This expert position statement reframes arthroplasty and spinal fusion complications under the unified endpoint of implant fixation failure, defined as loss of mechanical integrity of the bone–implant unit over time. It synthesizes mechanistic and clinical evidence and provides evidence-informed recommendations for peri-operative bone health optimization. Osteoporosis is traditionally conceptualized as causing fragility fractures. However, compromised bone quality also affects the integrity of bone–implant constructs, influencing whether implants maintain fixation, interfaces remain stable, and fusion constructs consolidate. To synthesize mechanistic, translational, and clinical evidence on how osteoporosis and osteoporosis pharmacotherapies influence implant fixation failure across arthroplasty and spinal fusion, and to provide evidence-informed clinical recommendations for peri-operative bone health assessment and optimization within a unified construct-level framework. A position statement was developed following a structured literature search. Evidence was synthesized narratively by defining implant fixation failure as a construct-level outcome encompassing periprosthetic fracture, loosening, subsidence, pseudarthrosis, and junctional failure. Recommendations were categorized by strength (strong or conditional) and certainty of evidence (high, moderate, or low). Low bone mineral density (BMD) is associated with implant fixation failure across arthroplasty and spinal fusion. In arthroplasty, randomized trials demonstrate preservation of periprosthetic BMD with bisphosphonates, while registry analyses suggest improved implant survival. In spinal fusion, antiresorptive and anabolic therapies influence fixation-related parameters, with anabolic agents showing the most consistent evidence for enhanced fusion mass and earlier union. Much of the literature relies on radiographic or biomechanical endpoints rather than definitive outcomes. Viewing arthroplasty and spinal fusion complications through a shared construct-level perspective provides a coherent link between osteoporosis and reconstructive durability. Systematic peri-operative bone health optimization may improve construct longevity, although more definitive outcome-driven trials are needed. Closer integration between orthopedic surgeons and osteoporosis specialists will be central to advancing peri-operative bone health care.

Considerable progress has been made in the management of cancer patients in the last decade with the arrival of anti-cancer immunotherapies (immune checkpoint inhibitors) and targeted therapies. As a result, a broad spectrum of cancers, not just hormone-sensitive ones, have seen several patients achieve profound and prolonged remissions, or even cures. The management of medium- and long-term side-effects of treatment and quality of life of patients are essential considerations. This is especially true for bone, as bone fragility can lead to increased fractures and loss of autonomy, ultimately reducing the possibility of resuming physical activity. Physical activity is essential for lasting oncological remission and prevention of fatigue. While the issue of hormone therapies and their association with breast cancer has been recognized for some time, the situation is relatively new with regards to targeted therapies and immunotherapies. This is particularly challenging given the wide range of available targeted therapies and their application to numerous cancer types. This article provides a comprehensive review of the bone effects of the main anti-cancer therapies currently in use. The review goes beyond glucocorticoids and hormone therapies and discusses for each drug category what is known regarding cellular effects, BMD effects, and fracture incidence.

The fracture risk assessment tool (FRAX) is a tool which calculates an individual 10-year fracture risk based on epidemiological data in patients with a risk of osteporosis. The aim of this study was to evaluate the value of FRAX to estimate the risk of postoperative periprosthetic fractures (PPF) in patients following with total hip and knee arthroplasty. 167 patients (137 periprosthetic fractures in total hip arthroplasty and 30 periprosthetic fractures in total knee arthroplasty) were included in this study. Patients' data was retrieved retrospectively. In each patient the 10-year probability of a major osteoporotic fracture (MOF) and an osteoporotic hip fracture (HF) was calculated using FRAX. According to the NOGG guideline 57% of total hip arthroplasty (THA) patients and 43.3% of total knee arthroplasty (TKA) patients were in need of osteoporosis treatment, whereas only 8% and 7% received an adequate one respectively. 56% of the patients with PPF after THA and 57% of the patients with PPF after TKA reported about a previous fracture. Significant associations between the 10-year probability of a MOF and HF calculated by FRAX and PPF in THA and TKA were seen. The results of the present study show that FRAX might have the potential to estimate the PPF in patients following THA and TKA. FRAX should be calculated before and after THA or TKA in order to assess the risk and counsel patients. The data show a clear undertreatment of patients with PPF in respect to osteoporosis.

Abstract Background Neoadjuvant chemotherapy in patients with primary osteosarcoma improves survival rates, but it also causes side effects in various organs including bone. Low bone mineral density (BMD) can occur owing partly to chemotherapy or limited mobility. This can cause a higher risk of fractures compared with those who do not receive such treatment. Changes in BMD alone cannot explain the propensity of fractures. Studying microarchitectural changes of bone might help to understand the effect. Questions/purposes (1) Do patients who were treated for osteosarcoma (more than 20 years previously) have low BMD? (2) Do these patients experience more fractures than controls who do not have osteosarcoma? (3) What differences in bone microarchitecture are present between patients treated for high-grade osteosarcoma and individuals who have never had osteosarcoma? Methods We contacted 48 patients who were treated for osteosarcoma and who participated in an earlier study. These patients underwent multimodal treatment including chemotherapy more than 20 years ago. Of the original patient group, 60% (29 of 48) were missing, leaving 40% (19 of 48) available for inclusion in this study; all 19 agreed to participate. There were nine men and 10 women with a mean age of 46 ± 4 years and a mean time from surgery to examination of 28 ± 3 years. BMD was measured by dual-energy x-ray absorptiometry, and any fracture history was assessed using a questionnaire. Additionally, high-resolution peripheral quantitative CT was performed to compare the groups in terms of microarchitectural changes, such as cortical and trabecular area, cortical and trabecular thickness, cortical porosity, and endocortical perimeter. Participants in the control group were selected from a cohort consisting of a population-based random sample of 499 healthy adult women and men. Osteoporosis or low BMD was not an exclusion criterion for entering this study; however, the patients in the control group were selected based on a normal BMD (that is, T score > -1.0 at both the spine and hip). Also, the participants were matched based on age and sex. Differences between patients and controls were assessed using the Wilcoxon rank sum test for continuous variables and a chi-square test for categorical variables. A multiple regression analysis was performed. Model assumptions were checked using histograms and quantile-quantile plots of residuals. Results Twelve of 19 patients who were treated for osteosarcoma had either osteopenia (eight patients) or osteoporosis (four patients). More patients with osteosarcoma reported sustaining fractures (11 of 19 patients) than did control patients (2 of 19 controls; p < 0.001). Among all microarchitectural parameters, only the endocortical perimeter was increased in patients compared with the control group (75 ± 15 mm versus 62 ± 18 mm; p = 0.04); we found no differences between the groups in terms of cortical and trabecular area, cortical and trabecular thickness, or cortical porosity. Conclusion Although patients who were treated for osteosarcoma had osteopenic or osteoporotic BMD and a higher proportion of patients experienced fractures than did patients in the control group, we could not confirm differences in microarchitectural parameters using high-resolution peripheral quantitative CT. Therefore, it seems that bone geometry and microstructural parameters are not likely the cause of the increased proportion of fractures observed in our patients who were treated for osteosarcoma. Until we learn more about the bone changes associated with chemotherapy in patients with osteosarcoma, we recommend that patients undergo regular BMD testing, and we recommend that physicians consider osteoporosis treatment in patients with low BMD. These data might provide the impetus for future multicenter prospective studies examining the association between chemotherapy and bone microarchitecture. Level of Evidence Level III, therapeutic study.

At the end of the nineteenth century, the imperial capital of the k.k. Danube monarchy, Vienna, enabled the meeting of two important figures in medical history: the surgeon Eduard Albert (1841-1900) and his student Adolf Lorenz (1854-1946). Both men had comparable traits: they came from humble backgrounds, were exceptionally talented and longed for a career in the supreme medical discipline-surgery. Both achieved the highest goals in their disciplines but the spectrum of their interests was much broader. The life of both and their contacts to each other are reported here. In this respect the Memorial Book of House No. 528 by Eduard Albert in Senftenberg was also evaluated.

Zusammenfassung Adolf Lorenz, der Begründer der Orthopädie in Österreich und Vater des späteren Nobelpreisträgers Konrad Lorenz, und der Gründer und erste Präsident der tschechoslowakischen Republik, Tomáš G. Masaryk, standen in Kontakt miteinander. In den siebziger und achtziger Jahren des 19. Jahrhunderts studierten beide an der Universität Wien: der um vier Jahre ältere Masaryk Philosophie und Lorenz Medizin. Die ersten Treffen fanden im Seziersaal des Anatomischen Institutes statt. Ihnen beiden gelangen (wissenschaftliche) Karrieren und sie wurden prominente Persönlichkeiten. Fast 40 Jahre nach der ersten zufälligen Begegnung erinnerte sich Lorenz an seinen ehemaligen Schüler, inzwischen Präsident der tschechoslowakischen Republik, und nahm mit ihm Briefkontakt auf. Die im Masaryk-Institut in Prag aufbewahrte Korrespondenz soll hier vorgestellt werden.

Almost 120 years ago, in 1902, the American multimillionaire J. Ogden Armour invited the Austrian orthopaedic surgeon Adolf Lorenz, professor at the University of Vienna, to treat his daughter Lolita. Lolita was born premature in 1896 and spent the first months of her life in an incubator. Later she was diagnosed with congenital dislocation of both hips. Lorenz had developed a "bloodless" treatment method and was invited by the Armour family to Chicago to "operate" on Lolita. Both hips had already been treated by an American orthopaedic surgeon before but without a satisfactory result. Lorenz should achieve a better one. The operation was performed in Chicago on 12 October 1902 and was accompanied by a very large media spectacle. This article is mainly based on contemporary newspaper reports.

Zusammenfassung Am Ende des 19. Jahrhunderts ermöglichte die Reichshauptstadt der k.k. Donaumonarchie, Wien, die Begegnung zweier bedeutender Persönlichkeiten der Medizingeschichte: des Chirurgen Eduard Albert (1841–1900) und dessen Schüler Adolf Lorenz (1854–1946). Beide Männer wiesen vergleichbare Züge auf: Sie stammten aus bescheidenen Verhältnissen, waren außergewöhnlich begabt und sehnten sich nach einer Karriere in der medizinischen Königsdisziplin – der Chirurgie. Beide erreichten in ihren Disziplinen die höchsten Ziele, aber das Spektrum ihrer Interessen war sehr viel breiter angelegt. Über das Leben beider und ihre Kontakte zueinander soll hier berichtet werden. Dabei konnte auch das „Gedenkbuch des Hauses Nr. 528“ von Eduard Albert in Senftenberg ausgewertet werden.

Dear MJM, Design has not been associated with medicine at all for years. Instead, medical technology has focused on developments from the technological point of view, whereas design of these products has been neglected. Now, this is slowly changing. More and more medical companies put their beliefs into the factor of design to improve their well engineered products. Through various design awards medical design has gained wide publicity. Design aims to create functional and/or pleasing products. It is not just applied arts or an aesthetical factor like stylish upper-class furniture. Good design complies with function or even improves it. Design has an inventive talent; it involves problem-solving and creativity. Design adds value to a product and makes it more competitive. But what is medical design? Medical design means introducing design into medicine and utilizing the advantages of good design to please patients. There seems to be no field in which design would be more required or helpful than in medicine. Instead of sterile ambiences or cold technological devices, design may help reduce fears and increase acceptance. It will generate more user-friendly products, in some cases demonstrating function by the form. Medical design has a positive psychological affect and helps to improve patient-doctor relationships. Patients feel more comfortable finally leading to better results in health care outcomes. Therefore, the Philips Company has developed the idea of Ambient Experience Design aiming to combine technology and design to establish high quality comfort in hospitals. This concept has been introduced at the Lutheran Hospital in Chicago. The CT scanner rooms have been equipped with smoothly shaped diagnostic apparatus. Furthermore, pictures of relaxing subjects for adults or cartoons for children have been projected onto the walls to make comfortable surroundings. This concept resulted in patients who were happier and less afraid, and a medical staff that felt more comfortable. Another example are hip protectors, developed to protect against hip fractures resulting from falls. However, currently the compliance with such devices is low. The AHIP Protectors from Astrotech Advanced Materials were designed to cope with patients' needs. It is a design product developed in co-operation with patients, medical doctors, material scientists and industrial designers. Its design serves to please patients and improve wearing comfort and compliance by increasing flexibility and introducing air holes. Diego a product by Gyrus, is a specially developed dissector for otorhinolaryngology surgery, which has been developed by a multidisciplinary team including designers. The heart of this tool is its hand piece which is ergonomically designed and therefore allows natural and comfortable hand positioning when performing sinusitis surgery. As a result, surgery can be carried out much quicker and with less bleeding, which is positive for both patients industrial designers. Its design serves to please patients and improve wearing comfort and compliance by increasing flexibility and introducing air holes. As the first design products have been introduced into medical practice only recently, results of their implementation are not yet available. But if we transfer the data from other fields, where design has shown positive effects, and you can just imagine how comfortable you feel in designed surroundings, we can expect the same results with medical design. Products that please the patient more will be more successful. In conclusion, medical design has many positive aspects, as these examples have shown. Furthermore, medical design has a lot of potential, due to medicine's broad range. So do not close your eyes to this effective factor that has been neglected for far too long. Sincerely,

Abstract Purpose Unicompartmental knee arthroplasty (UKA) is a treatment option for anteromedial osteoarthritis of the knee. The number of UKA has been increasing constantly worldwide in recent decades. The aim of this study was to determine the most frequently cited scientific articles addressing this subject and to establish a ranking of the 50 most influential papers. Methods The 50 most cited articles related to UKA were searched in Web of Science® (Clarivate Analytics, Penn., USA) by the use of defined search terms. All types of scientific papers with reference to this topic were ranked according to the absolute number of citations and analyzed for the following characteristics: journal title, year of publication, number of citations, citation density, geographic origin, article type, and level of evidence. Results The 50 most cited articles had up to 453 citations. Most papers were published in the Journal of Bone and Joint Surgery (British volume). More than half of the articles were published in the 2000s and 2010s (n = 30). Ten countries contributed to the top 50 list, with most contributions from the UK (n = 17). Most articles could be attributed to the category of Clinical Science (n = 33), and most reported level IV studies. Conclusion Most of the frequently cited articles in UKA are clinical studies that have a low level of evidence. Few basic scientific studies could be identified, which suggests that most product development is done by commercial companies.

За последние несколько десятилетий количество эндопротезирований суставов неуклонно возрастает. Большинство таких пациентов — старшего возраста, и из-за остеопороза качество костной ткани у них снижается. У пациентов с остеопорозом, перенесших замену сустава, часто наблюдаются следующие осложнения: интраоперационные перипротезные переломы, перипротезный остеолиз, увеличение миграции имплантатов или послеоперационные перипротезные переломы. Мы представляем обзор литературы по проблемам остеопороза у пациентов, перенесших эндопротезирование сустава. Оценка качества костной ткани является важным моментом при лечении пациентов в плане обеспечения наилучшего ухода и оптимизирования долгосрочных хирургических результатов. При необходимости больных следует проинформировать о возможности нутритивной поддержки препаратами кальция и витамина D. Кроме того, в периоперационном периоде целесообразно достижение физиологических уровней витамина D. У женщин в постменопаузальном периоде, мужчин старше 70 лет, женщин и мужчин с повышенным риском развития остеопороза в течение двух лет после полной замены сустава следует выполнять оценку минеральной плотности кости. У пациентов с пониженным качеством костной ткани следует рассмотреть возможность лечения бисфосфонатами, деносумабом или терипаратидом для улучшения остеоинтеграции бесцементных имплантатов, увеличения срока службы имплантатов, а также для сокращения перипротезных переломов и переломов в целом. В отдельных случаях пациентам с остеопорозом может потребоваться использование цементных протезных компонентов (особенно при тотальном эндопротезировании тазобедренного сустава).

Die Kindheits- und Jugendjahre sind entscheidend im Leben. Das Ziel dieser Arbeit war, die Entwicklungsjahre von Adolf Lorenz, dem Begründer der Orthopädie in Österreich und der weltweit Spuren hinterlassen hat, hinsichtlich seiner Berufswahl zu analysieren. Der Sohn armer Leute aus dem ehemaligen Grenzgebiet der k.k.-Monarchie gegen Polen, damals Österreichisch-Schlesien, erhielt einen Freiplatz als Sängerknabe an einem Kärntner Stiftsgymnasium und setzte seine Gymnasialstudien in der Provinzstadt Klagenfurt fort. Das letzte Schuljahr verbrachte er als Hauslehrer in Siebenbürgen und maturierte als Externist. In diese Zeit fiel schließlich die Entscheidung für das Studium der Medizin. Die Menschen und Ereignisse, die zu diesem Entschluss führten, sollen hier beleuchtet werden.

In long-term survivors of osteosarcoma and Ewing sarcoma treated with the addition of radio- and chemotherapy, low bone mineral density (BMD) and fractures have been observed, presumably resulting from these adjuvants. Because patients with chondrosarcoma usually are not treated with conventional adjuvant treatment, observation of low BMD in patients with chondrosarcoma presumably would be the result of other mechanisms. However, BMD in patients with a history of chondrosarcoma has not been well characterized.

Subchondral bone changes seem to contribute to the progression of knee osteoarthritis (OA). The study aimed to analyze subchondral bone microstructure in specimens of late-stage knee OA in respect to articular cartilage damage, meniscus integrity and knee joint alignment. Methods and Materials: 30 proximal tibiae of 30 patients (20 female and 10 male) with late-stage OA retrieved during total knee arthroplasty (TKA) were scanned using a high-resolution MicroComputed Tomography (μCT). The scans were semi-automatically segmented into five volumes of interest (VOIs). The VOIs were than further analyzed using commercially available software. The degree of articular cartilage damage was assessed semi-quantitatively by magnetic resonance imaging (MRI) before surgery. Results: The mean bone fraction volume (BV/TV) in all weight bearing locations was significantly higher compared to the non weight-bearing reference point below the anterior cruciate ligament (p=0,000). The mean BV/TV in the medial compartment was significantly higher compared to the lateral compartment (p=0,007). The BV/TV in intact menisci, there was a significantly lower subchondral BV/TV compared to subluxated or luxated menisci in the medial (p=0,020) and lateral compartment (p=0,005). Varus alignment had a significantly higher subchondral BV/TV in the medial compartment, whereas valgus alignment had a significantly higher subchondral BV/TV in the lateral compartment (p=0,011). Conclusion: The results show significant differences of subchondral bone microstructural parameters in respect to cartilage damage, meniscus’ structural integrity and knee joint alignment. Therefore, subchondral bone changes seem to be a secondary process in the late-stage OA of knee caused by mechanical changes.

Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to the concept of orthogeriatric co-management (OGC). OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams taking care of frail elderly patients. The models are country specific. Despite several published models there are still no clear recommendations on how this service should be best organized. The 12 outcome parameters published by the Experts’ Roundtable in 2013 were recommended to be used for the further assessment of different OCG models. This literature review was prepared accordingly and showed the need for further studies to determine the best OGC model and to define a uniform set of outcome parameters for use in future clinical studies.

Osteoporosis is a systemic disease of the bone that affects millions of people and causes burden for both the affected individual and health systems and societies worldwide. Since the 1970s much research has been done in the field of osteoporosis. The number of citations of a paper reflects its influence and importance to the field. Thomson ISI Web of Science database was searched to retrieve a list of the fifty most cited articles related to osteoporosis and its research. The fifty most cited articles in absolute numbers in the field of osteoporosis were cited from 877 to 3056 times (mean 1141 ± 537). Most papers were published in the basic science category (n = 23). 395 authors contributed; a single paper had between one and 62 authors (mean: 10.02 ± 9.9 authors). 12 authors (3.04%) contributed between 7 and 4 papers; 340 authors (86.1%) were at least named once. Corresponding authors were from eight countries with most contributions from the United States (n = 34, 68%). The majority of papers were published in the 1990s (n = 29). The list of 50 most cited papers presents citation classics in the field of osteoporosis and related research.

Background and purpose Dupuytren’s disease (DD) is a benign fibroproliferative process of the palmar aponeurosis showing similarities to wound healing. Communication of cells involved in wound healing is mediated by the composition of gap junction (GJ) proteins. We investigated the expression of 3 GJ proteins, connexins 26, 30, and 43 (Cx26, Cx30, and Cx43) in DD. Patients and methods Fragments of Dupuytren’s tissue from 31 patients (mean age 56 (30–76) years, 24 male) were analyzed immunohistochemically and compared to control tissue for expression of the GJ proteins Cx26, Cx30, and Cx43 and also alfa-smooth muscle actin (α-SMA). Results 14 of 31 samples could be attributed to the involutional phase (α-SMA positive) whereas 17 samples had to be considered cords in the residual phase (α-SMA negative). Expression of Cx26 and Cx43 was seen in 12 of the 14 samples from the involutional phase, and Cx30 was seen in 7 of these. Only 4 of the 17 samples from the residual phase showed any Cx, and there was none in the controls. Interpretation The high expression of GJ proteins Cx26, Cx30, and Cx43 in α-SMA positive myofibroblast-rich nodules, which are characteristic of the active involutional phase of DD, suggests that connexins could be a novel treatment target for the treatment of DD.

Background Multimodal treatment regimens for Ewing’s sarcoma have led to survival rates approaching 70% of patients with no metastases at diagnosis. However, these treatments have long-term side effects. Low bone mineral density (BMD) and risk of fractures can occur owing in part to chemotherapy and limited mobility from local control of the primary tumor. Questions/purposes We performed this study to answer the following questions: (1) Do long-term survivors of the Ewing family of tumors sustain low BMD? (2) Which factors are associated with BMD in these patients? (3) Do they experience fractures? (4) Are BMD and fractures associated with each other? Methods We queried our institutional registry to identify all known survivors of Ewing tumors who were treated before 2005. Of 100 such patients, 67 (67%) responded to a postal survey to participate in this study, and an additional 11 (11%) patients were excluded according to prespecified criteria. In the remaining 56 long-term survivors (27 females, 29 males; mean ± SD age at followup, 32 ± 10 years; mean followup, 15 ± 7 years), BMD was measured by dual-energy x-ray absorptiometry and history of fractures was assessed using a questionnaire. Associations were tested using univariate and multivariate models by stepwise variable selection procedure, including Bonferroni correction. Results Thirty-one of 56 (56%) patients had a pathologic BMD. Seven (13%) had osteoporosis and 24 (43%) had osteopenia. Factors related to low BMD after Bonferroni correction were the length of time between surgery and followup and the BMI at followup. Twenty-one patients reported 29 fractures. With the numbers available, BMD levels were not associated with fractures. Conclusions We could not confirm some potentially important predictors for fractures to be associated with clinical events of interest. However, the data are valuable as hypothesis-generating pilot data for future, multicenter prospective studies. If BMD changes cannot explain the propensity of fractures, there may be other bone characteristics like microarchitectural changes of bone to more accurately explain the effect. Level of Evidence Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.