Teriparatide for treatment of patients with bisphosphonate-associated atypical fracture of the femur.

The Fracture Improvement with Teriparatide (Fix-IT) study randomized 13 women with an atypical femur fracture to immediate vs delayed teriparatide therapy; all were followed for 12 months. Results suggested a trend for superior healing and lesser bone mineral density declines in the immediate vs delayed group with no differences in adverse events. PURPOSE: Little clinical data are available on the use of teriparatide for the treatment of bisphosphonate-associated atypical femur fractures (AFF). The goal of the Fix-IT study was to determine if immediate therapy with teriparatide was superior for fracture healing after an AFF compared to a 6-month delay in teriparatide therapy. METHODS: This randomized pilot clinical trial included 13 women with an AFF who were randomized to immediate teriparatide vs a delay of 6 months. All were followed for 12 months on teriparatide. The primary outcomes included individual and composite measures of radiologic bone healing (scored 1 point [no healing] to 4 points [complete healing]) at 6 and 12 months. Secondary outcomes included bone mineral density of the unfractured contralateral hip, spine, 1/3 distal radius, and adverse events. RESULTS: We found there was a trend for superior healing with the composite score (12.6 vs 11.2 at 6 months and 15.4 vs 13.2 at 12 months), and lesser bone mineral density declines at the 1/3 distal radius (12-month change - 1.9 vs - 6.1%) in the immediate vs the delayed group. There were no differences in adverse events. There was one implant failure in the delayed group. CONCLUSIONS: There is a preliminary signal for greater improvements with immediate teriparatide therapy vs delayed therapy. However, because an AFF is a rare event, and only a small number of patients were included, the results must be interpreted with caution.

Plate augmentation for femoral nonunion: more than just a salvage tool?

OBJECTIVE: The aim of the current study was to determine whether plate augmentation was a successful treatment algorithm for selected femoral nonunions initially managed with intramedullary nailing. MATERIALS AND METHODS: A total of 30 femoral nonunion cases were managed using the plate augmentation strategy with 13 primary cases and 17 multi-operated femurs (avg 2.8 ineffective procedures). Adjunctive strategies included autologous bone grafting and/or BMP for atrophic/oligotrophic and bone defect cases. Deformity correction was performed when required. RESULTS: Osseous union occurred in 29 of 30 cases. One multi-operated case with bone defect and prior infection required repeat autologous grafting prior to union. CONCLUSION: Plate augmentation should be added to the armamentarium for management of selected femoral nonunion that have failed initial intramedullary nailing.

Wedge effect following intramedullary hip screw fixation of intertrochanteric proximal femur fracture.

INTRODUCTION: The aim of the current study was to determine whether application of an intramedullary hip screw for definitive management of intertrochanteric fracture was associated with post-operative deformity. Specifically this study investigated whether nail insertion would cause a "wedge effect" of the intertrochanteric fracture manifesting as lateralization of the femoral shaft and varus malalignment. MATERIALS AND METHODS: The trauma database at the University of Pittsburgh Medical Center was investigated to identify all intertrochanteric fractures (AO/OTA 31A) over the past 3 years treated with an IMHS. Fractures eligible for inclusion were performed under the supervision of a fellowship trained orthopedic trauma surgeon. All fractures were reduced in optimal alignment using percutaneous or mini-open strategies during the reaming process and nail insertion. The entry portal was over-reamed by at least 1.5 mm. Cases selected for review of the "wedge effect" had optimal post-operative imaging allowing for assessment of discrepancy between the operative and normal hip. RESULTS: Forty six patients with an average age of 77 years were included for study. Fifty percent were classified as unstable patterns. Shaft lateralization following IMHS fixation of the fractured hip was found to be an average of 7 mm greater than the contralateral intact hip (p < 0.001) (range 0-30 mm). The neck-shaft angle of the operative hips was 129° as compared to 133° on the intact side (p = 0.009). The stability of the fracture pattern was not predictive for post-operative lateralization of the femoral shaft or varus angulation (p > 0.05) (Table 2). There was no difference in post-operative deformity among techniques used for maintenance of reduction during reaming and nail insertion (p > 0.05). Despite deformity, all cases demonstrated radiographic radiographic fracture union. CONCLUSION: Despite attention to detail, the application of an intramedullary hip screw for intertrochanteric fracture has the tendency to lateralize the shaft relative to the head/neck segment (The "wedge effect").

Penning ionization and ion fragmentation of formamide HCONH2 by He*, Ne*, and Ar* in molecular beams.

Mass spectra from Penning ionization by metastable atom bombardment (MAB) in the title system at kinetic energies near 1 kcal/mol are reported. The experiments employ a supersonic excited noble gas beam crossing an effusive beam of formamide vapor. Product ions are extracted perpendicular to the plane of the beams, analyzed by a quadrupole mass filter, and counted by a scintillation-type ion counter. Relative to 70 eV electron impact, the He(*) and Ne(*) spectra show more extensive breakage of C-N and C-H bonds despite the smaller available energy, while the Ar(*) spectrum shows only the molecular ion (m/z 45), H atom elimination (44), and the decarbonylation products CO+NH(3)(+) (17). Fragmentation in the latter system has been analyzed using a combination of ab initio calculations and Rice-Ramsperger-Kassel-Marcus theory with tunneling correction; good agreement with the experimental 45/44/17 intensity ratio 100/6.8+/-0.7/6.2+/-1.7 is obtained. 15% of m/z 17 and 50% of m/z 44 is attributed to tunneling. The ab initio decarbonylation reaction path yields a hydrogen bonded H(2)N-HCO(+) transition state, which transfers a proton while proceeding downhill to the observed products, while both the path and the energetics support the earlier conclusion that the lowest lying electronically excited state of the ion (2pi or 2a(")) crosses the ground state early along the reaction path, thereby dominating the dynamics of decarbonylation.

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau.

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

Dynamics of ionization of H2 by Ne*(3P) investigated by electron spectroscopy.

The Penning ionization reaction Ne*(2p(5)3s 3P)+H2-->[NeH2]+ +e- has been studied in crossed supersonic molecular beams with electron-energy analysis at four collision energies E = 1.83, 2.50, 3.16, and 3.89 kcal/mol. The electron kinetic-energy spectra, which directly reflect the ionizing transition region, show resolved peaks assignable to v' = 0-4 of H2+. The vibrational populations deviate systematically from Franck-Condon behavior, suggesting that the discrete-continuum coupling increases with H2 bond stretching. Each peak displays both increasing breadth and increasing blueshift with increasing E, and the blueshift also increases with increasing v'. The first two properties are consistent with a predominantly repulsive excited-state potential-energy surface, while the last is speculated to be a reflection of the rHH dependence of the ionic surface. Quantum scattering calculations based on ab initio potential surfaces for the excited and ionic states in spherical and infinite-order-sudden rigid rotor approximations are in semiquantitative agreement with the measurements. Discrepancies suggest changes in the imaginary, absorptive part of the excited surface, which probably can be best effected by multiproperty fitting calculations.

Angle-energy distributions of Penning ions in crossed molecular beams. IV. He*(21 S,2 3S)+H2-->He+H2+ +e-.

Relative doubly differential cross sections for the Penning ionization of H(2) by spin-state-selected metastable He (1s2s) are reported at center-of-mass collision energies E of 3.1 and 4.2 kcal/mol in a crossed supersonic beam experiment employing a rotatable mass spectrometer detector. The measurements are sufficiently dense in velocity space as to avoid having to functionalize the differential cross sections in order to transform the intensities into the c.m. The H(2) (+) product is scattered sharply forward, c.m. Deltatheta<10 degrees half-width at half-maximum, with respect to the incident direction of H(2) at both energies for both spin states. On the average the products have lost energy upon recoil, mean recoil energy E(')

Classification of inhalation injuries.

A new system of classification of inhalation injuries called APB classification is proposed. The classification is based on the anatomical level of the injury (A), degree of pathological changes of the respiratory tract mucosa (P), extent and severity of associated cutaneous burns (B). The authors assume the classification would be of help in the analysis of severity, prognosis and treatment methods of inhalation injuries particularly in larger groups of burn patients.