Carbon-carbon composite nail for intramedullary osteosynthesis in rats with experimental osteoporosis

Background. In Ukraine, there has recently been an increase in the number of limb bone fractures among the population, in particular, due to increase in the number of elderly people, which is associated with the development of age-related osteoporosis and fragility of bones. Therefore, the use of artificial implants in traumatology is becoming increasingly important. The search for new bioinert and biodegradable materials, that are capable of providing rapid fracture consolidation and do not require repeated surgical intervention, continues. Objective. To elaborate a model for the research of using carbon-carbon composite nail for intramedullary osteosynthesis in laboratory rats with fractures of femur and tibia in norm and with experimental osteoporosis. Methods. The work investigated the lower limbs of 6 groups of Wistar rats. The first part of the study involved 4 groups of rats with modeled tibial fracture with subsequent osteosynthesis in norm and with experimental osteoporosis. The second part of the research included two groups of laboratory rats with modeled femur fracture. In both parts we used metal injection needle, as well as carbon-carbon composite nail for osteosynthesis. Results. All animals underwent surgery well, stepped on the injured limb. X-ray examination after the osteosynthesis demonstrated satisfactory reposition of the fragments. One month after modeled fracture in rats with experimental osteoporosis a violation of the normal consolidation of the fracture was observed, especially in the group where carbon-carbon composite nails were used for osteosynthesis. Further, until the 180th day after the surgery there were no peculiarities, function of the limbs was restored, mainly without expressed angular deformities. Conclusion. The above mentioned model was successfully elaborated for the research of using carbon-carbon composite nail for intramedullary osteosynthesis in laboratory rats with fractures of femur and tibia in norm and with experimental osteoporosis.

Revisiting Nonoperative Treatment of Lateral Compression Pelvic Fractures. Analysis of Rehabilitation and Radiologic Outcomes in a Historical Cohort Using Today's AO Stability Criteria.

Background: Type I lateral compression pelvic fractures (LC-I) have historically been treated conservatively. Inferior outcomes in a distinctive subset of these injuries has been reported, therefore their management has shifted towards surgery. Revisiting historical series of LC-I allows us to determine whether non-operative management of these unstable patterns result in poorer outcomes. The objective was to evaluate the differences in the rehabilitation progress, fracture consolidation and displacement in non-operatively treated LC-I fractures that would be considered unstable using today´s AO criteria.Methods: We conducted a retrospective review of conservatively treated LC-I injuries in a single level I trauma center, between June 2010 and June 2014. Patients were distributed in Stable (Group A) and unstable (Group B) groups according to 2018 AO classification. Time to walk independently (TWI), time to return to work (TRW), fracture consolidation and displacement were analyzed. Results: 34 patients, mean aged 45.5 ±14.5 years, were included. Mean TWI in groups A and B were 71.2 ±31.9 and 105.9 ±50.9 days (p=0.027). Mean TRW was 106 ±51.3 and 157 ±84 days in Groups A and B respectively (p=0.038). A difference in mean TWI and TRW of 34.7 and 51.3 days between groups was observed. No significant differences in fracture consolidation or displacement were observed.Conclusion: Unstable fractures presented significantly longer TWI and TRW. The revised AO classification contributes in the identification of fracture patterns that correlate with prolonged rehabilitation in which additional treatment strategies might be considered.

Остеосинтез у разі переломів шийки та вертлюгової зони стегнової кістки в дітей

Proximal femur fractures are uncommon injuries in children, accounting for less than 1 % of all fractures per year, but usually result in hospitalization and are at risk of complications. We have designed a device for bone fragments fixation in the case of proximal femur fractures and the method of its application in adults. The device consists of rods that are screwed into the cap of the head, the diaphyseal part and the module, which is located in the subtrochanter area. The rods can be connected to the module at any angle in the frontal plane. The device provides a certain stage of installation of the elements, which allows you to effectively place it with minimal bone destruction. Objective. Share your own experience in the treatment of femoral neck and proximal femur fractures in children. Material. The experience of treatment of 28 children with femoral neck fracture or proximal femur fractures for the period 2005–2020 is presented, 11 of them were treated conservatively with the skeletal traction. Osteosynthesis by the author’s device was performed in 17 patients: 15 closed reduction, 2 in case of intertrochanteric fracture, — open reduction. The method of osteosynthesis and postoperative management of patients is described in detail. Results. In children who were treated conservatively, the fracture consolidation was achieved within 5–7 months, in one of them — in the position of varus deformity. In contrast to conservative treatment, children began to walk with crutches after a few days after surgery, with partial weight-bearing on injured limb. The device was removed in 16 patients after 5–8 months, and complete fracture consolidation of the fragments in their anatomical position was noted. There were no pathological tissue reactions to the metal device. Conclusions. The proposed device and method of closed osteosynthesis with its usage in the case of proximal femur and femoral neck fractures in children can be recommended in the practice of pediatric traumatology.

Violation of consolidation of the femur after untimely dynamization of the intramedullary blocking rod

Violation of femoral fracture consolidation after blocking intra­medullary osteosynthesis is a fairly common pathology, and requires the attention of physicians due to its prevalence. There are several reasons for this complication: it is the instabi­lity in the system «bone-implant», and the untimely dynamization of the locking nail. Methods. This article presents a case of fracture violated consolidation after blocking intramedullary osteosynthesis caused a nonunion due to nail failure. Results. Patient was injured on 29.12.2018, as a result of a traffic accident. 01.15.2019, the surgery was performed: closed reduction, blocking intramedullary osteosynthesis of the fracture of the middle shaft of the right thigh, static fixation of the nail. Next visit to the clinic was on 02.01.2020, because of pain in the middle third of the thigh, problems with axial weight-bearing on the right leg, limitation of the flexion in the right knee joint. Control radiographs demonstrated no signs of consolidation of the femoral shaft fracture, and migration of the distal locking screw. 08.01.2020 revision surgical treatment was performed. Given the presence of 5 mutually perpendicular holes in the distal part of the nail, two of them were locked in the anterio-posterior view by the free hand method, the migrated screw in the distal part of the nail was replaced, and the nail was dynamized in the proximal part taking into account its design features. Conclusions. To normalize the consolidation processes in patients with nonunion femoral fractures, bone physiology and the positive effect of autocompression should be considered. The described case demonstrates the necessity for timely dynamization of the blocking nail, which confirms our own observations and literature data. Despite the fact that the dynamization of the nail was performed 1 year after blocking intramedullary osteosynthesis, fracture consolidation occurred 5 months after its implementation. Key words. Femoral fracture, blocked intramedullary osteosynthesis, disorders consolidation, dynamization of the construction.

STRESS FRACTURE AT DOCKING SITE AFTER BONE TRANSPORT MANAGED WITH INTRAMEDULLARY INTERLOCKING NAIL AND ILIAC AUTOGRAFT - A RARE CASE REPORT

INTRODUCTION : Distraction osteogenesis was introduced by Ilizarov and further developed by Cataneo et al. The concept of formation of new bone and soft tissues from distraction osteogenesis and freshening the sclerosed bone ends by corticotomy for stronger bony union and consolidation is applied here. Here we present a CASE REPORT : rare case of young adult operated by tibial bone transport using monolateral external xator, who presented to us after refracture near the docking site. We managed this patient with intramedullary reamed nailing and iliac crest autografting, showing good bony union and functional outcome at 3 months postoperatively. CONCLUSION : Thus from previous literature and our case ndings, we conclude that re-fractures and other complications of bone transport can be effectively managed by intramedullary reamed nailing leading to good bony union and fracture consolidation. The intramedullary nail provides rigid stability to both new bone regenerate due to callotasis and union at docking sit, signicantlydecreased rates of future refractures. This signicantly decreases patients morbidity and delivering satisfactory functional outcome.

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture

Introduction Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks. Materials and methods In a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization. Results Unclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons’ decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28–6.81, p = 0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as ‘other’) (OR 2.64; 95% CI 1.31–5.33, p = 0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18–19.52, p = 0.01 versus Europe) were more likely to recommend continued immobilization. Conclusion Adoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance.

Osteoporosis drug treatment after fracture

The prevalence of osteoporosis, especially among the elderly, is increasing exponentially, leading to an increase in the number of fractures and disability. As a result, new requirements for anti-osteoporotic therapy appear, associated with its influence not only on the remodeling of healthy bone, but also on the acceleration of fracture consolidation. The article provides a brief overview of the effect of various anti-osteoporotic drugs on the healing of bone fractures. An assessment of the consolidating effect of antiresorptive drugs — bisphosphonates and denosumab, and anabolic drug — teriparatide, monoclonal antibodies blocking the protein sclerostin, strontium ranelate is given. The use of antiresorptive drugs did not affect, according to the literature, the slowing down of consolidation after fractures of various parts of the skeleton (hip, vertebrae, distal radius). The introduction of anabolic drugs, in particular teriparatide, is accompanied by faster healing of fractures in comparison with the timing of natural bone regeneration or the intake of bisphosphonates, causing an improvement in the formation of callus. The use of drugs that block sclerostin also increases bone formation and bone strength. Based on the available data, it can be concluded that fractures should not be considered as a contraindication to the use of these drugs and be the reason for the late initiation of drug treatment of osteoporosis.

Dynamics of biochemical bone and endothelial parameters during the replacement of bone defects in dogs with hydroxyapatite ceramic doped with silicon

Metal structures for osteosynthesis available in veterinary orthopedics are not able to compensate for the lost elements of bone tissue in complex splinter fractures. It is prompt the use of hydroxyappatite materials that replaced bone defects for maintenance of osteoconductive function, and ideally would combine osteointegration and osteoinductive properties. However, their influence on the biological processes of fracture consolidation which go through a number of successive stages and end with the formation of bone tissue in the fracture zone identical to the maternal, is insufficiently substantiated according to the criteria of the molecular biological phase of reparative osteogenesis. The aim of the study was to investigate the dynamics of biochemical osteotropic parameters and the level of NO using silicon-doped ceramics for fractures heeling in dogs. Materials and methods. The animals suffering of fractures that were admitted to the faculty clinic were divided into control (n=7) and experimental (n=7) groups. In both groups, extracortical osteosynthesis was performed with a support plate from an unalloyed titanium alloy. In the control group, bone defects were left to heal under spontaneous blood clot, and in the experimental group, they were replaced with ceramic based on hydroxyapatite with β-tricalciumphosphate doped with silicon (HA/β-TCP/l-Si–3).Blood samples were taken after the injury no later than the 48th day, and on the 3th, 12th, 21th, 42th and 60th days after osteosynthesis. To increase the objectivity of the biochemical analysis, we additionally formed a group of clinically healthy dogs that were admitted to the clinic for routine vaccination (n=10). It included the spectrophotometric determination of the content of NO, BALP, TRACP, Ca, P, Mg, total protein in blood serum, and fibrinogen in blood plasma. Research results. A clinical study showed that in the case of using HA/β-TCP/l-Si–3for splinter fractures, the stages of reparative osteogenesis are more optimized in time, and their consolidation occurs on average 19 days earlier than in the control group. The results of the biochemical study showed that when using HA/β-TCP/l-Si–3, it is accompanied by a peak NO value already on the third day, which is significantly higher than in the control group and indicates early angiogenesis in the research group. In terms of TRACP, the period of osteoresorption in the control group was permanent with little expressed peaks of activity. However, in the research group, the peak of TRACP activity is limited to 12 and 21 days, which is evidence of an optimized inflammatoryresorptive phase. In parallel with this, the activity of BALP increases, which indicates the consistency of the stages of reparative osteogenesis and provides an optimized and accelerated consolidation of fractures in the research group. Conclusion. The dynamics of NO, BALP and TRACP pathochemically substantiates the optimized reparative osteogenesis when using HA/β-TCP/l-Si–3 for bone defects replacement in cases of splinter fractures of tubular bones. Key words: bone markers, bone isoenzyme of alkaline phosphatase, NO, tartrate-resistant acid phosphatase, fibrinogen, calcium, phosphorus.

Humeral fracture repair using a robust fixation in an adult Giant Anteater (Myrmecophaga tridactyla): case report

ABSTRACT The treatment of fractures from the thoracic limb in giant anteaters is extremely challenging. Unfamiliar and peculiar anatomical characteristics, robust musculature and the imminent need for an early return to limb function highlight such challenges. The objective of this report was to describe the successful use of anatomical osteosynthesis with a robust locking compression plate in a humeral fracture of an adult giant anteater. The patient was rescued on the highway after being run over and presented for treatment at the Veterinary Teaching Hospital. Surgical stabilization was performed using a craniomedial approach to the humerus, using a customized broad 3.5mm locking compression plate. The patient presented early limb support at 24 hours postoperatively. Radiographic monitoring was performed at 30, 60 and 90 days postoperatively, and bone healing was observed without any complications. It is concluded that the treatment of humerus fractures in giant anteaters requires robust fixation. The use of a reinforced locking compression plate system proved to be effective and adequate to the mechanical load that an adult individual of this species needs for early use of the thoracic limb and, at the same time, efficient in controlling interfragmentary movement, which allowed fracture consolidation.

Comparable results using 2.0-mm vs. 3.5-mm screw augmentation in midshaft clavicle fractures: a 10-year experience

Purpose Absence of cortical alignment in wedge-shaped and multifragmentary fractures (Fx) results in decreased fixation stability. The aim of this study was to compare the outcome using 2.0- vs. 3.5-mm screws for open reduction and internal fixation (ORIF) in dislocated, wedge-shaped or fragmentary midshaft clavicle fractures. Materials and methods Patients suffering from AO/OTA 15 2.A-C midshaft clavicle fractures were operatively treated between 2008 and 2018. 2.0- or 3.5-mm cortical screws were used to restore anatomic alignment in dislocated, wedge-shaped and fragmentary clavicle fractures. Data of radiologic outcome were collected until fracture consolidation was identified. Results 80 consecutive patients with a mean age of 44.5 ± 16.3 years, who were operatively treated for dislocated midshaft clavicle fractures were enrolled. 40 patients were treated using 2.0-mm and 40 patients using routine 3.5-mm cortical screws, respectively. Time to fracture consolidation was 12.8 ± 7.8 months. No mal- or non-unions occurred during routine follow-up until 18 months postoperatively. Conclusion Restoring anatomic alignment in wedge or fragmentary clavicle fractures can ultimately be addressed using cortical screw augmentation. Both groups showed comparable results with respect to fracture reduction, fixation and stability as well as time to consolidation of the fracture, while the 2.0-mm screw diameter was associated with easier handling of small Fx fragments.