The Effect of Strontium Ranelate on Fracture Healing: An Animal Study.

BACKGROUND: Strontium ranelate (StR) is an antiosteoporotic agent previously utilized for the enhancement of fracture union. We investigated the effects of StR on fracture healing using a rabbit model. METHODS: Forty adult female rabbits were included in the study and were divided in 2 equal groups, according to StR treatment or untreated controls. All animals were subjected to osteotomy of the ulna, while the contralateral ulna remained intact and served as a control for the biomechanical assessment of fracture healing. Animals in the study group received 600 mg/kg/day of StR orally. All animals received ordinary food. At 2 and 4 weeks, all animals were euthanatized and the osteotomy sites were evaluated for healing through radiological, biomechanical, and histopathological studies. RESULTS: The treatment group presented statistically significant higher callus diameter, total callus area, percentage of fibrous tissue (p < 0.001), vessels/mm2, number of total vessels, and lower osteoclast number/mm2 (p < 0.05) than the control group at 2 weeks. Additionally, the treatment group presented significantly higher percentages of new trabecular bone, vessels/mm2, osteoclast number/mm2, and lower values for callus diameter, as well as total callus area (p < 0.05), than the control group at 4 weeks. At 4 weeks, in the treatment group, force applied (p = 0.003), energy at failure (p = 0.004), and load at failure (p = 0.003) were all significantly higher in the forearm specimens with the osteotomized ulnae compared to those without. Radiological bone union was demonstrated for animals receiving StR at 4 weeks compared with controls (p = 0.045). CONCLUSION: StR appears to enhance fracture healing but further studies are warranted in order to better elucidate the mechanisms and benefits of StR treatment.

Simultaneous Periprosthetic Fractures of the Femur and the Acetabulum After Bipolar Hip Arthroplasty.

BACKGROUND Although periprosthetic fractures of the femur are a recognized complication of total hip arthroplasty, periprosthetic fractures of the acetabulum are rare. Simultaneous periprosthetic fractures of both the acetabulum and the femur have not been reported, to our knowledge. CASE REPORT We report a simultaneous fracture of the acetabulum and the femur in a 68-year-old female patient who had previously sustained a subcapital fracture of the femur, treated with a bipolar uncemented prosthesis. We discuss the possible mechanism of this combination of fractures. CONCLUSIONS Simultaneous periprosthetic fractures of the femur and the acetabulum can occur if, in the presence of osteoporotic bone, the metallic femoral head has migrated medially in the acetabulum while the femoral stem is not loose.

Small diameter acetabulum and femoral head in total hip arthroplasty for developmental dysplasia of the hip, with no femoral osteotomy.

We present the results of 66 total hip arthroplasties in 62 patients of mean age 46 years (24-74 years), with developmental dysplasia of the hip. In all cases the centre of rotation of the new hip was positioned at the site of the true acetabulum. In all patients cementless press fit acetabular components of small diameter (42-44 mm) were used, articulating exclusively with a 22.25 mm modular metal femoral head, without the use of bone grafts or shortening osteotomies of the femur. Despite the use of small diameter femoral heads the rate of dislocation was 3%. After an average follow-up period of 9 years (4-18 years), no revisions were required for infection, loosening or wear or implant migration. Osteolytic lesions were seen in the periacetabular region in 3 patients who were symptom free. A total of 2 revisions were required for instability and 2 patients had the wires of their trochanteric osteotomy removed because of bursitis. Leg length inequality was improved in 55% of the patients and one postoperative transient sciatic nerve lesion settled within 4 months. We believe that in patients with painful dysplastic hips, the use of small diameter implants with the centre of rotation at the true acetabulum, can give very satisfactory results, without any supplementary procedures.

The association of adipokine levels in plasma and synovial fluid with the severity of knee osteoarthritis.

OBJECTIVE: We sought to determine the association between plasma and SF levels of leptin and adiponectin in patients with knee OA. METHODS: Plasma and SF levels of adipokines and soluble leptin receptor (sOB-R) were determined by ELISA in 96 patients with knee OA at different stages, according to Ahlback's classification. RESULTS: Levels of adiponectin, leptin, sOB-R and free leptin in plasma and SF did not differ significantly across categories of OA severity. However, the ratio of SF to plasma leptin was significantly lower in the advanced OA stage compared with early stages of the disease (P = 0.02). After adjustment for sex and BMI, plasma leptin positively correlated with categories of OA severity (r = 0.23, P = 0.02), whereas SF/plasma leptin negatively correlated with OA stage (r = -0.27, P = 0.01). Cluster analysis showed that all men were included in one cluster and distributed in different stages of OA, whereas women formed three clusters with similar BMI, but those who were older and had the highest plasma leptin levels suffered from advanced OA. CONCLUSION: Plasma leptin positively correlated with the severity of knee OA. The ratio of SF to plasma leptin might be a marker related to the severity of knee OA. Further studies should investigate whether similar associations exist in other joints affected by OA.

Application of PRP gel alone or in combination with guided bone regeneration does not enhance bone healing process: An experimental study in rabbits.

INTRODUCTION: The aim of this study was to assess the hypothesis that application of platelet-rich plasma (PRP) gel in mandibular defects in rabbits, alone or in combination with guided bone regeneration (GBR) techniques, could enhance the bone healing process. MATERIALS AND METHODS: Thirty New Zealand white rabbits were used. Three groups of 10 animals each were assigned, and the animals were sacrificed after 12 weeks. During the operation, a rotating trephine bur was used to create circular defects 10-mm in diameter in the region anterior to the jaw angles. In group human fascia lata (HFL), a human fascia lata membrane was used. In group PRP, PRP gel was used to fill the defect, and in group HFL+PRP, PRP was used to fill the defect which after that was covered with a human fascia lata membrane. RESULTS: In general, none of the control sides and the PRP treated sides had full development of bone or filling of the defect through bone bridging. Conversely, the sides on which the fascia lata membrane or the combination of membrane and PRP had been applied were characterized mostly by development of newly formed bone that bridged the gap. CONCLUSIONS: Our results suggest that the application of PRP gel alone or in combination with GBR does not enhance bone healing process.

Effect of combined administration of transforming growth factor-b1 and insulin-like growth factor I on the mechanical properties of a patellar tendon defect model in rabbits.

The aim of this study was to test the hypothesis that combined administration of TGF-b1 and IGF-I in a patellar tendon defect model could enhance the mechanical properties of the healed tendon. Twenty four New Zealand white rabbits were used for this purpose. In each animal, the right knee was used for the application of the growth factors, whereas the left knee served as an untreated control. The growth factors were mixed with fibrin sealant as a delivery vehicle. Two groups of rabbits were sacrificed after 2 weeks and 6 weeks respectively. Application of the growth factors resulted in a significant increase in force at failure, ultimate stress, stiffness, and energy uptake at 2 weeks, whereas none of the parameters revealed any significant difference between the two groups at 6 weeks. This study provides valuable information on the effect of the two growth factors on this patellar tendon defect model.

Serum TGF-beta2 and TGF-beta3 are increased and positively correlated to pain, functionality, and radiographic staging in osteoarthritis.

The goal of this study was to verify or reject the hypothesis that systematic differences exist in various profibrotic or antifibrotic factors between osteoarthritic patients and controls, as well as between different stages of osteoarthritis. The study group comprised 63 patients with knee osteoarthritis and 18 controls. Transforming growth factor-beta (TGF-beta)1, -2, -3; tissue inhibitor of metalloproteinase (TIMP)-1 protein levels; and gelatinolytic activity of matrix metalloproteinase (MMP)-1, -2, -3, -9 activities were measured by enzyme-linked immunosorbent assay and gelatin zymography, respectively. Visual analog scale scores, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, Lequesne clinical osteoarthritis scales, and Kellgren-Lawrence radiographic grading were recorded for each patient.Transforming growth factor-beta2 and -3 (in contrast to TGF-beta1 and TIMP-1) serum protein levels were significantly higher in osteoarthritic patients compared to controls (210%+/-14% [P<.001] and 232%+/-7% [P<10(-7)], respectively). Additionally, TGF-beta2 and -3 were strongly positively correlated to Kellgren-Lawrence radiographic grading of the disease (P<10(-5) and P<10(-7), respectively). Moreover, TGF-beta2 correlated positively with the WOMAC scale (P=.007). However, TIMP-1 decreased as osteoarthritis progressed clinically, but remained irrelevant to radiographic staging. Furthermore, activities of MMP-2 and -9, but not MMP-1+/-3, were lower in patients with osteoarthritis.

Temporal and spatial expression of TGF-beta1 in an Achilles tendon section model after application of platelet-rich plasma.

BACKGROUND: To investigate the effect of platelet-rich plasma (PRP) on TGF-beta1 expression during tendon healing. METHODS: We used 48 skeletally mature New Zealand White rabbits. 24 rabbits received the PRP, and 24 rabbits served as an untreated control group. Equal numbers of animals were sacrificed at 1st, 2nd, 3rd, and 4th week. The surgical procedure involved a transverse incision to transect the Achilles tendon. A volume of 1ml of PRP was then injected into the tendon mass in the PRP group. Histological and immunohistochemical evaluations with an anti-TGF-beta primary antibody were performed. RESULTS: The pattern of expression of TGF-beta1 in the PRP group was characterized by a significant upregulation during the first 2 weeks and subsequently significant downregulation in the 3rd and 4th week in comparison with the controls. CONCLUSIONS: Our results suggest that PRP may affect the tendon healing process by altering the expression of TGF-beta1.

Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing.

AIM: Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients. MATERIALS-METHODS: This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy). The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization. RESULTS: Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p>0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism. CONCLUSION: We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.

Peroneal nerve damage by bicortical tibial screw in ACL reconstruction.

Arthroscopically assisted anterior cruciate ligament reconstruction is regarded as a minimally invasive surgery with low morbidity but complications still occur. Reports of neurovascular injuries related to graft harvesting, tunnel placement, or graft fixation are limited. A rare case of peroneal nerve injury related to hardware used for graft fixation in the tibial in a 28-year-old female patient who underwent an anterior cruciate ligament reconstruction surgery using a patellar tendon graft (bone-tendon-bone graft) is presented. Post-operatively, the patient presented with clinical signs of peroneal nerve damage and a reduced range of motion of the knee. Plain radiographs of the knee showed the bicortical screw which used for tibial fixation of the graft, penetrating the fibula and projecting beyond the lateral cortex of the fibular neck. The patient was treated with removal of the hardware and the graft. Intensive physiotherapy resulted in gradual improvement and at 6 months after the second operation the patient regained full range of motion of the knee and almost full muscle strength performing her daily activities without any difficulty and she is at the moment unwilling to undergo further procedure.

Can low doses of simvastatin enhance fracture healing? An experimental study in rabbits.

Several observational and experimental studies have investigated the potential anabolic effects of statins on undisturbed bone but only a few recent studies have examined the effect of statins on skeletal repair. The goal of the study is to investigate any potential early anabolic effect of the systemic administration of simvastatin in low doses (based on earlier safety and efficacy studies on undisturbed bone) on fracture healing. Fifty-four skeletally mature male New Zealand White rabbits were used for the study. The rabbits were assigned to one of three experimental groups: a control group, and two groups that were orally administrated a diet with 10 and 30 mg/kg/day of simvastatin, respectively. A complete biochemical blood count was performed to exclude drug-induced complications. Half of the animals of each group were sacrificed at 15 days and the other half at 30 days after surgery at which time intervals healing quality was assessed. The bones were subjected to biomechanical testing, histomorphometric analysis and peripheral quantitative computed tomography. In animals received simvastatin of 30 mg/kg/day a significant reduction of BMD, stiffness, and energy absorbed to failure were observed. At 15 days, the amount of cartilaginous callus formation was reduced, and the void space was significantly increased, in the animals of both groups that received simvastatin when compared to the control group (p<.05). Our results suggest that simvastatin doses of 30 mg/kg/day may have a negative anabolic effect on callus formation in rabbits, whereas doses of 10 mg/kg/day seem not to produce a significant positive or a negative effect, especially at the early stages of fracture remodeling.

Immunohistochemical study of angiogenesis after local administration of platelet-rich plasma in a patellar tendon defect.

A full thickness defect was made in the central portion of the patellar tendon of 48 New Zealand white rabbits. Platelet-rich plasma (PRP) gel was then applied and filled the tendon defect. The same procedure was performed in the control group, without the application of PRP. Animals were sacrificed after one, two, three, and four weeks. Histological and immunohistochemical analyses using a monoclonal antibody against CD31 were performed. The histological examination showed a superior healing process in the PRP group compared with the control group. Especially in the third week, the tissue formed in the PRP group was more mature and dense with less elastic fibres remaining. Neovascularisation was significantly higher in the PRP group during the first two weeks and significantly lower in the third and fourth weeks (p < 0.0001). Histological examination and study of angiogenesis showed that the application of PRP enhances and accelerates the tendon healing process.

The influence of platelet-rich plasma on angiogenesis during the early phase of tendon healing.

BACKGROUND: The poor vascularity of tendons is a major factor in their limited healing capacity. The aim of this study was to assess the effect of Platelet Rich Plasma (PRP) on angiogenesis during tendon healing. MATERIALS AND METHODS: Forty-eight skeletally mature New Zealand White rabbits were used. The Achilles tendon was transected transversely and 0.5 ml of PRP was injected into the tendon mass on each side of the incision on both limbs. The injection in the control group consisted of saline. Six animals from each group (12 tendons each) were sacrificed after 1, 2, 3, and 4 weeks following treatment. Three sections from each Achilles were stained with hematoxylinosin for microscopic examination. Further three sections were immunostained with a monoclonal antibody against CD31 (Daco Co), followed by image analysis to count new vessel numbers and statistical analysis was performed. RESULTS: There was significantly more angiogenesis in the PRP group compared to the control group during the first two weeks of the healing process, i.e., inflammatory and proliferative phase (p < 0.0001). The orientation of collagen fibers in the PRP group was better organized. The number of the newly formed vessels in the PRP group were significantly reduced at 4 weeks compared to the controls (p < 0.0001) suggesting the healing process was shortened. CONCLUSION: PRP seems to enhance neovascularization which may accelerate the healing process and promote scar tissue of better histological quality. CLINICAL RELEVANCE: Although these results need replication and further biomechanical research, PRP may promote tendon healing acceleration.

The effect of platelet-rich plasma gel in the early phase of patellar tendon healing.

INTRODUCTION: The aim of this study is to assess if an application of platelet-rich plasma (PRP) gel would improve the mechanical properties of rabbit's patellar tendon after resecting its central portion. MATERIALS AND METHODS: Forty skeletally mature New Zealand White rabbits were used. Two groups ten rabbits each (PRP and control group) were used to evaluate mechanical properties and histology after 14 days and two groups ten rabbits each (PRP and control groups) were used to evaluate mechanical properties and histology after 28 days. RESULTS: At 14 days, PRP group showed a 72.2% increase in force at failure, a 39.1% increase in ultimate stress, and a 53.1% increase in stiffness, as compared with controls. These changes were statistically significant (P < 0.05). At 28 days, there was no longer any significant difference between PRP and control groups (P > 0.05). DISCUSSION: In our study, the mechanical properties of the regenerated tendon in the PRP group were significantly improved in relation to the control group. It appears that PRP has a strong effect in the early phase of tendon healing. This effect is probably due to the growth factors that are released from the platelets during activation.

Classifying fractures of the distal radius: impossible or unnecessary? Review of the literature and proposal of a grouping system.

Reviewing the literature it was found that no classification of fractures of the distal radius is universally accepted regarding reproducibility, treatment orientation, and ability to predict outcome. The authors find the use of the existing classifications extremely difficult in practice, especially when trying to communicate, and believe that classification, treatment, and prognosis cannot be directly connected because of the complexity of fracture patterns and treatment options. Five hundred fractures of the distal radius were studied and a grouping system was developed in which fractures are positioned according to the direction of displacement of the distal part and the existence of an intra-articular extension. Nine special parameters are also defined that characterize the personality of each fracture of the distal radius. According to this personality, a fracture can be finally connected to treatment, which is presented in a special protocol also developed after a wide review of the literature. An easily reproduced and remembered grouping system of fractures of the distal radius is offered. This, when combined with the special parameters, leads to a complete description of the fracture and is directly connected to the treatment guidelines presented here as a special protocol.

A humeral shaft fracture complicated with anterior shoulder dislocation in a young male treated with modified Intramedullary nailing prior to reduction: a case report.

INTRODUCTION: Anterior dislocation of the shoulder joint with an ipsilateral fracture of the humeral shaft is a rare injury which may require demanding technical skills. CASE PRESENTATION: A 33 years old male sustained a work accident. Radiographs showed an anterior dislocation of the shoulder with a transverse fracture of the middle third of the humeral shaft on the same side. The dislocation proved to be irreducible in the setting of the fracture humerus. Thus, stabilization of the shaft fracture was successfully applied with an intramedullary nail and a small antirotational plate prior to the reduction. The patient recovered full function of the shoulder. CONCLUSION: Performing primary intramedullary nailing of the humeral shaft fracture before manipulation of the joint resulted to an excellent outcome.

Littler's flap revisited: an anatomic study, literature review, and clinical experience in the reconstruction of large thumb-pulp defects.

BACKGROUND: An anatomic study and the authors' clinical experience with 15 flaps used for resurfacing sizable thumb defects are presented. MATERIAL/METHODS: Sixteen upper extremities from fresh cadavers were dissected to delineate the anatomy, vascular pattern, and reconstructive potential of the heterodigital island flap. Fifteen heterodigital island flaps were also performed between 1996 and 2004 in 15 patients (mean age: 41.2 years) suffering from a major trauma of the thumb. Flap and donor site skin quality, scar contractures, finger mobility expressed in terms of total active movement, sensibility evaluated by two-point discrimination and the Semmes-Weinstein (SW) monofilament tests, cold intolerance, double-sensibility phenomenon, and cosmetic results were assessed. All patients were reviewed over a postoperative follow-up period of 10-18 months. RESULTS: Good coverage with well-vascularized skin was obtained and donor-finger full-thickness skin grafting was successful in all cases. All flaps survived completely. Mild cold intolerance was seen in all donor fingers, but no flap had hyperesthesia 10 months postoperatively. Total active range of motion was rated as good or excellent in all patients for both the donor finger and the thumb. Sensation in the donor finger was reported as "slightly altered" and the double-sensibility phenomenon was present in all patients. CONCLUSIONS: The heterodigital arterialized flap is a single-stage, thin, fairly mobile flap that produces an excellent cosmetic result, restores sensibility, and enables early mobilization of the hand. Morbidity in the donor finger is within acceptable limits and its usefulness in the reconstruction of thumb pulp defects is well documented.

Diagnostic value of conventional arthrography in investigating post-traumatic ulnar wrist pain: are MRI and MR arthrography always necessary?

BACKGROUND: Ulnar wrist pain is a difficult problem to diagnose and treat. Many diagnostic methods can be used, each having its own value, but the surgeon should know which is the simplest and most appropriate for each case. CASE REPORT: Such a case, investigated adequately by conventional arthrography is presented. A review of the relevant literature and a discussion of whether conventional MR and MR arthrography are always necessary or not is provided. CONCLUSIONS: MR arthrography does not need be performed in every case of ulnar wrist pain, this depending on the findings of conventional arthrography, an opinion that has also been confirmed by the authors' own previous experience.

Talar body fracture combined with bimalleolar fracture.

The incidence of talar fractures is relatively low affecting usually young patients, while recent epidemiological studies have shown that talar body fractures represent a significant proportion of the total number of talar fractures. Talar body fractures are usually high-energy injuries and often a combined talar neck and body fracture is noted. An association between talar body fractures and ankle fractures has also been recorded involving the medial or lateral malleolus. The only report of a talar fracture combined with a bimalleolar ankle fracture that was found in the literature is referred to a talar neck fracture. In this report, a combination of a talar body fracture and bimalleolar ankle fracture in a polytraumatised young patient is presented. This combined injury pattern seems to be very rare, since a similar case was not found in the literature. An open reduction and internal fixation of the talar body fracture as well as the bimalleolar fracture, followed by a prolonged non-weight bearing, led to a fracture healing with no evidence of osteonecrosis. Minimal osteoarthritic changes of the tibiotalar joint were noted at 3 years follow-up with satisfactory functional results.

Neglected Hangman's fracture in association with rupture of the trachea.

BACKGROUND CONTEXT: Rupture of the trachea combined with a Hangman's fracture has been reported rarely in the literature. We present a case of a rupture of the trachea combined with a type IV Hangman's fracture that remained undiagnosed for 7 weeks, in a 25-year-old woman after a road traffic accident. PURPOSE: To underline the necessity that physicians treating patients with multiple injuries including the trachea and the mediastinum should be aware of the fact that injuries of the trachea can be accompanied by trauma to other contents of the mediastinum and of the cervical spine. STUDY DESIGN: A 24-year-old woman was involved in a head on collision road traffic accident. She has suffered from a rupture of the trachea combined with a type IV Hangman's fracture that remained undiagnosed for 7 weeks. METHODS: Emergency surgical repair of the rupture of the trachea was performed. A halo vest for a total period of 4 months was applied. RESULTS: The patient followed a rehabilitation program, and, at her last visit, 12 months after her injury, had remained asymptomatic. A computed tomography scan of her cervical spine showed union through callous formation, and she had returned to her previous job and recreational activities. CONCLUSIONS: Physicians treating patients with multiple injuries including the trachea and the mediastinum should be aware of the fact that injuries of the trachea can be accompanied by trauma to other contents of the mediastinum and of the cervical spine.