Computed tomographic assessment of fracture characteristics and subchondral bone injury in Thoroughbred racehorses with lateral condylar fractures and their relationship to outcome.

OBJECTIVE: To investigate the effects of fracture characteristics and concurrent subchondral bone pathology identified with computed tomography (CT) on the racing performance of Thoroughbred racehorses with fractures of the MC3/MT3 lateral condyle. STUDY DESIGN: Retrospective cohort study. SAMPLE POPULATION: Thoroughbred racehorses (n = 50) with a fracture of the MC3/MT3 lateral condyle, which had preoperative CT and internal fixation performed. METHODS: Medical records were reviewed for age, sex, limb, and surgical treatment. Computed tomography scans were evaluated to determine fracture characteristics including length, whether the fracture was incomplete or complete, and displacement. The presence of subchondral bone injury (SBI), sesamoid bone fracture, articular comminution, and fragmentation in the joint was noted. Racing data was obtained from an online database. Univariable and multivariable analyses determined associations between independent variables and outcomes. RESULTS: Thirty-three (66%) horses raced after surgery. Horses with sesamoid bone fractures (P = .021), MC3/MT3 comminution (P = .016) and intra-articular fragmentation (P = .015) were less likely to race postoperatively. Concurrent SBI did not affect outcome. In the final multivariable model, sex (P = .015) and whether a fracture was incomplete or complete (P = .007) were the most significant predictors of racing postoperatively with females and horses with complete fractures being less likely to race. CONCLUSION: The prognosis for racing after a lateral condylar fracture is favorable but is decreased in horses with complete fractures and certain concurrent joint pathology. CLINICAL SIGNIFICANCE: Horses presenting with lateral condylar fractures commonly have concurrent joint pathology. Computed tomography can aid in preoperative evaluation and prognostication by enabling more complete fracture assessment.

Assessment of risk factors for bone fractures in patients with type 2 diabetes mellitus: A study in Saudi Arabia.

BACKGROUND AND AIMS: This study aimed to estimate the prevalence of bone fractures and analyze their associated risk factors in people with and without type 2 diabetes (T2D) in Saudi Arabia. METHODS: This study was conducted among 1188 people (581 type 2 diabetes) in Prince Sultan Military Medical City, Riyadh, Saudi Arabia. In addition to the demographic variables, glycated hemoglobin (HbA1c), creatinine, estimated glomerular filtration rate (eGFR), use of teriparatide, presence of rheumatoid arthritis, presence of chronic obstructive pulmonary disease (COPD), Bone mineral density (BMD), Trabecular Bone Score (TBS) and Fracture Risk using the Fracture Risk Assessment Tool (FRAX) were also collected. RESULTS: There were 1188 people (mean age 66.5 ± 8.7yrs) included in this study, of which 1068 (89.9%) were female, and 120 (10.1%) were male. A total of 112 (9.4%) individuals had a fracture history. Female, use of teriparatide, TBS (partially degraded and degraded), FRAX with TBS (MOF), and FRAX with TBS (Hip fx) were identified as independent risk factors for fracture in the whole study population. Teriparatide use and FRAX with TBS (MOF) were observed as independent risk factors for fracture in the non-diabetic population, whereas age, creatinine, eGFR, teriparatide, osteopenia, osteoporosis, TBS (partially degraded, degraded), FRAX with TBS (MOF), FRAX with TBS (Hip fx) were determined as independent risk factors for fracture among patients with diabetes. CONCLUSION: Patients with T2D were observed to have a higher risk for fractures. The findings of the study highlight the requirement for fracture prevention strategies in patients with diabetes.

Survey of MRI Usefulness for the Clinical Assessment of Bone Microstructure.

Bone microarchitecture has been shown to provide useful information regarding the evaluation of skeleton quality with an added value to areal bone mineral density, which can be used for the diagnosis of several bone diseases. Bone mineral density estimated from dual-energy X-ray absorptiometry (DXA) has shown to be a limited tool to identify patients' risk stratification and therapy delivery. Magnetic resonance imaging (MRI) has been proposed as another technique to assess bone quality and fracture risk by evaluating the bone structure and microarchitecture. To date, MRI is the only completely non-invasive and non-ionizing imaging modality that can assess both cortical and trabecular bone in vivo. In this review article, we reported a survey regarding the clinically relevant information MRI could provide for the assessment of the inner trabecular morphology of different bone segments. The last section will be devoted to the upcoming MRI applications (MR spectroscopy and chemical shift encoding MRI, solid state MRI and quantitative susceptibility mapping), which could provide additional biomarkers for the assessment of bone microarchitecture.

Spatio-temporal characterization of fracture healing patterns and assessment of biomaterials by time-lapsed in vivo micro-computed tomography.

Thorough preclinical evaluation of functionalized biomaterials for treatment of large bone defects is essential prior to clinical application. Using in vivo micro-computed tomography (micro-CT) and mouse femoral defect models with different defect sizes, we were able to detect spatio-temporal healing patterns indicative of physiological and impaired healing in three defect sub-volumes and the adjacent cortex. The time-lapsed in vivo micro-CT-based approach was then applied to evaluate the bone regeneration potential of functionalized biomaterials using collagen and bone morphogenetic protein (BMP-2). Both collagen and BMP-2 treatment led to distinct changes in bone turnover in the different healing phases. Despite increased periosteal bone formation, 87.5% of the defects treated with collagen scaffolds resulted in non-unions. Additional BMP-2 application significantly accelerated the healing process and increased the union rate to 100%. This study further shows potential of time-lapsed in vivo micro-CT for capturing spatio-temporal deviations preceding non-union formation and how this can be prevented by application of functionalized biomaterials. This study therefore supports the application of longitudinal in vivo micro-CT for discrimination of normal and disturbed healing patterns and for the spatio-temporal characterization of the bone regeneration capacity of functionalized biomaterials.

A Novel Instant 3-Dimensional Printing System for Postoperative Fracture Patients: A Comparative Cohort Study.

BACKGROUND Traditional plaster (TP) is a widely used auxiliary fixation (AF) approach for postoperative fracture patients. However, patient discomfort and inconvenience to clinicians has limited its application. We introduce a novel instant 3-dimensional printing appliance system (3D-AS) to address such issues. MATERIAL AND METHODS Twenty-seven postoperative fracture patients were divided randomly between a TP group and a 3D-AS group, and analyzed retrospectively. Radiographic images during follow-up were evaluated for fracture healing and fracture reduction quality. The range of motion (ROM) was recorded to assess motor performance. Patient pain was assessed using the Visual Analogue Scale (VAS). Complications were also compared between the 2 groups. RESULTS The patients comprised 17 men and 10 women with ages ranging from 21 to 69 years (mean age: 47.35). All patients completed a follow-up visit (range: 14-19 months, mean: 13.59 months). Although no significant difference was found between general characteristics (P>0.05) and the time of fracture union (P>0.05), significant differences between groups were seen in complications (P<0.05), VAS (P<0.01), patient satisfaction (P<0.05), and ROM for the upper joints (P<0.05). CONCLUSIONS Our study suggests that 3D-AS provides better upper-limb ROM and more comfortable healing for postoperative fracture patients, indicating that it can be recommended for use in such patients.

Value of SPECT/CT in the assessment of necrotic bone fragments in patients with delayed bone healing or non-union after traumatic fractures.

OBJECTIVE: To evaluate the value of single-photon emission computed tomography / computed tomography (SPECT/CT) compared with planar bone scintigraphy (BS) in the assessment of necrotic bone fragments in patients with delayed bone healing or non-union after traumatic fractures. METHODS: Retrospective evaluation of patients with traumatic fractures and suspected delayed healing or non-union and/or persistent pain or suspected infection who had undergone planar late phase BS and SPECT/CT between 2011 and 2018. On the BS and SPECT/CT images, a necrotic fragment was considered if there was an area of absent radiotracer uptake (photopenia) related to bone at the fracture site. Histology served as a reference standard (presence or absence of necrotic bone fragments). If histology was not available, intraoperative findings and combined clinical and imaging follow-up served as reference standards. RESULTS: In 37 consecutive patients with traumatic fractures (femur (n = 18), tibia (11), humerus (6), radius (1), jaw (1)), necrotic bone fragments were suspected in 11 fractures (29.7%) on BS and in 16 fractures (43.2%) on SPECT/CT. 35 fractures (94.6%) had metallic implants. Histology showed necrotic fragments in 10/11 (90.9%) patients. For the detection of necrotic bone fragments, SPECT/CT showed sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%, 95%, 94%, 100%, and 97%, respectively, and BS 67%, 95%, 91%, 81%, and 83%, respectively. SPECT/CT significantly outperformed BS with better area under curve (AUC) for SPECT/CT (0.9773) compared to planar imaging (0.8106) (p-value < 0.01). CONCLUSIONS: SPECT/CT is an accurate tool in the assessment of necrotic bone fragments in patients with delayed bone healing or non-union after traumatic bone fractures and is superior to conventional planar BS. ADVANCES IN KNOWLEDGE: SPECT/CT is accurate and superior to planar BS in identification of necrotic bone fragments, responsible for delayed bone healing/non-union after fractures.

A comparison of three methods in categorizing functional status to predict hospital readmission across post-acute care.

BACKGROUND: Methods used to categorize functional status to predict health outcomes across post-acute care settings vary significantly. OBJECTIVES: We compared three methods that categorize functional status to predict 30-day and 90-day hospital readmission across inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF) and home health agencies (HHA). RESEARCH DESIGN: Retrospective analysis of 2013-2014 Medicare claims data (N = 740,530). Data were randomly split into two subsets using a 1:1 ratio. We used half of the cohort (development subset) to develop functional status categories for three methods, and then used the rest (testing subset) to compare outcome prediction. Three methods to generate functional categories were labeled as: Method I, percentile based on proportional distribution; Method II, percentile based on change score distribution; and Method III, functional staging categories based on Rasch person strata. We used six differentiation and classification statistics to determine the optimal method of generating functional categories. SETTING: IRF, SNF and HHA. SUBJECTS: We included 130,670 (17.7%) Medicare beneficiaries with stroke, 498,576 (67.3%) with lower extremity joint replacement and 111,284 (15.0%) with hip and femur fracture. MEASURES: Unplanned 30-day and 90-day hospital readmission. RESULTS: For all impairment conditions, Method III best predicted 30-day and 90-day hospital readmission. However, we observed overlapping confidence intervals among some comparisons of three methods. The bootstrapping of 30-day and 90-day hospital readmission predictive models showed the area under curve for Method III was statistically significantly higher than both Method I and Method II (all paired-comparisons, p<.001), using the testing sample. CONCLUSIONS: Overall, functional staging was the optimal method to generate functional status categories to predict 30-day and 90-day hospital readmission. To facilitate clinical and scientific use, we suggest the most appropriate method to categorize functional status should be based on the strengths and weaknesses of each method.

Sex differences in fracture outcomes within Taiwan population: A nationwide matched study.

BACKGROUND AND AIMS: Because the sex difference in outcomes of fracture was incompletely understood, we evaluated the post-fracture complications and mortality of female and male patients. METHODS: We conducted a nationwide study of 498,586 fracture patients who received inpatient care using Taiwan's National Health Insurance Research Database 2008-2013 claims data. Female and male fracture patients were selected for comparison by using a propensity-score matching procedure. Age, low income, types of fracture, fracture with surgery, several medical conditions, number of hospitalization and emergency visits were considered as potential confounding factors. Multivariate logistic regressions were used to calculate the adjusted odds ratios (OR), the 95% CI of post-fracture complications and 30-day in-hospital mortality differences between women and men. RESULTS: Male patients had a higher risk of post-fracture pneumonia (OR 1.96, 95% CI 1.83-2.11), acute renal failure (OR 1.85, 95% CI 1.60-2.15), deep wound infection (OR 1.63, 95% CI 1.51-1.77), stroke (OR 1.58, 95% CI 1.49-1.67), septicemia (OR 1.51, 95% CI 1.42-1.61), acute myocardial infarction (OR 1.38, 95% CI 1.09-1.75) and 30-day in-hospital mortality (OR 1.69, 95% CI 1.48-1.93) compared with female patients. However, a lower risk of post-fracture urinary tract infection (OR 0.69, 95% CI 0.65-0.72) was found in men than in women. Male patients also had longer hospital stays and higher medical expenditures due to fracture admission than did the female patients. Higher rates of post-fracture adverse events in male patients were noted in all age groups and all types of fractures. CONCLUSION: We raised the possibility that male patients showed more complications and higher mortality rates after fracture admission compared with female patients, with the exception of urinary tract infections.

Scaphoid fractures: has magnetic resonance imaging become a cost-effective alternative to definitive diagnosis?

BACKGROUND: A clinical examination finding of anatomical snuffbox tenderness (AST) with plain film radiographs alone yields low sensitivity and specificity in diagnosing scaphoid fractures. International guidelines suggest immediate referral for magnetic resonance imaging (MRI) following one non-diagnostic radiograph in such patients. Perceived cost, high demand and limited capacity of MRI scanners have resulted in few suspected fractures following this pathway in our institution. AIMS: Our study aimed to audit cost-effectiveness of immediate MRI referral following one non-diagnostic radiograph in the patient with AST versus current local practice. METHODS: Retrospective analysis of all patients with suspected scaphoid fractures referred from the ED to the orthopaedic service over a six-month period was performed. Mean pricing per radiograph, casting, MRI and fracture clinic presentation was obtained from our hospital's Finance department. RESULTS: Ninety-seven patients were identified; 26 had scaphoid fractures (26.8%). Seventy-one patients with no fractures cost a mean €82,111.50 (IQR: €55,025, €98,335) having a mean of 3.1 clinic visits, 4.6 radiographs and 4.7 weeks casted, versus €40,115 for early MRI referral as per guidelines (p > 0.05). CONCLUSIONS: In conclusion, when compared with current local practice, immediate referral of the patient with AST for MRI following one non-diagnostic ED radiograph is potentially cost-effective in establishing efficient diagnosis of scaphoid fractures. We recommend the implementation of published international guidelines in the investigation of query scaphoid fractures as a pragmatic and cost-effective practice.

Burden of disease in pediatric patients with hypophosphatasia: results from the HPP Impact Patient Survey and the HPP Outcomes Study Telephone interview.

BACKGROUND: Hypophosphatasia (HPP) is a rare, inherited, metabolic bone disease caused by deficient tissue-non-specific isoenzyme of alkaline phosphatase activity that manifests as a broad range of signs/symptoms, including bone mineralization defects and systemic complications. The burden of disease is poorly characterized, particularly in children. This study aimed to characterize the patient-reported burden of disease among children with HPP using two survey instruments: the HPP Impact Patient Survey (HIPS) and the HPP Outcomes Study Telephone interview (HOST). METHODS: Between September 2009 and June 2011, pediatric patients (aged younger than 18 years) with HPP were recruited to participate in the study via patient advocacy groups or their medical provider. Survey questions were used to capture information on patient demographics, HPP-related medical history, mobility, and health-related quality of life (HRQoL; using the 10-item Short-Form Health Survey for Children [SF-10], HIPS only). RESULTS: Common clinical features of the 59 pediatric survey respondents (mean [standard deviation] age: 7.6 [5.1] years; 51% male) included pain (86% of patients), muscle weakness (71%), difficulty gaining weight (64%), and delayed walking (59%). Fracture was reported by 36% of patients; multiple fractures were also reported (15% of patients). Use of assistive devices for mobility was frequent among the study population (51%). In response to the SF-10, patients reported a substantial impact of HPP on their HRQoL; physical function was the most severely impaired component relative to normative data. Of patients responding to the HOST, two-thirds experienced worsening of at least one of their HPP-related signs/symptoms over a 5-year period. CONCLUSIONS: In pediatric patients, HPP is associated with a high burden of disease and a substantial negative impact on HRQoL. The burden of HPP may increase and HRQoL reduce further over time as signs/symptoms that affect HRQoL worsen or new signs/symptoms manifest.

Outcome Assessment of Z-shaped Osteotomy in the Management of Humeral Shaft Nonunion Secondary to Failed Plate Osteosynthesis.

Restoration of fracture alignment by osteotomy is crucial for the management of humeral nonunion. In the present study, we introduced a new way of osteotomy (Z-shaped) in treating humeral shaft nonunion secondary to failed plate osteosynthesis. Clinical data of 24 patients with humeral shaft nonunion following implant failure (from 2010 to 2014) were retrospectively evaluated. These patients underwent Z-shaped osteotomy in revision surgery after the initial surgery, plate osteosynthesis, was failed. Outcomes were evaluated using visual analogue scale (VAS) and Constant and Murley score. Repeated analysis of variance (ANOVA) was used for statistical analysis. Patients were followed up for a minimum of 24 months (26.83±4.33 months). The operative time was 102.33±10.16 min, and hospital stay averaged 9.75±2.13 days. All patients achieved clinical union at the latest follow-up. Complications included radial palsy (n=1) and superficial wound infection (n=1). The postoperative VAS scores decreased significantly compared to preoperative score (F=257.99, P<0.01). Constant and Murley score increased and reached 81.33±0.95 at 24 months' follow-up (F=247.35, P<0.01). Among all the cases, 15 cases were graded as "excellent", and 9 as "good". In conclusion, Z-shaped osteotomy was easy to perform, and it provided additional medial support with more bone contact areas. Revision surgery using locking plate and Z-shaped osteotomy achieved high union rate and improved functional outcome. It was a reasonable and safe option for treating humeral nonunion following implant failure.

Novel, cost-effective, Cu-doped calcium silicate nanoparticles for bone fracture intervention: Inherent bioactivity and in vivo performance.

Copper (Cu)-doped calcium silicate nanoparticles were synthesized by a wet precipitation method as economical bone fracture filler. The aim was to improve the overall physicochemical properties, bioactivity, and biological performance of the bone fracture filler prepared herein. The synthesized nanoparticles were evaluated using X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), and transmission electron microscopy (TEM). The bioactivity of the prepared nanoparticles was investigated after immersion in simulated body fluid (SBF) by means of inductively coupled plasma (ICP), SEM coupled with energy dispersive X-rays (EDX), and FTIR. The size and bioactivity of the prepared nanoparticles after 15 days of immersion in SBF was dependent on the Cu concentrations. The fracture healing ability of the fabricated nanoparticles on adult aged male Wistar rats was enhanced by the presence of copper. All the obtained results are of high relevance for fabricating improved Cu-doped calcium silicate nanoparticles (∼50 nm) as low cost bone fracture filler. In addition, the in vivo study presented complete healing of the tibiae bone with normal architecture of bone tissue specifically calcium silicate nanoparticles doped with 3% and 5% Cu. Hence, the presence of copper is a promising tactic for improving the biological properties of calcium silicate. Therefore, the designed nanoparticles have huge potential for the treatment of bone fractures. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 107B: 388-399, 2019.

Incidence, Costs and Predictors of Non-Union, Delayed Union and Mal-Union Following Long Bone Fracture.

Fracture healing complications are common and result in significant healthcare burden. The aim of this study was to determine the rate, costs and predictors of two-year readmission for surgical management of healing complications (delayed, mal, non-union) following fracture of the humerus, tibia or femur. Humeral, tibial and femoral (excluding proximal) fractures registered by the Victorian Orthopaedic Trauma Outcomes Registry over five years (n = 3962) were linked with population-level hospital admissions data to identify two-year readmissions for delayed, mal or non-union. Study outcomes included hospital length-of-stay (LOS) and inpatient costs. Multivariable logistic regression was used to determine demographic and injury-related factors associated with admission for fracture healing complications. Of the 3886 patients linked, 8.1% were readmitted for healing complications within two years post-fracture, with non-union the most common complication and higher rates for femoral and tibial shaft fractures. Admissions for fracture healing complications incurred total costs of $4.9 million AUD, with a median LOS of two days. After adjusting for confounders, patients had higher odds of developing complications if they were older, receiving compensation or had tibial or femoral shaft fractures. Patients who are older, with tibial and femoral shaft fractures should be targeted for future research aimed at preventing complications.

Digital Tomosynthesis Applications in Pediatric Orthopedic Imaging: A Case Series.

Digital tomosynthesis (DTS) is an emerging technology that provides cross-sectional, three-dimensional imaging similar to computed tomography (CT) at a fraction of the radiation dose and cost. In this article, we describe multiple cases where our pediatric orthopedic surgeons have used DTS imaging to help in clinical management of fracture healing.

Assessment of the degradation rates and effectiveness of different coated Mg-Zn-Ca alloy scaffolds for in vivo repair of critical-size bone defects.

Surgical repair of bone defects remains challenging, and the search for alternative procedures is ongoing. Devices made of Mg for bone repair have received much attention owing to their good biocompatibility and mechanical properties. We developed a new type of scaffold made of a Mg-Zn-Ca alloy with a shape that mimics cortical bone and can be filled with morselized bone. We evaluated its durability and efficacy in a rabbit ulna-defect model. Three types of scaffold-surface coating were evaluated: group A, no coating; group B, a 10-µm microarc oxidation coating; group C, a hydrothermal duplex composite coating; and group D, an empty-defect control. X-ray and micro-computed tomography(micro-CT) images were acquired over 12 weeks to assess ulnar repair. A mechanical stress test indicated that bone repair within each group improved significantly over time (P < 0.01). The degradation behavior of the different scaffolds was assessed by micro-CT and quantified according to the amount of hydrogen gas generated; these measurements indicated that the group C scaffold better resisted corrosion than did the other scaffold types (P < 0.05). Calcein fluorescence and histology revealed that greater mineral densities and better bone responses were achieved for groups B and C than for group A, with group C providing the best response. In conclusion, our Mg-Zn-Ca-alloy scaffold effectively aided bone repair. The group C scaffold exhibited the best corrosion resistance and osteogenesis properties, making it a candidate scaffold for repair of bone defects.

Simulation enabled search for explanatory mechanisms of the fracture healing process.

A significant portion of bone fractures fail to heal properly, increasing healthcare costs. Advances in fracture management have slowed because translation barriers have limited generation of mechanism-based explanations for the healing process. When uncertainties are numerous, analogical modeling can be an effective strategy for developing plausible explanations of complex phenomena. We demonstrate the feasibility of engineering analogical models in software to facilitate discovery of biomimetic explanations for how fracture healing may progress. Concrete analogical models-Callus Analogs-were created using the MASON simulation toolkit. We designated a Target Region initial state within a characteristic tissue section of mouse tibia fracture at day-7 and posited a corresponding day-10 Target Region final state. The goal was to discover a coarse-grain analog mechanism that would enable the discretized initial state to transform itself into the corresponding Target Region final state, thereby providing an alternative way to study the healing process. One of nine quasi-autonomous Tissue Unit types is assigned to each grid space, which maps to an 80×80 µm region of the tissue section. All Tissue Units have an opportunity each time step to act based on individualized logic, probabilities, and information about adjacent neighbors. Action causes transition from one Tissue Unit type to another, and simulation through several thousand time steps generates a coarse-grain analog-a theory-of the healing process. We prespecified a minimum measure of success: simulated and actual Target Region states achieve ≥ 70% Similarity. We used an iterative refinement protocol to explore many combinations of Tissue Unit logic and action constraints. Workflows progressed through four stages of analog mechanisms. Similarities of 73-90% were achieved for Mechanisms 2-4. The range of Upper-Level similarities increased to 83-94% when we allowed for uncertainty about two Tissue Unit designations. We have demonstrated how Callus Analog experiments provide domain experts with a fresh medium and tools for thinking about and understanding the fracture healing process.

Quality of life after hip, vertebral, and distal forearm fragility fractures measured using the EQ-5D-3L, EQ-VAS, and time-trade-off: results from the ICUROS.

INTRODUCTION: The International Costs and Utilities Related to Osteoporotic fractures Study is a multinational observational study set up to describe the costs and quality of life (QoL) consequences of fragility fracture. This paper aims to estimate and compare QoL after hip, vertebral, and distal forearm fracture using time-trade-off (TTO), the EuroQol (EQ) Visual Analogue Scale (EQ-VAS), and the EQ-5D-3L valued using the hypothetical UK value set. METHODS: Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall), and at 4, 12, and 18 months after fracture. Health state utility values (HSUVs) were derived for each fracture type and time-point using the three approaches (TTO, EQ-VAS, EQ-5D-3L). HSUV were used to estimate accumulated QoL loss and QoL multipliers. RESULTS: In total, 1410 patients (505 with hip, 316 with vertebral, and 589 with distal forearm fracture) were eligible for analysis. Across all time-points for the three fracture types, TTO provided the highest HSUVs, whereas EQ-5D-3L consistently provided the lowest HSUVs directly after fracture. Except for 13-18 months after distal forearm fracture, EQ-5D-3L generated lower QoL multipliers than the other two methods, whereas no equally clear pattern was observed between EQ-VAS and TTO. On average, the most marked differences between the three approaches were observed immediately after the fracture. CONCLUSIONS: The approach to derive QoL markedly influences the estimated QoL impact of fracture. Therefore the choice of approach may be important for the outcome and interpretation of cost-effectiveness analysis of fracture prevention.

The virtual approach to the assessment of skeletal injuries in human skeletal remains of forensic importance.

While assessing skeletal injuries in human skeletal remains, forensic anthropologists are frequently presented with fractured, fragmented, or otherwise modified skeletal remains. The examination of evidence and the mechanisms of skeletal injuries often require that separate osseous elements be permanently or temporarily reassembled or reconstructed. If not dealt with properly, such reconstructions may impede accurate interpretation of the evidence. Nowadays, routine forensic examinations increasingly incorporate digital imaging technologies. As a result, a variety of PC-assisted imaging techniques, collectively referred to as the virtual approach, have been made available to treat fragmentary skeletal remains. The present study employs a 3D virtual approach to assess mechanisms of skeletal injuries, and provides an expert opinion of causative tools in three forensic cases involving human skeletal remains where integrity was compromised by multiple peri- or postmortem alterations resulting in fragmentation and/or incompleteness. Three fragmentary skulls and an incomplete set of foot bones with evidence of perimortem fractures (gunshot wounds) and sharp force trauma (saw marks) were digitized using a desktop laser scanner. The digitized skeletal elements were reassembled in the virtual workspace using functionalities incorporated in AMIRA® version 5.0 software, and simultaneously in real physical space by traditional reconstructive approaches. For this study, the original skeletal fragments were substituted by replicas built by 3D printing. Inter-method differences were quantified by mesh-based comparison after the physically reassembled elements had been re-digitized. Observed differences were further reinforced by visualizing local variations using colormaps and other advanced 3D visualization techniques. In addition, intra-operator and inter-operator error was computed. The results demonstrate that the importance of incorporating the virtual approach into the assessment of skeletal injuries increases with the complexity and state of preservation of a forensic case. While in relatively simple cases the virtual approach is a welcome extension to a traditional approach, which merely facilitates the analysis, in more complex and extensively fragmentary cases such as multiple gunshot wounds or dismemberment, the virtual approach can be a crucial step in applying the principles of gunshot wounds or sharp force traumatic mechanisms. The unrestricted manipulation with digital elements enabling limitless repairs and adjustments to a "best-case scenario" also produced smaller inter-operator variation in comparison to the traditional approach.

The Role of the Fracture Liaison Service in Osteoporosis Care.

Osteoporosis is a disease classified by the alteration of bony microarchitecture predisposing a person to fragility fractures. This costs the US $19 billion per year and is expected to rise as our population ages. Only 20% of patients with fragility fractures receive treatment for osteoporosis. A Fracture Liaison Service is a cost-effective way to follow patients and improve appropriate work up and management from multiple medical disciplines.

Assessment of trochanteric osteotomy fragment union after acetabular fracture surgery.

BACKGROUND: Trochanteric osteotomies are performed in conjunction with standard approaches to improve surgical exposure during open reduction and internal fixation (ORIF) of acetabular fractures. The literature on total hip arthroplasty reports nonunion rates as high as 30% associated with trochanteric osteotomies; however, few data exist regarding the outcomes of trochanteric osteotomies for acetabular fracture surgery. Our hypotheses were 1) patients receiving trochanteric osteotomies during ORIF of acetabular fractures have a low rate of nonunion of the osteotomy fragment, and 2) hip abduction precautions are not necessary with digastric type osteotomies. PATIENTS AND METHODS: A retrospective review was conducted to identify patients with acetabular fractures between July 2002 and June 2010 (n=734 fractures) who required trochanteric osteotomies (n=64, 9% of fractures). Forty-seven met inclusion criteria of adequate follow-up (>56days). No excluded patient experienced a complication. Fractures were classified using the Letournel-Judet classification system. RESULTS: Only seven (20%) of 35 patients who received digastric osteotomies had hip abduction precautions applied during the postoperative period. All study patients were shown to have radiographic union at the trochanteric osteotomy site (100% union rate, n=47). Hip abduction precautions intended to protect the osteotomy site and reduce the risk of nonunion and fixation failure were infrequently applied to patients with digastric osteotomies (20%) in this cohort. Multiple protective factors against nonunion were present in this study population compared with previous arthroplasty studies from other institutions. CONCLUSIONS: Trochanteric osteotomies are not associated with a significant nonunion rate, and digastric osteotomies might be safely managed without hip abduction precautions.