Radiologic evaluation of fracture healing

Pulsed ultrasound and moderate exercise accelerate bone healing in an experimental tibial fracture model: biochemical, radiological and biomechanical evidence

Currently, therapeutic strategies involving mechanical stress play a key role in fracture consolidation. However, no literary evidence exists regarding the combined effects of low-intensity pulsed ultrasound (LIPUS) and moderate aerobic exercise. This study aimed to investigate the effects of LIPUS and moderate aerobic exercise on bone consolidation in 48 male Wistar rats. The animals were divided into four groups (n = 12 per group): Bone Fracture (BF); BF + LIPUS; BF + Exercise (Ex); BF + Ex + LIPUS. A transverse osteotomy with Kirschner wire fixation was performed, followed by therapeutic interventions for 19 days, three times a week. LIPUS was applied for 10 min (1.5 MHz, 0.4 W/cm2, 3 cm2 area), and aerobic exercise lasted 30 min/day with progressive speed. Radiographic analyses were conducted on days 1, 12, and 24 post-fracture, and euthanasia occurred 72 h after the final session. The combined group exhibited improved radiographic scores and increased birefringent collagen fibers. IL-4, IL-10, and TGF-β levels were significantly higher in treated groups, particularly the combined intervention. Additionally, oxidative stress markers showed reduced nitrite levels, controlled sulfhydryl oxidation, and enhanced SOD and GSH activity. Biomechanically, the combined group tolerated higher loads and demonstrated superior deformation capacity and tissue elasticity. The combination of aerobic exercise and LIPUS enhanced radiographic healing, modulated inflammation, reduced oxidative stress, and improved mechanical properties, supporting its potential for fracture rehabilitation.

Experimental study on the biomechanical loading of a four-dimensional plate for the fixation of femoral shaft fractures

OBJECTIVE

To explore the biomechanical properties of a four-dimensional structure locking osteosynthesis plate that can alter its structure and functionality over time.

METHODS

According to the AO classification (AO-A2) standard, 18 artificial femoral shaft oblique fracture models with the same position and shape were generated and subsequently randomly divided into 2 groups (n = 9). In the experimental group, the four-dimensional locking plate was fixed, and in the control group, the locking plate was fixed. In vitro loading experiments were carried out under three conditions: 1400 N axial compression, 500 N internal and external four-point bending, and 15 N·m torsion. The average compression stiffness, average bending stiffness, average torsional stiffness, and displacement were compared between the two groups.

RESULTS

Under vertical loading, the average compression stiffness of the experimental group (558.7 ± 39.1) N/mm was greater than that of the control group (548.8 ± 24.5) N/mm, (P = 0.73); and the average displacement of the fracture end of the experimental group (3.3 ± 0.2) mm was lower than that of the control group (3.4 ± 0.3) mm, (P = 0.47). The differences were not statistically significant. Under four-point bending loading, the average bending stiffness of the experimental group (466.6 ± 85.8) N/mm was lower than that of the control group (542.5 ± 43.2) N/mm, and the difference was not statistically significant (P = 0.24). The average displacement of the fracture ends in the experimental group (1.6 ± 0.2)mm was greater than that in the control group (1.2 ± 0.1)mm, and the difference was statistically significant (P = 0.02). Under torsional loading, the average torsional stiffness of the experimental group (1.0 ± 0.1) N·m/deg was lower than that of the control group (1.1 ± 0.1) N·m/deg, (P = 0.27); and the average angular displacement of the fracture end of the experimental group (15.9 ± 1.3) deg was greater than that of the control group (14.6 ± 1.3) deg, (P = 0.26). There was no significant difference between the two groups.

CONCLUSION

The anti-compression, anti-bending and anti-torsion properties of four-dimensional locking plates are similar to those of conventional locking plates and can meet the mechanical requirements of internal fracture fixation.

Reliability of radiographic union score and correlation of clinical outcomes in children operated for supracondylar humerus fracture: A prospective study

Background

Supracondylar humerus fractures are common in childhood, and postoperative follow-up planning for surgically treated fractures is still controversial. This study aims to investigate the interobserver and intraobserver reliability of the Radiographic Union Score for Tibial Fracture in the postoperative radiological follow-up of pediatric supracondylar humerus fractures and to evaluate the clinical results with the scores obtained during follow-up.

Methods

In this prospective study, patients who were operated on for supracondylar humerus fractures were called for follow-up three times: postoperative splint removal, pin removal, and final control. A total of 58 patients, 34 boys and 24 girls, who provided regular follow-ups, were included in the study. During follow-ups, the Radiographic Union Score for Tibial Fracture was calculated by evaluating the patients' elbow anteroposterior and lateral radiographs, and the elbow joint range of motion was recorded with a goniometer. In two experiments, orthopedic surgeons evaluated intraobserver and interobserver reliability using the intraclass correlation coefficient at different times. The patients were evaluated at the last follow-up according to the Flynn criteria.

Results

The first follow-up Radiographic Union Score for Tibial Fracture (median (range) was 8 (7-10), the second follow-up was 11 (9-12), and the third follow-up was 12 (11-12). Range of motion was 40° at the first follow-up, 90° at the second follow-up, and 120° at the third follow-up. Radiographic Union Score for Tibial Fracture and range of motion increased significantly as the weeks progressed (p < 0.001). Interobserver intraclass correlation coefficient at first follow-up was 0.80 (95% confidence interval 0.69-0.87), second follow-up was 0.85 (0.77-0.91), and third follow-up was 0.79 (0.67-0.87). Intraobserver intraclass correlation coefficient was 0.92 (0.88-0.95) at the first follow-up, 0.93 (0.98-0.96) at the second follow-up, and 1.00 (1.00-1.00) at the third follow-up. Flynn score results are functional; the cosmetic results were excellent in 46 patients, good in 4 patients, fair in 5 patients, poor in 3 patients, and cosmetic results were excellent in 54 patients and good in 4 patients.

Conclusion

Our study determined that the radiographic union of fractures in pediatric supracondylar humerus fractures is reliably evaluated with the Radiographic Union Score for Tibial Fracture score. Radiographic Union Score for Tibial Fracture can be used to provide data-driven estimates of splint and pin removal.

Level of evidence

Level II, prospective study.

A study on early diagnosis for fracture non-union prediction using deep learning and bone morphometric parameters

Background

Early diagnosis of non-union fractures is vital for treatment planning, yet studies using bone morphometric parameters for this purpose are scarce. This study aims to create a fracture micro-CT image dataset, design a deep learning algorithm for fracture segmentation, and develop an early diagnosis model for fracture non-union.

Methods

Using fracture animal models, micro-CT images from 12 rats at various healing stages (days 1, 7, 14, 21, 28, and 35) were analyzed. Fracture lesion frames were annotated to create a high-resolution dataset. We proposed the Vision Mamba Triplet Attention and Edge Feature Decoupling Module UNet (VM-TE-UNet) for fracture area segmentation. And we extracted bone morphometric parameters to establish an early diagnostic evaluation system for the non-union of fractures.

Results

A dataset comprising 2,448 micro-CT images of the rat fracture lesions with fracture Region of Interest (ROI), bone callus and healing characteristics was established and used to train and test the proposed VM-TE-UNet which achieved a Dice Similarity Coefficient of 0.809, an improvement over the baseline's 0.765, and reduced the 95th Hausdorff Distance to 13.1. Through ablation studies, comparative experiments, and result analysis, the algorithm's effectiveness and superiority were validated. Significant differences (p < 0.05) were observed between the fracture and fracture non-union groups during the inflammatory and repair phases. Key indices, such as the average CT values of hematoma and cartilage tissues, BS/TS and BS/TV of mineralized cartilage, BS/TV of osteogenic tissue, and BV/TV of osteogenic tissue, align with clinical methods for diagnosing fracture non-union by assessing callus presence and local soft tissue swelling. On day 14, the early diagnosis model achieved an AUC of 0.995, demonstrating its ability to diagnose fracture non-union during the soft-callus phase.

Conclusion

This study proposed the VM-TE-UNet for fracture areas segmentation, extracted micro-CT indices, and established an early diagnostic model for fracture non-union. We believe that the prediction model can effectively screen out samples of poor fracture rehabilitation caused by blood supply limitations in rats 14 days after fracture, rather than the widely accepted 35 or 40 days. This provides important reference for the clinical prediction of fracture non-union and early intervention treatment.

Serum miR-519d-3p and BMP2: potential early diagnostic markers and their mechanism in delayed fracture healing

BACKGROUND

Delayed fracture healing (DFH) affects patients' quality of life, and there are limitations in diagnosis by CT scan. The purpose of the study is to evaluate the potential and mechanism of clinical application of miRNAs in DFH for early diagnosis and intervention.

METHODS

Serum samples were obtained from delayed and normal fracture healing patients and the levels of miR-519d-3p and BMP2 were measured by RT-qPCR, and the value of both in the diagnosis of DFH was assessed by ROC curve. Cell viability and apoptosis were monitored using CCK8 kit and flow cytometry, respectively, and mRNA expression of osteogenesis and apoptosis-related genes were detected by RT-qPCR. The molecular interactions were verified using luciferase reporter gene system and RIP technique.

RESULTS

Up-regulation of miR-519d-3p expression and down-regulation of BMP2 in the serum of fracture patients four weeks after surgery can be used as an early warning marker of DFH and a risk factor for poor fracture healing. Further studies showed that overexpression of miR-519d-3p markedly inhibited the expression of RUNX2, OCN and ALP and prevented osteoblast differentiation. Meanwhile, it inhibited cell viability, promoted apoptosis, upregulated Bax and Cleaved-caspase-3 mRNA expression, and downregulated Bcl-2 expression. BMP2, targeted by miR-519d-3p, enhanced osteogenesis and reversed the inhibitory of action miR-519d-3p.

CONCLUSIONS

Serum miR-519d-3p and BMP2 can be used as early diagnostic markers for DFH. miR-519d-3p inhibited osteogenesis by targeting BMP2, which may slow down fracture healing.

Low-grade infections in nonunion of the femur and tibia without clinical suspicion of infection - Incidence, microbiology, treatment, and outcome

Treatment algorithms for fracture nonunion depend on the presence or absence of bacterial infection. However, it is often impossible to identify infection preoperatively. While some infections may present with clinical signs of infection, low-grade infections lack infection signs and have a clinical presentation similar to aseptic nonunion. The clinical relevance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the role of low-grade infection in the development and management of lower extremity nonunion. A prospective multicenter clinical study enrolled patients with femoral or tibial shaft nonunion and regular healed fractures, scheduled for nonunion revision and routine implant removal, respectively. Preoperatively, serum markers including C-reactive protein (CRP), leukocytes, and procalcitonin were determined, clinical infection signs were recorded, and a suspected septic or aseptic diagnosis was made prior to surgery and further diagnostics. Tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for twelve months, during which the definitive diagnosis of "septic" or "aseptic" nonunion was made according to diagnostic criteria for fracture-related infection. One hundred and ten patients with nonunion and 34 patients with regular healed fractures were included. Sixty-two nonunion patients were diagnosed as aseptic, 22 with expected and confirmed infection, and 23 with unexpected low-grade infection. Three patients had an unclear diagnosis. Low-grade infection was detected in 28 % of presumed aseptic nonunion patients. Sensitivity and specificity for the suspected diagnosis were 49 % and 95 %, respectively. The suspected diagnosis had a significant impact on revision strategy. All medians of the preoperative blood values were within the reference ranges except for CRP, which was slightly elevated in the expected and confirmed infected nonunion group. Expected and confirmed septic nonunion and unexpected low-grade infected nonunion demonstrated a similar bacterial spectrum. While 10 % of patients with aseptic nonunion required follow-up surgeries, re-operation rates were higher in patients with low-grade infection and expected and confirmed infection at 30 % and 64 %, respectively. Patients with low-grade infections were treated less frequently with systemic antibiotics and for a shorter duration than patients with expected and confirmed infections, with no significant difference in healing rate which was 83 % in low-grade and 62 % in expected and confirmed infections. The healing rate of aseptic nonunion was 90 %. A limitation of this study is the limited number of tissue samples for microbiological and histopathological diagnostics in the suspected aseptic nonunion cohort, which may have led to an underestimation of the low-grade infection rate. Our findings suggest that unexpected low-grade infection is frequently associated with nonunion. While expected and confirmed infected nonunion differs significantly from aseptic nonunion, low-grade infected nonunion is very similar to aseptic nonunion, except for intraoperative bacterial detection. In addition to antibiotic therapy, surgical nonunion revision with implant exchange and debridement appears to be highly effective in achieving consolidation of low-grade infected nonunion.

Evaluation of bone healing in trabeculae structure of mandibular corpus and angulus fracture patients with fractal dimension analysis

Background

Fractures of the mandibular corpus and angulus are affected by different forces result from different strength of the muscles that influenced them. Therefore, it is presumed that there is a different in healing rate. Fractal dimension radiologic analysis assesses the trabecular pattern, due to it can be used to observe the healing process of bone fractures.

Purpose

The study aimed to compare the healing process of mandibular corpus and angulus fractures with fractal dimension analysis (FD) of trabecular patterns on panoramic radiographs through ImageJ software as consideration to determine mastication loading time.

Methods

This retrospective cross-sectional study observed medical records and panoramic radiographs of patients with a diagnosis of corpus and or mandibular angulus fractures undergoing open reduction (ORIF) 1 plate treatment combined with maxillomandibular fixation (MMF) at Hospital in 2017-2023. Observations were carried out on postoperative 1st day, 2nd week, 8-13th week and >13th week respectively.

Results

Twenty-five subjects who met the inclusion requirements were involved in the study. The results of Two-Way ANOVA statistical test and Fisher's LSD post-hoc showed that the FD values of corpus fracture were significantly greater than that of mandibular angulus with p 0.000 (H1), 0.003 (H2), 0.03 (H3), 0.000 (H4) respectively. In both groups of mandibular corpus and angulus fractures, there was a significant effect of time with p = 0.00 in each group. The longer the observation time, the more trabeculae patterns were formed in the healing process of corpus and angulus fractures.

Conclusion

Post ORIF observation of corpus fracture shows a greater trabecula formation value which indicates faster healing when compared to mandibular angulus fracture.

Autopsy doesn't always tell all: The importance of exhuming skeletal remains of cemetery unidentified decedents

The process of personal identification differs according to the state of preservation of the corpse, becoming more complicated when dealing with remains altered by taphonomic variables. Since 2015, the staff of the Laboratory of Forensic Anthropology and Odontology (LABANOF) of the University of Milan has been engaged in recovering the skeletons of 36 unknown people from the cemeteries of the city of Milan, to redraw their biological profiles and give them back the possibility of being identified. Of the 36 starting skeletons, 7 have been identified and therefore are not the object of this study, 25 individuals were previously subjected to an autopsy examination and 4 skeletons were studied for the first time in the present work. The post-mortem data of all the individuals who had previously undergone autopsy and had not yet been identified (n = 25) have been retrieved from the archives of the Institute of Forensic Medicine in Milan and allowed for a comparison with those obtained from the new anthropological study of each exhumed skeleton. The authors aim to present the three most interesting cases to better highlight the results that emerged from the comparison. The autopsy information alone lacked important details. In all cases, the anthropological examination proved to be capable of detailing the biological profile of the unknowns even after a long period of inhumation (even more than 20 years). The limitations of instrumental investigations in achieving the goal single-handedly and the importance of recovering the unknown skeletons from cemeteries for identification purposes are discussed.

Improving agreement in assessing subtrochanteric fracture healing among orthopedic surgeons using the Radiographic Union Score for Hip (RUSH)

BACKGROUND

Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing.

METHODS

We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve.

RESULTS

Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511-0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663-0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670-0.868), 0.779 (95% CI: 0.681-0.876), and 0.771 (95% CI: 0.674-0.867), respectively.

CONCLUSIONS

Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.

Proximal femoral nailing for intertrochanteric fracture combined with contralateral femoral neck local osteo-enhancement procedure (LOEP) for severe osteoporotic bone loss: An original Italian case series

Proximal femoral fractures in elderly women are a major cause of morbidity and mortality worldwide and a public health concern. Although pharmacological therapies have shown potential in improving bone mineral density (BMD) and decreasing fracture risk, the current research effort is focused on developing a procedure that can ensure both immediate and long-term efficacy. A minimally-invasive surgical approach, known as AGN1 local osteo-enhancement procedure (LOEP), has been recently developed to promote bone augmentation. The procedure implies the preparation of an enhancement site, a specific location where new bone is required within a local bony area weakened by osteoporotic bone loss, and the insertion of a triphasic, resorbable, calcium-based implant material. The results of this procedure have shown a significant and sustainable long-term increase in the proximal femur BMD and consequently in bone strength, thereby improving the femoral neck's resistance to compression and distraction forces that may result in fall-related fractures. A preliminary case series of ten women, suffering from intertrochanteric fracture and contralateral proximal femur severe osteoporotic bone loss, who underwent a combined procedure of proximal femoral nailing and AGN1 local osteo-enhancement procedure, has been developed over the course of a year of clinical and radiological data collection.

Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review

Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing.

BACKGROUND

Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing.

METHODS

Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).

RESULTS

Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans.

CONCLUSION

Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.

Effect of cranial tibial artery laceration on radiographic bone healing and perioperative complications in dogs undergoing tibial plateau leveling osteotomy

During tibial plateau leveling osteotomy (TPLO), the laceration of the cranial tibial artery (LCTA) may occur, and the ligation of the cranial tibial artery might lead to impaired blood supply to the osteotomy site. The present case-control study aimed to evaluate the effect of LCTA on TPLO healing and the occurrence of perioperative complications. The incidence and predisposing factors to LCTA were also investigated. Fourteen cases experiencing LCTA were retrospectively enrolled from medical records of two veterinary teaching hospitals (LCTA group), whereas 28 randomly selected TPLOs that did not experience LCTA were included in the control group. Signalment data, proximal tibial epiphysis conformation, osteotomy features, perioperative complications, and bone healing were compared between the two groups. Bone healing was evaluated using the modified radiographic union scale for tibial fracture and the visual analog scale. The mean incidence was 9.6%. Bodyweight was significantly higher in the LCTA group compared to the control group (P = 0.009). Dogs belonging to the LCTA groups were significantly younger (P = 0.01). Intraoperative hypotension was significantly overreported in the LCTA group (P = 0.0001). None of the other variables differed significantly between the two groups. Dogs' size seems to be a predisposing factor, with dogs weighing >15 kg having 22 times more chance of experiencing LCTA. Due to the well-developed collateral blood supply of the canine hindlimb, LCTA and the closure of the cranial tibial artery did not appear to delay the radiographic bone healing or affect the incidence of perioperative complications.

Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion

Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.

Comparison of Radiographic Outcomes Assessed via the Radiographic Union Scale for Tibial Fractures and Alkaline Phosphatase Levels during the Tibial Healing Process: A Series of Case Reports

BACKGROUND/OBJECTIVES

Tibial diaphysis fractures are common injuries resulting from high-to-low-energy traumas in patients of all age groups, but few reports currently provide complementary parameters for the assessment of bone healing processes in the postoperative period. Serum alkaline phosphatase (ALP) and the scores from the Radiographic Union Scale for Tibial Fractures (RUST) can promote new horizons in this context. Therefore, the aim of this study was to assess the behavior of ALP and RUST through within-subject comparisons from immediately post-surgery to 49 days after tibial diaphysis fracture repair.

METHODS

This article included four case studies where patients underwent the same procedures. Adults of both sexes aged 18 to 60 years with tibial fractures requiring surgery were included. After surgical intervention (T1), the patients were followed for 49 days after surgery, returning for follow-up appointments on the 21st (T2) and 49th (T3) days. At the follow-up appointments, new X-ray images were obtained, and blood samples were collected for ALP measurement.

RESULTS

Serum ALP levels increased by T2 following tibial reamed intramedullary nailing surgery. While this increase persisted into T3 for two patients, a decline was observed during the same period for the other two patients. Both events are indicative of the bone consolidation process, and RUST scores at the T3 corroborate this perspective for all patients included in this study. Considering that delta ALP (T3-T1 value) was lower in patients who exhibited the highest RUST score, we suggest that a synchronized analysis between ALP and RUST allows medics to diagnose bone consolidation.

CONCLUSIONS

Therefore, it can be concluded that the analysis of ALP alongside RUST may be complementary for evaluating bone consolidation following tibial reamed intramedullary nailing surgery, but future studies are needed to confirm this assertion.

Osteosynthesis by locking plate for proximal tibial fractures

INTRODUCTION

Treatment of proximal tibial fractures is known to be difficult. We report our own experience of the treatment of these fractures and evaluate our results. The hypothesis was that the clinical and radiological results were good.

MATERIAL AND METHOD

From January 2004 to October 2008, fourteen AO-type 41A2-3 and C1 fractures have been treated with a LCP locking plate (8 women and 6 men, average age 60.42). Plating was performed either with an open approach or a minimal invasive approach. Clinical and radiological follow-up was carried out looking for range of motion of the knee joint and autonomy level.

RESULTS

Mean follow-up was 32.63 months (12-70). Range of motion was maintained with a mean arch of 117.5° Autonomy was maintained in all cases. Professional, domestic and sports activities were unchanged. No infection or general complication occurred. Bone fusion was obtained in all cases after an average of 13.28 weeks. 6° of valgus deformation, already seen immediately postoperatively was observed once. Secondary displacement was observed in 6 cases, with an average of 2.83° DISCUSSION-CONCLUSION: We report good radiological results, with only one initial malalignment. The hypothesis was confirmed. However, X-ray analysis at consolidation shows 6 secondary displacements, without any satisfactory explanation. Though the clinical consequences of these malunions are minimal. Osteosynthesis with plate, in the sight of this study, yields good clinical results. Radiological evolution concerning the evolution of bone axes puts the emphasis on careful operative technique and adequate time to weight bearing.

LEVEL OF EVIDENCE

retrospective study, IV.

In vivo axial load-share ratio measurement using a novel hexapod system for safe external fixator removal

BACKGROUND

External fixation is widely used in the treatment of traumatic fractures; however, orthopedic surgeons encounter challenges in deciding the optimal time for fixator removal. The axial load-share ratio (LS) of the fixator is a quantitative index to evaluate the stiffness of callus healing. This paper introduces an innovative method for measuring the LS and assesses the method's feasibility and efficacy. Based on a novel hexapod LS-measurement system, the proposed method is to improve the convenience and precision of measuring LS in vivo, hence facilitating the safe removal of external fixators.

METHODS

A novel hexapod system is introduced, including its composition, theoretical model, and method for LS measurement. We conducted a retrospective study on 82 patients with tibial fractures treated by the Taylor Spatial Frame in our hospital from September 2018 to June 2020, of which 35 took LS measurements with our novel method (Group I), and 47 were with the traditional method (Group II). The external fixator was removed when the measurement outcome (LS < 10%) was consistent with the surgeon's diagnosis based on the clinical and radiological assessment (bone union achieved).

RESULTS

No significant difference was found in the fracture healing time (mean 25.3 weeks vs. 24.9 weeks, P > 0.05), frame-wearing duration (mean 25.5 weeks vs. 25.8 weeks, P > 0.05), or LS measurement frequency (mean 1.1 times vs. 1.2 times, P > 0.05). The measurement system installation time in Group I was significantly shorter compared to Group II (mean 14.8 min vs. 81.3 min, P < 0.001). The LS value of the first measurement in Group I was lower than that of Group II (mean 5.1% vs. 6.9%, P = 0.011). In Group I, the refracture rate was 0, but in Group II it was 4.3% (2/47, P > 0.05).

CONCLUSION

The novel hexapod LS-measurement system and involved method demonstrated enhanced convenience and precision in measuring the LS of the external fixator in vivo. The LS measurement indicates the callus stiffness of fracture healing, and is applicable to evaluate the safety of removing the fixator. Consequently, it is highly recommended for widespread adoption in clinical practice.

Elastic stable intramedullary nail combined with Kirschner wire (E-K) technique for treating pediatric distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures

OBJECTIVE

Elastic stable intramedullary nail (ESIN) is a commonly used method for treating diaphyseal fractures of the tibia, but its application in Distal Tibial Diaphyseal Metaphyseal Junction (DTDMJ) fractures has been a subject of controversy. This study aims to evaluate the clinical efficacy of the Elastic stable intramedullary nail-Kirschner wire (E-K) technique in treating pediatric DTDMJ fractures, providing better clinical decision-making for clinicians in diagnosing and treating such fractures.

METHODS

We conducted a retrospective analysis of patients aged 3-9 years who received treatment at our hospital from January 2019-January 2021 for distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures. Based on their surgical procedures, they were categorized into the Elastic Stable Intramedullary Nail-Kirschner wire group (E-K) and the ESIN group. Demographic data, surgical duration, clinical outcomes, complications, and imaging data were recorded.

RESULTS

The study included a total of 57 patients, with 24 cases in the E-K group and 33 cases in the ESIN group. There were 30 males and 27 females. The average age was (6.25 ± 1.59) years in the E-K group and (6.27 ± 1.48) years in the ESIN group. There were no significant differences between the two groups in terms of gender, age, weight, time from injury to surgery, follow-up time, side of injury, associated injuries, nail site infection, deep infection, and nail removal time (P > 0.05). Neither group experienced nonunion or refracture. The E-K group exhibited significantly lower coronal and sagittal plane angular values at the final follow-up compared to the ESIN group (P < 0.001). In the E-K group, the final follow-up coronal plane angle was 2.67 (1.09)°, while in the ESIN group, it was 6.55 (2.05)°. The final follow-up sagittal plane angle was 3.12 (1.54)° in the E-K group and 7.58 (1.48)° in the ESIN group. Both groups showed good alignment in the initial postoperative x-rays, with no statistically significant differences. However, during clinical healing, the ESIN group exhibited significant displacement, whereas the E-K group had minimal displacement, demonstrating a significant statistical difference (P < 0.001). There was a statistically significant difference in the AOFAS joint function assessment between the two groups (P = 0.027).

CONCLUSION

The E-K technique is a viable option for treating DTDMJ fractures in pediatric patients, with well-established clinical efficacy. Its advantages include a straightforward surgical procedure, safety, and a low incidence of severe complications.

A comparative study of image quality and diagnostic confidence in diagnosis and follow-up of scaphoid fractures using photon-counting detector CT and energy-integrating detector CT

PURPOSE

Scaphoid fractures in patients and assessment of healing using PCD-CT have, as far as we know, not yet been studied. Therefore, the aim was to compare photon counting detector CT (PCD-CT) with energy integrating detector CT (EID-CT) in terms of fracture visibility and evaluation of fracture healing.

METHOD

Eight patients with scaphoid fracture were examined with EID-CT and PCD-CT within the first week post-trauma, and with additional scans at 4, 6 and 8 weeks. Our clinical protocol for wrist examination with EID-CT was used (CTDIvol 3.1 ± 0.1 mGy, UHR kernel Ur77). For PCD-CT matched radiation dose, reconstruction kernel Br89. Quantitative analyses of noise, CNR, trabecular and cortical sharpness, and bone volume fraction were conducted. Five radiologists evaluated the images for fracture visibility, fracture gap consolidation and image quality, and rated their confidence in the diagnosis.

RESULTS

The trabecular and cortical sharpness were superior in images obtained with PCD-CT compared with EID-CT. A successive reduction in trabecular bone volume fraction during the immobilized periods was found with both systems. Despite higher noise and lower CNR with PCD-CT, radiologists rated the image quality of PCD-CT as superior. The visibility of the fracture line within 1-week post-trauma was rated higher with PCD-CT as was diagnostic confidence, but the subsequent assessments of fracture gap consolidation during healing process and the confidence in diagnosis were found equivalent between both systems.

CONCLUSION

PCD-CT offers superior visibility of bone microstructure compared with EID-CT. The evaluation of fracture healing and confidence in diagnosis were rated equally with both systems, but the radiologists found primary fracture visibility and overall image quality superior with PCD-CT.

Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria

Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.

Experimental study on determining the degree of bone healing by wall thickness ratio analysis

To verify the reliability and accuracy of wall thickness ratio analysis to determine the degree of bone healing, fracture models were established with 6 beagles. X-ray, micro-CT, and CT scans were performed at 24 weeks. The healthy side and the affected side were used to simulate the three-dimensional geometric model after internal fixation, and the mesh was divided. The mean and median CT wall thickness values were obtained through the wall thickness analysis. X-ray, CT, micro-CT, and gross appearance were used to determine the degree of bone healing, which was compared with wall thickness analysis. There was a positive correlation between the average CT value and the median wall thickness. The correlation coefficient analysis of the median wall thickness ratio (R2) and healing index ratio (R3) showed a positive correlation. The results of the wall thickness ratio (R2) and the healing index ratio (R3) were used to determine bone healing, and the results were consistent with the results of the actual mechanical test and image analysis. The results of wall thickness ratio analysis were significantly correlated with the degree of bone healing. This method is simple, rapid, and practical to analyze and judge the degree of bone healing.

Gait analysis: An effective tool to mechanically monitor the bone regeneration of critical-sized defects in tissue engineering applications

INTRODUCTION

Tissue engineering has emerged as an innovative approach to treat critical-size bone defects using biocompatible scaffolds, thus avoiding complex distraction surgeries or limited stock grafts. Continuous regeneration monitoring is essential in critical-size cases due to the frequent appearance of non-unions. This work evaluates the potential clinical use of gait analysis for the mechanical assessment of a tissue engineering regeneration as an alternative to the traditional and hardly conclusive manual or radiological follow-up.

MATERIALS AND METHODS

The 15-mm metatarsal fragment of eight female merino sheep was surgically replaced by a bioceramic scaffold stabilized with an external fixator. Gait tests were performed weekly by making the sheep walk on an instrumented gangway. The evolution of different kinematic and dynamic parameters was analyzed for all the animal's limbs, as well as asymmetries between limbs. Finally, potential correlation in the recovery of the gait parameters was evaluated through the linear regression models.

RESULTS

After surgery, the operated limb has an altered way of carrying body weight while walking. Its loading capacity was significantly reduced as the stance phases were shorter and less impulsive. The non-operated limbs compensated for this mobility deficit. All parameters were normalizing during the consolidation phase while the bone callus was simultaneously mineralizing. The results also showed high levels of asymmetry between the operated limb and its contralateral, which exceeded 150% when analyzing the impulse after surgery. Gait recovery significantly correlated between symmetrical limbs.

CONCLUSIONS

Gait analysis was presented as an effective, low-cost tool capable of mechanically predicting the regeneration of critical-size defects treated by tissue engineering, as comparing regeneration processes or novel scaffolds. Despite the progressive normalization as the callus mineralized, the bearing capacity reduction and the asymmetry of the operated limb were more significant than in other orthopedic alternatives.

Survey on Energy Harvesting for Biomedical Devices: Applications, Challenges and Future Prospects for African Countries

Self-powered biomedical devices, which are the new vision of Internet Of Things (IOT) healthcare, are facing many technical and application challenges. Many research works have reported biomedical devices and self-powered applications for healthcare, along with various strategies to improve the monitoring time of self-powered devices or to eliminate the dependence on electrochemical batteries. However, none of these works have especially assessed the development and application of healthcare devices in an African context. This article provides a comprehensive review of self-powered devices in the biomedical research field, introduces their applications for healthcare, evaluates their status in Africa by providing a thorough review of existing biomedical device initiatives and available financial and scientific cooperation institutions in Africa for the biomedical research field, and highlights general challenges for implementing self-powered biomedical devices and particular challenges related to developing countries. The future perspectives of the aforementioned research field are provided, as well as an architecture for improving this research field in developing countries.

Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control

PURPOSE

The management of overriding distal forearm fractures is still controversial. This study aimed to evaluate the efficacy of immediate closed reduction and cast immobilization (CRCI) at the emergency department (ED) using equimolar nitrous oxide (eN2O2) as conscious sedation, and without the use fluoroscopic assistance.

METHODS

Sixty patients with overriding distal forearm fracture were included in the study. All procedures were performed in the ED without fluoroscopic assistance. Antero-posterior and lateral wrist radiographs were taken after CRCI. Follow-up radiographs were taken 7 and 15 days post-reduction, and at cast removal to evaluate callus formation. Depending on the radiological outcome, two groups of patients could be identified: Group 1 (satisfactory reduction and maintenance of alignment) and Group 2 (poor reduction or secondary displacement requiring further manipulation and surgical fixation). Group 2 was additionally divided into Group 2A (poor reduction) and Group 2B (secondary displacement). Pain was assessed using Numeric Pain Intensity (NPI) score, while functional outcome was measured according to Quick DASH questionnaire.

RESULTS

Mean age at the time of injury was 9.2 ± 2.4 years (range, 5-14). Twenty-three (38%) patients were aged between 4 and 9 years old, 20 (33%) patients between 9 and 11, 11 (18%) patients between 11 and 13, and 6 (10%) patients between 13 and 14. The mean follow-up time was 45.6 ± 12 months (range, 24-63). Satisfactory reduction with maintenance of alignment was achieved in 30 (50%) patients (Group 1). Re-reduction was performed in the remaining 30 (50%) patients (Group 2) due to poor reduction (Group 2A) or secondary displacement (Group 2B). No complications related to the administration of eN2O were recorded. No statistically significant difference could be identified between the three groups for any clinical variable (Quick DASH and NPI).

CONCLUSION

Overriding distal forearm fractures may be safely treated with CRCI at ED using eN2O2 as conscious sedation. However, fluoroscopic assistance during CRCI might significantly improve the quality of reduction thus avoiding further treatment as the lack of relaxed muscle can restrain reduction.

Results of the Use of Bioabsorbable Magnesium Screws for Surgical Treatment of Mason Type II Radial Head Fractures

Background

In Mason classification type II radial head fractures, compared to plate fixation, fixation with cannulated headless screws and absorbable pins has been reported to provide more favorable postoperative outcomes, including less postoperative limitation in range of motion. The fact that radial head fractures are less prone to weight-bearing during fracture union further supports the use of absorbable screws as a suitable alternative treatment option in radial head fractures. This study aimed to perform fixation through open reduction using bioabsorbable magnesium screws for Mason type II radial head fractures and to report radiographic and clinical results.

Methods

Among patients who visited the orthopedic department from April 2017 to August 2021, 22 with surgical indications were selected for participation. Radiographic tests were conducted at 2 weeks, 4 weeks, 8 weeks, 12 weeks, 6 months, and over 1 year after surgery to confirm the degree of bone union, reduction loss, and degree of H2 gas production. The Disabilities of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance Score (MEPS), hand grip power, and range of joint motion were measured at the 6-month follow-up to evaluate the clinical efficacy of the operation.

Results

Bone union was confirmed in all 22 cases, and the mean time to union was 10.2 weeks. DASH score was 22.27 on average and no patients complained of significant discomfort after the surgery. The mean MEPS was 91.1. The hand grip power of the affected hand was similar to that of the unaffected hand, being 1.19% weaker on average. These differences reached statistical significance (p = 0.002). The range of elbow joint motion was measured: mean flexion, 146.1°; mean extension, 1.4°; mean pronation, 88.2°; and mean supination, 87.9°.

Conclusions

In treating Mason type II radial head fractures, the use of bioabsorbable screws made of magnesium showed satisfactory results in radiographic and clinical evaluations. Magnesium bioabsorbable screws can maintain sufficient stability at the fracture site and have the advantage of avoiding secondary operation for the removal of internal fixation devices.

Management of distal femoral fractures with metaphyseal and articular comminution (AO/OTA 33C) using nail and plate fixation: a technical note and case series of 14 patients

PURPOSE

To describe the surgical technique and the outcome of a case series of comminuted intra-articular distal femur fractures (AO/OTA 33C) treated with a nail-plate combination (NPC) implant.

METHODS

We retrospectively analyzed a case series of 14 patients with comminuted intra-articular distal femur fractures (DFF) treated with an intramedullary retrograde nail in combination with a lateral low-contact condylar locking plate, in a period between June 2020 and January 2023 at a Level 1 trauma center. Baseline demographic and clinical data were recorded. Time to bone healing, function using Schatzker Lambert Score, and complications were documented.

RESULTS

Fourteen patients, 8 males and 6 females, with a total of 15 NPC implants, were included in this study. Eight out of 14 patients had open fractures, all with a Gustilo Anderson type IIIA exposure. The mean age was 48.5 ± 18.05 years. The median follow-up was 392 days, with only one patient lost to follow-up. 11 out of 15 implants achieved complete radiographic consolidation during follow-up, at a mean of 5.40 ± 1.07 months. At the 12-month follow-up, all patients could fully bear weight painlessly or with mild pain. Schatzker Lambert Score was excellent for 4 patients, good for 2 patients, fair for 5 patients, and failure for 2 patients. The main postoperative complications were rigidity (3 cases), limb shortening (2 cases), and septic non-union (1 case).

CONCLUSION

This study suggests that the nail-plate combination (NPC) may provide a more effective surgical technique for addressing the challenges associated with comminuted intra-articular distal femur fractures (AO/OTA 33C).

LEVEL OF EVIDENCE: 4

Employing direct electromagnetic coupling to assess acute fracture healing: An ovine model assessment

OBJECTIVES

This study explored the efficacy of collecting temporal fracture site compliance data via an advanced direct electromagnetic coupling (DEC) system equipped with a Vivaldi-type antenna, novel calibration technique, and multi-antenna setup (termed maDEC) as an approach to monitor acute fracture healing progress in a translational large animal model. The overarching goal of this approach was to provide insights into the acute healing dynamics, offering a promising avenue for optimizing fracture management strategies.

METHODS

A sample of twelve sheep, subjected to ostectomies and intramedullary nail fixations, was divided into two groups, simulating normal and impaired healing scenarios. Sequential maDEC compliance or stiffness measurements and radiographs were taken from the surgery until euthanasia at four or eight weeks and were subsequently compared with post-sacrifice biomechanical, micro-CT, and histological findings.

RESULTS

The results showed that the maDEC system offered straightforward quantification of fracture site compliance via a multiantenna array. Notably, the rate of change in the maDEC-measured bending stiffness significantly varied between normal and impaired healing groups during both the 4-week (p = 0.04) and 8-week (p = 0.02) periods. In contrast, radiographically derived mRUST healing measurements displayed no significant differences between the groups (p = 0.46). Moreover, the cumulative normalized stiffness maDEC data significantly correlated with post-sacrifice mechanical strength (r2 = 0.80, p < 0.001), micro-CT measurements of bone volume fraction (r2 = 0.60, p = 0.003), and density (r2 = 0.60, p = 0.003), and histomorphometric measurements of new bone area fraction (r2 = 0.61, p = 0.003) and new bone area (r2 = 0.60, p < 0.001).

CONCLUSIONS

These data indicate that the enhanced maDEC system provides a non-invasive, accurate method to monitor fracture healing during the acute healing phase, showing distinct stiffness profiles between normal and impaired healing groups and offering critical insights into the healing process's progress and efficiency.

Wall thickness analysis method for judging the degree of lower extremity long bone healing

To evaluate the possibility of judging the degree of bone healing by wall thickness analysis provide reference for quantitative analysis of bone healing. Patients with lower limb fracture from April 2014 to October 2019 were recruited and divided into bone healing (group A), poor bone healing (group B), and nonunion (group C). Models were built in Mimics 20.0 with DICOM 3.0 data obtained from patient's CT. Three-dimensional geometric models of unaffected limb and affected limb after simulated removal of internal fixation were established, corresponding to basic phase and simulated phase, respectively. Wall thickness analysis was performed to obtain median wall thickness after meshing. R2 (median wall thickness ratio), R4 (CT value ratio), and R5 (healing index ratio) were obtained by calculating the ratio of each value in simulated phase to that in basic phase. Receiver operating characteristic curve analysis was used to evaluate the ability of Wall Thickness Analysis to indicate fracture healing. 112 CT scans of 79 patients were included in the study. The frequency of categorization in groups A, B, and C was 49, 37 and 26, respectively. The median R2 in groups A, B, and C was 0.91, 0.80, and 0.67, respectively (group A > group B > group C, all P < 0.05). The best cutoff point for R2 in predicting bone healing was 0.84, and predicting bone nonunion was 0.74. The Wall Thickness Analysis can be used to quantitatively evaluate fracture healing state, with median wall thickness ratio as a more intuitive and reliable judgment index.

Comparison of reconstruction nails versus dual implants in the treatment of ipsilateral femoral neck and shaft fractures in adults: a meta-analysis and systematic review

OBJECTIVE

There is no consensus on the optimal treatment for ipsilateral femoral neck and shaft fractures. This meta-analysis aims to assess the effectiveness of reconstruction nails and dual implants in treating ipsilateral femoral neck and shaft fractures to provide a basis for decision-making when selecting the optimal approach.

METHODS

Relevant articles were retrieved from Pubmed, Embase, and Cochrane databases using the keywords "neck of femur", "shaft" and "fracture fixation" from inception until November 17, 2022. The screening process of the studies was conducted independently by two assessors, who assessed each study's eligibility and two assessors assessed the quality. Then compared differences in outcome measures using RevMan 5.3 software.

RESULTS

A total of ten retrospective cohort studies were included. There were no significant differences in union time, union rate, union-related complications (malunion, nonunion, delayed union) of femoral neck and shaft fractures, osteonecrosis of the femoral head, and functional outcomes (Friedman-Wyman scoring system) (P > 0.05).

CONCLUSION

Our pooled estimates indicated that reconstruction nails and dual implants for ipsilateral femoral neck and shaft fractures could yield satisfactory surgical results, and that there is no difference between the two treatment methods.

TRIAL REGISTRATION

This meta-analysis was registered on the PROSPERO website (registration number: CRD42022379606).

Computed tomography micromotion analysis in the follow-up of patients with surgically treated pelvic fractures: a prospective clinical study

PURPOSE

High-energy pelvic fractures are complex injuries often requiring surgical treatment. Different radiological methods exist to evaluate the reduction and healing process postoperatively but with certain limitations. The aim of this study was to evaluate Computed Tomography Micromotion Analysis (CTMA) in a clinical setting for follow-up of surgically treated pelvic fracture patients.

METHODS

10 patients surgically treated for a pelvic fracture were included and prospectively followed with Computed Tomography (CT) at 0, 6, 12 and 52 weeks postoperatively. CTMA was used to measure postoperative translation and rotation of the pelvic fracture during the 52 weeks follow-up. Clinical outcomes were collected through the questionnaires EQ-5D index score and Majeed score.

RESULTS

10 patients were included with mean age (± SD, min-max) 52 (16, 31-80) years and 70% (n = 7) were males. The median (IQR, min-max) global translation from 0 to 52 weeks was 6.0 (4.6, 1.4-12.6) millimeters and median global rotation was 2.6 (2.4, 0.7-4.7) degrees. The general trend was a larger translation between 0 and 6 weeks postoperatively compared to 6-12 and 12-52 weeks. For the clinical outcomes, the general trend was that all patients started from high scores which decreased in the first postoperative follow-up and recovered to different extent during the study period.

CONCLUSION

CTMA was successfully used in the follow-up of surgically treated pelvic fracture patients. Movement in the pelvic fractures after surgical fixation was largest between 0 and 6 weeks.

Evaluation of bony changes observed in mandibular osteotomy lines and mandibular condyles following bilateral sagittal ramus osteotomy by fractal analysis

OBJECTIVES

This study aimed to evaluate the surgically impacted trabecular changes in mandibular osteotomy lines and mandibular condyles after bilateral sagittal split ramus osteotomy using the fractal analysis method.

MATERIALS AND METHOD

The study population consisted of 30 patients (9 male, 21 female) diagnosed with mandibular prognathism and operated with bilateral sagittal split ramus osteotomy under general anesthesia. Fractal analyses observed the alterations on the trabecular structure of osteotomy lines, and mandibular condyles on panoramic radiographs obtained preoperatively, postoperatively, 1st week, 6th month, and 12th month. The box-counting method was used to evaluate the changes in trabecular structure by fractal analysis. P-values of less than 0.05 were considered significant.

RESULTS

The fractal dimension values in both osteotomy lines and mandibular condyles were significantly decreased on postoperative 1st week regarding preoperative values. However, fractal dimension values commenced increasing in the following postoperative period. The fractal dimension values of the horizontal and vertical osteotomy lines reached their preoperative values on postoperative 6th and 12th month, respectively. The decreased fractal dimension values observed in the early postoperative period in the right and left condyles reached their preoperative values at the 6th postoperative month.

CONCLUSION

Fractal analyses performed postoperatively can provide information about trabecular changes and bone healing of structures such as osteotomy lines directly affected by bilateral sagittal split ramus osteotomy and indirectly affected mandibular condyles. The results support that fractal analysis can be used together with clinical data in the evaluation of bone healing process.

Combined press-fit and extracortical fixation in patellar tendon anterior cruciate ligament reconstruction results in reliable graft fixation and early bone block incorporation

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction with bone-patellar-tendon-bone (BPTB) autograft has the potential biological advantage of direct bone-to-bone healing over soft tissue grafts. The primary aim of this study was to investigate possible graft slippage and therefore fixation strength in a modified BPTB autograft technique with suspensory fixation on both sides for primary ACL reconstruction until bony integration takes place.

METHODS

Twenty-one patients undergoing primary ACL reconstruction with a modified BPTB autograft (bone-on-bone (BOB) technique) between August 2017 and August 2019 were included in this prospective study. A computed tomography (CT) scan of the affected knee was performed directly postoperatively, as well as 3 months postoperatively. Examiner-blinded parameters for graft slippage, early tunnel widening, bony incorporation, as well as remodeling of the autologous refilled patellar harvest site were investigated.

RESULTS

A series of 21 patients treated with a BPTB autograft with this technique underwent two CT investigations. Comparison of CT scans showed no bone block displacement and therefore no graft slippage in the patient cohort. Only one patient showed signs of early tunnel enlargement. Radiological bone block incorporation took place showing bony bridging of the graft to the tunnel wall in 90% of all patients. Furthermore, 90% showed less than 1 mm bone resorption of the refilled harvest site at the patella.

CONCLUSIONS

Our findings suggest graft fixation stability and reliability of anatomic BPTB ACL reconstruction with a combined press-fit and suspensory fixation technique by absence of graft slippage within the first 3 months postoperatively.

Early Internal Fixation of Concomitant Clavicle Fractures in Severe Thoracic Trauma Prevents Posttraumatic Pneumonia

BACKGROUND

Severe thoracic trauma can lead to pulmonary restriction, loss of lung volume, and difficulty with ventilation. In recent years, there has been increasing evidence of better clinical outcomes following surgical stabilization of clavicle fractures in the setting of this combination of injuries. The aim of this study was to evaluate surgical versus non-surgical treatment of clavicle fractures in severe thoracic trauma in terms of clinical and radiological outcomes in order to make a generalized treatment recommendation based on the results of a large patient cohort.

PATIENTS AND METHODS

This retrospective study included 181 patients (42 women, 139 men) from a European level I trauma centre with a median of 49.3 years in between 2005 and 2021. In 116 cases, the clavicle fracture was stabilized with locking plate or hook plate fixation (group 1), and in 65 cases, it was treated non-surgically (group 2). Long-term functional outcomes at least one year postoperatively using the disabilities of the arm, shoulder and hand (DASH) questionnaire and the Nottingham Clavicle Score (NCS) as well as radiological outcomes were collected in addition to parameters such as hospital days, intensive care days, and complication rates.

RESULTS

The Injury Severity Score (ISS) was 17.8 ± 9.8 in group 1 and 19.9 ± 14.4 in group 2 (mean ± SEM; p = 0.93), the time in hospital was 21.5 ± 27.2 days in group 1 versus 16 ± 29.3 days in group 2 (p = 0.04). Forty-seven patients in group 1 and eleven patients in the group 2 were treated in the ICU. Regarding the duration of ventilation (group 1: 9.1 ± 8.9 days, group 2: 8.1 ± 7.7 days; p = 0.64), the functional outcome (DASH group 1: 11 ± 18 points, group 2: 13.7 ± 18. 4 points, p = 0.51; NCS group 1: 17.9 ± 8.1 points, group 2: 19.4 ± 10.3 points, p = 0.79) and the radiological results, no significant differences were found between the treatment groups. With an overall similar complication rate, pneumonia was found in 2% of patients in group 1 and in 14% of patients in group 2 (p = 0.001).

DISCUSSION

This study could demonstrate that surgical locking plate fixation of clavicle fractures in combination with CWI significantly reducing the development of posttraumatic pneumonia in a large patient collection and, therefore, can be recommended as standard therapeutic approach for severe thoracic trauma.

The value of sonication in the differential diagnosis of septic and aseptic femoral and tibial shaft nonunion in comparison to conventional tissue culture and histopathology: a prospective multicenter clinical study

BACKGROUND

Septic and aseptic nonunion require different therapeutic strategies. However, differential diagnosis is challenging, as low-grade infections and biofilm-bound bacteria often remain undetected. Therefore, the examination of biofilm on implants by sonication and the evaluation of its value for differentiating between femoral or tibial shaft septic and aseptic nonunion in comparison to tissue culture and histopathology was the focus of this study.

MATERIALS AND METHODS

Osteosynthesis material for sonication and tissue samples for long-term culture and histopathologic examination from 53 patients with aseptic nonunion, 42 with septic nonunion and 32 with regular healed fractures were obtained during surgery. Sonication fluid was concentrated by membrane filtration and colony-forming units (CFU) were quantified after aerobic and anaerobic incubation. CFU cut-off values for differentiating between septic and aseptic nonunion or regular healers were determined by receiver operating characteristic analysis. The performances of the different diagnostic methods were calculated using cross-tabulation.

RESULTS

The cut-off value for differentiating between septic and aseptic nonunion was ≥ 13.6 CFU/10 ml sonication fluid. With a sensitivity of 52% and a specificity of 93%, the diagnostic performance of membrane filtration was lower than that of tissue culture (69%, 96%) but higher than that of histopathology (14%, 87%). Considering two criteria for infection diagnosis, the sensitivity was similar for one tissue culture with the same pathogen in broth-cultured sonication fluid and two positive tissue cultures (55%). The combination of tissue culture and membrane-filtrated sonication fluid had a sensitivity of 50%, which increased up to 62% when using a lower CFU cut-off determined from regular healers. Furthermore, membrane filtration demonstrated a significantly higher polymicrobial detection rate compared to tissue culture and sonication fluid broth culture.

CONCLUSIONS

Our findings support a multimodal approach for the differential diagnosis of nonunion, with sonication demonstrating substantial usefulness.

LEVEL OF EVIDENCE

Level 2 Trial registration DRKS00014657 (date of registration: 2018/04/26).

Efficacy of Postoperative Radiographs After Intramedullary Nailing of the Tibia and Femur: When Are They Useful?

INTRODUCTION

Postoperative radiographs are used to monitor fractures of the tibia and femur after intramedullary fixation. This study sought to examine how frequently these radiographs change management.

METHODS

This was a single-center chart review of patients over a 4-year period at a level I trauma center. Radiographs were defined as either performed for routine surveillance or performed with some clinical correlate on history and examination. Participants received intramedullary nailing for diaphyseal fractures of the femur or tibia. Patients required at least one postoperative radiograph. All patients were subject to our institution's follow-up protocol: visits at 2, 6, 12, and 24 weeks. Radiographs that changed management were those that led to alterations in follow-up, directed counseling, or contributed to the decision to proceed with revision surgery.

RESULTS

A total of 374 patients were found. Two hundred seventy-seven received at least one post-op radiograph. The median follow-up was 23 weeks. Six hundred seventeen total radiographs were reviewed. Nine radiographs contributed to a change in management (9/617 = 1.5%). No surveillance radiograph taken before 14 weeks resulted in changes in management.

DISCUSSION

Our results suggest that radiographs taken in the first 3 months post-op in asymptomatic patients treated with lower extremity intramedullary rods do not result in changes to clinical management.

Comparison of Posterior and Anterolateral Surgical Approaches in Treating Adult Humeral Shaft Fractures

AIM

The purpose of this study is to compare the outcomes and complications of two different surgical approaches, the anterolateral and posterior approaches, for treating humeral shaft fractures.

MATERIALS AND METHODS

 Between January 2015 and May 2021, 51 patients with humeral shaft fractures were treated with anterolateral and posterior approaches. Twenty-nine patients were operated with the posterior approach (group 1) and 22 with the anterolateral approach (group 2). Statistical analyses were performed between the two groups regarding age, gender distribution, fractured side, body mass index (BMI), type of trauma, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification, and follow-up time. Complications such as operative time, amount of bleeding, incision length and implant fracture, radial nerve palsy, wound infection, and nonunion were compared between the two groups. Functional results of the elbow joint were evaluated with the Mayo Elbow Performance Score.

RESULTS

 The mean follow-up period was 49.10±21.15 months (12-75 months) in group 1 and 50.00±23.71 months (range: 15-70 months) in group 2. There was no statistical difference between the groups in terms of age, gender distribution, fractured side, BMI, trauma type, AO/OTA classification, and follow-up time (p>0.05). There was no significant difference between the two groups in terms of operation time, intraoperative bleeding, and incision length (p>0.05). The mean Mayo Elbow Performance Score was 77.24±20.03 (range: 70-100 points) in group 1 and 81.36±8.34 (range: 70-100 points) in group 2, and no significant difference was found (p>0.05). When evaluated in terms of complications, there was no significant difference between the groups (p>0.05). While there was no significant difference between the two groups regarding elbow joint range of motion, the limitation was observed in more patients in group 1.

CONCLUSION

 Similar satisfactory treatment results were obtained in patients who underwent anterolateral and posterior approaches in treating humeral shaft fractures. Furthermore, no difference was found between the two approaches regarding complication rates.

Assessment of fracture healing in orthopaedic trauma

Fracture healing is a complex physiologic process, relying on the crucial interplay between biological and mechanical factors. It is generally assessed using imaging modalities, including conventional radiology, CT, MRI and ultrasound (US), based on the fracture and patient features. Although these techniques are routinely used in orthopaedic clinical practice, unfortunately, they do not provide any information about the biomechanical status of the fracture site. Therefore, in recent years, several non-invasive techniques have been proposed to assess bone healing using ultrasonic wave propagation, changes in electrical properties of bones and callus stiffness measurement. Moreover, different research groups are currently developing smart orthopaedic implants (plates, intramedullary nails and external fixators), able to provide information about the fracture healing process. These devices could significantly improve orthopaedic and trauma clinical practice in the future and, at the same time, reduce patients' exposure to X-rays. This study aims to define the role of traditional imaging techniques and emerging technologies in the assessment of the fracture healing process.

[Development and principles of intramedullary and extramedullary segmental bone transport: overview and clinical results]

BACKGROUND

Segmental bone transport using intramedullary or extramedullary techniques is one of the most commonly used procedures for bone defect management in the diaphyseal region of long bones.

OBJECTIVE

The purpose of this work is to provide an overview of the historical development and general principles as well as the current status of extramedullary and intramedullary techniques of bone segment transport. In addition, own results on internal segmental bone transport are presented.

MATERIAL AND METHODS

A retrospective database analysis included all patients between May 2019 and January 2021 who underwent segmental bone transport via a fully implantable intramedullary segment transport nail system. In addition to the radiological outcome, the clinical outcome was assessed using the lower extremity functional scale (LEFS).

RESULTS

A total of 9 patients (8 male, 1 female; age 41.7 ± 3.9 years) could be included. The cause of the segmental bone defect was chronic fracture-related infection in all cases. The segmental defect size was 62 ± 10 mm. Sufficient bridging of the bone defect was achieved in all patients, with a mean distraction rate of 0.9 ± 0.1 mm per day. Bony consolidation of the regeneration was achieved after 292 ± 57 days, and final bony consolidation of the docking zone was achieved after 469 ± 116 days. At 22 ± 3 months after implantation of the segmental transport nail, the LEFS demonstrated a result of 59 ± 4 points. No recurrence of infection or regeneration failure occurred.

CONCLUSION

The aim of treating segmental bone defects, in addition to reconstructing a load-bearing bone, is to restore correct joint angles, leg length, and leg axis without torsional deviation and can be achieved via classical external segmental bone transport. In recent years, internal segmental bone transport has been developed as an alternative. It remains to be seen whether the preliminary and reproducibly good clinical and radiological results of segmental transport nails can be confirmed for widespread use in the future.

Comparison of ultrasonography and conventional radiography in the diagnosis of extremity fractures in the emergency department

Objective: The purpose of the study is to compare the diagnostic accuracy (sensitivity and specificity) of ultrasonography (USG) with that of conventional radiography (CR), the standard imaging modality used to diagnose acute extremities fractures. Materials and Methods: The prospective investigation examined 245 patients with clinical symptoms of an extremity fracture. Radiography (anteroposterior and lateral radiographs for each patient, oblique if necessary) and USG were performed on all participants and compared with all the results. Results: CR verified 98.5% of 132 patients who were determined to have extremities fractures with USG. CR, on the other hand, confirmed 99.1% of 112 patients who were reported to have no extremities fractures by USG. The sensitivity (detection of fractures based on USG of patients with fractures detected based on the CR imaging) was 99.2% (95%CI=95.8-99.9); selectivity (no fracture was detected based on USG of patients with no fracture detected based on the CR imaging) was 98.2% (95%CI=93.8-99.7); the positive predictability was 98.48% (95%CI=94.2-99.6), whereas the negative predictability value was 99.1%(95%CI=94-99.8). Conclusion: USG and CR showed similar diagnostic performances in the diagnosis of extremity fractures. USG can be considered an alternative to CR in the examination of extremity fractures with comparable diagnostic performance.

Osteoimmunology: The effect of autoimmunity on fracture healing and skeletal analysis

Understanding factors that affect bone response to trauma is integral to forensic skeletal analysis. It is essential in forensic anthropology to identify if impaired fracture healing impacts assessment of post-traumatic time intervals and whether a correction factor is required. This paper presents a synthetic review of the intersection of the literature on the immune system, bone biology, and osteoimmunological research to present a novel model of interactions that may affect fracture healing under autoimmune conditions. Results suggest that autoimmunity likely impacts fracture healing, the pathogenesis however, is under researched, but likely multifactorial. With autoimmune diseases being relatively common, significant clinical history should be incorporated when assessing skeletal remains. Future research includes the true natural healing rate of bone; effect of autoimmunity on this rate; variation of healing with different autoimmune diseases; and if necessary, development of a correction factor on the natural healing rate to account for impairment in autoimmunity.

Long-Term Assessment of Bone Regeneration in Nonunion Fractures Treated with Compression-Resistant Matrix and Recombinant Human Bone Morphogenetic Protein-2 in Dogs

OBJECTIVE

 The aim of this study was to assess bone density, bone architecture and clinical function of canine nonunion distal appendicular long bone fractures with a defect treated with fixation, compression-resistant matrix and recombinant human bone morphogenetic protein-2 (rhBMP-2).

STUDY DESIGN

 Prospective cohort study with dogs at least 1-year post treatment. Computed tomography was performed and quantitative measurements from previous fracture sites were compared with measurements from contralateral limbs. Subjective evaluation included gait assessment and palpation.

RESULTS

 Six patients met the inclusion criteria. The rhBMP-2 treated bone exhibited higher density at the periphery and lower density in the centre, similar to the contralateral limb. All patients were weight bearing on the treated limb and all fractures were healed.

CONCLUSION

 The rhBMP-2-treated bone underwent restoration of normal architecture and density. Acceptable limb function was present in all patients. The results of this study can serve as a basis for long-term response in treating nonunion fractures in veterinary patients.

Osseous Union after Jaw Reconstruction with Fibula-Free Flap: Conventional vs. CAD/CAM Patient-Specific Implants

This is a monocentric, retrospective study of patients who underwent successful immediate or delayed maxilla or mandible reconstructions with FFF from January 2005 to December 2021. Panoramic radiograph, computed tomography scans, and cone-beam CTs were analyzed concerning the osseous union of the intersegmental junctions between maxillary or mandibular native jaw and fibular bone. The primary parameter was to estimate the status of osseous union according to osteosynthesis type. A total number of 133 patients (PSI: n = 64, non-PSI: n = 69) were included in the present study. The mean age was 56.7 ± 14.0 (Range: 14.7−82.7); the primary diagnosis was in 105 patients a malignant (78.9%) and in 20 patients a benign (15.0%) tumor. Mandible reconstruction was performed on 103 patients (77.4%), and on 30 patients (22.6%), maxilla reconstruction was performed. The radiographic images provided a rate of incomplete osseous union (IOU) of about 90% in both groups in the first 6 months. Imaging between 6 and 12 months reveals an IOU rate in the non-PSI group of 46.3% vs. 52.5% in the PSI group, between 12 and 24 months, an IOU rate of 19.6% vs. 26.1%, between 24 and 36 months 8.9% vs. 21.7%, and after 36 months the IOU rate decreases to 4.2% vs. 18.2%. Multivariate logistic regression shows that only osteosynthesis type (OR = 3.518 [95%-CI = 1.223−10.124], p = 0.02) and adjuvant radiotherapy (OR = 4.804 [95%-CI = 1.602−14.409], p = 0.005) are independent risk factors for incomplete osseous union. Cox regression revealed that the variables plate-system (Hazard ratio, HR = 5.014; 95 %-CI: 1.826−3.769; p = 0.002) and adjuvant radiotherapy (HR = 5.710; 95 %-CI: 2.066−15.787; p < 0.001) are predictors for incomplete osseous union. In our study, the rate of incomplete bony fusion was significantly higher in the PSI group. Jaw-to-fibula apposition zones were significantly more affected than intersegmental zones. In multivariate analysis, a combination of osteosynthesis with PSI and adjuvant radiotherapy could be identified as a risk constellation for incomplete ossification.

Internal Fixation of Garden Type III Femoral Neck Fractures with Sliding Hip Screw and Anti-Rotation Screw: Does Increased Valgus Improve Healing?

Background and Objectives: The aim of this study was to compare the effect of valgus versus anatomic reduction on internal fixation of Garden type III femoral neck fractures using the sliding hip screw (SHS) and anti-rotation screw (ARS) regarding the radiographic and therapeutic outcome. Patients and Methods: A retrospective case-controlled study was performed in a level I trauma center. All patients between 2006 and 2020 aged younger than 70 years with a Garden type III femoral neck fracture and a Kellgren-Lawrence score under grade III stabilized using SHS and ARS were identified. One-hundred and nine patients were included, with a group distribution of sixty-eight patients in group A (anatomic reduction) and forty-one patients in group B (valgus reduction). Results: Mean age was 55 years, and the mean Kellgren-Lawrence score was 1 in both groups. Mean femoral neck angle was 130.5 ± 3.8° in group A and 142.8 ± 4.3° in group B (p = 0.001), with an over-correction of 12° in group B. Tip-apex distance was 10.0 ± 2.8 mm in group A versus 9.3 ± 2.8 mm in group B (p = 0.89). Healing time was 9 weeks in group A compared to 12 weeks in group B (p = 0.001). Failure rate was 4.4% in group A and 17.1% in group B (p = 0.027). Conclusions: Anatomic reduction of Garden type III femoral neck fractures in patients younger than 70 years treated using SHS and ARS resulted in significantly lower failure rates and shorter healing times than after valgus reduction. Therefore, it can be recommended to achieve anatomic reduction.

Common Ultrasound Applications for Pediatric Musculoskeletal Conditions

PURPOSE OF REVIEW

To discuss the use of ultrasound for diagnosis and management of common pediatric musculoskeletal conditions through a case-based approach.

RECENT FINDINGS

Ultrasound is an essential diagnostic modality in the early detection of developmental dysplasia of the hips and can be used as early as 6 weeks of age when the ossific nucleus has not developed yet. Ultrasound is helpful in diagnosing traumatic injuries such as fractures and intramuscular hematomas, can visualize fracture healing at early stages, and can also be used to guide aspiration of hematomas that can help with decreasing pain and faster recovery. Ultrasound is superior to radiographs in evaluating joint effusions and soft tissue infections or masses and is better tolerated by children compared to other imaging modalities such as magnetic resonance imaging (MRI). Ultrasound is an easily accessible, affordable, non-invasive, and radiation-free imaging modality that is well tolerated by children and their families. It can aid in the diagnosis and management of a wide variety of musculoskeletal conditions including developmental, traumatic, and infectious etiologies, as well as in the evaluation of superficial soft tissue masses.

High Rate of Radiographic Union at the Fibular Osteotomy Site With No Complications After an Acute Oblique Osteotomy and Ligation Procedure to Shorten the Fibula in High Tibial Osteotomy

Background:

A fibular shortening osteotomy is needed to perform lateral closing-wedge high tibial osteotomy (LCW-HTO). To achieve this shortening, we have recently developed an acute oblique osteotomy and ligation (AO/L) procedure for the center of the fibular shaft, based on the AO procedure.

Purpose:

To compare the 2-year follow-up outcomes between the AO/L procedure and the AO procedure.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A prospective comparative cohort study was conducted involving 83 patients (83 knees) who underwent shortening osteotomy of the fibula in LCW-HTO between April 2017 and March 2019. The first consecutive 41 knees (AO group) underwent fibular osteotomy with the AO procedure. The remaining 42 knees (AO/L group) underwent fibular osteotomy with the AO/L procedure. All of the patients were evaluated for at least 2 years postoperatively via clinical and radiological assessments. To determine the time needed for complete union at the osteotomy site, we evaluated the radiographs using a radiographic union score for tibial fractures, which was modified for fibular osteotomy. Comparison of outcomes between the 2 groups was performed using the Student t test for continuous variables and the Mann-Whitney U test or Fisher exact test for discrete variables.

Results:

Around the fibular osteotomy site, no perioperative complications were found in either group. The radiographic union score was significantly higher in the AO/L group than in the AO group (P < .0001 at 2, 3, and 6 months; P = .0290 at 12 and 24 months). The union rate at the fibular osteotomy site was significantly higher in the AO/L group (97.6%) than in the AO group (82.9%) at 12 months (P = .0290).

Conclusion:

The AO/L procedure significantly accelerated the formation of bridging callus at the fibular osteotomy site and provided a significantly higher union rate compared with the AO procedure. Both AO/L and AO procedures were free from perioperative complications. These results suggest that the AO/L procedure is clinically useful as an osteotomy procedure to shorten the fibula in LCW-HTO.

Utility of micro-CT for dating post-cranial fractures of known post-traumatic ages through 3D measurements of the trabecular inner morphology

Fracture dating is an issue at the forefront of forensic sciences. While dating fracture is crucial to understanding and verifying the chronology of events in cases of abuse and violent death, its application is the subject of considerable discussion in the scientific community, filled with limitations and difficulties. Current methods for fracture dating are mainly based on a qualitative assessment through macroscopy, microscopy, and imaging and subject to variations depending on the experience of the observer. In this paper, we investigated the potential of quantifiable micro-CT analysis for fracture dating. Five histomorphometric parameters commonly used for the study of the 3D bone trabecular microarchitecture with micro-CT were calculated based on nine fractures of known post-traumatic ages, including the degree of anisotropy, connectivity density, bone volume fraction, trabecular thickness, and trabecular separation. As a result, trends in the evolution of the microarchitecture of the bone relative to age of the callus could be identified, in particular concerning anisotropy, trabecular separation and connectivity density, consistent with the healing bone process. The findings obtained in this pilot study encourage further research in quantifiable parameters of the bone microarchitecture as they could represent useful features for the construction of objective models for fracture dating.

The Effect of Hand Dominance, Age, Gender, Fracture Comminution and ASA Status on Time to Fracture Healing Following Surgical Fixation of Distal Radius Fractures

Background: There is recent renewed interest in the effect of hand dominance on distal radius fractures. Current studies focus on functional or patient-reported outcomes, with lack of studies pertaining to radiological outcomes. The primary aim of this study is to examine the effect of hand dominance on time to fracture healing following surgical fixation of distal radius fracture. We also looked at the effect of age, gender, fracture comminution and American Society of Anaesthesiologists (ASA) status on time to fracture healing.

Methods: Patients who underwent distal radius fracture fixation surgery in our department from 1 January 2015 to 31 December 2015 were included. Time to fracture healing was taken from the day of surgery to when radiographic union was present as evidence by bridging callus or osseous bone. We looked at the effect of hand dominance, age, gender, fracture comminution and ASA status on time to fracture healing.

Results: One hundred and forty-five consecutive patients (80 females and 65 males) had a mean period of 56.2 ± 41.8 days to fracture healing post-operatively. Patients with dominant hand injury had a shorter duration to fracture healing than patients with non-dominant hand injury (mean 47.3 ± 31.1 days versus 62.1 ± 46.8 days, p = 0.023). Patients ≥ 65 years and with pre-existing medical conditions (ASA Class II and above) had a longer duration to fracture healing (mean 63.7 ± 53.0 days versus 51.9 ± 33.4 days, p = 0.036 and mean 47.9 ± 30.0 days versus 62.0 ± 47.7 days, p = 0.016, respectively). In addition, patients with comminuted fractures took longer to heal than patients with non-comminuted fractures (mean 57.6 ± 33.4 days versus 48.3 ± 20.8 days, p = 0.038).

Conclusion: Time to fracture healing post distal radius fracture fixation surgery was significantly related to hand dominance, as well as age, ASA classification and fracture configuration. Dominant wrist injuries had shorter time to fracture healing.

Level of Evidence: Level IV (Therapeutic)

[Flap combined with induced membrane technique in treatment of post-traumatic tibial osteomyelitis with soft tissue defect]

Objective

To investigate the effectiveness of flap combined with induced membrane technique in treatment of post-traumatic tibial osteomyelitis with soft tissue defect.

Methods

A clinical data of 33 patients with post-traumatic tibial osteomyelitis with soft tissue defect who met the selection criteria between August 2015 and October 2018 was retrospectively analyzed. There were 21 males and 12 females. The age ranged from 19 to 70 years, with an average of 39 years. The osteomyelitis located in the upper 1/3 of tibia in 8 cases, in the middle 1/3 of tibia in 14 cases, and in the lower 1/3 of tibia in 11 cases. According to Cierny-Mader classification standard, 19 cases of osteomyelitis were type Ⅲ and 14 cases were type Ⅳ. The duration of osteomyelitis ranged from 2 months to 20 years (median, 3 months). In the first-stage operation, after radical debridement, the length of bone defect was 1.5-12.5 cm (mean, 5.0 cm) and the size of soft tissue defects ranged from 5 cm×4 cm to 15 cm×12 cm. Bone cement containing antibiotics was implanted into the bone defect and the personalized flap was used to repair the wound. After the wound healed at 6-8 weeks and the infection was controlled, bone grafting was performed to repair bone defects in the second-stage operation.

Results

The flaps survived completely after the first-stage operation in 29 cases. Partial necrosis of the flap occurred in 4 cases and healed after surgical dressing change. All the incisions healed by first intention after the second-stage operation. All patients were followed up 24-32 months (mean, 28 months). All the bone grafts healed after operation, and the radiographic healing time was 3-9 months (mean, 5 months). The clinical healing time was 4-14 months (mean, 8 months). There was no recurrence of osteomyelitis during follow-up. At last follow-up, according to Johner-Wruhs evaluation criteria, the limb function was excellent in 27 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 93.9%.

Conclusion

For the post-traumatic tibial osteomyelitis with soft tissue defect, the flap combined with induced membrane technique is a reliable and effective method and can effectively restore the function of lower limbs with satisfactory effectiveness.

Postmortem and Antemortem Forensic Assessment of Pediatric Fracture Healing from Radiographs and Machine Learning Classification

Simple Summary

Being able to estimate from X-rays alone how long ago a child’s bone was fractured is important for prosecuting suspected child abuse of living or dead children. This estimate can also help identify a child when all that remains are bones. Experts use various indicators to make these estimates of the age of healing and fully healed fractures, in living and deceased persons, even years after the injury occurred. However, it is not a precise science. We proposed a method using a new combination of indicators to classify fracture healing in children and adolescents. We tested its accuracy with a public database of X-rays of children’s fractures taken during the treatment and healing process. We used part of the X-ray database for training artificial intelligence (AI, or machine learning) programs to classify stages of bone healing when using our new system. We used another portion of the same database to test the performance of the AI system that had been trained with our new classification system. Our new system addresses certain classification ambiguities of a currently used system and is similar in accuracy.

Abstract

A timeline of pediatric bone healing using fracture healing characteristics that can be assessed solely using radiographs would be practical for forensic casework, where the fracture event may precede death by days, months, or years. However, the dating of fractures from radiographs is difficult, imprecise, and lacks consensus, as only a few aspects of the healing process are visible on radiographs. Multiple studies in both the clinical and forensic literature have attempted to develop a usable scale to assess pediatric bone healing on radiographs using various healing characteristics. In contrast to the orthopedic definition, a fracture in forensic casework is only considered to be healed when the area around the fracture has been remodeled to the point that the fracture is difficult to detect on a radiograph or on the surface of the bone itself, a process that can take several years. We subjectively assessed visible characteristics of healing in radiograms of fractures occurring in 942 living children and adolescents. By dividing these assessments into learning and test (validation) sets, the accuracy of a newly proposed fracture healing scale was compared to a previous study. Two machine learning models were used to test predictions of the new scale. All three models produced similar estimates with substantial imprecision. Results corroborate the Malone model with an independent dataset and support the efficacy of using less complex models to estimate fracture age in children.