Vitamin D and Metabolic Supplementation in Orthopedic Trauma.

Active assessment and management of hypovitaminosis D among orthopedic patients is low-risk and low-cost while retaining significant potential to improve patient care. Vitamin D has an established role in musculoskeletal development and calcium homeostasis, and vitamin D deficiency is pervasive in orthopedic trauma populations. Clinical guidelines for screening and supplementation for hypovitaminosis D are lacking. Literature on the effects of vitamin K on bone health is limited. Anabolic hormone analogues may have a future role in delayed union or nonunion treatment. Vitamin D deficiency and other endocrine abnormalities should be considered in orthopedic trauma patients presenting with fracture nonunion of uncertain cause.

The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial.

AIMS: To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture. PATIENTS AND METHODS: Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D3 orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out. RESULTS: In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement. CONCLUSIONS: Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D3. Cite this article: Bone Joint J 2017;99-B:1520-5.

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.

Implantable electrical bone stimulation for arthrodeses of the foot and ankle in high-risk patients: a multicenter study.

This study assessed arthrodesis procedures performed in the foot and ankle of high-risk patients following implantation of an internal electrical bone stimulator. Criteria defining patients as "high risk" included diabetes, obesity, habitual tobacco and/or alcohol use, immunosuppressive therapy, and previous history of nonunion. Standard arthrodesis protocol of bone graft and internal fixation was supplemented with the implantable electrical bone stimulator. A retrospective, multicenter review was conducted of 26 patients (28 cases) who underwent 28 forefoot and hindfoot arthrodeses from 1998 to 2002. Complete fusion was defined as bony trabeculation across the joint, lack of motion across the joint, maintenance of hardware/fixation, and absence of radiographic signs of nonunion or pseudoarthrosis. Radiographic consolidation was achieved in 24 of the 28 cases at an average 10.3+/-4.0 weeks. Followup averaged 27.2 months. Complications included 2 patients who sustained breakage of the cables to the bone stimulator. Five patients underwent additional surgery. Four of the 5 patients had additional surgery in order to achieve arthrodesis. All 4 went on to subsequent arthrodesis. This study demonstrates how arthrodesis of the foot and ankle may be enhanced by the use of implantable electrical bone stimulation.

Implantable electrical stimulation in high-risk hindfoot fusions.

The risk of nonunion in both the ankle and subtalar joints has been reported as high as 41% and 16%, respectively. Several factors have been reported to significantly increase the incidence of nonunion: smoking, previous nonunion, osteonecrosis, history of infection, fracture type, and major medical problems. A single surgeon's experience is retrospectively reviewed. Thirteen patients who were identified as high risk for non-union had an implantable electrical stimulator placed at the time of their ankle or hindfoot fusion along with bone grafting. Three ankle, two subtalar, six tibiotalocalcaneal, and two tibiocalcaneal fusions were performed. All 13 patients had a minimum of two major risk factors for non-union. Of the 13 patients, 11 were active smokers and five of 13 had three or more major risk factors. At a minimum of one year follow-up (average, 24.6 months), successful fusion was achieved in 12 of 13 (92%) patients. Pain scores improved from a mean of 8.5 points preoperatively (range, 7 to 10) to a mean of 1.9 points postoperatively (range, 1 to 6), while the preoperative mean modified AOFAS score of 31.2 points (range, 15 to 55) improved to 85.4 points (range, 45 to 100) postoperatively. The improvement was statistically significant at p<0.01. Eleven of 13 patients (85%) ranked their pain as a 1 or 2 out of 10, and achieved a modified AOFAS score of 80 or better. No additional procedures were done to achieve fusion. Four patients developed superficial wound infections requiring local wound care. The subcutaneous battery pack was bothersome to eight of 13 patients, painful to one, and removed in four patients. The results suggest that electrical implantable stimulation may be a useful adjunct to rigid internal fixation and bone grafting for ankle and hindfoot fusions in high-risk patients.

Potential role of bone morphogenetic proteins in fracture healing.

Since their discovery, bone morphogenetic proteins have held the promise for use in various orthopaedic diseases. One of the largest areas of likely application is the area of fracture repair. Although millions of fractures occur annually and the majority heal satisfactorily, 5% to 10% go on to delayed union or nonunion. Bone morphogenetic proteins may be able to improve bony healing in these conditions and perhaps enhance the healing of fractures that otherwise heal satisfactorily. This study examines the preclinical data to support the concept of enhancing bony healing and discusses the preliminary data from clinical trials using bone morphogenetic proteins to augment bony healing. Although the potential clinical uses of bone morphogenetic proteins in fracture healing remain significant, this potential has yet to be realized.

Stimulation of bone healing in new fractures of the tibial shaft using interferential currents.

The aim of this research was to establish whether interferential currents (IFC) could significantly reduce the healing time for fractures of the tibia and thereby prevent nonunion. Males between the ages of 12 and 86, who had sustained fractures of the tibiae, were entered into this double blind clinical trial. According to strict inclusion and exclusion criteria, a final sample of 227 cases (208 subjects) were entered by block randomization into two groups; an experimental group (n = 41) and placebo group (n = 35). A further group was entered retrospectively--control group (n = 151). IFCs were applied to the experimental group via suction electrodes for 30 minutes per day for 10 days, using a beat frequency of 10-25 Hz and a swing mode of 6 integral of 6. The placebo group had only suction electrodes applied, the intermittent mode produced a rhythmical massage effect; subjects in this group commented on pain relief which resulted in the addition of the control group as a check on the possible effect of intermittent suction. The control group received no intervention. The data were analysed using analysis of covariance which resulted in a finding of no significant difference in the time taken to union for the three groups. This means that to date there is no reason to believe that IFCs (using the parameters of this trial) can reduce the healing time for new fractures of the tibia or prevent nonunion. However, further investigation is recommended.