Fracture healing and bone repair are postnatal

Fracture healing and bone repair are postnatal processes that mirror many of the ontological events that take place during embryonic development of the skeleton and have been extensively reviewed. The recapitulation of these ontological processes is believed to make fracture healing one of the few postnatal processes that is truly regenerative, restoring the damaged skeletal organ to its pre-injury cellular composition, structure and bio- mechanical function. Interestingly, a comparison of the transcriptome of mouse callus tissues across a 21-day period of fracture healing showed that about one-third of the mouse homologues of the genes expressed by human embryonic stem cells are preferentially induced. Many of the homeotic genes that control appendicular limb development also show increased expression during fracture healing.Finally, all the primary morphogenetic pathways that are active during embryonic skeletal development are expressed in fracture calluses,and have therefore become the focal point of efforts to develop new therapies. In this Review, we place these biological processes in the context of how trauma and the immune system, as a component of the injury response, are related to the developmental aspects of fracture healing. We then review the relationships between ontogeny and the recovery of skeletal function. Finally, we focus on specific biophysical, local and systemic therapies that have been used to promote fracture healing and on the various biological processes they promote.

Phases of fracture healing

Fracture healing and skeletal tissue repair involve an initial anabolic phase characterized by an increase in tissue volume related to the de novo recruitment and differentiation of stem cells that form skeletal and vascular tissues. Immediately adjacent to the fracture line, a cartilaginous callus will form. Peripheral to this central region, at the edges of the new cartilage tissues, the periosteum swells and primary bone formation is initiated. Concurrent with cartilage tissue development, cells that will form the nascent blood vessels that supply the new bone are recruited and differentiate in the surrounding muscle sheath. The increases in the vascular bed that surrounds and then grows into the callus are further reflected by the increased blood flow into the area of tissue repair. As chondrocyte differentiation progresses, the cartilage extracellular matrix undergoes mineralization and the anabolic phase of fracture repair terminates with chondrocyte apoptosis. The histological and cellular progression of these events .The anabolic phase is followed by a prolonged phase in which catabolic activities predominate, and is characterized by a reduction in the volume of the callus tissues. During this phase of predominately catabolic activity, such as cartilage resorption, specific anabolic processes continue to take place; secondary bone formation is initiated as the cartilage is resorbed and primary angiogenesis continues as the nascent bone tissues replace the cartilage. Subsequently, when bone remodelling begins, the first mineralized matrix produced during primary bone formation is resorbed by osteoclasts, and then the secondary bone laid down during the period of cartilage resorption is also resorbed. As the bony callus tissue continues to be resorbed, this prolonged period is characterized by coupled cycles of osteoblast and osteoclast activity in which the callus tissues are remodelled to the bone's original cortical structure (termed `coupled remodelling' here). During this period, the marrow space is re-established and the original marrow structure of haematopoietic tissue and bone is regenerated. In the final period of the catabolic phase, extensive vascular remodelling takes place in which the increased vascular bed regresses and the high vascular flow rate returns to its pre-injury level. Although these processes take place consecutively, they overlap substantially and are a continuum of changing cell populations and signalling processes within the regenerating tissue.

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What is Flat Foot Reconstruction

What is Flat Foot Reconstruction

Flat feet (sometimes referred to as “fallen arches”) are very common and may occur in childhood (when arches do not properly develop) or adulthood (when arches fall over time). Although many cases of flat feet do not require surgery, a surgical approach may be recommended if painful symptoms persist and non-surgical therapies are not successful.

The goal of flat foot reconstruction is to properly realign the foot with a combination of procedures, tailored to the individual’s needs, to relieve pain, redistribute pressure and restore function. Flat foot reconstruction may involve tendon and ligament repair, bone cuts and/or joint fusion to provide the most optimal long term result.

It is important to begin treatment as early as possible. Over time, flat feet may result in arthritis and stiffness which can make the condition more difficult to treat.
What types of Flat Foot Reconstruction does Mercy offer?

Surgical treatment for an adult flat foot deformity can include several types of procedures:Tendon Repair and Transfer
Ligament Reconstruction
Bone Cuts and Realignment
Joint Fusion

Tendon Repair and Transfer / Ligament Reconstruction

If the posterior tibial tendon (a tendon which runs underneath the arch of the foot) has ruptured and is causing the flat foot, it will not be possible to repair the tendon because it will quickly stretch out and tear again. In this case the surgeon will use a tendon transfer to correct the issue. The surgeon may also repair damaged ligaments to help support the reconstructed arch.
Bone Cuts and Realignment

There are several different types of bone cuts (osteotomies) that may be used to realign the foot and repair a flat foot.

A posterior tibial tendon transfer is often combined with a cut on the heel bone (calcaneal osteotomy) in order to shift the heel bone and add support to the tendon transfer. The heel is fixed in place with metal screws or a plate.

In more severe cases osteotomies are used to reshape and elongate part of the foot. Some of these procedures require a bone graft. Bone grafts may be taken from the patient’s own bone (typically from the hip) or a bone bank, which can significantly reduce risks associated with removing bone from the pelvis. The graft is carefully shaped and placed to reform the natural shape of the foot.
Joint Fusion

Severe, late stages of flat foot tend to be inflexible (stiff) and require joint fusion (called arthrodesis) within the foot. The surgeon may need to join one or more joints together permanently with screws. In this case inward/outward movement of the foot may be lost, however, up and down movement of the foot is maintained.

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Hip Replacement Surgery

During hip replacement, a surgeon removes the damaged sections of the hip joint and replaces them with parts usually constructed of metal, ceramic and very hard plastic. This artificial joint (prosthesis) helps reduce pain and improve function.

Also called total hip arthroplasty, hip replacement surgery might be an option if hip pain interferes with daily activities and nonsurgical treatments haven't helped or are no longer effective. Arthritis damage is the most common reason to need hip replacement.

Conditions that can damage the hip joint, sometimes making hip replacement surgery necessary, include:

Osteoarthritis. Commonly known as wear-and-tear arthritis, osteoarthritis damages the slick cartilage that covers the ends of bones and helps joints move smoothly.
Rheumatoid arthritis. Caused by an overactive immune system, rheumatoid arthritis produces a type of inflammation that can erode cartilage and occasionally underlying bone, resulting in damaged and deformed joints.
Osteonecrosis. If there isn't enough blood supplied to the ball portion of the hip joint, such as might result from a dislocation or fracture, the bone might collapse and deform.

Hip replacement may be an option if hip pain:

     * Persists, despite pain medication
     * Worsens with walking, even with a cane or walker
     * Interferes with sleep
     * Affects the ability to walk up or down stairs
     * Makes it difficult to rise from a seated position

Blood clots. Clots can form in the leg veins after surgery. This can be dangerous because a piece of a clot can break off and travel to the lung, heart or, rarely, the brain. Blood-thinning medications can reduce this risk.

Infection. Infections can occur at the site of the incision and in the deeper tissue near the new hip. Most infections are treated with antibiotics, but a major infection near the new hip might require surgery to remove and replace the artificial parts

Fracture. During surgery, healthy portions of the hip joint might fracture. Sometimes the fractures are small enough to heal on their own, but larger fractures might need to be stabilized with wires, screws, and possibly a metal plate or bone grafts.

Dislocation. Certain positions can cause the ball of the new joint to come out of the socket, particularly in the first few months after surgery. If the hip dislocates, a brace can help keep the hip in the correct position. If the hip keeps dislocating, surgery may be needed to stabilize it.

Change in leg length. Surgeons take steps to avoid the problem, but occasionally a new hip makes one leg longer or shorter than the other. Sometimes this is caused by a contracture of muscles around the hip. In these cases, progressively strengthening and stretching those muscles might help. Small differences in leg length usually aren't noticeable after a few months.

Loosening. Although this complication is rare with newer implants, the new joint might not become solidly fixed to the bone or might loosen over time, causing pain in the hip. Surgery might be needed to fix the problem.

         Nerve damage. Rarely, nerves in the area where the implant is placed can be injured. Nerve damage can cause numbness, weakness and pain.

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Midsubstance repair is an alternative technique to treat Achilles tendon ruptures

 The minimally invasive midsubstance surgical technique for acute midsubstance Achilles tendon ruptures passes sutures longitudinally through the distal Achilles stump and anchors proximal sutures into the calcaneus for early range of motion and weight-bearing.The midsubstance SpeedBridge (Arthrex) technique may be particularly helpful for distal Achilles tears when a limited amount of the patient’s tendon is available.

Distal anchor preparation

If fixation of the proximal Achilles tendon sutures to bone is desired, the midsubstance construct can be used instead of distal Achilles tendon percutaneous suture passing. Two longitudinal incisions are made along the posterior aspect of the heel at the peripheral insertion of the Achilles tendon distal to the maximal convexity. Incisions are spaced along the sides of the Achilles tendon insertion. A 3.5-mm drill and drill guide are used through each incision and placed flush against bone (Figure 1). The drill is inserted into bone and oriented slightly convergent towards midline and slightly plantar. Each drill hole widened using a tap.

A rigid suture passer with inner Nitinol wire is passed longitudinally through the center of the distal Achilles tendon stump using controlled, continuous pressure. The surgeon’s dominant thumb guides the sharp tip of the passer through tendon. The passer is brought out through the proximal incision to retrieve one pair of proximal sutures. During suture passing, the Nitinol wire is drawn back to the tip of the passer. Then, the entire device is removed from the distal incision. Trying to pass the sutures only through the inner Nitinol wire can result in suture tangling and increased resistance.

Achilles tensioning, anchor insertion

The ankle is plantar flexed to tension the Achilles so that end-to-end proximal and distal tendon apposition is achieved. An assistant holds tension on the opposite pair of sutures to ensure that Achilles tension does not change prior to anchor insertion. The rupture site should be palpated to confirm that no residual gap or excessive overlap of the tendon ends is present. Sutures are passed through the eyelet of the 4.75-mm anchor, which is gently malleted into the calcaneal drill hole and hand tightened until the anchor is flush with or slightly buried in the bone.

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Closed-Suction Drain Use in Shoulder Arthroplasties

Closed-suction drainage after total hip (THA), knee (TKA), and shoulder (TSA) arthroplasty has been routinely used by surgeons for years. This procedure was thought to improve healing and reduce infections; however, these benefits have not been proven in THA and TKA literature. Research in this area has found closed-suction drainage increases post-operative blood-loss, elevates the need for blood transfusions, escalates the risk of infection and has no proven benefits in healing wounds.

Despite current research showing the lack of benefits in using closed-suction drainage after THA and TKA, there has been little research on the benefits or risks of closed-suction drainage on TSA. As a result, Columbia Orthopedics providers David P. Trofa, MD, Charles M. Jobin, MD, William N. Levine, MD and Christopher S. Ahmad, MD conducted a prospective evaluation of drain use in TSA to determine the benefits, risks, and costs associated with this procedure

“Drains are commonly used after shoulder arthroplasties, despite no evidence that they improve patient outcomes. In fact, literature from hip and knee arthroplasty investigations have shown that drains increase post-operative transfusion rates and result in increased hospital costs,” said Dr. Trofa. “The purpose of this prospective randomized controlled trial was to assess immediate outcomes during the peri-operative period associated with drain use in the setting of a shoulder arthroplasty.”

The study, titled “Short-term outcomes associated with drain use in should arthroplasties: a prospective, randomized controlled trial,” was conducted at a tertiary referral center and studied 100 consecutive TSA patients from December 2015 to 2017, who did or did not receive closed-suction drainage devices at the time of the surgery. Patient demographic information as well as intraoperative and post-operative data was collected for each patient. Columbia Orthopedics providers hypothesized that the drain use would result in lower hemoglobin (HgB) and hematocrit (Hct) levels, higher transfusion requirements, longer hospital durations, and increased cost; but no differences in wound complications. As hypothesized, the drain use had no effect on the immediate post-operative outcomes of patients undergoing TSA. However, the results also illustrated that drain use had no effect on post-operative blood transfusions and was not associated with an increased hospital stay.

“After randomizing 100 patients we identified no significant differences between patients who received a drain and those that did not,” stated Dr. Trofa. “Additionally, we found an average cost increase of $7,423.00 associated with drain use, which while not statistically significant, represents a significant yet unnecessary healthcare expenditure. As such, we concluded that while drain usage is safe, it is unnecessary for routine shoulder arthroplasty cases.”

#Shoulder surgery#Elbow Surgery
#musculoskeletal trauma#spine diseases
#Physiotherapy
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