Eugenio Chiarello

Atypical femoral fractures.

Bisphosphonates (BPs) represent the most widely used therapy for osteoporosis. Recently, a relationship between long-term treatment with BPs and a subset of atypical femoral fractures (AFFs) from below the lesser trochanter to the sovracondilar line has been described. Many etiopathogenetic theories have been invoked to explain AFFs: reduced bone turnover and increased osteoblast bone apposition with accumulation of microdamage and decreased bone toughness with subsequent increased risk of micro-cracks and duration fractures, collagen fiber cross-linking and vascularization impairment. Based on published studies, a task force of the American Society for Bone and Mineral Research has redacted the diagnostic criteria of AFFs by classifying them according to their major and minor criteria. The treatment for displaced AFFs is osteosynthesis, but there is a lack of evidence for undisplaced AFFs and the duration of fracture treatment. BPs have a proven efficacy in osteoporotic fracture reduction as well as in the treatment of other bone diseases caused by the downregulation of osteoclast activity. BPs have an excellent benefit-to-risk ratio; however, minor adverse events, such as AFFs, occur in a variable percentage of patients treated over a long period of time.

Autograft, allograft and bone substitutes in reconstructive orthopedic surgery

Reconstruction of bone defects is a challenge for all orthopedic surgeons worldwide; to overcome this problem there are different options: the use of autografts, allografts and bone substitutes (BSs) to enhance and accelerate bone repair. Autografts have excellent biological properties but are associated with morbidity of the donor site and are restricted in volume. Allografts are available in adequate quantity but concerns still remain about the risk of infections, moreover they do not have osteogenetic properties. Bone substitutes have different indications and are very attractive for orthopedic surgeons. The present paper briefly reviews the advantages and disadvantages of autografts, allografts and BSs for bone reconstruction.

Viscosupplementation for grade II osteoarthritis of the ankle: a prospective study at 18 months’ follow-up

BackgroundViscosupplementation, with hyaluronan derivates injected into the intra-space of osteoarthritic joints, is now widely used for the treatment of knee osteoarthritis. This study evaluates the results in terms of pain and disability of intra-articular injections of hyaluronan derivates into the ankle joint in patients suffering from grade II primary or secondary osteoarthritis of the ankle.MethodsTwenty-one patients with a painful ankle and radiographic evidence of grade II osteoarthritis had three weekly intra-articular injections of 2 ml of hylan G-F 20 (10 mg/ml) into the ankle joint. The primary clinical outcome measurement was the ankle osteoarthritis score (AOS) at the baseline, and at 6, 12 and 18 months.ResultsSignificant improvement of the AOS from baseline was seen after 6 months (p=0.0001). This improvement was maintained over time with no further changes at 12- and 18-month follow-ups. Regarding pain, the AOS improved over time from the baseline to the 18-month follow up and became statistically significant at the 12- and 18-month follow-ups (p<0.05).

Do Ion Levels in Metal-on-metal Hip Resurfacing Differ From Those in Metal-on-metal THA at Long-term Followup?

BackgroundMetal-on-metal hip resurfacing arthroplasty (MOM HR) has become an established alternative to traditional metal-on-metal total hip arthroplasty (MOM THA) for younger, more active patients. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting systemic metal ion distribution.Questions/purposesWe therefore asked whether (1) serum ion concentrations in patients with MOM HR at the time of long-term followup were higher than concentrations in a control population with no hip implants; (2) the ion concentrations in patients with MOM HR were different from those in patients with MOM THA; and (3) sex would influence ion levels with regard to implant type.MethodsThe MOM HR and MOM THA groups consisted of 25 patients (evaluated at a minimum of 96 months) and 16 patients (evaluated at a minimum of 106 months), respectively. Forty-eight healthy donors were recruited for reference values. Cobalt, chromium, nickel, and molybdenum were measured by furnace graphite atomic absorption spectrophotometry.ResultsIon concentrations of cobalt, chromium, and molybdenum in MOM HR were higher than in controls. Chromium and cobalt release were higher in MOM HR than in MOM THA. The sex-based analysis showed the difference was because women had higher concentrations in the MOM HR group than in the MOM THA group, whereas there was no difference between the men in the two groups.ConclusionsIn MOM HR, high metal ion release persists for the long term. Consequently, it is important to implement strict biomonitoring for patients who have received these implants. The sustained high levels of chromium in females within the MOM HR group are concerning and merits strong consideration when choosing implants in this patient group.Level of EvidenceLevel III, therapeutic study. See the Instructions for Authors online for a complete description of level of evidence.

Subcutaneous injection of diclofenac for the treatment of pain following minor orthopedic surgery (DIRECT study): a randomized trial.

Parenteral diclofenac is frequently used for analgesia following minor orthopedic interventions. Currently available diclofenac formulations are for intramuscular (IM) or intravenous injection. A new 1 mL volume formulation of diclofenac containing hydroxypropyl‐β‐cyclodextrin (HPβCD) allows both SC and IM administration. The objective of this open‐label, randomized, parallel group, active‐controlled study was to assess the safety and efficacy of 75 mg diclofenac HPβCD, administered SC or IM, compared with IM Voltaren® 75 mg in inpatients undergoing minor orthopedic surgeries with moderate‐to‐severe postoperative pain.

Electromagnetic bone growth stimulation in patients with femoral neck fractures treated with screws: prospective randomized double-blind study

BackgroundTo determine the effect of pulsed electro-magnetic fields (PEMF) on time to healing, onset of osteonecrosis of the femoral head and pain in patients with intracapsular femoral neck fracture. MethodsSeventy-seven patients had their fracture fixed with cannulated screws. After surgery, patients were randomized to receive either an active or placebo PEMF stimulator and were instructed to use it for at least 8 h per day for 90 days. Patient compliance was monitored by a clock inside the stimulator. The active stimulators generated PEMF at 75 Hz, 1.3 m/s impulse length, 2 mTesla peak magnetic field. Fracture healing and onset of osteonecrosis were evaluated on radiographs obtained 30, 60 and 90 days and then at 6, 12 and 24 months after surgery. During the first three visits pain was assessed by a visual analog scale (VAS). ResultsFracture healing was achieved in 94% of active compliant patients compared with 69% of the placebo group. The percentage of osteonecrosis was higher in the placebo group but does not reach statistical significance (37% vs. 49%). Pain assessment with the VAS evidenced significantly lower levels in the compliant active group compared with the placebo group at all visits. No differences were observed between patients who were noncompliant with the PEMF protocol and the placebo group. ConclusionsThis study shows that stimulation with PEMF accelerates fracture healing and reduces pain, leading to a better quality of life in patients suffering femoral neck fractures.

Ankle fractures in elderly patients

The incidence of ankle fractures (AFs) in the elderly is rising due to the increase in life expectancy. Rather than directly related to osteoporosis, AFs are a predictor of osteoporotic fractures in other sites. In women AFs are associated with weight and BMI. AFs are difficult to categorize; therapeutic options are non-operative treatment with plaster casts or surgical treatment with Kirschner’s wires, plates and screws. The choice of treatment should be based not only on the fracture type but also on the local and general comorbidity of the patient. Considering the new evidence that postmenopausal women with AFs have disrupted microarchitecture and decreased stiffness of the bone compared with women with no fracture history, in our opinion low-trauma AFs should be considered in a similar way to the other classical osteoporotic fractures.

How Do Metal Ion Levels Change over Time in Hip Resurfacing Patients? A Cohort Study

Metal-on-metal hip resurfacing (MOM-HR) is offered as an alternative to traditional hip arthroplasty for young, active adults with advanced osteoarthritis. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting increase in metal ion levels. We evaluated three cohorts of patients with Birmingham hip resurfacing (BHR) at an average follow-up of 2, 5, and 9 years. We asked whether there would be differences in ion levels between the cohorts and inside the gender. Nineteen patients were prospectively analyzed. The correlation with clinical-radiographic data was also performed. Chromium, cobalt, nickel, and molybdenum concentrations were measured by atomic absorption spectrophotometry. Chromium and cobalt levels demonstrated a tendency to decrease over time. Such tendency was present only in females. An inverse correlation between chromium, implant size, and Harris hip score was present at short term; it disappeared over time together with the decreased ion levels. The prospective analysis showed that, although metal ion levels remained fairly constant within each patient, there was a relatively large variation between subjects, so mean data in this scenario must be interpreted with caution. The chronic high exposure should be carefully considered during implant selection, particularly in young subjects, and a stricter monitoring is mandatory.

Distal Humeral Fractures in Elderly Patients: Synthesis or Prosthesis

Distal humeral fractures in elderly patients represent a challenge; in literature there is still a debate about the best treatment.

The importance of rehabilitation after lower limb fractures in elderly osteoporotic patients

Improving rehabilitation strategies after lower limb fractures among elderly patients is an urgent public health challenge due to the increasing proportion of older population and therefore the raised number of falls and fractures. Due to their strategic positioning, physiatrists should aim not only to improve functional outcomes after acute fracture treatment but also to address the underlying osteoporotic condition in order to prevent the devastating socioeconomic consequences of osteoporotic fractures.