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Synthetic bone models such as polyurethane (PU) foam are a well-established substitute to cadaveric bone for screw pull-out testing; however, little attention has been given to the effect of PU foam anisotropy on orthopaedic implant testing. Compressive and screw pull-out performance in three PU foam densities; 0.16 g/cm3 (PCF 10), 0.32 g/cm3 (PCF 20) and 0.64 g/cm3 (PCF 40) were performed in each of the X, Y or Z orientations. The maximum compressive force, stiffness in the linear region, maximum stress and modulus were determined for all compression tests. Pedicle screws were inserted and pulled out axially to determine maximum pull-out force, energy to failure and stiffness. One-way ANOVA and post hoc tests were used to compare outcome variables between PU foam densities and orientations, respectively. Compression tests demonstrated the maximum force was significantly different between all orientations for PCF 20 (X, Y and Z) while stiffness and maximum stress were different between X versus Y and X versus Z. Maximum pull-out force was significantly different between all orientations for PCF 10 foam. No significant differences were noted for other foam densities. There is potential for screw pull-out testing results to be significantly affected by orientation in lower density PU foams. It is recommended that a single, known orientation of the PU foam block be used for experimental testing. [ABSTRACT FROM AUTHOR]

Background Lateral compression type-1 pelvic fractures are a common fragility fracture in older adults. Patients who do not mobilise due to ongoing pain are at greater risk of immobility-related complications. Standard treatment in the United Kingdom is provision of pain relief and early mobilisation, unlike fragility hip fractures, which are usually treated surgically based on evidence that early surgery is associated with better outcomes. Currently there is no evidence on whether patients with lateral compression type-1 fragility fractures would have a better recovery with surgery than non-surgical management. Objectives To assess the clinical and cost effectiveness of surgical fixation with internal fixation device compared to non-surgical management of lateral compression type-1 fragility fractures in older adults. Design Pragmatic, randomised controlled superiority trial, with 12-month internal pilot; target sample size was 600 participants. Participants were randomised between surgical and non-surgical management (1 : 1 allocation ratio). An economic evaluation was planned. Setting UK Major Trauma Centres. Participants Patients aged 60 years or older with a lateral compression type-1 pelvic fracture, arising from a low-energy fall and unable to mobilise independently to a distance of 3 m and back due to pelvic pain 72 hours after injury. Interventions Internal fixation device surgical fixation and non-surgical management. Participants, surgeons and outcome assessors were not blinded to treatment allocation. Main outcome measures Primary outcome – average patient health-related quality of life, over 6 months, assessed by the EuroQol-5 Dimensions, five-level version utility score. Secondary outcomes (over the 6 months following injury) – self-rated health, physical function, mental health, pain, delirium, displacement of pelvis, mortality, complications and adverse events, and resource use data for the economic evaluation. Results The trial closed early, at the end of the internal pilot, due to low recruitment. The internal pilot was undertaken in two separate phases because of a pause in recruitment due to the coronavirus disease 2019 pandemic. The planned statistical and health economic analyses were not conducted. Outcome data were summarised descriptively. Eleven sites opened for recruitment for a combined total of 92 months. Three-hundred and sixteen patients were assessed for eligibility, of whom 43 were eligible (13.6%). The main reason for ineligibility was that the patient was able to mobilise independently to 3 m and back (n = 161). Of the 43 eligible participants, 36 (83.7%) were approached for consent, of whom 11 (30.6%) provided consent. The most common reason for eligible patients not consenting to take part was that they were unwilling to be randomised to a treatment (n = 10). There were 11 participants, 5 randomised to surgical management with internal fixation device and 6 to non-surgical management. The average age of participants was 83.0 years (interquartile range 76.0, 89.0) and the EuroQol-5 Dimensions, five-level version utility score at 6 months post randomisation (n = 8) was 0.32 (standard deviation 0.37). A limitation of the trial was that study objectives were not addressed due to poor recruitment. Conclusions It was not feasible to recruit to this trial in the current context. Further research to understand the treatment and recovery pathways of this group of patients, along with their outcomes, would be needed prior to undertaking a future trial. Future work Exploration of equipoise across different healthcare professional groups. Investigate longer-term patient outcomes. Trial registration This trial is registered as ISRCTN16478561. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/57) and is published in full in Health Technology Assessment; Vol. 28, No. 15. See the NIHR Funding and Awards website for further award information. Plain language summary When older adults with weak bones fall onto their side, they can fracture the pelvis in a certain way known as a ‘lateral compression type-1 fracture’; this summary will use ‘pelvic fracture’. Pelvic fractures can heal without surgery; patients are offered pain relief and encouraged to move as much as they can after the injury. Pelvic fractures can be painful, and some people are not able to get up and walk for weeks. These fractures can cause health problems such as chest infections, urinary tract infections, pressure sores and blood clots. To avoid these problems, we are trying to find treatments to help people recover sooner. Pelvic surgeons think patients may benefit from surgery with an internal fixation device (a bar and screws) to stabilise the pelvis; however, there can be risks and complications with any surgery. This study aimed to find out which treatment is better for patients and better value for money for the National Health Service. This required 600 people aged over 60, in hospital with a pelvic fracture and having difficulty walking to take part. Three hundred would receive surgery and 300 would receive non-surgical treatment. Over 6 months, participants would complete questionnaires, a walking assessment and have X-rays to check healing. The trial had a 12-month run-in period to see if enough people would take part. The trial closed early as we were unable to recruit sufficient people into the study. Fewer older patients with pelvic fractures were identified than expected, 51% were able to walk after a few days and therefore were not eligible to be included in the study. Of the patients, 13.6% were eligible and 30.6% of those consented to take part. Restrictions on visitors during the coronavirus disease 2019 pandemic made it difficult to discuss the study with patients’ families and fewer patients were admitted to hospital where the study was taking place. The research question could not be answered by this study at the present time. Scientific summary Background Lateral compression type-1 (LC-1) pelvic fractures are a common fragility fracture in older adults. Older patients who do not get back walking following an LC-1 fracture due to ongoing pain are at greater risk of immobility-related complications. In the UK, standard treatment for LC-1 fragility fracture is to ‘mobilise as pain allows’, involving prescribing pain relief, getting patients up within a few days of injury with physiotherapy input and encouraging them to mobilise with an assistive device until the fracture heals. This is unlike fragility hip fractures (fractures involving the upper end of the femur) where there is evidence that early surgery (within 1–2 days) is associated with reduced risk of death and pressure sores and these fractures are usually treated surgically. Despite LC-1 fractures being similarly disabling for some patients in terms of pain and immobility and occurring in the same patient group as hip fractures, to date, it has not been shown whether elderly patients with LC-1 fractures would have a better recovery with surgery than non-surgical management. Objectives To assess the clinical and cost effectiveness of surgical fixation with internal fixation device (INFIX) compared to non-surgical management of LC-1 fragility fractures in older adults (L1FE trial): undertake a 12-month internal pilot to obtain robust estimates of recruitment and confirm trial feasibility undertake a parallel group multicentre randomised controlled trial (RCT) to assess the effectiveness of surgical fixation with INFIX versus non-surgical management of LC-1 fragility fractures in older adults undertake an economic evaluation to compare the cost effectiveness of surgical fixation compared to non-surgical management, to determine the most efficient provision of future care and to describe the resource impact on the NHS for the two treatment options undertake a long-term review of patient well-being [EuroQol-5 Dimensions, five-level version (EQ-5D-5L) and mortality] 12 months after entering the trial. Design Pragmatic, randomised controlled superiority trial, with 12-month internal pilot to assess recruitment assumptions, and an economic evaluation. Participants were randomised between INFIX surgical fixation and non-surgical management of LC-1 pelvic fracture with a 1 : 1 allocation ratio. The target sample size was 600 participants. For the internal pilot the target was to set up a minimum of 19 recruitment sites and randomise 148 participants in order to meet the target sample size in the main trial. To progress to the main trial, an average recruitment rate of one participant per centre per month was required. Setting and participants Participants were recruited from Major Trauma Centres (MTCs) in the UK. Adults aged 60 years or older with an LC-1 pelvic fracture, arising from a low-energy fall from standing height or less, and unable to mobilise independently to a distance of around 3 m and back due to pelvic pain 72 hours after injury were eligible for inclusion. Interventions Internal fixation device surgical fixation and non-surgical management (both groups received pain relief and were seen by a physiotherapy team who worked to mobilise the patients as pain allowed). Internal fixation device surgery uses an INFIX to stabilise the pelvis. INFIX devices have screws that are secured into the pelvic bone, and these are connected by a metal bar across the front of the patient. The INFIX device sits entirely under the patient’s skin. Main outcome measures Primary outcome – average patient health-related quality of life, over 6 months, assessed by the patient-reported outcome measure, EQ-5D-5L utility score. Collected at baseline, 2 weeks, 6 weeks, 12 weeks and 6 months post-randomisation time points. Secondary outcomes – health-related quality of life using the EQ-5D-5L visual analogue scale (VAS); physical function using the eight-item Patient-Reported Outcome Measures Information System (PROMIS) lower extremity function (LEF) (mobility) – Short Form and Timed Up and Go (TUG) test; mental health using the PROMIS Scale v1.2 – Global Health Mental 2a subscale; pelvic pain using a VAS; delirium using the Abbreviated Mental Test Score (AMTS) and 4AT Rapid Assessment Test for Delirium; displacement of the pelvis based on a radiological assessment at the 12-week visit; mortality; complications and adverse events including lateral cutaneous nerve injury which was an adverse event of special interest (AESI); resource use; long-term review of patient well-being using the EQ-5D-5L and mortality at 12 months (optional follow-up for those recruited early in the trial). Information on resource use such as length of hospital stay, medication use, surgery details and details of rehabilitation therapy received was collected throughout the follow-up period to assess the impact on the NHS as part of the economic evaluation. Sample size Sample size was calculated based on the primary outcome, EQ-5D-5L. To be conservative, we took the lowest published estimate of the minimal clinically important differences (MCID) (0.074) with an estimated standard deviation (SD) of 0.25 (estimated from the 0.30 reported for the 3L version and adjusted down to account for the 5L version’s greater sensitivity). Based on these assumptions we would have needed to analyse 480 participants (240 per group) and, after accounting for loss to follow-up of 20%, we would have needed to recruit and randomise 600 participants for a study with 90% power (2p = 0.05). Randomisation Intervention allocation was assigned using an online data management system developed for the L1FE study by the software team at York Trials Unit (YTU). There was independent and concealed random allocation (1 : 1 ratio), using computer-generated random permuted blocks of random sizes (4, 6 and 8), stratified by centre, following confirmation of eligibility and written consent. Analysis The originally planned primary analysis was a mixed-effects linear regression model, with EQ-5D-5L scores at 2, 6 and 12 weeks and 6 months follow-up as the dependent variable, adjusting for baseline EQ-5D-5L, randomised group and other pertinent baseline characteristics as fixed effects. The plan was to control for potential clustering at hospital site level by including it in the model as a random effect and to account for the correlation of scores within patients over time by means of an appropriate covariance structure. Due to the small sample size and stopping at the end of the internal pilot, a descriptive analysis was undertaken with no formal hypothesis testing. All reported summary statistics are given at both a treatment group and overall level. The planned economic analysis was to examine the overall difference in EQ-5D-5L index scores between the two groups using regression methods, consistent with the model selected in the statistical analysis. The EQ-5D-5L health states were to be valued in accordance with National Institute for Health and Care Excellence (NICE) guidance. Quality-adjusted life-years (QALYs) were to be calculated by plotting the utility scores at each of the four time points and estimating the area under the curve and regression methods used to express the incremental cost per QALYs gained. Results were to be presented using incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves (CEACs). Results The trial closed early, at the end of the internal pilot due to low recruitment. The internal pilot took place in two separate phases (August 2019 to March 2020 and March 2021 to September 2021) because of a 1-year recruitment pause due to the coronavirus disease 2019 (COVID-19) pandemic. Site set-up Eleven sites in England and Wales were opened during the first phase of the internal pilot. Ten of these re-opened following the study recruitment pause. A further 10 sites, including 3 in Scotland, were interested in participating and were in various stages of set-up prior to study closure. The 11 sites were open for a combined total of 92 months. Patient screening During the internal pilot, 316 patients were assessed for eligibility, of whom 43 were eligible (13.6%). The main reasons for ineligibility were: patient able to mobilise independently 3 m and back (n = 161), concomitant injury that impedes mobilisation (n = 57), surgery contraindicated (n = 40), patient did not have a low-energy LC-1 pelvic fracture (n = 38), unable to schedule surgery within 10 days of injury (n = 34), patient was under 60 years of age (n = 23) and/or the patient was non-ambulatory or required assistance prior to injury (n = 22). Recruitment, withdrawals and follow-up Of the 43 eligible participants, 36 (83.7%) were approached for consent, of whom 11 (30.6%) provided consent. Eleven (100%) of the consenting patients were randomised into the study. The most common reason for eligible patients not consenting to take part was that they were unwilling to be randomised to a treatment (n = 10). The average recruitment rate per site per month was 0.175, well below the target rate of one patient per site per month. Eleven patients were randomised, five to INFIX surgical fixation and six to non-surgical management. Three participants in the non-surgical management group were withdrawn from the study. One participant died, one participant lost capacity and their family member no longer wanted them to take part in the study and one participant had sight problems and considered themselves too frail to continue. Of the five participants randomised to surgical fixation, all received surgery and no one in the non-surgical management group received surgery. All participants in the surgical fixation group completed the 6-month questionnaires and the remaining participants in the non-surgical management group provided data at 6 months (3/6). The average age of participants was 83.0 years (interquartile range 76.0–89.0) and the EQ-5D-5L utility score at 6 months post randomisation (n = 8) was 0.32 (SD 0.37). Barriers to recruitment and actions taken There were multiple barriers to recruitment, which, combined with the impact of COVID-19 on the NHS, resulted in a very low recruitment rate. These included: Fewer patients than anticipated were screened and screening activity was variable across sites. Patients had multiple entry points to hospital for treatment with onward admissions to several possible departments (Geriatric ward, Orthopaedic ward, Medical ward or an Admissions unit). This made screening resource-intensive for the research teams at sites. This became particularly challenging following the recruitment pause, as recruiting staff at sites were not all back to full capacity. A substantial proportion of patients were able to mobilise by 72 hours post injury and therefore did not meet the eligibility criteria for the trial. There was also variation across sites in how the assessment of mobility was undertaken and the extent of assistance provided to patients. The COVID-19 pandemic led to a concerted focus on avoidance of hospital admissions where possible, thereby minimising hospital stays. Because the pre-trial standard care for LC-1 pelvic fragility fractures was non-surgical management, there were challenges in the delivery of the L1FE trial. Patients were increasingly being discharged before the 72-hour assessment to nursing homes, residences with care packages or rehabilitation hospitals and could not be screened for the trial. There was evidence of a lack of equipoise amongst both surgical and non-surgical healthcare professionals, with a preference for non-surgical management in some centres. For example, some surgeons felt that INFIX was not a good treatment for this patient cohort, or they felt that most patients could mobilise fairly quickly. The recruiting window was relatively small. There were 3 days before the initial approach was permitted, with the surgery required to take place before day 10 (but in reality, this was often shorter due to 1 day per week operating lists or no operating at weekends at some sites). Making a decision about participating in a trial where the interventions are very different in intensity and risks is potentially a daunting one for patients and their consultees (where patients lacked capacity). From the perspective of recruiting staff, the resulting consent process was experienced as time consuming, involving difficult conversations and a lot of back-and-forth, waiting for patients to discuss the trial with their relatives and/or surgeon, or for next of kin to do so. This was exacerbated by the COVID-19 pandemic. Where patients lacked capacity, discussions with consultees had to take place remotely and recruitment staff felt that it was more difficult to build rapport and trust. There was a perception amongst staff that patients’ next of kin were also reluctant to consent on behalf of the patient whom they were unable to see due to COVID-19 visiting restrictions, in order to have a better idea of how they were doing, or get a better sense of the study. We used multiple strategies to mitigate against the barriers identified. We used cross-site meetings with the aim of bringing together research staff at recruiting sites to discuss the challenges with recruitment experienced at each site, share knowledge and provide support from the central trial team. We obtained approval for changes to the protocol clarifying how the 72-hour mobility inclusion criterion was implemented. During the recruitment pause we developed new resources to support recruitment staff: a short video introduction to the trial that sites could share across departments; a narrated animation on identifying patients across departments; a video resource on how to undertake the 72-hour mobility assessment for the trial; a patient-facing consent video; and updated consent guidance. We obtained approval for the associate principal investigator (API) scheme to be extended to orthogeriatricians to increase their engagement with the study. The trial team including the chief investigator (CI), physiotherapist, orthogeriatrician and trial co-ordinators provided support to address issues at individual sites. With the input of our patient and public involvement (PPI) group, the patient information sheet (PIS) was also revised. Despite the efforts of the central trial team and recruiting teams at sites, the strategies did not sufficiently mitigate against the barriers. Conclusions It is not feasible to recruit to this trial in the current context. Further research to understand the treatment and recovery pathways of this group of patients, along with their outcomes, would be needed prior to undertaking a future trial. Trial registration This trial is registered as ISRCTN16478561. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/57) and is published in full in Health Technology Assessment; Vol. 28, No. 15. See the NIHR Funding and Awards website for further award information.

Background and Objectives: The purpose of the current study was to evaluate the functional outcome of bicondylar tibial plateau fractures treated by open reduction and internal fixation utilising: Rasmussen's functional grading system and Rasmussen's radiological grading system. Both of these grading systems were developed by Rasmussen. Methods: The GIMSR Department of Orthopaedics at Visakhapatnam, Andhra Pradesh, conducted a prospective observational study from August 2021 to January 2023. Surveyed were orthopaedic patients with bicondylar tibial plateau fractures. Tibial Plateau fractures were most common in adults, especially urbanites. Thirty bicondylar tibial plateau fractures needed correction. A sample size of 26 is needed to obtain 80% power and 95% accuracy if % of participants have a certain functional outcome. 30 participants were used to adjust for dropouts. Result: For evaluating each individual who took part in the research project, Rasmussen's functional and radiological grading systems, which he had devised, were applied. Both of the grading methods had a strong correlation (r = 0.888) not only with one another but also with the overall result. Conclusion: Open reduction and internal fixation of bicondylar tibial plateau fractures will restore articular congruity, enable early motion, minimise post-traumatic OA, and optimise knee function. Regardless of velocity and initial comminution, careful articular reduction and waiting for soft tissue healing yield good functional results. The locking compression plate is stable for tibial plateau fractures, and the locking screw held well even in osteoporotic bones. Malalignment and instability affect function more than joint surface deformity. [ABSTRACT FROM AUTHOR]

Conventional dense titanium (Ti) implants cause stress shielding, aseptic loosening and implant failure. This study investigates the effects of porous dental implants (63% porous and 77% porous) with different neck angles (straight, 10° and 15°) on the healthy and osteoporotic bone under different loading conditions (axial load and buccolingual load). Simulation results showed that in cortical bone, the von Mises stresses are greater in the case of 77% porous Ti implant A (straight) as compared to implant B and C (10°, 15° angled neck). Overall, in the case of the osteoporotic bone, the strains are higher than the healthy bone. [ABSTRACT FROM AUTHOR]

Background: Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. Methods: A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. Discussion: The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. Trial registration: International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019 [ABSTRACT FROM AUTHOR]

Aims: The association of auraptene (AUR), a 7-geranyloxycoumarin, on osteoporosis and its potential pathway was predicted by network pharmacology and confirmed in experimental osteoporotic mice. Methods: The network of AUR was constructed and a potential pathway predicted by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway and Gene Ontology (GO) terms enrichment. Female ovariectomized (OVX) Institute of Cancer Research mice were intraperitoneally injected with 0.01, 0.1, and 1 mM AUR for four weeks. The bone mineral density (BMD) level was measured by dual-energy X-ray absorptiometry. The bone microstructure was determined by histomorphological changes in the femora. In addition, biochemical analysis of the serum and assessment of the messenger RNA (mRNA) levels of osteoclastic markers were performed. Results: In total, 65.93% of the genes of the AUR network matched with osteoporosis-related genes. Osteoclast differentiation was predicted to be a potential pathway of AUR in osteoporosis. Based on the network pharmacology, the BMD and bone mineral content levels were significantly (p < 0.05) increased in the whole body, femur, tibia, and lumbar spine by AUR. AUR normalized the bone microstructure and the serum alkaline phosphatase (ALP), bone-specific alkaline phosphatase (bALP), osteocalcin, and calcium in comparison with the OVX group. In addition, AUR treatment reduced TRAP-positive osteoclasts and receptor activator of nuclear factor kappa-B ligand (RANKL)+nuclear factor of activated T cells 1 (NFATc1)+ expression in the femoral body. Moreover, the expressions of initiators for osteoclastic resorption and bone matrix degradation were significantly (p < 0.05) regulated by AUR in the lumbar spine of the osteoporotic mice. Conclusion: AUR ameliorated bone loss by downregulating the RANKL/NFATc1 pathway, resulting in improvement of osteoporosis. In conclusion, AUR might be an ameliorative cure that alleviates bone loss in osteoporosis via inhibition of osteoclastic activity. Cite this article: Bone Joint Res 2022;11(5):304–316.

Aims With the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI). Methods A total of 120 six-month-old Sprague-Dawley (SD) rats were randomized to six groups: Sham, sham + infection (Sham-Inf), sham with infection + antibiotics (Sham-Inf-A), ovariectomized (OVX), OVX + infection (OVX-Inf), and OVX + infection + antibiotics (OVX-Inf-A). Open femoral diaphysis fractures with Kirschner wire fixation were performed. Staphylococcus aureus at 4 × 104 colony-forming units (CFU)/ml was inoculated. Rats were euthanized at four and eight weeks post-surgery. Radiography, micro-CT, haematoxylin-eosin, mechanical testing, immunohistochemistry (IHC), gram staining, agar plating, crystal violet staining, and scanning electron microscopy were performed. Results Agar plating analysis revealed a higher bacterial load in bone (p = 0.002), and gram staining showed higher cortical bone colonization (p = 0.039) in OVX-Inf compared to Sham-Inf. OVX-Inf showed significantly increased callus area (p = 0.013), but decreased high-density bone volume (p = 0.023) compared to Sham-Inf. IHC staining showed a significantly increased expression of TNF-α in OVX-Inf compared to OVX (p = 0.049). Significantly reduced bacterial load on bone (p = 0.001), enhanced ultimate load (p = 0.001), and energy to failure were observed in Sham-Inf-A compared to Sham-Inf (p = 0.028), but not in OVX-Inf-A compared to OVX-Inf. Conclusion In osteoporotic bone with FRI, infection was more severe with more bone lysis and higher bacterial load, and fracture-healing was further delayed. Systemic antibiotics significantly reduced bacterial load and enhanced callus quality and strength in normal bone with FRI, but not in osteoporotic bone. Cite this article: Bone Joint Res 2022;11(2):49–60.

Aims: The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD). Methods: A total of 54 human cadaver forearms (ten singles, 22 pairs) (19 to 90 years) were systematically assessed by clinical radiograph (XR), dual-energy X-ray absorptiometry (DXA), CT, as well as high-resolution peripheral quantitative CT (HR-pQCT). Cortical bone thickness (CBT) of the distal radius was measured on XR and CT scans, and two cortical indices mean average (CBTavg) and gauge (CBTg) were determined. These cortical indices were compared to the BMD of the distal radius determined by DXA (areal BMD (aBMD)) and HR-pQCT (volumetric BMD (vBMD)). Pearson correlation coefficient (r) and intraclass correlation coefficient (ICC) were used to compare the results and degree of reliability. Results: The CBT could accurately be determined on XRs and highly correlated to those determined on CT scans (r = 0.87 to 0.93). The CBTavg index of the XRs significantly correlated with the BMD measured by DXA (r = 0.78) and HR-pQCT (r = 0.63), as did the CBTg index with the DXA (r = 0.55) and HR-pQCT (r = 0.64) (all p < 0.001). A high correlation of the BMD and CBT was observed between paired specimens (r = 0.79 to 0.96). The intra- and inter-rater reliability was excellent (ICC 0.79 to 0.92). Conclusion: The cortical index (CBTavg) at the distal radius shows a close correlation to the local BMD. It thus can serve as an initial screening tool to estimate the local bone quality if quantitative BMD measurements are unavailable, and enhance decision-making in acute settings on fracture management or further osteoporosis screening. Cite this article: Bone Joint Res 2021;10(12):820–829.

Background: The buddy anchor technique is useful to reinforce loose anchors in the osteoporotic humeral head during arthroscopic rotator cuff repair. However, theoretical parallel insertion of the buddy anchor to index a loose anchor is challenging in arthroscopy and can widen the entry site and decrease structural integrity. Purpose: To investigate and compare the biomechanical stability between 2 buddy anchor insertion techniques (parallel insertion vs divergent insertion) in the osteoporotic humeral head. Study Design: Controlled laboratory study. Methods: A total of 24 paired fresh-frozen cadaveric shoulders were used, and each pair was randomly assigned to either the parallel insertion group or the divergent insertion group. In the parallel insertion group, the buddy anchor was inserted parallel to the index loose anchor. In the divergent insertion group, the buddy anchor was inserted at a 20° angle in the medial direction to the index loose anchor. The insertion torque of the buddy anchor and ultimate pull-out strength of the index anchor were measured and compared between the 2 groups. Results: The mean maximum insertion torque was significantly higher in the parallel insertion group (16.1 ± 1.8 cN·m) compared with the divergent insertion group (12.0 ± 1.5 cN·m) (P <.001). The mean ultimate pull-out strength was significantly higher with divergent insertion (192.2 ± 28.6 N) than with parallel insertion (147.7 ± 23.6 N) (P <.001). Conclusion: For application of the buddy anchor system in the cadaveric osteoporotic humeral bone model, divergent insertion showed better ultimate pull-out strength than conventional parallel insertion, despite inferior maximum insertion torque. Clinical Relevance: The results of this study widen the applicability and accessibility for the buddy anchor system. [ABSTRACT FROM AUTHOR]

Floating limb is a complicated injury and is associated with limb deformation and increased morbidity and mortality. We report a rare case of a floating upper limb in a 77-year old woman with ipsilateral humeral shaft, olecranon, distal radial and metacarpal bone fractures after a simple fall. The patient underwent surgery for humerus shaft, olecranon, and distal radius and was treated surgically with the 4th metacarpal conservative method. At the final follow-up 3 years after surgery, the patient had no complaints, all fracture had healed completely and elbow-wrist range of motion was complete. We discuss the surgical procedures that we used for the fractures, the mechanism of injury and the functional and radiological results. Multiple bone fractures in the same limb are rare and typically associated with high-trauma. We reported a unique case of an elderly patient with osteoporosis having multiple fractures in the same extremity that occurred as a result of low-energy trauma. [ABSTRACT FROM AUTHOR]

Pedicle bone screws are one of the most critical materials used in spinal orthopaedic operations. Screw loosening and pull-out (PO) are basic complications encountered during or after surgery. Pull-out Strength (POS) of the bone is one of the significant parameters to understand the mechanical behaviour of a screw fixed to poor quality or osteoporotic bone. This study investigates how the POS of a pedicle screw is affected by the factors of the screw diameter and the polyurethane (PU) foam density by experimental analysis. In the experiments, two different diameter (5.5 and 6.5 mm) of conical pedicle screws and five different density (0.08, 0.16, 0.24, 0.32 and 0.48 g·cm-3) PU foams were used. According to the force-displacement curves obtained from experimental results, the POS increased with the increases in screw diameter and PU foam density. [ABSTRACT FROM AUTHOR]

Proximal humeral fractures occur predominantly in elderly, osteoporotic individuals, especially women, with surgery performed in one-fifth. Proximal humeral locking plates are the gold standard operative treatment; however, complications are frequent, partially because of poor screw purchase in osteoporotic bone. A new method uses threaded posts through which threaded cross-elements orthogonally pass to create a 3-dimensional scaffold for bone engagement. We examined the pullout characteristics of the posts with (1 or 2) or without the cross-elements and tested 2 types of 3.5-mm cortical locking screws for comparison. Low-density closed-cell polyurethane foam served as a model osteoporotic bone substrate. Following implantation in the substrate, the devices were axially loaded by a mechanical test system. Quantities of interest included failure mode, peak load, displacement to peak load, initial stiffness, and work expended. The post groups outperformed the 3.5-mm screw groups, as expected. Relative to posts with no cross-elements, 1 and 2 cross-elements increased the peak load by 29% and 87% and increased the work to peak load by 126% and 343%, respectively. After reaching peak load, 1 and 2 cross-elements increased the work-resistance to further displacement by 158% and 330%, respectively. Cross-elements significantly increased the ability of the threaded posts to resist axial displacement from a model osteoporotic bone substrate. This suggests that posts, used in conjunction with cross-elements, have the potential to enhance the stability of proximal humeral locking plates in osteoporotic bone. [ABSTRACT FROM AUTHOR]

Background: Backing out and failure of pedicle screws in patients with osteoporosis is becoming a big problem due to wide use of these screws nowadays. Purpose: The aim of this study is to evaluate the purchase of fenestrated pedicle screws augmented with cement in patients with osteoporosis. Study Design: This was retrospective observational study. Patients and Methods: From May 2015 to January 2016, 25 patients with a poor bone stock condition underwent posterior fixation by fenestrated pedicle screws and cement augmentation. Assessment of pain improvement was done by visual analogue score (VAS) score while the long-term clinical outcome was assessed using Oswestry low back disability questionnaire (Oswestry disability index [ODI]). Implant stability was evaluated by plain radiography. Complications were evaluated in all cases. Results: All patients were followed up clinically and radiographically for a mean age of 24.84 months. There was a significant reduction in pain and improvement of the quality of life as detected using VAS scores and ODI questionnaire consecutively (P < 0.001). No radiological loosening or backing out of screws was observed. Cement leakage occurred in five cases. Conclusion: Augmentation of fenestrated screws with cement provided effective and lasting purchase in patients with osteoporosis. The only clinical complication strictly related to this technique was cement leakage.

Biomaterials-mediated bone formation in osteoporosis (OP) is challenging as it requires tissue growth promotion and adequate mineralization. Based on our previous findings, the development of scaffolds combining bone morphogenetic protein 2 (BMP-2) and matrix metalloproteinase 10 (MMP-10) shows promise for OP management. To test our hypothesis, scaffolds containing BMP-2 + MMP-10 at variable ratios or BMP-2 + Alendronate (ALD) were prepared. Systems were characterized and tested in vitro on healthy and OP mesenchymal stem cells and in vivo bone formation was studied on healthy and OP animals. Therapeutic molecules were efficiently encapsulated into PLGA microspheres and embedded into chitosan foams. The use of PLGA (poly(lactic-co-glycolic acid)) microspheres as therapeutic molecule reservoirs allowed them to achieve an in vitro and in vivo controlled release. A beneficial effect on the alkaline phosphatase activity of non-OP cells was observed for both combinations when compared with BMP-2 alone. This effect was not detected on OP cells where all treatments promoted a similar increase in ALP activity compared with control. The in vivo results indicated a positive effect of the BMP-2 + MMP-10 combination at both of the doses tested on tissue repair for OP mice while it had the opposite effect on non-OP animals. This fact can be explained by the scaffold’s slow-release rate and degradation that could be beneficial for delayed bone regeneration conditions but had the reverse effect on healthy animals. Therefore, the development of adequate scaffolds for bone regeneration requires consideration of the tissue catabolic/anabolic balance to obtain biomaterials with degradation/release behaviors suited for the existing tissue status.

• Neglected femoral neck fracture led to severe disuse osteoporos is resulting very brittle acetabulum floor and proximal femur shaft. • The decision to use uncemented Total Hip Replacement was taken to reduce the risk of pulmonary embolism. • Plasticity of the osteoporotic acetabulum floor caused bouncing effect in every single hit resulting in cup fixation failure and massive acetabulum perforation. • In emergency situation, an acceptable result could be achieved by constructing an unusual cup composite, made from the remaining cancellous chondral shell of the femoral head as a base, the failed uncemented cup as a cage and a cemented cup fixed together with gentamycine loaded bone cement. Uncemented total hip for neglected nonunion femoral neck fracture hopefully could minimize the post operative complications. Nevertheless, due to plasticity of the brittle osteoporotic bone, unexpected fracture may occur. We presented an unusual reconstruction of acetabulum which was accidently perforated during uncemented cup insertion. A 76 years old wheelchair bound female showed a nonunion fracture of the right femoral neck due to a fall 7 years ago. She had right hip instability with 5 cm leg shortening. Uncemented total hip replacement was originally planned, however, due to unexpected perforation of the acetabulum, it was ended in total hip after creating a composite layers to fix a cemented cup. Patient was full ambulatory with walker at 4 months. Harris Hip Score at 15 months showed 71.3%, compared with 20.2% before surgery. The plasticity of the osteoporotic acetabulum floor was the reason why the uncemented cup could not be fixed, instead it caused massive perforation of the floor. The acetabulum reconstruction was done by composite layers made from remaining chondral bone shell, absorbable hemostatic gelatin sponge and cancellous bone of the femoral head, porous collagen matrix and uncemented titanium acetabulum cup fixed with two screws. In unexpected acetabulum perforation, the remaining chondral shell of femoral head together with uncemented cup as a cage support and bone cement can be used to reconstruct the acetabulum floor. More stability can be achieved using reconstruction cage with allograft and or metal augments or using a cemented total hip arthroplasty. [ABSTRACT FROM AUTHOR]

This paper proposes an optimum design of the pedicle screw with respect to bone density and variables of the screw design. First, pedicle screws are designed and manufactured with design variables including the core diameter and conical angle that affect the pullout force of the pedicle screw. Variables of bone density are also classified into two groups, namely grade 10 (0.16 g/cc) with osteoporotic bone density and grade 20 (0.32 g/cc) with normal bone density. The effect of each parameter on the pullout force and relationship between the pullout force and screw designs are investigated. Furthermore, bone damage after fixation failure or insertion in the patient body is considered separately from the pullout strength. Therefore, cross sectional images of the artificial bone are observed to analyze the degree of damage after the pullout test of the pedicle screw by using micro-CT (computed tomography). The region and degree of bone damage are quantitatively analyzed. The effects of the core diameter and conical angle of the pedicle screw on the pulling force, bone damage, and fracture behavior are analyzed via the aforementioned experiments and analysis. An optimal pedicle screw design is suggested based on the experimental results. [ABSTRACT FROM AUTHOR]

Parathyroid hormone (1-34, PTH) combined β-tricalcium phosphate (β-TCP) achieves stable bone regeneration without cell transplantation in previous studies. Recently, with the development of tissue engineering slow release technology, PTH used locally to promote bone defect healing become possible. This study by virtue of collagen with a combination of drugs and has a slow release properties, and investigated bone regeneration by β-TCP/collagen (β-TCP/COL) with the single local administration of PTH. After the creation of a rodent critical-sized femoral metaphyseal bone defect, β-TCP/COL was prepared by mixing sieved granules of β-TCP and atelocollagen for medical use, then β-TCP/COL with dripped PTH solution (1.0 µg) was implanted into the defect of OVX rats until death at 4 and 8 weeks. The defected area in distal femurs of rats was harvested for evaluation by histology, micro-CT, and biomechanics. The results of our study show that single-dose local administration of PTH combined local usage of β-TCP/COL can increase the healing of defects in OVX rats. Furthermore, treatments with single-dose local administration of PTH and β-TCP/COL showed a stronger effect on accelerating the local bone formation than β-TCP/COL used alone. The results from our study demonstrate that combination of single-dose local administration of PTH and β-TCP/COL had an additive effect on local bone formation in osteoporosis rats. [ABSTRACT FROM AUTHOR]

The objective of the present study was to incorporate strontium into calcium phosphate cement combined with a lower single-dose local administration of bone morphogenetic protein-2 to enhance its in vivo biodegradation and bone tissue growth. After the creation of a rodent critical-sized femoral metaphyseal bone defect, strontium-modified calcium phosphate cement was prepared by mixing sieved granules of calcium phosphate cement and 5% SrCO3 for medical use, and then strontium-modified calcium phosphate cement with dripped bone morphogenetic protein-2 solution (5 µg) was implanted into the defect of OVX rats until death at eight weeks. The defected area in distal femurs of rats was harvested for evaluation by histology, micro-CT, and biomechanics. The results of our study show that a lower single-dose local administration of bone morphogenetic protein-2 combined local usage of strontium-modified calcium phosphate cement can increase the healing of defects in OVX rats. Furthermore, treatments with single-dose local administration of bone morphogenetic protein-2 and strontium-modified calcium phosphate cement showed a stronger effect on accelerating the local bone formation than calcium phosphate cement and strontium-modified calcium phosphate cement used alone. The results from our study demonstrate that combination of a lower single-dose local administration of bone morphogenetic protein-2 and strontium-modified calcium phosphate cement had an additive effect on local bone formation in osteoporosis rats. [ABSTRACT FROM AUTHOR]

Objective: Hip fractures in the elderly are usually associated with a high rate of morbidity and mortality and affect quality of life. On review of published data, the current guidelines in the literature indicate that early surgery should be performed within 24 h of injury because it is associated with better functional outcomes and lower rates of perioperative complications and mortality. The aim of this study was to evaluate whether any correlation exists between early surgical intervention and functional outcomes. Methods: In a retrospective study, we analyzed the records between January 2010 and December 2016 and 550 elderly patients between the age group of 65-95 were included. Results: The results of early surgery were promising, 451 (82%) patients did not have any complication, 42 (7.6%) has developed bed sore, 23 (4%) developed a hospital-acquired infection, 13 (2.3%) developed wound infection, 08 (1.4%) developed DVT, 04 (0.7%) developed implant failure, and 09 (01%) died of some or other complications. Conclusion: Still, there is conflicting evidence in the published data that early surgery would improve mortality and function. However, early surgery definitively improves outcome and reduces morbidity, bed sores, infection, and the length of hospital stay could be improved by reducing the waiting time of hip surgery following fracture. We concluded that it is beneficial to the elderly patients to receive surgical treatment as early as possible. [ABSTRACT FROM AUTHOR]

The use of polymethylmethacrylate cement for in-situ implant augmentation has considerable disadvantages: it is potentially cytotoxic, exothermic and non-degradable. Therefore, the primary aim of this study was to develop a magnesium phosphate cement which meets the requirements for in-situ implant augmentation as an alternative. Secondly, this experimental cement was compared to commercial bone cements in a biomechanical test set-up using augmented femoral head blades. A total of 40 human femoral heads were obtained from patients who underwent total hip arthroplasty. After bone mineral density was quantified, specimens were assigned to four treatment groups. A blade of the Trochanteric Fixation Nail Advanced™ was inserted into each specimen and augmented with either Traumacem™ V+, Paste-CPC, the experimental magnesium phosphate cement or no cement. A rotational load-to-failure-test (0° to 90°) was performed. A conventional two-component magnesium phosphate cement failed in-situ implant augmentation consistently due to filter pressing. Only a glycerol-based magnesium phosphate paste was suitable for the augmentation of femoral head blades. While the blades augmented with Traumacem™ V+ yielded the highest maximum torque overall (22.1 Nm), the blades augmented with Paste-CPC and the magnesium phosphate paste also showed higher maximum torque values (15.8 and 12.8 Nm) than the control group (10.8 Nm). This study shows for the first time the development of a degradable magnesium phosphate cement paste which fulfills the requirements for in-situ implant augmentation. Simultaneously, a 48% increase in stability is demonstrated for a scenario where implant anchorage is difficult in osteoporotic bone. [Display omitted] • Two component cement systems fail in-situ augmentation due to filter-pressing. • Bimodal magnesium phosphate cement paste allows in-situ augmentation for the first time. • Magnesium paste augmented blades yield 48% higher stability in human femoral heads. • Polymethylmethacrylate and calcium phosphate cement paste also increase stability. • Correlation of torque, cement volume and bone marrow density. [ABSTRACT FROM AUTHOR]

This paper proposes an optimum design of the pedicle screw with respect to bone density and variables of the screw design. First, pedicle screws are designed and manufactured with design variables including the core diameter and conical angle that affect the pullout force of the pedicle screw. Variables of bone density are also classified into two groups, namely grade 10 (0.16 g/cc) with osteoporotic bone density and grade 20 (0.32 g/cc) with normal bone density. The effect of each parameter on the pullout force and relationship between the pullout force and screw designs are investigated. Furthermore, bone damage after fixation failure or insertion in the patient body is considered separately from the pullout strength. Therefore, cross sectional images of the artificial bone are observed to analyze the degree of damage after the pullout test of the pedicle screw by using micro-CT (computed tomography). The region and degree of bone damage are quantitatively analyzed. The effects of the core diameter and conical angle of the pedicle screw on the pulling force, bone damage, and fracture behavior are analyzed via the aforementioned experiments and analysis. An optimal pedicle screw design is suggested based on the experimental results.

Background: Backing out and failure of pedicle screws in patients with osteoporosis is becoming a big problem due to wide use of these screws nowadays. Purpose: The aim of this study is to evaluate the purchase of fenestrated pedicle screws augmented with cement in patients with osteoporosis. Study Design: This was retrospective observational study. Patients and Methods: From May 2015 to January 2016, 25 patients with a poor bone stock condition underwent posterior fixation by fenestrated pedicle screws and cement augmentation. Assessment of pain improvement was done by visual analogue score (VAS) score while the long-term clinical outcome was assessed using Oswestry low back disability questionnaire (Oswestry disability index [ODI]). Implant stability was evaluated by plain radiography. Complications were evaluated in all cases. Results: All patients were followed up clinically and radiographically for a mean age of 24.84 months. There was a significant reduction in pain and improvement of the quality of life as detected using VAS scores and ODI questionnaire consecutively (P < 0.001). No radiological loosening or backing out of screws was observed. Cement leakage occurred in five cases. Conclusion: Augmentation of fenestrated screws with cement provided effective and lasting purchase in patients with osteoporosis. The only clinical complication strictly related to this technique was cement leakage. [ABSTRACT FROM AUTHOR]

Evidence suggests that chiropractic manipulation might exert positive effects in osteoporotic patients. The aim of this study was to evaluate the effects of chiropractic manipulation on bone structure and skeletal muscle in rats with bone loss caused by ovariectomy (OVX). The 6-month old Sprague-Dawley rats at 10 weeks following OVX or sham operation (Sh) did not suffer chiropractic manipulation (NM group) or were submitted to true chiropractic manipulation using the chiropractic adjusting instrument Activator V® three times/week for 6 weeks as follows: Force 1 setting was applied onto the tibial tubercle of the rat right hind limb (TM group), whereas the corresponding left hind limb received a false manipulation (FM group) consisting of ActivatorV® firing in the air and slightly touching the tibial tubercle. Bone mineral density (BMD) and bone mineral content (BMC) were determined in long bones and L3-L4 vertebrae in all rats. Femora and tibia were analyzed by μCT. Mechano growth factor (MGF) was detected in long bones and soleus, quadriceps and tibial muscles by immunohistochemistry and Western blot. The decrease of BMD and BMC as well as trabecular bone impairment in the long bones of OVX rats vs Sh controls was partially reversed in the TM group versus FM or NM rats. This bone improvement by chiropractic manipulation was associated with an increased MGF expression in the quadriceps and the anterior tibial muscle in OVX rats. These findings support the notion that chiropractic manipulation can ameliorate osteoporotic bone at least partly by targeting skeletal muscle. [ABSTRACT FROM AUTHOR]

Introduction: The main purpose of this retrospective, non-randomized, case series study was to evaluate the clinical and radiographic outcomes of distal humerus fractures (DHFs) in a consecutive series of elderly patients operatively treated by two surgeons, and second, to identify proper indications for two elderly age ranges and two fracture pattern groups.Materials and Methods: From January 2009 to June 2014, 51 patients (pts) underwent open reduction and internal fixation (ORIF) using the locking compression plate (LCP) distal humerus plate (DHP) system at our institution. Medical records and radiographs were retrospectively assessed. Patients were divided into 3 groups according to gender, age (pts <85 years, pts ≥85 years) and AO classification (13-B1-B2-C1-C2 or 13-C3). All subjects completed MEPS, Quick-DASH and SF-36 PCS/MCS scores at final follow-up, and statistical analysis was performed.Results: 36 patients (20 women, 16 men), mean age 80.3 years, with AO type 13-B and 13-C DHFs were included with a mean follow-up of 56 months (range 24-92). The most common mechanism of trauma was a fall from ground level (55.6%). The mean MEPS was 78.9 points, Quick-DASH 28.4, SF-36 PCS 48.3 and MCS 48.9. There was statistically significant evidence that having a 13-C3 fracture leads to worse results in MEPS, Quick-DASH and SF-36. The female gender correlates with worse results in SF-36. The patients ≥85 years had a worse prognosis according to Quick-DASH and SF-36, while the AO 13-C3 pattern obtained the worst ROM outcomes versus AO 13 B1-B2-C1-C2 (normal ROM 0°-140°): mean ROM 24°-114° vs 10°-130°, mean flexion deficit 26° vs 10°, mean extension deficit 24° vs 10°, respectively). Complications were presents in 36.1% of patients, overall belonging to the AO type 13-C fracture pattern and to the group ≥85 years.Conclusion: These study data seem to confirm our hypothesis that plate fixation for DHFs guarantees adequate fracture osteosynthesis and satisfactory functional outcomes at medium to long-term follow-up, not only in elderly patients, but also in octogenarian osteoporotic patients (≥85 years) with 13-C1 and 13-C2 fracture patterns, while an alternative solution should be considered for type C3 fractures, even in a primary trauma setting. [ABSTRACT FROM AUTHOR]

Bioactive ions released from bioceramics play important roles in bone regeneration; however, it is unclear how each ionic composition in complex bioceramics exerts its specific effect on bone regeneration. The aim of this study is to elucidate the functional effects of Sr and Si ions in bioceramics on the regeneration of osteoporotic bone. A model bioceramic with Sr- and Si-containing components (SMS) was successfully fabricated and the effects of ionic products from SMS bioceramics on the osteogenic, osteoclastic and angiogenic differentiation of rBMSCs-OVX and RANKL-induced osteoclasts were investigated. The results showed that SMS bioceramics could enhance ALP activity and expression of Col 1 , OCN , Runx2 , and angiogenic factors including VEGF and Ang-1 . SMS bioceramics not only rebalanced the OPG / RANKL ratio of rBMSCs-OVX at early stage, but also repressed RANKL-induced osteoclast formation and expression of TRAP , DC-STAMP , V-ATPase a3 , and NFATc1 . The synergistic effects of Sr and Si ions were further investigated as compared with those of similar concentrations of Sr and Si ions alone. Sr and Si ions possessed synergistic effects on osteogenesis, osteoclastogenesis, and angiogenesis, attributed to the dominant effects of Sr ions on enhancing angiogenesis and repressing osteoclastogenesis, and the dominant effects of Si ions on stimulating osteogenesis. The in vivo study using critical-size mandibular defects of OVX rat models showed that SMS bioceramics could significantly enhance bone formation and mineralization compared with β-TCP bioceramics. Our results are the first to elucidate the specific effect of each ion from bioceramics on osteogenesis, osteoclastogenesis and angiogenesis for osteoporotic bone regeneration, paving the way for the design of functional biomaterials with complex compositions for tissue engineering and regenerative medicine. Statement of significance Bioactive ions released from bioceramics play important roles for bone regeneration; however, it is unclear how each of ionic compositions in complex bioceramics exerts its specific effect on bone regeneration. The aim of present study is to elucidate the functional effects of Sr and Si ions in complex bioceramics on the regeneration of osteoporotic bone. A model bioceramic with Sr and Si-containing components (SMS) was successfully fabricated and the effects of ionic products from SMS bioceramics on the osteogenic, osteoclastic and angiogenic differentiation of rBMSCs-OVX and RANKL-induced osteoclasts were investigated. The results showed that SMS bioceramics could enhance ALP activity and expression of Col 1, OCN, Runx2 and angiogenic factors including VEGF and Ang-1. SMS bioceramics not only rebalanced the ratio of OPG/RANKL of OVX-BMSCs at early stage, but also repressed RANKL-induced osteoclast formation and expression of TRAP, DC-STAMP, V-ATPase a3, and NFATc1. The synergistic effects of Sr and Si ions were further investigated as compared with the similar concentration of Sr and Si ions alone. It was found that Sr and Si ions possessed synergistic effects on osteogenesis, osteoclastogenesis and angiogenesis, attributed to the dominant effects of Sr ions on enhancing angiogenesis and repressing osteoclastogenesis, and the dominant effects of Si ions on stimulating osteogenesis. The in vivo study using critical-size mandibular defects of OVX rat models showed that SMS bioceramics could significantly enhance bone formation and mineralization as compared with β-TCP bioceramics. It is suggested that SMS bioceramics may be a promising biomaterial for osteoporotic bone regeneration. To our knowledge, this is the first time to elucidate the specific effect of each ion from bioceramics on osteogenesis, osteoclastogenesis and angiogenesis for osteoporotic bone regeneration, paving the way to design functional biomaterials with complex compositions for tissue engineering and regenerative medicine. [ABSTRACT FROM AUTHOR]

Background Context Compromise of pedicle screw purchase is a concern in maintaining rigid spinal fixation, especially with osteoporosis. Little consistency exists among various tapping techniques. Pedicle screws are often prepared with taps of a smaller diameter, which can further exacerbate inconsistency. Purpose The objective of this study was to determine whether a mismatch between tap thread depth (D) and thread pitch (P) and screw D and P affects fixation when under-tapping in osteoporotic bone. Study Design This study is a polyurethane foam block biomechanical analysis. Materials and Methods A foam block osteoporotic bone model was used to compare pullout strength of pedicle screws with a 5.3 nominal diameter tap of varying D's and P's. Blocks were sorted into seven groups: (1) probe only; (2) 0.5-mm D, 1.5-mm P tap; (3) 0.5-mm D, 2.0-mm P tap; (4) 0.75-mm D, 2.0-mm P tap; (5) 0.75-mm D, 2.5-mm P tap; (6) 0.75-mm D, 3.0-mm P tap; and (7) 1.0-mm D, 2.5-mm P tap. A pedicle screw, 6.5 mm in diameter and 40 mm in length, was inserted to a depth of 40 mm. Axial pullout testing was performed at a rate of 5 mm/min on 10 blocks from each group. Results No significant difference was noted between groups under axial pullout testing. The mode of failure in the probe-only group was block fracture, occurring in 50% of cases. Among the other six groups, only one screw failed because of block fracture. The other 59 failed because of screw pullout. Conclusions In an osteoporotic bone model, changing the D or P of the tap has no statistically significant effect on axial pullout. Osteoporotic bone might render tap features marginal. Our findings indicate that changing the characteristics of the tap D and P does not help with pullout strength in an osteoporotic model. The high rate of fracture in the probe-only group might imply the potential benefit of tapping to prevent catastrophic failure of bone. [ABSTRACT FROM AUTHOR]

Osteoporosis, a quietly progressing metabolic bone disease that leads to minimizing of bone mass, is widely prevalent in India and fractures due to osteoporosis are a common cause of mortality and morbidity in adult Indian males and females. Low bone mass with microarchitectural deterioration of bone tissue is the main characteristic features of osteoporosis and are also the leading causes for increasing risk of fractures. Likelihood of developing osteoporosis in women is 4 times when compared to men. The maintenance of oral health in adults with osteoporosis is important. Studies revealed that osteoporosis is one of the risk factors for osseointegration process during dental implant healing. Hence, osteoporosis is considered a questionable condition for the placement of dental implants. However, literature states that osteoporosis patients are not contraindicated for dental implants. The aim of this study was to determine whether a diagnosis of osteoporosis shows its effect on the survival rate of osseointegrated dental implants. Aim: The aim is to evaluate the success rate of implants with osteoporotic bone. Objectives: (1) To evaluate the implant success rate in the patients with osteoporotic bone, (2) To assess various treatment options in the patients with osteoporotic bone. Study and Design: A review was done on the success rate of dental implants with osteoporotic bone. A wide evaluation of articles was done, and the data were collected from various search engines such as Google Scholar, PubMed, research gate, Scholars portal database, Medline, Embase, and few other hand search articles. The bibliographies were evaluated with the other electronically searched articles. The studies included were evaluated and analyzed. Conclusion: Based on the above literature search, dentists should perform a proper assessment of treatment planning while placing dental implants in osteoporotic patients for a better implant survival rate. [ABSTRACT FROM AUTHOR]