Quantification of bone strength by intraoperative torque measurement: a technical note

Introduction: Bone strength describes the resistance of bone against mechanical failure. Bone strength depends on both the amount of bone and the bone's quality, and the bone strength may be looked upon as a relevant parameter to judge an osteosynthesis' stability. Information about bone strength was barely available intraoperatively in the past. The previous work of our group reported on development and laboratory evaluation of mechanical torque measurement as a method for the intraoperative quantification of bone strength. With the clinical series presented here we intend to verify that the im gesamten Text DensiProbe™ instrumentation for intraoperative torque measurement and the related measurement method are eligible for intraoperative use based on the following criteria: application of the method may not create complications, the measurement can be performed by the surgeon himself and may only cause a limited increase in the procedure time. Patients and methods: From December 2006 until May 2007 ten patients with a pertrochanteric femoral fracture or a lateral femoral neck fracture eligible for stabilization with DHS® were included in the study after having received informed consent. Any medication and comorbidity that might have influenced bone quality or bone mineral density (BMD) in these patients was documented. Bone strength was intraoperatively measured with DensiProbe®. Complications that were obviously related with torque measurement were documented as well as any deviation from the suggested procedure; 6 and 12 weeks postoperative follow-up included clinical and radiological examination. The time required for torque measurement, the overall operating time and the number of persons present in the operating room were protocolled. BMD values of the contralateral femoral neck were postoperatively assessed by dual energy X-ray absorptiometry (DEXA) and compared to intraoperative peak torque values measured by DensiProbe®. Results: No major complication was observed during intraoperative application of DensiProbe®by trained surgeons. The unintended extraction of the guide wire together with the torque measurement probe was reported only once and is looked upon as a minor complication. Fracture healing was uneventful in all patients. The mean time for torque measurement was 2.35±0.9min accounting for 2.2±1.1% of total surgery time. The presence of an additional person was not required to perform torque measurement but to protocol the data. There was a tendency towards correlation between BMD values of the femoral neck and intraoperative peak torque values. Discussion: The data presented clearly indicate that the DensiProbe® instrumentation and measurement principle are eligible for routine intraoperative use by trained surgeons. Interpretation of possible correlations between BMD values measured by means of DEXA and the Peak Torque values assessed by DensiProbe® has to be considered very carefully, because BMD and Peak Torque analyse bone at a different scale. Only within the framework of a multicenter study it will be possible to include a sufficient number of patients for calculation of the methods' predictive value towards implant failure and to verify acceptance of the method by the surgeon

Scope and Limits of Teriparatide Use in Delayed and Nonunions: A Case Series

Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the "off-label" character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing

Long PHILOS plate fixation in a series of humeral fractures

Aim: The purpose of the article is to highlight a specific fracture pattern encountered by us in the osteoporotic upper humerus. We present our results of management of such metadiaphyseal fractures of the upper humerus with less invasive plating. The additional steps taken to improve final outcome and the reasoning behind each are discussed. Patients and methods: In our department, a total of 13 fractures (in 12 patients) were managed for a metadiaphyseal fracture of the upper humerus between 2010 and 2013. There were 2 males and 10 females. The average age in the cohort was 74.3 (52-95) years. In 9 fractures, the fracture line was extending above the surgical neck. All patients were managed with a locking compression plate (long PHILOS or LCP) using two approach windows (proximal deltopectoral and a distal anterior or lateral). Patients were evaluated for clinical outcome using the Quick DASH score and assessed for radiological union, complications or re-operations retrospectively. Results: The mean follow-up was 14.3months (4-36). All fractures were united, and there was no evidence of avascular necrosis or non-union. Two patients showed varus collapse of the anatomical head of which one patient needed change of screws at 12weeks from index surgery. In patients, when a distal lateral window was used, 2 patients out of 4 had radial nerve palsy post-operatively. In the rest, when the plate was twisted by 45° to allow anterior placement using the brachialis split, none had radial nerve injury. Conclusion: The osteoporotic bone failingunder a low-energy mechanism seemed to dictate this fracture pattern. The fracture is either a bending wedge or a long spiral with or without a large butterfly and often extends into the humeral head. The fractures are better managed surgically, a primary reduction allowing contact of fragments is essential, and using an anterior window distally with a 45° contoured plate will achieve good plate placement as well as decreases the risk of radial nerve injury considerably compared to total lateral plate positioning

Posterior pelvic ring fractures: Closed reduction and percutaneous CT-guided sacroiliac screw fixation

Purpose: To assess the midterm results of closed reduction and percutaneous fixation (CRPF) with computed tomography (CT)-guided sacroiliac screw fixation in longitudinal posterior pelvic ring fractures. Methods: Thirteen patients with 15 fractures were treated. Eleven patients received a unilateral, two a bilateral, screw fixation. Twenty-seven screws were implanted. Continuous on-table traction was used in six cases. Mean radiological follow-up was 13 months. Results: Twenty-five (93%) screws were placed correctly. There was no impingement of screws on neurovascular structures. Union occurred in 12 (80%), delayed union in 2 (13%), and nonunion in 1 of 15 (7%) fractures. There was one screw breakage and two axial dislocations. Conclusion: Sacroiliac CRPF of longitudinal fractures of the posterior pelvic ring is technically simple, minimally invasive, well localized, and stable. It should be done by an interventional/surgical team. CT is an excellent guiding modality. Closed reduction may be a problem and succeeds best when performed as early as possibl

Fluoroscopy-Based SurgicalNavigation versus Fluoroscopic Guidance to Control Guide WireInsertion for Osteosynthesis of Femoral NeckFractures: An ExperimentalStudy

Abstract : Background and Purpose: : Long fluoroscopic times and related radiation exposure are a universal concern when C-arm fluoroscopy is used to guide percutaneous procedures. Fluoroscopy-based surgical navigation has been proposed as an alternative guidance method requiring limited fluoroscopic times to achieve precision. The purpose of this experimental study was to compare fluoroscopy-based surgical navigation with C-arm fluoroscopy for guidance with respect to the precision achieved, the fluoroscopic time, and the resources needed. Material and Methods: : 114 guide wires were placed in 38 synthetic bone models using either C-arm fluoroscopy (group A) or fluoroscopy-based surgical navigation (group B) for guidance. Precision of guide wire placement was rated on the basis of an individual CT scan on all fracture models of both groups. The fluoroscopic time, the procedure time, and the number of attempts required to place the guide wires were documented as well. Results: : An average fluoroscopic time of 26 s was needed with C-arm fluoroscopy to place three guide wires compared with an average fluoroscopic time of 2 s that was needed when fluoroscopy-based surgical navigation was used for guidance (p < 0.0001). Precision of guide wire placement and procedure times required to place the guide wires did not differ significantly between both groups. The number of attempts required for correct placement was found significantly reduced with fluoroscopy-based surgical navigation when compared with fluoroscopic guidance (p = 0.04). Conclusion: : Fluoroscopic times to achieve precision are reduced with fluoroscopy-based surgical navigation compared with C-arm fluoroscopy. The impact of this new technique on minimally invasive, percutaneous procedures has to be evaluated in controlled prospective clinical studie

Radiographic quantification of dynamic hip screw migration

Purpose: This study aimed to propose a technique to quantify dynamic hip screw (DHS®) migration on serial anteroposterior (AP) radiographs by accounting for femoral rotation and flexion. Methods: Femoral rotation and flexion were estimated using radiographic projections of the DHS® plate thickness and length, respectively. The method accuracy was evaluated using a synthetic femur fixed with a DHS® and positioned at pre-defined rotation and flexion settings. Standardised measurements of DHS® migration were trigonometrically adjusted for femoral rotation and flexion, and compared with unadjusted estimates in 34 patients. Results: The mean difference between the estimated and true femoral rotation and flexion values was 1.3° (95% CI 0.9-1.7°) and −3.0° (95% CI - 4.2° to −1.9°), respectively. Adjusted measurements of DHS® migration were significantly larger than unadjusted measurements (p = 0.045). Conclusion: The presented method allows quantification of DHS® migration with adequate bias correction due to femoral rotation and flexion

Prevalence and incidence of iron deficiency in European community-dwelling older adults : An observational analysis of the DO-HEALTH trial

Background and aim Iron deficiency is associated with increased morbidity and mortality in older adults. However, data on its prevalence and incidence among older adults is limited. The aim of this study was to investigate the prevalence and incidence of iron deficiency in European community-dwelling older adults aged ≥ 70 years. Methods Secondary analysis of the DO-HEALTH trial, a 3-year clinical trial including 2157 community-dwelling adults aged ≥ 70 years from Austria, France, Germany, Portugal and Switzerland. Iron deficiency was defined as soluble transferrin receptor (sTfR) > 28.1 nmol/L. Prevalence and incidence rate (IR) of iron deficiency per 100 person-years were examined overall and stratified by sex, age group, and country. Sensitivity analysis for three commonly used definitions of iron deficiency (ferritin  1.5) were also performed. Results Out of 2157 participants, 2141 had sTfR measured at baseline (mean age 74.9 years; 61.5% women). The prevalence of iron deficiency at baseline was 26.8%, and did not differ by sex, but by age (35.6% in age group ≥ 80, 29.3% in age group 75–79, 23.2% in age group 70–74); P  1.5. Occurrences of iron deficiency were observed with IR per 100 person-years of 9.2 (95% CI 8.3–10.1) and did not significantly differ by sex or age group. The highest IR per 100 person-years was observed in Austria (20.8, 95% CI 16.1–26.9), the lowest in Germany (6.1, 95% CI 4.7–8.0). Regarding the other definitions of iron deficiency, the IR per 100 person-years was 4.5 (95% CI 4.0–4.9) for ferritin  1.5. Conclusions Iron deficiency is frequent among relatively healthy European older adults, with people aged ≥ 80 years and residence in Austria and Portugal associated with the highest risk

Injectable bone cement augmentation for the treatment of distal radius fractures : a review

Fractures of the distal radius often occur as a result of low-energy trauma and are frequently seen in osteoporotic patients. Many biomechanical studies and clinical case series have been carried out to investigate the effects on the fractured bones of different fixation methods such as cast immobilization, percutaneous pins, external fixators, or open reduction with internal fixation. In addition, the use of different bone cements as stand-alone solutions or as an adjunct to the aforementioned fixation methods is described as one possible way of increasing the performance of the fixation by reducing secondary dislocation of the fragments and allowing more intensive rehabilitation of the patients. This review aims to provide an overview of some of the main issues under discussion and a critical evaluation of the different treatments

Postoperative Betreuung nach operativer Frakturbehandlung

The postoperative management after open reduction and internal fixation (ORIF) of fractures is addressed with this article. The topics selected focus on topics that are of relevance for the family practitioner. Because of large differences in the treatment of adult - and geriatric fracture patients these two groups are separately looked at in Part 1 and Part 2 of the article. Fractures in children or fractures of the growing skeleton are not addressed. In the early postoperative phase, the fracture patient might seek for advice in case of complications, such as wound infection or complex regional pain syndrome (CRPS). After fracture healing, the decision on implant removal has to be made. Geriatric fracture patients mostly cannot return back home directly from the hospital. Instead they are transferred to a rehabilitation center. In these patients secondary fracture prevention should be in the focus of the family practitioner. This means osteoporosis diagnostics and treatment shall be initiated, if not done before. Another important task is to guarantee for compliance with the therapy once it is initiated