Study Design: Prospective observational study. Objectives: To score the severity of injury to (a) vertebrae and (b) intervertebral discs following thoraco-lumbar fracture, and compare the two in their ability to predict clinical outcome at 1–2 years. Methods: 44 patients with fractures between T11 and L5 without neurological deficit were treated conservatively. All had plain X-rays and MRI scans immediately and at one year post-injury. Bony injury severity was scored on a seven-point ordinal scale based on a) comminution, b) apposition and c) kyphosis. Disc injury severity was scored on a six-point ordinal scale based on a) change in signal, b) change in height, c) indentation /herniation. Outcome was assessed at one to two years from injury (av. 18.1 + 5.6 months) Non-parametric correlation coefficients were calculated between injury severity variables and outcome variables. Outcome measures: Modified Oswestry disability questionnaires, SF-36 questionnaires (physical and mental component summary scores – PCS and MCS), verbal and numeric rating scale of ability to perform pre-morbid activities/work. Detailed analysis of a.) pain (intensity, duration, character, distribution, etc.), b.) early morning stiffness (severity, frequency, and duration). Results: According to the AO classification, 25% of the fractures were A1 (wedge), 9% were A2 (split), 45% were A3 (burst) and 20% were B1 (flexion-distraction with posterior ligament injury). Disc injuries scored as: grade 3 (mild) in 14%, grade 4 in 36%, grade 5 in 36% and grade 6 (very severe) in 14%. The spearman correlation coefficients between injury severity and outcome were consistently higher with disc injury severity than bony. For the Oswestry disability score the correlation coefficients for disc and bone injury severity respectively were 0.50 (p< .0001) and 0.40 (p< .05), for SF36-PCS: 0.43 (p< .005) and 0.32 (p< .05), for SF36-MCS: 0.43 (p< .005) and 0.06 (NS), for return to pre-morbid activities and work: 0.32 (p< .05) and 0.25 (p< .5), for pain intensity by numeric rating scale: 0.69 (p< .0001) and 0.41 (p< .01), and for pain intensity by verbal rating scale: 0.65 (p< .0001) and 0.28 (p< 0.1). Conclusion: In all clinical outcomes assessed, there was consistently better prediction by measures of injury severity to the disc than the bone. This study offers possible explanation for previously low or conflicting evidence of correlation between clinical outcome and bony injury in thoraco-lumbar spine fractures uncomplicated by neurological injury. It implies that in selected patients with severe disc injury, treatment focused on eliminating the effects of the disc injury may result in better clinical outcome

Aims. Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. Methods. We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term “electric scooter”. We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. Results. We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. Conclusion. The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost. Cite this article: Bone Jt Open 2022;3(9):674–683

Summary Statement

Bone stress fracture triggers a rapid increase in blood flow in association with mast cell production of inducible nitric oxide synthase (iNOS). NOS inhibition blocks the increase in blood flow and reduces woven bone formation needed for stress fracture healing.

The August 2024 Spine Roundup. 360. looks at: Laminectomy adjacent to instrumented fusion increases adjacent segment disease; Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: a retrospective multicentre study; Lumbar vertebral body tethering: single-centre outcomes and reoperations in a consecutive series of 106 patients; Machine-learning algorithms for predicting Cobb angle beyond 25° in female adolescent idiopathic scoliosis patients; Pain in adolescent idiopathic scoliosis; Teriparatide prevents surgery for osteoporotic vertebral compression fracture

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

Renal Osteodystrophy is a type of metabolic bone disease characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities. Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. Treatment involves medical management to resolve the etiology of the underlying renal condition, as well as management (and prevention) of pathological fractures. A 66-year-old female patient, with severe osteoporosis and chronic kidney disease undergoing haemodialysis, has presented with multiple fractures along the years. She was submitted to bilateral proximal femoral nailing as fracture treatment on the left and prophylactically due to pathological bone injury on the right, followed by revision of the left nail with a longer one after varus angulation and fracture distal to the nail extremity. Meanwhile, the patient suffered a pathological fracture of the radial and cubital diaphysis and was submitted to conservative treatment with cast, with consolidation of the fracture. Posteriorly, she re-fractured these bones after a fall and repeated the conservative treatment. Clinical management: There is a multidisciplinary approach to manage the chronic illness of the patient, including medical management to resolve the etiology and consequences of her chronic kidney disease, pain control, conservative or surgical fracture management and prevention of falls. The incidence of chronic renal disease is increasing and the patients with this condition live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Their quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. A multidisciplinary approach is required to treat these patients, controlling their chronic diseases, managing fractures and preventing falls

An isolated avulsion fracture of the peroneus longus tendon is seldom seen and potentially can go undiagnosed using basic imaging methods during an initial emergency visit. If not managed appropriately it can lead to chronic pain, a reduced range of motions and eventually affect mobility. This article brings to light the effectiveness of managing such injuries conservatively. A 55 year old postman presented to clinic with pain over the instep of his right foot for 2 months with no history of trauma. Clinically the pain was confined to the right first metatarsophalangeal joint with occasional radiation to the calf. X-ray films did not detect any obvious bony injury. MR imaging revealed an ununited avulsion fracture of the base of the 1st metatarsal. The patient was subsequently injected with a mix of steroid and local anesthetic injections at the painful nonunion site under fluoroscopic guidance. Post procedure there was no neurovascular deficit. The patient was reviewed at three months and his pain score and functional outcome improved significantly. Moreover following our intervention, the Manchester Oxford Foot Questionnaire reduced from 33 to 0. At the one year follow up he remained asymptomatic and was discharged. The peroneus longus tendon plays a role in eversion and planter flexion of foot along with providing stabilization to arches of foot. The pattern of injury to this tendon is based on two factors one is the mechanism of insult, if injured, and second is the variation in the insertion pattern of peroneus longus tendon itself. There is no gold standard treatments by which these injuries can be managed. If conservative management fails we must also consider surgery which involves percutaneous fixation, or excision of the non-healed fracture fragment and arthrodesis. To conclude isolated avulsion fractures of peroneus longus tendon are rare injuries and it is important to raise awareness of this injury and the diagnostic and management challenges faced. In this case conservative management was a success in treating this injury however it is important to take factors such as patient selection, patient autonomy and clinical judgement into account before making the final decision

Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

Anti-personnel (AP) mines pose a serious threat to mine clearance personnel and developing effective foot/ leg protection is of benefit. In order to evaluate the effectiveness of a protective system it is necessary to have a physical model of the human leg and foot that replicates bony injury from AP mines. The purpose of this study was to develop and assess a lower limb model (LLM) that reflects human bony injury from AP mines. The LLM comprised a red deer tibia, calcaneum, talus, tarsus and metatarsal encased in 20% gelatine. A British Army combat boot was fitted onto the LLM. Two types of simulated AP mine were used comprising 29g and 50g of plastic explosive (PE). Mines were surface laid and the heel of the boot was placed directly over the top of the mine. Firings with both mine types were performed with the heel in contact with the mine. Further firings with the 50g PE mine included a variable stand-off (e.g. distance of the sole of the boot from the mine) of 25–100mm. The LLM was assessed for bony injury using the International Committee for the Red Cross (ICRC) mine injury system and a mine fracture score (MFS). The pattern of injury resulting from the two mine types, with no stand-off, was different. The 50g mine produced traumatic amputations in four out of five firings, fractures occuring at 3–11 cm from the ankle joint line (pattern 1 injury – ICRC classification). The 29g mine produced hindfoot injuries with comminuted fractures of the calcaneum and talus in all five firings. These are similar to the bony injuries seen in AP mine casualties in Croatia. Use of the MFS allowed comparison with previous cadaver experiments and demonstrated a graded response to increasing stand-off. The LLM replicated the pattern of some bony injuries seen in landmine casualties and could be used to assess the effectiveness of mine protective foot/leg wear

Abstract. Objectives. The aim of this study was to test the hypothesis that there are two different mallet injuries; specifically, tendinous ones are primarily low energy avulsion injuries whilst bony ones are primarily high-energy hyper-extension injuries. Methods. We reviewed in detail the demographics, mechanisms of injury, concomitant injuries and the radiological findings of patients presenting with bony and tendinous mallet deformities. The sizes of the bony fragments and angulation of the mallet deformities were measured on the initial radiographs using an established technique. Results. There were 62 tendinous mallet injuries (62 patients). These were mostly low energy injuries in men with a mean age of 57 years affecting primarily the middle and ring fingers. They were rarely associated with other injuries. There were 85 bony mallet injuries (83 patients). These were all high energy injuries also mostly in men with a mean age of 40 years primarily affecting the ring and little fingers. There were two double injuries and seven other concomitant injuries in the patients with bony mallet injuries. The extensor lags were a mean of 300 (range 3–590) for the tendinous injuries and 130 (range 0–380) for the bony injuries (p<0.00001). The fracture fragments were a mean of 51 (range 24–80) %; there was no correlation between fragment size and extensor lag. Conclusions. This study and review of the literature further confirm the substantial differences between tendinous and bony mallet injuries. In particular tendinous mallet injuries are avulsion injuries whilst bony mallet injuries are dorsal impaction fractures; they should be assessed and treated differently. Bony mallet injuries may be multiple and may be associated with other injuries. Low energy mallet deformities do not need radiographs

In order to predict more detailed outcomes of paralysis in patients with acute cervical cord injury, we have compared degree of paralysis at the time of admission and the time after more than 6 months by using our modification of Frankel’s criteria. Material and Method: The modified Frankel’s criteria comprises following items. Frankel B is divided into B1, B2, B3, C into C1, C2, D into D0, D1, D2, D3. B1; toutch sensation is preserved only in sacral segment, B2; it is preserved in more area, B3; pain sensation preserved. C1; MMT of the L/E has 1~2, C2; MMT of L/E 3. D1; ambulant but wheel chair is practically used. D2; crutch gait or central cord injury type, being liberated from wheel-chair. D3; completely independent. 2) 298 patients were included in this study, 259 males and 39 females, aged 48.1 yrs. in av. The time of admission from injury was within 7 days(average 1.7 days) and follow-up period was 28.6 months in av. Number of cases with bony injuries accounted for 154, those with no bony injury for 144. Patients with bony injury were treated operatively in acute stage; posterior reduction/fusion with wiring +or− anterior fusion . Patients with no bony injury were treated conservatively. Result: Out of 151 pts with Frankel A, only 5 pts(3.3%) were restored to D, also B to D in 37%, C to D in 79%. Itemizing group B pts, B1 recovered to D in 20%, B2 to D in 32%, B3 to D in 80%. Itemizing group C pts, C1 improved to D in 61%, C2 to D in 97%. There were statistically differences between them. At the goal stage there were 111 Frankel D pts and they divited to D1(30%), D2(40%), D3(30%). D2 and D3 showed better abilities in whole ADLs than D1. Conclusion: Comparing to the result reported by Frankel et al in 1969 we found that there were few neurologic improvement despite new technology. Using our modified Frankel’s classification we can estimate pts neurology more precisely and predict outcomes practically more in detail which have benefits to set the goal of treatment

Introduction. The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Methods. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated. Results. 28 patients were included in the study. 54% of the patients were female and the mean age was 45 years (range 16 to 90 years). The incidence of a radial head fracture was 54%, coronoid fracture 43% and epicondyle avulsion 18% on CT. The inter-observer reliability was only shown to be fair amongst registrars and the intra-observer variability moderate. Conclusions. Computerised tomography is a useful adjunct in the assessment of associated osseous injuries following an elbow dislocation due to the presence of a high number of injuries. Plain radiographs alone have been shown to have only a fair and moderate inter and intra-observer variability respectively, therefore a low threshold to obtain further 3D imaging should be practised. Level of Evidence. IV

Background context: Stable thoracolumbar spinal fracture is a common injury, yet there remains a relative lack of evidence that would allow reliable prediction of outcome. Variation in outcome in stable thoracolumbar spine fracture without neurological deficit could not be explained by the assessment made from x-rays and CT imaging alone, which measures mainly the bony injury severity. So far, no good classification system has been developed to assess the severity of soft tissue injury (disc). Objectives: To measure short-term outcome of stable thoracolumbar fracture and analyse aspects of injury severity for their ability to predict outcome. To develop a new disc injury severity grading system in thoracolumbar spine fractures. Study design: Prospective observational. Patient sample: 44 patients with stable fractures between T11 and L5 vertebra with no neurological deficit and treated conservatively were selected. Methods: All had plain x-rays, CT and MRI scans post-injury and at one year post-injury (except CT). Bony injury severity was scored on a seven-point ordinal scale based on (a) communication, (b) apposition and (c) kyphosis. Disc injury severity was scored by the newly developed six-point ordinal scale (none to severe) based on the following variables: (a) Herniation of the disc, (b) Indentation of the end plate, (c) Change in height and (d) Change in signal. Outcome was assessed at one to two years from injury. The following outcome measures were collected: (A) Five domains of pain symptoms – intensity, duration, bothersome, interference and satisfaction. (B) Five domains of function – Physical Component Summary (PSC) measure, Mental Component Summary (MSC) measure, Oswestry disability score, return to pre-injury level of overall activities and return to employment. Non-parametric correlation coefficients were calculated between outcome variables and other variables to look for the predictors of outcome. Stepwise linear regression analysis was performed to compare the predictive values and to look at what proportion of outcome is predicted by different predictors. Results: According to AO classification, the fractures were A1, A2, A3 and B1. The Spearman correlation coefficients between outcome and injury severity were consistently higher with disc injury severity than bony. For the outcome of pain intensity, the correlation coefficients for disc and bone injury severity respectively were:.63 (p < .0001) and.28 (NS-not significant). Similarly for SF36 PSC were: .41 (p < .01) and.25 (NS). The predictive value of pain at F < .01 was 29% for disc injury severity and all other variable were not significant and excluded. At F < .05, the predictive value of disc injury severity (29%) increased further by 9%, 8% and 6% by addition of variable “Patient’s pre-injury SF36 MSC”, “Legal and Compensation issues pending” and “Physical demand of job” respectively. The predictive value of function at F < .01 was 16% for disc injury severity and it increased to 31% by the addition of “physical demand of the job” variable. At F < 0.05 the predictive value further increased by 5% by addition of variable “Legal and Compensation issues pending”. All other variables were not significant. Conclusions: A new grading system of disc injury severity was developed and it showed good predictive value for pain and functional outcome. Disc injury severity has a better predictive value for short term outcome than bony injury severity in stable thoracolumbar fractures. In the spectrum of injuries studies, the AO classification and the degree of kyphosis provided no prediction of outcome

Abstract. 3D printing of synthetic scaffolds mimicking natural bone chemical composition, structure, and mechanical properties is a promising approach for repairing bone injuries. Direct ink writing (DIW), a type of 3D printing, confers compatibility with a wide range of materials without exposing these materials to extreme heat. Optimizing ink properties such as filament formation capabilities, shear-thinning, and high storage modulus recovery would improve DIW fabrication characteristics. In this study, composite inks based on biodegradable polycaprolactone (PCL), reinforced with nano-hydroxyapatite (HAp), and loaded with vancomycin were designed and evaluated for their rheological properties, wettability, mechanical properties, and antimicrobial properties. The formulated composite inks displayed a shear-thinning behaviour exhibited storage modulus recovery percentages above 80% for all formulations, which is essential for extrusion deposition by DIW at room temperature. Ink formulations were able to form fully interconnected lattice scaffolds with porosities ranging from 42% to 65%. Increasing the HAp concentrations from 55% to 85% w/w increased the shear thinning behaviour and reduced the printed filament width to more closely match the nozzle diameter; this indicates higher HAp proportion reduces ink shrinkage. The scaffold had high wettability at HAp proportions above 65% w/w and the compressive elastic modulus of DIW printed scaffolds exhibited within the range of trabecular bone. Antimicrobial activity was apparent from the agar diffusion assay; zones of inhibition ranging from 15.82 ± 0.25 mm and 20.06 ± 0.25 mm were observed after 24 hr for composite scaffolds loaded with 3% and 9% w/w vancomycin respectively. Vancomycin-loaded PCL/HAp composite inks were developed, displaying good printability, wettability, mechanical properties, and antimicrobial properties, making them an attractive choice for bone repair and regeneration. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

The stem cell fraction of a cell population is finely tuned by stimuli from the external microenvironment. Among these stimuli, a decrease of extracellular pH (pHe) may occur in a variety of physiological and pathological conditions, including hypoxia and inflammation. Also in bone, the maintenance of acid-base balance is fundamental for skeleton homeostasis. Bone cells are extremely sensitive to the effects of interstitial pH. Acidosis inhibits mineral deposition by osteoblasts and activates osteoclast-mediated bone resorption. Moreover, acidosis is associated with inflammation, and in case of bone injury, local short-term acidosis is a crucial regulator of the healing process. Evidence of the role of acidosis as an enhancer of MSC stemness and for their activation as sensors and switcher of inflammation will be discussed

There is a high incidence of ipsilateral knee injuries with the Floating knee, which makes these fractures even more challenging to manage. We present the impact knee injuries have on the final outcome of the floating knee. We propose a protocol for assessment & management of knee injuries with the Floating knee. This prospective study included 29 patients with floating knee injuries. Knee injuries encountered were divided into bony, ligamentous and soft tissue. Bony injuries were assessed with radiographs and managed surgically along with the floating knee injury. Patients were assessed clinically for knee ligament injuries after fixation of the fractures intra-operatively and managed surgically. Soft tissue injuries around the knee were managed conservatively. Final outcome was assessed using the Karlstrom criteria. Ten of the 29 patients had knee injuries: 3 patella fractures, 2 anterior cruciate ligament injuries, 1 posterior cruciate ligament injury, 1 medial meniscus injury and 3 extensive soft tissue injuries. The complications were knee stiffness and superficial infection. The end results according to the Karlstrom criteria were Good – 6, Acceptable – 1 and Poor – 3. The associated knee injury in the floating knee is an important prognostic indicator. Soft tissue injury seems to have a very poor prognosis. We propose clinical evaluation of the knee after fixation of the fractures, surgical management of ligament & bony injuries and a proper rehabilitation programme to improve outcomes

Stable thoracolumbar fracture is a common injury. The factors that determine its outcome are unclear. Aspects of injury severity were analysed for their ability to predict outcome by controlling other outcome-affecting factors (patient's pre-injury health status, legal aspects, associated injuries, etc.). No reliable disc injury severity grading system was available and therefore a new system was developed. A prospective observational study of 44 conservatively treated patients with stable fractures between T11 and L5 was conducted. Bony injury severity was scored based on comminution, apposition and kyphosis parameters. Disc injury severity was scored by the new scale based on variables – Herniation, Indentation, Height decrease and Signal change – seen in MRI. Ten outcome domains (five domains of pain and function each) were assessed at 1 to 2 years from injury. The data was analysed by non-parametric correlation and stepwise-linear regression analysis to assess the predictive value of different variables (patient factors, injury factors and social factor) to outcome. The correlation coefficients between injury severity and outcome were consistently higher with disc injury severity than bony. Disc injury severity showed highest predictive value for both pain (29%) and functional (16%) outcomes, whereas the bony injury severity parameters (kyphosis, etc.) and the posterior ligament injury severity provided no prediction of outcome. According to AO classification, the fractures were A1, A2, A3 and B1; in this spectrum of injuries, the AO classification had no prediction of outcome. The disc injury score also had a good predictive value for final disc degeneration. Disc injury severity should be gauged in advising prognosis and treatment. The new disc injury severity grading system showed good construct validity

While new biomaterials for regenerative therapies are being reported in the literature, clinical translation is slow. Existing regenerative approaches rely on high doses of growth factors, such as BMP-2 in bone regeneration, which can cause serious side effects. We describe an ultra-low-dose growth factor technology yielding high bioactivity based on a simple polymer, poly (ethyl acrylate) (PEA), and report its translation to a clinical veterinary setting. This polymer-based technology triggers spontaneous fibronectin organization and stimulates growth factor signaling, enabling synergistic integrin and BMP-2 receptor activation in mesenchymal stem cells. To translate this technology, we use plasma-polymerized PEA on 2D and 3D substrates to enhance cell signaling in vitro, showing the complete healing of a critical-size bone injury in mice in vivo. We demonstrate its safety and efficacy in a Münsterländer dog with a non-healing humerus fracture, establishing the clinical translation of advanced ultra-low-dose growth factor treatment

The Orthopaedic Unit at The Alfred has been using an external fixator in a novel configuration for protecting lower limb wounds after free flap surgery (sometimes even in the absence of a concomitant bony injury). This soft-tissue frame allows the limb to be elevated without contact so that there is no pressure on the flap and its pedicle. Thus, optimising the arteriovenous circulation. We report our initial experience with these soft tissue frames. The soft tissue frame is not necessarily applied for definitive fracture care, but constructed or modified to optimise elevation of the leg, remove direct pressure from the soft tissues, and stabilise the muscles adjacent to the flap. All ankle-spanning frames held the foot in a plantargrade position to optimise blood flow and recovery (prevent equinus), and minimise intra-compartmental pressure. During 2007, the Plastic Surgery Unit performed 23 free flaps to the lower limbs of 22 patients. Five of these patients had a soft-tissue frame constructed. One patient had a frame applied purely to manage the soft tissue injury, and the other four, who required an external fixator for a bony injury, had their frame modified. Four of the five patients study patients were injured in motor vehicle accidents and one was injured in a simple fall. All five free flaps survived and none required any further surgery. No patients suffered complications (such as bleeding, pin-track infections, or osteomyelitis) related to the soft tissue frame. We strongly recommend considering an external fixator in a modified configuration after lower limb free flap surgery. Constructing a soft tissue frame has no added risks if the fixator is already required. In the case where there is no bony injury, a soft tissue frame has the benefits of providing optimal flap conditions and maintaining anatomical joint alignment. However, this must be balanced against the small risk associated with the insertion of pins (such as infection) and the need for an extra procedure to remove the frame. As always, treatment must be tailored to the individual patient

Bone formation proceeds through two distinct processes. One involves the deposition of bone by osteoblasts (intramembranous ossification) and another through the remodeling of an intermediate cartilaginous matrix formed by chondrogenic differentiation of mesenchymal stem/stromal cells (MSCs) aggregates – a process called endochondral ossification (EO). EO is responsible for formation of long bones during development and most prevalent during facture repair upon callus formation. In adult bone injuries MSCs from periosteum form bone via EO whereas MSCs from bone marrow are primarily differentiate to osteoblast in vivo. We hypothesized that the unique biophysical and biochemical properties of bone mineral phase has a role in programming MSCs. Using a biomimetic bone like apatite (BBHAp) as surrogate for bone mineral phase, we studied the chondrogenic differentiation of human marrow derived MSCs and observed that the BBHAp dictates MSCs fate and strictly dictates the pathway of bone formation in vivo. Through exhaustive dissection of the signaling pathways at play, a prominent role of PTH1R in modulating the effects imposed by the BBHAp has been unraveled. These fundamental insights gained in how bone microenvironment might alter fate of MSCs has important implications for bone repair and regeneration therapies