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Long bone metastases are a disease of high social importance. The goals of surgical treatment are to relieve pain, maintain or restore joint function, and prevent or treat pathological fractures. "Oligometastases" is a disease with a limited number (3-5) of metastatic lesions in the same body district, where an aggressive treatment can be carried out with "curative" intent. This study aimed to evaluate patients with bone metastases surgically treated to determine how surgical treatment can influence prognosis and quality of life, comparing solitary metastasis, oligometastases, and multiple metastases.This is a retrospective analysis of 130 patients with long bone metastases surgically treated between October 2015 and August 2019: 40 patients had solitary metastasis; 38 had less than three metastases (oligometastases), and 52 had multiple metastases. Surgery was resection and reconstruction with a cemented prosthesis (95) or nailing (35).Overall survival was significantly better in patients with solitary metastasis or oligometastases than in those with multiple metastases (p0.0001). Patients treated with resection and prosthesis had significantly better survival than those treated with nailing (p0.0001). Implant complications requiring surgical revision occurred in 20 patients treated with prostheses, while no complications occurred in patients treated with nailing.Survival of cancer patients has improved in the last two decades, leading to an increase of diagnosed metastases. Patients with oligometastases have a survival similar to those with a single metastasis. Optimal implants survival curves should stay above the curves of patients survival.Since there are no differences in survival, patients with oligometastases should be treated as patients with a solitary lesion, with more aggressive surgery (wide resection and reconstruction with prosthesis). Intramedullary nailing is still indicated in metaphyseal or diaphyseal metastases in patients with advanced disease or poor prognosis when the life expectancy does not overcome the expected survival of the nail, avoiding the need for further surgery.

Background It is recommended to have 6 bicortical screws for plate fixation of long bone fractures; however, many metacarpal fractures do not allow 6 screws due to size limitations and proximity of crucial anatomical structures. The purpose of this biomechanical study was to determine whether the mechanical properties of a 4-screw nonlocking construct are noninferior to those of a 6-screw nonlocking construct. Methods Metacarpal sawbones were used to simulate a midshaft, transverse fracture. Nonlocking bicortical screws were placed in the 6-hole plate, and the metacarpals were randomly assigned to 2 equal study groups: (1) 4 screws, 2 on either side of the fracture (4S); and (2) 6 screws, 3 on either side of the fracture (6S). The metacarpals were tested in a cyclic loading mode and load to failure in a cantilever bending mode. Results Maximum deflection was significantly higher for 4S compared with 6S. Cyclic root mean square (RMS) was also significantly greater for 4S at 70 and 100 N. There were no statistically significant differences observed between the 2 constructs for maximum bending load, bending stiffness, and cyclic RMS at 40 N. The maximum bending load in 4S and 6S was 245.6 ± 37.9 N and 230.8 ± 41.9 N, respectively; 4S was noninferior and not superior to 6S. Noninferiority testing was inconclusive for bending stiffness. Conclusions A 4-screw bicortical nonlocking construct is noninferior to a 6-screw bicortical nonlocking construct for fixation of metacarpal fractures, which may be advantageous to minimize disruption of soft tissues while maintaining sufficient construct stability.

Background There is a need for a novel therapeutic strategy for an earlier prediction of long bone union failure as compared to previous methodologies. This study aimed to determine whether a combination of two diagnostic tools would result in a more accurate diagnosis of delayed union. Methods The inclusion criteria were as follows: patients with tibial shaft fracture who underwent treatment with intramedullary nailing (IMN) as definitive internal fixation (IF). The study included a total of 114 patients with 116 tibial shaft fractures treated with IMN as definitive IF. Radiographic apparent bone gap (RABG) and nonunion risk determination score (NURDS) can be used to predict nonunion. However, this study aimed to determine whether combination of RABG and NURDS could help deduce a more accurate prediction of delayed union. Results The union rate was found to be 85% (99 fractures), the delayed union rate was found to be 15% (17 fractures), and the rate of nonunion requiring additional surgical intervention was estimated to be 4% (5 out of the 17 delayed union cases). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RABG were found to be 82.3%, 76.0%, 36.8%, and 96.2%, respectively, when an RABG cutoff value of 5.0 mm was applied to our patient cohort. The sensitivity, specificity, PPV, and NPV of NURDS were found to be 47.1%, 82.0%, 30.8%, and 90.1%, respectively, when a NURDS cutoff value of 8.0% was applied to our patient cohort. When RABG and NURDS were above their respective cutoff values, the sensitivity and PPV were estimated to be 90.0% and 56.3%, respectively. When RABG and NURDS were below their respective cutoff values, the specificity and NPV were estimated to be 90.1% and 98.5%, respectively. Conclusions The combination of RABG and NURDS evaluation immediately after surgery helps surgeons identify patients who are at a high risk of delayed union, facilitating careful monitoring of these patients and consideration of additional treatments.

A full-term male infant born from consanguineous Saudi parents, with one other live child, is suspected to have skeletal dysplasia on a fetal anomaly scan. Clinical findings at birth included short stature, bowed long bone affecting the lower limbs more than the upper limbs, severe joint contractures with restricted movement, failure to thrive, hypertonia, and camptodactyly of the index fingers. During infancy, the baby is noted to have sucking and swallowing difficulties necessitated nasogastric tube feeding, and recurrent respiratory distress episodes with frequent admissions due to respiratory failure required intensive care admission and mechanical ventilation. The skeletal survey demonstrated dysplasia of long bones and spine. To investigate a suspect genetic syndrome, a whole-exome sequencing test was performed, which identified a novel homozygous mutation in the LIFR gene.

Masquelet technique is one of the modalities for the treatment of long bone defect. However, using cancellous bone graft to fill the bone defect is always a concern in children due to the small size of their iliac crest and open growth plate. We reported a case of 13-year-old male who presented with gap non-union of middle third of tibia. We applied a modified Masquelet technique by using only the cortical fibular graft instead of cancellous bone to fill the space surrounded by induced membrane. Fibula was used as a nonvascularized strut graft and matched stick graft to achieve complete union. We concluded that nonvascularized fibula grafting is an easy and effective option to fill the bone defect in children in the second stage of Masquelet technique.

Background Variants in PAPSS2 (3’-PhosphoAdenosine 5’-Phosphosulphate Synthetase 2) present with varying degrees of brachyolmia (short trunk, platyspondyly, mild long bone abnormalities). Our objective is to present the phenotype of male and female siblings with the same novel inactivating variant in PAPSS2. Case report A Jordanian female (case 1), born to consanguineous parents, was referred at 10 years for short stature (SS). She had normal laboratory work up including normal growth hormone (GH) stimulation testing. Spine x-rays done for clinical scoliosis revealed platyspondyly. She attained an adult height of 143.5 cm (-3 SDS). Years later, her brother (case 2) was referred at 21 months of age for SS. His laboratory work up and bone age were normal. His growth velocity declined at 6 years of age, but normal growth factors did not suggest GH deficiency. He returned during puberty and disproportionate body measurements were noted. The skeletal survey revealed platyspondyly, increasing suspicion for growth plate pathology. Exome sequencing in the family revealed a homozygous variant, p.His496Pro (H496P) in PAPSS2 (NM_004670.3:c.1487A>C). Both parents are carriers of the same variant. Discussion PAPSS2 assists with the sulfonation of dehydroepiandrosterone (DHEA) to dehydroepiandrosterone sulphate (DHEA-S) and the sulfonation of proteoglycans in the cartilage, necessary for endochondral bone formation. PAPSS2 inactivating variants present with skeletal dysplasia and elevated DHEA. Conclusion This novel variant in PAPSS2 manifested with mild brachyolmia but disproportionate SS in male and female siblings. Biochemical phenotype with low circulating DHEA-S and high DHEA levels reflect the sulfonation defect.

Las fracturas de diáfisis tibiales cerradas son las fracturas de huesos largos más comunes, siendo a su vez las fracturas de espina tibial (FET) que conllevan a inestabilidad y artrosis en la rodilla si no es tratada adecuada y oportunamente. El estudio fue observacional descriptivo con una población de 33 pacientes con fractura de espina tibial. De acuerdo con la clasificación de Meyers y Mc-Keever, el tipo I donde no existe desplazamiento y sólo el labio anterior de la espina están ligeramente elevado, sin exposición, fue el tipo de fractura más frecuente. Se obtuvo que el hueso tibial izquierdo fue ligeramente más frecuente (51,5 %) respecto al del lado derecho; el mecanismo de lesión más frecuente fue la hiperextensión de la rodilla (60,6 %), las causas más frecuentes de la lesión fueron accidente tránsito y la lesión deportiva (ambas representaron el 27,3 %). El 78,8 % de las fracturas no fueron expuestas y de acuerdo con la clasificación de Meyers y McKeever, el tipo I fue el tipo de fractura más frecuente (57,6 %). Dentro de las afecciones que suelen acompañar a la fractura de espina tibial, sólo un 15 % presentó afección meniscal y; sólo un 12 % presentó afección al platillo tibial.

To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion.Retrospective chart review.Level 1 trauma center.Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant.Surgical debridement and placement of a type of antibiotic-coated intramedullary implant.Union and need for reoperation.At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods.Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Остеосинтез (osteosynthesis; греч. osteon (кость) + synthesis (соединение)) — это хирургическое соединение отломков костей в правильном положении с целью стабильной фиксации до полной их консолидации (костного сращения) и восстановления целости и функции кости. Обследовано 34 больных в возрасте 17–58 лет с гнойными осложнениями после остеосинтеза при переломах длинных костей, в том числе у 29 мужчин и 5 женщин. В сыворотке кpови больных определяли следующие биохимические показатели: активность коллагеназы, фpакции гидpоксипpолина, гликозаминогликаны, кальций, фосфор и электролиты (Na+, K+, Ca++).Результаты исследования показывают, что у больных с гнойными осложнениями после остеосинтеза длинных костей при рецидиве воспалительного процесса усиливается катаболическая фаза метаболизма основных компонентов органической основы костной ткани. Об этом свидетельствуют показатели, отражающие синтетическую и катаболическую фазы метаболизма основных компонентов соединительной ткани — коллагена и гликозаминогликанов. Данные, полученные при исследовании минерального обмена, отражают нарушения минерализации костной ткани, что подтверждается показателями содержания общего кальция, ионизированного кальция, фосфора и электролитов.

PURPOSE: The aim of this study was to investigate the prevalence of long bone fractures among cats, presented at the Small Animal Clinic, Faculty of Veterinary Medicine, Trakia University, a center that attracts cases from all over Bulgaria, and to analyze their seasonal, breed-, sex- and age-related distribution. METHODS: The study cohort comprised 267 cats with long bone fractures. All patients were analyzed retrospectively for a period of five years (2016 to 2020). Data about cat signalment (breed, sex, age, body weight) and fractured bone were evaluated. RESULTS: The cases with fractured femur were statistically significantly (p=0.0001) more prevalent (n=139; 52.06%) than those of all other affected long bones. Long bone fracture tended to occur most commonly in male (54.68%), than female (45.32%) cats. Statistically significantly (p

Introduction: The most prevalent benign tumour affecting the metaphysis of long bone is osteochondroma, a form of cartilaginous tumour. Solitary or multiple osteochondromas can prevail.Hereditary multiple exostosis (HME) or familial osteochondromatosis is the multiple variant, which is an autosomal dominant syndrome. Case Presentation: A 35-year old female with right-hand dominance was referred todepartment of physiotherapy. On palpation small nodular swelling of marble size was present in left axilla. X-rays findings showed increased scapular mass and ribs were compressed laterally. Discussion: The most widespread benign tumour is osteochondroma. In 3.0-6.4 percent of all instances, the scapula is implicated. The osteochondroma normally develops on the scapula's anterior aspect. The scapula osteochondroma induces pain and a grating sound when the scapula is moved. Mechanic irritation of muscle, tendon, or soft tissue, emergence of a pseudoaneurysm or bursa, fracture, or malignant transformation are all causes of symptoms. Conclusion: Osteochondroma is a common benign tumor. Management of osteochondroma is important to improve the quality of life. Physiotherapy plays an important role in managing Scapular osteochondroma.

Hypophosphatemic rickets is a hereditary disease of childhood that affects bone metabolism. Patients with this disease can have poor bony healing at growth centers due to impaired mineralization of the cartilaginous bone plates. The orthopedic literature has shown appropriate long bone healing in patients with rickets who are undergoing concurrent medical management. However, there has never been a report of successful osteotomy or fracture of the maxillomandibular skeleton in a patient with rickets with documented radiographic and clinical resolution. This report describes a case of successful Le Fort I osteotomy with bilateral mandibular sagittal split osteotomies with concurrent medical management in an 18-year-old female with hypophosphatemic rickets. Before surgery the patient was consented and understood that because there has never been a documented case such as this, she might especially risk complications including non-union, malunion, or unfavorable osteotomy splits. The intraoperative quality of the patient's bone was of normal caliber and allowed routine osteotomy creation and internal fixation with no complications. She was followed for over 3 years and showed uneventful healing. While this disease is especially rare, practitioners should be aware that acceptable healing alongside appropriate medical management has been documented.

Florid reactive periostitis ossificans (FRPO) is a benign juxta-cortical lesion of unknown etiology which most commonly occurs in the hands and feet. We report the radiographic, CT, and MR features of a pathologically confirmed FRPO in the distal femur, a location in which only a handful of cases has been reported. A 26-year-old male who presented with distal thigh pain initially underwent radiograph and CT, which illustrated a well-circumscribed, ossified lesion associated with the cortex of the femur without contiguity with the medullary canal. A subsequent MRI demonstrated heterogeneous signal intensity corresponding to the ossified portion of the lesion with a T2 hyperintense cartilaginous cap and surrounding edema. The lesion was surgically excised and pathologic diagnosis of FRPO, a mixture of osteoid, mature bone, cartilage and fibrous tissue, with associated inflammatory cells, was confirmed. Follow up four months after surgery revealed significant improvement in the patient's pain.

This is the repository associated with the paper of the same name (DOI: 10.1002/oa.2942, see citation information below). Thanks to Ailidh Hathway, Ellie Gooderham, and Jolyane Saule for reviewing draft of these files.

Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account.We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls.The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes.Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020;15(2):106-116.

Background Progressive maturation of growth plate chondrocytes drives long bone growth during endochondral ossification. Signals from the Epidermal Growth Factor Receptor (EGFR), and from Bone Morphogenetic Protein-2 (BMP2), are required for normal chondrocyte maturation. Here, we investigated cross-talk between EGFR and BMP2 signals in developing and adult growth plates. Results Using in vivo mouse models of conditional cartilage-targeted EGFR- or BMP2- loss, we show that canonical BMP signal activation is increased in the hypertrophic chondrocytes of EGFR-deficient growth plates; whereas EGFR signal activation is increased in the reserve, prehypertrophic and hypertrophic chondrocytes of BMP2-deficient growth plates. EGFR-deficient chondrocytes displayed increased BMP signal activation in vitro, accompanied by increased expression of IHH, COL10A1 and RUNX2. Hypertrophic differentiation and BMP signal activation were suppressed in normal chondrocyte cultures treated with the EGFR ligand betacellulin, effects that were partially blocked by simultaneous treatment with BMP2 or a chemical EGFR antagonist. Conclusions Cross-talk between EGFR and BMP2 signals occurs during chondrocyte maturation. In the reserve and prehypertrophic zones, BMP2 signals unilaterally suppress EGFR activity; in the hypertrophic zone, EGFR and BMP2 signals repress each other. This cross-talk may play a role in regulating chondrocyte maturation in developing and adult growth plates. This article is protected by copyright. All rights reserved.

Introduction: Chronic osteomyelitis is a challenging condition in the orthopedic practice and traditionally treated using local and systemic antibiotics in a two-stage surgical procedure. With the introduction of the antimicrobial biomaterial S53P4 bioactive glass (Bonalive®), chronic osteomyelitis can be treated in a one-stage procedure. This study evaluated the mid-term clinical results of patients treated with S53P4 bioactive glass for long bone chronic osteomyelitis. Methods: In this prospective multi-center study, patients from two different university medical centers in the Netherlands were included. One-stage treatment consisted of debridement surgery, implantation of S53P4 bioactive glass, and treatment with culture-based systemic antibiotics. If required, wound closure by a plastic surgeon was performed. The primary outcome was the eradication of infection, and a secondary statistical analysis was performed on probable risk factors for treatment failure. Results: In total, 78 patients with chronic cavitary long bone osteomyelitis were included. Follow-up was at least 12 months (mean 46; standard deviation, SD, 20), and 69 patients were treated in a one-stage procedure. Overall infection eradication was 85 %, and 1-year infection-free survival was 89 %. Primary closure versus local/muscular flap coverage is the only risk factor for treatment failure. Conclusion: With 85 % eradication of infection, S53P4 bioactive glass is an effective biomaterial in the treatment of chronic osteomyelitis in a one-stage procedure. A major risk factor for treatment failure is the necessity for local/free muscle flap coverage. These results confirm earlier published data, and together with the fundamentally different antimicrobial pathways without antibiotic resistance, S53P4 bioactive glass is a recommendable biomaterial for chronic osteomyelitis treatment and might be beneficial over other biomaterials.

AIM: Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS: A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS: Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION: In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria. pmid: 34531088 ispartof: INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED vol:52 issue:11 pages:3200-3205 ispartof: location:Netherlands status: published

Objective To evaluate the operative methods and clinical results of surgical treatment in a case series of 10 patients with hemophilic pseudotumors. Methods Ten patients with hemophilic pseudotumors who received surgical resection treatment in our hospital from October 2017 to June 2020 were retrospectively reviewed. All patients were hemophilia A (factor VIII deficiency).The age range was 20–51 years. Preoperative imaging examination revealed the size of irregular mass from 8.2 cm× 3.3 cm× 2.3 cm to 22.3 cm× 15.5 cm× 17.0 cm. With the supplementary of recombinant coagulation factor VIII, five cases received complete resection; one received resection and skin grafting; one received cytoreduction surgery as the pseudotumor closing to iliac vessel and nerve; three cases received complete resection and construction as bone destruction. The perioperative variables were recorded and all the patients were followed in the outpatient clinic. Clinical and radiological assessments were conducted. Results In these patients, the average intraoperative blood loss volume was 783.1 mL (range, 240–2100 mL). Six patients received blood transfusion during perioperative period. The average duration of surgery was 140.7 min (range, 110–240 min). All wounds healed smoothly and there was no infection or chronic sinus formation. The average length of hospital stay was 16.3 days (range, 12–25 days). There is no iatrogenic vascular nerve injury in our series. Complete follow‐up was performed in all patients. Mean follow‐up duration was 14.2 months (range, 6–26 months). One patient with pseudotumor in the thigh had a recurrence 1 year after operation, then secondary operation was performed. In three cases who received complete resection and construction, patient 8 obtained bone graft and late fixation. X‐ray examination showed bone formation in the lesion at the 2‐year follow‐ups after operation. Patient 9 underwent knee replacement, his left knee showed flexion deformity in preoparation. At the last follow‐up, range of motion was improved from 0° to 40° compared with preoperative status. Patient 10 had pseudotumor in the distal femur, received long bone graft and intramedullary nail fixation. Conclusions Surgical resection for hemophilic pseudotumors is an effective and safe method. The choice of surgical procedure must be individualized according to the localization and progress of pseudotumor., Pseudotumors occur in 1% to 2% of patients with severe hemophilia and they are associated with encapsulated blood after bleeding in soft tissue or subperiosteum. There are three kinds of pseudotumors: Type I, a simple cyst which develops within the muscle; Type II, a cyst that develops in a muscle and has an extensive blood supply in region of its attachment to a bone, which leads to compression to cortex and thinning of the cortex of bone; Type III, which starts as subperiosteal hemorrhage and destroys the structure of the underlining bone, and is considered as true pseudotumor, and originate from the bone itself. Due to the enlarged cyst resulting in compression of bone, pseudotumors often lead to bone structure erosion and fracture. Treatment for this type of hemophilic complication is very difficult due to its rarity.

Fracture-related infection (FRI) is a feared complication with substantial clinical and economic consequences. The main objective of this study was to compare direct and indirect healthcare costs related to long bone fractures in patients with and without FRI and to assess its impact on the patient's quality of life (QoL).Between January 2015 and March 2019, 175 patients with FRI were treated at the University Hospitals Leuven (Belgium). Using a matched-pair analysis, patients with an FRI were matched by age, sex, and fracture location (humeral, femoral, or tibial shaft) to a non-FRI cohort treated during the same time period. Clinical and process-related variables, direct hospital-related healthcare costs, and indirect costs due to absenteeism were compared between the two groups. Furthermore, the patient's QoL was evaluated using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference.After matched-pair analysis, 15 patients in both the FRI and non-FRI group were included. FRI was associated with direct hospital-related costs being eight times that of non-FRI patients (€ 47,845 [€ 43,072-€ 82,548] vs. € 5,983 [€ 4,519-€ 8,428], p 0.001). Furthermore, FRI was associated with prolonged absenteeism (340 [340-676] vs. 86 [65-216] days, p = 0.007) and a median indirect cost that was nearly four times that of patients without FRI (€ 77,909 vs. € 19,706). Lastly, FRI patients showed significantly poorer outcomes on both physical function (35.6 vs. 48.4, p 0.001) and pain interference (60.4 vs. 46.3, p 0.001) PROMIS scales.Direct hospital-related healthcare costs of FRI are eight times that of non-FRI long bone fractures. Total healthcare costs are mainly driven by hospitalisation costs, wherein FRI is associated with prolonged length of stay. To the best of our knowledge, this study is the first to demonstrate that FRI is also associated with substantial absenteeism, which is almost four times higher compared to non-FRI patients. In addition to this economic impact, FRI significantly deteriorates QoL. Generalizing the outcome of this study should be done cautiously due to the small sample size of 15 patients in both the FRI and non-FRI group after matched-pair analysis.

Summary Background Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. Methods This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. Results Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10–20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. Conclusions Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

Lower limb long bone fractures are vulnerable for venous thromboembolism leading to pulmonary thromboembolism. Here, we present a case of preexisting pulmonary thromboembolism with pulmonary artery hypertension posted for bipolar hemiarthroplasty.In hemodynamically stable patients it is better to operate the underlying fracture early to avoid recurrence and worsening of pulmonary thromboembolism. This case was successfully managed under general anesthesia. Keywords : Pulmonary thromboembolism, Pulmonary artery hypertension, Bipolar hemiarthroplasty, Computed tomography pulmonary angiography, General anesthesia.

The problem of long bones fractures treatment remains actual, despite a significant number of studies carried out on this topic. Such fractures of the musculoskeletal system occur more often and are accompanied by various complications, significantly compromise the quality of patients life and often lead to the disability. Objective. To analyze different types of traumatic injuries in patients with the consequences of long bone fractures, to evaluate the effectiveness of diagnostics, treatment and to analyze the state of disability. Methods. A retrospective medical and social analysis of theresults of treatment of 333 patients (232 (69.6%) men, 101 (30.4%) women) with the consequences of long bone fractures, based on theobtained study group in the Kharkiv Regional Center for Medical and Social Expertise № 2, for the period 2018–2019. Results. Three main methods of surgical treatment were analyzed: internal fixation (ORIF), blocking intramedullary nailing (IMN) and treatment with external fixation devices (EF). They were applied in thefollowing rate: ORIF — 204 (61.3%) cases, IMN — 98 (29.4%), EF— 31(9.3%). The most typical complications of the treatment of patients with fractures of the long bones were delayed union or nonunion, neuropathies of the treated extrimities, joint contractures, osteoarthritis of adjacent joints, deformities of affected extrimities, osteomyelitis. Causes of disability were: 63% — severity of injuries, 46% — different posttraumatic complications, 6.5%— iatrogenic complications. Among the latter, the most common were: diagnostic — 7.1%, incorrect method of treatment — 29.7%, iatrogenic incorrect surgery methods — 45%. Conclusions. The data obtained showed that the improvement of organization measures for the prevention of complications and disability in patients with consequences of long bones fractures could help to increase the efficiency and quality of specialized medical help. Key words. Fractures, long bones, limbs, consequences, complications, disability., Проблема лікування переломів довгих кісток кінцівок залишається актуальною, незважаючи на значну кількість проведених досліджень. Такі переломи серед усіх ушкоджень опорно-рухової системи трапляються найчастіше та супроводжуються розвитком різноманітних ускладнень, які значно погіршують якість життя хворих і часто призводять до інвалідності. Мета. Проаналізувати різні типи травматичних ушкоджень у хворих із наслідками переломів довгих кісток кінцівок (НПДКК), оцінити ефективність діагностики, методів лікування, а також стан інвалідності й основні причинні чинники її розвитку. Методи. Проведено ретроспективний медико-соціальний аналіз результатів лікування 333 пацієнтів (232 (69,6 %) чоловіки, 101 (30,4 %) жінка) із НПДКК за матеріалами Харківського обласного центру медико-соціальної експертизи № 2 у період 2018–2019 рр. Результати. Проаналізовано три основні методи хірургічного лікування переломів: накістковий остеосинтез (НО), блокувальний інтрамедулярний остеосинтез (БІОС) ілікування апаратами зовнішньої фіксації (АЗФ). Загалом застосовано: НО — 204 (61,3%) випадки, БІОС — 98 (29,4%), АЗФ— 31(9,3%). Визначено найбільш типові ускладнення лікування хворих із переломами довгих кісток кінцівок: уповільнене зрощення/незрощення, невропатії сегментів кінцівок, контрактури суглобів, деформівний артроз суміжних суглобів, осьові деформації сегментів кінцівок, остеомієліт. Причинами призначення інвалідності стали: 63% — тяжкість ушкоджень, 46%— різні типи ускладнень, 6,5%— лікарські помилки. Серед останніх найбільш типовими були: діагностичні — 7,1%, неправильний вибір методу лікування— 29,7%, порушення техніки виконання операцій — 45%. Висновки. Одержані даніпоказали, що удосконалення комплексу організаційних заходів щодо профілактики виникнення ускладнень та інвалідності ухворих ізнаслідками переломів довгих кісток кінцівок сприятиме підвищенню ефективності та якості надання спеціалізованої медичної допомоги. Ключові слова. Переломи, довгі кістки, кінцівки, наслідки, ускладнення, інвалідність

Background The management of an infected nonunion of long bones is difficult and challenging. A staged procedure comprising radical debridement followed by definitive internal fixation was favored. However, no standard treatment has been established to determine the appropriate waiting period between initial debridement and definitive internal fixation. We propose a management method that incorporates early definitive internal fixation in infected nonunion of the lower limb. Methods Thirty-four patients (28 men and 6 women; mean age 46.09 years; range 25–74 years) with infected nonunion of the tibia or femur were included. Initial infected bone resection and radical debridement were performed in each patient in accordance with the preoperative plans. Definitive surgery was performed 2–3 weeks after the resection (4 weeks after flap surgery was required), and a third surgery was performed to fill the bone defect through bone grafting or transport (three-stage surgery). In cases of unplanned additional surgery, the reason for the requirement was analyzed, and radiological and functional results were investigated in accordance with the Association for the Study and Application of the Method of Ilizarov criteria. Results Bone union was achieved in all patients, and treatment was conducted as planned preoperatively in 28 patients (28/34, 82.35%). The mean interval between primary debridement and secondary definitive fixation was 2.76 weeks (range 2–4 weeks). Six unplanned additional surgeries were performed, and the infection relapsed in two cases. The radiological and functional outcomes were good or better in 32 and 31 patients, respectively. Conclusions Early definitive surgery can be performed to treat infected nonunion by thorough planning and implementation of radical resection, active response to infection, restoration of defective bones, and soft tissue healing through a systemic approach.

Background: Reconstruction of stature from broken fragments of bones is used as a part of the analysis in forensic anthropology for the purpose of identification of an individual. Long bones are traditionally used for estimation of stature. Long bones such as femur and tibia are the most important components of an individual’s stature. In the present study, regression equation was derived for estimation of maximum femoral length from measurements of the proximal end of femur. Aims and Objectives: To derive regression equations using femur length from measurements of neck-shaft angle and maximum vertical diameter of femur head. Materials and Methods: Two hundred unpaired femurs, devoid of gross pathology and irrespective of gender obtained from the Department of Anatomy of both VMKVMC &VMHMC were used for this study. The correlation coefficients of the neck-shaft angle and maximum diameter of head of femur to the maximum length of femur was calculated. These co-efficient were used for formulation of regression equation. Results: The present study was done to show that the maximum length of femur can be best calculated from the metric evaluation of vertical diameter of the head when the proximal fragments are available. The parameters in our study which includes maximum vertical diameter of the head showed positive correlation but the neck- shaft angle showed a low correlation and is not reliable to measure MFL from it. Conclusion: The present study concludes that the maximum length of femur can be best calculated from the metric evaluation of vertical diameter of the head when the proximal fragments are available.

Aging induces changes in bone. Growth hormone (GH) is reduced by aging, and age-related changes observed in old bones might be due to a decrease in the GH/insulin-like growth factor-I (IGF-I) axis. GH administration on aged individuals is controversial. This study aimed to assess the effect of systemic GH treatment on bone properties, bone metabolism, and bone mineral density (BMD) in long bone of old rats. Aged Wistar rats were treated with GH at a dose of 2 mg/kg/day during 10 weeks. Plasma osteocalcin, IGF-I, and carboxy-terminal telopeptide of type I collagen levels were measured. Cross-sectional bone areas and BMD were measured by morphometric and densitometric analysis, respectively. Femora were analyzed by three point-bending testing. t-Test was used for statistical evaluation. p < 0.05 was considered to be significant. Significantly enhanced bone area, at the expense of the cortical area, was found in treated rats. The densitometric analysis showed 11% higher BMD in the experimental group. Significantly higher bone flexural modulus, stiffness, and ultimate load were observed in the treated rats. Plasma osteocalcin and IGF-I levels were significantly increased in the treated group, while the resorption marker concentration remained unchanged. Within the limitations of this experimental study, systemic GH administration has shown to enhance biomechanical properties, BMD, cortical mass, and plasma IGF-I and osteocalcin in old treated rats, compared to the control group; consequently, GH could be considered as an alternative therapy against age-related changes in the bone.

Background Following traumatic bone loss or removal of bone tumors, the failure of bone allograft transplantation for large bone defect repair remains a significant problem in orthopedics. Therefore, new strategies that can efficiently enhance allograft healing and long-term incorporation are critically needed. Method In this study, we first injected Notch-activating Jagged1 peptide to mice and then isolated bone marrow tissues and cells for proliferation and differentiation assays. Femur bone allograft surgery was also performed in Jagged1 pre-treated mice, and bone defect healing process were monitored by histology, Micro-CT and biomechanical testing. Result Our results showed that Jagged1 therapeutic injection is sufficient to maximally activate Notch and promote bone marrow stromal cell proliferation in vivo, while no effects on bone structure were observed. More importantly, Jagged1 pre-treatment significantly promoted bone callus formation and increased bone mechanical strength during allograft healing in a femur bone defect mouse model. Conclusion This study reveals that Notch in vivo activation can be induced by injection of Jagged1 peptide for expansion of local native stromal cells that will significantly enhance bone callus formation. The Translational potential of this Article The clinical uses of this therapeutic strategy would be immediately applicable for chronic long bone defect repair. More importantly, this devised strategy for expansion of endogenous BMSCs can also be applied to enhance other tissue and organ repair.

Aim: To investigate the effectiveness of the non-union scoring system (NUSS) in predicting the result and in guiding the treatment by comparing the treatment methods applied to non-union patients we treat in our clinic with the treatment methods suggested by the NUSS. Methods: The study included 116 patients, who were diagnosed with long bone (femur, tibia and humerus) non-union and treated in our clinic. Of the 116 patients with non-union, 48 had femur (41.38 %), 39 had tibia (33.62%) and 29 had humerus (25%) non-union. The patient scores were calculated according to the NUSS criteria. The patients were divided into four groups according to their total scores. There were 34 patients in the first group (0-25 points), 49 patients in the second group (26-50 points), 30 patients in the third group (51-75 points) and three patients in the fourth group (76-100 points). Results: Union that was achieved in 79 (68.10%) of all patients was detected in 97.05% of the patients in the first group, 83.67% in the second group, and 16.66 % in the third group. Amputation, arthroplasty and arthrodesis were applied to three patients in the fourth group. While union rate was 100 % in the femur and tibia in the first group, it was 90% in the humerus. The union rates were 85.71% in the humerus, 75% in the femur and 100% in the tibia in the second group. They were 20 % in the humerus, 15.38% in the femur and 16.66% in the tibia in the third group. The number of patients treated with the treatment proposed by the NUSS: 100% in the group 1, 83.67% in the group 2, 20% in the group 3 and 100% in the group 4. The risk of non-union in those who were not treated according to the NUSS recommendations was 28 times higher than that of others. Conclusions: The results of our study suggest that more frequent use of the NUSS procedure in non-union treatment planning may increase treatment success. In addition, NUSS can provide information about the treatment process of non-unions.

Background and Objectives: Fracture of Tibia shaft are the most common long bone fractures. The difficulty in treating the fracture of tibial metaphysis is exemplified by orthopaedists, who in the first half of 20th century, believed the injuries were so severe and operative repair was fraught with so many complications that the fracture was deemed not amenable for surgical reconstruction. Since there was no definitive protocol for the treatment of such fractures, the Hybrid External Fixator seemed suitable for such fractures as they combine the advantages of monolateral and circular fixation, Tensioned wires provide improved fixation in the peri-articular fragments. It allows early weight bearing and movement of the knee and ankle at all times.Methods: A Prospective study of 51 cases of surgically managed fractures of proximal Tibia using Hybrid External fixation undertaken at Department of Orthopaedics, J.J.M Medical College, Davangere from 1st June 2017 to 30th August 2020 who follow Inclusion and Exclusion criteria and followed up for a period of 6-24 months.Results: 9 patients were lost to follow up before removal of the fixator and were thus not included in the statistics. All the fractures consolidated at an average of 14 weeks and the fixators were removed. All but one of the studied fractures resulted in good union. Two proximal tibial fracture resulted in non-union. 14 patients developed pin tract infections which resolved with regular dressings.10 patients had stiffness of the knee joint. This was probably due to the patient incompliance to the physiotherapy regimen. 4 cases had delayed union which resulted in union after bone marrow injection and 2 case of non-union. Results according to the Iowa score of knee showed 5(12%) excellent, 32 (76%) good and 5(12%) fair results. Interpretation and Conclusion: Hybrid external fixator is simple, rapid and straightforward application, reduced surgical time, minimally invasive and adjustable. It has negligible complications and resulted in excellent results for this type of fractures.

Fire death investigations attempt to determine whether a subject was alive or dead before the fire started. Therefore, it is essential to assess if the bone damage is traumatic or the result of exposure to heat. This observational study aims to expose the specific CT semiology of thermal bone lesions to allow the forensic radiologist to identify and distinguish them from traumatic lesions that would have preceded death. We retrospectively reviewed the CT findings of 25 bodies with thermal bone lesions for which a postmortem computed tomography (PMCT) was performed prior to an autopsy. Imaging findings were correlated to the autopsy data to identify the specific features of thermal bone lesions. Specific signs of thermal injuries to bone were identified on PMCT on all deceased cases. Thermal damages predominated in areas directly exposed to flames (rib cage, distal extremities) with less soft tissue coverage (“soft tissue shielding”). The mottled appearance of bone marrow was a constant sign of burned bones. Heat fractures such as trans-diploic fractures of flat bones and beveled (“flute-mouthpiece”) fractures of extremities seemed specifically related to thermal mechanism. In addition, we provided a better description of superficial cortical fissures of flat bones (“ancient Chinese porcelain”) and observed a “stair step” fracture of a long bone until now undescribed in radiological literature. Thermal bone lesions have specific CT findings, different on several points from traumatic injuries. Their knowledge is essential for radiologists and forensic physicians to provide an accurate report of injury and conclusions.

Background: Post-earthquake in Nepal many patients were rescued by the Nepalese Army and transferred to Shree Birendra Hospital where they were managed and discharged postoperatively to the area with substandard care. Objectives: This study aimed to establish the relation of type of fracture with the amount of fluid infused/transfused and postoperative hospital stay during earthquake victim resuscitation and care in April 2015. Methods: Hospital based data registered during the period of 25th April 2015 to 15th May 2015 were collected for this analytical study design. Seventy-five orthopaedic cases were selected randomly and analysed with software Minitab 17. Results: Fifty-three patients had long bone fractures, out of which 32 were infused with low, 18 with moderate, and three with high amounts of fluids. Similarly, 15 patients with non-long bone fractures were infused with low and seven patients with moderate amounts of fluid. The Chi-square association between type of fracture and amount of postoperative fluid therapy is 1.418, DF = 2 with p = 0.49. Similarly, the Chi-square association between the type of fracture and duration of hospital stay is 5.423 with DF = 4 and p = 0.247. Conclusion: Long bone fractures are more debilitating but are not a cause for long hospital stay postoperatively. And there is no significant relationship between the type of fracture and the amount of postoperative fluid therapy. Hence during the time of disaster, patients can be cared for in the hospital ward for a certain time and shifted to other areas of sub-standard care. This in turn can accommodate large victims during such critical times.

Background. The reconstruction of long bone defects that occur after resection of tumors is a problem that requires constant study. Bone allografts are often used in this scenario. Unfortunately, while they are prepared, allografts partially lose their strength and osteoinductive properties; their survivability in oncological patients is only 40% after 10 years. This is why the search for superior allograft treatment methods and the study of allograft remodeling and incorporation in oncological patients, whose state has been affected by radiation or chemotherapy, is an area of interest. Purpose – study the structure of bone tissue in the distal metaphysis of a rat’s femur after bone allograft implantation (sterilized using gamma radiation or antibiotic saturation) and post-operative intraperitoneal cisplatin injection. Materials and Methods. Experiments were performed on 20 male white rats aged 5–6 months at the beginning of the experiment and weighed 365.8 ± 6.4g. All rats underwent a surgery that created a defect in the distal metaphysis of the femur which was filled with a bone allograft treated with gamma radiation (Control-1 and Experimental-1 groups) or saturated with an antibiotic (Control-2 and Experimental-2 groups). 14 days after allograft implantation, animals from the control groups received an intraperitoneal injection of 2.0–2.4 ml of 0.9% NaCl, while animals from the experimental groups received 2.5mg/kg of cisplatin. Histological analysis and histomorphometry were completed 30 days after the surgery. Results. 30 days after the operation, the smallest relative area of bone tissue (11.79%) was observed in rats from the Experimental-1 group, with gamma radiation treated allografts and post-operative intraperitoneal cisplatin injections. A somewhat higher value was found in the Experimental-2 group (antibiotic saturation + cisplatin) – 31.64%. In the control groups, (intraperitoneal injection 0.9% NaCl), the relative area of bone tissue was 16.7% (Control-1, gamma radiation treatment) and 58.09% (Control-2, antibiotic saturation). The relative area of fibrous tissue was the largest in the Experimental-1 group – 31.55% and the smallest in the Control-2 group – 12.79%. Conclusions. Allograft remodeling occurs along with the formation of bone and fibrous tissue when allografts are used to fill defects in the distal femoral metaphysis of rats, However, the relative percentages of those tissues depend on the allograft sterilization method and the use of cytostatic agents. The largest relative percentage of bone tissue (58.09%) was obtained using an allograft saturated with antibiotics and without the administration of cisplatin. The smallest (11.79%), on the other hand, occurred in gamma radiation treated allografts with cisplatin injected intraperitoneally after the operation, Актуальність. Реконструкція післярезекційних дефектів довгих кісток у разі їхнього ураження пухлинами є актуальною проблемою, що потребує постійного вивчення. Кісткові алоімплантати часто використовують для цієї мети. Проте, на жаль, під час виготовлення вони частково втрачають міцність та остеоіндуктивні властивості, а їхня виживаність в онкологічних пацієнтів становить 40% через 10 років. Тому становить інтерес пошук більш досконалих методів обробки кісткових алоімплантатів, а також вивчення їхньої перебудови й інкорпорації в онкологічних хворих, стан організму яких змінений внаслідок променевої або хіміотерапії. Мета роботи – дослідити структуру кісткової тканини після імплантації в дистальний метафіз стегнової кістки щурів алогенного кісткового матеріалу, стерилізованого за допомогою γ-випромінювання або шляхом просочування антибіотиком, та післяопераційного внутрішньоочеревинного введення цисплатину. Матеріали та методи. Експеримент виконано на 20 самцях білих щурів (вік на початок експерименту 5–6 міс., маса тіла – 365,8 ± 6,4 г). Усім щурам виконали дірчастий дефект у дистальному метафізі стегнової кістки та заповнили його алогенним кістковим матеріалом, стерилізованим за допомогою γ-випромінювання (Контроль-1 та Дослід-1) або насиченням антибіотика (Контроль-2 та Дослід-2). Щурам контрольних груп через 14 днів після операції внутрішньоочеревинно вводили 2,0–2,4 мл розчину 0,9 % NaCl, дослідних – 2,5 мг/кг цисплатину. Гістологічний аналіз із гістоморфометрією виконано через 30 днів після операції. Результати та їх обговорення. Через 30 діб після операції найменша кількість кісткової тканини (11,79%) утворилася в дефектах щурів групи Дослід-1, яким встановлено стерилізований за допомогою радіаційного γ-випромінювання алоімплантат на фоні внутрішньоочеревинного введення цисплатину. Дещо кращий показник виявився в групі Дослід-2 (стерилізація антибіотиком + цисплатин) – 31,64%. У контрольних групах (внутрішньоочеревинне введення 0,9% натрію хлориду) відносний обсяг кісткової тканини становив 16,7% (Контроль-1, радіаційне γ-випромінювання) і 58,09% (Контроль-2, антибіотик). Вміст сполучної тканини був найбільшим у групі Дослід-1 – 31,55%, а найменшим – у групі Контроль-2 – 12,79%. Висновки. Визначено, що за умов використання для пластики метафізарних дефектів стегнової кістки щурів кісткових алоімплантатів відбувається їхня перебудова з утворенням кісткової та сполучної тканини. Проте відносний вміст цих тканин залежить від способу стерилізації алоімплантату і використання цитостатика. Зокрема, найбільший вміст кісткової тканини (58,09%) виявлено у разі застосування стерилізованого антибіотиком алоімплантату без уведення цитостатика, а найменший – у випадку заміщення дефекту алоімплантатом, стерилізованим за допомогою радіаційного γ-випромінювання, на фоні введення цитостатичного препарату.

Catastrophic antiphospholipid syndrome (CAPS) is an uncommon and the most severe form of antiphospholipid syndrome (APS). A 33-week pregnant patient with Klippel-Trenaunay syndrome, past SARS-CoV-2 infection and type I fetal growth restriction with shortening of the fetal long bone was diagnosed in our center with a probable CAPS. Cesarean section was performed four days after the diagnosis due to the torpid evolution of the patient. Clinical improvement was noted a few days later and the mother and baby were discharged within a week. We review the current literature on CAPS during pregnancy and provide an updated view.

Background Signal transducer and activator of transcription 3 (Stat3) is a cytoplasmic transcription factor that participates in various biologic processes. Loss of Stat3 causes hyperimmunoglobulin E syndrome, presenting with skeletal disorders including osteoporosis, recurrent fractures, scoliosis, and craniosynostosis. The objective of this study is to explore the effect and mechanism of Stat3 on osteogenesis of mesenchymal progenitors. Methods Stat3 was conditionally knockout (CKO) in mesenchymal progenitors by crossing the pair-related homeobox gene 1-cre (Prx1-Cre) with Stat3-floxed strain mice. Whole-mount-skeletal staining, histology, and micro-CT were used to assess the differences between Stat3 CKO and control mice. Further, in vitro experiments were conducted to evaluate the osteogenesis potential of primary isolated bone marrow mesenchymal stem cells (BMSCs) from both control and Stat3 CKO mice. After osteogenic induction for 14d, alizarin red staining was used to show the calcium deposit, while the western blotting was applied to detect the expression of osteogenic markers. Results Compared with the control, Stat3 CKO mice were present with shortened limbs, multiple fractures of long bone, and open calvarial fontanels. The abnormal growth plate structure and reduced collagen fiber were found in Stat3 CKO limbs. According to micro-CT analysis, the reduced cortical bone thickness and bone volume were found on Stat3 CKO mice. The in vitro osteogenic differentiation of BMSCs was inhibited in Stat3 CKO samples. After osteogenic induction for 14d, the significantly diminished calcium deposits were found in Stat3 CKO BMSCs. The decreased expression of osteogenic markers (OPN and COL1A1) was observed in Stat3 CKO BMSCs, compared with the control. Conclusions Stat3 played a critical role in bone development and osteogenesis. Loss of Stat3 impaired the osteogenesis of mesenchymal progenitors in vivo and in vitro.

Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia. Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed. Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17–69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring − 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli. CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Chronic long bone osteomyelitis is a challenging condition to handle. Despite not commonly isolated, anaerobes also have this infectious potential. Bacteroides fragilis is a known anaerobic bacterium causing intraabdominal infections with remote vertebral osteomyelitis cases and knee septic arthritis rarely reported in the literature. We aim to report a rare long bone infection due to B. fragilis, a relatively uncommon bacterium in the everyday orthopedic practice. A patient with a gunshot trauma 21 years ago, treated with knee fusion, was admitted due to chronic osteomyelitis. Debridement cultures were positive for Staphylococcus epidermidis and B. fragilis. The patient was empirically treated as no anaerobe sensitivity testing could be provided. Finally, the patient was amputated due to local squamous cell carcinoma. To our knowledge, there are no reports of B. fragilis isolation in cultures obtained from long bone tissues. In this article, we underline the particularity in managing anaerobe long bone osteomyelitis, as it remains a rare entity.

The emergence of pastoralism and animal husbandry has been a critical point in the history of human evolution. Beyond profound behavioural changes in domesticated animals compared to wild ones, characterising the morphological changes associated with domestication process remains challenging. Because reindeer (Rangifer tarandus) can be considered to still be in the early phases of the domestication process, the study of modern populations provides a unique opportunity to examine the impact of captivity and selective breeding on skeletal changes. In this work, we investigated the morphological changes in long limb bone cross-sections using 137 wild and domestic reindeer individuals bred in free-range, in captivity or used for racing and pulling. The shape and shaft cortical thickness of the six long limb bones (i.e., humerus, radioulna, metacarpal, femur, tibia and metatarsal) were measured using a 2D-geometric morphometrics approach taking into account subspecies, sex, body mass and lifestyle differences. These bones are important to understanding functional morphological changes because they can provide information on feeding and locomotor behaviours, as well as on body propulsion and weight bearing. Apart from the effects of taxonomy, etho-ecology and sex, we have found that captivity and selection induced important variations in the size and body mass of modern reindeer. Our results also showed that patterns of variation in cortical bone thickness of long limb bone cross-sections were strongly impacted by body mass and human-imposed restrictions in roaming. This demonstrates that bone cross-sections can provide information on changes in locomotor, reproductive and feeding behaviours induced by the domestication process. These results are valuable not only for (paleo) biologists studying the impact of captivity and selection in ungulates but also for archaeologists exploring the origins of domestication and early herding strategies.

Injuries in children are a well-known occurrence and often lead to fractures. The fractures may affect long bones, occur in all ages and could be accidental or non-accidental with associated injuries that may cause disability or permanent deformity. Lack of epidemiological research on causes, mechanism of injury and site of long bone fractures in children in our environment prompted this study. The study evaluates variables that maybe responsible for long bone fractures in children and document them accordingly for use in planning injury prevention strategies in children. The study was carried out in a tertiary hospital in a metropolitan city (Enugu State University of Science and Technology [ESUT] Teaching Hospital, Enugu, Nigeria). Medical records of patients, ward admission register, accident and emergency register and theatre registers were used for data collection. Children under 16 years who presented to the hospital with long bone fractures between January 2015 and December 2017 were part of the study. Eighty-five children with 86 long bone fractures out of 258 children that presented and were admitted into the orthopedic service were noted. Mean age of patients was 7.2 years + 1.8 years. The commonest long bone fractured was the femur n- 23 (26.7%). Males-female ratio was 1.15:1. Fall from height was the commonest cause of injury and abrasion/laceration the commonest associated injuries. Long bone fractures in children occur mostly due to falls from height and affects the femur more than any other bone. Bimodal annual occurrence rate has been noted and caregivers ought to be more vigilant during those times to help reduce the rate of long bone fractures in children.

Giant cell tumour of bone (GCT) is a relatively rare, locally aggressive benign neoplasm observed in the long bone epiphyseal-metaphyseal regions of young adults. The optimal treatment strategy for these tumours remains controversial, and a huge amount of contradictory data regarding the functional and oncological outcomes can be found. Therefore, we performed a systematic review intended to investigate the functional and oncological outcomes after surgical treatment of GCTs arising around the knee, namely in the distal femur and proximal tibia. A trend towards better oncological control was found using wide resections, nonetheless, curettage-based techniques achieve a highly acceptable recurrence rate with overall better knee function. A slight advantage favouring proximal tibia GCTs regarding the Musculoskeletal Tumor Society (MSTS) score was also observed. Prospective studies comparing groups of more homogeneous patients, tumours, and treatment options should be developed to obtain more conclusive and definitive results regarding the optimal strategy for treating GCTs.Cite this article: EFORT Open Rev 2021;6:641-650. DOI: 10.1302/2058-5241.6.200154

Background and Purpose. Trauma is a significant burden on causes of death, disability, and financing in least developed or "third world" countries. Fracture healing, especially in wounds and tissues, begins with a hemostatic and inflammatory phase triggered by inflammatory mediators such as cytokines, particularly IL-1β and TNF-. The purpose of this study was to determine the difference in levels of interleukin-1β in open and closed fractures of long bones in PadangMethod. This type of research is analytic observational with cross sectional design with primary data. The data were taken from the examination of IL-1β levels in long bone fracture patients at RSUP Dr. M. Djamil, RSKB Ropanasuro and RST Reksodiwiryo Padang for 4 months starting from March 2021 to July 2021. The sampling technique in this study used non-probability sampling with the consecutive sampling method. The analysis was carried out using the Independent sample T-Test to see the difference in mean IL-1 which would be calculated for open fractures and closed fractures of long bones.Results. The results showed that most (92.9%) of the patients were male, 50% had open fractures, and 50% closed fractures. The mean value of the patient's age was 34 years and the mean level of IL-1β was 555,951 pq/L. Most of the fracture sites in patients were tibia and fibula (35.7%) and femur (35.7%) and 28.6% were radius and ulna. The results showed that there was a significant difference in the mean levels of IL-1β in patients with open and closed fractures of long bones (p-value = 0.007)Conclusion. There are differences in the levels of interleukin-1β in open and closed fractures of long bones in Padang. This research is expected to provide consideration to support examinations in health services, in this case in fracture patients

Since the cross-sectional geometries of long bone diaphyses preserve evidence of a bone's mechanical loading history, examination of a bones' cross-sectional properties can be used to inform its loading history. Here, we use a novel colormap method to quantitatively visualize the topography of cortical bone, second moment of areas, and polar moment of areas along the humeral diaphyses to shed light on the potential manipulative behaviors of the Tianyuan 1 fossil human (Homo sapiens). We compare both humeri of Tianyuan 1 to two Holocene Chinese populations. Our results show that the standardized cortical bone thickness, standardized second moment of areas, and standardized polar moment of areas of Tianyuan 1's right humeral diaphysis are greater than those of the left diaphysis. This evidence supports the hypothesis that the individual was right-handed. The greater medial and lateral cortical reinforcement in the right midshaft humerus, relative to that of the left humerus, may be related to increased unilateral physical activity of the right arm. Unlike the lower humeral asymmetry of recent human agriculturalists, the relatively higher bilateral asymmetry, combined with the relatively larger femoral robusticity, indicate that Tianyuan 1 lived an activity lifestyle compared to the agriculturalists investigated in this study. The bilateral asymmetry of the right and left humeri may be more informative for discriminating between fossil and recent modern human samples than cortical thickness or rigidity values in only one side. This study also indicates that upper limb internal structures can provide important information for inferring the behavior of ancient hominins.

Objectives We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures; early (within 4 days) definitive stabilization (EDS) can be performed without an increase in post-operative ventilation and post-operative complications. Design Retrospective Cohort Study SETTING:: Level 1 Trauma Centre PATIENTS:: In total 103 patients were included in this study of which 18 (17.5%) were female and 85(82.5%) were male. These patients were borderline trauma patients who had the following parameters prior to definitive surgery, normal coagulation profile, lactate Intervention These patients were treated either according to Early Total Care (ETC), definitive surgery on day of admission, or Damage Control Orthopaedics (DCO) principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (LDS) (>4 days). Main outcome measurements Primary outcome measured was duration of ventilation more than 3 days post definitive surgery and presence of post-operative complications. Results 35 (34.0%) patients received ETC, while 68 (66.0%) patients were treated with DCO. In total 51 (49.5%) of all patients had LDS while 52 (50.5%) patients had EDS. On Logistic Regression the following factors were found to be predictive of higher rates of post -operative ventilation ≥ 3 days, Units of Blood Transfused and time to definitive surgery>4 days. Increased age, Head AIS 3 or more and Time to definitive surgery were found to be associated with an increased risk of post-operative complications. Conclusions Borderline polytrauma patients with no severe soft tissue injuries such as chest or head injuries may be treated with EDS if adequately resuscitated with no increase in need for post-operative ventilation and complications. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background and Purpose There are few studies addressing the rate of application of bone allograft and its use; hence, the present study aimed to compare the clinical outcomes of using bone allograft and autograft in patients with long bone fracture. Method In this clinical trial study, all patients who underwent bone graft surgery with the diagnosed long bone fractures of upper and lower limbs at Shahid Beheshti Hospital were included in the research. Patients were divided into two groups, autograft and allograft, according to type of treatment. They were evaluated for their union, complications, and range of motion. Results In the present study, 124 people were studied. Among them, 100 patients were eligible and included in the study. The allograft and autograft groups did not have any statistical significant differences in terms of age, sex, location, causes of fracture, and surgical methods. Results of the present research on patients in terms of fracture site indicated that there was no significant relationship between the two groups in rate of union (P = 0.18). Allograft and autograft had no difference in terms of complications. Studied range of motion indicated that patients were not different in terms of their ranges of motion. Conclusion Based on findings of the present study, allograft could be a suitable substitute for the autograft. The two graft methods were similar in terms of complications, union, and ranges of motion.

Non-union after fracture depicts a devastating complication in trauma surgery and studies assessing patient-reported outcome measures after stable bone consolidation are rare. Therefore, we aimed to evaluate the long-term impact of aseptic long bone non-union on the patients' physical health state and psychological wellbeing. For this purpose, quality of life after successful surgical treatment of long bone non-union was assessed.Sixty-one patients with aseptic long bone non-union surgically treated in our department between November 2009 and March 2019 with achieved bone consolidation were included. Quality of life was evaluated with the EQ-5D and SF-36 outcome instruments as well as with an ICD-10 based symptom rating (ISR) and compared to normative data.With a minimum follow-up time of one year after the last surgery (mean 4.7 ± 2.7 years) the mean physical health component score of the SF-36 was 38.9 ± 13.7 and the mean mental health component score of the SF-36 was 49.0 ± 5.9, indicating lower quality of life compared to German normative values of 48.4 ± 9.4 (p .001) and 50.9 ± 8.8 (p = 1.61), respectively. The mean EQ-5D index value reached 0.827 ± 0.18 with an EQ-5D VAS rating of 64.4 ± 21.5 compared to scores of 0.922 (p .001) and 72.9 ± 1.1 (p .001) obtained from an age-matched reference population. Mean scores of the ISR did not reveal significant psychological symptom burden in any scale, while an individual analysis showed moderate to severe impairments in 11.5% of the patients in total.Even 4.7 years on average after surgically successful treatment of aseptic long bone non-union, patients still report significant lower quality of life in comparison to normative data. Future clinical studies on non-unions should focus on patient-related outcome measures. Newly emerging treatment strategies and interdisciplinary approaches should be implemented to improve the overall quality of life of non-union patients.

Purpose As the monolateral external fixator is increasingly used in trauma-control and definitive management for high-energy long bone fractures, timing the fixator removal remains a challenge for surgeons. The purpose of this study was to determine the feasibility and effectiveness of the bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely. Methods A total of 131 patients with tibial shaft fractures treated by the monolateral external fixator in our institution were collected from January 2013 to July 2019. In group I, the fixators were removed based on the clinical and radiological assessment only by the treating surgeon. As for group II, the axial load-share (LS) ratio test was accomplished by another medical team without the knowledge of the clinical results. The external fixator was removed when the mechanical test outcome (LS ratio Results There was no statistical significance in demographic data between the two groups (P > 0.05). In group I, four patients suffered refracture (the refracture rate was 7.7%) after fixator removal and were successfully treated by an intramedullary nail. In group II, 71 patients underwent fixator removal after the first mechanical test, and another eight patients terminated the external fixation after the second test. None of the 79 patients in group II suffered refracture (the refracture rate was 0%). There was statistical significance in the refracture rate between the two groups (P Conclusion The bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo using the additional circular frame components is an effectively quantitative indicator to complement the clinical assessment of fracture healing in a monolateral external fixation treatment. Removal of the monolateral external fixator is safe when the axial load-share ratio dropped below 10%.

Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients’ ages were 41.33 and 13–81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p

In clinical practice, autologous bone transplantation is usually used to treat large-scale bone defects. However, autologous bone can cause complications such as secondary injury to patients, the scarcity of autografts. In this study, the study of using super active platelet lysate (sPL) and allogeneic bone to treat the 15 mm long bone defect in right radius of rabbits, and provide an experimental basis for the next step of clinical bone defect treatment. The critical-size defect of New Zealand white rabbits was made and divided into three groups: autologous bone group, allogeneic bone group, and sPL group. They were euthanized 1, 2, and 3 months after the operation, perform imaging and histological observation on the repair of bone defect area. The results showed that there were varying degrees of new bone in the bone defect. CT data showed that the bone defect repair rate and new bone mass in each group increased month by month (P .05). Bone tissue (BV) and bone tissue to the total volume (BV/TV, %) in the sPL groupallogeneic bone group, autologous bone groupallogeneic bone group, with statistical significance (P .05). Compared with the allogeneic bone group, the sPL group can significantly promote the healing of bone defects, enhance the bone density after fracture healing. The repair effect after 3 months was similar to that of the autogenous bone group. The use of allogeneic bone and sPL therapy may become part of a comprehensive strategy for tissue engineering to treat bone defects.

Osteogenesis imperfecta (OI) is characterized by fractures and progressive bone deformities. Fracture rates peak during the toddler and adolescent years and decline during adulthood but do not stop entirely. We describe a kindred, the affected members of which were the mother and two sons, who presented with an apparently unique phenotype of OI. Our patients demonstrated a pattern of prenatal bone deformities followed by multiple, nontraumatic long bone fractures within the first two years of life and then an absence of nontraumatic fractures thereafter. No extra-skeletal manifestations have been noted to date. The mother did not receive bisphosphonate therapy but had no nontraumatic fractures after the age of five months. Intravenous bisphosphonate therapy was started for both sons within two months of birth, with the most recent infusions at age 18 months and 28 months in Patients 2 and 3, respectively. Two patients harbored a variant of uncertain significance in the COL1A1 gene. This heterozygous variant, c.3548C>T; p.(Pro1183Leu), is listed in the OI Variant Database as affecting only one other individual with osteopenia. We describe three family members with a unique presenting phenotype of OI, characterized by cessation of nontraumatic fractures after the first two years of life.

Two 8-week-old Finnish Lapphund dogs presented with pain on manipulation, abnormal long bone conformation, retrognathism, and stunted growth compared to their litter mates. Multiple long bone fractures were evident on radiographs. Clinical pathology showed an atypically normal serum alkaline phosphatase activity for dogs this age. Due to poor quality of life, the dogs were humanely euthanized and subjected to a complete necropsy. On necropsy, all bones were soft and easily broken. Histologic examination revealed that the secondary spongiosa was diminished with abnormal bony trabeculae embedded in abundant loose vascular stroma. No Haversian canals were observed and the cortices contained abundant woven bone separated by fibrovascular tissue consistent with the diagnosis of osteogenesis imperfecta (OI). Inbreeding of the sire and female offspring led to a suspicion of recessive inheritance and the particular genetic collagen disorder remains to be identified in this breed.

Metastatic bone disease is a common sequela of malignancy and can lead to significant morbidity on patients. Systemic medical therapies and oncology surgery have greatly enhanced cancer survival rates over recent decades. Orthopaedic surgeons occupy a key position within the multidisciplinary team and coordinate surgical care for bone metastases where appropriate. This review describes the investigations for, and management of, patients with metastases to the appendicular skeleton. National guidelines exist to help orthopaedic clinicians and departments optimize patient care and outcomes. We outline and illustrate the freely available OPTIModel app from the Netherlands, which is an innovative, straightforward and useful tool for prognostic evaluation and suggestion of loco-regional treatment options for patients with symptomatic long bone metastases.