Union rates and functional outcome of double plating of the femur: systematic review of the literature.

BACKGROUND: The optimal treatment strategy for the surgical management of femur fractures and non-unions remains unknown. The aim of this study is to assess union rates, complications and outcome after femoral double plating. Treatment of shaft, distal, periprosthetic fractures and pathological proximal femur fractures as well as femoral non-unions with double plating were evaluated. METHODS: A systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was conducted. Published literature reporting on the treatment and clinical outcome of femoral fractures and non-unions with double plating was identified. In total, 24 studies with 436 cases of double plating, 64 cases of single plating, 84 cases of intramedullary nailing (IM), and 1 interfragmentary screw treatment met the inclusion criteria of this systematic review. The evaluated literature was published between 1991 and 2020. RESULTS: Double plating of femoral fractures achieved high healing rates and few complications were reported. It displayed significantly less intraoperative haemorrhage, shorter surgery time reduced risk of malunion in polytraumatised patients when compared to IM. Fracture healing rate of double-plating distal femoral fractures was 88.0%. However, there were no significant differences regarding fracture healing, complication or functional outcome when compared to single plating. Treatment of periprosthetic fractures with double plating displayed high healing rates (88.5%). Double plating of non-unions achieved excellent osseous union rates (98.5%). CONCLUSIONS: The literature provides evidence for superior outcomes when using double plating in distal femoral fractures, periprosthetic fractures and femoral non-unions. Some evidence suggests that the use of double plating of femoral fractures in polytraumatised patients may be beneficial over other types of fracture fixation. LEVEL OF EVIDENCE: IV.

[Periprosthetic fractures: basics, classification and treatment principles]. / Periprothetische Frakturen: Grundlagen, Klassifikation und Therapieprinzipien.

Periprosthetic fractures (PPFx) are becoming an increasingly important topic in orthopedics and trauma surgery due to the rising number of endoprosthetic joint replacements. The recently published unified classification system (UCS) has replaced numerous historical classification systems and can be applied to all PPFx regardless of the bone or joint involved. The treatment of PPFx requires individual therapeutic concepts taking patient-dependent and patient-independent factors into consideration. The conservative treatment of PPFx is only justified in exceptional situations. In contrast, the choice between operative treatment and deciding between osteosynthesis or revision arthroplasty is particularly based on the assessment of the implant stability. In order to achieve fracture consolidation and also a good functional outcome, knowledge of the basic biomechanical principles of operative (osteosynthesis or endoprosthesis) treatment of periprosthetic fractures is necessary.

[Stimulation of fracture healing by growth factors and cell-based technologies]. / Stimulation der Frakturheilung durch Wachstumsfaktoren und zellbasierte Technologien.

Bone has the special capability to completely regenerate after trauma and to re-establish its original geometry and biomechanical stability corresponding to the pretrauma conditions. Nevertheless, in daily clinical practice impaired fracture healing and nonunions are regular complications as a result of inadequate mechanical stability and/or insufficient biological processes around the fracture region. Since the beginning of the millennium, intensive research on the physiological processes in bone healing as well as the production and clinical administration of growth factors have enabled the possibility to improve the local biological processes during fracture healing by osteoinduction. Although the initial clinical results, particularly of bone morphogenetic proteins, in fracture healing were promising, growth factors did not become established for unrestricted use in the clinical application. Currently, additional growth factors are being investigated with respect to the potential supportive and osteoinductive characteristics for enhancement of fracture healing and possible clinical applications. Furthermore, the development of cell-based technologies is another promising approach to positively stimulate fracture healing. In addition to the gold standard of autologous bone grafting, harvesting of mesenchymal stroma cells by aspiration has gained in importance in recent years. Allogeneic bone cell transplantation procedures and in particular gene therapy are promising new strategies for the treatment of disorders of fracture healing. This review gives an overview of present and future possibilities for modulation of fracture healing by growth factors and cell-based technologies.

[Pseudarthroses of the long bones]. / Pseudarthrosen der langen Röhrenknochen.

Pseudarthrosis development is dependent on the presence of individual risk factors in approximately 10% as a result of fractures and are more frequently located in the region of the long bones. The development of non-union regularly results in prolonged pain and reduced functionality of the affected limb. The resulting clearly increased socioeconomic costs are caused by the complex operative treatment strategies and increased indirect costs, which include lost wages, social benefits and compensation. Altogether, non-unions require a differentiated therapeutic treatment strategy. The analysis of the non-union based on the diamond concept is the key for a successful planning and therapy. In this context, the use of focused, high-energy extracorporeal shock waves may be possible under specific circumstances; however, in most cases an operative revision is necessary to optimize the biomechanical stability and/or improve the local biology.

[Extracorporal shock wave therapy for the treatment of pseudarthrosis : New experiences with an old technology]. / Extrakorporale fokussierte Stoßwellentherapie zur Behandlung von Pseudarthrosen : Neue Erfahrungen mit einer alten Technologie.

BACKGROUND: Between 5 and 10 % of all fractures show disturbed healing or nonunion formation. Extracorporeal shock wave therapy (ESWT) has been described as a non-surgical treatment option. Even though the outcome has shown promising results, the procedure is not commonly used in clinical practice. The purpose of this study was to analyze the union rate of pseudarthrosis and the cost savings after ESWT. METHODS: In this study 42 nonunions were treated with shock waves (LithSpaceOrtho, JenaMedtech). The follow up examinations were performed over a period of six months. Outcome measurement included radiological fracture union and pain (VAS). The study group contained 39 pseudarthrosis in the six-week follow-up (93 %), 41 after three months (98 %) and 41 after six months (98 %). RESULTS: After six weeks, 13 % of patients showed fracture union. After three months 61 % and after six months 73 % of the fractures were completely healed. The fracture healing was significantly lower in older nonunions. All patients presented significantly lower pain levels six weeks after ESWT. Shock wave treatment of all 42 pseudarthrosis made up less than one quarter of the overall operative costs. CONCLUSION: We established the ESWT as an important treatment option for fracture nonunion in our clinic. Considering the selection of patients in this study with a high mean time from injury to ESWT and multiple prior operations, the fracture healing rate of 73 % after ESWT is comparable with operative healing rates of nonunions. Further prospective, randomized and controlled studies are needed to show the effectiveness of ESWT in the treatment of nonunions on a higher level of evidence and to identify pseudarthrosis that particularly responds to the EWST.

[The Biological Knife II - Fracture Healing and Pharmacological Interactions]. / Das biologische Skalpell II - Frakturheilung und pharmakologische Einflussfaktoren.

The reasons for delayed fracture healing or non-union formation are multifactorial. Mechanical factors are well known to influence the process of fracture healing. However, there is a lack of knowledge about the biological conditions that have to be achieved for adequate bone healing. Treatment of non-unions is still demanding and we have only poor options to stimulate the bone healing process. Therefore, it is important to optimise the biological conditions to avoid non-union formation. Beside patient-related factors, pharmacological drugs are able to impede or stimulate fracture healing. Especially geriatric patients show a pre-existing drug medication due to different co-morbidities. However, also younger patients are frequently treated with different drugs for infection prophylaxis, analgesia or thrombosis prophylaxis. The aim of the current review article is to give an overview about the influence of different pharmacological agents on the process of fracture healing. A deeper understanding of a drug-related influence on fracture healing could help the medical practitioner to optimise the general conditions for adequate fracture healing, i.e., by avoiding specific pharmacological agents. Vice versa some drugs could be used to stimulate fracture healing in the future.

[Quantitative morphological investigation of the effect of thiobutabarbitone sodium anaesthesia on the endocrine and exocrine pancreas of the albino rat (author's transl)]. / Quantitativ-morphologische Untersuchung über die Wirkung einer Narkose mit Thiobutabarbital-Natrium auf das endokrine und exokrine Pankreas der Albinoratte.

In respect of controls the beta-cells of the Islets of Langerhans in fed rats showed a significant decrease in nuclear volume after 40 min of anaesthesia with Thiobutabarbitone Sodium in a double-maximum-load dose. The alpha-cells and the cells of the exocrine pancreas do not show such alteration. The reduction in beta-cell acitivity is referred to a time and dose dependent effect of narcosis on the metabolism of the beta-cells and possible membrane phenomena. According to the morphological picture the otherwise missing signs of impaired function of the cells indicate a peripheral disturbance of glucose utilization during nacrosis. The blood-sugar levels support the proposed explanation.