Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation: A prospective 2-year follow-up study of 182 patients

Background and purposeProspective studies on patient related outcome in patients <70 years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20–69 years old patients with a FNF treated with internal fixation.Patients and methods182 patients, 20–69 years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations.ResultsAt 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5D_index in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p < 0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p < 0.001).InterpretationTwo thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.     

Osteoclast depletion with clodronate liposomes delays fracture healing in mice

Osteoclasts are abundant within the fracture callus and also localize at the chondro‐osseous junction. However, osteoclast functions during fracture healing are not well defined. Inhibition of osteoclast formation or resorptive activity impairs callus remodeling but does not prevent callus formation. Interestingly, though anti‐osteoclast therapies differentially affect resolution of callus cartilage into bone. Treatments that inhibit osteoclast formation or viability tend to impair callus cartilage resolution, while treatments that target inhibition of bone resorption generally do not affect callus cartilage resolution. Here, we tested whether depletion of osteoclasts by systemic treatment with clodronate liposomes would similarly impair callus cartilage resolution. ICR mice were treated by intraperitoneal injections of clodronate‐laden liposomes or control liposomes and subjected to closed femur fracture. Femurs were resected at multiple times after fracture and analyzed by radiography, histology, and mechanical testing to determine effects on healing. Clodronate liposome treatment did not prevent callus formation. However, radiographic scoring indicated that clodronate liposome treatment impaired healing. Clodronate liposome treatment significantly reduced callus osteoclast populations and delayed resolution of callus cartilage. Consistent with continued presence of callus cartilage, torsional mechanical testing found significant decreases in callus material properties after 28 days of healing. The results support a role for osteoclasts in the resolution of callus cartilage into bone. Whether the cartilage resolution role for osteoclasts is limited to simply resorbing cartilage at the chondro‐osseous junction or in promoting bone formation at the chondro‐osseous junction through another mechanism, perhaps similar to the reversal process in bone remodeling, will require further experimentation. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1699–1706, 2017.

     

Repair of long bone defects with demineralized bone matrix and autogenous bone composite

Background:

Repair of diaphyseal bone defects is a challenging problem for orthopedic surgeons. In large bone defects the quantity of harvested autogenous bone may not be sufficient to fill the gap and then the use of synthetic or allogenic grafts along with autogenous bone becomes mandatory to achieve compact filling. Finding the optimal graft mixture for treatment of large diaphyseal defects is an important goal in contemporary orthopedics and this was the main focus of this study. The aim of this study is to investigate the efficacy of demineralized bone matrix (DBM) and autogenous cancellous bone (ACB) graft composite in a rabbit bilateral ulna segmental defect model.

Materials and Methods:

Twenty-seven adult female rabbits were divided into five groups. A two-centimeter piece of long bone on the midshaft of the ulna was osteotomized and removed from the rabbits’ forearms. In group 1 (n=7) the defects were treated with ACB, in group 2 (n=7) with DBM, and in group 3 (n=7) with ACB and DBM in the ratio of 1:1. Groups 4 and 5, with three rabbits in each group, were the negative and positive controls, respectively. Twelve weeks after implantation the rabbits were sacrificed and union was evaluated with radiograph (Faxitron), dual-energy x-ray absorptiometry (DEXA), and histological methods (decalcified sectioning).

Results:

Union rates and the volume of new bone in the different groups were as follows: group 1 - 92.8% union and 78.6% new bone; group 2 - 72.2% union and 63.6% new bone; and group 3 - 100% union and 100% new bone. DEXA results (bone mineral density [BMD]) were as follows: group 1 - 0.164 g/cm², group 2 - 0.138 g/cm², and group 3 - 0.194 g/cm².

Conclusions:

DBM serves as a graft extender or enhancer for autogenous graft and decreases the need of autogenous bone graft in the treatment of bone defects. In this study, the DBM and ACB composite facilitated the healing process. The union rate was better with the combination than with the use of any one of these grafts alone.     

Endoscopic vs open saphenous vein harvest for coronary artery bypass grafting: a prospective randomized trial

OBJECTIVE: Endoscopic saphenous vein harvesting (EVH) for coronary artery bypass grafting (CABG) has been developed to reduce leg wound morbidity and improve patient satisfaction. Choosing between EVH of a short vein segment from the thigh and open venous harvesting (OVH) of a short segment from the calf represents a clinical dilemma as EVH is easiest to perform from the thigh and OVH is easiest to perform from the calf. The purpose of this study was to investigate whether leg wound morbidity was reduced after EVH of a short vein segment from the thigh compared with OVH from the calf. Secondly we investigated whether EVH would reduce length of hospital stay and improve cosmetic results. METHODS: From April 2004 to June 2007, 132 patients undergoing elective isolated CABG were randomized to have a short segment of saphenous vein harvested either by the EVH or OVH technique. Clinical follow-up was scheduled at day 5 and at 1 month. Primary end-points included wound morbidity. Secondary end-points included harvest time, length of hospital stay, cosmetic results and need for additional wound care after discharge. RESULTS: The groups were preoperative similar. Three patients in the OVH group were excluded from the study as it became apparent that it was necessary to extend the incision beyond the knee. Harvest time was longer for the EVH group, but these patients suffered from significantly fewer cases of infectious and non-infective wound complications, with a substantial reduction in the need for post-discharge leg wound care. The purulent infection rates in the EVH and OVH groups were 0% and 11%, respectively. The overall leg wound morbidity rates regarding cellulitis, purulent infection, dehiscence and skin necrosis were 3% and 27% in the EVH and OVH groups, respectively (p<0.001). The length of hospital stay was similar. The conversion rate from EVH to OVH was 14%. The EVH group experienced less pain and better cosmetic results. CONCLUSIONS: EVH of a short vein segment from the thigh results in less wound morbidity and better cosmetic results compared with OVH of a short vein segment from the calf.     

Vascular endothelial growth factor and its receptor expression during the process of fracture healing

Objective： To study the expression regularity of vascular endothelial growth factor （VEGF） during the process of fracture healing, and the type of VEGF receptor expressed in the vascular endothelial cells of the fracture site.
Methods： The fracture model was made in the middle part of left radius in 35 rabbits. The specimens from the fracture site were harvested at 8, 24, 72 hours and 1, 3, 5, 8 weeks, and then fixed, decalcified, and sectioned frozenly to detect the expression of VEGF and its receptor at the fracture site by in situ hybridization and immunochemical assays.
Results： VEGF mRNA and VEGF expression was detected in many kinds of cells at the fracture site during 8 hours to 8 weeks after fracture. Fltl receptor of VEGF was found in the vascular endothelial cells at the fracture site during 8 hours to 8 weeks after fracture, and strong expression of flkl receptor was detected from 3 days to 3 weeks after fracture.
Conclusions： The expression of VEGF and fltl receptor appears during the whole course of fracture healing, especially from 1 to 3 weeks. Flkl receptor is highly expressed in a definite period after fracture. VEGF is proved to be involved in the vascular reconstruction and fracture healing.     

自体半腱肌复合骨形态发生蛋白和同种异体骨重建前交叉韧带后腱-骨愈合的生物力学研究

目的研究骨形态发生蛋白(BMP)复合同种异体骨(DPB)对自体半腱肌肌腱重建前交叉韧带后腱-骨愈合的影响。方法取64只成年新西兰大白兔,分成4组,建立左侧膝前交叉韧带(ACL)完全断裂模型。重建ACL时,于股骨隧道内分别植入BMP结合DPB、BMP、DPB。结果术后3、6、12及24周BMP结合DPB腱-骨愈合及移植物抗拉强度大于其他各治疗组,P<0.05。结论缓释载体DPB能延长BMP作用时间,提高移植物生物力学特性,拮抗骨吸收因子的负面效应,促进腱-骨愈合。     

兔骨髓基质细胞和骨血肿块移植促进骨折愈合的研究

目的：研究骨折后骨血肿块和骨髓基质细胞的骨再生潜能，以及骨血肿块和骨髓基质细胞联合移植对骨折愈合的影响，探讨促进骨折愈合的新途径。方法：在新西兰兔胫骨上制造骨缺损模型，3d后取出骨血肿，并从股骨抽骨髓血分离出骨髓基质细胞，将骨髓基质细胞联合骨血肿块回植到实验组骨缺损区；对照组骨缺损区则单纯行骨血肿块回植。定期拍X线片和取出骨痂行组织学观察。结果：骨缺损处骨痂生成数量在实验组和对照组两组间有显著性差异，骨髓基质细胞联合骨血肿块移植组的骨痂形成数量和骨膜反应明显多于以单纯骨血肿块移植组；组织学观察：实验组成骨样细胞形成数量也明显多于对照组。结论：骨髓基质细胞有较强的骨再生潜能，骨髓基质细胞和骨血肿块联合移植比单纯骨血肿移植成骨效果更好。     

富血小板血浆治疗下肢慢性难愈合伤口47例随访研究

目的 探讨富血小板血浆(platelet-rich plasma,PRP)对下肢慢性难愈合伤口的修复作用. 方法 2007年5月-2007年11月,采用PRP注射治疗下肢慢性难愈合伤口47例.男41例,女6例;年龄15～68岁,平均43.2岁.原发疾病:胫腓骨骨折20例,跟骨骨折4例,跖骨骨折1例,下肢多发开放性骨折3例,胫骨骨髓炎10例,股骨骨髓炎1例,足踝部软组织损伤4例,截肢术后感染2例,足部矫形术后感染及跟腱修补术后感染各1例.外院治疗后2～4个月创口未愈合转入合并骨折未愈合23例,细菌培养结果 阳性38例.患者予2次清创加自体PRP伤口内注射,每次间隔2个月. 结果 患者均于首次注射PRP后获随访,随访时间4个月.首次注射PRP2个月后,34例伤口明显缩小,坏死组织及脓苔清除,组织色泽健康,血供良好,外露骨或肌肉组织被新牛肉芽组织覆盖.4个月随访时,无肌肉和骨组织外露患者,创面覆盖率79.3%4±18.O%,总治愈率29.8%.治疗前创口体积(11.8±5.6)mL,治疗后为(2.5±2.7)mL,创口体积缩小(9.3±4.9)mL,治疗前后创口体积比较差异有统计学意义(P＜0.05).术前23例合并骨折未愈合者,随访4个月时骨折完全愈合9例,骨痂生长明显增多12例,无明显改变2例,均无骨髓炎征象加重.细菌培养阳性结果 15例. 结论 PRP能有效促进软组织缺损修复,加速下肢慢性难愈合伤口愈合.     

小鼠全层皮肤创伤愈合过程中基质细胞衍生因子-1及其受体CXCR4基因表达的研究

目的：研究小鼠全层皮肤创伤愈合过程中创面基质细胞衍生因子-1（stroma-cell derived factor-1,SDF-1）及其受体CXCR4的基因表达情况。方法：建立小鼠背部皮肤正中近颈侧1.5cm×1.5cm的正方形皮肤全层缺损模型,分别于伤后1、2、3、4、5、7、10和14d获取创缘组织,应用半定量逆转录-聚合酶链反应检测损伤后各时间点创面SDF-1及CXCR4的mRNA表达,并观察组织病理学变化。结果：伤后1～3d创面有大量炎症细胞浸润,4d时有肉芽组织形成,5d可见上皮细胞覆盖创面,7d时创面周围明显上皮化,14d创面基本完全愈合。SDF-1及CXCR4在创面愈合过程均呈双峰表达,SDF-1基因表达于伤后1d明显增高（P〈0.01）,随后下降,于伤后3d达最低,随后再次升高,于伤后5d达峰值（P〈0.01）,然后下降,14d时接近伤前值。CXCR4基因表达于伤后1d升高,然后继续升高,至伤后5d达峰值,随后下降,于伤后10d表达最少（P〈0.01）,伤后14d表达再次增加（P〈0.01）。结论：SDF-1/CXCR4轴参与了创伤愈合的炎症反应期和增殖期的愈合过程,在皮肤组织创伤愈合过程中起着重要作用。     

釉基质蛋白对人角质形成细胞粘附、增殖及迁移影响的体外研究

目的：观察釉基质蛋白对体外培养的人角质形成细胞粘附、增殖及迁移等生物功能的影响。方法：消化法培养人正常角质形成细胞，采用MTT比色法及体外划痕法，观察人正常角质形成细胞在不同浓度釉基质蛋白（50、100、150及200μg／ml等浓度的 EbtPs）包被的培养孔表面粘附、增殖及迁移情况，试验各组依次命名为EP1、EP2、EP3、EP4组。结果：①细胞粘附性实验中，EP2、EP3及EP4组在接种细胞4．5h后结果均高于空白对照组（P〈0．05）；②细胞增殖实验中，在各时间点各组之间无统计学差异（P〉00．05）；③细胞迁移实验中，各实验组和空白对照组间并无统计学差异（P〉0．05）。结论：EbtP对人正常角质形成细胞粘附有促进作用，而对其增殖和迁移则没有影响。