A 42-year-old patient presenting with femoral head migration after hemiarthroplasty performed 22 years earlier: a case report

Introduction

Treatment of femoral neck fractures in young adults may require total hip arthroplasty or hip hemiarthroplasty using a bipolar cup. The latter can, however, result in migration of the femoral head and poor long-term results.

Case presentation

We report a case of femoral head migration after hemiarthroplasty performed for femoral neck fracture that had occurred 22 years earlier, when the patient (a Japanese man) was 20 years old. He experienced peri-prosthetic fracture of the femur, subsequent migration of the prosthesis, and a massive bone defect of the pelvic side acetabular roof. After bone union of the femoral shaft fracture, the patient was referred to our hospital for reconstruction of the acetabular roof. Intra-operatively, we placed two alloimplants of bone from around the transplanted femoral head into the weight-bearing region of the acetabular roof using an impaction bone graft method. We then implanted an acetabular roof reinforcement plate and a cemented polyethylene cup in the position of the original acetabular cup. Eighteen months post-operatively, X-rays showed union of the transplanted bone.

Conclusions

Treatment of femoral neck fractures in young adults is usually accomplished by osteosynthesis, but it may be complicated by femoral head avascular necrosis or by infection or osteomyelitis. In such cases, once an infection has subsided, either hip hemiarthroplasty using a bipolar cup or total hip arthroplasty may be required. However, if the acetabular side articular cartilage is damaged, a bipolar cup should not be used. Total hip arthroplasty should be performed to prevent migration of the implant.     

The biomaterial influences the ossification after sinus floor elevation using tissue-engineered bone grafts

Sinus floor elevation is the standard procedure that allows dental implant insertion in the atrophic posterior maxilla. Instead of autogenous bone, tissue-engineered bone grafts can be used, but clear comparative clinical studies also assessing the influence of the biomaterial are missing. In six patients, tissue-engineered bone grafts were used in eight sinus floor elevations. After culturing osteoblast-like cells from biopsies of the maxilla, they were seeded on scaffolds made either from demineralised bovine bone matrix (DBBM) or from solvent-dehydrated mineralised bone (SDBB), and grafted. In all patients primary wound healing was without complications, except for one patient in the SDBB group. After 12 months, implant insertion was possible only in the SDBB group; in the DBBM group, fibrous connective tissue was found in an attempt of implant insertion. After 5 months, implant placement was performed in one patient of each group. However, the two implants inserted in the DBBM group were lost after 6 weeks. Histology of the bone cores in the DBBM group at 5 months showed lamellar bone and osteoid, and at 12 months showed fibrous connective tissue. Inflammation and some resorption of the scaffold was found 5 months after SDBB grafting, and after 12 months cancellous bone formation encapsulating SDBB remnants were observed. These preliminary data suggest that the preparation method of the bovine bone matrix, in particular the mineral content, and therefore the mechanical stability may have some influence on the generation of new bone.     

不同植入物内固定治疗四肢创伤骨折后骨不连的临床对比研究

目的:探讨不同植入物内固定治疗四肢创伤骨折后骨不连的临床疗效。方法:选择我科2010年2月~2013年2月四肢创伤骨折后骨不连患者38例,按照随机数表法将38例患者随机分为两组,分别为LC-DCP组以及LCP组,每组各19例,观察两组患者的平均手术持续时间、骨折临床愈合时间、X线骨痂评分以及并发症。结果:LC-DCP组平均手术持续时间为(134.73±12.91)min,LCP组为(129.54±14.87)min,两组比较不存在统计学差异(P0.05)。LC-DCP组患者平均骨折临床愈合时间为(3.94±0.83)月,LCP组为(3.81±0.69)月,两组间不存在统计学显著性差异(P0.05)。LC-DCP组患者X线骨痂评价标准平均评分值为(2.73±0.51)分,LCP组为(2.86±0.49)分,两组间差异不存在统计学意义(P0.05)。结论:两种钢板联合植骨治疗四肢创伤骨折后骨不连均能够取得良好的治疗效果,均可以作为治疗四肢创伤骨折后骨不连患者的有效方法。     

Metabolic bone disease: atypical femoral fractures

Since 2005 reports have been published describing unusual femoral shaft fractures primarily in postmenopausal women treated for prolonged periods with a bisphosphonate drug for osteoporosis. In some patients pain develops in the femur prior to a completed fracture. Bilateral fractures have occurred in some patients. It is unclear whether oversuppression of bone cell activity is a major factor in the pathogenesis of the fractures, or whether these are a rare manifestation of the underlying bone disease. Such fractures do occur in other metabolic bone disorders in which there are marked abnormalities of bone structure.     

骨水泥强化椎弓根内固定治疗骨质疏松性脊柱骨折的效果

目的:探讨内固定与植骨融合术治疗骨质疏松性椎体骨折的临床疗效。方法:回顾性分析我院2011年7月至2012年7月收治的80例骨质疏松性椎体骨折患者的临床资料。根据固定方式,将37例采用PMMA骨水泥强化椎弓根内固定的患者作为研究组,其余43例单纯应用椎弓根内固定的患者作为对照组。收集两组患者的手术时间、术中出血量、术后疼痛程度、愈合时间等临床资料。评价患者手术前后侧位X线片椎体高度和内固定效果。术后随访24个月。结果:两组患者的手术时间、术中出血量、住院时间及骨折愈合时间等无显著性差异(P0.05);研究组患者术后疼痛程度、椎体高度、内固定物松动及断裂情况等显著优于对照组,差异具有统计学意义(P0.01)。结论:骨水泥强化椎弓根螺钉治疗骨质疏松性椎体骨折具有良好的临床效果,值得推广应用。     

Resorbable plate osteosynthesis of dislocated or pathological mandibular fractures: a prospective clinical trial of two amorphous L-/DL-lactide copolymer 2-mm miniplate systems

The purpose of this study was to evaluate the indication for resorbable miniplates in traumatic and pathological mandibular fractures. Two resorbable miniplate systems, the 2.0-mm MacroSorb (Macropore, San Diego, Calif.) and the PolyMax (Synthes, Oberdorf, Switzerland), were prospectively used in 24 mandibular osteosyntheses. Made from amorphous 70:30 poly-L/DL-lactide, amorphous copolymer plates have not yet been evaluated for mandibular osteosyntheses. The main advantage of the amorphous copolymer-structure is continuous hydrolysis through water penetration into the implant body during the first 6 months. Hydrolysis breaks the copolymer chains into smaller particles that later become degraded through phagocytotic cells. Twelve patients, aged 13 to 83 years, were treated after providing informed consent. Fourteen dentate patients with moderately dislocated traumatic fractures and two edentulous atrophic and dislocated traumatic mandibular fractures were treated. Two patients with pathological fractures due to osteomyelitis received osteosynthesis after sequestrectomy. Histological specimens of the plates, screws, and surrounding soft tissues were taken after 3, 6, 9, and 12 months in secondary dental implant operations. A total of 22 osteosyntheses healed well without clinical or radiological signs of dislocation, insufficient or excess formation of callus, pseudarthrosis, or plate fracture. The follow-up time ranged from 4 to 22 months. One patient with osteomyelitis worsened because of widespread osseous infection, and one with atrophic fracture developed a bland fibrous pseudarthrosis. The histological specimens showed a moderate inflammatory foreign body reaction. No sinuous drainage or clinically apparent inflammation occurred. The presented osteosynthesis systems showed reliable stability for mandibular osteosynthesis in cooperative patients; however, two treatment failures occurred (8 percent). Disadvantages of the resorbable osteosyntheses were costs, greater diameter, screw breakage, and the need to place the screws vertically to the plate. The use of resorbable osteosyntheses in dislocated fractures should be further evaluated in controlled studies.     

Direct local approach through a W-shaped incision in moderate or severe blowout fractures of the medial orbital wall

For moderate or severe blowout fractures of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomic reconstruction of the wall without surgical complications. Various surgical approaches have been used, depending on the anatomic location and the extent of medial wall fracture. However, there is no consistent method to achieve the treatment goals with minimal morbidity because of one or more problems of limitation of entire medial wall exposure, limitation of large implant or bone graft insertion, surgical damage of important periorbital or intraorbital structures, or postoperative scar deformities. In this study, a direct local approach through a 3-cm, W-shaped incision on the superior medial orbital area was used as a consistent method to reconstruct medial orbital blowout fractures. The angle of the W-limbs is 110 to 120 degrees. Four limbs of the W were placed parallel or oblique to the relaxed skin tension lines. This technique was applied to 39 orbits of 37 patients with moderate or severe blowout fractures of the medial orbital wall. This approach provided exposure of the entire medial orbital wall, adequate placement of a large implant, short operation time within 2 hours, and no damage of important internal structures. Postoperative computed tomographic scans showed complete reduction of the herniated orbital tissues and anatomic reconstruction of the medial orbital wall without complication related to the surgical approach in all cases. During the follow-up period of 6 to 14 months, excellent functional and cosmetic results were observed with an inconspicuous scar without secondary scar deformities. Therefore, a direct local approach through a W-shaped incision on the superior medial orbit may be a consistent method to gain the surgical goal in treatment of moderate or severe blowout fractures of the medial orbital wall.     

Resorbable plate osteosynthesis of sagittal split osteotomies with major bone movement

This study evaluates resorbable miniplate osteosyntheses in sagittal split osteotomies with major bone repositioning. Two resorbable 2.0-mm miniplate systems, MacroSorb (Macropore, San Diego, Calif.) and PolyMax (Synthes, Oberdorf, Switzerland), were compared consecutively. Amorphous 70:30 poly-L/DL-lactide copolymer plates sustain continuous hydrolysis through water penetration into the implant body during the first 6 months in situ. This breaks copolymer chains into smaller particles, which later become degraded through phagocytotic cells. Eighteen patients, 10 women and eight men, 16 to 57 years old (average, 27 years) were examined. They had severe dysgnathia caused by congenital craniofacial malformations, systemic disorders, trauma, amelogenesis imperfecta, oligodontia, and other conditions, and they needed five 8- to 10-mm and 13 major 10- to 12-mm repositions. Twelve sagittal split osteotomies were fixed with 12 MacroSorb plates in six patients, and 24 osteotomies were filled with 32 PolyMax plates in 12 patients. Ten mandibular plate, screw, hard-tissue, and soft-tissue specimens were taken at 3, 6, 9, or 12 months postoperatively in secondary operations (e.g., dental implant placement).Follow-up ranged from 4 to 19 months; all osteosyntheses reossified. Four patients showed proximal fragments rotated up to 5 mm sagittally anteriorly and nonaligned burr holes on the postoperative radiogram, suggesting plate fractures or screw pullout. When plate fracture was noted, guided occlusion was maintained 4 weeks after surgery. Occlusal, radiologic, and skeletal results remained stable. After starting fixation with two plates on each side, no more plate fractures were seen. In three other patients, minor skeletal relapses up to 3 mm horizontally resulted. Local histologic inspection of specimens showed thorough osseous union. Screw remnants embedded in bone made screw pullout unlikely; rather, screw-head or plate fractures were found as multiple degraded particles. Microscopy showed a chronic foreign body reaction. Two patients (11 percent) developed a sterile fistula 3 and 4 months after surgery, draining implant debris. Here, the biopsies showed a granulocytic infiltrate that subsided clinically after excisional biopsy. The assignment of MacroSorb plates followed by PolyMax plates was done in an otherwise unchanged treatment protocol. Comparison of the number of patients in each group with stable osteosyntheses and regular healing showed no significant differences by Fisher's exact test (p = 0.1516); therefore, the authors focused on the combined results for both treatments.The current osteosynthesis systems showed sufficient stability for mandibular fixation after sagittal split osteotomy and repositioning more than 10 mm distant when two plates were applied to each side; however, 27 percent of patients had complications, including relapses. Disadvantages were the cost, breakability, diameter, and need to place the screws vertically to the plate, necessitating a bent instrument or transbuccal incisions.     

Patterns of fractures in accidental and non-accidental injury in children: a comparative study.

The incidence and pattern of fractures in children who had been abused were compared with those of fractures sustained by children of similar ages in whom abuse had been excluded. From 1976 to 1982 there were 35 children with fractures resulting from child abuse, and all were aged under 5. Of the 826 children in the control group, seen from January to June 1981, 85% were aged over 5. Abused children were much more likely to have multiple fractures (p less than 0.001) and bruising of the head and neck (p less than 0.001). Fractures of the ribs were common in children who had been abused, and their presence, in the absence of major chest trauma, strongly suggested that abuse was occurring. Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation--both "gripping or twisting" injuries. Spiral fracture of the humeral shaft was significantly more common (p less than 0.001) in the group of abused children. Classic metaphyseal chip fractures were uncommon. One child in eight aged under 18 months who sustains a fracture may be a victim of child abuse.     

Maxillary reconstruction with a fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants

The fibula osteoseptocutaneous flap is a good option for reconstruction of three-dimensional composite maxillary defects. This flap provides both bone and soft-tissue reconstruction and allows osseointegrated dental implantation, either simultaneously or in a second-stage procedure. Simultaneous placement of osseointegrated dental implants reduces operative sessions and allows faster oral rehabilitation for properly selected patients. The defects may result from trauma or resection of benign tumors or low-grade malignancies. Between August of 1999 and July of 2001, three patients underwent maxillary reconstruction with the fibula osteoseptocutaneous flap and simultaneous osseointegrated dental implants. The cause of the defect was trauma in two cases and resection of an adenoid cystic carcinoma in the other. The mean length of the fibula used for bony reconstruction was 4.7 cm. One osteotomy was performed in one case and no osteotomy was necessary in the other two. Skin islands of 8 x 2.5 cm and 16 x 3.5 cm were used for two patients. For the other patient, a double skin island was used for both nasal (6 x 4 cm) and oral (6 x 5 cm) reconstructions. Two osseointegrated implants were inserted into the fibular bone for each patient. Six months after the first-stage procedure, palatal rotation flaps or mucosa grafts were used to cover the exposed implant necks and prepare the implants for prostheses. One month after the second-stage procedure, prostheses were placed. An implant-supported prosthesis was used for one patient and implant/tissue-supported prostheses were used for the others. At a mean follow-up time of 30 months (range, 16 to 38 months), all patients were able to use the dental prosthesis for chewing (beginning 6 weeks after the final procedure) and all patients were satisfied with the cosmetic results.     

Free fibula long bone reconstruction in orthopedic oncology: a surgical algorithm for reconstructive options

The fibula free flap became popular in orthopedic oncology for limb-sparing long bone tumor resection. It is particularly suitable for intercalary or resection arthrodesis options. In the present series, a surgical reconstruction algorithm was used, enabling each patient to receive a personalized technique. During the years 1998 to 2002, 30 patients underwent limb-sparing surgery for long bone sarcoma. There were 18 males and 12 females. Their mean age was 23 years (range, 9 to 70 years). The diagnoses were Ewing's sarcoma (11 patients), osteogenic sarcoma (eight patients), chondrosarcoma (five patients), giant cell tumor of bone (three patients), high-grade soft-tissue sarcoma (two patients), and leiomyosarcoma of bone (one patient). The majority of tumors where located in the lower extremity (23 patients), mostly in the femur (15 patients with four tumors in the proximal femoral shaft, five tumors in the distal femoral shaft, five tumors in the whole femoral shaft, and one tumor in the proximal femoral head). In seven patients, the upper extremity was involved; in six patients, the radius was involved; and in one patient, the humerus was involved. The free fibula flap was used in three types of approaches: vascularized fibula as an osseous flap only (18 patients), a combination of a vascularized fibula flap in conjunction with an allograft (Capanna's technique; 10 patients), and a free double-barreled fibula (two patients). All flaps survived. Postoperatively, all patients were monitored clinically, radiologically, and by radioisotope bone scan studies. Callus formation and union were shown 2.6 to 8 months postoperatively. Patients who underwent lower extremity reconstruction were nonweightbearing for 3 to 9 months, with a transition period in which they used a brace and gradually increased weightbearing until full weightbearing was achieved. Eight patients had 11 recipient-site complications. Two patients (6.7 percent) had hematomas, and three patients (10 percent) had infection and dehiscence of the surgical wound with bone exposure in one patient; all complications resolved with conservative treatment only. Failure of the hardware fixation system occurred in two patients, mandating surgical correction. No fibula donor-site complications were recorded. In intercalary resections, the use of the vascularized fibula flap as an isolated osseous flap might be insufficient. Different body sites have different stress loads to carry, depending on the age of the patient and on his individual physical status. To achieve initial strength in the early period, the authors combined the free fibula flap with an allograft (Capanna's method) or augmented it as a double-barreled fibula. They propose a surgical algorithm to assist the surgeon with the preferred method for reconstruction of various long bone defects in different body locations at childhood or adulthood. Long bone reconstruction using a vascularized fibula flap, alone or in combination with an allograft, autogenous bone graft, or double-barreled fibula for limb-sparing surgery, is a safe and reliable method with a predictable bony union, good functional outcome, and a low complication rate.     

The Mechanical Benefit of Medial Support Screws in Locking Plating of Proximal Humerus Fractures

Background

The purpose of this study was to evaluate the biomechanical advantages of medial support screws (MSSs) in the locking proximal humeral plate for treating proximal humerus fractures.

Methods

Thirty synthetic left humeri were randomly divided into 3 subgroups to establish two-part surgical neck fracture models of proximal humerus. All fractures were fixed with a locking proximal humerus plate. Group A was fixed with medial cortical support and no MSSs; Group B was fixed with 3 MSSs but without medial cortical support; Group C was fixed with neither medial cortical support nor MSSs. Axial compression, torsional stiffness, shear stiffness, and failure tests were performed.

Results

Constructs with medial support from cortical bone showed statistically higher axial and shear stiffness than other subgroups examined (P<0.0001). When the proximal humerus was not supported by medial cortical bone, locking plating with medial support screws exhibited higher axial and torsional stiffness than locking plating without medial support screws (P≤0.0207). Specimens with medial cortical bone failed primarily by fracture of the humeral shaft or humeral head. Specimens without medial cortical bone support failed primarily by significant plate bending at the fracture site followed by humeral head collapse or humeral head fracture.

Conclusions

Anatomic reduction with medial cortical support was the stiffest construct after a simulated two-part fracture. Significant biomechanical benefits of MSSs in locking plating of proximal humerus fractures were identified. The reconstruction of the medial column support for proximal humerus fractures helps to enhance mechanical stability of the humeral head and prevent implant failure.     

Bone regeneration within a coralline hydroxyapatite implant.

The hypothesis that incomplete resorption of osteons in an autogenous cortical bone graft may limit its replacement by new bone regeneration was explored by implanting a hydroxyapatite replica of a coral skeletal structure into bone gaps. This implant contained channels and interconnections similar to those in osteon-evacuated bone grafts. In 6 implanted mandibular defects in dogs, two of which were examined at two, 4, and 6 months, 11 percent, 46 percent, and 88 percent of the implant areas were filled with regenerated bone. The regenerated bone was a woven type at two months, but changed to a lamellar type by 6 months. In two implanted defects examined at 12 months, biodegradation of 29 percent of the implant had occurred. The bone regeneration was physiological, the implant was biocompatible, and the biodegradation began after the bone had regenerated.     

A combined RSA and FE study of the implanted proximal tibia: correlation of the post-operative mechanical environment with implant migration

There is strong evidence to suggest that inducible displacements, migration and implant loosening are closely related to the initial mechanical environment of the implanted tibia. If this is true, then it should be possible to predict the likelihood of implant migration using patient-specific finite element models. Finite element models of the proximal implanted tibiae were analysed based on pre-operative quantitative computed tomography data of four patients entered into a radiographic migration study. These four patients were also part of an radiostereometric analysis (RSA) study. A variety of load cases were analysed and the risk of bone failure determined for a 2 mm layer of bone immediately beneath the tibial tray. The results were compared with the RSA data measured 1 year post-operatively for each patient. For each patient, an appropriate load case was selected based on patient weight and on the varus-valgus migrations observed in the migration study. The two patients with press-fit implants were predicted to have the highest risk of failure and were found to migrate the most. The two patients with bonded implants (one HA coated and one cemented) were found to have a low risk of failure and these implants migrated the least. This study suggests that the degree of implant migration is dependent on the initial mechanical environment and can be determined using patient-specific finite element analysis.     

胫骨髓内钉入路治疗胫骨干骨折的临床进展

胫骨干骨折是最常见的长骨骨折,对于不稳定的胫骨骨折,胫骨髓内钉因其独特的优势逐渐成为首选治疗方式。当前对于胫骨干髓内钉入路主要分为髌骨上入路和髌骨下入路。髌骨上入路放置髓内钉时,患肢半伸直位有利于胫骨干骨折的复位与固定,但可能会造成髌骨关节面损伤。髌骨下入路患肢屈曲位可能会造成胫骨干复位的丢失,进而影响患者的预后。因此,胫骨髓内钉置入不同入路可能造成不同临床结局,会对临床结局造成不同的影响。目前对于胫骨髓内钉最佳入路仍然存在争议,针对最近发表的相关文献我们对胫骨髓内钉入路及其优缺点进行讨论综述。     

Porous polyethylene implants in orbital floor reconstruction

The purpose of this article is to present the authors' experience with the use of porous polyethylene ultrathin sheets for orbital floor reconstruction. Thirty-two patients with orbital floor fractures were treated with porous polyethylene ultrathin sheets. Sixteen cases corresponded to orbitozygomatic fractures, 11 cases corresponded to pure orbital floor fractures, and five corresponded to panfacial fractures. The subciliary approach was used in 15 patients and the transconjunctival approach in nine; another three patients were operated on through a preexisting eyebrow wound, two were operated on with a subtarsal approach, two were operated on through an eyebrow extension of a facial wound, and one patient was operated on through the facial wound. Intraoperatively, all patients received a prophylactic dose of intravenous antibiotics. Postoperatively, 24 patients received amoxicillin clavulanate for 5 to 7 days, two patients received clindamycin, and six patients received no antibiotics. Enophthalmos was corrected in 15 of 24 patients (62.5 percent), and hypoglobus in nine of 11 (82 percent). Diplopia was resolved in 25 of 28 patients (89.3 percent) with preoperative impairment. Extrinsic eye movement impairment was resolved in 25 of 27 patients (92.6 percent). A preoperative visual acuity deficit was present in four patients (12.5 percent) and was resolved in one (from 20/100 to 20/20). Visual acuity improved in one patient (from 20/60 to 20/30). In the other two patients, visual acuity remained altered (from 20/30 to 20/30). One patient (3.1 percent) suffered blindness induced by surgery. Nine of 26 patients (34.6 percent) had residual infraorbital nerve hypesthesia and five (19.2 percent) had residual paresthesias. Postoperatively, epiphora was present in six patients (18.8 percent) and ectropion in five (15.6 percent). Although there was no statistical significance between the surgical approach and the presence of epiphora (p = 0.211) and ectropion (p = 0.422), patients who were treated using the transconjunctival approach suffered reduced ectropion (0 percent) compared with patients treated using the subciliary approach (20 percent). However, patients treated using the transconjunctival approach suffered increased epiphora (22.2 percent) compared with those treated with the subciliary approach (13.3 percent). There were four cases (12.5 percent) of postoperative facial infections. Two of these cases were resolved with systemic antibiotics, one was resolved with bone sequestrum resection, and one patient needed removal of the implant. Orbital infections were related in all cases to titanium osteosynthesis miniplates or skull bone graft. When comparing patients who were treated with and without antibiotics, no statistical differences (p = 0.958) were found relative to the presence of infections. Correction of hypoglobus is technically easier than enophthalmos, because enophthalmic correction requires a wide, deep subperiosteal dissection and implant positioning, posterior to the equator of the globe, with the inherent risk of orbital apex injury.     

The use of deep frozen and irradiated bone allografts in the reconstruction of tibial plateau fractures

To investigate the clinical behavior of deep frozen and irradiated bone allografts in the treatment of depressed tibial plateau fractures. Twenty-two patients with a tibial plateau fracture were treated with cancellous bone allografts. The bone allograft preparation process included fresh-freezing at ?70 °C for 4 weeks and gamma-irradiation at 25 kGy. All of the patients were followed for 1–2 years. The clinical effects were assessed using the Rasmussen score for tibial head fractures and X-rays. Postoperatively, the average excellent and fair Rasmussen scores were 88.9 %. Only one patient developed an infection, with no integration between allograft and recipient bone observed. All of the other bone allografts were incorporated successfully, and no osteoporosis or sclerosis was observed. The frozen and gamma-irradiated bone allograft is a good alternative in the treatment of tibial plateau fractures, which we have shown can integrate with the surrounding host bone.     

Intramedullary Nail versus Dynamic Compression Plate Fixation in Treating Humeral Shaft Fractures: Grading the Evidence through a Meta-Analysis

There is a debate regarding the choice of operative intervention in humeral shaft fractures that require surgical intervention. The choices for operative interventions include intramedullary nailing (IMN) and dynamic compression plate (DCP). This meta-analysis was performed to compare fracture union, functional outcomes, and complication rates in patients treated with IMN or DCP for humeral shaft fractures and to develop GRADE (Grading of Recommendations, Assessment, Development, and Evaluation)-based recommendations for using the procedures to treat humeral shaft fractures. A systematic search of all the studies published through December 2012 was conducted using the Medline, Embase, Sciencedirect, OVID and Cochrane Central databases. The randomized controlled trials (RCTs) and quasi-RCTs that compared IMN with DCP in treating adult patients with humeral shaft fractures and provided data regarding the safety and clinical effects were identified. The demographic characteristics, adverse events and clinical outcomes were manually extracted from all of the selected studies. Ten studies that included a total of 448 patients met the inclusion criteria. The results of a meta-analysis indicated that both IMN and DCP can achieve similar fracture union with a similar incidence of radial nerve injury and infection. IMN was associated with an increased risk of shoulder impingement, more restriction of shoulder movement, an increased risk of intraoperative fracture comminution, a higher incidence of implant failure, and an increased risk of re-operation. The overall GRADE system evidence quality was very low, which reduces our confidence in the recommendations of this system. DCP may be superior to IMN in the treatment of humeral shaft fractures. Because of the low quality evidence currently available, high-quality RCTs are required.     

股骨近端抗旋髓内钉与第三代Gamma钉治疗股骨转子间骨折的效果对比

目的:探讨股骨近端抗旋转髓内钉与第三代Gamma钉治疗股骨转子间骨折的临床疗效,为骨科手术提供可借鉴的资料。方法:2009年4月-2013年3月期间在我院接受治疗的40例股骨转子间骨折患者,随机分为两组。其中,PFNA组20例患者采用股骨近端抗旋转髓内钉质量,而Gamma 3组20例患者采用第三代Gamma钉治疗。观察并比较两组患者的手术时间、影像增强剂时间和失血量,术后评价复位质量和内置物位置,在随访中,记录术后并发症,包括股骨干骨折、切出、再次手术、肺炎、尿路感染、脑梗塞、心肌梗塞和褥疮性溃疡等。另外,用Parker-Palmer活动评分系统评价行走能力。结果:PFNA和Gamma 3组在手术时间、影响增强剂时间和失血量上没有差异(P0.05);Gamma 3组病例复位质量要好于PFNA组,差异显著且具有统计学意义(P0.05);两组在内置物位置、行走能力和术后并发症上没有显著差异(P0.05)。结论:PFNA与Gamma 3治疗股骨转子间骨折具有很好的安全性和有效性,但Gamma3可获得更好的复位质量,应进一步在临床推广。     

Surface porous fibre-reinforced composite bulk bone substitute

The aim of this study was to describe and evaluate the significance of a porous surface with bioactive glass granules (S53P4) covering an artificial bulk material based on polymethylmetacrylate (PMMA) and fibre-reinforced composite (FRC) technology. Effort was focused particularly on characters of the porous surface and biomechanical properties of the material in vitro, and test in vivo the implant in reconstruction in an experimental long bone segment defect model. The defect, 10 mm in length, created in the shaft of rabbit tibia, was reconstructed by the implant and fixed by intramedullary K-wires. The implant was incorporated within 4 weeks by new bone growth from the host bone covering particularly its posterior surface and cortex/implant junctions with bridging trabecular bone. Later, at 8 weeks, new bone was found also at the cortex/implant interface and in the medullary canal of the implant. Histometric measurements revealed direct bone/implant surface contact in 34% at the interface. Bioactive glass granules in the porous surface evoked the most direct contact with bone. The implants manufactured from PMMA only served as a control group, and showed significantly lower osteoconductive properties. Biomechanical measurements in vitro of fibre-reinforced PMMA specimens revealed values for bending strength and the flexural modulus to match them to human bone. This artificial bulk bone material based on PMMA/FRC technology seems to have proposing properties to be used as a bone substitute on load-bearing conditions. This revised version was published online in July 2006 with corrections to the Cover Date.