Delay in fracture healing is a complex clinical and economic issue for patients and health services.
To assess the incremental effectiveness and costs of bone morphogenetic protein (BMP) on fracture ...healing in acute fractures and nonunions compared with standards of care.
We searched The Cochrane Library (2008, Issue 4), MEDLINE, and other major health and health economics databases (to October 2008).
Randomised controlled trials (RCTs) and full or partial economic evaluations of BMP for fracture healing in skeletally mature adults.
All clinical and economic data were extracted by one author and checked by another.
Eleven RCTs, all at high risk of bias, and four economic evaluations were included. Apart from one study, the times to fracture healing were comparable between the BMP and control groups. There was some evidence for increased healing rates, without requiring a secondary procedure, of BMP compared with usual care control in acute, mainly open, tibial fractures (risk ratio (RR) 1.19, 95% CI 0.99 to 1.43). The pooled RR for achieving union for nonunited fractures was 1.02 (95% CI 0.90 to 1.15). One study found no difference in union for patients who had corrective osteotomy for radial malunions. Data from three RCTs indicated that fewer secondary procedures were required for acute fracture patients treated with BMP versus controls (RR 0.65, 95% CI 0.50 to 0.83). Adverse events experienced were infection, hardware failure, pain, donor site morbidity, heterotopic bone formation and immunogenic reactions. The evidence on costs for BMP-2 for acute open tibia fractures is from one large RCT. This indicates that the direct medical costs associated with BMP would generally be higher than treatment with standard care, but this cost difference may decrease as fracture severity increases. Limited evidence suggests that the direct medical costs associated with BMP could be offset by faster healing and reduced time off work for patients with the most severe open tibia fractures.
This review highlights a paucity of data on the use of BMP in fracture healing as well as considerable industry involvement in currently available evidence. There is limited evidence to suggest that BMP may be more effective than controls for acute tibial fracture healing, however, the use of BMP for treating nonunion remains unclear. The limited available economic evidence indicates that BMP treatment for acute open tibial fractures may be more favourable economically when used in patients with the most severe fractures.
The fluid flow in fracture porous media plays a significant role in the assessment of deep underground reservoirs, such as through CO2 sequestration, enhanced oil recovery, and geothermal energy ...development. Many methods have been employed—from laboratory experimentation to theoretical analysis and numerical simulations—and allowed for many useful conclusions. This Special Issue aims to report on the current advances related to this topic. This collection of 58 papers represents a wide variety of topics, including on granite permeability investigation, grouting, coal mining, roadway, and concrete, to name but a few. We sincerely hope that the papers published in this Special Issue will be an invaluable resource for our readers.
The fluid flow in fracture porous media plays a significant role in the assessment of deep underground reservoirs, such as through CO2 sequestration, enhanced oil recovery, and geothermal energy ...development. Many methods have been employed—from laboratory experimentation to theoretical analysis and numerical simulations—and allowed for many useful conclusions. This Special Issue aims to report on the current advances related to this topic. This collection of 58 papers represents a wide variety of topics, including on granite permeability investigation, grouting, coal mining, roadway, and concrete, to name but a few. We sincerely hope that the papers published in this Special Issue will be an invaluable resource for our readers.
Only few case series of capitellar and trochlear fractures have been reported. Some of them assume that the presence of a posterior comminution (type B according to Dubberley classification) can ...represent a negative risk factor for treatment and prognosis respect to the type A cases (without posterior comminution). Nevertheless, how this parameter impacts the treatment and the prognosis has never been quantified before.
All the capitellar and trochlear fractures treated from 2007 to 2015 have been retrospectively reviewed. The presence of posterior comminution on a pre-operative CT-scan was correlated to the surgical technique, to the timing of initiation of rehabilitation and to clinical outcomes.
45 Consecutive patients have been selected, 17 not presenting a posterior comminution (type A), and 28 with posterior comminution (type B). In all the type A fractures a lateral approach (Kocher o Kocher extensile) was used and the fragment fixation was always performed using only screws. Elbow replacement or olecranon osteotomy were performed only to treat type B fractures. Augmented fixations, using plates and k-wires, or prosthetic replacement have been used only in type B fractures. The post-operative immobilization was significantly inferior for type A fracture. Better results have been obtained in type A fractures: mean MEPI score was 86 in type A and 73 in type B, the range of motion was significatively higher in type A both in flexion-extension and in pronation-supination. In type B fractures a significant higher number of complications have been observed (64% vs 29%) along with more reoperations.
The study has confirmed that, even without considering the extension of the fracture on the coronal plane, the presence of posterior comminution represents an evident negative risk factor, influencing the surgical approach and treatment, the fixation technique, the post-operative rehabilitation, the clinical outcomes, the complications and re-operation rates.
The analysis of the present case series shows how the treatment and the outcomes can be significantly anticipated based on the presence or absence of posterior comminution. Patients with type A fracture are more likely treated with a Kocher approach, screw fixation, an early rehabilitation is performed. In type A fractures better outcomes and low complications rate are expected.
Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with ...locking plate compared with non-operative treatment for these fractures.
The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 95% CI -7.8 to 9.4, p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded.
This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial.
ClinicalTrials.gov NCT01246167.
Purpose of Review
Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a ...particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures.
Recent Findings
Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems.
Summary
Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.
Abstract Due to the increasing life expectancy, orthopaedic surgeons are more and more often confronted with fragility fractures of the pelvis (FFPs). These kinds of fractures are the result of a ...low-energy impact or they may even occur spontaneously in patients with severe osteoporosis. Due to some distinct differences, the established classifications for pelvic ring lesions in younger adults do not fully reflect the clinical and morphological criteria of FFPs. Most FFPs are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to increasing displacement, nonunion and persisting instability. Therefore, new concepts for surgical treatment have to be developed to address the functional needs of the elderly patients. Based on an analysis of 245 consecutive patients with FFPs, we propose a novel classification system for this condition. This classification is based on morphological criteria and it corresponds with the degree of instability. Also in the elderly, these criteria are the most important for the decision on the type of treatment as well as type and extent of surgery. The estimation of the degree of instability is based on radiological and clinical findings. The classification gives also hints for treatment strategies, which may vary between minimally invasive techniques and complex surgical reconstructions.
Objective
To report the successful treatment of septic nonunion in two dogs with large segmental defects secondary to long‐bone fractures by using a novel human placenta‐derived matrix (hPM) as ...adjunct to fixation.
Animals.
One 3‐kg 9‐year‐old neutered male Yorkshire terrier with a distal antebrachial fracture and one 6‐kg 4‐year‐old spayed female miniature pinscher with a distal humeral fracture.
Study design.
Short case series.
Methods
Both dogs presented for septic nonunion after internal fixation of Gustilo type II open diaphyseal fractures from dog bite injuries. During revision, debridement of nonviable bone resulted in segmental defects of 32% and 20% of the bone length for the antebrachial and humeral fractures, respectively. The antebrachial fracture was stabilized with a circular external fixator, and the humeral fracture was stabilized with biaxial bone plating. The fracture sites were not collapsed, and full length was maintained with the fixation. Autogenous cancellous bone graft and canine demineralized bone allograft were packed into the defects, and hPM was injected into the graft sites after closure.
Results
Radiographic union was documented at 8 weeks and 6 weeks for the antebrachial and humeral fractures, respectively. Both dogs became fully weight bearing on the affected limbs and returned to full activity.
Conclusion
Augmenting fixation with grafts and hPM led to a relatively rapid union in both dogs reported here.
Abstract Introduction Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 ...to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability. Patients and methods A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion. Results 28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI > 30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors ( P < 0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach. Discussion Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.
To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome.
Retrospective.
Two trauma centers.
Two hundred thirty ...consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively.
Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up.
At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients 23%, 95% confidence interval (CI): 17%-31% of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910).
Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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