1001
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Abstract
Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis. The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age.
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Affiliation(s)
- V. I. Roberts
- University Hospitals of Leicester, Leicester
General Hospital, Gwendolen Road, Leicester
LE5 4PW, UK
| | - B. Komarasamy
- Kovai Medical Centre and Hospitals, Avinashi
Road, Coimbatore, Tamil
Nadu 641 14, India
| | - R. Pandey
- University Hospitals of Leicester, Leicester
General Hospital, Gwendolen Road, Leicester
LE5 4PW, UK
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1002
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Copuroglu C, Heybeli N, Ozcan M, Yilmaz B, Ciftdemir M, Copuroglu E. Major extremity injuries associated with farmyard accidents. ScientificWorldJournal 2012; 2012:314038. [PMID: 23002385 PMCID: PMC3353295 DOI: 10.1100/2012/314038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/13/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of the study is to analyze the major agricultural injuries related to the extremities. PATIENTS We evaluated a 3-year period including 41 patients. Data on age, sex, injury patterns, anatomical localizations, injury season, length of stay in the hospital, and infections were evaluated, and the patients were examined with SF-36 in the follow-up period. RESULTS Hand was the most commonly injured part (n: 9) followed by the distal part of the lower limb (cruris) (n: 7) and foot (n: 7). Mean time between trauma and emergency-department arrival was 115 minutes (60-360). Mean length of stay was 24 days (4-150), and mean number of operations during hospitalization was 2.4 (1-30). Deep wound infection was seen in 8 patients. Seasonal distribution for accidents was even for spring and fall (27% each), high for summer (36%), and less for winter (10%). CONCLUSIONS Distal parts of the elbow and knee were affected more frequently. Due to the high microbiological load and high incidence of crush-type injuries, repetitive debridements and long duration of hospital stay were needed. Attention should be paid in the harvesting times to the farmyard injuries. Due to the seasonal variation, more resources should be allocated to treat the increasing incidence of injury over the period from spring to fall.
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Affiliation(s)
- Cem Copuroglu
- Department of Orthopaedics and Traumatology, Trakya University, 22050 Edirne, Turkey.
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1003
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Launonen AP, Lepola V, Flinkkilä T, Strandberg N, Ojanperä J, Rissanen P, Malmivaara A, Mattila VM, Elo P, Viljakka T, Laitinen M. Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture. A prospective randomized study. BMC Musculoskelet Disord 2012; 13:167. [PMID: 22954329 PMCID: PMC3520878 DOI: 10.1186/1471-2474-13-167] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 08/31/2012] [Indexed: 11/25/2022] Open
Abstract
Background Proximal humerus fracture is the third most common fracture type after hip and distal radius fracture in elderly patients. A comprehensive study by Palvanen et al. demonstrated an increase in the annual fracture rate of 13.7% per year over the past 33 years. Should this trend continue, the fracture rate would triple over the next three decades. The increasing incidence of low-energy fractures raises questions about the optimal treatment in terms of functional outcome, pain, and rehabilitation time, as well as the economical impact. Despite the high incidence and costs of proximal humerus fractures, there is currently no valid scientific evidence for the best treatment method. Several publications, including a Cochrane review outline the need for high-quality, well-designed randomized controlled trials. Methods/Design The study is a prospective, randomized, national multi-center trial. The hypothesis of the trial is that surgical treatment of displaced proximal humerus fractures achieves better functional outcome, pain relief, and patient satisfaction compared to conservative treatment. The trial is designed to compare conservative and surgical treatment of proximal humerus fractures in patients 60 years and older. The trial includes two strata. Stratum I compares surgical treatment with locking plates to conservative treatment for two-part fractures. Stratum II compares multi-fragmented fractures, including three- and four-part fractures. The aim of Stratum II is to compare conservative treatment, surgical treatment with the Philos locking plate, and hemiarthroplasty with an Epoca prosthesis. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score and the secondary outcome measures will be the EuroQol-5D (EQ-5D) value, OSS, Constant-Murley Score, VAS, and 15D. Recruiting time will be 3 years. The results will be analyzed after the 2-year follow-up period. Discussion This publication presents a prospective, randomized, national multi-center trial. It gives details of patient flow, randomization, aftercare and also ways of analysis of the material and ways to present and publish the results. Trial registration ClinicalTrials.gov identifier: NCT01246167
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Affiliation(s)
- Antti P Launonen
- Department of Orthopaedics, Tampere University Hospital, Teiskontie 35, PL2000, Tampere 33521, Finland.
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1004
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Pagni G, Kaigler D, Rasperini G, Avila-Ortiz G, Bartel R, Giannobile W. Bone repair cells for craniofacial regeneration. Adv Drug Deliv Rev 2012; 64:1310-9. [PMID: 22433781 DOI: 10.1016/j.addr.2012.03.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/02/2012] [Accepted: 03/05/2012] [Indexed: 12/17/2022]
Abstract
Reconstruction of complex craniofacial deformities is a clinical challenge in situations of injury, congenital defects or disease. The use of cell-based therapies represents one of the most advanced methods for enhancing the regenerative response for craniofacial wound healing. Both somatic and stem cells have been adopted in the treatment of complex osseous defects and advances have been made in finding the most adequate scaffold for the delivery of cell therapies in human regenerative medicine. As an example of such approaches for clinical application for craniofacial regeneration, Ixmyelocel-T or bone repair cells are a source of bone marrow derived stem and progenitor cells. They are produced through the use of single pass perfusion bioreactors for CD90+ mesenchymal stem cells and CD14+ monocyte/macrophage progenitor cells. The application of ixmyelocel-T has shown potential in the regeneration of muscular, vascular, nervous and osseous tissue. The purpose of this manuscript is to highlight cell therapies used to repair bony and soft tissue defects in the oral and craniofacial complex. The field at this point remains at an early stage, however this review will provide insights into the progress being made using cell therapies for eventual development into clinical practice.
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1005
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Miyazaki AN, Estelles JRD, Fregoneze M, Santos PD, da Silva LA, do Val Sella G, Ishioka FE, Rosa JP, Checchia SL. EVALUATION OF THE COMPLICATIONS OF SURGICAL TREATMENT OF FRACTURES OF THE PROXIMAL EXTREMITY OF THE HUMERUS USING A LOCKING PLATE. Rev Bras Ortop 2012; 47:568-74. [PMID: 27047867 PMCID: PMC4799444 DOI: 10.1016/s2255-4971(15)30005-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 03/08/2012] [Indexed: 11/30/2022] Open
Abstract
Objective: To evaluate the complications from surgical treatment using a locking plate among patients with fractures of the proximal extremity of the humerus. Methods: Between July 2004 and December 2009, 56 patients with fractures of the proximal extremity of the humerus were treated using the PHILOS® plate. There were 19 male patients and 37 female patients, with a mean age of 62 years (range: 30 to 92 years). All the cases had a mean postoperative followup period of 12 months. Thirteen fractures were classified as presenting in two parts, 28 as three, eight as four and seven as epiphyseal fractures. Results: Among the patients operated, 26 were considered to have achieved excellent results, twelve good, ten fair and eight poor, according to the UCLA score. Thirty complications occurred in 20 patients (35.7%), among which the most frequent complication was inadequate reduction of the fracture, which occurred in eight cases. Subacromial impact, caused by the plate, occurred in seven cases, while inadequate fixation occurred in six cases. Other complications such as pseudarthrosis, adhesive capsulitis, avascular necrosis, loss of varus reduction and infection were also seen. Conclusion: The functional results from treating fractures of the proximal extremity of the humerus using a locking plate depended on correct anatomical reduction of the fracture and stable fixation of the implant. Complications still occur frequently, particularly because of intraoperative technical difficulty, fracture severity and possible inexperience of the surgeon.
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Affiliation(s)
- Alberto Naoki Miyazaki
- Assistant Professor and Head of the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - José Renato Depari Estelles
- Resident in the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Fregoneze
- Assistant Professor and Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - Pedro Doneux Santos
- Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - Luciana Andrade da Silva
- Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - Guilherme do Val Sella
- Attending Physician in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - Fábio Eduardo Ishioka
- Trainee in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - João Polydoro Rosa
- Trainee in the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
| | - Sergio Luiz Checchia
- Adjunct Professor, Academic Consultant and Member of the Shoulder and Elbow Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil
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1006
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Wiedenhöfer B, Hemmer S, Akbar M, Lehner B, Schmidmaier G, Klöckner C. [Gold standard for implant selection in operative therapy of spondylitis/spondylodiscitis]. DER ORTHOPADE 2012; 41:721-6. [PMID: 22923160 DOI: 10.1007/s00132-012-1916-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The operative therapy management of vertebral osteomyelitis including debridement and stabilization is well established. Autologous bone is the preferred graft material but is limited due to availability, failure of consolidation in large defects and donor morbidity. Titanium mesh cages are alternatively equally well evaluated and other materials are also mentioned. Immobilization of affected segments is the fundamental requirement for healing of osteomyelitis. The operative therapy of choice is meticulous debridement and internal stabilization of the defect. Autologous bone seems to provide the best conditions to bridge and consolidate defects. Bone marrow aspirate, reaming irrigator aspiration (RIA) and bone marrow protein (BMP) in combination with cages have the same qualities considering bone healing but they are not yet sufficiently evaluated for management of vertebral osteomyelitis. Autologous bone graft remains the gold standard, nevertheless, its disadvantages point out the need for alternative grafts. Titanium is well proven to provide stability but bone substitutes are not sufficiently evaluated but seem to be promising.
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Affiliation(s)
- B Wiedenhöfer
- Department für Orthopädie, Unfallchirurgie und Paraplegiologie, Sektion Wirbelsäulenchirurgie, Stiftung Orthopädische Universitätsklinik Heidelberg, Heidelberg, Deutschland.
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1007
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Skeppholm M, Olerud C. Pain from donor site after anterior cervical fusion with bone graft: a prospective randomized study with 12 months of follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:142-7. [PMID: 22890567 DOI: 10.1007/s00586-012-2456-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 07/06/2012] [Accepted: 07/22/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Harvesting bone graft from the iliac crest in spinal fusion surgery is a widely used technique. However, complications can occur and there are also reports of patients with persistent graft site pain after surgery. The aim of this study was to evaluate pain from the donor site (DS) over time, and register associated complications and if it affected health-related quality of life (HRQoL). MATERIAL AND METHODS One hundred and seven patients participating in an RCT between two different methods of reconstruction after cervical decompression were included in this study. One group underwent surgery with bone graft (BG) from the iliac crest and the other with no bone graft (NBG). All patients were evaluated concerning pain at DS and HRQoL preoperatively, at 4 weeks, 3 months and 1 year. Pain was evaluated with visual analog scale (VAS) and HRQoL with EQ-5D. RESULTS A statistically significant difference was found at all times of follow-up in the BG group compared to preoperative levels and the NBG group. The VAS levels at follow-ups at 3 months and 1 year were however of questionable clinical importance. Two patients in the BG group had superficial wound infections postoperatively and five patients still had sensory disturbance in the area of graft site at 12 months. No major complications were registered. No difference could be seen in EQ-5D at any time of follow-up between the groups. CONCLUSION Harvesting of iliac crest bone graft is associated with significant pain. However, at 3 months postoperatively, the negative effect of clinical importance seemed to have disappeared compared to when no bone graft was harvested. The pain from bone graft harvesting does not seem to affect the quality of life at 4 weeks postoperatively and onward.
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Affiliation(s)
- M Skeppholm
- Stockholm Spine Center, Löwenströmska Hospital, Upplands Vasby, Sweden.
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1008
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Epstein NE. Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs. Surg Neurol Int 2012; 3:S143-56. [PMID: 22905321 PMCID: PMC3422096 DOI: 10.4103/2152-7806.98575] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 04/04/2012] [Indexed: 12/21/2022] Open
Abstract
Background: Grafting choices available for performing anterior cervical diskectomy/fusion (ACDF) procedures have become a major concern for spinal surgeons, and their institutions. The “gold standard”, iliac crest autograft, may still be the best and least expensive grafting option; it deserves to be reassessed along with the pros, cons, and costs for alternative grafts/spacers. Methods: Although single or multilevel ACDF have utilized iliac crest autograft for decades, the implant industry now offers multiple alternative grafting and spacer devices; (allografts, cages, polyether-etherketone (PEEK) amongst others). While most studies have focused on fusion rates and clinical outcomes following ACDF, few have analyzed the “value-added” of these various constructs (e.g. safety/efficacy, risks/complications, costs). Results: The majority of studies document 95%-100% fusion rates when iliac crest autograft is utilized to perform single level ACDF (X-ray or CT confirmed at 6-12 postoperative months). Although many allograft studies similarly quote 90%-100% fusion rates (X-ray alone confirmed at 6-12 postoperative months), a recent “post hoc analysis of data from a prospective multicenter trial” (Riew KD et. al., CSRS Abstract Dec. 2011; unpublished) revealed a much higher delayed fusion rate using allografts at one year 55.7%, 2 years 87%, and four years 92%. Conclusion: Iliac crest autograft utilized for single or multilevel ACDF is associated with the highest fusion, lowest complication rates, and significantly lower costs compared with allograft, cages, PEEK, or other grafts. As spinal surgeons and institutions become more cost conscious, we will have to account for the “value added” of these increasingly expensive graft constructs.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurosurgery, The Albert Einstein College of Medicine, Bronx, N.Y. 10451, and Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, N.Y. 11501
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1009
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Guyver P, Wakeling C, Naik K, Norton M. Judet osteoperiosteal decortication for treatment of non-union: the Cornwall experience. Injury 2012; 43:1187-92. [PMID: 22542168 DOI: 10.1016/j.injury.2012.03.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 03/20/2012] [Accepted: 03/31/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The treatment of non union can be challenging with a variety of surgical options available to achieve bone consolidation. Robert Judet first described a method of osteo-periosteal decortication in 1963. He stated that by elevating cortical chips that remain attached to the periosteum and overlying soft tissues surrounding the site of non-union, combined with mechanical support, the bone consolidated. Despite excellent results presented in 2008 of 99% union rates with a mean delay of 8 months, the technique has not yet become popularised. We aim to show that Judet's method of decortication can achieve good results in the management of failure of union in a hospital other than Judet's. METHODS Retrospective analysis was performed from December 2002 to December 2008 of 40 cases in 39 patients of osteoperiosteal decortication for fracture non-union. Concurrent stabilisation was with internal fixation only. All procedures were performed by one surgeon (MN) using the Judet technique after learning the technique in the originators hospital. A preoperative non union scoring system was also used to assess its use in predicting persistent non-union. RESULTS Union was successfully achieved in 36 of the 39 surviving cases (92.3%) after a median delay of 8 months (range 3-47, SD 9.2) Twenty-six patients (65%) achieved union following the decortication procedure without subsequent operations. Factors such as open fracture and smoking did not have a statistically significant effect on union. The mean number of procedures following decortication was 0.68 (range 0-4). Metalwork failure occurred in 11 cases (28%), the majority in femoral decortications (n=9, 82%). The femur was the site of all persistent non unions in the series. Three patients had superficial infections and two had deep infections. The pre-operative non union scoring system (0-100) means were noticeably worse for the persistent non union group 42.0 (20-46) compared with the union group 31.0 (range 4-52). CONCLUSIONS Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union. The non union scoring system is a reliable predictor of persistent non union after this type of surgery. CLINICAL RELEVANCE Relevant to general trauma orthopaedic surgeon and specialist orthopaedic surgeons with an interest in fracture non-union.
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Affiliation(s)
- Paul Guyver
- Royal Devon & Exeter Hospital, Barrack Rd, Exeter, EX2 5DW, United Kingdom.
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1010
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Sharma A, Meyer F, Hyvonen M, Best SM, Cameron RE, Rushton N. Osteoinduction by combining bone morphogenetic protein (BMP)-2 with a bioactive novel nanocomposite. Bone Joint Res 2012; 1:145-51. [PMID: 23610684 PMCID: PMC3629446 DOI: 10.1302/2046-3758.17.2000082] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 05/30/2012] [Indexed: 11/22/2022] Open
Abstract
Objectives There is increasing application of bone morphogenetic proteins
(BMPs) owing to their role in promoting fracture healing and bone
fusion. However, an optimal delivery system has yet to be identified.
The aims of this study were to synthesise bioactive BMP-2, combine
it with a novel α-tricalcium phosphate/poly(D,L-lactide-co-glycolide)
(α-TCP/PLGA) nanocomposite and study its release from the composite. Methods BMP-2 was synthesised using an Escherichia coli expression
system and purified. In vitro bioactivity was confirmed
using C2C12 cells and an alkaline phosphatase assay. The modified
solution-evaporation method was used to fabricate α-TCP/PLGA
nanocomposite and this was characterised using X-ray diffraction
and scanning electron microscopy. Functionalisation
of α-TCP/PLGA nanocomposite by adsorption of BMP-2 was performed
and release of BMP-2 was characterised using an enzyme-linked immunosorbent
assay (ELISA). Results Alkaline phosphatase activity of C2C12 cells was increased by
the presence of all BMP-2/nanocomposite discs compared with the
presence of a blank disc (p = 0.0022), and increased with increasing
incubation concentrations of BMP-2, showing successful adsorption
and bioactivity of BMP-2. A burst release profile was observed for
BMP-2 from the nanocomposite. Conclusions Functionalisation of α-TCP/PLGA with BMP-2 produced osteoinduction
and was dose-dependent. This material therefore has potential application
as an osteoinductive agent in regenerative medicine.
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Affiliation(s)
- A Sharma
- University of Cambridge, Department of Materials Science, Pembroke Street, Cambridge CB2 3QZ, UK
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1011
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Martinez V, Ammar SB, Judet T, Bouhassira D, Chauvin M, Fletcher D. Risk factors predictive of chronic postsurgical neuropathic pain: The value of the iliac crest bone harvest model. Pain 2012; 153:1478-1483. [DOI: 10.1016/j.pain.2012.04.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 03/08/2012] [Accepted: 04/05/2012] [Indexed: 11/25/2022]
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1012
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Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review. Injury 2012; 43:999-1005. [PMID: 21968245 DOI: 10.1016/j.injury.2011.08.025] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 07/25/2011] [Accepted: 08/18/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Locking plate osteosynthesis of proximal humeral fractures are widely recommended and used, even in complex intraarticular fracture patterns such as AO/OTA Type C fractures. We systematically reviewed clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in AO/OTA Type C fractures of the proximal humerus. METHODS We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study the outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently. RESULTS Twelve studies and 282 Type C fractures were included. Results were categorised according to study type and synthesised qualitatively. No randomised clinical trials were identified. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range, 4-33%), screw perforations (range, 5-20%), loss of fixation (range, 3-16%), impingement (range, 7-11%) and infections range 4-19%. Reoperation rate ranged from 6 to 44%. CONCLUSIONS Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in AO/OTA Type C fractures.
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1013
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Vilaça PR, Uezumi MK. Anterior minimally invasive bridge-plate technique for treatment of humeral shaft nonunion. J Orthop Traumatol 2012; 13:211-6. [PMID: 22717617 PMCID: PMC3506836 DOI: 10.1007/s10195-012-0203-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 06/06/2012] [Indexed: 11/29/2022] Open
Abstract
Background The present study introduces a new surgical technique and the results of a case series of patients with humeral shaft nonunion. Materials and methods Fifteen patients with diagnosis of diaphyseal nonunion of humerus were operated by a bridge-plate technique. A 4.5-mm plate is slid on the anterior surface of the humerus, submuscular to the brachial muscle. With the plate over the anterior surface of the humerus, screws are inserted from anterior to posterior on the ends of the plate. When there is a small bone gap, an iliac autologous graft is inserted. Minimum follow-up was 1 year. Results Bone healing was obtained in all patients: 1.5 months postoperatively in 11 patients, 2 months in 3 patients, and 3 months in 1 patient. There were no postoperative infections, there was one case with loosening of the screws and plate, and there were no nerve injuries. Conclusions The present technique avoids wide dissection, radial nerve isolation, and periosteum stripping. The anterior minimally invasive bridge-plate technique for treatment of humeral shaft nonunion is a safe procedure and obtained bone healing in all patients in this series.
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Affiliation(s)
- Paulo Roberto Vilaça
- Brazilian Orthopaedics and Traumatology Society-SBOT, Associação Beneficente Nossa Senhora do Pari, Hospital Nossa Senhora do Pari, Rua Hannemann, 234, São Paulo, SP, Brazil.
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1014
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Abstract
INTRODUCTION Antegrade intramedullary nailing is the method of choice in most femoral shaft fractures. The trochanteric entry portal of classic femoral nails is in close proximity to the piriformis tendon, the gluteus minimus tendon, the obturator tendons, and the medial femoral circumflex artery. Nail insertion lateral to the tip of the greater trochanter may be more favorable but needs the use of a helical implant. MATERIAL AND METHODS Measurement of the reamer pathway through an entry point lateral to the superior trochanteric border was performed with a three-dimensional motion tracking sensor in human cadaveric femurs. These results provided a scientific rationale for the design of a helical femoral nail (LFN®). In a prospective multicenter study a total of 227 femoral shaft fractures were treated by nailing with the LFN. Patients were followed at 3 months (n=193) and 12 months (n=167). RESULTS The ease of defining the entry point and inserting the nail was rated as"very good and good" by 90% of the surgeons. Intraoperative technical complications included incomplete reduction (14%), additional iatrogenic fractures (6%), and difficulties in interlocking (3.5%). At the 1-year follow-up, delayed unions were seen in 10%, secondary loss of reduction in 3%, and deep infection in 1.8% of the patients. Angular malalignment of more than 5° was seen in 5%, mostly in valgus. A normal walking capacity was seen in 68% and normal active hip flexion in 45%. CONCLUSION The results obtained in this study during 1 year do not provide evidence for an advantage of the LFN over conventional antegrade femoral nails.
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1015
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1016
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Niikura T, Miwa M, Lee SY, Oe K, Iwakura T, Sakai Y, Koh A, Koga T, Dogaki Y, Okumachi E, Kurosaka M. Technique to prepare the bed for autologous bone grafting in nonunion surgery. Orthopedics 2012; 35:491-5. [PMID: 22691637 DOI: 10.3928/01477447-20120525-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This article describes a technique for preparing the bed for autologous bone grafting in nonunion surgery. The procedure is divided into 2 steps. First, both ends of the fracture fragments are chipped into small pieces using an osteotome and hammer without peeling off the periosteum, creating pathways into the bone marrow. Second, cancellous bone harvested from the iliac crest is grafted into the aperture created by the previous bone chipping treatment. The technique is easy to perform and is a promising approach for enhancing bone healing in nonunion and delayed union.
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Affiliation(s)
- Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan. tniikura@ med.kobe-u.ac.jp
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1017
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Koth K, Boniface J, Chance EA, Hanes MC. Enterobacter asburiae and Aeromonas hydrophila: soft tissue infection requiring debridement. Orthopedics 2012; 35:e996-9. [PMID: 22691684 DOI: 10.3928/01477447-20120525-52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Enterobacter asburiae and Aeromonas hydrophila are gram-negative bacilli that have been isolated in soil and water. Enterobacter asburiae can cause an array of diseases, and exposure to A hydrophila can cause soft tissue infections, including necrotizing faciitis.A healthy-appearing 22-year-old man presented with an innocuous soft tissue injury to his leg due to an all-terrain vehicle crash. He received intravenous antibiotics and was discharged with prophylactic oral antibiotics. After the rapid onset of high fevers (102°F-103°F) <24 hours postinjury, he returned to the emergency department. Emergent surgical debridement was performed, and broad-spectrum intravenous antibiotics were started. Fevers persisted, and the patient underwent repeat extensive surgical debridement and antibiotic bead placement <30 hours after the initial surgical debridement and broad-spectrum antibiotics. Intraoperative cultures found E asburiae and A hydrophila in the wound. Following a long course of antibiotics and a skin graft, he fully recovered and had no functional deficits 1 year postoperatively.Extensive research revealed that these organisms are rare in soft tissue infections. E asburiae is opportunistic but has not been reported as a primary wound organism, and A hydrophila infections have been reported following motor vehicle crashes involving wound contamination. At presentation, it is challenging to determine rare organisms in a timely fashion; however, emergent extensive surgical intervention of an accelerated aberrant disease process should be considered to avoid catastrophic outcomes.
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1018
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1019
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Makridis KG, Ahmad MA, Kanakaris NK, Fragkakis EM, Giannoudis PV. Reconstruction of iliac crest with bovine cancellous allograft after bone graft harvest for symphysis pubis arthrodesis. INTERNATIONAL ORTHOPAEDICS 2012; 36:1701-7. [PMID: 22729663 DOI: 10.1007/s00264-012-1572-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 05/01/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the safety and efficiency, as well as the incorporation characteristics of a specific type of xenograft used for iliac crest defects post-harvesting tri-cortical iliac crest bone graft. METHODS Sixteen patients diagnosed with chronic anterior pelvic pain were operated for pubic symphysis fusion. The tri-cortical graft harvested from the iliac crest was inserted into the pubic symphysis and compressed with a reconstruction plate. The defect in the iliac crest was filled with a block of cancellous bovine substitute (Tutobone®). The length of iliac crest defect, time to fusion of pubic symphysis, time to incorporation of the graft and complications were recorded. The postoperative pain and patients' satisfaction were evaluated. RESULTS The median age of patients was 36.5 years (range 27-75). Fusion was obtained in 15 patients (94 %). The median time to fusion was four months (range three to seven). The length of the iliac crest bone defect ranged from 40 to 70 mm. Integration of the bovine substitute was achieved in 15 patients (94 %) over a median period of three months (range two to six). The postoperative median pain score was 2 (range 1-5). Twelve patients (75 %) reported good satisfaction. No major complications or allergic reactions were observed. CONCLUSIONS The xenograft used in this study provided a safe and effective method of reconstruction of iliac crest donor site defects. It has satisfactory incorporation, high biocompatibility and no signs of inflammatory reactions. This new technique is simple and easily reproducible in routine clinical practice.
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Affiliation(s)
- Konstantinos G Makridis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing Level A, Great George Street, LS1 3EX, Leeds, West Yorkshire, UK
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1020
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Wijnands KAP, Brink PRG, Weijers PHE, Dejong CHC, Poeze M. Impaired fracture healing associated with amino acid disturbances. Am J Clin Nutr 2012; 95:1270-7. [PMID: 22492379 DOI: 10.3945/ajcn.110.009209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Five percent to 10% of all fracture patients experience an inadequate healing process that results in a nonunion of fracture parts. Previous experimental studies have indicated the importance of sufficient nitric oxide production from arginine during normal fracture healing. However, during conditions of stress, such as inflammation, arginine availability can become limited, which may lead to a nonunion as a result of insufficient callus formation. OBJECTIVE The aim of this study was to measure callus and plasma amino acid concentrations in patients with and without a fracture nonunion. DESIGN Amino acid concentrations in plasma and callus were measured with HPLC in atrophic nonunions (n = 12) and compared with those in hypertrophic nonunions (n = 12), acute fractures (n = 15), and healed fractures (n = 8). RESULTS Arginine (61 compared with 180 μmol/mg; P < 0.0001), citrulline (13 compared with 44 μmol/mg; P < 0.0001), and ornithine (25 compared with 149 μmol/mg; P < 0.0001) in callus were significantly lower in atrophic-nonunion patients than in healed-fracture patients. In hypertrophic nonunions, arginine was significantly higher and ornithine was lower than in healed fractures. Plasma arginine concentrations were significantly lower in patients with hypertrophic nonunions (62 μmol/L; P < 0.001) and acute-fracture patients (41 μmol/L; P < 0.001) but not in atrophic-nonunion patients. Plasma ornithine concentrations were lower in all groups than in acute-fracture patients. CONCLUSIONS Amino acid concentrations were significantly changed in nonunion patients. Atrophic nonunions had lower concentrations of all amino acids, whereas hypertrophic nonunions had higher arginine and lower ornithine concentrations at fracture sites than did healed-fracture and acute-fracture patients.
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Affiliation(s)
- Karolina A P Wijnands
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
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1021
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TeBockhorst S, Gurunluoglu R. Four Extremity Necrotizing Fasciitis without Involvement of the Trunk or Head. Am Surg 2012. [DOI: 10.1177/000313481207800406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Seth TeBockhorst
- Rocky Mountain Regional Trauma Center at Denver Health Medical Center University of Colorado Denver, Colorado
| | - Raffi Gurunluoglu
- Rocky Mountain Regional Trauma Center at Denver Health Medical Center University of Colorado Denver, Colorado
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1022
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Chen SB, Zhang CQ, Jin DX, Cheng XG, Sheng JG, Zeng BF. Treatment of aseptic nonunion after intramedullary nailing fixation with locking plate. Orthop Surg 2012; 1:258-63. [PMID: 22009872 DOI: 10.1111/j.1757-7861.2009.00040.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of locking plate combined with bone grafting in the treatment of aseptic nonunion following intramedullary nailing fixation of fractures of the long bones. METHODS Thirty-eight consecutive patients treated in our hospital between January 2004 and December 2006 were included in this retrospective study. The nonunions included 20 femurs, 15 tibias, and 3 humeri. The duration of non-union ranged from 6 to 84 months and 21 (55.3%) of them were located around the metaphysis of the affected long bones. There were 12 women and 26 men with a mean age of 39.2 years (range, 9-70 years). Locking plate combined with bone grafting was the procedure chosen to treat every case of nonunion in this series. The clinical outcomes were evaluated. RESULTS All patients were followed up for 6-20 months (average 11.6 months). After locking plate fixation combined with bone grafting, union was achieved in all cases, the average healing time being 5.3 months (range, 4-8 months). Infection of the superficial incision occurred in three cases (7.9%) and delayed healing of the incision in one case, all of which healed with no further complications. The function of the adjacent joints was excellent to good in 30 patients (78.9%), fair in 7 (18.4%) and poor in 1 (2.6%) after follow-up. CONCLUSION Locking plate fixation combined with bone grafting is a highly effective treatment for aseptic nonunions of the long bones after intramedullary nailing fixation, especially in the case of metaphyseal nonunion.
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Affiliation(s)
- Sheng-bao Chen
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
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1023
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Jaeger M, Izadpanah K, Maier D, Reising K, Strohm P, Südkamp N. Frakturen des Humeruskopfes. Chirurg 2012; 83:285-94; quiz 295-6. [DOI: 10.1007/s00104-011-2262-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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1024
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Microbiology and surgical indicators of necrotizing fasciitis in a tertiary hospital of southwest Taiwan. Int J Infect Dis 2012; 16:e159-65. [DOI: 10.1016/j.ijid.2011.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 10/12/2011] [Accepted: 08/26/2011] [Indexed: 11/19/2022] Open
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1025
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Abstract
Locking plates are increasingly used to surgically treat proximal humerus fractures. Knowledge of the bone quality of the proximal humerus is important. Studies have shown the medial and dorsal aspects of the proximal humeral head to have the highest bone strength, and this should be exploited by fixation techniques, particularly in elderly patients with osteoporosis. The goals of surgery for proximal humeral fractures should involve minimal soft tissue dissection and achieve anatomic reduction of the head complex with sufficient stability to allow for early shoulder mobilization. This article reviews various treatment options, in particular locking plate fixation. Locking plate fixation is associated with a high complication rate, such as avascular necrosis (7.9%), screw cutout (11.6%), and revision surgery (13.7%). These complications are frequently due to the varus deformation of the humeral head. Strategic screw placement in the humeral head would minimize the possibility of loss of fracture reduction and potential hardware complications. Locking plate fixation is a good surgical option for the management of proximal humerus fractures. Complications can be avoided by using better bone stock and by careful screw placement in the humeral head.
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Affiliation(s)
- Neil G Burke
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland.
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1026
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Liu CT, Chen YC, Chen TH, Ou TY. Necrotizing fasciitis of thigh associated with Escherichia coli bacteremia in a patient on chronic hemodialysis. Hemodial Int 2012; 16:564-7. [PMID: 22304536 DOI: 10.1111/j.1542-4758.2011.00658.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Necrotizing fasciitis is a lethal soft tissue infection for its rapid progression to septic shock. We present a 59-year-old male on chronic hemodialysis (HD). We made the diagnosis of necrotizing fasciitis of the right thigh due to the crepitus from physical examination and subcutaneous emphysema from an X film. He was successfully treated with antibiotics and surgical debridement. The blood and surgical drainage cultures showed Escherichia coli, which is less commonly seen in cutaneous infection. The colonoscopic finding revealed adenomatous polyps. Necrotizing fasciitis in patients on HD requires early diagnosis and aggressive treatment to ensure the favorable clinical outcomes.
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Affiliation(s)
- Chung-Te Liu
- Division of Nephrology, Department of Medicine, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
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1027
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Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S. Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury 2012; 43:153-8. [PMID: 21570073 DOI: 10.1016/j.injury.2011.04.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/28/2011] [Accepted: 04/04/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters. METHODS A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05. RESULTS In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate. CONCLUSION Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.
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Affiliation(s)
- Francois Hardeman
- Orthopaedics and Traumatology, University Hospital Leuven, Leuven, Belgium.
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1028
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O'Malley NT, Kates SL. Advances on the Masquelet technique using a cage and nail construct. Arch Orthop Trauma Surg 2012; 132:245-8. [PMID: 22072192 DOI: 10.1007/s00402-011-1417-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Indexed: 11/24/2022]
Abstract
Traumatic, cancerous or infectious loss of bone is treated by either amputation or reconstruction. With limb salvage always preferable, surgeons rely on already established techniques such as grafting and distraction osteogenesis to avoid amputation, and ideally restore structure and thus function. The Masquelet technique is an effective method of bone reconstruction and limb salvage which is underreported in the English literature, and we report a case with advances using a cage and nail construct, resulting in successful eradication of methicillin resistant staphylococcus aureus infection and reconstitution of a 17 cm diaphyseal defect in the tibia.
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Affiliation(s)
- Natasha T O'Malley
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY 14624, USA
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1029
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Complex fractures of the proximal humerus in the elderly—outcome and complications after locking plate fixation. Musculoskelet Surg 2012; 96 Suppl 1:S3-11. [PMID: 22287062 DOI: 10.1007/s12306-012-0181-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 01/16/2012] [Indexed: 10/14/2022]
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1030
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Acklin Y, Sommer C. Plate fixation of proximal humerus fractures using the minimally invasive anterolateral delta split approach. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:61-73. [DOI: 10.1007/s00064-011-0051-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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1031
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Necrotizing Fasciitis: Diagnostic Challenges in a Mute Bedridden Patient with Atypical Laboratory Parameters. Case Rep Med 2012. [PMID: 23197984 PMCID: PMC3502839 DOI: 10.1155/2012/253906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 27-year-old mute bedridden patient required parenteral corticosteroids and antibiotics, and hospitalization for an acute respiratory illness. After 2 days, staff noted a ~0.3 cm blister on the patient's right heel. Within 19 hours, blistering increased and the foot became partly gangrenous. The patient developed high fever (40.3°C), and leukocytosis (count: 13 × 109/L; was 6.5 × 109/L ten days earlier). Necrotizing fasciitis (NF) was diagnosed and treated with emergency leg amputation. Histopathology revealed necrosis of fascia, muscle, subcutaneous tissue, and skin.
In bedridden patients, corticosteroids may particularly facilitate serious infections, and initial NF blistering may be mistaken for pressure ulcers. Vigilant and frequent whole body monitoring is necessary for all patients incapable of verbalizing their symptoms.
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1032
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Abstract
There remains a substantial shortfall in the treatment of severe skeletal injuries. The current gold standard of autologous bone grafting from the same patient has many undesirable side effects associated such as donor site morbidity. Tissue engineering seeks to offer a solution to this problem. The primary requirements for tissue-engineered scaffolds have already been well established, and many materials, such as polyesters, present themselves as potential candidates for bone defects; they have comparable structural features, but they often lack the required osteoconductivity to promote adequate bone regeneration. By combining these materials with biological growth factors, which promote the infiltration of cells into the scaffold as well as the differentiation into the specific cell and tissue type, it is possible to increase the formation of new bone. However due to the cost and potential complications associated with growth factors, controlling the rate of release is an important design consideration when developing new bone tissue engineering strategies. This paper will cover recent research in the area of encapsulation and release of growth factors within a variety of different polymeric scaffolds.
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1033
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Looney M, Shea HO, Gunn L, Crowley D, Boyd D. An evaluation of the processing conditions, structure, and properties (biaxial flexural strength and antibacterial efficacy) of sintered strontium–zinc–silicate glass ceramics. J Biomater Appl 2011; 27:937-47. [DOI: 10.1177/0885328211430423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of artificial bone grafts has increased in order to satisfy a growing demand for bone replacement materials. Initial mechanical stability of synthetic bone grafts is very advantageous for certain clinical applications. Coupled with the advantage of mechanical strength, a material with inherent antibacterial properties would be very beneficial. A series of strontium-doped zinc silicate (Ca–Sr–Na–Zn–Si) glass ceramics have been characterized in terms of their crystalline structure, biaxial flexural strength and antibacterial efficacy based on the identification of optimum sintering conditions. All three glass ceramics, namely, BT110, BT111, and BT112 were found to be fully crystalline, with BT111 and BT112 comprising of biocompatible crystalline phases. The biaxial flexural strengths of the three glass ceramics ranged from 70 to 149 MPa and were shown to be superior to those of clinically established ceramics in dry conditions and following incubation in simulated physiological conditions. The bacteriostatic effect for each glass ceramic was also established, where BT112 showed an inhibitory effect against three of the most common bacteria found at implantation sites, namely, Enterococcus faecalis, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa. The results of the evaluation suggest that the materials studied offer advantages over current clinical materials and indicate the potential suitability of the glass ceramics as therapeutic bone grafts.
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Affiliation(s)
- Mark Looney
- Medical Engineering Design and Innovation Centre, Cork Institute of Technology, Ireland
| | - Helen O' Shea
- Department of Biological Sciences, Cork Institute of Technology, Ireland
| | - Lynda Gunn
- Department of Biological Sciences, Cork Institute of Technology, Ireland
| | - Dolores Crowley
- Department of Biological Sciences, Cork Institute of Technology, Ireland
| | - Daniel Boyd
- Department of Applied Oral Sciences, Dalhousie University, Halifax, B3H 4R2, Canada
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1034
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Roje Z, Roje Ž, Matić D, Librenjak D, Dokuzović S, Varvodić J. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emerg Surg 2011; 6:46. [PMID: 22196774 PMCID: PMC3310784 DOI: 10.1186/1749-7922-6-46] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/23/2011] [Indexed: 12/20/2022] Open
Abstract
Necrotizing fasciitis (NF) is an uncommon soft tissue infection, usually caused by toxin-producing virulent bacteria. It is characterized by widespread fascial necrosis primarily caused by Streptococcus hemolyticus. Shortly after the onset of the disease, patients become colonized with their own aerobic and anaerobic microflora from the gastrointestinal and/or urogenital tracts. Early diagnosis with aggressive multidisciplinary treatment is mandatory. We describe three clinical cases with NF. The first is a 69 years old man with diabetes mellitus type II, who presented with NF on the posterior chest wall, shoulder and arm. He was admitted to the intensive care unit (ICU) with a clinical picture of severe sepsis. Outpatient treatment and early surgical debridement of the affected zones (inside 3 hours after admittance) and critical care therapy were performed. The second case is of a 63 years old paraplegic man with diabetes mellitus type I. Pressure sores and perineal abscesses progressed to Fournier's gangrene of the perineum and scrotum. He had NF of the anterior abdominal wall and the right thigh. Outpatient treatment and early surgical debridement of the affected zones (inside 6 hour after admittance) and critical care therapy were performed. The third patient was a 56 year old man who had NF of the anterior abdominal wall, flank and retroperitoneal space. He had an operation of the direct inguinal hernia, which was complicated with a bowel perforation and secondary peritonitis. After establishing the diagnosis of NF of the abdominal wall and retroperitoneal space (RS), he was transferred to the ICU. There he first received intensive care therapy, after which emergency surgical debridement of the abdominal wall, left colectomy, and extensive debridement of the RS were done (72 hours after operation of inquinal hernia). On average, 4 serial debridements were performed in each patient. The median of serial debridement in all three cases was four times. Other intensive care therapy with a combination of antibiotics and adjuvant hyperbaric oxygen therapy (HBOT) was applied during the treatment. After stabilization of soft tissue wounds and the formation of fresh granulation tissue, soft tissue defect were reconstructed using simple to complex reconstructive methods.
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Affiliation(s)
- Zdravko Roje
- Division of Plastic Surgery and Burns, University Hospital Centre Split, Croatia
| | - Željka Roje
- Department of Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Dario Matić
- Department of Surgery, University Hospital Centre Split, Croatia
| | - Davor Librenjak
- Department of Urology, University Hospital Centre Split, Croatia
| | - Stjepan Dokuzović
- Department of Orthopedic Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Josip Varvodić
- Deparment of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
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1035
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Abstract
Proximal humeral fractures were managed with primary hemiarthroplasty in 57 patients, 53 women (93%) and 4 men (7%) aged 51–87 years (mean 72.2). The mean follow-up period was 52 months (range 12–98), and the mean Constant score was 59.2 (range 38–76). Patients were very satisfied (n = 19); satisfied (n = 32) or dissatisfied with the outcome (n = 5). One patient required early revision surgery. Surgical treatment of three- and four-part fractures of the proximal humerus with hemiarthroplasty is a safe and effective approach, the outcome of which appears to be related to the quality of the anatomical reconstruction of the tuberosities.
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1036
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Abstract
BACKGROUND Locking-plate technology has renewed interest in plate fixation for treating proximal humerus fractures. Complications associated with these devices, including loss of reduction, screw cutout, and intra-articular penetration, are frequent. Establishing a second column of support may reduce complications and improve clinical outcome scores. QUESTIONS/PURPOSES We asked whether addition of an endosteal cortical allograft strut, used as an augment to locking-plate fixation for displaced proximal humerus fractures, would reduce complications and improve clinical outcome scores. PATIENTS AND METHODS We retrospectively reviewed the charts and radiographs of 38 patients treated by this method. All patients were evaluated with serial radiographs, as well as the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores. There were seven two-part, 19 three-part, and 12 four-part fractures. The minimum followup was 49 weeks (average, 75 weeks; range, 49-155 weeks). RESULTS No patient had intra-articular screw penetration or cutout. No patient had complete osteonecrosis, but one had partial osteonecrosis. The reduction was lost in one patient. The mean Disabilities of the Arm, Shoulder, and Hand score was 15 (range, 0-66.4). The mean Constant-Murley score was 87 (range, 51-95). CONCLUSIONS Low rates of complication and high clinical outcome scores can be achieved when treating complex proximal humerus fractures with locking-plate fixation and an endosteal strut augment. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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1037
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Steckel H, Baums MH, Tennstedt-Schenk C, Klinger HM. Necrotizing fasciitis of the knee following primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2011; 19:2076-9. [PMID: 21647659 DOI: 10.1007/s00167-011-1561-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 05/19/2011] [Indexed: 10/24/2022]
Abstract
Necrotizing fasciitis is a rare, life-threatening and rapidly spreading soft-tissue infection that results in necrosis of the muscle, fascia and surrounding tissue. It can be result of a polymicrobial synergistic infection or a streptococcal infection. The authors report a case of necrotizing fasciitis occurring in the knee of a 65-year-old woman following an uneventful primary total knee arthroplasty and resulting in above-the-knee amputation. Having in mind severe infections like necrotising fasciitis, one should be aware of the possibility of such postoperative complications especially in patients with risk factors even in routine procedures like a total knee arthroplasty.
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1038
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Südkamp NP, Audigé L, Lambert S, Hertel R, Konrad G. Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures. J Shoulder Elbow Surg 2011; 20:1207-16. [PMID: 21920779 DOI: 10.1016/j.jse.2011.06.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 06/06/2011] [Accepted: 06/13/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated. MATERIALS AND METHODS Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships. RESULTS Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30° were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships. CONCLUSION Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture.
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Affiliation(s)
- Norbert P Südkamp
- Orthopädie und Traumatologie, Universitätsklinikum Freiburg, Albert-Ludwigs-Universität, Freiburg, Germany
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1039
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Konrad G, Hirschmüller A, Audige L, Lambert S, Hertel R, Südkamp NP. Comparison of two different locking plates for two-, three- and four-part proximal humeral fractures--results of an international multicentre study. INTERNATIONAL ORTHOPAEDICS 2011; 36:1051-8. [PMID: 22127383 DOI: 10.1007/s00264-011-1410-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/01/2011] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates. METHODS The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year. RESULTS At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p < 0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p > 0.05). CONCLUSIONS PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures.
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Affiliation(s)
- Gerhard Konrad
- Orthopaedic and Trauma Surgery, KKH Erding, Bajuwarenstrasse 5, 85435, Erding, Germany.
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1040
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Jaeger M, Maier D, Izadpanah K, Strohm P, Südkamp NP. Grenzen der Rekonstruktion – Prothesen. Unfallchirurg 2011; 114:1068-74. [PMID: 22108770 DOI: 10.1007/s00113-011-2054-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Jaeger
- Department Orthopädie und Traumatologie, Universitätsklinikum Freiburg, Hugstetter Straße 55, 79106, Freiburg i.Br., Deutschland.
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1041
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Wähnert D, Windolf M, Brianza S, Rothstock S, Radtke R, Brighenti V, Schwieger K. A comparison of parallel and diverging screw angles in the stability of locked plate constructs. ACTA ACUST UNITED AC 2011; 93:1259-64. [PMID: 21911539 DOI: 10.1302/0301-620x.93b9.26721] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the static and cyclical strength of parallel and angulated locking plate screws using rigid polyurethane foam (0.32 g/cm(3)) and bovine cancellous bone blocks. Custom-made stainless steel plates with two conically threaded screw holes with different angulations (parallel, 10° and 20° divergent) and 5 mm self-tapping locking screws underwent pull-out and cyclical pull and bending tests. The bovine cancellous blocks were only subjected to static pull-out testing. We also performed finite element analysis for the static pull-out test of the parallel and 20° configurations. In both the foam model and the bovine cancellous bone we found the significantly highest pull-out force for the parallel constructs. In the finite element analysis there was a 47% more damage in the 20° divergent constructs than in the parallel configuration. Under cyclical loading, the mean number of cycles to failure was significantly higher for the parallel group, followed by the 10° and 20° divergent configurations. In our laboratory setting we clearly showed the biomechanical disadvantage of a diverging locking screw angle under static and cyclical loading.
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Affiliation(s)
- D Wähnert
- University Hospital Münster, Department of Trauma Surgery, Waldeyerstrasse 1, Münster 48149, Germany.
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1042
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Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury 2011; 42:1283-8. [PMID: 21310406 DOI: 10.1016/j.injury.2011.01.017] [Citation(s) in RCA: 229] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Revised: 01/11/2011] [Accepted: 01/17/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Several studies reported high failures rates after internal fixation of proximal humerus fractures. Loss of reduction and screw cut-out are the most common reasons for revision surgery. Several risk factors for failure have been described in the literature. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup. METHODS Two different surgical techniques (PHILOS locking plate and Humerusblock) were used. In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure. In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure. The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support. RESULTS The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support. The failure rate significantly increased with the number of risk factors. CONCLUSION Preoperative assessment of the local BMD and the patients' biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures. Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure. If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered.
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Affiliation(s)
- Dietmar Krappinger
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstraße 35, A-6020 Innsbruck, Austria.
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1043
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Noh JH, Yang BG, Roh YH, Lee JS. Synovialization on second-look arthroscopy after anterior cruciate ligament reconstruction using Achilles allograft in active young men. Knee Surg Sports Traumatol Arthrosc 2011; 19:1843-50. [PMID: 21409462 DOI: 10.1007/s00167-011-1476-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 02/24/2011] [Indexed: 12/24/2022]
Abstract
PURPOSE This study is to assess the relationship between clinical outcomes and the extent of synovialization through second-look arthroscopy for anterior cruciate ligament (ACL) reconstruction using Achilles allograft in active young men. METHODS Ninety-five subjects were diagnosed with ACL rupture and underwent reconstruction with Achilles allograft. Median age was 22 years old (range, 17-40). Mean period from injury to operation was 15.1 ± 18.2 weeks. Lysholm score, IKDC classification, range of motion (ROM) of knee, and side-to-side difference (SSD) in anterior instability were evaluated preoperatively and at the last follow-up. Tegner activity scale was evaluated before injury and at the final follow-up. The extent of synovialization of the graft was evaluated under second-look arthroscopy at least 1 year after surgery. Formation of the synovial membrane was divided into four groups-group 1 for 25% or less, group 2 for 25-50%, group 3 for 50-75%, and group 4 for more than 75%. Outcomes were compared between each group. RESULTS Lysholm score and IKDC classification were improved after surgery (P < 0.05). Most subjects had full ROM at the final follow-up except three subjects that showed flexion deficit of 5 degrees or less. Mean SSD in anterior instability was 9.0 ± 2.1 mm preoperatively and 1.6 ± 2.0 mm at the final follow-up (P < 0.001). Median Tegner activity scale was 7 before injury and 7 at the final follow-up (P < 0.001). Twelve subjects were in group 1, 10 in group 2, 14 in group 3, and 59 in group 4. Clinical outcomes depending on the extent of synovialization of the grafts were different between each group (P < 0.05). The average period from injury to reconstruction in each group was significantly different (P < 0.001). Correlation coefficient between the period from injury to reconstruction and the extent of synovialization was -0.411 (P < 0.001). CONCLUSION The extent of the synovialization is positively correlated with clinical outcomes and is negatively correlated with the period from injury to reconstruction.
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Affiliation(s)
- Jung Ho Noh
- National Police Hospital, Songpa-gu, Seoul, Korea
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1044
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Abstract
Unstable and displaced proximal humerus fractures remain a treatment challenge. The use of locked plates has improved construct stability, but complication rates remain high. Biomechanical studies have emphasized the importance of anchoring screws in the subchondral bone of the humeral head to improve implant stability. However, the spherical shape of the proximal humerus and the limited tactile sensation of its soft cancellous bone make determining accurate screw length difficult, and reported rates of intraoperative screw penetration are high. Iatrogenic screw penetration, even if recognized and corrected before leaving the operating room, may lead to late failure. We present a simple technique of quickly and safely determining screw length using a blunt-tipped Kirschner wire and instruments found in basic orthopaedic sets.
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1045
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Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma 2011; 25:612-7. [PMID: 21654525 DOI: 10.1097/bot.0b013e3182008df8] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Proximal humerus fractures are common in the setting of osteopenia and osteoporosis and can often be treated nonoperatively. There are few studies that evaluate the long-term outcomes of nonoperative treatment of these fractures. We performed a systematic review of the literature to examine the results of nonoperative treatment of proximal humerus fractures. METHODS The PubMed search engine and EMBASE database were used. Inclusion criteria were: 1) proximal humerus fractures resulting from trauma; 2) age older than 18 years; 3) more than 15 patients in the study; 4) greater than 1 year follow-up; 5) at least one relevant functional outcome score; and 6) a quality outcome score of at least a 5 of 10 according to previously published scoring system. RESULTS We identified 12 studies that included 650 patients with a mean age of 65.0 years (range, 51-75 years) and a mean follow-up of 45.7 months (range, 12-120 months). There were 317 one-part fractures, 165 two-part fractures, 137 three-part fractures, and 31 four-part fractures. The rate of radiographic union was 98% and the complication rate 13%. The average range of motion reported in five studies was 139° forward flexion, 48° external rotation, and 52° internal rotation. The average Constant score reported in six studies was 74 (range, 55-81). Varus malunion was the most common complication reported, whereas avascular necrosis was uncommon (13 cases). CONCLUSIONS We conclude that our systematic review of the literature on the nonoperative treatment of proximal humerus fractures demonstrates high rates of radiographic healing, good functional outcomes, and a modest complication rate.
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Affiliation(s)
- Jaicharan J Iyengar
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
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1046
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Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. The calcar screw in angular stable plate fixation of proximal humeral fractures--a case study. J Orthop Surg Res 2011; 6:50. [PMID: 21943090 PMCID: PMC3189144 DOI: 10.1186/1749-799x-6-50] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 09/24/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With new minimally-invasive approaches for angular stable plate fixation of proximal humeral fractures, the need for the placement of oblique inferomedial screws ('calcar screw') has increasingly been discussed. The purpose of this study was to investigate the influence of calcar screws on secondary loss of reduction and on the occurrence of complications. METHODS Patients with a proximal humeral fracture who underwent angular stable plate fixation between 01/2007 and 07/2009 were included. On AP views of the shoulder, the difference in height between humeral head and the proximal end of the plate were determined postoperatively and at follow-up. Additionally, the occurrence of complications was documented. Patients with calcar screws were assigned to group C+, patients without to group C-. RESULTS Follow-up was possible in 60 patients (C+ 6.7 ± 5.6 M/C- 5.0 ± 2.8 M). Humeral head necrosis occurred in 6 (C+, 15.4%) and 3 (C-, 14.3%) cases. Cut-out of the proximal screws was observed in 3 (C+, 7.7%) and 1 (C-, 4.8%) cases. In each group, 1 patient showed delayed union. Implant failure or lesions of the axillary nerve were not observed. In 44 patients, true AP and Neer views were available to measure the head-plate distance. There was a significant loss of reduction in group C- (2.56 ± 2.65 mm) compared to C+ (0.77 ± 1.44 mm; p = 0.01). CONCLUSIONS The placement of calcar screws in the angular stable plate fixation of proximal humeral fractures is associated with less secondary loss of reduction by providing inferomedial support. An increased risk for complications could not be shown.
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Affiliation(s)
- Georg Osterhoff
- Division of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
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1047
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Necrotizing fasciitis of the extremities: a prospective study. Strategies Trauma Limb Reconstr 2011; 6:121-5. [PMID: 21863299 PMCID: PMC3225576 DOI: 10.1007/s11751-011-0116-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 07/09/2011] [Indexed: 12/02/2022] Open
Abstract
Necrotizing fasciitis is a rapidly progressive infection and is a necrosis of the fascia and surrounding tissues. Despite recent advances in its management, outcomes have not improved and mortality rate is still high. Between September 2007 and August 2009, we prospectively studied twenty-four histopathologically proven necrotizing fasciitis patients to assess the prognostic factors that indicate the outcome. Mortality rate was 20.8%. Twelve patients (50%) improved, while seven patients (29.2%) were complicated by limb loss. Mortality rates related to upper and lower limb involvement were similar (20% vs. 22.2%). The rates of gangrene and amputation in patients with diabetes mellitus were significantly higher than other comorbidities. Patients with gram-positive infections had significantly lower rates of amputation (15.4% vs. 54.5%, P = 0.04). Mean band cell count and serum potassium level were significantly higher in the nonsurvivors same as leukocyte count in the patients with gangrene, while serum sodium level was significantly lower in nonsurvivors. We conclude that hyponatremia, hyperkalemia, and increased band cells in the peripheral blood of patients may be useful parameters in distinguishing life-threatening necrotizing fasciitis; hence, we recommended lower threshold to amputation during surgery for this group of patients.
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1048
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Brorson S, Frich LH, Winther A, Hróbjartsson A. Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus. Acta Orthop 2011; 82:475-81. [PMID: 21657970 PMCID: PMC3237040 DOI: 10.3109/17453674.2011.588856] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 03/08/2011] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There is considerable uncertainty about the optimal treatment of displaced 4-part fractures of the proximal humerus. Within the last decade, locking plate technology has been considered a breakthrough in the treatment of these complex injuries. METHODS We systematically identified and reviewed clinical studies on the benefits and harms after osteosynthesis with locking plates in displaced 4-part fractures. RESULTS We included 14 studies with 374 four-part fractures. There were 10 case series, 3 retrospective observational comparative studies, 1 prospective observational comparative study, and no randomized trials. Small studies with a high risk of bias precluded reliable estimates of functional outcome. High rates of complications (16-64%) and reoperations (11-27%) were reported. INTERPRETATION The empirical foundation for the value of locking plates in displaced 4-part fractures of the proximal humerus is weak. We emphasize the need for well-conducted randomized trials and observational studies.
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Affiliation(s)
- Stig Brorson
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark.
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1049
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Management of a periprosthetic fracture after humeral head resurfacing total shoulder replacement: a case report. J Shoulder Elbow Surg 2011; 20:e18-21. [PMID: 21600790 DOI: 10.1016/j.jse.2011.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 02/06/2011] [Accepted: 02/11/2011] [Indexed: 02/01/2023]
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1050
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Cornell CN, Ayalon O. Evidence for success with locking plates for fragility fractures. HSS J 2011; 7:164-9. [PMID: 22754418 PMCID: PMC3145849 DOI: 10.1007/s11420-010-9194-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 12/15/2010] [Indexed: 02/07/2023]
Abstract
Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.
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Affiliation(s)
- Charles N. Cornell
- Hospital For Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Weill Cornell College of Medicine, New York, NY 10065 USA
| | - Omri Ayalon
- Hospital For Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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