Fracture Consolidation Research Articles

Periprosthetic fractures: basics, classification and treatment principles

Periprosthetic fractures (PPFx) are becoming an increasingly important topic in orthopedics and trauma surgery due to the rising number of endoprosthetic joint replacements. The recently published unified classification system (UCS) has replaced numerous historical classification systems and can be applied to all PPFx regardless of the bone or joint involved. The treatment of PPFx requires individual therapeutic concepts taking patient-dependent and patient-independent factors into consideration. The conservative treatment of PPFx is only justified in exceptional situations. In contrast, the choice between operative treatment and deciding between osteosynthesis or revision arthroplasty is particularly based on the assessment of the implant stability. In order to achieve fracture consolidation and also a good functional outcome, knowledge of the basic biomechanical principles of operative (osteosynthesis or endoprosthesis) treatment of periprosthetic fractures is necessary.

A choice of surgical approach for osteosynthesis in fractures of the lateral tibial condyle

Intention. To conduct a comparative analysis of the dynamics of the consolidation of intraarticular fractures of the posterolateral parts of the lateral tibial condyle, the anatomical and functional outcomes of surgical treatment of these patients after plate osteosynthesis with traditional anterolateral and posterolateral transfibular surgical approaches as well.Methodology. A comparative prospective study of the effectiveness of osteosynthesis in patients with fractures of the posterolateral part of lateral tibial condyle in two compatible clinical groups was performed in dynamics for periods of 7–10 days, 1, 3, 6 and 9 months after surgery. In the first group (25 patients), bone osteosynthesis was performed from traditional anterolateral approach (TALA), and in the second group (20 patients), from the posterolateral transfibular approach (PLTFA). The average duration of osteosynthesis operations was compared. The displacements of fragments of the articular surface of the lateral tibial condyle, the indices of the KSS and Lysholm scales, the results of measurements of the angle of flexion and valgus stress test of the knee joint were evaluated. Data processing was performed using the Data Analysis and Chart Master modules (Excel), the Basic Statistics / Tables module (Statistic for Windows) as well.Results and Discussion. In the PLTFA group, the average operation time was (81.0 ± 8.5) minutes (from 67 to 96 minutes), in the TALA group, the duration of operations was 35.8 % longer and averaged (110 ± 5.2) minutes (from 82 to 125 minutes) (p < 0.05). The values of the KSS and Lysholm scales in dynamics showed a steady and statistically significant (p < 0.01) increase with increasing time after surgery without significant differences between the groups. The angle of flexion of the knee joint increased more rapidly during the first three months, then the rate decreased from 6 to 9 months (p < 0.05) without significant differences between the groups. The frequency of displacements of fragments of the articular surface in the first group was statistically significantly (p < 0.05) higher than in the second group. Differences in the valgus-stress test indices in both groups reached a maximum after 9 months – 52 and 30 %, respectively.Conclusion. With PLTFA, surgery duration decreases, articular surface fragments are better reduced, and their subsequent displacement at the stages of treatment is less likely; therefore, this approach is preferable for osteosynthesis of fractures of the posterolateral parts of the lateral tibial condyle.

A lean magnesium–zinc–calcium alloy ZX00 used for bone fracture stabilization in a large growing-animal model

Over the last decade, demand has increased for developing new, alternative materials in pediatric trauma care to overcome the disadvantages associated with conventional implant materials. Magnesium (Mg)-based alloys seem to adequately fulfill the vision of a homogeneously resorbable, biocompatible, load-bearing and functionally supportive implant. The aim of the present study is to introduce the high-strength, lean alloy Mg‒0.45Zn‒0.45Ca, in wt% (ZX00), and for the first time investigate the clinical applicability of screw osteosynthesis using this alloy that contains no rare-earth elements. The alloy was applied in a growing sheep model with osteotomized bone (simulating a fracture) and compared to a non-osteotomy control group regarding degradation behavior and fracture healing. The alloy exhibits an ultimate tensile strength of 285.7 ± 3.1 MPa, an elongation at fracture of 18.2 ± 2.1%, and a reduced in vitro degradation rate compared to alloys containing higher amounts of Zn. In vivo, no significant difference between the osteotomized bone and the control group was found regarding the change in screw volume over implantation time. Therefore, it can be concluded that the fracture healing process, including its effects on the surrounding area, has no significant influence on degradation behavior. There was also no negative influence from hydrogen-gas formation on fracture healing. Despite the proximal and distal screws showing chronologically different gas release, the osteotomy showed complete consolidation. Statement of SignificanceConventional implants involve several disadvantages in pediatric trauma care. Magnesium-based alloys seem to overcome these issues as discussed in the recent literature. This study evaluates the clinical applicability of high-strength lean Mg‒0.45Zn‒0.45Ca (ZX00) screws in a growing-sheep model. Two groups, one including a simulated fracture and one group without fracture, underwent implantation of the alloy and were compared to each other. No significant difference regarding screw volume was observed between the groups. There was no negative influence of hydrogen-gas formation on fracture healing and a complete fracture consolidation was found after 12 weeks for all animals investigated.

Anterior Midline Incision is a Safe and Effective Approach for High-energy Medial Shear Fractures of the Tibial Plateau

Objective: We present a technical trick for surgical treatment of with (Schatzker IV) medial tibial plateau fractures treated with a standardized operative protocol with early radiographic and clinical outcomes. Methods: Skeletally mature patients with a medial tibial plateau fracture (Schatzker IV) admitted to an academic level 1 trauma center between 2002 and 2017 were identified by institutional database review. Screening of operative reports selected patients treated with a single anteromedial approach following a standard surgical protocol by a single surgeon. Data relevant to initial injury characteristics, patient comorbidities, operative management, and follow-up were extracted by chart review. Preoperative and postoperative clinical documentation and radiographs were examined to measure specific injury and outcome variables. Radiographic and clinical outcomes were validated by one fellowship-trained orthopedic trauma surgeon and 2 orthopedic trauma fellows. Results: Review of 335 patients with tibial plateau fractures during the study period identified a series of 17 high-energy, medial partial articular fractures that met the inclusion criteria. Injury pattern included articular depression in all patients, meniscal injury in 59%, ligamentous injury in 65% and none had compartment syndrome. Immediate radiographic analysis showed restoration of the articular surface, condylar width, and mechanical alignment for all patients. No patient experienced wound healing complications, soft tissue infection or skin necrosis. Median time to radiographic fracture consolidation was 12.9 weeks and ambulation without achieved at 18.9 weeks. Conclusions: The use of a standard anteromedial approach to the knee via medial parapatellar arthrotomy with full-thickness medial skin flap for isolated high-energy medial column tibial plateau fractures offers improved visualization and facilitates reduction and fixation of the lateral and anterior articular impaction while enabling immediate repair or reconstruction of associated meniscal and ligamentous (anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament) pathology. Short-term and mid-term follow-up demonstrates good clinical and radiographic patient outcomes. This approach is a safe and reliable option for treatment of this unique and challenging injury pattern.

Fracturas transversales del cuerpo del semilunar con retraso en la consolidación. Experiencia en el tratamiento artroscópico

Background and aimLunate traumatic fractures represent between 0.5% and 1% of carpal bone fractures. Transverse fracture through the body of the lunate (type V) are the least frequent and need surgical treatment if displaced, because it has a high risk of necrosis or pseudoarthrosis. The objective of this paper is to present our experience with arthroscopic treatment in patients with a delay in consolidation after a transverse fracture through the body of the lunate. MethodsTwo clinical cases of delay in consolidation in transverse fracture through the body of the lunate are presented. Both cases have delay in consolidation. ResultsBoth fractures were misdiagnosed in initial simple radiographic exploration and were diagnosed with computerised tomography. Both patients were treated by debridement, bone grafting and osteosynthesis under arthroscopic control, obtaining a correct radiographic consolidation. ConclusionArthroscopic treatment is a valid, effective and safe technique for the treatment of delay in consolidation of transverse fractures through the body of the lunate and avoids complications and soft tissues injury of the open surgery techniques.

General fracture principles and imaging characteristics

In the process of fracture healing, two different types (direct and indirect) are observed, which can be distinguished by radiologic imaging. If afracture insufficiently consolidates without further treatment, regardless of the duration of prior treatment, it is referred to as a"non-union". This occurs in about 10% of long bone fractures. The aim of this article is to provide an overview of the classification of fractures, an explanation of fracture healing and non-unions as well as their radiologic characteristics. The diagnosis of fractures is based on physical examination and x‑ray with aminimum of two planes. If asoft tissue defect or complex fracture is suspected, aCT or MRI should be considered. For the treatment of non-unions, it might be helpful to expand the diagnostics to aCEUS (contrast-enhanced ultrasound) or DCE-MRI (dynamic contrast-enhanced magnetic resonance imaging). Non-unions represent a severe limitation for the patient's quality of life and are often associated with a long period of suffering. In recent years, CEUS has been shown to be a useful and precise method for the diagnosis and assessment of non-unions and as a surrogate parameter for fracture consolidation.

Features of choosing the tactics and method of treatment of external joint frequencies of long external bones in people living with HIV

Objective. Develop an algorithm for determining tactics and parameters of their treatment to improve treatment outcomes. Methodology. Material and research methods. A statistical analysis of the treatment results of 90 HIV-infected patients aged from 23 to 54 years with extra-articular fractures of long bones of the extremities was carried out. When determining the tactics and method of treatment, the peculiarities of the effect of HIV infection, antiretroviral drugs, and opportunistic diseases on the patient’s body were not taken into account. Results. Non-infectious complications are characteristic of HIV-infected patients: sides of the postoperative wound (seromas, hematomas, discrepancy of wound edges, delayed crushing), aseptic loosening and migration of fixatives, delayed consolidation of fractures. The presence of a statistically significant relationship between the objective factors characterizing the course of HIV infection: the stage of the disease, the number of CD lymphocytes, the ratio of CD4 / CD8 lymphocytes, viral load and the risk of postoperative complications was revealed.Conclusion. The application of the developed algorithm allows you to objectify the procedure and provide an individual approach in determining the tactics and method of treatment for HIV-infected patients with extraarticular fractures of long bones of the extremities

The effect of low-intensity pulsed ultrasound on rib fracture: An experimental study.

In this study, we aimed to investigate the effects of lowintensity pulsed ultrasound on rib fracture healing in a rat model. A total of 72 male Wistar-Albino rats were randomly divided into three equal groups. To induce a rib fracture, right thoracotomy was performed under general anesthesia and a 0.5-cm segment was removed from the fourth and fifth ribs. After 24 h of surgery, low-intensity pulsed ultrasound was implemented according to the groups. Group 1 served as the control group for the observation of normal bone healing. Low-intensity pulsed ultrasound was applied at a dose of 20% (2 msn pulse-8 msn pause) 100 mW/cm2 and 50% (5 msn pulse-5 msn pause) 200 mW/cm2 for six min, respectively in Group 2 and Group 3. All subjects were followed for six weeks. Eight animals from each group were sacrificed at two, four, and six weeks for further assessment. Histological alterations in the bone were examined. Although there was no statistically significant difference in osteoblasts, osteoclasts, new bone formation, and lymphocyte count among the groups, histological consolidation was significantly increased by low-intensity pulsed ultrasound. While low-intensity pulsed ultrasound induced osteoblastic, osteoclastic, and new bone formation, it inhibited lymphocyte infiltration. Low-intensity pulsed ultrasound, either at low or high doses, induced the histological consolidation of rib fractures and inhibited lymphocyte infiltration. This effect was more prominent in the long-term and at higher dose with increased daily and total administration time. We, therefore, believe that accelerating the natural healing process in patients with rib fractures would enable to treat more effectively in short-term.

Validation of a long bone fracture non-union healing score after treatment with mesenchymal stromal cells combined to biomaterials

The available scores to clinically evaluate fracture consolidation encounter difficulties to interpret progression towards consolidation in long-bone non-union, particularly when incorporating biomaterials in the surgical treatment. The aims of this study were to validate the REBORNE bone healing scale in tibia, humerus and femur non-unions treated by a combination of mesenchymal stromal cells (MSCs) and biomaterials, through the interclass correlation (ICC) among raters, and to define reliability and concordance in anteroposterior and lateral radiographs, compared to computed tomography (CT). MethodsTwenty-six cases from the EudraCT 2011-005441-13 clinical trial underwent bone healing evaluation, if at least 3 out of 4 cortical views clearly identified. Three senior orthopaedic surgeons evaluated radiographs and CTs at 3 and 6 months FU. All cases included preoperative imaging and radiographs at 12 months. The 4-stage scale score was obtained from each cortical view in orthogonal radiographs or CTs. A score of 0.6875 (11/16) was set as a threshold for bone healing. Statistically, ICC evaluated agreement among raters. Cronbach's alpha coefficient tested reliability. Lin's concordance correlation coefficients (CCC) were estimated between mean CT scores and mean radiographic scores. Bland and Altman graphs provided the limits of agreement between both imaging techniques. Sensitivity and specificity were assessed in radiographs (against CT), and the Area Under the Receiver Operating Characteristics (ROC) Curve was estimated. The probability to predict bone consolidation with REBORNE scores obtained from radiographs was modelled. ResultsAn ICC of 0.88 and 0.91 (CT and radiographs) confirmed agreement in the REBORNE score for non-union bone healing, with an inter-rater reliability of 0.92 and 0.95. Scores through the radiographic evaluation were found equivalent to the CTs at 6 months FU. A CCC of 0.79 was detected against CT. The radiographic scores in the REBORNE bone healing scale correctly classified bone consolidation in 77%, with an accuracy of 83% based on ROC curves. ConclusionsThe REBORNE score measured with CT or radiographic images was reliable among raters at a follow-up time above 6 months for long bone non-union fractures. The REBORNE scale measured with radiographs proved valid to assess consolidation against CT measurements.

Minimally Invasive Plate Osteosynthesis for Distal Radius Fractures: Are There Any Advantages Against Conventional Technique?

Purpose of the study — to illustrate the potential and to evaluate the late term results of minimally invasive plate fixation for distal radius fractures (DRF) and compare it to the treatment outcomes for patients with similar injuries where internal fixation was performed through conventional volar surgical approach. Material and Methods. 96 patients with DRF fractures were included into the study who underwent volar plate fixation by with angular stability. The main group included 42 patients (29 women and 13 men) with DMR where minimally invasive volar approach was used. Mean age of patients was 38 years (from 21 to 57 years). Control group consisted of 54 patients (33 women and 21 men) with mean age of 43 years (from 26 to 64 years) who underwent fracture stabilization via conventional volar approach. Minimal follow up after surgery and discharge was 3 months. In the late period roentgenological, functional and cosmetic outcomes were evaluated as well as patients’ satisfaction by QuickDASH-9 survey. Results. 95 patients (98.9%) demonstrated fracture consolidation in terms up to 6 weeks irrespective of surgical technique which was confirmed by X-rays during control examination. In one female patient (1.1%) consolidation following minimally invasive plating was not achieved even in one year after surgery which was considered as distal radius pseudarthrosis but featuring excellent functional outcome. Surgery time for minimally invasive fixation was 47 (41;53) minutes and for conventional surgical approach – 43 (37;46) minutes (р = 0.731). Mean time of image intensifier use during internal fixation averaged 54 (47;63) seconds during minimally invasive technique and 33 (29;37) seconds for conventional open technique (р = 0.046). Statistically significant larger flexion and extension ranges, pronation and supination angles as well as higher grip force were observed in the group of minimally invasive internal fixation in 1, 2 and 3 months after the surgery (р0.001). Statistically lower scores for QuickDASH-9 survey were reported for the main group in 2 and 3 months postoperatively (р0.001). Cosmetic results were better in patients after minimally invasive approach. Conclusion. Minimally invasive plating fixation of DRF is the efficient and relatively safe surgical option for such injuries. The key arguments for such approach: preservation of bone vascularization which minimally slows down fracture healing, reduced risk of infectious complications, fast functional wrist recovery already in early postoperative period as well as satisfaction of patients with cosmetic effects.

Pediatric mandibular fracture therapy: A case report

Introduction. Frequency of pediatric mandibular fractures is relatively uncommon. Apart from rare exceptions, there is minimal invasive access in the treatment of those injuries in order to avoid the future developmental disorders. Case report. During the game with a colt, a 6-year-old boy was kicked by hoof in the chin. The child did not lose consciousness and did not experience nausea or vomiting. According to clinical examination and radiological analysis, diagnosis was assigned as dislocated mandibular fracture in the parasymphysis part of the jaw and luxation injury of teeth 31 and 72. The surgical treatment under general anesthesia encompassed reduction and bimanual manipulation of bone fragments up to the optimal restoration of the dental occlusion, along with osteosynthesis with titanium miniplates. Luxated deciduous tooth 72 at the fracture line was extracted and luxated permanent tooth 31 was fixed to tooth 41 with wire. The patient was given antibiotic therapy. Additional immobilization of the luxated tooth 31 and mandibular fracture was performed after surgery by composite resin splint. During five-month follow-up period there were no signs of pathological movements in the fracture line, no luxation of tooth 31 and no restriction in mouth opening. Conclusion. Osteosynthesis with miniplates is adequate and very efficient treatment method in dislocated mandibular fracture that is recommended in children with both deciduous and mixed dentition. It is necessary to remove miniplates after fracture consolidation.

ПАТОЛОГИЧЕСКИЕ ПЕРЕЛОМЫ ЛУЧЕВЫХ КОСТЕЙ У БОЛЬНОЙ С АУТОИММУННЫМ ПОЛИГЛАНДУЛЯРНЫМ СИНДРОМОМ 1-ГО ТИПА

The author observed 1 patient with APGS-1 type. The disease was manifested by autoimmune damage of peripheral glands (hypoparathyroidism, adrenal insufficiency, hypothyroidism, hypogonadism), destructive keratitis and candidiasis. With a minor injury, pathological fractures of radial bones in the lower third of the forearm have been reported over last 14 years. Within a year, it was not possible to consolidate these fractures completely. The author suggests that the the diversity of the signs can be explained only by the presence of another genetic disease - imperfect osteogenesis. A complex of measures for the correction of APGS-1 and acceleration of consolidation of pathological fractures is proposed.

Физическая активность и консолидация переломов проксимального отдела бедра у лиц старческого возраста

We analyzed the results of treatment of 23 patients of old age with proximal hip fractures. We carried out the work on the basis of the trauma department of Kotovsk City Clinical Hospital in the period from 2017 to 2019. After the surgical treatment, patients underwent monthly control examinations, as well as control radiographs after three, six, ten and twelve months. As a result of the study we highlighted three groups. The first group is 8 patients with normal fracture consolidation in accordance with the postoperative treatment term; the second group – 10 patients whose period of consolidation of fracture y exceeded the planned ones; the third group - patients with a non-growing fracture of the femur neck, revealed at control examinations. It is worth noting that all patients, regardless of belonging to one of the groups, performed movement independently or with additional support in the form of walkers, while walking slightly relying on the operated lower limb. Among all patients, we were able to achieve positive results through surgical treatment and subsequent early activation of patients. There were no fatalities.

Surgical treatment of extra articular supra condylar fractures of distal humerus in old aged patients with using closed reduction and fixation with 4mm cc screws

Background: This study evaluate clinical, radiological, functional outcomes and complications with a long follow-up of extra articular supracondylar fracture in elderly patient treated with closed reduction and fixation with using 4mm cc screws.Methods: This study was conducted in Parul institute of medical science and research (PIMSR) vadodara, between January 2017 to December 2019, During that period Total 20 consecutive elderly patients 12 female and 8 male with extra articular supracondylar fracture treated with closed reduction and fixation with using 4mm cc screws. The clinical outcome was measured with pain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-up were assessed for union, delayed union, nonunion, and hardware failure.Results: At most recent follow-up, The mean Mayo Elbow Performance scores were 92. According to Mayo Elbow Performance Index 16 patients had excellent outcome, 2 had good, 1 had fair and 1 had poor outcomes. Complications included nonunion, delayed union, implant backout screws required revision surgery with removal of implant + Open reduction plating and bone grafting.Discussion: Operative time was very less, all fracture were treated in manner of closed reduction so no much blood loss which were again helped in post of recovery of patient and added biological fixation advantages to fracture which further giving early consolidation of fracture in elderly patients with early mobilization and better outcome with very less complications.

METHOD OF FORENSIC ASSESSMENT OF RISK FACTORS OF TREATMENT FAILURE OUTCOMES AS AN ELEMENT OF QUALITY MANAGEMENT OF MEDICAL CARE

The aim: The aim of this research was to study causes of the development of adverse outcomes in isolated femоral diaphyseal fractures. Materials and methods: A retrospective analysis of the protocols of clinical and radiological examination of 21 patients was performed. Based on the initial expert assessment, these patients have not been established the severity of injuries due to the development of complications in the postoperative period. Conclusions: Patient-dependent, implant-dependent, and surgery-dependent causes that caused a violation of the stability of osteosynthesis (95.2%) were identified. This led to a secondary displacement of bone fragments (71.4%), delayed fracture consolidation (61.9%), the formation of pseudarthrosis (38.1%), the development of post-traumatic osteomyelitis (14,3), migration of screws from the osseous plate (47.6%), and the development of post-traumatic contracture of the knee joint (81.0%).

The Effect of External Fixator Configurations on the Dynamic Compression Load: An Experimental and Numerical Study

(1) Objective: External fixation systems are commonly used by surgeons to ensure stabilization and consolidation of bone fractures, especially in patients who are at high risk for systematic complications. Both rigid and elastic external fixations are important in the fracture healing process. This study aims to evaluate the behavior of the Orthofix Limb Reconstruction System (LRS)® in the dynamic compression mode. (2) Methods: Experimental and numerical setups were developed using a simplified model of a human tibia which consisted of a nylon bar with a diameter of 30 mm. The bone callus was included in both setups by means of a load cell-based system, which consisted of two carbon epoxy laminated composite plates with a final stiffness of 220 N/mm. The system was evaluated experimentally and numerically, considering different numbers of pins and comparing distances between the external fixator frame and the bone, achieving a good correlation between experimental and numerical results. (3) Results: The results identified and quantified the percental load transferred to the fracture and its sensibility to the distance between the external fixator and bone. Additionally, LRS locking stiffness was evaluated which resulted from the clamp-rail clearances. The results show that the blocking effects of the free clamp movement are directly related to the fixator configuration and are responsible for changes in the amount of load that crosses the bone callus. (4) Conclusions: From the biomechanical point of view, the results suggest that the average bending span of Schanz pins and the weights of the patients should be included into clinical studies of external fixators comparisons purpose.

Effect of topical Vancomycin on consolidation of sternum surgical fracture in open-heart surgery

Introduction: The physiological process of sternum surgical fracture consolidation in patients undergoing cardiac surgery could be prolonged by the invasion of gram-positive saprophytic bacteria which perpetuates the local inflammatory process despite the standardized aseptic and antiseptic measures in cardiac surgery. In this regard, the topical application of Vancomycin can exert a positive effect and prevent the perpetuation of the local inflammatory process by the elimination of these bacteria which in turn reduces bone consolidation time.The purpose of the current study was to determine the effect of topical Vancomycin on sternum surgical fracture consolidation in patients undergoing to open-heart surgery. Materials and Methods: Patients who underwent open heart surgery were assigned into groups receiving the topical application of bone wax or Vancomycin mass in the spongy tissue exposed by surgical sternotomy, prior to sternal closure. The bone consolidation processes were assessed by two expert radiologists with simple chest computed tomography (CT) in the postoperative period (4, 8, and 12 weeks). Results: The study was conducted on 55 patients in Vancomycin (n=33) and bone wax group (n=19). The computerized axial tomography (CAT) scan revealed a higher number of patients with early bone consolidation (Medullar and bone continuity, and callus bone) in Vancomycin group, as compared to bone wax group (p values between 0.004-0.02 at 4 weeks and 0.01-0.06 at 8 weeks). However, no difference was observed at 12 weeks (P=0.09-0.11). Moreover, The magnitude effect of topical Vancomycin was high (>90%) at 3, 8, and 12 weeks of follow up, compared to the patients who received bone wax (<90%). Conclusion: The topical Vancomycin application had a positive effect on sternal surgical fracture and promotes an early bone consolidation in patients undergoing open-heart surgery.

Osteosynthesis of segmental alveolar fractures by internal fixation and the prognosis of the fractures and teeth.

Fracture of the alveolar process is a common injury, but the traditional splinting fixation may not be possible in some cases. The aim of this study was to describe the osteosynthesis performed in segmental alveolar fractures by internal fixation and evaluate the prognosis of the fractures and teeth involved. Twenty-two patients who were identified as having segmental alveolar fractures treated with osteosynthesis by internal fixation at the authors' department from January 2007 to December 2016 were included with 90 traumatized teeth. The prognosis of the fractures and teeth involved in the fractures was evaluated by the post-operative computed tomography combined with a follow-up study. All patients achieved healing and consolidation of the alveolar fractures. Furthermore, the occlusion was restored and the wounds healed. During the surgical procedures, no observed iatrogenic dental damage caused by the interdental drilling was found. Eventually, only 15.6% of the teeth had pulp necrosis, whereas the other healing complications were rare or not observed in the study. Osteosynthesis by internal fixation is an effective and safe treatment for some segmental alveolar fractures. The teeth involved in these fractures also have good prognosis.

DELAYED UNION OF MANDIBULAR FRACTURES: ANALYSIS OF 74 CLINICAL CASES

Delayed union of bone tissue in patients with mandibular fractures is observed in 2.4 – 26 % of clinical cases. Solution of this problem yet very much far from the final solutio and there is an urgent requirement in the comprehensive analysis of role of general and local factors of origin of delayed union MF. Methods. Modern clinical, laboratory and microbiological research methods were used in the work. Densitometry conducted on computed tomograph Planmeca Promax 3d (Finland) (85 kV 5–7 mA). The basal values of immunoglobulins of the main classes and interleukins IL-1β, FNT-α, IL-4, MDA, SOD and catalase activity, POL, β-Cross Laps and osteocalcin in peripheral blood were determined in 74 patients with delayed consolidation of the mandibular fractures. Correlation analysis of local and general (concomitant somatic pathology) factors, and clinic-laboratorial parameters in patients with delayed consolidation of the mandibular fractures is conducted. Results. There is a high correlation between β-Cross Laps (negative) and osteocalcin (positive) and bone mineral density. The mean inverse correlation relationship was established between the MDA and catalase activity and BMD (r=–0.57), and the high correlation of these indices with markers of bone remodeling (positive to β-Cross Laps (r=0.80 and r=0.87, respectively) and negative to osteocalcin (r=–0.80 and r=–0.84, respectively). High direct correlation between FNT-α indices and POL, MDA, and catalase indices, as well as very strong with β-Cross Laps (positive) and osteocalcin (negative), and also with high-correlation ligaments of sIgA and IL-1β. Discussion. Convincing clinical and laboratory data were obtained that the combined effect of local and general (concomitant somatic pathology) factors on the basis of the activation of inflammation processes, which increase the indirect influence on immune factors, processes of radical oxidation and bone metabolism, is resulted to delayed union. It was also found that clinical signs of the development of consolidation complications in patients with MF include increased signs of inflammation (oedema, exudation, etc.) up to the 3rd day and preservation of even moderate signs of inflammation (inflation, local hyperemia, and others) after the 7th day, BMD below 600 HU. Among the local factors that increase the infectious risk and inflammatory reaction, the following clinical situations should be distinguished: comminuted fracture; the presence of a tooth in the line of fractures; partially edentulous with loss of antagonist teeth (according to Eichner); complete adentia with mandible atrophy.

General treatment principles for fracture-related infection: recommendations from an international expert group

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients’ short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.