Surgical treatment and management of hip fracture patients.

INTRODUCTION: Osteoporosis-related hip fractures are associated with high mortality and costs. The optimum type of treatment for such fractures is controversial. To shed some light on this issue, the surgical treatment and management of osteoporotic hip fractures were discussed during a hip fracture surgical working group at the 2009 International Society For Fracture Repair Annual Meeting comprising leading experts in the field. MATERIALS AND METHODS: The working group consisted of eight orthopaedic surgeons, six industry representatives and one research scientist. Eleven participants were from Europe and four were from the USA and Canada. Two chairmen posed 12 questions relating to the surgical treatment and management of osteoporotic hip fractures. Each question was discussed and key points were noted. RESULTS: Surgery should commence within 24-48 h but the patient should be optimized if presenting with ≥3 comorbidities. Specialized centres integrating orthopaedics, geriatricians and rheumatologists could be a solution for the lack of specialist care post-surgery. Surgical technique is important in fracture fixation, as is the implant, but there has been no improvement in implant design in the past 50 years. As a consequence, malunion has become unjustifiably accepted. Fracture healing can be accelerated using pharmaceuticals which are also important in secondary prophylaxis. All displaced femoral neck fractures in geriatric patients should be treated with hip replacement, the choice between using cemented or uncemented fixation being at the surgeon's discretion. DISCUSSION AND CONCLUSION: This working group discussion highlighted several important issues which could be of interest to the orthopaedic community.

Healing of segmental bone defects with granular porous hydroxyapatite augmented with recombinant human osteogenic protein-1 or autologous bone marrow.

Hydroxyapatite is a synthetic bone graft, which is used for the treatment of bone defects and nonunions. However, it is a rather inert material with no or little intrinsic osteoinductive activity. Recombinant human osteogenic protein-1 (rhOP-1) is a very potent biological agent, that enhances osteogenesis during bone repair. Bone marrow contains mesenchymal stem cells, which are capable of new bone formation. Biosynthetic bone grafts were created by the addition of rhOP-1 or bone marrow to granular porous hydroxyapatite. The performance of these grafts was tested in a sheep model and compared to the results of autograft, which is clinically the standard treatment of bone defects and nonunions. A 3 cm segmental bone defect was made in the tibia and fixed with an interlocking intramedullary nail. There were five treatment groups: no implant (n=6), autograft (n=8), hydroxyapatite alone (n=8), hydroxyapatite loaded with rhOP-1 (n=8), and hydroxyapatite loaded with autologous bone marrow (n=8). At 12 weeks, healing of the defect was evaluated with radiographs, a torsional test to failure, and histological examination of longitudinal sections through the defect. Torsional strength and stiffness of the healing tibiae were about two to three times higher for autograft and hydroxyapatite plus rhOP-1 or bone marrow compared to hydroxyapatite alone and empty defects. The mean values of both combination groups were comparable to those of autograft. There were more unions in defects with hydroxyapatite plus rhOP-1 than in defects with hydroxyapatite alone. Although the differences were not significant, histological examination revealed that there was more often bony bridging of the defect in both combination groups and the autograft group than in the group with hydroxyapatite alone. Healing of bone defects, treated with porous hydroxyapatite, can be enhanced by the addition of rhOP-1 or autologous bone marrow. The results of these composite biosynthetic grafts are equivalent to those of autograft.

Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations.

BACKGROUND: Studies of traumatic knee dislocations have failed to provide a consensus regarding the best method of treatment. PURPOSE: Our purpose was to evaluate the results after surgical repair or reconstruction versus nonsurgical treatment and to compare the influence of prognostic factors. STUDY DESIGN: Retrospective study. METHODS: Eighty-nine patients were treated for traumatic knee dislocation. Surgical repair or reconstruction of the cruciate ligaments was performed in 63 patients (repair, 49; reconstruction, 14). In 26 patients, nonsurgical treatment was undertaken. RESULTS: At an average follow-up of 8.2 years, the mean Lysholm and Tegner scores were 75 and 3.7, respectively. The outcome in the surgical group was better than in the nonsurgical group. The scores were higher in patients who were 40 years of age or younger, who had sports injuries rather than motor vehicle accident injuries, and who had undergone functional rehabilitation rather than immobilization. CONCLUSIONS: Surgical repair or reconstruction of the cruciate ligaments was superior to nonsurgical treatment. Functional rehabilitation was the most important positive prognostic factor. Surgical repair or reconstruction of the cruciate ligaments is mandatory to achieve sufficient stability for functional rehabilitation. In cases of cruciate ligament avulsion, repair with transosseous fixation is a reasonable alternative to reconstruction, provided that it is performed within 2 weeks of trauma.

Autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects.

Autologous bone grafting is currently considered the treatment of choice for correction of large bone defects. However, to avoid morbidity associated with autologous bone harvesting many artificial bone-substitute materials have been developed over the years. A new generation of resorbable materials is emerging, with promising results so far. In order to investigate the possibility to use one of these new materials as an alternative with better results than hydroxyapatite, an experimental study was performed. A new resorbable calcium phosphate particles and paste forms, the latter of which hardens in situ after application. In 28 sheep, a 3-cm segmental tibial defect was made and intramedullary fixed by an interlocking nail. Twelve weeks after defect filling, radiological, biomechanical, and histological examinations were performed. Mean radiographic and biomechanical tests results were compared with the Mann-Whitney test. Significance was set at p<0.05. Radiographically, the resorbable paste group performed better than all other groups. Biomechanical investigations showed a higher torsional stiffness (p=0.049) for the resorbable calcium-phosphate paste group in comparison with autologous bone. On histological examination, no adverse effects were observed in the calcium-phosphate groups. Resorption by osteoclasts was seen in the resorbable implants. In conclusion, the current study shows an advantageous radiological and mechanical outcome for resorbable calcium phosphates. This indicates that these new materials might be a potential alternative for autologous bone grafting in humans.

Proprioception and EMG pattern after capsulolabral reconstruction in shoulder instability: a clinical and experimental study.

The anterior capsulolabral reconstruction according to JOBE [13] is a modification of the Bankart operation. The capsular shift is performed via a subscapularis-split approach avoiding any incision into the musculature. A total of 43 patients with posttraumatic, chronic anterior shoulder instability underwent surgery. All patients had at least four dislocations preoperatively. Thirty-five patients were examined after an average of 3.7 +/- 1.4 years. Twenty-nine (82.9%) of these patients were free of pain, with functional assessment showing a mean external rotation deficit of 4.1 degrees +/- 2.9 degrees without any further movement restrictions. On average, a Rowe-Score of 86.1 +/- 12.4 points and an ASES-Score of 93.3 +/- 8.4 were achieved. The reluxation rate was 7.7%. The study demonstrated that despite the good clinical results, only 69% of patients were able to return to their previous sports activity level. This special problem is in agreement with other similar studies [4, 18] so that this relevant fact was further addressed by determination of proprioception and electromyographic muscle activity. Postoperatively, in contrast to other studies [1, 21, 24], a persisting proprioceptive deficit as well as an altered EMG pattern was found together with a significant reduction in activity of the deltoideus muscle on the operated side. These results may explain the problem to achieve complete restitution of the function of the shoulder joint after capsulolabral reconstruction.

Plate fixation with hydroxyapatite-coated screws: a comparative loaded study.

The authors evaluated whether AO/ASIF screws coated with hydroxyapatite are better fixed than standard screws in a highly loaded plate fixation animal study. Twelve sheep were divided into two groups. The medial tibial middiaphysis was exposed and a 5-mm long bone cylinder was removed. The tibiae were fixed with six-hole dynamic compression plates. Six sheep received standard AO/ASIF stainless steel cortical screws (Group A), and six sheep received AO/ASIF stainless steel cortical screws coated with hydroxyapatite (Group B). Three months after surgery, the sheep were euthanized. The mean screw insertion torque was 4800 +/- 768 N/mm in Group A and 4847 +/- 450 N/mm in Group B. The mean screw extraction torque was 530 +/- 374 N/mm in Group A and 3733 +/- 849 N/mm in Group B. Extraction torque of Group A was significantly lower compared with the corresponding insertion torque. In Group B, there were no differences between extraction and insertion torque. Morphologic analyses showed marked fibrous tissue encapsulation in Group A and bone to screw direct contact in Group B. The results confirm that hydroxyapatite-coated AO/ASIF screws prevent deterioration of screw anchorage, even under highly loaded conditions. By using hydroxyapatite-coated screws, complications resulting from inadequate fixation could be avoided.