901
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Sartelli M, Malangoni MA, May AK, Viale P, Kao LS, Catena F, Ansaloni L, Moore EE, Moore FA, Peitzman AB, Coimbra R, Leppaniemi A, Kluger Y, Biffl W, Koike K, Girardis M, Ordonez CA, Tavola M, Cainzos M, Di Saverio S, Fraga GP, Gerych I, Kelly MD, Taviloglu K, Wani I, Marwah S, Bala M, Ghnnam W, Shaikh N, Chiara O, Faro MP, Pereira GA, Gomes CA, Coccolini F, Tranà C, Corbella D, Brambillasca P, Cui Y, Segovia Lohse HA, Khokha V, Kok KY, Hong SK, Yuan KC. World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections. World J Emerg Surg 2014; 9:57. [PMID: 25422671 PMCID: PMC4242587 DOI: 10.1186/1749-7922-9-57] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 09/26/2014] [Indexed: 12/16/2022] Open
Abstract
Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62019 Italy
| | | | - Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee USA
| | - Pierluigi Viale
- Clinic of Infectious Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lillian S Kao
- Department of Surgery, The University of Texas Medical School, Houston, USA
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, USA
| | - Fred A Moore
- Department of Surgery, University of Florida, Gainesville, Florida USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Medical Center, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, University of Florida, Gainesville, Florida USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Carlos A Ordonez
- Department of Surgery, Fundación Valle del Lilí, Universidad del Valle, Cali, Colombia
| | - Mario Tavola
- Department of Anesthesia and ICU, Villa Scazzi Hospital, Genoa, Italy
| | - Miguel Cainzos
- Department of Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Igor Gerych
- Department of Surgery 1, Lviv Regional Hospital, DanyloHalytskyLviv National Medical University, Lviv, Ukraine
| | | | - Korhan Taviloglu
- Department of General Surgery, Istanbul Doctor's Center, Istanbul, Turkey
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Miklosh Bala
- General Surgery and Trauma Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Wagih Ghnnam
- Department of Surgery Mansoura, Faculty of medicine, Mansoura University, Mansoura, Egypt
| | - Nissar Shaikh
- Department of Anesthesia and ICU, Hamad Medical Corporation, Doha, Qatar
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Mario Paulo Faro
- Department of General and Gastrointestinal Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira
- Emergency Surgery and trauma Unit, Department of Surgery, Ribeirão, Preto Brazil
| | - Carlos Augusto Gomes
- Hospital Universitário Therezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Universidade Federal de Juiz de Fora (UFJF), Minas Gerais, Brasil
| | | | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62019 Italy
| | - Davide Corbella
- Department of Anestesiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | | | - Kenneth Yy Kok
- Department of Surgery, Ripas Hospital, Bandar Seri Begawan, Brunei
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Kuo-Ching Yuan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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902
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Hadjiargyrou M, O'Keefe RJ. The convergence of fracture repair and stem cells: interplay of genes, aging, environmental factors and disease. J Bone Miner Res 2014; 29:2307-22. [PMID: 25264148 PMCID: PMC4455538 DOI: 10.1002/jbmr.2373] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 08/11/2014] [Accepted: 09/10/2014] [Indexed: 01/07/2023]
Abstract
The complexity of fracture repair makes it an ideal process for studying the interplay between the molecular, cellular, tissue, and organ level events involved in tissue regeneration. Additionally, as fracture repair recapitulates many of the processes that occur during embryonic development, investigations of fracture repair provide insights regarding skeletal embryogenesis. Specifically, inflammation, signaling, gene expression, cellular proliferation and differentiation, osteogenesis, chondrogenesis, angiogenesis, and remodeling represent the complex array of interdependent biological events that occur during fracture repair. Here we review studies of bone regeneration in genetically modified mouse models, during aging, following environmental exposure, and in the setting of disease that provide insights regarding the role of multipotent cells and their regulation during fracture repair. Complementary animal models and ongoing scientific discoveries define an increasing number of molecular and cellular targets to reduce the morbidity and complications associated with fracture repair. Last, some new and exciting areas of stem cell research such as the contribution of mitochondria function, limb regeneration signaling, and microRNA (miRNA) posttranscriptional regulation are all likely to further contribute to our understanding of fracture repair as an active branch of regenerative medicine.
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Affiliation(s)
- Michael Hadjiargyrou
- Department of Life Sciences, New York Institute of Technology, Old Westbury, NY, USA
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903
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El Dafrawy MH, Kebaish KM. Percutaneous S2 alar iliac fixation for pelvic insufficiency fracture. Orthopedics 2014; 37:e1033-5. [PMID: 25361366 DOI: 10.3928/01477447-20141023-90] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/25/2014] [Indexed: 02/03/2023]
Abstract
Pelvic insufficiency fractures are fairly common in elderly patients and can be a source of major functional impairment, particularly when they involve the ilium. Early rehabilitation with adequate pain relief has been the traditional method of treatment. The recently developed S2 alar iliac technique involves placing pelvic fixation into the ilium through a pathway from the sacral ala. The bony channel between the second dorsal sacral foramen and the anterior inferior iliac spine is used to provide rigid sacropelvic fixation for adult and pediatric spine deformities. The authors describe a new minimally invasive approach that allows percutaneous stabilization of an iliac fracture with 2 S2 alar iliac screws. A 65-year-old woman with a history of rectal carcinoma that was treated with pelvic radiation had an iliac stress fracture that progressed to nonunion. Extensive nonoperative treatment was unsuccessful, and the patient continued to have symptoms 5 years after the initial diagnosis. An open approach vs a minimally invasive technique was debated. The S2 alar iliac screws were used to stabilize the fracture through a minimally invasive approach. Most of the symptoms resolved in 2 months, with radiographic evidence of union at 6 months. To the authors' knowledge, this report is the first to describe a percutaneous approach for stabilizing iliac insufficiency fractures. This technique provides a safe surgical option for treating iliac stress fractures in some patients for whom nonoperative treatment fails while avoiding the complications and soft tissue compromise associated with open procedures. Longer follow-up and a larger series are needed to show the safety and efficacy of this technique.
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904
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Grote S, Prall W. Revision einer VKB-Plastik. ARTHROSKOPIE 2014. [DOI: 10.1007/s00142-014-0828-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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905
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Liu Z, Wang K, Zhang K, Zhou J, Zhang Y. Minimally invasive surgery (MIS) of anterior ring fracture combined with pubic symphysis separation. Med Sci Monit 2014; 20:1913-7. [PMID: 25308286 PMCID: PMC4207289 DOI: 10.12659/msm.892358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The aim of this study was to evaluate the reliability of open reduction and minimally invasive plate osteosynthesis (MIPO) for anterior ring fracture combined with pubic symphysis separation and to explore the operative techniques and therapeutic efficacy. Material/Methods We used minimally invasive plate osteosynthesis (MIPO) to treat anterior ring fracture combined with pubic symphysis separation. Results During postoperative follow-up, all patients recovered well, with no fat liquefaction, infection, femoral nerve or iliac blood vessels injury, deep vein thrombosis, heterotopic ossification, or any and other complications. Conclusions The MIS or MIPPO for anterior ring fracture combined with pubic symphysis separation has the advantages of short operation time and less blood loss. This clinical operation is safe and feasible, with therapeutic efficacy.
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Affiliation(s)
- Zhendong Liu
- Department of Orthopaedics and Traumatology, Third Xiangya hospital of Central South University, Changsha, China (mainland)
| | - Kuixiang Wang
- Department of Orthopaedics and Traumatology, Third Xiangya hospital of Central South University, Changsha, China (mainland)
| | - Kexiang Zhang
- Department of Orthopaedics and Traumatology, Third Xiangya hospital of Central South University, Changsha, China (mainland)
| | - Jiahui Zhou
- Department of Orthopaedics and Traumatology, Third Xiangya hospital of Central South University, Changsha, China (mainland)
| | - Yuanjun Zhang
- Department of Orthopaedics and Traumatology, Third Xiangya hospital of Central South University, Changsha, China (mainland)
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906
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Malham GM, Parker RM, Ellis NJ, Blecher CM, Chow FY, Claydon MH. Anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2: a prospective study of complications. J Neurosurg Spine 2014; 21:851-60. [PMID: 25279655 DOI: 10.3171/2014.8.spine13524] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECT The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in anterior lumbar interbody fusion (ALIF) is controversial regarding the reported complication rates and cost. The authors aimed to assess the complication rates of performing ALIF using rhBMP-2. METHODS This is a prospective study of consecutive patients who underwent ALIF performed by a single spine surgeon and a single vascular surgeon between 2009 and 2012. All patients underwent placement of a polyetheretherketone (PEEK) cage filled with rhBMP-2 and a separate anterior titanium plate. Preoperative clinical data, operative details, postoperative complications, and clinical and radiographic outcomes were recorded for all patients. Clinical outcome measures included back and leg pain visual analog scale scores, Oswestry Disability Index (ODI), and SF-36 Physical and Mental Component Summary (PCS and MCS) scores. Radiographic assessment of fusion was performed using high-definition CT scanning. Male patients were screened pre- and postoperatively regarding sexual dysfunction, specifically retrograde ejaculation (RE). RESULTS The study comprised 131 patients with a mean age of 45.3 years. There were 67 men (51.1%) and 64 women (48.9%). Of the 131 patients, 117 (89.3%) underwent ALIF at L5-S1, 9 (6.9%) at L4-5, and 5 (3.8%) at both L4-5 and L5-S1. The overall complication rate was 19.1% (25 of 131), with 17 patients (13.0%) experiencing minor complications and 8 (6.1%) experiencing major complications. The mean estimated blood loss per ALIF level was 115 ml. There was 1 incidence (1.5%) of RE. No significant vascular injuries occurred. No prosthesis failure occurred with the PEEK cage and separate anterior screw-plate. Back and leg pain improved 57.2% and 61.8%, respectively. The ODI improved 54.3%, with PCS and MCS scores improving 41.7% and 21.3%, respectively. Solid interbody fusion was observed in 96.9% of patients at 12 months. CONCLUSIONS Anterior lumbar interbody fusion with a vascular access surgeon and spine surgeon, using a separate cage and anterior screw-plate, provides a very robust and reliable construct with low complication rates, high fusion rates, and positive clinical outcomes, and it is cost-effective. The authors did not experience the high rates of RE reported by other authors using rhBMP-2.
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907
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Zamparelli A, Zini N, Cattini L, Spaletta G, Dallatana D, Bassi E, Barbaro F, Iafisco M, Mosca S, Parrilli A, Fini M, Giardino R, Sandri M, Sprio S, Tampieri A, Maraldi NM, Toni R. Growth on poly(L-lactic acid) porous scaffold preserves CD73 and CD90 immunophenotype markers of rat bone marrow mesenchymal stromal cells. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2014; 25:2421-2436. [PMID: 24997163 DOI: 10.1007/s10856-014-5259-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 06/14/2014] [Indexed: 06/03/2023]
Abstract
Few data are available on the effect of biomaterials on surface antigens of mammalian bone marrow-derived, adult mesenchymal stromal cells (MSCs). Since poly(L-lactic acid) or PLLA is largely used in tissue engineering of human bones, and we are developing a reverse engineering program to prototype with biomaterials the vascular architecture of bones for their bioartificial reconstruction, both in humans and animal models, we have studied the effect of porous, flat and smooth PLLA scaffolds on the immunophenotype of in vitro grown, rat MSCs in the absence of any coating, co-polymeric enrichment, and differentiation stimuli. Similar to controls on plastic, we show that our PLLA scaffold does not modify the distribution of some surface markers in rat MSCs. In particular, the maintained expression of CD73 and CD90 on two different subpopulations (small and large cells) is consistent with their adhesion to the PLLA scaffold through specialized appendages, and to their prominent content in actin. In addition, our PLLA scaffold favours retention of the intermediate filament desmin, believed a putative marker of undifferentiated state. Finally, it preserves all rat MSCs morphotypes, and allows for their survival, adhesion to the substrate, and replication. Remarkably, a subpopulation of rat MSCs grown on our PLLA scaffold exhibited formation of membrane protrusions of uncertain significance, although in a size range and morphology compatible with either motility blebs or shedding vesicles. In summary, our PLLA scaffold has no detrimental effect on a number of features of rat MSCs, primarily the expression of CD73 and CD90.
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Affiliation(s)
- Alessandra Zamparelli
- Department of Biomedical, Biotechnological and Translational Sciences (S.Bi.Bi.T) - Laboratory of Regenerative Morphology and Bioartificial Structures/S.Bi.Bi.T. Museum - Section of Human Anatomy, University of Parma, Parma, Italy
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908
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Delayed bone healing following high tibial osteotomy related to increased implant stiffness in locked plating. Injury 2014; 45:1648-52. [PMID: 24813098 DOI: 10.1016/j.injury.2014.04.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/31/2014] [Accepted: 04/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Asymmetrical callus formation and incomplete bone formation underneath stiff locking plates have been reported recently in clinical and experimental fracture healing studies. After similar effects were observed in the outcome of high tibial osteotomy (HTO) patients, a retrospective study was performed to quantify the frequency and level of such incomplete healing cases. MATERIAL AND METHODS Twenty-three patients treated with medial open wedge HTO and locking plate (Tomofix™) for posttraumatic or congenital genu varum were investigated. No bone grafts were applied to fill the osteotomy gap. The median correction angle was 8° (5-18°). Elective hardware removal was performed after a median of 19.5 months (12-58 months) following an uneventful clinical course. The most recent postoperative X-ray available (median 21 months; 13-56 months) was evaluated for consolidation of the osteotomy. We performed an in vitro biomechanical experiment using the same HTO on a loaded cadaver knee joint to compare interfragmentary movements (IFMs) when using regular locking screws with the Tomofix™ plate and screws that enabled dynamic stabilisation of this plate. RESULTS Fifteen patients (65%) displayed incomplete consolidation of the osteotomy underneath the locking plate (10.9% of the osteotomy length) and cortical deficiency. The time to implant removal for these patients of 27 months was longer than the 21 months for the patients with a complete osteotomy gap healing. The biomechanical experiment demonstrated that very low IFMs and corresponding interfragmentary strain occur underneath the plate when using regular locking screws. Replacement with dynamic screws resulted in an increased IFM. DISCUSSION AND CONCLUSIONS These results support the hypothesis that low bone formation underneath locking plates is induced by increased stiffness. This high stiffness situation could be altered by replacing the standard screws with dynamic screws which allow for a movement of 0.35mm perpendicular to the screw axis. This resulted in an approximately threefold increase in the IFM and may be a potential concept to avoid incomplete bone healing under stiff plate fixations.
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909
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Laschke MW, Schank TE, Scheuer C, Kleer S, Shadmanov T, Eglin D, Alini M, Menger MD. In vitro osteogenic differentiation of adipose-derived mesenchymal stem cell spheroids impairs their in vivo vascularization capacity inside implanted porous polyurethane scaffolds. Acta Biomater 2014; 10:4226-35. [PMID: 24998773 DOI: 10.1016/j.actbio.2014.06.035] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/06/2014] [Accepted: 06/24/2014] [Indexed: 12/22/2022]
Abstract
Undifferentiated adipose-derived mesenchymal stem cell (adMSC) spheroids are attractive vascularization units for tissue engineering. Their osteogenic differentiation further offers the possibility of directed generation of bone constructs. The aim of this study was to analyze how this differentiation affects their in vivo vascularization capacity. Green fluorescent protein (GFP)-positive adMSCs were isolated from C57BL/6-TgN(ACTB-EGFP)1Osb/J mice for the generation of undifferentiated and differentiated spheroids using the liquid overlay technique. Subsequently, polyurethane scaffolds were seeded with these spheroids and successful osteogenic differentiation was proven by von Kossa staining and high-resolution microtomography. The scaffolds were then implanted into dorsal skinfold chambers of C57BL/6 wild-type mice to analyze their vascularization and incorporation using intravital fluorescence microscopy, histology and immunohistochemistry. Scaffolds seeded with differentiated spheroids exhibited a markedly impaired vascularization. Immunohistochemical analyses revealed that this was caused by the lost ability of differentiated spheroids to form GFP-positive microvascular networks inside the scaffolds. This was associated with a reduced tissue incorporation of the implants. Moreover, they no longer exhibited a mineralized matrix after the 14day implantation period, indicating the dedifferentiation of the spheroids under the given in vivo conditions. These findings indicate that osteogenic differentiation of adMSC spheroids markedly impairs their vascularization capacity. Hence, it may be reasonable to combine adMSC spheroids of varying differentiation stages in scaffolds for bone tissue engineering to promote both vascularization and bone formation.
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910
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Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg 2014; 1:36. [PMID: 25593960 PMCID: PMC4286984 DOI: 10.3389/fsurg.2014.00036] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/24/2014] [Indexed: 01/18/2023] Open
Abstract
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.
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Affiliation(s)
- Evangelos P. Misiakos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - George Bagias
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Paul Patapis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Dimitrios Sotiropoulos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Prodromos Kanavidis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
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911
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Saka T. Principles of postoperative anterior cruciate ligament rehabilitation. World J Orthop 2014; 5:450-459. [PMID: 25232521 PMCID: PMC4133451 DOI: 10.5312/wjo.v5.i4.450] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/19/2014] [Accepted: 06/03/2014] [Indexed: 02/06/2023] Open
Abstract
It is known that anterior cruciate ligament (ACL) reconstruction needs to be combined with detailed postoperative rehabilitation in order for patients to return to their pre-injury activity levels, and that the rehabilitation process is as important as the reconstruction surgery. Literature studies focus on how early in the postoperative ACL rehabilitation period rehabilitation modalities can be initiated. Despite the sheer number of studies on this topic, postoperative ACL rehabilitation protocols have not been standardized yet. Could common, “ossified” knowledge or modalities really prove themselves in the literature? Could questions such as “is postoperative brace use really necessary?”, “what are the benefits of early restoration of the range of motion (ROM)?”, “to what extent is neuromuscular electrical stimulation (NMES) effective in the protection from muscular atrophy?”, “how early can proprioception training and open chain exercises begin?”, “should strengthening training start in the immediate postoperative period?” be answered for sure? My aim is to review postoperative brace use, early ROM restoration, NMES, proprioception, open/closed chain exercises and early strengthening, which are common modalities in the very comprehensive theme of postoperative ACL rehabilitation, on the basis of several studies (Level of Evidence 1 and 2) and to present the commonly accepted ways they are presently used. Moreover, I have presented the objectives of postoperative ACL rehabilitation in tables and recent miscellaneous studies in the last chapter of the paper.
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912
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Abstract
Determining whether a bone fracture is healed is one of the most important and fundamental clinical determinations made in orthopaedics. However, there are currently no standardized methods of assessing fracture union, which in turn has created significant disagreement among orthopaedic surgeons in both clinical and research settings. An extensive amount of research has been dedicated to finding novel and reliable ways of determining healing with some promising results. Recent advancements in imaging techniques and introduction of new radiographic scores have helped decrease the amount of disagreement on this topic among physicians. The knowledge gained from biomechanical studies of bone healing has helped us refine our tools and create more efficient and practical research instruments. Additionally, a deeper understanding of the molecular pathways involved in the bone healing process has led to emergence of serologic markers as possible candidates in assessment of fracture union. In addition to our current physician centered methods, patient-centered approaches assessing quality of life and function are gaining popularity in assessment of fracture union. Despite these advances, assessment of union remains an imperfect practice in the clinical setting. Therefore, clinicians need to draw on multiple modalities that directly and indirectly measure or correlate with bone healing when counseling patients.
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Affiliation(s)
- Saam Morshed
- Department of Orthopaedic Surgery, University of San Francisco School of Medicine, San Francisco, CA 94143-0410, USA
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913
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Kinaci A, Neuhaus V, Ring DC. Trends in bone graft use in the United States. Orthopedics 2014; 37:e783-8. [PMID: 25350620 DOI: 10.3928/01477447-20140825-54] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/30/2014] [Indexed: 02/03/2023]
Abstract
Bone graft and bone graft substitutes are used to provide structural support and enhance bone healing. Autogenous, allogeneic, and artificial bone grafts each have advantages and drawbacks. The development of allografts, synthetic bone grafts, and new operative techniques may have influenced the use of bone grafts in recent years. The goal of this study was to analyze the use of bone grafts and bone graft substitutes in the United States during a 16-year period. Using data from the National Hospital Discharge Survey, the authors analyzed the use of autogenous and artificial bone grafts in almost 2 million patients in the United States between 1992 and 2007 using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in 4 periods (1992-1995, 1996-1999, 2000-2003, and 2004-2007). Among an estimated almost 2 million bone graft procedures (83% autogenous, 17% artificial), the use of both types of grafts decreased. The main diagnoses for which bone grafts were used did not change; however, cervical spine diseases and lower-limb fractures decreased more remarkably. Although sex (52% male in the early 1990s to 47% in 2000-2003) and discharge status (more discharges to a short-term or long-term-care facility) significantly changed, age increased from 47 to 53 years and inpatient days decreased significantly from 6 to 5 days during the study period. The use of bone grafts and bone graft substitutes is decreasing in the United States, with a slight shift from autogenous to substitute grafts.
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914
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Khatib O, Onyekwelu I, Zuckerman JD. The incidence of proximal humeral fractures in New York State from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older. J Shoulder Elbow Surg 2014; 23:1356-62. [PMID: 24725897 DOI: 10.1016/j.jse.2013.12.034] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 12/20/2013] [Accepted: 12/25/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures. METHODS We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). RESULTS The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P < .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in 2010. DISCUSSION The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.
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Affiliation(s)
- Omar Khatib
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Ikemefuna Onyekwelu
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Joseph D Zuckerman
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA.
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915
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Relph N, Herrington L, Tyson S. The effects of ACL injury on knee proprioception: a meta-analysis. Physiotherapy 2014; 100:187-95. [DOI: 10.1016/j.physio.2013.11.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 11/25/2013] [Indexed: 11/26/2022]
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916
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Sohn HS, Shin SJ. Minimally invasive plate osteosynthesis for proximal humeral fractures: clinical and radiologic outcomes according to fracture type. J Shoulder Elbow Surg 2014; 23:1334-40. [PMID: 24618198 DOI: 10.1016/j.jse.2013.12.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 12/10/2013] [Accepted: 12/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study evaluated the clinical and radiologic outcomes, according to fracture type, of proximal humeral fractures treated by the minimally invasive plate osteosynthesis (MIPO) technique. MATERIALS AND METHODS Of 85 patients with proximal humeral fractures who were treated by the MIPO technique, 62 were evaluated: 27 with 2-part fractures, 24 with 3-part fractures, and 11 with 4-part fractures. An additional inferomedial screw or fibular allograft was used when severe medial cortical comminution was found in the proximal humerus. Clinical and radiographic outcomes were evaluated during the follow-up of 37 months. RESULTS There was a significant difference in the Constant scores of patients with 4-part fractures compared with those with 3-part fractures (P = .039). The neck-shaft angle in 4-part fractures (121° ± 3°) at final follow-up was significantly lower compared with other fracture types (2-part: 129° ± 9°, P = .036; 3-part: 129° ± 2°, P = .031). Complication rates (72.7%) of 4-part fractures were significantly higher than with other fracture types (2-part, 7.4%; 3-part, 20.8%; P = .001). Sixteen fractures were fixed with an additional inferomedial screw, and 3 patients had insertion of a fibular allograft. CONCLUSION Satisfactory clinical and radiologic outcomes were obtained by the MIPO technique in proximal humeral fractures. In addition, medial cortical support can be performed with an inferomedial screw or fibular allograft in the MIPO technique. However, the MIPO technique for 4-part fractures showed relatively inferior outcomes compared with 2- and 3-part fractures. Conversion to open plating is also considered if adequate reduction, that is, a neck-shaft angle >120°, is not able to be obtained in the MIPO technique for 4-part fractures of the proximal humerus.
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Affiliation(s)
- Hoon-Sang Sohn
- Orthopaedic Surgery, National Medical Center, Seoul, South Korea
| | - Sang-Jin Shin
- Department of Orthopaedic Surgery, Ewha Womans University College of Medicine, Seoul, South Korea.
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917
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Meyer GPC, Choi G, Bandharkar A, Choi PS, Lee SH, Cristante AF, Marcon RM, Iutaka AS, Barros TEPD. Transcorporeal cervical foraminotomy: description of technique and results. COLUNA/COLUMNA 2014. [DOI: 10.1590/s1808-18512014130300r78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE: Retrospective analyses of 216 patients undergoing foraminal decompression with transcorporeal approach and review of the surgical technique. METHOD: 216 patients with minimum follow-up of 2 years and an average of 41.8 months were included in the study. The clinical records of these patients were reviewed for complications, NDI (neck disability index) and VAS (visual analogue scale). Pre and post-operative radiographs were used to evaluate the disc height. RESULTS: At the end of follow-up patients had significant clinical improvement with reduction of NDI of 88.3% and 86.5% and 68.3% of the VAS for neck and upper limb, respectively (p<0.05). A reduction of 8.8% of the disc height was observed without other complications associated (p<0.05). CONCLUSION: Radicular decompression through a transcorporeal approach is an alternative that provides good clinical results without the need for a fusion and with few complications.
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Affiliation(s)
| | - Gun Choi
- Wooridul Spine Hospital, South Korea
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918
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Theologie-Lygidakis N, Chatzidimitriou K, Tzerbos F, Kolomvos N, Iatrou I. Development of surgical techniques of secondary osteoplasty in cleft patients following 12 years experience. J Craniomaxillofac Surg 2014; 42:839-45. [DOI: 10.1016/j.jcms.2013.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 09/05/2013] [Accepted: 12/17/2013] [Indexed: 11/16/2022] Open
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919
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Skovrlj B, Marquez-Lara A, Guzman JZ, Qureshi SA. A review of the current published spinal literature regarding bone morphogenetic protein-2: an insight into potential bias. Curr Rev Musculoskelet Med 2014; 7:182-8. [PMID: 24878966 PMCID: PMC4596160 DOI: 10.1007/s12178-014-9221-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a potent biologic agent that carries both osteoinductive and osteoconductive properties. Its potential as an autologous bone graft substitute in spine surgery led to its approval by the United States Food and Drug Administration (FDA) in 2002 following a series of industry-sponsored trials. Although approved for a single level anterior lumbar interbody fusion from L4-S1 with a proprietary cage, the off-label use of rhBMP-2 rapidly escalated. Soon thereafter, reports of serious and potentially life-threatening complications associated with rhBMP-2 began emerging, which sparked concerns with regards to potential bias in the original FDA trials. Ultimately, an independent review of all published and unpublished data on the safety and effectiveness of rhBMP-2 by the Yale University Open Data Access (YODA) Project determined that while rhBMP-2 is as effective as iliac crest bone graft (ICBG) in potentiating spinal fusion, there was significant bias and conflicts of interests that resulted in an underreporting of complications in the original industry-sponsored trials.
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Affiliation(s)
- Branko Skovrlj
- />Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Javier Z. Guzman
- />Department of Orthopaedics, Mount Sinai School of Medicine, 5 East 98th Street, Box 1188, New York, NY USA
| | - Sheeraz A. Qureshi
- />Department of Orthopaedics, Mount Sinai School of Medicine, 5 East 98th Street, Box 1188, New York, NY USA
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920
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De Waele JJ. Management of necrotizing skin and soft tissue infections. Expert Rev Anti Infect Ther 2014; 10:805-14. [PMID: 22943403 DOI: 10.1586/eri.12.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although rare, necrotizing skin and soft tissue infections can be devastating infections that are difficult to diagnose and challenging to manage. Clinical presentation is often insidious, and a low index of suspicion is critical. Various diagnostic tools, such as scoring systems or imaging techniques, have been introduced, but none is convincingly superior to sound clinical judgment. Early diagnosis allows early adequate therapy that includes antibiotic therapy, critical care support, specific interventions such as intravenous immunoglobulin in selected patients and, most importantly, early source control. Empirical antibiotic therapy should cover a broad range of both Gram-negative and Gram-positive aerobic and anaerobic microorganisms, and clindamycin is recommended when group A Streptococcus is a suspected pathogen.
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Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Gent, Belgium.
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921
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Moest T, Koehler F, Prechtl C, Schmitt C, Watzek G, Schlegel KA. Bone formation in peri-implant defects grafted with microparticles: a pilot animal experimental study. J Clin Periodontol 2014; 41:990-8. [PMID: 25131387 DOI: 10.1111/jcpe.12295] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2014] [Indexed: 01/01/2023]
Abstract
AIM This study aimed to evaluate the healing of peri-implant defects grafted with microparticles (MPs). MATERIAL AND METHODS Six domestic pigs received nine standardized defects at the calvaria, and an implant was inserted in the middle of each defect. The space between the implant and lateral bone portion was filled with MP pellets (n = 18) or MP supernatant (n = 18) or left unfilled (n = 18). After 14 and 28 days, three animals were sacrificed and specimens removed for further processing. Samples were microradiographically and histologically analysed. In addition, we immunohistochemically stained for anti-vWF as a marker of angiogenesis. RESULTS In the case of bone regeneration and vessel formation, the null hypothesis can be partially rejected. After 14 and 28 days, no significant difference was observed within groups regarding de novo bone formation, bone density and osseointegration. However, superior vessel formation was found at both time points. CONCLUSION Microparticles represent a promising treatment option to accelerate peri-implant vessel formation. Further studies are needed to investigate the regenerative properties of MPs more precisely.
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Affiliation(s)
- Tobias Moest
- Oral and Maxillofacial Surgery, University Hospital Erlangen, Erlangen, Germany
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922
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Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation - an anatomical study. Injury 2014; 45:1185-9. [PMID: 24907010 DOI: 10.1016/j.injury.2014.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 04/24/2014] [Accepted: 05/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The antegrade intramedullary Locking Blade Nail (Marquardt, Germany) is a device aimed at improving purchase in the humeral head and reducing varus displacement by providing medial buttress support and triangular stability within the humeral head. The aim of this study is to measure the relationship of the proximal fixation screws to the axillary nerve. METHODS 13 whole cadavers underwent insertion of an antegrade proximal humeral blade nail via a deltoid split approach to both shoulders. The anatomic proximity of the anterior branch of the axillary nerve to the screws was measured following soft tissue dissection and inspection of the nerve. RESULTS The mean distance of the nerve from the anterolateral acromion was 62 mm (range 45-81 mm). The nerve lay closest to the distal blade fixation screw 4.9 mm (range 0-19 mm). In three cases the nerve lay directly underneath the washer and in all three cases there was macroscopic evidence of damage to the nerve. In 5 cases the nerve travelled obliquely in a cranial direction to lie 1.8 mm (range 0-3 mm) from the distal blade fixation screw, in 2 of these cases the nerve lay beneath the washer. CONCLUSION The anterior branch of the axillary nerve is placed at risk during insertion of the locking screws despite use of protection sleeves and trocars. We advocate that when using antegrade intramedullary nails that incorporate an inferomedial calcar screw an extended anterolateral acromial approach is undertaken.
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923
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Adelved A, Tötterman A, Hellund JC, Glott T, Madsen JE, Røise O. Radiological findings correlate with neurological deficits but not with pain after operatively treated sacral fractures. Acta Orthop 2014; 85:408-14. [PMID: 24694272 PMCID: PMC4105773 DOI: 10.3109/17453674.2014.908344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Neurological deficits and pain are common after displaced sacral fractures. However, little is known about the association between the long-term clinical outcomes and radiological findings. We examined the long-term radiological findings and their correlations with lumbosacral pain and neurological deficits in the lower extremities after surgery for sacral fractures. METHODS 28 consecutive patients with operatively treated displaced sacral fractures were followed for mean 11 (8-13) years. Sensorimotor impairments of the lower extremities were classified according to the American Spinal Injury Association (ASIA). Pain was assessed using a visual analog scale (VAS). All patients underwent conventional radiographic examination and CT, and the images were scrutinized for nonunion, residual displacement, narrowing of the sacral foramina, and post-foraminal encroachment of the L5 and S1 nerves. RESULTS There was residual displacement of ≥ 10 mm in 16 of the 28 patients. 26 patients had narrowing of 1 or more neural root foramina in L5-S4. 8 patients reported having no pain, 11 had pain only in the lumbosacral area, and 9 had pain in combination with radiating leg pain. Statistically significant correlations were found between narrowing of the sacral foramina and neurological deficits in the corresponding dermatomes. Significant correlations were also found between post-foraminal encroachment of L5 nerves and both sensory and motor deficits. No correlations were found between pain and radiological findings. INTERPRETATION Pathological radiological findings are common 11 years after operatively treated displaced sacral fractures. Sacral foraminal and L5 post-foraminal bony encroachments were common findings and correlated with neurological deficits. However, lumbosacral pain did not correlate with radiological sequelae after fracture healing.
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Affiliation(s)
- Aron Adelved
- Department of Orthopaedics, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Ullevaal,Department of Orthopaedics, Akershus University Hospital, Lørenskog, Norway
| | - Anna Tötterman
- Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | | | - Thomas Glott
- Department of Spinal Cord Injury and Multitrauma Unit, Sunnaas Hospital, Nesodden
| | - Jan Erik Madsen
- Department of Orthopaedics, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Ullevaal,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Olav Røise
- Department of Orthopaedics, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Ullevaal,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
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924
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925
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Chauhan A, Wigton MD, Palmer BA. Necrotizing fasciitis. J Hand Surg Am 2014; 39:1598-601; quiz 1602. [PMID: 24861383 DOI: 10.1016/j.jhsa.2014.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 04/12/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Aakash Chauhan
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA
| | - Michael D Wigton
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA
| | - Bradley A Palmer
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA.
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926
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Burke NG, Kennedy J, Cousins G, Fitzpatrick D, Mullett H. Locking plate fixation with and without inferomedial screws for proximal humeral fractures: a biomechanical study. J Orthop Surg (Hong Kong) 2014; 22:190-4. [PMID: 25163953 DOI: 10.1177/230949901402200215] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE. To compare the efficacy of locking plate fixation with and without inferomedial screws in maintaining the reduction of a proximal humeral fracture. METHODS. 22 synthetic humerus models were used. A standardised 3-part proximal humeral fracture with a 4-mm wedge segment was created and fixed with a locking plate and screws with (n=11) and without (n=11) inferomedial screws. The intrafragmentary motion of the construct at 250, 500, 750, and 1000 cycles of 532 N loading, and the load to failure of the 2 groups were compared. RESULTS. Locking plate fixation with inferomedial screws reduced the mean intrafragmentary motion in all cycles (p<0.01) and increased the load to failure (1452 N vs. 1159 N, p<0.001), compared to fixation without inferomedial screws. CONCLUSION. Additional inferomedial screws provide medial column support for fracture healing. This may reduce intrafragmentary motion and thus implant complications resulting from varus malalignment such as screw perforation or loss of reduction.
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Affiliation(s)
- Neil G Burke
- Department of Orthopaedic Research, Royal College of Surgeons, Dublin, Ireland
| | - Jim Kennedy
- Department of Orthopaedic Research, Royal College of Surgeons, Dublin, Ireland
| | - Grainne Cousins
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland
| | - David Fitzpatrick
- School of Electrical and Mechanical Engineering, University College Dublin, Ireland
| | - Hannan Mullett
- Department of Orthopaedic Research, Royal College of Surgeons, Dublin, Ireland
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927
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Jha S, Khan WS, Siddiqui NA. Mammalian bite injuries to the hand and their management. Open Orthop J 2014; 8:194-8. [PMID: 25067974 PMCID: PMC4110393 DOI: 10.2174/1874325001408010194] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 03/23/2014] [Accepted: 03/27/2014] [Indexed: 11/22/2022] Open
Abstract
Bite wounds are a common form of hand injury with the potential to lead to severe local and systemic sequelae and permanent functional impairment. Mammalian bite wounds may be caused by a variety of animal class and species; injuries resulting from dogs, cats and humans are the most widely discussed and reported in the literature. Bite wounds may be contaminated with aggressive pathogens and the anatomical vulnerability of structures within the hand means that without early recognition and treatment with irrigation and antibiotics, alongside a low index of suspicion for deep structural involvement requiring formal surgical exploration and washout, the consequences of such injuries can be disastrous. We review the literature and discuss the epidemiology, pathophysiology and microbiology relating to these injuries, as well as clinical aspects including signs, symptoms, and management.
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Affiliation(s)
- Shilpa Jha
- Department of Trauma & Orthopaedics, Kingston Hospital NHS Trust, Kingston, London, UK
| | - Wasim S Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, UK
| | - Nashat A Siddiqui
- Department of Trauma & Orthopaedics, Kingston Hospital NHS Trust, Kingston, London, UK
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928
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Jordan RW, Modi CS. A review of management options for proximal humeral fractures. Open Orthop J 2014; 8:148-56. [PMID: 25067968 PMCID: PMC4110401 DOI: 10.2174/1874325001408010148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 03/19/2014] [Accepted: 03/24/2014] [Indexed: 01/25/2023] Open
Abstract
Proximal humeral fractures are common and although the majority can be managed non-operatively, the optimal treatment of displaced or complex fractures remains controversial. Non-operative treatment is typically selected for minimally displaced fractures where union rates are high and good or excellent outcomes can be expected in approximately 80% of cases. The aims of surgical fixation are to restore articular surface congruency, alignment and the relationship between the tuberosities and the humeral head. Hemiarthroplasty provides patients with reliable pain relief and its indications include fracture dislocations, humeral head splitting fractures and some three- and four- part fractures. The key areas of surgical technique that influence functional outcome include correctly restoring the humeral height, humeral version and tuberosity position. Function, however, is poor if the tuberosities either fail to unite or mal-unite. The interest in reverse shoulder arthroplasty as an alternative option has therefore recently increased, particularly in older patients with poor bone quality and tuberosity comminution. The evidence supporting this, however, is currently limited to multiple case series with higher level studies currently underway.
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Affiliation(s)
- Robert W Jordan
- Coventry and Warwickshire Shoulder and Elbow Unit, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Chetan S Modi
- Coventry and Warwickshire Shoulder and Elbow Unit, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
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929
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Navinan MR, Yudhishdran J, Kandeepan T, Kulatunga A. Necrotizing fasciitis--a diagnostic dilemma: two case reports. J Med Case Rep 2014; 8:229. [PMID: 24965382 PMCID: PMC4086700 DOI: 10.1186/1752-1947-8-229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/22/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Necrotizing soft tissue infections can affect various tissue planes. Although predisposing etiologies are many, they mostly center on impaired immunity occurring directly or indirectly and loss of integrity of protective barriers which predispose to infection. The nonspecific presentation may delay diagnosis and favor high mortality. Case presentation Two case vignettes are presented. The first patient, a 44-year-old healthy South Asian man with a history of repeated minor traumatic injury presented to a primary health care center with a swollen left lower limb. He was treated with antibiotics with an initial diagnosis of cellulitis. Because he deteriorated rapidly and additionally developed intestinal obstruction, he was transferred to our hospital which is a tertiary health care center for further evaluation and management. Prompt clinical diagnosis of necrotizing soft tissue infection was made and confirmed on magnetic resonance imaging as necrotizing fasciitis. Urgent debridement was done, but the already spread infection resulted in rapid clinical deterioration with resultant mortality. The second patient was a 35-year-old South Asian woman with systemic lupus erythematous receiving immunosuppressive therapy who developed left lower limb pain and fever. Medical attention was sought late as she came to the hospital after 4 days. Her condition deteriorated rapidly as she developed septic shock and died within 2 days. Conclusions Necrotizing fasciitis can be fatal when not recognized and without early intervention. Clinicians and surgeons alike should have a greater level of suspicion and appreciation for this uncommon yet lethal infection.
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930
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Kralinger F, Blauth M, Goldhahn J, Käch K, Voigt C, Platz A, Hanson B. The Influence of Local Bone Density on the Outcome of One Hundred and Fifty Proximal Humeral Fractures Treated with a Locking Plate. J Bone Joint Surg Am 2014; 96:1026-1032. [PMID: 24951739 DOI: 10.2106/jbjs.m.00028] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is biomechanical evidence that bone density predicts the mechanical failure of implants. The aim of this prospective study was to evaluate the influence of local bone mineral density on the rate of mechanical failure after locking plate fixation of proximal humeral fractures. METHODS We enrolled 150 patients who were from fifty to ninety years old with a closed, displaced proximal humeral fracture fixed with use of a locking plate from July 2007 to April 2010. There were 118 women and thirty-two men who had a mean age of sixty-nine years. Preoperative computed tomography (CT) scans were done to assess bone mineral density of the contralateral humerus, and dual x-ray absorptiometry of the distal end of the radius of the unaffected arm was conducted within the first six weeks postoperatively. At follow-up evaluations at six weeks, three months, and one year postoperatively, pain, shoulder mobility, strength, and multiple functional and quality-of-life outcome measures (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire; Shoulder Pain and Disability Index [SPADI]; Constant score; and EuroQuol-5D [EQ-5D]) were done and standard radiographs were made. We defined mechanical failure as all complications related to bone quality experienced within one year. RESULTS After locking plate fixation, fifty-three (35%) of 150 patients had mechanical failure; loss of reduction and secondary screw loosening with perforation were common. CT assessments of local bone mineral density showed no difference between patients with and without mechanical failure (89.82 versus 91.51 mg/cm3, respectively; p = 0.670). One-year DASH, SPADI, and Constant scores were significantly better for patients without mechanical failure (p ≤ 0.05). CONCLUSIONS We did not find evidence of an association between bone mineral density and the rate of mechanical failures, which may suggest that patients with normal bone mineral density are less prone to sustain a proximal humeral fracture. Future studies should target other discriminating factors between patients with and without mechanical failure. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Franz Kralinger
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. E-mail address for F. Kralinger:
| | - Michael Blauth
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. E-mail address for F. Kralinger:
| | - Jörg Goldhahn
- Institute for Biomechanics, ETH Zurich, Wolfgang-Pauli-Strasse 10, CH-8093 Zürich, Switzerland
| | - Kurt Käch
- Department of Trauma Surgery, Kantonsspital Winterthur, Brauerstr. 15, CH-8401 Winterthur, Switzerland
| | - Christine Voigt
- Department of Trauma and Reconstructive Surgery, Friederikenstift, Humboldstr. 5, D-30169 Hannover, Germany
| | - Andreas Platz
- Department of General, Hand, and Trauma Surgery, Stadtspital Triemli, Birmensdorferstr. 497, CH-8063 Zürich, Switzerland
| | - Beate Hanson
- AO Clinical Investigation and Documentation, AO Foundation, Stettbachstrasse 6, CH-8600 Duebendorf, Switzerland
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931
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Frich LH, Jensen NC. Bone properties of the humeral head and resistance to screw cutout. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2014; 8:21-6. [PMID: 24926160 PMCID: PMC4049036 DOI: 10.4103/0973-6042.131851] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Surgical treatment of fractures involving the proximal humeral head is hampered by complications. Screw cutout is the major pitfall seen in connection with rigid plating. We have exploited a bony explanation for this phenomenon.
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Affiliation(s)
- Lars Henrik Frich
- Department of Orthopaedics, Odense University Hospital, Odense, Denmark
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932
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Mao Z, Zhang L, Zhang L, Zeng X, Chen S, Liu D, Zhou Z, Tang P. Operative versus nonoperative treatment in complex proximal humeral fractures. Orthopedics 2014; 37:e410-9. [PMID: 24810816 DOI: 10.3928/01477447-20140430-50] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 11/08/2013] [Indexed: 02/03/2023]
Abstract
This updated meta-analysis investigated whether operative treatment is superior to nonoperative treatment in complex proximal humeral fractures. The authors searched the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE. Randomized controlled trials that evaluated operative vs nonoperative treatment for exclusively 3- or 4-part proximal humeral fractures were considered. Six studies with a total of 287 patients who had proximal humeral fractures were included. According to the meta-analysis, no statistically significant differences were found between operative and nonoperative treatment in Constant-Murley shoulder scores (Constant scores); Disabilities of the Arm, Shoulder, and Hand scores; total complication events; mortality; infection; nonunion; avascular necrosis; osteoarthritis; redisplacement of fractures; or dislocation or resorption of tuberosity. For health-related quality of life, EuroQol-5D (EQ-5D) favored operative treatment, but 15D scores showed no significant difference. Compared with nonoperative treatment, open reduction and internal fixation required significantly more additional surgeries (risk ratio, 6.50; 95% confidence interval, 1.54-27.50; P=.01), and more penetrations into joint space occurred (risk ratio, 9.56; 95% confidence interval, 2.27-40.13; P=.002). The limited evidence suggests that no convincing findings support the use of either open reduction and internal fixation or hemiarthroplasty for the treatment of complex proximal humeral fractures. The findings of the current study should be interpreted cautiously because of the modest sample size and the short follow-up period.
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933
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Nodzo SR, Kaplan NB, Hohman DW, Ritter CA. A radiographic and clinical comparison of reamer-irrigator-aspirator versus iliac crest bone graft in ankle arthrodesis. INTERNATIONAL ORTHOPAEDICS 2014; 38:1199-203. [PMID: 24770726 DOI: 10.1007/s00264-014-2348-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/31/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated radiographic fusion at follow-up and complication rates in patients who had either iliac crest (ICBG) or femoral reamer-irrigator-aspirator (RIA) bone graft for tibiotalar fusion. METHODS We retrospectively reviewed charts and radiographs of all patients who had a tibiotalar fusion from August 2007 to February 2011. Records were analysed for patient demographics, complications, and clinical symptoms. Radiographs were reviewed in sequential order by two fellowship-trained foot and ankle surgeons and one orthopaedic surgeon who specialises in foot and ankle surgery to determine radiographic fusion at routine follow-up. Patients were contacted to determine current visual analog scores (VAS) at their graft site. RESULTS Mean patient age was 49.4 ± 12.1 years in the RIA group and 49.3 ± 15.4 years in the ICBG group (p = .97). Pre-operative characteristics showed no significant differences between groups. The ICBG group had significantly more nonunions than the RIA group (six vs. one, p = 0.04). Two patients in the ICBG had chronic pain at their graft site based on their VAS score; there were none in the RIA group. Radiographic fusion at follow-up was similar between groups, with no significant difference (12.48 ± 3.85 weeks vs.12.21 ± 3.19 weeks, p = .80). CONCLUSIONS There was a significantly higher nonunion rate in the ICBG group, but both groups had a solid radiographic bony fusion at similar follow-up time points. Our results suggest RIA bone graft is a viable alternative to ICBG for tibiotalar fusion.
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Affiliation(s)
- Scott R Nodzo
- Department of Orthopedics, University at Buffalo, 462 Grider Street, Buffalo, NY, 14215, USA,
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934
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McAnany S, Parsons BO. Treatment of Proximal Humeral Fractures: A Critical Analysis Review. JBJS Rev 2014; 2:01874474-201404000-00005. [PMID: 27490870 DOI: 10.2106/jbjs.rvw.m.00045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Steven McAnany
- Leni and Peter W. May Department of Orthopaedic Surgery, Mount Sinai School of Medicine, 5 East 98th Street, 9th Floor, New York, NY 10029
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935
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Euler SA, Hengg C, Kolp D, Wambacher M, Kralinger F. Lack of fifth anchoring point and violation of the insertion of the rotator cuff during antegrade humeral nailing: pitfalls in straight antegrade humeral nailing. Bone Joint J 2014; 96-B:249-53. [PMID: 24493192 DOI: 10.1302/0301-620x.96b2.31293] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as 'critical types', due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation. We therefore emphasise the need for 'fastidious' pre-operative planning to minimise this risk.
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Affiliation(s)
- S A Euler
- Medical University Innsbruck, Department of Trauma Surgery and Sports Medicine, Anichstr 35, Innsbruck 6020, Austria
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936
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Health literacy in an orthopaedic trauma patient population: improving patient comprehension with informational intervention. J Orthop Trauma 2014; 28:e75-9. [PMID: 23899766 DOI: 10.1097/bot.0b013e3182a66921] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study aims to evaluate the change in comprehension of diagnoses, treatment plans, and discharge instructions after orthopaedic trauma patients are given an informational document that includes pictorial representations at the time of discharge. It also seeks to determine if the intervention has a greater impact on patients with lower educational backgrounds. DESIGN Prospective comparative cohort study. SETTING Academic level 1 trauma center. PATIENTS From April to December 2011, 529 orthopaedic trauma patients with an operatively fixed isolated fracture were eligible for inclusion. Two hundred ninety-nine eligible questionnaires were collected (56.5% response rate). INTERVENTION Patients were administered a questionnaire regarding their treatment and discharge instructions during their first postoperative clinic visit before being seen by a physician. The questionnaire included demographic information and questions regarding: (1) which bone was fractured, (2) type of implanted fixation, (3) weight-bearing status, (4) expected recovery time, and (5) need for deep vein thrombosis prophylaxis. All patients had received verbal instructions outlining this information at postoperative hospital discharge. During the second half of the study, patients were given an additional informational sheet with both text and pictorial representations at discharge. Multivariable log-binomial regression analyses were used to examine the impact of this intervention. RESULTS One hundred forty-six patients were given only the standard discharge instructions, whereas 153 patients were also administered the additional information document. The mean score for patients who received the intervention was 2.90 (out of 5) compared with the mean score of 2.54 for patients who did not receive the intervention (P = 0.013). Patients who received the intervention were 1.3 times more likely to know which bone was fractured (P = 0.007) and 1.1 times more likely to be able to correctly name the medication(s) they were prescribed for deep vein thrombosis prophylaxis (P = 0.03). CONCLUSIONS Overall performance on comprehension questionnaires in orthopaedic trauma patients was significantly improved via a text and pictorial intervention. The intervention did not preferentially aid patients with lower education backgrounds. Future studies should evaluate long-term postoperative results to determine if improved patient comprehension has an effect on surgical outcomes and patient satisfaction.
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937
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Pascarella R, Commessatti M, Politano R, Maresca A, Del Torto M, Chehrassan M, Fantasia R. Bone graft from greater trochanter in posterior wall fractures with impacted fragments. J Orthop Traumatol 2014; 15:181-7. [PMID: 24671489 PMCID: PMC4182615 DOI: 10.1007/s10195-014-0291-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 03/05/2014] [Indexed: 11/20/2022] Open
Abstract
Background Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment. Materials and methods Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months. Results The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected. Conclusions Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment. Level of evidence Level IV.
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Affiliation(s)
- R Pascarella
- Orthopedic and Traumatology Department, Riuniti Hospital, Ancona, Italy,
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938
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Tiren D, Vos DI. Correction osteotomy of distal radius malunion stabilised with dorsal locking plates without grafting. Strategies Trauma Limb Reconstr 2014; 9:53-8. [PMID: 24610600 PMCID: PMC3951621 DOI: 10.1007/s11751-014-0190-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/02/2014] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to evaluate the results of our correction osteotomies of distal radial malunions without a bone graft. Eleven consecutive patients (mean age 52 years, range 18–71) were treated. A dorsal approach was utilised to perform an opening-wedge osteotomy which then was stabilised with two dorsal columnar plates without filling the osteotomy gap. All patients went on to radiographic union with a filling of the osteotomy gap within a mean period of 3 months (range 2–6 months). All patients had satisfactory results in terms of function and pain. Correction osteotomy and stabilisation with bicolumnar locked plate fixation without a bone graft provides sufficient stability to allow the highly vascularised metaphysis to heal. In patients without risk factors predisposing to non-union, this procedure is safe and feasible.
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Affiliation(s)
- D Tiren
- Department of General and Trauma Surgery, Amphia Hospital, Postbus 90158, 4800 RK, Breda, The Netherlands,
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939
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Balakumar B, Babu S, Varma HK, Madhuri V. Triphasic ceramic scaffold in paediatric and adolescent bone defects. J Pediatr Orthop B 2014; 23:187-95. [PMID: 24201074 DOI: 10.1097/bpb.0000000000000004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
We evaluated novel triphasic hydroxyapatite tricalcium phosphate calcium silicate scaffold (HASi) in the management of paediatric bone defects. Their main advantage is considered to be adequate strength and stimulation of bone formation without resorting to autograft. A total of 42 children younger than 16 years of age were recruited over a period of 1 year and were treated with this synthetic bone substitute as a stand-alone graft for pelvic, femur, calcaneal and ulnar osteotomies, cystic bone lesions, subtalar arthrodesis and segmental bone defects. Forty children, 22 boys and 18 girls, mean age 8.3 years and a mean follow-up of 18.51 months, were available for evaluation. Analysis showed that younger age, cancellous defects and no internal fixation were associated with significantly faster healing. Partial incorporation was observed in 22.5% and complete incorporation in 77.5% of cases at 18 months of follow-up. Sex, type of defect, BMI and the shape of the ceramic graft did not significantly affect the rate of healing. Complications attributable to HASi included four nonunions, three of which were diaphyseal. HASi was found to be safe in children with cancellous or benign cavitatory defects. It is not suitable for diaphyseal and segmental bone defects as a stand-alone graft.
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Affiliation(s)
- Balasubramanian Balakumar
- aPaediatric Orthopaedic Unit, Christian Medical College, Vellore, Tamil Nadu bBioceramic Laboratory, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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940
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The use of demineralized bone matrix for anterior cruciate ligament reconstruction: a radiographic, histologic, and immunohistochemical study in rabbits. J Surg Res 2014; 187:219-24. [DOI: 10.1016/j.jss.2013.09.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/04/2013] [Accepted: 09/18/2013] [Indexed: 12/30/2022]
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941
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Boccaccini AR, Kneser U, Arkudas A. Scaffolds for vascularized bone regeneration: advances and challenges. Expert Rev Med Devices 2014; 9:457-60. [DOI: 10.1586/erd.12.49] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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942
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Niikura T, Lee SY, Sakai Y, Nishida K, Kuroda R, Kurosaka M. Comparison of radiographic appearance and bone scintigraphy in fracture nonunions. Orthopedics 2014; 37:e44-50. [PMID: 24683656 DOI: 10.3928/01477447-20131219-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Many surgeons assess the biological activity of fracture nonunions by the presence or absence of callus on radiographs. However, the assessment of biological activity by radiographic appearance alone is controversial. Bone scintigraphy reflects blood flow and new bone formation; therefore, it is useful in assessing such biological activity in nonunion cases. This retrospective study compared radiographs with Tc-99m bone scintigraphy in 48 patients with uninfected nonunions. Positive uptake was observed in all cases. The uptake patterns were classified into 4 types: type 1, intense, uniform uptake; type 2A, a definite photon-deficient cleft between 2 areas of intense uptake; type 2B, a photon-deficient area other than type 2A; and type 3, an intermediate pattern with uneven, distributed uptake. The percentage of type 1 with intense uptake does not decrease with time, and type 2 does not increase. When uptake was compared in patients with a nonunion and a united fracture, higher uptake in nonunion was seen in 46% and lower uptake was seen in 27%. All cases of hypertrophic and more than half of oligotrophic nonunions were type 1. Type 2 was seen in 17% of oligotrophic, 67% of comminuted, 100% of defect, and 57% of atrophic nonunions. Poor callus visualization may not preclude biological activity. Long duration from injury may not equate to declines in biological activity. Comparing uptake in nonunions and united fractures in the same patient may help to assess biological activity. The photon-deficient area is helpful to assess the necessity of bone graft or other osteogenic supplementation.
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943
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Abstract
OBJECTIVES To provide evidence on the midterm sexual-function- and health-related quality-of-life outcome of patients with a traumatic pelvic fracture, as recorded at least 12 months after their surgery. DESIGN Prospective noncomparative study. SETTING Tertiary referral centre for pelvic-and-acetabular reconstruction. PATIENTS AND PARTICIPANTS Cohort of patients attending a dedicated pelvic-and-acetabular reconstruction clinic because of blunt pelvic trauma, at a minimum of a year after their injury. INTERVENTION Operatively treated pelvic fractures and concomitant surgical interventions for associated injuries, if any, sustained by the patients after blunt trauma. MAIN OUTCOME MEASURES Sexual function questionnaires: IIEF (international index of erectile function) and FSFI (female sexual function index). Quality of life was assessed with the EuroQol-5D questionnaire. RESULTS Of a cohort of 110 patients, 80 patients (48 males and 32 females) consented to participate with a median age of 46 years (range, 19-65 years). Of the above cohort, 62.5% were a result of road traffic accidents and 52.5% were classified as lateral compression type fractures. Assessment occurred at a median period of 36 months after injury (range, 12-96). Overall, significant decrease of their quality of life (P < 0.0001) and sexual function were recorded (males, P < 0.00014; females, P < 0.001). Sexual dysfunction was identified in 43.8% of the female and 52.1% of the male patients, as per the validated gender-specific sexual function scores (female sexual function index and international index of erectile function, respectively). Regression analysis identified the presence of urinary tract injury (P < 0.049) and open surgical treatment (P < 0.047) as independent risk factors for sexual dysfunction. A near significant association with injury severity score (P = 0.05) was seen. Male gender (P < 0.006), abdominal injury (P < 0.0001), pelvic fracture severity (P < 0.049), pain (P < 0.0001), and sexual dysfunction (P < 0.034) were identified as significant independent risk factors for decreased quality of life. CONCLUSIONS All domains of female and male sexual function were significantly decreased at a minimum of a year after pelvic fracture. Quality of life was also significantly decreased in this group with sexual dysfunction shown to be an independent risk factor for decreased quality of life after injury. Further pivotal clinical studies should follow based on the provided evidence. High clinical suspicion and prompt engagement of appropriate multidisciplinary pathways, including urological, gynecological, and psychiatric consultations, is recommended. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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944
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Niikura T, Lee SY, Sakai Y, Nishida K, Kuroda R, Kurosaka M. Causative factors of fracture nonunion: the proportions of mechanical, biological, patient-dependent, and patient-independent factors. J Orthop Sci 2014; 19:120-4. [PMID: 24081392 DOI: 10.1007/s00776-013-0472-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 09/05/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Understanding the causative factors of fracture nonunion leads to both prevention and improvements in treatment. The purpose of this study was to understand the clinical characteristics and causative factors of nonunion in a case series. METHODS One hundred two consecutive patients with fracture nonunions of the extremities who were surgically treated in our hospital over the last decade were analyzed. Data were collected by reviewing medical charts. Radiographs were reviewed to classify the nonunion by radiographic appearance. Causative factors of nonunions were identified for each patient. Factors relating to inadequate mechanical stability or reduction and those relating to a decline in biological activity were investigated. Mechanical factors included inappropriate dynamization, inappropriate reduction, inappropriate surgical management, insufficient fixation, and conservative treatment. Surgical technical errors were identified through careful review by three experienced trauma surgeons. Biological activity factors included comminution and bone loss, open fracture, excessive surgical exposure, infection, previous radiation therapy, alcohol abuse, diabetes mellitus, smoking, genetic disorders, and metabolic disease or endocrine pathology. We also classified the causative factors as patient-dependent or patient-independent factors. RESULTS Of the 102 nonunions, 47 were oligotrophic, 22 were hypertrophic, 17 were atrophic, 12 were defect types, and 4 were comminuted. Twenty-four cases had factors of inadequate mechanical stability or reduction, 23 cases had biological factors, and 55 cases had both types of factors. Four cases had patient-dependent factors, 40 cases had patient-independent factors, and 58 cases had both types of factors. CONCLUSIONS Our results demonstrated that there were a considerable number of nonunions with causative factors which can be improved, such as inadequate fracture management.
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Affiliation(s)
- Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan,
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945
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Dapunt U, Klingmann A, Schmidmaier G, Moghaddam A. Necrotising fasciitis. BMJ Case Rep 2013; 2013:bcr-2013-201906. [PMID: 24326439 DOI: 10.1136/bcr-2013-201906] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A patient in his late 50s who suffered from necrotising fasciitis is described in this case report. The patient first presented at the chest pain unit, where he reported of respiratory distress and showed systemic signs of an infection. Because of progressive skin lesions indicative of necrotising fasciitis on both the lower extremities, the patient was immediately rushed into surgery and was treated at the intensive care unit. Despite receiving immediate treatment, the patient died of this rapidly spreading infectious disease. Because of the fast advance of this disease, we would like to emphasise the importance of early recognition of symptoms.
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Affiliation(s)
- Ulrike Dapunt
- Department of Orthopaedics and Trauma Surgery, Heidelberg University, Heidelberg, Germany
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946
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Goetschius J, Kuenze CM, Saliba S, Hart JM. Reposition Acuity and Postural Control after Exercise in Anterior Cruciate Ligament Reconstructed Knees. Med Sci Sports Exerc 2013; 45:2314-21. [DOI: 10.1249/mss.0b013e31829bc6ae] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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947
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Mobbs RJ, Chung M, Rao PJ. Bone graft substitutes for anterior lumbar interbody fusion. Orthop Surg 2013; 5:77-85. [PMID: 23658041 DOI: 10.1111/os.12030] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/18/2012] [Indexed: 12/22/2022] Open
Abstract
The procedure of anterior lumbar interbody fusion (ALIF) is commonly performed on patients suffering from pain and/or neurological symptoms associated with disorders of the lumbar spine caused by disc degeneration and trauma. Surgery is indicated when prolonged conservative management proves ineffective. Because an important objective of the ALIF procedure is solid arthrodesis of the degenerative spinal segment, bone graft selection is critical. Iliac crest bone grafts (ICBG) remain the "gold standard" for achieving lumbar fusion. However, patient dissatisfaction stemming from donor site morbidity, lengthier operating times and finite supply of ICBG has prompted a search for better alternatives. Here presented is a literature review evaluating available bone graft options assessed within the clinical setting. These options include autografts, allograft-based, synthetic and cell-based technologies. The emphasis is on the contentious use of recombinant human bone morphogenetic proteins, which is in widespread use and has demonstrated both significant osteogenic potential and risk of complications.
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Affiliation(s)
- Ralph J Mobbs
- Neuro Spine Clinic, Prince of Wales Private Hospital, Randwick, Australia.
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948
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Pullisaar H, Tiainen H, Landin MA, Lyngstadaas SP, Haugen HJ, Reseland JE, Ostrup E. Enhanced in vitro osteoblast differentiation on TiO2 scaffold coated with alginate hydrogel containing simvastatin. J Tissue Eng 2013; 4:2041731413515670. [PMID: 24555011 PMCID: PMC3927861 DOI: 10.1177/2041731413515670] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/14/2013] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to develop a three-dimensional porous bone graft material as vehicle for simvastatin delivery and to investigate its effect on primary human osteoblasts from three donors. Highly porous titanium dioxide (TiO2) scaffolds were submerged into simvastatin containing alginate solution. Microstructure of scaffolds, visualized by scanning electron microscopy and micro-computed tomography, revealed an evenly distributed alginate layer covering the surface of TiO2 scaffold struts. Progressive and sustained simvastatin release was observed for up to 19 days. No cytotoxic effects on osteoblasts were observed by scaffolds with simvastatin when compared to scaffolds without simvastatin. Expression of osteoblast markers (collagen type I alpha 1, alkaline phosphatase, bone morphogenetic protein 2, osteoprotegerin, vascular endothelial growth factor A and osteocalcin) was quantified using real-time reverse transcriptase–polymerase chain reaction. Secretion of osteoprotegerin, vascular endothelial growth factor A and osteocalcin was analysed by multiplex immunoassay (Luminex). The relative expression and secretion of osteocalcin was significantly increased by cells cultured on scaffolds with 10 µM simvastatin when compared to scaffolds without simvastatin after 21 days. In addition, secretion of vascular endothelial growth factor A was significantly enhanced from cells cultured on scaffolds with both 10 nM and 10 µM simvastatin when compared to scaffolds without simvastatin at day 21. In conclusion, the results indicate that simvastatin-coated TiO2 scaffolds can support a sustained release of simvastatin and induce osteoblast differentiation. The combination of the physical properties of TiO2 scaffolds with the osteogenic effect of simvastatin may represent a new strategy for bone regeneration in defects where immediate load is wanted or unavailable.
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Affiliation(s)
- Helen Pullisaar
- Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Hanna Tiainen
- Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Maria A Landin
- Oral Research Laboratory, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Ståle P Lyngstadaas
- Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Håvard J Haugen
- Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Janne E Reseland
- Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Esben Ostrup
- Department of Biomaterials, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway ; Norwegian Center for Stem Cell Research, Institute of Immunology, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
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949
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Tepass A, Rolauffs B, Weise K, Bahrs SD, Dietz K, Bahrs C. Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009. Patient Saf Surg 2013; 7:34. [PMID: 24268107 PMCID: PMC4176190 DOI: 10.1186/1754-9493-7-34] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 11/05/2013] [Indexed: 12/16/2022] Open
Abstract
Background The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns. Methods The databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test. Results Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)]. The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores. Discussion Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.
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Affiliation(s)
- Alexander Tepass
- Department of Radiology, Eberhard-Karls University, Tübingen, Germany.
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Seagrave RA, Sojka J, Goodyear A, Munns SW. Utilizing reamer irrigator aspirator (RIA) autograft for opening wedge high tibial osteotomy: A new surgical technique and report of three cases. Int J Surg Case Rep 2013; 5:37-42. [PMID: 24412805 PMCID: PMC3907197 DOI: 10.1016/j.ijscr.2013.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/25/2013] [Accepted: 11/05/2013] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The lateral closing wedge high tibial osteotomy (HTO) was popularized by Coventry in the 1960s. In the 1990s the medial opening wedge osteotomy gained popularity because it could achieve greater valgus correction and it did not require dissociation of the fibula from the tibia, an important consideration when treating varus knees with lateral and posterolateral ligament deficiencies (Noyes’ double-varus and triple-varus knees). However, it has the disadvantage of requiring bone graft to fill bony defects. Recently, the reamer-irrigator-aspirator (RIA; Synthes, Paoli, PA) system was developed, and as a result of this procedure, a large amount of usable autogenous bone graft can be collected safely for use. To our knowledge, there is no published series combining opening wedge HTO with the use of RIA obtained autogenous bone graft. PRESENTATION OF CASE We present a novel technique in which a series of three patients underwent opening wedge HTO using ipsilateral, retrograde femur RIA graft to fill the bone defect. All patients had satisfactory clinical and radiologic outcomes following the new technique at latest follow up. DISCUSSION Opening wedge high tibial osteotomy is a well-documented and accepted orthopedic procedure, however, has the disadvantage of requiring varying amounts of bone graft. Traditionally, iliac crest or tricortical allograft have been the grafting modalities of choice, however both have inherent drawbacks to their use. In our series, the use of RIA autograft is a safe and reliable harvest technique for high tibial osteotomy, providing abundant and quality autogenous bone graft. CONCLUSION All three of our patients achieved radiographic union with high clinical patient satisfaction without any major complications. We feel this novel technique is a safe and acceptable operative solution grafting opening wedge osteotomies about the knee.
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Affiliation(s)
- Richard A Seagrave
- University of Kansas Medical Center, Department of Orthopedics, 3901, Rainbow Boulevard, Kansas City, KS 66160, United States.
| | - John Sojka
- University of Kansas Medical Center, Department of Orthopedics, 3901, Rainbow Boulevard, Kansas City, KS 66160, United States.
| | - Adam Goodyear
- University of Kansas Medical Center, Department of Orthopedics, 3901, Rainbow Boulevard, Kansas City, KS 66160, United States.
| | - Stephen W Munns
- University of Kansas Medical Center, Department of Orthopedics, 3901, Rainbow Boulevard, Kansas City, KS 66160, United States.
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