Fractures Bone

Objectives. Among patients who arrive at an emergency department (ED) with pain, over half remain in moderate or severe pain at ED discharge. Our objectives were to identify ED physicians' prescribing patterns when discharging patients with common musculoskeletal conditions and to determine if disparities in opioid prescribing exist.p me_884 1072..1077 Design. Five-year retrospective investigation. Setting. An urban, academic ED with approximately 100,000 annual visits, where physicians write discharge prescriptions, including over-the-counter medications, using a computerized order entry system. Patients. Adult patients who were discharged home from an ED with fractures (clavicle or long bone fractures) or non-fracture musculoskeletal diagnoses (sprains, strains, sciatica, or back pain). Results. The study sample included 13,335 patients with a mean age of 39 years. Half were female; 52% were white; 39% were black; and 7% were Hispanic. Among fracture patients, 77% received an opioid prescription, 2% received a non-opioid prescription, and 21% received no analgesic prescription. The percentages for patients with non-fracture diagnoses were 65% (opioids), 18% (non-opioid analgesics), and 17% (no analgesic). Patients aged 80 years and older were significantly less likely to receive opioid prescriptions. Although prescribing by race for fractures was similar, significantly fewer black and Hispanic patients with non-fracture diagnoses received opioid prescriptions, compared with white patients. Conclusions. Approximately one fifth of patients in the fracture and non-fracture groups did not receive an analgesic prescription. Age greater than 80 years and minority race/ethnic status were associated with lower rates of opioid prescribing.

Background Low bone mineral density (BMD) is a public health issue in Saudi Arabia. This study measured the prevalence and factors associated with low BMD in Saudi women in Riyadh, Saudi Arabia. Methods A cross sectional study using two stage cluster sampling technique was conducted in Riyadh, 2009. Thirty clusters, each comprising of 300 houses were randomly chosen and from each cluster 38–40 households were selected to identify 1150 women of >40 years. Women were invited to primary health care center for filling of self-administered questionnaire (n = 1069) comprising of sociodemographic, health, diet and physical activity variables. 1008 women underwent screening for low BMD using the quantitative ultrasound technique. 535 (53%) women with positive screening test were referred to King Khalid Hospital for Dual X-ray Energy absorptiometry (DXA). Results 362 women underwent DXA and 212 (39.6%) were screened low BMD either at lumbar spine or femur neck. Mean age of women was 55.26...

Background: Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients. Methods: Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily. Results: The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 ϫ 5 cm to 7 ϫ 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic. Conclusions: Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered. (Plast.

Background: Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients. Methods: Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily. Results: The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 ϫ 5 cm to 7 ϫ 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic. Conclusions: Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered. (Plast.

The purpose of this study was to clarify the differences in the causes of osteochondral lesions (OCL) of the ankle based on the presence of distal fibular fractures and lateral instability of the ankle. Type of Study: Case series. Methods: We evaluated 92 cases of distal fibular fractures and 86 cases of lateral instability of the ankle, including 36 feet with subacute lateral instability of the ankle and 50 feet with chronic lateral instability of the ankle. In diagnosing OCL, we used a combination of magnetic resonance imaging to evaluate the subchondral conditions and ankle arthroscopy to evaluate the chondral conditions. Results: Of a total of 92 distal fibular fractures, 65 cases (70.7%) had OCL at the time of osteosynthesis and 27 did not (29.3%). Among the latter group, 2 developed OCL about 1 year after surgery. Of a total of 86 cases of lateral instability of the ankle, 35 (40.7%) had OCL. Among the subacute cases, 7 of 36 (19.4%) had OCL, versus 28 of 50 cases (56.0%) with chronic lateral instability of the ankle. Conclusions: Our study suggests that recurrent ankle sprains with remaining lateral instability and distal fibular fractures could be one of the causes of OCL of the ankle.

Background Cartilage defects are created on intraarticular osteochondral fragments at the entrance holes of fixation devices when these fragments are fixed to the original sites. Conventional fixation devices hinder repair of these defects and there is a latent risk of secondary osteoarthritis. We therefore developed a novel fixation device system consisting of bone screws made of cortical bone for osteochondral fragments to improve repair of these surface defects. Questions/purposes We asked whether bone screws had advantages over poly-L-lactic acid (PLLA) screws in terms of (1) gross assessment of the surface, (2) volume and histologic quality of the repair tissue, and (3) biomechanical assessment of the tissue stiffness. Methods We examined gross morphology, microCT, histology, and stiffness of the repaired tissue with PLLA (n = 32) and bone (n = 32) screws in a rabbit model of osteochondral fracture, compared with normal controls (n = 16). Results Gross morphology and histology revealed better quality with bone screws than with PLLA screws. Mean repaired volumes in microCT were 70.6% ± 14% with bone screws and 50.3% ± 15% with PLLA screws. Average stiffness values for PLLA screws, bone screws, and normal cartilage were 1.67 ± 0.54 N/mm, 2.63 ± 0.42 N/mm, and 3.15 ± 0.49 N/mm, respectively. Conclusions Our results show better repaired tissue was observed for quality and quantity when chondral fractures were treated with bone screws than when treated with PLLA screws. Clinical Relevance Bone screws made of cortical bone may have applications in clinical situations for the fixation of intraarticular osteochondral fragments.

Background. Pegs made from cortical bone are used to fi x osteochondral fractures and osteochondral dissecans. This technique has many advantages, but it requires long-term immobilization. This study examined the effect of surface roughness on fi xation with bone and metal pegs. Methods. Pegs with either rough or smooth surfaces were made of cortical bone from Japanese black cattle or from stainless steel (SUS316L). The mean roughness of the rough surface was 15.0 μm, whereas that of the smooth surface was less than 0.6 μm. Pegs were inserted into holes made in the distal femurs of 34 rabbits. At the time of surgery and 14 days later, mechanical tests and micro-computed tomography were performed. Results. At the time of surgery, although the push-out forces were less than 0.3 N, the rough surface had a higher value than the smooth surface (P = 0.0002). No difference was observed according to the material (P = 0.54). Fourteen days after surgery, no signifi cant difference was detected in the push-out forces between bone pegs with rough and smooth surfaces (489.0 ± 149.6 vs 478.3 ± 134.4 N (mean ± SD), respectively), but a marked difference was seen with the metal pegs (235.7 ± 115.7 vs 2.2 ± 1.6 N). The bone pegs with rough surfaces made contact with the recipient bone at the high points on the abraded surfaces. After the mechanical tests, the fusion was broken within the new bone for bone pegs with rough or smooth surfaces, but no breakage occurred at the junction of bone peg and new bone. The surface roughness of bone pegs has little effect on bone-to-bone fusion 2 weeks postoperatively, unlike the effect with metal pegs.

Objective-To evaluate a dorsoproximal extra-articular approach for insertion of 8.25-mm, solid-titanium, intramedullary (IM) interlocking nails into ostectomized foal third metacarpal (MC3) and third metatarsal (MT3) bones; to compare the monotonic mechanical properties of IM nail constructs with paired intact bones; and to determine the effects of age, body weight, fore-or hindlimb, and left or right limb on the mechanical testing variables. Animals or Sample Population-Twenty bone pairs (10 MC3, 10 MT3) collected from 10 foals of various weights and ages. Methods-One bone from each pair was randomly selected to be ostectomized and stabilized using an 8.25-mm, solid-titanium IM nail, and four 3.7-mm titanium interlocking screws (construct). Constructs and contralateral intact bone specimens were tested in axial compression and palmaro-/ plantarodorsal (PD) 4-point bending. Monotonic mechanical properties were compared between intact specimens and constructs with an ANOVA; significance was set at P Ͻ .05. Results-Nail insertion caused bone failure in 6 MC3 and 2 MT3. In general, mean mechanical testing values indicated that intact specimens were significantly stronger and stiffer than constructs for all age and weight ranges when tested in compression and PD 4-point bending (P Ͻ .05). Bone strength and stiffness of intact specimens tested in compression and bending tended to increase linearly with age and weight. Conclusions-IM interlocking nail fixation of gap-ostectomized MC3 and MT3 with 8.25-mm IM nails and 3.7-mm interlocking screws did not achieve sufficient strength or stiffness to be recommended as the sole means of repair for comminuted MC3 and MT3 fractures in young foals. Clinical Relevance-IM interlocking nail fixation of foal cannon bone fractures may be useful to decrease soft-tissue disruption at the fracture site; however, there is a risk of bone failure associated with extra-articular insertion. This method should be combined with other forms of external coaptation for added stability in axial compression and PD bending.

After trauma, obese patients have an increased risk of developing acute kidney injury (AKI). We have demonstrated that obese Zucker (OZ) rats, but not lean Zucker (LZ) rats, develop AKI 24 h after orthopedic trauma. ROS have been implicated in the pathophysiology of AKI in models of critical illness. However, the contribution of ROS to trauma-induced AKI in the setting of obesity has not been determined. We hypothesized that AKI in OZ rats after trauma is mediated by increased oxidative stress. Male LZ and OZ rats were divided into control and trauma groups, with a subset receiving treatment after trauma with the antioxidant apocynin (50 mg/kg ip, 2 mM in drinking water). The day after trauma, glomerular filtration rate, plasma creatinine, urine kidney injury molecule-1, and albumin excretion as well as renal oxidant and antioxidant activity were measured. After trauma, compared with LZ rats, OZ rats exhibited a significant decrease in glomerular filtration rate along with significa...

Objectives: This study aims to assess the efficacy of the Masquelet technique in addressing post-traumatic long bone defects. Through a two-stage process involving temporary spacer implantation and subsequent staged bone grafting, the objective is to evaluate the technique's ability to provide mechanical stability, combat infections, and promote successful osseous consolidation, affirming its viability as a surgical solution. Methods: From January 2019 to December 2022, we enrolled patients with post-traumatic bone defects treated using the Masquelet technique. Comprehensive evaluations included injury nature, defect location, soft-tissue condition, defect extent, antibiotics, and cementation duration. We documented fixation methods, infections, and the patient's current health status for a thorough assessment. Results: In this study of 15 consecutive patients (ten men, five women; average age 43), bone defects were diverse in location (six tibia, four femur, three humerus, one olecranon, and one calcaneum). Eight cases involved closed fractures with infection/nonunion; seven were open fractures (Gustilo II/IIIA). Spacer antibiotic use (gentamicin/vancomycin), bone consolidation, and limb stabilization were successful, with no reported complications in the 40-day average follow-up period. Conclusion: The delayed bone grafting approach, following cement spacer placement, presents a promising solution for significant bone loss in extremity reconstruction. This method, whether immediate or delayed, demonstrates favorable outcomes, with the induced membrane fostering a conducive environment for bone formation. As broader adoption occurs, ongoing clinical evidence will further clarify optimal graft materials, solidifying the efficacy of this innovative strategy in addressing segmental bone loss.

Purpose: To compare computed tomography (CT) in the sagittal plane and plain film radiography in the diagnosis of scaphoid fracture and displacement. Methods: Three groups of scaphoids (no fracture, undisplaced fractures, fractures with displacement Ͼ 1 mm) from 11 cadaver wrists were prepared. Each wrist then was imaged by using sagittal plane CT scans in the long axis of the scaphoid and plain film imaging using 6 standard scaphoid views. Eight readers from 3 specialties read each group of images. The sensitivity and specificity for the presence of fracture and fracture displacement were calculated in addition to interobserver and intraobserver reliabilities for each. Results: Both x-ray and CT scans showed a high sensitivity and specificity in detecting the presence of a fracture with no interspecialty differences. The sensitivity for displacement greater than 1 mm was lower for both modalities with no inter-specialty differences. The specificities for x-ray and CT for detecting displacement greater than 1 mm were 84% and 89%, respectively. The poor sensitivity for detecting displacement was explained by the low sensitivity of CT in the diagnosis of radial/ulnar displacement compared with x-ray and the low sensitivity of x-ray in the diagnosis of volar/dorsal displacement compared with CT scans. When fellowship-trained hand surgeons reviewed CT scans and plain films together the sensitivity and specificity for fracture displacement increased significantly. Intraobserver and interobserver reliability for both x-ray and CT scans was excellent except for the reading of CT scans among emergency physicians and for the reading of plain x-rays among senior house staff, representing moderate agreement. Conclusions: Based on these results both CT scans in the sagittal plane and plain films accurately detect fractures with a high degree of interobserver and intraobserver reliability, but they fall short in detecting displacement greater than 1 mm. (

N umerous publications on ultrasound (US) imaging in actual and analogue spacefl ight environments report reliance on remote guidance (RG) of minimally trained caregivers or research operators with no professional expertise in US. 1 , 2 , 4 High-quality US images from multiple organ systems (e.g., cardiovascular, respiratory, musculoskeletal, genitourinary) have been obtained consistently, attesting to the general maturity of the remotely guided diagnostic US capability in orbital spacefl ight and in remote terrestrial settings with communication latency of up to 2 s. 7 , 8 , 14 However, increased latency in data fl ow and voice communication associated with greater distances is expected to impair the eff ectiveness of these techniques. Th e actual communication delay that would render RG ineff ective has not been objectively established. Th e two-way communication delay on missions to the Moon is expected to reach ; 5-6 s and the delay on missions to Mars is expected to last 10 to 45 min. 3 , 5 , 13 A simulated Mars mission with a 15-min communication delay demonstrated successful use of US by a

Background: HIV infection has been associated with an increased risk of fragility fracture. We explored whether or not this increased risk persisted in HIV infected and uninfected men when controlling for traditional fragility fracture risk factors. Methodology/Principal Findings: Cox regression models were used to assess the association of HIV infection with the risk for incident hip, vertebral, or upper arm fracture in male Veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC). We calculated adjusted hazard ratios comparing HIV status and controlling for demographics and other established risk factors. The sample consisted of 119,318 men, 33% of whom were HIV infected (34% aged 50 years or older at baseline, and 55% black or Hispanic). Median body mass index (BMI) was lower in HIV infected compared with uninfected men (25 vs. 28 kg/m 2 ; p,0.0001). Unadjusted risk for fracture was higher among HIV infected compared with uninfected men [HR: 1.32 (95% CI: 1.20, 1.47)]. After adjusting for demographics, comorbid disease, smoking and alcohol abuse, HIV infection remained associated with an increased fracture risk [HR: 1.24 (95% CI: 1.11, 1.39)]. However, adjusting for BMI attenuated this association [HR: 1.10 (95% CI: 0.97, 1.25)]. The only HIV-specific factor associated with fragility fracture was current protease inhibitor use [HR: 1.41 (95% CI: 1.16, 1.70)]. Conclusions/Significance: HIV infection is associated with fragility fracture risk. This risk is attenuated by BMI.

Background Patients with multiple sclerosis (MS) have been reported to be at higher risk of fracture than other people. We sought to test this hypothesis in a large database of hospital admissions in England. Methods We analysed a database of linked statistical records of hospital admissions and death certificates for the whole of England (1999–2010). Rate ratios for fractures were determined, comparing fracture rates in a cohort of all people in England admitted with MS and rates in a comparison cohort. Results Significantly elevated risk for all fractures was found in patients with MS (rate ratio (RR) = 1.99, 95% confidence interval (CI) = 1.93-2.05)). Risks were particularly high for femoral fractures (femoral neck fracture RR = 2.79 (2.65-2.93); femoral shaft fracture RR 6.69 (6.12-7.29)), and fractures of the tibia or ankle RR = 2.81 (2.66-2.96). Conclusions Patients with MS have an increased risk of fractures. Caregivers should aim to optimize bone health in MS patients.

Background: Heterotopic ossification around the elbow can result in pain, loss of motion, and impaired function. We hypothesized that a single dose of radiation therapy could be administered safely and acutely after elbow trauma, could decrease the number of elbows that would require surgical excision of heterotopic ossification, and might improve clinical results. Methods: A prospective randomized study was conducted at three medical centers. Patients with an intraarticular distal humeral fracture or a fracture-dislocation of the elbow with proximal radial and/or ulnar fractures were enrolled. Patients were randomized to receive either single-fraction radiation therapy of 700 cGy immediately postoperatively (within seventytwo hours) or nothing (the control group). Clinical and radiographic assessment was performed at six weeks, three months, and six months postoperatively. All adverse events and complications were documented prospectively. Results: This study was terminated prior to completion because of an unacceptably high number of adverse events reported in the treatment group. Data were available on forty-five of the forty-eight patients enrolled in this study. When the rate of complications was investigated, a significant difference was detected in the frequency of nonunion between the groups. Of the nine patients who had a nonunion, eight were in the treatment group. The nonunion rate was 38% (eight) of twenty-one patients in the treatment group, which was significantly different from the rate of 4% (one) of twenty-four patients in the control group (p = 0.007). There were no significant differences between the groups with regard to the prevalence of heterotopic ossification, postoperative range of motion, or Mayo Elbow Performance Score noted at the time of study termination. Conclusions: This study demonstrated that postoperative single-fraction radiation therapy, when used NOTE: The authors thank Mathew King and the Carolinas Medical Center Department of Orthopaedic Clinical Research for their aid in preparation of this manuscript.

The anterior iliac crest is the harvest site preferred by many surgeons because of the quantity and quality of bone obtainable and the simplicity of harvesting techniques. Avulsion fracture of the iliac crest following bone grafting is an extremely rare occurrence. We present a case report of avulsion fracture of the anterior iliac crest following bone graft harvesting for anterior cervical fusion in a 63-year-old man. Non-operative treatment was the method of our treatment in the patient. By means of the presented case, iliac crest bone grafting techniques, risk factors of avulsion fracture, and treatment options were reviewed.

The anterior iliac crest is the harvest site preferred by many surgeons because of the quantity and quality of bone obtainable and the simplicity of harvesting techniques. Avulsion fracture of the iliac crest following bone grafting is an extremely rare occurrence. We present a case report of avulsion fracture of the anterior iliac crest following bone graft harvesting for anterior cervical fusion in a 63-year-old man. Non-operative treatment was the method of our treatment in the patient. By means of the presented case, iliac crest bone grafting techniques, risk factors of avulsion fracture, and treatment options were reviewed.

The null hypothesis that exercise has no effect on fracture rates in old age cannot be rejected on the basis of any published, randomized, prospective data. The view that exercise reduces the number of fractures is based on prospective and retrospective, observational cohort studies and case-control studies, all hypothesis-generating, not hypothesis-testing. Consistently replicated sampling bias may con rm the nding when evaluating other than randomized prospective studies. Better health, better muscle function, more muscle mass, better coordination may lead to exercise. The causal relationship could be between better health and exercise and better health and fewer fractures, not exercise and fewer fractures. The hypothesis should be tested in prospective, randomized studies evaluating hip, spine and other fragility fractures separately. There are rm data supporting the view that exercise during growth builds a stronger skeleton. Exercise during growth seems to result in high peak BMD and high muscle strength. However, the Achilles heel of exercise is its cessation. Are the skeletal and muscular bene ts attained during growth retained after the cessation of exercise and can any residual bene ts be found in old age, the period when fragility fractures rise exponentially? Does exercise during adulthood produce any biologically important reduction in surrogate endpoints for fractures other than BMD, since BMD can be in uenced only marginally by exercise after completion of growth? Recommendations for exercise should be based on evidence, not on opinion. Can continued recreational exercise maintain some of the bene ts in BMD and

The aim of this study was to evaluate a general school-based one-year exercise intervention program in a population-based cohort of girl at Tanner stage I. Fifty-three girls aged 7 to 9 years were included. The school curriculum based exercise intervention program included 40 minutes per school day. Fifty healthy age-matched girls assigned to the general school curriculum of 60 minutes physical activity per week served as controls. Bone mineral content (BMC; g) and areal bone mineral density (aBMD; g/cm 2 ) were measured with dual X-ray absorptiometry (DXA) of the total body (TB), lumbar spine (L2-L4 vertebra), the third lumbar vertebra (L3), the femoral neck (FN) and the leg. Volumetric bone mineral density (vBMD; g/cm 3 ) and bone width were calculated at L3 and FN. Total lean body mass and total fat mass were estimated from the total body scan. No differences were at baseline found in age, anthropometrics or bone parameters when the groups were compared. The annual gain in BMC was in the cases 4.7 percentage points higher in lumbar spine and 9.5 percentage points higher in L3 than in the controls (both p<0.001). The annual gain in aBMD was in the cases 2.8 percentage points higher in lumbar spine and 3.1 percentage points higher in L3 than in the controls (both p<0.001). The annual gain in bone width was in the cases 2.9 percentage points higher in L3 than in the controls (p<0.001). A general school-based exercise program in 7 -9-year-old girls enhances the accrual of BMC and aBMD and increases bone width.

The null hypothesis that exercise has no effect on fracture rates in old age cannot be rejected on the basis of any published, randomized, prospective data. The view that exercise reduces the number of fractures is based on prospective and retrospective, observational cohort studies and case-control studies, all hypothesis-generating, not hypothesis-testing. Consistently replicated sampling bias may con rm the nding when evaluating other than randomized prospective studies. Better health, better muscle function, more muscle mass, better coordination may lead to exercise. The causal relationship could be between better health and exercise and better health and fewer fractures, not exercise and fewer fractures. The hypothesis should be tested in prospective, randomized studies evaluating hip, spine and other fragility fractures separately. There are rm data supporting the view that exercise during growth builds a stronger skeleton. Exercise during growth seems to result in high peak BMD and high muscle strength. However, the Achilles heel of exercise is its cessation. Are the skeletal and muscular bene ts attained during growth retained after the cessation of exercise and can any residual bene ts be found in old age, the period when fragility fractures rise exponentially? Does exercise during adulthood produce any biologically important reduction in surrogate endpoints for fractures other than BMD, since BMD can be in uenced only marginally by exercise after completion of growth? Recommendations for exercise should be based on evidence, not on opinion. Can continued recreational exercise maintain some of the bene ts in BMD and

The adrenal-derived hormones dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) are the most abundant circulating hormones and their levels decline substantially with age. DHEAS is considered an inactive precursor, which is converted into androgens and estrogens via local metabolism in peripheral target tissues. The predictive value of serum DHEAS for fracture risk is unknown. The aim of this study was, therefore, to assess the associations between baseline DHEAS levels and incident fractures in a large cohort of older men. Serum DHEAS levels were analyzed with mass spectrometry in the population-based Osteoporotic Fractures in Men study in Sweden (n = 2568, aged 69 to 81 years). Incident X-ray validated fractures (all, n = 594; non-vertebral major osteoporotic, n = 255; hip, n = 175; clinical vertebral, n = 206) were ascertained during a median follow-up of 10.6 years. DHEAS levels were inversely associated with the risk of any fracture (hazard ratio [HR] per SD decrease = 1.14,...

One risk factor for osteoporosis which has attracted increasing attention in recent years is exposure to cadmium. The aim of this study was to examine the associations between low-level cadmium exposure, from diet and smoking, and BMD and incident fractures in elderly men. The study population consisted of 936 men from the Swedish cohort of the MrOS study, aged 70-81 years at inclusion (year 2002-2004), with reliable data on cadmium in urine (U-Cd) analyzed using inductively coupled plasma mass spectrometry in baseline samples. The participants also answered a questionnaire on lifestyle factors and medical history. BMD was measured at baseline using DXA in the total body, hip, and lumbar spine. During the follow-up period (until 2013), all new fractures were registered by date and type. Associations between BMD and U-Cd were assessed using multiple linear regression, and associations between incident fractures and baseline U-Cd were analyzed using Cox regression. In both cases, a nu...

Cortical porosity increases with age and affects bone strength, but its association with fracture in older men is unknown. The aim of this study was to investigate whether cortical porosity is associated with prevalent fractures in older men. A subsample of 456 men aged 80.2 AE 3.5 (mean AE SD) years, with available high-resolution peripheral quantitative computed tomography measurements at the tibia from the 5-year follow-up exam, was drawn from the prospective MrOS Gothenburg study. Dual-energy X-ray absorptiometry was used to measure areal bone mineral density (aBMD). Data on physical activity, calcium intake, medications, diseases, and smoking were collected on questionnaires at the follow-up exam. Of 87 men (19.1%) with fracture at or after age 50 years (all fracture group), 52 (11.4%) had had a self-reported fracture before the baseline exam and 35 (7.7%) had had an X-ray-verified fracture between baseline and follow-up. Men in the all-fracture group and in the X-ray-verified group had 15.8% (13.2% AE 4.9% versus 11.4% AE 3.8%; p < 0.001) and 21.6% (14.1% AE 5.2% versus 11.6% AE 3.9%; p < 0.01) higher cortical porosity, respectively, than men in the nonfracture group. The independent associations between bone microstructure parameters and fracture were tested using multivariate logistic regression with age, height, weight, calcium intake, smoking, physical activity, medications, and diseases as covariates. Cortical porosity was independently associated with any fracture (reported or X-ray-verified; OR per SD increase 1.49; 95% confidence interval (CI), 1.17 to 1.90) and with any X-ray-verified fracture alone (OR 1.73; 95% CI, 1.23 to 2.42). Including aBMD (spine or hip, respectively) in the multivariate logistic regression above revealed that cortical porosity was associated with any fracture (OR 1.54; 95% CI, 1.17 to 2.01) and with X-ray-verified fracture alone (OR 1.49; 95% CI, 1.00 to 2.22). Cortical porosity was associated with prevalence of fracture even after adjustment for aBMD.

Most previous genetic epidemiology studies within the field of osteoporosis have focused on the genetics of the complex trait areal bone mineral density (aBMD), not being able to differentiate genetic determinants of cortical volumetric BMD (vBMD), trabecular vBMD, and bone microstructural traits. The objective of this study was to separately identify genetic determinants of these bone traits as analysed by peripheral quantitative computed tomography (pQCT). Separate GWA meta-analyses for cortical and trabecular vBMDs were performed. The cortical vBMD GWA meta-analysis (n = 5,878) followed by replication (n = 1,052) identified genetic variants in four separate loci reaching genome-wide significance (RANKL, rs1021188, p = 3.6610 214 ; LOC285735, rs271170, p = 2.7610 212 ; OPG, rs7839059, p = 1.2610 210 ; and ESR1/C6orf97, rs6909279, p = 1.1610 29 ). The trabecular vBMD GWA meta-analysis (n = 2,500) followed by replication (n = 1,022) identified one locus reaching genome-wide significance (FMN2/GREM2, rs9287237, p = 1.9610 29 ). High-resolution pQCT analyses, giving information about bone microstructure, were available in a subset of the GOOD cohort (n = 729). rs1021188 was significantly associated with cortical porosity while rs9287237 was significantly associated with trabecular bone fraction. The genetic variant in the FMN2/GREM2 locus was associated with fracture risk in the MrOS Sweden cohort (HR per extra T allele 0.75, 95% confidence interval 0.60-0.93) and GREM2 expression in human osteoblasts. In conclusion, five genetic loci associated with trabecular or cortical vBMD were identified. Two of these (FMN2/GREM2 and LOC285735) are novel bonerelated loci, while the other three have previously been reported to be associated with aBMD. The genetic variants associated with cortical and trabecular bone parameters differed, underscoring the complexity of the genetics of bone parameters. We propose that a genetic variant in the RANKL locus influences cortical vBMD, at least partly, via effects on cortical porosity, and that a genetic variant in the FMN2/GREM2 locus influences GREM2 expression in osteoblasts and thereby trabecular number and thickness as well as fracture risk.

at prospective and retrospective observational studies with fracture as the end-point and RCTs with BMD or a frequency of a fall as the surrogate end-point for fractures. Nutrition. The role of calcium in attaining an adequate peak bone mass and reducing age-related bone loss has been 0

Quantitative ultrasound of the heel captures heel bone properties that independently predict fracture risk and, with bone mineral density (BMD) assessed by X-ray (DXA), may be convenient alternatives for evaluating osteoporosis and fracture risk. We performed a meta-analysis of genome-wide association (GWA) studies to assess the genetic determinants of heel broadband ultrasound attenuation (BUA; n 5 14 260), velocity of sound (VOS; n 5 15 514) and BMD (n 5 4566) in 13 discovery cohorts. Independent replication involved seven cohorts with GWA data (in silico n 5 11 452) and new genotyping in 15 cohorts (de novo n 5 24 902). In combined random effects, meta-analysis of the discovery and replication cohorts, nine single nucleotide polymorphisms (SNPs) had genome-wide significant (P < 5 3 10 28 ) associations with heel bone properties. Alongside SNPs within or near previously identified osteoporosis susceptibility genes including ESR1 (6q25.1: rs4869739, rs3020331, rs2982552), SPTBN1 (2p16.2: rs11898505), RSPO3 (6q22.33: rs7741021), WNT16 (7q31.31: rs2908007), DKK1 (10q21.1: rs7902708) and GPATCH1 (19q13.11: rs10416265), we identified a new locus on chromosome 11q14.2 (rs597319 close to TMEM135, a gene recently linked to osteoblastogenesis and longevity) significantly associated with both BUA and VOS (P < 8.23 3 10 214 ). In meta-analyses involving 25 cohorts with up to 14 985 fracture cases, six of 10 SNPs associated with heel bone properties at P < 5 3 10 26 also had the expected direction of association with any fracture (P < 0.05), including three SNPs with P < 0.005: 6q22.33 (rs7741021), 7q31.31 (rs2908007) and 10q21.1 (rs7902708). In conclusion, this GWA study reveals the effect of several genes common to central DXA-derived BMD and heel ultrasound/DXA measures and points to a new genetic locus with potential implications for better understanding of osteoporosis pathophysiology.

Osteoporosis has be reported to be a complication of active antiretroviral therapy of HIV infection. We studied 148 HIV-infected men stratified according to their treatment. Our data show that these patients have an average 9% decreased BMD, irrespective of their treatment. Low body mass index and high resorption markers were associated with low bone density. Osteoporosis has been reported in HIV-infected (HIV ϩ ) patients, and it has been suggested that it may be linked to protease-inhibitor treatments (PI). Materials and Methods: To assess this risk and to investigate its putative link with treatments, we compared the bone density of HIV ϩ men, who were either receiving treatment (including PI [PI ϩ ], n ϭ 49; without PI [PI Ϫ ], n ϭ 51) or untreated (UT, n ϭ 48). We included 81 age-matched control HIV-negative (HIV Ϫ ) males (age, 40 Ϯ 8 years). Results: BMD adjusted for age (Z-score) was lower in the HIV ϩ patients at the lumbar spine (HIV ϩ : Ϫ1.08 Ϯ 1.21, HIV Ϫ : Ϫ0.06 Ϯ 1.26, p Ͻ 0.001) and the femoral neck (HIV ϩ : Ϫ0.39 Ϯ 1.05, HIV Ϫ : 0.25 Ϯ 0.87, p Ͻ 0.001). The prevalence of osteoporosis was 16% in HIV ϩ and 4% in HIV Ϫ subjects (p Ͻ 0.01). In the HIV ϩ subjects, the Z-score was correlated only to body mass index (r ϭ 0.27 at lumbar spine and 0.35 at femoral neck). Untreated HIV ϩ patients had a negative Z-score (Ϫ0.82 Ϯ 1.15 for the lumbar spine), which was not different from the one of treated HIV ϩ patients. In the PI ϩ and PI Ϫ groups, the Z-score did not depend on the presence of lipodystrophy or the proportion of fat in the abdomen and legs measured by DXA. Markers of bone remodeling were measured in the 132 HIV ϩ and 35 HIV Ϫ subjects. Compared with controls, HIV ϩ patients had lower bone alkaline phosphatase and higher urinary cross-laps/Cr, which was negatively correlated with the Z-score at both the femoral neck (r ϭ Ϫ0.22) and lumbar spine (r ϭ Ϫ0.21). TNF␣ was increased in untreated compared with treated HIV ϩ subjects and was not correlated to the Z-score. Conclusion: Our cross-sectional study does not show any deleterious effect of the treatment but does indicate a decrease in bone density in HIV ϩ patients irrespective of the treatment. This low bone density is in part related to the low body weight and is associated with increased bone resorption.

Bone fractures in birds are usually diagnosed with the aid of traditional radiography. However, this technique remains limited because of the difficulties associating this examination with real-time procedures. The aim of this study was to describe the use of B-mode ultrasound to assess the long bones of two avian orders. For the study, we used carcases of birds from the orders Falconiformes (n = 9) and Strigiformes (n = 12), with weights ranging from 108 to 1020 g. An ultrasound device with a 5-12 MHz linear probe was employed to produce images of the long bones (humerus, radius, ulna, femur and tibiotarsus). Ultrasound (US) measurements and physical measurements using a caliper were applied to compare the diameter of the bones. Images were also recorded from the US examination performed in two live patients attending the hospital with suspected bone fractures. No statistical difference was found between the two methods of measurement in carcases weighing up to 267 g (P &gt; 0.01)....

The current focus on reducing the risk of osteoporosis and skeletal fractures in later life has placed an emphasis on the role of calcium in building strong bones during childhood and adolescence. Recent National Institutes of Health (NIH) Consensus Development Conference recommendations for optimal calcium intake encourage increased intake. Strategies to enhance optimal calcium intake in children and adolescents include dietary choices and the use of supplements.

Integrins mediate cell adhesion to extracellular matrix components. Integrin ␣1␤1 is a collagen receptor expressed on many mesenchymal cells, but mice deficient in ␣1 integrin (␣1-KO) have no gross structural defects. Here, the regeneration of a fractured long bone was studied in ␣1-KO mice. These mice developed significantly less callus tissue than the wild-type (WT) mice, and safranin staining revealed a defect in cartilage formation. The mRNA levels of nine extracellular matrix genes in calluses were evaluated by Northern blotting. During the first 9 days the mRNA levels of cartilage-related genes, including type II collagen, type IX collagen, and type X collagen, were lower in ␣1-KO mice than in WT mice, consistent with the reduced synthesis of cartilaginous matrix appreciated in tissue sections. Histological observations also suggested a diminished number of chondrocytes in the ␣1-KO callus. Proliferating cell nuclear antigen staining revealed a reduction of mesenchymal progenitors at the callus site. Although, the number of mesenchymal stem cells (MSCs) obtained from WT and ␣1-KO whole marrow was equal, in cell culture the proliferation rate of the MSCs of ␣1-KO mice was slower, recapitulating the in vivo observation of reduced callus cell proliferation. The results demonstrate the importance of proper collagen-integrin interaction in fracture healing and suggest that ␣1 integrin plays an essential role in the regulation of MSC proliferation and cartilage production.

Neurofibromatosis type 1 (NF1) is an inherited disease with an incidence of about 1:3000 worldwide. Approximately half of all patients with NF1 present osseous manifestations, which can vary from mild to severely debilitating changes such as congenital pseudarthrosis. In the present study, fracture healing of mouse tibia was followed and specimens were collected 5, 9, 14, and 22 days postoperatively. Experimental pseudarthrosis of rat was followed up to 15 weeks postoperatively. In situ hybridization and immunohistochemistry were used to demonstrate expression of NF1 tumor suppressor and phosphorylated p44/42 mitogen-activated protein kinase (MAPK), an indicator of the Ras-MAPK pathway. The results showed that ossified callus was formed in mouse fracture 22 days after the operation. The final outcome of rat pseudarthrosis was detected 9 weeks after the operation, presenting abundant cartilaginous callus at the pseudarthrosis. NF1 gene expression was noted in the maturing and in the ...

Integrins mediate cell adhesion to extracellular matrix components. Integrin ␣1␤1 is a collagen receptor expressed on many mesenchymal cells, but mice deficient in ␣1 integrin (␣1-KO) have no gross structural defects. Here, the regeneration of a fractured long bone was studied in ␣1-KO mice. These mice developed significantly less callus tissue than the wild-type (WT) mice, and safranin staining revealed a defect in cartilage formation. The mRNA levels of nine extracellular matrix genes in calluses were evaluated by Northern blotting. During the first 9 days the mRNA levels of cartilage-related genes, including type II collagen, type IX collagen, and type X collagen, were lower in ␣1-KO mice than in WT mice, consistent with the reduced synthesis of cartilaginous matrix appreciated in tissue sections. Histological observations also suggested a diminished number of chondrocytes in the ␣1-KO callus. Proliferating cell nuclear antigen staining revealed a reduction of mesenchymal progenitors at the callus site. Although, the number of mesenchymal stem cells (MSCs) obtained from WT and ␣1-KO whole marrow was equal, in cell culture the proliferation rate of the MSCs of ␣1-KO mice was slower, recapitulating the in vivo observation of reduced callus cell proliferation. The results demonstrate the importance of proper collagen-integrin interaction in fracture healing and suggest that ␣1 integrin plays an essential role in the regulation of MSC proliferation and cartilage production.

Purpose In the surgical treatment for lower-leg intraarticular fractures, the fragments have to be positioned and aligned to reconstruct the fractured bone as precisely as possible, to allow the joint to function correctly again. Standard procedures use 2D radiographs to estimate the desired reduction position of bone fragments. However, optimal correction in a 3D space requires 3D imaging. This paper introduces a new navigation system that uses pre-operative planning based on 3D CT data and intra-operative 3D guidance to virtually reduce lower-limb intra-articular fractures. Physical reduction in the fractures is then performed by our robotic system based on the virtual reduction. Methods 3D models of bone fragments are segmented from CT scan. Fragments are pre-operatively visualized on the screen and virtually manipulated by the surgeon through a dedicated GUI to achieve the virtual reduction in the fracture. Intra-operatively, the actual position of the bone fragments is provided by an optical tracker enabling real-time 3D guidance. The motion commands for the robot connected to the bone fragment are generated, and the fracture physically reduced based on the surgeon's virtual reduction. To test the system, four femur models were fractured to obtain four different distal femur fracture types. Each one of them was

Purpose : In epileptic patients fractures are six times more frequent than in the general population. Known predisposing factors are anticonvulsant drugs, malnutrition, lack of physical activity and sunlight exposure. Methods : In this study we describe two patients, one with a bilateral supracondylar fracture and one with a unilateral supracondylar fracture after an epileptic seizure. The literature concerning femur fracture following an epileptic insult is reviewed. Results : A review of the literature revealed several cases of femur fractures associated with epilepsy, however no cases were found involving a supracondylar femur. Conclusions : Our hypothesis is that a tonic seizure with simultaneous contraction of both agonists and antagonists can cause this type of fracture in predisposing patients.

Introduction: Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest. Methods: A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CTscan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury. Results: The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR = 6.73, 95% CI = 2.56, 17.70, p < 0.001), reduced airentry (OR = 4.48, 95% CI = 1.33, 15.02, p = 0.015) and/or abnormal respiratory effort (OR = 4.05, 95% CI = 1.28, 12.66, p = 0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. Conclusion: In alert patients without evidence of chest wall tenderness, reduced airentry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.

The aim of this study was to describe social participation expressed as accomplished ordinary activities, health-related quality of life (HRQoL) and life satisfaction (LS), among elderly men and women with osteoporosis-related fractures with and without pain, compared to non-fractured controls. The study was a population-based case-control study conducted at a university hospital, including 408 subjects from the Good Ageing in Ska ˚ne investigation. Fractured men and women of age 60-93 years were divided into two groups: one with pain (FP; n = 87) and one without pain (FnP; n = 82). Fractures included vertebrae, hip, pelvis or ankle according to International Classification of Diseases version 10 (ICD-10). A third group of non-fractured subjects without pain (n = 239) was used as controls (CnP). Questionnaires were used to collect information about HRQoL, LS, social participation in ordinary activities such as social, cultural and leisure time activities, pain during past month, co-morbidity, alcohol and tobacco consumption, medication, exercise earlier in life, walking-aid, and socio-demographic variables. The results showed that FP scored significantly lower than CnP in HRQoL and LS. In general, fractured were more restricted in participation and in 12 out of 21 activities FP had a significant lower participation compared to CnP. In a regression model, participation in social and leisure activities as well as fracture predicted independently levels of HRQoL and LS.

Background Bisphosphonates such as pamidro- nate disodium inhibit osteoclast-induced bone resorption associated with cancer that has metastasized to bone. Women with stage IV breast cancer who were receiving cytotoxic chemotherapy and had at least one lytic bone lesion were given either placebo or pamidronate (90 mg) as a two-hour intravenous infusion monthly for 12 cycles. Skeletal complications, including pathologic fractures, the need for radiation to bone or bone surgery, spinal cord compression, and hypercalcemia (a serum calcium concentration above 12 mg per deciliter [3.0 mmol per liter] or elevated to any degree and requiring treatment), were assessed monthly. Bone pain, use of analgesic drugs, performance status, and quality of life were assessed throughout the trial. The efficacy of treatment was evaluated in 380 of 382 randomized patients, 185 receiving pamidronate and 195 receiving placebo. The median time to the occurrence of the first skeletal complication was greater in the pamidronate group than in the placebo group (13.1 vs. 7.0 months, P ϭ 0.005), and the proportion of patients in whom any skeletal complication occurred was lower (43 percent vs. 56 percent, P ϭ 0.008). There was significantly less increase in bone pain (P ϭ 0.046) and deterioration of performance status (P ϭ 0.027) in the pamidronate group than in the placebo group. Pamidronate was well tolerated. Conclusions Monthly infusions of pamidronate as a supplement to chemotherapy can protect against skeletal complications in women with stage IV breast cancer who have osteolytic bone metastases. (N Engl

Vplyv akromegálie na kosť a riziko fraktúr nebol doteraz dostatočne preskúmaný. Akromegália stimuluje kostný obrat, čo vedie k vzostupu osteoresorpčných aj osteoformačných markerov. Pacienti s akromegáliou majú normálnu alebo dokonca zvýšenú denzitu kostnej hmoty (BMD -bone mineral density), existujú však aj práce, v ktorých bola pozorovaná nízka BMD u akromegalikov s hypogonadizmom, predovšetkým na lumbálnej chrbtici, pričom na krčku femoru bol tento efekt menej výrazný, čo sa vysvetľuje pozitívnym vplyvom hypersekrécie na kortikálnu kosť. Viaceré štúdie dokumentovali morfometrické vertebrálne fraktúry (VF) u tretiny akromegalikov. Medzi hlavné rizikové faktory vedúce k vzniku VF patrí hypogonadizmus, diabetes mellitus a predchádzajúca VF, avšak riziko fraktúr nekoreluje s BMD, preto sa v súčasnosti väčšina prác upriamuje na stanovenie kvality kosti, t. j. kostnej sily a mikroštruktúry. The impact of acromegaly on bone and the risk of fractures has not been sufficiently investigated. GH hypersecretion stimulates bone turnover, leading to an increase in bone turnover markers. Normal or even increased bone mineral density (BMD) in comparison to healthy controls have been reported, but there are some works where decreased BMD was observed among acromegaly patients with hypogonadism, particularly at lumbar spine. Less pronounced effect of GH overproduction was observed at the femoral neck, as explained by the positive effect of hypersecretion on the cortical bone (due to periosseal ossification). Several studies have documented morphometric vertebral fractures (VF) in 1/3 of acromegaly patients. The major risk factors leading to the development of VF include hypogonadism, diabetes mellitus and previous VF. Because the risk of fractures does not correlate with BMD most of the studies are currently focused on bone quality, bone strength and microstructure.

Study Design: Case study. Objectives: To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot. Background: Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined. Methods and Measures: Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status. The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 1 W / o return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 1 W h reduction of swelling with ankle girth to normal; ~W/O range of motion of ankle and subtalar joints. Strength in plantar flexion and ewrsion remained 20% impaired (80"/0 retum to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 1 W / 0 of strength in hip and ankle, and ~W/O retum of balance. She could squat and jump without pain and she returned to full premorbid activity level. Conclusiom: Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain. / Orthop Sports Phys Ther 2000;30:580-594.

In 1989, a prospective randomized multicenter study was initiated in order to determine the safety and efficacy of oral clodronate in myeloma patients. The primary objective of this long-term trial is to evaluate whether supportive clodronate is able to prevent or retard the progression of bone disease and reduce the occurrence of characteristic complications: pain, pathologic fractures, and hypercalcemia. We now report first results as an interim analysis, including data obtained from 26 patients (total number of Tt~bingen patients n = 36) who entered the study at the Medizinische Universitatsklinik Tabingen. Patients were randomized to receive either chemotherapy alone (melphalan 15 mg/m a i.v. on day 1 and prednisolone 60 mg/m 2 orally on days 1-4 every 4 weeks (control group) or in combination with 1600 mg clodronate/day orally as a single dose for a period of at least 1 year. Repeated radiologic examinations in addition to hematologic and biochemical analysis were performed in order to evaluate the skeletal status with respect to lytic bone lesions and osteoporosis and the course of serum M protein and light chain excretion into urine. Clodronate treatment resulted in a significant decrease of serum calcium concentrations and of biochemical indices for bone resorption. No clodronate-related toxicity or hypocalcemia was oberved. In patients treated with chemotherapy alone, this effect was less marked and discontinuous. Clodronate-treated patients developed fewer progressive bone lesions (significant for lytic, not for osteoporotic lesions). No hypercalcemic episodes occurred in the clodronate-treated patients, but there were six episodes in the control group. Whereas the number of vertebral fractures was evidently less is clodronate-treated patients, three of those patients suffered from multiple fractures of * Presented at the annual meeting of the German Society for Hematology and Oncology, 4-7

Women residing in Olmsted County (n ϭ 9,258) who underwent hysterectomy in 1965-2002, compared to an equal number of age-and sex-matched community controls. Intervention(s): Observational study of the effect of hysterectomy for various indications on subsequent fractures. Main Outcome Measure(s): Fractures of any type, and at osteoporotic sites (e.g., hip, spine, or wrist) alone, as assessed by electronic review of inpatient and outpatient diagnoses in the community. Result(s): Compared with controls, there was a significant increase (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.13-1.29) in overall fracture risk among the women with a hysterectomy, but osteoporotic fracture risk was not elevated (HR, 1.09; 95% CI, 0.98 -1.22). Most hysterectomy indications were associated with fractures generally, although these were not often statistically significant. Only operations for a uterine prolapse were associated with osteoporotic fractures (HR, 1.33; 95% CI, 1.01-1.74). Oophorectomy was not an independent predictor of fracture risk (HR, 1.0; 95% CI, 0.98 -1.15). Hysterectomy does not appear to pose much long-term risk for fractures, but the association of fractures with surgery for uterine prolapse deserves further attention. (Fertil Steril 2007

Thinking of the future and walking back to normal: an exploratory study of patients’ experiences during recovery from lower limb fracture¶ Admission to hospital following a traumatic lower limb fracture is undoubtedly a stressful life event; however, few studies have detailed this from the patient’s perspective. By exploring patients’ experiences of hospitalization with lower limb trauma, this study aimed to explicate some of the factors impinging on the recovery trajectory. Patients’ perceptions of the events influencing their strategies for coping with stress, hospitalization and temporary incapacity were investigated using a qualitative methodology. A convenience sample of nine patients was recruited from an orthopaedic ward in a district general hospital in Wales. The respondents used health diaries to document their recovery for up to 6 weeks after emergency surgery. These diaries were validated and supplemented by semi‐structured interviews. Following their traumatic injuries,...