The effects of diabetes medications on post-operative long bone fracture healing.

PURPOSE: Diabetes has long been known to have an impact on bone repair. More recently, however, most diabetic patients receive medications to normalise this hyperglycaemic environment. To date, no studies have investigated the effects of diabetic medications on fracture healing in humans. METHOD: Patients were identified from two tertiary trauma centres. Inclusion criteria were adult patients having sustained a closed diaphyseal femoral or tibial fracture, treated surgically. Exclusion criteria were open, pathological or peri-prosthetic fractures, and patients having sustained polytrauma. Matched non-diabetic controls were identified, matched for age, sex, fracture classification and osteosynthesis. Output measures were: time to callus first appearance, bridging of involved cortices and time to union, along with the eventual outcome: union/non-union. RESULTS: A total of 36 (25 males) eligible patients were identified with a control group of 166 patients (138 males). ANOVA demonstrated class of medication to have a significant effect at two of the three time points and on the eventual outcome. Multiple regression analysis also demonstrated significant impact (p = 0.02). CONCLUSION: All classes of medication demonstrated anti-osteogenic effects compared to the control cohort. Biguanides demonstrated this in contrast to the in vitro evidence to date. Sulphonylureas demonstrated this to a greater extent; however, no in vitro evidence is available for comparison within this class. Clinicians should be aware of these delays in bone healing when treating diabetic patients and aim for optimal blood glucose control until such time as further research can be undertaken.

Revision anterior cruciate ligament reconstruction: an update.

With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.