Background: Despite of advanced implant modifications and surgical techniques, internal fixation of proximal femur fractures in osteoporotic elderly is conditioned by high rate of complicated healing and implant failure. The deterioration in micro architecture and the loss in mechanical properties of trabecular bone due to impaired bone turnover must be treated. Teriparatide(TPTD) has been demonstrated to improve of new bone formation in both trabecular and cortical envelopes and thus bone strength. Moreover in a number of fracture models on anims stimulates the healing process generating larger total callus volume. The aim of this study was to determine if bone anabolic agent (TPTD) may enhance the repair of femoral neck fractures in osteoporotic elderly synthesized with internal fixation and prevent complications.

Study Design: 31 compliant females between 57 and 95 years-old presenting a lateral femoral neck fracture was considered. At admission in orthopaedic unit they were undergone to haematochemical exams extended to bone turnover markers, lumbar and contralateral femoral BMD measured by DXA and x-rays of dorsal-lumbar spine. They were divided in two subgroups on the basis of concomitant vertebral compression fracture (VCF) discovered. To the patients with VCF was administrated daily subcutaneous injection of 20 microgr. of TPTD (TPTD group). Both groups received 1g of calcium carbonate and 1200 IU of colecalciferol daily from the first post-operative week. All the patients repeated x-rays of affected segments and bone turnover markers at 1,3,6 months. The pain was detected through a self-reported visual analogue scale (VAS). The functional outcome was evaluated in term of hospitalization, of walking on two crutches and their abandon.

Results: At admission serum 25(OH) vitamin D concentration was at lower levels but the supplementation was sufficient to normalize even if in TPTD group it remained lower than control. In TPTD group the bone formation markers were significantly increased at 1st month and peaked at 3rd month without an increase in bone resorption markers. In TPTD group the callus formation was radiologically evident from 1st month followed by consolidation within 3rd month for all. While in control group the fracture repair was less detectable at 3rd month with heterogeneous trend: one needed a re-operation, four were afflicted by delayed union and another one by VCF. Moreover earlier walking and abandon of crutches in TPTD group was related to significant decrease of pain. At 6th month BMD is significantly increased only in TPTD group.

Conclusions: In osteoporotic femoral neck fractures the demonstration of enhanced repair, the stability of the osteosynthesis, the pain relief and the recovery of autonomy in walking obtained with adjuvant anabolic therapy (TPTD) opens new therapeutic perspectives.

Introduction: Between the elderly affected by femoral neck or diaphyseal fractures are emerging few serious complications as delate union, instability of osteosynthesis, re-fracture or periprosthetic fracture. In addition the co-morbidity elevate ulteriorly the risks of the new operation which is often impossible or refused. Recently it has been recommended to orthopaedic surgeons the managment and treatment of osteoporosis.

The aim of this study was to consider at 2 years follow-up the functional outcome of femoral fracture in osteoporotic elderly treated with a surgical procedure followed by daily assumption of teriparatide, an anabolic agent increasing bone mineral content, density and strength.

Materials and Methods: 21 compliant female between 63 and 94 years-old presenting a femoral fracture were recruited. Before operation they undergone to a routinary instrumental examins completed by bone metabolism screening. This was constituted by biochemical bone turnover markers, standard radiograms of dorsal and lumbar spine. Lumbar and contralateral femoral BMD was measured by DXA during hospitalization before the assumption of anabolic agent.

They received daily subcutaneous teriparatide (20 microg) per day for 18 months, 1g of calcium and 800 UI of vitamin D3 daily as oral supplementation from day 15 by operation.

All the patients repeated: xrays of affected segment at 2, 4, 6 months; biochemical bone markers 1, 3, 6, 12, 18 and 24 months; DEXA at first and second year.

The evaluation of the quality of life was evaluated in terms of recovery of walking, need of re.operation, occurance of new fracture and with a questionnaire.

Results: eleven lateral femoral neck fracture treated with endomedullary nail, six medial femoral neck fracture treated with cemented endoprosthesis, four periprosthetic fracture of the femur treated with plaque and screws. The healing was detected with radiograms before 4th month. The vitamin D was at lower levels at admission but the supplementation was sufficient to normalize. The other biochemical variables of bone formation and resorption peaked within the consolidation process then remained normalized for two years.

Lumbar and contralateral femoral BMD were increased after 12 months and maintained at 24 months.

At 2 years follow-up all patients live, walk in autonomy without or with stick and none of them have needed a re-operation or was afflicted by new vertebral or non vertebral fracture.

Conclusions: The clinical relevance of the present study is the significant improvement of functional outcome and quality of life after femoral fracture in osteoporotic elderly with post-operative assumption of anbolic agent as Teriparatide.

Introduction: The time necessary to return to sports activities after ACL reconstruction is 6 months. Few authors have speculated on the possibility to reduce this time with accelerated rehabilitation. But nobody has considered the proprioceptive aspects. Recently some experiments have demonstrated that a perturbation training program can improve the functional stability in ACL injured and reconstructed knees. Nevertheless there are no studies showing the effects of these exercises in long period.

The aim of this study was to find out if a specific proprioceptive exercise as perturbation training permits a further and durable recovery of proprioception after ACL reconstruction for an early return to agonism.

Material and Methods: 70 sportsmen with an isolated ACL injury were recruited. They were undergone to arthroscopic ACL reconstruction with the ST+G tendons by the same team. At discharge they were randomly assigned to two homogeneous groups: the first one ‘self-controlled’ composed by patients that followed the standard rehabilitation protocol without any help of therapist; the second group ‘Perturbation’ constituted by patients that followed between the 2nd and the 3rd months a specific proprioceptive protocol that included perturbation exercises on support surfaces (perturbation training).

They have been clinically evaluated before surgery and after 2, 3, 6 and 12 months after surgery with a kinaesthetic device constituted by a tilting platform equipped by digitalized sensor connected to a computer. The protocol included three repetition of one and two legged standing balance. The statistical analyses with t-test considered significant value of p< 0.05.

Results: All the test shows a significant improvement between pre and post-operative values. The improvements in the Perturbation group are more significant than the ones in the ‘self-controlled’ group at the 3rd month (two legged stance test: p=0,001; one legged stance on the operated side: p=0,003; one legged stance on the healthy side: p=0,0001).

Best results in the Perturbation group are maintained at the 6th month only in the one legged stance on healthy side (p=0,014) but any difference is still present at 12 months.

Conclusion: The significant improvement of the Perturbation group’s values at 3rd month demonstrates that accelerated rehabilitation of proprioception after ACL reconstruction may enhance knee proprioception and suggests the possibility of an early return to sports activities. Nevertheless it must be considered the duration of benefits obtained is limited to the period of application. Therefore other studies are necessary to establish if it’s only a problem of time and duration of application and/or type of specific rehabilitative exercises.

Despite several anatomical and neurophysiological studies have demonstrated the sensory role of anterior cruciate ligament (ACL), it is still unclear how significant the absence of the ACL will affect knee proprioception. Also because some mechanoreceptors has been discovered in the injured bundle commonly resected during ACL reconstruction.

In fact recently it has been observed that subjects with long standing ACL deficiency have not a knee joint pro-prioceptive deficit as measured by threshold of passive movement detenction and the ability to reproduce flex-ion angles, commonly accepted methods.

The aim of this study was to investigate the possibility to recognize a sensorial and behavior impairment in ACL deficient knee.

Through a computerized device the kinaesthetic data were collected from 120 sportsmen between 20–49 years (mean 32,4) affected by unilateral isolated ACL injury diagnosed with MRI and verified arthroscopically. The protocol consisted in four exercises, two bipodal on static and dynamic stance and two monopodal on healthy and injured lower limb. The balance index was divided in four areas on two dimensional plane for a qualitative assessment.

The mathematical and statistical elaboration revealed on bipodal static test a significant and costant displacement on the left side indipendently by the injured side and age. The kinaesthetic awarness was confirmed also by a significant increase of balance index in all exercises. Further studies are necessary to a better knowledge as a possible new tool.

In conclusion, this is the first report of a typical sensorial and behavior impairment in ACL deficient knee with intriguing clinical significance.

Background. Understanding of the pathogenetic mechanisms of non-union can not ignore bone remodelling and its cascade of processes at cellular and biochemical levels culminating in an incomplete structural and functional restoration of the damaged bone.

Osteoprotegerin (OPG) is expressed by osteoblasts and functions as a decoy receptor that is able to control and to regulate osteoclastogenesis and therefore to prevent bone resorption.

The objectives of our study were: to investigate OPG serum levels in shaft fractures non-union compared to controls; to assess the use of OPG as a marker for the early identification of fracture non-unions.

Material and Methods. OPG serum levels were determined in 25 male patients (aged between 20–59 years, mean 35.44 ± 11.53) with a shaft fracture non-union at the time of minimum six months (mean 16.83 ± 10.87) since trauma and age matched with 25 male controls patients (aged 20–59 mean 35.44 ± 11.76) with a shaft fracture healed. All patients were correctly operated with different types of synthesis for complex fractures of a long bone (humerus, femur, tibia). Osteocalcin, bone isoenzyme of alkaline phosphatase and deoxypyridino-line (DPD) were also measured.

Results. OPG levels were significantly higher in non-union cases compared to age matched controls (mean 10.17 ± 3.08 vs 8.54 ± 1.18 U/L; p=0.0084). DPD level was significantly higher in cases respect to controls (mean 7.9 ± 2.74 vs 3.8 ± 1.00 nmolDPD/mmol urinary creatinine excretion; p=0.0001). ROC analysis and the classification for probability cut-off show a very good negative predictive value (84%) for a cut-off of OPG 10 U/L, indicating that all patients having OPG lower than 10 U/L are probably free of non-union. Similarly, for an increase of 1 U/L of OPG there is an increase of probability of being a case of 92%. Higher OPG levels clearly carries a higher risk of non-union, thus indicating the usefulness of OPG evaluation in the follow-up of fractured patients. Larger groups will allow the estimation of the correct level of OPG threshold by age, which we are now able to estimate of about 8 U/L for young patients and 10 U/L for older ones in our population.

Conclusion. Shaft fracture non-union may occur following appropriate osteosynthesis in consequence of a condition of altered bone osteoclastic activity. OPG could be directly involved in the pathogenesis of shaft fractures non-union and seems to be an accurate predictive marker in non-union evaluation.