The efficacy of autologous platelet gel in pain control and blood loss in total knee arthroplasty. An analysis of the haemoglobin, narcotic requirement and range of motion.

Biological materials used to assist in haemostasis following total knee arthroplasty have been the subject of much recent research. Autologous platelet gel is a substance that is derived from platelet-rich plasma extracted from the patient's blood and centrifuged perioperatively, and is applied to exposed tissues, synovium and the lining of the wound at closure. Concentrating and applying these factors directly to the wound at the end of a total knee arthroplasty procedure may lead to more complete haemostasis, a reduction in perioperative blood loss, accelerated tissue repair and decreased postoperative pain. In this study, 98 unilateral total knee arthroplasties were evaluated retrospectively, 61 of which involved the intaroperative use of platelet gel, and 37 of which served as control subjects. Outcomes analysed were postoperative haemoglobin changes, intravenous and oral narcotic requirements, range of motion on discharge and total days in hospital. Patients receiving platelet gel during surgery had less postoperative blood loss as measured by differences in the preoperative and postoperative haemoglobin on day 3 (2.7 vs. 3.2 g/dl; P=0.026). The narcotic requirement was less in the platelet gel group for both intravenous (17.0 vs. 36.3 mg/day; P=0.024) and oral (1.84 vs. 2.75 tabs/day; P=0.063) medication. This group also achieved a higher range of motion prior to discharge (78.2 vs. 71.9; P=0.052) and were discharged an average of 1 day earlier than their control counterparts. Though further prospective trials are necessary, this study indicates that the application of autologous platelet gel may lead to improved haemostasis, better pain control and a shortened hospital stay.

Malreduction of the tibiofibular syndesmosis in ankle fractures.

BACKGROUND: Diagnosis and reduction of syndesmosis injuries in ankle fractures can be challenging. Previous studies have demonstrated that standard radiographic measurements used to evaluate the integrity of the syndesmosis are inaccurate. The purpose of this study was to determine the adequacy of standard postoperative radiographic measurements in assessing syndesmotic reduction compared to CT and to determine the prevalence of postoperative syndesmotic malreduction in a patient cohort. METHODS: Twenty-five patients with ankle fractures and syndesmotic instability who had open reduction and syndesmotic fixation were evaluated. All patients had a standard radiographic series postoperatively followed by a CT scan. Radiographic measurements were made by three observers to determine the tibiofibular relationship. Axial CT scan images were judged for quality of reduction of the syndesmosis by measuring the distance between the fibula and the anterior and posterior facets of the incisura. Differences between the anterior and posterior measurements of more than 2 mm were considered incongruous. RESULTS: Six patients (24%) had evidence of postoperative diastasis using the radiographic criteria, four of whom had evidence of malreduction on postoperative CT scan. Conversely, 13 patients (52%) had incongruity of the fibula within the incisura on CT scan (average 3.6 mm, range 2.0 to 8.0 mm), only four of whom had one or more abnormal radiographic measurements. In 10 (77%) of the 13 malreductions seen on CT scan, the posterior measurement was greater, indicating that internal rotation or anterior translation of the fibula may have occurred. Sensitivity of radiographs was 31% and the specificity was 83% compared to CT. CONCLUSIONS: Many syndesmoses were malreduced on CT scan but went undetected by plain radiographs. Radiographic measurements did not accurately reflect the status of the distal tibiofibular joint in this series of ankle fractures. Furthermore, postreduction radiographic measurements were inaccurate for assessing the quality of the reduction. Although we did not seek to correlate functional outcomes, the known morbidity of postoperative syndesmotic malreduction should lead to heightened vigilance for assessing accurate syndesmosis reduction intraoperatively.

Hybrid locked plating of osteoporotic fractures of the humerus.

BACKGROUND: Locked plating techniques recently have gained popularity and offer a different biomechanical approach for fracture fixation compared with traditional compression plating. In certain clinical situations, it may be preferable to employ a "hybrid" construct, in which an unlocked screw is used to assist with reduction and locked screws are subsequently used to protect the initial reduction. In the present study, we used an unstable osteoporotic fracture model of the humerus to determine (1) whether a hybrid construct behaved more like a locked construct or a conventional unlocked construct and (2) whether there was a difference between locked and unlocked constructs. METHODS: Thirty third-generation Sawbones humeri were divided into three groups of ten humeri each. A locking plate with combination holes was applied to each bone with use of either a locked construct, an unlocked construct, or a hybrid construct. To simulate purchase in osteoporotic bone, all screw-holes were drilled to 0.3 mm less than the diameter of the screw used. Each specimen was then osteotomized in the middle part of the shaft, and a 5-mm segment was removed. Oscillating cyclic torsion testing was performed to +/-10 N-m for 1000 cycles, torsional stiffness was determined at periodic cyclic intervals, and the groups were compared. RESULTS: The locked and hybrid constructs demonstrated similar behavior. The initial stiffness was similar in these two groups. At ten cycles, the locked and hybrid constructs retained 96.3% and 95.4% of their initial stiffness, respectively. During the remainder of cycling the stiffness of the locked and hybrid constructs decreased in a linear fashion (R(2) = 0.89 and 0.88, respectively), and at 1000 cycles the stiffness of the locked and hybrid constructs averaged 80.0% and 79.2% of the initial values, respectively (p = 1.0). In contrast, the unlocked constructs initially were significantly less stiff than both the locked and hybrid constructs (p < 0.001). At ten cycles the unlocked constructs retained 80.4% of their initial stiffness, and at 1000 cycles they retained only 22.3% of their initial stiffness. CONCLUSIONS: Hybrid constructs are mechanically similar to locked constructs, and both are significantly more stable than unlocked constructs under torsional cyclic loading. CLINICAL RELEVANCE: Combining screws in the hybrid configuration used in the present study did not compromise the mechanical performance of the construct. Hybrid constructs may decrease cost and may provide additional clinical value when treating fractures in osteoporotic bone.

In vivo cyclic axial compression affects bone healing in the mouse tibia.

Abundant evidence exists that fracture healing can be influenced by mechanical loading. However, the specific loading parameters that are osteogenic remain unknown. We hypothesized that the bone healing response in mouse tibial osteotomies would be different with a short delay before loading compared to immediate load application, as well as with higher and lower load magnitudes applied. Eighty 12-week-old mice underwent osteotomy of the left tibia followed by intramedullary nailing. Mice were divided into six groups based on days delayed until application of load (0 days or 4 days) and amplitude of cyclic load (0.5N, 1N, or 2N). Loading regimens were applied at 1 Hz for 100 cycles per day, 5 days per week for 2 weeks, using an external device that applied axial compression to the tibia. Bone healing was assessed by both microcomputed tomography (CT) and four-point bend testing. A short delay followed by cyclic application of a relatively low load led to improved fracture healing, as determined by increased callus strength, but this enhancement disappeared as load amplitudes increased. Load initiation immediately following fracture inhibited healing, regardless of the magnitude of load applied. MicroCT measurements of calluses in the early healing stage did not predict the mechanical strength of the fractures. These findings confirm that controlled, noninvasive cyclic loading can improve the strength of healing callus. However, application of load immediately after fracture appears to be detrimental to healing. Load magnitude also plays a critical role, and must be taken into account in future studies and clinical applications. As the loading parameters necessary to enhance fracture healing become refined, external compression may be used as a potent stimulus for treating fractures with decreased biological capacity.

The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study.

OBJECTIVES: The Lauge-Hansen classification system was designed to predict the mechanism and ligament injury patterns of ankle fractures on the basis of x-rays. The purpose of this study was to evaluate the accuracy of these predicted injury sequences using magnetic resonance imaging (MRI) in a series of patients with ankle fractures. DESIGN: Retrospective cohort. SETTING: Two university level 1 trauma centers. PATIENTS: Fifty-nine patients with operative ankle fractures who were evaluated with both x-ray and MRI were included. INTERVENTION: All patients had a standard 3-view ankle x-ray series before fracture reduction, followed by an MRI. All plain x-rays were assigned to a Lauge-Hansen category by an experienced orthopedic traumatologist. MRI studies were subsequently read by an MRI musculoskeletal radiologist for the integrity of the ankle ligaments. MAIN OUTCOME MEASUREMENTS: After evaluation of the x-rays, fractures were classified according to the system of Lauge-Hansen, and the predicted presence, sequence, and mechanism of injury was determined. These were then compared to the actual injured structures on MRI in each case, and the ability of the Lauge-Hansen system to accurately predict the complete injury pattern was determined for the entire cohort. RESULTS: Average patient age was 59 (range: 18 to 84) years. Of the 59 ankle fractures evaluated, 37 (63%) were classified as supination external rotation, 11 (19%) were pronation external rotation, 1 (2%) was supination adduction, and 10 (17%) were not classifiable on the basis of the Lauge-Hansen system. Of the 49 fractures that fit into Lauge-Hansen categories, 26 (53%) had patterns of ligamentous injury and fracture morphology that did not coincide with the Lauge-Hansen predictions. A common fracture pattern was observed in 8 of the 10 unclassifiable fractures, which included a high spiral fracture of the fibula, vertical shear fracture of the medial malleolus, posterior malleolar fracture, and complete tears of the anterior-inferior tibiofibular ligament and the interosseous membrane. In addition, over 65% of patients in this series had complete ligamentous injury and a fracture of the malleolus to which the ligament attaches. CONCLUSIONS: These results demonstrate that the Lauge-Hansen classification system may have some limitations as a predictor of the mechanism of injury and the presence of soft-tissue damage associated with ankle fractures. The identification of a novel pattern of ankle fracture also illustrates how the system fails to describe all possible fracture patterns. For these reasons, we recommend that the Lauge-Hansen system be used only as a guide in the diagnosis and management of ankle fractures and not solely relied upon for treatment decisions. Although the exact clinical implications of the variety of ligamentous injuries observed on MRI are yet to be determined, this technique may be useful in individual cases in which doubt about joint stability and soft-tissue integrity exists. Additionally, MRI may be helpful in planning surgical approaches in atypical fractures in which injury patterns are less predictable solely on the basis of x-ray.

Osteoporosis and skeletal fractures.

Osteoporosis affects millions of individuals worldwide, rendering them susceptible to fragility fractures of the spine, hip, and wrist and leading to significant morbidity, mortality, and economic cost. Given the substantial impact of osteoporosis on both patients and the medical community, it is imperative that physicians improve awareness and knowledge of osteoporosis in the setting of low-energy fractures. In this review, we provide information on effective means of preventing fragility fractures and introduce clinicians to issues pertinent to the patient who suffers an osteoporotic fracture. Prevention of fragility fractures centers around adequate mineral nutrition, including daily calcium and vitamin D supplementation, as well as prescription antiresorptive medications such as bisphosphonates or teriparatide therapy in severe cases, both of which have been shown to decrease future fracture risk. Balance and strength training also play important roles in the management of the osteoporotic patient, particularly following a low-energy fracture, and external hip protectors may be useful for certain patients. Kyphoplasty and vertebroplasty are two minimally invasive techniques that show great promise in the treatment of vertebral compression fractures, although questions regarding long-term biomechanical effects still exist. Traditionally, osteoporosis has been underdiagnosed and undertreated following a low-energy fracture in an elderly patient. Although treatment rates may be improving through public health initiatives, the majority of patients with osteoporosis remain inadequately treated. Perioperative intervention programs that focus on patient education about osteoporosis and treatment options lead to significant increases in intervention and treatment. Reducing the risk of skeletal fractures in patients susceptible to osteoporosis involves improved physician education on the risk factors and management of osteoporosis, as well as informing patients on the significance of dual-energy X-ray absorptiometry testing and medical treatment so that they may serve as their own healthcare advocates in this often-undertreated disease.

Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial.

BACKGROUND: Treatment of osteoporosis following a hip fracture has been notoriously poor. Many efforts have been made to improve treatment rates. The purpose of this study was to determine whether a perioperative inpatient intervention program, involving patient education and providing a list of questions for the primary care physician, increased the percentage of patients in whom osteoporosis was addressed following a hip fracture. METHODS: A prospective, randomized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted. During their hospitalization, the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures, the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment, and the importance of medical follow-up for osteoporosis management. These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician, and they were reminded about the questions during a follow-up telephone call six weeks later. The patients in the control group received a brochure describing methods for preventing falls. Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed. Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy. RESULTS: The average age in each group was eighty-two years, and 78% of the patients were female. Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial. Fifteen (42%) of the thirty-six patients who had been randomized to the study group, compared with only seven (19%) of the thirty-six patients in the control group, had their osteoporosis addressed by their primary physician. This difference between the groups was significant (p = 0.036). CONCLUSIONS: Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions. Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management.