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Background: The aim of this study is to determine the best plate to use as a substitute to fix a medial femoral condyle fracture. Materials and methods: The first part is to measure the best fit between several anatomical plates including the Proximal Tibia Anterolateral Plate (PT AL LCP), the Proximal Tibia Medial Plate (PT M LCP), the Distal Tibia Medial Locking Plate (DT M LCP) and the Proximal Humerus (PHILOS) plate against 28 freshly embalmed cadaveric distal femurs. Measurements such as plate offset and number of screws in the condyle and shaft shall be obtained. The subsequent part is to determine the compressive force at which the plate fails. After creating an iatrogenic medial condyle fracture, the cadavers will be fixed with the two plates with the best anatomical fit and subjected to a compression force using a hydraulic press. Results: The PT AL LCP offered the best anatomical fit whereas the PHILOS plate offered the maximal number of screws inserted. The force required to create 2 mm of fracture displacement between the two is not statistically significant (LCP 889 N, PHILOS 947 N, p = 0.39). The PT AL LCP can withstand a larger fracture displacement than the PHILOS (LCP 24.4 mm, PHILOS 17.4 mm, p = 0.004). Discussion and conclusion: Both the PT AL LCP and the PHILOS remain good options in fixing a medial femoral condyle fracture. Between the two, we would recommend the PT AL LCP as the slightly superior option. [ABSTRACT FROM AUTHOR]

Objective: Investigating what contributes to perceptions of ambiguity in stepfamily relationships among adolescents, and which strategies adolescents use to deal with ambiguity. Background: Relational losses or acquisitions marked by ambiguity (i.e., ambiguous losses and gains) are taxing as they often evade resolution. The frequent assumption that family relationships in postdivorce stepfamilies are per se ambiguous has only received limited empirical foundation. Little is known about how adolescents experience ambiguity, how and why ambiguity emerges, and what strategies adolescents develop to deal with ambiguity. Method: Semi‐structured interviews with 30 Dutch adolescents (aged 16–20) living in diverse postdivorce stepfamilies were conducted. The data were analyzed using open, axial, and selective coding. Results: Relationships with stepparents, stepsiblings, and biological parents were especially likely to be experienced as ambiguous. Two key categories of reasons emerged that helped to explain the emergence of ambiguity: information (i.e., incomplete or contradictory knowledge about family relationships), and relationality (i.e., the ways in which family relationships were assessed and compared to each other). Results point towards potential chains of ambiguity in stepfamilies, and show that respondents compared their relations with constructed archetypes of stepparents. Respondents used three strategies to deal with ambiguity: (a) improving relationships, (b) accepting ambiguity, and (c) creating distance. Conclusion: Ambiguity was common in postdivorce stepfamilies, yet mostly confined to relationships between adolescents and stepparents, stepsiblings, and biological parents. This suggests that, in stepfamilies, ambiguous gain might occur more frequently than ambiguous loss. The negative feelings associated with ambiguity might explain why many adolescents perceive living in stepfamilies as burdensome. [ABSTRACT FROM AUTHOR]

Despite the potential importance of kin to divorced parents in particular, prior research rarely studied how kinship patterns vary between married and divorced parents, nor within-group variations depending upon postdivorce residence arrangements and repartnering. We estimated mixed-effects logistic regression models using data from samples of Dutch married (N = 1,336) and divorced parents (N = 3,464) to predict the extent to which parents considered various blood relatives and (former) in-laws kin (i.e. parents, siblings, aunts/uncles, nieces/nephews, and cousins) and investigated differences within the divorced group per residence arrangements and repartnering. We found that married and divorced parents barely differed in the extent to which they considered blood relatives kin, but differences were large for (former) in-laws, and particularly great when parents did not reside with their biological child. Repartnered divorced parents were less likely to consider their former in-laws kin than single divorced parents but considered their new in-laws kin to high extents. For both blood relatives and (former) in-laws, parents were most often, and cousins least often considered kin. These results indicate that kinship patterns only differ for in-laws between married and divorced parents. Resident children may lead parents to consider former in-laws kin, whereas repartnering leads to exclusion of former in-laws. [ABSTRACT FROM AUTHOR]

Background: Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF). Methods: All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared. Results: Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant. Conclusion: rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. [ABSTRACT FROM AUTHOR]

Background: Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF). Methods: All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared. Results: Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant. Conclusion: rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. [ABSTRACT FROM AUTHOR]

Purpose: Glenoid component loosening is a potential complication of reverse total shoulder arthroplasty (rTSA), occurring in part due to lack of adequate screw purchase in quality scapular bone stock. This study was to determine the efficacy of a surgeon-designed, 3D-printed patient-specific instrumentation (PSI) compared to conventional instrumentation (CI) in achieving longer superior and inferior screw lengths for glenoid component fixation. Methods: A multi-centre retrospective analysis of patients who underwent rTSA between 2015 and 2020. Lengths of the superior and inferior locking screws inserted for fixation of the glenoid baseplate component were recorded and compared according to whether patients received PSI or CI. Secondary outcomes included operative duration and incidence of complications requiring revision surgery. Results: Seventy-three patients (31 PSI vs. 42 CI) were analysed. Average glenoid diameter was 24.5 mm (SD: 3.1) and 81% of patients had smaller glenoid dimensions compared to the baseplate itself. PSI produced significantly longer superior (44.7 vs. 30.7 mm; P < 0.001) and inferior (43.0 vs. 31 mm; P < 0.001) mean screw lengths, as compared to CI. A greater proportion of maximal screw lengths for the given rTSA construct (48 mm) were observed in the PSI group (71.9% vs. 11.9% superior, 59.4% vs. 11.9% inferior). Operative duration was not statistically significantly different between the PSI and CI groups (150 min vs. 169 min, respectively; P = 0.229). No patients had radiographic loosening of the glenoid component with an average of 2-year follow-up. Conclusion: PSI facilitates longer superior and inferior screw placement in the fixation of the glenoid component for rTSA. With sufficient training, PSI can be designed and implemented by surgeons themselves. [ABSTRACT FROM AUTHOR]

This article investigates how international students find and maintain housing and what constraints they have to deal with in the process. It reveals how the interplay between personal characteristics and housing-market features shapes housing biographies and unequally disadvantages certain international students over others. Eighteen in-depth interviews with international students were conducted about the housing situation for them in Utrecht, a Dutch student city. Qualitative Content Analysis (QCA) of the interview data found that international students' housing biographies differ substantially, both in progression and outcomes. Despite some students successfully finding adequate housing, many described living involuntarily in conditions of stress, instability and insecurity and a number experienced progressively worsening housing conditions. The students ascribed their difficulties to discrimination and structural disadvantages on the housing market. In light of these findings, this article calls for a re-evaluation of the Dutch student housing system. [ABSTRACT FROM AUTHOR]

Introduction: The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture.Methods: This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes.Results: Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores.Conclusion: Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Case: A 44-year-old man with osteogenesis imperfecta presented with multiple debilitating musculoskeletal deformities. Bi-level osteotomies, assisted by 3-dimensional (3D)-printed patient-specific cutting guides, were performed to correct extraarticular valgus and procurvatum tibial deformities. Concomitant computer-navigated total knee arthroplasty was performed to restore neutral mechanical alignment. Postoperative x-ray showed good correction of deformities, and 1 year postoperatively, the patient is able to walk unaided with significant resolution of knee pain. Conclusion: 3D-printed osteotomy guides and computer navigation can be instrumental in procedures requiring a high degree of precision. With sufficient training, modern orthopaedic technologies can be implemented by surgeons themselves and combined to facilitate precise and personalized management of challenging conditions. [ABSTRACT FROM AUTHOR]

Background: Plate fixation is frequently used to treat displaced midshaft clavicular fractures, however the ideal plate choice remains subject to discussion; reconstruction locking compression plates (RLCPs) are cheaper and can be easily contoured, whereas anatomically pre-contoured locking compression plates (ALCPs) are thought to provide better stability and therefore lower rates of mechanical failure. To compare the incidence of mechanical failures, functional and radiological outcomes in patients with midshaft clavicular fractures treated with ALCPs versus RLCPs.Methods: A propensity score matched retrospective cohort study was conducted across two centers. One hundred and six consecutively recruited patients with displaced midshaft clavicular fractures, who were treated with plate fixation and had a minimum follow-up of 6 months, were matched on gender, age, fracture grading, energy of injury, and fracture location. The resulting groups included 53 ALCP-treated fractures and 53 matched controls treated with RLCPs.Results: During a mean follow-up of 20.5 months, there were no implant deformities in the ALCP group whereas the RLCP group had 6 patients (11.3%, p = 0.012) with implant deformities (5 occurrences of plate bending with fracture union, and 1 plate breakage with nonunion). Despite the higher rate of plate deformities in the RLCP group, there were no statistically significant differences in number of patients recovering full shoulder range of motion (ALCP 90.6%, RLCP 88.7%, p = 0.751), incidence of rest pain (ALCP 13.2%, RLCP 9.4%, p = 0.542), or implant removals (ALCP 49.1%, RLCP 56.6%, p = 0.439).Conclusion: ALCPs may be superior to RLCPs in terms of implant stability but appear to produce similar clinical results. [ABSTRACT FROM AUTHOR]

• Dynamization of intramedullary nails for treating atypical femoral significantly reduces time-to-union and is associated with lower rates of non-union and treatment failure. • Static locking and varus reduction are independent risk factors for reoperation and treatment failure. Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking. Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons. A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82–0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24–10.96 vs 13.0 months; 95% CI = 10.60–15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction. Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures. [ABSTRACT FROM AUTHOR]

Purpose: Distal radius fractures are associated with a high incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance.Methods: Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54 years old.Results: Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC.Conclusions: A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic. [ABSTRACT FROM AUTHOR]

ABSTRACT: A novel computational model of implant migration in trabecular bone was developed using smoothed‐particle hydrodynamics (SPH), and an initial validation was performed via correlation with experimental data. Six fresh‐frozen human cadaveric specimens measuring 10 × 10 × 20 mm were extracted from the proximal femurs of female donors (mean age of 82 years, range 75–90, BV/TV ratios between 17.88% and 30.49%). These specimens were then penetrated under axial loading to a depth of 10 mm with 5 mm diameter cylindrical indenters bearing either flat or sharp/conical tip designs similar to blunt and self‐tapping cancellous screws, assigned in a random manner. SPH models were constructed based on microCT scans (17.33 µm) of the cadaveric specimens. Two initial specimens were used for calibration of material model parameters. The remaining four specimens were then simulated in silico using identical material model parameters. Peak forces varied between 92.0 and 365.0 N in the experiments, and 115.5–352.2 N in the SPH simulations. The concordance correlation coefficient between experimental and simulated pairs was 0.888, with a 95%CI of 0.8832–0.8926, a Pearson ρ (precision) value of 0.9396, and a bias correction factor Cb (accuracy) value of 0.945. Patterns of bone compaction were qualitatively similar; both experimental and simulated flat‐tipped indenters produced dense regions of compacted material adjacent to the advancing face of the indenter, while sharp‐tipped indenters deposited compacted material along their peripheries. Simulations based on SPH can produce accurate predictions of trabecular bone penetration that are useful for characterizing implant performance under high‐strain loading conditions. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1114–1123, 2018. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study is to report on the observed incidence of complications following pedicle screw and rod internal fixator (INFIX) stabilization of pelvic ring fractures.Methods: In a retrospective review of consecutive patient series conducted in a University level 1 trauma hospital, 43 patients (21 female and eight male), mean age 64.2 (range 16-87) with OTA/AO type B or C pelvic ring fractures received percutaneous pedicle screw and rod internal fixator (INFIX) anterior stabilization of pelvic ring fractures; 29 fulfilled inclusion criteria with three months' minimal follow-up or known complication. Mean follow-up was 7.2 months. Main outcome measure was the incidence of complications and adverse outcomes.Results: Fourteen (48.3%) had injury to the lateral femoral cutaneous nerve (LFCN). Three (10.3%) had chronic pain of the pelvis not related to the LFCN. Five out of 29 (17%) of patients had unplanned removal before six weeks with two due to early loosening, one femoral nerve palsy, one deep infection and one painful implant impingement. There were no patients with deep vein thrombosis, no intra-abdominal violations or vascular complications; 22 (76%) returned to their premorbid walking status.Conclusion: With high risk of LFCN injury, we caution against liberal use of the INFIX in patients with stable fractures where conservative treatment may be more appropriate. Most complications occurring from INFIX are self-limiting. [ABSTRACT FROM AUTHOR]

Background: The primary goal of treatment for open book pelvic injuries after high-energy trauma is to control haemorrhage and to close the pelvic ring anatomically. Less commonly, patients may present late with malunion or non-union.Methods: We reviewed five operatively treated patients with delayed severe open book deformities who had a diastasis of more than 6 cm. We describe the pre-operative workup, surgical strategy and challenges experienced. They specifically include: extensive scar and contracture formation, malunion, urogenital prolapse and difficult reduction of vertical shear element. A 5 to 15-point clinical scoring system based on quality of life regarding pain, ambulation, social function, continence control and presence of prolapse is proposed.Results: One elderly patient had early mortality after surgery. The other four patients had quality of life improvement by 3 to 5 points after one year. Correction is often clinically successful despite technical challenges and unpredictable radiological results.Conclusion: External fixator and the C-clamp are good reduction tools. Powerful implants should be used and fixation of the posterior ring is mandatory. Staged urogenital and pelvic floor reconstruction is recommended before bony reconstruction to minimize the risk of wound contamination. Patients receiving this complex procedure have a good chance for improvement in pain and functional status. [ABSTRACT FROM AUTHOR]

Case: We describe 2 patients who sustained a periprosthetic humeral fracture with a loosened long-stemmed Coonrad-Morrey total elbow prosthesis. As noted in the literature, the success rate for a major revision with use of strut grafts is around 70%; therefore, both cases were managed without revision of the prosthesis. A submuscular locking plate was placed following typical fracture fixation principles. Screws that interfered with the humeral stem and the distal flange stabilized both the distal fragment and the humeral stem. Conclusion: At 2 years postoperatively, both fractures had healed, with increased endosteal bone stock. In each case, the prosthesis was successfully salvaged, and radiographic reconstitution of the implant-bone interface was noted after 2 years. [ABSTRACT FROM AUTHOR]

We compared the Austin Moore hemiarthroplasty versus cemented hemiarthroplasties using a propensity score matched cased control study. For a consecutive cohort of 450 patients with displaced intracapsular neck of femur fractures, 128 matched cases in each group were selected based on age, gender, walking status, nursing home residency, delays in surgery, ASA score, and the Charlson comorbidity score. At a mean follow-up of 16.3 months, we evaluated their outcomes. Significantly more patients with AMA experienced thigh pain (RR = 3.5, 95% CI: 1.67–7.33,  p=0.000), overall complications (RR = 4.47, 95% CI: 1.77–11.3, p=0.000), and implant loosening (RR = 8.42, 95% CI: 2.63–26.95, p=0.000). There were no definite cement related deaths in this series. There was no significant difference in mortality, walking status, and the number of revisions between the groups. We support the routine use of cemented hemiarthroplasty instead of the Austin Moore for treating elderlies with displaced intracapsular neck of femur fractures. [ABSTRACT FROM AUTHOR]

In osteoporotic hip fractures, fracture collapse is deliberately allowed by commonly used implants to improve dynamic contact and healing. The muscle lever arm is, however, compromised by shortening. We evaluated a cohort of 361 patients with AO/OTA 31.A1 or 31.A2 intertrochanteric fracture treated by the dynamic hip screw (DHS) who had a minimal follow-up of 3 months and an average follow-up of 14.6 months and long term survival data. The amount of fracture collapse and shortening due to sliding of the DHS was determined at the latest follow-up and graded as minimal (<1 cm), moderate (1-2 cm), or severe (>2 cm). With increased severity of collapse, more patients were unable to maintain their premorbid walking function (minimal collapse = 34.2%, moderate = 33.3%, severe = 62.8%, and p=0.028). Based on ordinal regression of risk factors, increased fracture collapse was significantly and independently related to increasing age (p=0.037), female sex (p=0.024), A2 fracture class (p=0.010), increased operative duration (p=0.011), poor reduction quality (p=0.000), and suboptimal tip-apex distance of >25 mm (p=0.050). Patients who had better outcome in terms of walking function were independently predicted by younger age (p=0.036), higher MMSE marks (p=0.000), higher MBI marks (p=0.010), better premorbid walking status (p=0.000), less fracture collapse (p=0.011), and optimal lag screw position in centre-centre or centre-inferior position (p=0.020). According to Kaplan-Meier analysis, fracture collapse had no association with mortality from 2.4 to 7.6 years after surgery. In conclusion, increased fracture collapse after fixation of geriatric intertrochanteric fractures adversely affected walking but not survival. [ABSTRACT FROM AUTHOR]

The article presents two case studies of atypical subtrochanteric fractures in patients who had undergone long-term bisphosphonate therapy. The first patient had taken alendronate for osteoporosis and was presented to the hospital after a minor twisting injury to the left leg. The second patient was presented to the hospital due to a low-energy trauma after three years of alendronate therapy for osteoporosis.

Background: It is unclear whether regional anesthesia with infraclavicular nerve block or general anesthesia provides better postoperative analgesia after distal radial fracture fixation, especially when combined with regular postoperative analgesic medications. The aim of this study was to compare the postoperative analgesic effects of regional versus general anesthesia. Methods: In this prospective, observer blinded, randomized controlled trial, 52 patients undergoing distal radial fracture fixation received either general anesthesia (n = 26) or regional anesthesia (infraclavicular nerve block, n = 26). Numerical rating scale pain scores, analgesic consumption, patient satisfaction, adverse effects, upper limb functional scores (Patient-Rated Wrist Evaluation, QuickDASH), health related quality of life (SF12v2), and psychological status were evaluated after surgery. Result: Regional anesthesia was associated with significantly lower pain scores both at rest and with movement on arrival to the post-anesthetic care unit; and at 1, 2, 24 and 48 h after surgery (p ≤ 0.001 at rest and with movement). Morphine consumption in the post-anesthetic care unit was significantly lower in the regional anesthesia group (p<0.001). There were no differences in oral analgesic consumption. Regional anesthesia was associated with lower incidences of nausea (p = 0.004), and vomiting (p = 0.050). Patient satisfaction was higher in the regional anesthesia group (p = 0.003). There were no long-term differences in pain scores and other patient outcomes. Conclusion: Regional anesthesia with ultrasound guided infraclavicular nerve block was associated with better acute pain relief after distal radial fracture fixation, and may be preferred over general anesthesia. Trial registration: Before subject enrollment, the study was registered at ClinicalTrials.gov (NCT03048214) on 9th February 2017. [ABSTRACT FROM AUTHOR]

Screw loosening is a common complication in plate fixation. However, the underlying mechanism is unclear. This study investigated screw loosening mechanisms by finite element analysis (FEA) simulation and clinical X‐ray feature analysis. Two FEA models incorporated bone heterogeneity and orthotropy, representing fracture fixation using dynamic compression plate (DCP) and locking compression plate (LCP), were developed. These models were used to examine the volume of bone exceeding a certain stress value around each screw under physiologically‐relevant loading conditions. These damaged bone was then separated and compared by the axial stress and radial stress of each screw. In addition, features of patients' X‐ray images showing screw loosening were analyzed to validate the loosening features simulated by the models. The FEA study showed that more damaged bone was found at the central two screws which gradually decreased toward the two end screws in all groups. More bone was damaged by the radial stress of each screw than by the axial stress. The radiological analysis of screw loosening showed that bone loss occurred at the screw closest to the fracture line first then subsequent bone loss at the screws further away from the fracture line occurred. This study found that the two screws nearest to the fracture line are more vulnerable to loosening. The radial stress of the screw plays a larger role in screw loosening than the axial stress. Bone resorption triggered by the high radial stress of screws is indicated as the mechanism of screw loosening in the diaphyseal plate fixation. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1498–1507, 2019. [ABSTRACT FROM AUTHOR]

Purpose: The current study investigated the accuracy in achieving proper lower limb alignment and individual component positions after total knee arthroplasty (TKA) with 3 different instrumentation techniques. It was hypothesized that patient-specific instruments (PSI) would achieve more accurate lower limb alignment and component positions compared to conventional instruments (CON).Methods: Ninety knees in 81 patients were randomized in 1:1:1 ratio into CON, computer navigation (NAV) and PSI groups to receive TKA. The surgical routines were standardized. The lower limb mechanical axis and individual component positions were assessed on standard radiographs. Tourniquet time, operation time and patients' functional scores were documented.Results: Conventional instruments and PSI were more likely to result in an excessively flexed femoral component (p = 0.001) compared to NAV. Number of outliers in postoperative lower limb alignment, and other components positions in the coronal and sagittal plane showed no statistically significant difference. The mean tourniquet time and operation time was significantly shorter in CON and PSI groups than NAV group (p < 0.001). Four early complications occurred in the PSI group (p = 0.015). At 3-month follow-up, there was no difference in terms of the knee range of motion and patients' function among the 3 groups.Conclusion: No significant radiological and clinical benefit could be demonstrated in using PSI over CON or NAV in TKA. Routine use of PSI is not recommended because of the extra cost and waiting time.Level Of Evidence: I. [ABSTRACT FROM AUTHOR]

Introduction: Midshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes. Methods: A systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe. Results: Of the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails. Conclusion: Surgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced. [ABSTRACT FROM AUTHOR]

Introduction: Topical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.Methods: A total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.Results: There was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760-1.795) in the TXA group and 1.078 L (IQR: 0.797-1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40-140) in the TXA group and 70 mL (IQR: 30-168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).Conclusion: A 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery. [ABSTRACT FROM AUTHOR]

Conventional evaluation of the stability of bone screws focuses on pullout strength, while neglecting lateral migration resistance. We measured pullout strength and lateral migration resistance of bone screws and determined how these characteristics relate to screw stability of locking plate (LP) and dynamic compression plate (DCP) fixation. Pullout strength and lateral migration resistance of individual bone screws with buttress, square, and triangular thread designs were evaluated in polyurethane foam blocks. The screw types with superior performance in each of these characteristics were selected. LP and DCP fixations were constructed using the selected screws and tested under cyclic craniocaudal and torsional loadings. Subsequently, the association between individual screws' biomechanical characteristics and fixation stability when applied to plates was established. Screws with triangular threads had superior pullout strength, while screws with square threads demonstrated the highest lateral migration resistance; they were selected for LP and DCP fixations. LPs with square-threaded screws required a larger force and more cycles to trigger the same amount of displacement under both craniocaudal and torsional loadings. Screws with triangular and square threads showed no difference in DCP fixation stability under craniocaudal loading. However, under torsional loading, DCP fixation with triangular-threaded screws demonstrated superior fixation stability. Lateral migration resistance is the primary contributor to locking screw fixation stability when applied to an LP in resisting both craniocaudal and torsional loading. For compression screws applied to a DCP, lateral migration resistance and pullout strength work together to resist craniocaudal loading, while pullout strength is the primary contributor to the ability to resist torsional loading. [ABSTRACT FROM AUTHOR]

Introduction: Cephallomedullary nail fixation is currently the most popular treatment for pertrochanteric fractures. Despite continuous improvement in implant design, fixation failures still occur in a concerning number of cases. This study aims to evaluate the effect of cement augmentation of the new-generation Trochanteric Femoral Nail Advanced (TFNA) perforated spiral blade on complications including fixation failure in the elderly population. Materials and methods: We retrospectively evaluated 107 patients aged 65 + treated for pertrochanteric fractures via TFNA between 2015 and 2019 based on whether cementation was used. Baseline demographics, fracture classifications, and reduction quality were compared. Patients with a follow-up of at least 6 months were analyzed for the primary outcome of fixation failure. All patients, regardless of loss to follow-up within 6 months, were analyzed for other complications including mortality. Results: Seventy-six patients (47 cemented, 29 non-cemented) had a minimum follow-up of 6 months (mean 13 months). There were no statistically significant differences between the two treatment groups in terms of patient demographics, ASA or AO/OTA fracture classification, reduction quality, or length of follow-up. There was a lower rate of fixation failure in the cement-augmented (CA) group versus the non-cement-augmented (NCA) group (2.1% vs 13.8%; p = 0.047). No cut-out or cut-through was observed in the CA group. Seven patients had adverse intraoperative events, with a significantly higher rate of fixation failure in these patients (40% vs 2.8%; p = 0.00). There were no statistically significant differences in 30-day mortality (6.3% CA vs 4.3% NCA; p = 0.632) or 3-month mortality (9.5% CA vs 12.8% NCA; p = 0.589). Conclusions: Cementation of TFNA blades may decrease risk of fixation failure, however, the surgeon must be aware of potential complications such as cement leakage into the hip joint and be able to manage them as they arise. [ABSTRACT FROM AUTHOR]