JAAOS, Volume 16, No. 11

Recent developments in the biology of fracture repair.

Fracture repair is dependent on local and systemic molecular and cellular processes. During fracture repair, mesenchymal stem cells are systemically recruited to the fracture site, and cytokines are released from the fracture site into the vascular system. In a significant minority of fractures, healing delays result from adverse clinical factors that interfere with these processes. Extrinsic factors, such as aging and smoking, adversely affect the molecular and cellular processes occurring locally in the fracture site. Fracture fixation affects healing through local changes in the biologic signaling within the fracture callus. Current biologic treatment of fractures includes the local application of osteoinductive bone morphogenetic proteins (ie, BMP-2, BMP-7) and cell-based therapies. Although clinical results with bone morphogenetic proteins have been satisfactory, they have not been as impressive as those reported in animal studies. Further understanding of the biology of fracture repair may lead to improved treatment modalities.

    • Keywords:
    • Age Factors|Aging|Animals|Anti-Inflammatory Agents

    • Non-Steroidal|Bone Morphogenetic Proteins|Fracture Fixation|Fracture Healing|Fractures

    • Bone|Humans|Microcirculation|Smoking|Stem Cells

    • Subspecialty:
    • Trauma

    • Basic Science

Extremity war injuries: challenges in definitive reconstruction.

The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft-tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft-tissue injury management, such as improvement in the use of free-tissue transfer and enhanced approaches to tissue-engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer-aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high-energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high-velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.

    • Keywords:
    • Blast Injuries|Extremities|Fractures

    • Open|Humans|Military Medicine|Osteogenesis

    • Distraction|Reconstructive Surgical Procedures|Registries|Soft Tissue Injuries|Tibial Fractures|United States|War

    • Subspecialty:
    • Trauma

Advancements in ankle arthroscopy.

Important progress has been made during the past 30 years in arthroscopic ankle surgery. Ankle arthroscopy has gradually changed from a diagnostic to a therapeutic tool. Most arthroscopic procedures can be performed by using the anterior working area with the ankle in dorsiflexion or plantar flexion; there is no need for routine ankle distraction. Anterior ankle problems, such as anterior impingement syndrome, are approached by anteromedial and anterolateral portals and, if necessary, an accessory portal. Most osteochondral defects can be reached from anterior with the ankle in plantar flexion. For a far posterior location, the osteochondral defect can be approached from posterior. The two-portal hindfoot endoscopic technique (ie, both arthroscopic and endoscopic surgery), with the patient in the prone position, provides excellent access to the posterior ankle compartment and to posteriorly located extra-articular structures.

    • Keywords:
    • Ankle Injuries|Ankle Joint|Arthroscopy|Debridement|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans|Ligaments

    • Articular

    • Subspecialty:
    • Foot and Ankle

Radiocarpal fracture-dislocations.

Radiocarpal fracture-dislocations most often are caused by high-energy trauma. These difficult, uncommon injuries involve significant soft-tissue and osseous trauma, requiring meticulous reduction and fixation. The mechanism of injury is generally a severe shear or rotational insult. Anatomically, the dislocation results in disruption of the radiocarpal ligaments and, usually, both the radial and the ulnar styloid. Understanding the anatomy of the radiocarpal joint is central to understanding the osseous and soft-tissue constraints that are disrupted with a radiocarpal dislocation. Diagnosis can be reliably made on physical examination and radiographic evaluation. Radiocarpal fracture-dislocation injuries must be differentiated from Barton fractures. Associated injuries such as open fractures, neurovascular involvement, and distal radioulnar dislocations also must be taken into account. Closed reduction can be obtained relatively easily, but open reduction and internal fixation is typically necessary to ensure accurate anatomic restoration of injured bone and ligaments.

    • Keywords:
    • Carpal Bones|Dislocations|Fracture Fixation

    • Internal|Humans|Joint Instability|Ligaments

    • Articular|Radius Fractures|Wrist Injuries

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Venous thromboembolism in spine surgery.

Venous thromboembolism is a life-threatening adverse event in spine patients and presents difficult decisions for the surgeon and patient. Prophylactic protocols have been established to prevent the occurrence of venous thromboembolism and its sequelae, including venous occlusion, edema, postthrombotic syndrome, and death. Despite the known benefits of prophylaxis, some surgeons choose not to use it because of concerns over increased bleeding complications and possible iatrogenic neurologic injury. Although mechanical prophylaxis remains an important element in venous thromboembolism prevention, low-molecular-weight heparin is better than other pharmacologic therapies in decreasing the incidence of major events.

    • Keywords:
    • Blood Coagulation|Decompression

    • Surgical|Humans|Orthopedic Procedures|Postoperative Complications|Practice Guidelines as Topic|Reconstructive Surgical Procedures|Risk Factors|Spinal Cord Injuries|Spinal Diseases|Spinal Fractures|Spine|Surgical Procedures

    • Elective|Venous Thromboembolism

    • Subspecialty:
    • Spine

Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures.

Treatment of intertrochanteric hip fracture is based on patient medical condition, preexisting degenerative arthritis, bone quality, and the biomechanics of the fracture configuration. A critical review of the evidence-based literature demonstrates a preference for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate-and-screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load-sharing intramedullary implants, this result has not been demonstrated in the current evidence-based literature.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Bone Nails|Bone Plates|Bone Screws|Femoral Fractures|Fracture Fixation

    • Internal|Fracture Fixation

    • Intramedullary|Hip Fractures|Humans|Traction|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

Antibiotic beads.

    • Keywords:
    • Aminoglycosides|Anti-Bacterial Agents|Bone Cements|Bone Diseases

    • Infectious|Comorbidity|Drug Delivery Systems|Equipment Design|Fractures

    • Open|Humans|Polymethyl Methacrylate|Soft Tissue Injuries

    • Subspecialty:
    • Sports Medicine

    • Trauma