Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes.

PURPOSE: To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated. METHODS: PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted. RESULTS: Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively. CONCLUSION: A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.

Traumatic hip dislocation in the paediatric population: A case series from a specialist centre.

INTRODUCTION: Traumatic hip dislocation is a rare injury in the paediatric population. It can occur after high energy trauma, but also after lower energy injuries especially in younger children. Posterior dislocation is the most common pattern of hip dislocation. In most cases, closed reduction is successful, but occasionally open reduction is required to achieve concentric reduction. The aim of our study was to present the 10-year experience from a Level-1 Trauma Paediatric Hospital and to comment on how our experience correlates with the current literature. PATIENTS AND METHODS: This is a retrospective case series of all paediatric patients (< 16 years old) with a traumatic hip dislocation presented and/or treated at our institution, between the 1st of January 2010 and 31st August 2020. RESULTS: Thirteen cases of traumatic hip dislocation were identified. There were 7 females. The mean age was 9.8 years. Typically, younger patients were involved in lower energy injuries. The direction of hip dislocation was posterior in ten cases. Associated injuries were seen in eight patients. All cases underwent closed reduction, which was successful in nine cases. Mean time to reduction was 6.8 hours. Post reduction imaging with CT and/or MRI was performed in all cases. There was residual subluxation in three cases, requiring open reduction. In one case with unrecognised undisplaced physeal injury, closed reduction resulted in a Delbet type 1 hip fracture. Two cases developed avascular necrosis (AVN). CONCLUSIONS: Traumatic paediatric hip dislocation is a rare injury. A target of 6 hours for reduction should be employed as this will reduce the risk of AVN in those who have not permanently damaged the vessels at the time of injury. We advocate all attempts for closed reduction to be performed in an operating theatre with the use of an image intensifier to help identifying associated injuries and confirm concentric reduction. If closed reduction fails, open reduction is required. Post-reduction MRI is an important adjunct to recognise associated soft tissue injuries. Follow up of patients should continue for 2 years as a minimum to help detect AVN.

Combined caesarean section and open reduction internal fixation for the treatment of an acetabular fracture in late pregnancy.

In this case, we opted for dual surgery combining caesarean section and internal fixation of acetabular fracture in late pregnancy, which allowed safe foetal delivery, fracture repair and early ambulation of the mother. In similar cases, this method could be potentially considered in the armamentarium of treatment options, aiming to facilitating prompt motherhood input and early hospital discharge, as well as minimising the risk of post-traumatic arthritis of the hip.

Outcomes of polytrauma patients with diabetes mellitus.

BACKGROUND: The impact of diabetes mellitus in patients with multiple system injuries remains obscure. This study was designed to increase knowledge of outcomes of polytrauma in patients who have diabetes mellitus. METHODS: Data from the Trauma Audit and Research Network was used to identify patients who had suffered polytrauma during 2003 to 2011. These patients were filtered to those with known outcomes, then separated into those with diabetes, those known to have other co-morbidities but not diabetes and those known not to have any co-morbidities or diabetes. The data were analyzed to establish if patients with diabetes had differing outcomes associated with their diabetes versus the other groups. RESULTS: In total, 222 patients had diabetes, 2,558 had no past medical co-morbidities (PMC), 2,709 had PMC but no diabetes. The diabetic group of patients was found to be older than the other groups (P <0.05). A higher mortality rate was found in the diabetic group compared to the non-PMC group (32.4% versus 12.9%), P <0.05). Rates of many complications including renal failure, myocardial infarction, acute respiratory distress syndrome, pulmonary embolism and deep vein thrombosis were all found to be higher in the diabetic group. CONCLUSIONS: Close monitoring of diabetic patients may result in improved outcomes. Tighter glycemic control and earlier intervention for complications may reduce mortality and morbidity.

The genetic profile of bone repair.

Bone repair following a fracture is a complex, well orchestrated, physiological process in response to injury. Even though the exact number of the genes and expressed proteins involved in fracture healing remains unknown, the molecular complexity of the repair process has been demonstrated, and it involves numerous genes and molecules, such as extracellular matrix genes, growth and differentiation factors, matrix metalloproteinases, angiogenic factors and others. Discrepancies in fracture healing responses and final outcome seen in the clinical practice may be attributed among other factors to biological variations between patients and different genetic "profiles", resulting in "altered" signalling pathways that regulate the bone repair process. Preliminary human studies support a "genetic" component in the pathophysiology of impaired bone repair seen in atrophic non-unions by correlating genetic variations of specific molecules regulating fracture healing with non-union. However, the role of the genetic "profile" of each individual in fracture healing and final outcome, and its possible interaction with other exogenous factors remains a topic of extensive research.

Implant longevity, complications and functional outcome following proximal femoral arthroplasty for musculoskeletal tumors: a systematic review.

A systematic review of the literature was undertaken to evaluate the outcomes and complications following proximal femoral arthroplasty for primary or metastatic tumors affecting the proximal femur. Six hundred sixty-eight patients were available for review. The length of resection ranged from 92 to 212 mm. Limb salvage rate reached over 90%. At 5 years the implant survival rate was 84% and at 10 years, it was 70%. The overall revision rate was 11.1%. Prevalence of venous thrombo-embolic (VTE) events was 8.5%, dislocation rate was 5.8%, infection was 5.2%, local tumor reoccurrence was 4.7%, perioperative mortality was 1.5%, and periprosthetic fracture was 0.6%. Where it was provided the Musculoskeletal Tumour Score was 70.8%. The implants tend to outlive patients with metastatic disease and high-grade localized disease, providing them with a relatively pain-free limb with good mobility and quality of life.

"Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature".

BACKGROUND: The purpose of this study is to evaluate the functional outcome, union and complication rates after surgical treatment of unstable or displaced proximal humeral fractures using the Polarus intramedullary nail, by reviewing our institutional experience and the relevant current literature. METHODS: Twenty-seven patients were treated operatively for proximal humeral fracture using the Polarus nail. Fractures were classified according to Neer's classification. A number of parameters including patient demographics, mechanism of injury, operative time, time to union and complications were recorded. Functional outcome was evaluated using the Constant Shoulder Score. A comparison among functional outcomes in patients >60 years in relation to the younger ones was performed. Moreover, a review of the literature was carried out to evaluate the overall union and complication rates. RESULTS: Two patients lost to follow-up were excluded from the analysis. For the twenty-five patients (mean age: 61 years), the mean follow-up was 36 months. There were 7 complications (28%), including one fixation failure, four protruded screws, one superficial infection and one case of impingement. The union rate was 96% (mean time to union: 4.2 months). The mean Constant score was 74.5 (range: 48-89). Patients under the age of 60 had a better functional outcome compared to patients >60 years of age (p<0.05). From the literature review and from a total of 215 patients treated with a Polarus nail, the mean union rate was 95.8%, the overall reported complication rate, including both minor and major complications, ranged widely from 9.3% up to 70%. CONCLUSIONS: The Polarus nail was found to be an effective implant for stabilisation of proximal humeral fractures. Functional outcome is for the vast majority of the cases excellent or good, but in elderly patients a lower Constant score can be expected.

The role of barrier membranes for guided bone regeneration and restoration of large bone defects: current experimental and clinical evidence.

Treatment of large bone defects represents a great challenge in orthopedic and craniomaxillofacial surgery. Although there are several methods for bone reconstruction, they all have specific indications and limitations. The concept of using barrier membranes for restoration of bone defects has been developed in an effort to simplify their treatment by offering a single-staged procedure. Research on this field of bone regeneration is ongoing, with evidence being mainly attained from preclinical studies. The purpose of this review is to summarize the current experimental and clinical evidence on the use of barrier membranes for restoration of bone defects in maxillofacial and orthopedic surgery. Although there are a few promising preliminary human studies, before clinical applications can be recommended, future research should aim to establish the 'ideal' barrier membrane and delineate the need for additional bone grafting materials aiming to 'mimic' or even accelerate the normal process of bone formation. Reproducible results and long-term observations with barrier membranes in animal studies, and particularly in large animal models, are required as well as well-designed clinical studies to evaluate their safety, efficacy and cost-effectiveness.

Bone graft substitutes: What are the options?

Currently, a number of bone grafting materials are available in the clinical setting to enhance bone regeneration, varying from autologous bone to several bone graft substitutes. Although autologous bone remains the "gold standard" for stimulating bone repair and regeneration, the morbidity from its harvesting and its restricted availability generated the need for the development of other materials or strategies either to substitute autologous bone graft or expand its limited supply. Bone graft substitutes can possess one or more components: an osteoconductive matrix, acting as a scaffold; osteoinductive proteins and other growth factors to induce differentiation and proliferation of bone-forming cells; and osteogenic cells for bone formation. Based on their distinct properties, all these bone grafting alternatives have specific indications, and can be used either alone or in combination. In this review, we summarise the available bone grafting materials, focussing mainly on the various bone substitutes and their characteristics, in an effort to specify the indications for their use.

The role of arterial embolization in controlling pelvic fracture haemorrhage: a systematic review of the literature.

OBJECTIVE: To evaluate the efficacy of emergency transcatheter arterial embolization (TAE) in controlling retroperitoneal arterial haemorrhage associated with unstable pelvic fractures. METHODS: A systematic review of the English literature yielded 21 eligible studies published from 1979 to 2010. Evaluation of clinical and methodological heterogeneity was based on recording certain descriptive characteristics in the component studies. Statistical heterogeneity was detected using Cochran chi-square and I square tests and, when absent, a pooled estimate of effect size for each outcome of interest was calculated. The principal outcomes of interest were efficacy rate of TAE to control intrapelvic bleeding, mortality rates and frequency of associated complications. RESULTS: All component studies were assigned a low to moderate quality score. Methodological and clinical heterogeneity was evident across component studies, but not strongly associated with the observed results. The efficacy rate of TAE ranged from 81 to 100%, while the frequency of repeat TAE for effective control of haemorrhage was 10% (95% CI: 7-13%, range: 0-19%). TAE was associated with an overall mortality ranging from 7 to 47%, and a 0-25% mortality due to intrapelvic bleeding (pooled estimate of effect size: 6%, 95% CI: 4-8%). A very low rate of associated complications were recorded in the component studies (pooled estimate of effect size: 1.1%, 95% CI: 0.1-2.1%). CONCLUSION: TAE is an efficient acute intervention for controlling severe arterial bleeding related to pelvic trauma with a low complication rate. Repeat of the procedure is occasionally necessary before the effective haemorrhage control.

What is the effect of compartment syndrome and fasciotomies on fracture healing in tibial fractures?

Acute compartment syndrome (ACS) in tibial diaphyseal fractures has been associated with such complications as infection, delayed fracture healing or non-union, sensory and motor deficits, deformities, and poor functional outcome. Essential condition of an uncomplicated recovery is early diagnosis with prompt decompression. A comprehensive review of the literature was performed to evaluate the impact of compartment syndrome and leg fasciotomies on the time to fracture union and the incidence of delayed union and non-union in tibial diaphyseal fractures. A total of 16 articles, which included 245 tibial fractures complicated with compartment syndrome were analysed. There were statistically significant differences in the time to healing, being longer by 4.90 weeks (p<0.001), and in the rates of delayed union or non-union (55% versus 17.8%) (p<0.001) when these fractures were compared to tibial fractures without compartment syndrome. Patients with ACS of the tibia undergoing leg fasciotomies should be informed about the increased risk of impaired fracture healing and longer time to union.

Preclinical animal models in trauma research.

Preclinical modeling of human disease with animals has not been standardized for many common pathologic processes. Assorted animal models are being used to investigate the pathogenesis, prevention, and treatment of disease processes. Certainly it is difficult to interpret the current literature because there are diverse and often irrelevant models being implemented. Some models are used for reasons of size or ease rather than the true modeling of a physiological process. Application to granting agencies and design of animal studies is difficult without standardization of the ideal preclinical model for disease states. The current article addresses the preclinical animal modeling of osteoporosis, infection, bone defects, and cartilage injury. This article is a discussion of the current literature, commonly used models, and suggests preferred preclinical models for future research design.

The use of bone graft substitutes in large cancellous voids: any specific needs?

Bone graft is the second most common transplantation tissue, with blood being by far the commonest. Autograft is considered ideal for grafting procedures, providing osteoinductive growth factors, osteogenic cells and an osteoconductive scaffold. Limitations, however, exist regarding donor site morbidity and graft availability. Allograft on the other hand poses the risk of disease transmission. Synthetic graft substitutes lack osteoinductive or osteogenic properties. Composite grafts combine scaffolding properties with biological elements to stimulate cell proliferation and differentiation and eventually osteogenesis. We present here an overview of bone graft substitutes available for clinical application in large cancellous voids.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review.

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Bone regeneration: current concepts and future directions.

Bone regeneration is a complex, well-orchestrated physiological process of bone formation, which can be seen during normal fracture healing, and is involved in continuous remodelling throughout adult life. However, there are complex clinical conditions in which bone regeneration is required in large quantity, such as for skeletal reconstruction of large bone defects created by trauma, infection, tumour resection and skeletal abnormalities, or cases in which the regenerative process is compromised, including avascular necrosis, atrophic non-unions and osteoporosis. Currently, there is a plethora of different strategies to augment the impaired or 'insufficient' bone-regeneration process, including the 'gold standard' autologous bone graft, free fibula vascularised graft, allograft implantation, and use of growth factors, osteoconductive scaffolds, osteoprogenitor cells and distraction osteogenesis. Improved 'local' strategies in terms of tissue engineering and gene therapy, or even 'systemic' enhancement of bone repair, are under intense investigation, in an effort to overcome the limitations of the current methods, to produce bone-graft substitutes with biomechanical properties that are as identical to normal bone as possible, to accelerate the overall regeneration process, or even to address systemic conditions, such as skeletal disorders and osteoporosis.

Masquelet technique for the treatment of bone defects: tips-tricks and future directions.

Reconstruction of diaphyseal bone defects still represents a major clinical challenge. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts. The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome. Future directions to increase its effectiveness and expand its application are also being discussed. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult.

What is the role of the orthopaedic surgeon in management of fragility fractures?

Fragility fractures are the most prevalent trauma condition that orthopaedic surgeons face today. Osteoporosis and susceptibility to falls are the key predisposing factors. Despite evidence supporting the impact of treating osteoporosis on reducing the incidence of fragility fractures, it is often left untreated. Orthopaedic surgeons are often the first physicians to assess and treat the patient after a fragility fracture. Their role therefore does not end in the skillful fixation of the fractures, but they have a unique opportunity to ensure that preventive measures are implemented. This includes falls prevention, investigation of possible causes underlying osteoporosis, attention to diet, exercise, calcium, and vitamin D supplementation as well as prescription of anti-resorptive and anabolic medication. The need for a dedicated multidisciplinary team needs to be emphasized and therefore effective communication between the different parties is of paramount importance.

Genetic predisposition to fracture non-union: a case control study of a preliminary single nucleotide polymorphisms analysis of the BMP pathway.

BACKGROUND: Despite the known multi-factorial nature of atrophic fracture non-unions, a possible genetic predisposition for the development of this complication after long bone fractures remains unknown. This pilot study aimed to address this issue by performing a preliminary SNP analysis of specific genes known to regulate fracture healing. METHODS: A total of fifteen SNPs within four genes of the Bone Morphogenetic Protein (BMP) pathway (BMP-2, BMP-7, NOGGIN and SMAD6) were examined, in 109 randomly selected patients with long bone fractures as a result of motor vehicle accident, fall or direct blow. There were sixty-two patients with atrophic non-union and forty-seven patients (54 fractures) with uneventful fracture union. Overall SNPs frequencies were computed with respect to patient's age, gender, smoking habits, fracture-associated parameters and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and tested for their association to the impaired bone healing process, using binary logistic regression (STATA 11.1; StataCorp, Texas USA). RESULTS: Statistical analysis revealed age to be an important covariate in the development of atrophic non-union (p = 0.01, OR 1.05 [per year]), and two specific genotypes (G/G genotype of the rs1372857 SNP, located on NOGGIN and T/T genotype of the rs2053423 SNP, located on SMAD6) to be associated with a greater risk of fracture non-union (p = 0.02, OR 4.56 and p = 0.04, OR 10.27, respectively, after adjustment for age). CONCLUSIONS: This is the first clinical study to investigate the potential existence of genetic susceptibility to fracture non-union. Even though no concrete conclusions can be obtained from this pilot study, our results indicate the existence of a potential genetically predetermined impairment within the BMP signalling cascade, initiated after a fracture and when combined with other risk factors could synergistically increase the susceptibility of a patient to develop non-union. Further research is desirable in order to clarify the genetic component and its role and interaction with other risk factors in the development of atrophic long bone non-union, as simple genetic testing may contribute to the early identification of patients at risk in the future and the on-time intervention at the biologic aspects of bone healing.