Bilateral Flexion-Type Supracondylar Humerus Fracture.

Supracondylar humerus fractures are common in the pediatric population, but flexion fractures are very rare in this population. The need for open reduction in these fractures is high and can be challenging for orthopaedic surgeons. In this article, we report a 9-year-old patient with bilateral flexion-type humeral fracture treated with closed reduction, which, to our knowledge, is the first report in the literature. We concluded that the first step in the treatment of flexion-type supracondylar fractures should be closed reduction with the help of an experienced assistant surgeon and that successful results can be obtained even in bilateral flexion-type fractures with appropriate treatment and follow-up.

Unexpected Positive Cultures in Hip and Knee Periprosthetic Fractures.

BACKGROUND: The purpose of this study was to determine the prevalence of unexpected positive cultures noted at the time of revision surgery for periprosthetic fracture (PPF) after total hip or knee arthroplasty. Moreover, we evaluated whether this finding should be considered clinically significant and what type of treatment, if any, was required. METHODS: This was a single-center retrospective review of 270 patients undergoing surgery for PPFs from December 2010 to December 2021. Exclusion criteria included: open fractures; history of infection at fractured joint; non-operatively treated patients; and intraoperative fractures. The primary end point was the prevalence of unexpected positive cultures noted at the time of revision surgery. This was defined as one or more positive cultures in a PPF that the surgeon had preoperatively classified as aseptic according to the 2018 International Consensus Meeting. Data collection included patient demographics, medical histories, preoperative investigations, postoperative microbiology, and treatment. RESULTS: During the study period, 159 patients were admitted with PPFs of the hip and 61 with PPFs of the knee. The mean age was 70 years (range, 32 to 93 years). Unexpected positive cultures were diagnosed postoperatively in 15 patients (6.8%; 10 hips, 5 knees). The most prevalent organism was Staphylococcus epidermidis (35.0%). Of those 15 patients, 6 required a surgical revision for infection. None of the patient-related risk factors were found to be associated with an increased risk of unexpected positive cultures. The comparison between infected and noninfected patients showed a significant association between preoperative C-reactive protein >10 mg/mL (P = .04), loose implant (P = .07), and infection. CONCLUSIONS: The prevalence of unexpected positive cultures was 6.8% in our study cohort. Although surgical treatment may be required, the majority of patients seem to require no treatment. Larger series are required to investigate the clinical importance of this rare finding. LEVEL OF EVIDENCE: III.

In-hospital outcomes following primary and revision total hip arthroplasty in nonagenarian patients.

PURPOSE: The primary goal of this study was to assess the risk of postoperative surgical and medical complications and problems among nonagenarian patients operated with hip arthroplasty. METHODS: Data from a specific high-volume arthroplasty clinic, were collected to evaluate postoperative morbidity and complication rates after hip arthroplasty in nonagenarians, compared with a control group of younger, but similar patients. Outcomes evaluated included length of stay, transfusion rate, and postoperative medical and surgical complication rates. RESULTS: A total of 97 nonagenarian patients (mean age 91.4 years) were included, and compared with 89 control group patients (mean age 70.18 years). Nonagenarian patients had significantly longer length of stay (11.44 vs. 7.98 days, p < 0.01), significantly higher risk of needing a transfusion (11.30% vs. 3.40%, p = 0.04), and significantly higher risk of a postoperative medical complication (28.90% vs. 11.20%, p = 0.03). There was no difference in postoperative surgical complication rate (7.20% vs. 2.20%, p = 0.12). CONCLUSION: Nonagenarian patients, when compared to a younger control group, experience significantly longer hospital stays, and risk of non-surgical complications. Arthroplasty in nonagenarian patients carries with it a high risk of complications, and thus careful pre-operative evaluation and the care of these patients at high volume, specialized clinics is important to optimize outcomes. LEVEL OF EVIDENCE: Level III retrospective cohort analysis.

Neutrophil-Lymphocyte Ratio and Lymphocyte-Monocyte Ratio correlate with Chronic Prosthetic Joint Infection but are not useful markers for diagnosis.

PURPOSE: To investigate reported correlations between Neutrophil-to-Lymphocyte (NLR) and Lymphocyte-to-Monocyte (LMR) ratios and their value in diagnosis of chronic prosthetic joint infection (PJI) in a large cohort of patients from a single specialist hospital. METHODS: Diagnostic aspirations of 362 patients under investigation for PJI were identified. Of the included patients 185 patients received a final diagnosis of PJI and 177 were classed as aseptic. Established criteria (ICM 2018) were employed to define PJI. Included in the analysis are differential white cell counts, C-Reactive Protein (CRP), Synovial Leukocyte Count, Synovial Alpha-defensin ELISA and Synovial Leukocyte esterase activity. Receiver-operator characteristic (ROC) curves were calculated for each of the available diagnostic tests together with the corresponding area under the curve values (AUC). Youden's index was utilized to identify the optimal diagnostic threshold point for the NLR and LMR. Other diagnostic tests were evaluated as per the threshold values previously defined in the literature and specified in the ICM criteria. RESULTS: Using Youden's Index to identify the optimal NLR cut-off within our cohort we established a value of 2.93. This yielded a sensitivity of 0.60 and specificity of 0.64. The area under the curve (AUC) of a receiving operator characteristics (ROC) curve was 0.625. Regarding the LMR the results demonstrate similar findings; a positive correlation with a diagnosis of infection but poor sensitivity and specificity. The AUC for LMR was 0.633 and was not superior to NLR (P = 0.753). CONCLUSIONS: There is a significant correlation between higher Neutrophil-Lymphocyte and Lymphocyte-Monocyte ratios, and a diagnosis of PJI. The sensitivity and specificity of this calculation is poor and the does not add value to the diagnostic algorithm for PJI. LEVEL OF EVIDENCE: Level III Retrospective Cohort analysis.

A secure blood-saving protocol for Jehovah's Witnesses in primary total hip replacement.

OBJECTIVES: The study aimed to analyze the efficacy of the blood management protocol developed by our team for patients who are Jehovah's Witnesses (JW) presenting for primary total hip replacement (THR). PATIENTS AND METHODS: Thirty JW patients (6 males, 24 females; mean age: 70.1±9.8 years; range, 65 to 81 years) and 30 age- and sex-matched controls (6 males, 24 females; mean age: 68.7±9.1 years; range, 62 to 79 years) who underwent primary THR at our institution between January 2018 and June 2020 were retrospectively evaluated. While the surgical technique of THR was not different among the groups, blood loss management differed between the groups. Patients in the control group were given 1 g of intravenous tranexamic acid (TXA) 15 min before the surgical incision. In addition to the same TXA protocol, intraoperative cell salvage with a continuous autologous transfusion system was used for JW patients. The estimated blood loss (EBL) was determined using Meunier's formula. Hemoglobin (Hgb) decline, EBL on the first and third postoperative days, allogenic blood transfusion (ABT) requirement, and complications were analyzed between groups. RESULTS: There were no significant differences between groups regarding demographic and clinical characteristics (p>0.05), ABT requirement (p>0.999), and Hgb decline in the first and third postoperative days (p=0.540 and p=0.836, respectively). Furthermore, both groups did not significantly differ between EBL in the first and third postoperative days (p=0.396 and p=0.616, respectively) and the length of hospital stay (p=0.547). Similar complication rates were noted for both groups. Hemoglobin level assessments revealed that values on the first and third postoperative days were significantly lower than the baseline Hgb value in both cohorts (p<0.001). CONCLUSION: A combination of intravenous administration of 1 g of TXA, meticulous hemostasis, and intraoperative use of cell saver constitutes a reasonable strategy for achieving the goal of transfusion-free primary THR with predictable levels of blood loss that are similar to non-JW patients.

The protective role of vitamins C and E in steroid-induced femoral head osteonecrosis: An experimental study in rats.

OBJECTIVES: This study aimed to determine whether vitamin C (VC) and vitamin E (VE) can effectively protect the femoral head and reduce the risk of developing osteonecrosis in rats that have been treated with steroids. MATERIALS AND METHODS: The study was conducted on 30 young adult male Sprague-Dawley rats (mean weight: 356±18 g; range, 330 to 375 g), which were randomly assigned to one of five groups. The control group received saline solution, while the other groups were given lipopolysaccharide/methylprednisolone (LPS/MPS) to induce osteonecrosis. Three groups in which osteonecrosis was induced were also intraperitoneally administered either VC, VE, or both once a day for four weeks. Intracardiac blood samples were taken at the end of the fourth week for biochemical examination, and the rats were then sacrificed under general anesthesia. After sacrification, right femurs were removed for histopathological, immunohistochemical, and radiologic examinations. RESULTS: The results showed that the mean trabecular number increased significantly in the VC+VE group. There was a substantial decrease observed in the mean trabecular separation within the LPS/MPS group compared to the control group, although trabecular separation decreased in all three vitamin groups compared to the LPS/MPS group. The surface area/bone volume was significantly increased in the VC+VE group compared to the LPS/MPS group. Histological, immunohistochemical, and radiological examinations showed that the administration of VC and VE significantly reduced oxidative stress, inflammation, and microvascular dysfunction in rats with steroid-induced femoral head osteonecrosis. CONCLUSION: This study suggests that VC, VE, and particularly VC+VE have a protective effect on the femoral head in rats with steroid-induced femoral head osteonecrosis. These findings may lead to new treatment options for patients.

What is the diagnostic accuracy of neutrophil to lymphocyte ratio and monocyte to lymphocyte ratio in detecting acute periprosthetic joint infections? A gender-specific analysis.

PURPOSE: The accurate and timely diagnosis of periprosthetic joint infection (PJI) is critical for guiding optimal treatment management and success, highlighting the requirement of readily available inexpensive serum biomarkers to increase the diagnostic accuracy for PJI. Many studies have investigated the diagnostic accuracy of neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte ratio (MLR). However, there is a lack of existing literature regarding optimal thresholds for acute PJI. The purpose of this study was to reveal the most appropriate cut-off values for MLR and NLR in detecting acute PJI with a gender specific analysis. METHODS: Patients were classified as having an acute PJI if they met the International Consensus Meeting (ICM) 2018 modified criteria. Patients who had a negative clinical and diagnostic workup for a PJI and the presence of erythema on the index surgical area were included in the erysipelas group (control group). Data obtained from all patients included age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), procedure type (THA or TKA), serum C-reactive protein (CRP), and blood studies at the admission and culture results were retrieved from the electronic medical record. RESULTS: ROC curve analysis was used to determine the gender-specific optimal threshold values for CRP, NLR, and MLR. Comparing the sensitivities and specificities of NLR and MLR at the identified best thresholds in males and females, the study found similar sensitivities of NLR in males and females with 0.84 and 0.84, respectively. On the other hand, an MLR of 0.67 or more reported a notably higher specificity in male patients [0.90 (95% CI 0.75-0.96) versus 0.70 (95% CI 0.56-0.80)]. CONCLUSION: NLR and MLR represent commonly ordered, low-cost, simple, and readily available complete cell count laboratory values and should be used as adjunct tests with reasonable diagnostic accuracy in detecting acute PJIs. Moreover, with its excellent specificity and PPV, MLR could provide valuable insight in diagnosing acute PJI, particularly in male patients. LEVEL OF EVIDENCE: Level III Retrospective Cohort analysis.

Comparison of the prophylactic use of ibandronate and its use in early-stage osteonecrosis in rats with steroid-induced osteonecrosis of the femoral head.

OBJECTIVES: The aim of this study was to investigate the effects of ibandronate before and after the onset of osteonecrosis in rats with steroid-induced osteonecrosis of the femoral head. MATERIALS AND METHODS: A total of 24 female Sprague-Dawley rats were used in this study. Three groups were formed with eight rats in each group. The first group was the prophylactic group that received ibandronate treatment before and after the onset of osteonecrosis (Group PT). The second group received ibandronate treatment three weeks after the development of osteonecrosis (Group TAO). The third group was the control group in which osteonecrosis was created, but only normal saline (NS) was given. At the end of the study, all rats were sacrificed, and their right femoral heads were removed, fixed with formalin, and sent for micro-computed tomography. Hematoxylin-eosin (H&E) and immunohistochemical examinations of the right femoral head sections were performed. RESULTS: In the PT group, the trabecular thickness was significantly higher compared to those of the TAO and control groups (p<0.05). The trabecular thickness did not significantly differ between the TAO and control groups. The trabecular bone pattern factor was significantly higher in the PT group compared to the control and TAO groups (p<0.05); however, it showed no significant difference between the TAO and control groups. The incidence of type 2 osteonecrosis in the PT and TAO groups was significantly lower than that in the control group (p<0.05). The incidence of tissue-non-specific alkaline phosphatase (TNAPase) immunoreactivity of osteoblast positivity was significantly higher in the PT and TAO groups compared to the control group (p<0.05), whereas the incidence of TRAPase immunoreactivity of osteoclastic positivity was significantly lower in the PT and TAO groups compared to the control group (p<0.05). CONCLUSION: Intravenous administration of ibandronate before the onset of the disease was more effective in the treatment of osteonecrosis in rats with steroid-induced osteonecrosis of the femoral head.

The effects of cephalexin on fracture healing in a rat femur fracture model.

OBJECTIVES: The aim of this study was to examine the effects of cephalexin on the fracture union histomorphometrically, radiologically, biomechanically, immunohistochemically, and histopathologically in a rat femur fracture model and to evaluate the effects of the antibiotics to be used in the prophylaxis of fracture infection on the union of the fracture. MATERIALS AND METHODS: A total of 48 male Wistar rats were divided into four groups as two-week control (C2) and cephalexin (CEP2) and four-week control (C4) and cephalexin (CEP4). After establishment of standard fracture model on right femurs, 60 mg/kg/day of cephalexin was applied to CEP2 and CEP4 by oral gavage. Radiological, biomechanical, histopathological, immunohistochemical, and histomorphometric examinations were performed on amputated femurs. RESULTS: Callus volume of CEP4 group significantly increased compared to CEP2 group (p=0.005), while no significant difference was found in the bone mineral density and callus/bone volume among the groups (p>0.05). There was no significant difference in flexural strength between the C4 and CEP4 groups (p=0.093). Histological healing scores increased from Week 2 to Week 4 (p=0.002) and inflammation scores decreased in both control and cephalexin groups (p=0.010 and p=0.008); however, no significant difference was found in healing and inflammation scores (p>0.05). The CD34+ immunoreactivity in the CEP2 group was significantly higher than the C2 group (p=0.029). Collagen type III level was significantly lower in the CEP2 and CEP4 groups compared to the corresponding control groups (p=0.008 and p=0.016, respectively). CONCLUSION: Cephalexin did not exert any radiological, histopathological, histomorphometric, biomechanical, and immunohistochemical adverse effects on the femoral fracture healing model in rats; however, it showed positive effects on CD34 and Collagen type III levels. Based on these findings, antibiotherapy with cephalexin may be considered as a safe treatment for fracture union.

Is the Citak classification of distal femur morphology age and gender dependent?

INTRODUCTION: The purpose of this study was to compare the distal femur morphology in different age and gender groups using the Citak classification. MATERIALS AND METHODS: All patients who had standard knee anteroposterior radiographs between 2010 and 2020 were retrospectively reviewed using the electronic patient database. Patients were divided into three age groups as follows: young adults (Group I, younger than 50 years), middle-aged adults (Group II, ranging from age 51 to 73 years), and elderly (Group III, more than 74 years). From each age group, 80 patients were randomly selected with an equal number of gender (40 males/40 females). An age-stratified selection was applied to obtain the best sample that represents the selected age groups. Patients younger than 18 years of age, history of previous fracture or surgical procedure, those with fixation implants or prosthesis, and abnormalities of the lower limb, such as a congenital deformity, were excluded from the study. All measurements were performed by an experienced orthopedic surgeon familiar with the Citak classification. All measured variables were compared between age and gender groups. RESULTS: There were 240 patients (120 male and 120 female) with a mean age of 59.6 ± 20.4 (range 18-95). The distal femur morphology index was similar (p:0.811), and the morphological types were equally distributed among age groups (p:0.819). Furthermore, there was no significant difference between genders on the measured variables (p > 0.05 for all variables). Citak classification types were similarly distributed between the genders (p:0.153). No correlation was found between age and the Citak index in either gender (p:0.967 and p:0.633, respectively). CONCLUSIONS: Distal femoral morphology classified by the Citak index is not age and gender dependent. Type C, which has a wider diaphyseal diameter, and is supposed to be more common in elderly subjects, was equally distributed in all age groups. LEVEL OF EVIDENCE: Level IV. Retrospective case series.

Exploring the molecular mechanism of linagliptin in osteosarcoma cell lines for anti-cancer activity.

BACKGROUND: Finding new applications for widely used current drugs is a fast and effective technique for discovering new anticancer chemicals. Osteosarcoma (OS), the most prevalent form of bone cancer, has several side effects that significantly lower patients' quality of life. This study aims to systematically examine the anti-cancer activity of linagliptin (LG) in the osteosarcoma cell line Saos-2. METHODS: MTT assays and flow cytometry were used to assess cell viability and apoptosis, respectively. qPCR array experiments were carried out to determine target gene expressions and explain the molecular mechanism of LG's action. RESULTS: Linagliptin treatment significantly decreased the viability of Saos-2 cells and hFOB1.19 cells (p < 0.001). The treatment also induced increased apoptotic effects in both Saos-2 cells (p < 0.001) and hFOB1.19 cells (p < 0.05). qPCR assays were conducted to assess cancer pathway analysis after applying specific quantities of LG to Saos-2 and hFOB1.19 cells. CONCLUSION: The findings of this study demonstrate that LG inhibits the proliferation of Saos-2 cells and induces cell death. LG supports cell death by suppressing the expression of specific genes involved in cancer pathways.

Unexpected Positive Cultures in Patients Who Have a History of Septic Revision in the Same Joint.

BACKGROUND: The prevalence of unexpected positive cultures (UPC) in an aseptic revision surgery of the joint with a prior septic revision in the same joint remains unknown. The purpose of this study was to determine the prevalence of UPC in that specific group. As secondary outcomes, we explored risk factors for UPC. METHODS: This retrospective study includes patients who had an aseptic revision total hip/knee arthroplasty procedure with a prior septic revision in the same joint. Patients who had less than 3 microbiology samples, without joint aspiration or with aseptic revision surgery performed <3 weeks after a septic revision were excluded. The UPC was defined as a single positive culture in a revision that the surgeon had classified as aseptic according to the 2018 International Consensus Meeting. After excluding 47, a total of 92 patients were analyzed, who had a mean age of 70 years (range, 38 to 87). There were 66 (71.7%) hips and 26 (28.3%) knees. The mean time between revisions was 83 months (range, 31 to 212). RESULTS: We identified 11 (12%) UPC and in 3 cases there was a concordance of the bacteria compared to the previous septic surgery. There were no differences for UPC between hips/knees (P = .282), diabetes (P = .701), immunosuppression (P = .252), previous 1-stage or 2-stages (P = .316), causes for the aseptic revision (P = .429) and time after the septic revision (P = .773). CONCLUSION: The prevalence of UPC in this specific group was similar to those reported in the literature for aseptic revisions. More studies are needed to better interpret the results.

Complex Open Metacarpophalangeal Joint Dislocation of the Index Finger in a Pediatric Patient: A Case Report.

Pediatric metacarpophalangeal (MCP) joint dislocations are rare. Open MCP injuries are rarer. There are different surgical approaches to its treatment, and each approach has advantages and disadvantages. Debridement and open reduction should be performed urgently in the treatment. In our study, we will present the treatment and follow-up of a 15-year-old patient with an open index finger MCP joint dislocation. In conclusion, open MCP dislocations adversely affect hand function when their treatment is delayed, and complications can be avoided if full anatomical reduction and soft tissue reconstruction are performed quickly.

Effects of Linagliptin and Pioglitazone on Fracture Healing in an Experimental Type 2 Diabetes Rat Model.

AIM: Our study aimed to examine the effects of Linagliptin, Pioglitazone, and their combination on fracture healing in a diabetes rat femur fracture model. MATERIAL AND METHODS: Type 2 diabetes mellitus (T2DM) induced rats were randomly divided into four groups: non-treated diabetes group (TD), Pioglitazone group (P), Linagliptin group (L), and Pioglitazone and Linagliptin group (PL). Daily oral dosage of pioglitazone (10 mg/kg/day), linagliptin (10 mg/kg/day), and their combination were administered. Femur fractures were stabilized intramedullary. At weeks 2 and 6, rats were sacrificed for evaluation radiologically, biomechanically, histopathologically, histomorphometrically, and immunohistochemically. RESULTS: Flexural strength of the L and PL groups were significantly higher compared to the P group. The highest healing score was in the L group and lowest in the P group, while the highest inflammation score was in the P group and lowest in the L group. A cluster of differentiation (CD) CD 34 reactivity was highest in the L group and lowest in the PL group. CONCLUSION: Linagliptin treatment significantly increased histological healing scores, callus volume, biomechanical strength, and vascularity, however, minimized the inflammatory process, which was increased by pioglitazone. The combination of linagliptin and pioglitazone restored BMD and increased biomechanical strength. Linagliptin monotherapy is rarely indicated; hence, T2DM patients with a high risk of bone fractures can be considered for combined therapy of pioglitazone and linagliptin.

The effects of thymoquinone on steroid-induced femoral head osteonecrosis: An experimental study in rats.

OBJECTIVES: In this study, we aimed to evaluate the antioxidant, anti-apoptotic, osteoblastic and hypolipidemic effects of thymoquinone (TQ) treatment on the steroid-induced osteonecrosis of femoral head (ONFH) model in rats. MATERIALS AND METHODS: A total of 24 rats were randomly divided into four groups: the control group administered saline; the TQ group administered 10 mg/kg/day TQ orally; lipopolysaccharide/methylprednisolone (LPS/MPS) group administered 20 µg/kg intraperitoneally LPS and 40 mg/kg intramuscularly MPS to establish ONFH model; and the LPS/ MPS+TQ group administered both LPS/MPS and, then, TQ once daily for four weeks. All rats were sacrificed after intracardiac blood collection and their right femurs were removed. RESULTS: Micro-computed tomography showed a higher bone mineral density and lower porosity, Tr. Sp and Tr. Sep data were detected in the LPS/MPS+TQ group. In histopathology, osteonecrosis increased significantly in the LPS/MPS group and osteonecrosis decreased in the LPS/MPS+TQ group compared to the LPS/MPS group (p=0.0077). Histomorphometric examination revealed that the percentage of BV/TV in the LPS/MPS group was significantly lower compared to control and other groups (p<0.01 and p<0.05, respectively), while it reached normal rates in the LPS/MPS+TQ group. Immunohistochemically, antioxidant, anti-apoptotic, and angiogenesis indicators (8-hydroxy-20- deoxyguanosine [8-OHdG], malondialdehyde [MDA], B-cell lymphoma [Bcl-2], caspase-3, vascular endothelial growth factor [VEGF]) were significantly improved in tissue and serum with TQ. Furthermore, TQ significantly reduced low- and high-density lipoprotein cholesterol ratio and carboxy-terminal type 1 collagen crosslink (CTX) in serum. CONCLUSION: Vascular and hematopoietic cell damages that occur due to steroid-induced deoxyribonucleic acid (DNA) oxidative and lipid peroxidative damages in an ONFH model can be successfully ameliorated by TQ administration. This antioxidant and anti-apoptotic effects of TQ may be a promising treatment option for early stage of osteonecrosis.

Effects of different vardenafil doses on bone healing in a rat fracture model.

OBJECTIVES: We aimed to investigate the radiological, biomechanical, histopathological, histomorphometric, and immunohistochemical effects of different doses of vardenafil on fracture healing. MATERIALS AND METHODS: Fifty-one rats were divided into three groups. Group V5 was given 5 mg/kg/day of vardenafil; Group V10 was given 10 mg/kg/day of vardenafil; and the control group was given the same volume of saline. Six rats from each group were sacrificed on Day 14 (early period) and the remaining rats were sacrificed on Day 42 (late period). Callus/femoral volume and bone mineral density were measured using micro-computed tomography. Five femurs from each group in the late period were examined by biomechanical tests. In addition to the histopathological and histomorphometric evaluations, immunohistochemical analyses were performed to examine the levels of inducible nitric oxide synthase (iNOS), transforming growth factor-3 (TGF-ß3), and nuclear factor kappa B (NF-κB) proteins. RESULTS: Both doses of vardenafil increased primary bone volume and maximal bone fracture strength in late period, compared to the control group (p<0.05). Histological healing scores of vardenafil groups were significantly higher in early period (p<0.001). While cartilaginous callus/total callus ratio in early period was higher, callus diameter/femoral diameter ratio in late period was lower in vardenafil groups (p<0.01). The NF-κB immunopositivity in V10 group decreased in early period, compared to control group (p<0.001). The TGF-ß3 and iNOS immunopositivity increased in both V5 and V10 groups, compared to the control group in early period, but returned to normal in late period. CONCLUSION: During the first period of fracture healing process in which vasodilation is mostly required with increasing inflammation, vardenafil has ameliorating effects on the bone union and supports fracture healing.