The incremental risk of fragility fractures in aging men.

INTRODUCTION: While the United States Preventative Services Task Force recommends osteoporosis screening for women 65 years and older, there is no definitive recommendation for routine osteoporosis screening in men. The purpose of this study was to determine the age at which the odds of fragility fractures (FFx) increase in men to help guide future policy discussions evaluating an optimal screening strategy in this population. METHODS: Men older than 49 years were identified in the PearlDiver Patient Records Database. Patients were excluded if they had a prior fragility fracture, if they were at high risk for osteoporosis due to comorbidities, or if they carried a diagnosis of and/or were on treatment for osteoporosis. The prevalence of FFx was trended for each age group. A stratum-specific likelihood ratio (SSLR) analysis was conducted to identify data-driven strata that maximize the incremental FFx risk by age for men. Logistic regression analyses controlling for potential confounders were conducted to test these identified strata. RESULTS: The incidence of FFx started to increase after the age of 64 years for men. Further, the identified data-driven age strata associated with a significant and incremental difference in fragility fractures were the following: 50-64, 65-69, 70-72, 73-75, 76-78, 79-80, and 81+. When compared to the youngest age stratum (50-64 years), multivariable regression showed the risk of fragility fracture incrementally increased starting in those aged 70-72 (RR, 1.31; 95% CI. 1.21-1.46; p < 0.001) with the highest risk in those aged 81+ (RR, 5.35; 95% CI, 5.10-5.62; p < 0.001). CONCLUSION: In men without a pre-existing history of osteoporosis, the risk of fragility fractures starts to increase after the age of 70. Further work building upon these data may help to identify a specific age at which routine bone health screening in males can help to minimize fractures and their associated morbidity and mortality.

Advanced glycation end-product accumulation differs by location and sex in aged osteoarthritic human menisci.

OBJECTIVE: There is a clear link between increasing age and meniscus degeneration, leading to increased injury, osteoarthritis (OA) progression, and often total knee replacement. Advanced glycation end-products (AGEs) are non-enzymatic crosslinks and adducts that accumulate in collagen with age, altering tissue mechanics and cell function, ultimately leading to increased injury and inflammation. AGEs, both fluorescent and non-fluorescent, play a central role in age-related degradation of tissues throughout the body; however, little is known about their role in meniscus degeneration. The objective of this study was to characterize changes in aged OA menisci, specifically evaluating zonal AGE accumulation, to gain a better understanding of changes that may lead to age-related meniscal degeneration. METHOD: Deidentified human menisci (N = 48, 52-84 years old) were obtained from subjects undergoing total knee replacement. Changes in extracellular matrix (ECM) were assessed by gross morphology, confocal analysis, and biochemical assays. Deoxyribonucleic acid (DNA), glycosaminoglycan (GAG), collagen, and AGE accumulation were compared with patient age, zonal region, and patient sex. RESULTS: There were minimal changes in DNA, GAG, and collagen concentration with age or zone. However, collagen fraying and AGEs increased with age, with more AGEs accumulating in the meniscal horns compared to the central body and in male menisci compared to females. CONCLUSIONS: Overall, this work provides greater insights into regional changes that occur in human menisci with age and OA. These results suggest AGEs may play a role in the degeneration of the meniscus, with AGEs being a possible target to reduce age-related tears, degeneration, and OA progression.

Evaluation of painful total knee arthroplasty: an approach based on common etiologies for total knee arthroplasty revision.

A differential diagnosis with emphasis on the common indications for revision should be utilized in the workup of painful total knee arthroplasty (TKA). The physician should identify the exact etiology of the patient's pain to maximize outcomes from treatment. Evaluation for infection should be completed using the Musculoskeletal Infection Society (MSIS) criteria. When common causes of revision TKA do not appear to be the cause of the pain, less likely causes should be not be ignored. Further advancements such as pressure sensing devices may be able to improve patient satisfaction and decrease the incidence of pain following TKA.

Olecranon fractures: treatment options.

Fractures of the olecranon process of the ulna typically occur as a result of a motor-vehicle or motorcycle accident, a fall, or assault. Nondisplaced fractures can be treated with a short period of immobilization followed by gradually increasing range of motion. Open reduction and internal fixation is the standard treatment for displaced intra-articular fractures. Stable internal fixation with figure-of-eight tension-band wire fixation for simple transverse fractures allows early motion to minimize stiffness. Use of two knots produces symmetric tension at the fracture site and provides more rigid fixation than a single knot. Care should be taken to ensure that the tension-band wire and the proximal ends of the Kirschner wires are positioned deep to the triceps fibers to prevent wire migration. If the anterior cortex is engaged, overpenetration of the wires into the soft tissues should be avoided. Plate fixation is appropriate for severely comminuted fractures, distal fractures involving the coronoid process, oblique fractures distal to the midpoint of the trochlear notch, Monteggia fracture-dislocations of the elbow, and nonunions. For comminuted fractures and nonunions, a dorsally applied limited-contact dynamic-compression plate with supplemental bone graft should be utilized to support comminuted depressed articular fragments. A one-third tubular hook-plate can be used for fractures with a small proximal fragment for which additional fixation of the olecranon tip is desired. Fragment excision and triceps advancement is appropriate in selected cases in which open reduction seems unlikely to be successful, such as in osteoporotic elderly patients with severely comminuted fractures.

Chest wall deformities.

Children present with chest wall deformities to their pediatrician because of physiologic and psychologic causes. We have a 22-year experience in the operative management of more than 300 of these children. Initial evaluation should accurately categorize the deformity, determine the severity, assess for associated problems and refer the child at an appropriate time for further management. Pectus carinatum is the most common deformity that can cause physical pain from an intercostal neuropathy and psychologic pain from the unsightly protuberance. Poland syndrome is managed by early correction of the hand deformity and later correction of the chest wall deformity if necessary for psychologic or functional reasons. Jeune syndrome and failure of sternal fusion may have severe associated cardiopulmonary compromise. Each should be corrected in infancy for the best results.

Increased satisfaction after total knee replacement using sensor-guided technology.

The aim of this prospective multicentre study was to report the patient satisfaction after total knee replacement (TKR), undertaken with the aid of intra-operative sensors, and to compare these results with previous studies. A total of 135 patients undergoing TKR were included in the study. The soft-tissue balance of each TKR was quantified intra-operatively by the sensor, and 18 (13%) were found to be unbalanced. A total of 113 patients (96.7%) in the balanced group and 15 (82.1%) in the unbalanced group were satisfied or very satisfied one year post-operatively (p = 0.043). A review of the literature identified no previous study with a mean level of satisfaction that was greater than the reported level of satisfaction of the balanced TKR group in this study. Ensuring soft-tissue balance by using intra-operative sensors during TKR may improve satisfaction.

A novel constrained acetabular liner design with increased range of motion.

One treatment strategy for recurrent dislocation after total hip arthroplasty is the use of a constrained acetabular component. A major drawback of currently available constrained components is the limited range of motion (ROM). We present a novel constrained component that employs a monopolar, highly cross-linked polyethylene liner with cutouts oriented to allow increased ROM, while maintaining constraint against dislocation. ROM and lever-out tests comparing this novel design with a conventional constrained component showed that the cutaway monopolar component allowed ROM substantially greater than a currently available design. The lever-out torque for the cutaway monopolar constrained component was 243% higher than the conventional constrained component. This novel constrained acetabular component offers promise for providing excellent constraint against dislocation, while maintaining a wide ROM.

An electronic database for outcome studies that includes digital radiographs.

We report on acquisition of key data from the clinical medical record, surgical data, radiologic studies, and patient surveys for a novel digital total hip arthroplasty (THA) registry that includes electronic capture of digital radiographic images into a database on an internet platform for query. We now have the ability to collect demographic and operative data, including the operative note, discharge summary, surgery data, and Digital Imaging Communications in Medicine (DICOM) radiology images. Steps are being completed to assemble office encounters, hospital procedural codes, and implant bar codes. Two examples include a THA surgery record and a THA outcome study with plain radiograph set. Analysis of such data could suggest ways to improve clinical practice.