Primary Hyperparathyroidism and Pulmonary Embolism in Patients With a Fractured Neck of Femur.

Two patients aged 82 and 77, with a fractured neck of the femur, were found to have primary hyperparathyroidism, characterized by hypercalcemia and hypercalciuria. Post-surgery, both developed pulmonary embolism (PE), highlighting a possible link between hypercalcemia and increased hypercoagulation risk. There have been few case reports suggesting the association between hypercalcemia due to hyperparathyroidism and the increase in tendency of hypercoagulation and subsequent risk of venous thromboembolism (VTE). This case series offers insights into how ionized calcium influences thrombin formation, platelet activation and aggregation, and activation of clotting factors such as factor VII and factor X, raising questions about the role of chronic hypercalcemia in VTE. Further research is needed to 1) establish whether chronic hypercalcemia in the absence of fracture can modulate the risk of hypercoagulation; 2) determine whether chronic hypercalcemia in individuals with bone fracture may represent a significantly higher hypercoagulability risk during the postoperative periods.

Total Hip Arthroplasty with Extra-small Femoral Stems in Extremely Hypoplastic Femurs: A Case-Series Study.

Background: Total hip arthroplasty (THA) in patients with hypoplastic femurs presents a significant challenge to orthopedic surgeons due to the limited space available for implant placement. Therefore, the extra-small femoral stems have been proposed as a solution to this problem, but there are limited data on the outcomes. We aimed to evaluate clinical and radiological outcomes of THA in patients with extremely hypoplastic femurs using the Bencox CM stem (Corentec), an extra-small femoral stem. Methods: We included 6 hips from 4 patients. The mean age of the patients was 41.2 years (range, 19.6-60.4 years). The mean height was 135.1 cm (range, 113.6-150.0 cm) with a mean body mass index of 25.7 kg/m2 (range, 21.3-31.1 kg/m2). The diagnoses for THA were sequelae of septic arthritis in childhood, pseudoachondroplasia, spondyloepiphyseal dysplasia, and juvenile rheumatoid arthritis. Preoperative computed tomography scans were conducted to assess the extent of proximal femoral hypoplasia. The clinical outcomes were assessed using the modified Harris Hip Score, while the radiological outcomes were evaluated using radiographs. The mean follow-up was 2.3 years (range, 1.0-5.9 years). Results: The average modified Harris Hip Score improved to 88.8 at the final follow-up. Intraoperative femoral fractures occurred in 2 cases (33.3%). During the follow-up, 1 stem underwent varus tilting from postoperative 6 weeks to 6 months without subsidence. Otherwise, all stems showed good osteointegration at the latest follow-up. No hip dislocations, periprosthetic joint infection, or loosening of the prosthesis occurred. Conclusions: The use of extra-small femoral stems in THA for extremely hypoplastic femurs can provide reasonable clinical and radiological outcomes with minimal complications. We suggest that this femoral stem could be a viable option for patients with extremely hypoplastic femurs.

Extra Medullary Fixation in Unstable Proximal Femoral Fractures by PF-LCP.

Purpose: Perception that extra-medullary fixation of these fractures are fraught with difficulties and deficiencies is becoming inappropriate. This device provides angular stable fixation retaining fracture biology with minimum interference to osseous and soft-tissue vascularity and it does not require reaming which destroys 80% of endosteal vasculature for 6-12 weeks. PFLCP averts iatrogenic fracture in lateral trochanteric wall (LTW) which is frequent with DHS, protects LTW from secondary fracture in post-operative period. Aim is to assess outcome of unstable proximal femur fracture fixation by PFLCP. Methods: Study included 64 from 2016 to 2020, divided in two groups. (A) Unstable intertrochanteric fracture and (B) subtrochanteric fracture (Seinsheimer types II-V). All fractures fixed by MIPO with PFLCP. Loss of reduction, infection, cut-out, cut-through, backing of screws, bending or breaking of plate and screw, malunion, non-union and revision were evaluated. Fracture healing and functional recovery assessed by Reborne Score and Parker Mobility Score (PMS) respectively. Results: Out of 64, 24 achieved pre-injury PMS, 32 declined by 1 point, 6 declined by 2 points and 1 by 3 points, one required revision. Using various parameters 37.5% patients had excellent results and 50% had good results, 9.38% had average and 3.12% had poor result. None reported non-union or breakage of plate. Conclusions: PFLCP provides angular stable fixation, torsional stability with high biomechanical strength to resist deforming stresses. MIPO avoids soft-tissue stripping reducing blood-loss, retains periosteal blood supply to inter-fragmentary bone fragments, enhancing fracture healing, reducing complications, such as delayed healing, nonunion, infection and implant failure.

Zoledronic Acid and Enriched Autologous Bone Marrow Stem Cell Implantation for Femoral Head Osteonecrosis.

Purpose: This study evaluated the clinical results of zoledronic acid in the treatment of early osteonecrosis of the femoral head (ONFH). Materials and Methods: Study retrospectively analyzed 60 patients with zoledronic acid with bone marrow stem cell (BMSC) implantation (The study group) and 64 patients with BMSC implantation (The control group). The primary evaluation index included VAS, HHS, collapsed rate, and total hip replacement arthroplasty (THA) conversion rate. Results: The study group had a lower VAS (1.12 ± 0.22 vs 1.44 ± 0.32) and higher HHS (75.07 ± 3.66 vs 68.78 ± 2.24) compared to the control group in 6 months after surgery (P < 0.05). In the study group, 12 hips (20%) collapsed, and 7 of 60 hips (11.67%) required THA surgery at the last follow-up. However, 25 hips (38.8%) collapsed in the control group, and 19 hips (29.69%) required THA surgery. The study group had a lower collapsed rate (P = 0.029) and THA conversion rate (P = 0.016) in survival analysis. Conclusion: Zoledronic acid and BMSC implantation in the treatment of early ONFH is safe and effective, reduces pain shortens recovery time, and reduces collapsed rate and THA conversion rate in ONFH patients.

Comparison of the efficacy and safety of transdermal buprenorphine patch to conventional analgesics after operative fixation of extra capsular fracture of proximal femur.

INTRODUCTION: Proximal femur fractures are common among older individuals and pose challenges in achieving effective post-operative analgesia. Age-related co-morbidities limit the selection of analgesics in this population. This study aimed to compare the safety and effectiveness of transdermal buprenorphine (TDB) patch with traditional analgesics after fixation of an extracapsular fracture of the proximal femur. METHODOLOGY: A prospective randomized controlled study was conducted over a 2-year period, involving 60 patients who underwent surgery for extra capsular intertrochanteric fracture fixation. The patients were randomly assigned to two groups by random envelope method. Group A received an intravenous formulation of paracetamol and tramadol for the initial 48 h, followed by an oral formulation. Group B received a transdermal buprenorphine (TDB) patch delivering 5 mcg/hour immediately after surgery, which continued for 2 weeks postoperatively. During the 14-day monitoring period, patients' pain scores were assessed using the Visual Analog Scale (VAS) at rest and during movement. The primary objective was to maintain a VAS score of 4 or lower. Rescue analgesics were administered if the VAS score reached 6. The secondary objectives included evaluating the quantity of rescue analgesics required and monitoring for any adverse effects or complications. RESULTS: Pain scores at rest and during movement were significantly lower in Group B at all-time points (p-value 0.0006 - ≤ 0.0001), and the requirement for rescue analgesia was also significantly lower in this group. The administration of the TDB patch did not result in any significant adverse effects. CONCLUSION: TDB patch is secure and offers better compliance and analgesia than other analgesics in the postoperative period whilst treating proximal femur extra capsular fracture.

Pilot study of three novel implants-GSK triangular system, locking hip screw and controlled sliding dynamic hip screw, for fixation of fracture of the neck of femur.

BACKGROUND AND OBJECTIVE: Intra capsular fracture of the neck of femur (FNF) treated traditionally with a dynamic hip screw (DHS) or three cancellous screws (3CS) has a high incidence of complications with reoperation rates between 20 % and 45 %. We hypothesized that FNF unites by primary healing. Therefore, intra-operative compression and absolute stability post-operatively until healing are essential. We postulated that FNF requires 2 types of implants- those which provide absolute stability for young patients with good bone stock and another with sliding mechanism for elderly patients with osteoporosis. We developed three novel fixation systems at our research institute in India using a modified DHS. In patients with good bone stock, locking DHS, called LHS and GSK triangular system (GSKT) provided intra-operative compression and absolute stability during the post-operative period. In those with poor bone stock, the controlled sliding DHS (CSDHS)was used as a locking implant might penetrate the hip joint. MATERIALS AND METHOD: 42 patients of FNF <55 years of age were studied. Among 39 patients with good bone stock, LHS was used in five patients and GSKT system was used in 34 patients. CSDHS was used in three patients with poor bone stock or communition. The patients were followed up for a minimum of eight months up to a maximum of two years, with the average follow up duration of 14 months. RESULTS: 32 out of 34 fractures treated by GSKT system united. Five cases managed by LHS and three by CSDHS, all united. The union rate was 95.2 %. Of the two failed cases, one patient had nonunion (NU), the other had deep infection. Avascular necrosis of the head (AVN) was detected in three patients treated with GSKT system in the second year following surgery. Two of them had hip pain while one was asymptomatic. Eight cases of FNF Pauwels type III underwent a primary valgus osteotomy. All of them united without complications. CONCLUSION: In patients with good bone stock, LHS and GSKT system allowed intra-operative compression and absolute post-operative stability without sliding of head fragment as the triangle construct is biomechanically the strongest. When bones are osteoporotic, a CSDHS provided controlled sliding (1 to 5 mm only). This pilot study showed a promising success rate of 95.2 %. We propose that the GSKT system may be used to treat intertrochanteric and other metaphyseal fractures as well. Further biomechanical studies are underway to strenghten the evidence needed for the widespread use of these implants.

Three-dimensional-printed femoral diaphysis for biomechanical testing-Optimization and validation.

Polylactic acid (PLA) models of normal human femoral diaphyses were designed using three-dimensional (3D) printing technology to create inexpensive, accessible, and reproducible specimens for flexural biomechanical studies. These models were subjected to three-point bending and their response to loading was characterized. The anisotropic mechanical behavior of the 3D-printed femurs and the influence of printing orientations, infill density, wall layers, resolution, and other printing parameters were explored to develop a design space. The objective of the design space was set to emulate the flexural biomechanical response of the normal human femur bones. Results show the 3D-printed PLA diaphyseal femurs with 5% infill density, two-four wall layers, and a resolution of 200 µm resulted in a flexural strength of 184.8 ± 8.18 MPa. Models with 20% infill density and six wall layers resulted in a flexural modulus of 18.54 ± 0.543 GPa. These results emulate the biomechanical response of the normal human femur, as determined by historical target values derived from prior cadaveric and 3D printing data. With further research, inclusive of modeling the proximal and distal femur and more comprehensive biomechanical testing, 3D-printed femurs may ultimately serve as a cheap, accessible biomechanical resource for surgeons and researchers.

Current Concepts in Management of Distal Femur Fractures.

Recent studies report the overall incidence of distal femur fractures as 8.7/100,000/year. This incidence is expected to rise with high energy motor vehicle collisions and elderly osteoporotic fractures in native and prosthetic knees keep increasing. These fractures are more common in males in the younger age spectrum while females predominate for elderly osteoporotic fractures. Surgical treatment is recommended for these fractures to maintain articular congruity, enable early joint motion and assisted ambulation. Over the last two decades, development of minimally invasive and quadriceps sparing surgical approaches, availability of angle stable implants have helped achieve predictable healing and early return to function in these patients. Currently, laterally positioned locked plate is the implant of choice across all fracture patterns. Retrograde with capital implantation of intramedullary nails with provision for multiplanar distal locking is preferred for extra-articular and partial articular fractures. Even with these advancements, nonunion after distal femur fracture fixation can be as high as 19%. Further recent research has helped us understand the biomechanical limitations and healing problems with lateral locked plate fixation and intramedullary nails. This has lead to development of more robust constructs such as nail-plate and double plate constructs aiming for improved construct strength and to minimise failures. Early results with these combination constructs have shown promise in high risk situations such as fractures with extensive metaphyseal fragmentation, osteoporosis and periprosthetic fractures. These constructs however, run the risk of being over stiff and can inhibit healing if not kept balanced. The ideal stiffness that is needed for fracture healing is not clearly known and current research in this domain has lead to the development of smart implants which are expected to evolve and may help improve clinical results in future.

Gene-based association analysis of a large patient cohort provides insights into genetics of atypical femur fractures.

BACKGROUND: Several small genetic association studies have been conducted for atypical femur fracture (AFF) without replication of results. We assessed previously implicated and novel genes associated with AFFs in a larger set of unrelated AFF cases using whole exome sequencing (WES). METHODS: We performed gene-based association analysis on 139 European AFF cases and 196 controls matched for bisphosphonate use. We tested all rare, protein-altering variants using both candidate gene and hypothesis-free approaches. In the latter, genes suggestively associated with AFFs (uncorrected P-values <0.01) were investigated in a Swedish whole-genome sequencing replication study and assessed in 46 non-European cases. RESULTS: In the candidate gene analysis, PLOD2 showed a suggestive signal. The hypothesis-free approach revealed 10 tentative associations, with XRN2, SORD, and PLOD2 being the most likely candidates for AFF. XRN2 and PLOD2 showed consistent direction of effect estimates in the replication analysis, albeit not statistically significant. Three SNPs associated with SORD expression according to the GTEx portal, were in linkage disequilibrium (R2 ≥ 0.2) with a SNP previously reported in a genome-wide association study of AFF. The prevalence of carriers of variants for both PLOD2 and SORD was higher in Asian versus European cases. CONCLUSIONS: While we did not identify genes enriched for damaging variants, we found suggestive evidence of a role for XRN2, PLOD2 and SORD, which requires further investigation. Our findings indicate that genetic factors responsible for AFFs are not widely shared among AFF cases. The study provides a stepping-stone for future larger genetic studies of AFF.

We investigated the genetic factors contributing to atypical femur fractures (AFF), which are rare and unusual fractures in the thigh bone These fractures are related to the use of bisphosphonates, which are prescribed to prevent fractures caused by osteoporosis. Previous studies suggested potential genetic links, but their findings were not confirmed in larger groups. To address this, we analyzed genetic data from 139 European individuals with AFF and 196 individuals without AFF, all of whom used bisphosphonates, using a genetic technique called whole exome sequencing (WES). Our results suggested three genes­XRN2, SORD, and PLOD2­might be linked to AFF, although the evidence was not conclusive. Importantly, our findings suggest that AFF may be caused by different genes in different individuals. A much larger sample size is now needed to fully understand the genetic architecture of AFF. These findings may guide future research into the genetic causes of AFF.

What features of stem increase the risk of intraoperative femoral fracture during cementless primary hip arthroplasty?

INTRODUCTION: Cementless fixation has become increasingly popular in hip arthroplasty due to its shorter operation time, easier technique, biologic fixation, and avoidance of bone cement implantation syndrome compared to cemented fixation. However, intraoperative periprosthetic femoral fracture (IOPFx) is a disconcerting complication during cementless hip arthroplasty. Our purpose was to identify the features of cementless stem that increase the risk of IOPFx during primary hip arthroplasty. MATERIALS AND METHODS: We retrospectively reviewed all 4806 hip arthroplasties that was performed in a single institution from May 2003 to December 2020. Age at the index arthroplasty, sex, body mass index, physical status, ambulatory function, side of the operation, operational history, cause of the index arthroplasty, type of arthroplasty, surgical approach, surgeon, implant information, and events during the operation were investigated. The shoulder geometry and length of stem were also reviewed. The event of interest was narrowed down to IOPFx among various records of intraoperative events. RESULTS: We found IOPFx of 2.6% among all the hips operated with cementless stem. In the multivariable analysis, female (OR = 1.52), childhood hip disease (OR = 2.30), stove-pipe femur (OR = 2.43), combined approach (OR = 2.60), and standard length of stem (OR = 1.59) were found to be significant risk factors of IOPFx. CONCLUSIONS: In conclusion, a stem with a standard length is significantly associated with risk of IOPFx compared to a shortened stem. These findings highlight the importance of careful consideration in terms of the risk of IOPFx when standard length cementless stem is chosen.

Retrospective evaluation of perioperative clinical outcomes of diaphyseal femoral fractures repaired with the string-of-pearls locking plate system with adjunctive fixation.

OBJECTIVE: To evaluate outcomes and complication rate of utilizing a string-of-pearls (SOP) plate augmented with adjunctive fixation in the repair of canine femur fractures. METHODS: Records of canine patients with mid-diaphyseal femoral fractures repaired with the SOP plate and adjunctive fixation were reviewed. Information retrieved from medical records included signalment, patient weight, fracture configuration, repair technique, healing time, and complications based on perioperative radiographic follow-up to clinical union. Forty client-owned dogs met inclusion criteria for this study. Variables analyzed for association with major complications included body weight, fracture configuration, repair technique, and adjunctive fixation. RESULTS: Major complications requiring surgical revision occurred in 8 of 40 fractures. Five cases experienced intramedullary pin migration and were successfully treated with sedated pin removal. The remaining 3 cases involved implant failure via screw shear breakage and required surgical revision of the fixation to achieve a successful outcome. On the basis of a calculated Bonferroni correction, no statistical significance of the tested variables was found in association with major complications; however, significance was limited due to the low statistical power of this study. CONCLUSIONS: The use of adjunctive fixation with the SOP locking plate system led to radiographic union without complication in most cases, and no instances of plate breakage were reported. However, implant complications secondary to the adjunctive fixation can occur. CLINICAL RELEVANCE: Adjunctive fixation used with the SOP plate for repair of canine femur fractures has a high success rate, though pin migration as a complication persists.

TREATMENT OF PEDIATRIC FEMUR FRACTURES WITH FLEXIBLE STAINLESS STEEL INTRAMEDULLARY NAIL.

OBJECTIVES: To identify the characteristics of patients and femur fractures treated with a stainless steel intramedullary nail (ESIN) in children under 15 years of age. Know the results of using the ESIN of related steel in the service. METHODS: Retrospective study with review of hospital records and organization of data in spreadsheets. RESULT: 24 cases were identified, 17 male cases and 7 female cases. A minimum age of 4 years and a maximum of 11 years were observed (average of 7 years). The 3 most common trauma mechanisms were being run over (n:8, 33%) and falling from a height (n:8, 3%). The most common location of the fractures was in the mid-diaphyseal region (n: 20, 88%), only one case presented a bilateral femur fracture. The most common associated trauma was traumatic brain injury. The observation period observed several months between 2 and 5. With regard to complications, 3 cases were observed (12.5%) being bursitis, vicious construction and loss of reduction. CONCLUSION: Steel HIF shows similar good results. As the study includes the retrospective profile, the absence of a group and the small sample size. Level of Evidence IV, Case series.

OBJETIVOS: Identificar as características dos pacientes e das fraturas de fêmur tratadas com haste intramedular flexível (HIF) de aço inoxidável em menores de 15 anos. A partir disso, conhecer os resultados relacionados ao uso da HIF de aço inoxidável no serviço. Métodos: Estudo retrospectivo, com revisão de prontuários hospitalares e organização dos dados em planilhas. RESULTADO: Identificados 24 casos, sendo 17 do gênero masculino e sete do gênero feminino. Foram observadas idade mínima de 4 anos e máxima de 11 anos (média de 7 anos). Os mecanismos de trauma mais comuns foram atropelamento (n: 8, 33%) e queda de altura (n: 8, 33%). A localização mais comum das fraturas foi na região médio diafisária (n: 20, 88%), apenas um caso apresentou fratura de fêmur bilateral. O trauma associado mais comum foi traumatismo crânio-encefálico. O período de consolidação observado variou entre 2 e 5 meses. No que se refere a complicações, foram observados três casos (12,5%), sendo estes: bursite, consolidação viciosa e perda de redução. Conclusão: A HIF de aço apresenta bons resultados, semelhantes aos das hastes de titânio. As limitações do estudo incluem o perfil retrospectivo, a ausência de grupo controle e o número pequeno da amostra. Nível de evidência IV, Série de casos.

Design and simulation of scaffolds with lattice microstructures for bioprinting bone tissue.

BACKGROUND: Tissue engineering seeks to improve, maintain, or replace the biological functions of damaged organs or tissues with biological substitutes such as the development of scaffolds. In the case of bone tissue, they must have excellent mechanical properties like native bone. OBJECTIVE: In this work, three geometric models were designed for scaffolds with different structure lattices and porosity that could be biomechanically suitable and support cell growth for trabecular bone replacement applications in tissue engineering and regenerative medicine to the proximal femur area. METHODS: Geometries were designed using computer-aided design (CAD) software and evaluated using finite element analysis in compression tests. Three loads were considered according to the daily activity: 1177 N for slow walking, 2060 N for fast walking, and 245.25 N for a person in a bipedal position. All these loads for an adult weight of 75 kg. For each of them, three biomaterials were assigned: two polymers (poly-glycolic acid (PGA) and poly-lactic acid (PLA)) and one mineral (hydroxyapatite (HA)). 54 tests were performed: 27 for each of the tests. RESULTS: The results showed Young's modulus (E) between 1 and 4 GPa. CONCLUSION: If the resultant E is in the range of 0.1 to 5 GPa, the biomaterial is considered an appropriate alternative for the trabecular bone which is the main component of the proximal bone. However, for the models applied in this study, the best option is the poly-lactic acid which will allow absorbing the acting loads.

Outcomes of distal femoral replacement versus internal fixation for metastatic bone diseases of the distal femur.

Background: In clinical practice, internal fixation (IF) is a commonly utilized technique for metastatic bone disease (MBD) to the distal femur. Additionally, distal femoral reconstruction (DFR) has shown to be an effective surgical technique for primary tumors and MBD in the distal femur. The existing body of research comparing these methods has not focused on MBD or pathological fractures and thus does not guide surgical approach in the case of distal femoral MBD. Methods: A multi-institutional retrospective review of musculoskeletal oncology patients treated surgically with IF (n = 29) or DFR (n = 34) for distal femoral MBD between 2005 and 2023. Overall survival, revision risk, and functional status were assessed. Results: 5-year patient overall survival was 47.9 % (CI, 29.5-77.6 %) and 46.6 % (CI, 31.5-68.8 %), for DFR and IF, respectively (p = 0.91). After competing risk analysis, the 5-year risk of implant revision for DFR was 18 % (95 % CI: 5.1-37 %) and 11 % for IF (95 % CI: 2.4-28 %) (p = 0.3). DFR had longer operative times (p = 0.002), higher blood loss (p < 0.001), and greater postoperative (p = 0.006) complications than IF. In addition, patients undergoing DFR had more distal lesions than patients who received IF (p = 0.003). Conclusion: Despite similar overall survival and revision rates, IF may be preferable for patients due to its shorter operative time and lower rates of complication than DFR. However, specific anatomic location in the distal femur must be considered prior to deciding which procedure is optimal.

Morphological Measurement and Clinical Significance of Abnormal Development of Distal Femur with Hemophilia Knee Arthritis: A Consideration on the Renewal of Total Knee Prosthesis.

OBJECTIVE: The knee joint of hemophiliacs may face the result of local morphological changes due to long-term irritation of synovitis. This study aims to elucidate the morphological characteristics of distal femur in hemophilic arthritis (HA) and compare the compatibility of three types of prostheses with the anteroposterior (AP) and mediolateral (ML) dimensions of the femoral osteotomy surface. METHODS: This study retrospectively and randomly selected 50 patients with HA registered for treatment at our hospital from June 2016 to August 2022 as the study subjects, with an equal number of male osteoarthritis (OA) patients and healthy male individuals set as the control group. This study used medical digitalization software to simulate osteotomies on the distal femur during total knee arthroplasties (TKA) for 50 patients with HA, OA patients, and the healthy population, respectively, and measure the morphological parameters to compare with three commonly used femoral components of TKA in clinical practice. The differences between the femur resection of anteroposterior and mediolateral (FRAP, FRML) osteotomy surface and the prosthesis's BOX-AP/ML were compared in three prostheses. One-way ANOVA and multiple Kruskal-Wallis H test were used for the normal or non-normal distribution data, and pairwise comparisons between groups were conducted using the Bonferroni method, and the linear correlation analysis was utilized to assess the relationship between section femoral morphological data and prosthesis parameters. RESULT: In HA patients, the morphological characteristics of the distal femur were shown as shorter than femur AP (FAP), medial and lateral condyle anterior-posterior dimension (FMCAP, FLCAP), notch width (NW), posterolateral condyle height (PLCH), posteromedial condyle width (PMCW), and posterior condylar axis length (PCAL) dimension. They had comparatively smaller femur section aspect ratios (p < 0.005). They showed longer posterolateral condyle width (PLCW), anterior condyle mediolateral dimension (FRACML), anterolateral condyle height (ALCH), and femur resection anterior condylar mediolateral (FRACML) dimension (p < 0.005). They showed larger distal femur aspect ratio and resection aspect ratio (FAR, FRAR, p < 0.005). All selected prostheses showed ML undercoverage under similar AP dimensions, and ML undersizing of Attune systems was more obvious in three femoral prostheses. CONCLUSION: The distal femur morphological change of HA patient is shown as smaller AP dimension, narrow posterior condyle spacing, lower and shallower trochlear, thinner anterior condyle, wider and lower intercondylar notch and higher posterior-lateral condyle. The selected prostheses showed ML undercoverage under similar AP dimensions. This typical morphological tendency of the distal femur seems to warrant consideration in the process of knee joint prosthesis upgrading.

A new insight for investigating the prenatal and postnatal ossification centers of pelvic and femur bones in white New Zealand rabbits (Oryctolagus cuniculus) using 3D CT, double stain technique, and morphometry.

BACKGROUND: The ossification centers in rabbit limbs are related to fetal age and bone maturation. OBJECTIVE: To address the limited studies on ossification in the hind limbs of New Zealand rabbits, we investigated the prenatal and postnatal development of the pelvic and femur bones. METHODS: Double staining with Alcian Blue and Alizarin Red, computed tomography (CT), and 3D reconstruction were employed to visualize and analyze ossification centers in detail. RESULTS: Using double staining, we observed these patterns: At prenatal days 18 and 21, ossification centers appeared in the ilium. By prenatal days 23 and 25, ossification began in the ischium. On postnatal day 1, ilium ossification centers spread across most of the ilium wings, except for the iliac crest, and new centers appeared in the pubis and cotyloid bones. Most bones had ossified by the third week and one month postnatal, except for the iliac crest and ischial tuberosity. At 1.5 months, both were fully ossified. On day 18 post coitum, an ossification center was visible in the middle of the femur shaft. By day 28 post coitum, ossification extended through the shaft, and postnatally, new ossification spots appeared at the extremities by day one and week one. By the third week, complete ossification of the femur head, lesser trochanter, third trochanter, medial condyle, and lateral condyle was observed. At 1.5 months, the entire proximal extremity was ossified. CONCLUSION: 3D CT provided clear imaging of ossification progression in the pelvic and femur bones. This study enhances our understanding of vertebrate skeletal development.

Differences in tissue-level properties as assessed by nano-scratching in patients with and without atypical femur fractures on long-term bisphosphonate therapy: a proof-of-concept pilot study.

Atypical femur fractures (AFFs) are a well-established complication of long-term bisphosphonate (BP) therapy, but their pathogenesis is not fully understood. Although many patients on long-term BP therapy have severe suppression of bone turnover (SSBT), not all such patients experience AFF, even though SSBT is a major contributor to AFF. Accordingly, we evaluated tissue level properties using nano-scratch testing of trans-iliac bone biopsy specimens in 12 women (6 with and 6 without AFF matched for age and race). Nano-scratch data were analyzed using a mixed-model ANOVA with volume-normalized scratch energy as a function of AFF (Yes or No), region (periosteal or endosteal), and a first-order interaction between region and AFF. Tukey post hoc analyses of the differences of least squared means of scratch energy were performed and reported as significant if p<.05. The volume-normalized scratch energy was 10.6% higher in AFF than in non-AFF patients (p=.003) and 17.9 % higher in the periosteal than in the endosteal region (p=.004). The differences in normalized scratch energy are suggestive of a higher hardness of the bone tissue after long-term BP therapy. The results of this study are consistent with other studies in the literature and demonstrate the efficacy of using Nano-Scratch technique to evaluate bone tissue that exhibits SSBT and AFF. Further studies using nano-scratch may help quantify and elucidate underlying mechanisms for the pathogenesis of AFF.

Cemented Bipolar Hemiarthroplasty as a Treatment Modality for Pathological Fracture in the Proximal Femur Metastasis Without the Recurrence of Primary Breast Cancer: A Case Report.

Metastatic lesions in the proximal femur are well-known in the literature and are important since they can progress to pathological fractures and impair the patient's mobility. We present the case of a middle-aged female with a history of breast carcinoma 20 years ago, who experienced diffuse chronic hip pain for the past two months. Radiographs, MRI, and PET scans revealed a metastatic lesion in her proximal femur. After consulting with an oncologist, it was determined that adjuvant chemoradiotherapy was unnecessary. The treatment strategy was dependent on the preoperative general health condition, the life expectancy, amount of metastasis, bone quality, pathological fractures and factors affecting the union and capacity to ambulate the patient postoperatively. The patient underwent a cemented bipolar hemiarthroplasty to excise all metastatic tissue and provide a painless, functional, and mobile joint. Bipolar hemiarthroplasties articulate at two levels, and this dual-bearing design is believed to reduce acetabular wear. The bipolar hemiarthroplasty also eliminated the risk of complications associated with the acetabular component, which would necessitate early revision surgery. Modular bipolar hemiarthroplasty is a good modality of replacement associated with fewer complications and improves quality of life.

Fractures of the proximal femur and hip osteoarthrosis - coincidence or coherence?

PURPOSE: The current study aimed to investigate the correlation between the grade of radiographic hip osteoarthritis (OA) and the fracture pattern observed in fragility fractures of the proximal femur. The information may help in cases of occult hip fractures. METHODS: In this retrospective study all 448 patients treated with fragility fractures of the proximal femur in the years 2014-2018 were included. Patients were allocated into two groups: Group I) intracapsular (femoral neck) fractures and Group II) extracapsular (pertrochanteric and subtrochanteric) femoral fractures. The radiographic grade of OA was determined according to Kellgren and Lawrence's classification. One single observer examined all radiographs. RESULTS: Patients' age ranged between 52 and 104 years with a mean of 80.0 years. There was a significant difference in mean age between the two groups (76.9 years intracapsular vs. 83.1 years extracapsular fractures). A total of 250 (55.8%) fractures were intracapsular (femoral neck) and 198 (44.2%) were located extracapsular (pertrochanteric, subtrochanteric). A significant correlation between the degree of OA to fracture pattern was observed: Higher degrees of OA were related to extracapsular fractures and lower degrees of OA to intracapsular fractures. CONCLUSION: The results of this study support the hypothesis that hip osteoarthritis affects the fracture pattern in proximal femur fractures. More severe hip OA is associated with extracapsular fractures that can be treated surgically with lower complication rates compared to intracapsular fractures.

Informed Consent Practices for Hip Fracture Surgeries at a Tertiary Care Hospital in Wad Madani, Sudan.

INTRODUCTION: An essential component of medical ethics and practice is informed consent. The General Medical Council (GMC) and the Royal College of Surgeons of England (RCS) provide guidelines for obtaining valid consent. Failing to obtain sufficient or valid consent can have legal consequences. MATERIALS AND METHODS: Over a period of two and a half months, from March 12 to May 28, 2022, a retrospective cross-sectional study was conducted to evaluate consenting practices for neck of femur fracture surgeries. A total of 88 patient consent forms were reviewed. The standard consent forms utilized in this study were those endorsed by the British Orthopaedics Association (BOA) and were based on the guidelines provided by the RCS and the GMC. RESULTS: Resident surgical trainees and medical officers obtained the majority of the consents, 31 (35.22%) and 49 (55.68%), respectively. The most frequently reported risks included infection, blood clots (deep vein thrombosis and pulmonary embolism), bleeding, and wound complications. Neurovascular injury was not mentioned in 75 (85.33%) consent forms. Additionally, hip stiffness, prosthetic dislocation, death, and leg length discrepancy were not discussed with any of the patients. Additionally, we observed that the diagnosis or reason for surgery was mentioned in only 60 (68.18%) consent forms. Furthermore, none of the forms specified the intended benefits, the necessity for a blood transfusion, or the patient identification details. CONCLUSION: Our study revealed inadequate documentation of surgical risks in patient consent forms for neck of femur fracture surgeries, with orthopaedic-specific risks often overlooked. This issue likely results from insufficient orthopaedic training among the medical officers and junior resident trainees responsible for obtaining consent. We recommend induction teaching sessions to improve their understanding of standard consenting practices and associated risks, along with implementing patient identification stickers.