Femoral neck shortening as a sequela of internal fixation for femoral neck fractures and its effect on the coronal alignment of the limb: a pilot study.

INTRODUCTION: Femoral neck shortening is a common phenomenon following osteosynthesis for femoral neck fractures, which was shown to have a negative effect on hip function. There is paucity of literature on the effect of shortening on the ipsilateral limb mechanical axis and knee coronal alignment. We hypothesized that postoperative femoral neck shortening can alter the limb's mechanical axis into valgus. METHODS: Of 583 patients screened, 13 patients with severe neck shortening (< 10 mm) following femoral neck fracture fixation, were found eligible and agreed to participate. A full-length lower limb radiographs were obtained and radiographic parameters (offset, neck-shaft angle, HKA, mLPFA, mDLFA, mMPTFA, MAD, MAD-r) as well as functional scores were obtained. RESULTS: Statistically significant differences in mechanical axis deviation ratio (MAD-r) were found between the ipsilateral and the contralateral extremities (0.41 ± 0.16 versus 0.55 ± 0.11, p = 0.03). A correlation between femoral neck length differences and MAD was not statistically significant although a tendency towards lateral deviation of the mechanical axis was noted (r = - 0.5, p = 0.077). A negative correlation was found between a greater difference in the femoral neck length and the SF12 score, both in the physical and the mental parts (r = - 0.69, p = 0.008; r = - 0.58, p = 0.035, respectively). CONCLUSION: We found a more lateralized mechanical axis in limbs that demonstrated post-operative ipsilateral femoral neck severe shortening. These findings may provide a possible explanation and rationale for knee pain and perhaps for the development of knee osteoarthritis as a sequalae of femoral neck shortening. Further investigation and larger cohort, long-term studies are needed to further explore this hypothesis.

Patterns of limitations in activities of daily living, sleep, and pain in the early postoperative period following total shoulder arthroplasty: a prospective study.

Background: The aim of this study is to investigate the pattern of changes in activities of daily living (ADLs), sleep disturbance, and pain in the early postoperative period following a total shoulder arthroplasty (TSA). Methods: Prospective data on patterns of limitation in ADLs, sleep disturbance, and pain were collected from patients undergoing elective TSA preoperatively and at specific time points postoperatively (2, 6, and 12 weeks). At each time point, patients were asked regarding the major limitation affecting their shoulder. Limitations in ADLs and sleep disturbances were scored on a 3-point scale (0 = unable to do, 3 = no difficulty) modeled after the ADL which require active external rotation score and visual analog scale scores were used for pain. Patient responses were analyzed with respect to patient factors (demographics, arm dominance, function of opposite arm, and ambulation status), and living situation (alone, or with caregiver). Results: Shoulder pain (43%) and inability to perform ADLs (38%) were the 2 most commonly reported limitations prior to undergoing TSA. Patients noticed progressive improvements in pain with 37% reductions in visual analog scale scores at 2 weeks and 67% reduction at 3 months. At 2 weeks after TSA, sleep disturbances were the most disabling issue in 33% of the cohort, with considerable improvements (104%) in sleep scores at 3 months compared to pre-op. The ADLs involving forward elevation and working at the waist level improved considerably between 6 weeks and 3 months, but activities involving rotation including reaching behind the back, across the chest, and use of strength showed mild improvements by 3 months. Conclusion: This prospective study demonstrates the chronology of improvements in pattern of limitations experienced by patients with respect to pain, sleep, and ADLs in the early postoperative period after TSA. Majority of patients can expect to have 2/3 resolution of pain, improved sleep, and improvement in ADLs involving forward elevation and waist level function by 3 months.

Overutilization of Radiographs for Pulled Elbow Among Orthopedic Surgeons Compared With Pediatricians.

METHODS: Electronic medical records of the largest health provider in Israel, which provides health services to more than 50% of the population, were reviewed for pulled elbow cases between 2005 and 2020. Patients aged 4.5 months to 7 years were included. Demographic information, the discipline of the treating physician, and acquisition of elbow radiographs were gathered. RESULTS: A total of 4357 patients, 62.8% girls, were included. The average body mass index was 16.1 (SD, 1.2). Most patients were from communities in the upper half of the socioeconomic status clusters 6 to 10 (64.63%). Most patients were attended by a pediatrician (51.5%), followed by an orthopedic surgeon (19.9%). Radiographs were acquired for 570 children (13.1%). Most radiographs (36.5%) were requested by orthopedic surgeons and for children in the boundary age groups. The patient's socioeconomic status was associated with access to physicians of different subspecialties, and lower income families had a higher tendency to be treated by nonspecialized physician ( P < 0.001). CONCLUSIONS: Orthopedic surgeons use elbow radiographs much more than pediatricians; effort should aim at reducing the imaging rate for this population.

3D-MRI versus 3D-CT in the evaluation of glenoid deformity in glenohumeral arthritis using Dixon 3D FLASH sequence.

OBJECTIVE: To compare MRI with 3D reconstructions and 3D-CT with respect to assessment of glenoid wear in osteoarthritic shoulders. METHODS: 3D reconstructions were generated for CT and MR (utilizing the Dixon technique) imaging performed on 29 osteoarthritic shoulders. Two reviewers independently performed glenoid morphometric measurements and evaluated glenoid erosion. Mean differences between the two modalities were calculated. Inter-observer agreement was calculated using kappa coefficient. RESULTS: The combined mean absolute difference (bias) in glenoid version between 3D-CT and 3D-MRI was 2.7° ± 1.6° (range 0.15-7.85, P value = 0.7). The combined mean absolute difference in glenoid inclination between 3D-CT and 3D-MRI was 6.8° ± 4.1° (range 0.8°-15.75°, P value = 0.17). No significant inter-reader variation in glenoid version and inclination measurements on 3D-CT and 3D-MRI was found (P > 0.05). The inter-reader reliability for both CT and MRI was high for Walch grading of glenoid bone loss (κ = 1, κ = 0.81, respectively). CONCLUSIONS: 3D-MRI is comparable to 3D-CT with respect to axial glenoid bone loss, as measured by glenoid version. However, for coronal bone loss estimation, measured by glenoid inclination, 3D-CT remains the gold standard. Thus, 3D-MR can be used as an alternative for preoperative assessment of glenoid version in arthritic shoulders.

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty.

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.

Effects of focused continuous pulsed electromagnetic field therapy on early tendon-to-bone healing.

AIMS: Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. METHODS: A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals' left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks. RESULTS: Extension of the tendon from preload to the maximum load to failure was significantly better in the PEMF-treated shoulders at three weeks compared to controls (p = 0.038). The percentage strain was significantly higher in the PEMF group at both timepoints (p = 0.037). Collagen organization was significantly better (p = 0.034) as was tissue mineral density in the PEMF-treated group at three weeks (p = 0.028). Tendon immunohistochemistry revealed a prominent increase in type I collagen at the repair site at three weeks following continuous PEMF treatment compared with controls. None of the other tested parameters differed between the groups. CONCLUSION: MED-generated PEMF may enhance early postoperative tendon-to-bone healing in an acute rat supraspinatus detachment and repair model. Superior biomechanical elasticity parameters together with better collagen organization suggest improved RC healing. Cite this article: Bone Joint Res 2021;10(5):298-306.

Correlation of Patient Reported Outcome Measurement Information System (PROMIS) with American Shoulder and Elbow Surgeon (ASES), and Constant (CS) scores in idiopathic adhesive capsulitis.

PURPOSE: To correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with pre-existing validated outcome scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC). METHODS: Patients with a clinical diagnosis of idiopathic AC ("freezing" or "frozen" phases) who agreed to complete the ASES, CS, and PROMIS UE scores during their office visit were included in this study. Trained researchers performed the objective clinical assessments on the included patients. Responses to the 3 outcome scores were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were calculated. RESULTS: The final cohort included 100 patients with AC, of whom there were 72% female and 87% right hand dominant, with a mean age of 55 years. The PROMIS UE required fewer question responses (5.02 ± 1.84) compared with the fixed question burden with ASES (12) and CS (9). The mean outcome scores were 34.6 ± 2.5 (PROMIS UE), 55 ± 22 (ASES), and 51 ± 16 (CS). The PROMIS UE displayed an excellent correlation with both the ASES (r = 0.80, 95% confidence interval [0.72, 0.86], P < .001) and CS (r = 0.76, 95% confidence interval [0.67, 0.83], P < .001). Neither ceiling nor floor effects were present. CONCLUSION: The PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in AC. A lower question burden with the PROMIS UE carries potential for wider acceptability with the researchers and patients with shoulder pathology.

Impact of preoperative 3-dimensional planning and intraoperative navigation of shoulder arthroplasty on implant selection and operative time: a single surgeon's experience.

BACKGROUND: Preoperative 3D planning and intraoperative navigation for shoulder arthroplasty has recently gained interest because of the potential to enhance the surgeon's understanding of glenoid anatomy and improve the accuracy of glenoid component positioning. The purpose of our study was to assess the impact of preoperative 3D planning on the surgeon's selection of the glenoid component (standard vs. augmented) and compare duration of surgery with and without intraoperative navigation. METHODS: We retrospectively analyzed 200 consecutive patients who underwent shoulder arthroplasty. The first group of 100 patients underwent shoulder arthroplasty using standard 2D preoperative planning based on standard radiographs and computed tomographic scans. The second group of 100 patients underwent shoulder arthroplasty using 3D preoperative planning and intraoperative navigation. Type of glenoid component and operative time were recorded in each case. RESULTS: For the group of patients with standard preoperative planning, only 15 augmented glenoid components were used, whereas in the group of patients with 3D preoperative planning and navigation, 54 augments were used (P < .001). The operative time was 11 minutes longer for the procedures that used intraoperative navigation, compared with those that did not (P < .001). This difference diminished as the surgeon became more proficient with the navigation technique. CONCLUSION: Use of preoperative 3D planning changes the surgeon's understanding of the patient's glenoid anatomy. In our study, using 3D planning increased the likelihood that the surgeon selected an augmented glenoid component compared with 2D planning. Intraoperative navigation slightly lengthened the duration of surgery, but this became insignificant as part of a learning curve within 6 months.

Biocompatibility of a Marine Collagen-Based Scaffold In Vitro and In Vivo.

Scaffold material is essential in providing mechanical support to tissue, allowing stem cells to improve their function in the healing and repair of trauma sites and tissue regeneration. The scaffold aids cell organization in the damaged tissue. It serves and allows bio mimicking the mechanical and biological properties of the target tissue and facilitates cell proliferation and differentiation at the regeneration site. In this study, the developed and assayed bio-composite made of unique collagen fibers and alginate hydrogel supports the function of cells around the implanted material. We used an in vivo rat model to study the scaffold effects when transplanted subcutaneously and as an augment for tendon repair. Animals' well-being was measured by their weight and daily activity post scaffold transplantation during their recovery. At the end of the experiment, the bio-composite was histologically examined, and the surrounding tissues around the implant were evaluated for inflammation reaction and scarring tissue. In the histology, the formation of granulation tissue and fibroblasts that were part of the inclusion process of the implanted material were noted. At the transplanted sites, inflammatory cells, such as plasma cells, macrophages, and giant cells, were also observed as expected at this time point post transplantation. This study demonstrated not only the collagen-alginate device biocompatibility, with no cytotoxic effects on the analyzed rats, but also that the 3D structure enables cell migration and new blood vessel formation needed for tissue repair. Overall, the results of the current study proved for the first time that the implantable scaffold for long-term confirms the well-being of these rats and is correspondence to biocompatibility ISO standards and can be further developed for medical devices application.

Total Shoulder Arthroplasty Utilizing the Subscapularis-Sparing Approach.

Traditionally, total shoulder arthroplasty is performed through the deltopectoral approach with violation of the subscapularis tendon. In order to reduce the incidence of postoperative subscapularis dysfunction, the subscapularis-sparing approach, performed entirely through the rotator interval, was developed. This technique allows earlier rehabilitation and may potentially prevent subsequent subscapularis insufficiency and clinical failures.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Their Effect on Musculoskeletal Soft-Tissue Healing: A Scoping Review.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are being increasingly employed as a part of multimodal non-opioid strategies to treat postoperative pain. In the present study, we sought to review the effects of short-term NSAID use on musculoskeletal soft-tissue healing. METHODS: We performed a scoping review of all studies that included the use of NSAIDs and their effect on healing of soft tissues, which for the purpose of this review refers to non-osseous musculoskeletal tissue such as ligament, tendon, labrum, and meniscus. The inclusion criteria encompassed all studies (human, animal, and in vitro) that evaluated the effect of NSAIDs on soft-tissue healing. Subgroup analyses, wherever applicable, were conducted on the basis of the type of NSAID (cyclooxygenase [COX]-specific or nonspecific) and the type of study (human, animal, or in vitro). Relevant metadata from each study were abstracted, and descriptive statistics were used to summarize the results. RESULTS: A total of 44 studies met the inclusion criteria, including 3 human studies, 33 animal studies, and 8 in vitro studies. These studies included 4 different NSAIDs in the human subgroup, 16 different NSAIDs in the animal subgroup, and 7 different NSAIDs in the in vitro subgroup. The majority of reported studies (including 1 of 2 human studies, 10 of 14 animal studies, and 3 of 3 in vitro studies) demonstrated that COX-2-selective inhibitors had negative impact on soft-tissue healing. In contrast, the majority of human and animal studies (2 of 2 and 19 of 30, respectively) demonstrated that nonselective COX inhibitors had no negative effect on the healing of labrum, tendons, and ligaments. The majority of in vitro studies demonstrated that NSAIDs have a harmful effect on biological processes involved in tendon-healing and regeneration (tenocyte proliferation, collagen and glycosaminoglycan synthesis). CONCLUSIONS: Current limited evidence demonstrates that selective COX-2 inhibitors can negatively affect healing of musculoskeletal soft tissue after surgical repair. In contrast, the majority of studies demonstrate that nonselective COX inhibitors have no negative effect on musculoskeletal soft-tissue healing. Additional high-quality human clinical trials are necessary to provide more definitive conclusions.

Rate and Outcome of Acute Kidney Injury Following Hip Fracture Surgery in Diabetic Older Patients Treated with Renin-Angiotensin-Aldosterone Antagonists.

BACKGROUND: The use of renin-angiotensin-aldosterone system inhibitors has increased over the past few years. There are conflicting data as to their relationship with acute kidney injury following surgery. OBJECTIVES: The objective of the article was to evaluate the risk of acute kidney injury in diabetic older patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and their medical outcomes following fragility hip fracture surgery. METHODS: Consecutive diabetic patients presenting with fragility hip fractures to our primary trauma center between January 2012 and June 2016 were included. Demographic and clinical data, including co-morbidities, medication use, and laboratory results, were collected from the electronic medical records. The primary outcome was the incidence of acute kidney injury; the secondary outcome was 1-year mortality. RESULTS: Two hundred and seventeen patients were included; 125 were receiving treatment with medications targeting the renin-angiotensin-aldosterone system. Demographic and clinical characteristics were similar between groups. No association was found between the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and the risk of acute kidney injury, which occurred in 25% of the cohort. Univariate analysis revealed that diuretic use, particularly furosemide, increased the risk of acute kidney injury during hospitalization (p = 0.003). However, in a multivariate analysis, only age and estimated glomerular filtration rates were associated with an increased risk of acute kidney injury. Patients with acute kidney injury were found to have increased mortality during the first post-operative year (p < 0.001). CONCLUSIONS: Acute kidney injury is a frequent complication after hip fracture surgery in elderly diabetic patients and is associated with increased 1-year mortality; however, it was not found to be associated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker pre-fracture treatment.

Total Shoulder Arthroplasty Using Intraoperative 3D Navigation.

Glenohumeral arthritis has become increasingly prevalent. For patients with glenohumeral arthritis and an intact rotator cuff, an anatomic total shoulder arthroplasty (TSA) has been shown to provide substantial pain relief with consistent, reproducible results. The primary indication is intractable pain that has not responded to nonoperative treatment, resulting in a substantial negative impact on the quality of life of the patient. Other indications for anatomic TSA include posttraumatic glenohumeral arthritis, inflammatory arthritis, and humeral head osteonecrosis. Contraindications include active infection, deltoid insufficiency, severe glenoid bone deficiency, and excessive glenohumeral posterior subluxation or laxity that cannot be surgically corrected. In order to provide the stability necessary to withstand the forces that impact the glenoid, the implant used in TSA should replicate the native anatomy of the individual patient by using a combination of implant modularity with different humeral neck angles and glenoid version augments, as well as dual eccentricity of the neck and head implant. The major steps in TSA include (1) preoperative planning, (2) patient positioning and setup, (3) surgical exposure, (4) accessing the glenohumeral joint, (5) preparation of the humerus, (6) exposure and preparation of the glenoid with component insertion, (7) humeral component insertion and trial reduction, (8) subscapularis reattachment and closure, and (9) postoperative immobilization and rehabilitation. The expected outcomes of TSA include improved quality of life (as indicated by improved outcome and patient satisfaction scores), shoulder active range of motion, and strength. In a large study examining outcomes of TSA in patients >55 years old, Patel et al.1 reported improved American Shoulder and Elbow Surgeons (48.3 ± 23.0), Constant (33.1 ± 16.7), and University of California Los Angeles (16.7 ± 6.3) shoulder scores, as well as improved active range of motion in active abduction (42° ± 41°), forward flexion (46° ± 40°), external rotation (33° ± 23°), and internal rotation (2.2° ± 1.8°) and decreased visual analog scale scores (-5.1 ± 2.9). Another study2 showed increased maximal weight improvement of 7.7 ± 4.0 lbs (3.5 ± 1.8 kg).

A Simple and Low-cost Drilling Simulator for Training Plunging Distance Among Orthopedic Surgery Residents.

OBJECTIVE: Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth. DESIGN, SETTING, PARTICIPANTS: This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58), and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 "senior residents" (3+ years) and the 7 "junior residents" during a training session. Measurements were taken again 2 weeks following the training session. RESULTS: Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs. 5.28 mm, respectively, p < 0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents. CONCLUSIONS: This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases.

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or "spare parts technique") has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the "spare parts". The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap. The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound. In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.

[BISPHOSPHONATES AS A PREVENTATIVE TREATMENT FOR OSTEOPOROTIC HIP FRACTURES: A MIXED BLESSING].

BACKGROUND: The widespread use of bisphosphonates for treating osteoporosis in the last two decades has raised concern about the complication of atypical hip fractures secondary to bisphosphonate treatment. These fractures may be the result of a minor trauma to the hip or without any trauma at all. It may be heralded by prodromal groin or hip pain. Prolonged bisphosphonate treatment and atypical fractures may exist, but the nature and the extent of this linkage are still unknown. Currently, there is a lack of adequate evidence-based methods or a consensus about the treatment of this unique phenomenon. METHODS: We retrospectively examined the records of all subtrochanteric hip fracture cases admitted to our department in the years 2010-2014. During that period, we treated a total of 1315 patients:726 patients with pertrochanteric fractures, 514 patients with subcapital fractures and 75 patients with distal subtrochanteric fractures. Among those, 16 patients (1.2%) qualified as atypical hip fractures. The location of the fracture, period of bisphosphonates use, fixation type, complications and recovery were recorded. RESULTS: The average age of the patients in our study was 76.9 years. All patients were treated with bisphosphonates and over 80% of the patients were treated specifically with Alendronate prior to the fracture. Mean treatment time was 7.8 years. Most of the fractures (75%) were subtrochanteric, and the others were at the femur midshaft. All patients received surgical fixation and all accomplished union of the fractures. CONCLUSIONS: It seems reasonable to assume a causative relationship between a long term use of bisphosphonates and the occurrence of atypical hip fractures. It is a relatively rare complication; nevertheless, it should be kept in mind during a long term use of bisphosphonates. According to our department's clinical experience we found no delay in bone union with these atypical hip fractures. It seems reasonable to prophylactically fixate atypical stress fractures before they become a full fracture.

Atypical fractures of the femur related to prolonged treatment with bisphosphonates for osteoporosis.

BACKGROUND: Bisphosphonates reduce the overall risk of fractures among patients with osteoporosis, and this beneficial effect is long-lasting. However, since bisphosphonates inhibit bone remodeling, they may enhance the formation and propagation of micro-cracks over time and patients may therefore be prone to atypical fatigue fractures, mainly in the subtrochanteric region and femoral shaft. OBJECTIVES: To present two cases of subtrochanteric fractures related to bisphosphonate treatment, and review the current literature. CONCLUSIONS: Despite the overall beneficial effect of bisphosphonates, further research is required to prevent this significant complication.

A multidisciplinary survey on controversies in the use of EUS-guided FNA: assessing perspectives of surgeons, oncologists and gastroenterologists.

BACKGROUND: EUS-guided FNA can help diagnose and differentiate between various pancreatic and other lesions.The aim of this study was to compare approaches among involved/relevant physicians to the controversies surrounding the use of FNA in EUS. METHODS: A five-case survey was developed, piloted, and validated. It was collected from a total of 101 physicians, who were all either gastroenterologists (GIs), surgeons or oncologists. The survey compared the management strategies chosen by members of these relevant disciplines regarding EUS-guided FNA. RESULTS: For CT operable T2NOM0 pancreatic tumors the research demonstrated variance as to whether to undertake EUS-guided FNA, at p < 0.05. For inoperable pancreatic tumors 66.7% of oncologists, 62.2% of surgeons and 79.1% of GIs opted for FNA (p < 0.05). For cystic pancreatic lesions, oncologists were more likely to send patients to surgery without FNA. For stable simple pancreatic cysts (23 mm), most physicians (66.67%) did not recommend FNA. For a submucosal gastric 19 mm lesion, 63.2% of surgeons recommended FNA, vs. 90.0% of oncologists (p < 0.05). CONCLUSIONS: Controversies as to ideal application of EUS-FNA persist. Optimal guidelines should reflect the needs and concerns of the multidisciplinary team who treat patients who need EUS-FNA. Multi-specialty meetings assembled to manage patients with these disorders may be enlightening and may help develop consensus.