Does Serum Vitamin D Influence the Prognosis of Critically Ill Patients with Trauma? A Prospective, Observational Study in a Trauma Center

Background@#Vitamin D concentrations are associated with sepsis, pneumonia, and mortality in critically ill patients. However, the role of vitamin D in critically injured patients with trauma remains unknown. This study investigated the effects of vitamin D concentrations on outcomes in critically injured patients with trauma. @*Methods@#A prospective observational study was conducted by randomly selecting 100 patients among those who visited our trauma center. The serum vitamin D concentration was measured upon arrival at the hospital, and the length of stay in a trauma intensive care unit after admission, duration of mechanical ventilation, number of days spent in the hospital, development of complications, and death were investigated. The association between the surveyed variables and vitamin D concentrations was investigated using regression analysis. @*Results@#Of the 100 patients, 69 were men and 31 were women with an average age of 51.7 years. The average intensive care unit stay length was 18.4 days, and 6 patients (5.9%) died. Univariate regression analysis showed that the factors affecting patient mortality were age (p = 0.02), volume of blood transfused within 24 hours of arrival (p = 0.009), systolic blood pressure measured upon hospital arrival (p = 0.01), and serum lactate concentration measured upon hospital arrival (p = 0.03). Multivariate regression analysis showed that the factors affecting patient mortality were age (p = 0.01), volume of blood transfusion (p = 0.04), and systolic blood pressure measured upon hospital arrival (p = 0.01). @*Conclusions@#There were no statistically significant effects of serum vitamin D concentrations in critically ill patients with trauma on death during hospitalization.

Cephalomedullary Nailing versus Dynamic Hip Screw Fixation in Basicervical Femoral Neck Fracture: A Systematic Review and Meta-Analysis

Purpose@#Although many studies have reported the use of dynamic hip screws (DHS) and cephalomedullary nailing (CMN) for basicervical femoral neck fracture (BFNF), no clear treatment protocols have been recommended. The present study aimed to compare the surgical outcomes associated with DHS and CMN to determine the appropriate fixation method for BFNF. @*Materials and Methods@#We systematically searched MEDLINE, Embase, and the Cochrane Library for studies published up to January 9, 2021 that compared the treatment outcomes between CMN and DHS in BFNF. The primary outcomes of the present meta-analysis were fracture union time, postoperative cut-out rate, and reoperation rate. @*Results@#We included seven studies involving 353 cases of BFNF in our review. Of these, 206 patients were treated using CMN, and DHS were utilized in 147 patients. In a pooled analysis, the DHS group required a longer time to achieve fracture union compared to the CMN group [mean difference (MD): -0.41; 95% confidence interval (CI): -0.70, -0.12; p=0.006; I 2 =0%]. However, the cut-out and reoperation rates exhibited no statistically significant differences between the DHS and CMN groups [cut-out odds ratio (OR): 0.54; 95% CI: 0.10, 2.82; p=0.47; I 2 =24%, reoperation rate OR: 0.65; 95% CI: 0.15, 2.86; p=0.57; I 2 =19%, respectively]. @*Conclusion@#Stable fixation using DHS and CMN does not show a significant clinical or radiographical difference in BFNF, and the implant can be selected based on the surgeon’s preference.

Bone Substitutes: From Basic to Current Update

Bone substitutes are being used increasingly in bony surgery as more than two million bone grafts are performed worldwide per year. Autobone grafts represent the gold standard for bone grafting, but morbidity and limited availability are the main problems. Allobone grafts are osteoconductive, but there are still concerns regarding the infection risks, costs, and donor availability issues. As an alternative, widely used ceramic-based synthetic bone substitutes are based alternatively on calcium (hydroxyapatite, tricalcium phosphate, calcium sulfate, calcium phosphate). Ceramic-based bone substitutes are osteoconductive, but they are weaker than cortical bone and are not osteoinductive. Bone morphogenic protein, demineralized bone matrix, and platelet-rich plasma are used to obtain an osteoinductivefunction. Recently, cell-based and gen-based bone substitutes were developed and studied. This paper reviews the basic information and the latest concepts on bone grafts and bone substitutes.

Reconstruction of a Mangled Foot with an Anterolateral Thigh Free Flap

PURPOSE: In recent decades, amputation is still recommended for patients with extensive lower extremity wounds requiring coverage. Although the feet contribute relatively little to total body surface area, they are essential organ for ambulation, and a high mortality rate after amputation has been reported. We report on 10 challenging cases of a mangled foot which was reconstructed using an anterolateral thigh (ALT) free flap, and analyze the advantages and disadvantages of this technique. MATERIALS AND METHODS: This retrospective study was conducted on 10 patients who underwent reconstructive surgery on a foot. Patients' charts were reviewed for age, sex, causes, defect size and site, flap size and type, flap type, and complications. Cases with a defect size of >100 cm2 were included. RESULTS: Seven of the 10 patients were male, and overall mean age was 38.5 years (range, 22 to 61 years). Mean defect size was 179.6 cm2 (range, 104 to 330 cm2), and mean flap size was 193 cm2 (range, 120 to 408 cm2). Three cases were reconstructed with a musculocutaneous free flap and seven cases were reconstructed with a fasciocutaneous free flap. There were two occurrences of local wound complication. All ten flaps survived well, however five patients underwent a debulking procedure to reduce flap volume. CONCLUSION: Reconstruction of a near completely degloved soft tissue defect or a wide defect containing two or more surfaces of extremity with an ALT free flap was performed. The purpose of this case study is to report on free tissue transfer using the ALT flap for salvage of the lower extremity.

Atypical Femoral Fracture Combined with Osteonecrosis of Jaw During Osteoporosis Treatment with Bisphosphonate

Bisphosphonate, a potent anti-resorptive agent, is generally accepted as a safe, effective, well tolerated treatment for postmenopausal osteoporosis. Atypical femoral fracture (AFF) and bisphosphonate related osteonecrosis of jaw (BRONJ) are the increasing morbidities in patients treated with long term bisphosphonate. Pathogenic mechanisms of AFF and BRONJ are not fully identified and not identical. We report a case of BRONJ followed by AFF and its nonunion in a 67-year-old woman patient receiving an oral bisphosphonate during 7 years for the treatment of osteoporosis.

Presence of a Nail in the Medullary Canal; Is It Enough to Prevent Femoral Neck Shortening in Trochanteric Fracture?

PURPOSE: Presence of a cephalomedullary nail (CMN) in the medullary canal has been thought as advantageous in the control of femoral neck shortening (FNS) and lag screw sliding in trochanteric fracture compared to extramedullary fixation system. However, researches on the factors that influence the degree of FNS after cephalomedullary nailing are lacking. MATERIALS AND METHODS: We observed 95 patients (mean age, 75+/-2.8 years) with trochanteric fractures who were treated with a CMN, and evaluated the relationship between FNS and patient factors including age, gender, fracture type (AO/OTA), bone mineral density, medullary canal diameter, canal occupancy ratio (COR=nail size/canal diameter), and tip-apex distance using initial, immediate postoperative, and follow-up radiography. RESULTS: Univariate regression analyses revealed that the degree of FNS was significantly correlated with fracture type (A1 versus A3, p<0.001), medullary canal diameter (p<0.001), and COR (p<0.001). Multiple regression analyses revealed that FNS was strongly correlated with fracture type (p<0.001) and COR (p<0.001). CONCLUSION: Presence of a CMN in the medullary canal could not effectively prevent FNS in patients with low COR and in A3 type fracture.

Separate Vertical Wiring for the Fixation of Comminuted Fractures of the Inferior Pole of the Patella

PURPOSE: Among patients over 50 years of age, separate vertical wiring alone may be insufficient for fixation of fractures of the inferior pole of the patella. Therefore, mechanical and clinical studies were performed in patients over the age of 50 to test the strength of augmentation of separate vertical wiring with cerclage wire (i.e., combined technique). MATERIALS AND METHODS: Multiple osteotomies were performed to create four-part fractures in the inferior poles of eight pairs of cadaveric patellae. One patella from each pair was fixed with the separate wiring technique, while the other patella was fixed with a combined technique. The ultimate load to failure and stiffness of the fixation were subsequently measured. In a clinical study of 21 patients (average age of 64 years), comminuted fractures of the inferior pole of the patellae were treated using the combined technique. Operative parameters were recorded from which post-operative outcomes were evaluated. RESULTS: For cadaveric patellae, whose mean age was 69 years, the mean ultimate loads to failure for the separate vertical wiring technique and the combined technique were 216.4+/-72.4 N and 324.9+/-50.6 N, respectively (p=0.012). The mean stiffness for the separate vertical wiring technique and the combined technique was 241.1+/-68.5 N/mm and 340.8+/-45.3 N/mm, respectively (p=0.012). In the clinical study, the mean clinical score at final follow-up was 28.1 points. CONCLUSION: Augmentation of separate vertical wiring with cerclage wire provides enough strength for protected early exercise of the knee joint and uneventful healing.

Treatment of Type IIIb Open Tibial Fractures

PURPOSE: The purpose of this study is to evaluate the outcome of treatment for patients with Type IIIb open tibial fractures. MATERIALS AND METHODS: This study targeted 35 adult patients for whom follow-up was possible over one year after undergoing surgical treatment. There were 29 males and six females with an average age of 45 years. RESULTS: Fracture location was proximal in 10 cases, midshaft in 13 cases, and the distal part of the tibia in 12 cases. An average of 10 days was observed for definitive fixation with soft tissue coverage of the injury. The mean time to radiographic union was 27 weeks. Sixteen cases (45.7%) of complications were observed. Three cases of superficial infection, two cases of deep infection, four cases of partial flap necrosis, three cases of mal-alignment, three cases of joint stiffness, and one case of hardware breakage were observed. The mean lower extremity functional scale score was 68.5 and the factors influencing the clinical results were severity of open wound (p=0.000) and occurrence of complications (p=0.000) according to results of multiple regression analysis. CONCLUSION: In treatment of Type IIIb open tibial fractures, good clinical results can be expected provided that complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation.

Erratum: Intermittent Parathyroid Hormone Treatment for Stimulation of Callus Formation in Elderly Patients

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Intermittent Parathyroid Hormone Treatment for Stimulation of Callus Formation in Elderly Patients

PURPOSE: The purpose of this study was to evaluate the effect of parathyroid hormone (PTH) on fracture healing in elderly patients. MATERIALS AND METHODS: We analyzed the radiologic results in 14 patients. Group I (n=7) was administrated intermittent PTH after surgical treatment and group II (n=7) was treated only with surgery. We checked the time of initial callus formation, bridging callus formation, and bone union through periodic follow-up radiographs by a radiologist who did not know the patient's information. RESULTS: The mean time to initial callus formation was 6 weeks for group I, compared with 6.7 weeks for group II. The mean time to bridging callus formation was 15.9 weeks for group I, compared with 23.0 weeks for group II. The mean time to bone union was 28.7 weeks for group I, compared with 41.9 weeks for group II. The difference in the cumulative detection rate (CDR) of the initial callus formation of group I and II was not statistically significant (p=0.793). However, the CDR of the bridging callus formation and bone union for group I were higher than those of group II (p=0.008, p=0.001, respectively). CONCLUSION: The intermittent PTH administration after surgical treatment and maximum possible preservation of the periosteum in elderly patients accelerates fracture healing.

Atypical Subtrochanteric and Diaphyseal Femoral Fractures

Increasing numbers of atypical subtrochanteric fractures have been reported among long-term bisphosphonate users. However, the nature and extent of the problem are unknown despite recent investigations. The task force of American Society for Bone and Mineral Research (ASBMR) defined major and minor features of complete and incomplete atypical femoral fractures; transverse or short oblique orientation, minimal or no associated trauma, a medial spike when the fracture is complete, and absence of comminution. Minor features include their association with cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including bisphosphonate, glucocorticoids, and proton pump inhibitors. Based on published data, the incidence of atypical femoral fractures associated with bisphosphonate therapy for osteoporosis appears to be very low, particularly compared with the number of vertebral, hip, and other fractures that are prevented by bisphosphonate. Physicians and patients should be aware of the possibility of atypical femoral fractures and of the potential for bilaterality.

Intermittent Parathyroid Hormone Treatment for Stimulation of Callus Formation on Distal Femoral Fracture in Elderly Patients: Case Report

Fracture healing is the ongoing process but it is often delayed in elderly patients. Because the fractures in elderly patients with osteoporosis are severely comminuted and their quality of bone is poor, the associated delay of fracture healing is likely to lead to surgical failure. Recently, as a way to promote healing fractures, intermittent systemic parathyroid hormone treatment has been actively researched. Although the effect of parathyroid hormone, which is demonstrated by animal experiments, is well known, there are not many clinical applications. The authors report 2 cases which had the time-shortened callus formation by intermittent parathyroid hormone (teriparatide) administration after surgical treatment, maximum preservation of periosteum as possible, in elderly patients who have supracondylar fracture on distal femur.

A Change of Pulmonary Function in the Patients with Severe Non-Idiopathic Scoliosis Following Reconstructive Spine Surgery / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study OBJECTIVES: We wanted to investigate the changes in pulmonary function after spine surgery for the patients suffering with severe non-idiopathic scoliosis. SUMMARY OF LITERATURE REVIEW: The potential for pulmonary function change after scoliosis surgery may be much greater for the patients with neuromuscular, congenital or neuro-fibromatosis because of the severe thoracic deformity. Yet few studies have been performed on this subject. MATERIALS AND METHODS: 12 non-idiopathic scoliosis patients (average age: 11.1 years) were followed up for more than one year. Among these patients, 7 had muscular dystrophy, 3 had spinal muscular atrophy, 1 had Guillain-BarreSyndrome and 1 had neuro-fibromatosis. Surgery was done through the anterior and posterior approaches in 7 cases, and the posterior approach was used in 5 cases. In the former group, open thoracotomy was performed in 6 cases. NIPPV (non-invasive positive pressure ventilation) was used for 4 patients before surgery. RESULTS: The average Cobb's angle improved from preoperative 93.9 to postoperative 42.4, showing 55% correction. The average FVC was 1270ml before surgery and 1365 ml postoperatively, and the average FEV1 was 1163 ml preoperatively and 1300 ml postoperatively, showing a slightly increased FEV1. When these data were analyzed in detail, the FVC was decreased from preoperative 72.3% to 63.8% postoperatively in the 6 patients who underwent open thoracotomy. On the other hand, it was increased from preoperative 43% to 47.5% postoperatively in the 6 patients who did not undergo thoracotomy. CONCLUSION: Although the pulmonary function deteriorated after reconstructive spine surgery in some patients, worsening was seen mainly in those patients who underwent thoracotomy. The pulmonary function was actually improved in the patients who underwent surgery without thoracotomy to correct their severe scoliosis

T Plate Fixation for Unstable Fracture of Distal Clavicle

PURPOSE: To review clinical and radiological results after open reduction and internal fixation with T plate for unstable distal clavicle fractures. MATERIALS AND METHODS: From July. 1999 to December 2002, nine patients with distal clavicle Neer type II fractures were treated by open reduction and internal fixation with T plate. The bony union was confirmed by plain radiography. The clinical results were analyzed according to the classification by Kona et al. RESULTS: Average time to fracture union was 8 weeks in all cases. The functional results were as follows: excellent in 7 cases and good in 2 cases. Screw loosening occurred in one case, but bony union was achieved. CONCLUSION: We recommend T plate fixation as another treatment method for unstable distal clavicle fractures.

Anatomic Study on the Cortical Branches of the Middle Cerebral Artery in Koreans / 체질인류학회지

The purpose of this study was to identify the branching patterns and the distribution of the cortical branches of the middle cerebral artery (MCA) in 100 cerebral hemispheres of Korean adults. The intracranial arteries were perfused with red latex compounds. The territory of the MCA was divided into 12 areas: orbitofrontal, prefrontal, precentral, central, anterior parietal, posterior parietal, angular, temporo -occipital, posterior temporal, middle temporal, anterior temporal and temporopolar. Branching pattern of the main trunk of the MCA was divided into five types: Type I: a single -trunk type of MCA in 34% of cases; Type II: bifurcation (57%); Type III: trifurcation (5%); Type IV: quadrifurcation (1%); Type V: two MCAs originated from the internal carotid artery (3%). The MCA of the bifurcation type was classified into equal bifurcation (20%), superior trunk dominant (11%) and inferior trunk dominant (26%) according to the cortical area. The superior trunk of the equal bifurcation supplied from the orbitofrontal to posterior parietal area. The outer diameter of the main trunk of the MCA was 3.15 +/-0.52 mm on average. The anatomical types of the MCA were discussed with the related symptoms in disease of the MCA.

A traumatic pseudoaneurysm of the superficial temporal artery

Pseudoaneurysm arising from the superficial temporal artery (STA) is very rare and is most commonly caused by blunt trauma. Most pseudoaneurysms of the STA usually present as a painless pulsating mass, with concomitant symptoms according to location, and their size may rapidly increase. The treatment of choice is ligation and resection. We present a case of pseudoaneurysm arising from STA after a penetrating injury caused by broken glass. We describe the history, findings of physical examination, Doppler sonography, angiography, histopathology, and the outcome of treatment. We also include a brief review of this condition.