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.

Treatment of aseptic tibial shaft non-union without bone defect.

Non-union is incomplete consolidation of a fracture, without effective formation of a uniting callus. Despite better understanding of the physiology of bone consolidation, management of tibial non-union remains a challenge for orthopedic surgeons. Several treatments have been developed in recent decades, and we now have a range of techniques, with indications based on type of non-union, prior treatments, available equipment, and the surgeon's experience. Firstly, there are surgical techniques such as osteo-periosteal decortication, cancellous iliac graft, or inter-tibiofibular graft. The decision to fix the non-union (or revise existing fixation) and choice of type of internal fixation depend on the stability of the fracture site. There are also non-operative biological and biochemical consolidation stimulation techniques: local injection of bone-marrow, platelet-rich plasma (PRP) or bone morphogenetic protein (BMP). Stimulation can also be physical, applying ultrasound or an electromagnetic field to the non-union site. Each technique may be used in isolation or association.

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.

Teriparatide treatment of femoral fracture nonunion that autogenous bone grafting failed to heal: a case report.

PURPOSE: Management of fracture nonunion is challenging as another surgical intervention for the patient is often a necessity, which has a huge impact on both quality of life and economic burden of the patient. Thus, a less aggressive and better accepted treatment for nonunion is required. METHODS: We gave teriparatide to a 45-year-old man with femoral fracture nonunion 1 year after he underwent surgery with autogenous bone grafting that failed to heal his initial nonunion. Successful union was obtained after once-daily administration of teriparatide for 9 months. RESULTS: Our case showed teriparatide could successfully treat a femoral fracture nonunion that autogenous bone grafting failed to heal. CONCLUSIONS: Teriparatide may provide an alternative treatment for fracture nonunion.

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.

Delayed Union of a Jones Fracture in a Patient With Rothmund-Thomson Syndrome: A Case Report and Review of the Literature.

Rothmund-Thomson syndrome is a rare autosomal recessive genodermatosis, characterized by poikiloderma, small stature, juvenile cataracts, sparse hair, skeletal abnormalities, and a predisposition to osteogenic sarcomas and skin cancers. Although numerous skeletal abnormalities have been described in patients with Rothmund-Thomson syndrome, to our knowledge, only 1 study has shown evidence of delayed fracture healing in a patient with Rothmund-Thomson syndrome. We present the case of a 13-year-old female diagnosed with Rothmund-Thomson syndrome who demonstrated delayed union of her fifth metatarsal after a Jones fracture. She was treated conservatively for 6 weeks with non-weightbearing cast immobilization and was then transitioned to a controlled ankle motion walker for an additional 4 weeks. Two months later, however, she continued to experience pain, and, on radiographic examination, the fracture remained unchanged. Therefore, with her guardian's consent, the patient elected to undergo open reduction and internal fixation of the fifth metatarsal fracture. At 8 weeks postoperatively, the patient reported a subsidence of symptoms and had returned to normal activity. With our report, we hope to increase practitioner awareness that delayed bone healing could be a possibility in patients with Rothmund-Thomson syndrome and encourage consideration of routine imaging and supplementation with calcium and vitamin D. Additionally, the present findings suggest that patients with Rothmund-Thomson syndrome could benefit from early surgical intervention, given their poor bone healing capacity and high likelihood of nonunion. Although the association between impaired bone healing and Rothmund-Thomson syndrome is rational, additional studies are needed to determine the prevalence of chronic nonunion in this patient population.

Post-traumatic nonunion of the clavicle in a 4-year-old boy and the importance of vitamin D level testing.

Clavicle fractures in children are common and usually go on to achieve solid union with closed treatment. A limited number of pediatric clavicle fracture nonunion cases have been reported in the literature, none of which were directly associated with hypovitaminosis D. We report the youngest case to our knowledge in a 4-year-old vitamin D-deficient male with a 6-month-old right midshaft clavicle fracture nonunion that was treated successfully with vitamin D supplementation, followed by open reduction and internal fixation with autologus iliac crest bone grafting.

Management of the complications of traditional bone setting for upper extremity fractures: the experiences of a French Forward Surgical Team in Chad.

The practice of traditional bone setting (TBS) in sub-Saharan Africa often leads to severe complications after upper extremity fracture. The purpose of this study was to evaluate the management of these complications by a French Forward Surgical Team deployed in Chad. An observational, prospective study was conducted over a six-month period between 2010 and 2011. During this period 28 patients were included. There were 20 males and 8 females with a mean age of 30.6 years (range 5-65 years). Thirteen patients (47%) had mal-union of their fracture, nine had non-union (32%), three children (10.5%) presented gangrene and three patients (10.5%) suffered from other complications. Fifteen (54%) patients did not undergo a corrective procedure either because it was not indicated or because they declined. Only 13 (46%) patients were operated on. Twelve of these patients were reviewed with a mean follow-up of 2.4 months. All of them were satisfied with conventional treatment. The infection seemed to be under control in every septic patient. Bone union could not be evaluated in most patients because of the short follow-up. Management of TBS complications is always challenging, even in a deployed Western medical treatment facility. Surgical expectations should be low because of the severity of the sequelae and the uncertainty of patient follow-up. Prevention remains the best treatment.

Early application of pulsed electromagnetic field in the treatment of postoperative delayed union of long-bone fractures: a prospective randomized controlled study.

BACKGROUND: Pulsed electromagnetic field (PEMF) is reported to be an effective adjunct for the management of nonunion long-bone fractures. Most studies implement PEMF treatment after 6 months or longer of delayed union or nonunion following fracture treatment. Despite these variations in treatment, the early application of PEMF following a diagnosis of a postoperative delayed union has not been specifically analyzed. In this study, the outcomes of postoperative delayed union of long-bone fractures treated with an early application of PEMF were evaluated as compared with a sham-treated control group. METHODS: In this prospective, randomized controlled study, a total of 58 long-bone fracture patients, who presented with delayed union of between 16 weeks and 6 months, were randomly split into two groups and subjected to an early application of PEMF or sham treatment. Clinical and radiological assessments were performed to evaluate the healing status. Treatment efficacy was assessed at three month intervals. RESULTS: Patients in the PEMF group showed a higher rate of union than those in the control group after the first three months of treatment, but this difference failed to achieve statistical significance. At the end of the study, PEMF treatment conducted for an average of 4.8 months led to a success rate of 77.4%. This was significantly higher than the control, which had an average duration of 4.4 months and a success rate of 48.1%. The total time from operation to the end of the study was a mean of 9.6 months for patients in the PEMF group. CONCLUSIONS: Fracture patients treated with an early application of PEMF achieved a significantly increased rate of union and an overall reduced suffering time compared with patients that receive PEMF after the 6 months or more of delayed union, as described by others.

Backout of the helical blade of proximal femoral nail antirotation and accompanying fracture nonunion.

This article describes a case of backout of the helical blade, a rare complication of proximal femoral nail antirotation. A 31-year-old man had sustained a trochanteric fracture of his right femur. Fracture fixation using proximal femoral nail antirotation and autologous bone grafting 7 months later were performed at another hospital. However, bony union was not obtained, and the patient's pain and limp persisted. Therefore, he presented to the current authors. A radiograph taken at presentation revealed backout of the helical blade and fracture nonunion. A radiograph taken 1 month later showed a more advanced backout of the helical blade. The authors performed exchange nailing supplemented with transplantation of peripheral blood CD34-positive cells and autologous bone grafting. The proximal femoral nail antirotation was revised to a long gamma 3 nail, and a U-lag screw was used to obtain better stability. The postoperative course was uneventful. The patient regained ambulation without pain or support at 12 weeks postoperatively. Radiographic bony union was completed 9 months postoperatively. At 1-year follow-up, he could run and stand on the previously injured leg and had returned to work. Backout of the helical blade should be considered as a possible complication of proximal femoral nail antirotation. Incomplete fixation of the helical blade is the possible reason for backout. The use of a helical blade in young patients may cause difficulty in insertion and result in incomplete fixation.

Complications of treatment of musculoskeletal injuries by bone setters.

BACKGROUND: Traditional bone setters (TBS) have existed for decades in Nigeria and other countries. Their treatment methods often lead to several complications, the most dangerous being extremity gangrene which usually leads to proximal amputation. OBJECTIVE: To apprise the Orthodox Practitioners of complications of musculoskeletal injuries treated by the bone setters, the factors that encourage patronage of TBS services and the outcome of the treatment of these complications by the orthodox practitioners. METHODS: This was a one-year prospective study involving one hundred and twenty-one consecutive patients presenting with complications related to treatment of their musculoskeletal injuries by bone setters. The following data were obtained using observer-administered questionnaires viz; demography, details of initial injury, reasons for patronage of TBS, nature of treatment, estimated cost of treatment and disability of patients at presentation. The outcome of orthodox treatment of these complications was assessed at six months using the following parameters --wound healing, bone union and use of prosthesis by the patients. RESULTS: One hundred and twenty-one patients with 155 musculoskeletal injuries and 168 complications of treatment by the TBS were seen 75 (57%) were male and 52 (43%) were female. The ages of the patients ranged from 6 weeks--72 years (mean 29.49 years). The common complications of TBS treatment were malunion and non-union which each accounted for 27 (16.1%) cases. The major reasons for TBS patronage was the perceived low cost of treatment in 47 (27.9%) and pressure from family and friends in 36 (25%) patients. The cost of treatment of the TBS ranged from USD 18-380, whereas, at the Orthopaedic Hospital, it ranged from USD 34-98. At six months after orthodox surgery, 10 (91%) of the patients who had amputation were yet to start using prosthesis, 3 (23%) who had internal fixation failed to unite. CONCLUSION: The commonest reason for patronage was the believed cheapness of the TBS services. However, this study showed that orthodox treatment is actually cheaper in most cases. Despite all the complications associated with their treatment, majority of the people still have a strong belief in their capability. A suggested solution will be the incorporation of the TBS into the healthcare system so that they could be better trained and controlled.

Complications of paediatric elbow trauma treatment by traditional bonesetters.

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.

The complications seen from the treatment by traditional bonesetters.

Traditional bone setters are rampant in the West African subregion but the atrocities committed by them have never been reported hence the need for this article that deals with the menace caused by them. All patients referred to the University College Hospital between 1996 and 2001 were included in this study. Only a few number of the patients have been selected just to illustrate the menace caused by the traditional bonesetters in so many African societies. The deformities, financial loss and amputations resulting from the management by traditional bonesetters have been highlighted. Suggestions are made on how to improve awareness in the way of adequate communications through televisions, radio and the press. Much need to be done in the society as it was found in the study that poverty or lack of education alone is not the major cause of the society seeking the help of the traditional healers, but probably the culture and traditional beliefs of the society.

Complications of fracture treatment by traditional bonesetters in southwest Nigeria.

BACKGROUND: Traditional bonesetters (TBS) practice widely in Nigeria. OBJECTIVE: Our aim was to evaluate the types of complications seen in patients previously treated by TBS and to assess factors that may predispose to the complications. METHODS: We carried out a prospective non-randomized controlled study in a general hospital in southwest Nigeria. All patients brought into the hospital over the 10-month study period with fractures who had been treated previously by a TBS and, as a control, all patients brought directly to and treated by us were studied. Each patient was assessed and prescribed the most appropriate treatment for their fracture: reduction, immobilization (operatively and otherwise) and physiotherapy. Malunion, non-union, delayed union, gangrene, stiffness of joints and loss of joint motion, Volkman's ischaemic contracture and tetanus were all investigated. RESULTS: Over half of the patients in the TBS subgroup had malunion, and a quarter had non-union. Only one out of the 36 (2.8%) had no complaints and was satisfied with the outcome of treatment of his fractures by the TBS. In the orthodox subgroup, there were seven complications as a result of treatment of a total of 49 bones (14%). Most of the complications involved the loss of joint motion. CONCLUSIONS: There were no statistically significant associations between the complications recorded and the ages of the patients, types of bone fractured or the duration of treatment in patients who were in the TBS subgroup. The introduction of a health insurance scheme in Nigeria may make it easier for individuals and families to be able to afford proper fracture treatment in hospitals.

Treatment of recalcitrant non-union with a capacitively coupled electrical field. A preliminary report.

Twenty-two well established non-unions in twenty patients were treated with a capacitively coupled electrical signal (sine wave, sixty kilohertz, five volts peak to peak) that was applied non-invasively through stainless-steel capacitor plates placed on the skin surface overlying the approximate site of the non-union. The average age of the eleven female and nine male patients in this series was 38.4 years, and the average duration of the twenty-two non-unions was 3.3 years. Seventeen of the non-unions were labeled recalcitrant, meaning that they had failed to heal after either previous bone-grafting or another type of electrical stimulation, or both. Five of the non-unions had not been previously treated. Seventeen (77.3 per cent) of the non-unions achieved solid osseous union after an average of 22.5 weeks of treatment with capacitive coupling. The results in this small series were not affected by the non-union being recalcitrant, by the fact that one patient bore full weight on the extremity in a cast, by the presence of osteomyelitis, or by the presence of remaining metallic internal-fixation devices in the bone. Since capacitive coupling is non-invasive, involves portable equipment, allows full weight-bearing on the lower extremity in a cast, is easy to apply, and does not require precise localization of the capacitor plates, it has distinct advantages over other methods of treating non-union with electricity.

Experimental model of electric stimulation of pseudarthrosis healing.

The effect of electric stimulation with direct constant current in induced pseudarthrosis was investigated in the radius of adult dogs. Two surgical techniques for inducing nonunion in the lower third of the radius of adult dogs are also described. Results were evaluated by clinical, radiologic, and histologic examinations and by 99mTc scintillation. A total of 57 animals (41 electrically stimulated and 16 control animals) was used. Statistically significant data show activation of endochrondral ossification and bone union by electric stimulation.