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Kadam A, Wani S, Gadekar G, Katage G, Garg K, Mungikar S. Effect of early weight bearing program with conventional physiotherapy on functional outcomes in surgically treated proximal tibia fracture: a pilot randomized controlled trial. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05347-w. [PMID: 38693286 DOI: 10.1007/s00402-024-05347-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/16/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Patients are often instructed to avoid weight bearing on the proximal tibia for 6 - 12 weeks post-surgery to avoid fracture fixation failure. However, delayed weight bearing leads to delayed mobility, causing difficulties in daily activities; problems such as pain, limited knee ROM, reduced quadriceps muscle strength, and impaired functional outcomes are reported in long-term follow-up. This study primarily aimed to evaluate the feasibility and explore the effect size. The secondary aim was to determine the effectiveness of early weight bearing along with conventional physiotherapy on functional outcomes. MATERIALS AND METHODS A single-blinded pilot randomized controlled trial with 30 participants with proximal tibia type I, II, and III fractures were included; they were randomized using computer-based software. Seven patients were lost to follow-up. Group I received early weight bearing along with conventional physiotherapy whereas Group II received restricted weight bearing along with conventional physiotherapy. Assessments were made on post-operative day 3 (POD-03), at discharge, at 6 weeks, and at 12 weeks. Radiographs were recorded immediately after the operation, at discharge, and at 12 weeks. RESULTS A full-scale RCT is feasible with an effect size between 0.3 - 0.7. A statistically significant difference (p < 0.05) was found within both groups 12 weeks post-surgery in all outcome measures; the difference was more prominent in the intervention group. A statistically significant difference (p < 0.05) was found between both the groups post-12 weeks in all outcome measures except quadriceps isometric muscle strength. CONCLUSION A full-scale RCT for early weight bearing along with conventional physiotherapy for patients operated for Type I, II, and III proximal tibia fracture is feasible. Early weight bearing along with conventional physiotherapy could have a positive effect on reducing patient's pain perception and increasing knee joint mobility, quadriceps isometric muscle strength, knee function, and quality of life without any adverse effects. TRIAL REGISTRATION ClinicalTrialsRegistry.gov (CTRI/2022/10/046797).
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Affiliation(s)
- Anagha Kadam
- Department of Musculoskeletal Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India
| | - Surendra Wani
- Department of Musculoskeletal Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India.
| | - Girish Gadekar
- Department of Orthopedics, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
| | - Goutami Katage
- Department of Musculoskeletal Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India
| | - Kapil Garg
- Department of Musculoskeletal Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India
| | - Sanket Mungikar
- Department of Musculoskeletal Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India
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Williams KE, Andraca Harrer J, LaBelle SA, Leguineche K, Kaiser J, Karipott S, Lin A, Vongphachanh A, Fulton T, Rosenthal JW, Muhib F, Ong KG, Weiss JA, Willett NJ, Guldberg RE. Early Resistance Rehabilitation Improves Functional Regeneration Following Segmental Bone Defect Injury. RESEARCH SQUARE 2023:rs.3.rs-3236150. [PMID: 37886569 PMCID: PMC10602073 DOI: 10.21203/rs.3.rs-3236150/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Mechanical loading is integral to bone development and repair. The application of mechanical loads through rehabilitation are regularly prescribed as a clinical aide following severe bone injuries. However, current rehabilitation regimens typically involve long periods of non-loading and rely on subjective patient feedback, leading to muscle atrophy and soft tissue fibrosis. While many pre-clinical studies have focused on unloading, ambulatory loading, or direct mechanical compression, rehabilitation intensity and its impact on the local strain environment and subsequent bone healing have largely not been investigated. This study combines implantable strain sensors and subject-specific finite element models in a pre-clinical rodent model with a defect size on the cusp of critically-sized. Animals were enrolled in either high or low intensity rehabilitation one week post injury to investigate how rehabilitation intensity affects the local mechanical environment and subsequent functional bone regeneration. The high intensity rehabilitation animals were given free access to running wheels with resistance, which increased local strains within the regenerative niche by an average of 44% compared to the low intensity (no-resistance) group. Finite element modeling demonstrated that resistance rehabilitation significantly increased compressive strain by a factor of 2.0 at week 1 and 4.45 after 4 weeks of rehabilitation. The resistance rehabilitation group had significantly increased regenerated bone volume and higher bone bridging rates than its sedentary counterpart (bone volume: 22.00 mm3 ± 4.26 resistance rehabilitation vs 8.00 mm3 ± 2.27 sedentary; bridging rates: 90% resistance rehabilitation vs 50% sedentary). In addition, animals that underwent resistance running had femurs with improved mechanical properties compared to those left in sedentary conditions, with failure torque and torsional stiffness values matching their contralateral, intact femurs (stiffness: 0.036 Nm/deg ± 0.006 resistance rehabilitation vs 0.008 Nm/deg ± 0.006 sedentary). Running on a wheel with no resistance rehabilitation also increased bridging rates (100% no resistance rehabilitation vs 50% sedentary). Analysis of bone volume and von Frey suggest no-resistance rehabilitation may improve bone regeneration and hindlimb functionality. These results demonstrate the potential for early resistance rehabilitation as a rehabilitation regimen to improve bone regeneration and functional recovery.
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Affiliation(s)
- Kylie E. Williams
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Julia Andraca Harrer
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
- Atlanta Veteran’s Affairs Medical Center, Decatur, GA
| | - Steven A. LaBelle
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 841123
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT 84112
| | - Kelly Leguineche
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Jarred Kaiser
- Atlanta Veteran’s Affairs Medical Center, Decatur, GA
- Emory University, Decatur, GA
| | - Salil Karipott
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Angela Lin
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Alyssa Vongphachanh
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Travis Fulton
- Atlanta Veteran’s Affairs Medical Center, Decatur, GA
| | - J. Walker Rosenthal
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Farhan Muhib
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 841123
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT 84112
| | - Keat Ghee Ong
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Jeffrey A. Weiss
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 841123
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 841123
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT 84112
| | - Nick J. Willett
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
| | - Robert E. Guldberg
- Phil and Penny Knight Campus for Accelerating Scientific Impact Department of Bioengineering, University of Oregon, Eugene, OR 97403
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3
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Pan RJ, Gui SJ, He YL, Nian F, Ni XY, Zhou YH, Wang MY, Wu JJ, Zeng GQ, Liang JH, Peng D. The effectiveness of optimal exercise-based strategy for patients with hip fracture: a systematic review and Bayesian network meta-analysis. Sci Rep 2023; 13:10521. [PMID: 37386114 PMCID: PMC10310779 DOI: 10.1038/s41598-023-37509-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
The implementation of exercise intervention (EI) presents a promising and economical way for patients with hip fracture. However, the optimal type of EI remains unclear. The objective of this study is to evaluate the efficacy of various EI approaches and identify the optimal intervention for improving the prognosis of patients with hip fracture. A comprehensive search of Medline (via PubMed), Web of Science, Embase, Cochrane Central Register of Controlled Trials, CINAHL, CNKI, Wan Fang, VIP, and CBM was conducted from their earliest records to June 2022. The included randomized controlled trials (RCTs) included at least one type of exercise for patients with hip fracture. The methodological quality of these trials was assessed using the Cochrane Collaboration Risk of Bias Tool. All direct and indirect comparisons were analyzed by Stata 14.0 and OpenBUGS 3.2.3 software. The primary outcome was hip function, and the secondary outcomes were activity of daily living (ADL), walking capacity and balance ability of patients. Based on the ranking probabilities, resistance exercise (RE) was ranked as the most effective among all exercise interventions (surface under cumulative ranking curve values [SUCRA]: 94.8%, [MD]: - 11.07, [Crl]: - 15.07 to - 7.08) in improving the efficacy of patients' hip function, followed by balance exercise (BE) ([SUCRA]:81.1%, [MD]: - 8.79, [Crl]: - 13.41 to - 4.18) and muscle strength exercise ([SUCRA]:57.6%, [MD]: - 5.35, [Crl]: - 9.70 to - 0.95). For the improvement of ADL for patients with hip fracture, BE ([SUCRA]:98.4%, [MD]: - 17.38, [Crl]: - 23.77 to - 11.04) may be the best EI. The findings of this study indicate that RE and BE might be the best approach to improve prognosis for patients with hip fracture. However, further rigorous and meticulously planned RCTs are required to substantiate the conclusions drawn from this study.
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Affiliation(s)
- Rong-Jia Pan
- School of Nursing, Hengyang Medical School, University of South China, 28 West Changsheng Road, Hengyang, 421001, Hunan, People's Republic of China
| | - Si-Jie Gui
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Yu-Lian He
- Department of Orthopedics and Trauma, the First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
| | - Fang Nian
- School of Nursing, Hengyang Medical School, University of South China, 28 West Changsheng Road, Hengyang, 421001, Hunan, People's Republic of China
| | - Xiao-Yan Ni
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Yan-Hui Zhou
- Department of Orthopedics and Trauma, the First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
| | - Man-Yi Wang
- School of Nursing, Hengyang Medical School, University of South China, 28 West Changsheng Road, Hengyang, 421001, Hunan, People's Republic of China
| | - Jing-Jing Wu
- School of Nursing, Hengyang Medical School, University of South China, 28 West Changsheng Road, Hengyang, 421001, Hunan, People's Republic of China
| | - Gu-Qing Zeng
- School of Nursing, Hengyang Medical School, University of South China, 28 West Changsheng Road, Hengyang, 421001, Hunan, People's Republic of China.
| | - Jing-Hong Liang
- Department of Maternal and Child Health, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China.
| | - Dan Peng
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China.
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Muacevic A, Adler JR, Alsheikh K, Alzahrani F, Alshaya RA, Ababtain I. Simultaneous Surgical Management of Acute Tibial Shaft Fracture and Post-traumatic Ankle Arthritis. Cureus 2022; 14:e33025. [PMID: 36721556 PMCID: PMC9880354 DOI: 10.7759/cureus.33025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 12/29/2022] Open
Abstract
The simultaneous management of tibial shaft fractures and post-traumatic ankle arthritis with ankle pain as the chief complaint can be challenging. Herein, we present a case managed with closed reduction, internal fixation, and tibiotalocalcaneal arthrodesis using a retrograde femoral nail. The patient was able to actively ambulate with full weight bearing and no pain approximately three months after the procedure. Patient consent for this case report was obtained.
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5
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John M, Mir HR. Extreme nailing and immediate weight bearing constructs in fractures of the distal tibia. OTA Int 2022; 5:e180. [PMID: 37781481 PMCID: PMC10538524 DOI: 10.1097/oi9.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/18/2021] [Indexed: 10/03/2023]
Abstract
Extraarticular fractures of the distal tibia can present as difficult but manageable lower extremity injuries. Historically, these injuries have been fixed in a myriad of ways. Early management with intramedullary nailing had higher complication rates due to the unique anatomical and biomechanical features of the distal tibia. Modern improvements in intramedullary nailing surgical techniques and implant design have significantly decreased complication rates and led to improvement in patient outcomes. Many surgeons protect weight bearing postoperatively, but recent literature suggests that patients may safely weight bear immediately following intramedullary fixation. This article reviews technique and implant design changes that have facilitated immediate safe weight bearing following intramedullary nailing of extraarticular distal tibia fractures.
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Affiliation(s)
- Mitchell John
- University of South Florida, Department of Orthopaedic Surgery
| | - Hassan R Mir
- University of South Florida, Department of Orthopaedic Surgery
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL
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Ziran N, McCarty CP, Ho NC, Gilmartin NF, Ebramzadeh E, Park SH, Sangiorgio SN. A novel intramedullary nail to control interfragmentary motion in diaphyseal tibial fractures. J Orthop Res 2022; 40:1053-1064. [PMID: 34251706 DOI: 10.1002/jor.25134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/21/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
Numerous animal and human studies have demonstrated the benefit of controlled interfragmentary motion on fracture healing. In this study, we quantified interfragmentary motion and load transfer in tibial fractures fixed using a novel intramedullary nail (IMN) that allows controlled axial motion. Fifty composite tibias with various fracture patterns were utilized. For all test conditions, two interlocking screws were used to fix the nail in the proximal metaphysis, and two interlocking screws through the distal metaphysis. The nail allowed either no motion (static mode) or 1 mm (dynamic mode) of cyclic axial motion between the two fracture fragments for every fracture pattern tested. As expected, strain shielding was more prominent under static nail conditions. In contrast, specimens tested under dynamic nail conditions transferred axial load between the fracture fragments such that strains near the fracture site were generally similar to those measured on an intact tibia. Maximum shear strains proximal to the fracture were significantly lower in specimens with oblique or butterfly fracture patterns (p < 0.01) compared to intact specimens. This decrease in shear strain indicates that strain shielding effects were likely present due to the implant. However, strain shielding appeared to be reduced in tensile and compressive principal strains. In summary, the novel IMN allowed controlled axial motion between the fragments in a variety of common diaphyseal tibial fracture patterns. Clinical Significance: The present in vitro biomechanical study investigated a novel intramedullary nail capable of controlled axial interfragmentary motion which may potentially enhance fracture healing.
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Affiliation(s)
- Navid Ziran
- OrthoX Innovation, Inc., Phoenix, Arizona, USA.,Department of Surgery, Creighton University School of Medicine, Phoenix, Arizona, USA
| | - Colin P McCarty
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California, USA
| | - Nathan C Ho
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California, USA
| | - Neda F Gilmartin
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California, USA
| | - Edward Ebramzadeh
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California, USA
| | - Sang-Hyun Park
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California, USA
| | - Sophia N Sangiorgio
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California, USA
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Lim A, Biosse-Duplan G, Gregory A, Mahbubani KT, Riche F, Brassett C, Scott J. Optimal location for fibular osteotomy to provide maximal compression to the tibia in the management of delayed union and hypertrophic non-union of the tibia. Injury 2022; 53:1532-1538. [PMID: 35168759 DOI: 10.1016/j.injury.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibial shaft fractures are the commonest long bone fracture, with early weight-bearing improving the rate of bony union. However, an intact fibula can act as a strut that splints the tibial segments and holds them apart. A fibular osteotomy, in which a 2.5 cm length of fibula is removed, has been used to treat delayed and hypertrophic non-union by increasing axial tibial loading. However, there is no consensus on the optimal site for the partial fibulectomy. METHODS Nine leg specimens were obtained from formalin-embalmed cadavers. Transverse mid-shaft tibial fractures were created using an oscillating saw. A rig was designed to compress the legs with an adjustable axial load and measure the force within the fracture site in order to ascertain load transmission through the tibia over a range of weights. After 2.5cm-long fibulectomies were performed at one of three levels on each specimen, load transmission through the tibia was re-assessed. A beam structure model of the intact leg was designed to explain the findings. RESULTS With an intact fibula, mean tibial loading at 34 kg was 15.52 ± 3.26 kg, increasing to 17.42 ± 4.13 kg after fibular osteotomy. This increase was only significant where the osteotomy was performed proximal to or at the level of the tibial fracture. Modelling midshaft tibial loading using the Euler-Bernoulli beam theory showed that 80.5% of the original force was transmitted through the tibia with an intact fibula, rising to 81.1% after a distal fibulectomy, and 100% with a proximal fibulectomy. CONCLUSION This study describes a novel method of measuring axial tibial forces. We demonstrated that a fibular osteotomy increases axial tibial loading regardless of location, with the greatest increase after proximal fibular osteotomy. A contributing factor for this can be explained by a simple beam model. We therefore recommend a proximal fibular osteotomy when it is performed in the treatment of delayed and non-union of tibial midshaft fractures.
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Affiliation(s)
- Anthony Lim
- Human Anatomy Teaching Group, Department of Physiology, Development and Neuroscience, University of Cambridge, CB2 3EL, UK.
| | - Garance Biosse-Duplan
- Human Anatomy Teaching Group, Department of Physiology, Development and Neuroscience, University of Cambridge, CB2 3EL, UK
| | - Alastair Gregory
- Department of Engineering, University of Cambridge, CB2 1PZ, Cambridge
| | | | - Fergus Riche
- Department of Engineering, University of Cambridge, CB2 1PZ, Cambridge
| | - Cecilia Brassett
- Human Anatomy Teaching Group, Department of Physiology, Development and Neuroscience, University of Cambridge, CB2 3EL, UK
| | - John Scott
- Human Anatomy Teaching Group, Department of Physiology, Development and Neuroscience, University of Cambridge, CB2 3EL, UK
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Bhanushali A, Kovoor JG, Stretton B, Kieu JT, Bright RA, Hewitt JN, Ovenden CD, Gupta AK, Afzal MZ, Edwards S, Jaarsma RL, Graff C. Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:3521-3527. [PMID: 35238986 PMCID: PMC9532312 DOI: 10.1007/s00068-022-01919-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing. METHOD This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis. RESULTS Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion. CONCLUSION The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.
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Affiliation(s)
- Ameya Bhanushali
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia
| | | | - James T Kieu
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Joseph N Hewitt
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia
| | - Christopher D Ovenden
- Discipline of Surgery, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mohamed Z Afzal
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- School of Public Health, Adelaide Health Technology Assessment, University of Adelaide, Adelaide, South Australia, Australia
| | - Ruurd L Jaarsma
- Flinders Medical Centre, Department of Orthopaedics and Trauma, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christy Graff
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia. .,Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia. .,Discipline of Surgery, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia.
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Dadwal UC, de Andrade Staut C, Tewari NP, Awosanya OD, Mendenhall SK, Valuch CR, Nagaraj RU, Blosser RJ, Li J, Kacena MA. Effects of diet, BMP-2 treatment, and femoral skeletal injury on endothelial cells derived from the ipsilateral and contralateral limbs. J Orthop Res 2022; 40:439-448. [PMID: 33713476 PMCID: PMC8435543 DOI: 10.1002/jor.25033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 02/08/2021] [Accepted: 03/10/2021] [Indexed: 02/04/2023]
Abstract
Type 2 diabetes (T2D) results in physiological and structural changes in bone, contributing to poor fracture healing. T2D compromises microvascular performance, which can negatively impact bone regeneration as angiogenesis is required for new bone formation. We examined the effects of bone morphogenetic protein-2 (BMP-2) administered locally at the time of femoral segmental bone defect (SBD) surgery, and its angiogenic impacts on endothelial cells (ECs) isolated from the ipsilateral or contralateral tibia in T2D mice. Male C57BL/6 mice were fed either a low-fat diet (LFD) or high-fat diet (HFD) starting at 8 weeks. After 12 weeks, the T2D phenotype in HFD mice was confirmed via glucose and insulin tolerance testing and echoMRI, and all mice underwent SBD surgery. Mice were treated with BMP-2 (5 µg) or saline at the time of surgery. Three weeks postsurgery, bone marrow ECs were isolated from ipsilateral and contralateral tibias, and proliferation, angiogenic potential, and gene expression of the cells was analyzed. BMP-2 treatment increased EC proliferation by two fold compared with saline in LFD contralateral tibia ECs, but no changes were seen in surgical tibia EC proliferation. BMP-2 treatment enhanced vessel-like structure formation in HFD mice whereas, the opposite was observed in LFD mice. Still, in BMP-2 treated LFD mice, ipsilateral tibia ECs increased expression of CD31, FLT-1, ANGPT1, and ANGPT2. These data suggest that the modulating effects of T2D and BMP-2 on the microenvironment of bone marrow ECs may differentially influence angiogenic properties at the fractured limb versus the contralateral limb.
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Affiliation(s)
- Ushashi C. Dadwal
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA,Richard L. Roudebush VA Medical Center, IN, USA
| | | | - Nikhil P. Tewari
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | | | | | - Conner R. Valuch
- Department of Biology, Indiana University Purdue University Indianapolis, IN, USA
| | - Rohit U. Nagaraj
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Rachel J. Blosser
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA,Richard L. Roudebush VA Medical Center, IN, USA
| | - Jiliang Li
- Department of Biology, Indiana University Purdue University Indianapolis, IN, USA
| | - Melissa Ann Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA,Richard L. Roudebush VA Medical Center, IN, USA,Corresponding Author: Melissa A. Kacena, Ph.D., Director of Basic and Translational Research, Professor of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN 46202, (317) 278-3482 – office, (317) 278-9568 – fax,
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10
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Quan K, Xu Q, Zhu M, Liu X, Dai M. Analysis of Risk Factors for Non-union After Surgery for Limb Fractures: A Case-Control Study of 669 Subjects. Front Surg 2022; 8:754150. [PMID: 34970588 PMCID: PMC8712717 DOI: 10.3389/fsurg.2021.754150] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The purpose of this study was to analyze the risk factors for limb fracture non-union in order to improve non-union prevention and early detection. Methods: A total of 223 patients with non-union after surgery for limb fractures performed at our institution from January 2005 to June 2017 were included as the case group, while a computer-generated random list was created to select 446 patients with successful bone healing after surgery for limb fractures who were treated during the same period as the control group, thus achieving a ratio of 1:2. The medical records of these patients were reviewed retrospectively. Age, sex, body mass index, obesity, smoking, alcohol, diabetes, hypertension, osteoporosis, fracture type, multiple fractures, non-steroidal anti-inflammatory drugs (NSAIDs) use, delayed weight bearing, internal fixation failure, and infection data were analyzed and compared between the two groups. A multivariate logistic regression model was constructed to determine relevant factors associated with non-union. Results: After comparison between two groups by univariate analysis and multivariate logistic regression, we found some risk factors associated that osteoporosis (odds ratio [OR] = 3.16, 95% confidence interval [CI]: 2.05–4.89, p < 0.001), open fracture (OR = 2.71, 95%CI: 1.72–4.27, p < 0.001), NSAIDs use (OR = 2.04, 95%CI: 1.24–3.37, p = 0.005), delayed weight bearing (OR = 1.72, 95%CI: 1.08–2.74, p = 0.023), failed internal fixation (OR = 5.93, 95%CI: 2.85–12.36, p < 0.001), and infection (OR = 6.77, 95%CI: 2.92–15.69, p < 0.001) were independent risk factors for non-union after surgery for limb fractures. Conclusions: Osteoporosis, open fracture type, NSAIDs use, delayed weight bearing, failed internal fixation, and infection were found to be the main causes of bone non-union; clinicians should, therefore, take targeted measures to intervene in high-risk groups early.
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Affiliation(s)
- Kun Quan
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, China
| | - Qiang Xu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, China
| | - Meisong Zhu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, China
| | - Xuqiang Liu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, China
| | - Min Dai
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, China
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11
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Förch S, Reuter J, von der Helm F, Lisitano L, Hartwig C, Sandriesser S, Nuber S, Mayr E. A minimally invasive cerclage of the tibia in a modified Goetze technique: operative technique and first clinical results. Eur J Trauma Emerg Surg 2021; 48:3115-3122. [PMID: 34951655 PMCID: PMC9360161 DOI: 10.1007/s00068-021-01857-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/04/2021] [Indexed: 12/02/2022]
Abstract
Introduction In spiral fractures of the tibia, the stability of an osteosynthesis may be significantly increased by additive cerclages and, according to biomechanical studies, be brought into a state that allows immediate full weight bearing. As early as 1933, Goetze described a minimally invasive technique for classic steel cerclages. This technique was modified, so that it can be used for modern cable cerclages in a soft part saving way. Method After closed reduction, an 8 Fr redon drain is first inserted in a minimally invasive manner, strictly along the bone and placed around the tibia via 1 cm incisions on the anterolateral and dorsomedial tibial edges using a curette and a tissue protection sleeve. Via this drain, a 1.7 mm cable cerclage can be inserted. The fracture is then anatomically reduced while simultaneously tightening the cerclage. Subsequently, a nail or a minimally invasive plate osteosynthesis is executed using the standard technique. Using the hospital documentation system, data of patients that were treated with additional cerclages for tibial fractures between 01/01/2014 and 06/30/2020 were subjected to a retrospective analysis for postoperative complications (wound-healing problems, infections and neurovascular injury). Inclusion criteria were: operatively treated tibial fractures, at least one minimally invasive additive cerclage, and age of 18 years or older. Exclusion criteria were: periprosthetic or pathological fractures and the primary need of reconstructive plastic surgery. SPSS was used for statistical analysis. Results 96 tibial shaft spiral fractures were treated with a total of 113 additive cerclages. The foregoing resulted in 10 (10.4%) postoperative wound infections, 7 of which did not involve the cerclage. One lesion of the profundal peroneal nerve was detected, which largely declined after cerclage removal. In 3 cases, local irritation from the cerclage occurred and required removal of material. Conclusion In the described technique, cerclages may be inserted additively at the tibia in a minimally invasive manner and with a few complications, thus significantly increasing the stability of an osteosynthesis. How this ultimately affects fracture healing is the subject of an ongoing study.
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Affiliation(s)
- Stefan Förch
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany.
| | - Jan Reuter
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Franziska von der Helm
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Leonard Lisitano
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Christopher Hartwig
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sabrina Sandriesser
- Institute for Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany.,Institute for Biomechanics, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Austria
| | - Stefan Nuber
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
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12
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Ganadhiepan G, Miramini S, Mendis P, Patel M, Zhang L. A probabilistic approach for modelling bone fracture healing under Ilizarov circular fixator. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3466. [PMID: 33864429 DOI: 10.1002/cnm.3466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/27/2020] [Accepted: 04/10/2021] [Indexed: 06/12/2023]
Abstract
Bone fracture treatments using Ilizarov circular fixator (ICF) involve dealing with uncertainties about a range of critical factors that control the mechanical microenvironment of the fracture site such as ICF configuration, fracture gap size, physiological loading etc. To date, the effects of the uncertainties about these critical factors on the mechanical microenvironment of the fracture site have not been fully understood. The purpose of this study is to tackle this challenge by using computational modelling in conjunction with engineering reliability analysis. Particularly, the effects of uncertainties in fracture gap size (GS), level of weight-bearing (P), ICF wire pretension (T) and wire diameter (WD) on the fracture site mechanical microenvironment at the beginning of the reparative phase of healing was investigated in this study. The results show that the mechanical microenvironment of fracture site stabilised with ICF is very sensitive to the uncertainties in P and GS. For example, an increase in the coefficient of variation of P (COVP ) from 0.1 to 0.9 (i.e., an increase in the uncertainty in P) could reduce the probability of achieving a favourable mechanical microenvironment within the fracture site (i.e., Probability of Success, PoS) by more than 50%, while an increase in the coefficient of variation of GS (COVGS ) from 0.1 to 0.9 could decrease PoS by around 30%. In contrast, an increase in the uncertainties in T and WD (COV increase from 0.1 to 0.9) has little influence on the fracture site mechanical microenvironment (PoS changes <5%).
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Affiliation(s)
- Ganesharajah Ganadhiepan
- Department of Infrastructure Engineering, The University of Melbourne, Parkville, Victoria, Australia
| | - Saeed Miramini
- Department of Infrastructure Engineering, The University of Melbourne, Parkville, Victoria, Australia
| | - Priyan Mendis
- Department of Infrastructure Engineering, The University of Melbourne, Parkville, Victoria, Australia
| | - Minoo Patel
- Centre for Limb Lengthening & Reconstruction, Epworth Hospital Richmond, Richmond, Victoria, Australia
| | - Lihai Zhang
- Department of Infrastructure Engineering, The University of Melbourne, Parkville, Victoria, Australia
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13
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Di Puccio F, Curreli C, Gagliani M, Mattei L. In silico re-foundation of strain-based healing assessment of fractures treated with an external fixator. J Mech Behav Biomed Mater 2021; 121:104619. [PMID: 34198040 DOI: 10.1016/j.jmbbm.2021.104619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 05/10/2021] [Accepted: 05/28/2021] [Indexed: 01/08/2023]
Abstract
In the last decades, the literature has demonstrated a renewed interest in finding quantitative and non-invasive techniques for the assessment of bone fractures, by replacing X-ray images. Many different approaches have been proposed from ultrasounds to vibrations. This study aims to numerically assess the foundation of a method firstly proposed in 70' years, based on strain gauges measurements on external fixators for fracture healing monitoring. The theoretical basis consists in the load transfer from the fixator to the bone caused by the callus stiffening during healing. The feasibility is questioned since the level of fixator strain and its variation in invivo conditions should be high enough to be detectable by the sensors. A finite element model of a fractured tibia phantom treated with a monolateral external fixator was developed and validated experimentally. Then, this reference model was used to simulate bone healing and to investigate the sensitivity of virtual strain measurements to callus geometry and loading conditions. The analysis of load distribution among fixator components and their strain maps allowed to identify optimum strain gauges locations which resulted on the pins more distant from the callus, regardless of the simulated conditions. Even in the worst case of a very thin (3 mm) transverse callus in constrained compression conditions, the strain level (≈100 με/100 N) and its variation per week (-50 με/100 N/wk) resulted measurable in the first healing phase, before plateau conditions occurring after about 6 weeks from fixation. A thicker callus causes higher strain levels and can significantly improve measurements, whilst the callus orientation and the loading conditions have a minor effect. However, in case of a free compression loading, also the rods could provide useful indications if sensorized. The results support the method applicability in invivo conditions for the considered test case. Further investigations will be addressed to evaluate the effect of the fixator structure and configuration as well as of patient specific healing timing on the method sensitivity.
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Affiliation(s)
- Francesca Di Puccio
- Department of Civil and Industrial Engineering, Università di Pisa, Largo Lucio Lazzarino 2, 56122, Pisa, Italy.
| | - Cristina Curreli
- Department of Civil and Industrial Engineering, Università di Pisa, Largo Lucio Lazzarino 2, 56122, Pisa, Italy.
| | - Matteo Gagliani
- Department of Civil and Industrial Engineering, Università di Pisa, Largo Lucio Lazzarino 2, 56122, Pisa, Italy.
| | - Lorenza Mattei
- Department of Civil and Industrial Engineering, Università di Pisa, Largo Lucio Lazzarino 2, 56122, Pisa, Italy.
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Uemi R, Takegami Y, Sakai R, Todoroki K, Kawasaki N, Imagama S. Early versus delayed weight bearing after intramedullary nailing for tibial shaft fracture: A multicenter, propensity score-matched study, the TRON study. Injury 2021; 52:1583-1586. [PMID: 33441252 DOI: 10.1016/j.injury.2020.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/05/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this multicenter study was to assess the differences in the rates of implant failure and bone union by X-ray examination, and walking ability between an early weight-bearing group (EWB) and a non-weight-bearing group (NWB) following treatment with intramedullary nailing (IMN) for tibial shaft fractures with a propensity score-matching method. MATERIAL AND METHODS We collected data from 336 patients with tibia fractures that were treated surgically. We excluded patients lost to follow-up and polytrauma patients. Finally, 263 patients were included who were divided into two groups, the early weight-bearing (EWB) group, in which partial weight-bearing walking within four weeks was encouraged, and a non-weight-bearing (NWB) group, in which no weight bearing was allowed for more than four weeks. To adjust for baseline differences between groups, a propensity score algorithm was used to match the EWB group with the NWB group in a 1:1 ratio of 75 cases each. After matching, we compared the rate of implant failure, the rate of bone union at six months and one year after surgery, and walking ability at the last follow-up between the two groups. RESULT Implant failure occurred in 0 of 75 patients in the EWB group vs. 1 of 75 in the NWB group (P = 1.0). Delayed bone union at six months occurred in 20 of 75 (26%) vs. 13 of 75 (17%) patients, and that at one year occurred in 5 of 75 (6.7%) vs. 3 of 75 (4%) patients. The median New Mobility Score was 9 (4-9) vs. 9 (0-9) points. CONCLUSIONS There were no statistically significant differences in the rate of implant failure, the rates of the bone union at six months and one year after surgery, and walking ability between the EWB group and NWB group. We suggest that instruction in early weight-bearing after IMN nailing for tibial shaft fracture may not be harmful.
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Affiliation(s)
- Ryota Uemi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Risa Sakai
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Kazunori Todoroki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Narumi Kawasaki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
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15
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Van Vugt TAG, Geurts JAP, Blokhuis TJ. Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series. Injury 2021; 52 Suppl 2:S67-S71. [PMID: 33039177 DOI: 10.1016/j.injury.2020.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/17/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented. METHODS In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication. RESULTS Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection. DISCUSSION These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.
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Affiliation(s)
- T A G Van Vugt
- Dept. Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - J A P Geurts
- Dept. Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - T J Blokhuis
- Dept. Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
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16
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Bhatti FUR, Dadwal UC, Valuch CR, Tewari NP, Awosanya OD, de Andrade Staut C, Sun S, Mendenhall SK, Perugini AJ, Nagaraj RU, Battina HL, Nazzal MK, Blosser RJ, Maupin KA, Childress PJ, Li J, Kacena MA. The effects of high fat diet, bone healing, and BMP-2 treatment on endothelial cell growth and function. Bone 2021; 146:115883. [PMID: 33581374 PMCID: PMC8009863 DOI: 10.1016/j.bone.2021.115883] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 02/08/2023]
Abstract
Angiogenesis is a vital process during the regeneration of bone tissue. The aim of this study was to investigate angiogenesis at the fracture site as well as at distal locations from obesity-induced type 2 diabetic mice that were treated with bone morphogenetic protein-2 (BMP-2, local administration at the time of surgery) to heal a femoral critical sized defect (CSD) or saline as a control. Mice were fed a high fat diet (HFD) to induce a type 2 diabetic-like phenotype while low fat diet (LFD) animals served as controls. Endothelial cells (ECs) were isolated from the lungs (LECs) and bone marrow (BMECs) 3 weeks post-surgery, and the fractured femurs were also examined. Our studies demonstrate that local administration of BMP-2 at the fracture site in a CSD model results in complete bone healing within 3 weeks for all HFD mice and 66.7% of LFD mice, whereas those treated with saline remain unhealed. At the fracture site, vessel parameters and adipocyte numbers were significantly increased in BMP-2 treated femurs, irrespective of diet. At distal sites, LEC and BMEC proliferation was not altered by diet or BMP-2 treatment. HFD increased the tube formation ability of both LECs and BMECs. Interestingly, BMP-2 treatment at the time of surgery reduced tube formation in LECs and humeri BMECs. However, migration of BMECs from HFD mice treated with BMP-2 was increased compared to BMECs from HFD mice treated with saline. BMP-2 treatment significantly increased the expression of CD31, FLT-1, and ANGPT2 in LECs and BMECs in LFD mice, but reduced the expression of these same genes in HFD mice. To date, this is the first study that depicts the systemic influence of fracture surgery and local BMP-2 treatment on the proliferation and angiogenic potential of ECs derived from the bone marrow and lungs.
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Affiliation(s)
- Fazal Ur Rehman Bhatti
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA
| | - Ushashi C Dadwal
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA
| | - Conner R Valuch
- Department of Biology, Indiana University Purdue University Indianapolis, IN, USA
| | - Nikhil P Tewari
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Olatundun D Awosanya
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | | | - Seungyup Sun
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Stephen K Mendenhall
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Anthony J Perugini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Rohit U Nagaraj
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Hanisha L Battina
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Murad K Nazzal
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Rachel J Blosser
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA
| | - Kevin A Maupin
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Paul J Childress
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA
| | - Jiliang Li
- Department of Biology, Indiana University Purdue University Indianapolis, IN, USA
| | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA; Richard L. Roudebush VA Medical Center, IN, USA.
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Bauwens PH, Malatray M, Fournier G, Rongieras F, Bertani A. Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients. Orthop Traumatol Surg Res 2021; 107:102877. [PMID: 33652149 DOI: 10.1016/j.otsr.2021.102877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/30/2020] [Accepted: 09/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union. HYPOTHESIS Active smoking and an initial open wound are independent risk factors for complications. MATERIALS AND METHODS We retrospectively included consecutive patients managed for open or closed tibial shaft fractures by primary intramedullary nailing between 2013 and 2018. We collected data on preoperative factors related to the patient and to the mechanism of injury (age, sex, smoking history, energy of the trauma, open wound), on intraoperative factors (residual interfragmentary gap), and on postoperative factors (early or delayed weight-bearing). We evaluated the associations between these factors and the occurrence of complications, notably non-union, by performing a univariate analysis followed by a multivariate analysis. RESULTS We included 184 patients [mean age, 38.5±17.6 (range, 15-91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76-22.7), a residual interfragmentary gap >5mm (OR, 4.92; 95%CI, 1.72-14.02), and an initial open wound (OR,5.16; 95%CI, 1.62-16.43) (p<0.05). The same three factors were significant risk factors for non-union. Energy of the trauma, age, sex, and early or delayed weight bearing were not significantly associated with an excess risk of complications. DISCUSSION Active smoking, a residual interfragmentary gap >5mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients. LEVEL OF EVIDENCE IV; single-centre retrospective cohort study.
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Affiliation(s)
- Paul-Henri Bauwens
- Service de chirurgie orthopédique et traumatologique, Pavillons E et H, Hôpital Édouard-Herriot, Hospices civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France.
| | - Matthieu Malatray
- Service de chirurgie orthopédique et traumatologique, Pavillons E et H, Hôpital Édouard-Herriot, Hospices civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France; Service de chirurgie orthopédique, Hôpital de la Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | - Gaspard Fournier
- Service de chirurgie orthopédique, Hôpital de la Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | - Frédéric Rongieras
- Service de chirurgie orthopédique et traumatologique, Pavillons E et H, Hôpital Édouard-Herriot, Hospices civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France
| | - Antoine Bertani
- Service de chirurgie orthopédique et traumatologique, Pavillons E et H, Hôpital Édouard-Herriot, Hospices civils de Lyon, 5, place d'Arsonval, 69008 Lyon, France
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Findakli F, Busse JW, Schemitsch EH, Lonn E, Farrokhyar F, Bhandari M. Smoking, Obesity, and Disability Benefits or Litigation Are Not Associated with Clinically Important Reductions in Physical Functioning After Intramedullary Nailing of Tibial Shaft Fractures: A Retrospective Cohort Study. Clin Orthop Relat Res 2021; 479:805-813. [PMID: 33196584 PMCID: PMC8083930 DOI: 10.1097/corr.0000000000001573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Forty percent of long bone fractures involve the tibia. These fractures are associated with prolonged recovery and may adversely affect patients' long-term physical functioning; however, there is limited evidence to inform what factors influence functional recovery in this patient population. QUESTION/PURPOSE In a secondary analysis of a previous randomized trial, we asked: What fracture-related, demographic, social, or rehabilitative factors were associated with physical function 1 year after reamed intramedullary nailing of open or closed tibial shaft fractures? METHODS This is a secondary (retrospective) analysis of a prior randomized trial (Trial to Re-evaluate Ultrasound in the Treatment of Tibial Fractures; TRUST trial). In the TRUST trial, 501 patients with unilateral open or closed tibial shaft fractures were randomized to self-administer daily low-intensity pulsed ultrasound or use a sham device, of which 15% (73 of 501) were not followed for 1 year due to early study termination as a result of futility (no difference between active and sham interventions). Of the remaining patients, 70% (299 of 428) provided full data. All fractures were fixed using reamed (298 of 299) or unreamed (1 of 299) intramedullary nailing. Thus, we excluded the sole fracture fixed using unreamed intramedullary nailing. The co-primary study outcomes of the TRUST trial were time to radiographic healing and SF-36 physical component summary (SF-36 PCS) scores at 1-year. SF-36 PCS scores range from 0 to 100, with higher scores being better, and the minimum clinically important difference (MCID) is 5 points. In this secondary analysis, based on clinical and biological rationale, we selected factors that may be associated with physical functioning as measured by SF-36 PCS scores. All selected factors were inserted simultaneously into a multivariate linear regression analysis. RESULTS After adjusting for potentially confounding factors, such as age, gender, and injury severity, we found that no factor showed an association that exceeded the MCID for physical functioning 1 year after intramedullary nailing for tibial shaft fractures. The independent variables associated with lower physical functioning were current smoking status (mean difference -3.0 [95% confidence interval -5 to -0.5]; p = 0.02), BMI > 30 kg/m2 (mean difference -3.0 [95% CI -5.0 to -0.3]; p = 0.03), and receipt of disability benefits or involvement in litigation, or plans to be (mean difference -3.0 [95% CI -5.0 to -1]; p = 0.007). Patients who were employed (mean difference 4.6 [95% CI 2.0 to 7]; p < 0.001) and those who were advised by their surgeon to partially or fully bear weight postoperatively (mean difference 2.0 [95% CI 0.1 to 4.0]; p = 0.04) were associated with higher physical functioning. Age, gender, fracture severity, and receipt of early physical therapy were not associated with physical functioning at 1-year following surgical fixation. CONCLUSION Among patients with tibial fractures, none of the factors we analyzed, including smoking status, receipt of disability benefits or involvement in litigation, or BMI, showed an association with physical functioning that exceeded the MCID. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Fawaz Findakli
- F. Findakli, J. W. Busse, F. Farrokhyar, M. Bhandari, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
- J. W. Busse, The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
- E. H. Schemitsch, Department of Surgery, University of Western Ontario, London, ON, Canada
- E. Lonn, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jason W Busse
- F. Findakli, J. W. Busse, F. Farrokhyar, M. Bhandari, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
- J. W. Busse, The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
- E. H. Schemitsch, Department of Surgery, University of Western Ontario, London, ON, Canada
- E. Lonn, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Emil H Schemitsch
- F. Findakli, J. W. Busse, F. Farrokhyar, M. Bhandari, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
- J. W. Busse, The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
- E. H. Schemitsch, Department of Surgery, University of Western Ontario, London, ON, Canada
- E. Lonn, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Eva Lonn
- F. Findakli, J. W. Busse, F. Farrokhyar, M. Bhandari, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
- J. W. Busse, The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
- E. H. Schemitsch, Department of Surgery, University of Western Ontario, London, ON, Canada
- E. Lonn, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- F. Findakli, J. W. Busse, F. Farrokhyar, M. Bhandari, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
- J. W. Busse, The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
- E. H. Schemitsch, Department of Surgery, University of Western Ontario, London, ON, Canada
- E. Lonn, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- F. Findakli, J. W. Busse, F. Farrokhyar, M. Bhandari, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
- J. W. Busse, The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
- E. H. Schemitsch, Department of Surgery, University of Western Ontario, London, ON, Canada
- E. Lonn, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Apostolides M, Barbur SA, Jowett AJL. Does immediate weight-bearing following intramedullary tibial nailing affect union rates? The results from a single UK trauma unit. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620976077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Extra-articular diaphyseal tibial fractures are a common injury and are often treated with intramedullary nailing (IMN). Weight-bearing (WB) of simple tibial fractures treated with an IMN immediately as pain allows is now standard practice. Our aim was to assess the impact of varied WB on fracture union following IMN of diaphyseal tibia fractures. Methods We conducted a retrospective cohort study of tibial fractures treated with IMN in our department between 2012-2017. WB status was recorded in the post-operative note and subsequently reviewed in the patients’ follow-up appointments. Patients were divided in three groups; Group I: immediate full-WB, Group II: non-WB for 6 weeks and Group III: 2 weeks non-WB, 4 weeks increasing partial-WB and full-WB at 6 weeks. Radiographic union score for tibial fractures (RUST) of ≥10 at a painless fracture site was considered as evidence of fracture union. Results 92 patients with comparable pre-operative demographics [mean age 40 y (16-88)] were included. The median union time in weeks for each group was: Group I 17.3, Group II 21.7 and Group III 19.5 (F 1.09, p 0.34). Survival analysis and log rank test did not show any difference in union times between the three groups (x2 1.1, p 0.57). 12 delayed unions were identified across all groups. Multiple logistic regression identified three factors that could increase the rate of delayed union – non-WB, smoking and IMN size 11/12 mm - however the results were not statistically significant. Conclusion Immediate post-operative WB does not adversely affect union time in statically locked IMNs. In fact, although our data show no statistically significant difference in fracture healing between the three groups, full WB seems to decrease overall time to union. In conclusion, we could suggest that full WB after IMN in patients with AO 42-A/B type fractures is safe practice.
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Affiliation(s)
- Michael Apostolides
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, UK
| | - Sabina A Barbur
- Department of Trauma and Orthopaedics, Southampton General Hospital, Southampton, UK
| | - Andrew JL Jowett
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, UK
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Abstract
PURPOSE OF REVIEW The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs. RECENT FINDINGS Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.
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Affiliation(s)
- G Bradley Reahl
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - Louis Gerstenfeld
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Michael Kain
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.
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