The August 2024 Research Roundup. 360. looks at: Effect of vitamin D deficiency on periprosthetic joint infection and complications after primary total joint replacement; Postoperative angiotensin receptor blocker use associated with decreased rates of manipulation under anaesthesia in patients undergoing total knee arthroplasty; Central sensitization: the missing link between psychological distress and poor outcome following primary total knee arthroplasty; Thromboprophylaxis for the trauma and orthopaedic surgeon; Life expectancy after treatment of metastatic bone disease: an international trend analysis

Aims. As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion. Methods. We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior lumbar fusion. The 'complex' group (CG) consisted of patients who had undergone fusion over three or more levels, or combined anterior and posterior surgery. On admission, the mFI-5 was calculated and nutritional parameters collected. Results. Complications occurred in 9.3% (37/396) of patients in the SG, and 10.1% (19/167) of patients in the CG. In the SG, the important predictors of complications were age (odds ratio (OR) 1.036; p = 0.002); mFI-5 (OR 1.026 to 2.411, as score increased to 1 ≥ 2 respectively. ;. p = 0.023); albumin (OR 11.348; p < 0.001); vitamin D (OR 2.185; p = 0.032); and total lymphocyte count (OR 1.433; p = 0.011) . In the CG, the predictors of complications were albumin (OR 9.532; p = 0.002) and vitamin D (OR 3.815; p = 0.022). Conclusion. The mFI-5 and nutritional status were effective predictors of postoperative complications in the SG, but only nutritional status was successful in predicting postoperative complications in the CG. The complexity of the surgery, as well as the preoperative frailty and nutritional status of patients, should be considered when determining if it is safe to proceed with lumbar spinal fusion. Cite this article: Bone Joint J 2020;102-B(12):1717–1722

Aims. Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI. Materials and Methods. A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Staphylococcus aureus screening, the management of anti-rheumatic medication, perioperative antibiotic prophylaxis, presurgical skin preparation, the operating room environment, irrigant options, and anticoagulation. Results. Poor glycaemic control, obesity, malnutrition, and smoking are all associated with increased rates of PJI. Vitamin D replacement has been shown in preliminary animal studies to decrease rates of PJI. Preoperative Staphylococcus aureus screening and appropriate treatment results in decreased rates of PJI. Perioperative variables, such as timely and appropriate dosage of prophylactic antibiotics, skin preparation with chlorohexidine-based solution, and irrigation with dilute betadine at the conclusion of the operation, have all been associated with reduced rates of PJI. Similarly, aggressive anticoagulation and increased operating room traffic should be avoided to help minimize risk of PJI. Conclusion. PJI remains a serious complication of arthroplasty. Surgeons should be vigilant of the modifiable risk factors that can be addressed in an attempt to reduce the risk of PJI

Aims. Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group. Patients and Methods. The World Hip Trauma Evaluation (WHiTE) is a multicentre, prospective cohort of hip fracture patients in NHS hospitals in England and Wales. Patients aged 60 years and older who received operative treatment for a hip fracture were eligible for inclusion in WHiTE. The prescription of bone protection medications was recorded from participants’ discharge summaries, and participant-reported use of bone protection medications was recorded at 120 days following surgery. Results. Of 5456 recruited patients with baseline data, 2853 patients (52%) were prescribed bone protection medication at discharge, of which oral bisphosphonates were the most common, 4109 patients (75%) were prescribed vitamin D or calcium, and 606 patients (11%) were not prescribed anything. Of those prescribed a bone protection medication, only 932 patients (33%) reported still taking their medication 120 days later. Conclusion. These data provide a reference for current prescription and adherence rates. Adherence with oral medication remains poor in patients with hip fracture. Cite this article: Bone Joint J 2019;101-B:1402–1407

1. A child is described who presented with very severe rickets and gross myopathy. The clinical, biochemical and radiological signs were identical with those to be expected of a very chronic and severe vitamin D deficiency. The child's diet, however, had been normal. 2. All the pathological signs, except for residual dwarfism and leg bowing, disappeared on treatment with very large doses of vitamin D. 2. Ordinary anti-rachitic doses had no effect. 3. We suggest that this child demonstrates a true resistance to the action of vitamin D and that the defect is permanent. The findings in two similar patients that we have seen suggest that the condition is inherited as an autosomal recessive gene, and that it may be the same disease as that described in the continental literature as "hereditäre pseudo-mangelrachitis" and by other names. 4. The disease seems distinct clinically and biochemically from the disease originally described under the name "vitamin resistant rickets," which does not respond so well to massive vitamin D therapy and which is usually inherited as a sex-linked dominant gene

The April 2015 Spine Roundup360 looks at: Hyperostotic spine in injury; App based back pain control; Interspinous process devices should be avoided in claudication; Robot assisted pedicle screws: fad or advance?; Vancomycin antibiotic power in spinal surgery; What to do with that burst fracture?; Increasing complexity of spinal fractures in major trauma pathways; Vitamin D and spinal fractures

The June 2013 Trauma Roundup. 360 . looks at: open foot fractures; the diagnostic accuracy of continuous compartment pressure monitoring; conservative treatment for supracondylar fractures; high complication rates in patellar fractures; vitamin D and fracture; better function with K-wires; and tensionless bands

1. A clinical, radiological and histological description of a patient with fibrogenesis imperfecta ossium is given. We think that this is the first case in which diagnosis has been made during the life of the patient. 2. The disease is characterised by a defect in the formation of the collagen fibres of the bone matrix. There is also a failure of normal calcification of the matrix, giving rise to the appearance of wide "osteoid" seams. When examined with the polarising microscope and when stained with Gomori's reticulin stain the collagen fibres can be seen to be grossly deficient and abnormal. 3. The patient presented at the age of fifty-four years with bone pain and multiple fractures. The only biochemical abnormality detected in the plasma was an elevated alkaline phosphatase. He was also in negative calcium balance. 4. Treatment with vitamin D. 2. , later changed to dihydrotachysterol, appears to have produced clinical, biochemical and radiological improvement. It appears that a direct action of the vitamin on the abnormal bone collagen must be postulated, in addition to its known actions on the calcifying mechanisms. 5. An unusual feature of the case was the slow development of a total unresponsiveness to large doses of vitamin D. 2. , in spite of a markedly elevated level of vitamin D in the plasma. There was later a response to a much smaller dose of dihydrotachysterol, which is being maintained to date

Slipped capital femoral epiphysis (SCFE) is uncommon in India and we routinely look for associated metabolic or endocrine abnormalities. In this study we investigated a possible association between vitamin D deficiency and SCFE. All children presenting with SCFE during the study period had their 25-hydroxyvitamin D levels measured as part of an overall metabolic, renal and endocrine status evaluation, which included measurement of body mass index (BMI). Vitamin D status was compared with age-, gender- and habitat-matched controls with acute trauma or sepsis presenting to our emergency department. A total of 15 children (12 boys and three girls) with a mean age of 13 years (. sd. 1.81; 10 to 16) presented for treatment for SCFE during a two-year period beginning in January 2010. Renal and thyroid function was within the normal range in all cases. The mean BMI was 24.9 kg/m. 2. (17.0 to 33.8), which was significantly higher than that of the controls (p = 0.006). There was a statistically significant difference between the mean values of 25-hydroxyvitamin D in the children with SCFE and the controls (11.78 ng/ml (. sd. 5.4) versus 27.06 ng/ml (. sd. 5.53), respectively; p < 0.001). We concluded that, along with high BMI, there is a significant association of vitamin D deficiency and SCFE in India. Cite this article: Bone Joint J 2013;95-B:851–4

Nutritional osteomalacia is a metabolic bone disorder common among the Asian female immigrant population in the United Kingdom. We describe the case of a female of Asian origin, who was found to have a unilateral undisplaced pseudofracture of the neck of the femur during pregnancy. Although not operated on the fracture was treated successfully with calcium and vitamin D supplement therapy. Within one month of treatment, the bone pain subsided and she was able to bear full weight. Subsequent radiological follow-up showed the pseudofracture to have healed sufficiently with no evidence of avascular necrosis. There should be a high index of suspicion of this disease, particularly among Asian patients presenting with persistent and non-specific musculoskeletal pain

Aims. Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques. The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate. Patients and Methods. The medical records and radiographs of all patients who underwent CHAOS for femoral deformity at our institution between 2005 and 2011 were retrospectively reviewed. Records were available for all 55 consecutive procedures undertaken in 49 patients with a mean age of 35.6 years (10.9 to 75.3) at the time of surgery. Results. Patients were assessed at a mean interval of 44 months (6 to 90) following surgery. The indications were broad; the most common were vitamin D resistant rickets (n = 10), growth plate arrest (n = 6) and post-traumatic deformity (n = 20). Multi-planar correction was required in 33 cases. A single level osteotomy was performed in 43 cases. Locking plates were used to stabilise the osteotomy in 33 cases and intramedullary nails in the remainder. Complications included two nonunions, one death, one below-knee deep vein thrombosis, one deep infection and one revision procedure due to initial under-correction. There were no neurovascular injuries or incidence of compartment syndrome. Conclusion. This is the largest reported series of femoral deformity corrections using the CHAOS technique. This series demonstrates that precise intra-operative realignment is possible with a hexapod external fixator prior to definitive stabilisation with contemporary internal fixation. This combination allows reproducible correction of complex femoral deformity from a wide variety of diagnoses and age range with a low complication rate. Cite this article: Bone Joint J 2017;99-B:283–8

Two patients, a Japanese man and woman both aged eighteen, developed symptoms and signs of osteomalacia over a period of five years. Each of them had a benign osteoblastoma, one in the right fourth metacarpal and the other in the uppermost third of the right humerus. Resection of the tumours without any treatment by vitamin D resulted in rapid cure of the osteomalacia. Attempts to prove a phosphaturic humoral substance or vitamin D antagonist in the osteoblastoma of the humerus were unsuccessful, probably due to prompt excretion from the tumour cells

The levels of the active metabolites of vitamin D were measured in the callus and in the epiphyseal growth plate of chicks given radioactive cholecalciferol during fracture healing. Those levels were correlated with the histological findings. Three groups of chicks were studied: a control group with no fracture, chicks with fractures fixed by Kirschner wire, and chicks with unfixed fractures. A significant increase in the levels of the active metabolites was found in the callus during the first few days after fracture. The levels of 25-hydroxycholecalciferol [25(OH)D3] and of 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were higher when there was no fixation, while those of 1,25-dihydroxycholecalciferol [1,25(OH)2D3] were higher after fixation. The concentrations of these metabolites in the proximal epiphysis of the tibia were similar to those found in the callus. Based on these findings it is suggested that the active metabolites of vitamin D are directly involved in the process of fracture repair

1. We have described here various forms of rickets and osteomalacia that we have studied ourselves and have come to recognise as comprising definite syndromes. We have included only diseases in which hereditary factors have been proved or might be suspected to play a part. 2. There are more of these syndromes than previously defined. 3. All these hereditary diseases can be treated, usually very satisfactorily, using the same general principles and with only very few simple medicines such as vitamin D and sodium bicarbonate. Careful control and long follow-up, however, may be required to achieve best results and to avoid accidents. 4. A study of the genetics of the diseases is a help in diagnosis and treatment. Broadly speaking the group of diseases which mimic vitamin D deficiency more or less closely tend to be inherited in dominant fashion. The groups with more severe degree of renal-tubule abnormality are inherited as recessives. 5. When more than one member of a family is affected it has been found that in each family each syndrome runs true to type

Mononuclear osteoclast precursors are present in the wear-particle-associated macrophage infiltrate found in the membrane surrounding loose implants. These cells are capable of differentiating into osteoclastic bone-resorbing cells when co-cultured with the rat osteoblast-like cell line, UMR 106, in the presence of 1,25(OH). 2. vitamin D. 3. In order to develop an in vitro model of osteoclast differentiation which more closely parallels the cellular microenvironment at the bone-implant interface in situ, we determined whether osteoblast-like human bone-derived cells were capable of supporting the differentiation of osteoclasts from arthroplasty-derived cells and analysed the humoral conditions required for this to occur. Long-term co-culture of arthroplasty-derived cells and human trabecular-bone-derived cells (HBDCs) resulted in the formation of numerous tartrate-resistant-acid-phosphatase (TRAP) and vitronectin-receptor (VNR)-positive multinucleated cells capable of extensive resorption of lacunar bone. The addition of 1,25(OH). 2. vitamin D. 3. was not required for the formation of osteoclasts and bone resorption. During the formation there was release of substantial levels of M-CSF and PGE. 2. Exogenous PGE. 2. (10. −8. to 10. −6. M) was found to stimulate strongly the resorption of osteoclastic bone. Our study has shown that HBDCs are capable of supporting the formation of osteoclasts from mononuclear phagocyte precursors present in the periprosthetic tissues surrounding a loose implant. The release of M-CSF and PGE. 2. by activated cells at the bone-implant interface may be important for the formation of osteoclasts at sites of pathological bone resorption associated with aseptic loosening

Aims. Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures. Materials and Methods. Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified. Results. For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing. Conclusion. Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295–302

1. Four cases of osteomalacia secondary to vitamin D deficiency have been investigated histologically and with the electron microscope. 2. Three main types of cells were found along the osteoid tissue. Cells of Group 1 are like normal osteoblasts, except that their cytoplasm has an ordered granular endoplasmic reticulum, without enlarged cysternae. Moreover, it contains isolated rosettes of glycogen. Cells of Group 2 are like young progenitor cells. There are almost no rough cysternae in the cytoplasm. This contains clusters of glycogen, isolated ribosomes and many mitochondria. Cells of Group 3 are structurally like "resting" flat osteoblasts in normal bone. 3. The paper discusses how the presence of the three groups may be related to vitamin D deficiency or secondary hyperparathyroidism. 4. Malacic osteoid tissue consists of apparently normal collagen fibrils. Both optical and electron microscopy show that this tissue can calcify. But calcification stops at an early stage, or proceeds much more slowly than normal. So large areas ofosteoid tissue are left uncalcified. 5. Calcium salts are laid down either as needle-shaped crystals exactly like those in normal bone, or else abnormally. Where abnormal they either appear in a finely granular, almost amorphous form, or else acquire a characteristic star-like crystalline structure. 6. Where calcification takes place bundles of laterally aggregated collagen fibrils are found

1. The clinical features, diagnosis and treatment of osteomalacia are discussed in relation to thirty-seven recently recognised cases. It is suggested that this disease is not uncommon in elderly women, among whom it is liable to be confused with senile osteoporosis. Osteomalacia may be distinguished by, firstly, the history, in which persistent skeletal pain of long duration and muscular weakness are typical of osteomalacia, but not of osteoporosis in which transient episodes of pain usually associated with a fracture are more characteristic. There is a high incidence of previous gastric surgery in the osteomalacia patients. Secondly, the physical examination shows skeletal tenderness in osteomalacia but this is not a particular feature of osteoporosis. A shuffling "penguin gait" suggests osteomalacia. Thirdly, the biochemistry shows a low plasma calcium and phosphate, and raised alkaline phosphatase levels commonly in osteomalacia but these are usually normal in osteoporosis. Reduced twenty-four-hour urinary calcium is characteristic of osteomalacia but not of osteoporosis. Fourthly, radiology will show diminished bone density which is common to both diseases, but if the changes are more marked in the peripheral bones than in the axial skeleton osteomalacia is suggested; the opposite is typical of osteoporosis. Skeletal deformity without fracture suggests osteomalacia, as do stress fractures and greenstick fractures in the elderly. Looser's zones are diagnostic of osteomalacia in which they are the most important radiological feature. Finally, histology will show the presence of excess osteoid tissue in undecalcified sections of bone in osteomalacia. This may be the earliest and most sensitive index of the disease and biopsy is indicated in all doubtful cases. 2. The etiology is discussed and it is suggested that a dietary deficiency of vitamin D, limited exposure to sunlight and mild degrees of malabsorption may all be important either alone or in combination. No satisfactory explanation is offered for the predominant female incidence. 3. A practical method of treatment is given and the dangers of uncontrolled administration of vitamin D indicated. 4. Treatment of osteomalacia is rapidly and consistently successful, and well justifies a thorough screening of all elderly patients presenting with weakness, skeletal pain, pathological fractures or with diminished radiographic density of bone

We describe a case of oncogenic osteomalacia in an adult male who presented with low back pain and bilateral hip pain. Extensive investigations had failed to find a cause. A plain pelvic radiograph showed Looser’s zones in both femoral necks. MRI confirmed the presence of insufficiency fractures bilaterally in the femoral head and neck. Biochemical investigations confirmed osteomalacia which was unresponsive to treatment with vitamin D and calcium. A persistently low serum phosphate level suggested a diagnosis of hypophosphataemic osteomalacia. The level of fibroblast growth factor-23 was highly raised, indicating the cause as oncogenic osteomalacia. This was confirmed on positron-emission tomography, MRI and excision of a benign fibrous histiocytoma following a rapid recovery. The diagnosis of oncogenic osteomalacia may be delayed due to the non-specific presenting symptoms. Subchondral insufficiency fractures of the femoral head may be missed unless specifically looked for

Aims

The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial. We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study.