Homeopathic Ankle Dislocation for Treatment of Unstable Trimalleolar Fractures Involving Posterior Die-Punch Fragment: A Retrospective Cohort Study

OBJECTIVES

Unstable trimalleolar fractures are relatively complex and more difficult to manage if die-punch fracture is present. We aimed to evaluate the curative effect of homeopathic ankle dislocation on the unstable trimalleolar fractures involving posterior die-punch fragments.

METHODS

A total of 124 patients diagnosed with unstable trimalleolar fractures combined with post-die punch fragment between June 2008 and June 2020 were retrospectively included. Patients who received homeopathic ankle dislocation were named as the experimental group, and patients who accepted conventional treatment were control group. The fracture healing time, wound healing, American Orthopedic Foot and Ankle Society ankle-hindfoot scale (AOFAS), visual analogue scale (VAS), the Kellgren-Lawrence arthritis grading scale (KLAGS) and short-form 36 score (SF-36) scores were collected. Student t-test was used for fracture healing time. Wound healing and SF-36 were compared using the Mann-Whitney test. Repeated measurement analysis of variance (ANOVA) was used for AOFAS and VAS. χ2-test was used for KLAGS.

RESULTS

AOFAS showed statistically significant differences between the two groups (p = 0.001). In non-weight-bearing and weight-bearing conditions, VAS scores were significant different between the two groups, and there was an interaction between group and time point (p < 0.001). The experimental group was superior to the control group in terms of physical function (p = 0.022), role-physical (p = 0.018), general health (p = 0.001) and social function (p = 0.042).The operation time of experimental group was shorter than that of control group (p < 0.001).

CONCLUSION

Homeopathic ankle dislocation is used for the unstable trimalleolar fractures involving posterior die-punch fragment, which can provide better functional outcomes while shortening the operation time and recovery period.

Functional outcome and risk of non-union for 5th metatarsal base fractures

OBJECTIVES

Treatment of 5th metatarsal fractures via direct discharge from virtual fracture clinic (VFC) has become common practice in the NHS. We aim to assess the functional outcome and incidence of non-union in a series of 5th metatarsal base fractures, exposed to 1-year of follow-up.

METHODS

194 patients who sustained a fracture between the period February 2019 to April 2020 were included, referred via the VFC pathway. Radiographs were reviewed to classify in which zone, the fracture occurred along with union on subsequent follow-up. Telephone follow-up was used to measure patient functional outcomes (EQ-5D & FAAM survey) and satisfaction with the VFC service.

RESULTS

Off 194 patients, 53 (27.3%) had zone 1, 99 (51%) had zone 2, and 42 (21.6%) had zone 3 fractures. 80 were discharged directly from VFC, with 114 patients being offered at least one face to face clinic follow-up. Six (3.1%) patients had clinical and radiological evidence of non-union; 4 in zone 2, and 2 in zone 3. No zone 1 injuries were identified as a non-union. Only 2 patients had surgery, 1 of which was for symptomatic non-union. Of the 6 non-union patients, 1 had surgery, 4 did not wish to have surgery and the final non-union patient was deemed unsuitable for surgery.

CONCLUSION

The VFC is an effective way of managing 5th metatarsal fractures, with high patient satisfaction. Conservative management has excellent outcomes, with a low percentage of zone 2 and 3 injuries developing a symptomatic non-union. Functional outcome surveys provide further reassurance.

Retrograde intramedullary nailing of AO/OTA 33C femur fractures in patients with below-knee amputations: technical note and case series

PURPOSE

Intra-articular distal femur fractures in patients with a lower extremity amputation can present a technical challenge for the treating surgeon in what may be otherwise considered a routine procedure in non-amputees. Difficulties with positioning, fracture reduction, limb contractures, and stump osteoporosis can present challenges with treatment. Here, we describe the surgical technique and outcome of a case series of amputee patients with AO/OTA 33C femur fractures.

METHODS

Retrospective case series of five patients with a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation treated with retrograde intramedullary nail at a single Level 1 trauma center from January 1, 2021, to January 1, 2023. Baseline demographic and clinical data were recorded. Rate of bony union and complications were documented.

RESULTS

Five patients (three females and two males) with a mean age of 48 years who were treated for a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation were identified. At the time of final follow-up (mean 109.3 days, range 29-183 days), all patients had healed their incisions and were progressing to return of function with their prosthesis. All patients were treated with the surgical technique described in this article, and no postoperative complications were reported.

CONCLUSION

This is an effective and safe technique for surgical treatment of comminuted intra-articular distal femur fractures in patients with an ipsilateral below-knee amputation. We believe that this technique can be utilized by any orthopedic surgeon taking trauma call and can avoid unnecessary transfers or delays to care.

The comparison of functional bracing of humeral shaft fractures: thermoplastic custom against preprepared commercial braces

BACKGROUND

Functional humeral bracing of midshaft humeral fractures has been widely accepted as a gold standard for nonoperative treatment. Despite reported high union rates, there is no proven superiority of any orthosis. Here we aim to compare the outcomes after the use of custom-made thermoplastic vs. commercial humeral brace with regard to time to union, nonunion rates, types of nonunion, and conversion to surgery.

METHODS

Patients with humeral fractures treated between 2018 and 2021 were identified retrospectively by electronic records. Only diaphyseal humerus fractures (AO 12) were included in the study. Proximal (AO 11) or distal (AO 13) fractures, open fractures, pathologic fractures, bilateral fractures, multiple fractures, and patients lost to follow-up were excluded. Patients attending one center received a custom-made thermoplastic splint, whereas those at the other center had an off-the-shelf humeral brace applied. Radiologic union was defined as healing of at least 3 of 4 cortices determined from follow-up radiographs. Data calculations were performed using the χ2 test.

RESULTS

A total of 53 patients treated with a thermoplastic brace and 43 with a commercial brace were identified. A total of 52 men were included, and the cohort's mean age was 60.1 years (standard deviation: 16.1 years). Both groups had similar gender and age distributions. More patients achieved union with a thermoplastic brace (79.2%) than those with a commercial brace (76.7%), which was statistically significant (χ2, P = .04). Although time to union was similar both clinically and radiologically, patients with a commercial brace converted to surgical treatment more frequently (11 vs. 14 cases).

CONCLUSION

Thermoplastic custom-made braces provide better fracture stability, allowing for statistically significantly higher rates of fracture union during a similar treatment period to commercially available splints. Patients wearing a commercial splint were significantly more likely to develop hypertrophic nonunion requiring surgery.

Advances in Hand Therapy: Best Practice in Conservative Management of Proximal Phalangeal Fractures in Children

BACKGROUND

Proximal phalangeal fractures are one of the most commonly treated hand injuries in children. Conservative management of these fractures is often to splint for 5 weeks post injury, despite children presenting as clinically healed at 3 weeks post injury. Therefore, we investigated the effect of splinting for only 3 weeks in children who present with clinically healed proximal phalangeal fractures at 3 weeks compared with usual care.

METHODS

Participants (n=80, aged 10.3 ±2.5 years) presenting to the Hand Clinic of a tertiary Children's Hospital in Sydney, Australia, were randomly allocated into a Current Protocol and a New Protocol group. Following were the inclusion criteria: aged between 5 and 16 years; present with an non-displaced or minimally displaced and stable fracture; no surgical intervention; assessed as clinically healed at 3-week visit. The primary outcome measure was total active motion (TAM) of the injured digit compared with the contralateral digit (deg), at 5 weeks post injury. Secondary outcome measures were grip strength, and a parent-reported questionnaire. Statistical analysis used χ 2 test and the absolute difference described by a 90% CI. The New Protocol was considered noninferior if the 90% CI overlap was > 20% of the Current Protocol. Analysis was by intention to treat.

RESULTS

There was a 10% loss to follow up at 5 weeks (Current Protocol =4, New Protocol =4). All CIs between groups overlapped by >10%. TAM 90% CI for Current Protocol was 17.7 to 5.4 degrees and for the New Protocol was 4.7 to 1.6 degrees.

CONCLUSIONS

A change in practice is warranted to cease immobilization for children with conservatively managed proximal phalangeal fractures who present as clinically healed at 3 weeks. Therapist assessment of fracture healing is an appropriate indicator for intervention and can be utilized in a therapist-led model of care.

LEVEL OF EVIDENCE

Level 1-noninferiority randomized control trial with 2 parallel arms.

Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study

BACKGROUND

Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity.

MATERIALS AND METHODS

Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18 months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis.

RESULTS

A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively.

CONCLUSIONS

Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions.

LEVEL OF EVIDENCE

Level III.

Fracture healing on non-union fracture model promoted by non-thermal atmospheric-pressure plasma

Non-thermal atmospheric-pressure plasma (NTAPP) is attracting widespread interest for use in medical applications. The tissue repair capacity of NTAPP has been reported in various fields; however, little is known about its effect on fracture healing. Non-union or delayed union after a fracture is a clinical challenge. In this study, we aimed to investigate how NTAPP irradiation promotes fracture healing in a non-union fracture model and its underlying mechanism, in vitro and in vivo. For the in vivo study, we created normal and non-union fracture models in LEW/SsNSlc rats to investigate the effects of NTAPP. To create a fracture, a transverse osteotomy was performed in the middle of the femoral shaft. To induce the non-union fracture model, the periosteum surrounding the fracture site was cauterized after a normal fracture model was created. The normal fracture model showed no significant difference in bone healing between the control and NTAPP-treated groups. The non-union fracture model demonstrated that the NTAPP-treated group showed consistent improvement in fracture healing. Histological and biomechanical assessments confirmed the fracture healing. The in vitro study using pre-osteoblastic MC3T3-E1 cells demonstrated that NTAPP irradiation under specific conditions did not reduce cell proliferation but did enhance osteoblastic differentiation. Overall, these results suggest that NTAPP is a novel approach to the treatment of bone fractures.

[Treatment of irreducible intertrochanteric femoral fracture in elderly by folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy]

Objective

To explore the effectiveness of irreducible intertrochanteric femoral fracture in the elderly by treating with folding top technique and right-angle pliers prying and pulling under G-arm X-ray fluoroscopy.

Methods

The clinical data of 74 elderly patients with irreducible intertrochanteric femoral fracture admitted between February 2016 and December 2022 and met the selection criteria were retrospectively analyzed. Among them, 38 cases were treated with folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy and intramedullary nailing fixation (study group), and 36 cases were treated with limited open reduction combined with other reduction methods and intramedullary nailing fixation (control group). There was no significant difference in baseline data between the two groups, such as age, gender, cause of injury, affected side and classification of fractures, complicated medical diseases, and time from injury to operation ( P>0.05). The operation time, intraoperative blood loss, hospital stay, fracture reduction time, fracture healing time, and complications of the two groups were recorded and compared. The quality of fracture reduction was evaluated by Baumgaertner et al. and Chang et al. fracture reduction standards.

Results

Patients in both groups were followed up 10-14 months, with an average of 12 months. The operation time and intraoperative blood loss in the study group were significantly less than those in the control group ( P<0.05), there was no significant difference in hospital stay between the two groups ( P>0.05). At 2 days after operation, according to the fracture reduction standards of Baumgaertner et al. and CHANG Shimin et al., the quality of fracture reduction in the study group was better than that in the control group, and the fracture reduction time in the study group was shorter than that in the control group, with significant differences ( P<0.05). After operation, the fractures of the two groups all healed, and there was no significant difference in healing time between the two groups ( P>0.05). During the follow-up, there was no complication such as incision infection, internal fixation failure, deep venous thrombosis of lower limbs, intramedullary nail breakage, spiral blade cutting, or hip varus in the two groups, except for 2 cases of coxa vara in the control group.

Conclusion

For the irreducible intertrochanteric femoral fracture, using folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy can obviously shorten the operation time, reduce the intraoperative blood loss, and improve the quality of fracture reduction.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Tenascin-C promotes endochondral ossification and fracture healing through Hedgehog and Hippo signaling

Fractures are frequent and severe musculoskeletal injuries. This study aimed to investigate the function of tenascin-C (TNC) in regulating chondrogenic during fracture healing and elucidate the underlying molecular mechanisms. A well-established femur fracture model in male C57BL/6J mice was used to transect the middle diaphysis of the femur. To identify the essential role of TNC, shTNC lentiviruses or TNC protein were administered in the animal model. Micro-CT analysis, histologic analysis, immunostaining assays, and gene expression analysis were employed to investigate the effect of TNC during fracture healing. An in vitro mesenchymal stem cell culture system was developed to investigate the role and molecular mechanism of TNC in regulating chondrogenesis. TNC expression was induced at the inflammatory phase and peaked at the cartilaginous callus phase during fracture healing. Knockdown of TNC expression in callus results in decreased callus formation and impaired fracture healing. Conversely, administration of exogenous TNC promoted chondrogenic differentiation, cartilage template formation and ultimately improved fracture healing. Both the Hedgehog and Hippo signaling pathways were found to be involved in the pro-chondrogenic function of TNC. Our observations demonstrate that TNC is a crucial factor responsible for endochondral ossification in fracture healing and provide a potential therapeutic strategy for promoting fracture healing.

Is there a role for N1-N2 neutrophil phenotypes in bone regeneration? A systematic review

PURPOSE

This review aims to provide an overview of the multiple functions of neutrophils, with the recognition of the inflammatory (N1) and regenerative (N2) phenotypes, in relation to fracture healing.

METHODS

A literature search was performed using the PubMed database. The quality of the articles was evaluated using critical appraisal checklists.

RESULTS

Thirty one studies were included in this review. These studies consistently support that neutrophils exert both beneficial and detrimental effects on bone regeneration, influenced by Tumor Necrosis Factor-α (TNF-α), Interleukin 8 (IL-8), mast cells, and macrophages. The N2 phenotype has recently emerged as one promoter of bone healing. The N1 phenotype has progressively been connected with inflammatory neutrophils during fracture healing.

CONCLUSIONS

This review has pinpointed various aspects and mechanisms of neutrophil influence on bone healing. The recognition of N1 and N2 neutrophil phenotypes potentially shed new light on the dynamic shifts taking place within the Fracture Hematoma (FH).

The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases

PURPOSE

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries.

METHODS

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

RESULTS

The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results.

CONCLUSION

Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

Biomechanical Effects of Mechanical Stress on Cells Involved in Fracture Healing

Fracture healing is a complex staged repair process in which the mechanical environment plays a key role. Bone tissue is very sensitive to mechanical stress stimuli, and the literature suggests that appropriate stress can promote fracture healing by altering cellular function. However, fracture healing is a coupled process involving multiple cell types that balance and limit each other to ensure proper fracture healing. The main cells that function during different stages of fracture healing are different, and the types and molecular mechanisms of stress required are also different. Most previous studies have used a single mechanical stimulus on individual mechanosensitive cells, and there is no relatively uniform standard for the size and frequency of the mechanical stress. Analyzing the mechanisms underlying the effects of mechanical stimulation on the metabolic regulation of signaling pathways in cells such as in bone marrow mesenchymal stem cells (BMSCs), osteoblasts, chondrocytes, and osteoclasts is currently a challenging research hotspot. Grasping how stress affects the function of different cells at the molecular biology level can contribute to the refined management of fracture healing. Therefore, in this review, we summarize the relevant literature and describe the effects of mechanical stress on cells associated with fracture healing, and their possible signaling pathways, for the treatment of fractures and the further development of regenerative medicine.

External fixator versus Ilizarov external fixator for pediatric tibial shaft fractures: A retrospective comparative study

INTRODUCTION

External fixators (EF) are widely employed for pediatric tibial shaft fractures, being a prevalent choice in clinical practice. However, they are associated with numerous complications, such as loss of reduction, delayed union, and nonunion. An alternative approach involves the use of Ilizarov external fixators (IEF), which have been documented in the treatment of tibial shaft fractures in various studies. This study endeavors to retrospectively compare the clinical outcomes of EF and IEF in the treatment of pediatric tibial shaft fractures.

METHODS

The study retrospectively examined patients aged 5-14 years who underwent treatment for tibial shaft fractures at our institute between January 2017 and January 2023. These individuals were subsequently classified into EF and IEF groups. Exclusions comprised patients presenting with pathological fracture, neuromuscular disorder, metabolic disease, prior tibial fracture or instrumentation, and polytrauma. Additionally, individuals with a follow-up duration of more than 12 months or incomplete medical records were excluded.

RESULTS

A total of 45 patients were divided into two groups: the EF group, comprising 24 patients (18 males, 6 females), and the IEF group, consisting of 21 patients (17 males, 4 females). The two groups exhibited no statistically significant differences in terms of sex, age, body weight, time from injury to surgery, AO classification, or concomitant injuries. There were two cases of nonunion in the EF group. Radiological union occurred more rapidly in the IEF group (7.8 ± 0.4 weeks) than in the EF group (9.3 ± 1.1 weeks) (P < 0.05). The mean hospitalization duration differed significantly between the EF group (6.7 ± 3.4 days) and the IEF group (7.5 ± 1.1 days) (P > 0.05). The mean duration of the operative procedure significantly differed between the IEF group (147.8 ± 24.5 min) and the EF group (77.2 ± 43.9 min) (P < 0.001). A significant difference (P < 0.001) in weight-bearing time was observed between the IEF group (2.6 ± 0.7 weeks) and the EF group (9.9 ± 1.4 weeks). According to the Johner-Wruhs criteria, no significant differences were found between the two groups. A significant difference (P < 0.001) in hospitalization costs was observed between the IEF group (7848.0 ± 262.4 $) and the EF group (5403.0 ± 233.3 $).

CONCLUSION

EF is cheaper, quicker and simpler and we need more randomized controlled studies and that this is a pilot study only. Both types of surgery are good choices for children. Nevertheless, the IEF group demonstrates advantages such as early weight-bearing capability and faster fracture healing.

Sildenafil delays bone remodeling of fractured femora in aged mice by reducing the number and activity of osteoclasts within the callus tissue

The elderly exhibit a reduced healing capacity after fracture, which is often associated with delayed or failed bone healing. This is due to a plethora of factors, such as an impaired bone vascular system and delayed angiogenesis. The phosphodiesterase-5 (PDE-5) inhibitor sildenafil exerts pro-angiogenic and pro-osteogenic effects. Hence, we herein investigated in aged mice whether sildenafil can improve fracture healing. For this purpose, 40 aged CD-1 mice (16-18 months) were daily treated with 5 mg/kg body weight sildenafil (n = 20) or vehicle (control, n = 20) by oral gavage. The callus tissue of their femora was analyzed at 2 and 5 weeks after fracture by X-ray, biomechanics, micro-computed tomography (µCT), histology, immunohistochemistry as well as Western blotting. These analyses revealed a significantly increased bone volume and higher ratio of callus to femoral bone diameter in sildenafil-treated mice at 5 weeks after fracture when compared to controls. This was associated with a reduced number and activity of osteoclasts at 2 weeks after fracture, most likely caused by an increased expression of osteoprotegerin (OPG). Taken together, these findings indicate that sildenafil does not improve fracture healing in the elderly but delays the process of bone remodeling most likely by reducing the number and activity of osteoclasts within the callus tissue.

Fracture gap and working length are important actionable factors affecting bone union after minimally invasive plate osteosynthesis for the treatment of simple diaphyseal or distal metaphyseal tibia fractures

INTRODUCTION

Indirect reduction of minimally invasive plate osteosynthesis (MIPO) can often result in delayed union in tibia fractures. This study evaluated several factors in MIPO in relation to bone union.

HYPOTHESIS

We hypothesized that the fracture gap, plate - tibia distance, or working length would have a substantial effect on the tibia union rate.

MATERIALS AND METHODS

Forty-one patients with simple diaphyseal or distal metaphyseal tibia fractures who underwent internal fixation surgery using the MIPO technique were divided into two groups: patients with delayed union and patients without delayed union. Non-actionable factors involving AO/OTA classification, fibula fracture and actionable factors including postoperative fracture gap, plate - tibia distance, working length in relation to parameters of bone union were compared between the two groups. Also cumulative rates of bone union and risk factors of delayed union according to variables of interest were investigated.

RESULTS

AO/OTA classification, site of fibula fracture, postoperative fracture gap, working length, and bone union rate of the two groups significantly differed (p<0.05). The cumulative rate of bone union during 1-year follow-up according to 43A tibia fracture, distal fibula fracture, fracture gap, and working length significantly differed between the two groups (p<0.05). By univariate Cox proportional hazards model, 43A tibia fracture, distal fibula fracture, facture gap, and short working length were risk factors for delayed union (p<0.05).

DISCUSSION

Non-actionable factors involving AO/OTA classification, distal fibula fracture and actionable factors including postoperative fracture gap, working length were significant factors affecting bone union after MIPO. The present study indicated that small fracture gap and long working length during MIPO might facilitate bone healing in tibia fracture.

LEVEL OF EVIDENCE

IV; single-center retrospective cohort study.

Biomechanical comparison of headless compression screws versus independent locking screw for intra-articular fractures

PURPOSE

Headless compression screws (HCS) have a variable thread pitch and headless design enabling them to embed below the articular surface and generate compression force for fracture healing without restricting movement. Locking screws have greater variety of dimensions and a threaded pitch mirroring the design of the HCS. The objective of this study is to determine whether locking screws can generate compression force and compare the compressive forces generated by HCS versus locking screws.

METHOD

A comparison between 3.5-mm HCS versus 3.5-mm locking screws and 2.8-mm HCS versus 2.7-mm locking screws was performed using a synthetic foam bone model (Synbone) and FlexiForce sensors to record the compression forces (N). The mean peak compression force was calculated from a sample of 3 screws for each screw type. Statistical analysis was performed using the one-way ANOVA test and statistical significance was determined to be p =  < 0.05.

RESULTS

The 3.5-mm Synthes and Smith and Nephew locking screws generated similar peak compression forces to the 3.5-mm Acutrak 2 headless compression screws with no statistically significant difference between them. The smaller 2.7-mm Synthes and Smith and Nephew locking screws initially generated similar compressive forces up to 1.5 and 2 revolutions, respectively, but their peak compression force was less compared to the 2.8-mm Micro Acutrak 2 HCS.

CONCLUSION

Locking screws are able to generate compressive forces and may be a viable alternative to headless compressive screws supporting their use for intra-articular fractures.

Conservative treatment versus transverse pinning in fifth metacarpal neck fractures in active adults: a randomized controlled trial

PURPOSE

Compare two simple ways for treating boxer's fractures in active adults; conservative management by ulnar gutter slab and transverse pinning in fixation of fifth metacarpal's neck fracture regarding union, functional outcomes, and complications.

PATIENTS AND METHODS

Ninety patients with fifth metacarpals' neck fractures with palmar angulation (30-70°) were managed either conservatively by an ulnar gutter slab or surgically by transverse pinning technique from January 2020 to December 2021. Only 84 patients completed a 1-year follow-up. Patients with old, open, or mal-rotated fractures were excluded. The block-randomization method was used to create equal groups. Patients were evaluated clinically and radiologically every 2-3 weeks until union, then at 6 and 12 months. Functional assessment at the final visit was done using the quick DASH score, total active motion (TAM), and total Active Flexion (TAF).

RESULTS

The mean radiological union time for the conservative group in this study was 7.76 weeks, while for the transverse pinning group, it was 7.38 weeks. There was no statistically significant difference between the two techniques regarding union rates and functional outcomes. All patients returned to their pre-injury jobs and level of activity.

CONCLUSION

Both conservative management in ulnar gutter slab and percutaneous transverse pinning are considered effective methods in the treatment of simple extra-articular fifth metacarpal neck fractures with angulation between 30 and 70 degrees (AO: 77 A3.1). The functional and radiological results using both methods were satisfactory and statistically comparable.

MAGP2 promotes osteogenic differentiation during fracture healing through its crosstalk with the β-catenin pathway

Osteogenic differentiation is important for fracture healing. Microfibrial-associated glycoprotein 2 (MAGP2) is found to function as a proangiogenic regulator in bone formation; however, its role in osteogenic differentiation during bone repair is not clear. Here, a mouse model of critical-sized femur fracture was constructed, and the adenovirus expressing MAGP2 was delivered into the fracture site. Mice with MAGP2 overexpression exhibited increased bone mineral density and bone volume fraction (BV/TV) at Day 14 postfracture. Within 7 days postfracture, overexpression of MAGP2 increased collagen I and II expression at the fracture callus, with increasing chondrogenesis. MAGP2 inhibited collagen II level but elevated collagen I by 14 days following fracture, accompanied by increased endochondral bone formation. In mouse osteoblast precursor MC3T3-E1 cells, MAGP2 treatment elevated the expression of osteoblastic factors (osterix, BGLAP and collagen I) and enhanced ALP activity and mineralization through activating β-catenin signaling after osteogenic induction. Besides, MAGP2 could interact with lipoprotein receptor-related protein 5 (LRP5) and upregulated its expression. Promotion of osteogenic differentiation and β-catenin activation mediated by MAGP2 was partially reversed by LRP5 knockdown. Interestingly, β-catenin/transcription factor 4 (TCF4) increased MAGP2 expression probably by binding to MAGP2 promoter. These findings suggest that MAGP2 may interact with β-catenin/TCF4 to enhance β-catenin/TCF4's function and activate LRP5-activated β-catenin signaling pathway, thus promoting osteogenic differentiation for fracture repair. mRNA sequencing identified the potential targets of MAGP2, providing novel insights into MAGP2 function and the directions for future research.

Zone 2 Fifth Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively

OBJECTIVES

To quantify the rate of union and time to clinical and radiographic healing in Zone 2 proximal fifth metatarsal (MT) fractures and compare these outcomes between Zone 2 fractures treated operatively and nonoperatively.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center.

PATIENT SELECTION CRITERIA

Patients with fifth MT fractures who presented between December 2012 and April 2022 and confirmed to have Zone 2 fractures (defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view) were included in the study analysis in either the operative or nonoperative cohort.

OUTCOME MEASURES AND COMPARISONS

Nonunion, time to clinical healing by, and time to radiographic healing between operative and nonoperative treatment.

RESULTS

Among the 499 included patients, 475 patients (95.2%) were initially treated nonoperatively and 24 patients (4.8%) were treated operatively. Both groups were similar in demographics. There was no difference in the proportion of patients with nonunions between groups (6.1% in the nonoperative group vs. 3.8% in the operative group, P = 1.000). In addition, there was no statistically significant difference between groups with respect to the time to clinical healing (9.9 ± 8.3 weeks for the nonoperative group vs. 15.4 ± 15.0 weeks for the operative group, P = 0.117) or the time to radiographic healing (18.7 ± 12 weeks for the nonoperative group vs. 18.5 ± 16.6 weeks for the operative group, P = 0.970).

CONCLUSIONS

Zone 2 fifth MT base fractures were successfully treated with nonoperative management. There was no evidence in this study that operative treatment leads to significantly faster clinical or radiographic healing.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Not Just Small Adults: Operative Versus Nonoperative Treatment in Adolescent Tibial Shaft Fractures

BACKGROUND

The standard of care for tibial shaft fractures in young children is nonoperative management, while in adults, operative treatment is considered the mainstay. There are no clear guidelines on preferred treatment for adolescents.

PURPOSE

This paper aims to 1) identify clinical and radiographic characteristics predictive of malalignment and 2) determine if treatment type affects malalignment risk.

METHODS

This retrospective cohort study identified patients aged 12 to 16 years old with a tibial shaft fracture at a Level 1 pediatric trauma center. The primary outcome of interest was malalignment, classified as meeting one or more of the following: >5° coronal angulation, >5° sagittal angulation, translation (cortical width or 100% displaced), and/or rotational deformity. Comparative analyses were done to identify risk factors for malalignment.

RESULTS

A total of 162 patients were included-initial treatment was "planned nonoperative" for 102 patients and "planned operative" for 60 patients. The malalignment rate was 34% in the planned nonoperative group versus 32% in the planned operative group. In a multivariate regression, older patients [odds ratio (OR)=-0.07, 95% CI: -0.13 to -0.01; P =0.024] and those with 100% initial displacement (OR=-0.35, 95% CI: -0.64 to -0.05; P =0.021) had decreased odds of malalignment, and having increased sagittal angulation (OR=0.02, 95% CI: 0.01-0.04; P =0.002) and a fibula fracture (OR=0.22, 95% CI: 0.03-0.41; P =0.023) increased the odds of malalignment. There was no difference in the rate of malalignment by initial treatment ( P =0.289). Having a planned nonoperative treatment (OR=22.7, 95% CI: 14.0-31.5; P <0.001) and having a fibula fracture (OR=8.52, 95% CI: 0.59-16.45; P =0.035) increased the time immobilized.

CONCLUSIONS

This study provides insight into factors affecting tibial shaft fracture alignment among patients aged 12 to 16 years. This study suggests that the risk of malalignment is higher among patients with increased initial sagittal angulation and concomitant fibula fractures, but the risk of malalignment is comparable in patients initially treated nonoperatively and operatively. Although healing parameters on average were similar, nonoperative treatment results in longer immobilization time and time for unrestricted weight bearing.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Photodynamic bone stabilization for traumatic and pathologic fractures: a systematic review of utilization, complications, and patient-reported outcomes

INTRODUCTION

The photodynamic bone stabilization system (PBSS) was was developed in 2010, and in 2018 gained FDA approval in the United States. Given its relative novelty, our analysis sought to analyze the available literature exploring the indications, outcomes, and complications of the PBSS.

METHODS

We performed a systematic review (PROSPERO registration of study protocol: CRD42022363065, October 8th, 2022). PubMed, EBSCOHost, and Google Scholar electronic databases were queried to identify articles evaluating PBSS in the treatment of pathologic or traumatic fractures between January 1 2010 and 15 October 2022. The quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies tool.

RESULTS

Our initial search yielded 326 publications, which were then screened for appropriate studies that aligned with the purpose of our review. A total of thirteen studies, comprising seven case series, four case reports, and two cohort studies. The total sample size of the included studies consisted of 345 patients, with 242 females (70%) and 103 males (30%). The implants were most commonly utilized in the humerus (41%), radius (12%), and metacarpal (12%). The most common complications were related to broken implants (5%) and dislocation (1%). Most studies reported complete fracture healing and return of full strength and range of motion.

CONCLUSION

Despite being a relatively novel technology, PBSS appears to be a viable option for fracture stabilization. Most studies included in our analysis reported complete fracture healing and return of function with minimal complications.

Operative versus non-operative treatment of extra-articular distal humeral shaft fractures: a retrospective comparative study evaluating clinical and radiological outcomes

PURPOSE

There is limited evidence for comparing operative and non-operative management of closed, extra-articular distal humeral shaft fractures. This study aims to evaluate these outcomes.

METHODS

A comparative retrospective study was performed for patients who underwent either operative fixation or conservative management with a humeral brace, with clinical and radiological outcomes at minimum 2-year follow-up.

RESULTS

Forty-two patients with median 4.6 years follow-up were included; 24 had surgical fixation and 18 were managed with humeral brace. Assessment of clinical and radiological outcomes demonstrated few statistically significant functional differences between the two groups. Surgical patients achieved faster union for non-comminuted fractures. All patients maintained functional range of motion, with similar complication rates.

CONCLUSION

This study suggests that similar outcomes can be achieved with both managements, though faster union times may be seen in the operative group. Further studies are recommended to evaluate the impact of fracture comminution causing delayed unions.

MiR-22-3p facilitates bone marrow mesenchymal stem cell osteogenesis and fracture healing through the SOSTDC1-PI3K/AKT pathway

Bone fractures are the most common form of musculoskeletal trauma worldwide. Numerous microRNAs (miRNAs) have been suggested to be participants in regulating bone-related diseases. Recent studies revealed the regulatory role of miR-22-3p in osteogenic differentiation, but its role in fracture healing has not been investigated previously. Here, a rat femoral fracture model was established, Bone marrow mesenchymal stem cells (BMSCs) were isolated to detect the specific function and underlying mechanisms of miR-22-3p. MiR-22-3p and sclerostin domain-containing 1 (SOSTDC1) expression was determined by RT-qPCR and immunohistochemistry staining. The levels of proteins associated with osteogenic differentiation were assessed by western blotting. Flow cytometry was conducted to identify the isolated rat BMSCs. Alizarin red staining, alkaline phosphatase staining and Oil Red O staining were used to evaluate the osteogenic and adipogenic differentiation of rat BMSCs. The interaction between miR-22-3p and SOSTDC1 was verified using a luciferase reporter assay. Haematoxylin and Eosin (H&E) staining of the bone tissues was performed to analyse the effect of miR-22-3p on histopathological changes in vivo. MiR-22-3p was downregulated in the callus tissues of rat femoral fracture, while the expression of SOSTDC1 was upregulated. The isolated rat BMSCs had the capacity for both osteogenic and adipogenic differentiation. The differentiation capacity of BMSCs into osteoblasts was increased by miR-22-3p overexpression. MiR-22-3p activated the PI3K/AKT pathway by targeting SOSTDC1. SOSTDC1 overexpression and PI3K/AKT signalling inhibitor LY294002 abolished the enhancing effect of miR-22-3p overexpression on the osteogenesis of BMSCs. Thus MiR-22-3p facilitated the femoral fracture healing in rats. MiR-22-3p overexpression promoted fracture healing via the activation of PI3K/AKT pathway by targeting SOSTDC1.

A magnesium screw with optimized geometry exhibits improved corrosion resistance and favors bone fracture healing

Stress-induced corrosion impairs the mechanical integrity of magnesium (Mg) and its alloys as potential orthopedic implants. Although there has been extensive work reporting the effects of stress on Mg corrosion in vitro, the geometric design principles of the Mg-based orthopedic devices still remain largely unknown. In this work, a numerical simulation model mimicking fractured bone fixation and surgical animal models were applied to investigate the effects of the geometric design of Mg screws on the stress distribution and the stress-induced degradation behavior. Finite element (FE) analysis was used for calculation of stress concentrations around the Mg screws, with different thread type, thread pitch, and thread width. Afterward, the Mg screws of the pre-optimization and post-optimization groups exhibiting the highest and lowest stress concentrations, respectively, were implanted in the fractured distal femora and back subcutaneous tissue of rabbits. Encouragingly, there was a significant difference between the pre-optimization and the post-optimization groups in the degradation rate of the stressed screw parts located around the fracture line. Interestingly, there was no significant difference between the two groups in the degradation rate of the non-stressed screw parts. Consistently, the Mg screw post-optimization exhibited a significantly lower degradation rate than that pre-optimization in the back subcutaneous implantation model, which generated stress in the whole screw body. The alteration in geometric design did not affect the corrosion rate of the Mg screws in an immersion test without load applied. Importantly, an accelerated new bone formation with less fibrous encapsulation around the screws was observed in the Mg group post-optimization relative to the Mg group pre-optimization and the poly (lactic acid) group. Geometry optimization may be a promising strategy to reduce stress-induced corrosion in Mg-based orthopedic devices. STATEMENT OF SIGNIFICANCE: Stress concentrations influence corrosion characteristics of magnesium (Mg)-based implants. The geometric design parameters, including thread type, thread pitch, and thread width of the Mg screws, were optimized through finite element analysis to reduce stress concentrations in a fractured model. The Mg screws with triangular thread type, 2.25 mm pitch, and 0.3 mm thread width, exhibiting the lowest maximum von Mises stress, showed a significant decrease in the volume loss relative to the Mg screws pre-optimization. Compared with the Mg screw pre-optimization and the poly(lactic acid) screw, the Mg screw post-optimization favored new bone formation while inhibiting fibrous encapsulation. Collectively, optimization in the geometric design is a promising approach to reduce stress-induced corrosion in Mg-based implants.