[Influence of frequently prescribed drugs on bone healing]. / Beeinflussung der Knochenheilung durch häufig verordnete Medikamente.

BACKGROUND: Bone healing after fractures is influenced by many different factors. Besides patient-related factors, such as age, gender and other comorbidities, other drugs taken also have a relevant impact on bone healing. OBJECTIVE: The aim of the study was to give an overview of the effects of frequently used drugs on fracture healing, with the exception of specific osteoporosis drugs and hormones. MATERIAL AND METHODS: This overview is based on a medline search with the search string of each pharmacological agent. RESULTS: Frequently used pharmacological substances were identified, for example corticosteroids, antihypertensive drugs, diuretics, antidepressive drugs, antiepileptics, statins, antibiotics, nonsteroidal anti-inflammatory drugs, anticoagulants and others. Except for antihypertensive drugs, thiazide diuretics and statins, which have osteoprotective effects and stimulate bone healing, all other drugs have negative effects on fracture healing in preclinical and animal studies. Clinical data are scarce. CONCLUSION: Data for the effects of the abovementioned pharmacological substances could be found mostly in preclinical studies. The effects of these agents on bone healing in humans has currently not been studied or published. Therefore, the use of these drugs should be discussed carefully in cases with a compromised fracture healing.

[Importance of osteoporosis-related fractures for patients]. / Bedeutung osteoporosebedingter Frakturen für den Patienten.

BACKGROUND: Osteoporosis is a common disease that affects both women and men. Due to a reduced bone mineral density and increasing age, the risk for atraumatic fractures increases. These fractures cause pain due to the fracture itself and also have far-reaching sequelae in nearly all areas of life of patients. OBJECTIVE: The aim of this article is to summarize the consequences of osteoporotic fractures from the patient's point of view and to highlight the consequences of osteoporosis for the patient. The necessity for timely diagnostics and treatment after a fracture event is explained. MATERIAL AND METHODS: For each term a literature search was performed using key topic-related terms and the results are presented as a narrative review. RESULTS: Various areas of importance for patients were identified. A direct assessment of the patient's point of view was not feasible using a literature search; however, studies with surveys of patients could be identified and therefore, the patient's point of view could be integrated. Areas of interest that could be identified in the literature were pain, psychological well-being, cognitive abilities, mortality and long-term need for nursing. CONCLUSION: The effects of osteoporosis and fractures are multifactorial and often severe for the patient. The measures for prevention of osteoporotic fractures should be consistently implemented in the daily clinical routine and the necessary diagnostics and treatment should be rapidly initiated.

Is there an association between low serum 25-OH-D levels and the length of hospital stay in orthopaedic patients after arthroplasty?

BACKGROUND: The purpose of this observational study was to evaluate serum levels of 25-OH-D in patients scheduled to undergo elective hip or knee arthroplasty. We hypothesised that 25-OH-D level is an independent risk factor for length of stay in orthopaedic patients after elective hip or knee arthoplasty. MATERIALS AND METHODS: 25-OH-D levels were measured in 1083 patients admitted to an orthopaedic surgery department to undergo elective hip or knee arthroplasty. Comparisons were performed using Chi square or Student's t test, followed by univariate and multiple linear regression analysis examining the correlation between the length of stay in the orthopaedic department and 25-OH-D level while adjusting for possible confounders. RESULTS: Overall, 86 % of patients had insufficient serum levels of 25-OH-D, and over 60 % were vitamin D deficient. The mean length of stay was 13.2 ± 8.3 days. In patients with hypovitaminosis D, the length of stay was significantly longer compared to patients with normal serum 25-OH-D levels (15.6 ± 7.2 compared to 11.3 ± 7.9 days, P = 0.014). In univariate analyses, serum 25-OH-D level was inversely related to the length of stay in our orthopaedic department compared to patients with normal vitamin D levels (r = -0.16; P = 0.008). In multivariate analyses, the length of stay remained significantly associated with low 25-OH-D levels (P = 0.002), indicating that low vitamin D levels increase the length of stay. CONCLUSIONS: We found a high frequency of hypovitaminosis D among orthopaedic patients scheduled to undergo elective arthroplastic surgery. Low vitamin D levels showed a significant inverse association to the length of stay in our orthopaedic department. Patients with vitamin D levels in the target range were hospitalised 4.3 days less than patients with hypovitaminosis D. Level 3 of evidence according to "The Oxford 2011 levels of evidence".

In-vivo analysis of epicutaneous pressure distribution beneath a femoral tourniquet--an observational study.

BACKGROUND: Compression of the tissue beneath tourniquets used in limb surgery is associated with varying degrees of soft tissue damage. The interaction between fluids and applied pressure seems to play an important role in the appearance of skin lesions. The extent of the transfer of force between the tourniquet and the skin, however, has yet to be studied. The aim of the present study was to quantify in-vivo the transfer of pressure between a tourniquet and the skin of the thigh. METHODS: Pressure under the tourniquet was measured using sensors in 25 consecutive patients over the course of elective surgical procedures. Linear mixed modeling was used to assess the homogeneity of the distribution of pressure around the circumference of the limb, variation in pressure values over time, and the influence of limb circumference and the Body-Mass-Index (BMI) on pressure transfer. RESULTS: Mean pressure on the skin was significantly lower than the inner pressure of the cuff (5.95%, 20.5 ± 9.36 mmHg, p < 0.01). There was a discrete, but significant (p < 0.001) increase in pressure within the first twenty minutes after inflation. Sensors located in the area of overlap of the cuff registered significantly higher pressure values (p < 0.01). BMI and leg circumference had no influence on the transfer of pressure to the surface of the skin (p = 0.88 and p = 0.51). CONCLUSIONS: Pressure transfer around the circumference of the limb was distributed inhomogeneously. The measurement series revealed a global pressure drop compared to the initial pressure of the cuff. No relationship could be demonstrated between the pressure transferred to the skin and the BMI or limb circumference.

Vitamin D insufficiency in the elderly orthopaedic patient: an epidemic phenomenon.

PURPOSE: The purpose of this observational study was to evaluate serum levels of 25-OH-D of elderly patients presenting with orthopaedic illness. Furthermore, we enquired about potential confounders and risk factors of hypovitaminosis D in comorbidities and daily medication of the elderly. METHODS: Vitamin D levels in 1,083 patients aged >70 years and admitted to an orthopaedic surgery department were measured. Univariate and multivariate analyses were used to assess risk factors for insufficient vitamin D levels. RESULTS: Overall, 86 % of patients had insufficient serum levels of 25-OH-D and >60 % were vitamin D deficient. Serum vitamin D levels were lower during winter and months with fewer sunshine hours. Patients presenting with obesity, hypertension and osteoporosis were more likely to have low vitamin D levels. CONCLUSIONS: We found a high prevalence of hypovitaminosis D in elderly, nonhospitalized orthopaedic patients. Given the well-known effects of vitamin D on bone metabolism and muscle health, as well as its nonskeletal effects, vitamin D insufficiency may have a negative impact.

Sports activities before and after medial unicompartmental knee arthroplasty using the new Heidelberg Sports Activity Score.

PURPOSE: The purpose of our study was to investigate the change of sports activities before and after medial unicompartmental knee arthroplasty (UKA) with the use of the Heidelberg Sports Activity Score (HAS). METHODS: The Heidelberg Sports Activity Score (HAS) as well as FFb-H-OA, Oxford-12-Score, Tegner, UCLA and ACS were carried out to assess sports activities in 157 patients with medial osteoarthritis of the knee joint before and after UKA. The newly developed HAS also records the important duration and the sporting activity. RESULTS: Patients practiced sports in a more deliberate manner after UKA. Hiking, cycling and swimming were the sports most increased after surgery. Patients ≤65 years of age were sportier than those >65 years. Men were sportier than women, but all became sportier postoperatively. Patients with a high body mass index (BMI) are less sporty at first, but then increase their sports activity after surgery. CONCLUSIONS: HAS is an effective and valid assessment scale for evaluating sports activities before and after knee replacement.

Is tartrate-resistant acid phosphatase 5b a potent bio-marker for late stage aseptic implant loosening?

PURPOSE: Aseptic loosening is a serious complication after total joint arthroplasty. Plain radiography, along with clinical signs of prosthesis loosening, is the technique of first choice to evaluate loosening of joint replacements. Nevertheless, radiographical signs of osteolysis may not be apparent until progressed stages of loosening. Thus the search for alternative diagnostic methods is of great importance. The purpose of the present study was to evaluate the potential diagnostic significance of TRAP 5b, Osteocalcin, CrossLaps and Bone ALP for aseptic loosening of total joint replacements. METHODS: Thirty-seven patients (25 women, 12 men, mean age 65 years, age range 54-76 years) treated with revision surgery due to clinically and radiologically confirmed late aseptic prosthesis loosening were examined prospectively. Serum levels of TRAP 5b, Osteocalcin, CrossLaps and Bone ALP were compared with a matched control group (n = 39). RESULTS: We found a significant decrease in TRAP 5B level in patients with aseptic loosening. Bone ALP and Osteocalcin as markers of osteoblast activity, and CrossLaps as another resorption marker did not allow any prediction of bone remodeling in this late phase of loosening. CONCLUSION: In the "late" phase of aseptic joint replacement loosening, no increase of TRAP 5b and therefore no increase of osteoclast number and activity was measurable. Thus, in this situation an anti-osteolytic therapy with a bisphosphonate or denosumab would not gain any further benefit.

Is there an association between periprosthetic joint infection and low vitamin D levels?

PURPOSE: Vitamin D is increasingly being recognized as an important mediator of immune function and may have a preventive role in the pathogenesis of periprosthetic joint infection. To the best of our knowledge, no other study has examined possible associations between periprosthetic joint infection and vitamin D deficiency. We investigated the rate of vitamin D deficiency in patients treated for periprosthetic joint infection and whether vitamin D deficiency is independent of other risk factors for vitamin D deficiency in patients with periprosthetic joint infection. METHODS: Serum 25-hydroxyvitamin D (25OHD) levels of every patient scheduled to receive a total prosthesis either of the hip, knee, or shoulder in the orthopaedic department of the Johannes-Guttenberg-University Hospital in Mainz, Germany (109 patients), were measured after admission. Furthermore, serum 25OHD levels were measured for every patient presenting with periprosthetic joint infection (n = 50) or aseptic loosening of the prosthesis (n = 31) scheduled to undergo revision surgery. The prevalence of normal (> 30 ng/ml), insufficient (20-30 ng/ml), and deficient (<20 ng/ml) 25OHD levels was determined. RESULTS: All tested patient subgroups showed low vitamin D levels. Statistical analysis found no significant difference in vitamin D levels comparing patients with prosthesis and patients with aseptic prosthesis loosening (p = 0.58). Significant differences in 25OHD levels were found comparing patients with periprosthetic joint infection and patients scheduled for primary arthroplasty (p < 0.001). In addition, we found a significant difference (p < 0,001) in 25OHD levels of patients with periprosthetic joint infection compared with patients with aseptic prosthesis loosening. CONCLUSION: We found a high frequency of vitamin D deficiency in patients being treated by primary arthroplasty and those with aseptic joint prosthetic loosening and periprosthetic joint infection. Vitamin D deficiency was severe in patients with periprosthetic joint infection.

Effectiveness of Mud-Pack Therapy and Mud-Bath Therapy in Osteoarthritis: A Systematic Review.

OBJECTIVES: Osteoarthritis has a tremendous socioeconomic impact in terms of drug spending, hospital admissions, work productivity, and temporary or permanent incapacity. Mud therapy has been discussed as potential conservative treatment options for osteoarthritis. However, findings from several trials still remain controversial. For this reason, we aimed to systematically review the highest evidence provided by published trials to estimate the clinical effect of mud-pack and mud-bath therapy for the treatment of osteoarthritis. METHODS: We searched PubMed, PEDro, and the Cochrane CENTRAL Register for Controlled Trials for articles published between 2000 and 2020 using the terms "orthopedics," "orthopaedics," "musculoskeletal," "osteoarthritis," and "mud bath," "mud pack." RESULTS: Of the 19 studies included, 15 examined the effects of mud-bath therapy in knee osteoarthritis treatment. One study focused on the treatment effect of mud bath on hand osteoarthritis, another study examined treatment effects in hip and knee osteoarthritis, and two studies enrolled patients with chronic low back pain caused by lumbar spine osteoarthritis. We systematically reviewed the data obtained from the literature and summarized the results on the basis of the main outcomes. The results show significant improvements in function, quality of life, and perceived pain for patients with osteoarthritis. CONCLUSION: Results of randomized controlled trials suggest that mud therapy is part of a promising integrated and synergistic multidisciplinary approach in combination with other treatment forms like pharmacotherapy or physiotherapy.Die sozio-ökonomischen Auswirkungen der Arthrose sind immens. Heiltorfbehandlungen sind seit einiger Zeit als mögliche Ergänzung der konservativen Therapieoptionen dieser Erkrankung Gegenstand wissenschaftlicher Untersuchungen. Ziel dieser Studie war es, die aktuellen Erkenntnisse zur Heiltorftherapie bei Arthrose zusammenzufassen.Wir führten eine systematische Literaturrecherche der Datenbanken Pubmed, PEDro und Cochrane CENTRAL Register of Controlled Trials durch. Hierbei wurden Artikel, die zwischen 2000 und 2020 publiziert wurden und mit den Schlagwörtern "orthopedics", "orthopaedics", "musculoskeletal", "osteoarthritis" und "mud-bath", "mud-pack" assoziiert waren, erfasst.Von den 19 näher untersuchten Studien beschäftigten sich 15 mit den Effekten der Heiltorftherapie bei Patienten mit Kniearthrose, eine Studie untersuchte Patienten mit Arthrose der Hand, eine weitere Studie untersuchte die Auswirkung der Therapie bei Arthrose der Hüfte. 2 Studien untersuchten den Effekt der Moorbäder bei Patienten mit chronischen Rückenschmerzen. Insgesamt zeigten sich signifikante Verbesserungen der Funktion, Lebensqualität und Schmerzlinderung bei den Patienten unter Heiltorftherapie.Die Ergebnisse der randomisierten, kontrollierten Studien zeigen, dass die Heiltorftherapie eine vielversprechende Ergänzung in einem multidisziplinären Ansatz der Arthrosetherapie ist.

Is there an epidemic vitamin D deficiency in German orthopaedic patients?

BACKGROUND: Vitamin D plays an essential role in bone health and muscle function. Some studies have shown a widespread rate of vitamin D deficiency in the general population, but few have reported on the vitamin D status of orthopaedic patients. QUESTIONS/PURPOSES: We investigated (1) the extent of hypovitaminosis D in orthopaedic patients, (2) seasonal variations in vitamin D levels, and (3) possible risk factors for insufficient vitamin D levels. METHODS: Vitamin D levels in 1119 patients consecutively admitted to an orthopaedic surgery department in 2011 were measured. To investigate the correlation between climate factors and vitamin D levels, the sunshine hours for each month in 2011 were collected by Deutscher Wetterdienst (the German weather service) in the region where most tested patients lived. The prevalence of normal (> 30 ng/mL), insufficient (20-30 ng/mL), and deficient (< 20 ng/mL) 25-hydroxyvitamin D levels was determined. Univariate and multivariate analyses were used to assess risk factors for insufficient vitamin D levels. RESULTS: Overall, 84% of patients had insufficient levels of vitamin D and 60% were vitamin D deficient. Only 15% were in the target range of 30 to 60 ng/mL. The prevalence of low vitamin D levels was greater during winter and months with fewer sunshine hours. Vitamin D levels did not vary according to age, sex, and disease. Individuals with obesity, hypertension, and osteoporosis were more likely to have low vitamin D levels compared with their healthy counterparts. CONCLUSIONS: There is an alarmingly high rate of hypovitaminosis D and vitamin D deficiency among orthopaedic patients in this region of Germany, whose latitude (50° N) is approximately the same as those of Vancouver (49°, 15' N) and Paris (48°, 51' N). Given the well-known effects on bone metabolism and muscle health, low vitamin D levels may negatively affect patients. Screening and treating hypovitaminosis D appears to be important in this patient population.

Vitamin D deficiency in orthopaedic patients: a single center analysis.

Vitamin D is essential to bone health and is a major regulator of calcium homeostasis. Many recent reports demonstrated worldwide high rates of vitamin D deficiency, but few studies have been published on the vitamin D status of orthopaedic patients. The present study aimed to investigate the extent of hypovitaminosis D of orthopaedic patients and possible variations in vitamin D status according to the body region which was scheduled to undergo surgery. We measured the vitamin D level of 1119 patients consecutively admitted to an orthopaedic surgery department of a university hospital in Germany in 2011. The prevalence of normal (< or =30 ng/ml), insufficient (20-30 ng/ml) and deficient (< or =20 ng/ml) 25-OH-D levels was determined. Serum Vitamin D levels and rates of insufficiency and deficiency were compared between the different cohorts using two-tailed tests. The level of significance was set at p < or =0.05. The serum 25-OH-D levels for all participants were normally distributed, with a mean of 2057 ng/ml. Overall, we noted an alarmingly high rate of vitamin D insufficiency or deficiency among orthopaedic patients. No significant difference was found related with the various body regions scheduled to undergo surgery. Given the well-known effects of vitamin D on bone metabolism and muscle health, vitamin D insufficiency may negatively affect patients.

Biological responses to individualized small titanium implants for the treatment of focal full-thickness knee cartilage defects in a sheep model.

BACKGROUND: The present study aimed to evaluate the functional, radiological and histological outcome of a customized focal implant for the treatment of focal full-thickness cartilage defects in sheep. METHODS: The study used magnetic resonance imaging data as the basis for construction of the titanium implant using a three-dimensional printing technique. This was then placed on the medial condyle of the knee joint in eight sheep and left in place in vivo over a period of six months. Following euthanasia, the local biological response was analyzed using micro-computed tomography, light microscopy and histological evaluation (International Cartilage Repair Society (ICRS) score). The variables were analyzed using a generalized linear mixed model. Odds ratios were given with 95% confidence intervals. RESULTS: The osseointegration rate was 62.1% (SD 3.9%). All implants were prone to the neighboring cartilage bed (4.4-1096.1 µm). Using the IRCS score, the elements 'surface', 'matrix', 'cell distribution' and 'cell population' all showed pathological changes on the operated side, although these did not correlate with implant elevation. On average, a difference of 0.7 mm (±2 mm) was found between the digitally planned implant and the real implant. CONCLUSIONS: As a result of imprecise segmentation and difficult preparation conditions at the prosthesis bed, as well as changes at the surface of the implant over the operational lifetime of the prosthesis, it must be stated that the approach implemented here of using a customized implant for the treatment of focal full-thickness cartilage defects at the knee did not meet our expectations.

Release of Antibiotics Out of a Moldable Collagen-ß-Tricalciumphosphate-Composite Compared to Two Calcium Phosphate Granules.

Bacterial bone infections after revision surgeries and diseases, like osteomyelitis, are still a challenge with regard to surgical treatments. Local bone infections were treated with antibiotics directly or by controlled drug-releasing scaffolds, like polymethylmethacrylate (PMMA) spheres, which have to be removed at a later stage, but there is a risk of a bacterial contamination during the removement. Therefore, biomaterials loaded with antibiotics for controlled release could be the method of choice: The biomaterials degrade during the drug release, therefore, there is no need for a second surgery to remove the drug eluting agent. Even non-resorbable bone materials are available (e.g., hydroxyapatite (HA)) or resorbable bone graft materials (e.g., beta-tricalcium phosphate (ß-TCP)) that will be replaced by newly formed bone. Composite materials with organic additives (e.g., collagen) supports the handling during surgery and enhances the drug loading capacity, as well as the drug releasing time. The purpose of this study was to investigate the loading capacity and the release rate of Vancomycin and Gentamicin on TCP and HA granules in the shape of a degradable scaffold compared to composite materials from TCP mixed with porcine collagen. Its antibacterial efficacy to a more elementary drug with eluting in aqueous solution was examined. The loading capacity of the biomaterials was measured and compared according to the Minimum Inhibition Concentration (MIC) and the Minimum Biofilm Eradication Concentration (MBEC) of a bacterial biofilm after 24 h aging. Antibiotic elution and concentration of gentamycin and vancomycin, as well as inhibition zones, were measured by using the Quantitative Microparticle Systems (QMS) immunoassays. The antibiotic concentration was determined by the automated Beckman Coulter (BC) chemistry device. For examination of the antibacterial activity, inhibition zone diameters were measured. Generally, the antibiotic release is more pronounced during the first couple of days than later. Both TCP granules and HA granules experienced a significantly decline of antibiotics release during the first three days. After the fourth day and beyond, the antibiotic release was below the detection threshold. The antibiotic release of the composite material TCP and porcine collagen declined less drastically and was still in the frame of the specification during the first nine days. There was no significant evidence of interaction effect between antibiotic and material, i.e., the fitted lines for Gentamycin and Vancomycin are almost parallel. During this first in vitro study, ß-TCP-Collagen composites shows a significantly higher loading capacity and a steadily release of the antibiotics Gentamycin and Vancomycin, compared to the also used TCP and HA Granules.

A Case Report of the Successful Conversion of One of the Longest Standing KineSpring Joint Unloading Systems.

INTRODUCTION: We present the case of a successful conversion of a KineSpring joint unloading system to a total knee replacement. This is, to the best of our knowledge, the so far longest surviving implant in Germany that has been successfully converted. CASE REPORT: The patient is a 75-year-old woman who presented to clinic with problems of her left knee. She had a KineSpring joint unloading system implanted in March 2011 for severe medial osteoarthritis of her left knee that was unresponsive to maximal conservative treatment. After nearly 7 pain-free years, we successfully converted the KineSpring joint unloading system into a total knee replacement (Vega, Aesculap, Germany). CONCLUSION: The KineSpring joint unloading system is possible treatment option for younger patients with mild-to-moderate osteoarthritis of the knee reluctant to total knee replacement, without compromising further surgical options.

[Livestock-Associated Methicillin-Resistant Staphylococcus aureus: Epidemiological Data from an Orthopaedic Department in North-West Germany]. / Livestock-assoziierter Methicillin-resistenter Staphylococcus aureus ­ Erhebung einer orthopädischen Fachklinik im Hochrisikogebiet Nord-West.

Background MRSA represents a considerable health threat to orthopaedic patients. Throughout the last decade, livestock-associated MRSA emerged increasingly in livestock all over Europe. LA-MRSA broke the species barrier, colonizing and causing infections in humans. Nevertheless, to date there are no studies concerning livestock-associated MRSA and orthopaedic patients. Therefore, we aimed to investigate the prevalence of LA-MRSA in a regional orthopaedic department localized in an area with high-density livestock. Patients and Methods 1544 persons were enrolled in this prospective study. Nasal swabs and questionnaires were collected in patients admitted to the orthopaedic hospital. Nasal carriage was assessed by using selective MRSA agars. MRSA-positive samples were spa typed. Results Overall, the prevalence of MRSA carriage was 3.3%, nearly all spa types were indicative for LA-MRSA. 91% of all LA-MRSA carriers had contact to livestock during the last 6 months before testing. Conclusion Livestock-associated MRSA emerged rapidly over the last few years and will contribute substantially to MRSA infection rates in orthopaedic hospitals. Livestock-associated patients must be screened before admission in order to control infectious complications.

Ibandronate: The loading dose concept in the treatment of metastatic bone pain.

BACKGROUND/AIM: Severe bone pain is experienced by 60-80% of patients with metastatic bone disease, and has a profound impact on quality of life. Therefore, effective pain relief is an important goal in managing metastatic bone disease. Orthopedic surgeons are often challenged with patients presenting with newly diagnosed bone metastases and severe and disabling bone pain. It is important to provide fast and sufficient analgesia. Clinical trials have demonstrated that bisphosphonates reduce effectively and sustained bone pain by approved standard dosage over time. Open label prospective trials have shown that short time high dose i.v. Ibandronate is effective in rapid pain relief in different primary tumors. PATIENTS AND METHODS: In 33 patients with metastatic bone pain from newly diagnosed skeletal metastases we utilized the loading-dose concept for intravenous ibandronate (6 mg infused over 1 h on 3 consecutive days). RESULTS: In 33 patients loading-dose ibandronate therapy significantly reduced bone pain within the first 5-7 days (VAS day 0: 6-8 vs. day 7: 3-4). Only 3 patients showed no response concerning a distinct pain reduction within the first days of therapy. There was no increase in pain medication. CONCLUSION: This clinical observational study in selected patients with severe metastatic bone pain undergoing an intensive high dosed ibandronate-therapy for a short period demonstrated that loading-dose ibandronate (6 mg i.v., 3 consecutive days) resulted in a reduction of pain within days.

The Importance of Bone Mineral Density in Hip Arthroplasty: Results of a Survey Asking Orthopaedic Surgeons about Their Opinions and Attitudes Concerning Osteoporosis and Hip Arthroplasty.

Objective. In patients scheduled to undergo total joint arthroplasty of the hip, the bone quality around the joint affects the safety of prosthetic implantation. Bone strength is clinically assessed by measuring bone mineral density (BMD); therefore we asked if BMD is important to orthopaedic surgeons performing hip arthroplasty. Methods. In a 14-question survey, we asked about treatment patterns with respect to BMD, osteoporosis work-up, and treatment for patients with low BMD scheduled to undergo hip arthroplasty. Results. 72% of all asked orthopaedics reported to use cementless implants as a standard in hip arthroplasty. Over 60% reported that low BMD is a reason to reconsider operation strategies, but only 4% performed BMD measurement preoperatively. 26% would change their treatment strategy in case of a BMD (T-Score) between -1.5 and -2 and 40% in case of a T-score between -2 and -2.5, and 29% would change their intraoperative strategy if a T-score smaller than -2.5 was measured. Conclusion. The majority of orthopaedic surgeons who responded to the survey reported that they do not perform routine measurement of BMD before arthroplasty. However, most surgeons commented that low bone mineral density will influence their surgical plan and the implant design.

Risk factors for pelvic insufficiency fractures and outcome after conservative therapy.

PURPOSE: The prevalence of osteoporosis has continuously increased over the past decades and it is set to increase substantially as life expectancy rises steadily. Fragility or osteoporotic fractures of the pelvis often occur after low energy falls e.g. from standing, however, some patients present with assumed insufficiency fractures of the pelvis without a previous trauma. Osteoporotic fractures impose a tremendous economic burden and these fractures deserve attention as they lead to a decrease in mobility with an increase in dependency and are associated with a high rate of mortality. To date, little is known about potential risk factors for pelvic insufficiency fractures. Furthermore, information on clinical outcome is scarce. In view of this rather limited knowledge, we aimed to identify potential risk factors for pelvic insufficiency fractures and to collect information on their short- and long-term outcomes. METHODS: Files of all consecutive patients admitted between January 2010 and December 2013 for a pelvic insufficiency fracture were enrolled in this study. Pelvic fractures that occurred on tumorous bone or after high-energy trauma were excluded. Fractures of the pelvis included all pelvic bones except the coccyx. For all patients, we recorded clinical and biological parameters available from their medical history. For comparison, the same biological and clinical parameters were evaluated in an age matched control group of 1083 patients aged over 70 who were admitted to our orthopaedic department to undergo knee or hip arthroplasty. The statistical analyses used or Fisher test for percentages comparison, 2-tailed t-tests and Mann Whitney for mean comparison. To determine what factors are predictors and what factors are confounders of pelvic insufficiency fractures, multivariate linear regression analysis using the fracture as a continuous variable was performed. RESULTS: Ninety-three patients with a pelvic insufficiency fracture were identified. Following the Rommens and Hofmann classification for fragility fractures of the pelvis (FFP), 51 were FFP Type Ia, 26 were FFP Type IIb lesions and 26 were FFP Type IIc. Osteoporosis was found to be significantly associated with pelvic insufficiency fractures (p=0.003), as was hypertension (p=0.036), diabetes (p=0.021), vitamin D deficiency (p=0.004), hypocalcaemia (p=0.002) and nicotine abuse (p=0.0012) after adjustment for possible confounders in the multivariate linear regression analysis. Comparing the autonomous state before and after pelvic fracture, a high loss of autonomy was observed. Patients needing daily assistance nearly doubled their number. Overall mortality was high (20%). CONCLUSIONS: In conclusion, this study showed multiple risk factors for pelvic insufficiency fractures. Some, like vitamin D deficiency, can benefit easy preventive measures. Outcome of conservative therapy is poor, with loss of social and physical independence and autonomy. The mortality rate is high. Efforts should be made in preventing pelvic insufficiency fractures. All patients should be treated for the severe osteoporosis being associated with these fracture type.

Prevalence of Vitamin D Deficiency in Patients with Bone Metastases and Multiple Myeloma.

BACKGROUND/AIM: Breast and prostate cancer are amongst the most prevalent malignancies globally and up to 40% of patients will develop metastatic disease, particularly to the skeleton. Multiple myeloma is the most common cancer to affect bone with up to 90% of patients developing bone lesions. Although several studies demonstrated that endocrine changes such as vitamin D deficiency promote secondary cancer growth in bone, relatively few have reported its prevalence. For this reason, the purpose of the present study was to evaluate the prevalence of hypovitaminosis D in patients with bone metastases and multiple myeloma. PATIENTS AND METHODS: Serum 25-OH-D levels of patients with metastatic bone disease were measured on admission. Statistical analyses was performed to evaluate for possible confounders of hypo-vitaminosis D. RESULTS: We found a widespread and alarming rate of vitamin D deficiency in patients with metastatic bone disease and multiple myeloma. Of note, patients with bone metastases due to breast cancer, prostate cancer and multiple myeloma rarely reached sufficient serum 25-OH-D levels. CONCLUSION: It is of utmost clinical importance to assess vitamin D levels in cancer patients, especially in those with, or at high risk of developing metastatic bone disease.

In vitro elution characteristics of gentamicin and vancomycin from synthetic bone graft substitutes.

OBJECTS: Beta tricalciumphosphate pellets loaded with individualized antibiotics may represent novel options in the treatment of osteomyelitis and infectious bone disease. Here, the in vitro antibiotic elution of vancomycin and gentamicin from the synthetic bone graft substitutes Cerasorb(®) and Cerasorb M(®) was tested. METHODS: Antibiotic elution and concentration of gentamcin and vancomycin were measured using photometrically-based measurement and homogeneous particle-enhanced turbidimetric inhibition immunoassays (PETINIA). RESULTS: Initially both materials showed a high release of the loaded antibiotics, with Cerasorb M(®) showing lower release levels for gentamicin and vancomycin than Cerasorb(®). Gentamicin concentrations of Cerasorb M granules and Cerasorb were below the minimum detectiontreshold until day four and six of the experiment respectively. The vancomycin release-level followed a similar pattern, although the vancomycin concentration eluted by Cerasorb M(®) granules stayed above the detection threshold during the experimental time. CONCLUSIONS: Cerasorb(®) and Cersorb M(®) may represent a new treatment option in osteomyelitis and infectious bone disease.