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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.

Resumen: Introducción: Las indicaciones sobre extracción de material de osteosíntesis no están bien definidas en la literatura actual derivando en indicaciones relativas, en función a experiencias, costumbres o a petición del paciente. El objetivo de este artículo es valorar las creencias, indicaciones, práctica habitual y complicaciones percibidas de los cirujanos de España sobre la extracción de material de osteosíntesis. Material y método: Realizamos un cuestionario de 44 preguntas que abarcan demográficos generales, opinión general y subjetiva sobre la retirada de implantes, actitudes específicas por tipo de implante y localización anatómica y hábitos personales. Resultados: Se reciben 164 cuestionarios. Las indicaciones más frecuentes son cerclajes en rótula y olécranon y clavos elásticos en los niños. Un 56% retira el implante a petición del paciente, un 31% lo retira siempre en niños, un 28% lo hace en pacientes asintomáticos para evitar posibles problemas quirúrgicos y un 14% para evitar una posible fractura periimplante y un 9% por simple preferencia. Las complicaciones intraoperatorias más frecuentes son cirugía más larga de lo esperado, crecimiento de hueso sobre el implante, alma de la cabeza del tornillo redondeada, fusión fría, dificultad para encontrar el implante e imposibilidad para retirar parte del implante. La complicación postoperatoria más frecuente es la persistencia de la sintomatología 39,8%. Conclusión: Los resultados aportan información para aconsejar al paciente en cuanto al resultado clínico esperado y las complicaciones intra- y postoperatorias. El cirujano debe indicar con cautela la extracción en el paciente asintomático dada la alta tasa de complicaciones. Abstract: 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.

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.

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.

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 (FIPS), fatty infiltration of erector spinae plus multifidus (FIES + 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, FIPS 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, FIPS and BA restoration rate were identified as independent risk factors. When the BA restoration rate exceeded 0.350, refractures were more likely to occur.

Background: To compare the radiological and clinical outcomes of kyphoplasty (KP) with intravertebral reduction device (IRD) and vertebroplasty (VP) for treating osteoporotic vertebral compression fracture (OVCF)-associated spinal canal encroachment (SCE). Materials and Methods: From January 2013 to December 2016, 57 patients with OVCF-associated SCE treated through VP or KP with an IRD were enrolled. Kyphotic angle (KA) anterior, middle, and posterior body heights (ABH, MBH, and PBH, respectively) at postoperative week 1 3, 6, and 12 months of the cemented vertebrae were evaluated. Visual analog scale (VAS), Oswestry Disability Index (ODI), and EuroQol-5D-5 L (EQ-5D-5 L) were followed, and the complications were recorded. Results: Sixteen and 41 patients were treated through KP with IRD and VP (IRD and VP groups, respectively), and their characteristics were comparable. Compared with the VP group, KA, ABH, MBH, and PBH in the IRD group were significantly greater after the operation at postoperative 12 months (IRD vs. VP: KA −1.68° ± 6.02° vs. −10.34° ± 4.99°; ABH 2.06 ± 0.29 vs. 1.35 ± 0.26; MBH 2.21 ± 0.51 vs. 1.21 ± 0.31; PBH 2.91 ± 0.62 vs. 2.11 ± 0.33 cm, P< 0.05). Significant postoperative improvements were observed in the VAS, ODI, and EQ-5D-5 L in both groups; these improvements were similar between the two groups. No new neurological deficits occurred, and the incidence rates of cement leakage into the SC were similar. Conclusions: KP with IRD was associated with better body heights and KA at least for 1 year for OVCF-associated SCE with noninferior clinical outcomes to VP.

Introduction Long bone refractures can be a common injury among pediatric population. Approaches to rehabilitation of children with refractures are similar to those used for primary injuries. However, refracture healing and bone repair involve specific pathways that should be considered in rehabilitative approaches to restorative treatment. Objective To identify morphological specific features of simulated reparative processes in long bone refractures of growing animals (rats) at different stages of observation. Material and methods Two series of experiments were carried out on 36 laboratory animals (rats) to explore histological picture at the healing site of primary and repeat fractures at different stages of reparative process. Transverse fracture of the tibial shaft was simulated and fixed with external fixation device in the first series (n = 18). Tibial shaft was refractured and fixed again with external fixation device after 21 days of primary injury in the second series (n = 18). Results Delayed osteogenesis and greater period of organotypical regenerate restructuring were observed in animals with long bone refractures. Mechanism of slower osteogenesis was found to be associated with disturbed blood supply affecting cell differentiation at the refracture site. Conclusion Delayed bone repair and longer period of organotypical regenerate restructuring were specifically detected in growing animals with long bone refractures.

Introduction: Delay in presentation and surgical intervention is quite usual in osteogenesis imperfecta (OI) because of various local and cultural beliefs. The purpose of this study is to review the results of 21 children who had intramedullary rodding and its effect on ambulation and refracture. Methods: We reviewed 21 children with a clinical diagnosis of OI. The mean age of children at presentation was 8.74 years (3–21 years). All children had recurrent fractures of long bones. Twenty eight femurs and 21 tibiae were stabilized with intramedullary rodding. Ambulatory status was assessed by the Hoffers and Bullock's (H and B) grading, and muscle power was recorded using the Medical Research Council, U. K., grade. Ten children had received intravenous bisphosphonates preoperatively. Postoperatively, the children were assessed for ambulatory status, pain, and ability for independent self-care. Results: The mean followup period was 34 months (24–48 months). Rush rods were used in 20 femurs, the Fassier–Duval (FD) rods in 6 femurs, and in two cases, with narrow intramedullary canals, Kirshner (K) wires were used. For the tibiae, 15 children received rush rods and in 6 cases, an FD rod was used. The mean time to fracture union was 8 weeks (6–12 weeks). Before surgery, 13 children were in H and B Grade 4 (wheel-chair independent or carried by parents usually in a developing country), four were able to ambulate with a walking aid (H and B Grade 3b), and four children were able to walk about in the house without aids (H & B Grade 2). After the rodding procedure, the ambulatoty status improved in 11 (50%) children. Seven children (33%) became household physiologic walkers (H & B Grade 3b), three achieved independent ambulation with orthosis (H & B Grade 1b), and one child with mild OI could walk unaided (H & B Grade 1a). No child had deterioration in ambulatory status. Only two children had refractures at the distal end of the rod due to continual growth of bones. Conclusions: Intramedullary rodding treatment for recurrent fractures in children with OI improves their mobility potential. It also and prevents repeated cast application, disuse wasting, and osteopenia which can lead to deterioration in the quality of the long bones.

Open reduction and pre-contoured locking plate fixation is a popular treatment option for displaced midshaft clavicle fracture. Lag screw and cerclage are 2 main intraoperative techniques to reduce and fix fragments. However, both lag screw and metallic cerclage have disadvantages. The doubled-suture Nice knot has been reported in many areas of orthopedic surgery for its effectiveness. This study aims to compare the outcomes of comminuted mid-shaft clavicle fractures reduced by Nice knots vs traditional techniques (lag screw or/and metallic cerclage) when bridged with pre-contoured locking plates. We retrospectively reviewed 101 patients (65 females and 36 males) diagnosed with midshaft clavicle fractures with at least one wedge fragment reduced by either Nice knots or traditional methods and bridged with pre-contoured locking plates between December 2016 and April 2019. Operation time, functional outcomes, pain, patient satisfaction, fracture healing, and complications were assessed at a follow-up of 12 to 40 months. The mean age of all the patients was 50.8 years. There were 52 and 49 patients in the Nice knot group and traditional group respectively, and no differences between 2 groups were found in general patient characteristics, fracture type, follow up and injury-to-surgery duration. The Nice knot group had significant less operation time (P

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.

Summary 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

Summary 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. Electronic supplementary material The online version of this article (10.1007/s00198-017-4367-7) contains supplementary material, which is available to authorized users.

Objective: To analysis the risk factors of nonsurgical vertebral refracture by making retrospectively study about patients with osteoporotic vertebral compression fractures (OVCF) had accepted vertebroplasty.Methods: From June 2016 to December 2017, there were 161 cases of OVCF patients were treated with single-segment vertebroplasty in our department, and follow-up data including age, gender, bone density, bone cement volume, bone cement puncture route, bone cement leakage and vertebral refracture were collected.T-test and chi-square test were used to analyze the possible risk factors for postoperative vertebral refracture.Results: Among 161 patients treated with vertebroplasty, 19 of them had refracture. Among the refracture group, including 2 males and 17 females,bone density (-3.49 + 0.20) in the refracture group, and bone density (-2.95 + 0.57) in the nonrefracture group.The difference was statistically significant (t=-4.162,PRead Complete Article at ijSciences: V72018121896 AND DOI: http://dx.doi.org/10.18483/ijSci.1896

In this study, we present the case of a nine-year-old male patient who had initially presented to the emergency department with a right both-bone forearm fracture. He was treated with closed reduction and long-arm casting. The cast was applied for six weeks and then replaced with a short-arm cast for two weeks. The patient returned with a both-bone forearm refracture one and a half months after the removal of the cast. Surgical treatment was initiated and an intramedullary nail fixation was applied. The patient sustained a new trauma five months postoperatively. The condition was diagnosed to be a refracture of the both-bone forearm with an intramedullary nail in situ. Closed reduction was performed, but an acceptable level of reduction was not achieved. Subsequently, intramedullary nails were replaced with new nails. At the one year follow-up, the patient was observed to have a full range of motion and reported no pain or muscle weakness.

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.

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. Keywords: Epidemiology, Hip fracture, Osteoporosis, Refracture

Rationale: Balloon kyphoplasty is a widely accepted treatment of osteoporotic vertebral compression fractures (OVCFs) with good results and a low risk for complications. A refracture of previously treated vertebra is a relatively rare condition. Patient concerns: We reported our 3 cases and reviewed all relevant literatures of 11 cases with refracture of osteoporotic vertebral body after kyphoplasty. Diagnoses: Follow-up radiographs or magnetic resonance imaging examination confirmed refractures of previously treated vertebrae after kyphoplasty. Interventions: One patient with 1 refracture of osteoporotic vertebral body after kyphoplasty was treated conservatively, but the other 2 patients were treated surgically because of multiple vertebral fractures or neurological deficits. Outcomes: The average age of the patients was 76.8 years (range, 63–86 years). All the patients had severe osteoporosis with a mean T-score of −3.46 (range −5.0 to −3.0). The sites of refractures are in the lumbar and thoracolumbar regions. Severe osteoporosis, the presence of intravertebral cleft, and a solid lump injection pattern of polymethylmethacrylate would result in insufficient strengthening effects of cement augmentation and therefore increased the likelihood of refractures of the kyphoplasty vertibrae. Lessons: Patients with OVCFs and intravertebral cleft who did not obtain complete pain-relief at the treated vertebral level after kyphoplasty should be strictly followed up. Early finding of this condition and rapid intervention might contribute to avoiding the occurrence of the cemented vertebral refracture after kyphoplasty. Conservative treatments such as back brace and antiosteoporotic medications were strongly recommended.

Fracture liaison services (FLS) are an accepted approach to lowering rates of osteoporotic refractures. However, resource allocations to FLS are open to challenge, as most relevant cost analyses are based on anticipated, rather than observed, benefits. To support informed decision making, we have estimated the cost of operating an FLS, from the perspective of the Australian health system, with real life costs. On the basis of hospital records, we compared total costs of two cohorts of patients presenting with minimal trauma fractures (MTFs) at two hospital emergency departments (EDs) across a 6‐month period (July to December 2010). The treatment cohort (FLS Cohort, n = 515) attended an ED at a hospital offering FLS post‐fracture care; the Usual Care Cohort (n = 416) attended an ED at a hospital without an FLS. Hospital records were reviewed for further attendance of both groups at their respective hospitals’ EDs with refractures for the subsequent 3 years. Costs were constructed from “bottom up” with a “microcosting” approach. Total costs for both cohorts included any FLS and the costs of refractures. Cohort costs were estimated for every 1000 patients over the 3 observed years. Compared with the Usual Care Cohort, the FLS Cohort had 62 fewer fractures per 1000 patients and $617,275 lower costs over 3 years. In a sensitivity analysis, where 20% of the Usual Care Cohort received FLS preventative treatment, FLS Cohort costs were lower by $880,154. As both hospitals consistently process around 2000 patients per year, the estimated annual saving is $1.2 million to $1.8 million (Australian dollars). From the perspective of the Australian public health system, investment in FLS can be a financially effective way of reducing the cost of osteoporotic fracture management. © 2018 The Authors JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

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

Vertebroplasty (VP) can effectively treat pain and immobility caused by vertebral compression fracture. Because of complications such as extravasation of bone cement (polymethylmethacrylate, PMMA) and adjacent vertebral fractures, some practitioners prefer to inject a small volume of PMMA. In that case, however, insufficient augmentation or a subsequent refracture of the treated vertebrae can occur. A 65-year-old woman visited our clinic complaining of unrelieved severe low back and bilateral flank pain even after she had undergone VP on the 1(st) and 4(th) (L1 and L4) lumbar vertebrae a month earlier. Radiologic findings showed the refracture of L1. We successfully performed the repeat VP by filling the vertebra with a sufficient volume of PMMA, and no complications occurred. The patient's pain and immobility resolved completely three days after the procedure and she remained symptom-free a month later. In conclusion, VP with small volume cement impaction may fail to relieve fracture-induced symptoms, and the refracture of an augmented vertebral body may occur. In this case, repeat VP can effectively resolve both the persistent symptoms and problems of new onset resulting from refracture of the augmented vertebral body due to insufficient volume of bone cement.

Aim: Although the femoral shaft fractures are treated conservatively for up to 6 years in children, surgical treatment should be considered in patients with femoral shaft fractures in school age or in those who have multiple long-bone fracture or organ injury. But it is a controversial issue which surgical treatment is ideal. Material and Method: Twenty-nine femoral fractures of 26 patients whose surgical treatment of femoral shaft fractures were made with Ender nails were prospectively evaluated. Under general anesthesia, 4,5 mm of 2 Ender nails were performed from the metaphysis to all of the patients. The patients were evaluated according to the type of the fracture, duration of the union, the discrepancy of shortening-length, the rotation, limitation of the joint movement, the complications such as refractures and the criterions of Flynn in terms of the clinical outcomes. Results: The mean age of the patients was 9.2 years (4-14). The type of the fracture was Winquist Hansen type 2 and 3. The mean duration of the followup was 18 months (13-38). While the etiology of the fractures was the traffic accidents in twenty of the patients, gunshot wounds and falling from height were in the others. The mean duration of the union was 6.5 (5-8) weeks in all patients. The discrepancy of shortening-length was an average of 6 mm (2-20), the difference of the rotation was an average of 3 degree (2-7), and the angulation of varus-valgus was an average of 4 degrees (2-9) in the femurs which were treated in the patients. The limitation of the movement in the knee joint was of an average 5 degrees (3-10) as the flexion and extension. None of the patients developed refractures. Excellent result in 20 fractures , good result in 7 fractures and bad result in 2 fractures were observed according to the criterions of Flynn. Discussion: Ender nail should be considered first for the possibility of early return to school, the low risk of refracture and the price advantage in the surgical treatment of femoral shaft fractures in children aged 5 and above

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.

Purpose Studies on the incidence and mortality of refractures after primary osteoporotic fracture are limited by the relatively rare incidence of such refractures and small sample sizes. The objectives of this research were: 1) to determine the incidence of osteoporotic refractures and fracture locations and 2) to assess mortality rates associated with osteoporotic refracture over a median follow up of 3 years using nationwide claim database. Materials and Methods Patients over 50 years of age who had an osteoporotic fracture that was confirmed operationally were enrolled. Refracture was defined as that after 6 months of an untreated period. Mortality rate was calculated using the Charlson comorbidity index and was analyzed using Cox proportional hazards regression analysis. Results A total of 18956 first-time instances of osteoporotic fracture were reported between 2007 and 2012 after a median follow up of 3.1 years (range, 1 to 7 years). Among 18956 patients, 2941 (15.50%) experienced refracture. After follow up for 1 year, cumulative mortality rates for re-fracture and non-refracture groups were 9.1% and 7.2%, respectively. After adjusting for covriates, mortality rate was 1.2 times greater in patients with re-fracture than in patients without re-fracture over a median follow up of 3 years (hazard ratio: 1.20, 95% confidence interval: 1.08–1.34, p

2008年4月から2009年5月までの期間に，小児前腕骨骨幹部骨折の8例に対して，手術治療を行った。男児5例，女児3例で，平均年齢は11.1歳（8歳?15歳）であった。骨折部位は遠位1/3骨幹部が3例，中央1/3骨幹部が5例であり，近位1/3骨幹部骨折はなかった。手術は，遠位1/3の骨幹部骨折に対してCross pinning 法を2例，中央1/3の骨折には髄内鋼線固定を4例に行った。なお粉砕骨折や年長児の2例に対してはplate 固定を行った。Cross pinning 法を行った2例のうち，1例で術後角状変形が生じたため，plate を用いた再手術を要した。また髄内鋼線固定術を行った4例中1例で再骨折を生じ，plate による再手術を要した。最終経過観察時，全例骨癒合が得られ平均骨癒合期間は11週（8?16）で，5度以上の角状変形が残存した症例はなく，可動域も正常であった。再手術を回避するためには，太いK-wire の選択や髄内のへ2本のK-wire 挿入，十分な外固定期間を考慮するなど，固定性を向上させる工夫が必要である。

成長期小児における不安定型の前腕骨骨幹部骨折の骨接合に用いたチタン性プレートの抜去困難例を経験した. チタン性製品は生体親和性が高いといわれ, 骨癒合に有利に働くと考えられて多用されているが, プレート固定の有用性, チタン製品使用上の問題点は無いのか, 文献的考察を加えた. 成人例では早期抜去後の再骨折が危惧されるため, 橈骨部のプレート抜去は術後18?24ヵ月とされているが, 小児例では骨癒合後早期の抜去が必要と考えられた. また, 抜釘困難時の対応として, 抜釘しないという選択も術前に十分Informed consentを得る必要があると考えられた

Refracture and a bent intramedullary nail in a patient with a healed femoral fracture. A rare case.

Objective. The objective of this study was to examine thecontent of transforming growth factor β1 (TGF-β1) in patientswith pseudoarthrosis of long bones at hyperhomocysteinemia(HHcy) and compare it with that of people with consolidatedfractures and practically healthy persons. Assessment ofcytokines depending on the availability of refracture and neurotrophic syndrome.Methods. The comparative study of the content of TGF-β1was conducted in healthy persons, patients with consolidatedfractures and 153 patients with nonunion of long bones atHHcy. The control group included 48 patients with diaphysealfractures consolidated at the femur and tibia, and 35 healthy individuals, representatives of age, gender, localization of damage.Refracture and neurotrophic syndrome diagnosed in 24 (15.7%)and in 43 (28.1%) individuals, respectively. The content ofTGF-β1 was determined by ELISA set «TGF-β1» (Biosource,Europe SA) analyzer STAT FAX 303/PLUS.Results. The mean values of TGF-β1 in patients with different clinical and radiographic pseudarthrosis types at HHcysignificantly differed among themselves. The level of cytokine inhyperplastic type was 93.4% higher, while hypoplastic and atrophic types of contrast by 24.8 and 64.5% lower thannormoplastic. The development of refrakture in patients withpseudarthrosis at HHcy associated with increased content ofserum TGF-β1.Field of application. Traumatology and Orthopedics.Conclusion. The level of TGF-β1 is regarded as one of thepossible factors that determine the formation of vital and avitaltypes of pseudarthrosis and complications of refracture in patients with violation of reparative osteogenesis at HHcy., Задача. Целью этого исследования было изучитьсодержание трансформирующего фактора роста β1 (TGF-β1) у пациентовпри псевдоартрозе длинных костей при гипергомоцистеинемии(HHcy) и сравните с результатами людей с консолидированнойпереломы и практически здоровые люди. Оценкацитокины в зависимости от наличия рефракта и нейротрофического синдрома.Методы. Сравнительное исследование содержания TGF-β1проводилось у здоровых лиц, пациентов с консолидированнойпереломов и 153 пациента с несращением длинных костейHHcy. В контрольную группу вошли 48 пациентов с диафизарнымпереломы консолидировались на бедренной и большеберцовой кость и у 35 здоровых лиц, представителей возраста, пола, локализации повреждения.Рефрактометрический синдром и нейротрофический синдром диагностированы у 24 (15,7%)и у 43 (28,1%) человек соответственно. СодержаниеTGF-β1 определяли с помощью набора ELISA «TGF-β1» (Biosource,Europe SA) анализатор STAT FAX 303 / PLUS.Полученные результаты. Средние значения TGF-β1 у пациентов с различными типами клинико-рентгенологического псевдоартроза при HHcyсущественно различались между собой. Уровень цитокинов вгиперпластический тип был на 93,4% выше, а гипопластический и атрофический типы контраста на 24,8 и 64,5% ниже, чемнормопластический. Развитие рефрактуры у пациентов спсевдоартроз при HHcy, связанный с повышенным содержаниемсыворотка TGF-β1.Область применения. Травматология и ортопедия.Вывод. Уровень TGF-β1 рассматривается как один извозможные факторы, определяющие формирование витального и авитальноготипы псевдоартроза и осложнения рефрактометрии у пациентов с нарушением репаративного остеогенеза при HHcy., Метою цього дослідження було вивчитивміст трансформуючого фактора росту β1 (TGF-β1) у пацієнтівз псевдоартрозом довгих кісток при гіпергомоцистеїнемії(HHcy) і порівняйте його з аналізом людей з консолідованимипереломи і практично здорові особи. Оцінкацитокіни залежно від наявності рефрактури та нейротрофічного синдрому.Методи. Порівняльне дослідження вмісту TGF-β1проводили у здорових людей, хворих на консолідованупереломи та 153 хворих з незрощенням довгих кісток приHHcy. Контрольна група включала 48 пацієнтів з діафізарною хворобоюпереломи, ущільнені на стегновій і гомілкової кістках, і 35 здорових осіб, представники віку, статі, локалізації пошкодження.Рефракція та нейротрофічний синдром діагностовано у 24 (15,7%)та у 43 (28,1%) осіб відповідно. ЗмістTGF-β1 визначали методом ІФА набору «TGF-β1» (Biosource,Europe SA) аналізатор STAT FAX 303 / PLUS.Результати. Середні значення TGF-β1 у пацієнтів з різними типами клінічного та рентгенологічного псевдартрозу при HHcyзначно відрізнялися між собою. Рівень цитокіну вгіперпластичний тип був на 93,4% вищим, тоді як гіпопластичний та атрофічний типи контрасту на 24,8 та 64,5% нижче, ніжнормопластична. Розвиток рефрактури у хворих напсевдартроз при HHcy, пов'язаний із підвищеним вмістомсироватковий TGF-β1.Область застосування. Травматологія та ортопедія.Висновок. Рівень TGF-β1 розглядається як один ізможливі фактори, що визначають формування життєвих і життєвихтипи псевдартрозу та ускладнення рефрактури у хворих із порушенням репаративного остеогенезу при ВГС.Ключові слова: трансформуючий фактор росту β1, гіпергомоцистеїнемія, псевдартроз, рефрактура.

The aim of the present study was to evaluate the application into clinical practice of therapeutic and diagnostic recommendations for the prevention of bone re-fracture in postmenopausal women after an hospitalization for hip fracture in clinical practice and to assess the relationship between the application of diagnostic recommendations and re-fracture or death risk. A retrospective cohort analysis was conducted. All female patients, at least 65 years old, and with an hospitalization with main or secondary diagnosis of hip fracture during the period 1 January 2006 – 31 December 2008, were included. Besides demographic characteristics and comorbidities, drug treatment prescriptions related to bone fracture or supplementary with calcium or vitamin D and prescriptions of recommended laboratory and instrumental diagnostic tests (e.g. spine radiography), were analysed. A total of 5,636 patients were included in the study. The prescription of a drug treatment aimed to reduce the risk of re-fracture was found in 16.3% of patients, among them 76.3% (699 patients) used bisphosphonates only, 17.1% (157 patients) strontium ranelate only and 4.9% (45 patients) used more than one treatment during the observation period. Among the patients who did not receive drug treatment, 17.5% made use of only supplemental calcium and vitamin D. The remaining part of patients (69.1%) received no treatment. The prescription of at least one laboratory test of first and second level was performed, respectively, on 53.7% and 43.1% of included patients, whereas the prescription of at least one instrumental test of first and second level was performed, respectively, on 5.9% and 0.8%. Although it is established that the prescription of the recommended tests and appropriate drug treatment are significantly associated with reduced risk of re-fracture and death, today the application of these recommendations is reduced.

Purpose To investigate the etiologic factors related to refractures of the upper extremity in children. Patients and Methods Eighteen refractures were divided into three groups according to the location of the initial fractures. They were analyzed in terms of the type of refractures, fracture patterns, and the existence of an underlying deformity. Results Of nine supracondylar fractures of the humerus, two involved refractures at the supracondylar region, and the other seven involved the lateral condyle. Underlying cubitus varus was present in six cases. Of three lateral condylar fractures of the humerus, one had a refracture at the supracondylar region, and two cases involved the lateral condyle. One had an underlying cubitus varus. All but one case in the humeral fractures group were late refractures, and were treated with surgery. Of six repeat forearm fractures, five were early type and occurred at the original site within nine weeks, four at the diaphysis of both bones of the forearm, and one at the diaphysis of the ulna. All cases in the forearm fractures group, save one, had volar angulation before the refracture, and were treated conservatively. Conclusion In the humerus, the underlying cubitus varus was the most important predisposing factor for refractures and lateral condyle fractures were common. In the forearm, volar angulation of the diaphysis was related to refractures, and complete and circular consolidation of the primary fracture of the forearm was thought to be important in prevention.

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

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