Fracture Consolidation Research Articles

Bone Immobilization devices and consolidation mechanisms: Impact on healing time

The human skeleton is formed by living tissues that react to loads and ensures the support of the remaining tissues of human body like muscles, ligaments, tendons, etc. However, its integrity can be compromised due to fractures or injuries of the bone tissue that require orthopedic surgery and immobilization methods, such as external fixators, intramedullary nail or osteosynthesis plates.One of the most important characteristics of living tissue is its capacity of self-regeneration. It is a complex process that implies several mechanisms during the consolidation time. Therefore, the knowledge of the involved mechanisms and their interdependence on external factors, will allow accelerating the regeneration process and contributing to the success of the rehabilitation process.Several techniques have been developed to characterizing characterize the mechanical loads acting in fractured bone to better understand the fracture consolidation and obtain useful information for the orthopedic doctors. This information is relevant to enable each patient follow-up and optimize the clinic procedures. As such, it is important to understand what happens during fracture consolidation to predict the necessary structural immobilization time and mechanical stimulus which shorten the healing process.The purpose of this work is twofold: primarily, to study the consolidation process using different immobilization systems, and secondarily, to explore the necessary time for bone consolidation by recording the relevant mechanical parameters time story.

RISK FACTORS OF FRACTURE NONUNION IN POLYTRAUMA

Aim. To carry out literature analysis devoted to pathological mechanisms of delayed union and nonunion of limb fractures and the influence of various osteosynthesis strategies on bone healing in polytrauma. The risk of bone fractures nonunion in polytrauma increases with high-energy complex comminuted and open fractures with severe injuries of soft tissues and bones, bruised lung, shock and severe massive blood loss. The development of a systemic inflammatory response affects local immune responses in the fracture zone to the early inflammatory phase of bone healing and disrupts subsequent osteogenesis and angiogenesis processes. Early stable-functional osteosynthesis using minimally invasive techniques creates optimal conditions for bone healing. When following the tactics of the stepwise treatment of Damage Control Orthopedics, the risk of infectious complications and fracture nonunion increases with the duration of treatment in the apparatus of external fixation. Conclusion. In polytrauma a violation of consolidation of bone fractures of the extremities occurs more often than in isolated trauma. Risk factors of fracture nonunion in polytrauma are the severity of bone and soft tissue damage, shock, acute blood loss and systemic inflammatory response, as well as unjustified delay in the final stable fixation of long bones fragments or using traumatic methods of their early osteosynthesis without taking into account the severity of the condition of the injured.

REVIEW ARTICLE: PERCUTANEOUS PATELLAR OSTEOSYNTHESIS

Background: Open reduction of patella fracture is the currently acceptable method for treating these fractures. In this study describe some minimally invasive techniques have been proposed as possible alternative methods with percutaneous reduction and fixation of patella fractures. The pur­pose of this article was to review percutaneous surgical techniques that preserve the vas­cular supply of patellar fragments, which may improve fracture consolidation, and decrease post operative complications as infection, delayed wound healing, broken wires, irritation, immigration of Kirschner wires, and fixation failure. Conclusion:Percutenous surgical techniques of fixation of patellar fracture offering better functional outcome, short operative time, provide stable fixation, minimal postoperative pain, excellent cosmoses and lower incidence of complications.

Intramedullary nailing in bifocal leg fractures: about 16 cases

Afin d'évaluer la gravité de cette lésion inhabituelle, nous avons mené une étude rétrospective intéressant les fractures bifocales fermées du tibia et nous avons étudié la place de l'enclouage centromédullaire ainsi que les différents moyens thérapeutiques. Seize patients avec fractures bifocales de jambe type 42C2 de l'AO ont été traités dans notre unité de traumatologie Orthopédie A du CHU Hassan II Fès. Il s'agissait de sujets jeunes, victimes de traumatisme de moyen à haute énergie. Cinq patients étaient polytraumatisés et deux poly fracturés. L'enclouage centromédullaire verrouillé avec alésage était utilisé dans six cas et sans alésage dans dix cas. Nous avons déplorés après enclouage deux cas de syndromes de loge. Le délai de consolidation moyen était de douze mois. Deux cas de pseudarthroses ont été repris avec succès par un enclouage avec sur alésage. La fracture bifocale de jambe pose de nombreux défis au chirurgien en raison de l'approvisionnement vasculaire précaire du segment intermédiaire et de la grave détérioration des tissus mous environnants. Elles doivent être individualisées de l'ensemble des fractures de jambe tant par leur contexte de survenue que par les difficultés de fixation et la lenteur de leur consolidation.

Elastic stable intramedullary nailing (ESIN) in the treatment of both-bone forearm fractures in the child: about 87 cases

Le but de notre étude est de décrire les complications de l'embrochage centromédullaire élastique stable (ECMES) dans le traitement des fractures diaphysaires des deux os de l'avant-bras chez l'enfant. Entre janvier 2009 et décembre 2013, 87 enfants présentant des fractures diaphysaires des os de l'avant-bras ont été traités par embrochage centro-médullaire élastique stable par des broches de Métaizeau. Il s'agissait de 76 garçons et 11 filles d'âge moyen 12 ans. L'embrochage a été réalisé d'emblée dans 50 cas et suite à un déplacement secondaire sous plâtre dans les autres. Les deux os ont été embrochés dans tous les cas. L'immobilisation plâtrée était systématique pour tous les malades pendant une durée moyenne d'un mois. Les broches ont été enlevées au bout d'environ 6 mois en moyenne. Les résultats fonctionnels ont été étudiés avec un recul moyen de 10 mois. Les complications ont été marquées par 14 infections superficielles, 2 cas d'ostéites sur matériel, 3 cas de refracture, 3 cas de pseudarthrose, 2 cas de retard de consolidation et une synostose radio-cubitale proximale. Bien que l'embrochage centro-médullaire soit une méthode d'ostéosynthèse idéalement adaptée aux enfants, il reste plus invasif que le traitement orthopédique. Ses indications doivent rester dans les limites de celui ci.

Surgical Treatment of Femoral Neck Fractures with Dynamic Derotation Оsteosynthesis

Fracture of the femoral neck is a common injury of the human skeleton. High rate of postoperative complications induces to the search of optimum osteosynthesis technique. Treatment results for 259 patients (182 females, 77 males, mean age 72 years) with femoral neck fractures were analyzed. In study group (n=114) a dynamic derotation osteosyntesis and in control group (n=145) - DHS, a bundle of V-shaped curved pins, cannulated screws were used. Mathematic modelling of bone-implant system in different variants of derotation fixator screws position under load was performed. Use of dynamic derotation constructions in Garden 1 and Garden 2 femoral neck fractures ensured a consolidation of fractures in all clinical observations, in Garden 3 fractures - in 46.4%. Early dosage weight bearing not exceeding 60% of the body weight did not result in either fragments displacement or raise of the rate of femoral head avascular necrosis development. In patients under 60 years it is preferably to use dynamic derotation constructions with 4 screws placed in the femoral neck.

Reliability of the radiographic union scale in tibial fractures (RUST)

ObjectiveThis study aimed to evaluate the inter- and intra observer reproducibility of the radiographic score of consolidation of the tibia shaft fractures. MethodsFifty-one sets of radiographs in anteroposterior (AP) and profile (P) of the tibial shaft treated with intramedullary nail were obtained. The analysis of X-rays was performed in two stages, with a 21-day interval between assessments by a group of nine evaluators. To evaluate the reproducibility of RUST score between the evaluators, the intra-class correlation coefficient (ICC) with a 95% confidence interval was used. ICC values range from +1, representing perfect agreement, to −1, complete disagreement. ResultsThere was a significant correlation among all evaluators: ICC=0.87 (95% CI 0.81 to 0.91). The intraobserver agreement proved to be substantial with ICC=0.88 (95% CI 0.85 to 0.91). ConclusionThis study confirms that the RUST scale shows a high degree of reliability and agreement.

Surgical Treatment of Femoral Neck Fractures with Dynamic Derotation Оsteosynthesis

Fracture of the femoral neck is a common injury of the human skeleton. High rate of postoperative complications induces to the search of optimum osteosynthesis technique. Treatment results for 259 patients (182 females, 77 males, mean age 72 years) with femoral neck fractures were analyzed. In study group (n=114) a dynamic derotation osteosyntesis and in control group (n=145) - DHS, a bundle of V-shaped curved pins, cannulated screws were used. Mathematic modelling of bone-implant system in different variants of derotation fixator screws position under load was performed. Use of dynamic derotation constructions in Garden 1 and Garden 2 femoral neck fractures ensured a consolidation of fractures in all clinical observations, in Garden 3 fractures - in 46.4%. Early dosage weight bearing not exceeding 60% of the body weight did not result in either fragments displacement or raise of the rate of femoral head avascular necrosis development. In patients under 60 years it is preferably to use dynamic derotation constructions with 4 screws placed in the femoral neck.

The place of platelet rich plasma in traumatic and degenerative diseases of the foot and ankle. Literature review

Platelet rich plasma (PRP) has been used for around ten years in degenerative and traumatic diseases of the locomotor apparatus by sports physicians, rheumatologists, radiologists and orthopaedic surgeons. Indications are currently increasing, unfortunately, however, there is a lack of evidence regarding the efficacy of PRP in these new indications. The aim of this article is to carry out a review of the literature, in order to state the level of evidence for the efficacy of PRP in five major diseases. For this literature review, the Pubmed and ScienceDirect search engines were used. The key words used for the search were [Platelet rich plasma], [Foot], [Ankle]. The articles selected were those that dealt with the benefit of PRP in tibiotalar arthritis, tendinopathies, ruptures of the Achilles tendon, plantar fasciitis and bone consolidation. Series of several cases were excluded. Articles needed to be from before 2010. Fifteen articles met the inclusion criteria. For arthritis of the ankle, the PRP injection was more effective than viscosupplementation or the injection of corticosteroids. The articles validate the data observed for gonarthrosis. For plantar fasciitis, PRP appeared to be as effective as corticosteroid injections. In ruptures of the Achilles tendon: there was no benefit seen for the injection of PRP into the rupture site. For chronic tendinopathy of the Achilles tendon: cases studies showed a benefit in terms of pain and function in the months following the injection. However, the only level 1 study did not find any significant difference compared with the placebo injection. PRP and bone consolidation: the number of articles was small. A single non-randomised study showed a benefit for talotibial arthrodesis. An assessment of the actual benefits of PRP is difficult, due to both the intra- and inter-individual variations of platelet levels. Unlike a pharmacological agent, the concentration of growth factors injected with PRP is not known. Literature regarding tibiotalar arthritis confirms the data for gonarthrosis. PRP is not validated for use in Achilles tendon rupture. In degenerative conditions of the Achilles tendon, studies are not consistent. However, there is considerable bias towards the injection site (intra or around the tendon). There is also bias regarding the “combing” effect linked to the intratendon injection. Regarding bone consolidation, only one series appeared to show a benefit in tibiotalar arthrodesis. The level of evidence regarding the place of PRP in arthrosis of the foot and ankle is equivalent to that for gonarthrosis. Regarding degenerative tendon conditions, the level of evidence is inadequate, with numerous bias and contradictory studies. The place of PRP in the consolidation of fractures and pseudoarthrosis of the foot has not been adequately studied.

Complications of Distal Radius Fractures Treated by Volar Locking Plate Fixation.

The current study investigated the incidence of complications after surgery for distal radial fractures. This multicenter retrospective study was conducted at 11 institutions. A total of 824 patients who had distal radius fractures that were treated surgically between January 2010 and August 2012 were identified. The study patients were older than 18 years and were observed for at least 12 weeks after surgery for distal radius fractures with a volar locking plate. Sex, age, fracture type according to AO classification, implants, wrist range of motion, grip strength, fracture consolidation rate, and complications were studied. Analysis included 694 patients, including 529 women and 165 men, with a mean age of 64 years. The mean follow-up period was 27 weeks. The fracture consolidation rate was 100%. There were 52 complications (7.5%), including 18 cases of carpal tunnel syndrome, 12 cases of peripheral nerve palsy, 8 cases of trigger digit, 4 cases of tendon rupture (none of the flexor pollicis longus), and 10 others. There was no rupture of the flexor pollicis longus tendon because careful attention was paid to the relationship between the implant and the tendon. Peripheral nerve palsy may have been caused by intraoperative traction in 7 cases, temporary fixation by percutaneous Kirschner wires in 3 cases, and axillary nerve block in 1 case; 1 case appeared to be idiopathic. Tendon ruptures were mainly caused by mechanical stress. [Orthopedics.2016; 39(5):e893-e896.].

Reprodutibilidade do escore radiográfico de consolidação das fraturas da tíbia (RUST)

ObjectiveThis study aimed to evaluate the inter‐ and intra observer reproducibility of the radiographic score of consolidation of the tibia shaft fractures. MethodsFifty‐one sets of radiographs in anteroposterior (AP) and profile (P) of the tibial shaft treated with intramedullary nail were obtained. The analysis of X‐rays was performed in two stages, with a 21‐day interval between assessments by a group of nine evaluators. To evaluate the reproducibility of RUST score between the evaluators, the intra‐class correlation coefficient (ICC) with a 95% confidence interval was used. ICC values range from +1, representing perfect agreement, to ‐1, complete disagreement. ResultsThere was a significant correlation among all evaluators: ICC=0.87 (95% CI 0.81 to 0.91). The intraobserver agreement proved to be substantial with ICC=0.88 (95% CI 0.85 to 0.91). ConclusionThis study confirms that the RUST scale shows a high degree of reliability and agreement.

Long endomedullary nail in proximal third humeral shaft fractures

IntroductionProximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new “Long” humeral nail for this type of lesion and identify the best distal locking. Materials and methodsForty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four‐part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. ResultsImprovements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. ConclusionsThe results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. Study designretrospective, cohort of cases. Level of evidenceIV.

A Retrospective Case Series of Carbon Fiber Plate Fixation of Ankle Fractures

Category: Ankle Introduction/Purpose: Ankle fractures encompass 9% of all orthopaedic fractures and when they require surgical fixation can use 1/3 rd tubular plates, locking plates, antiglide plates, lagging screws, intramedullary nails which have been made from various metals most commonly stainless steel or titanium alloys. Carbon fiber implants have been used for a number of years more frequently in the humerus, the femur, and the spine. Our hypothesis is that the carbon fiber plates are just as efficacious in fixing ankle fractures as titanium and stainless steel plates. Methods: This is retrospective study of one surgeon’s ankle fractures which were fixed by ORIF with carbon fiber plates. All patients from Jan 2013-May 2015 who underwent a ankle orif with carbon fiber plate were collected and assessed for time to fracture consolidation, return to function, and complications and these were compared to historical models of fracture fixation with titanium and stainless steel plates. The results were assessed by ANOVA statistical models. Results: We found that the carbon fiber plates are equal in their time to consolidation, wound healing, and return to function, however we found that the carbon fiber plates allow for better fracture site visualization post operatively to determine fracture consolidation Conclusion: The carbon fiber plate is a viable alternative to ankle fracture ORIF especially in patients where close follow up of the fracture site is of benefit.

Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature.

Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes. Level III-systematic review of level III/IV studies.

Factors Affecting the Terms of Fracture Consolidation

Dependence of the consolidation of spiral tibial fracture treated with transosseous osteosynthesis upon the initial transverse fragments dislocation, patient’s age, remoteness of injury, reposition accuracy and fixation stability was analyzed. Priority factors that will allow realizing the maximum potentialities of the technique are determined.

Factors Affecting theTerms of Fracture Consolidation

Dependence of the consolidation of spiral tibial fracture treated with transosseous osteosynthesis upon the initial transverse fragments dislocation, patient’s age, remoteness of injury, reposition accuracy and fixation stability was analyzed. Priority factors that will allow realizing the maximum potentialities of the technique are determined.

A clinical case study of long-term injury of the thoracic and lumbar spine

Overestimation of the efficacy of conservative treatment of spine injuries children often leads to unsatisfactory long-term results. The effective correction of post-traumatic spinal column deformities occurs in patients who undergo the operation in the early post-traumatic period. While choosing treatment strategies for children, higher reparative opportunities, which provide early fracture consolidation, including those in faulty positions, should be considered. This study presents a case of surgical treatment for uncomplicated injury of the thoracic and lumbar spine, with long-term compression fragmental fracture of the L1 vertebra body in a 12-year-old child. Due to the long-standing character of the injury right thoraco-frenotomy was conducted with partial L1 vertebral body and resection of the adjacent discs, deformity correction of the thoracic and lumbar spine with a transpedicular system, and ventral spondylodesis with an autograft. This extensive intervention was justified by the peculiarities in the vertebral body damage and the post-traumatic segmental kyphotic deformity that resulted from delayed medical treatment. An anterior approach was chosen to achieve immobilization at the site of the damage before correction using the transpedicular system. Surgical correction of long-term spinal injuries in children, with the use of a combined approach, is usually laborious and traumatic. The prevention of rigid post-traumatic spine deformities with the help of timely diagnostics and appropriate treatment, including surgery, should be a priority to prevent such cases.

Outcome analysis of intercondylar humerus fractures treated by locking compression plates

Background: Distal humeral fractures are uncommon fractures. They occur in both younger as well as older patients. The complex shape of the elbow joint, the adjacent neurovascular structures, the sparse soft tissue cover combine to make treatment difficult. Previous methods of conservative treatment have caused significant functional impairment. Thus the consensus has shifted towards treatment with open reduction and internal fixation so as to provide stability and early mobilization. Different modalities like 1/3 rd tubular plate, reconstruction plate, K wires, double tension band wiring have been tried. The quality of elbow function following the treatment is related to the degree to which the normal anatomic relationships are restored. Materials and Methods: 27 patients of Intercondylar Humerus fractures classified by Riseborough & Radin system and treated by ORIF by pre-contoured AO Locking compression plates. Clinical and radiological follow-up performed and patients assessed for pain, range of motion, and Mayo elbow performance score. Results: Average follow up was of 6 months. Average age was 37.5 years (18-62 years). Fracture consolidation observed at an average of 12.8 weeks (10-14 weeks). The outcome was excellent or good in 17 patients. 3 patients had infection, 1 case each of ulnar neuropathy, mal-union and myositis ossificans. There were no cases of implant migration, secondary displacement or implant failure. Conclusion: Anatomically pre-shaped distal humerus locking plate system is useful in providing stable fixation for complex distal articular fracture and facilitating early postoperative rehabilitation. The low rate of implant failure in the present study indicates that the technique is promising.

Effectiveness of treatment of transtrochanteric fractures with Dynamic Hip Screws using minimally invasive access

ObjectiveTo analyze the short-term results from treating unstable intertrochanteric fractures with Dynamic Hip Screws (DHS), using a minimally invasive route, focusing on the functional aspects and complication and mortality rates of the method. MethodsThis was a prospective longitudinal study on 140 patients who underwent fixation of transtrochanteric fractures with the DHS system with a lateral minimally invasive access in the hip, between January and December 2013. The patients were evaluated pre and postoperatively (after six months of follow-up) by means of the Parker and Palmer mobility score. Women comprised 65.7% of the sample, and 54.3% of the fractures were on the right side. The patients’ mean age was 80 years, ranging from 60 to 93 years. ResultsWe observed an overall decrease in the mobility score and an increase in the degree of dependence over the short term. However, we encountered only two deaths in the study sample and there were no cases of infection or nonunion. ConclusionDespite the efficacy of the treatment with DHS, with high rates of fracture consolidation and a low mortality rate, we noted that the patients still showed significant functional limitation at the follow-up six months after the operation.

Radial Nerve Palsy after Humeral Fracture: To Explore or Not to Explore? - A Case Report

The incidence of radial nerve injuries varies from 2-17% and humeral fracture is the most common cause in young adults. The treatment of radial nerve damage, especially in cases of fracture, remains a challenge. The authors report a case of radial nerve palsy related to humeral shaft fracture and shall revise the literature about their treatment. Whether fracture or associated radial nerve injury, were treated conservatively, and the patient referred, of course, to Physiatry, to start intensive functional recovery of the affected upper limb. At 5-6 months after fracture, patient maintains radial sensory and motor deficits, and it was proposed surgical exploration of the radial nerve, which was scheduled, because a week before the alleged scheduled surgery, he demonstrated a recovery, and has fully function of the radial nerve after 2 weeks. Humeral shaft fractures are treated mostly conservatively, the radial nerve usually suffers neuropraxia and their function returns spontaneously after fracture healing, as happened in this case. The nerve exploration is reserved for cases in which there is no recovery of nerve function 3-4 months or a little more, after the fracture consolidation. Thus, nerve routine operation would subject many patients to unnecessary complications of surgery.