Instability and results after non-operative treatment of large anterior glenoid rim fractures: is there a correlation between fragment size or displacement and recurrence?

INTRODUCTION: There is little data available on non-operative treatment of anterior glenoid rim fractures (GRF). Nothing is known about fracture size and displacement in comparison to clinical outcomes and instability in a mainly middle-aged patient population. The aim of this study was to demonstrate the results of non-operative treatment in anterior glenoid rim fractures with the special focus on potential instability/recurrence. METHODS: The inclusion criteria were non-operatively treated anterior GRF of at least ≥ 5 mm width using the age- and gender-matched Constant/Murley score (a.-/g.-CMS) and the Western Ontario Instability Index (WOSI). Radiographic parameters (fracture morphology, displacement, major tuberosity fractures and Hill-Sachs lesion using initial CT and radiographs) and the proportion of the fractured glenoid were detected (2D-CT-circle-method) and osteoarthritis (A.P. and axial radiographs) was classified according to Samilson/Prieto. Proportion of fractured glenoid and medial displacement were correlated with the recurrence rate and the clinical scores. RESULTS: N = 36 patients could be followed-up after a mean of 4.4 years [12-140 month, average age: 58 (± 13, 33-86) years]. The a.-/g.-CMS was 93 (± 11, 61-100) points, and the WOSI was 81% (± 22%, 35-100%) on average. The mean intraarticular displacement was 4 mm (± 3 mm; 0-14 mm). The 2D-circle-method showed a mean glenoid fracture involvement of 21% (± 11, 10-52%). Two cases of frozen shoulders and one case with biceps pathology were associated with the trauma. Within the followed-up patient group re-instability has occurred in n = 2 patients (6%) within the first two weeks after trauma. Osteoarthritis was found in n = 11 cases. There was no correlation between the scores and the fracture size/displacement [(a.-/g.-CMS vs. displacement: r = - 0.08; p = 0.6; vs. size: r = - 0.29; p = 0.2); (WOSI vs. displacement: r = - 0.14; p = 0.4; vs. size: r = - 0.37; p = 0.06)], but very large (≥ 21%) fractures with displacement ≥ 4 mm showed slightly worse results without significant difference (a.-/g.-CMS p = 0.2; WOSI p = 0.2). The apprehension test was negative in all patients at final follow-up. CONCLUSION: Non-operative treatment of anterior GRF was associated with overall good results within a mainly middle-aged larger patient group. Re-instability is rare and is not associated with fragment size but can occur in the first weeks after trauma. Size and dislocation of the fracture is not a criterion for the prognosis of potential instability. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing.

INTRODUCTION: Humeral shaft nonunion after intramedullary nailing is a rare but serious complication. Treatment options include implant removal, open plating, exchange nailing and external fixation. The objective of this retrospective study was to determine whether augmentation plating without nail removal is feasible for treating a humeral shaft nonunion. MATERIALS AND METHODS: Between 2002 and 2014, 37 patients (mean age 51, range 20-84 years) with aseptic humeral shaft nonunions prior to intramedullary nailing were treated with augmentation plating. The initial fractures had been fixed with retrograde nails (10 cases) or anterograde nails (27 cases). There were 34 atrophic nonunions and 3 hypertrophic nonunions. Nonunion treatment of all patients consisted of local debridement through an anterior approach to the humerus and anterior placement of the augmentation plates. Supplemental bone grafting was performed in all atrophic nonunion cases. All patients were followed until union was radiologically confirmed. RESULTS: Union was achieved in 36 patients (97 %) after a mean of 6 months (range 3-24 months). There was one case of iatrogenic median nerve palsy that showed complete spontaneous recovery 6 weeks postoperatively. One patient sustained a peri-implant stress fracture that was treated successfully by exchanging the augmentation plate to bridge the nonunion and the fracture. No infections or wound healing complications developed. At a mean follow-up of 14 months, all patients showed free shoulder and elbow motion and no restrictions in daily or working life. CONCLUSIONS: The results indicate that augmentation plating using an anterior approach is a safe and reliable option for humeral shaft nonunions after failed nailing, and the treatment has no substantial complications. Because the healing rates are similar to the standard technique of nail removal and fixation by compression or locking plates, we consider this technique to be an alternative choice for treatment.

Recent advances in the use of serological bone formation markers to monitor callus development and fracture healing.

The failure of an osseous fracture to heal, or the development of a nonunion, is common; however, current diagnostic measures lack the capability of early and reliable detection of such events. Analyses of radiographic imaging and clinical examination, in combination, remain the gold standard for diagnosis; however, these methods are not reliable for early detection. Delayed diagnosis of a nonunion is costly from both the patient and treatment standpoints. In response, repeated efforts have been made to identify bone metabolic markers as diagnostic or prognostic tools for monitoring bone healing. Thus far, the evidence regarding a correlation between the kinetics of most bone metabolic markers and nonunion is very limited. With the aim of classifying the role of biological pathways of bone metabolism and of understanding bone conditions in the development of osteoporosis, advances have been made in our knowledge of the molecular basis of bone remodeling, fracture healing, and its failure. Procollagen type I amino-terminal propeptide has been shown to be a reliable bone formation marker in osteoporosis therapy and its kinetics during fracture healing has been recently described. In this article, we suggest that procollagen type I amino-terminal propeptide presents a good opportunity for early detection of nonunion. We also review the role and potential of serum PINP, as well as other markers, as indications of fracture healing.

Necrotizing fasciitis and the midterm outcomes after survival.

BACKGROUND AND AIMS: Radical surgical intervention is necessary to save patients' lives in cases of necrotizing fasciitis. This leads to persistent disabilities and most likely to a deteriorated quality of life. The purpose of this study was to evaluate the midterm outcomes after survival of necrotizing fasciitis. MATERIALS AND METHODS: A retrospective analysis of 69 patients, treated for necrotizing fasciitis between 2003 and 2012. The patients were identified using the International Classification of Diseases (10th Revision) code M 72.6. Of the 50 survivors, 22 patients completed the Short Form 36 and Short Musculoskeletal Function Assessment questionnaires as a postal survey. The follow-up averaged 59 months (range: 6-128 months). RESULTS: The average age at the time of necrotizing fasciitis was 60.0 years. The body mass index average was 29.7. The patients had a significantly decreased physical component summary score of 33.3 compared to a normative group (p < 0.001) (Short Form 36). They further showed a significantly decreased dysfunction and bother indices (Short Musculoskeletal Function Assessment) (p < 0.001). An increased age (⩾70 years) was associated with an inferior role emotional (p = 0.048) and physical functioning (p = 0.011) as well as social functioning (p = 0.038) (Short Form 36). The majority of patients (16, 72.7%) complained of pain at the final follow-up and 50% of patients required an assistive device on a regular basis. CONCLUSION: Patients who survived necrotizing fasciitis suffer from functional impairment and changed body appearance. Assistive devices or pain medication are often required, and the patients present with significantly decreased physical, social, and emotional functioning at the midterm follow-up. The patient's age is a critical factor regarding functional or mental outcome parameters. Further research on the post-hospital course and long-term multidisciplinary care is required to improve the outcomes of these patients.

A 23-year-old patient with secondary tumoral calcinosis: Regression after subtotal parathyroidectomy: A case report.

INTRODUCTION: Tumoral calcinosis (TC) is a rare disorder defined by hyperphosphatemia and ectopic calcifications in various locations. The most common form of TC is associated with disorders such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The primary (hereditary) TC is caused by inactivating mutations in either the fibroblast growth factor 23 (FGF23), the GalNAc transferase 3 (GALNT3) or the KLOTHO (KL) gene. PRESENTATION OF CASE: We report here a case of secondary TC in end-stage renal disease. The patient was on regular hemodialysis and presented with severe painful soft-tissue calcifications around her left hip and shoulder that had been increasing over the last two years. Initially, she was treated with dietary phosphate restriction and phosphate binders. Because of high phosphate blood levels, which were not yet managed with dialysis and medical therapy, a subtotal parathyroidectomy (sP) was performed. This approach demonstrated significant response. Three months after surgery a rapid regression of the tumors was observed. DISSCUSION: Regardless of the etiology, the two types of TC do not differ in their radiologic or histopathologic presentations but need to be diagnosed correctly to initiate targeted and effective treatment. Considering the primary TC, primary treatment is early and complete surgical excision. In case of secondary TC surgical excision of the tumoral masses should be avoid because of extensive complications. These patients benefit from sP. CONCLUSION: After initial conservative therapy chronic kidney disease patients with TC might benefit from sP to avoid prolonged suffering and potential mutilations.

Results of 70 consecutive ulnar nightstick fractures.

BACKGROUND: Adult isolated ulnar shaft fractures (IUSFs) are uncommon, and treatment remains controversial. The purpose of this study was to compare results of operative (reduction internal fixation (RIF)) and nonoperative treatment (NOT) in patients with IUSF. MATERIAL AND METHODS: A retrospective case-control analysis was undertaken on patients diagnosed with IUSF between 2002 and 2008 at a Level I teaching trauma center. Clinical outcomes consisted of complications and functional ability. RESULTS: Seventy patients had a mean age of 44.6 years (18-86) and a body mass index (BMI) of 27.9 (17-47). The mechanism of injury included high-energy injuries (60/70, 85.7%), low-energy falls (8/70, 11.4%), and sports (2/70, 2.9%). Treatment consisted of 33/70 (47.1%) NOT and 37/70 (52.9%) RIF. The AO/OTA fracture classification was 48 A1, 20 B2, and two C1. The level of activity (LOA) was 60 without restrictions, six with restrictions, and three who did not return to work. The function determined by range of motion was 55/70 (78.6%) full, 11 slightly limited, and one severely limited. A total of 14 nonunions (NUs) and 17 malunions (MUs) occurred. NOT was associated with NU (χ(2)=0.001) and MU (χ(2)=0.000), respectively. Fracture angulation ≥8° was related to the inability to return to previous LOA (ρ=0.406, p=0.001). Secondary displacement >2mm contributed to MU (R(2)=0.238, p=0.000) and NU (R(2)=0.076, p=0.021). NU was related to a minor functional result (ρ=0.315, p=0.009). CONCLUSIONS: IUSF treatment remains challenging in the adult population. Nonoperative treatment of displaced fractures produces a high risk of complications, and the fracture characteristics determine patient outcome. LEVEL OF EVIDENCE: Level III.

Results and complications of operative and non-operative navicular fracture treatment.

BACKGROUND: Navicular fractures (NF) are uncommon. The purpose of this study was to compare results of operative (ORIF) and non-operative (NOT) treatment in NF. METHODS: A retrospective analysis was undertaken on patients diagnosed with NF between March 2002 and June 2007 at a Level I teaching trauma centre. Clinical outcome consisted of functional ability and complications. RESULTS: Eighty-eight patients with 90 fractures were identified including 56 males and 32 females with a mean age of 38 (range 17-72) and body mass index of 28.2 (range 18.7-48.9). Twenty-one of 90 (23.3%) injuries were isolated. Ten of 90 (11.1%) injuries were open. Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting. Complications included one ipsilateral deep vein thrombosis, one avascular necrosis, one nonunion, seven infections (two deep and five superficial), and 56 cases of secondary osteoarthrosis (SOA). ORIF had significantly more SOA (χ(2)=0.000). Secondary surgery was 25 hardware removals (16 for irritation, five for prominent or broken plates), nine arthrodeses/-plasties, two debridements for infection, and one tarsal tunnel release. Pain was present at final follow up in 39/90 (43.3%) feet. Work status was 64 without restrictions, 17 with restrictions, and 5 did not return to work. Sixty-two of 88 (69%) patients were able to wear normal shoes, which were related to return to work without restrictions (ρ=-0.508, p=0.000). Inability to return to previous work was related to pain (ρ=-0.394), SOA (ρ=-0.280), and poor reduction quality (ρ=-0.384) with significance at p<0.01. Increased BMI (>35) related to pain (ρ=0.250) and poor reduction quality (ρ=0.326) at a σ<0.05. CONCLUSIONS: Despite modern surgical techniques, operative treatment of displaced fractures is at high risk for complications. Obesity, pain, and secondary osteoarthrosis determine shoe wear, return to function, and employment status. LEVEL OF EVIDENCE: Level III.

Evidence of woven bone formation in heart valve disease.

The pathogenesis of acquired cardiac valve disease still remains a matter of controversy. In this work, scanning electron and polarised light microscopic investigations in addition to energy dispersive X-ray microanalyses (EDAX) were carried out on explanted human aortic and mitral valves to determine the morphology and element composition of calcified areas in valvular lesions. Biopsies were taken from aortic valves removed from 28 male patients (average age, 75+/-1 years) and 46 females (68+/-3 years) and from mitral valves obtained from 18 male patients (72+/-3 years) and 8 females (71+/-6 years). By means of scanning electron microscopy, multiple foci of calcified areas were identified. Endothelial cells in these areas appeared swollen and displayed reduced cell-cell contacts. The calcium deposits were separated from the adjacent tissue by layers of collagen fibers. Often a layer of woven bone tissue separated intravalvular inclusions from hyperplastic collagen fibers. Using EDAX analysis, calcium and phosphorus were detected in these valvular lesions. The major finding of our study is the presence of woven bone tissue in explanted cardiac valves, which may result from pathological strains or mechanical overloading of the collagen fibers.

Progressive right ventricular failure is not explained by myocardial ischemia in a pig model of right ventricular pressure overload.

BACKGROUND: Current concepts of acute pulmonary embolism suggest that right ventricular (RV) dilatation and failure are the consequence of pressure overload-induced RV hypoperfusion and ischemia. METHODS: Sixteen human-sized hybrid pigs were instrumented for the measurement of RV and aortic pressure, aortic and right coronary artery blood flow (RCA BF), RV oxygen consumption (RV MVO(2)) and RV free wall segment length. The pulmonary artery was constricted (PAC) to increase RV peak pressure acutely 2.5-fold (from 27+/-2 to 64+/-3 mmHg, n=9), and the constriction was maintained for 6h. RESULTS: At 10 min after PAC, a RV work index (RVWI, RV pressure-segment length loops) was increased 2.3-fold, indicating an initial RV adaptation to increased afterload. At 1h, 3h and 6h after PAC, however, RVWI decreased progressively towards control levels, while RCA BF and RV MVO(2) continued to increase. The arterial-coronary venous pH difference did not increase throughout the protocol. Arterial troponin T concentration increased from 0.08+/-0.03 to 0.80+/-0.20ng/ml at 6h after PAC. None of the parameters changed in control animals (n=7). CONCLUSION: We conclude that in our model RV failure during PAC develops in spite of increased coronary blood flow and MVO(2). Thus, mechanisms different from ischemia may contribute to progressive RV failure after pulmonary embolism.

Progressive loss of myocardial contractile function despite unimpaired coronary blood flow after cardiac surgery.

OBJECTIVE: Mild to moderate transient contractile dysfunction is frequently observed after cardiac surgery on cardiopulmonary bypass (CPB) but may also lead to low-cardiac-output (LCO) failure especially in patients with unstable angina, and is often referred to represent myocardial stunning. Whether time course of contractile dysfunction after cardiac surgery is similar to that of myocardial stunning was investigated in pigs. METHODS: After baseline measurements of systemic hemodynamics (micromanometry), myocardial contractile function (sonomicrometry), cardiac output and coronary flow (ultrasonic probe), CPB was instituted. Control animals (n = 7) were weaned after 3 h from CPB. In LCO animals (n = 8), global ischemia was induced for 10 min by aortic crossclamping, followed by 1 h of cardioplegic cardiac arrest. After declamping and reperfusion, CPB was terminated after a total of 3 h. Measurements were repeated at 15 min, 4 h and 8 h after CPB. Systemic TNFalpha-plasma concentrations were measured (ELISA) and left ventricular biopsies were analyzed with respect to myocardial TNFalpha (immunohistochemistry) and irreversible cellular damage (light/electron microscopy). RESULTS: Contractile function decreased in LCO (75 +/- 12%) and control (83 +/-17%) at 15 min compared to baseline (p < 0.05). Thereafter, contractile function remained unchanged in control, but progressively decreased in LCO (52 +/- 12% at 4 h; 36 +/- 5% at 8 h; p < 0.05). Coronary flow remained unchanged in both groups. Cardiac output progressively decreased to 2.8 +/- 0.9 l/min at 8 h in the LCO group compared to baseline (5.9 +/- 1.1 l/min, p < 0.05) and control (5.7 +/- 1.4 l/min, p < 0.05). There was no evidence for myocardial infarction. TNFalpha-plasma concentrations and myocardial TNFalpha-staining were increased at 8 h after CPB in the LCO group compared to baseline and control (p < 0.05). CONCLUSIONS: The progressive pattern of myocardial dysfunction apart from ongoing ischemia after cardiac surgery suggested underlying mechanisms at least partially different from those of myocardial stunning.