Factors Affecting the Second Complete Atypical Femoral Fracture after the First Atypical Fracture.

OBJECTIVES: Atypical femoral fracture (AFF) is an atypical low-energy subtrochanteric and diaphyseal femoral fracture. Even if bone fusion is achieved in patients with AFF, the risk of AFF in the contralateral femur must be considered. This study aimed to investigate the factors affecting complete AFF in the contralateral femur and conservatively treated incomplete AFF. SUBJECT AND METHODS: Radiographs of 111 femurs in 104 AFF cases were examined, and the femurs were classified as follows: 85 contralateral femurs with complete AFF; 18 contralateral femurs with incomplete AFF; 8 femurs with incomplete AFF without surgical treatment. Various patients' clinical data were collected, and we investigated the factors affecting the second complete AFF. RESULTS: Complete fractures occurred in 10 (9.7%) of 103 femurs without incomplete AFF at the first visit and in 3 (37.5%) of 8 femurs with incomplete AFF. The Kaplan-Meier curve revealed that lateral cortical bone thickening and thigh pain were associated with significantly poorer prognoses (p = 0.026 and p = 0.013, respectively). Multivariate analyses revealed that eldecalcitol usage after AFF onset (p = 0.0094) and previous use of bisphosphonate or denosumab (p = 0.0126) were protective factors for second complete AFF and that the presence of thigh pain (p = 0.0134) was a risk factor for second complete AFF. CONCLUSIONS: Eldecalcitol administration after bone union of first AFF may prevent AFF recurrence. In addition, painful incomplete AFF has a high risk of developing a complete fracture.

Effects of bisphosphonates and treadmill exercise on bone and kidney in adenine-induced chronic kidney disease rats.

INTRODUCTION: The increasing prevalence of osteoporosis and chronic kidney disease (CKD) due to the aging of society has highlighted the need for development of effective treatments for elderly patients. This study examined whether the combination of treadmill exercise therapy and alendronate (ALN) can improve bone mineral density (BMD) and bone strength without worsening renal function in adenine-induced CKD model rats. MATERIALS AND METHODS: 8-week-old male Wistar rats (n = 70) were divided into experimental groups based on the treatment protocol, i.e., non-CKD (control), vehicle only (CKD), ALN only, exercise only, and combined ALN plus exercise. A 0.75% adenine diet was used to induce CKD. Groups were killed at either 20 or 30 weeks of age. Comprehensive assessments included serum and urine biochemistry tests, renal histology, bone histomorphometry, BMD measurement, micro-computed tomography examinations, and biomechanical testing. RESULTS: Blood biochemistry tests, urine analyses and histological evaluations of the kidney demonstrated that ALN treatment did not worsen renal function or kidney fibrosis in moderate-stage CKD model rats. Both ALN and treadmill exercise significantly suppressed bone resorption (p < 0.05-p < 0.01). Moreover, ALN monotherapy and combined ALN and treadmill exercise significantly improved BMD of the lumbar spine and femur, bone microstructure, and trabecular bone strength (p < 0.05-p < 0.01). Treadmill exercise was also shown to decrease cortical porosity at the mid-diaphysis of the femur and improve kidney fibrosis. CONCLUSION: The combination of ALN and treadmill exercise is effective in improving BMD, the microstructure of trabecular and cortical bone, and bone strength, without compromising renal function in adenine-induced CKD model rats.

Effects of teriparatide and low-intensity aerobic exercise on osteopenia in type 2 diabetes mellitus rats.

INTRODUCTION: In patients with type 2 diabetes mellitus (T2DM), bone fragility increases fracture risk. Teriparatide (TPTD) improves bone strength, and exercise therapy suppresses blood glucose levels in T2DM. In this study, the combined effects of TPTD and exercise therapy on trabecular and cortical bone were examined in advanced T2DM model rats. MATERIALS AND METHODS: Thirty-week-old Otsuka Long-Evans Tokushima Fatty rats were divided into four groups (n = 9-10 in each group at two time points): Cont group (vehicle-treated control), TPTD group (TPTD 30 µg/kg injected subcutaneously, 3 times/week), Exe group (treadmill exercise, 10 m/min, 60 min/day, 5 times/week), and Comb group (TPTD-treated and treadmill exercise combined). Five and 10 weeks after treatment, bone mineral density (BMD), bone strength, and bone micro-architecture were measured. RESULTS: TPTD and combined treatment significantly increased BMDs of the lumbar spine and femur compared to the Cont group (p < 0.05 to p < 0.01). In the three-point bending test of the femur, only combined treatment increased the maximum load at 5 weeks compared with the Cont and Exe groups (p < 0.01). In the compression test of the distal femoral metaphysis, both TPTD and combined treatment increased the trabecular bone strength compared with the Cont and Exe groups (p < 0.05 to p < 0.01). Although TPTD and combined treatment improved the micro-architecture of trabecular bone (p < 0.05 to p < 0.01), only combined treatment improved the micro-structures of cortical bone from 5 weeks of treatment (p < 0.05 to p < 0.01). CONCLUSION: The combination of TPTD and treadmill exercise increased BMD and trabecular and cortical bone strength of the femur with improved micro-architecture in T2DM model rats.

Teriparatide and exercise improve bone, skeletal muscle, and fat parameters in ovariectomized and tail-suspended rats.

INTRODUCTION: Although teriparatide (TPTD) and exercise may improve osteoporosis, muscle atrophy, and fat metabolism during ageing, the effects of treatment with a combination of TPTD and exercise on these factors remain unclear. Therefore, this study examined the effects of TPTD and exercise on bone, skeletal muscle, and fat in ovariectomized and tail-suspended rats. MATERIALS AND METHODS: Seven-month-old female Wistar rats were ovariectomized and subjected to tail suspension. The rats were then randomized into one of the following four groups (n = 20/group) after 4 weeks: control group, treated with TPTD vehicle and no exercise; TPTD group (30 µg/kg TPTD, 3 days/week); Exercise group (treadmill at 12 m/min, 60 min/day, 5 days/week); and Combined group treated with TPTD and treadmill exercise. After 1 and 8 weeks of treatment, bone, skeletal muscle, and fat tissue parameters were evaluated. RESULTS: TPTD improved bone mineral density (BMD), bone structure, bone strength at the femoral metaphysis, and the percentage of skeletal muscle mass, and decreased the percentage of fat mass and the adipose volume in the bone marrow. Treadmill exercise increased BMD, bone strength of cancellous bone, and the percentage of skeletal muscle mass, and decreased the percentage of fat mass as seen on dual-energy X-ray absorptiometry. Furthermore, combined treatment significantly affected BMD, bone structure, and bone strength of cortical bone at the femoral diaphysis. CONCLUSION: TPTD or treadmill exercise improved bone, skeletal muscle, and fat mass. Combination therapy with TPTD and exercise had synergistic effects on BMD, structure, and bone strength in ovariectomized, tail-suspended rats.

Effectiveness of Ilizarov external fixation in elderly patients with pilon fractures.

BACKGROUND: Pilon fractures are associated with soft tissue complications such as skin necrosis, and deep infections have been reported very often. This study retrospectively compared the treatment effects of Ilizarov external fixation and of internal fixation methods in elderly patients with pilon fractures. METHODS: A total of 37 patients >60 years old with pilon fractures (AO classification type 43) were investigated. Patients were treated either with internal fixation (n = 15) or Ilizarov external fixation (n = 22). The patients' mean age was 74.2 (range, 60-78) years in the internal fixation group and 76.1 (range, 60-82) years in the Ilizarov external fixation group. Many patients in the internal fixation group received toe-touch to 1/3 partial weight-bearing at 2-4 weeks postoperatively and full weight-bearing by 6-8 weeks postoperatively. Many patients in the Ilizarov external fixation group received partial weight-bearing (as tolerated) 1 day postoperatively, 1/2 partial weight-bearing at 2 weeks postoperatively, and full weight-bearing at 4 weeks postoperatively. RESULTS: The mean duration of hospitalization was 79.1 ± 30.1 days for the internal fixation group and 29.1 ± 18.8 days for the Ilizarov external fixation group (p < 0.05). Bone mineral density (T-score) was 2.6 ± 0.7 for the internal fixation group and 3.6 ± 1.2 for the Ilizarov external fixation group (p < 0.05). The incidence of skin disorders that required additional surgical treatment was 33.3% (5/15 patients) in the internal fixation group and 0% (0/22 patients) in the Ilizarov external fixation group (p < 0.05). CONCLUSIONS: In elderly patients with periarticular fractures of the ankle, those who underwent Ilizarov external fixation had a shorter duration of hospitalization and fewer complications than those who underwent internal fixation.

Evaluation of the Nature and Etiologies of Risk Factors for Diaphyseal Atypical Femoral Fractures.

OBJECTIVES: Differences in mechanisms of subtrochanteric and diaphyseal atypical femoral fractures (AFFs) are speculated in studies that analyzed differences in the patients' background. However, the etiologies of each type of AFF have not been studied in detail. This study aimed to investigate the nature and etiologies of the risk factors for diaphyseal AFFs. MATERIALS AND METHODS: Eighty consecutive Japanese patients with 91 diaphyseal AFFs (AFF group) and 110 age-matched women with osteoporosis (non-AFF control group) were included. Their clinical data were compared; factors affecting AFFs were investigated, and the etiologies of the risk factors for diaphyseal AFFs were examined. RESULTS: Multivariate analysis revealed that femoral serrated changes, bisphosphonate or denosumab usage, and lateral and anterior femoral curvatures were risk factors for diaphyseal AFFs (p < 0.0011, p = 0.0137, and p < 0.0001, respectively). Multivariate analyses revealed that serrated changes and low serum 25(OH)D levels affected the lateral curvature (p = 0.0088 and 0.0205, respectively), while serrated changes affected the anterior curvature (p = 0.0006), each significantly affected the femoral curvature. High serum calcium (Ca) levels, lateral femoral curvature, and anterior femoral curvature were predictors of serrated changes (p = 0.0146, 0.0002, and 0.0098, respectively). CONCLUSION: Risk factors for diaphyseal AFFs were bone resorption inhibitor usage, a strong femoral curvature, and serrated changes. Low serum 25(OH)D levels and serrated changes are risk factors for lateral curvature, while a high serum Ca level is a risk factor for serrated changes.

Effects of bazedoxifene and low-intensity aerobic exercise on bone and fat parameters in ovariectomized rats.

INTRODUCTION: Postmenopausal osteoporosis and dyslipidemia are well-known skeletal and metabolic changes in middle-aged women. We investigated the effects of combined treatments with a selective estrogen receptor modulator (SERM) and exercise on bone and fat parameters in ovariectomized (OVX) rats. MATERIALS AND METHODS: Sixteen-week-old female Sprague-Dawley rats underwent bilateral ovariectomy, and rats were randomized to BZA (bazedoxifene at 0.3 mg/kg/day), Exe (treadmill exercise at 12-15 m/min, 60 min/day, 5 days/week), Comb (BZA and Exe), and Cont (control treated with vehicle and no exercise) groups 8 weeks after ovariectomy. After 4 or 8 weeks of treatment, bone mineral density (BMD) of the total femur and lumbar spine and whole-body percentage fat mass were determined by dual-energy X-ray absorptiometry, and mechanical testing of the femoral shaft, and bone and fat histomorphometric analyses of the proximal tibia were performed. RESULTS: Treadmill exercise had decreased bone marrow adipocytes from 4 weeks of treatment and whole-body percentage fat mass at 8 weeks. BZA increased BMD at the lumbar spine and decreased the whole-body percentage fat mass from 4 weeks and bone marrow adipocytes at 8 weeks. Combination therapy increased BMD for the lumbar spine and decreased bone marrow adipocytes and whole-body percentage fat mass from 4 weeks. CONCLUSION: Combination therapy with BZA and exercise appears effective to improve bone and fat parameters in OVX rats.

Effectiveness of circular hexapod external fixation with soft tissue reconstruction in treating severe knee dislocation due to burn scarring: a case report.

BACKGROUND: Severe varus deformity and soft tissue injury caused by a burn around a complex knee dislocation is a rare injury. Soft tissue reconstruction and deformity correction with circular hexapod external fixation of the knee and hinged total knee arthroplasty (TKA) are challenging and can lead to major complications if not performed appropriately. We present a case in which a combination of soft tissue reconstruction, circular hexapod external fixation, and TKA was used treat severe knee dislocation due to burn scarring. CASE PRESENTATION: We report the case of a 58-year-old woman who presented for knee surgery with soft tissue reconstruction, deformity correction with circular hexapod external fixation, and hinged TKA for a severe complex deformity and soft tissue injury caused by a burn injury at 6 months of age. The left leg was shorter by 35 mm in terms of functional leg length discrepancy. She walked with a limp, with a marked varus deformity of the left knee during the stance phase of walking. After a 3-stage repair, the patient was able to walk without assistance, confirming improvement of mobility. CONCLUSION: The treatment method was an effective use of a combination of soft tissue reconstruction, circular hexapod external fixation, and rehearsal surgery using a 3D printed bone model of the modular rotating hinge component of TKA, which was successfully used to treat a severe knee dislocation due to burn scarring. This staged surgery maintained the leg length and ultimately achieved a satisfactory alignment.

Ilizarov external fixation for a periprosthetic tibial fracture in severe osteoporosis: a case report.

BACKGROUND: The incidence of periprosthetic fractures after total knee arthroplasty (TKA) is rising due to the increasing number of TKAs performed annually and the growing elderly population. A periprosthetic fracture of the proximal tibia following TKA is a rare injury that may be a challenging clinical scenario. CASE PRESENTATION: The case of an 84-year-old woman who sustained a periprosthetic tibial fracture 10 years after a TKA is presented. This patient had multiple risk factors. The fracture was not deemed amenable to conventional treatment because the bone fragment was too small. This patient underwent fixation of her tibial fracture above the TKA using a five-ring Ilizarov external fixator. This allowed immediate full weight-bearing. The fixator was removed at 12 weeks, at which time the fracture was solidly healed. At the most recent follow-up, 2 years from injury, she was fully weight-bearing without walking aids and had a knee range of motion (ROM) of 0-110°. CONCLUSION: To the best of our knowledge, this is the first report in which Ilizarov external fixation has been used for a periprosthetic tibial fracture after TKA.

Effectiveness of circular external fixator in periprosthetic fractures around the knee.

BACKGROUND: The incidence of periprosthetic fractures after total joint arthroplasty (TJA) is rising due to an increasing number of TJAs performed annually and the growing elderly population. In many elderly patients with periprosthetic fractures, the bone strength is lowered due to the deterioration of bone quality and a decrease in bone quantity; rigid fixation of the fracture is difficult. It is a challenging operation for orthopedic surgeons. The usefulness of circular external fixation for periprosthetic fractures has been reported in several case studies. The aim of this study was to investigate the rate of union and complications associated with circular external fixation in periprosthetic fractures around the knee. METHODS: We included 19 patients with periprosthetic femur and tibial fractures who underwent osteosynthesis using a circular external fixator and had at least 2 years of follow-up. All patients had comorbidities and high risks associated with anesthesia. Tourniquets were not used in any of the patients. There were no cases in which the skin incision was placed, and the closed reduction technique was used in all cases. RESULTS: A 100% union rate was achieved with no serious complications. All fractures healed after a mean time of 14.3 ± 5.2 weeks (range, 8-38 weeks). The walking ability was the same level as before the injury in 13 cases. DISCUSSION: There are many comorbidities associated with periprosthetic fractures in elderly patients. Double-plate or revision surgery were largely invasive and had high risks associated with anesthesia. Circular external fixation is a feasible and effective treatment option because it provides stable fixation, prompt postoperative mobilization, and has no major complications, especially in elderly patients who are treated for periprosthetic fractures. CONCLUSION: Circular external fixation is a safe and reliable method for periprosthetic fractures around the knee in elderly patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis.

BACKGROUND: In highly active older individuals, end-stage ankle osteoarthritis has traditionally been treated using tibiotalar arthrodesis, which provides considerable pain relief. However, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy is a type of joint preservation surgery that has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator for treating ankle osteoarthritis. METHODS: A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed, followed by angled osteotomy and correction of the distal tibia; the ankle joint was then stabilized after its condition improved. An external fixator was used in all patients, and joint distraction of approximately 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery. RESULTS: The anteroposterior and lateral mortise angle during weight-bearing, talar tilt angle, and anterior translation of the talus on ankle stress radiography were improved significantly (P < 0.05). Signal changes on magnetic resonance imaging also improved in all patients. Visual analog scale and American Orthopedic Foot & Ankle Society scores improved significantly (P < 0.05), and no severe complications were observed. CONCLUSION: DTO with joint distraction may be useful as a joint-preserving surgery for medial ankle osteoarthritis in older patients with high levels of physical activity. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Screw Internal Fixation and Ilizarov External Fixation: A Comparison of Outcomes in Ankle Arthrodesis.

The purpose of this study was to compare the mid-term clinical outcomes between screw internal fixation and Ilizarov external fixation in patients who underwent ankle arthrodesis and to elucidate the differences between the 2 fixation methods. This study investigated 43 ankles in 41 patients who underwent ankle arthrodesis at 1 of the 2 study institutions. There were 15 men and 26 women, and their mean age was 66.2 (range 49 to 87) years. The primary disease included osteoarthritis (OA) (79%), rheumatoid arthritis (RA) (16.3%), and Charcot joint (4.7%). Patients were divided into 2 groups depending on the surgical approach: the screw group (S) and the Ilizarov group (I). The following items were evaluated and compared between the 2 groups: patient characteristics, Tanaka-Takakura classification based on preoperative plain X-ray images, duration of surgery, blood loss, surgical complications, time to start weightbearing, and the Japanese Society of Surgery of the Foot (JSSF) standard rating system for the ankle-hindfoot. Duration of surgery was significantly shorter in the S group (162.3 versus 194.9 min), and the amount of blood loss was also significantly lower in the S group (29.2 versus 97.5 ml). Preoperative JSSF scale was significantly lower in the I group (44.8 versus 33), but postoperative JSSF scale was not significantly different between the 2 groups (82.1 versus 77.9). The S group had satisfactory clinical outcomes with a shorter duration of surgery and smaller amount of blood loss than the I group. However, severe patients in the I group achieved similar treatment outcomes.

Enhanced bone healing and decreased pain in sacral insufficiency fractures after teriparatide treatment: retrospective clinical-based observational study.

The purpose of this retrospective clinical-based observational study was to evaluate the effects of teriparatide (TPTD) on clinical outcomes and radiologic findings of sacral insufficiency fractures (SIFs). Seven elderly women with SIFs received TPTD for at least 6 months. We evaluated the symptoms, pain, and radiological findings. At their initial clinic visit, 86% patients could not walk or sit. Computed tomography (CT) images revealed sacral wing fracture in 6 patients, and bone scintigram showed H-shaped uptake over the bilateral sacral wings in 1 patient. After the treatment, 5 patients could walk. Mean visual analog scale score was significantly lower after (12.9 mm) than before (87.4 mm) TPTD treatment (p < 0.0001). CT images revealed bone union (four patients) and sclerotic changes (three patients) at the fracture sites. Seven elderly women with SIFs had significant improvement in pain and demonstrated bone union or sclerotic changes at fracture sites by TPTD.

Effects of risedronate alone or combined with vitamin K2 on serum undercarboxylated osteocalcin and osteocalcin levels in postmenopausal osteoporosis.

Risedronate decreases osteoporotic fracture incidence; however, its effects remain unclear in elderly osteoporotic patients. Vitamin K mediates carboxylation of osteocalcin (OC), and high undercarboxylated osteocalcin (ucOC) levels indicate vitamin K deficiency and increased osteoporotic fracture risk. We aimed to evaluate the effects of risedronate alone or combined with vitamin K2 on serum ucOC, OC, and incidence of vertebral fractures in elderly osteoporotic patients. A total of 101 women with postmenopausal osteoporosis aged >60 years were randomly stratified into two groups-R group (n = 51), treated with risedronate alone; and R + K group (n = 50), treated with risedronate and vitamin K2. Serum ucOC, OC and incidence of vertebral fractures were evaluated before treatment and at 6 and 12 months post-treatment. Decreased ucOC rates at 6 and 12 months were not significant between groups. However, at 6 and 12 months, decreased OC rates in the R group (p < 0.01 and 0.05, respectively) were significantly higher than in the R + K group, and ucOC/OC change rates in the R group (p < 0.05 and 0.001, respectively) were significantly lower than in the R + K group. Vertebral fracture incidence was not significantly different between the groups at 6 and 12 months. ucOC levels in patients with incident vertebral fractures were significantly higher than in patients without incident vertebral fractures in the R group at 6 months (p < 0.05). Although no significant difference was observed for ucOC decrease rate and incidence of vertebral fractures between treatments, ucOC levels in patients with incident vertebral fractures were significantly greater than in patients without when using risedronate alone.

Pathological fracture of the femur in Alagille syndrome that was treated with low-intensity pulsed ultrasound stimulation and an Ilizarov ring fixator: a case report.

BACKGROUND: Alagille syndrome is a multisystem disorder, which is characterized by hypoplasia of the intrahepatic bile ducts, malformations of the cardiovascular system, eyes, and vertebral column, and abnormal facies. Several of the characteristics of Alagille syndrome may result in an especially high risk of fracture. The majority of patients suffer from chronic cholestasis, which can have a variety of adverse effects on bone metabolism. In Alagille syndrome, fractures primarily occur in the lower limb long bones in the absence of significant trauma. CASE PRESENTATION: A 9-year-old Japanese girl with Alagille syndrome was admitted to our institution with marked hyperbilirubinemia and a pathological fracture of the femur. She had been diagnosed with biliary atresia at the age of 1 month and treated with surgical bile duct reconstruction, vitamins D and K, and ursodeoxycholic acid. However, her liver dysfunction and hyperbilirubinemia worsened. The pathological fracture of the femur was treated with low-intensity pulsed ultrasound stimulation (LIPUS) and an Ilizarov ring fixator. Seventy-four days after surgery, the patient had anatomically and functionally recovered. There was no leg-length discrepancy and no angular malalignment of the lower extremities as measured clinically and radiographically. The range of motion of the hip, knee, and ankle of the patient's operative leg matched the range of motion in the nonoperative leg. CONCLUSION: To the best of our knowledge, there are no reports on use of the Ilizarov frame and LIPUS in diaphyseal femoral fractures in Alagille syndrome. This case report provides evidence that this procedure is successful for managing such diaphyseal fractures in Alagille syndrome.

Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report.

BACKGROUND: Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described. CASE PRESENTATION: The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation. CONCLUSION: When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.

The successful treatment of a Gustilo-Anderson type IIIc distal leg injury with a large bone defect in elderly patient with severe osteoporosis: a case report.

BACKGROUND: Gustilo-Anderson type IIIc tibial open fracture with large bone defects in elderly patients with severe osteoporosis is a rare injury that may be a challenging clinical scenario. CASE PRESENTATION: This study presents the case of a 68-year-old Japanese man who sustained a Gustilo-Anderson type IIIc open tibial fracture with a large bone defect. The patient had severe osteoporosis and the bone was contaminated; therefore, we determined that the bone could not be returned to the tibia. The patient underwent acute limb shortening and gradual lengthening with an Ilizarov external fixator combined with low-intensity pulsed ultrasound and teriparatide administration for limb reconstruction, which allowed immediate full weight-bearing capacity. The fixator was removed at 12 months postoperatively, and by this time, the fracture had completely healed. At the most recent 5-year follow-up after the injury, the patient reported full weight-bearing capacity without walking aids and had full knee and ankle range of motion. CONCLUSIONS: To the best of our knowledge, this is the first study to report the use of combined Ilizarov technique, low-intensity pulsed ultrasound, and teriparatide for limb reconstruction of Gustilo-Anderson type IIIc open tibial fractures with large bone defects in elderly patients with severe osteoporosis.

Skip Fusion With Sacral-Alar-Iliac Screw Fixation for Pelvic Ring and Lumbar Fractures: A Case Report.

Pelvic ring fractures are associated with high-energy trauma and high mortality owing to critical blood loss and concomitant injuries. If there is a concurrent lumbar fracture, the postoperative range of motion will be limited owing to the increased fusion range. Here, we report a case in which skip fusion with sacral-alar-iliac screw fixation was effective as a minimally invasive procedure for treating pelvic ring and lumbar fractures.

Evaluation of Medial Meniscal Extrusion Using Radiography.

Recently, there has been increasing interest in medial meniscal extrusion (MME), but few reports have evaluated MME via X-ray. In this study, the amount of MME and meniscal height at the medial border of the tibia were measured via X-ray with gradation processing. The extrusion length divided by the meniscal height yields the meniscal extrusion ratio, which was used as an index. In addition, the medial meniscal length of the part protruding from the medial border of the tibia on MRI was measured as an absolute value. Then, the correlation between the meniscal extrusion ratio and the amount of MME on MRI was examined, and there was a strong correlation between the meniscal extrusion ratio via X-ray and the amount of MME on MRI (correlation coefficient 0.860, p < 0.0001). The cut-off value of the meniscal extrusion ratio via X-ray for positive meniscal extrusion on MRI was 0.50, with an AUC of 0.9825, sensitivity of 0.9063, and specificity of 0.8663. From the present study, it was possible to measure the extrusion length and meniscal height via gradation processing, with X-ray and without MRI, and to calculate the meniscal extrusion ratio, which strongly correlates with the amount of MME on MRI.

Teriparatide and etelcalcetide improve bone, fibrosis, and fat parameters in chronic kidney disease model rats.

Objectives: Chronic kidney disease (CKD) complicated by secondary hyperparathyroidism (SHPT) is associated with an increased risk of fragility fractures. Etelcalcetide (EC) is a treatment for SHPT that reduces serum parathyroid hormone (PTH) levels. However, the effects of combined treatment with osteoporosis drugs such as teriparatide (TPTD) remain unclear. This study investigates the combined effects of EC and TPTD on bone in CKD model rats. Methods: The CKD model was established in 8-week-old male Wistar rats by feeding them a 0.75% adenine diet for 4 weeks. At 20 weeks of age, the rats were divided into 4 groups (N = 9-10 in each group): CKD group (vehicle administration), TPTD group (30 µg/kg, 3 times/week), EC group (0.6 mg/kg, daily), and Comb group (TPTD and EC combined). EC was injected for 12 weeks starting at 20 weeks of age, and TPTD was injected for 8 weeks starting at 24 weeks of age. After treatment, the followings were evaluated: bone mineral density, bone strength, biochemical tests, bone and fat histomorphometry, and micro-computed tomography. Results: In CKD model rats, the combination of EC and TPTD was more effective in increasing cortical bone thickness and bone strength and inhibiting porosity. In addition, the combined treatment decreased bone marrow adiposity and fibrosis, and it increased bone mass and improved bone microstructure in trabecular bone. Conclusions: With the observed benefits such as improved bone mass, bone strength, structural properties, and bone marrow adiposity, combination therapy may be a potential way to improve bone fragility in CKD.