Should hip fractures be operated upon only by specialist hip unit surgeons in order to lower rates of surgical site infection?

PURPOSE: The purpose of this study was to compare outcomes of hip fractures treated by orthopaedic surgeons, performed by specialist vs. non-specialist surgeons. The rate of surgical site infection (SSI) obtained is taken as the main variable. METHODS: This was a prospective controlled cohort study of 814 patients presenting with hip fractures, operated on by a group of orthopaedic surgeons within the same hospital department. Patients were classified according to whether the surgeons belonged to a specialist hip unit (group A = 212 cases) or not (group B = 602 cases). RESULTS: Multivariate logistic regression showed that there was no relation between gender, SSI, Charlson's index, preoperative period, surgical technique or study groups (A or B). Only age was a determinant factor (rank-sum test p = 0.03; OR 95% CI = 1.07, p = 0.005). CONCLUSIONS: Since there were no differences in the SSI outcome between surgeons working in a specialist hip unit and the general orthopaedic surgeons, delaying operative treatment for hip fractures to enable treatment in such a unit or creating a new unit of this type is not necessary. In this respect, the only significant variable is the patient's age.

Trapezio-metacarpal arthrodesis: procedure and results.

The high prevalence of trapezio-metacarpal joint (TMJ) osteoarthritis leads to develop techniques to improve surgical outcomes when conservative treatment has failed. We have evaluated 18 patients with Eaton III TMJ osteoarthritis, who underwent an arthrodesis. Using a dorsal-radial curved shaped skin incision the TMJ was exposed through the space between the abductor pollicis longus and the extensor pollicis brevis muscles. The articular capsule was divided and the TMJ was opened. Neat curettage was then performed in both joint surfaces by removing all the articular cartilage until some cancellous bone hints appeared underneath. The joint was then fixed in the optimal position by a 1.6 mm Kirschner wire and a 1.1 mm guide wire. A cannulated drill for the guide wire was used and matched to a cannulated lag screw. Then, a cylinder-shaped cancellous bone autograft harvested from the distal radius by a percutaneous approach was applied in the hole by drilling backwards in order to spread the bone about onto the hole walls. The joint was then definitively fixed by the cannulated lag screw. The K wires were removed by that time. DASH score changed from an average of 68 in the preoperative assessment to 39.4 at the end of the evolution time. The evolution of pain has decreased from 9.2 points preoperatively to 3.9 points in the postoperative using the visual analogue scale. In terms of mobility, it has decreased from 4 points preoperatively to 3.9 postoperatively, 14 patients got opposition of the thumb to the fifth finger, two of them to the head of the fifth metacarpal bone, one patient to the fourth finger, and one to the third. This slight decrease of mobility had no effect on performing activities of daily life, as expressed by the patients. The grip strength increased from 17 to 21.7 kg and the thumb opposition from 7.8 to 11.2 kg. All patients, except one, would have the operation again after knowing the final results. This patient said that results did not meet previous expectations. On the radiographic evaluation, consolidation has been achieved in 17 patients. When thumb carpo-metacarpal arthrodesis is indicated, the procedure provides a reliable and lasting treatment with satisfactory results. The development of new implants and the possibility of introducing autologous graft percutaneously as is described using this technique leads to improve the results.

Evaluation of posterolateral lumbar fusion in sheep using mineral scaffolds seeded with cultured bone marrow cells.

The objective of this study is to investigate the efficacy of hybrid constructs in comparison to bone grafts (autograft and allograft) for posterolateral lumbar fusion (PLF) in sheep, instrumented with transpedicular screws and bars. Hybrid constructs using cultured bone marrow (BM) mesenchymal stem cells (MSCs) have shown promising results in several bone healing models. In particular, hybrid constructs made by calcium phosphate-enriched cells have had similar fusion rates to bone autografts in posterolateral lumbar fusion in sheep. In our study, four experimental spinal fusions in two animal groups were compared in sheep: autograft and allograft (reference group), hydroxyapatite scaffold, and hydroxyapatite scaffold seeded with cultured and osteoinduced bone marrow MSCs (hybrid construct). During the last three days of culture, dexamethasone (dex) and beta-glycerophosphate (ß-GP) were added to potentiate osteoinduction. The two experimental situations of each group were tested in the same spinal segment (L4-L5). Spinal fusion and bone formation were studied by clinical observation, X-ray, computed tomography (CT), histology, and histomorphometry. Lumbar fusion rates assessed by CT scan and histology were higher for autograft and allograft (70%) than for mineral scaffold alone (22%) and hybrid constructs (35%). The quantity of new bone formation was also higher for the reference group, quite similar in both (autograft and allograft). Although the hybrid scaffold group had a better fusion rate than the non-hybrid scaffold group, the histological analysis revealed no significant differences between them in terms of quantity of bone formation. The histology results suggested that mineral scaffolds were partly resorbed in an early phase, and included in callus tissues. Far from the callus area the hydroxyapatite alone did not generate bone around it, but the hybrid scaffold did. In nude mice, labeled cells were induced to differentiate in vivo and monitored by bioluminescence imaging (BLI). Although the cultured MSCs had osteogenic potential, their contribution to spinal fusion when seeded in mineral scaffolds, in the conditions disclosed here, remains uncertain probably due to callus interference with the scaffolds. At present, bone autografts are better than hybrid constructs for posterolateral lumbar fusion, but we should continue to seek better conditions for efficient tissue engineering.

Immediate management of a stable patient with unstable pelvis.

The diagnosis of a traumatic unstable pelvis in a stable patient is a temporary concept depending on when we see the patient, as all patients presenting with hemorrhagic shock have hemodynamic stability until they become unstable. As a rule, the more unstable the pelvic fracture is, the higher the risk of bleeding and hemodynamic instability it has. Therefore, in unstable pelvic fractures, hemodynamic stability should be a diagnosis by exclusion. For bleeding detection in stable patients, an immediate one-stage contrast-enhanced CT scan is the appropriate diagnosis test; however, since CT scan radiation is always an issue, X-rays should be considered in those cases of hemodynamically stable patients in whom there is a reasonable suspicion that no unsafe bleeding is going on. Pelvic fracture classification is essential as usually there is an association between the injury mechanism, the fracture displacement, and the hemodynamic stability. Anteroposterior and, particularly, vertical traumatisms have much more proclivity to provoke major pelvic displacement and bleeding. The use of a pelvic binder, as early as possible including pre-hospital management, should be standard in high-impact blunt trauma patients independently of the trauma mechanisms. External fixation is the preferred method of stabilization in case of open fractures, and, in closed ones, when the schedule for definite osteosynthesis prolongs because of the patient's general condition. If possible, immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures produce excellent results even in open fractures.

L4 fixation is not necessary in L5-Iliac spinopelvic fixation after trauma, but coadjutant transilio-transsacral fixation is.

INTRODUCTION: Spinopelvic dissociation (SPD) is a severe injury characterized by a discontinuity between the spine and the bony pelvis consisting of a bilateral longitudinal sacral fracture, most of the times through sacral neuroforamen, and a horizontal fracture, usually through the S1 or S2 body. The introduction of the concept of triangular osteosynthesis has shown to be an advance in the stability of spinopelvic fixation (SPF). However, a controversy exists as to whether the spinal fixation should reach up to L4 and, if so, it should be combined with transiliac-transsacral screws (TTS). OBJECTIVE: The purpose of this study is to compare the biomechanical behavior in the laboratory of four different osteosynthesis constructs for SPD, including spinopelvic fixation of L5 versus L4 and L5; along with or without TTS in both cases. MATERIAL AND METHODS: By means of a formerly described method by the authors, an unstable standardized H-type sacral fracture in twenty synthetic replicas of a male pelvis articulated to the lumbar spine, L1 to sacrum, (Model: 1300, SawbonesTM; Pacific Research Laboratories, Vashon, WA, USA), instrumented with four different techniques, were mechanically tested. We made 4 different constructs in 5 specimen samples for each construct. Groups: Group 1. Instrumentation of the L5-Iliac bones with TTS. Group 2. Instrumentation of the L4-L5-Iliac bones with TTS. Group 3. Instrumentation of L5-Iliac bones without TTS. Group 4: Instrumentation of L4-L5-Iliac bones without TTS. RESULTS AND CONCLUSIONS: According to our results, it can be concluded that in SPD, better stability is obtained when proximal fixation is only up to L5, without including L4 (alternative hypothesis), the addition of transiliac-transsacral fixations is essential.

The treatment of bacterial biofilms cultivated on knee arthroplasty implants using the bioelectric effect.

Introduction: The formation of bacterial biofilms on knee arthroplasty implants can have catastrophic consequences. The aim of this study was to analyze the effectiveness of the bioelectric effect in the elimination of bacterial biofilms on cultivated knee arthroplasty implants. Methods: A novel device was designed to deliver a bioelectric effect on the surface of knee arthroplasty implants. 4-femoral prosthetic implants were cultivated with a staphylococcus aureus inoculum for 15 days. The components were divided into four different groups: A (not treated), B (normal saline 20-minutes), C (bioelectric effect 10-minutes), D (bioelectric effect 20-minutes). The implants were sonicated, and the detached colonies were quantified as the number of colony-forming unit (CFUs). The implants were sterilised and the process was repeated in a standardized manner four more times, to obtain a total of five samples per group. Results: The number of the CFUs after a 10-minute exposure to the bioelectric effect was of 208.2 ± 240.4, compared with 6,041.6 ± 2010.7 CFUs in group A, representing a decrease of 96.5% ± 4.3 (p = 0.004). And a diminution of 91.8% ± 7.9 compared with 2,051.0 ± 1,364.0 CFUs in group B (p = 0.109). The number of bacterial colonies after a 20-minute exposure to the bioelectric effect was 70 ± 126.7 CFUs, representing a decrease of 98.9% ± 1.9 (p = 0.000) compared with group A. And a decrease of 97.8% ± 3.0 (p = 0.019) compared with group B. Conclusions: The bioelectric effect was effective in the elimination of bacterial biofilm from knee arthroplasty implants. This method could be used in the future as part of conventional surgical procedures.

Treatment of periprosthetic infections: an economic analysis.

This review summarizes the existing economic literature, assesses the value of current data, and presents procedures that are the less costly and more effective options for the treatment of periprosthetic infections of knee and hip. Optimizing antibiotic use in the prevention and treatment of periprosthetic infection, combined with systemic and behavioral changes in the operating room, the detection and treatment of high-risk patient groups, as well as the rational management of the existing infection by using the different procedures according to each particular case, could allow for improved outcomes and lead to the highest quality of life for patients and the lowest economic impact. Nevertheless, the cost-effectiveness of different interventions to treat periprosthetic infections remains unclear.

The Use of ß-Blockers and the Risk of Undergoing a Knee Arthroplasty: A Nested Case-Control Study.

BACKGROUND: Research has indicated that ß-blockers may downregulate various inflammatory mediators that are involved in osteoarthritis (OA). The objective of this study was to analyze the likelihood of total knee arthroplasty (TKA) among patients with OA who were being treated with ß-blockers. METHODS: A nested case-control study was conducted with use of clinical records from our institutional database. We included patients who attended our outpatient clinic with a history of new-onset knee pain between 2010 and 2019. The case group included individuals who had undergone primary TKA between 2018 and 2019, whereas the control group included subjects who had not undergone TKA. Controls were matched by date of birth ±2 years, sex, calendar time (first outpatient visit ±1 year), and the grade of arthritis; the control-to-case ratio was 1:1. Adherence to ß-blocker use was measured with use of the proportion of days covered (PDC) (i.e.,<0.25, ≥0.25 to <0.75, ≥0.75), and the cumulative effect was measured on the basis of the total number of years of treatment with ß-blockers. A binary logistic regression analysis adjusted to potential confounders was carried out to assess the risk of TKA associated with the intake of ß-blockers. RESULTS: A total of 600 patients were included (300 in the case group and 300 in the control group). Compared with non-users, any use of ß-blockers during the follow-up period was associated with a reduction in the likelihood of undergoing TKA (adjusted odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77). The adjusted ORs for the use of selective ß1-blockers and nonselective ß1-blockers were 0.69 (95% CI, 0.36 to 1.31) and 0.42 (95% CI, 0.24 to 0.70), respectively. The adjusted ORs for any recent use, PDC of <0.25, PDC of ≥0.25 to <0.75, and PDC of ≥0.75 were 0.65 (95% CI, 0.51 to 0.99), 0.62 (95% CI, 0.21 to 1.85), 0.32 (95% CI, 0.09 to 1.22), and 0.55 (95% CI, 0.34 to 0.88), respectively. Regarding the cumulative effect of ß-blockers, the adjusted ORs for the use for <1 year, ≥1 to <5 years, and ≥5 years were 0.41 (95% CI, 0.20 to 0.85), 0.52 (95% CI, 0.21 to 1.33), and 0.36 (95% CI, 0.22 to 0.60), respectively. CONCLUSIONS: The use of nonselective ß-blockers was associated with a lower likelihood of undergoing TKA. Patients treated for prolonged periods were at a lower likelihood for undergoing TKA. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness analysis of the Geriatric Fracture Center (GFC) concept: a prospective multicentre cohort study.

INTRODUCTION: Geriatric Fracture Centers (GFCs) are dedicated treatment units where care is tailored towards elderly patients who have suffered fragility fractures. The primary objective of this economic analysis was to determine the cost-utility of GFCs compared with usual care centres. METHODS: The primary analysis was a cost-utility analysis that measured the cost per incremental quality-adjusted life-year gained from treatment of hip fracture in GFCs compared with treatment in usual care centres from the societal perspective over a 1-year time horizon. The secondary analysis was a cost-utility analysis from a societal perspective over a lifetime time horizon. We evaluated these outcomes using a cost-utility analysis using data from a large multicentre prospective cohort study comparing GFCs versus usual care centres that took place in Austria, Spain, the USA, the Netherlands, Thailand and Singapore. RESULTS: GFCs may be cost-effective in the long term, while providing a more comprehensive care plan. Patients in usual care centre group were slightly older and had fewer comorbidities. For the 1-year analysis, the costs per patient were slightly lower in the GFC group (-$646.42), while the quality-adjusted life-years were higher in the usual care centre group (+0.034). The incremental cost-effectiveness ratio was $18 863.34 (US$/quality-adjusted life-year). The lifetime horizon analysis found that the costs per patient were lower in the GFC group (-$7210.35), while the quality-adjusted life-years were higher in the usual care centre group (+0.02). The incremental cost-effectiveness ratio was $320 678.77 (US$/quality-adjusted life-year). CONCLUSIONS: This analysis found that GFCs were associated with lower costs compared with usual care centres. The cost-savings were greater when the lifetime time horizon was considered. This comprehensive cost-effectiveness analysis, using data from an international prospective cohort study, found that GFC may be cost-effective in the long term, while providing a more comprehensive care plan. A greater number of major adverse events were reported at GFC, nevertheless a lower mortality rate associated with these adverse events at GFC. Due to the minor utility benefits, which may be a result of greater adverse event detection within the GFC group and much greater costs of usual care centres, the GFC may be cost-effective due to the large cost-savings it demonstrated over the lifetime time horizon, while potentially identifying and treating adverse events more effectively. These findings suggest that the GFC may be a cost-effective option over the lifetime of a geriatric patient with hip fracture, although future research is needed to further validate these findings. LEVEL OF EVIDENCE: Economic, level 2. TRIAL REGISTRATION NUMBER: NCT02297581.

Result of a pyrocarbon prosthesis after comminuted and unreconstructable radial head fractures.

BACKGROUND: The purpose of this study is to analyze the results of treating unreconstructable acute radial head fractures associated with other elbow fractures and soft-tissue injuries with a pyrocarbon radial head prosthesis replacement, as well as repair of the associated injuries. MATERIALS AND METHODS: Twenty-eight patients with Mason type III unreconstructable and unstable radial head fractures and with associated injuries (according to Hotchkiss classification modified by van Riet) were treated with a pyrocarbon radial head prosthesis replacement; repair of collateral ligaments and associated elbow fractures was also carried out. Patients were evaluated in accordance with the Mayo Elbow Performance Score, measuring pain, grip strength, range of motion, and stability, as well as radiographic images. RESULTS: After a mean of 32 months postoperatively (range, 12-62 months), the mean Mayo Elbow Performance Score was 92 points. The result was considered excellent or good in 25 patients, with a high degree of satisfaction and functional restoration. CONCLUSION: The results of treating Mason type III radial head fractures with additional elbow fractures and soft-tissue injuries with pyrocarbon radial head prostheses are satisfactory; nevertheless, long-term follow-up is still necessary.

ACL reconstruction with single tibial tunnel: single versus double bundle.

Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction is designed with the aim of reproducing the anatomy and the function of a healthy knee. This can be done by creating two femoral tunnels and one tibial tunnel (DB-3T), or two femoral and two tibial tunnels (DB-4T), There is very little comparative information regarding DB-3T, which is supposed to be more anatomical than DB-4T, and single bundle (SB). DB-3T reconstruction produces greater joint stability and clinical behavior than SB. Consecutive patients with a unilateral rupture of the ACL treated with the DB-3T technique, and a control group of 36 nonconcurrent patients, with similar conditions, treated with the SB technique were followed during 2 years. Anterior/posterior translation (APT), pivot-shift test, one-leg hop, and IKDC (International Knee Documentation Committee) subjective evaluations were performed. There were no significant differences in the reduction of APT. However, there was a significant improvement in the remaining parameters in the DB-3T group: greater reduction in rotational instability, greater one-leg hop capacity, and greater subjective evaluation. At the 2-year follow-up, patients having undergone ACL reconstruction using hamstring tendons by means of a DB technique with a single tibial tunnel showed greater rotational stability, greater one-legged hop capacity, and a greater subjective evaluation than those having undergone SB reconstruction.

Surgical treatment of spondylodiscitis. An update.

CONCEPT: Spondylodiscitis refers to an infection affecting the intervertebral disk, the vertebral body or the posterior arch of the vertebra being aetiologically, pyogenic, granulomatous (tuberculosis, brucellosis, or fungal infection) or parasitic. DIAGNOSIS: Spondylodiscitis diagnosis is based on clinical symptoms, a combination of erythrocyte sedimentation rate with C-reactive protein (CRP) tests and, less useful, leukocytosis. Blood culture is also a very cost-effective method of identifying organisms. Plain radiographs are useful, however changes may take several months to appear. Radionuclide tests are currently less used; nevertheless, fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) shows encouraging results particularly when magnetic resonance images (MRI) are unconvincing in the distinction between degenerative changes and infection. MRI with gadolinium enhancement is the choice for image diagnosis. MANAGEMENT: Medical management is usually the basis for treatment, alone or in combination with surgery. Surgical approach, either by endoscopy or open, is indicated for biopsy when clinical evolution is unsatisfactory and no micro-organism has been isolated, and also whenever a root, spinal cord or dural compression is seen on MRI; spinal instability or severe deformity are also clear indications for surgical treatment. Less invasive surgery either CT-scan guided or, particularly, by endoscopy has good results. However open surgery is still the standard. The anterior approach allows for anterior disc and bone debridement. The posterior approach is indicated when posterior elements are involved or in the presence of an epidural abscess. Although good results have been claimed, the use of instrumentation in the presence of an infected focus is controversial, as the use of cages or BMPs are.

Spondylodiscitis in patients under haemodyalisis.

PURPOSE: The purpose of this study was to reach conclusions about the diagnosis and treatment of a series of patients with spondylodiscitis under haemodialysis treatment. METHODS: We collected and studied 23 patients included in a prospective database from two neighbouring hospitals. Descriptive statistical analysis was performed. RESULTS: The diagnosis was frequently made very late and early negative cultures were not uncommon; magnetic resonance images allowed for an early diagnosis with accurate anatomical information. Empirical antibiotic treatment with prompt surgery produced good results in patients under risk of, or having neurological problems. Surgical approaches did not differ from pyogenic or tuberculous spondylodiscitis. Age in our series was not a predictive issue. CONCLUSIONS: Whenever a patient under haemodialysis has symptoms of spinal disease, particularly back pain with fever, they should undergo an MRI. If diagnosis of spondylodiscitis is made prompt empirical antibiotherapy should be instituted. Blood cultures should be performed and tissue samples taken for cultures; however, culture outcome must not delay therapy. Early surgical decompression leads to good results.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study.

OBJECTIVE: The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes. DESIGN: Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year. SETTING: International (six countries, three continents) multicentre study. PARTICIPANTS: 281 patients aged ≥70 with operatively treated proximal femur fractures. INTERVENTIONS: Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy. OUTCOME MEASURES: Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life. RESULTS: Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002). CONCLUSIONS: Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02297581.

Editorial. The Challenges of Orthopaedic Trauma in Spain.

Spain is considered the healthiest nation in the world, due to lifepromoting aspects such as good diet, care facilities and a favourable family environment. However, although increased life expectancy is an indicator of development, it may have a negative impact on the other two variables of health service efficiency, namely health expenditure per capita and its relative weight in Gross Domestic Product.

Should concurrent infections be treated before performing hip arthroplasty for hip fracture?

AIMS: A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery. METHODS: A total of 11 databases were examined using the COre, Standard, Ideal (COSI) protocol. Bibliographic searches (no chronological or linguistic restriction) were conducted using, among other methods, the Patient, Intervention, Comparison, Outcome (PICO) template. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for flow diagram and checklist. Final reading of the complete texts was conducted in English, French, and Spanish. Classification of papers was completed within five levels of evidence (LE). RESULTS: There were a total of 621 hits (526 COre; 95 Standard, Ideal) for screening identification, and 107 records were screened. Overall 67 full-text articles were assessed for eligibility, and 21 articles were included for the study question. A total of 46 full-text articles were excluded with reasons. No studies could be included in quantitative synthesis (meta-analyses), and there were many confounding variables including surgeons' experience, prosthesis models used, and surgical technique. CONCLUSION: Patients with hip fracture and with a viral infection in the upper respiratory tract or without major clinical symptoms should be operated on as soon as possible (LE: I-III). There is no evidence that patients with coronavirus disease 2019 (COVID-19) should be treated differently. In relation to pneumonia, its prevention is a major issue. Antibiotics should be administered if surgery is delayed by > 72 hours or if bacterial infection is present in the lower respiratory tract (LE: III-V). In patients with hip fracture and urinary tract infection (UTI), delaying surgery may provoke further complications (LE: I). However, diabetic or immunocompromised patients may benefit from immediate antibiotic treatment. Cite this article: Bone Joint Res 2020;9(12):884-893.

Composition and characteristics of trabecular bone in osteoporosis and osteoarthritis.

BACKGROUND: Bone strength depends on multiple factors such as bone density, architecture and composition turnover. However, the role these factors play in osteoporotic fractures is not well understood. PURPOSE: The aim of this study was to analyze trabecular bone architecture, and its crystal and organic composition in humans, by comparing samples taken from patients who had a hip fracture (HF) and individuals with hip osteoarthritis (HOA). METHODS: The study included 31 HF patients and 42 cases of HOA who underwent joint replacement surgery between 1/1/2013 and 31/12/2013. Trabecular bone samples were collected from the femoral heads and analyzed using a dual-energy X-ray absorptiometry, micro-CT, and solid-state high-resolution magic-angle-spinning nuclear magnetic resonance (MAS-NMR) spectroscopy. RESULTS: No differences in proton or phosphorus concentration were found between the two groups using 1H single pulse, 31P single pulse, 31P single pulse with proton decoupling NMR spectroscopy, in hydroxyapatite (HA) c-axis or a-axis crystal length. Bone volume fraction (BV/TV), trabecular number (Tb.N), and bone mineral density (BMD) were higher in the HO group than in the HF group [28.6% ± 10.5 vs 20.3% ± 6.6 (p = 0.026); 2.58 mm-1 ± 1.57 vs 1.5 mm-1 ± 0.79 (p = 0.005); and 0.39 g/cm2 ± 0.10 vs. 0.28 g/cm2 ± 0.05 (p = 0.002), respectively]. The trabecular separation (Tp.Sp) was lower in the HO group 0.42 mm ± 0.23 compared with the HF group 0.58 mm ± 0.27 (p = 0.036). In the HO group, BMD was correlated with BV/TV (r = 0.704, p < 0.001), BMC (r = 0.853, p < 0.001), Tb.N (r = 0.653, p < 0.001), Tb.Sp (-0.561, p < 0.001) and 1H concentration (-0.580, p < 0.001) in the HO group. BMD was not correlated with BV/TV, Tb.Sp, Tb.Th, Tb.N, Tb.PF, 1H concentration or HA crystal size in the HF group. CONCLUSIONS: Patients with HO who did not sustain previous hip fractures had a higher femoral head BMD, BV/TV, and Tb.N than HF patients. In HO patients, BMD was positively correlated with the BV/TV and Tb.N and negatively correlated with the femoral head organic content and trabecular separation. Interestingly, these correlations were not found in HF patients with relatively lower bone densities. Therefore, osteoporotic patients with similar low bone densities could have significant microstructural differences. No differences were found between the two groups at a HA crystal level.

Pin tract infection prophylaxis and treatment.

Pin tract infection in external fixation (ExFix) is a frequent finding which can eventually lead to loosening, osteomyelitis and loss of fixation. Its diagnosis is based on high empiricism and low validity, although it is possible to distinguish between minor and major infection. The first is limited to soft tissues, whereas the latter includes bone involvement. The rate of infection after conversion of external fixation to intramedullary nailing (IMN) is not well known. Unfortunately, papers referring to infection after the conversion of ExFix to intramedullary nailing (IMN) are of evidence level IV or V. It is suggested that conversion of ExFix to IMN should be carried out in a 2 step regimen. The time interval of 2 step regimen is uncertain although some authors have recommended to occur within 9 days. There is no consensus as to which prophylaxis protocol should be applied prior to conversion. In order to throw more light into this important issue, registries capturing important related parameters to the development of infection should be established.

Damage control orthopaedics: State of the art.

Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the "second hit" effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.