Outcomes of Demineralized Bone Matrix Enriched with Concentrated Bone Marrow Aspirate in Lumbar Fusion

BACKGROUND

Multiple studies have demonstrated that a significant amount of variability exists in various demineralized bone matrix (DBM) formulations, which casts doubts on its reliability in consistently promoting fusion. Bone marrow aspirate (BMA) is a cellular based graft that contains mesenchymal stem cells (MSCs) and growth factors can confer osteogenic and osteoinductive potential to DBM. The goal of this study was to describe the outcome of DBM enriched with concentrated BMA in patients undergoing combined lumbar interbody and posterolateral fusion.

METHODS

Eighty patients with a minimum of 12 months of follow-up were evaluated. Fusion and rates of complication were evaluated. Functional outcomes were assessed based on the modified Odom's criteria. Multiple logistic regression analysis was used to examine the effects of independent variables on fusion outcome.

RESULTS

The overall rate of solid fusion (i.e patients with both solid posterolateral and interbody fusion) was 81.3% (65/80). Specifically, the radiographic evidence of solid posterolateral and interbody fusions were 81.3% (65/80) and 92.5% (74/80), respectively. Seven (8.75%) patients developed hardware-related complications, 2 (2.5%) patients developed a postoperative infection and 2 (2.5%) patients developed clinical pseudarthrosis. Charlson comorbidity index (CCI) scores of 3 and 4 were associated with non-solid unions (CCI-3, p = 0.048; CCI-4, p = 0.03). Excellent or good outcomes were achieved in 58 (72.5%) patients.

CONCLUSIONS

Patients undergoing lumbar fusion using an enriched bone graft containing concentrated BMA added to DBM can achieve successful fusion with relatively low complications and good functional outcomes. Despite these findings, more studies with higher level of evidence are needed to better understand the efficacy of this promising graft option.

Bone healing in 2016

Delayed fracture healing and nonunion occurs in up to 5-10% of all fractures, and can present a challenging clinical scenario for the treating physician. Methods for the enhancement of skeletal repair may benefit patients that are at risk of, or have experienced, delayed healing or nonunion. These methods can be categorized into either physical stimulation therapies or biological therapies. Physical stimulation therapies include electrical stimulation, low-intensity pulsed ultrasonography, or extracorporeal shock wave therapy. Biological therapies can be further classified into local or systemic therapy based on the method of delivery. Local methods include autologous bone marrow, autologous bone graft, fibroblast growth factor-2, platelet-rich plasma, platelet-derived growth factor, and bone morphogenetic proteins. Systemic therapies include parathyroid hormone and bisphosphonates. This article reviews the current applications and supporting evidence for the use of these therapies in the enhancement of fracture healing.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly

BACKGROUND

Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population.

METHODS

Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months).

RESULTS

There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity.

CONCLUSION

The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

Hertel 7 fracture of the humeral head. Can two different fixation systems (Diphos/PHP) lead to different outcomes? A retrospective study

OBJECTIVE

To compare clinical outcomes and complication rates in the medium-to-long-term follow-up of Hertel 7 humeral head fractures treated with two different locking plates.

MATERIALS AND METHODS

A total of 52 patients with type 7 humeral head fracture (in accordance with Hertel classification) were enrolled retrospectively: 24 patients [4 male, 20 female; mean age (standard deviation [SD]): 68.9 (5.8) years] were treated with Diphos H plate (Group A) and 28 patients [6 male, 22 female; mean age (SD): 61.0 (7.5) years] with Proximal Humeral Plate (PHP; Group B). The mean follow-up periods were 25.6 and 18.9 months, respectively. Functional outcomes were assessed using the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score; X-ray evaluation was also performed and complications were recorded.

RESULTS

The mean Constant score in the Diphos and PHP groups at follow-up were 75.6 (SD 13.4) and 78.9 (SD 12.8), respectively (p>0.05). The DASH score was similar in both groups (Diphos: 18.6, range 0-51.5; PHP: 16.8, range 0-47.8) (p>0.05). In our series, 9.6% of patients had complications; these included a case of aseptic non-union and a case of avascular necrosis of the humeral head in each group, and a secondary screw perforation in a patient treated with Diphos.

CONCLUSIONS

In patients with Hertel 7 proximal humeral fractures, Diphos and PHP lead to similar satisfactory functional outcomes and are associated with low complication rates; this confirms that both are useful implants for the treatment of this pattern of fracture.

Membrane Induced Osteogenesis in the Management of Posttraumatic Bone Defects

OBJECTIVE

To evaluate the union rate of posttraumatic bone defects treated with the induced membrane technique.

DESIGN

Single-center retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Thirty-three patients who sustained 34 posttraumatic bone defects (19 tibia, 15 femur).

INTERVENTION

Staged management using the induced membrane technique described by Masquelet. After extensive debridement at the fracture site, a polymethylmethacrylate (PMMA) spacer was inserted into the resulting void. After soft tissue recovery, the spacer was removed, and the void, now enveloped by an induced membrane, was filled with an autologous iliac crest bone graft.

MAIN OUTCOME MEASURES

Bone union rate, time to achieve bone union, length of hospital stay, number of surgeries, infection resolution, range of motion, musculoskeletal tumor society system functional score, and limb shortening.

RESULTS

The mean defect size was 6.7 cm, and infection was present in 23 (68%) of the bone defects. Bone union was evident in 91% of cases (31/34). The average time to union was 8.5 months. In 7 of 23 (30%) of infected cases, the infection recurred, and in 3 of them, the graft was resorbed, resulting in treatment failure.

CONCLUSION

The induced membrane technique was effective for managing posttraumatic bone defects. A recurrence of infection was associated with treatment failure.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implantation of Stromal Vascular Fraction Progenitors at Bone Fracture Sites: From a Rat Model to a First-in-Man Study

Stromal Vascular Fraction (SVF) cells freshly isolated from adipose tissue include osteogenic- and vascular-progenitors, yet their relevance in bone fracture healing is currently unknown. Here, we investigated whether human SVF cells directly contribute to the repair of experimental fractures in nude rats, and explored the feasibility/safety of their clinical use for augmentation of upper arm fractures in elderly individuals. Human SVF cells were loaded onto ceramic granules within fibrin gel and implanted in critical nude rat femoral fractures after locking-plate osteosynthesis, with cell-free grafts as control. After 8 weeks, only SVF-treated fractures did not fail mechanically and displayed formation of ossicles at the repair site, with vascular and bone structures formed by human cells. The same materials combined with autologous SVF cells were then used to treat low-energy proximal humeral fractures in 8 patients (64-84 years old) along with standard open reduction and internal fixation. Graft manufacturing and implantation were compatible with intraoperative settings and led to no adverse reactions, thereby verifying feasibility/safety. Biopsies of the repair tissue after up to 12 months, upon plate revision or removal, demonstrated formation of bone ossicles, structurally disconnected and morphologically distinct from osteoconducted bone, suggesting the osteogenic nature of implanted SVF cells. We demonstrate that SVF cells, without expansion or exogenous priming, can spontaneously form bone tissue and vessel structures within a fracture-microenvironment. The gained clinical insights into the biological functionality of the grafts, combined with their facile, intra-operative manufacturing modality, warrant further tests of effectiveness in larger, controlled trials. Stem Cells 2016;34:2956-2966.

Biomarkers of inflammation and innate immunity in atrophic nonunion fracture

BACKGROUND

Nonunion is a failure of healing following a bone fracture. Its physiopathology remains partially unclear and the discovery of new mediators could promote the understanding of bone healing.

METHODS

Thirty-three atrophic nonunion (NU) patients that failed to demonstrate any radiographic improvement for 6 consecutive months were recruited for providing serum samples. Thirty-five healthy volunteers (HV) served as the control group. Proteomics studies were performed using SELDI-TOF-MS and 2D-DIGE approaches, associated or not with Proteominer® preprocessing, to highlight biomarkers specific to atrophic nonunion pathology. Peak intensities were analyzed by two statistical approaches, a nonparametric Mann-Whitney U tests (univariate approach) and a machine-learning algorithm called extra-trees (multivariate approach). Validation of highlighted biomarkers was performed by alternative approaches such as microfluidic LC-MS/MS, nephelometry, western blotting or ELISA assays.

RESULTS

From the 35 HV and 33 NU crude serum samples and Proteominer® eluates, 136 spectra were collected by SELDI-TOF-MS using CM10 and IMAC-Cu(2+) ProteinChip arrays, and 665 peaks were integrated for extra-trees multivariate analysis. Accordingly, seven biomarkers and several variants were identified as potential NU biomarkers. Their levels of expression were found to be down- or up-regulated in serum of HV vs NU. These biomarkers are inter-α-trypsin inhibitor H4, hepcidin, S100A8, S100A9, glycated hemoglobin β subunit, PACAP related peptide, complement C3 α-chain. 2D-DIGE experiment allowed to detect 14 biomarkers as being down- or up-regulated in serum of HV vs NU including a cleaved fragment of apolipoprotein A-IV, apolipoprotein E, complement C3 and C6. Several biomarkers such as hepcidin, complement C6, S100A9, apolipoprotein E, complement C3 and C4 were confirmed by an alternative approach as being up-regulated in serum of NU patients compared to HV controls.

CONCLUSION

Two proteomics approaches were used to identify new biomarkers up- or down-regulated in the nonunion pathology, which are involved in bone turn-over, inflammation, innate immunity, glycation and lipid metabolisms. High expression of hepcidin or S100A8/S100A9 by myeloid cells and the presence of advanced glycation end products and complement factors could be the result of a longstanding inflammatory process. Blocking macrophage activation and/or TLR4 receptor could accelerate healing of fractured bone in at-risk patients.

Minimally invasive polyaxial locking plate osteosynthesis for 3-4 part proximal humeral fractures: our institutional experience

INTRODUCTION

The objectives of this study were to describe the surgical technique of fixation of 3-4 part proximal humeral fractures with polyaxial locking plates utilising a minimally invasive approach and to evaluate the accuracy of reduction and stability of fixation.

PATIENTS AND METHODS

We retrospectively reviewed 90 patients. Fractures were classified according to the Neer classification system. Different radiological parameters were measured to assess the quality of reduction and the stability of fixation. Complications and clinical outcomes were evaluated after one year of minimum follow up.

RESULTS

There were 76 women and 14 men, with a mean age of 67.4years ±13 (range, 29-85). There were 60 3-part and 30 4-part fractures. Frozen cancellous allograft was used in 30 cases (33.3%). All fractures progressed to union and at one year follow up, the mean Constant score was 79.6±12(range, 62-100). Mean forward flexion, abduction, external rotation and internal rotation were 155°, 148°, 39° and vertebra Dorsal 8, respectively. Complications were noted in seven patients while the postoperative "head-diaphysis angle", "greater tuberosity height" and "medial metaphysis reconstruction" were close to the anatomical parameters; no significant differences were noted at one year radiological follow up.

CONCLUSION

Reliable and stable fixation can be expected with the use of polyaxial locking plate through a minimally invasive approach for the treatment of 3-4 part proximal humeral fractures. Satisfactory functional results for this procedure can be obtained.

Outcome Analysis of Locking Plate Fixation in Proximal Humerus Fracture

INTRODUCTION

Proximal humerus fractures account for approximately 5% of all fractures. Stable minimally displaced fractures can be treated nonoperatively but the management of displaced fractures remain controversial with various modalities of treatment available. Locking plates provide stable fixation and enable early postoperative mobilization specially in osteoporotic proximal humerus fracture.

AIM

To evaluate the functional outcome of locking plate fixation and to compare the results of two approaches used for fixation.

MATERIALS AND METHODS

This prospective study was conducted at a tertiary level hospital between September 2011 to December 2013. PHILOS plates were used for internal fixation of displaced proximal humerus fractures Neer's type 2 part, 3 part and 4 part fractures on 26 patients (M/F ratio 1.36:1; mean age 46 years). According to Neer classification, 5,12 and 9 patients had displaced 2, 3 and 4 part fractures respectively. Deltopectoral and deltoid splitting approaches were used for fixation on 13 patients each. Functional outcome was assessed using Constant-Murley shoulder score. Graphpad software version 6.0 was used with Chi-square test and Fisher-exact test are used to compare data. The p-value< 0.05 is considered significant.

RESULTS

Of the 26 patients, all fractures united radiologically and clinically and average constant score at final follow-up was 72.5. At the final follow-up 8 patients had good score, 10 patients had moderate score, 6 patients had excellent outcome and 2 patients had poor outcome according to Constant score. Mean time to union was 12.3 weeks (9 -15 weeks). Four complications (15.4%) were encountered, 2 cases of varus malunion, 1 case of wound infection which required wound debridement and 1 case of screw cut-out in which screw removal was done. Mean constant score in delto splitting approach was 70.9 and 74 in deltopectoral group (p-value= 0.54). No significant difference existed in constant score in 2 approaches. No significant difference existed between groups in terms of complications (P > .05) and all fractures were united.

CONCLUSION

Our study demonstrates that locking plate fixation gives good functional outcomes in treatment of proximal humerus fractures. There was no significant difference in the two approaches used for exposure. Our results are comparable to various studies conducted by other authors which states that locking plates provide better functional and radiological outcomes as compared to other fixation methods like Tension band wiring, percutaneous K-wire fixation, non-locking plates, intramedullary nails.

Augmentative locking plate with autologous bone grafting for distal femoral nonunion subsequent to failed retrograde intramedullary nailing

Objective

To explore the indications and efficacy of augmentative locking compression plate (LCP) or less invasive stabilization system (LISS)with autogenous bone grafting (BG) in treating distal femoral nonunion subsequent to failed retrograde intramedullary nailing (RIN).

Methods

A retrospective study was performed for 21 patients with distal femoral nonunion subsequent to failed RIN, who received therapy with either augmentative LCP (n = 11) or LISS with autogenous BG (n = 13). Operation time, time to union, union rate, time to renonunion, complication rate and SF-36 scores a year after hardware removal were compared between the two groups.

Results

The bone union occurred in 13/13 (100%) cases in augmentative LISS group versus 9/11 (81.8%) cases in augmentative LCP group [odds ratio (OR) = 3.21, 95% confidence interval (CI) 0.7–13]. Time to union, time to renonunion, complication rate of the augmentative LCP group were significantly more than that of the augmentative LISS with autogenous BG group (p = 0.023, p = 0.021 and p = 0.033). No significant difference was found in the average operation time of two groups (p = 0.121). At the follow-up a year after hardware removal, statistically significant HRQOL improvement in the augmentive LISS group was measured at the level of pain (p = 0.003) and general health perception (p = 0.011), as compared to the augmentive LCP group.

Conclusions

We suggest augmentative LCP, for distal femoral nonunios after RIN, may be optimal for that of typeAO33A fractures, whereas augmentative LISS for that of typeAO33C fractures more.

Mechanical Properties of Additively Manufactured Thick Honeycombs

Honeycombs resemble the structure of a number of natural and biological materials such as cancellous bone, wood, and cork. Thick honeycomb could be also used for energy absorption applications. Moreover, studying the mechanical behavior of honeycombs under in-plane loading could help understanding the mechanical behavior of more complex 3D tessellated structures such as porous biomaterials. In this paper, we study the mechanical behavior of thick honeycombs made using additive manufacturing techniques that allow for fabrication of honeycombs with arbitrary and precisely controlled thickness. Thick honeycombs with different wall thicknesses were produced from polylactic acid (PLA) using fused deposition modelling, i.e., an additive manufacturing technique. The samples were mechanically tested in-plane under compression to determine their mechanical properties. We also obtained exact analytical solutions for the stiffness matrix of thick hexagonal honeycombs using both Euler-Bernoulli and Timoshenko beam theories. The stiffness matrix was then used to derive analytical relationships that describe the elastic modulus, yield stress, and Poisson’s ratio of thick honeycombs. Finite element models were also built for computational analysis of the mechanical behavior of thick honeycombs under compression. The mechanical properties obtained using our analytical relationships were compared with experimental observations and computational results as well as with analytical solutions available in the literature. It was found that the analytical solutions presented here are in good agreement with experimental and computational results even for very thick honeycombs, whereas the analytical solutions available in the literature show a large deviation from experimental observation, computational results, and our analytical solutions.

Fibular Strut Graft Augmentation for Open Reduction and Internal Fixation of Proximal Humerus Fractures: A Systematic Review and the Authors' Preferred Surgical Technique

BACKGROUND

Proximal humerus fractures are common problems plaguing the elderly population.

PURPOSE

The purposes of this study were to determine the outcomes of fibular strut allografts in treatment of proximal humerus fractures with open reduction internal fixation (ORIF) and to present the authors' preferred surgical technique. The hypothesis was that the use of fibular strut allografts in treating proximal humerus fractures with ORIF will provide low reoperation rates with acceptable outcomes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was registered with PROSPERO and performed with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting arthroscopic elbow outcomes with levels of evidence 1 through 4 were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents and countries. Statistics were calculated using Student t tests, 1-way analysis of variance, chi-square tests, and 2-proportion Z tests.

RESULTS

Four studies met the inclusion criteria. While there is great heterogeneity existing in the literature surrounding use of a fibular strut allograft as an adjunct to ORIF of proximal humerus fractures, current evidence shows a humeral head screw penetration rate of 3.7% with acceptable functional outcome scores, with a reoperation rate of 4.4% at a weighted mean 80.78 weeks (1.55 years) of postoperative follow-up.

CONCLUSION

There is great heterogeneity that exists in the literature surrounding the use of a fibular strut allograft as an adjunct to ORIF of proximal humerus fractures. Current evidence shows a screw penetration rate of 3.7% with acceptable functional outcome scores, demonstrating fibular strut allograft is a viable option for treating proximal humerus fractures.

A comparative evaluation of the effect of polymer chemistry and fiber orientation on mesenchymal stem cell differentiation

Bioengineered tissue scaffolds in combination with cells hold great promise for tissue regeneration. The aim of this study was to determine how the chemistry and fiber orientation of engineered scaffolds affect the differentiation of mesenchymal stem cells (MSCs). Adipogenic, chondrogenic, and osteogenic differentiation on aligned and randomly orientated electrospun scaffolds of Poly (lactic‐co‐glycolic) acid (PLGA) and Polydioxanone (PDO) were compared. MSCs were seeded onto scaffolds and cultured for 14 days under adipogenic‐, chondrogenic‐, or osteogenic‐inducing conditions. Cell viability was assessed by alamarBlue metabolic activity assays and gene expression was determined by qRT‐PCR. Cell‐scaffold interactions were visualized using fluorescence and scanning electron microscopy. Cells grew in response to scaffold fiber orientation and cell viability, cell coverage, and gene expression analysis showed that PDO supports greater multilineage differentiation of MSCs. An aligned PDO scaffold supports highest adipogenic and osteogenic differentiation whereas fiber orientation did not have a consistent effect on chondrogenesis. Electrospun scaffolds, selected on the basis of fiber chemistry and alignment parameters could provide great therapeutic potential for restoration of fat, cartilage, and bone tissue. This study supports the continued investigation of an electrospun PDO scaffold for tissue repair and regeneration and highlights the potential of optimizing fiber orientation for improved utility. © 2016 The Authors Journal of Biomedical Materials Research Part A Published by Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 2843–2853, 2016.

[Postoperative necrotizing fasciitis: a rare and fatal complication]

Les complications pariétales post opératoire peuvent être exceptionnellement majeures et graves menaçant le pronostic vital. La fasciite nécrosante est une infection rare de la peau et des tissus sous-cutanés profonds, se propageant le long des fascias et du tissu adipeux. Elle est surtout causée par le streptocoque du groupe A Streptococcus pyogènes mais également par d'autres bactéries telles que Vibrio vulnificus, clostridium perfringens ou Bacteroides fragilis. La fasciite nécrosante est une véritable urgence médicochirurgicale. Nous rapportons dans ce travail une observation très rare d'une gangrène pariétale abdominale survenant chez une patiente de 75 ans au cinquième jour post-opératoire d'un kyste de l'ovaire. L’évolution était marquée par l'installation d'un état de choc septique réfractaire rapidement fatal à J3 de la prise en charge.

Anterior Cervical Discectomy and Fusion: Practice Patterns Among Greek Spinal Surgeons

Background

A web-based survey was conducted among Greek spinal surgeons to outline the current practice trends in regard to the surgical management of patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathology. Various practice patterns exist in the surgical management of patients undergoing anterior cervical discectomy for degenerative pathology. No consensus exists regarding the type of the employed graft, the necessity of implanting a plate, the prescription of an external orthotic device, and the length of the leave of absence in these patients.

Methods

A specially designed questionnaire was used for evaluating the criteria for surgical intervention, the frequency of fusion employment, the type of the graft, the frequency of plate implantation, the employment of an external spinal orthosis (ESO), the length of the leave of absence, and the prescription of postoperative physical therapy. Physicians’ demographic factors were assessed including residency and spinal fellowship training, as well as type and length in practice.

Results

Eighty responses were received. Neurosurgeons represented 70%, and orthopedic surgeons represented 30%. The majority of the participants (91.3%) considered fusion necessary. Allograft was the preferred type of graft. Neurosurgeons used a plate in 42.9% of cases, whereas orthopedic surgeons in 100%. An ESO was recommended for 87.5% of patients without plates, and in 83.3% of patients with plates. The average duration of ESO usage was 4 weeks. Physical therapy was routinely prescribed postoperatively by 75% of the neurosurgeons, and by 83.3% of the orthopedic surgeons. The majority of the participants recommended 4 weeks leave of absence.

Conclusions

The vast majority of participants considered ACDF a better treatment option than an ACD, and preferred an allograft. The majority of them employed a plate, prescribed an ESO postoperatively, and recommended physical therapy to their patients.

Clinical evaluation of an allogeneic bone matrix containing viable osteogenic cells in patients undergoing one- and two-level posterolateral lumbar arthrodesis with decompressive laminectomy

Background

Trinity Evolution® cellular bone allograft (TE) possesses the osteogenic, osteoinductive, and osteoconductive elements essential for bone healing. The purpose of this study is to evaluate the radiographic and clinical outcomes when TE is used as a graft extender in combination with locally derived bone in one- and two-level instrumented lumbar posterolateral arthrodeses.

Methods

In this retrospective evaluation, a consecutive series of subject charts that had posterolateral arthrodesis with TE and a 12-month radiographic follow-up were evaluated. All subjects were diagnosed with degenerative disc disease, radiculopathy, stenosis, and decreased disc height. At 2 weeks and at 3 and 12 months, plain radiographs were performed and the subject’s back and leg pain (VAS) was recorded. An evaluation of fusion status was performed at 12 months.

Results

The population consisted of 43 subjects and 47 arthrodeses. At 12 months, a fusion rate of 90.7 % of subjects and 89.4 % of surgical levels was observed. High-risk subjects (e.g., diabetes, tobacco use, etc.) had fusion rates comparable to normal patients. Compared with the preoperative leg or back pain level, the postoperative pain levels were significantly (p < 0.0001) improved at every time point. There were no adverse events attributable to TE.

Conclusions

Fusion rates using TE were higher than or comparable to fusion rates with autologous iliac crest bone graft that have been reported in the recent literature for posterolateral fusion procedures, and TE fusion rates were not adversely affected by several high-risk patient factors. The positive results provide confidence that TE can safely replace autologous iliac crest bone graft when used as a bone graft extender in combination with locally derived bone in the setting of posterolateral lumbar arthrodesis in patients with or without risk factors for compromised bone healing.

Trial registration

Because of the retrospective nature of this study, the trial was not registered.

Review of 58 patients with necrotizing fasciitis in the Netherlands

Background

Necrotizing fasciitis is a rare, life threatening soft tissue infection, primarily involving the fascia and subcutaneous tissue. In a large cohort of patients presenting with Necrotizing fasciitis in the Netherlands we analysed all available data to determine the causative pathogens and describe clinical management and outcome.

Methods

We conducted a retrospective, multicentre cohort study of patients with a necrotizing fasciitis between January 2003 and December 2013 in an university medical hospital and three teaching hospitals in the Netherlands. We only included patients who stayed at the Intensive Care Unit for at least one day.

Results

Fifty-eight patients were included. The mortality rate among those patients was 29.3 %. The central part of the body was affected in 28 patients (48.3 %) and in 21 patients (36.2 %) one of the extremities. Most common comorbidity was cardio vascular diseases in 39.7 %. Thirty-nine patients (67.2 %) were operated within 24 h after presentation. We found a type 1 necrotizing fasciitis in 35 patients (60.3 %) and a type 2 in 23 patients (39.7 %).

Conclusions

Our study, which is the largest study in Europe, reaffirmed that Necrotizing fasciitis is a life threatening disease with a high mortality. Early diagnosis and adequate treatment are necessary to improve the clinical outcome. Clinical awareness off necrotizing fasciitis remains pivotal.

Anatomic feasibility of a new endopelvic approach for iliac crest bone harvesting

PURPOSE

For the past few years, anterior exposure for surgery of the lumbar spine has gained popularity for the treatment of disk disease or spondylosis. Cancellous bone remains the gold standard for fusion. Iliac crest bone harvesting is safe but there are donor site complications. Bone substitutes exist, like recombinant human bone morphogenic protein-2 rhBMP-2. This alternative offers a high rate of fusion but with local and general complications. The aim of our study is to show the feasibility of an endopelvic approach for iliac bone crest harvesting to avoid donor site complication.

METHOD

Twenty anterior retroperitoneal lumbar spine approaches have been realized in the anatomy department of the University of Bordeaux. The volumes of cancellous bone have been measured and procedure complications have been reported.

RESULTS

The mean volume of cancellous bone was 5.9 cc, the maximum volume was 8.2 cc and the minimum volume was 4.5 cc. No complications have been reported during the approach or the bone harvesting.

CONCLUSIONS

Anterior retroperitoneal approach for iliac bone crest harvesting is a safe way to obtain sufficient volume of cancellous bone for a single lumbar spinal fusion. This exposure avoids the risks of an iliac crest donor site complications or rhBMP-2 complications.

Acellular hydroxyapatite-collagen scaffolds support angiogenesis and osteogenic gene expression in an ectopic murine model: Effects of hydroxyapatite volume fraction

Acellular hydroxyapatite (HA) reinforced collagen scaffolds were previously reported to induce angiogenesis and osteogenesis after ectopic implantation but the effect of the HA volume fraction was not investigated. Therefore, the objective of this study was to investigate the effect of HA volume fraction on in vivo angiogenesis and osteogenesis in acellular collagen scaffolds containing 0, 20, and 40 vol % HA after subcutaneous ectopic implantation for up to 12 weeks in mice. Endogenous cell populations were able to completely and uniformly infiltrate the entire scaffold within 6 weeks independent of the HA content, but the cell density was increased in scaffolds containing HA versus collagen alone. Angiogenesis, remodeling of the original scaffold matrix, mineralization, and osteogenic gene expression were evident in scaffolds containing HA, but were not observed in collagen scaffolds. Moreover, HA promoted a dose-dependent increase in measured vascular density, cell density, matrix deposition, and mineralization. Therefore, the results of this study suggest that HA promoted the recruitment and differentiation of endogenous cell populations to support angiogenic and osteogenic activity in collagen scaffolds after subcutaneous ectopic implantation. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 2178-2188, 2016.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial

BACKGROUND

Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures.

METHODS

In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates.

RESULTS

There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672).

CONCLUSION

Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.

Evaluation of Anterior Vertebral Interbody Fusion Using Osteogenic Mesenchymal Stem Cells Transplanted in Collagen Sponge

STUDY DESIGN

The study used a rabbit model to achieve anterior vertebral interbody fusion using osteogenic mesenchymal stem cells (OMSCs) transplanted in collagen sponge.

OBJECTIVE

We investigated the effectiveness of graft material for anterior vertebral interbody fusion using a rabbit model by examining the OMSCs transplanted in collagen sponge.

SUMMARY OF BACKGROUND DATA

Anterior vertebral interbody fusion is commonly performed. Although autogenous bone graft remains the gold-standard fusion material, it requires a separate surgical procedure and is associated with significant short-term and long-term morbidity. Recently, mesenchymal stem cells from bone marrow have been studied in various fields, including posterolateral spinal fusion. Thus, we hypothesized that cultured OMSCs transplanted in porous collagen sponge could be used successfully even in anterior vertebral interbody fusion.

METHODS

Forty mature male White Zealand rabbits (weight, 3.5-4.5 kg) were randomly allocated to receive one of the following graft materials: porous collagen sponge plus cultured OMSCs (group I); porous collagen sponge alone (group II); autogenous bone graft (group III); and nothing (group IV). All animals underwent anterior vertebral interbody fusion at the L4/L5 level. The lumbar spine was harvested en bloc, and the new bone formation and spinal fusion was evaluated using radiographic analysis, microcomputed tomography, manual palpation test, and histologic examination at 8 and 12 weeks after surgery.

RESULTS

New bone formation and bony fusion was evident as early as 8 weeks in groups I and III. And there was no statistically significant difference between 8 and 12 weeks. At both time points, by microcomputed tomography and histologic analysis, new bone formation was observed in both groups I and III, fibrous tissue was observed and there was no new bone in both groups II and IV; by manual palpation test, bony fusion was observed in 40% (4/10) of rabbits in group I, 70% (7/10) of rabbits in group III, and 0% (0/10) of rabbits in both groups II and IV.

CONCLUSIONS

These findings suggest that mesenchymal stem cells that have been cultured with osteogenic differentiation medium and loaded with collagen sponge could induce bone formation and anterior vertebral interbody fusion. And the rabbit model we developed will be useful in evaluating the effects of graft materials for anterior vertebral interbody fusion. Further study is needed to determine the most appropriate carrier for OMSCs and the feasibility in the clinical setting.

Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: a cost-utility analysis

BACKGROUND

Shoulder hemiarthroplasty (HA) has been the standard treatment for complex proximal humerus fractures in the elderly requiring surgery but not amenable to fixation. Reverse total shoulder arthroplasty (RTSA) has also emerged as a costly albeit highly effective alternative. The purpose of this study was to compare the cost-effectiveness of nonoperative fracture care, HA, and RTSA for complex proximal humerus fractures from the perspective of both U.S. payors and hospitals.

METHODS

A Markov model was constructed for the treatment alternatives. Costs were expressed in 2013 U.S. dollars and effectiveness in quality-adjusted life-years (QALYs). The principal outcome measure was incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to evaluate model assumptions.

RESULTS

In the base case, from the payor perspective, RTSA was associated with an ICER of $8100/QALY; HA was eliminated from payor analysis as a cost-ineffective strategy. From the hospital perspective, however, HA was not cost-ineffective and the ICER for HA was $36,700/QALY, with RTSA providing incremental effectiveness at $57,400/QALY. RTSA was the optimal strategy in 61% and 54% of payor and hospital probabilistic sensitivity analyses, respectively. The preferred strategy was dependent on associated QALY gains, primary RTSA cost, and failure rates for RTSA.

CONCLUSIONS

RTSA can be a cost-effective intervention in the surgical treatment of complex proximal humerus fractures. HA can also be a cost-effective intervention, depending on the cost perspective (cost-ineffective for payor but cost-effective for the hospital). This analysis highlights the opportunities for increased cost-sharing strategies to alleviate the cost burden on hospitals.

Lung complications are common in intensive care treated patients with pelvis fractures: a retrospective cohort study

Background

The incidence of severe respiratory complications in patients with pelvis fractures needing intensive care have not previously been studied. Therefore, the aims of this registry study were to 1) determine the number of ICU patients with pelvis fractures who had severe respiratory complications 2) whether the surgical intervention in these patients is associated with the pulmonary condition and 3) whether there is an association between lung complications and mortality. We hypothesized that acute hypoxic failure (AHF) and acute respiratory distress syndrome (ARDS) 1) are common in ICU treated patients with pelvis fractures, 2) are not related to the reconstructive surgery, or to 3) to mortality.

Methods

All patients in the database cohort (n = 112), scheduled for surgical stabilization of pelvis ring and/or acetabulum fractures, admitted to the general ICU at Uppsala University Hospital between 2007 and 2014 for intensive care were included.

Results

The incidence of AHF/ARDS was 67 % (75/112 patients), i.e., the percentage of patients that at any period during the ICU stay fulfilled the AHF/ARDS criteria. The incidence of AHF was 44 % and incidence of ARDS was 23 %. The patients with AHF/ARDS had more lung contusions and pneumonia than the patients without AHF/ARDS. Overall, there were no significant changes in oxygenation variables associated with surgery. However, 23 patients with pre-operative normal lung status developed AHF/ARDS in relation to the surgical procedure, whereas 12 patients with AHF/ARDS normalized their lung condition. The patients who developed AHF/ARDS had a higher incidence of lung contusion (P = 0.04) and the surgical stabilization was performed earlier (5 versus 10 days) in these patients (P = 0.03).

Conclusions

We found that the incidence of respiratory failure in ICU treated patients with pelvis fractures was high, that the procedure around surgical stabilization seems to be associated with a worsening in the respiratory function in patients with lung contusion, and that mortality was low and was probably not related to the respiratory condition.

Trial registration

Study was registered at ISRCTN.org number, ISRCTN10335587.

Preliminary Results of Bioactive Amniotic Suspension with Allograft for Achieving One and Two-Level Lumbar Interbody Fusion

BACKGROUND

Bone graft material for lumbar fusion was historically autologous bone graft (ABG). In recent years alternatives such as allograft, demineralized bone matrix (DBM), ceramics, and bone morphogenetic protein (BMP) have gained favor, although the complications of these are not fully understood. Bioactive amniotic suspension (BAS) with allograft is a new class of material derived from human amniotic tissue.

METHODS

Eligible patients receiving a one or two level lumbar interbody fusion with Nucel, a BAS with allograft, were contacted and scheduled for a mininmim 12 month follow-up visit. Patients were evaluated for fusion using CT's and plain radiographs. Clincal outcomes, including ODI, VAS back and leg were collected, as well as comorbidities including BMI, smoking status, diabetes and previous lumbar surgery.

RESULTS

One-level patients (N=38) were 71.1% female with mean age of 58.4 ± 12.7 and mean BMI of 30.6 ± 6.08. Two-level patients (N=34) were 58.8% female with mean age of 49.3 ±10.9 and mean BMI of 30.1 ± 5.82. Kinematic fusion was achieved in 97.4% of one-level patients and 100% of two-level patients. Baseline comorbidities were present in 89.5% of one-level patients and 88.2% of two-level patients. No adverse events related to BAS were reported in this study.

CONCLUSION

Fusion status is evaluated with many different biologics and varying methods in the literature. BAS with allograft in this study demonstrated high fusion rates with no complications within a largely comorbid population. Although a small population, BAS with allograft results were encouraging for one and two-level lumbar interbody fusion in this study. Further prospective studies should be conducted to investigate safety and efficacy in a larger population.

Hybrid Macro-Porous Titanium Ornamented by Degradable 3D Gel/nHA Micro-Scaffolds for Bone Tissue Regeneration

Porous titanium is a kind of promising material for bone substitution, while its bio-inert property results in demand of modifications to improve the osteointegration capacity. In this study, gelatin (Gel) and nano-hydroxyapatite (nHA) were used to construct 3D micro-scaffolds in the pores of porous titanium in the ratios of Gel:nHA = 1:0, Gel:nHA = 1:1, and Gel:nHA = 1:3, respectively. Cell attachment and proliferation, and gene and protein expression levels of osteogenic markers were evaluated in MC3T3-E1 cells, followed by bone regeneration assessment in a rabbit radius defect model. All hybrid scaffolds with different composition ratio were found to have significant promotional effects in cell adhesion, proliferation and differentiation, in which the group with Gel:nHA = 1:1 showed the best performance in vitro, as well as the most bone regeneration volume in vivo. This 3D micro-scaffolds modification may be an innovative method for porous titanium ornamentation and shows potential application values in clinic.

Dentoalveolar reconstruction: modern approaches

PURPOSE OF REVIEW

A variety of bone grafting materials is available to facilitate the augmentation of defective alveolar ridges. This review evaluates current literature regarding bone grafting materials with emphasis on autologous and allogeneic bone block augmentation.

RECENT FINDINGS

Autogenous bone is a reliable grafting material providing predictable long-term results with high implant survival/success rates and low morbidity rates. The resorption properties of the iliac crest are well known and are compared with calvarial grafts more prominent. Recent studies demonstrated surgical techniques to prevent graft resorption after iliac crest grafting. Allogeneic block graft and implant survival rates appear promising in short-term clinical studies.

SUMMARY

At this stage, iliac crest remains the gold standard in large alveolar bone defects. Autogenous material is not a panacea; however, none of the available materials can currently surpass it. Rather, each material has its specific advantage for certain indications. Evident long-term studies of allogeneic bone grafting are lacking. Detected cells in allogeneic bone substitute material are positive for major histocompatibility complex classes I and II. Despite the promising clinical results achieved with allogeneic bone grafts, the current literature lacks sufficient data on antigenicity.

Arthrofibrosis After Periarticular Fracture Fixation

Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.

Nonunion of the Femur and Tibia: An Update

Delayed union and nonunion of tibial and femoral shaft fractures are common orthopedic problems. Numerous publications address lower extremity long bone nonunions. This review presents current trends and recent literature on the evaluation and treatment of nonunions of the tibia and femur. New studies focused on tibial nonunion and femoral nonunion are reviewed. A section summarizing recent treatment of atypical femoral fractures associated with bisphosphonate therapy is also included.

Least Possible Fixation Techniques of 4-Part Valgus Impacted Fractures of the Proximal Humerus: A Systematic Review

The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. We systematically reviewed clinical studies assessing the benefits and harms of least possible fixation techniques (LPFT) for this unique fracture type. Such information would be potentially helpful in developing an evidence-based approach in the management of these complex injuries. We performed analytic searches of PubMed, Embase, Web of Science, Google Scholar and the Cochrane Library, restricting it to the years 1991-2014. Included studies had to describe outcomes and complications after primary osteosynthesis with any type of LPFT apart from plate-screws and intramedullary nailing. Eligibility criteria were also included English language, more than 5 cases, minimum follow up of one year and report of clinical outcome using at least one relevant score (Constant, Neer or ASES). Based on 292 database hits we identified 12 eligible studies including 190 four-part valgus impacted fractures in 188 patients. All eligible studies were case series composed of min 8 to max 45 patients per study. The gender distribution was 60% (112) female and 40% (76) male. The average age of the patients at the time of injury was 54.5 years. In 8/12 studies an open reduction was used for fracture fixation using different surgical techniques including KW, cerclage wires, cannulated screws and osteosutures. Closed reduction and percutaneous fixation was used in 4 studies. Mean follow-up time ranged from 24 to 69 months. A good functional outcome (constant score >80) was reported in 9/12 studies. The most common complication was avascular necrosis of the humeral head with an overall incidence of 11% (range, 0-26.3%). Total avascular necrosis (AVN) was found in 15/188 patients (7.9%) and was more common in percutaneous techniques and partial AVN in 6/188 (3.1%) being more common in open techniques. The overall re-operation rate was very low (3.7%). Insufficient study designs cannot provide definite treatment recommendations and quantitative data synthesis of outcome. In general, LPFT for 4-part VI fractures leads to satisfactory outcomes with low incidence of complications. A considerable risk of biases can be attributed to fracture classification, proper radiological control, mean age of patients, mixed types of fixation methods, nonage adjusted clinical scoring and small follow up periods. These factors are discussed in detail. Level of evidence: systematic review of literature (level IV) as most of the studies were level IV.

PROPRIOCEPTION, BODY BALANCE AND FUNCTIONALITY IN INDIVIDUALS WITH ACL RECONSTRUCTION

OBJECTIVE

: To evaluate and compare proprioception, body balance and knee functionality of individuals with or without unilateral anterior cruciate ligament (ACL) reconstruction.

METHODS

: Forty individuals were divided in two groups: Experimental group, 20 individuals with ACL reconstruction at six months postoperative, and control group, 20 individuals with no history of lower limb pathologies. In the experimental group, we assessed lower limbs with reconstructed ACL and contralateral limb; in the control group the dominant and the non-dominant lower limbs were assessed. All subjects were submitted to joint position sense test to evaluate proprioception, postural control measure in single-limb, and step up and down (SUD) test for functional assessment.

RESULTS

: There were no deficits in proprioception and postural control. In the SUD test, a 5% decrease in lift up force was found in reconstructed ACL lower limbs, however, a statistically not significant difference. The impact and step down force during the course of test were 30% greater in anatomic ACL than in control lower limbs.

CONCLUSION

: The individuals with ACL reconstruction at six months postoperative did not show changes in proprioception and postural control, but showed motor control changes, influencing knee functionality. Level of Evidence IV, Prognostic Studies.

Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle

Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion.

Complications related to bone augmentation procedures of localized defects in the alveolar ridge. A retrospective clinical study

PURPOSE

This retrospective clinical study aims to evaluate complications after augmentation of localized bone defects of the alveolar ridge.

METHODS

From standardized registrations, the following complications related to bone augmentation procedures were recorded: soft tissue dehiscence, infection, sensory disturbance, additional augmentation procedures needed, and early implant failure.

RESULTS

A total of 223 patients (132 women, 91 men; mean age 23.5 years; range 17-65 years) with 331 bone defects had bone augmentation performed into which 350 implants were placed. Soft tissue dehiscence occurred in 1.7 % after GBR procedures, 25.9 % after staged horizontal ridge augmentation, and 18.2 % after staged vertical ridge augmentation. Infections were diagnosed in 2 % after GBR procedures, 12.5 % after sinus floor elevation (SFE) (transcrestal technique), 5 % after staged SFE, 11 % after staged horizontal ridge augmentation, and 9 % after staged vertical ridge augmentation. Additional augmentation procedures were needed in 2 % after GBR procedures, 37 % after staged horizontal ridge augmentation, and 9 % after staged vertical ridge augmentation. A total of six early implant failures occurred (1.7 %), four after GBR procedures (1.6 %), and two (12 %) after staged vertical ridge augmentation.

CONCLUSIONS

Predictable methods exist to augment localized defects in the alveolar ridge, as documented by low complication rates and high early implant survival rates.

Influence of plate material and screw design on stiffness and ultimate load of locked plating in osteoporotic proximal humeral fractures

INTRODUCTION

The main purpose was to compare the biomechanical properties of a carbon-fibre reinforced polyetheretherketone (CF-PEEK) composite locking plate with pre-existing data of a titanium-alloy plate when used for fixation of an unstable 2-part fracture of the surgical neck of the humerus. The secondary purpose was to compare the mechanical behaviour of locking bolts and conventional locking cancellous screws.

METHODS

7 pairs of fresh frozen human humeri were allocated to two equal groups. All specimens were fixed with the CF-PEEK plate. Cancellous screws (PEEK/screw) were compared to locking bolts (PEEK/bolt) for humeral head fixation. Stiffness, fracture gap deflection and ultimate load as well as load before screw perforation of the articular surface were assessed. Results were compared between groups and with pre-existing biomechanical data of a titanium-alloy plate.

RESULTS

The CF-PEEK plate featured significantly lower stiffness compared to the titanium-alloy plate (P<0.001). In ultimate load testing, 6 out of 14 CF-PEEK plates failed due to irreversible deformation and cracking. No significant difference was observed between results of groups PEEK/screw and PEEK/bolt (P>0.05).

DISCUSSION

The CF-PEEK plate has more elastic properties and significantly increases movement at the fracture site of an unstable proximal humeral fracture model compared to the commonly used titanium-alloy plate. The screw design however does neither affect the constructs primary mechanical behaviour in the constellation tested nor the load before screw perforation.

Transiliac Osteotomy in Surgical Management of Pelvic Post-Traumatic Malunions: A Retrospective Study

While uncommon, post-traumatic pelvic malunions present reconstructive challenges and are associated with significant disability and financial burden. A transiliac osteotomy is a surgical technique useful to correct certain types of pelvic fracture malunions, and is only used when the correction of a limb-length discrepancy is the primary goal. This study aims to present our experience with this technique in the treatment of post-traumatic pelvic malunions. Eight patients who underwent transiliac osteotomies for post-traumatic pelvic malunions at our department from 2006 to 2011 were included in this study. We reviewed the clinical and radiographic results of these patients. By the time of their last follow-up, all osteotomy sites and iliac bone graft had healed with no evidence of internal fixation failure. Of the 3 patients who complained of preoperative posterior pain, 2 reported an improvement. All 8 patients noted the resolution of their lower back pain. At the time of their final follow-up, 4 patients could walk normally, 2 had a slight limp without a cane, 1 patient used a cane to help with standing and walking, and the final felt limited during ambulation with a cane. Limb-lengthening relative to preoperative measurements was 2.86 cm (2.2-3.0 cm) at the time of the last follow-up. Two patients were able to return to their previous jobs, 4 patients changed their jobs or engaged in light manual labor while the final 2 were able to perform activities of daily living but were unable to participate in work or labor. Three patients reported being "extremely satisfied" with their outcomes, 3 were "satisfied," and 2 were "unsatisfied." A transiliac osteotomy can be used to manage selected cases of post-traumatic pelvic malunions that are unable to be corrected with a traditional release and osteotomy. However, in these cases the correction of limb-length discrepancies should be the primary reconstructive goal.

Tissue engineering advances in spine surgery

Autograft, while currently the gold standard for bone grafting, has several significant disadvantages including limited supply, donor site pain, hematoma formation, nerve and vascular injury, and fracture. Bone allografts have their own disadvantages including reduced osteoinductive capability, lack of osteoprogenitor cells, immunogenicity and risk of disease transmission. Thus demand exists for tissue-engineered constructs that can produce viable bone while avoiding the complications associated with human tissue grafts. This review will focus on recent advancements in tissue-engineered bone graft substitutes utilizing nanoscale technology in spine surgery applications. An evaluation will be performed of bone graft substitutes, biomimetic 3D scaffolds, bone morphogenetic protein, mesenchymal stem cells and intervertebral disc regeneration strategies.

Sequential necrotizing fasciitis caused by the monomicrobial pathogens Streptococcus equisimilis and extended-spectrum beta-lactamase-producing Escherichia coli

Necrotizing fasciitis is a rapidly progressing bacterial infection of the superficial fascia and subcutaneous tissue that is associated with a high mortality rate and is caused by a single species of bacteria or polymicrobial organisms. Escherichia coli is rarely isolated from patients with monomicrobial disease. Further, there are few reports of extended-spectrum beta-lactamase (ESBL)-producing E. coli associated with necrotizing fasciitis. We report here our treatment of an 85-year-old man who was admitted because of necrotizing fasciitis of his right thigh. Streptococcus equisimilis was detected as a monomicrobial pathogen, and the infection was cured by amputation of the patient's right leg and the administration of antibiotics. However, 5 days after discontinuing antibiotic therapy, he developed necrotizing fasciitis on his right upper limb and died. ESBL-producing E. coli was the only bacterial species isolated from blood and skin cultures. This case demonstrates that ESBL-producing E. coli can cause monomicrobial necrotizing fasciitis, particularly during hospitalization and that a different bacterial species can cause disease shortly after a previous episode.

Corrective osteotomies of the radius: Grafting or not?

AIM: To review the current literature regarding corrective osteotomies to provide the best evidence of the rule of bone grafting.

METHODS: Our MEDLINE literature search included 280 studies using the following key words “Malunited distal radius fracture” and 150 studies using key words “Corrective osteotomy of the distal radius”. Inclusion criteria were: Malunited distal radial, extra articular fracture, volar locking plate, use of iliac bone graft (cancellous or corticocancellous), non-use of bone graft. Twelve studies met the inclusion criteria.

RESULTS: Seven of the 12 studies considered, described the use of a graft; the remaining five studies didn’t use any graft. Type of malunion was dorsal in most of the studies. The healing time was comparable using the graft or not (mean 12.5 wk), ranging from 7.5 to 16 wk. The mean disabilities of the arm, shoulder and hand score improvement was 23 points both in the studies that used the graft and in those not using the graft.

CONCLUSION: This review demonstrated that corrective osteotomy of extra-articular malunited fractures of the distal radius treated by volar locking plate does not necessarily require bone graft.

Radiographic morphometry and densitometry predict strength of cadaveric proximal humeri more reliably than age and DXA scan density

Methods are needed for identifying poorer quality cadaver proximal humeri to ensure that they are not disproportionately segregated into experimental groups for fracture studies. We hypothesized that measurements made from radiographs of cadaveric proximal humeri are stronger predictors of fracture strength than chronological age or bone density values derived from dual-energy x-ray absorptiometry (DXA) scans. Thirty-three proximal humeri (range: 39-78 years) were analyzed for: (1) bone mineral density (BMD, g/cm(2)) using DXA, (2) bulk density (g/cm(3)) using DXA and volume displacement, (3) regional bone density in millimeters of aluminum (mmAl) using radiographs, and (4) regional mean (medial+lateral) cortical thickness and cortical index (CI) using radiographs. The bones were then fractured simulating a fall. Strongest correlations with ultimate fracture load (UFL) were: mean cortical thickness at two diaphyseal locations (r = 0.71; p < 0.001), and mean mmAl in the humeral head (r = 0.70; p < 0.001). Weaker correlations were found between UFL and DXA-BMD (r = 0.60), bulk density (r = 0.43), CI (r = 0.61), and age (r = -0.65) (p values <0.01). Analyses between UFL and the product of any two characteristics showed six combinations with r-values >0.80, but none included DXA-derived density, CI, or age. Radiographic morphometric and densitometric measurements from radiographs are therefore stronger predictors of UFL than age, CI, or DXA-derived density measurements.

Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls

Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Deficiency of inducible and endothelial nitric oxide synthase results in diminished bone formation and delayed union and nonunion development

BACKGROUND

Between 5% and 10% of all fractures fail to heal adequately resulting in nonunion of the fracture fragments. This can significantly decrease a patient's quality of life and create associated psychosocial and socio-economic problems. Nitric oxide (NO) and nitric oxide synthases (NOS) have been found to be involved in fracture healing, but until now it is not known if disturbances in these mechanisms play a role in nonunion and delayed union development. In this study, we explored the role of endothelial and inducible NOS deficiency in a delayed union model in mice.

MATERIALS AND METHODS

A 0.45mm femur osteotomy with periosteal cauterization followed by plate-screw osteosynthesis was performed in the left leg of 20-24week old wild type, Nos2(-/-) and Nos3(-/-) mice. Contralateral unfractured legs were used as a control. Callus volume was measured using micro-computed tomography (μCT) after 28 and 42days of fracture healing. Immuno histochemical myeloperoxidase (MPO) staining was performed on paraffin embedded sections to assess neutrophil influx in callus tissue and surrounding proximal and distal marrow cavities of the femur. After 7 and 28days of fracture healing, femurs were collected for amino acid and RNA analysis to study arginine-NO metabolism.

RESULTS

With μCT, delayed union was observed in wild type animals, whereas in both Nos2(-/-) and Nos3(-/-) mice nonunion development was evident. Both knock-out strains also showed a significantly increased influx of MPO when compared with wild type mice. Concentrations of amino acids and expression of enzymes related to the arginine-NO metabolism were aberrant in NOS deficient mice when compared to contralateral control femurs and wild type samples.

DISCUSSION AND CONCLUSION

In the present study we show for the first time that the absence of nitric oxide synthases results in a disturbed arginine-NO metabolism and inadequate fracture healing with the transition of delayed union into a nonunion in mice after a femur osteotomy. Based on these data we suggest that the arginine-NO metabolism may play a role in the prevention of delayed unions and nonunions.

The treatment of atrophic, recalcitrant long-bone nonunion in the upper extremity with human recombinant bone morphogenetic protein-7 (rhBMP-7) and plate fixation: A retrospective review

INTRODUCTION

Recombinant Human Bone Morphogenetic Protein-7 (rhBMP-7) has been shown to promote fracture healing in both clinical studies and basic science models, however, there is little information from large-scale studies of its use for human nonunion. The purpose of this study was to determine the safety and efficacy of rhBMP-7 in the treatment of atrophic human long-bone nonunions in the upper extremity.

PATIENTS AND METHODS

This was a single center, retrospective, longitudinal cohort study of patients treated with compression plating and the application of rhBMP-7 in isolation to a long-bone nonunion. Patients over sixteen years of age with an atrophic, aseptic nonunion of a humerus, radius, ulna or clavicle were eligible for inclusion.

RESULTS

We identified seventy eligible patients who were treated with rhBMP-7 for a long-bone nonunion between July 1997 and April 2012. The mean age of the patients at the time of treatment with rhBMP-7 was 50.7 years (range, 20-92 years). Five patients were lost to follow-up prior to definitive clinical or radiographic union. During the one-year post-operative period fifty-six patients had achieved union and two patients developed a stable fibrous union after the index procedure. Two patients had early implant failure and five patients had persistent nonunion. Thus, the union rate following initial surgery was 89% (58/65) and four of the five nonunion patients went on to heal following revision open reduction and internal fixation.

CONCLUSION

We found that the application of rhBMP-7 for upper extremity nonunion was an effective method (89% union rate) of treating this challenging pathology. Additionally, if not initially successful, further reconstruction was not compromised by rhBMP-7 use.

Open reduction and internal fixation of three- and four-part proximal humeral fractures by intra-focal distraction: observational study of twenty five cases

PURPOSE

Reduction and fixation of proximal humerus fracture (PHF) by intra-focal distraction with a cemented device is seldom used. A cementless stem called JUST was developed to simplify and standardise reduction and fixation of three- or four-part fractures (3-/4-PFs). This study is designed to evaluate the performances of this device. In addition, we compared the results to those of a previous study based on cemented stems.

METHOD

Twenty-five patients underwent surgery between 2009 and 2011: ten 3-PFs and 15 4-PFs, with a median age of 65.5 and 71 years, respectively. The reduction and fixation device comprises a staple placed in the humeral head and a cementless stem impacted in the diaphysis that works like a jack. Median follow-up was 28 months.

RESULTS

For the ten 3-PFs, the median raw and weighted Constant score were 66.5 and 86, respectively. Only one case presented with secondary displacement. All fractures healed and there was only one case of avascular necrosis. For the 15 4-PFs, the median raw and weighted Constant score were 64 and 76, respectively. Only one case of secondary cephalic displacement was observed and no cases of tuberosity displacement were observed. All fractures healed except for one case of pseudarthrosis of the lesser tuberosity. Five cases of avascular necrosis were observed.

CONCLUSIONS

This device resolves the mechanical difficulties relating to fixation of 3- and 4-PFs by providing stable fixation but does not prevent the risk of avascular necrosis. The cementless stem is more convenient but does not yield better results than the cemented stem.

Complications and Rates of Subsequent Lumbar Surgery Following Lumbar Total Disc Arthroplasty and Lumbar Fusion

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To examine complications and rates of subsequent surgery following lumbar spinal fusion (LF) and lumbar total disc arthroplasty (TDA) at up to 5-year follow-up.

SUMMARY OF BACKGROUND DATA

LF is commonly used in the management of degenerative disc disease causing pain refractory to nonoperative management. Lumbar TDA was developed as an alternative to fusion with the theoretical advantage of reducing rates of adjacent segment pathology and reoperation. Most prior reports comparing these 2 interventions have come from industry-sponsored investigational device exemption trials and no large-scale administrative database comparisons exist.

METHODS

The California Office of Statewide Health Planning and Development discharge database was queried for patients aged 18 to 65 years undergoing lumbar TDA and LF for degenerative disc disease from 2004 to 2010. Patient characteristics were collected, and rates of complications and readmission were identified. Rates of repeat lumbar surgery were calculated at 90-day and 1-, 3-, and 5-year follow-up intervals.

RESULTS

A total of 52,877 patients met the inclusion criteria (LF = 50,462, TDA = 2415). Wound infections were more common following LF than TDA (1.03% vs. 0.25%, P < 0.001). Rates of subsequent lumbar surgery at 90-day and 1-year follow-up were lower with lumbar TDA than LF (90-day-TDA: 2.94% vs. LF: 4.01%, P = 0.007; 1-yr-TDA: 3.46% vs. LF: 4.78%, P = 0.009). However, there were no differences in rates of subsequent lumbar surgery between the 2 groups at 3-year and 5-year follow-up.

CONCLUSION

Lumbar TDA was associated with fewer early reoperations, though beyond 1 year, rates of reoperation were similar. Lumbar TDA may be associated with fewer acute infections, though this may be approach related and unrelated to the device itself.

LEVEL OF EVIDENCE

3.