A physiological approach in stabilization and consolidation of unstable femoral neck fracture in osteoporotic elderly patients: A retrospective review

ArticleinEuropean Journal of Orthopaedic Surgery & Traumatology 13(3):145-155 · September 2003with 15 Reads
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Abstract
A retrospective review was performed on 46 unstable femoral neck fractures in osteoporotic elderly patients. They were treated with internal fixation using a nail-plate associated with filling of the metaphysis with a biomaterial - natural coral - which undergoes bone incorporation. From 1992 to 1996, the increased knowledge for use of natural coral in the surgical procedures allowed a progressively decrease in the mean time to weight bearing, starting from 26.3 days (1992) to 11.2 days (1996). Primary stabilization at the fracture site was obtained in 42 patients (91.3%), clinically evidenced by the absence of pain from unlimited weight bearing. Only four mild impactions were reported. Consolidation was observed in all cases but one. Among them, more than half of the patients (53.3%) had a time to consolidation equal or lower than to 45 days; 70% healed in 2 months. Biocompatibility of the coral was perfect. Full bioresorbability was observed-partially in five cases, in all other cases from 3 to 18 months. The biomaterial was filled with bone marrow. It acts "as if" it was a real autologous graft. A mechanically perfectly stabilized fracture site, a large amount of biomaterial, a spheric shape, 4 mm diameter, injected with bone marrow, filled in a good environment, are the best conditions to obtain good result with an easily reproducive system.

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  • Chapter
    La survenue d’un traumatisme des membres inférieurs chez une personne âgée doit être considérée, comme dans toute décision médicale, au regard d’une balance avantages/risques, avec cependant la particularité d’un plateau « risques » particulièrement chargé et inhabituel en traumatologie. En effet, et à titre d’exemple, la survenue d’une fracture de l’extrémité proximale du fémur nécessiterait d’évaluer, chez un sujet jeune, les risques liés à un traumatisme à haute énergie, éventuellement chez un polytraumatisé, et secondairement les séquelles fonctionnelles généralement mineures; dans le cas d’une fracture articulaire, ce traumatisme soulèverait la question supplémentaire de la prévention et du traitement d’une ostéonécrose de la tête du fémur chez un jeune patient. Les mêmes lésions, d’ailleurs décrites par les mêmes numéros dans les classifications systématiques, soulèvent des problèmes différents si elles surviennent chez une personne âgée. L’énergie du traumatisme est presque constamment faible, n’entraînant pas de polytraumatisme, alors que pourtant le risque de décès est très élevé, variant de 25 à 40 % [1]. Les séquelles anatomiques sont souvent modestes, alors que pourtant les conséquences fonctionnelles et sociales de la fracture sont majeures. En effet, il n’est pas question d’incapacité temporaire de travail ou permanente professionnelle, mais cependant plus de 25 % des patients qui vivaient autonomes à leur domicile perdront, du fait de cette fracture, leur autonomie et devront être définitivement institutionnalisés [1]. Chez le sujet jeune, la récidive est rare, sauf chez quelques patients intrépides, alors qu’elle touche à moyen terme 10 à 15 % des personnes âgées [2]. La technique chirurgicale peut être rendue difficile chez un sujet jeune, notamment du fait de la comminution ou des lésions des parties molles liées à l’énergie traumatique; en revanche, la tenue du matériel est très généralement bonne. Les difficultés techniques sont inverses chez le sujet âgé, les lésions associées locorégionales sont rares, alors que l’os est généralement raréfié avec une tenue médiocre des implants. Ces difficultés s’accroissent encore lorsque cette fracture du fémur survient aux confins d’une prothèse, problème pour le moins exceptionnel chez le sujet jeune.
  • Article
    Full-text available
    Cytocompatibility of 5 coral aquaculture skeleton species derived from two families (Acroporidae and Pocilloporidae) was studied over the course of in vitro culturing in continuous human fibroblast culture by the MMT test. Biocompatibility and capacity of scaffold to "transfer" cell cultures (specifically, multipotent mesenchymal stromal cells) to sites of implantation were studied in vivo by subcutaneous implantation of skeletal fragments to rats. All coral skeleton aquaculture specimens were cytocompatible (nontoxic and with surface matrix characteristics satisfactory for cells), biocompatible, and could be tried as 3D matrices for bone tissue engineering.
  • Article
    Natural coral and metal plate stabilization were used to obtain bone consolidation in a context of posttraumatic atrophic pseudarthrosis of a femoral shaft with nonunion. Bone substitute bioresorption was the result of dual, interdependent biological and mechanical processes. The process was exponential (natural logarithm). The coral beads were arranged in adjacent columns along the long axis of the femoral shaft parallel to the femoral shaft cortex. This demonstrates the role of natural stresses, which acted in the same manner as on a fracture-free bone. The resorption of the columns aligned in the same wall occurred in a definite order. The subperiosteal column was resorbed before that adjacent to the medullary canal. This shows the role played by the double vascularization of long bones in biomaterial resorption and callus formation.Le corail naturel, associ une stabilisation mtallique, a t utilis dans le but dobtenir la consolidation dune pseudarthrose atrophique de la diaphyse fmorale dorigine post-traumatique. La transformation du substitut osseux seffectue selon un double processus biologique et mcanique troitement imbriqus dans le temps. La biorsorbabilit au niveau des parois se fait selon une courbe exponentielle (Log. nprien). Lorganisation architecturale des sphres se fait en colonnes adosses alignes selon le grand axe de la diaphyse. Ceci souligne le rle des contraintes mcaniques qui agissent de la mme faon que sur un os non fractur. La rsorbabilit des colonnes alignes dans la mme paroi se fait dans un ordre prcis. La colonne au niveau de la corticale sous-prioste se rsorbe avant celle situe du ct endo-mdullaire. Ceci souligne le rle de la double vascularisation dun os long dans la rsorption du biomatriau et, paralllement, la formation du cal osseux.
  • Article
    Coral has ben used for the last ten years as bone substitution in the body because of its mechanical an osteoconductor properties. Our primary studies have shown, for the first time, the quantitative behavior of the atomic components. We study by some physical method of analysis a biocoral implanted in vivo. The natural biocorals used in this work are the calcium carbonated exoskeletons built by Madrepian coral polyps. Neutron activation analysis showed that initial coral, essentially CaCO3, becomes a new material which has a mineral composition close to that of bone. In this work, we have studied the calcification mechanism of this implant by using radioactive tracers. We have established the transfer kinetics of calcium biomaterial in the blood circuit and showed its use by the organism for skeleton mineralization.
  • L'appui précoce après ostéosynthèse par vis plaque THS des fractures cervicotrochantériennes
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  • Article
    Full-text available
    Measurement of the compressive strength and elastic modulus of the skeletal material of three common Caribbean corals suggests that the mechanical properties of coral skeleton are an important factor in the adaptive repertoire of these animals. The strength (stress at fracture) of the specimens tested is 12-81 meganewtons/meter2, with material from branched colonies being generally stronger than material from massive colonies. These values are lower than the strength of most other carbonate skeletal materials, but higher than that of carbonate engineering materials like concrete and limestone. The comparatively low strength of coral skeleton may be the result of architectural properties produced by the requirements of competing adaptive factors, such as polyp phototropism, or it may reflect the low probability that a colony will be broken, and therefore need to be stronger, before it achieves reproductive parity. The skeleton of the three species tested here is strongest when stress is applied parallel to the growth direction of the polyps. Strength varies inversely with skeletal porosity. Decreasing porosity in highly stressed colonies represents a potentially valuable adaptation for enhancing strength. The adaptive value of porosity modification may explain differences in porosity and strength between highly stressed branched growth forms and more moderately stressed massive growth forms. Boring organisms reduce the strength of coral skeleton by increasing its porosity. Only minor amounts of boring can produce strength reductions of up to 50%. Specialized, stress-minimizing branch arrangements help maximize resistance of coral structures to mechanical degradation in situations where colony size is unusually large or hydraulic energy dangerously high.
  • Article
    1. Trochanteric fractures are classified, with special emphasis on the stability or instability of the fracture. The importance of the cortical buttress of bone on the inner side of the femoral neck and shaft is stressed. 2. Three series of cases are presented: a) one hundred and one cases treated conservatively in hospital; b) twenty-five cases sent home by reason of lack of hospital beds; c) twenty-two cases treated by fixation with a Capener-Neufeld nail-plate. 3. From consideration of these three series, and from study of similar series of cases reported in the literature, it is suggested that routine operative treatment of trochanteric fractures has the advantages of greater comfort and mobility of the patient, lowered mortality, and economy of hospital beds. 4. Certain features of the operation of internal fixation by the Capener-Neufeld nail-plate are discussed. A director, for more efficient insertion of the nail-plate, is described. 5. The importance of early mobility after operation is emphasized. Only a small proportion of Patients can be allowed early weight-bearing but almost all can be got up in a chair, and most can be taught to get about with crutches, without weight-bearing on the fractured limb, within a few days of operation.
  • Article
    Biocoral is a biomaterial derived from natural corals, and it has surgical applications. Since 1992 the author has been using this material as a bone graft substitute in maxillofacial surgery. Seventy-seven clinical implantations were done for different indications. The results suggest that coral grafts are well tolerated and become partially ossified when the calcified skeleton is resorbed. This material has been demonstrated to be successful.
  • Article
    The value of using biodegradable devices and particularly coral in cervical spine surgery is linked to the desire to supress the disadvantages of taking bone graft for arthrodeses (using the Robinson's technique), be it iliac, fibular or tibial. The chemical, microscopical, biomechanical and clinical study of coral since 1970 enabled us to show the value of a material whose structure resembles that of bone, degrading itself completely and being replaced by newly formed bone. Our first results in 37 cases confirm these data by studying the evolution of coral, the good clinical tolerance, its good radiological incorporation with no alteration of the static balance of the cervical spine. A literature review on the subject of the use of biodegradable devices shows the advantages and disadvantages of each explaining the reason for our choice.L'intrt d'utiliser des biomatriaux et particulirement du corail en chirurgie rachidienne cervicale est li la volont de supprimer les inconvnients lis la prise de greffe osseuse dans les arthrodses, que cette greffe soit iliaque ou encore pronire ou tibiale. L'tude du corail depuis 1970, chimique, microscopique, biomcanique puis clinique a permis de montrer l'intrt d'un matriau dont la structure rappelle celle de l'os, se dgradant compltement et tant remplac par de l'os noform. Nos premiers rsultats sur 37 cas revus confirment ces donnes en tudiant l'volution du corail, sur la bonne tolrance clinique, sa bonne incorporation radiologique sans modification de la statique rachidienne. Une revue de la littrature au sujet des biomatriaux utiliss montre les avantages et les inconvnients de chacun expliquant le pourquoi de notre choix.
  • Le corail substitué à l'apport osseux dans l'arthrodèse vertébrale postérieure chez l'enfant
    • Jc Pouliquen
    • N Jean
    • M Noat
    • Jm Boyer
    • Yannoutsos
  • Article
    Natural coral skeleton (NCS) has recently been proposed as a bone graft substitute that enhances bone formation. The present paper describes the effects of implanting NCS in bone cavities prepared in the mandibles of miniature pig, and compares these with the effects of two alloplastic materials; a tricalcium phosphate (TCP) and a porous hydroxyapatite (PHA). On 11 pigs, 5 5 mm windows were created through alveolar bone of the four mandibular incisors. Three cavities were filled with the various materials and the fourth was left unfilled. The animals were slaughtered at 0, 1, 2, 4, 12, 26 and 52 weeks post-operatively and the tissues were examined histologically. Healing completed at 26 weeks for NCS and TCP, and at 52 weeks for PHA. NCS granules provided surface for cell attachment and deposition of a distinguishable organic matrix two weeks post-operatively. This matrix developed to bone after four weeks. The granules gradually resorbed and were replaced by bone at 52 weeks. The excellent properties of NCS, biocompatibility, porosity and osteogenic effect make us suggest that it might be a suitable replacement for bone grafting.
  • Article
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  • Article
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  • Article
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  • Article
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  • Article
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  • Article
    The treatment of the most common osteoporotic fractures has been reviewed. In general, early functional treatment is used to allow early restoration of function and weight bearing. Fracture treatment should always be accompanied by an investigation of the bone mass in these patients. Nutritional support and calcium and vitamin supplementation should be provided during the healing phase.
  • Article
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  • Article
    Experiments have been performed to investigate the use of coral skeletons as bone graft substitutes. Skeletal fragments of different coral genera were implanted into cortical and spongy bone defects and used to bridge transcortical resections in the femur. The implant site was monitored for up to 18 months. Radiographically, both cortical and spongy bone defects were at least partially filled by new bone after 8 weeks while the implants underwent continuous resorption. Coral resorption and replacement by new tissue was also observed in the transcortical resections. The process of resorption was attributed to the enzymatic attack, especially carboanhydrase. This was confirmed by experiments in which dogs were implanted with coral in transcortical resections and treated daily with acetazolamide, a carboanhydrase inhibitor; the absorption appeared delayed and the resections failed to heal.
  • Article
    Full-text available
    This investigation was designed to describe the 12-month functional recovery following hip fracture, testing the hypothesis that intensive rehabilitation would enhance the level of functional recovery. The study included 50 patients with intertrochanteric, and 25 patients with subcapital hip fractures who were admitted to the Massachusetts General Hospital teaching service (67% women, mean age = 78 yr). Twenty-nine percent of the patients died in the year after fracture. Among survivors, only 33% and 21% regained their prefracture function in five basic and six instrumental activities of daily living, respectively. Twenty-six percent regained their prefracture level of social/role functioning. There were no statistically significant differences in mortality, hospital discharge status, or pattern and level of functional recovery, between patients receiving experimental and standard approaches to hospital rehabilitation.
  • Article
    Echinoderm skeletons are composed of high-magnesium calcite having a fenestrate structure. Each skeletal ossicle appears to be a single crystal of calcium carbonate rather than a polycrystalline aggregate as, for example, are mollusc shells. Measurements of crushing strength for spines of three species of sea urchin demonstrate that the strength to weight ratio of these spines is equivalent to or greater than that of mollusc skeletons and most calcareous rocks. Echinoderms utilize calcium carbonate with unusually high efficiency, fulfilling the strength and volumetric requirements of a suitable skeleton with a minimum amount of material. Comparative dimensional analysis of structural and mechanical properties of these skeletal materials may provide further insight into the evolution of echinoderms.
  • Article
    A prospective randomized study was set up, comparing a compression hip screw with the Vandeputte (VDP) endoprosthesis treatment for fresh, unstable peritrochanteric fractures, according to the Evans-Jensen and AO systems. Ninety patients, ages > or = 70 years, 47 of whom were treated with a compression hip screw and 43 with a VDP endoprosthesis, were included. All patients were being followed for 3 months. No difference between the two groups was found for operating time, wound complications, and mortality rate, but there was a higher transfusion need in VDP treatment. Severe fracture redisplacement or total collapse of the fracture occurred in 11 (26%) compression hip screw patients, two of whom had revision surgery. Only one patient needed reintervention after VDP treatment. Functional capacity of preoperative independent patients at hospital discharge did not differ for the two groups. In conclusion, the compression hip screw seemed to be an appropriate implant for most of the peritrochanteric fractures, but for very old patients with advanced osteoporosis, with a complex, unstable peritrochanteric fracture, and who are eligible for early mobilization, primary cemented endoprosthesis might be the best treatment.
  • Article
    Solid coral blocks have been used as a bone graft substitute in clinical orthopedics for more than 12 years. In this study, 36 patients with 54 craniofacial osseous contour defects received subperiosteal augmentations with natural coral granules made chiefly of calcium carbonate. The patients were followed for 12 to 36 months. The postoperative results were satisfactory; there were only 5 sites of clinically evident resorption. There were 2 incidences of wound irritation and 1 instance of overt infection. Technical aspects of the procedure are discussed.
  • Article
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  • Article
    A resorbable coralline calcium carbonate graft material (CalCarb) was compared to open flap debridement (DEBR) in human periodontal osseous defects. Following appropriate initial preparation procedures, flap surgery with defect and root debridement was performed in 20 patients. Alternating defects in each segment of surgery were treated with each procedure. Appropriate periodontal maintenance schedules were followed, and at 6 to 12 months a re-entry flap surgery was performed for documentation and finalization of treatment. Forty defects which received CalCarb grafts demonstrated significantly better mean defect fill of 2.3 mm (67.7%) versus a mean defect fill of 0.7 mm (25.9%) (P < 0.01) for 39 defects treated with DEBR. Other hard tissue findings showed similar clinically superior results with the use of CalCarb. Relative defect fill results showed 88% positive (50% to 100% defect fill) responses with CalCarb and only 13% positive responses with DEBR. There were 7 times more failures (minimal response) with DEBR than with CalCarb. Soft tissue findings showed no significant differences between treatments. These results are similar to those with other synthetic and natural bone replacement graft materials. However, the ease of handling of the CalCarb material, its resorbability, and its potential for improved bone regeneration may be of clinical advantage.
  • Article
    In a 3-year prospective randomized trial, the prognostic value of osteoporosis in terms of predicting healing complications due to implant failures or loss of fracture reduction has been studied in 113 patients with inter-trochanteric hip fractures treated with either a sliding screwplate or Ender nailing. According to the Barnet and Nordin's osteoporosis index, 66 patients were considered to have moderate or severe osteoporosis. There were no differences between patients with or without osteoporosis as regards the number of fractures with collapse in varus > 10 degrees, redislocation > 10 mm, or compression exceeding 10 mm. Six months after surgery, 48 patients failed in healing or healed with complications. These cases disclosed increased osteoporosis in comparison with those showing noncomplicated healing. Patients with osteoporosis who had unstable fractures treated by Ender nailing were found to have the worst prognosis for healing complications (p = 0.006). Of the 33 fractures with implant failures, 25 (76%) occurred in patients with osteoporosis (p = 0.04). In patients with osteoporosis, the frequency of mechanical failures was significantly higher in fractures with the device positioned incorrectly. Independently of the device used, patients with unstable trochanteric hip fractures and osteoporotic bone were the group with the highest risk for failures of the implant.
  • Article
    Sliding of compression hip screws (CHS) is advantageous when it allows for controlled collapse of a hip fracture and progressive stabilization. A retrospective review was performed on 47 intertrochanteric (IT) fractures treated with a Zimmer CHS. Previous studies had identified certain parameters as being important to CHS sliding characteristics in vitro. Using conventional diagnostic material (radiographs), we sought to use these parameters as clinically useful tools. Screw sliding, as well as geometric parameters of CHS that relate to screw sliding, such as barrel engagement in relation to screw extension and screw-plate angle, were measured and calculated from serial radiographs. Almost all screw sliding occurred within 30 days postoperation. Fracture stability and quality of reduction were two main factors relating to screw sliding (p < 0.01). High screw-plate angle and longer screw-barrel engagement had no correlation with screw sliding even in unstable fractures. All five failures were due to cut-out after complete or almost complete collapse of the sliding mechanism in non-anatomically reduced fractures in osteoporotic females. Unstable fractures in osteoporotic bone do seem to require supplementary fixation beyond sliding screw fixation alone. None of the mechanical parameters (as judged from plane radiographs) that control the tendency of the CHS to slide could be statistically correlated with incidence or degree of sliding. Therefore, it was concluded that it is impractical to attempt to predict sliding tendency from plane radiograph measurements.
  • Article
    Full-text available
    The Staca nail-plate (SNP) is 32 years old. This implant was created by Descamp and Kerner from Nice in 1964. This study evaluates the experience with the SNP in two Orthopaedic Departments from Metz and Nancy Regional Hospitals, between January 1989 and July 1991. This is a clinical and radiological retrospective study. Out of the 175 patients, 152 were reviewed at 3 months and 127 at more than 9 months. The radiological assessment was made by measuring the post-operative cervical angle, the position of the nail within the femoral neck, the inter-fragmentary distance and the distance between nail and femoral head cartilage. 175 trochanteric fractures (119 women and 56 men) had osteosynthesis with the SNP. The mean age was 79 years (range: 36 to 96 years). Only 29 patients were free of general associated pathology. The fracture was always traumatic. The right femur was involved in 97 cases. Following the Ender classification there were 87 stable and 88 unstable fractures (59 complex pertrochanteric, 19 inter and sub-trochanteric and trochantero-diaphyseal). Post-operative reduction was anatomical in 66 per cent and satisfactory in 89 per cent of cases. In three cases there was an acetabular protrusion of the nail, in two cases there was a varus reduction and fixation and in six cases the plate was not fitting correctly the diaphysis. The average per-operative blood-loss was 300 cc. There was one per-operative death and eight early post-operative deaths. Sitting was allowed 24 hrs, after surgery in 94 per cent of patients. 68 per cent of patients started walking within the first 15 days after surgery. There were 37 per cent general complications, mainly respiratory and urinary infections, but also 2 deep-vein phlebitis, with pulmonary embolism and death. 17 post-operative hematoma were noted, out of which two required surgery. The general mortality reached 15 per cent in three months and 22 per cent in nine months. 70 per cent of the patients were free of pain at 3 months and 78 per cent at 9 months, 65 per cent being able to walk without crutches. Nail acetabular protrusion was observed in 16 cases (3 in early post-operative period, 8 within three months and 2 between the third and the ninth month). The protrusion was related to the nail positioning in 11 out of the 16 cases. This complication required SNP removal in 7 cases, replacement of the SNP in 3 cases and total hip arthroplasty in two cases. Correct nail length assessment is the important step in order to avoid protrusion and has to take into account the interfragmentary distance after reduction (if any). A good per-operative nail impaction is mandatory. Compared to other implants (THS, DHS, Gamma-nail, Ender), the SNP gives comparable results and a stable fixation. The SNP is a reliable implant. The most common complication in our series is protrusion which required reintervention in 6.8 per cent of the cases. Currently we avoid this complication by a good per-operative nail impaction.
  • Article
    Infection risk makes the management of a bone bank more and more difficult. On the other hand, realizing an autologous graft is not always without consequences. That is why we estimated the mechanical quality, the osteo-integration and the biocompatability of a coral graft. Between 1988 and 1992, two of us systematically used coral graft as "support" after lifting of some articular depression in fractures of inferior limb. Osteosynthesis was systematically associated. In this way, we operated 13 fractures of the lateral tibial plateau, 8 thalamic fractures of the calcaneus and 2 fractures of the inferior extremity of the tibia. Average follow-up is 20 months, with extremes of 68 and 12 months. Material ablation was realized 13 times and coral graft biopsy 4 times. Bone integration was estimated radiologically in 3 stages: stage 1: non union = "margin" around the coral, stage 2: possible integration = the coral is perfectly visible, but its borders grow indistinct, stage 3: certain integration = peripheral disparition of the coral weft, radiological interpenetration between coral and bone framework. We systematically searched for secondary displacements and complications. Mechanical conditions were respected, there was no secondary displacement. "Possible integration" (stage 2) was found in 8 cases at an average follow-up of 20 months. In 9 cases, we found "certain integration" (stage 3), at an average follow-up of 28 months. It is possible that a more important follow-up time would allow to find more integration cases. Biocompatibility is debatable under the operating conditions of the authors. We counted 5 aseptic serous flows which continued to be aseptic (1 tibial plateau, 1 inferior extremity of the tibia, 3 calcaneum). Three coral grafts were removed to obtain healing. When biocompatibility is satisfactory the integration is certain. The longer the follow-up time, the more stage 3 cases can be observed. Nevertheless, this integration runs out with time. We did not find any explication to aseptic serous flows. It may result from some impurities. On the other hand, use of the coralin hydroxyapatite does not seem to drive to allergic complications. In accordance with this study, we use the coral graft only in case of tibial plateau fracture. Our experience with coral graft in the other fields of bone surgery is not sufficient to express an opinion.
  • Article
    Biocoral is a biomaterial derived from natural corals, and it has surgical applications. Since 1992 the author has been using this material as a bone graft substitute in maxillofacial surgery. Seventy-seven clinical implantations were done for different indications. The results suggest that coral grafts are well tolerated and become partially ossified when the calcified skeleton is resorbed. This material has been demonstrated to be successful.
  • Article
    A madreporic coral graft was used for orbital floor reconstruction following facial trauma. This report presents a multicentric study of 83 patients with a follow-up period of 15 to 24 months. The results of this study indicate no significant rejection or infection opposed to so many synthetic implants outcome. The radiological follow-up demonstrates a partially resorption of the implant within about 2 years and its replacements by new bone. Coral implant was used to correct enophthalmos or diplopia due to enlarged orbital dimensions. It was technically easy to insert and its anatomic shape does not require to be fashioned before use. Its inflexibility allows to bridge large bone defects and this implant should be considered as an attractive alternative to autogenous grafts, avoiding a second surgical site, in reconstructing orbital floor fractures.
  • Article
    The study aimed to compare two successive series of procedure using first pieces of natural madreporic coral, then coralline hydroxyapatite in traumatology. The goal of this work was to evaluate long term radiological features of absorption and influencing factors. Within six years, 65 pieces were used; only impaction articular fracture on the lateral tibial plateau (31) and calcaneum fractures (23) were included 21 cases completed inclusion criteria. As there were 3 secondary infections, 18 had therefore, an aseptic evolution and were included in this series. Absorption was evaluated in five degrees according to the volume of the remaining piece on X-rays. We also took into consideration the position of the pieces and the amount of surfaces in contact with cancellous bone. Among the 18 pieces followed up for more than 19 months (average 40), there were 4 sequestrations (1 tibia, 3 calcaneum), all were natural madreporic coral, the others presented osteointegration. Only natural madreporic coral pieces were absorbed, but never completely and the absorption was slow (3 to 7 years) and never complete. A radiolucent line was present in 7 out of 10 pieces of madreporic coral and none around coralline hydroxyapatite. Three developed favorably. Four were sequestred. Number of surfaces in contact with cancellous bone was correlated with osteointegration. The calcium carbonate which makes up the natural madreporic coral pieces is the site of destruction by osteoclasts. The radiolucent line is the specific witness of this biochemical activity. The radiolucent line proceeds sequestrations. No substitute of coralline hydroxyapatite has presented the same sign of peripheral absorption or sequestration. Coralline hydroxyapatite could be the correct coralline material to fill cancellous defect after elevation of an articular depression. In every case, the piece of coral must be fitted in contact with the cancellous bone in the depth of the bone. Conditions of osteoconduction of madreporic coral must be reconsidered. The degree and speed of peripheral absorption must be controlled before weight bearing is allowed.
  • Article
    Full-text available
    Bone morphogenetic protein (BMP) has been shown to induce bone formation and union in long bone defects and nonunions. We report a preliminary study of a composite implant consisting of a biocoral frame, carrier collagen and bovine BMP in the treatment of scaphoid nonunions. Two proximal and eight waist area scaphoid nonunions were treated using BMP/coral implant combined with either the Matti-Russe procedure (2 cases) or an interpositional bone graft fixed with screws or compression fixation pins (8 cases). In two cases only a one piece BMP/coral implant was used as an interpositional graft and in other cases interpositional autograft was used with granular BMP/coral implant placed between the fragments and the graft. Only two wrists resulted in complete union. These preliminary results suggest that composite implant of BMP, as used in the present study, may not solve the problems encountered in the treatment of scaphoid nonunions. Poor vascular conditions in scaphoid may not provide enough mandatory osteogenic cells for BMP to function properly. In avascular conditions coral does not resorb edequately and implants may also work as a sequester between the bone graft and the scaphoid bone and therefore actually inhibit the healing process.