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Background: Septic arthritis in native hip joints is a rare but serious condition in adult patients. Prompt aggressive surgical and medical treatment is a challenge, and the outcomes after delayed management can be devastating. This article reports the findings of treatment of recalcitrant cases using a standardized protocol., Methods: Fourteen consecutive patients (15 hips) were treated with two-stage total hip arthroplasty (THA) for septic arthritis of the hip joint over a 6-year period. All patients underwent resection arthroplasty and implantation of an antibiotic-loaded articulating spacer in the first stage, short-term systemic antibiotic therapy during the interim period, and subsequent THA without bone cement in the second stage., Results: One patient required additional debridement and spacer reinsertion before THA. The mean interim period was 12.9 weeks (range, 6-31 weeks). After an average follow-up period of 42.5 months (range, 25-72 months) after THA, there was no evidence of recurrent infection or loosening of the prostheses in any patient. The average Merle D'Aubigne and Postel hip score improved from 9.3 (range, 5-15) to 13.5 (range, 12-16) between stages and to 16.7 (range, 15-18) at the latest follow-up., Conclusions: Two-stage uncemented THA is a reliable treatment option for adult patients with recalcitrant septic hips. If an antibiotic-loaded interim spacer is used, routine, prolonged systemic antibiotic therapy may not be necessary.

Background: We investigated the effect of hyperbaric oxygen (HBO) therapy on the early phase of tibial lengthening in our established rabbit model., Methods: Twenty-four male rabbits (six per group) underwent right tibial lengthening by 5 mm. Group 1 then underwent 2.5 atmospheres of absolute hyperbaric oxygenation for 2 hours daily for 6 weeks postoperatively; group 2, for early 5 weeks (weeks 1-5), group 3, for late 5 weeks (weeks 2-6), and group 4 had no HBO therapy. Bone mineral density (BMD) was measured before surgery and weekly thereafter from weeks 2 through 6. The mechanical strengths of the lengthened tibias were measured., Results: Significantly higher mean %BMDs were obtained for groups 1 and 2 compared with groups 3 and 4. There was no difference in the mean %BMD between groups 1 and 2 (p > 0.05). The results were similar for mean percentage maximal torque; group 1 had the maximum torque, followed sequentially by groups 2 though 4., Conclusion: The study results suggest that early and full-term administration of HBO therapy on tibial lengthening may achieve better benefits.

Background: Hyperbaric oxygen therapy is a method for augmenting oxygen availability to tissues. This study investigated the effect of hyperbaric oxygen therapy on the collagenase-induced tendinopathy in the rabbit patellar tendon., Methods: In this study, 13 rabbits were treated by ultrasound-guided injection of 0.025 mL collagenase into the patellar tendon at the right knee, with the left knee serving as a control condition. The rabbits were randomly divided into two groups. After tendinopathy had been confirmed by histologic examination 3 weeks after treatment, hyperbaric oxygen therapy was initiated for group 1. The hyperbaric oxygen therapy involved 30 daily sessions of 2.5 ATA for 120 minutes starting 6 weeks after treatment. The rabbits in group 2 were put in normobaric room air. Both groups were killed 10 weeks after treatment. Histologic examinations as well as mechanical and biochemical tests were performed after the animals were killed., Results: The ultimate tensile load in the tendon that had hyperbaric oxygen therapy was 34.8% greater than that in the control tendon 10 weeks after treatment (p < 0.05). Hydroxyproline concentrations increased 82.2% simultaneously in the tendons that had hyperbaric oxygen therapy, as compared with the concentrations in the control tendons (p < 0.05). However, no statistical difference was found between the two groups in terms of pyridinoline concentration at the 10th week (p > 0.05). The histologic examination demonstrated an increase in blastlike tenocytes in group 1, with more mature phenotype, more organized collagen matrix, absence of myxoid degeneration, and increased vascularity at the 10th week, as compared with the control knee., Conclusions: The results validate the effectiveness of hyperbaric oxygen therapy in the treatment of tendinopathy. Hyperbaric oxygen therapy may increase collagen synthesis and collagen cross-link formation during the early healing process.

In therapeutic bone repairs, autologous bone grafts, conventional or vascularized allografts, and biocompatible artificial bone substitutes all have their shortcomings. The bone formed from peptides [recombinant human bone morphogenetic proteins (BMPs)], demineralized bone powder, or a combination of both is small in size. Tissue engineering may be an alternative for cranial bone repair. In this study, the authors developed an animal model to test the hypothesis that replication-defective, adenovirus-mediated human BMP-2 gene transfer to bone marrow stromal cells enhances the autologous bone formation for repairing a critical-size craniofacial defect. The mesenchymal stromal cells of miniature swine were separated from the iliac crest aspirate and expanded in monolayer culture 1 month before implantation. The cultured mesenchymal stromal cells were infected with recombinant, replication-defective human adenovirus BMP-2, 7 days before implantation. Bilateral 2 x 5-cm2 cranial defects were created, leaving no osteogenic periosteum and dura behind. Mesenchymal stromal cells at 5 x 10(7)/ml were mixed with collagen type I to form mesenchymal stromal cell/polymer constructs. Mesenchymal stromal cells used for the control site were infected with adenovirus beta-Gal under the same conditions. After 6 weeks and 3 months, 10 miniature swine were euthanized and the cranium repair was examined. Near-complete repair of the critical-size cranial defect by tissue-engineered mesenchymal stromal cell/collagen type I construct was observed. The new bone formation area (in square centimeters) measured by three-dimensional computed tomography demonstrated that the improvement from 6 weeks to 3 months was significantly greater on the experimental side than on the control side (2.15 cm2 versus 0.54 cm2, p < 0.001) and significantly greater at 3 months than at 6 weeks (2.13 cm2 versus 0.52 cm2, p < 0.001). The difference between the experimental and control groups was significant at 3 months (mean difference, 2.13 cm2; p < 0.001). The maximal compressive strength of the new bone was similar to that of the normal cranial bone when evaluated by biomechanical testing (cranium bone versus tissue-engineered bone, 88.646 +/- 5.121 MPa versus 80.536 +/- 19.302 MPa; p = 0.227). Adenovirus was absent from all constructs by immunochemical staining at 6 weeks and 3 months after implantation. The successful repair of cranial defects in this experiment demonstrates the efficacy of the integration of the autologous stem cell concept, gene medicine, and polymers in producing tissue-engineered bone.

Background: The purpose of this study is to evaluate the facilitating effect of hyperbaric oxygen (HBO) on posterolateral intertransverse fusion using a validated rabbit model., Methods: Twenty-four male New Zealand rabbits underwent posterolateral intertransverse fusion at L5-L6 with autogenous iliac bone graft. They were evenly divided into two groups: the HBO group and the normal room air (RA) group. Each group had six rabbits killed at 4 weeks and 8 weeks, respectively. The rabbits in the HBO groups were treated with 100% oxygen at 2.5 atm for 2 hours a day. After being killed, all rabbits were subjected to radiographic examination, manual testing, and torsional loading to evaluate the results of spinal fusion., Result: Radiographic union of intertransverse fusion areas at 4-week RA, 4-week HBO, 8-week RA, and 8-week HBO were 2 of 12, 7 of 12, 7 of 12, and 10 of 12, respectively. Solid union proven by manual palpation was found to be zero of six, three of six, four of six, and five of six of the cases, respectively. The average peak torsional momentums were 2120.2, 2576.5, 2661.6, and 3079.8 N-mm, respectively. Spinal fusion was significantly improved in the HBO groups at both 4 weeks and 8 weeks., Conclusion: The results of this study suggest that intermittent hyperbaric oxygen therapy will hasten the bone healing process and improve the fusion rate as compared with the non-HBO group.

Background: The aim of this study was to compare the superiority between the newly designed modified AO tension band wiring technique and the traditional modified AO tension band wiring technique in treating an olecranon fracture., Methods: Eight pairs of fresh cadaveric ulnae were tested biomechanically. After transverse osteotomy of the olecranon, all left ulnae were fixed by the traditional modified AO technique with two Kirschner wires inserted through the anterior ulnar cortex and all right ulnae by the new technique with two Kirschner wires inserted into the marrow cavity from the olecranon to the ulnar styloid process. All specimens were tested by the Material Testing System machine to evaluate fragment displacement and the maximal failure load. A dual linear variable displacement transducer was used to measure relative minimal displacement., Results: There was no significant difference between the techniques. The maximal failure load by either technique was more than 80 kg. Even at testing failure, no Kirschner wires migrated proximally., Conclusion: The new technique may be applied widely to treat all olecranon fractures, because it is a technically easier and safer technique. Less than 5.5-kg loads could be permitted in daily activity postoperatively. A single tolerable loading weight should not exceed 8 kg. Kirschner wires will not migrate proximally, despite increased joint loading. Clinically, this study may confirm indirectly the hypothesis that proximal migration of Kirschner wires was mainly due to triceps traction.

Object: We investigated whether -intermittent hyperbaric oxygen (HBO) therapy can mitigate the adverse effects of cigarette smoking on the bone healing of tibial lengthening by using a previously validated rabbit model., Methods: Eighteen male rabbits were randomly divided into three groups of six animals each. Group 1 (smoking plus HBO) went through intermittent cigarette smoke inhalation and hyperbaric oxygen therapy, group 2 (control) did not go through intermittent cigarette smoke inhalation or hyperbaric oxygen therapy and group 3 (smoking) went through intermittent cigarette smoke inhalation. Each animal's right tibia was lengthened 5 mm by using an uniplanar lengthening device. Bone mineral density (BMD) study was performed for all the animals at 1 day before operation and 3, 4, 5, and 6 weeks after operation. All of the animals were killed at 6 weeks postoperatively for biomechanical testing., Results: By using the preoperative BMD as an internal control, we found that the BMD of group 1 (smoking plus HBO)and group 2 (control) was superior to that of group 3 (smoking). The mean %BMD at 3, 4, 5, and 6 weeks were 58.6%, 66.6%, 73.7%, and 83.8%, respectively, in group 1, whereas the mean %BMD were 52.0%, 64.3%, 70.1%, and 76.2%, respectively, in group 2, and the mean %BMD were 46.2%, 54.0%, 64.9%, and 69.4%, respectively, in group 3 (two-tailed t test, p > 0.05, p > 0.05, p > 0.05, and p < 0.05 at 3, 4, 5, and 6 week respectively between group 1 and group 2, p < 0.01,p < 0.01,p < 0.01, and p < 0.01 at 3, 4, 5, and 6 week, respectively, between group 1 and group 3 and p < 0.05, p < 0.05, p < 0.05, and p < 0.05 at 3, 4, 5, and 6 week respectively between group 2 and group 3). By using the contralateral nonoperated tibia as an internal control, we found that the torsional strength of group 1 (smoking plus HBO) and group 2 (control) was superior to that of group 3 (smoking). The mean percentage of maximum torque was 80.9% in group 1 (smoking plus HBO) and was 78.0% in group 2 (control), whereas the mean percentage of maximum torque was 59.6 % in group 3 (smoking) (two-tailed t test, p < 0.05 between groups land 3 and between groups 2 and 3, whereas p > 0.05 between groups 1 and 2)., Conclusion: This study suggests that smoke inhalation delays the bone healing in tibial lengthening; however, HBO mitigates the delayed healing effect of smoke inhalation and, thus, helps the smoking animal in achieving an expeditious bone healing in tibial lengthening.

Objectives: To investigate and compare closed and open revision techniques in the treatment of ununited femoral shaft fractures associated with locked nail breakage., Design: Retrospective., Setting: University hospital., Methods: Ununited femoral shaft fractures associated with locked nail breakage were treated with either closed or open revision (nine or eighteen cases, respectively). The closed technique entailed closed removal of the broken nail and reinsertion of a stable intramedullary nail after reaming the marrow cavity. The open technique included open removal of the broken nail, reinsertion of a stable intramedullary nail or plate, and cancellous bone graft supplementation. Union rate, union period, perioperative course, and complications were compared., Results: Eight closed and fifteen open technique cases were followed for at least one year (median two years). Cases treated with the closed technique had a union rate of 100 percent, a union period of 4.4+/-0.9 months, an operating time of 1.5+/-0.4 hours, no blood transfusion, and no complications. Open technique cases demonstrated a union rate of 100 percent, a union period of 5.7+/-1.5 months (p = 0.033), an operating time of 2.4+/-0.4 hours (p < 0.001), blood transfusion of 1,000+/-500 milliliters (p < 0.001), and no complications., Conclusions: We recommend the closed revision technique because its union period and operating time are shorter, and it does not require a blood transfusion. Because there is no local wound dissection, infection rates should also be lower. However, the procedure is technically demanding. If it cannot be completed successfully, using the open technique can still achieve a satisfactory outcome.

Background: The aim of this prospective study was to investigate and compare the results of treatment of femoral neck nonunions using a sliding compression screw (SCS) with and without subtrochanteric valgus osteotomy (SVO)., Methods: Thirty-two consecutive patients with femoral neck nonunions, which sustained no osteonecrosis of the femoral head based on bone scan study, were prospectively treated with SCS with (21 patients) or without (11 patients) SVO. The indication for SCS with SVO was a femoral neck nonunion with leg shortening of more than 1.5 cm. SCS without SVO was for leg shortening of less than 1.5 cm., Results: Seventeen patients with osteotomy and nine patients without osteotomy were followed for at least 2 years (range, 2-8 years). All femoral neck fractures healed, with a union period of 4.6+/-1.0 months (95% confidence interval, 4.1-5.1 months) for osteotomy cases and 4.6+/-1.1 months (95% confidence interval, 3.8-5.4 months) for nonosteotomy cases (p = 0.83). However, in the osteotomy group, two patients sustained osteonecrosis of the femoral head, and nonunion remained in 1 patient at the osteotomy site (complication rate, 18%; 3 of 17 patients). There were no complications in the nonosteotomy group (p = 0.26). The average lengthening achieved from osteotomy was 1.0 to 1.5 cm (p < 0.001)., Conclusion: Using SCS without SVO to treat femoral neck nonunions can result in a very satisfactory outcome. It is thus preferred for indicated patients. SCS without SVO, however, cannot concomitantly correct a femoral neck shortening; furthermore, shortening may deteriorate because of a telescoping effect. For patients with evident shortening, therefore, combined SVO with SCS is more suitable.

Objective: To investigate the effects of tibial exchange nailing in treating a tibial shaft aseptic nonunion and to establish optimal indications for using this technique., Design: Prospective, consecutive., Setting: University hospital., Methods: Twenty-five consecutive tibial shaft aseptic nonunions were prospectively treated with the exchange nailing technique. Indications for this procedure were a tibial shaft aseptic nonunion that had previously been treated with an inserted nonreamed or reamed intramedullary nail, displayed less than one centimeter of shortening, was with or without rotational or angular deformity, exhibited no segmental bony defects, and was anatomically suited for conventional or locked reamed intramedullary nail stabilization. The marrow cavity was reamed as extensively as possible, and a rigid intramedullary nail with stable fixation was inserted., Results: During a follow-up period of two to four years (median thirty-two months), twenty-four nonunions healed, on average, in four months (range three to six months). The one remaining nonunion healed four months after a cancellous bone grafting procedure. No wound infection or malunion was noted., Conclusion: Because of its high union rate, low complication rate, and simplicity of method, we believe that the exchange nailing technique should be considered preferentially for all indicated cases.

Objective: We investigated the effect of intermittent cigarette smoke inhalation on the bone healing of tibial lengthening in rabbits., Methods: Twelve male rabbits were divided into two groups of six animals each. The first group underwent intermittent cigarette smoke inhalation, and the second group did not undergo intermittent cigarette smoke inhalation. Each animal's right tibia was lengthened 5 mm by using an uniplanar lengthening device. Bone mineral density (BMD) study was performed for all of the animals 1 day before operation and 3, 4, 5, and 6 weeks after operation. All of the animals were killed 6 weeks postoperatively for biomechanical testing., Results: By using the preoperative BMD as an internal control, we found that the BMD of the smoke-inhalation group was decreased significantly compared with the non-smoke-inhalation group. The mean %BMD at 3, 4, 5, and 6 weeks were 49.9%, 61.2%, 65.9%, and 71.0%, respectively, in the smoke-inhalation group, whereas the mean %BMD were 54.9%, 71.8%, 76.4%, and 82.0%, respectively, in the non-smoke-inhalation group (two-tailed t test, p > 0.05, p < 0.01, p < 0.01 and p < 0.01 at 3, 4, 5, and 6 weeks, respectively). By using the contralateral nonoperated tibia as internal control, we found that torsional strength of the smoke-inhalation group was decreased significantly compared with the non-smoke-inhalation group. The mean percentage of maximal torque was 63.8% in the smoke-inhalation group, whereas the mean percentage of maximal torque was 77.1% in the non-smoke-inhalation group (two tailed t test, p < 0.01)., Conclusion: This study suggests that cigarette smoking delays the mineralization during the bone healing process of distraction osteogenesis and, thus, decreases the mechanical strength of the regenerating bone.

Objective: The aim of this retrospective study was to investigate and compare the effects of plating and intramedullary nailing in the treatment of clavicular aseptic nonunion., Methods: Thirty-three consecutive patients with middle-third clavicular aseptic nonunions with previous nonoperative treatment were treated by plating (13 patients) and intramedullary nailing (20 patients) with supplementary cancellous bone grafting. The indications for such treatment were middle-third aseptic nonunions without previous operative treatment and with local pain or tenderness, deformity, or neurologic complaint. The choice of plating or intramedullary nailing was according to the surgeon's individual preference., Results: Twenty-nine patients were followed for at least 1 year (range, 1-7 years; median, 3 years; plating, 11; intramedullary nailing, 18). The union rate was 81.8% (9 of 11) for plating and 88.9% (16 of 18) for intramedullary nailing (p = 0.35, Fisher's exact test). The union period was 4.0 +/- 1.3 months for plating and 4.1 +/- 1.1 months for intramedullary nailing (p = 0.80, unpaired Student's t test). The complication rate was 27.3% (3 of 11) for plating and 11.1% (2 of 18) for intramedullary nailing (p = 0.21, Fisher's exact test). There were no significant differences in other parameters., Conclusion: Intramedullary nailing may have a higher union rate with a lower complication rate than plating (p > 0.05). At least in common situations, it is not inferior to plating. Whenever possible, therefore, intramedullary nailing should be used preferentially to treat clavicular aseptic nonunion without previous operative treatment. Nevertheless, both techniques have relatively higher nonunion rates in the treatment of clavicular nonunion than in the treatment of other long-bone nonunions. Gentle handling of surrounding soft tissues to reduce bony fragments should be strictly executed.

We investigated the effect of intermittent hyperbaric oxygen (HBO) therapy on the bone healing of tibial lengthening in rabbits. Twelve male rabbits were divided into two groups of six animals each. The first group went through 2.5 atmospheres absolute of hyperbaric oxygenation for 2 hours daily, and the second group did not go through hyperbaric oxygenation. Each animal's right tibia was lengthened 5 mm using an uniplanar lengthening device. Bone mineral density (BMD) study was performed for all of the animals at 1 day before operation and at 3, 4, 5, and 6 weeks after operation. All of the animals were killed at 6 weeks postoperatively for biomechanical testing. Using the preoperative BMD as an internal control, we found that the BMD of the HBO group was increased significantly compared with the non HBO group. The mean %BMD at 3, 4, 5, and 6 weeks were 69.5%, 80.1%, 87.8%, and 96.9%, respectively, in HBO group, whereas the mean %BMD were 51.6%, 67.7%, 70.5%, and 79.2%, respectively, in non-HBO group (two tailed t test, p < 0.01, p < 0.01, p < 0.01, and p < 0.01 at 3, 4, 5, and 6 weeks, respectively). Using the contralateral nonoperated tibia as an internal control, we found that torsional strength of lengthened tibia of the HBO group was increased significantly compared with the non-HBO group. The mean percent of maximal torque was 88.6% in HBO group at 6 weeks, whereas the mean percent of maximal torque was 76.0% in non-HBO group (two-tailed t test, p < 0.01). The results of this study suggest that the bone healing of tibial lengthening is enhanced by intermittent hyperbaric oxygen therapy.

We investigated the effect of intermittent cigarette smoke inhalation on the bone healing of tibial lengthening in rabbits. Thirty-eight male rabbits were divided into two groups of 19 animals each. The first group went through intermittent cigarette smoke inhalation, and the second group did not go through intermittent cigarette smoke inhalation. Each animal's right tibia was lengthened 5 mm using an uniplanar lengthening device. Five animals of each group were killed at 4, 6, and 8 weeks postoperatively for biomechanical testing, and one animal of each group was killed at 2, 4, 6, and 8 weeks postoperatively for histologic study. Using the contralateral nonoperated tibia as an internal control, we found that torsional strength of the lengthened tibia of the smoke inhalation group was decreased significantly compared with the non-smoke inhalation group. The mean percent of maximal torque at 4, 6, and 8 weeks were 22.0, 66.3, and 78.6%, respectively, in the smoke inhalation group, whereas the mean percent of maximal torque were 48.0, 84.1, and 90.8% %, respectively, in non-smoke inhalation group (one-tailed t test, p < 0.01, p < 0.01, and p < 0.05 at 4, 6, and 8 weeks, respectively). Our histologic observations revealed that the granulation tissue resorption, bone formation, and remodeling were delayed in smoke inhalation group. The results of this study suggest that intermittent inhalation of cigarette smoke delays, but does not prevent, the bone healing in tibial lengthening.

Objective: The aim of this study was to assess the most adequate location of a lag screw of a dynamic hip screw in the treatment of an unstable intertrochanteric fracture., Methods: Six pairs of proximal femora obtained from fresh adult cadavers were inflicted with iatrogenic unstable intertrochanteric fractures. Fractures of both sides were stabilized with two different favored locations of a lag screw and tested by a Material Testing System machine with increased loads to evaluate the relative migration of the femoral head., Results: There was significant difference (p < 0.05) with less migration of the femoral head by inferior insertion of a lag screw in the frontal plane and central insertion in the coronal plane., Conclusions: Based on theoretical and experimental considerations, the most adequate location of a lag screw of a dynamic hip screw should be inferior in the frontal plane and central in the coronal plane.