Genetic analysis of the cap5 locus of Staphylococcus aureus

BACKGROUND: Fifteen patients with femoral shaft fractures complicated by infected nonunions were treated with a two-stage protocol. METHODS: In the first stage, radical debridement was performed along with antibiotic bead chains local therapy and external skeletal fixation. In the second stage, the debrided nonunion site was repaired with bone grafting and the external skeletal fixator was used until bony union was achieved. The time between the first and second stages of treatment was 2 to 6 weeks. The debrided bone defects ranged from 0.5 to 15 cm. Autogenous iliac cancellous bone grafting was performed in 11 patients, and microvascularized osteoseptocutaneous fibular transfer was performed in 4 patients. RESULTS: Wound healing and bone union were achieved in all 15 cases. The duration of external fixation of these patients ranged from 7 to 15 months, with an average of 9 months. Minor pin-track infection was seen in seven patients. Postoperative infection after the second-stage bone grafting occurred in three patients. These three infections were arrested by limited debridement along with 2 to 4 weeks of parenteral antibiotic therapy. In one case, stress fracture occurred at 11 months after microvascularized fibular transfer; this was managed with another 5 months of external skeletal fixation. With an aggressive physical therapy program, 10 patients achieved nearly full range of knee motion and 5 patients had relevant knee flexion deficits. The follow-up averaged 58 months (range, 40-76 months); no recurrence of osteomyelitis was observed even at 76 months. CONCLUSION: We have found that our two-stage treatment with antibiotic beads local therapy, definitive external skeletal fixation, and staged bone grafting is an acceptable treatment protocol for the management of femoral diaphyseal infected nonunion. It results in rapid recovery from osteomyelitis and a predictable recovery from nonunion.     

The Nicolas Andry Award-1995. Fracture healing. Radiation induced alterations

This study investigated the effects of radiation on fractures in a rat femur model. Two different radiation dosage fractionation schemes (1100 rads given in one dose and 2500 rads given in 10 divided doses over 12 days) and three different times of initiation of radiation (1 day before fracture, 3 or 10 days after fracture) were studied. Fractures exposed to these levels of radiation all appeared to heal during the course of this experiment, although with varying degrees of delay, with the exception of those exposed to a single dose of 1100 rads 3 days after fracture. These animals remained at a more immature level of repair histologically compared with the control group, throughout the entire time evaluated. The strength of the final repair remained less than the control for all the groups receiving treatment. These results may offer some explanation for the clinical observations of an increased incidence of delayed union and nonunion of fractures, an increased incidence of fracture and refracture in irradiated bone, and an increased incidence of fracture and nonunion in constructs using radiation in conjunction with allogeneic bone. Furthermore, the observed effects were generally no different in the animals treated with the two clinically relevant dose fractionation schemes chosen for this study.     

Progress in imaging diagnosis of circulatory diseases

Five patients with femoral nonunion and a broken interlocking nail were treated with the augmentative plating procedure. This group included two male and three female patients whose average age was 25 years (range, 21-35 years). All of the injuries resulted from traffic accidents and were closed fractures. Four of the injuries were initially managed with a Grosse-Kempf interlocking nailing system, and one case was managed with an AO interlocking nailing system. The broken interlocking nail was left in place in situ, and an augmentative plate fixation was applied to the fracture site to provide a rigid fixation. Simultaneous bone grafting was performed in three of the patients to repair the bony defect. All of these patients walked bearing full weight on the extremity without aching at the fracture site within 3 months, and all of these five fractures obtained a bony union within an average of 5.4 months after this treatment. From our experience, we have found this method to be a useful treatment for the nonunion of femoral shaft fracture with a broken interlocking nail.     

Pathological changes in levels of three small stress proteins, alphaB crystallin, HSP 27 and p20, in the hindlimb muscles of dy mouse

The authors analyse 5 cases of gunshot wounds involving limbs with a diaphyseal fracture of the radius and ulna: 3 of the cases concern the radius and ulna and the remaining 2 involve the tibial bone. These wounds were encountered in civilian practice (3 rixes, 2 gun-shot injuries). In all of the cases, the emergency treatment consisted of extensive debridment, bone fixation by intramedullary nailing in most cases, cancellous iliac bone grafting in 2 cases, cover with a Latissimus dorsi free flap in 1 case. In all of the cases, development was free of infections bone union time was 3 to 12 months; last functional results were satisfactory.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

In vitro cytotoxicity of guanylhydrazones (MGBG and PGBG) on cultured Chinese hamster ovary cells

Periosteum was obtained within 10 days of injury from the site of 17 adult tibial diaphyseal fractures during internal fixation. Osteogenic cells, non-osteogenic cells and vascular elements were identified in situ using a variety of techniques. In all cases, the periosteum was thickened with randomly distributed plaques of cartilage and bone. Cells covering newly formed bone trabeculae expressed osteocalcin. Lectin-binding revealed high vascularity. Few mast cells were observed. Macrophages and acid phosphatase positive cells, some multinucleate, were observed in abundance. These findings suggest that the repair of the adult human diaphyseal fracture is similar to that of experimental fractures in rapidity of onset, high vascularity and in bone and cartilage formation. They differ in the fact that chondrogenesis and osteogenesis appear to be simultaneous in human fractures but sequential in experimental fractures. The paucity of mast cells suggests that they probably play no significant role in the repair of the human fractures.     

Iliac crest bone grafting and Herbert screw fixation of nonunions of the scaphoid with avascular proximal poles

Between 1989 and 1991, 137 nonunions of the scaphoid were treated by the senior author, who noted that 26 of these nonunions had an avascular proximal pole (no punctate bleeding from the bone at the time of surgery). All 26 nonunions were treated with iliac crest bone grafting and Herbert screw fixation. Of these 26 patients, 17 were followed for more than 1 year after their surgery (average follow-up period, 31 months). The average time from injury to surgery was 31 months. Of the 17 patients included in this study, 12 were treated with a palmar approach to the nonunion, 5 with a dorsal approach. The 12 nonunions that occurred at either a midwaist or distal location were approached through a palmar modified Russe incision and treated with interpositional corticocancellous iliac crest bone graft in addition to the Herbert bone screw. The five nonunions with a very small proximal fragment were approached through a dorsal incision and treated with cancellous iliac crest bone graft and Herbert screw fixation. All patients were immobilized after operation in a short-arm thumb spica cast for 3 months and were then allowed active range of motion of their wrists. Return to full activity was permitted once preoperative wrist motion was restored. Radiographic union, as defined as bridging trabeculae of bone present in all x-ray films, occurred in nine patients, an incomplete union or persistent fibrous union in seven, and a nonunion in one patient. Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength, and patient satisfaction, functional results were graded as excellent in six patients, good in five patients, fair in four patients, and poor in two patients. The average range of motion of the wrist did not significantly improve after surgery, but the average grip strength of the injured hand increased by 29 lbs. There were no intraoperative complications. However, three patients required further operative procedures including radial styloidectomy, pin removal, and carpal tunnel release. No patient has required either a proximal row carpectomy or wrist arthrodesis. Previously published results of avascular proximal pole scaphoid nonunions suggest that union cannot be obtained and functional results are uniformly poor. In contrast, the functional and x-ray results of our patients are markedly improved over these previous studies--emphasizing the importance of iliac crest bone grafting, rigid internal fixation, and appropriate postoperative immobilization.     

The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study

A multicentric study was conducted by the European Musculoskeletal Oncology Society on 113 cases of resection for tumors of the major long bones and reconstruction with massive allografts, as intercalary diaphyseal or for arthrodesis. The follow-up was at least 12 months. There was a 14% incidence of infection, with a higher frequency (18.5%) in intercalary grafts as compared to arthrodeses (7%). Fracture of the graft occurred in 15.5% of the cases with a prevalence in the humerus (28.5%) as compared to the tibia (21.4%) and femur (14.7%). Fracture constantly occurred after osteosynthesis with screws, in 16% of the cases after osteosynthesis with a plate, and in 12.5% of the cases after osteosynthesis with an intramedullary nail. It was observed in 32% of the grafts preserved at -30 degrees, in 17% of those irradiated, and in 7% and 7.6% of those preserved at -180 degrees and -80 degrees, respectively. Delayed union and non-union was observed in 57% of the cases: 63% in intercalary grafts, 48% in arthrodeses. Final results after treatment of complications were excellent and good in 63% of the entire series. The results should, however, be evaluated after 3 years, as during this period of time important transformation phenomena of the graft occur. Complications are observed in 75% of the cases, but they may be reduced if planning is correct and surgery is accurate. Each complication may be dealt with and resolved without high risks for preservation of the limb.     

Nonmonotonous changes in erythrocyte sedimentation rate in whole blood

Scaphoid nonunion with avascular necrosis of the proximal pole remains a difficult problem. We have endeavoured to heal the fracture, restore scaphoid height and revascularize the proximal pole of the scaphoid by means of a vascularized dorsal interposition graft from the distal radius. The procedure has resulted in union of six of ten fractures. Fractures that healed had not been treated by a previous bone grafting procedure. Dissatisfaction was due to loss of motion in patients who had healed fractures, and pain in those patients with persistent non-unions.     

Evaluation of bovine-derived bone protein with a natural coral carrier as a bone-graft substitute in a canine segmental defect model

The efficacy of a bone-graft substitute (bovine-derived bone protein in a carrier of natural coral) in the healing of a segmental defect of a weight-bearing long bone was evaluated. Twenty dogs, divided into two groups, underwent bilateral radial osteotomies with creation of a 2.5 cm defect. On one side of each dog, the defect was filled with autogenous cancellous bone graft. Contralateral defects received, in a blinded randomized fashion, cylindrical implants consisting of natural coral (calcium carbonate) or calcium carbonate enhanced with a standard dose of bovine-derived bone protein (3.0 mg/implant; 0.68 mg bone protein/cm3). The limbs were stabilized with external fixators, and all animals underwent monthly radiographs. They were killed at 12 (group 1) or 24 (group 2) weeks, and regenerated bone was studied by biomechanical testing and histology. Radiographic union developed in all 20 radii with autogenous cancellous bone grafts and in all 10 of the radii with the composite implants. None of the radii with implants of calcium carbonate alone showed radiographic evidence of union. This represented a statistically significant difference between implant types. In addition, calcium carbonate implants both with and without bone protein demonstrated radiographic evidence of near total resorption of the radiodense carrier by 12 weeks. This resorption facilitated radiographic evaluation of healing. Mean values for biomechanical parameters of radii with the composite implants exceeded those for the contralateral controls at 12 and 24 weeks; the difference was statistically significant at 12 weeks. Histology revealed scant residual calcium carbonate carrier at either time in the defects with calcium carbonate implants; however, a moderate amount was present in defects with the composite implants. In these specimens, the residual carrier was completely surrounded by newly formed bone that may have insulated the calcium carbonate from further degradation. The present study used a carrier of granular calcium carbonate reconstituted with bovine type-I collagen to deliver an osteoinductive protein to the defect site. This carrier is of nonhuman origin (eliminating the risk of disease transmission or antigenicity) and resorbs rapidly. In this model, bovine-derived bone protein in a natural coral carrier performed consistently better than the gold standard autogenous cancellous bone graft in terms of the amount of bone formation and strength of the healed defect. This may have implications for removal of hardware or resumption of weight-bearing in certain clinical situations. These data also indicate that coralline calcium carbonate alone represents a poor option as a bone-graft substitute in this critical-sized segmental defect model.     

Treatment of tibial defects and nonunions using ipsilateral vascularized fibular transposition

Eight patients had nine ipsilateral vascularized fibular transpositions (IVFTs) in the period 1978-1987. The procedure, which involves no microvascular anastomosis, was done for difficult problems of the tibia including two long-standing posttraumatic nonunions, three allograft nonunions after tumor surgery, and four segmental tibial defects also after tumor surgery. The average duration of problems before surgery was 3.5 years, and the patients averaged 3.1 procedures before IVFT. The patients were followed for an average of 52.4 months. The average time to union was 4.2 months, and in all patients the grafts healed within six months. Late fracture of the graft developed in two patients after fixation removal; one required an additional procedure, and both eventually healed. Ipsilateral vascularized fibular grafting is a useful alternative to conventional, nonvascularized grafts for difficult tibial nonunions and segmental defects. It offers the advantages of a vascularized graft (early healing and hypertrophy), yet avoids the time-consuming microvascular anastomosis and distant donor site morbidity of free fibular grafts.     

Indications for use of the long Gamma nail

A retrospective analysis of 42 patients treated by intramedullary nailing with the Gamma nail with a mean followup of 22.4 months is reported. The indications for the use of this nail were subtrochanteric fractures in 31 cases, diaphyseal femoral fractures in 10 cases, and segmental fracture in one case. Seven cases of the diaphyseal fractures were renailings for a previously placed nail. There was one pathologic fracture in the subtrochanteric group and three in the diaphyseal group. The indications of this new technique and its complications are analyzed.     

Intestinal flora in the neonate: impact on morbidity and therapeutic perspectives

A nonunion of a diaphyseal fracture of the humerus can present a major functional problem even in the elderly population. Advances in operative exposures combined with newer techniques of achieving stable internal fixation even in the presence of pathologic bone have enabled the surgeon to successfully treat even the most complex nonunions.     

Recalcitrant nonunion

One surgeon treated 13 patients with 14 long home fractures that remained ununited for 10 or more years (average, 16 years) and after an average of three prior surgeries. The clavicle was involved in two cases, the humerus in five (one proximal, three diaphyseal, and one distal intraarticular), the femoral diaphysis in three, and the tibial diaphysis in four. The patients were observed for an average of 54 months. All of the fractures healed, and every patient in the series regained functional use of the involved limb without reports of pain, instability, or persistent swelling related to the site of nonunion. Three patients had persistent leg length discrepancies, and five had substantial residual stiffness of one or both adjacent joints. This experience has shown that despite the longevity of the nonunions, healing can be achieved using the basic concepts of the creation of a stable skeletal fixation in the presence of a well vascularized environments with the addition of autogenous bone graft. By the same token, the duration of the nonunion will lead to soft tissue maladaptation and contracture that at times compromise successful restoration of limb length or adjacent articular mobility.     

Use of full cortical allograft to repair a metatarsal fracture in a foal

A 4-month-old Quarter Horse colt was admitted for repair of an open, comminuted fracture of the proximal portions of the diaphyses of the left second, third, and fourth metatarsal bones. Initial repair included internal fixation and cancellous bone graft. However, the third metatarsal bone became infected and failed to heal. After removal of infected portions of the bone, a 5-cm, fullthickness cortical allograft was placed in the defect. Rigid internal fixation provided stability for the allograft and remaining fracture fragments so that the horse was able to bear weight on the second and fourth metatarsal bones. The allograft was ultimately resorbed; however, appositional bone growth permitted a massive, functional metatarsal bone to form that incorporated the second, third, and fourth metatarsal bones. The colt went on to compete successfully, long term, as a show horse.     

Loss of dopamine D2 receptors in Alzheimer''s disease with parkinsonism but not Parkinson''s or Alzheimer''s disease

Qualitative analyses of midfoot stabilization in triple arthrodeses utilizing bone staple versus 4.5-mm cannulated cancellous screw fixation, with and without washers, were performed in fresh cadaveric specimens. Twenty-two trials (11 matched-pair feet) were used for direct comparison. Stiffness, defined as force/displacement, was determined at each talonavicular and calcaneocuboid joint. Ultimate load failure points of each specimen were also calculated. Trial results showed no statistically significant difference in stiffness or ultimate failure between these two forms of midfoot fixation for triple arthrodeses.     

Interlocking compression nailing: a report on 402 applications

Nailing techniques have changed tremendously in recent years. One significant development has been the interlocking compression nail (ICN) which provides active interfragmentary compression. Apart from its beneficial effect in the treatment of acute fractures, allowing early weight-bearing and mobilization of the patient the ICN is useful in many types of revision operations: resection and stabilization of pseudarthroses without cancellous bone grafts, corrective operations of malalignments through a minimally invasive technique, as well as the readaptation of the resection sites in arthrodeses. Between April 1993 and September 1996, 402 consecutive applications of an ICN were followed prospectively to evaluate the practibility and reliability of the system. A special focus was placed on the active compression device. Along with 153 acute fractures, 112 non-unions and 41 cases of malalignment were treated; 96 arthrodeses were performed. Even for difficult courses of healing only a low complication rate was observed, and a remarkably high percentage was managed successfully.     

The reconstruction locked nail for complex fractures of the proximal femur

Thirty-seven patients with 37 proximal femoral fractures were treated with a reconstruction locked femoral nail. There were four ipsilateral intracapsular femoral neck and shaft fractures, two intertrochanteric fractures, 18 intertrochanteric fractures with diaphyseal extension, eight subtrochanteric fractures with involvement of the lesser trochanter, and five subtrochanteric fractures without involvement of the lesser trochanter. The overall union rate was 92%. Twenty-one complications developed in 13 patients (35%) which included three of the four femoral neck and shaft fractures, and six of 18 intertrochanteric fractures with diaphyseal extension. Of the five intertrochanteric fractures with diaphyseal extension in which anatomic reduction was not achieved, four developed a complication. Of the nine proximal screws in nine fractures, which were placed short (below the subchondral bone of the femoral head), six fractures developed a complication. The complications included three nonunions, one delayed union, two leg-length discrepancies of > 2.5 cm, two cases of varus deformity of > 10 degrees, two varus deformities < 10 degrees, four instances of revision surgery including one broken 13-mm nail, four proximal screws that backed out and required removal, two cases of pudendal nerve palsy, and one case of heterotopic ossification. Seven patients developed more than one complication. Eleven of the 13 patients with complications required a second surgery to treat the complication. We conclude that the reconstruction locked femoral nail is not a good choice for ipsilateral intracapsular neck and shaft fractures. Our recommendation is that anatomic reduction should be achieved for all cases using the reconstruction femoral nail, but it is absolutely required when treating the intertrochanteric fracture with diaphyseal extension. Reconstruction femoral nails have a high rate of complication due to the complex nature of the fractures as well as the device.     

Proximal femur fractures after free vascularized fibular grafting to the hip

The management of symptomatic femoral head osteonecrosis in young, active patients is troublesome and controversial. At the authors' institution, 707 consecutive free vascularized fibular grafts were performed for femoral head osteonecrosis between October 1979 and October 1995. Patients who underwent this procedure were at increased risk for proximal femur fractures because of the 16 to 21 mm core drilled through the lateral femoral cortex for removal of the avascular bone and placement of the fibular graft. An ongoing prospective database of patients who underwent this procedure was accessed to determine the incidence of and factors associated with postoperative subtrochanteric femur fractures. Eighteen subtrochanteric fractures occurred for an overall incidence of 2.5%. All fractures occurred through the core decompression site in the lateral femoral cortex. The treatment was nonoperative in seven patients and operative in 11. Fourteen of 18 fractures (77%) healed with an average of 4.1 months until radiographically documented union. Four fractures had nonunions develop, three of which later healed with bone grafting and internal fixation, whereas the fourth eventually required conversion to total hip arthroplasty. Twelve fractures in 251 patients occurred when the weightbearing regimen was touchdown weightbearing for the first 6 weeks and five fractures in 456 patients occurred when the weightbearing regimen was changed to nonweightbearing. The results indicate that nonweightbearing in the immediate postoperative period is associated with the lowest fracture rate.     

Treatment of tibial plateau fractures by limited internal fixation

Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.