Osteology

Background: Effects of anti-citrullinated polypeptide antibodies (ACPA) on the bone mineral density (BMD) reduction and incidence of major osteoporotic fractures (MOF) in patients with rheumatoid arthritis (RA) were evaluated using a retrospective longitudinal case-control study. Methods: Patients with RA who were examined using dual-energy X-ray absorptiometry and simultaneously treated for more than 5 years were recruited. BMD absolute value and Z-scores at initial measurements (baseline) and changes of these values from baseline were assessed, and associations between BMD and candidate risk factors including ACPA positivity and serum titer levels were statistically evaluated. Additional statistical evaluations of ACPA positivity in regard to the incidence of MOF were tested. Results: A total of 222 patients were included. Higher ACPA titers correlated significantly with lower BMD and Z-scores at baseline using a multivariate model (p < 0.05). ACPA positivity correlated significantly with lower values and an annual decrease in the Z-score in total hip at follow-up using a univariate model (p < 0.05), whereas no significant correlation was found using a multivariate model. Z-scores in the ACPA-positive group were significantly lower than those of the ACPA-negative group (p < 0.05). However, ACPA-positivity demonstrated no higher risk for incident MOF. Conclusions: The presence of ACPA is a potential risk of BMD loss however weak. Full article

Protrusio acetabuli is a unique osteological condition that has been long described in the literature and is known to potentially increase both the surgical complexity and the risk of complications when performing total hip arthroplasty. Although grading systems for native hip protrusio have been described in the past, there has not yet been a widely adopted classification system that categorizes the condition into separate classes in order to guide management. We propose a novel classification system with the goal of simplifying and standardizing the management of protrusio acetabuli in the context of modern total hip arthroplasty. This classification system describes protrusio based on the relationship of the femoral head to the ilioischial and iliopectineal lines, allowing for a more reproducible and consistent categorization of pathology. We also discuss general recommendations and technical pearls for total hip arthroplasty in the protrusio patient population, including the use of strategic soft tissue releases, fluoroscopy, navigation, bone graft, and augments. Full article

There is evidence to suggest that restoration of major/rare biominerals by supplementation can produce osteogenic and anti-resorptive effects in humans. LithoLexal^® is a natural extract harvested from a marine alga, Lithothamnion sp., with a porous microstructure and multimolecular composition rich in calcium (32% w/w) and magnesium (2.2% w/w) together with ~72 trace bioelements. In vitro, LithoLexal^® demonstrated cellular-level osteogenic efficacy through enhancing the maturation and activity of pre-osteoblasts. This extract also expressed the ability to suppress osteoclastogenesis by downregulating the pro-resorptive cytokines TNF-α and IL-1β and the master regulator of inflammation NF-κB. Parathyroid hormone inhibition of parathyroid hormone secretion is another bioactivity of LithoLexal^® Bone reported with both short- and long-term administration at a longer duration and higher magnitude than what calcium carbonate could induce. Due to these bioactivities that affect pathogenetic factors of osteoporosis, LithoLexal^® Bone is referred to as a disease-modifying adjunctive therapy (DMAT). In postmenopausal animal models, LithoLexal^® monotherapy preserved bone mineral density, microarchitecture, and biomechanical properties, while calcium carbonate failed to produce significant outcomes. The pro-resorptive effect of a high-fat diet was also efficiently counteracted in vivo by supplementary LithoLexal^®. A large clinical trial on postmenopausal women verified the mitigating effects of LithoLexal^® Bone on bone resorption and turnover rate. The characteristic composition of LithoLexal^® together with its lattice microstructure are suggested to underlie its in vivo bioactivities. In conclusion, adjunctive therapy with LithoLexal^® Bone is an attractive option for clinical prevention and treatment of osteopenia/osteoporosis. Full article

Vitamin D plays a pivotal role in calcium metabolism and bone mineralization. Sufficient vitamin D levels are important for the health and functionality of the musculoskeletal system. Hypovitaminosis D is a phenomenon affecting orthopedic patients worldwide. This study researched whether most orthopedic patients in two different cities of different countries had hypovitaminosis D, whether there was a correlation between sunshine hours and vitamin D serum levels, and whether hours of sunshine alone were enough to achieve vitamin D sufficiency among orthopedic patients regardless of their activities. The vitamin D serum levels of 500 orthopedic patients in Regensburg and 500 in Patras were assessed, in addition to their medical histories. The mean sunshine hours throughout the year were also calculated. Both the German and Greek groups showed hypovitaminosis D. Older patients were more affected. Although there were more hours of sunshine in Greece, Greek orthopedic patients also showed hypovitaminosis D. Hypovitaminosis D affects orthopedic patients independent of their latitude. Supplementation of vitamin D may be considered among orthopedic patients to achieve sufficient levels in serum. Sufficient vitamin D levels may be helpful for the treatment of orthopedic patients, reduce the negative effects of operations or postoperational settings. Full article

I previously reported that F-box/leucine-rich repeat protein 14 (FBXL14) expressed in periosteum-derived cells, and F-box and WD-40 domain-containing protein 2 (FBXW2) in the periosteum form a fiber-like structure. Here, two culture medium conditions, that is, media with and without ascorbic acid, were compared during explant culture. In the absence of ascorbic acid, the expression patterns of osteocalcin, FBXW2, and elastin were compared using fluorescent immunostaining during weeks 3–5. By observing the periosteum, cambium layer and bone, I demonstrated FBXL14 expression in micro-vessels and bone lacuna. Fluorescent immunostaining revealed that, without ascorbic acid, the FBXL14 layer was thin. Conversely, in the presence of ascorbic acid, FBXL14 formed a thick membrane-like structure inside the periosteum, and the multilayer of periosteum-derived cells (PDCs) was strong. The expression patterns of osteocalcin and FBXW2 were similar. Elastin retained its fiber structure for up to five weeks. Although osteocalcin and FBXW2 were expressed in regions similar to elastin, they could not retain their fiber structures. In conclusion, FBXL14 appears to play a role in preparing a native scaffold for forming a multilayered sheet of PDCs inside the periosteum. FBXW2 and osteocalcin appear to separate from elastic fibers during calcification. Full article

Depression constitutes a risk factor for osteoporosis (OP). Increasing physical activity might mitigate this risk, although intensive exercising may lead to opposing effects in depressed patients. The purpose of this scoping review was to summarize the evidence regarding the influence of exercise on bone health in depressed patients, divided into two sections: (1) Which bone markers are affected by depression? (2) How does exercise affect bone health in patients with depressive symptoms? A search of the literature was conducted in PubMed and Web of Science between August 2020–2022. Studies were included based on predetermined criteria for each sub-question. Regarding sub-question 1, eight studies revealed the following bone markers to be influenced by depression: P1NP, BAP, CTX, OC, RANKL, OPG, DPD, and PYD. Regarding sub-question 2, one study found a correlation between depression and bone health in an exercising population, and other studies detected improvements in bone health (n = 4) and depressive symptoms (n = 4) after exercise interventions. The current review shows the potential of exercise as a treatment form to improve bone health in depressed patients. Future trials are needed to assess the influence of exercise intervention on bone health in depressed patients. Full article

Background: Heterotopic Ossification (HO) of the knee is most commonly formed anteriorly to the distal femoral shaft in the quadriceps expansion. Although the incidence of severe HO with large dimensions affecting the knee and resulting in severe consequences is extremely rare, these cases are extremely difficult to prevent and have severe clinical limitations for the patient. Aim: The purpose of this study was to present and explore HO formation after Total Knee Arthroplasty (TKA). Conclusions: It is crucial to perform a stratification of patients for the risk of HO formation after TKA and to gain a better understanding of the fundamental role of post-operative treatments. In severe HO, surgery should be considered following appropriate investigations and should only be considered when the HO has fully matured. In comparison to Total Hip Arthroplasty (THA), HO formation after TKA is less frequent and underexplored. Therefore, further studies are required. This case report can represent a protocol for the treatment of clinically relevant HO in the knee after TKA. Full article

Anterior shoulder instability with Bankart lesion and associated posterior humeral head injury (Hill–Sachs) is common in athletes. Several treatments have been proposed for the management of the Hill–Sachs lesion, from bone grafts or rotation osteotomies to capsulotendinous interposition, such as remplissage. This procedure has been shown to be safe and effective in increasing glenohumeral stability. However, the correct indication concerning the bone defect and its effects in terms of range of motion and function, especially in highly demanding patients, is still debated. This narrative review aims to present the current state-of-the-art of the posterior capsulotenodesis in association with Bankart repair, for treating anterior shoulder instability in competitive athletes. Full article

A vertebral compression fracture (VCF) is a pathological condition, which can be caused by osteoporotic degeneration or metastatic disease. It represents a socioeconomic burden on healthcare systems, due to increased pain, long-term morbidity, and disability. Vertebroplasty (VP) is an image-guided, minimally invasive, interventional procedure, in which bone cement is injected via a percutaneous approach into the vertebral soma, to provide structural support and to stabilize the weakened structure. The aim of this narrative review is to describe vertebral column biomechanics, as well as indications, contraindications, and techniques to successfully perform VP for the treatment of VCFs. Methods: We performed a narrative literature review on the main online databases regarding VP, and mainly focused on patient selection, preoperative imaging, procedural steps, complications, and outcomes. Results: The most recent evidence in the literature has shown that VP provides significant and sustained clinical benefits for patients with a VCF, and it is indicated in patients with comorbidities that make prolonged bed rest dangerous, patients with fractures that fail to heal, and as palliation in patients with a painful VCF due to metastatic disease. Conclusions: VP is considered to be a safe and effective treatment option for the treatment of osteoporotic and malignant VCFs that are resistant to adequate medical therapy. Patient selection, preprocedural evaluation, and proper technique execution are the key points to obtain the best outcomes and to minimize complications. Full article

Shoulder instability is described as a functional deficiency caused by excessive mobility of the humeral head over the glenoid. Various Glenohumeral Instability (GI) types have been described, but the traumatic anteroinferior form is the most frequent. The differences between engaging and non-engaging Hill–Sachs lesions (HSLs) are linked to bone loss assessment. On the contrary, the novel difference between “on-track” and “off-track” lesions is strictly related to surgical techniques. The specific involvement of glenoid and humerus bone defects in recurrent GI was poorly assessed in the literature before the glenoid-track concept (GT). Magnetic Resonance Imaging (MRI) and Arthro-MRI have been widely used to identify and characterize lesions to the ligamentous structures. However, only new technologies (3 Tesla MRI) accurately detect HSLs. On the contrary, Computed Tomography (CT) has been adopted to quantify glenoid bone deficit. The GT concept is a valuable tool for evaluating anterior shoulder instability in patients. Shoulders out of alignment may require more than just an arthroscopic Bankart, and a remplissage or bone transfer may be necessary. Specifically, isolated Bankart repair should be considered in patients with recurrent instability and an on-track lesion with less than 25% glenoid bone loss. In off-track lesions and less than 25% glenoid bone loss, remplissage should be used. Bone transplant surgery is required for patients with a glenoid bone defect of more than 25%. This narrative review aims to report the most updated findings on “on-track” and “off-track” lesions in GI. Full article

(1) Background: This systematic review summarizes the available studies investigating when it is safe for most patients to return to driving and when to modify for individual patients following elective foot and ankle procedures. (2) Methods: A systematic review of the literature was performed using three different electronic databases to identify English-language studies from 1999 to present that investigate the return to driving after right-sided elective foot and ankle procedures. (3) Results: A total of eight studies met inclusion criteria. All the studies investigated brake reaction time (BRT) as measured by a driving simulator as their primary outcome. Patients undergoing right ankle or subtalar arthroscopy should wait 2 weeks to drive, after total ankle arthroplasty or corrective hallux valgus surgery patients should wait 6 weeks, and the appropriate time to return to driving after ankle arthrodesis is still uncertain. Additionally, various clinical factors can be used to predict who may still be unfit to drive past the usual length of time. (4) Conclusions: The recommendations from these reviewed studies can guide physicians when counseling their patients on when they can expect to safely return to driving after a specific elective foot and ankle procedure. However, these recommendations should be tailored to the patient specifically based upon how they are doing clinically. Full article

Calcific shoulder tendinopathy (CT) is a common condition involving the central part or insertion of the rotator cuff tendons (RC) or the subacromial-subdeltoid bursa (SASD). The calcific deposits consist of poorly crystallized calcium hydroxyapatite but the mechanism of their formation still remains unclear. CT can be divided into three distinct stages, as reported by Uthhoff et al. Clinically, this condition varies with the extent of the calcification and the phase of the condition. In particular, the disorder is asymptomatic or may cause mild discomfort during the deposition of calcium, while it becomes acutely painful during the resorptive phase. US-PICT (ultrasound-guided percutaneous irrigation of calcific tendinopathy) is indicated in the acute phase (resorptive phase) of CT with significant pain relief and a very low rate of minor complications. The aim of this manuscript is to define the rationale of the ultrasound-guided percutaneous irrigation of calcific tendinopathy, correlating it with the sequence of biochemical processes that lead to the hydrolysis of hydroxyapatite. Furthermore, we will explain the reasons why we prefer using the three-needle technique for the dissolution of calcifications. Full article

Fractures of the lateral process of the talus have been associated with snowboarding, so much so that they have earned the nickname “snowboarder’s ankle”; these typically occur with relatively low-energy injuries when compared with fractures of the talar head, neck, and body. We have observed that snowboarding portends a higher risk of talus fractures when compared with skiing and can include higher energy injury patterns. This study describes a series of talar head, neck, and body fractures caused by snowboarding, their treatment, and outcomes. A retrospective chart review was performed on all surgical cases collected from 2007 to 2012 to include talar head, neck, body, or lateral process fractures sustained while snowboarding. Radiographs were reviewed and the fractures were characterized. Questionnaires, including the Foot and Ankle Disability Index (FADI), were mailed to the patients. The pre-operative reports, surgical treatments, and outcomes were evaluated. Nine patients were identified with fractures of the talus caused by a snowboarding injury. One patient sustained an isolated talar head fracture, three sustained isolated talar neck fractures, one patient had an isolated talar body fracture, and two patients had isolated lateral process fractures. Two patients had a combination of talar injuries. At 2.5 years mean follow-up (range 6 months to 5 years), none of the patients developed avascular necrosis, nonunion/malunion, or required subsequent surgery. FADI scores indicated good to excellent results post-operatively. Full article

The standard surgical approach for the fusion of the tarsometatarsal (TMT) joint involves a two-incision approach. Philpott et al. proposed a modified, single-incision dorsal approach that yields a similar exposure. This study compares the joint preparation between the standard and modified dorsal approach. Ten fresh frozen cadaver specimens were randomly assigned to receive either a standard or modified dorsal operative approach to the TMT joint. The joint surface was prepared, and the joint was disarticulated. Image analysis, using ImageJ, was performed by two blinded reviewers to assess the joint surface preparation and this was compared by surgical approach. There was no significant difference in the amount of joint prepared when comparing the standard versus modified dorsal approach for TMT joints one through three (p = 0.548, p = 0.310, p = 0.548). First, TMT was 67.6% prepared by the standard approach vs 71.7% by the modified dorsal approach, second TMT was 67.9% vs. 65.7%, and third TMT was 65.9% vs. 59.6%. With our findings, we demonstrate that a modified dorsal approach with a single incision did not limit the ability to prepare the joint space. This study adds credibility backed by data to those set forth by Philipott et al. Full article

Resilience is a dynamic construct defined as the ability to recover from stress. There is no literature examining the impact of resilience on outcomes following foot and ankle surgery. Retrospective analysis of patients who underwent first MTP arthrodesis from September 2011 to May 2020 were reviewed for patient characteristics and union status. PROMIS Physical Function (PF), Pain Interference (PI), Depression (D), and Foot Function Index (FFI) were collected. Resilience was measured using the Brief Resilience Scale. A multivariable linear regression analysis examining the impact of resilience on patient reported was conducted. At an average of 3.4 years postoperatively, resilience was found to independently affect patient reported outcomes across all instruments, except the FFI pain subscale. In the first study examining the impact of resilience following foot and ankle surgery, we found that resilience has an independent positive effect on overall physical function, disability, pain, and mental health following MTP arthrodesis. Preoperative resilience scores could be used to predict postoperative functional outcomes following MTP arthrodesis and guide postoperative rehabilitation. These findings help establish the role of early positive psychosocial characteristics within orthopaedic foot and ankle population. Full article

Background: metatarsal fractures are a commonly encountered musculoskeletal injury. Scant literature exists to support current treatment guidelines and few studies describe the functional or occupational outcomes of patients with lesser metatarsal fractures. The purpose of this study is to describe occupational outcomes for traumatic lesser metatarsal fractures in relation to current treatment guidelines. Methods: a retrospective review of metatarsal fractures in adult military patients 18 years and older was performed. Data included: patient demographics, fracture angulation and displacement, treatment modality, associated injuries, rate of return to active duty, requirement for additional surgeries, ability to run a 2-mile physical fitness test, and presence of permanent activity limitations. Treatment guideline criteria were applied and compared with the occupational outcomes measured. Results: 38 fractures were included. The mean age was 27.2 ± 7.8 (19–48). Here, 28 fractures were initially treated non-operatively. Fractures selected for non-operative treatment had a mean displacement of 1.7 +/− 1.1 mm and a mean angulation of 3.3 +/− 3.5° at initial presentation. Fractures selected for operative treatment had a mean displacement of 4.5 +/− 2.4 mm and a mean angulation of 15.7 +/− 13.8° at initial presentation. The return to run rate was 89% in non-operatively treated patients and 50% in operatively treated patients (p = 0.02). Non-operative patients returned to running at a mean of 119 +/− 103 days and operative patients returned to running at a mean of 306 +/− 191 days (p = 0.0039). 50% of operatively treated patients and 11% of non-operatively treated patents were unable to remain in the military due to their metatarsal fractures. Conclusions: patients treated non-operatively were more likely to return to running and returned to running sooner than operatively treated patients. Current treatment guidelines could not be supported or refuted based upon the study results. The occupational and functional outcomes demonstrated in this study may assist surgeons in counseling patients on their planned treatment and anticipated recovery following a lesser metatarsal fracture. Full article

While Achilles tendon injuries are common amongst the general population, there are very few cases in which simultaneous bilateral injuries occur. Medial malleolar fractures at the time of Achilles tendon rupture have been cited in the literature and are commonly missed. The following case outlines the presentation, treatment, and outcome of a United States Army Soldier with simultaneous bilateral Achilles tendon ruptures in addition to a unilateral right medial malleolar fracture. This patient was able to completely return to duty within 1 year after being treated with ORIF of the medial malleolus, bilateral end-to-end repair of the AT, and accelerated rehabilitation beginning at 2 weeks on the left and 6 weeks on the right. Full article