Immediate implant stability is a key factor for success in cementless total hip arthroplasty (THA). Low bone mineral density (BMD) and age-related geometric changes of the proximal femur may jeopardize initial stability and osseointegration. We compared migration of hydroxyapatite-coated femoral stems in women with or without low systemic BMD. 61 female patients with hip osteoarthritis were treated with cementless THA with anatomically designed hydroxyapatite-coated femoral stems and ceramic-ceramic bearing surfaces (ABG-II). Of the 39 eligible patients between the ages of 41 and 78 years, 12 had normal systemic BMD and 27 had osteopenia or osteoporosis. According to the Dorr classification, 21 had type A bone and 18 had type B. Translational and rotational migration of the stems was evaluated with radiostereometric analysis (RSA) up to 2 years after surgery. Patients with low systemic BMD showed higher subsidence of the femoral stem during the first 3 months after surgery than did those with normal BMD (difference = 0.6, 95% CI: 0.1-1.1; p = 0.03). Low systemic BMD (odds ratio (OR) = 0.1, CI: 0.006-1.0; p = 0.02), low local hip BMD (OR = 0.3, CI: 0.1-0.7; p = 0.005) and ageing (OR = 1.1, CI: 1.0-1.2; p = 0.02) were risk factors for delayed translational stability. Ageing and low canal flare index were risk factors for delayed rotational stabilization (OR = 3, CI: 1.1-9; p = 0.04 and OR = 1.1, CI: 1.0-1.2; p = 0.02, respectively). Harris hip score and WOMAC score were similar in patients with normal systemic BMD and low systemic BMD. Low BMD, changes in intraosseous dimensions of the proximal femur, and ageing adversely affected initial stability and delayed osseointegration of cementless stems in women.

A retrospective review of the roentgenograms of 750 patients treated in our institution for tarsometatarsal joint injuries or metatarsal fractures over a 10-year-period was performed. Injuries of the Lisfranc joint were found in 66 patients (9%). twelve patients (19%) had a total dislocation, 47 patients (71%) a partial dislocation, and seven patients (11%) a subtle injury of the Lisfranc joint. Four main groups of trauma mechanisms were identified (low-energy injuries, falls from a height, direct crush injuries, and high-energy vehicular crashes). Lisfranc joint injuries caused by low-energy injuries (21 patients) were as frequent as those caused by high-energy vehicular crashes (22 patients). There was no apparent relationship between the mechanism of injury and the type of Lisfranc joint dislocation. All patients except three had associated metatarsal fractures, most commonly in the second metatarsal. The location of associated metatarsal fractures was different from that in patients with metatarsal fractures alone (p 0.001). Fractures, dislocations, or fracture- dislocations of midtarsal bones (cuneiforms, cuboid, navicular) occurred in 26 patients (39%). Multiple metatarsal fractures and midtarsal bone injuries were more frequent in high-energy vehicular crashes than in low-energy injuries (p = 0.016 and p = 0.033, respectively). In 23 patients (35%), the treatment had been focused on multiple metatarsal fractures or midtarsal bone injuries without full appreciation of the concomitant Lisfranc joint incongruity. Increasing the knowledge of normal foot anatomy and the appreciation of the risk of Lisfranc joint injury even in seemingly trivial stumbling accidents obviously may improve the diagnosis and treatment of these potentially disabling injuries. The goal of treatment should be the restoration of the normal anatomy and joint congruence.

The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to improve the healing of open tibial shaft fractures has been the focus of two prospective clinical studies. The objective of the current study was to perform a subgroup analysis of the combined data from these studies. Two prospective, randomized clinical studies were conducted. A total of 510 patients with open tibial fractures were randomized to receive the control treatment (intramedullary nail fixation and routine soft-tissue management) or the control treatment and an absorbable collagen sponge impregnated with one of two concentrations of rhBMP-2. The rhBMP-2 implant was placed over the fracture at the time of definitive wound closure. For the purpose of this analysis, only the control treatment and the Food and Drug Administration-approved concentration of rhBMP-2 (1.50 mg/mL) were compared. Patients who anticipated receiving planned bone-grafting as part of a staged treatment were excluded from enrollment. Fifty-nine trauma centers in twelve countries participated, and patients were followed for twelve months postoperatively. Two subgroups were analyzed: (1) the 131 patients with a Gustilo-Anderson type-IIIA or IIIB open tibial fracture and (2) the 113 patients treated with reamed intramedullary nailing. The first subgroup demonstrated significant improvements in the rhBMP-2 group, with fewer bone-grafting procedures (p = 0.0005), fewer patients requiring invasive secondary interventions (p = 0.0065), and a lower rate of infection (p = 0.0234), compared with the control group. The second subgroup analysis of fractures treated with reamed intramedullary nailing demonstrated no significant difference between the control and the rhBMP-2 groups. The addition of rhBMP-2 to the treatment of type-III open tibial fractures can significantly reduce the frequency of bone-grafting procedures and other secondary interventions. This analysis establishes the clinical efficacy of rhBMP-2 combined with an absorbable collagen sponge implant for the treatment of these severe fractures. Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.