A Case of Paediatric Non-union of Tibia Treated With Tibialization of Fibula

Management of non-union with bone gap in tibia is difficult, especially if superimposed by infection of bone. Various modalities have been described for the treatment of gap non-union, with their own advantages and disadvantages. A case of a paediatric patient with traumatic left tibia fracture which was complicated by subsequent osteomyelitis and non-union presented to tertiary care hospital. After failure of different modalities of treatment, to provide union, the patient was managed with tibialization of fibula with fibula strut graft supported by a rush nail

Effect of Systemic Administration of Granulocyte-Colony Stimulating Factor on Rate of Fracture Healing of Bone Defect in Goats as Animal Model

@#Granulocyte-colony stimulating factor (G-CSF) serves as an important cytokine in haematopoiesis; released at both physiological and pathological conditions by a range of cells. We hypothesized that the systemic administration of G-CSF would produce an accelerated fracture-healing rate in non-union bone defects; thus, potentially leading to useful clinical applications. Ten male adult Katjang goats, weighing about 15-26 kilograms were randomly chosen and a tibial bone defect was induced in each animal. The defect was maintained by internal fixation with a titanium plate and reinforced by an external fiberglass cast. Post-operative radiographs were performed twice weekly and radiographic assessments were performed by evaluating the bridging and union measurements through a validated method. In the treatment group, the time for bridging and union exhibited statistically significant differences when compared with a control group. The outcomes of the present study establishing a notion that administration of G-CSF besides inducing haematopoiesis, promotes healing of fractures and non-union bone defects as well.

Femoral Neck Non-union Treated using Compression Screw with or without Gluteus Medius Trochanteric Flap: A Case Series of Ten patients

@#Non-union is a challenging complication following a femoral neck fracture. Inability to achieve anatomical reduction and compression over the fracture leads to non-union. We reported a 10-case series of femoral neck non-union treated with sliding compression screw and anti-rotational screw with or without gluteus medius local trochanteric flap. When compression could not be achieved and a gap was present over the non-union site, a gluteus medius trochanteric flap was used to enhance the union. Surgeries were performed as a single-stage procedure through the Watson Jones approach. The initial implants were removed, followed by fracture reduction, during which the varus deformity was corrected, and the neck length was preserved as much as possible. Patients were advised for strict non-weight bearing until the presence of trabecular bone crossing the fracture on the radiographs. Union was achieved at three months in all cases. Patients undergoing surgery without trochanteric flap had normal abduction strength, and the neck length was maintained. All cases had no significant loss of function. Patients with trochanteric myo-osseous flap had neck shortening with weak abductors with MRC grade 4. Two out of 10 cases developed avascular necrosis of the femoral head before intervention. One case progressed to collapse of the femoral head requiring implant removal. This and the femoral neck shortening, caused this patient to have weak abductors and a positive Trendelenburg gait. We observed that delayed surgery leads to neck shortening and fracture gap requiring trochanteric myo-osseous flap to achieve union.

Role of Primary Autologous Bone Graft at Docking Site in the Treatment of Infected Non-union Tibia Using Rail Fixation System

@#Introduction: Distraction osteogenesis has been used effectively in the management of tibia non-unions with skeletal defect. A retrospective case series study of the infected non-union tibia managed with acute docking in a rail fixation system was conducted at a tertiary care hospital in South India. It was designed to evaluate the use of autologous bone graft at the docking site in achieving an early union with a seven years follow-up period. Materials and Methods: From 2010 to 2017, a total of 19 patients with infected tibia non-union and a bone defect less than 3cm, were treated with debridement and a monolateral frame fixation with acute shortening and lengthening. The patients were divided into two groups: one in which no bone graft was used at the docking site during early years of the study; and a later group in which autologous bone graft was used at the acute docking site primarily in addition to compression. Consolidation at the docking site was assessed both radiographically and clinically, and the results were statistically analysed. Results: There were 12 patients in Group I without bone graft, where consolidation at the docking site was noted after a mean duration of 22.08 ± 3.87 weeks. There were seven patients in Group II with bone graft, where the mean time for docking site consolidation was significantly lower at 16.57 ± 3.82 weeks. No docking site complications were noted in either group. Conclusion: Primary autologous bone graft enhances docking site consolidation in acute shortening. The routine use of bone graft at the docking site in acute shortening will expedite the docking site union with reduction of treatment time.

Modelo predictivo de la no unión de tibia / Tibia non union predictive model

OBJETIVOS: Estimar un modelo predictivo para la no-unión en pacientes que presentan fractura de tibia. MATERIALES Y MÉTODOS: Estudio de cohorte retrospectivo, en pacientes con fractura de tibia operadas entre 2012 y 2018, con un mínimo de 12 meses de seguimiento, excluyendo amputaciones traumáticas. Realizamos un modelo de regresión logística con 13 variables descritas en la literatura. Se descartaron las variables estadísticamente no significativas y las que no causaban efecto de confusión. Se evaluó la bondad de ajuste mediante el test de Hosmer-Lemeshow y la discriminación del modelo con la curva ROC. RESULTADOS: Se incluyeron 411 fracturas de tibia, las variables estadísticamente significativas fueron: exposición ósea OR » 2,57(IC:1,15­5,75, p » 0,022), diabetes OR » 3,29 (IC:1,37­7,91, p » 0,008) y uso de tutor externo OR » 1,77(IC:0,81­3,85), el que tuvo efecto de confusión. La bondad de ajuste demostró que los datos se ajustan adecuadamente al modelo (p » 0,35). La curva ROC demuestra un 70,91% de poder discriminatorio. Al evaluar aisladamente las fracturas expuestas, no hubo asociación estadísticamente significativa con ninguna variable. DISCUSIÓN: Al evaluar el modelo, obtuvimos una asociación estadísticamente significativa entre: no unión, exposición ósea, diabetes y uso de tutor externo, información concordante con la literatura. Al estudiar el subgrupo de fracturas expuestas, las demás variables son estadísticamente no significativas. Eso refleja que la exposición ósea es la variable que confiere mayor riesgo. El seguimiento adecuado de esos pacientes es fundamental dado este alto riesgo de evolucionar con no-unión. CONCLUSIÓN: En nuestra serie, la exposición ósea es el factor de riesgo más importante para presentar no unión de tibia.

OBJECTIVES: Estimate a predictive model for non-union in patients presenting with a tibial fracture. MATERIALS AND METHODS: Retrospective cohort study in patients with tibia fractures operated between 2012 and 2018, with a minimum follow-up of 12 months, excluding traumatic amputations. We performed a multivariate logistic regression model with 13 variables described in the literature. The variables that were statistically non-significant and those variables that do not cause confusion, were discarded. Goodness of fit was evaluated using the Hosmer-Lemeshow test and the discrimination of the model with the ROC curve. RESULTS: 411 tibial fractures were included, the statistically significant variables were: bone exposure OR » 2.57(CI:1.15­5.75, p » 0.022), diabetes OR » 3.29(CI:1.37­7.91, p » 0.008) and use of external fixation OR » 1.77(CI:0.81­3.85), being included in the model because of its confounding effect. Goodness of fit demonstrates that the data fit the model adequately(p » 0.35). The ROC curve demonstrates 70.91% discriminatory power. When evaluating the exposed fractures in isolation, there was no statistically significant association with any variable. DISCUSSION: When evaluating the model, we obtained a statistically significant association between non-union, bone exposure, diabetes and use of external fixation, being consistent with the literature. When studying the subset of exposed fractures, the other variables are statistically non-significant. This reflects that bone exposure is the variable that confers the greatest risk. Proper follow-up of these patients is essential given this high risk of evolving with non-union. CONCLUSION: In our series, bone exposure is the most important risk factor for presenting tibial non-union.

A Novel Technique for Fixation of Non-union Unicondylar Hoffa’s Fracture: A Case Report

@#Hoffa fractures are rare and difficult fractures to manage. Hoffa fracture involves a coronal plane fracture of posterior femoral condyle. Non-union in Hoffa fracture is further difficult to manage. The surgical management for such nonunion includes open reduction with recon/LCP plate or screw fixation with bone grafting. The problem with plates is the difficulty in contouring the plates according to the shape of posterior femoral condyles. We describe a new technique with 2 L shaped neutralisation plates placed in a circular fashion. This technique provides a more rigid construct and gives better holding strength of screws in Hoffa fragment. This enhances union and mobilisation can be started early.

The Effect of Intra-carpal Kirschner Wire Augmentation in Screw Fixation of Scaphoid – A Retrospective Cohort Study

@#Introduction: Scaphoid fractures are most often treated with a single headless compression screw. However, intercarpal Kirschner wire (K-wire) might be added to improve stability and fracture outcomes. This study will determine if there is a difference in treatment outcome (union rate and time to union) between scaphoid fracture fixations using a single headless compression screw with and without augmentation using a intracarpal intramedullary K-wire. Material and Methods: We conducted a retrospective review of patients who underwent surgery for isolated scaphoid fractures over a 15 years period from December 2000 to December 2015. Only patients who underwent open surgery with bone grafting were included. They were divided into a group treated with a single screw fixation, and another group treated with screw and K-wire fixations. Results: Forty-four (58.7%) patients had single screw fixation and 31 (41.3%) had screw augmented with K-wire fixation. The overall union rate was 88.0%, with an overall mean time to union of 5.3 months. There was no difference in union rate (p=0.84) and time to union (p=0.66) between the single screw group and combined screw and K-wire group. Univariate analysis found that older age (t=-2.11, p=0.04) had a significant effect on union rate. Regression model showed that age had a significant effect on months to union. Conclusion: In open fixation of scaphoid fractures with compression screw and bone grafting, union rate and time to union is comparable whether or not screw fixation was augmented with an intracarpal K-wire. There was no increased risk of complications associated with augmented screw. Age of patient affected time to union and union rate.

Manejo artroscópico de pseudoartrosis de escafoides con deformidad en joroba: técnica quirúrgica y serie de casos / Arthroscopic treatment for scaphoid pseudarthrosis with humpback: surgical technique and case series

INTRODUCCIÓN: La pseudoartrosis de escafoides con deformidad en joroba es una patología compleja que si no recibe tratamiento oportuno puede llevar a una deformidad avanzada, con colapso del carpo produciendo un deterioro significativo en la función de la muñeca. En la actualidad se considera como tratamiento estándar la reducción abierta de la deformidad utilizando injerto estructural. El OBJETIVO del presente trabajo es describir una técnica de reducción artroscópica, utilizando injerto no estructural para la no-unión de escafoides con deformidad en joroba. Se muestran los resultados obtenidos en una serie de casos manejados con la técnica propuesta. MATERIAL Y MÉTODO: Estudio retrospectivo de una serie de casos de pacientes diagnosticados con pseudoartrosis de escafoides con deformidad en joroba manejados con la técnica propuesta. Se describe la técnica quirúrgica. Se utiliza el programa STATA 15 para el análisis estadístico de los resultados, al igual que test de Wilcoxon para variables no paramétricas. RESULTADOS: Once pacientes de sexo masculino, con edad promedio de 23,4 años, completaron seguimiento promedio de 12 meses. En todos los pacientes se comprobó consolidación de la no-unión mediante Tomografía Computada en un tiempo promedio de 9,1 semanas. Todos los pacientes mejoraron sus rangos de movilidad y ángulos imagenológicos de manera significativa y mejoraron en la prueba funcional de DASH (p » 0.0033). DISCUSiÓN: Se muestra una técnica de reducción percutánea con asistencia artroscópica utilizando injerto no estructural para corregir la no-unión de escafoides con deformidad en joroba produciéndose buenos resultados clínicos con consolidación, en todos los pacientes de nuestra serie, similar a lo encontrado en la literatura internacional. Creemos que esa técnica permite una corrección parcial de la anatomía del carpo y favorece la consolidación ósea al tener las ventajas teóricas de una técnica mínimamente invasiva.

INTRODUCTION: Scaphoid pseudoartrosis with humpback deformity is a complex pathology that if not treated promptly can lead to an advanced deformity with collapse of the carpus producing a significant deterioration in wrist function. At present, open reduction of the deformity using structural bone graft is considered the gold standard of treatment. The AIM of the present study is to describe a surgical technique of percutaneous reduction with arthroscopic assistance using non-structural bone graft for scaphoid non-union with humpback deformity. We present a case series of patients treated with the proposed technique. MATERIAL AND METHODS: Retrospective study of a case series of patients diagnosed with scaphoid pseudarthrosis with humpback deformity treated with the proposed technique. We describe the surgical technique. We used STATA 15 for the statistical analysis and Wilcoxon test for non-parametric variables. RESULTS: 11 male patients, with an average age of 23.4 years, completed an average follow-up of 12 months. Bone healing was confirmed with Computed Tomography in an average time of 9.1 weeks in all of our patients. All patients improved their range of mobility and radiographic measurements significantly and all improved in the DASH functional test (p » 0.0033). DISCUSSION: We describe a technique of percutaneous reduction with arthroscopic assistance using non-structural graft to correct scaphoid non-union with humpback deformity. We found good clinical results and high union rate in all the patients of our series. Similar to what is found in international literature, we believe that this technique allows a partial correction of carpal anatomy and favors bone consolidation by having the advantages of a minimally invasive technique.

Artrodesis total de muñeca en paciente con síndrome de Hajdu Cheney: reporte de caso / Total wrist arthrodesis in a patient with Hajdu-Cheney syndrome: a case report

El síndrome de Hajdu-Cheney, es una patología infrecuente caracterizada por alteraciones esqueléticas que se manifiestan con acro-osteolisis y osteoporosis generalizada. Su frecuencia es extremadamente rara y existen escasos reportes en la literatura a nivel mundial. Se presenta un caso de un paciente con colapso avanzado del carpo producto de una no unión de escafoides no tratada. Se describen características clínicas y radiográficas del paciente y la resolución del caso con artrodesis total de muñeca.

Hajdu-Cheney syndrome is an uncommon skeletal disorder characterized by acroosteolysis and generalized osteoporosis. It is an extremely rare condition and few reports have been published in worldwide literature. We present a case of a patient with advanced carpal collapse product of a scaphoid non-union with Hajdu-Cheney syndrome. We describe clinical and radiographic characteristics and resolution of the case with total wrist arthrodesis.

​Clinicoradiological Assessment of Treatment of Infective Non-union in Fracture Shaft Femur using Ilizarov Ring Fixator

Background: The management of infective non-union of long bones has always been a dare for orthopedic surgeons. Treatmentgoals were the annihilation of infection and augmenting bony union. For the span of distraction osteogenesis, physiologicalskeletal loading and active mobilization are vital.Aim: This study intended at evaluating the clinicoradiological result of using Ilizarov ring fixator in managing patients withinfective non-union fracture of shaft of the femur.Materials and Methods: A total of 40 patients with infective non-union of the femoral shaft were incorporated in the study between2017 and 2018. The follow-up period lasted for 14–20 months. Skeletal measurements and functional results were calculated,and difficulties were stratified according to the association for the study and relevance of the technique of Ilizarov guidelines.Results: The infection was eradicated in 32 patients before the fixator removal. Tremendous radiological bone healing wasfound in 32 patients and excellent functional result in 28 of 40 patients.Conclusion: Ilizarov ring fixator is a valuable method for the managing of infective non-union of femoral shaft fractures withsatisfactory radiological and clinical outcome and less serious complications.

Sciatic nerve: Non-union of its components and clinical implication

Background: Having prior anatomical knowledge of the anatomical variations is a must for the accurate and effective diagnosis of clinical conditions associated with the sciatic nerve. Sciatic nerve, the longest nerve in the human body has been of great interest for the clinicians and anatomists; though many studies have been conducted in the past to study its anatomical aspect. Till now high division or low formation of the sciatic nerve has been reported but this article highlights the non-union of the components of the sciatic nerve and its clinical outcomes. It had been observed that the common fibular and tibial nerve which arise separately from the sacral plexus remain separated throughout their course. They do not join to form the sciatic nerve. Non-union of the components can result in incomplete blockade of the nerve but selective blockade of one of the components can be done when needed. Aim of the study was to determine the level of formation and the level of division of the sciatic nerve.Methods: Sixty-two lower limbs were taken from the Department of Anatomy, AIIMS, New Delhi and gluteal region was observed for common fibular and tibial nerve and their joining to form the sciatic nerve.Results: Out of 62 lower limbs; 52 specimens showed formation within the pelvis but in 10 specimens the sciatic nerve did not form at any point. Division of the nerve in 52 specimens were at various levels on the posterior aspect of thigh.Conclusions: While giving anaesthesia it’s important to know the formation as well as division of the nerve for an effective lower limb block for various surgical interventions and in case of non union of tibial and common fibular nerve to form the sciatic nerve individual nerve block can be given.

Fisioterapia con compresión cíclica en la estrategia de reconstrucción funcional en la no-unión infectada de diáfisis de húmero en un paciente pediátrico: reporte de un caso / Physiotherapy With Cyclic Compression In The Strategy Of Functional Reconstruction In The Infected Non-Union Of Diaphysis Of Humerus In A Child: Report Of A Case

Introducción Las fracturas de humero diafisiarias abarcan del 5% de todas las fracturas del cuerpo humano. La infección asociada a la no-unión de humero en niños es una patología extremadamente rara e incapacitante, que de no ser tratada adecuadamente puede comprometer de manera definitiva la función de toda la extremidad. Reporte de Caso Se reporta el caso de un paciente masculino de 9 años de edad quien consulta a nuestra institución con la no-unión infectada de humero izquierdo, asociado a pérdida de sustancia ósea, muscular y cutánea, con lesión del nervio radial y con una nula funcionalidad de la extremidad. Se plantea una estrategia de reconstrucción en 5 fases y se presenta el uso de terapias de compresión cíclica como factor clave para la consolidación de la fractura. Discusión En este caso complejo y poco común, se cumplieron todos los objetivos propuestos en el tratamiento de una no-unión infectada, la erradicación de la infección con la adecuada consolidación ósea, recuperación funcional y estética en un lapso de 10 meses.

Background Diaphysis humerus fractures constitute 5% of all fractures in the human body. The infection associated with the non-union of humerus in children is an extremely rare and incapacitating condition, which, if not treated properly, can definitively compromise the function of the whole limb. Case Report The case is presented of a 9 year-old male patient who visited this hospital with a left humerus infected non-union, associated with loss of bone, muscular and cutaneous substance, with radial nerve injury, and a lack of limb functionality. A 5-stage reconstruction strategy is presented, and the use of cyclic compression therapies is as a key factor for fracture consolidation. Discussion In this complex and uncommon case, all the proposed objectives in the treatment of an infected non-union: the eradication of the infection with adequate bone consolidation, functional recovery, and aesthetics were fulfilled within a period of 10 months.

Surgical Fixation and Inter-phalangeal Arthrodesis of Symptomatic Non-union of Fracture of a Lesser Toe Distal Phalanx: A Case Report

@#Distal phalanx fractures of the toes are common injuries. The majority of them are treated conservatively with good outcome. We present the case of a painful non-union fracture of the distal phalanx of the 4th toe in a 60-year-old female patient with symphalangism of the 4th and 5th toes. She underwent surgical fixation of the fracture with concomitant inter-phalangeal joint (IPJ) arthrodesis for better stability. A transverse dorsal incision was made just distal to the IPJ to allow preparation of both the fracture site and IPJ. Fibrous tissue at the fracture non-union site was removed and the opposing surfaces drilled with a 0.88mm Kwire. Cartilaginous tissue at the IPJ was removed and similarly drilled with the 0.88mm K-wire. Stabilisation was achieved with a percutaneous headless compression screw. Radiographic union was achieved and the patient had resolution of symptoms 16 weeks after the surgery. The patient continued to be symptom-free at one year follow-up. This is the first case report of a surgically treated symptomatic non-union of distal phalanx fracture of a lesser toe in the literature.

Fracture Non-Union: A Review of Clinical Challenges and Future Research Needs

@#Non-union of bone following fracture is an orthopaedic condition with a high morbidity and clinical burden. Despite its estimated global prevalence of nine million annually, the limit of bone regeneration therapy still results in patients living with pain, a reduced quality of life and associated psychological, social and financial repercussions. This review provides an overview of the current epidemiological and aetiological data, and highlights where the clinical challenges in treating non-union lie. Current treatment strategies are discussed as well as promising future research foci. Development in biotechnologies to treat non-union provides exciting scope for more effective treatment for this debilitating condition.

In Situ Fixation of Symptomatic Fibrous Non-union Hoffa Fracture: A Case Report

@#Femoral condyle fracture in coronal plane, also known as Hoffa fracture, is a rare fracture. Non-union of Hoffa fracture is even rarer. We present a case of fibrous nonunion of a Hoffa fracture in which the fractured fragment, though not freely movable, led to painful walking. Since the fragment was un-displaced and non-movable we fixed the fractured fragment in situ. Patient regained full range of motion of the knee and was asymptomatic on follow-up.

Infected Non-union of Tibia Treated with Ilizarov External Fixator: Our Experience

@#Introduction: Tibia is the most common long bone fractured due its vulnerable subcutaneous location and most often associated with acquired complications of delayed union or non-union due to infection. Amongst the various treatment options to treat them, the Ilizarov external fixator application is considered superior due to its multiple advantages. The objective of this study was to analyse the role of Ilizarov fixation in infected tibial non-union, as well as to assess bony union and associated functional outcomes. Materials and Methods: A retrospective review was conducted for the duration between 1st January 2005 to 31st December 2016. Total of fifty-one patients with tibial non-union associated with infection who treated with the Ilizarov fixator were included in the study. Patient records were reviewed for union of bone, bone and functional outcomes and complications. Results:The most common organism for infection was identified to be Staphylococcus Aureus. At the time of final follow-up all patients had achieved union except two, one of whom had to undergo amputation due to non-union and sepsis. Majority of the patients had an excellent score as per ASAMI grading system for bone and function results. The most common complication noted was pin track infections. Conclusion: In our experience, Ilizarov external fixator is better suited for infected non-union of tibia because it can provide a stable mechanical environment, bone transport, correct deformities, and enable weight bearing and hence we recommend its use for the same.

Osteoprogenitor cells can enhance early bone formation in critical bone defects in dogs / Células osteoprogenitoras podem aumentar a formação óssea precoce em defeitos ósseos críticos de cães

ABSTRACT: The aim of this study was to evaluate the effect of osteoprogenitor cells derived from mesenchymal stem cells from adipose tissue (OC-AD-MSCs), and differentiated into osteoblasts, in the treatment of critical bone defects in dogs. Adipose tissue derived mesenchymal stem cells (AD-MSCs) were subjected to osteogenic differentiation for 21 days and used in the treatment of bone defects in dogs radius. Either three experimental groups were bone defects treated with OC-AD-MSCs (OC), defects filled with autogenous bone (Control- C +), or empty defects (Control- C -). Bone regeneration was assessed by radiology, densitometry, and histomorphometry. The area of new bone formation was higher in the OC group compared to the control group (C-) on postoperative day 15. Defects treated with OC-AD-MSCs showed greater neovascularization than the other two groups at 90 days. We concluded that treatment with OC-AD-MSCs increased the area of new bone formation 15 days after surgery; however, it didn’t complete the bone union in critical bone defects in the radius of dogs at 90 days.

RESUMO: O objetivo deste estudo foi avaliar o efeito das células osteoprogenitoras derivadas de células tronco mesenquimais do tecido adiposo (CO-CTM-AD) no tratamento de defeitos ósseos críticos de cães. As células tronco mesenquimais do tecido adiposo (CTM-AD) foram submetidas à diferenciação osteogênica por 21 dias e usadas no tratamento de defeitos ósseos em rádios de cães. Foram constituídos três grupos experimentais: defeitos ósseos tratados com CO-CTM-AD (OC), defeitos preenchidos com osso autógeno (C+) e defeitos não preenchidos (C-). A regeneração óssea foi avaliada por meio de exames radiográficos, densitométricos e histomorfométricos. A área de neoformação óssea foi maior no grupo OC em relação ao grupo C- no 15o dia de pós-operatório. Os defeitos tratados com CO-CTM-AD mostraram maior neovascularização que os demais grupos aos 90 dias de avaliação. Conclui-se que o tratamento com CO-CTM-AD aumentou a área de osso neoformado no 15o dia de pós-operatório, mas não foi suficiente para que houvesse a completa união óssea em defeitos ósseos críticos no rádio de cães aos 90 dias.

Two Staged Surgery for Gap Non-Union of Patella Fracture: A Good Alternative.

Gap Nonunion of patella fractures are rare conditions whose treatment is challenging for surgeons. Strict protocol for such fracture gap nonunion of patella is not well documented in the literature. The decision in treatment of these conditions is based on many factors such as functional demands of the patient, factors leading to nonunion, and presence of an intact extensor mechanism of the knee. We present a case of neglected gap nonunion of a transverse fracture of patella treated at 5 months after injury with a two stage reconstruction procedure.

Valores de vitamina D en fracturas no consolidadas / Vitamin D levels in non-union fractures

Introducción: La falta de consolidacion de una fractura es, en general, un fenomeno multifactorial. El objetivo de este estudio fue estimar los valores de referencia de vitamina D (25OHD3) en fracturas que no consolidaron, estudiar su asociacion con la edad y su localizacion. Materiales y Métodos: Estudio prospectivo, de observacion y descriptivo en 29 pacientes con fracturas no consolidadas. Se determinaron las concentraciones sericas de vitamina D (25OHD3) junto con los estudios prequirurgicos. Se calcularon modelos generalizados para estimar los efectos de la edad y la localizacion, y detectar grupos de pacientes con niveles inferiores al valor recomendado. Resultados: El 68,9% de los pacientes tenia concentraciones sericas promedio de vitamina D inferiores al valor normal (30,0 ng/ml), que se asociaron inversamente con la edad, 40 anos fue el punto de corte a partir del cual otras caracteristicas, como la localizacion de la fractura (en huesos que afectan a los miembros inferiores), condicionan conjuntamente la falta de consolidacion. Conclusiones: La mayoria de los pacientes cuya fractura no consolido tenia deficiencia de vitamina D y este fenomeno es marcado a partir de los 40 anos de edad. Es importante identificar a los pacientes con mayor riesgo de presentar este deficit en las primeras etapas del tratamiento de las fracturas, ya que el aporte de este micronutriente es un factor reconocido para disminuir el riesgo de falta de consolidacion. Nivel de Evidencia: IV

Introduction: Absence of bone union after a fracture is generally multifactorial phenomenon. The objective of this study was to determine reference vitamin D values (25OHD3) in non-unions, and to study their association with age and localization. Methods: A prospective, observational and descriptive study was performed to evaluate 29 patients with non-union fractures. Serum vitamin D levels (25OHD3) were determined together with standard preoperative studies. Generalized models were used to estimate the effects of age and location, as well as to detect the group of patients with vitamin D levels lower than recommended. Results: The 68.9% had serum levels of vitamin-D lower than the normal value (30 ng/mL), which was inversely associated with age, being the age of 40 the cutoff point from which other characteristics, such as location, conditioned simultaneously the non-union. Conclusions: Most patients with a non-union fracture had vitamin D deficiency, and this phenomenon was more evident in patients >40 years. Prompt identification of patients with increased risk of presenting this deficiency is important, as treatment could reduce the incidence of fractures that evolve into a non-union. Level of Evidence: IV

Recombinant Human Bone Morphogenetic Protein-2 in Posterolateral Spinal Fusion: What's the Right Dose?

STUDY DESIGN: Single center retrospective cohort analysis. PURPOSE: The goal was to evaluate the influence of varying amount of recombinant human bone morphogenetic protein 2 (rhBMP-2) per level on fusion rates and complications in posterolateral spinal fusions. OVERVIEW OF LITERATURE: rhBMP-2 has been utilized for lumbar posterolateral fusions for many years. Initial rhBMP-2 recommendations were 20 mg/level of fusion. Dose and concentration per level in current studies vary from 4.2 to 40 mg and 1.5 to 2.0 mg/mL, respectively. Variable fusion and complication rates have been reported. METHODS: Patients (n=1,610) undergoing instrumented lumbar spinal fusion (2003-2009) with utilization of rhBMP-2 were retrospectively evaluated. Patient demographics, body mass index (BMI), comorbidities, number of levels, associated interbody fusion, and types of bone void filler were analyzed. Fusions rates and nonunions were subdivided into number of levels and amount of rhBMP-2 used per level. RESULTS: Patients (n=559) were evaluated with 58.5% females having an average age of 63 years, BMI of 31 kg/m2. Number of levels fused ranged from 1 to 8. rhBMP-2 averaged 7.3 mg/level (range, 1.5-24 mg/level) based upon length of collagen sponge in relation to length of fusion levels. Patients with non-union formation had lower rhBMP-2 dose per level (p=0.016). A significant difference in non-union rate was found between patients undergoing fusion with 6 mg/level (9.1% vs. 2.4%, χ2=0.012). No significant differences were noted between 6-11.9 mg/level and ≥12 mg/level. No threshold was found for seroma formation or bone overgrowth. CONCLUSIONS: Previous recommendation of 20 mg/level of rhBMP-2 is more than what is required for predictable fusion rates of 98%. No dose related increase of infection, seroma formation, and bone overgrowth has been found. In order to provide variable dosing and cost reduction, industry generated rhBMP-2 kit size should be optimized.