Epidemiology and Postoperative Outcomes of Atypical Femoral Fractures in Older Adults: A Systematic Review.

OBJECTIVE: To review the literature on epidemiology and postoperative outcomes particularly surgical, functional and quality of life of atypical femoral fractures (AFFs) in the older population (aged ≥65 years) using the first and second American Society of Bone Mineral Research (ASBMR) Task Force consensus definition. METHODS: Electronic search for articles on AFFs and bisphosphonates published in English was performed. Eligible studies were reviewed systematically in relation to (a) the epidemiology of AFFs in older people and (b) postoperative outcomes of AFFs. RESULTS: Twenty-three studies on AFFs were included: 14 on epidemiology and 11 on treatment outcomes (two articles reported on both aspects). The epidemiological studies showed that the incidence of AFFs is low (3.0-9.8 per 100,000 person-years) but relative risk increased with longer duration of bisphosphonates use, especially after more than three years. Most cases of AFFs occurred in older people aged 65 years and above. However, in six studies, the mean age of patients with bisphosphonate-related AFFs is younger than those with typical proximal femoral fractures (mean age range of 66-75 years versus 75-89 years respectively). Varying postoperative and functional outcomes have been reported but differences in study population, management approaches and endpoints may account for these variations. For incomplete AFFs, prophylactic surgical intervention is potentially beneficial. CONCLUSION: The benefits of bisphosphonates in reducing osteoporotic fractures still outweigh the risk of AFFs in view of its low absolute risk, when the ASBMR Task Force criteria for this type of fracture were applied. The risk of AFFs in different age groups is not well defined but tends to affect the younger patients more (aged <65 years) as compared to the older population (aged ≥65 years). Evidence supporting different types of treatment in AFFs such as intramedullary or extramedullary surgical devices and the use of teriparatide, a parathyroid hormone analogue, is not yet well established.

Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health.

To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.

Weight-bearing-induced displacement and migration over time of fracture fragments following split depression fractures of the lateral tibial plateau: a case series with radiostereometric analysis.

We investigated the stability of seven Schatzker type II fractures of the lateral tibial plateau treated by subchondral screws and a buttress plate followed by immediate partial weight-bearing. In order to assess the stability of the fracture, weight-bearing inducible displacements of the fracture fragments and their migration over a one-year period were measured by differentially loaded radiostereometric analysis and standard radiostereometric analysis, respectively. The mean inducible craniocaudal fracture fragment displacements measured -0.30 mm (-0.73 to 0.02) at two weeks and 0.00 mm (-0.12 to 0.15) at 52 weeks. All inducible displacements were elastic in nature under all loads at each examination during follow-up. At one year, the mean craniocaudal migration of the fracture fragments was -0.34 mm (-1.64 to 1.51). Using radiostereometric methods, this case series has shown that in the Schatzker type II fractures investigated, internal fixation with subchondral screws and a buttress plate provided adequate stability to allow immediate post-operative partial weight-bearing, without harmful consequences.

Surgical anatomy for pelvic external fixation.

Pelvic external fixators have a high rate of reported complications, most of which relate to pin placement. In this descriptive study, we analyzed the morphology of the ilium in cadaveric specimens and compared these with the measures obtained from normal human pelvic computer tomograph scans, and how these related to each of the three basic configurations of pin positioning for the external fixation of a pelvis: anterosuperior (Slätis type), anteroinferior (supra-acetabular), and subcristal. The irregular shape and size of the iliac wing and the abdominal wall overlying the pin's insertion site could hinder accurate placement of anterosuperior pins. Potential disadvantages of the use of anteroinferior pins was found related to the deep location of the anterior inferior iliac spine, interference with the hip flexion area, risk of hip joint penetration, and the variable obliquity of the ilium. As subcristal pins are positioned between two superficial bony landmarks of the iliac crest, our findings suggest that they are more likely to have a correct placement and avoid complications.

Clinical implications of stiffness and strength changes in fracture healing.

In the assessment of fracture healing by monitoring stiffness with vibrational analysis or instrumented external fixators, it has been assumed that there is a workable correlation between stiffness and strength. We used four-point bending tests to study time-related changes in stiffness and strength in healing tibial fractures in sheep. We aimed to test the validity of the measurement of stiffness to assess fracture strength. At each duration of healing examined, we found marked variations in stiffness and strength. Stiffness was shown to be load-dependent: measurements at higher loads reflected ultimate strength more accurately. There was a biphasic relationship between stiffness and strength: at first there was a strong correlation regardless of loading conditions, but in the second phase, which included the period of 'clinical healing', stiffness and strength were not significantly correlated. We conclude that the monitoring of stiffness is useful primarily in assessing progress towards union but is inherently limited as an assessment of strength at the time of clinical union. Any interpretation of stiffness must take into account the load conditions.