Radiographic Fracture Healing Research Articles

Long-term functional outcomes of BIFOLD osteosynthesis in distal femoral fractures with metaphyseal comminution: A retrospective analysis

BackgroundThis retrospective study aimed to evaluate the long-term functional outcomes of BIFOLD osteosynthesis, employing retrograde nailing and distal femoral locked plating, in patients with distal femoral fractures and metaphyseal comminution. MethodsA retrospective analysis was conducted on patients treated for distal femur fractures with metaphyseal comminution between 2012 and 2022, with a minimum follow-up of 2 years. Inclusion criteria encompassed distal femur fractures with metaphyseal comminution, excluding specific conditions. BIFOLD osteosynthesis was employed in all 33 cases, utilizing retrograde SIGN (Surgical Implant Generation Network Nail) and distal femoral locking plates. Primary outcome measures included radiographic and functional outcomes assessed through the Sanders functional evaluation score, with secondary outcomes focusing on perioperative or postoperative complications. ResultsA total of 33 patients (21 male, 12 female) were included, with an average age of 51.4 years. BIFOLD osteosynthesis exhibited an average radiographic fracture healing time of 6.2 ± 2.5 months. The procedure's average operative time was 100 ± 15 min, and blood loss averaged 420 ± 50 ml. According to Sanders criteria, 28 patients (84.84 %) demonstrated well-to-excellent functional outcomes, while 3 patients (9.09 %) reported fair outcomes, and 2 patients (6.06 %) reported poor outcomes. No significant shortening or implant failure occurred, and all patients achieved over 90 degrees of knee range of motion within 8 weeks. One patient experienced superficial infection, and two patients exhibited insignificant coronal plane deformity. ConclusionBIFOLD osteosynthesis, combining intra and extra medullary fixation principles, offers a stable construct for distal femoral fractures with metaphyseal comminution. This approach facilitates faster ambulation, pain relief, early knee joint mobilization, and significant early union, resulting in improved functional outcomes. Additionally, BIFOLD osteosynthesis helps prevent collapse, translational and rotational deformities, as well as shortening.

Greater Socioeconomic Deprivation is Associated with Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures.

This study explored the hypothesis that social determinants of health (SDOH), including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation (ORIF) of humeral shaft fractures. Design: Retrospective. Single, academic, tertiary Level-I trauma center. Adults with midshaft humerus fractures (AO/OTA 12) treated operatively with plate fixation from 05/2011 to 05/2021 with a minimum follow-up of nine months. Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. SDOH were assessed using the Area Deprivation Index (ADI). Demographics, complications rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles. 196 patients fit the study criteria. The average age of the cohort was 47 years with 50 women (51%). Comparisons of the least deprived quartile (n=49) to the most deprived quartile (n=49) yielded similar sex distribution (59% vs 43% female, p=0.15), fewer non-white patients (8% vs 51%, p<0.01), older average age (51 years vs 43 years, p=0.05), similar BMI (30.5 vs. 31.8, p=0.45), and higher Charlson Comorbidity Index (CCI) (2.2 vs.1.1, p=0.03). While nonunion rates were similar (p=0.20) between groups, the most deprived quartile had 2.3 times greater odds of post-operative complications (p=0.04). Patients in the most deprived group exhibited higher PROMIS Pain Interference (PI) scores (p<0.01) and PROMIS Depression (D) scores (p=0.01), with lower PROMIS Physical Function (PF) scores (p<0.01) at 6-month follow-up than the least depriver cohort. The most deprived cohort had three times higher odds of missing scheduled appointments within the first post-operative year (p<0.01), resulting in a significantly higher no-show rate (p<0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments (p<0.01), no-show rates (p=0.04), and experiencing one of the following post-operative complications during recovery: Nonunion, radial nerve injury, or dysfunction (p=0.03). Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation, emphasizing that baseline socioeconomic disparities predict unfavorable post-operative outcomes even given favorable baseline health status according to the CCI score. Level III. See Instructions for Authors for a complete description of levels of evidence.

Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail.

Antegrade intramedullary nailing in humeral shaft fracture has been abandoned by certain orthopedic surgeons because of rotator cuff injury caused by first- and second-generation intramedullary nails (IMNs). However, only a few studies have specifically addressed the results of antegrade nailing for the treatment of humeral shaft fractures with a straight third-generation IMN; thus, complications need to be re-evaluated. We hypothesized that fixation of displaced humeral shaft fractures with a straight third-generation antegrade IMN with the percutaneous technique avoid shoulder problems (stiffness and pain) incurred by first- and second-generation IMNs. This was a retrospective, single-center, nonrandomized study of 110 patients with a displaced humeral shaft fracture between 2012 and 2019 treated surgically with a long third-generation straight IMN. Mean follow-up was 35.6 months (range, 15-44 months). There were 73 women and 37 men with a mean age of 64.7±19 years. All fractures were closed (37.3% 12A1, 13.6% 12B2, and 13.6% 12B3 AO/OTA classification). Mean Constant score was 82±19, Mayo Elbow Performance Score 96±11 and the mean EQ-5D visual analog scale score was 69.7±21.5. Mean forward elevation 150°±40°, abduction 148°±45°, and external rotation 38°±15°. Symptoms associated with rotator cuff disease were present in 6.4%. Evidence of radiographic fracture healing was detected in all but 1 case. One postoperative nerve injury and 1 adhesive capsulitis were present. Overall, 6.3% underwent second surgeries (4.5% were minor surgeries like hardware removal). Percutaneous antegrade intramedullary nailing of humeral shaft fractures with a straight third-generation nail considerably reduced complications related to shoulder problems and achieved good functional results.

Do peripheral melatonin agonists improve bone fracture healing? The effects of agomelatine and ramelteon on experimental bone fracture

Melatonin improves fracture healing, but the long-term use of melatonin seems impracticable in the treatment of fracture due to side effects caused by hormonal stress on chronological rhythm. Ramelteon (RAMEL) and agomelatine (AGO) are non-selective peripheral melatonin receptor (MT) agonists. This study investigated the effects on bone fracture healing of these MT agonists, which do not affect the central nervous system.The rats were divided into 6 groups, including Group 1 (SHAM): sham operated group; Group 2 (FRACTURE): femoral fracture control; Group 3 (FR + AGO30): femoral fracture + agomelatine 30 mg/kg; Group 4 (FR + AGO60): femoral fracture + agomelatine 60 mg/kg; Group 5 (FR + RAMEL3): femoral fracture + ramelteon 3 mg/kg; and Group 6 (FR + RAMEL6): femoral fracture + ramelteon 6 mg/kg.After 21 days, the rats were subjected to X-ray imaging. Bone healing was evaluated with hematoxylin-eosin (HE) staining. Messenger RNA (mRNA) expressions of bone formation markers, such as bone alkaline phosphatase (ALP), osteocalcin (OC), and osteopontin (OP), were evaluated by real-time polymerase chain reaction (RT-PCR) and with immunohistochemistry (IHC) staining.The radiographic fracture healing scores were statistically significantly higher in the FR + AGO60 group and the FR + RAMEL3 group than in the FRACTURE group. The histopathology and molecular results supported the radiographic results.It was shown that agomelatine and ramelteon increase bone fracture healing, leading to the conclusion that a preference for agomelatine, an antidepressant, and ramelteon, a sleep aid, will increase bone fracture healing in patients with fractures.

Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Clinical Outcomes of a Multicenter 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients.

To assess whether the fixation method and vitamin D supplementation affect the risk of patient-important outcomes within 12 months of injury in nongeriatric femoral neck fracture patients. A pilot factorial randomized controlled trial. Fifteen North American clinical sites. Ninety-one adults 18-60 years of age with a femoral neck fracture requiring surgical fixation. Participants were randomized to a surgical intervention (sliding hip screw or cancellous screws) and a vitamin D intervention (vitamin D3 4000 IU daily vs. placebo for 6 months). The primary clinical outcome was a composite of patient-important complications (reoperation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion). Secondary outcomes included fracture-healing complications and radiographic fracture healing. Eighty-six participants with a mean age of 41 years were included. We found no statistically significant difference in the risk of patient-important outcomes between the surgical treatment arms (hazard ratio 0.90, 95% confidence interval 0.40-2.02, P = 0.80) and vitamin D supplementation treatment arms (hazard ratio 0.96, 95% confidence interval 0.42-2.18, P = 0.92). These pilot trial results continue to describe the results of current fixation implants, inform the challenges of improving outcomes in this fracture population, and may guide future vitamin D trials to improve healing outcomes in young fracture populations. Although the pilot trial was not adequately powered to detect treatment effects, publishing these results may facilitate future meta-analyses on this topic. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is Ebselen A Therapeutic Target in Fracture Healing?

We investigated the effect of ebselen on fracture healing in an experimental fracture model. We divided rats into two groups, 6 rats in each: the experimental femur fracture control group and the ebselen treatment group with an experimental femur fracture. In the experimental femur fracture control group, we created only experimental femur fracture. In the ebselen treatment group, we administered ebselen treatment with creating an experimental femur fracture. We administered ebselen intraperitoneally at 5 mg/kg once daily for 1 month after the 1st day of experimental femur fracture in the ebselen treatment group. We evaluated the recovery status of fractured femurs at the end of 1st month with radiographic, histopathological, and immunohistochemical methods. According to the radiographic fracture healing scores, ebselen treatment increased the extent of new bone formation and fracture cartilage callus significantly compared to the control group. According to the histopathological recovery scores, ebselen treatment significantly improved healing scores compared to the control group. Ebselen treatment increased the expression scores of bone healing markers in the ebselen treatment group, such as vascular endothelial growth factor and osteocalcin, compared to the control group. We demonstrated that ebselen treatment increases the formation of new bone in the femur in an experimentally created femoral fracture model. Ebselen has been shown to improve the bone fracture healing in a radiological and histopathological manner, and more detailed studies are needed.

Effect of NSAID Use on Bone Healing in Pediatric Fractures: A Preliminary, Prospective, Randomized, Blinded Study.

This study aimed to investigate if nonsteroidal anti-inflammatory drugs (NSAIDs) used in the acute phase of bone healing in children with fractures result in delayed union or nonunion as compared with patients who do not take NSAIDs for pain control during this same time period. In this prospective, randomized, parallel, single-blinded study, skeletally immature patients with long bone fractures were randomized to 1 of 2 groups for their postfracture pain management. The NSAID group was prescribed weight-based ibuprofen, whereas the control group was not allowed any NSAID medication and instead prescribed weight-based acetaminophen. Both groups were allowed to use oxycodone for breakthrough pain. The primary outcome was fracture healing assessed at 2, 6, and 10 weeks. One-hundred-two patients were enrolled between February 6, 2014 and September 23, 2016. Ninety-five patients (with 97 fractures) completed a 6-month follow-up (46 patients with 47 fractures in the control group and 49 patients 50 fractures in the NSAID group). None achieved healing at 1 to 2 weeks. By 6 weeks, 37 of 45 patients (82%) of control group and 46 out of 50 patients (92%) of ibuprofen group had healed fractures (P=0.22). At 10 to 12 week follow-up, 46 (98%) of the control group fractures were healed and 50 (100%) of the ibuprofen group fractures were healed. All were healed by 6 months. Healing was documented at a mean of 40 days in the control group and 31 days in the ibuprofen group (P=0.76). The mean number of days breakthrough oxycodone was used was 2.4 days in the control group and 1.9 days in the NSAID group (P=0.48). Ibuprofen is an effective medication for fracture pain in children and its use does not impair clinical or radiographic long bone fracture healing in skeletally immature patients. Level I-therapeutic.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing.

Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic. The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15years. The characteristics of the primary fractures and treatment course were evaluated. Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277days, and in 5 of the 6 patients refractures occurred within 6months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%). Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

Quick-DASH as a main early outcome of humeral shaft fractures: A Latin American multicenter prospective study.

The main objective of this study was to evaluate the Quick-Disabilities of the Arm, Shoulder and Hand Score (DASH) score as the main early (90 days) outcome in a prospective multicenter observational Latin American study on isolated humeral shaft fractures. From December 2015 to April 2017, in six Latin American countries, patients 18 years or older with a closed, isolated nonpathological 12A, 12B, or 12C AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fractures were included. The 90 (±10)-day Quick-DASH score was used to compare the results of the different treatments. The secondary outcomes were patient treatment satisfaction, shoulder and elbow range of motion, and radiographic evaluation. A total of 92 patients successfully completed the Quick-DASH questionnaire. Surgical treatments resulted in better outcomes than nonsurgical treatment, but only minimally invasive plate osteosynthesis produced significantly lower Quick-DASH scores than nonsurgical treatment (p < 0.05). There were strong correlations between patient self-evaluation and the Quick-DASH score (p < 0.0005) but not between the Quick-DASH score and radiographic fracture healing. No significant difference was found between the treatments regarding the rate of return to work, but the medical center had a significant influence on treatment choice (p < 0.0005). The high correlation between Quick-DASH score and patient satisfaction and functional outcome indicates that the Quick-DASH questionnaire is a suitable tool for evaluating adult humeral shaft fracture outcomes. Patients with a Quick-DASH score below 15 could be considered recovered, and patients with a Quick-DASH score above 40 could be considered not yet recovered. Quick-DASH scores were not significantly associated with radiographic fracture healing.

Surgical Implant Generation Network Implant Follow-up: Assessment of Squat and Smile and Fracture Healing.

To evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond 1-year postoperation. Retrospective review of the Surgical Implant Generation Network (SIGN) database. The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy. One hundred fifty patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least 1 year (9-16 months) after surgery. None. We extracted clinical data and calculated scores for the S&S photographs and radiographs at the 1-year (9-16 month postoperative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using Radiographic Union Scale for Tibia fracture scores as the gold standard for fracture union. Of the 126 patients analyzed, 21% were found to have incomplete healing at 1 year, whereas 17% of the 64 patients with further follow-up past 1 year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good interrater reliability (k = 0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the 1-year follow-up. The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at 1 year. Fractures deemed incompletely healed by radiographic evaluation at 1 year after SIGN implant may still have the potential to heal over time. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Efficacy of Low Intensity Pulsed Ultrasound in Facilitating Mandibular Fracture Healing—A Blinded Randomized Controlled Clinical Trial

The aim of the study was to evaluate the role of low intensity pulsed ultrasound (LIPUS) in improving fracture healing in American Society of Anesthesiologists Class II patients with mandibular fractures. A randomized controlled clinical trial of 40 patients with mandibular fractures was conducted. The patients were randomly allocated to the study and control groups, with 20 members each. A standardized surgical protocol was followed to manage the fractures by open reduction and internal fixation. After fixation, the study group received LIPUS stimulation (1.5MHz, 30mW/cm2) on postoperative days 4, 8, 14, and 20 for 20minutes daily; the control group received no LIPUS stimulation. The outcome parameters assessed were postoperative pain, wound healing, teeth mobility, and radiographic and ultrasound fracture healing. The study variables were analyzed using the independent samples t test or Mann-Whitney U test. The pain score was reduced in the study group on all postoperative days (P<.001). The mean amount of wound healing was better in the study group than in the control group on days 5 and 9 (P<.004 and P<.019, respectively). The mean score for the ultrasound assessment of fracture healing was greater in the study group, with a statistically significant difference. LIPUS application reduced postoperative pain and facilitated fracture healing in patients with compromised healing potential.

Clinical and Radiological Outcomes of Minimally Invasive Reduction and Percutaneous K-wire Fixation for Intra-articular Calcaneal Fractures.

There has been much controversy over the optimal operative treatment of intra-articular calcaneal fractures. Open reduction and internal fixation is associated with a high incidence of postoperative soft tissue complications. This study sought to evaluate the outcomes of indirect reduction and percutaneous K-wire fixation for displaced intra-articular calcaneal fractures. This was a prospective study of 40 consecutive patients with 44 Sanders type II or III intra-articular calcaneal fractures who had undergone closed or mini-open reduction and percutaneous K-wire fixation from 2013 to 2016. The Maryland Foot Score and visual analog scale score for pain were used to assess functional outcomes and postoperative patient satisfaction. Twenty-two patients were men and 18 patients were women, with a mean age of 34.5 years. According to the Sanders classification, 26 fractures were type II and 18 were type III. Mean follow-up was 31.9 months. The clinical outcome was satisfactory for 36 fractures (81.8%) and unsatisfactory for 8 fractures (18.2%). Mean time of radiological union was 8.7 weeks. Mean full weight-bearing time was 13 weeks. Mean visual analog scale score was 1.4 when radiographic fracture healing was detected. Repeated follow-up radiographs showed no loss of reduction or collapse of the posterior facet. Closed or mini-open reduction and percutaneous K-wire fixation of Sanders type II or III calcaneal fractures has excellent functional outcomes with minimal soft tissue complications. [Orthopedics. 2020; 43(2): 97-101.].

Study protocol: design and rationale for an exploratory phase II randomized controlled trial to determine optimal vitamin D3 supplementation strategies for acute fracture healing

BackgroundObservational studies have found that 75% of healthy adult fracture patients (ages 18–50) have serum 25-hydroxyvitamin D (25(OH)D) levels < 30 ng/mL. Although lower serum 25(OH)D levels have yet to be correlated to fracture healing complications or poor fracture outcomes, many orthopedic surgeons are routinely prescribing vitamin D supplements to improve fracture healing in healthy non-osteoporotic patients. To address this gap in the literature, we propose a phase II exploratory randomized controlled trial comparing three vitamin D3 dosing regimens for early surrogate treatment response.MethodsWe will conduct a 4-arm blinded exploratory phase II trial in 96 adults aged 18–50 years with a closed or low-grade open (Gustilo type I or II) tibial or femoral shaft fracture. Eligible patients will be randomized in equal allocation ratio of 1:1:1:1 to one of the treatment groups: (1) 150,000 IU loading dose vitamin D3 plus daily dose placebo; (2) loading dose placebo plus 4000 IU vitamin D3 per day, (3) loading dose placebo plus 600 IU vitamin D3 per day, or (4) loading dose placebo plus daily dose placebo. The primary outcome is fracture healing, assessed as follows: (1) clinical fracture healing measured using the Function IndeX for Trauma, (2) radiographic fracture healing measured using the Radiographic Union Score for Tibial fractures, and (3) biological fracture healing measured using serum levels of cross-linked C-terminal telopeptides of type I collagen and amino-terminal procollagen propeptides of collagen type I. The main secondary outcome will be assessed by measuring serum 25(OH)D levels. All outcome analyses will be exploratory and adhere to the intention-to-treat principle. Per-protocol sensitivity analyses will also be conducted.DiscussionStudy results will be disseminated through a publication in an academic journal and presentations at orthopedic conferences. Study results will inform dose selection for a large definitive randomized controlled trial and provide preliminary clinical data on which dose may improve acute fracture healing outcomes in healthy adult patients (18–50 years) at 3 months.Trial registrationVita-Shock (A Blinded Exploratory Randomized Controlled Trial to Determine Optimal Vitamin D3 Supplementation Strategies for Acute Fracture Healing) was registered at ClinicalTrials.gov (identifier NCT02786498) prior to enrollment of participants.

Surgical Results of Plantar Plating for Fifth Metatarsal Stress Fracture

Category:Midfoot/Forefoot, Sports, TraumaIntroduction/Purpose:The treatment of 5th metatarsal stress fractures of the can be challenging and at times can result in significant disability. Intramedullary screw fixation has become a popular surgical method for management. However, many recent reports have described failures after screw fixation in athletes. The aim of this study was to determine rates of clinical and radiographic fracture healing, return to sport, and complications of elite athletes with proximal fifth metatarsal fracture treated with plantar plating.Methods:Thirty-eight patients with fifth metatarsal stress fractures treated using the plantar plating technique in four hospitals from 2013 to 2018 were evaluated retrospectively. All of the patients were elite athletes. Demographic data, radiographic evaluation, and the time until union and return to unrestricted sporting competition were collected and analyzed.Results:A total of 38 patients underwent the plantar plating for 5th metatarsal stress fracture with a mean follow-up of 23 months (range, 12-49 months). The mean time to radiologic union as determined by CT was 9.3 weeks (range, 8-16 weeks). However, during follow-up, there were 4 refractures but no union problems. One patient experienced temporary sensory disturbance that resolved within 3 months. There was one patient with temporary wound complication, two cases with hardware prominence. All but one patients were able to return to their previous levels of sporting activity at 21 ± 4 (range, 18 to 40) weeks.Conclusion:With minimum 1-year follow-up, the described plantar plating technique is a good alternative method for the surgical treatment of fifth metatarsal stress fractures with less complications.

Long-term clinical and radiographic results after lag screw ostheosynthesis of short incomplete proximal sagittal fractures of the proximal phalanx in horses not used for racing.

To determine long term outcomes of nonracing equines athletes treated for short incomplete proximal sagittal fractures of the proximal phalanx (SIPSFP1) by lag screw fixation. Retrospective study. Thirty-one horses. Medical records from horses with an SIPSFP1 (2008-2014) were reviewed. Long-term (≥12 months) outcomes were assessed with telephone interviews and clinical and radiographic examinations. Warmblood was the predominant breed in cases included in the study. Among horses with long-term interview information, 27 of 31 returned to previous athletic activity level. In total, 15 horses with 19 fractures had clinical and radiographic assessment after a minimum of 12 months. Among those, nine of 15 horses were sound at the trot, and six of 15 were mildly lame. Complete radiographic healing was confirmed in six limbs, and the facture line was evident in 13. The position of the proximal screw was not associated with radiographic fracture healing or return to soundness. Most horses treated for SIPSFP1 with lag screw fixation returned to previous activity levels, although radiographic fracture healing remained incomplete 12 months or more after surgery. Lag screw fixation is a valid treatment for horses not used for racing that are experiencing an SIPSFP1 and results in a high rate of return to intended use, although complete radiographic fracture healing cannot be expected.

Short-term daily teriparatide improve postoperative functional outcome and fracture healing in unstable intertrochanteric fractures

BackgroundThere has been heightened interest in the effect of osteoanabolic agents on acceleration of fracture healing. ObjectivesThe purpose of this study was to identify whether short-term daily teriparatide prescribed for osteoporosis treatment would improve postoperative outcomes including clinical scores, radiographic healing, and complication rates. MethodsBetween 2014 and 2017, we retrospectively assessed 112 patients who underwent closed reduction and internal fixation with proximal femoral nail (PFN) for unstable intertrochanteric fractures. In 60 of 112 patients, patients were treated with a PFN alone (group I). These patients were compared with 52 patients for whom the same device was used and a daily subcutaneous injection of teriparatide (1–34 PTH, Forsteo®) was prescribed postoperatively (group II). Teriparatide was administered by nurses during a hospital stay and then self-injection was monitored by follow-up visits to the outpatient clinic after discharge. Questionnaire surveys were conducted and patients completed a self-report Harris hip score (HHS) and visual analog scale (VAS) scores. ResultsTeriparatide therapy significantly increased HHS (p = 0.02) and decreased VAS pain scores (p = 0.008). The mean time to fracture healing post-operatively was 14.8 weeks (SD 7.1) and 12.1 weeks (SD 6.4) in group I and II, respectively (p = 0.002). The frequency of patients reporting postoperative complications was also markedly reduced in the teriparatide-treated groups (p = 0.028). ConclusionsShort-term daily teriparatide used for osteoporosis treatment improved radiographic fracture healing of a hip fracture and reduced complication rates. However, because of the limited power of the study, additional randomized placebo-controlled trials are needed to determine the potential benefit of PTH as an adjunct to enhance fracture healing and its efficacy in broader populations with varying comorbidities and fracture types.

Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2\u2009\xd7\u20092 factorial randomized controlled trial in young femoral neck fracture patients

BackgroundFemoral neck fractures in patients ≤ 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial.MethodsWe will conduct a multicenter, concealed randomized controlled pilot study, using a 2 × 2 factorial design in 60 patients aged 18–60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed.DiscussionResults of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations.Trial registrationThe FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant.

Surgical treatment of mid-shaft clavicle fractures by minimally invasive internal fixation facilitated by intra-operative external fixation: A preliminary study

BackgroundMid-shaft clavicle fractures are common and may require surgery. The objective of this study in adults with high-risk mid-shaft clavicle fractures was to evaluate the clinical and radiological outcomes of a minimally invasive surgical technique involving a minimally invasive approach, fracture reduction, temporary intra-operative external fixation, and locking plate internal fixation. HypothesisThis minimally invasive surgical technique for mid-shaft clavicle fractures ensures satisfactory radiographic fracture healing and medium-term functional outcomes, with a short immobilisation, rapid return to sports, and low complication rate. Material and methodA retrospective review was performed of patients managed using our minimally invasive surgical technique between 1 January 2012 and 31 December 2016. The primary outcome measure was the 3-month radiographic healing rate. The secondary outcome measures were duration of post-operative immobilisation, 3- and 6-month QuickDASH scores, and post-operative complications. ResultA total of 19 patients were included, 18 males and 1 female with a mean age of 37 years. Radiographic healing was consistently achieved within 3 months. Immobilisation duration was 3 weeks. The mean QuickDASH score was 23.75 after 3 months and 7.5 after 6 months. Return to sports occurred after 3 months. The only complication was transient paraesthesia in the distribution of the C8 nerve root in 1 patient. DiscussionThe management of mid-shaft clavicle fractures remains controversial. The high complication rates associated with conventional surgical techniques make treatment decisions difficult. A surgical technique characterised by temporary intra-operative external fixation to facilitate minimally invasive internal fixation may have a lower complication rate and shorter immobilisation requirements compared to conventional surgery. Level of evidenceIV, retrospective observational study.

Treatment of Bennett fractures with tension-band wiring through a small incision under loupes and a headlight

ABSTRACTPurpose: The aim of the study was to present a novel treatment strategy for Bennett fractures using a tension-band wiring technique performed through a small incision with loupes and a headlight. Additionally, this study compared this technique with the conventional percutaneous pinning technique.Methods: Between January 2014 and January 2017, the tension-band wiring technique was used in 37 patients with Bennett fractures (study group). The range of motion, pinch and grip strengths, and hand function were assessed at the final follow-up. A control group comprising 35 patients treated with the percutaneous pinning technique was included in the study for comparison. A p-value <0.05 was considered statistically significant. (Clinical Trial Registration number: ISRCTN64894535 at http://www.isrctn.com/ISRCTN64894535)Results: No fixation failure or infection occurred in either group. Radiographic fracture healing was achieved in all cases. Follow-up lasted over 1 year. The mean Kapandji opposition score was 9.31 (range 8–10) points in the study group and 8.45 (range 7–10) points in the control group (p < 0.05). The mean Disabilities of the Arm, Shoulder, and Hand score was 1.06 (range 0–2) in the study group and 1.77 (range 0–3) in the control group (p < 0.05). The mean Smith and Cooney Score were 90 (range 80–100) in the study group and 85 (range 75–100) in the control group (p < 0.05).Conclusions: The tension-band wiring technique using loupes and headlights enables reduction and fixation of Bennett fractures under direct visualization of the deep operative field. Restoration of thumb function using the tension-band wiring technique is significantly better than that observed with the conventional percutaneous pinning technique.

Does short-term weekly teriparatide improve healing in unstable intertrochanteric fractures?

Level IV, therapeutic study.