Fracture risk of young adults receiving proton-pump inhibitors and H2-receptor antagonists.

INTRODUCTION: Proton-pump inhibitors (PPI) and histamine (type 2) receptor antagonists (H2RA) have the potential to interfere with calcium metabolism. Several authors have evaluated the effect of these medications on fracture incidence in older adults. A recent large epidemiologic study demonstrated a higher risk of fractures in young adults receiving PPI. AIM: To evaluate the effect of PPI and H2RA use on fracture incidence in a large retrospective cohort of military recruits representative of general population of young adults. METHODS: A retrospective cohort of 254 265 male and 234 670 female non-combat military conscripts ages 18-25. Subjects were divided into three groups by PPI use (no PPI use, 1-100 tablets and more than 100 tablets) and two groups by H2RA use (no H2RA use, any H2RA use). Multivariate logistic regression was used to adjust fracture risk for age, BMI, education level, socio-economic level, ethnic origin, occupation and duration of follow-up in months. MAIN OUTCOME MEASURES: At least one fracture during the study period. RESULTS: Use of PPI and H2RA was not associated with an increased risk of fractures. In men, the predictors of an increased fracture risk were higher BMI (OR = 1.007, P < 0.001), origin from a developing country (OR = 1.15, P < 0.001) and service as a driver (OR = 1.11, P < 0.001). Higher education, higher socioeconomic status and service as an officer or as an administrative worker had a protective effect on fracture incidence. In women, fractures were associated with higher BMI (OR = 1.035, P < 0.001). Origin from a developed country, as well as service as an officer or an administrative worker was associated with lower fracture risk. CONCLUSIONS: There was no association between the use of PPI or H2-antagonists and fracture incidence in this retrospective cohort of healthy young military recruits.

Plate Fixation of Proximal Fifth Metatarsal Fracture.

BACKGROUND: Intramedullary screw fixation of fractures of the proximal fifth metatarsal bone may not be satisfactory in comminuted fractures or when the lateral metatarsal bowing has to be restored. We report our experience with plate fixation in these circumstances. METHODS: Between June 1, 2009, and January 31, 2013, 13 patients who had comminuted fracture or nonunion of fracture of the proximal fifth metatarsal bone underwent plate fixation. Study patients were followed up for a mean of 500 days (range, 51-1238 days). Their medical records and radiographs were retrospectively reviewed for demographic and operative data and radiologic evidence of fracture healing. At their most recent follow-up, patients were evaluated for pain levels with a visual analog scale, for foot function with the Foot and Ankle Disability Index, and for quality of life with the 12-Item Short-Form Health Survey. RESULTS: Fracture union was evident in 12 patients after a mean of 56.8 days (range, 30-92 days). There was only one major complication of sural nerve neuroma and reflex sympathetic dystrophy. Four patients required reoperation for plate removal. Plate fixation of proximal fifth metatarsal comminuted fractures is associated with high union rates, relief of pain, and patient satisfaction. However, plate removal for various reasons was required in approximately one-third of the study patients. This high revision rate might be avoided by better selection of patients and meticulous intraoperative identification and preservation of the sural nerve. CONCLUSIONS: We recommend reserving plate fixation for proximal fifth metatarsal fractures for cases of laterally bowed fifth metatarsal or comminuted fractures.

In-shoe center of pressure: indirect force plate vs. direct insole measurement.

BACKGROUND: In-shoe center of pressure (COP) measurement is essential in biomechanics. COP can be measured directly utilizing pressure-sensitive insoles, or calculated indirectly via force plate-generated data. While the latter does not require the use of additional measurement hardware (shoe insoles), its precision at calculating in-shoe COP has not been determined. Our purpose was to ascertain the precision of force plate in-shoe COP calculations and enhance their accuracy through a mathematical algorithm. METHODS: Twelve male students participated in the study. In-shoe COP was measured synchronously via the Pedar-X insole system and AMTI force plates, comparing the measurements of both systems. A mathematical algorithm was created to improve agreement between the systems and comparisons were recalculated. RESULTS: The two methods showed different measurements of in-shoe COP. The medio-lateral (ML) and anterior-posterior (AP) Pearson correlation coefficients between systems were 0.44 ± 0.35 and 0.99 ± 0.01, and the ML and AP RMS errors were 6.3 ± 3.0 mm and 43.0 ± 12.5 mm, respectively. Using a mathematical algorithm, the differences between the measurements of each system could be reduced significantly (all P<0.001). CONCLUSIONS: Without adjustment, force plates give an approximate location of the COP. Using an adjustment model greatly improves the accuracy of the COP trajectory during stance.

Treatment of diaphyseal nonunion of the femur and tibia using an expandable nailing system.

INTRODUCTION: We evaluated the efficacy of the expandable nailing system for treating femur and tibia shaft nonunions. PATIENTS AND METHODS: Records of 24 patients (25 fractures) were retrospectively reviewed: 16 with femur and 8 with tibia nonunions. The bones underwent reaming, and the largest possible nail sizes were inserted during re-operation. Bone debris obtained from the reaming was used for bone graft at the site of the nonunion. RESULTS: The mean age of the patients was 32 years for the tibia group and 49 years for the femur group. The respective intervals between trauma and re-operation were 11 and 13 months, the operation times 60 and 78 min, and the fluoroscopy times 21 and 32s. Twenty-four of the 25 nonunions healed satisfactorily without requiring additional procedures. In 1 case, demineralised bone matrix was injected percutaneously and the femoral nonunion resolved. Healing time was 23 weeks (6-52) and 17 weeks (6-40) in the tibia and femur groups, respectively. We were able to reduce the need of an autologous bone graft to only two cases by using reamed debris in 17 of the 19 patients who required grafting. CONCLUSIONS: Our results demonstrated satisfactory healing for the treatment of diaphyseal nonunions of the femur and tibia. The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. We recommend expandable nail systems for femur and tibia shaft nonunions and the use of reamed debris in order to decrease the use of autogenous bone graft.

Very long-term radiographic and bone scan results of frozen autograft and allograft bone grafting in 17 patients (20 grafts) a 30- to 35-year follow-up.

In the early 1950s, 48 patients received bone implants from a bone bank in Tel-Hashomer Hospital that stored frozen autograft and allograft bones at temperatures less than -17 degrees C. Seventeen (35%) of these patients (20 implants), 10 men and 7 women, with a mean age of 52.4 (34-69) years were available for follow-up after a mean period of 32.5 (30-35) years. They underwent clinical examination, radiographs and bone scans to evaluate their surgical results. Fracture healing, non-union, graft resorption, osteoporosis and bone sclerosis were used as radiographic criteria for bone incorporation, and normal, increased and decreased uptake served to assess the bone scan. Based on the above criteria, the results were satisfactory in 17 (85%) and poor in 3 (15%). The three failures were after shelf operation for hip dysplasia that used two allografts and one autograft. Allogenous or a combination of allogenous with autogenous frozen bone grafts proved to be a satisfactory and durable method for filling bone defects.

[Posterior tibial tendon dysfunction].

Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot in adults. The posterior tibial tendon is the primary dynamic stabilizer of the medial longitudinal arch of the foot. Various histological alterations in the tendon substance disrupt the normal linear structure of the collagen fibers. As a result the tendon weakens, elongates, tears and its function is compromised. This in turn places the static stabilizers of the arch under excessive stress, which eventually leads to their collapse and formation of pes planovalgus deformity. Many etiologies have been proposed as an underlying cause of posterior tibial tendon dysfunction. The average age at the time of presentation is forty years and many of the patients are women, white, obese and suffer from hypertension. The diagnosis is mainly based on clinical findings and supported by radiographic findings. Posterior tibial tendon dysfunction was classified by Johnson and Strom according to the appearance of pes planovalgus deformity, its flexibility and the development of arthritic changes in the subtalar and ankle joints. In Stage I there is no deformity, in Stage II there is a flexible deformity, in stage III there is a rigid deformity and in stage IV there is an involvement of the ankle joint secondary to long standing rigid deformity of the hindfoot. The initial treatment for any stage should be non-operative and includes immobilization and anti-inflammatory drugs for the acute phase and different kinds of orthotics for the chronic phase. Failure of the non-operative treatment is an indication for surgery. The surgical procedures for the first stage include soft tissue debridement with or without tendon transfer. The surgical procedures for second stage include tendon transfer combined with various osteotomies or joint fusions. The surgical procedures for the third and fourth stages are triple arthrodesis and pantalar arthrodesis respectively.

Removal of a broken distal closed section intramedullary nail: report of a case using a simple method.

A simple method to remove a broken distal closed section intramedullary nail is presented. The surgical technique and a case report are described. This technique eliminates the need for an additional exposure, other than that required to insert the nail, or any specialized equipment.

[Effects of smoking on orthopaedic disorders and surgery].

It is well known that cigarette smoking is implicated in the etiology of cardiovascular disease, lung disease and a multitude of other types of cancer as well. Smoking is the leading avoidable cause of mortality and morbidity. The orthopaedic community is aware of the relation between smoking and its impact on the results of conservative and surgical treatment. It has been shown that smoking may adversely affect bone metabolism, lumbar disk disorders, fracture and wound healing. Most of the available data did provide varying degrees of correlation between smoking and orthopaedic conditions. In this review we attempted to summarize and present the clinical data regarding smoking and its impact on orthopaedic disorders and surgery.