Introduction: This research aims to study the efficacy and effect of Bone Marrow Stromal Stem Cell (BMSSC) implantation on healing of refractory fracture non-union.

Methods: Approved by the local Ethics Committee, twelve patients (9M and 3F), age range 38 to 76 years (mean 49.9) with non-union resistant to multiple previous attempts of treatment (mean 3.75 procedures) were treated. Four tibial and eight femoral non-union.

The patients were admitted for harvesting of stromal stem cells by bone marrow aspiration from the iliac bone. BMSSC were expanded in tissue cultures for three weeks to an average of 5 x 10⁶ cells. After successful culture the non-union site underwent decortication and BMSSC added to synthetic bone substitute (different types) on one side of the fracture (medial or lateral) according to randomisation. The side of treatment was blinded to patient, surgeons and radiologist.

Standard radiographs were taken and evaluated independently by three experienced musculoskeletal radiologists. The extent of callus formation on each side was recorded. In equivocal cases computerized tomography (CT) was also obtained.

Results: No patient developed systemic complications related to the procedure. On follow-up callus formation was present in 9 of 12 patients. Callus was more marked on the cell implantation side in 6/12 patients (50%), control side in 1/12 (8.3%) and on both sides in 2 patients. 3 patients showed no change.

Discussion: These findings suggest that implantation of BMSSC can enhance bone formation in persistent non-union. A larger randomized controlled trial will follow to test this new treatment.

Purpose: To evaluate the diagnostic parameters for detection of pelvic bone infections and to present the results of conservative and operative treatment.

Materials-methods: 17 children with acute osteomyelitis of the pelvis or septic sacroiliitis were treated from 1992 to 2000. They were followed-up for 1,5 to 8 years.

10 patients presented with leukocytosis. In 15 patients ESR exceeded 40 mm and in 10 patients CRP exceeded 20 mg%. Blood cultures yielded Staphylococcus aureus in 6 cases and Streptococcus in one. In only 2 cases were plain X-Rays suggestive of infection. Every patient had a positive Tc99m MDP bone scan (increased absorption), which permitted localization of the infection. Furthermore, MRI was performed on 12 patients, yielding abnormal findings in all cases.

All patients received antistaphylococcal antibiotics intravenously for 10–14 days, followed by a further 3–8 week course per os, depending upon the response to treatment. Treatment started with considerable delay for 3 patients; they all were submitted to surgical drainage and debridement.

Results: All patients were normal at clinical follow-up by the end of treatment. By the end of follow-up no signs of osteomyelitis or residual deformity appeared.

Conclusions: The usual laboratory and radiological investigations can be misleading. Tc99m MDP bone scan and MRI permit prompt diagnosis and localization of the infection. With the appropriate antibiotics the clinical results are usually excellent, provided that the disease is diagnosed without delay. Surgical drainage and debridement is necessary in cases of delayed or missed diagnosis.

Purpose: To evaluate the assumption that reaming is the main reason for problems of shoulder function (pain – restricted range of motion) after antegrade intramedullary nailing of humerus (unless impingement of fixation material on the rotator cuff or acromion occurs).

Materials – Methods: From January 1999 until March 2003 55 patients underwent unreamed antegrade intra-medullary nailing for treatment of recent fractures of the humeral shaft. Two different intramedullary nailing systems were used, that do not protrude from the humeral shaft and that do not require reaming for insertion. Patients with concomitant problems or complications that could affect the final functional result were excluded from the study (e.g. multiple injuries, brachial plexus lesions, etc.). The remaining 32 patients were examined for postoperative pain and functional problems in the shoulder joint.

Results: No patient complained of persistent shoulder pain. Range of motion was found comparable to that of the other shoulder.

Conclusions: Reaming seems to exert a harmful influence on the rotator cuff, due to direct injury caused by the reamers as they are inserted and withdrawn from the humeral head. Furthermore it is possible that bone reaming products, accumulating under the rotator cuff, contribute to the persistence of pain and loss of motion.

Purpose: To describe a technique that allows “closed” reduction and “percutaneous” fixation of intertrochanteric fractures that were unable to be reduced preoperatively, with the use of the Trochanteric Gamma Nail.

Materials-methods: From October 2001 until March 2003 we treated 11 patients with intertrochanteric fractures that were unable to be reduced with preoperative manipulation. To achieve “closed”, intaoperative reduction of fractures, the Trochanteric Gamma Nail was used as a lever. The operation was performed through a 2–3 cm long skin incision (“percutaneous technique”).

Results: There were no particular difficulties with this method. Stable fixation was achieved in all cases and mobilization, full-weight bearing, was allowed from the first day postoperatively. No intraoperative or postoperative complications occurred. Intraoperative blood loss averaged 150 cc.

Conclusion: Use of the TGN in the treatment of pre-operatively unreducible fractures can help to avoid an “open” reduction. Furthermore, placement of the nail through a minimal cutaneous incision can offer all the advantages of closed intramedullary nailing, such as reduced complications, small blood loss, and unrestricted, early mobilization of the patient.

Diaphyseal femoral fracture (DFF) and fixation elicit a bistep inflammatory response (two-hit model). The timing of fixation potentially affects lung function and blood biochemistry. In 24 patients with DFF we measured CRP, albumin, albumin/globulin ratio (A/G) total protein, triglycerides, low (LDC) and high (HDC) density cholesterol at (1) admission, (2) day of operation, and (3) 48 hours postoperatively. We considered group A: (early fixation, day 1–4, 2.6±0.9, n=12) and B: (late fixation, day 5–12, 8.7±2.6, n=12). Statistical analysis was performed by ANOVA and multivariable tests. CRP increases from injury to operation and further to 48 hours postoperatively (p< 0.001) in both groups. Early fixation results in vigorous CRP increase, compared to late fixation, yet the pattern is parallel. Biphasic decrease of albumin (p< 0.001), A/G (p< 0.001) and total protein (p< 0.001), attributable to the inflammatory response, and that of HDC (p< 0.001) and LDC (p< 0.05) are identical in both groups.

It is known that CRP peaks at 48 hours posttrauma. In early operation there is an additive effect of the two inflammatory hits, whereas, in delayed fixation the first hit fades, thus lowering the starting point of the second hit. Protein and HDC biphasic drop is not affected by the timing of fixation. We have no explanation for HDC drop. The timing of femoral shaft fracture fixation affects significantly CRP release and its impact on convalescence is worth investigating.