Bridging Callus Formation Research Articles

Percutaneous injection of autologous platelet gel accelerate healing in diabetic tibial non union: On going longitudinal study

IntroductionIn this study the tibial shaft fracture non unions in diabetes mellitus are evaluated with percutaneous autologous platelet gel supplementation to accelerate union are compared with individually matched control group with autologous iliac crest bone marrow aspirate injection. Material and methodsThis present study was carried out on tibial non unions in diabetic patients recruited in an ongoing longitudinal study over a period of 2006 to 2017, treated by one surgeon at one institute, are included in this report. Each of 18 established tibial atrophic, aseptic non unions treated by percutaneous autologous platelets and iliac crest bone marrow aspirate were followed up on regular basis up till 9 months. The healing of non union was assessed clinically by painless full weight bearing and the radiological union was judged by bridging callus formation observed on at least 3 of 4 cortices in anteroposterior and lateral views. ResultsUnion was observed in 17 (94.4 %) patients of the autologous platelet group. The average time to union was 9.2 weeks (range 8 to 18 weeks) after percutaneous autologous platelet injection (P < 0.0517) .In the control group, union was observed in 14 (77.8 %) patients (P = 0.672). The average time to union following percutaneous bone marrow injection was 11.6 weeks (range 9 to 28 weeks). The proximal 1/3 shaft non union healed comparatively faster than the distal 1/3 shaft tibia (P ≤ 0.0612). No correlation was observed between the comminuted and non comminuted fracture non union (P = 0.789). A significant correlation was noted as regards the non union healing time duration in patients who were on insulin and oral hypoglycemic drugs (P ≤ 0.001) and also about the total duration of diabetes mellitus in years (P ≤ 0.003). ConclusionThis investigation showed that percutaneous autologous platelet gel delivery is sufficient method to obtain union in diabetic tibial fracture non unions, which is less invasive procedure than bone marrow injection. The efficacy of this autologous platelets is once again well established and this study reinforced categorically the previously published report by the author.

Acetabular Distraction: Promising 5-Year Outcomes for the Treatment of Chronic Pelvic Discontinuity

BackgroundSevere acetabular bone loss encountered during revision total hip arthroplasty (THA) poses a clinical challenge. In cases involving pelvic discontinuity, where the ilium is separated superiorly from the inferior ischiopubic segment through the acetabulum, acetabular distraction may be used to restore the biomechanics of the hemipelvis. This technique allows for correct sizing of the acetabulum, and the subsequent peripheral distraction and medial compression at the discontinuity provide initial mechanical stability and biological fixation as bone in growth occurs. Accordingly, this study aimed to assess long-term 5-year outcomes following acetabular distraction across 2 institutions. MethodsWe retrospectively identified all patients who underwent revision THA in which the acetabular distraction technique was performed for the treatment of chronic pelvic discontinuity between 2002 and 2018. Demographic, operative, and clinical postoperative data were collected. Clinical endpoints included postoperative radiographic outcomes, complications requiring additional surgery, and reoperation for all causes. Only patients who had a minimum 5-year follow-up were included in this study. ResultsA total of 15 patients (Paprosky IIC: one patient, 6.7%; Paprosky IIIA: 5 patients, 33.3%; Paprosky IIIB: 9 patients, 60%) who had a mean follow-up time of 9 years (range, 5.1 to 13.5) were analyzed. Porous tantalum augments were used in 11 (73.3%) cases to primarily address posteriorsuperior defects (100%). There were 4 (26.7%) patients that required reoperation, only 2 of which were for indications related to the acetabular construct, leading to an overall survivorship of 86.7%. Both patients had a prior revision THA before the implementation of the distraction technique. Evidence of bridging callus formation was reported radiographically for 14 (93.3%) patients at the time of the last clinical follow-up. ConclusionsFor patients who have chronic pelvic discontinuity, acetabular distraction shows promising long-term outcomes. Even so, larger multi-center studies are needed to better support the efficacy of this technique. Level of EvidenceLevel III, retrospective comparative study.

In vitro and in vivo assessment of decellularized platelet-rich fibrin-loaded strontium doped porous magnesium phosphate scaffolds in bone regeneration

The present work reports the effect of decellularized platelet-rich fibrin (dPRF) loaded strontium (Sr) doped porous magnesium phosphate (MgP) bioceramics on biocompatibility, biodegradability, and bone regeneration. Sustained release of growth factors from dPRF is a major objective here, which conformed to the availability of dPRF on the scaffold surface even after 7 days of in vitro degradation. dPRF-incorporated MgP scaffolds were implanted in the rabbit femoral bone defect and bone rejuvenation was confirmed by radiological examination, histological examination, fluorochrome labeling study, and micro-CT. μ-CT examination of the regained bone samples exhibited that invasion of mature bone in the pores of the MgP2Sr-dPRF sample was higher than the MgP2Sr which indicated better bone maturation capability of this composition. Quantifiable assessment using oxytetracycline labeling showed 73.55 ± 1.12% new osseous tissue regeneration for MgP2Sr-dPRF samples in contrast to 65.47 ± 1.16% for pure MgP2Sr samples, after 3 months of implantation. Histological analysis depicted the presence of abundant osteoblastic and osteoclastic cells in dPRF-loaded Sr-doped MgP samples as compared to other samples. Radiological studies also mimicked similar results in the MgP2Sr-dPRF group with intact periosteal lining and significant bridging callus formation. The present results indicated that dPRF-loaded Sr-doped magnesium phosphate bioceramics have good biocompatibility, bone-forming ability, and suitable biodegradability in bone regeneration.

Short term outcomes and complications of distal ulnar ostectomy in 23 juvenile dogs with carpal valgus secondary to discordant radial-ulnar physeal growth.

ObjectiveThe goal of this study was to report short term clinical and radiographic outcomes after distal ulnar ostectomy in dogs with carpal valgus due to discordant radial-ulnar growth.Study designRetrospective case study.Sample groupClient owned dogs under 1 year of age with carpal valgus and open distal radial physes pre-operatively.MethodsMedical records from four veterinary referral centers were searched from January 1, 2015 to January 1, 2022 for juvenile dogs that had been treated with distal ulnar ostectomy for carpal valgus due to premature closure of the distal ulnar physis. Patients were excluded if they were skeletally mature at the time of ostectomy; medical records were incomplete; radial physis was closed at surgery; or definitive corrective osteotomy was performed. Radiographs were evaluated pre-operatively and for short term follow up at ~8 weeks. Complications and short term clinical outcomes were evaluated also.Results31 limbs from 23 dogs were evaluated. Patients ranged from 4 to 10.8 months of age. All dogs presented for visible carpal valgus and varying degrees of thoracic limb lameness. Sixty-four percent of patients showed resolution of lameness while an additional 13% showed an improvement in clinical lameness without complete resolution. Complications were seen in 32% of patients with 70% percent of those being minor, bandage related complications. Radiographically, 38% of limbs showed bridging callus formation of the ostectomy at an average of 7.5 weeks post operatively and 75% percent of patients with elbow incongruity improved radiographically. There was no significant difference in radial joint angles pre-operatively and at the time of follow up.ConclusionDistal ulnar ostectomy ameliorates lameness in juvenile dogs with premature distal ulnar physeal closure and shows lack of progression of distal carpal valgus deformity, but does not improve joint angulation.Clinical significanceDistal ulnar ostectomy is associated with mild bandage-related complications and halting of progressive limb deformity within the time frame evaluated, and should therefore be considered a treatment for premature closure of the distal ulnar physis. It does not lead to deformity correction at 8 weeks following surgery but is associated with improved elbow congruity.

High Rate of Radiographic Union at the Fibular Osteotomy Site With No Complications After an Acute Oblique Osteotomy and Ligation Procedure to Shorten the Fibula in High Tibial Osteotomy.

Background:A fibular shortening osteotomy is needed to perform lateral closing-wedge high tibial osteotomy (LCW-HTO). To achieve this shortening, we have recently developed an acute oblique osteotomy and ligation (AO/L) procedure for the center of the fibular shaft, based on the AO procedure.Purpose:To compare the 2-year follow-up outcomes between the AO/L procedure and the AO procedure.Study Design:Cohort study; Level of evidence, 2.Methods:A prospective comparative cohort study was conducted involving 83 patients (83 knees) who underwent shortening osteotomy of the fibula in LCW-HTO between April 2017 and March 2019. The first consecutive 41 knees (AO group) underwent fibular osteotomy with the AO procedure. The remaining 42 knees (AO/L group) underwent fibular osteotomy with the AO/L procedure. All of the patients were evaluated for at least 2 years postoperatively via clinical and radiological assessments. To determine the time needed for complete union at the osteotomy site, we evaluated the radiographs using a radiographic union score for tibial fractures, which was modified for fibular osteotomy. Comparison of outcomes between the 2 groups was performed using the Student t test for continuous variables and the Mann-Whitney U test or Fisher exact test for discrete variables.Results:Around the fibular osteotomy site, no perioperative complications were found in either group. The radiographic union score was significantly higher in the AO/L group than in the AO group (P < .0001 at 2, 3, and 6 months; P = .0290 at 12 and 24 months). The union rate at the fibular osteotomy site was significantly higher in the AO/L group (97.6%) than in the AO group (82.9%) at 12 months (P = .0290).Conclusion:The AO/L procedure significantly accelerated the formation of bridging callus at the fibular osteotomy site and provided a significantly higher union rate compared with the AO procedure. Both AO/L and AO procedures were free from perioperative complications. These results suggest that the AO/L procedure is clinically useful as an osteotomy procedure to shorten the fibula in LCW-HTO.

Minimal invasive plating osteosynthesis (MIPO) for distal femur fractures functional outcome.

Objective: To determine the functional outcome of minimally invasive plating osteosynthesis (MIPO) for distal femur fractures. Study Design: Description Study. Setting: Orthopedic Department of Allied Hospital, Faisalabad. Period: August 2020 to February 2021. Material &amp; Methods: 115 patients of both gender with age ranging from 18 to 50 years and having lower 1/3 femur shaft fractures. Patients having nerve, vascular injury and opened fracture were excluded. All patients were treated with minimally invasive plating osteosynthesis (MIPO). Criteria for bone union was bridging callus formation across the fracture site in antero-posterior and lateral knees x-rays without evidence of loosening breakage and migration of the implants with painless weight bearing on that lower limb. IKDC score at 12 weeks after the procedure was used to assess the functional &amp; clinical outcome. Results: These were excellent function result seen in 65 (56.51%) patients, good in 32 (27.83%), fair in 11 (9.57%) and poor out come in 07 (6.09%). 105 (91.30%) patients with distal 1/3 femur shaft fracture had achieved the union. Conclusion: Our study concluded minimally invasive plating osteosynthesis (MIPO) is an excellent method for the treatment of distal femoral shaft fractures.

A prospective study on the role of limb reconstruction System in infective non-union of femur and tibia

Introduction: Infected non-union of long bones is the state of failure of union and the persistence of infection at the fracture site for a period of 6 to 8 months or more. This condition possesses a challenge for optimal treatment to the orthopaedic surgeon. Limb reconstruction system (LRS) is a single bar device with telescoping facility which allows increased axial movement at the fracture site by permitting conversion from rigid to dynamic fixation resulting in formation of external bridging callus. The regenerated bone restores length and eliminates infection. This procedure does not require much expertise of the treating orthopaedic surgeon and is associated with high patient compliance.Materials and Methods: 20 adult patients with infective non-union of femur and tibia were admitted in Silchar Medical College and Hospital, Silchar between September 2019 to August 2020 after being diagnosed clinically and radiologically as infective non-union. Preoperative radiographs were taken to assess the type of non-union, presence of infection, implants, quality of bone stock and level of non-union. Patients were classified according to the classification by Rosen et al. in the A.O. manual into quiescent, active and draining types. Follow up was done every 4 weeks and Association for the Study and Application of Methods of Ilizarov (ASAMI) score was used to categorize the outcome into excellent, good, fair and poor.Results: It was observed that 90% patients showed excellent to good functional as well as bone healing outcomes.Discussion: Results of mean bony transport, mean implant index and outcomes are comparable to previous studies conducted.Conclusion: LRS application to infective non-union of long bones is a cost-effective procedure which favours both the surgeon and patient as compared to other available treatment modalities.

Scattering and clustering the proximal screw construct in unilateral locking plate osteosynthesis of distal femoral fractures.

The importance of fixation construct in locking compression plate (LCP) is not well enlightened until recently. The aim of this study was to investigate radiological and clinical outcomes of scattering and clustering of the proximal screw fixation construct in unilateral LCP treatment of the distal femoral fractures. Patients who were treated for distal femoral fractures using unilateral LCP between January 2014 and December 2019 in our institute were included in this retrospective study. They were divided into groups 1 (35 cases, scattered proximal screw fixation) and 2 (35 cases, clustered proximal screw fixation). Mean follow-up period was 23.6months for group 1 and 21.3months for group 2. Medical history, patient demographics, injury characteristics, and surgical characteristics were reviewed and analyzed. Radiological findings including time to callus formation, bridging callus formation, union, and symmetry of the union were assessed and compared between the groups. Clinical outcomes included total blood loss during the operation, postoperative range of motion, and number of revision surgery. The time for callus formation (5.8weeks in group 1 vs. 4.1weeks in group 2, p = 0.009) and bridging callus formation (12.5weeks in group 1 vs. 10.7weeks in group 2, p = 0.009) was significantly earlier in group 2. Despite similar union rates between groups, the mean time for radiological union was longer in group 2 (10.7 vs 7.4months, p = 0.001). Though statistically insignificant, more asymmetric union was observed in group 2 (17 vs 11 cases). Despite a delay in initial callus and bridging callus formation, scattering the proximal screws was better in achieving earlier and more balanced radiographic union than the clustered fixation. We recommend to avoid bridging more than five holes in the whole plate fixation construct to lessen the asymmetric callus formation and to prevent eventual plate breakage.

Development of a tibial experimental non-union model in rats

BackgroundMany non-union animal models have been developed to explore the problems surrounding fracture healing. However, the existing models are not perfect and cannot satisfy all non-union studies. This study aimed to make a non-union model of the tibia in rats by cauterization of the posterior of 2 mm on both sides of the fracture end after open osteotomy of the tibia and fixing the fractured tibia with a Kirschner wire 0.8 mm in diameter.MethodsFor this study, 96 female adult Sprague-Dawley (SD) rats were used. The rats underwent surgery to produce a tibial open fracture and were fixed with a 0.8-mm diameter Kirschner wire. In 48 of the rats, the periosteum proximal and distal to the fracture end was cauterized.ResultsAt 2, 4, 6, and 8 weeks after surgery, radiological and histological analysis showed typical physiological healing in the control group, and the healing rate was 100% at 6 weeks. But the non-union group was characterized by resorption of the fracture ends with few callus formations and no bridging callus formation, and the healing rate was 0% at 8 weeks.ConclusionsThis method represents a reproducible model to create atrophic non-unions. This model provides a new option for studying the basic healing mechanisms and evaluating new therapies for bone regeneration and treatment of non-unions.

Elastic intramedullary nailing in the management of forearm fractures in children: A clinical study

Introduction: Forearm fractures are the most prevalent in childhood and adolescence and correspond to between 30% and 50% of all lesions that affect the immature skeleton. Successful treatment of fracture shafts of Radius and Ulna must aim at restoring full function of pronation and supination without which full use of hand is not possible. With conservative treatment, there are increased chances of redisplacement leading to high rates of failure. Intramedullary fixation is an attractive option because of short operative time, excellent cosmesis, minimal soft-tissue dissection, ease of hardware removal and early motion. Materials and Methods: This was a prospective study of 32 children of forearm fractures treated by elastic intramedullary nailing and their outcome. The study was conducted in the Department of Orthopaedics, Hindu Rao Hospital, Delhi in between March 2015 to April 2016. Forearm fractures of all children admitted through Emergency Department and Out Patient Department were included in the study. Their functional results were analysed using Price et al criteria. Results: Majority of patients were males accounting to 78.12% (n=25). Male to Female ratio was 3.6:1. Mean age of patients was 9.4 years with standard deviation (S.D) of 1.9. Fall during play accounted to majority of the cases (81.25%, n=26). Majority of the patients in this study had fractures on the left side accounting to 62.5% (n=20). Left: Right ratio was 5:3. Majority of the patients in this study had fracture both bone forearm (22A3) accounting for 53.12% (n=17). In majority of the patients, intra-operative reduction was achieved by closed means (87.5% n=28), while open reduction was required in (12.5% n= 4). Conclusion: Closed intramedullary fixation is a biological method of fixation with less damage to the muscles and the periosteum, the fracture hematoma is intact, thus leading to early bridging callus formation. The undisturbed surrounding muscles and soft tissues help in spontane

How do pilon fractures heal? An analysis of dual plating and bridging callus formation

Objectives1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation. DesignRetrospective comparative study. SettingSingle level one trauma center. PatientsFifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation. InterventionInternal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation. Main Outcome MeasurementsModified RUST (mRUST) scores at three and six months and reoperation rate. ResultsAt six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates. ConclusionsPilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable. Level of EvidenceThree

Vigorous Endosteal Reaming across Fracture Site to Aid Union in Atypical Femur Fractures

Background: Bisphosphonate abuse is associated with atypical femur fractures, which despite different fixation methods have increased non-union, delayed union, and re-operation rates. Therefore, there is a need for a surgical technique that may enhance union in such cases. Herein we are introducing a novel technique of sequential multiple vigorous reaming across the fracture site to introduce reaming debris/endosteal bone graft around the fracture site. Materials and Methods: We present a retrospective analysis of five prospectively treated patients with atypical diaphyseal femur fracture who presented to us from January 2015 to August 2019. All the patients were followed up at regular intervals and assessed both clinically and radiologically. Results: All 5 cases operated with our technique showed union at a mean follow-up of 16 weeks (12 - 20 weeks). There were no complications reported in our study at the last mean follow-up of 25 months (12 - 51 months). Conclusion: This technique of multiple vigorous reaming at and around the fracture site provides a new paradigm in the management of AFF. The autograft around the outer cortex promotes the formation of bridging callus and results in the early union.

Experimental study of the time effect of controlled micromovement on the influence of the fracture healing

Objective To explore the influence and mechanism of time effect of the controlled micromovement on fracture healing. Methods Forty-eight rabbit models of femoral fracture were prepared and fixed with unilateral two-bar external fixator. They were randomly divided into four groups: continuing immobilization group, instant micromovement group, 1-week micromovement group and 2-week micromovement group. Postoperative radiographs were taken at 1, 2, 3 and 5 weeks to observe callus growth. The maximum load, deflection and rigidity of callus at fracture end were measured 5 weeks after operation. At 1, 2 and 3 weeks after operation, the histological morphology of callus was observed, and the expression and distribution of osteocalcin (oc) in callus were detected. Results At 5 weeks after operation, the X-ray scores of fracture line in 1-week micromovement group and 2-week micromovement group were 10.384±0.744 mm, 10.412±0.482 mm, significantly higher than those in continuing immobilization group (7.518±0.536). The anteroposterior diameter and the exterior and interior diameter of the external callus in 1-week micromovement group and 2-week micromovement group were 14.3±3.2 mm, 14.0±2.8 mm and 14.6±2.1 mm, 15.2±3.1 mm, which were smaller than those in the continuing immobilization group 15.3±2.3 mm and 16.7±1.9 mm, but there was no significant difference. The bone mineral density value and proportion rate in the fracture site were 0.446±0.020 g/cm2, 0.416±0.021 g/cm2 and 1.171%±0.056%, 1.143%±0.040% in 1-week micromovement group and 2-week micromovement group, which were significantly higher than those in continuing immobilization group which were 0.376±0.022 g/cm2 and 0.912%±0.051%. The maximum load of callus in 1-week micromovement group and 2-week micromovement group was 415.6±27.2 N, 400.3±28.5 N, which was significantly higher than that in continuing immobilization group 329.2±18.4 N and instant micromovement group 272.8±22.7 N. There was no difference of the deflection of callus between groups. The rigidity of callus in 1-week micromovement group was 590.4±24.2 N/mm, which was significantly higher than that in other groups; the rigidity of callus in the 2-week micromovement group was 540.6±22.8 N/mm, which was significantly higher than those in the instant micromovement group and the continuing immobilization group (152.4±21.7 N/mm, 174.8±20.6 N/mm). Conclusion Micromovement begins from one or two weeks can significantly raise external callus formation and vagueness level of fracture line, accelerating bridging callus formation, and can significantly raise bone mineral density and rigidity of callus. It also accelerates the maturity, hypertrophy and mineralization of chondrocyte, resulting in the stimulation of the fracture healing through endochondral ossification; it seemingly can improve the amount and density of osteoclasts in callus to stimulate the maturity and mineralization of chondrocyte. The strengthening coupling of osteoblasts and osteoclasts can promote the transformation from soft callus to hard callus and the remolding of hard callus. Key words: Fractures, bone; Fracture healing; External fixators

Effectiveness of the Dynamic Internal Fixator System in Metaphyseal and Epiphyseal Femoral Fractures: 10 Years of Experience and Future Expectations.

Angular stability plates are largely used for treating complex fractures, but the incidence of nonunion is high. The innovative dynamic internal fixator (DIF) system is comprised of a plate with angular stability that combines the principles of internal fixator with dynamic device. In this study, we evaluate the feasibility of surgical reconstruction using the DIF in adult patients with epiphyseal-metaphyseal femur fractures and examine complications and outcomes at long-term follow-up. We retrospectively analyze 26 patients (14 females and 12 males), with a mean age of 64 yr, who were treated for femoral fractures between 2008 and 2017. Primary fractures were stratified according to the Muller AO Classification of fractures (mostly types 33-A3 and 31-A3). One patient was treated for a periprosthetic fracture and another for the early breakage of a conventional plate. Mean overall follow-up was 4.3 yr. Fracture healing with complete bony consolidation was achieved in 25 of 26 patients (96%). Two patients experienced complete union after revision surgery. The mean time to bridging callus formation was 58 d (range, 41 d to 4 mo) and to radiographic union was 4.6 mo (range, 1.2 to 12.5 mo). Dynamization of the system was performed in 16 cases. The following major complications occurred in 15% of cases: wound dehiscence (1), nonunion (2), and deep infection (1). No implant breakdowns were observed. The DIF system merged the advantages of angular stability plates with the possibility of dynamization, increasing fracture site compression to modulate and guarantee the healing process.

PDGF-BB Induces Formation of Bridging Callus After Reconstructive Surgery of Large Bone Defect

Background:Reconstructive surgery by using allografts often conducted to manage large bone defects, either due to traumatic or non-traumatic causes. However, poor vascularization of the graft bed is still problematic. To overcome this, bone tissue engineering method has been developed that uses growth factor as an angiogenic stimulator, such as platelet derived growth factor BB (PDGF BB).Objective:This study aimed to evaluate the administration of recombinant rat Platelet Derived Growth Factor BB (rrPDGF BB) on bone healing process, showed by formation of bridging callus, Vascular Endothelial Growth Factor (VEGF), Bone Morphogenetic Protein-2 (BMP-2) and osteocalcin inmassivefresh frozen allograft post reconstructive surgery.Methods:This was a Post Test Only Control Group Design study involved 32 Wistar rats divided into two groups,i.e.treatment group (defect on right femoral bone and received fresh frozen allograft with the addition of rrPDGF BB) and control group (without addition of rrPDGF BB). Expression of VEGF, BMP-2 and osteocalcin was identified through immunohistochemistry.Results:A significantly higher expression of VEGF, BMP-2 and osteocalcin was observed in the treatment group as compared to the control group (p&lt; 0.05). The presence of bridging callus on the fresh frozen allograft also showed to be significant (p= 0.003). Path analysis showed formation of bridging callus after administration of PDGF on allograft occur through three pathways, in which VEGF holds the most important role.Conclusion:The application of rrPDGF BB significantly enhances the formation of new bone through increased expression of VEGF, BMP-2 and osteocalcin.

Functional outcome of treatment of paediatric diaphysial femur fractures operated using titanium elastic nailing

Objectives: to review the experience of clinical recovery in treatment of pediatric shaft femur fracture with titanium elastic nailing. Observation: common type of fracture were transverse (41.5%) and spiral (39%) fracture. And at 12 weeks only 2 (4.9%) patients had the significant tenderness, 4 (9.8%) of patients had limb length discrepancy of 1 to 2 cms, and 41 (100%) radiological union was seen in (100%) patients. The final outcome according to Flynn’s criteria shows that excellent outcome seen in 35 (85.3%) of patients, while 4 (9.8%) patients showed satisfactory outcome. Conclusion: Titanium elastic nail seems advantageous over other surgical methods particularly in this age group because it is simple, is a load shearing device, internal splint that doesn’t violate open physis, allows early mobilization and maintains alignment. Micromotion conferred by the elasticity of the fixation promotes faster external bridging callus formation. The periostium is not disturbed and being a closed procedure there is no disturbance of fracture hematoma, thereby less risk of infection.

Giant cell tumor of the thoracic spine completely removed by total spondylectomy after neoadjuvant denosumab therapy

Denosumab, a novel monoclonal antibody that targets the receptor activator of nuclear factor-κB (RANK) ligand (RANKL), has recently been used to treat patients with giant cell tumor of bone (GCTB). However, few reports have described the clinical results of denosumab therapy for spinal GCTB and evaluated treatment efficacy with respect to the entirety of the resected vertebra after denosumab therapy. We present the case of a 51-year-old man with T12 GCTB that was completely removed by a total spondylectomy following 10 courses of neoadjuvant denosumab therapy. Post-therapy radiological findings indicated epidural tumor reduction in the spinal canal and sclerotic rim formation. However, the affected vertebra collapsed despite denosumab therapy and a massive bridging callus formation was present between the spinal GCTB and adjacent vertebra. These morphological changes made the tumor margins unclear and increased the difficulty of dissection of the segmental arteries from the vertebral body and en bloc corpectomy by a posterior-approach. Pathological findings indicated increased woven bone at the peripheral lesion of the resected vertebra and RANKL-positive stromal cells remained around the woven bone. These findings support that GCTB stromal cells survived around the newly formed woven bone after long-term denosumab treatment and total surgical resection of such primary spinal lesions as the gold-standard treatment, even following administration of denosumab. Surgeons should note that prolonged adjuvant denosumab therapy may increase the difficulty of performing a posterior-approach total en bloc spondylectomy.

III–2 Porosis on the Side Treated With Low-Intensity Pulsed Ultrasound (LIPUS) After Intramedullary Nailing of Femoral Shaft Fractures

Objective: We previously reported that low-intensity pulsed ultrasound (LIPUS) treatment after intramedullary nailing of femoral shaft fractures effectively promotes early bone healing. In this study, we examined whether porosis occurs on the side treated with LIPUS by prospectively comparing the treatment and non-treatment groups. Methods: After we performed intramedullary nailing in 17 patients (12 men and 5 women) with AO type A femoral shaft fracture, the patients were divided into the LIPUS treatment group (n = 8) and non-treatment group (n = 9) for examination. Using front and side postoperative plain radiography, we examined whether porosis occurred significantly on the treated side by evaluating the appearance order of anterior, posterior, lateral, and medial calluses and days required for bridging callus formation. Results: In the treatment group, the mean appearance order of the anterior callus was 1.5 months, earlier than those of the posterior and medial calluses (3.5 and 2.9, respectively), whereas the order of the lateral callus was 2.2, earlier than that of posterior callus (P < 0.05). Meanwhile, no significant differences were observed in the appearance orders of the calluses in the non-treatment group. When the 2 groups were compared, only the appearance order of the anterior callus was earlier in the treatment group (1.5 vs. 2.7; P = 0.02). The days required for bridging callus formation was shorter in the anterior side (44 days in average) than in the posterior side (93 days in average) only in the treatment group (P = 0.02). When the 2 groups were compared, the bridging callus of the only anterior side was formed earlier (P = 0.03) in the treatment group (44 vs. 78 days). Conclusions: Induction of porosis occurred from the anterior and lateral sides, which were treated with LIPUS after intramedullary nailing of the femoral shaft fractures.

Osteogenic Matrix Cell Sheets Facilitate Osteogenesis in Irradiated Rat Bone.

Reconstruction of large bone defects after resection of malignant musculoskeletal tumors is a significant challenge in orthopedic surgery. Extracorporeal autogenous irradiated bone grafting is a treatment option for bone reconstruction. However, nonunion often occurs because the osteogenic capacity is lost by irradiation. In the present study, we established an autogenous irradiated bone graft model in the rat femur to assess whether osteogenic matrix cell sheets improve osteogenesis of the irradiated bone. Osteogenic matrix cell sheets were prepared from bone marrow-derived stromal cells and co-transplanted with irradiated bone. X-ray images at 4 weeks after transplantation showed bridging callus formation around the irradiated bone. Micro-computed tomography images at 12 weeks postoperatively showed abundant callus formation in the whole circumference of the irradiated bone. Histology showed bone union between the irradiated bone and host femur. Mechanical testing showed that the failure force at the irradiated bone site was significantly higher than in the control group. Our study indicates that osteogenic matrix cell sheet transplantation might be a powerful method to facilitate osteogenesis in irradiated bones, which may become a treatment option for reconstruction of bone defects after resection of malignant musculoskeletal tumors.

The effects of an injury to the brain on bone healing and callus formation in young adults with fractures of the femoral shaft

In patients with traumatic brain injury and fractures of long bones, it is often clinically observed that the rate of bone healing and extent of callus formation are increased. However, the evidence has been unconvincing and an association between such an injury and enhanced fracture healing remains unclear. We performed a retrospective cohort study of 74 young adult patients with a mean age of 24.2 years (16 to 40) who sustained a femoral shaft fracture (AO/OTA type 32A or 32B) with or without a brain injury. All the fractures were treated with closed intramedullary nailing. The main outcome measures included the time required for bridging callus formation (BCF) and the mean callus thickness (MCT) at the final follow-up. Comparative analyses were made between the 20 patients with a brain injury and the 54 without brain injury. Subgroup comparisons were performed among the patients with a brain injury in terms of the severity of head injury, the types of intracranial haemorrhage and gender. Patients with a brain injury had an earlier appearance of BCF (p < 0.001) and a greater final MCT value (p < 0.001) than those without. There were no significant differences with respect to the time required for BCF and final MCT values in terms of the severity of head injury (p = 0.521 and p = 0.153, respectively), the types of intracranial haemorrhage (p = 0.308 and p = 0.189, respectively) and gender (p = 0.383 and p = 0.662, respectively). These results confirm that an injury to the brain may be associated with accelerated fracture healing and enhanced callus formation. However, the severity of the injury to the brain, the type of intracranial haemorrhage and gender were not statistically significant factors in predicting the rate of bone healing and extent of final callus formation.