Komplikationsmanagement bei fehlender Knochenbruchheilung: Pseudarthrosen

The critical impact of traumatic muscle loss on fracture healing: Basic science and clinical aspects

Musculoskeletal trauma, specifically fractures, is a leading cause of patient morbidity and disability worldwide. In approximately 20% of cases with fracture and related traumatic muscle loss, bone healing is impaired leading to fracture nonunion. Over the past few years, several studies have demonstrated that bone and the surrounding muscle tissue interact not only anatomically and mechanically but also through biochemical pathways and mediators. Severe damage to the surrounding musculature at the fracture site causes an insufficiency in muscle-derived osteoprogenitor cells that are crucial for fracture healing. As an endocrine tissue, skeletal muscle produces many myokines that act on different bone cells, such as osteoblasts, osteoclasts, osteocytes, and mesenchymal stem cells. Investigating how muscle influences fracture healing at cellular, molecular, and hormonal levels provides translational therapeutic solutions to this clinical challenge. This review provides an overview about the contributions of surrounding muscle tissue in directing fracture healing. The focus of the review is on describing the interactions between bone and muscle in both healthy and fractured environments. We discuss current progress in identifying the bone-muscle molecular pathways and strategies to harness these pathways as cues for accelerating fracture healing. In addition, we review the existing challenges and research opportunities in the field.

Is it really necessary to perform venous anastomosis in vascularized corticoperiosteal bone flap? A randomized prospective 4-year follow-up study

BACKGROUND

This study aims to investigate the treatment results of atrophic nonunion of the lower and upper limb with vascularized bone flaps performed with only arterial anastomosis versus the execution of flaps performed with arterial and venous anastomosis, comparing the surgical time and the healing rate of these two techniques.

METHODS

49 patients were enrolled in this study and were randomly divided into two groups: group A, the control group, consisted of 27 patients, who underwent vascularized corticoperiosteal bone flap with both arterial and venous anastomosis; group B, consisted of 22 patients, who underwent vascularized corticoperiosteal bone flap with only arterial anastomosis. The surgical time, the time to harvest the graft and the microsurgical time were evaluated. Radiological and clinical follow-ups were performed with one independent and blinded investigator to avoid bias.

RESULTS

A significant reduction in the duration of the intervention in group B was found: a 13.63% reduction of the total surgical time and a 41.75% reduction of the microsurgical time. A significant difference was not found between groups A and B in bone healing time. All the patients of both groups were able to return to their daily life activities.

CONCLUSIONS

Our investigation suggests that it isn't necessary to perform the venous anastomosis between the flap pedicle and the recipient area. Presumably, the venous blood flow reaches the systemic circulation through the vascular bone marrow network. Our procedure avoids venous trauma during the dissection and execution of the anastomosis and, therefore, can minimize complications such as venous thrombosis.

Percutaneous Cementoplasty to Treat Sternal Instability After Cardiac Surgery

Introduction

Although rare, sternal pseudarthrosis is encountered after cardiac surgery and impacts the quality of life by triggering motion-dependent chest pain. We thought to describe its treatment by percutaneous cementoplasty and report the clinical follow-up of patients treated in our institution.

Methods

This case series is a retrospective study based on five patients who benefited from a sternal cementoplasty as a treatment for symptomatic pseudarthrosis after cardiac surgery. The progression of the symptoms was assessed during clinical follow-up using the Quebec back pain disability (QBPD) scale and Visual Analog Scale (VAS).

Results

None of the patients presented evidence of local complications or neurological disorders. The intra- et post-operative images show no major leak of the cement, no embolism and no damage to the internal mammary artery or the heart. All patients described an improved quality of life due to reduced pain in all-day clinical activities. The QBPD scores improved from 54.8 ± 29.3 to 30.0 ± 17.4 (p = 0.02) and the VAS from 7.0 ± 2.8 to 1.6 ± 1.6 (p = 0.01). Furthermore, three out of five patients could completely stop taking analgesics.

Conclusion

Sternal pseudarthrosis is a debilitating affliction that may complicate sternotomy after cardiac surgery. This series demonstrates that a more conservative approach such as cementoplasty can be successful in terms of reducing pain, and constitutes a promising technique in selected cases.

[General fracture principles and imaging characteristics]

BACKGROUND

In the process of fracture healing, two different types (direct and indirect) are observed, which can be distinguished by radiologic imaging. If a fracture insufficiently consolidates without further treatment, regardless of the duration of prior treatment, it is referred to as a "non-union". This occurs in about 10% of long bone fractures.

AIM

The aim of this article is to provide an overview of the classification of fractures, an explanation of fracture healing and non-unions as well as their radiologic characteristics.

METHODS

The diagnosis of fractures is based on physical examination and x‑ray with a minimum of two planes. If a soft tissue defect or complex fracture is suspected, a CT or MRI should be considered. For the treatment of non-unions, it might be helpful to expand the diagnostics to a CEUS (contrast-enhanced ultrasound) or DCE-MRI (dynamic contrast-enhanced magnetic resonance imaging).

CONCLUSION

Non-unions represent a severe limitation for the patient's quality of life and are often associated with a long period of suffering. In recent years, CEUS has been shown to be a useful and precise method for the diagnosis and assessment of non-unions and as a surrogate parameter for fracture consolidation.