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Srinath A, Southall WGS, Nazal MR, Mechas CA, Foster JA, Griffin JT, Muhammad M, Moghadamian ES, Landy DC, Aneja A. Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis. J Orthop Trauma 2024; 38:220-224. [PMID: 38457751 DOI: 10.1097/bot.0000000000002798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). METHODS DESIGN Retrospective cohort. SETTING Single level I trauma center. PATIENT SELECTION CRITERIA Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. OUTCOME MEASURES AND COMPARISONS The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. RESULTS There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. CONCLUSIONS This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arjun Srinath
- Department of Orthopaedic Surgery, University of Miami, Miami, FL
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Mark R Nazal
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Charles A Mechas
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | | | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
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Koch L, Orth M, Fink T, Meiser A, Volk T, Menger MD, Laschke MW, Pastor T, Knobe M, Pohlemann T, Ganse B. Lower oxygen saturation with higher rates of norepinephrine in bone fractures of polytrauma patients: a pilot study. Crit Care 2023; 27:367. [PMID: 37743472 PMCID: PMC10518976 DOI: 10.1186/s13054-023-04657-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Laura Koch
- Werner Siemens-Endowed Chair for Innovative Implant Development (Fracture Healing), Departments and Institutes of Surgery, Saarland University, Homburg, Germany
| | - Marcel Orth
- Department of Trauma, Hand and Reconstructive Surgery, Departments and Institutes of Surgery, Saarland University, Homburg, Germany
| | - Tobias Fink
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University, Homburg, Germany
| | - Andreas Meiser
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University, Homburg, Germany
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University, Homburg, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
| | - Torsten Pastor
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Westmuensterland Hospital, Ahaus, Germany
- Medical Faculty, University of Zurich, Zurich, Switzerland
- Medical Faculty, RWTH University Aachen, Aachen, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Departments and Institutes of Surgery, Saarland University, Homburg, Germany
| | - Bergita Ganse
- Werner Siemens-Endowed Chair for Innovative Implant Development (Fracture Healing), Departments and Institutes of Surgery, Saarland University, Homburg, Germany.
- Department of Trauma, Hand and Reconstructive Surgery, Departments and Institutes of Surgery, Saarland University, Homburg, Germany.
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3
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Arthur RY, Johnson JP. Surgical treatment of sacral nonunions. Injury 2023:S0020-1383(23)00406-0. [PMID: 37179204 DOI: 10.1016/j.injury.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.
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Affiliation(s)
- Rodney Y Arthur
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St South, Faculty Office Tower 901, Birmingham, AL 35294, USA
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St South, Faculty Office Tower 901, Birmingham, AL 35294, USA.
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Bläsius FM, Greven J, Guo W, Bolierakis E, He Z, Lübke C, Simon TP, Hildebrand F, Horst K. Local YB-1, Epo, and EpoR concentrations in fractured bones: results from a porcine model of multiple trauma. Eur J Med Res 2023; 28:25. [PMID: 36639666 PMCID: PMC9837984 DOI: 10.1186/s40001-023-00996-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023] Open
Abstract
Little is known about the impact of multiple trauma (MT)-related systemic hypoxia on osseous protein concentration of the hypoxia transcriptome. To shed light on this issue, we investigated erythropoietin (Epo), erythropoietin receptor (EpoR), and Y-box binding protein 1 (YB-1) concentrations in the fracture zone in a porcine MT + traumatic hemorrhage (TH) model. Sixteen male domestic pigs were randomized into two groups: an MT + TH group and a sham group. A tibia fracture, lung contusion, and TH were induced in the MT + TH group. The total observation period was 72 h. YB-1 concentrations in bone marrow (BM) were significantly lower in the fracture zone of the MT + TH animals than in the sham animals. Significant downregulation of BM-localized EpoR concentration in both unfractured and fractured bones was observed in the MT + TH animals relative to the sham animals. In BM, Epo concentrations were higher in the fracture zone of the MT + TH animals compared with that in the sham animals. Significantly higher Epo concentrations were detected in the BM of fractured bone compared to that in cortical bone. Our results provide the first evidence that MT + TH alters hypoxia-related protein concentrations. The impacts of both the fracture and concomitant injuries on protein concentrations need to be studied in more detail to shed light on the hypoxia transcriptome in fractured and healthy bones after MT + TH.
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Affiliation(s)
- Felix Marius Bläsius
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XInsitute of Pharmacology and Toxicology, University Hospital, RWTH University, Aachen, Germany
| | - Johannes Greven
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Weijun Guo
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Eftychios Bolierakis
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Zhizhen He
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Cavan Lübke
- grid.1957.a0000 0001 0728 696XDepartment of Intensive Care and Intermediate Care, University Hospital, RWTH University, Aachen, Germany
| | - Tim-Philipp Simon
- grid.1957.a0000 0001 0728 696XDepartment of Intensive Care and Intermediate Care, University Hospital, RWTH University, Aachen, Germany
| | - Frank Hildebrand
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Klemens Horst
- grid.1957.a0000 0001 0728 696XDeptartment of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital, RWTH University, Pauwelsstraße 30, 52074 Aachen, Germany
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5
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Nau C, Weber B, Marzi I. [Treatment of prehospital emergencies and multiple trauma]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:776-779. [PMID: 36042052 DOI: 10.1007/s00113-022-01230-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Christoph Nau
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Goethe Universität, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Birte Weber
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Goethe Universität, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Ingo Marzi
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Goethe Universität, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
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Charles SJC, Chen SR, Mittwede P, Rai A, Moloney G, Sabzevari S, Lin A. Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures. J Shoulder Elbow Surg 2022; 31:e498-e506. [PMID: 35472574 DOI: 10.1016/j.jse.2022.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal management of a displaced midshaft clavicle fracture remains controversial. This study assessed demographic factors, fracture pattern, and surgical technique as potential predictors of surgical complications. Smoking, diabetes, obesity, polytrauma, high-energy mechanism, inpatient status, transverse or comminuted fractures, and single-plating technique were hypothesized to be associated with an increased risk of complications following clavicle fracture open reduction internal fixation (ORIF). METHODS Consecutive patients with minimum 12-week follow-up from the trauma and sports medicine divisions at a single tertiary institution who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2020 were retrospectively identified. Patient demographics, fracture pattern, plating technique, and postoperative complications were recorded. Postoperative complications were classified into major (reoperation) and minor (no reoperation) complications. Chi-squared statistics, Fisher's exact test, analysis of variance, Kruskal-Wallis test, and multivariate logistic regression modeling were utilized with a significance level set to P < .05. RESULTS One hundred ninety-eight patients (average = 39.5 ± 14.6 years) were identified with an average follow-up of 9.1 ± 10.7 months. The cohort consisted of 155 males (78.3%), 62 smokers (31.3%), and 12 diabetics (6.1%). Injury characteristics revealed 80 transverse fractures (40.4%), 87 oblique fractures (43.9%), and 31 Z-type fractures (15.7%). Seventy-nine patients (39.9%) underwent superior plating, 72 (36.4%) underwent anterior plating, and 47 (23.7%) underwent dual plating. Overall, postoperative complications occurred in 47 patients (23.7%), 29 minor (14.6%) and 18 major (9.1%). Major complications requiring reoperation were symptomatic hardware, nonunion, deep infection, wound dehiscence, and broken hardware. Minor complications consisted of sensory deficit or paresthesia beyond peri-incisional numbness, superficial infections, postoperative pain and/or stiffness, and delayed union. Smoking status (P = .008), obesity (P = .009), and transverse or Z-type fractures (P = .002) were significant prognostic factors for overall complication risk. Only manual labor was predictive of minor complications (P = .019). Transverse or Z-type fractures and single plating were predictive of major complications (P = .004 and P = .008, respectively). No reoperations occurred in patients who underwent dual plating. Smokers (P = .027) with transverse/Z-type fractures (P = .022) were at the highest risk of reoperation with single plating. CONCLUSION The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. Given relatively high complication rates, in instances when nonoperative vs. operative management is equivocal, nonoperative management should be strongly considered in obese patients, smokers, and patients who present with transverse or Z-type fracture. If operative management is indicated, use of dual plating may decrease reoperation rates.
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Affiliation(s)
| | - Stephen R Chen
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ajinkya Rai
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gele Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Soheil Sabzevari
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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7
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Sabaté-Brescó M, Berset CM, Zeiter S, Stanic B, Thompson K, Ziegler M, Richards RG, O'Mahony L, Moriarty TF. Fracture biomechanics influence local and systemic immune responses in a murine fracture-related infection model. Biol Open 2021; 10:270855. [PMID: 34240122 PMCID: PMC8496694 DOI: 10.1242/bio.057315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 07/05/2021] [Indexed: 11/26/2022] Open
Abstract
Biomechanical stability plays an important role in fracture healing, with unstable fixation being associated with healing disturbances. A lack of stability is also considered a risk factor for fracture-related infection (FRI), although confirmatory studies and an understanding of the underlying mechanisms are lacking. In the present study, we investigate whether biomechanical (in)stability can lead to altered immune responses in mice under sterile or experimentally inoculated conditions. In non-inoculated C57BL/6 mice, instability resulted in an early increase of inflammatory markers such as granulocyte-colony stimulating factor (G-CSF), keratinocyte chemoattractant (KC) and interleukin (IL)-6 within the bone. When inoculated with Staphylococcus epidermidis, instability resulted in a further significant increase in G-CSF, IL-6 and KC in bone tissue. Staphylococcus aureus infection led to rapid osteolysis and instability in all animals and was not further studied. Gene expression measurements also showed significant upregulation in CCL2 and G-CSF in these mice. IL-17A was found to be upregulated in all S. epidermidis infected mice, with higher systemic IL-17A cell responses in mice that cleared the infection, which was found to be produced by CD4+ and γδ+ T cells in the bone marrow. IL-17A knock-out (KO) mice displayed a trend of delayed clearance of infection (P=0.22, Fisher’s exact test) and an increase in interferon (IFN)-γ production. Biomechanical instability leads to a more pronounced local inflammatory response, which is exaggerated by bacterial infection. This study provides insights into long-held beliefs that biomechanics are crucial not only for fracture healing, but also for control of infection. Summary: Physical movement between bone fragments after a fracture influence healing, and are shown here, for the first time, to influence immune responses and infection.
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Affiliation(s)
- Marina Sabaté-Brescó
- AO Research Institute Davos, AO Foundation, Davos, Switzerland.,Swiss Institute of Asthma and Allergy Research, University of Zurich, Davos, Switzerland
| | - Corina M Berset
- Swiss Institute of Asthma and Allergy Research, University of Zurich, Davos, Switzerland
| | - Stephan Zeiter
- AO Research Institute Davos, AO Foundation, Davos, Switzerland
| | - Barbara Stanic
- AO Research Institute Davos, AO Foundation, Davos, Switzerland
| | - Keith Thompson
- AO Research Institute Davos, AO Foundation, Davos, Switzerland
| | - Mario Ziegler
- Swiss Institute of Asthma and Allergy Research, University of Zurich, Davos, Switzerland
| | | | - Liam O'Mahony
- Swiss Institute of Asthma and Allergy Research, University of Zurich, Davos, Switzerland
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8
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Madry H, Grässel S, Nöth U, Relja B, Bernstein A, Docheva D, Kauther MD, Katthagen JC, Bader R, van Griensven M, Wirtz DC, Raschke MJ, Huber-Lang M. The future of basic science in orthopaedics and traumatology: Cassandra or Prometheus? Eur J Med Res 2021; 26:56. [PMID: 34127057 PMCID: PMC8200553 DOI: 10.1186/s40001-021-00521-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/20/2021] [Indexed: 12/23/2022] Open
Abstract
Orthopaedic and trauma research is a gateway to better health and mobility, reflecting the ever-increasing and complex burden of musculoskeletal diseases and injuries in Germany, Europe and worldwide. Basic science in orthopaedics and traumatology addresses the complete organism down to the molecule among an entire life of musculoskeletal mobility. Reflecting the complex and intertwined underlying mechanisms, cooperative research in this field has discovered important mechanisms on the molecular, cellular and organ levels, which subsequently led to innovative diagnostic and therapeutic strategies that reduced individual suffering as well as the burden on the society. However, research efforts are considerably threatened by economical pressures on clinicians and scientists, growing obstacles for urgently needed translational animal research, and insufficient funding. Although sophisticated science is feasible and realized in ever more individual research groups, a main goal of the multidisciplinary members of the Basic Science Section of the German Society for Orthopaedics and Trauma Surgery is to generate overarching structures and networks to answer to the growing clinical needs. The future of basic science in orthopaedics and traumatology can only be managed by an even more intensified exchange between basic scientists and clinicians while fuelling enthusiasm of talented junior scientists and clinicians. Prioritized future projects will master a broad range of opportunities from artificial intelligence, gene- and nano-technologies to large-scale, multi-centre clinical studies. Like Prometheus in the ancient Greek myth, transferring the elucidating knowledge from basic science to the real (clinical) world will reduce the individual suffering from orthopaedic diseases and trauma as well as their socio-economic impact.
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Affiliation(s)
- Henning Madry
- Institute of Experimental Orthopaedics and Osteoarthritis Research, Saarland University, Homburg, Germany
| | - Susanne Grässel
- Experimental Orthopedics, Department of Orthopedic Surgery, University of Regensburg, Regensburg, Germany
| | - Ulrich Nöth
- Department of Orthopaedics and Trauma Surgery, Evangelisches Waldkrankenhaus Berlin Spandau, Berlin, Germany
| | - Borna Relja
- Experimental Radiology, University Clinic for Radiology and Nuclear Medicine, Otto-Von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Anke Bernstein
- G.E.R.N. Research Center for Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Breisgau, Germany
| | - Denitsa Docheva
- Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg, Germany
| | - Max Daniel Kauther
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Jan Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Rainer Bader
- Department of Orthopaedics, Research Lab for Biomechanics and Implant Technology, Rostock University Medical Center, Rostock, Germany
| | - Martijn van Griensven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN-Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands
| | - Dieter C Wirtz
- Department of Orthopaedics and Trauma Surgery, University Hopsital Bonn, Bonn, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma-Immunology (ITI), University Hospital Ulm, Helmholzstr. 8/1, Ulm, Germany.
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Fracture nonunion in long bones: A literature review of risk factors and surgical management. Injury 2021; 52 Suppl 2:S3-S11. [PMID: 33221036 DOI: 10.1016/j.injury.2020.11.029] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.
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10
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Abstract
The management of multiply injured or severely injured patients is a complex and dynamic process. Timely and safe fracture fixation is a critical component of the multidisciplinary care that these patients require. Effective management of these patients, and their orthopaedic injuries, requires a strong understanding of the pathophysiology of the response to trauma and indicators of patient status, as well as an appreciation for the dynamic nature of these parameters. Substantial progress in both clinical and basic science research in this area has advanced our understanding of these concepts and our approach to management of the polytraumatized patient. This article summarizes a symposium on this topic that was presented by an international panel of experts at the 2020 Virtual Annual Meeting of the Orthopaedic Trauma Association.
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11
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Hofman M, Andruszkow H, Heyer FL, Kobbe P, Hildebrand F, Poeze M. Risk factors of non-union in intramedullary stabilized diaphyseal long bone fractures: identifying the role of fracture stabilization strategies and concomitant injuries. Eur J Trauma Emerg Surg 2020; 47:1903-1910. [PMID: 32140749 PMCID: PMC8629802 DOI: 10.1007/s00068-020-01335-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/18/2020] [Indexed: 12/01/2022]
Abstract
Purpose Concomitant chest injury is known to negatively affect bone metabolism and fracture healing, whereas traumatic brain injury (TBI) appears to have positive effects on bone metabolism. Osteogenesis can also be influenced by the timing of fracture stabilization. We aimed to identify how chest injuries, TBI and fracture stabilization strategy influences the incidence of non-union. Methods Patients with long bone fractures of the lower extremities who had been treated between 2004 and 2014 were retrospectively analysed. Non-union was defined as fracture healing not occurring in the expected time period and in which neither progression of healing nor successful union is expected without intervention. Diverse clinical and radiological parameters were statistically analysed using the Statistical Package for the Social Sciences (SPSS). Results The total number of operations before consolidation was an independent predictor (odds ratio [OR] = 6.416, p < 0.001) for the development of non-union in patients with long bone fractures. More specifically, patients treated according to the damage control orthopaedics (DCO) principle had a significantly higher risk of developing a non-union than patients treated according to the early total care (ETC) principle (OR = 7.878, p = 0.005). Concomitant chest injury and TBI could not be identified as influencing factors for non-union development. Conclusion Our results indicate that the number of operations performed in patients with long bone fractures should be kept as low as possible and that the indication for and the timing of DCO treatment should be meticulously noted to minimize the risk of non-union development.
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Affiliation(s)
- Martijn Hofman
- Department of Orthopedic Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Hagen Andruszkow
- Department of Orthopedic Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frans L. Heyer
- Division of Traumasurgery,, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Philipp Kobbe
- Department of Orthopedic Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedic Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Martijn Poeze
- Division of Traumasurgery,, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
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Horst K, Greven J, Lüken H, Zhi Q, Pfeifer R, Simon TP, Relja B, Marzi I, Pape HC, Hildebrand F. Trauma Severity and Its Impact on Local Inflammation in Extremity Injury-Insights From a Combined Trauma Model in Pigs. Front Immunol 2020; 10:3028. [PMID: 31993054 PMCID: PMC6964795 DOI: 10.3389/fimmu.2019.03028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/10/2019] [Indexed: 01/06/2023] Open
Abstract
Background: Extremity fracture is frequently seen in multiple traumatized patients. Local post-traumatic inflammatory reactions as well as local and systemic interactions have been described in previous studies. However, trauma severity and its impact on the local immunologic reaction remains unclear. Therefore, fracture-associated local inflammation was investigated in a porcine model of isolated and combined trauma to gain information about the early inflammatory stages. Material and Methods: Polytrauma (PT) consisted of lung contusion, liver laceration, femur fracture, and controlled hemorrhage. Monotrauma (MT) consisted of femur fracture only. The fracture was operatively stabilized and animals were monitored under ICU-standard for 72 h. Blood, fracture hematoma (FH) as well as muscle samples were collected throughout the experimental period. Levels of local and systemic pro- and anti-inflammatory as well as angiogenetic cytokines were measured by ELISA. Results: Both groups showed a significant decrease in pro-inflammatory IL-6 in FH over time. However, concentrations in MT were significantly higher than in PT. The IL-8 concentrations initially decreased in FH, but recovered by the end of the observation period. These dynamics were only statistically significant in MT. Furthermore, concentrations measured in muscle tissue showed inverse kinetics compared to those in FH. The IL-10 did not present statistical resilient dynamics over time, although a slight increase in FH was seen by the end of the observation time in the MT group. Conclusions: Time-dependent dynamics of the local inflammatory response were observed. Trauma severity showed a significant impact, with lower values in pro- as well as angiogenetic mediators. Fracture repair could be altered by these trauma-related changes of the local immunologic milieu, which might serve as a possible explanation for the higher rates of delayed or non-union bone repair in polytraumatised patients.
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Affiliation(s)
- Klemens Horst
- Department of Orthopedic Trauma, University Hospital Aachen, Aachen, Germany.,Orthopedic Trauma Research Laboratory, University Hospital Aachen, Aachen, Germany
| | - Johannes Greven
- Department of Orthopedic Trauma, University Hospital Aachen, Aachen, Germany.,Orthopedic Trauma Research Laboratory, University Hospital Aachen, Aachen, Germany
| | - Hannah Lüken
- Department of Orthopedic Trauma, University Hospital Aachen, Aachen, Germany
| | - Qiao Zhi
- Orthopedic Trauma Research Laboratory, University Hospital Aachen, Aachen, Germany
| | - Roman Pfeifer
- Department of Orthopaedic Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Tim P Simon
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Borna Relja
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany.,Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Ingo Marzi
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Hans-Christoph Pape
- Department of Orthopaedic Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Frank Hildebrand
- Department of Orthopedic Trauma, University Hospital Aachen, Aachen, Germany
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13
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Pan Z, Pan J, Wang H, Yu Z, Li Z, Yang W, Li J, Zhu Q, Luo Z. Healing physiology following delayed surgery for femoral midshaft fracture caused by high-energy injury: an in vivo study in dogs. J Int Med Res 2019; 47:5155-5173. [PMID: 31370721 PMCID: PMC6833404 DOI: 10.1177/0300060519860704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective An experimental model of severe soft tissue damage was designed to simulate high-energy fracture and observe the fracture healing process following early surgery and surgery delayed by 1 week. Methods Forty dogs were randomized to Group A (immediate surgery) and B (delayed surgery). The femur was broken, and the two ends were forcefully stabbed to damage the surrounding soft tissues. The fracture was repaired using a custom six-hole steel plate. Four dogs were killed on day 3 and weeks 1, 2, 4, and 8 following bone fracture. Soft tissue and bone were examined by light and electron microscopy. Results In Group A, no callus was present at 1, 2, 4, and 8 weeks following fracture, resulting in atrophic nonunion. In Group B, visible weak external callus was present 1 week following fracture, and good external callus growth was present at 2, 4, and 8 weeks, leading to callus healing. Conclusion These findings suggest that the first week is critical for fracture healing. Absence of callus in the early stage is indicative of absence of callus growth throughout the entire healing process, while the presence of callus in the early stage is indicative of vigorous callus growth thereafter.
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Affiliation(s)
- Zhijun Pan
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jingxin Pan
- Department of Orthopedics, The Fourth Hospital of Yulin, Yulin, Shaanxi, China
| | - Hanli Wang
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhou Yu
- Department of Burn, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhong Li
- Department of Orthopedics, Xi'an Honghui Hospital, Xi'an, Shaanxi, P.R. China
| | - Wenxue Yang
- Department of Orthopedics, The Fourth Hospital of Yulin, Yulin, Shaanxi, China
| | - Jing Li
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qingsheng Zhu
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhuojing Luo
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
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Early Immunologic Response in Multiply Injured Patients With Orthopaedic Injuries Is Associated With Organ Dysfunction. J Orthop Trauma 2019; 33:220-228. [PMID: 31008819 DOI: 10.1097/bot.0000000000001437] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To quantify the acute immunologic biomarker response in multiply injured patients with axial and lower extremity fractures and to explore associations with adverse short-term outcomes including organ dysfunction and nosocomial infection (NI). DESIGN Prospective cohort study. SETTING Level 1 academic trauma center. PATIENTS Consecutive multiply injured patients, 18-55 years of age, with major pelvic and lower extremity orthopaedic injuries (all pelvic/acetabular fractures, operative femur and tibia fractures) that presented as a trauma activation and admitted to the intensive care unit from April 2015 through October 2016. Sixty-one patients met inclusion criteria. INTERVENTION Blood was collected upon presentation to the hospital and at the following time points: 8, 24, 48 hours, and daily during intensive care unit admission. Blood was processed by centrifugation, separation into 1.0-mL plasma aliquots, and cryopreserved within 2 hours of collection. MAIN OUTCOME MEASUREMENTS Plasma analyses of protein levels of cytokines/chemokines were performed using a Luminex panel Bioassay of 20 immunologic mediators. Organ dysfunction was measured by the Marshall Multiple Organ Dysfunction score (MODScore) and nosocomial infection (NI) was recorded. Patients were stratified into low (MODS ≤ 4; n = 34) and high (MODS > 4; n = 27) organ dysfunction groups. RESULTS The MODS >4 group had higher circulating levels of interleukin (IL)-6, IL-8, IL-10, monocyte chemoattractant protein-1 (MCP-1), IL-1 receptor antagonist (IL-1RA), and monokine induced by interferon gamma (MIG) compared with the MODS ≤4 group at nearly all time points. MODS >4 exhibited lower levels of IL-21 and IL-22 compared with MODS ≤4. Patients who developed NI (n = 24) had higher circulating concentrations of IL-10, MIG, and high mobility group box 1 (HMGB1) compared with patients who did not develop NI (n = 37). CONCLUSIONS Temporal quantification of immune mediators identified 8 biomarkers associated with greater levels of organ dysfunction in polytrauma patients with major orthopaedic injuries. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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15
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Rupp M, Kern S, El Khassawna T, Ismat A, Malhan D, Alt V, Heiss C, Raschke MJ. Do Systemic Factors Influence the Fate of Nonunions to Become Atrophic? A Retrospective Analysis of 162 Cases. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6407098. [PMID: 30911545 PMCID: PMC6399554 DOI: 10.1155/2019/6407098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/29/2019] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Nonunions are a challenge for orthopedic surgeons. In hypertrophic nonunions, improvement of mechanical stability usually is the satisfactory treatment, whereas in atrophic nonunions improvement of the biological environment is most important. However, scientific evidence revealed that "avital" nonunions are not avascular and fibrous tissue contains cells with osteogenic potential. To find out if systemic factors suppress this intrinsic potential in atrophic nonunions, this study compares characteristics of hypertrophic with atrophic nonunion patients. METHODS We analyzed medical records of 162 surgically treated patients suffering from aseptic long bone nonunions. Atrophic and hypertrophic nonunions were distinguished by absence or presence of callus and calcification in the fracture gap. Mechanical implant loosening and patient characteristics such as age, gender, and body mass index were assessed. Fracture classification according to AO/OTA, open and closed fractures, and osteosynthesis were recorded. In addition, comorbidities and allergies between both groups were compared. RESULTS A higher number of hypertrophic nonunion patients were male with often allergies. Hypertrophic nonunion occurred more often after intramedullary nailing compared to atrophic nonunions. Atrophic nonunion patients being nonallergic were significantly older than nonallergic patients suffering from hypertrophic nonunions. In both atrophic and hypertrophic nonunion patients, age was lower in patients with accompanying injuries compared with age of patients with isolated fractures. CONCLUSION Systemic factors influence development of nonunion types. In nonallergic patients, atrophic nonunions occur more often in the elderly. This manuscript is a first step to identify different factors which might influence the nature of nonunion. To enable nonunion treatment which is tailored to individual patient characteristics, further prospective studies with more sophisticated research methods are necessary.
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Affiliation(s)
- Markus Rupp
- Justus-Liebig-University Giessen, University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma-, Hand- and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Stefanie Kern
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Thaqif El Khassawna
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Abdullah Ismat
- Justus-Liebig-University Giessen, University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma-, Hand- and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Deeksha Malhan
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Volker Alt
- Justus-Liebig-University Giessen, University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma-, Hand- and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Christian Heiss
- Justus-Liebig-University Giessen, University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma-, Hand- and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany
- Justus-Liebig-University Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Michael J. Raschke
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma-, Hand- and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
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16
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Ferree S, van der Vliet QMJ, Nawijn F, Bhashyam AR, Houwert RM, Leenen LPH, Hietbrink F. Epidemiology of distal radius fractures in polytrauma patients and the influence of high traumatic energy transfer. Injury 2018; 49:630-635. [PMID: 29429577 DOI: 10.1016/j.injury.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/05/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION For several extremity fractures differences in morphology, incidence rate and functional outcome were found when polytrauma patients were compared to patients with an isolated injury. This is not proven for distal radius fractures (DRF). Therefore, this study aimed to analyse fracture morphology in relation to energy transfer in both poly- and mono-trauma patients with a DRF. METHODS This was a retrospective cohort study. All patients aged 16 years and older with a DRF were included. Patients with an Injury Severity Score of 16 or higher were classified as polytrauma patients. Injuries were defined as high or low energy. All DRFs were classified using the AO/OTA fracture classification system. RESULTS A total of 830 patients with a DRF were included, 12% were polytrauma. The incidence rate of DRF in polytrauma patients was 3.5%. Ipsilateral upper extremity injury was found in >30% of polytrauma and high-energy monotrauma patients, compared to 5% in low-energy monotrauma patients. More type C DRF were found in polytrauma and high-energy monotrauma patients versus low-energy monotrauma patients. Operative intervention rates for all types of DRF were similar for polytrauma and high-energy monotrauma patients. Non-union rates were higher in polytrauma patients. CONCLUSION Higher energy mechanisms of injury, in polytrauma and high-energy monotrauma patients, were associated with more severe complex articular distal radius fractures and more ipsilateral upper extremity injuries. Polytrauma and high-energy monotrauma patient have a similar fracture morphology. However, polytrauma patients have in addition to more injured body regions also more non-union related interventions than high-energy monotrauma patients.
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Affiliation(s)
- Steven Ferree
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
| | | | - Femke Nawijn
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
| | - Abhiram R Bhashyam
- Harvard Combined Orthopaedics Residency Program, Boston, MA, United States.
| | - Roderick M Houwert
- Department of surgery, University Medical Centre Utrecht, The Netherlands; Utrecht Traumacenter, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
| | - Falco Hietbrink
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
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17
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van Niekerk AH, Birkholtz FF, de Lange P, Tetsworth K, Hohmann E. Circular external fixation and cemented PMMA spacers for the treatment of complex tibial fractures and infected nonunions with segmental bone loss. J Orthop Surg (Hong Kong) 2018. [PMID: 28639529 DOI: 10.1177/2309499017716242] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The purpose of this study was to compare the outcome of combined circular external fixation and cemented polymethylmethacrylate (PMMA) spacer application between a cohort of patients with grade 3 open fractures and infected tibial nonunions and concomitant segmental bone loss. METHODS The study was designed as a retrospective cohort study. All patients who were treated for complex tibial fractures or infected nonunions with segmental bone loss between 2009 and 2013 were included if they were aged between 16 years and 60 years, sustained acute traumatic grade 3 open tibial fractures, presented with infected nonunion, and were followed up for a minimum of 12 months. Patients with a history of ipsilateral tibial fractures, contralateral lower extremity fractures, polytrauma, chest, or abdominal trauma and patients with head injuries were excluded. Both groups were treated with aggressive debridement, circular external fixation, and antibiotic-impregnated PMMA spacer. Outcome measures were the time in the external fixator (EFT) and the external fixation index (EFI). RESULTS Twenty-four patients with a mean age of 32 ± 14.7 years were included. Twelve patients with a mean age of 32 + 14 years and a mean bone defect of 82 + 36 mm were treated for acute complex grade 3 open tibial fractures, and 12 patients with a mean age of 35.1 + 15.7 years and a mean bone defect of 50 + 26 mm were treated for infected nonunions. There was no significant difference ( p = 0.44) between the groups for EFT (249 ± 99 days-tibial fractures; 255 ± 142 days-infected nonunion). There were significant between group differences ( p = 0.027) for EFI (37.3 ± 9.1 cm/days-tibial fractures; 56 ± 14.5 cm/days-infected nonunion). CONCLUSION The findings of this study suggest that patients were treated for infected nonunion with segmental bone loss using circular external fixation, distraction osteogenesis, and antibiotic-impregnated PMMA spacers, and the spacers may not offer any advantage over a conventional approach using the principles of osteogenesis only. In contrast, antibiotic-impregnated spacers for open tibial trauma were advantageous and reduced the EFI considerably.
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Affiliation(s)
- Andries H van Niekerk
- 1 Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Franz F Birkholtz
- 1 Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa.,2 Walk-a-Mile Centre for Advanced Orthopaedics, Netcare Unitas Hospital, Mediclinic Midstream Hospital, Pretoria, South Africa
| | - Phillip de Lange
- 2 Walk-a-Mile Centre for Advanced Orthopaedics, Netcare Unitas Hospital, Mediclinic Midstream Hospital, Pretoria, South Africa
| | - Kevin Tetsworth
- 3 Department of Orthopaedic Surgery, Royal Brisbane Hospital, Brisbane, Australia.,4 Queensland University of Technology, Brisbane, Australia.,5 University of Queensland School of Medicine, Brisbane, Australia.,6 Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia
| | - Erik Hohmann
- 2 Walk-a-Mile Centre for Advanced Orthopaedics, Netcare Unitas Hospital, Mediclinic Midstream Hospital, Pretoria, South Africa.,6 Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,7 Medical School, University of Queensland, Queensland, Australia.,8 School of Medicine, University of Pretoria, Pretoria, South Africa
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18
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Weber CD, Hildebrand F, Kobbe P, Lefering R, Sellei RM, Pape HC. Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications. Eur J Trauma Emerg Surg 2018; 45:445-453. [PMID: 29396757 DOI: 10.1007/s00068-018-0916-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/31/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. METHODS A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). RESULTS Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. CONCLUSION Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.
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Affiliation(s)
- Christian David Weber
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany.
| | - Frank Hildebrand
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Richard M Sellei
- Department of Trauma Surgery and Orthopaedics, Sana Klinikum, Offenbach, Germany
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Hohmann E, Birkholtz F, Glatt V, Tetsworth K. The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma. Injury 2017; 48:1211-1216. [PMID: 28351547 DOI: 10.1016/j.injury.2017.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/07/2017] [Accepted: 03/15/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature. METHODS This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations. RESULTS Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union. CONCLUSION The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature. LEVEL OF EVIDENCE Level IV; case series.
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Affiliation(s)
- Erik Hohmann
- School of Medicine, University of Pretoria, South Africa; Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates.
| | - Franz Birkholtz
- Walk-a-Mile Centre for Advanced Orthopaedics, Pretoria, South Africa; Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, South Africa
| | - Vaida Glatt
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia; Queensland University of Technology, Orthopaedic Research Institute, Australia
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