Potential for bone turnover markers to cost-effectively identify and select post-menopausal osteopenic women at high risk of fracture for bisphosphonate therapy

Introduction and hypothesis Over half of all fractures among post-menopausal women occur in those who do not have osteoporosis by bone density criteria. Measurement of bone turnover may cost-effectively identify a subset of women with T-score >−2.5 for whom anti-resorptive drug therapy is cost-effective. Methods Using a Markov model, we estimated the cost per quality adjusted life year (QALY) for five years of oral bisphosphonate compared to no drug therapy for osteopenic post-menopausal women aged 60 to 80 years with a high (top quartile) or low (bottom 3 quartiles) level of a bone turnover marker. Results For women with high bone turnover, the cost per QALY gained with alendronate compared to no drug therapy among women aged 70 years with T-scores of −2.0 or −1.5 were $58,000 and $80,000 (U.S. 2004 dollars), respectively. If bisphosphonates therapy also reduced the risk of non-vertebral fractures by 20% among osteopenic women with high bone turnover, then the costs per QALY gained were $34,000 and $50,000 for women age 70 with high bone turnover and T-scores of −2.0 and −1.5, respectively. Conclusion Measurement of bone turnover markers has the potential to identify a subset of post-menopausal women without osteoporosis by bone density criteria for whom bisphosphonate therapy to prevent fracture is cost-effective. The size of that subset highly depends on the assumed efficacy of bisphosphonates for fracture risk reduction among women with both a T-score >−2.5 and high bone turnover and the cost of bisphosphonate treatment.     

The Hyperplantarflexion Ankle Fracture Variant

Various patterns of ankle fractures that are not accounted for by common classification systems have been the subject of case reports. The first difficulty with these variant patterns is recognizing all associated pathology, followed by the successful application of stable fixation. The purpose of this study was to describe the common morphologic features and ligamentous injuries of a unique variant fracture pattern, as well as the surgical treatment technique and the short-term functional and radiographic outcomes. Of 121 consecutive unstable ankle fractures over a 2-year period, 7 patients were found to have a similar constellation of injuries around the ankle. A vertical shear fracture of the posteromedial tibial rim was the main feature. Six of the 7 also had a fracture of the posterior malleolus. On magnetic resonance imaging, the deltoid and posterior tibiofibular ligaments were intact in all cases. Fractures were treated with open anatomic reduction of the posteromedial and posterior fragments with antiglide plate fixation. All fractures healed at 2 months without loss of reduction, fixation failure, or surgical complications. The average American Academy of Orthopaedic Surgeons lower extremity score was 79 at an average of 8 months' follow-up. The common radiographic and morphologic features associated with this posteromedial fracture indicate that it likely occurs through a common mechanism that involves hyperplantarflexion. The characteristics of this fracture pattern have not been fully described previously, but this ankle fracture variant may occur in up to 6% of cases. Unstable ankle fractures should be evaluated carefully for evidence of posteromedial involvement so appropriate treatment may proceed.     

Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients

With the introduction of Locking Compression Plates (LCP), Minimally Invasive Plate Osteosynthesis (MIPO) has become widely used. The plates act as internal fixators in a bridging manner, thus resulting in secondary bone healing. We retrospectively evaluated the healing pattern and the clinical evolution of diaphyseal and distal tibial shaft fractures over two and a half years in 32 patients (6 females, 26 males). Fractures were classified according to AO classification and included all 42A-C, 43A-B and 43C1-2 types. For open fractures, Gustillo Anderson classification was used. Plates consisted of the 4.5mm LCP and 3.5mm LCP-Pilon form plate. Clinical and radiological assessment was performed at 6 weeks, and at 3, 6, 9, and 12 months. Two patients were lost to follow-up. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and posterior-anterior X-ray, and full, painless weight bearing. Ten patients at 3 months, 23 at 6 months, and 27 at 9 months met the criteria for a healed fracture. Plate bending was observed in one patient and called for re-operation at 5 months. Two patients required re-operation at 13 months secondary to pseudoarthrosis. Though MIPO seems more advantageous for soft tissue and bone biology, prolonged healing was observed in simple fracture patterns when a bridging plate technique was used.     

Delayed fracture of a ceramic insert with modern ceramic total hip replacement

We report a case of ceramic liner fracture in a 34-year-old man that occurred 1 year 9 months after total hip arthroplasty with a BiCONTACT (Aesculap, Tuttlingen, Germany) ceramic-on-ceramic prosthesis. The ceramic liner was found within the metal shell in 4 large pieces and multiple small fragments in the peripheral portions. Its condition indicated that the possible mechanism of late ceramic liner chip fracture was repeated episodes of impingement between the prosthetic neck and the edge of the ceramic liner. Squatting, kneeling, and sitting cross-legged caused impingement. These positions are more common in Asian populations than in Western populations. After the joint was thoroughly irrigated, a new modular ceramic liner and a 28-mm ceramic head were implanted.     

Another option to treat Kümmell’s disease with cord compression

The efficiency of short-segment fixation with transpedicle body augmenter (a titanium spacer with bone-ingrowth porous surface, TpBA) to treat Kümmell's disease with cord compression (stage III) was retrospectively evaluated. No laminectomy or instrumentation reduction was done. Inclusion criteria included Frankel CDE, single-level within T10-L2. FU rate was 88%, i.e. 21 cases were included. Frankel function classification was 6E9D6C. Mean age was 72+/-8 years. F:M was 16:5. FU period was 48 M (range, 30-76 M). The hospitalization was 4.5+/-2.2 days; operation time, 70.4+/-17.2 min; blood loss, 150+/-72 cc. Final Frankel class was 20E1D. Complications included two superficial infection and one pneumonia. Body height and kyphosis were all corrected significantly and well preserved at the final visit. No TpBA dislodgement or implant failure was noted; however, three cases developed new compression fractures. The clinical outcome showed 81% with P1 or P2 by Denis pain scale. This method can decompress spinal canal, maintain kyphosis correction and vertebral restoration, prevent implant failure, and attain good clinical results.     

Osteochondral Fracture of the Fourth Metatarsal Head Treated by Open Reduction and Internal Fixation

Fracture of the metatarsal head is uncommon, and reports of isolated osteochondral fracture of the metatarsal head are rare. Because of the distal location of the fracture, it is difficult to achieve and maintain reduction, and potential complications include avascular necrosis and subchondral fatigue fracture. The authors present a case of an osteochondral fracture in a 40-year-old man, which was treated by open reduction and internal fixation with a single twist-off screw, with good results 12 months postoperatively.     

T型AO外固定架治疗胫腓骨近关节骨折的临床评价

目的：探讨应用T型AO外固定架治疗距踝关节4cm以内的胫腓骨骨折及Pylon骨折的临床效果及其影响因素。方法：分析我科自1999年1月－2001年2月采用T型外固定架治疗距踝关节4cm以内的胫腓骨骨折及Pylon骨折14例。术后早期功能锻炼，定期复查，有明确骨性愈合后拆除外固定架。结果：14例病人经随诊6个月左右，100％达到骨性愈合，功能恢复完全正常。结论：T型AO外固定架是非常适合于距踝关节4cm以内的胫腓骨折及Pylon骨折的治疗方法。具有操作简单，手术时间短，创伤小，骨折易愈合，固定可靠的优点，功能恢复满意。     

首次手术失败的胸腰椎陈旧性骨折再手术分析

目的：探讨首次手术失败的胸腰椎陈旧性骨折再手术的意义。方法：9例首次手术失败的胸腰椎陈旧性骨折经原内固定拆除，前路减压、撑开复位、取髂骨植骨、“Z”形钢板内固定治疗。并对其结果进行临床和影像学检查评价。结果：本组病例均随访，植骨于术后3－4个月骨性融合。恢复之椎间高度不发生再丢失，胸腰椎生理弧度良好，无继发性后凸畸形发生。无钢板、螺钉折断、松动及滑脱等并发症。所有病例至少有Frankel1级以上的功能恢复。结论：前路减压与脊柱重建是治疗首次手术失败的胸腰椎陈旧性骨折的理想方法。     

股骨转子周围骨折的髓内钉固定

目的探讨带锁髓内钉固定在股骨转子周围骨折中的应用价值以及相关并发症的防治。方法回顾分析了自1993年12月至2001年9月间作者收治的180例(181髋)经髓内钉治疗的转子周围骨折,其中应用亚太型Gamma钉96例(97髋)、股骨重建钉54例、股骨近端钉(PFN)30例。结果平均手术时间65分钟,术中术后输血患者仅占15.6%;平均随访时间为16个月,96%的骨折获得愈合,平均愈合时间为3.5个月;按黄公怡评价标准,髋关节功能优良率为90.2%;发生9种类型的并发症。结论髓内钉固定在治疗股骨转子间骨折中具有较大的临床价值,但仍存在一定的并发症,应引起足够重视。     

股骨转子间骨折与股骨颈骨折内固定失效后行人工髋关节置换术的比较

目的将股骨转子间骨折行动力髋部螺钉(DHS)内固定术后的人工髋关节置换术与股骨颈骨折AO螺钉内固定术后行全髋关节置换术的临床结果相比较,总结股骨转子间骨折行DHS内固定术后的人工髋关节置换术经验以及治疗过程中的困难和随访结果。方法将1984年6月～2001年8月有完整资料的19例股骨转子间骨折行DHS内固定术后和配对的19例股骨颈骨折AO螺钉内固定术后行人工髋关节置换术的结果进行比较。使用SPSS软件中的配对T检验方法对本组病人的年龄、性别、DHS失效的原因、骨折至关节置换术时间、早期并发症、失血、手术时间及临床Harris的评分进行统计分析。结果在DHS组中,术后早期并发症(术中股骨近端骨折或术后髋关节脱位)的发生率明显高于AO螺钉组(0.01相似文献