Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone

BACKGROUND

Failure to achieve stable fixation with medial support in proximal humeral fractures can result in varus malalignment and cut-through of the proximal screws. The purpose of this study was to investigate the influence of an intramedullary fibula bone graft on the biomechanical properties of proximal humeral fractures stabilized by angular stable plate fixation in a bone model under cyclic loading.

METHODS

Two fixation techniques were tested in 20 composite analog humeri models. In group F- (n = 10), fractures were fixed by an anatomically formed locking plate system. In group F+ (n = 10), the same fixation system was used with an additional fibular graft model with a length of 6 cm inserted in an intramedullary manner. Active abduction was simulated for 400 cycles by use of a recently established testing setup. Fragment gap distance was measured, and thereby, intercyclic motion, fragment migration, and residual plastic deformation were determined.

RESULTS

The addition of a fibular graft to the fixation plate led to 5 times lower intercyclic motion, 2 times lower fragment migration, and 2 times less residual plastic deformation. Neither screw pullout, cut-through, nor implant failure was observed.

CONCLUSION

Medial support with an intramedullary fibular graft in an angular stable fixation of the proximal humerus in vitro increases overall stiffness of the bone-implant construct and reduces migration of the humeral head fragment. This technique might provide a useful tool in the treatment of displaced proximal humeral fractures, especially when there is medial comminution.

The microbiological profile and presence of bloodstream infection influence mortality rates in necrotizing fasciitis

Introduction

Necrotizing fasciitis (NF) is a life threatening infectious disease with a high mortality rate. We carried out a microbiological characterization of the causative pathogens. We investigated the correlation of mortality in NF with bloodstream infection and with the presence of co-morbidities.

Methods

In this retrospective study, we analyzed 323 patients who presented with necrotizing fasciitis at two different institutions. Bloodstream infection (BSI) was defined as a positive blood culture result. The patients were categorized as survivors and non-survivors. Eleven clinically important variables which were statistically significant by univariate analysis were selected for multivariate regression analysis and a stepwise logistic regression model was developed to determine the association between BSI and mortality.

Results

Univariate logistic regression analysis showed that patients with hypotension, heart disease, liver disease, presence of Vibrio spp. in wound cultures, presence of fungus in wound cultures, and presence of Streptococcus group A, Aeromonas spp. or Vibrio spp. in blood cultures, had a significantly higher risk of in-hospital mortality. Our multivariate logistic regression analysis showed a higher risk of mortality in patients with pre-existing conditions like hypotension, heart disease, and liver disease. Multivariate logistic regression analysis also showed that presence of Vibrio spp in wound cultures, and presence of Streptococcus Group A in blood cultures were associated with a high risk of mortality while debridement > = 3 was associated with improved survival.

Conclusions

Mortality in patients with necrotizing fasciitis was significantly associated with the presence of Vibrio in wound cultures and Streptococcus group A in blood cultures.

Improving fixation of the osteoporotic fracture: the role of locked plating

The use of locking technology has expanded significantly over the last decade. This technology has led to improvements in implant design for fixation in osteoporotic bone and allowed more secure and stable constructs. Locking plates and screws have been helpful in surgical repair of metaphyseal fractures and those with significant comminution and in the elderly. Biomechanically, creating a fixed-angle design leads to stronger constructs and potentially decreases failure rates. The use of this technology must be tempered by awareness of the complications associated with both the technique and implants.

Management of proximal humeral fractures in elderly patients with uni- or polyaxial locking osteosynthesis system

INTRODUCTION

To evaluate the clinical efficacy of uni- and polyaxial locking osteosynthesis systems in the management of proximal humeral fractures in elderly patients, totally 76 cases were reviewed including 18 cases of two-part (Neer classification), 36 cases of three-part, and 22 cases of four-part fractures.

METHODS

All the patients received open reduction and internal fixation with proximal humerus internal locking osteosynthesis system (PHILOS) or Numelock systems designed for proximal humerus.

RESULTS

Results showed no significant difference between groups considering the Constant-Murley scores assessed at 6 and 12 months, postoperatively. Satisfactory outcomes were achieved in 73.7 and 75.0% of the patients from the PHILOS and Numelock groups, respectively. Complications included four cases of varus malunion, one case of screw cut-out, and another case of avascular necrosis.

CONCLUSION

Both of the PHILOS and Numelock systems showed equally good results considering fixation stability and functional outcomes of proximal humeral fractures in elderly patients.

A systematic review of locking plate fixation of proximal humerus fractures

PURPOSE

Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates.

METHODS

The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias.

RESULTS

Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%.

DISCUSSION

Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.

Complex proximal humeral fractures: a prospective study of 22 cases treated using the "Bilboquet" device

INTRODUCTION

Despite recent improvements in surgical devices, complex proximal humerus fractures internal fixation still encounters frequent mechanical failures.

HYPOTHESIS

The aim of this study was to confirm that the Bilboquet device (a design mimicking the cup-and-ball game) helps solving mechanical difficulties associated with these fractures internal fixation and to present a simplified version of the original surgical procedure.

PATIENTS AND METHOD

This non-randomised prospective study included 22 fractures in 22 patients, mean age: 70 years. According to the Neer classification there were three-part fractures in seven cases and four-part fractures in 15 cases. Fractures were all reduced and treated by internal fixation in a simplified surgical procedure using the Bilboquet device.

RESULTS

Mean postoperative follow-up was 34 months. The mean Constant score was 66 and the weighted Constant score was 86. Mean active forward elevation was 108° and mean active external rotation was 28°. No per- or postoperative complications occurred. Initial reduction of the tuberosity was incomplete in four cases. Union was obtained in all fractures. There was no secondary tilting of the head, and no migration or pseudarthrosis of the tuberosities. Five patients developed postoperative avascular necrosis of the humeral head.

DISCUSSION

The Bilboquet staple component provides a supporting platform for the entire humeral head area. This peripheral stabilization associated with tension band wiring explains the lack of secondary displacement in these cases. Although the Bilboquet device provides a solution to the mechanical problems of complex fractures of the proximal humerus, it does not solve the problem of secondary avascular necrosis of the humeral head, which occurred in 23% of the patients in this series and in 33% of patients in the four-part fractures subgroup.

LEVEL OF EVIDENCE

IV (non-randomised prospective study).

A 5-mm femoral defect in female but not in male rats leads to a reproducible atrophic non-union

INTRODUCTION

The objectives of this study were to (1) establish a reproducible atrophic non-union model in rats by creation of a segmental femoral bone defect that allows, (2) in-depth characterization of impaired healing, and (3) contrast its healing patterns to the normal course. Hypothesis was that a 5-mm bone defect in male rats would deviate from uneventful healing patterns and result in an atrophic non-union.

MATERIALS AND METHODS

A femoral osteotomy was performed in two groups of 12-week-old male rats (1 vs. 5 mm gap) stabilized with an external fixator. Bone healing in these models was evaluated by radiology, biomechanics, and histology at 6 or 8 weeks. The evaluation of the 5-mm group revealed in some cases a delayed rather than a non-union, and therefore, a group of female counterparts was included.

RESULTS

The creation of a 5-mm defect in female rats resulted in a reproducible atrophic non-union characterized by sealing of the medullary canal, lack of cartilage formation, and negligible mechanical properties of the callus. In both gap size models, the male subjects showed advanced healing compared to females.

DISCUSSION AND CONCLUSION

This study showed that even under uneventful healing conditions in terms of age and bone defect size, there is a sex-specific advanced healing in male compared to female subjects. Contrary to our initial hypothesis, only the creation of a 5-mm segmental femoral defect in female rats led to a reproducible atrophic non-union. It has been shown that an atrophic non-union exhibits different healing patterns compared to uneventful healing. A total lack of endochondral bone formation, soft tissue prolapse into the defect, and bony closure of the medullary cavity have been shown to occur in the non-union model.

Proprioception in anterior cruciate ligament deficient knees and its relevance in anterior cruciate ligament reconstruction

Injury to the anterior cruciate ligament (ACL) not only causes mechanical instability but also leads to a functional deficit in the form of diminished proprioception of the knee joint. "Functional" recovery is often incomplete even after "anatomic" arthroscopic ACL reconstruction, as some patients with a clinically satisfactory repair and good ligament tension continue to complain of a feeling of instability and giving way, although the knee does not sublux on clinical testing. Factors that may play a role could be proprioceptive elements, as the intact ACL has been shown to have significant receptors. Significant data have come to light demonstrating proprioceptive differences between normal and injured knees, and often between injured and reconstructed knees. ACL remnants have been shown to have proprioceptive fibers that could enhance functional recovery if they adhere to or grow into the reconstructed ligament. Conventionally the torn remnants are shaved off from the knee before graft insertion; modern surgical techniques, with remnant sparing methods have shown better outcomes and functional recovery, and this could be an avenue for future research and development. This article analyzes and reviews our understanding of the sensory element of ACL deficiency, with specific reference to proprioception as an important component of functional knee stability. The types of mechanoreceptors, their distribution and presence in ACL remnants is reviewed, and suggestions are made to minimize soft tissue shaving during ACL reconstruction to ensure a better functional outcome in the reconstructed knee.

Complex wounds and their management

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Proximal humeral fractures are common injuries. The management, including surgical intervention, of these fractures varies widely.

OBJECTIVES

To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in March 2010.

SELECTION CRITERIA

All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected.

DATA COLLECTION AND ANALYSIS

Two people performed independent study selection, risk of bias assessment and data extraction. Trial heterogeneity prevented meta-analysis.

MAIN RESULTS

Sixteen small randomised trials with 801 participants were included. Bias in these trials could not be ruled out.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate physiotherapy programme.Surgery improved fracture alignment in two trials but was associated with more complications in one trial, and did not result in improved shoulder function. Preliminary data from another trial showed no significant difference in complications, quality of life or costs between plate fixation and conservative treatment. In one trial, hemiarthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries.Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a high re-operation rate in one trial. One trial found better functional results for one type of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes.

Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy?

BACKGROUND

Prolonged use of bisphosphonates in patients with osteoporosis reportedly induces femoral insufficiency fractures. However, the natural course of these fractures and how to treat them remain unknown.

QUESTIONS/PURPOSES

We determined the rates of fracture displacement and subsequent operations of undisplaced insufficiency fractures of the femur in patients treated with prolonged bisphosphonate therapy.

PATIENTS AND METHODS

We retrospectively collected and reviewed the clinical course of 11 patients (14 fractures) who had been diagnosed as having an insufficiency fracture of the femur after prolonged use (mean, 4.5 years; range, 3-10 years) of bisphosphonate. All patients were women with a mean age of 68 years (range, 57-82 years). The fracture site was subtrochanteric in six and femoral shaft in eight. The minimum followup was 12 months (mean, 27 months; range, 12-60 months).

RESULTS

During the followup period, secondary displacement of the fracture occurred in five of the 14 fractures after a mean of 10 months (range, 1-19 months). Three fractures were treated with internal fixation using a compression hip screw and two with intramedullary nailing. Because five additional fractures were treated surgically owing to intractable pain, surgery was performed in 10 of 14 insufficiency fractures during the followup period. All 10 fractures healed during followup. The remaining four patients (four fractures) not undergoing any surgery had persistent pain.

CONCLUSIONS

Femoral insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most patients had surgery either for fracture displacement or persistent pain.

Surgical treatment of unstable pelvic fracture in children: long term results

Paediatric pelvic fractures are rare lesions. In the literature still controversy exists regarding the management of these injuries. The sequelae of these types of lesions has been described. We report the management and long term outcome of 8 patients with paediatric pelvic fractures treated in our institution. Associated injuries to the Risser's growth nuclei are described that has not been previously reported. Anatomical reduction of the displaced fracture should be considered to minimise the risk of long term functional impairment.

[Update on shoulder surgery 2010: current treatment strategies for traumatic lesions of the shoulder]

The article summarizes the basic literature findings and innovations in the treatment of traumatic shoulder lesions published during the last 3 years. It covers trends in acromioclavicular joint dislocation, traumatic shoulder instability, rotator cuff tears as well as fractures of the humeral head. In particular prospective clinical studies with a high level of evidence are cited, which concern about the outcome of surgical and non-surgical treatment methods and the optimal point for treatment. The aim of this review is therefore to provide direct implications for the clinical treatment algorithm of such lesions.

Demographics, nature and treatment of orthopaedic trauma injuries occurring in an agricultural context in the West of Ireland

BACKGROUND

Farming is a major industry in the West of Ireland. This prospective study examined the age profile, nature and treatment of orthopaedic injuries occurring in agricultural surroundings presenting at the Orthopaedic Unit of Merlin Park Hospital, Galway.

METHODS

The cohort consisted of 70 direct or indirect farm employees presenting with orthopaedic injuries caused in an accident occurring on a farm.

RESULTS

There were significantly (P < 0.01) more male than female farmers (73 vs. 27%) with a mean age of 63 years (ranging from 13 to 87 years). Average number of out-patient visits related to the injury was 3.6. Injuries involving livestock resulted in the majority of accidents (P < 0.05) with a significant rise in the number of visits with increasing age (P < 0.01) with older patients having more severe injuries. Soft tissue injuries and fractures were commonly encountered. Complex fractures were the slowest injury to heal requiring eight subsequent out-patient visits.

Da Vinci System: clinical experience with complex proximal humerus fractures

The purpose of this study is to report the clinical and radiographic outcomes after open reduction and internal fixation of displaced proximal humerus fractures with the "Da Vinci System". It is a triangle-shaped cage whose opposite faces are pierced, and it represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. The new device is an interesting innovation to treat the difficult problem of fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization. According to the technique, authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage, and they are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. If the fracture line involves the proximal portion of the diaphysis, it is possible to use a short low profile plate. Between May 2005 and November 2009, we treated 71 patients (34 men and 37 women), even though we included in our study only 59 patients, who had a minimum follow-up of 12 months. The first patient has been treated in May 2005 and the last one in September 2008. The mean age was 60.8 years (minimum 27, maximum 78). There were 8 displaced 3-part fractures, 20 displaced 4-part fractures, 10 4-part fracture-dislocations, 5 head splitting, 12 unclassified multifragmentary fractures, 1 2-part fracture with multifragmentary calcar and 3 malunions of 4-part fracture. The functional results were evaluated by the Constant score. With a mean follow-up of 24 months (minimum 12, maximum 36 months), the mean Constant score was 80.25. The results were excellent or good in 48 cases, bad in 2 cases and satisfactory in 9; the mean active anterior elevation (AAE) was 160 degrees . All fractures but one healed; in one case, we had a deep infection after 80 days since the operation, treated with a preformed cement spacer.

Unusual "flesh-eating" strain of Escherichia coli

We report an exceptional case of life-threatening Escherichia coli-induced necrotizing fasciitis. A combined host-pathogen genetic analysis explained the phenotype: the host displayed a susceptibility to intravascular coagulation, and the strain was capable of producing a necrotic toxin (cytotoxic necrotizing factor 1), showing how E. coli can be a dermonecrotic pathogen.

Laboratory indicators for early detection and surgical treatment of vibrio necrotizing fasciitis

BACKGROUND

Vibrio necrotizing fasciitis is a rare and life-threatening soft tissue infection, with fulminant clinical courses and high mortality rates. However, the lack of specific disease characteristics and diagnostic tools during the initial examination may delay diagnosis.

QUESTIONS/PURPOSES

We (1) asked whether the clinical indicators could predict laboratory findings during the initial stage of Vibrio necrotizing fasciitis and (2) determined the relationships between the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and the diagnosis of Vibrio infection.

METHODS

We retrospectively reviewed 70 patients with 71 episodes of Vibrio necrotizing fasciitis and sepsis. Of the 70 patients, 68 had a history of contact with seawater or raw seafood; 66 had underlying chronic diseases.

RESULTS

Eighteen patients (25.7%) died a mean 18.7 days after admission, and 52 patients survived. A systolic blood pressure of 90 mm Hg or less at the time of admission to the emergency room was associated with mortality. Patients who died had lower leukocyte counts, segmented leukocyte counts, platelet counts, and serum albumin levels compared with the patients who survived and higher counts of band forms of leukocytes. Only eight patients (11%) who survived had a LRINEC score of 6 or greater.

CONCLUSIONS

The LRINEC scoring system is not applicable when treating such a highly lethal disease. We propose that severe hypoalbuminemia, severe thrombocytopenia, and increased banded forms of leukocytes are laboratory risk indicators of necrotizing fasciitis that aid in pointing toward initiation of early surgery and predict a higher risk of death.

LEVEL OF EVIDENCE

Level III Prognostic study. See the Guidelines for Authors for complete descriptions of levels of evidence.

Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up

Objective

The purpose of this study is to determine the efficacy of the open reduction and fixation of a dislocated proximal humerus fracture with a locking plate, also evaluating the incidence of complications and functional recovery of the shoulder. A retrospective study focusing on patients who had suffered a fracture of the proximal humerus and were treated by means of an open reduction and internal fixation with a locking plate, using either the Philos or the LPHP plate. We have also included a comparison of these two plates.

Method

Ninety-two patients were found to be eligible and were included in our study. These patients had all been treated for a proximal humerus fracture between 2002 and 2008. We included those patients who could be classified as a class 2, 3, or 4 according to the Neer classification. Demographic data, surgical technique, and peri/post-operative complications were collected from medical records. Patients were followed-up and the Oxford Shoulder Score (OSS) was filled in by phone. The mean age of our patient population was 66.2 (15–97), with a male: female ratio of 1:5 (15:77). (The median follow-up was 2.4 years (0.2–5.8). Fourteen of our patients died during follow-up, while 25 patients were otherwise lost to follow-up. For this study, out of the original 131 patients, this finally resulted in 92 patients whom we followed-up post-operatively.

Results

Ninety-two patients (70%, 92/131) were interviewed. The mean Oxford Shoulder Score (OSS) was 19.76 (11–54). The overall complication rate was 39.1% (36/92). The most frequently occurring complications in our patient population were hemorrhage 3.3%; dislocation of the caput humeri and/or tuberculum majus 2.2%; persistent pain 3.3%; Avascular necrosis (AVN) of the humeral head 0%; Loss of reduction and screw cutout 6.5%; Plate breakout 6.5%; Subacromial Impingement 11.9%; Frozen shoulder 3.3%; rotator cuff rupture 1.1%, and infection 1.1%. Of the entire group of patients originally included in this study, 29% was re-operated due to one of the above-mentioned complications.

Conclusion

In conclusion, the locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. The incidence of complications and subsequent re-operation is relatively high, however, comparable to or slightly better when compared to data found in literature. Subacromial Impingement seems to occur more frequently when a Philos plate is implemented. We therefore suggest that randomized clinical trials determining the possible superiority of one specific type of plate in patients with a displaced proximal humerus fracture are to be performed in future.

Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer)

We report a case of under treated necrotizing fasciitis (NF) in a 65-year-old woman with diabetes misdiagnosed as Mycobacterium ulcerans infection. She came to the Institut Médical Evangélique (IME) with an extensive painful edematous ulcerated lesion on the dorsum of the right foot and ankle. The diagnosis of Buruli ulcer (BU) was based initially on clinical findings and place of residence (Songololo Territory, the largest known focus of BU in Bas-Congo province). Tissue specimens gave negative results for acid-fast bacilli (AFB), culture, and polymerase chain reaction (PCR) for M. ulcerans. Histopathologic analysis revealed marked necrosis of the lower dermis and subcutaneous tissue. No AFB was found. Later, scattered foci of intracellular gram-positive cocci typical of streptococci were seen. Clinicopathologic correlation of these findings strongly supported the diagnosis of NF. This patient shows the difficulties that may be encountered even in known endemic areas in recognizing BU cases purely on clinical findings.

Use of bone morphogenetic proteins in arthrodesis: clinical results

Bone grafting is not routinely required in primary arthrodesis in the absence of infection, avascular necrosis, bone defect or previous non-union; when any of the above factors is present, autograft is the gold-standard method. However, donor site morbidity and the quantitative and qualitative limitations of autograft have led to the development of alternatives. This study documents the use of the bone morphogenetic protein BMP-7 in a total of 19 joint fusions (ankle, subtalar, talonavicular, pubic and sacroiliac). Healing rates of 90% and satisfactory subjective functional outcome in 70% of cases were recorded over a minimum follow-up of 15 months. These data should provide a sound foundation for future clinical trials evaluating the application of BMP-7 in the fusion of joints.

A case series describing 118 patients with lower limb necrotizing fasciitis

Necrotizing fasciitis of the lower limb is not uncommon, with poor outcome. This study reviewed 118 cases (78 males and 40 females) with mean age of 45 + 16.5 years (range 12-95 years) of lower limb necrotizing fasciitis admitted to the Department of Surgery, BHU in India between 1995 and 2007. Most patients (n = 97) presented with fever. Other presenting symptoms included painful swelling, bullae, erythema, ulcer, and necrosis. Comorbid conditions such as diabetes, tuberculosis, malignancy, and immunosuppressive therapy were associated in 72 (61%) cases. Amputations were done in 24 patients. Thirty one patients developed septic shock. Renal dialysis was done in 16 patients and ventilatory support was needed in 12 patients. The most common organism identified was beta-hemolytic streptococci (n = 42). Eighteen patients died, a mortality of 15%. The authors consider early diagnosis and aggressive surgical intervention to be crucial for the successful treatment of disease.

Necrotizing fasciitis of the lower extremity: a case report and current concept of diagnosis and management

Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis, involving subcutaneous tissues. This rare condition carries high mortality rate and require prompt diagnosis and urgent treatment with radical debridement and antibiotics. We describe a case of 21-year old man who presented with the history of trivial injury to the knee. Initially he was admitted and treated for septic arthritis but later was diagnosed as necrotizing fasciitis which was successfully treated with no ill effects what so ever from this devastating condition. This rare condition has been reported in literature but still early diagnosis, which is a key for successful treatment, remains a challenge.

Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft

OBJECTIVE

To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union.

DESIGN

Retrospective clinical analysis of patients' medical charts and radiographs.

SETTING

Clinical practice of senior authors.

PATIENTS/PARTICIPANTS

Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded.

INTERVENTION

All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft.

MAIN OUTCOME MEASUREMENT

Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome.

RESULTS

Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5.

CONCLUSION

Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.

Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: a prospective randomised clinical study on 120 patients

The purpose of this prospective randomised clinical study was to compare the efficacy of recombinant bone morphogenetic protein 7 (rhBMP-7) and platelet-rich plasma (PRP) as bone-stimulating agents in the treatment of persistent fracture non-unions. One hundred and twenty patients were randomised into two treatment groups (group rhBMP-7 vs. group PRP). Sixty patients with sixty fracture non-unions were assigned to each group (median age: 44 years, range 19-65, for the rhBMP-7 group and 41 years, range 21-62, for the PRP group, respectively). In the rhBMP-7 group, there were 15 tibial non-unions, 10 femoral, 15 humeral, 12 ulnar, and 8 radial non-unions. In the PRP group, there were 19 tibial non-unions, 8 femoral, 16 humeral, 8 ulnar, and 9 radial non-unions. The median number of operations performed prior to our intervention was 2 (range 1-5) and 2 (range 1-5) with autologous bone graft being used in 23 and 21 cases for the rhBMP-7 and PRP groups, respectively. Both clinical and radiological union occurred in 52 (86.7%) cases of the rhBMP-7 group compared to 41 (68.3%) cases of the PRP group, with a lower median clinical and radiographic healing time observed in the rhBMP-7 group (3.5 months vs. 4 months and 8 months vs. 9 months, respectively). This study supports the view that in the treatment of persistent long bone non-unions, the application of rhBMP-7 as a bone-stimulating agent is superior compared to that of PRP with regard to their clinical and radiological efficacy.