Haim Stein

Stress fractures of the femoral neck following strenuous activity.

Summary: Stress fractures of the femoral neck following sustained strenuous physical activity are uncommon. In 194 military recruits in elite basic training who had sustained 257 stress fractures, most of them in long bone diaphyses, nine such fractures were located in the femoral neck. Seven of these fractures were transverse and undisplaced, and were treated successfully by bed rest and non-weight bearing for 6–8 weeks. The other two fractures displaced into a varus position. One of them was treated successfully by manipulation and plaster of paris spica immobilization. Solid union of the fracture followed within 3 months. The second displaced fracture was treated by two successive procedures of internal fixation because it did not unite after the first intervention and slipped again into varus position. It is therefore suggested that unstable stress fractures of the femoral neck should be initially operated on and stabilized by rigid internal fixation, in order to avoid displacement and severe disability.

The surgical treatment of severe comminuted intraarticular fractures of the distal radius with the small AO external fixation device. A prospective three-and-one-half-year follow-up study.

Although fractures of the distal radius are very common, an optimal treatment has not been clearly delineated. This is a prospective study of 40 patients, mainly young and active adults, with comminuted and unstable intraarticular fractures of the distal radius. The end results of closed reduction and rigid fixation with the small AO external fixator includes 36 patients (90%) with excellent and good results. Roentgenograms of 33 of these patients showed accurate alignment of the healed fractures. Four patients (10%) had a fair functional result, with a partial restriction of the range of movement, although roentgenograms demonstrated good alignment of the healed fractures. The small AO external fixator is both a useful and convenient method for the reconstruction and treatment of comminuted intraarticular fractures of the distal radius.

Cast or external fixation for fracture of the distal radius: A prospective study of 126 cases

In a prospective 4-year study, 126 consecutive patients with a fracture of the distal radius were followed. Functional, anatomic, and radiographic final results of fixation with above-the-elbow cast immobilization were compared with the results obtained with external fixation. The results following external fixation of comminuted intraarticular fractures were better than those of similar fractures treated in a cast. Aged osteoporotic patients tolerated better residual deformities, and the clinical results had a relatively low correlation with the final anatomic alignment. We suggest that extraarticular fractures of the distal radius should be treated with cast immobilization. Comminuted intraarticular fractures of the distal radius should be treated with external fixation, which maintains accurate anatomic position until solid fracture healing is achieved.

The muscle bed--a crucial factor for fracture healing: a physiological concept.

The results of studies performed on rabbit, rat, and sheep tibiae indicate a possible contribution of viable muscle bed to the biology of callus formation, and thus, fracture healing.

Interleukin-6 modulates trabecular and endochondral bone turnover in the nude mouse by stimulating osteoclast differentiation

A great deal of evidence has been accumulating that implicates the immune system in normal and pathological bone turnover. The objective of the present study was to examine the possible involvement of cytokines produced by T lymphocytes in bone metabolism. We have chosen the immunologically compromised athymic mouse, which demonstrate sclerotic features in its trabecular bone, as the animal model for assessment of possible modulation effects of interleukin-1alpha (IL-1alpha) and interleukin-6 (IL-6) on bone and cartilage metabolism. The cytokines were applied by daily subcutaneous injections for 3 consecutive days. Histomorphometry, measuring epiphyseal trabecular bone volume (ETBV), metaphyseal trabecular bone volume (MTBV), and the width of the growth plate, and tartrate-resistant acid phosphatase (TRAP) histochemistry were used to assess parameters of bone turnover in the proximal tibia. IL-6, but not IL-1alpha, reduced ETBV and MTBV. Both IL-6 and IL-1alpha reduced the width of the growth plate. IL-6, but not IL-1alpha, increased the number of chondroclasts and osteoclasts in the primary spongiosa of the proximal tibia, as well as the number of nuclei. The resultant bone resembled that of the wild-type mouse. The results point to IL-6 as a possible regulator of bone turnover in vivo. It is suggested that the athymic mouse has a deficiency somewhere in the cascade of events leading to the production of IL-6 or, alternatively, that IL-6 replaces other factors that are supplied by T lymphocytes directly or indirectly. As T lymphocytes interact with B lymphocytes it is suggested that the athymic mouse might be appropriate for studying the in vivo effects of the immune system on normal bone metabolism.

Unilateral hinged external fixation frame for elbow compression arthrodesis: the stepwise attainment of a stable 90-degree flexion position: a case report.

We report a case of an elbow arthrodesis using a modular hinged external fixation device in a patient who sustained a complex high-energy injury. The extensive bone and soft-tissue loss and local infection precluded restoration of the articular anatomy. Other reconstructive options, including total elbow arthroplasty and allograft reconstruction, were not appropriate in this clinical situation. A transelbow hinged external fixator was applied with the elbow in extension. Subsequently, the hinge was brought gradually into 90 degrees of flexion as the elbow fused. Fixation and arthrodesis were successfully achieved by using this modular device, despite severe tissue loss and local septic complications. Furthermore, by gradually flexing the frame from full extension to 90 degrees , the need for flap coverage of the open wound was avoided.

Minimally Invasive Surgical Techniques for the Reconstruction of Calcaneal Fractures

The soft tissues play a crucial part in both the stabilization of the multiple joint surfaces of the calcaneus and in allowing propulsion as needed. Therefore, minimally invasive functional stabilization of heel bone fracture is a promising technique, which may bypass all published controversies. Experience has shown that ligamentotaxis, which means the use of mechanical forces applied to the soft-tissue envelope of fractures without the surgical disruption of the latter, contributes to fracture healing and reconstruction. Therefore, based on our results, minimally invasive techniques are useful and promising in calcaneal fracture treatment.

The Biological Basis of the Bone-Muscle Inter-relationship in the Algorithm of Fracture Healing

The biological cascade of fracture healing is intimately linked to the muscle envelope. It further depends on the preservation of stable, perpetual axial micromovements. The current study was designed to demonstrate that high molecular weight bioactive substances diffuse from the muscle envelope to initiate osteoinductive activity at experimental fracture sites. Forty-eight rats underwent an experimental fracture of the left tibia and stabilization with an intramedullary 20-gauge needle. The animals were divided into 4 groups (A-D) of 12 rats each according to the post-fracture treatment. In group A (control) no additional treatment was applied following fracture and intramedullary fixation. In groups B, C, and D, a nitrocellulose membrane of various sizes was wrapped around the fracture, separating the periosteum from the muscle envelope. The groups differed by the membrane pore size, allowing passage of the following molecular sizes: 50 kilodaltons (kDa), 12 to 14 kDa, and 3.5 kDa in groups B, C, and D, respectively. Four animals in each group were sacrificed 2, 5, and 10 weeks after the procedure for radiographic and histological evaluation of fracture healing. Radiographic evaluation revealed a decreased rate of bone synthesis that correlated with the nitrocellulose pore size. Morphological and functional analysis of the bone explants indicated poorly healed fractures in groups B, C, and D. Direct contact between fractured bone and its muscle envelope is essential for the biological sequence of new bone formation. The extent of obstruction between the fracture and its muscle envelope correlates with the delay in fracture healing.

Vascularized Muscle Pedicle Flap for Osteonecrosis of the Femoral Head

Osteonecrosis is a devastating, locally progressive degenerative condition that mainly affects young adults. Osteonecrosis of the femoral head requires biological hip reconstruction. This article describes a technique that uses a vascularized muscle pedicle flap as a viable bone graft for treatment of this condition.

Extreme Bone Lengthening Using Distraction Osteogenesis After Trauma: A Case Report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 × 20 cm. An acute shortening using a 50° angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.