 year age range was 77% of YAM in men and in women, that in the 70–79 year age range was 47% of YAM. PBS was strongly dependent on age, while physical status had less effect

In the assessment of fracture healing by monitoring stiffness with vibrational analysis or instrumented external fixators, it has been assumed that there is a workable correlation between stiffness and strength. We used four-point bending tests to study time-related changes in stiffness and strength in healing tibial fractures in sheep. We aimed to test the validity of the measurement of stiffness to assess fracture strength. At each duration of healing examined, we found marked variations in stiffness and strength. Stiffness was shown to be load-dependent: measurements at higher loads reflected ultimate strength more accurately. There was a biphasic relationship between stiffness and strength: at first there was a strong correlation regardless of loading conditions, but in the second phase, which included the period of ‘clinical healing’, stiffness and strength were not significantly correlated. We conclude that the monitoring of stiffness is useful primarily in assessing progress towards union but is inherently limited as an assessment of strength at the time of clinical union. Any interpretation of stiffness must take into account the load conditions

Introduction. Closed avulsion of the Flexor Digitorum Profundus (FDP) from distal phalanx most commonly affects the ring finger when an extensive force is applied to a finger in active flexion. Whilst it is undoubtably reasonable to provide treatment for those who present with symptoms, there may be a cohort of people who sustain an avulsion without noticing. This study aims to quantify the effect of ring finger FDP avulsion on overall grip strength to determine the functional effect of a missed injury. Method. Right handed volunteers, with no abnormality on examination were included (N= 42). Proximal muscle group action was excluded. Grip strength was tested using a Jamar dynamometer with and without splinting of the ring finger to block flexion at the DIPJ and repeated six times alternately to mitigate the effects of fatigue. Results. Most subjects showed a small (0.3–3kg) change in their average grip strength with the splint (N= 29). Some showed a dramatic change in their grip strength (6–11.4) (N=6) others showed no change or slight improvement with the splint (−3–0) (N=7). Data were not normally distributed (kolmogorov-smirnov p=0.023). A wilcoxon signed rank test showed a statistically significant difference in performance with, compared to without, the splint, mean 2.34kg reduction (−3.3 − 11.4) (p <0.0005. Discussion. Horton et al have examined the quadriga effect and shown that the individual strength of other digits is reduced when one FDP is isolated. This implies overall grip strength should be reduced; our data supports this assertion. However despite splinting, the majority of subjects were still within the normal range of power for age. Larger scale studies are required to assess the functional effect of repair vs conservative management

Dynamometric measurement of the grasp strength is commonly used in wrist assessment. On the other hand measurement of the pronation-supination (PS) strength has been few studied. The longitudinal forearm rotation needs integrity of the two radioulnar joints and of the antebrachial interosseous membrane. The strength developed during PS assesses also trophicity of pronator and supinator muscles. A PS dynamometer (Baseline ®, AREX) is now available for such measurements. The aims of this study were: 1) to study the best way to neutralize the shoulder movements of abduction-adduction, 2) to find the values of PS Strength in a healthy population, and 3) to study correlations between this PS force and several biometric items. A first series of measurements des PS strength was performed thanks to the Baseline dynamometer in 8 people, in association with two devices neutralizing the shoulder movements of abduction-adduction, in repeated campaigns allowed the authors to determine and keep the better one for optimal measurements following campaigns. To assess the normal values of PS Strength in a healthy population, 38 healthy volunteers from both genders and different ages, classified according their age class, from three different forearm position: neutral, from 90 ° of supination and 90 ° of pronation. Finally, statistical analysis looked for correlations between PS strength and some biometric data. Manipulations beginning from a neutral position of forearm were the most reliable. The mean strength within the whole studied sample (76 wrists, 17 male, 21 female) was 10.6 N.m (standard deviation SD 3.26) for the supination and 13.9 N.m (standard deviation 4.19) for the supination. The dominant side exhibited a PS strength superior by 7.5% to that of the non-dominant side. Male gender, the height and weight of the body, forearm circumference displayed positive relationships with PS strength. Mean values of PS strength, measured from a neutral forearm rotation and with the best device to neutralize the shoulder movements, in a healthy population of 38 volunteers, allowed the authors establishing reference values. They will allow precise comparisons between the values found in patients suffering from forearm and/or wrist pathology and the healthy population, taking into account the age, gender and hand dominance

Introduction. Total leg muscle function in hip OA patients is not well studied. We used a test-retest protocol to evaluate the reproducibility of single- and multi-joint peak muscle torque and rapid torque development in a group of 40–65 yr old hip patients. Both peak torque and torque development are outcome measures associated with functional performance during activities of daily living. Material and Methods. Patients: Twenty patients (age 55.5±3.3, BMI 27.6±4.8) who underwent total hip arthroplasty participated in this study. Reliability: We used the intra-class correlation (ICC) and within subject coefficients of variation (CVws) to evaluate reliability. Agreement: Relative Bland-Altman 95% limits of agreements (LOA) and smallest detectable difference (SDD) were calculated and used for evaluation of measurement accuracy. Parameters: Maximal muscle strength (peak torque, Nm) and rate of torque development (Nm•sec-1) for affected (AF) and non-affected (NA) side were measured during unilateral knee extension-flexion (seated), hip extension-flexion, and hip adduction-abduction (standing), respectively. Contractile RTD100, 200, peak was derived as the average slope of the torque-time curve (torque/time) at 0–100, 0–200 and 0 peak relative to onset of contraction. Protocol: After 5 min level walking at self-selected and maximum speeds each muscle group was tested using 1–2 sub-maximal contraction efforts followed by 3 maximal contractions 4s duration. Statistics: The variance components were estimated using STATA12, with muscle function and occasion as independent variable and patients as random factor, using the restricted maximum likelihood method (=0.05). Results. For all exercises and sides, the ICC's for peak torque were good (0.81–0.96) with CVws ranging from 5.0–10.8%. Similar good ICC's were observed for RTD200 on the non-affected side (0.83–0.93), whereas most exercises (4/6) on the affected side showed moderate to good ICC (0.72–0.82). We found moderate CVws for RTD200 with 12.8–18.7% and 10.3–18.9%, affected and non-affected, respectively. With few exceptions the ICC's and CVws for RTD100 were moderate to poor on the affected side but good to moderate on the non-affected side. The SDD's for peak torque ranged from 14.9 Nm to 39.0 Nm, equal to relative LOA of 13.9–23.8%. For RTD200, the SDD's were 77–257 Nm•sec-1 and 29.2–86.2%, absolute and relative, respectively. With few exceptions interventions measuring RTD100 and RTDpeak would have to find changes exceeding 60% for them to be statistical significant. Conclusions. Our novel set-up for lower limb isometric muscle testing showed overall good reproducibility for peak torque, moderate for RTD200, while poor for RTD100 and RTDpeak. The results for peak torque and RTD200 are promising for defining relevant changes in muscle function in future longitudinal clinical trials in this patient group

The use of external fixation in the management of long bone fractures has long been recognised.

The aim of this study was to compare 3 differing constructs of Hoffman-2 and Hoffman-3 External Fixator systems to assess which potentially withstood the greatest load.

Three different constructs (2, 3 and 4-bar) of Hoffman 2 and 3 External Fixation systems were tested. A UHMWPE tube was utilised as a bone substitute to construct a biomechanically reproducible model which could be tested on an MTS testing jig. Each construct was loaded to 3, 5, 8, 12 and 15mm of displacement at the fracture gap. Each construct was cyclically loaded 200 times for each test and repeated 5 times.

The results demonstrate that the Hoffman-3 configurations withstood a load of at least twice that of the Hoffman 2 configurations across all displacements. Using a 2-way ANOVA test at all displacements the 2-bar configuration withstood greater load than the 3 bar (P<0.0001). With Hoffman 2 the 2-bar configuration withstood a greater load than the 4 bar diamond configuration.

These results demonstrate that Hoffman-3 External Fixation Device has a greater axial loading capacity than its Hoffman-2 predecessor.

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (sd 33 900) vs 12 800 cycles (sd 6100); p = 0.007) and mean axial stiffness (220 N/mm (sd 80) vs 70 N/mm (sd 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (sd 0.9) vs 5.1 Nm/° (sd 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (sd 25 600) vs 52 400 cycles (sd 22 500); p = 0.04).

The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients.

Cite this article: Bone Joint J 2014;96-B:114–21.

Aims. There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. Methods. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. Results. Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges’ g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. Conclusion. We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953–962

Aims. Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy. Methods. Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year. Results. A total of 116 (97%) of 120 enrolled participants commenced treatment. Of those, 21 were lost to follow-up, resulting in 30 participants in the advice leaflet, 32 in the advice video, and 33 face-to-face therapy arms, respectively at six weeks of follow-up. There was no significant difference between the treatment groups in the DASH at six weeks (advice leaflet vs face-to-face therapy, p = 0.69; advice video vs face-to-face therapy, p = 0.56; advice leaflet vs advice video, p = 0.37; advice leaflet vs advice video vs face-to-face therapy, p = 0.63). At six weeks, there were no differences in any secondary outcome measures except for the DASH work subscale, where face-to-face therapy conferred benefit over advice leaflet (p = 0.01). Conclusion. Following cast removal for nonoperatively treated distal radius fractures, offering an advice leaflet or advice video for rehabilitation gives equivalent patient-reported outcomes to a course of face-to-face therapy. Cite this article: Bone Joint J 2021;103-B(6):1033–1039

Aims. The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking. Methods. Patients were treated in a single level I trauma centre over a 2.5-year period. Group allocation was not randomized; both the micromotion nail and standard-of-care static locking nails (control group) were commercially available and selected at the discretion of the treating surgeons. Injury risk levels were quantified using the Nonunion Risk Determination (NURD) score. Radiological healing was assessed until 24 weeks or clinical union. Low-dose CT scans were acquired at 12 weeks and virtual mechanical testing was performed to objectively assess structural bone healing. Results. A total of 37 micromotion patients and 46 control patients were evaluated. There were no significant differences between groups in terms of age, sex, the proportion of open fractures, or NURD score. There were no nonunions (0%) in the micromotion group versus five (11%) in the control group. The proportion of fractures united was significantly higher in the micromotion group compared to control at 12 weeks (54% vs 30% united; p = 0.043), 18 weeks (81% vs 59%; p = 0.034), and 24 weeks (97% vs 74%; p = 0.005). Structural bone healing scores as assessed by CT scans tended to be higher with micromotion compared to control and this difference reached significance in patients who had biological comorbidities such as smoking. Conclusion. In this pilot study, micromotion fixation was associated with improved healing compared to standard tibial nailing. Further prospective clinical studies will be needed to assess the strength and generalizability of any potential benefits of micromotion fixation. Cite this article: Bone Jt Open 2021;2(10):825–833

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

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Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data.

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The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

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Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Aims

The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty.

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

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Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients.