When is a fracture healed? Radiographic and clinical criteria revisited

When to Radiate and When to Stop? Timing Radiographic Surveillance During Nonoperative Treatment of Pediatric Diaphyseal Clavicle Fractures

INTRODUCTION

Conservative management of most pediatric clavicle fractures is standard. Despite a predictable nonoperative course, evidence about the timeliness of healing is lacking. The goal of this study was to identify when radiographic signs of healing should be expected during routine conservative management of closed pediatric diaphyseal clavicle fractures.

METHODS

Patients 18 years or younger with an acute diaphyseal clavicle fracture treated at a large academic multispecialty orthopaedic practice over 5 years were retrospectively reviewed. Patients who completed nonoperative management until radiographic and clinical evidence of union were included and categorized into 3 age groups: infants and toddlers (0 to 2 y old), school-aged children (3 to 9 y old), and adolescents (10 to 18 y old). Radiographic healing was analyzed within each 2- to 4-week interval.

RESULTS

Among 390 patients, 303 met inclusion criteria. Overall shortening and displacement averaged 0.3±0.6 centimeters and 42.6%±43.0%, respectively. Follow-up averaged 50±24 days with an orthopaedic physician and 16.3±14.8 months for a well-child check. No clinically relevant or statistically significant improvements in the number of cortices bridged were observed in infants/toddlers after 4 weeks (average 20.4±4.3 d from injury), in school-aged children after 8 weeks (average 39.7±7.9 d from injury), or in adolescents after 12 weeks (average 66.4±8.1 d from injury).

CONCLUSIONS

This study provides an age-dependent timeline during which adequate radiographic healing should be expected in nonoperatively managed pediatric diaphyseal clavicle fractures. Radiographic protocols can be purposefully timed to visualize sufficient healing in infants and toddlers by 4 weeks, school-aged children by 8 weeks, and adolescents by 12 weeks.

LEVEL OF EVIDENCE

Level III.

Short term temporal outcomes after intramedullary fixation of lateral malleolus fractures

Ankle fractures are a common intra-articular trauma. The gold standard treatment for unstable ankle fractures has been Open Reduction Internal Fixation with plating and lag screw(s). Advocates for intramedullary nailing of the fibula note decreased wound complications and greater biomechanical strength. We hypothesized that time to union and time to weight bearing would be decreased with a fibular intramedullary nail compared to prior ankle ORIF literature. A retrospective cohort study was conducted of 65 consecutive ankle fracture patients treated with a fibular nail. The median follow-up time was 18.3 months (IQR: 55.4 - 97.6 days). All patients (100%) achieved clinical and radiographic union at a median of 9.6 (IQR: 54 - 78 days) and 10.8 weeks (IQR: 58 - 95 days), respectively. Post-operatively patients bore weight in walking boot and athletic shoe at a median 6.1 and 9.4 weeks, respectively. Fifteen patients suffered complications (23.1%). Patients with history of prior or active smoking were significantly correlated to longer time to union (p=0.016). Time to union also took 0.43 days longer for each additional year of age (t-value 2.13, p-value = 0.038). Nineteen out of 65 patients (29.2%) participated in the Olerud-Molander Ankle Scoring and the median functional outcome score was 71 (IQR: 56 - 93). While fibular nailing has advanced passive range of motion and weight bearing in our institution, time to weight bearing is clouded by surgeon comfort. Further study comparing fibular fracture healing and weight bearing status in regards to intramedullary and plate fixation in needed. LEVEL OF EVIDENCE: IV.

Factors Associated With Reoperation After Distal Radius Nonunion Repair

PURPOSE

This study aimed to evaluate the incidence of, and factors associated with, reoperation after distal radius nonunion repair.

METHODS

We conducted a retrospective cohort study at a multicenter academic institution and identified adult patients who underwent open reduction and internal fixation for distal radius nonunion between January 2005 and August 2021. Thirty-three patients were included in this study. The cohort consisted of 13 males (13/33) and had a median age of 56 years (interquartile ranges: 49-64). Median follow-up was 59 months (interquartile ranges: 23-126).

RESULTS

Unplanned reoperations occurred in eight of 33 patients. The most common reasons for reoperation were irrigation and debridement for infection, revision surgery for persistent nonunion, and unplanned hardware removal. In total, 10 complications occurred in nine patients. The most common complications were infection and persistent nonunion; both occurred in three cases.

CONCLUSIONS

Complications after distal radius nonunion repair are common. Reoperation after distal radius nonunion repair is required in approximately one of four cases.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

Follow-up non-attendance after long-bone fractures in a low-resource setting: a prospective study of predictors and interventions to increase attendance rates

BACKGROUND

While the majority of traumatic injuries occur in low- and middle-income countries, the published literature comes chiefly from high-income countries due to poor follow-up. Clinical and radiographic post-surgical trauma follow-up is essential to high-quality research and objective monitoring for healing and/or complications. This study aimed to identify the predictors of follow-up non-attendance in a low-resource setting and investigate the extent to which interventional efforts based on mobile phone technology (MPT) and home visits improved the follow-up rates for fractures treated with SIGN nails.

METHODS

This was a prospective study of 594 patients with long-bone fractures. Socio-demographic (e.g. age, gender, marital status, education level, etc.) and clinical (e.g. fracture type, concomitant injuries, comorbidity, etc.) data were collected on each patient. Before discharge, the importance of follow-up was explained to patients and their relations. They were encouraged to attend even if they felt well. Their residential addresses and telephone numbers were validated and securely stored. Patients who missed their appointments were contacted by phone. Those who failed to honour 2 or 3 rescheduled appointments were visited in their home. The patients were divided into those who returned for the primarily scheduled follow-up without prompting (volition group) and those who did not come (non-attenders). Univariate analyses and binary logistic regression were conducted to determine the significant predictors of non-attendance.

RESULTS

The proportion of patients in the volition group reduced from 96.1% at 6 weeks to 53.0% at 12 weeks and 39.2% at 6 months. However, interventional efforts increased these values to 98.5%, 92.5%, and 72.4% respectively. Walking unaided before the primarily scheduled 12-week appointment was the major reason for not attending the follow-up. Education, occupation, post-operative length of hospital stay (PLOS) and infection were significantly associated with non-attendance but younger age, long distances from the hospital, being separated or divorced, difficulty paying the in-patient care bill, closed fracture, having no (or a non-limb) concomitant injury, achieving painless weight bearing ≤ 6 weeks post-operatively and needing no additional surgery were independent predictors of non-attendance.

CONCLUSIONS

Our study sheds light on the predictors of follow-up non-attendance and demonstrates how interventional efforts improved attendance rates in a low-resource setting. In addition, efforts that better the socio-economic status of people such as more-encompassing health insurance coverage and greater work flexibility can improve the follow-up attendance rates.

Most Fractures Treated Nonoperatively in Individuals With Fibrodysplasia Ossificans Progressiva Heal With a Paucity of Flareups, Heterotopic Ossification, and Loss of Mobility

BACKGROUND

Fibrodysplasia ossificans progressiva (FOP) is an ultrarare genetic disorder with episodic and progressive heterotopic ossification. Tissue trauma is a major risk factor for flareups, heterotopic ossification (HO), and loss of mobility in patients with FOP. The International Clinical Council on FOP generally recommends avoiding surgery in patients with FOP unless the situation is life-threatening, because soft tissue injury can trigger an FOP flareup. Surprisingly little is known about flareups, HO formation, and loss of mobility after fractures of the normotopic (occurring in the normal place, distinct from heterotopic) skeleton when treated nonoperatively in patients with FOP.

QUESTIONS/PURPOSES

(1) What proportion of fractures had radiographic evidence of union (defined as radiographic evidence of healing at 6 weeks) or nonunion (defined as the radiographic absence of a bridging callus at 3 years after the fracture)? (2) What proportion of patients had clinical symptoms of an FOP flareup because of the fracture (defined by increased pain or swelling at the fracture site within several days after closed immobilization)? (3) What proportion of patients with fractures had radiographic evidence of HO? (4) What proportion of patients lost movement after a fracture?

METHODS

We retrospectively identified 36 patients with FOP from five continents who sustained 48 fractures of the normotopic skeleton from January 2001 to February 2021, who were treated nonoperatively, and who were followed for a minimum of 18 months after the fracture and for as long as 20 years, depending on when they sustained their fracture during the study period. Five patients (seven fractures) were excluded from the analysis to minimize cotreatment bias because these patients were enrolled in palovarotene clinical trials (NCT02190747 and NCT03312634) at the time of their fractures. Thus, we analyzed 31 patients (13 male, 18 female, median age 22 years, range 5 to 57 years) who sustained 41 fractures of the normotopic skeleton that were treated nonoperatively. Patients were analyzed at a median follow-up of 6 years (range 18 months to 20 years), and none was lost to follow-up. Clinical records for each patient were reviewed by the referring physician-author and the following data for each fracture were recorded: biological sex, ACVR1 gene pathogenic variant, age at the time of fracture, fracture mechanism, fracture location, initial treatment modality, prednisone use at the time of the fracture as indicated in the FOP Treatment Guidelines for flare prevention (2 mg/kg once daily for 4 days), patient-reported flareups (episodic inflammatory lesions of muscle and deep soft connective tissue characterized variably by swelling, escalating pain, stiffness, and immobility) after the fracture, follow-up radiographs of the fracture if available, HO formation (yes or no) as a result of the fracture determined at a minimum of 6 weeks after the fracture, and patient-reported loss of motion at least 6 months after and as long as 20 years after the fracture. Postfracture radiographs were available in 76% (31 of 41) of fractures in 25 patients and were independently reviewed by the referring physician-author and senior author for radiographic criteria of fracture healing and HO.

RESULTS

Radiographic healing was noted in 97% (30 of 31) of fractures at 6 weeks after the incident fracture. Painless nonunion was noted in one patient who sustained a displaced patellar fracture and HO. In seven percent (three of 41) of fractures, patients reported increased pain or swelling at or near the fracture site within several days after fracture immobilization that likely indicated a site-specific FOP flareup. The same three patients reported a residual loss of motion 1 year after the fracture compared with their prefracture status. HO developed in 10% (three of 31) of the fractures for which follow-up radiographs were available. Patient-reported loss of motion occurred in 10% (four of 41) of fractures. Two of the four patients reported noticeable loss of motion and the other two patients reported that the joint was completely immobile (ankylosis).

CONCLUSION

Most fractures treated nonoperatively in individuals with FOP healed with few flareups, little or no HO, and preservation of mobility, suggesting an uncoupling of fracture repair and HO, which are two inflammation-induced processes of endochondral ossification. These findings underscore the importance of considering nonoperative treatment for fractures in individuals with FOP. Physicians who treat fractures in patients with FOP should consult with a member of the International Clinical Council listed in the FOP Treatment Guidelines ( https://www.iccfop.org ).

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years

BACKGROUND

Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus.

METHODS

This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24 months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis).

RESULTS

Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good.

CONCLUSION

The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis.

LEVEL OF EVIDENCE

IV, case series.

The contribution of lower-mineralized tissue to the healing of distal radius fractures assessed using HR-pQCT

High-resolution peripheral quantitative CT (HR-pQCT) enables quantitative assessment of distal radius fracture healing. In previous studies, lower-mineralized tissue formation was observed on HR-pQCT scans, starting early during healing, but the contribution of this tissue to the stiffness of distal radius fractures is unknown. Therefore, the aim of this study was to investigate the contribution of lower-mineralized tissue to the stiffness of fractured distal radii during the first twelve weeks of healing. We did so by combining the results from two series of micro-finite element (μFE-) models obtained using different density thresholds for bone segmentation. Forty-five postmenopausal women with a conservatively-treated distal radius fracture had HR-pQCT scans of their fractured radius at baseline (BL; 1-2 weeks post-fracture), 3-4 weeks, 6-8 weeks, and 12 weeks post-fracture. Compression stiffness (S) was computed using two series of μFE-models from the scans: one series (Msingle) included only higher-mineralized tissue (>320 mg HA/cm3), and one series (Mdual) differentiated between lower-mineralized tissue (200-320 mg HA/cm3) and higher-mineralized tissue. μFE-elements were assigned a Young's Modulus of 10 GPa (higher-mineralized tissue) or 5 GPa (lower-mineralized tissue), and an axial compression test to 1 % strain was simulated. The contribution of the lower-mineralized tissue to S was quantified as the ratio Sdual/Ssingle. Changes during healing were quantified using linear mixed effects models and expressed as estimated marginal means (EMMs) with 95 %-confidence intervals (95 %-CI). Median time to cast removal was 5.0 (IQR: 1.1) weeks. Sdual and Ssingle gradually increased during healing to a significantly higher value than BL at 12 weeks post-fracture (both p < 0.0001). In contrast, Sdual/Ssingle was significantly higher than BL at 3-4 weeks post-fracture (p = 0.0010), remained significantly higher at 6-8 weeks post-fracture (p < 0.0001), and then decreased to BL-values at the 12-week visit. EMMs ranged between 1.05 (95 %-CI: 1.04-1.06) and 1.08 (95 %-CI: 1.07-1.10). To conclude, combining stiffness results from two series of μFE-models obtained using single- and dual-threshold segmentation enables quantification of the contribution of lower-mineralized tissue to the stiffness of distal radius fractures during healing. This contribution is minor but changes significantly around the time of cast removal. Its course and timing during healing may be clinically relevant. Quantification of the contribution of lower-mineralized tissue to stiffness gives a more complete impression of strength recovery post-fracture than the evaluation of stiffness using a single series of μFE-models.

Assessing independence in mobility activities in trauma care: Validity and reliability of the Activity Independence Measure-Trauma (AIM-T) in humanitarian settings

The importance of measuring outcomes after injury beyond mortality and morbidity is increasingly recognized, though underreported in humanitarian settings. To address shortcomings of existing outcome measures in humanitarian settings, the Activity Independence Measure-Trauma (AIM-T) was developed, and is structured in three subscales (i.e., core, lower limb, and upper limb). This study aimed to assess the AIM-T construct validity (structural validity and hypothesis testing) and reliability (internal consistency, inter-rater reliability and measurement error) in four humanitarian settings (Burundi, Iraq, Cameroon and Central African Republic). Patients with acute injury (n = 195) were assessed using the AIM-T, the Barthel Index (BI), and two pain scores. Structural validity was assessed through confirmatory factor analysis. Hypotheses were tested regarding correlations with BI and pain scores using Pearson correlation coefficient (PCC) and differences in AIM-T scores between patients' subgroups, using standardized effect size Cohen's d (d). Internal consistency was assessed with Cronbach's alpha (α). AIM-T was reassessed by a second rater in 77 participants to test inter-rater reliability using intraclass correlation coefficient (ICC). The results showed that the AIM-T structure in three subscales had an acceptable fit. The AIM-T showed an inverse weak to moderate correlation with both pain scores (PCC<0.7, p≤0.05), positive strong correlation with BI (PCC≥0.7, p≤0.05), and differed between all subgroups (d≥0.5, p≤0.05). The inter-rater reliability in the (sub)scales was good to excellent (ICC 0.86-0.91) and the three subscales' internal consistency was adequate (α≥0.7). In conclusion, this study supports the AIM-T validity in measuring independence in mobility activities and its reliability in humanitarian settings, as well as it informs on its interpretability. Thus, the AIM-T could be a valuable measure to assess outcomes after injury in humanitarian settings.

Novel Claw-shaped Bone Plate in Complex Unstable Scapular Neck and Body Fractures: Comparison with Reconstruction Locking Plate

OBJECTIVE

For complex and unstable scapular fractures requiring simultaneous fixation of the glenoid neck, the lateral margin of the body, and/or the scapular diaphysis, reconstruction locking plate is difficult to achieve satisfactory fixation. In order to optimize the fixation effect, the newly designed claw-shaped bone plate was designed for fixing such fractures. We also evaluate the clinical effects and follow-up at an average of 1 year after treatment in scapular internal fixation by using reconstruction locking plate and claw-shaped bone plate in complex unstable scapular body and glenoid neck fracture.

METHODS

A retrospective study was conducted from 2018 to 2021, thirty-three patients (27 males and six females) who were defined unstable scapular fractures by Ada-Miller. Fifteen patients (52.86 ± 8.26 years) received claw-shaped bone plate and 18 cases (51.61 ± 11.31 years) received reconstruction locking plate with the intermuscular approach. The clinical effect was evaluated based on the operation time, intraoperative blood loss, surgical complications, clinical healing time and Constant-Murley score (CMS). The data analysis by Student t, Mann-Whitney U test and Pearson's chi squared test.

RESULTS

Compared with reconstruction locking plate, the claw-shaped bone plate showed shorter operation time (102.73 ± 18.43 min vs. 156 ± 37.53, P < 0.0001), higher CMS (94.00 ± 4.07 vs. 89.88 ± 5.42, P = 0.02) and no differences between the two groups regarding intraoperative blood loss (208.00 ± 96.45 mL vs. 269.44 ± 120.21, P = 0.12) and clinical healing times (9.96 ± 1.52 vs. 10.05 ± 1.67, P = 0.87). Follow-up were conducted at first, third, 6 and 12 months after surgery. The operation was successful in all patients with no intraoperative complications.

CONCLUSIONS

For the treatment of complex and unstable scapular neck body fractures, the application of claw-shaped bone plate demonstrated short operation time, better stability of the fracture block, and higher CMS. In the intraoperative and postoperative follow-up showed better clinical results and rehabilitation effects.

Combined press-fit and extracortical fixation in patellar tendon anterior cruciate ligament reconstruction results in reliable graft fixation and early bone block incorporation

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction with bone-patellar-tendon-bone (BPTB) autograft has the potential biological advantage of direct bone-to-bone healing over soft tissue grafts. The primary aim of this study was to investigate possible graft slippage and therefore fixation strength in a modified BPTB autograft technique with suspensory fixation on both sides for primary ACL reconstruction until bony integration takes place.

METHODS

Twenty-one patients undergoing primary ACL reconstruction with a modified BPTB autograft (bone-on-bone (BOB) technique) between August 2017 and August 2019 were included in this prospective study. A computed tomography (CT) scan of the affected knee was performed directly postoperatively, as well as 3 months postoperatively. Examiner-blinded parameters for graft slippage, early tunnel widening, bony incorporation, as well as remodeling of the autologous refilled patellar harvest site were investigated.

RESULTS

A series of 21 patients treated with a BPTB autograft with this technique underwent two CT investigations. Comparison of CT scans showed no bone block displacement and therefore no graft slippage in the patient cohort. Only one patient showed signs of early tunnel enlargement. Radiological bone block incorporation took place showing bony bridging of the graft to the tunnel wall in 90% of all patients. Furthermore, 90% showed less than 1 mm bone resorption of the refilled harvest site at the patella.

CONCLUSIONS

Our findings suggest graft fixation stability and reliability of anatomic BPTB ACL reconstruction with a combined press-fit and suspensory fixation technique by absence of graft slippage within the first 3 months postoperatively.

Return to sport after forearm fractures in children: A scoping review and survey

Purpose

A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations.

Methods

A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury.

Results

Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly returned to sport by 4 weeks after initial injury, while survey respondents recommended over 6 weeks. Survey respondents valued fracture stability the highest when making return to sport recommendations. Children with simple, metaphyseal, single-bone fractures were usually allowed to return to sport at 8-10 weeks post-injury. Diaphyseal and complete fractures were prescribed longer return to sport intervals. Australian respondents also prescribed longer return to sport intervals.

Conclusion

Children with distal radius buckle fractures may return to sport by 4 weeks after initial injury, sooner than recommended. Published recommendations remain limited for other fractures. However, our survey suggests children with simple, metaphyseal, single-bone fractures may return to sport at 8-10 weeks. Children with diaphyseal and complete fractures should abstain from sport for longer than metaphyseal and greenstick fractures, respectively.

Level of evidence

level V.

Tension-band wiring through a single cannulated screw combined with suture anchors to treat inferior pole fracture of the patella

PURPOSE

To evaluate the feasibility and clinical outcomes of tension-band wiring through a single cannulated screw combined with two suture anchors in treating inferior pole fracture of the patella.

METHODS

Between September 2018 and September 2021, a total of 22 patients with a mean age of 55 years who sustained inferior pole fracture of the patella and were treated by tension-band wiring through a single cannulated screw combined with two suture anchors were enrolled. X-ray radiographs were performed to observe the bone union time. The duration of each operation was recorded to reflect the complexity of surgical treatment. Functional measurements, comprising range of motion (ROM), the Böstman scale, and the Knee Injury and Osteoarthritis Outcome Score (KOOS), were taken. Postoperative complications including fixation failure, incision infection, loss of reduction, and malunion were evaluated.

RESULTS

All patients were followed up for an average of 17 months (range: 12-25 months). The average clinical bone union time was 8 weeks (range: 6-12 weeks), and the radiographic bone union time was 11 weeks (range: 8-12 weeks). At the final follow-up, the mean ROM was 136° (range: 115°-140°), the KOOS was 85 (range: 68-100) and the Böstman score was 28 (range: 20-30); these outcomes were classified as excellent in 17 cases and good in 5 cases, with no instances of poor results. Loss of reduction occurred in one case, while no cases of incision infection, fixation failure or malunion were observed.

CONCLUSION

For inferior pole fracture of the patella, tension-band wiring through a single cannulated screw combined with suture anchors can offer sufficient fixation stability to achieve a satisfactory clinical outcome with reduced operational complexity; this procedure should be recommended in clinical practice.

Comparison of radiographic scoring systems for assessment of bone healing after tibial plateau leveling osteotomy in dogs

Introduction

Accurate radiographic assessment of bone healing is vital in determining both clinical treatment and for assessing interventions aimed at the promotion of bone healing. Several scoring systems have been used to evaluate osteotomy changes following tibial plateau leveling osteotomy (TPLO). The goal of this study was to compare the ability of five radiographic scoring systems to identify changes in bone healing following TPLO over time (Aim I), and to evaluate the influence of limb positioning on TPLO osteotomy scoring (Aim II).

Materials and methods

Phase I-A randomized, blinded, prospective study was conducted using similarly positioned postoperative TPLO radiographs from seven dogs taken immediately postoperatively, 6-weeks, and 8-weeks postoperatively. Ten reviewers assessed the radiographs, and five different scoring systems were tested for each set including three previously published ones, a Visual Analog Score (VAS), and a subjective 11-point scale. For each system, responses for 6-week postoperative were compared to 8-week postoperative. Scores were judged as correct (=showing an increase in score), incorrect (=decrease in score), or unchanged (=same score). Phase II-An international group of 39 reviewers was asked to score radiographs from three dogs, taken in different positions, using the VAS grading system. Scores were averaged and comparisons were made for each set.

Results

Phase I-The VAS system identified the greatest number of sets correctly (76%), with the least unchanged scores (15%), and 9% incorrect scores. Phase II-All three patients had an increase in the average difference between VAS-scores for differently positioned radiographs compared to similarly positioned radiographs. The magnitude of change between different positions far exceeded the magnitude of comparison of the similarly positioned radiographs from the 6- and 8-week time point.

Discussion/Conclusion

The VAS system appears to be the most appropriate of the tested systems to identify small changes in bone healing. In addition, the positioning of postoperative TPLO radiographs makes a substantial difference in the healing score that is assigned. Care must be undertaken when performing postoperative radiographs in both the clinical and research setting to ensure accurate assessment of bone healing.

Does matching degree matter for proximal femoral intramedullary nail on reoperation rate in intertrochanteric fractures?

INTRODUCTION

Previous articles reported on the tip-apex distance, lag screw placement, fracture pattern, reduction quality, osteoporosis and other factors associated with second surgery. The current study focused on investigating the association of the matching degree between proximal femoral intramedullary nail and femoral medullary cavity on reoperation rate.

PATIENTS AND METHODS

A retrospective cohort study was conducted. It included patients with intertrochanteric fracture who were treated with proximal femoral anti-rotatory intramedullary nail (PFNA) between January 2016 and April 2021. The gap between the intramedullary nail and the femoral medullary cavity was equal to the difference in diameter between the two. According to the gap size, all patients were divided into three groups, as follows: high-matching group: gap ≤ 2 mm; middle-matching group: 2 < gap < 4 mm; and low-matching group: gap ≥ 4 mm. The mean gap was measured through standard images. The primary observational index was whether the reoperation was needed, and secondary observational indexes included operative time, length of hospital stay. Patient characteristics were recorded, as follows: age, sex, follow-up time, fracture pattern, reduction grade and length of intramedullary nail.

RESULTS

A total of 203 eligible patients were recorded, including 78 males (38.4%) and 125 females (61.6%). They had a mean age of 77.8 ± 9.9 years old and an average follow-up time of 58.1 ± 24.0 weeks. Twenty-seven patients (13.3%) needed a second operation. Coxa varus combined with screw cutting was the most common reason for reoperation (11 cases). Unstable fracture pattern with poor reduction grade tended to contribute to reoperation, whose odds ratio (OR) was 6.61 (95% confidence interval [CI], 1.98-22.09; P = 0.002). The three groups had 11 cases (13.7%), 12 cases (13.8%) and 4 cases (11.1%) of reoperation, respectively, and logistic regression showed no significant association was noted between matching degree of intramedullary nail and reoperation rate.

CONCLUSIONS

The matching degree between proximal femoral intramedullary nail and femoral medullary cavity did not seem to be an important factor for reoperation, which offered more options of intramedullary nail size intraoperatively and reduced implants stock from inventory.

Isolated open tibial shaft fracture: a seven-hospital, prospective observational study in two Latin America countries

INTRODUCTION

open tibial fractures are challenging due to the frequent severe bone injury associated with poor soft tissue conditions. This is relevant in low- and middle-income countries, mainly related to delayed definitive fixation and lack of adequate training in soft tissue coverage procedures. Due to these factors, open tibial fracture is an important source of disability for Latin American countries. Herein we sought to provide an epidemiological overview of isolated open tibial shaft fracture across seven hospitals in southern cone of Latin America. The secondary goal was to assess the impact on quality of life based on return-to-work rate (RWR).

METHODS

patients with an isolated open tibial shaft fracture treated in seven different hospitals from Brazil and Argentina from November 2017 to March 2020 were included in the study. Clinical and radiographic results were evaluated throughout the 120-day follow-up period. Final evaluation compared RWR with the SF-12 questionnaire, bone healing, and gait status.

RESULTS

Seventy-two patients were treated, 57 followed for 120 days and 48 completed the SF-12 questionnaire. After 120 days, 70.6% had returned to work, 61.4% had experienced bone healing. Age, antibiotic therapy, type of definitive treatment, and infection significantly influenced the RWR. Gait status exhibited strong correlations with RWR and SF-12 physical component score.

CONCLUSIONS

Isolated open tibial shaft fractures are potentially harmful to the patient's quality of life after 120 days of the initial management. RWR is significantly higher for younger patients, no history of infection, and those who could run in the gait status assessment.

Evaluation of a modified radiographic union scale for tibial fractures scoring system in staged bilateral tibial plateau leveling osteotomy procedures and comparison of first and second side radiographic bone healing

OBJECTIVE

To evaluate the inter- and intra-rater reliability of the tibial plateau leveling osteotomy (TPLO) modified radiographic union scale for tibial fractures (mRUST), a semiquantitative scoring system, as compared with the subjective evaluation of radiographic union for staged TPLOs.

STUDY DESIGN

Retrospective study.

ANIMALS

Forty-eight dogs, 96 stifles.

METHODS

Medical records were reviewed for dogs with bilateral cranial cruciate ligament injuries diagnosed at presentation that underwent staged bilateral TPLOs within 6 months and had both immediate and recheck postoperative radiographs. Radiographs were anonymized, reviewers were blinded, radiographic union was evaluated subjectively, and TPLO mRUST scores were assigned.

RESULTS

The subjective evaluation's intra-rater reliability was 0.72 (Kappa 95% CI 0.65-0.79) and inter-rater reliability was 0.33 (Kappa 95% CI 0.28-0.39). The TPLO mRUST scoring system intra-rater reliability was 0.73 (95% CI 0.68-0.78) and inter-rater reliability was 0.56 (95% CI 0.41-0.68). There was no difference in the degree of bone healing quantified by the TPLO mRUST scoring system (95% CI - 0.1-1.2, P = .09) or subjective evaluation (P = .48) between the first and second side TPLOs. The TPLO mRUST scores were positively correlated with subjective healing (r = 0.94, 95% CI 0.92-0.96, P < .0001, and for scores ≥10/12, 99%, 244/246) were subjectively assigned as radiographically healed.

CONCLUSION

The TPLO mRUST scoring system improved inter-rater reliability compared to subjective evaluation of radiographic union.

CLINICAL SIGNIFICANCE

The TPLO mRUST scoring system should be considered as a semiquantitative supplemental tool for evaluating radiographic union.

Application of tomosynthesis for vertebral compression fracture diagnosis and bone healing assessment in fracture liaison services

Early identification of vertebral compression fractures (VCFs) is crucial for successful secondary fracture prevention. Tomosynthesis, a low-dose tomographic imaging technique, may facilitate the evaluation and long-term follow-up of VCFs in patients with osteoporosis. Herein, we compared the performances of plain radiography and tomosynthesis for VCF diagnosis and healing assessment in patients enrolled in fracture liaison services in our hospital. Forty-nine patients with new VCFs at the T10–L5 levels were prospectively recruited between August 2018 and May 2020; all patients underwent thoracolumbar plain radiography and tomosynthesis. We evaluated the accuracy of the VCF diagnosis, image quality, and VCFs healing process. Tomosynthesis identified 90 levels of VCF in 49 patients, while plain radiography revealed only 87.8% (79/90) of them. There were 44.9% (22/49) patients with neglected chronic VCFs as seen on tomosynthesis. Tomosynthesis images had improved VCF diagnostic accuracy up to 12.2% and showed significantly more anatomic details than plain radiography. For diagnosis of VCFs, the performance of plain radiographs was poorer than that of tomosynthesis images (plain radiographs: sensitivity 84%, specificity 93.5%, false positive rate 6.5%, and false negative rate 16%; tomosynthesis: sensitivity 93.2%, specificity 100%, false positive rate 0%, and false negative 6.8%), using magnetic resonance imaging (MRI) as gold standard. The Kappa coefficient between Tomosynthesis and MRI is 0.956 while between radiography and MRI is 0.704. Tomosynthesis showed significantly more anatomic details than plain radiography and all the examiners revealed a clear preference for tomosynthesis. Tomosynthesis scored 3.3 times higher on the fracture healing assessment at the 3-month follow-up than plain radiographs. Tomosynthesis is a promising tool for VCF screening and diagnosis in patients with osteoporosis and for monitoring fracture healing status at a low radiation dose and cost.

Management of femoral head fracture by Ganz surgical dislocation of the hip

INTRODUCTION

Posterior hip dislocation is the commonest type of hip dislocation. It is associated with femoral head fracture in 7% of cases. Urgent and congruent hip reduction is mandatory to improve clinical outcomes and avoid irreversible complications. The purpose of this study is to assess the safety and functional and radiological outcomes of surgical hip dislocation by Ganz technique for treatment of femoral head fracture.

PATIENTS AND METHODS

In this retrospective study, 18 cases of femoral head fracture were included. Six cases had Pipkin type I and 12 had Pipkin type II fracture. They were treated through surgical hip dislocation. All cases were followed up for at least 24 months. Matta's criteria were used for radiological evaluation (plain radiographs). Functional evaluation was done using Harris Hip Score and modified Merle d'Aubigne and Postel score at final follow-up.

RESULTS

No patients were lost during the follow-up period. No signs of infection or wound dehiscence were noted in this study. There was one case of osteonecrosis. All cases had labral injury, which was debrided. None of our cases needed suture anchor repair of the labrum. Radiographical evaluation according to Matta's criteria yielded anatomic fracture reduction in 17 patients but imperfect in 1 patient. According to Harris Hip Score, four Pipkin type I cases were rated as excellent and two as good. Among cases of Pipkin type II fracture, six were rated as excellent, four as good, one as fair, and one as poor. According to modified Merle d'Aubigne and Postel score, 11 cases had excellent results, 5 cases were rated as good, one as fair, while one case had poor results.

CONCLUSION

Open reduction and internal fixation of femoral head fracture using surgical hip dislocation through Ganz approach is a viable treatment option and provides satisfactory results with low complication rate.

Does Surgery Improve Healing After Isolated Diaphyseal Ulna Fractures?

PURPOSE

Isolated diaphyseal ulna fractures can be treated nonsurgically or with open reduction and internal fixation (ORIF). It is unclear whether ORIF provides quicker and/or more predictable healing. The purpose of this study was to compare the healing characteristics of isolated diaphyseal ulna fractures after surgical and nonsurgical treatment.

METHODS

All patients treated for an isolated diaphyseal (distal- or middle-third) ulna fracture between 2010 and 2018, with a minimum of 3 months of follow-up, were identified. Electronic medical records were reviewed to record patient demographics, assess the treatments used, and compare outcomes. We determined healing and nonunion rates, complications, reoperations, and final radiographic fracture alignment.

RESULTS

Ninety-five patients were included with a median follow-up of 20 weeks. Of these, 56 patients were treated nonsurgically and 39 patients were treated with ORIF. At the time of the final follow-up, 51 of the 56 (91.1%) nonsurgically treated fractures had healed and 38 of the 39 (97.4%) surgically managed fractures had healed. There were 5 nonunions after nonsurgical treatment (8.9%) and 1 nonunion after ORIF (2.6%). Eleven patients (19.6%) treated nonsurgically required conversion to ORIF, whereas 4 patients (10.3%) treated with ORIF required reoperation. Middle-third fractures treated nonsurgically had a higher rate of nonunion (30.8%) compared with distal-third fractures treated nonsurgically (2.3%).

CONCLUSIONS

The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment. However, nearly 20% of the patients treated nonsurgically may require eventual ORIF. Distal-third fractures may be at a higher risk of conversion to ORIF, and middle-third fractures may be at a higher risk of nonunion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Future modalities to assess fracture healing

Objectives:

Methods:

Results:

Conclusions:

New Sub-Classification of Vancouver B2 Periprosthetic Hip Fractures According to Fracture Pattern

INTRODUCTION

There is currently a debate on whether all Vancouver type B2 (V-B2) periprosthetic hip fractures (PPHF) should be revised. Vancouver classification takes into account fracture location, implant stability and bone stock, but it does not distinguish between fracture patterns. The aim of our work was to study the different fracture patterns of V-B2 PPHF and to analyze if there is any pattern that presents lower osteosynthesis failure rates.

MATERIAL AND METHODS

All patients with V-B2 PPHF treated by osteosynthesis between January 2009 and January 2019 were included in the study. Using the Gruen system the proximal femur was divided into 3 zones. The lateral zone (Gruen 1±2±3), medial zone (Gruen 5±6±7), and distal zone (Gruen 4±3±5) were analysed and it was determined whether each of the 3 zones was fractured.

RESULTS

56 patients were included in the study. Their mean age was 79 years (R 45 - 92). The chosen treatment was: 39 Open reduction and internal fixation (ORIF), 10 Stem revision and 7 nonoperatively treatment. In ORIF group, no implant complications (0/24) were found in patients with a single fractured zone, while 5 implant complications (5/15) were discovered in patients with two or more fractured areas; this difference was significant (p=0.0147). All patients treated by stem revision had a fracture that involved two or more zones. In the nonoperatively group, the fracture pattern did not influence the treatment because of all of them had a very precarious functional and medical situation.

CONCLUSIONS

V-B2 PPHF treated via ORIF affecting only one zone (medial, lateral, or distal) have a lower risk of complication than those affecting two or more zones. We propose a sub-classification of Vancouver B2 type fractures: B2.1 (1 fractured zone) and B2.2 (≥2 fractured zones).

LEVEL OF EVIDENCE

Historical cohorts. Level III.

Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?

OBJECTIVES

To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs.

DESIGN

Retrospective case series.

SETTING

Urban academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up.

INTERVENTION

Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure.

MAIN OUTCOME MEASUREMENTS

Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure.

RESULTS

The fifth percentile and median times, respectively, for reaching "any radiographic healing" (RUST = 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST = 9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs.

CONCLUSIONS

The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fraturas expostas isoladas da diáfise da tíbia: estudo prospectivo observacional em sete hospitais de dois países da América Latina

RESUMO Introdução: o tratamento de fraturas expostas isoladas da diáfise da tíbia (FEIDT) apresenta desafios por frequentemente associar severa lesão óssea com condições ruins de tecido mole, fatores relevantes em países de média e baixa renda, especialmente devido a atrasos na implementação da fixação definitiva e falta de treinamento adequado no manejo de tecidos moles. Consequentemente, FEIDTs representam importante fonte de incapacitação na América Latina. Este estudo objetivou apresentar uma visão geral das FEIDTs em sete hospitais do cone sul da América Latina. O objetivo secundário foi avaliar o seu impacto na qualidade de vida baseado na taxa de retorno ao trabalho (TRT). Métodos: foram incluídos no estudo pacientes com FEIDT tratados em sete hospitais de Brasil e Argentina entre novembro de 2017 e março de 2020. Resultados clínicos e radiográficos foram analisados num período de 120 dias. Avaliação final comparou TRT com o questionário SF-12, consolidação óssea e condições de marcha. Resultados: setenta e dois pacientes foram tratados, 57 seguidos por 120 dias e 48 completaram o questionário SF-12. Após 120 dias, 70,6% havia retornado ao trabalho, 61,4% tinha fratura consolidada. Idade, antibioticoterapia, tipo de tratamento definitivo e infecção influenciaram significativamente na TRT. A condição de marcha apresentou forte correlação com TRT e o componente físico do SF-12. Conclusão: FEIDTs são potencialmente deletérias à qualidade de vida dos pacientes 120 dias após o tratamento inicial. TRT é significativamente maior para pacientes mais jovens, sem história de infecção e que conseguem correr na avaliação da condição de marcha..

Serum Calcium Level Combined with Platelet Count May Be Useful Indicators for Assisted Diagnosis of Extremity Posttraumatic Osteomyelitis: A Comparative Analysis

Background

A previous study had reported that patients with osteomyelitis (OM) appeared to be more likely to develop hypocalcemia before and after surgery. Calcium sulfate (CS) is frequently used as a local antibiotic vehicle in the treatment of OM, which may also affect serum calcium level. However, whether changes of serum calcium level are caused by OM and/or local use of calcium sulfate remains unclear. Also, platelet (PLT) count plays a crucial predictive role in periprosthetic joint infections (PJIs), but its role in assisted diagnosis of OM is largely unknown. The purpose of this study was to determine whether serum calcium level and PLT count may be helpful in assisted diagnosis of PTOM.

Methods

Between January 2013 and December 2018, we analyzed 468 consecutive patients (392 males and 76 females), including 170 patients with posttraumatic OM (PTOM), 130 patients with aseptic bone nonunion (ABN), and 168 patients recovered from fractures with requirement of implant removal set as controls. Preoperative serological levels of calcium, phosphorus, and PLT were detected, and comparisons were conducted among the above three groups. Additionally, correlations and receiver operating characteristic (ROC) curves were displayed to test whether calcium level and PLT can differentiate patients with ABN and PTOM.

Results

Outcomes showed that the incidences of asymptomatic hypocalcemia (PTOM vs. ABN vs. controls = 22.94% vs. 6.92% vs. 8.82%, χ² = 21.098, P < 0.001) and thrombocytosis (PTOM vs. ABN vs. controls = 35.3% vs. 13.84% vs. 12.35%, χ² = 28.512, P < 0.001) were highest in PTOM patients. Besides, the mean serological levels of phosphorus in PTOM and ABN patients were significantly higher than those in the controls (P = 0.007). The Area Under the Curve (AUC) of the ROC curve outcomes revealed that, with the combination of serum calcium level with PLT count, the predictive role was acceptable (AUC 0.730, P < 0.001, 95% CI 0.681-0.780). Also, serological levels of calcium of 2.225 mmol/L and PLT count of 246.5 × 10⁹/L were identified as the optimal cut-off values to distinguish patients with and without PTOM. However, age- and gender-related differences in serum calcium levels (age, P = 0.056; gender, P = 0.978) and PLT count (age, P = 0.363; gender, P = 0.799) were not found to be statistically significant in any groups. In addition, no significant correlations were identified between serum calcium level and PLT count (R = 0.010, P = 0.839).

Conclusions

Asymptomatic hypocalcemia and thrombocytosis appeared to be more frequent in this cohort with PTOM. Serological levels of calcium and PLT count may be useful biomarkers in screening patients suspected of PTOM.

Interleukin-6 versus Common Inflammatory Biomarkers for Diagnosing Fracture-Related Infection: Utility and Potential Influencing Factors

Currently, the utility of white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), for diagnosis of fracture-related infection (FRI), is still controversial, and potential efficiency of interleukin-6 (IL-6) as a novel cytokine in assisted diagnosis of FRI remains unclear. This study is aimed at investigating the utility and potential influencing factors of IL-6 and the common biomarkers for diagnosing FRI. Preoperative serological levels of IL-6 and the three biomarkers were compared between 407 FRI patients and 195 fracture-healed (FH) patients. Diagnostic efficiency of the indicators was evaluated using the areas under the receiver operating characteristic (ROC) curves, and their potential influencing factors were also analyzed. Outcomes showed that the median levels of all of the four biomarkers were significantly higher among the FRI patients than those among the FH patients (P < 0.01). The areas below the ROC curves of ESR, CRP, and IL-6 were 76.5%, 76.4%, and 71.8%, respectively, with WBC of only 56.9%. Compared with ESR and CRP, IL-6 displayed a lower sensitivity (ESR vs. CRP vs. IL − 6 = 72.7% vs. 65.6% vs. 57.5%) but a higher specificity (ESR vs. CRP vs. IL − 6 = 70.3% vs. 75.4% vs. 83.6%). Serological IL-6 level was influenced by pathogen culture result and pathogen number; nonetheless, bacteria type appeared to have no influence on the levels of the four biomarkers. In short, this study displayed similar value of IL-6 with that of ESR and CRP in assisted diagnosis of FRI. Whether IL-6 can be regarded as a promising diagnostic indicator requires more studies.

Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients

PURPOSE

Double level osteotomy (DLO) (femoral and tibial) is a technically demanding procedure for which pre-operative planning accuracy and intraoperative correction are key factors. The aim of this study was to assess the accuracy of the achieved correction using patient-specific cutting guides (PSCGs) compared to the planned correction, its ability to maintain joint line obliquity (JLO), and to evaluate clinical outcomes and level of patient satisfaction at a follow-up of two years.

METHODS

A single-centre, prospective observational study including 22 patients who underwent DLO by PSCGs between 2014 and 2018 was performed. Post-operative alignment was evaluated and compared with the target angular values to define the accuracy of the correction for the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), lateral distal femoral angle (ΔLDFA), and posterior proximal tibial angle (ΔPPTA). Pre- and post-operative JLO was also evaluated. At two year follow-up, changes in the KOOS sub-scores and patient satisfaction were recorded. The Mann-Whitney U test with 95% confidence interval (95% CI) was used to evaluate the differences between two variables; the paired Student's t test was used to estimate evolution of functional outcomes.

RESULTS

The mean ΔHKA was 1.3 ± 0.5°; the mean ΔMPTA was 0.98 ± 0.3°; the mean ΔLDFA was 0.94 ± 0.2°; ΔPPTA was 0.45 ± 0.4°. The orientation of the joint line was preserved with a mean difference in the JLO of 0.4 ± 0.2. At last follow-up, it was recorded a significant improvement in all KOOS scores, and 19 patients were enthusiastic, two satisfied, and one moderately satisfied.

CONCLUSION

Performing a DLO using PSCGs produces an accurate correction, without modification of the joint line orientation and with good functional outcomes at two year follow-up.

Periprosthetic Hip Fractures With a Loose Stem: Open Reduction and Internal Fixation Versus Stem Revision

BACKGROUND

It is recommended revision for periprosthetic hip fractures (PPHF) with a loose stem. However, several authors have argued that under certain conditions, this fracture could be treated using osteosynthesis. The aim is to compare stem revision versus internal fixation in the treatment of PPHF with a loose stem.

METHODS

All patients with PPHF with a loose stem treated by osteosynthesis and stem revision between January 2009 and January 2019 were included. We assessed hospital stay, American Society of Anesthesiologists, Charlson comorbidity index, surgery time, blood transfusion, complications, reoperation rate, first-year mortality, radiological, and functional results.

RESULTS

A total of 57 patients were included (40 osteosyntheses and 17 stem revision), with an average follow-up time of 3.1 years. Their mean age was 78.47 years (R 45-92). In the osteosynthesis group, fewer patients required blood transfusion (32.5% vs. 70.6%), surgical times were shorter (108 minutes vs. 169 minutes), and the cost was lower, both in terms of total cost (€14,239.07 vs. €21,498.45 and operating room cost (€5014.63 vs. €8203.34). No significant differences were found between the groups in terms of complications, reoperation rate, or functional outcomes.

CONCLUSION

Compared with stem revision, osteosynthesis requires less surgery time, has a lower need for blood transfusions, and a reduced hospital cost. Stem revision remains the treatment of choice in PPHF with a loose stem, but in V-B2 fractures in elderly patients with low functional demand, high anesthetic risk (American Society of Anesthesiologists ≥3), and many comorbidities (Charlson comorbidity index ≥5) in whom anatomic reconstruction is possible, osteosynthesis can be a viable option.

EVIDENCE LEVEL

Historical cohorts. Level III.

Endochondral Bone Tissue Engineering Using Human Induced Pluripotent Stem Cells

There has been great interest in the use of induced pluripotent stem cells (iPSCs) in bone regenerative strategies for bone defects. In the present study, we investigated whether the implantation of chondrogenically differentiated iPSC-derived mesenchymal stem cells (iMSCs) could lead to the successful regeneration of bone defects in nude mice. Two clones of human iPSCs (201B7 and 454E2) were used. After the generation of iMSCs, chondrogenic differentiation was achieved using a three-dimensional pellet culture. Then, a 2-mm defect was created in the radius of nude mice and chondrogenically differentiated iMSC pellets were placed in the defect. Micro-computed tomography (μ-CT) imaging analysis was performed 8 weeks after transplantation to assess bone regeneration. Eleven out of 11 (100%) radii in the 201B7 cell-derived-pellet transplantation group and 7 out of 10 (70%) radii in the 454E2 cell-derived-pellet transplantation group showed bone union. On the other hand, only 2 out of 11 radii (18%) in the control group showed bone union. Therefore, the bone union rates in the experimental groups were significantly higher than that in the control group (p < 0.05). Histological analysis 2 weeks post-implantation in the experimental groups revealed hypertrophic chondrocytes within grafted iMSC pellets, and the formation of woven bone around them; this hypertrophic chondrocyte transitioning to the newly formed bone suggests that the cartilaginous template can trigger the process of endochondral bone ossification (ECO). Four weeks post-implantation, the cartilage template was reduced in size; newly formed woven bone predominated at the defect site. New vessels were surrounded by a matrix of woven bone and the hypertrophic chondrocytes transitioning to the newly formed bone indicated the progression of ECO. Eight weeks post-implantation, the pellets were completely resorbed and replaced by bone; complete bone union was overall observed. Dense mature bone developed with evidence of lamellar-like bone formation. Collectively, our results suggest that iMSC-based cartilage grafts recapitulating the morphogenetic process of ECO in the context of embryonic skeletogenesis are a novel and promising strategy for the repair of large bone defects.

Monitoring of fracture healing. Update on current and future imaging modalities to predict union

Fracture nonunion causes considerable patient morbidity and an associated burden to society. Traditional reliance on radiographs to monitor union has limitations as bridging callus of long bone fractures can take three or more months to occur. Computed Tomographic (CT) scanning is becoming increasingly popular and can evaluate bridging callus in the late stages of healing to confirm union. The use of dynamic contrast enhanced Magnetic Resonance Imaging (MRI) and advances in nuclear imaging may yield benefits in the assessment of the infected nonunion. Emerging evidence supports the use of ultrasound to detect bridging callus prior to radiographic confirmation and it may be of use to predict patients at high risk of nonunion. This paper is part of a Supplement supported by The Osteosynthesis and Trauma Care Foundation (OTCF).

Smart implants in fracture care - only buzzword or real opportunity?

The assessment of fracture healing is still marked by a subjective and diffuse outcome due to the lack of clinically available quantitative measures. Without reliable information on the progression of healing and uniform criteria for union and non-union, therapeutic decision making, e.g. regarding the allowed weight bearing, hinges on the experience and the subjective evaluation of physicians. Already decades ago, fracture stiffness has been identified as a valid outcome measure for the maturity of the repair tissue. Despite early promising results, so far no method has made its way into practice beyond clinical studies. However, with current technological advancements and a general trend towards digital health care, measuring fracture healing seems to regain momentum. New generations of instrumented implants with sensoring capabilities, often termed as "smart implants", are under development. They target X-ray free and timely provision of reliable feedback upon the mechanical competence of the repair tissue and the healing environment to support therapeutic decision making and individualized after-care. With the gained experience from these devices, the next generations of smart implants may become increasingly sophisticated by internally analyzing the measured data and suggesting adequate therapeutic actions on their own.

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures

Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed.

Open reduction and internal fixation might be a valuable alternative to stem revision in Vancouver B2 periprosthetic femoral fractures, irrespective of the stem's design

BACKGROUND

The purpose of this study was to compare the clinical and radiological outcomes following open reduction and internal fixation (ORIF) of Vancouver B2 periprosthetic femoral fractures versus stem revision (SR) surgery.

METHODS

Between 2004 and 2018, 39 patients were treated with SR and 31 with ORIF for a Vancouver type B2. Mean follow-up was 40.4 months for the ORIF group and 43.5 months for the SR group. 22 of 31 stems in the ORIF group were uncemented, of which 7 (23%) were short stems. Perioperative complications, intraoperative blood loss, revision rate, and mortality were recorded. Functional outcomes included Harris Hip Score, Parker Mobility Score and hip abductor strength.

RESULTS

Both groups did not differ in the American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, body mass index, age, and sex. Compared to SR, patients treated with ORIF had a decreased blood loss, transfusion rate, operation duration, and mortality. Total complication and re-operation rates were similar. The relative risk for complication and re-operation was 0.5 and 0.7, respectively, in favour of ORIF.

CONCLUSIONS

ORIF might be a valuable alternative to SR in the treatment of Vancouver type B2 periprosthetic fractures with shorter operation duration, lower blood loss and similar complication rate compared to SR. Moreover, re-stabilization seems possible irrespective of stem's design or fixation technique.

LEVEL OF EVIDENCE

Level III.

Semi-quantitative CT scoring of nailed shaft fractures during normal healing and in non-unions: comparison with radiographic scoring

PURPOSE

To compare tomographic (TUS) with radiographic (RUS) union scores in nailed shaft fractures during normal healing and in non-unions.

METHODS

Two radiologists blinded to fracture age separately determined RUS and TUS in nailed femoral or tibial shaft fractures by analyzing the radiographic and CT examinations obtained in 47 patients during normal healing (early fracture group; 24 study participants, 17 men,19 tibias, mean fracture-CT delay 109 ± 57 days [42-204 days]) and in surgically proven non-united fractures (late fracture group, 23 patients, 14 men, 12 tibias, mean fracture-CT delay 565 ± 519 days[180-1983 days]). In both study groups, we determined the inter- and intra-observer agreement of RUS and TUS and compared TUS with RUS.

RESULTS

Intra- and inter-observer agreement of RUS and TUS was very good in the early fracture group and good in the late fracture group for both readers. TUS correlated with RUS substantially in the early fracture group and only weakly in the late fracture group. TUS was statistically significantly lower than RUS in study participants with RUS ≥ 8 or 9 for R2 only and ≥ 10 for both readers in the early fracture group and in patients with RUS ≥ 8, 9 or 10 in the late fracture group for both readers.

CONCLUSION

RUS and TUS of nailed shaft fractures during normal healing or in non-unions are both feasible and reproducible. They yield similar values in fractures with no or limited callus. TUS yields lower values than RUS in fractures with callus.

Reliability of radiographic union scale in tibial fractures and modified radiographic union scale in tibial fractures scores in the evaluation of pediatric forearm fracture union

Objectives

This study aims to evaluate the reliability of the radiographic union scale in tibial (RUST) fractures and modified RUST (mRUST) fractures in pediatric forearm fractures treated with elastic stable intramedullary nail (ESIN) and to investigate the effect of the experience of surgeon, thresholds for union, and delayed union decisions.

Patients and methods

In this retrospective study, radiographic images of 20 patients (10 males, 10 females; mean age 8.6±4.3; range, 4 to 11 years) with forearm fractures treated using ESIN between January 2013 and December 2018 were scored by 20 observers based on the RUST and mRUST scores. The observers scored the radiographs at immediate postoperative period, and at 4-, 8-, and 12-week follow-up. Intra- and interobserver agreement for each cortex, RUST, and mRUST were evaluated using intraclass correlation coefficient (ICC). The Fleiss’ kappa (k) coefficient was used in the agreement between evaluators regarding union decision. Receiver operating curves were created to determine the thresholds for radiographic union and delayed union.

Results

Intra- and interobserver reliability of the mRUST score (ICC: 0.84 and 0.79) were slightly higher than that of the RUST score (ICC: 0.80 and 0.72). Pediatric orthopedic and trauma surgeons had slightly higher agreement than the residents and general orthopedists for the total mRUST and RUST scores of the eight-week radiographs. Mean RUST and mRUST scores at the union for all fractures were 10.2±3.4 and 13.0±2.1, respectively. Kappa value for union was moderate (0.74). The total mRUST score had a higher predictive value for union than the total RUST score (area under the curve: 0.986 vs. 0.889). A mRUST score of ≥12 and RUST score of ≥9 were considered as the predictors of union. In addition, a mRUST score of ≤7 and RUST score of <9 were considered as the predictors of delayed union.

Conclusion

A moderate agreement for both RUST and mRUST scores was found. However, the agreement for mRUST was found to be slightly higher. Healing and union of forearm fractures treated with ESIN can be reliably assessed using RUST and mRUST.

Atypical periprosthetic femoral fractures of the hip: characterisation of three cases

INTRODUCTION

Long-term use of bisphosphonates (BPs) has been associated with a specific type of tensile side femoral stress fracture known as Atypical Femoral Fracture (AFF). Theoretically periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, emerging evidence correlates prolonged BPs use with the occurrence of a type of PFF with an atypical pattern (atypical PFF, APFF). The aim of the present study is to report 3 cases of APFF treated at a single centre.

METHODS

Clinical and radiographic records of PFF that occurred between January 2016 and August 2018 were retrospectively reviewed. All patients meeting the American Society for Bone and Mineral Research (ASBMR) criteria for definition of PFF were included. Management strategies for APFF and patient outcomes, including fracture healing and hip function (assessed by the Oxford Hip Score [OHS]) were collected.

RESULTS

3 patients in the study period were identified as APFF (1 incomplete, 2 complete). All patients were females with a mean age of 83.3 years. All patients were treated with lateral plating. The application of a contralateral strut allograft resulted in fracture healing in cases of complete fractures. Mean OHS at final follow-up was 34.3.

CONCLUSIONS

Despite occurring around a hip stem like PFF, APFF had peculiar clinical and radiographic features, making them more similar to AFF. Therefore, the orthopaedic surgeon should also consider the natural history and healing problems associated with AFF prior in order to choose the most appropriate management for APFF.

Minimally-invasive hallux arthrodesis with endomedullary and a crossed screw fixation

BACKGROUND

Minimally invasive surgery has several advantages: minor pain, smaller incisions and less tissue damage than traditional open surgery. Hallux arthrodesis with an endomedullary screw fixation provides compression and axial stability. The aim of this study was to describe the procedure and evaluate our first results of the minimally invasive first metatarsophalangeal arthrodesis with an endomedullary screw combined with a crossed screw fixation.

METHODS

We retrospectively studied 15feet, with a minimum 1year follow-up. Patients were evaluated with full-load radiographs and AOFAS score preoperatively and at last follow-up.

RESULTS

Consolidation rate was 93.3%, radiological consolidation time was 18 weeks (14-60). Radiographic alignment was achieved with satisfactory results. The preoperative AOFAS score improved from a mean 49 to 90 (p=0.001). There was one postoperative superficial site infection, which healed and a patient developed a pseudarthrosis but it was asymptomatic.

CONCLUSIONS

The minimally invasive metatarsophalangeal arthrodesis with an intramedullary screw is a secure procedure with comparable results to open techniques.

LEVEL OF CLINICAL EVIDENCE

4.

Percutaneous hallux valgus surgery: comparison between mini-invasive Chevron and Bosch osteotomies

BACKGROUND AND OBJECTIVE

Through percutaneous approaches, hallux valgus corrections can be performed with minimal soft tissue injury, less postoperative pain and good cosmetic results. Bosch osteotomy and MICA (Minimally Invasive Chevron Akin) have shown to be effective techniques for the correction of hallux valgus, although there are currently no publications comparing each other. The aim of this study is to compare the radiological and functional results of both techniques.

MATERIALS AND METHODS

A retrospective, comparative study was carried out on patients with moderate hallux valgus. They were divided into two groups according to the percutaneous technique performed: Chevron osteotomy and Bosch osteotomy with screw fixation. The metatarsophalangeal, intermetatarsal, and distal articular veneer declination angles of the first metatarsal and the bone consolidation time were evaluated radiologically. The American Orthopaedic Foot and Ankle Surgery (AOFAS) score was used for functional assessment. Complications were registered during the first year.

RESULTS

Thirty-eight patients in each group were included for the study. In each of the groups, the radiological angles were compared preoperatively and at final follow-up, showing statistically significant changes in the three variables considered; but no differences were obtained by comparing them with each other. The time of consolidation was also similar in both groups. As for the AOFAS scale, an improvement was obtained with both techniques, but the difference was not significant when comparing them.

CONCLUSIONS

Both Bosch and MICA techniques showed comparable results at the end of the follow-up. Further work is needed to determine the advantages of each in the immediate postoperative time.

Determining diagnosis of scaphoid healing: Comparison of cone beam CT and X-ray after six weeks of immobilization

PURPOSE

To assess the accuracy and reliability of using cone beam computed tomography (CBCT) compared to X-ray six weeks after injury for predicting scaphoid union.

MATERIALS AND METHODS

Overall; 52 patients with scaphoid fractures between April 2018 and March 2019 were prospectively included in this study. The mean age was 34.52 (13-88) years, and the gender ratio male/female 43/9. Of the fractures, 26 had occurred on the right side, and 26 on the left side. In total, 28 % of patients were manual workers. All patients underwent X-ray and CBCT six weeks after injury. Four readers, two radiologists, and two hand surgeons analyzed the findings using double-blinded X-ray and CBCT and categorized fractures as consolidated based on a 50 % visibility threshold concerning trabecular bridges. Proximal pole sclerosis, communition, cyst formation, and humpback deformity were similarly analyzed for all cases. Agreement between readers was calculated using Kappa, and sensitivity, specificity, and accuracy using RStudio software. The gold standard was the radiologic and clinical follow-up for all patients at two months.

RESULTS

Inter-reader agreement between the four readers was moderate concerning X-ray (0.543) but substantial concerning CBCT (0.641). It was almost perfect between seniors regarding CBCT (Kappa = 0.862). Sensitivity, specificity, and accuracy were 0.75-0.78, 0.4, and 0.61-0.64, respectively, for two readers regarding CBCT. The X-ray values were 0.65-0.71, 0.35-0.4, and 0.53-0.59, respectively.

CONCLUSION

CBCT proves more accurate and reliable than X-ray for diagnosing scaphoid union at an early follow-up and prevents longer immobilization and interruption of activity or work.

Reliability of RUST and Modified RUST Scores for the Evaluation of Union in Humeral Shaft Fractures Treated with Different Techniques

BACKGROUND

The study aimed to evaluate the agreement between the radiographic union scale (RUST) and modified RUST (mRUST) in humeral shaft fractures treated with different techniques, and the effect of surgeons' experience and thresholds for determining bone union.

MATERIALS AND METHODS

A total of 20 orthopedic surgeons reviewed and scored radiographs of 30 patients with humeral shaft fractures treated by external fixation, intramedullary nailing, and plating using the RUST and mRUST on the 0 day, 6 weeks, 12 weeks and 24 weeks follow-up radiographs. Bone healing, interrater agreement between RUST and mRUST scores, and the threshold for radiographic union were evaluated.

RESULTS

The intraclass correlation coefficient (ICC) was slightly higher for the mRUST score than the RUST score (0.71 versus [vs.] 0.67). There was substantial agreement between the mRUST and RUST scores for external fixation (0.75 and 0.69, respectively) and intramedullary nailing (0.79 and 0.71); there was moderate agreement between them for plating (0.59 and 0.55). Surgeons with varying experience had a similar agreement for both scores and scores for each humeral cortex. The external fixation and intramedullary nailing group had higher RUST and mRUST scores than the plating group. The ICC for union was substantial (0.64; external fixation: 0.68, intramedullary nailing: 0.64, and plating: 0.61). More than 90% of the reviewers recorded scores of 10/12 for RUST and 13/16 for mRUST at the time of union.

CONCLUSIONS

RUST and mRUST scores can be used reliably for the evaluation of bony union in humeral fractures treated with an external fixator and intramedullary nailing. In cases of humeral plating, a more sensitive tool for evaluation of fracture union is needed.

Intramedullary nailing for treatment of forearm non-union: Is it useful? - A case series

INTRODUCTION

Intramedullary osteosynthesis is often considered a second-order method for treatment of forearm non-union.

METHODS

We evaluated clinical and functional results from 49 patients affected by radio and/or ulna non-union treated using intramedullary nailing, with possible tricortical autologous bone grafting. Healing rate (primary outcome), healing time and functional status have been assessed.

RESULTS

Healing was observed in 46 cases (93.9%), the average healing time was 6.3 (SD ± 2.5) months. Excellent result (Anderson score) was reached in 38 cases (77.6%), satisfactory in 7 cases (14.3%).

CONCLUSIONS

Forearm non-unions represent a therapeutic challenge. Intramedullary nailing is a successful option of treatment.

Tibial Fracture Healing Score: A Novel Tool to Predict Tibial Nonunion

The aim of the study was to investigate the utility of a simple office-based tool in predicting the need for secondary intervention to obtain union in patients with tibial fractures. All patients 18 years and older with isolated tibial shaft fractures (OTA 41A, 42A-C, and 43A) treated with intramedullary nailing from 2013 to 2017 were screened. Eighty-seven patients met enrollment criteria. Surgeon assessment of the following 3 clinical parameters was performed at routine office visits and scored as follows: (1) pain (none/mild/decreased=1, no change/increased=0); (2) function (minimal limp/able to perform a single-leg stance=1, significant limp/unable to perform single-leg stance=0); and (3) examination (no/minimal pain with manipulation=1, pain with manipulation=0). Radiographic healing was assessed by the adjusted radiographic union scale in tibial fractures (aRUST). The tibial fracture healing score (TFHS) is the sum of 3 clinical scores (0 to 3) and aRUST score (1 to 3) at 3 months postoperatively. The overall nonunion rate was 11%. A RUST score of 5 or less and a sum of the 3 clinical scores of less than 2 at 3 months were found be predictive of nonunion. A TFHS of less than 3 at 3 months was more reliable in identifying patients requiring nonunion repair, especially for those with minimal radiographic healing (RUST score 6 or 7) at 3 months. The TFHS is a simple office-based clinical tool that may identify patients at high risk of nonunion (TFHS <3) following isolated tibial shaft fracture more effectively than clinical examination or radiographic assessment alone. [Orthopedics. 2020;43(4);e323-e328.].

Early Radiographic Union Score for Hip Is Predictive of Femoral Neck Fracture Complications Within 2 Years

OBJECTIVES

To determine if the Radiographic Union Score for Hip (RUSH) measured at 3 and 6 months after femoral neck fracture were predictive of reoperation for infection, nonunion, delayed union, avascular necrosis, or implant failure within 24 months of initial surgery.

DESIGN

Secondary analysis of a randomized controlled trial. Logistic regression was performed to investigate associations between lower RUSH and reoperation. Results were reported as odds ratios (OR), 95% confidence intervals (CIs), and associated P values. All tests were 2 tailed with alpha = 0.05.

SETTING

Eighty-one clinical sites across 8 countries.

PATIENTS/PARTICIPANTS

Data from 734 of the clinical trial participants with radiographs at 3 and 6 months after fracture fixation were included.

INTERVENTION

A reviewer blinded to patients' outcomes independently assigned a RUSH at each follow-up time point.

MAIN OUTCOME MEASURES

Revision surgery rate related to intervention.

RESULTS

Lower RUSH at 3 and 6 months were associated with increased odds of reoperation within 24 months of fracture fixation. For every 2-point decrease in RUSH at 3 months, there was a 16% increase in the odds of a patient experiencing a re-operation (OR, 1.16; 95% CI, 1.10-1.22; P < 0.0001). A similar association was observed at the 6-month assessment for every 2-point decrease (OR = 1.05; 95% CI, 1.01-1.09; P = 0.005).

CONCLUSIONS

Decreased radiographic healing as early as 3 months post fracture fixation is associated with developing patient important femoral neck fracture reoperations. This relationship may guide early treatment decisions, suggesting that 3- and 6-month RUSH are a useful surrogate measure of reoperations within 24 months of fracture fixation.

LEVEL OF EVIDENCE

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

Radiographic evaluations: Which are most effective to follow fracture healing?

The assessment of fracture healing is an imperative and fundamental clinical aspect within orthopaedics. Despite that, there have historically been non-reliable methods utilized to assess for fracture union and nonunion. In recent years, a number of radiographic assessment tools such as the Radiographic Union Score for Tibial fractures (RUST) and Radiographic Union Score for Hip fracture (RUSH) have been developed in order to improve the reliability of fracture assessment for union. These scores have not only increased the reliability of assessments but have also provided thresholds to aid in predicting nonunion as well as union. The nonunion risk determination (NURD) Score was also created to prognosticate these clinical presentations. With the large burdens of cost, lower quality of life and morbidity associated with fracture nonunion, these evaluation methods have provided orthopaedic surgeons with an improved ability to predict nonunion and assist in the management of patients. This review outlines the development, reliability testing as well as biomechanical validity testing associated with these scoring systems.

Altered microRNA profile during fracture healing in rats with diabetes

Background

MicroRNAs (miRNAs) are a class of small non-coding RNA molecules that regulate gene expression. There is increasing evidence that some miRNAs are involved in the pathology of diabetes mellitus (DM) and its complications. We hypothesized that the functions of certain miRNAs and the changes in their patterns of expression may contribute to the pathogenesis of impaired fractures due to DM.

Methods

In this study, 108 male Sprague–Dawley rats were divided into DM and control groups. DM rats were created by a single intravenous injection of streptozotocin. Closed transverse femoral shaft fractures were created in both groups. On post-fracture days 5, 7, 11, 14, 21, and 28, miRNA was extracted from the newly generated tissue at the fracture site. Microarray analysis was conducted with miRNA samples from each group on post-fracture days 5 and 11. The microarray findings were validated by real-time polymerase chain reaction (PCR) analysis at each time point.

Results

Microarray analysis revealed that, on days 5 and 11, 368 and 207 miRNAs, respectively, were upregulated in the DM group, compared with the control group. The top four miRNAs on day 5 were miR-339-3p, miR451-5p, miR-532-5p, and miR-551b-3p. The top four miRNAs on day 11 were miR-221-3p, miR376a-3p, miR-379-3p, and miR-379-5p. Among these miRNAs, miR-221-3p, miR-339-3p, miR-376a-3p, miR-379-5p, and miR-451-5p were validated by real-time PCR analysis. Furthermore, PCR analysis revealed that these five miRNAs were differentially expressed with dynamic expression patterns during fracture healing in the DM group, compared with the control group.

Conclusions

Our findings will aid in understanding the pathology of impaired fracture healing in DM and may support the development of molecular therapies using miRNAs for the treatment of impaired fracture healing in patients with DM.

Effect of changes in serum levels of endogenous hydrogen sulfide on fracture healing: Study protocol clinical trial (SPIRIT compliant)

BACKGROUND

Fracture is a common disease; many factors affect fracture healing. Recent studies have confirmed that hydrogen sulfide (H2S) plays an essential role in bone formation, but most of these studies are drawing conclusions based on animal experiment; whether H2S could promote fracture healing in patients is still unclear. We aim to investigate the change of serum H2S in fracture patients, and analyze its effort on fracture healing.

METHODS

This is a single-center, prospective cohort study. Patients with spinal or limb fracture will be recruited. Patient's serum and urine will be collected at baseline for examination (serum H2S, β-CTX, OC, PINP, 25-OH-VitD3, S-CTX, urinary calcium, and urinary creatinine). All patients will be followed-up for 24 months in outpatients settings, the image of X-ray or CT will be reviewed and fracture healing will be judged by 2 experienced orthopedic physicians. The difference in serum parameters especially H2S will be compared between patients with fracture healed within 9 months and those with fracture unhealed at 9 months.

DISCUSSION

Results of the trial could provide insight into influence of H2S on fracture healing.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of School of Medicine UESTC & Sichuan Provincial People's Hospital Ethics Committee. All the participants will be asked to provide written informed consent before data collection. The findings of the study will be published in peer-reviewed journals and will be presented at national or international conferences.

Platelet-rich plasma decreases fibroblastic activity and woven bone formation with no significant immunohistochemical effect on long-bone healing: An experimental animal study with radiological outcomes

PURPOSE

This study aimed to analyze the immunohistochemical effect of platelet-rich plasma (PRP) on healing of long-bone fractures in terms of bone morphogenetic protein-2 (BMP-2), vascular endothelial growth factor (VEGF), the Ki-67 proliferation index, and radiological and histological analyses.

METHODS

Sixteen adult rabbits, whose right femoral diaphysis was fractured and fixed with Kirschner wires, were randomly divided into two groups, control and PRP (groups A and B, respectively). PRP was given to group B at 1 week postoperatively, and all animals were euthanized after 12 weeks. Radiographic evaluations were performed periodically. Cortical callus formation, chondroid and woven bone area percentages, osteoblastic and fibroblastic activities, and mature bone formation were examined. The depths of BMP-2 and VEGF staining were measured. The Ki-67 proliferation index was also calculated.

RESULTS

The mean radiological union score of group B was significantly higher than that of group A. There were also statistically significant differences between groups A and B in terms of cortical callus formation, woven bone area percentage, fibroblast proliferation, and mature bone formation. Group B had significantly more cortical callus and mature bone formation with less woven bone and fibroblast proliferation. Immunohistochemical analysis revealed no statistically significant difference between the groups in terms of BMP-2 and VEGF staining and the Ki-67 index.

CONCLUSIONS

PRP had no effect on BMP-2 or VEGF levels with no increase in the Ki-67 proliferation index, although its application had a positive effect on bone healing by increasing callus and mature bone formation with decreased woven bone and fibroblast proliferation.

Treatment of Periprosthetic Femoral Fractures Vancouver Type B2: Revision Arthroplasty Versus Open Reduction and Internal Fixation With Locking Compression Plate

Introduction:

The Vancouver algorithm recommends revision arthroplasty (RA) for Vancouver type B2 (VTB2) fractures. However, open reduction and internal fixation (ORIF) using locking compression plates (LCP) may be a valid and less invasive alternative treatment.

Materials and Methods:

Between January 2007 and March 2017, we retrospectively recruited all patients treated with either ORIF with LCP or RA for VTB2 fractures in our clinic. All of the following were reviewed: the length of hospital stay, the operating time, the need for blood transfusions during and/or after surgery, implant-related and patient-related complications, need for revision surgery, and the radiological outcome. Additionally, the functional outcome was investigated.

Results:

Fifty-nine patients were recruited. Thirty-five (59.3%) patients underwent RA, while 24 (40.7%) patients received ORIF with LCP. The median surgical time was 137.50 minutes in the LCP group compared to 160.00 minutes in the RA group (P = .051). Three (12.5%) patients in the LCP group and 10 (28.6%) patients in the RA group experienced an implant-associated complication (P = .131). Patient-related complications occurred in 3 (12.5%) patients in the LCP group versus 6 (17.1%) patients in the RA group (P = .628). The mean preoperative Parker mobility score was 9 points in both groups and decreased in both groups to a mean of 5 points in the LCP and 7 points in the RA group.

Discussion:

Open reduction and internal fixation with LCP seems to be a less invasive procedure for VTB2 fractures in comparison to RA. It is a bone-sparing procedure that can be advantageous for further revision operations. Moreover, some fractures can only be anatomically reduced by ORIF with LCP, whereas for proximal fractures with a radiologically unambiguously loosened stem RA might be advantageous.

Conclusion:

In line with previously published studies, our data suggest that ORIF using LCP is a valid treatment option for VTB2 fractures.

Semi-quantitative CT assessment of fracture healing: How many and which CT reformats should be analyzed?

PURPOSE

To assess how many and which CT reformats of long bone non-unions should be analyzed to best approximate the analysis of a larger number of CT reformats obtained in the three orthogonal planes.

METHOD

We used 29 CT examinations of tibial or femoral non-unions to obtain 87 stacks of 7 CT reformats each in the coronal (n = 29), sagittal (n = 29) or transverse (n = 29) planes. Two independent radiologists scored two fracture sites on each CT reformat by using a Tomographic Union Score (TUS) (1: no callus, 2: non-bridging callus; 3: bridging immature callus; 4: bridging remodeled callus). The reference standard was the mean of the three TUS calculated from the cortical scores obtained on all the sagittal, coronal and transverse CT reformats. We determined the agreement (intra-class correlation coefficient (ICC) between the reference standard and 33 models combining one to seven CT reformats from one to three planes. The three best models were compared following a resampling procedure by a Wilcoxon's signed rank test.

RESULTS

Three models combining two (mid-coronal and mid-sagittal), three (mid-coronal, mid-sagittal and mid-transverse) or four (two paramedian coronal and sagittal) CT reformats had the highest ICC (ICC ≥ 0.89) for both observers. After resampling, the model combining the two paramedian sagittal and coronal CT reformats statistically outperformed the two other models.

CONCLUSION

Semi-quantitative analysis of the two paramedian sagittal and coronal CT reformats is an acceptable alternative to the analysis of more numerous reformats.