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BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has recently become an option for the treatment of proximal humerus fractures (PHFs) or as a salvage procedure after failure of another treatment. The purpose of this study was to compare primary RTSA with delayed RTSA in the treatment of displaced PHFs. STUDY DESIGN & METHODS: A retrospective cohort study was conducted on patients with PHFs who were treated between May 2013 and December 2021 with primary or delayed RTSA after failure of conservative treatment or osteosynthesis. Clinical data were withdrawn from our local computerized database. Complications, active range of motion, as well as the functional outcome were recorded at the end of the follow-up period. Differences between clinical outcomes were analyzed using a logistic regression analysis. RESULTS: A total of 70 individuals were included in this study (41 primary RTSA and 29 delayed RTSA). The mean of follow-up time was of 112 and 60 months, respectively. There were no differences between groups regarding fracture type according Neer Classification, ASA score or the presence of complications. Q-DASH and Oxford Shoulder scores were significantly better when patients underwent a primary RTSA (49.8 vs 31.4, p = 0.006 and 37.2 vs 27.5, p = 0.004 respectively). In addition, primary RTSA achieved more degrees of flexion and abduction than delayed RTSA (96.8 vs 72.9, p < 0.001 and 94.1 vs 69.3, p < 0.001 respectively). CONCLUSION: Primary RTSA for PHFs achieved better functional outcomes and a wider range of motion when compared with delayed RTSA. However, primary and delayed RTSA have similar complication and reintervention rates. LEVEL OF CLINICAL EVIDENCE: 3.

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Osteoporosis is an underdiagnosed disease that results in bone fragility and risk of fractures. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of a FLS protocol showed an increase of anti-osteoporotic drug prescription and significant reduction of all-cause mortality. INTRODUCTION: Hip fractures are the most severe osteoporotic fracture due to their associated disability and elevated risk of mortality. FLS programs have enhanced the management of osteoporosis-related fractures. Our objective is to analyze the effect of the FLS model over survival and 2-year mortality rate following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during 3 consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2018). Patients' information was withdrawn from our local computerized database. Patients were followed for 2 years after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model. RESULTS: A total of 1101 patients were included in this study (i.e., 357 before FLS implementation and 744 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (583 (78.4%) vs 44 (12.3%); p < 0.01). There was an increase of adherence to treatment after FLS implementation (227 (38.9%) vs 12 (3.3%); p = 0.03). A total of 222 (29.8%) patients after FLS implementation and 114 (31.9%) individuals before FLS implementation (p = 0.44) died during the follow-up period. A second fracture occurred in 49 (6.6%) patients after FLS implementation and in 26 (7.3%) individuals before FLS implementation (p = 0.65). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower all-cause 1-year and 2-year mortality compared with patients managed before the implementation of the FLS protocol (adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59-0.96; HR 0.87, 95% CI 0.69-1.09, respectively). CONCLUSIONS: The implementation of a FLS protocol was associated with an increase of anti-osteoporotic treatment, higher adherence, and greater survival in elderly hip fracture patients. There was a significant reduction of all-cause mortality in the FLS patients treated with anti-osteoporotic. However, the application of the FLS did not affect the risk of suffering a second fragility fracture.

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Extra-articular procedures for the improvement in rotational stability after anterior cruciate ligament (ACL) reconstruction have gained popularity in the last decade. This surgical gesture hoped to improve resistance to the high tensional forces affecting the ACL graft during cutting and pivoting movements of the lower extremity and eventually prevent ACL reconstruction failure. We performed this study to analyze the long-term results of patients undergoing ACL reconstruction using a nonanatomic double-bundle technique with an additional extra-articular augmentation. All the cases that underwent an ACL reconstruction using a nonanatomic double-bundle technique with an extra-articular reinforcement during the period between 1992 and 1997 were reviewed. The inclusion criteria for this study included a minimum follow-up of 10 years and age between 14 and 45 years at the time of the surgery. Forty patients were included in this series (34 males and 6 females). The mean Lysholm score after a minimum follow-up period of 10 years was 92.3 (standard deviation [SD], 9.4). The average preoperative Tegner score of the participants was 7.0 (SD, 1.1). This score decreased to 5.7 (SD, 1.2) at the end of follow-up. Follow-up X-rays were reviewed to assess the degenerative changes in the three knee compartments. Degenerative changes ≥ Kellgren-Lawrence grade 2 were observed in our six (15%) patients, all of them in the medial knee compartment. With these results, we conclude that double-bundle nonanatomic ACL reconstruction combined with an extra-articular reinforcement resembling the anterolateral ligament offers good overall long-term results, with relatively low rates of osteoarthritis.

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Osteoporosis is a metabolic disorder that results in increased bone fragility and risk of fractures. Hip fracture is the most important fragility fracture. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of an intensive FLS model could decrease 1-year-mortality of hip fracture patients. INTRODUCTION: Hip fractures are a clinical manifestation of osteoporosis, and these patients are at risk of premature death and suffering subsequent fractures. FLS is an approach for secondary facture prevention by identifying patients with fragility fractures and initiating the appropriate treatment. Our objective is to analyze the effect of the FLS model over the first-year mortality rates following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during two consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2017). Patients' information was withdrawn from our local computerized database. Patients were followed for 1 year after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model. RESULTS: A total of 724 individuals were included in this study (i.e., 357 before FLS implementation and 367 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation [275 (74.9%) vs 44 (12.3%); p < 0.01]. A total of 74 (20.2%) patients after FLS implementation and 92 (25.8%) individuals before FLS implementation (p = 0.07) died during the follow-up period. A second fracture occurred in 17 (4.6%) patients after FLS implementation and 13 (3.6%) individuals before FLS implementation (p = 0.50). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower 1-year mortality compared with patients managed before the implementation of the FLS protocol (treated or not treated with anti-osteoporotic drugs) [adjusted hazard ratio (HR) 0.66; 95% confidence interval (CI) 0.47-0.94; p < 0.05]. CONCLUSIONS: We did not observe significant 1-year-mortality differences following a hip fracture between patients treated before the implementation of an FLS protocol and patients treated after its implementation. The application of the FLS did not affect the risk of suffering a second osteoporotic fracture. However, patients treated with anti-osteoporotic drugs in an FLS context had a lower mortality rate compared with patients managed before the implementation of the FLS. LEVEL OF CLINICAL EVIDENCE: 2.

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Please find below the correction for the paragraph under the Heading "Materials and methods - Regulatory approval".

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The objective of this study was to analyze the effect of acetylcholinesterase inhibitors (AChEIs) on the risk of osteoporotic fractures in Alzheimer patients. A nested case-control study was conducted on 1190 cases and 4760 controls. The use of AChEIs was found to decrease the risk of osteoporotic fractures in these patients. INTRODUCTION: The objective of this study is to estimate the extent to which the use of AChEIs is associated with a reduction in the risk of osteoporotic fractures. METHODS: A nested case-control study was conducted using data from the UK Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) database (1998-2013). The study cohort consisted of Alzheimer's Disease (AD) patients aged ≥ 65 years with no previous history of osteoporotic fractures at cohort baseline. Cases were individuals who suffered an osteoporotic fracture during the study period, whereas controls were subject who did not experience any osteoporotic fractures during the same period. Controls were drawn from the population time at risk while being matched to the cases in respect to age, sex, up-to-standard follow-up in the CPRD, calendar time, and duration of AD (control-to-case ratio: 4-to-1). Information on the use of AChEIs and the relevant potential confounders was ascertained from the CPRD database for all the cases and controls. RESULTS: We identified 1190 cases and 4760 controls. Compared to non-users, any use of AChEIs prior to the fracture was associated with a reduction in the fracture risk [adjusted odds ratio (OR) 0.80 (confidence interval (CI) 95%, 0.70-0.91)]. The use of AChEIs corresponding to a proportion of days covered of 0.8-1.0 was associated with a lower osteoporotic fracture risk compared to non-use [adjusted OR 0.76 (CI 95%, 0.66-0.87)]. CONCLUSIONS: In this study using large primary care databases, the use and treatment adherence to AChEIs were associated with a decreased risk of osteoporotic fractures in elderly AD patients.

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There is increasing evidence suggesting that the use of acetylcholinesterase inhibitors may have beneficial effects on bone. Data on the potential post-surgical effects of these medications on orthopedic interventions are very limited. This study was designed to determine whether the use of acetylcholinesterase inhibitors is associated with a decrease in post-surgical mortality and complications in hip fracture patients with Alzheimer's disease. To accomplish this objective, a retrospective cohort study was performed using data from the Clinical Practice Research Database, UK. The study included 532 Alzheimer's disease patients of age 65 years and older, who sustained a hip fracture between 1998 and 2012. During the follow-up period, 34% of the patients died (n=182), 22% sustained a second hip fracture (n=118) and 5% (n=29) required reintervention. The users of acetylcholinesterase inhibitors had a 56% reduction in all-cause mortality (HR= 0.44, 95% CI 0.30-0.63) and a 41% reduction in second hip fracture incidence during a year of post-surgical follow-up (HR= 0.59, 95% CI 0.38-0.94) after adjusting for potential confounders. Our results show that acetylcholinesterase inhibitors may have the potential to reduce all-cause mortality and the risk of suffering a second hip fracture during the first year after surgery.

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OBJECTIVES: This study was designed to assess effects of cholinergic stimulation using acetylcholinesterase inhibitors (AChEIs), a group of drugs that stimulate cholinergic receptors and are used to treat Alzheimer's disease (AD), on healing of hip fractures. METHODS: A retrospective cohort study was performed using 46-female AD patients, aged above 75 years, who sustained hip fractures. Study analyses included the first 6-months after hip fracture fixation procedure. Presence of AChEIs was used as predictor variable. Other variables that could affect study outcomes: age, body mass index (BMI), mental state or type of hip fracture, were also included. Radiographic union at fracture site (Hammer index), bone quality (Singh index) and fracture healing complications were recorded as study outcomes. The collected data was analyzed by student's-t, Mann-Whitney-U and chi-square tests. RESULTS: No significant differences in age, BMI, mental state or type of hip fracture were observed between AChEIs-users and nonusers. However, AChEIs-users had better radiographic union at the fracture site (relative risk (RR),2.7; 95%confidence interval (CI),0.9-7.8), better bone quality (RR,2.0; 95%CI,1.2-3.3) and fewer healing complications (RR,0.8; 95%CI,0.7-1.0) than nonusers. CONCLUSION: In elderly female patients with AD, the use of AChEIs might be associated with an enhanced fracture healing and minimized complications.

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Bone remodeling is regulated by the two branches of the autonomic nervous system: the adrenergic and the cholinergic branches. Adrenergic activity favors bone loss, whereas cholinergic activity has been recently shown to favor bone mass accrual. In vitro studies have reported that cholinergic activity induces proliferation and differentiation of bone cells. In vivo studies have shown that the inhibition of cholinergic activity favors bone loss, whereas its stimulation favors bone mass accrual. Clinical studies have shown that bone density is associated with the function of many cholinergic-regulated tissues such as the hypothalamus, salivary glands, lacrimal glands and langerhans cells, suggesting a common mechanism of control. Altogether, these observations and linked findings are of great significance since they improve our understanding of bone physiology. These discoveries have been successfully used recently to investigate new promising therapies for bone diseases based on cholinergic stimulation. Here, we review the current understanding of the cholinergic activity and its association with bone health.

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A case of delayed signs of intracranial hypertension following closed head injury with a depressed cranial fracture and superior sagittal sinus thrombosis is reported. Conservative treatment of intracranial hypertension, including just repeated lumbar puncture and oral acetazolamide, was performed. Spontaneous recanalization of the superior sagittal sinus was observed. Pathogenesis and different modalities of treatment are discussed.

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