Vassilios S. Nikolaou

Fracture vascularity and bone healing: A systematic review of the role of VEGF

SUMMARYnFracture healing constitutes a complex and delicate physiological process. Local vascularity at the site of the fracture has been identified as one of the most significant parameters influencing the healing procedure. VEGF is the most important component of the regeneration of the vascular system at the fracture site. The aim of this review is to determine the evidence supporting the direct role of VEGF in the enhancement of fracture healing and the possible clinical use of VEGF for non-unions. The literature search was performed via the internet using the Medline. The key words which were searched in the abstracts were the terms VEGF, angiogenesis, fracture, bone and healing. Twenty-five articles were relevant to the topic of interest. A total of 11 articles were excluded from our research due to non conformity of their content to the inclusion criteria. Evidence retrieved suggests that VEGF could be extremely valuable for the treatment of critical size bone defects and that VEGF could have a direct effect on osteoprogenitor cells, mainly by promoting the differentiation of osteoblasts and by increasing the mineralisation of the regenerated bone. The former observation could have very interesting repercussions for the field of non-unions and the latter for the field of osteoporosis.

The influence of osteoporosis in femoral fracture healing time

AIMnIn order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed.nnnPATIENTS AND METHODSnPatients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis.nnnRESULTSnIn all group A patients Singh score < or =4 and CBR>0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score > or =5 and CBR<0.48. Fractures of group A healed in 19.38+/-5.9 weeks (12-30) and in group B 16.19+/-5.07 weeks (10-28), P=0.02.nnnCONCLUSIONSnFracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process.

MRI efficacy in diagnosing internal lesions of the knee: a retrospective analysis

BackgroundMany surgeons tend to believe that MRI is an accurate, non invasive diagnostic method, enough to lead to decisions for conservative treatment and save a patient from unnecessary arthroscopy. We conducted a retrospective study to investigate the accuracy of the MRI of the knee for the detection of injuries of the meniscus, cruciate ligaments and articular cartilage, in comparison with the preoperative clinical examination and intraoperative findings. Between May 2005 and February 2006 102 patients after clinical examination were diagnosed with meniscal or cruciate injury and underwent definitive treatment with arthroscopy. 46 of these patients fulfilled the inclusion criteria. The accuracy, sensitivity, specificity, negative and positive predictive values of the MRI findings were correlated with the lesions identified during arthroscopy. The diagnostic performance of the initial clinical examination was also calculated for the meniscal and cruciate ligament injuries.ResultsThe accuracy for tears of the medial, lateral meniscus, anterior and posterior cruciate ligaments and articular cartilage was 81%, 77%, 86%, 98% and 60% respectively. The specificity was 69%, 88%, 89%, 98% and 73% respectively. The positive predictive value was 83%, 81%, 90%, 75% and 53% respectively. Finally, the clinical examination had significant lower reliability in the detection of these injuries.ConclusionMRI is very helpful in diagnosing meniscal and cruciate ligament injuries. But in a countable percentage reports with false results and in chondral defects its importance is still vague. The arthroscopy still remains the gold standard for definitive diagnosis.

Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience

A review of prospectively collected data in our trauma unit for the years 1998–2003 was undertaken. Adult patients who suffered multiple trauma with an Injury Severity Score (ISS) of ≥16, admitted to hospital for more than 72 hours and with sustained blunt chest injuries were included in the study. Demographic details including pre-hospital care, trauma history, admission vital signs, blood transfusions, details of injuries and their abbreviated injury scores (AIS), operations, length of intensive care unit and hospital stays, Injury Severity Score (ISS) and mortality were analysed. Fulfilling the inclusion criteria with at least one chest injury were 1,164 patients. The overall mortality reached 18.7%. As expected, patients in the higher AIS groups had both a higher overall ISS and mortality rate with one significant exception; patients with minor chest injuries (AISchestu2009=u20091) were associated with mortality comparable to injuries involving an AISchestu2009=u20093. Additionally, the vast majority of polytraumatised patients with an AISchestu2009=u20091 died in ICU sooner than patients of groups 2–5.RésuméNous avons pratiqué une revue prospective des données de notre unité de traumatologie pour lannée 1998 à 2003. Les patients présentant des polytraumatismes sévères et dont le score ISS était de 16, admis à lhôpital pour plus de 72 heures et présentant des traumatismes thoraciques ont été inclus dans cette étude. Les détails démographiques, les traitements pratiqués, lhistoire du traumatisme, les signes vitaux, les lésions vitales à ladmission, les transfusions sanguines, le détail des traumatismes selon le score AIS, les traitements en unité de soins intensifs ainsi que la durée de séjour, le score de sévérité des traumatismes et la mortalité ont été analysés. 1 164 patients présentant au moins un traumatisme thoracique ont été inclus. Le taux de mortalité a été de 18,7%. Les patients avec un score AIS élevé, associés à un score ISS élevé avaient un taux de mortalité significatif avec une exception significative pour les patients présentant un traumatisme thoracique minime (AIS thoraciqueu2009=u20091) associés à une mortalité comparable aux traumatismes de score AISu2009=u20093. De plus, la grande majorité des patients polytraumatisés avec un score AISu2009=u20091 sont décédés en unité de soins intensifs de façon plus précoce que les patients des groupes 2 à 5.

Treatment and outcomes of pelvic malunions and nonunions: a systematic review.

Although acute management of pelvic fractures and their long-term functional outcome have been widely documented, important information regarding malunion and nonunion of these fractures is sparse. Despite their relative rarity, malunions and nonunions cause disabling symptoms and have major socioeconomic implications. We analyzed the factors predisposing a pelvic injury to develop malunion/nonunion, the clinical presentation of these complications, and the efficacy of the reported operative protocols in 437 malunions/nonunions of 25 clinical studies. Treatment of these demanding complications appeared effective in the majority of the cases: overall union rates averaged 86.1%, pain relief as much as 93%, patient satisfaction 79%, and return to a preinjury level of activities 50%. Nevertheless, the patient should be informed about the incidence of perioperative complications, including neurologic injury (5.3%), symptomatic vein thrombosis (5.0%), pulmonary embolism (1.9%), and deep wound infection (1.6%). For a successful outcome, a thorough preoperative plan and methodical operative intervention are essential. In establishing effective evidence-based future clinical practice, the introduction of multicenter networks of pelvic trauma management appears a necessity.Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Innovations in osteosynthesis and fracture care.

Over the years giant steps have been made in the evolution of fracture fixation and the overall clinical care of patients. Better understanding of the physiological response to injury, bone biology, biomechanics and implants has led to early mobilisation of patients. A significant reduction in complications during the pre-operative and post-operative phases has also been observed, producing better functional results. A number of innovations have contributed to these improved outcomes and this article reports on the advances made in osteosynthesis and fracture care.

Proximal tibial fractures: early experience using polyaxial locking-plate technology

Between 2004 and 2009, 60 patients with proximal tibial fractures were included in this prospective study. All fractures were treated with the polyaxial locked-plate fixation system (DePuy, Warsaw, IN, USA). Clinical and radiographic data, including fracture pattern, changes in alignment, local and systemic complications, hardware failure and fracture union were analysed. The mean follow-up was 14xa0(12–36) months. According to the Orthopaedic Trauma Association (OTA) classification, there were five 41-A, 28 41-B and 27 41-C fractures. Fractures were treated percutaneously in 30% of cases. Double-plating was used in 11 cases. All but three fractures progressed to union at a mean of 3.2xa0(2.5–5) months. There was no evidence of varus collapse as a result of polyaxial screw failure. No plate fractured, and no screw cut out was noted. There was one case of lateral joint collapse (>10°) in a patient with open bicondylar plateau fracture. The mean Knee Society Score at the time of final follow-up was 91 points, and the mean functional score was 89 points. The polyaxial locking-plate system provided stable fixation of extra-articular and intra-articular proximal tibial fractures and good functional outcomes with a low complication rate.

Surgical techniques—How do I do it?: Open reduction and internal fixation of posterior wall fractures of the acetabulum

Posterior wall fractures are the commonest type of acetabular fracture. Nonoperative management is associated with significant complications and poor outcome. Consequently, open reduction and internal fixation has become increasingly common. In this article, inaugurating the new section of how do I do it, we present our current approach to the treatment of posterior wall fractures of the acetabulum, including the preoperative planning, the details of the operative procedure in terms of patients positioning and draping, surgical approach, osteosynthesis and wound closure.

Elderly tibial shaft fractures: Open fractures are not associated with increased mortality rates

OBJECTIVESnThis study aims to assess whether elderly patients (>65 years) with open tibial shaft fractures (OFs) have increased mortality rates than those with closed fractures (CFs).nnnPATIENTS AND METHODSnPatients admitted during 2003-2005 with open/closed diaphyseal (AO 42) fractures of the tibia were eligible to participate.nnnEXCLUSION CRITERIAnPathological and peri-prosthetic fractures.nnnRESULTSnA total of 54 patients (38 females) met the inclusion criteria. Twenty-six patients had sustained CF and 28 OF (Gustilo grade I (11), grade II (five), grade IIIa (two) and grade IIIb (10)). The OF group was statistically significantly different with higher injury severity score, secondary procedures and length of hospital stay (p<0.05). A higher rate of admission/length of stay to intensive care unit and complication rate was noted in the OF group. Mortality rate between the two groups was comparable (CF=2/26, OF=3/28).nnnCONCLUSIONSnElderly patients with OFs of the tibial shaft have similar mortality rate to those with CFs.

Fondaparinux for the Prevention or Treatment of Venous ThromboEmbolism Related to Lower Limb Trauma: Evidence Today

Patients with lower limb and pelvic trauma, or undergoing major orthopaedic surgery represent one of the highest risk groups for the development of venous thromboembolism (VTE). A significant number of pharmacological and mechanical agents have been used for the prophylaxis and treatment of VTE. Fondaparinux is a relative new pharmacological agent that selectively binds to antithrombin, and represents a new class of synthetic selective inhibitors of activated factor X. Eleven percent of the fondaparinux-related English language literature, between 2001 and 2007, refers to orthopaedic trauma, and was the sample assessed for this critical analysis review. The clinical studies evaluating the safety, efficacy, and financial implications associated with lower limb orthopaedic trauma show that fondaparinux has comparable results with the well-established use of enoxaparin. However, the scientific community has raised several issues regarding mostly fondaparinuxs safety, timing of its 1(st) dose, bleeding side effects, duration of administration and lack of a reliable reversing agent. Further trials are necessary focusing on the safety and efficacy of this drug mostly in relation to clinical relevant outcomes and to different fields of trauma surgery (pelvis, long bone fractures and polytrauma patients).