Bone Fracture Surgery Research Articles

Magnetic Resonance Imaging of Postoperative Fracture Healing Process without Metal Artifact: A Preliminary Report of a Novel Animal Model.

Background. Early radiological diagnosis and continual monitoring are of ultimate importance for timely treatment of delayed union, nonunion, and infection after bone fracture surgery. Although magnetic resonance imaging (MRI) could provide superior detailed images compared with X-ray and computed tomography (CT) without ionizing radiation, metal implants used for fracture fixation lead to abundant artifacts on MRI and thus prohibit accurate interpretation. The authors develop a novel intramedullary fixation model of rat femoral fracture using polyetheretherketone (PEEK) threaded rods and investigate its feasibility for in vivo MRI monitoring of the fracture healing process without artifact. Methods. Femoral fractures of 3 adult male Sprague-Dawley rats were fixed with intramedullary PEEK threaded rods. X-ray and MRI examinations were performed at day 7 postoperatively. Radiological images were analyzed for the existence of artifact interruption and postoperative changes in bone and peripheral soft tissue. Results. Postoperative plain film revealed no loss of reduction. MRI images illustrated the whole length of femur and peripheral tissue without artifact interruption, and the cortical bone, implanted PEEK rod, and soft tissue were clearly illustrated. Conclusion. This preliminary study introduced a novel rat model for in vivo MRI monitoring of the fracture healing process without metal artifact, by using intramedullary fixation of femur with PEEK threaded rod.

Prospective, double-blind, randomized trial evaluating subject pain, bleeding, and wound healing using biodegradable pure collagen sponge(Colladerm�) as endo-nasal packing materials in nasal bone fracture surgery.

Prospective, double-blind, randomized trial evaluating subject pain, bleeding, and wound healing using biodegradable pure collagen sponge(Colladerm�) as endo-nasal packing materials in nasal bone fracture surgery.

Efficacy of fascia iliaca compartment nerve block as part of multimodal analgesia after surgery for femoral bone fracture

Fascia iliaca compartment nerve block (FICNB) has been an established technique for postoperative analgesia after surgery for femoral bone fracture. FICNB is technically easy, effective for postoperative pain control after operation for femoral bone fracture and decreases the complications induced by systemic analgesic drugs. The severity of postoperative pain is affected by genetics, cultural and social factors across the world. In this study we assessed the efficacy of fascia iliaca compartment nerve block when it is used as part of multimodal analgesia after surgery for femoral bone fracture. An institution-based case control study was conducted from September, 2013 to May, 2014. All patients who had been operated on under spinal anesthesia for femoral bone fracture were included. The patients divided into a FICNB group (n=20) and a control group (n=20). The FICNB group was given 30 mL of 0.25% bupivacaine at the end of the operation. Postoperative pain was assessed within the first 24 hours, i.e. at 15 minutes, 2 hours, 6 hours, 12 hours and 24 hours using 100 mm visual analogue scale (VAS), total analgesic consumption, and the time for the first analgesic request. VAS pain scores were reduced within the first 24 hours after operation in the FICNB group compared wtih the control group. VAS scores at 2 hours were taken as median values (IQR) 0.00 (0.00) vs.18.00 (30.00), P=0.001; at 6 hours 0.00 (0.00) vs. 34.00 (20.75), P=0.000; at 24 hours 12.50 (10.00) vs. 31.50 (20.75), P=0.004; and at 12 hours (17.80±12.45) vs. (29.95±12.40), P=0.004, respectively. The total analgesic consumption of diclofenac at 12 and 24 hours was reduced in the FICNB group, and the time for the first analgesic request was significantly prolonged (417.50 vs. 139.25 minutes, P=0.000). A single injection for FICNB could lead to postoperative pain relief, reduction of total analgesic consumption and prolonged time for the first analgesic request in the FICNB group after surgery for femoral bone fracture. We recommend FICNB for analgesia after surgery for femoral bone fracture and for patients with femoral bone fracture at the emergency department.

Lacrimal Gland Fistula following Severe Head Trauma.

We aim to present a unique case with discharging lacrimal gland fistula secondary to severe head trauma by an animal. A 9-year-old girl presented with serous fluid discharge from a cutaneous fistula in the left orbital region. The patient had history of surgery for traumatic frontal bone fracture and skin laceration in the superior orbital rim three weeks earlier. She underwent a complete ophthalmological examination and there was no anterior segment or fundus pathology. The orifice of the fistula was detected in mediolateral part of the left superior orbital rim and fluid secretion was increasing with irritation of the left eye. Neurosurgical complications were excluded and radiological assessment was nonremarkable. The patient's legal representatives were informed and lacrimal gland fistulectomy was planned. However, the fistula was self-closed one week after initial ophthalmological examination, and the patient had no symptoms. In conclusion, traumatic injuries of superior orbital region should be carefully evaluated and wounds should be well closed to prevent consecutive lacrimal gland fistula.

Cognitive plasticity as a moderator of functional dependency in elderly patients hospitalized for bone fractures

Bone fractures in older adults involve hospitalization and surgical intervention, aspects that have been related to loss of autonomy and independence. Several variables have been studied as moderators of how these patients recover. However, the implications of cognitive plasticity for functional recovery have not been studied to date. The present study analyzes the relationship between cognitive plasticity--defined as the capacity for learning or improved performance under conditions of training or performance optimization--and functional recovery in older adults hospitalized following a bone fracture. The study comprised 165 older adults who underwent surgery for bone fractures at a hospital in southern Spain. Participants were evaluated at different time points thereafter, with instruments that measure activities of daily life (ADL), namely the Barthel Index (BI) and the Lawton Index, as well as with a learning potential (cognitive plasticity) assessment test (Auditory Verbal Learning Test of Learning Potential, AVLT-LP). Results show that most of the participants have improved their level of independence 3 months after the intervention. However, some patients continue to have medium to high levels of dependency and this dependency is related to cognitive plasticity. The results of this study reveal the importance of the cognitive plasticity variable for evaluating older adults hospitalized for a fracture. They indicate a possible benefit to be obtained by implementing programs that reduce the degree of long-term dependency or decrease the likelihood of it arising.

Perioperative factors affecting the occurrence of acute complex regional pain syndrome following limb bone fracture surgery: data from the Japanese Diagnosis Procedure Combination database

Complex regional pain syndrome (CRPS) describes a broad spectrum of symptoms that predominantly localize to the extremities. Although limb fracture is one of the most frequently reported triggering events, few large-scale studies have shown the occurrence of and factors associated with CRPS following limb fracture. This study aimed to show the occurrence and identify of those factors. Using the Japanese Diagnosis Procedure Combination database, we identified 39 patients diagnosed with CRPS immediately after open reduction and internal fixation (ORIF) for limb fracture from a cohort of 185 378 inpatients treated with ORIF between 1 July and 31 December of each year between 2007 and 2010. Patient and clinical characteristics such as age, gender, fracture site, duration of anaesthesia and use of regional anaesthesia were investigated by logistic regression analyses to examine associations between these factors and the in-hospital occurrence of CRPS after ORIF. The occurrence of CRPS was relatively high in fractures of the distal forearm, but low in fractures of the lower limb and in patients with multiple fractures. Generally females are considered to be at high risk of CRPS; however, we found a comparable number of male and female patients suffering from CRPS after ORIF for limb fracture. In terms of perioperative factors, a longer duration of anaesthesia, but not regional anaesthesia, was significantly associated with a higher incidence of CRPS. Although a limited number of CRPS patients were analysed in this study, reduced operative time might help to prevent the development of acute CRPS following limb fracture.

Anesthetic Management of Patient with Duchenne Muscular Dystrophy

Duchenne muscular dystrophy is a hereditary disorder which is characterized by progressive muscle weakness. Specialconcern is needed in these patients during anesthesia, because cardiac and pulmonary systems are commonly involved, andfetal complications may be happen by anesthetics such as succinylcholine or volatile agents. This is a case report of a 5-yearoldboy with Duchenne muscular dystrophy who underwent repair surgery for nasal bone fracture under general anesthesia.

Pulmonary and Cerebral Fat Embolism Syndrome After Total Knee Replacement

Fat embolism occurs after long bone fracture or orthopedic surgery and usually shows mild symptom. But it rarely results in fat embolism syndrome, presenting as multiorgan dysfunction such as lung, brain and skin. Although the diagnosis of fat embolism syndrome is mostly based on clinical features, we experienced fat embolism syndrome involving lung and brain, showing typical imaging findings in pulmonary computed tomography and brain magnetic resonance image. So we present interesting case about fat embolism syndrome after total knee replacement with reviewing associated literatures including imaging findings.

Fat embolism due to bilateral femoral fracture: a case report

Fat embolism syndrome is usually associated with surgery for large bone fractures. Symptoms usually occur within 36 hours of hospitalization after traumatic injury. We present a case with fat embolism syndrome due to femur fracture. Prompt supportive treatment of the patient’s respiratory system and additional pharmaceutical treatment provided the positive clinical outcome. There is no specific therapy for fat embolism syndrome; prevention, early diagnosis, and adequate symptomatic treatment are very important. Most of the studies in the last 20 years have shown that the incidence of fat embolism syndrome is reduced by early stabilization of the fractures and the risk is even further decreased with surgical correction rather than conservative management.

Treatment of non-infective nonunion with locking plates following surgery for long bone fractures

Objective To investigate the cause of fracture nonunion and discuss the experience of locking plates fixation combined with autoallergic cancellous bone in the management of non-infective long bone nonunion.Methods A retrospective analysis was made in 38 patients(29 males and 9 females)with fracture nonunion treated with locking plates fixation combined with autoallergic cancellous bone from August 2006 to August 2010.Of all,22 patients were treated with plates and 16 with interlocking intramedullary nails.Results All the patients were followed up for a mean of 12 months(range,6-24 months).The bone union time for all the fractures averaged 5.3 months(range,3-7 months),with no complications like implant loosening or fracture.Conclusions Iatrogenic factor is the main cause for fracture nonunion after open reduction and internal fixation of long bone fractures and the locking plates combined with autoallergic cancellous bone are a safe and effective treatment procedure. Key words: Fracture fixation, internal; Bone transplantation; Fractures,ununited

医療用ドリルの最適形状の選定

Optimally designed surgical drills are necessary to avoid thermal damage to osseous tissues and to ensure rapid and accurate drilling during bone fracture surgery. Bony necrosis is believed to occur at temperatures of 50℃ or more and is strongly related to the length of exposure to high temperatures. A drill with a low thrust force that suppresses heat generation is thus necessary to avoid bone necrosis. This study quantitatively examined the effects of surgical drill geometry on heat generation and thrust force using experimental design, analysis of variances and statistical technique. The helix angle, web thickness, and point angle of the fundamental drill elements were evaluated to determine the optimal drill geometry at various cutting and feed speeds. Thrust force and drilling temperature were measured while drilling porcine femoral bone to examine the influence of drill geometry on these factors. A 40° helix angle, 23% web thickness, and 90° point angle were found to be the optimal choices for suppressing heat generation.

Usefulness of Intraoperative Computed Tomography in Facial Bone Fracture Repair and Sinus Surgery

Background and Objectives : The usefulness of intraoperative CT (iCT) in rhinologic surgery including reduction of facial bone fracture and sinus surgery was evaluated. Subjects and Method : Medical records and radiological findings of 17 patients who took iCT at the Medical Center between December 2008 and February 2010 were reviewed retrospectively. The mean follow-up period was 2.2 months. The 17 patients included 14 facial bone fractures and three sinus surgeries. Indications for iCT and the need for additional procedure after iCT were investigated. All operations were performed by the senior author. Results : Indications for iCT were comminuted nasal bone fracture with or without septal fracture, displaced zygoma fracture and orbital blowout fracture. The complex frontal sinus anatomy either by anatomic variation or tumor invasion was an indication for iCT in sinus surgery cases. Additional surgeries were necessary after iCT for five patients (29.4%) as follows: nasal bone reduction (2), zygomatic bone reduction (1), and the removal of meningioma (1) and inverted papilloma (1). Except for one patient, all patients showed satisfactory surgical outcomes in terms of completeness of fracture reduction or surgical removal of sinus pathology. Conclusion : In complex facial bone fracture or sinus diseases, an iCT helps to evaluate the completeness of fracture reduction or sinus dissection during the surgery and to decide the necessity for further surgery.

Giant endocarditis vegetation on a pace-maker lead

A 19 year-old man presented with a 2-month history of fever, cough and hemoptysis that were unresponsive to broad spectrum antibiotics. He had been implanted with an epicardial pace-maker at the age of 5 for complete heart block. One year before presentation, he experienced rupture of the epicardial implant following a car accident, and underwent emergency placement of an endocardial pacemaker. He also underwent orthopedic and abdominal surgery for multiple bone fractures and mesenteric artery aneurysm, with a resultant long-lasting intensive care unit stay. On admission to our hospital, computed tomography of the chest showed bilateral pulmonary inflammatory infiltrates with multiple pulmonary artery emboli. Trans-thoracic echocardiography showed a massive, mobile structure adhering to the pace-maker lead and severe pulmonary hypertension. Multiple blood cultures grew Candida albicans. The patient remained highly febrile and septic despite full dose combination antifungal treatment with caspofungin and fluconazole.

Outcomes of prophylactic antibiotics following surgery for zygomatic bone fractures

Data regarding the use of prophylactic antibiotics and infection rate following surgery for fractures of the zygomatic bone is scarce. Therefore an audit of the use and outcomes of antibiotic prophylaxis for surgery of fractures of the zygoma was undertaken. Following audit approval, four maxillofacial surgery units in the Yorkshire Region gathered prospective data for 134 patients undergoing surgery for fractures of the zygoma. Data was collected on four groups of patients undergoing surgery for fractures of the zygomatic bone: uncomplicated reductions of the zygomatic arch, reductions of the zygomatic complex without mini-plate fixation, reductions of the zygomatic complex using mini-plate fixation but excluding zygomatico-maxillary buttress, and fixation of the zygomatic complex with miniplates including the zygomatico-maxillary buttress. The choice and timing of any antibiotics given peri-operatively was recorded, and 30 days after the operation, the patients' notes were reviewed to identify any episodes of surgical site infection (SSI) requiring the prescription of antibiotics, or any instances of plate removal in the post-operative period. This data has demonstrated that the prescription of antibiotic prophylaxis for surgery for fractures of the zygomatic bone is extremely variable, and that the infection rate is low.

Orthodontic treatment for oral rehabilitation after multiple maxillofacial bone fractures

We present the orthodontic treatment of a patient with occlusal dysfunction after plastic surgery for multiple maxillofacial bone fractures caused by a traffic accident. The patient had mandibular deviation to the right because of inappropriate repositioning and fixation of the fractured bone and complete avulsion of both mandibular central incisors. The bilateral mandibular incisors, canines, and premolars were also suspected of partial avulsion or alveolar bone fracture. Several tests, including percussion and dental computed tomography, were performed on these teeth to rule out ankylosis and confirm tooth movement. Camouflage orthodontic treatment was carried out with expansion of the maxillary arch, alignment of both arches, and space closure between the mandibular lateral incisors to improve the occlusion. Good occlusion and interdigitation were obtained. Orthodontic treatment is useful for the rehabilitation of occlusal dysfunction caused by multiple maxillofacial bone fractures.

Pulmonary Extramedullary Haematopoiesis After Allogeneic Stem-Cell Transplantation

Practitioners performing stem-cell transplantation (SCT) sometimes experience temporary hypoxia during stem-cell infusion, which is recognized subjectively as chest discomfort and resolves completely after the infusion. Some physicians believe that this hypoxia is caused by a temporary embolism because of the presence of infused stem cells in the pulmonary artery. To the best of our knowledge, however, it remains unproven that stem cells aggregate in the small vessels of the pulmonary artery during stem-cell infusion. This infusion-related pulmonary event could be prevented by other interventions, such as filtration of the infusion stem cells to release cell clusters. A 52-year-old male aplastic anemia patient underwent allogeneic SCT from a sex-mismatched related donor. The stem-cell source was bone marrow from an human leukocyte antigen full-matched related donor with a conventional cyclophosphamide/total body irradiation regimen. Nine years after SCT, he suffered from late-onset noninfectious pulmonary complications constituting severe restrictive lung disease with pneumothorax. He underwent video-assisted thoracoscopic surgery for lung biopsy. Before video-assisted thoracoscopic surgery, his pulmonary function test showed a severe restrictive pattern, as following %VC was 45.8%, FEV1.0% was 100%, and FEV1.0 was 1.72 L. Chest x-ray photograph and chest computed tomography showed a broad low-attenuation area in the whole lung reflecting emphysema, and a reticulo-nodular shadow predominantly along the pleura. Computed tomography imaging specified bronchoectasia mainly in the bilateral upper lungs. Pathological findings of his right lung incidentally showed intravascular hematopoiesis containing immature granulocytes, erythrocytes, and megakaryocytes in his pulmonary artery (Fig. 1a). Evidence of the existence of stem cells was gained by partial staining by CD34 immunostaining in a few cells of the extramedullary hematopoiesis (EMH) site. The hematopoietic cells had XX signals detected by fluorescent in situ hybridization (Fig. 1b). There was no obvious hematological abnormality in his peripheral blood, and the proportion of XX and XY cells in the peripheral blood analyzed by fluorescent in situ hybridization revealed a 99.6% donor (XX) pattern with 0.0% XY signals. Bone marrow findings were normal, and no peripheral lymphadenopathy or hepatosplenomegaly was detected.FIGURE 1.: Pathological findings of lung biopsy (a) (×100) and sexual chromosome fluorescent in situ hybridization (FISH) in the same tissue (b) (×400). Extramedullary hematopoiesis (EMH) in the pulmonary artery was detected by XX chromosomal signals.EMH is a rare condition defined as the appearance of hematopoietic elements outside of the bone marrow. EMH is generally assumed to be a compensatory hyperplastic phenomenon when associated with anemia or space-occupying bone marrow disease (1). Though the presence of EMH in the lung is much less common (2), it is occasionally associated with traumatic events, such as a complicating bone fracture or cardiac surgery, leading to bone marrow embolism (3). In the present case, the patient’s aplastic anemia was in remission and the pathogenesis described above was not found. Peripherally transfused stem cells circulate to the lung arteries, where they may survive and continue hematopoiesis for several years after SCT. Spontaneous hypoxia during peripheral blood progenitor cell (PBPC) infusion may be recognizable if a massive cluster of stem cells occludes pulmonary circulation for a time and most of the cells recirculate while some stay to seed. Sale and Storb (4) reported the death of a dog due to extensive ossification of the lungs after dog leukocyte antigen-matched allograft transplantation. They explained that EMH needs not only hematopoietic cells but also an in vivo microenviroment including osteoblasts, fat cells, and fibroblasts. Mesenchymal cell growth could have resulted in the respiratory failure of the dog. This experimental phenomenon might provide the explanation for late-onset noninfectious pulmonary complications in the present case. And the early report concerning to the experimental model for chasing the transfused stem cells that initial sojourn of transplanted cells in the lungs last for 1 or 2 days (5). This might be associated to the early adverse events of respiratory system after transplantation. In conclusion, an influence of stem cells for lungs should be researched farther. To the best of our knowledge, this is the first documented case in the literature of isolated EMH in the lungs after SCT. Osamu Imataki Hiroaki Ohnishi Division of Haematology Department of Internal Medicine Faculty of Medicine Kagawa University Kagawa, Japan Yoshio Kushida Division of Pathology Kagawa University Hospital Kagawa, Japan Akira Kitanaka Department of Laboratory Medicine Faculty of Medicine Kagawa University Kagawa, Japan Yoshitsugu Kubota Transfusion Medicine Faculty of Medicine Kagawa University Kagawa, Japan

Appraisal of Early Evaluation of Blunt Chest Trauma: Development of a Standardized Scoring System for Initial Clinical Decision Making

Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma. A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693). Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.

FRACAS: A system for computer‐aided image‐guided long bone fracture surgery

FRACAS: A system for computer‐aided image‐guided long bone fracture surgery