Fractures non traumatiques en fin de grossesse: s'agit-il toujours d'une ostéoporose? A propos de deux cas [Non-traumatic fractures at the end of a pregnancy: are there always of osteoporotic origin].

Pregnancy-associated osteoporosis usually appears during the first pregnancy and does not affect the followings. We report two cases where non-traumatic fractures have been diagnosed shortly after delivery of second pregnancies. Wide investigations could not find a cause of secondary osteoporosis. In the first case we came to the diagnosis of pregnancy-associated osteoporosis and an intravenous treatment of ibandronate has been prescribed. In the second case the bone mineral density (BMD) being almost normal and the localisation of the fracture being atypical, we concluded to a fracture of non-osteoporotic origin, probably due to mechanical stress during pregnancy. No therapy against osteoporosis has been prescribed.

Six Years of Denosumab Treatment in Postmenopausal Women with Osteoporosis: Results From the First Three Years of the FREEDOM Extension

Background/Purpose: Denosumab (DMAb) is an approved therapy for the treatment of postmenopausal women with osteoporosis at increased risk for fracture. A favorable risk/benefit profile was demonstrated in the pivotal, 3-year FREEDOM trial (Cummings et al NEJM 2009). The open-label, active-treatment FREEDOM Extension study is investigating the efficacy and safety of DMAb for up to 10 years. The Extension trial enrolled women who had received DMAb or placebo in FREEDOM and provides an opportunity to evaluate the long-term efficacy and safety of continuous DMAb treatment (long-term group), and to replicate the DMAb findings observed in FREEDOM (cross-over group). Here, we report the results from the first 3 years of the Extension, representing up to 6 continuous years of DMAb exposure. Methods: During the Extension, each woman is scheduled to receive 60 mg DMAb every 6 months and supplemental calcium and vitamin D daily. For the analyses reported here, women from the FREEDOM DMAb group received 3 more years of DMAb for a total of 6 years of exposure (long-term group) and women from the FREEDOM placebo group received 3 years of DMAb exposure (cross-over group). Results: Of the 5928 women eligible for the Extension, 4550 (77%) enrolled (N_2343 long-term; N_2207 cross-over). In the long-term group, further significant mean increases in bone mineral density (BMD) occurred 4044 for cumulative 6-year gains of 15.2% at the lumbar spine and 7.5% at the total hip (Figure). During the first 3 years of DMAb treatment during the Extension, the cross-over group had significant mean gains in BMD at the lumbar spine (9.4%) and total hip (4.8%), similar to those observed in the long-term DMAb group during the first 3 years of FREEDOM (lumbar spine, 10.1%; total hip, 5.7%). Serum CTX was rapidly and similarly reduced after the 1st (cross-over) or 7th (long-term) DMAb dose with the characteristic attenuation observed at the end of the dosing period. In the cross-over group, yearly incidences of new vertebral and nonvertebral fractures were lower than in the FREEDOM placebo group. Fracture incidence remained low in the long-term group. Incidences of adverse events (AEs) and serious AEs did not increase over time with DMAb treatment. There were 2 subjects with AEs adjudicated to ONJ in the cross-over group and 2 in the long-term group. Both cases in the cross-over group healed completely and without further complications; 1 of these subjects continues to receive DMAb. Both women in the long-term group continue to be followed. No atypical femur fractures have been observed to date. Figure. Percent changes in bone mineral density during FREEDOM and the Extension Conclusion: DMAb treatment for 6 continuous years (long-term group) remained well tolerated, maintained reduced bone turnover, and continued to significantly increase BMD. Fracture incidence remained low. DMAb treatment for 3 years in the cross-over group reproduced the original observations in FREEDOM

Efficacy of a hip flexion assist orthosis in adults with hemiparesis after stroke.

Background During gait, the hip flexors generate 40% of the total power. Nevertheless, no device has been tested extensively for clinical purposes to cope with weakness in the hip flexors in patients with stroke. Objective The purpose of this study was to assess the efficacy and safety of a newly developed hip flexion assist orthosis in adult patients with hemiparesis after stroke. Design The study used a prospective, randomized, before-after trial design. The inclusion criteria were hemiparesis resulting from stroke (onset ≥8 weeks); ability to walk, even if with assistance; and hip flexion weakness (Medical Research Council Scale score ≤4).¦METHODS: /b> The main outcome measures were the 10-Meter Walk Test and the Six-Minute Walk Test. Patients also were evaluated with the Trunk Control Test, the Functional Ambulation Categories, the Motricity Index, and hip flexor strength on the Medical Research Council Scale. Sixty-two survivors of stroke were tested in random order with and without the orthosis. Any adverse event associated with its use was recorded.¦RESULTS: /b> Both the Six-Minute Walk Test and the 10-Meter Walk Test scores improved with the use of the orthosis. A significant negative correlation was found for improvement between scores on the 2 main outcome measures with the orthosis and the Functional Ambulation Categories scores. The improvement in Six-Minute Walk Test scores with the orthosis was related inversely to hip flexor strength.¦CONCLUSIONS: /b> The data showed that the use of a hip flexion assist orthosis can improve gait in patients with poststroke hemiparesis, particularly those with more severe walking impairment.

Dorsal fractures of the Triquetrum : MRI findings with an emphasis on dorsal carpal ligament injuries

Contexte et but de l'étude: Les fractures du triquetrum sont les deuxièmes fractures des os du carpe en fréquence, après celles du scaphoïde. Elles représentent environ 3.5% de toutes les lésions traumatiques du poignet, et résultent le plus souvent d'une chute de sa hauteur avec réception sur le poignet en hyper-extension. Leur mécanisme physiopathologique reste débattu. La première théorie fut celle de l'avulsion ligamentaire d'un fragment osseux dorsal. Puis, Levy et coll. ainsi que Garcia-Elias ont successivement suggéré que ces fractures résultaient plutôt d'une impaction ulno-carpienne. De nombreux ligaments (intrinsèques et extrinsèques du carpe) s'insèrent sur les versants palmaires et dorsaux du triquetrum. Ces ligaments jouent un rôle essentiel dans le maintien de la stabilité du carpe. Bien que l'arthro-IRM du poignet soit l'examen de référence pour évaluer ces ligaments, Shahabpour et coll. ont récemment démontré leur visibilité en IRM tridimensionnelle (volumique) après injection iv. de produit de contraste (Gadolinium). L'atteinte ligamentaire associée aux fractures dorsales du triquetrum n'a jusqu'à présent jamais été évalué. Ces lésions pourraient avoir un impact sur l'évolution et la prise en charge de ces fractures. Les objectifs de l'étude étaient donc les suivants: premièrement, déterminer l'ensemble des caractéristiques des fractures dorsales du triquetrum en IRM, en mettant l'accent sur les lésions ligamentaires extrinsèques associées; secondairement, discuter les différents mécanismes physiopathologiques (i.e. avulsion ligamentaire ou impaction ulno-carpienne) de ces fractures d'après nos résultats en IRM. Patients et méthodes: Ceci est une étude rétrospective multicentrique (CHUV, Lausanne; Hôpital Cochin, AP-HP, Paris) d'examens IRM et radiographies conventionnelles du poignet. A partir de janvier 2008, nous avons recherché dans les bases de données institutionnelles les patients présentant une fracture du triquetrum et ayant bénéficié d'une IRM volumique du poignet dans un délai de six semaines entre le traumatisme et l'IRM. Les examens IRM ont été effectués sur deux machines à haut champ magnétique (3 Tesla) avec une antenne dédiée et un protocole d'acquisition incluant une séquence tridimensionnelle isotropique (« 3D VIBE ») après injection iv. de produit de contraste (Gadolinium). Ces examens ont été analysés par deux radiologues ostéo-articulaires expérimentés. Les mesures ont été effectuées par un troisième radiologue ostéo-articulaire. En ce qui concerne l'analyse qualitative, le type de fracture du triquetrum (selon la classification de Garcia-Elias), la distribution de l'oedème osseux post- traumatique, ainsi que le nombre et la distribution des lésions ligamentaires extrinsèques associées ont été évalués. Pour l'analyse quantitative, l'index du processus de la styloïde ulnaire (selon la formule de Garcia-Elias), le volume du fragment osseux détaché du triquetrum, et la distance séparant ce fragment osseux du triquetrum ont été mesurés.

Failure of the surgical treatment in 115 infected hip arthroplasties-­analysis of a 12-­year prosthetic joint cohort study (1999-­2010)

Background:¦Infection after total or partial hip arthroplasty (HA) leads to significant long-­term morbidity and high healthcare cost. We evaluated reasons for treatment failure of different surgical modalities in a 12-­year prosthetic hip joint infection cohort study.¦Method:¦All patients hospitalized at our institution with infected HA were included either retrospectively (1999-­‐2007) or prospectively¦(2008-­‐2010). HA infection was defined as growth of the same microorganism in ≥2 tissues or synovialfluid culture, visible purulence, sinus tract or acute inflammation on tissue histopathology. Outcome analysis was performed at outpatient visits, followed by contacting patients, their relatives and/or treating physicians afterwards.¦Results:¦During the study period, 117 patients with infected HA were identified. We excluded 2 patients due to missing data. The average age was 69 years (range, 33-­‐102 years); 42% were female. HA was mainly performed for osteoarthritis (n=84), followed by trauma (n=22), necrosis (n=4), dysplasia(n=2), rheumatoid arthritis (n=1), osteosarcoma (n=1) and tuberculosis (n=1). 28 infections occurred early(≤3 months), 25 delayed (3-­‐24 months) and 63 late (≥24 months after surgery). Infected HA were¦treated with (i) two-­‐stage exchange in 59 patients (51%, cure rate: 93%), (ii) one-­‐stage exchange in 5 (4.3%, cure rate: 100%), (iii) debridement with change of mobile parts in 18 (17%, cure rate: 83%), (iv) debridement without change of mobile¦parts in 17 (14%, cure rate : 53% ), (v) Girdlestone in 13 (11%, cure rate: 100%), and (vi) two-­‐stage exchange followed by¦removal in 3 (2.6%). Patients were followed for an average of 3.9 years (range, 0.1 to 9 years), 7 patients died unrelated to the infected HA. 15 patients (13%) needed additional operations, 1 for mechanical reasons(dislocation of spacer) and 14 for persistent infection: 11 treated with debridement and retention (8 without change; and 3 with change of mobile parts) and 3 with two-­‐stage exchange. The average number of surgery was 2.2 (range, 1 to 5). The infection was finally eradicated in all patients, but the functional outcome remained unsatisfactory in 20% (persistent pain or impaired mobility due to spacer or Girdlestone situation).¦Conclusions:¦Non-­‐respect of current treatment concept leads to treatment failure with subsequent operations. Precise analysis of each treatment failure can be used for improving the treatment algorithm leading to better results.

Incidents occuring during anesthesia for total hip arthroplasty: a comparison of general versus regional anaesthesia

Background: The type of anesthesia to be used for total hip arthroplasty (THA) is still a matter of debate. We compared the occurrence of per- and post-anesthesia incidents in patients receiving either general (GA) or regional anesthesia (RA). Methods: We used data from 29 hospitals, routinely collected in the Anaesthesia Databank Switzerland register between January 2001 and December 2003. We used multi-level logistic regression models. Results: There were more per- and post-anesthesia incidents under GA compared to RA (35.1% vs 32.7 %, n = 3191, and 23.1% vs 19.4%, n = 3258, respectively). In multi-level logistic regression analysis, RA was significantly associated with a lower incidence of per-anesthetic problems, especially hypertension, compared with GA. During the post-anesthetic period, RA was also less associated with pain. Conversely, RA was more associated with post-anesthetic hypotension, especially for epidural technique. In addition, age and ASA were more associated with incidents under GA compared to RA. Men were more associated with per-anesthetic problems under RA compared to GA. Whereas increased age (>67), gender (male), and ASA were linked with the choice of RA, we noticed that this choice depended also on hospital practices after we adjusted for the other variables. Conclusions: Compared to RA, GA was associated with an increased proportion of per- and post-anesthesia incidents. Although this study is only observational, it is rooted in daily practice. Whereas RA might be routinely proposed, GA might be indicated because of contraindications to RA, patients' preferences or other surgical or anaesthesiology related reasons. Finally, the choice of a type of anesthesia seems to depend on local practices that may differ between hospitals.

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures.

Objective: To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture. Methods: Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified. Results: The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm2 and the T score was ¿2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm2 and the T score was ¿2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60¿70, and 60% in patients over 70. Conclusion: These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures.

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.

Management of fragility fractures in Switzerland: results of a nationwide survey.

A nationwide survey was conducted in Switzerland to assess the quality level of osteoporosis management in patients aged 50 years or older presenting with a fragility fracture to the emergency ward of the participating hospitals. Eight centres recruited 4966 consecutive patients who presented with one or more fractures between 2004 and 2006. Of these, 3667 (2797 women, 73.8 years old and 870 men, 73.0 years old in average) were considered as having a fragility fracture and included in the survey. Included patients presented with a fracture of the upper limbs (30.7%), lower limbs (26.4%), axial skeleton (19.5%) or another localisation, including malleolar fractures (23.4%). Thirty-two percent reported one or more previous fractures during adulthood. Of the 2941 (80.2%) hospitalised women and men, only half returned home after discharge. During diagnostic workup, dual x-ray absorptiometry (DXA) measurement was performed in 31.4% of the patients only. Of those 46.0% had a T-score < or =-2.5 SD and 81.1% < or =-1.0 SD. Osteoporosis treatment rate increased from 26.3% before fracture to 46.9% after fracture in women and from 13.0% to 30.3% in men. However, only 24.0% of the women and 13.8% of the men were finally adequately treated with a bone active substance, generally an oral bisphosphonate, with or without calcium / vitamin D supplements. A positive history of previous fracture vs none increased the likelihood of getting treatment with a bone active substance (36.6 vs 17.9%, ? 18.7%, 95% CI 15.1 to 22.3, and 22.6 vs 9.9%, ? 12.7%, CI 7.3 to 18.5, in women and men, respectively). In Switzerland, osteoporosis remains underdiagnosed and undertreated in patients aged 50 years and older presenting with a fragility fracture.

Tension-band wiring of olecranon fractures - Biomechanical analysis of different fixation techniques

Tension-band wiring is a recognised standard treatment for fixation of olecranon fractures. The classical operation technique is well known and widespread among the orthopaedic surgeons. Nevertheless complications like K-wire migration or skin perforation and difficult technical as well as anatomical prerequisites require better-adapted operation fixation methods. In older female patients a cut through of the Kirschner wires with concomitant secondary displacement was observed. We intent to develop a new, better adapted operation technique for olecranon fractures in the old patients, in order to decrease complications and follow-up procedures. In this study we compare two different K-wire positions: 10 models of the classical AO tension-banding to 10 models with adapted K-wire insertion. In this group the K-wire passes from the tip of the olecranon to the posterior cortical of the distal fragment of the ulna. We tested maximal failure load, maximal opening angle as well as maximal work to achieve maximal force. In either technique we were able to determine different variables: a maximal failure load of more than 600N (p = 0.94) for both fixation methods and a maximal opening angle for both techniques of about 10° (p = 0.86). To achieve the maximal force our modified technique required a slightly increased work (p = 0.16). In this study no statistical significant differences between the two fixation techniques was shown. This leads to the conclusion that the modified version is comparable to the classical operation technique considering the stability, but due to the adaption of the angle in the modified procedure, less lesions of neurovascular structures on the volar side can be expected. To support our findings cadaver studies are needed for further investigations.