The “Road to Union” protocol for the reconstruction of isolated complex high-energy tibial trauma

IntroductionThe purpose of this study was to describe a standardized staged approach, “The Road to Union”, for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.MethodsThis retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson’s moment correlations.ResultsThirty-two patients with a mean age of 34.7 ± 14.2 years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66 ± 32 mm. The total EFT was 42.5 ± 14.8 weeks; the EFI measured 51.9 ± 25.3 days/cm, and the DCI measured 48.3 ± 21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r = 0.92, p = 0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.ConclusionThe findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.Level of evidenceLevel IV; case series     

带血管的薄层皮质骨－骨膜瓣移植治疗骨折不愈合

目的 探讨骨折不愈合的治疗新方法.方法 以游离皮质骨-骨膜瓣移植治疗骨不愈合、骨缺损病例.结果 自2001年6月到2005年12月,共用以治疗骨不愈合13例,获得满意效果.结论 皮质骨-骨膜瓣血运丰富,易成活,并发症少,是治疗骨不愈合的理想术式.     

骨折周围骨痂移植治疗骨不愈合的形态学观察

目的　观察骨不愈合采用骨折断端周围自体骨痂移植治疗的效果。方法　新西兰兔 42只 ,双侧桡骨中段模拟骨折 ,观察至明显骨痂生长随机分配实验Ⅰ组 36只 ,实验Ⅱ组 6只 ,随机选择一侧髂骨切取部分全层骨和双侧骨折处周围骨痂备用 ,并建立 1 0cm骨缺损的标准不愈合模型。实验Ⅰ组 ,左桡骨移植骨痂为A组 ,右桡骨移植髂骨为B组 ,术后分别于 2、 4、 6、9、 12、 15周各处死 6只兔并取标本作X线摄片和图像分析、标本大体观察 ,组织切片检查。实验Ⅱ组 ,左桡骨移植髂骨为C组 ,右桡骨空白对照为D组 ,术后定期X线摄片检查。结果　①术后 15周 ,A、B、C组全部完成骨不愈合的修复 ;②D组无一例骨不愈合完整修复 ;③A、B组修复骨不愈合的病理过程相仿 ,首先是桥梁骨痂和连接骨痂形成 ,而后是成熟骨板期 ,最后是塑形期 ,但修复进程在实验 9周存在明显差异 (P <0 0 5 ) ,A组优于B组。结论　骨折周围骨痂和髂骨都是较为理想的骨移植材料 ,在治疗骨不愈合过程中 ,骨痂移植在早期有加速骨缺损修复的趋势。     

对骨不连致因的再认识

目的　探讨医源性骨不连的发生原因。方法　对 72例中的 6 2例 (86 1% )骨不连患者的X线片、骨折的类型及手术方式、内固定材料等综合分析来判断导致骨不连的原因。结果　内固定术后骨折端不稳定所导致骨不连占 92 % ,其致因有内固定物选择错误 ;对内固定的技术原理缺乏了解导致操作失误 ;对骨骼自身的生物力学知识缺乏导致了内固定物与骨骼的生物力学不相吻合。缺乏对骨折治疗“生物学固定”原则的理解 (18例 ) ,缺乏手术后对患者康复的正确指导 (6 5 5 % )是导致骨不愈合的原因。结论　作者认为骨折早期处理中遵循骨折固定的基本原则和手术后正确的康复训练是预防医源性骨不连的关键。     

The effect of bioactive glasses on spinal fusion: A cross-disciplinary systematic review and meta-analysis of the preclinical and clinical data

Pseudarthrosis following spinal fusion is correlated with poorer patient outcomes and consequently is an area of continued interest within spinal research. Recently, bioactive glasses have been proposed as a means of augmenting fusion rates. Here, we present the first systematic review and meta-analysis of the existing preclinical and clinical literature on the effect of bioactive glasses on spinal fusion. Using the MEDLINE, Embase, and Web of Science databases, we queried all publications in the English-language literature examining the effect of bioactive glasses on spinal fusion. The primary endpoint was fusion rate at last follow-up and the secondary endpoint for clinical studies was the rate of deep wound infection. Random-effects meta-analyses were performed independently for the preclinical and clinical data. Twelve preclinical studies (267 animals) and 12 clinical studies (396 patients) evaluating a total of twelve unique bioactive glass formulations were included. Across clinical studies, fusion was seen in 84% treated with bioactive glass. On sub-analysis, fusion rates were similar for standalone autograft (91.6%) and bioactive glass-local autograft mixtures (89.6%). Standalone bioactive glass substrates produced inferior fusion rates relative to autograft alone (33.6% vs. 98.8%; OR 0.01, p < 0.02). Rates of deep wound infection did not differ between the bioactive glass and autograft groups (3.1%). The preclinical data similarly showed comparable rates of fusion between autograft and bioactive glass-treated animals. The available data suggest that bioactive glass-autograft mixtures confer similar rates of spinal fusion relative to standalone autograft without altering the risk of deep wound infection.     

Early predictive value of supine and upright X-ray films of odontoid fractures treated with halo-vest immobilization

BACKGROUND: Although halo-vest immobilization remains a common form of treatment for type II odontoid fractures, nonunion and C1-2 instability may be the result in up to 20% to 40% of patients. PURPOSE: Supine and upright lateral X-ray films may allow early identification of patients likely to fail halo-vest treatment and earlier surgical treatment with decreased morbidity from prolonged unsuccessful halo-vest immobilization. STUDY DESIGN/SETTING: A prospective cohort study was performed. PATIENT SAMPLE: Twenty patients with type II odontoid fractures. OUTCOME MEASURES: Posttreatment nonunion and C1-2 instability as determined by plain X-ray films and computed tomography scan. METHODS: Both supine and upright lateral X-ray films were obtained immediately after halo-vest application and at the 2-week, 6-week, and 3-month follow-up. Flexion-extension lateral X-ray films were obtained after halo-vest removal. Patients with nonunion or instability underwent computed tomography scan. Upright X-ray films were compared serially to identify loss of reduction. Pairs of supine and upright X-ray films were compared to measure any change in displacement or angulation upon transition from supine to upright position. Nonunion patients were compared with healed patients to determine any difference in fracture behavior based on serial supine and upright X-ray films. RESULTS: Twenty patients with type II odontoid fractures were identified during the study period. Three patients with multiple trauma underwent immediate surgical stabilization. Three elderly patients with nondisplaced fractures were treated in a cervical orthosis. Fourteen patients initiated and completed 3 months of halo-vest immobilization. After halo-vest removal, 4 of 14 patients (29%) showed radiographic nonunion or instability. In all 4 nonunion patients, supine and upright radiographs at 2 weeks revealed change in fracture angulation > or =5 degrees between the supine and upright positions. In three of these patients standard serial upright lateral X-ray films failed to identify any loss of reduction. In the remaining patient, progressive angulation of 15 degrees was observed. No measurable change in angulation between supine and upright X-ray films was observed in any patient who healed successfully with halo-vest treatment. CONCLUSIONS: Obtaining both supine and upright lateral X-ray films during the follow-up period may identify patients at risk for failure of halo-vest treatment as early as 2 weeks after initiation of treatment. A change in fracture angulation > or =5 degrees suggests an increased risk of treatment failure and the potential benefit of early surgical stabilization.