Joshua Langford

Essential Nutrients for Bone Health and a Review of their Availability in the Average North American Diet

Osteoporosis and low bone mineral density affect millions of Americans. The majority of adults in North America have insufficient intake of vitamin D and calcium along with inadequate exercise. Physicians are aware that vitamin D, calcium and exercise are essential for maintenance of bone health. Physicians are less likely to be aware that dietary insufficiencies of magnesium, silicon, Vitamin K, and boron are also widely prevalent, and each of these essential nutrients is an important contributor to bone health. In addition, specific nutritional factors may improve calcium metabolism and bone formation. It is the authors’ opinion that nutritional supplements should attempt to provide ample, but not excessive, amounts of factors that are frequently insufficient in the typical American diet. In contrast to dietary insufficiencies, several nutrients that support bone health are readily available in the average American diet. These include zinc, manganese, and copper which may have adverse effects at higher levels of intake. Some multivitamins and bone support products provide additional quantities of nutrients that may be unnecessary or potentially harmful. The purpose of this paper is to identify specific nutritional components of bone health, the effects on bone, the level of availability in the average American diet, and the implications of supplementation for each nutritional component. A summary of recommended dietary supplementation is included.

Silicon: a review of its potential role in the prevention and treatment of postmenopausal osteoporosis.

Physicians are aware of the benefits of calcium and vitamin D supplementation. However, additional nutritional components may also be important for bone health. There is a growing body of the scientific literature which recognizes that silicon plays an essential role in bone formation and maintenance. Silicon improves bone matrix quality and facilitates bone mineralization. Increased intake of bioavailable silicon has been associated with increased bone mineral density. Silicon supplementation in animals and humans has been shown to increase bone mineral density and improve bone strength. Dietary sources of bioavailable silicon include whole grains, cereals, beer, and some vegetables such as green beans. Silicon in the form of silica, or silicon dioxide (SiO2), is a common food additive but has limited intestinal absorption. More attention to this important mineral by the academic community may lead to improved nutrition, dietary supplements, and better understanding of the role of silicon in the management of postmenopausal osteoporosis.

Perioperative lateral trochanteric wall fractures: sliding hip screw versus percutaneous compression plate for intertrochanteric hip fractures.

Objectives: This study was performed to determine the incidence of perioperative lateral wall fractures with a standard sliding hip screw (SHS) versus a percutaneous compression plate (PCCP) using identical meticulous closed reduction techniques in both groups. Design: Retrospective analysis of a prospective trauma registry. Setting: Urban Level I trauma center. Patients: Over a 7-year period, 337 patients with intertrochanteric hip fractures were treated with either a SHS or a PCCP at our institution. The PCCP group (Group 1) consisted of 200 patients, of which 141 (71%) had adequate images to be included in the study. The SHS group (Group 2) consisted of 137 patients, of which 100 (73%) had adequate images to be included in the study. Intervention: Closed reduction and plate application with either a standard sliding hip screw or a percutaneous compression plate for an Orthopaedic Trauma Association 31A1 or 31A2 intertrochanteric hip fracture. Main Outcome Measure: Radiographic evidence of lateral trochanteric wall fracture as measured by intraoperative and perioperative radiographs. Results: There was an overall lateral wall fracture incidence of 20% in the SHS group versus 1.4% in the PCCP group (P < 0.01). For the unstable 31A2 fracture types, there was a lateral wall fracture incidence of 29.8% in the SHS group versus 1.9% in the PCCP group (P < 0.01). Conclusions: Overall, the PCCP group had a significantly decreased incidence of lateral trochanteric wall fracture compared with the SHS group. This difference became greater when just unstable intertrochanteric fractures were analyzed. An anatomic reduction, combined with a device (PCCP) that uses small-diameter defects in the lateral trochanteric wall, essentially eliminates perioperative lateral trochanteric wall fractures.

Pelvic Fractures: Part 2. Contemporary Indications and Techniques for Definitive Surgical Management

&NA; Once the patient with pelvic fracture is resuscitated and stabilized, definitive surgical management and anatomic restoration of the pelvic ring become the goal. Understanding injury pattern by stress examination with the patient under anesthesia helps elucidate the instability. Early fixation of the unstable pelvis is important for mobilization, pain control, and prevention of chronic instability or deformity. Current pelvic fracture management employs a substantial amount of percutaneous reduction and fixation, with less emphasis placed on pelvic reconstruction proceeding from posterior to anterior, and most reduction and fixation of unstable pelvic fractures done with the patient supine. Compared with control subjects with acetabular fracture or pelvic fracture alone, patients with combined injury have a significantly higher Injury Severity Score, lower systolic blood pressure, and higher mortality rates; they are also transfused more packed red blood cells. Even with anatomic restoration of the pelvis, long‐term outcomes after severe pelvic trauma are below population norms. The most common chronic problems relate to sexual dysfunction and pain. Regardless of fracture type, neurologic injury is a universal harbinger of poor outcome.

Pelvic Fractures: Part 1. Evaluation, Classification, and Resuscitation

&NA; Pelvic fractures range in severity from low‐energy, generally benign lateral compression injuries to life‐threatening, unstable fracture patterns. Initial management of severe pelvic fractures should follow Advanced Trauma Life Support protocols. Initial reduction of pelvic blood loss can be provided by binders, sheets, or some form of external fixation, which serve to reduce pelvic volume, stabilize clot formation, and reduce ongoing tissue damage. Persistently unstable patients may benefit from angiography with selective embolization, pelvic packing, or a combination of these interventions. Open pelvic fractures involving the perineum or bowel injury benefit from fecal diversion by colostomy. Trauma team coordination facilitates efficient resuscitative efforts and may affect definitive management by optimizing incision, ostomy, or catheter placement. Established protocols for both open and closed pelvic fractures help to standardize care.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Muscle Viability Revisited: Are We Removing Normal Muscle? A Critical Evaluation of Dogmatic Debridement.

Purpose: Determination of muscle viability during debridement is a subjective process with significant consequences. Evaluating muscle color, consistency, contractility, and capacity to bleed (the 4 Cs) was established by a study performed half a century ago. This work reinvestigates the utility of the 4 Cs using current histopathologic techniques. Methods: After institutional review board approval, 36 biopsies were prospectively collected at a level-1 trauma center from 20 patients undergoing a debridement for open fracture (81%), compartment syndrome (11%), infection (5%), or crush injury (3%). Surgeons graded the biopsies using the 4 Cs, and provided their overall impression as healthy, borderline, or dead. Blinded pathological analysis was performed on each specimen. A correlation between the 4 Cs and surgeon impression with histopathological diagnosis was sought through a univariate statistical analysis. Results: The surgeons impression was dead muscle in 25 specimens, borderline in 10, and healthy in 1. Pathological analysis of the 35 specimens considered as dead or borderline muscle by the surgeon demonstrated normal muscle or mild interstitial inflammation in 21 specimens (60%). Color (P = 0.07), consistency (P = 0.12), contractility (P = 0.51), capacity to bleed (P = 0.07), and surgeon impression (P = 0.50) were unable to predict histologic appearance. Conclusions: Neither the 4 Cs nor the surgeons impression correlate with histological findings regarding muscle viability. In 72% of specimens, the treating surgeons gross assessment differed from the histopathologic appearance. Although the fate of the debrided muscle remains unclear if left in situ, these results raise questions regarding current practices, including the possibility that surgeons are debriding potentially viable muscle. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is there a role for intramedullary nails in the treatment of simple pilon fractures? Rationale and preliminary results

INTRODUCTION Certain patients with pilon fractures present with significant soft-tissue swelling or with a poor soft-tissue envelope typically not amenable to definitive fixation in the early time period. The objective of this study was to review the treatment of simple intra-articular fractures of the tibial plafond (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 43C1-C2) via intramedullary nailing (IMN) with the assessment of clinical and radiographic results and any associated complications. MATERIALS AND METHODS Retrospective clinical and radiological reviews of 31 patients sustaining AO/OTA type 43C distal tibial fractures treated with IMN were evaluated. Our main outcome measurement included achievable alignment in the immediate postoperative period and at the time of union along with complications or need for secondary procedures within the first year of follow-up. RESULTS Seven patients were lost to follow-up. All the remaining patients achieved bony union at a mean union time of 14.1 ± 4.9 weeks with no evidence of malunion or malrotation. All patients were at full-weight-bearing status at 1-year follow-up. Complications were notable for one delayed union, one non-union, one patient with superficial wound drainage, two with deep infection, one with symptomatic hardware and one with deep vein thrombosis. CONCLUSION Simple articular fractures of the tibial plafond (AO/OTA type 43C) treated via IMN can achieve excellent alignment and union rates with proper patient selection and surgical indication. One should not hesitate to use additional bone screws or plating options to help achieve better anatomic reduction. However, larger, prospective randomised trials comparing plating versus nailing, in experienced hands, are needed to completely delineate the utility of this treatment modality.

Complications of Patellar Fracture Repair: Treatment and Results

Open reduction and internal fixation (ORIF) of patellar fractures generally leads to good results; however, the potential for surgical complications exists. Nonunion, infection, posttraumatic arthritis, arthrofibrosis, symptomatic hardware, and extensor mechanism insufficiency have all been described following patellar ORIF, and the risk of their occurrence may be augmented by patient-, injury-, and treatment-related factors. When complications arise, advanced reconstructive techniques are often required for successful management. This review will report the incidence of the aforementioned complications, highlight risk factors contributing to their frequency, discuss treatment options, and present the reported results of selected treatment strategies from available literature.

Nailing of proximal and distal fractures of the femur: limitations and techniques.

Over the last 15 years, a continual evolution of nail design and techniques has made nailing at the extremes of the femur more commonplace. This evolution has yielded a better understanding and ability to control fractures of the metaphysis and, in the distal femur, even intra-articular fractures. With understanding of common pitfalls and reduction techniques, uneventful healing with anatomic alignment, rotation, and length can be achieved with nails at both far proximal and far distal fractures of the femur.