Effects of modified version of the Hospital Elder Life Program on post-discharge cognitive function and activities of daily living among older adults undergoing total knee arthroplasty.

OBJECTIVES: This study aimed to investigate the effects of a modified Hospital Elder Life Program (mHELP) on post-discharge cognition and physical function among older adults undergoing total knee arthroplasty (TKA), and to evaluate the incidence of postoperative delirium. DESIGN: Non-randomized intervention trial. SETTING AND PARTICIPANTS: A total of 140 patients aged 60 years and older scheduled for elective orthopedic surgery at our institution between August 2017 and December 2018 were included. METHODS: Ward-level stratification was used with one surgical ward receiving mHELP (intervention group), including orientation communication, early mobilization, vision/hearing impairment equipment, and dehydration prevention, and another ward providing usual care (control group). All participants were assigned to two surgical wards. Outcome measures were collected using MMSE telephone version (tMMSE), activities of daily living (ADL) and instrumental activities of daily living (IADL) instruments at 1, 6, and 12 months after discharge. Multiple linear regression analysis was used to measure effects of mHELP intervention on mean differences in tMMSE, ADL and IADL scores from baseline to 1-, 6- and 12-months. RESULTS: Effects of mHELP intervention significantly preserved cognitive function at 1 and 12 months, but not at 6 months, compared with controls, regardless of adjustments for confounders. However, no intervention effects were noted in ADL and IADL scores. Postoperative delirium in the whole cohort was 3.6 % (2.5 % in intervention group, 5.1 % in control group, P = 0.41). CONCLUSIONS: mHELP intervention preserves post-discharge cognitive function, but has no notable effect on ADL and IADL function in older adults undergoing elective TKA surgery.

Peri-implant Fractures Following Hook Plate Fixation for Unstable Distal Clavicle Fractures.

Clavicle hook plate is a common implant for treating distal clavicle fracture. Although high bone union rate and good functional outcome have been reported, so have several complications, such as osteolysis and fracture of the acromion, loss reduction, hook impingement, and rotator cuff tear. Peri-implant fracture over the medial side of the hook plate is a rare complication. Sporadic cases have been reported, and most of them have had no history of trauma. Between June 2015 and August 2018, 7 patients treated for distal clavicle fracture with a 3.5-mm locking compression hook plate with no history of trauma experienced peri-implant fracture of the medial clavicle. This complication occurred at a mean of 29 days. The incidence rate was 9.8%. Peri-implant fracture following hook plate fixation for distal clavicle fracture was not rare. Small hook angle, prolonged retention of the implant, an eccentric medial screw, high plate screw density, and small clavicle diameter may be risk factors for peri-implant fracture. Regarding treatment, 2 patients chose fracture revision with a distal clavicle locking plate and 5 patients chose conservative treatment. All patients achieved bone union at fracture sites. Surgical and conservative management of peri-implant fracture can achieve good functional outcome. [Orthopedics. 2020;43(5);e359-e363.].

Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy.

The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, -3.7° (18.0%) for the Thomas test, -15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (all P < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.

Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial.

PURPOSE: To prospectively compare the efficacy of intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) with a sham control group (normal saline solution [NS]) for knee osteoarthritis in a randomized, dose-controlled, placebo-controlled, double-blind, triple-parallel clinical trial. METHODS: A total of 87 osteoarthritic knees (53 patients) were randomly assigned to 1 of 3 groups receiving 3 weekly injections of either leukocyte-poor PRP (31 knees), HA (29 knees), or NS (27 knees). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and International Knee Documentation Committee (IKDC) subjective score were collected at baseline and at 1, 2, 6, and 12 months after treatment. Data were analyzed using generalized estimating equations. RESULTS: All 3 groups showed statistically significant improvements in both outcome measures at 1 month; however, only the PRP group sustained the significant improvement in both the WOMAC score (63.71 ± 20.67, increased by 21%) and IKDC score (49.93 ± 17.74, increased by 40%) at 12 months. For the intergroup comparison, except for the first month, there was a statistically significant difference between the PRP and NS groups in both scores throughout the study duration (regression coefficients of 8.72 [P = .0015], 7.94 [P = .0155], and 11.92 [P = .0014] at 2, 6, and 12 months, respectively, for WOMAC score, and 9.1 [P = .0001], 10.28 [P = .0002], and 13.97 [P < .0001], respectively, for IKDC score). There was no significant difference in both functional outcomes between the HA and NS groups at any time point. Only the PRP group reached the minimal clinically important difference in the WOMAC score at every evaluation (15%, 21%, 18%, and 21% at 1, 2, 6, and 12 months, respectively) and the minimal clinically important difference in the IKDC score at 6 months (improvement of 11.6). CONCLUSIONS: Intra-articular injections of leukocyte-poor PRP can provide clinically significant functional improvement for at least 1 year in patients with mild to moderate osteoarthritis of the knee. LEVEL OF EVIDENCE: Level I, randomized controlled single-center trial.

WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet.

BACKGROUND: The wide-awake local anesthesia no tourniquet (WALANT) technique is applied during various hand surgeries. We investigated the perioperative variables and clinical outcomes of open reduction and internal fixation (ORIF) for distal radius fractures under WALANT. METHODS: From January 2015 to January 2017, 60 patients with distal radius fractures were treated, and 24 patients (40% of all) were treated with either a volar or a dorsal plate via WALANT procedure. Of these 24 patients, 21 radius fractures were fixed with a volar plate, and the other 3 were fixed with a dorsal plate. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated. RESULTS: One of the 24 patients could not tolerate the WALANT procedure and was reported as a failed attempt at WALANT. In the cohort, 23 patients successfully received distal radius ORIF under WALANT procedure. The average age is 60.9 (range, 20-88) years. The average operation time was 64.3 (range, 45-85) minutes, the average blood loss was 18.9 (range, 5-30) ml, and the average of duration of hospitalization is 1.8 (range, 1-6) days. The average postoperative day one VAS was 1.6 (range, 1-3). The average time of union was 20.7 (range, 15-32) weeks. The mean follow-up period was 15.1 (range, 12-24) months. Functional 1-year postoperative outcomes revealed an average Quick DASH score of 7.60 (range, 4.5-13.6) and an average wrist flexion and extension of 69.6° (range, 55-80°) and 57.4° (range, 45-70°). There was no wound infection, neurovascular injury, or other major complication noted. CONCLUSIONS: WALANT for distal radius fracture ORIF is a method to control blood loss by the effects of local anesthesia mixed with hemostatic agents. Without a tourniquet, the procedure prevents discomfort caused by tourniquet pain. Without sedation, patients could perform the active range of motion of the injured wrist to check if there is impingement of implants. It eliminates the need of numerous preoperative examinations, postoperative anesthesia recovery room care, and side effects of the sedation. However, patients who are not amenable to the awake procedure are contraindications.

Comparing morbidities of bone graft harvesting from the anterior iliac crest and proximal tibia: a retrospective study.

BACKGROUND: The anterior iliac crest (AIC) and proximal tibia (PT) are common donor sites for autologous bone graft harvesting. We compared pain levels at these harvest sites on 1 day, 5 days, 2 weeks, 4 weeks, and 8 weeks post-harvest. METHODS: We retrospectively reviewed 18 patients undergoing autologous bone grafting surgery at a level I trauma center between June 2013 and October 2014. Ten grafts were harvested from the AIC group and eight from the PT group. A standard visual analog scale (VAS) was used to rate pain at the harvest sites on postoperative day (POD) 1, 5, 14, 28, and 56 and at the recipient site on POD 1. RESULTS: There were no statistically significant differences between both groups in age (p = 0.474), gender (p = 1.00), incidence of harvest site morbidity (p = 1.00), and average VAS at the recipient site on POD 1 (p = 0.471). VAS at the harvest site on POD 1, 5, and 14 confirmed statistically that pain was more severe in the AIC group than in the PT group (p < 0.001). However, no significant difference was observed on POD 28 and 56 between both groups. Pain was significantly less on POD 1 in the PT group at the harvest site than at the recipient site (p < 0.001). CONCLUSIONS: The PT is a suitable harvest site, producing statistically less pain for at least two postoperative weeks than the AIC. Besides, patients report less postoperative pain at the PT harvest site than at the recipient site.

Single coracoclavicular suture fixation with Mersilene tape versus hook plate in the treatment of acute type V acromioclavicular dislocation: a retrospective analysis.

BACKGROUND: Here, we compared the clinical and radiographic outcomes between coracoclavicular (CC) fixation with Mersilene tape and hook plate for acute unstable acromioclavicular (AC) joint dislocation treatment. METHODS: We enrolled 49 patients with unstable acute AC dislocation who, between January 2010 and January 2014, underwent surgery with single CC suture fixation with Mersilene tape (M group, 25 cases) or clavicle hook plate (H group, 24 cases). In M and H groups, the average age was 43.7 (range 18-72) and 42.0 (range 17-84) years, the male to female ratio of each group was 15:20 and 19:5, and the injured side left to right ratio was 12:13 and 11:13, respectively. All patients were right-handed. We retrospectively compared the operation time, complication rate, visual analog scale (VAS), University of California at Los Angeles (UCLA) shoulder rating scale, Oxford shoulder scores, and the radiographic outcomes based on reduction loss of CC distance on postoperative follow-up. RESULTS: No significant difference in patient demographics between the two groups in age (p = 0.709), gender (p = 0.217), time from injury to surgery (p = 0.863), and injured side (p = 1.000). The mean follow-up was 26.2 months (range 24-35 months). Nine cases of reduction loss (36%) and one of distal clavicle osteolysis (4%) were noted in the M group. CC distance improvement in the H group was significantly superior to that in the M group at 3 months (before hook plate removal, p < 0.001) and 12 months postoperatively (after hook plate removal, p = 0.004), while subacromial erosions were revealed in nine cases (37.5%) in the H group. No significant difference in operative time (p = 0.846), complication rate (p = 1.000), VAS (p = 0.199), mean UCLA shoulder rating scale (p = 0.353), and Oxford shoulder (p = 0.224) scores between the two groups. CONCLUSIONS: Both hook plate and Mersilene tape fixations provided temporary stabilization of acute type V AC dislocation and yielded comparable clinical outcomes. The hook plate provided better maintenance of reduction of radiographic outcomes. CC suture fixation with Mersilene tape may serve as an alternative method of stabilization which provides acceptable outcome without the need of implant removal.

The titanium elastic nail serves as an alternative treatment for adult proximal radial shaft fractures: a cohort study.

BACKGROUND: To investigate whether closed reduction and internal fixation (CRIF) with titanium elastic nails (TENs) is a viable alternative treatment in proximal radial fractures. METHODS: In Kaohsiung Veterans General Hospital, from November 2013 to April 2015, five adult male patients with forearm injuries (average age 43 years; range 35-64 years) were treated for proximal radial shaft fractures. CRIF with TENs for radial shaft fractures was performed in these five patients. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated in our study. RESULTS: Mean follow-up period was 30 months (range 28-36 months). Average time of radius union was 7.3 months (range 6-10 months). Functional outcomes 1 year after operation revealed an average Quick DASH score of 7.92 (range 4.5-25), an average VAS of 1.5 (range 1-3), and average forearm supination and pronation of 69.2° (range 45°-75°) and 82.5° (range 80°-85°). No major complication was noted. CONCLUSIONS: CRIF with TEN for adult proximal radial fractures is a method to avoid extensive exposure or nerve injury during ORIF, especially in multiple trauma patients who require short operative time, uremia patients with ipsilateral forearm AV shunt, severe soft tissue swelling due to direct muscle contusion or strong muscularity before surgery, extensive radial fracture, and those in pursuit of cosmetic outcomes.

An Intramuscular Chondrolipoma of the Scapula: A Case Report of a Rare Tumor in an Unusual Location.

INTRODUCTION: Chondrolipomas are rare benign mesenchymal tumors primarily occurring in the shoulder region. To the best of our knowledge, only one case of chondrolipoma arising from the shoulder has been reported. We herein report an intramuscular chondrolipoma located in an unusual area of the scapula. Our case is interesting because magnetic resonance imaging (MRI) that shows lipomatous tumor masses with cartilaginous nodules may mislead surgeons into not considering the possibility of chondrolipomas. CASE REPORT: A 62-year-old female, without any systemic disease, trauma, or history of surgery, presented with a unique case of a large intramuscular chondrolipoma ofthe scapula. This protruding lump over the right shoulder was present for 3 months in the patient without pain or limited range of motion. A sonographic evaluation revealed a homogeneous hypoechoic lesion in the posterior right shoulder. MRI showed that the chondrolipoma measured 7.5 x 4.6 x 3.9 cm, without remarkable bony invasion, with high signal intensity over the mass in T1- weighted images, indicating cystic changes, and mild signal enhancement within the cyst in T2-weighted images. Surgical marginal excision was performed. We identified yellowish, greasy, and firm soft tissue and two cartilaginous nodules inside the lipomatous tissue. Pathological findings revealed mature adipose tissue with a fibrous capsule and true cartilage inside. Post-operative outpatient follow-up found no recurrence after 2 years. CONCLUSION: Intramuscular chondrolipoma arising from the shoulder has been rarely reported. MRI and sonography are helpful in the diagnosis.

Strategies for obstacle crossing in older adults with high and low risk of falling.

[Purpose] Tripping is a frequent cause of falls among aging adults. Appropriate limb movements while negotiating obstacles are critical to trip avoidance. The aim of our study was to investigate the mechanics of obstacle crossing in older adults at low or high risk of falling. [Subjects and Methods] Twenty community-dwelling adults aged ≥55 years, were evaluated with the Tinetti Balance and Gait scale and classified as being at high or low risk of falling. Between-group comparisons of kinematics were evaluated for obstacle heights of 10%, 20%, and 30% of leg length. [Results] The high-risk group demonstrated greater toe-obstacle clearance of the leading leg. Increasing obstacle height led to increased maximal toe-obstacle clearance, toe-obstacle distance, and shortened swing phase of the leading limb. Adaptation of clearance height was greater for the trailing leg. Individuals at high risk of falling demonstrated less symmetry between the leading and trailing legs and a narrower step width, features that increase the likelihood of tripping. [Conclusion] Kinematic parameters of obstacle clearance, including the symmetry index described in our study, could provide clinicians with a quick screening tool to identify patients at risk of falling and to evaluate outcomes of training programs.

The double-pulley technique for anatomical double-bundled medial patellofemoral ligament reconstruction.

INTRODUCTION: Majority of the current medial patellofemoral ligament (MPFL) reconstruction techniques vary with respect to methods of fixation on the patella. In an effort to maximise the area of patellar footprint coverage and minimise the complication of patellar fracture, we developed a procedure that implemented the double-pulley suture anchors technique. DESIGN: Prospective case series. SETTING: A primary medical centre in Kaohsiung, Taiwan. PATIENTS AND METHODS: Eighteen consecutive patients (18 knees) who met the inclusion criteria underwent the aforementioned operation between January 2010 and March 2012. Patients were evaluated using functional scores (Kujala and Tegner-Lysholm scores), apprehension test, and radiographic examination (congruence angle and patellar tilting angle) preoperatively and at the follow-up. RESULTS: The mean follow-up was 35 months. A firm endpoint to lateral patellar translation was noted in all patients at the last follow-up with a mean lateral translation quadrant of 1.5 (improved from 3.5 preoperatively, p<0.001). Both clinical and radiographic assessment improved significantly (p<0.001); the mean Kujala score improved from 55.3±6.8 preoperatively to 95.2±3.5 at the last follow-up; TegnerLysholm from 43.6±8.1 to 93.6±6.8; the mean congruence angle improved from 20.6°±2.1° preoperatively to -5.2°±2.4° at the last follow-up; and the patellar tilting angle from 23.8°±2.3° to 9.6°±1.3°. CONCLUSION: The double-pulley patellar fixation technique, by having a result that is comparable with those of other studies that used aperture fixation techniques, can be a promising surgical option for anatomically reconstructing the medial petellofemoral ligament.

Clinical results of using minimally invasive long plate osteosynthesis versus conventional approach for extensive comminuted metadiaphyseal fractures of the radius.

INTRODUCTION: The minimally invasive plate osteosynthesis (MIPO) technique has been introduced recently. The extensive comminuted fractures of the distal radial metaphysis with diaphyseal involvement are probably good indications for MIPO technique because of less extensive dissection and soft-tissue stripping. The purpose of this retrospective study was to compare the clinical results of MIPO technique to those of conventional open reduction in extensive metadiaphyseal fractures of distal radius. MATERIALS AND METHODS: Of 34 patients treated for comminuted metadiaphyseal fractures of the distal radius between June 2006 and May 2012, all the patients had extra-articular fractures. Twenty-one patients underwent MIPO technique and 13 underwent conventional open reduction with long periarticular locking plates system (Zimmer). Six patients in the MIPO group and three in the conventional group who had concomitant distal ulnar fractures or distal radioulnar joint (DRUJ) injury underwent plate osteosynthesis or Kirschner-wire fixation before radial fixation. Perioperative parameters and union time were recorded. Radiologic assessment, Mayo Wrist Score, and satisfaction scale were evaluated at the final follow-up. RESULTS: All fractures united without secondary procedures. Radiologic assessment, Mayo wrist score, and time to union showed no significant difference between the two groups, but the MIPO group had significantly smaller incision wound, higher satisfaction scale, and shorter operative time than did the conventional group. CONCLUSIONS: MIPO is capable of achieving functional results as good as those of conventional open reduction, with a higher satisfaction scale, smaller incision, and shorter operative time. When MIPO intervention is planned, concurrent distal ulnar fracture or DRUJ injury should be repaired first, thus facilitating subsequent indirect reduction. For treating intra-articular fractures, anatomical reduction of the articular surface is more important, and the MIPO technique described here is not recommended.

Comparison of outcome of unilateral locking plate and dual plating in the treatment of bicondylar tibial plateau fractures.

BACKGROUND: Tibial plateau fracture (TPF) includes different fracture patterns with varied degrees of articular depression and displacement. Many kinds of fixators, including newly designed plate with locking screws, were applied to treat these complicated fractures. We intended to follow up the surgical outcomes of (1) unilateral locking plate, (2) classic dual plates, or (3) hybrid dual plates for TPF. MATERIALS AND METHODS: We retrospectively reviewed 76 patients with TPF, Schatzker types V and VI, who we operated from June 2006 to May 2009 in our institute. Excluding patients who expired due to other medical conditions and without complete follow-up, 45 patients were sorted out in this series. The scheme of surgical intervention was designed by visiting staff, and 15 patients, as group I, were treated with unilateral locking plate. The other 19 patients, as group II, were treated with classic dual plates. The residual 11 patients, as group III, were treated with hybrid dual plates (one lateral approach locking compression plate (LCP) + medial anti-gliding plate). All patients were under periodic F/U at about 6 weeks interval for at least 18 months postoperatively. RESULTS: In group I, 13 cases achieved solid bony union without obvious traumatic OA change, limitation of ROM, or malalignment. In groups II and III, 15 and 10 patients reached the same goal, respectively. By analysis of the recorded parameters with statistical software (SPSS 12.0), there were five parameters with significant difference, including Schatzker classification, operation time, staged treatment or not, hospitalization period, and hardware impingement. CONCLUSIONS: There was no significant statistical difference of union rate between these three groups in our series. Based on our clinical follow-up, several key points were emphasized: (1) Soft tissue problems should be kept in mind, and usage of locking plate can reduce the discomfort of hardware impingement effectively. (2) The single lateral approach technique for TPF with locking plate results in less operation time and shorter hospitalization period. (3) If the medial buttress cannot be established by reduction of the lateral fracture, then open reduction of the medial side is necessary and buttresses the medial fragment by dual plates.

Comparison of single coracoclavicular suture fixation and hook plate for the treatment of acute unstable distal clavicle fractures.

BACKGROUND: Surgical managements are recommended for unstable distal clavicle fractures because of a high incidence of nonunion. A variety of methods have been previously reported, but there is no current consensus regarding which method is the most suitable. METHODS: Between December 2004 and August 2010, we treated 68 patients with Neer type IIB distal clavicle fractures using single coracoclavicular suture fixation with Mersilene tape (M group) or clavicular hook plate (H group). Sixty-eight patients were followed at least 24 months (mean, 37.9 months). We retrospectively compared the functional outcome, parameters, and perioperative course of the two treatments. Statistical analysis was performed with independent sample t test and chi-square test. RESULTS: The M group presented significantly less operation time (P = 0.005) and intra-operative blood loss (P = 0.010) than the H group. The mean University of California at Los Angeles (UCLA) shoulder rating scale, Oxford shoulder score, VAS scale, and satisfaction score revealed no significant difference between the M group and the H group. The M group had better range of motion in the operated shoulder during forward flexion and abduction at 3 and 6 months postoperatively. However, the range of motion at 1 and 2 years after operation revealed almost the same results. Two acromial osteolysis and one acromial fracture were noted in the H group and one superficial wound infection and one frozen shoulder in the M group during follow-up. Finally, there was no significant difference in the complication rate between the two groups, and all fractures achieved union clinically at final follow-up. CONCLUSIONS: Both single coracoclavicular suture fixation and clavicular hook plate offered effective treatment in acute unstable distal clavicle fractures. However, single coracoclavicular suture fixation with Mersilene tape provided early recovery of shoulder motion and avoided further morbidity of the acromion.

Influence of nail prominence and insertion point on anterior knee pain after tibial intramedullary nailing.

Chronic anterior knee pain is the most common complication after tibial nail insertion. Its etiology remains unknown, and multifactorial sources have been suggested. The authors believe that nail prominence and the insertion point of the nail are important in the development of anterior knee pain. The purpose of this retrospective study was to evaluate the roles of the insertion point and nail prominence in anterior knee pain after tibial intramedullary nailing using a transtendinous approach and a common nail type. A total of 108 patients with tibial shaft fractures underwent reamed intramedullary nailing using a transtendinous approach between 2006 and 2009. Mean follow-up was 26.8±5.0 months. A visual analog scale (0-100) was used to estimate anterior knee pain severity while patients performed 7 activities retrospectively. Radiographic assessments, including nail prominence and insertion point, were performed. Sixty (55.6%) patients experienced knee pain (group P) and 48 (44.4%) did not (group N). Significant differences were not found between the groups with respect to demographics, nail diameters, or fracture classifications. Less superior and more anterior nail prominences in radiographic assessments were significantly associated with anterior knee pain. When the insertion point was over the bottom half of the anterior cortex, the influence of anterior nail prominence was more obvious. Nail removal resulted in diminished pain during the 7 assessed activities. Nail insertion should be over the bottom half of the anterior cortex, with minimal anterior nail prominence. If anterior knee pain occurs, removal of the nail should be considered.

An open-label, prospective pilot clinical study of denosumab for severe hyperparathyroidism in patients with low bone mass undergoing dialysis.

CONTEXT: Denosumab is widely used for bone diseases with increased bone resorption. Its effectiveness in patients with severe secondary hyperparathyroidism on dialysis is unclear. OBJECTIVE: This study aimed to evaluate the efficacy and safety of denosumab in patients with severe secondary hyperparathyroidism who are on dialysis. DESIGN: This 6-month prospective, open-labeled study evaluated 12 patients (five women, seven men; mean age 53.5 ± 3.8 y). All had intact PTH (iPTH; > 1000 pg/mL), low bone mass (T-score < -1.0 SD), and bone pain and were poor surgical candidates. Serum calcium, phosphorus, alkaline phosphatase (AP), and iPTH levels were assessed at baseline and every month thereafter. Vertebral spine x-rays and bone mineral densities (BMDs) (lumbar spine and femoral neck) were assessed at the start and end of the study. All patients received denosumab (60 mg), calcitriol, phosphate binders, and dialysate calcium that were adjusted according to the biochemistry data. RESULTS: The BMD increased in both the femoral neck (mean increase 23.7% ± 4.0%) and lumbar spine (17.1% ± 2.6%) after 6 months. In the first month, most patients had increased iPTH levels, which dramatically decreased from 1702.1 ± 181.9 to 518.8 ± 126.8 pg/mL by the end of the study after increasing the calcitriol dose. All patients had significant decreases in AP, calcium × phosphorus, and bone pain. Changes in femoral neck BMD correlated only with AP and iPTH levels. CONCLUSIONS: Denosumab is effective in restoring bone mass and reducing bone pain in patients on dialysis with secondary hyperparathyroidism. It also allows for a more aggressive use of calcitriol to control hyperparathyroidism.

Free non-vascularized fibular strut bone graft for treatment of post-traumatic lower extremity large bone loss.

Post-traumatic large bone defects of more than 4 cm occur sometimes in open lower extremity fractures. Management of this kind trauma can be a challenge to orthopedic surgeons. We have managed this kind of bone defect by the use of free non-vascularized fibular strut bone grafts (FNVFG) harvested subperiosteally and held by screw fixation of the strut ends to the ends of the bone defect. Ten patients, eight males and two females, with a mean age of 44 years (range 26-76 years) underwent this procedure. The length of defect was 7.0 cm on average (ranging from 4 to 8 cm). Ten grafts (100%) united at both ends within an average of 6 months (range 5-9 months). Nine patients walked independently, and one patient walked with a stick. FNVFG is a simple procedure and a reliable method to bridge huge bone loss due to open fractures of lower extremities successfully in selected cases.

Impact of foot progression angle on the distribution of plantar pressure in normal children.

BACKGROUND: Plantar pressure distribution during walking is affected by several gait factors, most especially the foot progression angle which has been studied in children with neuromuscular diseases. However, this relationship in normal children has only been reported in limited studies. The purpose of this study is to clarify the correlation between foot progression angle and plantar pressure distribution in normal children, as well as the impacts of age and sex on this correlation. METHODS: This study retrospectively reviewed dynamic pedobarographic data that were included in the gait laboratory database of our institution. In total, 77 normally developed children aged 5-16 years who were treated between 2004 and 2009 were included. Each child's footprint was divided into 5 segments: lateral forefoot, medial forefoot, lateral midfoot, medial midfoot, and heel. The percentages of impulse exerted at the medial foot, forefoot, midfoot, and heel were calculated. FINDINGS: The average foot progression angle was 5.03° toe-out. Most of the total impulse was exerted on the forefoot (52.0%). Toe-out gait was positively correlated with high medial (r = 0.274; P < 0.001) and forefoot impulses (r = 0.158; P = 0.012) but negatively correlated with midfoot impulse (r = -0.273; P<0.001). The moderating effects of age and sex on these correlations were insignificant. INTERPRETATION: Foot progression angle demonstrates significant impact on the distribution of foot pressure, regardless of age or sex. Foot progression angle should be taken into consideration when conducting pedobarographic examinations and balancing plantar pressure as part of the treatment of various foot pathologies.

Biomechanical comparison of axial load between cannulated locking screws and noncannulated cortical locking screws.

The goal of this study was to compare the biomechanical stability of cannulated locking screws and noncannulated cortical locking screws in a periarticular locking plate. Twelve fresh-frozen porcine tibias with a 1-cm gap created distal to the tibial plateau were used to simulate an unstable proximal tibial fracture. All specimens were fixed with a periarticular proximal lateral tibial locking plate and divided into 2 groups based on whether the proximal metaphyseal screw holes of the plate were inserted with either cannulated locking screws or noncannulated cortical locking screws. An axial compressive load was applied to cause failure in each specimen using a materials testing instrument. The axial stiffness and maximum failure strength in axial loading were recorded. Axial stiffness of the constructs using noncannulated cortical locking screw was significantly higher than that of the constructs using cannulated locking screws (P=.006). Axial failure strength of the constructs using noncannulated cortical locking screw was significantly higher than that of the constructs using cannulated locking screws (P=.002). The failure mode observed in all specimens was a permanent screw-bending deformity over the head-shaft junction of proximal metaphyseal screws, irrespective of whether they were cannulated or noncannulated cortical locking screws. Fixation with noncannulated cortical locking screws offered more stability than cannulated locking screws with regard to axial stiffness and failure strength in a porcine model with unstable proximal tibial fractures.