Treatment Of Fragility Fractures Research Articles

[Translated article] Truths and myths about augmentation techniques in the treatment of fragility fractures

The main event of osteoporosis is fragility fractures. Vertebral compression fractures are the most commonly fragility fracture related to osteoporosis.Our goal is to review the available literature to confirm or deny concepts learned about spinal cementation and adapt our clinical practice according to scientific evidence.In the complex world of spine surgery, constant innovations seek to improve the quality of life of patients. Among these, vertebral augmentation has emerged as an increasingly popular technique, but often shrouded in myths and misunderstandings. In this systematic review, we will thoroughly explore the truths behind vertebral augmentation, unravelling common myths and providing a clear insight into this technique. As specialists in the field, it is crucial to understand the reality surrounding these interventions to offer our patients the best possible information and make informed decisions.

High and very high risk of osteoporotic fracture in Colombia, 2003-2022: identifying diagnostic and treatment gaps.

This study aimed to assess the clinical features and refracture rates among patients with high- and very-high-risk osteoporosis in Colombia, highlighting diagnostic and treatment gaps. A retrospective observational study was conducted using the medical records of patients aged ≥ 50years who experienced fragility fractures between 2003 and 2022. Clinical and demographic characteristics at the time of the initial fracture were analyzed, as well as the subsequent imminent risk (refracture rate) and the diagnosis and treatment gap. 303.982 fragility fractures occurred, and only 5.3% of patients were diagnosed with osteoporosis upon discharge. The most prevalent index fractures were forearm, vertebral, rib, and hip. Only 17.8% of the cohort had a matched osteoporosis diagnosis, indicating a low healthcare capture. Among the diagnosed patients, 10.08% were classified as high- and very high-risk of fracture, predominantly women with a mean age of 73years. Comorbidities included diabetes, Sjögren's syndrome, and heart failure. The prevalence of osteoporosis has increased significantly from 2004 to 2022, possibly due to improved detection methods, an aging population, or a combination of both. Despite this increase, treatment delay was evident. Refractures affected 70.5% of the patients, with forearm, hip, humerus, and vertebral fractures being the most common, with a mean time of refracture of 7months. Significant delays were observed in the diagnosis and treatment of fragility fractures. Colombia's government and health system must address osteoporosis by implementing national policies that prioritize osteoporosis and fragility fracture prevention and reduce delays in diagnosis and treatment.

Anaphase-Promoting Complex Subunit 1 Associates with Bone Mineral Density in Human Osteoporotic Bone.

Genome-wide association studies (GWAS) are one of the most common approaches to identify genetic loci that are associated with bone mineral density (BMD). Such novel genetic loci represent new potential targets for the prevention and treatment of fragility fractures. GWAS have identified hundreds of associations with BMD; however, only a few have been functionally evaluated. A locus significantly associated with femoral neck BMD at the genome-wide level is intronic SNP rs17040773 located in the intronic region of the anaphase-promoting complex subunit 1 (ANAPC1) gene (p = 1.5 × 10-9). Here, we functionally evaluate the role of ANAPC1 in bone remodelling by examining the expression of ANAPC1 in human bone and muscle tissues and during the osteogenic differentiation of human primary mesenchymal stem cells (MSCs). The expression of ANAPC1 was significantly decreased 2.3-fold in bone tissues and 6.2-fold in muscle tissue from osteoporotic patients as compared to the osteoarthritic and control tissues. Next, we show that the expression of ANAPC1 changes during the osteogenic differentiation process of human MSCs. Moreover, the silencing of ANAPC1 in human osteosarcoma (HOS) cells reduced RUNX2 expression, suggesting that ANAPC1 affects osteogenic differentiation through RUNX2. Altogether, our results indicate that ANAPC1 plays a role in bone physiology and in the development of osteoporosis.

Effects of anti-osteoporosis therapy on the risk of secondary fractures and surgical complications following surgical fixation of proximal humerus fracture in older people.

age-related fragility fractures cause significant burden of disease. Within an ageing society, fracture and complication prevention will be essential to balance health expenditure growth. to assess the effect of anti-osteoporotic therapy on surgical complications and secondary fractures after treatment of fragility fractures. retrospective health insurance data from January 2008 to December 2019 of patients ≥65years with proximal humeral fracture (PHF) treated using locked plate fixation (LPF) or reverse total shoulder arthroplasty were analysed. Cumulative incidences were calculated by Aalen-Johansen estimates. The influence of osteoporosis and pharmaceutical therapy on secondary fractures and surgical complications were analysed using multivariable Fine and Gray Cox regression models. a total of 43,310 patients (median age 79years, 84.4% female) with a median follow-up of 40.9months were included. Five years after PHF, 33.4% of the patients were newly diagnosed with osteoporosis and only 19.8% received anti-osteoporotic therapy. A total of 20.6% (20.1-21.1%) of the patients had at least one secondary fracture with a significant reduction of secondary fracture risk by anti-osteoporotic therapy (P < 0.001). An increased risk for surgical complications (hazard ratio: 1.35, 95% confidence interval: 1.25-1.47, P < 0.001) after LPF could be reversed by anti-osteoporotic therapy. While anti-osteoporotic therapy was more often used in female patients (35.3 vs 19.1%), male patients showed significantly stronger effects reducing the secondary fracture and surgical complication risk. a significant number of secondary fractures and surgical complications could be prevented by consequent osteoporosis diagnosis and treatment particularly in male patients. Health-politics and legislation must enforce guideline-based anti-osteoporotic therapy to mitigate burden of disease.

Innovation and Adaptation

Innovation has been the cornerstone for advances in any field of endeavor throughout the history of man and has driven the relentless forward journey of the human race. This special Orthopedics issue highlights a number of articles that showcase innovations – ideas, devices, and systems.&#x0D; The article by Aljibe, et al. showcases a novel method of producing patient-specific templates. While it is still in its infancy, the in vitro model is a first step towards a goal of translating this technology into surgical applications. This is an example of innovation driving medicine forward. 3-D printing has evolved from a hobbyist’s dream to an important tool in prosthetics, industry, drug delivery, and medicine.1-3 It is certainly exciting that scientists, engineers, and medical practitioners in our country are beginning to engage in this trailblazing field.&#x0D; The article by Gavino, et al. combines two highly specialized procedures – brachial plexus reconstruction and markerless motion analysis, the latter an innovation in itself, and creates a novel method of evaluating results of surgical procedures.4,5 Treatment of brachial plexus injuries, which bring catastrophic damage to the nerve supply to the upper extremity, need accurate evaluation of their outcomes. Only by knowing what is achieved by current treatments can we hope to better the plight of these patients.&#x0D; Genuino, et al. present a paradigm shift in delivery of services in a tertiary hospital whose main client base are the indigent. An innovation in the provision of necessary orthopedic implants to patients who have no capacity to pay for these themselves allows the bypass of charitable donors and puts the responsibility of supplying and paying for these implants on the government. This is a small but vital cog in the journey towards universal health care.&#x0D; Adaptation is highlighted by the changes forced upon us by the COVID-19 pandemic. The treatment of fragility fractures, a fraught process in the best of times, was further complicated with the restrictions that came with the lockdown. Risks already present in this elderly population were compounded by risks of transmission of this modern plague.6,7 Tabu and Cortez present in their article the adaptations instituted and the short-term results of fragility fractures managed during this period. Education also needed to adapt to the changing milieu.8 Online and distance education became a mainstay in medical education and training. Garduce, et al. present their evaluation of a hybrid method of residency education.&#x0D; The rest of the articles included in this Orthopedics special issue represent continuing efforts in scientific research in our field. They showcase contributions to the body of knowledge and experience that should prove useful to our readers and ultimately, to our patients.&#x0D; Tammy L. Dela Rosa, MD, MMedScDepartment of Orthopedics,Philippine General Hospital, University of the Philippines ManilaDepartment of Biochemistry and Molecular Biology,College of Medicine, University of the Philippines Manila&#x0D; &#x0D; REFERENCES&#x0D; 1. Lambert KF, Whitehead M, Betz M, Nutt J, Dubose C. An overviewof 3-D printing for medical applications. Radiol Technol. 2022Mar;93(4):356-67.2. Zeeshan F, Madheswaran T, Pandey M, Gorain B. Three-dimensional(3-D) printing technology exploited for the fabrication of drugdelivery systems. Curr Pharm Des. 2018;24(42):5019-28. doi: 10.2174/1381612825666190101111525.3. Pehde CE, Bennett J, Lee Peck B, Gull L. Development of a 3-Dprinting laboratory for foot and ankle applications. Clin PodiatrMed Surg. 2020 Apr;37(2):195-213. doi: 10.1016/j.cpm.2019.12.011.4. Rammer J, Slavens B, Krzak J, Winters J, Riedel S, Harris G.Assessment of a markerless motion analysis system for manualwheelchair application. J Neuroeng Rehabil. 2018 Nov;15(1):96.doi: 10.1186/s12984-018-0444-1.5. Huber ME, Seitz AL, Leeser M, Sternad D. Validity and reliabilityof Kinect skeleton for measuring shoulder joint angles: a feasibilitystudy. Physiotherapy. 2015 Dec;101(4):389-93. doi: 10.1016/j.physio.2015.02.002.6. Cortez KA, Lai JGL, Tabu IA. Economic burden and the effectsof early versus delayed hospitalization on the treatment cost ofpatients with acute fragility hip fractures under the UPM-PGHOrthogeriatric Multidisciplinary Fracture Management Model andFracture Liaison Service. Osteoporos Sarcopenia. 2021 Jun;7(2): 63–8.doi: 10.1016/j.afos.2021.05.004. 7. Pouramin P, Li CS, Busse JW, Sprague S, Devereaux PJ, Jagnoor J, et al.Delays in hospital admissions in patients with fractures across 18 lowincome and middle-income countries (INORMUS): A prospectiveobservational study. Lancet Glob Health. 2020 May; 8(5): e711-20.doi: 10.1016/S2214-109X(20)30067-X.8. Dedeilia A, Sotiropoulos MG, Hanrahan JG, Janga D, Dedeilias P,Sideris M. Medical and surgical education challenges and innovationsin the COVID-19 Era: a systematic review. In Vivo. 2020 Jun;34(3 Suppl):1603-11. doi: 10.21873/invivo.11950.

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019.

The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed. Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type. This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001). Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

Prevalence and treatment of fragility fractures in Spanish primary care: PREFRAOS study

SummaryIn Spanish primary care (PC), the prevalence of fragility fractures (FF) in subjects ≥ 70 years old is high, especially in women. One-third of subjects with an FF lacked osteoporosis (OP) diagnosis and >50% were not currently receiving OP medication. An improvement of the FF management in this population is needed.PurposeIn Spanish PC, the prevalence of FF is high, especially in women. One-third of subjects with a FF lacked an OP diagnosis and more than half were not currently receiving OP medication. Several studies reported underdiagnosis/undertreatment of OP in PC among elderly subjects with FF. To date, no such data exist for Spain. The purpose is to estimate the prevalence of FF in the elderly population (≥ 70 years old) and to describe the characteristics, risk factors, comorbidities, and OP diagnosis and treatment rates of subjects with FF in Spanish PC centers.MethodsThis is an observational, retrospective study in Spain consisting of two phases. Phase A included all subjects ≥ 70 years old listed in the center’s medical records from November 2018 to March 2020. Phase B included subjects with FF and prior consultation at the center for any reason. Subjects were excluded only if they had previously participated in another study. Primary outcomes were prevalence of FF (phase A) and characteristics of subjects with at least one FF (phase B).ResultsThe overall prevalence of FF was 17.7% among subjects visiting medical centers for any reason (24.1% women vs. 8.0% men) (30 PC centers from 14 Spanish regions). Vertebral (5.1%) was the most prevalent fracture. Of 665 subjects in phase B, most (87%) were women and ≥ 80 years old (57%), suffered mainly major OP fracture (68%), and had multiple comorbidities (≥ 2, 89.2%). While two-thirds had OP diagnosis and 61.1% received OP medication anytime in the past, 56.8% were not currently receiving OP medication. Diagnosis and treatment rates were lower among men (43% and 38% vs. 70% and 65%, respectively).ConclusionPrevalence of FF was high, especially in women. One-third of subjects lacked OP diagnosis and ≥ 50% were not receiving OP treatment; diagnosis and treatment gaps were larger among men. This reinforces the need to improve the management of FF in the elderly population. However, as PC centers participating in this study had high OP experience that have the potential to do better in terms of diagnosis and treatment, caution in the generalization of these data should be taken.

A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries

BackgroundFragility fractures without significant trauma of the pelvic ring in older patients were often treated conservatively. An alternative treatment is surgery involving percutaneous screw fixation to stabilize the posterior pelvic ring. This surgical treatment enables patients to be mobilized quickly and complications associated with bedrest and temporary immobility are reduced. However, the functional outcome following surgery and quality of life of the patients have not yet been investigated. Here, we present a comprehensive study addressing the long-term well-being and the quality of life of patients with fragility pelvic ring fractures after surgical treatment.MethodsBetween 2011–2019, 215 geriatric patients with pelvic ring fractures were surgically treated at the university hospital in Göttingen (Germany). Of these, 94 patients had fragility fractures for which complete sets of computer tomography (CT) and radiological images were available. Fractures were classified according to Tile and according to the FFP classification of Rommens and Hofmann. The functional outcome of surgical treatment was evaluated using the Majeed pelvic score and the Short Form Health Survey-36 (SF-36).ResultsThirty five tile type C and 48 type B classified patients were included in the study. After surgery eighty-three patients scored in average 85.92 points (± 23.39) of a maximum of 100 points using the Majeed score questionnaire and a mean of 1.60 points on the numerical rating scale ranging between 0 and 10 points where 0 points refers to “no pain” and 10 means “strongest pain”. Also, the SF-36 survey shows that surgical treatment positively effects patients with respect to their general health status and by restoring vitality, reducing bodily pain and an increase of their general mental health.ConclusionsPatients who received a percutaneous screw fixation of fragility fractures of the posterior pelvic ring reported an overall positive outcome concerning their long-term well-being. In particular, older patients appear to benefit from surgical treatment.Trial registrationFunctional outcome and quality of life after surgical treatment of fragility fractures of the posterior pelvic ring, DRKS00024768. Registered 8th March 2021 - Retrospectively registered. Trial registration number DRKS00024768.

A country-specific FRAX model for Botswana

IntroductionHip fracture rates in Botswana were used to create a FRAX® model for fracture risk assessment.ObjectiveThis paper describes the development and characteristics of a country-specific FRAX model for Botswana.MethodsAge-specific and sex-specific incidence of hip fracture and national mortality rates was incorporated into a FRAX model for Botswana. Ten-year fracture probabilities were compared with those from African countries having a FRAX model and African Americans from the USA.ResultsThe probabilities of hip fracture and major osteoporotic fracture were low compared with those from South Africa (Black and Coloured) and US Blacks. Probabilities were marginally higher than for Tunisia.ConclusionThe creation of a FRAX model is expected to help guide decisions about the prevention and treatment of fragility fractures in Botswana.

Incidence, Risk-Factors and Associated Mortality of Complications in Orthogeriatric Co-Managed Inpatients.

Introduction:Pneumonia, thromboembolic and ischemic events, urinary tract infections (UTI), delirium and acute kidney injury (AKI) are common complications during the treatment of fragility fractures. In a 2 years-follow-up we determined the according incidence and risk factors of these and other complications in orthogeriatric inward patients, as well as the respective associated mortality.Methods:All patients treated on an orthogeriatric co-managed ward over the course of a year were included. Besides injury, therapy and geriatric assessment parameters, we evaluated the inward incidence of common complications. In a 2 years-follow-up the associated death rates were aquired. SPSS (IBM) was used to determine the importance of risk factors predisposing to the respective occurrence of a complication and accordingly determine it’s impact on the patients’ 1- and 2-years-mortality.Results:830 orthogeriatric patients were initially assessed with a remaining follow-up cohort of 661 (79.6%). We observed very few cases of thrombosis (0.6%), pulmonary embolism (0.5%), apoplex (0.5%) and myocardial infarction (0.8%). Pneumonia was seen in 42 (5.1%), UTI in 85 (10.2%), delirium in 186 (22.4%) and AKI in 91 (11.0%) patients. Consistently ADL on admission was found to be a relevant risk factor in the development of each complication. After adjustment only AKI showed a significant increased mortality risk of 1.60 (95%CI:1.086-2.350).Discussion:In our fracture-independent assessment of complications in the orthogeriatric treatment of inward patients we’ve seen very rare cases of cardiac and thrombotic complications. Typical fragility-fracture associated common events like pneumonia, UTI, delirium and AKI were still more incidental. No complication except AKI was associated to significant increased mortality risk.Conclusions:The relevance of orthogeriatric care in prevention and outcome of inward complications seems promising, needing still more controlled studies, evaluating not just hip fracture patients but more diverse groups. Consensus is needed in the scholar evaluation of orthogeriatric complications.

Ankle Arthrodesis Nail Combined with Locking Compression Plate to Stabilize Two-Level Pathologic Tibial Fractures

Treatment of fragility fractures of the distal tibia in the elderly is demanding because of osteopenic bone quality, the delicate soft tissue cuff and frequent critical circulation. We report the case of two-level tibial pseudarthroses in an 83- year-old woman caused by multiple myeloma successfully stabilized by a long ankle arthrodesis nail combined with locking compression plate osteosynthesis. This case is unique, as to our best knowledge, herein diaphyseal fractures were treated for the first time using a technique reported hitherto primarily for fragility ankle and pilon fractures.

Management of primary and secondary osteoporosis in children.

Osteoporosis in children differs from adults in terms of definition, diagnosis, monitoring and treatment options. Primary osteoporosis comprises primarily of osteogenesis imperfecta (OI), but there are significant other causes of bone fragility in children that require treatment. Secondary osteoporosis can be a result of muscle disuse, iatrogenic causes, such as steroids, chronic inflammation, delayed or arrested puberty and thalassaemia major. Investigations involve bone biochemistry, dual-energy X-ray absorptiometry scan for bone densitometry and vertebral fracture assessment, radiographic assessment of the spine and, in some cases, quantitative computed tomography (QCT) or peripheral QCT. It is important that bone mineral density (BMD) results are adjusted based on age, gender and height, in order to reflect size corrections in children. Genetics are being used increasingly for the diagnosis and classification of various cases of primary osteoporosis. Bone turnover markers are used less frequently in children, but can be helpful in monitoring treatment and transiliac bone biopsy can assist in the diagnosis of atypical cases of osteoporosis. The management of children with osteoporosis requires a multidisciplinary team of health professionals with expertise in paediatric bone disease. The prevention and treatment of fragility fractures and improvement of the quality of life of patients are important aims of a specialised service. The drugs used most commonly in children are bisphosphonates, that, with timely treatment, can give good results in improving BMD and reshaping vertebral fractures. The data regarding their effect on reducing long bone fractures are equivocal. Denosumab is being used increasingly for various conditions with mixed results. There are more drugs trialled in adults, but these are not yet licenced for children. Increasing awareness of risk factors for paediatric osteoporosis, screening and referral to a specialist team for appropriate management can lead to early detection and treatment of asymptomatic fractures and prevention of further bone damage.

A consideration of prevention and treatment of fragility fracture by an orthopaedic surgeon

脆弱性骨折の治療は早期手術と早期リハビリテーションによって術前のQOLを再獲得することが最も重要であり，術後は骨粗鬆症の治療と転倒予防の指導を行うことによって二次骨折を防止することが重要である．脆弱性骨折特に大腿骨近位部骨折の患者は超高齢者が多く，多くの併存症を持っていることが多い．脆弱性骨折患者を集約し，老年病医は全身管理を整形外傷医は骨折の治療をと，それぞれが自分の専門領域のみに専念できる体制が1日も早く整うことを願っている．

The GLP-1 Receptor Agonist Exenatide Ameliorates Bone Composition and Tissue Material Properties in High Fat Fed Diabetic Mice.

Type 2 diabetes mellitus (T2DM) has recently been recognized as a significant risk factor for bone fragility. Careful investigations of bone mechanical properties in human studies suggested possible alterations of bone composition, although this axis has poorly been investigated. The main aim of this study was to evaluate the impact of high fat diet-induced diabetes and therapy using the clinically approved GLP-1 receptor agonist, exenatide, on tissue bone mechanical properties and compositional parameters. Male mice had free access to high fat diet for 16 weeks to induce diabetes prior to commencement of the study. Exenatide was administered twice daily by i.p. injection at a dose of 25 nmol/kg for 52 days. Normal and high fat diet fed (HFD) mice injected with saline were used as controls. Bone mechanical properties was assessed at the organ level by 3-point bending and at the tissue level by nanoindentation. Bone microarchitecture was investigated by microcomputed tomography and bone composition was evaluated by Fourier transform infrared imaging. HFD mice exhibited profound alterations of bone mechanical properties at both the organ and tissue level. Collagen maturity as well as trabecular and cortical bone microarchitectures were abnormal. Administration of exenatide, led to clear ameliorations in bone mechanical properties at the organ and tissue levels by modifications of both cortical microarchitecture and bone compositional parameters (collagen maturity, mineral crystallinity, carbonate/phosphate ratio, acid phosphate content). These results bring new light on the mode of action of exenatide in bone physiology and demonstrate the value of GLP-1 mimetics in the treatment of fragility fractures in diabetes.

Guidelines for the management of osteoporosis and fragility fractures

The purpose of this document, a result of the harmonisation and revision of Guidelines published separately by the SIMFER, SIOMMMS/SIR, and SIOT associations, is to provide practical indications based on specific levels of evidence and various grades of recommendations, drawn from available literature, for the management of osteoporosis and for the diagnosis, prevention, and treatment of fragility fractures. These indications were discussed and formally approved by the delegates of the Italian Scientific Associations involved in the project (SIE, SIGG, SIMFER, SIMG, SIMI, SIOMMMS, SIR, and SIOT).

Orthogeriatrie

Fragility fractures are associated with a substantial mortality and morbidity. Because of the high prevalence of comorbidities and a high risk of complications the application of geriatric principles in the complex treatment of these patients is vital. The last years have seen a paradigm shift in the treatment of fragility fractures from an orthopedic disorder towards an orthogeriatric syndrome. This article reviews the orthogeriatric principles of treating fragility fractures.

Perioperative care of older patients with hip fractures

The number of osteoporotic fractures is increasing along with population aging. Most patients with these type of fractures are older than 65 years, with multiple chronic conditions and different degrees of disability. Hip fracture is the most relevant osteoporotic fracture due to its frequency, costs, severity and complications. Multidisciplinary management is of the utmost importance to obtain good therapeutic results. We herein review the management of this fracture. Orthogeriatric joint management should be incorporated in fragility fracture treatment. We contribute with general recommendations for the perioperative management, which can be homologated for the management of older patients with other type of fragility fractures.

Fatigue failure of plated osteoporotic proximal humerus fractures is predicted by the strain around the proximal screws.

The high rate of required reoperation indicates that treatment of fragility fractures at the proximal humerus still remains a major challenge in trauma surgery. Improved fixation approaches are needed. Several limitations of the conventional implant development process involving experimental testing could be overcome by using computer models that would allow systematic and efficient analyses. However, such models require experimental validation. This study investigated if linear elastic continuum finite element (FE) models can predict experimental fatigue failure in locking plate fixation of osteoporotic proximal humerus fractures. Three-part fractures were created in twenty fresh-frozen proximal humeri of elderly donors, stabilized with angular stable plate osteosythesis and tested to failure in a previously developed experimental setup using a cyclic loading protocol with increasing peak load. Case-specific, linear elastic FE models of the instrumented samples were created from CT images and loaded virtually by mimicking the experimental conditions. Average principal strains were evaluated in cylindrical regions around the proximal screws. Parametric sensitivity analysis was performed to investigate the effects of specific model parameters on the results. The number of cycles to failure was 10500 ± 3300 (mean ± SD, range: 3100 - 16400) and showed a strong logarithmic correlation with the average compressive principal strain around the screws (R2 = 0.90). These results suggest that the latter parameter may be used as a surrogate estimate for construct stability under cyclic loading. The computationally cheap linear elastic continuum FE analysis could be used as an efficient screening tool for optimization and development of implants. Further work is required to investigate if the findings of this study apply to other loading modes and bone-implant constructs.

A position statement of the Traumatology Society of Slovenia on the treatment of fragility fractures of the pelvic ring

Because of the ageing crisis in western world the fragility fractures of the pelvic ring joint the big four group of typical fractures in osteoporotic elderly patients: fractures of the proximal femur, fractures of the proximal humerus, fractures of the distal radius and thoracic and lumbar low energy spinal fractures. All these fractures are the result of low energy with the typical fall of the patient from the standing height. The Slovenian recommendations include Rommens classification for non-displaced and displaced fractures of the anterial and posterial pelvic ring with the operative indications. The recommendations were launched at the Slovenian society of trauma surgeons meeting in November 7 th , 2015.

Risk factors for hospital re-presentation among older adults following fragility fractures: a systematic review and meta-analysis

BackgroundOlder adults hospitalized with fragility fractures are at high risk of negative events that can culminate in re-presentations to hospital emergency departments or readmissions to hospital. This systematic review aimed to identify patient, clinical, or hospital-related factors that are identifiable at the index admission and that may be associated with re-presentations to hospital emergency departments or hospital readmissions in older adults following fragility fractures.MethodsFour electronic databases (PubMed, CINAHL, Embase, and Scopus) were searched. A suite of search terms identified peer-reviewed English-language articles that examined potential correlates of hospital re-presentation in older adults (mean age ≥ 65 years) who were discharged from hospital following treatment for fragility fractures. A three-stage screening process (titles, abstracts, full text) was conducted by two researchers independently. Participant characteristics, study design, potential correlates examined, analyses, and findings were extracted for studies included in the review. Quality and risk of bias were assessed with the Effective Public Health Practice Project Quality Assessment Tool. The strength of evidence was incorporated into a best evidence synthesis, and meta-analysis was conducted where effect pooling was possible.ResultsEleven of 35 eligible studies were categorized as high quality studies. These studies reported that age, higher Cumulative Illness Rating scores, American Society of Anesthesiologists scores > 3, longer length of stay, male sex, cardiovascular disease, low post-operative hemoglobin, kidney disease, dementia and cancer were factors identified at the index admission that were predictive of subsequent re-presentation to hospital. Age was the only predictor for which pooling of effects across studies was possible: pooling was conducted for re-presentation ≤ 30 days (pooled OR, 1.27; 95 % CI, 1.14–1.43) and > 30 days (pooled OR, 1.23; 95 % CI, 1.01–1.50).ConclusionsThe best-evidence synthesis, in addition to the meta-analysis, identified a range of factors that may have utility in guiding clinical practice and policy guidelines for targeted interventions to reduce the need for re-presentation to hospital among this frail clinical population. The paucity of studies investigating re-presentations to hospital emergency departments without admission was an important gap in the literature identified in this review. Key limitations were exclusion of non-English language studies and grey literature.Systematic review registrationPROSPERO CRD42015019379.