Combined electric and magnetic field therapy for bone repair and regeneration: an investigation in a 3-mm and an augmented 17-mm tibia osteotomy model in sheep.

BACKGROUND: Therapies using electromagnetic field technology show evidence of enhanced bone regeneration at the fracture site, potentially preventing delayed or nonunions. METHODS: Combined electric and magnetic field (CEMF) treatment was evaluated in two standardized sheep tibia osteotomy models: a 3-mm non-critical size gap model and a 17-mm critical size defect model augmented with autologous bone grafts, both stabilized with locking compression plates. CEMF treatment was delivered across the fracture gap twice daily for 90 min, starting 4 days postoperatively (post-OP) until sacrifice (9 or 12 weeks post-OP, respectively). Control groups received no CEMF treatment. Bone healing was evaluated radiographically, morphometrically (micro-CT), biomechanically and histologically. RESULTS: In the 3-mm gap model, the CEMF group (n = 6) exhibited higher callus mineral density compared to the Control group (n = 6), two-fold higher biomechanical torsional rigidity and a histologically more advanced callus maturity (no statistically significant differences). In the 17-mm graft model, differences between the Control (n = 6) and CEMF group (n = 6) were more pronounced. The CEMF group showed a radiologically more advanced callus, a higher callus volume (p = 0.003) and a 2.6 × higher biomechanical torsional rigidity (p = 0.024), combined with a histologically more advanced callus maturity and healing. CONCLUSIONS: This study showed that CEMF therapy notably enhanced bone healing resulting in better new bone structure, callus morphology and superior biomechanical properties. This technology could transform a standard inert orthopedic implant into an active device stimulating bone tissue for accelerated healing and regeneration.

Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma.

BACKGROUND: The purpose of this study was to compare the clinical effects of antibiotic calcium sulfate-loaded hybrid transport (ACSLHT) and traditional Ilizarov bone transport (TIBT) in the treatment of large tibial defects after trauma. METHODS: Eighty-five patients with large tibial defects after trauma were selected for retrospective study. The range of tibial defects was 6-22 cm. After thorough debridement and infection controlled, bone transport technique was used to reconstruct tibial defects. Forty-four patients were treated with ACSLHT technique (the ACSLHT group), while the other 41 were treated with TIBT technique (the TIBT group). Time in external fixator was evaluated by EFI score. Enneking score was used to evaluate limb functions. SAS score was used to evaluate postoperative anxiety status. In addition, complication incidence was compared, including axis deviation, docking site nonunion, infection recurrence and so on. RESULTS: There was no significant difference in preoperative general data between ACSLHT and TIBT group. EFI score in ACSLHT and TIBT group was 0.6 ± 0.1 cm/month and 1.7 ± 0.3 cm/month, respectively (P < 0.05). Enneking score of ACSLHT and TIBT group was 86.5% and 75.1% (P < 0.05). SAS score of ACSLHT group was significantly lower than that of TIBT group (P < 0.05). Complication incidence in ACSLHT group was significantly lower than that in TIBT group (P < 0.05). CONCLUSIONS: Compared with TIBT group, ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower complication incidence which is worth of clinical promotion.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

A Modified 2-Stage Treatment for AO/OTA 43-C1 Pilon Fractures Accompanied by Distal Fibular and Posterior Lip of the Distal Tibia Fracture.

The management of pilon fractures remains challenging owing to the high-energy axial loading mechanism that produces comminution of the articular surface, displacement of tibia metaphysis, and severe soft tissue injury. How to preserve the vitality of soft tissue and achieve anatomic reduction has become a timely issue. We report and evaluate the effect of a modified staging treatment for AO Foundation/Orthopaedic Trauma Association (AO/OTA) 43C1 pilon fracture accompanied by distal fibular and posterior lip of the distal tibia fracture. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. In the first stage, the posterolateral incision was used for simultaneous reduction of fibula and posterior malleolus, and the tibia was fixed with an external fixator. In the second stage, the external fixator was removed, and the medial malleolus and tibia were fixed after the edema of soft tissue had subsided. The following data were collected: Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, Burwell-Charnley fracture reduction score, and postoperative complications. Twenty-seven patients were monitored for an average of 31.70 ± 7.38 months. The Burwell-Charnley fracture reduction scores had anatomic and fair ratings of 92.59%. SF-36 physical component score was 42.94 ± 12.47 and mental component score was 48.73 ± 9.79. Score data from the multiple scales of FAOS included pain, 88.79 ± 8.59; activities of daily living, 91.89 ± 7.50; quality of life, 90.26 ± 10.52; sports, 87.93 ± 11.64; and symptoms, 85.32 ± 8.65. The AOFAS ankle-hindfoot scores were 87.30 ± 13.45. Complications were reported in 5 patients (18.52%). Our study provides a good alternative to the existing protocol for type C1 pilon fractures with distal fibular and posterior lip of the distal tibia fracture and effectively reduces soft tissue complications.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre.

AIM: We examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. METHOD: Patients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured. RESULTS: We identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation. CONCLUSION: Limb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Green Tea Catechin (-)-Epigallocatechin-3-Gallate (EGCG) Facilitates Fracture Healing.

Green tea drinking can ameliorate postmenopausal osteoporosis by increasing the bone mineral density. (-)-Epigallocatechin-3-gallate (EGCG), the abundant and active compound of tea catechin, was proven to be able to reduce bone loss and ameliorate microarchitecture in female ovariectomized rats. EGCG can also enhance the osteogenic differentiation of murine bone marrow mesenchymal stem cells and inhibit the osteoclastogenesis in RAW264.7 cells by modulation of the receptor activator of nuclear factor-kB (RANK)/RANK ligand (RANKL)/osteoprotegrin (OPG) (RANK/RANKL/OPG) pathway. Our previous study also found that EGCG can promote bone defect healing in the distal femur partially via bone morphogenetic protein-2 (BMP-2). Considering the osteoinduction property of BMP-2, we hypothesized that EGCG could accelerate the bone healing process with an increased expression of BMP-2. In this manuscript, we studied whether the local use of EGCG can facilitate tibial fracture healing. Fifty-six 4-month-old rats were randomly assigned to two groups after being weight-matched: a control group with vehicle treatment (Ctrl) and a study group with 10 µmol/L, 40 µL, EGCG treatment (EGCG). Two days after the operation, the rats were treated daily with EGCG or vehicle by percutaneous local injection for 2 weeks. The application of EGCG enhanced callus formation by increasing the bone volume and subsequently improved the mechanical properties of the tibial bone, including the maximal load, break load, stiffness, and Young's modulus. The results of the histology and BMP-2 immunohistochemistry staining showed that EGCG treatment accelerated the bone matrix formation and produced a stronger expression of BMP-2. Taken together, this study for the first time demonstrated that local treatment of EGCG can accelerate the fracture healing process at least partly via BMP-2.

The Effect of Foot Massage on Pain Intensity and Anxiety in Patients Having Undergone a Tibial Shaft Fracture Surgery: A Randomized Clinical Trial.

OBJECTIVE: To determine the effect of massage therapy on pain intensity and anxiety in patients who have undergone tibial shaft fracture surgery. DESIGN: This study was a randomized clinical trial with a pre-post design. As the study included 2 treatment groups, it was a parallel study. SETTING: Khatam-Al-Anbia Hospital in Zahedan, Iran, between July and August 2017. PATIENTS: In all, 66 patients who underwent a tibial shaft fracture surgery were enrolled and randomly assigned to intervention and control groups (33 patients each). INTERVENTION: The intervention included a 10-minute foot massage (5 minutes per leg) using sweet almond oil, the most common lubricant used in massage therapy. MAIN OUTCOME MEASUREMENTS: Data were collected using pain numeric rating scale and Spielberger State-Trait Anxiety Inventory before and after intervention. RESULTS: After intervention, the mean scores for pain intensity, and anxiety in the intervention and control groups were 4.72 (0.97) and 5.72 (0.91), and 42.84 (6.50) and 58.36 (10.37), respectively. A significant difference was noted between the intervention and control groups concerning pain intensity and anxiety. CONCLUSIONS: The results indicated that massage therapy reduced pain intensity and anxiety in patients who underwent tibial shaft fracture surgery. Therefore, using massage as a noninvasive and acceptable intervention is suggested in orthopaedic surgery, especially after tibial shaft fracture surgeries. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of hyperbaric oxygen therapy on open tibial fractures in rabbits after transient seawater immersion.

OBJECTIVE: To explore the effect and mechanism of hyperbaric oxygen (HBO2) therapy of open tibial fractures in rabbits after transient seawater immersion. METHODS: Forty-eight (48) New Zealand rabbits were randomly and averagely divided into an HBO2 therapy group (Group A) and a control group (Group B). All rabbits were subjected to unilateral open tibial fractures, while immersed in artificial seawater (20-22 °C) for three hours prior to debridement and external fixation. Group A was treated with HBO2 at 2 atmospheres absolute (ATA) for 50 minutes once daily for two weeks; Group B received postoperative routine treatments only. The fracture zone in each group was compared by radiological, histological and immunohistochemical examinations. RESULTS: In Group A, bony callus and mature osteocytes without infiltration of inflammatory cells were observed in the fracture zone. Vascular endothelial growth factor (VEGF) was expressed mainly in the cytoplasm of osteoblasts, chondrocytes and osteocytes, and exhibited significant changes at different time points. The gray value of bony callus in Group A was 190.58 ± 7.52; that of Group B was 144 ± 8.11. Difference between the groups was statistically significant (P ⟨ 0.01). The content of malondialdehyde (MDA) in Group A was significantly lower than Group B (P ⟨ 0.01), and the activity of superoxide dismutase (SOD) in Group A was higher than Group B (P ⟨ 0.01) at four weeks. There were no significant differences in MDA content and SOD activity between groups at eight and 12 weeks. CONCLUSIONS: HBO2 treatment of open tibial fractures in seawater can reduce the inflammatory reaction and reperfusion injury, and promote osteocytic proliferation and fracture healing.

Evaluating augmentation with calcium phosphate cement (chronOS Inject) for bone defects after internal fixation of proximal tibial fractures: A prospective, multicenter, observational study.

INTRODUCTION: Managing subchondral bone defects in proximal tibia fractures after plateau reduction is an important consideration. ChronOS Inject is a recently developed calcium phosphate bone substitute that shows relatively fast osteointegration. HYPOTHESIS: Using chronOS Inject during internal fixation of proximal tibial fractures provides a satisfactory treatment option that is both clinically and radiologically safe. PATIENTS AND METHODS: Patients enrolled in this study were treated with chronOS Inject bone void filler, during internal fixation of proximal tibial fractures. Patients were evaluated preoperatively and at 6 weeks, 6 and 12 months postoperative. Radiographic union was assessed using plain films supplemented by CT scans. Pain, function and adverse events were collected at all visits. A total of 36 patients were enrolled in the study and treated according to a predetermined protocol. Seven of the 36 patients (19.4%) were lost to follow-up. RESULTS: Successful radiographic union was achieved in 27/29 (93.1%) of patients at final follow-up. Articular subsidence of>2mm only occurred in one patient. Statistical analysis showed significant improvements both in leg pain and knee function. Progress in knee function was observed in 93.1% (27/29) of patients from 6 weeks to 12 months. No product-related complications were reported. CONCLUSIONS: Successful union was achieved based on radiographic criteria as well as clinical outcomes. When managing bone defects after internal fixation of proximal tibial fractures, the use of chronOS Inject resulted in significant improvement of knee function and reduction of leg pain. LEVEL OF EVIDENCE: Level IV, prospective observational study.

Low power laser stimulation of the bone consolidation in tibial fractures of rats: a radiologic and histopathological analysis.

The objective of this study is to analyze the effectiveness of low power laser irradiation in the bone consolidation of tibial fractures in rats. An experimental, comparative, prospective study with control group was designed. Twenty Wistar rats were grouped into control (n = 10) and experimental groups (n = 10). A tibial fracture, with a mechanical drill, was inflicted in all rats. The experimental group received ten days of low power arsenide-gallium laser irradiation of 850 nm (KLD, Sao Paulo, Brasil)-100 mW, 8 J/cm(2), 64 s. Before and after the laser treatment, a radiologic analysis was carried out in both groups, in which the rats were graded from 0 to IV according the Montoya scale of bone consolidation. Also, we histopathologically analyzed the bone to estimate the proliferation of fibroblasts, bone matrix, and angiogénesis with a microscopy, which were graded as I (thin layer of fibroblasts and osteoid matrix), II (thick layer of fibroblasts and osteoid matrix), or III (thick layer of fibroblasts and osteoid matrix and new blood vessels). Radiologic data showed that the experimental group had a higher bone consolidation of Montoya scale after ten days of laser irradiation compared to control group (P < 0.004). Histopathologic data showed more fibroblasts and angiogenesis presence in the group receiving laser irradiation, compared to control group (P < .002). The low power laser radiation therapy may expedite the bone repair after tibial fractures in rats, according to radiologic and histopathologic analysis.

In vivo heat-stimulus-triggered osteogenesis.

Several studies have reported that heat stress stimulates the activity of osteoblastic cells in vitro. However, few have addressed the effects of heat stress on osteogenesis in vivo, nor have the optimal temperatures for bone formation been determined. The aim of the present study was to investigate the effects of hyperthermia treatment on osteogenesis in a rat tibial defect model. Forty-four Sprague Dawley rats were divided into two groups with or without hyperthermia treatment. A 3-mm circular defect in the proximal tibia filled with magnetite cationic liposomes embedded in alginate beads was subjected to hyperthermia treatment (43-46 °C). Radiological assessment at 2 weeks after the treatment showed that significantly stimulated osteogenesis was observed in the hyperthermia group as compared to the control group (p = 0.003). Histomorphometrical analysis at 2 weeks revealed a significant increase of newly formed bone in the hyperthermia group, compared with the control group (p < 0.001). Area of newly formed bone in each hyperthermia group was significantly increased as compared with the control group (43 °C; p = 0.005, 44 °C; p = 0.019, 45 °C; p = 0.003, and 46 °C; p = 0.003, respectively). Alkaline phosphatase was overexpressed at the surfaces of newly formed bone adjacent to magnetite cationic liposome implantation. Our results demonstrate for the first time that heat stimulus accelerates osteogenesis in vivo, and may thus be of interest as a novel and promising tool to induce osteogenesis clinically as well.

CERAMENT treatment of fracture defects (CERTiFy): protocol for a prospective, multicenter, randomized study investigating the use of CERAMENT™ BONE VOID FILLER in tibial plateau fractures.

BACKGROUND: Bone graft substitutes are widely used for reconstruction of posttraumatic bone defects. However, their clinical significance in comparison to autologous bone grafting, the gold-standard in reconstruction of larger bone defects, still remains under debate. This prospective, randomized, controlled clinical study investigates the differences in pain, quality of life, and cost of care in the treatment of tibia plateau fractures-associated bone defects using either autologous bone grafting or bioresorbable hydroxyapatite/calcium sulphate cement (CERAMENT™|BONE VOID FILLER (CBVF)). METHODS/DESIGN: CERTiFy (CERament™ Treatment of Fracture defects) is a prospective, multicenter, controlled, randomized trial. We plan to enroll 136 patients with fresh traumatic depression fractures of the proximal tibia (types AO 41-B2 and AO 41-B3) in 13 participating centers in Germany. Patients will be randomized to receive either autologous iliac crest bone graft or CBVF after reduction and osteosynthesis of the fracture to reconstruct the subchondral bone defect and prevent the subsidence of the articular surface. The primary outcome is the SF-12 Physical Component Summary at week 26. The co-primary endpoint is the pain level 26 weeks after surgery measured by a visual analog scale. The SF-12 Mental Component Summary after 26 weeks and costs of care will serve as key secondary endpoints. The study is designed to show non-inferiority of the CBVF treatment to the autologous iliac crest bone graft with respect to the physical component of quality of life. The pain level at 26 weeks after surgery is expected to be lower in the CERAMENT bone void filler treatment group. DISCUSSION: CERTiFy is the first randomized multicenter clinical trial designed to compare quality of life, pain, and cost of care in the use of the CBVF and the autologous iliac crest bone graft in the treatment of tibia plateau fractures. The results are expected to influence future treatment recommendations. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT01828905.

Femoral and tibial stress fractures associated with vitamin D insufficiency.

We describe a case highlighting the need to consider hypovitaminosis-D when investigating background causation and treatment of femoral and tibial stress fractures. The case also suggests that prescribing calcium and vitamin D supplementation may help with fracture healing in soldiers presenting with stress fractures who may have unrecognised hypovitaminosis-D which if left untreated may delay fracture healing.

[Close reduction by Chinese traditional manipulation and MIPPO for the treatment of tibial fractures in middle and distal segment].

OBJECTIVE: To explore the technique and clinical results of close manipulative reduction and minimally invasive percutaneous plate osteosynthesis (MIPPO) for the treatment of tibial fractures in the middle and distal segment. METHODS: From Jan. 2005 to Dec. 2009, 40 patients with tibial fractures in middle and distal segment were treated with close manipulative reduction and MIPPO fixation, including 28 males and 12 females with an average age of 54 years old (ranging from 21 to 76). According to AO fractures classification for the tibial fractures in the middle and distal segment, there were 26 cases of type A, 8 of type B, 6 of type C. RESULTS: All patients were followed up for 12 to 24 months (averaged 18 months). All the fractures gained bone healing, and the time required for the bony union ranged from 3 to 18 months (averaged 4 months). The patients were evaluated with respect to functional recovery according to Mazur Grating System for the ankle. The aggregate score was 96.67 +/- 3.91, involving pain 48.59 +/- 2.28, hills up 2.95 +/- 0.22, hills down 2.85 +/- 0.37, stairs down 2.92 +/- 0.35, run score 4.95 +/- 0.32, plantar flexion score 4.62 +/- 0.54, dorsiflexion score 4.13 +/- 0.61. The clinical results were excellent in 36 cases, good in 3 and fair in 1. CONCLUSION: Close manipulative reduction and MIPPO fixation is a good method for the treatment of the tibial fractures in the middle and distal segment.

Pulsed electromagnetic field stimulation for acute tibial shaft fractures: a multicenter, double-blind, randomized trial.

BACKGROUND: Tibial shaft fractures are sometimes complicated by delayed union and nonunion, necessitating further surgical interventions. Pulsed electromagnetic field stimulation is an effective treatment for delayed unions and nonunions, but its efficacy in preventing healing complications in patients with acute fractures is largely untested. The purpose of this pragmatic trial was to determine whether adjuvant pulsed electromagnetic field therapy for acute tibial shaft fractures reduces the rate of surgical revision because of delayed union or nonunion. METHODS: In a double-blind randomized trial involving six metropolitan trauma hospitals, 259 participants with acute tibial shaft fractures (AO/OTA type 42) were randomized by means of external allocation to externally identical active and inactive pulsed electromagnetic field devices. Participants were instructed to wear the device for ten hours daily for twelve weeks. Management was otherwise unaltered. The primary outcome was the proportion of participants requiring a secondary surgical intervention because of delayed union or nonunion within twelve months after the injury. Secondary outcomes included surgical intervention for any reason, radiographic union at six months, and the Short Form-36 Physical Component Summary and Lower Extremity Functional Scales at twelve months. Main analyses were by intention to treat. RESULTS: Two hundred and eighteen participants (84%) completed the twelve-month follow-up. One hundred and six patients were allocated to the active device group, and 112 were allocated to the placebo group. Compliance was moderate, with 6.2 hours of average daily use. Overall, sixteen patients in the active group and fifteen in the inactive group experienced a primary outcome event (risk ratio, 1.02; 95% confidence interval, 0.95 to 1.14; p = 0.72). According to per-protocol analysis, there were six primary events (12.2%) in the active, compliant group and twenty-six primary events (15.1%) in the combined placebo and active, noncompliant group (risk ratio, 0.97; 95% confidence interval, 0.86 to 1.10; p = 0.61). No between-group differences were found with regard to surgical intervention for any reason, radiographic union, or functional measures. CONCLUSIONS: Adjuvant pulsed electromagnetic field stimulation does not prevent secondary surgical interventions for delayed union or nonunion and does not improve radiographic union or patient-reported functional outcomes in patients with acute tibial shaft fractures.

Distal tibial fracture repair in a neurofibromatosis type 1-deficient mouse treated with recombinant bone morphogenetic protein and a bisphosphonate.

Congenital pseudarthrosis of the tibia is an uncommon manifestation of neurofibromatosis type 1 (NF1), but one that remains difficult to treat due to anabolic deficiency and catabolic excess. Bone grafting and more recently recombinant human bone morphogenetic proteins (rhBMPs) have been identified as pro-anabolic stimuli with the potential to improve the outcome after surgery. As an additional pharmaceutical intervention, we describe the combined use of rhBMP-2 and the bisphosphonate zoledronic acid in a mouse model of NF1-deficient fracture repair. Fractures were generated in the distal tibiae of neurofibromatosis type 1-deficient (Nf1(+/-)) mice and control mice. Fractures were open and featured periosteal stripping. All mice received 10 µg rhBMP-2 delivered in a carboxymethylcellulose carrier around the fracture as an anabolic stimulus. Bisphosphonate-treated mice also received five doses of 0.02 mg/kg zoledronic acid given by intraperitoneal injection. When only rhBMP but no zoledronic acid was used to promote repair, 75% of fractures in Nf1(+/-) mice remained ununited at three weeks compared with 7% of controls (p < 0.001). Systemic post-operative administration of zoledronic acid halved the rate of ununited fractures to 37.5% (p < 0.07). These data support the concept that preventing bone loss in combination with anabolic stimulation may improve the outcome following surgical treatment for children with congenital pseudarthosis of the tibia and NF1.

Fixation and deformity correction by plate osteosynthesis of a tibial shaft malunion after traditional African bone setting.

Given the global nature of modern travel and the possibility of deployment to the African continent, it is conceivable that medical officers in the course of their general duties may be exposed to patients managed with traditional bone setting techniques. Whilst these techniques may prove effective for many, complications may still arise and their management may be challenging.

Systemic treatment with strontium ranelate promotes tibial fracture healing in ovariectomized rats.

UNLABELLED: Systemic treatment with strontium ranelate (SR) was performed on ovariectomized (OVX) rats with fractured tibiae. Callus quality was assessed by radiographic, histological, micro-computerized tomography, and biomechanical examinations at 4 and 8 weeks after fracture. Results revealed that systemic applied SR promoted osteoporotic fracture healing. INTRODUCTION: Several studies have demonstrated the dual effect of SR on osteoporotic and undisturbed bone. However, reports of their effect on osteoporotic fracture healing are limited. This study was designed to investigate the effects of SR on bone regeneration in OVX rats with fractured tibiae. METHODS: Three months after being OVX, female Sprague-Dawley rats accepted bilateral osteotomy on proximal tibiae fixed with intramedullary wires and were divided into two groups: OVX and OVX + SR (625 mg/kg/day). Callus quality was evaluated at 4 and 8 weeks postfracture. RESULTS: Compared with OVX group, SR treatment significantly increased bone formation, BMD, biomechanical strength, and improved microstructural properties of the callus. The ultimate load was increased by 211.0% and 61.4% (p<0.01), and the total bone volume of callus by 74.8% and 79.3% (p<0.01) at 4 and 8 weeks postfracture, respectively. SR treatment also promoted healing progress with increased osteogenesis at 4 weeks; more mature and tightly arranged woven or lamellar bone at 8 weeks across the fracture gap in histological analysis. CONCLUSION: This study suggests that systemic treatment with strontium ranelate could promote tibial fracture healing in OVX rats.

Low-magnitude high-frequency mechanical signals accelerate and augment endochondral bone repair: preliminary evidence of efficacy.

UNLABELLED: Fracture healing can be enhanced by load bearing, but the specific components of the mechanical environment which can augment or accelerate the process remain unknown. The ability of low-magnitude, high-frequency mechanical signals, anabolic in bone tissue, are evaluated here for their ability to influence fracture healing. The potential for short duration (17 min), extremely low-magnitude (25 microm), high-frequency (30 Hz) interfragmentary displacements to enhance fracture healing was evaluated in a mid-diaphyseal, 3-mm osteotomy of the sheep tibia. In a pilot study of proof of concept and clinical relevance, healing in osteotomies stabilized with rigid external fixation (Control: n = 4), were compared to the healing status of osteotomies with the same stiffness of fixation, but supplemented with daily mechanical loading ( EXPERIMENTAL: n = 4). These 25-microm displacements, induced by a ferroactive shape-memory alloy ("smart" material) incorporated into the body of the external fixator, were less than 1% of the 3-mm fracture gap, and less than 6% of the 0.45-mm displacement measured at the site during ambulation (p < 0.001). At 10-weeks post-op, the callus in the EXPERIMENTAL group was 3.6-fold stiffer (p < 0.03), 2.5-fold stronger (p = 0.05), and 29% larger (p < 0.01) than Controls. Bone mineral content was 52% greater in the EXPERIMENTAL group (p < 0.02), with a 2.6-fold increase in bone mineral content (BMC) in the region of the periosteum (p < 0.001). These data reinforce the critical role of mechanical factors in the enhancement of fracture healing, and emphasize that the signals need not be large to be influential and potentially clinically advantageous to the restoration of function.