Intramedullary Rod Fixation Research Articles

A literature review of current surgical treatment for congenital pseudoarthrosis of the tibia

Congenital pseudarthrosis of the tibia (CPT) is an infrequently observed condition. However, it is considered to be one of the most complex ailments in the field of pediatric orthopedics. In cases where a tibial fracture is absent, the conventional treatment approach involves using bracing as a preventive measure against fractures. Various surgical modalities have been proposed for the management of CPT, including intramedullary (IM) rod fixation, external fixators, on-lay grafts, cancellous grafts, periosteal grafts, Paley cross-union, amputation, vascularized fibula grafts, and induced membrane techniques. These modalities can be used in different combinations and permutations. The need for repetitive surgical interventions due to unsuccessful therapeutic outcomes or modifications in secondary treatments can significantly disrupt the childhood experience, resulting in prolonged and recurrent functional limitations. In certain instances, amputation may be required as a primary or secondary treatment modality. This literature review will clarify the current surgical interventions for CPT disease based on a summary of research data. The surgery the patient receives significantly impacts their general health and capacity to heal.

Comparison of two different intramedullary rods combined with Ilizarov external fixation and wrapped autologous iliac bone grafting for the treatment of congenital tibial pseudarthrosis in children

Objective: To compare the initial clinical efficacy of extensible intramedullary rod fixation and Williams intramedullary rod fixation combined with Ilizarov external fixation and wrapped autologous iliac bone grafting in the treatment of congenital tibial pseudarthrosis in children. Methods: A retrospective analysis was conducted on the clinical data of 60 children with Crawford Ⅳtype congenital pseudarthrosis of the tibia treated with combined surgery at the Orthopedics Department of Hunan Children's Hospital from January 2013 to December 2020.According to different internal fixation methods,patients were divided into the extensible intramedullary rod group (30 cases) and the Williams intramedullary rod group (30 cases). There were 12 males and 18 females in the extendable intramedullary rod group, aged (33.6±6.3) months (range: 18 to 44 months), while there were 10 males and 20 females in the Williams intramedullary rod group, aged (47.8±8.6) months (range: 36 to 66 months). The anteroposterior and lateral views of tibia and fibula and the full length anteroposterior film of both lower limbs were examined to compare the clinical treatment effects of the two groups at 1-,3-,6-,9-, and 12-month after surgery. Independent sample t-test, χ2 test or Fisher exact test was used for inter group comparison. Results: Both groups of children underwent surgery successfully, with postoperative follow-up time greater than 2 years. The extensible intramedullary rod group was followed up for (49.5±6.4) months, while the Williams intramedullary rod group was followed up for (53.7±10.5) months. The initial bone healing time between the broken ends of the tibial pseudarthrosis was (5.1±0.8) months in the extensible intramedullary rod group and (5.0±0.6) months in the Williams intramedullary rod group. There was no statistically significant difference between the two groups (t=0.584, P=0.562). The initial postoperative bone healing rate of the extensible intramedullary rod group was 93.3% (28/30), while that of the Williams intramedullary rod group was 96.7% (29/30). There was no statistically significant difference between the groups (χ2=0.351 P=0.554).The postoperative fracture rate of the extensible intramedullary rod group was 20.0% (6/30), while that of the Williams intramedullary rod group was 16.7% (5/30);Six cases (20.0%) in the extensible intramedullary rod group had unequal limb lengths in both lower limbs after surgery, with a limb length difference of (2.5±1.4)cm (range: 1.5 to 5.2 cm). Eight cases (26.7%) in the Williams intramedullary rod group had a limb length difference of (2.8±1.4)cm (range: 1.8 to 6.0 cm);After surgery, there were 4 (13.3%) cases of proximal tibial valgus deformity in the extensible intramedullary rod group, with an valgus angle range of (12.5±4.9)° (range: 7 °to 18°), and 3 (10.0%) cases in the Williams intramedullary rod group, with an valgus angle of (15.0±6.0)° (range: 9°to 21°). There were 2 (6.7%) cases of ankle valgus deformity in the extensible intramedullary rod group, with an valgus angle of (11.5±4.9)° (range: 8 °to 15°), and 4 (13.3%) cases in the Williams intramedullary rod group, with an valgus angle of (14.8±6.2)° (range: 6 °to 20°). The postoperative activities of the knee and ankle joints in the extensible intramedullary rod group were normal and unrestricted, with 4 cases of extensible intramedullary rod displacement.In the Williams intramedullary rod group, there were 30 cases of postoperative ankle joint stiffness and no displacement of the fixation position of the intramedullary rod.There was no statistically significant difference in postoperative complications between the two groups of children (all P>0.05). Conclusions: The use of both extensible intramedullary rods and Williams intramedullary rods in the combined surgery for congenital tibial pseudarthrosis in children can achieve effective internal fixation results. The initial postoperative bone healing rate is high, and there is no difference in the incidence of postoperative complications between groups. Both internal fixation methods have their own advantages and disadvantages, and suitable internal fixation methods can be selected based on the characteristics of the patient.

Efficacy of Hematoma Block after Intramedullary Rod Fixation of Femoral Shaft Fractures: A Prospective, Double-Blinded, Randomized Controlled Trial.

To evaluate the efficacy of an intraoperative, post-fixation fracture hematoma block on postoperative pain control and opioid consumption in patients with acute femoral shaft fractures. Prospective, double-blinded, randomized controlled trial. Academic Level I Trauma Center.Patients/Participants: 82 consecutive patients with isolated femoral shaft fractures (OTA/AO 32) underwent intramedullary rod fixation. Patients were randomized to receive an intraoperative, post-fixation fracture hematoma injection containing either 20 mL of normal saline or 0.5% ropivacaine in addition to a standardized multimodal pain regimen that included opioids. Visual analog scale (VAS) pain scores and opioid consumption. The treatment group demonstrated significantly lower VAS pain scores than the control group in the first 24-hour postoperative period (5.0 vs 6.7, p=0.004), 0-8 hours (5.4 vs 7.0, p=0.013), 8-16 hours (4.9 vs 6.6, p=0.018), and 16-24 hours (4.7 vs 6.6, p=0.010) postoperatively. In addition, the opioid consumption (morphine milligram equivalents) was significantly lower in the treatment group compared to the control group over the first 24-hour postoperative period (43.6 vs 65.9, p=0.008). No adverse effects were observed secondary to the saline or ropivacaine infiltration. Infiltrating the fracture hematoma with ropivacaine in adult femoral shaft fractures reduced postoperative pain and opioid consumption compared with saline control. This intervention presents a useful adjunct to multimodal analgesia to improve postoperative care in orthopaedic trauma patients. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Complications among patients with osteogenesis imperfecta following surgical interventions

Objectives: Osteogenesis imperfecta (OI) is a genetic bone disorder caused mainly by a defect in the COL1A1 or COL1A2 genes. This study aimed to analyze the complication using surgical interventions, including intramedullary telescopic rod fixation, Rush pin fixation, and Kirschner-wire (K-wire) fixation. Methods: This retrospective and cohort study was conducted in our institution, Riyadh, Saudi Arabia. A total of 23 patients with OI were treated from 2018 to 2022, out of which 19 were treated surgically. A total of 29 long bones were surgically managed. Our patients’ data were collected from the hospital’s electronic system. Results: The overall incidence of Rush pin fixation post-operative complications was 57% (five out of seven cases) and K-wire fixation was 50% (one out of two cases). The main indications for intramedullary telescopic rod implantation were osseous deformities and fractures, with the overall incidence of post-operative complications reaching around 35% (seven out of 20 cases). Conclusion: In our population, the overall incidence of complications after intramedullary telescopic rod fixation was lower than those after Rush pin fixation and K-wire fixation. In addition, more studies are needed to add to the literature new ways of tackling post-operative complications following the insertion of intramedullary telescopic rods, such as nail migration and new fractures or refractures.

Long term follow-up evaluation of combined surgery for congenital tibial pseudarthrosis in children

Objective: To explore the long-term effect of combined surgery for the treatment of congenital tibial pseudarthrosis in children. Methods: The clinical data of 44 children with congenital tibial pseudarthrosis who underwent combined surgery (tibial pseudarthrosis tissue resection, intramedullary rod fixation, Ilizarov external fixator fixation, wrapped autologous iliac bone graft) from August 2007 to October 2011 at the Department of Pediatric Orthopedics, Hunan Children's Hospital were collected retrospectively. There were 33 males and 11 females. The age at the time of surgery was (3.7±2.2)years (range:0.6 to 12.4 years), including 25 cases under 3 years old and 19 cases above 3 years old.Among them, 37 cases were complicated with neurofibromatosis type 1.The operation status, postoperative complications and follow-up results were recorded. Results: The follow-up time after surgery was (10.9±0.7)years (range:10 to 11 years).Thirty-nine out of 44 patients (88.6%) achieved initial healing of tibial pseudarthrosis, with an average healing time of (4.3±1.1)months (range:3 to 10months).In the last follow-up, 36 cases (81.8%) had unequal tibial length, 20 cases (45.4%) had refractures, 18 cases (40.9%) had ankle valgus, 9 cases (20.4%) had proximal tibial valgus, and 11 cases (25.0%) had high arched feet.Nine cases (20.4%) developed distal tibial epiphyseal plate bridging.17 cases (38.6%) had abnormal tibial mechanical axis.Seven cases (15.9%) developed needle infection, and one case (2.3%) developed tibial osteomyelitis. 21 patients (47.7%) had excessive growth of the affected femur.Five patients (11.3%) had ankle stiffness, and 34 patients (77.2%) had intramedullary rod displacement that was not in the center of the tibial medullary cavity.Among them, 8 cases (18.1%) protruded the tibial bone cortex and underwent intramedullary rod removal.18 children have reached skeletal maturity, while 26 children have not been followed up until skeletal maturity. Conclusion: Combined surgery for the treatment of congenital pseudarthrosis of the tibia in children has a high initial healing rate, but complications such as unequal tibia length, refracture, and ankle valgus occur during long-term follow-up, requiring multiple surgical treatments.

Intramedullary rod failure in metastatic breast cancer: Do triple negative cancer patients have more revision surgery?

BackgroundBreast cancer is the most common cancer and second cause of death in women worldwide. Patients with breast cancer are classified into subgroups based on the presence or absence of hormone receptors and the human epidermal growth factor 2-neu (HER-2) marker, the different molecular profiles come with an associated prognosis and variety of possible treatment options. Patients with triple negative cancer have a worse prognosis, a more aggressive behavior, higher likelihood of spreading, a higher risk of recurrence and a poorer outcome overall. Intramedullary rod fixation has proven to provide a good outcome and function in patients with metastatic breast cancer, but no study has addressed the receptor-status potential outcome differences that may affect disease progression at an orthopaedic surgery site. Questions/Purposes(1) Do patients with triple negative breast cancer have a higher revision rate of intramedullary rod fixation of bone metastases? (2) Do patients with metastatic triple negative breast cancer have a higher revision rate of intramedullary rod fixation due to local disease progression? MethodsThis was a single-center, observational, retrospective cohort study. Fifty-seven patients with a diagnosis of breast cancer metastatic to long bones who underwent surgical fixation with an intramedullary rod for a pathological fracture or an impending fracture due to a bone metastasis with a Mirels’ score equal or above 8 between January 2004 and December 2016 at our institution were included. All implants used were from the same manufacturer (Stryker Corp., Mahwah, NJ, USA). Patients were divided into two groups based on the receptor status of the tumor and were classified either as triple negative, when the tumor lacked progesterone, estrogen and HER-2 receptors, or as receptor-positive when the presence of one or a combination of either three was proven. In the triple-negative tumor group the mean follow up time was 26 months (SD 29) and median follow up time was 16 months. In the receptor-positive tumor group mean follow up was 27 months (SD 24) with a median follow up of 19 months. To assess possible associations between different factors and the outcomes of interest, we used either the chi-square test or Fisher’s exact test for categorical variables and the ANOVA test for continuous variables. For the survival assessment, a Kaplan-Meier analysis was performed and for the cumulative incidence a competing risk analysis was utilized. ResultsThe intramedullary rod revision rate for patients in the triple-negative tumor group was 17%, while for the receptor-positive group it was 12%, this was not statistically different for our sample size. The mean time for revision of the intramedullary rod in the whole sample was 19 months (SD 11, range 6–40). The causes of revision were disease progression (43%), nonunion (29%) and surgeon error (29%). The cumulative incidence of revision surgery was 6% (CI 95%, 2–14%) at 12 months and 20% (CI 95%, 8–36%) at 60 months. ConclusionsIntramedullary rodding can be considered for the treatment of long bones metastases in breast cancer patients for an impending or actual pathological fracture. There is no difference in the intramedullary rod revision rate among patients with different receptor-status when comparing triple-negative tumor patients and receptor-positive ones. Level of EvidenceLevel III, therapeutic study.

Congenital Pseudarthrosis of the Tibia: Results, at Skeletal Maturity, of the Charnley-Williams Procedure.

Background:This study assessed the outcomes, at skeletal maturity, for 34 patients in whom congenital pseudarthrosis of the tibia (CPT) had been treated with intramedullary (IM) rod fixation.Methods:The results in skeletally mature patients in whom type-4 CPT had been treated with an IM rod at an average of 11.9 years earlier were reviewed. The rod procedures varied according to whether both the tibia and the fibula were resected and both bones (type A) or just the tibia (type B) were fixed with an IM rod or whether only the tibia was resected and the fibula received no surgery (type C). Outcome grading ranged from unequivocal union with brace-free function (grade 1) to a functional limb with residual angulation or cortical defects (grade 2) to a severely impaired extremity with insufficient union or refracture (grade 3).Results:Thirty-four patients were evaluated at a mean age of 16.9 years, a mean of 11.9 years after their initial surgical procedure. Seventeen patients had a grade-1 result; 11 patients, grade 2; and 6, grade 3. Thus, 82% (28) of the 34 patients had a functional extremity at maturity. All patients with a final grade-3 outcome eventually requested amputation. The final outcomes were not affected by the age at the initial fracture or surgery, the presence of neurofibromatosis-1, or cross-ankle fixation. A total of 58 IM rod procedures were performed in the 34 patients. Twenty-four (73%) of the 33 type-A procedures produced grade-1 or 2 outcomes, as did 14 (88%) of the 16 type-B procedures. Of the 9 type-C procedures, none produced a grade-1 result and 4 produced a grade-2 outcome. The results of types A and B combined were superior to those of type-C procedures (p = 0.03). Refracture occurred in 13 of 33 patients with initial stability/union after rod fixation, with 3 of those fractures remaining ununited at the latest follow-up. A dystrophic fibula had no effect on the eventual achievement of a grade-1 or 2 outcome.Conclusions:This review, in which all patients had reached skeletal maturity, documents functional (grade-1 or 2) outcomes in 82% of cases of IM rod fixation for CPT. This finding was almost identical to the result in our earlier report and confirms the long-term value of permanent IM rod fixation in maintaining union and function in patients with CPT. Procedures not addressing the fibula produced inferior results. Although 13 patients had a refracture following initial union, only 3 of these fractures failed to heal with additional treatment.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mid-term Results of Femoral and Tibial Osteotomies and Fassier-Duval Nailing in Children With Osteogenesis Imperfecta.

Patients with osteogenesis imperfecta (OI) have significant burden of both fractures and bony deformities. The present approach to care in this disorder is a combination of surgical care with intramedullary rod fixation, cyclic bisphosphonate therapy, and rehabilitation with goal of maximizing patient function and quality of life. Retrospective chart review identified 58 children with OI who had realignment osteotomies with Fassier-Duval (FD) intramedullary nailing of the lower extremity by a single surgeon. This is a consecutive series treated between 2003 and 2010. Postoperatively, patients were followed up clinically and radiologically. Motor function was assessed using the Brief Assessment of Motor Function score and the walking scale subset of the Gillette Functional Assessment Questionnaire. Fifty-eight patients had 179 lower extremity FD intramedullary rods placed. This technique allowed for intervention on multiple long bones, with 29% having bilateral femur and tibial rodding in the same procedure. Revisions were required in 53% of patients, which occurred at a mean time of 52 months after initial rodding surgery. In most cases, revision surgery was related to patient growth and subsequent fracture, although rod migration did occur in a minority of patients. Nonunion or incomplete union was 14.5% in this series. Bisphosphonate infusion was not postponed after surgical procedures. Patients had improvement in mobility status at the latest follow-up. This series lends evidence to the medium-term utility of FD intramedullary rods as an effective and less invasive platform for stabilization and correction of deformity in long bones of patients with OI. Relatively low blood loss and relatively short hospitalizations were noted. Nonunion rate was comparable with existing literature noting that our patients did not have postsurgical postponement of bisphosphonate therapy. Therapeutic study to investigate the results of treatment with FD rods. Retrospective case series model of Level IV evidence quality.

Locking plate placement with unicortical screw fixation adjunctive to intramedullary rodding in long bones of patients with osteogenesis imperfecta.

Intramedullary rodding has been the mainstay of long-bone stabilization in osteogenesis imperfecta. However, in some cases, intramedullary rodding cannot provide adequate fixation because of a lack of rotational control and thin diameter of long bones. We have applied adjunctive unicortical locking plate fixation in selected cases of osteogenesis imperfecta to address these biomechanical issues. Thirty-seven bone segments of twenty-four patients with osteogenesis imperfecta (ten type III, nine type IV, three type I, and two type V), in which unicortical locking plate fixation was applied adjunctive to intramedullary rodding and was later removed after union had been achieved, were the study subjects. The mean patient age at the time of surgery was 15.5 years (range, 6.2 to 39.8 years). Medical records and follow-up radiographs were reviewed to evaluate healing, complications, and the fates of screw holes after plate removal. All fractures or osteotomies healed completely. Locking plates were removed postoperatively at a mean time (and standard deviation) of 1.8 ± 0.9 years (range, 0.3 to 3.8 years). In seven of the thirty-seven cases, fractures through the screw hole occurred; all of these were treated conservatively. In eighteen of nineteen cases that were followed for more than a year after plate removal without screw hole-related complication, screw holes healed and were no longer visualized by radiography. Unicortical locking plate fixation effectively supplements intramedullary rod fixation in selected cases of osteogenesis imperfecta. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In Vitro Biomechanical Comparison of 3.5 mm LC‐DCP/Intramedullary Rod and 5 mm Clamp‐Rod Internal Fixator (CRIF)/Intramedullary Rod Fixation in a Canine Femoral Gap Model

To compare the biomechanical properties of clamp rod internal fixation (CRIF)/rod and LC-DCP/rod constructs in a canine femoral gap model. Cadaveric biomechanical study. Canine femora (n = 10 pair). Femora with 40 mm ostectomies were assigned to LC-DCP/rod or CRIF/rod treatment groups. Five construct pairs had 4-point bending and 5 pairs had torsional loading. Construct stiffness, strength, and bending angle at failure or permanent angular deformation (torsional loading) were determined. Statistical comparisons were performed using Student t tests; significance was set at P ≤ .05. There was significantly greater permanent angular deformation, or residual twist, in the CRIF/rod constructs (23.1 ± 0.89°) compared with LC-DCP/rod constructs (7.47 ± 2.08°). Whereas there was no significant difference in torsional stiffness of these constructs at torsional loads <4.92 N m (P = .819), LC-DCP/rod constructs had significantly greater torsional stiffness (0.303 ± 0.079 N m/°) and strength (11.546 ± 2.79 N m) than CRIF/rod construct stiffness (0.06 ± 0.013 N m/°) and strength (6.078 ± 0.527 N m) at torsional loads >4.92 N m. Differences in stiffness and strength in 4-point bending were not statistically significant. LC-DCP/rod constructs had significantly less permanent angular deformation than CRIF/rod constructs. CRIF/rod constructs became less stiff as torsional load was increased, thus the LC-DCP/rod constructs had significantly greater torsional stiffness and strength under high torsional loads. LC-DCP/rod and CRIF/rod constructs performed similarly under 4-point bend loading conditions.

Intramedullary rod fixation of fibrous dysplasia without use of bisphosphonates

Controversy exists regarding approach to treatment of pediatric patients with fibrous dysplasia. We retrospectively reviewed medical records of seven patients who were treated at our institution for fibrous dysplasia by intramedullary rod fixation without bisphosphonate supplementation. Seven patients with a total of ten fibrous dysplasia lesion sites surgically treated by intramedullary rod fixation were included. Of these ten lesion sites, eight demonstrated pathologic fracture at the time of fixation. Complete fracture healing was observed in all eight sites, with no incidence of recurrent pathologic fractures examined radiographically. There were no major infections or neurologic deficits, and lesions appeared to stabilize. In this series, intramedullary rod fixation proved to be successful in treatment of acute pathologic fracture and incompletely healed fibrous dysplasia lesions. We observed partial resolution of fibrous dysplasia lesions at all ten sites without significant long-term complications. Following treatment, there were no refractures. Level IV, case series.

Novel Venting Technique for Intramedullary Rod Fixation of Pathologic Fractures

This article introduces a novel technique to vent the femur and potentially decrease the embolic load created by reaming during intramedullary rod fixation of impending pathologic femur fractures. We used readily available operating room equipment to create a distal femoral vent hole without interfering with standard intramedullary instrumentation and with minimal increase in surgical time. This technique can be used for the prophylactic intramedullary stabilization of impending pathologic femur fractures from metabolic bone disease, metastatic cancer, and bisphosphonate use.

A Case Report: Femoral Fracture in a Multiple Sclerosis Patient with Vitamin D Deficiency−A Preventable Injury

In this report, we describe the management of a multiple sclerosis patient with a femoral fracture who had severe vitamin D deficiency. After the patient's preoperative laboratory studies revealed a normal platelet count, the orthopedic surgeon performed an intramedullary rod fixation on the patient's left femoral fracture. After the surgery, the diagnosis of vitamin D deficiency was made by measuring the circulating serum concentration of 25-dihydroxyvita-min D (25(OH)D) via Disorin's Vitamin D immunochemiluminometric assay LIASION by LabCorp (Laboratory Corporation of America). The patient's postoperative management included the oral administration of 4000 IU of vitamin D3 in a gel-cap suspension that resulted in an elevation of the blood serum concentration of 25(OH)D to an optimal concentration of >80 nmol/L (32 ng/ml).

Tibial Lengthening Over an Intramedullary Nail

Tibial Lengthening Over an Intramedullary Nail

Tibial rotational osteotomy with intramedullary nail fixation

There are several theoretic advantages of using intramedullary rod fixation for tibial osteotomy fixation. We performed a retrospective review of patients who were treated with a mid-diaphyseal osteotomy of the tibia fixed with an intramedullary rod for isolated, symptomatic tibial torsion. Forty patients (59 tibias) were included in the study and were followed for a minimum of 12 months or until rod removal (average follow-up 22.6 months). Major complication rate was 8.5%, which is comparable to alternative methods of fixation. We believe that intramedullary rods are a safe alternative for fixation of tibial rotational osteotomy in patients with physeal closure.

Bisphosphonate-associated femoral fracture: implications for management in patients with malignancies

Reports of femoral shaft fractures in patients on long-term bisphosphonates (BPs) have raised important concerns on the safety for this class of drugs. Patients with malignancies are potentially at a higher risk for this complication considering the dose and the duration of treatment with BPs. In this report we describe the case of 56-year-old woman with multiple myeloma who developed a non-traumatic left femoral shaft fracture after treatment with high dose BPs for 6 years, following a bone marrow transplant. Intramedullary rod fixation of the fractured femur resulted in "splitting" of the fractured bone followed by poor healing and nonunion of the fractured bone. This case illustrates a potential problem in the management of patients with femoral shaft fractures from prolonged BPs, most especially those who are on high doses for malignant conditions. However, considering the number of patients who benefit from BPs, this complication should not discourage clinicians from using these agents in patients where treatment is indicated.

Is There a Standard Rehabilitation Protocol After Femoral Intramedullary Nailing?

The purpose of this article was to describe the impairments and functional deficits associated with femoral shaft fractures treated with an intramedullary (IM) nail and to illustrate an evaluation-based rehabilitation program designed to target these functional deficits. The current literature describing management of diaphyseal femur fractures is replete with evidence regarding surgical management and optimal bone healing. However, a dearth exists with respect to postoperative rehabilitation recommendations, targeting the impairments that often limit return to activity. Current literature suggests that residual impairments after IM rod fixation of a femoral shaft fracture include hip abduction weakness, knee extensor weakness, anterior knee pain, and gait abnormalities. Any combination of these impairments can potentially limit the ability of a patient to return to prior levels of function. A rehabilitation program designed to target these impairments provides the best opportunity for a favorable outcome. REHABILITATION PROTOCOL: An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. Progression through the program is dependent on successful attainment of baseline goals. These goals address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. The program is a dynamic incorporation of interventions designed to target these known impairments. An evaluation-based rehabilitation protocol for femur fractures treated with an IM nail can facilitate restoration of function in a predictable manner and should be considered as a standard for patients with these injuries.

Management of femoral fracture in a patient with essential thrombocythemia treated with plateletpheresis and intramedullary rod fixation, followed by hydroxyurea: a case report

We describe the management of a patient with a femoral fracture who had asymptomatic essential thrombocythemia. When the diagnosis of essential thrombocythemia was made, the patient was treated with plateletpheresis to reduce the platelet count before intramedullary rod fixation of his fracture. His postoperative management included the examination of his peripheral blood as well as bone marrow, which confirmed that the cause of his elevated platelet count was due to JAK2 V617F mutation that is treated by hydroxyurea and aspirin after being discharged from the hospital.

Gustilo Grade IIIB Tibial Fractures Requiring Microvascular Free Flaps

Gustilo IIIB fractures involve high-energy tibial fractures for which there is inadequate soft tissue coverage. In addition to orthopedic fixation, these injuries require soft tissue reconstruction, often in the form of a microvascular free flap. Although the majority of orthopedic literature favorably compares intramedullary rod fixation to external fixation in open tibial fractures, these studies have not focused on the role of either method of fixation in relation to the soft tissue reconstruction. Because we had noted numerous complications after providing free-flap coverage over intramedullary rodded fractures, we sought to investigate whether there were differences in outcomes between free flap-covered lower-extremity fractures which were fixated by external fixation versus intramedullary rods. A retrospective chart review was performed on all patients in our institution who had lower-extremity free flaps for coverage of Gustilo IIIB fractures from 1995-2005 in relation to the type of bony fixation. Of the 38 patients studied, 18 underwent external fixation of the tibial fracture, and 20 had intramedullary rodding. Overall flap survival was 95%, with 1 failure in each group. However, the intramedullary rod group had higher incidences of wound infection, osteomyelitis, and bony nonunion (25%, 25%, and 40%, respectively) than the external fixation group (6%, 11%, 17%, respectively). For Gustilo IIIB fractures that require free-flap coverage, the added bony and soft tissue manipulation required for intramedullary rodding may disrupt the surrounding blood supply and lead to higher rates of complications that threaten the overall success of the reconstruction. Plastic and orthopedic surgeons should discuss the optimal method of bony fixation for complex tibial fractures when a free flap will likely be needed for soft tissue coverage. This integrated team approach may help minimize complications.

BOSENTAN, A NON-SPECIFIC ENDOTHELIN ANTAGONIST, STIMULATES FRACTURE HEALING

It is assumed that bosentan, a non-selective ET-1 receptor antagonist, will enhance fracture healing. The aim of this prospective randomized controlled study was to investigate the effects of transcutaneous bosentan administration into diaphyseal bone fractures using radiology, histology, prostaglandin E2 (PGE2) and leukotrien C 4 (LTC4) activity measurements. A closed diaphyseal fracture was created in the hind limbs following intramedullary rod fixation of Guinea pigs. Bosentan was administred by repetitive weekly 0.1 μg transcutaneous injections into the fracture site. The effects of bosentan were evaluated by radiology and histology on weeks 1, 2 and 4, whereas prostaglandin E2 (PGE2)-like and leukotrien C 4 (LTC4)-like activity was assessed on weeks 1 and 2. The radiological degree of union (p = 0.001) at the fracture site and cortex-callus ratio (p = 0.02) was significantly better in the bosentan administered site at week 1 when compared to the control. Histology presented an initial stimulation of bone formation on weeks 1 and 2 in the experimental group. PGE2-like activity was significantly higher (p = 0.002) on week 1 and 2 in the bosentan-administered side. LTC4-like activity remained constant on week one and decreased on week two. Transcutaneous repetitive bosentan administration into the fracture site initially stimulated periosteal bone healing that resulted with extracellular matrix mineralization. The inflammatory mediators PGE2/LTC4 played a significant role in this process.