Unhealed Fractures Research Articles

Impressive clinical improvement and disappearance of neuropathic pain in an adult patient with hypophosphatasia treated with asfotase alfa

Hypophosphatasia (HPP) is a rare disorder, resulting from loss-of-function variants of the ALPL gene encoding non-tissue specific alkaline phosphatase (TNSALP). Presentation varies largely, with increased severity usually occurring with earlier disease onset. Here we describe the clinical improvement of a 57-year-old woman with childhood onset HPP, after initiating treatment with asfotase alfa (Strensiq®). This was started because of the rapid and progressive radiological deterioration of bone structure after placement of nails in both upper legs for spontaneous atypical femur fracture (AFF) - like fractures. Initiation of treatment, not only resulted in stabilization of bone structure on X-rays, but within a few weeks there was a dramatic reduction of burning pain sensations in the lower legs, attributed in retrospect to neuropathic pain, and also almost complete disappearance of headaches. Additionally, unhealed metatarsal fractures finally healed after almost 10 years. Drug efficacy was further evaluated through -quality of life questionnaires and multiple tests conducted by the physiotherapist, and showed clear improvements. Within 3 months after starting asfotase alfa, the patient was able to carry out her daily tasks indoors without relying on a walker and even started electric bike rides for 20 km/day. In conclusion, treatment with asfotase alfa, halted rapid radiological bone deterioration after bilateral intramedullary femoral pen placement and strongly increased quality of life, marked by rapid disappearance of neuropathic pain, reduction in headaches and musculoskeletal pains, and enhanced muscle strength and mobility. The quick and almost complete disappearance of neuropathic pain and headache suggests a relation with disturbed levels of metabolites in HPP.

Joint Mobilization and its Resultant Effects

Joint mobilization also called joint manipulation technique commonly used in a clinical setting to improve the range of movement of a joint in order to prevent stiffness and pain. Any joint which presents with pain or stiffness can be treated with mobilization except in rare instances such as where there is malignancy, bone infection, spinal cord compression or unhealed fracture. There are different grades of mobilization used to treat various conditions. Where there is significant local pain and inflammation, gentle mobilization is used (Grade 1 or 2) to help with pain relief and reduce inflammation by promoting movement. In conditions where there is not much pain but rather the main problem is joint stiffness, then a more vigorous mobilizing technique (Grade 3 or 4) can be used to help restore full range of movement. The manipulation can be considered as an advanced way of joint mobilization, because it shares the same biomechanical principles. So, in OMT, the manipulation consists on a linear translatoric movement (traction or gliding) performed in the joint’s resting position, through a high velocity, low amplitude and low force thrust. These linear translatoric thrust techniques are technically more difficult to perform, but equally effective and much safer than the rotatory thrusts that have been traditionally performed. The manipulations are performed with the aim of obtaining joint surface separation and restoring the gliding component in joints that, even if they show an appropriate end-feel, they are hypomobile when examining them. It is a very effective technique if it is performed correctly and if it is indicated, but in the opposite cases it also carries serious injury risk. Because of the risk it can carry, and because of the expertise grade it requires for its execution, the manipulation training, mainly in the spine, for those physical therapists who have demonstrated their experience in the joint mobilization. However, basic low risk and equally ...

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union.

To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care. Retrospective cohort study. Academic Level II trauma center. All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up. The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care. One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004). Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures. Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17–84). The mean follow-up time was 26 months (range 12–72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1–10 weeks after injury; 13.1% at 11–52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96–5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14–1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852–6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29–0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.

Upper limb pediatric fractures in 22 tertiary children's hospitals, China: a multicenter epidemiological investigation and economic factor analysis of 32,832 hospitalized children

BackgroundFractures are the most common type of unintentional injury in children, with traumatic upper limb fractures accounting for approximately 80% of all childhood fractures. Many epidemiological investigations of upper limb fractures in children have been conducted, but with the development of society, the patterns of childhood fractures may have changed. This study aimed to analyze the epidemiology and economic cost factors of upper limb fractures in Chinese children.MethodsWe retrospectively reviewed children with upper limb fractures or old upper limb fractures hospitalized between December 1, 2015, and December 31, 2019, in 22 tertiary children’s hospitals, under China’s Futang Research Center of Pediatric Development. We used the ICD10 codes on the front sheet of their medical records to identify cases and extracted data on age, sex, injury cause, fracture site, treatment, the year of admission and discharge, visiting time, and various costs during hospitalization from the medical record.ResultsA total of 32,439 children (21,478 boys and 10,961 girls) were identified, of whom 32,080 had fresh fractures and 359 had old fractures. The peak age was 3–6 years in both sexes. A total of 4788 were infants, 14,320 were preschoolers, 10,499 were in of primary school age, and 2832 were adolescent. Fractures were most frequent in autumn (August to October). Admissions peaked at 0 o’clock. Among the 32,080 children with fresh upper limb fractures, the most common fracture site was the distal humerus, with a total of 20,090 fracture events including 13,134 humeral supracondylar fractures and 4914 lateral humeral condyle fractures. The most common cause of injuries was falling over. The most common joint dislocation accompanying upper limb fractures occurred in the elbow, involving 254 cases. Surgery was performed in 31,274 children, and 806 did not receive surgery. Among those with clear operative records, 10,962 children were treated with open reduction and 18,066 with closed reduction. The number of cases was largest in the East China region (Anhui Province, Shandong Province, Jiangsu Province, Zhejiang Province, and Fujian Province), with 12,065 cases overall. Among the 359 children with old fractures, 118 were admitted with a diagnosis of “old humerus fracture,” accounting for the highest proportion; 244 underwent surgical open reduction, 16.16% of whom had osteotomy. For the children with fresh fractures, the average total hospital cost was 10,994 yuan, and the highest average total hospital cost was 14,053 yuan, for humeral shaft fractures. For the children with old fractures, the average total hospital cost was 15,151 yuan, and the highest average total hospital cost was 20,698 yuan, for old ulna fractures. Cost of materials was the principle factor affecting total hospital cost, followed by surgery and anesthesia costs, both in children with fresh fractures and those with old fractures. Significant differences were observed in all hospital costs (P < 0.001) except treatment costs (P = 0.702), between children with fresh fractures and those with old fractures. Among the 32,439 children, full self-payment accounted for the highest proportion of all payment methods, involving 17,088 cases, with an average cost of 11,111 yuan.ConclusionInformation on the epidemiological characteristics of childhood fractures suggests that health and safety education and protective measures should be strengthened to prevent upper limb fractures in children. For both fresh and old fractures, the cost of materials was the principal factor affecting total hospital cost, followed by surgery and anesthesia costs. The overall average total hospital cost is higher in children with old fractures than in children with fresh fractures. Among all children, full self-payment, at 53% of children, accounted for the highest proportion of all payment methods. Hospital costs are a headache for those families who will pay on their own. It can lead to a delayed treatment and unhealed fractures or malunion in some children. Therefore, the child trauma care system and training on fractures need to be improved, to reduce the late presentation of fractures. These combined measures will improve children’s quality of life, reduce the expenditure of families, and decrease the public health burden. To provide better medical services for children, authorities must improve the allocation of health resources, establish a comprehensive medical security system for children, and set up more child trauma centers.

Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection.

The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England). A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required. All 13 patients achieved infection remission rate with an average follow-up of 19.7months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8months (range 4-12) from debridement. No patients developed aseptic wound leak. Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.

Age, material source, and formation mechanism of bedding-parallel calcite beef veins: Case from the mature Eocene lacustrine shales in the Biyang Sag, Nanxiang Basin, China

The mechanisms leading to the formation of bedding-parallel calcite beef veins have been widely debated, with discussions centered on timing or burial depth of vein generation, source of the vein material, driving forces for vein initiation and widening, and growth direction and mechanism. To address these issues, a comprehensive study of drill core samples containing beef veins in the mature Eocene lacustrine Hetaoyuan Formation in the Biyang Sag, Nanxiang Basin, China was undertaken through a combination of microstructural observation, isotopic geochronological, geochemical, and fluid inclusion analyses, as well as basin modeling. X-ray diffraction and total organic carbon content analyses indicate that most of the beef veins accumulated in calcite-rich laminated shales with high organic matter contents. These beef veins yielded an absolute laser ablation−multi-collector−inductively coupled plasma−mass spectrometry U-Pb age of ca. 41.02 ± 0.44 Ma, which corresponds to a burial depth of 500−800 m. Such a shallow burial depth suggests that the full compaction and consolidation of sediments would not yet have been achieved, which is compatible with the following observations: (1) plastic deformation of shale laminae adjacent to the veins, and (2) a beef vein formation temperature of ∼59 °C derived from fluid-inclusion microthermometry. The radio-isotopic age of the beef veins is ∼1−3 m.y. younger than the stratigraphic age of the host rock (ca. 43.1 Ma) but earlier than the model-derived timing of oil generation (ca. 35.8 Ma) and tectonic extrusion (ca. 23.0−13.0 Ma). The beef vein formation predated bacterial sulfate reduction, as evidenced by crosscutting relationships with carbonate concretions, pyrite framboids, and apatite pellets. A two-stage formation model for these beef veins is proposed. When burial depth of laminated shales rich in organic matter and calcite reaches the methanogenic zone, overpressure triggered by biogenetic gas generation results in horizontal hydrofracturing, initiating cracks that act as gas expulsion pathways. Once all the generated gas has migrated, the opened fractures close again due to overburden load. The materials fed by pressure solution of host-rock calcite fractions then mobilized into the unhealed horizontal fractures by diffusion. Subsequently, by a force of crystallization, antitaxial, displacive growth of calcite fibers commenced, contemporaneous with fracture dilation, eventually leading to the formation of bedding-parallel beef veins.

Long noncoding RNA XIST modulates microRNA-135/CREB1 axis to influence osteogenic differentiation of osteoblast-like cells in mice with tibial fracture healing.

Fracture healing is a complex event with the involvement of many cell systems, cytokines, as well as mRNAs. Herein, we report the interactions among long noncoding RNA X-inactive specific transcript (XIST)/microRNA-135 (miR-135)/cAMP response element-binding protein 1 (CREB1) axis during fracture healing. We observed increased expression of XIST in patients with long-term unhealed fracture by microarray analysis. Subsequently, a mouse model with tibial fracture and a cell model using osteoblast-like MC3T3-E1 cells were generated. The XIST overexpression during fracture healing decreased proliferation and differentiation of MC3T3-E1 cells, while silencing of XIST facilitated MC3T3-E1 cell growth. Furthermore, miR-135 targeted CREB1 and negatively regulated its expression. XIST acted as a sponge for miR-135, thereby upregulating CREB1 and promoting the activity of the TNF-α/RANKL pathway. Transfection of miR-135 inhibitor or CREB1 overexpression blocked the stimulating effects of XIST knockdown on MC3T3-E1 cell growth. Besides, specific inhibitors of the TNF-α/RANKL pathway reversed the repressive role of XIST in cell osteogenic differentiation. All in all, these findings suggest that XIST knockdown induces the differentiation of osteoblast-like cells via regulation of the miR-135/CREB1/TNF-α/RANKL axis. XIST, as a consequence, represents an attractive therapeutic strategy to accelerate fracture healing.

Arthroscopically assisted resection of overlooked fracture of posterior talar procesus

Introduction. The fractures of the posterior process of the talus are relatively rare injuries of the ankle. They most frequently occur via the mechanism of the forced hyper plantar flexion and inversion. Sometimes they are not initially diagnosed, since over 40% of cases of the fractures of the posterior process of the talus are not seen in the initial radiography. The objective of this work is the review of the case study of the arthroscopically treated unhealed fracture of the posterior process of the talus. Case outline. In our case report we present a 30-year-old male, professional soccer player, with a threemonth-long history of chronic pain in the region of the left ankle and heel and the fracture of the posterior process of the talus. Conclusion. The work shows all the advantages of minimally invasive surgery ? arthroscopic excision of the fragment, quick recovery and returning to physical activities.

Midshaft Clavicle Fractures Treated Nonoperatively Using Figure-of-Eight Bandage: Are Fracture Type, Shortening, and Displacement Radiographic Predictors of Failure?

As there are no clear and unique radiographic predictors of healing disturbances for acute midshaft clavicle fractures, their treatment is still controversial. The aim of the study was to evaluate in midshaft clavicle fractures treated nonoperatively if fracture type (FT), shortening, and displacement, assessed before and after figure-of-eight bandage (F8-B) application, could be considered prognostic factors of delayed union and nonunion. One hundred twenty-two adult patients presenting a closed displaced midshaft clavicle fracture, managed nonoperatively with an F8-B, were enrolled. FT, initial shortening (IS), and initial displacement (ID) were radiographically evaluated at diagnosis, and both residual shortening (RS) and displacement (RD) were measured after F8-B application. The patients were followed up 1, 3, 6, and 12 months post-injury. Multivariate statistical analysis was performed. RD should be considered as radiological predictor of sequelae. Further, an RD equal to 104% of clavicle width was identified as an optimal cut-off point to distinguish between healed and unhealed fractures, and 140% between delayed union and nonunion. Our data pointed out the effectiveness of the F8-B in reducing fracture fragments and restoring clavicular length. In midshaft clavicle fractures of adults, fracture comminution and clavicular shortening did not influence bone healing. On the contrary, RD has been shown as the most likely predictor of both delayed union and nonunion.

Arthroscopic tri-pulley Technology reduction and internal fixation of pediatric Tibial Eminence fracture: a retrospective analysis

BackgroundFixing a tibial eminence fracture with a tri-pulley is a new technique. The purpose of this study was to present the early clinical outcome of arthroscopic tri-pulley suture fixation for tibial eminence fractures in children.MethodsTwenty-one pediatric patients with type II or type III anterior tibial eminence fractures were included in this retrospective study. All Patients underwent surgical fixation by tri-pulley technology and were followed up for at least 24 months. They were evaluated preoperatively and postoperatively by physical, X-ray, and computed tomography (CT) examination and subjectively with the International Knee Documentation Committee (IKDC), and Lysholm questionnaires.ResultsThe patients included 12 males and 9 females; mean age, 12.5 years (range, 8 ~ 16 years). They were followed-up for a median of 27 months (range, 24 ~ 39 months). We did not find post-operative instability in any of the patients by physical examination. The KT-2000 difference of both knees decreased from 9.3 ± 1.2 mm preoperatively to 2.6 ± 0.8 mm 24 months postoperatively (P < 0.001); the IKDC subjective knee evaluation score improved from 43.1 ± 13.2 preoperatively to 83.8 ± 6.3 postoperatively (P < 0.001); and Lysholm improved from 48.3 ± 6.21 to 87.1 ± 9.8 (P < 0.001). No unhealed fractures or epiphyseal damage were reported in the postoperative X-ray and CT.ConclusionsArthroscopic tri-pulley fixation technology may provide a suitable technique for repair of tibial eminence fractures in skeletally immature patients.Level of evidenceCase series; Level of evidence IV.

Association of Three-Month Radiographic Union Score for Tibia Fractures (RUST) with Nonunion in Tibial Shaft Fracture Patients.

ObjectivesNonunions of tibial shaft fractures have profound implications on patient quality of life and are associated with physical and mental suffering. Radiographic Union Score for Tibia Fractures (RUST) may serve as an important prognostic tool for identifying patients at a high risk of nonunion.DesignWe used data from the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) and Fluid Lavage of Open Wounds (FLOW) trials to explore the association of three-month RUST scores with nonunion in patients with tibial shaft fractures treated with intramedullary nailing. We performed a retrospective cohort study nested within two multi-center, randomized controlled trials.ParticipantsThe patients included in the current study: (1) sustained a tibial shaft fracture and were enrolled in the SPRINT or FLOW randomized trials, (2) had initial operative management with intramedullary nailing, (3) showed radiographic evidence of an unhealed fracture at the three-month follow-up, and (4) their healing status (union or nonunion) was captured at 12-months postoperatively.InterventionMultivariable binary logistic regression was carried out to identify factors associated with nonunion, including open versus closed injury, fracture severity, fracture gap, and three-month RUST score. We determined the concordance statistic (c statistic) for our regression model both with and without the RUST score.Outcome Measurements and ResultsOf the 155 tibial fracture patients with complete data available for analysis, the overall rate of nonunion at 12 months was 30% (n=47). The mean three-month RUST score in patients with nonunion at 12 months was 4.8 (standard deviation (SD) 1.1) as compared to 6.3 (SD 1.7) for those healed at 12 months. In our multivariable regression analysis, open fractures conferred five-fold greater odds of nonunion at 12 months as compared to closed fractures (odds ratio (OR) 4.76, 95% confidence interval (CI):1.71-13.30). Further, three-month RUST scores of 4 and 5-6 were associated with a 47% (95% CI: 18%-73%) and 23% (4.5-51.5%) absolute risk increase of nonunion as compared to a score of ≥ 7, respectively. The addition of RUST scores to our adjusted regression model improved the c statistic from 0.70 (95%CI: 0.61-0.79) to 0.81 (95%CI: 0.74-0.88).ConclusionA third of patients with tibial shaft fractures who have failed to heal by three months will show nonunion at one year. Open fractures and lower three-month RUST scores are strongly associated with a higher risk of nonunion at one year. Further research is needed to establish whether prognosis in this high-risk group can be modified.

Pain Reduction by Percutaneous Vertebroplasty for Vertebral Compression Fractures with and without Intravertebral Clefts

Background:Vertebroplasty has become a common treatment for relieving pain in osteoporotic vertebral fractures. However, there is contradictory evidence regarding its efficacy. The aim of this study was to determine the degree of pain relief offered by percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures (OVCFs) in patients with or without an intravertebral cleft. Material and Methods: In this multicenter, randomized, placebo-controlled trial all patients who had one or multiple painful, unhealed compression fractures were randomly assigned to undergo vertebroplasty or a sham procedure. The patients in the vertebroplasty group were divided into two subgroups: A - with intravertebral cleft, and B - without intravertebral cleft. They were followed up for the mean pain reduction assessed by visual analogue scale (VAS), and changes in the quality of life using the osteoporosis and Roland-Morris disability questionnaire scores (RDQ) at 1, 6, and 12 months, and two years after the procedure. Results: A total of 1,311 patients were studied (vertebroplasty 661, sham 650). The data showed that those with intravertebral clefts had significantly less severe back pain (p = 0.01) and functional disability (p=0.03) at month 12 compared to those without intravertebral cleft. However, the study groups did not differ significantly with respect to the pain score or the RDQ score at other measurement points (p>0.05). There was a trend in the RDQ score toward less pain in patients with filled clefts compared with patients without clefts after one and two years after surgery, this difference did not approach statistical significance. Conclusion: We found no significant benefit of percutaneous vertebroplasty (PVP) over a sham procedure in patients with vertebral compression fractures with or without vertebral clefts 6 months after surgery. One and two years after surgery, there was a trend toward less pain.

General treatment principles for fracture-related infection: recommendations from an international expert group

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients’ short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

Postcranial axial skeletal pathology in Commerson's dolphins Cephalorhynchus c. commersonii from Tierra del Fuego, Argentina.

Commerson's dolphins Cephalorhynchus c. commersonii are the small cetacean most frequently found stranded along the coast of Tierra del Fuego, Argentina, but little is known about their pathologies. We examined the postcranial axial skeleton of 425 Commerson's dolphins collected in the period 1974-2011 for the presence of pathologies. Miscellaneous lesions were detected in 107 (25.2%) of the specimens. Among them, idiopathic hyperostosis was the most frequent pathology (73.8%), followed by spondyloarthropathy (40.2%). Traumata (25.2%), spondylitis (10.3%) and osteoarthritis (11.2%) occurred less frequently. The type of lesion was statistically associated with the region of the vertebral column. Idiopathic hyperostosis occurred significantly more frequently in the lumbar vertebrae than in other parts of the vertebral column, while spondyloarthropathy was more frequent in the thoracic and caudal vertebrae. Both conditions were predominantly seen in mature dolphins. Osteoarthritis affected the transverse processes of the thoracic vertebrae of 6 males, 3 females and 3 individuals of undetermined sex, all mature. Healed and unhealed fractures were observed in the ribs of 27 specimens and in the transverse processes of 3 others. Spondylitis of various degrees of severity affected the cervical, thoracic, lumbar and caudal regions of 11 individuals. Together these data indicate that bone lesions and traumata commonly occur in Commerson's dolphins, likely causing pain and morbidity in severe cases.

Vertebroplasty in Elderly Patients: A Clinical Effectiveness Analysis

Minimally invasive vertebral augmentation procedures (VAP) have been first introduced to provide pain relief in patients with osteoporotic vertebral fractures (VF). However, in the last decade scientific literature revealed to be quite controversial about their efficacy. The aim of this review was to analyze clinical evidences from current literature, supported by our own experience. Compared to conservative therapies, VAP represent an effective treatment for recent VF and, in elderly patients, reduce mortality and morbidity. Advances in technology have widened the fields of application towards other spine pathologies typical of elderly, such as primary and metastatic tumors. In patients with severe pain for recent or un-healed vertebral fracture, VAP are clinically more effective than conservative treatment. Accurate pain assessment and pre-procedural Magnetic Resonance Imaging are highly recommended to obtain optimal patient selection and best treatment results.

Percutaneous vertebroplasty: Current controversy

Percutaneous vertebroplasty: Current controversy

Comparison of Medial Malleolar Fracture Healing at 8 Weeks After Open Reduction Internal Fixation Versus Percutaneous Fixation: A Retrospective Cohort Study

Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection associated with an open approach but can also result in inadequate anatomic reduction. No studies have compared the incidence of radiographic healing of medial malleolar fractures between an open approach and percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic reliability, leading to poor anatomic reduction and inaccurate fixation.

How to remove a bent intramedullary nail inexpensively: a technical trick

Background: A bent femoral intramedullary nail is a rare complication following secondary trauma to an unhealed femoral fracture site. Existing strategies for removal require the use of specialized instrumentation such as a diamond tipped drill or a high speed burr. Specialized orthopedic instrumentation is often expensive and frequently unobtainable in the developing world. Objectives: To provide a solution in resource poor settings and describe a unique approach to managing such complex cases. Methods: Novel, low cost, and successful use of industrial instruments for removing a femoral nail bent in situ in a 43 year old man who would have likely required a much more extensive operation without it. Results: Instrumentation was obtained from a local market and at a fraction of the cost of specific orthopedic instruments. This case presents a technical tip for managing this complication in the developing world. Conclusions: In a resource poor setting, we can recommend the judicious use of inexpensive industrial materials and instruments to manage complex cases. Keywords: Bent, developing, femoral nail, fracture, resource-poor setting

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. Level IV, therapeutic study.