Jack Besjakov

A School Curriculum–Based Exercise Program Increases Bone Mineral Accrual and Bone Size in Prepubertal Girls: Two-Year Data From the Pediatric Osteoporosis Prevention (POP) Study†

This 2‐year prospective controlled exercise intervention trial in 99 girls at Tanner stage 1, evaluating a school curriculum–based training program on a population‐based level, showed that the annual gain in BMC, aBMD, and bone size was greater in the intervention group than in the controls.

Fractures of the Radial Head and Neck Treated with Radial Head Excision

BACKGROUND The reported long-term outcomes of the treatment of radial head and neck fractures with excision of the radial head have been mixed. The purpose of the present study was to evaluate the long-term outcomes of primary or delayed radial head excision for the treatment of these fractures. METHODS Sixty-one individuals (mean age, forty-four years) with thirty-nine Mason type-II, ten Mason type-III, and twelve Mason type-IV fractures were evaluated subjectively, objectively, and radiographically at a mean of eighteen years (range, eleven to thirty-three years) after treatment. Forty-three fractures were treated with primary radial head excision, and the remaining eighteen were treated with delayed radial head excision at a median of five months (range, one to 238 months) after the injury. RESULTS At the time of follow-up, twenty-eight individuals had no symptoms, twenty-seven had occasional elbow pain, and six had daily pain. Four individuals with daily pain had had a Mason type-IV fracture. The range of motion of the formerly injured upper extremities was slightly less than that of the uninjured upper extremities in terms of flexion (139 degrees +/- 11 degrees compared with 142 degrees +/- 8 degrees ), extension (-7 degrees +/- 12 degrees compared with -1 degrees +/- 6 degrees ), and supination (77 degrees +/- 20 degrees compared with 85 degrees +/- 10 degrees ) (all p < 0.01). A higher percentage of formerly injured elbows than uninjured elbows had cysts, sclerosis, and osteophytes (73% compared with 7%; p < 0.001), but none had a reduced joint space. No differences were found between the outcomes for individuals treated with a primary radial head excision and those for individuals treated with a delayed excision. CONCLUSIONS Following a displaced radial head or neck fracture, excision of the radial head often leads to a good or fair result. We found no differences in outcome between primary and delayed radial head excisions following a Mason type-II, III, or IV fracture. The outcomes are associated with the type of fracture, with Mason type-IV fractures having the worst results, rather than with the timing of the radial head excision (primary or delayed).

Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study.

BACKGROUND The purpose of this study was to evaluate the incidence and the long-term results of closed uncomplicated Mason type-II and III fractures in a defined population of adults. METHODS Seventy women and thirty men who were a mean of forty-seven years old when they sustained a fracture of the radial head or neck (a Mason type-II fracture in seventy-six patients and a Mason type-III fracture in twenty-four) were reexamined after a mean of nineteen years. Radiographic signs of degenerative changes of the elbow were recorded. The fracture had been treated with an elastic bandage or a collar and cuff sling with mobilization for forty-four individuals, with cast immobilization for thirty-four, with resection of the radial head in nineteen, with open reduction of the radial head in two, and with a collateral ligament repair in one. Secondary excision of the radial head was performed because of residual pain in nine patients, and a neurolysis of the ulnar nerve was performed in one patient. RESULTS Seventy-seven individuals had no symptoms in the injured elbow at the time of follow-up, twenty-one had occasional pain, and two had daily pain. The injured elbows had a slight flexion deficit compared with the uninjured elbows (mean and standard deviation, 138 degrees +/- 8 degrees compared with 140 degrees +/- 7 degrees ) as well as a small extension deficit (mean and standard deviation, -4 degrees +/- 8 degrees compared with -1 degrees +/- 6 degrees ) (p < 0.001 for both). The prevalence of degenerative changes was higher in the injured elbows than in the uninjured ones (76% compared with 16%, p < 0.001). CONCLUSIONS The results following uncomplicated Mason type-II and III fractures are predominantly favorable. A secondary radial head resection is usually effective for patients with an unfavorable outcome (predominantly long-standing pain). LEVELS OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Primary nonoperative treatment of moderately displaced two-part fractures of the radial head

BACKGROUND Moderately displaced two-fragment fractures of the radial head have been treated predominantly nonoperatively. Recently, however, open reduction and internal fixation has gradually gained interest, without clear evidence that initial nonoperative treatment leads to an unfavorable outcome. As a consequence, the purpose of the present study was to evaluate the long-term outcome after the initial nonoperative treatment of this type of fracture. METHODS Fifteen men and thirty-four women, with a mean age of forty-nine years at the time of the injury, were included in the study. All patients initially had been managed nonoperatively for a two-fragment fracture of the radial head that was displaced 2 to 5 mm and that included >/=30% of the joint surface (a Mason type-IIa fracture). Early mobilization had been used for twenty-seven patients, and cast immobilization for a mean of two weeks (range, one to four weeks) had been used for twenty-two. All patients were reevaluated with a questionnaire after a mean of nineteen years, and thirty-four also had a clinical and a radiographic evaluation. Six patients had had a delayed radial head excision because of an unsatisfactory primary outcome. RESULTS Forty of the forty-nine patients had no subjective complaints, eight were slightly impaired as the result of occasional elbow pain, and one had daily pain. Flexion was slightly impaired in the injured elbows as compared with the uninjured elbows (137 degrees +/- 8 degrees compared with 139 degrees +/- 7 degrees ), as was extension (-3 degrees +/- 7 degrees compared with 1 degrees +/- 5 degrees ) and supination (86 degrees +/- 7 degrees compared with 88 degrees +/- 4 degrees ) (p < 0.05 for all comparisons). The prevalence of degenerative changes on radiographs was higher for the injured elbows than for the uninjured elbows (82% [twenty-eight of thirty-four] compared with 21% [seven of thirty-four]; p < 0.01). CONCLUSIONS The initial nonoperative treatment of Mason type-IIa fractures of the radial head that are displaced by 2 to 5 mm is associated with a predominantly favorable outcome, especially if a delayed radial head excision is performed in the few cases in which the early outcome is unsatisfactory. LEVEL OF EVIDENCE Therapeutic Level IV.

Arthrodesis of the ankle secondary to replacement.

One hundred total ankle arthroplasties were performed in our department between 1974 and 1994, and of these, 21 have been reoperated on with arthrodesis due to septic or nonseptic failures after 6 months to 15 years (median 40 months). Immobilization using a Hoffman external fixator was the dominating method. The total ankles were of six different designs. Sixteen of the 21 patients suffered from rheumatoid arthritis. Four of the 21 ankles did not fuse whereas 17 did: 13 at the first attempt and 4 after repeat arthrodesis. At the time of the review, two patients had died. Of the remaining 15 patients whose ankles had fused, all but one were satisfied or somewhat satisfied with the result. Twelve of these 15 ankles rated excellent or good according to the Mazur and Kofoed scoring systems. We conclude that arthrodesis can be performed successfully after a failed ankle arthroplasty.

Cemented tibial component fixation performs better than cementless fixation: a randomized radiostereometric study comparing porous-coated, hydroxyapatite-coated and cemented tibial components over 5 years.

Background The question whether the tibial component of a total knee arthroplasty should be fixed to bone with or without bone cement has not yet been definitely answered. We studied movements between the tibial component and bone by radiostereometry (RSA) in total knee replacement (TKR) for 3 different types of fixation: cemented fixation (C-F), uncemented porous fixation (UC-F) and uncemented porous hydroxyapatite fixation (UCHA-F). Patients 116 patients with osteoarthrosis, who had 146 TKRs, were included in 2 randomized series. The first series included 86 unilateral TKRs stratified into 1 of the 3 types of fixation. The second series included 30 patients who had simultaneous bilateral TKR surgery, and who were stratified into 3 subgroups of pairwise comparisons of the 3 types of fixation. Results After 5 years 2 knees had been revised, neither of which were due to loosening. 1 UCHA-F knee in the unilateral series showed a large and continuous migration and a poor clinical result, and is a pending failure. The C-F knees rotated and migrated less than UC-F and UCHA-F knees over 5 years. UCHA-F migrated less than UC-F after 1 year. Interpretation Cementing of the tibial component offers more stable bone-implant contact for 5 years compared to uncemented fixation. When using uncemented components, however, there is evidence that augmenting a porous surface with hydroxyapatite may mean less motion between implant and bone after the initial postoperative year.

Long-Term Survival and Fracture Risk After Hip Fracture: A 22-Year Follow-Up in Women

Hip fracture is associated with high early mortality. Little is known about long‐term survival and subsequent fracture risk. The aim of this study was to evaluate survival and fracture risk after hip fracture in women at different ages. All women suffering a hip fracture during 1984–1985 in Malmö, Sweden, were identified (n = 766) and followed up to 22 yr or death. All new radiographic examinations related to musculoskeletal trauma with or without fracture were registered. Survival (mortality) and fracture was evaluated in 5‐yr age bands and in age groups (<75, 75–84, and ≥85 yr). Mean age was 79.6 ± 9.9 yr (range, 31.6–99.4 yr), with 42% between 75 and 85 yr of age. Overall 22‐yr survival was 6%: 79% at 1 yr, 48% at 5 yr, and 33% at 10 yr (i.e., population at risk). One‐year mortality was 7%, 21%, and 33% for <75, 75–84, and ≥85 yr of age, respectively, and 95% of those ≥85 yr were dead at 10 yr. Prior hip fracture did not affect age‐adjusted mortality (OR, 1.05; 95% CI, 0.756–1.20; p = 0.15). A total of 768 fractures were registered at 715 occasions in 342 women (45%; mean, 2.3 fractures/woman; range, 1–11 fractures/woman). Of the fracture occasions, 15% occurred within the first year, 27% within 2 yr, and 73% within 5 yr. The residual lifetime fracture risk was 45%, with a mortality‐adjusted increase to 86%. The 10‐yr fracture risk was 40%; with a mortality‐adjusted increased to 65%. In conclusion, almost one half of all women with a hip fracture suffer a new fracture during their remaining lifetime. Fracture risk is highly dependent on age and survival, emphasizing that preventive strategies need to be tailored to each age group specifically.

Exercise, bone mass and bone size in prepubertal boys: one-year data from the pediatric osteoporosis prevention study.

This non‐randomized prospective controlled study evaluates a daily school‐based exercise intervention program of 40 min/school day for 1 year in a population‐based cohort of 81 boys aged 7–9 years. Controls were 57 age‐matched boys assigned to the general school curriculum of 60 min/week. Bone mineral content (BMC; g) and areal bone mineral density (aBMD; g/cm2) were measured with dual X‐ray absorptiometry (DXA) of the total body, the third lumbar vertebra (L3) and the femoral neck (FN). Bone width for L3 and FN was calculated from the lumbar spine and hip scan. No differences between the groups were found at baseline in age, anthropometrics or bone parameters. The mean annual gain in L3 BMC was 5.9 percentage points higher (P<0.001), L3 aBMD a mean 2.1 percentage points higher (P=0.01) and L3 width a mean 2.3 percentage points higher (P=0.001) in the cases than in the controls. When all individuals were included in one cohort, the total duration of exercise including both school‐based and spare‐time training correlated with L3 BMC (r=0.26, P=0.003), L3 aBMD (r=0.18, P=0.04) and L3 width (r=0.24, P=0.006). The study suggests that exercise in pre‐pubertal boys influences the accrual of bone mineral and bone width and that a 1‐year school‐based exercise program confers skeletal benefits, at least in the lumbar spine.

Tibio-talocalcaneal arthrodesis as a primary proce dure using a retrograde intramedullary nail : A retrospective study of 26 patients with rheumatoid arthritis

Background Arthrodesis of the ankle joint using screws or external fixation is often a demanding procedure, notably in patients with rheumatoid arthritis. We investigated whether tibio-talocalcaneal arthrodesis with the use of an intramedullary nail is a safe and simple procedure. Patients and methods We retrospectively reviewed 25 ankles (25 patients) at median 3 (1–7) years after tibio-talocalcaneal arthrodesis because of rheumatoid arthritis. All had been operated on by retrograde insertion of a retrograde nail. 5 types of nail had been used. Complications, functional outcome scores, and patient satisfaction were determined and the radiographs evaluated for healing. Results All but 1 ankle had a radiographically healed arthrodesis. We recorded 3 deep infections, all healed—in 2 cases after extraction of the nail—and the arthrodesis healed in all 3 patients. The average functional scores at follow-up were high, considering that the patients suffered from rheumatoid arthritis. 23 patients were satisfied with the outcome. We found a correlation between the functional scores and the general activity of the disease expressed as a Health Assessment Questionnaire score. Interpretation In patients with rheumatoid arthritis, tibio-talocalcaneal arthrodesis with a retrograde intra-medullary nail results in a high rate of healing, a high rate of patient satisfaction, and relatively few complications.BACKGROUND Arthrodesis of the ankle joint using screws or external fixation is often a demanding procedure, notably in patients with rheumatoid arthritis. We investigated whether tibio-talocalcaneal arthrodesis with the use of an intramedullary nail is a safe and simple procedure. PATIENTS AND METHODS We retrospectively reviewed 25 ankles (25 patients) at median 3 (1-7) years after tibio-talocalcaneal arthrodesis because of rheumatoid arthritis. All had been operated on by retrograde insertion of a retrograde nail. 5 types of nail had been used. Complications, functional outcome scores, and patient satisfaction were determined and the radiographs evaluated for healing. RESULTS All but 1 ankle had a radiographically healed arthrodesis. We recorded 3 deep infections, all healed--in 2 cases after extraction of the nail--and the arthrodesis healed in all 3 patients. The average functional scores at follow-up were high, considering that the patients suffered from rheumatoid arthritis. 23 patients were satisfied with the outcome. We found a correlation between the functional scores and the general activity of the disease expressed as a Health Assessment Questionnaire score. INTERPRETATION In patients with rheumatoid arthritis, tibio-talocalcaneal arthrodesis with a retrograde intra-medullary nail results in a high rate of healing, a high rate of patient satisfaction, and relatively few complications.

Migration of the Charnley stem in rheumatoid arthritis and osteoarthritis. A roentgen stereophotogrammetric study

Migration of 65 Charnley stems implanted with modern cementing techniques was studied by roentgen stereophotogrammetry. There were 25 patients with rheumatoid arthritis (RA) and 40 with osteoarthritis (OA) followed up for two years. In 43 cases a bone sample for histomorphometric analysis was obtained from the femur during the operation. In 22 cases the mean subsidence of the prosthetic head was 0.40 mm and in 20 the mean posterior migration was 1.25 mm. There was no difference in migration between the two diagnostic groups (p = 0.8) after adjusting for variations in gender, age and weight. Male gender was associated with increased subsidence (p = 0.006). Histological examination showed that the RA series had more osteoid surface (p = 0.04), but neither this, nor any of the other histomorphometric variables, influenced migration. These results suggest that, unlike the acetabular socket, the cemented Charnley femoral component is equally secure in osteoarthritis and in rheumatoid arthritis, and that its initial fixation is not influenced by the quality of the local cancellous bone. Our results provide data with which the early performance of new prosthetic designs and fixation methods can be compared.