Costal cartilage fractures in blunt polytrauma patients - a prospective clinical and radiological follow-up study.

PURPOSE: To assess the healing of costal cartilage fractures (CCFX) in patients with blunt polytrauma with follow-up imaging and clinical examination. Effect on physical performance and quality of life (QoL) was also evaluated. METHODS: The study group comprised twenty-one patients with diagnosed CCFX in trauma CT. All the patients underwent MRI, ultrasound, ultra-low-dose CT examinations, and clinical status control. The patients completed QoL questionnaires. Two radiologists evaluated the images regarding fracture union, dislocation, calcifications, and persistent edema at fracture site. An attending trauma surgeon clinically examined the patients, with emphasis on focal tenderness and ribcage mobility. Trauma registry data were accessed to evaluate injury severity and outcome. RESULTS: The patients were imaged at an average of 34.1 months (median 36, range 15.8-57.7) after the initial trauma. In 15 patients (71.4%), CCFX were considered stable on imaging. Cartilage calcifications were seen on healed fracture sites in all the patients. The fracture dislocation had increased in 5 patients (23.8%), and 1 patient (4.8%) showed signs of a non-stable union. Four patients (19.0%) reported persistent symptoms from CCFX. CONCLUSION: Non-union in CCFX is uncommon but may lead to decreased stability and discomfort. Both clinical and radiological examinations play an important part in the post-traumatic evaluation of CCFX. CT and MRI visualize the healing process, while dynamic ultrasound may reveal instability. No significant difference in QoL was detected between patients with radiologically healed and non-healed CCFX. Post-traumatic disability was mostly due to other non-thoracic injuries.

Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke.

PURPOSE: BCVI may lead to ischemic stroke, disability, and death, while being often initially clinically silent. Screening criteria for BCVI based on clinical findings and trauma mechanism have improved detection, with Denver criteria being most common. Up to 30% of patients do not meet BCVI screening criteria. The aim of this study was to analyze the effect of augmented Denver criteria on detection, and to determine the relative risk for ischemic stroke. METHODS: Denver screening criteria were augmented by any high-energy trauma of the cervical spine, thorax, abdomen, or pelvis. All acute blunt trauma WBCT including CT angiography (CTA) over a period of 38 months were reviewed retrospectively by two Fellowship-trained radiologists, as well as any cerebral imaging after the initial trauma. RESULTS: 1544 WBCT studies included 374 CTA (m/f = 271/103; mean age 41.5 years). Most common mechanisms of injury were MVA (51.5%) and fall from a height (22.3%). We found 72 BCVI in 56 patients (15.0%), with 13 (23.2%) multiple lesions. The ICA was affected in 49 (68.1%) and the vertebral artery in 23 (31.9%) of cases. The most common injury level was C2, with Biffl grades I and II most common in ICA, and II and IV in VA. Interobserver agreement was substantial (Kappa = 0.674). Of 215 patients imaged, 16.1% with BCVI and 1.9% of the remaining cases had cerebral ischemic stroke (p < .0001; OR = 9.77; 95% CI 3.3-28.7). Eleven percent of patients with BCVI would not have met standard screening criteria. CONCLUSIONS: The increase in detection rate for BCVI justifies more liberal screening protocols.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

Remember the Vessels! Craniofacial Fracture Predicts Risk for Blunt Cerebrovascular Injury.

PURPOSE: The risk factors for blunt cerebrovascular injuries (BCVIs) are currently under intensive research, yet it is still controversial who should be screened. This study aimed to determine whether craniofacial fractures are associated with BCVI. PATIENTS AND METHODS: This retrospective cohort study focused on patients with suspected polytrauma after whole-body computed tomographic angiography of the cervical arteries. Patients were reviewed for BCVI and craniofacial fractures. Exclusion criteria were hanging injury, gunshot injury or other penetrating injury to the neck, and a cervical fracture on any level. The outcome variable was BCVI, and the main predictor variable was a craniofacial fracture. A secondary predictor variable was a type of craniofacial fracture classified as a facial fracture, skull fracture, or a combination of facial and skull fracture. Other predictor variables were gender, age, and mechanism of injury. In addition, specific craniofacial fractures were analyzed in more detail. The relevance of associations between BCVI and the predictors underwent χ2 testing. Significance was set at .01. RESULTS: Four hundred twenty-eight patients 13 to 90 years old during a 12-month period were included in the analysis. Craniofacial fractures occurred in 75 (17.5%). BCVI occurred significantly more frequently in those with than in those without a craniofacial fracture (18.6 vs 7.4%; P = .002). Patients with craniofacial fracture had a 4-fold increased risk for BCVI, whereas those 31 to 50 years old had 3.4-fold increased risk. Type of craniofacial fracture, gender, and mechanism of injury were not associated with BCVI. CONCLUSION: Craniofacial fractures are a serious risk factor for BCVI. This research suggests that in patients with any craniofacial fracture and suspected polytrauma, rigorous imaging of cervical arteries in search of BCVI is essential.

Gas-foamed poly(lactide-co-glycolide) and poly(lactide-co-glycolide) with bioactive glass fibres demonstrate insufficient bone repair in lapine osteochondral defects.

Deep osteochondral defects may leave voids in the subchondral bone, increasing the risk of joint structure collapse. To ensure a stable foundation for the cartilage repair, bone grafts can be used for filling these defects. Poly(lactide-co-glycolide) (PLGA) is a biodegradable material that improves bone healing and supports bone matrix deposition. We compared the reparative capacity of two investigative macroporous PLGA-based biomaterials with two commercially available bone graft substitutes in the bony part of an intra-articular bone defect created in the lapine femur. New Zealand white rabbits (n = 40) were randomized into five groups. The defects, 4 mm in diameter and 8 mm deep, were filled with neat PLGA; a composite material combining PLGA and bioactive glass fibres (PLGA-BGf); commercial beta-tricalcium phosphate (ß-TCP) granules; or commercial bioactive glass (BG) granules. The fifth group was left untreated for spontaneous repair. After three months, the repair tissue was evaluated with X-ray microtomography and histology. Relative values comparing the operated knee with its contralateral control were calculated. The relative bone volume fraction (∆BV/TV) was largest in the ß-TCP group (p ≤ 0.012), which also showed the most abundant osteoid. BG resulted in improved bone formation, whereas defects in the PLGA-BGf group were filled with fibrous tissue. Repair with PLGA did not differ from spontaneous repair. The PLGA, PLGA-BGf, and spontaneous groups showed thicker and sparser trabeculae than the commercial controls. We conclude that bone repair with ß-TCP and BG granules was satisfactory, whereas the investigational PLGA-based materials were only as good as or worse than spontaneous repair.

Articular cartilage repair with recombinant human type II collagen/polylactide scaffold in a preliminary porcine study.

The purpose of this study was to investigate the potential of a novel recombinant human type II collagen/polylactide scaffold (rhCo-PLA) in the repair of full-thickness cartilage lesions with autologous chondrocyte implantation technique (ACI). The forming repair tissue was compared to spontaneous healing (spontaneous) and repair with a commercial porcine type I/III collagen membrane (pCo). Domestic pigs (4-month-old, n = 20) were randomized into three study groups and a circular full-thickness chondral lesion with a diameter of 8 mm was created in the right medial femoral condyle. After 3 weeks, the chondral lesions were repaired with either rhCo-PLA or pCo together with autologous chondrocytes, or the lesion was only debrided and left untreated for spontaneous repair. The repair tissue was evaluated 4 months after the second operation. Hyaline cartilage formed most frequently in the rhCo-PLA treatment group. Biomechanically, there was a trend that both treatment groups resulted in better repair tissue than spontaneous healing. Adverse subchondral bone reactions developed less frequently in the spontaneous group (40%) and the rhCo-PLA treated group (50%) than in the pCo control group (100%). However, no statistically significant differences were found between the groups. The novel rhCo-PLA biomaterial showed promising results in this proof-of-concept study, but further studies will be needed in order to determine its effectiveness in articular cartilage repair. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:745-753, 2016.

Fixation of distal femoral osteotomies with self-reinforced polymer/bioactive glass rods: an experimental study on rabbits.

Two self-reinforced poly(desamino tyrosyl-tyrosine ethyl ester carbonate), poly(DTE carbonate) or self-reinforced poly(DTE carbonate)/bioactive glass rods, (2 mm by 40 mm) were implanted into the dorsal subcutaneous tissue and osteotomies of the distal femur were fixed with these rods (2 mm by 26 mm) in 36 rabbits. The follow-up times varied from three to 100 weeks. After sacrifice, three-point bending and shear tests and molecular weight measurements were performed for subcutaneously placed rods. Radiological, histological, histomorphometrical, microradiographic, and oxytetracycline-fluorescence studies of the osteotomized and intact control femora were performed. The initial mechanical properties were higher with the SR-poly(DTE carbonate) rods, but the SR-poly(DTE carbonate)/bioactive glass rods lost their mechanical properties slower. At 100 weeks the bending strength had decreased to 21% of the initial value with the SR-poly(DTE carbonate) rods and to 49% with the SR-poly(DTE carbonate)/bioactive glass rods. The shear strength had decreased to 10% with the SR-poly(DTE carbonate) rods and to 23% of the initial value with the SR-poly(DTE carbonate)/bioactive glass rods. Two slight displacements and one delayed union and one failure of fixation were seen in the SR-poly(DTE carbonate) group. In the SR-poly(DTE carbonate)/bioactive glass group five delayed unions and seven slight displacements were seen. No signs of osteolysis or foreign body reactions were observed. Signs of resorption of the implants were seen at 100 weeks in the SR-poly(DTE carbonate)/bioactive glass group. The present investigation showed that the mechanical strength and fixation properties of SR-poly(DTE carbonate) and SR-poly(DTE carbonate)/bioactive glass rods are suitable for fixation of cancellous bone osteotomies in rabbits.

In vitro and in vivo behavior of self-reinforced bioabsorbable polymer and self-reinforced bioabsorbable polymer/bioactive glass composites.

The aim of this study was to investigate the in vitro and in vivo properties and degradation of (1) self-reinforced (SR) lactide copolymer, P(L/DL)LA 70:30, and (2) SR composites of the same polylactide and bioactive glass 13-93. The following three polymer and polymer-bioactive glass samples were studied: SR-PLA70, SR-PLA70 + BaG15s, and SR-PLA70 + BaG20c. In vitro behavior was studied in a phosphate-buffered saline for 87 weeks at 37 degrees +/- 1 degrees C and a pH of 7.4 +/- 0.2. In vivo behavior was studied by implanting the rods in the dorsal subcutaneous tissue of rats (SR-PLA70 + BaG20c) or rabbits (SR-PLA70 and SR-PLA70 + BaG15s) for 48 weeks. The degradation of the specimens was evaluated by measuring the changes in mechanical properties, crystallinity and molecular weight of polymer, water absorption, weight loss, and structural changes. Results showed that the addition of bioactive glass filler modified the degradation kinetics and material morphology.

Fixation of distal femoral osteotomies with self-reinforced poly(L/DL)lactide 70:30 and self-reinforced poly(L/DL)lactide 70: 30/bioactive glass composite rods. an experimental study on rabbits.

Two self-reinforced poly(L/DL)lactide 70:30 or self-reinforced poly (L/DL)lactide 70:30/ bioactive glass (SR-P(L/DL)LA/bioactive glass) composite rods (2 mm x 40 mm) were implanted into the dorsal subcutaneous tissue and osteotomies of the distal femur were fixed with these rods (2 mm x 26 mm) in 36 rabbits. The follow-up times varied from 3 to 100 weeks. After the animals were killed, three-point bending and shear tests and molecular weight measurements were performed for subcutaneously placed rods. Radiological, histological, histomorphometrical, microradiographic and oxytetracycline-fluorescence studies of the osteotomized and intact control femora were performed. After 12 weeks the SR-P(L/DL)LA rods had fragmented into pieces and the mechanical properties could not be measured. The SR-P(L/DL)LA/bioactive glass rods lost their mechanical properties slower, and at 24 weeks the bending strength had decreased by 39% and the shear strength by 50%. After that the mechanical properties of the SR-P(L/DL)LA/bioactive glass rods could not be measured. All osteotomies healed well, and no gross signs of inflammatory reactions were observed. One slight displacement was seen in the three-week follow-up group with SR-P(L/DL)LA rods. Signs of resorption of the implants were seen after 48 weeks in the SR-P(L/DL)LA group and after 24 weeks in the SR-P(L/DL)LA/bioactive glass group. The SR-P(L/DL)LA/bioactive glass rods were almost totally resorbed from the bone at 100 weeks. The present investigation showed that the mechanical strength and fixation properties of the SR-P(L/DL)LA and the SR-P(L/DL)LA/bioactive glass composite rods are suitable for fixation of cancellous bone osteotomies in rabbits.

Fixation of distal femoral osteotomies with self-reinforced poly(desamino tyrosyl-tyrosine ethyl ester carbonate) rods: an experimental study on rats.

Self-reinforced poly(desamino tyrosyl-tyrosine ethyl ester carbonate) poly(DTE carbonate) rods (diameter, 2 mm; length, 26 mm) were implanted into the dorsal subcutaneous tissue of 16 rats. Osteotomies of the distal femur were fixed with these rods (2 mm by 15 mm) in 64 other rats. The follow-up times varied from 1 week to 1 year. After sacrifice, three-point bending and shear tests and molecular weight measurements were performed for subcutaneously placed rods. Radiological, histological, histomorphometrical, microradiographic, and oxytetracycline-fluorescence studies of the osteotomized and intact control femurs were performed. At 36 weeks, the bending strength of the rods was nearly at the same level as the initial value, and the shear strength was decreased to about one quarter of the initial value. One of the 64 evaluated osteotomies showed signs of infection at 24 weeks, and there were five failures of fixation. Fifty-eight osteotomies healed uneventfully. No gross signs of inflammatory or foreign-body reactions were observed. The present investigation showed that the mechanical strength and fixation properties of SR-poly(DTE carbonate) rods are suitable for fixation of cancellous bone osteotomies in rats. The present article is the first report on successful application of SR-poly(DTE carbonate) rods for fixation of cancellous bone osteotomies.