Solid Bony Union Research Articles

Evaluation of arthroscopic ankle fusion for diabetic ankle fractures

Background Ankle fractures are a very common orthopedic trauma. One in eight patients undergoing ankle fixation is diabetic. Most of these patients also have additional comorbidities including peripheral arterial disease and diabetic neuropathy. Therefore, on one hand surgical intervention can pose challenges for wound healing and risk of infection, but non-operative management increases the risk for loss of reduction and therefore stresses the condition of the surrounding soft tissue. The aim of this work was to observe the radiological and functional outcome of arthroscopic ankle fusion in diabetic ankle fractures. Methods This prospective study was carried out on 20 patients, both sexes, with clinical criteria of displaced ankle fractures in diabetics, adults, closed ankle fractures, isolated trauma, diabetic patients with neuropathy and Adelaide Fracture in the Diabetic Ankle score more than or equal 5. Results Fourteen cases had solid bony union at a mean of 27.2 weeks while six cases had stable ankles with stiff fibrous nonunion at the end of the follow up period. Two of which had a breakage of distal locking screws. However, stiff fibrous nonunion of tibio-talar joint with the foot in a stable plantigrade position was considered satisfactory and no further intervention was advised. Our limb salvage rate was 100%. No below knee amputation was done. Conclusions Ankle fractures in diabetic patients are increasingly frequently encountered in comorbid patients with suboptimal overlying soft tissue integrity. Arthroscopic assisted ankle fusion can be considered a valid primary definitive treatment option to help reduce the potential perioperative soft tissue insult and associated complications. Utilizing an arthroscopic-assisted approach to this procedure is of added benefit in allowing for articular preparation and thereby reducing the risk of non-union while also minimizing additional extensive soft tissue insult in patients with underlying soft tissue compromise.

Primary dynamic interlocking nail in femoral shaft fracture: A case series

Introduction and importanceFemoral shaft fracture is one of the most frequent injuries encountered by an orthopedic surgeon. Surgical treatment is commonly needed. Intramedullary nailing remains the gold-standard in surgical treatment of femoral shaft fracture. One of the constant dilemmas in intramedullary nailing is whether to use a static or dynamic locking screw for treating femoral shaft fractures. Case presentationWe reported three cases of simple femoral shaft fracture and surgically fixed with primary dynamic interlocking nail. Closed reduction with reamed nail was performed in 2 cases, and mini open reduction with un-reamed nail was performed to the other one. Early weight bearing was instructed at day 1 post-operative. Mean follow-up period was 12.6 months. A solid bony union was achieved by all patients, and no complications were observed at the final follow up. Clinical discussionIntramedullary nailing can be made static or dynamic. It is thought that in static mode of the intramedullary nailing, the axial weight is transferred through the locking screws rather than the fracture site, thus altering the callus formation and delaying fracture healing. A prompt dynamization of the fragments allows the contact of both fragments during mobilization and promotes early callus formation. ConclusionPrimary dynamic interlocking nail is an effective option for surgical treatment in simple or short oblique femoral shaft fracture.

Full-Endoscopic Anterior Odontoid Screw Fixation: A Novel Surgical Technique.

ObjectiveFirst, to propose a novel minimally invasive technique of full‐endoscopic anterior odontoid fixation (FEAOF) that aims to reduce the risk of retropharyngeal approach (both open and percutaneous techniques) to anterior odontoid screw fixation. Second, to describe steps of the procedure and, lastly, to report the initial outcomes in patients treated with this novel technique.MethodsFour non‐consecutive patients who were diagnosed with a displaced odontoid fracture (Anderson‐D'Alonzo classification type II and Grauer subclassification type A or B) from 2019 to 2020 underwent surgical fixation by our novel technique for anterior odontoid screw fixation. A detailed technical approach of FEAOF for the surgical treatment of type II odontoid fractures was described, and the patients' outcomes based on postoperative radiographic results including computed tomography (CT), clinical outcome parameters including visual analogue scale (VAS) for neck pain both preoperatively and at postoperative follow‐up, and range of neck motion at the final follow‐up were reported.ResultsThe mean age was 33.5 years (24–41), three patients were male. The mean operative time was 93.75 min, and the mean blood loss was 7.5 ml. An immediate post‐operative thin‐sliced CT showed that all patients achieved satisfactory reduction and proper screw position. No screw malposition or penetration was found. At a 6‐month follow‐up, a thin‐sliced CT demonstrated solid bony union in every case. The mean VAS for neck pain was reduced from 6.5 to 0.6 at the 6‐months follow‐up. At the final follow‐up, all patients showed improvement in ranges of motion without any complications; however, one patient was lost to follow‐up.ConclusionsFEAOF is a feasible and effective option for treating type II odontoid fractures. The procedure is less invasive than other techniques and provides clear direct visualization of the involved structures.

Comparative study of functional outcome of unilateral locking plate and dual plating in the treatment of bicondylar proximal tibia fractures

Background: Proximal Tibia Fracture (PTF) includes different fracture patterns with varied degrees of articular depression and displacement. Many kinds of fixators, including newly designed plate with locking screws were applied to treat these complicated fractures. We intended to follow up the surgical outcomes of 1. Unilateral locking plate and 2.Classic dual plates. Materials and Methods We retrospectively reviewed 66 patients with PTF, Schatzker types V and VI, who we operated in our institute. Excluding patients who expired due to other medical conditions and without complete follow-up. e scheme of surgical intervention was designed by visiting staff, and 15 patients, as Group I, were treated with unilateral locking plate. e other 19 patients, as Group II, were treated with classic dualplates (one lateral approach locking compression plate (LCP)+medial anti-gliding plate). All patients were under periodic follow up at about 6 weeks interval for at least 18 months postoperatively. Results: In Group I, 11 cases achieved solid bony union without obvious traumatic OA change, limitation of ROM, or malalignment. In Group II, 17 patients reached the same goal, respectively. By analysis of the recorded parameters with statistical software (SPSS 12.0), there were five parameters with significant difference, including Schatzker classification, Operation time, Staged treatment done or not done, Period of hospitalization and Hardware impingement. Conclusion: Our study shows Dual plating provides better stability and outcome than unilateral plate fixation for Schatzker type V and type VI fractures. On clinical follow up one should keep a close eye.

Minimally invasive surgery for paravertebral or psoas abscess with spinal tuberculosis \u2014 a long-term retrospective study of 106 cases

BackgroundMinimally invasive surgery (MIS) is a common treatment option for paravertebral or psoas abscesses (PAs) in patients with spinal tuberculosis (ST). However, its efficacy remains controversial. The aim of the study was to evaluate the efficacy of MIS for PA with ST combined with anti-tuberculous chemotherapy.MethodsA total of 106 consecutive patients who underwent MIS for ST with PA from January 2002 to Oct 2012 were reviewed. The MIS involved computed tomography (CT)-guided percutaneous catheter drainage and percutaneous catheter infusion chemotherapy. Clinical outcomes were evaluated based on the changes observed on preoperative and postoperative physical examination, inflammatory marker testing, and magnetic resonance imaging (MRI).ResultsThe mean follow-up period was 7.21 ± 3.15 years. All surgeries were successfully completed under CT-guidance without intraoperative complications and all patients experienced immediate relief of their symptoms, which included fever and back pain. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination.ConclusionMIS carries advantages in terms of less invasiveness, precise drainage, and enhanced local drug concentration. While the technique has not been fully characterized and clinically prove, its use in addition to conservative chemotherapy and open debridement and instrumental fixation may be recommended for patients with ST and PA.

Outcomes Following Open Reduction and Internal Fixation in Proximal Phalangeal Fracture with Rotational Malalignment.

Background: The rotational malalignment in proximal phalanx fracture is unacceptable. Authors attempted to describe clinical and radiographic outcomes as well as complications after open reduction and internal fixation with screw only or plate for phalangeal fractures accompanied by rotational malalignment. Methods: Authors conducted a retrospective review of 46 patients who had been treated between Jan. 2010 and Dec. 2016. The average follow-up period was 16.7 months. A total active motion (TAM), Disability of Arm, Shoulder and Hand score (DASH), and tip pinch power between thumb and fractured finger were measured at the final follow-up. Complications were investigated during the follow up. We assessed the amount of rotation by measuring angle between 3rd ray and fractured finger. The measurement was divided into two groups depending on rotation direction, divergent and convergent direction group. Results: Twenty-eight cases were fixed with mini LCP plate, 12 cases with lag screws, and rest 6 cases with combined. All patients showed solid bony union on radiographs on average follow-up of 68 days (range, 41-157 days). Average TAM of the injured finger was 244 degrees and average DASH score was 4.9 at the last follow-up. Tip pinch power was 3.2 kg, which was not significantly different from that of the contralateral side at 3.4 kg (p = 0.21). The preexisting rotational angle was significantly adjusted (overall, 11.1°). Depending on rotation direction, preoperative 21.7° to postoperative 12.1° in 27 patients of convergent group and preoperative -5.0° to postoperative 8.3° in 19 patients of divergent group were achieved. Conclusions: The rotation from proximal phalanx fractures could be corrected with anatomic reduction by open reduction. Our results showed that open reduction and rigid internal fixation after physical examination for acute proximal phalanx fractures accompanied by rotational malalignment could achieve good clinical results.

Operative treatment of chronic ulnar collateral ligament humeral origin avulsion fracture in young baseball players.

Chronic ulnar collateral ligament humeral origin avulsion fracture in young baseball players is a rare condition and a difficult problem to treat. Eight high school or college student baseball players with onset of symptoms in their adolescent ages were collected in this series. Their mean age at surgical intervention was 17.8 ± 1.99 years. The fracture was operated on with muscle splitting, ulnar nerve-sparing technique. Suture anchors were employed to fix the avulsed fragment. Visual analog scale, Mayo elbow performance score, and Conway scale were used for objective patient evaluation. The patients were followed up for 30.8 ± 10.2 months. Six patients have achieved solid bony union, and 2 had partial union. All patients showed no medial space widening on followed-up stress films. Visual Analogue Scale score improved from 9 to 0. The Mayo elbow performance score improved from 60 ± 10 to 85 ± 15 points pre- and post-operatively. The Conway scale had 3 excellent, 3 good, and 2 fair results. The average return to pitching occurred 7 months post-operatively at a rate of 75%. The present results indicate that open reduction and fixation with suture anchors is an effective treatment method for chronic ulnar collateral ligament humeral origin avulsion fracture in young baseball players.

The effect of insulin dependent diabetes on bone metabolism and growth after spinal fusion

STUDY DESIGNExperimental animal model. OBJECTIVEThe purpose of this study was to evaluate the hypothesis that insulin dependent diabetes mellitus (IDDM) will inhibit the formation of a solid bony union after spinal fusion surgery via an alteration of the microenvironment at the fusion site in a rat model. SUMMARY OF BACKGROUND DATAPrevious studies report diabetes mellitus (DM) and specifically IDDM as a risk factor for complications and poor surgical outcomes following spinal fusion. METHODSTwenty control and 22 diabetic rats were obtained at 5 weeks of age. At 20 weeks of age, all animals underwent posterolateral lumbar fusion surgery using a tailbone autograft with diabetic rats receiving an implantable time release insulin pellet. A subset of rats was sacrificed 1-week postsurgery for growth factor (PDGF, IGF-I, TGF-β, and VEGF) and proinflammatory cytokine ELISA analysis. All other rats were sacrificed 3-months postsurgery for fusion evaluation via manual palpation and micro CT. Glycated hemoglobin (HbA1c) was measured at surgery and sacrifice on all animals. RESULTSCompared with healthy rats undergoing spinal fusion, rats with IDDM demonstrated a significant reduction in manual palpation fusion rates (16.7% vs. 43%, p<.05). Average bone mineral density, bone volume, and bone volume fraction were also significantly reduced and negatively correlated to blood glucose levels. IL-1B, IL-5, IL-10, TNF-α, and KC/GRO were significantly elevated in fusion beds of IDDM rats. CONCLUSIONSThis study demonstrates that rats with IDDM demonstrate a reduced rate and quality of spinal fusion with increased local levels of inflammatory cytokines. Targeted modalities are required to improve bone healing in this growing, high-risk population. CLINICAL SIGNIFICANCEThis is the first translational animal model of IDDM to evaluate the rate and quality of spinal fusion while controlling for other surgical and patient-related risk factors. Our findings demonstrate the complex nature by which IDDM impairs bone healing and highlight the need for additional basic science research to further elucidate this mechanism in order to develop more effective therapeutic interventions.

Evaluation of Kangli hollow screws with sliding compression locking plate system for treatment of femoral neck fractures

Objective To evaluate Kangli hollow screws with sliding compression locking plate system (KHS) in the treatment of femoral neck fractures. Methods From February 2015 to October 2016, 47 femoral neck fractures were treated at Department of Orthopaedics, Wuhan Fourth Hospital, Wuhan Puai Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology. They were 30 men and 17 women, aged from 26 to 68 years (average, 43.5 years). According to the Pauwels classification, there were 24 cases of type Ⅰ, 16 cases of type Ⅱ and 7 cases of type Ⅲ; according to the Garden classification, there were 23 cases of type Ⅱ, 19 cases of type Ⅲ and 5 cases of type Ⅳ. All the fractures were immobilized with KHS after closed reduction or open reduction (3 cases). The fracture union time, femoral head necrosis and femoral neck shortening were observed after operation. The Harris scores were used to evaluate therapeutic effects at the final follow-up. Results All the patients were followed up for an average of 29.7 months (from 22 to 39 months). All the fractures obtained solid bony union after 9 to 15 weeks(average, 12.2 weeks). Femoral head necrosis occurred in one case (2.1%). Femoral neck shortening ≤ 5 mm was observed in 6 cases and femoral neck shortening >5 mm <10 mm in 2 cases, giving a total shortening rate of 17.0%. The Harris scores at the final follow-up ranged from 77 to 98 points, averaging 92.2 points. There were 42 excellent, 3 good and 2 moderate cases, giving an excellent and good rate of 95.7%. Conclusion KHS can lead to excellent therapeutic effects in the treatment of femoral neck fractures. Key words: Femoral neck fractures; Fracture fixation, internal; Bone plates; Therapeutic effect

The impact of type 2 diabetes on bone metabolism and growth after spinal fusion

BACKGROUND CONTEXTSome clinical reports suggest diabetes may have a negative effect on spinal fusion outcomes, although no conclusive experimental research has been conducted to investigate the causality, impact, and inherent risks of this growing patient population. PURPOSETo analyze the hypothesis that type 2 diabetes (T2DM) inhibits the formation of a solid bony union after spinal fusion surgery by altering the local microenvironment at the fusion site through a reduction in growth factors critical for bone formation. STUDY DESIGN/SETTINGIn vivo rodent model of type 2 diabetes. METHODSTwenty control (Sprague Dawley, SD) and 30 diabetic (Zucker Diabetic Sprague Dawley, ZDSD) rats underwent posterolateral and laminar fusion surgery using a tailbone autograft implanted onto the L4/L5 transverse processes. A subset of animals was sacrificed 1-week postsurgery for growth factor analysis. Remaining rats were sacrificed 3-month postsurgery for fusion evaluation via manual palpation, micro-CT, and histology. RESULTSThere was no significant difference in the manual palpation fusion rate between ZDSD rats and SD control rats. Growth factor assay of fusion site explants at early sacrifice demonstrated PDGF was upregulated in the ZDSD rats. TGFB, IGF, and VEGF were not statistically different between groups. Bone mineral density as determined by micro-CT was significantly lower in ZDSD rats compared to SD controls and was a significant function of HbA1c. CONCLUSIONSData generated in this in vivo rat model of T2DM demonstrate that the metabolic dysregulation associated with the diabetic condition negatively impacts the quality and density of the formed fusion mass. Increased measures of diabetic status, as determined by blood glucose and HbA1c, were correlated with decreased quality of formed fusion, highlighting the importance of diabetic status monitoring and regulation to bone health, particularly during bone healing. CLINICAL RELEVANCET2DM rats demonstrated increased rates of infection, metabolic dysregulation, and a reduction in spinal fusion consolidation. Clinicians should consider these negative effects during preoperative care and treatment of this growing patient population.

Odontoid Fracture in Patients Age >75 Years Surgically Managed by the Harms Technique: Bone Healing and 1-Year Mortality Rate in 57 Cases

Odontoid fracture is the most common lesion of the cervical spine in persons age >70 years. Management of these fractures has become a public health issue. In this study, we evaluated bone fusion, early complications, and mortality in a cohort of patients age >75years who underwent surgical management of odontoid fracture using the Harms technique. This study is a retrospective analysis of 57 patients treated surgically between 2002 and 2016 in a single spine surgery institution. Age at diagnosis, comorbidities, and American Society of Anesthesiologists (ASA) score were analyzed. At a 6-month follow-up, bone healing was evaluated with computed tomography scans. The mean patient age was 85.5 ± 6.6 years, and 53% of the patients had an ASA score ≥3. According to the Anderson classification, 70% of the patients had a type 2 odontoid fracture. The average duration of follow-up was 15.7 months. Ten patients were lost to follow-up. The rate of early complications was 19%, with no mechanical complications reported. At a 6-month follow-up, a solid bony union was seen in all patients. The 1-year mortality was 14%. Surgical management of odontoid fractures in elderly patients using the Harms technique is associated with an excellent rate of bone healing with acceptable rates of early complications and mortality.

Distal humerus nonunions after failed internal fixation: Treatment with Ilizarov external fixator

Introduction/Objective. Nonunions of distal humerus after unsuccessful surgical treatment represents challenging surgical problem. The complexity of this condition is increased by bone atrophy, scar tissue, poorly vascularized bone fragment, limited elbow mobility, osteomyelitis and local neurological damage. The advantages of using Ilizarov external fixation method are stable fixation, adequate fracture reduction and fragment compression accompanied by minimal soft tissue trauma, with the possibility of early elbow mobilization. This aim of this paper is to present the treatment results of 19 patients with nonunion of distal humerus after internal osteosynthesis managed by Ilizarov external fixation method. Methods. nineteen consecutive patients were treated with the Ilizarov external fixator. The study group includes 11 male and 8 female patients with an average age of 42 years. Surgical technique consisted of approaching the nonunion, removing loose fixation material, making resection and debridement of bone fragments, after which Ilizarov fixator was placed. Rehabilitation of the elbow started in early postoperative period. The functional status of the arm was evaluated using the DASH score (Disabilities of the Arm, Shoulder and Head). Results. All patients achieved solid bony union after average 7 months from application of external fixator. In 17 patients radiographic analysis indicated the preservation of joint space, while two showed degenerative changes. All patients showed improvement in elbow range of motion and significantly better DASH score with postoperative value of 21. Conclusion. As treatment of distal humerus nonunion, Ilizarov external fixation method provides successful healing and increased range of motion in the elbow.

En bloc resection, intraoperative extracorporeal irradiation and re-implantation of involved bone for the treatment of limb malignancies.

Reconstruction of the defect following limb-sparing resection of malignant bone tumors is controversial and extremely challenging. Extracorporeal irradiation (ECI) and re-implantation have been used for limb salvage surgery for patients, with major advantages, including biological reconstruction, ready availability and preservation of bone stock, over replacement with a megaprosthesis. The purpose of the present study was to present our experience and details of all patients treated with this surgery. Between June 2005 and December 2014, we followed-up 23 patients with limb malignancies who were treated with en bloc excision followed by 50-Gy single dose ECI and re-implantation of involved bone segments. All cases were evaluated based on clinical and radiological examinations, complications and Musculoskeletal Tumor Society (MSTS) score. Mean follow-up period was 77.6 months (range, 17-116 months). A total of 17 patients (73.9%) demonstrated no evidence of disease, 5 (21.7%) patients succumbed to the disease and 1 (4.3%) patient was alive with the disease at the final follow-up. Local recurrence occurred in 3 patients (recurrence rate, 13.0%) in the bed outside of the irradiated graft, and 4 of the 5 patients that lost their lives did so due to associated metastatic disease. The mean value of the MSTS score was 78.8% (50-93.3%). The majority of patients demonstrated solid bony union; however, 3 patients had non-union (13.0%) and 1 had a delayed union (4.3%). Early or late complications occurred in 11 patients (47.8%). Although the complication rate (47.8%) and re-operation rate (39.1%) were high, ECI and re-implantation may be a useful and cheap technique following en bloc resection for limb salvage in appropriately selected patients.

Kirschner Wire Fixation of Neglected Lateral Condylar Fracture of the Humerus in Children

Background: Delayed presentation of lateral condylar fractures of the humerus is relatively common in the developing regions of the world. Fractures of lateral condyle of humerus in pediatric age group, the most common being distal humerus epiphyseal injury, are commonly associated with delayed presentation to terminal health care providers. Materials and Methods: Twenty-one children having fracture of lateral condyle of humerus with duration of trauma more than 3 weeks were included in the prospective study. Among the 21 patients, 13 were male and 8 were female. Average time of presentation was after 3 weeks of injury. All patients had Milch type II injury. The patients were treated by open reduction and internal fixation using Kirschner wire. The outcome assessment according to the scoring system proposed by Dhillon et al. was used. Result: Mean month at operation is 81.5 months (range, 64-112 months); 8 Right/13 Left. Reason for presentation: Pain, swelling in 12; Pain, decreased elbow motion in 7; Restriction of the elbow flexion in 2. Time from injury to Operation with mean 6.34 weeks, 3 weeks-≤ 6 weeks in 13 Patients, and > 6 weeks in 8 patients; Previous treatment: Plaster cast in 15 Patients, and No treatment in 6 Patients; Mean time of Follow-up: 66 Months; Mean Age at last Follow-up was 11.6 (range, 8.4-15.0). To tell result, 38.1% is in Excellent; 33.3% is in Good; 14.3% is in Fair; and 14.3% is in Poor. Comparison of accepted result from time of injury to operation was 3-6 weeks better than over 6 weeks with P Valuate 0.001387. There were AVN in 1 case, Nonunion in 2 cases. Conclusion: Osteosynthesis by Kirschner wire without bone grafting could provide solid bony union and improve elbow function. However, this technique could not prevent an angular deformity completely. Corrective osteotomy should be considered in patients with valgus or varus deformities.

Distal humerus fractures nonunion with elbow stiffness in working adults: Can triple tension band technique and Lambda Plate(®) be a standby solution?

Distal humerus fracture nonunion and associated elbow stiffness are two intermingled orthopaedic challenges for working adults. This prospective study aimed to evaluate the short-term results of the triple tension band and Lambda plate in managing both problems. The study included fourteen cases. The mean age was 35.7±8.5 years (range 25-49). Eight cases were males. Initial management was conservative in three cases. Three cases had a history of infected nonunion. Eight cases had initially OTA type C injuries and six cases had type A injuries. All cases had olecranon osteotomy, triple tension band, Lambda plating, and autogenous bone grafting. Five cases had ulnar nerve anterior transposition. Evaluation of the cases was objectively via Mayo Elbow Performance (MEP) score and subjectively through Disabilities of the Arm, Shoulder and Hand (DASH) score. The average follow-up period was 23.7±5.3 months. All cases had a solid bony union in a mean of 16.4±2.1 weeks and the final range of motion averaged 100±19.6°. MEP and DASH scores had significant improvement at the final follow-up periods (P=0.001). Cases with transposed ulnar nerve had significantly less MEP scores (P=0.028) and more DASH scores (P=0.013). The prescribed technique could be a good alternative to the known traditional methods with the advantages of: good exposure for arthrolysis; rigid and stable internal fixation even with low bone quality or small-sized distal fragments; and secure early rehabilitation.

Osteosynthesis in Distal Radius Fractures with Conventional Bridging External Fixator; Tips and Tricks for Getting Them Right

Distal radius fractures are the commonest fractures occurring in the upper extremity, accounting for 15-20% of patients treated in emergency department. Although distal radial fractures were described 200 years ago, they still remain as unsolved fractures with no clear guidelines. It is often reported that anatomical reduction has a bearing on the functional outcome. To study the management of distal end radius fracture by utilizing the principle of ligamentotaxis where in the reduction obtained by closed means is maintained by external fixator till solid bony union occurs. A total of 26 cases were selected for study by scrutiny of the inclusion and exclusion criteria. Most of our cases were treated with external fixator within 8 hrs of injury. Small A.O external fixator (bridging ex-fix) with 2 pins each in radius and 2(nd) metacarpal percutaneously was used for all the cases. Selective k wire fixation was done in cases of instability. Fixator was removed after 6 weeks. Guided physiotherapy was ensured in all the cases. Patients were followed up for an average of 9 months. Modified Gartland and Werley scoring system was used to evaluate the overall functional results. Excellent to good results were achieved in 88.45% of our cases while fair result was in 11.54 %. One case had pin loosening and two other cases had malunion. External fixator used for ligamentotaxis is an effective method of treating unstable extraarticular and complex intraarticular fractures of distal radius. Improved anatomical restoration with early rehabilitation has produced favourable functional outcome in our series. The complications like pin tract infection is rare due to the availability of superior antibiotics and sterile surgical technique. complications like wrist and finger stiffness has improved with physiotherapy.

Clinical findings of conservative cases with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body.

This report describes the characteristics of conservative cases with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body. Eight consecutive patients with a coronally oriented vertical fracture of the posterior region of the axis body who received conservative treatment were retrospectively reviewed. All the patients were male. The average patient age at injury was 71.4 years. The medical records of the patients were reviewed, and we identified the fractures associated with the cervical spine, other associated spinal fractures and the details of conservative treatment. Six patients had associated cervical spinal fractures, such as Jefferson fractures in four cases, spinous process fractures of the lower cervical spine in two cases, a teardrop fracture in one case and a unilateral spinous process fracture of C2 in one case. Two patients had associated spinal fractures in the thoracic spine. All the patients acquire solid bony fusion, including fusion of the associated cervical spinal fractures. The patients with a coronally oriented vertical fracture of the posterior region of the C2 vertebral body consisted were all elderly males in our study. Six of the eight patients demonstrated associated cervical spinal fractures; however, all patients acquired solid bony union, including fusion of the associated cervical spinal fractures. We suggest that a Philadelphia collar may be sufficient for conservatively treating coronally oriented vertical C2 body fractures, including associated cervical spinal fractures.

Trends in Epidemiology and Management of Traumatic Type II Odontoid Fracture: Experience in Latin America

Introduction Odontoid fractures (OF) are frequent in the trauma population, and there is no universally accepted single method of management. The objective of this study was to evaluate the epidemiology and management of type II OF in Latin America treated either with rigid cervical orthosis or surgery. Patients and Methods A total of 83 patients treated conservatively or by surgery were enrolled in this retrospective study. Medical charts, imaging studies, and outcomes of patients were analyzed in the pretreatment period and at the last medical evaluation. The fractures were assessed using conventional radiographs, three-dimensional computed tomographic (3D-CT) scans, and magnetic resonance images. Fracture gaps, the direction and the degree of displacement of the odontoid process, the fracture line anatomy, the degrees of atlantoaxial instability, the comminuted fracture, and the surface contact area were analyzed. The decision for operative or nonoperative treatment was based on anesthesia risk, and patient's choice of the nonoperative treatment. The nonoperative management generally consisted of a rigid cervical orthosis for 3 months. The type of surgery to be performed was chosen by the surgeon. The solid bony union was defined as the presence of bony bridges and the definite continuity of cortical bone. Fibrous union was considered present when no degree of motion was evident in dynamic radiographs despite persistent cortical bone discontinuity within a fracture gap on 3D CT scans. Nonunion was defined as a definite fracture gap with abnormal motion of the fractured dens on dynamic radiographs and on a 3D CT scan. Results A total of 83 patients were included in this study. The patients were 78.3% men, the mean age = 44.98 ( ± 23.20 years) years. Traffic accidents (66.3%) were the most common cause of trauma. The main symptom was pain (85.5%) in the posterior cervical region. The median time elapsed from accident to surgery was 7 days (P25: 2/P75: 27.5). Median follow-up was 23.66 ( ± 25.43 months) months. Conservative treatment with cervical orthosis, for example, Miami J collar or halo-vest was used in 20.5% of the cases. Odontoid screw technics (57.6%) were the most common surgical treatment adopted as primary surgical treatment. Symptomatic nonunion was observed in two cases with conservative treatment and three cases after odontoid screw fixation. All the patients were referred to posterior C1–C2 fixation. The posterior fixation tended to be used after conservative failed therapy, after nonunion anterior screw surgery, and in fractures with greater displacement. The most common radiological feature was no displacement of the odontoid process in relation to the body of C2, horizontal fracture line, gap fracture &lt; 2 mm, no subluxation across each C1–C2 facet joint and no comminuted fracture. Conclusion The patients treated nonoperatively with a rigid collar may have an overall favorable outcome compared with surgical treatment. A well-designed prospective study is needed to better elucidate optimal treatment algorithms from both an outcomes and cost-effectiveness perspective.

The relationship between serum vitamin D levels and spinal fusion success: a quantitative analysis.

An in vivo dosing study of vitamin D in a rat posterolateral spinal fusion model with autogenous bone grafting. Rats randomized to 4 levels of vitamin D-adjusted rat chow, longitudinal serum validation, surgeons/observers blinded to dietary conditions, and rats followed prospectively for fusion endpoint. To assess the impact of dietary and serum levels of vitamin D on fusion success, consolidation of fusion mass, and biomechanical stiffness after posterolateral spinal fusion procedure. Metabolic risk factors, including vitamin D insufficiency, are often overlooked by spine surgeons. Currently, there are no published data on the causal effect of insufficient or deficient vitamin D levels on the success of establishing solid bony union after a spinal fusion procedure. Fifty rats were randomized to 4 experimentally controlled rat chow diets: normal control, vitamin D-deficient, vitamin D-insufficient, and a nontoxic high dose of vitamin D, 4 weeks prior to surgery and maintained postsurgery until sacrifice. Serum levels of 25(OH)D were determined at surgery and sacrifice using radioimmunoassay. Posterolateral fusion surgery with tail autograft was performed. Rats were sacrificed 12 weeks postoperatively, and fusion was evaluated via manual palpation, high-resolution radiographs, micro-computed tomographic scans, and biomechanical testing. Serum 25(OH)D and calcium levels were significantly correlated with vitamin D-adjusted chow (P < 0.001). There was a dose-dependent relationship between vitamin D-adjusted chow and manual palpation fusion, with greatest differences found in measures of radiographical density between high and deficient vitamin D (P < 0.05). Adequate levels of vitamin D (high and normal control) yielded stiffer fusion than inadequate levels (insufficient and deficient) (P < 0.05). Manual palpation fusion rates increased with supplementation of dietary vitamin D. Biomechanical stiffness, bone volume, and density were also positively related to vitamin D and calcium. N/A.

Posterolateral lumbar fusion using Escherichia coli–derived rhBMP-2/hydroxyapatite in the mini pig

Background contextHydroxyapatite (HA) is used as a bone graft extender for posterolateral spinal fusion in human. It is also useful as a recombinant human bone morphogenetic protein (rhBMP)-2 carrier because of its high affinity for rhBMP-2. PurposeTo assess the osteoinductivity of Escherichia coli–derived rhBMP-2 (E-BMP-2) using HA granules as a carrier and to evaluate the bone-forming ability depending on the different dosages of E-BMP-2. Study designA mini-pig lumbar posterolateral fusion model using microcomputed tomography (μCT) scanning. Patient sampleThirty-one adult male mini pigs were randomized into a single control group (n=8) without E-BMP-2 and two experimental groups with two different doses of E-BMP-2 (1 mg per side, n=8 and 3 mg per side, n=15). Outcome measuresOutcome was measured by plain radiography, manual palpation, CT, three-dimensional μCT, and histologic examinations. MethodsBilateral intertransverse process arthrodesis was performed, and E-BMP-2 (0, 1.0, 3.0 mg per side) was implanted into the intertransverse space using HA granules as a carrier. ResultsThree mini pigs were removed because of death. Among 28 experimental subjects, 19 animals achieved solid bony union. The fusion rates were 37.5% for control group, 71.4% for 1 mg group, and 84.6% for 3 mg group. Fusion rates were significantly different among groups (p=.031). However, there was no statistically significant difference in fusion rates between 1 and 3 mg groups (p=.587). Thirty-eight intertransverse fusion masses of 19 subjects underwent μCT scanning. The bone volumes determined by μCT were 12,603±3,240 mm3 for control group, 18,718±3,000 mm3 for 1 mg group, and 26,768±7,256 mm3 for 3 mg group, and the difference between groups was statistically significant (p<.001). ConclusionsThis study shows that E-BMP-2 has osteoinductive activity in dose-dependent fashion, and porous HA granule is suitable for E-BMP-2 carrier in a porcine posterolateral fusion model. These preliminary findings suggest that E-BMP-2–adsorbed porous HA granules could be a novel effective bone graft substitute.