ABSTRACT
Tissue engineering is a promising alternative that may facilitate bony regeneration in small defects in compromised host tissue as well as large mandibular defects. This scoping systematic review was therefore designed to assess in vivo research on its use in the reconstruction of mandibular defects in animal models. A total of 4524 articles were initially retrieved using the search algorithm. After screening of the titles and abstracts, 269 full texts were retrieved, and a total of 72 studies included. Just two of the included studies employed osteonecrosis as the model of mandibular injury. All the rest involved the creation of a critical defect. Calcium phosphates, especially tricalcium phosphate and hydroxyapatite, were the scaffolds most widely used. All the studies that used a scaffold reported increased formation of bone when compared with negative controls. When combined with scaffolds, mesenchymal stem cells (MSC) increased the formation of new bone and improved healing. Various growth factors have been studied for their potential use in the regeneration of the maxillofacial complex. Bone morphogenic proteins (BMP) were the most popular, and all subtypes promoted significant formation of bone compared with controls. Whilst the studies published to date suggest a promising future, our review has shown that several shortfalls must be addressed before the findings can be translated into clinical practice. A greater understanding of the underlying cellular and molecular mechanisms is required to identify the optimal combination of components that are needed for predictable and feasible reconstruction or regeneration of mandibular bone. In particular, a greater understanding of the biological aspects of the regenerative triad is needed before we can to work towards widespread translation into clinical practice.
Subject(s)
Bone Regeneration , Tissue Engineering , Tissue Scaffolds , Animals , Durapatite , Mandible , OsteogenesisABSTRACT
Charcot neuroarthropathy is a rare but serious complication of diabetes, causing progressive destruction of the bones and joints of the foot leading to deformity, altered biomechanics and an increased risk of ulceration. Management is complicated by a lack of consensus on diagnostic criteria and an incomplete understanding of the pathogenesis. In this review, we consider recent insights into the development of Charcot neuroarthropathy. It is likely to be dependent on several interrelated factors which may include a genetic pre-disposition in combination with diabetic neuropathy. This leads to decreased neuropeptides (nitric oxide and calcitonin gene-related peptide), which may affect the normal coupling of bone formation and resorption, and increased levels of Receptor activator of nuclear factor kappa-B ligand, potentiating osteoclastogenesis. Repetitive unrecognized trauma due to neuropathy increases levels of pro-inflammatory cytokines (interleukin-1ß, interleukin-6, tumour necrosis factor α) which could also contribute to increased bone resorption, in combination with a pre-inflammatory state, with increased autoimmune reactivity and a profile of monocytes primed to transform into osteoclasts - cluster of differentiation 14 (CD14). Increased blood glucose and loss of circulating Receptor for Advanced Glycation End-Products (AGLEPs), leading to increased non-enzymatic glycation of collagen and accumulation of AGLEPs in the tissues of the foot, may also contribute to the pathological process. An understanding of the relative contributions of each of these mechanisms and a final common pathway for the development of Charcot neuroarthropathy are still lacking. Cite this article: S. E. Johnson-Lynn, A. W. McCaskie, A. P. Coll, A. H. N. Robinson. Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy. Bone Joint Res 2018;7:373-378. DOI: 10.1302/2046-3758.75.BJR-2017-0334.R1.
ABSTRACT
OBJECTIVE: To assess reliability and discriminative validity of cartilage compositional magnetic resonance imaging (MRI) in knee osteoarthritis (OA). DESIGN: The study was carried out per PRISMA recommendations. We searched MEDLINE and EMBASE (1974 - present) for eligible studies. We performed qualitative synthesis of reliability data. Where data from at least two discrimination studies were available, we estimated pooled standardized mean difference (SMD) between subjects with and without OA. Discrimination analyses compared controls and subjects with mild OA (Kellgren-Lawrence (KL) grade 1-2), severe OA (KL grade 3-4) and OA not otherwise specified (NOS) where not possible to stratify. We assessed quality of the evidence using Quality Appraisal of Diagnostic Reliability (QAREL) and Quality Assessment of Diagnostic Accuracy (QUADAS-2) tools. RESULTS: Fifty-eight studies were included in the reliability analysis and 26 studies were included in the discrimination analysis, with data from a total of 2,007 knees. Intra-observer, inter-observer and test-retest reliability of compositional techniques were excellent with most intraclass correlation coefficients >0.8 and coefficients of variation <10%. T1rho and T2 relaxometry were significant discriminators between subjects with mild OA and controls, and between subjects with OA (NOS) and controls (P < 0.001). T1rho showed best discrimination for mild OA (SMD [95% CI] = 0.73 [0.40 to 1.06], P < 0.001) and OA (NOS) (0.60 [0.41 to 0.80], P < 0.001). Quality of evidence was moderate for both parts of the review. CONCLUSIONS: Cartilage compositional MRI techniques are reliable and, in the case of T1rho and T2 relaxometry, can discriminate between subjects with OA and controls.
Subject(s)
Cartilage, Articular/diagnostic imaging , Cartilage, Articular/pathology , Magnetic Resonance Imaging/methods , Osteoarthritis, Knee/diagnostic imaging , Osteoarthritis, Knee/pathology , Aged , Case-Control Studies , Female , Humans , Male , Middle Aged , Reference Values , Reproducibility of Results , Sensitivity and Specificity , Severity of Illness IndexABSTRACT
Introduction The weekend effect is a perceived difference in outcome between medical care provided at the weekend when compared to that of a weekday. Clearly multifactorial, this effect remains incompletely understood and variable in different clinical contexts. In this study we analyse factors relevant to the weekend effect in elective lower-limb joint replacement at a large NHS multispecialty academic healthcare centre. Materials and Methods We reviewed the electronic medical records of 352 consecutive patients who received an elective primary hip or knee arthroplasty. Patient, clinical and time-related variables were extracted from the records. The data were anonymised, then processed using a combination of uni- and multivariate statistics. Results There is a significant association between the selected weekend effect outcome measure (postoperative length of stay) and patient age, American Society of Anesthesiologists classification, time to first postoperative physiotherapy and time to postoperative radiography but not day of the week of operation. Discussion We were not able to demonstrate a weekend effect in elective lower-limb joint replacement at our institution nor identify a factor that would require additional weekend clinical medical staffing. Rather, resource priorities would seem to include measures to optimise at-risk patients preoperatively and measures to reduce time to physiotherapy and radiography postoperatively. Conclusions Our findings imply that postoperative length of stay could be minimised by strategies relating to patient selection and access to postoperative services. We have also identified a powerful statistical methodology that could be applied to other service evaluations in different clinical contexts.
Subject(s)
Arthroplasty, Replacement, Hip/statistics & numerical data , Arthroplasty, Replacement, Knee/statistics & numerical data , Elective Surgical Procedures/statistics & numerical data , Length of Stay/statistics & numerical data , Aged , Analysis of Variance , Female , Humans , Male , Middle Aged , Perioperative Care , Time FactorsABSTRACT
Trauma and Orthopaedic care has been through a rapid evolution over the past few decades. This Editorial discusses some of the advances.
Subject(s)
Acupuncture Therapy/trends , Manipulation, Orthopedic/trends , Orthopedic Procedures/trends , Acupuncture Therapy/methods , Bone Diseases/therapy , Forecasting , Humans , Joint Diseases/therapy , Manipulation, Orthopedic/methods , Orthopedic Procedures/methods , Quality ControlABSTRACT
PURPOSE: Poor knee extension function after total knee arthroplasty (TKA) is associated with factors including articular geometry and alignment. Femoral trochlear geometry has evolved from symmetrical to become more prominent proximal-laterally, with the groove aligned proximal-lateral to distal-medial. This study in vitro tested the hypothesis that a modern asymmetrical prosthesis would restore patellar tracking and stability to more natural behaviour than an older symmetrical prosthesis. METHODS: Six knees had their patellar tracking measured optically during active knee extension. Medial-lateral force versus displacement stability was measured at fixed angles of knee flexion. The measurements were repeated after inserting each of the symmetrical and asymmetrical TKAs. RESULTS: Significant differences of patellar lateral displacement stability, compared to normal, were not found at any angle of knee flexion. The patella tracked medial-laterally within 2.5 mm of the natural path with both TKAs. However, for both TKAs near knee extension, the patella was tilted laterally by approximately 6° and was also flexed approximately 8° more than in the natural knee. CONCLUSION: The hypothesis was not supported: The more anatomical component design did not provide more anatomical patellar kinematics and stability.
Subject(s)
Arthroplasty, Replacement, Knee/instrumentation , Knee Joint/physiology , Knee Prosthesis , Patella/physiology , Biomechanical Phenomena , Femur , Humans , Knee Joint/surgery , Patella/surgery , Range of Motion, Articular , RotationABSTRACT
Topography and surface chemistry have a profound effect on the way in which cells interact with an implant, which in turn impacts on clinical use and performance. In this paper we examine an electrochemical polishing approach in H2SO4/methanol that can be applied to the widely used orthopaedic/dentistry implant material, Ti6Al4V, to produce structured surfaces. The surface roughness, as characterized by R(a), was found to be dependent on the time of electropolishing but not on the voltage parameters used here. The surface chemistry, however, was dependent on the applied electrochemical potential. It was found that the chemical composition of the surface layer was modified during the electrochemical process, and at high potentials (9.0 V) a pure TiO2 layer of at least 10 nm was created on top of the bulk alloy. Characterization of these surfaces with rat cells from the osteoblast lineage provided further evidence of contact guidance by microscale topography with morphology analysis correlating with surface roughness (R(a) 300550 nm). Formation of a bone-like matrix after long-term culture on these surfaces was not strongly dependent upon R(a) values but followed the voltage parameter. These findings suggest that the surfaces created by treatment at higher voltages (9.0 V) produced a nanoscale layer of pure TiO2 on the Ti6Al4V surface that influenced the programme of cellular differentiation culminating in osteogenesis.
Subject(s)
Biocompatible Materials/chemistry , Osteoblasts/cytology , Osteoblasts/physiology , Titanium/chemistry , Alloys , Animals , Cell Survival , Cells, Cultured , Electroplating , Materials Testing , Rats , Surface PropertiesABSTRACT
OBJECTIVES: The genetic aetiology of osteoarthritis has not yet been elucidated. To enable a well-powered genome-wide association study (GWAS) for osteoarthritis, the authors have formed the arcOGEN Consortium, a UK-wide collaborative effort aiming to scan genome-wide over 7500 osteoarthritis cases in a two-stage genome-wide association scan. Here the authors report the findings of the stage 1 interim analysis. METHODS: The authors have performed a genome-wide association scan for knee and hip osteoarthritis in 3177 cases and 4894 population-based controls from the UK. Replication of promising signals was carried out in silico in five further scans (44,449 individuals), and de novo in 14 534 independent samples, all of European descent. RESULTS: None of the association signals the authors identified reach genome-wide levels of statistical significance, therefore stressing the need for corroboration in sample sets of a larger size. Application of analytical approaches to examine the allelic architecture of disease to the stage 1 genome-wide association scan data suggests that osteoarthritis is a highly polygenic disease with multiple risk variants conferring small effects. CONCLUSIONS: Identifying loci conferring susceptibility to osteoarthritis will require large-scale sample sizes and well-defined phenotypes to minimise heterogeneity.
Subject(s)
Osteoarthritis, Hip/genetics , Osteoarthritis, Knee/genetics , Case-Control Studies , Genetic Predisposition to Disease , Genome-Wide Association Study , Humans , Multifactorial Inheritance , Polymorphism, Single NucleotideABSTRACT
There is a paucity of information detailing functional outcome following total knee arthroplasty for this length of follow-up. We collected data from 187 knees in 150 surviving patients, beyond 15 years from implantation. Survival of the implant was confirmed and a patient administered questionnaire including WOMAC, SF-36 and patient satisfaction was used, data was scrutinised for differences between primary and revision knee surgery. Seventy knees were revised at a mean of 10.8 years. The mean WOMAC Pain score was 72 indicating predominantly mild pain. The mean WOMAC Function scores were lower at 55 indicating moderate limitation of most activities. No significant differences were found between revised and un-revised patients. Long-term pain and satisfaction scores in this population were good illustrating the benefits of TKA in the long term even in patients who have undergone revision surgery.
Subject(s)
Arthroplasty, Replacement, Knee , Outcome Assessment, Health Care , Activities of Daily Living , Aged , Arthritis, Rheumatoid/surgery , Female , Follow-Up Studies , Humans , Male , Middle Aged , Osteoarthritis, Knee/surgery , Pain Measurement , Patient Satisfaction , Quality of Life , Reoperation/statistics & numerical data , Surveys and Questionnaires , United KingdomABSTRACT
INTRODUCTION: The introduction of minimally invasive techniques for hip replacement into clinical practice has been driven by the perceived benefits of smaller incisions, shorter in-patient stays and faster rehabilitation. This may be at the cost of higher complication rates. The purpose of this study was to explore the opinions and priorities of patients in relation to these techniques. PATIENTS AND METHODS: A cross-sectional survey was performed in an elective out-patient setting. RESULTS: Of 44 patients approached, 36 agreed to participate. From most important to least important, patients rated the following items in order: 'rate of complications'; 'implant survival'; 'length of rehabilitation'; 'time in hospital' and 'length of scar'. Despite this, 21 of 35 (60%) responders stated they would accept the offer of minimally invasive techniques if made. CONCLUSIONS: Patients appear to prioritise long-term outcomes and low complication rates over the shorter scars, reduced in-patient stay and reduced rehabilitation times potentially offered by minimally invasive hip arthroplasty. Despite this, the technique remains popular among patients.
Subject(s)
Arthroplasty, Replacement, Hip/psychology , Minimally Invasive Surgical Procedures/psychology , Osteoarthritis, Hip/surgery , Patient Satisfaction , Aged , Aged, 80 and over , Ambulatory Care/statistics & numerical data , Arthroplasty, Replacement, Hip/rehabilitation , Cicatrix/pathology , Cicatrix/psychology , Cross-Sectional Studies , England , Female , Humans , Length of Stay , Male , Middle Aged , Minimally Invasive Surgical Procedures/rehabilitation , Osteoarthritis, Hip/psychologyABSTRACT
Interest in football continues to increase, with ever younger age groups participating at a competitive level. Football academies have sprung up under the umbrella of professional clubs in an attempt to nurture and develop such talent in a safe manner. However, increased participation predisposes the immature skeleton to injury. Over a five-year period we have prospectively collected data concerning all injuries presenting to the medical team at Newcastle United football academy. We identified 685 injuries in our cohort of 210 players with a mean age of 13.5 years (9 to 18). The majority of injuries (542;79%) were to the lower limb. A total of 20 surgical procedures were performed. Contact injuries accounted for 31% (210) of all injuries and non-contact for 69% (475). The peaks of injury occurred in early September and March. The 15- and 16-year-old age group appeared most at risk, independent of hours of participation. Strategies to minimise injury may be applicable in both the academy setting and the wider general community.
Subject(s)
Musculoskeletal System/injuries , Soccer/injuries , Adolescent , Age Distribution , Child , England/epidemiology , Humans , Incidence , Leg Injuries/epidemiology , Leg Injuries/etiology , Male , Prospective Studies , Seasons , Soft Tissue Injuries/epidemiology , Soft Tissue Injuries/etiologyABSTRACT
The role of modular tibial implants in total knee replacement is not fully defined. We performed a prospective randomised controlled clinical trial using radiostereophotogrammetric analysis to compare the performance of an all-polyethylene tibia with a metal-backed cruciate-retaining condylar design, PFC-Sigma total knee replacement for up to 24 months. There were 51 patients who were randomised into two treatment groups. There were 10 subsequent withdrawals, leaving 21 all-polyethylene and 20 metal-backed tibial implants. No patient was lost to follow-up. There were no significant demographic differences between the groups. At two years one metal-backed implant showed migration > 1 mm, but no polyethylene implant reached this level. There was a significant increase in the SF-12 and Oxford knee scores after operation in both groups. In an uncomplicated primary total knee replacement the all-polyethylene PFC-Sigma tibial prosthesis showed no statistical difference in migration from that of the metal-backed counterpart. There was no difference in the clinical results as assessed by the SF-12, the Oxford knee score, alignment or range of movement at 24 months, although these assessment measures were not statistically powered in this study.
Subject(s)
Knee Prosthesis , Polyethylene , Tibia/surgery , Aged , Aged, 80 and over , Arthritis, Rheumatoid/surgery , Arthroplasty, Replacement, Knee/methods , Female , Humans , Knee Joint/physiopathology , Male , Osteoarthritis, Knee/surgery , Photogrammetry/methods , Prospective Studies , Prosthesis Design , Range of Motion, Articular , Treatment OutcomeABSTRACT
INTRODUCTION: A cross-sectional study was performed to compare the practice of total hip replacement (THR) in the UK against national guidelines. MATERIALS AND METHODS: A postal questionnaire was sent to all fellows of the British Orthopaedic Association. RESULTS: Of the 1587 questionnaires sent out, 966 (60.9%) were returned. Of these, 706 (73.1%) were available for data collection and analysis. CONCLUSIONS: Consensus was observed in several areas including the use of pre-admission clinics and modern cementing techniques. Facilities deemed necessary for THR surgery such as HDU/ITU back-up, ultra-clean air and dedicated orthopaedic wards are almost universally available. However, a lack of consensus is evident in many areas including the process of obtaining written consent, thrombo-embolic prophylaxis, duration of antibiotic prophylaxis, supervision of trainee surgeons and follow-up arrangements. The proliferation in the range of implants, particularly aimed at 'younger' patients, available to surgeons has once again been highlighted.
Subject(s)
Arthroplasty, Replacement, Hip/standards , Guideline Adherence/standards , Practice Guidelines as Topic/standards , Clinical Competence/standards , Consensus , Cross-Sectional Studies , Humans , Medical Staff, Hospital/standards , Postoperative Complications/etiology , Postoperative Complications/prevention & control , Practice Patterns, Physicians'/standards , Surveys and Questionnaires , Thromboembolism/prevention & control , Time Factors , United KingdomABSTRACT
Resurfacing arthroplasty of the hip is being performed more frequently in the United Kingdom. The majority of these patients are younger than 55 years of age, and in this group the key benefits include conservation of femoral bone stock and the potential reduction in the rate of dislocation afforded by the larger resurfacing head. Early aseptic loosening is well recognised in patients younger than 55 years of age, and proponents of resurfacing believe that the improved wear characteristics of the metal-on-metal bearing may improve the long-term survival of this implant. There has been some concern, however, that resurfacing may not be conservative of acetabular bone. We compared a series of 33 consecutive patients who had a hybrid total hip arthroplasty with an uncemented acetabular component and a cemented femoral implant, with 35 patients undergoing a Birmingham hip resurfacing arthroplasty. We compared the diameter of the implanted acetabulum in both groups and, because they were not directly comparable, we corrected for patient size by measuring the diameter of the contralateral femoral head. The data were analysed using unpaired t-tests and analysis of covariance. There was a significantly larger acetabulum in the Birmingham arthroplasty group (mean diameter 56.6 mm vs 52.0 mm; p < 0.001). However, this group had a significantly larger femoral head diameter on the contralateral side (p = 0.03). Analysis of covariance revealed a significant difference between the mean size of the acetabular component implanted in the two operations. The greatest difference in the size of acetabulum was in those patients with a larger diameter of the femoral head. This study shows that more bone is removed from the acetabulum in hip resurfacing than during hybrid total hip arthroplasty, a difference which is most marked in larger patients.
Subject(s)
Acetabulum/surgery , Arthroplasty, Replacement, Hip/methods , Acetabulum/diagnostic imaging , Acetabulum/pathology , Age Factors , Aged , Cementation , Female , Femur Head/diagnostic imaging , Femur Head/pathology , Humans , Male , Middle Aged , Observer Variation , Postoperative Period , Radiography , Reproducibility of Results , Retrospective StudiesABSTRACT
The restrained dynamic creep behaviour and mechanical properties of SmartSet GHV bone cement have been investigated at both room temperature and body temperature. It was found that the bone cement behaves significant differently at room temperature from that at body temperature. The test temperature had a strong effect on the creep performance of the bone cements with a higher creep rate observed at body temperature at each loading cycle. For both temperatures, two stages of creep were identified with a higher creep rate during early cycling followed by a steady state creep rate. The relationship between creep deformation and loading cycle can be expressed by a Hyperb 1 model. As a visco-elastic material, the sensitivity of bone cement to the temperature change was evident during mechanical testing. Compared to the mechanical strength at room temperature, a decreased value was demonstrated at body temperature. The bending modulus was very sensitive to the change in testing temperature, where a reduction of 52% was recorded. A significant reduction in compressive and bending strength, 31 and 23% were recorded respectively. The effect of temperature on bending strength was less apparent, where only 13% reduction was exhibited at body temperature compared to room temperature.
Subject(s)
Bone Cements/analysis , Bone Cements/chemistry , Compressive Strength , Elasticity , Hardness , Materials Testing , Molecular Weight , Particle Size , Powders , Temperature , Tensile Strength , ViscosityABSTRACT
Hip resurfacing is being performed more frequently in the United Kingdom. The possible benefits include more accurate restoration of leg length, femoral offset and femoral anteversion than occurs after total hip arthroplasty (THA). We compared anteroposterior radiographs from 26 patients who had undergone hybrid THA (uncemented cup/cemented stem), with 28 who had undergone Birmingham Hip Resurfacing arthroplasty (BHR). We measured the femoral offset, femoral length, acetabular offset and acetabular height with reference to the normal contralateral hip. The data were analysed by paired t-tests. There was a significant reduction in femoral offset (p = 0.0004) and increase in length (p = 0.001) in the BHR group. In the THA group, there was a significant reduction in acetabular offset (p = 0.0003), but femoral offset and overall hip length were restored accurately. We conclude that hip resurfacing does not restore hip mechanics as accurately as THA.
Subject(s)
Arthroplasty, Replacement, Hip/methods , Hip Joint/physiopathology , Acetabulum , Adult , Biomechanical Phenomena , Femur , Hip Joint/diagnostic imaging , Hip Prosthesis , Humans , Middle Aged , Postoperative Complications/physiopathology , Prosthesis Failure , Radiography , Reproducibility of ResultsABSTRACT
Fatigue fractures which originate at stress-concentrating voids located at the implant-cement interface are a potential cause of septic loosening of cemented femoral components. Heating of the component to 44 degrees C is known to reduce the porosity of the cement-prosthesis interface. The temperature of the cement-bone interface was recorded intra-operatively as 32.3 degrees C. A simulated femoral model was devised to study the effect of heating of the component on the implant-cement interface. Heating of the implant and vacuum mixing have a synergistic effect on the porosity of the implant-cement interface, and heating also reverses the gradients of microhardness in the mantle. Heating of the implant also reduces porosity at the interface depending on the temperature. A minimum difference in temperature between the implant and the bone of 3 degrees C was required to produce this effect. The optimal difference was 7 degrees C, representing a balance between maximal reduction of porosity and an increased risk of thermal injury. Using contemporary cementing techniques, heating the implant to 40 degrees C is recommended to produce an optimum effect.
Subject(s)
Arthroplasty, Replacement, Hip/methods , Bone Cements , Femur Head/physiology , Hip Prosthesis , Hot Temperature , Cementation , Femur Head/surgery , Humans , Photomicrography , Porosity , Prosthesis FailureABSTRACT
The cellular reaction to wear debris may result in the failure of an artificial joint's fixation to the skeleton. The influence of debris opsinization on cell activity has received little attention. This study seeks to establish whether different proteinaceous culture environments may invoke variant cellular responses to debris challenge. Consideration of the zeta potential of a low density polyethylene particle group and an ex vitro ultrahigh molecular weight polyethylene particle group revealed that the nature of the protein adsorbants is related to the concentration of the proteins in solution. Furthermore, the composition of the adsorbed layer was shown to vary with the spectra of proteins in solution. In standard cell culture conditions zeta potential approached zero, indicating the high probability of particle agglomeration. Cell challenge studies with U937 macrophages showed that BSA and FCS protein adsorption mediated increased cell adhesion, while bovine IgG showed little change over control values. No changes in behavior of osteoblastic cells were observed in similar experiments.
Subject(s)
Biocompatible Materials/pharmacology , Macrophages/drug effects , Osteoblasts/drug effects , Polyethylenes/pharmacology , Adsorption , Algorithms , Animals , Cell Line, Tumor , Colloids/pharmacology , Culture Media , Electromagnetic Fields , Humans , Particle Size , Proteins/chemistry , Rats , Serum Albumin, Bovine/chemistry , U937 CellsABSTRACT
Despite the fact that 50% of postmenopausal women with Colles' fracture have evidence of osteoporosis, the vast majority of women with forearm fractures are neither investigated nor treated for osteoporosis. Digital X-ray radiogrammetry (DXR) provides an attractive option in patients with distal forearm fracture, as it requires no additional X-rays over and above those performed as part of clinical management. We have compared DXR analysis of nonstandardised plain films taken routinely in accident and emergency with peripheral dual energy X-ray absorptiometry (pDXA) in a group presenting with distal forearm fracture. Women presenting with a fracture of the distal forearm underwent pDXA measurements of the calcaneus. Plain X-rays performed at the time of presentation were taken to allow adequate fracture treatment. No additional radiographer training or standardisation of films was performed. The DXR technique relies upon visualisation of the metacarpal shafts and this was not visualised on 123 of 201 (61%) films. The AP plain film was thus assessed using DXR for BMD in the remaining 78 patients with a mean age of 70.6 years (SE = 1.3). Mean BMD for DXR was 0.46 g/cm2 (SE = 0.01) and for pDXA was 0.40 g/cm2 (SE = 0.01). The correlation between BMD measured using the two techniques was 0.55 (P < 0.001). Although DXR measurements could not be performed in all patients, this proportion could easily be increased by routinely including the metacarpal shaft region in X-rays obtained after suspected distal forearm fracture. The correlation between the pDXA and DXR results is comparable with those reported between DXA measurements at the forearm, spine and hip. Our study suggests that DXR may provide a feasible method for the assessment of future fracture risk. The potential advantage of DXR over calcaneal pDXA measurements is that standard forearm X-ray obtained as part of fracture management could be used.