The ageing population and an increase in both the incidence and prevalence of cancer pose a healthcare challenge, some of which is borne by the orthopaedic community in the form of osteoporotic fractures and metastatic bone disease. In recent years there has been an increasing understanding of the pathways involved in bone metabolism relevant to osteoporosis and metastases in bone. Newer therapies may aid the management of these problems. One group of drugs, the antibody mediated anti-resorptive therapies (AMARTs) use antibodies to block bone resorption pathways. This review seeks to present a synopsis of the guidelines, pharmacology and potential pathophysiology of AMARTs and other new anti-resorptive drugs.

We evaluate the literature relating to AMARTs and new anti-resorptives with special attention on those approved for use in clinical practice.

Denosumab, a monoclonal antibody against Receptor Activator for Nuclear Factor Kappa-B Ligand. It is the first AMART approved by the National Institute for Health and Clinical Excellence and the US Food and Drug Administration. Other novel anti-resorptives awaiting approval for clinical use include Odanacatib.

Denosumab is indicated for the treatment of osteoporosis and prevention of the complications of bone metastases. Recent evidence suggests, however, that denosumab may have an adverse event profile similar to bisphosphonates, including atypical femoral fractures. It is, therefore, essential that orthopaedic surgeons are conversant with these medications and their safe usage.

Take home message: Denosumab has important orthopaedic indications and has been shown to significantly reduce patient morbidity in osteoporosis and metastatic bone disease.

Cite this article: Bone Joint J 2016;98-B:160–5.

Introduction and purpose: Distal radius fractures often affect the joint surface; their reduction is difficult and may be incomplete. In these cases the use of an arthroscope may help reconstruct the joint surface of the radius and allow the diagnosis of ligament injuries. The purpose of this study is to analyze the results of this type of fractures by means of this technique.

Materials and methods: Between November 2001 and January 2007 we reduced 24 fractures of the distal extremity of the radius that involved the joint surface with arthroscopic control. The mean age of the patients was 36 years (range: 21–55). We used Barbieri and Geissler’s classification. We recorded the approach route, arthroscopic ports, ligament injuries observed and complications. Also both radiological and functional results were assessed.

Results: In 18 of the 24 patients some sort of ligamentous or osteochondral lesion was found (lunate-pisiform ligament, scaphoid-lunate ligament or triangular cartilage). All achieved union after a mean period of 8 weeks. By means of x-rays we measured a mean intraarticular step-off of 0.29 mm and a mean interfragment distance of 0.5 mm. Joint balance and force were normal at the end of rehabilitation in 22 out of 24 cases.

Conclusion: The use of arthroscopy in intraarticular fractures of the distal extremity of the radius is a technique that helps achieve a more accurate reduction of the joint surface and allows the repair of lesions which would have been overlooked during traditional surgery without decreasing union rate or functional results.

Introduction and Aims: Recurrent disc herniation or sciatica is one of the major complications of discectomy, often leading to a cascade of surgical procedures of increasing magnitude, but decreasing surgical outcome. We undertook a study to see if prolapsed disc fragment type can predict the possibility of recurrence of disc herniation or sciatica.

Method: We looked at the records of patients who had a discectomy operation during a 10-year period from 1992–2002. We excluded from the study patients who had a concomitant fusion operation, patients with multiple level disc operations and those who have diabetes. We went through the operation records, looking for the type of the disc fragment, i.e. whether it was contained, extruded or sequestrated disc. In the follow-up notes we recorded the patients that complained of leg pain, starting three months after the operation and continuing despite treatment. We recorded the length of follow-up.

Results: Sixty-five patients were entered for the study. There were 31 males and 34 females. The age range at surgery was 16–61 years (average 42.1 year). The follow-up ranged from 18 months to 10 years (average 30 months). We divided the patients into two groups. Group A, those patients with recurrent leg pain; and group B, those patients with no leg pain.

There were 18 patients in group A – they were all subjected to further examination with MRI scan. In five of the patients, the scan showed recurrence of disc herniation. It was an ipsilateral reherniation in four patients and contralateral in one patient. Eight of these 18 patients required repeat surgery.

In the five patients with reherniation (7.69% of whole series), the repeat surgery was a discectomy. In another three patients the surgery was a wide decompression and fusion. On further analysing the pathology found at the initial discectomy, in the group A patients, six (33%) had extruded discs and 12 (66%) had contained discs. In group B, 34 (72%) had extruded discs and 13 (27%) had contained discs. The statistical significance in this small series is debatable.

Conclusion: Patients with extruded discs do much better than those with contained discs. Recurrent disc herniation is more common in contained discs and less common in extruded discs. If we could select pre-operatively those patients with contained disc herniations, we could elect to persist with conservative treatment for longer in this group.