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Surgical navigation systems have demonstrated improvements in alignment accuracy in a number of arthroplasty procedures, but they have not yet been widely adopted for use in total shoulder arthroplasty (TSA). We believe this is due in part to the obtrusiveness of conventional optical tracking systems, as well as the need for additional intraoperative steps such as calibration and registration. The purpose of this study is to evaluate the feasibility of adapting a less-intrusive dental navigation system for use in TSA. We developed a proof-of-concept system based on validated laser-engraved surgical tools recently introduced for use in dental surgery that are calibrated once when manufactured and not recalibrated at time of use. The design also features a notably smaller bone-mounted tracker that can be tracked from a wide range of viewing angles. To assess our system’s performance, we modified the dental surgical software to support guidance of a TSA procedure. We then conducted a user study in which three participants with varying surgical experience used the system to drill 30 holes in a glenoid model. Using a coordinate measuring machine, we determined the resulting drilled trajectory and compared this to the pre-planned trajectory. Since we used a model glenoid rather than anatomical specimens, we report on targeting precision rather than overall procedure precision or accuracy. We found targeting precision

Rotator cuff repair is a commonly performed shoulder procedure. In the past 20 years, there has been a shift from mini-open towards arthroscopic repair, and many units exclusively use arthroscopic techniques for rotator cuff surgery. The aim of this study was to find out whether withholding antibiotics had any effect on the infection rate in patients undergoing arthroscopic rotator cuff repair. A retrospective analysis of 336 consecutive patients with an arthroscopic rotator cuff repair (RCR) and a minimum 2-year follow-up was performed. The control group received prophylactic antibiotics (controls) and the cases of interest did not receive perioperative antibiotics. A power analysis was performed according to literature regarding infection proportions. The primary outcome was an infection (superficial or deep) in the operated shoulder. There were 336 patients who underwent a RCR. Two-hundred-and-twelve in the control group and 124 in the non-antibiotic group. Average ages were 57.3 ± 12.5 and 56.8 ± 13.2 years in each group, respectively. The follow-up times ranged from 24 to 76 months. Equipment used and surgical techniques were identical, only operating times were statistically different between the groups (control 77.2 ± 41.3 min versus no antibiotic cases 52.9 ± 16.7 min) (p = 0.000009). There was no recorded infection in either group. Infection following arthroscopic surgery is uncommon. Small incisions, constant lavage with saline, minimal hardware insertion and short operating times all combine to minimise the risks. Current results point towards no detriment in withholding prophylactic antibiotics in low-risk patients undergoing routine rotator cuff repair surgery. Therefore, judicious use of prophylactic antibiotics in patients undergoing this procedure is advocated to prevent potential harm to those it is administered to. Level III.

BACKGROUND Currently, non-surgical treatments for glenohumeral osteoarthritis (GH-OA) mainly aim to reduce pain. Autologous conditioned serum (ACS), Orthokine, an interleukin-1 inhibitor from the patient's own blood has an anti-inflammatory effect. The objective was to determine whether intra-articular injections of this ACS improved symptoms in patients with GH-OA and delayed the need for a shoulder replacement. METHODS A total of 36 consecutive patients, 40 shoulders, with OA received up to 6-weekly intra-articular injections of ACS were included. Imaging of GH-OA, range of motion, visual analogue scale (VAS) pain, Shoulder Pain And Disability Index (SPADI), American Shoulder and Elbow Surgeons and Constant scores were assessed pre-injection and post treatment at 3 months. At a minimum of 2 years, VAS and SPADI scores and whether anyone had progressed to a shoulder replacement were recorded. RESULTS Outcomes 3 months post-ACS injections demonstrated on average statistically significant improvement (P

The presence of an intra-articular air bubble adjacent to the rotator cuff at the time of diagnostic shoulder arthroscopy will confirm an intact rotator cuff and is helpful in ambiguous cases. After the introduction of the arthroscope, air is pulled owing to negative air pressure in the joint cavity. Fluid inflow is then started after the inflow has been properly flushed of all air. This creates an intra-articular air bubble, which can be found at the top of the capsular-supraspinatus attachment site in cases with an intact rotator cuff. Secondary subacromial positioning of the arthroscope is used to confirm the intact rotator cuff from the bursal side.

Background COVID-19 was declared a global emergency in the first quarter of 2020. It is has resulted in and continues in over a million deaths worldwide and halted medical systems and particularly elective surgeries worldwide. The aim of this study was to identify the effect of the initial COVID-19 pandemic months on orthopaedic surgeons in British Columbia. Methods The study surveyed (June until August 2020) 187 orthopaedic surgeons in British Columbia affiliated with the University of British Columbia or the British Columbia Orthopaedic Association using an online survey to help identify the impact of COVID-19 on patient care, work and personal life. Results Eighty-seven out of 187 (46.5%) orthopaedic surgeons participated in the online survey. All types of surgeries were completely cancelled for 23 respondents. Elective surgeries were cancelled for most respondents (in-hospital n = 38 and/or ambulatory n = 32). Trauma cases were reduced according to 35 respondents. Outpatient clinics were stopped initially and transferred in virtual clinics (telemedicine). Approximately 40% of respondents were afraid of infecting others (patients, family) and 25% admitted to drink more heavily. Ninety percent of respondents reported an income loss of > 15% (range 0–100%). Conclusion Orthopaedic surgeons and their patients have been significantly affected by the COVID-19 pandemic. Cancellation of surgeries has created an increased backlog of 32,400 orthopaedic surgeries in British Columbia. However, the COVID-19 pandemic has expedited the implementation of telemedicine, which will be a long-lasting benefit in providing healthcare.

Hypothalamic-pituitary disconnection (HPD) leads to low bone turnover followed by bone loss and reduced biomechanical properties in sheep. To investigate the role of peripheral hormones in this centrally induced systemic bone loss model, we planned a hormone replacement experiment. Therefore, estrogen (OHE), thyroxin (OHT) or a combination of both (OHTE) was substituted in ovariectomized HPD sheep, as both hormones are decreased in HPD sheep and are known to have a significant but yet not fully understood impact on bone metabolism. Bone turnover and structural parameters were analyzed in comparison to different control groups - untreated sheep (C), ovariectomized (O) and ovariectomized+HPD sheep (OH). We performed histomorphometric and HR-pQCT analyses nine months after the HPD procedure, as well as biomechanical testing of all ewes studied. In HPD sheep (OH) the low bone turnover led to a significant bone loss. Treatment with thyroxin alone (OHT) mainly increased bone resorption, leading to a further reduction in bone volume. In contrast, the treatment with estrogen alone (OHE) and the combined treatment with estrogen and thyroxin (OHTE) prevented HPD-induced bone loss completely. In conclusion, peripheral hormone substitution was able to prevent HPD-induced low-turnover osteoporosis in sheep. But only the treatment with estrogen alone or in combination with thyroxin was able to completely preserve bone mass and structure. These findings demonstrate the importance of peripheral hormones for a balanced bone remodeling and a physiological bone turnover.

BACKGROUND Age- and sex-specific 3D bone structure patterns in human radii and tibiae were investigated with respect to individuals' osteodensitometric status to unravel associations with site-specific fracture occurrences and underlying loading patterns. METHODS A sample of 385 patients (121 men and 264 women, age range: 23-91 years) were investigated. The patients were classified according to dual X-ray absorptiometry T-scores in three groups: control (n = 60), osteopenia (n = 160), and osteoporosis (n = 165). Bone architecture and geometry were assessed by high-resolution peripheral quantitative computed tomography of the cortical and trabecular compartments in distal radii and tibiae. RESULTS We found site-dependent age- and sex-related trends regarding bone architecture and geometry. Females displayed more pronounced age-related changes than males. Specifically, female radii showed both cortical and trabecular structural deterioration with aging, whereas the tibiae demonstrated exclusively cortical deterioration. The mean cortical perimeter revealed a significant age-related increase for both sexes even after adjusting for body height and weight, which suggests that periosteal expansion can be observed in both the tibia and also in the radius. Osteopenia and osteoporosis cases did not reveal higher cortical perimeters in comparison to controls. CONCLUSIONS The tomographic assessment of bone structure further clarifies the architectural basis for increased bone fragility at distal radii and tibiae with advanced age leading to fracture predilection in females. Our findings may represent a morphological link to epidemiological data on age-dependent fracture incidences. Our data support the presence of periosteal apposition at both skeletal sites despite different loading magnitudes, and challenges the view on periosteal expansion just as a compensatory mechanism to counterbalance bone loss.

Background Degenerative adult de novo (DAD) scoliosis appears characteristically in the sixth or seventh decade with symptoms of severe back pain and radiculopathy or spinal claudication. The aim of this study was to enhance the knowledge of perioperative complications and detect possible risk factors in this selective DAD scoliosis surgery. Methods This retrospective study included only patients with DAD scoliosis undergone correction spondylodesis with previous failure of conservative treatment. Excluded were patients with other types of scoliosis and previous fusion surgeries. Patient epidemiological data, medical comorbidities and treatments were included. Intraoperative data and perioperative complications were documented. Analyses regarding early, late and no complications were undertaken. Results A total of 92 patients with a mean age of 67.29 ± 7.93 years and clinical follow-up visits of minimum 12 months were included. On average, 5.26 ± 2.24 segments were fused. Early complications (e.g. wound healing defects, paresis, screw loosing) occurred in 23 patients and often required a re-operation. Cardiac arrhythmias, pacemaker and coumarin derivative therapies were associated with increased perioperative complications. The transforaminal lumbar interbody fusion technique was associated with early complications. Adjacent segment failure occurred in 36% and was the major late complication. Twenty patients did not have any complications in the minimum follow-up. Conclusions This study analysed a selective DAD scoliosis collective and its’ surgical treatment outcomes. It identified numerous perioperative complications (adjacent segment failure, postoperative paresis and epidural hematoma) and multiple possible predisposing risk factors (e.g. operative techniques and anti-coagulation therapies). This here gained information raises awareness in preoperative patient selection and preparation. Further studies in DAD scoliosis and a risk-adjusted patient selection/preparation are needed to improve treatment quality and outcomes.

Alveolar bone structures are mostly investigated in small animal models. The majority of these studies examined local influences on the alveolar bone, but only a few examined systemic influencing factors. The hypothalamic-pituitary axis is known to be essential for a vital bone balance. The aim of this study was to analyse the effects that selective hormone treatments have on alveolar bone structure and quality in a sheep model for alveolar bone loss, induced by hypothalamic-pituitary disconnection (HPD). Thirty sheep were randomly selected into six groups of five each: control (C), ovariectomy—OVX (O), O + HPD (OH), OH with oestrogen treatment (OHE), OH with thyroxine (T4) treatment (OHT), and OH with a combined treatment of oestrogen and thyroxine (OHTE). After OVX and HPD procedures and an additional 9-month observation/treatment period, structural bone analyses of the mandible were performed by contact radiography, micro-CT, and static histomorphometry. The HPD procedure caused structural alveolar bone parameters to decrease significantly compared to controls (C). Treatment with oestrogen (OHE) was protective and bone structure was maintained at baseline levels. Thyroxine treatment (OHT) promoted significant bone loss, but the combined treatment (OHTE) improved bone structure and volume parameters even above baseline levels. Alveolar bone homeostasis significantly underlies systemic regulatory systems. Centrally induced (HPD) bone loss can be prevented by combined peripheral treatment with oestrogen and thyroxine. These results demonstrate the significance of a balanced hormonal regulatory system for steady bone remodelling and maintenance of healthy alveolar bone.

Summary Chronic environmental fluoride exposure under calcium stress causes fragility fractures due to osteoporosis and bone quality deterioration, at least in sheep. Proof of skeletal fluorosis, presenting without increased bone density, calls for a review of fracture incidence in areas with fluoridated groundwater, including an analysis of patients with low bone mass. Introduction Understanding the skeletal effects of environmental fluoride exposure especially under calcium stress remains an unmet need of critical importance. Therefore, we studied the skeletal phenotype of sheep chronically exposed to highly fluoridated water in the Kalahari Desert, where livestock is known to present with fragility fractures. Methods Dorper ewes from two flocks in Namibia were studied. Chemical analyses of water, blood and urine were executed for both cohorts. Skeletal phenotyping comprised micro-computer tomography (μCT), histological, histomorphometric, biomechanical, quantitative backscattered electron imaging (qBEI) and energy-dispersive X-ray (EDX) analysis. Analysis was performed in direct comparison with undecalcified human iliac crest bone biopsies of patients with fluoride-induced osteopathy. Results The fluoride content of water, blood and urine was significantly elevated in the Kalahari group compared to the control. Surprisingly, a significant decrease in both cortical and trabecular bones was found in sheep chronically exposed to fluoride. Furthermore, osteoid parameters and the degree and heterogeneity of mineralization were increased. The latter findings are reminiscent of those found in osteoporotic patients with treatment-induced fluorosis. Mechanical testing revealed a significant decrease in the bending strength, concurrent with the clinical observation of fragility fractures in sheep within an area of environmental fluoride exposure. Conclusions Our data suggest that fluoride exposure with concomitant calcium deficit (i) may aggravate bone loss via reductions in mineralized trabecular and cortical bone mass and (ii) can cause fragility fractures and (iii) that the prevalence of skeletal fluorosis especially due to groundwater exposure should be reviewed in many areas of the world as low bone mass alone does not exclude fluorosis.

Health risks due to chronic exposure to highly fluoridated groundwater could be underestimated because fluoride might not only influence the teeth in an aesthetic manner but also seems to led to dentoalveolar structure changes. Therefore, we studied the tooth and alveolar bone structures of Dorper sheep chronically exposed to very highly fluoridated and low calcium groundwater in the Kalahari Desert in comparison to controls consuming groundwater with low fluoride and normal calcium levels within the World Health Organization (WHO) recommended range. Two flocks of Dorper ewes in Namibia were studied. Chemical analyses of water, blood and urine were performed. Mineralized tissue investigations included radiography, HR-pQCT analyses, histomorphometry, energy-dispersive X-ray spectroscopy and X-ray diffraction-analyses. Fluoride levels were significantly elevated in water, blood and urine samples in the Kalahari group compared to the low fluoride control samples. In addition to high fluoride, low calcium levels were detected in the Kalahari water. Tooth height and mandibular bone quality were significantly decreased in sheep, exposed to very high levels of fluoride and low levels of calcium in drinking water. Particularly, bone volume and cortical thickness of the mandibular bone were significantly reduced in these sheep. The current study suggests that chronic environmental fluoride exposure with levels above the recommended limits in combination with low calcium uptake can cause significant attrition of teeth and a significant impaired mandibular bone quality. In the presence of high fluoride and low calcium-associated dental changes, deterioration of the mandibular bone and a potential alveolar bone loss needs to be considered regardless whether other signs of systemic skeletal fluorosis are observed or not.

Introduction The goal of this retrospective study was to evaluate the safety and efficacy of ibandronate for bone marrow oedema (BMO) syndrome and stress fracture cases, and to demonstrate an additional field of therapeutic importance—the high-performance athlete. Patients and methods This retrospective study included twenty-five high-performance athletes. Sixty per cent of the athletes were European soccer players and 40.0% other high-class international athletes (3 women and 22 men with an average age of 25.0 ± 4.2), with BMO of the lower trunk or extremity diagnosed by magnetic resonance imaging (MRI). The treatment regimen consisted of high-dose vitamin D supplementation and intravenous ibandronate therapy. Results The time between the onset of pain and proper diagnosis of BMO was 106.3 ± 104.1 days. Excellent pain reduction (pain at rest and under strain) and improved mobility was reported within the first two weeks after the first ibandronate administration by sixteen patients (64%). The time from first treatment until return to competition (RTC) was on average 102.6 ± 65.2 days in total. If the time from onset of pain until diagnosis was within 40 days, the RTC was significantly reduced (p ≤ 0.05) to almost 50% (63.8 ± 48.1 days) when compared to the athletes with later diagnosis (124.4 ± 63.2 days). Conclusions The here-applied therapy regimen of intravenous BPs application and vitamin D supplementation in BMO syndrome has a beneficial effect for high-performance athletes. An early diagnosis and rapid treatment start can reduce the RTC significantly. An optimal bone metabolism with sufficient daily calcium and vitamin D intake is crucial and should not only be strived for the professional but also for the recreational athlete.

Background The aim of this large collective and meticulous study of primary bone tumours and tumourous lesions of the hand was to enhance the knowledge about findings of traumatological radiographs and improve differential diagnosis. Methods This retrospective study reviewed data collected from 1976 until 2006 in our Bone Tumour Registry. The following data was documented: age, sex, radiological investigations, tumour location, histopathological features including type and dignity of the tumour, and diagnosis. Results The retrospective analysis yielded 631 patients with a mean age of 35.9 ± 19.2 years. The majority of primary hand tumours were found in the phalanges (69.7%) followed by 24.7% in metacarpals and 5.6% in the carpals. Only 10.6% of all cases were malignant. The major lesion type was cartilage derived at 69.1%, followed by bone cysts 11.3% and osteogenic tumours 8.7%. The dominant tissue type found in phalanges and metacarpals was of cartilage origin. Osteogenic tumours were predominant in carpal bones. Enchondroma was the most commonly detected tumour in the hand (47.1%). Conclusions All primary skeletal tumours can be found in the hand and are most often of cartilage origin followed by bone cysts and osteogenic tumours. This study furthermore raises awareness about uncommon or rare tumours and helps clinicians to establish proper differential diagnosis, as the majority of detected tumours of the hand are asymptomatic and accidental findings on radiographs.