Iliopsoas pathology after total hip arthroplasty: a young person's complication.

AIMS: Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes. METHODS: A retrospective review of 1,000 patients who underwent THA over a five-year period was conducted, to determine the incidence of patients diagnosed with iliopsoas pathology. Outcome following non-surgical and surgical management was assessed. RESULTS: In all, 24 patients were diagnosed as having developed symptomatic iliopsoas pathology giving an incidence of 2.4%. While the mean age for receiving a THA was 65 years, the mean age for developing iliopsoas pathology was 54 years (28 to 67). Younger patients and those receiving THA for conditions other than primary osteoarthritis were at a higher risk of developing this complication. Ultrasound-guided steroid injection/physiotherapy resulted in complete resolution of symptoms in 61% of cases, partial resolution in 13%, and no benefit in 26%. Eight out of 24 patients (who initially responded to injection) subsequently underwent surgical intervention including tenotomy (n = 7) and revision of the acetabular component (n = 1). CONCLUSION: This is the largest case series to estimate the incidence of iliopsoas pathology to date. There is a higher incidence of this condition in younger patients, possibly due to the differing surgical indications. Arthoplasty for Perthes' disease or developmental dysplasia of the hip (DDH) often results in leg length and horizontal offset being increased. This, in turn, may increase tension on the iliopsoas tendon, possibly resulting in a higher risk of psoas irritation. Image-guided steroid injection is a low-risk, relatively effective treatment. In refractory cases, tendon release may be considered. Patients should be counselled of the risk of persisting groin pain when undergoing THA. Cite this article: Bone Joint J 2021;103-B(2):305-308.

The Relationships between the Rotational Axes of the Distal Femur in the Arthritic Caucasian Knee: A Magnetic Resonance Imaging Analysis.

Four distal femoral axes have been described to aid in the accuracy of transverse plane component alignment in total knee arthroplasty (TKA). These include the surgical epicondylar axis (SEA), the posterior condylar axis (PCA), and the anteroposterior (AP) axis. Therefore, the primary purpose of this study is to identify the axial femoral relationship with the least variation in a Caucasian population awaiting TKA for osteoarthritis. Secondarily, we further plan to determine if these femoral axis relationships differ with respect to sex or preoperative coronal alignment. These anatomic relationships were measured using preoperative magnetic resonance imaging, which was performed within 2 months of the planned operation date for patient specific instrumentation templating. In terms of our primary outcome, the mean SEA/AP angle was 92.8 degrees (standard deviation [SD]: 2.5 degrees), the mean PCA/AP angle was 95.7 degrees (SD: 2.8 degrees), and the mean PCA/SEA angle was 3.4 degrees (SD: 1.8 degrees). Overall, the PCA/SEA relationship had the smallest variance, while the PCA/AP had the most variance for all comparisons. In terms of our secondary outcome, there was no statistical difference between femoral axis relationships based on preoperative coronal plane alignment. In terms of sex differences, the PCA/SEA was significantly higher in female knees compared with males. Females had a PCA/SEA relationship of 4.7 degrees (SD: 1.3 degrees) compared with 2.6 degrees (SD: 1.2 degrees) for males (p < 0.05). By using the PCA/AP axes, the AP axis was externally rotated by 96.7 degrees (SD: 2.3 degrees) in females, compared with 93.2 degrees (SD: 2.1 degrees) in males, from the PCA. In conclusion, our results demonstrate that the PCA/SEA relationship should be used to determine axial rotation in TKA as it shows the least variation. When using the PCA, approximately 5 degrees of external rotation for Caucasian women and 3 degrees of external rotation for the Caucasian men should be dialed into the femoral cutting block to restore anatomic axial rotation. Further evaluation is needed to determine to role of preoperative coronal alignment on distal femoral axial alignment.

Does quality of care in hip fracture vary by day of admission?

This study investigates if the day of the week a person is admitted with a hip fracture influences the quality of care they receive. We found those admitted Thursday and Friday were likely to obtain poorer postoperative care, indicating a need to optimize services ensuring equality for all. PURPOSE: We sought to investigate how the day of admission affects the quality of care provided to hip fracture patients according to national standards (The Scottish Standards of Care for Hip Fracture Patients [SSCHFP]). METHODS: Retrospective analysis of national cohort data. Data were collected by the Scottish Hip Fracture Audit (SHFA) local audit co-ordinators (LACs) at participating Scottish hospitals on behalf of NHS Scotland and the Scottish Government. Adherence to the SSCHFP included assessment of both individual and cumulative standard attainment as a marker for quality of patient care. RESULTS: From January 2014 to April 2018, 15,351 admissions for hip fracture were recorded. Compared with Monday admission (reference day), patients admitted on a Thursday or Friday had a significantly lower likelihood of achieving the postoperative standards of prompt mobilization (OR 1.77; p < 0.001 & OR 1.48; p < 0.001, respectively); prompt physiotherapy assessment (OR 8.61; p < 0.001 & OR 3.47; p < 0.001, respectively); and prompt comprehensive geriatric assessment (OR 1.88; p < 0.001 & OR 1.41; p < 0.001, respectively). Patients admitted on a Friday or Saturday were less likely to receive the preoperative standards of no delay prior to theatre (OR 1.24; p = 0.001 & OR 1.23; p = 0.002, respectively) and avoidance of repeat fasting (OR 1.22; p = 0.009 & OR 1.22; p = 0.01, respectively). CONCLUSION: Patients admitted on Thursday or Friday were significantly more likely to not receive postoperative care standards than patients admitted on the reference day (Monday). This appears to be related to inequalities in service provision for Saturday and Sunday compared with the rest of the week.

Quality of Care in Hip Fracture Patients: The Relationship Between Adherence to National Standards and Improved Outcomes.

BACKGROUND: Optimizing the perioperative care of patients with a hip fracture is a key health-care priority. We aimed to determine whether adherence to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP) was associated with improved patient outcomes. METHODS: In this retrospective cohort study of prospectively collected data from the Scottish National Hip Fracture Audit, we assessed adherence to the SSCHFP in 21 Scottish hospitals over a 9-month period in 2014 and examined the effect of the guidelines on 30 and 120-day mortality, length of hospital stay, and discharge destination. RESULTS: A total of 1,162 patients who were ≥50 years old and admitted with a hip fracture were included. There was a significant association between low adherence to the SSCHFP and increased mortality at 30 and 120 days (odds ratio [OR], 3.58 [95% confidence interval (CI), 1.75 to 7.32; p < 0.001] and 2.01 [95% CI, 1.28 to 3.12; p = 0.003], respectively). Low adherence was associated with a reduced likelihood of a short length of stay (OR, 0.58; 95% CI, 0.42 to 0.78; p < 0.0001), but increased odds of discharge to a high-care setting (OR, 1.63; 95% CI, 1.12 to 2.36; p = 0.01). Early physiotherapy input and occupational therapy input were associated with a reduced likelihood of discharge to a high-care setting (OR, 0.64 [95% CI, 0.44 to 0.98; p = 0.04] and 0.34 [95% CI, 0.23 to 0.48; p <0.001], respectively). CONCLUSIONS: Adherence to the SSCHFP is associated with better patient outcomes. These findings confirm the clinical utility of the SSCHFP and support their use as a benchmarking tool to improve quality of care for hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Aseptic Lymphocyte-Dominated Vasculitis-Associated Lesion as Early as Six Weeks After Total Hip Replacement: A Case Report.

CASE: A 40-year-old man who underwent total hip replacement on the left side with a metal-on-metal (MOM) implant reported swelling at the operative site within 6 weeks of the arthroplasty. Tissue sampled during the revision arthroplasty showed an aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). CONCLUSION: ALVAL is a widely recognized complication of MOM hip implants and needs to be considered early, even in completely asymptomatic patients with normal metal ion levels and normal radiographs.

Using national hip fracture registries and audit databases to develop an international perspective.

Hip fracture is the commonest reason for older people to need emergency anaesthesia and surgery, and leads to prolonged dependence for many of those who survive. People with this injury are usually identified very early in their hospital care, so hip fracture is an ideal marker condition with which to audit the care offered to older people by health services around the world. We have reviewed the reports of eight national audit programmes, to examine the approach used in each, and highlight differences in case mix, management and outcomes in different countries. The national audits provide a consistent picture of typical patients - an average age of 80 years, with less than a third being men, and a third of all patients having cognitive impairment - but there was surprising variation in the type of fracture, of operation and of anaesthesia and hospital length of stay in different countries. These national audits provide a unique opportunity to compare how health care systems of different countries are responding to the same clinical challenge. This review will encourage the development and reporting of a standardised dataset to support international collaboration in healthcare audit.

Femoro Patella Vialla patellofemoral arthroplasty: An independent assessment of outcomes at minimum 2-year follow-up.

AIM: To determine outcomes using the Femoro-Patella Vialla (FPV) arthroplasty and if there is an ideal patient for this implant. METHODS: A total of 41 FPV patellofemoral joint replacements were performed in 31 patients (22 females, 9 males, mean age 65 years). Mean follow-up was 3.2 years (minimum 2 years). Radiographs were reviewed preoperatively and postoperatively. We assessed whether gender, age, previous surgery, patella atla or trochlear dysplasia influenced patient satisfaction or patient functional outcome. RESULTS: The median Oxford Knee Score was 40 and the median Melbourne Patellofemoral Score was 21 postoperatively. Seventy-six percent of patients were satisfied, 10% unsure and 14% dissatisfied postoperatively. There was no radiological progression of tibiofemoral joint arthritis, using the Ahlback grading, in any patient. One patient, who was diagnosed with rheumatoid arthritis postoperatively, underwent revision to total knee replacement. There were no intraoperative lateral releases and no implant failures. Gender, age, the presence of trochlear dysplasia, patella alta or bilateral surgery did not influence patient outcome. Previous surgery did not correlate with outcome. CONCLUSION: In contrast to the current literature, the FPV shows promising early results. However, we cannot identify a subgroup of patients with superior outcomes.

National audits of hip fractures: Are yearly audits required?

INTRODUCTION: Hip fractures are a significant cause of morbidity and mortality to the increasing elderly population. The Scottish Hip Fracture Audit started in 1993 with national audits from 2002. It was a national prospective audit reporting on clinical standards in hip fracture care and produced an annual report. Due to national funding changes the continual audit was discontinued in 2008. In 2013, the MSK Audit Group published a "snapshot" into a 4 month period of hip fracture care in Scotland. Our purpose was to identify whether there had been an initial improvement in hip fracture care and whether this improvement was sustained with the discontinuation of the annual audit. METHODS: The reported outcomes from the annual Scottish Hip Fracture Audit from 2003 to 2008 were compared to the latest MSK Hip Fracture Audit published in 2013. Some data is available from the 2014 MSK Hip Fracture Audit and this was also used for comparison purposes. Local audit co-ordinators at each participating site collected a data-set for all patients admitted with a hip fracture. The case mix variables and management variables were compared for the reported years. RESULTS: The continual audit demonstrated an improvement in the percentage of patients discharged from accident and emergency in 4h (80.5% 2003 vs. 96% 2008) which was not maintained 5 years later. An improvement in the percentage of patients having surgery within 48 h of admission (89.9-98.4%) was also not maintained after 5 years (91.8%). 30 day mortality improved with continual audit, a trend which continued in 2013. The re-introduction of continuous audit in 2014 demonstrated an improvement in accident and emergency waiting times and time to theatre. DISCUSSION: The Scottish Hip Fracture Audit demonstrated improved standards of care until it was discontinued in 2008. The improvement was not sustained throughout all variables with the 2013 audit. With the re-introduction of regular audit, standards once again improved. We would recommend a more regular audit in an effort to not only improve standards of care for patients with a hip fracture but to maintain them.

Pre-operative analysis of lower limb coronal alignment - a comparison of supine MRI versus standing full-length alignment radiographs.

BACKGROUND: In this study we compare the results of pre-operative standing full-length alignment (SFLA) radiographs with supine MRI assessment of the lower limb alignment prior to MRI based patient specific total knee arthroplasty (TKA). METHODS: Imaging was performed in 45 knees (45 patients). Assessment of SFLA radiographs was performed by three independent assessors. Inter-observer correlation was high and so the mean values were calculated. This data was then compared to MRI alignment data used to create the patient specific cutting jigs. RESULTS: The range of alignment on SFLA radiographs ranged from +25° to -13° versus +20° to -11° with MRI. The mean difference between techniques was 2° (range 0-8°, SD ± 3°). Supine MRI under-estimated the degree of deformity in 31/45 (69%) cases. In 25/45 (56%) cases the supine MRI result was within ±2° of the value on SFLA radiographs, 31/45 (69%) were within ±3° and 38/45 (84%) within ±5°. There was no correlation between the degree of varus/valgus deformity and the magnitude of the difference between imaging modalities (Spearman's r(2)=0.02, p=0.41). CONCLUSIONS: The findings from this study would indicate that supine MRI underestimates the degree of deformity at the knee joint, a conclusion which may be important for pre-operative planning or follow-up of corrective osteotomy or TKA.

The ethical and practical challenges of patient noncompliance in orthopaedic surgery.

A fifty-five-year old man attends a trauma follow-up clinic six weeks after undergoing primary repair of a zone-II finger flexor tendon laceration. The patient has a history of substance abuse and has been noncompliant with postoperative treatment. He has not attended any postoperative outpatient or physiotherapy appointments, he removed his splint immediately on discharge, and he admits to moving the finger freely without restrictions, against advice. On examination it is evident that the patient has sustained a rupture of the tendon repair. Does the history of noncompliance with initial treatment affect decisions regarding the further management of this patient? The term compliance relates to the degree of constancy and accuracy with which an individual patient follows a prescribed treatment. Patient noncompliance is a common problem across all specialties and presents a major obstacle to safe, effective, and efficient health-care delivery. In this article, we discuss the risk factors for noncompliance, the difficult ethical and medico-legal dilemmas posed by this issue, and mechanisms for potential solutions to this common problem.

Outcome after sequential hip fracture in the elderly.

BACKGROUND: Hip fracture is a common cause of morbidity and mortality in the elderly. As the risk factors for hip fracture often persist after the original injury, patients remain at risk for sequential fractures. Our aim was to report the incidence, epidemiology, and outcome of sequential hip fracture in the elderly. METHODS: Data were collected during the acute hospital stay and at 120 days after admission from twenty-two acute orthopaedic units across Scotland between January 1998 and December 2005. These data were analyzed according to two separate time periods: by six-month intervals up to eight years after the primary fracture and by twenty-day intervals for the first two years after the primary fracture. RESULTS: The risk of sequential fracture was highest in the first twelve months, affecting 3% of surviving patients and decreasing to 2% per survival year thereafter. Survival to twelve months after sequential fracture was 63% compared with 68% for those with a single fracture (p = 0.03). Sequential hip fracture was also associated with greater loss of independent mobility and changes in residential status compared with single fractures. CONCLUSIONS: Sequential hip fracture is a relatively rare injury. Individuals who sustain this injury combination have poorer outcomes both in terms of survival and functional status. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Does bone mineral density affect hip fracture severity?

The association between hip fracture and reduced bone mineral density is well documented, with reduced bone mineral density predisposing to fracture. However, it is unknown whether an association exists between the magnitude of bone density lost and the severity of the hip fracture sustained. One hundred forty-two patients (96 women, 46 men) with a mean age of 74 years (range, 49-92 years) who sustained a hip fracture following a simple ground-level fall and were treated for this injury were reviewed. All patients had undergone dual-energy x-ray absorptiometry bone scanning of the contralateral hip and lumbar spine. Fractures were classified as intra- or extracapsular or subtrochanteric and then subclassified by degree of severity as simple (stable) or multifragmentary (unstable) fracture patterns.Although a low hip bone mineral density (T- or Z score <2.5) was associated with an increased risk of extracapsular fracture (P=.025) compared with other fracture types, no association existed between bone mineral density and the severity of the resultant hip fracture. Although an association exists between bone mineral density and the risk of fragility fractures, the results of the current study suggest that the severity of hip fractures does not follow this correlation. Therefore, no assumption can be made about bone mineral density of the proximal femur based on the severity of the fracture observed on plain radiographs.

A novel technique for femoral canal occlusion during cement pressurization in proximal femoral arthroplasty.

We describe a novel technique for occluding the femoral canal distal to the isthmus during proximal femoral arthroplasty. Synthetic bone models were reamed and sectioned to simulate loss of the proximal femur. Two experimental conditions were used. The first used no restrictor to act as a control. The second used calcium sulphate pellets impacted in distal femoral canal. A 100 × 12 mm Limb Preservation System stem (DePuy, Leeds, UK) was used in all experiments. We recorded cement pressure, leakage of cement, and penetration of cement into the femoral condyles. The calcium sulphate pellets prevented cement leakage, enabled higher cementing pressures, and prevented penetration of the cement into the femoral condyles. We would recommend this technique in cases where loss of proximal femoral bone loss requires the use of a cemented proximal femoral replacement.

Outcome after femoral revision using the restoration cone/conical femoral revision stem.

Despite improvements in implant technology and surgical technique, failure of total hip arthroplasty (THA) remains a persistent problem. This article reports clinical outcomes at a mean follow-up of 42 months using the Restoration cone/conical modular femoral revision stem (Stryker, Newbury, United Kingdom). A prospective cohort study was performed of 46 consecutive patients who underwent revision THA between January 2004 and June 2007. Patients were reviewed pre- and postoperatively at regular intervals for clinical and radiological assessment. Forty-six patients (17 men, 29 women) with a mean age of 72 years (range, 44-93 years) were observed for a mean of 42 months (range, 28-66 months). Indications for surgery included aseptic loosening/osteolysis (38/46 [83%]), periprosthetic fracture (4/46 [9%]), and infection (4/46 [8%]). Median time from index procedure was 16 years (range, 1-26 years). No patient was lost to follow-up. Two patients (4%) with well-fixed asymptomatic stems died during follow-up. Three patients (7%) sustained an early postoperative dislocation. One patient sustained a periprosthetic fracture after a fall. This was treated by osteosynthesis, and stem revision was not required. Mean Oxford Hip Score improved from 42 points (range, 24-57 points) to 28 points (range, 18-51 points) at 3-month follow-up (P=.003). Median stem subsidence was 1.0 mm (standard error of the mean, ±1.7 mm; range, 0-7mm) at last follow-up. No patient developed loosening or osteolysis around the stem. The Restoration femoral revision system has favorable clinical and radiological outcomes at a mean follow-up of 42 months.

Revision total hip arthroplasty: the femoral side using cemented implants.

Advances in surgical technique and implant technology have improved the ten-year survival after primary total hip arthroplasty (THA). Despite this, the number of revision procedures has been increasing in recent years, a trend which is predicted to continue into the future. Revision THA is a technically demanding procedure often complicated by a loss of host bone stock which may be compounded by the need to remove primary implants. Both cemented and uncemented implant designs are commonly used in the United Kingdom for primary and revision THA and much controversy still exists as to the ideal method of stem fixation. In this article we discuss revision of the femur using cemented components during revision THA. We focus on three clinical scenarios including femoral cement-in-cement revision where the primary femoral cement-bone interface remains well fixed, femoral cement-in-cement revision for peri-prosthetic femoral fractures, and femoral impaction grafting. We discuss the clinical indications, surgical techniques and clinical outcomes for each of these procedures.

Efficacy of outpatient bilateral simultaneous hallux valgus surgery.

Bilateral simultaneous hallux valgus correction is traditionally performed as an inpatient procedure due to concerns regarding adequate postoperative analgesia and difficulty mobilizing. We prospectively evaluated 40 consecutive patients (80 feet) who underwent outpatient surgical correction of bilateral symptomatic hallux valgus. Patients underwent preoperative radiological and clinical assessment using pain and American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scores. Patients underwent preoperative counseling and were assessed for medical suitability for outpatient surgery. They were instructed to have responsible adult caregivers available for 24 hours postoperatively, easy access to after-hours emergency medical care, and access to a telephone. Procedures were performed under general anesthesia with local anesthetic ankle block. Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff with an oral analgesia regimen. Cast immobilization was not used. Patients were reviewed at 6 weeks and 3 months postoperatively with repeated clinical and radiological assessment. All patients were discharged home and none required inpatient ward admission. Post-discharge, no patient presented to the emergency department or their general practitioner as a consequence of poor pain control. At final follow-up assessment, mean AOFAS hallux scores had improved from 58.1 (range, 29-80) to 89.0 (range, 47-100) (P<.001). The mean hallux valgus angle improved from 33.2 degrees (range, 15 degrees -53 degrees) to 16.9 degrees (range, 3 degrees -39 degrees) and the intermetatarsal angle had improved from 13.2 degrees (range, 6 degrees -23 degrees) to 8.5 degrees (range, 4 degrees -15 degrees) (P<.001). Eighty-five percent of patients reported that they would recommend outpatient surgery. Bilateral hallux valgus surgery can be performed safely as an outpatient procedure in selected patients with acceptable levels of patient satisfaction.

Outcome after short intramedullary nail fixation of unstable proximal femoral fractures.

In this study we assess the clinical and radiological outcomes after surgical fixation of unstable, extracapsular fractures of the proximal femur using two designs of short intramedullary nail. We reviewed 158 patients of which 131 had fixation using the Intra Medullary Hip Screw (IMHS original Richards Compression Hip Screw design) and 27 with the original design Proximal Femoral Nail (PFN Synthes). Outcome measures including non-union, peri-implant fracture, post-operative function and mortality were similar between groups. Proximal screw cut-out and consequently re-operation rate were significantly higher for the PFN. A number of variables may predispose a patient to develop screw cut-out including gender, experience of surgeon, fracture pattern, implant design and tip-apex distance. As such a multivariable logistic regression model was used to investigate the independent effects of these variables on proximal screw cut-out. Only tip-apex distance was found to have a significant association with proximal screw cut-out and differences between implant designs could be accounted for by surgical technique rather than implant design. The results of this study suggest that both implants have similar post-operative outcome measures and complication rates when implanted correctly.

Effect of alendronate on pseudomembrane cytokine expression in patients with aseptic osteolysis.

To determine whether alendronate alters the pseudomembrane inflammatory cytokine profile in patients with established aseptic osteolysis. A prospective, double-blind, randomized, controlled trial was conducted. Ten individuals listed for revision surgery for aseptic failure of a primary cemented arthroplasty were randomly assigned placebo/alendronate 70 mg once weekly for 8 weeks before revision surgery. Formalin-preserved pseudomembrane samples were paraffin-sectioned for immunohistochemical analysis to assess inflammatory cytokine protein expression. Polymerase chain reaction was carried out to assess expression of relevant mRNA. No significant difference was detected in the inflammatory cytokine protein or mRNA expression between groups. Alendronate 70 mg administered for an 8-week period before surgery did not alter the pseudomembrane inflammatory cytokine profile in patients with established aseptic osteolysis. Any potential biological effects may occur due to downstream effects on osteoclast and osteoblast function.

Prospective, double blind, randomized, controlled trial of simvastatin in human fracture healing.

Although statins are widely prescribed as cholesterol-lowering drugs, a number of studies suggest that these compounds may have anabolic effects on bone. Our aim was to assess whether simvastatin affects the rate of fracture healing in humans. A prospective, double-blind, randomized controlled trial was performed. Individuals who had sustained an undisplaced, extra-articular fracture of the distal radial metaphysis were recruited from a trauma clinic. Patients were randomized to receive simvastatin 20 mg once daily or a placebo. Regular clinical and radiological follow-up was undertaken for a 12 week period. Dual-energy X-ray absorptiometry assessment of bone mineral density was conducted at 2 and 12 weeks postinjury. Biochemical markers of bone turnover were assayed during the study period. Time to fracture union was defined as the time to cortical bridging in four cortices on plain radiographs. In addition, the rate of trabecular union was assessed. Eighty patients were recruited, of which 62 completed the study (31 in each group). Study cohorts were matched for age and gender. For patients receiving simvastatin therapy, the mean time to fracture union was 71.6 days (SD 22.2 days, SEM 3.8 days). This compared to 71.3 days (SD 21.3, SEM 4.1 days) for the control cohort (p = 0.6481). There was no significant difference between bone mineral density or bone biochemical markers between groups (p > 0.05). Despite promising results from in vivo and in vitro animal studies, simvastatin at a treatment dose of 20 mg once daily does not affect the rate of fracture healing in humans.