Higher Fracture Rate Research Articles

Is a Tooth Extraction Required If Dentition Lies Within a Mandible Fracture?

Is a Tooth Extraction Required If Dentition Lies Within a Mandible Fracture?

Annual incidence of osteoporotic hip fractures in Iran: a systematic review and meta-analysis

BackgroundOsteoporosis (OP) is progressively becoming a global concern with the aging of the world’s populations. Osteoporotic fractures are associated with significantly increased mortality rates and a financial burden to health systems. This Meta-analysis aims to estimate the annual incidence of osteoporotic fractures in Iran.MethodsA comprehensive systematic literature search was performed through Medline (PubMed), Embase, Scopus, Web of Science, and Google Scholar to identify studies which contain an investigation of the incidence of osteoporotic fractures in Iran up to December 3rd 2020, with no time and language restriction. For the risk of bias assessments of studies, the Joanna Briggs Institute (JBI) critical appraisal checklist for studies reporting prevalence data was used. The pooled estimation of the incidence of osteoporotic fractures in population aged≥50 years was calculated using random-effects meta-analysis, and the heterogeneity of included studies was quantified with the I2 statistic.ResultsIn all, 6708 papers were initially retrieved from the electronic databases, among which seven studies were included in the meta-analysis. The pooled standardized annual cumulative incidence of hip fractures was estimated as 138.26 (95% CI: 98.71–193.65) per 100,000 population and 157.52 (95% CI: 124.29–199.64) per 100,000 population in men and women, respectively.ConclusionThis study showed a high incidence rate of osteoporotic hip fractures in Iran. Early detection and treatment of individuals with higher risks of primary fragility fractures at primary health care as well as implementing fracture liaison services to prevent secondary fractures are highly recommended. The results suffer from the following limitations: first, a low number of studies that were eligible for inclusion; second, the lack of population-based studies; and presence of highly heterogeneous studies despite the use of a random effect model.

Divergent effects of sex and calcium/vitamin D supplementation on serum magnesium and markers of bone structure and function during initial military training.

Maintaining Mg status may be important for military recruits, a population that experiences high rates of stress fracture during initial military training (IMT). The objectives of this secondary analysis were to (1) compare dietary Mg intake and serum Mg in female and male recruits pre- and post-IMT, (2) determine whether serum Mg was related to parameters of bone health pre-IMT, and (3) whether Ca and vitamin D supplementation (Ca/vitamin D) during IMT modified serum Mg. Females (n 62) and males (n 51) consumed 2000 mg of Ca and 25 μg of vitamin D/d or placebo during IMT (12 weeks). Dietary Mg intakes were estimated using FFQ, serum Mg was assessed and peripheral quantitative computed tomography was performed on the tibia. Dietary Mg intakes for females and males pre-IMT were below the estimated average requirement and did not change with training. Serum Mg increased during IMT in females (0·06 ± 0·08 mmol/l) compared with males (-0·02 ± 0·10 mmol/l; P < 0·001) and in those consuming Ca/vitamin D (0·05 ± 0·09 mmol/l) compared with placebo (0·001 ± 0·11 mmol/l; P = 0·015). In females, serum Mg was associated with total bone mineral content (BMC, β = 0·367, P = 0·004) and robustness (β = 0·393, P = 0·006) at the distal 4 % site, stress-strain index of the polaris axis (β = 0·334, P = 0·009) and robustness (β = 0·420, P = 0·004) at the 14 % diaphyseal site, and BMC (β = 0·309, P = 0·009) and stress-strain index of the polaris axis (β = 0·314, P = 0·006) at the 66 % diaphyseal site pre-IMT. No significant relationships between serum Mg and bone measures were observed in males. Findings suggest that serum Mg may be modulated by Ca/vitamin D intake and may impact tibial bone health during training in female military recruits.

Improving Secondary Bone Protection Prescription in Patients Admitted With a Femoral Neck Fracture

BackgroundThe socioeconomic burden caused by fragility fractures is well recognised in today’s ageing society, with hip fractures making a notable contribution. There is a significant national drive for secondary-prevention bone-protection prescription given the high morbidity and mortality rates of femoral neck fractures. A Specific, Measurable, Achievable, Relevant, Time-bound (SMART) aim was constructed to reach the gold standard in a level 2 trauma centre, utilising the Model for Improvement methodology.MethodologyBaseline data were collected for 79 consecutive patients admitted with a neck of femur fracture. A total of 14% were managed with bone-protection plans. The root cause analysis identified three elements having a major impact on the prescription of secondary bone-protection medication: the lack of awareness, education, and a structured multidisciplinary team (MDT) approach. Appropriate plan-do-study-act cycles were implemented and change audited.ResultsFollowing cycles one and two, the mean percentage of patients managed with bone-protection plans increased from 14% to 44% and 76%, respectively. A statistical process control chart demonstrated positive change for each cycle, with p-values of <0.01 and <0.001, respectively. After our final cycle, 100% of patients suffering from a femoral neck fracture were being managed with appropriate bone-protection plans according to the Royal College of Physicians’ national hip fracture database. We observed 100% sustainability two years later, despite the coronavirus disease 2019 pandemic service disruptions and redeployment of staff.ConclusionsDepartmental awareness and education played an important role in this quality improvement project. The ultimatum and sustainability intervention was ‘responsibility charting’ among the MDT: setting clear roles within the team to deliver better patient care.

Fall, Crush, Kick: Mechanisms and Outcomes in a Cohort of Equine-Related Injuries.

The potential for significant traumatic injury to individuals who interact with horses remains high due to animal size, forces applied, and unpredictability. Despite an estimated 30 million riders in the United States annually, few recent publications have addressed this patient population. This study describes characteristics of patients injured in interactions with horses, focusing on mechanism of injury and use of protective equipment. We queried our institution's trauma registry for all patients admitted for equine-related injuries (ERI) between January 1, 2013 and December 31, 2017. We categorized by specific mechanism of injury (fall, crush, kick, fall + crush, and fall + kick) and presence or absence of protective devices. We discovered 143 patients admitted for injuries in equine-related accidents. Patients averaged 49.2years old, and 62.2% were female. Crush injuries resulted in a high rate of rib fractures. Riders who were kicked had an increased chance of solid organ and facial injuries and falls most commonly led to rib fractures and extremity trauma. Despite lack of documentation on most subjects, protective devices were associated with less severe injuries in those with data (n = 36). In this relatively large series of patients with ERI, we found mechanism differences within injury groups. Providers should more carefully document specific circumstances of ERIs. All individuals working with or around horses should exercise prudence and consider using protective equipment.

Watercraft propellers as a mechanism of orthopaedic injuries: injury patterns, management, and complications.

Recreational watercraft use is popular across the United States, and there is a high rate of injury associated with the use and misuse of these vehicles. Watercraft propeller injuries represent a particularly devastating mechanism of injury. We aim to describe and analyze the range of orthopaedic injuries sustained from a watercraft propeller with a particular focus on the mechanism, injury pattern, management, and complications associated with these unique, high-energy injuries. A retrospective review of 42 patients who sustained injuries from watercraft propeller that presented to a level 1 trauma center was performed. Data collected included patient demographics, mechanism of injury, surgical management, antibiotic use, and complications. Forty-two patients sustained 96 fractures. Ninety-one fractures (94.8%) were open and 5(5.2%) were closed. Twenty (20.8%) were of the upper extremity, 70(72.9%) were of the lower extremity, and 6(6.3%) were of the pelvic ring. The majority of open fractures were Gustilo-Anderson Type IIIA or greater (54, 59.3%). There were 9 total infections affecting 8 of 96 fracture sites (cumulative risk of 8.3%), and other complications included stiffness (3), heterotopic ossification (1), non-union (1), flap failure (1), DVT (2), PE (1), and systemic infection (1) for a total of 19 complications. Watercraft propellers often result in devastating injuries with high rates of morbidity. The high rate of open fractures and neurovascular injury, necessity for multiple surgeries, and extended length of hospital stay show the need for continued awareness about boat safety and the danger of propellers.

Surgical repair of lumbar stress fractures in professional cricketers .

Professional cricket fast bowlers sustain high rates of lumbar stress fractures (spondylolysis). Limited research exists around the success of surgical repair when these injuries fail conservative treatment. We present an ambispective cohort study of spondylolysis surgical repair in a consecutive group of multi-national professional cricket fast bowler using a technique not previously reported in this unique sporting group. Between 2004 and 2019, a consecutive series of male professional fast bowlers with lumbar spondylolysis who had repeatedly failed conservative treatment and subsequently received surgical repair using a cable-screw construct were reviewed. Analysis comprised of ambispective outcome and radiological data collection and a survey at final follow-up. The cohort included 13 elite (7 state and 6 international) cricket fast bowlers from 3 countries (New Zealand, Australian and India) with an average age of 26 years (range, 20.3-29.5 years). All returned to play professional cricket at a median time of 8 months (IQR, 7-11 months) post surgery. All ten players surveyed at final follow-up [median, 38 (IQR, 31-103) months, range, 15-197 months] rated their bowling performance as the 'same or better' compared with prior to surgery. At final follow-up, 10 players continue to play cricket professionally ranging from 15 to 107 months post-surgery [median 35 (IQR, 24-43) months]. Our cohort demonstrated favorable return to play rates and career longevity following surgical repair of spondylolysis. To our knowledge it is the largest published surgical series of spondylolysis repair in cricketers, and the first to document the success of a cable-screw surgical technique in this sporting group.

Influence of the Connector Area on the Chipping Rate of the VM9 Veneering Ceramic in a Posterior Four-Unit Yttria-Stabilized Tetragonal Zirconia Polycrystal Fixed Dental Prostheses: A Pilot Study

Abstract Objective The purpose of this study was to evaluate the influence of the connector area on the chipping rate of the VM9 veneering ceramic in a 4-unit yttria-stabilized tetragonal zirconia polycrystal (Y-TZP) framework, using a novel sonographic technique. Materials and Methods The framework was designed as a 4-unit fixed dental prostheses (FDP) with two abutment teeth at the first mandibular premolar and second mandibular molar. The cross-sectional area of the connector was 7.5, 8, or 9 mm2. The prepared teeth were scanned using CAD/CAM technology, and five frameworks were prepared for each design, making a total of 15. The frameworks were divided according to the veneering ceramics: Y-TZP FDPs using Vita VM9 (12 frameworks), and porcelain fused to metal (PFM) FDPs using Vita VM13 (3 frameworks). The specimens were statically loaded until failure. To capture the initiation of the failure within the specimens, a novel sonographic technique, designed for this research, combining acoustic emission and visual monitoring during live load bearing tests, was used to determine the failure load value. Failed frameworks were inspected using a microscope, and failure patterns were identified. One-way ANOVA and Tukey HSD tests were applied for statistical analysis of the results (p-value ≤ 0.05). Results Despite the fact that the chipping strength is proportional to the cross-sectional area of the connector, the effect of the cross-sectional area on chipping load revealed no statistically significant differences, while PFMs showed superior chipping strength relative to the zirconia frameworks regardless of the connector's size. A high rate of catastrophic fracture occurred while loading the specimens. Conclusion The effect of the cross-sectional area on chipping load revealed no statistically significant differences in Y-TZP frameworks. The novel sonographic technique may be a potential method to study the behavior of dental ceramics, including chipping and fracture.

Strategies for the implementation of an electronic fracture risk assessment tool in long term care: a qualitative study

BackgroundOlder adults in long-term care (LTC) homes experience high rates of fractures, which are detrimental to their quality of life. The purpose of this study is to identify and make recommendations on strategies to implementing an evidence-based Fracture Risk Clinical Assessment Protocol (CAP) in LTC.MethodsFollowing the Behaviour Change Wheel framework, we conducted six focus group interviews with a total of 32 LTC stakeholders (e.g. LTC physicians) to identify barriers and facilitators, suggest implementation strategies, and discuss whether the identified strategies were affordable, practicable, effective, acceptable, safe, and if they promote equity (APEASE). The interviews were transcribed verbatim and analyzed using thematic content analysis.ResultsThemes of implementation strategies that met the APEASE criteria were minimizing any increase in workload, training on CAP usage, education for residents and families, and persuasion through stories. Other strategy themes identified were culture change, resident-centred care, physical restructuring, software features, modeling in training, education for staff, social rewards, material rewards, public benchmarking, and regulations.ConclusionsTo implement the Fracture Risk CAP in LTC, we recommend using implementation strategies centred around minimizing any increase in workload, training on CAP usage, providing education for residents and families, and persuading through stories. Through improving implementation of the fracture risk CAP, results from this work will improve identification and management of LTC residents at high fracture risk and could inform the implementation of guidelines for other conditions in LTC homes.

Upper Paleolithic ceramic figurines and similarities to some late Pleistocene pigment and pottery materials and technologies of Eurasia

Three soft stone technologies that characterize the Upper Paleolithic period are fired ceramic figurines, pigments prepared from colored minerals that often consist of or include clay, and, lastly, pottery vessels. The earliest synthetic material of which we have a permanent artifactual record was made at 26,000 cal BP (Klima 1959b, 1963), marking the beginnings of chemical technology and pyrotechnology and is the concern of the first part of this paper. A review is presented of Upper Paleolithic ceramic figurines at the group of habitation sites in Moravia that includes Dolní Věstonice, Pavlov, Předmosti and Petřkovice. Dolní Věstonice, the only proven production site with the largest collection of ceramics, was the focus of the study because of the possibility of analyzing figurine fragments, kiln remains and raw materials that enabled reverse engineering of the technology. The size of the ceramic inventory and the presence of kilns argue for intentional production of ceramic objects and demonstrates that the relevant cultural practices over time involved repetition and both transmission and learning of a specific, patterned performance behavior of ceramic technology. The high fracture rate encountered and the resistance of the raw material to thermal shock, however, strongly suggest that what was important was not the final, durable product, but rather the process of making and firing and/or refiring of the objects, probably for ritual, ceremonial and political purposes. Similar additive fabrication methods and firing of local pluvial clay deposits was practiced at the site of Maina in Siberia at ca. 15,000 cal BP to make a singular ceramic figurine. At the southern end of the Urals is Kapovaya, a cave with images and a date similar to those at Lascaux and where a single small bowl that may be a fired ceramic was excavated.The second part discusses examples of ceramic processing technology without firing, if we understand ceramics as we define them today to include non-clay products made by processing of fine sub-10 μm, equiaxed or platy particles. Fine clay and pigment particles behave similarly when processed. Clays and pigments were processed at the cave site of Lascaux where excavation of the floor produced evidence of selected, collected and imported naturally occurring mineral and sediment blocks as well as fabricated chalk-like sticks referred to as “crayons.” These ground and fabricated blocks were used as manufacturing elements to apply red, yellow and black pigment to the cave walls at Lascaux. Stone ‘palettes’ were excavated from the floor with in-situ powders that indicate grinding and mixing of clays and pigments. This mixing also occurred on the tips of crayons.The third part is focused on a third ceramic performance technology that preserved physical health of community members: the making and using of pottery vessels for cooking and storage, and a description of some problems involved in reconstructing the processing technology.

Fracture Rates in Men With Non-Metastatic Prostate Cancer on Androgen Deprivation Therapy With or Without Anti-Osteoporosis Treatment

Abstract Introduction: Androgen deprivation therapy (ADT) decreases bone mineral density and increases osteoporotic fracture (OsteoFx) risk. Hypothesis: To assess OsteoFx incidence most predictive of future OsteoFx among men with prostate cancer on ADT. Methods: 4370 electronic medical records were reviewed of adult men with prostate cancer on cancer therapy +/- anti-osteoporotic therapy (Anti-OsteoRx) from 2011–2019. Cancer therapy included ADT (anti-androgens, GnRH agonists &amp; antagonists, orchiectomy) and supplemental cancer therapy (SupplRx) (prostatectomy, brachytherapy, radiation, immunotherapy, and chemotherapy). Anti-OsteoRx included bisphosphonates, denosumab, and parathyroid hormone analogs. Patients with other cancers within 5 years of initial visit, metastasis or traumatic fractures were excluded. Retrospective analysis was done to determine baseline characteristics, type and duration of ADT, Anti-OsteoRx, SupplRx, and OsteoFx incidence. Results: Fracture rate subgroups: • ADT only - Anti-OsteoRx 37/ 374 fractured (9.89%) • ADT only + Anti-OsteoRx 10/52 fractured (19.23%) • ADT + SupplRx + Anti-OsteoRx 2/19 fractured (10.53%) • ADT + SupplRx + Anti-OsteoRx 13/170 fractured (7.65%) Comparing fracture rates between subgroups: • Comparing ADT only +/- Anti-OsteoRx, statistical significance was observed with higher fracture rate in patients taking Anti-OsteoRx (19.23% vs. 9.89%, p &amp;lt; 0.044) • Comparing ADT + SupplRx +/- Anti-OsteoRx, no significant difference in fracture rates due to small number of fractures Comparing combined subgroups: • ADT +/- SupplRx + Anti-OsteoRx 12/71 (16.9%) fractured • ADT +/- SupplRx - Anti-OsteoRx 50/544 (9.19%) fractured • Statistically significant between groups fracture rates was observed (p= 0.042) in patients treated with Anti-OsteoRX. Discussion: Patients receiving Anti-OsteoRx, regardless of their prostate cancer therapies, had higher rates of fractures (16.9 vs. 9.19%, p= 0.042) due to their being selected for therapy based on greater clinical risks. The Anti-OsteoRx group had a higher percentage of glucocorticoid listed as a historical medication (26.8 vs.15.3% vs, p= 0.023), glucocorticoids administered (50.7 vs. 30.3% p=0.001), and anticonvulsants and proton-pump inhibitor use (45.1 vs. 26.5%, p= 0.002). Conclusion: Higher fracture rates were observed in patients on Anti-OsteoRx that could be related to their being selected for treatment based on risk factors known to be associated with osteoporosis. Limited Anti-OsteoRx use in our study is possibly related to lack of standardized guidelines for prevention of osteoporotic fractures in prostate cancer patients. OsteoFx risk assessment utilizing CRF, DXA, and FRAX may prevent fractures in these high-risk patients. Further long-term prospective studies to address these unresolved queries are warranted.

English

Management of non-vital immature anterior permanent teeth in children remains a challenge in paediatric dentistry and endodontics. Once the tooth becomes non-vital, root development ceases, rendering the tooth weak, and unable to withstand physiological forces of mastication. This results in a high rate of root fracture with poor prognosis in the medium to long term. Despite being endodontically treated, over 50 % of such teeth will be lost in the first 10 years following trauma. Traditional endodontic treatment does not contribute to any quantitative or qualitative increase in root dimensions resulting in life-long oral disability. The advancement in the science of Endodontics - Regenerative Endodontics has revolutionized current treatment strategies in treating the immature non-vital permanent tooth which has overcome the drawbacks of traditional treatment approaches. This report provides an insight view on successful maturogenesis of immature non-vital permanent incisors by induction of intracanal bleeding along with complications endured during the process. Regenerative endodontics is defined as “biologically based procedures designed to replace damaged structures, including dentin and root structures, as well as cells of the pulp - dentin complex”.1 Continued root development and reestablishment of pulp - dentine complex can be achieved by these procedures. Two major concepts in the regenerative endodontics are guided tissue regeneration (GTR) and tissue engineering. The base of these procedures is stem cells which can differentiate into the desired tissue component, growth factors or other tissue - inducing mediators and scaffold.2 Regenerative endodontic procedure (REP) includes induction of intracanal bleeding, placement of platelet rich fibrin (PRF), and platelet rich plasma (PRP). The goals of these procedures were elimination of signs and symptoms, continued root development, apical healing, and positive response to vitality testing. But preparation of PRP and PRF requires withdrawal of blood and sight of syringe can add emotional stress to young patients. Revascularization may be defined as the invagination of undifferentiated periodontal cells from the apical region in immature teeth.3,4 The nature of tissue formed after revascularization is not certain and can be confirmed by histological evaluation. Presence of blood supply is reliable. Revascularization considers only one facet - nature of newly formed tissue thus making term revascularization inaccurate and thus many authors disagreed with this term.5

Short distance from the keel to the posterior tibial cortex is associated with fracture after cementless Oxford UKA in Asian patients.

Tibial plateau fractures are serious complications of Oxford mobile-bearing unicompartmental knee arthroplasty (OUKA). This study examined where the fracture lines arises and evaluated the keel-cortex distances (KCDs) using three-dimensional computed tomography (3D-CT) and the effects of technical error (assessed by tibial component positions) and proximal tibial morphology on the KCDs. This retrospective study included 217 OUKAs with cementless tibial components. Fifteen patients had tibial fractures after surgery. Anterior and posterior KCDs and fracture line origins were assessed using 3D-CT postoperatively. Proximal tibial morphology was assessed using the medial eminence line (MEL), which runs parallel to the tibial axis and passes through the tip of the medial intercondylar eminence of the tibia on long-leg anteroposterior radiograph. Knees had overhanging medial tibial condyle if the MEL passed medially to the medial tibial cortex. KCDs were compared between patients with/without fractures. Tibial component positions were evaluated, considering effects of tibial morphologies and component positions on fracture prevalence and KCDs. Fracture lines were found between the keel and posterior cortex in 12/15 patients. Posterior KCDs were significantly shorter in patients with fractures than in patients without (2.7 ± 1.6mm vs 5.2 ± 1.7mm, P < 0.001). Patients with medial overhanging condyles were more likely to have fracture (10/51 vs 5/166, P < 0.001) and had significantly shorter posterior KCD than those without (3.6 ± 1.5mm vs 5.5 ± 1.8mm, P < 0.001). Patients with tibial component that was set too medial, low, and valgus had higher rates of fracture than those without (7/39 vs 8/178, P = 0.008). Medial (r = 0.30, P < 0.001), low (r = -0.33, P < 0.001), and valgus implantations (r = 0.35, P < 0.001) of tibial components were related to shorter posterior KCDs. Short posterior KCD after OUKA is a risk factor for postoperative tibial fracture. Patients with either malposition of the tibial component (too medial, low, and valgus) and/or a medial overhanging condyle exhibit a shorter distance of posterior KCD and higher rate of fracture. Level III.

Improving Lower Extremity Casting Quality by Providing an Experienced Assistant in Pediatric Tibia Fractures Managed by Trainees.

Background: The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. Purpose: We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. Methods: We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Results: Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. Conclusion: When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types.

Abstract GS2-02: 12 year results of anastrozole versus tamoxifen for the prevention of breast cancer in postmenopausal women with locally excised ductal carcinoma in-situ

Abstract Background: Two large clinical trials have reported divergent results in their initial analysis of the benefit of aromatase inhibitors compared to tamoxifen in women with ductal carcinoma in situ (DCIS) (IBIS-II and NSABP B-35). Here, we report blinded 12-year median follow-up efficacy and adverse event data for the IBIS-II trial, which compared anastrozole to tamoxifen in women with hormone receptor positive DCIS and focus on the post-treatment follow-up period.Methods: A multi-centre randomised trial of 1mg/day anastrozole (N=1471) vs. 20mg/day tamoxifen (N=1509) for five years was conducted in postmenopausal women with locally excised DCIS diagnosed between 2003 and 2009. The primary objective of this analysis was to determine the efficacy of anastrozole compared to tamoxifen in preventing recurrences overall, and in particular in the post 5-year treatment period. Secondary endpoints included type of recurrence, breast cancer mortality, other cancers, cardiovascular disease, fractures, adverse events and non-breast cancer deaths.Results: After a median follow-up of 11.6 years (IQR 9.9 to 13.4), a total of 221 breast cancer recurrences (7.4%) have been recorded. No difference in overall recurrence was observed (102 (6.9%) anastrozole vs. 119 (7.9%) tamoxifen; HR=0.87 (0.67-1.14), P=0.32) overall (Table), in the 5-year treatment period (HR=0.82 (0.53-1.27), P=0.37), or the post treatment follow-up period (HR=0.91 (0.65-1.27), P=0.57). Oestrogen receptor (ER) positive breast cancers were reduced by 28% with anastrozole when compared to tamoxifen (58 vs. 82; HR=0.72 (0.52-1.01), P=0.056) but this did not reach significance. In contrast, no effect was observed for ER-negative breast cancer with anastrozole (Table). No significant difference for the reduction in invasive breast cancer recurrence was observed with anastrozole when compared to tamoxifen (Table). Invasive ER-positive breast cancer was non-significantly reduced by 24% with anastrozole when compared to tamoxifen (44 vs. 59; HR=0.76 (0.51-1.12), P=0.17). A total of 127 deaths have been reported, with no significant difference in all-cause mortality between the two treatment arms (61 vs. 66; HR=0.94 (0.67-1.33), P=0.74). Only 7 deaths from breast cancer (3 vs. 4) were reported, with so few deaths from breast cancer at 12 years, any impact on survival is unlikely to emerge with longer follow-up. 214 cancers other than breast were reported, with a non-significant decrease observed with anastrozole (97 vs. 117, OR=0.84 (0.63-1.12), P=0.22). Endometrial (2 vs. 13, OR=0.16 (0.02-0.0.69)), ovarian cancer (1 vs. 9, OR=0.11 (0.003-0.82)), and non-melanoma skin cancer (11 vs. 21) were less common with anastrozole. Significantly higher rates of fractures (181 vs. 145, OR=1.32 (1.04-1.68)) and transient ischaemic attacks (15 vs. 5, OR=3.10 (1.07-10.92)) were observed with anastrozole compared to tamoxifen. A comprehensive adverse event profile will be reported. Conclusions: No clear efficacy differences were seen between the two treatments, although the data suggests possible greater efficacy for anastrozole over tamoxifen for prevention of ER-positive breast cancers. There were some clear differences in adverse events and anastrozole may be more appropriate for some women with contraindications for tamoxifen. Table: Number of events and Hazard Ratios (95% CI) according to treatment allocation.Anastrozole(N=1471)Tamoxifen(N=1509)HR (95% CI)Any recurrence1021190.87 (0.67-1.14)ER-positive58820.72 (0.52-1.01)ER-negative24151.63 (0.86-3.11)Invasive66760.89 (0.64-1.23)ER-positive44590.76 (0.51-1.12)ER-negative17121.44 (0.69-3.02)DCIS35420.85 (0.54-1.33)ER-positive14230.62 (0.32-1.21)ER-negative732.38 (0.61-9.20)Numbers do not add up due to missing information Citation Format: Ivana Sestak, Jack Cuzick, Bernardo Bonanni, Nigel Bundred, Christelle Levy, Sibylle Loib, Patrick Neven, Michael Stierer, Chris Holcombe, Robert Coleman, John Forbes, Anthony Howell. 12 year results of anastrozole versus tamoxifen for the prevention of breast cancer in postmenopausal women with locally excised ductal carcinoma in-situ [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS2-02.

High Rates of Spacer Fracture in the Setting of Extended Trochanteric Osteotomy With a Specific Thin-Core Articulating Antibiotic Hip Spacer

BackgroundTwo-stage revision remains the standard of care for prosthetic joint infection after total hip arthroplasty. However, there are substantial complications associated with articulating antibiotic hip spacers. Handmade and molded spacers have been shown to have higher rates of spacer fracture than antibiotic-coated prostheses (ACPs). The aim of this study is to review outcomes with an implant that is often categorized as an ACP spacer, the Zimmer-Biomet StageOne Select Femoral Spacer (ZBSO). MethodsA retrospective review was performed of 63 patients who underwent placement of a ZBSO. Patients were compared based on whether or not an extended trochanteric osteotomy (ETO) was performed using Fisher’s exact and t-tests. ResultsFive patients were excluded due to lack of follow-up or death shortly after stage 1 surgery, leaving 58 patients. Spacer fracture was noted in 5 of 58 patients (8.6%). Sixteen patients underwent ETO and 25.0% suffered a spacer fracture compared to 2.3% without ETO (odds ratio 13.7, P = .0248). There was no association between patient demographics or ETO length and spacer fracture. Two patients had periprosthetic fractures (3.4%) and 4 had dislocations (6.9%). Forty-nine patients (84.4%) went on to second-stage revision; of those 26.5% failed to clear the infection and required an average of 2.2 additional surgeries. ConclusionThe ZBSO spacer has overall complication rates similar to previously reported spacer series. Although the ZBSO looks like an ACP spacer, in the setting of ETO, it behaves like a molded or handmade spacer with a high rate of spacer fracture (25%) due to the small diameter of the core. This implant should be used with caution in combination with an ETO.

Segmental tibial fractures treated with Ilizarov circular fixator

Background/Aim. Segmental fractures represent complex tibial injuries, featuring a unique fracture type that is most commonly caused by high-energy trauma. These fractures are considered to be a treatment challenge for orthopaedic surgeons due to their sporadic presentation, wide zone of soft tissue injury, and increased rate of complications. They are characterized by a highly unstable intermediary segment and a high rate of open fractures. The method of Ilizarov with its characteristics could offer many advantages over the existing operative techniques. This method, using a percutaneous approach, minimizes the intraoperative trauma and avoids the additional compromising of the biological environment at the fracture site. The aim of this study was to evaluate the results of the Ilizarov fixator in the treatment of segmental tibial fractures. Methods. We analyzed 30 patients treated with the Ilizarov fixator between 2012 and 2017. The average age of patients was 36 years (from 24 to 65). The most common mechanism of injury was a road traffic accident. Open fractures were noted in 22 cases. All fractures were reduced using indirect percutaneous techniques with a great focus on achieving the correct length, rotation, and axial alignment of fragments. All patients were advised to bear weight as tolerated from the second postoperative day. Bone healing and functional results were evaluated according to the criteria established by the Association for the Study and Application of the Method of Ilizarov. Results. Bone healing was achieved in all patients. The average time to union was 25 weeks (19 to 36 weeks). Bone results were excellent in 23 patients, good in five, and fair in two patients. Functional results were excellent in 22 cases, good in 5, and fair in three cases. Eight patients had minor pin-tract infections, successfully treated with oral antibiotics. Patients were without any major complications. Conclusion. The Ilizarov method is a safe and efficient treatment modality for segmental tibial fractures.

Neurologically Asymptomatic Lumbar Traumatic Dislocation With Vascular Compression in a Patient With Ankylosing Spondylitis: Case Report.

Ankylosing spondylitis (AS) is associated with high rates of severe thoracolumbar fractures, in many cases with neurological deficits. It is currently a point of debate as to whether the optimal surgical treatment is posterior fixation and fusion or combined approaches. Vascular injuries in this kind of fracture are a challenging issue to solve in the management of these patients. We are reporting the case of a 65-year-old man who presented an L4 traumatic fracture-dislocation. He had a long history of symptomatic AS. No neurological deficits were detected during the initial exploration. During the preoperative work-up, a lumbar spine computed tomography (CT) scan was taken with vascular reconstruction of the abdominal vessels. It confirmed the compression of the abdominal aorta, which had caused more than 90% stenosis. A posterior approach, an open reduction, and fixation with pedicle screws were performed, without hemodynamic or neurological changes. A postoperative angiography demonstrated a complete recovery of the vessel caliber, without contrast leaks. After a 2-year follow-up, the patient was pain free and the CT scan revealed bone fusion. The vascular structures involved in severe thoracolumbar fractures present a dangerous situation that should be considered in the choice of the surgical approach. The posterior approach alone may be a good option in the absence of vascular damage. However, due to risk of vessel rupture during the fracture reduction, vascular surgeons must take part in the surgery. 5. The article provides help for surgeons who have to treat severe fractures in the context of ankylosing spondylitis.

Sex Differences in Bone-Active Medication Utilization Before and During the Year After Hip Fracture

Bone-active medications (BAM) [prescriptions (RxBAM) and supplements(calcium/vitamin D] increase bone mineral density and reduce osteoporotic fracture risk. However, RxBAM utilization rates are low, and it is unclear who is treated with BAMs before/after a hip fracture. This study examined sex differences in BAM use at baseline and predicted the probability of RxBAM use during follow-up(2, 6, and 12-months). The sample included frequency-matched males and females 65 years or older from the Baltimore Hip Studies’ seventh cohort. Differences in baseline characteristics between males and females with complete data(n=313) were assessed using t-tests and chi-square tests. Generalized estimating equations(GEE) predicted the probability of RxBAM use by sex among participants(n=270) with outcome data during follow-up adjusted for baseline characteristics. Prior to fracture, there were sex-differences in BAM use, with fewer men than women taking RxBAMs(9% versus 26%), calcium(18% vs. 57%) and vitamin D (55% vs. 68%). These differences remained over the year post-hip fracture. Only 12(3.5%) participants took RxBAM the entire study period. Of RxBAM users n=70(26%), there were few new-users (n=35), and many participants stopped or never started treatment. Unadjusted GEEs showed that men were less likely to use RxBAM (OR= 0.42; 95% CI:0.22,0.78, p=.007), during the hip fracture recovery period compared to females. However, after controlling for differences in baseline characteristics between males and females, particularly pre-fracture BAM medication use, the observed association (OR=0.62; 95% CI:0.29, 1.31; p= 0.23). RxBAM use was low, especially in men and may contribute to the high rates of preventable subsequent osteoporotic fractures and post-fracture mortality.

Prior loss of body mass index, low body mass index, and central obesity independently contribute to higher rates of fractures in elderly women and men.

We aimed to comprehensively evaluate the association of body composition with fracture risk using longitudinal data from a Swedish cohort of 44,366 women and men (mean age of 70 years) and a subcohort of 5022 women. We estimated hazard ratios (HRs) of fracture for baseline body mass index (BMI), BMI change during the prior 12 and 18 years, baseline waist-to-height ratio, total and regional distribution of fat and lean mass, with and without areal bone mineral density (BMD) adjustment. During follow-up (median 8.7 years), 7290 individuals sustained a fracture, including 4279 fragility fractures, of which 1813 were hip fractures. Higher baseline BMI and prior gain in BMI were inversely associated with all types of fracture. Lower fracture rate with higher baseline BMI was seen within every category of prior BMI change, whereas higher prior BMI gain conferred a lower rate of fracture within those with normal baseline BMI. Each standard deviation (SD) higher baseline waist-to-height ratio, after adjustment for BMI, was associated with higher rates of hip fracture in both women and men (HR 1.12; 95% CI, 1.05-1.19). In the subcohort (median follow-up 10 years), higher baseline fat mass index (FMI) and appendicular lean mass index (LMI) showed fracture-protective effects. After BMD adjustment, higher baseline BMI, total LMI, FMI, and higher prior BMI gain were associated with higher fracture rate. Baseline fat distribution also was associated with fracture rate; a 1-SD higher android to gynoid fat mass ratio in prior BMI gainers was associated with BMD-adjusted HRs of 1.16 (95% CI, 1.05-1.28) for any fracture and 1.48 (95% CI, 1.16-1.89) for hip fracture. This pattern was not observed among prior BMI losers. These findings indicate that for optimal fracture prevention, low baseline BMI, prior BMI loss and high baseline central obesity should be avoided in both women and men. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).