Diabetes and Healing Outcomes in Lower Extremity Fractures: A Systematic Review

Fatty Infiltration, Tear Size, and Retraction Size Are Significant Risk Factors for Retear following Arthroscopic Rotator Cuff Repair: A Systematic Review

PURPOSE

To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear.

METHODS

A systematic review with PRISMA guidelines was performed. Of the initial 3,158 titles, a total of 31 studies met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting clinical outcomes (4) performed within 5 years (5) and studies investigating pre-operative risk factors for retear. After full-text review, 18 risk factors were analyzed.

RESULTS

The most consistently significant risk factors were acromiohumeral distance (AHD) (80%), critical shoulder angle (CSA) (67%), tear size (63%), anterior/posterior (AP) dimension (60%), fatty infiltration (FI, 58%), and retraction size (56%). FI was analyzed using different methods between studies with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% finding significant results and 63% of all studies analyzing quantitatively. Risk factors consistently found to be non-significant included age, sex, diabetes mellitus (DM), symptom duration, hand dominance, repair technique, smoking and body mass index (BMI).

CONCLUSIONS

Tear size, fatty infiltration, and retraction size were found to be significant risk factors in the majority of included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, DM, symptom duration, hand dominance, repair technique, smoking, and BMI. Risk factors that require further investigation include CSA, AHD, and AP tear dimension. Level III, systematic review of Level III-V studies.

Prevalence of Diabetes Mellitus and Clinical Differences in Patients with Severe Osteoporosis and Fragility Fractures

Background: Diabetes mellitus (DM) and osteoporosis are two of the most widespread metabolic diseases in the world. The aim of this study is to investigate the prevalence of DM among patients affected by osteoporosis and fragility fractures, and to search for differences in clinical characteristics. Methods: This is a single-center retrospective, case-controlled study. A total of 589 patients attending CTO Bone Unit between 2 January 2010 and 31 May 2023, due to osteoporosis and fragility fractures, were divided into two groups, according to the diagnosis of DM. The clinical and bone characteristics of patients were compared. Results: Prevalence of DM was 12.7%. Compared to patients without DM, the median age at the time of first fracture was similar: 72 years ± 13.5 interquartile range (IQR) vs. 71 years ± 12 IQR; prevalence of combination of vertebral and hip fractures was higher (p = 0.008), as well as prevalence of males (p = 0.016). Bone mineral density (BMD) at all sites was higher in DM group; trabecular bone score (TBS), instead, was significantly lower (p < 0.001). Conclusions: Patients with fragility fractures and DM more frequently show combination of major fractures with higher BMD levels. In these patients, TBS could be a better indicator of bone health than BMD and, therefore, might be used as a diagnostic tool in clinical practice.

Promoting bone callus formation by taking advantage of the time-dependent fracture gap strain modulation

Delayed union and non-union of fractures continue to be a major problem in trauma and orthopedic surgery. These cases are challenging for the surgeon. In addition, these patients suffer from multiple surgeries, pain and disability. Furthermore, these cases are a major burden on healthcare systems. The scientific community widely agrees that the stability of fixation plays a crucial role in determining the outcome of osteosynthesis. The extent of stabilization affects factors like fracture gap strain and fluid flow, which, in turn, influence the regenerative processes positively or negatively. Nonetheless, a growing body of literature suggests that during the fracture healing process, there exists a critical time frame where intervention can stimulate the bone's return to its original form and function. This article provides a summary of existing evidence in the literature regarding the impact of different levels of fixation stability on the strain experienced by newly forming tissues. We will also discuss the timing and nature of this "window of opportunity" and explore how current knowledge is driving the development of new technologies with design enhancements rooted in mechanobiological principles.

Links among Obesity, Type 2 Diabetes Mellitus, and Osteoporosis: Bone as a Target

Obesity, type 2 diabetes mellitus (T2DM) and osteoporosis are serious diseases with an ever-increasing incidence that quite often coexist, especially in the elderly. Individuals with obesity and T2DM have impaired bone quality and an elevated risk of fragility fractures, despite higher and/or unchanged bone mineral density (BMD). The effect of obesity on fracture risk is site-specific, with reduced risk for several fractures (e.g., hip, pelvis, and wrist) and increased risk for others (e.g., humerus, ankle, upper leg, elbow, vertebrae, and rib). Patients with T2DM have a greater risk of hip, upper leg, foot, humerus, and total fractures. A chronic pro-inflammatory state, increased risk of falls, secondary complications, and pharmacotherapy can contribute to the pathophysiology of aforementioned fractures. Bisphosphonates and denosumab significantly reduced the risk of vertebral fractures in patients with both obesity and T2DM. Teriparatide significantly lowered non-vertebral fracture risk in T2DM subjects. It is important to recognize elevated fracture risk and osteoporosis in obese and T2DM patients, as they are currently considered low risk and tend to be underdiagnosed and undertreated. The implementation of better diagnostic tools, including trabecular bone score, lumbar spine BMD/body mass index (BMI) ratio, and microRNAs to predict bone fragility, could improve fracture prevention in this patient group.

Risk factors for tibial infections following osteosynthesis - a systematic review and meta-analysis

Aim

This study aimed to quantitatively summarise risk factors associated with surgical site infection (SSI) following surgically managed tibial fractures.

Method

We searched the Embase/Medline, Cochrane Library, and Scopus databases for relevant studies in October 2023. We included original studies investigating risk factors for SSI following surgically managed traumatic tibial fractures that included ≥10 adult patients with SSIs. Meta-analysis was performed when >5 studies investigated the same risk factor. The risk of bias was assessed using the critical appraisal checklist from Joanna Briggs Institute for cohort studies.

Results

This study included 42 studies comprising 24,610 patients with surgically managed tibial fractures and 2,418 SSI cases. The following were identified as significant risk factors for SSI (p < 0.05): compartment syndrome (odds ratio [OR] = 3.8, 95% confidence interval [CI]: 2.4-6.0), blood transfusion (OR = 3.8, 95% CI: 2.1-6.6), open fracture (OR = 3.6, 95% CI: 2.5-5.1), Gustilo-Anderson classification >2 (OR = 3.1, 95% CI: 2.1-4.6), external fixation (OR = 2.9, 95% CI: 2.3-3.8), American Society of Anesthesiologists classification >2 (OR = 2.5, 95% CI: 1.5-4.1), polytrauma (OR = 2.4, 95% CI: 1.5-4.0), dual incision approach (OR = 2.1, 95% CI: 1.5-3.0), smoking (OR = 1.8, 95% CI: 1.5-2.1), male sex (OR = 1.6, 95% CI: 1.3-1.8), high energy trauma (OR = 1.5, 95% CI: 1.1-2.1), and prolonged surgery time (OR = 0.62, 0.43-0.82). Other factors, including diabetes, hypertension, and time to surgery, were not identified as risk factors for SSI. However, the included studies were generally of poor quality and at risk of bias.

Conclusions

The review provides a basis for preoperatively assessing a patient's risk of developing an SSI, which could be used to initiate adjusted antibiotic regimes and more frequent postoperative controls. Furthermore, it indicates the risk factors future research should include when adjusting for confounding factors.

Diabetes and the Microvasculature of the Bone and Marrow

PURPOSE OF REVIEW

The purpose of this review is to highlight the evidence of microvascular dysfunction in bone and marrow and its relation to poor skeletal outcomes in diabetes mellitus.

RECENT FINDINGS

Diabetes mellitus is characterized by chronic hyperglycemia, which may lead to microangiopathy and macroangiopathy. Micro- and macroangiopathy have been diagnosed in Type 1 and Type 2 diabetes, coinciding with osteopenia, osteoporosis, enhanced fracture risk and delayed fracture healing. Microangiopathy has been reported in the skeleton, correlating with reduced blood flow and perfusion, vasomotor dysfunction, microvascular rarefaction, reduced angiogenic capabilities, and augmented vascular permeability. Microangiopathy within the skeleton may be detrimental to bone and manifest as, among other clinical abnormalities, reduced mass, enhanced fracture risk, and delayed fracture healing. More investigations are required to elucidate the various mechanisms by which diabetic microvascular dysfunction impacts the skeleton.

Fluoride-modified implant surfaces improves osseointegration in the tibias of rats with induced diabetes

This study evaluated the influence of a fluoride-modified titanium surface on osseointegration in rats with induced diabetes. One hundred and eighty rats were randomly allocated into 3 groups with 60 animals each: Control group (C): Animals without diabetes; Diabetes Group (D): Animals with uncontrolled induced diabetes; Controlled Diabetes Group (CD): Animals with diabetes induced controlled by the insulin administration. Diabetes was induced by streptozotocin injection. Each animal received 2 implants in the proximal tibial metaphysis, one with the machined surface (M) and the other one with a fluoride-modified titanium surface (F), after 4 weeks of induction of diabetes. The animals were submitted to euthanasia 2, 4, and 6 weeks after the implant placement (n = 20 animals/group). The osseointegration was evaluated by the implant removal torque test and the histometric analysis of the non-decalcified histological sections: 1) Contact bone/implant (%BIC); 2) Bone tissue area between implant threads (%BBT). Implants with F surface showed a higher removal torque than implants with surface M in all groups. There was no difference in %BIC between the groups regardless of the surface used. The F surface showed a tendency to present higher %BBT values for the 3 evaluation periods in the D group. The fluoride-modified implant surface has no impact on the %BIC and %BBT. However, the fluoride-modified implant surface increases the locking of the implants with the bone. The hyperglycemia was associated with lower removal torque values despite the surfaces of the implant used.

Recent progress in bone-repair strategies in diabetic conditions

Bone regeneration following trauma, tumor resection, infection, or congenital disease is challenging. Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia. It can result in complications affecting multiple systems including the musculoskeletal system. The increased number of diabetes-related fractures poses a great challenge to clinical specialties, particularly orthopedics and dentistry. Various pathological factors underlying DM may directly impair the process of bone regeneration, leading to delayed or even non-union of fractures. This review summarizes the mechanisms by which DM hampers bone regeneration, including immune abnormalities, inflammation, reactive oxygen species (ROS) accumulation, vascular system damage, insulin/insulin-like growth factor (IGF) deficiency, hyperglycemia, and the production of advanced glycation end products (AGEs). Based on published data, it also summarizes bone repair strategies in diabetic conditions, which include immune regulation, inhibition of inflammation, reduction of oxidative stress, promotion of angiogenesis, restoration of stem cell mobilization, and promotion of osteogenic differentiation, in addition to the challenges and future prospects of such approaches.

Diabetic microvascular disease in non-classical beds: the hidden impact beyond the retina, the kidney, and the peripheral nerves

Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.

Outcomes of Fracture Surgery in Patients With Escalating Hemoglobin A1C in the Setting of Unmanaged Diabetes

OBJECTIVE

To determine whether there is a threshold of elevated hemoglobin A1C (HbA1c) above which the complication risk is so high that fracture fixation should be avoided.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I trauma center.

PATIENTS/PARTICIPANTS

A cohort of 187 patients with HbA1c values >7 and operatively treated extremity fractures.

INTERVENTION

Surgical fixation of extremity fractures.

MAIN OUTCOME MEASUREMENTS

Rate of major orthopaedic complication (loss of reduction, nonunion, infection, and need for salvage procedure).

RESULTS

34.8% demonstrated HbA1c > 9% and 12.3% with HbA1c > 11. Major complications occurred in 31.4%; HbA1c values were not predictive. We found no evidence of a clinically or statistically significant relationship between HbA1c and risk of major complication. The odds ratio for a one-point increase in HbA1c was 1.006 ( P = 0.9439), and the area under the receiver operating characteristic curve, which reflects the average probability that someone with a major complication will have a higher HbA1c than someone without, was 0.51 (95% confidence interval 0.42-0.61), equivalent to random chance.

CONCLUSION

Diabetic patients with fracture demonstrated an extremely high overall rate of complications, with 30.5% experiencing a major complication. However, patients with extreme diabetic neglect did not have higher complication rates after extremity fracture fixation when compared with patients with controlled and uncontrolled diabetes. There was no correlation between rate of complication and level of HbA1c. In addition, there was no difference in complication rate between upper and lower extremity fractures or between fractures treated with open or percutaneous fixation. This suggests that fracture treatment decision-making should not be altered for patients with poor diabetic control, and that surgery is not contraindicated in patients with an extremely high HbA1c.

LEVEL OF EVIDENCE

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

Accumulation of advanced glycation end products promotes atrophic nonunion incidence in mice through a CtBP1/2-dependent mechanism

Atrophic nonunion (AN) is a complex and poorly understood pathological condition resulting from impaired fracture healing. Advanced glycation end products (AGEs) have been implicated in the pathogenesis of several bone disorders, including osteoporosis and osteoarthritis. However, the role of AGEs in the development of AN remains unclear. This study found that mice fed a high-AGE diet had a higher incidence of atrophic nonunion (AN) compared to mice fed a normal diet following tibial fractures. AGEs induced two C-terminal binding proteins (CtBPs), CtBP1 and CtBP2, which were necessary for the development of AN in response to AGE accumulation. Feeding a high-AGE diet after fracture surgery in CtBP1/2-/- and RAGE-/- (receptor of AGE) mice did not result in a significant occurrence of AN. Molecular investigation revealed that CtBP1 and CtBP2 formed a heterodimer that was recruited by histone deacetylase 1 (HDAC1) and runt-related transcription factor 2 (Runx2) to assemble a complex. The CtBP1/2-HDAC1-Runx2 complex was responsible for the downregulation of two classes of bone development and differentiation genes, including bone morphogenic proteins (BMPs) and matrix metalloproteinases (MMPs). These findings demonstrate that AGE accumulation promotes the incidence of AN in a CtBP1/2-dependent manner, possibly by modulating genes related to bone development and fracture healing. These results provide new insights into the pathogenesis of AN and suggest new therapeutic targets for its prevention and treatment.

Risk factors for fracture-related infection after ankle fracture surgery

INTRODUCTION

Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures.

METHODS

A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University Hospital in the period of 2015-2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients' age and presence of one or more risk factors.

RESULTS

FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < .001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8-10.1) and 4.7 (95% CI 1.6-14.1) respectively.

CONCLUSION

The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery.

LEVEL OF EVIDENCE

Level III retrospective case-control study.

A Model Study to Evaluate Osseointegration and Fracture Healing Following Open Reduction and Internal Fixation (ORIF) in Diabetic Lewis Rats

There is a higher risk of implant osseointegration failure after open reduction and internal fixation (ORIF) in patients with diabetes due to increased inflammatory conditions, associated metallic corrosion and infection. While it is possible to avoid elective osseous surgery in patients with diabetes, it may not be the case in nonelective cases, such as ORIF ankle fractures. A total of 30 male Lewis rats (12-15 weeks old) were distributed into diabetic (D) and nondiabetic (ND) groups. Fracture healing and osseointegration were evaluated at 2-, 10-, and 21-day time points. Microtomographic and histological analysis depicted distinct differences in fracture healing and osseointegration between D and ND animals. Immunohistochemical analysis exhibited elevated proliferation (PCNA) and osteogenic (Runx2) cells for ND animals, while HMGB1 (inflammatory marker) was elevated for D animals during healing. Bone resorption marker CTX-1 was elevated in the plasma of D animals at 2 days, while bone formation marker P1NP was higher for ND animals at 10 days. Overall, this model resulted in delayed implant osseointegration and fracture healing in diabetic animals, highlighting the importance of developing new biomaterials or implant coatings that can improve bone healing outcomes in this patient population.

Risk Factors for Reoperation to Promote Union in 1111 Distal Femur Fractures

OBJECTIVES

To identify modifiable and nonmodifiable risk factors for reoperation to promote union after distal femur fracture.

DESIGN

Multicenter retrospective cohort study.

SETTING

Ten Level-I trauma centers.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 33A or C distal femur fractures (n = 1111).

INTERVENTION

Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination.

MAIN OUTCOME MEASUREMENTS

The outcome of interest was unplanned reoperation to promote union.

RESULTS

There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P < 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P < 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive.

CONCLUSIONS

Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups.

LEVEL OF EVIDENCE

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

Effect of Dietary Geranylgeraniol and Green Tea Polyphenols on Glucose Homeostasis, Bone Turnover Biomarkers, and Bone Microstructure in Obese Mice

Previously, we demonstrated that the administration of either geranylgeraniol (GGOH) or green tea polyphenols (GTP) improved bone health. This study examined the combined effects of GGOH and GTP on glucose homeostasis in addition to bone remodeling in obese mice. We hypothesized that GGOH and GTP would have an additive or synergistic effect on improving glucose homeostasis and bone remodeling possibly in part via suppression of proinflammatory cytokines. Forty-eight male C57BL/6J mice were assigned to a high-fat diet (control), HFD + 400 mg GGOH/kg diet (GG), HFD + 0.5% GTP water (TP), or HFD + GGOH + GTP (GGTP) diet for 14 weeks. Results demonstrated that GTP supplementation improved glucose tolerance in obese mice. Neither GGOH nor GTP affected pancreas insulin or bone formation procollagen type I intact N-terminal, bone volume at the lumbar vertebrae, or bone parameters at the trabecular bone and cortical bone of the femur. There was an interactive effect for serum bone resorption collagen type 1 cross-linked C-telopeptide concentrations, resulting in no-GGOH and no-GTP groups having the highest values. GGOH increased trabecular number and decreased trabecular separation at the lumbar vertebrae. GTP increased trabecular thickness at lumbar vertebrae. The GG group produced the greatest connectivity density and the lowest structure model index. Only GTP, not GGOH, decreased adipokines concentrations (resistin, leptin, monocyte chemoattractant protein-1, and interleukin-6). In an obese male mouse model, individual GGOH and GTP supplementation improved glucose homeostasis, serum CTX, and trabecular microstructure of LV-4. However, the combined GGOH and GTP supplementation compromises such osteoprotective effects on serum CTX and trabecular bone of obese mice.

Clinical features and independent predictors of postoperative refractory trauma to anal fistula combined with T2DM: A propensity score-matched analysis-retrospective cohort study

Background

Refractory wound is a common postoperative complication in anal fistula surgery, when combined with type 2 diabetes mellitus (T2DM) it presents a slower recovery time and more complex wound physiology. The study aims to investigate factors associated with wound healing in patients with T2DM.

Materials and methods

365 T2DM patients who underwent anal fistula surgery at our institution were recruited from June 2017 to May 2022. Through propensity score-matched (PSM) analysis, multivariate logistic regression analysis was applied to determine independent risk factors affecting wound healing.

Results

122 pairs of patients with no significant differences were successfully established in matched variables. Multivariate logistic regression analysis revealed that uric acid (OR: 1.008, 95% CI: 1.002-1.015, p = 0.012), maximal fasting blood glucose (FBG) (OR: 1.489, 95% CI: 1.028-2.157, p = 0.035) and random intravenous blood glucose (OR: 1.130, 95% CI: 1.008-1.267, p = 0.037) elevation and the incision at 5 o'clock under the lithotomy position (OR: 3.510, 95% CI: 1.214-10.146, p = 0.020) were independent risk factors for impeding wound healing. However, neutrophil percentage fluctuating within the normal range can be considered as an independent protective factor (OR: 0.906, 95% CI: 0.856-0.958, p = 0.001). After executing the receiver operating characteristic (ROC) curve analysis, it was found that the maximum FBG expressed the largest under curve area (AUC), glycosylated hemoglobin (HbA1c) showed the strongest sensitivity at the critical value and maximum postprandial blood glucose (PBG) had the highest specificity at the critical value. To promote high-quality healing of anal wounds in diabetic patients, clinicians should not only pay attention to surgical procedures but also take above-mentioned indicators into consideration.

Liraglutide in Combination with Insulin Has a Superior Therapeutic Effect to Either Alone on Fracture Healing in Diabetic Rats

Purpose

Fractures in patients with type 2 diabetes mellitus are at a high risk of delayed union or non-union. Previous studies have shown a protective effect of liraglutide on bone. In the present study, we aimed to investigate the effects of a combination of liraglutide and insulin on fracture healing in a rat model of diabetes and the mechanisms involved.

Materials and Methods

Closed femoral mid-shaft fractures were established in male Sprague-Dawley rats with or without diabetes mellitus, and the diabetic rats were administered insulin and/or liraglutide. Six weeks after femoral fracture, the femoral callus was evaluated by immunohistochemistry, histology, and micro-computed tomography. Additionally, the effects of liraglutide on high-glucose-stimulated MC3T3-E1 cells were analyzed by Western blotting.

Results

Micro-computed tomography and safranin O/fast green staining showed that fracture healing was delayed in the diabetic rats, and this was accompanied by much lower expression of osteogenic markers and greater osteoclast activity. However, treatment with insulin and/or liraglutide prevented these changes. Liraglutide in combination with insulin treatment resulted in lower blood glucose concentrations and significantly higher osteocalcin (OCN) and collagen I (Col I) expression six weeks following fracture. Western blot analysis showed that liraglutide prevented the low expression of the bone morphogenetic protein-2, osterix/SP7, OCN, Col I, and β-catenin in high-glucose-stimulated MC3T3-E1 cells.

Conclusion

These results demonstrate that insulin and/or liraglutide promotes bone fracture healing in the DF model. The combination was more effective than either single treatment, which may be because of the two drugs' additive effects on the osteogenic ability of osteoblast precursors.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Fracture-related infection

Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.

A Comparative Study of Treatment With External Fixator Versus Antibiotic Coated Intramedullary Nail in Infected Non-union Long Bones

Introduction: Infected non-union of bones shows problems in providing stability and controlling the infection. The treatment comprises debridement with or without the use of antibiotic cement and achieving stability by either external or internal fixation with or without bone grafting. The use of antibiotic-impregnated cement-coated intramedullary nailing gives stability and treats the infection, thereby permitting early mobilization. External fixation is a definitive mode of fracture stabilization indicated in cases of infected non-unions of the humerus, tibia, and juxta-articular bone. The present study was conducted to compare the results of management of infected non-union long bones treated with an external fixator (Ilizarov and Limb Reconstruction System (LRS)) and vancomycin-coated intramedullary nail.

Materials and method: The present prospective study was conducted on 40 study subjects aged >18 years, and were randomly divided using the alternative method into two groups. Group A: 20 Patients were treated with antibiotic-coated intramedullary interlocking nail (ACIIN). Group B: 20 patients were treated with the external fixator (LRS/Ilizarov). All patients were then evaluated post-operatively using laboratory investigations, and for any sign of inflammation or infection. Results were evaluated using association for the study and application of methods of Ilizarov (ASAMI) scoring system. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA).

Results: It was observed that 80.0% of patients in Group A, and 70% of subjects in Group B showed bony union, revealing a statistically significant (p-value<0.05) difference. Infection control, limb length discrepancy, and deformity were also assessed in both groups. Bone and functional outcomes were assessed using the ASAMI score in both groups. In LRS/Ilizarov, it was observed that 55% of subjects had no infection, 15% showed loosening, and 30% had an infection.

Conclusion: The ACIIN should not be used for bone defects more than 4 cm as it does not achieve stability and for these cases, procedures like external fixators (Ilizarov and LRS) should be used. Antibiotic-coated nail eliminated the complications of the external fixators like pin loosening, and pin infections and was technically less demanding. In our study, stiffness of adjacent joints was more in external fixators (LRS/Ilizarov) than ACIIN.

Effect of Silver Nanoparticles With Thermoplastic Polyurethane on Postoperative Rehabilitation of Diabetic Patients With Open Fracture of Lower Extremities

Objective

This retrospective study aims to explore the effect of silver nanoparticles with thermoplastic polyurethane (TPU/NS) on the rehabilitation of diabetic patients with open fracture of lower extremities.

Methods

Diabetic patients (n = 98) with open fracture of lower extremities treated in our hospital were analyzed retrospectively from June 2015 to December 2021. TPU/NS nanocomposites were prepared for postoperative treatment of diabetic patients with open fracture of lower extremities. First, the cultured Staphylococcus aureus and Escherichia coli were used to test the antibacterial effect of TPU/NS dressing in vitro. After using TPU/NS dressing (observation group) and traditional dressing (control group), the inflammatory reaction, clinical treatment, functional rehabilitation, and adverse reactions in patients were compared.

Results

TPU/NS dressing effectively inhibited the growth of bacteria with a minimum inhibitory concentration of 2 μg/mL. The usage of TPU/NS dressing reduced the inflammatory reaction by reducing positive rate of bacteria after the dressing on the seventh day postoperatively. Besides, the times of dressing, stopping time of wound exudation, wound healing time, length of hospital stay, and VAS score in the observation group were lower than those in the control group; the incidence of adverse reactions after treatment was lower in the observation group as compared with the control group (17.07% vs. 35.09%). Meanwhile, the functional rehabilitation and life quality of patients in the observation group were better TPU/NS dressing treatment.

Conclusion

TPU/NS dressing has the function of promoting the postoperative recovery of patients by inhibiting the bacterial infection of the wound, thus improving the limb function and life quality. As a result, there was a tremendous potential to apply the constructed TPU/NS membrane to diabetic patients with open fractures, especially those with soft tissue injury.

Patient and Surgical Factors Affecting Fusion Rates After Arthroscopic and Open Ankle Fusion: A Review of a High-Risk Cohort

ABSTRACT

We present a case series with the objective of identifying risk factors for nonunion after open and arthroscopic primary ankle arthrodesis. Eighty-seven patients who underwent primary ankle arthrodesis and met inclusion criteria were divided into open (N = 46) and arthroscopic (N = 41) groups. Patient and operative characteristics were retrospectively analyzed as possible risk factors for nonunion within each technique. The nonunion rate was 11% in the open and 12% in the arthroscopic group. Obesity, smoking, and ASA class 3 were highly prevalent in both groups. In the arthroscopic group, a remote history of infection and the use of headed screws had notably higher risk of nonunion, though not statistically significant. In the open group, use of bone graft trended toward lower risk of nonunion, though also not statistically significant. The results of this study demonstrated, nonunion rates are comparable between open and arthroscopic ankle arthrodesis in high-risk patients. For patients with a remote history of infection, open ankle arthrodesis may be preferable, and bone graft importance may vary with open versus arthroscopic technique.

LEVEL OF EVIDENCE

III.

Smoking Impairs Hematoma Formation and Dysregulates Angiogenesis as the First Steps of Fracture Healing

Bone fracture healing is an overly complex process in which inflammation, osteogenesis, and angiogenesis are tightly coupled, and delayed fracture repair is a very common health risk. One of the major causes of delayed healing is the formation of insufficient vasculature. Precise regulation of blood vessels in bone and their interplay with especially osteogenic processes has become an emerging topic within the last years; nevertheless, regulation of angiogenesis in (early) diseased fracture repair is still widely unknown. Here, we aim to develop an in vitro model for the analysis of early fracture healing which also enables the analysis of angiogenesis as a main influencing factor. As smoking is one of the main risk factors for bone fractures and developing a delay in healing, we model smoking and non-smoking conditions in vitro to analyze diverging reactions. Human in vitro fracture hematomas mimicking smokers’ and non-smokers’ hematomas were produced and analyzed regarding cell viability, inflammation, osteogenic and chondrogenic differentiation, and angiogenic potential. We could show that smokers’ blood hematomas were viable and comparable to non-smokers. Smokers’ hematomas showed an increase in inflammation and a decrease in osteogenic and chondrogenic differentiation potential. When analyzing angiogenesis, we could show that the smokers’ hematomas secrete factors that drastically reduced HUVEC proliferation and tube formation. With an angiogenesis array and gene expression analysis, we could identify the main influencing factors: Anpgt1/2, Tie2, and VEGFR2/3. In conclusion, our model is suitable to mimic smoking conditions in vitro showing that smoking negatively impacts early vascularization of newly formed tissue.

Comparative Outcomes for Trauma Patients in Prison and the General Population

BACKGROUND

Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma.

METHODS

The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality-the primary outcome.

RESULTS

From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409).

DISCUSSION

Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.

Epidemiological status and risk factors of deep vein thrombosis in patients with femoral neck fracture

Objectives

The purpose of this study was to investigate the incidence of deep vein thrombosis (DVT) and clarify the risk factors of DVT in patients with femoral neck fracture.

Methods

A self-designed questionnaire was used to collect the clinical data of 1209 patients with femoral neck fracture in our hospital from January 2019 to December 2019. The content of the questionnaire mainly includes general information, past medical history, history of present illness, operation related information, occurrence of DVT. The collected data were entered into Excel to analyze the incidence and risk factors of DVT in patients with femoral neck fracture. Chi square test and binary logistic regression model was used to screen the risk factors of DVT.

Results

1209 cases of femoral neck fracture were included in this study. The incidence of DVT was 28.0% (339 patients). Among them, 71.7% (243 patients) were preoperative DVT and 28.3% (96 patients) were postoperative DVT. For the risk-factor analysis, gender, age, time from injury to hospitalization, operative method, anesthesia method and intraoperative blood loss were independent risk factors for DVT.

Conclusion

The incidence of DVT in patients with femoral neck fracture is relatively high, and there are many related risk factors.

Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery.

METHODS

We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery.

RESULTS

This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]).

CONCLUSIONS

DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.

Development and Validation of a Post-Operative Non-Union Risk Score for Subtrochanteric Femur Fractures

Background: Our objective was to develop and validate a predictive model for non-union following a subtrochanteric fracture of the femur. Methods: Following institutional board approval, 316 consecutive patients presenting to our institution (84 non-unions) who fulfilled the inclusion criteria were retrospectively identified. To identify potential unadjusted associations with progression to non-union, simple logistic regression models were used, followed by a revised adjusted model of multiple logistic regression. Results: Having established the risk factors for non-union, the coefficients were used to produce a risk score for predicting non-union. To identify the high-risk patients in the early post-operative period, self-dynamisation was excluded. The revised scoring system was the sum of the following: diabetes (6); deep wound infection (35); simple or severe comminution (13); presence of an atypical fracture (14); lateral cortex gap size ≥5 mm (11), varus malreduction (5–10 degrees) (9); varus malreduction (>10 degrees) (20). On the ROC (receiver operating characteristic) curve, the area under the curve (0.790) demonstrated very good discriminatory capability of the scoring system, with good calibration (Hosmer–Lemeshow test; p = 0.291). Moreover, 5-fold cross validation confirmed good fit of the model and internal validity (accuracy 0.806; Kappa 0.416). The cut-point determined by Youden’s formula was calculated as 18. Conclusion: This study demonstrates that the risk of non-union can be reliably estimated in patients presenting with a subtrochanteric fracture, from the immediate post-operative period. The resulting non-union risk score can be used not only to identify the high-risk patients early, offering them appropriate consultation and in some cases surgical intervention, but also informs surgeons of the modifiable surgery related factors that contribute to this risk.

Diabetic ankle fracture complications: a meta-analysis

INTRODUCTION

This meta-analysis aimed to review complication rates following the treatment of an ankle fracture in diabetic patients and to early detect the subgroup of patients at potential risk in order to minimise this complication rate.

METHODS

A search of 3 databases was performed for studies published till March 2018. Twelve studies met the eligibility criteria for further statistical analysis. An odds ratio (OR) with a 95% confidence interval (95% CI) for each complication was calculated between the diabetic and non-diabetic groups.

RESULTS

The overall complication risk after ankle fracture was twice as high in diabetes mellitus (DM) than non-diabetes mellitus (non-DM) patients (OR 1.9, 95%CI: 1.7-2.03). This risk was considerably higher with surgery versus non-surgical treatment (OD 3.7, 95%CI: 2.3-6.2). The risk of infection was 3 times higher in DM than in non-DM patients (OR 3.4, 95%CI: 2.9-9.8). The complication rate was even higher in patients with advanced DM (OR 8.4, 95%CI: 2.9-24.5).

CONCLUSION

This meta-analysis provides evidence that diabetic patients are at a greater risk of complication after an ankle fracture.

Non-union bone fractures

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

Matched retrospective analysis of three different fixation devices for chevron osteotomy

Chevron osteotomy with consecutive fixation is a commonly performed operative treatment option for hallux valgus deformities. The present retrospective study aims to compare the clinical and radiological outcome of novel bioabsorbable magnesium screw fixation with metal screw and Kirschner wire fixation. Eighteen matched triplets were assembled according to the following criteria: female gender, age difference less than 5 years, date of operation within 4 months, difference in preoperative intermetatarsal angle less than 5°, and equal experience of the first and second surgeon. These patients, between 18 and 85 years of age and with a minimum follow-up period of 12 months, were invited to a follow-up examination, of which only 16 matched triplets of patients entirely kept the appointment. Thus, 48 feet of 44 patients were clinically evaluated using the American Orthopaedic Foot & Ankle Society scale, Foot Function Index, University of California and Los Angeles Activity Score, as well as a visual analogue scale for pain, satisfaction, cosmetic results, and functional impairment. Radiographical assessment included measuring intermetatarsal angle and first metatarsophalangeal angles. All occurring complications and revision surgeries were noted. Significant differences were observed for postoperative intermetatarsal angle between magnesium screw and pin fixation (p = 0.009). Moreover, patients receiving magnesium screw were significantly more prone to undergo the same procedure again (p = 0.03). In conclusion, if the advantages of bioabsorbable magnesium screws outweigh the drawbacks of increased costs and a higher surgical demand, this implant might serve as possible chevron osteotomy fixation method. Compression screws and Kirschner wires also show comparable satisfactory outcomes. LEVEL OF EVIDENCE: III retrospective comparative study.

Risk factors for treatment failure of fracture-related infections

OBJECTIVE

Infection after fracture fixation is a potentially devastating outcome, and surgical management is frequently unsuccessful at clearing these infections. The purpose of this study is to determine if factors can be identified that are associated with treatment failure after operative management of a deep surgical site infection.

METHODS

We retrospectively reviewed the billing system at a Level I trauma center between March 2006 and December 2015. We identified 451 patients treated for deep surgical site infection after fracture fixation at our center. A multivariate regression analysis was then performed to evaluate for factors associated with treatment failure.

RESULTS

Mean follow-up was 2.3 years. One hundred fifty-six patients (35%) failed initial surgical management. Risk factors associated with treatment failure included initial culture results positive for polymicrobial organisms (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.4), removal of implants (OR, 1.9; 95% CI, 1.2-2.9), or Gustilo-Anderson IIIB/IIIC injury (OR, 2.0; 95% CI, 1.1-3.7). Increased body mass index and fulfilling the criteria to have a methicillin-resistant Staphylococcus aureus (MRSA) nasal swab screening showed a trend toward increased risk of failure.

CONCLUSION

Treatment failure after deep surgical site infection was relatively common. Three distinct factors (polymicrobial infection, removal of implants, and IIIB/C fracture) were associated with failure to eradicate the infection in the first series of surgeries and antibiotics. These data might help guide clinicians as they counsel patients on the risk of treatment failure and might focus efforts to improve treatment toward patients at higher risk of treatment failure.

A Dual Peptide Sustained-Release System Based on Nanohydroxyapatite/Polyamide 66 Scaffold for Synergistic-Enhancing Diabetic Rats' Fracture Healing in Osteogenesis and Angiogenesis

Diabetes mellitus impairs fracture healing and function of stem cells related to bone regeneration; thus, effective bone tissue engineering therapies can intervene with those dysfunctions. Nanohydroxyapatite/polyamide 66 (n-HA/PA66) scaffold has been used in fracture healing, whereas the low bioactivity limits its further application. Herein, we developed a novel bone morphogenetic protein-2- (BMP-2) and vascular endothelial growth factor- (VEGF) derived peptides-decorated n-HA/PA66 (BVHP66) scaffold for diabetic fracture. The n-HA/PA66 scaffold was functionalized by covalent grafting of BMP-2 and VEGF peptides to construct a dual peptide sustained-release system. The structural characteristics and peptide release profiles of BVHP66 scaffold were tested by scanning electron microscopy, Fourier transform infrared spectroscopy, and fluorescence microscope. Under high glucose (HG) condition, the effect of BVHP66 scaffold on rat bone marrow mesenchymal stem cells’ (rBMSCs) adherent, proliferative, and differentiate capacities and human umbilical vein endothelial cells’ (HUVECs) proliferative and tube formation capacities was assessed. Finally, the BVHP66 scaffold was applied to fracture of diabetic rats, and its effect on osteogenesis and angiogenesis was evaluated. In vitro, the peptide loaded on the BVHP66 scaffold was in a sustained-release mode of 14 days. The BVHP66 scaffold significantly promoted rBMSCs’ and HUVECs’ proliferation and improved osteogenic differentiation of rBMSCs and tube formation of HUVECs in HG environment. In vivo, the BVHP66 scaffold enhanced osteogenesis and angiogenesis, rescuing the poor fracture healing in diabetic rats. Comparing with single peptide modification, the dual peptide-modified scaffold had a synergetic effect on bone regeneration in vivo. Overall, this study reported a novel BVHP66 scaffold with excellent biocompatibility and bioactive property and its application in diabetic fracture.

Endoscopic resection of scar tissues and bone graft with an intramedullary nail left in situ for distal femoral nonunion after nailing: A case report

Femoral shaft nonunion after the intramedullary nailing has been successfully treated with advances in surgical technique. Nonetheless, the techniques cause morbidity to periosteum at the fracture site. We report the case of a 67-year-old man who underwent endoscopic surgery for refractory nonunion following the fracture of the distal femoral shaft, despite two fixations using an interlocking nail. In addition, the patient had uncontrolled diabetic mellitus. Endoscopy allowed us to acquire a clear view of the nonunion site, in which the resection of scar tissues and the packing of the cancellous bone were performed. At the final follow-up, bone healing was observed, and the patient was able to return to normal daily and social activity.

Diabetic Pilon Factures: Are They as Bad as We Think?

OBJECTIVE

To identify how diabetes impacts the risk of complications requiring further surgery (deep surgical site infection, nonunion, amputation, and arthrodesis) after pilon fracture fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS

Two hundred seventy-nine pilon fractures (276 patients) were identified. A retrospective review was performed to find patients who presented for open reduction and internal fixation of a tibial pilon fracture (OTA/AO 43). Patient demographics, medical comorbidities, OTA/AO fracture type, and surgical outcomes were reviewed.

INTERVENTION

Patients were stratified into cohorts based on the presence or absence of diabetes at the time of surgery.

MAIN OUTCOME MEASUREMENTS

The complications of interest that proved significant during univariate analyses were then entered into a multivariable logistic regression model using a stepwise method to identify the independent predictors for complications.

RESULTS

There were 43 fractures (15.4%) in patients with diabetes mellitus; 17 (39.5%) of whom were insulin-dependent diabetics. Diabetic patients were significantly more likely to have a higher body mass index (34.81 vs. 29.57, P = 0.002) and be older (55.30 ± 16.3 years vs. 41.70 ± 14.05, P < 0.001) at the time of injury. Patients without diabetes were more likely to sustain an OTA/AO 43-C3 fracture (36.0% vs. 11.6%, P = 0.001). Diabetic patients were 5.5 times more likely to require an arthrodesis [95% confidence interval (CI) = 1.894-16.214; P = 0.001] and 2.7 times more likely to develop a deep infection (95% CI = 1.261-5.630; P = 0.008).

CONCLUSIONS

Overall, diabetic patients in this study were 3.64 times more likely (95% CI = 1.854-7.159; P < 0.001) to experience any complication, despite having less complex fractures.

LEVEL OF EVIDENCE

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

Is Reoperation Higher Than Expected after Below-the-knee Amputation? A Single-center Evaluation of Factors Associated with Reoperation at 1 Year

BACKGROUND

Below-the-knee amputation (BKA) is relatively common among patients with vascular disease, infection, trauma, or neoplastic disease. Many BKAs are performed in patients with incompletely treated medical comorbidities, and some are performed in patients with acute high-energy trauma or crush injuries, malignant neoplasm undergoing time-sensitive limb removal, and diabetes with active infection or sepsis. Consequently, revision is common. Prior studies of outcomes after BKA, including several based on the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, have follow-up periods that do not cover the entire at-risk period.

QUESTIONS/PURPOSES

(1) What is the survivorship free from unplanned reoperation within 1 year of BKA? (2) What patient characteristics are associated with reoperation within 1 year of BKA?

METHODS

We retrospectively studied all BKAs performed by the orthopaedic surgery service at a Level 1 trauma center from 2008 to 2018, as identified by Current Procedural Terminology (CPT) codes. Twenty-eight percent (38 of 138) underwent amputation as treatment for traumatic injury, 57% (79 of 138) for infection, and 15% (21 of 138) for malignancy. A total of 17% (23 of 138) had a final follow-up encounter before the 1-year study minimum, without differential loss to follow-up by surgical indication (p = 0.43) or hemoglobin A1c (p = 0.71). Median (range) follow-up was 570 days (6 to 3375). The primary outcome was survivorship from unplanned reoperation within 1 year of BKA index surgery or last planned reoperation, as determined by Kaplan-Meier estimation. Secondarily, we identified patient characteristics independently associated with reoperation within 1 year of BKA. Collected data included age, indication, BMI, diabetes, hemoglobin A1c level, closure method, and substance use. Unplanned reoperation was defined as irrigation and débridement, stump revision, or revision to a higher-level amputation; this did not include planned reoperations for BKAs closed in a staged manner. Factors associated with reoperation were determined using multivariate logistic regression analyses. All endpoints and variables related to patients and their surgical procedures were extracted from electronic medical records by someone other than the operating surgeon.

RESULTS

Using Kaplan-Meier estimation, 38% of patients (95% confidence interval 29 to 46) who underwent BKA had an unplanned reoperation within 1 year of their index surgery. Twelve percent of patients (95% CI 7 to 17) who underwent BKA did not reach 30 days with the limb survivorship free from unplanned reoperation. The median (range) time between the initial surgery and reoperation was 54 days (6 to 315). After controlling for potential confounding variables like age, gender, platelet count, albumin, and the reason for undergoing amputation, a hemoglobin A1c level greater than 8.1% (relative to A1c ≤ 8.1%) was the only variable independently associated with increased odds of reoperation (odds ratio 4.6 [95% CI 1.3 to 18.1]; p = 0.02).

CONCLUSION

BKA carries a higher risk for reoperation than currently reported in studies that use 30-day postoperative follow-up periods. Clinicians should critically assess whether BKA is necessary, especially in patients with uncontrolled diabetes assessed by hyperglycemia. Before planned BKA, patients should have documented glycemic control to minimize the odds of reoperation. Because many of this study's limitations were due to its retrospective single center design, we recommend that future work cover a clinically appropriate surveillance period using a larger cohort such as a national database and/or employ a prospective design.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A systematic review of ankle fracture treatment modalities in diabetic patients

AIM

This systematic review evaluated the surgical outcomes of various ankle fracture treatment modalities in patients with Diabetes Mellitus as well as the methodological quality of the studies.

METHODS

For our review, four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). The overall methodological quality of the studies was assessed with the Coleman Methodology Score. Data regarding diabetic ankle fractures were pooled into three outcomes groups for comparison: (1) the standard fixation cohort with management of diabetic ankle fractures using ORIF with small or mini fragment internal fixation techniques following AO principles, (2) the minimally invasive cohort with diabetic ankle fracture management utilizing percutaneous cannulated screws or intramedullary fixation, and (3) the combined construct cohort treated with a combination of ORIF and another construct (transarticular or external fixation).

RESULTS

The search strategy identified 2228 potential studies from the four databases and 11 were included in the final review. Compared to the standard fixation cohort, the minimally invasive cohort had increased risk of hardware breakage or migration and the combined constructs cohort had increased risk of hardware breakage or migration, surgical site infection and nonunion. Limb salvage rates were similar for the standard fixation and minimally invasive cohorts; however, the combined constructs cohort had a significantly lower limb salvage rate compared to that of the standard fixation cohort. The mean Coleman Methodology Score indicated the quality of the studies in the review was poor and consistent with its limitations.

DISCUSSION

The overall quality of published studies on operative treatment of diabetic ankle fractures is low. Treating diabetic ankle fractures operatively results in a high number of complications regardless of fixation method. However, limb salvage rates remain high overall at 97.9% at a mean follow-up of 21.7 months. To achieve improved limb salvage rates and decrease complications, it is critical is to follow basic AO principles, respect the soft tissue envelope or utilize minimally invasive techniques, and be wary that certain combined constructs may be associated with higher complication rates.

LEVEL OF EVIDENCE

2.

Transcutaneous CO2 application accelerates fracture repair in streptozotocin-induced type I diabetic rats

INTRODUCTION

Diabetes mellitus (DM) negatively affects fracture repair by inhibiting endochondral ossification, chondrogenesis, callus formation, and angiogenesis. We previously reported that transcutaneous CO₂ application accelerates fracture repair by promoting endochondral ossification and angiogenesis. The present study aimed to determine whether CO₂ treatment would promote fracture repair in cases with type I DM.

RESEARCH DESIGN AND METHODS

A closed femoral shaft fracture was induced in female rats with streptozotocin-induced type I DM. CO₂ treatment was performed five times a week for the CO₂ group. Sham treatment, where CO₂ was replaced with air, was performed for the control group. Radiographic, histologic, genetic, and biomechanical measurements were taken at several time points.

RESULTS

Radiographic assessment demonstrated that fracture repair was induced in the CO₂ group. Histologically, accelerated endochondral ossification and capillary formation were observed in the CO₂ group. Immunohistochemical assessment indicated that early postfracture proliferation of chondrocytes in callus was enhanced in the CO₂ group. Genetic assessment results suggested that cartilage and bone formation, angiogenesis, and vasodilation were upregulated in the CO₂ group. Biomechanical assessment revealed enhanced mechanical strength in the CO₂ group.

CONCLUSIONS

Our findings suggest that CO₂ treatment accelerates fracture repair in type I DM rats. CO₂ treatment could be an effective strategy for delayed fracture repair due to DM.

Prior bariatric surgery and perioperative cardiovascular outcomes following noncardiac surgery in patients with type 2 diabetes mellitus: hint from National Inpatient Sample Database

Background

Both diabetes and obesity are risk factors for perioperative major adverse events. This study aims to evaluate the association between prior bariatric surgery (prior-BS) and perioperative cardiovascular outcomes following noncardiac surgery in patients with type 2 diabetes mellitus (T2DM).

Methods

We used the National Inpatient Sample Database to identify T2DM patients undergoing major noncardiac surgery from 2006 to 2014. The primary outcome was major perioperative adverse cardiovascular and cerebrovascular events (MACCEs), which include death, acute myocardial infarction and acute ischaemic stroke. In-hospital outcomes between patients with prior BS and morbid obesity were compared using unadjusted logistic, multivariable logistic and propensity score matching analyses.

Results

A weighted of 1,526,820 patients diagnosed with T2DM who underwent noncardiac surgery were included. The rates of both prior BS and morbid obesity significantly increased during the study period (P < 0.0001). Patients with prior BS were younger, were more likely to be female, and had lower rates of cardiovascular risk factors but had higher rates of smoking, alcohol abuse, anaemia, prior venous thromboembolism and prior percutaneous coronary intervention. The incidence of MACCEs was 1.01% and 3.25% in patients with prior BS and morbid obesity, respectively. After multivariable adjustment, we found that prior BS was associated with a reduced risk of MACCEs (odds ratio [OR] = 0.71; 95% confidence interval [CI] 0.62–0.81), death (OR = 0.64, 95% CI 0.52–0.78), acute kidney injury (OR = 0.66, 95% CI 0.62–0.70) and acute respiratory failure (OR: 0.46; 95% CI 0.42–0.50).

Conclusions

Prior bariatric surgery in T2DM patients undergoing noncardiac surgery is associated with a lower risk of MACCEs. Prospective studies are needed to verify the benefits of bariatric surgery in patients undergoing noncardiac surgery.

Rates and Risk Factors for Failure of Surgical Repair of the Knee Extensor Mechanism

OBJECTIVES

To evaluate rates and risk factors for failed surgical repair of the knee extensor mechanism.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

Two hundred ninety-four patients and a total of 303 extensor mechanism repairs were included. This encompassed 113 quadriceps tendon repairs (QTR), 112 fracture repairs (FR), and 68 patellar tendon repairs (PTR).

MAIN OUTCOME MEASUREMENT

Repair failure.

RESULTS

There were 6 failures (5%) in the QTR group, 21 failures (17%) in the FR group, and 2 failures (3%) in the PTR group. The difference in failure rates between the groups was significant (P = 0.001), but the rate of revision fixation or repair was not (P = 0.315). In the QTR group, a history of inflammatory arthritis was found to be significantly different between patients who had repair failure and patients who did not (P = 0.014) with a relative risk for failure of 17.8 (confidence interval 4.5-70.4). In the FR group, patient age (P = 0.001) and comorbid diabetes mellitus (P = 0.046) were found to be significantly different between patients with and without repair failure in univariate analysis, but only patient age (P = 0.005) was significant in multiple logistic regression analysis. The relative risk for FR failure was 6.6 (confidence interval 2.3-18.3) for age greater than 60. No risk factors for failure were identified in the PTR group.

CONCLUSIONS

Overall, patients with fractures were more likely experience repair failure than patients with tendon injuries, but all patients underwent similar rates of reoperation. Inflammatory arthritis in patients with QTRs and older patient age in FRs are risk factors for repair failure.

LEVEL OF EVIDENCE

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

Connection of discontinuous segments in early functional recovery from thoracic ossification of the posterior longitudinal ligament treated with posterior instrumented surgery

OBJECTIVE

The objective of this study was to investigate the relationship between morphological changes in thoracic ossification of the posterior longitudinal ligament (T-OPLL) and postoperative neurological recovery after thoracic posterior fusion surgery. Changes of OPLL morphology and postoperative recovery in cases with T-OPLL have not been examined.

METHODS

In this prospective study, the authors evaluated data from 44 patients (23 male and 21 female) who underwent posterior decompression and fusion surgery with instrumentation for the treatment of T-OPLL at our hospital. The patients’ mean age at surgery was 50.7 years (range 38–68 years). The minimum duration of follow-up was 2 years. The location of thoracic ossification of the ligamentum flavum (T-OLF), T-OLF at the OPLL level, OPLL morphology, fusion range, estimated blood loss, operative time, pre- and postoperative Japanese Orthopaedic Association (JOA) scores, and JOA recovery rate were investigated. Reconstructed sagittal multislice CT images were obtained before and at 3 and 6 months and 1 and 2 years after surgery. The basic fusion area was 3 vertebrae above and below the OPLL lesion. All parameters were compared between patients with and without continuity across the disc space at the OPLL at 3 and 6 months after surgery.

RESULTS

The preoperative morphology of OPLL was discontinuous across the disc space between the rostral and caudal ossification regions on sagittal CT images in all but one of the patients. Postoperatively, these segments became continuous in 42 patients (97.7%; occurring by 6.6 months on average) without progression of OPLL thickness. Patients with continuity at 3 months had significantly lower rates of diabetes mellitus (p < 0.05) and motor palsy in the lower extremities (p < 0.01). The group with continuity also had significantly higher mean postoperative JOA scores at 3 (p < 0.01) and 6 (p < 0.05) months and mean JOA recovery rates at 3 and 6 months (both p < 0.01) after surgery.

CONCLUSIONS

Preoperatively, discontinuity of rostral and caudal ossified lesions was found on CT in all patients but one of this group of 44 patients who needed surgery for T-OPLL. Rigid fixation with instrumentation may have allowed these segments to connect at the OPLL. Such OPLL continuity at an early stage after surgery may accelerate spinal cord recovery.

Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society

Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.

Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.

The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.

The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.

Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.

The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.

Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037

Impact of Diabetes Mellitus on Bone Health

Long-term exposure to a diabetic environment leads to changes in bone metabolism and impaired bone micro-architecture through a variety of mechanisms on molecular and structural levels. These changes predispose the bone to an increased fracture risk and impaired osseus healing. In a clinical practice, adequate control of diabetes mellitus is essential for preventing detrimental effects on bone health. Alternative fracture risk assessment tools may be needed to accurately determine fracture risk in patients living with diabetes mellitus. Currently, there is no conclusive model explaining the mechanism of action of diabetes mellitus on bone health, particularly in view of progenitor cells. In this review, the best available literature on the impact of diabetes mellitus on bone health in vitro and in vivo is summarised with an emphasis on future translational research opportunities in this field.

Does Age Influence the Outcome of Lower Limb Non-Union Treatment? A Matched Pair Analysis

Background: Fractures in elderly patients are common and have severe implications on a socioeconomic level, as musculoskeletal integrity and competence is crucial for independence. Changes in both composition and biology of bones during aging potentially affect fracture healing adversely. The current study sought to determine the influence of age on the outcome of non-union therapy of atrophic and hypertrophic non-unions based on the “diamond concept”, as well as to evaluate the well-known risk factors impairing bone healing. Patients and Methods: All medical records, operative notes, lab data, and radiological imaging of patients that received surgical treatment of both atrophic and hypertrophic non-unions of the femur or tibia between 1 January 2010 and 31 December 2016 were thoroughly reviewed and analyzed. Patients who participated in our standardized follow-up for at least 12 months were included into a database. Patients older than 60 years were matched with patients younger than 60 based on five established criteria. The study was approved by the local ethics committee (S-262/2017). According to our inclusion criteria, a total of 76 patients older than 60 years were eligible for analysis. Via matching, two groups were formed: study group (SG; >60 years; n = 45) and control group (CG; <60 years; n = 45). Results: Twelve months subsequent to treatment, the consolidation rate was equivalent in both groups (SG: 71% vs. CG: 67%). The consolidation for all patients before matching was 73%. The clinical results for the complete collective were no pain or pain with high or medium strain for 62.5%, whereas 29.6% had pain with low strain or constant pain. 7.87% had no pain levels given. Logistic regression modeling showed no influence of age >60 years on radiological or clinical outcome, whereas a significant negative correlation was revealed between patients aged 40–49 years and radiological non-union consolidation (b = −1.145 and p = 0.048). In addition, diabetes had a negative influence on non-union therapy (b = −1.145 and p = 0.048). As expected, the clinical outcome correlated significantly with the radiological outcome (p < 0.001). Conclusion: Surgeons should optimize both modifiable risk factors such as diabetes mellitus, as well as surgical treatment in order to achieve the best possible outcome in elderly patients. Elderly patients benefit from osseous consolidation by enabling and maintaining musculoskeletal competence due to the close correlation between clinical and radiological outcome. Advanced age alone does not negatively influence the outcome of non-union therapy and should, therefore, not be considered a risk factor. In contrast, patients in their fifth decade suffering from lower limb non-unions should be considered as high-risk patients and treatment should be modified accordingly.

Bone turnover markers in children and adolescents with type 1 diabetes-A systematic review

Type 1 diabetes (T1D) is associated with impaired bone health and both osteocalcin (OCN) and procollagen type 1 amino terminal propetide (P1NP) (markers of bone formation) and C-terminal cross-linked telopeptide (CTX) (marker of bone resorption) are decreased in adult patients with T1D. We review the existing literature characterizing these bone turnover markers in children and adolescents with T1D and by meta-analysis examine whether alterations in OCN, P1NP, and CTX are evident and if potential changes correlate to the metabolic control (hemoglobin A1c, HbA1c). Systematic searches at MEDLINE and EMBASE were conducted in January 2018 identifying all studies describing OCN, P1NP, or CTX in children and adolescents with T1D. A total of 26 studies were included, representing data from more than 1000 patients with T1D. Pooled analyses of standard mean difference and summary effects analysis were performed when sufficient data were available. Pooled analysis revealed mean OCN to be significantly lower in children and adolescents with T1D compared to healthy controls (standard mean difference: -1.87, 95% confidence interval, CI: -2.83; -0.91) whereas both P1NP and CTX did not differ from the controls. Only data on OCN was sufficient to make pooled correlation analysis revealing a negative correlation between OCN and HbA1c (-0.31 95% CI: -0.45; -0.16). In conclusion, OCN is decreased in children and adolescents with T1D, whether CTX and P1NP are affected as well is unclear, due to very limited data available. New and large studies including OCN, P1NP, and CTX (preferably as z-scores adjusting for age variability) is needed to further elucidate the status of bone turnover in children and adolescents with T1D.

The risk factors of nonunion after intramedullary nailing fixation of femur shaft fracture in middle age patients

Although the optimal treatment for femur shaft fracture is intramedullary nailing fixation, nonunion still occurs. We determined the oligotrophic nonunion rate among femur fractures managed operatively and identified risk factors for reoperation. This was a retrospective clinical study. The data of the patients between 40 and 70 years old with diaphyseal femur fracture who have received reamed and interlocked intramedullary nailing fixation in our hospital from February 2014 to April 2018 were collected. They were followed at regular intervals for at least 1 year after the operation. The primary outcome was nonunion of the fracture site that required reoperation in accordance with the radiographic union scale for tibial shaft fracture (RUST), which is a reasonable score system for lower limb diaphyseal fracture. Three of them were hypertrophic nonunion (1.9%) and the other 13 cases were oligotrophic nonunion (8.6%) at postoperative 12 months follow-up. All of the postoperative plain films showed adequate reduction quality. The three hypertrophic nonunion cases were all obese male with fracture site comminution. Fracture at the proximal third junction, hypertension (HTN) and diabetes mellitus (DM) was significantly associated with oligotrophic nonunion of the fracture site from logistic regression analysis. The mean RUST score 3 months after the operation was not significantly different between the union group and nonunion group but was significantly lower 6 months after the operation in the nonunion group. In conclusion, intramedullary nailing of the femur shaft fractures was associated with a low risk of nonunion at the 1-year follow-up in the middle age group. Those with comorbidity such as obese, HTN, and DM, with fracture site at the proximal third junction or comminution should be followed up closely and rehabilitation with cause aggressively. Radiographic scale as the RUST score at postoperative 6 months could be used to predict this complication.

Trauma in the Diabetic Limb

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.