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Purpose. Poller screws may serve as an adjunctive reduction tool and aid fracture reduction while augmented with intramedullary (IM) nailing for treating diaphyseal or metaphyseal fractures of the femur and tibia. However, there is no consistent conclusion about whether the method of using IM nailing augmented with poller screws is more advantageous than using IM nailing alone. Methods. A total of 96 patients who received IM nailing with or without supportive poller screw for treating long-bone fractures in lower limbs and who experienced difficulties in performing reduction or IM insertion during the surgical process were included in this retrospective cohort study (33 patients with poller screws in group A versus 63 patients without poller screws in group B). Patient demographics including age, gender, and body mass index; injury-related data including fracture location, classification, and injury mechanism; operation-related data including American Society of Anesthesiologists, duration of operation, poller screw time, method of anesthesia, and volume of intraoperative hemorrhage; outcomes including fracture healing time; and incidence of outcomes of nonunion, malunion, infection, and secondary surgical procedures were evaluated. Results. Fracture healing time of patients in group A was significantly shorter than that of group B (18.3 ± 4.8 weeks versus 24.3 ± 3.0 weeks, p = 0.023). Union rate was higher (100.0% versus 87.3%, p = 0.048), and malunion rate and secondary surgical procedure rate were lower (both are 3.0% versus 19.0%, p = 0.031) in group A than that of group B. Conclusion. Poller screw augmentation of IM nailing is a favourable option to shorten fracture healing time and to reduce complication rates in terms of nonunion, malunion, and secondary surgical procedure in the treatment of both diaphyseal/metaphyseal fractures of the femur or tibia while compare with those treated by IM nailing alone. [ABSTRACT FROM AUTHOR]

Objective. To investigate if 3D printed guides and preoperative planning can accurately control femoral stem anteversion. Methods. A prospective comparative study was carried out from 2018 to 2020, including 53 patients who underwent hip arthroplasty for femoral neck fracture. The target rotation center of the femoral head is determined by three-dimensional planning. In group A, planning was made by 2D templates. In group B, preoperative 3D planning and 3D printed osteotomy/positioning guides were performed. After the operation, 3D model registration was performed to calculate the accuracy of anteversion restoration. Results. We screened 60 patients and randomized a total of 53 to 2 parallel study arms: 30 patients to the group A (traditional operation) and 23 patients to the group B (3D preoperative planning and 3D printed guide). There were no significant differences in demographic or perioperative data between study groups. The restoration accuracy of group A was 5.42 ° ± 3.65 ° and of group B was 2.32 ° ± 1.89 ° . The number and rate of abnormal cases was 15 (50%) and 2 (8.7%), respectively. Significant statistical differences were found in angle change, restoration accuracy, and number of abnormal cases. Conclusion. Three-dimensional preoperative planning and 3D printed guides can improve the accuracy of the restoration of femoral anteversion during hip arthroplasty. [ABSTRACT FROM AUTHOR]

This biomechanical study assessed the influence of changing antegrade cephalomedullary nail insertion point from anterior to neutral to posterior locations relative to the tip of the greater trochanter with or without anterior cortical perforation in the distal femur. Artificial osteoporotic femurs and cephalomedullary nails were used to create 5 test groups each with 8 specimens: intact femur without a nail or perforation, anterior nail insertion point without perforation, neutral nail insertion point without perforation, posterior nail insertion point without perforation, and posterior nail insertion point with perforation. Nondestructive biomechanical tests were done at 250 N in axial, coronal 3-point bending, sagittal 3-point bending, and torsional loading in order to measure overall stiffness and bone stress. The intact femur group vs. all femur/nail groups had lower stiffness in all loading modes (p ≤ 0.018), as well as higher bone stress in the proximal femur (p ≤ 0.027) but not in the distal femur above the perforation (p = 0.096). Compared to each other, femur/nail groups only showed differences in sagittal 3-point bending stiffness for anterior and neutral vs. posterior nail insertion points without (p ≤ 0.025) and with perforation (p ≤ 0.047). Although it did not achieve statistical significance (p ≥ 0.096), moving the nail insertion point from anterior to neutral to posterior to posterior with perforation did gradually increase bone stress by 45% (proximal femur) and 46% (distal femur). No femur or hardware failures occurred. Moving the nail insertion point and the presence of a perforation had little effect on stiffness, but the increased bone stress may be important as a predictor of fracture. Based on current bone stress results, surgeons should use anterior or neutral nail insertion points to reduce the risk of anterior cortical perforation. [ABSTRACT FROM AUTHOR]

Background. A total hip reconstruction is related to the stress distribution throughout the prosthesis, cement, and femur. Researches on reducing the stress in all components to minimize the risk of failure are of great significance. The objective of our study was to determine the biomechanical variation in overall femoral stress and periprosthetic femoral stress distribution after implantation with the Ribbed anatomic prosthesis. Methods. Three-dimensional finite element models of intact femur and Ribbed prosthesis were developed according to the morphology, while the hip joint loading and the strength of related muscles were applied in the models. The overall stress changes of the intact femur before and after the implantation were analyzed, and the periprosthetic stress distribution especially in the proximal region of the femur was quantified. Results. As a result, the overall stress pattern of the femur did not change after the implantation compared with the intact femur. The region of peak stress value was located in the middle and lower segments of the full length femur, but the stress value level decreased. The final prosthesis resulted in a significant decrease in the equivalent stress level of the periprosthetic bone tissue, and the most severe area appeared at the endmost posterior quadrant. The stress shielding ratio of the Ribbed prosthesis was 71.6%. The stress value level gradually increased towards the distal part of the prosthesis and recovered to physiological level at the end of the prosthesis. Conclusions. The Ribbed prosthesis can cause significant stress shielding effect in the proximal femur. These results may help optimize prosthetic design to reduce stress shielding effect and improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Background. Physical activity in elderly patients is crucial for recovery from proximal femoral fractures. Considering the limited possibilities for objective measurement, we aimed to evaluate the use of an accelerometer in this population to determine activity's association with functional independence, quality of life, and course of recovery. Methods. 52 patients undergoing operative treatment for proximal femur fractures (81.3 ± 7.5 years) were included in a prospective cohort study. 12 patients with fall but without fracture of the lower extremities (80.8 ± 9.5 years) served as control. An Axivity AX3 tracker continuously recorded signal vector magnitudes during the hospital stay. Additionally, 2 ± 1 and 8 ± 3 days (time point 1 and 2) after operation EuroQol-5D and Barthel-20 indices were evaluated. Results. Physical activity increased in all patients with time. Multiple regression analyses revealed that a high Barthel-20 before fracture, a low age, a high body mass index, high albumin, and low C-reactive protein levels were independent predictors for high physical activity at time point 1 (p < 0.05). Physical activity correlated significantly with EuroQol-5D and Barthel-20 at time point 1 and 2 (p < 0.02). Furthermore, physical activity at time point 1 predicted EuroQol-5D, physical activity, and Barthel-20 at time point 2 (p < 0.01). A multiple regression demonstrated equal physical activity in patients with or without a hip fracture. Conclusions. Accelerometer signals correlate with postoperative physical activity, Barthel-20 and quality of life in elderly patients. Physical activity is thereby positively influenced by a high prefall functional independence and a good nutrition status. A timely and adequate operation provided, there is no difference between patients with or without a fracture. This trial is registered with DRKS 00011934 on 10th April 2017. [ABSTRACT FROM AUTHOR]

Objective. Bone marrow-derived mesenchymal stem cells (BMSCs) have multilineage differentiation potential, which allows them to progress to osteogenesis, adipogenesis, and chondrogenesis. An imbalance of differentiation between osteogenesis and adipogenesis will result in pathologic conditions inside the bone. This type of imbalance is also one of the pathological findings in osteonecrosis of the femoral head (ONFH). Chicken ovalbumin upstream promoter-transcription factor II (COUP-TFII) was previously reported to mediate the differentiation of mesenchymal stem cells. This study investigated the expression of the osteogenesis regulator Runx2, osteocalcin, the adipogenesis regulator PPARγ, and COUP-TFII in the femoral head tissue harvested from ONFH patients, and characterized the effect of COUP-TFII on the differentiation of primary BMSCs. Methods. Thirty patients with ONFH were recruited and separated into 3 groups: the trauma-, steroid- and alcohol-induced ONFH groups (10 patients each). Bone specimens were harvested from patients who underwent hip arthroplasty, and another 10 specimens were harvested from femoral neck fracture patients as the control group. Expression of the osteogenesis regulator Runx2, osteocalcin, the adipogenesis regulator PPARγ, C/EBP-α, and COUP-TFII was analyzed by Western blotting. Primary bone marrow mesenchymal cells were harvested from ONFH cells treated with COUP-TFII RNA interference to evaluate the effect of COUP-TFII on MSCs. Results. ONFH patients had significantly increased expression of the adipogenesis regulator PPARγ and C/EBP-α and decreased expression of the osteogenesis regulator osteocalcin. ONFH bone tissue also revealed higher COUP-TFII expression. Immunohistochemical staining displayed strong COUP-TFII immunoreactivity adjacent to osteonecrotic trabecular bone. Increased COUP-TFII expression in the bone tissue correlated with increased PPARγ and decreased osteocalcin expression. Knockdown of COUP-TFII with siRNA in BMSCs reduced adipogenesis and increased osteogenesis in mesenchymal cells. Conclusion. Increased COUP-TFII expression mediates the imbalance of BMSC differentiation and progression to ONFH in patients. This study might reveal a new target in the treatment of ONFH. [ABSTRACT FROM AUTHOR]

Purpose. To verify the biomechanical importance with respect to the integrity of posteromedial cortex of femoral neck fracture (FNF) and demonstrate whether the modified fixation of cannulated screws (CSs) could increase the biomechanical strength. Methods. A total of 24 left artificial femurs were randomly divided into three groups. The osteotomy was made in the center of the femoral neck at a 20° angle to the shaft axial. The posteromedial cortices of femoral neck were removed in groups B and C. In group A, 8 femurs with intact posteromedial cortex were fixed with three parallel partial thread screws (PTSs), forming a standard triangle. In group B, the femurs were stabilized with the same fixation of CSs like group A. In group C, two inferior PTSs were replaced by two fully thread screws (FTSs). Results. The lower A-P and axial stiffness and load to failure along with higher axial displacement were found in group B compared with group A (p≤0.001 for all). Between groups B and C, the modified fixation of CSs increased A-P and axial stiffness and load to failure and reduced the axial displacement (p≤0.001 for all). Conclusions. We verified that the comminuted posteromedial cortex affected the biomechanical strength adversely and resulted in higher displacement. The modified fixation of CSs characterized by two inferior FTSs could improve the biomechanical performance and buttress the femoral head fragment better. [ABSTRACT FROM AUTHOR]

Resurfacing hip and knee endoprostheses are generally embedded in shallow, prepared areas in the bone and secured with cement. Massive cement penetration into periarticular bone, although it provides sufficient primary fixation, leads to the progressive weakening of peri-implant bone and results in failures. The aim of this paper was to investigate in an animal model the first biomimetic fixation of components of resurfacing arthroplasty endoprostheses by means of the innovative multispiked connecting scaffold (MSC-Scaffold). The partial resurfacing knee arthroplasty (RKA) endoprosthesis working prototype with the MSC-Scaffold was designed for biomimetic fixation investigations using reverse engineering methods and manufactured by selective laser melting. After Ca-P surface modification of bone contacting surfaces of the MSC-Scaffold, the working prototypes were implanted in 10 swines. Radiological, histopathological, and micro-CT examinations were performed on retrieved bone-implant specimens. Clinical examination confirmed very good stability (4 in 5-point Likert scale) of the operated knee joints. Radiological examinations showed good implant fixation (radiolucency less than 2 mm) without any signs of migration. Spaces between the MSC-Scaffold spikes were penetrated by bone tissue. The histological sections showed newly formed trabecular bone tissue between the spikes, and the trabeculae of periscaffold bone were seen in contact with the spikes. The micro-CT results showed the highest percentage of bone tissue ingrowths into the MSC-Scaffold at a distance of 2.5÷3.0 mm from the spikes bases. The first biomimetic fixation for resurfacing arthroplasty was successfully verified in 10 swines investigations using RKA endoprosthesis working prototypes. The performed research shows that the MSC-Scaffold allows for cementless and biomimetic fixation of resurfacing endoprosthesis components in periarticular cancellous bone. [ABSTRACT FROM AUTHOR]

Background. Intramedullary nails have been the treatment of choice for acute femur-shaft fractures in adults. However, the infraisthmal location has a high risk of nonunion and is easy to malalign. This study evaluated radiologic outcomes of initial supportive use of poller screws in combination with antegrade femoral nailing in infraisthmal femur-shaft fracture. Methods. A total of 49 patients who had undergone antegrade nailing with or without supportive poller-screw insertion for infraisthmal femur-shaft fracture were included in this retrospective cohort study (23 patients with poller screws in group 1 versus 26 patients without poller screws in group 2). Patient demographics including sex, age, classification, mechanism of injury, operative time, poller-screw time, and radiologic outcomes, including union rate, time to union, and number of malunions, were evaluated. Results. Union rate in group 1 (95.6%) was significantly higher than that in group 2 (84.6%) (p = 0.04). Time to union was 19.8 weeks in group 1 and 20.3 weeks in group 2 (p = 0.31). Conclusion. Initial supportive insertion of two poller screws after nailing took a mean of 21minutes additionally but could lessen the risk of nonunion significantly in this study. We believe that these findings may have important clinical relevance for the treatment of infraisthmal femur-shaft fracture. [ABSTRACT FROM AUTHOR]

Aim. This study aimed at comparing the mechanical properties of conventional and locking dual plates in adjacent and orthogonal orientations for the surgical fixation of transverse femoral shaft fractures. It also assessed the failure mechanics after dual adjacent and orthogonal locking plate removal. Methods. Thirty-two composite femurs were transversally osteotomized and randomly assigned for fixation with either dual locking or compression plates in an adjacent or orthogonal configuration. Sixteen specimens were preloaded axially to 20 N and single-leg stance loads were simulated. The remaining sixteen constructs were subjected to torsional loads of 10 Nm at a rate of 10 Nm/s in external and internal rotation of the femoral head in relation to the knee. Overall combined rotational stiffness was calculated. Eight different specimens with no osteotomy underwent the same experiments after dual locked plate removal and were tested to failure in combined eccentric axial and torsional modes. Data were statistically processed using a two-tailed t-test and one-way analysis of variance for the comparison of means between two or more groups, respectively. Results. Orthogonal constructs were statistically stiffer in axial loading compared to their adjacent counterparts in both conventional and locking configurations (p<0.001). Dual locking plates provided higher torsional stiffness than conventional ones within each plate orientation (p<0.01). Neither axial/torsional strength nor failure loads differed between constructs that had adjacent or orthogonal dual locking plates instrumented and then removed (p>0.05). Conclusions. In both orthogonal and adjacent orientations, double locking plates provide higher stability than their dual conventional counterparts. Orthogonal dual plate configuration is more stable and biomechanically superior to dual adjacent plating for constructs fixed with either standard compression or locking plates. [ABSTRACT FROM AUTHOR]

Austin-Moore hemiarthroplasty (HA) had been selectively used for elderly patients with femoral neck fractures. With increasing life span and activity, the sequela of Austin-Moore HA make the implant no longer favorable. The treatment of failed Austin-Moore HA with advanced acetabular erosion is challenging; however, little has been published regarding this topic. The aim of this study was to evaluate the mid-term results of using cementless total hip arthroplasty (THA) in octogenarians. Between 2008 and 2011, 47 patients (32 women and 15 men) with an average age of 86 years (range 83-89 years) were enrolled in this retrospective study. After an average follow-up period of 6.2 years (range 5.0-7.8 years), no migration or loosening of the cup or femoral stem was found. Harris hip scores improved from 36 (range 15-42) preoperatively to 87 (range 80-90). There were no complications directly associated with the procedure except for superficial infections in two patients. Our results suggest that using cementless THA can result in favorable radiographic and clinical outcomes in octogenarian patients. [ABSTRACT FROM AUTHOR]

Background and Importance. Cerebral fat embolism (CFE) occurs mainly after long-bone fractures. Often reducing to minor neurological disorders as confusion, it can sometimes cause more severe consequences such as coma or even death. While CFE has been described for several years, there is no consensual treatment. Clinical Presentation. We report the case of a 15-year-old girl with a severe cerebral fat embolism secondary to a longboard fall with a femur fracture. She developed in less than 4 hours a coma. On day 4, she lost her brainstem reflexes with a clinical condition close to brain death, with a very high intracranial pressure (ICP) value above 75 mmgH at worst. She was treated as having a trauma brain injury based on ICP control with a decompressive hemicraniectomy. She recovered in some weeks, allowing discharge to a post ICU rehabilitation center, one month after admission. Conclusion. We report a severe case of cerebral fat embolism with good outcome. It was managed as a trauma brain injury. We emphasize the neurological management based on ICP and discuss the position of hemicraniectomy. [ABSTRACT FROM AUTHOR]

Nonunion is a relatively rare, yet challenging problem after fracture of the femoral neck. Risk factors include verticality of the fracture line and presence of comminution of the posteromedial calcar, as well as quality of reduction. Treatment options consist of valgus intertrochanteric osteotomy versus arthroplasty. Treatment should be tailored to the individual patient, taking into account patient age and activity demands. This review outlines the principles and technical considerations for valgus osteotomy of the proximal femur in the setting of femoral neck nonunion. [ABSTRACT FROM AUTHOR]

Objectives. We evaluated the biomechanical outcome of different plate fixation strategies (the single plate construct, 45° double-plate construct, 90° double-plate construct, 135° double-plate construct, and 180° double-plate construct) used for the fixation of the femoral shaft nonunion with no cortical support opposite the primary lateral plate. This may help surgeons choose the optimal therapy to the femoral shaft nonunion. Methods. The femoral shaft nonunion with no medial support and the models of lateral plate and medial plate was constructed in 3-matic software and UG-NX software, respectively. We then assembled the single plate and different double plates to the fracture model separately to form the fixation models. After meshing the models’ elements, we used the ABAQUS software to perform the finite element analysis. Values of the von Mises Stress (VMS) distribution of the implant, peak VMS, and model displacement and deformation were used to capture the mechanical factors in this study. Results. Our results indicated that the peak von Mises Stress (VMS) of the lateral plate was concentrated in middle surface of the lateral plate near the fragment of each group. The peak VMS was 5201.0 MPa (the single-plate construct), 3490.0 MPa (45° double-plate construct), 1754.0 MPa (90° double-plate construct), 1123.0 MPa (135° double-plate construct), and 816.5 MPa (180° double-plate construct). The additional short plate dispersed some stress leading to the decrease in the peak VMS of the lateral plate. As angle formed by the double plates increased, the dispersed function of the additional plate was becoming obvious. The bending angles of the lateral plate were 18° versus 12° versus 3° versus 2° versus 1° (the single-plate construct versus 45° double-plate construct versus 90° double-plate construct versus 135° double-plate construct versus 180° double-plate construct). Conclusions. Our study indicated that increasing the angle between the plates in a double-plate construct improves the stability of the construct over a single lateral plate when there is no cortical support opposite to the lateral plate. The strongest fixation occurred when the angle between the two plates was greater than ninety degrees. [ABSTRACT FROM AUTHOR]

Background. Early postoperative physical activity in elderly patients suffering from proximal femoral fractures may reduce mortality. We hypothesized that activity trackers can reliably and objectively monitor the in-hospital mobilization, correlating with functional independence and quality of life. Methods. Three different tracker types (Fitbit™ flex, Misfit™ Shine, and Axivity AX3) at three locations (wrist, ankle, and femur) recorded steps and signal vector magnitudes (SVM) in 22 patients. They were 81±8 years old, were equally distributed between the sexes, and had an ASA score of 2.5±0.6. Single protocoled activity events (n=191) were clinically categorized into 4 levels and correlated with the monitored signals. Additionally, 2±1 and 8±3 days after the operation, the EuroQol-5D and the Barthel-20 index supplemented this data. Results. All measurements at the wrist (Fitbit, Misfit) resulted in unacceptable accuracy; however, sensitivity and specificity reached around 90% using the Misfit at the ankle. Applying this combination, the correlation between real and measured steps (R2 = 0.99) and the category discrimination were statistically significant (p<0.002). A discriminant analysis featured the calculation of four activity levels based on SVM measurements using the Axivity tracker at the femur. A cluster analysis showed a 100% agreement between the clinically observed and the calculated activity levels. The amount of active minutes or periods and both the EuroQol-5D and the Barthel-20 indices significantly increased between the analyzed time points after the operation. However, only the Barthel-20 was associated with the measured activity levels (p<0.01). Conclusion. The Misfit and the Axivity trackers can reliably monitor activity in elderly patients after operative treatment of proximal femur fractures. However, the wear location is decisive. Objectively measured activity correlated with functional independence and quality of life. [ABSTRACT FROM AUTHOR]

Introduction. We focus on trauma care conducted in the context of a simulated traumatic event. This is in this study defined as a four-meter fall onto a hard surface, resulting in severe injuries to extremities in the form of bilateral open femur fractures, an open tibia fracture, and a closed pelvic fracture, all fractures bleeding extensively. Methods. The simulated trauma care competence of 63 ambulance nurses in prehospital emergency care was quantitatively evaluated along with their perception of their sufficiency. Data was collected by means of simulated trauma care and a questionnaire. Results. Life-saving interventions were not consistently performed. Time to perform interventions could be considered long due to the life-threatening situation. In comparison, the ambulance nurses’ perception of the sufficiency of their theoretical and practical knowledge and skills for trauma care scored high. In contrast, the perception of having sufficient ethical training for trauma care scored low. Discussion. This study suggests there is no guarantee that the ambulance nurses’ perception of theoretical and practical knowledge and skill level corresponds with their performed knowledge and skill. The ambulance nurses rated themselves having sufficient theoretical and practical knowledge and skills while the score of trauma care can be considered quite low. [ABSTRACT FROM AUTHOR]

This study aimed to determine the kinetics of four inflammatory markers and to identify the variables that affect the natural kinetics of inflammatory markers in aged patients having hip fractures with and without elevated preoperative CRP. 240 elderly patients who have been operated on for femoral neck fracture with no infectious complications were divided into two groups on elevated preoperative CRP level (>10 mg/L). The temporal values of four inflammatory markers of WBC, neutrophil count (N) (%), ESR, and CRP were assessed eight times every other day until the 14th postoperative day. At 48–60 h postoperatively, mean CRP was markedly higher in patients with preoperatively elevated CRP than in those with nonelevated CRP (122.1±65.9 and 73.7±35.5, p<0.001). However, the abrupt elevation of CRP in the elevated group was conversely decreased on the 4th-5th postoperative day, demonstrating similar kinetic curves with no significant differences between both groups. For WBC, N (%), and ESR, both groups showed similar patterns of temporal values 14 days after surgery regardless of preoperative CRP level. Our findings could be used as guidelines for patient discharge and during the follow-up period after surgery. [ABSTRACT FROM AUTHOR]

Objectives. To examine the effect of fluoroscopy devices with different sizes of image intensifier and C-arm maneuverability on operating time, fluoroscopy time, radiation dose and reduction, and fixation quality at intertrochanteric femoral fractures. Design. Single-center, randomized, prospective study. Setting. Academic Level I trauma hospital. Patients and Intervention. 34 patients treated with cephalomedullary nailing for a stable, intertrochanteric proximal femur fracture (OTA A1). Main Outcome Measurement. The total working time of the fluoroscopy device, the dose-area product (DAP), operating time, reduction quality (cortical continuity, symmetrical collodiaphyseal angle, and shortness), and fixation quality (Bosworth quadrants, the tip-apex distance, TAD). Results. There were no cases of poor reduction; also the placement of the blade was optimal for 14 patients and suboptimal in 3 patients in each group. Superior-posterior placement of the blade or TAD > 25 mm was not seen in any patient. Total operating time was significantly shorter when using device A compared to the use of device B (20.1±3.4 mins versus 25.3±5.4 mins, p<0.001). Total radiation time was significantly shorter with device A compared to the use of device B (58.1±19.4 secs versus 98.9  ±  55.4 secs, p=0.008). The measured radiation dose was lower with the use of device A compared to device B (3.5  ±  1.2 Gy·cm2 versus 7.3  ±  4.5 Gy·cm2, p=0.002). Conclusion. Physical properties of fluoroscopy devices used during the fixation of intertrochanteric fractures could yield significant differences in operating times and the radiation dose while having comparable clinical results. [ABSTRACT FROM AUTHOR]

Introduction. The aim of the study was to compare the clinical outcomes following elective and traumatic total hip arthroplasty in Parkinson’s disease patients. Materials and Methods. Ten patients with osteoarthritis comprise the elective group (mean age at operation 74 years; mean follow-up 82 months). Thirteen patients with femoral fracture comprise the hip fracture group (mean age 76 years; mean follow-up 54 months). All patients were followed up at 6 and 36 months postoperatively and at the time of the latest follow-up. Results. Despite the significant improvement in Merle d’Aubigné-Postel and pain scores, disability related to Parkinson’s disease increased during the follow-up. Whereas more than 1/3 of hip fracture patients and all elective patients walked independently at 36 months after total hip arthroplasty, 43% of living patients from both groups were able to walk independently at the time of the latest follow-up. The medical complications were seen mainly in patients with hip fracture. Conclusions. Excellent pain relief with preserved walking ability without support of another person and acceptable complication profile was observed in Parkinson’s disease patients at 36 months after elective total hip arthroplasty. This procedure may be indicated in Parkinson’s disease patients after careful and individualized planning. [ABSTRACT FROM AUTHOR]

The objective of this study was to more fully understand the mechanical behavior of bone tissue that is important to find an alternative material to be used as an implant and to develop an accurate model to predict the fracture of the bone. Predicting and preventing bone failure is an important area in orthopaedics. In this paper, the macrodamage accumulation models in the bone tissue have been investigated. Phenomenological models for bone damage have been discussed in detail. In addition, 3D finite element model of the femur prepared from imaging data with both cortical and trabecular structures is delineated using MIMICS and ANSYS® and simulated as a composite structure. The damage accumulation occurring during cyclic loading was analyzed for fatigue scenario. We found that the damage accumulates sooner in the multiaxial than in the uniaxial loading condition for the same number of cycles, and the failure starts in the cortical bone. The damage accumulation behavior seems to follow a three-stage growth: a primary phase, a secondary phase of damage growth marked by linear damage growth, and a tertiary phase that leads to failure. Finally, the stiffness of the composite bone comprising the cortical and trabecular bone was significantly different as expected. [ABSTRACT FROM AUTHOR]

Acetabular fractures involving predominantly the anterior column associated with a disruption of the quadrilateral surface can be treated with instrumentation implementing the stabilization of the quadrilateral surface. The recently introduced suprapectineal quadrilateral buttress plate is specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced ability for partial weight bearing. Whereas there are guidelines available for safe screw fixation for the anterior and posterior columns, there might be a concern for intra-articular placement of screws placed through the infrapectineal part of the quadrilateral buttress plate. Within this report we analyzed retrospectively screw placement in 30 plates in postoperative CT scans using algorithms for metal artifact reduction. None of the screws of the buttress plate penetrated the hip joint. We describe the placement, length, and spatial orientation of the screws used for fracture fixation and suggest that the use of intraoperative image intensifiers with a combined inlet-obturator view of 30–45° best projects the screws and the hip joint. Preoperative knowledge of approximate screw placement and information for accurate intraoperative imaging may contribute to safe acetabular fracture fixation and may reduce operating time and limit radiation exposure to the patient and the personnel. This trial is registered with KEK-BE: 266/2014. [ABSTRACT FROM AUTHOR]

We present the case of a patient who suffered a comminuted supracondylar periprosthetic femur fracture. The patient was an 86-year-old lady who suffered a minor fall at home and presented at our hospital with a right comminuted distal femur fracture around a total knee arthroplasty. The patient was submitted to a cruciate-sacrificing total knee replacement 6 years before at the same institution. Despite severe metaphyseal fragmentation and short distal fragment, the prosthesis was stable; thus, open fracture reduction and stabilization with internal fixation were performed. The surgical technique included the use of a nonvascularized autologous fibular strut graft as an augmentation technique in conjunction with double plating fixation. Clinically, patient presented a painless aligned knee 12 months after femur fixation, although she was not able to return to an independent level of activity. No pain involving the donor graft site was reported at the time of the most recent follow-up examination. This case study demonstrates the use of free nonvascularized autogenous fibular strut bone graft as an option to bridge major bone defects. This proved to be a relatively simple, not expensive procedure that can be done percutaneously and does not need high-quality training. [ABSTRACT FROM AUTHOR]

Purpose. The purpose of this study is to evaluate the learning curve of performing surgery with the InterTan intramedullary nail in treating femoral intertrochanteric fractures, to provide valuable information and experience for surgeons who decide to learn a new procedure. Methods. We retrospectively analyzed data from 53 patients who underwent surgery using an InterTan intramedullary nail at our hospital between July 2012 and September 2015. The negative exponential curve-fit regression analysis was used to evaluate the learning curve. According to 90% learning milestone, patients were divided into two group, and the outcomes were compared. Results. The mean operative time was 69.28 (95% CI 64.57 to 74.00) minutes; with the accumulation of surgical experience, the operation time was gradually decreased. 90% of the potential improvement was expected after 18 cases. In terms of operative time, intraoperative blood loss, hospital stay, and Harris hip score significant differences were found between two groups (p=0.009, p=0.000, p=0.030, and p=0.002, resp.). Partial weight bearing time, fracture union time, tip apex distance, and the number of blood transfusions and complications were similar between two groups (p>0.5). Conclusion. This study demonstrated that the learning curve of performing surgery with the InterTan intramedullary nail is acceptable and 90% of the expert’s proficiency level is achieved at around 18 cases. [ABSTRACT FROM AUTHOR]

The purpose of our study was to investigate the radiographic characteristics of atypical femoral shaft fractures (AFSFs) in females with a particular focus on femoral bow and cortical thickness. We performed a fracture location-, age-, gender-, and ethnicity-matched case-control study. Forty-two AFSFs in 29 patients and 22 typical osteoporotic femoral shaft fractures in 22 patients were enrolled in AFSF group and control group, respectively. With comparing demographics between two groups, radiographically measured femoral bow and cortical thicknesses of AFSF group were compared with control group. All AFSF patients were females with a mean age of 74.4 years (range, 58–85 years). All had a history of bisphosphonate (BP) use with a mean duration of 7.3 years (range 1–17 years). Femoral bow of AFSF group was significantly higher than control group on both anteroposterior (AP) and lateral radiographs after age correction. Mean femoral bow on an AP radiograph was 12.39°±5.38° in AFSF group and 3.97±3.62° in control group (P<0.0001). Mean femoral bow on the lateral radiograph was 15.71°±5.62° in AFSF group and 10.72°±4.61° in control group (after age correction P=0.003). And cortical thicknesses of AFSF group demonstrated marked disparity between tensile and compressive side of bowed femurs in this study. An adjusted lateral cortical thickness was 10.5±1.4 mm in AFSF group and 8.1±1.3 mm in control group (after age correction P<0.0001) while medial cortical thickness of AFSF group was not statistically different from control group. Correlation analysis showed that the lateral femoral bow on the AP radiograph was solely related to lateral CTI (R=0.378, P=0.002). AFSFs in female BP users were associated with an increased anterolateral femoral bow and a thicker lateral cortex of femurs. [ABSTRACT FROM AUTHOR]

Background. The aim of this study was to examine clinical and radiographic healing after rhBMP-2 application in children and adolescents presenting with nonunion of the femur and to investigate the safety of rhBMP-2 use in these cases. Materials and Methods. We reviewed the medical records of five patients with a mean age of 11 years (5.4 to 16.2) with nonunion of the femur who were treated with rhBMP-2 and internal fixation using a locking plate at a single institution. Particular attention was paid to identify all adverse events that may be due to rhBMP-2 use. Results. Union occurred in four of five patients at a mean of 12.1 months (7.9 to 18.9). The locking plates were removed after a mean of 16 months (11 to 23). One patient had nonunion due to deep infection. After a mean follow-up of 62.5 months (17 to 100), union was still evident in all four patients and they were fully weight-bearing without pain. Discussion. In this retrospective study, rhBMP-2 combined with a locking plate has been used successfully to treat children and adolescents with nonunion of the femur in four of five cases. One major complication was thought to be possibly related to its use. [ABSTRACT FROM AUTHOR]

The use of modular endoprostheses is a viable option to manage both tumor resection and severe bone loss due to nonneoplastic conditions such as fracture sequelae, failed osteoarticular grafts, arthroplasty revisions, and periprosthetic fractures. We sought to investigate both midterm complications and failures occurred in 87 patients who underwent a megaprosthetic reconstruction in a nonneoplastic setting. After a mean follow-up of 58 (1–167) months, overall failure-free survival was 91.5% at 1 year, 80% at 2 years, 71.6% at 5 years, and 69.1% at 5 and 10 years. There was no significant difference in the survival rate according to the diagnosis at the index procedure (p=0.921), nor to the reconstruction site (p=0.402). The use of megaprostheses in a postneoplastic setting did not affect survival rate in comparison with endoprosthetic reconstruction of pure nonneoplastic conditions (p=0.851). Perimegaprosthetic infection was the leading complication, occurring in 10 (11.5%) patients and implying a megaprosthetic revision in all but one case. Physicians should consider these results when discussing with patients desired outcomes of endoprosthetic reconstructions of a nonneoplastic disease. [ABSTRACT FROM AUTHOR]

This paper highlights the potential of integrating SHM concepts into an external fixator with the aim of using it to assess the healing of a fractured femur. A finite element analysis was first performed on the fixated femur to understand the response of the fixated femur in its fractured and healed state. The underlying mechanics will be used to establish a suitable monitoring strategy for assessment of healing. The results will be supported by a series of experiments using a fixated saw-bone femur, which has been cut to simulate fracture. The cut was filled with epoxy, and the curing of this epoxy was used to simulate healing of the fractured region. The findings lead to an actuation and sensing protocol able to determine the state of union of a fixated long bone. This methodology was tested further by using modelling clay to approximate the mass added by soft tissue surrounding the bone. These results illustrate that the integration of SHM and orthopaedic concepts can provide a quantitative measure that can be used in conjunction with existing techniques for the monitoring of the state of healing of the fracture. This represents a significant potential of reducing or eliminating the qualitative healing assessment. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The purpose of this study is to compare clinical characteristics and surgical outcome of atypical complete femoral fractures associated with bisphosphonates (BPs) use and those of fractures not associated with BPs use. Seventy-six consecutive patients (81 fractures) who had been operatively treated for a complete atypical femoral fracture were recruited. Of the 81 fractures, 73 occurred after BPs medication of at least 3 years (BP group) while 8 occurred without a history of BP medication (non-BP group). There were no differences in demographic data and fracture- and surgery-associated factors between the two groups. Of 76 patients (81 fractures), 54 (66.7%) fractures showed bony union within 6 months after the index surgery and 23 (28.4%) showed delayed union at a mean of 11.2 months (range, 8–18 months). The remaining 4 fractures were not healed, even 18 months after the index surgery. There was no difference in healing rate between the BP group and the non-BP group. There were strong correlations between the fracture height and the degree of bowing regardless of BPs medication. All fractures except 1 occurred at the diaphyseal region of the femur when not associated with BP medication. [ABSTRACT FROM AUTHOR]

The association between height and risk of hip fracture has been investigated in several studies, but the evidence is inconclusive. We therefore conducted this meta-analysis of prospective cohort studies to explore whether an association exists between height and risk of hip fracture. We searched PubMed and EMBASE, Web of Science, and the Cochrane Library for studies of height and risk of hip fracture up to February 16, 2016. The random-effects model was used to combine results from individual studies. Seven prospective cohort studies, with 7,478 incident hip fracture cases and 907,913 participants, were included for analysis. The pooled relative risk (RR) was 1.65 (95% confidence interval (CI): 1.26–2.16) comparing the highest with the lowest category of height. Result from dose-response analysis suggested a linear association between height and hip fracture risk (P-nonlinearity = 0.0378). The present evidence suggests that height is positively associated with increased risk of hip fracture. Further well-designed cohort studies are needed to confirm the present findings in other ethnicities. [ABSTRACT FROM AUTHOR]

An 81-year-old female was treated for a pertrochanteric multifragmentary fracture of the proximal femur with a third-generation Gamma nail. After 3 months she presented herself again with acute pain and inability to bear weight on the leg. Radiographs showed medial migration of the lag screw. She was treated with a total hip arthroplasty, after which she was successfully discharged. In this case report the possible causes of this late and unusual complication are discussed. [ABSTRACT FROM AUTHOR]

Fracture of the femoral head and the acetabulum with traumatic dislocation of the hip is a severe injury representing various types and unfavorable outcome. We showed a 45-year-old man with Pipkin type-IV fracture and coxa valga. An immediate closed reduction was achieved followed by open reduction and internal fixation via a posterior approach 6 days later. However, dislocation occurred three times without traumatic events after three weeks. CT demonstrated no displacement of posterior fragments or implant failure. Femoral intertrochanteric varus osteotomy was performed to gain concentric stability and successfully resolved recurrent dislocation. Another 45-year-old woman with Pipkin type-IV fracture and coxa valga also underwent closed reduction initially and then continued conservative treatment. After eight weeks, when she started gait training, progressive pain became symptomatic. Persistent hip pain at weight bearing was not improved in spite of arthroscopic synovectomy and osteochondroplasty. Two years after injury, femoral intertrochanteric varus osteotomy was indicated and her refractory pain was resolved gradually. We suggest that femoral varus osteotomy should be considered for superolateral subluxation associated fracture dislocation of the hip in Pipkin type-IV and coxa valga. [ABSTRACT FROM AUTHOR]

We present a case of a 53-year-old woman with subchondral insufficiency fracture (SIF) of the femoral head without history of severe osteoporosis or overexertion. Plain radiographs showed acetabular overcoverage with excessive lateralization of the acetabular rim. A diagnosis of SIF was made by typical MRI findings of SIF. The lesion occurred at the antipodes of the extended rim. Increased mechanical stress over the femoral head due to impingement against the excess bone was suspected as a cause of SIF. The distinct femoral head deformity is consistent with this hypothesis. This is the first report of SIF associated with acetabular overcoverage. [ABSTRACT FROM AUTHOR]

Background. Early radiological diagnosis and continual monitoring are of ultimate importance for timely treatment of delayed union, nonunion, and infection after bone fracture surgery. Although magnetic resonance imaging (MRI) could provide superior detailed images compared with X-ray and computed tomography (CT) without ionizing radiation, metal implants used for fracture fixation lead to abundant artifacts on MRI and thus prohibit accurate interpretation. The authors develop a novel intramedullary fixation model of rat femoral fracture using polyetheretherketone (PEEK) threaded rods and investigate its feasibility for in vivo MRI monitoring of the fracture healing process without artifact. Methods. Femoral fractures of 3 adult male Sprague-Dawley rats were fixed with intramedullary PEEK threaded rods. X-ray and MRI examinations were performed at day 7 postoperatively. Radiological images were analyzed for the existence of artifact interruption and postoperative changes in bone and peripheral soft tissue. Results. Postoperative plain film revealed no loss of reduction. MRI images illustrated the whole length of femur and peripheral tissue without artifact interruption, and the cortical bone, implanted PEEK rod, and soft tissue were clearly illustrated. Conclusion. This preliminary study introduced a novel rat model for in vivo MRI monitoring of the fracture healing process without metal artifact, by using intramedullary fixation of femur with PEEK threaded rod. [ABSTRACT FROM AUTHOR]

Background. Delayed union and nonunion are common complications in atypical femoral fractures (AFFs) despite having good fracture fixation. Demineralized bone matrix (DBM) is a successfully proven method for enhancing fracture healing of the long bone fracture and nonunion and should be used in AFFs. This study aimed to compare the outcome after subtrochanteric AFFs (ST-AFFs) fixation with and without DBM. Materials and Methods. A prospective study was conducted on 9 ST-AFFs patients using DBM (DBM group) during 2013-2014 and compared with a retrospective consecutive case series of ST-AFFs patients treated without DBM (2010–2012) (NDBM group, 9 patients). All patients were treated with the same standard guideline and followed up until fractures completely united. Postoperative outcomes were then compared. Results. DBM group showed a significant shorter healing time than NDBM group (28.1 ± 14.4 versus 57.9 ± 36.8 weeks, p=0.04). Delayed union was found in 4 patients (44%) in DBM group compared with 7 patients (78%) in NDBM group (p>0.05). No statistical difference of nonunion was demonstrated between both groups (DBM = 1 and NDBM = 2, p>0.05). Neither postoperative infection nor severe local tissue reaction was found. Conclusions. DBM is safe and effective for accelerating the fracture healing in ST-AFFx and possibly reduces nonunion after fracture fixation. Trial registration number is TCTR20151021001. [ABSTRACT FROM AUTHOR]

Arthroplasty implant fracture is a rare but critical complication that requires difficult revision surgery, often with poor results, patient disability, and significant cost. Several reports show component fracture either at the stem or at the neck interface after a relatively short postoperative course. We report such failure after 12 years, suggesting no safe period after which femoral implant fracture does not occur. [ABSTRACT FROM AUTHOR]

We report about a fracture of a modular, uncemented femoral revision stem (Zimmer, Revitan®) due to a not previously described intraoperative technical problem. During implantation, a small ring, part of the proximal part of the trial stem, was left on the distal part of the definite stem. Following this, the top screwcap of the proximal part of the definite stem could not be tightened properly. However, the stem was thought to be stable, and the situation left. Two and a half years later, the proximal part of the stem fractured and the situation became unstable. It is very useful to know about this ring and that it should always be removed, otherwise, there is possibility that it may be left on the definite distal part of the stem with the possibility of a later fracture. [ABSTRACT FROM AUTHOR]

Rothmund-Thomson syndrome is a rare autosomal recessive genodermatosis characterized by a poikilodermatous rash starting in infancy as well as various skeletal anomalies, juvenile cataracts, and predisposition to certain cancers. Although Rothmund-Thomson syndrome is associated with diminished bone mineral density in addition to multiple skeletal abnormalities, there are few reports of the association with stress fractures or pathologic fractures in low energy trauma or delayed healing of fractures. Presented is a case of a young adult male with Rothmund-Thomson syndrome presenting with multiple episodes of long bone fractures caused by low energy trauma with one of the fractures exhibiting significantly delayed healing. The patient was also found to have an asymptomatic stress fracture of the lower extremity, another finding of Rothmund-Thomson syndrome rarely reported in the literature. A thorough review of the literature and comprehensive presentation of Rothmund-Thomson syndrome is provided in conjunction with our case. [ABSTRACT FROM AUTHOR]

In surgical treatment for atypical femoral fractures (AFFs), reconstruction nail fixation is recommended for both complete and incomplete fractures. Although it has been reported that AFF is affected by many factors, The ASBMR Task Force 2013 Revised Case Definition of AFFs states that a curved femur is often seen in Asian patients. It is sometimes difficult to insert a nail into a femur in incomplete AFF patients with severely curved femurs. We report two incomplete bisphosphonate-related AFF patients with marked femoral curvatures treated by locking plates and teriparatide, showing early bone unions and favorable long-term outcomes. [ABSTRACT FROM AUTHOR]

MicroRNAs are small noncoding RNAs involved in numerous biological processes. Emerging pieces of evidence suggest that microRNAs play important roles in osteogenesis and skeletal homeostasis. Recent studies indicated the significant regulation function of mir-21 in osteogenesis in vitro, but little information is known about its veritable functions in vivo. In the present study, we aimed to investigate the effect of mir-21 intervention on osteogenic differentiation of rats bone marrow derived mesenchymal stem cells (rBMSCs) and repair capacity in rats closed femur fracture model with internal fixation. The results showed that the upregulation of mir-21 not only increased the expression of osteopontin and alkaline phosphatase in rBMSCs but also promoted mineralization in the condition of osteogenic induction. Furthermore, the bone healing properties were also improved in fracture healing model according to the results of micro-CT, mechanical test, and histological analysis. The current study confirms that the overexpression of mir-21 could promote osteogenesis and accelerate bone fracture healing, which may contribute to a new therapeutic way for fracture repair. [ABSTRACT FROM AUTHOR]

As the American healthcare system shifts towards bundled payments, readmissions will become a measure of healthcare quality. The purpose of this study was to characterize readmission trends and factors influencing readmission in patients with diaphyseal femur and tibia fractures. Through a retrospective chart review, all patients who presented to a level 1 trauma center from 2004 to 2006 were evaluated. By using current procedural terminology codes, 1,040 patients with diaphyseal tibia or femur fractures fixed by IMN were identified. 645 patients were included for analysis. 30-day, 60-day, and 90-day readmission rates were compared with fracture type, reason for readmission, and basic demographic information. The 60-day readmission rate for open tibia fractures (14.8%) was significantly higher than the 60-day readmission rate for closed tibia fractures (8.0%) (p=0.037). When comparing reasons for 60-day readmissions, 50% of closed fractures were readmitted due to infection, while the other 50% needed additional surgery. 91.7% of open fractures readmitted in 60 days were due to infection. In a bundled payment system, orthopedic trauma must gain insight into drivers of readmission to identify those at risk for readmission and design effective healthcare plans for these patients. [ABSTRACT FROM AUTHOR]

Objective. To evaluate differences in the short-term relationship between weather conditions and the incidence of hip fracture in people aged 65 and over among two regions of Spain. Methods. Hip fracture incidence was calculated for the years 2000–2008 for residents of Health Area 14 in Valencian Community (Mediterranean climate) and the “Mancha Centro” Health Area in Castilla-La Mancha (inland climate), Spain. The relationship between hip fracture incidence and weather was analyzed with a case-crossover design and explored in subgroups defined by sex, age, and fracture type. Results. In the inland area, a positive and significant tendency for hip fracture incidence was observed (annual increase: 1.5%) whereas in the Mediterranean area a seasonal increase of 9% was noted in autumn and winter with respect to spring. Weather conditions, especially wind, were significantly associated with hip fracture incidence: days with more frequent windy periods and/or a greater wind velocity were associated with an increase in hip fracture incidence of 51% in the Mediterranean area and 44% in the inland area. Conclusions. Hip fracture incidence exhibits seasonal changes that differ between the Mediterranean and inland areas. The short-term relationship with climate, although similar in both areas, may partly explain these seasonal changes. [ABSTRACT FROM AUTHOR]

We aimed to investigate differentially expressed genes (DEGs) in different stages after femoral fracture based on rat models, providing the basis for the treatment of sport-related fractures. Gene expression data GSE3298 was downloaded from Gene Expression Omnibus (GEO), including 16 chips. All femoral fracture samples were classified into earlier fracture stage and later fracture stage. Total 87 DEGs simultaneously occurred in two stages, of which 4 genes showed opposite expression tendency. Out of the 4 genes, Rest and Cst8 were hub nodes in protein-protein interaction (PPI) network. The GO (Gene Ontology) function enrichment analysis verified that nutrition supply related genes were enriched in the earlier stage and neuron growth related genes were enriched in the later stage. Calcium signaling pathway was the most significant pathway in earlier stage; in later stage, DEGs were enriched into 2 neurodevelopment-related pathways. Analysis of Pearson's correlation coefficient showed that a total of 3,300 genes were significantly associated with fracture time, none of which was overlapped with identified DEGs. This study suggested that Rest and Cst8 might act as potential indicators for fracture healing. Calciumsignaling pathway and neurodevelopment-related pathways might be deeply involved in bone healing after femoral fracture. [ABSTRACT FROM AUTHOR]

Objectives. To study the correlation between avascular necrosis and the demographics, time elapsed from fracture to surgery, quality of reduction, Garden classification, and the position of the screw following use of the dynamic hip screw (DHS) in the treatment of subcapital neck fractures. Methods. A prospective study of 96 patients with subcapital neck fractures was carried out in a faculty hospital. Patients underwent surgery with closed reduction and internal fixation with DHS. Results. There were 58% male and 42% female patients, with a mean age of 53 years (+/-14). In terms of Garden classification, 60% were Garden IV, 26% were Garden III, and 14% were Garden II. Nonunion was observed in three cases (3%) and was treated with valgus intertrochanteric osteotomy, in all cases leading to successful healing. Avascular necrosis was observed in 16% of patients. The positioning of the screw into the femoral head showed a significant correlation with necrosis. Conclusions. The incidence of necrosis in patients under the age of 50 years is twice as high as that in older patients. Displacement is a predictive factor regarding osteonecrosis and is associated with a high and anterior position of the screw in the femoral head. Level II of evidence. Study Type: therapeutic study. [ABSTRACT FROM AUTHOR]

Osteoporosis is associated with delayed and/or reduced fracture healing. As cervus and cucumis are the traditional Chinese treatments for rheumatoid arthritis, we investigated the effect of supplementation of these peptides (CCP) on bone fracture healing in ovariectomized (OVX) osteoporotic rats in vitro and in vivo. CCP enhanced osteoblast proliferation and increased alkaline phosphatase activity, matrix mineralization, and expression of runt-related transcription factor 2 (Runx2), bone morphogenetic protein 4 (BMP4), and osteopontin. In vivo, female Sprague-Dawley rats underwent ovariectomy and the right femora were fractured and fixed by intramedullary nailing 3 months later. Rats received intraperitoneal injections of either CCP (1.67mg/kg) or physiological saline every day for 30 days. Fracture healing and callus formation were evaluated by radiography, micro-CT, biomechanical testing, and histology. At 12 weeks after fracture, calluses in CCP-treated bones showed significantly higher torsional strength and greater stiffness than control-treated bones. Bones inCCP-treated rats reunified and were thoroughly remodeled,while two saline-treated rats showed no bone union and incomplete remodeling. Taken together, these results indicate that use of CCP after fracture in osteoporotic rats accelerates mineralization and osteogenesis and improves fracture healing. [ABSTRACT FROM AUTHOR]

Simultaneous bilateral femoral neck fractures are unusual lesions, generally associated with an underlying condition which causes impaired bone mineralization, triggered by an increased bone stress. We present a 24-year-old cerebral palsy patient, who was previously evaluated in another institution due to inability to walk, interpreted as abdominal pain. No alteration in blood analysis or abdominal X-rays was found. As no response to treatment was observed, a new abdominal X-ray was taken, which incidentally depicted bilateral medial femoral neck fracture. He was referred to our practice after a resection arthroplasty was offered in another institution. After admission, bilateral one-stage THA was performed. Several reports emphasize bone disease as a major precipitating factor, and there is an increased incidence of hip fractures in chronic epilepsy, renal osteodystrophy, and chronic steroid use. Femoral head resection has been proven to be effective in immobilized patients, whereas this was not a reasonable option in this patient who presented walking ability. Despite the treatment election, primary care physicians should be aware of and alert to the possibility of fractures in patients with neurological disorders and calcium metabolism alterations. Late diagnosis of orthopedic injuries in this type of patients may lead to permanent disability. [ABSTRACT FROM AUTHOR]

Arterial injury following impalement due to a trochanteric hip fracture-fragment per se has been documented rarely. We report a case of pseudoaneurysm of profunda femoris artery at the first perforator branch in a 48-year-old male, with trochanteric hip fracture following a fall during an epileptic episode. Persistent recalcitrant pain, globular swelling in the groin, unexplained drop in the haemoglobin level, and color doppler ultrasonography findings were salient features to the diagnosis. Additionally, we collected all reported cases of pseudoaneurysm associated with hip fractures. We reviewed the literature regarding the incidence, treatment, and prognosis for the same. Acute vascular injury was probably caused by the spikes of fractured lesser trochanter which was found to be displaced superomedially. All trochanteric fractures especially those with displaced lesser trochanter fragment should be closely watched for the possibility of vascular injury. Early diagnosis and treatment in a staged manner can prevent the catastrophic vascular event and hence the limb. [ABSTRACT FROM AUTHOR]

Osteopetrosis is a rare hereditary disease which is characterized by increased bone density. Bone resorption is insufficient or fails due to the osteoclast defect in osteopetrosis. Half of the patients are asymptomatic and diagnosed incidentally or based on the presence of fracture. Adult onset osteopetrosis usually presents with hip and proximal femoral fractures. Internal fixation can be performed; however, technical challenges may be experienced due to increased bone density. As in other fractures, nonunion or varus malunion of these fractures may occur. Although rare, osteopetrosis may complicate treatment of fractures in such patients. In this study, we aimed to present two new cases of ADO type II with an osteopetrotic femoral fracture along with the clinical and radiological findings in the light of a comprehensive literature review. Orthopaedics surgeons should be aware of intraoperative technical difficulties and possible postoperative complications during the follow-up period. Investigation would be beneficial for the diagnosis of osteopetrosis such the patient with fractures who has minor trauma history and increased bone density in radiography. [ABSTRACT FROM AUTHOR]

Acute compartment syndrome is a surgical emergency and its diagnosis is more difficult in obtunded or insensate patients. We present the case of a 34-year-old woman who sustained a Gustilo-Anderson grade III open midshaft femur fracture with an isolated femoral vein injury treated with direct repair. She developed lower leg compartment syndrome at 48 hours postoperatively, necessitating fasciotomies. She was subsequently found to have a DVT in her femoral vein at the level of the repair and was started on therapeutic anticoagulation. This case highlights the importance of recognition of isolated venous injuries in a trauma setting as a risk factor for developing compartment syndrome. [ABSTRACT FROM AUTHOR]

Intramedullary nailing has become the treatment of choice for diaphyseal femur fractures. Malrotation is a well-recognized complication of femoral nailing. Various techniques including the cortical step sign (CSS) have been described to minimize iatrogenic rotational deformity during femoral nailing. We present a case in which the use of the CSS resulted in a clinically significant malrotation requiring revision. [ABSTRACT FROM AUTHOR]

Background. Intertrochanteric fractures of the proximal femur are one of the most common fractures encountered, and dynamic hip screw with a side plate is the standard treatment. We compared a minimally invasive surgical technique with the conventional surgical technique used in the fixation of intertrochanteric fractures with the dynamic hip screw (DHS) device. Methods. Thirty patients with such fractures were treated with the conventional open technique and 30 with a new minimally invasive technique. Patients in both groups were followed up for 1 year. Results. There was less blood loss, minimal soft tissue destruction, shorter hospital stay, and early mobilization with the minimally invasive technique. Conclusion.The present study finds minimally invasive technique superior to conventional (open) DHS. [ABSTRACT FROM AUTHOR]