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An intrathoracic shoulder dislocation is a rare injury, usually the result of high-energy trauma [Hawkes et al. in Am J Orthop 43(4):E74-E78, 2014; Tsai et al. in Ann Thorac Cardiovasc Surg 20:592-594, 2014, in Rupprecht et al. Bull Emerg Trauma 5(3):212-214, 2017; Abellan et al. J Orthop Surg (Hong Kong)18(2):254-257, 2010]. It often occurs in conjunction with thoracic, pelvic, and long bone injuries. In addition, there is often significant injuries to the shoulder girdle and chest wall associated with neurovascular compromise [Abellan et al. J Orthop Surg (Hong Kong)18(2):254-257, 2010; Lin et al. JBJS Case Connect 6(1):e61, 2016]. Following a literature review, it appears that no cases have been reported of an intrathoracic shoulder dislocation associated with a rupture of the ipsilateral main bronchus. We present a case of a rupture of the right main bronchus that occurred due to high-energy impact and an associated intrathoracic right-shoulder fracture dislocation. Computed tomography identified diastasis of the ipsilateral first intercostal space, humeral head indentation in the hilum of the lung, and a pneumoarthrogram of the right glenohumeral joint. [ABSTRACT FROM AUTHOR]

Introduction: Distal radius fractures (DRF) are the most common fractures of the upper extremities. The incidence is expected to continue rising in the next years due to the increased life expectancy. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF with a complication rate of 8-39% reported in the literature. Main aim of this study was to investigate the incidence of complications after DRF stabilization using palmar angular stable locking plate.Methods: A retrospective medical records review conducted from January 2013 to December 2016 included a total of 392 patients with DRF, that were stabilized using palmar angular stable locking plate and showed a minimum follow-up of 3 months. The group comprised 259 female and 133 male patients with a mean follow-up interval of 11 months (range 3-52 months). All recorded complications were documented. Range of motion (ROM) in extension, flexion, supination, pronation, radial- and ulnar deviation of the last follow-up was noted. Age was divided into younger than 65 years (< 65 years) and older than 65 years (≥ 65 years). The primary, immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off.Results: A total of 51 (13%) early and 17 late (4%) complications were recorded in 392 patients. The most common complications included carpal tunnel syndrome (3%), complex regional pain syndrome (3%) and loss of reduction (2%). Of the 68 complications, only 25 (6%) were directly related to the plate. 73% of all complications occurred in AO type C fractures. Patients without complications showed a significantly better ROM in extension, flexion, pronation and supination than patients with complications. No significant differences in incidence of complications, ROM or loss of reduction could be found between patients over and under 65 years of age. Gender and type of immobilization showed no significant influence on the complication rate.Conclusions: Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment. In the majority of the cases a good clinical and radiological outcome with no complications was documented. Gender and type of immobilization had no impact on the complication rate and an age over 65 years is not associated with an increased risk for complications or restricted ROM. [ABSTRACT FROM AUTHOR]

Background: The added value of routine radiography in the follow-up of extremity fractures is unclear. The aim of this systematic review was to create an overview of radiography use in extremity fracture care and the consequences of these radiographs for the treatment of patients with these fractures.Materials and Methods: Studies were included if they reported on the use of radiography in the follow-up of extremity fractures and on its influence on treatment strategy, clinical outcome, or complications. A comprehensive search of electronic databases (i.e., PubMed, Embase, and Cochrane) was performed to identify relevant studies. Methodological quality was assessed with the Newcastle-Ottawa scale for cohort studies. Level of evidence was assessed using GRADE. The search, quality appraisal, and data extraction were performed independently by two researchers.Results: Eleven studies were included. All studies were retrospective cohorts. Of these, only two used a comparative design. Two of the included studies described fractures of both the upper and lower extremities, four studies concerned fractures of the lower extremity only, and five studies focused on fractures of the upper extremity. Pooling of data was not performed because of clinical heterogeneity. Eight studies reported on a change in treatment strategy related to radiography. Percentages ranged from 0 to 2.6%. The overall results indicated that radiographs in the follow-up of extremity fractures seldom alter treatment strategy, that the vast majority of follow-up radiographs are obtained without a clinical indication and that detection of a complication on a radiograph, in the absence of clinical symptoms, is unlikely. All included studies were regarded of a 'very low' level using GRADE.Conclusions: Based on current literature, the added value of routine radiography in the follow-up of extremity fractures seems limited. Results, however, should be interpreted with care, considering that available evidence is of a low level. [ABSTRACT FROM AUTHOR]

Introduction: We aim to review the incidence and risk factors for the development of intraoperative periprosthetic femur fractures while performing a bipolar hemiarthroplasty for displaced neck of femur fractures. Our secondary aim is to characterize the types of intraoperative periprosthetic fractures, the steps leading to the fractures, and the salvage treatments instituted.Materials and Methods: 271 patients treated with bipolar hemiarthroplasty after traumatic displaced femoral neck fractures were retrospectively analyzed. Demographic data, co-morbidities, vitamin D level, consumption of steroids, ASA score, surgical approach, surgeon experience, use of cemented or uncemented implants, proximal femur morphology, and types of anaesthesia were analyzed statistically.Results: There were 28 patients (10.3%) with intraoperative periprosthetic femur fractures. We found two significant independent risk factors which were the use of uncemented prosthesis (OR 4.15; 95% CI 1.65-10.46; p = 0.003) and Dorr type C proximal femurs (Dorr A OR 3.6; 95% CI 1.47-8.82; p = 0.005). In addition, patients with Dorr type C proximal femurs who underwent uncemented bipolar hemiarthroplasty were more likely to sustain an intraoperative periprosthetic fracture (14(73.7%) out of 19 patients; p = 0.002). There were no significant differences found in other risk factors. The most common location for these fractures was at the greater trochanter at 11 (39.3%) cases. Majority of them, 15 (53.6%), had intraoperative fractures during trial implant insertion and reduction.Conclusion: The overall incidence of intraoperative periprosthetic femur fractures during hemiarthroplasty for displaced neck of femur fractures was 10.3%. The incidence was significantly higher for uncemented (14.7%) when compared to cemented prosthesis (5.4%) and the greater trochanter was the commonest area for periprosthetic fractures during trial implant insertion and reduction. Uncemented prosthesis and Dorr type C proximal femurs were two significant independent risk factors contributing to intraoperative periprosthetic fractures. By identifying these risk factors, surgeons can take ample precautions to prevent complications. [ABSTRACT FROM AUTHOR]

Introduction: It is likely that posterior-wall involvement in association with two-column fractures plays a pivotal role in outcomes because of the potential for hip instability if it is not anatomically reduced and fixed. Uncertainty remains about how this fracture is best treated, especially regarding how posterior-wall involvement may affect functional results.Materials and Methods: To better understand the role that posterior-wall involvement may play in determining functional results, we compared data for outcomes for patients with posterior-wall involvement and for those without in a consecutive series of two-column fractures. Between 2000 and 2013, 42 patients who underwent surgical treatment for two-column acetabular fractures were evaluated after a minimum follow-up period of 1 year. Data were prospectively collected and retrospectively evaluated. Of the 42 patients, 25 had only a two-column fracture (group 1) and 17 had a two-column fracture with posterior-wall involvement (group 2).Results: There were no differences between groups in terms of reduction accuracy, radiographic results, clinical results, or complication rates. All hips in patients with internal fixation for the associated posterior-wall fracture had anatomical reduction. At the latest follow-up evaluation, three patients from group 1 (without posterior-wall involvement) and three patients from group 2 (with posterior-wall involvement) had undergone total hip arthroplasty.Conclusion: These results suggest that a posterior-wall fracture in a two-column fracture does not compromise functional outcomes when the treatment algorithm discussed here is followed. [ABSTRACT FROM AUTHOR]

Introduction: Several reconstructive procedures have been used in management of large tibial bone defects including bone graft, bone transport (distraction osteogenesis) using various external fixators, and vascularized bone graft. Each of these procedures has its limitations and complications. The study describes gradual medial fibular transfer using Ilizarov external fixators in management of patients with large tibial defect, either following infection or trauma.Patients and Methods: Between May 2011 and June 2013, 14 patients were prospectively included in the current study. The inclusion criteria were large tibial defect due to trauma or infection with severe soft tissue compromise, and small or poor tibial bone remnants making bone lengthening difficult. Exclusion criteria were patients with vascular or nerve injuries. The average age of the patients was 31.64 (± 6.5) years. Medial fibular transfer was done for all patients using Ilizarov at a rate of 0.5 mm twice daily. Iliac bone graft was used in all patients after the transfer.Results: The average segmental bone defect of the tibia was (13.2 ± 2.6), ranging between 8 and 18.6 cm. Union was achieved in all patients with average fixator time was 32.42 (± 4.32) weeks. Average follow-up after removal of the fixator was 40.5 (± 6.9) months.Conclusion: Gradual fibular transfer by Ilizarov external fixator is a reliable technique in management of post-traumatic and post-infection large tibial bone defects with good clinical outcome, and with few complications. [ABSTRACT FROM AUTHOR]

Introduction: Isolated greater tuberosity (GT) fractures (AO 11-A1) tend to occur in the younger patient population and are poorly managed by most precontoured proximal humerus locking plates. The goal of this study was to identify and assess an alternative treatment strategy for greater tuberosity fractures.Materials and Methods: A retrospective review of all cases of isolated greater tuberosity fractures treated with a 2.4/2.7 mesh plate (Synthes) between 2010 and 2015 was conducted. Patient demographics, operative reports, and clinical notes were reviewed. The time to radiographic union was assessed. Clinical outcomes were retrieved from patients at their follow-up visits or via mailed Disabilities of the Arm, Shoulder, Hand (DASH) questionnaires.Results: Ten patients with isolated GT fractures treated with mesh plating were identified with an average age of 47.1 years. The average radiographic follow-up was 7.2 months and the average clinical follow-up was 8.0 months. The mean time to union was 8.5 weeks. Two patients underwent elective hardware removal. The mean DASH at final follow-up was 28.2 (±22.4), while the mean DASH work was 13.6 (±19.1).Conclusion: We have identified a viable alternative treatment option for the surgical management of isolated greater tuberosity fractures using a mesh plate that can be contoured to the patient's anatomy. Surgeons should be aware of this option for select patients. [ABSTRACT FROM AUTHOR]

Purpose: To show the differences in lateral and anterior femoral shaft bowing (FSB) between radiographic and computed tomography (CT) images and to assess whether FSB is associated with various predictive factors in women with knee osteoarthritis (OA) using CT images.Methods: We enrolled 135 Japanese women with medial compartment knee OA. Lateral and anterior FSB were measured by radiography and reconstructed CT. Age, body mass index (BMI), femorotibial angle (FTA), femoral length, and lumbar spine and femoral neck bone mineral density (BMD) were set as predictive factors for progression of knee OA. We compared predictive factors in the lateral FSB group having lateral angulations of >5° with those in the nonbowing group and compared predictive factors in the anterior FSB group having anterior angulations of >11° with those in the nonbowing group. Binomial logistic regression modeling was applied to determine independent predictors of both FSB.Results: There were significant differences in both FSB between the radiographic and reconstructed CT images (P = 0.005 and P = 0.047, respectively). In binomial logistic regression analyses for lateral FSB on CT, age, BMI, and lumbar spine BMD were significant predictors, with odds ratios of 1.16, 1.22, and 0.03, respectively; for anterior FSB on CT, age was a significant predictor, with an odds ratio of 1.06.Conclusions: It is preferable to measure both FSB on reconstructed CT when planning reconstructive knee surgeries. Age, BMI, and lumbar spine BMD were predictors of lateral FSB progression, and age was a predictor of anterior FSB progression. Level of evidence Level III. [ABSTRACT FROM AUTHOR]

Introduction: Infected nonunion of the tibial diaphysis poses one of the most challenging scenarios. There is no clear cut guidelines for cases of infected diaphyseal nonunion with bony defects of ≤6 cm.Materials and Methods: A retrospective comparative study was conducted on 30 patients who sustained resistant infected tibial diaphyseal nonunion with bony defect of ≤6 cm. The 30 patients were the sum of two groups; group I (16 patients, mean age 33.6 years) which included all patients, who underwent two stage reconstructions, and Group II patients (14 patients, mean age 29.5 years) who were managed by application of Ilizarov ring external fixator in a single stage surgery. Union was judged both clinically and radiologically. A scoring system comprising dual functional and bony grading was employed to evaluate the final results of both groups.Results: The results of both groups regarding the size of the resultant bony defect, the time to union, and the postoperative limb length discrepancy showed no statistically significant differences. Group II patients needed postoperative plastic reconstruction procedures significantly more than group I patients (p = 0.019). Similarly, group II patients exhibited more complications than group I patients (p = 0.003). Regarding both clinical and bony grading, the results of group I showed superiority to group II results with the only significant difference being the preservation of the preoperative range of motion of both ankle and subtalar joints (p = 0.072).Conclusions: The use of two stage reconstruction in cases of resistant infected tibial diaphyseal nonunion gives comparable results to the Ilizarov ring external fixator in cases associated with bony defects within the confines of 6 cm with superiority in preservation of ankle and subtalar joints range of motion. [ABSTRACT FROM AUTHOR]

Background: Fall-induced fractures of older adults are a major public health concern. However, nationwide information on recent fracture trends is sparse.Methods: We determined the trend in the number and incidence (per 100,000 persons) of fall-induced ankle fractures among older adults in Finland by taking into account all persons 60 years of age or older who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2014.Results: The number of fall-induced ankle fractures among 60-year-old or older Finnish persons increased steadily and sharply between 1970 (369 fractures) and 1997 (1668 fractures), but since then, the increase has slowed down (1835 fractures in 2014). The raw incidence of ankle fracture, showing a clear rise from 57 fractures per 100,000 persons in 1970 to 169 fractures in 1997, declined steadily between 1997 and 2014 (to 126 fractures in 2014). Observations on the age-adjusted fracture incidence were similar. During 1970-1997, the age-adjusted incidence of fall-induced ankle fracture clearly rose in both women and men, but thereafter, the incidence declined; in women, from 199 in 1997 to 158 in 2014, and in men, from 123 in 1997 to 80 in 2014.Conclusions: The sharp rise in the incidence of fall-induced ankle fracture in Finnish older adults from early 1970s until late 1990s has been followed by a declining fracture rate. Despite this welcome development, the rapid aging of our population is likely to increase the absolute number of these fractures in the near future, and therefore, large-scale fracture-preventing intervention studies are urgently needed. [ABSTRACT FROM AUTHOR]

Introduction: Tibial nonunion is the most common nonunion encountered by the orthopedic surgeon. Repeated surgeries, cost, increased duration of hospital stay, disability, pain all contribute to the increased morbidity. Many methods have been used to treat nonunion of tibia with variable results and none of them are 100 % successful. Our objective was to determine the effectiveness of modification of Judet's decortication technique and buttress plating, without bone graft, in the treatment of aseptic, atrophic tibial nonunion. Also, to find the correlation between time of achieving union and time since injury to decortication. Materials and Methods: Ours is a retrospective study conducted at a Level I trauma center. A total of 35 cases of atrophic tibial nonunion, irrespective of the cause, was treated by modifying Judet's osteoperiosteal decortication and plating during the time period January 2006 to July 2013. Demographic data, range of motion, time of achieving union and clinico-radiological evaluation for union of fracture were included as main outcome measurements. Results: Union was achieved in all cases with a mean duration of 8.34 months. Pain and stiffness of joints were not reported in any case on long-term follow-up and the patients had satisfactory range of motion. Implant removal was done in three cases after fracture union. Conclusion: Treatment of atrophic tibial nonunion is challenging and management of each nonunion has to be customized based on the biological and mechanical characteristics of the nonunion. Plating with osteoperiosteal decortication is an effective and simple technique, which in our hands has shown to result in 100 % union rates without the need of additional bone healing augmentation procedures like bone grafting. Level Of Evidence: Level II. [ABSTRACT FROM AUTHOR]

Background: Despite several randomized controlled trials comparing operative to nonoperative management of primary patellar dislocation, the optimal management of this condition remains a subject of controversy. The aim of this study was to compare surgical to conservative treatment of outcomes for primary patellar dislocation by meta-analysis all the relative randomized controlled trials.Study Design: Meta-analysis.Methods: After searching multiple online databases (MEDILINE, EMBASE, CLINICAL, OVID, BISOS and Cochrane registry of controlled clinical trials), eight randomized controlled trials including 430 patients were meta-analyzed in which operative treatment was compared with non-operative treatment for primary patellar dislocation. Outcomes evaluated were redislocation rate, Kujala score, episode of instability, Tegner activity score, Hughston visual analog score (VAS) and patient satisfaction.Results: Outcomes on recurrent patellar dislocation (P = 0.004) and Hughston VAS (P = 0.03) were statistically significant in favor of operative management. Tegner activity score (P < 0.00001) was significantly higher in favor of conservative treatment, though only a few studies were identified. There was no significant difference between the two treatments regarding episode of instability (P = 0.41), Kujala score (P = 0.32) or patient satisfaction (P = 0.49).Conclusion: Surgical treatment may be better than conservative treatment for patients with primary patellar dislocation on incidence of redislocation. However, since these findings are built on a limited number of studies available, well-designed, multicenter clinical trials with long-term follow-up are required to provide more solid evidence concerning optimal strategies. [ABSTRACT FROM AUTHOR]

Background: Although a variety of suitable fracture models for mice exist, in many studies bone healing was still analyzed without fracture stabilization. Because there is little information whether the healing of non-stabilized fractures differs from that of stabilized fractures, we herein studied the healing process of non-stabilized compared to stabilized femur fractures.Materials and Methods: Twenty-one CD-1 mice were stabilized after midshaft fracture of the femur with an intramedullary screw allowing micromovements and endochondral healing. In another 22 mice the femur fractures were left unstabilized. Bone healing was studied by radiological, biomechanical, histomorphometric and protein expression analyses.Results: Non-stabilized femur fractures revealed a significantly lower biomechanical stiffness compared to stabilized fractures. During the early phase of fracture healing non-stabilized fractures demonstrated a significantly lower amount of osseous tissue and a higher amount of cartilage tissue. During the late phase of fracture healing both non-stabilized and stabilized fractures showed almost 100 % osseous callus tissue. However, in stabilized fractures remodeling was almost completed with lamellar bone while non-stabilized fractures still showed large callus with great amounts of woven bone, indicating a delay in bone remodeling. Of interest, western blot analyses of callus tissue demonstrated in non-stabilized fractures a significantly reduced expression of vascular endothelial growth factor and a slightly lowered expression of bone morphogenetic protein-2 and collagen-10.Conclusion: Non-stabilized femur fractures in mice show a marked delay in bone healing compared to stabilized fractures. Therefore, non-stabilized fracture models may not be used to analyze the mechanisms of normal bone healing. [ABSTRACT FROM AUTHOR]

Objectives: It is unclear whether all completely displaced midshaft clavicle fractures require primary surgical intervention. The aim of this study was to elucidate the radiological and clinical outcomes after conservative treatment, and to identify subgroups at risk of an inferior outcome.Design: Retrospective case series.Setting: Level II trauma center.Patients: Between 2005 and 2008, 122 patients were conservatively treated for a completely displaced midshaft clavicle fracture of whom 92 were eligible for inclusion in this study. Of these, 59 completed the study after a median of 2.7 years after the fracture (min-max, 1.1-4.9).Intervention: The patients received the standard treatment administered at our institution at the time: nonsurgically with a sling without physiotherapy. Patients with painful nonunions were subsequently offered surgery.Main Outcome Measurements: At follow-up, the patients' Disabilities of Arm, Shoulder, and Hand (DASH) and the Constant scores were evaluated. Radiographs were taken at follow-up and compared to those taken acutely.Results: Nonunion was found in 9 of the 59 (15.3%) patients. Twenty-four (24%) patients reported a fair-to-poor DASH score (i.e. >20). Patients with fractures that were vertically displaced by more than 100% (one bone width) were significantly less satisfied than those with fractures vertically displaced at 100% (p = 0.04). Initial shortening of more than 15 mm was not associated with a worse outcome or nonunion. The odds ratio of developing a nonunion increased with age (p = 0.04).Conclusions: By treating completely displaced midshaft clavicle fractures conservatively with a sling and offering plate fixation for eventual painful nonunions, we found a 24% risk of a fair or poor clinical result with a DASH score over 20. A vertical displacement of more than 100 % between the main fragments on the initial radiograph was associated with an inferior clinical outcome in this study.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Introduction: Drilling of bones in orthopaedic and trauma surgery is a common procedure. There are yet no recommendations about which drill bits/coating should be preferred and when to change a used drill bit.Materials and Methods: In preliminary studies typical "drilling patterns" of surgeons concerning used spindle speed and feeding force were recorded. Different feeding forces were tested and abrasion was analysed using magnification and a scanning electron microscope (SEM). Acquired data were used for programming a friction stir welding machine (FSWM). Four drill bits (a default AISI 440A, a HSS, an AISI 440B and a Zirconium-oxide drill bit) were analysed for abrasive wear after 20/40/60 machine-guided and hand-driven drilled holes. Additionally different drill coatings [diamond-like carbon/grafitic (DLC), titanium nitride/carbide (Ti-N)] were tested.Results: The mean applied feeding force by surgeons was 45 ± 15.6 Newton (N). HSS bits were still usable after 51 drill holes. Both coated AISI 440A bits showed considerable breakouts of the main cutting edge after 20 hand-driven drilled holes. The coated HSS bit showed very low abrasive wear. The non-coated AISI 440B bit had a similar durability to the HSS bits. The ZrO2 dental drill bit excelled its competitors (no considerable abrasive wear at >100 holes).Conclusions: If the default AISI 440A drill bit cannot be checked by 20-30× magnification after surgery, it should be replaced after 20 hand-driven drilled holes. Low price coated HSS bits could be a powerful alternative. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include reconstruction of segmental bone defects, limb lengthening intramedullary, and corrections around the knee.

Purpose: The purpose of this study is to evaluate the radiographic and clinical outcomes of the Frag-Loc compression screw with palmar plate fixation on distal radius fractures that include a displaced dorsoulnar fragment. Patients and methods: This retrospective comparative study enrolled 48 patients who had an unstable distal radius fracture and a dorsoulnar fragment that was more than 2 mm displaced and that had involvement of more than one-quarter of the articular surface. Twenty-six of the 48 patients were treated with a palmar locking plate without a Frag-Loc compression screw (group 1) and the other 22 patients were treated with palmar locking plate with a Frag-Loc compression screw to fix the dorsoulnar fragment (group 2). First, we reviewed all pre-surgical computerized tomographic (CT) scans. Second, we used the gap distance between the dorsoulnar and palmar fragment as seen on post-surgical axial and sagittal CT scans to determine outcome. The gap distance was measured at the point of maximum distance perpendicular to the plane of the main fracture line. Clinical outcomes were evaluated based on the patient-rated wrist evaluation (PRWE) score; the disabilities of the arm, shoulder and hand score; wrist active range of motion; and grip strength. Results: There were no statistically significant differences in clinical outcome between the two groups. However, there were statistically significant differences in post-surgical gap distance. The mean post-surgical gap distances for group 1 were 1.3 mm (range 0.2-3.8 mm) on axial CT scans and 1.4 mm (range 0.5-2.4 mm) on sagittal CT scans, while the mean post-surgical gap distances for group 2 were 0.7 mm (range 0.7-1.6 mm) and 0.7 mm (range 0.3-1.1 mm). Conclusion: This study shows that the Frag-Loc compression screw can reduce the gap distance between the dorsoulnar fragment and the distal radius, according to evaluation of post-surgical axial and sagittal CT scans. This result suggests that the Frag-Loc compression screw is an effective and simple treatment option to immobilize a dorsoulnar fragment associated with distal radius fracture. [ABSTRACT FROM AUTHOR]

The analysis of peripheral serum cytokine expression patterns has been shown to be a possible method for demonstrating changes in bone metabolism. The aim of this study is to evaluate the effectiveness of this method within the treatment of long bone non-union with intramedullary reaming, a well-established non-union treatment concept. Materials and methods: Three groups were added to this study: group one (G1) suffered from long bone non-unions, treated successfully with intramedullary reaming; group two (G2) consisted of long bone fractures with proper fracture healing; and group three (G3) included long bone fractures resulting in non-unions. We took blood samples on day 2, and after week 1, 4, 6, month 3 and 6 after initial treatment. Clinical and radiological follow-up were provided for 6 months. We measured transforming growth factor ß-1 (TGFß-1), platelet-derived growth factor (PDGF-AB), and insulin like growth factor-1 (IGF-1) at all-time points. Results: TGF-ß1 levels in G1 and G2 increased from day 2 to 6 weeks after surgery. In general, G1 and G2 showed parallel TGF-ß1 expression patterns, and G3 had a significant peak during first week compared to G1 ( p = 0.023). PDGF peaked in G3 during first week after treatment, whereas G1 had its maximum after 4 weeks and G2 after 6 weeks. We were able to detect a significantly lower PDGF concentration at 3 months in G1 compared to G3 ( p = 0.029). IGF-1 showed a peak concentration in G1 during the first 4 weeks. Afterwards, concentration levels in both G1 and G2 were higher. Conclusions: Our study was able to show that the cytokine expression pattern in physiological bone healing is similar to that in successful non-union treatment with intramedullary reaming. Our results show that the effect of non-union therapy could be observed objectively by measuring cytokine expression patterns in peripheral blood even in a small group of patients. [ABSTRACT FROM AUTHOR]

Purpose: Several radiographic carpal alignment indices are used to evaluate the deformities of scaphoid fractures. The purpose of this study was to determine the reliabilities and validities of radiographic carpal alignment indices commonly used to evaluate deformities of scaphoid fractures. Methods: Thirty-six patients with a scaphoid fracture were evaluated. Five carpal alignment indices were assessed on lateral plain radiographs, namely, scapholunate angle, radioscaphoid angle, radiolunate angle, radiocapitate angle, and capitolunate angle. Three examiners measured these radiographic indices at two sessions, and intraobserver and interobserver reliabilities were determined and expressed as intraclass correlation coefficients. Discriminant validities of radiographic carpal alignment indicies between injured and uninjured wrists were evaluated. For convergent validity testing, the correlation between the radiographic carpal alignment indices and intrascaphoid angles (ISAs) or height-to-length (HL) ratios on CT longitudinal scans was assessed. Further, carpal alignment indices after surgical reconstruction were compared to the Mayo wrist score. Results: Scapholunate and radiolunate angles had the highest reliabilities, and radiocapitate angle had the lowest. Radiolunate angle had the highest discriminant validity followed by scapholunate, and capitolunate angles. In convergent validity testing, scapholunate angles and radiolunate angles correlated with ISA angles, and radiolunate and capitolunate angles correlated with HL ratios. Only the radiolunate angles correlated with the Mayo wrist scores. Conclusions: Among radiographic carpal alignment measures, radiolunate angle is the most reliable and valid carpal alignment index for evaluating deformities of scaphoid fractures. Scapholunate and capitolunate angles could be used as an alternative, but have less validity. [ABSTRACT FROM AUTHOR]

Background: The treatment of large posttraumatic tibial bone defects using the Ilizarov method was shown to be successful in several studies. These studies, however, typically focus on the radiological and functional outcome using objective parameters only. The aim of the present study was therefore to assess the objective and subjective outcome of a consecutive series of patients with large posttraumatic tibial bone defects using the Ilizarov method. Additionally, it was our goal to assess the physical and mental stress for the patients and their relatives during the long treatment period and the general health status at final follow-up. Methods: A consecutive series of 15 patients with posttraumatic tibial bone defects of >30 mm after sustaining open tibial fractures and failure of internal fixation was included. The objective outcome was assessed at final follow-up using Paley's criteria. For the assessment of the subjective outcome, all patients were asked to evaluate their satisfaction with the function of the lower leg, the cosmetic appearance and overall outcome as well. The physical and mental stress of the treatment for the patients and the nearest relative of patients were assessed at the time of frame removal using a custom-made questionnaire. The SF-36 was used to evaluate the general health status at final follow-up. Results: Solid bone union with stable soft tissue coverage and eradication of infection was achieved in all patients despite a high complication rate. The functional outcome at final follow-up was excellent or good in all patients. The patients' satisfaction with the overall outcome and the function of the lower extremity was high as well. The fear of amputation and complications was the major subjective burden for both the patients and their relatives. The long external fixation time is another relevant issue. Conclusion: The Ilizarov method is a safe option for the treatment of large posttraumatic tibial bone defects after failure of internal fixation despite the high complication rate. It is essential to comment this to the patients and their relatives prior to the application of the frame increase their compliance with the long and emotionally draining treatment. The Ilizarov method is worth the effort only in patients, who will presumably comply with this treatment option and all of its drawbacks. [ABSTRACT FROM AUTHOR]

Introduction: Bone and cartilage deficits in the posterior acetabular wall are severe complications resulting from the unsuccessful management or delayed treatment of acetabular fracture. This potentially disastrous condition cannot be treated reliably with the use of reconstruction plates and screws alone. Therefore, this technical report describes a modified anatomical reconstruction method that uses a structural iliac crest autograft and an acetabular tridimensional memory alloy fixation system (ATMFS) to treat late-stage deficits in the posterior wall of the acetabulum. This paper also describes a clinical study of 22 patients with an average of 6.3 years follow-up to evaluate the clinical outcomes of this method. Methods: Twenty-two patients, who had an acetabular reconstruction between January 2000 and December 2011 that used a structured free iliac crest autograft to treat late-stage bone and cartilage deficits in the posterior acetabular wall were followed annually with clinical and radiographic evaluations. The average age of the patients was 36.4 years at the time of the procedure, and the average time of follow-up was 6.3 years. Results: None of the patients in this study lost reduction after surgery, and there were no cases of implant failure. Radiographic analysis using Matta's X-ray evaluation criteria were excellent in eleven cases, good in eight, and fair on three. The Merle D'Aubigné and Postel clinical outcomes at the final follow-up were as follows: seven cases were excellent, ten cases were good, three cases were fair and two cases were poor. Conclusions: The use of a modified iliac crest grafting and ATMFS fixation, as a biological method to reconstruct the acetabulum anatomically may offer better congruence of the joint surface and may ensure good hip joint stability during early postoperative exercise. The medium to long-term results of this method are encouraging. [ABSTRACT FROM AUTHOR]

Background: Proximal femur fractures carry significant levels of morbidity and mortality. Surgical delay is one factor that adversely affects outcome in these patients. In 2010, hospital-income from patients with proximal femur fractures was linked to the surgery being undertaken within 36 h of admission. Can we deliver this target? Materials and methods: Data from the 2009 National Hip Fracture Database was interrogated and appropriate patients were identified. Patient records were reviewed to identify the reasons for surgical delay. Mortality rates were compared within 36 h and after. Results: Five-hundred and thirty-two patients were admitted in 2009, 118 (22 %) of them were delayed more than 36 h. Surgery was delayed for a variety of identified reasons. Median time to surgery was 24 h (1-273). Ninety-day mortality for patients treated within 36 h was 12.4 %, but 25 % ( P = 0.047) in patients delayed for medical problems. Conclusions: Not all patients with a fracture of the proximal femur can have surgery within 36 h of their injury. However, we have identified and describe four specific areas that could increase the number of patients who meet this target. [ABSTRACT FROM AUTHOR]

We report the 18-year follow-up of a patient who underwent rotationplasty for severe bone loss and infection after an grade IIIC open fracture of the distal femur. The patient is now 49 years old and fully satisfied with his life. During the follow-up period, he has never had significant physical or psychological problems directly concerning the rotationplasty. The analysis of quality of life using the SF36 questionnaire revealed even higher scores than the normal healthy population in seven out of eight sub-categories. Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg. The active extension/flexion of the prosthetic knee was 0°-0°-100° and 10°-0°-70° of the ankle joint. Manual testing of motor strength revealed grade five of five for dorsiflexion and plantar flexion of the ankle. Gait patterns including climbing slopes and stairs were close to normal. Examination in sports physiology showed lower maximum power of hip and knee muscles compared to the healthy side, but better muscular endurance. These findings emphasize that rotationplasty can be a good alternative to arthrodesis or amputation in trauma patients providing high satisfaction and activity levels in the long-term follow-up. [ABSTRACT FROM AUTHOR]

The increased concentration of platelets within platelet-rich plasma (PRP) provides a vehicle to deliver supra-physiologic concentrations of growth factors to an injury site, possibly accelerating or otherwise improving connective tissue regeneration. This potential benefit has led to the application of PRP in several applications; however, inconsistent results have limited widespread adoption in bone healing. This review provides a core understanding of the bone healing mechanisms, and corresponds this to the factors present in PRP. In addition, the current state of the art of PRP preparation, the key aspects that may influence its effectiveness, and treatment outcomes as they relate specifically to bone defect healing are presented. Although PRP does have a sound scientific basis, its use for bone healing appears only beneficial when used in combination with osteoconductive scaffolds; however, neither allograft nor autograft appear to be appropriate carriers. Aggressive processing techniques and very high concentrations of PRP may not improve healing outcomes. Moreover, many other variables exist in PRP preparation and use that influence its efficacy; the effect of these variables should be understood when considering PRP use. This review includes the essentials of what has been established, what is currently missing in the literature, and recommendations for future directions. [ABSTRACT FROM AUTHOR]

Background: Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures. Methods: The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion. Results: A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion ( p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion. Conclusions: Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion. [ABSTRACT FROM AUTHOR]

Background: Fractures of the distal radius represent the most common fractures in adults. Volar locked plating has become a popular method for treating these fractures, but has been subject to several shortcomings in osteoporotic bone, such as loss of reduction and screw purchase. In order to overcome these shortcomings, cement augmentation has been proposed. Methods: AO-type 23-A3.3 fractures were made in 8 pairs of fresh frozen osteoporotic cadaveric radial bones. All specimens were treated with volar plating, and divided into cement augmentation or non-augmentation groups ( n = 8/group). Constructs were tested dynamically and load to failure, construct-stiffness, fracture gap movement and screw cutting distance were measured. Results: Cement augmentation resulted in a significant increase in cycles and load to failure, as well as construct stiffness at loads higher than 325 N. When compared to the non-augmented group, fracture gap movement decreased significantly at this load and higher, as did screw cutting distance at the holes of the ulnar column. The cycles to failure depend on the BMD in the distal region of the radius. Conclusion: Cement augmentation improves biomechanical properties in volar plating of the distal radius. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the incidence, amount, morphology and clinical significance of bone tunnel widening (TW) at a mean 5-year period after anterior cruciate ligament reconstruction (ACLR) with a transtibial drilling technique. Methods: Fifty-nine patients undergoing primary ACLR using quadrupled hamstring autografts, biodegradable transfemoral pins for femoral-sided and 2-mm oversized interference screws for tibial-sided graft fixation were followed up at a mean 61 months postoperatively. Patients were examined clinically and by MRI. Tunnel cross-sectional areas (CSA) were related to drill diameters, which were significantly correlated with radiographic tunnel sizes. Tunnel morphologies were assessed and their positions determined using an anatomical coordinate system. Results: CSA had more than doubled in all segments measured ( p < 0.0001) except at the femoral notch level. Greatest CSA increases were found at the femoral graft suspension point (122 %) and at the central tibial tunnel segment (134 %). 54 (92) and 56 (95 %) patients had significant TW, i.e., CSA increase of more than 50 %, in at least one tunnel segment femorally and tibially. Four different tunnel morphologies were observed, of which the linear type was most often encountered on either side. Mean side-to-side difference in anterior-posterior laxity was 1.0 ± 1.4 mm, while Lysholm, IKDC and Tegner acitivity scores were 90 ± 12, 84 ± 15 and 4 (1-9); clinical outcomes were not found to be correlated with tunnel sizes and morphologies as were tunnel positions and tunnel sizes. Conclusions: This study demonstrates that considerable TW occurs in virtually all patients in the mid term after ACLR using a transtibial drilling technique with 'high' femoral tunnel positions. Yet, neither amount nor morphology or tunnel position does affect knee stability or function. [ABSTRACT FROM AUTHOR]

Objective: Intramedullary nailing is widely used in the treatment of long bone fractures. But some patients suffer from nonunion after receiving intramedullary nailing. This paper investigates the methods and effects of locking compression plate (LCP) in the treatment of long bone nonunion after intramedullary nailing. Methods: A total of 6 patients (4 males, 2 females) with long bone nonunion were enrolled. All these patients had previously undergone intramedullary nailing for fractures of long bones (4 femurs, 2 tibiae). The average time from injury to LCP treatment was 12.2 months. The locking compression plate was applied over the intramedullary nail, and unicortical purchase achieved with locking head screws due to underlying nails. Autologous bone grafting was done in all cases. Results: Six patients were followed up for 12-20 months (mean 14.2 months). X-ray imaging showed bone callus at the broken ends of the fracture at 3-7 (mean 4.5) months after surgery. All patients did not have any complications such as infection, breaking or loosening of the LCPs. Conclusion: LCP can be used for the treatment of long bone nonunion after intramedullary nailing for its convenience, minimal invasion and curative effect. [ABSTRACT FROM AUTHOR]

Introduction: Patients with pyogenic lumbar spondylodiscitis can be successfully treated by non-operative methods. However, the typical operation for this condition includes debridement of the infected site, bone grafting and internal fixation to stabilize the spine. Single-stage anterior debridement and fusion with autografting and internal fixation of one spinal segment were performed on nine patients with pyogenic lumbar spondylodiscitis. This operative procedure is rarely documented for pyogenic lumbar spondylodiscitis. Aim: To evaluate the safety and effectiveness of single-stage anterior debridement, autografting and internal fixation of one spinal segment for pyogenic lumbar spondylodiscitis. Results: At the final follow-up, seven out of the nine patients were pain free. Two patients had mild, intermittent back pain (Visual Analogue Scale rating of 1-2), which represented an improvement from their preoperative pain. All nine patients had no clinical, laboratory or radiological evidence of recurrence of infection. Moreover, all the patients showed solid bony fusion. Conclusion: Based on the limited population studied, it suggested that this technique may be a safe and effective operative procedure for appropriate pyogenic lumbar spondylodiscitis in patients. [ABSTRACT FROM AUTHOR]

Background: LCP-DF (locking compression plate-distal femur) has been introduced as an anatomically pre-shaped plate that does not require further contouring. However, the LCP-DF was developed based on skeletal measurements in Caucasians. It is unknown whether the LCP-DF fits Asians. Objective: The purpose of this study was to assess the conformity of the LCP-DF in Asian adult femurs and also to determine the matching pattern of this anatomically pre-shaped LCP-DF in normal Asian adult femurs and the clinical implications of the matching pattern. Methods: Sixty adult cadaver femurs were obtained from 41 male and 19 female cadavers with an average age of 63 years (31-95). An 11-hole LCP-DF was applied to the lateral surface of the distal femur according to the contour. Any mismatches between the bone and the plate were recorded. Then the distance from the inner surface of the plate to the cortex was measured at the sites of mismatch. C-arm AP image of the distal femur was taken and the angle between the distal most locking screw and the joint line was measured, and it was named as joint screw angle (JSA). Results: Mismatch was found at the level of proximal 4-5 holes of the plate with an average distance of 11.36 mm (range 0-32 mm) at the tip of the plate. Otherwise, the overall conformity of the LCP-DF was good. The average JSA was 2.15 ± 1.78° (ranged from 0° to 5°). Conclusion: A rather consistent pattern of mismatch was found at the proximal part of the 11-hole LCP-DF. An attempt to fit the plate to the bone at this level may cause valgus malalignment at the fracture site. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to evaluate the clinical and radiological results of internal fixation of patella fractures, comparing tension band wiring techniques with proximal only and proximally and distally bend Kirschner wires (K-wires). Methods: Over a period of 6 years, 60 patients met the criteria to be included in this study of which 40 were available for mid-term (2-8 years) clinical and radiological follow-up. Results: Out of 60, 9 failures of fixation occurred, 3 due to migration of the K-wires and 6 because of insufficient tensioning of the tension band. Failure due to migration, only occurred in the group with the proximally bend only K-wire technique. Conclusion: Our recommendation is to distally bend the K-wires as well as proximally to prevent migration of K-wires. [ABSTRACT FROM AUTHOR]

Introduction: Approximately 10-15% of all fractures of long bones heal with delay, prolonged immobilization and repetitive operative interventions. Despite intense investigations, the pathomechanism of impaired healing of skeletal tissue remains unclear. An important role in the pathomechanism of mal-union of close fractures plays subclinically proceeding infections. Aim: The question arises whether colonization and proliferation of bacteria in the fracture gap could be related to the mutation of genes for factors regulating local antimicrobial response, such as pathogen recognizing receptors (PRR), cytokines and chemokines. Methods: We carried out studies in patients with delayed long bone fractures estimating the frequency of mutation of genes crucial for pathogen recognition (TLR2, TLR4 and CD14), and elimination (CRP, IL-6, IL-1ra), as well as wound healing (TGF-β). The molecular milieu regulating healing process (IGF-1, COLL1a, TGF-β, BMP-2, and PDGF) was validated by Western blot analysis of the gap tissue. Results: Microbiological investigations showed the presence of viable bacterial strains in 34 out of 108 gaps in patients with non-healing fractures (31.5%) and in 20 out of 122 patients with uneventful healing (16.4%) ( P < 0.05). The occurrence of mutated TLR4 1/W but not 2/W gene was significantly higher ( P < 0.05) in the non-healing infected than sterile group. In the non-healing infected group 1/W mutated gene frequency was also higher than in healing infected. In the TGF-β codon 10 a significantly higher frequency of mutated homozygote T and heterozygote C/T in the non-healing infected versus non-healing sterile subgroup was observed ( P < 0.05). Similar difference was observed in the non-healing infected versus healing infected subgroup ( P < 0.05). The CRP (G1059C), IL1ra (genotype 2/2), IL-6 (G176C), CD14 (G-159T), TLR2 (G2259A) and TLR4/2 (Thr399Ile) polymorphisms did not play evident role in the delay of fracture healing. Conclusions: Individuals bearing the mutant TLR 4 gene 1/W (Asp299Gly) and TGF-β gene codon 10 mutant T and T/C allele may predispose to impaired pathogen recognition and elimination, leading to prolonged pathogen existence in the fracture gaps and healing delays. [ABSTRACT FROM AUTHOR]

Introduction: Based on the considerable experience for management of combined bone and composite soft-tissue defects in the limbs by free vascularized fibula or osteocutaneous fibular flap grafting, the authors present the effective alternative for management of the severe comminuted tibial shaft fractures in one-stage reconstructive technique. Method: Twenty-six patients were male and 12 were female, and their mean age was 32 years (range 15-57 years). Ten tibial shaft fractures were closed and 28 were open. Based on the AO classification, there were 12 group C1 fractures and 24 group C3 fractures according to the fracture pattern and degree of comminution. Results: With the exception of eight cases that were delayed for 3-5 days for primary treatment in another hospital, 30 cases were treated on an emergency basis within an average of 12 h since the initial injury (range 6-22). Normal healing occurred in 31 fractures with a mean healing time of 21 weeks (range 18-24 weeks). Delayed union in 7 with a mean of 32 weeks (range 28-41 weeks), and there were no nonunion and infections. The vascularized fibula allows for fast bone fusion. In this context, the grafted fibula segment appeared to be a valuable reconstructive tool that offered good fracture stabilization and vascularised bone graft. Conclusion: The attached fibular flap can also provide a large piece of mobile skin to cover the soft-tissue defect in grade III open-tibial fractures. It demonstrates that this early free vascularized fibula graft is a useful and effective option for treating the severe comminuted tibial shaft fractures. [ABSTRACT FROM AUTHOR]

Fracture stabilization and reduction using temporary plates during intramedullary tibial nailing was introduced as a novel concept in fracture surgery by Benirschke et al. (Orthop Trans 18:1055–1056, ). The concept of temporary reduction using one-third tubular plates proved useful in aiding metaphyseal and periarticular fracture fixation also. However, planning the strategic location of final plate was the main limitation with this technique using one-third tubular plates. We used 2.0 mini plates as provisional reduction plates that solved the issue of planning and placement of plates. The main advantage of our technique is that the final definitive plate can be applied directly over the mini plates. Here, we will describe our technique using relevant fracture case in metaphyseal–periarticular location. [ABSTRACT FROM AUTHOR]

Background: Femoral fractures in polio survivors present unique challenges; the bone is often small, deformed, osteoporotic and hypovascularized. Locked compression plating aided in achieving a better construct stability of osteoporotic fractures. Methods: A total of 13 unilateral femoral fractures in adult polio patients were fixed with locked compression plating in a prospective study. Mean age was 49.8 years (range 34–62). In 6 cases, the small size of the bone matched only narrow plates, and in 6 cases the plate was contoured to fit the cortex. Average follow-up period was 18.4 months (range 12–24). Results: Radiological evidence of union was apparent in 12 cases after 12–20 weeks (mean 16.3). One case was considered ununited after 28 weeks and progressed to union with bone grafting after another 12 weeks. At the end of the follow-up period, 12 patients returned to their prefracture Vignos disability scale, only the case that experienced nonunion showed functional deterioration. Conclusion: The locked compression plate withstood fixing femoral fractures in polio patients, addressing the challenges of a smaller, osteoporotic, less vascularized and sometimes deformed femur. [ABSTRACT FROM AUTHOR]

Objective: To compare the results of two-staged open reduction and internal fixation (ORIF) and limited internal fixation with external fixator (LIFEF) for closed tibial plafond fractures. Methods: From January 2005 to June 2007, 56 patients with closed type B3 or C Pilon fractures were randomly allocated into groups I and II. Two-staged ORIF was performed in group I and LIFEF in group II. The outcome measures included bone union, nonunion, malunion, pin-tract infection, wound infection, osteomyelitis, ankle joint function, etc. These postoperative data were analyzed with Statistical Package for Social Sciences (SPSS) 13.0. Results: Incidence of superficial soft tissue infection (involved in wound infection or pin-tract infection) in group I was lower than that in group II ( P < 0.05), with significant difference. Group I has significantly less radiation exposure ( P < 0.001). Group II had higher rates of malunion, delayed union, and arthritis symptoms, with no statistical significance. Both groups resulted similar ankle joint function. Logistic regression analysis indicated that smoking and fracture pattern were the two factors significantly influencing the final outcomes. Conclusions: In the treatment of closed tibial plafond fractures, both two-staged ORIF and LIFEF offer similar results. Patients undergo LIFEF carry significantly greater radiation exposure and higher superficial soft tissue infection rate (usually occurs on pin tract and does not affect the final outcomes). [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the correlation between clinical, radiological and histopathological signs of scaphoid non-unions (SNU) with regard to the age of the fracture, primarily because this is relevant for therapy and compensation claims. Materials and methods: Thirty-eight patients with SNU underwent clinical and radiological examination of the wrist prior to surgery. Preoperative X-rays of the wrist were analysed using the scores of Herbert and Fisher, Filan and Herbert, Trojan and Jahna, Gupta as well as scaphoid non-union advanced collapse. Sclerotic bone of the SNU was resected during surgery. Resected material was evaluated histologically after staining with hematoxylin–eosin and periodic acid-Schiff reaction. Radiological and histological examinations were performed by independent investigators in a blinded fashion. Results: The preoperative range of motion of the injured compared to the contralateral wrist was significantly reduced for the dorsi- and palmar flexion and for the radial and ulnar deviation; however, this reduction was not time dependent. There was no significant correlation between the radiological results and the age of the SNU, while fibrous tissue or fibrocartilage in the fracture gap was present in all cases. Significantly less fibrous or fibrocartilage bone cysts ( p = 0.041) and bone remodelling ( p = 0.031) were seen in older SNU (at 45 months). Definitive sclerotic bone covering of the fracture edges was significantly more common in older SNU ( p = 0.035). Conclusion: Radiological and most of the conventional histological findings do not correlate with time after initial injury. [ABSTRACT FROM AUTHOR]

The application of interference screws for the fixation of bone-patellar tendon-bone (BPTB) grafts is a well-established technique in anterior-cruciate ligament reconstruction. Interference screws derived from bovine compact bone are a biological alternative to metallic or biodegradable polymer interference screws. In 60 porcine specimens, the tibial part of an anterior-cruciate ligament reconstruction was performed using a BPTB graft. To secure the graft, either an 8-mm titanium interference screw or a self-made bovine interference screw (BC), or a commercial bovine compact bone screw (Tutofix®) was used. The maximum failure load was determined by means of a universal testing machine with computer interface at a testing speed of 50 mm/min. In a second test series, cyclic sub-maximal load was applied to the test specimen from 40 to 400 N with a number of 1,000 load cycles and a frequency of 1 Hz. Subsequently, the maximum failure load was determined. The stiffness of the test specimen was investigated in both test series. Each type of interference screw was tested 10 times. A secure fixation of the grafts was achieved with all interference screws. In the experiments on the maximum load to failures, the titanium screws showed significantly higher failure loads than the Tutofix® screws ( P = 0.005). The stiffness of the grafts fixed with BC screws was significantly higher as compared to the fixation with Tutofix® screws ( P = 0.005). After cyclic sub-maximal loading, the maximum failure load of the titanium screws was significantly higher than that of the Tutofix® screws ( P = 0.033). The fixation of the BC screws showed a significantly higher failure load ( P = 0.021) and stiffness ( P = 0.032) than the Tutofix® screw fixation. Except for two screw head fractures and two intra-tendinous graft ruptures, the failure mode was slippage in the interface between interference screw and bone plug. Interference screws derived from bovine compact bone show similar good results as the titanium interference screws. Therefore, the safety and in vivo performance of products derived from xenogenic bone should be the focus of further investigations. [ABSTRACT FROM AUTHOR]

There are no reported series that specifically deal with repair of infected nonunions of the diaphysis of the forearm bones. We sought to determine whether a standardized treatment protocol we have utilized for 15 patients from 1989 to 2005 results in a high union rate, resolution of infection, and a good functional outcome. The study cohort included nine male and six female patients who presented to a University hospital setting with an infected nonunion of the diaphysis of the radius or ulna. Every patient had a minimum of 2-year follow-up. The average patient age was 45 years (range 17–79). Eight of the patients had fractures involving their dominant arm. Thirteen patients had initially fractured both the radius and ulna, but two of these patients had subsequently healed one of the bones. One patient had an isolated radius fractures, and one patient fractured the ulna alone. All patients underwent a protocol that combines aggressive surgical debridements as necessary, definitive fixation after 7–14 days, tricortical iliac crest bone grafting for segmental defects, leaving wounds open to heal by secondary intention, 6 weeks of culture-specific intravenous antibiotics, and early active range of motion (ROM) exercises. We sought to report our success rate of nonunion repair, number of re-interventions, complication rate, final ROM, and the ability to eradicate the infection using this treatment regimen. At most recent follow-up (average 5 years, range 2–15 years), all patients had united and resolved their infections. One case was considered a failure, although he did go on to unite a one-bone forearm and was free of infection at most recent follow-up. All but three patients, including the one failure, had at least 50° of supination/pronation and 30–130° of flexion/extension arc. Excluding the one failure that united his one-bone forearm at 46 months, the average time to union was 13.2 weeks (range 10–15 weeks). The results of this study indicate that our standard protocol for treatment of infected nonunion of the shafts of the radius and ulna is reliable at obtaining fracture union with a good functional result, while also resolving the infection. [ABSTRACT FROM AUTHOR]

Minimal invasive technique along with the widespread use of the new pre contoured locking plates (LCP PLT, LISS PLT) has given rise many alignment related problems in fractures of proximal tibia. A significant implant related problem with the use of pre contoured locking plate in proximal tibia fractures is the hardware irritation of the subcutaneous tissue by upper end of plate. This is caused by the large profile of the implant which sits off the bone at the proximal end. A general recommendation made by some is to try and reduce the bone and plate together with the help of pelvic reduction clamps. We have identified this as a source of error in our practice which has a potential to introduce malalignment in tibia, most often discovered post operatively. Here we will describe with relevant cases, the pitfall in the recommended technique and steps to be taken to avoid this error. [ABSTRACT FROM AUTHOR]

The purpose of the present study is to evaluate the results of the treatment of intra-articular fractures with the volar 2.4 mm LCP with regard to loss of reduction, clinical outcome and complications. Patients treated with a volar 2.4 mm LCP following a complex intra-articular distal radius fracture were assessed by clinical and radiological examination of both wrists, the Disability of Arm, Shoulder and Hand (DASH) outcome instrument, Martini score and the pain Visual Analogue Scale score. Forty patients (40 fractures: 5 type C1, 11 type C2, and 24 type C3 according to AO/OTA classification) were followed at a mean 18 months from the injury. Of the initial 40 fractures, 4 fractures required surgical revision (1 because of loss of reduction, 2 due to fracture incongruity as seen on the postoperative computer tomogram and 1 case of screw displacement in the radial shaft). Radiographs in the immediate postoperative period showed a radial inclination of 22.1°, volar tilt of 7.2°, and ulnar deviation of 0.2 mm (means). At follow-up examination, radial inclination was 23.8°, volar tilt was 6.2° and ulnar deviation was 0.9 mm (means). Average final wrist range of motion was significantly ( p < 0.05) decreased in comparison to contralateral wrist. Average DASH and Martini scores were 18 and 27, respectively, with no significant differences between C1-, C2- and C3-type fractures. Patients who underwent a surgical revision had poorer Martini score. Complications were an EPL tendon rupture, a tendon irritation and a complex regional pain syndrome in a patient who underwent revision. The treatment of complex intra-articular distal radius fractures with the volar 2.4 mm LCP provides sufficient fixation to prevent clinically significant loss of articular reduction, acceptable patient outcomes and minimal soft tissue complications. [ABSTRACT FROM AUTHOR]

This single centre retrospective study reviews the outcomes of 30 war-injured patients with established infected tibial nonunion after sustaining grade IIIB open fractures. Patients were treated by radical bony and soft-tissue resection and bone transport using the Ilizarov bifocal technique, without the use of systemic antibiotics or bone grafting. The series comprised 29 males and 1 female with a mean age of 30.4 years and a mean nonunion of 8.6 months at index operation. Patients had previously undergone a mean of 1.3 operations (range 1–3), and the mean size of tibial defect was 6.9 cm (range 4–11 cm) post radical debridement. Bony union was achieved at the tibial docking sites after a mean of 4.5 months in 29 patients (97%) and frames were worn for a mean of 9.7 months (range 7.2–15 months), giving a mean fixation index of 1.48 months/cm. One patient failed to unite at their tibial docking site. Soft-tissue transport successfully closed the soft-tissue defects in all but four patients, who required split-skin grafting. According to the Paley scoring system 19 patients had excellent bony results, 10 good and 1 poor; the functional results were excellent in 13 patients, good in 14, fair in 2 and poor in 1; and there were 1.4 complications per patient. Over a mean follow-up of 99 months no patient refractured their reconstruction, developed any symptoms or signs of recurrent infection, or required amputation. The Ilizarov technique with bone transport continues to be the most versatile, adaptive and effective method of treatment in these complex cases, and can very successfully deal with the associated large soft-tissue and bony defects without the use of routine bone-grafting, systemic antibiotics or soft-tissue flaps. [ABSTRACT FROM AUTHOR]

Fractures are a common problem for patients with spinal muscular atrophy (SMA). A total of 131 patients with proximal SMA with an average age of 13.2 ± 9.2 years (0.7–65.6) were evaluated retrospectively. In 60 patients 94 different fractures were observed. The group consisted of 11 patients with type Ib, 81 with type II, 33 with type IIIa, 4 with IIIb and 2 with type IV. 38 of 81 SMA II patients and 17 of 33 SMA IIIa patients had suffered fractures at an average age of 8.3 ± 5.3 years (0.0–25.1) (SMA II) and 9.3 ± 6.0 years (0.0–22.1) (SMA IIIa). The most frequent fractures were of the femur (50), usually distal, of the lower leg and ankle (15), and upper arm (9). The distribution of fractures was different in SMA II and SMA IIIa. Most of the fractures could be treated conservatively. Only two femoral shaft fractures, one upper arm and a lower arm fracture were treated surgically by osteosynthesis. Competent fracture treatment is an important part of the orthopaedic care of SMA patients. [ABSTRACT FROM AUTHOR]

In orthopaedic surgery, small bicortical circular bone defects are often produced as a result of internal fixation of fractures. The aim of this study was to determine the amount of torsional strength reduction in animal bone with a bicortical bone defect and how much residual strength remains if the bicortical bone defect was occluded. Forty pig femurs were divided into four groups. Group 1 femurs were left intact. Group 2 femurs were given a 4 mm bicortical bone defect. Group 3 were prepared as in Group 2, but occluded with a 4.5 mm cortical screw. Group 4 were prepared as in Group 2, but occluded with plaster of paris. Measurements including the length of the bone, working length of the bone, mid-diaphyseal diameter and cortical thickness were recorded. All specimens were tested until failure under torsional loading. Peak torque at failure and angular deformation were recorded. One-way analysis of variance was used to test the sample groups, with a value of P < 0.05 considered to be statistically significant. When compared with Group 1, all of the other groups showed a reduction in peak torque at failure point. Only the difference in peak torque between Groups 1 and 2 was statistically significant ( P = 0.007). Group 2 showed the most reduction with 23.11% reduction in peak torque and 38.19% reduction in total energy absorption. No significant difference was found comparing the bone length, bone diameter and the cortical thickness. The presence of the defect remains the major contributing factor in long bone strength reduction. It has been shown that a 10% bicortical defect was sufficient to produce a reduction in peak torque and energy absorption under torsional loading. By occluding this defect using a screw or plaster of paris, an improvement in bone strength was achieved. These results may translate clinically to an increased vulnerability to functional loads immediately following screw removal and prior to the residual screw holes healing. [ABSTRACT FROM AUTHOR]

Intertrochanteric fractures of femur are common in elderly patients. The compression hip screw has become the predominant method for osteosynthesis of intertrochanteric fractures. However, the conventional dynamic hip screws (CDHS) technique has some disadvantages. Recently, we have used a minimally invasive dynamic hip screws (MIDHS) technique to reduce these disadvantages. This prospective study is to compare curative effect of MIDHS with that of CDHS with open reduction on Evans type 1 intertrochanteric fractures. All 97 fractures were classified according to the Evans systems. The MIDHS group included 47 patients with an average age of 68.7 years, and the CDHS group included 50 patients with an average age of 68.7 years. The Singh index was used as a measure of osteoporosis. Both groups were similar in injury mechanism, fracture types, mean Singh index and medical diseases (all P > 0.50). All fractures were healed within 4 months in both groups except three cases who were implant failure and nonunion in the CDHS group. The MIDHS group had significantly smaller wound size, shorter surgery time, less blood loss, lower blood transfusion rate, earlier active mobilization of fractured hip joint, shorter hospital stay, lower serious complication rate and higher Harris hip score than the CDHS group (all P < 0.05). The satisfactory reduction, adequate screw position, healing time and union rate was not significantly difference between two groups (all P > 0.05). When the fractures are treated adequately, either the MIDHS or the CDHS with open reduction is an effective and safe method, but the MIDHS is superior to the CDHS with open reduction for the treatment of Evans type 1 intertrochanteric fractures of femur. [ABSTRACT FROM AUTHOR]

Isolated lateral malleolar fractures usually result from a supination-external rotation (SER) injury and may include a deltoid ligament rupture. The necessity of operative treatment is based on the recognition of a relevant medial soft-tissue disruption. Currently used tests to assess ankle stability include manual stress radiographs and gravity stress radiographs, but seem to overestimate the need for fracture fixation. We investigated the use of weightbearing radiographs to distinguish stable and unstable isolated lateral malleolar fractures induced by the SER mechanism in 57 patients. Patients with stable fractures (SER type II according to the Lauge-Hansen classification) were treated non-operatively with varying external support. Forty-seven patients were evaluated by questionnaire and AOFAS ankle-hindfoot score. Follow-up was 18–120 months (mean 62). Fifty-one of fifty-seven (90%) patients were found to have stable fractures (SER type II) and were treated non-operatively. The AOFAS score was 96.1 points on average (range 85–100) at latest follow-up. Four patients reported minor complaints. A “moderate” correlation of risk factors (i.e. smoking) to delayed bone healing was found while the correlation of varying external support (i.e. bandage, cast) to the AOFAS score and delayed bone healing was “poor”. The use of weightbearing radiographs is an easy, pain-free, safe and reliable method to exclude the need for operative treatment, with excellent clinical outcome in the majority of the patients seen at latest follow-up. The delay of 3–10 days until the decision about surgical treatment is well accepted by the patients. [ABSTRACT FROM AUTHOR]

The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization. Special attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score. There were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points. All fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15° angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement. Early physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus. [ABSTRACT FROM AUTHOR]

It is our goal to present an alternative, less invasive surgical technique for corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails (ESIN) and to present our results in a consecutive patients series. Between January 2003 and December 2006, five patients aged between 23 and 44 years presented with a symptomatic malunion after nonoperative treatment of displaced midshaft clavicular fractures. Corrective osteotomy was performed without bone grafting. The osteotomy sites united in all patients after a mean of 4.4 months. The nails were removed in all patients after 7 months. At final follow-up, DASH and Constant Scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with cosmetical appearance and overall outcome. Clavicular shortening was also significantly improved. Elastic stable intramedullary nailing leads to favourable results in corrective osteotomy of malunited midshaft clavicular fractures. We therefore recommend this technique for corrective osteotomy of symptomatic midshaft clavicular malunions. [ABSTRACT FROM AUTHOR]

Antegrade nailing allows a stable fixation and, thus, an early functional after treatment in proximal humerus fractures. Since the surgical procedure in antegrade humeral nailing requires a split of the supraspinatus tendon, the question arises whether the surgical approach causes microcirculatory dysfunction of the tendon. A total of 15 consecutive patients suffering from proximal humerus fractures were enrolled. During the implantation of an antegrade humerus nail, microvascular perfusion of the supraspinatus tendon was directly visualized after the exposition and stabilization of the fracture using the OPS-imaging technique. Immediately after exposure, the nutritive perfusion showed physiological values of tendon microcirculation. After implanting antegrade humeral nails, the perfusion of the supraspinatus tendon reduced markedly. Capillary width was unaffected by the surgical procedure. The trauma leading to proximal humerus fracture causes no fundamental impairment of nutritive perfusion of the rotator cuff. Whereas the implantation of an antegrade humerus nail, which necessarily includes a splitting of the rotator cuff, nearly halves the functional capillary density of the supraspinatus tendon. Even though this effect seems to be reversible, the surgical dissection of the supraspinatus tendon should be performed in a soft tissue sparing way. [ABSTRACT FROM AUTHOR]

The aim was to evaluate if concomitant injury to the rotator cuff is important for functional outcome in proximal humerus fractures, and to relate loss of function to malunion of the fractures. A total of 76 patients treated conservatively for proximal humerus fracture were included in this cohort study. Performing an MRI examination at the time of injury and after 12 months, tears of the rotator cuffs were classified as partial- or full thickness. The fractures were classified, according to the AO classification, and the degree of tubercle displacement and humeral head inclination evaluated at 12 months. Constant score was used as outcome measure. Magnetic resonance imaging (MRI) examinations confirmed 22 rotator cuff tears (four full thicknesses) diagnosed at the time of injury, and 10 additional tears (three full thicknesses) at one year. Functional loss at one year significantly corresponded to the tears at the time of injury ( P = 0.004), varus malunion of the head and displacement of tubercles ( P < 0.001). Partial- as well as full thickness tears of the rotator cuff are important for functional outcome. Skeletal deterioration seems even more important. [ABSTRACT FROM AUTHOR]