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Long-bone fractures occasionally develop excessive callus formation in the presence of traumatic brain injury, a clinically relevant but poorly understood injury response. Although this phenomenon is known for decades, the causal factors are still underexplored, and no systemic biomarkers are currently available to predict the exuberant bone-mass-formation at an early timepoint after injury. In this study, we used small-RNA-seq, bioinformatic analyses, and in vitro assays to identify a set of micro-RNAs in sera of hypertrophic callus patients that could serve as potential biomarkers. The identified miRNAs are highly expressed in the human brain, particularly in the pituitary gland, and have been shown to regulate mRNA targets implicated in osteogenic processes.

Aims The BioBone consortium aims to validate circulating CD8 + TEMRA cells as a prognostic biomarker for predicting impaired fracture healing outcomes in a prospective, blinded, multicenter clinical study. The primary performance parameters are the pre-operative identification of at least 30% of patients who ultimately experience impaired healing at the first clinical endpoint, with a specificity greater than 90% to minimize the false-positive rate. Methods BioBone is a prospective, blinded, multicenter biomarker validation study designed to assess the prognostic value of circulating CD8 + TEMRA cells in fracture healing. A total of 640 patients aged 18 to 80 years with fractures of the humeral diaphysis, radial and/or ulnar diaphysis, femoral neck, trochanteric femur, femoral diaphysis, distal femur, proximal tibia, tibial diaphysis and distal tibia will be enrolled. The study is powered to validate the target assay performance and accounting for 6–7 potential confounders at an expected incidence of 10% impaired healing. Biomarker levels will be measured pre- and post-operatively using flow cytometry (FC) and patients will be monitored for one year. The primary endpoint is fracture healing status at 17–19 weeks (normal healing or delayed healing), while the secondary endpoint evaluates healing at nine months (delayed healing or pseudarthrosis). Fracture consolidation will be assessed through radiographs or computed tomography (CT) scans in conjunction with clinical assessments such as range of motion and weight-bearing capacity. Key outcome measures include radiographic analysis (RUST/RUSH scores), functional and patient-reported outcomes (e.g. weight bearing ability, range of motion, and the SF-36 questionnaire), as well as socioeconomic parameters (e.g. work capacity, rehabilitation needs, mobility). The predictive performance (sensitivity, specificity, NPV, PPV) of the biomarker will be determined in a prospective, double-blinded analysis, where CD8 + TEMRA blood levels are measured prior to surgical treatment and healing status at clinical endpoints is assessed by independent observers. Additional immunological examination and in vitro analysis of blood and fracture hematoma samples will further investigate the mechanism of action of CD8 + TEMRA cells in impaired human bone regeneration. Conclusion The BioBone study will validate the suitability of CD8 + TEMRA cells as a prognostic marker for impaired fracture healing and their integration into routine clinical practice. The results could have a global impact by incorporating immune-based prognostic tools into clinical workflows, paving the way for precision medicine approaches in trauma care. The BioBone study is funded by the German Federal Ministry of Education and Research (BMBF).

Background Trauma is now one of the fastest growing epidemics globally but low and middle-income countries (LMICs) are more severely affected in terms of cost, disability and death. The high-energy trauma of road traffic accidents and violence often produces open fractures which can be difficult to manage in resource-poor settings. Adequate stabilization, such as provided by locked nails, has been found to ensure better outcome for open fractures. There is dearth of published studies on the use of locked intramedullary nail in the treatment of open fractures in Nigeria. Methods This is a prospective observational study of all the 101 open fractures of the humerus, femur and tibia treated over a period of 92 months with Surgical Implant Generation Network (SIGN) nail. Fracture severity was classified according to the modified Gustilo-Anderson system. The intervals between fracture and antibiotics administration, débridement and definitive fixation, as well as surgery duration and method of fracture reduction were noted. Outcomes measured at follow-up included infection, ongoing radiographic healing, knee flexion/shoulder abduction beyond ninety degrees (KF/SA > 90 0 ), full weight bearing (FWB), painless squatting (PS&S)/shoulder abduction-external rotation (SAER). Results Most of the patients fall between ages 20 and 49 years; 75.5% of them were males. There were more Gustilo-Anderson type IIIA fractures than other types but nine type IIIB tibia fractures were also nailed. The overall infection rate was 15%, contributed mostly by the type IIIB fractures. By the 12th post-operative week, at least 79% had ongoing radiographic healing and had achieved all of KF/SA > 90 0 , FWB, and PS&S/SAER. Conclusion The SIGN nail’s solid construct reduces the risk of infection and allows earlier use of the limb, making it particularly suitable in LIMCs where socioeconomic functioning often requires an unhindered use of the limbs.

BackgroundOne of the challenge to manage long bone fracture is the risk of infection. Intramedullary nailing is the standard treatment of long bone shaft fractures. Infection from the surgical site during orthopedic management is posing postoperative burdens in different perspectives like patient perspectives and healthcare facilities. However, there is limited information on the magnitude of infection in Ethiopia after surgical implant generation network (SIGN) nailing in the treatment of long bone shaft fractures. Therefore, the current study aimed to assess the prevalence of infection in patients with long bone shaft fractures treated with surgical implant generation network (SIGN) nailing.ObjectiveTo assess prevalence of infection in patients with long bone shaft fractures treated with SIGN nailing at Felege Hiwot Referral Hospital from January 1, 2015, to December 31, 2018, Bahir Dar, Northwest, Ethiopia.MethodsThis was a retrospective study over a period of 4 years. SIGN surgical-related data, presence or absence of infection from the documented information were collected from the chart/the source. The types of infection were also collected with the standard classification as superficial, deep and deep with osteomyelitis. Age, sex, fracture pattern, nature of fracture, mechanism of injury, prophylaxis antibiotics, nail type, follow-up in weeks and other factors were also extracted from the patients’ charts with structured checklist. Data were analyzed with statistical package for social sciences (SPSS) version 23. The analyzed data were presented with texts, tables and a graph.ResultsThree hundred and eighty-two long bone fractures were treated by locked SIGN intramedullary nailing during the study period. After screening the inclusion criteria, a total of 311 cases were included in this study. A total of 13 (4.2%) patients who treated with SIGN intramedullary nailing developed infection.ConclusionsWe conclude that the overall prevalence of infection with SIGN intramedullary nailing is almost similar with the surgeries done in the developed countries.

Background Children and adolescents are at high risk of sustaining fractures during growth. Therefore, epidemiological assessment is crucial for fracture prevention. The AO Comprehensive Injury Automatic Classifier (AO COIAC) was used to evaluate epidemiological data of pediatric long bone fractures in a large cohort. Methods Data from children and adolescents with long bone fractures sustained between 2009 and 2011, treated at either of two tertiary pediatric surgery hospitals in Switzerland, were retrospectively collected. Fractures were classified according to the AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF). Age, sex, BMI, injury and treatment data were recorded. Children were classified into four age classes and five BMI classes were applied. Seven major accident categories were established. Study parameters were tabulated using standard descriptive statistics. The relationship of categorical variables was tested using the chi-square test. The Children’s BMI was compared to WHO reference data and Swiss population data. Results For a total of 2716 patients (60% boys), 2807 accidents with 2840 long bone fractures (59% radius/ulna; 21% humerus; 15% tibia/fibula; 5% femur) were documented. Children’s mean age (SD) was 8.2 (4.0) years (6% infants; 26% preschool children; 40% school children; 28% adolescents). Adolescent boys sustained more fractures than girls (p < 0.001). The leading cause of fractures was falls (27%), followed by accidents occurring during leisure activities (25%), at home (14%), on playgrounds (11%), and traffic (11%) and school accidents (8%). There was boy predominance for all accident types except for playground and at home accidents. The distribution of accident types differed according to age classes (p < 0.001). Twenty-six percent of patients were classed as overweight or obese — higher than data published by the WHO for the corresponding ages — with a higher proportion of overweight and obese boys than in the Swiss population (p < 0.0001). Conclusion Overall, differences in the fracture distribution were sex and age related. Overweight and obese patients seemed to be at increased risk of sustaining fractures. Our data give valuable input into future development of prevention strategies. The AO PCCF proved to be useful in epidemiological reporting and analysis of pediatric long bone fractures.

Background Wire cerclages play a fundamental role in fracture fixation. With an increasing variety of designs being commercially available the question arises which cerclage should be used. This study investigates the biomechanical properties of metallic and non-metallic cerclages and their different application-types. Furthermore, potential influence of muscular interposition between bone and cerclage constructs was tested. Methods Samples of the following four different cerclage types were tested on 3D printed models of human humeri as well as on human cadaveric humeri with and without muscular interposition: Titanium Cable Cerclage (CC), Steel Wire Cerclage (SWC), Suture Tape (ST), Suture Tape Cerclage (STC) with both single- (sSTC) and double-loop application (dSTC). A preinstalled self-locking mechanism secured by the provided tensioner in the STCs being the main difference to the STs. Cyclic loading was performed to 1 kN and then linearly to a maximum load of 3 kN. Statistical analysis was performed using either one-way ANOVA and post-hoc Tukey or Kruskal–Wallis and post-hoc Dunn test depending on normalization of data ( p  < 0.05). Results Whilst all cerclage options could withstand high loads during failure testing, only within the CC and dSTC group, all samples reached the maximal testing load of 3000 N without any failure. The SWC reached 2977.5 ± 63.6 N, the ST 1970.8 ± 145.9 N, and the sSTC 1617.0 ± 341.6 N on average. Neither muscular interposition nor bone quality showed to have a negative influence on the biomechanical properties of the cerclage constructs, presenting no significant differences. Conclusion All tested cerclage constructs produce reliable stability but differ in their resulting compression forces, in a simplified fracture model. Therefore, non-metallic cerclage alternatives can provide similar stability with less compression and stiffness to metallic cable constructs, but they may offer several advantages and could possibly provide future benefits. Especially, by offering more elasticity without losing overall stability, may offer a biologic benefit. Installing any cerclage constructs should be performed carefully, especially if poor bone quality is present, as the tightening process leads to high forces on the construct.

Introduction  Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma. Materials and Methods A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery. Results Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7–35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8–4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2–9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13–50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study. Conclusions  Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Birth-related fractures are an important differential diagnosis of child abuse in early infancy. While fractures associated to vaginal deliveries are well known, cesarean section is not necessarily known to cause such injuries. Nevertheless neonatal fractures have been described after cesarean sections. To give an overview over the frequency and typical locations of such fractures, the appearance of symptoms and the timespan until diagnosis, a literature research was conducted via Google scholar and Pubmed, using the key words “cesarean section” and “fractures”. Birth-related fractures after cesarean sections are rare but can occur, with the long bones being particularly affected. Therefore, birth injuries should always be considered in the forensic medical assessment of fractures in early infancy, even after cesarean section. To enable a differentiation between birth trauma and physical abuse, birth and operation records should be checked for surgical manoeuvres, possible difficulties during the procedure or other risk factors. Birth-related fractures are usually detected early; in rare cases, the diagnosis is made only weeks after birth.

Background Pulsed electromagnetic field (PEMF) is reported to be an effective adjunct for the management of nonunion long-bone fractures. Most studies implement PEMF treatment after 6 months or longer of delayed union or nonunion following fracture treatment. Despite these variations in treatment, the early application of PEMF following a diagnosis of a postoperative delayed union has not been specifically analyzed. In this study, the outcomes of postoperative delayed union of long-bone fractures treated with an early application of PEMF were evaluated as compared with a sham-treated control group. Methods In this prospective, randomized controlled study, a total of 58 long-bone fracture patients, who presented with delayed union of between 16 weeks and 6 months, were randomly split into two groups and subjected to an early application of PEMF or sham treatment. Clinical and radiological assessments were performed to evaluate the healing status. Treatment efficacy was assessed at three month intervals. Results Patients in the PEMF group showed a higher rate of union than those in the control group after the first three months of treatment, but this difference failed to achieve statistical significance. At the end of the study, PEMF treatment conducted for an average of 4.8 months led to a success rate of 77.4%. This was significantly higher than the control, which had an average duration of 4.4 months and a success rate of 48.1%. The total time from operation to the end of the study was a mean of 9.6 months for patients in the PEMF group. Conclusions Fracture patients treated with an early application of PEMF achieved a significantly increased rate of union and an overall reduced suffering time compared with patients that receive PEMF after the 6 months or more of delayed union, as described by others.

ABSTRACT Fractures related to long bones in female Beetal goats fail to heal or show delayed healing that leads to intensified morbidity. Bone marrow aspirate (BMA) has been suggested as an efficient biological adjuvant for healing long bone fractures. BMA comprises bone mesenchymal stem cells. This study aims to assess the potential of autologous BMA on metacarpal and metatarsal fracture of Beetal goats presented at the surgery clinic of the University of Veterinary and Animal Sciences Lahore, Pakistan. Beetal goats were selected (n=20), and divided into four different groups. The first group was designated as bone plating with bone marrow aspirate (BPMA) in which fracture was reduced by using the bone plates along with the application of multiple BMA on days: 0, 14, 28, and 45. Furthermore, the second group was designated as bone plating with normal saline (BPNS) in which fracture was reduced by using the bone plates along with the application of normal saline. Additionally, the third group was designated as bone wiring with bone marrow aspirate (BWBM), and the fourth group, was bone wiring with normal saline (BWNS). Both third and fourth groups were treated with bone wiring along with BMA and bone wiring along with NS respectively. The rate of healing post-treatment was assessed by radiographic union score (RUS), weight-bearing score (WBS), and serobiochemical evaluations on days: 0, 7, 14, 28, and 45. Our data showed a significant difference in the healing of fractures treated with BMA as compared to NS on days; 7 and 14. Moreover, the RUS, WBS, and serobiochemical profiles of goats treated with BMA showed improved healing of fractures as compared to the goats treated with NS. In summary, we observed that the healing process of the metacarpal and metatarsal fractured bones was reduced by bone plating, and bone wiring was ameliorated with the application of multiple BMA. We proposed further studies on larger cohorts. BMA may be used as supportive therapy to enhance the healing process of fractures in goats.