Atypical forearm fractures associated with long-term bisphosphonate use: the perspective of a hand surgeon

Bisphosphonates have been widely used to treat osteoporosis, but atypical femoral fractures have emerged as serious complication. Similar fractures of the forearm have been reported since 2010 and retrospective studies have revealed a number of details. Clinicians should remember that bisphosphonates can affect all bony structures in the body. When misdiagnosed as an ordinary fracture and treated with surgical fixation, unexpected nonunion may occur. Therefore, I would like to share our experience from the perspective of a hand surgeon.

Endogenous DHEAS is Causally Linked with Lumbar Spine Bone Mineral Density and Forearm Fractures in Women

Context A recent pooled analysis of four clinical trials demonstrated that treatment with dehydroepiandrosterone (DHEA) increases lumbar spine BMD (LS-BMD) in women. The causal effect of endogenous adrenal-derived DHEA-sulphate (DHEAS) on LS-BMD and fracture risk in women is unknown. Objective To determine whether circulating DHEAS is causally associated with LS-BMD and fracture risk in women. Methods A two-sample mendelian randomization study using genetic predictors of serum DHEAS derived from the largest available female-specific genome wide association study (GWAS) meta-analysis (n=8 565). Genetic associations with DXA-derived BMD (n=22 900) were obtained from female specific GWAS summary statistics available from the GEFOS consortium while individual-level data of 238 565 women of white ancestry from the UK Biobank were used for associations with fractures (11 564 forearm fractures, 2 604 hip fractures) and estimated heel BMD by ultrasound (eBMD). Results A 1 standard deviation (SD) genetically instrumented increase in log serum DHEAS levels was associated with a 0.21 SD increase in LS-BMD (P-value: 0.01) and a 0.08 SD increase in eBMD (P-value: <0.001). Genetically predicted DHEAS decreased forearm fracture risk (odds ratio (OR): 0.70, 95% confidence interval (CI): 0.55-0.88 per SD increase in DHEAS) while no significant causal association with hip fractures was observed. Conclusions Genetically predicted serum DHEAS increases LS-BMD and decreases forearm fracture risk in women. Based on the results of the present study and previous RCTs of DHEA treatment, we propose that both endogenous adrenal-derived DHEA(S) and pharmacological DHEA treatment improve bone health in women.

Bioresorbable implants vs. Kirschner-wires in the treatment of severely displaced distal paediatric radius and forearm fractures – a retrospective multicentre study

BackgroundDistal radius fractures are very common in paediatric patients. Severely displaced fractures may require surgical intervention. The gold standard surgical method is percutaneous K-wire osteosynthesis followed by immobilisation. Metal implants can be removed with a second intervention; however, these extra procedures can cause further complications. Several studies confirm the benefits of bioabsorbable implants for paediatric patients. The aim of this retrospective study was to compare the complication rates of displaced distal metaphyseal radius and forearm fractures in children operated on with K-wires versus a novel technique with bioresorbable implants.MethodsWe retrospectively reviewed 94 patients in three paediatric trauma centres who underwent operations due to severely displaced distal forearm or metaphyseal radial fractures between January 2019 and January 2020. The mean age was 8.23 (ranging from 5-12). 30 patients (bioresorbable group, BR-group) were treated with biodegradable PLGA implants (Bioretec®, ActivaPin®), 40 patients with one or two stainless steel Kirschner-wires (K-wires, Sanatmetal®) which were buried under the skin (KW I-group) and 30 children with K-wires left outside the skin. (KWII. Group). We examined the number of minor and major complications as well as the need for repeated interventions. Follow-up was at least one year.ResultsThere was no significant difference between the complication rates at the two KW groups (p = 0.241; Cramer’s V = 0.211), while the complication rate of the BR group was significantly lower. (p = 0.049; Cramer’s V = 0.293 and p = 0.002; Cramer’s V = 0.418 respectively). No later than half a year after the injury, no difference was observed between the functional outcomes of the patients in each group. One and a half years after the injury, no signs of growth disturbance were found in any of the children. No second surgical intervention was required in the BR group.ConclusionsSurgeries with bioresorbable intramedullary implants may have fewer complications than K- wire osteosynthesis in the treatment of severely displaced distal forearm fractures. The benefits are most pronounced in the first six weeks after surgery, reducing the number of outpatient visits and increasing the child's sense of comfort. As no second intervention is required, this can lead to significant cost savings. After half a year, there is no difference in the outcomes between the different surgical treatment strategies.

Effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions: A scoping review

Background In the field of orthotics, the use of three-dimensional (3D) technology as an alternative to the conventional production process of orthoses is growing. Purpose This scoping review aimed to systematically map and summarize studies assessing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions, and to identify knowledge gaps. Methods The Cochrane Library, PubMed, EMBASE, CINAHL, Web of Science, IEEE, and PEDro were searched for studies of any type of 3D-printed orthoses for traumatic and chronic hand conditions. Any outcome related to the effectiveness of 3D-printed orthoses was considered. Two reviewers selected eligible studies, charted data on study characteristics by impairment type, and critically appraised the studies, except for case reports/series. Results Seventeen studies were included: four randomized controlled trials, four uncontrolled trials, four case series and five case reports. Only three studies had a sample size >20. Impairments described were forearm fractures (n = 5), spasticity (n = 5), muscle weakness (n = 4), joint contractures (n = 2) and pain (n = 1). Four poor to fair quality studies on forearm fractures supported the effectiveness of 3D-printed orthoses on hand function, functionality, and satisfaction. One good quality study on spasticity demonstrated the effectiveness of 3D-printed orthoses on hand function. One poor quality pain study reported limited positive effects on satisfaction. Studies on muscle weakness and joint contractures showed no benefits. Conclusion Current literature addressing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions consists primarily of small and poor methodological quality studies. There is a need for well-designed controlled trials including patient-related outcomes, production time and cost analyses.

Comparing titanium elastic nailing and plate osteosynthesis in treating both bone diaphyseal fractures of forearm in children

<p class="abstract"><strong>Background:</strong> The present study aimed to compare the outcome of fixation of diaphyseal fractures of both bones of forearm using plate osteosynthesis (PO) and titanium elastic nail (TEN).</p><p class="abstract"><strong>Methods:</strong> This comparative non-randomized clinical trial was done on children aged 5 to 15 years, with diaphyseal fractures of both bone forearm fractures, operated and managed at the department of orthopedics, Assam Medical College and Hospital, Dibrugarh. Intra- and post-operative findings were compared between PO and TEN group patients.<strong></strong></p><p class="abstract"><strong>Results:</strong> Duration of hospital stay was significantly lower in patients in the TEN group (44.75±6.38 minutes) as compared to those in the PO group (69.71±5.91 minutes), p value &lt;0.01. Similarly, duration of hospital stay was significantly lower in patients in the TEN group (5.01±0.67 days) as compared to those in the PO group (8.32±1.44 days), p value &lt;0.05. Based on price criteria, 80% of the patients in the PO group and 85% in TEN group had excellent functional outcome. Radiological union time, maximum radial bow and location of maximal radial bow were found to be statistically similar in the two groups. Complication rate was similar in the two study groups.</p><p class="abstract"><strong>Conclusions:</strong> Based on the results of the present study, we conclude that both PO and TEN are be safely performed in children with diaphyseal both bone forearm fractures. With comparable functional and radiological outcomes, future studies are required before one technique can be recommended over the other.</p>