This document discusses fracture healing and the underlying biological processes. It is divided into three phases: inflammation, repair, and remodeling. The inflammation phase occurs within the first week as the body clears debris. The repair phase over the next 2-3 months involves callus formation through intramembranous or endochondral ossification. During the remodeling phase, which can last years, the callus is reshaped into lamellar bone through cutting cones and modeling. Key cell types and growth factors that regulate healing are also described.
Fracture Healing,Introduction,Pathology&Stages,Factors influencing osteogenesis,differences in healing of fractured bone by conservative&operative management.
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https://sethiortho.blogspot.com/
Fracture Healing and
Mechanical stability
Perren`s strain theory
Fracture healing
Indirect Healing
Direct healing
Fixation techniques and stability
Nonunion and Management
Fracture healing
Biological environment
Age
Nutritional status
Blood supply
Metabolic
Mechanical stability
Absolute
Relative
Surgical procedure
Alters biological environment
Selection of fixation
Alters mechanical environment
Mechanical Stability
Parren's strain theory
Strain
Relative deformation of a material when a given force is applied
Relative changes in the fracture gap divided by original fracture gap = L / L
Stability determines the Strain at the fracture site
Stable fixation – less strain
Unstable fixation – high strain
Large gap fracture – less strain
Cross section of the fracture-
Fracture gap strain VS cells response
The degree of inter fragmentary strain appears to govern the cellular response.
Each of these tissues is able to tolerate a different amount of strain:
Perren's strain theory….
When the inter fragmentary strain is <2% bone repair occurs by direct healing
While for intermediate amount of IFS (5–10%) the fracture heals by indirect healing.
Stain theory of healing –Indirect healing
Indirect Healing
Indirect Healing…
Hard callus formation
Indirect Healing
Remodeling Stage
Months to years
Conversion of woven bone into lamellar bone
Formation of Medullary cavity
Return of biomechanical property
Influenced by wolf law – Remodeling based on stress
Stain theory of healing…pseudo arthrosis
Complete instability
Callus is unable to form because the strain is too much for it to tolerate.
The more strain-tolerant fibrous tissue forms
Bone ends are sealed over with cortical bone
Formation of false joint with synovial fluid in the gap
Hypertrophic nonunion
Unstable fracture
Excess callus formation unable to reduce the IFS
Creates a hypertrophic non union
Direct Healing
Anatomically reduced rigid fixed fractures
Formation of cutting cones
>100,000 remodeling units work at time
Direct osteonal remodeling
Without callous
Activation
resorption by osteoclasts
osteoid formation by osteoclasts
Primary osteons
Mineralization
Direct Healing….
Fixation techniques and stability
Relative stability
Intramedullary nailing
Load sharing device
Inter fragmentary micro motion
Fracture gap strain is usually 2-10%
Body responds by forming more soft callus to try and decrease the strain
Fixation of diaphyseal fractures – strength and less duration
Relative stability
Absolute stability
Absolute stability
TBW
Lag screw fixation
Interfragmentary strain,
Nonunion and Management
Nonunion ….
Fracture is fixed rigidly but a gap is present
Direct healing may not be able to bridge the gap
The lack of strain may inhibit callus formation and secondary healing
Predispose to non-union
Management –
Hip resurfacing has emerged as a viable alternative to replacement for arthritis in young patients. Selected individuals will benefit by Hip resurfacing arthroplasty offered by the Madras Joint replacement center in India. See if you qualify for this procedure.
Fracture Healing,Introduction,Pathology&Stages,Factors influencing osteogenesis,differences in healing of fractured bone by conservative&operative management.
Can read freely here
https://sethiortho.blogspot.com/
Fracture Healing and
Mechanical stability
Perren`s strain theory
Fracture healing
Indirect Healing
Direct healing
Fixation techniques and stability
Nonunion and Management
Fracture healing
Biological environment
Age
Nutritional status
Blood supply
Metabolic
Mechanical stability
Absolute
Relative
Surgical procedure
Alters biological environment
Selection of fixation
Alters mechanical environment
Mechanical Stability
Parren's strain theory
Strain
Relative deformation of a material when a given force is applied
Relative changes in the fracture gap divided by original fracture gap = L / L
Stability determines the Strain at the fracture site
Stable fixation – less strain
Unstable fixation – high strain
Large gap fracture – less strain
Cross section of the fracture-
Fracture gap strain VS cells response
The degree of inter fragmentary strain appears to govern the cellular response.
Each of these tissues is able to tolerate a different amount of strain:
Perren's strain theory….
When the inter fragmentary strain is <2% bone repair occurs by direct healing
While for intermediate amount of IFS (5–10%) the fracture heals by indirect healing.
Stain theory of healing –Indirect healing
Indirect Healing
Indirect Healing…
Hard callus formation
Indirect Healing
Remodeling Stage
Months to years
Conversion of woven bone into lamellar bone
Formation of Medullary cavity
Return of biomechanical property
Influenced by wolf law – Remodeling based on stress
Stain theory of healing…pseudo arthrosis
Complete instability
Callus is unable to form because the strain is too much for it to tolerate.
The more strain-tolerant fibrous tissue forms
Bone ends are sealed over with cortical bone
Formation of false joint with synovial fluid in the gap
Hypertrophic nonunion
Unstable fracture
Excess callus formation unable to reduce the IFS
Creates a hypertrophic non union
Direct Healing
Anatomically reduced rigid fixed fractures
Formation of cutting cones
>100,000 remodeling units work at time
Direct osteonal remodeling
Without callous
Activation
resorption by osteoclasts
osteoid formation by osteoclasts
Primary osteons
Mineralization
Direct Healing….
Fixation techniques and stability
Relative stability
Intramedullary nailing
Load sharing device
Inter fragmentary micro motion
Fracture gap strain is usually 2-10%
Body responds by forming more soft callus to try and decrease the strain
Fixation of diaphyseal fractures – strength and less duration
Relative stability
Absolute stability
Absolute stability
TBW
Lag screw fixation
Interfragmentary strain,
Nonunion and Management
Nonunion ….
Fracture is fixed rigidly but a gap is present
Direct healing may not be able to bridge the gap
The lack of strain may inhibit callus formation and secondary healing
Predispose to non-union
Management –
Hip resurfacing has emerged as a viable alternative to replacement for arthritis in young patients. Selected individuals will benefit by Hip resurfacing arthroplasty offered by the Madras Joint replacement center in India. See if you qualify for this procedure.
Orthopedics is a Reconstructive Surgery. Mangled extremity is an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels). A Decision have to be made Amputation + Prosthesis Vs. Limb salvage procedure which includes Irrigation & Debridement, External fixation, Antibiotic bead spacers, Soft tissue coverage and finally Restoring Skeletal Stability by Salvage of Bone Defect
Orthopedics is a Reconstructive Surgery. Mangled extremity is an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels). A Decision have to be made Amputation + Prosthesis Vs. Limb salvage procedure which includes Irrigation & Debridement, External fixation, Antibiotic bead spacers, Soft tissue coverage and finally Restoring Skeletal Stability by Salvage of Bone Defect
This comprehensive lecture by Dr. Anthony Perez discusses the epidemiology, presentation, management and preventive strategies against surgical site infections
Presentation of common upper limb fractures and dislocations. Covering all the injuries from many sides (Definition - Classification - Mechanisms of injury - Clinical features - Radiological studies - Management - Complications)
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Bone healing, direct bone healing, indirect bone healing, primary and secondary bone healing, stages of bone healing, substitute of bone healing, autografting and allograft, fracture healing
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
How to Create Map Views in the Odoo 17 ERPCeline George
The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
2024.06.01 Introducing a competency framework for languag learning materials ...
Fracture healing
1. Fracture Healing DR HARDIK PAWAR DNB ORTHO RESIDENT. CARE HOSPITAL , HYDERABAD.
2. Types of Bone Lamellar Bone - Orderly cellular distribution Collagen fibers arranged in parallel layers Normal adult bone Woven Bone or immature bone (non-lamellar) Randomly oriented collagen fibers In adults, seen at sites of fracture healing, tendon or ligament attachment and in pathological conditions
3. Lamellar Bone Cortical bone - Comprised of osteons (Haversian systems) runs longitudinally Osteons communicate with medullary cavity by Volkmann’s canals that run horizontally
5. Woven Bone Coarse with random orientation Weaker than lamellar bone Normally remodeled to lamellar bone Figure from Rockwood and Green’s: Fractures in Adults, 4th ed
7. Osteoblasts Derived from mesenchymal stem cells Line the surface of the bone and produce osteoid Immediate precursor is fibroblast-like preosteoblasts Picture courtesy Gwen Childs, PhD.
8. Osteocytes Osteoblasts surrounded by bone matrix trapped in lacunae Function poorly understood regulating bone metabolism in response to stress and strain Picture courtesy Gwen Childs, PhD.
9. Osteocyte Network Osteocyte lacunae are connected by canaliculi Osteocytes are interconnected by long cell processes that project through the canaliculi Preosteoblasts also have connections via canaliculi with the osteocytes Network probably facilitates response of bone to mechanical and chemical factors
10. Osteoclasts Derived from hematopoietic stem cells (monocyte precursor cells) Multinucleated cells whose function is bone resorption Reside in bone resorption pits (Howship’s lacunae) Parathyroid hormone stimulates receptors on osteoblasts that activate osteoclastic bone resorption Picture courtesy Gwen Childs, PhD.
12. FRACTURE Fracture is a break in the structural continuity of bone . It may be a crack , a crumpling or a splintering of the cortex.
13. TYPES OF FRACTURES ON BASIS OF ETIOLOGY - Traumatic fracture - pathologic fractures due to some diseases - stress fracture ON BASIS OF DISPLACEMEMT - undisplaced - displaced translation ( shift ) angulation ( tilt ) rotation ( twist )
14. ON BASIS OF RELATIONSHIP WITH EXTERNAL ENVIRONMENT - simple / closed fracture - open fracture ON BASIS OF PATTERN - transverse - oblique - spiral - comminuted - segmental
16. Mechanisms of Bone Formation Cutting Cones Intramembranous Bone Formation Endochondral Bone Formation
17. Cutting Cones Primarily a mechanism to remodel bone Osteoclasts at the front of the cutting cone remove bone Trailing osteoblasts lay down new bone Courtesy Drs. Charles Schwab and Bruce Martin
18. Intramembranous (Periosteal) Bone Formation Mechanism by which a long bone grows in width Osteoblasts differentiate directly from preosteoblasts and lay down seams of osteoid Does NOT involve cartilage . It mainly forms cancellous bone.
20. Endochondral Bone Formation Mechanism by which a long bone grows in length Osteoblasts line a cartilage precursor The chondrocytes hypertrophy, degenerate and calcify (area of low oxygen tension) Vascular invasion of the cartilage occurs followed by ossification (increasing oxygen tension)
22. Blood Supply Long bones have four blood supplies Nutrient artery (intramedullary) Periosteal vessels Metaphyseal vessels Epiphysial vessels Periosteal vessels Nutrient artery Metaphyseal vessels Figure adapted from Rockwood and Green, 5th Ed
23. Nutrient Artery Normally the major blood supply for the diaphyseal cortex (80 to 85%) Enters the long bone via a nutrient foramen Forms medullary arteries up and down the bone
24. Periosteal Vessels Arise from the capillary-rich periosteum Supply outer 15 to 20% of cortex normally Capable of supplying a much greater proportion of the cortex in the event of injury to the medullary blood supply
25. Metaphyseal Vessels Arise from periarticular vessels Penetrate the thin cortex in the metaphyseal region and anastomose with the medullary blood supply
26. Vascular Response in Fracture Repair Fracture stimulates the release of growth factors that promote angiogenesis and vasodilation Blood flow is increased substantially to the fracture site Peaks at two weeks after fracture
27. Fracture healing Introduction Fracture healing is a complex process that requires the recruitment of appropriate cells (fibroblasts, macrophages, chondroblasts, osteoblasts, osteoclasts) and the subsequent expression of the appropriate genes (genes that control matrix production and organization, growth factors, transcription factors) at the right time and in the right anatomical location
28. HISTORY In 1975, Cruess and Dumont proposed that fracture healing may be considered to consist of three overlapping phases: an inflammatory phase, a reparative phase, and a remodeling phase In 1989, FROST proposed the stages of fracture healing five stages. stage of haematoma stage of granulation tissue stage of callus stage of modelling stage of remodelling
29. For convenience, we describe fracture healing in terms of the three phases recognized by Cruess and Dumont, noting that the reparative phase combines several processes. Inflammation stage of haematoma formation Repair stage of granulation tissue stage of callus formation Remodelling Stages of Fracture Healing
30. Duration The inflammatory phase peaks within 48 hours and is quite diminished by 1 week after fracture. The reparative phase becomes activated within the first few days after fracture and persists for 2-3 months. The remodelling phase lasts for many years
31.
32. Inflammation inflammatory phase is identical to the typical inflammatory response of most tissues to traumatic injury. Vasodilation and hyperemia, presumably mediated by histamines, prostaglandins, and various cytokines, accompany invasion of the injury site by neutrophils, basophils, and phagocytes that participate in clearing away necrotic debris.
33. Disruption of blood vessels in the bone, marrow, periosteum, and surrounding tissue disruption at the time of injury results in the extravasation of blood at the fracture site and the formation of a hematoma Local vessels thrombose causing bony necrosis at the edges of the fracture Increased capillary permeability results in a local inflammatory milieu Osteoinductive growth factors stimulate the proliferation and differentiation of mesenchymal stem cells
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35. Reparative phase The reparative phase, which usually begins 4 or 5 days after injury, is characterized by the invasion of pluripotentialmesenchymal cells, which differentiate into fibroblasts, chondroblasts, and osteoblasts and form a soft primary fracture callus. Proliferation of blood vessels (angiogenesis) within the periosteal tissues and marrow space helps route the appropriate cells to the fracture site and contributes to the formation of a bed of granulation tissue.
36.
37. Mesenchymal cells at the fracture site proliferate differentiate and produce the fracture callus Two types of callus : Primary callus or Soft callus – forms in the central region in which there is relatively low oxygen tension . The primary callus may consist of cartilage, fibrous tissue, osteoid, woven bone, and vessels. If the primary callus is successful, healing progresses to the stage of bridging callus or hard callus. Hard callus – formed at the periphery of the callus by intermembranous bone formation
38. Periosteal callus forms along the periphery of the fracture site Intramembranous ossification initiated by preosteoblasts Intramedullary callus forms in the center of the fracture site Endochondral ossification at the site of the fracture hematoma Chemical and mechanical factors stimulate callus formation and mineralization
40. Remodeling The biochemical composition of the fracture callus matrix changes as repair progresses. The cells replace the fibrin clot with a loose fibrous matrix containing glycosaminoglycans, proteoglycans, and types I and III collagen In many regions they convert this tissue to more dense fibrocartilage or hyaline-like cartilage. With formation of hyaline-like cartilage, type II collagen, cartilage-specific proteoglycan and link protein content increase.
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42. Woven bone is gradually converted to lamellar bone Medullary cavity is reconstituted Stability of the fracture fragments progressively increases . eventually clinical union occurs that is, the fracture site becomes stable and pain-free. Radiographic union occurs when plain radiographs show bone trabeculae or cortical bone crossing the fracture site, and often occurs later than clinical union . Despite successful fracture healing, the bone density of the involved limb may be decreased for years
43.
44. Types for Bone Healing Direct (primary) bone healing Indirect (secondary) bone healing
45. Direct Bone Healing Mechanism of bone healing seen when there is no motion at the fracture site (i.e. absolute stability) Does not involve formation of fracture callus Osteoblasts originate from endothelial and perivascular cells
46. Components of Direct Bone Healing Contact Healing Direct contact between the fracture ends allows healing to be with lamellar bone immediately Gap Healing Gaps less than 200-500 microns are primarily filled with woven bone that is subsequently remodeled into lamellar bone Larger gaps are healed by indirect bone healing (partially filled with fibrous tissue that undergoes secondary ossification)
48. Indirect Bone Healing Mechanism for healing in fractures that have some motion, but not enough to disrupt the healing process. Bridging periosteal (soft) callus and medullary (hard) callus re-establish structural continuity Callus subsequently undergoes endochondral ossification Process fairly rapid - weeks
50. I. Systemic factors or patient variables A. Age B. Activity level including 1. immobilization C. Nutritional status D. Hormonal factors 1. Growth hormone 2. Corticosteroids 3. Others (thyroid, estrogen, androgen, calcitonin, parathyroid hormone, prostaglandins) E. Cigarette smoking
51. E. Diseases: diabetes,anemia,neuropathies, tabesdorsalis F. Vitamin deficiencies: A, C, D, K G. Drugs: nonsteroidalantiinflammatory drugs (NSAIDs), anticoagulants, factor XIII, calcium channel blockers (verapamil), cytotoxins, diphosphonates, phenytoin (Dilantin), sodium fluoride, tetracycline H. Other substances (nicotine, alcohol) I. Hyperoxia J. Systemic growth factors K. Environmental temperature L. Central nervous system trauma
52. II. Local factors or tissue variables A. Factors independent of injury, treatment, or complications 1. Type of bone cortical or cancellous 2. Abnormal bone a. Radiation necrosis b. Infection c. Tumors and other pathological conditions 3. Denervation
53. B. Factors depending on injury or injury variables 1. Degree of local damage a. Compound fracture b. Comminution of fracture c. segmental fractures d. Velocity of injury e. Low circulatory levels of vitamin K1 2. Extent of disruption of vascular supply to bone, its fragments (macrovascular osteonecrosis), or soft tissues; 3. Type and location of fracture (one or two bones, e.g., tibia and fibula or tibia alone 4. Loss of bone 5. Soft-tissue interposition 6. Local growth factors 7. Intraarticular fractures
54. C. Factors depending on treatment OR treatment variables 1. Extent of surgical trauma (blood supply, heat) 2. Implant-induced altered blood flow 3. Degree and kind of rigidity of internal or external fixation and the influence of timing 4. Degree, duration, and direction of load- induced deformation of bone and soft tissues 5. Apposition of fracture fragments (gap, displacement, overdistraction) 6. Factors stimulating posttraumatic osteogenesis (bone grafts, bone morphogenetic protein, electrical stimulation, surgical technique, intermittent venous stasis .
55. D. Factors associated with complications 1. Infection 2. Venous stasis 3. Metal allergy
56. Local Regulation of Bone Healing Growth factors Transforming growth factor Bone morphogenetic proteins Fibroblast growth factors Platelet-derived growth factors Insulin-like growth factors Cytokines Interleukin-1,-4,-6,-11, macrophage and granulocyte/macrophage (GM) colony-stimulating factors (CSFs) and Tumor Necrosis Factor Prostaglandins/Leukotrienes Hormones Growth factor antagonists
57. Transforming Growth Factor Super-family of growth factors (~34 members) Acts on serine/threoninekinase cell wall receptors Promotes proliferation and differentiation of mesenchymal precursors for osteoblasts, osteoclasts and chondrocytes Stimulates both enchondral and intramembranous bone formation Induces synthesis of cartilage-specific proteoglycans and type II collagen Stimulates collagen synthesis by osteoblasts
58. Bone Morphogenetic Proteins Osteoinductive proteins initially isolated from demineralized bone matrix Induce cell differentiation BMP-3 (osteogenin) is an extremely potent inducer of mesenchymal tissue differentiation into bone Promote endochondral ossification BMP-2 and BMP-7 induce endochondral bone formation in segmental defects Regulate extracellular matrix production BMP-1 is an enzyme that cleaves the carboxy termini of procollagens I, II and III
59. Bone Morphogenetic Proteins These are included in the TGF-β family Except BMP-1 Sixteen different BMP’s have been identified BMP2-7,9 are osteoinductive BMP2,6, & 9 may be the most potent in osteoblastic differentiation Involved in progenitor cell transformation to pre-osteoblasts Work through the intracellular Smad pathway Follow a dose/response ratio
60. Timing and Function of Growth Factors Table from Dimitriou, et al., Injury, 2005
61. Clinical Use of BMP’s Used at doses between 10x & 1000x native levels Negligible risk of excessive bone formation rhBMP-2 used in “fresh” open fractures to enhance healing and reduce need for secondary procedures after unreamedIM nailin It is found that application of rhBMP-2 decreases infection rate in Type IIIA & B open fractures. BMP-7 approved for use in recalcitrant nonunions in patients for whom autografting is not a good option (i.e. medically unstable, previous harvesting of all iliac crest sites, etc.)
62. BMP Future Directions BMP-2 Increased fusion rate in spinal fusion BMP-7 equally effective as ICBG in nonunions (small series: need larger studies) Must be applied locally because of rapid systemic clearance
63. BMP Antagonists May have important role in bone formation Noggin Extra-cellular inhibitor Competes with BMP-2 for receptors BMP-13 found to limit differentiation of mesenchymalstromal cells Inhibits osteogenic differentiation
64. Fibroblast Growth Factors Both acidic (FGF-1) and basic (FGF-2) forms Increase proliferation of chondrocytes and osteoblasts Enhance callus formation FGF-2 stimulates angiogenesis
65. Platelet-Derived Growth Factor A dimer of the products of two genes, PDGF-A and PDGF-B PDGF-BB and PDGF-AB are the predominant forms found in the circulation Stimulates bone cell growth Mitogen for cells of mesenchymal origin Increases type I collagen synthesis by increasing the number of osteoblasts PDGF-BB stimulates bone resorption by increasing the number of osteoclasts
66. Insulin-like Growth Factor Two types: IGF-I and IGF-II Synthesized by multiple tissues IGF-I production in the liver is stimulated by Growth Hormone Stimulates bone collagen and matrix synthesis Stimulates replication of osteoblasts Inhibits bone collagen degradation
67. Cytokines Interleukin-1,-4,-6,-11, macrophage and granulocyte/macrophage (GM) colony-stimulating factors (CSFs) and Tumor Necrosis Factor Stimulate bone resorption IL-1 is the most potent IL-1 and IL-6 synthesis is decreased by estrogen May be mechanism for post-menopausal bone resorption Peak during 1st 24 hours then again during remodeling Regulate endochondral bone formation
68. Specific Factor Stimulation of Osteoblasts and Osteoclasts Cytokine Bone Formation Bone Resorption IL-1 + +++ TNF-α + +++ TNF-β + +++ TGF-α -- +++ TGF-β ++ ++ PDGF ++ ++ IGF-1 +++ 0 IGF-2 +++ 0 FGF +++ 0
69. Prostaglandins / Leukotrienes Effect on bone resorption is species dependent and their overall effects in humans unknown Prostaglandins of the E series Stimulate osteoblastic bone formation Inhibit activity of isolated osteoclasts Leukotrienes Stimulate osteoblastic bone formation Enhance the capacity of isolated osteoclasts to form resorption pits
70. Hormones Estrogen Stimulates fracture healing through receptor mediated mechanism Modulates release of a specific inhibitor of IL-1 Thyroid hormones Thyroxine and triiodothyronine stimulate osteoclastic bone resorption Glucocorticoids Inhibit calcium absorption from the gut causing increased PTH and therefore increased osteoclastic bone resorption
71. Hormones (cont.) Parathyroid Hormone Intermittent exposure stimulates Osteoblasts Increased bone formation Growth Hormone Mediated through IGF-1 (Somatomedin-C) Increases callus formation and fracture strength
72. Vascular Factors Metalloproteinases Degrade cartilage and bones to allow invasion of vessels Angiogenic factors Vascular-endothelial growth factors Mediate neo-angiogenesis & endothelial-cell specific mitogens Angiopoietin (1&2) Regulate formation of larger vessels and branches
73. Electromagnetic Field Electromagnetic (EM) devices are based on Wolff’s Law that bone responds to mechanical stress: In vitro bone deformation produces piezoelectric currents and streaming potentials. Exogenous EM fields may stimulate bone growth and repair by the same mechanism Clinical efficacy very controversial No studies have shown PEMF to be effective in “gap healing” or pseudarthrosis
74. Types of EM Devices Microamperes Direct electrical current Capacitively coupled electric fields Pulsed electromagnetic fields (PEMF)
75. PEMF Approved by the FDA for the treatment of non-unions Efficacy of bone stimulation appears to be frequency dependant Extremely low frequency (ELF) sinusoidal electric fields in the physiologic range are most effective (15 to 30 Hz range) Specifically, PEMF signals in the 20 to 30 Hz range (postural muscle activity) appear more effective than those below 10 Hz (walking)
76. Ultrasound Low-intensity ultrasound is approved by the FDA for stimulating healing of fresh fractures Modulates signal transduction, increases gene expression, increases blood flow, enhances bone remodeling and increases callus torsional strength in animal models
77. Ultrasound Human clinical trials show a decreased time of healing in fresh fractures treated nonoperatively Four level 1 studies show a decrease in healing time up to 38% Has also been shown to decrease the healing time in smokers potentially reversing the ill effects of smoking
78. Summary Fracture healing is influenced by many variables including mechanical stability, electrical environment, biochemical factors and blood flow Our ability to enhance fracture healing will increase as we better understand the interaction between these variables If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to hardikpawar103@gmail.com