An Sermon

What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature

IntroductionOsteoarthritis (OA) is a disease of the synovial joints and is the most common cause of chronic pain in the elderly. One of the treatment modalities for OA of the hip is viscosupplementation (VS). Today there are several different formulations of viscosupplements produced by different manufactures of different molecular weights. The objective of this review is to asses the efficacy of VS treatment of hip OA osteoarthritis in the current literature.Material and methodsThe following databases were searched: Medline (period 1966 to November 2006), Cochrane Database of Systematic Reviews (1988 to November 2006), Cochrane Clinical Trial Register (1988 to November 2006), Database of Abstracts on Reviews and Effectiveness, Current Controlled Trials, National Research Register and Embase (January 1988 to November 2006). The search terms [osteoarthritis, hip (joint), viscosupplementation, hyaluronic acid, hyaluronan, sodium hyaluronate and trade names] were applied to identify all studies relating to the use of VS therapy for OA of the hip joint.ResultsSixteen articles concerning the efficacy of a total of 509 patients undergoing VS treatment for hip OA were included. Twelve European studies, three Turkish studies and one American study with Levels of Evidence ranging from I to IV evaluated the following products: Hylan G-F 20, Hyalgan®, Ostenil®, Durolane®, Fermatron® and Orthovisc®. Heterogeneity of included studies did not allow pooled analysis of data.DiscussionDespite the relatively low Level of Evidence of the included studies, VS performed under fluoroscopic or ultrasound guidance seems an effective treatment and may be an alternative treatment of hip OA. Intra-articular injection of (derivatives of) HA into the hip joint appears to be safe and well tolerated. However, VS cannot be recommended as standard therapy in hip OA for wider populations, and therefore the indications remain a highly individualised matter.

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission.

Potential of polymethylmethacrylate cement-augmented helical proximal femoral nail antirotation blades to improve implant stability--a biomechanical investigation in human cadaveric femoral heads.

Background: Cement augmentation may improve fixation stability and reduce cut-out rate in the treatment of intertrochanteric hip fractures. The aim of this study was to compare the number of cycles to failure of polymethylmethacrylate (PMMA)-augmented helical blades with nonaugmented ones in human cadaveric femoral heads. Methods: Six pairs of cadaveric femoral heads were instrumented with a perforated proximal femoral nail antirotation blade. Within each pair, one blade was augmented using 3 mL of PMMA. All specimens underwent cyclic axial loading under physiologic conditions. Starting at 1,000 N, the load was monotonically increased by 0.1 N/cycle until construct failure occurred. To monitor the migration of the blade, anteroposterior radiographs were taken at 250 cycle increments. Nonparametric test statistics were done to calculate correlations and identify differences between study groups. Results: Inducing failure required a significantly higher number of cycles in the augmented group (p = 0.028). Bone mineral density was significantly related with the number of cycles to failure in nonaugmented specimens (p < 0.001, R2 = 0.97), but not in the augmented group (p = 0.91, R2 = 0.34). Conclusion: Implant augmentation with small amounts of PMMA enhances the cut-out resistance in proximal femoral fractures. Especially in osteoporotic bone, the procedure may improve patient care.

Biomechanical evaluation of bone-cement augmented Proximal Femoral Nail Antirotation blades in a polyurethane foam model with low density

BACKGROUND Helically shaped cephalic implants have proven their benefit to provide an improved stabilization of unstable hip fractures. However, cut out ratios up to 3.6% still occur. This in vitro study evaluated the biomechanical performance of a novel cement augmentation technique of the Proximal Femoral Nail Antirotation in surrogate femora. METHODS Four study groups were formed out of 24 polyurethane foam specimens with low density. Proximal Femoral Nail Antirotation blades were implanted, either non-augmented, or augmented using 3ml of injectable Polymethylmethacrylate bone-cement. The influence of implant mal-positioning was investigated by placing the blade either centered in the femoral head or off-centric in an anteroposterior direction. All specimens underwent cyclic loading under physiological conditions. Starting at 1000 N, the load was monotonically increased by 0.1N/cycle until construct failure. Movement of the head was identified by means of optical motion tracking. Non-parametric test statistics were carried out on the cycles to failure, to compare between study groups. FINDINGS Compared to control samples; augmented samples showed a significantly increased number of cycles to failure (P=0.012). In the groups with centric position of the Proximal Femoral Nail Antirotation blade, cement augmentation led to an increase in loading cycles of 225%. In the groups with off-centric positioning of the blade, this difference was even more accentuated (933%). INTERPRETATION Cement augmentation of the Proximal Femoral Nail Antirotation blade with small amounts of bone-cement for treatment of osteoporotic hip fractures clearly enhances fixation stability and carries high potential for clinical application.

Once-yearly zoledronic acid in older men compared with women with recent hip fracture

To assess the efficacy of once‐yearly zoledronic acid (ZOL) 5 mg in increasing bone mineral density (BMD) in men with a recent hip fracture participating in the Health Outcomes and Reduced Incidence with Zoledronic Acid Once‐ Yearly Recurrent Fracture Trial and to compare the efficacy with that in women from the same study.

Individual risk factors for deep infection and compromised fracture healing after intramedullary nailing of tibial shaft fractures: A single centre experience of 480 patients

INTRODUCTION Despite modern advances in the treatment of tibial shaft fractures, complications including nonunion, malunion, and infection remain relatively frequent. A better understanding of these injuries and its complications could lead to prevention rather than treatment strategies. A retrospective study was performed to identify risk factors for deep infection and compromised fracture healing after intramedullary nailing (IMN) of tibial shaft fractures. MATERIALS AND METHODS Between January 2000 and January 2012, 480 consecutive patients with 486 tibial shaft fractures were enrolled in the study. Statistical analysis was performed to determine predictors of deep infection and compromised fracture healing. Compromised fracture healing was subdivided in delayed union and nonunion. The following independent variables were selected for analysis: age, sex, smoking, obesity, diabetes, American Society of Anaesthesiologists (ASA) classification, polytrauma, fracture type, open fractures, Gustilo type, primary external fixation (EF), time to nailing (TTN) and reaming. As primary statistical evaluation we performed a univariate analysis, followed by a multiple logistic regression model. RESULTS Univariate regression analysis revealed similar risk factors for delayed union and nonunion, including fracture type, open fractures and Gustilo type. Factors affecting the occurrence of deep infection in this model were primary EF, a prolonged TTN, open fractures and Gustilo type. Multiple logistic regression analysis revealed polytrauma as the single risk factor for nonunion. With respect to delayed union, no risk factors could be identified. In the same statistical model, deep infection was correlated with primary EF. CONCLUSIONS The purpose of this study was to evaluate risk factors of poor outcome after IMN of tibial shaft fractures. The univariate regression analysis showed that the nature of complications after tibial shaft nailing could be multifactorial. This was not confirmed in a multiple logistic regression model, which only revealed polytrauma and primary EF as risk factors for nonunion and deep infection, respectively. Future strategies should focus on prevention in high-risk populations such as polytrauma patients treated with EF.

From unstable internal fixation to biological osteosynthesis. A historical overview of operative fracture treatment.

Abstract The first techniques of operative fracture treatment were developed in the 19th century. In fact, these methods only consisted of an open reduction of the fracture followed by a usually very unstable fixation. This method gave rise to the combination of the disadvantages of the conservative and the operative fracture treatment: the fracture had to be opened with a real risk for (sometimes lethal) infection, the bone healing was disturbed, there was muscular atrophy and joint stiffness. The successes were very rare and catastrophes were often seen. Küntscher’s endomedullary rods can be considered as the first useful implants in the treatment of diaphyseal fractures. Reaming of the medullary canal and the development of interlocking nails have enlarged the indications for intramedullary nailing. The classic Dynamic Compression Plates from the seventies were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates and reamed nails disturbed the vascularisation of the bone fragments, leading to a high infection rate (particularly in open fractures) and delayed union (particularly after plate and screw fixation). These insights lead to the development of the “biological osteosynthesis”: a terminology introduced to indicate a new type of osteosynthesis leading to a sufficiently stable fixation of the bone fragments allowing early mobilisation, but without major disturbance of the vascularisation. The unreamed nail can also be considered as a biological osteosyn-thesis and in a lot of cases it is the implant of choice for tibial and femoral shaft fractures, especially in polytrauma patients. Finally, some new devices contributing to the principles of biological osteosynthesis like locking plates and the LIS-System are gaining popularity.

Limited V-shaped cement augmentation of the proximal femur to prevent secondary hip fractures.

Patients with a femoral fracture due to osteoporosis are at high risk of sustaining a secondary fracture on the contralateral side. A prophylactic mechanical reinforcement of the contralateral side during operation of the initial fracture could be of interest for such patients. This biomechanical in vitro study investigates the potential of a limited V-shaped bone cement augmentation to prevent secondary hip fractures by targeting the areas of the proximal femur with the highest stresses during a fall. Five pairs of human cadaveric proximal femora were tested in a configuration simulating a fall on the greater trochanter. The femoral neck of one specimen of each pair was augmented with 8–14 ml polymethylmethacrylate from the lateral cortex towards inferior and superior, spanning a V-shaped cement pattern. Clinical relevant fractures were generated with a 45 kg mass in controlled free fall. Load-displacement data were recorded and energy to fracture, fracture load, yield load and stiffness were statistically evaluated. Augmented samples absorbed 124% more energy until fracture compared to their controls (p = 0.043). No significant differences were found between the two groups for fracture load (p = 0.5), yield load (p = 0.35) and stiffness (p = 0.5). Biomechanically, a limited V-shaped prophylactic cement augmentation carries potential to prevent secondary hip fractures indicated by increased energy absorption until fracture. Further investigations are necessary to minimize interference with the biology and to maximize the mechanical benefit of prophylactic augmentation.

Trans-iliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum

Background: Osteoporosis is an increasing problem attributed to the greater longevity of the population and the incidence of fractures related to osteoporosis. The presence of osteoporotic bone, comorbidities, and functional status of the patient require adequate solutions to improve the clinical outcome of sacral insufficiency fractures. Conservative treatment by means of prolonged bed rest and analgesics are associated with increased risks and complications. A sacroplasty significantly improves the functional outcome. We describe the trans-iliac-sacral-iliac-bar (TISIB) procedure and our clinical experience to treat insufficiency fractures of the sacrum. Materials and Methods: The records of 19 consecutive patients with a mean age of 71.7 years (range: 57-82 years) who had been managed with a TISIB procedure from 2005 till 2007 were reviewed retrospectively. There were 15 females and 4 males. Predisposing factors for sacral insufficiency fractures were osteoporosis (n = 12, 63%), radiotherapy (n = 6, 32%), and rheumatoid arthritis (n =1). Diagnosis with a mean delay of 3.7 months was mainly made by CT. All patients were preoperatively and at follow-up assessed by means of the visual analogue score (VAS), analgesic consumption, and the ability to perform activities of daily living (ADLs) using a 5-point pain scale: 1, without pain; 2, mild pain; 3, moderate pain; 4, severe pain and, 5 unable to perform ADLs because of pain. Results: The average duration of postoperative follow-up was 9 months (range: 3–24.5 months). No neurological complications occurred during the surgery. A postoperative radiographic study showed a well-positioned bar in every case. The mean VAS improved 44.7 mm (preoperative: 67.8; at follow-up: 23.2). Fifteen patients (79%) consumed narcotic analgesics before surgery, and only one (5%) at follow-up; two patients (10%) consumed NSAIDS before surgery and three (15%) after. Two patients (10%) consumed minor analgesics before, and 11 (58%) after the procedure. Finally, four patients (21%) were not taking any analgesics at follow-up. Before surgery, 9 patients (47%) were able to perform ADLs with a pain score of 4; 6 (32%) with a score of 3, and 4 (21%) a score of 2. At follow-up 1 (5%) did have a score of 4; 1 (5%) a score of 3, 8 (42%) a score of 2 and 9 (47%) a pain score of 1. Conclusion: A TISIB procedure relies on the principles of fracture treatment: fracture stabilisation and compression. The incapacitating problem of an insufficiency fracture of the sacrum can be elegantly solved by means of this minimally invasive procedure. A near-immediate improvement is noticed when looking at the VAS score, analgesics consumption, and the ability to perform ADLs.

Intramedullary fixation of proximal humerus fractures: do locking bolts endanger the axillary nerve or the ascending branch of the anterior circumflex artery? A cadaveric study

BackgroundProximal humerus fractures are one of the most common fractures. Intramedullary locked nailing is becoming a popular alternative treatment, especially for easier fracture patterns. Although axillary nerve injury has been reported, no study has compared the safety of the proximal locking options relative to the axillary nerve and the ascending branch of the anterior circumflex artery.MethodSix different commercially available proximal humeral nails were implanted in 30 shoulders of 18 cadavers. After fluoroscopically guided implantation the shoulders were carefully dissected and the distance between the locking screws, the axillary nerve and the ascending branch of the anterior circumflex artery was measured.ResultsThe course of the axillary nerve varies. A mean distance of 55.8 mm (SD = 5.3) between the lateral edge of the acromions and the axillary nerve at the middle of the humerus in a neutrally rotated position was observed. The minimum distance was 43.4 mm, the maximum 63.9 mm.Bent nails with oblique head interlocking bolts appeared to be the most dangerous in relation to the axillary nerve. The two designs featuring such a bend and oblique bolt showed a mean distance of the locking screw to the axillary nerve of 1 mm and 2.7 mm respectively Sirus (Zimmer®) and (Stryker®) T2 PHN (Proximal Humeral Nail)).Regarding the ascending branch of the anterior circumflex artery, there was no difference between the nails which have an anteroposterior locking option.ConclusionIt is of great importance for surgeons treating proximal humerus fractures to understand the relative risk of any procedure they perform. Since the designs of different nailing systems risk damaging the axillary nerve and ascending branch, blunt dissection, the use of protection sleeves during drilling and screw insertion, and individual risk evaluation prior to the use of a proximal humeral nail are advocated.