Mellick J. Chehade

Circulating RANKL is inversely related to RANKL mRNA levels in bone in osteoarthritic males

IntroductionThe relationship of circulating levels of receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG) with the expression of these molecules in bone has not been established. The objective of this study was to measure, in humans, the serum levels of RANKL and OPG, and the corresponding levels in bone of mRNA encoding these proteins.MethodsFasting blood samples were obtained on the day of surgery from patients presenting for hip replacement surgery for primary osteoarthritis (OA). Intraoperatively, samples of intertrochanteric trabecular bone were collected for analysis of OPG and RANKL mRNA, using real time RT-PCR. Samples were obtained from 40 patients (15 men with age range 50 to 79 years, and 25 women with age range 47 to 87 years). Serum total RANKL and free OPG levels were measured using ELISA.ResultsSerum OPG levels increased over the age range of this cohort. In the men RANKL mRNA levels were positively related to age, whereas serum RANKL levels were negatively related to age. Again, in the men serum RANKL levels were inversely related (r = -0.70, P = 0.007) to RANKL mRNA levels. Also in the male group, RANKL mRNA levels were associated with a number of indices of bone structure (bone volume fraction relative to bone tissue volume, specific surface of bone relative to bone tissue volume, and trabecular thickness), bone remodelling (eroded surface and osteoid surface), and biochemical markers of bone turnover (serum alkaline phosphatase and osteocalcin, and urinary deoxypyridinoline).ConclusionThis is the first report to show a relationship between serum RANKL and the expression of RANKL mRNA in bone.

The subcristal pelvic external fixator: technique, results, and rationale.

We report a new technique for pelvic external fixation that we have developed as an alternative to the anterosuperior (Slätis) and the anteroinferior (supra-acetabular) type pelvic external fixator configurations. The method principally differs from the other techniques by virtue of the subcristal positioning of the pins and offers advantages in terms of easier pin placement, less skin irritation, less pin tract infection and loosening, and less interference with hip flexion, while allowing dressing, sitting, and walking. Between 1992 and 2006, we successfully used subcristal pelvic external fixators as the definitive fixation device for 20 patients with pelvic ring disruptions. The only complications encountered were superficial pin tract infections in 4 patients (20%) who were successfully treated with wound care and antibiotics.

Weight-bearing-induced displacement and migration over time of fracture fragments following split depression fractures of the lateral tibial plateau: A CASE SERIES WITH RADIOSTEREOMETRIC ANALYSIS

We investigated the stability of seven Schatzker type II fractures of the lateral tibial plateau treated by subchondral screws and a buttress plate followed by immediate partial weight-bearing. In order to assess the stability of the fracture, weight-bearing inducible displacements of the fracture fragments and their migration over a one-year period were measured by differentially loaded radiostereometric analysis and standard radiostereometric analysis, respectively. The mean inducible craniocaudal fracture fragment displacements measured -0.30 mm (-0.73 to 0.02) at two weeks and 0.00 mm (-0.12 to 0.15) at 52 weeks. All inducible displacements were elastic in nature under all loads at each examination during follow-up. At one year, the mean craniocaudal migration of the fracture fragments was -0.34 mm (-1.64 to 1.51). Using radiostereometric methods, this case series has shown that in the Schatzker type II fractures investigated, internal fixation with subchondral screws and a buttress plate provided adequate stability to allow immediate post-operative partial weight-bearing, without harmful consequences.

Surgical Education and Training in Australia and New Zealand

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate’s specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees’ progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.

Ensuring quality of care through implementation of a competency‐based musculoskeletal education framework

Introduction As the Bone and Joint Decade 2000–2010 draws to a close, it is timely to review its impact on musculoskeletal medical education, which was clearly identified by the World Health Organization as a key factor contributing to less than optimal musculoskeletal care (1). The increasing burden of musculoskeletal disorders (including chronic bone and arthritic conditions) and the uncertain quality of care provided (2,3) has meant that there is a growing imperative to ensure that optimal, evidence-based, and cost-effective treatment is being provided to people with musculoskeletal disorders by medical practitioners (4). In 2004, the Bone and Joint Decade established the International Education Task Force and Undergraduate Curriculum Development Group to develop strategies to address the issue of insufficient and/or inadequate medical education, particularly in the areas of basic and clinical science (5,6). They released global core recommendations for a musculoskeletal undergraduate medical curriculum, which were designed to enable the development of a locally applicable musculoskeletal curriculum that was able to meet national guidelines and be reflective of local needs, priorities, and opportunities (5). Despite the release of the global core recommendations for a musculoskeletal undergraduate medical curriculum, in 2007 Woolfe and Akesson identified that the poor quality of medical education and a lack of coordination between the different disciplines and professional specialties working in musculoskeletal health care have meant that people do not receive the best practice treatment (6). Furthermore, in 2007 Day et al demonstrated significant deficiencies in the knowledge of chronic arthritic conditions in graduating medical students (2). Deficiencies in undergraduate education in musculoskeletal science have also been identified by medical students and graduates in studies conducted in a number of countries (2,7–10), and there is an obvious requirement for clinically relevant, evidence-based curriculum design that integrates traditional scientific and clinical disciplines. The Australian Musculoskeletal Education Collaboration (AMSEC) project began in Australia in 2005, with the aim of developing nationally agreed musculoskeletal core competencies (based on the Bone and Joint Decade curriculum recommendations) for implementation in all Australian medical schools. Initiated by the Australian Orthopaedic Association and funded by the Australian government, this project has succeeded in bringing together all key musculoskeletal specialist and representative organizations in a national, multidisciplinary education collaboration (including orthopedics, rheumatology, general practice, rehabilitation medicine, sports medicine, endocrinology, neurology, geriatrics, radiology, pediatrics, nursing, and interested allied health professions). While the Bone and Joint Decade recommendations formed the base from which the Australian competencies were developed, it was also vital that specific Australian standards and requirements were considered. The AMSEC competencies were therefore also related directly to the Australian Medical Council standards and principles and The National Patient Safety Framework (11,12). The purpose of this article is to outline the relevance of a competency-based approach to musculoskeletal education and to describe the development of theAMSECmusculoskeletal core competencies. Furthermore, we demonstrate the significance of the AMSEC competencies and the competency education process for optimal education in musculoskeletal medicine relative to chronic rheumatic disease.

Surgical anatomy for pelvic external fixation

Pelvic external fixators have a high rate of reported complications, most of which relate to pin placement. In this descriptive study, we analyzed the morphology of the ilium in cadaveric specimens and compared these with the measures obtained from normal human pelvic computer tomograph scans, and how these related to each of the three basic configurations of pin positioning for the external fixation of a pelvis: anterosuperior (Slätis type), anteroinferior (supra‐acetabular), and subcristal. The irregular shape and size of the iliac wing and the abdominal wall overlying the pins insertion site could hinder accurate placement of anterosuperior pins. Potential disadvantages of the use of anteroinferior pins was found related to the deep location of the anterior inferior iliac spine, interference with the hip flexion area, risk of hip joint penetration, and the variable obliquity of the ilium. As subcristal pins are positioned between two superficial bony landmarks of the iliac crest, our findings suggest that they are more likely to have a correct placement and avoid complications. Clin. Anat. 21:674–682, 2008.

The accuracy and precision of radiostereometric analysis in monitoring tibial plateau fractures

Background and purpose The application of radiostereometric analysis (RSA) to monitor stability of tibial plateau fractures during healing is both limited and yet to be validated. We therefore evaluated the accuracy and precision of RSA in a tibial plateau fracture model. Methods Combinations of 3, 6, and 9 markers in a lateral condyle fracture were evaluated with reference to 6 proximal tibial arrangements. Translation and rotation accuracy was assessed with displacement-controlled stages, while precision was assessed with dynamic double examinations. A comparison of error according to marker number and arrangement was completed with 2-way ANOVA models. Results The results were improved using more tantalum markers in each segment. In the fracture fragment, marker scatter in all axes was achieved by a circumferential arrangement (medial, anterior, and lateral) of the tantalum markers above the fixation devices. Markers placed on either side of the tibial tuberosity and in the medial aspect of the fracture split represented the proximal tibial reference segment best. Using 6 markers with this distribution in each segment, the translation accuracy (root mean square error) was less than 37 μm in all axes. The precision (95% confidence interval) was less than ± 16 μm in all axes in vitro. Rotation, tested around the x-axis, had an accuracy of less than 0.123° and a precision of ± 0.024°. Interpretation RSA is highly accurate and precise in the assessment of lateral tibial plateau fracture fragment movement. The validation of our centers RSA system provides evidence to support future clinical RSA fracture studies.

Common Pitfalls in Syndesmotic Rupture Management: A Clinical Audit

Background: Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes. Materials and Methods: This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients’ notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period. Results: There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient. Conclusions: The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically. Level of Evidence: Level III, retrospective comparative series.

Current perspectives in the treatment of periprosthetic upper extremity fractures

Periprosthetic factures around the shoulder and elbow are rare and are often difficult to treat. Treatment options depend on the stability of the prosthesis, the location of the fracture, and the bone quality. The basic principles of treatment are that loose or unstable prostheses are removed and revised to a longer prosthesis with the possible addition of cortical struts and/or plate and screws. If the prosthesis is stable, nonoperative measures may be tried initially. In cases of nonunion, surgical treatment is recommended. This article describes the current literature related to periprosthetic fractures around the shoulder and the elbow.

Influence of fracture stability on early patient mortality and reoperation after pertrochanteric and intertrochanteric hip fractures

Objectives: To determine the influence of fracture stability on early patient mortality and complications requiring reoperation after trochanteric hip fracture. Design: Prospective consecutive cohort study. Setting: The orthopaedic unit of a public teaching hospital. Participants: Seven hundred twenty-eight patients with 743 consecutive stable (n = 446) pertrochanteric and unstable (n = 297) pertrochanteric or intertrochanteric fractures (median age: 84 years, 71% females) resulting from a low-impact injury and surgically managed. Mean follow-up of surviving patients was 4 years (range: 2–6 years). Intervention: Fracture fixation by dynamic hip screw extramedullary device or intramedullary nail (Austofix or Gamma3) based on surgeon preference. Main Outcome Measures: Mortality within 6 and 12 months and surgical complications requiring device reoperation within 12 months of surgery (multivariate logistic regression and Kaplan–Meier survival analyses). Results: Patients with unstable fractures were at 1.61 times (95% confidence interval: 1.18–2.21, P = 0.003) and 1.37 times (95% confidence interval: 1.02–1.83, P = 0.037) greater odds of dying within 6 and 12 months, respectively, than those with stable fractures. Older age, male gender, higher American Society of Anesthesiologists classification, in residential care, and inpatient-reported medical complications were also independent risk factors for early mortality. Increasing fracture instability and fixation using the Austofix nail were associated with early device reoperation. Comparable results were reported for the dynamic hip screw and Gamma3 nail, although the Gamma3 nail may offer advantages for more complex unstable fractures. Conclusions: Fracture instability influences early mortality after surgical fixation of trochanteric hip fracture. The Austofix double lag screw device had suboptimal results. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.