Outcome after polyaxial locking plate osteosynthesis in proximal tibia fractures: a prospective clinical trial.

BACKGROUND: The aim of this study was to evaluate the clinical and/or radiologic outcome using different polyaxial locking plates for the treatment of proximal tibia fractures, the Non-Contact-Briding plate (NCB-PT®) by Zimmer or the Variable Angle Locking Compression Plate (VA-LCP®) by Synthes. METHODS: This study enrolled 28 patients with proximal tibia fractures (AO/ OTA 41 B-C) and indication for locking plate osteosynthesis. All patients were treated with a polyaxial locking plate system. Depending on the fracture morphology, patients were either treated with a NCB-PT® or VA-LCP®. The implant was chosen according to the surgeon's experience and preference, in case of a higher degree of comminution the tendency was observed to use the NCB-PT® plate. After a time interval of 12 months postoperative we conducted clinical (e.g. range of motion, the Rasmussen score) and radiological (e.g. primary/secondary loss of reduction) follow-ups. RESULTS: Patients provided with the NCB-PT® (9 patients) showed longer operation time, use of longer implants, longer interval from injury to surgery and lower clinical scores after the 12 months follow-up compared with the VA-LCP® group (19 patients). Interestingly, the results showed no significant differences regarding the clinical and radiologic outcome. CONCLUSIONS: The small number of patients as well as the heterogeneity of fractures constitute a limitation of this study. Nevertheless, the differentiated use of implants is associated with comparable clinical and radiological outcomes. This trial emphasizes the need for further prospective randomised trials with higher patient numbers. TRIAL REGISTRATION: Retrospectively registered 21.12.2020. Registration number NCT04680247 .

Perioperative multi-system optimization protocol in elderly hip fracture patients: a randomized-controlled trial.

PURPOSE: Hip fractures in elderly patients are associated with increased postoperative morbidity and mortality. We evaluated whether a perioperative multi-system optimization protocol can reduce postoperative complications in these patients. METHODS: Immediately after diagnosis of hip fracture, patients ≥ 60 yr were randomized to an intervention or control group. Patients in the intervention group were admitted to our postanesthesia care unit where they were treated with goal-directed hemodynamic management, optimized pain therapy, oxygen therapy, and optimized nutrition. Patients in the control group were managed according to our usual standard of care on a regular ward. Postoperative complications during hospital stay included pre-determined cardiovascular, respiratory, neurologic, renal, or surgical events. RESULTS: The incidence of at least one postoperative complication (primary outcome) was seen in 32 of 65 (49%) controls compared with 24 of 62 (39%) in the intervention group (relative risk [RR], 0.79; 95% confidence interval [CI], 0.53 to 1.17; P = 0.23). The secondary unadjusted outcomes showed that patients in the intervention group received more Ringer's acetate compared with controls (median difference, 1.3 L; 95% CI, 0.6 to 2.1 L; P < 0.001), had more frequently a mean arterial pressure > 70 mmHg (57% control vs 75% intervention; median percentage difference, 16%; 95% CI, 7 to 25%; P = 0.001), better pain control (numeric rating scale < 4 at all postoperative measurements; 25% control vs 81% intervention; RR, 0.26; 95% CI, 0.15 to 0.43; P < 0.001), and possibly a lower incidence of acute renal failure (RR, 0.37; 95% CI, 0.14 to 0.98; P = 0.04). CONCLUSIONS: The implementation of a perioperative multi-system optimization protocol algorithm did not significantly reduce the risk of postoperative complications. Nevertheless, we likely over-estimated the potential treatment effect in our study design and thus were under-powered to show an effect. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01673776). Registered 23 August, 2012.

Balloon-guided inflation osteoplasty in the treatment of Hill-Sachs lesions of the humeral head: case report of a new technique.

BACKGROUND: The use of the extra-vertebral balloon osteoplasty is increasing and in the meanwhile it has become a safe surgical technique in the treatment of tibial head, distal radius and calcaneus fractures. In addition, we already could show in a biomechanical setup that the balloon osteoplasty might be a safe tool for reduction in the treatment of Hill-Sachs lesions, but clinical application has not been performed so far. CASE PRESENTATION: We report the case of a 53 year- old male patient who was referred to our Trauma department (level I trauma center) after the first manifestation of a posterior shoulder dislocation due to an epileptic seizure, originated in a- up to this date unknown -glioblastoma. After closed reduction of the dislocated shoulder the X-ray showed a subcapital fracture of the proximal humerus with a large reversed Hill-Sachs lesion. We performed an open surgery via a deltoideopectoral approach and balloon osteoplasty was used to reduce the impression fracture (Hill-Sachs lesion) before fixing the fracture with a locking plate. In the post-operative CT scan we could show an anatomical reduction of the Hill-Sachs lesion. At the follow-up examination one year after surgery the patient reached full range of motion and stated no re-dislocation of the shoulder nor instability or pain. CONCLUSION: The reduction of an impressed humeral head fracture by use of balloon osteoplasty is a safe technique. This technique could be a new option in the treatment of Hill-Sachs lesions and might be an alternative to well known standard procedures like the remplissage or tendon transfers without affecting rotation.

Green Tea Extract (GTE) improves differentiation in human osteoblasts during oxidative stress.

BACKGROUND: Oxidative stress is involved in the pathogenesis of bone diseases such as osteoporosis, which has a high coincidence with fractures in elderly. Several studies showed positive effects of herbal bioactive substances on oxidative stress. This study analyses the effect of green tea extract (GTE) Sunphenon 90LB on primary human osteoblasts differentiation and viability during H2O2-induced oxidative stress. Moreover, it was analyzed, whether GTE acts during the HO-1 signaling pathway. METHODS: Human osteoblasts were isolated from femoral heads of patients undergoing total hip replacement. Beneficial effects of GTE on osteoblasts were examined in a dose- and time-dependent manner. Furthermore, GTE was given before, simultaneous with and after induction of oxidative stress with 1 mM H2O2 to simulate prophylactic, acute and therapeutic use, respectively. Cell damage was measured by LDH leakage and cell viability by MTT assay. Flow cytometry was applied to measure formation of Reactive Oxygen Species by using 2`7`-dichlorofluorescein-diacetate. The formation of Extracellular Matrix after differentiation with GTE supplementation during oxidative stress was visualized with von Kossa and Alizarin Red staining. Last one was additionally photometrically quantified. To assess the effects of H2O2 and GTE on the osteogenic genes, RT-PCR was performed. To evaluate the intramolecular influence of GTE after the stimulation the protein levels of HO-1 were analyzed. RESULTS: Stimulation of primary human osteoblasts with low doses of GTE during oxidative stress over 21 days improved mineralization. Furthermore, GTE supplementation in combination with H2O2 leads to a higher gene expression of osteocalcin and collagen1α1 during osteoblasts differentiation. Both are important for bone quality. Pre-incubation, co-incubation and post-incubation of osteoblasts with high doses of GTE protect the osteoblasts against acute oxidative stress as shown by increased cell viability, decreased LDH leakage, and reduced production of intracellular free radicals. Functional analysis revealed an increased HO-1 protein synthesis after stimulation with GTE. CONCLUSIONS: Incubation of human primary osteoblasts with GTE significantly reduces oxidative stress and improves cell viability. GTE also has a beneficial effect on ECM production which might improve the bone quality. Our findings suggest that dietary supplementation of GTE might reduce inflammatory events in bone-associated diseases such as osteoporosis.

Safe surgical technique: cement-augmented pedicle screw instrumentation and balloon-guided kyphoplasty for a lumbar burst fracture in a 97-year-old patient.

BACKGROUND: During the last few years, an increasing number of unstable thoracolumbar fractures, especially in elderly patients, has been treated by dorsal instrumentation combined with a balloon kyphoplasty. This combination provides additional stabilization to the anterior spinal column without any need for a second ventral approach. CASE PRESENTATION: We report the case of a 97-year-old male patient with a lumbar burst fracture (type A3-1.1 according to the AO Classification) who presented prolonged neurological deficits of the lower limbs - grade C according to the modified Frankel/ASIA score. After a posterior realignment of the fractured vertebra with an internal screw fixation and after an augmentation with non-absorbable cement in combination with a balloon kyphoplasty, the patient regained his mobility without any neurological restrictions. CONCLUSION: Especially in older patients, the presented technique of PMMA-augmented pedicle screw instrumentation combined with balloon-assisted kyphoplasty could be an option to address unstable vertebral fractures in "a minor-invasive way". The standard procedure of a two-step dorsoventral approach could be reduced to a one-step procedure.

Treatment for unstable distal clavicle fractures (Neer 2) with locking T-plate and additional PDS cerclage.

PURPOSE: The purpose of the current study was to assess the clinical and radiological results after locking T-plate osteosynthesis with coracoclavicular augmentation of unstable and displaced distal clavicle fractures (Neer type 2). METHODS: Thirty patients, treated between January 2007 and January 2010 were followed up after a median follow-up time of 12.2 months (range 4.7-37.2). The Constant and DASH scores were used to evaluate the clinical outcome, and anterior-posterior and 30° cephalic view radiographs were performed to assess the bony healing. RESULTS: In all patients, the fracture healing was achieved within the first 10 weeks after surgery. All patients regained good or excellent shoulder function and returned to previous occupation and activity levels. The mean Constant and DASH scores were 92.3 points and 6.2 points, respectively. We did not observe any severe intra- or post-operative complication within the time of follow-up. CONCLUSION: The presented technique turned out to be a reliable method providing good results without showing severe complications. LEVEL OF EVIDENCE: Case series, Level IV.

Balloon osteoplasty--a new technique for reduction and stabilisation of impression fractures in the tibial plateau: a cadaver study and first clinical application.

PURPOSE: Fractures of the tibial plateau are among the most severe injuries of the knee joint and lead to advanced gonarthrosis if the reduction does not restore perfect joint congruency. Many different reduction techniques focusing on open surgical procedures have been described in the past. In this context we would like to introduce a novel technique which was first tested in a cadaver setup and has undergone its successful first clinical application. METHODS: Since kyphoplasty demonstrated effective ways of anatomical correction in spine fractures, we adapted the inflatable instruments and used the balloon technique to reduce depressed fragments of the tibial plateau. RESULTS: The technique enabled us to restore a congruent cartilage surface and bone reduction. CONCLUSIONS: In this technique we see a useful new method to reduce depressed fractures of the tibial plateau with the advantages of low collateral damage as it is known from minimally invasive procedures.

Green tea protects human osteoblasts from cigarette smoke-induced injury: possible clinical implication.

PURPOSE: Recent reports discuss the altered bone homeostasis in cigarette smokers, being a risk factor for osteoporosis and negatively influencing fracture healing. Cigarette smoke is known to induce oxidative stress in the body via an increased production of reactive oxygen species (ROS). These increases in ROS are thought to damage the bone-forming osteoblasts. Naturally occurring polyphenols contained in green tea extract (GTE), e.g., catechins, are known to have anti-oxidative properties. Therefore, the aim of this study was to investigate whether GTE and especially catechins protect primary human osteoblasts from cigarette smoke-induced damage and to identify the underlying mechanisms. METHODS: Primary human osteoblasts were isolated from patients' femur heads. Cigarette smoke medium (CSM) was obtained using a gas-washing bottle and standardized by its optical density (OD(320)) at λ = 320 nm. ROS formation was measured using 2'7'dichlorofluorescein diacetate, and osteoblasts' viability was detected by resazurin conversion. RESULTS: Co-, pre-, and post-incubation with GTE and catechins significantly reduced ROS formation and thus improved the viability of CSM-treated osteoblasts. Besides GTE's direct radical scavenging properties, pre-incubation with both GTE and catechins protected osteoblasts from CSM-induced damage. Inhibition of the anti-oxidative enzyme HO-1 significantly reduced the protective effect of GTE and catechins emphasizing the key role of this enzyme in GTE anti-oxidative effect. CONCLUSIONS: Our data suggest possible beneficial effects on bone homeostasis, fracture healing, and bone mineral density following a GTE-rich diet or supplementation.

Quercetin protects primary human osteoblasts exposed to cigarette smoke through activation of the antioxidative enzymes HO-1 and SOD-1.

Smokers frequently suffer from impaired fracture healing often due to poor bone quality and stability. Cigarette smoking harms bone cells and their homeostasis by increased formation of reactive oxygen species (ROS). The aim of this study was to investigate whether Quercetin, a naturally occurring antioxidant, can protect osteoblasts from the toxic effects of smoking. Human osteoblasts exposed to cigarette smoke medium (CSM) rapidly produced ROS and their viability decreased concentration- and time-dependently. Co-, pre- and postincubation with Quercetin dose-dependently improved their viability. Quercetin increased the expression of the anti-oxidative enzymes heme-oxygenase- (HO-) 1 and superoxide-dismutase- (SOD-) 1. Inhibiting HO-1 activity abolished the protective effect of Quercetin. Our results demonstrate that CSM damages human osteoblasts by accumulation of ROS. Quercetin can diminish this damage by scavenging the radicals and by upregulating the expression of HO-1 and SOD-1. Thus, a dietary supplementation with Quercetin could improve bone matter, stability and even fracture healing in smokers.

TGF-ß1 as possible link between loss of bone mineral density and chronic inflammation.

BACKGROUND: The TGF family plays a key role in bone homeostasis. Systemic or topic application of proteins of this family apparently positively affects bone healing in vivo. However, patients with chronic inflammation, having increased TGF-ß(1) serum-levels, often show reduced bone mineral content and disturbed bone healing. Therefore, we wanted to identify intracellular mechanisms induced by chronic presence of TGF-ß(1) and their possible role in bone homeostasis in primary human osteoblasts. METHODOLOGY/PRINCIPAL FINDINGS: Osteoblasts were isolated from femur heads of patients undergoing total hip replacement. Adenoviral reporter assays showed that in primary human osteoblasts TGF-ß(1) mediates its signal via Smad2/3 and not Smad1/5/8. It induces proliferation as an intermediate response but decreases AP-activity and inorganic matrix production as a late response. In addition, expression levels of osteoblastic markers were strongly regulated (AP↓; Osteocalcin↓; Osteopontin↑; MGP↓; BMP 2↓; BSP2↓; OSF2↓; Osteoprotegerin↓; RANKL↑) towards an osteoclast recruiting phenotype. All effects were blocked by inhibition of Smad2/3 signaling with the Alk5-Inhibitor (SB431542). Interestingly, a rescue experiment showed that reduced AP-activities did not recover to base line levels, even 8 days after stopping the TGF-ß(1) application. CONCLUSIONS/SIGNIFICANCE: In spite of the initial positive effects on cell proliferation, it is questionable if continuous Smad2/3 phosphorylation is beneficial for bone healing, because decreased AP-activity and BMP2 levels indicate a loss of function of the osteoblasts. Thus, inhibition of Smad2/3 phosphorylation might positively influence functional activity of osteoblasts in patients with chronically elevated TGF-ß(1) levels and thus, could lead to an improved bone healing in vivo.

C-reactive protein levels for early detection of postoperative infection after fracture surgery in 787 patients.

BACKGROUND AND PURPOSE: For early detection of postoperative infections, the level of C-reactive protein (CRP) may be useful. We analyzed baseline and time-dependent reference values for the postoperative use of CRP as an indicator of infection. METHODS: We studied the kinetics of CRP levels after fracture surgery in 1,418 patients. In 787 cases the operative fracture treatment was uneventful; in 17 of the other cases a deep wound infection occurred. RESULTS: In the uneventful cases, a similar evolution in CRP concentrations was found: the peak level, which occurred on the second postoperative day, depended on the region (136 mg/L in femoral fractures and 45 mg/L in ankle fractures) and reflected the extent of surgical trauma. For deep wound infection, a cutoff level of 96 mg/L (sensitivity 92%, specificity 93%) after the fourth day of surgery was recorded. INTERPRETATION: CRP kinetics permit establishment of a time-dependent set of reference values of CRP after operative fracture treatment. Deviations of this course--especially CRP concentrations above 96 mg/L after the fourth day--may aid in early detection of surgical complications.

C-reactive protein as a parameter of surgical trauma: CRP response after different types of surgery in 349 hip fractures.

BACKGROUND: Postoperative C-reactive protein (CRP) levels in serum appear to reflect surgical trauma. We examined CRP levels after different types of surgery in hip fractures. METHODS: We studied the CRP response after 349 operative procedures in proximal femur fractures with a normal postoperative course. 5 different operative techniques were used: 3-4 percutaneous cancellous screws, dynamic hip screw (DHS), proximal femur nail (PFN), hemiarthroplasty (HA), and total hip arthroplasty (THA). RESULTS: Peak CRP levels were reached on the second postoperative day in each group (medians: screws 8.7, DHS 12, PFN 14, HA 16, THA 16 mg/dL). Significant differences were found between screws and all others, and between DHS and arthroplasties. INTERPRETATION: CRP levels following surgical trauma can be used to quantify the degree of tissue damage and invasiveness of a procedure and reflect the perioperative stress experienced by the patient.