Sister’s fracture history may be associated with perimenopausal bone fragility and modifies the predictability of fracture risk

Summary  The present study investigated the effects of first degree relatives’ fractures on fracture incidence after the menopause. Sister’s, but not other relatives’, wrist or hip fracture history was associated with increased risk of fragility fractures after the menopause. This suggests genetic predisposition to bone fragility among postmenopausal women. Objective  The aim of the present study was to investigate the association between first degree relatives’ fractures and perimenopausal bone fragility. Materials and methods  The study sample of 971 perimenopausal women was extracted from randomly selected Kuopio Osteoporosis Risk Factor and Prevention cohort and measured with dual X-ray absorptiometry in femoral neck (FN) in baseline (1989–1991), in 5 years (1994–97), and in 10 years (1999–2001). All low-trauma energy fractures during the 10-year follow-up were recorded based on self-reports and validated from medical records. First degree relatives’ history of life-time hip and wrist fractures (exact classification or trauma energy not specified) was questioned by postal inquiries. Results  There was a significant correlation between fathers’ vs. brothers’ and mothers’ vs. sisters’ fractures (p < 0.01 in Pearson bivariate correlations). Sister’s, but not mother’s, father’s, or brother’s wrist and hip fractures were associated with significantly lowered 10-year fragility fracture-free survival rate (HR = 0.56, p = 0.006). Sisters’ or other relatives’ fractures were not associated with FN bone loss rate or bone mineral density (BMD) in the follow-up measurements (p = NS in ANCOVA). The predictive power of BMD for fragility fractures differed according to sisters’ fracture history: Baseline FN T score predicted fracture-free survival only among women without sisters’ fracture history (HR 0.62, p < 0.001 vs. women with sisters’ fracture in Cox regression). Conclusions  In conclusion, sisters’ fracture history is associated with 10-year fracture-free survival in perimenopausal women but not with BMD or its changes. Predictability of fragility fracture risk with BMD may depend on sister’s fracture history. This may indirectly suggest genetic predisposition to bone fragility independently of BMD.     

Parenchyma-sparing anatomical liver resection based on Hjortsjo’s concept

Purpose

Anatomical liver resection is usually based on Couinaud’s anatomical concept. In contrast, Hjortsjo’s concept, which divides the right anterior section of the liver into ventral and dorsal segments by the vertical plane named the ventral segment fissure (VSF), has been rarely utilized for liver resection. Identification of the VSF is the most difficult step in liver resection based on Hjortsjo’s concept. This study aimed to detail liver resection based on Hjortsjo’s concept and report surgical outcomes of this procedure.

Methods

We reviewed the records of 166 consecutive patients who underwent liver resection between September 2009 and June 2012 at Kyoto Medical Center and identified seven liver resections in which Hjortsjo’s concept was utilized. These patients consisted of four men and three women aged 55–79 years. Four patients had hepatocellular carcinoma and cirrhosis and three patients had metachronous colorectal liver metastasis.

Results

Liver resection along the VSF consisted of two extended left medial sectionectomies, three extended right posterior sectionectomies, and one Sg 7+8-dorsal resection by a venous-drainage-guided approach and one Sg 8-dorsal resection by a Glissonian approach. In all patients, the VSF was successfully identified as a congested or ischemic border on the liver surface. Mortality and major morbidity were nil. No patients underwent blood transfusion. After a median follow-up of 15 months, there were no deaths or local recurrence.

Conclusions

Anatomical liver resection based on Hjortsjo’s concept is feasible and advantageous over conventional liver resection because it preserves more parenchyma. The venous-drainage-guided approach is an effective method for identifying the VSF.     

A new approach to the diagnosis of children’s urolithiasis based on the Bonn Risk Index

Published data on the association between calcium oxalate (CaOx) crystallization and kidney stone disease in children are scarce. The aims of this study were to determine CaOx crystallization using the Bonn Risk Index (BRI) in children with urolithiasis in comparison to healthy controls, to evaluate the relationships between BRI and urinary parameters, such as pH, calciuria, oxaluria and citraturia, and to assess the association between BRI and the size of renal stones. We compared the BRI in 142 Caucasian children and adolescents (76 girls, 66 boys) aged 3-18 years with kidney stones and 210 healthy age- and sex-matched controls without urolithiasis. Urinary ionized calcium ([Ca2+]) was measured using a selective electrode, while the onset of spontaneous crystallization was determined using a photometer and titration with 40 mmol/L ammonium oxalate (Ox2-). The calculation of the BRI value was based on the Ca2+:Ox2- ratio. High-resolution renal ultrasonography was carried out to estimate the size of the renal stones. The BRI values were 15-fold higher in children with renal stones than in healthy children without stones. The same trend was shown by BRI/kg body weight (tenfold greater in children with renal stones than in healthy children without stones), BRI/per 1.73 m2 body surface (13-fold greater) and BRI/body mass index (23-fold greater). No association was observed between BRI and the diameter of stones. Children with kidney stones, both males and females, had an increased BRI compared with subjects without urolithiasis. High BRI suggests an association with lower urinary pH, hypercalciuria, hyperoxaluria or hypocitraturia, which are all risk factors of kidney stones. An increased BRI in children, although unrelated to renal stone size, reflects the risk of calcium oxalate crystallization and may indicate early metabolic disorders leading to urolithiasis.     

Liposuction infiltration: The Quito formula �C a new approach based on an old concept

INTRODUCTION:

Liposuction is a highly sought after surgical procedure. Despite its popularity, not all of the factors associated with its execution are well understood. No well-established guidelines exist for plastic surgeons regarding the subcutaneous infiltration of fluid and, thus, the procedure is often performed subjectively.

OBJECTIVE:

To establish the usefulness of the Quito formula (infiltrate volume = weight [kg] × percentage of body surface to be liposuctioned × 2.4 [mL]) for calculating the volume of fluid to be infiltrated subcutaneously during small-volume liposuction performed under epidural anesthesia.

METHODS:

A prospective study was conducted on a group of 50 patients who were candidates for liposuction on multiple body parts between November 2004 and February 2010.

RESULTS:

The maximum volume of infiltrate was 5000 mL and the maximum volume of aspirate was 4500 mL, with a 30% total aspirated area. No patient required blood transfusion, and there were no major complications. However, one patient presented with a small local infection, another with a sacral seroma and two patients had postdural puncture headaches. No patient showed clinical signs consistent with overhydration, dehydration, pulmonary embolism, fat embolism or lidocaine intoxication.

CONCLUSIONS:

When performing small-volume liposuction, subcutaneous infiltration using the Quito formula to calculate the volume of infiltrate proved to be useful, safe and objective.     

Is the T-shaped acetabular fracture really likes a "T"? A study based on three-dimensional fracture mapping

ObjectivesTo explore the morphological pattern of T-shaped acetabular fractures (T-SAFs) by mapping the fracture line using 3D software.Material and methodsWe retrospectively reviewed 1298 consecutive patients with acetabular fractures, and a total of 56 T-SAF patients were enrolled. After the simulated reduction of each fracture in the software, the fracture lines of all patients were overlaid and plotted on a template. A frequency heat map was generated according to the differences in fracture line density distribution. According to the location of fracture lines, all cases were divided into three groups: posterior group, anterior group, extra-posterior group. In surgically treated patients, the surgical approach, fixation methods, and reduction quality were recorded or evaluated.ResultsThe transverse fracture line was sinuous without involving the acetabular roof, and the longitudinal fracture line sloped forward or backward along the edge of the acetabular fossa to split the obturator foramen. The anterior and posterior edges of the acetabular fossa, the transition zone of the acetabular roof and anterior wall, the transition zone of the superior pubic ramus and anterior wall, and the posterior wall near the greater sciatic notch were areas with high rates of fracture incidence. The posterior group included 26 patients (46.4%) and the distribution of fracture lines resembled a “T” or “Y”. The anterior group included 25 patients (44.6%) and the distribution of fracture lines resembled a “7″. The extra-posterior group included 5 patients (8.9%) and the fracture lines run through the ischial body. The surgical strategies vary among different groups of T-SAF patients.ConclusionOur findings shed light on the characteristics of fracture lines for T-SAFs and provide a reference for surgical treatment strategies.     

Pre-fracture quality of life predicts 1-year survival in elderly patients with hip fracture—development of a new scoring system

Summary

Hip fractures are common in elderly people. Despite great progress in surgical care, the outcome of patients with hip fracture remains disappointing. This study determined four prognostic factors (lower ASA score, higher pre-fracture EQ-5D index, higher MMSE score, and female gender) to predict 1-year survival in patients with hip fracture.

Introduction

This study determined the prognostic factors for 1-year survival in patients with hip fracture. Based on these predictors, a scoring system was developed for use upon patients’ admission to the hospital.

Methods

Hip fracture patients, aged ≥60 years, were prospectively enrolled. Upon admission, patients’ sociodemographic data, type of fracture, American Society of Anesthesiologists (ASA) score, health-related quality of life scores (EQ-5D index) and Mini-Mental State Examination (MMSE) scores were recorded, among other parameters.Correlational analysis was performed on all potential variables to identify relevant predictor variables of 1-year survival. Univariate regression analysis was performed on all selected variables, followed by a multivariate analysis for variables that were significant in the univariate analysis. The final score was developed by converting the β-coefficients of each variable from the multivariate analysis into a scoring system.

Results

For 391 hip fracture patients, complete data were available at the time of the 1-year follow-up. In multivariate regression analysis, independent predictors of 1-year survival were lower ASA score, higher pre-fracture EQ-5D index, higher MMSE score, and female gender.The different variables were weighted according to their β-coefficient to build the prognostic score, which ranged from 0 to 10 points. The ROC curve for 1-year mortality after hip fracture showed an area under the curve of 0.74 (R ²?=?0.272; 95 % CI 0.68–0.79; p?<?0.001).

Conclusions

With only four instruments, the new score represents a useful tool for estimating 1-year survival in elderly patients with hip fractures. At present, the score is limited due to a lack of validation. A validation study is currently underway to prove its reliability.

     

Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability?

In the management of a pelvic fracture prompt recognition of an unstable fracture pattern is important in reducing mortality and morbidity. It is believed that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. However, there is little evidence in the literature to support this view. The aim of this study was to determine whether a fracture of the transverse process of L5 is a reliable predictor of pelvic fracture instability. We reviewed our hospital trauma database and identified 80 patients who sustained a pelvic fracture between 2006 and 2010. There were 32 women and 48 men with a mean age of 40 years (10 to 96). Most patients were injured in a road traffic accident or as a result of a fall from a height. A total of 41 patients (51%) had associated injuries. The pelvic fractures were categorised according to the Burgess and Young classification. There were 45 stable and 35 unstable fractures. An associated fracture of the transverse process of L5 was present in 17 patients; 14 (40%) of whom had an unstable fracture pattern. The odds ratio for an unstable fracture of the pelvis in the presence of a fracture of the transverse process of L5 was 9.3 and the relative risk was 2.5. A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture. Its presence should alert the attending staff to this possibility.     

Risk of fracture in patients with Parkinson’s disease

Summary

The aim of the study was to determine fracture risk in incident Parkinson’s disease (PD) patients. This study showed that fracture risk assessment may be indicated among patients with PD, in particular when they have recently used selective serotonin re-uptake inhibitors or high-dose antipsychotics, or have a history of fracture, falling, low body mass index (BMI) or renal disease.

Introduction

PD is a movement disorder associated with falling and detrimental effects on bone. Both are recognized risk factors for fracture. Therefore, the aim was to determine fracture risk in incident PD patients stratified by treatment, severity, duration of disease and related comorbidities.

Methods

We conducted a retrospective cohort study using the UK General Practice Research Database (1987–2011). Each PD patient was matched by age, sex, calendar time and practice to a control patient without history of PD.

Results

We identified 4,687 incident PD patients. Compared to controls, a statistically significant increased risk was observed for any fracture (adjusted hazard ratio [AHR], 1.89; 95 % confidence interval [CI], 1.67–2.14), osteoporotic fracture (AHR, 1.99; 95 % CI, 1.72–2.30) and hip fracture (AHR 3.08; 95 % CI, 2.43–3.89). Fracture risk further increased with history of fracture, falling, low BMI, renal disease, antidepressant use and use of high-dose antipsychotics.

Conclusion

This study showed that incident PD patients have a statistically significant increased risk of fracture. Therefore, fracture risk assessment may be indicated among PD patients, who, besides the general risk factors for fracture, like increasing age and female gender, have recently used selective serotonin re-uptake inhibitors or high-dose antipsychotics or have a history of fracture, falling, low BMI or renal disease.     

Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8?years of service provision

Summary  

The cost-effectiveness of Fracture Liaison Services (FLSs) for prevention of secondary fracture in osteoporosis patients in the United Kingdom (UK), and the cost associated with their widespread adoption, were evaluated. An estimated 18 fractures were prevented and ￡21,000 saved per 1,000 patients. Setup across the UK would cost an estimated ￡9.7 million.     

Risk of hip fracture following a wrist fracture—A meta-analysis

AimsThis purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture.MethodStudies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included.Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool.A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies.Results12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93–4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used.ConclusionRisk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43).Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture.This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.     

Dislocation fracture of the pisiform in a 14-year-old—a rare injury to the hand

Isolated dislocation or dislocation fracture of the pisiform are rare injuries with only few cases reported in the literature. Injuries to the pisiform occur more often in combination with other carpal injuries as the sturdiness and stability of its ligamentous attachments protect it from dislocating following a minor trauma. The most cases of dislocation or fracture occur following a direct trauma to the palmar and ulnar aspects of the wrist. Predominantly young male patients present with this problem. We present a case of a 14-year-old female who suffered from a dislocation fracture after falling from her bicycle on her outstretched hand. After confirming the diagnosis of pisiform dislocation fracture and reviewing the literature, we performed pisectomy with rerouting of the flexor carpi ulnaris tendon by suturing it to the ligamentous attachments. These rare injuries to the wrist are demanding in diagnostics and treatment and could be neglected in acute period. However, with a correct diagnosis and appropriate treatment, an excellent clinical outcome can be achieved.Level of Evidence: Level V, diagnostic study     

Destruction of choroid plexus cells in vitro: a new concept for the treatment of hydrocephalus?

OBJECTIVE: The current treatment of hydrocephalus using ventriculoperitoneal shunts and third ventriculostomies remains problematic. We revisited the concept of destruction of the choroid plexus for the treatment of hydrocephalus by using an immunotoxin-based technique to specifically destroy this tissue. This approach was based on the observation that, as an epithelial tissue, choroid plexus expresses a number of specific cell-surface proteins that represent excellent potential targets for the creation of a choroid plexus-specific immunotoxin. METHODS: In this study, we characterized sheep and human choroid plexus cells (including atypical and carcinoma cell lines) using fluorescence microscopy in combination with histochemical staining of rat brain and confirmed the presence of a number of epithelium-specific proteins in choroid plexus cells. Immunotoxins were then manufactured by linking these antibodies to ricin A chain and ricin A-B chain. These immunotoxins were delivered to choroid plexus-derived cells in culture, and the results were compared with results of exposure to a nonspecific immunotoxin. RESULTS: Complete cell death of choroid plexus cells was seen after only a 1-hour exposure to the specific immunotoxin, as opposed to the minimal cell death seen with a nonspecific immunotoxin after several hours of exposure. CONCLUSION: These results suggest that immunotoxin-mediated ablation of choroid plexus may be a viable method of treating hydrocephalus and choroid plexus-derived tumors.     

Assessment of the continence status and patients’ satisfaction after retropubic radical prostatectomy: a questionnaire based study

OBJECTIVE: The aim of this study was to assess the continence status and patients' satisfaction after retropubic radical prostatectomy by a self-administered questionnaire composed of 12 questions. MATERIALS AND METHODS: In total, 143 patients who underwent RRP operation at our department from 1992 to 2000 with a minimum 6 months of follow-up were assessed. Seventy two patients participated in the study. The continence status was classified as follows; patients who did not leak were considered as "continent", those who had leakage that occurred less frequent than or equal to once a day were regarded as "socially continent", and those who had more than once a day leakage were regarded as "incontinent". The correlation between urinary leakage, patients' satisfaction and pre-operative, peri-operative and post-operative factors were investigated. Univariate and multivariate analyses were done using Fisher's exact, chi-square, Student's-t and logistic regression tests. RESULTS: The mean age of patients at surgery was 63.9 years (49-76) with a follow-up period of 37.1 months (6-97). Of these patients, 44% were continent, 48% were socially continent, 8% were incontinent. A total of 64 of 72 patients (89%) were satisfied with their final continence status, and 63 (87%) patients accepted to undergo the same surgery again if it is indicated. Pre-, peri- and post-operative factors did not influence the urinary leakage rates. Patients with nocturnal leakage, urgency, decreased urinary flow and patients who use pad (-s) were significantly less satisfied on univariate analysis, while only nocturnal leakage had a significant impact on patients' satisfaction on multivariate analysis. CONCLUSION: Urinary leakage and patients' satisfaction rates after RRP were 56% and 89%, respectively. None of the factors could predict the post-operative continence status. When evaluating the patients' satisfaction, only nocturnal leakage was found to have an adverse affect on multivariate analyses.     

CT-guided internal fixation of a hangman’s fracture

Most hangman’s fractures are treated conservatively. If surgery is indicated, an anterior approach using a C2/C3 graft and plate fusion is usually preferred. Another surgical method according to Judet is direct transpedicular osteosynthesis by the dorsal approach. This surgery is frequently rejected because of the high risk of spinal cord damage or vertebral artery tear. Direct transpedicular osteosynthesis of hangman’s fracture according to Judet is a “physiological operation” that does not cause fusion and creates anatomical conditions. This procedure enables appropriate reduction, compression of fragments and immediate stabilization of the C2 segment. A new aspect of Judet’s method of internal fixation of a hangman’s fracture is now proposed. Computed tomographic (CT) guidance is used to ensure safe and exact introduction of two screws from the posterior approach. This method of CT-guided internal fixation of hangman’s fracture allows, preoperatively, for an accurate assessment of the pattern and course of fracture line, selection of the anatomically safest screw path and determination of an appropriate screw length. The procedure also allows for accurate intraoperative control of instrument and implant placement, screw tightening, fracture reduction and anchoring of the screw tip in the contralateral cortex, using repeated CT scans. The procedure is performed in a CT unit under sterile conditions. This method was used in the treatment of eight male and two female patients aged 21–71 years. All treated patients were without neurological deficit. Follow-up ranged from 12 to 57 months (mean 33.3 months). No intraoperative or early or late postoperative complications were apparent. This new aspect of the surgical procedure ensures highly accurate screw placement and minimal risks, and fully achieves the “physiological” internal fixation. Received: 25 January 1999/Revised: 26 February 2000/Accepted: 23 March 2000