Locking versus nonlocking construct in an osteoporotic, segmental fibula defect model.

Early studies on the treatment of osteoporotic distal fibular fractures suggest that poor bone quality can compromise fixation and, therefore, clinical outcome. Multiple prior biomechanical studies evaluated length-stable fracture models with destructive load-to-failure protocols, which may not represent a clinically relevant failure mode. The current authors compared a lateral locked construct with 2 distinct nonlocked constructs in an osteoporotic, segmental fibula defect model. Eighteen adult cadaveric ankles were randomized to a one-third tubular plate with nonlocking screws, a precontoured fibular plate with nonlocking screws, or the same pre-contoured plate with locking screws. Each was nondestructively loaded with an external rotation of 2.5 Nm for 10,000 cycles. The primary outcome was the change in construct stiffness. Secondary outcomes included maximal rotational displacement and change in insertion torques. Average increase in stiffness of the one-third tubular plate was 0.35 Nm/degree (P<.001), which was significantly greater than that in the nonlocking and locking precontoured plates (0.15 and 0.17 Nm/degree, respectively; P=.69). All 3 constructs externally rotated to 11.7°±4.6°, 8.6°±3.6°, and 10.9°±4.7°, respectively (P=.50). Average loss of insertion torque in the 4 proximal positions was 32.7%±19%, 41.3%±20.2%, 57.8%±19%, and 64.9%±29.2% (P>.05). Average loss in the 4 distal positions for nonlocking constructs (71.6%±21%, 70.4%±26.4%, 93.1%±11%, and 83.3%±35.4%) was significantly different from that for the locking construct (15%±21.4%, 11.7%±24%, 9.2%±9.2%, and 20.8%±23.3%) (P<.05). No evidence in the current study supports the use of a locking plate for osteoporotic specimens.

The retropatellar portal as an alternative site for tibial nail insertion: a cadaveric study.

OBJECTIVE: To define spatial relationships between major intra-articular structures of the knee and the entry site of a tibial nail inserted using a retropatellar portal. DESIGN: Cadaveric study using 16 fresh-frozen limbs. SETTING: University-affiliated cadaver and anatomy laboratory. RESULTS: The mean distance of the nail entry site and the medial and lateral menisci were 6.6 ± 3.2 mm and 6.4 ± 4.4 mm, respectively. The distance to the medial and lateral articular surfaces were 5.6 ± 3.6 mm and 7.4 ± 4.2 mm, respectively. The mean distance to the anterior cruciate ligament footprint was 7.5 ± 3.5 mm. The lateral meniscus was never injured during the procedure. The anterior cruciate ligament was undisturbed in all specimens. The medial meniscus was injured 1 to 2 mm in 12.5% of specimens. The intermeniscal ligament was injured 1 to 2 mm in 81.2% of the specimens. CONCLUSION: The intermeniscal ligament and medial meniscus are at the most risk during intramedullary nailing of the tibia using the retropatellar technique. This may be corrected by avoiding an excessively medial start point. Damage to the intermeniscal ligament and medial meniscus occurs more commonly with the retropatellar portal, but this damage was never more than 1 to 2 mm. This risk, however, appears similar to the pattern and incidence of injury that occurred in prior studies investigating tibial nail insertion through a standard patellar tendon approach. The retropatellar technique demands clinical investigation to further define both its safety and its use.

Nonunions and the potential of stem cells in fracture-healing.

Recent progress in human embryonic and adult stem cell research is a cause for much enthusiasm in bone and joint surgery. Stem cells have therapeutic potential in the realm of orthopaedic surgery because of their capacity to self-renew and differentiate into various types of mature cells and tissues, including bone. Because nonunions remain a clinically important problem, there is interest in the use of cell-based strategies to augment fracture repair. Such strategies are being investigated with variations in the model systems, sources of stem cells, and methods for the application and enhancement of osseous healing, including genetic modifications and tissue-engineering. This review highlights the recent progress in the utilization of stem cells and cell-based gene therapy in promoting fracture-healing and its potential utility in the clinical setting.