Injury
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Fracture healing is a complex physiological process. With the latest advances made in molecular biology and genetics it is now known that it involves the spatial and temporal coordinated action of several different cell types, proteins and the expression of hundreds of genes working towards restoring its structural integrity without scar formation. ⋯ The available scientific evidence supports the view that all the 4 known factors contributing to bone restoration should be given an equal acknowledgment and recognition. The traditional discussed triangular concept therefore should be reconsidered and be accepted as the 'diamond concept'.
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Most surgeons feel that angular stable implants have improve the ability to obtain reliable fixation of an osteoporotic fracture of the proximal humerus fracture, but complications such as varus fracture collapse and screw penetration of the articular surface remain problematic. The use of limited drilling, blunt tipped locking bolts and routine incorporation of the rotator cuff into the internal fixation construct may help limit these complications. It may be of benefit to replace the concept of standard screw fixation of the osteoporotic proximal humerus with a concept of an angular stable scaffold support of the subchondral bone combined with fixation that does not rely on bone quality and utilizes the more predictable fixation of sutures through the rotator cuff attachments.
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Post-trauma and post-partum pelvic ring instability and non-union are treated operatively with internal fixation and a biological enhancement stimulus. The application of BMP-7 in nine cases of persistent instability located at the anterior or the posterior elements of the pelvic girdle is prospectively evaluated for its safety and efficacy. ⋯ Encouraging results of biological enhancement of bone healing with BMP-7 at the clinical setting of traumatic pelvic ring non-unions and postpartum instability were achieved. The implantation of BMP-7 in pelvic reconstruction procedures adds another alternative to the treatment methods of contemporary orthopaedics.
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While the rate of failure following hip fracture surgery for extracapsular hip fractures in the elderly is low, an incidence of implant cutout from the femoral head remains regardless of whether fixation is by sliding hip screw or intramedullary nail. In general, a well-executed osteosynthesis is the best assurance of a good outcome with few complications, and typically a less than ideal placement of the implant in the femoral head is the reason for cut-out and failure of the operation. ⋯ However, what is less clear is whether there are newer ideas and/or implant designs that represent true advances in the treatment of extracapsular fractures in the elderly. The following review focuses on just this issue.
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The treatment of complex non-unions may be lengthy and very expensive. The majority of aseptic non-union cases require a variable degree of biological enhancement. ⋯ However, other means of biological stimulation are currently available in the armamentarium of the treating physician. This review article reports on the different available biological treatment options for the management of complex aseptic bone non-unions.