Minimally invasive percutaneous compression plating versus dynamic hip screw for intertrochanteric fractures: a randomized control trial

Objective：Intertrochanteric femur fracture is a common injury in elderly patients.The dynamic hip screw （DHS） has served as the standard choice for fixation; however it has several drawbacks.Studies of the percutaneous compression plate （PCCP） are still inconclusive in regards to its efficacy and safety.By comparing the two methods,we assessed their clinical therapeutic outcome.Methods：Atotal of 121 elderly patients with intertrochanteric femur fractures （type AO/OTA 31.A 1-A2,Evans type 1） were divided randomly into two groups undergoing either a minimally invasive PCCP procedure or a conventional DHS fixation.Results：The mean operation duration was significantly shorter in the PCCP group （55.2 min versus 88.5 min,P＜0.01）.The blood loss was 156.5 ml±18.3 ml in the PCCP group and 513.2 ml±66.2 ml in the DHS group （P＜0.01）.Among the patients treated with PCCP,3.1％ needed blood transfusions,compared with 44.6％ of those that had DHS surgery （P＜0.01）.The PCCP group displayed less postoperative complications （P＜0.05）.The mean American Society of Anesthesiologists score and Harris hip score in the PCCP group were better than those in the DHS group.There were no significant differences in the mean hospital stay,mortality rates,or fracture healing.Conclusion：Due to several advantages,PCCP has the potential to become the ideal choice for treating intertrochanteric fractures （type AO/OTA 31.A1-A2,Evans type 1）,particularly in the elderly.     

Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system?

IntroductionThe surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature.Patients and methodsSeventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate? (Arthrex^®) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH).ResultsThe follow-up examinations were on average 13.9 ± 4.5 months (10–27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification.ConclusionThe data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.     

Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate

BackgroundPlate and screw fixation was introduced for complex fractures of the hand. Several risk factors for a poor functional outcome have been identified, but there is a paucity of evidence regarding predictors of finger stiffness in difficult hand fractures. The purpose of this prospective cohort study was to identify independent prognostic factors of the postoperative total active motion (%TAM) in the treatment of metacarpal and phalangeal fractures.MethodsSeventy-two patients (62 males, 10 females; 37 ± 15 years) with periarticular fractures involving metaphyseal comminution and displacement were evaluated at a minimum of 1 year following surgery. There were 49 phalangeal bone fractures, 30 intra-articular fractures and 20 associated soft-tissue injuries. The locations of plate placement were lateral in 42 patients and dorsal in 30. The mean duration from injury to surgery was 7.6 days (range, 0–40 days). There were eight examined variables related to patient characteristics (age, gender and hand dominance), fracture characteristics (fracture location, joint involvement and associated soft-tissue injury) and surgical variables (location of plate placement and duration from injury to surgery). Univariate and multivariate linear regression analysis were used to identify the degree to which variables affect %TAM at the final follow-up.ResultsUnivariate analysis indicated moderate correlations of %TAM with fracture location, associated soft-tissue injury and age. Multiple linear regression modelling including fracture location, age and associated soft-tissue injury resulted in formulae that could account for 46.3% of the variability in %TAM: fracture location (β = ?0.388, p < 0.001), age (β = ?0.339, p < 0.001) and associated soft-tissue injury (β = –0.296, p = 0.002).ConclusionPhalangeal fracture, increasing age and associated soft-tissue injury were important risk factors to identify the postoperative %TAM in the treatment of comminuted periarticular metacarpal or phalangeal fracture with a titanium plate.     

Biomechanical comparison of different acetabular plate systems and constructs--the role of an infra-acetabular screw placement and use of locking plates

IntroductionThe aim of this study was the direct comparison of the static fixation strength of two common plate systems: MPS (Matta Pelvic System) and LPPS (Low Profile Plate System). Furthermore the role of a modified screw placement with addressing the infra-acetabular corridor and the use of locking screws were evaluated.Materials and methodsCustom made anterior column fractures in artificial SYNBONE pelves were fixed with different acetabular plates (group I: MPS, group II: LPPS none locking and group III: LPPS locking). Each pelvis was tested twice, with the additionally placed infra-acetabular lag screw [+] first, followed by a repeated measurement without the infra-acetabular screw [?]. Six pelves per group were tested under static loading with six cycles up to 800 N, each. The fracture displacement was measured in the weight bearing dome using an ultrasound based Zebris-3D-Motion Analyzer.ResultsThe MPS-plate had a less fixation strength compared to the LPPS-plate (mean ± SD of maximum fracture displacement [mm] in group I vs. group II = 0.63 ± 0.02 vs. 0.37 ± 0.02, p < 0.05). The locking feature did not increase the fracture fixation strength (mean ± SD of maximum fracture displacement [mm] in group II vs. group III: 0.37 ± 0.02 vs. 0.37 ± 0.03; ns).The infra-acetabular screw significantly reduces the maximum fracture displacement in all groups, independent of the plate systems ([Delta%] in group I = 50; group II = 63 and group III = 40; p < 0.05 each).ConclusionThe LPPS-plate performed superior fixation strength for anterior column fractures compared to the MPS-plate. The locking plate modality did not reduce the maximum fracture displacement, whereas the additional infra-acetabular screw placement actually doubles the fracture fixation strength independent of the used plate system.     

Medical management of patients over 50 years admitted to orthopedic surgery for low-energy fracture

ObjectiveTo develop a cost-effective strategy for improving osteoporosis management in patients admitted to an orthopedic surgery department for low-energy fractures.MethodsFrom November 2003 to July 2004, all patients over 50 years admitted to the orthopedics department of the Caen Teaching Hospital (France) for low-energy fractures were identified and evaluated by rheumatology department physicians in the same hospital.ResultsDuring the study period, 313 patients were identified, 257 women (mean age, 79.5 ± 10.2 years) and 56 men (mean age, 74.6 ± 10.8 years), each with one fracture (proximal femur, 58.9%; wrist, 13%). Among them, 91 (29%) had a previous history of osteoporotic fractures. Mean bone mineral density (BMD) values were lower at the femoral neck than at the total hip or lumbar spine (e.g. in women, −2.3 ± 0.9 versus −1.8 ± 1.0 and −1.4 ± 1.7, respectively). Osteoporosis treatment was given to 88 (28%) patients and consisted of calcium and vitamin D supplements, combined with alendronate in 32 patients. Complete loss of self-sufficiency occurred in 73 patients. Thus, 161 patients (88 with osteoporosis treatment and 73 with loss of self-sufficiency) received optimal treatment.ConclusionCooperation between the orthopedics and rheumatology departments improved the management of osteoporosis in patients with low-energy fractures. However, appropriate investigation and treatment of osteoporosis proved difficult in the oldest old and in patients with cognitive impairments.     

The epidemiology of fractures of the proximal ulna

IntroductionThe aim of our study was to report the epidemiological characteristics of fractures of the proximal ulna.MethodsFrom our prospective trauma database of 6872 fractures, we identified all acute fractures of the proximal ulna from a 1-year period between July 2007 and June 2008. Age, gender, mode of injury, fracture classifications, associated injuries and treatment were the factors documented and analysed.ResultsThere were 78 fractures of the proximal ulna with a mean age of 57 years (15–97). Males (n = 35) sustained their fracture at a significantly younger age than females (p = 0.041), with no gender predominance seen (p = 0.365). The overall fracture distribution was a unimodal older male and unimodal older female type-F curve. The most common mode of injury was a simple fall from standing height (n = 52, 67%), with younger patients more likely to sustain their injuries following a high-energy mechanism such as sports or a motor vehicle collision (p < 0.001). Seventeen (22%) patients sustained associated injuries to the ipsilateral limb, with an associated proximal radial fracture most frequent (n = 13, 17%). Open fractures were seen in five (6.4%) patients. A total of 64 patients had a fracture of the olecranon, with the Mayo 2A most frequently seen (n = 47, 60%).ConclusionsFractures of the proximal ulna are fragility fractures that predominantly occur in elderly patients. Given the number of elderly patients sustaining these injuries, research is needed to determine the role of non-operative treatment for these fractures, particularly in patients with multiple co-morbidities and low functional demands.     

Biomechanical cadaver testing of a fixed-angle plate in comparison to tension wiring and screw fixation in transverse patella fractures

IntroductionOperative treatment of patella fractures is frequently associated with implant failure and secondary dislocation which can be attributed to the employed hardware. Therefore, a 2.7 mm fixed-angle plate designed for the treatment of patella fractures was tested biomechanically against the currently preferred methods of fixation. It was hypothesized that under simulated cyclic loading fixed-angle plating would be superior to modified anterior tension wiring or cannulated lag screws with anterior tension wiring.Materials and methodsEighteen human cadaver knees, matched by bone mineral density and age, were divided into three groups of six. After setting a transverse patella fracture each group received one of the osteosyntheses mentioned above. Repetitive testing over 100 cycles was performed at non-destructive loads by simulating knee motion from 90° flexion to full extension.ResultsAnterior tension wiring as well as lag screws with tension wiring showed significant fracture displacement after the initial cycle already. Both constructs, lag screws plus wiring (3.7 ± 2.7 mm) as well as tension wiring alone (7.1 ± 2.2 mm) displayed fracture displacement of >2 mm which is clinically regarded as failure. Those patellae stabilized with fixed-angle plates showed no significant fracture gap widening after completion of 100 cycles (0.7 ± 0.5 mm). The differences between the fixed-angle plate group and the other two groups were statistically significant (p < 0.05).ConclusionIn contrast to modified anterior tension wiring and cannulated lag screws with anterior tension wiring the bilateral fixed-angle plate was the only fixation device to stabilize transverse patella fractures securely and sustainably.     

Assessment of aortic wall stiffness in patients with Familial Mediterranean Fever

IntroductionTo evaluate aortic wall stiffness and its relation between the aortic stiffness and the left ventricular function in patients with Familial Mediterranean Fever (FMF).MethodsThe study population was composed of 31 patients with FMF in attack-free period (12 men, 19 women; mean age: 36 ± 7 years) and 27 healthy subjects (10 men, 17 women; mean age: 34 ± 7 years) who had volunteered to participate. Aortic stiffness indices, aortic strain and distensibility, were calculated from the aortic diameters measured by echocardiography and blood pressure obtained by sphygmomanometry.ResultsThere were significant differences between the control and the patient group in aortic strain (mean (SD), 7.23 ± 2.14 versus 4.91 ± 1.66%, p = 0.01) and distensibility (4.02 ± 1.42 versus 2.84 ± 1.46, 10^?6 cm² dyn^?1, p = 0.001). Although there was no correlation between the aortic stiffness parameters and the left ventricular function parameters, there were significant negative correlations between the disease duration and aortic strain index (r = ?0.29, p < 0.001), and between the disease duration and distensibility (r = ?0.32, p < 0.001).ConclusionAortic stiffness measurements were found abnormal in patients with FMF. We have also demonstrated that there were significant correlations between aortic stiffness parameters and disease duration.     

Preoperative plasma B-type natriuretic peptide (BNP) identifies abnormal transthoracic echocardiography in elderly patients with traumatic hip fracture

IntroductionThis prospective study was designed to evaluate whether preoperative plasma brain natriuretic peptide (BNP) could identify significant preoperative cardiovascular disease in elderly hip-fractured patients.Patients and methodsPreoperative plasma BNP measurement and rest transthoracic echocardiography (TTE) were performed within 24 h after admission in consecutive hip-fractured patients aged ≥65 years. The major echocardiographic abnormality (MEA) group included patients with at least one TTE abnormality, defined as systolic pulmonary artery pressure (PAP_s) ≥50 mmHg, left ventricular (LV) systolic dysfunction, increased LV filling pressure (LVFP) or severe valvular disease. The control group included the remaining patients.ResultsSeventy-five patients (mean ± SD (range) age = 85 ± 5 (69–97) years) were included during a 6-month period. Twenty-four (32%) patients constituted the MEA group (17 elevated PAP_s, three LV systolic dysfunctions, 10 increased LVFP, one severe aortic stenosis and one severe mitral regurgitation). Median (interquartile) preoperative BNP value was significantly greater in MEA than in the control group (527 (361) vs. 119 (154) pg ml^?1; p < 0.0001). A preoperative plasma BNP cut-off value at 285 pg ml^?1 predicted well MEA with an area under the receiver operating characteristic (ROC) curve equal to 0.895 (p < 0.0001) and with a hazard ratio (HR) (confidence interval, CI) of 23.8 (3.7–142.9) (p = 0.0008) on multivariate analysis. The presence of MEA or BNP ≥ 285 pg ml^?1 was associated with high mortality.DiscussionThe incidence of echocardiographic signs of elevated PAP_s or elevated LVFP in elderly hip-fractured patients was high. A preoperative BNP value ≥285 pg ml^?1 can discriminate between elderly hip-fractured patients with or without MEA.     

Biomechanical analysis of locked and non-locked plate fixation of the clavicle

IntroductionDuring plate fixation of clavicular fractures the brachial plexus and subclavian vessels are vulnerable to injury beneath the clavicle. Locking plate fixation allows for mono-cortical fixation, theoretically reducing the risk of injury to these structures. Biomechanical analysis of the performance of such fixation is limited, and this study was designed to explore this further as a treatment option in clavicle fractures.Materials and methodsFixation of fifteen simulated mid-shaft fractures was undertaken using a combination of mono-cortical locked, bicortical locked and bicortical non-locked plating methods in cadaveric clavicles. Samples were then tested via three-point bending to destruction, and the performance of each with respect to failure load, bending stress, bending stiffness and Young's modulus was then analysed. The influence of the number of cortices engaged and locking was also assessed.ResultsClavicles fixed with monocortical locking plates displayed a significantly lower bending stress (12 ± 1 MPa) than both the bicortical locking (28 ± 3 MPa, p = 0.015) and non-locking specimens (24 ± 3 MPa, p = 0.002). Engaging two cortices with the fixation produced a significant increase in failure load (291 ± 28 N vs 138 ± 48 N, p = 0.018) and bending stress (26 ± 2 MPa vs 9.9 ± 3.5 MPa, p = 0.002) compared to single cortex fixation.DiscussionThe greatest influence upon the performance of the fixation was the number of cortices engaged, with bicortical fixation performing significantly better than mono-cortical. Whether or not the fixation device was a locking one did not have a significant bearing upon the performance.ConclusionThis in vitro biomechanical analysis demonstrates that mono-cortical locked plating fails at significantly lower levels of load and stress than bicortical locked and non-locked plating in mid-shaft fractures of the clavicle, and caution would therefore be advised in its use as a fixation modality for these injuries.     

No differences of carotid intima-media thickness between young patients with ankylosing spondylitis and healthy controls

ObjectiveAccelerated atherosclerosis in inflammatory rheumatic diseases such as ankylosing spondylitis (AS) stands out among the leading causes of morbidity and mortality. We assessed the correlation between subclinical carotid atherosclerosis and its related clinical parameters in AS patients.MethodsTwenty-eight patients (23 males, 5 females) with AS and 27 sex- and age-matched controls were consecutively recruited to this study. We estimated the carotid intima–media thickness (IMT) and parameters related to arterial elastic properties, including the distensibility coefficient (DC), stiffness index (β), and incremental elastic modulus (E_inc) using high-resolution ultrasonography. Serum levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and monocyte chemoattractant protein-1 (MCP-1) were measured using enzyme-linked immunosorbent assay (ELISA).ResultsCarotid IMT values and arterial elastic parameters in AS patients showed no statistical significance compared to those of controls (0.57 ± 0.07 vs 0.55 ± 0.05, p = 0.387 for IMT, 28.45 ± 9.23 vs 31.93 ± 9.52, p = 0.175 for DC, 2.32 ± 0.18 vs 2.29 ± 0.15, p = 0.559 for stiffness index (β), and 0.14 ± 0.05 vs 0.12 ± 0.03, p = 0.116 for E_inc). The serum level of IL-6 in AS patients was significantly different compared with controls (p = 0.001), but not in serum levels of TNF-α and MCP-1 (p = 0.162, p = 0.087, respectively). Carotid IMT and all arterial elastic parameters calculated in this study were not found to be associated with serum levels of TNF-α, IL-6, and MCP-1.ConclusionThis cross-sectional study showed that carotid IMT and parameters related with arterial elastic properties in young AS patients without clinically evident cardiovascular risk factors were not different from those of sex- and age-matched healthy controls. Serum levels of TNF-α, IL-6, and MCP-1 did not reflect the degree of carotid subclinical atherosclerosis. However, these findings should be confirmed further in a larger population.     

The treatment strategies of intertrochanteric fractures nonunion: An experience of 23 nonunion patients

BackgroundIntertrochanteric femoral fractures are common, but the nonunion of intertrochanteric fractures is not. The purpose of this study was to divide intertrochanteric fracture nonunion into different types and give corresponding treatment strategies.MethodsWe retrospectively evaluated 23 patients with intertrochanteric fracture nonunion. The patients were divided into five groups and each group was treated with a different strategy. All patients had staged clinical and radiographic follow-ups and the mean follow-up was 16.0 ± 4.6 months.ResultsExcept for the patients treated with total hip arthroplasty, all patients achieved fracture union. The mean union time was 4.7 ± 1.2 months. The Harris hip function score differed significantly from preoperative (28.9 ± 6.8) to postoperative (83.8 ± 6.3; p < 0.05). For the three patients who were classified as type III, the femoral neck shaft angle was corrected to a significant degree, from 97.3 ± 6.4 to 127.3 ± 2.5 (p < 0.05). For the four patients who were classified as type V, the mean time from debridement to re-internal fixation was 3.7 ± 1.5 months.ConclusionsThere are several factors associated with the failure of intertrochanteric fracture treatments. We need to analyze the causes of fracture treatment failure carefully. Based on our five classifications and corresponding treatment strategies, the radiographic and functional treatment outcomes were satisfactory. Future larger comparative studies are needed to confirm our results.     

Mean platelet volume (MPV) as an inflammatory marker in ankylosing spondylitis and rheumatoid arthritis

AimsThe aim of this retrospective study was to investigate the correlation between MPV and the clinical disease activity indices of rheumatoid arthritis and ankylosing spondylitis.MethodsThe study consisted of 32 active RA patients (males/females: 7/25, mean age: 49 ± 13) and 30 active AS patients (males/females: 15/15, mean age: 36 ± 12) along with 26 osteoarthritis (OA) patients (males/females: 4/22, mean age: 52 ± 8) and 29 age-matched healthy subjects (males/females: 5/24, mean age: 41 ± 7) as control groups for RA and AS, respectively.ResultsMPV was significantly lower in both AS patients and RA patients with active disease as compared to controls (RA vs OA p < 0.001, AS vs healthy subjects p < 0.001). After treatment MPV values significantly increased in AS and RA (p < 0.001 for all). However, MPV values remained somewhat lower in RA patients than OA patients (p = 0.019). There was a negative correlation between MPV values and BASDAI scores in AS patients after two months of treatment (r = ?0.507; p = 0.004).ConclusionOur results suggest that assessment of MPV may provide additional information about inflammation in AS and RA.     

Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft

ObjectivesThe study aims to evaluate outcomes of autologous iliac bone impaction grafts (AIBIGs) with locking-compression plates (LCPs) in four-part proximal humeral fracture.MethodsBetween October 2004 and October 2008, 21 AIBIG with LCP osteosyntheses were done for four-part proximal humeral fractures. Patients included seven males and 14 females. Their mean age at the time of the operation was 66.3 ± 16.9 years (range: 24–87 years). Five patients had high-energy fractures other than fall from standing height. There were two fracture-dislocation cases, and three valgus-impacted fractures. The length of the calcar segment attached to the articular segment was 7.04 ± 6.10 mm; 13 of the 21 cases had lengths less than 8 mm. Medial-hinge displacement was 16.77 ± 15.84 mm; 19 of the 21 cases had displacements more than 2 mm.ResultsThere was no avascular necrosis of the humeral head and union was achieved in all cases. Varus collapse and hardware-related complications were not observed. Postoperative neck-shaft angles were found to be 129 ± 9° (range: 109–146°). Neer scores were 92.0 ± 6.3 (range: 81–100).ConclusionThe results of using AIBIG with LCP for four-part proximal humeral fractures are excellent. There are significant bone defects in osteoporotic or comminuted fractures and LCP alone does not always provide reliable fixation. Therefore, meticulous technique and use of AIBIG in this complicated type of fracture can ensure a favourable outcome.     

Duration of breastfeeding as a risk factor for vertebral fractures

PurposeAmong the risk factors for osteoporosis and fractures, gynecological history (fertile period, parity and breastfeeding) play an important part. Changes in calcium metabolism to enable an adequate mineral transfer to the milk have a prominent role in bone loss during breastfeeding. Data on the influence of breastfeeding in postmenopausal osteoporosis are inconsistent. The aim of the present study was to identify any association between duration of breastfeeding and vertebral fractures in postmenopausal women.MethodsAll patients underwent the following tests: bone mineral density measurements of the lumbar spine (L1–L4) and the total and femoral neck using dual-energy X-ray absorptiometry and antero-posterior and lateral radiography of the thoracic and lumbar spine to identify vertebral fractures.ResultsThe study involved 752 women with a mean age of 64.5 ± 9.3; 23% of them reported vertebral osteoporotic fractures. The women with vertebral fractures had breastfed for longer periods (11.8 ± 12.9 vs. 9.3 ± 11.2 months, p = 0.03) and had more pregnancies (2.6 ± 2.2 vs. 2.2 ± 1.3, p = 0.002). Breastfeeding for more than 18 months was associated with a two-fold risk of developing vertebral fractures (OR 2.12, 95% CI 1.14–5.38, p = 0.04), particularly in those without current or past use of drugs positively affecting bone.ConclusionsOur study showed an association between long periods of breastfeeding and vertebral fractures, supporting a role for lengthy lactation as a risk factor for osteoporotic fractures after menopause. Bearing in mind all the benefits of breastfeeding, this finding suggests the importance of an adequate calcium and vitamin D intake during pregnancy and breastfeeding, with the aid of dietary supplements if necessary.     

Effect of dynamic hip system blade on the treatment of femoral neck fractures in elderly patients with osteoporosis

Objective：To discuss the curative effect of the dynamic hip system blade （DHS-blade） on the treatment of femoral neck fractures in elderly patients with osteoporosis.Methods：A retrospective study was conducted to analyse the clinical data of 60 elderly patients with osteoporosis who had been treated for femoral neck fractures with DHS-blade in our department between September 2012 and February 2014.There were 22 males and 38 females with a mean age of （66.8±3.2） years.According to the Singh Index Classification,all the patients＇ Singh index was below level 3.The Harris criterion and function recovery after operation were analysed.Results：All patients were followed up for 12-17 months （mean 14 months）.No femoral head necrosis,femoral neck shortening,internal fixation loosening or backing out of the nails occurred.Bone nonunion was found in one case and he had a good recovery after total hip arthroplasty.The time for fracture healing ranged from 3-6 months （average 3.5 months）.According to Harris criterion,35 cases were rated as excellent,22 good,2 fair and 1 poor.The Harris scale was significantly improved from 28.46±2.35 preoperatively to 91.98±3.26 at 6 months postoperatively （P＜0.05）.Conclusion：DHS-blade,being minimally invasive,allowing earlier postoperative exercise and avoiding the complications elicited by traditional internal fixation,is advisable for treatment of femoral neck fractured patients with osteoporosis.     

Calcaneous quantitative ultrasound measurements predicts vertebral fractures in idiopathic male osteoporosis

ObjectivesThe aim of this study was to identify the differences in ultrasound bone variables (QUS) and to test the ability to discriminate male patients with and without vertebral fractures.MethodsWe therefore measured broadband ultrasound attenuation (BUA) and speed of sound (SOS) matched for bone mineral density (BMD) and vertebral deformity in idiopathic male osteoporosis.ResultsOne hundred and seventeen men (age 56.6 range 27–78) were divided into three groups (osteoporosis n = 25, osteopenia n = 58 and age-matched control n = 34) according to BMD T-score by WHO criteria. We found 66 patients (56%) with at least one vertebral deformity during the study. BMD and BUA did not differ, while SOS was lower in osteoporosis (p < 0.001) and control group (p < 0.001) between the patients with and without vertebral compression. Strong positive correlation was demonstrated between BUA and BMD (lumbar spine r = 0.44, p < 0.001, femoral neck r = 0.56, p < 0.001, radius r = 0.40, p < 0.001), while similar association between SOS and BMD values was not shown. There was no relationship between the BUA and vertebral fracture risk (Odds ratio: 1.14 95% CI: 0.80–1.61). However, the relative risk of vertebral fracture by SOS was 1.56 (95% CI: 1.08–2.62). Adjusting for age and BMI the risk of vertebral fracture did not change (odds ratio for SOS 1.50 95% CI: 1.02–2.22). After adjustment for BMD SOS was still associated with fracture risk at all measured sites (odds ratio: 1.43, 95% CI: 1.02–2.22; 1.41, 95% CI: 1.02–2.17 and 1.32, 95% CI: 1.02–2.0).ConclusionOur results suggest that BUA values are more closely related to density and structure while SOS values are able to predict fractures.     

Auto-antibodies do not influence development of atherosclerotic plaques in rheumatoid arthritis

BackgroundMany questions remain unanswered about premature atherosclerosis in rheumatoid arthritis (RA). Besides inflammation, some studies have suggested the role of autoantibodies on its pathogenesis.ObjectiveThe aim of this study was to investigate the presence of antibodies against phospholipids, beta2-glycoprotein1 (beta2-gp1), lipoprotein lipase, and heat shock proteins (Hsp) in RA patients and to evaluate their possible association with subclinical carotid atherosclerosis.MethodsSeventy-one RA patients and 53 age- and sex-matched controls were selected to perform anticardiolipin antibodies (aCL) (IgG and IgM), anti-beta2-gp1 (IgG, IgM, and IgA), anti-lipoprotein lipase (anti-LPL), anti-Hsp 60, and anti-Hsp 65 by ELISA tests. Intima-medial thickness (IMT) of common carotid and presence of plaques were assessed by high-resolution B-mode ultrasonography. Exclusion criteria were smoking, diabetes, and arterial hypertension. Lipoproteins, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen levels, as well as health assessment questionnaire (HAQ) and disease activity score (DAS) 28 were also evaluated.ResultsAge (48.93 ± 12.31 vs. 45.37 ± 9.37 years; p = 0.20) and body mass index (BMI) (p = 0.69) were similar in RA and controls, as well as female gender (p = 0.56). The mean IMT was similar between RA and controls (0.721 ± 0.16 vs. 0.667 ± 0.14 mm, p = 0.07) but the frequency of plaques was higher in RA (14.1% vs. 1.9%; p = 0.02). In RA patients, IMT measurements did not differ according to the presence or absence of these antibodies: IgG aCL (0.62 ± 0.64 vs. 0.72 ± 0.17 mm, p = 0.24), IgM aCL (0.65 ± 0.79 vs. 0.73 ± 0.17 mm, p = 0.33), anti-Hsp 60 (0.78 ± 0.20 vs. 0.71 ± 0.16 mm, p = 0.27), anti-Hsp 65 (0.73 ± 0.16 vs. 0.72 ± 0.17 mm, p = 0.77), IgG anti-beta2-gp1 (0.73 ± 0.16 vs. 0.71 ± 0.17 mm, p = 0.72), and anti-CCP (0.71 ± 0.16 vs. 0.76 ± 0.20 mm, p = 0.36). In addition, IMT did not correlate with antibodies titers: IgG aCL (r = ? 0.09, p = 0.47), IgM aCL (r = ? 0.15, p = 0.21), anti-Hsp 60 (r = 0.10, p = 0.42), anti-Hsp 65 (r = 0.05, p = 0.69), IgG anti-beta2-gp1 (r = ? 0.07, p = 0.57), IgM anti-beta2-gp1 (r = ? 0.05, p = 0.69), IgA anti-beta2-gp1 (r = 0.03, p = 0.79), and anti-CCP (r = ? 0.07, p = 0.57). RA patients with plaques had a significantly higher age compared to those without plaques (p = 0.001), as well as higher mean IMT (p < 0.001), total cholesterol (p = 0.001), and LDL (p = 0.003).ConclusionsIn RA a clear association between all autoantibodies studied herein and increased IMT or presence of plaques was not observed. The great prevalence of carotid atherosclerosis in RA was related to age, total and LDL cholesterol, as identified in normal population.     

Locking plate fixation of humeral head fractures with a telescoping screw. A comparative biomechanical study versus a standard plate

ObjectivesLocking plate fixation of humeral head fractures bares the risk of glenohumeral screw penetration. In order to circumvent this problem it is recommended to insert shorter locking screws having at least a 6 mm distance to the humeral head cortex. This in turn may reduce fixation stability and may lead to early varus displacement. One second frequent failure mechanism is cranial displacement of the greater tubercle. The study evaluates the biomechanical properties of a locking plate employing an additional telescoping screw that may enhance resistance to varus displacement. Screw in screw fixation of the greater tubercle may reduce the rate of cranial displacement.MethodsIn four paired fresh-frozen human cadaver humeri (age > 70 years) a Neer IV/3 fracture was created with a 5 mm osteotomy gap simulating metaphyseal comminution. Limbs were randomly assigned to receive plate fixation with an additional telescoping screw (Humerus Tele Screw: HTS) and on the contralateral limb Philos plate fixation before biomechanical evaluation (MTS-Bionix 858.2). Standard locking screws were placed in both groups 6 mm below the radiological head circumference; the telescoping screw was placed in the subchondral layer. The greater tubercle was fixed with an additional screw in both techniques, in the HTS group the screw was anchored in the sleeve of the telescrew (screw in screw fixation).FindingsFixation stability with a mean stiffness of 300.9 ± 28.8 N/mm in the HTS plate group proved to be significantly higher than in the Philos plate group (184.2 ± 23.4 N/mm; p = 0.006). The HTS plate also resisted higher loads in terms of fixation failure with loss of reduction at 290 ± 58.6 N in comparison to 205 ± 8.6 N for the Philos plate (p = 0.2). Displacement of the greater tubercle occurred in no case of the HTS plate group and in two out of four cases in the Philos plate group.InterpretationThe HTS plate provides high fixation stability in an in vitro humeral head fracture model and securely prevents displacement of the greater tubercle.     

Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures

ObjectiveIn the treatment of proximal humeral fractures, the decision between open fixation and arthroplasty is often difficult. Applicable radiographic prognostic factors would be useful. The purpose of the present study was to investigate the influence of calcar comminution on the clinical and radiologic outcome after locking plate fixation of these fractures.MethodsIn patients with proximal humeral fractures that were treated by locking plate fixation, fracture morphology and the presence of comminution of the calcar were documented on preoperative radiographs. Follow-up for at least 2 years with radiologic assessment and functional outcome measurements including Constant score, subjective shoulder value (SSV), disabilities of the arm, shoulder and hand score (DASH), visual analogue scale (VAS) and short form (SF)-36 was performed.ResultsFollow-up examination (50.8 ± 20.6 months) was possible in 74 patients (46 female, 28 male, age 63.0 ± 15.9 years). Mean absolute Constant score (CS abs), CS adapted to age and gender (CS adap), DASH, SSV and VAS were 72.4 ± 14.5, 85.2 ± 17.3%, 15.7 ± 17.3, 80.3 ± 19.6% and 2.1 ± 2.2. Nonunion was present in 1.3%, cut-out in 5.4% and implant failure in 1.3%. Avascular necrosis (AVN) was seen in 12.2%, in three cases >24 months after the initial trauma. In the presence of calcar comminution, the clinical outcome (CS abs, CS adap, SSV and several parameters of SF-36) was significantly impaired, the odds ratio for these patients to have an absolute CS < 65 was 4.4 (95% confidence interval (CI): 1.4–13.7).ConclusionsThe treatment of proximal humeral fractures with locking plate fixation achieves good clinical mid-term results. Calcar comminution is a relevant and easy-to-detect prognostic factor for the functional and subjective outcome in these fractures.