Risk Of Refracture Research Articles

Antipsychotic Medication in Schizophrenic Patients is Associated with Higher Risks of Developing Bone Fractures and Refractures

ObjectiveThe relationship of antipsychotics and the risk of refracture in treated patients is unclear. The aim of this study is to evaluate the association between prolonged antipsychotic and the incidences of bone fractures and refractures in schizophrenia.MethodsThis is a retrospective nested case-control study using Taiwan National Health Insurance Research Database recorded from 2000 to 2005, with cases followed up to end of 2011. Total of 7,842 schizophrenic patients, 3,955 had developed bone fractures were compared with 3,887 control subjects matched in age, sex, and index date. Antipsychotic drug exposure was classified based on the drug type and medication duration. Conditional logistic regression analyses were performed. Odds ratio (OR) and confidence interval (CI) were calculated.ResultsWe found (after adjustments) higher risks of developing fractures under continued use of typical (OR = 1.70; 95% CI, 1.51−1.91) or atypical antipsychotics (OR = 1.43; 95% CI, 1.28−1.60) were found. Additionally, continued use typical (OR = 1.84; 95% CI, 1.35−2.50) or atypical antipsychotics (OR = 1.44; 95% CI, 1.06−1.95) was positively associated with refracture risks. Moreover, refractures were associated with continuous use of chlorpromazine (one typical antipsychotics, OR = 2.45; 95% CI, 1.14−5.25), and risperidone (OR = 1.48; 95% CI, 1.01−2.16) or zotepine (OR = 2.15; 95% CI, 1.06−4.36) (two atypical antipsychotics).ConclusionHigher risks of bone fracture and refracture were found in schizophrenia under prolonged medication with typical or atypical antipsychotics. We therefore recommend that clinicians should pay more attention on bone density monitoring for patients using long-term antipsychotics.

Analysis of Clinical Risk Factors for Refracture in Osteoporosis

Objective: To observe and explore the clinical risk factors for refracture in patients with osteoporosis. Methods: A total of 32 patients with fractures and refractures after osteoporosis diagnosis from our hospital were enrolled from June to December 2018. The clinical situations of the two groups (fracture or refracture) were compared with particular regard for the main risk factors after fracture. Results: Through an analysis of the clinical data, we found that sex, age, time needed to stand from lying down, and low bone mineral density T-score are clinical risk factors for refracture. People of an older age, a bone mineral density T-score lower than normal, and females who require more time to stand from a lying down position have a higher risk of refracture. Conclusion: There a number of complex risk factors for refracture in elderly patients with osteoporosis. Early investigation and targeted preventive measures have great significance in reducing the incidence of refracture.

Does the Inion OTPSTM absorbable plating system induce higher foreign-body reaction than titanium implants? An experimental randomized comparative study in rabbits

Hardware removal after complete fracture healing is a laborious and traumatic procedure that bears the risks of refracture, infection, and soft tissue damage. Absorbable materials for fracture fixation have the advantage of eliminating the need for removal; however, they may stimulate a considerable inflammatory response. For that reason, we compared in a prospective randomized experimental animal model study the incidence of foreign-body reactions between Inion OTPSTM absorbable plate implants, consisting of carbon trimethylene, L-polylactic acid, and D, L-polylactic acid, and conventional titanium plates. Seventy rabbits were equally divided into two groups. Titanium (Group A) or absorbable (Group B) plates and screws were implanted in the femoral shaft of the rabbits. Wound reaction and laboratory tests including white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) values were measured and compared at different time points. Radiographs and histological analysis of tissue samples from all animals were also used to identify potential foreign-body reactions. WBC showed normal values in both groups. In Group A, ESR levels were higher at all time points but CRP values were normalized at 3 weeks postoperatively. In Group B, ESR and CRP levels reached a peak at 3 weeks and were above normal values throughout the whole experiment (p < 0.001). Radiologic examination revealed periosteal thickening and surrounding sclerosis in 23 out of 35 animals of Group B (66%). All Group A animals had normal radiographic findings. Histopathology showed a typical non-specific foreign-body reaction in all animals in Group B (100%) but none in Group A. However, only four of them (11.8%) developed non-infected wound complications and showed significantly elevated CRP and ESR values (p = 0.054). Although Inion OTPSTM Biodegradable Plating System stimulates a foreign-body reaction, only a small but not negligible percentage of almost 12% may lead to wound problems. However, this difference compared to titanium plates was of borderline not statistically significant. Future studies should focus on the development of absorbable implants with improved biocompatibility aiming to further decrease the potential of foreign-body reaction and eliminate the need for additional reoperative procedures.

Effect of Preoperative Zoledronic Acid Administration on Pain Intensity after Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures.

Introduction This study aimed to compare and analyze the effect of preoperative zoledronic acid (ZOL) administration on pain intensity after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (OVCF). Methods The study included 242 patients with OVCFs who underwent PVP in our hospital between January 2015 and June 2018. The patients were randomly assigned to either a ZOL group (n = 121) or a control group (n = 121). The patients in the ZOL group were treated preoperatively with intravenous infusion of 5 mg ZOL. Those in the control group were treated without ZOL. All the patients were followed up for 1 year. Results No statistically significant differences in age, sex, weight, and body mass index (BMI) were found between the two groups. During the follow-up period, the visual analog scale score and Oswestry dysfunction index score in the ZOL group were lower than those in the control group. The bone mineral density at 6 or 12 months after treatment was significantly higher and the levels of the bone metabolism markers were significantly lower in the ZOL group than in the control group (P < 0.05 for both). Two patients in the treatment group had new vertebral fractures, whereas 13 patients in the control group had new vertebral fractures, which translate to recompression vertebral fracture incidence rates of 1.7% and 10.7%, respectively. The incidence rate of mild adverse reactions was significantly higher in the ZOL group than in the control group, but all the cases were endurable. Conclusion Intravenous infusion of ZOL before PVP can effectively reduce postoperative pain intensity, reduce bone loss, increase bone density, reduce the risk of refracture, and improve patient quality of life.

Management of spinal deformities and tibial pseudarthrosis in children with neurofibromatosis type 1 (NF-1)

Summary of background dataThe skeletal system is affected in up to 60% of patients with neurofibromatosis type 1. The most commonly observed entities are spinal deformities and tibial dysplasia. Early recognition of radiologic osseous dystrophy signs is of utmost importance because worsening of the deformities without treatment is commonly observed and surgical intervention is often necessary. Due to the relative rarity and the heterogenic presentation of the disease, evidence regarding the best surgical strategy is still lacking.PurposeTo report our experience with the treatment of skeletal manifestations in pediatric patients with (neurofibromatosis type 1) NF-1 and to present the results with our treatment protocols.Materials and methodsThis is a retrospective, single expert center study on children with spinal deformities and tibial dysplasia associated with NF-1 treated between 2006 and 2020 in a tertiary referral institution.ResultsSpinal deformity: Thirty-three patients (n = 33) were included. Mean age at index surgery was 9.8 years. In 30 patients (91%), the deformity was localized in the thoracic and/or lumbar spine, and in 3 patients (9%), there was isolated involvement of the cervical spine. Eleven patients (33%) received definitive spinal fusion as an index procedure and 22 (67%) were treated by means of “growth-preserving” spinal surgery. Halo-gravity traction before index surgery was applied in 11 patients (33%). Progression of deformity was stopped in all patients and a mean curve correction of 60% (range 23–98%) was achieved. Mechanical problems with instrumentation requiring revision surgery were observed in 55% of the patients treated by growth-preserving techniques and in none of the patients treated by definitive fusion. One patient (3%) developed a late incomplete paraplegia due to a progressive kyphotic deformity.Tibial dysplasia: The study group comprised of 14 patients. In 5 of them (36%) pathological fractures were present on initial presentation. In the remaining 9 patients (64%), anterior tibial bowing without fracture was observed initially. Four of them (n = 4, 28%) subsequently developed a pathologic fracture despite brace treatment. Surgical treatment was indicated in 89% of the children with pathological fractures. This involved resection of the pseudarthrosis, autologous bone grafting, and intramedullary nailing combined with external fixation in some of the cases. In 50% of the patients, bone morphogenic protein was used “off-label” in order to promote union. Healing of the pseudarthrosis was achieved in all of the cases and occurred between 5 to 13 months after the index surgical intervention. Four of the patients treated surgically needed more than one surgical intervention in order to achieve union; one patient had a re-fracture. All patients had a good functional result at last follow-up.ConclusionEarly surgical intervention is recommended for the treatment dystrophic spinal deformity in children with NF-1. Good and sustainable curve correction without relevant thoracic growth inhibition can be achieved with growth-preserving techniques alone or in combination with short spinal fusion at the apex of the curve. Preoperative halo-gravity traction is a safe and very effective tool for the correction of severe and rigid deformity in order to avoid neurologic injury. Fracture union in tibial dysplasia with satisfactory functional results can be obtained in over 80% of the children by means of surgical resection of the pseudarthrosis, intramedullary nailing, and bone grafting. Wearing a brace until skeletal maturity is achieved is mandatory in order to minimize the risk of re-fracture.

Plating and cortical bone grafting of clavicular nonunions: clinical outcome and its relation to clavicular length restoration

BackgroundThe goal of this study was to evaluate whether plating and cortical bone grafting of shortened clavicular nonunions would restore clavicular length and enable bone healing. The association between the clavicular length difference (CLD) between sides and long-term functional outcome was also explored.MethodsFor this retrospective 2-center study, patients who underwent plate fixation with cortical bone grafting of a clavicular nonunion were assessed after ≥2 years. The CLD and bone union were assessed using radiography and navigation ultrasound. The functional outcome was determined by the Constant score, Simple Shoulder Test score, and Subjective Shoulder Value, as well as local pain (0-10 numeric rating scale).ResultsBetween 2 and 13 years after surgery, 25 patients (mean age, 53 years; 13 female patients) were examined. The median CLD was 0 mm (range, –17 to 13 mm) on ultrasound measurements and 2 mm (range, –32 to 9 mm) on radiographs. At follow-up, the median Constant score, Simple Shoulder Test score, Subjective Shoulder Value, and pain level were 82 points (range, 38-95 points), 12 points (range, 3-12 points), 95% (range, 60%-100%), and 0 (range, 0-8), respectively. There was no correlation between the CLD and all functional outcome scores. Bone union was achieved in all patients. After plate removal, 4 refractures occurred, 3 of which required revision.ConclusionsPlate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union. There is, however, a considerable risk of refracture following plate removal. There was no association between the CLD and clinical outcome.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing.

Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic. The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15years. The characteristics of the primary fractures and treatment course were evaluated. Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277days, and in 5 of the 6 patients refractures occurred within 6months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%). Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

Correlation between C-reactive protein/albumin and contralateral hip refracture after total hip arthroplasty in elderly patients with hip fractures.

There is still a risk of refracture of the contralateral hip after total hip replacement, to analyze the expression of C-reactive protein (CRP) and albumin (Alb) in elderly patients with contralateral hip refracture after total hip arthroplasty (THA), and to determine its correlation with the risk of post-surgery refracture and guide the prediction of the risk of contralateral hip fracture in the future. The medical records of elderly patients who suffered hip fracture and underwent THA at our hospital between July 2016 and July 2019 were reviewed, and 224 eligible patients were finally enrolled. The patients were divided into the refracture group and the control group according to the incidence of contralateral hip refracture. The baseline data of the two groups were compared, and all relevant laboratory tests were performed before surgery. The serum levels of CRP and Alb were compared, along with the CRP/ Alb ratio, between the two groups to establish whether CRP/Alb is a predictor for post-surgery contralateral hip refracture in elderly patients. Twenty (8.93%) of the 224 patients suffered post-surgery contralateral hip refracture. There were no significant differences in the baseline data of the refracture and control groups (P>0.05). However, the patients who experienced refracture had significantly higher CRP levels and lower Alb levels compared with the controls, resulting in an elevated CRP/Alb ratio in the patients with refracture (P<0.05). Serum CRP level was negatively correlated to that of Alb (r=-0.443, P<0.001). The linear regression equation was Y=2.718-0.598X, indicating that the CRP/Alb ratio is a risk factor for contralateral hip refracture in elderly hip fracture patients following THA (P<0.05). The area under the receiver operating characteristic (ROC) curve of the CRP/Alb ratio as a predictor for post-THA contralateral hip refracture was 0.841 (95% CI: 0.702-0.914). The optimal cutoff value was 1.12, which corresponded to high specificity and sensitivity of 0.782 and 0.945, respectively, and the Youden index was 0.727. Serum CRP level is closely associated with Alb level in elderly hip fracture patients, and the CRP/Alb ratio is a risk factor for post-THA contralateral hip refracture. Therefore, preoperative measurement of serum CRP/Alb level can assist with predicting the risk of post-THA refracture in elderly hip fracture patients.

Percutaneous cyst aspiration with injection of two different bioresorbable bone cements in treatment of simple bone cyst.

IntroductionSimple bone cysts (SBCs) are common in children and adolescents. The risk of refracture and the probability of spontaneous healing in SBCs are mainly dependent on the activity of the cyst and can be quantified with the Cyst-Index. Avoiding pathological fractures is the primary goal. Our study presents a comparison of two different bioresorbable bone graft substitutes (BGSs) in the minimally-invasive treatment of SBC in the active stage by percutaneous cyst aspiration and injection.MethodsBetween 2006 and 2017, 38 patients (aged two to 37 years; mean age 12.4 (sd 5.6)) were treated with percutaneous cyst aspiration and refilled with bioresorbable BGSs in three hospitals. The cysts of 21 patients (11 humerus, five femur, four calcaneus, one fibula) were refilled with porous beta-tricalcium phosphate (PB-TP group) (ChronOS Inject) and of 17 patients (nine humerus, six femur, one calcaneus, one fibula) with hydroxyapatite/calcium sulphate (H/CS group) (CERAMENT|BONE VOID FILLER). There were 13 (62%) preceding fractures in the PB-TP group and eight (47%) in the H/CS group. The follow-up of all patients was at least two years. During follow-up, radiological healing (modified Neer classification), activity level, refracture rates, recurrence rates, resorption period and complications were analyzed.ResultsIn all, 21 patients treated with PB-TP group experienced 27 operations (one refracture, three recurrences and one persistent cyst). A total of 17 patients treated with H/CS experienced 20 operations (one refracture and one recurrence). After six weeks, 95% in the PB-TP group returned to unrestricted activity with one refracture in the femur due to insufficient biomechanical stability and all returned to unrestricted activity in the H/CS group. Partial or complete radiological response was observed in 81% after 13 months (sd 3.4). Three recurrences (14%) occurred in the PB-TP group and one recurrence (6%) occurred in the H/CS group. The refracture rates were similar in both groups; one (5%) in the PB-TP group and one (6%) in the H/CS group. All H/CS treated cysts showed completed resorption after two years, whilst in PB-TP treated cysts no resorption occurred in five cases (25%) (p = 0.031). Two (10%) wound infections occurred in the PB-TP group and no infections occurred in the H/CS group.ConclusionBoth PB-TP and H/CS can provide stability and prevent refracture in patients with single bone cysts at the upper extremity or the foot. For the proximal femur, additional stabilization is necessary, due to the weight-bearing and associated high refracture rate. The H/CS bone graft substitute has a better resorption rate than the PB-TP graft.Level of EvidenceIII

Buried intramedullary implants for paediatric forearm fractures. Does the refracture rate improve?

IntroductionUnstable forearm fractures may require surgical management by reduction and osteosynthesis with intramedullary needles. This fixation should be removed early if it has been left exposed, but this could increase the risk of refracture in a bone in the period of remodelling. As an alternative we can keep the needles, buried subcutaneously, for a longer time, to protect the bone callus. ObjectiveTo assess whether there are differences between using exposed needles with respect to burying them in paediatric patients with forearm fractures. Our hypothesis is that by burying the needles we keep them longer by reducing forearm refractures. Material and methodsWe present a cohort of 75 paediatric patients with a forearm fracture between 2010 and 2016. Demographic data, surgical technique, complications and patient follow-up were collected. ResultsThe implants were left exposed in 50 patients and 25 buried. The average time of removal of the exposed implants was 6.8weeks and 17.6weeks in the buried ones. No significant differences were found in terms of consolidation (p=0.19) or immobilisation time (p=0.22). Regarding refractures, a greater number was observed in the exposed osteosynthesis group (4 patients) compared to only one case with buried osteosynthesis, but there were no significant differences (p=0.49). No postsurgical complications were detected and the functionality was excellent at the end of the follow-up in both groups. ConclusionLeaving implants buried in relation to skin exposed does not cause a decrease in the number of refractures or other complications, with adequate patient functionality in both cases.

Quality Improvement Initiatives in Fragility Fracture Care and Prevention.

This review sought to describe quality improvement initiatives in fragility fracture care and prevention. A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance. Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.

Implantes intramedulares enterrados para fracturas de antebrazo pediátricas. ¿Mejora la tasa de refracturas?

IntroductionUnstable forearm fractures may require surgical management by reduction and osteosynthesis with intramedullary needles. This fixation should be removed early if it has been left exposed, but this could increase the risk of refracture in a bone in the period of remodelling. As an alternative we can keep the needles, buried subcutaneously, for a longer time, to protect the bone callus. ObjectiveTo assess whether there are differences between using exposed needles with respect to burying them in paediatric patients with forearm fractures. Our hypothesis is that by burying the needles we keep them longer by reducing forearm refractures. Material and methodsWe present a cohort of 75 paediatric patients with a forearm fracture between 2010 and 2016. Demographic data, surgical technique, complications and patient follow-up were collected. ResultsThe implants were left exposed in 50 patients and 25 buried. The average time of removal of the exposed implants was 6.8weeks and 17.6weeks in the buried ones. No significant differences were found in terms of consolidation (P=.19) or immobilization time (P=.22). Regarding refractures, a greater number was observed in the exposed osteosynthesis group (4patients) compared to only one case with buried osteosynthesis, but there were no significant differences (P=.49). No postsurgical complications were detected and the functionality was excellent at the end of the follow-up in both groups. ConclusionLeaving implants buried in relation to skin exposed does not cause a decrease in the number of refractures or other complications, with adequate patient functionality in both cases.

Stent-Screw Assisted Internal Fixation of Osteoporotic Vertebrae: A Comparative Finite Element Analysis on SAIF Technique.

Vertebral compression fractures are one of the most relevant clinical consequences caused by osteoporosis: one of the most common treatment for such fractures is vertebral augmentation through minimally invasive approaches (vertebroplasty or balloon-kyphoplasty). Unfortunately, these techniques still present drawbacks, such as re-fractures of the treated vertebral body with subsidence of the non-augmented portions or re-fracture of the non-augmented middle column at the junction with the augmented anterior column. A novel minimally-invasive augmentation technique, called Stent-Screw Assisted Internal Fixation, has been recently proposed for the treatment of severe osteoporotic and neoplastic fractures: this technique uses two vertebral body stents and percutaneous cannulated and fenestrated pedicular screws, through which cement is injected inside the expanded stents to achieve optimal stents' and vertebral body's filling. The role of the pedicle screws is to anchor the stents-cement complex to the posterior column, acting as a bridge across the middle column and preserving its integrity from possible collapse. In order to evaluate the potential of the new technique in restoring the load bearing capacity of the anterior and middle spinal columns and in reducing bone strains, a Finite Element model of an osteoporotic lumbar spine has been developed. Both standard vertebroplasty and Stent-Screw Assisted Internal Fixation have been simulated: simulations have been run taking into account everyday activities (standing and flexion) and comparison between the two techniques, in terms of strain distribution on vertebral endplates and posterior and anterior wall, was performed. Results show that Stent-Screw Assisted Internal Fixation significantly decrease the strain distribution on the superior EP and the cortical wall compared to vertebroplasty, possibly reducing the re-fracture risk of the middle-column at the treated level.

Anatomical Structures at Risk in Proximal Fifth Metatarsal Fracture Fixation: A Cadaver Study

Category:Sports, Trauma, Cadaver studyIntroduction/Purpose:Jones fractures are fractures of the proximal fifth metatarsal involving the metaphyseal-diaphyseal junction. They have an increased risk for refracture, delayed union and nonunion secondary to poor blood supply to this área. They are usually treated conservatively, but when chosen for surgical treatment percutaneous fixation with screws is the most used. Few studies have evaluated the complications of injury to nearby structures during the percutaneous fixation. It has been shown, however, that the peroneal brevis and longus, the cuboid, and the sural nerve lie in close proximity to this starting point and are, therefore, at theoretical risk of injury. The study aims to evaluate the presence of injury of the structures at risk and to measure the distance of these structures to the entry point.Methods:Eleven fresh-frozen below-the-knee specimens underwent standard operative fixation for a Jones fracture via the “High and inside” percutaneous technique. A guide wire was placed through the medullary canal and confirmed on fluoroscopy. The cannulated drill with drill sleeve was then placed over the wire and advanced to the diaphysis. The guide wire was left and the skin and subcutaneous tissues were carefully removed from the lateral midfoot to fully expose the structures at risk. The guidewire was then removed, and then the solid screw was placed.Neurovascular and tendinous structures were assessed for any injury. The distance of the wire in the base of fifth metatarsal and these structures was measured and documented, including the branches of the sural nerve, cuboid, fourth metatarsal, peroneus longus, and peroneus brevis tendons.Results:The structure with the shortest average distance from the pin was the peroneus brevis, measuring 0.91 mm (±1.22 mm S.D.), followed by the cuboid articular surface, sural nerve, peroneus longus, and base of the fourth metatarsal, respectively. The pin had damaged the peroneus brevis in 5 of 11 cadavers. However, it did not damage at the tendon insertion point in any specimen. The average distance from the tendon insertion point was 7.2 mm. The furthest measured distance was 10 mm, while the closest was 3 mm. The screw head contacted the articular surface of the cuboid in 3 of 11 cadavers. There were no instances of pin contact with or damage to the peroneus longus, sural nerve, or fourth metatarsal head.Conclusion:This is the only study that evaluated the risk of injury the structures after a procedure that simulated an actual surgical act. It is also the only one that was aware of the risk of tendon injury not only in its insertion but also in its path during the placement of the wire and drill. We conclude that percutaneous fixation of fractures of the base of the fifth metatarsus presents a risk of partial lesion of the peroneus brevis tendon and lateral aspect of the cuboid. Therefore, specific care with these structures can be taken during the procedure.

P43. Percutaneous vertebroplasty for vertebral compression fracture in glucocorticosteroid-induced osteoporosis: a case-control study

BACKGROUND CONTEXT Glucocorticoids-induced osteoporosis (GIOP) is a common form of secondary osteoporosis that often precipitates osteoporotic vertebral compression fracture (VCF). Comparing to conservative therapeutic strategies for VCF, percutaneous vertebroplasty (PVP) could quickly relieve back pain and improve overall life quality. But recent studies demonstrate that the risk of refracture following PVP surgery is high among patients with GIOPVCF. Thus, it is vital that the outcomes of different treatments for GIOPVCF are clearly understood and the clinical guidelines for treating this disease are defined. We designed a prospective cohort study to compare differences of therapeutic effects and incidence of refractures between conservative treatment and PVP for GIOPVCF. PURPOSE To investigate the clinical characteristics of vertebral compression fracture (VCF) in glucocorticosteroid-induced osteoporosis (GIOP) and risk of vertebral refracture after percutaneous vertebroplasty (PVP) STUDY DESIGN/SETTING A retrospective cohort study. PATIENT SAMPLE A total of 570 cases who received PVP as treatments of VCF from January 2010 to December 2013 were retrospective reviewed. Forty-two cases were GIOP and 21 cases were followed up as GIOP group, other 528 cases were primary osteoporosis and 391 cases were followed up, 84 cases of them were selected based on age and gender as control group. OUTCOME MEASURES Primary Outcome Measure: Incidence of vertebral refracture; Secondary Outcome Measure: fracture location, ratio of single segment fracture and multiple segments fracture in two groups. METHODS Compared the fracture location, ratio of single segment fracture and multiple segments fracture in two groups. In final follow up, compared the reoperation rate for vertebral refractures by the Kaplan-Meier methodin two groups. RESULTS Follow-up period were 24.0±13.1 months in GIOP group and 25.8±14.4 months in control group (P>0.05). In GIOP group, there were 11 cases with one-segment fracture, 2 cases with two-segments fracture, 3 cases with three-segments fracture, 2 cases with four-segments fracture, 2 cases with five-segments fracture and 1 case with eight-segments fracture. In control group, there were 67 cases with one-segment fracture, 12 cases with two-segments fracture, 3 cases with three-segment fracture, 2 cases with four-segments fracture. The ratio of single segment fracture in GIOP group was significantly lower than that in control group (52.4% vs 79.8%, P=0.01. There were 50 fracture segments in GIOP group and 109 fracture segments in control group. The ratio of fracture segments located in thoracic segments (T1-T10, thoracolumbar segments (T11-L1) and lumbar segments (L2-L5) was 18%, 46% and 36% in GIOP group and 11.9%,58.7% and 29.4% in control group (P>0.05). The refracture rate in GIOP group was higher than that in control group (23.8% vs 6.0%. The survival rate is lower in GIOP group than that in control group (P CONCLUSIONS Predilection site of VCF was similar in GIOP and primary osteoporosis (thoracolumbar segments> thoracic segments > lumbar segments). The risk of multiple segments VCF was higher in GIOP than in primary osteoporosis. The risk of vertebral refractures after PVP was higher in GIOP than in primary osteoporosis. FDA DEVICE/DRUG STATUS Stryker PCD Mixer and Delivery System (Approved for this indication).

Fracture types affect clinical outcomes of patients managed within the fracture liaison and osteoporosis medication management services

Osteoporosis medication in fragility fracture patients is associated with better outcomes. However, limited studies have investigated whether fracture types affect outcomes among patients undergoing treatment. We performed a secondary data analysis on participants from a fracture liaison service and an osteoporosis medication management service. Participants (n = 974) were regrouped into hip fracture (HF), vertebral fracture (VF), HF + VF, and NO HF/VF groups at baseline. Bivariate and multivariate logistic regressions were performed to identify baseline correlates on one-year mortality, incident refractures, and falls. Baseline characteristics were different among fracture groups. The HF group was oldest, with the lowest body mass index (BMI), lowest FRAX® T-score and had the highest 10-year fracture risk. After intervention, the HF group still had the highest mortality, but the HF + VF group had the highest refracture and incident fall rates. In the multivariate regression analysis, prevalent HF and VF, lower BMI and albumin level, and having chronic kidney disease or cancer were associated with higher mortality rates. HF + VF patients had the highest refracture risk. Prevalent HF and VF, older age and higher BMI, and having cancer or osteoarthritis were associated with a greater fall risk. HF and VF are associated with adverse outcomes, even under an optimal fracture care.

Five-year refracture rates of a province-wide fracture liaison service.

To examine refractures among patients screened in a province-wide fracture liaison service (FLS). We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates. The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50-65 age group, refracture risk increased monotonically with age group (66-70years: HR = 1.3, CI 95%, 1.0-1.7; 71-80years: HR = 1.7, CI 1.4-2.1; 81+ years: HR = 3.0, CI 2.4-3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6-3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6-0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0-1.5). One in ten patients in our cohort refractured within 5years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.

Treatment progress in minimally invasive intramedullary fixation for midshaft clavicle fracture

Nowadays, more and more studies on mini-invasive treatment of clavicle fractures have been reported. Firstly, based on the newly published literature about intramedullary fixation for midshaft clavicle fractures, this paper reviews its indications and advantages. Next, the design characteristics, surgical procedures, therapeutic effects and latest treatment advances concerning the intramedullary implants are systemically demonstrated and compared. Intramedullary fixation can be used in most midshaft clavicle fractures except those with neurovascular lesions or with comminuted segments, or obsolete ones. The commonly used intramedullary implants include Kirschner wires, cannulated screws, titanium elastic nails, threaded nails, and second-generation intramedullary nails. Intramedullary fixation has potential advantages of a smaller incision, fewer complications, a lower refracture risk and faster bone healing but also limitations in strength and stability. However, more and more intramedullary implants, from cannulated screws to second-generation intramedullary nails, have been used in clinic, leading to fine therapeutic effects. New products are being developed to overcome the previous shortcomings. Key words: Midshaft clavicle fracture; Fracture fixation, intramedullary; Surgical operation, minimallynvasive; Latest advances

Magnetic resonance imaging T1 and T2 mapping provide complementary information on the bone mineral density regarding cancellous bone strength in the femoral head of postmenopausal women with osteoarthritis

BackgroundSince bone mass is not the only determinant of bone strength, there has been increasing interest in incorporating the bone quality into fracture risk assessments. We aimed to examine whether the magnetic resonance imaging (MRI) T1 or T2 mapping value could provide information that is complementary to bone mineral density for more accurate prediction of cancellous bone strength. MethodsFour postmenopausal women with hip osteoarthritis underwent 3.0-T MRI to acquire the T1 and T2 values of the cancellous bone of the femoral head before total hip arthroplasty. After the surgery, the excised femoral head was portioned into multiple cubic cancellous bone specimens with side of 5 mm, and the specimens were then subjected to microcomputed tomography followed by biomechanical testing. FindingsThe T1 value positively correlated with the yield stress (σy) and collapsed stress (σc). The T2 value did not correlate with the yield stress, but it correlated with the collapsed stress and strength reduction ratio (σc/σy), which reflects the progressive re-fracture risk. Partial correlation coefficient analyses, after adjusting for the bone mineral density, showed a statistically significant correlation between T1 value and yield stress. The use of multiple coefficients of determination by least squares analysis emphasizes the superiority of combining the bone mineral density and the MRI mapping values in predicting the cancellous bone strength compared with the bone mineral density-based prediction alone. InterpretationThe MRI T1 and T2 values predict cancellous bone strength including the change in bone quality.

Risk Factors for Poor Functional Recovery, Mortality, Recurrent Fractures, and Falls Among Patients Participating in a Fracture Liaison Service Program

ObjectiveA fracture liaison service (FLS) for patients with fractures is a promising approach for improving outcomes, but barriers to the successful implementation of an FLS remain. The factors influencing the outcomes of patients already receiving FLS care are unclear. DesignA prospective multicenter cohort study. Settings and participantsPatients with incident hip and clinical vertebral fractures treated at 2 institutions between January 2014 and June 2016 were prospectively enrolled. Demographic profiles, comorbidities, prior fracture experiences, T scores, Fracture Risk Assessment Tool (FRAX) scores, and serum markers were examined. MeasuresSelf-reported functional status (at the 4th month), mortality, recurrent fractures, and falls (at the 2-year follow-up). ResultsOf 712 patients screened for eligibility, 600 (84%) participants (age 78 ± 10 years) were enrolled in the FLS program. At 4 months, 58%, 53%, and 60% of the participants reported improved mobility, self-care, and daily activities after FLS care, respectively. After 2 years, 85 (14%) died, 36 (6%) developed recurrent fractures, and 199 (33%) had 1 or more fall episodes. Multivariate logistic regression showed that neurologic disorders, heart disease, and diabetes were associated with a decreased probability of functional recovery. Cox regression showed that older age and chronic kidney disease (CKD) were predictive of increased mortality, whereas heart disease was correlated with an increased refracture risk. Older age and cancer or osteoarthritis were associated with a higher risk of falls. Importantly, a higher body mass index predicted a lower risk of mortality and a higher probability of improved self-care but a higher risk of fall at follow-up. Conclusions/ImplicationsWe discovered that comorbidities including CKD, heart disease, cancer, and osteoarthritis could influence short-term functional changes, survival, and the risk of refractures or falls among patients participating in FLSs. These factors are expected to aid in prognosis estimation and management planning for those with fractures.