Brian H. Mullis

Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing.

Nonsteroidal anti-inflammatory drugs continue to be prescribed as analgesics for patients with healing fractures even though these drugs diminish bone formation, healing, and remodeling. Inhibition of bone formation can be clinically useful in preventing heterotopic ossification in selected clinical situations. In this regard, naproxen may be more efficacious than the traditional indomethacin, and short-term administration is as effective as long-term. When fracture healing or spine fusion is desired, nonsteroidal anti-inflammatory drugs should be avoided. Some nonsteroidal anti-inflammatory drugs have a positive effect on soft-tissue healing; they stimulate collagen synthesis and can increase strength in the early phases of repair during skin and ligament healing. Cyclooxygenase-2 inhibitors have an adverse effect on bone healing and may have an adverse effect on ligament healing. Therefore, further investigation is necessary to confirm that traditional nonsteroidal anti-inflammatory drugs may be preferable for the healing of collagenous tissues.

Hip arthroscopy to remove loose bodies after traumatic dislocation

Objectives: This study was designed to review the incidence of arthroscopically detected intra-articular loose bodies found in patients after traumatic hip dislocation or small acetabular wall fracture which would not otherwise be treated without surgery. Design: Retrospective review. Setting: Level 1 academic trauma center. Patients: Thirty-six patients who sustained traumatic hip injuries and subsequently had 39 hip arthroscopies between November 1997 and January 2004 were reviewed. Intervention: All patients had standard AP pelvis x-rays and CT scans performed. At our institution, patients with hip dislocations or acetabular wall fractures not otherwise requiring surgery are routinely offered hip arthroscopy to remove loose bodies. The radiographs were reviewed to determine incidence of loose bodies or nonconcentric reduction before hip arthroscopy. Chart review provided incidence of loose bodies found during arthroscopy. Main Outcome Measurements: Comparison was made between radiographic data obtained preoperatively and operative findings. Results: Loose bodies were found in the hips of 33 of 36 patients (92%) who were arthroscoped. Loose bodies were found in 7 of 9 cases (78%) in which standard radiographic studies (AP pelvis x-rays and CT scan) found no loose bodies and a concentric reduction. Conclusions: Loose bodies are routinely present after closed treatment of hip dislocations or wall fractures not otherwise requiring surgery, even when radiographs are negative. Hip arthroscopy may be indicated for loose body removal when open treatment is not otherwise necessary.

Hip dislocation: evaluation and management.

&NA; A simple hip dislocation is one without fracture of the proximal femur or acetabulum. Complex fracture‐dislocations involve the acetabulum, femoral head, or femoral neck. The incidence of posttraumatic arthritis is much lower in simple dislocations than in fracture‐dislocations. The most common mechanism of injury is a high‐energy motor vehicle accident, which is usually associated with other systemic and musculoskeletal injuries. The hip should be reduced emergently in an atraumatic fashion. For acetabular fracture, intraoperative stress views may be necessary to evaluate for instability and to determine whether surgical fixation is required. The appearance of a concentric reduction on plain radiographs and CT does not rule out intra‐articular hip pathology; such injury may contribute to long‐term degenerative changes. Other complications of hip dislocation include osteoarthritis, osteonecrosis, and sciatic nerve injury. Indications for surgical management include nonconcentric reduction, associated proximal femur fracture (including hip, femoral neck, and femoral head), and associated acetabular fracture producing instability. Surgical management ranges from formal open arthrotomy to minimally invasive hip arthroscopy. Hip arthroscopy has become popular for treating intraarticular hip pathology, including loose bodies, chondral defects, and labral tears.

Minimum 1-year follow-up for patients with vertical shear sacroiliac joint dislocations treated with iliosacral screws: does joint ankylosis or anatomic reduction contribute to functional outcome?

Objective: To prospectively analyze a homogenous group of trauma patients with pure sacroiliac (SI) joint dislocations treated with iliosacral screws (ISS), with specific attention to functional outcome and its correlation with the presence or absence of SI joint ankylosis and quality of reduction. Design: Retrospective chart and radiographic review of initial injury and treatment, with prospective long-term evaluation of radiographs, computed tomography (CT) scans, and functional assessments. Setting: Level One Regional Trauma Center. Patients: Twenty-three patients who were skeletally mature with traumatic vertical shear pelvic injuries associated with a pure SI joint dislocation. Intervention: Treatment consisted of closed or open reduction in the supine or prone position and insertion of a single ISS placed percutaneously for the fixation of the posterior ring injury. Main Outcome Measurement: Each patient was evaluated for functional outcome using version 2 of the Short-Form 36 (SF-36v2), the short version of the Musculoskeletal Functional Assessment (sMFA), the Iowa Pelvic Scoring System, and the Majeed Pelvic Scoring System. Additionally, at the follow-up visit, each patient received plain radiographs of the pelvis and CT scanning of the pelvis. Results: Minimum follow-up was 1 year postindex procedure (13-120 months). In this subset of patients with pure SI dislocations treated with ISS alone, anatomic reduction was the only predictor of a more favorable functional outcome (P = 0.04). Specifically, SI joint ankylosis did not affect functional outcome in these patients. Conclusions: Based on the results of this study, in the treatment of vertically displaced, pure SI joint dislocations, an anatomic reduction (whether closed or open), followed by ISS fixation should be the goal because this appears to be the only predictor of a more favorable functional outcome in patients with this injury. Complete SI joint ankylosis appears to have no effect, either positive or negative, on functional outcome in these patients.

Engineering of a 129-residue tripod protein by chemoselective ligation of proline-II helices

Abstract A 129-residue tripod protein was designed, synthesized, and biophysically characterized. This receptor-adhesive modular protein contained three 30-residue proline-II helices linked to a 9-residue proline-II helix through thioether bonds. Coupling of 6-maleimidohexanoic acid succinimido ester to cis - N α -Boc-4-amino-L-proline furnished in 77% yield the maleimido acid cis - N -Boc-4-(6-maleimidohexanamido)-L-proline (Boc-Prm), which was used in the solid-phase synthesis of the linker peptide CH 3 -CO-Pro 3 -Prm 3 -Pro 3 -***NH 2 . The leg peptide, the 40-residue thiol Gly-Arg-Gly-Asp-Ser-Pro-Gly-Tyr-Gly-Pro 30 -Cys-NH2, was also made by solid-phase synthesis. The tripod protein was prepared by Michael addition of the thiol groups of three leg peptides to the three maleimide groups of the linker peptide. By 13 C NMR spectrometry, the linker peptide was a proline-II helix, as indicated by the presence of only trans Pro-Pro resonances for its β and γ carbons. By circular dichroic spectroscopy, the model peptide CH 3 -CO-Pro 9 -NH 2 , the linker peptide, the leg peptide, and the tripod protein each contained substantial proline-II helix, as indicated by a strong negative band at 205 nm and a weak positive band at 226 nm. Since the Pro 30 proline-II helix of each leg is about 93 A long, two Arg-Gly-Asp sites on different legs of the tripod protein could be as much as ≈250 A apart.

Does Syndesmotic Injury Have a Negative Effect on Functional Outcome? A Multicenter Prospective Evaluation.

Objective: To evaluate the effect of syndesmotic disruption on the functional outcomes of Weber B, SE4 ankle fractures treated operatively. Setting: Multicenter trauma hospitals. Patients: Data were prospectively gathered during a previous, multicenter randomized trial including 242 patients (136 women, 106 men) from 9 trauma centers with operatively treated Weber B SE4 ankle fractures. There were 81 patients (35%) with syndesmotic instability confirmed intraoperatively after fibula fixation. Intervention: Functional evaluations were performed postoperatively at 6, 12, 26, and 52 weeks. The presence of symptomatic hardware and peroneal tendon discomfort was evaluated with 9–12 months of follow-up. Main Outcome Measures: Functional outcomes evaluated included Short Musculoskeletal Function Assessment (SMFA), Bother index, and American Orthopaedic Foot and Ankle Society (AOFAS) scores. The recovery curve of the 2 groups was analyzed using a mixed linear regression analysis for repeated measures and included gender and race in the model. Symptomatic hardware and peroneal tendon discomfort were compared between the 2 groups with a &khgr;2 analysis. Results: The adjusted mean linear regression analyses demonstrated that patients without a syndesmotic injury had better functional outcomes for some outcome measures. SMFA scores at 12 weeks were statistically lower in patients without syndesmotic injury (P = 0.02), but not at other visits. AOFAS scores were significantly higher (P = 0.0006), and Bother index trended toward lower results (P = 0.07) in patients without syndesmotic injury at all time points. Isolated analyses (T-tests) at 1 year demonstrated a difference in the SMFA (P = 0.04) and Bother index (P = 0.05), but not the AOFAS (P = 0.21). Men consistently demonstrated better recovery than women for all outcomes, whereas race was not significant for any measure. Symptomatic hardware and peroneal tendon irritation was not statistically different between the groups. Conclusions: The recovery curves after ankle fractures were different based on syndesmotic injury. However, the difference was at the limit of clinical significance. Syndesmotic injury has a slightly detrimental effect on outcomes of operatively treated Weber B SE4 fractures. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The role of débridement in low-velocity civilian gunshot injuries resulting in pelvis fractures: A retrospective review of acute infection and inpatient mortality

Objectives: To determine the use of surgical débridement in the management of low-velocity gunshot injuries (GSIs) resulting in pelvis fractures. Design: Retrospective chart review. Setting: Level I trauma center in a major metropolitan area. Patients: Fifty-six patients from 1991 to 2007 treated for pelvis GSIs with resulting pelvis fractures with six acute mortalities and 40 patients with at least 1-year follow-up. Intervention: Patient data were reviewed for incidence of infection related to pelvis GSIs. Information regarding surgical débridement of pelvis GSI wounds, retained foreign bodies, and/or concomitant gastrointestinal (GI) injury was analyzed for relationships of such events to infection rate. Main Outcome Measurements: Incidence of infection related to pelvis GSIs at least 1 year after GSI date. Results: Three patients (6%) developed a deep infection related to their pelvis GSIs. There were no cases of osteomyelitis. The rate of concomitant GI injuries was 36% and the overall infection rate among those with GI injuries was 12% versus 3% for those without a GI injury (P = 0.34). There were infection rates of 7% and 6% among patients who underwent surgical débridement and those who did not, respectively. Of those with GI injuries, 41% underwent primary surgical débridement and none developed infection. In the group of remaining patients with GI injuries who did not undergo débridement of their GSI wounds, two (20%) developed an infection. The mortality rate of low-energy GSIs to the pelvis was six of 53 (11%). Conclusion: There was no increased incidence of infection in the absence of aggressive surgical débridement of pelvis GSI wounds. The study also demonstrated that retained bullets and bullet fragments did not increase the risk of infection, even after penetrating the GI tract organs. Finally, this study suggests there may be an increased risk of infection related to pelvis GSIs compared with reported infection rates related to GSIs of the extremities, likely secondary to a high rate of concomitant GI injuries associated with pelvis GSIs; however, there was no incidence of osteomyelitis.

A case report: Periprosthetic acetabulum fracture with combined pelvic ring injury

Periprosthetic fractures of the acetabulum are largely underreported in the literature, none of which describes the management of such injuries associated with a pelvic ring injury. Our case report discusses our approach to managing a periprosthetic both-column acetabulum fracture associated with an open-book pelvic ring injury. Instead of a revision total hip arthroplasty, we chose to perform an open reduction internal fixation to maintain sufficient bone stock for future revision, if necessary. At 18 months postoperative follow-up, the patient was ambulating independently and had sufficient range of motion that was comparable to the contralateral hip.

Use of bioabsorbable pins in surgical fixation of comminuted periarticular fractures.

Objectives: To determine if bioabsorbable pins can be used for stabilization of comminuted articular fragments in periarticular fractures with adequate quality of fixation, while eliminating the potential complications related to use of traditional implants. Design: Multicenter retrospective review. Setting: Two Level 1 trauma centers. Patients/Participants: Institutional billing records identified all cases (83) in which bioabsorbable pins were implanted. All charts were reviewed, and all periarticular fracture cases (80 fractures in 78 patients) were included. Intervention: Open reduction and internal fixation of highly comminuted periarticular fractures, using bioabsorbable poly-p-dioxanone and poly-l-lactic acid pins to stabilize the fragments of articular surface. Main Outcome Measurements: Outcomes were determined by maintenance of articular reduction assessed at 6 weeks and 3 months; development of posttraumatic arthritis assessed radiographically and by clinical examination at 1 year postoperatively; and rates of local complications including infection, pin migration, and pin-related soft tissue complications evaluated by complete medical record review. Results: No patients showed loss of articular reduction at 6 weeks or 3 months. There were no pin-related local complications or pin migration and no instances of delayed union or nonunion. Radiographs showed 19% arthritic changes at 12 months, with 16% loss to follow-up. Infection rate was 6%. Conclusions: In highly comminuted periarticular fractures, bioabsorbable pins are an intriguing alternative to traditional fixation methods. They afford similar effectiveness in maintaining stability without evidence of pin migration or other concerns of buried metallic implants. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The properties of inducible membranes in animals and humans

Membranes form around spacers used in large bone defects. We studied the effect of the spacer material on the ability of the membrane to promote osteogenesis in an animal model and the gene expression patterns of membranes obtained from humans. Critical-sized osseous defects were created in the ulnae of 12 rabbits. Stainless steel (SS) or polymethymethacrylate (PMMA) spacers were inserted into the defects, and the animals healed for four or eight weeks. After sacrifice, samples of the membrane were grown in cell culture. Human membrane samples were collected for gene expression analyses. Cultures of rabbit membranes with bone marrow cells showed significantly greater alkaline phosphatase activity (PMMA) and mineral deposition (SS) than bone marrow cells alone. All membranes had elevated expression of osteoblast-related genes. Inducible membranes around orthopaedic implants likely contain active cells of the OB lineage and the spacer material may influence the healing properties of the membrane.