. Methods: Ninety-nine consecutive patients (109 fractures) who had been surgically treated for a complete atypical femoral fracture were enrolled. All patients had a documented history of bisphosphonate therapy at the time of presentation, with an average duration of 7.4 ± 3.5 years (range, 3 to 20 years). Baseline demographic data, characteristics of the fracture and surgery, and radiographic findings including femoral neck-shaft angle, coronal and sagittal bowing of the femur, and thickness of the femoral cortex were examined. Univariate and multivariate logistic regression analyses were performed to identify predictive factors associated with delayed union or nonunion. Results: Of the 109 fractures, 76 (69.7%) showed osseous union within 6 months after the index surgery and were assigned to the successful healing group. The remaining 33 fractures (30.3%), which showed delayed union or nonunion, were assigned to the problematic healing group. There were differences in body mass index (BMI), bisphosphonate therapy duration, and the rate of prodromal symptoms between the 2 groups. Supra-isthmic fracture location, femoral bowing of ≥10° in the coronal plane, and a lateral/medial cortical thickness ratio of ≥1.4 were predictive of problematic healing but were uncontrollable factors. Iatrogenic cortical breakage around the fracture site as well as a ratio of ≥0.2 between the remaining gap and the cortical thickness on the anterior and lateral sides of the fracture site were controllable predictive factors associated with problematic healing. Conclusions: Intramedullary nailing without cortical breakage around the fracture site and decreasing the anterior and lateral fracture gaps (avoidance of distraction) as much as possible are recommended to reduce healing time in complete femoral fractures associated with long-term use of bisphosphonates. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence....

Objectives: This study was designed to investigate the incidence and risk factors of postoperative venous thromboembolism (VTE) in a series of patients with fractures below the hip. In addition, we sought to examine the rates of VTE before and after introduction of thromboprophylaxis. Design: Retrospective review. Setting: University-based academic medical center. Patients: Nine hundred one consecutive patients met the inclusion criteria. Of the 901 patients, 337 (37.4%) were treated before the initiation of institutional guidelines for thromboprophylaxis and 564 (62.6%) received thromboprophylaxis in accordance with our hospitalization protocol. Intervention: Surgical intervention for fractures occurring in the lower extremity below the hip. Main Outcome Measurements: Symptomatic thromboembolic events within 90 days of surgery and risk factors of postoperative VTE. Results: Of the 901 patients, 25 (2.7%) had confirmed symptomatic deep vein thrombosis and 13 (1.4%) had symptomatic pulmonary embolism. The overall incidence of symptomatic VTE was significantly different between the patients not receiving thromboprophylaxis (6.8%; 23 of 337) and those receiving thromboprophylaxis (2.3%; 13 of 564). Of the 31 variables tested for an association with VTE, an advanced age of more than 60 years, cardiovascular disease, and chronic lung disease were independent risk factors. Conclusions: Clinically detectable VTE in fractures of the lower extremity below the hip are not uncommon, and thromboprophylaxis seemed to decrease the incidence of postoperative VTE. Level of Evidence: Prognostic Level II. See the guidelines for authors for a complete description of levels of evidence.

Background: Intramedullary hip nails may be classified as blades or screws depending on the type of lag screw used. Recently, a combination of lag screw types with a U-clip insertion has also been used. The purpose of this study was to evaluate the clinical and radiological outcomes of these new screw types.Methods: A total of 185 patients with trochanteric femoral fractures (age ≥ 65 years) who underwent surgery with intramedullary nails were selected. Surgeries with InterTrochanteric/SubTrochanteric (ITST), Proximal Femoral Nail Antirotation (PFNA), and Gamma 3 U-Blade lag screws were performed between January 2011 and June 2016. The AO/OTA classification, presence of a basicervical fracture type on 3D-CT, BMI, BMD, reduction quality, position of the lag screw, TAD (tip apex distance) of the lag screw, sliding distance of the lag screw, varus change (neck shaft angle), radiological union period, fixation failure and functional outcome as determined by walking ability were analyzed.Results: There were 3/60 (5.0%) cases of fixation failure in the ITST group, all caused by cut-out; 4/57 (7.0%) in the PFNA II group: 3 caused by cut-through and 1 by metal fracture; 1/68 (1.5%) in the Gamma 3 U-Blade lag screw group (P= 0.301). In each group, the sliding distance of the lag screw showed a significant difference (P= 0.017), whereas significant sliding over 10 mm showed no statistically significant results.Conclusion: There was only one (1.5%) case of fixation failure in the Gamma 3 U-Blade lag screw group. The sliding distance of the U-Blade was found to be in the middle, between the PFNA II (shorter) and ITST (longer) implants. The new rotational control lag screw seems to be comparable to other screw types.

In present study, icariin (ICA)/tannic acid (TA)-nanodiamonds (NDs) were prepared as follows. ICA was anchored to ND surfaces with absorbed TA (ICA/TA-NDs) and we evaluated their in vitro anti-inflammatory effects on lipopolysaccharide (LPS)-activated macrophages and in vivo cartilage protective effects on a rat model of monosodium iodoacetate (MIA)-induced osteoarthritis (OA). The ICA/TA-NDs showed prolonged release of ICA from the NDs for up to 28 days in a sustained manner. ICA/TA-NDs inhibited the mRNA levels of pro-inflammatory elements, including matrix metalloproteinases-3 (MMP-3), cyclooxygenase-2 (COX-2), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α), and increased the mRNA levels of anti-inflammatory factors (i.e., IL-4 and IL-10) in LPS-activated RAW 264.7 macrophages. Animal studies exhibited that intra-articular injection of ICA/TA-NDs notably suppressed levels of IL-6, MMP-3, and TNF-α and induced level of IL-10 in serum of MIA-induced OA rat models in a dose-dependent manner. Furthermore, these noticeable anti-inflammatory effects of ICA/TA-NDs remarkably contributed to the protection of the progression of MIA-induced OA and cartilage degradation, as exhibited by micro-computed tomography (micro-CT), gross findings, and histological investigations. Accordingly, in vitro and in vivo findings suggest that the prolonged ICA delivery of ICA/TA-NDs possesses an excellent latent to improve inflammation as well as defend against cartilage disorder in OA.