[Vertebroplasty and kyphoplasty : A critical statement].
Radiologe. 2020 Feb;60(2):138-143
Authors: Langner S, Henker C
BACKGROUND: Despite optimal drug-conservative therapy, a relevant percentage of patients with vertebral compression fractures (WKF) do not experience any relevant improvement in their pain symptoms. Vertebroplasty (VP) and kyphoplasty (KP) are described in the literature as percutaneous interventional procedures for the treatment of WKF.
OBJECTIVE: Assessment of the effectiveness of the VP and KP in the treatment of WKF and discussion of the procedures in the context of the current literature.
MATERIAL AND METHODS: Presentation of the fundamentals of VP and KP and their further developments. Description of indications and contraindications. Discussion of the current literature and recommendations of the individual professional associations.
RESULTS: In patients with vertebral compression fractures, VP or KP of the affected vertebral body leads to a pain reduction in more than 90% of cases. Clinically relevant complications occur in less than 1% of interventions.
CONCLUSION: VP and KP are a safe and effective method for treating painful WKF. Optimal patient selection improves the clinical outcome.
PMID: 31989205 [PubMed - indexed for MEDLINE]
Pubertal timing and adult fracture risk in men: A population-based cohort study.
PLoS Med. 2019 12;16(12):e1002986
Authors: Vandenput L, Kindblom JM, Bygdell M, Nethander M, Ohlsson C
BACKGROUND: Puberty is a critical period for bone mass accrual, and late puberty in boys is associated with reduced bone mass in adult men. The role of variations in pubertal timing within the normal range for adult fracture risk in men is, however, unknown. We, therefore, assessed the association between age at peak height velocity (PHV), an objective measure of pubertal timing, and fracture risk in adult men.
METHODS AND FINDINGS: In the BMI Epidemiology Study Gothenburg, 31,971 Swedish men born between January 1, 1945, and December 31, 1961, with detailed growth data (height and weight) available from centrally archived school healthcare records and the conscription register were followed until December 31, 2016. Age at PHV was calculated according to a modified infancy-childhood-puberty model, and fracture information was retrieved from the Swedish National Patient Register. The mean ± SD age at PHV was 14.1 ± 1.1 years. In total, 5,872 men (18.4%) sustained at least 1 fracture after 20 years of age and 5,731 men (17.9%) sustained a non-vertebral fracture after 20 years of age during a mean ± SD follow-up of 37.3 ± 11.7 years. Cox proportional hazards models adjusted for birth year and country of origin revealed that age at PHV was associated with the risk of any fracture and non-vertebral fracture. Participants with age at PHV in the highest tertile (after 14.5 years of age) were at greater risk of any fracture (hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.08-1.22, P < 0.001) and non-vertebral fracture (HR 1.16, 95% CI 1.09-1.24, P < 0.001) compared with those with age at PHV in the lowest tertile (at 13.6 years of age or younger). Additional adjustments for birthweight, childhood BMI, adult educational level, and young adult height did not attenuate the associations between age at PHV and adult fracture risk. Limitations of this study include the inability to adjust for important risk factors for fracture, inadequate power to assess the relation between pubertal timing and specific fracture types, and the limited generalizability to other populations.
CONCLUSIONS: In this study, we observed that late pubertal timing was associated with increased adult fracture risk in men. These findings suggest that information on pubertal timing might aid in the identification of those men at greatest risk of fracture.
PMID: 31790400 [PubMed - indexed for MEDLINE]
High Rate of Fibrinolytic Shutdown and Venous Thromboembolism in Patients With Severe Pelvic Fracture.
J Surg Res. 2020 02;246:182-189
Authors: Nelson JT, Coleman JR, Carmichael H, Mauffrey C, Vintimilla DR, Samuels JM, Sauaia A, Moore EE
BACKGROUND: Trauma patients with pelvic fractures have a high rate of venous thromboembolism (VTEs). The reason for this high rate is unknown. We hypothesize that fibrinolysis shutdown (SD) predicts VTE in patients with severe pelvic fracture.
METHODS: Retrospective chart review of trauma patients who presented with pelvic fracture from 2007 to 2017 was performed. Inclusion criteria were injury severity score > 15, abdomen/pelvis abbreviated injury scale >/= 3, blunt mechanism, admission citrated rapid thrombelastography (TEG). Fibrinolytic phenotypes were defined by fibrinolysis on citrated rapid TEG as hyperfibrinolysis, physiologic lysis, and SD. Univariate analysis of TEG measurements and clinical outcomes, followed by multivariable logistic regression (MV) with stepwise selection, was performed.
RESULTS: Overall, 210 patients were included. Most patients (59%) presented in fibrinolytic shutdown. VTE incidence was 11%. There were no significant differences in fibrinolytic phenotypes or other TEG measurements between those who developed VTE and those who did not. There was a higher rate of VTE in patients who underwent pelvic external fixation or resuscitative thoracotomy. On MV, pelvic fixation and resuscitative thoracotomy were independent predictors of VTE.
CONCLUSIONS: In severely injured patients with pelvic fractures, there was a high rate of VTE and the majority presented in SD. However, we were unable to correlate initial SD with VTE. Ultimately, the high rate of VTE in this patient population supports the concept of implementing VTE chemoprophylaxis measures as soon as hemostasis is achieved.
PMID: 31593862 [PubMed - indexed for MEDLINE]
Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture?
J Surg Res. 2020 02;246:123-130
Authors: Lipa SA, Sturgeon DJ, Blucher JA, Harris MB, Schoenfeld AJ
BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures.
MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent.
RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09).
CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.
PMID: 31569034 [PubMed - indexed for MEDLINE]
Bone Stress Injuries Are Associated With Differences in Bone Microarchitecture in Male Professional Soldiers.
J Orthop Res. 2019 12;37(12):2516-2523
Authors: Schanda JE, Kocijan R, Resch H, Baierl A, Feichtinger X, Mittermayr R, Plachel F, Wakolbinger R, Wolff K, Fialka C, Gruther W, Muschitz C
Bone stress injuries are commonly due to repetitive loading, as often described in competitive athletes or military recruits. The underlying pathophysiology of bone stress injuries is multifactorial. The present cross-sectional study investigated (i) cortical and trabecular bone microstructure as well as volumetric bone mineral density in subjects with bone stress injuries at the tibial diaphysis, measured at the distal tibia and the distal radius by means of high-resolution peripheral quantitative computed tomography (CT), (ii) areal bone mineral density using dual-energy X-ray absorptiometry as well as calcaneal dual X-ray absorptiometry and laser, and (iii) the influence on bone turnover markers of formation and resorption at the early phase after injury. A total of 26 Caucasian male professional soldiers with post-training bone stress injury at the tibial diaphysis were included (case group). A total of 50 male, Caucasian professional soldiers from the same military institution served as controls (control group). High-resolution peripheral quantitative CT revealed a higher total area at the radius within the case group. Cortical bone mineral density was reduced at the radius and tibia within the case group. The trabecular number and trabecular thickness were reduced at the tibia in the case group. The trabecular network was more inhomogeneous at the radius and tibia within the case group. Calcaneal dual X-ray absorptiometry and laser was significantly reduced in the case group. This study quantified differences in bone microstructure among otherwise healthy individuals. Differences in bone microarchitecture may impair the biomechanical properties by increasing the susceptibility to sustain bone stress injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2516-2523, 2019.
PMID: 31410876 [PubMed - indexed for MEDLINE]
Secondary Perforation Risk in Plate Osteosynthesis of Unstable Proximal Humerus Fractures: A Biomechanical Investigation of the Effect of Screw Length.
J Orthop Res. 2019 12;37(12):2625-2633
Authors: Ciric D, Mischler D, Qawasmi F, Wenzel L, Richards RG, Gueorguiev B, Windolf M, Varga P
Secondary perforation of screws into the joint surface is a commonly reported mechanical fixation failure mode in locked plating of proximal humerus fractures (PHF). This study investigated the influence that screws tip to joint distance (TJD) has on the biomechanical risk of secondary screw perforation and the stability of PHF. Ten pairs of cadaveric proximal humeri with a wide range of bone mineral density were used. Each specimen was osteotomized and instrumented with the PHILOS plate, simulating a highly unstable 3-part fracture. Bones were randomized into a long screw group (LSG) with 4 mm TJD, or a short screw group (SSG) with 8 mm TJD. A custom biomechanical setup was used to test the samples to failure cyclically with a constant valley load and an increasing ramp. The number of cycles to the initial screw loosening event was significantly higher for the LSG (mean ± standard deviation: 17,532 ± 6,458) compared with the SSG (11,102 ± 5,440) (p < 0.01). The mode of failure during testing was lateral-inferior displacement combined with varus collapse, with calcar screws perforating first. The number of cycles to failure event for LSG (27,849 ± 5,648) was not significantly different compared with SSG (28,782 ± 7,307) (p = 0.50). Screws that purchase closer to the joint had better initial stability and resistance against loosening. Placing longer screws, within limits dictated by the surgical guide, is expected to decrease the risk of secondary perforation failures in unstable PHF. These findings require clinical corroboration. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2625-2633, 2019.
PMID: 31350928 [PubMed - indexed for MEDLINE]
Comparison of once-weekly teriparatide and alendronate against new osteoporotic vertebral fractures at week 12.
J Bone Miner Metab. 2020 Jan;38(1):44-53
Authors: Ikeda S, Nakamura E, Narusawa K, Fukuda F, Matsumoto H, Nakai K, Sakata T, Yoshioka T, Fujino Y, Sakai A, KOTU T-WRAP Study Investigators
The objective of the present multicenter randomized study was to compare weekly teriparatide with alendronate in their inhibition of vertebral collapse, effects on delayed union, pain relief, and improvement of quality of life (QOL) in women with new osteoporotic vertebral fractures within 1 week after onset of the fracture. Patients were randomly allocated to the teriparatide and alendronate groups. Vertebral collapse, low back pain assessed by a visual analog scale, and QOL assessed by EuroQol 5 dimension at weeks 1, 2, 4, 8, and 12 after the start of the treatment were compared between the groups. Lumbar bone mineral density (BMD) at baseline and week 12 and the rate of delayed union at week 12 were also compared. Each group consisted of 48 subjects. Vertebral collapse progressed over time in both groups, with no significant difference between the groups. Pain on rising up from lying position, turning over in bed, and resting in the lying position improved over time in both groups, with no significant difference between the groups. There were no significant differences in increase in BMD and delayed union. QOL in the teriparatide group showed significant improvement in comparison with that in the alendronate group at week 12. The weekly formulation of teriparatide showed comparable inhibition of vertebral collapse, increase in BMD, promotion of bone union, and improvement of pain and significant improvement of QOL at week 12 in comparison with alendronate in patients with a new osteoporotic vertebral fracture within 1 week after onset of the fracture. The weekly formulation of teriparatide may have improved components of QOL other than pain at week 12.
PMID: 31297652 [PubMed - indexed for MEDLINE]
Clavicle and coracoid process periprosthetic fractures as late post-operative complications in arthroscopically assisted acromioclavicular joint stabilization.
Knee Surg Sports Traumatol Arthrosc. 2019 Dec;27(12):3797-3802
Authors: Thangaraju S, Tauber M, Habermeyer P, Martetschläger F
PURPOSE: Arthroscopic-assisted stabilization surgery for acute acromioclavicular joint (ACJ) disruption shows excellent and reliable clinical outcomes. However, characteristic complications such as fracture of the clavicle and coracoid have been reported to occur during the early post-operative period. The main goal of this study was to highlight the occurrence of fractures as a late post-operative complication. The secondary goals were to describe possible fracture morphologies and treatment outcomes.
METHOD: Patient records from a single surgery centre were searched for all patients presenting with late fracture complication following arthroscopically assisted acromioclavicular stabilization. Medical reports including the operative notes and pre- and post-operative X-rays were reviewed. A telephone interview was conducted with each patient to access the American Shoulder and Elbow Surgeons shoulder score.
RESULTS: A total of four patients presented with late fracture complication following arthroscopic-assisted ACJ stabilization surgery. All patients were males and presented following trauma at a median duration of 19.5 months after the index surgery. Fracture morphology differed between patients; the treatment was conservative in three patients, while one patient underwent osteosynthesis.
CONCLUSION: Traumatic peri-implant fractures can occur, even 2 years after arthroscopically assisted ACJ reconstruction. This needs to be considered when planning for surgical intervention in acute ACJ disruption, especially in a high-risk population.
LEVEL OF EVIDENCE: Therapeutic study, Level IV.
PMID: 30900030 [PubMed - indexed for MEDLINE]