Fracture non-union can be as high as 20% in certain clinical scenarios and has a high associated socioeconomic burden. Boron has been shown to regulate the Wnt/β-catenin pathway in other bodily processes. However, this pathway is also critical for bone healing. Here we aim to demonstrate that the local delivery of boric acid can accelerate bone healing, as well as to elucidate how boric acid, via the regulationtheWnt/β-catenin pathway, impacts theosteogenic response of bone-derived osteoclasts and osteoblasts during each phase of bone repair.

Bilateral femoral cortical defects were created in 32 skeletally mature C57 mice. On the experimental side, boric acid (8mg/kg concentration) was injected locally at the defect site whereas on the control side, saline was used. Mice were euthanized at 7, 14, and 28 days. MicroCT was used to quantify bone regeneration at the defect. Histological staining for ALP and TRAP was used to quantify osteoblast and osteoclast activity respectively. Immunohistochemical antibodies, β-catenin and CD34 were used to quantify active β-catenin levels and angiogenesis respectively. Sclerostin and GSK3β were also quantified and are both inhibitors of the wnt signaling pathway via degradation and inactivation of β-catenin.

The boron group exhibited higher bone volume and trabecular thickness at the defect site by 28 days on microCT. ALP activity was significantly higher in boron group at 7 days whereas boron had no effect on TRAP activity. Additionally, CD34 staining revealed increased angiogenesis at 14 days in boron treated groups. β-catenin activity on immunohistochemistry was significantly higher in the boron group at 7 days, GSK3β was significantly higher in the boron group at 14 days and Sclerostin was significantly higher in the boron group at 28 days.

Boron appears to increase osteoblast activity at the earlier phases of healing. The corresponding early increase in β-catenin along with ALP likely supports that boron increases osteoblast activity via the wnt/β-catenin pathway. Increased angiogenesis at 14 days could be a separate mechanism increasing bone formation independent of wnt/β-catenin activation. Neither GSK3β or Sclerostin levels correlated with β-catenin activity therefore boron likely increases β-catenin through a mechanism independent of both GSK3β and Sclerostin. The addition of this inexpensive and widely available ion could potentially become a non-invasive, cost-effective treatment modality to augment fracture healing and decrease non-union rates in high risk patients.

The treatment of critical-sized bone defects still remains today a challenge, especially when the surrounding soft, vascularized and innervated tissues have been damaged - a lack of revascularization within the injured site leading to physiological disorders, from delayed healing to osteonecrosis. The axial insertion of a vascular bundle (e.g. arterio-venous loop, AVL) within a synthetic bone filler to initiate and promote its revascularization has been foreseen as a promising alternative to the current strategies (e.g., vascularized free flaps) for the regeneration of large bone defects. In a previous work, we showed that the insertion of a vein in a 3D-printed monetite scaffold induced its higher revascularization than AVL, thus a possible simplification of the surgical procedures (no microsurgery required). Going further, we investigate in this study whether or not the presence of a vein could stimulate the formation of mineralized tissue insides a synthetic scaffold filled with bone marrow and implanted in ectopic site.

Monetite scaffolds were produced by additive manufacturing according to a reactive 3D-printing technique co-developed by the authors then thoroughly characterized. Animal study was performed on 14 male Wistar rats. After anesthesia and analgesia, a skin medial incision in rat thigh allowed the site on implantation to be exposed. Bone marrow was collected on the opposite femur through a minimally invasive procedure and the implant was soaked with it. For the control group (N=7), the implant was inserted in the incision and the wound was closed whereas the femoral bundle was dissected and the vein inserted in the implant for the experimental group (N=7). After 8 weeks animals were sacrificed, the implant collected and fixed in a 4% paraformaldehyde solution. Explants were characterized by µCT then embedded in poly-methyl methacrylate prior SEM, histology and immunohistochemistry. Images were analyzed with CT-Analyzer (Bruker) and ImageJ (NIH) and statistical analyses were carried out using SPSS (IBM).

Implants were successfully 3D-printed with a +150 µm deviation from the initial CAD. As expected, implants were composed of 63%wt monetite and 37%wt unreacted TCP, with a total porosity of 44%. Data suggested that scaffold biodegradation was significantly higher when perfused by a vein. Moreover, the latter allowed for the development of a dense vascular network within the implant, which is far more advanced than for the control group. Finally, although mineralized tissues were observed both inside and outside the implant for both groups, bone formation appeared to be much more important in the experimental one.

The ectopic formation of a new mineralized tissue within a monetite implant soaked with bone marrow seems to be highly stimulated by the simple presence of a vein alone. Although AVL have been studied extensively, little is known about the couple angiogenesis/osteogenesis which appears to be a key factor for the regeneration of critical-sized bone defects. Even less is known about the mechanisms that lead to the formation of a new bone tissue, induced by the presence of a vein only. With this in mind, this study could be considered as a proof of concept for further investigations.

Bone regeneration includes a well-orchestrated series of biological events of bone induction and conduction. Among them, the Wnt/β-catenin signaling pathway is critical for bone regeneration. Being involved in several developmental processes, Wnt/β-catenin signaling must be safely targeted. There are currently only few specific therapeutic agents which are FDA-approved and already entered clinical trials. A published work has shown that Tideglusib, a selective and irreversible small molecule non-ATP-competitive glycogen synthase kinase 3-β(GSK-3β) inhibitor currently in trial for Alzheimer's patients, can promote tooth growth and repair cavities. [1]Despite some differences, they are some similarities between bone and tooth formation and we hypothesise that this new drug could represent a new avenue to stimulate bone healing.

In this work, we locally delivered Tideglusib (GSK3β inhibitor) in the repair of femoral cortical window defects and investigated bone regeneration. A biodegradable FDA-approved collagen sponge was soaked in GSK-3βinhibitor solution or vehicle only (DMSO) and was implanted in 1 × 2 mm unicortical defects created in femora of 35 adult wild-type male mice. Bone defect repair on control and experimental (GSK-3βinhibitor) groups was assessed after 1 week (n=22), 2 weeks (n=24) and 4 weeks (n=24) with microCT and histological analysis foralkaline phosphatase (ALP, osteoblast activity), tartrate resistant acid phosphatase (TRAP, osteoclasts), and immunohistochemistry to confirm the activation of the Wnt/β-catenin pathway.

Our results showed that Tideglusib significantly enhanced cortical bone bridging (20.6 ±2.3) when compared with the control (12.7 ±1.9, p=0.001). Activity of GSK-3β was effectively downregulated at day 7 and 14 resulting in a higher accumulation of active β-catenin at day 14 in experimental group (2.5±0.3) compared to the control (1.1±0.2, p=0.03). Furthermore, the onset of ALP activity appears earlier in the experimental group (day 14, 1.79±0.28), a level of activity never reached at any end-point by the control defects. At 4 weeks treatment, we observed a significant drop in ALP in the experimental group (0.47±0.05) compared to the control (1.01±0.19, p=0.02) and a decrease in osteoclast (experimental=1.32±0.36, control=2.23±0.67, p=0.04).

Local downregulation of GSK-3β by tideglusib during bone defect repair resulted in significant increase in amount of new bone formation. The early upregulation of osteoblast activity is one explanation of bone healing augmentation. This is likely the effect of upregulation of β-catenin following pharmaceutical inhibition of GSK-3β since β-catenin activation is known to positively regulate osteoblasts, once committed to the osteoblast lineage. As a GSK-3β inhibitor, Tideglusib demonstrates a different mechanism of action compared with other GSK-3β antagonists as treatment was started immediately upon injury and did not interfere with precursor cells recruitment and commitment. This indicates that tideglusib could be used at the fracture site during the initial intraoperative internal fixation without the need for further surgery. This safe and FDA-approved drug could be used in prevention of non-union in patients presenting with high risk for fracture-healing complications.

Background

Open reduction and internal fixation using plate osteosynthesis for midshaft clavicle fractures is often associated with hardware prominance. Although clinical studies have suggested a role for the use of thinner 2.7mm plates as a means of increasing cosmetic acceptability this still remains an area of controversy. We investigated the effect of plate size (2.7mm vs. 3.5mm), plate treatment (annealed vs. cold worked) and number of screws on the stiffness and yield point.

Introduction

Orthopaedic trauma surgery is characterised by repetitive, forceful tasks that are physically demanding, thus theoretically increasing the risk of musculoskeletal injuries in these surgeons. The aim of this study is to assess prevalence, characteristics and impact of musculoskeletal disorders among orthopaedic trauma surgeons.

Hospital type is an indicator for structures and processes of care. The effect of hospital type on hip fracture in-hospital mortality is unknown. We determine whether hip fracture in-hospital mortality differs according to hospital type.

We retrieved records of hip fracture for 167,816 patients aged 65 years and older, who were admitted to a Canadian acute hospital between 2004 and 2012. For each hospital type we measured and compared the cumulative incidence of in-hospital death by in-patient day, accounting for discharge as a competing event.

The cumulative incidence of in-hospital death at in-patient day 30 was lowest for teaching hospital admissions (7.3%) and highest for small community hospital admissions (11.5%). The adjusted odds of in-hospital death were 12% (95% CI 1.06–1.19), 25% (95% CI 1.17–1.34), and 64% (95% CI 1.50–1.79) higher for large, medium, and small community hospital versus teaching hospital admissions. The adjusted odds of nonoperative death were 1.6 times (95% CI 1.42–1.86), and 3.4 times (95% CI 2.96–3.94) higher for medium and small community hospital versus teaching hospital admissions. The adjusted odds of postoperative death were 14% (95% CI 1.07–1.22) and 20% (95% CI 1.10–1.31) higher at large and medium community hospitals versus teaching hospitals. The adjusted odds of postoperative death were largest at small community hospitals but the confidence interval crossed 1 (OR = 1.25, 95% CI 0.92–1.70).

A higher proportion of hip fracture patients die at non-teaching compared to teaching hospitals accounting for length of stay. Higher mortality at small community hospitals may reflect disparities in access to resources and delay to treatment.

Significance

Acute compartment syndrome (ACS) occurs after muscle injury and is characterised by increased pressure in the muscle compartment that can result in devastating complications if not diagnosed and treated appropriately. ACS is currently confirmed by repeated needle sticks to measure the compartment pressure using a hand-held compartment pressure monitor. This approach is often not reproducible and is not appropriate for continuous monitoring. To address the shortcomings of currently available technology we are developing an implantable micro-device that will measure compartment pressure directly and continuously over the 24 hours critical period following injury using a radio frequency identification (RFID) platform integrated with a MEMS capacitive pressure sensor.

Introduction: Surgical fixation of intra-articular distal femoral fractures has been associated with nonunion & varus collapse. The soft tissuestripping associated with this fracture andthe surgical exposure have been factors associated with delayed union & infection. The limited soft tissue exposure has been lauded the as a solution to this fracture. However, it has occurred with the new fixation as well.(Locked Plate)

Aims: This study is an attempt to look at the fixation. Does the LISS system improve the results of this difficult fracture? Is there truly a difference in the outcome of this fracture utilizing the Locked plate system or is the percieved difference due to the surgical mini invasive approach.

Patients & Methods: One hunderd & forty patients were screened, only 53 were randomized and fixed in six academic centers over 5 years. All C3 fractures were excluded as they were felt not to be treatable by the DCS device, but they were treated appropiately. 35 females and 18 males were included in the study and randomized appropiatley.

Results: Fifty-three patients were randomized, 28 had the LISS implant and 25 had the DCS utilized. There were 3 nonunions in the LISS group plus two patients with early loss of reduction that required reoperation in the early post operative period. One patient developed arthrofibrosis requiring arthroscopic release and subsequently the implant failed necessitating refixation. In the DCS group, only one nonunion reported & required second surgery. This translated to a reoperation rate of 21% in the LISS group compared to 4% with DCS.

Conclusion: This prospective randomized multicentre trial showed a difference when comparing the LISS to the DCS in the supracondylar distal femur fractures.

Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation by a solid fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures.

During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations.

All fractures healed within the first six months with no loss of correction. The surgical technique was found easy by all surgeons, the axillary nerve was palpated and protect with this new technique. No infection or avascular necrosis were seen. No axillary nerve deficit was identified. At the last follow-up (average nineteen months, twelve months minimum), the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independently predictive of both the Constant and DASH functional scores. Patients improved until one year of follow up.

Percutaneous insertion of a locking proximal humerus plate is safe and produces gives good early functional and radiologic outcomes. Recuperation from a proximal humerus fracture can be seen until one year.

In our cadaver study plating the fibula in addition to nailing the tibia decreased the mean rotation across the tibial osteotomy site compared to nailing the tibia alone. Although this is statistically significant (p=0.0034) it may not be clinically relevant as the mean values for ROM were 19.10 and 17.96 degrees respectively. Plating the fibula resulted in no statistically significant difference in the mean vertical displacement, angulation or neutral zone.

Therefore, we may conclude that plating the fibula in a combined distal third tibia and fibula fracture does not enhance the stability of tibial IM nailing.

The purpose of this study was to determine if combined distal third tibia and fibula fractures are more stable when fibular fixation is added to the standard tibial IM rodding.

In combined distal third tibia and fibula fractures, plating the fibula does not enhance stability of intramedullary tibial nailing.

No additional incision or soft tissue stripping is required for plating of the fractured fibula.

The average range of motion in rotation was 19.1° for tibial and fibular fixation combined, and 18.0 ° for tibial fixation alone with a difference of 1.1°, which was clinically significant ( p=0.0034). The mean differences in vertical displacement, angulation, and neutral zone were not statistically significant.

Five matched pairs of embalmed cadaveric lower limbs were dissected and stripped of soft tissue. Each tibia received a 9mm solid titanium nail that was locked proximally and distally. Fibular fixation consisted of a seven- hole LCDCP. A 1.5 cm section of tibia and a 1.0 cm section of fibula were removed. Testing was accomplished with an MTS machine. Vertical displacement was tested with an axial load to 500 N, rotation was tested with an internal and external torque of 5 Nm, and angulation was calculated from the vertical displacement data. All displacement data was measured across the osteotomy site.

The mean range of motion in rotation was the only statistically significant finding. However, considering the average range of motion with and without fibular plating of 17.96° and 19.10° respectively, this finding is likely not clinically relevant.

Funding: Tibial nails, bolts, fibular plates and screws provided by Synthes (Paoli, PA, USA)

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of internal fixation. The current investigation examines the biomechanical properties of a unique plate versus a standard plate for internal fixation of proximal humerus fractures. The unique plate employs screws that thread into the plate, creating a multi-planer, fixed angle device. A cadaveric model was developed that relied on the rotator cuff musculature as the primary deforming force. The locking plate displayed significantly greater holding power on the humeral head (p=0.007). This may lead to more consistent results in two-part fractures treated with internal fixation.

The current investigation evaluates a unique plate designed to treat fractures of the proximal humerus. The plate employs screws that thread into the plate creating a fixed angle device. This plate was tested versus a standard cloverleaf plate.

The locking plate displayed greater holding power on the humeral head in the model tested. This may lead to decreased failure rates in two-part fractures treated with internal fixation.

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of common internal fixation modalities. This is done with the acceptance of possible non-union and loss of function. A more reliable method for stable internal fixation is therefore desirable.

A significant difference was found (p=0.007) with the locking plate displaying greater holding capability on the humeral head.

Eight pairs of preserved, cadaveric humeri were dissected and plated with either the locking plate or standard cloverleaf plate followed by an osteotomy at the surgical neck. A servo-hydraulic testing machine was then used to pull on the rotator cuff musculature until failure was achieved. Failure of the plate-head interface was reached in five of the eight pairs. Previous biomechanical studies have not taken into account the clinical mode of failure when testing internal fixation modalities for proximal humerus fractures. The current study has reproduced failure into varus by relying on the rotator cuff musculature as the primary deforming force.

Funding: All implants donated by Synthes, Canada

We examined the relationship between waiting times for ACL surgery and the need for meniscal surgery at time of reconstruction. Using the Provincial Billing Database we identified 3812 ACL reconstructions between 1999–2001. Patients waited on average four hundred and twenty-two days from initial medical visit to reconstruction. 1722 patients (45%) required meniscal surgery with the ACL procedure. The delay to surgery was: two hundred and fifty-one days (no meniscal surgery required), four hundred and thirteen days (meniscal repair) and six hundred and seventy-six days (meniscectomies). This difference was significant, p< .01, ANOVA. The rate of meniscal surgery per time period was also significantly different: 17% if < 3months, 57% if > 6months. Our present Health Care policies place patients at risk of requiring avoidable meniscal surgery and developing osteoarthritis.

The purpose of this study was to examine the relationship between waiting times for ACL surgery and outcome.

The outcome measure was the need for meniscal surgery at the time of ACL reconstruction. The Provincial Data Base Billing information was reviewed for ACL reconstruction between 1999–2001. The simultaneous need for a meniscal procedure was noted. Tracking back in time, all demographic, diagnostic and interventional billing data (ICD & Visit billing code) preceding their ACL surgery was recorded.

Between 1999–2001, 3812 ACL reconstructions were identified. Of these, 1722 patients required a meniscal procedure (45%). On average, patients waited over four hundred and twenty-two days from injury to reconstruction. Patients who did not require any meniscal procedure waited on average two hundred and fifty-one days, meniscal repairs waited four hundred and thirteen days, while meniscectomies waited six hundred and seventy-six days. More importantly, the need for a meniscal procedure correlated with the timing of surgery: 17% of those reconstructed < three months from injury had a significant meniscal injury, compared to 57% at > six months. Almost half of which (48%) required a meniscectomy for significant meniscal injury. These differences all attained statistical significance (p< 0.01).

Previous reports suggest that the ACL-deficient knee increases the risk of meniscal injury and meniscal incompetence hastens OA. Our data show a progressive increase in the rate to meniscal surgery, and meniscal injury complexity with time. These delays and rates are higher than the ones proposed in the literature.

It appears that the experience in our Province simply reproduces (rather than improves upon) the natural history of the ACL injury. We postulate restricting access to specialists and to surgery place the patient at risk for requiring avoidable surgery and developing osteoarthritis

A tantalum AVN implant was used in sixteen patients with advanced AVN (Grade 3/4). No reports have been published of use of this implant in advanced disease. Outcomes included radiological, SF36, Harris hip score and secondary surgeries. HHS improved from fifty-two to seventy. SF36 scores approached controls. At over one year average follow-up five patients are revised to THA, however, all hips except one have at least minor pain. Revisions occurred in older patients or those with 100% head involvement. In younger patients, with up to 50% head involvement, this technique seems to be a viable option for advanced AVN. Evaluation of tantalum AVN implants in patients with advanced AVN. In younger patients, with up to 50% hip head involvement, this technique seems to be a viable option for advanced AVN. Revisions in general are in older patients or those with 100% head involvement.

Most treatment options have had poor outcomes with advanced AVN. Surgeons generally perform THA or core decompression in these cases. Market pressure for a non-vascularized option to fill the channel after decompression has resulted in new implants. A tantalum device has been designed to fill the post-core decompression channel to allow subchondral support. This is a minimally invasive procedure with theoretically low morbidity. The average orthopedic surgeon would have no difficulty in the use of this implant.

HHS improved from fifty-two to seventy. SF36 scores were below age-matched controls. At over one-year average follow-up five patients are revised to THA, however, all hips except one have at least minor pain. Revisions in general are in older patients or those with 100% involvement. In younger patients, with up to 50% head involvement, this technique seems to be a viable option.

This device was used in a prospective cohort of sixteen patients with advanced AVN (Grade 3/4) with femoral head fracture/collapse. Operative technique including reduction of the fracture allows for improved results. Outcomes included radiological parameters (advancing disease, placement, ingrowth), SF36, Harris hip score and secondary surgeries.

Non-unions of pilon fractures are difficult Orthopaedic problems. Significant bone loss and infection can lead to amputation. Joint stiffness in conjunction with disuse osteopenia make stabilization in this area challenging. We present the use of a custom blade plate design that offers sufficient stability for successful treatment in six successive cases. With a mean follow-up of thirty-three months, all fractures treated with this method healed. The five infected cases healed without recurrence of infection. With average scores of 70.7 on the Maryland Foot Score, and sixty-eight on the Foot and Ankle Society Ankle-Hindfoot Scale, the patients overall had satisfactory results.

The purpose of this study was to describe a new technique of treating non-unions of distal tibia pilon fractures using a custom blade plate design. A report of successful outcomes in six consecutive cases.

A retrospective analysis of fifty-six pilon fractures treated over a three- year period revealed six patients with significant complications related to their fractures. Of these, all had significant bone loss and five were infected. All six failures were revised using a custom blade plated design with oblique locking screws for triangular fixation of the distal pilon. The average follow-up period was thirty-three months. These patients were evaluated with the Maryland Foot Score (MFS) and the Foot and Ankle Society Ankle-Hindfoot Scale (AHS).

All of the six patients treated with the proposed method went on to heal without recurrence of infection. Three patients required additional surgical interventions including bone grafting, debridement and hardware removal to achieve the final result. Their average MFS and AHS were 70.7 and sixty-eight respectively.

Stable fixation is an absolute necessity for a successful outcome in the failed pilon fracture. A custom blade plate design with oblique interlocked screws offers sufficient long-term stability, despite infection and disuse osteopenia, for healing of the non-united fracture to occur. As shown by our series, satisfactory clinical results can be expected and amputation can be avoided in complicated cases using this surgical technique.

This study attempted to ascertain if patients with high superior pubic ramus fractures (HSPR) have worse clinical functional outcomes than patients with low superior pubic ramus fractures (LSPR). A retrospective cohort of patients was examined. A statistically significant difference was found with respect to Harris Hip Score, MFA score, Bother Index, and Functional Index. Patients with LSPR fractures consistently scored better on mobility and activity of daily living functional testing. Patients with HSPR fractures were limited in physical abilities and lifestyle adjustment. This study illustrates a need to re-examine our treatment of high pubic ramus fractures.

The purpose of this study was to ascertain if patients with high superior pubic ramus fractures have worse clinical functional outcomes than patients with low superior pubic ramus fractures.

Patients with Low Superior Pubic Ramus (LSPR) fractures consistently scored better on mobility and activity of daily living functional testing. Patients with High Superior Pubic Ramus (HSPR) fractures were more limited in physical abilities and lifestyle adjustment.

No distinction of level of this common fracture is routinely distinguished with treatment usually independent of level. This study illustrates a need to re-examine our treatment of high pubic ramus fractures.

A statistically significant difference was found when the HSPR fracture group was compared to the LSPR fracture group with respect to Harris Hip Score (P=0.0024), MFA score (P=0.0304), Bother Index (P=0.0338), and Functional Index (P=0.0385), and had hip pain which was a limiting factor (P=0.011).

This is a retrospective cohort study of patients sustaining a superior pubic ramus fracture. The criterion for grouping was fracture proximity to the acetabulum. MFA (Short Form) and Harris Hip Score were performed. A physical exam was performed on all patients. The two groups were compared using the Wilcoxon test for continuous variables and the Chi-square test for contingency tables.

These fractures are commonly felt to be of minimal significance. Common treatment regimes consist of pain control and early mobilization. The etiology of the increased pain and functional disability in patients with HSPR fractures is unclear. Our hypotheses include labral tear and missed true acetabular fractures.

Avascular necrosis is poorly understood. The etiological factors have not been fully delineated. This disease process had a huge cost impact on the health system due to surgical treatment. Patients with avascular necrosis seen at a single institution underwent DNA extraction and analysis, coagulation-related analysis and buccal smears with DNA analysis. In this patient group 60% tested positive for at least one thrombophilic or hypofibrinolysis factor. We make recommendations depending on the defect in the cascade, allowing for potential non-surgical management of osteonecrosis in patients undergoing therapy with known antagonistic medications (i.e. corticosteroids).

The etiology and pathogenesis of nontraumatic AVN need to be better elucidated.

Our study identifies the potential association of thrombophilic and hypofibrinolytic factors and osteonecrosis of the hip, particularly genetic markers as identified through DNA markers

The significance of this study:

Osteonecrosis is a devastating musculoskeletal condition;

60% of patients had at least one tested thrombophilic or hypofibrinolysis factor positive. Most patients never had a thrombotic event.

Genetic screening, multiple hematological paramteres were tested on patients with avascular necrosis.

hypercoagulability plays a role in the development of AVN of the hip, mainly at the microvascular level;

A variety of surgical procedures are reported for the management of large volumetric bone loss about the ankle. Although the success rates of these various methods are generally adequate for fusion, they commonly utilize autogenous bone graft and usually result in limb shortening. In seven patients a titanium spinal cage was utilized as a structural support augmented with bone graft for complex ankle arthrodesis. This technique offers immediate structural support, maintenance of limb length, and limits autogenous graft morbidity. Early results of ankle arthrodesis with this cage are encouraging with regard to fusion rates, aesthetic attribute and functional outcome.

To present a novel method of tibio-talar and tibio-calcaneal arthrodesis utilizing a titanium spinal cage for the management of bone loss.

Complex ankle arthrodesis management with a spinal cage offers reliable fusion rates (comparable with existing techniques) without limb shortening.

A variety of procedures are reported for the challenging management of bone loss in ankle arthrodesis. Although the success rates of these various methods are generally good, they commonly utilize large autogenous bone grafts and are subject to donor site morbidities. Most methods also require significant shortening with commensurate functional and aesthetic deficits.

Early results of ankle arthrodesis with a titanium spinal cage are encouraging with regard to fusion rates and functional outcome. A cohort of seven patients treated by this technique has resulted in a 100% fusion rate without loss of limb length. Hindfoot and SMFA scores have revealed good functional results for a usually devastating problem.

A titanium cage was utilized as a structural support for complex ankle arthrodesis with large volumetric bone loss. The cage was contoured at the time of each operation to fit in situ. This technique offers immediate structural support and reliable fusion while limiting autogenous graft morbidity and limb shortening.

Using finely reconstructed helical pelvis CT scans of ninety-three cases and image analysis software, we define the “Safe Zone” for the extra-articular placement of screws during internal fixation of the acetabulum, using a Stoppa approach. Screws should be at most: 11mm from the top of the Sciatic notch, 23mm from the tip of the Ischial Spine, and at most 5mm posterior to the top of the Obturator canal, along the pelvic brim.

The purpose of this study was to identify a “safe zone” in the inner pelvis, to allow extra-articular screw placement using the Stoppa approach.

Acetabulum internal fixation screws can safely (extra-articular position) be placed through the Stoppa approach using three identifiable landmarks.

Surgeons can use these identifiable anatomic landmarks for the safe placement of screws along the inner aspect of the acetabulum.

Study Population: males:females 47%:53%, mean age: 51,3yrs (18–88). Reference measurements (means): Femoral Head (FH): 45,5mm (36–6), Inter-SI joint:177,9mm (102–34). Safe distance to joint: 1) from Sciatic notch: 11mm; 2) from Ischial Spine: 23mm; 3) from Obturator roof: 5mm. The Ischial Spine Distance (ISD) showed clustering (p< 0.05) into two groups according to Femoral Head diameter: FH< 47mm: Safe ISD=23mm ; FH≥47mm: Safe IS=28mm.

Ninety-three Helical Pelvis CT scans with fine reconstruction were done between July 1, 1999-June 30, 2000. Axial images were analyzed using GE Vox Tool® v.3.0.3 image analysis software. The femoral head diameter and the Inter-SI joint distance were used as reference. The distance between three identifiable bony landmarks and the point which would allow the placement of a 4mm screw outside the hip joint were measured. Inter and Intra-observer reliability study showed a difference < 1mm in > 90% of cases.

Surgical approaches which avoid extensive dissection and manipulation of the gluteal musculature are gaining in popularity. The Stoppa is such an approach which gives access to the medial acetabular wall and to the inner pelvis from the SI joint to the symphysis along the pelvic brim. This blind approach does not allow visualisation of the joint and confirmation of screw placement. The present paper offers surgeons these reference points.