OBJECTIVE: Additional CT imaging for fragility fractures of the pelvis (FFP) has a high detection rate for concomitant posterior ring fractures (cPRFs). However, the clinical value of routine additional CT imaging is unknown. This study aimed to determine the additional clinical value of routine CT imaging by changes in treatment policy and to establish the predictive value of pain localized around the sacroiliac joint (SIJ) for cPRFs.
METHODS: A prospective cohort study was conducted in a single teaching hospital in the Netherlands between November 2019 and November 2020. Patients were included if they were ≥ 65 years and had a (suspected) FFP on the pelvic radiograph. All patients underwent additional CT imaging. Changes in treatment policies ((possible) surgery, restrictive weight-bearing, hospital admission and outpatient follow-up) after CT imaging were registered.
RESULTS: Fifty-one patients (44 female) were included with a mean age of 80.6 years. Routine CT imaging revealed an additional cPRF in 27 patients (53%). A change in treatment occurred in 29 patients (57%), of which 7 (12%) were managed either surgical or with restrictive weight-bearing. The presence of pain around the SIJ had a sensitivity of 89% and specificity of 61% for detecting a cPRF.
CONCLUSIONS: Routine additional CT imaging has few direct therapeutic consequences with regards to surgical management or restrictive weight-bearing. These findings may be altered when considering a lower threshold for surgical intervention. The presence of pain around the SIJ was highly predictive for a clinically relevant cPRF.
BACKGROUND: NL8011 on 02-09-2019.

Rheumatoid arthritis (RA) is characterised by a chronic, progressive inflammation in the joints and leads to substantial pain, disability, and other morbidities. Few studies document the occurrence of insufficiency fractures, but no studies document the patient\'s perspective on incurring an insufficiency fracture. The aim of this qualitative study was to explore the patients\' perspective on how insufficiency fractures influence their level of activity and to detect their need for rehabilitation. Two focus-group interviews were performed with 10 patients diagnosed with RA and insufficiency fractures. The data from the focus-group interviews were subjected to thematic analysis to provide a sense of the important themes. The 10 patients were all females, aged 57-88 years. Magnetic resonance imaging were performed at a mean of six months and seven days. All patients identified the delayed diagnosis of fracture as a significant burden. They experienced pain but did not receive a diagnosis. When the patients were immobilised, some of them were offered aids such as crutches, which they were unable to use due to their RA. The patients needed a focus on diagnosis and individually customised rehabilitation, taking into account RA and including guidance concerning daily activities, aids, and the regain of physical function.

The objective of this prospective, randomised study was to examine the feasibility and clinical outcome of balloon sacroplasty and radiofrequency sacroplasty.
In 40 patients with a total of 57 sacral fractures, CT-guided cement augmentation was performed by means of BSP or RFS. For BSP, the balloon catheter was inflated and deflated in the fracture zone, and the hollow space, thus, created was then filled with PMMA cement. For RFS, the spongious space in the fracture zone was initially extended using a flexible osteotome, and the highly viscous PMMA cement, activated by radiofrequency, was then inserted into the prepared fracture zone. Pain intensity was determined on a VAS before the intervention, on the second day, and 6, 12 and 18 months after the intervention. The results were tested for significance by means of paired Wilcoxon rank-sum tests and Mann-Whitney U tests.
BSP and RFS were technically fully feasible in all patients. An average of 6.3 ml cement per fracture was inserted in the BSP group and an average of 6.1 ml per fracture in the RFS group. Leakage could be ruled out for both procedures. The mean pain score on the VAS before the intervention was 8.6 ± 0.55 in the BSP group and 8.8 ± 0.58 in the RFS group. On the second postoperative day, a significant pain reduction was seen (p < 0.001), with an average value of 2.5 (BSP ± 0.28, RFS ± 0.38) for both groups. After 6 (12; 18) months, these values were stable for the BSP group at 2.3 ± 0.27 (2.3 ± 0.24; 2.0 ± 0.34) and for the RFS group at 2.4 ± 0.34 (2.2 ± 0.26; 2.0 ± 0.31). With regard to pain, exceedance probability values of p = 0.86 (6 months), p = 0.94 (12 months) and p = 1 (18 months) were seen, so that neither treatment method leads to differences in results.
BSP and RFS are interventional, minimally invasive procedures that enable reliable cement augmentation and achieve equally good clinical outcomes in the medium term.

Subchondral insufficiency fractures (SIF), previously termed spontaneous osteonecrosis of the knee, are marked by a sudden onset of severe pain. Other than the size of the lesion, prediction for progression to joint replacement is difficult. The objective was to determine if quantitative analysis of bone texture using digital tomosynthesis imaging would be useful in predicting more rapid progression to joint replacement.
Tomosynthesis studies of 30 knees with documented SIF were quantified by fractal, mean intercept length (MIL), and line fraction deviation analyses. Fractal dimension, lacunarity, MIL, and line fraction deviation variables measured from these analyses were then correlated to short interval progression to joint replacement surgery.
Higher odds for joint replacement were related to higher values of the standard deviation of slope lacunarity and to morphometric measures (eg, MIL).
Using digital tomosynthesis images for bone texture assessment may help distinguish condylar bone response in SIF, potentially acting as a clinically relevant predictive tool. In the future, contrasting SIF to the more gradual long-term process of osteoarthritis, there may be a better understanding of the different mechanisms for the two conditions.