Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC).

BACKGROUND: Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS). METHODS: A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate. RESULTS: 159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091. CONCLUSIONS: The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.

Long-term results of acetabular reconstruction using irradiated allograft bone.

AIMS: The management of acetabular defects at the time of revision hip arthroplasty surgery is a challenge. This study presents the results of a long-term follow-up study of the use of irradiated allograft bone in acetabular reconstruction. PATIENTS AND METHODS: Between 1990 and 2000, 123 hips in 110 patients underwent acetabular reconstruction for aseptic loosening, using impaction bone grafting with frozen, irradiated, and morsellized femoral heads and a cemented acetabular component. A total of 55 men and 55 women with a mean age of 64.3 years (26 to 97) at the time of revision surgery are included in this study. RESULTS: At a mean follow-up of 16.9 years, there had been 23 revisions (18.7%), including ten for infection, eight for aseptic loosening, and three for dislocation. Of the 66 surviving hips (58 patients) that could be reassessed, 50 hips (42 patients; 75.6%) were still functioning satisfactorily. Union of the graft had occurred in all hips with a surviving implant. Survival analysis for all indications was 80.6% at 15 years (55 patients at risk, 95% confidence interval (CI) 71.1 to 87.2) and 73.7% at 20 years (eight patients at risk, 95% CI 61.6 to 82.5). CONCLUSION: Acetabular reconstruction using frozen, irradiated, and morsellized allograft bone and a cemented acetabular component is an effective method of treatment. It gives satisfactory long-term results and is comparable to other types of reconstruction. Cite this article: Bone Joint J 2018;100-B:1449-54.

The cement spacer with multiple indentations: increasing antibiotic elution using a cement spacer 'teabag'.

We investigated whether the indentation of bone cement spacers used in revision of infected joint arthroplasty with a MacDonald dissector increased the elution of antibiotic in vitro. A total of 24 cement discs containing either 0.17 g (0.88% w/w), 0.25 g (1.41% w/w), or 0.33 g (1.75% w/w) gentamicin of constant size were made. Of these, 12 were indented with the dissector. Each disc was immersed in ammonium acetate buffer in a sealed container, and fluid from each container was sampled at zero, one, three, six, 24, 48 and 72 hours and at one, and two weeks. The concentration of gentamicin in the fluid was analysed using high performance liquid chromatography mass spectrometry. The fluid sampled at 72 hours from the indented discs containing 0.17 g gentamicin (0.88% w/w) contained a mean of 113 mcg/ml (90.12 to 143.5) compared with 44.5 mcg/ml (44.02 to 44.90) in the fluid sampled from the plain discs (p = 0.012). In discs containing 0.33 g gentamicin (1.75% w/w), the concentration eluted from the indented discs at 72 hours was a mean of 316 mcg/ml (223 to 421) compared with a mean of 118 mcg/ml (100 to 140) from the plain discs (p < 0.001). At two weeks, these significant differences persisted. At nine weeks the indented discs eluted a greater concentration for all gentamicin doses, but the difference was only significant for the discs containing 0.17 g (0.88% w/w, p = 0.006). However if the area under the curve is taken as a measure of the total antibiotic eluted, the indented discs eluted more gentamicin than the plain discs for the 0.17 g (0.88% w/w, p = 0.031), the 0.25 g (1.41% w/w, p < 0.001) and the 0.33 g (1.75% w/w, p < 0.001) discs. When preparing antibiotic spacers for use in staged revision arthroplasty surgery we recommend indenting the spacer with a MacDonald dissector to increase the elution of antibiotic.

Comparison of the management and in-hospital outcomes of acute coronary syndrome patients in Australia and New Zealand: results from the binational SNAPSHOT acute coronary syndrome 2012 audit.

BACKGROUND/AIMS: We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome (ACS). METHODS: We used comprehensive data from the binational Australia and New Zealand ACS 'SNAPSHOT' audit, acquired on individual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. RESULTS: There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand; Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P < 0.0001). However, at discharge, Australian NSTEMI/UAP survivors were less likely to receive aspirin (84% vs 89%, P = 0.0079, a second anti-platelet agent (57% vs 63%, P = 0.050) or a beta blocker (67% vs 77%, P = 0.0002). In-hospital death rates were not different (2.7% vs 3.2%, P = 0.55) between Australia and New Zealand. CONCLUSIONS: Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group.

Prevalence of abdominal aortic aneurysm in patients referred for transthoracic echocardiography.

BACKGROUND: Previous studies have documented the prevalence of abdominal aortic aneurysm (AAA) during transthoracic echocardiography, but the effect of such screening on subsequent vascular interventions remains unclear. AIM: This study aimed to determine the utility of opportunistic selective screening for AAA in a contemporary large series of patients having transthoracic echocardiography. METHODS: Subjects aged 50 years or older having transthoracic echocardiography had scanning of the infrarenal aorta in a consecutive series of 10 403 men and women. RESULTS: The study subjects had a mean age of 70.2 ± 10.7 years, and 54.1% were men. There was a 3.5% (95% confidence interval (CI) 3.2-3.9%) prevalence of AAA with a median diameter of 39 mm (interquartile range 32 mm-48 mm). In males ≥ 65 years the prevalence of newly diagnosed AAA was 6.2% (95% CI 5.5-7.0%). Of those with newly diagnosed AAA, 39.7% underwent AAA repair. Age and male gender were associated with AAA prevalence. After adjustment for age and gender, echocardiographic variables associated with AAA were left ventricular end diastolic dimension (odds ratio (OR) 1.02, 95%CI 1.01-1.04), interventricular septum thickness (OR 1.11, 95% CI 1.06-1.17), left ventricular posterior wall thickness (OR 1.09, 95% CI 1.03-1.15), left atrial diameter (OR 1.04, 95% CI 1.02-1.07) and aortic root diameter (OR 1.09, 95% CI 1.06-1.11). CONCLUSIONS: This study revealed a high prevalence of newly diagnosed AAA in a group of older men having cardiac evaluation. There was a relationship of increasing age with AAA, and a significant proportion of newly diagnosed subjects were not suitable for AAA repair.

Major surgery in severe haemophilia A with inhibitors using a recombinant factor VIIa and activated prothrombin complex concentrate hybrid regimen.

Major surgery in persons with haemophilia A and inhibitors is increasingly being performed. Both recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (APCC) are used to cover surgery but it remains unclear what the optimal dosing schedules are. We describe the use of a hybrid regimen in four inhibitor patients undergoing eight major surgical procedures using rFVIIa in the initial 2-6 postoperative days followed by FEIBA for the remaining period. All patients were also treated with tranexamic acid while receiving rFVIIa. We performed six major orthopaedic procedures, one emergency orchidectomy and one open appendectomy. The dosing schedules were at the higher end of those described in the literature but within the recommendations of the summary of product characteristics. Despite this, we encountered non-surgical bleeding in four of eight episodes. Three of these occurred in one individual suggesting a patient factor. The overall outcome was good for all episodes. The hybrid regimen combines flexibility of dose and dosing frequency of rFVIIa in the immediate postoperative setting with the advantage of a reduced dosing frequency with FEIBA in the subsequent days. This study also emphasizes that surgical procedures in this patient group remain a challenge.

Forced-air patient warming blankets disrupt unidirectional airflow.

We have recently shown that waste heat from forced-air warming blankets can increase the temperature and concentration of airborne particles over the surgical site. The mechanism for the increased concentration of particles and their site of origin remained unclear. We therefore attempted to visualise the airflow in theatre over a simulated total knee replacement using neutral-buoyancy helium bubbles. Particles were created using a Rocket PS23 smoke machine positioned below the operating table, a potential area of contamination. The same theatre set-up, warming devices and controls were used as in our previous study. This demonstrated that waste heat from the poorly insulated forced-air warming blanket increased the air temperature on the surgical side of the drape by > 5°C. This created convection currents that rose against the downward unidirectional airflow, causing turbulence over the patient. The convection currents increased the particle concentration 1000-fold (2 174 000 particles/m(3) for forced-air warming vs 1000 particles/m(3) for radiant warming and 2000 particles/m(3) for the control) by drawing potentially contaminated particles from below the operating table into the surgical site. Cite this article: Bone Joint J 2013;95-B:407-10.

Mortality, morbidity and evidence-based management amongst patients in regional New Zealand with severe left ventricular systolic dysfunction (1997-2011).

BACKGROUND: Heart failure and its management represents a significant health burden, the extent of which is poorly understood in regional New Zealand. AIMS: To investigate mortality, quality of life, hospitalisation, and evidence-based medical and device management of severe left ventricular (LV) systolic dysfunction in a regional New Zealand setting. METHODS: A retrospective case series was undertaken of 1126 patients with a LV ejection fraction <36% on transthoracic echocardiograms performed between 1 October 1997 and 31 March 2011 in Nelson Marlborough District Health Board. All-cause mortality and hospitalisation data were analysed for all participants. Substudies were undertaken regarding pharmacotherapy, demographics, implantable cardioverter-defibrillator implantation rates and quality of life based on the EQ-5D questionnaire and New York Heart Association class. RESULTS: Five-year cumulative survival was 44.5%. The mean annual medical admission rate was 204/100 000; 54.84% of which were readmissions in the same year. Prescription rates for angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, beta-blockers and spironolactone were 68.3%, 74.2% and 24.9%, respectively, with only 17.6%, 19.0% and 16.4% on maximum recommended doses. implantable cardioverter-defibrillator devices were inserted in 11.5% of eligible patients. Quality of life was impaired in patients <70 years relative to the age-approximated New Zealand index population. Mean EQ-5D visual analogue score was 72.6 ± 0.032 and self-reported New York Heart Association class 2.09 ± 0.107 CONCLUSION: Patients with severe LV systolic dysfunction in this regional New Zealand community experience similar mortality and first hospitalisation rates to those seen elsewhere in patients with clinical heart failure, but a greater number of readmissions. Medical and device therapy utilisation was suboptimal, and quality of life impaired, together supporting the need for a dedicated heart failure service.

Plasma total bilirubin levels predict amputation events in type 2 diabetes mellitus: the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

AIMS/HYPOTHESIS: Bilirubin has antioxidant and anti-inflammatory activities. Previous studies demonstrated that higher bilirubin levels were associated with reduced prevalence of peripheral arterial disease (PAD). However, the relationship between bilirubin and lower-limb amputation, a consequence of PAD, is currently unknown. We hypothesised that, in patients with type 2 diabetes, bilirubin concentrations may inversely associate with lower-limb amputation. METHODS: The relationship between baseline plasma total bilirubin levels and amputation events was analysed in 9,795 type 2 diabetic patients from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. The analysis plan was pre-specified. Lower-limb amputation was adjudicated blinded to treatment allocation. Relevant clinical and biochemical data were available for analyses. Amputation was a pre-specified tertiary endpoint. RESULTS: Bilirubin concentrations were significantly inversely associated with lower-limb amputation, with a greater than threefold risk gradient across levels. Individuals with lower bilirubin concentrations had a higher risk for first amputation (HR 1.38 per 5 µmol/l decrease in bilirubin concentration, 95% CI 1.07, 1.79, p = 0.013). The same association persisted after adjustment for baseline variables, including age, height, smoking status, γ-glutamyltransferase level, HbA1c, trial treatment allocation (placebo vs fenofibrate), as well as previous PAD, non-PAD cardiovascular disease, amputation or diabetic skin ulcer, neuropathy, nephropathy and diabetic retinopathy (HR 1.38 per 5 µmol/l decrease in bilirubin concentration, 95% CI 1.05, 1.81, p = 0.019). CONCLUSIONS/INTERPRETATION: Our results identify a significant inverse relationship between bilirubin levels and total lower-limb amputation, driven by major amputation. Our data raise the hypothesis that bilirubin may protect against amputation in type 2 diabetes.

Do forced air patient-warming devices disrupt unidirectional downward airflow?

Patient warming significantly decreases the risk of surgical site infection. Recently there have been concerns that forced air warming may interfere with unidirectional airflow, potentially posing an increased risk of infection. Our null hypothesis was that forced air and radiant warming devices do not increase the temperature and the number of particles over the surgical site when compared with no warming device. A forced air warming device was compared with a radiant warming device and no warming device as a control. The temperature and number of particles were measured over the surgical site. The theatre was prepared as for a routine lower-limb arthroplasty operation, and the same volunteer was used throughout the study. Forced air warming resulted in a significant mean increase in the temperature (1.1°C vs 0.4°C, p < 0.0001) and number of particles (1038.2 vs 274.8, p = 0.0087) over the surgical site when compared with radiant warming, which raises concern as bacteria are known to require particles for transport.

Long-term outcome of a cementless, hemispherical, press-fit acetabular component: survivorship analysis and dose-response relationship to linear polyethylene wear.

Between 1988 and 1998 we implanted 318 total hip replacements (THRs) in 287 patients using the Plasmacup (B. Braun Ltd, Sheffield, United Kingdom) and a conventional metal-on-polyethylene articulation. The main indications for THR were primary or secondary osteoarthritis. At follow-up after a mean 11.6 years (7.6 to 18.4) 17 patients had died and 20 could not be traced leaving a final series of 280 THRs in 250 patients. There were 62 revisions (22.1%) in 59 patients. A total of 43 acetabular shells (15.4%) had been revised and 13 (4.6%) had undergone exchange of the liner. The most frequent indications for revision were osteolysis and aseptic loosening, followed by polyethylene wear. The mean Kaplan-Meier survival of the Plasmacup was 91% at ten years and 58% at 14 years. Osteolysis was found around 36 (17.1%) of the 211 surviving shells. The median annual rate of linear wear in the surviving shells was 0.12 mm/year and 0.25 mm/year in those which had been revised (p < 0.001). Polyethylene wear was a strong independent risk factor for osteolysis and aseptic loosening. The percentage of patients with osteolysis increased proportionately with each quintile of wear-rate. There is a high late rate of failure of the Plasmacup. Patients with the combination of this prosthesis and bearing should be closely monitored after ten years.

Mid- to long-term results of irradiated allograft in acetabular reconstruction: a follow-up report.

Between 1990 and 2000, 123 hips in 110 patients were reconstructed for aseptic loosening using impaction bone grafting with frozen, irradiated, morsellised femoral heads and cemented acetabular components. This series was reported previously at a mean follow-up of five years. We have extended this follow-up and now describe the outcome of 86 hips in 74 patients at a mean of ten years. There have been 19 revisions, comprising nine for infection, seven for aseptic loosening and three for dislocation. In surviving acetabular reconstructions, union of the graft had occurred in 64 of 67 hips (95.5%). Survival analysis for all indications at ten years was 83.3% (95% confidence interval (CI) 68 to 89) and 71.3% (95% CI 58 to 84) at 15 years. Acetabular reconstruction using irradiated allograft and a cemented acetabular component is an effective method of reconstruction, providing results in the medium- to long-term comparable with those of reported series where non-irradiated freshly-frozen bone was used.

Total knee replacements in a patient with the Morquio syndrome.

The Morquio syndrome is a rare disorder which presents with a number of musculoskeletal problems. The literature describing total knee replacement in these patients is sparse. We describe the management of a patient with bilateral instability and pain in the knees using bilateral constrained knee replacements, and followed up for five years with pre- and postoperative knee scores. We highlight the difficulties encountered and discuss the end results.

Intraoperative red blood-cell salvage in revision hip surgery. A case-matched study.

BACKGROUND: Revision hip arthroplasty is commonly associated with substantial blood loss and the subsequent need for transfusion. This leads to an increased risk of blood-borne infection and hemolytic reactions. The purpose of this study was to demonstrate whether the use of intraoperative red blood-cell salvage in revision hip arthroplasty reduces the overall rate of allogeneic transfusion. METHODS: Forty-seven patients who had undergone revision hip arthroplasty with the use of intraoperative cell salvage were identified. A computer database was used to individually match these patients, for age, sex, and eleven operative variables, to control patients who had undergone revision hip arthroplasty in the same unit without intraoperative cell salvage. Data gathered included the total allogeneic transfusion requirement for each patient, preoperative and postoperative hemoglobin levels, and operative time. RESULTS: The total allogeneic transfusion requirement was significantly lower in the group that had intraoperative cell salvage than in the control group (median, 2 compared with 6 U of packed red blood cells, p = 0.0006), with a median reduction in allogeneic transfusion of 4 U. There was no significant difference in preoperative or postoperative hemoglobin levels between the groups. CONCLUSIONS: The use of intraoperative cell salvage significantly lowered the allogeneic transfusion requirement, which can lead to substantial cost savings. To our knowledge, this is the first study in which the use of intraoperative red blood-cell salvage in revision hip arthroplasty was evaluated by matching patients on the basis of age, sex, and operative variables.

Effect of femoral stem centralizer design on cement mantle porosity.

We studied whether prosthetic femoral stem centralizers have a detrimental effect on the macroporosity of the cement mantle. With pressure and time monitoring identically cast, moulded prosthetic femora had Charnley C-stems implanted. The stems were removed and the cement mantle was sectioned and photographed to record the size and location of voids (macropores). Cement voids were found in 85% of femora when a centralizer was used compared to 20% of the control group (p=0.002). A modular centralizer produced cement voids of a larger volume and more frequent occurrence (p=0.002). The macroporosity of the cement mantle was independent of the rate of implantation (p=0.39). Modern distal stem centralizers therefore increase the incidence of void formation in the cement mantle; although they help guard against malposition of the implant, they may have implications for early loosening.

Clinical and radiological outcome of total hip replacement five years after pamidronate therapy. A trial extension.

Bisphosphonates reduce peri-prosthetic bone loss in the short term after total hip replacement but the mid- and longer term effects are not known. The aims of this randomised trial were to examine the effect of a single dose of 90 mg of pamidronate on the clinical and radiological outcome and peri-prosthetic bone mineral density in 50 patients (56 hips) over a five-year period, following total hip replacement. At five years, 37 patients (42 hips) returned for assessment. The Harris hip scores were similar in the pamidronate and placebo groups throughout the study. Also at five years, four patients, two from each group had osteolytic lesions on plain radiography. These were located around the acetabular component in three patients and in the femoral calcar in one. The femoral and acetabular peri-prosthetic bone mineral density in the pamidronate group and the control group was similar at five years. Pamidronate given as a single post-operative dose does not appear to influence the clinical outcome or prevent the development of osteolytic lesions at five years after total hip replacement.

Total hip replacement in a patient with systemic mastocytosis: a case report.

Systemic mastocytosis is a rare condition that often involves the bone marrow. We report the case of a patient with systemic mastocytosis who underwent total hip replacement. Technical difficulties encountered during the procedure included a narrow medullary canal and abnormally hard bone, later confirmed by laboratory measurements. Follow-up at five years showed a good clinical and radiological outcome.

Bone remodelling around a cemented polyethylene cup. A longitudinal densitometry study.

The aims of this study were to examine the repeatability of measurements of bone mineral density (BMD) around a cemented polyethylene Charnley acetabular component using dual-energy x-ray absorptiometry and to determine the longitudinal pattern of change in BMD during the first 24 months after surgery. The precision of measurements of BMD in 19 subjects ranged from 7.7% to 10.8% between regions, using a four-region-of-interest model. A longitudinal study of 27 patients demonstrated a transient decrease in net pelvic BMD during the first 12 months, which recovered to baseline at 24 months. The BMD in the region medial to the dome of the component reduced by between 7% and 10% during the first three months, but recovered to approximately baseline values by two years. Changes in BMD in the pelvis around cemented acetabular components may be measured using dual-energy x-ray absorptiometry. Bone loss after insertion of a cemented Charnley acetabular component is small, transient and occurs mainly at the medial wall of the acetabulum. After two years, bone mass returns to baseline values, with a pattern suggesting a uniform transmission of load to the acetabulum.

Changes in bone mass and bone turnover following tibial shaft fracture.

INTRODUCTION: Bone loss occurs in the regional bone following tibial shaft fracture. An earlier cross-sectional study showed that measurements made at the metaphyseal region of the tibia using peripheral quantitative computed tomography (pQCT) and the ultradistal region of the tibia using dual-energy X-ray absorptiometry (DXA) were the most responsive at monitoring this bone loss. Biochemical markers of bone turnover enable us to assess the activity of bone formation and resorption during fracture healing. The aim of this longitudinal study was to determine the pattern and distribution of bone loss and bone turnover following a tibial shaft fracture treated with either plaster cast or intramedullary nail. METHODS: Eighteen subjects underwent bone mass measurements using DXA at the tibia and hip and quantitative ultrasound (QUS) at the tibia and calcaneus of both limbs at 2 weeks, 8 weeks, 12 weeks and 24 weeks following fracture, with hip and tibia DXA measurements also performed at 52 weeks. Nine of the patients treated with plaster cast had pQCT measurements at the tibia at 24 weeks. We measured three bone formation markers, bone alkaline phosphatase (bone ALP), osteocalcin (OC) and procollagen type 1 N-terminal peptide (PINP), a marker of bone resorption, serum C-telopeptides of type 1 collagen (beta-CTX) and a marker of collagen III turnover, procollagen type III N-terminal peptide (PIIINP) at 1 day, 3 days and 7 days and at 2, 4, 8, 12, 16 and 24 weeks following fracture. The greatest bone losses were observed at the ultradistal region of the tibia using DXA (28%, p <0.001) and the metaphyseal region of the tibia using pQCT (26-31%, p <0.001) at 24 weeks. In the hip, the greatest loss was in the trochanter region at 24 weeks (10%, p <0.001). The greatest loss at the calcaneus measured using QUS was for broadband ultrasound attenuation (BUA) measured using CUBA Clinical at 24 weeks (13%, p =0.01). RESULTS: At 1 year, there was a small recovery in bone loss (ultradistal tibia DXA, 20%, p <0.01; trochanter DXA 9%, p <0.001). Bone turnover increased following fracture (PINP +72+/-21%, p <0.0001, bone ALP +199+/-22%, p =0.004, beta-CTX +105+/-23%, p <0.0001, all at 24 weeks). There was a smaller +33+/-10% increase in osteocalcin at 24 weeks. PIIINP concentration peaked at week 8 (+57+/-9%, p <0.0001). The bone resorption marker beta-CTX showed an earlier rise (week 2, 139+/-33%) than the bone formation markers. CONCLUSIONS: We conclude that: (1) bone loss following tibial shaft fracture occurs both proximal and distal to the fracture; (2) the decreased BMD is largest for trabecular bone in the tibia with similar measurements using DXA and pQCT; (3) there is limited recovery of bone lost at the hip and tibia at 1 year; (4) tibial speed of sound (SOS) demonstrated a greater decrease than calcaneal SOS when comparing z -scores; (5) BUA is the QUS variable that shows the biggest decrease of bone mass at the calcaneus; (6) increase in bone turnover occurs following fracture with an earlier increase in bone resorption markers and a later rise in bone formation markers.