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Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study.
Hofmann, A, Gorbulev, S, Guehring, T, Schulz, AP, Schupfner, R, Raschke, M, Huber-Wagner, S, Rommens, PM, ,
The Journal of bone and joint surgery. American volume. 2020;(3):179-193
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Abstract
BACKGROUND Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT). METHODS In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs. RESULTS Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups. CONCLUSIONS Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Maxillofacial trauma in a pregnant patient: Contemporary management principles with a case report & review of literature.
Sridharan, G, Panneerselvam, E, Ponvel, K, Tarun, S, Krishna Kumar Raja, VB
Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2020;(2):78-83
Abstract
Trauma during pregnancy deserves special attention because of its management objectives, i.e. well-being of both pregnant woman and foetus. Maxillofacial trauma directly affects the nutrition of foetus by interfering with the normal functions in a pregnant woman such as mouth opening, mastication and breathing. Hence early restitution of form and function of maxillofacial skeleton is essential. However, the gravid status is associated with numerous anatomical and physiological changes which present with clinical dilemma related to imaging and treatment. A careful scrutiny of the patient's systemic and gestational status is absolutely essential before, during and after instituting any interventional procedures. We present a case of bilateral condyle fracture in a 30-year-old pregnant woman in the third trimester (32 weeks). She was treated with inter maxillary fixation using orthodontic brackets & elastics. After successful restitution of occlusion, the patient was advised aggressive physiotherapy which ensured normal mouth opening. Two weeks later, the patient delivered uneventfully. The patient was followed up at one month and 3 month and demonstrated restitution of normal occlusion, mouth opening and lower facial height. This article aims at analyzing the contemporary principles in management of maxillofacial trauma in a pregnant woman and clarifying the common misconceptions.
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Comparison of Proximal Femoral Nail Antirotation and Dynamic Hip Screw Internal Fixation on Serum Markers in Elderly Patients with Intertrochanteric Fractures.
Wang, B, Liu, Q, Liu, Y, Jiang, R
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2019;(7):644-648
Abstract
OBJECTIVE To compare effect of proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS) internal fixation on serum inflammatory mediators (CRP, IL-1, IL-6 and TNF-α), myocardial injury markers (cTnT, CK-MB), and Myo-heart failure marker (BNP) in elderly patients with intertrochanteric fractures. STUDY DESIGN Experimental study. PLACE AND DURATION OF STUDY Department of Orthopedics, The Second Affiliated Hospital of Xuzhou Medical University, China, from January 2016 to February 2018. METHODOLOGY A total of 114 patients with intertrochanteric fractures were randomly divided into Group A and Group B, with 57 cases in each group. Group A was treated with PFNA and Group B with DHS internal fixation. Serum CRP, IL-1, IL-6, TNF-α, cTnT, CK-MB, Myo, BNP and surgical indication were compared. RESULTS Operation time and weight-bearing time in Group A were shorter than Group B (both p<0.001). Intraoperative blood loss and postoperative drainage volume in Group A were lower than Group B (both p<0.001). On the 7ᵗʰ day after surgery, serum CRP, IL-1, IL-6, TNF-α, cTnT, CK-MB, Myo and BNP in Group A were lower than Group B (all p<0.001). CONCLUSION Compared with DHS, PFNA effectively reduced serum inflammatory mediators with less damage to cardiac function and myocardium in elderly patients with intertrochanteric fractures.
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Spontaneous bilateral femoral neck fractures in a young male adult: a case report and literature review.
Arisumi, S, Mawatari, T, Ikemura, S, Matsui, G, Iguchi, T, Mitsuyasu, H
BMC musculoskeletal disorders. 2019;(1):449
Abstract
BACKGROUND Simultaneous bilateral femoral neck fracture is a very rare condition, even in osteoporotic elderly individuals. We report an atypical case of a young male adult who developed simultaneous bilateral femoral neck fractures without previous trauma or overuse. CASE PRESENTATION A 33-year-old man presented with discomfort in the bilateral groin, which had started 2 weeks previously. Bilateral femoral neck fractures were observed on a radiograph, and in addition, a fracture line was seen at the right subchondral region of the acetabulum using magnetic resonance imaging (MRI). Although the patient had no obvious risk factors associated with bone fragility, his bone mineral density measured using dual X-ray absorptiometry indicated severe osteoporosis (lumber spine: T score - 3.4 standard deviation [SD]; femoral neck: T score - 2.8 SD). Serum 25-hydroxyvitamin D level was deficient (19 ng/mL), which was considered to be partly due to non-sunlight exposure for 3 years owing to social withdrawal. Bilateral osteosynthesis was performed, considering his young age, although more than 2 weeks had passed since the onset of the fracture. Bone union and non-occurrence of osteonecrosis of the femoral head were confirmed via radiography and MRI 8 months after the surgery. CONCLUSIONS Our case suggests that simultaneous non-traumatic bilateral femoral neck fractures can occur in healthy young men.
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Optimizing the Host in Fracture Surgery.
Bergin, PF, Tarkin, IS, Kempton, LB, Sagi, HC, Hsu, J, Archdeacon, MT
Journal of orthopaedic trauma. 2019;:S34-S38
Abstract
Multiple factors impact fracture healing; thus, endocrine optimization and nutritional optimization warrant investigation in the acute fracture and nonunion patient. This article presents current evidence regarding the role of the endocrinologists and the dietician in the fracture patient as well as the most recent data assessing the vitamin D axis in these populations. Similarly, the most recent information regarding the use and risks of NSAIDs in fracture healing are presented. The fracture surgeon must consider each individual patient and weigh the benefits versus the costs of host optimization.
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Extent and location of fixation affects the biomechanical stability of short- or long-segment pedicle screw technique with screwing of fractured vertebra for the treatment of thoracolumbar burst fractures: An observational study using finite element analysis.
Wang, H, Mo, Z, Han, J, Liu, J, Li, C, Zhou, Y, Xiang, L, Yang, L
Medicine. 2018;(26):e11244
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Abstract
Intermediate screw fixation at the fracture level has been widely accepted to treat thoracolumbar burst fractures, but no study has shown the effect of the extent and location of fixation. The effect of the extent and location of fixation on short- or long-segment pedicle screw fixation through intermediate screw fixation at the fracture level in the treatment of thoracolumbar burst fractures is discussed.Posterior intermediate screw fixation techniques in treating T12 vertebral fracture models were simulated and compared using finite element methods; the fixation techniques included M3-L1 (bilateral 3 monoaxial pedicle screw fixation from L1 to T11), M3-L2, M4-L1 (bilateral 4 monoaxial pedicle screw fixation from L1 to T10), M4-L2, M4-L3, and M5-L2 (bilateral 5 monoaxial pedicle screw fixation from L2 to T10). Range of motion (ROM) and largest von Mises stress (LVMS) of the instrumentations were recorded and analyzed.No significant differences were observed in the mean ROM of all states of motion between the M3-L1 model and the other fixation models except for M5-L2. The LVMS of the pedicle screws and rods all occurred during flexion. The LVMS values of the pedicle screws were larger in the M3-L2 fixation model and M4-L3 fixation model than in the other fixation models. The M3-L1 model presented a significantly smaller mean LVMS of the pedicle screws in all states of motion than the M3-L2 model (P = .026). The LVMS values of the rods were larger in the M3-L2 fixation model, M4-L3 fixation model, and M4-L2 fixation model than in the other fixation models. No significant differences were observed in the mean LVMS of the rods in all states of motion among all the fixation models.When choosing short-segment pedicle screw fixation with the screwing of fractured vertebrae to treat thoracolumbar fractures, we suggest M3-L1 over M3-L2. More severe injuries can be considered to identify an alternative treatment to long-segment monoaxial pedicle fixation constructs such as the M4-L1 and M5-L2 techniques.
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Pedicle screw augmentation in osteoporotic spine: indications, limitations and technical aspects.
Hoppe, S, Keel, MJ
European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2017;(1):3-8
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Abstract
PURPOSE The need for spinal instrumented fusion in osteoporotic patients is rising. In this review, we try to give an overview of the current spectrum of pedicle screw augmentation techniques, safety aspects and indications. METHODS Review of literature and discussion of indications, limitations and technical aspects. RESULTS Various studies have shown higher failure rates in osteoporotic patients, most probably due to reduced bone quality and a poor bone-screw interface. Augmentation of pedicle screws with bone cement, such as polymethylmethacrylate or calcium based cements, is one valid option to enhance fixation if required. CONCLUSIONS Crucial factors for success in the use of augmented screws are careful patient selection, a proper technique and choice of the ideal cement augmentation option.
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Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management.
Koh, A, Guerado, E, Giannoudis, PV
The bone & joint journal. 2017;(3):295-302
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AIMS: Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures. MATERIALS AND METHODS Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified. RESULTS For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing. CONCLUSION Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295-302.
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Optimal Positioning for Volar Plate Fixation of a Distal Radius Fracture: Determining the Distal Dorsal Cortical Distance.
Vosbikian, MM, Ketonis, C, Huang, R, Ilyas, AM
The Orthopedic clinics of North America. 2016;(1):235-44
Abstract
Distal radius fractures are currently among the most common fractures of the musculoskeletal system. With a population that is living longer, being more active, and the increasing incidence of osteoporosis, these injuries will continue to become increasingly prevalent. When operative fixation is indicated, the volar locking plate has recently become the treatment of choice. However, despite its success, suboptimal position of the volar locking plate can still result in radiographic loss of reduction. The distal dorsal cortical distance is being introduced as an intraoperative radiographic tool to help optimize plate position and minimize late loss of fracture reduction.
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Optimizing Stability in Femoral Neck Fracture Fixation.
Ye, Y, Hao, J, Mauffrey, C, Hammerberg, EM, Stahel, PF, Hak, DJ
Orthopedics. 2015;(10):625-30
Abstract
Optimizing stability of femoral neck fracture fixation is important in obtaining a successful outcome. The mechanical problems and strategies for achieving optimal stability differ depending on patients' age and degree of osteoporosis. Femoral neck fractures in younger adults usually result from high-energy trauma and have a vertical fracture pattern. Strategies for optimizing fixation stability in this group include placing additional screws at right angles to the fracture plane and medial buttress plate augmentation. In elderly patients, screw position relative to the intact cortical femoral neck bone is of critical importance. Additional strategies for optimizing fixation stability in this group include the concept of length stable fixation, use of adjunctive calcium phosphate cement, and use of novel fixed angle fixation implants.