Effectiveness of Locked Nailing for Displaced Three-Part Proximal Humeral Fractures

BACKGROUND

Published reports about locked nailing for displaced comminuted proximal humeral fractures are few and the results contradictory.

METHODS

Locked nailing was used to treat 27 selective patients with displaced three-part proximal humeral fractures. The average age of patients was 54.3 years. The operative indications were persistent severe displacement, intact or minimally displaced lesser tuberosity, tolerance of anesthesia, and adherence to rehabilitation programs. Three patients had associated shoulder dislocation and two had fractures with diaphyseal extension. By transdeltoid approach, the fractures were reduced and then fixed by antegrade nailing with either upward or downward locking screws. The patients were prospectively followed up for an average of 24 months.

RESULTS

All fractures achieved eventual union. Three patients with proximal screw loosening required screw removal. On the basis of Neer criteria, excellent or satisfactory results were obtained in 21 patients whose scores averaged 87.5 points. Six patients had unsatisfactory outcomes, with an average of 75.8 points. Two patients with the complication of avascular necrosis still had a satisfactory outcome. Varus deformity of shoulder joints, deformity of the greater tuberosity, collapse of the humeral head, and old age could adversely affect shoulder elevation. However, the anatomic abnormalities might have limited effects on the pain scale, muscle power, and shoulder stability.

CONCLUSIONS

Locked nailing can be an effective treatment for selected severely displaced three-part proximal humeral fractures. It is particularly useful for fractures with diaphyseal involvement. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful treatment results.

The usefulness of computed tomography following open reduction and internal fixation of acetabular fractures

PURPOSE

To investigate the role of a supplemental imaging modality in postoperative assessment of acetabular fractures following open reduction and internal fixation.

METHODS

Postoperative axial computed tomographic (CT) scans were compared with plain radiographs of 20 patients with regard to their sensitivity for detecting articular fracture reduction in terms of gap displacement and step deformity or offset. Three observers independently reviewed the plain radiographs and CT scans at 2 separate time points and categorised the outcome as either anatomical or non-anatomical. The inter-observer reliability and intra-observer reproducibility of these measurements was expressed as a kappa statistic. The radiological result was correlated with the clinical outcome measures using the Merle D'Aubigne scale, the Harris Hip Score, and the SF-36 score.

RESULTS

Plain radiography was less effective in the detection of postoperative articular displacement (mean, 75.1% sensitive). The inter-observer and intra-observer agreement between reviewers was good to excellent in detecting reduction quality between the 2 modalities. Patient management was not altered by the findings of the CT scans.

CONCLUSIONS

Although postoperative CT scanning of acetabular fractures in selective cases may be useful, issues such as higher cost, less effective allocation of resources, and excessive radiation doses do not support its routine use.

Three-dimensional reconstruction of fracture callus morphogenesis

Rat and mouse femur and tibia fracture calluses were collected over various time increments of healing. Serial sections were produced at spatial segments across the fracture callus. Standard histological methods and in situ hybridization to col1a1 and col2a1 mRNAs were used to define areas of cartilage and bone formation as well as tissue areas undergoing remodeling. Computer-assisted reconstructions of histological sections were used to generate three-dimensional images of the spatial morphogenesis of the fracture calluses. Endochondral bone formation occurred in an asymmetrical manner in both the femur and tibia, with cartilage tissues seen primarily proximal or distal to the fractures in the respective calluses of these bones. Remodeling of the calcified cartilage proceeded from the edges of the callus inward toward the fracture producing an inner-supporting trabecular structure over which a thin outer cortical shell forms. These data suggest that the specific developmental mechanisms that control the asymmetrical pattern of endochondral bone formation in fracture healing recapitulated the original asymmetry of development of a given bone because femur and tibia grow predominantly from their respective distal and proximal physis. These data further show that remodeling of the calcified cartilage produces a trabecular bone structure unique to fracture healing that provides the rapid regain in weight-bearing capacity to the injured bone.

Interlocking nailing of forearm fractures

INTRODUCTION

With the exception of forearm fractures, intramedullary techniques are preferred for osteosynthesis in the case of long-bone fractures. For the latter, however, the main problem remains insufficient stability against torsional forces resulting in high rates of non-union. This is why plate osteosynthesis by means of a DCP 3.5 or LC-DCP 3.5 is still being described as the standard procedure.

MATERIALS AND METHODS

In a prospective study, 32 patients (33 forearms) with fractures of one or both forearm bones were treated by implantation of 40 intramedullary ForeSight nails (ulna: 23; radius: 17). Clinical and radiographic follow-up was performed at 6, 12, 26, and--if needed--52 weeks postoperatively. Time to follow-up was 31.4 months on average (range 24-44 months).

RESULTS

The average time to fracture healing for 36 fractures of 29 patients was 4.4 months. A free range of motion was seen in 86%, and only four forearms had a loss of pronation and supination. DASH score averaged at 13.7. There were few complications: non-union 1, delayed union 2, radioulnar synostosis 2, and infections 0. No refracture was seen after 19 implant removals so far. Average time needed per operation was 67 min, average time for fluoroscopy was 4.4 min.

CONCLUSION

This intramedullary nail can do justice to the specific anatomical needs in the case of the forearm. Static interlocking guarantees adequate stability in all fracture types. The surgical technique is demanding. Nonetheless, this system can yield results of comparable quality to those of plate osteosynthesis. So far, no refractures after removal of the implants and no complications connected with the actual implants have been observed.

Treatment of volar Barton's fractures: comparison between two common surgical techniques

BACKGROUND

Volar Barton's fractures are not uncommon but more convincing treatment methods are still controversial. Currently, open reduction with buttress plating or closed reduction with external fixation and percutaneous Kirschner wire fixation have achieved most support.

METHODS

Twenty-three consecutive volar Barton's fractures treated with either open reduction and buttress plate fixation (12 cases) or closed reduction with external fixation and percutaneous Kirschner wire fixation (11 cases) were compared retrospectively. The fractures were followed-up for a mean of 30 months (range, 24-50 months).

RESULTS

All 23 fractures healed without major complications. The wrist function was satisfactory in all plating patients (12 out of 12) and nine out of 11 external fixation patients (p = 0.22).

CONCLUSION

Both the above mentioned surgical techniques give a high success rate. Despite the fact that each technique has advantages and disadvantages, the results from the plating treatment seem to be superior.

Muscle strength recovery and its effects on outcome after open reduction and internal fixation of acetabular fractures

OBJECTIVE

To determine the relationship between muscle strength recovery and functional outcome in patients who were treated for an acetabular fracture via an anterior approach.

DESIGN

Case series.

SETTING

University Medical Center.

PATIENTS

Fifteen patients with a displaced acetabular fracture treated via an anterior, ilioinguinal approach were studied. Hip muscle strength of these patients was then compared with the muscle strength of a similar group of patients treated via a Kocher-Langenbeck approach (posterior approach). These patient groups were then combined and muscle strength recovery was compared with the functional outcome.

MAIN OUTCOME MEASURE

Primary outcome measures included hip muscle strength, including work (J/min) and maximum torque (Nm/kg) for abductors/adductors and flexors/extensors. Clinical outcome was assessed with the Musculoskeletal Function Assessment (MFA) questionnaire and the results correlated with muscle strength. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, severity of heterotopic ossification, and range of motion of the affected and unaffected hips.

RESULTS

At an average follow-up of 44 months, patients treated via an anterior approach had an overall muscle strength deficit of 9%. Hip extension strength was affected to the least extent (6% deficit when compared with the unaffected hip) whereas abduction, adduction, and flexion strength was affected to a greater degree. For each measure the affected side was typically weaker than the unaffected side. The average MFA score for the anterior approach group was 17 (range, 0 to 47) with most patients reporting poorest results in those domains assessing activities of the arms and legs, and those involving life changes and feelings. When MFA scores were compared with the muscle strength, a relationship was found between hip extension/flexion work and maximum torque and hip adduction work and maximum torque and MFA score. For each of these muscle groups, patients reported worsening function with decreased muscle strength. Assessment of the most recent radiographs revealed 9 patients with an excellent radiographic grade, 3 patients with a good grade, 1 patient with a fair grade, and 2 patients with a poor grade. Hip range of motion was not statistically different when the affected hip was compared with the unaffected hip, and none of these variables correlated with outcome. Heterotopic ossification was found in 8 patients; 4 with grade 1, and 4 with grade 2.

CONCLUSIONS

Standardized muscle strength determination and completion of an MFA questionnaire provided a thorough evaluation of patients who had undergone open reduction and internal fixation of a displaced acetabular fracture. In these patients, hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome. Therefore, in order to maximize the outcome of these patients, particular attention must be paid to postoperative muscle strengthening protocols and accurate and validated methods to assess strength and outcomes.

Assessment of Bone Union/Nonunion in an Experimental Model Using Microcomputed Technology

BACKGROUND

High-resolution microcomputed tomography (microCT) is one of the most recent technical developments to visualize and quantify primarily cancellous bone. Regarding bone formation, microCT is becoming increasingly important, although its reliability has not yet been evaluated. Our study had two goals: to develop a reproducible nonunion model and to determine the efficacy of microCT for the assessment of bone healing in this model.

METHODS

The designed fracture model in the rat simulates secondary fracture healing. After plate fixation to the femur, diaphysis transverse middiaphyseal osteotomy was performed with a reciprocating saw, resulting in a 0.38-mm gap with a defect of bone and periosteum corresponding to the thickness of the blade. Proximally and distally to this gap, the periosteum was preserved. Thus, three separate zones were defined: proximal femur diaphysis with periosteum, gap, and distal femur diaphysis with periosteum. In the nonunion group (NM group), a model of impaired bone healing (nonunion), silicone foil was wrapped around the femur diaphysis to block any influence from surrounding tissue. Coverage of the bone repair site by thigh muscles was designed for a model of bone union (M group). Four weeks postoperatively, callus formation was determined by conventional anterior-posterior and lateral plain radiographs. Ten weeks later, a second x-ray series was done as the clinical standard evaluation method. Afterward, specimens were harvested for microCT examination (two-dimensional and three-dimensional [3D]). Biomechanical testing was carried out to determine fracture healing.

RESULTS

Our model is highly reproducible and results in bone nonunion in five out of six cases (83.3%). In determining fracture site, plain radiographs the least reliable method in comparison to the biomechanical testing which is the most accurate reference method. In contrast, microCT (the 3D reconstruction) showed significant correlation (r = 1) to the results assessed by biomechanical testing, whereas microCT was correct in 100%. We found bone healing in five out of six animals in the M group verified by microCT (in accordance to biomechanical data). In the M group, significantly enhanced bone formation (50%) (p = 0.008) was observed within the osteotomy site (i.e. within the gap), but there was no difference in periosteal bone formation between the groups proximally and distally to the gap. Interestingly, we did not find statistically significant differences in mineralization.

CONCLUSION

We conclude that microCT with 3D reconstruction is the optimal method diagnostic tool in fracture healing, especially in nonunion. Furthermore, direct coverage of the fracture site by muscle flaps results in a mineralized enhanced bone formation within the osteotomy site (i.e. within the gap). Skeletal muscle coverage hypothetically might have osteogenic augmentation potential, thus being able to prevent pseudoarthrosis.

[Treatment of comminuted fractures at distal femur and proximal tibia with less invasive stabilization systems]

OBJECTIVE

To study the clinical outcome of comminuted fractures at distal femur and proximal tibia treated with AO less invasive stabilization systems (LISS).

METHODS

The clinical data of 14 cases of distal femoral fracture and proximal tibial fracture from September 2003 to May 2005 were analyzed retrospectively. The injury was caused by traffic accident in 9 cases, by fall in 3 cases and by slipping in 2 cases. Of 14 cases, there were 5 open fractures and 9 close fractures, including 5 cases of distal femoral comminuted fracture and 9 cases of proximal shaft comminuted fractures. According to AO/OTA classification, the fractures were classified as 33C2 in 3 cases, 33C3 in 2 cases, 41A2 in 2 cases, 41A3 in 2 cases, 41B2 in 3 cases and 41C2 in 2 cases. All patients were treated by the internal fixation with LISS-distal femur or with LISS-proximal tibia. Healing of wounds, the X-ray films before and after operations, and the recovery of joint function were observed.

RESULTS

The patients were followed up from 1 month to 20 months (11 months on average). Twelve cases achieved solid osseous unions from 3 months to 5 months postoperatively; 2 cases had a good reduction and recovered smoothly 2-3 months postoperatively. The results were excellent in 10 cases, good in 3 cases and fair in 1 case according to Johner-Wruhs knee scoring. The range of knee flexion-extension was 110-130 degrees in 11 cases, 100 degrees in 2 cases and 80 degrees in 1 case.

CONCLUSION

LISS is an effective method of internal fixation for treating comminuted fracture of distal femur or proximal tibia. It has the advantages of less injury, satisfied reduction and reliable fixation.

Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing

BACKGROUND

Delayed union or nonunion of a fracture of the humerus is an infrequent but debilitating complication. Open reduction and internal fixation combined with autologous bone-grafting can result in reliable healing of the fracture; however, there is morbidity associated with the bone-graft donor site. This study was designed to evaluate healing of ununited fractures of the humeral shaft treated by one surgeon at one institution with a strict and consistent surgical protocol but with the use of two different types of bone graft: autologous iliac crest bone graft and demineralized bone matrix.

METHODS

A consecutive retrospective cohort series was analyzed. From 1992 to 1999, forty-five patients with an aseptic, atrophic delayed union or nonunion of a humeral shaft fracture were treated with open reduction and internal fixation with a plate and autologous iliac crest bone graft. The mean time from the fracture to the surgery was 14.0 months, and the mean duration of follow-up was 32.8 months. From 2000 to 2003, thirty-three patients with the same condition were treated with the same protocol with the exception that demineralized bone matrix was used instead of autologous iliac crest bone graft. The mean time from the fracture to the surgery in that group was 22.6 months, and the mean duration of follow-up was 20.4 months. All patients in both groups were assessed clinically and radiographically.

RESULTS

Osseous union was noted clinically and radiographically following the index surgery in 100% of the forty-five patients treated with autologous bone graft and 97% (thirty-two) of the thirty-three patients treated with demineralized bone matrix. The mean time to union was 4.5 months in the group treated with autologous bone graft and 4.2 months in the group treated with demineralized bone matrix. The overall functional outcome did not differ between the groups; however, twenty (44%) of the autologous bone-graft recipients had donor site morbidity, including a prolonged pain in the majority and a superficial infection requiring irrigation and débridement in one patient.

CONCLUSIONS

Healing of an ununited humeral shaft fracture can be achieved consistently with rigid plate fixation and lag-screw compression augmented with either autologous cancellous bone graft or commercially available demineralized bone matrix. The harvest of the autologous bone graft is frequently associated with complications.

LEVEL OF EVIDENCE

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

Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures

Recent reports have shown that some displaced supracondylar humerus fractures can be treated in a delayed fashion the day following injury and complication rates will not be increased. This study determined if the quality of the reduction, as determined by restoration of Baumann's angle, is affected by surgical timing. Forty two patients ranging in age from 2 to 12 years were treated. Delayed intervention was defined as > 8 hours post-injury. Acute intervention occurred in 25 patients with a mean age of 5.5 years. Delayed intervention occurred in 17 patients with a mean age of 5.8 years. Baumann's angle was restored to within an average of 2.2 degrees of the contralateral elbow in the acute group and to within 1.2 degrees in the delayed group. Gartland type 2 fractures were more likely to be delayed in this retrospective study and these fractures showed better improvements in Baumann's angle restoration than did type 3 injuries when treated in a delayed fashion. In type 2 injuries and type 3 injuries without neurovascular compromise, delaying operations until the next morning will not compromise the quality of the reduction.

Two cannulated hip screws for femoral neck fractures: treatment of choice or asking for trouble?

INTRODUCTION

Undisplaced intracapsular fractures are predominantly treated with a minimally invasive fixation technique, whereas the standard treatment for displaced intracapsular fractures is still a subject of discussion. The purpose of this study was to identify the determinants influencing the outcome of intracapsular femoral neck fractures, treated with two cannulated hip screws.

PATIENTS AND METHODS

From January 1998 through December 2002 data of all consecutive patients with an intracapsular femoral fracture, treated with two cannulated screws, were documented. Consolidation was chosen as the primary endpoint, mortality and a reoperation for replacement of osteosynthesis were defined secondary endpoints.

RESULTS

One hundred and twelve patients were included in the study. Fifty six percent of the intracapsular fractures healed within 1 year. Consolidation was accomplished in 95% of the stable fractures. Consolidation rates were negatively influenced by unstable fractures and inadequate anatomical reduction. The position of the screws did not influence consolidation rates. Reintervention rates were related to the number of local complications and the fracture type.

CONCLUSION

In conclusion, the results of this study show that in case of operative treatment, undisplaced femoral neck fractures can be adequately fixated by two cannulated hip screws. Unstable, anatomically reduced femoral neck fracture (Garden III/IV) may be treated with a more stable implant (e.g. DHS) to avoid redisplacement. If adequate reduction cannot be achieved, endoprosthetic replacement is recommended.

P-15 small peptide bone graft substitute in the treatment of non-unions and delayed union. A pilot clinical trial

Treatment of non-unions and delayed unions often requires osteogenic material. Recently, a biomimetic bone matrix that simulates the cellular environment of hard tissue, identified as P-15, was introduced to the orthopaedic community. A total of 22 patients with mal-union or delayed union fractures was treated from June 2000 to October 2003 with P15- bone graft substitute (P15-BGS) in the site of fracture and mostly with internal fixation. Patients were examined by independent radiographic analysis. Assessment criteria included time elapsed until bone bridging and time to full consolidation. In addition, histological assessment of the callus was done at the time of recovery of metal implants in five patients. Full consolidation was achieved in 90% (20 out of 22) of the patients treated with P15-BGS. The average time for full consolidation was 4.2 months. Histological assessment of the fracture callus in five of the patients confirmed the positive clinical and radiographic results. P15-BGS appears to offer a safe, economical and clinically useful alternative to autograft in the repair of ununited fractures. These results compare favourably with those in the published literature as an alternative to autograft.

Ipsilateral hip and femoral shaft fractures treated with intramedullary nails

This study retrospectively analysed 34 patients with ipsilateral hip and femoral shaft fractures treated over a period of 10 years between January 1995 and January 2005. They had an average age of 35 years. Twenty-six (76.47%) of these cases suffered high-velocity trauma (RTA); six others had fallen from a height (17.65%), and two had suffered only minimal trauma (5.88%). Twenty were extracapsular (58.82%) and 14 were intracapsular. They were evaluated with an average follow-up of 28 months, both clinically and radiologically; 26 patients (76.47%) had a good result (Friedman and Wyman score). When the intracapsular fracture was detected postperatively, there was one delayed union and one non-union. When the fracture is diagnosed preoperatively, we recommend reconstruction nail fixation. If the hip fracture is diagnosed intra- or postoperatively following nailing of the shaft, we propose the miss-a-nail technique as an option.

New biological method of internal fixation of the femur

One of the main goals in fracture treatment is reservation of both intramedular and periosteal vascularisation. The aim of this paper is to show a new method of internal fixation which accomplishes these goals. The paper presents the results of clinical application of Mitkovic Internal Fixator, new self-dynamisable device, which provides fixation of the femur using minimally invasive technique. This device has been investigated experimentally on 60 animals. It has been applied to 267 patients. Here is presented a series of 92 fixations of femoral diaphyses after fresh fractures and after unsuccessful treatment using other methods. Follow-up was 3.1 years (2 to 7 years). Bone healing was achieved in all patients within 3.5 months (2.7-9 months) with big amount of periosteal callus formation. There were no complications in all patients seen. It can be concluded that this method and device meet biological and biomechanical requirements for safe fracture treatment.

Augmented bone-matrix formation and osteogenesis under magnetic field stimulation in vivo XRD, TEM and SEM investigations

Bone is a composite biomaterial, which is formed, when proteins constituting collagen fibers attract calcium, phosphate and hydroxide ions in solution to nucleate atop the fibers. It grows into a hard structure of tiny crystallites of hydroxyapatite, aligned along the long axis of collagen fibers. The present work reports the stimulating effect of static magnetic field on microstructure and mineralization process of bone repair. A unilateral transverse fracture of mid-shaft of metacarpal was surgically created in healthy goats under thiopental sedation and xylocaine analgesia. Two bar magnets (approximately 800 gauss/cm2 field strength) were placed across the fracture line at opposite pole alignment immobilized in Plaster of Paris (POP) splint bandage for static magnetic field stimulation. Radiographs were taken at weekly intervals up to 45 days. Results show that formation of extra-cellular matrix and its microstructure can be influenced by non-invasive physical stimulus (magnetic field) for achieving an enhanced osteogenesis, leading to quicker regeneration of bone tissue in goats. X-ray diffraction (XRD) patterns of treated (magnetic field-exposed) and control samples revealed the presence and orientation of crystalline structures. Intensity of diffraction peaks corresponding to 310 and 222 planes were enhanced with respect to 211 families of reflections, indicating preferential alignment of the crystals. Also, the percent crystallinity and crystal size were increased in treated samples. The study provides a biophysical basis for augmented fracture healing under the influence of semi-aligned static magnetic field applied across the fracture line.

Distraction Rate and Latency: Factors in the Outcome of Pediatric Mandibular Distraction

BACKGROUND

Distraction osteogenesis was initially devised as a way to lengthen the lower extremity. All the basic tenets of the technique were developed based on this use. This includes both the supposed need for a latency period before distraction begins (3 to 5 days) and the ideal rate of distraction (1 mm/day). There is no evidence that these values apply to craniofacial distraction osteogenesis, particularly in children. Indeed, with the markedly improved blood supply in the face when compared with the lower extremity and the use of the technique in children versus adults, one might assume that a shorter latency period and a more rapid rate of distraction are possible.

METHODS

This study is a retrospective review of 22 pediatric patients with mandibular hypoplasia undergoing mandibular distraction osteogenesis. All patients were operated on by a team consisting of an oral surgeon and a plastic surgeon. All the distraction devices used were external. All patients had a latency period, before activation, of less than 24 hours and a distraction rate of 2 mm/day.

RESULTS

Two patients developed cellulitis at the pin sites, one patient developed premature healing, one patient developed a nonunion that required further surgery. This was the only patient in the series who had distraction of a previous bone graft. No patient undergoing distraction of native mandible developed a nonunion.

CONCLUSIONS

Eliminating the latency period and rapidly distracting the mandible in pediatric cases has an acceptably low complication rate. This benefits the patient in terms of an overall reduction in the amount of time that the child needs to remain in the distraction device. The patient spends less time with the distraction device, thus reducing the potential morbidity and increased cost of the treatment. Potential explanations for why this variation in distraction technique is successful include the improved blood supply in the face of children and the failure of external devices to translate all the distracted movements to the bone interface. Some of this force is translated into both bending of the pins and migration of the pins through bone. Although a latency period might be necessary in the distraction of the lower extremities, the application of this concept to the craniofacial skeleton in children is erroneous.

Management of type C intercondylar fractures of lower end humerus in adults: A clinical study

Thirty-six patients of type C intercondylar fractures of lower end of humerus who visited JN Medical College, Aligarh between January, 2001 and January, 2003 were included in the study. All patients were treated surgically by open reduction and internal fixation with 4mm cancellous screws, reconstruction plates, one-third tubular plates. Early physiotherapy was started and the results graded using Krishnamoorthy criteria.

Surgical Treatment for Distal Clavicle Fracture Associated With Coracoclavicular Ligament Rupture Using a Cannulated Screw Fixation Technique

BACKGROUND

A clavicle fracture is a common traumatic injury. However, the high percentage of distal clavicle fractures associated with a rupture of the coracoclavicular (CC) ligament can result in delayed union or nonunion. There is no standard treatment for a clavicle fracture. This report introduces a method for treating distal clavicle fractures associated with a ruptured CC ligament using a cannulated screw.

METHODS

Seventeen patients suffering from a clavicle fracture caused by a rupture of the CC ligament were treated with a closed reduction and a cannulated screw fixation technique. Twelve patients were male and five were female and the average age was 30.5 years (range, 8-64 years). The patients were assessed using a clinical and radiologic evaluation as well as by the University of California at Los Angeles (UCLA) shoulder rating scale for 12 to 16 months after surgery.

RESULTS

After confirming the formation of a callus, the implants were routinely removed approximately 8 weeks after surgery in all patients except for one. In this patient, the implant was removed 16 weeks after surgery as a result of a loosened screw, which caused displacement at the fracture site. During the final follow-up, the fracture site displayed nonunion and a partially limited range of motion (ROM). The shoulder function of the other 16 patients was restored to the preinjury level after 4 approximately 6 months of treatment. In one patient, heterotopic ossification was observed along the CC ligament without any functional deficit. All but one patient showed good results according to the UCLA scale.

CONCLUSIONS

The cannulated screw fixation technique can maintain the rigid fixation of fracture fragments and allow an early return to work and sport activities. Therefore, the cannulated screw fixation technique is expected to be a useful method for treating distal clavicle fractures associated with a coracoclavicular ligament rupture.

Matricellular proteins: Extracellular modulators of bone development, remodeling, and regeneration

Matricellular proteins are components of the extracellular matrix which are highly expressed in the developing and mature skeleton. Members of this protein class serve as biological mediators of cell function by interacting directly with cells or by modulating the activity of growth factors, proteases, and other extracellular matrix proteins. Although skeletons of matricellular protein-null mice are grossly normal, they each display unique deficiencies that are often magnified under pathological conditions. In addition, bone cells from wild-type and matricellular protein-null mice behave differently in various in vitro models of bone matrix synthesis and turnover. In this review, osteopontin, bone sialoprotein, tenascin C, SPARC, and thrombospondins 1 and 2 will each be discussed in the context of bone cell biology. Because the biological effects of matricellular proteins are largely context dependent, in vivo and in vitro results must be considered together in order to fully appreciate the specific contributions that matricellular proteins make to bone physiology and pathophysiology. In particular, it is clear that although matricellular proteins are not required for bone development and function, the proteins act to modulate post-natal bone structure in response to aging, ovariectomy, mechanical loading, and bone regeneration.

[Mandibular fractures in children. Apropos of 20 cases]

Authors report their experiences about the caring for child mandible fractures at Yalgado Ouedraogo University Hospital Centre, CHUYO. These fractures constitute day-to-day relative immediate emergencies. The techniques of retention used after bone setting are various. Ligatures with steel thread are frequently used. The retention is shortened because of the quick strengthening noticed in child. The satisfying results reveal the necessity of classical retention and ligatures with steel thread in jawbone fractures.

Instability prolongs the chondral phase during bone healing in sheep

In this sheep study, we investigated the influence of fixation stability on the temporal and spatial distribution of tissues in the fracture callus. As the initial mechanical conditions have been cited as being especially important for the healing outcome, it was hypothesized that differences in the path of healing would be seen as early as the initial phase of healing. Sixty-four sheep underwent a mid-shaft tibial osteotomy that was treated with either a rigid or a semi-rigid external fixator. Animals were sacrificed at 2, 3, 6 and 9 weeks postoperatively and the fracture calluses were analyzed using radiological, biomechanical and histological techniques. Statistical comparison between the groups was performed using the Mann-Whitney U test for unpaired non-parametric data. In the callus of the tibia treated with semi-rigid fixation, remnants of the fracture haematoma remained present for longer, although new periosteal bone formation during early healing was similar in both groups. The mechanical competence of the healing callus at 6 weeks was inferior compared to tibiae treated with rigid fixation. Semi-rigid fixation resulted in a larger cartilage component of the callus, which persisted longer. Remodeling processes were initiated earlier in the rigid group, while new bone formation continued throughout the entire investigated period in the semi-rigid group. In this study, evidence is provided that less rigid fixation increased the time required for healing. The process of intramembranous ossification appeared during the initial stages of healing to be independent of mechanical stability. However, the delay in healing was related to a prolonged chondral phase.

[Operative management of acetabular fracture]

OBJECTIVE

To investigate the indication, operative approach, postoperative management, and complication of acetabular fracture.

METHODS

Sixty-eight patients (51 males, 17 females; age 15-65 years) with acetabular fracture were reviewed retrospectively. Among the patients, 55 were injured in the traffic accidents and 13 were injured in the falls (acute injury in 60, old injury in 8). According to the Letournel classification, 16 had a fracture of the posterior wall, 13 had a fracture of the posterior wall and posterior column, 12 had a fracture of the anterior wall and anterior column, 8 had a fracture of the anterior and posterior column, and 19 had a transverse acetabular fracture. All the patients underwent an operative treatment.

RESULTS

There was no injury to the nerves and blood vessels during the operation. According to the 1-12-year follow-up for 51 patients, 26 (51.0%) patients had an excellent function, 17 (33.3%)had a good function, 6 (11.8%) had a fair function, and 2 (3.9%) had a poor function. The excellent and good rate was 84.3%. After operation, heterotopic ossification was observed in 4 patients, and necrosis of the femoral head in 2 patients.

CONCLUSION

Operative management should be performed as soon as possible in the patients with a displaced acetabular fracture. Recovery of the stability of the acet cartilage is important to the recovery of the function. tawulum and smoothness of the acetabular articular