Displaced femoral shaft fractures treated by antegrade nailing with the assistance of an intramedullary reduction device.

PURPOSE: This study aims to assess the outcomes of displaced femoral shaft fractures (DFSFs) treated by antegrade nailing with the assistance of a newly invented intramedullary (IM) reduction device. METHODS: From December 2012 to August 2013, 43 adult patients with unilateral DFSFs, including 31 males and 12 females, were enrolled into this study. During the operation, the device was used to adjust the direction of guide wire to insert it into the medullary cavity of distal femur and used as a "joystick" to align the femoral shaft fractures before the insertion of IM nail. The operative time and fluoroscopy time were recorded. Follow-up was conducted to assess the fracture union and functional recovery of the affected limbs. RESULTS: The IM reduction device was used intra-operatively to advance the guide wire into the distal femoral medullary cavity successfully in all 43 cases, with a single attempt in 37 cases and two or three attempts in six cases. The average operative time and fluoroscopy time were 58.3 minutes (40-85 minutes) and 9.2 seconds (4.1-21.8 seconds), respectively. All fractures healed well on an average of 5.4 months post-operatively. No limb-length discrepancy or observable malalignment was noted at the follow ups. CONCLUSIONS: The IM reduction device can facilitate the insertion of a guide wire into the distal femoral medullary cavity in a closed and controllable manner, be used as a "joystick" to align the femoral shaft fracture, and subsequently facilitate IM nail insertion in the proper position.

[Effects of different intakes of protein on nutritional status in severe stroke patients].

OBJECTIVE: To investigate the effects of different intake of protein on nutritional indicators in severe stroke patients. METHODS: 89 patients with severe stroke and NRS-2002 scores not less than 3 were enrolled. The patients were divided into group A, group B and group C by random, and 28 cases were in group A with protein intake at 0.9 g/kg, 30 cases were in group B with protein intake at 1.2 g/kg and 31 cases were in group C with protein intake at 1.6 g/kg, all patients were given the same calories support (25 kcal/kg). On the day of pre-intervention, the 7th and 14th day of post-intervention, fasting blood samples were collected from every subjects. The total protein (TP), albumin (ALB), hemoglobin (Hb), creatinine (Cr), blood urea nitrogen (BUN), midarm circumference (MAC) and calf circumference (CC) were recorded. RESULTS: (1) The MAC and CC of health side body decreased on the 14th day post-intervention in group A and group B, the differences were significant compared with pre-intervention and on the 7th day post-intervention (P < 0.05), but there were no statistical differences between group A and group B. The index of group C had no significant changes from pre-intervention to the 14th day post-intervention. The differences among the three groups were statistically significant on the 14th day post-intervention (P < 0.05). (2) TP, ALB and Hb in group A were decreased from pre-intervention to the 14th day post-intervention, the differences were statistically significant. The levels of TP and Hb decreased in group B during the observation period, the differences were statistically significant. ALB in group B was decreased on the 7th day post-intervention, but it was increased on the 14th day post-intervention, there was no statistical difference compared with pre-intervention. The levels of TP, ALB and Hb in group C had no significant differences on the 7th day post-intervention, but they all increased on the 14th day post-intervention. The differences of ALB and Hb in group C were statistically significant on the 14th day post-intervention compared with pre-intervention and on the 7th day post-intervention. The differences of TP, ALB and Hb among the three groups were statistically significant on the 14th day post-intervention. (3) Cr in the three groups did not have significant differences during the observation period. BUN of group A and group B were both increased post-interventinon, the differences were statistically significant compared with pre-intervention and there were statistically significant differences between group A and group B (P < 0.05). BUN in group C did not have significant changes during the observation period. On the 14th day post-intervention, the differences of BUN were statistically significant among the three groups (P < 0.05). CONCLUSION: The nutritional effect of protein intake at 1.6 g/kg is better than 0.9 g/kg and 1.2 g/kg on improving the nutritional status in severe stroke patients.

Multiple increased osteoclast functions in individuals with neurofibromatosis type 1.

Skeletal abnormalities including scoliosis, tibial dysplasia, sphenoid wing dysplasia, and decreased bone mineral density (BMD) are associated with neurofibromatosis type 1 (NF1). We report the cellular phenotype of NF1 human-derived osteoclasts and compare the in vitro findings with the clinical phenotype. Functional characteristics (e.g., osteoclast formation, migration, adhesion, resorptive capacity) and cellular mechanistic alterations (e.g., F-actin polymerization, MAPK phosphorylation, RhoGTPase activity) from osteoclasts cultured from peripheral blood of individuals with NF1 (N = 75) were assessed. Osteoclast formation was compared to phenotypic, radiologic, and biochemical data. NF1 osteoprogenitor cells demonstrated increased osteoclast forming capacity. Human NF1-derived osteoclasts demonstrated increased migration, adhesion, and in vitro bone resorption. These activities coincided with increased actin belt formation and hyperactivity in MAPK and RhoGTPase pathways. Although osteoclast formation was increased, no direct correlation of osteoclast formation with BMD, markers of bone resorption, or the clinical skeletal phenotype was observed suggesting that osteoclast formation in vitro cannot directly predict NF1 skeletal phenotypes. While NF1 haploinsufficiency produces a generalized osteoclast gain-in-function and may contribute to increased bone resorption, reduced BMD, and focal skeletal defects associated with NF1, additional and perhaps local modifiers are likely required for the development of skeletal abnormalities in NF1.

Ras dependent paracrine secretion of osteopontin by Nf1+/- osteoblasts promote osteoclast activation in a neurofibromatosis type I murine model.

Neurofibromatosis type 1 (NF1) is a pandemic genetic disorder characterized by malignant and nonmalignant manifestations, including skeletal abnormalities, such as osteoporosis, scoliosis, short stature, and pseudarthrosis. Recent studies in genetically inbred mice and from human patients with NF1 have identified multiple gains in osteoclast (OCL) functions both in vitro and in vivo. Given that osteoblasts secrete cytokines that promote OCL maturation/activation, we sought to identify whether haploinsufficiency of Nf1 (Nf1+/-) osteoblasts and their precursors secrete cytokines that have a central role in this process. Osteoblast conditioned media (OBCM) from Nf1+/- osteoblasts promoted OCL migration and bone resorption compared with WT OBCM. Osteopontin (OPN), a matrix protein found in mineralized tissues and pivotal in modulating OCL functions, was present in increased concentrations in Nf1+/- osteoblasts. Addition of OPN neutralizing antibody to Nf1+/- OBCM diminished the gain in bioactivity on OCL functions, including OCL migration and bone resorption. Our study identifies an important paracrine loop whereby elevated secretion of OPN by osteoblasts activate Nf1+/- OCLs that already have an intrinsic propensity for bone resorption leading to osteopenia and osteoporosis.