Can a Wireless Full-HD Head Mounted Display System Improve Knee Arthroscopy Performance? - A Randomized Study Using a Knee Simulator

INTRODUCTION

Our prototype wireless full-HD Augmented Reality Head-Mounted Display (AR-HMD) aims to eliminate surgeon head turning and reduce theater clutter. Learning and performance versus TV Monitors (TVM) is evaluated in simulated knee arthroscopy.

METHODS

19 surgeons and 19 novices were randomized into either the control group (A) or intervention group (B) and tasked to perform 5 simulated loose-body retrieval procedures on a bench-top knee arthroscopy simulator. A cross-over study design was adopted whereby subjects alternated between devices during trials 1-3, deemed the "Unfamiliar" phase, and then used the same device consecutively in trials 4-5, to assess performance in a more "Familiarized" state. Measured outcomes were time-to-completion and incidence of bead drops.

RESULTS

In the unfamiliar phase, HMD had 67% longer mean time-to-completion than TVM (194.7 ± 152.6s vs 116.7 ± 78.7s, P < .001). Once familiarized, HMD remained inferior to TVM, with 48% longer completion times (133.8 ± 123.3s vs 90.6 ± 55s, P = .052). Cox regression revealed device type (OR = 0.526, CI 0.391-0.709, P < .001) and number of procedure repetitions (OR = 1.186, CI 1.072-1.311, P = .001) are significantly and independently related to faster time-to-completion. However, experience is not a significant factor (OR = 1.301, CI 0.971-1.741, P = .078). Bead drops were similar between the groups in both unfamiliar (HMD: 27 vs TVM: 22, P = .65) and familiarized phases (HMD: 11 vs TVM: 17, P = .97).

CONCLUSION

Arthroscopic procedures continue to be better performed under conventional TVM. However, similar quality levels can be reached by HMD when given more time. Given the theoretical advantages, further research into improving HMD designs is advocated.

Should nails be locked dynamically or statically in atypical femoral fractures? - A radiological analysis of time to union and reoperations in 236 displaced fractures with 4 years average follow-up

INTRODUCTION

Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking.

METHODS

Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons.

RESULTS

A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82-0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24-10.96 vs 13.0 months; 95% CI = 10.60-15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction.

CONCLUSIONS

Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures.

Outcomes of fracture-related infections - do organism, depth of involvement, and temporality count?

Purpose: To determine mortality and outcomes of patients diagnosed with fracture-related infections (FRIs).Methods: FRI patients treated at a trauma centre between 2001 and 2020 were analysed. The primary outcome was 1-year mortality; mortality associations with FRI organism, depth of involvement, and temporality were investigated with multivariable survival analysis. Healthcare-associated and serological outcomes were reported as secondary outcomes. Results: 311 FRIs with mean age of 67.0 and median Charlson comorbidity index of 0 were analysed. Methicillin-sensitive Staphylococcus aureus (MSSA) (29.9%) was the most frequently implicated organism. The majority of FRIs were deep infections (62.7%). FRIs were diagnosed at a median of 40 (IQR 15-200) days post index surgery. The mean follow-up was 5.9 years. One-year mortality amounted to 17.7%. MSSA FRIs were associated with better survival (adj HR 0.34, 95%CI 0.15-0.76, p = 0.008). There was no difference in survivorship between deep or superficial FRI (adj HR 0.86, 95%CI 0.62-1.19, p = 0.353) or in relation to onset time (adj HR 1.0, 95%CI 0.99-1.00, p = 0.943). Implant removal or debridement alone was performed in 61.7% and 17% respectively. Antibiotics was prescribed for 53 (IQR 23-110) days, and patients were hospitalised for 39 (IQR 19-78) days. CRP and ESR normalised in 70.3% (median 46 days) and 53.8% (median 86 days) patients respectively. Conclusion: Fracture-related infections are associated with significant mortality and morbidity regardless of depth and temporality. Non-MSSA FRIs are associated with inferior survival.

Development and initial validation of a novel thread design for nonlocking cancellous screws

High failure rates have been associated with nonlocking cancellous screws with a typical buttress thread in patients with osteoporotic bone. This study aimed to develop a novel thread design and compare its fixation stability with that of a typical buttress thread. Nonlocking cancellous screws with a novel thread design (proximal flank angle of 120 degrees, a flat crest feature, a tip-facing undercut feature) and nonlocking cancellous screws with a typical buttress thread were manufactured using stainless steel. Fixation stabilities were evaluated individually by the axial pullout and lateral migration tests, and they were evaluated in pairs together with a dynamic compression plate in an osteoporotic bone substitute (10 PCF polyurethane foam per ASTM F1839) under cyclic craniocaudal and torsional loadings. Pullout strength and lateral migration resistance for the individual screw test and the force, torque, and number of cycles required to achieve specific displacement and torsion for the multi-screw test were comparatively analyzed between both screw types. A finite element analysis model was constructed to analyze the stress distributions in the bone tissue adjacent to the threads. The biomechanical test revealed the novel undercut thread had superior axial pullout strength, lateral migration resistance, and superior fixation stability when applied to a dynamic compression plate under cyclic craniocaudal loading and torsional loading than those in the typical buttress thread. The finite element analysis simulation revealed that the novel thread can distribute stress more evenly without high-stress concentration at the adjacent bone tissue when compared to that of a typical buttress thread.

Biomechanical comparison of the undercut thread design versus conventional buttress thread for the lag screw of the dynamic hip screw system

Objective: To compare the fixation stability of the lag screw with a undercut thread design for the dynamic hip screw (DHS) system versus the lag screw with the conventional buttress thread. Methods: The lag screws with the undercut thread (a flat crest feature, a tip-facing undercut feature) and buttress thread were both manufactured. Fixation stability was investigated using cyclic compressive biomechanical testing on custom osteoporotic femoral head sawbone. The forces required for the same vertical displacement in the two types of lag screw were collected to evaluate the resistance to migration. Varus angle was measured on X-ray images to assess the ability in preventing varus collapse. Finite element analysis (FEA) was performed to analyze the stress and strain distribution at the bone-screw interface of the two types of lag screws. Results: The biomechanical test demonstrated that the force required to achieve the same vertical displacement of the lag screw with the undercut thread was significantly larger than the lag screw with conventional buttress thread (p < 0.05). The average varus angles generated by the undercut and buttress threads were 3.38 ± 0.51° and 5.76 ± 0.38°, respectively (p < 0.05). The FEA revealed that the region of high-stress concentration in the bone surrounding the undercut thread was smaller than that surrounding the buttress thread. Conclusion: The proposed DHS system lag screw with the undercut thread had higher migration resistance and superior fixation stability than the lag screw with the conventional buttress thread.

Defining blood gas analysis stability limits across five sample types

Accurate reporting of blood gas samples is dependent upon following proper preanalytical sample handling requirements though there is variation for sample acceptability criteria across institutions. We examined five common sample types (arterial, venous, umbilical arterial, umbilical venous and capillary) stored at either room temperature or on crushed ice in a time series (0, 15, 30, 45, 60, 90, 180, 240 min) and applied local regulatory and/or institutional allowable performance limits to determine the need for cold preservation and/or maximum stability time for pH, pO₂, pCO₂, glucose, lactate, sodium, potassium, chloride, and ionized calcium where applicable in each sample type. Although changes in sample pO₂ and/or lactate values were responsible, in part or in whole, for surpassing the allowable limits in nearly all sample types analyzed, this was not uniformly observed across sample types within the typical time limits that are referenced in literature. Furthermore, we demonstrated that cold preservation may not ubiquitously provide longer stability for blood gas specimens and this is dependent on the sample type and analyte in question. Nevertheless, these results demonstrate the known instability of pO₂ and lactate and suggest that it may be possible to simplify the monitoring of preanalytical conditions by first evaluating pO₂ and lactate in patient blood gas samples if applicable.

Development and initial validation of a novel undercut thread design for locking screws

BACKGROUND

Locking screws with a typical buttress thread have high levels of failure in patients with osteoporotic bones. This study aims to develop a novel thread design for the locking screw and compare its fixation stability with the typical buttress thread.

METHODS

Locking screws with a novel thread design that possess an undercut feature and locking screws with a typical buttress thread were manufactured from stainless steel. Their fixation stabilities were then evaluated individually under a lateral migration test and evaluated in pairs together with a locking plate (LP) in an osteoporotic bone substitute under cyclic craniocaudal and torsional loadings. A finite element analysis (FEA) model was constructed to analyze the stress distributions present in the bone tissue adjacent to the novel thread versus the buttress thread.

RESULTS

The biomechanical test revealed that the novel thread had a significantly higher lateral migration strength than the buttress thread. When applied to a LP, the locking screw with the novel thread requires more cycles and higher forces or torque to resist migration up to 5 mm or 10° than the buttress thread. The FEA simulation showed that the novel thread can make the stress distribute more evenly at the adjacent bone tissue when compared with the buttress thread.

CONCLUSIONS

The locking screw with the novel undercut thread had superior lateral migration resistance during both initial and continued migration and superior fixation stability when applied to a LP under both cyclic craniocaudal loading and torsional loading than the locking screw with a typical buttress thread.

Orthogeriatric Multidisciplinary Co-Management Across Acute and Rehabilitation Care Improves Length of Stay, Functional Outcomes and Complications in Geriatric Hip Fracture Patients

Introduction

As the global number of geriatric hip fracture cases continues to proliferate, a newly developed orthogeriatric co-management multidisciplinary care model has been implemented since November 2018 to meet further increases in demand. Our objective was to evaluate the effectiveness of the new pathway in improving the clinical outcomes of fragility hip fractures.

Methods

The data of geriatric hip fracture patients from 1 April 2018 till 30 October 2018 was collected as the conventional orthopaedic care model (pre-orthogeriatric care model) to compare with data from the orthogeriatric co-management model, 1 Feb 2019 till 31 August 2019. Clinical outcomes were analyzed between the groups, with the efficiency of the programme reflected in the total length of stay in acute and convalescent hospitals.

Results

194 patients were recruited to the conventional group and 207 were recruited to the orthogeriatric group, 290 patients (72.3%) were female. The mean (SD) patient age was 84.2 (7.9) years. The median length of stay in the acute and rehabilitation hospitals decreased by 1 day and 2 days, respectively (P=.001). The orthogeriatric group was associated with a higher Modified Barthel Index score on discharge from the rehabilitation hospital and more patients in the orthogeriatric collaboration group received osteoporosis medication prescription within one year after the index fracture. There was no difference in the 28-days unplanned readmission rate, complication rate, mortality rate or Elderly Mobility Scale scores on discharge from the rehabilitation hospital between the two groups.

Conclusion

Orthogeriatric collaboration has been proven to be effective in terms of a decreased length of stay in both the acute and the rehabilitation hospitals.

The effect of early mobilization on functional outcomes after hip surgery in the Chinese population - A multicenter prospective cohort study

OBJECTIVE

To compare the functional status and quality of life (QoL) between patients who underwent an early mobilization scheme and those who underwent a late mobilization scheme after hip fracture fixation surgery in elderly Chinese patients.

METHODS

This was a prospective cohort study. Patients (≥65 years old) with unstable intertrochanteric fractures treated with intramedullary nails were recruited from nine centers in China. Study centers either performed early mobilization or late mobilization scheme. All patients performed immediate in-bed mobilization after surgery and followed a standardized daily exercise program at home during the first 12 weeks. Functional status was measured by the Modified Barthel Index at postoperative visit, 6 weeks, and 12 weeks. QoL was measured by the EuroQol-5D (EQ-5D) at 12 weeks.

RESULTS

One hundred and forty-eight patients were enrolled to early mobilization, and 136 to late mobilization. At 6 weeks, early mobilization resulted in a significantly better Modified Barthel Index than late mobilization (mean [SD]: 83.7 [12.0] vs. 67.0 [17.5], p < .001). Adjusted mixed effects model showed significantly higher Modified Barthel Index for early mobilization at postoperative visit, 6 weeks, and 12 weeks (all p < .001). Patients in the early mobilization group had slightly better EQ-5D Index at 12 weeks than patients in the late mobilization group (mean: 0.91 vs 0.87, p = .002).

CONCLUSIONS

Early postoperative mobilization resulted in better functional outcomes up to 12 weeks. QoL was rated statistically significantly better in the early mobilization group, but the difference was small and may not be clinically relevant.

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

INTRODUCTION

Topical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.

METHODS

A total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.

RESULTS

There was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760-1.795) in the TXA group and 1.078 L (IQR: 0.797-1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40-140) in the TXA group and 70 mL (IQR: 30-168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).

CONCLUSION

A 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.

The Development of a Magnesium-Releasing and Long-Term Mechanically Stable Calcium Phosphate Bone Cement Possessing Osteogenic and Immunomodulation Effects for Promoting Bone Fracture Regeneration

Bone grafts are commonly used for the treatment of critical sized bone defects. Since the supply of autologous bone is insufficient, allogeneic bone grafts have been used most of the time. However, the poor osteogenic property of allogeneic bone grafts after pretreatment results in delayed union, non-union, or even occasional deformity. Calcium phosphate cement (CPC) is one of the most promising bone filling materials due to its good biocompatibility and similar chemical components as natural bone. However, clinical applications of CPC were hampered by limited osteogenic effects, undesired immune response which results in resorption, and poor mechanical stability in vivo. Magnesium (Mg) has been proven to trigger bone regeneration through modulating cell behaviors of mesenchymal stem cells and macrophages significantly. Unfortunately, the degradation raters of pure Mg and Mg oxide are extremely fast, resulting in early collapse of Mg contained CPC. In this study, we developed a novel magnesium contained calcium phosphate bone cement (Mg-CPC), possessing long-term mechanical stability and osteogenic effects through sustained release of Mg. Furthermore, in vitro studies showed that Mg-CPC had no cytotoxic effects on hBMMSCs and macrophage RAW 264.7, and could enhance the osteogenic differentiation as determined by alkaline phosphate (ALP) activity and calcium nodule staining, as well as suppress the inflammatory as determined by expression of anti-inflammatory cytokine IL-1RA. We also found that Mg-CPC promoted new bone formation and bone maturation in vivo. These results suggest that Mg-CPC should be a good substitute material for bone grafts in clinical use.

Stenotic intercondylar notch is not a risk factor for posterior cruciate ligament rupture: a morphological analyses using magnetic resonance imaging

PURPOSE

The present study aimed to examine the factors related to the morphological characteristics of the femoral condyle in posterior cruciate ligament rupture in female and male populations.

METHODS

One hundred and three patients (41 females, 62 males) with posterior cruciate ligament rupture from 2010 to 2020 were included in this retrospective case-control study. The sex and age of the posterior cruciate ligament rupture group were matched to those of the control group (41 females, 62 males; age range 16-69 years). Magnetic resonance imaging was used to measure the intercondylar notch width, femoral condylar width, and intercondylar notch angle in both the axial and coronal images. The 'α' angle was also measured using magnetic resonance imaging. The notch width index is the ratio of the intercondylar notch width to the femoral condylar width. Three types of intercondylar notch shapes (types A, U, and W) were evaluated in the axial magnetic resonance imaging images.

RESULTS

The difference in the mean coronal notch width index between the study groups was statistically significant in the female population. The difference in the mean coronal femoral condylar width between the study groups was statistically significant in the male population.

CONCLUSIONS

A larger coronal notch width index was the greatest risk factor for posterior cruciate ligament rupture in the female population. In the male population, decreased coronal condylar width was the greatest risk factor for posterior cruciate ligament rupture. The results did not indicate that patients with a PCL rupture have a stenotic intercondylar notch. Posterior cruciate ligament injury prevention strategies could be applied to females with a larger coronal notch width index and males with a decreased condylar width.

LEVELS OF EVIDENCE

Level III.

Development and validation of a modularized external fixator for generating standardized fracture healing micromotions in rats

Aims

To fully verify the reliability and reproducibility of an experimental method in generating standardized micromotion for the rat femur fracture model.

Methods

A modularized experimental device has been developed that allows rat models to be used instead of large animal models, with the aim of reducing systematic errors and time and money constraints on grouping. The bench test was used to determine the difference between the measured and set values of the micromotion produced by this device under different simulated loading weights. The displacement of the fixator under different loading conditions was measured by compression tests, which was used to simulate the unexpected micromotion caused by the rat’s ambulation. In vivo preliminary experiments with a small sample size were used to test the feasibility and effectiveness of the whole experimental scheme and surgical scheme.

Results

The bench test showed that a weight loading < 500 g did not affect the operation of experimental device. The compression test demonstrated that the stiffness of the device was sufficient to keep the uncontrollable motion between fracture ends, resulting from the rat’s daily activities, within 1% strain. In vivo results on 15 rats prove that the device works reliably, without overburdening the experimental animals, and provides standardized micromotion reproductively at the fracture site according to the set parameters.

Conclusion

Our device was able to investigate the effect of micromotion parameters on fracture healing by generating standardized micromotion to small animal models.

Cite this article: Bone Joint Res 2021;10(11):714–722.

Distal radius fracture: An opportunity for osteoporosis intervention

Background

Distal radius fractures have been reported as a predictor of subsequent osteoporotic fragility fractures. This retrospective study evaluated the proportion of patients with distal radius fractures at a government hospital in Hong Kong who received diagnostic evaluation or treatment for osteoporosis within 1 year.

Methods

Five hundred sixty-one postmenopausal women aged >50 years admitted to a public hospital between 2013 and 2017 for a low-energy distal radius fracture were analysed for initiation of osteoporosis medications and/or arrangement of dual-energy X-ray absorptiometry screening within 1 year of injury.

Results

Within 1 year, 8.4% of patients were prescribed osteoporosis medication and 6.1% of patients had dual-energy X-ray absorptiometry arranged. Patients with a previous fracture were more likely to receive osteoporosis medication (18.6% vs 7.5%, P = 0.012) and either intervention (screening or medication) overall (23.3% vs 10.4%, P = 0.011).

Conclusions

Few postmenopausal women who suffered a distal radius fracture received osteoporosis intervention within 1 year. Orthopaedic surgeons should be aware of the possibility of underlying osteoporosis and opportunity for intervention when managing fragility distal radius fractures.

Non-union bone fractures

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

Differences in soft tissue damage using a percutaneous versus open approach for antegrade straight humeral nailing: a quantitative and qualitative anatomical study

BACKGROUND

Percutaneous insertion of third-generation straight humeral nails is a recent alternative to the conventional open method. Rather than splitting, retracting and subsequently repairing the supraspinatus fibers to visualize the humeral head entry site, the percutaneous approach utilizes a cannulated awl to enter the intramedullary canal through the supraspinatus fibers without visualizing internal shoulder structures. Despite recent evidence demonstrating satisfactory outcomes in the percutaneous method, the potential for iatrogenic injury to the rotator cuff and other shoulder structures is not fully understood.

MATERIALS AND METHODS

We performed an anatomical study of 46 shoulders in 23 cadavers to compare damage caused to internal shoulder structures between the open and percutaneous techniques. Dimensions and morphologies of supraspinatus and humeral head perforations were recorded.

RESULTS

The percutaneous technique produced greater latitudinal tearing (p = 0.002) and less longitudinal tearing (p < 0.001) of muscle fibers, however there was no difference in supraspinatus hole area (p = 0.748). The long head biceps tendon was within 3 mm of the bone entry hole in 13 (28%) shoulders, with one shoulder in the open group exhibiting full tendon transection.

CONCLUSIONS

Percutaneous insertion of intramedullary nails using a cannulated awl appears to produce similar soft tissue and bone entry site morphology as compared to the conventional open technique. The percutaneous method was associated with slightly greater latitudinal tearing, however the effects of this remain to be clarified through clinical studies. External rotation should be avoided during instrumentation to reduce the risk of biceps tendon transection.

A comparison of six outcome measures across the recovery period after distal radius fixation-Which to use and when?

PURPOSE

Many standardized outcome measures exist to measure recovery after surgical fixation of distal radius fractures, however, choosing the optimal instrument is difficult. We evaluated responsiveness, ceiling/floor effects, and criterion validity over multiple time intervals across a 2-year follow-up period for six commonly used instruments.

METHODS

A total of 259 patients who received open reduction and internal fixation for distal radius fractures between 2012 and 2015 were recruited. Patients were administered the Patient-Rated Wrist Evaluation (PRWE), Shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), Green and O'Brien score (Cooney modification) (CGNO), Gartland and Werley score (Sarmiento modification) (SGNW), flexion-extension arc (FEArc), and grip fraction test (GripFrac) at 1.5, 3, 6, 12, and 24 months postoperatively. Responsiveness was evaluated by calculating standardized response means (SRM) and Cohen's d effect sizes (ES), and by correlating each instrument's change scores against those of QuickDASH and PRWE, which were also used as external comparators to assess criterion validity. Ceiling/floor effects were calculated for all measures at each time point.

RESULTS

SRM (1.5-24 months) were 1.81, 1.77, 1.43, 1.16, 2.23, 2.45 and ES (1.5-24 months) were 1.81, 1.82, 1.95, 1.31, 1.99 and 2.90 for QuickDASH, PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Spearman correlation coefficients against QuickDASH at 24 months were: 0.809, 0.248, 0.563, 0.285, and 0.318 for PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Significant (>15% of patients reaching maximum score) ceiling effects were observed before 6 months for PRWE and SGNW.

CONCLUSIONS

Our evidence supports the use of QuickDASH, PRWE, FEArc and GripFrac up to 6 months postsurgery, and QuickDASH and PRWE after 6 months.

LEVEL OF EVIDENCE

Level II.

Lateral migration resistance of screw is essential in evaluating bone screw stability of plate fixation

Conventional evaluation of the stability of bone screws focuses on pullout strength, while neglecting lateral migration resistance. We measured pullout strength and lateral migration resistance of bone screws and determined how these characteristics relate to screw stability of locking plate (LP) and dynamic compression plate (DCP) fixation. Pullout strength and lateral migration resistance of individual bone screws with buttress, square, and triangular thread designs were evaluated in polyurethane foam blocks. The screw types with superior performance in each of these characteristics were selected. LP and DCP fixations were constructed using the selected screws and tested under cyclic craniocaudal and torsional loadings. Subsequently, the association between individual screws’ biomechanical characteristics and fixation stability when applied to plates was established. Screws with triangular threads had superior pullout strength, while screws with square threads demonstrated the highest lateral migration resistance; they were selected for LP and DCP fixations. LPs with square-threaded screws required a larger force and more cycles to trigger the same amount of displacement under both craniocaudal and torsional loadings. Screws with triangular and square threads showed no difference in DCP fixation stability under craniocaudal loading. However, under torsional loading, DCP fixation with triangular-threaded screws demonstrated superior fixation stability. Lateral migration resistance is the primary contributor to locking screw fixation stability when applied to an LP in resisting both craniocaudal and torsional loading. For compression screws applied to a DCP, lateral migration resistance and pullout strength work together to resist craniocaudal loading, while pullout strength is the primary contributor to the ability to resist torsional loading.

Multi-Component Care Bundle in Geriatric Fracture Hip for Reducing Post-Operative Delirium

Background:

Delirium in elderly orthopaedic patients poses an enormous medical, social and financial burden to the healthcare system, and causes significant distress to patients and their caregivers. We examined whether a Multi-component Care Bundle (MCB) could reduce the incidence of post-operative delirium (POD) in fractured hip patients.

Methods:

An observational study was conducted, analyzing 154 patients (mean age ± SD, 85 ± 7.8, 68% women) admitted to Queen Mary Hospital with hip fracture. Half of the patients were cared for in the control group before MCB was introduced, which included installation of orientation aids, introduction of a Caregiver Empowerment Program, and incorporation of ultrasound-guided Fascia Iliaca Block (FIB) into the analgesia protocol.

Results:

There were fewer patients with POD in the MCB group, compared with the control group (18/76, 23.4% v 34/76, 44.2%, p = 0.006). Patients in MCB group consumed less opioid ( 4/77 v 13/77, p = 0.048), experienced less post-operative dizziness (2/77, 2.6% v 13/77, 16.9%, p = 0.003) and had a shorter median day to start walking post-operatively (day 1 [IQR 1-2] vs day 2 [IQR 2-3]; p = 0.001) than the control group. Length of stay was not affected.

Conclusion:

MCB effectively reduces POD, postoperative dizziness, opioid consumption, and days to start mobilization postoperatively.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire

INTRODUCTION

The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture.

METHODS

This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes.

RESULTS

Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores.

CONCLUSION

Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Reverse contralateral proximal tibial plating and cannulated screws fixation for Hoffa fracture: A case report

Hoffa fracture is a rare type of distal femoral fracture occurs in the coronal plane of either femoral epicondyle. To date, screws in combination with lateral plate fixation is widely accepted to achieve stable fixation and good results. However, up to now there has not been a specially designed anatomical plate for lateral fixation of Hoffa fracture. In this report, we demonstrate a case of Hoffa fracture fixed with reverse application of “L” shaped contralateral proximal tibia plate and cannulated screws, resulting in good one-year results.

The AO trauma CPP bone infection registry: Epidemiology and outcomes of Staphylococcus aureus bone infection

Bone infection represents a serious complication of orthopedic surgery and Staphylococcus aureus is the most common pathogen. To improve the understanding of host-pathogen interaction, we developed a biospecimen registry (AO Trauma CPP Bone Infection Registry) to collect clinical data, bacterial isolates, and serum from patients with S. aureus bone infection. A prospective multinational registry with a 12-month follow-up was created to include adult patients (18 years or older) with culture-confirmed S. aureus infection in long bones after fracture fixation or arthroplasty. Baseline patient attributes and details on infections and treatments were recorded. Blood and serum samples were obtained at baseline, 6, and 12 months. Patient-reported outcomes were collected at 1, 6, and 12 months. Clinical outcomes were recorded. Two hundred and ninety-two patients with fracture-related infection (n = 157, 53.8%), prosthetic joint infection (n = 86, 29.5%), and osteomyelitis (n = 49, 16.8%) were enrolled. Methicillin-resistant S. aureus was detected in 82 patients (28.4%), with the highest proportion found among patients from North American sites (n = 39, 48.8%) and the lowest from Central European sites (n = 18, 12.2%). Patient outcomes improved at 6 and 12 months in comparison to baseline. The SF-36 physical component summary mean (95% confidence interval) score, however, did not reach 50 at 12 months. The cure rate at the end of the study period was 62.1%. Although patients improved with treatment, less than two-thirds were cured in 1 year. At 12-month follow-up, patient-reported outcome scores were worse for patients with methicillin-resistant S. aureus infections.

Evaluation of an expectation and outcome measurement questionnaire in ankle fracture patients: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) Eurasia study

BACKGROUND

The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) questionnaire is a self-administered, patient-rated outcome measurement questionnaire designed to measure both 'expectation' and 'outcome' in orthopaedic trauma patients using two subsets of 10 items. We aimed to validate this instrument in a culturally diverse cohort of patients recruited from Asian and European regions.

METHODS

A total of 193 adult patients with surgically treated AO Foundation/Orthopaedic Trauma Association types 43 and 44 ankle malleolar and distal tibia fractures were recruited with 158 followed up till 1 year. Expectations were assessed prior to surgery, at 2 weeks and after 6 months using the trauma expectation factor (TEF) score. Outcomes were evaluated at 2 weeks, 6 and 12 months using the trauma outcome measure (TOM), American Academy of Orthopaedic Surgeons (AAOS), foot and ankle outcome score (FAOS) and short form-36 (SF-36) questionnaires. Psychometric properties of TEFTOM were assessed.

RESULTS

TEF and TOM demonstrated good internal consistency (Cronbach's α > 0.87) and reliability at all time points (intra-class correlation coefficients > 0.90). TOM showed strong correlations (R² ≥ 0.60) with the AAOS foot and ankle score, all FAOS subscales, except 'symptoms' and SF-36 physical functioning, role physical, bodily pain, social functioning and the physical component summary at 6 and 12 months. Effect sizes for TOM were 2.30 and 0.74 from 2 weeks to 6 months and from 6 months to 12 months, respectively. The baseline patient TEF was predictive for the 1-year TOM score.

CONCLUSIONS

TEFTOM demonstrated good psychometric properties in this cohort of patients with ankle fractures. The TEF 'expectation' score was predictive of the TOM 'outcome' score. We recommend researchers and clinicians to utilize TEFTOM when patient expectation measurement is concerned for orthopaedic trauma patients.

Cementation: for better or worse? Interim results of a multi-centre cohort study using a fenestrated spiral blade cephalomedullary device for pertrochanteric fractures in the elderly

INTRODUCTION

Cephallomedullary nail fixation is currently the most popular treatment for pertrochanteric fractures. Despite continuous improvement in implant design, fixation failures still occur in a concerning number of cases. This study aims to evaluate the effect of cement augmentation of the new-generation Trochanteric Femoral Nail Advanced (TFNA) perforated spiral blade on complications including fixation failure in the elderly population.

MATERIALS AND METHODS

We retrospectively evaluated 107 patients aged 65 + treated for pertrochanteric fractures via TFNA between 2015 and 2019 based on whether cementation was used. Baseline demographics, fracture classifications, and reduction quality were compared. Patients with a follow-up of at least 6 months were analyzed for the primary outcome of fixation failure. All patients, regardless of loss to follow-up within 6 months, were analyzed for other complications including mortality.

RESULTS

Seventy-six patients (47 cemented, 29 non-cemented) had a minimum follow-up of 6 months (mean 13 months). There were no statistically significant differences between the two treatment groups in terms of patient demographics, ASA or AO/OTA fracture classification, reduction quality, or length of follow-up. There was a lower rate of fixation failure in the cement-augmented (CA) group versus the non-cement-augmented (NCA) group (2.1% vs 13.8%; p = 0.047). No cut-out or cut-through was observed in the CA group. Seven patients had adverse intraoperative events, with a significantly higher rate of fixation failure in these patients (40% vs 2.8%; p = 0.00). There were no statistically significant differences in 30-day mortality (6.3% CA vs 4.3% NCA; p = 0.632) or 3-month mortality (9.5% CA vs 12.8% NCA; p = 0.589).

CONCLUSIONS

Cementation of TFNA blades may decrease risk of fixation failure, however, the surgeon must be aware of potential complications such as cement leakage into the hip joint and be able to manage them as they arise.

Effect of the screw tightening sequence on the stress distribution of a dynamic compression plate: A pilot finite element study

OBJECTIVE

Although the optimal screw tightening sequence is a common question orthopaedists encounter during fractures fixation with a dynamic compression plate (DCP), the effect of the screw tightening sequence on the stability of the plate has never been explored. This study explores the effect of the screw tightening sequence on the stress distribution of a DCP using a finite element method.

METHODS

Idealized finite element analysis models of the femoral diaphysis with six-hole or eight-hole DCPs were constructed. The screw tightening preload was simulated using 'bolt load' in ABAQUS. Two screw tightening sequences were studied for the six-hole plate and six sequences were studied for the eight-hole plate. U magnitude and Von Mises stress were used to evaluate the deformation and stress distribution of the plate, respectively. Deformation and stress distribution plots from different sequences were compared.

RESULTS

The different screw tightening sequences showed different deformation processes, while all had the same final deformation after all the screws were tightened. Each screw tightening step of different tightening sequences showed different stress distributions in the plate, while all had the same stress distribution after all the screws were tightened.

CONCLUSION

Using different screw tightening sequences to fix the same DCP can produce the same stability, which means in terms of fixation stability, after the two screws nearest to the fracture line are tightened, surgeons do not need to hesitate about the order in which the rest screws should be inserted during the surgery.

Comparison of radiological and clinical outcomes, complications, and implant removals in anatomically pre-contoured clavicle plates versus reconstruction plates - a propensity score matched retrospective cohort study of 106 patients

Background

Plate fixation is frequently used to treat displaced midshaft clavicular fractures, however the ideal plate choice remains subject to discussion; reconstruction locking compression plates (RLCPs) are cheaper and can be easily contoured, whereas anatomically pre-contoured locking compression plates (ALCPs) are thought to provide better stability and therefore lower rates of mechanical failure.

To compare the incidence of mechanical failures, functional and radiological outcomes in patients with midshaft clavicular fractures treated with ALCPs versus RLCPs.

Methods

A propensity score matched retrospective cohort study was conducted across two centers. One hundred and six consecutively recruited patients with displaced midshaft clavicular fractures, who were treated with plate fixation and had a minimum follow-up of 6 months, were matched on gender, age, fracture grading, energy of injury, and fracture location. The resulting groups included 53 ALCP-treated fractures and 53 matched controls treated with RLCPs.

Results

During a mean follow-up of 20.5 months, there were no implant deformities in the ALCP group whereas the RLCP group had 6 patients (11.3%, p = 0.012) with implant deformities (5 occurrences of plate bending with fracture union, and 1 plate breakage with nonunion). Despite the higher rate of plate deformities in the RLCP group, there were no statistically significant differences in number of patients recovering full shoulder range of motion (ALCP 90.6%, RLCP 88.7%, p = 0.751), incidence of rest pain (ALCP 13.2%, RLCP 9.4%, p = 0.542), or implant removals (ALCP 49.1%, RLCP 56.6%, p = 0.439).

Conclusion

ALCPs may be superior to RLCPs in terms of implant stability but appear to produce similar clinical results.

Infraclavicular nerve block reduces postoperative pain after distal radial fracture fixation: a randomized controlled trial

Background

It is unclear whether regional anesthesia with infraclavicular nerve block or general anesthesia provides better postoperative analgesia after distal radial fracture fixation, especially when combined with regular postoperative analgesic medications. The aim of this study was to compare the postoperative analgesic effects of regional versus general anesthesia.

Methods

In this prospective, observer blinded, randomized controlled trial, 52 patients undergoing distal radial fracture fixation received either general anesthesia (n = 26) or regional anesthesia (infraclavicular nerve block, n = 26). Numerical rating scale pain scores, analgesic consumption, patient satisfaction, adverse effects, upper limb functional scores (Patient-Rated Wrist Evaluation, QuickDASH), health related quality of life (SF12v2), and psychological status were evaluated after surgery.

Result

Regional anesthesia was associated with significantly lower pain scores both at rest and with movement on arrival to the post-anesthetic care unit; and at 1, 2, 24 and 48 h after surgery (p ≤ 0.001 at rest and with movement). Morphine consumption in the post-anesthetic care unit was significantly lower in the regional anesthesia group (p<0.001). There were no differences in oral analgesic consumption. Regional anesthesia was associated with lower incidences of nausea (p = 0.004), and vomiting (p = 0.050). Patient satisfaction was higher in the regional anesthesia group (p = 0.003). There were no long-term differences in pain scores and other patient outcomes.

Conclusion

Regional anesthesia with ultrasound guided infraclavicular nerve block was associated with better acute pain relief after distal radial fracture fixation, and may be preferred over general anesthesia.

Trial registration

Before subject enrollment, the study was registered at ClinicalTrials.gov (NCT03048214) on 9th February 2017.

A Retrospective Review on Atypical Femoral Fracture: Operative Outcomes and the Risk Factors for Failure

Background

Atypical femoral fractures have been demonstrated to have high risks of reoperation and nonunion. The aim of this study is to evaluate whether the quality of reduction following operative fixation of atypical femoral fracture predicts failure.

Methods

This is a 6.5-year retrospective review of atypical femoral fractures from 2 centers in a high-income region. A total of 56 patients with 66 fractures met our inclusion criteria. The quality of reduction was evaluated from postoperative films according to Hoskins' modification of Baumgartner criteria for subtrochanteric fractures. Our primary outcome measure was failure of treatment, defined as either reoperation or nonunion at 12 months.

Results

There were a total of 8 reoperations (12% of all fractures) and 8 nonunion (12% of all fractures), affecting a total of 12 fractures (18%) in 12 patients (21%). Closed reduction (P = .04) and poor quality of reduction (P = .0227 Fisher exact test) are statistically significant risk factors for failure.

Conclusions

An aim for anatomical reduction with both <4 mm maximal cortical displacement and <10° angulation can improve the operative outcome of atypical femoral fractures. The addition of open reduction may be beneficial.

Anoikis resistant mediated by FASN promoted growth and metastasis of osteosarcoma

The pulmonary metastasis of osteosarcoma (OS) occurs commonly, which resulted from anoikis resistant (AR) of tumor cells as reported by previous studies, but the exact roles of AR in osteosarcoma were not fully studied. Our previous investigations showed fatty acid synthase (FASN) was relating to clinical features of patients with OS. In this study, we aim to explore the functions of FASN in the AR OS cells in vitro and in vivo and study the downstream effectors of FASN. In the present study, we used our established cell model to study the AR. We revealed that AR promoted cell proliferation and migration as determined by colony formation assay and transwell assay. In addition, AR assisted tumor growth in vivo. In the AR cells, the expression of FASN was higher. Thus, we constructed lentiviruses to silence or overexpress FASN in four cell lines to study functions of FASN. Silence of FASN reduced cell colonies and migration while overexpression of FASN increased colonies and migration in suspended cells. Loss of functions of FASN induced cell apoptosis in suspended OS cells while gain of function of FASN suppressed apoptosis as determined by flow cytometry. We found the levels of p-ERK1/2 and Bcl-xL declined when FASN was silenced while they increased when FASN was overexpressed. In addition, results showed that the levels of FASN and its potential related molecules (p-ERK1/2 and Bcl-xL) increased in 143B-AR and MG-63-AR cells. In vivo study showed that inhibition of FASN decreased pulmonary metastasis of OS. In conclusion, we showed that anoikis resistant and FASN as two interactional factors facilitated the progress of osteosarcoma.

Comparing 3 Different Techniques of Patella Fracture Fixation and Their Complications

Introduction:

Patella fractures managed by fixation with metal implants often cause local soft tissue irritation and necessitate implant removal. An alternative is to utilize suture-based fixation methods. We have adopted suture and hybrid fixation in the routine management of patella fractures. Here, we compare the results of 3 fixation techniques.

Materials and Methods:

Eighty-seven eligible patients underwent patella fracture fixation over a 3-year period. As determined by fracture configuration, patients received (1) suture fixation (transosseous sutures and figure-of-eight tension banding with FiberWire), (2) hybrid fixation (transosseous FiberWire sutures and metal tension banding), or (3) metal fixation. Primary outcome measures included reoperation rate and soft tissue irritation. Secondary outcomes included surgical complications, radiological, and functional parameters.

Results:

Reoperation rate was highest for metal fixation (25/57, 43.9%) and lowest for suture fixation (2/13, 15.4%). Soft tissue irritation necessitating implant removal was the predominant reason for reoperation and was significantly less prevalent following suture fixation (1/13, 7.7%, P < .01). Hybrid fixation resulted in similar rates of soft tissue irritation (6/17, 35.3%) and implant removal (7/17, 41.2%) as compared to metal fixation. There was a significant increase in patella baja (13/17, 76.5%) and reduction in Insall-Salvati ratio (0.742; 95% confidence interval: 0.682-0.802) following hybrid fixation as compared to the other 2 fixation methods (P < .05).

Discussion:

Suture fixation results in the least amount of soft tissue irritation and lowest reoperation rate, but these advantages are negated with the addition of a metal tension band wire. Hybrid fixation also unbalances the extensor mechanism.

Conclusion:

Patients should be counseled as to the expected sequelae of their fixation method. Suture fixation is the favored means to fix distal pole fractures of the patella. An additional metal tension band loop may confer additional stability but should be applied with caution.

A novel fracture mechanics model explaining the axial penetration of bone-like porous, compressible solids by various orthopaedic implant tips

Many features of orthopaedic implants have been previously examined regarding their influence on migration in trabecular bone under axial loading, with screw thread design being one of the most prominent examples. There has been comparatively little investigation, however, of the influence that implant tip design has on migration under axial loads. We present a novel fracture mechanics model that explains how differences in tip design affect the force required for axial penetration of porous, compressible solids similar to trabecular bone. Three tip designs were considered based on typical 5 mm diameter orthopaedic locking screws: flat and conical tip designs, as well as a novel elastomeric tip. Ten axial penetration trials were conducted for each tip design. In order to isolate the effect of tip design on axial migration from that of the threads, smooth steel rods were used. Tip designs were inserted into polyurethane foam commonly used to represent osteoporotic trabecular bone tissue (ASTM Type 10, 0.16 g/cc) to a depth of 10 mm at a rate of 2 mm/min, while force and position were recorded. At maximum depth, elastomeric tips were found to require the greatest force for axial migration (mean of 248.24 N, 95% Confidence Interval [CI]: 238.1-258.4 N), followed by conical tips (mean of 143.46 N, 95% CI: 142.1-144.9 N), and flat tips (mean of 113.88 N, 95% CI: 112.2-115.5 N). This experiment was repeated in cross-section while recording video of material compaction through a transparent window. Strain fields for each tip design were then generated from these videos using digital image correlation (DIC) software. A novel fracture mechanics model, combining the Griffith with porous material compaction, was developed to explain the performance differences observed between the three tip designs. This model predicted that steady-state stress would be roughly the same (~ 4 MPa) across all designs, a finding consistent with the experimental results. The model also suggested that crack formation and friction are negligible mechanisms of energy absorption during axial penetration of porous compressible solids similar to trabecular bone. Material compaction appears to be the dominant mechanism of energy absorption, regardless of tip design. The cross-sectional area of the compacted material formed during migration of the implant tip during axial penetration was shown to be a strong determinant of the force required for migration to occur (Pearson Coefficient = 0.902, p < .001). As such, implant tips designed to maximize the cross-sectional area of compacted material - such as the elastomeric and conical tips in the present study - may be useful in reducing excessive implant migration under axial loads in trabecular bone.

Restoration of Humeral Bone Stock Two Years After Internal Fixation of a Periprosthetic Fracture with a Loose Stem: A Report of Two Cases

CASE

We describe 2 patients who sustained a periprosthetic humeral fracture with a loosened long-stemmed Coonrad-Morrey total elbow prosthesis. As noted in the literature, the success rate for a major revision with use of strut grafts is around 70%; therefore, both cases were managed without revision of the prosthesis. A submuscular locking plate was placed following typical fracture fixation principles. Screws that interfered with the humeral stem and the distal flange stabilized both the distal fragment and the humeral stem.

CONCLUSION

At 2 years postoperatively, both fractures had healed, with increased endosteal bone stock. In each case, the prosthesis was successfully salvaged, and radiographic reconstitution of the implant-bone interface was noted after 2 years.

Abnormal subchondral bone remodeling and its association with articular cartilage degradation in knees of type 2 diabetes patients

Type 2 diabetes (T2D) is associated with systemic abnormal bone remodeling and bone loss. Meanwhile, abnormal subchondral bone remodeling induces cartilage degradation, resulting in osteoarthritis (OA). Accordingly, we investigated alterations in subchondral bone remodeling, microstructure and strength in knees from T2D patients and their association with cartilage degradation. Tibial plateaus were collected from knee OA patients undergoing total knee arthroplasty and divided into non-diabetic (n=70) and diabetes (n=51) groups. Tibial plateaus were also collected from cadaver donors (n=20) and used as controls. Subchondral bone microstructure was assessed using micro-computed tomography. Bone strength was evaluated by micro-finite-element analysis. Cartilage degradation was estimated using histology. The expression of tartrate-resistant acidic phosphatase (TRAP), osterix, and osteocalcin were calculated using immunohistochemistry. Osteoarthritis Research Society International (OARSI) scores of lateral tibial plateau did not differ between non-diabetic and diabetes groups, while higher OARSI scores on medial side were detected in diabetes group. Lower bone volume fraction and trabecular number and higher structure model index were found on both sides in diabetes group. These microstructural alterations translated into lower elastic modulus in diabetes group. Moreover, diabetes group had a larger number of TRAP⁺ osteoclasts and lower number of Osterix⁺ osteoprogenitors and Osteocalcin⁺ osteoblasts. T2D knees are characterized by abnormal subchondral bone remodeling and microstructural and mechanical impairments, which were associated with exacerbated cartilage degradation. In regions with intact cartilage the underlying bone still had abnormal remodeling in diabetes group, suggesting that abnormal bone remodeling may contribute to the early pathogenesis of T2D-associated knee OA.

Arthroscopic Removal of Suprapatellar Fibroma of Tendon Sheath

Intra-articular fibroma of tendon sheath is a rare disease. To our knowledge, less than 20 cases have been reported in the literature, and none of them was a Chinese patient. In this case report, we present a Chinese patient with intra-articular fibroma of tendon sheath of the knee joint which was excised arthroscopically. We also summarized the clinical presentation, diagnosis, and subsequent management of intra-articular fibroma of tendon sheath.

The effectiveness of a multidisciplinary hip fracture care model in improving the clinical outcome and the average cost of manpower

After the implementation of the multidisciplinary geriatric hip fracture clinical pathway in 2007, the hospital length of stay and the clinical outcomes improves. Moreover, the cost of manpower for each hip fracture decreases. It proves that this care model is cost-effective.

INTRODUCTION

The objective of this study is to compare the clinical outcomes and the cost of manpower before and after the implementation of the multidisciplinary geriatric hip fracture clinical pathway (GHFCP).

METHODS

The hip fracture data from 2006 was compared with the data of four consecutive years since 2008. The efficiency of the program is assessed using the hospital length of stay. The clinical outcomes include mortality rates and complication rates are compared. Cost of manpower was also analysed.

RESULTS

After the implementation of the GHFCP, the preoperative length of stay shortened significantly from 5.8 days in 2006 to 1.3 days in 2011. The total length of stay in both acute and rehabilitation hospitals were also shortened by 6.1 days and 14.2 days, respectively. The postoperative pneumonia rate also decreased from 1.25 to 0.25%. The short- and long-term mortalities also showed a general improvement. Despite allied health manpower was increased to meet the increased workload, the shortened length of stay accounted for a mark decrease in cost of manpower per hip fracture case.

CONCLUSION

This study proves that the GHFCP shortened the geriatric hip fracture patients' length of stay and improves the clinical outcomes. It is also cost-effective which proves better care is less costly.

Seasonal Variation in Hip Fracture Mortality

Objectives:

This study aims to identify if wintertime surgery increases the mortality of the patients after hip fracture operations.

Design:

Retrospective observational cohort study.

Setting:

The data for this citywide retrospective observational cohort study came from Clinical Data Analysis Reporting System.

Patient:

This study included 35 409 patients with hip fracture operations from July 2005 to December 2013.

Main Outcome Measures:

Cox regression hazard model was used to estimate the independent effect of operation being performed in winter on the hazard of mortality. The hazard model included covariates found to be independent predictors of mortality: age, sex, surgical delay, and Charlson Comorbidity Index (CCI).

Results:

There was a seasonal variation with more hip fracture operations happening in the winter months. The 1-month, 6-month, 1-year, and 5-year mortality were 3%, 11%, 17%, and 47%, respectively. Operation performed in winter was associated with a higher hazard of mortality (hazard ratio [HR] 1.040; 95% confidence interval: 1.010-1.072; P = .009). The HR was greater with male sex (HR 1.786; P = .000), advanced age (≥85 years old: HR 2.819; P = .000), the longer surgical delay (HR 1.018; P = .000), and higher CCI (severe CCI group: HR 2.963; P = .000).

Conclusion:

Wintertime hip fracture surgery was associated with an increased hazard of mortality after adjusting for other known risk factors affecting mortality post hip fracture operations.

Androgen deprivation therapy and fracture risk in Chinese patients with prostate carcinoma

OBJECTIVE

Androgen deprivation therapy (ADT) increases fracture risk in men with carcinoma of the prostate, but little is known about the fracture risk for different types of ADT. We studied the fracture risk amongst Chinese patients with carcinoma of the prostate prescribed different ADT regimens.

SUBJECTS AND METHODS

This was a single-centered observational study that involved 741 patients with carcinoma of the prostate from January 2001 to December 2011.

RESULTS

After a median follow-up of 5 years, 71.7% of the study cohort received ADT and the incidence rate of fracture was 8.1%. Multivariable Cox regression analysis revealed that use of ADT was significantly associated with risk of incident fracture (Hazard Ratio [HR] 3.60; 95% Confidence Interval [95% CI] 1.41-9.23; p = 0.008), together with aged >75 years and type 2 diabetes. Compared with no ADT, all three types of ADT were independently associated with the risk of incident fracture: anti-androgen monotherapy (HR 4.47; 95% CI 1.47-13.7; p = 0.009), bilateral orchiectomy ± anti-androgens (HR 4.01; 95% CI 1.46-11.1; p = 0.007) and luteinizing hormone-releasing hormone agonists ± anti-androgens (HR 3.16; 95% CI 1.18-8.43; p = 0.022). However, there was no significant difference in the relative risks among the three types of ADT.

CONCLUSIONS

Fracture risk increases among all types of ADT. Clinicians should take into account the risk-benefit ratio when prescribing ADT, especially in elderly patients with type 2 diabetes.

miR-375-3p negatively regulates osteogenesis by targeting and decreasing the expression levels of LRP5 and β-catenin

Wnt signaling pathways are essential for bone formation. Previous studies showed that Wnt signaling pathways were regulated by miR-375. Thus, we aim to explore whether miR-375 could affect osteogenesis. In the present study, we investigated the roles of miR-375 and its downstream targets. Firstly, we revealed that miR-375-3p negatively modulated osteogenesis by suppressing positive regulators of osteogenesis and promoting negative regulators of osteogenesis. In addition, the results of TUNEL cell apoptosis assay showed that miR-375-3p induced MC3T3-E1 cell apoptosis. Secondly, miR-375-3p targeted low-density lipoprotein receptor-related protein 5 (LRP5), a co-receptor of the Wnt signaling pathways, and β-catenin as determined by luciferase activity assay, and it decreased the expression levels of LRP5 and β-catenin. Thirdly, the decline of protein levels of β-catenin was determined by immunocytochemistry and immunofluorescence. Finally, silence of LRP5 in osteoblast precursor cells resulted in diminished cell viability and cell proliferation as detected by WST-1-based colorimetric assay. Additionally, all the parameters including the relative bone volume from μCT measurement suggested that LRP5 knockout in mice resulted in a looser and worse-connected trabeculae. The mRNA levels of important negative modulators relating to osteogenesis increased after the functions of LRP5 were blocked in mice. Last but not least, the expression levels of LRP5 increased during the osteogenesis of MC3T3-E1, while the levels of β-catenin decreased in bone tissues from osteoporotic patients with vertebral compression fractures. In conclusion, we revealed miR-375-3p negatively regulated osteogenesis by targeting LRP5 and β-catenin. In addition, loss of functions of LRP5 damaged bone formation in vivo. Clinically, miR-375-3p and its targets might be used as diagnostic biomarkers for osteoporosis and might be also as novel therapeutic agents in osteoporosis treatment. The relevant products of miR-375-3p might be developed into molecular drugs in the future. These molecules could be used in translational medicine.

How to obtain and identify the acetabular anterior column axial view projection in patients?

PURPOSE

This study aims at sharing our experience as how to obtain and identify axial view image of the acetabular anterior column in patients.

METHODS

Pelvic computed tomography data of six normal adults were used to reconstruct three-dimensional (3D) models. The transparency of each 3D model was downgraded at the view perpendicular to the cross section of the anterior column axis to simulate the anterior column axial view image. Fluoroscopy was performed in all patients to obtain the anterior column axial view image in the operating room. Each fluoroscopic image was compared with the corresponding simulation image to analyze potential anatomic landmarks that were helpful to identify the translucent area (projection of the screw path) in the patients.

RESULTS AND CONCLUSIONS

To obtain ideal anterior column axial fluoroscopic image, the patient should be positioned supine with the leg of "abnormal side" straight and contralateral side flexion, abduction, and external rotation; the C-arm machine should be placed at the caudal end of the operation table with the C-arm fluoroscopic intensifier first positioned at the pelvic lateral view and then tilted approximately 30° toward the "abnormal side" and rotated approximately 45° toward the caudal end of the operation table. To identify the translucent area on the anterior column axial view fluoroscopic image obtained from the patient, the greater sciatic notch, the true pelvis edge, and the acetabulum should be identified first and the translucent area is located in the area surrounded by these three anatomic landmarks.

Infection after fracture osteosynthesis - Part II

In the first part of this article, we have discussed the pathogenesis, clinical presentation, diagnosis and classification of infection after fracture osteosynthesis with implants, termed here as osteosynthesis-associated infection (OAI). Prolonged antibiotic treatment is usually necessary. Implant retention and maintenance of fracture stability to allow for fracture healing in spite of infection are allowed for OAI. Depending on the severity of infection, status of fracture healing and host status, the treatment follows five common pathways. These are non-operative treatment, debridement with implant retention, conversion of fixation, implant removal and suppression therapy. The decision-making process leading to each treatment pathway and challenging scenarios is discussed in detail.

Infection after fracture osteosynthesis - Part I

Bone and surgical site infections after osteosynthesis are notoriously difficult to manage and pose a tremendous burden in fracture management. In this article, we use the term osteosynthesis-associated infection (OAI) to refer to this clinical entity. While relatively few surgically treated fractures become infected, it is challenging to perform a rapid diagnosis. Optimal management strategies are complex and highly customized to each scenario and take into consideration the status of fracture union, the presence of hardware and the degree of mechanical stability. At present, a high level of relevant evidence is unavailable; most findings presented in the literature are based on laboratory work and non-randomized clinical studies. We present this overview of OAI in two parts: an examination of recent literature concerning OAI pathogenesis, diagnosis and classification and a review of treatment options.

The use of three-dimensional printing technology in orthopaedic surgery

Three-dimensional (3-D) printing or additive manufacturing, an advanced technology that 3-D physical models are created, has been wildly applied in medical industries, including cardiothoracic surgery, cranio-maxillo-facial surgery and orthopaedic surgery. The physical models made by 3-D printing technology give surgeons a realistic impression of complex structures, allowing surgical planning and simulation before operations. In orthopaedic surgery, this technique is mainly applied in surgical planning especially revision and reconstructive surgeries, making patient-specific instruments or implants, and bone tissue engineering. This article reviews this technology and its application in orthopaedic surgery.