Stimulation of bone formation and fracture healing with pulsed electromagnetic fields: biologic responses and clinical implications.

Pulsed electromagnetic fields (PEMF) have been used for several years to supplement bone healing. However, the mode of action of this non-invasive method is still debated and quantification of its effect on fracture healing is widely varied. At cellular and molecular level, PEMF has been advocated to promote the synthesis of extracellular matrix proteins and exert a direct effect on the production of proteins that regulate gene transcription. Electromagnetic fields may also affect several membrane receptors and stimulate osteoblasts to secrete several growth factors such as bone morphogenic proteins 2 and 4 and TGF-beta. They could also accelerate intramedullary angiogenesis and improve the load to failure and stiffness of the bone. Although healing rates have been reported in up to 87 % of delayed unions and non-unions, the efficacy of the method is significantly varied while patient or fracture related variables could not be clearly associated with a successful outcome.

Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature.

Treatment of complex distal humeral fractures in older patients with osteopenic bone remains a major surgical challenge. We report the results of 11 patients over 75 years of age who underwent semiconstrained sloppy-hinge total elbow arthroplasty (TEA) due to comminuted intraarticular fractures of the distal humerus. There were 9 women and 2 men with a mean age of 79.6 years. The mean duration of follow up was 2.8 years. According to AO classification, there were 8 type C3 and 3 type C2 fractures. The mean time from injury to operation was 4.3 days and the mean length of hospital stay was 9.8 days. The elbow flexion/extension and forearm pronation/supination arc of motion averaged 107(0) and 121(0) respectively. The mean Mayo Elbow Performance Score (MEPS) was 90 points, equivalent to excellent result. One patient sustained a periprosthetic humeral fracture and signs of non-progressive radiolucency were found in 8 out of the 11 elbows. Our search in the English and International literature revealed 9 other clinical studies describing the results of TEA in 167 patients with 168 distal humeral fractures. The mean age of patients varied from 69 to 84.6 years and the mean follow up from 17.8 months to 7 years. The mean MEPS among the studies was between 85 and 95 points. Wound infection was diagnosed in 9 cases (5.4%) but component removal and subsequent reimplantation was only applied in 3 elbows (1.8%). Partial ulnar nerve lesions were reported in 11 patients (6.5%) and reflex sympathetic dystrophy was developed in 5 patients (3%). In 3 elbows (1.8%) a periprosthetic fracture after a fall was recorded. Radiolucent lines between the cement mantle and bone interface were described in 24 cases (14.3%) but the majority of them (17 cases) were stable and asymptomatic. In conclusion, TEA constitutes a viable treatment option for the complex distal humeral fractures in elderly and medically compromised patients. Careful patient selection and regular follow up evaluation are mandatory for achieving an optimal result and eliminating the risks of mismanagement and early implant failure.

The role of erythropoietin in the acute phase of trauma management: evidence today.

Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.

Is the lateral sacral fluoroscopic view essential for accurate percutaneous sacroiliac screw insertion? An experimental study.

The aim of this study was to evaluate the role of the lateral fluoroscopic view in optimising percutaneous sacroiliac screw insertion. Plastic pelvic models (n=26) were used for the introduction of 104 cannulated screws into the first and second sacral (S1 and S2) vertebral bodies, controlled with an image intensifier using either two views (inlet/outlet) for the right side (group A, n=52) or three views (inlet/outlet/lateral) for the left side (group B, n=52). The mean radiation exposure times for S1 were 18.6s and 14s, in groups A and B, respectively, and for S2 were 16.1s and 12.2s, respectively; 13 cortex perforations were noted in group A and 20 in group B. After insertion into S1, in both groups there were three cases of foraminal and none of central canal perforation, but after S2 insertion in both groups there were ten foraminal and five canal perforations. A higher incidence of misplacement of S1 screws was found in group A in comparison with group B (p=0.001), with sufficient data to support percutaneous screw fixation using inlet, outlet and lateral views rather than only inlet and outlet acquisition images.

Bilateral volar lunate dislocation.

A 12 years follow-up of a case of bilateral volar lunate dislocation treated by open reduction and K-wire stabilisation of both wrists six days after injury is described. Despite aseptic necrosis of both lunates, the patient is pain free and has useful function, without the development of lunate ischaemia and collapse, carpal instability or posttraumatic osteoarthritis.

Neglected trans-scaphoid trans-styloid volar dislocation of the lunate. Late result following open reduction and K-wire fixation.

A rare case of radiocarpal dislocation is presented. The lunate and proximal pole of the scaphoid were displaced in a volar and proximal direction. The injury was missed initially and the patient was subsequently operated on six weeks later. Open reduction and internal fixation of the scaphoid was performed and this was followed by an uneventful postoperative period, with a satisfactory functional outcome at the eight-year follow-up, despite carpal instability non-dissociative-dorsal intercalated segmental instability configuration of the carpus. We believe that although open reduction in neglected cases carries the potential risks of avascular necrosis and nonunion of the affected carpal bones, an attempt should be made to restore the anatomy of the carpus.