Early period of fracture healing in ovariectomized rats

Objective. To evaluate the effect of osteoporosis on fracture healing through observing the hlstomorphological changes, bone mineral density of callus and expression and distribution of transforming growth factor beta 1 (TGF-β1 ), basic fibroblast growth factor (bFGF)and bone morphogenetic protein.2 (BMP-2) in ovariectomized rats. Methods. Sixty female Sprague-Dawley rats ( aged 12 weeks and weighing 235 g on average ) were randomly divided into an ovariectomized (OVX) group (n =30) anda sham-operated (SO) group ( n = 30). Ovariectomy was performed in the OVX rats and same incision was made in the SO rats. Three months later, fracture of femoral shaft was made on all the rats. Then they were killed at different time points. Callus formation was observed with histological and imethods. Results: A reduction in callus and bone mineral density in the healing femur and a decrease of osteoblasts expressing TGF-β1 near the bone trabecula were observed in the OVX rats 3-4 weeks after fracture.Histomorphological analysis revealed a higher content of soft callus in the OVX rats than that in the SO rats.Immunohistochemistry results showed that no remarkable difference in expression and distribution of BMP-2 and bFGF between the OVX and SO groups was found. Conclusions: Osteoporosis influences the quantity and quality of callus during the early period of fracture healing. The effect of osteoporosis on fracture healing has no relationship with the expression of BMP-2 or bFGF. The decreased expression of TGF-I31 in osteoblasts may cause a decrease in quality of facture healing after osteoporosis.     

Role of dual energy X-ray absorptiometry in monitoring fracture healing in a rat femoral fracture model

Earlymobilizationandweightbearingplayimportantrolesinminimizingtheamountofbonelosstoachievegoodhealingafterbonefracture.1Areliableandnoninvasivemethodforevaluatingfracturehealingcannotonlyhelpdecidewhentostarweightbearing, butalsohelpdetecttheimpairedboneunionearlytopreventdelayedunionsornonunions.However, objectivequantitativemethodsforearlyevaluationoffracturehealinghavenotbeendevelopedyet. DualenergyX rayabsorptiometry(DEXA)isoneofthemostaccuratemethodsformeasuringbonemassinvivo. Itismain…     

Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome

Summary

Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point.

Introduction

Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome.

Methods

VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry.

Results

Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3–17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2–15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), ?0.5?±?1.1; p?=?0.001) and at 3 months (?0.6?±?1.1; p?<?0.001), but not at 6 months (?0.3?±?1.3; p?=?0.066) or 12 months (?0.3?±?1.2; p?=?0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p?=?0.003). A subgroup (N?=?16; 25 %) had LS BMD Z-scores that were ≤?1.0 at 12 months. In these children, each additional 1,000 mg/m² of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, ?0.71 to ?0.07; p?=?0.017).

Conclusions

The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤?1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.     

Legg–Calvé–Perthes disease following Ender nail fixation of a pediatric femoral fracture

Introduction and importanceLegg–Calvé–Perthes disease (LCPD) sometimes occur in children, however it is difficult to diagnose it at the early stage especially in the cases there are no complaints of symptoms. Femoral shaft fractures in children cause various complications such as leg-length discrepancy, nonunion and malunion, refracture, and osteonecrosis of the femoral head. We presented a rare case in which a pediatric patient developed LCPD after femoral shaft fracture.Case presentationA healthy 8-year-old boy sustained a left femoral diaphyseal fracture following a pedestrian car accident. Fixation was achieved using retrograde Ender nails; bone union was confirmed at 3 months postoperatively, and the Ender nails were removed at 8 months postoperatively without any problems. Unfortunately, the morphological change of the ipsilateral femoral head and subtle symptoms were missed until the femoral head collapsed. LCPD was successfully treated with intertrochanteric varus osteotomy, which achieved a good clinical result.Clinical discussionAlthough the reason for the ipsilateral LCPD after the femoral shaft fracture is unclear, this case highlights the need for close postoperative follow-up of pediatric femoral fractures resulting from high-energy trauma to prevent the misdiagnosis of this coincidental complication.ConclusionThis case report describes a missed ipsilateral LCPD after a femoral diaphyseal fracture caused by high-energy trauma. Close postoperative follow-up with a detailed assessment and vigilant interpretation of postoperative radiography is imperative to avoid delayed/missed diagnosis of conditions for which early management may provide better outcomes.     

Evaluation of malrotation following intramedullary nailing in a femoral shaft fracture model: Can a 3D c-arm improve accuracy?

IntroductionDifficulty determining anatomic rotation following intramedullary (IM) nailing of the femur continues to be problematic for surgeons. Clinical exam and fluoroscopic imaging of the hip and knee have been used to estimate femoral version, but are inaccurate. We hypothesize that 3D c-arm imaging can be used to accurately measure femoral version following IM nailing of femur fractures to prevent rotational malreduction.MethodsA midshaft osteotomy was created in a femur Sawbone to simulate a transverse diaphyseal fracture. An intramedullary (IM) nail was inserted into the Sawbone femur without locking screws or cephalomedullary fixation. A goniometer was used to simulate four femoral version situations after IM nailing: 20° retroversion, 0° version, 15° anteversion, and 30° anteversion. In each simulated position, 3D c-arm imaging and, for comparison purposes, perfect lateral radiographs of the knee and hip were performed. The femoral version of each simulated 3D and fluoroscopic case was measured and the results were tabulated.ResultsThe measured version from the 3D c-arm images was 22.25° retroversion, 0.66° anteversion, 19.53° anteversion, and 25.15° anteversion for the simulated cases of 20° retroversion, 0° version, 15° anteversion, and 30° anteversion, respectively. The lateral fluoroscopic views were measured to be 9.66° retroversion, 12.12° anteversion, 20.91° anteversion, and 18.77° anteversion for the simulated cases, respectively.ConclusionThis study demonstrates the utility of a novel intraoperative method to evaluate femur rotational malreduction following IM nailing. The use of 3D c-arm imaging to measure femoral version offers accuracy and reproducibility.     

Early prediction of tibial and femoral fracture healing: Are we reliable?

IntroductionTo evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures.Materials and methodsEight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union.ResultsNine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25–0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330–0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p = 0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons’ years in clinical practice were not associated with accuracy of predictions.ConclusionsAt 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort.     

“Ratio of fracture site diameter to isthmus femoral canal diameter” as a predictor of complication following treatment of infra-isthmal femoral shaft fracture with antegrade intramedullary nailing

IntroductionFixation of infra-isthmus femoral shaft fracture using antegrade intramedullary (IM) nailing is difficult and is associated with a high complication rate. This study aimed to identify risk factors for complications following this procedure. The ratio of the fracture site diameter to the diameter of the femoral intramedullary canal of the isthmus (FI ratio) was evaluated as a novel parameter to predict complication.Materials and methodsPatients who underwent antegrade IM nailing for infra-isthmus femoral shaft fracture between January 2008 and December 2018 and had a minimum of 12 months of follow-up were retrospectively reviewed. The primary outcome was occurrence of complication, including non-union, mal-alignment, fixation failure, or progressive loss of reduction. Logistic regression analysis was performed to identify risk factors of complication. The sensitivity and specificity of FI ratio as a predictor of complication was calculated. A receiver operating characteristic (ROC) curve was generated to establish an FI ratio threshold to predict occurrence of complication following antegrade IM nailing.ResultsSixty-five patients with a mean age of 47.1 years were included. Using univariate logistic regression analysis, comminuted fracture pattern (p=0.026), distance from screws to fracture site (< 3cm) (p=0.002), and higher FI ratio (p=0.001) were associated with complication. Using multivariate logistic regression analysis, FI ratio was identified as an independent risk factor for complication following antegrade IM nailing (p=0.038). ROC curve indicated that FI ratio ≥ 2 had sensitivity and specificity of 0.72 and 0.72, respectively, in predicting complication.ConclusionsOur study indicates that wider intramedullary diameter at the fracture site was associated with higher complication rate following antegrade IM nailing in distal infra-isthmal femoral fractures. The FI ratio could be a reliable predictor of complication after antegrade IM nailing for such fracture, and alternative strategies should be considered for patients with higher FI ratio (≥ 2).     

Risk of hip fracture following a wrist fracture—A meta-analysis

AimsThis purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture.MethodStudies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included.Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool.A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies.Results12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93–4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used.ConclusionRisk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43).Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture.This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.     

Magnetic resonance imaging assessment of cardiac function in a swine model of hibernating myocardium 3 months following bypass surgery

Objective

Clinical studies demonstrate delayed recovery of hibernating myocardium (HM) following coronary artery bypass graft (CABG) surgery. Cardiac magnetic resonance (CMR) imaging is effective in identifying HM in clinical settings. Our animal model of HM shows partial but incomplete functional recovery 1 month following CABG using echocardiography. This study uses CMR imaging to determine completeness of recovery 3 months post-CABG.

Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients

The aim of the study was to determine if the level of an intracapsular femoral fracture influences the risk of non-union or avascular necrosis occurring after internal fixation. An observer blinded to the outcome of the treatment (fracture union, non-union or avascular necrosis) reviewed the radiographs of 411 patients with an intracapsular fracture, which had been treated by internal fixation. The level of the fracture was determined by two methods, a direct distance measurement and a ratio method. In addition, the diameter of the femoral head was measured. Results indicated that none of the methods for determining the fracture level had any relationship to the risk of non-union or avascular necrosis occurring. Undisplaced fractures were found to be more proximally located than displaced fractures. We conclude that the level of an intracapsular fracture should not be used as a method of deciding if the femoral head should be preserved or replaced. The level of an intracapsular fracture may determine if the fracture displaces at the time of injury.     

Osteogenic role played by fibroblasts in secondary healing of fracture

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Does femoral offset recover and affect the functional outcome of patients with displaced femoral neck fracture following hemiarthroplasty?

BackgroundRestoring preoperative horizontal femoral offset (FO) promised good functional outcome in patients receiving total hip arthroplasty. However, relatively little was known regarding the clinical relevance of restoring the offset in patients with bipolar hemiarthroplasty to treat displaced femoral neck fracture. Therefore, the objective of this study was to evaluate postoperative FO accurately and verify its relation with functional outcome.MethodsOne hundred elderly patients who received bipolar hemiarthroplasty to treat displaced femoral neck fracture were identified. Preoperative CT scanning of contralateral hip joint and reconstruction of images led to rotation-free FO. By referencing postoperative implant specification and comparing to measured values in Picture Archive and Communication System, rotation-free postoperative FO and the amount of change were acquired. Postoperative Harris Hip Score (HHS) and Modified Barthel Index (MBI) were evaluated to measure functional outcome at 12-month after the surgery. Patients with significant FO change were identified. Multiple regression analysis was conducted to determine if the FO change might independently affect the outcome regardless of confounding factors.ResultsThe mean preoperative offset was 37.4 ± 2.5 increased by 12.7 ± 9.6% after the surgery. Only 25.0% of postoperative offset after hemiarthroplasty was changed within ±5% of preoperative offset. A total of 45.0% of postoperative offset changed within ±10% while 77.0% of postoperative offset changed within ±20%. 23% of patients whose FO changed more than 20% showed significantly worse outcome score than the patients whose FO change remained within ±20% of initial value. Mean MBI and HHS were negatively correlated with FO change. After adjusting for confounding factors, significant correlation remained between modification of FO and MBI, but not between FO change and HHS (B = 4.576; β = 0.235; 95% confidence interval of B: 0.534 to 8.135).ConclusionsFO was not properly restored in 23% of subjects receiving bipolar hemiarthroplasty due to femoral neck fracture. FO restoration independently predicted fair MBI after the surgery. Therefore, surgeons should pay attention to restoring FO with meticulous templating.     

Migration of a broken Kirschner pin into thoracic spinal canal 4 years following internal fixation of a clavicle fracture

Fractures of the clavicle are common injuries and some of them need open reduction and internal fixation. As one of economical and practical implants, Kirschner pins (K-pins) are widely employed to treat clavicle fractures through percutaneous fixation in minimal invasion. However, as one of rare and severe complications, K-pins migrations to ascending aorta, thorax, spine and neck have been published previously. Here, a case of migration of a broken K-pin to thoracic spinal canal 4 years following internal fixation of a clavicle fracture is reported, and concerning attention in clinical practice is discussed.     

Enlarging lymphoepithelial cyst of the pancreas during 12 months of observation: report of a case

Pancreatic lymphoepithelial cysts (LECs) are rare benign pancreatic cystic lesions, the etiology of which is unknown. We report a case of a pancreatic LEC, discovered incidentally in a 63-year-old man during a follow-up clinic visit for an abdominal aneurysm. Computed tomography showed a multilocular cyst, 60-mm diameter in the body of the pancreas. This cyst increased from 6.0 to 6.5 cm during 12 months of observation. Part of the cyst was also visualized on positron emission tomography imaging. Since a pancreatic cystic neoplasm could not be ruled out, we performed distal pancreatectomy and postoperative pathological examination confirmed that the lesion was an LEC of the pancreas. Despite the conclusive postoperative findings, resection is unavoidable when a true pancreatic neoplasm cannot be excluded.     

Osteoporosis influences the middle and late periods of fracture healing in a rat osteoporotic model

Osteoporosisischaracterizedbydecreasedbonemass, increasedbonefragilityinducedbydemolitionofbonemicrostructureandincreasedsusceptibilitytofracture. Currentstudiesmainlyfocusonthepreventionoffracture. However, theinfluenceofosteoporosisonthefracturehealingremainspoorlyunderstoodandcontroversial.Inourpreviousstudy, wehaveevaluatedtheeffectofosteoporosisontheearlyperiodoffracturehealing, andfoundthatosteoporosisinfluencesthequantityandqualityofcallusduringtheearlyperiodofracturehealing.1 Incurrent…     

Spatial clustering of remodeling osteons in the femoral neck cortex: a cause of weakness in hip fracture?

Intracapsular femoral neck fractures are associated with decreased cortical width and increased proportions of Haversian canals with diameters greater than the normal mean plus 3 SD (i.e., >385 microm). Such canals might be formed if closely associated resorbing osteons merge; a cortical event analogous with the loss of cancellous connectivity. To test this, we investigated the pattern of osteon distribution in the aging femoral neck to determine if remodeling osteons were distributed in anatomical clusters. Femoral neck biopsies from female patients with intracapsular hip fractures (n = 13) were compared with age/gender-matched cadaveric controls (n = 13). Solochrome-stained sections were analyzed for Haversian canal location, canal diameter, and the presence of an osteoid surface. Clustering was investigated using statistical software with a cluster defined as two or more osteoid-bearing osteon centers within 0.75 mm of each other. Clusters occurred more frequently than would be expected by chance (p < 0.001). Fracture cases had more clusters per unit area (3.14 +/- 0.31 clusters/25 mm2 of cortical bone) than controls (1.89 +/- 0.22) (p = 0.002). In fracture cases, the antero-inferior, antero-superior, and infero-anterior regions had more clusters per 25 mm2 than comparable control regions (ant/inf: 4.12 +/- 0.79, 1.70 +/- 0.60,p = 0.025; ant/sup: 5.31 +/- 1.1, 1.80 +/- 0.59,p = 0.013; inf/ant: 3.15 +/- 0.49, 1.27 +/-0.29, p = 0.004). The mean number of clusters per 25 mm2 per region correlated with the mean porosity per region (adjusted r2 = 0.60;p = 0.014), and the total number of giant canals per region correlated with the total number of clusters per region (adjusted r2 = 0.58; p = 0.011). In conclusion, remodeling osteons are clustered or grouped anatomically, and fracture cases have more clusters than controls. Our data suggest that merging of adjacent, clustered osteons during resorption could lead to the rapid development of canals with excessive diameters and focal weakness. Clustering is greatest in those regions that we have previously shown to have the largest relative reductions in bone strength compared with controls and known to be maximally loaded during a sideways fall. This implicates the remodeling process underlying clustering of remodeling osteons in the aetiology of hip fracture.