Our aim was to assess the outcome of the treatment of Segmental fracture of the humerus in adult patients. From January 1994 to December 2003, 24 (17 females) consecutive adult patients with segmental humeral fractures were treated in our unit. Segmental fracture was defined as a two-level humeral fracture with at least one intermediate segment (AO type 12C). The mean age of the patients was 56.5 years(range 29–95) and the mean ISS was 14.1(range 9–29). The causes of injury included 8 vehicular accidents, 15 falls from heights, and 1 skiing injury. Thirteen patients had associated injuries. Three fractures were open (1 grade II, and 2 grade IIIA). At final follow up all patients were assessed in terms of radiological result and functional capacity (range of motion). The mean follow up was 36 months (range 24–60). There were 5 radial nerve palsies. Seven cases involved 4 fracture segments. The mean length of segment was 7 cm (range 5–16). All fractures but 5(20.8%) progressed to union (1 infected non-union, 1 hypertrophic after ex-fix, 1 atrophic after stabilization with rush pins, one was associated with failure of fixation proximally and required hemiarthroplasty). The mean number of procedures to achieve union in total was 1.6(range 1–3). There was one implant failure and one persistent non-union. At final follow up, the mean abduction was 1100 (900–1400) and the mean forward flexion was 1200 (1000–1500). Internal external rotation was 700 (50–90) and 250 (20–45). The risk of non-union is as high as 20.8 % and additional procedures often required to achieve union of the fragments. The method of stabilization depends on several factors including fracture configuration, the available bone stock and the surgeons’ expertise. Despite the severity of this injury a satisfactory outcome can be expected.
We investigated whether lateral compression type I injuries of the pelvic ring are inheritably mechanically stable. Between January 2005 to January 2007 all consecutive admissions of a tertiary referral center for pelvic ring reconstruction with a LC I injury pattern were eligible for inclusion. Exclusion criteria were other patterns of pelvic ring injuries. All patients underwent radiological assessment including AP pelvis, inlet/outlet views and CT. Patient demographics, mechanism of injury, other associated injuries, ISS, length of hospitalisation, type of operation, mode of mobilization, preoperative and postoperative visual analogue score pain VAS and follow up until fracture union were prospectively documented. Mechanical stability of the pelvic ring was assessed in the operating theatre under general anaesthesia. Instability was defined as displacement >
2 cm of the anterior or posterior elements. The minimum follow up was 12 months. Of 210 patients admitted with pelvic fractures, 40 fulfilled the inclusion criteria (LC1 type). There were 23 female 17 male and with a mean age of 33.5 (range 18–68). The mean ISS was 10 (range 9–19). 23 patients (group 1) were found to have more than 2 cm rotational displacement during EUA and were stabilised with SI screws posteriorly and a combination of retro-pubic screws, external fixator or plating anteriorly. 17 patients (group 2) exhibited minimal displacement less than 5mm and were not stabilised. Rotational instability >
2cm was characterised by complete fracture of the sacrum posteriorly. Stabilisation of the pelvic ring in group I was associated with a significant reduction of the VAS within 72 hours from surgery, early ambulation and discharge from the hospital. This study supports the view that not all LCI fracture patterns are mechanically stable. Examination under anaesthesia of the pelvic ring can assist the clinician in the decision making progress.
The purpose of this study was to assess the effect of human autologous serum on the proliferation and differentiation of MSCs and to analyze the serum growth factor content. Serum was obtained from 8 patients suffering from lower limb long bone fractures requiring surgical intervention. Serum samples were obtained on admission and the 1st-3rd–5th and 7th postoperative day. During the surgical procedure cancellous bone pieces from the fracture were obtained and MSCs were isolated. Cells were cultured with autologous serum from each sample. The cellular potential for proliferation and osteogenic differentiation was assessed. Fetal calf serum (FCS) was used for comparison. The presence of growth factors in the serum was investigated using commercially available colorimetric assays read on Elisa plate reader. We studied the serum content on Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF) and Insulin-like Growth Factor I (IGF-1). The maximal upregulation of cellular proliferation and osteogenic differentiation was noted in cells cultured from serum obtained between third and seventh days. Cellular proliferation in comparison to FCS was increased by 32% with the use of serum from admission, 23% with the use of serum of the 1st day and 37% and 42% with the serum from 3rd and 7th days respectively. Serum analysis revealed an increase of 80% of PDGF between the 1st and 3rd postoperative day and 135% from 3rd–7th postoperative day. IGF-1 was increased by 35% between day 1 and 7. VEGF was increased by 120% during the first two postoperative days and a further increase of 190% occurred between days 3 and 7. Growth factors are released in peripheral circulation and are gradually increased after fracture. MSCs under their influence proliferate faster and up-modulate their osteogenic differentiation. These findings should be considered when using functional assays for tissue regeneration techniques.
The purpose of this study was to evaluate the efficacy of autologous cancellous bone grafting (ABG) for the treatment of long bone fracture non-unions. Patients who were treated with ABG for fracture non-unions of the lower extremities were identified from our prospectively entered database. Non-union was defined as failure of the fracture to unite within a period of 9 months. Demographics, comorbidities, medications, complications and surgical outcomes were all recorded and subsequently analysed. Chi square test was used to analyse the results. In total 82(54 male) patients met the inclusion criteria. The mean age was 43.6 years (range 18–78). Ten patients were diagnosed with femoral and 72 with tibial fracture non-unions. Fifty three (64.6%) were open fractures at presentation. In the tibial non-union group, initially, 67 fractures were stabilised with IM nailing and 5 with plating. During revision surgery, 33 patients underwent exchanged nailing and ABG whereas 34 received ABG without revision of the metal work. All five tibial plantings required re-plating and ABG. In the femoral non-union group, five fractures were initially stabilised with IM nailing and the rest with plating. During revision surgery, six patients underwent change of fixation (exchange nailing) and ABG and four received only ABG. Overall 73/82 patients progress uneventfully to union and the success rate was 89%. A second and a third attempt of ABG was made for 6/86 patients (7.31%) and 2/82 patients (2.44%) respectively, till clinical and radiological union. All but one of the patients united their fractures. One patient underwent amputation due to underlying osteomyelitis. The mean time to union following the ABG procedures was 8.4 months (range 3–18). Autologous bone grafting is an effective method of treating fracture non-unions. Success rates of as high as 89% can be achieved as seen in this series of patients.
We aim to define the role of pelvic fractures (PFx) due to falls, in auditing Trauma Care. We present a retrospective case-control study, based on autopsy. Univariate analysis was used to identify factors predicting mortality and a backward stepwise logistic regression multivariate analysis determined relationships. Of 970 patients who sustained a fatal fall, 209 (21.5%) constituted the PFx-group, and the remaining 761 the control-group. The PFx-group had a median age of 55 years (15–96), while the control 66 years (1–99). The multivariate analysis revealed that gender, age, intention, and height of fall were risk factors for PFx after a fall. An approximately 300% higher odds of suffering a psychiatric history was found in the PFx-group, (p<
0.001). The median ISS of the PFx-group was 50(17–75), and was significant higher than the 26(1–75) of the control-group, (p<
0.0001). The “potentially-preventable” deaths (ISS<
75) constituted 78%, while the “non-preventable” 22%. The most common AIS 3–5 injuries in the “potentially-preventable” deaths were located in the: lower extremities 133(81.6%), thorax 130(79.7%), abdominal and pelvic contents 99(60.7%), head 95(58.3%) and the spine 26(15.9%) of the patients. A subset of 126 (60.3%) “potentially-preventable” deaths of the PFx-group had at least one AIS-90 code other than the PFx denoting major hemorrhage. Deaths directly attributed to pelvic fractures were limited to 6 (2.9%). The post-traumatic median survival-time for the PFx-group was 30 minutes, while for the control group 20 hours and 15 min. For one group increment in the range of ISS-groups, the probability of post-traumatic survival rate was reduced by 57% (p<
0.0001). Multiplicity, severity and the short posttraumatic survival time in the PFx group render PFx an index-injury for audit of polytrauma. A reproducible method of autopsy-data analysis was outlined. Pelvic fracture is a paradigm of injury that selected an index-population among 970 fatal falls and an appropriate basis to construct a template for evaluation of trauma &
polytrauma care.
We aim to evaluate the effect of fasciotomies following compartment syndrome on the healing of closed tibia diaphyseal fractures. Between January 2002 and January 2005 165 patients were treated in our institution with closed tibial diaphyseal fractures. Patients were divided in to two groups; Group A (study group) consisted of patients that, after surgery, developed compartment syndrome and were submitted to fasciotomies and group B (control group) of patients who underwent reamed IM nailing and did not require such intervention. Patients with open fractures, pathological fractures, revision surgery, severe brain injuries, prolonged ITU stay and severe co-morbidities were excluded. Fracture pattern, ISS score, smoking habits, drugs intake, mode of mobilization and additional procedures were prospectively documented. Fracture healing more than 24 weeks was defined as delayed union and over 36 weeks as non-union. All patients had been followed-up clinically and radiologically until fracture union. One hundred twenty five out of 165 patients fulfilled the inclusion criteria for this study. 30 patients were classified in group A and 95 in group B. Eighteen patients of group A required skin graft coverage after the fasciotomies. There was no difference between the two groups in terms of the studied parameters. Four patients from group A and one from group B, went to non-union and required second procedures to achieve union. These patients were excluded from the final analysis. Delayed union occurred in 11 (36.6%) patients in group A and in 10 (10.5%) patients in group B (P<
0.05). Overall, fracture healing was prolonged in the fasciotomy group but the difference was not statistical significant, 24.27 weeks (10 – 48) versus 22.19 (12 – 40), (P= 0.157) in group A and group B respectively. Compartment syndrome and fasciotomies is associated with delayed fracture healing. Nevertheless, this delay was not statistically significant different.
In order to assess the effect of osteoporosis on healing time we retrospectively reviewed the files of 165 patients with femoral shaft fractures that were treated in our service by locked, intramedullary nailing. Patients were divided in two age groups; Group A (study group) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (control group) of patients between 18 and 40 years old with no signs of osteoporosis. Sixty-six out of 165 patients fulfilled the inclusion criteria for this study. Patients with open fractures, pathological fractures, revision surgery, severe brain injuries, prolonged ITU stay and severe co morbidities were excluded. Twenty-nine patients were classified in group A and 37 in group B. All patients had been assigned the Injury Severity Score (ISS) and had been followed-up clinically and radiographically until fracture union. In all patients the Singh Index Score for osteoporosis was assigned. In all group A patients Singh score 4 or less was assigned, suggesting the presence of installed osteoporosis, whereas group B patients were assigned with Sighn score 5 or 6. Fracture healing was significantly different between the groups. Fractures of Group A healed in 19.38±5.9 weeks (12–30) and in group B 16.19±5.07 weeks (10–28) (P=0.02) Fracture healing of nailed femoral diaphyseal fractures significantly delays in older osteoporotic patients. Further studies are mandatory to clarify the exact impact of osteoporosis in the whole healing process and the possible future therapeutic strategies.
Sepsis and multiple-organ failure are common sequelae of multiple trauma. Although sepsis is considered to result from bacteria translocating through the gut mucosa, evidence for that is lacking. In order to define the chronic involvement of bacterial translocation, fracture was induced after crushing of the right femor on its mid in 11 rabbits. Blood was collected at regular time intervals for quantitative culture and for estimation of endotoxins (LPS) by the QCL LAL-assay, tumor necrosis factor-alpha (TNFalpha) by a bioassay in L929 fibrosarcoma cell line and malondialdehyde (MDA) by HPLC. After death, segments of liver, lung and spleen were cut for quantitative culture. Mean +/−SE of the log10 of viable cells in blood were 2.48 +/− 0.43, 3.16 +/− 0.46, 2.77 +/− 0.69 and 2.12 +/− 0.43 at 2, 4, 24 and 48 hours after fracture. Respective values for LPS were 1.50 +/−0.29, 1.54 +/− 0.44, 1.17 +/− 0.17 and <
1.00; for MDA 3.57 +/− 0.55, 7.50 +/− 3.00, 15.77 +/− 12.26 and 5.07 +/− 2.18 μM; and for TNFalpha 11.8 +/− 1.2, 36.7 +/− 25.9, 40.7 +/− 24.0 and 56.8 +/− 45.3 pg/ml. Positive tissue cultures for Serratia marscecens and Pseudomonas aeruginosa were found for six rabbits. Median survival for animals drawn positive tissue cultures was 1.00 days and 7.00 days for animals with negative tissue cultures (p: 0.0092). It is concluded that bacterial translocation is a process occurring early in a significant percentage in the field of multiple trauma. Its occurrence is accompanied by rapid progression to death. Further research is mandatory to clarify the reasons favoring that process in certain hosts compared to others.
Material – Methods: From 1980 until 1997, 17 patients 3 females and 14 males, average age 25.53 (19 – 44) underwent surgery suffering recurrent sprain of the ankle. In 11 patients the right ankle was involved and in 6 patients the left ankle. The cause of the injury was: athletic activities in 9 cases, weekend activities in 7 cases and daily activities in 1 case. The patients were suffering from ankle instability 4–15 years prior the operation. All the patients underwent reconstructive surgery of the anterolateral elements (capsule and ligaments) according to senior author’s method. This included shortening of the anterolateral elements, capsule and ligaments, overlaping the anterolateral part over the anterolateral one in such a way, that the anterior drawer and varus tests were negative with the patient under anaesthesia.