Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure.

AIMS: The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures. PATIENTS AND METHODS: A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. RESULTS: Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001). CONCLUSION: Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered. TAKE HOME MESSAGE: Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion.

Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure.

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

The need for training frameworks and scientific evidence in developing scarless surgery: a national survey of surgeons' opinions on single port laparoscopic surgery.

INTRODUCTION: Single port/incision laparoscopic surgery (SPILS) is a recent innovation in minimally invasive surgery whereby operations are performed through a single point of entry. Despite the relative paucity of clinical data, the procedure is increasingly being used to minimise scarring and pain associated with the multiple entry points of traditional laparoscopic surgery. This study aimed to analyse the awareness, experience and opinions of British surgeons regarding SPILS. METHODS: Electronic, 13-item, self-administered, anonymous questionnaire survey distributed via national/regional surgical mailing lists and websites. Results were collated and analysed with SPSS v17.0 for Windows (SPSS, Inc, Chicago, IL). RESULTS: 342 fully completed responses received, including 72 (21%) Consultants and 189 (55%) higher surgical trainees. Overall 330 (96.5%) were aware of SPILS; there was no significant difference in awareness between grades. Only 37% had assisted or performed SPILS procedures. More consultants performed these than trainees (56.3 vs 32.0%, p < 0.05). Operative experience was limited, with only 6% of those undertaking SPILS performing ≥25 procedures, and 60% performing ≤5. 61.4% believed SPILS takes longer to perform, and 32.8% believed it has higher complication rate. Factors cited as limiting uptake included: lack of evidence (70%), insufficient training opportunities (78%), incorrect instrumentation (70%), increased cost (62%), and hospital policy (44.5%). Patient preference was considered to have negatively affected SPILS uptake by only 9% of respondents. A greater proportion of trainees (94.6% vs 78.9%) felt there were insufficient SPILS training opportunities (p = 0.001). CONCLUSIONS: Although awareness of SPILS is high, operative experience is limited and negative perceptions regarding operating time and complications remain. The findings suggest future uptake relies strongly on the availability of evidence, training, instrumentation and reduced costs. Scientific studies are still awaited to assess effectiveness and provide clinical and economic evaluation.

Hydrogen sulphide-releasing diclofenac derivatives inhibit breast cancer-induced osteoclastogenesis in vitro and prevent osteolysis ex vivo.

BACKGROUND AND PURPOSE: Hydrogen sulphide (H(2)S) and prostaglandins are both involved in inflammation, cancer and bone turnover, and non-steroidal anti-inflammatory drugs (NSAIDs) and H(2)S donors exhibit anti-inflammatory and anti-tumour properties. H(2)S-releasing diclofenac (S-DCF) derivatives are a novel class of NSAIDs combining the properties of a H(2)S donor with those of a conventional NSAID. EXPERIMENTAL APPROACH: We studied the effects of the S-DCF derivatives ACS15 and ACS32 on osteoclast and osteoblast differentiation and activity in vitro, human and mouse breast cancer cells support for osteoclast formation and signalling in vitro, and osteolysis ex vivo. KEY RESULTS: The S-diclofenac derivatives ACS15 and ACS32 inhibited the increase in osteoclast formation induced by human MDA-MB-231 and MCF-7 and mouse 4T1 breast cancer cells without affecting breast cancer cell viability. Conditioned media from human MDA-MB-231 cells enhanced IκB phosphorylation and osteoclast formation and these effects were significantly inhibited following treatment by ACS15 and ACS32, whereas the parent compound diclofenac had no effects. ACS15 and ACS32 inhibited receptor activator of NFκB ligand-induced osteoclast formation and resorption, and caused caspase-3 activation and apoptosis in mature osteoclasts via a mechanism dependent on IKK/NFκB inhibition. In calvaria organ culture, human MDA-MB-231 cells caused osteolysis, and this effect was completely prevented following treatment with ACS15 and ACS32. CONCLUSIONS AND IMPLICATIONS: S-diclofenac derivatives inhibit osteoclast formation and activity, suppress breast cancer cell support for osteoclastogenesis and prevent osteolysis. This suggests that H(2)S-releasing diclofenac derivatives exhibit anti-resorptive properties, which might be of clinical value in the treatment of osteolytic bone disease.