The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial

AIMS

To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture.

PATIENTS AND METHODS

Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D₃ orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out.

RESULTS

In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement.

CONCLUSIONS

Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D₃. Cite this article: Bone Joint J 2017;99-B:1520-5.

Ligamentous contributions to pelvic stability

The purpose of this study was to examine the ligamentous contributions to pelvic stability. Thirteen fresh frozen cadaver pelves were loaded in an MTS materials testing machine, and the supporting ligaments were sequentially cut. After each ligament was cut, measurements of pelvic stability were made. Pelvic stability was maintained most effectively when the pelvic ring remained intact. The sacrotuberous and sacrospinous ligaments contributed little to overall pelvic stability. The posterior sacroiliac ligament and the pubic symphyseal ligaments contributed most to pelvic stability, but overall it was clear that a ligament's contributions to pelvic stability depended not only on the ligament's size, but also on the other ligament remaining intact and the mode in which the pelvis was loaded.

Biomechanical analysis of the Gamma nail and sliding hip screw

Nine pairs of human cadaveric femora were used to study the biomechanical characteristics of the Gamma nail and a standard telescoping screw plate implant (Ambi) to determine whether there were any mechanical advantages of one system over the other. Parameters studied included structural stiffness, strain distribution, and failure modes for intertrochanteric and subtrochanteric fractures. There was no significant difference in structural stiffness for stable intertrochanteric and subtrochanteric fractures. The Gamma Nail composites, however, were stiffer than the Ambi for unstable subtrochanteric fractures. Both implants effectively unloaded the proximal medial cortex. In each instance, failure of the Gamma nail composite occurred through the distal locking screws. The Gamma nail does not appear to offer any distinct biomechanical advantage over the sliding hip screw system in the treatment of stable and unstable intertrochanteric fractures, but it may play a role in the treatment of unstable subtrochanteric fractures.

Seidel intramedullary nailing of humeral diaphyseal fractures: a preliminary report

Forty-two humeral diaphyseal fractures in 41 patients were treated at three centers between April 1988 and November 1989. There were 28 acute fractures; four were open. Average time to union was 8 weeks. There were no infections. Six patients with seven pathologic fractures due to metastatic disease died during the course of this study, but the nail had allowed them to be functional with minimal surgical dissection. Five of six nonunions united with one procedure. There was one residual nonunion in a patient with a wide canal and an arthrodesed shoulder above the nonunion. There were three preoperative radial and two preoperative axillary nerve palsies, and no iatrogenic nerve palsies. In all patients with anterior deltoid incisions, shoulder motion returned reliably, but took as long as 6 months. Four rods were left prominent in the rotator cuff and the patients had symptoms of impingement until rod removal. Six patients had restricted shoulder function, one due to a fracture of the humeral head and five from a lateral deltoid incision. This incision was used in 12 cases. There were no stiff shoulders when using an anterior deltoid incision.

Dynamic condylar screw: a new device. A preliminary report

The dynamic condylar screw (DCS) is a new implant engineered by the AO/ASIF Group for use in management of proximal and distal femoral fractures. This device has some technical advantages over the AO condylar blade plate. In a prospective study we reviewed the use of the DCS in the treatment of supracondylar fractures, intertrochanteric fractures, subtrochanteric fractures, nonunions, and malunions in 18 patients (19 femora). The results are based on an average follow-up of 9 months. Seventeen femurs went on to clinical and radiological union with good functional results. There were two failures because of delayed unions.

Scapulothoracic dissociation

Scapulothoracic dissociation is a rare entity that consists of disruption of the scapulothoracic articulation. The mechanism of injury is probably traction caused by a blunt force to the shoulder girdle. This lesion is characterized by massive soft-tissue swelling of the shoulder; lateral displacement of the scapula, measured radiographically; an injury to bone (an acromioclavicular separation, a displaced fracture of the clavicle, or a sternoclavicular disruption); a severe neurovascular injury; and a variety of upper and lower-extremity fractures. We treated fifteen patients who had this lesion, most of whom had several associated injuries. Three patients died: two from exsanguination and one from a cardiac arrest. In most patients, the damaged artery was repaired and the brachial plexus was explored. All of the twelve patients who had a complete brachial-plexus injury were left with a flail upper extremity. Most patients refused amputation.

Ipsilateral fractures of the femoral neck and shaft. A treatment protocol

Ipsilateral fractures of the femoral neck and shaft present diagnostic difficulties and complex choices as to treatment. A review of the eighty-three cases reported in the literature revealed that one-third of the fractures of the femoral neck were missed initially. No consistent method of treatment can be recommended on the basis of this review. Our present protocol for this double fracture is treatment with immediate internal fixation: the femoral neck fracture is given first priority and is reduced and immobilized with multiple cancellous screws, and the femoral shaft fracture is then treated with retrograde closed intramedullary Küntscher nailing. Appropriate exceptions to the protocol exist. We reviewed the cases of fifteen patients who were treated at Harborview Medical Center and University Hospital from 1971 through 1981. Our experience with the first two patients led to the development of our protocol, which was applied in the thirteen subsequent double fractures. Two of the fifteen femoral-neck fractures were missed initially. All of the fractures had united four months postoperatively. Of the nine patients who were followed for three years or more, two had aseptic necrosis of the femoral head. Compared with other reports, our protocol seems to have produced somewhat better functional results.

The response of articular cartilage to the in vivo replacement of synovial fluid with saline

Experiments on rabbits were performed to determine whether continuous irrigation of a synovial joint produced irreversible degenerative changes in the articular cartilage. Continuous irrigation of a synovial joint permits observations of the effect on articular cartilage of altering the intra-articular environment. The right knee joints were irrigated with normal saline for varying periods, up to 14 days, and the left knees served as nonirrigated controls. One group of animals (short-term) was killed immediately following irrigation, while another group (long-term) was assessed after six months of cage activity following the irrigation period. Within each group, half were skeletally immature and half were mature. No differences in cell density, nuclei-to-lacunae ratio, or the ratio of calcified layer to total cartilage thickness were found in any group. Irrigation did produce a significant reduction in matrix staining with safranin-O. This was first detectable following three days of irrigation and was severe by seven to 14 days. Staining properties returned to normal after six months of cage activity. No obvious difference was found between immature and mature animals.

Cross-sectional anatomy of the adult bony acetabulum

Cross-sectional cuts through the acetabulum of a cadaveric pelvis were obtained to evaluate the bony anatomy. There are six slices of 1 cm thickness which define the acetabulum. This information has been important to us primarily to assess acetabular fractures with computerized tomography.

Acetabular fracture assessment with computerized tomography

Twenty-four patients have been evaluated to demonstrate the role of computerized tomography (CT) in assessment of acetabular fractures. CT is important in defining the articular dome, intraarticular and femoral head abnormalities, associated sacroiliac damage and soft-tissue injury. The CT examination can be obtained with minimal additional discomfort to the patient.

Acetabular fracture assessment with computerized tomography

Twenty-four patients have been evaluated to demonstrate the role of computerized tomography (CT) in assessment of acetabular fractures. CT is important in defining the articular dome, intraarticular and femoral head abnormalities, associated sacroiliac damage and soft-tissue injury. The CT examination can be obtained with minimal additional discomfort to the patient.

Cross-sectional anatomy of the adult bony acetabulum

Cross-sectional cuts through the acetabulum of a cadaveric pelvis were obtained to evaluate the bony anatomy. There are six slices of 1 cm thickness which define the acetabulum. This information has been important to us primarily to assess acetabular fractures with computerized tomography.

Pelvic disruption in the polytraumatized patient: a management protocol

This article reviews the experience with the management of 79 polytraumatized patients with pelvic fractures. The incidence of involvement of other systems was measured by the injury severity score. The average severity score was 33.5, and the mortality was 19%. Patients with a posterior disruption of the pelvis had a higher mortality, a higher "injury severity score," and required greater resuscitation efforts. Resuscitation of these patients requires efficient effective action. Adherence to our management algorithm, based on assessment of the patient's response, should help achieve that end.

Arteriosclerotic femoral artery aneurysms

Arteriosclerotic aneurysms of the femoral artery are uncommon lesions that occur in elderly men. In 30 patients 36 aneurysms were repaired at the Toronto Western Hospital from January 1965 to June 1977. Half of the patients presented with ischemia and one quarter with an enlarging mass, and one quarter had no symptoms. Two thirds had other aneurysms and one third had suffered from cerebral or myocardial ischemia. The technique of repair changed from reconstructive aneurysmorrhaphy before 1970 to use of an interposition arterial prosthesis thereafter. Minimal groin dissection, internal control of blood flow in the deep femoral artery, and use of an appropriate arterial prosthesis provided excellent results. Surgical repair is recommended for most symptomatic ones when the patient's life expectancy is more than 2 years.