A novel retractor-assisted closed reduction combined with percutaneous pinning fixation for the treatment of elderly distal radius fractures: a retrospective cohort study.

BACKGROUND: Percutaneous pinning fixation (PCP) has been used for the treatment of distal radius fractures for decades, especially in the elderly with fragile soft tissue. However, achieving and maintaining a sound anatomic reduction before PCP is difficult if we use the manipulative reduction method alone. Our study innovatively applied the Steinmann pin retractor for closed reduction combined with PCP, to provide a new protocol for the treatment of distal radius fractures. METHODS: From March 2017 to July 2018, 49 patients out of 57 that met the inclusion criteria but not the exclusion criteria were included in our retrospective cohort study. Sixteen patients were treated with Steinmann pin retractor-assisted closed reduction combined with PCP (S-PCP), and 19 patients were treated with the manipulative reduction combined with PCP (M-PCP), and 14 patients were treated with the manipulative reduction combined with cast splint (M-C). All these patients received a positive postoperative radiological and clinical evaluation. RESULTS: All the patients were followed up for a minimum of 2 years. The radiological parameters in each group improved significantly postoperative (posttreatment). In the S-PCP group, the values of radial height (postoperative, 13.33±1.74 mm; the first follow-up, 13.27±1.81mm; last follow-up, 13.16±1.76mm) and ulnar variance (postoperative, -0.10±1.29mm; the first follow-up, -0.05±1.27mm; last follow-up, -0.12±1.09mm) significantly improved as compared to the M-PCP and M-C groups. While the patients in the M-C group experienced significant re-displacement at the first and last follow-ups, in the S-PCP group, the range of wrist motion including extension (89.94±5.21%), radial deviation (90.69±6.01%), and supination (90.25±5.87%); ulnar deviation (89.81±5.82%) and QuickDASH score (2.70±3.64); and grip strength (92.50±5.59%), pronation (90.50±6.04%), and modified Mayo wrist score (90.94±4.17, the excellent rate reached up to 75%) also improved as compared to the M-PCP group, M-C group, or both groups at the last follow-up. CONCLUSION: S-PCP improves fracture reduction and wrist function and can serve as an effective method for A2(AO/OTA) and A3 type of distal radius fractures in the elderly with limited dorsal comminution, including intra-articular fractures with displacement less than 2mm.

Mid- and Long-Term Outcome After Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Refixation-Good to Excellent Results in Spite of Some Loss of Stability of the Distal Radioulnar Joint.

PURPOSE: To evaluate mid- and long-term outcomes after arthroscopically-assisted transosseous reattachment of the triangular fibrocartilage complex (TFCC) and to analyze the association of distal radioulnar joint (DRUJ) stability with the clinical outcome. METHODS: Patients treated with an arthroscopically-assisted transosseous reattachment of the deep layer of the TFCC between 2000 and 2009 and a minimum follow-up of 12 months at mid-term and 4 years at long-term follow-up were retrospectively reviewed. Mayo Modified Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; pain visual analogue scale (VAS); grip strength and stability of the DRUJ were assessed at 2 follow-up clinical examinations. At the last follow-up, the Patient-Rated Wrist Evaluation score was additionally recorded. RESULTS: Thirty patients with a mean age of 29 (±13) years were included. Most of the patients were female (70%, n = 21). The mid-term evaluation took place at a median of 30 months (range, 12-83 months). The assessed scores showed statistically significant clinical improvement (MMWS, P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 23 (76.7%) patients. At a median of 106 months (range 52-215 months), the long-term clinical assessment was performed. The evaluated scores demonstrated persisting significant improvement (MMWS P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 19 patients (63.3%). DRUJ instability did not correlate with clinical outcome. No permanent surgery-related complications occurred. CONCLUSION: Arthroscopically-assisted transosseous reattachment of the deep fibers of radioulnar ligaments leads to excellent and good clinical results in mid- and long-term follow-up. In 95.5% of the analyzed patients, the measured improvement in the DASH score exceeded the in literature reported minimal clinically important difference of 13.5. Loss of DRUJ stability during follow-up was not associated with deterioration of clinical parameters and patient satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Radial neck fracture in children: anatomic and functional results of Metaizeau technique.

Fractures of the radial neck accounts for 1% of all childhood fractures and 5% to 10% of childhood traumatic lesions involving the elbow. Intramedullary percutaneous nail reduction (Metaizeau technique) is considered the most effective surgical technique. The purpose of this study was to identify the main clinical features of radial neck fracture in children and to evaluate the anatomical and functional results of the Metaizeau technique. In this retrospective study, we evaluated 22 patients under the age of 16 who were treated for radial neck fracture at the orthopedic and trauma surgery department of Sahloul University Hospital in Sousse over a period of 16 years from January 2001 to April 2017. Authors used Metaizeau classification. Functional results were evaluated by Mayo elbow performance score (MEPS) and the radiological evaluation was based on standard images with measurement of the residual rocker. The average age was 8.6 years (5-13 years). Seven fracture were grade III injuries and three grade IV. In the immediate postoperative period, radiological measurements showed a residual rocker less than 20° in 86.3% and more than 20° in 13.7% of cases. At an average follow-up of 13 months and a half, the MEPS score was excellent and good for 17 patients. Four types of complications were found: necrosis of the radial head in 1 case, pseudarthrosis in 1 case, periarticular calcification in 2 cases and stiff-ness of the elbow in 3 cases. Despite the small number of patients in our series, we believe that the elastic stable intramedullary pinning according to the Metaizeau technique is the treatment of choice for displaced radial neck fractures in children.

Biomechanical analysis of simultaneous distal and proximal radio-ulnar joint instability.

BACKGROUND: Simultaneous dislocation of the proximal and distal radio-ulnar joints without bony injuries has been reported, but the mechanism remains unclear. We investigated concurrent proximal and distal radio-ulnar joint instability after sequential sectioning of the annular ligament, triangular fibrocartilage complex, and quadrate ligament. METHODS: We performed this biomechanical study with six fresh-frozen cadaveric upper extremities. Proximal and distal radio-ulnar joint displacement was measured using an electromagnetic tracking device during passive mobility testing with anterior, lateral, and posterior loads on the radial head with pronation, supination, and neutral rotation. Measurements were statistically analyzed using the generalized linear mixed model. FINDINGS: Proximal radio-ulnar joint instability was significantly greater after sectioning of the annular (lateral: 1.4%, P < .05; posterior: 0.7%, P < .05) and quadrate (lateral: 43.7%, P < .05; posterior: 29.5%, P < .05) ligament. Distal radio-ulnar joint instability was significantly greater in every sequential stage (final stage: anterior: 24.1%, P < .05; lateral 21.0%, P < .05; posterior: 31.3%, P < .05). Finally, significant simultaneous instability of the joints was observed after sectioning of the annular ligament, triangular fibrocartilage complex, and quadrate ligament, and neutral rotation potentially induced gross instability. INTERPRETATION: Our ligament injury model induced simultaneous proximal and distal radio-ulnar joint instability without bony or interosseous membrane injury, probably induced by severe soft tissue injury. Proximal radio-ulnar joint instability may influence distal radio-ulnar joint instability from pivoting of the interosseous membrane. Our findings will help surgeons evaluate the magnitude of soft tissue injury and plan surgery for patients with simultaneous proximal and distal radio-ulnar joint instability.

Effect of ulnar angulation and soft tissue sectioning on radial head stability in anterior Monteggia injuries: an in vitro biomechanical study.

BACKGROUND: Radial head instability continues to be a challenge in the management of anterior Monteggia injuries; however, there is a paucity of literature on the factors that contribute to this instability. The aim of this biomechanical investigation was to examine the effects of ulnar angulation and soft tissue insufficiency on radial head stability in anterior Monteggia injuries. METHODS: Six cadaveric arms were mounted in an elbow motion simulator. Radial head translation was measured during simulated active elbow flexion with the forearm supinated. After testing the elbows in the intact state, the ulna was osteotomized and tested at 0°, 10°, 20°, and 30° of extension angulation. To examine the effect of soft tissue insufficiency, the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane (IOM) were sequentially sectioned. RESULTS: There was a significant increase in anterior radial head translation with greater ulnar extension angulation. Sequential soft tissue sectioning also significantly increased anterior radial head translation. There was no increase in radial head translation with isolated sectioning of the anterior radiocapitellar joint capsule. Additional sectioning of the annular ligament and quadrate ligament slightly increased anterior radial head translation but did not reach statistical significance. Subsequent sectioning of the proximal and middle IOM resulted in significant increases in anterior radial head translation. CONCLUSION: Our study demonstrates that progressive ulnar extension angulation results in an incremental increase in anterior radial head translation in anterior Monteggia injuries. Moreover, increasing magnitudes of soft tissue disruption result in greater anterior radial head instability.

Correlation between radiographic findings and clinical failure in monopolar radial head replacement.

INTRODUCTION: The purpose of this study is to analyze the mid-term outcomes of a modular monopolar type of radial head arthroplasty in the treatment of complex fractures associated with acute elbow joint instability. We postulated that radiographic changes are related to the development of clinical complications. MATERIALS AND METHODS: We evaluated at last follow-up 26 radial head arthroplasties in 26 consecutive patients who were followed for at least one and a half year. All patients had suffered radial head fractures (Mason III) in the context of unstable elbow injuries. Definitive treatment of the radial fracture was performed with modular and monopolar prosthesis which was inserted as a press fit. All patients were evaluated preoperatively and postoperatively. The evaluation included a clinical examination and a protocolized imaging study (standard X-Rays and CT) of the elbow. We analyzed the incidence of: heterotopic ossifications, secondary radiocapitellar joint osteoarthritis, hardware loosening, hardware disengagement, and joint infection. Diagnosis of clinical failure of the implant was defined as the time to the second surgery due to major complications related to the prosthesis, such as persistent lateral side pain or elbow stiffness and any kind of implant instability or dislocation. RESULTS: The implant-specific reoperation rate was 15% (four reoperations). The need for the second surgery was statistically associated with heterotopic ossifications, radiocapitellar osteoarthritis and cortical resorption around radial neck (p = 0.054, p = 0.033, and p = 0.019, respectively), being periprosthetic osteolysis the most likely factor related to failure, and radial pain the main symptom leading to surgical revision. CONCLUSIONS: Our study shows a positive association between radiographic findings and patient symptoms for postoperative complications after radial head arthroplasty. Failed radial head replacements may lead to reoperation mainly due to pain, and this can be distinguished from other causes of pain in elbow region based on its radial location. Radiological loosening was prevalent in this group of failed replacement.

Bone Health Following Bariatric Surgery: An Update.

Obesity rates are increasing rapidly, and bariatric surgery is currently the most effective tool for weight loss. Recently, bariatric surgery induced bone loss has gained attention. Such detrimental effect on bone is multifactorial and causes may include nutrient deficiencies, gut and gonadal hormonal changes, mechanical unloading, loss of lean mass, increased bone marrow fat, and increased risk of fall. This review describes the available evidence on bone loss and fracture risk following bariatric surgery and summarizes the guidelines on the topic. Increased bone resorption starts early postsurgery, and bone markers peak at 1-2 yr. Across studies, the drop in areal bone mineral density is inconsistent at the lumbar spine, while a 2%-5% drop at 6 mo and a 6%-10.5% at 9-12 mo are observed at the total hip. Conversely, studies using quantitative CT showed a 6%-7% decrease in volumetric bone mineral density at the lumbar spine at 6-12 mo postsurgery. These studies also report significant bone loss at the radius and tibia, in addition to alteration in bone microarchitecture. Fracture risk increases 2 yr after surgery, more so following malabsorptive procedures. Fractures were reported at axial, weight bearing sites and at appendicular sites. The available evidence is very heterogeneous, and mostly derived from studies on Roux-en-y gastric bypass in premenopausal women. Data on restrictive procedures is scarce. Our findings suggest that the early postoperative phase represents the "golden window" to intervene and promote bone health. More research is needed to determine the effect of different bariatric procedures on bone, to identify optimal interventions to prevent bone loss and to characterize high risk individuals who should be targeted.

Instability of the proximal radioulnar joint in Monteggia fractures-an experimental study.

BACKGROUND: A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach. METHODS: Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane. RESULTS: An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures. CONCLUSION: On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

Thrombocytopenia with absent radii (TAR) syndrome in a female neonate: a case report.

Thrombocytopenia absent radius (TAR) syndrome is a rare congenital disorder that is consistently associated with skeletal abnormality and thrombocytopenic haemorrhage. This is a case of a neonate with bilateral absent radius and thrombocytopenia. The rarity of this case prompted this report.

High FGF23 levels are associated with impaired trabecular bone microarchitecture in patients with osteoporosis.

This cross-sectional study examined the associations between c-terminal FGF23 levels, laboratory markers of bone metabolism and bone microarchitecture in 82 patients with osteoporosis. Higher FGF23 levels were associated with impaired trabecular but not cortical bone microarchitecture, and this was confirmed after adjusting for confounding variables such as age or BMI. INTRODUCTION: Fibroblast growth factor 23 (FGF23) is an endocrine hormone-regulating phosphate and vitamin D metabolism. While its mode of action is well understood in diseases such as hereditary forms of rickets or tumor-induced osteomalacia, the interpretation of FGF23 levels in patients with osteoporosis with regard to bone microarchitecture is less clear. METHODS: C-terminal FGF23 levels and bone turnover markers were assessed in 82 patients with osteoporosis (i.e., DXA T-score ≤ - 2.5 at the lumbar spine or total hip). Bone microarchitecture was measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) at the distal radius and tibia. Data were analyzed in a cross-sectional design using correlation and regression models. RESULTS: We found a significant negative logarithmic correlation between FGF23 levels and trabecular but not cortical bone microarchitecture at both skeletal sites. Furthermore, using a multiple linear regression model, we confirmed FGF23 as a predictor for reduced trabecular parameters even when adjusting for confounding factors such as age, BMI, phosphate, bone-specific alkaline phosphatase, vitamin D3, and PTH. CONCLUSIONS: Taken together, high FGF23 levels are associated with impaired trabecular bone microarchitecture in osteoporosis patients, and this association seems to occur after adjustment of confounding variables including phosphate and vitamin D. Future longitudinal studies are now needed to validate our findings and investigate FGF23 in relation to fracture risk.

Abaloparatide effect on forearm bone mineral density and wrist fracture risk in postmenopausal women with osteoporosis.

PURPOSE: Wrist fractures are common, contribute significantly to morbidity in women with postmenopausal osteoporosis, and occur predominantly at the ultradistal radius, a site rich in trabecular bone. This exploratory analysis of the phase 3 ACTIVE study evaluated effects of abaloparatide versus placebo and teriparatide on forearm bone mineral density (BMD) and risk of wrist fracture. METHODS: Forearm BMD was measured by dual energy X-ray absorptiometry in a subset of 982 women from ACTIVE, evenly distributed across the three treatment groups. Wrist fractures were ascertained in the total cohort (N = 2463). RESULTS: After 18 months, ultradistal radius BMD changes from baseline were 2.25 percentage points greater for abaloparatide compared with placebo (95% confidence interval (CI) 1.38, 3.12, p < 0.001) and 1.54 percentage points greater for abaloparatide compared with teriparatide (95% CI 0.64, 2.45, p < 0.001). At 18 months, 1/3 radius BMD losses (versus baseline) were similar for abaloparatide compared with placebo (-0.42; 95% CI -1.03, 0.20; p = 0.19) but losses with teriparatide exceeded those of placebo (-1.66%; 95% CI -2.27, -1.06; p < 0.001). The decline with abaloparatide was less than that seen with teriparatide (group difference 1.22%; 95% CI 0.57, 1.87; p < 0.001). The radius BMD findings, at both ultradistal and 1/3 sites, are consistent with the numerically lower incidence of wrist fractures observed in women treated with abaloparatide compared with teriparatide (HR = 0.43; 95% CI 0.18, 1.03; p = 0.052) and placebo (HR = 0.49, 95% CI 0.20, 1.19, p = 0.11). CONCLUSIONS: Compared with teriparatide, abaloparatide increased BMD at the ultradistal radius (primarily trabecular bone) and decreased BMD to a lesser extent at the 1/3 radius (primarily cortical bone), likely contributing to the numerically lower wrist fracture incidence observed with abaloparatide.

Disrupted radial and tibial microarchitecture in patients with monoclonal gammopathy of undetermined significance.

Patients with monoclonal gammopathy of undetermined significance (MGUS) had abnormalities in volumetric BMD (vBMD), microarchitecture, and stiffness at both the radius and tibia by high-resolution peripheral quantitative CT compared to matched controls. This is the first report demonstrating that patients with MGUS have microarchitectural deficits at multiple skeletal sites. INTRODUCTION: Fracture risk is elevated in patients with monoclonal gammopathy of undetermined significance (MGUS). However, the pathogenesis of bone disease in these patients is poorly understood. Prior work using high-resolution peripheral CT (HRpQCT) demonstrated abnormal microarchitecture at the radius, with predominantly cortical abnormalities. We hypothesized that patients with MGUS have abnormal microarchitecture at both radius and tibia compared to controls, reflecting global skeletal effects of the disease. METHODS: This case-control study enrolled 36 subjects; patients with MGUS (n = 12) were matched 1:2 by age, sex, and race to controls (n = 24). Areal BMD (aBMD) was measured by DXA, vBMD, and microarchitecture by HRpQCT, and whole bone stiffness by finite element analysis. Serum was drawn for markers of bone metabolism and inflammation. RESULTS: By DXA, MGUS patients had lower aBMD at the lumbar spine, femoral neck, and 1/3 radius. Markers of bone metabolism and inflammation did not differ. By HRpQCT at the radius, MGUS patients had lower total, trabecular and cortical density, lower trabecular number, and greater trabecular separation and heterogeneity. At the tibia, MGUS patients had lower total and trabecular density, lower trabecular number, greater separation and heterogeneity, and lower whole bone stiffness. CONCLUSIONS: Patients with MGUS had lower vBMD, cortical, and trabecular abnormalities at the radius compared to matched controls. At the tibia, trabecular abnormalities predominated. These results suggest that in addition to previously described cortical deficits, deterioration of trabecular bone may contribute to a generalized skeletal fragility in patients with MGUS.

Comparison of three plain radiography methods for evaluating proximal humerus bone strength in women.

BACKGROUND: We assessed the correlation between three methods for measuring cortical thickness of the humerus on a plain radiograph and bone mineral density measured by dual-energy X-ray absorptiometry in order to establish a simple bone strength evaluation method in patients at risk of proximal humerus fragility fracture. METHODS: In this retrospective study, 1732 patients underwent screening of the distal third radius, proximal femur, and lumbar spine by dual-energy X-ray absorptiometry. We identified 224 patients who also underwent anteroposterior shoulder radiography. Patients with fractures or who had undergone surgery in the region of interest were excluded. The study consisted of 80 women with a mean age of 76 years (range: 39-94 years). Cortical thickness, cortical index, and deltoid tuberosity index were determined to assess the proximal humerus. Correlation between bone mineral density measured by dual-energy X-ray absorptiometry and cortical thickness determined using these three methods was examined. We defined the osteoporosis group as patients satisfying both the World Health Organization criteria and the diagnostic criteria for primary osteoporosis (2012 revision) and compared values between the osteoporotic and non-osteoporotic groups. RESULTS: BMD correlated positively with cortical thickness, cortical index, and deltoid tuberosity index values, but the strength of correlation differed. These values were significantly lower in the osteoporotic group than in the non-osteoporotic group. Receiver operating characteristic curve analysis revealed that only the distal third radius had an area under the curve of 0.7 or more for all methods. CONCLUSIONS: All three methods yielded values that correlated with the dual-energy X-ray absorptiometry bone mineral density measured at the distal third radius, the proximal femur, and the lumbar spine. The correlation coefficient in the radius was high and differed significantly from those of weight-bearing bones (proximal femur, lumbar spine).

Associations between radius low-frequency axial ultrasound velocity and bone fragility in elderly men and women.

An exploratory study in elderly women and men from the Geneva Retirees Cohort indicates that low-frequency quantitative ultrasound measurement at the radius captures aBMD, bone size, and cortical tissue mineral density and might be used for screening purposes prior to DXA to evaluate fracture risk. INTRODUCTION: The contribution of distal radius bone mineral density (BMD) and cortical microstructure to fracture risk has recently been demonstrated. In this exploratory study, we investigated whether low-frequency quantitative ultrasound measurement at the distal radius may capture the peripheral determinants of bone fragility assessed with dual-energy X-ray absorptiometry (DXA) and high-resolution peripheral quantitative computed tomography (HR-pQCT). METHODS: Low-frequency velocity (VLF) was measured at the radius using OsCare Sono®, a portable axial transmission ultrasonometer, in 271 community-dwelling postmenopausal women and men (age 71.5 ± 1.4 years) from the Geneva Retirees Cohort. Cortical (Ct) and trabecular (Tb) volumetric (v) BMD and microstructure at the distal radius were assessed by HR-pQCT, in addition to areal (a) BMD by DXA, at the same time point. RESULTS: VLF was highly correlated with aBMD at the distal third radius (r = 0.72, p < 0.001). For microstructure parameters, the highest correlation was observed with cortical area (r = 0.59, p < 0.001). VLF also captured bone geometry (total area) and cortical tissue mineral density independently of aBMD. In models adjusted for age and sex, VLF was significantly associated with prevalent low-trauma fractures [OR 95%CI for one SD decrease of VLF 1.50 (1.05, 2.14), p = 0.024], with discrimination performance comparable to femoral neck or distal radius aBMD. CONCLUSION: Measurement of VLF at the radius captures aBMD, bone size, and cortical tissue mineral density and might be used for screening purposes prior to DXA to evaluate fracture risk.

Longitudinal 5-Year Evaluation of Bone Density and Microarchitecture After Roux-en-Y Gastric Bypass Surgery.

Context: Bone health declines in the initial years after Roux-en-Y gastric bypass (RYGB), but long-term skeletal effects are unclear. Objective: To document longitudinal changes in bone mineral density (BMD) and microarchitecture 5 years after RYGB. Design, Setting, and Participants: Prospective 5-year observational study of 21 adults with severe obesity receiving RYGB at an academic medical center. Main Outcome Measures: Spine and hip areal BMD were measured by dual-energy X-ray absorptiometry, and trabecular volumetric BMD (vBMD) of the spine was assessed by quantitative CT (QCT). We measured vBMD and microarchitecture of the distal radius and tibia by high-resolution peripheral QCT in a subset of subjects. Serum type I collagen C-terminal telopeptide (CTX) and procollagen type I N-terminal propeptide (P1NP) were also measured. Results: Areal BMD declined by -7.8% ± 7.6% at the spine and -15.3% ± 6.3% at the total hip by 5 years after RYGB (P ≤ 0.001), although the rate of bone loss slowed in later years. Trabecular spine vBMD decreased by -12.1% ± 12.3% by 5 years (P ≤ 0.001). At peripheral sites, vBMD continued to decrease steadily throughout 5 years, with parallel declines in cortical and trabecular microarchitecture, leading to decreases in estimated failure load of -20% and -13% at the radius and tibia, respectively (P < 0.001). Five years after RYGB, CTX and P1NP were 150% and 34% above baseline (P < 0.001 and P = 0.017, respectively). Conclusions: Sustained high-turnover bone loss and bone microarchitectural deterioration occur in the 5 years after RYGB. Adults receiving RYGB warrant assessment of bone health.

Effect of radiocapitellar Achilles disc arthroplasty on coronoid and capitellar contact pressures after radial head excision.

BACKGROUND: Long-term radiographic arthritis has been commonly reported after radial head excision. Concern over radial head arthroplasty may arise in certain situations including capitellar arthritis, radiocapitellar malalignment, and in young and active patients. We hypothesized that radial head excision increases coronoid contact pressures, which may at least be partially reduced by radiocapitellar Achilles tendon disc arthroplasty. METHODS: Coronoid and capitellar contact pressure was measured on 6 human cadaveric elbows on a custom-designed gravity-valgus simulator under passive flexion from 0° to 90°. Sequential testing, starting with the intact specimen, resection of the radial head, and finally, radiocapitellar Achilles tendon disc arthroplasty were performed on each specimen. RESULTS: Mean contact pressure of the coronoid significantly increased after radial head excision (P < .0001) and significantly improved after Achilles disc arthroplasty (P < .0001). The pressure difference was most pronounced on the lateral coronoid. From 15° to 85° of elbow flexion, mean contact pressures on the lateral coronoid were 291 kPa and 476 kPa before and after radial head excision, respectively (P < .0001). Achilles disc arthroplasty significantly lowered coronoid contact pressures to 385 kPa (P = .002); however, they remained significantly higher than those in the intact radial head group (P = .0009). CONCLUSIONS: Radial head resection increases contact pressure in the coronoid, especially the lateral coronoid. This study showed that radiocapitellar Achilles disc arthroplasty significantly improves contact pressures on the coronoid after radial head resection. Achilles disc arthroplasty could be considered in patients who are not candidates for radial head arthroplasty.

Long-term results after simple rotational osteotomy of the radius shaft for congenital radioulnar synostosis.

BACKGROUND: The present study was conducted to clarify the long-term (≥10 years) results of simple rotational osteotomy for congenital radioulnar synostosis (CRUS). METHODS: Twelve forearms in 9 Asian patients with CRUS who underwent simple rotational osteotomy of the radius shaft were monitored for an average of 13.6 years (range, 10-19 years) postoperatively. Before surgery, the forearm fixation averaged 51.3° of pronation (range, 30°-90°). The true position of the forearm in ankylosis was measured by a line through the styloid processes of the radius and the ulna. Palm pronation and supination angles were also measured. The osteotomy was performed at the insertion of the pronator teres to the shaft of the radius. The pronation position was then corrected manually to allow 90° of palm supination with compensatory rotation around the wrist, and a cast was applied. We evaluated activities of daily living items at a mean of 5.2 years after surgery. At the final follow-up, the 11-item version of the Disability of the Arm, Shoulder and Hand score was recorded. RESULTS: After surgery, the forearm was fixed at an average of 4.2° of supination. At the final follow-up, the palm was able to achieve an average motion arc ranging from 26° of pronation to 62° of supination. There were no neurologic or circulatory complications after surgery. Ability to perform daily activities was markedly improved, and all patients were satisfied with the results of surgery. The average score on the 11-item version of the Disability of the Arm, Shoulder, and Hand was 3.79 points at the final follow-up. CONCLUSION: Our procedure for forearm rotation in patients with CRUS is simple, reliable, satisfactory, and safe.

Long-Term and Recent Weight Change Are Associated With Reduced Peripheral Bone Density, Deficits in Bone Microarchitecture, and Decreased Bone Strength: The Framingham Osteoporosis Study.

Weight loss in older adults is associated with increased bone loss and fracture. Little is known about the potential impact of weight loss on cortical and trabecular bone density, microarchitecture, and strength. In this study, participants were members of the Framingham Offspring Cohort (769 women, 595 men; mean age 70 ± 8 years), who underwent high-resolution peripheral quantitative computed tomography (HR-pQCT) scanning at the tibia and radius in 2012 to 2016. Weight measurements taken every 4 to 6 years were used to assess recent weight change over 6 years and long-term change over 40 years. General linear models, adjusting for age, sex, height, smoking, and diabetes, were used to evaluate the association between HR-pQCT indices and relative long-term and recent weight change. We found that long-term and recent weight loss were associated with lower cortical density and thickness, higher cortical porosity, and lower trabecular density and number. Associations were stronger for the tibia than radius. Failure load was lower in those individuals with long-term but not short-term weight loss. Deterioration in both cortical and trabecular indices, especially at the weight-bearing skeleton, characterizes bone fragility associated with long-term and recent weight loss in older adults. © 2018 American Society for Bone and Mineral Research.

Predictive value of dynamic change of haemoglobin levels during therapy on treatment outcomes in patients with Enneking stage IIB extremity osteosarcoma.

BACKGROUND: We aimed to investigate the roles of hemoglobin (Hb) concentrations and dynamic change during treatment on outcomes of patients with extremity osteosarcoma. METHODS: We retrospectively analysed 133 patients with Enneking stage IIB extremity osteosarcoma who underwent standard treatments, including univariate and multivariate analyses of patient charateritics, Hb concentrations and changes during pretreatment, neoadjuvant, adjuvant chemotherapy, and decreased Hb levels (ΔHb) to assess their prognostic value in 5-year overall survival (OS) and lung metastasis-free survival (LMFS). RESULTS: Five-year OS or LMFS were similar between patients who were anaemic and non-anaemic during pretreatment, neoadjuvant or adjuvant chemotherapy. Patients with continuously decreasing Hb had lower 5-year OS (52.3%) than those without continuous Hb decrease (68.5%, P = 0.04). Patients with ΔHb > 7.6 g/L had lower 5-year OS (57.5%) than those with ΔHb ≤7.6 g/L (75.8%, P = 0.04). However, continuous Hb decrease had no prognostic effect on 5-year LMFS. Subgroup analyses showed that patients who were anaemic during pretreatment, neoadjuvant, or adjuvant chemotherapy with ΔHb ≤7.6 g/L had better outcomes than those with ΔHb > 7.6 g/L (P < 0.05, for both). CONCLUSION: Dynamic Hb decrease and ΔHb > 7.6 predicted poor5-year OS in patients with Enneking stage IIB extremity osteosarcoma. Attempts to correct anaemia and their effects on outcomes for osteosarcoma patients should be investigated in future trials.

The contribution of the posterolateral capsule to elbow joint stability: a cadaveric biomechanical investigation.

BACKGROUND: Elbow posterolateral rotatory instability occurs after an injury to the lateral collateral ligament complex (LCLC) in isolation or in association with an osteochondral fracture of the posterolateral margin of the capitellum (Osborne-Cotterill lesion [OCL]). The contribution to elbow stability of the posterolateral capsule, attached to this lesion, is unknown. This study quantified the displacement of the radial head on simulated posterior draw with sectioning of the posterior capsule (a simulated OCL) or LCLC. METHODS: Biomechanical testing of the elbow was performed in 8 upper limb cadavers. With the elbow 0°, 30°, 60°, and 90° degrees of flexion, posterior displacement of the radius was measured at increments of a load of 5 N up to 50 N. A simulated OCL and LCLC injury was then performed. RESULTS: A simulated OCL results in significantly more displacement of the radial head compared with the intact elbow at 30° to 60° of elbow flexion. LCLC resection confers significantly more displacement. An OCL after LCLC resection does not create further displacement. CONCLUSIONS: The degree of radial head displacement is greater after a simulated OCL at 30° to 60° of flexion compared with the intact elbow with the same load but not as great as seen with sectioning of the LCLC. This study suggests that the posterior capsule attaching to the back of the capitellum is important to elbow stability and should be identified as the Osborne-Cotterill ligament. Clinical studies are required to determine the importance of these biomechanical findings.