Current management of tibial shaft fractures: A survey of 450 Canadian orthopedic trauma surgeons

Background and purpose?Strategies to manage tibial fractures include nonoperative and operative approaches. Strategies to enhance healing include a variety of bone stimulators. It is not known what forms of management for tibial fractures predominate among Canadian orthopedic surgeons. We therefore asked a representative sample of orthopedic trauma surgeons about their management of tibial fracture patients.

Methods?This was a cross-sectional survey of 450 Canadian orthopedic trauma surgeons. We inquired about demographic variables and current tibial shaft fracture management strategies.

Results?268 surgeons completed the survey, a response rate of 60%. Most respondents (80%) managed closed tibial shaft fracture operatively; 47% preferred reamed intramedullary nailing and 40% preferred unreamed. For open tibial shaft fractures, 59% of surgeons preferred reamed intramedullary nailing. Some surgeons (16%) reported use of bone stimulators for management of uncomplicated open and closed tibial shaft fractures, and almost half (45%) made use of this adjunctive modality for complicated tibial shaft fractures. Low-intensity pulsed ultrasound and electrical stimulation proved equally popular (21% each) and 80% of respondents felt that a reduction in healing time of 6 weeks or more, attributed to a bone stimulator, would be clinically important.

Interpretation?Current practice regarding orthopedic management of tibial shaft fractures in Canada strongly favors operative treatment with intramedullary nailing, although respondents were divided in their preference for reamed and unreamed nailing. Use of bone stimulators is common as an adjunctive modality in this injury population. Large randomized trials are needed to provide better evidence to guide clinical decision making regarding the choice of reamed or unreamed nailing for tibial shaft fractures, and to inform surgeons about the actual effect of bone stimulators.     

Growth factors: Possible new clinical tools: A review

Bone tissue contains numerous cell-to-cell signaling peptides called growth factors with potent effects on bone cell metabolism. in vivo studies over the last 5 years have demonstrated that growth factors can stimulate bone formation and bone healing and these results have made them candidates for use in orthopedic surgery. in numerous clinical conditions enhanced bone formation and bone healing could improve the results of surgery; clinical trials using growth factors to stimulate bone formation in spinal surgery, and to stimulate healing of bone defects, have been initiated. Growth factors for clinical use will become commercially available in the near future.

This review describes the main growth factors and their actions in vitro and in vivo in relation to bone tissue and bone healing. Possible areas for clinical use are also discussed.     

碱性成纤维细胞生长因子加速慢性难愈合创面愈合

目的　观察碱性成纤维细胞生长因子（ｂ Ｆ Ｇ Ｆ）对慢性难愈合创面（溃疡）的促修复作用并探讨其促修复机制。方法　２８ 例共３３ 个慢性难愈合创面,其中创伤性溃疡１２ 例（１４ 个创面）,压迫性溃疡 ９ 例（１２ 个创面）,糖尿病溃疡 ４ 例,放射性溃疡 ３ 例。所有创面经清创后用ｂ Ｆ Ｇ Ｆ 治疗（１５０ Ｕ／ｃｍ ２ 创面,每天１ 次）。结果　所有经ｂ Ｆ Ｇ Ｆ治疗的创面都产生了明显的愈合,其中２ 周内愈合者２０ 个创面,３ 周内愈合者 ３ 个创面,４ 周内愈合者８ 个创面,超过４ 周愈合者２个创面。４ 周内总愈合率为９３．９％ 。结论　ｂ Ｆ Ｇ Ｆ可以显著地加速慢性难愈合创面愈合,其可能的机制涉及外源性ｂ Ｆ Ｇ Ｆ能够补充内源性ｂ Ｆ Ｇ Ｆ 的不足或调控内源性ｂ Ｆ Ｇ Ｆ活性。     

Reconstruction of critical size segmental femoral diaphyseal defects of New Zealand rabbits by using combined titanium mesh cage and induced membrane technique

Purpose

Long bone defects due to fractures resulting from high-energy trauma, infections and tumor resections are problems that orthopedic surgeons commonly face. We investigated the effects of a titanium mesh cage on bone healing with an induced membrane technique.

Methods

Three groups, each composed of eight rabbits, were formed. Extraarticular diaphyseal bone defects were created. Femora of the first group were fixed with an empty titanium mesh cage and two K-wires. After formation of the defect, polymethylmethacrylate was inserted and fixed with a K-wire in the second group. At the third week, the cement was removed, a sterilized cancellous graft-filled titanium mesh cage was placed into the defect, and the membrane that was previously formed over the cement was placed on the cage and repaired. In the third group, sterilized cancellous grafts were filled into the titanium mesh cage, and the titanium mesh cage was fitted into the bone defect area.

Results

At the end of the third month, all subjects were killed. Radiological data revealed that the healing of the bone in the second and third groups was significantly better than that in the first group. There was no difference between the second and third groups. A histological evaluation of the healing status, such as fibrous tissue, cartilage tissue and mature or immature bone formation, was performed. Histological healing in the second and third groups was also significantly better than that in the first group.

Conclusion

We concluded that the combination of membrane-induced bone healing and graft-filled titanium mesh cages expedites osteogenesis in extraarticular bone defects.

     

The basic science of peri-implant bone healing

Given the popularity of cementless orthopedic implants, it is imperative for orthopedic surgeons to have a basic understanding of the process of peri-implant bone healing. Contact and distance osteogenesis have been used to explain peri-implant bone healing. In contact osteogenesis, de novo bone forms on the implant surface, while in distance osteogenesis, the bone grows from the old bone surface toward the implant surface in an appositional manner. Contact osteogenesis may lead to bone bonding if the surface of the implant displays the appropriate surface topography. The early stage of peri-implant bone healing is very important and involves the body’s initial response to a foreign material: protein adsorption, platelet activation, coagulation, and inflammation. This results in the formation of a stable fibrin clot that is a depot for growth factors and allows for osteoconduction. Osteoconduction is the migration and differentiation of osteogenic cells, such as pericytes, into osteoblasts. Osteoconduction allows for contact osteogenesis to occur at the implant surface. The late stage of healing involves the remodeling of this woven bone. In many respects, this process is similar to the bone healing occurring at a fracture site.     

Collective review: bioactive implants coated with poly(D,L-lactide) and growth factors IGF-I, TGF-beta1, or BMP-2 for stimulation of fracture healing

Demographic data reveal that due to the increasing aging of the population, complications with the musculoskeletal system will increase in the next years. One major problem in orthopedic and trauma surgery are the delayed healing or non-unions of long bone fractures. The exogenous application of growth factors can stimulate the bone healing to reduce these complications. Beside the choice of the optimal growth factor the application system is important. Therefore, we developed a new bioactive coating method for implants, which is based on a biodegradable poly(D,L-lactide) (coating thickness: 10 mum).This coating allows the incorporation of growth factors and the controlled release of these factors during the healing process without the need for further devices. The effect of different growth factors (IGF-I, TGF-beta1, and BMP-2) locally released from coated intramedullary implants on fracture healing was investigated with biomechanical and histological analysis in rats. All investigated growth factors stimulated the fracture healing as assessed with biomechanical tests and histological analysis. The local application of combined IGF-I and TGF-beta1 had the most stimulating effect on fracture healing, followed by the effect of BMP-2, IGF-I, and TGF-beta1 alone. Bioactive coating of biomechanical well-established implants can on the one hand stabilize the fracture and on the other hand stimulate healing processes to increase healing and to reduce the rate of complications.     

Harmful lifestyles on orthopedic implantation surgery: a descriptive review on alcohol and tobacco use

Alcohol abuse and smoking habits have adverse effects on bone health and are a risk factor for osteoporosis, fractures and impaired fracture repair. Osteointegration processes around implanted biomaterials involve a coordinated cascade of complex events that are very similar to those occurring during fracture repair and require a suitable microenvironment and the coordinated action of cells and signal molecules. Therefore, diseases and harmful lifestyles that impair the normal bone healing process can reduce the success of implant surgery and may negatively influence the osteointegration of prostheses and implant devices for fracture fixation such as screws, nails and plates. Understanding the effects of harmful lifestyles on bone implant osteointegration is important for successful implant therapy, orthopedic reconstructive surgery and tissue-engineered-based therapies. However, the mechanisms by which smoking and alcoholism affect bone metabolism, bone mass and the balance of bone resorption and formation, also in the presence of an orthopedic implant, are not completely understood and remain inadequately elucidated. This review aims to analyze in vitro and in vivo studies regarding orthopedic implant integration in the presence of tobacco smoking and alcohol consumption with a focus on pathophysiology and local or systemic mechanisms of action on bone.     

Bisphosphonates in orthopedic applications

Bisphosphonates (BPs) exert potent effects on the skeleton. As such, there are important questions relating to how treatment with BPs for metabolic disorders might affect outcomes of orthopedic problems. A further question is what role, if any, might BPs play as adjunctive therapeutics for orthopedic problems. This article outlines the research thus far in the application of BPs to the management of osteonecrosis, bone repair, and joint arthroplasty. Many animal studies show a benefit to decreasing bone resorption in models of osteonecrosis. These include studies in both small and large animals, backed up by limited human data. Further clinical trials are underway for this indication. In bone repair, again, multiple studies exist. There are concerns that BPs could interfere with the normal processes of healing. Some of the controversy about benefits or adverse effects of BPs in this context can be distilled down to effects of dosing and administration. With some exceptions, longer intervals between dosing seem to be more beneficial while not producing adverse healing effects in animal studies. In joint arthroplasty, animal studies suggest a role for topical or systemic BPs for enhancing bone on-growth to implant surfaces and strength of mechanical fixation, although these are yet to be confirmed in clinical studies. Clinical studies show that BPs inhibit periprosthetic bone loss due to strain-adaptive remodeling and after impaction bone grafting, although an efficacy in inhibiting inflammatory bone loss due to wear particle-induced osteolysis has not been confirmed. Lastly, as anabolic drugs have become available, there is increasing interest in their combined use with BPs. From experimental data, manipulation of both the anabolic and catabolic responses is a powerful approach in models of bone repair.     

C5aR-antagonist significantly reduces the deleterious effect of a blunt chest trauma on fracture healing

Confirming clinical evidence, we recently demonstrated that a blunt chest trauma considerably impaired fracture healing in rats, possibly via the interaction of posttraumatic systemic inflammation with local healing processes, the underlying mechanisms being unknown. An important trigger of systemic inflammation is the complement system, with the potent anaphylatoxin C5a. Therefore, we investigated whether the impairment of fracture healing by a severe trauma resulted from systemically activated complement. Rats received a blunt chest trauma and a femur osteotomy stabilized with an external fixator. To inhibit the C5a‐dependent posttraumatic systemic inflammation, half of the rats received a C5aR‐antagonist intravenously immediately and 12 h after the thoracic trauma. Compared to the controls (control peptide), the treatment with the C5aR‐antagonist led to a significantly increased flexural rigidity (three‐point‐bending test), an improved bony bridging of the fracture gap, and a slightly larger and qualitatively improved callus (µCT, histomorphometry) after 35 days. In conclusion, immunomodulation by a C5aR‐antagonist could abolish the deleterious effects of a thoracic trauma on fracture healing, possibly by influencing the function of inflammatory and bone cells locally at the fracture site. C5a could possibly represent a target to prevent delayed bone healing in patients with severe trauma. © 2011 Orthopaedic Research Society. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 30:581–586, 2012     

Treatment of nonunited fractures with capacitively coupled electric field

Abstract Fracture healing undoubtedly depends on the orthopedic treatment applied: alignment, immobilization and contact between the stumps of the fracture constitute the biomechanical basis for any effective orthopedic treatment capable of ensuring fracture healing. However, the relevance of the biological environment and the need to maximize the endogenous osteogenetic activity are becoming evident. Presently, osteogenesis can be enhancement by means of growth factors or physical stimulation. The aim of this study was to evaluate the effects of capacitively coupled electric field (CCEF), a physical method to stimulate osteogenesis, in patients suffering from nonunited fractures. Thirty patients were included in the study. Inclusion criteria foresaw: no radiological evidence of callus formation, the fracture site had to be stable, bone stumps were aligned and, in the presence of bone loss, its extension could not exceed half the diameter of the treated bone. The presence of infection did not preclude recruitment. Standard radiographs were used to determine fracture healing. Out of 30 patients, 22 were men and 8 women. The sites of treatment were: 10 tibiae, 9 femura, 5 forearms, 2 humeri and 4 others. The average length of the stimulation was 10 weeks and the average daily time of CCEF use was 8 h. Among patients that met the inclusion criteria the success healing rate was 84%, in contrast, healing was not observed among the 5 patients who did not meet the inclusion criteria (p<0.05). Our findings show that electrical stimulation of endogenous bone repair with CCEF is an effective treatment when the inclusion criteria, mechanical stability, contact and alignment at the fracture site are maintained. The presence of infection did not negatively affect bone healing. The treatment is well accepted by patients and compliance is definitely high; this study shows that 8 hours of daily use is effective.     

生物降解可吸收骨折内固定物的临床应用

目的　阐明生物降解可吸收骨折内固定物治疗不同部位骨折的临床应用效果及并发症 ,指出目前存在的问题和今后努力方向。方法　回顾近年来有关生物降解可吸收骨折内固定物的临床应用报道及研究进展 ,总结其对骨折固定和骨折愈合的作用。结果　可吸收骨折内固定物对骨折愈合无不良影响 ,固定稳定性良好 ,收到较好的临床治疗效果。结论　生物降解可吸收骨折内固定物有广泛的临床应用前景 ,但仍存在一些并发症 ,应进一步深入研究预防措施     

微创整形技术在面部碾挫伤中的应用

目的：回顾性分析面部碾挫伤患者采用微创整形技术缝合的临床效果。方法：2006年4月-2009年9-月共治疗28例患者，伤口均在面部，采用精细的原位再生清创术和综合性的整形缝合技术。结果：均达到I期愈合，恢复快，创伤小，外观自然，瘢痕不明显，无明显组织牵拉，患者对外形满意。结论：在面部碾挫伤中，综合运用微创整形技术，可以明显减轻患者的创伤，促进愈合，避免术后瘢痕及畸形的发生，是处理面部急诊外伤的好方法。     

Growth factors--BMPs, DBMs, and buffy coat products: are there any proven differences amongst them?

Advances in the understanding of bone repair and improved biotechnology have led to the introduction of new strategies for orthopedic surgeons to control and modulate bone healing using growth factors. However, many orthopedic surgeons are uncertain about the current levels of evidence supporting the use of materials that possess these properties and their therapeutic role in the management of skeletal problems such as fracture, long-bone nonunion, and spine fusion. In particular, the differences amongst osteoinductive factors synthesized by recombinant gene technology, or derived from demineralized bone matrix or platelet rich plasma requires clarification.     

Side effects of chemotherapy in musculoskeletal oncology

With recent advances in medical and orthopedic oncology, radiation therapy and single- or multiple-agent perioperative chemotherapy are currently applied as an essential part of the multidisciplinary treatment to improve disease-free and overall survival of patients with primary and metastatic bone and soft tissue tumors. However, these treatments have led to unwanted complications. A better understanding of the effects of various antineoplastic agents on bone, soft tissue, and organs may provide the basis for the more efficacious use of antiproliferative drugs when fracture healing or allograft incorporation is required. This knowledge may also provide a rationale for concurrent treatment with drugs that protect against or compensate for adverse effects in osseous repair resulting from chemotherapy.     

Use of bone morphogenetic proteins for treatment of non-unions and future perspectives

Still a major problem in orthopedic and trauma surgery is the delayed healing or the non-union of long bone fractures. Demographic data reveal that due to the steadily rising age of the population, complications with the musculoskeletal system will increase during the next years. Bone morphogenetic proteins (BMPs) have successfully been applied in clinic for the treatment of delayed healing and non-unions. The broad difference concerning the indication, timing of treatment, dosage and application technique of BMPs calls for the need to perform further prospective studies in order to standardize the treatment and furthermore optimize the procedures or even develop new therapeutic strategies. For example, the application technique may be improved and in some cases injectable BMP preparations could be of use. Also the coating of implants with growth factors might be valuable in order to stimulate bone healing and to prevent delayed healing or non-union. This article tries to discuss some of the open questions, however can and will not reflect the absolute standard of care. To make the BMP treatment a standard of care, more clinical data and long time experiences are necessary. The intramedullary application of BMP in combination with autologous or allogenic bone grafts or bone substitutes after debridement and stabilization with implants seems to be an adequate procedure for treatment of atrophic non-unions. However, the total number of patients is too small to draw final conclusions. Further clinical studies need to be performed in the future.     

Lipopolysaccharide impairs fracture healing: an experimental study in rats

Background It has been shown that trauma causes translocation of lipopolysaccharide (LPS) endotoxins from the gut. LPS has been identified as a major bacterial bone resorbing factor. The effects of LPS on bone healing are therefore of clinical interest, as trauma involving fractures followed by sepsis is a clinical scenario. We investigated the effects of systemic and local administration of LPS on the healing of femoral fractures in rats.

Animals and methods In 3 groups, each consisting of 9 rats, a mid-diaphyseal osteotomy/fracture of the femoral bone was performed and then nailed. In one group of animals, LPS was applied intraperitoneally (systemically), and in another group, LPS was applied locally at the fracture site. The third group served as a control. The animals were killed after 6 weeks, and the mechanical characteristics of the healing osteotomies were evaluated.

Results We found that LPS induced a hypertrophic and immature callus, as evaluated by bone mineral content and density. In the rats given LPS intraperitoneally, the mechanical strength characteristics were reduced, as evaluated by bending moment, rigidity, and energy absorption.

Interpretation The rats given LPS intraperitoneally reflect a clinical situation with fracture trauma and endotoxinemia. Our findings indicate that endotoxinemia may impair the fracture healing processes.

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Woven bone formation around implants and the effect of bacterial infection.

Several implant materials used in dental and orthopedic surgery were placed in rat tibial bones to study their effects on mineralization. The implants consisted of bone bonding and non-bonding materials. Changes in mineralization were defined by morphometric analysis of matrix vesicle distribution at the implant interface and in normal bone healing following marrow injury. Bone-bonding materials induced an increase in matrix vesicle activity. This finding was supported by study of the biochemical changes in the same model that manifested high correlations to the morphometrical observations with regard to enhancement or delay of primary mineralization. In addition, the study of healing using nuclear methods indicated that implants alter bone healing as shown by the different uptakes of 99mTc and 32P in the different bone compartments. Decreased 32P uptake by the organic phase in the presence of bone-bonding implants suggested that cleavage of 99mTc-MD32P into its technetium and methylene diphosphonate moieties was inhibited by administration of implants. Further studies on the effect of bacterial infection on the peri-implant tissues revealed a decrease in woven bone formation due to infection.     

Rare shear-type fracture of the talar head in a thirteen-year-old child — Is this a transitional fracture: A case report and review of the literature

BACKGROUNDTalar fractures are exceedingly rare in childhood. There are very few studies on the clinical aspects, the long-term outcomes and the appropriate treatment of these fractures in pediatric patients. The mechanism of trauma consists of the application of a sudden dorsiflexion force on a fully plantar-flexed foot. Traumatic mechanism, symptoms and imaging of injuries of the talar head are similar to transitional fractures that are normally described at the distal epiphysis of the tibia: the so-called transitional fracture is defined as an epiphyseal injury when the growth plate has already started to close.CASE SUMMARYA thirteen-year-old girl reported a high-energy trauma to her right foot, due to falling from her horse. X-rays at the Emergency Department were negative. Because of persistent pain, the patient was assessed by an orthopedic surgeon after two weeks and computed tomography scans revealed a misdiagnosed displaced shear-type fracture of the talar head. Hence, surgical open reduction and fixation with two headless screws was performed. The girl was assessed regularly, and plain films at follow-up revealed complete healing of the fracture. Within six months after surgery, the patient returned to pre-injury sport activities reporting no complications.CONCLUSIONInjuries of the talar head in childhood should be considered as transitional fractures. Open reduction with internal fixation aims to reduce malalignment and osteoarthritis. Computed tomography scans are recommended in these cases.     

Inhibition of sclerostin by monoclonal antibody enhances bone healing and improves bone density and strength of nonfractured bones

Therapeutic enhancement of fracture healing would help to prevent the occurrence of orthopedic complications such as nonunion and revision surgery. Sclerostin is a negative regulator of bone formation, and treatment with a sclerostin monoclonal antibody (Scl‐Ab) results in increased bone formation and bone mass in animal models. Our objective was to investigate the effects of systemic administration of Scl‐Ab in two models of fracture healing. In both a closed femoral fracture model in rats and a fibular osteotomy model in cynomolgus monkeys, Scl‐Ab significantly increased bone mass and bone strength at the site of fracture. After 10 weeks of healing in nonhuman primates, the fractures in the Scl‐Ab group had less callus cartilage and smaller fracture gaps containing more bone and less fibrovascular tissue. These improvements at the fracture site corresponded with improvements in bone formation, bone mass, and bone strength at nonfractured cortical and trabecular sites in both studies. Thus the potent anabolic activity of Scl‐Ab throughout the skeleton also was associated with an anabolic effect at the site of fracture. These results support the potential for systemic Scl‐Ab administration to enhance fracture healing in patients. © 2011 American Society for Bone and Mineral Research.     

Surgery for chronic symptoms after whiplash injury: Follow-up of 20 cases

Whereas continuous exposure to PTH results in bone resorption, administration at intermittent doses results in bone formation by increasing osteoblast number and activity. The anabolic action of PTH has also been demonstrated in clinical trials, in which PTH increased the bone mass and reduced fracture rate in patients with osteoporosis. In animal models of fracture healing and fixation of orthopedic implants, PTH increases the bone density in a dose-dependent manner, leading to faster repair and better fixation. The effect appears to be stronger on the new forming bone than on pre-existing bone. Based on these preclinical studies, we suggest that intermittent PTH treatment may also benefit fracture healing and implant fixation in patients.