What are the differences in outcomes between simple and complicated FSF managed by early IMN?

PURPOSE: To compare the outcomes of simple versus complicated femoral shaft fracture (FSF) treated by early intramedullary nail. METHODS: Retrospective cohort study in level 1 trauma center including patients with FSF. Management consisted of intramedullary nailing (IMN) after adequate resuscitation within 24 h. Data were prospectively collected on admission (trauma base) consisted of demographics, biological parameters, associated injuries and injury severity score (ISS). Complicated fractures consisted of type C fracture or any type associated with bilateral femur fracture, floating knee, associated femoral neck fracture, dislocated hip, concomitant neurovascular injury. Simple fractures were Isolated type A and B fracture. Simple and complicated fracture groups were compared using stratification by ISS (ISS < 16; 16 ≤ ISS < 25; ISS ≥ 25). RESULTS: Inclusion of 191 consecutive patients: simple FSF (N = 109) versus complicated FSF (N = 82) (type 32C, n = 36; bilateral, n = 44; associated neck of femur fracture, n = 15; floating knee, n = 36; concomitant femoral artery injury, n = 3 or sciatic nerve injury, n = 7). Complicated fractures were associated with higher rate of associated injuries (thoracic, 56.1 vs. 40.4%, p = 0.04; head 25.6 vs 10.1%, p = 0.005) and ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3 days, p = 0.019) and hospital stay (24.3 vs. 15.7 days, p < 0.001). After stratification, differences in morbidity between simple and complicated FSF were significant solely in range 16≤ISS < 25. Complicated fractures had longer operation duration (297 vs. 151 min, p < 0.001) due to additional IMN (tibial, humeral) requirements (24% vs. 1.8%, p < 0.001) and longer femoral IMN duration (133 vs. 104 min, p < 0.05). Pseudarthrosis was higher in complicated fracture group (9.6 vs. 3.7%, p = 0.002). CONCLUSION: Complicated femoral fractures are associated with higher morbidity, especially in less severely injured polytrauma, which eventually results in longer hospital stay. Patients with moderate ISS and complicated fracture may have an increased risk of ARDS.

Dual-mobility or Constrained Liners Are More Effective Than Preoperative Bariatric Surgery in Prevention of THA Dislocation.

BACKGROUND: Obesity is associated with an increased risk of dislocation after total hip arthroplasty (THA). However, in patients with obesity, it is not known whether the risk is only in the early postoperative period or whether it persists several years after surgery, and whether having bariatric surgery before undergoing THA and/or receiving a specific device (such as a dual-mobility or constrained acetabular liner) is more effective in terms of decreasing the risk of dislocation. QUESTION/PURPOSES: (1) What is the cumulative risk of dislocation in patients with obesity after THA in the absence of a dual-mobility or constrained liner, and is this related to component positioning? (2) Does bariatric surgery before undergoing THA decrease dislocation risk in patients with obesity? (3) Are dual-mobility and constrained liners efficient in preventing dislocation in patients with obesity? METHODS: At our university-based practice, all surgeons adhered to the following treatment approaches: Before 2000 no dual-mobility implants or constrained liners were used for primary THAs. Between 2000 and 2008, all patients whose body mass index (BMI) was greater than 30 kg/m(2) received dual-mobility liners (or constrained liners), except when they had previously had bariatric surgery. After 2008, all patients with BMIs over 30 kg/m(2) as well as those patients who were previously treated with bariatric surgery (regardless of BMI at the time of the index THA) received dual-mobility or constrained liners. This case-control study compared the dislocation percentage between 215 hips in nonobese patients (BMI ≤ 30 kg/m(2)), 215 hips in patients with obesity (BMI > 30 kg/m(2)) who received standard cups, 85 hips in patients with bariatric surgery before THA using standard cups (with reduction to a BMI < 30 kg/m(2)), and 155 hips in patients with obesity who received dual-mobility (when younger than 70 years) or constrained liners (when older than 70 years). All patients received the same implants except for different femoral head diameters (32-mm head with standard cups and 28-mm head with dual-mobility or constrained liners). The patients were followed at routine intervals and were specifically queried about dislocation. All the 670 hips had a minimum followup of 5 years with a mean followup of 14 years (range 5-25 years). At the most recent followup, 101 (15%) hips were lost to followup (respectively, 36 of 215, 34 of 215, five of 85, 24 of 155), which is the same ratio as observed among the underlying populations from which the patients were drawn. RESULTS: With standard liners, more hips in patients with BMI > 30 kg/m(2) dislocated than did hips in nonobese (BMI < 30 kg/m(2)) patients. The cumulative number of dislocations (first time without recurrent dislocation) was 6% (13 of 215) at 1-year followup in obese patients compared with 2% (four of 215) in nonobese patients (odds ratio [OR], 3.4; 95% confidence interval [CI] 1.09-10.58; p = 0.03) and was 13% (28 of 215) at 15 years followup compared with 4% (eight of 215) in nonobese patients (OR, 3.9; 95% CI 1.72-8.71; p = 0.001). When bariatric surgery was performed before THA, BMI declined from 42 kg/m(2) to 28 kg/m(2), but with the same standard liners, more hips after bariatric surgery dislocated at 1-year followup than did hips in patients with obesity without preoperative bariatric surgery (13% [11 of 85] compared with 6% [13 of 215]; OR, 0.43; 95% CI 0.18-1.01; p = 0.05). Dual-mobility or constrained implants decreased the risk of dislocation, and fewer hips in patients with obesity with dual-mobility or constrained liners at 7 years followup had dislocated than did hips with standard liners (2% [three of 155] compared with 9% [20 of 215]; OR, 0.19; 95% CI 0.05-0.66; p = 0.01) bringing this number in line with the number observed in nonobese subjects with standard cups. CONCLUSIONS: With standard liners, the risk of dislocation is increased in patients with obesity. Preoperative decrease of BMI (with bariatric surgery) in patients with obesity did not prevent the risk of dislocation with standard liners. Use of dual-mobility or constrained liners in these patients is an effective technique to reduce the risk of postoperative hip dislocation. However, we do not yet know the full risks of loosening of dual-mobility and constrained liners in this obese population. LEVEL OF EVIDENCE: Level III, therapeutic study.

Local transplantation of bone marrow concentrated granulocytes precursors can cure without antibiotics infected nonunion of polytraumatic patients in absence of bone defect.

PURPOSE: Infected, long bone non-unions present a significant clinical challenge. New and alternative therapies are needed to address this problem. The purposes of this study were to compare the number of circulating granulocyte-macrophage colony-forming units (CFU-GM) in the peripheral blood of polytraumatic patients with infected tibial non-unions and in the peripheral blood of control patients with the hypothesis that their number was decreased in polytraumatic patients; and to treat their infection without antibiotics and with local transplantation of bone marrow concentrated granulocytes precursors. METHODS: Thirty (18 atrophic and 12 hyperthrophic ) infected tibial non-unions (without bone defect) that occurred after open fractures in polytraumatic patients were treated without antibiotics and with percutaneous injection of autologous bone marrow concentrate (BMC) containing granulocytes precursors (CFU-GM). CFU-GM progenitors were assessed in the bone marrow aspirate, peripheral blood, and fracture site of these patients. The number of these progenitors was compared with the CFU-GM progenitors of control patient samples (healthy donors matched for age and gender). Outcome measures were: timing of union, callus formation (radiographs and CT scan), and recurrence of clinical infection. RESULTS: As compared to control patients, the number of CFU GM derived colonies was lower at peripheral blood in patients with infected nonunions. The bone marrow graft injected in nonunions contained after concentration 42 621 ± 20 350 CFU-GM-derived colonies/cc. Healing and cure of infection was observed at six months for 25 patients and at one year follow up for 30 patients. At the median ten year follow-up (range: 5 to 15), only one patient had clinical recurrent infection after healing (between 6 months and last follow-up). CONCLUSION: The peripheral blood of these polytraumatic patients with infected nonunions had a remarkable decrease in CFU-GM-derived colonies as compared with normal controls. Local transplantation of concentrated CFU-GM-derived colonies aspirated from bone marrow allowed cure of infection and healing without antibiotics.

Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress.

Avascular necrosis of the femoral head is caused by a multitude of etiologic factors and is associated with collapse with a risk of hip arthroplasty in younger populations. A focus on early disease management with the use of stem cells was proposed as early as 1985 by the senior author (PH). We undertook a systematic review of the medical literature to examine the progress in cell therapy during the last 30 years for the treatment of early stage osteonecrosis.