Introduction. Long-term use of bisphosphonates has been known to induce femoral insufficiency fracture in osteoporotic patients. We followed patients who had femoral insufficiency fractures after a long-term use of bisphosphonates. Methods. Eleven patients (14 hips) were diagnosed as having an insufficiency fracture of the femur after long-term (> 4 years) use of bisphosphonate to treat osteoporosis between January 2002 and December 2008. All patients were women who had a mean age of 68 years (range, 57 to 82 years). The fracture site was located in the subtrochanteric area in 6 hips and the femoral shaft in 8 hips. Three patients had bilateral involvement. These patients were followed-up for a mean of 27 months (range, 12 to 60 months). Results. Five hips in five patients displaced during the follow-up period. The mean period from the diagnosis of insufficiency fracture to the displacement was 10 months (range, 1 to 19 months). Five hips (five patients) underwent internal fixation due to persistent pain. Thus, during the follow-up of 27 months, operation was necessary in 71% (10 hips) of 14 insufficiency fractures. Four hips (four patients) that did not undergo any operation had persistent pain at the latest follow-up. Conclusion. The insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most of them required operation due to fracture displacement or persistent pain. We recommend preventive surgery to prevent further fracture displacement and persistent pain

Introduction. Subchondral insufficiency fractures of the femoral head (SIFFH) occur with normal or physiological stress in patients with poor bone quality. We evaluated the clinical characteristics of SIFFH. Methods. Nine cases of SIFFH were treated and followed up for an average of 9 months. Femoral head collapse (FHC) on radiographs was classified as minimal (< 2 mm), moderate (2-4 mm), and severe (> 4 mm). The severity of osteopenia was scored by Singh index (SI). Other characteristics of SIFFH were ascertained by assessing the clinical course as well as Body Mass Index (BMI) and magnetic resonance imaging (MRI). Results. There were 8 women and 1 man who had a mean age of 67 years. FHC was identified in 6 cases (1 minimal, 3 moderate, and 2 severe). SI scores ranged from 1 to 4. Mean BMI was 22.4 Kg/m. 2. In all affected hips, MRI demonstrated a subchondral fracture line with localized or diffuse bone-marrow-edema pattern in the femoral head. Initially, all cases were treated with conservative nonweight bearing therapy. In 7 of 9 cases, the pain decreased gradually and disappeared almost completely within 5 months regardless of the extent of FHC, SI score, and BMI. The remaining 2 cases (1 moderate and 1 severe FHC) were treated with total hip arthroplasty due to intractable pain. Conclusion. This study showed that conservative treatment could be considered as the first treatment choice for SIFFH independent of predisposing factors

Similar to the radiological findings in rapidly destructive arthrosis of the hip joint (RDA), subchondral insufficiency fracture of the femoral head (SIF) can result in progressive femoral head collapse of unknown etiology. We thus examined the osteoclast activity in hip joint fluid in SIF with progressive collapse in comparison to that in RDA. Twenty-nine hip joint fluid samples were obtained intraoperatively with whole femoral heads from 12 SIF patients and 17 RDA patients. SIF cases were classified into subgroups based on the presence of ≥2mm collapse on preoperative radiographs: SIF with progressive collapse (n=5) and SIF without progressive collapse (n=7). The levels of tartrate-resistant acid phosphatase (TRACP)-5b, interleukin-8, vascular endothelial growth factor (VEGF), and matrix metalloproteinase (MMP)-9 were measured. Numbers of multinuclear giant cells at the subchondral region were assessed histopathologically using mid-coronal slices of each femoral head specimen. Median levels of all markers and median numbers of multinuclear giant cells in SIF with progressive collapse were significantly higher than those in SIF without progressive collapse, while there were no significant differences in SIF with progressive collapse versus RDA. Regression analysis showed that the number of multinuclear giant cells correlated positively with the level of TRACP-5b in joint fluid. This study suggests an association of increased osteoclast activity with the existing condition of progressive collapse in SIF, which was quite similar to the findings in RDA. Therefore, high activation of osteoclast cell may reflect the condition of progressive collapse in SIF as well as RDA

Introduction. Subchondral insufficiency fracture of the femoral head (SIF) often occurs in osteoporotic elderly patients. Patients usually suffer from acute hip pain without any obvious antecedent trauma. Radiologically, a subchondral fracture is seen mainly in the superolateral portion of the femoral head. The T1-weighted magnetic resonance (MR) images show a low-intensity band in the subchondral area of the femoral head, which tends to be irregular, disconnected, and convex to the articular surface. This low-intensity band in SIF was histologically proven to correspond to the fracture line with associated repair tissue. Some cases of SIF resolve after conservative treatment, while others progress until collapse, thereby requiring surgical treatment. The prognosis of SIF remains unclear. This study investigated the risk factors that influence the prognosis of SIF based on the progression of the collapse. Methods. Between June 2002 and June 2008, seventeen patients diagnosed as SIF were included in this study. Sequential radiographs were evaluated for the presence of progression of the collapse. The clinical profiles, including the age, body mass index (BMI), follow-up period and Singh index were examined. The morphological characteristics of the low intensity band on the T1-weighted magnetic resonance images were also examined, with regard to the band length, band thickness and band length ratio; which is defined as a proportion of the band length to the weight-bearing portion of the femoral head. Results. Radiographically, a progression of the collapse was observed in 8 of 17 (47.1%) patients. The band length in patients with progression of the collapse (mean: 22.6 mm) was significantly larger than that in those without progression of the collapse (mean: 12.3 mm; P < 0.05). The band length ratio in patients with progression of the collapse (mean: 73.3 %) was also significantly higher than that in those without progression of the collapse (mean: 42.3 %; P < 0.01). No significant differences were seen in the other variables (the age, BMI, follow-up period, Singh index, and band thickness). Conclusion. One of the important differential diagnoses in determining SIF may include osteonecrosis. The shape of the low signal intensity band on the T1-weighted MR images is one of the characteristic findings in SIF: namely, it is generally irregular, serpiginous, convex to the articular surface, and often discontinuous. This low-intensity band is generally surrounded by bone marrow edema. Histopathologically the band in SIF represents the fracture line with associated repair tissue. On the other hand, in osteonecrosis, since the low-intensity band represents repair tissue, it is generally smooth and circumscribes all of the necrotic segments. In this study, the prognosis of SIF varied even though all the patients received similar non-operative treatments. If the prognosis for SIF can be predicted at the early stage, it would allow the design of optimal treatments in each patient. In this preliminary investigation, both the band length and band length ratio were demonstrated to be useful when selecting the optimal treatment for SIF

Introduction. Subchondral insufficiency fracture of the femoral head (SIF) is a recently proposed concept. It is generally seen in elderly people, however, some young adults have also been reported to suffer from this fracture. The purpose of this study was to investigate the clinical results of a transtrochanteric anterior rotational osteotomy (ARO) performed in young adults with SIF. Methods. This study focused on young SIF cases (age range from 10 to 29 years). Five patients were diagnosed to have SIF at our institution and conservative treatment was initially performed. The symptoms resolved in 1 case while the other 4 cases showed progression of a collapse. In these 4 cases, ARO was performed, since the fractured area was located in the anterosuperior portion of the femoral head. The average age of the patients was 22 years (range, 16 to 29 years) at the time of surgery, consisting of 2 men and 2 women. Results. All cases were followed-up and the average follow-up period was 3.4 years (range, 1.8 to 6.8 years). The average preoperative Harris hip score was 67 points, which improved to an average of 93 points at the latest follow-up. Radiographically, the fractured lesion healed and no progression of a collapse was observed in any of the 4 cases. Conclusion. In the majority of SIF cases, only the anterosuperior portion of the femoral head is involved by the fracture. When considering the optimal surgical treatments for SIF, ARO may be one of the useful options, especially for the treatment of young patients

Introduction

Rising incidence of fracture neck of femur (NOF) are associated with rising geriatric population. Majority of patients are suffering from comorbid factors. Impaired renal function is a common comorbid factor and most of the time it is attributed to an acute renal impairment following the fracture and surgery.

Objective of this study was to identify the effect of renal comorbid factors and their probable relative risk for a fracture and compare the results with Asian and European data. Specific objective was to identify a possibility of presence of pretraumatic subclinical chronic renal failure among fractured Sri Lankans.

Emerging evidence has linked the long-term use of alendronate (fosamax) with subtrochanteric insufficiency fractures. However, findings to date have been anecdotal. The aims of this study were to determine the incidence of subtrochanteric insufficiency fractures and identify whether they were more prevalent following the introduction of alendronate in Australia. All patients that presented between January 2007 and February 2009 with low- energy subtrochanteric fracture were identified. Similar data were collected between January 1995 and February 1997 as this was immediately prior to introduction of alendronate in Australia. The radiographs were examined for failure due to pre- existing insufficiency fracture. Characteristic findings were a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. We also separately identified all patients that presented between 2007 and 2009 with a proximal femoral fracture and determined the proportion taking alendronate. One hundred and seventeen patients with low-energy subtrochanteric fracture were included. Seventy-nine patients presented between 2007 and 2009 and 38 presented between 1995 and 1997. Forty-one of the 79 (52%) patients were identified as having radiograph findings suggestive of underlying insufficiency fracture, whilst none were identified prior to the introduction of alendronate. Of the 41 patients with subtrochanteric insufficiency fracture, 40 (98%) had been taking alendronate and one had been taking risedronate. Twenty-nine of the 41 (71%) complained of prodromal pain in the affected femur. Eighteen of the 41 (44%) demonstrated subtrochanteric insufficiency changes on the contralateral side and 9 of 41 (22%) sustained spontaneous non-traumatic fracture during activities of daily living. Of the 38 patients without insufficiency changes, 12 (32%) had been taking alendronate. Alendronate use was therefore strongly suggestive of insufficiency fracture (sensitivity = 98%, specificity = 84%, PPV = 77%, NPV = 99%, LR+ = 6). The mean duration of alendronate use in those with insufficiency fracture was 7.1 years (95% CI, 6.6-7.6 years). The mean duration in those without was 3.2 years (95% CI, 2.6-3.8 years, P<0.0001). Three hundred and ninety eight patients presented with a low-energy proximal femur fracture between 2007 and 2009. Of these, only 52 (13%, P<0.0001) were taking alendronate. This is the largest study in the literature on subtrochanteric insufficiency fractures and alendronate therapy. Confirming recent reports, alendronate use was strongly suggestive of subtrochanteric insufficiency fracture. Our findings provide the most compelling evidence to date of the potential long-term sequelae of alendronate but more research is needed before definitive conclusions can be made

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters. We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications. There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture. Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident

Background: Osteoporotic tibial fractures may be a challenge both in diagnosis and treatment. The aim of treatment is obtaining joint congruity and normal alignment, joint stability, adequate soft tissue healing and functional range of motion. The goal is prevention of degenerative osteoarthritis. In the majority of cases the treatment of tibial plateau fractures consists of open reduction and internal fixation. Objectives: The presentation of two aspects of the osteoporotic fracture – the insufficiency fracture and fixation of the fractures by a more appropriate method. Patients: We present our experience with 7 cases treated during the past 2 years. Two of these cases presented with no story of trauma, normal X-rays and were diagnosed clinically and on CT and bone scanning. The other 5 cases resulted of minor trauma and operative treatment was in order, using a modified fixation technique – a small fragment plate. Results: The patients suffering from fractures with normal X-rays suffered from insufficiency fractures and were treated conservatively. The patients suffering from depressed, split or comminuted fractures were treated by open reduction and internal fixation with a small fragment plate. Discussion and Conclusion: Insufficiency fractures often are misdiagnosed as exacerbation of chronic metabolic or inflammatory diseases and a fracture is not suspected until intense augmentation of radionuclide is seen on bone scan. Screening of patients presenting wit non-traumatic knee pain has shown a prevalence insufficiency fractures of the tibial plateau between 3 to 8% of the cases. These cases may be much more common than we commonly presume. The fractures in need of reduction and fixation of the plateau fracture involve raising the depressed articular fragment, the possible addition of bone graft augmentation and buttressing of the osteochondral fragment with a plate. These buttress plates may hold the cortical rim of the plateau but many times fail in maintaining the reduction of the intra-articular surface of the plateau. This again results in degenerative changes in the joint and pain. Internal fixation of these fractures with small fragment plates may be a solution to this problem, as demonstrated by the 5 presented cases treated operatively. The plates are smaller in size and are held by more screws, which are more proximal to the articular surface. This way they allow better control and maintenance of the anatomic reduction and in combination with an a-traumatic dissection and less stress shielding effect, result in a low rate of local complications

Rapidly progressive osteoarthritis of the hip (RPOH) is an unusual subset of osteoarthritis. It is characterized by rapid joint space loss, chondroly­sis, and sometimes marked femoral head and acetabular destruction as a late finding. The exact pathogenetic mechanism is unknown. Potential causes of RPOH include subchondral insufficiency fracture resulting from osteoporosis, increasing posterior pelvic tilt as a mechanical factor, and high serum levels of matrix metalloproteinase (MMP)-3 as biological factors. This study was aimed to identify some markers that associate with the destructive process of RPOH by analyzing the proposed pathological factors of the disease, MMP-3, pelvic tilt, and osteoporosis. Of female patients who visited our hospital with hip pain from 2012 through 2018, this study enrolled female patients with sufficient clinical records including the onset of hip pain, age and body mass index (BMI) at the onset, a series of radiographs during the period of >12 months from the onset of hip pain, and hematological data of MMP-3 and C-reactive protein (CRP). We found the hip joints of 31 patients meet the diagnostic criteria of RPOH, chondrolysis >two mm in one year, or 50% joint space narrowing in one year. Those patients were classified into two groups, 17 and 14 patients with and without subsequent femoral head destruction in one year shown by computed tomography, respectively. Serum MMP-3 and CRP were measured with blood samples within one year after the hip pain onset. The cortical thickness index (CTI) as an indicator of osteoporosis and pelvic tilt parameters were evaluated on the initial anteroposterior radiograph of the hip. These factors were statistically compared between the two groups. This study excluded male patients because RPOH occurs mainly in elderly females and the reference intervals of MMP-3 are different between males and females. There was no difference in age at onset or bone mass index between the RPOH patients with and without subsequent femoral head destruction. Serum levels of MMP-3 were significantly higher in the RPOH patients with the destruction (152.1 ± 108.9 ng/ml) than those without the destruction (66.8 ± 27.9 ng/ml) (P = 0.005 by Mann-Whitney test). We also found increased CRP in the patients with femoral head destruction (0.725 ± 1.44 mg/dl) compared with those without the destruction (0.178 ± 0.187 mg/dl) (P = 0.032 by Mann-Whitney test). No difference in the duration between the hip pain onset and the blood examination was found between the two groups. There was no significant difference in CTI or pelvic tilt between the two groups. The pathological condition that may increase serum MMP-3 and CRP could be involved in femoral head destruction after chondrolysis of the hip in patients with RPOH

Historically spine surgeons have been powerless to help most patients with painful vertebral insufficiency fractures. Treatment was supportive, hoping that fractures could heal in situ, and accepting the resulting kyphosis and its consequences. Surgery was the court of last resort in instances of disabling neurologic deficits. The very same deficient skeleton that lead to the clinical issue, was simultaneously the principal limiting factor in surgical undertakings. Complications could be common and substantial. Vertebroplasty was born out necessity in the treatment of ‘inoperable’ vertebral metastases. The technique has become a widely adopted method of managing refractory painful vertebral insufficiency fractures, especially those due to osteoporosis. In skilled hands, vertebroplasty provides a high degree of pain relief and patient satisfaction. The fracture is fixed in situ as the marrow space is embolised with PMMA. Kyphoplasty is a technical evolution that enables active fracture reduction before fixation with PMMA. Much is made about the potential differences between the two treatment methods, but no direct comparative studies are available to allow objective conclusions. In any event, as medical therapies improve the treatment of osteoporosis in general, surgeons now have the opportunity to intervene when painful vertebral fractures are a primary source of functional impairment and life quality

It is well appreciated that thigh pain following recent arthroplasty surgery is likely to be due to prosthetic loosening or infection. Both these sequelae can lead to periprosthetic fracture presenting complex challenges to even experienced surgeons. Revision arthroplasty patients are prone to both fatigue and insufficiency fractures as they may have reduced bone stock after previous surgery and reduced bone density secondary to medical and immobility reasons. The post operative painfree condition will frequently permit early load bearing leading to a relatively rapid increase in activity and load bearing. Fatigue fractures occur in bone of normal quality subject to abnormal cyclical overloading, leading to resorption and eventual failure, before adequate time has passed to permit adaptive remodelling. Insufficiency fractures occur when normal physiological loads are applied to bone of abnormal quality. Surprisingly few periprosthetic stress fractures are reported in the literature but a series notes lateral tensile stress fractures associated with varus prosthetic alignment. These all occurred near the tip of the prosthesis. The case of an unusual Gruen Zone 2, Vancouver B1 stress fracture, 9 months following revision arthroplasty is reported. Initially loosening was suspected due to the development of load bearing thigh pain. Plain radiography revealed the development of a dreaded black line, consistent with a stress fracture. Bone scintigraphy revealed the typical appearance of a stress fracture in the absence of loosening or infection. The unusual location of this stress fracture allowed consideration of conservative non weight bearing management which lead to the alleviation of symptoms rather than further revision surgery. This report illustrates this unusual stress fracture and highlights the importance of careful loading practises to permit adequate remodelling following complex revision surgery

Recent reports suggest that long-term alendronate therapy may result in an unusual pattern of femoral subtrochanteric fracture. We aimed to determine if the presence of a specific radiographic feature in patients on alendronate could be used to predict an impending insufficiency fracture and thereby prevent its occurrence through further investigations and prophylactic fixation in high-risk patients. Sixty-two subtrochanteric fractures treated surgically from 2001 to 2007 were reviewed and radiographs of 25 low-energy fractures were independently evaluated. Incidence of alendronate therapy, clinical data, and other investigations like bone mineral density (BMD) scans were recorded. Seventeen fractures (68%) were associated with alendronate therapy. Hypertrophy of the lateral cortex of the femur with splaying of the fracture ends was noted in 70.1% of patients on alendronate; initial radiographs were not available in 17.6% and 11.8% had stress fractures identified by bone scan. None of the fractures in the non-alendronate group had this pattern. The fracture configuration in the alendronate group suggested that an ellipsoid thickening in the lateral cortex had been present prior to fracture. Indeed, 6 patients on alendronate (35.3%) had pre-existing radiographs as early as 3 years prior to fracture and all had this feature. Four of them had bone scans, which confirmed a stress fracture. Hip pain was often associated with this radiographic sign but may not be specific as patients were already on follow-up for other musculoskeletal conditions. BMD scans were not predictive of an impending fracture as they were mostly in the osteopaenic range. Only 50% with proven stress fractures had prophylactic fixation, while the remainder sustained overt fractures. Alendronate-related subtrochanteric fractures are associated with a specific pre-existing radiographic abnormality. We recommend that all patients on long-term alendronate - particularly those with hip pain or a previous subtrochanteric fracture - be routinely followed-up with plain radiographs of the pelvis. If an ellipsoid feature is noted in the subtrochanteric region, further investigations like bone scan or MRI should be sought. Patients with evidence of stress fracture should be strongly considered for prophylactic operative fixation. We believe this is a cost-effective strategy to prevent subtrochanteric insufficiency fractures in patients on alendronate

Introduction. The incidence of distal femoral fractures in the geriatric population is growing and represents the second most common insufficiency fracture of the femur following fractures around the hip joint. Fixation of fractures in patients with poor bone stock and early mobilisation in feeble and polymorbide patients is challenging. Development of a fixation approach for augmentation of conventional LISS (less invasive stabilization system) plating may result in superior long-term clinical outcomes and enhance safe weight bearing. Objectives. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented LISS plating for treatment of osteoporotic fractures of the distal femur in comparison to conventional LISS plating. Materials & methods. Unstable distal femoral fracture AO/OTA 33-A3 was set in artificial femora with low density simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for instrumentation with a 9-hole LISS plate, a LISS plate with an additional 3D-printed polyactide cylindrical intramedullary graft, as well as a LISS plate plus a medial 3.5mm LCP (locking compression plate) - double plating. All specimens were non-destructively tested under axial (20–150N) and torsional (0–4Nm) quasi-static loading. Each construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Results. Interfragmentary displacement along the femur axis (mm) under 150N axial loading was 2.03±0.23/1.65±0.27 for LISS with long/short WL, 0.18±0.06/0.18±0.04 for double plating with long/short WL, and 0.40±0.05/0.30±0.05 for LISS plus graft with long/short WL. Shear interfragmentary displacement (mm) under 4Nm torsional loading in internal rotation was 1.16±0.17/0.92±0.11 for LISS with long/short WL, 0.40±0.10/0.43±0.07 for double plating with long/short WL, and 1.09±0.13/0.82±0.11 for LISS plus graft with long/short WL. Double plating revealed significantly smaller longitudinal and shear displacement compared to the other two techniques for long and short WL, respectively (P≤0.010). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating for long and short WL, respectively (P≤0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (P≤0.032), but not for double plating (P=1.000). Conclusion. Intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. However, it was not efficient enough to achieve comparable stability to double plating

Medial meniscus tear has been proposed as a potential etiology of spontaneous osteonecrosis of the knee (SONK). Disruption of collagen fibers within the meniscus causes meniscal extrusion, which results in alteration in load distribution in the knee. A recent study has demonstrated high incidence of medial meniscus extrusion in the knee with SONK. Our purpose was to determine whether the extent of medial meniscus extrusion correlates with the severity of SONK in the medial femoral condyle. Anteroposterior and lateral knee radiographs were taken with the patients standing. Limb alignment was expressed as the femorotibial angle (FTA) obtained from the anteroposterior radiograph. The stage of progression of SONK was determined according to the radiological classification system described by Koshino. After measurement of anteroposterior, mediolateral, and superoinferior dimensions of the hypointense T1 signal intensity lesion of MRI, its ellipsoid volume was calculated with the three dimensions. Meniscal pathology (degeneration, tear, and extrusion) were also evaluated by MRI. Of the 18 knees with SONK, we found 5 knees at the radiological stage 2 lesions, 9 knees at the stage 3, and 4 knees at the stage 4. Whereas the ellipsoid volume of SONK lesion significantly increased with the stage progression, the volume was significantly greater at stage 4 than stage 2 or 3. All the 18 knees with SONK in the present study showed substantial extrusion (> 3mm) and degeneration of the medial meniscus. While medial meniscal extrusion increased with the stage progression, medial meniscus was significantly extruded at stage 3 or 4 compared with stage 2. A significant increase in FTA was found with the stage progression. FTA was significantly greater at stage 4 than stage 2 or 3. Multiple linear regression analysis revealed that medial meniscus extrusion and FTA were useful predictors of the volume of SONK lesion. This study has clearly shown a significant correlation between the extent of medial meniscus extrusion and the stage and volume of SONK lesion. Degeneration and tears of the medial meniscus in combination with extrusion may result in loss of hoop stress distribution in the medial compartment, which could increase the load in the medial femoral condyle. In addition to meniscal pathology, knee alignment can influence load distribution in the medial compartment biomechanically. Multiple linear regression analysis indicates that an increase in FTA concomitant with a greater extrusion of medial meniscus could result in greater lesion and advanced radiological stage of SONK. Taken together, alteration in compressive force transmission through the medial compartment by meniscus extrusion and varus alignment could develop subchondral insufficiency fractures in the medial femoral condyle, which is considered to be one of the main contributing factors to SONK development. There was high association of medial meniscus extrusion and FTA with the radiological stage and volume of SONK lesion. Increased loading in the medial femoral condyle with greater extrusion of medial meniscus and varus alignment may contribute to expansion and secondary osteoarthritic changes of SONK lesion

Recently, a new technique of custom-made cutting guides for TKA is introduced to clinical practice. However, no published data yet on the comparison between this new technique against both navigation and conventional techniques. The author prospectively compared between custom-made cutting guides, navigation and conventional techniques. A total number of 90 cases were included in this study with 30 consecutive cases for each technique. The highest number of medically unfit patients and those with articular and extra articular deformities were in custom guides groups. The results showed one case of aseptic loosening after one year in custom guides, one case of superficial infection and loose pins but with no fracture in navigation group, and higher need for blood transfusion in conventional. One case in the custom guide group had a periprosthetic fracture 3 weeks postoperatively diagnosed as insufficiency fracture after a relatively minor trauma to an osteoporotic bone. Navigation was the most accurate in alignment but custom guides was the most accurate in implant sizing and had the least bleeding. This clinical study showed some advantages of custom-made cutting guides over conventional instrumentation. It eliminated medullary guides, reduced operative time, and provided better accuracy. The technique was proved to be useful in complex cases of deformities and unfit patients

Modulus femoral prosthesis is a modular cementless femoral system which consists of 5 degree tapered conical stem made of a titanium alloy with 8 fins of 1mm and modular neck. Modular neck enables to control any ideal stem anteversion as a surgeon prefers. This system is considered to be useful in severe hip deformity, for example developmental dysplasia of the hip (DDH). In this study, clinical and radiographic outcomes of the Modulus femoral prosthesis were evaluated at a mean of 3.6 (2–6) years postoperatively. We assessed the results of 193 primary total hip arthroplasty using a Modulus femoral prosthesis in 169 patients (15 males, 154 females) undergoing surgery between September 2007 and December 2011. The mean age at the time of surgery was 65.6 (31–86) years old. The diagnoses were osteoarthritis (OA) in 178 hips (including 167 hips of DDH), rapidly destructive coxopathy (RDC) in 6 hips, rheumatoid arthritis (RA) in 6 hips, osteonecrosis in 2 hips, and subchondral insufficiency fracture in one hip. Clinical outcomes were assessed using Japan Orthopedic Association (JOA) hip scores and complications. Radiographic assessments were including stem alignment, bone on-growth, cortical hypertrophy, stress shielding and stem subsidence. 43.8 points of the preoperative mean JOA score was significantly improved to 93.1 points postoperatively. In one case intraoperative femoral fracture was occurred. One dislocation had occurred and thigh pain was observed in one hip. No revision surgery was required. In 192 hips of 193 hips (99.5%), stem was implanted in neutral position (within ±2 degrees). Bone on-growth was observed in all cases (94.3% in zone 3; 73.1% in zone 5; 30.6% in zone 2; 22.3% in zone 6). Cortical hypertrophy was observed in 66 hips (34.2%) at zone 3 and 5. Reduction of bone density due to stress shielding was observed (1. st. degree was 58.5%; 2. nd. degree was 29.5%; 3. rd. degree was 11.9%; 4. th. degree was 0%). In 22 cases (11.4%), more than 2mm of stem subsidence was observed, however the subsidence was stopped within 6 months in all cases. Modulus femoral prosthesis showed good clinical results and radiographic findings up to 6 years postoperatively

Diphosphonates remain among the most common drug treatments for osteoporosis. Recent evidence has implicated diphosphonate therapy, specifically, alendronate, with low-energy fractures of the subtrochanteric region of the femur. The general conclusion is that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. Three case reports of patients with alendronate related insufficiency are discussed here with their treatment modalities and lessons learnt. One of the three patients had bilateral subtrochanteric stress fracture. A comprehensive review of the literature is presented with the best evidence for investigating, treating and preventing these fractures. Our experience in Launceston has increased awareness amongst the local medical community regarding the long term use of Diphosphnates and the fractures they may cause. Changes to our practice have included: Increased suspicion of patients with hip pain on diphosphonate therapy, imaging the contralateral femur to rule out stress fractures, reassuring GP's and Patients that benefits of Diphosphonate therapy far outweigh the potential risks. There are many unresolved questions about the prolonged use of diphosphonates, but there is sufficient evidence to show subtrochanteric stress fractures do occur. We, as Orthopaedic Surgeons, must be able to recognize this new entity and educate our medical colleagues appropriately

Aims

The aims of this study were: 1) to describe extended restricted kinematic alignment (E-rKA), a novel alignment strategy during robotic-assisted total knee arthroplasty (RA-TKA); 2) to compare residual medial compartment tightness following virtual surgical planning during RA-TKA using mechanical alignment (MA) and E-rKA, in the same set of osteoarthritic varus knees; 3) to assess the requirement of soft-tissue releases during RA-TKA using E-rKA; and 4) to compare the accuracy of surgical plan execution between knees managed with adjustments in component positioning alone, and those which require additional soft-tissue releases.

Aims

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.