Refracture-related bone transport of tibia: technical notes and preliminary clinical results in nineteen cases

PURPOSE

Refracture is one of the main complications of bone transport, which brings additional physical and mental burden to surgeries and patients. We aimed to raise a new classification system of refracture-related bone transport based on the Simpson classification and to present our experience on treatment.

METHODS

This retrospective analysis included 19 patients with refracture-related bone transport (average age of 37.7 years; 18 men). We developed a modified Simpson classification system to assist decision-making (conservative versus surgical). The ASAMI criteria were used to assess the outcomes at last follow-up.

RESULTS

The mean follow-up was 12.3 ± 3.2 months. Complete union was achieved in all patients, with no reinfection. Based on the modified Simpson classification, refracture was Ia type (within regeneration area) in three cases, Ib (collapsed fracture at the regeneration area) in one case, Ic (stress fracture) in three cases, II (at the junction between the regenerate and original bone) in one case, III (at the docking site) in nine cases, and V (at distant site) in two cases. Refracture was managed conservatively in six cases and surgically in 13 cases. Average time to bone union was 2.8 ± 1.2 months in the conservative group versus 4.4 ± 1.4 months in the surgery group. Assessment at the final follow-up using the ASAMI criteria revealed excellent bone result in all patients, excellent functional results in six patients (31.6%), and good functional results in 13 patients.

CONCLUSIONS

The modified Simpson classification could include refracture at the docking site and stress fracture in the regeneration zone and provide some guidance in determining the appropriate treatment strategy.

Refracture following vertebral fragility fracture when bone fragility is not recognized: summarizing findings from comparator arms of randomized clinical trials

PURPOSE

Since vertebral fragility fractures (VFFs) might increase the risk of subsequent fractures, we evaluated the incidence rate and the refracture risk of subsequent vertebral and non-vertebral fragility fractures (nVFFs) in untreated patients with a previous VFF.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library up to February 2022 for randomized clinical trials (RCTs) that analyzed the occurrence of subsequent fractures in untreated patients with prior VFFs. Two authors independently extracted data and appraised the risk of bias in the selected studies. Primary outcomes were subsequent VFFs, while secondary outcomes were further nVFFs. The outcome of refracture within ≥ 2 years after the index fracture was measured as (i) rate, expressed per 100 person-years (PYs), and (ii) risk, expressed in percentage.

RESULTS

Forty RCTs met our inclusion criteria, ranging from medium to high quality. Among untreated patients with prior VFFs, the rate of subsequent VFFs and nVFFs was 12 [95% confidence interval (CI) 9-16] and 6 (95% CI 5-8%) per 100 PYs, respectively. The higher the number of previous VFFs, the higher the incidence. Moreover, the risk of VFFs and nVFFs increased within 2 (16.6% and 8%) and 4 years (35.1% and 17.4%) based on the index VFF.

CONCLUSION

The highest risk of subsequent VFFs or nVFFs was already detected within 2 years following the initial VFF. Thus, prompt interventions should be designed to improve the detection and treatment of VFFs, aiming to reduce the risk of future FFs and properly implement secondary preventive measures.

Effect of sarcopenia on refractures of adjacent vertebra after percutaneous kyphoplasty

PURPOSE

To explore the effect of sarcopenia on recurrent fractures of adjacent vertebra after percutaneous kyphoplasty (PKP).

METHODS

A total of 376 osteoporotic vertebral compression fractures (OVCFs) patients over 55 years old who were admitted to the Hospital from August 2020 to January 2021 were selected. Among them, 38 patients with recurrent fractures in adjacent vertebra after PKP were selected as the refracture group (RG), and the remaining 338 patients were selected as the non-refracture group (NRG). The age, gender, grip strength, body mass index (BMI), bone mineral density (BMD), visual analogue scale (VAS) of pain before and one month after surgery, Oswestry disability index (ODI) before and one month after surgery and the occurrence of sarcopenia were compared between the two groups. Logistic regression analysis was used to evaluate the effect of related risk factors on refracture after vertebral PKP.

RESULTS

The results of t-test and Chi-square test showed that there were no obvious differences in gender, BMI, preoperative VAS score (t=-0.996, P = 0.320) and ODI (t=-0.424, P = 0.671), one month postoperative VAS score (t=-0.934, P = 0.355) and ODI score (t=-0.461, P = 0.645). while the age and grip strength showed significant differences between the two groups. Logistic regression analysis showed that BMI and gender had no significant effect on refracture after PKP, while sarcopenia and advanced age were independent risk factors for refracture after PKP. Also, increased BMD was a protective factor for refracture after PKP.

CONCLUSION

Sarcopenia is an independent risk factor for recurrent fractures after PKP in OVCF patients. The screening and diagnosis of sarcopenia should be strengthened. At the same time, anti-sarcopenia treatment should be actively performed after surgery.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fracture treatment and risk factor screening for postoperative refracture

Osteoporotic vertebral compression fracture (OVCF) is a serious complication of osteoporosis, and percutaneous vertebroplasty (PVP) is a major therapeutic method for OVCF. This study aimed to evaluate the clinical efficacy and postoperative complications of robot-assisted targeted PVP for the treatment of OVCF. The data from 202 OVCF patients were analyzed in this study, including 72 cases received traditional PVP (PVP group), 68 cases received robot-assisted PVP (R-PVP group), and 62 cases underwent robot-assisted PVP combined with targeted plugging (R-PVP + TP group). The fluoroscopic exposure conditions, operative duration, lengths of stay, postoperative bone cement leakage, refracture, Visual Analog Scale (VAS) score, and Oswestry Disability Index (ODI) score were obtained and compared between the three groups. The Kaplan-Meier method and logistic regression model were adopted to screen the risk factors related with postoperative refracture. R-PVP and R-PVP + TP group had significantly reduced fluoroscopic frequency and radiation dose, and reduced cement leakage compared with PVP group. R-PVP + TP not only showed more obvious advantages in these aspects, but also had a lower probability of postoperative refracture. In addition, BMD, fracture vertebral distribution, cement leakage, and surgery methods were independent related with refracture. All the results demonstrated robot assistance could improve the application of PVP in the treatment of OVCF, and robot-assisted PVP combined with targeted plugging showed significantly reduced fluoroscopic exposure, bone cement leakage, and rate of postoperative refracture. BMD, fracture vertebral distribution, cement leakage, and operation methods were identified as four risk factors for the onset of refracture after PVP.

Analysis of Prognostic Factors in Osteoporotic Patients Who Were Treated with Percutaneous Vertebroplasty for Refracture After Vertebral Augmentation

OBJECTIVE

To retrospectively analyze prognostic factors in osteoporotic patients who treated with percutaneous vertebroplasty for refracture after vertebral augmentation.

METHODS

A retrospective analysis was performed of 61 patients with refractures after vertebral augmentation who received percutaneous vertebroplasty treatment again from January 2019 to December 2021. Based on the presence of back pain at the last follow-up, 17 patients were placed in the pain group, and 44 patients were placed in the pain-free group. The following covariates were reviewed: age; bone mineral density; bone cement dosage; bone cement leakage; body mass index; and rate of anterior vertebral height (AVH) loss in the target before surgery, 1 week after surgery, and at last follow-up. Patients were assessed using visual analogue scale score and Oswestry Disability Index.

RESULTS

Binary logistic regression analysis revealed that the rate of AVH loss after surgery was associated with postoperative back pain. According to the receiver operating characteristic curve analysis, the area under the curve of AVH loss rate at 1 week after surgery was 0.6845, and the cutoff value was 0.18; the area under the curve of AVH loss rate at the last follow-up was 0.7306, and the cutoff value was 0.2815. Kaplan-Meier survival analysis showed that patients with lower AVH loss rates had lower incidence of postoperative back pain and better prognosis.

CONCLUSIONS

Occurrence of postoperative back pain was strongly associated with AVH loss after surgery. Patients with a lower rate of AVH loss had a lower incidence of postoperative back pain and a better prognosis.

The Association of nutritional status and physical activity on osteoporotic refractures among older adults

BACKGROUND

This paper focuses on revealing the relationship between the Geriatric Nutritional Risk Index (GNRI) and Activity of Daily Living (ADL) with osteoporotic refracture.

METHODS

Data from 1068 inpatients with osteoporotic fractures were analyzed. Binary logistic regression, Cox proportional hazard regression and Kaplan-Meier curves were performed for osteoporosis characteristics and its risk factors. Receiver operating characteristic (ROC) curve was developed to predict the cut-off value.

RESULTS

The study showed that older age, lower ADL and lower GNRI were independent risk factors for osteoporotic fracture with OR of 1.039, 0.946, 0.892 and HR of 1.033, 0.967, 0.947 respectively. According to the results of ROC, the predictive accuracy of GNRI was high with an area under ROC (AUC) of 0.715, sensitivity of 76.6%, specificity of 53.5% and a threshold value of 99.65.

CONCLUSION

Older age, lower ADL and lower GNRI were independent risk factors for osteoporotic refracture.

Development of a nomogram model for prediction of new adjacent vertebral compression fractures after vertebroplasty

BACKGROUND

Vertebroplasty is the main minimally invasive operation for osteoporotic vertebral compression fracture (OVCF), which has the advantages of rapid pain relief and shorter recovery time. However, new adjacent vertebral compression fracture (AVCF) occurs frequently after vertebroplasty. The purpose of this study was to investigate the risk factors of AVCF and establish a clinical prediction model.

METHODS

We retrospectively collected the clinical data of patients who underwent vertebroplasty in our hospital from June 2018 to December 2019. The patients were divided into a non-refracture group (289 cases) and a refracture group (43 cases) according to the occurrence of AVCF. The independent predictive factors for postoperative new AVCF were determined by univariate analysis, least absolute shrinkage and selection operator (LASSO) logistic regression, and multivariable logistic regression analysis. A nomogram clinical prediction model was established based on relevant risk factors, and the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA) were used to evaluate the prediction effect and clinical value of the model. After internal validation, patients who underwent vertebroplasty in our hospital from January 2020 to December 2020, including a non-refracture group (156 cases) and a refracture group (21 cases), were included as the validation cohort to evaluate the prediction model again.

RESULTS

Three independent risk factors of low bone mass density (BMD), leakage of bone cement and "O" shaped distribution of bone cement were screened out by LASSO regression and logistic regression analysis. The area under the curve (AUC) of the model in the training cohort and the validation cohort was 0.848 (95%CI: 0.786-0.909) and 0.867 (95%CI: 0.796-0.939), respectively, showing good predictive ability. The calibration curves showed the correlation between prediction and actual status. The DCA showed that the prediction model was clinically useful within the whole threshold range.

CONCLUSION

Low BMD, leakage of bone cement and "O" shaped distribution of bone cement are independent risk factors for AVCF after vertebroplasty. The nomogram prediction model has good predictive ability and clinical benefit.

Sequential treatment of teriparatide and alendronate versus alendronate alone for elevation of bone mineral density and prevention of refracture after percutaneous vertebroplasty in osteoporosis: a prospective study

BACKGROUND

Percutaneous vertebroplasty was the most common strategy for osteoporotic vertebral compression fracture. However, refracture after vertebroplasty also occurred and bone mineral density (BMD) was one of the main factors associated with refracture after percutaneous vertebroplasty.

AIMS

To investigate the efficacy of a short-sequential treatment of teriparatide followed by alendronate on prevention of refracture after percutaneous vertebroplasty in osteoporotic patients, and compare it with the therapy of alendronate alone.

METHODS

From January 2018 to January 2020, we recruited 165 female osteoporosis patients after percutaneous vertebroplasty who were assigned into sequential treatment of teriparatide followed by alendronate group (TPTD + ALN group) and alendronate alone group (ALN group). The vertebral fracture occurred during this process was also recorded in both the groups. A total of 105 participants completed the 1-year follow-up. Furthermore, BMD and serum procollagen type I N-terminal propeptide (PINP) and C-terminal cross-linking telopeptide of type I collagen (CTX) were compared between the two groups during 1-year follow-up.

RESULTS

The 105 patients were finally included, with 59 in ALN group and 46 in TPTD + ALN group. During 1-year follow-up, the vertebral refracture rate in TPTD + ALN group was much lower than that in ALN group (2.2% vs. 13.6%, p < 0.05). At 12 months, the BMDs at lumbar in TPTD + ALN group were significantly elevated when compared to the ALN group (0.65 ± 0.10 vs. 0.57 ± 0.07, p < 0.001).

DISCUSSION AND CONCLUSION

A short-sequential administration of teriparatide followed by alendronate was more effective in elevating the BMD and decreasing the refracture rate at 12-month follow-up, compared to the counterpart with alendronate alone.

Longer time of implantation using the buried pin technique for intramedullary nailing would decrease refracture in the diaphyseal forearm fracture in children-retrospective multicenter (TRON) study

BACKGROUND

Intramedullary nailing using Kirschner wires in pediatric diaphyseal forearm fractures is often performed as a less invasive treatment than plate fixation, but it remains controversial whether the tips of Kirschner wires are buried or exposed. The purpose of this study was to investigate the relationship between whether the tips are buried or exposed and complications, especially of refracture.

METHODS

Data of 405 patients under 16 years who underwent surgical treatment for diaphyseal forearm fractures in our 11 hospitals between 2010 and 2020 were collected. Finally, 143 patients who underwent intramedullary nailing with at least 6-month follow-up were analyzed. We investigated difference in complication rates depending on whether the Kirschner wire tips were buried (Group B: n = 79) or exposed (Group E: n = 64). Regarding refractures, we also examined time of onset and status of bone union before the refracture occurred.

RESULTS

The duration before implant removal in Group B was more than 4 times longer than that in Group E (mean 187.9 vs. 41.4 days, p<0.001), although there was no significant difference in the progression of bone union between the two groups. Regarding postoperative complications, Group B had a significantly lower rate of refractures than Group E (7.9% vs. 32.8%, p<0.001), although the rate of irritation pain was significantly higher (15.2% vs. 1.6%, p = 0.006). The infection rate was also lower in Group B than Group E, but not significantly so (3.8% vs. 10.9%, p = 0.112). Refractures between 3 and 9 months after surgery accounted for 66.7% of all refractures, and those within 3 months accounted for 14.5% of all fractures. There was no significant difference in the status of bone union before the refracture occurred between patients with and without refracture.

CONCLUSIONS

The present study showed that longer time of implantation using the buried pin technique for intramedullary nailing reduces refracture of pediatric diaphyseal forearm fractures. Because of the risk of refracture during remodeling, we recommend the implantation of intramedullary nailing for 6-9 months and the instruction for the patients and the parents to pay more attention to refracture at least within 9 months postoperatively.

LEVEL OF EVIDENCE

Level Ⅲ, Multicenter retrospective study.

[Clinical therapeutic strategies of refracture after bone transport for tibial bone defect]

OBJECTIVE

To explore the clinical therapeutic strategies of refracture after Ilizarov bone transport technique in the treatment of tibial bone defect.

METHODS

A retrospective study was performed on 19 patients with infected tibial bone defect treated by Ilizarov bone transport technique and then refracture from August 2010 to January 2020, including 18 males and 1 female with an average age of (37.7±13.0) years old ranging from 15 to 66 years old. Cause of injury invlved falling injury in 4 cases, crashing injury 1 case, crushing injury in 1 case and without obvious injury history in 13 cases. The ipsilateral distal femoral fracture in 2 cases occurred before the external fixator of tibia was removed, and the other 17 cases had a minimum of 1 day and a maximum of 30 months after the external fixator had been removed. The site of refracture was at regenerative zone in 8 cases, at docking site in 9 cases, at ipsilateral femoral shaft in 2 cases. According to the modified Simpson classification proposed by the author, the refracture was classified. The treatment of refracture include plaster splint, traction or external fixation. Bone healing and function were evaluated according to the standards of the Association for the Study and Application of the Method of Ilizarov(ASAMI).

RESULTS

All patients were followed up, and the duration ranged from 9 to 17 months with an average of (12.3±3.2) months. According to the modified Simpson classification, there were 3 cases of type Ⅰa, 1 case of type Ⅰb, 3 cases of type Ⅰc, 1 case of type Ⅱ, 9 cases of type Ⅲ and 2 cases of type Ⅴ. All the refractures healed without infection or malunion. The fracture healing time of conservative treatment for 6 cases were 3, 5, 3, 2, 2, 2 months fespectively;and the healing time of fracture treated by surgery for 13 cases was 2 to 6 months, with an average of(4.4±1.4) months. According to ASAMI evaluation criteria, bony results showed all patients obtained excellent results, and functional results showed 6 patients got excellent results, 13 good beacause of ankle or knee stiffness.

CONCLUSION

The modified Simpson classification could contain most clinical types of refracture after bone transport, and the external fixation is a simple and effective method for refracture.

Functional and radiological outcomes after treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique: a retrospective single-center study

BACKGROUND

Congenital pseudarthrosis of the tibia (CPT) is a challenging problem in orthopedic practice, with high rates of non-union, refracture, and residual deformities. After union, long-term follow-up is required to manage late post-union complications. This study aimed to assess the outcomes of the Ilizarov technique in the management of CPT.

MATERIALS AND METHODS

This retrospective study included patients with CPT treated with the Ilizarov method between 2005 and 2018. Intramedullary rods were used in 9 cases and iliac bone graft was used in 12 cases. An orthosis was applied till the end of follow-up in all cases. The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used for the evaluation of the functional outcomes.

RESULTS

This study included 16 patients, 11 males and 5 females, with an average age of 5.4 ± 2.8 years. Seven cases had multiple previous surgeries. Six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average AOFAS score improved significantly from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up. Union was achieved in 15 cases, and persistent non-union occurred in one case. The clinical results were excellent in one patient, good in seven cases, fair in 6, and poor in 2 cases. The radiological results were excellent in one patient, good in seven cases, fair in seven, and poor in one case.

CONCLUSIONS

The Ilizarov technique combined with intramedullary rod and primary or secondary bone graft provides a high union rate of CPT and can achieve simultaneous effective management of problems related to pseudarthrosis, including non-union, deformity, limb shortening, and adjacent joint contracture and subluxation. Level of evidence Level IV.

Assessment of clinical, imaging, surgical risk factors for subsequent fracture following vertebral augmentation in osteoporotic patients

INTRODUCTION

Currently, the risk factors for subsequent fracture following vertebral augmentation remain incomplete and controversial. To provide clinicians with accurate information for developing a preventive strategy, we carried out a comprehensive evaluation of previously controversial and unexplored risk factors.

METHODS

We retrospectively reviewed patients with osteoporotic vertebral compression fracture in lumbar spine who received vertebral augmentation between January 2019 and December 2020. Based on whether refracture occurred, patients were assigned to refracture and non-refracture group. The clinical characteristics, imaging parameters (severity of vertebral compression, spinal sagittal alignment, degeneration of paraspinal muscles), and surgical indicators (cement distribution and leakage, correction of spinal sagittal alignment) were collected and analyzed.

RESULTS

There were 128 patients and 16 patients in non-refracture and refracture group. The incidence of previous fracture, multiple fractures, and cement leakage were notably higher, relative cross-sectional area of psoas (r-CSA_PS) was significantly smaller, CSA ratio, fatty infiltration of erector spinae plus multifidus (FI_ES+MF), FI_PS, postoperative lumbar lordosis (post-LL), correction of body angel (BA), and LL were significantly greater in refracture group. Binary logistic regression analysis revealed previous fracture, cement leakage, post-LL, and correction of BA were independent risk factors. According to the ROC curve, correction of BA showed the highest prediction accuracy, and the critical value was 3.45°.

CONCLUSIONS

The occurrence of subsequent fracture might be the consequence of multiple factors. Previous fracture, cement leakage, post-LL, and correction of BA were identified as independent risk factors. Furthermore, the correction of BA should not exceed 3.45°, especially in patients with risk factors.

Analysis of risk factors affecting union and refracture after combined surgery for congenital pseudarthrosis of the tibia: a retrospective study of 255 cases

Background

Congenital pseudarthrosis of the tibia (CPT) is a rare disease occurring in children. The aim of this study is to identify the factors affecting bone union and re-fracture after surgery for CPT and to provide reliable evidence for clinics.

Methods

We collected the detailed information of 255 cases with Crawford IV CPT treated by combined surgery in our hospital from 2013 to 2020. Basic characteristics were recorded. Univariate variance and logistic regression analysis were used to compare the correlations between factors and outcomes.

Results

92.5% of patients achieved primary union, 7.5% of patients had non-union and 13.3% of patients had re-fracture. Logistic regression analysis showed that age at index surgery (Coef. = 0.171, 95%CI 0.015–0.327, P = 0.032), and CPT location (Coef. = − 1.337, 95%CI − 2.218–0.456, P = 0.003) had statistical differences, while no factors had significant correlation with re-fracture. Furthermore, ROC curve showed that the optimal age threshold for first surgery was 2.37 years old.

Conclusions

For patients with Crawford IV CPT treated by combined surgery, the younger the age at index surgery and the closer the CPT location to the distal end, the easier to achieve bone union.

[Analysis of risk factors of healthy side fracture after hip fracture surgery in the elderly]

OBJECTIVE

To investigate the incidence and related risk factors of healthy side fracture after hip fracture surgery in the elderly, so as to provide basis for the prevention of re-fracture.

METHODS

The data of 452 patients over 65 years old with femoral neck fracture or intertrochanteric fracture treated with hip arthroplasty or proximal femoral intramedullary nailing from June 2012 to June 2017 were analyzed, including 168 males and 284 females, the age ranged from 65 to 97(75.5±7.5) years. There were 191 cases of femoral neck fracture and 261 cases of femoral intertrochanteric fracture. According to whether there was a fracture in the healthy hip after operation, the patients were divided into fracture group and no fracture group. The gender, age, body mass index, fracture type, initial treatment method, bone mineral density, bed time, medical compliance, postoperative short-term delirium, whether there were medical diseases before injury and Harris score of hip joint in the final follow-up were recorded. Univariate Logistic regression analysis was used to screen out the risk factors of healthy side fracture after operation, and then statistically significant risk factors were included in multi factor Logistic regression analysis to screen out the independent risk factors of healthy side fracture after operation of hip fracture in the elderly.

RESULTS

Among them, 42 of the 452 patients had hip fractures on the healthy side with an incidence of 9.3%. The average interval between the two fractures was (2.9±2.1) years. Univariate Logistic regression analysis showed that there were significant differences in age, bone mineral density, medical compliance, short-term postoperative deliriun, pre-injury complicated with medical diseases and Harris score of hip joint in the final follow-up (P<0.05). Multivariate Logistic analysis showed that age(OR=4.227), bone mineral density(OR=4.313), combined with medical diseases (OR=5.616) and low hip Harris score at the final follow-up (OR=3.891) were independent risk factors for healthy side fractures after hip fracture surgery in elderly(P<0.05).

CONCLUSION

The age, bone mineral density, combined with medical diseases and low Harris score of hip joint in the final follow-up are the main risk factors of healthy side fracture after hip fracture in the elderly. It is necessary to strengthen the treatment of medical diseases, anti osteoporosis and improve hip joint function within 3 years after operation, so as to prevent the occurrence of healthy side hip fracture.

Forearm Plate Fixation: Should Plates Be Removed?

Background

Refracture after both bone forearm fracture fixation may vary with or without plate removal. We tested the null hypothesis that there is no difference in the rate of refracture in patients who have undergone open reduction and internal fixation of a diaphyseal forearm bone who have retained implants versus removed implants. We also studied factors associated with plate removal.

Methods

We retrospectively identified 645 adult patients with a total of 925 primary fractures that underwent primary plate fixation of an ulnar or radial shaft fracture between 2002 and 2015 at a single institutional system. Patients with nonunion, pathological fracture or infection were excluded. Independent factors associated with refracture and plate removal were identified using multivariable analysis.

Results

Refractures occurred in 6.3% of the fractures that had forearm implant removal, compared to 2.1% of the fractures with retained plates. Refractures were independently associated with plate removal (OR: 3.7, 95% CI: 1.2-11.7, P=0.023) and was more frequent in the radius (OR: 2.4, 95% CI: 1.0-5.8, P=0.06). A refracture after implant removal occurred within 3 months after removal. Ulnar plates were removed more often compared to radial plates (OR: 2.6, 95% CI: 1.4-4.7, P=0.002) as were plates used for type A fractures compared to type C fractures (OR: 3.2, 95% CI: 1.1-9.2, P=0.032).

Conclusion

The rate of refracture is higher after plate removal compared to patients who did not have plates removed. Although uncommon, refractures of the radius tend to be more common than a refracture of the ulna. If the implant is symptomatic on the ulnar side, it may be preferable to remove the ulnar implant and retain the radius implant rather than remove both plates when possible. Furthermore, limiting strenuous activity for three months after implant removal is a consideration.

Intervertebral bridging ossification after kyphoplasty in a Parkinson’s patient with Kummell’s disease: A case report

BACKGROUND

The short-term therapeutic efficacy of kyphoplasty on Kummell’s disease is obvious. However, postoperative refracture and adjacent vertebral fracture occur occasionally and are difficult to treat. Parkinson's disease (PD) is a pathological disorder associated with heterotopic ossification. In a patient with PD, an intervertebral bridge was formed in a short period of time after postoperative refracture and adjacent vertebral fracture, providing new stability.

CASE SUMMARY

A 78-year-old woman had been suffering from PD for more than 10 years. Three months before operation, she developed lower back pain and discomfort. The visual analog scale (VAS) score was 9 points. Preoperative magnetic resonance imaging indicated collapse of the L2 vertebra. Kyphoplasty was performed and significantly decreased the severity of intractable pain. The patient’s VAS score for pain improved from 9 to 2. Fifty days postoperatively, the patient suddenly developed severe back pain, and the VAS score was 9 points. X-ray showed L2 vertebral body collapse, slight forward bone cement displacement, L1 vertebral compression fracture, and severe L1 collapse. The patient was given calcium acetate capsules 0.6 g po qd and alfacalcidol 0.5ug po qd, and bed rest and brace protection were ordered. After conservative treatment for 2 mo, the patient's back pain was alleviated, and the VAS score improved from 9 to 2. Computed tomography at the 7-mo follow-up indicated extensive callus formation around the T12-L2 vertebrae and intervertebral bridging ossification, providing new stability.

CONCLUSION

Kyphoplasty is currently a conventional treatment for Kummell's disease, with definite short-term effects. However, complications still occur in the long term, and these complications are difficult to address; thus, the treatment needs to be selected carefully. To avoid refracture, an interlaced structure of bone cement with trabeculae should be created to the greatest extent possible during the injection of bone cement. Surgical intervention may not be urgently needed when a patient with PD experiences refracture and adjacent vertebral fracture, as a strong bridge may help stabilize the vertebrae and relieve pain.

What are risk factors for subsequent fracture after vertebral augmentation in patients with thoracolumbar osteoporotic vertebral fractures

Background

Due to its unique mechanical characteristics, the incidence of subsequent fracture after vertebral augmentation is higher in thoracolumbar segment, but the causes have not been fully elucidated. This study aimed to comprehensively explore the potential risk factors for subsequent fracture in this region.

Methods

Patients with osteoporotic vertebral fracture in thoracolumbar segment who received vertebral augmentation from January 2019 to December 2020 were retrospectively reviewed. Patients were divided into refracture group and non-refracture group according to the occurrence of refracture. The clinical information, imaging findings (cement distribution, spine sagittal parameters, degree of paraspinal muscle degeneration) and surgery related indicators of the included patients were collected and compared.

Results

A total of 109 patients were included, 13 patients in refracture group and 96 patients in non-refracture group. Univariate analysis revealed a significantly higher incidence of previous fracture, intravertebral cleft (IVC) and cement leakage, greater fatty infiltration of psoas (FI_PS), fatty infiltration of erector spinae plus multifidus (FI_ES + MF), correction of body angle (BA), BA restoration rate and vertebral height restoration rate in refracture group. Further binary logistic regression analysis demonstrated previous fracture, IVC, FI_PS and BA restoration rate were independent risk factors for subsequent fracture. According to ROC curve analysis, the prediction accuracy of BA restoration rate was the highest (area under the curve was 0.794), and the threshold value was 0.350.

Conclusions

Subsequent fracture might cause by the interplay of multiple risk factors. The previous fracture, IVC, FI_PS and BA restoration rate were identified as independent risk factors. When the BA restoration rate exceeded 0.350, refractures were more likely to occur.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04946-7.

[Analysis of related risk factors for the refracture of adjacent vertebral body after percutaneous kyphoplasty]

OBJECTIVE

To investigate the risk factors of vertebral refracture after percutaneous kyphoplasty (PKP) for osteoprotic vertebral compression fractures (OVCFs), and to provide reference for clinical prevention.

METHODS

A retrospective analysis of 228 OVCFs patients who met the inclusion criteria admitted from November 6, 2013 to December 14, 2018. There were 35 males and 193 females, with a male-to-female ratio of 3∶20, and aged 58 to 91 years with an average of (69.70±7.03) years. All patients were treated with PKP and had complete clinical data. According to whether refracture occurred after operation, they were divided into refracture group (24 cases) and non refracture group (204 cases). Factors that may be related to refracture (including gender, age, surgical segment, number of vertebral bodies in the surgical segment, whether combined with degenerative scoliosis, whether anti-osteoporosis treatment) were included in the univariate analyses, and the single factor analysis of statistically significant risk factors was carried out with multiple Logistic regression analysis to further clarify the independent risk factors for vertebral body refracture after PKP. Survival analysis was performed using the time of vertebral refracture after PKP as the end time of follow up, the occurrence of refracture after PKP as the endpoint event, and the presence or absence of degenerative lateral curvature as a variable factor.

RESULTS

All 228 patients were followed up for 1.8 to 63.6 months with an average of (28.8±15.6) months, and the refracture rate was 10.5%(24/228). There were statistically significant differences between two groups in age, number of operative vertebral bodies, whether combinedwith degenerative scoliosis and whether anti osteoporosis treatment (P<0.05). Univariate Logistic regression analysis showed that the number of vertebral bodies in the surgical segment and whether combined with degenerative scoliosis may be risk factors for refracture after PKP. Multiple Logistic regression analysis of the above possible risk factors showed that combined scoliosis was an independent risk factor for vertebral refracture of the vertebral body. Survival analysis showed that the mean survival time was 42.1 months, the P value was 0.00, and the mean 95% confidence interval was 34.4-49.7 months, indicating that the combination of degenerative lateral bending might be related to the occurrence of refracture.

CONCLUSION

Combined scoliosis is an independent risk factor for refracture after OVCFs vertebroplasty, and it is also a possible high-risk factor for refracture after surgery.

Refracture after Ilizarov fixation of infected ununited tibial fractures-an analysis of eight hundred and twelve cases

INTRODUCTION

Refracture of the tibia after union is a challenging problem for the patients and the surgeons. The purpose of the current study is to present our experience in conservative management of such patients with refracture of infected ununited tibia after successful treatment by Ilizarov external fixator and bone transport.

MATERIAL AND METHODS

We reviewed the files of 812 patients with infected ununited tibia who were treated by debridement, corticotomy, and bone transport using Ilizarov methods in our institute between 1997 and 2017. Inclusion criteria were patients with refracture after union and removal of the Ilizarov apparatus. Twenty-two patients with 23 refracture tibia were included in the study. All the 23 tibias were treated conservatively by above knee cast that was converted to Sarmiento below knee cast after early callus formation, except in the case of upper tibial fracture that continued in above knee cast till union. Afterwards, a protective splint was used for additional two months.

RESULTS

There were 19 males (86.4%) and three females (13.6%), the mean age of the patients was 38.39 years, the mean time of Ilizarov external fixator application was 10.86 months (range, 6-17), and the mean time of refracture after fixator removal was 2.33 months. Union was achieved in 19 tibias (82.6%), with a mean time of 7.2 months (range, 4-12). Complications included five cases of skin irritation that was treated by large windows in the cast and changing the casts more frequently, three cases developed DVT (deep venous thrombosis), and axial deviation occured in four tibias (17.3%).

CONCLUSION

Conservative treatment of refractured tibia after removal of Ilizarov external fixator following treatment of infected non-union tibia by above knee cast is effective in achieving union. However, complications as skin irritation, DVT (deep venous thrombosis), and axial deviation can be anticipated.

Does prophylactic vertebral augmentation reduce the refracture rate in osteoporotic vertebral fracture patients: a meta-analysis

PURPOSE

In order to prevent the recurrent fracture after vertebral augmentation, the concept of prophylactic vertebral augmentation has been proposed, but its efficacy is still controversial. This study aimed to determine the efficacy of prophylactic vertebral augmentation for prevention of refracture in osteoporotic vertebral fracture patients.

METHODS

Following PRISMA guidelines, a literature search was performed using PubMed, Embase and Web of Science databases for relevant studies published until February 2021. A meta-analysis of randomized controlled trials and retrospective controlled trials comparing prophylactic group versus nonprophylactic group was conducted. The primary outcome was the incidence of new vertebral compression fracture (VCF), and secondary outcomes were incidence of adjacent vertebral fracture (AVF) and remote vertebral fracture (RVF).

RESULTS

A total of 6 studies encompassing 618 patients were included in the meta-analysis. The incidence of new VCF was reported in all six studies, and the result showed no significant difference between the two groups (OR: 0.509; 95% CI: 0.184-1.409). Four studies provided data on the incidence of AVF, and it was revealed that there was no significant difference between the two groups (OR: 0.689; 95% CI: 0.109-4.371). In view of the incidence of RVF, prophylactic group also did not differ significantly compared with nonprophylactic group (OR: 0.535; 95% CI: 0.167-1.709).

CONCLUSIONS

The current evidence suggested that prophylactic vertebral augmentation might not be appropriate to diminish the risk of new VCF. Therefore, there is a need to investigate the mechanism of refracture and explore other preventive regimens to reduce the risk.

Refracture after locking compression plate removal in displaced midshaft clavicle fractures after bony union: a retrospective study

Background

A midshaft clavicle fracture is a common fracture that typically responds well to open reduction and internal fixation (ORIF). However, refracture can occur after implant removal (IR). This study aimed to analyze the rate of refracture and related factors after removal of the locking compression plate (LCP) for displaced midshaft clavicle fractures.

Methods

We retrospectively reviewed the medical records of 201 patients who had undergone ORIF with LCP for midshaft clavicle fractures after IR after bony union from January 2011 to May 2018 at our institute. We evaluated basic demographic characteristics and radiographic parameters. All patients were treated with an LCP for primary fracture. The patients were divided into two groups: a refracture group that experienced a second fracture within 1 year after IR and a no-fracture group.

Results

There were four cases (1.99%) of refracture; three were treated conservatively, while one was treated surgically. All patients achieved bony union. The average interval between refracture and IR was 64 days (range, 6–210 days). There was a significant difference in classification of fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] classification) between the two groups. However, other patient demographics and radiographic measurements between refracture and IR, such as bone diameter, showed no significant difference between the two groups.

Conclusions

This study showed that one in 50 patients suffered from refracture after removal of the LCP. Thus, if patients desire IR, the surgeon should explain that there is a relatively higher possibility of refracture for cases with simple or segmental fractures than for other types of fracture.

Implant removal of osteosynthesis. Results of a survey among Spanish orthopaedic surgeons

INTRODUCTION

The indications on extraction of osteosynthesis material are not well defined in the current literature deriving in relative indications, depending on experiences, customs or patient's request. The aim of this article is to assess the beliefs, indications, usual practice and perceived complications of surgeons in Spain regarding on extraction of osteosynthesis material.

METHODS

We conducted a questionnaire of 44 questions covering general demographics, general and subjective opinion on implant removal, specific attitudes by implant type and anatomical location, and personal habits.

RESULTS

164 questionnaires were received. The most frequent indications are patellar and olecranon cerclage wires and elastic nails in children. 56% remove the implant at the patient's request, 31% always remove it in children, 28% do it in asymptomatic patients to avoid possible surgical problems, 14% to avoid a possible peri-implant fracture and 9% by simple preference. The most frequent intraoperative complications are surgery longer than expected, bone growth over the implant, rounded screw head core, cold fusion, difficulty in finding the implant and impossibility to remove part of the implant. The most frequent postoperative complication was persistence of symptoms 39.8%.

CONCLUSION

The results provide information to advise the patient regarding the expected clinical outcome and intra and postoperative complications. The surgeon should cautiously indicate extraction in the asymptomatic patient given the high rate of complications.

Antipsychotic Medication in Schizophrenic Patients is Associated with Higher Risks of Developing Bone Fractures and Refractures

Objective

The relationship of antipsychotics and the risk of refracture in treated patients is unclear. The aim of this study is to evaluate the association between prolonged antipsychotic and the incidences of bone fractures and refractures in schizophrenia.

Methods

This is a retrospective nested case-control study using Taiwan National Health Insurance Research Database recorded from 2000 to 2005, with cases followed up to end of 2011. Total of 7,842 schizophrenic patients, 3,955 had developed bone fractures were compared with 3,887 control subjects matched in age, sex, and index date. Antipsychotic drug exposure was classified based on the drug type and medication duration. Conditional logistic regression analyses were performed. Odds ratio (OR) and confidence interval (CI) were calculated.

Results

We found (after adjustments) higher risks of developing fractures under continued use of typical (OR = 1.70; 95% CI, 1.51−1.91) or atypical antipsychotics (OR = 1.43; 95% CI, 1.28−1.60) were found. Additionally, continued use typical (OR = 1.84; 95% CI, 1.35−2.50) or atypical antipsychotics (OR = 1.44; 95% CI, 1.06−1.95) was positively associated with refracture risks. Moreover, refractures were associated with continuous use of chlorpromazine (one typical antipsychotics, OR = 2.45; 95% CI, 1.14−5.25), and risperidone (OR = 1.48; 95% CI, 1.01−2.16) or zotepine (OR = 2.15; 95% CI, 1.06−4.36) (two atypical antipsychotics).

Conclusion

Higher risks of bone fracture and refracture were found in schizophrenia under prolonged medication with typical or atypical antipsychotics. We therefore recommend that clinicians should pay more attention on bone density monitoring for patients using long-term antipsychotics.

Risk factors of cemented vertebral refracture after percutaneous vertebral augmentation: a systematic review and meta-analysis

To evaluate the risk factors of cemented vertebral refracture after percutaneous vertebral augmentation (PVA) for patients with osteoporotic vertebral compression fractures (OVCFs). We performed a literature search on cemented vertebral refracture after PVA using the PubMed, EMBASE, and Cochrane Library medical databases. The clinical data, including literature information, basic patient information, observational factors, and interventional factors, were extracted by two authors. The pooled results and related heterogeneity of each factor between the refracture group and the non-refracture group were evaluated using Review Manager software 5.35. A total of 3185 patients from 10 studies were included, with 195 patients in the refracture group and 2990 patients in the non-refracture group. The mean follow-up duration was 18.9 months. According to the meta-analysis, age, low bone marrow density (BMD), intravertebral cleft (IVC), high anterior vertebral height (AVH) restoration/high Cobb angle restoration, and low cement dose were the risk factors of cemented vertebral refracture after PVA. Our results showed that age, low BMD, IVC, high AVH restoration, high Cobb angle restoration, and low cement dose were the risk factors for cemented vertebral refracture after PVA.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing

PURPOSE

Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic.

METHODS

The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15 years. The characteristics of the primary fractures and treatment course were evaluated.

RESULTS

Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277 days, and in 5 of the 6 patients refractures occurred within 6 months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%).

CONCLUSIONS

Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

Risk factors for refracture after plate removal for midshaft clavicle fracture after bone union

Background

Open reduction and internal fixation (ORIF) with plates and screws is one of the treatment options for clavicle fractures. However, an additional operation for implant removal after union of the fracture is commonly performed due to a high incidence of hardware irritation. Despite union of the fracture, a subsequent refracture might occur after removal of the implant which requires additional surgeries for fixation. This study aims to determine the risk factors associated with refracture of the clavicle after hardware removal.

Methods

We retrospectively reviewed the medical records of 278 patients that were diagnosed with a midshaft clavicle fracture (male 190; female 88) that had (1) undergone ORIF of the clavicle with plates and (2) received a second operation for removal of hardware after solid union of the fracture between 2010 and 2017. Their mean age was 40.1 ± 15.1 years, and mean interval from fixation to plate removal was 12.5 ± 7.5 months. The patients were then divided into two groups based on the presence of refracture (n = 20) or without refracture (n = 258). We analyzed patient demographics, interval between fixation and implant removal, fracture classification (AO/OTA, Robinson), fixation device, whether wires or interfragmentary screws were used, clavicular length, and bone diameter at the fracture site.

Results

The overall refracture rate was 7.2%, and the mean interval between plate removal and refracture was 23.9 days. A multivariate analysis showed that female (adjusted odds ratio [aOR] 4.74; 95% CI 1.6–14.1) and body mass index [BMI] (for every 1-unit decrease, aOR 1.25; 95% CI 1.06–1.48) were risk factors for refracture. In women, BMI was the only risk factor. The optimal BMI cutoff value was 22.73. In a female patient with a lower BMI, the refracture rate was 29.8%.

Conclusions

There are no significant radiographic parameters associated with refracture. Routine plate removal in a female patient with a low BMI after bony union of a midshaft clavicle fracture is not recommended because of a high refracture rate.

The association between sarcopenia and osteoporotic vertebral compression refractures

Sarcopenia was reported to be significantly associated with osteoporosis. In this study, we reported for the first time that sarcopenia was an independent risk predictor of osteoporotic vertebral compression refractures (OVCRFs). Other risk factors of OVCRFs are low bone mass density T-scores, female sex, and advanced age.

INTRODUCTION

The purpose of this study was to investigate the association between osteoporotic vertebral compression refractures (OVCRFs) and sarcopenia, and to identify other risk factors of OVCRFs.

METHODS

We evaluated 237 patients with osteoporotic vertebral compression fracture who underwent percutaneous kyphoplasty (PKP) in our hospital from August 2016 to December 2017. To diagnose sarcopenia, a cross-sectional computed tomography (CT) image at the inferior aspect of the third lumbar vertebra (L3) was selected for estimating muscle mass. Grip strength was used to assess muscle strength. Possible risk factors, such as age, sex, body mass index (BMI), bone mineral density (BMD), location of the treated vertebra, anterior-posterior ratio (AP ratio) of the fractured vertebra, cement leakage, and vacuum clefts, were assessed. The multivariable analysis was used to determine the risk factors of OVCRFs.

RESULTS

During the follow-up period, OVCRFs occurred in 64 (27.0%) patients. Sarcopenia was present in 48 patients (20.3%), including 21 OVCRFs and 27 non-OVCRFs patients. Sarcopenia was significantly correlated with advanced age, lower BMI, lower BMD, and hypoalbuminemia. Compared with non-sarcopenic patients, sarcopenic patients had higher OVCRFs risk. In univariate analysis, sarcopenia (p = 0.003), female (p = 0.024), advanced age (≥ 75 years; p < 0.001), lower BMD (p < 0.001), lower BMI (p = 0.01), TL junction (vertebral levels at the thoracolumbar junction) (p = 0.01), cardiopulmonary comorbidity (p = 0.042), and hypoalbuminemia (p = 0.003) were associated with OVCRFs. Multivariable analysis revealed that sarcopenia (OR 2.271; 95% CI 1.069-4.824, p = 0.033), lower BMD (OR 1.968; 95% CI 1.350-2.868, p < 0.001), advanced age (≥ 75 years; OR 2.431; 95% CI 1.246-4.744, p = 0.009), and female sex (OR 4.666; 95% CI 1.400-15.552, p = 0.012) were independent risk predictors of OVCRFs.

CONCLUSIONS

Sarcopenia is an independent risk predictor of osteoporotic vertebral compression refractures. Other factors affecting OVCRFs are low BMD T-scores, female sex, and advanced age.

Kyphosis and canal compromise due to refracturing of an L1 cemented vertebra managed with posterior surgery alone

Background:

An already cemented vertebral body rarely refractures and its occurrence may be signaled by the reappearance of pain and/or significant vertebral collapse/kyphosis resulting in canal compromise and neurological deterioration.

Case Description:

An 81-year-old male originally underwent an L1 kyphoplasty for an osteoporotic compression fracture. Nine months later, he presented with the late onset of recurrent collapse of the cemented vertebral body, leading to pain, kyphosis, and canal compromise. Surgery warranted total L1 corpectomy, reconstruction of the anterior column, and a posterior fixation through a purely posterior approach (posterior vertebral column resection [pVCR]).

Conclusion:

Here, we presented the safety/efficacy of utilizing a purely posterior approach (e.g., including L1 corpectomy, reconstruction of the anterior column, and posterior fusion: pVCR) in the management of a repeated fracture of a cemented L1 vertebra resulting in kyphosis and canal compromise.

Incidence of Osteoporotic Refractures Following Proximal Humerus Fractures in Adults Aged 50 Years and Older in Korea

Background

The purpose of this study was to investigate the incidence and characteristics of osteoporotic refractures after proximal humerus fracture in Korean adults aged above 50 years.

Methods

Patients aged 50 years or older with initial proximal humerus fractures reported in 2012 were enrolled and followed up until 2016 using the Korean National Health Insurance data. Based on the last claim date, the refractures were classified as osteoporotic fractures including spine, hip, distal radius, and humerus 6 months after the index fracture involving the proximal humerus. Each osteoprotic fracture was identified using specific International Classification of Diseases, 10th Revision codes and site-specific physician claims for procedures.

Results

A total of 5,587 first-time fractures involving proximal humerus were reported in 2012. Among them, a total of 1,018 osteoporotic refractures occured between 2012 and 2016. The total cumulative incidence of osteoporotic refractures was 4.85% (271/5,587) at 1 year, 9.61% (537/5,587) at 2 years, 14.21% (794/5,587) at 3 years, and 18.22% (1,018/5,587) at 4 years. In terms of site by year, the incidence of associated refractures was as follows: spine, 48.62% (495/1,018); hip, 25.83% (263/1,018); wrist 18.57% (189/1,018); and humerus 6.97% (71/1,018) during all the follow-up periods.

Conclusions

Our study showed that the cumulative incidence of osteoporotic refractures following proximal humerus fractures in the elderly population has been increasing over the years. Given that osteoporotic refractures are associated with an increased mortality risk, a public health strategy to prevent the refracture after proximal humerus fracture in the elderly is imperative.

Epidemiology of fragility hip fractures in Nan, Thailand

Objectives

Hip fracture is the most serious consequence of falling in elderly with osteoporosis. Patients with hip fractures suffer functional deterioration and increased morbidity especially during the first year after fracture. Rapid increase in the proportion of the elderly increases the prevalence of hip fractures in Thailand, leading to major problem for public health. There is substantial variation in the incidence of hip fracture in different regions of Thailand. Demographic data are required to improve management and prevention. This study was aimed to describe the demographic data and to determine the incidence of fragility hip fractures in Nan, Thailand.

Methods

A retrospective, cohort study had been conducted in Nan and Pua hospital. Patients with hip fractures were sorted by International Classification of Diseases 10th Revision (S72.0-S72.2) from September 1, 2014 to December 31, 2017. Statistical analyses were conducted using descriptive analysis and 95% confidence interval.

Results

The incidence of hip fractures in Nan province in 2015-2017 were 211.6, 214.9 and 238.5 per 100,000 person-years, respectively. There were 876 patients in this study. Higher incidence was found in female (ratio, 2.5:1). About 87.2% of the fracture occurred inside the house. There were 5.9% who had refracture. The median for refracture time was 143 weeks.

Conclusions

The incidence of hip fractures in Nan province was classified as moderate severity and was increasing between 2015 and 2017. A coordinated, multidisciplinary approach in homecare management especially in fall prevention are important factors to reduce incidence of fragility hip fracture.

Refracture of the Pediatric Forearm with Intramedullary Nails in situ

INTRODUCTION

There are few described cases in literature describing the management of refracture of both bone forearm fractures with elastic stable intramedullary nails (ESIN) in situ. We describe our experience and discuss it in the context of existing reports.

CASE REPORT

A 6-year-old girl presented to our unit with a refracture of her forearm with ESIN in situ following a trauma, 5 months post her index injury and ESIN procedure. She was managed with closed reduction under general anesthesia with a good outcome.

DISCUSSION

Treatment of this unusual injury is challenging given the paucity of evidence to inform management. Many existing case series fail to report this complication. We echo those studies that have employed similar strategies and note potential complications associated with this management including altered biomechanics of the ESIN.

CONCLUSION

Closed reduction of a refracture of pediatric forearm with ESIN in situ is an acceptable approach to this unusual injury. Caution must be taken intraoperatively and postoperatively to account for any biomechanical deficiencies in the ESIN resulting from the forces applied to cause the refracture and forces applied to the in situ nails to achieve correction intraoperatively.

Risk of subsequent fracture after prior fracture among older women

Among 377,561 female Medicare beneficiaries who sustained a fracture, 10% had another fracture within 1 year, 18% within 2 years, and 31% within 5 years. Timely management to reduce risk of subsequent fracture is warranted following all nontraumatic fractures, including nonhip nonvertebral fractures, in older women.

INTRODUCTION

Prior fracture is a strong predictor of subsequent fracture; however, postfracture treatment rates are low. Quantifying imminent (12-24 month) risk of subsequent fracture in older women may clarify the need for early postfracture management.

METHODS

This retrospective cohort study used Medicare administrative claims data. Women ≥ 65 years who sustained a clinical fracture (clinical vertebral and nonvertebral fracture; index date) and were continuously enrolled for 1-year pre-index and ≥ 1-year (≥  2 or ≥ 5 years for outcomes at those time points) post-index were included. Cumulative incidence of subsequent fracture was calculated from 30 days post-index to 1, 2, and 5 years post-index. For appendicular fractures, only those requiring hospitalization or surgical repair were counted. Death was considered a competing risk.

RESULTS

Among 377,561 women (210,621 and 10,969 for 2- and 5-year outcomes), cumulative risk of subsequent fracture was 10%, 18%, and 31% at 1, 2, and 5 years post-index, respectively. Among women age 65-74 years with initial clinical vertebral, hip, pelvis, femur, or clavicle fractures and all women ≥ 75 years regardless of initial fracture site (except ankle and tibia/fibula), 7-14% fractured again within 1 year depending on initial fracture site; risk rose to 15-26% within 2 years and 28-42% within 5 years. Risk of subsequent hip fracture exceeded 3% within 5 years in all women studied, except those < 75 years with an initial tibia/fibula or ankle fracture.

CONCLUSIONS

We observed a high and early risk of subsequent fracture following a broad array of initial fractures. Timely management with consideration of pharmacotherapy is warranted in older women following all fracture types evaluated.

Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing

PURPOSE

This study aims to investigate risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing (ESIN).

METHODS

Clinical data of 267 patients who had been treated for forearm fractures by ESIN in our hospital from January 2010 to December 2014 were retrospectively reviewed. Risk factors for forearm refractures were determined using logistic regression analysis.

RESULTS

Forearm refractures occurred in 11 children. Univariate analysis revealed that age, body weight, number of fractures, open fracture, nail diameter, and immobilization time were not associated with refractures. However, gender (male, P = 0.042) and fracture location (lower third, P = 0.007) were significantly associated with refractures. Multivariate analysis revealed that fracture location was an independent risk factor for forearm refractures (P = 0.031).

CONCLUSION

Forearm refracture is uncommon in children treated with ESIN. Fracture location is an independent risk factor for forearm refractures in these patients.

The risk factors of vertebral refracture after kyphoplasty in patients with osteoporotic vertebral compression fractures: a study protocol for a prospective cohort study

BACKGROUND

Percutaneous kyphoplasty (PKP) is the first-line treatment for osteoporotic vertebral compression fractures (OVCFs) that can immediately relieve pain and allow the quick recovery of lost mobility. However, some studies reported that after PKP, the incidence of vertebral refracture, particularly adjacent vertebral fracture (AVF), was high. Our previous meta-analysis suggested that the risks for vertebral refracture and AVF did not increase after percutaneous vertebral augmentation in OVCF patients. Despite the negative results of our meta-analysis, there is still significant evidence regarding the relationship between kyphoplasty and AVF, so a new prospective cohort study is warranted. In addition, in our previous retrospective study, we found that advanced age, female sex and low oestradiol (E₂) concentrations might be related to the occurrence of postoperative vertebral refracture after PKP. To sufficiently evaluate the probable factors involved in the occurrence of postoperative vertebral refracture, we designed this prospective study.

METHODS

This is a prospective cohort study of patients admitted for PKP to treat painful OVCFs. The baseline data, including demographic information, lifestyle, bone metabolic status, sex hormone and sex hormone-binding globulin (SHBG) levels, and clinical characteristics will be collected at the time of enrolment. Surgical features of PKP will be recorded on the operation day. Lifestyle, bone metabolic status, sex hormone levels, and SHBG levels will be assessed during the follow-up period at 1 m, 3 m, 12 m, and 24 m postoperatively. Patients suffering from acutely aggravated back pain will be referred to an orthopaedist, and refractured vertebrae will be confirmed by magnetic resonance imaging and computed tomography. The primary outcome will be the incidence of vertebral refracture. Multivariate analyses will be carried out to evaluate the variables that are independently correlated with vertebral refracture.

DISCUSSION

To evaluate the risk of postoperative refracture preoperatively and to identify the surgical points related to postoperative refracture, this study will explore the risk factors related to vertebral refracture after PKP. The results may provide new information about defining OVCF patients suitable for PKP treatment.

TRIAL REGISTRATION

ChiCTR-ROC-17011562 . Registered on July 4th, 2017.

Bisphosphonate use after clinical fracture and risk of new fracture

Among older adults with a previous fracture, treatment for osteoporosis was initially associated with a higher risk of new fracture. However, the relative risk of new fracture decreased over time, a trend that is consistent with a beneficial effect, as treatment for osteoporosis is prescribed to reduce high fracture risks.

INTRODUCTION

The purpose of this study was to examine whether bisphosphonate use is associated with a lower risk of new fracture after a clinical fracture in older adults.

METHODS

Data were available for 3,329,400 adults in Sweden who were aged ≥ 50 years between 2006 and 2011. During this period, 260,353 sustained a clinical fracture and were naïve to bisphosphonates at the time. Those who subsequently received a bisphosphonate were matched to up to three others on sex, year of birth, and type and year of initial fracture. The final cohort comprised 83,104 adults (26.3% bisphosphonate users).

RESULTS

During the period from initial fracture to initiation of bisphosphonate treatment, the incidence rate of any new clinical fracture was higher in those who later became bisphosphonate users than in those who remained nonusers (175.1 vs. 75.9 per 1000 person-years; hazard ratio 2.30, 95% confidence interval 2.19 to 2.41). Similarly, during the first 6 months of treatment, the incidence rate was higher in bisphosphonate users than in nonusers (128.8 vs. 90.2 per 1000 person-years; hazard ratio 1.41, 95% confidence interval 1.32 to 1.51). However, this difference decreased over time: by months 12 to 18, the incidence rate was similar in users and nonusers (59.3 vs. 55.3 per 1000 person-years; hazard ratio 1.03, 95% confidence interval 0.91 to 1.16).

CONCLUSIONS

There was a decrease in the relative risk of new fracture during bisphosphonate treatment, a trend that is consistent with a beneficial treatment effect, as bisphosphonates are prescribed to reduce high fracture risks.

Diagnosis of painful cemented vertebrae from failed vertebroplasty: modified dynamic radiographs play an important role

PURPOSE

The diagnosis of painful cemented vertebrae resulting from failed PV is not clearly defined in literature. This report evaluates the effectiveness of modified dynamic radiographs in diagnosing painful cemented vertebrae resulting from failed PV.

METHODS

From January 2011 to June 2015, 345 patients with a total of 399 VCFs underwent PV at our institution. Among the 345 patients, 27 patients underwent repeated PV at the cemented vertebrae because of persisting or recurrent pain after vertebroplasty. The prevertebroplasty examinations included routine radiographs, modified dynamic radiographs, and MRI. Kyphotic angles and the anterior vertebral body height (AVBH) were measured. The image findings in routine radiographs, modified dynamic radiographs, and MRI were compared. Finally, a visual analog scale was used to measure the outcome.

RESULTS

The patients ranged in age from 67 to 90 years. MRI revealed a moderate amount of fluid (definite diagnosis of refracture) in the cemented vertebrae in seven patients, bone edema without fluid in nine patients, and bone edema with minimal fluid in ten patients. The rate of diagnosis of painful cemented vertebrae according to MRI was 27% (7/26). The difference in the kyphotic angle between sitting and supine cross-table lateral radiographs was -9.36° ± 5.20° (P < 0.001). The difference in AVBH was 8.08 ± 3.21 mm (P < 0.001). All 27 patients were confirmed to have dynamic mobility according to the modified dynamic radiographs.

CONCLUSIONS

When the diagnosis of painful cemented vertebrae is questionable, modified dynamic radiographs can help diagnose painful cemented vertebrae resulting from failed PV.

Analysis of Risk Factors for Secondary New Vertebral Compression Fracture Following Percutaneous Vertebroplasty in Patients with Osteoporosis

OBJECTIVE

The aim of this article was to analyze risk factors for secondary new vertebral compression fractures (SNVCFs) after percutaneous vertebroplasty in patients with osteoporosis.

METHODS

We investigated medical records and radiologic images of patients undergoing percutaneous vertebroplasty for osteoporotic vertebral compression fracture between October 2009 and September 2014. We assessed patients' age, past medical history, and bone mineral content using computed tomography. Procedure-specific outcomes were assessed, including ratio of injected bone cement to vertebral body volume, bone cement distribution in the vertebral body (to identify degree of consistency in bone cement injection), presence of bone cement leakage into adjacent disc space, segmental kyphosis, and time interval between first and second fracture events.

RESULTS

Percutaneous vertebroplasty was performed in 293 patients (60 men and 233 women) with 336 affected levels. Of this cohort, 34 (14.6%) patients sustained SNVCFs. We compared patients in 2 groups: patients who experienced SNVCFs, and patients who did not experience fractures. Significant differences were identified in bone mineral content (P = 0.000) and bone cement distribution (P = 0.000). Patients exhibiting bone cement leakage into disc space revealed a higher incidence of SNVCF than patients without leakage (P = 0.039).

CONCLUSIONS

Poor bone mineral content can be a predictive factor of SNVCFs. To prevent SNVCFs, bone cement should be injected as evenly as possible into the vertebral body. Bone cement leakage into the disc space should be avoided.

Antiresorptive therapy and risk of mortality and refracture in osteoporosis-related hip fracture: a nationwide study

We analyzed the association of bisphosphonate therapy with mortality and hip refracture incidence among osteoporosis-related hip fracture patients in Austria. Mortality was lower in primarily female bisphosphonate users, while hip refracture incidence was generally elevated relative to controls, indicating beneficial effects of bisphosphonates other than on bone.

INTRODUCTION

The purpose of this study was to analyze mortality and hip refracture risk in osteoporotic hip fracture patients with and without antiosteoporotic medication.

METHODS

We retrospectively analyzed data on 31,668 Austrian patients ≥50 years with a hip fracture between July 2008 and December 2010 for antiosteoporotic drug treatment with respect to outcome parameters all-cause mortality, hip refracture incidence, and hip refracture-free days. Outcomes when bisphosphonate (BP) treatment was begun before or after fracture were compared with an age- and sex-matched hip fracture control without antiosteoporotic medication.

RESULTS

27.69 % of patients (33.01 % of women, 13.13 % of men) were prescribed antiosteoporotic medication, primarily BPs. Females having initiated BP treatment before first fracture had lower odds for mortality 1 and 3 year(s) post-fracture, whereas hip refracture incidence under pre-fracture BP initiation was generally higher. Treatment that was started after fracture, however, entailed significantly lower mortality hazards for both genders (HR 0.43, 95 %CI 0.36-0.52, p < 0.0001 after 1 year) but significantly higher hip refracture incidence except for patients aged 50-69 years and more hip refracture free days for females. Hip refractures overall amounted to 29.22/1000 patient years differing significantly between women and men (31.03 vs. 23.89, respectively, p < 0.0001), and longer hip refracture free survival was observed for women than for men (499 vs. 466 median days, respectively, p < 0.0001).

CONCLUSIONS

Although BP use is associated with reduced mortality after hip fracture, notably among women, hip refracture incidences are likewise elevated, which is most likely accounted for by a high probability of BP prescription to more comorbid patients suffering from more severe osteoporosis. Concomitantly, through possible effects other than on bone, BPs might be able to curtail mortality. Male hip fracture patients' low treatment frequency in particular reflects underdiagnosis and undertreatment of osteoporosis in Austria.

Predictive risk factors for refracture after percutaneous vertebroplasty

Objective

To identify risk factors for developing a vertebral refracture after percutaneous vertebroplasty.

Method

A retrospective analysis of 60 patients who had undergone percutaneous vertebroplasty between January 2008 and April 2010 was conducted. All patients were observed for a 1 year follow-up period, and fracture was defined when it was both clinically reported and radiographically confirmed. Twenty-seven patients with a refractured vertebra and 33 patients without a refracture were included. Of the 60 patients, 20 presented with a refracture from a cemented vertebra, whereas the remaining 40 patients did not. Clinical, imaging and procedure-related factors for each group were analyzed by the Fisher's exact, chi-square, and the Mann-Whitney U-tests.

Results

Local kyphotic angle and sagittal index were significant as a result of researching various risk factors related to vertebral refracture (p<0.001, p<0.001, respectively) and refracture from a cemented vertebra itself (p=0.004, p<0.001, respectively). Other factors were not significant.

Conclusion

Patients who had a high preoperative local kyphotic angle and a high sagittal index required a close follow-up and attention.

Closed reduction of radius refracture: A case report

INTRODUCTION

Refractures of the radius and ulna in the paediatric patient with flexible intramedullary nails in situ are known to occur. There are no formal guidelines currently in the literature to guide the management of such fractures.

PRESENTATION OF CASE

A 10-year-old Caucasian girl, sustained a closed refracture of the radius at the same level, with the flexible intramedullary nails in situ to treat her recent ulna and radius fractures.

DISCUSSION

We proposed a new non-invasive way of reducing and maintaining such fractures without removal of the bent nail completely.

CONCLUSION

This method does not significantly reduce the mechanical strength of the nail, as we do not advocate applying an external lateral force, which would compromise nail mechanical strength and eventually lead to breakage of the nail in situ.

Polyaxial Locked Implants in the Treatment of Type Vancouver B1 Periprosthetic Fractures of the Femur: Retrospective Clinical Examination in 58 Cases with Review of the Literature

We concluded a retrospective study of the outcomes of a consecutive series of Vancouver B1 and C femoral injuries using two specific locked implants. The study center is a dedicated trauma hospital with a large catchment area. Over a five-year period we treated 58 patients with a periprosthetic fracture of the femur with an angular stable plate, defined as the index procedure. The mean age at the index procedure was 72.4 years; 40 patients were female (69%). In 32 cases (55.2%) we saw a hip endoprosthesis, in 21 cases (36.2%) a knee endoprosthesis, and in five cases both (8.6%). Outcome measures were intra- and postoperative complications, bony union, degree of mobility and social status with comparison to the preoperative status, Barthel index, and timed ''up and go'' test. Union occurred in 56 cases (96.5%) after the index procedure. Three patients were bedridden before the injury; the remainder regained full weight-bearing status. The mean duration until full weight-bearing status in these patients was 8.6 weeks (4-13). Early implant failure with proximal dislocation of the screws occurred in two cases (3.5% revision rate). At follow up, 78% had maintained the same social status as before the injury. Fifty-two patients (89%) had regained their previous level of mobility. The mean Barthel index was 85 points (70-100) out of a possible 100, and improved from a mean of 35 points at the start of rehabilitation. It decreased on average by ten points compared to the preoperative status. The mean ''up and go'' time was measured as 21.4 s. In conclusion, polyaxial plates can achieve excellent surgical results. On the other hand, patients with this type of injury exhibit a clear deterioration in their social status, especially regarding lower limb motor function and self-independence.