Femoral Neck Research Articles

Postoperative Care and Outcomes in Solid-Organ Transplant Patients Undergoing Lower Extremity Fracture Treatment.

To determine the postoperative outcomes in solid-organ transplant (SOT) patients undergoing operative treatment of lower extremity fractures. Retrospective comparative study. Academic Level 1 trauma center. Patients who underwent SOT and operative treatment of lower extremity fracture from 2013 to 2021 were identified, excluding pathologic fractures. Postoperative complications, length of stay, time to death, 90-day and 1-year readmission rates, readmission causes, discharge location, and immunosuppressive regiments. Sixty-one patients with an average age of 67 years (range 29-88) were included. The mortality rate was 37.7%. The average follow-up was 15.2 months (range of 2 weeks-10 years). The majority of patients (32.8%) had received a liver transplant, and femoral neck fractures constituted the largest fracture group. The average length of stay was 10 days, with the shortest being 1 day and the longest being 126 days (SD 18). The majority of patients (57.3%) were not discharged home. Only 2 suffered from a postoperative complication requiring another procedure: hardware removal and liner exchange for periprosthetic joint infection, respectively. There was a 27.9% 90-day readmission rate with 2 deaths within that period with the most common being altered mental status (29.4%), genitourinary infections (17.6%), repeat falls (11.8%), and low hemoglobin requiring transfusion (11.8%). The longest average time to death analyzed by transplant type was found among lung transplant patients (1076 days, 62.5% mortality), followed by liver transplant patients (949 days, 35.0% mortality), and then kidney transplant patients (834 days, 38.9% mortality). The shortest time to death was 71 days from index procedure. Family members of SOT patients undergoing operative treatment of lower extremity fractures should be made aware of the high risk for 90-day readmission postoperatively (27.9%) and overall mortality (12.5%). Providers should be aware of the need for multidisciplinary involvement for inpatient care, monitoring postoperative complications, and facilitating discharge planning. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preliminary clinical and radiological evaluation of osteosynthesis using the Femoral Neck System (FNS) for subcapital fractures of the femur

Addressing subcapital fractures of the femur poses a substantial clinical challenge, complicated by the diverse range of available osteosynthesis materials. This study is dedicated to a comprehensive analysis of the clinical and radiological implications linked with the implementation of the Femoral Neck System (FNS) in osteosynthesis procedures. A descriptive study was conducted involving patients who underwent osteosynthesis for subcapital fractures of the femur utilizing the FNS during the period from 2019 to 2022. The investigation encompassed various facets, including the classification of fractures according to the Garden and Pauwells classifications, criteria for achieving precise reduction based on the Garden criteria and Tip Apex Distance (TAD). At the one-year follow-up, factors such as fracture consolidation, loss of reduction, fracture collapse, complications, and functional outcomes were evaluated utilizing the Harris Hip Score (HHS) scale. The study cohort included a total of 26 patients, among whom 22 exhibited non-displaced subcapital femur fractures categorized as Garden I and II. Successful reduction was accomplished in 23 cases, in which 24 cases (92.3%) displayed a TAD measurement below 25 mm. According to the HHS, patients achieved an average score of 90.9 (ranging from 63 to 100) following the surgical intervention, with predominantly "excellent" and "good" outcomes. The outcomes derived from our investigation corroborate the viability of the Femoral Neck System (FNS) as a reliable option for osteosynthesis in femoral neck fractures. The results obtained are comparable to those achieved with other available implants, as highlighted by previous studies.

Should a low starting point be abandoned for cannulated screw fixation of femoral neck fractures?

A validated femoral neck fracture model stabilized with three inverted cannulated screws was used to consider different intraoperative scenarios when the inferior screw hole is inadvertently started too inferiorly. These scenarios were to: (1) abandon the misplaced inferior screw hole and restart this hole more proximally, or (2) accept the mispositioned placement of the inferior screw and insert the remaining superior screws parallel or convergent to the inferior screw. Utilizing the second option and accepting the errant hole was associated with the greatest interfragmentary motion and stresses in the bone and hardware. In contrast, the first option created an improved mechanical environment for healing.

Two-year outcomes of internal fixation with femoral neck system in patients with femoral neck fracture in an Asian population

BackgroundFemoral neck fractures (FNF) are one of the most common fractures, with a projected increase in incidence with population growth and ageing. The Femoral Neck System (FNS) launched in 2019 was developed specifically for fixation of FNF with the purported advantages of providing both angular and rotational stability. We report our experience with the FNS and evaluate its effectiveness and associated complications. MethodsA retrospective case series of 50 patients who underwent surgical fixation for FNF from August 2020 to October 2021 using the FNS in two Singapore tertiary institutions with at least 2 years follow-up were included. Clinical data (patients’ demographics, fracture classification, intra-operative and post-operative complications) were reviewed. Radiological analysis assessed the pre- and immediate post-operative garden alignment index (GAI) and presence of femoral neck shortening at 3 months. ResultsThe mean age was 63.5 years (SD 16.9, range 26–92). Five (10 %), 34 (68 %) and 11 (22 %) were ASA 1, 2 and 3 respectively. Twenty-four (48 %), 16 (32 %), 4 (8 %), and 6 (12 %) patients sustained Garden's 1, 2, 3 and 4 FNF respectively. The mean operative duration was 66.2 min (SD 20.5) and length of stay was 6.9 days (SD 4.6).The post-operative improvement in garden alignment index (GAI) was a mean of 9.1° (p < 0.001) on lateral view. The mean femoral neck shortening was 1.97 mm (SD 5.3) at 3 months. There were no intra-operative complications. Post-operatively, 1 (2 %) patient required blood transfusion, 1 (2 %) patient had implant cut-out and non-union managed non-operatively, 2 (4 %) patients developed avascular necrosis and required revision to total hip replacements. There were two (4 %) cases of 1-year mortality. ConclusionThe FNS achieved good outcomes with low rates of complications. The promising results justify its continued use and further evaluation in comparison to other devices.

Predictive value of sarcopenia components for all-cause mortality: findings from population-based cohorts

BackgroundLow grip strength and gait speed are associated with mortality. However, investigation of the additional mortality risk explained by these measures, over and above other factors, is limited.AimWe examined whether grip strength and gait speed improve discriminative capacity for mortality over and above more readily obtainable clinical risk factors.MethodsParticipants from the Health, Aging and Body Composition Study, Osteoporotic Fractures in Men Study, and the Hertfordshire Cohort Study were analysed. Appendicular lean mass (ALM) was ascertained using DXA; muscle strength by grip dynamometry; and usual gait speed over 2.4–6 m. Verified deaths were recorded. Associations between sarcopenia components and mortality were examined using Cox regression with cohort as a random effect; discriminative capacity was assessed using Harrell’s Concordance Index (C-index).ResultsMean (SD) age of participants (n = 8362) was 73.8(5.1) years; 5231(62.6%) died during a median follow-up time of 13.3 years. Grip strength (hazard ratio (95% CI) per SD decrease: 1.14 (1.10,1.19)) and gait speed (1.21 (1.17,1.26)), but not ALM index (1.01 (0.95,1.06)), were associated with mortality in mutually-adjusted models after accounting for age, sex, BMI, smoking status, alcohol consumption, physical activity, ethnicity, education, history of fractures and falls, femoral neck bone mineral density (BMD), self-rated health, cognitive function and number of comorbidities. However, a model containing only age and sex as exposures gave a C-index (95% CI) of 0.65(0.64,0.66), which only increased to 0.67(0.67,0.68) after inclusion of grip strength and gait speed.ConclusionsGrip strength and gait speed may generate only modest adjunctive risk information for mortality compared with other more readily obtainable risk factors.

Quality of cementing in hemiarthroplasty for elderly neck of femur fractures does not affect short term functional outcomes.

Cemented hip hemiarthroplasty is a routine surgical option for elderly neck of femur (NOF) fractures. It is uncertain if quality of cementing has any effect on functional outcomes. The aim of this study was to determine if the quality of cementing would affect short term functional outcomes in elderly neck of femur fractures. Retrospective analysis of 637 single-centre cemented hip hemiarthroplasties from 2014 to 2021 was performed. Each post-operative radiograph was double-read by 2 authors (1 resident and 1 fellowship trained surgeon) to determine quality of cementing via the Barrack grading. Disagreements were reviewed by a third reader. Cement grades were grouped as Optimal (Barrack grade A-B), or Suboptimal (Barrack grade C-D). Functional outcomes were compared using mobility (community- or home-ambulant), assistance required for mobility, and Modified Barthel Index (MBI). Surgical parameters were compared between the groups. There were 429 Optimal and 208 Suboptimal cases of cementing performed. There was no difference in age, American Society of Anesthesiologists score, mobility, assistance required, and MBI score pre-operatively (p > 0.05). Patients in the "Suboptimal" cementing group had a higher Charlson Comorbidity Index (CCI) score (p < 0.001). At 1year post-operation, there was no significant difference between "Optimal" and "Suboptimal" cementing with regards to the proportion of community ambulators (30.2% vs. 25.7%, p = 0.252), walking independence (independent walkers (19.8% vs.17.3%), independent walkers with aids (41.3%vs.42.1%), walker with caregiver assistance (29.2%vs.33.7%), wheelchair-bound (9.6%vs.6.9%), p = 0.478), and distribution of MBI score (81.1%vs.82.2% achieving MBI > 60, p = 0.767). There was no significant difference in the proportion of patients with postoperative delirium (7.9% vs. 5.8, p = 0.324) or 1-year mortality rates (3.5% vs. 2.9%, p = 0.685). Except for stem design (12.2% tapered vs 20.1% collared; p = 0.011), no other surgical parameters were significantly different. The kappa value for inter-reader agreement was "substantial" at 0.727 (95% CI 0.682-0.772) (p < 0.001). Quality of cementing in cemented hip hemiarthroplasty for elderly NOF fractures does not affect the short-term functional outcomes. In low demand patients and patients at risk of BCIS, optimal cementing may not be necessary to achieve similar short-term functional outcomes. Further studies should be conducted to determine the effect of sub-optimal cementing on long-term functional outcomes.

Prediction of subsequent fragility fractures: application of machine learning

BackgroundMachine learning (ML) has shown exceptional promise in various domains of medical research. However, its application in predicting subsequent fragility fractures is still largely unknown. In this study, we aim to evaluate the predictive power of different ML algorithms in this area and identify key features associated with the risk of subsequent fragility fractures in osteoporotic patients.MethodsWe retrospectively analyzed data from patients presented with fragility fractures at our Fracture Liaison Service, categorizing them into index fragility fracture (n = 905) and subsequent fragility fracture groups (n = 195). We independently trained ML models using 27 features for both male and female cohorts. The algorithms tested include Random Forest, XGBoost, CatBoost, Logistic Regression, LightGBM, AdaBoost, Multi-Layer Perceptron, and Support Vector Machine. Model performance was evaluated through 10-fold cross-validation.ResultsThe CatBoost model outperformed other models, achieving 87% accuracy and an AUC of 0.951 for females, and 93.4% accuracy with an AUC of 0.990 for males. The most significant predictors for females included age, serum C-reactive protein (CRP), 25(OH)D, creatinine, blood urea nitrogen (BUN), parathyroid hormone (PTH), femoral neck Z-score, menopause age, number of pregnancies, phosphorus, calcium, and body mass index (BMI); for males, the predictors were serum CRP, femoral neck T-score, PTH, hip T-score, BMI, BUN, creatinine, alkaline phosphatase, and spinal Z-score.ConclusionML models, especially CatBoost, offer a valuable approach for predicting subsequent fragility fractures in osteoporotic patients. These models hold the potential to enhance clinical decision-making by supporting the development of personalized preventative strategies.

The Association Between CYP2R1 rs10741657 Polymorphisms and Bone Variables, Vitamin D, and Calcium in Iranian Children and Adolescents: A Cross-Sectional Study.

Osteoporosis is a common disorder with a strong genetic component. Bone mineral density (BMD), vitamin D, and calcium levels declining are a main contributor of osteoporosis and fragility fractures. This cross-sectional study designed to explore the possible link between CYP2R1 rs10741657 polymorphism and BMD of the total hip, lumbar spine and femoral neck, vitamin D, and calcium in Iranian children and adolescents. 247 children and adolescents (127 girls and 120 boys) between 9 and 18 years old from Kawar (an urban area located 50 km east of Shiraz, the capital city of the Fars province in the south of Iran) were randomly selected based on age-stratified systematic sampling and recruited for genetic analysis. The polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was used for genotyping CYP2R1 rs10741657. Anthropometric, biochemical, and bone mineral density (BMD) parameters were also measured. The results specified that in the dominant [P < 0.0001, -2.943 (-4.357-1.529)] and over-dominant [P < 0.0001, 2.789 (1.369-4.209)] models, vitamin D concentration significantly differed between genotypes. The highest vitamin D levels were displayed for participants carrying the rs10741657 AG genotype (16.47 ng/ml). In regard to calcium, in a dominant model [P = 0.012, 0.194 (0.043-0.345)] and over-dominant model [P = 0.008, 0.206 (-0.357-0.055), there was a significant association. AG genotype displayed the highest (9.96 mg/dl) and GG genotype the lowest (9.75 mg/dl) calcium values. This study reported the association of CYP2R1 rs10741657 polymorphisms with calcium and vitamin D levels in Iranian children and adolescents.

An in-depth analysis of young adults with osteonecrosis secondary to developmental dysplasia of the hip who underwent total hip arthroplasty

BackgroundPatients with osteonecrosis of the femoral head secondary to DDH frequently require total hip arthroplasty (THA), but it is not well understood which factors necessitate this requirement. We determined the incidence of THA in patients who have osteonecrosis secondary to DDH and factors associated with need for THA.MethodsWe included patients who received closed or open reductions between 1995 and 2005 with subsequent development of osteonecrosis. We determined osteonecrosis according to Bucholz and Ogden; osteoarthritis severity (Kellgren-Lawrence), subluxation (Shenton’s line); neck-shaft angle; and acetabular dysplasia (centre-edge and Sharp angles). We also recorded the number of operations of the hip in childhood and reviewed case notes of patients who received THA to describe clinical findings prior to THA. We assessed the association between radiographic variables and the need for THA using univariate logistic regression.ResultsOf 140 patients (169 hips), 22 patients received 24 THA (14%) at a mean age of 21.3 ± 3.7 years. Associated with the need for THA were grade III osteonecrosis (OR 4.25; 95% CI 1.70-10.77; p = 0.0019), grade IV osteoarthritis (21.8; 7.55–68.11; p < 0.0001) and subluxation (8.22; 2.91–29.53; p = 0.0003). All patients who required THA reported at least 2 of: severe pain including at night, stiffness, and reduced mobility. Acetabular dysplasia and number of previous operations were not associated with the need for THA.ConclusionsWe identified a 14% incidence of THA by age 34 years in patients with osteonecrosis secondary to DDH. Grade III osteonecrosis (global involvement femoral head and neck) was strongly associated with THA, emphasising the importance to avoid osteonecrosis when treating DDH.

Extensive Gouty Tophus in Neglected Femoral Neck Fracture: A Case Report

Extensive Gouty Tophus in Neglected Femoral Neck Fracture: A Case Report

Bone mineral density in women with rheumatoid arthritis: A link between immune and biochemical markers

To study the association of bone mineral density (BMD) with serum biochemical and immunological markers in postmenopausal women with rheumatoid arthritis (RA). The study included 173 women with RA (age 61.0 [56.0; 66.0] years). A survey, dual-energy X-ray absorptiometry to measure the BMD of the lumbar spine (LI-LIV), femoral neck (FN) and total hip (TH), routine blood chemistry, measurement of C-reactive protein (CRP), rheumatoid factor, cyclic citrullinated peptide antibodies (CCPA), parathyroid hormone (PTH), vitamin D3, myostatin, follistatin, interleukin-6 (IL-6), IL-6 receptors, insulin-like growth factor 1, adiponectin, leptin, fibroblast growth factor 23, and tumor necrosis factor SF12 were performed. PTH (β=-0.22, -0.35 and -0.30 for LI-LIV, FN and TH, respectively), CRP (β=-0.18, 0.23 and -0.22 for LI-LIV, FN and TH, respectively) and leptin (β=0.35, 0.32 and 0.42 for LI-LIV, FN and TH, respectively) were shown a significant association with BMD in all sites of measurement. It was independent of age, body mass index and postmenopause duration. Associations were also found between adiponectin and BMD of LI-LIV and TH (β=-0.36 and -0.28, respectively), CCPA and BMD of FN and TH (β=-0.21, -0.24, respectively) and IL-6 and BMD of FN (β=0.37). The study of biochemical and immunological markers in women with RA demonstrated that CRP, CCPA, PTH, IL-6, adiponectin, and leptin influenced BMD.

Stem anteversion is not affected by proximal femur geometry in robotic-assisted total hip arthroplasty

BackgroundIn the present study, the surgeon aimed to align the stem at 5° to 25° in anteversion. The robotic technology was used to measure stem anteversion with respect to proximal femur anteversion at different levels down the femur.MethodsA total of 102 consecutive patients underwent robotic-arm-assisted total hip arthroplasty (RTHA). 3D CT-based preoperative planning was performed to determine femoral neck version (FNV), posterior cortex anteversion (PCA), anterior cortex anteversion (ACA), and femoral metaphyseal axis anteversion (MAA) at 3 different levels: D (10 mm above lesser trochanter), E (the midpoint of the planned neck resection line) and F (head-neck junction). The robotic system was used to define and measure stem anteversion during surgery.ResultsMean FNV was 6.6° (SD: 8.8°) and the mean MAA was consistently significantly higher than FNV, growing progressively from proximal to distal. Mean SV was 16.4° (SD: 4.7°). There was no statistically significant difference (P = 0.16) between SV and MAA at the most distal measured level. In 96.1% cases, the stem was positioned inside the 5°–25° anteversion range.ConclusionsFemoral anteversion progressively increased from neck to proximal metaphysis. Aligning the stem close to femoral anteversion 10 mm above the lesser trochanter often led to the desired component anteversion.

Risk of low bone mineral density in young pediatric cancer survivors with sarcopenia.

10070 Background: Required treatments to cure pediatric cancer at such a young age increase the risk of later health-related complications. Early exposure to DNA damaging agents, during a vital period of active skeletal growth, interferes with accrual of bone mass. Treatments not only impair bone health, but also affect skeletal muscle function and mass. Long-term pediatric cancer survivors present these limitations due to myofibrillary atrophy caused by degradation of myosin heavy chain and decrease in myosin synthesis death. Muscle weakness (both muscle strength deficits and low lean mass hereafter referred to as sarcopenia) and low areal bone mineral density (aBMD) have been observed to coexist in adult survivors of paediatric cancer. However, in young pediatric cancers survivors, associations between sarcopenia and low aBMD are not well described. Therefore, this study aimed to examine the risk of low aBMD in young pediatric cancer survivors with sarcopenia confirmed/probable, compared to not having sarcopenia. Methods: This cross-sectional study included 116 pediatric cancer survivors (12.1±3.3 years old; 42% female) enrolled on a randomized controlled trial designed to improve bone health (iBoneFIT project). Handgrip strength was used to assessed muscle strength. Dual-energy X-ray absorptiometry estimated aBMD (g/cm2) at the total body (less head), lumbar spine, total hip and femoral neck, and appendicular lean mass index (ALMI, kg/m2). Sarcopenia status was determined using age and sex specific international reference data from a healthy population. “No sarcopenia” was defined when muscle strength was &gt;decile 2. “Sarcopenia probable” was defined when muscle strength was ≤decile 2 and ALMI Z-score was &gt; -1.5 standard deviation (SD). “Sarcopenia confirmed” was defined when muscle strength was ≤decile 2 and ALMI Z-score ≤-1.5 SD. Logistic regression, adjusted for time from treatment completion and radiation exposure, was used to evaluate the risk of low aBMD (age-, sex- and race-specific aBMD Z-score &lt; -1.0) by sarcopenia status. Results: More than one-third of survivors met criteria for sarcopenia confirmed (37.9%); 19.0% met criteria for sarcopenia probable. Survivors with sarcopenia confirmed had higher risk of low aBMD at the total body (odd ratio [OR]: 6.91, 95% confidence interval [CI]: 2.31-24.15), total hip (OR: 2.98, 95% CI: 1.02-9.54) and femoral neck (OR: 4.72, 95% CI: 1.72-14.19) than those without sarcopenia. Survivors with sarcopenia probable had higher risk of having low aBMD only at the total body (OR: 4.13, 95% CI: 1.04-17.60) than those without sarcopenia. Conclusions: Over one-third of young paediatric cancer survivors presented sarcopenia confirmed with higher risk of low aBMD. These findings suggest that interventions to mitigate osteosarcopenia in this population should be implemented at early stages after treatment completion.

Birmingham Hip Resurfacing at 25 years.

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon's consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years. The study extends the reporting on the first consecutive 144 resurfacing procedures in 130 patients for all indications. All operations were undertaken between August 1997 and May 1998. The mean age at operation was 52.1 years (SD 9.93; 17 to 76), and included 37 female patients (28.5%). Failure was defined as revision of either component for any reason. Kaplan-Meier survival analysis was performed. Routine follow-up with serum metal ion levels, radiographs, and Oxford Hip Scores (OHSs) was undertaken. Overall implant survival was 83.50% (95% confidence interval (CI) 0.79 to 0.90) at 25 years, and the number at risk was 79. Survival in male patients at 25 years was 89.5% (95% CI 0.83 to 0.96) compared to 66.9% for female patients (95% CI 0.51 to 0.83). Ten additional failures occurred in the period of ten to 25 years. These involved an adverse reaction to metal debris in four patients, a periprosthetic femoral neck fracture affecting five patients, and aseptic loosening in one patient. The median chromium levels were 49.50 nmol/l (interquartile range (IQR) 34 to 70), and the median cobalt serum levels were 42 nmol/l (IQR 24.50 to 71.25). The median OHS at last follow-up was 35 (IQR 10 to 48). During the 25-year study period, 29 patients died. Patient survival at 25 years was 75.10% (95% CI 0.67 to 0.83). This study demonstrates that MoM hip resurfacing using the BHR provides a durable alternative to total hip arthroplasty (THA), particularly in younger male patients with osteoarthritis wishing to maintain a high level of function. These results compare favourably to the best results for THAs.

EGFL6 activates the ERK signaling to improve angiogenesis and osteogenesis of BMSCs in patients with steroid-induced osteonecrosis of the femoral head.

Recently, epidermal growth factor-like domain protein 6 (EGFL6) was proposed as a candidate gene for coupling angiogenesis to osteogenesis during bone repair; however, the exact role and underlying mechanism are largely unknown. Here, using immunohistochemical and Western blotting analyses, we found that EGFL6 was downregulated in the femoral head tissue of patients with steroid-induced osteonecrosis of the femoral head (SONFH) compared to patients with traumatic femoral neck fracture (FNF), accompanied by significantly downregulation of osteogenic and angiogenic marker genes. Then, bone marrow mesenchymal stem cells (BMSCs) were isolated from the FNF and the SONFH patients, respectively, and after identification by immunofluorescence staining surface markers, the effect of EGFL6 on their abilities of osteogenic differentiation and angiogenesis was evaluated. Our results of alizarin red staining and tubular formation experiment revealed that BMSCs from the SONFH patients (SONFH-BMSCs) displayed an obviously weaker ability of osteogenesis than FNF-BMSCs, and EGFL6 overexpression improved the abilities of osteogenic differentiation and angiogenesis of SONFH-BMSCs. Moreover, EGFL6 overexpression activated extracellular signal-regulated kinases 1/2 (ERK1/2). ERK1/2 inhibitor U0126 reversed the promoting effect of EGFL6 overexpression on the expression of osteogenesis and angiogenesis-related genes in the SONFH femoral head. In conclusion, EGFL6 plays a protective role in SONFH, it promotes osteogenesis and angiogenesis of BMSCs, and its effect is likely to be related to ERK1/2 activation.

Choi IIIB sequelae of septic hip: etiologically different entities clubbed together?

BackgroundChoi IIIB sequela (pseudarthrosis of femoral neck) is an uncommon complication of septic hip. Only few cases are reported in literature and experience with the entity is limited. Variable pseudarthrosis behaviour and treatment outcomes are reported questioning the mechanical etiology for Choi III sequela. MethodsWe briefly analysed the relevant literature and propose two different pathomechanism for the entity. Three illustrative cases in support of proposed etiology are presented. ResultsThere seems to be two distinct mechanisms of pseudarthrosis formation in Choi IIIB. The originally described mechanism is the articulating head getting dissociated from proximal femur due to a mechanical cause. The second proposed mechanism is the damage of physis and adjoining metaphysis by the septic inflammatory process (Choi II type sequela). ConclusionsIt is important to understand the possible etiologies in Choi IIIB pseudarthrosis as the treatment planning and outcomes may vary. It will also help in prognostication.

Effects of walnut consumption for 2 years on older adults' bone health in the Walnuts and Healthy Aging (WAHA) trial.

Nutritional strategies to maintain bone health in aging individuals are of great interest. Given the beneficial nutrient composition of walnuts, rich in alpha-linolenic (the vegetable n-3 fatty acid) and polyphenols, their regular consumption might be a dietary option to reduce age-related bone loss. We determined whether daily walnut consumption improves bone mineral density (BMD) and circulating biomarkers of bone turnover. The Walnuts and Healthy Aging study (WAHA) is a two-center, parallel, randomized controlled trial evaluating the effect of a diet enriched with walnuts at ≈15% energy compared with a control diet for 2 years on age-related health outcomes in healthy men and women aged 63-79 years. Changes in BMD were a prespecified secondary outcome only at the Barcelona node of the trial, where 352 participants were randomized. Retention rate was 92.6%. Primary endpoints were 2-year changes in BMD at the spine and the nondominant femoral neck, determined by dual-energy X-ray absorptiometry (DXA). Secondary endpoints were 2-year changes in bone turnover biomarkers (adrenocorticotropic hormone, Dickkopf WNT signaling pathway inhibitor-1, osteoprotegerin, osteocalcin, osteopontin, sclerostin, parathyroid hormone, and fibroblast growth factor-23), which were quantified in 211 randomly selected participants. The walnut diet versus the control diet had no effect on 2-year changes in BMD at the spine (0.15% vs. 0.35%, p = 0.632) and femoral neck (-0.90% vs. -0.70%, p = 0.653), or on bone turnover biomarkers. Results were similar in participants treated or not with bone resorption inhibitors or those with or without osteoporosis/osteopenia at inclusion. Compared with the usual diet, a diet enriched with walnuts at 15% of energy for 2 years failed to improve BMD or circulating markers of bone metabolism in healthy older people.

Incidence and predictors of dorsal comminution in older adults with low-energy distal radius fracture.

To identify the incidence of dorsal comminution using computed tomography (CT) images and identify predictors of this phenomenon in older adults with low-energy distal radius fractures (DRFs). A total of 150 patients aged > 50 years with fall-induced dorsally angulated DRFs were enrolled in this study. Patients were divided into two groups based on the presence of dorsal comminution, defined as a metaphyseal void of greater than one-third of the maximum posterior to anterior depth of the bone on at least three cuts in the sagittal plane on post-reduction CT images. Data on participants' basic demographics, including age, sex, body mass index (BMI), and AO classification of DRFs, were collected. Bone mineral density (BMD) was assessed using T-scores of the femoral neck, and cortical thickness of the distal radius was determined from plain post-reduction radiographs. Radiological parameters and combined ulnar fractures were measured on plain pre-reduction radiographs. Among study participants, 91 (61%) had dorsal comminution, whereas 59 (39%) had no dorsal comminution on CT images. Both patient groups were compared based on presence of dorsal comminution, and showed no significant differences in age, sex, BMI, BMD, or cortical thickness on radiographs. However, all radiological parameters were better in the no dorsal comminution group than in the dorsal comminution group, and the proportion of patients with combined ulnar fractures was higher in the dorsal comminution group. In the multivariate analysis, the presence of combined ulnar fractures was the only significant predictor of dorsal comminution (p = 0.029, odds ratio = 2.267, 95% confidence interval: 1.085-4.736). The incidence of dorsal comminution is relatively high in patients with low-energy DRFs aged > 50 years. In particular, the presence of combined ulnar fractures is closely associated with dorsal comminution of DRFs. Thus, surgeons should exercise caution when evaluating this phenomenon.

The dynamic locking blade plate: seven-year follow-up results of 389 patients with a femoral neck fracture.

This study aimed to investigate the long-term outcomes of patients with a femoral neck fracture (FNF), treated with the Dynamic Locking Blade Plate (DLBP). Retrospective analysis of prospectively collected data of a multicentre cohort of patients with FNFs was conducted, regarding the long-term incidence of revision surgery after DLBP. Implant failure was evaluated using Kaplan-Meier and Cox regression analysis. Secondary outcomes were the indication for revision surgery, complications, time to revision surgery, rate of elective removal of the implant, potential predictors for revision surgery and mortality. Median follow-up of 389 included patients was 98 months; 20.6% underwent revision surgery; 28.8% after treatment of a displaced FNF (dFNF) and 10.0% with a undisplaced FNF (uFNF). 5.7% (n = 22) of the patients had operation related complications and 32.9% (n = 128) deceased during follow-up. Median time to revision surgery was 13 (dFNF) and 18 months (uFNF). 15.7% of the DLBPs were electively removed. In the multivariate Cox regression analysis, female gender (hazard ratio 2.1, 95% CI 1.2-3.7) and a TAD > 25mm (hazard ratio 2.9, 95% CI 1.7-5) were significant predictors for revision surgery in patients with dFNF. This study is the first long-term follow-up study on the outcome of the DLBP. The DLBP demonstrated positive long-term results in the treatment of FNF.

Outcomes and Risks Associated With Subsequent Contralateral Hip Fractures.

Hip fractures constitute a major public health problem for older individuals. They are associated with functional deterioration, limited mobility, and increased mortality, while contributing to economic and social hardships that are compounded by a second hip fracture. With the aging US population and increasing rates of hip fractures, it is essential to understand factors surrounding subsequent contralateral hip fractures. This descriptive study was a retrospective review of patients 60 years and older who were identified in the institutional geriatric hip fracture database as having had an initial and subsequent contra-lateral hip fracture, with the second treated at our tertiary referral center. The incidence of subsequent hip fracture was 13.2%. The mean time to second hip fracture was 3.5 years after the initial injury. The first fracture tended to be a femoral neck fracture, whereas the second injury was more likely to have an intertrochanteric pattern. There was a higher complication rate after a subsequent hip fracture. Patients taking osteoporosis and adjuvant medication prior to admission for the second fracture tended to have a lower 90-day mortality rate. Patients with a history of any fracture prior to the first hip fracture, with cancer, and with osteopenia had shorter intervals to the subsequent event. Subsequent hip fractures carry high morbidity and mortality rates. Steps should be taken after the initial injury to optimize outcomes in the case of a subsequent event. Patients discharged after initial hip fracture should be maintained with osteoporosis medication. [Orthopedics. 202x;4x(x):xx-xx.].