Kyphoplasty vs conservative treatment: a case-control study in 110 post-menopausal women population. Is kyphoplasty better than conservative treatment?

OBJECTIVE

Osteoporosis is a highly prevalent disease worldwide. Consequences of vertebral osteoporotic fractures include pain and progressive vertebral collapse resulting in spinal kyphosis, decreased quality of life, disability and mortality. Minimally invasive procedures represent an advance to the treatment of osteoporotic VCFs. Despite encouraging results reported by many authors, surgical intervention in an osteoporotic spine is fraught with difficulties. Advanced patients age and comorbidities are of great concern.

PATIENTS AND METHODS

We designed a retrospective case-control study on 110 post-menopausal women consecutively visited at our institution. Study population was split in a surgical and a conservative cohort, according to the provided treatment.

RESULTS

Kyphoplasty treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients (p < 0.05). EQ5D validated questionnaire also showed a better quality of life at 1 month for surgically treated patients (p < 0.05). SF-12 scores showed greater improvements at 1 month and 3 months with statistically significant difference between the two groups just at 3 months (p < 0.05). At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 54.55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average.

CONCLUSIONS

Kyphoplasty is a modern minimal invasive surgery, allowing faster recovery than bracing treatment. It can avoid the deformity in kyphosis due to VCF. In fact, the risk to develop a new vertebral fracture after the first one is very high.

Phloretin promotes osteoclast apoptosis in murine macrophages and inhibits estrogen deficiency-induced osteoporosis in mice

Bone-remodeling imbalance induced by increased osteoclast formation and bone resorption is known to cause skeletal diseases such as osteoporosis. The reduction of estrogen levels at menopause is one of the strongest risk factors developing postmenopausal osteoporosis. This study investigated osteoprotective effects of the dihydrochalcone phloretin found in apple tree leaves on bone loss in ovariectomized (OVX) C57BL/6 female mice as a model for postmenopausal osteoporosis. OVX demoted bone mineral density (BMD) of mouse femurs, reduced serum 17β-estradiol level and enhanced serum receptor activator of NF-κB ligand (RANKL)/osteoprotegerin ratio with uterine atrophy. Oral administration of 10 mg/kg phloretin to OVX mice for 8 weeks improved such effects, compared to sham-operated mice. Phloretin attenuated TRAP activity and cellular expression of β3 integrin and carbonic anhydrase II augmented in femoral bone tissues of OVX mice. This study further examined that osteogenic activity of phloretin in RANKL-differentiated Raw 264.7 macrophages into mature osteoclasts. Phloretin at 1-20 μM stimulated Smac expression and capase-3 activation concurrently with nuclear fragmentation of multi-nucleated osteoclasts, indicating that this compound promoted osteoclast apoptosis. Consistently, phloretin enhanced bcl-2 induction but diminished bax expression. Furthermore, phloretin activated ASK-1-diverged JNK and p38 MAPK signaling pathways in mature osteoclasts, whereas it dose-dependently inhibited the RANKL-stimulated activation of ERK. Therefore, phloretin manipulated ASK-1-MAPK signal transduction leading to transcription of apoptotic genes. Phloretin was effective in preventing estrogen deficiency-induced osteoclastogenic resorption.

A rare presentation of subclinical Cushing's syndrome as a pubic fracture

Osteoporosis and bone fractures are commonly seen in patients with Cushing's syndrome (CS). Fractures usually occur in the vertebrae and ribs whereas pubic fractures are less common. Similar to obvious hypercortisolemia, subclinical hypercortisolemia can increase the risk of fractures. However, in subclinical cases, bone fractures are very rarely seen as the presenting symptom. We herein report the case of a 62-year-old postmenopausal woman who was presented with a pubic fracture. During the evaluation of the fracture, thoracoabdominal magnetic resonance imaging of the patient demonstrated an adrenal mass. Although the patient did not show any signs of overt hypercortisolism, an endocrinologic evaluation revealed hypercortisolism due to an adrenal tumor. Adrenalectomy was performed, which resulted in a cure of the disease. During the orthopedic follow-up, the patient's pubic area pain gradually improved, and the pubic fracture healed without any accompanying new bone fractures. One year after the surgery, a remarkable improvement was detected in the patient's bone density in spite of the lack of administration of any medications for osteoporosis. Subclinical CS can present as a pubic fracture, and awareness of this relationship can help physicians to diagnose the disease.

[Percutaneous vertebroplasty with only few complications--a retrospective study]

INTRODUCTION

Percutaneous vertebroplasty (PVP) was introduced in 1984 and has proved to be valuable in the treatment of painful vertebral lesions such as haemangiomas, metastasis, and osteoporotic fractures. According to the literature, the operation provides pain relief with only few and harmless complications. The aim of this study was to evaluate our perioperative experiences with special reference to the safety of the procedure.

MATERIAL AND METHODS

A total of 156 procedures were performed in 148 patients with osteoporotic fractures. Both acute and chronic fractures were treated. All patients had plain radiographs of the spine. Magnetic resonance imaging (MRI) or bone scans were performed in case of old fractures or more than one fracture in patients with acute back-pain. At follow-up after three and 12 months, plain radiographs were performed in conjunction with physical examinations and interviews. Data were collected retrospectively.

RESULTS

We identified 40.4% cemental leaks (confidence interval (CI) 32.6; 48.5). None of these resulted in neurological symptoms. One patient experienced shortness of breath after the procedure, one had atrial fibrillation, and one patient had an iatrogenic pneumothorax. In all, the frequency of symptomatic complications was 1.9% (CI -0.4; 5.5).

CONCLUSION

We believe that PVP is a safe procedure with only few symptomatic complications when performed under local anaesthesia and by a specialist in transpedicular approach.

Outcome of hybrid stem fixation in osteoporotic female patients. A minimum five-year follow-up study

In osteoporotic patients cemented stems are usually used to achieve a good primary stability. However, when patients are obese or active the long-term survival of cemented prostheses is questioned. In these patients, a partially-cemented stem with a hybrid fixation could be advantageous. A hybrid stem was retrospectively evaluated at a minimum follow-up of 60 months (mean, 75 months) in 58 osteoporotic women: seventeen with a body mass index (BMI) >30 (obese), 41 with a BMI between 25 and 29.9 (overweight), and an UCLA score for activity level >6. At the latest follow up, the Harris hip score improved from 33.5 points preoperatively to 81.6 points, and the WOMAC score improved significantly. Three stems (4.9%) had an asymptomatic subsidence of less than 2.5 mm; no stem was revised. These results support the use of partially-cemented stems in heavy or active osteoporotic women.

Microcrack frequency and bone remodeling in postmenopausal osteoporotic women on long-term bisphosphonates: a bone biopsy study

We sought whether microdamage could rise in postmenopausal osteoporotic women on long-term bisphosphonates, as suggested by recent animal studies. We found few microcracks in iliac bone biopsies, despite a marked reduction in bone turnover.

INTRODUCTION

Animal studies suggest that bisphosphonates (BPs) could increase microdamage frequency in a dose-dependent manner, caused by excessively suppressed bone turnover. However, there is limited data in humans receiving BP therapeutic doses for >3 yr.

MATERIALS AND METHODS

We measured microcrack frequency and histomorphometry parameters on transiliac bone biopsies in 50 postmenopausal osteoporotic women (mean age = 68 yr) who had received BP therapy (3 on intravenous pamidronate, 37 on oral alendronate, and 10 on oral risedronate) for at least 3 yr (mean treatment duration = 6.5 yr). We compared these results with transiliac bone biopsies obtained from 12 cadavers. We used bulk staining with green calcein as a fluorochrome. The microcracks were quantified in three 100-microm-thick sections using optic microscopy and were confirmed by laser confocal microscopy. Microcrack frequency (number of microcracks/mm2 of bone tissue) was compared between treated women and controls using nonparametric tests. We also explored predictors of microcrack frequency, including age, duration of BP therapy, and activation frequency.

RESULTS

Among treated women, cancellous bone microcrack frequency was low (mean, 0.13 microcracks/mm2) and did not differ significantly from that observed in controls (0.05 microcracks/mm2; p = 0.59). Of note, 54% of the treated women and 58% of the controls had no observable microcracks. There was no association between microcrack frequency and the duration of BP therapy (for microcracks/mm2 and duration, Spearman r = 0.04, p = 0.80) and between patients' ages and the number of microcracks (Spearman r = -0.09, p = 0.61). Although bone remodeling parameters were suppressed in treated women, we found no relationship between microcrack density and activation frequency (Spearman r = -0.003, p = 0.99). Also, microcrack frequency was not increased in women with prevalent vertebral fracture compared with those without fractures.

CONCLUSIONS

Among postmenopausal osteoporotic women on long-term BPs, microcrack frequency in the iliac bone is low, despite a marked reduction of bone turnover.

Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures

STUDY DESIGN

Prospective, double-cohort study.

OBJECTIVE

To evaluate conservative and percutaneous vertebroplasty (PV) management of osteoporotic vertebral fractures.

SUMMARY OF BACKGROUND DATA

PV is an elective alternative to conservative management for the treatment of a painful osteoporotic vertebral fracture.

METHODS

We performed a prospective study consisting of 101 consecutive patients who underwent PV and 27 patients who refused PV treatment and were managed conservatively. We used a data evaluation and outcomes system that was developed to evaluate the outcomes of surgical intervention.

RESULTS

Patients that elected for PV as a treatment of their fractures had significantly more pain and functional impairment before the procedure than the patients of the conservative group (P < 0.001). The pain, functional, and general health scores of the PV group were improved from the preoperative mean values (P < 0.001) in all postoperative periods. Compared with the conservative treatment group, there was a significant difference at month 3. However, no statistical differences on function were observed between these groups at 6 months and 1 year posttreatment.

CONCLUSIONS

PV demonstrated a rapid and significant relief of pain and improved the quality of life. PV election for treatment of painful osteoporotic vertebral fracture after 6 weeks of conservative treatment was based on pain and functional impairment.

Percutaneous sacroplasty using CT fluoroscopy

Sacral insufficiency fractures frequently cause significant pain and limit activities of daily living in patients with osteoporosis. Percutaneous vertebroplasty is a common procedure to alleviate the pain associated with thoracic and lumbar vertebral compression fractures. The sacral percutaneous vertebroplasty procedure (sacroplasty) has recently been introduced as an alternative to medical management of osteoporotic sacral insufficiency fractures. We describe our CT fluoroscopy technique in performing percutaneous sacroplasty.

[Compound osteosynthesis as treatment for an osteoporotic LWK-1 burst fracture in a 76 year old female patient]

The surgical treatment of osteoporotic vertebral compression fractures is rarely necessary and is mostly done in fractures with neurological deficit. We present a case of compound osteosynthesis in an osteoporotic fracture of the first lumbar vertebra as a "salvage procedure" after a dislocation of a dorsal internal fixator in a 76 year old female sustaining incomplete paraplegia. In this case, an additional ventral stabilization using a vertebral body replacement was not practicable because of old age and previous pneumonia. We performed an additional compound osteosynthesis using bone cement because of insufficient stability when only using cement for augmentation of the pedicle screws.

A technique to circumvent subcutaneous cement tracts during percutaneous vertebroplasty

The deposition of a subcutaneous cement tract is a potential complication of percutaneous vertebroplasty. These tracts can be a source of pain and tenderness for the patient. We describe a case of symptomatic cement deposition within a needle tract in the subcutaneous tissues that required surgical removal, and we describe a technique to prevent this complication in a second patient, by using needle redirection to cut across the cement core.

[Vertebral body stenting. A method for repositioning and augmenting vertebral compression fractures]

Purpose of the study was to demonstrate the effectiveness of expanding a fractured vertebral body by transpedicular dilatation and stenting. 7 human cadaveric vertebral bodies from L2 to L5 underwent axia compression until a vertebral burst fracture was provoked. Then, by bilateral transpedicular approach, balloon-catheters were introduced, which were armed with stents, usually used for angioplasty. The catheters were inflated with radiolucent fluid and the stents expanded under radiologic control. After expansion, the balloon was deflated and removed, the stents resting inside the vertebral body, holding their inflated shape. Then, the resulting hole was filled with an injectable biodegradable calcium-phosphate. CT-scans were performed after destruction and after expansion. Morphology before and after expansion was judged, using 3-D reconstructions. Vertebral body strength was measured before destruction and after treatment with an Instron testing machine.

RESULTS

Vertebral body shape could be restored. Also impressed central parts of the bony endplate could be elevated by using a convergent approach through the pedicles. There was no collapse of the vertebral body after removing the catheter-balloons The vertebral body strength could be restored up to a physiologic level. This procedure gives new perspectives in the treatment either of osteoporotic compression or traumatic vertebral fracture. By using CT-guided technique, it could be performed by a minimally invasive approach percutaneously.

[Percutaneous vertebroplasty--a new method for alleviation of back pain]

Percutaneous vertebroplasty (PV) is an interventional radiological procedure for the treatment of pain in patients with vertebral compressions caused by osteoporosis, metastases or hemangioma. The method was introduced by Professors P Galibert and H Deramond at the University Hospital of Amiens, France in 1984. It consists of percutaneous injection of bone cement (polymethylmethacrylate) into the vertebral body under fluoroscopy guidance. PV has proved to be effective and safe. Permanent complete or partial pain relief is obtained within hours or days in more than 90% of cases. The complication rate is low, less than 3% for patients with osteoporosis and up to 10% in patients with metastases. We report on the first 17 patients (11 with osteoporosis, 3 with metastases and 3 with hemangiomas) treated in Sweden at the Department of Interventional Neuroradiology, Sahlgrenska Hospital, Göteborg University. We obtained complete pain relief in 71% and partial pain relief in 17% of cases. The majority of the patients improved in mobility and quality of life. We had no clinical complications.

[Treatment of fragmented femur fracture following unilateral hip hemiarthroplasty and total knee arthroplasty]

In this paper is presented a case of the 80 years old patient with femur fracture after unilateral hip arthroplasty because of femur neck fracture and knee arthroplasty following osteoarthritis. First was done the stabilization of the fracture using a plate. Because of second fracture and damage the plate stabilization next operation was done using intramedullary Küntscher nail which was non typically inserted and with additional fixation by bone cement. The result were good stabilization and healing of the fracture after 4 months.

The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior

STUDY DESIGN

Ex vivo biomechanical study using osteoporotic cadaveric vertebral bodies.

OBJECTIVE

To determine the association between the volume of cement injected during percutaneous vertebroplasty and the restoration of strength and stiffness in osteoporotic vertebral bodies, two investigational cements were studied: Orthocomp (Orthovita, Malvern, PA) and Simplex 20 (Simplex P with 20% by weight barium sulfate content; Stryker-Howmedica-Osteonics, Rutherford, NJ).

SUMMARY OF BACKGROUND DATA

Previous biomechanical studies have shown that injections of 8-10 mL of cement during vertebroplasty restore or increase vertebral body strength and stiffness; however, the dose-response association between cement volume and restoration of strength and stiffness is unknown.

METHODS

Compression fractures were experimentally created in 144 vertebral bodies (T6-L5) obtained from 12 osteoporotic spines harvested from female cadavers. After initial strength and stiffness were determined, the vertebral bodies were stabilized using bipedicular injections of cement totaling 2, 4, 6, or 8 mL and recompressed, after which post-treatment strength and stiffness were measured. Strength and stiffness were considered restored when post-treatment values were not significantly different from initial values.

RESULTS

Strength was restored for all regions when 2 mL of either cement was injected. To restore stiffness with Orthocomp, the thoracic and thoracolumbar regions required 4 mL, but the lumbar region required 6 mL. To restore stiffness with Simplex 20, the thoracic and lumbar regions required 4 mL, but the thoracolumbar region required 8 mL.

CONCLUSION

These data provide guidance on the cement volumes needed to restore biomechanical integrity to compressed osteoporotic vertebral bodies.

An ex vivo biomechanical evaluation of a hydroxyapatite cement for use with vertebroplasty

STUDY DESIGN

Comparative ex vivo biomechanical study.

OBJECTIVE

To determine the strength and stiffness of osteoporotic vertebral bodies subjected to compression fractures and stabilized via bipedicular injections of the following: 1) Simplex P (Stryker-Howmedica-Osteonics, Rutherford, NJ), 2) Simplex P formulated consistent with the practice of vertebroplasty (F2), or 3) BoneSource (Stryker-Howmedica-Osteonics).

SUMMARY OF BACKGROUND DATA

Little is known about the mechanical stabilization afforded by new materials proposed for use with vertebroplasty.

METHODS

Vertebral bodies (T8-T10 and L2-L4) from each of 10 fresh spines were harvested from female cadavers (81 +/- 12 years), screened for bone density (t score, -3.8 +/- 1.1; bone mineral density, 0.75 +/- 15 g/cm2), disarticulated, and compressed to determine initial strength and stiffness. The fractured vertebral bodies were stabilized via bipedicular injections of 4 mL (thoracic) or 6 mL (lumbar) and then recrushed.

RESULTS

Vertebral bodies repaired with Simplex P resulted in significantly greater strength (P < 0.05) relative to their prefracture states, those repaired with BoneSource resulted in the restoration of initial strength for both the thoracic and lumbar level, and those repaired with F2 resulted in significantly greater strength (P < 0.05) in the thoracic region and restoration of strength in the lumbar region. All cement treatments resulted in significantly less stiffness compared with initial values.

CONCLUSIONS

All three materials tested restored or increased vertebral body strength, but none restored stiffness. Both new materials show promise for use in percutaneous vertebroplasty, but they need clinical evaluation.

[Percutaneous vertebral augmentation (PVA) in osteoporosis of the vertebrae--an experimental study]

The present study was conducted with the aim of establishing whether minimally invasive percutaneous techniques used to stabilize osteoporotic vertebrae are technically feasible. Two different methods were investigated in human thoracolumbar cadaveric vertebrae. In the first technique, special titanium implants were placed via a postero-lateral approach. With the second method, the vertebrae were filled with different types of cement of different viscosities. After each procedure, the vertebrae were examined with conventional X-ray and CT scans. The first technique proved quite unsuccessful--the insertion of the titanium implants proving difficult despite the use of special instruments. The results achieved with the second method were much better. The use of low-viscosity bone cement produced the best results. Despite a single lateral point of entry, the vertebrae were almost completely filled right into the contralateral side. Lumbar vertebrae required an average volume of cement of 7 ml (range: 6.5-10 ml) and thoracic vertebrae 5.5 ml (range: 4-7 ml). Specially developed cement application devices made possible problem-free, controlled introduction of the cement.

Prophylactic intramedullary femoral rodding during total knee arthroplasty with simultaneous femoral plate removal

Removal of a plate from the distal femur creates a risk of fracture through the screw holes. This is a particular concern when a total knee arthroplasty is present because supracondylar fracture may occur with minimal trauma. A patient who presents after prior plating of a distal femur fracture with osteoporosis, retained hardware associated with pain, and gonarthrosis severe enough to warrant total knee arthroplasty is often difficult to manage. Prophylactic intramedullary rodding is a well-accepted method of treating pathologic stress risers in the femur. An intramedullary rod can be inserted into the femur at the time of total knee arthroplasty. This method permits simultaneous plate removal and total knee arthroplasty while protecting the femur from postoperative fracture.

Biomaterials for orthopedic surgery in osteoporotic bone: a comparative study in osteopenic rats

To evaluate orthopedic devices in pathological bone, an experimental study was performed by implanting Titanium (Ti) and Hydroxyapatite (HA) rods in normal and osteopenic bone. Twenty-four rats were used: 12 were left intact (

CONTROL

C) while the other 12 were ovariectomized (OVX). After 4 months all the animals were submitted to the implant of Ti or HA in the left femoral condyle (Ti-C, HA-C, Ti-OVX, HA-OVX). Two months later the animals were sacrificed for histomorphometric, ultrastructural and microanalytic studies. Our results show a significant difference between the Affinity Index (A.I.) of HA-C and Ti-C (77.0 +/- 7.4 vs 61.2 +/- 9.7) (p < 0.05). No significant differences were observed between the osteointegration of Ti-C and Ti-OVX (61.2 +/- 9.7 vs 48.2 +/- 6.7). Significant differences also exist between the osteointegration of HA-C and HA-OVX (77.0 +/- 7.4 vs 57.6 +/- 11.5) (p < 0.01). Microanalysis shows some modifications in Sulphur (S) concentration at the bone/biomaterial interface of the Ti-OVX group. Therefore our results confirmed the importance of biomaterials characteristics and of bone quality in osteointegration processes.

[Pathologic fractures: diagnostic and therapeutic considerations and results of treatment]

Compared with bone fractures caused by trauma, pathologic fractures due to diseased bone are rare events. A pathologic fracture is one that occurs without adequate trauma and is caused by a benign or malignant bone lesion. Diagnosis of the basic disease is important for the subsequent therapy. In cases of benign bone lesions the aim of treatment is total osseus healing with complete restoration of function. In malignant pathologic fractures surgery is an essential part of the overall oncologic treatment design. In most cases it is combined with adjuvant therapy. Various surgical procedures are available for fractures at different sites and depending on whether the operation is performed with curative or palliative intent. In cases of progressive neoplastic disease stabilization is necessary to attenuate pain and to maintain mobility. Between 1983 and 1993 we treated 131 patients with 143 pathologic fractures. Conservative therapy was possible in 10 cases, while 133 fractures had to be treated surgically. Most fractures were caused by skeletal metastasis (61), solitary bone cysts (19), osteoporosis (17) and plasmocytoma (16). The most frequent localizations of pathologic fractures were humerus and femur. The favoured methods of surgical stabilization were endoprosthesis and reinforced osteosynthesis. Most fractures appeared in adolescent patients up to the age of 19 and in adults between the 5th and the 7th decade, and 57.3% of the fractures were caused by a primary or secondary malignant tumour lesion. Surgical treatment was performed in all but 1 case of malignant pathologic fractures. Of 74 patients, with malignant bone lesions 6 (8.1%), are still alive. For 68 patients who died after stabilization, the average survival time was 11.6 months; individual survival time depended on the kind of the tumour present. In 55 patients with fractures in the area of benign bone lesions complete healing was achieved, in 9 cases with conservative therapy. The rate of recurrence for solitary bone cysts treated by curettage or segment resection was 23.5%. Compared with the recurrence rates published by other authors this is a very good result.

[Improvement in the primary stability of the dynamic hip screw osteosynthesis in unstable, pertrochanteric femoral fractures of osteoporotic bones by a new glass ionomer cement]

Internal fixation of unstable intertrochanteric fractures of osteoporotic femurs often leads to complications, which are primarily caused by the mechanically weak bone. The aim of this study was to test whether a new glass-ionomeric cement could reinforce the weak trabecular bone of the femoral head and thus improve the preliminary stability of dynamic hip screws (DHS) used for internal fixation. As a standardized model, a intertrochanteric osteotomy was performed on eight pairs of human, female, cadaver femora; a bony defect was also created medially to diminish support of the femoral neck. To stabilize the osteotomy a 135 degrees DHS was inserted. In one femur of each pair the glass-ionomer cement was applied to see whether this would enhance stability. The elastic and irreversible deformation of the internal fixation was measured at the osteotomy level under a cyclic load of 1400 N applied to the femoral head. In both the cemented and the uncemented cases, the femoral head shifted irreversibly in the caudal direction and tilted into a varus position. Movements of the femoral head in other directions were mainly reversible and small. The irreversible movement of the femoral head was significantly larger, approximately twice as great, following uncemented DHS fixation than after cemented fixation. Most movement occurred during the first ten load cycles; higher load cycles did not increase the irreversible deformation in the cemented group, but in the uncemented group a further increase in deformation was detected. These results indicate that internal fixation of unstable intertrochanteric femoral fractures can be significantly improved by the use of cement.(ABSTRACT TRUNCATED AT 250 WORDS)

[Structure of the axis--key to the etiology of the dens fracture]

Fractures of the dens are seen especially in young adolescents but also in individuals after the sixth decade of life. The etiology of these fractures and the occurrence of non-union after initial treatment is still discussed controversially. To address these issues, the axis was removed from thirty-seven autopsy cases for histomorphometric analysis. The base of the dens is a region of least resistance for fractures due to its reduced trabecular bone volume, a poorer trabecular interconnection and a cortical thickness one third that of the axis. In all of the cases, trabeculae disconnected from the trabecular lattice, and in 30% microcallus formations were demonstrated in the base of the dens. In osteoporotics the microarchitectural differences of cancellous bone between the base of the dens and the other regions of the axis are increased markedly. The obtained data suggest that the bone structure of the axis is responsible for the location, the distribution and the frequency of fractures of the odontoid process. The deficiency of bone mass within the base also offers a new explantation for the occurrence of non-unions even after treatment of fractures of the base of the dens.

Bundle nailing in nonunion of the distal radius: case report

A previously unreported technique for dealing with severe distal radial nonunion in the presence of marked osteoporosis and deformity in a 65-year-old female is presented. The technique involves temporary ankylosis of the wrist with bundle nails connecting the second and third metacarpal with the distal and proximal fragment of the radius, dorsal to the carpal bones and joints. Union was achieved radiographically after nine months. When the bundle nails were removed, there was some recovery of wrist movement and useful function.