Fracture Site Research Articles

Partially Edentulous Arches and Bilateral Mandibular Fracture: Application of Condensation-Silicone Bite Block-Splint, Mandibulo-Maxillary Fixation Screws, and Elastics for Intraoral Immobilization

Each mandibular fracture is unique. It requires individual treatment solutions due to different number of fracture sites, fracture terms, level of dislocation, presence/absence of the infection, number, location, and condition of teeth, etc. Management of jaw fractures in partially edentulous arches are even more complicated and typically can involve assistance of a dental technician. Published English language literature lacks information about application of condensation silicone (C-silicone) bite block-splint with mandibulo-maxillary fixation (MMF) screws and elastics for management of bilateral mandibular fracture. This is why we present this novel technique developed by our team based on fracture treatment in a 38-year-old male partially edentulous patient. Also, we introduce a Kyiv’s Modification of the Kennedy Classification System of the partially edentulous arches useful for mandible fracture cases. The Kennedy–Kyiv Classification System considers the non-treated teeth roots as supporting locking points (temporary additional retention points) that increase the stability of the bite block-splint and decrease probability of micromovements. Moreover, it contraindicates extracting such teeth roots immediately before the block-splint fixation as extraction of such roots can provoke the alveolar osteitis upon the fracture site(s) healing and immobilization period what will increase the risk of the block removal for the treatment of osteitis. A review of published MMF techniques and appliances designed for mandible fracture treatment is performed. Multiple appliances for partially and totally edentulous mandibles are considered as well as for the dentulous jaws. The Gunning-type splints and its modifications were considered. An in-chair fabrication of C-silicone bite block-splint and its combined application with MMF screws and elastics is a novel alternative for the Gunning splint. This appliance allows to decrease the time typically required for the Gunning splints fabrication, decreases number of the involved specialists, decreases cost of treatment, and easy for performance.

Comparative Analysis of Complication Rates in Tibial Shaft Fractures: Intramedullary Nail vs. Ilizarov External Fixation Method.

Background: The external fixation (EF) Ilizarov method, shown to offer efficacy and relative safety, has unique biomechanical properties. Intramedullary nail fixation (IMN) is an advantageous alternative, offering biomechanical stability and a minimally invasive procedure. The aim of this study was to assess outcomes in patients undergoing tibia fracture fixation, comparing the Ilizarov EF and IMN methods in an early phase of IMN implementation in Serbia. Methods: This was a retrospective study including patients with radiologically confirmed closed and open (Gustilo and Anderson type I) tibial diaphysis fractures treated at the Institute for Orthopedic Surgery "Banjica'' from January 2013 to June 2017. The following demographic and clinical data were retrieved: age, sex, chronic disease diagnoses, length of hospital stay, surgical wait times, surgery length, type of anesthesia used, fracture, prophylaxis, mechanism of injury, postsurgical complications, time to recovery, and pain reduction. Pain intensity was measured by the Visual Analog Scale (VAS), a self-reported scale ranging from 0 to 100 mm. Results: A total of 58 IMN patients were compared to 74 patients who underwent Ilizarov EF. Study groups differed in time to recovery (p < 0.001), length of hospitalization (p = 0.007), pain intensity at the fracture site (p < 0.001), and frequency of general anesthesia in favor of intramedullary fixation (p < 0.001). A shorter surgery time (p < 0.001) and less antibiotic use (p < 0.001) were observed when EF was used. Additionally, we identified that the intramedullary fixation was a significant predictor of pain intensity. Conclusions: The IMN method offers faster recovery and reduced pain intensity in comparison to EF, while the length of surgery predicted the occurrence of any complication.

FUNCTIONAL OUTCOME OF TOTAL HIP ARTHROPLASTY WITH DUAL MOBILITY CUPS IN HIP ARTHRITIS-A PROSPECTIVE COHORT STUDY

Background: Dual mobility (DM) total hip arthroplasty (THA) has gained popularity due to its potential to enhance stability and reduce dislocation rates compared to traditional THA constructs. However, there is a need for further investigation into its functional outcomes, complications, and implant survivorship. Method: We conducted a hospital-based prospective study involving 50 patients undergoing total hip replacement over a one-year period. Functional outcomes were assessed using the Harris Hip Score (HHS) and Posterior Muscle Endurance (PME) Score. Descriptive statistics were used for data analysis. Results: The study population consisted predominantly of older patients (mean age 64.30 years), with a higher representation of males (56%). The most common diagnosis was neck of femur fracture (NOF#) (75%), with a balanced distribution of cemented (40%), uncemented (40%), and hybrid (20%) fixation techniques. HHS and PME scores showed significant improvements over 12 months, with excellent outcomes observed in 61.1% of participants. Complications occurred in 14% of patients, with peri-prosthetic fracture and surgical site infection being the most common. Implant survivorship at final follow-up was 94%. Conclusion: Dual mobility cup total hip replacement demonstrates promising outcomes in terms of functional improvement, low complication rates, and high implant survivorship. It represents a viable option for patients undergoing THA, particularly those at risk of dislocation. Further research, including prospective comparative studies, is needed to better understand its long-term efficacy and suitability across different patient populations.

Epidemiology of Stress Fracture in Police Trainees.

Military recruits and athletes have high occurrence of stress fractures, with very high incidence among military recruits. Symptomatic stress fractures can be disabling in some people. This study aims at identifying pattern and distribution of such fractures in Nepal Police trainee and assess the risk factors and demographics that may help to develop the local guidelines. This study analysed 65 police trainees who presented to the orthopaedic Out Patient Department at Nepal Police and Province Police Hospital diagnosed as a case of stress fracture from 29 December, 2020 to 29 December, 2021. Ethical approval was obtained and different variables analysed were age, sex, Body Mass Index, location of fracture, duration of pain, method of treatment, time to heal the fracture and time to pain free mobilisation of patient. There were 65 trainees with 86 sites of fracture at different bones with 50.8% (33) of male population. The majority of fracture was located at tibia (58.1%) followed by pubic rami (33.7%) with potentially debilitating fracture neck of femur seen in 4.6% subjects. Mean duration of pain was 20.7±14.2 days with mean time for pain free mobilisation 42.2±17.7 days after presentation. 96.5% of those recovered with conservative treatment (activity restriction or cast). The location of stress fracture depends upon the type of training or activities. Modification of activities in early phase of training with early visit for medical care in case of trainees with increasing pain may decrease morbidities and complications requiring operative treatment.

Correlation between psychological status, revised Müller AO classification and patient-reported outcomes: a prospective cohort analysis.

The impact of psychological status on clinical outcomes is valued in several medical conditions, but rare attention is given to it in orthopedic trauma. We aimed to assess the correlation between psychological status, fracture severity and patient-reported outcomes in fractured patients needing urgency surgical treatment. We prospectively followed 139 consecutive patients undergoing urgency surgical treatment of a lower/upper limb fracture. Before surgery, all patients were divided into grades of fracture severity according to the Revised AO Müller Classification (AO grades). On the 15th and the 120th days after surgery, all patients underwent a psychological status assessment through the Hospital Anxiety and Depression Score (HADS), in addition to a pain evaluation through VAS. One year after surgery, patient-reported outcomes were obtained by using specific scales depending on the site of fracture. AO grades and VAS scores were significantly correlated to scores at HADS-A (anxiety component) and HADS-D (depression component), both on the 15th and the 120th. Patients presenting persistent HADS-A and HADS-D scores equal or greater than 8 points had a risk of more than 2.5 or 2.0 times of experiencing unsatisfactory surgical outcomes, respectively [HADS-A: RR = 2.8 (95% CI: 2.2-3.5)] [HADS-D: RR = 2.2 (95% CI: 1.7-3.1)]. AO grade C and the persistency of significant symptoms of anxiety or depression were independent predictors of unsatisfactory patient-reported outcomes (OR: 1.7, p = 0.03 // OR: 2.9, p < 0.01). Female gender, age, and BMI did not present any statistically significant utility in predicting unsatisfactory patient-reported outcomes. In fractured patients needing urgency surgical treatment, the risk of presenting unsatisfactory outcomes is more than twice as high in patients that present significant persistent changes in psychological status. Changes in psychological status are more frequent in patients presenting more severe pain and more severe fractures. AO grades and HADS scores are independent predictors of unsatisfactory outcomes in these patients.

Evaluation and Performance Analysis of Liquefied Petroleum Gas Cylinders

This paper presents the experimental results of the tensile, bending, hardness, hydrostatic testing, and microstructural properties of liquefied petroleum gas cylinders from local sources. The burst pressure and fracture sites were also investigated. In addition, know how LPG cylinders are compliant with ISO 4706 requirements as per standard to get approval and acceptance. The tests were performed on three samples (C1, C2, and C3), and all the tests were according to the specification. Tensile testing was carried out at room temperature (23C°) as per ISO 6892-2016. Tensile test specimens with a gauge length of 50 mm were prepared from the sidewall of cylinders. The equipment used is built up around a 250 KN maximum capacity of (Instron Servo-Hydraulic Testing Machine Model 1332). At the same time, micro-hardness testing was carried out as per ASTM A384. Diamond indenter (pyramid) with a face angle of 136° was used. During testing (1kg) load was applied on the sample with a dwell time of 15 seconds. As for bending tests were carried out in accordance with ISO 7438 for all cylinders to evaluate their welding qualities. The results of microstructural characterization show that the carbon content for all samples averaged ~ 0.067 wt.% and manganese ~ 0.46 wt.% and the microstructure was largely ferritic. The tensile strength of the parent metal showed that LPG gas cylinders recorded high tensile strength of ~ 418 MPa on average, yield strength of ~ 291 MPa on average, a % elongation 26.6 (for parent metal), the tensile strength of ~ 449 MPa as average, yield strength of ~ 314 MPa as average, % elongation 32 (for weld metal) and hardness of ~ 143 (kg/mm2) as average by Vickers scale. Moreover, in the hydrostatic pressure test, the computer controlled electro-hydraulic servo pressure test machine was used. The results of the hydrostatic pressure test were as follows, pressure burst (BP) 103 bar, nominal hoop stress 528 MPa, volumetric expansion 25%, hydrostatic extend ratio 3.9%, sites of failure exist out of welding, and finally no fragmentation observed regarding to fracture types. All samples tested exhibited high resilience to crack propagation which showed ductile fracture after burst and tensile tests.

Elbow Reconstruction with Megaprosthesis: An Effective Strategy for Salvage Surgery in Trauma Patients.

Delayed fracture healing can have devastating functional consequences, including pseudoarthrosis. Many factors can contribute to delayed healing, including decreased vascularity, micro-motion at the fracture site, large fracture gaps, multiple traumas at the same site, compromised metabolic status, surgical complications, and other conditions. A 61-year-old female patient was referred to our hospital with left distal humeral pseudarthrosis, accompanied by chronic pain and disability. Two years prior, the patient suffered a traumatic incident. At another medical facility, the patient underwent open reduction and internal fixation surgery with simultaneous ulnar nerve transposition. She showed favorable postoperative recovery. Unfortunately, approximately one year later, the patient sustained a second trauma to the same arm. This led to peri-implant fracture and post-traumatic aseptic degradation of the osteosynthesis system which was subsequently removed. Twelve months after the last surgery, the patient was referred to our hospital and, after thorough consideration of the therapeutic options, we decided to perform left elbow arthroplasty with left distal humeral reconstruction by using Zimmer's Comprehensive Segmental Revision System. This approach is generally reserved for tumors, and only a handful of cases of megaprostheses for non-tumoral indications have been previously reported. The surgery and perioperative care of our patient were optimal, there were no complications, and the patient recovered arm functionality following rehabilitation.

Pelvic packing or endovascular interventions: Which should be given priority in managing hemodynamically unstable pelvic fractures? A systematic review and a meta-analysis

BackgroundPelvic fractures in trauma patients can be associated with substantial massive hemorrhage. Hemostasis interventions mainly consist of pelvic packing (PP) and endovascular intervention (EI), such as angiography-embolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA). Whether PP or EI should be prioritized for the management of hemodynamic unstable patients with pelvic fractures remains under debate. This meta-analysis aimed to establish the evidence-based recommendations for the management of hemodynamic unstable patients. Materials and methodsPubMed, CENTRAL, and EMBASE databases were searched for articles published from January 1, 2000 to January 31, 2023. Eligible studies, such as retrospective cohort studies, propensity score matching studies, prospective cohort studies, observational cohort studies, quasi-randomized clinical trials evaluating PP and EI (AE or REBOA) for the management of patients with hemodynamically unstable pelvic fractures, were included. Mean Difference (MD), relative risk (RR), and 95 % confidence intervals (CI) were calculated using fixed- or random-effects models depending on the heterogeneity of included trials. We compared the effectiveness of the two methods in terms of mortality, unstable fracture pattens, injury severity score (ISS), systolic blood pressure (SBP), lactate (LA), base deficiency (BE), hemoglobin preoperatively, blood transfusion requirement, the time to and of operation, complications. ResultsOverall, 15 trials enrolling 1136 patients were analyzed, showing a total mortality rate of 28.4 % (323/1136). No effect of PP preference on the ISS (PP 36.4 ± 10.4 vs. EI 34.5 ± 12.7), SBP (PP 81.1 ± 24.3 mmHg vs. EI 94.2 ± 32.4 mmHg), LA (PP 4.66 ± 2.72 mmol/L vs. 4.85 ± 3.45 mmol/L), BE (PP 8.14 ± 5.64 mmol/L vs. 6.66 ± 5.68 mmol/L), and unstable fracture patterns (RR = 1.10, 95 % CI [0.63, 1.92]) was observed. PP application was associated with lower preoperative hemoglobin level (PP 8.11 ± 2.28 g/dL vs. EI 8.43 ± 2.43 g/dL, p < 0.05), more preoperative transfusion (MD = 2.53, 95 % CI [0.01, 5.06]), less postoperative transfusion within the first 24 h (MD = −1.09, 95 % CI [−1.96, −0.22]), shorter waiting time to intervention (MD = −0.93, 95 % CI [−1.54, −0.31]), and shorter operation time of intervention (MD = −0.41, 95 % CI [−0.52, −0.30]). PP had lower mortality rate owing to uncontrolled hemorrhage in the acute phase (RR = 0.41, 95 % CI [0.22, 0.79]). There was neither difference in mortality due to other complications (RR = 1.60, 95 % CI [0.79, 3.24]), nor in total mortality (RR = 0.92, 95%CI [0.49, 1.74]) (p > 0.05). ConclusionsPP showed advantages of reducing the amount of postoperative transfusion, shortening the time of waiting and operating, and decreasing mortality due to uncontrolled hemorrhage in the acute phase without raising the odds of mortality due to complications. PP, a reliable hemostatic method, should be prioritized for resuscitating most pelvic fractures with hemodynamically unstable, especially in case of bleeding from veins and fracture sites, as well as inadequate EI.

Evaluation of the treatment outcome of tibia shaft fracture by close reduction and internal fixation with interlocking intramedullary nail, Freetown, Sierra Leone, 2023

Introduction: The tibia shaft is a common site for bone fractures and open fractures. Tibia shaft fracture is mostly caused by high-energy trauma such as a fall from a height or a road traffic accident. The objective of this study was to evaluate the treatment outcome of tibia shaft fracture managed by close reduction and internal fixation with interlocking Intramedullary Nails (IMN) and to determine factors that are associated with tibia fracture infection. Methods: This retrospective study was conducted at the Emergency Trauma Hospital, Freetown, Sierra Leone. We analyzed the medical records of a mixed cohort of patients who were treated for, tibia shaft fracture by closed reduction and internal fixation with interlocking intramedullary nails for the period January 2020 to January 2022; with at least 15 months of follow-up. We later used both bivariate and multivariate logistic regressions to determine the factors that are associated with wound infection post-internal fixation. Results: A total of Ninety (n = 90) patients’ medical records were reviewed of which 79 were included for analysis. The median age was 30 years (Inter Quartile Range: 16-67 years). The average hospital stay was 20 days (Inter Quartile Range: 6-156 days). The mean fracture nailing time was 11 days. Infection and non-union rates were at 18.99% and 3.8% respectively. Type of tibia shaft fracture (AOR = 25.51, 95% CI = 2.06-422.75,) and characteristics of wound (AOR = 29.51, 95% CI = 2.06-422.75) were significantly associated with wound infection. The treatment outcome categorization of IMN was successful in 88.61% of the patients. Conclusion: This study concludes that the type of tibia shaft fracture and characteristics of the wound are major predictors of wound infection. The findings of this study suggest that IMN fixation of closed and Gustilo type 1 Tibia shaft fracture led to successful healing in the majority of the cases with a low non-union rate.

The water-soluble TF3 component from Eupolyphaga sinensis Walker promotes tibial fracture healing in rats by promoting osteoblast proliferation and angiogenesis

ObjectiveTo determine the active components of Eupolyphaga sinensis Walker (Tu Bie Chong) and explore the mechanisms underlying its fracture-healing ability. MethodsA modified Einhorn method was used to develop a rat tibial fracture model. Progression of bone healing was assessed using radiological methods. Safranin O/fast green and CD31 immunohistochemical staining were performed to evaluate the growth of bone cells and angiogenesis at the fracture site. Methylthiazoletetrazolium blue and wound healing assays were used to analyze cell viability and migration. The Transwell assay was used to explore the invasion capacity of the cells. Tubule formation assays were used to assess the angiogenesis capacity of human vascular endothelial cells (HUVECs). qRT-PCR was used to evaluate the changes in gene transcription levels. ResultsTu Bie Chong fraction 3 (TF3) significantly shortened the fracture healing time in model rats. X-ray results showed that on day 14, fracture healing in the TF3 treatment group was significantly better than that in the control group (P = .0086). Tissue staining showed that cartilage growth and the number of H-shaped blood vessels at the fracture site of the TF3 treatment group were better than those of the control group. In vitro, TF3 significantly promoted the proliferation and wound healing of MC3T3-E1s and HUVECs (all P < .01). Transwell assays showed that TF3 promoted the migration of HUVECs, but inhibited the migration of MC3T3-E1 cells. Tubule formation experiments confirmed that TF3 markedly promoted the ability of vascular endothelial cells to form microtubules. Gene expression analysis revealed that TF3 significantly promoted the expression of VEGFA, SPOCD1, NGF, and NGFR in HUVECs. In MC3T3-E1 cells, the transcript levels of RUNX2 and COL2A1 were significantly elevated following TF3 treatment. ConclusionTF3 promotes fracture healing by promoting bone regeneration associated with the RUNX2 pathway and angiogenesis associated with the VEGFA pathway.

Validation of a patient-specific finite element analysis framework for identification of growing rod-failure regions in early onset scoliosis patients

PurposeGrowing rods are the gold-standard for treatment of early onset scoliosis (EOS). However, these implanted rods experience frequent fractures, requiring additional surgery. A recent study by the U.S. Food and Drug Administration (FDA) identified four common rod fracture locations. Leveraging this data, Agarwal et al. were able to correlate these fractures to high-stress regions using a novel finite element analysis (FEA) framework for one patient. The current study aims to further validate this framework through FEA modeling extended to multiple patients.MethodsThree patient-specific FEA models were developed to match the pre-operative patient data taken from both registry and biplanar radiographs. The surgical procedure was then simulated to match the post-operative deformity. Body weight and flexion bending (1 Nm) loads were then applied and the output stress data on the rods were analyzed.ResultsRadiographic data showed fracture locations at the mid-construct, adjacent to the distal and tandem connector across the patients. Stress analysis from the FEA showed these failure locations matched local high-stress regions for all fractures observed. These results qualitatively validate the efficacy of the FEA framework by showing a decent correlation between localized high-stress regions and the actual fracture sites in the patients.ConclusionsThis patient-specific, in-silico framework has huge potential to be used as a surgical tool to predict sites prone to fracture in growing rod implants. This prospective information would therefore be vital for surgical planning, besides helping optimize implant design for reducing rod failures.

Homogenized finite element analysis of distal tibia sections: Achievements and limitations

High-resolution peripheral quantitative computed tomography (HR-pQCT) based micro-finite element (μFE) analysis allows accurate prediction of stiffness and ultimate load of standardised (∼1 cm) distal radius and tibia sections. An alternative homogenized finite element method (hFE) was recently validated to compute the ultimate load of larger (∼2 cm) distal radius sections that include Colles' fracture sites. Since the mechanical integrity of the weight-bearing distal tibia is gaining clinical interest, it has been shown that the same properties can be used to predict the strength of both distal segments of the radius and the tibia. Despite the capacity of hFE to predict structural properties of distal segments of the radius and the tibia, the limitations of such homogenization scheme remain unclear. Therefore, the objective of this study is to build a complete mechanical data set of the compressive behavior of distal segments of the tibia and to compare quantitatively the structural properties with the hFE predictions. As a further aim, it is intended to verify whether hFE is also able to capture the post-yield strain localisation or fracture zones in such a bone section, despite the absence of strain softening in the constitutive model.Twenty-five fresh-frozen distal parts of tibias of human donors were used in this study. Sections were cut corresponding to an in-house triple-stack protocol HR-pQCT scan, lapped, and scanned using micro computed tomography (μCT). The sections were tested in compression until failure, unloaded and scanned again in μCT. Volumetric bone mineral density (vBMD) and bone mineral content (BMC) were correlated to compression test results. hFE analysis was performed in order to compare computational predictions (stiffness, yield load and plastic deformation field pattern) with the compressive experiment. Namely, strain localization was assessed based on digital volume correlation (DVC) results and qualitatively compared to hFE predictions by comparing mid-slices patterns.Bone mineral content (BMC) showed a good correlation with stiffness (R2 = 0.92) and yield (R2 = 0.88). Structural parameters also showed good agreement between the experiment and hFE for both stiffness (R2 = 0.96, slope = 1.05 with 95 % CI [0.97, 1.14]) and yield (R2 = 0.95, slope = 1.04 [0.94, 1.13]). The qualitative comparison between hFE and DVC strain localization patterns allowed the classification of the samples into 3 categories: bad (15 sections), semi (8), and good agreement (2).The good correlations between BMC or hFE and experiment for structural parameters were similar to those obtained previously for the distal part of the radius. The failure zones determined by hFE corresponded to registration only in 8 % of the cases. We attribute these discrepancies to local elastic/plastic buckling effects that are not captured by the continuum-based FE approach exempt from strain softening. A way to improve strain localization hFE prediction would be to use longer distal segments with intact cortical shells, as done for the radius. To conclude, the used hFE scheme captures the elastic and yield response of the tibia sections reliably but not the subsequent failure process.

Research on the solid particle erosion wear of pipe steel for hydraulic fracturing based on experiments and numerical simulations

Erosion wear is a common failure mode in the oil and gas industry. In the hydraulic fracturing, the fracturing pipes are not only in high-pressure working environment, but also suffer from the impact of the high-speed solid particles in the fracturing fluid. Beneath such complex conditions, the vulnerable components of the pipe system are prone to perforation or even burst accidents, which has become one of the most serious risks at the fracturing site. Unfortunately, it is not yet fully understood the erosion mechanism of pipe steel for hydraulic fracturing. Therefore, this article provides a detailed analysis of the erosion behavior of fracturing pipes under complex working conditions based on experiments and numerical simulations. Firstly, we conducted erosion experiments on AISI 4135 steel for fracturing pipes to investigate the erosion characteristics of the material. The effects of impact angle, flow velocity and applied stress on erosion wear were comprehensively considered. Then a particle impact dynamic model of erosion wear was developed based on the experimental parameters, and the evolution process of particle erosion under different impact angles, impact velocities and applied stress was analyzed. By combining the erosion characteristics, the micro-structure of the eroded area, and the micro-mechanics of erosion damage, the erosion mechanism of pipe steel under fracturing conditions was studied in detail for the first time. Under high-pressure operating conditions, it was demonstrated through experiments and numerical simulations that the size of the micro-defects in the eroded area increased as the applied stress increased, resulting in more severe erosion wear of fracturing pipes.

The significance of recent fracture location for imminent risk of hip and vertebral fractures—a nationwide cohort study on older adults in Sweden

SummaryThe role of recent fracture site in predicting the most detrimental subsequent fractures, hip and vertebral, is unclear. This study found that most recent fracture sites were associated with an increased risk of both hip and vertebral fracture, a finding that may impact the design of secondary prevention programs.BackgroundHip and vertebral fractures are the most serious in terms of associated morbidity, mortality, and societal costs. There is limited evidence as to which fracture types are associated with the highest risk for subsequent hip and vertebral fractures. This study aims to explore the dependency of imminent hip and vertebral fracture risk on the site of the recent index fracture.MethodsConducted as a nationwide retrospective cohort study, we utilized Swedish national registers to assess the risk of hip and vertebral fractures based on the site of the recent (≤ 2 years) index fracture and an old (> 2 years) prevalent fracture. This risk was compared to that observed in individuals without any prevalent fractures. This study encompassed all Swedes aged 50 years and older between 2007 and 2010. Patients with a recent fracture were categorized into specific groups based on the type of their previous fracture and were followed until December 2017, with censoring for death and migration. The study assessed the risk of hip and vertebral fractures during the follow-up period.ResultsThe study included a total of 3,423,320 individuals, comprising 145,780 with a recent fracture, 293,051 with an old fracture, and 2,984,489 without a previous fracture. The median follow-up times for the three groups were 7.6 years (IQR 4.0–9.1), 7.9 years (5.8–9.2), and 8.5 years (7.4–9.7), respectively. Patients with a recent fracture at almost all sites exhibited a significantly increased risk of hip fracture and an elevated risk of vertebral fracture compared to controls.Patients with recent fractures had an increased risk of subsequent hip and vertebral fractures, regardless of the index fracture site. These results strengthen the notion that all patients with a recent fracture, regardless of fracture site, should be included in secondary prevention programs, to improve the prevention of the clinically most serious fractures.

Bone mineral density T-scores comparison between obese and non-obese individuals included in a Fracture Liaison Service following a recent fragility fracture.

This study aimed to compare the mean T-scores of obese and non-obese patients after recent fragility fractures. Over a period of 5 and a half years, from January 2016 to May 2021, patients from a fracture liaison service were identified and their demographic characteristics, osteoporosis risk factors, BMD T-scores, and fracture sites were compared between obese (BMI ≥ 30kg/m2) and non-obese (19kg/m2 < BMI < 30kg/m2) patients. A total of 712 patients were included (80.1% women; mean age 73.8 ± 11.3years). Sixteen % had type 2 diabetes mellitus and 80% had a major osteoporotic fracture (MOF). 135 patients were obese and 577 non-obese, with obese patients younger (p < 0.001) and more frequently female (p = 0.03). Obese patients presented with fewer hip fractures (10% vs. 21%, p = 0.003) and more proximal humerus fractures (16% vs. 7%, p < 0.001) than non-obese patients. After adjusting for age, sex, and diabetes mellitus, BMD T-score values were significantly higher at all measurement sites (lumbar spine, total hip, and femoral neck) in obese patients than in non-obese patients for all types of fractures, with a mean difference of 1 standard deviation (p < 0.001 for all comparisons). The same results were observed in the population limited to MOF. Given the crucial role of BMD T-score in determining the need for anti-osteoporotic medication following fragility fractures, it is reasonable to question the existing T-score thresholds in obese patients.

Clinical Characteristics and Outcomes of Limb Fractures in Saudi Children.

Children's bones are at high risk of fracture as they grow. The clinical characteristics of fractures in children differ from those in adults. Studying fractures in healthy children is critical for identifying cases of fragility fractures. The aim of this study was to assess the clinical characteristics of limb fractures as well as clinical indicators of fracture healing outcomes in healthy Saudi children seen in an emergency room. A retrospective review of the treatment course of all pediatric fractures and related factors treated at King Abdullah Specialist Children's Hospital (KASCH) in Riyadh between 2016 and 2018 was conducted. Children with a primary bone disorder or chronic comorbidities known to affect bone health were excluded. The study included 143patients(mean age ±SD =8.23 + 3.76 years), and 71% (n= 102) were males. Motor vehicle accidents (MVAs) were the most common mechanism of injury, accounting for 50 (35%) cases, followed by fall injuries, sports injuries, and pedestrian accidents at 45 (31.4%), 16 (11.2%), and 13 (9.1%), respectively. A total of 178 fractures were reported, with the femur (n= 75, 42.1%) being the most common of the reported fracture sites, followed by the forearm (n= 44, 24.7%). The most common type of fracture was transverse fracture (n= 96, 54% of patients). Vitamin D levels were measured in 53/143 cases. Of these, vitamin D deficiency was found in 38 (71.7%) patients. The average time for fracture healing was 32.9 ± 30.2 weeks. The mechanisms of injury, including MVAs and sports injuries, as well as femur and forearm fractures, were clinical factors that were independently associated with a longer duration of fracture healing time (p< 0.001), but age, gender, and vitamin D status were not associated with that outcome. MVAs andfall injurieswere the most common causes of fracture in our patients. MVAs and sports injurieswere associated with prolonged healing time. Large prospective, multicenter, or field studies may be required to further explore clinical characteristics, outcomes, and environmental factors.

Close negative correlation of local and circulating Dickkopf-1 and Sclerostin levels during human fracture healing

Wnt signaling is critically involved in fracture healing. Existing data predominantly relies on rodent models. Here, we explored local and circulating Dickkopf-1 (DKK1) levels in patients with respect to fracture healing and explore its association to sclerostin (SOST). 69 patients after surgical stabilization of long bone fractures of which six patients had impaired fracture healing were included in this study. Life-style and patient related factors with a known effect on DKK1 and SOST were recorded. DKK1 and SOST concentrations were measured using enzyme-linked immunosorbent assay (ELISA) at the fracture site and in circulation. DKK1 and SOST showed a close inverse correlation. In fracture hematoma and immediately after trauma DKK1 levels were significantly reduced while SOST levels were significantly increased, compared to healthy control. Postoperatively, DKK1 peaked at week 2 and SOST at week 8, again demonstrating a close negative correlation. Age and smoking status affected the balance of DKK1 and SOST, while type 2 diabetes and sex did not demonstrate a significant influence. Early postoperative elevation of SOST without compensatory DKK1 decrease was associated with fracture non-union in younger patients (< 50a). The close inverse correlation and very rapid dynamics of DKK1 and SOST locally as well as systemically suggest their critical involvement during human fracture healing. Importantly, as immediate compensatory feedback mechanism are apparent, we provide evidence that dual-blockade of DKK1 and SOST could be critical to allow for therapeutic efficiency of Wnt targeted therapies for fracture healing.

Minimizing porosity and optimizing microstructure of hot-wire arc additive manufactured Al-Cu-Mg-Ag alloy for strength increment

Here, wire arc additive manufacturing (WAAM) is employed for the fabrication of Al-Cu-Mg-Ag alloy, focusing on improving mechanical property via eliminating porosity and tuning microstructures. Via optimizing the hot-wire current and pulse frequency of WAAM, the volume fraction of porosity reduces from 3.13 % to 1.77 %, along with grain refinement. Overhigh pulse frequency leads to lower sphericity of pores and larger grain size. Finite element analysis performed by Abaqus software reveals that both ultimate tensile strength (UTS) and elongation decrease with higher volume fraction of porosity, and large pores are the preferential sites of strain concentration, crack initialization and final fracture. Based on the optimization of WAAM processing parameters, a WAAM-customized T6 temper is proposed for the Al-Cu-Mg-Ag alloy, to enable the formation of strengthening Ω precipitates. Resultantly, UTS and yield strength (YS) reach 425.2 ± 6.0 MPa and 400.3 ± 4.6 MPa, respectively, which increased by 42.6 % and 111.2 % compared with as-deposited alloy.

Prevalence and Characteristics of Pathological Fractures in Patients Referred to Specialist Palliative Care: A Retrospective Study From India.

Background: Prevalence of pathological fractures in palliative care is less studied. This study aimed to determine the annual prevalence of pathological fractures and describe the characteristics and treatments in patients with pathological fractures referred to a specialist palliative care clinic in a tertiary care cancer center in India. Methods: Data of adult cancer patients newly referred to the specialist palliative care clinic over 1year with a clinico-radiological diagnosis of pathological fracture was included. Key outcomes of interest were annual prevalence, clinical characteristics, symptoms and treatments offered. Results: 75 out of 5800 (1.29%) patients newly referred to the clinic over 1year had pathological fractures. Lung cancer was the most common primary diagnosis (n = 23).Dorsal spine (n = 25) was the most common site of fracture. Pain was the predominant symptom. Mean pain score was 7.04(SD = 1.75) and 42 patients (56%) required strong opioids for analgesia. Only 11 (16%) patients underwent surgical fixation. Median duration from diagnosis of cancer to occurrence of fracture was found to be 329days. Treatment goals changed to best supportive care in 33 patients (44%) post fracture. Patients with bone and soft tissue neoplasms and those who received only chemotherapy previously had a higher risk of occurrence of fractures. Conclusion: Annual prevalence of pathological fractures in patients referred to the specialist palliative care clinic was 1.29%. It was associated with significant symptom burden and affected oncological treatments. Close monitoring of patients with bone metastases is crucial and proactive implementation of prophylactic measures to prevent such skeletal related events is warranted.

Study on the characteristics of increased mechanical stiffness according to changes in LCP shape to reinforce clavicle fractures

The clavicle has various anatomic shapes unique to each individual. Additionally, with the increase in high-energy traumas such as sports injuries and traffic accidents, the patterns of fractures become complex and complicated. Thus, there is a need for a variety of shapes of locking compression plates (LCP) to accommodate different types of fractures and facilitate quicker rehabilitation. The aim of this study is to present different types of LCP that secure fracture fragments and distribute stress evenly, in comparison to typical anatomical LCPs, for reinforcing clavicle fractures. Three models were compared in this study: the typical shape, the center hole removed shape, and the double-curved wing shape. The DICOM (Digital Imaging and Communications in Medicine) file obtained from the computed tomography scan of the patient’s clavicle was used to extract the three-dimensional (3D) clavicle structure. Finite element analysis (FEA) simulation was employed to analyze the structural changes of the LCP under external forces. A reinforced jig was used to apply the same type of external force to each LCP, and an experiment was conducted to analyze the mechanical impact of the LCP’s structural characteristics. When comparing the stress values at the fracture zone point, resulting from the FEA simulation with applied bending forces, it was calculated that the stress dispersion effect was approximately ten times greater when transitioning from a typical LCP shape to a double-curved partial wing structure. Moreover, the ultimate stress increased 3.33 times, from 241.322 to 804.057 N, as the LCP design changed under cantilever bending conditions. This double-curved wing LCP design reduces stress concentration at the fracture site and minimizes stress in the fracture area when subjected to cantilever bending forces. Consequently, this newly designed LCP has the potential to decrease complications related to the plate and accelerate rehabilitation protocols.