Stable Nonunion Research Articles

TROCHANTERIC OSTEOTOMY AND TRANSFER DURING TOTAL HIP ARTHROPLASTY IN PATIENTS WITH DISLOCATED DYSPLASTIC HIPS: UNION RATE USING MONOFILAMENT TRANSVERSE WIRE CERCLAGE

Securing the osteotomized greater trochanter (GT) during total hip arthroplasty (THA) for dislocated dysplastic hips (DDH) poses a significant challenge. This study evaluates the union rate and effectiveness of a 2-strand transverse wiring technique utilizing the lesser trochanter for wire anchorage and tensioning.A digastric anterior slide trochanteric osteotomy was performed in 106 patients (118 hips) undergoing THA for DDH. Following uncemented stem insertion, the GT was transferred and fixed to the lateral cortex of the proximal femur using monofilament stainless steel wires. In 72 out of 106 patients (80 hips), the GT was fixed with 2 transverse wire cerclages threaded through 2 drill holes in the base of the lesser trochanter, spaced vertically 5–10 millimeters apart. The wires were wrapped transversely over the GT and tightened, avoiding contact with its tendinous attachments. Patients were regularly monitored, and GT union was assessed clinically and radiographically.Patient ages ranged from 20 to 57 years (mean 35.5), with a follow-up period ranging from 1.5 to 12 years (mean 6.2). The mean union time was 3.3 months (range 2–7). Among all hips, two developed stable nonunion and single wire breakage, but no fragment displacement (2.5%). Two hips exhibited delayed union, eventually healing at 6 and 7 months after surgery.Reattachment of the greater trochanter utilizing a 2-strand transverse wire cerclage anchored at the base of the lesser trochanter demonstrated a high rate of union (97.5%) following THA in dislocated DDH cases.

CHARCOT NEUROARTHROPATHY: SURGICAL OUTCOMES FOLLOWING HIND- AND MIDFOOT RECONSTRUCTION. A MINIMUM 12-MONTH FOLLOW-UP FROM A TERTIARY HOSPITAL

BackgroundCorrective fusion of a deformed / unstable Charcot neuroarthropathy (CN)of the midfoot and hindfoot is performed with the aim to prevent ulcers and maintain patient mobility.MethodsBetween October 2007 and July 2018, 103 CN mid and hind foot corrections in 95 patients were performed. There were 34 hind-foot, 38 mid-foot and 31 combined hind and mid-foot surgeries. 83 feet had single stage corrections, whereas 20 required a staged operation.ResultsNinety-five patients were prospectively followed up. The mean patient age in our study was 57 years (21 – 85). Twenty-seven patients had type1 diabetes, 64 patients had type 2 and 4 patients had a neuropathy secondary to other conditions. Forty patients (42%) were offered a below knee amputation prior to attending our foot clinic. At a mean follow up of 56 months (12 – 140) we achieved 100% limb salvage with a 75% full bone fusion rate. There were 17 mortalities within our cohort at a mean period of 3 years. Ninety-seven percent (n=92) patients were mobilizing post-operatively in orthotic footwear. Fifty-two feet had pre-operative ulcers. Post-operatively 17 feet (16 patients) had persistent ulceration. Eight patients had ulcer resolution following further surgery and alteration of footwear, one patient has been listed for a below knee amputation for unstable non-union, whilst the remaining 7 patients have stable ulcers which are managed with dressings. Of the 26 feet (25 patients) with non-unions, 6 patients had revision fixation procedures whilst 8 patients required minor surgical procedures. The remaining 11 patients are stable non-unions who are asymptomatic and weight bearing. Other complications included a deep infection rate of 8% (n=7).ConclusionWe demonstrated a 100% limb salvage rate and an 83% success rate in ulcer resolution. We recommend this be done with the support of the multi-disciplinary team.

THE SIGNIFICANCE OF NONUNION IN TYPE II ODONTOID FRACTURE TREATMENT

The second type of dens fracture, according to the An­derson and D’Alonzo classification, is the most preva­lent among the three types, accounting for 60-80% of all cases. It is characterized by instability, and the fracture line extends to the base of the odontoid process. Type II fractures can be managed through conservative appro­aches involving both rigid and non-rigid immobilization or through surgical intervention. When treated conserva­tively, the rate of nonunion ranges from 50-85%, which decreases to 10-30% when surgical treatment is admi­nistered. There is no united consensus on the primary objective of treating Type II odontoid fractures. Some authors debate whether the goal should be achieving os­seous union, ensuring fracture stability, or improving cli­nical outcomes. Certain studies suggest that the frequent complications associated with surgical treatment, without a proven survival benefit, indicate that most patients may be better off with conservative management. On average, around 9.9% of patients shift from non-operative to sur­gical intervention due to several factors, including radio­logical findings, with the aim of averting the occurrence of future pain or neurological complications. While it is generally accepted worldwide to surgically treat patients with unstable nonunion, persistent neck pain, or neuro­logical symptoms, there is no consensus on how to ma­nage stable nonunion or even asymptomatic nonunion. Recent research studies suggest that radiologically stable nonunion, in the absence of persistent neck pain and ne­urological symptoms, might be a satisfactory outcome for patients aged 65 and older.

Reevaluation of a classification system: stable and unstable odontoid fractures in geriatric patients—a radiological outcome measurement

ObjectivesWe carried out a retrospective cohort study to differentiate geriatric odontoid fractures into stable and unstable and correlated it with fracture fusion rates. Results are based on the literature and on our own experience. The authors propose that the simple Anderson and D’Alonzo classification may not be sufficient for geriatric patients.MethodsThere were 89 patients ≥ 65 years who presented at our institution with type II and III odontoid fractures from 2003 until 2017 and were included in this study. Each patient was categorized with CT scans to evaluate the type of fracture, fracture gap (mm), fracture angulation (°), fracture displacement (mm) and direction (ventral, dorsal). Fractures were categorized as stable [SF] or unstable [UF] distinguished by the parameters of its angulation (< / > 11°) and displacement (< / > 5 mm) with a follow-up time of 6 months.SFs were treated with a semi-rigid immobilization for 6 weeks, UFs surgically—preferably with a C1–C2 posterior fusion.ResultsThe classification into SFs and UFs was significant for its angulation (P = 0.0006) and displacement (P < 0.0001). SF group (n = 57): A primary stable union was observed in 35, a stable non-union in 10, and an unstable non-union in 8 patients of which 4 were treated with a C1/2 fixation. The overall consolidation rate was 79%. UF group (n = 32): A posterior C1–C2 fusion was carried out in 23 patients, a C0 onto C4 stabilization in 7 and an anterior odontoid screw fixation in 2. The union rate was 100%. Twenty-one type II SFs (91%) consolidated with a nonoperative management (P < 0.001). A primary non-union occurred more often in type II than in type III fractures (P = 0.0023). There was no significant difference in the 30-day overall case fatality (P = 0.3786).ConclusionTo separate dens fractures into SFs and UFs is feasible. For SFs, semi-rigid immobilization provides a high consolidation rate. Stable non-unions are acceptable, and the authors suggest a posterior transarticular C1–C2 fixation as the preferred surgical treatment for UFs.Level of evidenceLevel III.

Arthroscopic Latarjet for Primary Shoulder Instability With Off-Track Lesions or Revision Surgery Yields Satisfactory Clinical Results and Reliable Return to Sport and Work at Minimum 3-Year Follow-Up

To retrospectively evaluate clinical and radiologic outcomes and return to sport and to work of patients after arthroscopic Latarjet stabilization for primary instability or revision surgery; factors influencing and determining results and potential predictors for clinical outcomes also were evaluated. This is a retrospective study including patients older than 18 years old who underwent arthroscopic Latarjet stabilization for recurrent anterior glenohumeral instability with off-track lesions, or for cases of recurrence after previous surgery, from 2011 to 2017. Patients were assessed preoperatively and at a minimum 3 years of follow-up using the Rowe score, the University of California at Los Angeles Shoulder Score and Simple Shoulder Test score; the range of motion, satisfaction rate, return to work and sport, perception of discomfort during sporting and daily activities, and complications and recurrence after surgery were also evaluated. The integration of the coracoid graft and the position of the screws were examined by computed tomography scan. At a mean follow-up time of 6 ± 2 years, 93 patients (95 shoulders) showed significant improvement of all scale scores (P < .001), 97.8% of the patients had returned to the same working condition as before surgery, and all the patients who practiced sports preoperatively (85; 91.4%) returned to sport after surgery; 97.9% of patients were satisfied with surgery. The complication rate was 5.4%, and 2 cases (2.1%) of recurrence occurred, both after high-energy trauma. At an average of 17 ± 13 months postoperatively, computed tomography scans showed 4 (6.6%) stable nonunions, 9 (14.8%) superior, and 1 (1.6%) inferior lyses of the graft; a correct positioning of the graft was observed in 86.9% of the cases. Greater satisfaction, fewer complications, less pain during daily activities, and a lower number of reoperations were associated with a shorter time between the first dislocation episode and surgery (P= .019, P < .001, P= .014, and P=.005, respectively). Complications were directly associated with older patient age at operation (P= .001). A greater number of nonunions was found in patients with increased angle between the line linking the posterior and anterior glenoid rim and the screw axis (P= .040) and a medial axial position or a lower coronal position of the graft (both P=.010). A lower age at the time of surgery predicted better Rowe scores at follow-up (P < .001), and a lower age at the time of the first episode of dislocation predicted better postoperative Simple Shoulder Test scores (P= .026). At a mean 6-year follow-up time, excellent clinical outcomes, and radiological results, with few complications, high rates of satisfaction and return to work and sport and low sports anxiety can be expected after arthroscopic Latarjet procedure. A shorter time between the first dislocation episode and surgery was associated with higher satisfaction, fewer complications, less pain during daily activities and lower reoperations; a lower age at the operation was associated with lower complications.

Ultrasound-guided injection of platelet-rich plasmaor cord blood platelet-rich plasma in nonunion: a randomized controlled trial.

Aim: To compare the ability of autologous platelet-rich plasma (PRP) and cord blood PRP (PRPc) to accelerate bone healing. Patients & methods: 71patients with mechanically stable nonunion were treated weekly (3consecutive weeks) with ultrasound-guided percutaneous injections of PRP or PRPc in a controlled randomized clinical trial. The primary outcome was healing (12months) andsecondary outcomes were radiological evolution (2and 6months) and changes in pain intensity (6months). Results & conclusion: Bone consolidation was assessed over time without significant differences between PRP and PRPc treatment. In patients with persistent nonunion, pain perception decreased more after PRP treatment. PRPc appears to be a valid alternative when specific clinical conditions suggest avoiding the use of autologous blood products.

Combined magnetic field results in higher fusion rates than pulsed electromagnetic field bone stimulation after thoracolumbar fusion surgery

BackgroundBone growth stimulators have been used as an adjunct to spinal fusion surgery in efforts to increase fusion rates. MethodsThe authors retrospectively reviewed the medical records of patients who underwent thoracolumbar fusion surgeries by a single surgeon. Patients were then separated into three groups; pulsed electromagnetic field stimulation (PEMF), combined magnetic field stimulation (CMF) or no stimulation (NS), and computed tomography radiographic results at least 1 year after surgery were compared (solid fusion, stable nonunion, and pseudarthrosis). ResultsA total of 60 patients were included; 16 (26.7%) used PEMF, 24 (40.0%) used CMF, and 20 (33.3%) had NS. There were no significant differences in patient demographics. There was no difference in the mean fusion levels (p = 0. 477). Solid fusion was achieved in 11/16 (68.8%) PEMF, 21/24 (87.5%) CMF, and 20/20 (100.0%) NS patients. Stable nonunion was displayed in 2/24 (8.3%) CMF, and zero PEMF and NS patients. There were 5/16 (31.3%) PEMF, 1/24 (4.2%) CMF, and zero NS patients demonstrating radiologic pseudarthrosis. There was a statistically significant difference between PEMF and CMF (p = 0.017) and between PEMF and NS (p = 0.006) groups. No statistical difference was found between CMF and NS (p = 1.000). ConclusionThis is the first study to compare PEMF and CMF bone growth stimulators in patients with degenerative pathologies who underwent thoracolumbar spinal fusions. Overall, the addition of these bone growth stimulators does not improve fusion outcomes, although CMF appears superior to PEMF.

P155. Clinical outcomes of conservatively managed type II odontoid fractures in older people

BACKGROUND CONTEXT Type II odontoid fractures is the most common cervical fracture in older people. Operative or conservative treatment options exist. In the UK they are frequently managed in a hard collar. Non-osseous union is common and in the elderly (>80 years) a stable non-union is often accepted. The natural history and clinical outcomes following conservative management is unknown. PURPOSE To compare pain and disability in older people following conservative management of type II odontoid fractures demonstrating osseous union and established fibrous non-union. STUDY DESIGN/SETTING A retrospective observational study. PATIENT SAMPLE Inclusion criteria: All patients discharged, >3months after type II odointoid fracture, >65 years at time of fracture, managed conservatively in a hard colllar from a single London hospital from 2008-2018. All surviving, English speaking patients were invited to complete self-reported questionnaires. Exclusion criteria: Patients with concurrent unstable cervical fractures; pathological fractures; Rheumatoid Arthritis; Ankylosing Spondylitis. OUTCOME MEASURES Neck disability index (NDI); reported as a percentage, higher score=greater disability Myelopathic disability index (MDI); score out of 30, higher score=greater disability. EuroQuol 5D (EQ5D); quality of life measure producing an index with a range -0.59-1 with 1=full health. Neck pain assessed by Numerical Rating Scale (NRS); 0-10 10= worst pain imaginable. Length of survival (all cause mortality). METHODS Eligible patients were identified by searching electronic patient records and demographic and clinical details retrieved. All surviving patients were telephoned and invited to participate. Self-rated questionnaires were posted to consenting participants or were completed over the phone. Frequency distributions and summary statistics were calculated for demographic and clinical variables. T-tests were used to investigate differences in distributions. Log rank was used to assess differences in survival between groups. Ethical and governance approvals were granted: 18/NE/0153 IRAS ID: 231129 KCH18-077. RESULTS A total of 133 patients were identified (77 female; 56 male). Thirty-seven (28%) demonstrated osseous union and 96 (72%) had established non-union. Mean age at fracture was 82.8 years (standard deviation 7.4) (osseous union 82.6(8.7) years; non-union 83.6(6.4) years). Fifty-two (39% (11 united; 41 non-union) had deceased. Mean length of survival: ossesous union 77.13 (8.9) months; non-union 53.7 (4.5) months; p=.04. No patient developed symptomatic myelopathy due to instability during the follow up period. No patient sustained traumatic spinal cord injury. Response rate: 41 (51%; 12 (46%) osseous union; 29 (53%) non-union). Questionnaire mean scores for ossesous-union and non-union respectively: NDI: 16.8%(17.4); 27.5%(20.8) p=.063. MDI: 3.58(3.78); 8.45(7.15) p=0.02. Pain NRS: 1.92(2.75); 2.72(2.55) p=.196. EQ5D indices: 0.733(0.179); 0.544(0.308) p=0.308 p=.166; EQ5D VAS health: 65.83(2.75); 58.28(22.17) p=.176. CONCLUSIONS Conservative management of type II odontoid fractures in older people is associated with low risk of disability, symptomatic myelopathy or spinal cord injury although there was a trend towards better outcomes for those demonstrating osseous union. This study is limited by its sample size, retrospective design and lack of adjusting for comordities or frailty. A prospective study is required. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Type II odontoid fracture in elderly patients treated conservatively: is fracture healing the goal?

Analysis of functional outcome of elderly patients with type II odontoid fractures treated conservatively in relation to their radiological outcome. A total of 50 geriatric patients with type II odontoid fractures were treated with Aspen/Vista collars. On admission, each patient was assessed assigning ASA score, modified Rankin Scale (mRS-pre) and Charlson Comorbidity Index (CCI). From 12-15months after treatment, functional evaluations were performed employing a second modified Rankin Scale (mRS-post) together with Neck Disability Index (NDI) and Smiley-Webster pain scale (SWPS). Radiological outcome was evaluated through dynamic cervical spine X-rays at 3months and cervical spine CT scans 6months after treatment. Three different conditions were identified: stable union, stable non-union and unstable non-union. Surgery was preferred whenever a fracture gap > 2mm, an antero-posterior displacement > 5mm, an odontoid angulation > 11° or neurological deficits occurred. Among the 50 patients, 24 reached a stable union, while 26 a stable non-union. Comparing the two groups, no differences in ASA (p = 0.60), CCI (p = 0.85) and mRS-pre (p = 0.14) were noted. Similarly, no differences in mRS-post (p = 0.96), SWPS (p = 0.85) and NDI (p = 0.51) were observed between patients who reached an osseous fusion and those with a stable fibrous non-union. No effects of age, sex, ASA, mRS-pre, fracture dislocation and radiological outcome were discovered on functional outcome. At logistic regression analysis, female sex and high values of CCI emerged associated with worse NDI. In geriatric type II odontoid fractures, pre-injury clinical status and comorbidities overcome imaging in determining post-treatment level of function. Hard collar immobilization led to a favourable functional outcome with mRS-post, NDI and SWPS values diffusely encouraging whatever a bony union or a fibrous non-union was obtained. These slides can be retrieved under Electronic Supplementary Material.

Screw Fixation Alone for Scaphoid Fracture Nonunion.

Scaphoid fracture nonunion can often lead to pain, arthrosis, and disability. While typically the result of delayed diagnosis or inadequate treatment, it can sometimes occur even if the initial care was timely and appropriate. Whereas early recognition of acute fractures allows for nonoperative management, nonunions frequently require surgical treatment. Traditionally, this has involved open debridement and bone grafting. However, some publications suggest that certain stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting. Although certain characteristics appear to be appropriate indications for such management, well-designed clinical studies are needed to better define them.

Successful management of intramedullary nail associated infection with reaming and antibiotic cement beads/rod

Objective To assess the efficacy of using reaming and antibiotic cement beads/rod for intramedullary nail as-sociated infection. Methods Data of 12 patients with intramedullary infection of tibia or femur following intramedullary nailing from October 2014 to April 2016 were retrospectively analyzed. There were 10 men and 2 women aged from 19 to 63 years old with an average age of 39.2 years. In 5 cases the disease was localized in the femur with one case of nonunion, and in other 7 cases the disease was localizedin the tibia with two cases of nonunion. The initial injury included closed fracture in 8 patients and open fracture in 4 patients which were all Gustilo-AndersonⅡ. According to the Cierny-Mader classification of adult osteomyelitis, 6 cases were typeⅠ (medullary osteomyelitis), 4 cases were type Ⅰcombined with type Ⅲ (medullary and localized osteomyelitis), and 2 cases were typeⅠ combined with type Ⅳ (medullary and diffuse osteomyelitis). Surgical technique included removal of the intramedullary nailand reaming and irrigation of the medullary canal to remove intramedullary debris. The drainage sinus and soft tissues abscess were excised if existed. An local or enbloc resection for the infected or necrotic bone was performed if there was lo-cal or diffuse infection in the fracture sites. Ilizarov technique was performed for segment bone defect. The bone union was ob-served in nine patients and stable nonunion in one. Antibiotic PMMA beads were inserted into intramedullary canal for these ten cases after debridement, and the antibiotic beads were removed approximately 12-14 days after implantation. The antibiotic ce-ment rod was inserted into the medullary canal to provide stabilization in the other 2 cases. All the patients received intravenous antibiotics systemically for three weeks, and followed by three weeks of oral antibiotics. Results At a mean follow-up period of 23.5 months (range, 15-33 months), no recurrence of infection was observed. There were 3 cases of nonunions. One case of tibial nonunion had been achieved union 10 months after insertion of an antibiotic cement rod. One with stable nonunion of tibia was treated with antibiotic PMMA beads, and enbloc resection for the infected bone was performed after the extension of infection had been narrowed at the nonunion. 6 cm of bone defect was treated with bone transport and then union was obtained 16 months after operation. The third case was infected nonunion in the femur with 4 cm bone defect after debridement. The femur was shortened and temporarily stabilized with the intramedullary antibiotic cement rod. The rod was removed three months after the operation, and then the femur was lengthened. The docking site and the regeneration area were healed 12 months after the lengthening opera-tion. Conclusion The clinical results shows that reaming and antibiotic cement beads/rod appears an effective and safe alterna-tive for management of intramedullary nail associated infection of the tibia and femur. Key words: Femur; Tibia; Infection; Fracture fixation, intramedullary

Upper Cervical Fusion in Children With Spondyloepiphyseal Dysplasia Congenita.

Paraplegia or death secondary to upper cervical spine instability and spinal cord compression are known consequences of spondyloepiphyseal dysplasia congenita (SEDC). Stabilization and occasionally decompression of the upper cervical spine are indicated to treat upper cervical instability and stenosis. The purpose of this study was to report the results of upper cervical spine fusion in children with SEDC who had upper cervical instability. Twenty children (17 females and 3 males) with SEDC who underwent upper cervical spine fusion at a mean age of 72 months were retrospectively analyzed. Three of these children were under the age of 2. Fifteen children had posterior instrumentation and fusion whereas 5 children had posterior in situ fusion without use of any implant. Thirteen of 20 children had iliac crest autograft. Radiographic and clinical results were reported. The average follow-up period was 8 years and 8 months. All children with instrumentation achieved fusion. Three of 5 children who had no instrumentation had nonunion (1 child had a stable nonunion and did not need revision; 1 had a single noninstrumented revision and ended up with a stable nonunion without further intervention; and the third one had a noninstrumented revision and had to have a second, instrumented, revision to achieve fusion). Six children had thoracolumbar scoliosis or kyphoscoliosis which required surgical management.No postoperative neurological deficits were observed. Two of the 3 children with a preoperative neurological deficit showed full recovery and the third one remained unchanged. Pseudarthrosis is the main complication for the noninstrumented group. Distal junctional instability after successful fusion is seen at long-term follow-up (average=6 y) for 13% of patients in instrumented group. Instrumentation and iliac bone grafting results in 100% upper cervical fusion for SEDC children who demonstrated instability before surgery. Level IV-therapeutic.

Non-vascularized bone grafting in scaphoid nonunion: principles and type of fixation.

In scaphoid fractures, delayed diagnosis and nonunion are fairly common as a result of several factors, including the difficulty of radiographic diagnosis of non-displaced fractures and underestimation of the injury by the patient. Main factors to consider when deciding treatment are the type of fracture and fracture stability. In the stable nonunion (Type D1 according to the Filan and Herbert classification, or linear type of Ikeda's classification), percutaneous screw fixation without bone graft is recommended. The indications of non-vascularized bone grafting are as follows: (1) arthroscopic cancellous bone graft in type D1 and cystic type of Ikeda's classification. (2) tricortical bone graft from the iliac crest in type D2 or D3 if the possibility of avascular necrosis of the proximal fragment is excluded. In this paper, our non-vascularized bone grafting for scaphoid nonunion would like to be described mainly about principles and type of fixation.

The Effect of Percutaneous Vertebral Augmentation on Stable and Unstable Vertebral Fracture Nonunion: A Three-Dimensional Finite Element Study

Introduction Our previous study suggested that vertebral fracture nonunion(VFNU) could be classified into stable and unstable types based on whether there are fracture fragment in the middle column of fractured vertebrae, and we hypothesize that vertebral augmentation could restore the stability of fractured vertebrae in unstable type of VFNU, this study is to determine the effect of percutaneous vertebral augmentation on stable and unstable vertebral fracture nonunion by three-dimensional finite element analysis. Material and Methods An elderly senior, who suffers from osteoporosis, but owns the normal alignment and profile of thoracolumbar spine was included into this finite element study and accepted CT examination. The finite element three-dimension model of physiological thoracolumbar spine (T11-L3) was established and investigated with Mimics, Rapidform, and Abaqus softwares, then wedge-shaped osteotomy was performed in L1 vertebral body to stimulate intravertebral bone defect, which is the main feature of VFNU, to make the pathological finite element model of type A VFNU, which is named pathological model A. Furthermore, the posterior–inferior region of vertebral body was cut to build a piece of separated fracture, with the purpose of simulation of the pathological feature of type B VFNU and establishment of corresponding Finite element model which is called as Pathological model B. After that, imitated bone cement augment was performed in pathological model A and B, distributing cement in the whole intervertebral cleft or 5 mm ahead posterior edge of vertebral body, to establish four therapy finite element model, which were called as therapy model A1, B1, A2, and B2. All of the models were calculated under the same axial loads of 400 N, to investigate the validity of physiological model and compare the mechanical status of different models. Results The physiological finite element model owns good mechanic conformity with the reported models. Compared with physiological model, there was notable stress, strain concentration in the L1 vertebral body of pathological model A, mainly distributing beside the posterior cortex and in the posterior inferior part of the vertebral body, which indicated that there was a risk of further fracture in this model. Although there was also stress and strain concentration in pathological model B, the extent and level of stress and strain were lower than the corresponding value in the pathological model A, furthermore, concentration mainly located in the posterior–inferior fracture piece, which implied that the separated posterior–inferior fracture piece of vertebral body intended to dislocate, and the stress, strain concentration were dispersed after pathological Model A became Model B. According to calculation of therapy model A1, A2, the stress and strain concentration could be dispersed with bone cement augmentation, and the mechanic conduction function of L1 vertebral body could be restored after imitated PVP, which indicated that vertebroplasty could be used effectively in VFNU patients with reliable mechanic stability. However, on the basis of the calculation of therapy model B1 and B2, the tendency of stress, strain concentration, and displacement of posterior–inferior fracture piece could be found, even though the whole concentration could be dispersed by cement augmentation, which implied that there was risk of dislocation of posterior–inferior fracture piece after bone cement augmentation in pathological model B. Conclusion A favorable mechanical performance was revealed in stable VFNU after PVA, but the risk of redislocation of posterior–inferior bony fragments might be increased result from PVA.

Treatment Algorithm for Dens Fractures: Non-Halo Immobilization, Anterior Screw Fixation, or Posterior Transarticular C1-C2 Fixation

The appropriate treatment of dens fractures is unclear. We established a staged treatment protocol for dens fractures and conducted a prospective study to evaluate the outcome of treatment based on this protocol. We prospectively evaluated sixty-nine consecutive patients who presented to our institution with a dens fracture. The mean duration of follow-up was 9.7 months (range, six to fifty-eight months). Fractures were categorized as stable or unstable. Stable fractures were treated by immobilization in a rigid collar. Patients seventy-five years or older with unstable fractures, patients with a neurological deficit, and patients with Anderson and D'Alonzo type-III fractures underwent posterior transarticular C1-C2 stabilization. Unstable fractures in patients younger than seventy-five years were stabilized with direct anterior screw fixation. Thirty-one patients were treated with a Philadelphia collar, twenty-five with posterior transarticular fixation, and thirteen with direct anterior screw fixation. Fracture-healing or solid fusion of C1-C2 was documented in sixty-eight of sixty-nine treated patients at final follow-up. The remaining patient had a stable nonunion of the dens. Secondary procedures were performed in five patients. Our treatment algorithm based on dens fracture type, fracture stability, and patient age was associated with a high success rate. Evaluating fracture stability is crucial when considering nonoperative treatment. External stabilization with a rigid cervical collar was adequate for stable fractures of the dens and was associated with a high healing rate. Posterior transarticular screw fixation of C1-C2 was associated with a high success rate, including in elderly patients. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Application of Platelet-rich Plasma or Bone Marrow Aspirate for Stable Nonunion

Despite current advances in orthopedic technology, nonunion of long bone fractures remains a common complication. The current “gold-standard” treatment for atrophic nonunions uses autologous iliac crest bone graft to augment healing, which has its own array of morbidities. Recent literature shows that percutaneously obtaining mesenchymal stem cells from the iliac crest offers similar success rates of union without the morbidity of graft harvesting. An additional option in treating atrophic nonunion is the use of platelet-rich plasma (PRP) to facilitate healing. PRP functions as an osteoinductive agent, containing several fundamental growth factors and chemoattractants, which may be deficient in the compromised host. This study reviews the technique of obtaining bone marrow aspirate and PRP for percutaneous introduction into tibial nonunions.

Management of Type II Odontoid Fractures in the Geriatric Population

Retrospective study. To analyze geriatric patients with Type II odontoid fractures treated either with rigid cervical orthosis (CO) or surgery (Odontoid Screw or Transarticular screw). Our literature search did not yield any studies on the outcome of Type II odontoid fractures in geriatric population treated with the rigid CO. We therefore designed a study to analyze geriatric patients with Type II odontoid fractures treated with either rigid cervical collar or surgery. This is a retrospective chart review of patients with Type II odontoid fractures between July 1998 and June 2006. Inclusion criteria consists of males and females of 70 years of age or older with Type II odontoid fractures who were treated with rigid cervical collar or surgery. Exclusion criteria were displacement >4 mm, posteriorly displaced fracture, neurologic compromise, multilevel cervical spine injury, and treatment in a halo vest. Medical comorbidities were assessed using the Modified Cumulative Illness Rating Scale for Geriatrics. Primary outcomes were mortality and fusion (union, stable nonunion, nonunion). Minimum of 3 months follow-up was acceptable. One hundred eighty four odontoid fractures were identified in 8 years. Twenty patients met our inclusion criteria (9 treated in rigid collar and 11 treated surgically). Median follow-up was 5.5 months. Out of 20 patients, 4 patients died (1 treated in CO, 3 treated surgically). Cumulative Illness Rating Scale for Geriatrics index was highest in patient treated in CO. In the rigid collar group, 6 patients had union (66.6%), and 2 developed stable nonunion (22.2%); whereas in the surgically treated group, 7 patients had union (87.5%), and 1 patient developed nonunion (12.5%). Patients treated nonoperatively in rigid collar seem to have an overall favorable outcome. A well-designed prospective study, to compare the outcomes of surgical intervention with nonsurgical management of Type II odontoid in elderly is recommended.

Odontoid Fractures and Their Management

Odontoid fractures are the most common cervical spine fracture in the elderly, and their incidence is increasing. The majority of these fractures are Type II and are associated with significant morbidity in the elderly population, irrespective of treatment options (surgical vs. nonsurgical). There is no clear consensus regarding the long-term morbidity of nonunion, with some authors advocating stable fibrous nonunion as an acceptable endpoint versus bony union. Surgical management is advocated by some due to the significantly greater union rate, and some studies report improved outcomes with surgery. Prospective studies are needed to better delineate optimal treatment.

Surgical Outcome of Stable Scaphoid Nonunion without Bone Graft

69 통신저자:공 일 규 광주시 동구 학동 8번지 전남대학교병원 정형외과 Tel:062-227-1640ᆞFax:062-225-7794 E-mail:kongilkyu@gmail.com 접수: 2009. 6. 22 심사 (수정): 1차 2009. 7. 22, 2차 2009. 9. 30 게재확정: 2009. 12. 6 Address reprint requests to:Il Kyu Kong, M.D. Department of Orthopedic Surgery, Chonnam National University School of Medicine, 8, Hak-dong, Dong-gu, Gwangju 501-757, Korea Tel:82-62-227-1640ᆞFax:82-62-225-7794 E-mail:kongilkyu@gmail.com 안정성 주상골 불유합에 대해 골이식을 동반하지 않는 수술적 치료 결과

SIGN Interlocking Nail for the Treatment of Infected Nonunion

Summary: Chronic infection of bone with nonunion and/or bone defects is traditionally treated by a 2-stage procedure involving initial debridement and antibiotic delivery for control of infection and then definitive internal fixation for fracture stabilization. The external fixators have been used to provide stability in the presence of active infection. A technique of Surgical Implant Generation Network (SIGN) solid interlocking nail is used in the femur and tibia bones after thorough irrigation and debridement at the same stage. Although not most suitable for all infected nonunions and/or segmental bone defects, this technique is particularly useful for patients who are poor and hence cannot afford multiple surgeries and are not ideal candidates for external fixation and for those who do not want to have an external fixator applied. This technique was used in a series of 250 patients from multiple centers. The goal of control of infection and bony union was achieved in 213 (85%) cases, 165 cases after a single operation, and 48 cases after additional interventions. In the remaining 37 (15%) patients, the goal of control of infection was achieved with stable nonunion, which were taken care of by standard procedure of bone grafting after control of active infection. Four patients needed exchange nailing to another thicker SIGN nail for continued infection and implant loosening. Subsequently complete control of infection could be achieved in these cases. From the total, 14 fractures went on bone healing despite persistent infection, with or without sinuses. Early removal of nail after union and thorough debridement made them free from infection. But 7 cases are still coming at follow-up with infection but pain-free functional limb, that is, persistent infection even after fracture union. In summary, control of infection and stability to promote union has traditionally been provided by 2 separate procedures, which have proved to be efficacious in the past. However, both these goals can be achieved with 1 surgical procedure in a variety of scenarios in our limited circumstances, using the technique of SIGN solid intramedullary nail. This 1-step surgical procedure eliminates the complications that can occur secondary to the use of external fixation and bone transport. It may also reduce the morbidity of 2 surgical procedures and inpatient admissions required for the two-stage procedures or for the application and removal of external fixators to that of a single procedure and inpatient admission. Additional procedures may be required with both treatment methods for achieving control of infection, bony union, or soft tissue coverage.