Scientific Review

Journal Review

The Bologna 2004 Conference Report

Author - Dr Mo Akmal (Organizing Committee)

Introduction

The 9th ISFR biennual conference was held in Bologna Nov 2nd -6th 2004. The conference brought together international experts in fracture management and the event was very successful in advancing the causes of the ISFR and its current initiative "The Osteoporotic Fracture Campaign". Many ISFR members attended the meeting and contributed to it.

Basic Science

The ISFR has always maintained high standards in its basic science representation at its meetings and this year was no exception. There were sections on biophysics, orthobiologics, biology of fracture healing and biomechanics. The quality and attendance of these sessions was very high and demonstrated the immense research being conducted in this area. The use of computer modelling to predict healing patterns and use of computer technology to simulate cyclical micromotion11 was presented during the biophysics session. The importance of micromovement and functional loading for vascularization and callus response was emphasised by a number of speakers ^12,13,14. Initial fracture haematoma contains an abundance of cytokines and growth factors such as VEGF, TGFb, PDGF and IGF that are mandatory for the recruitment of mesenchymal progenitor cells and their differentiation to osteoblasts. The mechanisms of action of these factors during the different stages of fracture healing was discussed ^20,21,22,23. It was shown that soft tissue damage has a negative impact on fracture healing and this effect may be mediated through inflammatory cytokines in response to injury rather than the direct effect of reduced vascularity ^28,29,30,31. Inflammatory cytokines may also be responsible for development of the fat embolism syndrome ⁽³²⁾.

Clinical developments

Complex tibial fractures continue to pose a challenge to the trauma surgeon and in the opening session it was demonstrated that a combination of arthroscopy, percutaneous or minimally invasive surgical approaches and MRI may not only identify a high rate of associated intra/extra-articular soft tissue injury but also allow earlier rehabilitation and good long term outcomes as a result of better anatomical reconstruction and less soft tissue trauma ^{1,2,3,5,6,7,10}. Cost analysis studies suggested that reamed intramedullary nailing for closed and open grade I tibial shaft fractures remains the most economical treatment method and casting alone may be associated with the highest costs8. The traditional approach of "rigidity" followed by dynamization for fracture treatment was challenged by a study demonstrating that movement followed by stability may be more effective at fracture healing and preventing delayed union and a new device with this incorporation was presented ⁹.

Fracture Callus after Dynamization followed by Stabilization

The Ilizarov method for complex tibial plateau, and pilon fractures continued to be advocated by those experienced in this technique. A host group from the Rizzoli Institute showed the possibility of avoiding the need for joint replacement or arthrodesis in malunited ankle fractures by utilizing late reconstructive procedures33,34,35. With a current interest by orthopaedic surgeons in minimally invasive hip surgery, percutaneous and minimally invasive procedures for femoral neck fractures were also presented^37,39.

Surgical solutions for proximal humeral fractures remain difficult and controversial.

Inadequate fixation methods of proximal humeral fractures

A number of new devices based on locking screw mechanisms and multiple fixation points were presented but there remains a need for a reliable fixation device for multi-part osteopenic proximal humeral fractures^54,55,56.

Osteoporotic fractures

Fragility fractures affect upto one-half of women and one-third of men over the age of fifty and continue to pose a challenge for orthopaedic surgeons. The mechanisms of failure are related to material properties, load and bone geometry and there is an intimate link of these factors to the biological bone microenvironment57,58. Together with early detection of osteopenia to reduce the future fracture burden, a need was emphasised for the development of improved surgical solutions. Locked compression plates, hydroxyapatite coating, metaphyseal intramedullary nails and multiple fixation point devices were presented in various sessions as possible improvements over current designs. The wide held view that kyphoplasty and vertebroplasty produce significant pain relief, early mobilisation and prevent further progression after vertebral compression fractures in both the short and long term was confirmed by a number of well conducted studies^{62,36p, 37p,39p}

Social Program

As well as a comprehensive educational program which included advanced workshops on a range of specific topics, there was an intense social program. Almost every evening was occupied by pre-arranged events. A visit to the Ferrari museum and a Gala dinner at the Rizzoli castle in its splendid setting were just a few of the delights that were on offer for those who managed to stay up at hours beyond midnight on previous nights. It was difficult to avoid sampling the varieties of Bolognese wine which was flowing in abundance. All delegates had a fantastic time and a great amount of positive feedback was received by the organizing committee. I would strongly recommend the next ISFR meeting in Australia 2006 to all readers.

Reference numbers refer to abstract numbers in the JOT supplement October 2004, Volume 18, Number 9. "p" denotes poster presentation.

Further details on ISFR website www.fractures.com