Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the "constant fragment" in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures

Heterotopic Ossification following Suprapatellar Intramedullary Nailing.

Introduction: Tibial shaft fractures are common fractures seen in trauma and orthopedic practice today. The majority of these fractures are treated with intramedullary nailing (IMN) which is rapidly becoming a gold standard. The procedure itself is performed by either a suprapatellar approach or infrapatellar approach. Suprapatellar approach is gaining popularity due to relative ease of insertion, decreased associated risk of anterior knee pain, and more accurate reduction. We report a case of heterotopic ossification noted in the knee following IMN of tibia performed using a suprapatellar approach. Case Report: A 27-year-old male, having sustained a left, Gustilo IIIB tibial shaft fracture following a motor vehicle accident, underwent a reamed intramedullary nail fixation performed through a suprapatellar approach. Two months later, he presented with intra-articular heterotopic ossification which was limiting his knee movement. He then underwent arthroscopic removal of the bony fragments which resolved his symptoms. Conclusion: An extensive search of literature did not yield any reported incidence of heterotopic ossification associated with IMN performed through a suprapatellar approach. We present this case report to raise awareness that although IMN through a suprapatellar approach is a safe approach, it does have associated risk of heterotopic ossification which needs to be included in the consent process

Effective treatment with rituximab for the maintenance of remission in frequently relapsing minimal change disease

AIM: Treatment of frequently relapsing or steroid-dependent minimal change disease (MCD) in children and adults remains challenging. Glucocorticoids and/or other immunosuppressive agents are the mainstay of treatment, but patients often experience toxicity from prolonged exposure and may either become treatment dependent and/or resistant. Increasing evidence suggests that rituximab (RTX) can be a useful alternative to standard immunosuppression and allow withdrawal of maintenance immunosuppressants; however, data on optimal treatment regimens, long-term efficacy and safety are still limited. METHODS: We undertook a prospective study of RTX to allow immunosuppression minimization in 15 young adults with frequently relapsing or steroid-dependent, biopsy-proven MCD. All patients were in remission at the start of treatment and on a calcineurin inhibitor. Two doses of RTX (1 gr) were given 6 months apart. A subset of patients also received an additional dose 12 months later, in order to examine the benefit of re-treatment. Biochemical and clinical parameters were monitored over an extended follow-up period of up to 43 months. RESULTS: Median steroid-free survival after RTX was 25 months (range 4-34). Mean relapse frequency decreased from 2.60 ± 0.28 to 0.4 ± 0.19 (P < 0.001) after RTX. Seven relapses occurred, five of which (71%) when CD19 counts were greater than 100 µ. Immunoglobulin levels remained unchanged, and no major side effects were observed throughout the follow-up period. CONCLUSIONS: Rituximab therapy is effective at maintaining prolonged steroid-free remission and reducing relapse frequency in this group of patients. Our study lends further support for the role of RTX in the treatment of patients with frequently relapsing or steroid-dependent MCD

How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study.

BACKGROUND: Tibial fractures have an incidence of 15% of all adult fractures. They have been shown to have the highest incidence of non-union in long bone fractures and the highest incidence of vascular injury. Evidence from the literature suggests that a good vascular supply is important to ensure bone union. The aim of our study was to prospectively assess the incidence of vascular injuries in open tibial fractures and determine whether they were associated with an increased risk of non-union. METHODS: We performed a prospective study to investigate the incidence of arterial injuries with computed tomography angiography (CTA) in patients with Gustilo-Anderson grade I-III open tibial fractures between 2013 and 2015. CTA was performed with the trauma series at acute admission and reported by two independent musculoskeletal radiologists. Patients were followed up with clinical and radiographic assessment for 1 year. RESULTS: We recruited 77 patients into the study, and 56 patients (47 males, 9 females) were available for the final analysis, between 16 and 90 years of age. At the initial assessment, 29% had signs of arterial injury with active extravasation in 5%. The most common site of injury was in the diaphysis (87.5%), and the commonest mechanism was a road traffic accident. We found no significant relation between occult vascular injury and non-union (p > 0.05). CONCLUSION: The incidence of vascular injury in open tibial fractures is 29%, and CTA is therefore a useful test in identifying vascular injuries that may require vascular intervention

Augmented compression in exchange nailing for femoral and tibial non-unions accelerates time to radiographic union.

PURPOSE: Exchange nailing is widely used for the management of aseptic femoral and tibial non-union. Compressive forces markedly reduce strain, increasing rate and incidence of union. Additional compressive forces can be applied to the non-union site by using the design features of some modern nailing systems. This study hypothesises that the use of additional compression in exchange nailing results in faster time to union. METHODS: All femoral and tibial shaft non-unions were identified over a 4-year period between 2014-2018. Intraoperative compression during exchange nailing was either applied or not applied with a dedicated active compression device through the intramedullary nail. An initial 'radiographic union score for tibia' (RUST) score was calculated from preoperative lateral and AP radiographs and compared with the postoperative radiographs at 6-8 weeks. Healing was defined as bridging callus on at least three cortices (RUST > 10). RESULTS: A total of 119 patients were identified. Following application of exclusion criteria, we analysed data for 19 patients, 10 undergoing exchange nailing with intraoperative compression and 9 without. The pre-exchange RUST score was comparable between the compressed group and standard exchange group with mean of 7.11 versus 7.5 (p = 0.636). At 6-8 weeks post-op, there was a significant difference between the median RUST score in the compressed group vs standard exchange group, 11 compared to 8.39 (p = 0.001). CONCLUSIONS: Our study shows that time to union was accelerated when additional compression was applied to exchange nailing, resulting in reduced follow-up visits and number of radiographs required

Schrodinger cat states prepared by Bloch oscillation in a spin-dependent optical lattice

We propose to use Bloch oscillation of ultra-cold atoms in a spin-dependent optical lattice to prepare schrodinger cat states. Depending on its internal state, an atom feels different periodic potentials and thus has different energy band structures for its center-of-mass motion. Consequently, under the same gravity force, the wave packets associated with different internal states perform Bloch oscillation of different amplitudes in space and in particular they can be macroscopically displaced with respect to each other. In this way, a cat state can be prepared.Comment: 4 pages, 3 figures; slightly modifie