Evaluation of the Effects of Photobiomodulation on Partial Osteotomy in Streptozotocin-Induced Diabetes in Rats.

OBJECTIVE: We examined the effects of photobiomodulation (PBM) on stereological parameters, and gene expression of Runt-related transcription factor 2 (RUNX2), osteocalcin, and receptor activator of nuclear factor kappa-B ligand (RANKL) in repairing tissue of tibial bone defect in streptozotocin (STZ)-induced type 1 diabetes mellitus (TIDM) in rats during catabolic response of fracture healing. BACKGROUND DATA: There were conflicting results regarding the efficacy of PBM on bone healing process in healthy and diabetic animals. MATERIALS AND METHODS: Forty-eight rats have been distributed into four groups: group 1 (healthy control, no TIDM and no PBM), group 2 (healthy test, no TIDM and PBM), group 3 (diabetic control, TIDM and no PBM), and group 4 (diabetic test, no TIDM and PBM). TIDM was induced in the groups 3 and 4. A partial bone defect in tibia was made in all groups. The bone defects of groups second and fourth were irradiated by a laser (890 nm, 80 Hz, 1.5 J/cm2). Thirty days after the surgery, all bone defects were extracted and were submitted to stereological examination and real-time polymerase chain reaction (RT-PCR). RESULTS: PBM significantly increased volumes of total callus, total bone, bone marrow, trabecular bone, and cortical bone, and the numbers of osteocytes and osteoblasts of callus in TIDM rats compared to those of callus in diabetic control. In addition, TIDM increased RUNX2, and osteocalcin in callus of tibial bone defect compared to healthy group. PBM significantly decreased osteocalcin gene expression in TIDM rats. CONCLUSIONS: PBM significantly increased many stereological parameters of bone repair in an STZ-induced TIDM during catabolic response of fracture healing. Further RT-PCR test demonstrated that bone repair was modulated in diabetic rats during catabolic response of fracture healing by significant increase in mRNA expression of RUNX2, and osteocalcin compared to healthy control rats. PBM also decreased osteocalcin mRNA expression in TIDM rats.

Local transplantation of bone marrow concentrated granulocytes precursors can cure without antibiotics infected nonunion of polytraumatic patients in absence of bone defect.

PURPOSE: Infected, long bone non-unions present a significant clinical challenge. New and alternative therapies are needed to address this problem. The purposes of this study were to compare the number of circulating granulocyte-macrophage colony-forming units (CFU-GM) in the peripheral blood of polytraumatic patients with infected tibial non-unions and in the peripheral blood of control patients with the hypothesis that their number was decreased in polytraumatic patients; and to treat their infection without antibiotics and with local transplantation of bone marrow concentrated granulocytes precursors. METHODS: Thirty (18 atrophic and 12 hyperthrophic ) infected tibial non-unions (without bone defect) that occurred after open fractures in polytraumatic patients were treated without antibiotics and with percutaneous injection of autologous bone marrow concentrate (BMC) containing granulocytes precursors (CFU-GM). CFU-GM progenitors were assessed in the bone marrow aspirate, peripheral blood, and fracture site of these patients. The number of these progenitors was compared with the CFU-GM progenitors of control patient samples (healthy donors matched for age and gender). Outcome measures were: timing of union, callus formation (radiographs and CT scan), and recurrence of clinical infection. RESULTS: As compared to control patients, the number of CFU GM derived colonies was lower at peripheral blood in patients with infected nonunions. The bone marrow graft injected in nonunions contained after concentration 42 621 ± 20 350 CFU-GM-derived colonies/cc. Healing and cure of infection was observed at six months for 25 patients and at one year follow up for 30 patients. At the median ten year follow-up (range: 5 to 15), only one patient had clinical recurrent infection after healing (between 6 months and last follow-up). CONCLUSION: The peripheral blood of these polytraumatic patients with infected nonunions had a remarkable decrease in CFU-GM-derived colonies as compared with normal controls. Local transplantation of concentrated CFU-GM-derived colonies aspirated from bone marrow allowed cure of infection and healing without antibiotics.

Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial.

INTRODUCTION: Open fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in many cases, multiple operations and prolonged rehabilitation. Use of hyperbaric oxygen therapy as an adjunct to standard orthopaedic trauma care has the potential to reduce the complications of musculoskeletal injury and thus improve outcomes. Two previous randomised trials have suggested some positive effect, but neither functional measures nor long-term outcomes were reported. METHODS AND ANALYSIS: An international, multicentre, randomised, open-label, clinical trial. Patients with trauma with an acute open fracture of the tibia with severe soft tissue injury (Gustilo grade 3) and high risk of injury-related complications were recruited from participating major trauma hospitals with hyperbaric facilities. Patients were enrolled with the expectation of commencing 12 sessions of hyperbaric oxygen therapy within 48 h of injury. The primary outcome measure is the incidence of acute complications of the open fracture wound at 14 days. Other short-term outcome measures include amputation, need for fasciotomy, time until wound closure, breakdown of closed wounds, time until definitive orthopaedic fixation, number of operative procedures, intensive care stay and hospital stay. Long-term follow-up will continue for 2 years postinjury. ETHICS AND DISSEMINATION: Ethics approval was given by The Alfred Health Human Ethics Committee (206/04) and the Monash University Human Research Ethics Committee (CF07/4208). Approval was also obtained from the institutional research ethics committee at each participating site. This study will make a significant contribution to the trauma literature and should answer the question of whether hyperbaric oxygen therapy can significantly improve outcomes in severe lower limb trauma. Collective study results will be published in international journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov: NCT00264511; Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12607000559415.

Custom-made antibiotic cement nails: a comparative study of different fabrication techniques.

INTRODUCTION: The management of intramedullary long bone infections remains a challenge. Placement of antibiotic cement nails is a useful adjuvant to the antibiotic treatment of osteomyelitis. However, fabrication of antibiotic cement nails can be arduous. The purpose of this article is to introduce an easy and reproducible technique for the fabrication of antibiotics cement nails. MATERIALS AND METHODS: We compared the time required to peel the chest tube off the 6 antibiotic cement nail using 2 different cement-cooling techniques and the addition of mineral oil in the chest tube. Additionally, we evaluated the optimal time to cut the chest tube (before and after cement hardening), consistency of nail's diameter, and the roughness of its surface. Cooling and peeling times were measured and failure was defined as a working time (from cement mixing to have a usable antibiotic cement nail) that exceeded 1 h. RESULTS: When the antibiotic cement nail was left to cool by convection (i.e. air-cooling), we failed to peel the plastic off the cement nail. When the chest tube was cut after conductive cooling (i.e. cold water-cooled), the cooling time was 10 min and the peeling time was 30 min without the use of mineral oil; the addition of mineral oil reduced peeling time to 7.5 min. Following peeling, residual adherent plastic pieces were found along the entire surface of the nail when no mineral oil was used. This was rarely seen when mineral oil was utilized to coat the inner layer of the chest tube. CONCLUSION: Conductively cooling of the cement nail (in cold water) and pre-lubricating the chest tube with mineral oil are 2 tricks that render fabrication of antibiotic nail more efficient, reliable, and practical.

Traumatic injuries in pregnant women: a case of motor vehicle accident for "Ground Round" discussion.

UNLABELLED: The main objective for introducing this case study is to create a platform from which the importance of road traffic related injuries and traumas can be emphasized and discussed within and across various fields of investigation. The long term goal is to entice public campaign around unmet needs for higher road safety measures to reduce primary, secondary, and tertiary risks of injuries and traumas. CASE: a 28-year-old pregnant woman with a 16-week gestational age fetus was involved in a road car crash resulting in multiple traumas. Evaluation and treatment was initiated in the local Urgent Care Unit and continued in the emergency department and operation room. Patient underwent the following procedures: laparotomy, diverting colostomy, terminating pregnancy, right calcaneal traction and long leg splint, as well as multiple irrigation-debridements. Finally, the wound was left open and the patient was admitted to Intensive Care Unit. We hope that the introduction of this case for a "Ground Round" discussion will stir up a comprehensive discussion regarding the injury and trauma related preventive measures as well as treatment approaches in cases involving pregnant women in car accidents, and will bring about a holistic overview of this issue by the experts in various fields.

PCL reconstruction with the tibial inlay technique following intra-medullary nail fixation of an ipsilateral tibial shaft fracture: a treatment algorithm.

Our case report highlights the complexity of treating multi-ligament knee injuries in the setting of ipsilateral long bone trauma. We describe the use of the tibial inlay technique for PCL reconstruction in the setting of a tibial shaft fracture treated with an intramedullary nail. We also present a comprehensive treatment algorithm for the treatment of ligamentous knee injuries in the setting of long bone trauma.

The effects of low-level laser therapy on bone in diabetic and nondiabetic rats.

OBJECTIVE: The aim of the present study was to examine the effects of low-level laser therapy (LLLT) on the tibia of streptozotocin-induced diabetic (STZ-D) rats. BACKGROUND DATA: LLLT has been found to accelerate fracture healing in animals. Diabetes mellitus decreases bone volume and its biomechanical parameters. MATERIALS AND METHODS: Twenty rats were divided randomly into four groups. Rats in the first two groups were administrated a single injection of STZ to induce diabetes, while animals in groups 3 and 4 were given a sham injection of distilled water. The right tibia in groups 1 and 2 was treated with a He-Ne laser (632.8 nm, 10 mW) of 28.6 and 382.2 J/cm(2), respectively. LLLT was performed daily for 14 consecutive days. The right tibia of rats in group 3 was treated with LLLT the same as group 2. The right tibia of rats in group 4 was used for based line studies. After 14 d, right tibiae and left tibiae (control bone) were extracted and subjected to the three-point bending test and histological study. RESULTS: Maximum force (N) was significantly greater in laser-treated bones of groups 2 and 3 compared with their relevant control groups (paired Student t test, p = 0.05 and p = 0.007, respectively). Density of the bone lamella meshwork of compact bone in group 2 was significantly greater in comparison with its control group (paired Student t test, p = 0.005). CONCLUSION: LLLT on tibia of STZ-D rats increased the bone lamella meshwork density of compact bone and also increased its strength.

Treatment of infected tibial nonunion with tobramycin-impregnated calcium sulfate: report of two cases.

The treatment of infected tibial nonunion usually includes a staged reconstruction protocol. We present 2 patients with tibial nonunion and plate loosening with oxacillin-resistant Staphylococcus aureus infection. The patients were treated using the removal of the plate, radical debridement, and implantation of gentamycin-impregnated cement beads during the first stage. During the second stage, plate fixation was performed and tobramycin-impregnated calcium sulfate (Osteoset T) was used as a bone graft substitute. Neither an autogenous bone graft nor an allograft was used. At 3 years of follow-up, each tibia showed good union, and there was no recurrence of infection. We consider tobramycin-impregnated calcium sulfate to be an alternative method of bone grafting to treat infected tibial nonunion.

No adverse effects of clodronate on fracture healing in rats.

Clodronate was administered daily 28 days before and after an experimental tibial fracture in 35 male rats, and the effect on fracture healing and posttraumatic bone loss was studied. 5 groups were tested. The clodronate/clodronate group received clodronate in daily doses of 10 mg/kg body weight for 28 days before being subjected to a standardized fracture of the right tibia, and during the fracture healing period of 28 days. The clodronate/saline group received clodronate before fracture and saline during the healing period. The saline/clodronate group received saline before and clodronate after fracture. The saline/saline group received saline only, while the control group served as unfractured, untreated controls. After 28 days of fracture healing, the tibias were evaluated with dual energy x-ray absorptiometry, and tested mechanically in a 3-point ventral bending test. Bone mineral content and bone mineral density were approximately 30% higher in the groups receiving clodronate during the experiment, compared to the untreated groups. The weight and cross-sectional area of the fracture callus were equal in all groups. Whether clodronate was administered before the fracture, after the fracture or both, did not affect the bone mineral. Ultimate bending moment, energy absorption, stiffness and deflection were not significantly different between the groups. Our findings suggest that clodronate increases bone mineral both when given before and after a tibial shaft fracture, without affecting fracture healing at 28 days.

Treatment of leg edema and wounds in a patient with severe musculoskeletal injuries.

This case report describes the application of a technique for the treatment of leg edema and wounds resulting from a severe distal tibiofibular fracture. Following injury and numerous fracture- and wound-related surgeries in the first year postinjury, this patient developed leg edema, required daily treatment of 2 leg wounds, and was unable to wear a shoe due to foot swelling. He was referred to the physical therapy clinic 1 year postinjury for ankle rehabilitation and to diminish the leg edema. Therapy consisting of manual lymph drainage, compressive bandaging, exercise, and skin care was provided for 7 weeks. A compression stocking was issued near the end of treatment, which the patient continued to wear daily thereafter. At the time of discharge from therapy, the leg edema had decreased 74% and the wound area of both wounds had decreased 89%. Improvements continued following discharge. By 10 weeks after the start of treatment, edema had decreased 80.9%, one wound had healed, and the second wound was 93% improved. The patient was able to wear a shoe and resume recreational activities. This case report provides insight into a treatment that may shorten rehabilitation and control the cost of caring for injuries complicated by prolonged edema.

Posttraumatic tibial osteomyelitis: diagnosis, classification, and treatment.

The problem of osteomyelitis has, to date, not been completely resolved. Recent research has provided additional insight into the pathogenesis of bone infection. Advances in pharmacology and in surgical techniques have enhanced our ability to treat such infections. Despite these advances, successful treatment of posttraumatic tibial osteomyelitis depends on adherence to several basic principles: complete debridement of necrotic and infected tissue, obtaining bony stability, the elimination of dead space, and the provision of durable soft tissue coverage. Armed with this new knowledge and surgical ability, treatment results have improved. We do not know, however, whether osteomyelitis can ever be "cured," since infections become manifest many years after injury or treatment.

Capacitively coupled electrical field in the treatment of a leg fracture after total knee replacement.

Electrical stimulation has been used as treatment for nonunions of fractures since the early 1950s, with a reported success rate of 80-85%. We report a case of nonunion of a tibial fracture below a revised total knee prosthesis treated with a capacitively coupled electrical field. After 3 months of treatment, consolidation of this difficult fracture was evident with abundant callus formation.

Piroxicam-induced reduction in osteopenia after external fixation of rabbit tibia.

Twelve rabbits were treated with a unilateral external fixator in one tibia for 12 weeks, while the other tibia served as an intact control. Half of the animals were also treated with 10 mg/kg/day of piroxicam, given in two daily oral doses. Changes in bone mineral content were determined using single photon absorptiometry. After 12 weeks, we found a 3 percent decrease in the bone mineral content in the tibia of the animals treated with piroxicam versus 9 percent in the nonpiroxicam group (P = 0.04). In the femurs, there was an insignificant decrease in bone mineral, 2 percent (piroxicam) and 1 percent (nonpiroxicam) respectively. The results indicate that piroxicam may reduce the osteopenia caused by external fixation.

Edema and lower leg perfusion in patients with post-traumatic dysfunction.

Impedancegraphy and laser Doppler flowmetry were used to measure whether limb circulation changes following post-traumatic immobilization and edema. Intermittent pneumatic compression was used for edema treatment. Limb blood flow due to edema was unchanged compared to the contralateral healthy leg. Intermittent pneumatic compression reduced edema very significantly (p less than 0.001). Intermittent compression showed a slight but significant (p less than 0.01) improvement in impedancegraph blood flow after treatment. Laser Doppler skin blood flow decreased non-significantly following the compression treatment.

Necrotizing myonecrosis and polymicrobial sepsis. The role of adjunctive hyperbaric oxygen.

A 19-year-old man, who was involved in a motorcycle accident, sustained a combined bony and vascular injury to his right lower extremity that required emergency surgery. Postoperatively, the patient developed a life-threatening, necrotizing, soft-tissue infection and sepsis. Hyperbaric oxygen therapy was used with surgery and antibiotics to control this rapidly progressive infection and to limit the extent of debridement needed. It was found to reverse the patient's deteriorating status and to halt the progression of the necrotizing infection. The scientific evidence for the use of hyperbaric oxygen in such cases is discussed.

Prevention of disuse muscle atrophy by means of electrical stimulation: maintenance of protein synthesis.

The effect of percutaneous electrical stimulation in preventing immobilisation-induced muscle atrophy was determined from measurements of quadriceps mass, composition, and rate of protein synthesis in seven men who had a fracture of one tibia immobilised in a long-leg cast for 6 weeks. These features were compared with those of fourteen men with similar injuries who did not use an electrical stimulator. In men who did not use the stimulator, quadriceps cross-sectional area (CSA) at midthigh, measured by ultrasonography, fell by a mean (SD) 17 (10)% and the rate of muscle protein synthesis was 23 (10)% lower on the immobilised than on the control side (0.037 [0.016] vs 0.048 [0.02]%/h). In contrast, in those who used the stimulator, quadriceps CSA (55.5 [7.3]) cm2 control leg, 50.9 [9.0] cm2 immobilised leg) and the rate of muscle protein synthesis (0.053 [0.009] %/h control leg, 0.059 [0.012] %/h immobilised leg) were similar on the two sides. The results suggest that brief periods of low-voltage percutaneous electrical stimulation will reduce quadriceps atrophy secondary to knee immobilisation, and that the mechanism includes prevention of the fall in muscle protein synthesis that usually occurs on immobilisation.