Monotherapy vs. polytherapy in the treatment of forearm non-unions and bone defects

OBJECTIVE

To determinate the efficacy of "polytherapy", a surgical technique that utilize all the components of the diamond concept (mesenchymal stem cells, bone morphogenetic proteins and scaffold) versus a "monotherapy", a surgical technique that utilize only one component of the diamond conceptin the treatment of severe forearm non-unions.

METHODS

We studied a database of 52 patients with 52 forearm non-unions; we classified the patients with the NUSS SCORE and we divided the patients in two group according to the treatment received. So we distinguished a group of patients treated according to the principles of "monotherapy" (33 patients) and a group of patients treated according to the principles of "polytherapy" (19 patients). The minimum follow up was 12 months.

RESULTS

In the monotherapy group 21/33 non-unions (63.64%) went on to develop a radiographic and clinical healing within a period of 12 months, the calculated DASH SCORE showed a mean value of 55.15 points. In the polytherapy group 17/19 (89.47%) nonunions went on to develop clinical and radiographic healing within 12 months, and the average DASH score showed a mean value of 45.47 points.

CONCLUSION

The polytherapy technique with the use of recombinant morphogenetic proteins, autologous MSCs and scaffold in the same surgical time appears to be an effective treatment for patients with severe forearm non-unions.

The use of bone-graft substitutes in large bone defects: any specific needs?

INTRODUCTION

The gold standard for restoring bone defects is still considered to be autologous bone grafting. However, clinical benefits are not guaranteed and donor-site complications and morbidity is not infrequent. Research is on-going for the development of alternative bone substitutes of both biological and synthetic origin. The purpose of this study was to evaluate the type of materials used and their efficacy for the treatment of large bone defects in traumatology and orthopaedic surgery.

MATERIALS AND METHOD

A literature review was carried out of Embase and PubMed databases. Inclusion criteria were articles in English language focusing on the use of bone substitutes in trauma and orthopaedic surgery for the treatment of bone defects and included details on the structural, biological or biomechanical properties of the pure product. Furthermore, based on two clinical challenges, fracture non-union and impaction grafting we elaborated on the use of polytherapy for large bone defects as guided by the diamond concept.

RESULTS

All the products indicated in this manuscript possess osteoconductive activities but have different resorption times and biomechanical properties. Bone graft substitute materials are used for a wide range of clinical applications even when the level of clinical evidence is low. The size and location of the defect and the local biological and mechanical environment as well as the biomechanical characteristics of the material determine the type of device that can be implanted in a bone defect.

CONCLUSION

Proper assessment of the biological and mechanical environment and accurate patient selection are necessary to judge the extent of therapy the injury warrants. A sound understanding of various aspects of biomaterial properties and their relation and influence towards bone healing is of utmost importance. We suggest the application of polytherapy for the treatment of large bone defects and advocate the use of the diamond concept as a guideline.

Polytherapy in Bone Regeneration: Clinical Applications and Preliminary Considerations

Polytherapy, namely the simultaneous application of three fundamental elements necessary for bone regeneration (growth factors, osteogenic cells and osteocnductive scaffolds) seems to lead to a very high success rate in the treatment of complex non-union (NU) cases and critical bone defects. NU are reported in 5–10% of long bone fractures. The use of autologous bone grafts has been long-considered the gold standard for the treatment of these cases. However the harvesting procedure from the iliac crest increases surgery time and presents some donor site complications which may be elevated. In recent years, surgeons have some alternatives to autologous grafting such as: application of organic or synthetic bone substitute, application of mesenchymal stromal cells (MSC) or growth factors (GF). In the literature there are many studies available about their application in monotherapy, but unfortunately the healing rate doesn't exceed 90%. Polytherapy seems to be a logical option to improve the healing rate, nevertheless, there are not still extensive studies that validate this strategy and moreover, some questions are not resolved.

Medical Ozone (O3) Oil or Gas Applications Heal Osteonecrosis of the Jaw (ONJ) in Patients Treated with Bisphosphonates (BPs). Preliminary Results of a Single Arm Study

Treatment of bone metastasis with BP is aimed at preventing skeletal related events (SREs) and rarely leads to ONJ (<1%) (Hoff, JBMR. 2008). Preventive dental care is a simple and effective way to reduce the risk reduction of ONJ in 75% of the cases (Ripamonti, Ann Oncol. 2009). To date, there are still no standardized therapy for the treatment of ONJ. We report the effect of localized of O3 oil or gas application in cancer patients (12 breast cancer, 4 prostate cancer, 2 lung cancer, 1 NHL, 3 multiple myeloma) with ONJ observed in our institution. Patients had previously received nitrogene-BPs treatment in the absence of odontoiatric preventive measures. All the patients were in had stable disease without progression; 10 of them had ONJ lesions ≤ to 2.5 cm.O3 oil suspension applications on ONJ lesions ≤ 2.5 cm was carried out with localized applications directly on the lesions; patients with larger lesions (≥ 2.5 cm) were treated with the ozone gas locally applied. All the patients received treatment of O3 oil every third day and all of them were treated with antibiotic therapy (azithromycin, 500 mg/day) 10 days prior the initiation of the treatment with O3 oil. The statistical analysis is based on a Simon two-stage design, the second stage is on-going. In this preliminary analysis we focus on 10 patients treated with O3 oil with a medium follow up of 8 months, and 12 patients on medical gas ozone.73% of the patients (n=16) showed complete response in terms of radiological lesion disappearance with complete reconstruction of oral tissue. Among them, fourteen patients developed spontaneous sequestrum with expulsion of the necrotic bone whereas in 2 patients with large extension of bone involvement surgical intervention was necessary.Seventy percent of the patients treated with O3 oil experienced a complete response after 4 applications whereas patients treated with gas needed 4 to 16 applications (depending on the severity of the lesion). No patients presented adverse events related to the use of ozone treatments. Six patients are still on treatment and are improving as well.According to these results few application of O3 oil suspension in patients with smaller lesions and gas medical ozone for wider lesions following antibiotic therapy can rapidly lead to complete healing of ONJ. Further cases and complete follow-up data are required. These data indicate that ONJ is a manageable condition which can be not only prevented by means previously dental examination but also healed with medical ozone applications.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5046.

The management of constipation in palliative care: clinical practice recommendations

Constipation is one of the most common problems in patients receiving palliative care and can cause extreme suffering and discomfort. The aims of this study are to raise awareness of constipation in palliative care, provide clear, practical guidance on management and encourage further research in the area. A pan-European working group of physicians and nurses with significant experience in the management of constipation in palliative care met to evaluate the published evidence and produce these clinical practice recommendations. Four potentially relevant publications were identified, highlighting a lack of clear, practical guidance on the assessment, diagnosis and management of constipation in palliative care patients. Given the limited data available, our recommendations are based on expert clinical opinion, relevant research findings from other settings and best practice from the countries represented. Palliative care patients are at a high risk of constipation, and while general principles of prevention should be followed, pharmacological treatment is often necessary. The combination of a softener and stimulant laxative is generally recommended, and the choice of laxatives should be made on an individual basis. The current evidence base is poor and further research is required on many aspects of the assessment, diagnosis and management of constipation in palliative care.

The MERITO Study: a multicentre trial of the analgesic effect and tolerability of normal-release oral morphine during 'titration phase' in patients with cancer pain

Adequate and rapid pain control is one of the main goals of cancer pain treatment. The objective of this study was to assess the effect and tolerability of oral normal-release morphine during the initial phase of treatment in patients with moderate-to-severe cancer pain. Consecutive patients naïve to strong opioids received normal-release morphine 5 or 10 mg every 4 h during the titration phase (first 5 days), depending on previous analgesic therapy. Pain intensity was assessed using an 11-point Numerical Rating Scale (0-10), and data were recorded in a patient-compiled diary. The primary endpoint was the proportion of time with pain control (a reduction of at least 50% with respect to the baseline pain score) during the titration phase. A total of 159 consecutive patients (102 men; mean age 65 years) with cancer-related pain were enrolled. Pain control was observed for 75% (95% CI 70-80) of the follow-up period in the intent-to-treat population. Overall, 50% and 75% of patients achieved pain control within 8 and 24 h after starting normal-release morphine therapy respectively. The mean pain score was 7.63 points at baseline, and decreased to 2.43 and 1.67 points (both P<0.001) at days 3 and 5 respectively. The most commonly reported adverse events were somnolence (24% of patients), constipation (22%), vomiting (13%), nausea (10%) and confusion (7%). Normal-release morphine results in rapid and satisfactory pain control, and is well tolerated, during the strong-opioid titration phase in patients with moderate-to-severe cancer pain.

Short-term effects of pamidronate on bone turnover: can bone markers be considered predictive of the analgesic response?

Few data are available on the ability of bone markers to predict the symptomatic response to bisphosphonate therapy in patients with painful bone metastases. We evaluated the levels of bone markers in patients with bone metastases receiving pamidronate and determined the corresponding analgesic response. Forty-two patients were administered two two-week cycles of intravenous pamidronate 60 mg/week with a three-week interval in between. Serum levels of bone formation, resorption and other bone-associated markers (osteoprotegerin, osteopontin and calcium) were measured. Levels of two urinary markers were also measured and the intensity of pain and analgesic drug consumption evaluated. A mixed effects linear modelling approach was adopted to account for possible correlation among marker levels and time on study or analgesic response. We created an indicator variable that classified the patients' analgesic response as 'improved/stationary' or 'worsened' determined by patient reported intensity of pain and analgesic drug consumption. Eighteen patients 'worsened' and 24 were 'improved/stationary'. The results of the mixed effects models for testing the association between marker levels and time on study or analgesic response showed: i) the changes in marker levels over time did not significantly differ between the two groups; ii) the overall test for time on study was not statistically significant for C-terminal telopeptide of type I collagen (ICTP), osteoprotegerin and osteopontin; iii) in contrast, ICTP and osteoprotegerin were significantly associated with analgesic response. Biochemical markers of bone turnover, in particular ICTP and osteoprotegerin seem promising for predicting and objectively assessing the analgesic response to pamidronate treatment.

Pain on movement and pain at rest decrease after zoledronic acid infusion in patients with bone metastases due to breast or prostate cancer

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Background: There is no study on bisphosphonates assessing separately pain at rest and incident pain. Aim of the study was to evaluate the reduction in pain at rest and incident pain after treatment (up to 6 infusions) with 4 mg zoledronic acid (ZA) I.V. every 28 days in patients with bone metastases. Methods: All consecutive patients with bone metastases from breast or prostate cancer starting ZA treatment (August 2002 - May 2004) at NCI of Milan were enrolled in this observational prospective longitudinal study. Pain at rest and incident pain referred to the prior week were measured by a six level verbal scale (0–5 score) at baseline and on each infusion as well as at follow-up visit (2 weeks after every infusion). The two main endpoints (estimated reduction in pain at rest and incident pain) were defined as the difference between the baseline score and the average of all the post-treatment scores for each patient, and are presented with their respective 95% Confidence Interval. Positive values indicate reduction. Because of the potential confounding effect of analgesics intake, patients without any increase in analgesic consumption while on study were also analyzed as a separate subgroup. Results: 48 patients (mean age 66 years, 33 female), with breast (34) or prostate cancer (14) were enrolled. 30 patients underwent 4 to 6 infusions while 7 dropped out before the first follow-up visit. The analysis was performed on the 41 patients with at least one follow-up evaluation (average number of evaluations = 8.1 range = 1–13). The estimated reduction in pain at rest and incident pain was 0.55 (0.19–0.91) and 0.73 (0.31–1.14) respectively. In the 13 patients who did not report increased analgesic consumption, the estimated reduction was still substantial: 0.61 (0.25–0.97) 1.12 (0.41–1.83) respectively. Conclusions: This is the first study showing that in patients with painful multiple bone metastases, ZA reduces both pain at rest and incident pain in patients with painful bone metastases.

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