The systemic angiogenic response during bone healing

Introduction  Angiogenesis is known to be a critical and closely regulated step during bone formation and fracture healing driven by a complex interaction of various cytokines. Delays in bone healing or even nonunion might therefore be associated with altered concentrations of specific angiogenic factors. These alterations might in turn be reflected by changes in serum concentrations. Method  To determine physiological time courses of angiogenic cytokines during fracture healing as well as possible changes associated with failed consolidation, we prospectively collected serum samples from patients who had sustained surgical treatment for a long bone fracture. Fifteen patients without fracture healing 4 months after surgery (nonunion group) were matched to a collective of 15 patients with successful healing (union group). Serum concentrations of angiogenin (ANG), angiopoietin 2 (Ang-2), basic fibroblast growth factor (bFGF), platelet derived growth factor AB (PDGF-AB), pleiotrophin (PTN) and vascular endothelial growth factor (VEGF) were measured using enzyme linked immunosorbent assays over a period of 24 weeks. Results  Compared to reference values of healthy uninjured controls serum concentrations of VEGF, bFGF and PDGF were increased in both groups. Peak concentrations of these cytokines were reached during early fracture healing. Serum concentrations of bFGF and PDGF-AB were significantly higher in the union group at 2 and 4 weeks after the injury when compared to the nonunion group. Serum concentrations of ANG and Ang-2 declined steadily from the first measurement in normal healing fractures, while no significant changes over time could be detected for serum concentrations of these factures in nonunion patients. PTN serum levels increased asymptotically over the entire investigation in timely fracture healing while no such increase could be detected during delayed healing. Conclusion  We conclude that fracture healing in human subjects is accompanied by distinct changes in systemic levels of specific angiogenic factors. Significant alterations of these physiologic changes in patients developing a fracture nonunion over time could be detected as early as 2 (bFGF) and 4 weeks (PDGF-AB) after initial trauma surgery. Authors Stefan Weiss and Gerald Zimmermann contributed equally to this work.     

Closing lateral wedge valgus osteotomy with dynamic hip screw for the treatment of varus nonunion of pertrochanteric fracture: can restoration of biomechanics and stabilization alone heal?

Introduction  Nonunion of pertrochanteric fracture is rare and its occurrence especially without prior surgical intervention has been hardly ever reported. Hence there is not much literature describing the best way to treat them. Nonunion of pertrochanteric fracture collapses in to varus by virtue of deforming action of muscles and thus deranging the biomechanics of the hip and indirectly preventing fracture union further. Hence it is very important to re-orient the abductor lever arm to biomechanically advantageous normal configuration favoring fracture healing. In general, principles of treatment of nonunion like open reduction of the fracture with freshening of fracture fragments, stabilization and bone grafting are very difficult to the surgeon and the patient. Method  We herewith describe for the first time in literature a prospective nonrandomized study of closing lateral wedge valgus intertrochanteric osteotomy in addition to dynamic hip screw osteosynthesis in the successful management of seven patients with varus trochanteric nonunion. Average operating time was 63 ± 13 min (range 39–93 min) and blood loss was 212 ± 32 ml (range 156–320 ml). Average pre-operative coxa vara of 94° ± 7° (range 85°–104°) had improved to a femoral neck shaft angle of 139° ± 4° (range 134°–145°) on postoperative radiographs. Results  All fractures and osteotomies had healed uneventfully at the last follow-up with good functional outcome. Harris Hip score had improved from 34 ± 6 (range 22–47) to 89 ± 4 (range 83–95) at an average of 11 months (range 7–13 months) follow-up. Valgus osteotomy converts shear forces across the fracture site into compressive forces thus achieving union.     

Success of junctional anterior cervical discectomy and fusion

BACKGROUND CONTEXT: Junctional breakdown has long been a consideration for surgeons when performing an arthrodesis in the cervical spine. Numerous authors have reported symptomatic junctional disease after fusion with varying degrees of reoperation. To our knowledge, there are no large series recording the fusion rate using instrumentation as an adjuvant to bone grafting. PURPOSE: To determine the fusion rate when arthrodesis is performed in the setting of junctional stenosis using iliac crest autograft and instrumentation. STUDY DESIGN/SETTING: This is a retrospective review performed on patients at the senior author's institution. PATIENT SAMPLE: The patient population consisted of a consecutive series of patients undergoing an elective anterior-only cervical arthrodesis for junctional stenosis. OUTCOME MEASURES: The primary outcome is a physiologic measure from dynamic radiographs. Fusion was assessed by the absence of motion and radiolucent lines at the bone graft interface. METHODS: During the study period, a total of 56 consecutive patients underwent anterior treatment for junctional cervical stenosis. Forty-nine of these patients were treated with an anterior discectomy and instrumented arthrodesis using iliac crest autograft, and seven underwent a corpectomy. We retrospectively reviewed the patients' charts and radiographs to determine the fusion rate. RESULTS: A solid fusion was obtained in 81.6% of patients in the study group. In patients undergoing a single-level arthrodesis adjacent to a one-level fusion, the fusion rate was 95.2%. The fusion rate significantly dropped in patients with longer preexisting fusion segments. In patients with a two- or three-level fusions preoperatively, the union rate was 81.3% and 57.1%, respectively. CONCLUSIONS: Anterior cervical discectomy and arthrodesis yields a high fusion rate for cervical stenosis adjacent to a single-level fusion. A multilevel preexisting fusion segment leads to a significant decline in successfully achieving a solid adjacent fusion despite using iliac crest autograft and instrumentation.     

体外冲击波结合红骨髓移植治疗骨不连的临床研究

目的研究体外冲击波疗法（ESWT）结合红骨髓移植治疗骨折延迟愈合和骨不连的疗效。方法局麻下自髂骨抽取自体红骨髓约10～15ml，在X线透视下进行严格的骨髓移植操作，同时配合ESWT治疗19例骨不连患者，与单纯ESWT治疗组23例进行对比分析。结果骨髓移植后随访1年，有16例长骨骨不连患者获得愈合，骨折愈合率84，2％，略高于单纯ESWT组；联合治疗组的骨折平均愈合时间为19．13周，比对照组短（P〈0．05）。结论自体骨髓移植后成骨作用明显；采用ESWT结合红骨髓移植治疗骨折延迟愈合和骨不连的方法简单、有效，不失为骨不连非手术疗法中的理想选择。     

旋肱前血管外侧降支为蒂肱骨上段骨膜瓣的应用解剖

目的：为带旋肱前动脉外侧降支为蒂的肱骨上段外侧面骨膜瓣痊术提供解剖依据：方法：在３８侧经动脉环绕色乳胶的成人上肢标本上对旋肱前上侧降支的来源、走行、分布进行了了解剖学观测,并在４侧标本上不幕拟手术实验。结果：旋肱前动脉经 肱肌和肱二头肌短头深面,绒上科颈外进至结节间沟外侧缘分别分出升支和降支。升支上行分布于肱骨头和小结节部。降支有２条分别沿胸大肌止腱内、个侧紧贴骨膜下行,为内侧降支和外侧降支。外侧     

体外冲击波治疗对动物骨不连愈合的影响及机理探讨

目的:应用体外冲击波治疗骨不连,了解其对骨不连愈合的影响,并对体外冲击波治疗骨不连的机理作初步探讨.方法:选用日本大耳白兔制作骨不连模型,以肥大型骨不连动物为实验对象,分治疗组和对照组;将体外冲击波的第二焦点对准骨不连两断端行冲击波治疗;定期拍片、光镜和电镜检查.结果:体外冲击波治疗12周X光片显示,治疗组骨不连愈合较对照组好,统计学检验有显著性差异;光镜及电镜检查显示:治疗组成骨细胞和间充质细胞聚集增生活跃,骨小梁形成丰富,骨不连愈合好.而对照组一直表现为慢性炎症反应,骨小梁形成少.可见破骨细胞活动.结论:体外冲击波治疗肥大型骨不连效果满意,其有望成为一种非手术治疗骨不连的良好方法.     

X线下经皮螺纹钉固定老年性股骨颈及粗隆间骨折

目的 检验螺纹钉国家治疗股骨及颈及粗隆间骨折。方法 １８２例老年性股骨近端骨折，分别经保守，三刃钉，螺纹钉，人工假体置换术。结果 螺纹钉治疗股骨近端骨折，方法简单，并发症少，治愈率高。结论本法效果好，值得临床推广应用。     

Bone morphogenetic proteins in orthopaedic surgery

Bone morphogenetic proteins (BMPs) are growth factors which induce new bone formation. They are an increasingly important adjunct in the treatment of certain musculoskeletal disorders. Their underlying basic science and role in bone healing is explained. Delivery systems, safety issues and current evidence-based clinical applications of BMPs in orthopaedic surgery are described.