First detection of primary cilia in injured human anterior cruciate ligament: A pilot study with pathophysiological reflections

The anterior cruciate ligament (ACL) plays a significant role in knee stability, protects the joint under multiple loading conditions and shows complex biomechanics. Beside mechanical stability, the ACL seems to play a crucial role in proprioception, and it is well known, that ACL injuries can cause functional deficits due to decreased proprioception. However, the mechanism of proprioception is not completely understood yet. In this context, primary cilia (PC), which play a significant role in the signaling between the intra- and extracellular space, could be of interest. However, until today, primary cilia are not yet described in human ACL. In total, seven human ACL's underwent transmission electron microscopical examination. Three cadaveric ACL's and four freshly injured ACL's were examined. Single cells of each ACL were examined regarding the presence of axonemes or basal bodies, which represent components of a PC. In total, 276 cells of the cadaveric ACL's and 180 cells of the injured ACL's were examined. Basal bodies could be detected in three of the four specimens of the injured ACL's as well as in one of the three cadaveric ACL's, resulting in a mean positivity of 2.54% in the cadaveric group and 2.78% in the injured group. In case of PC-presence, only one PC per cell could be detected. No statistically significant difference regarding the frequency could be detected between both groups. In this pilot-study, we present for the first time an ultrastructural study of human ACLs with respect to the occurrence of PC and any structural and morphological features of these complex and dynamic cell organelles. PCs are present in almost all non-hematopoietic tissues of the human body. However, there are different reports on the number, incidence, orientation, and morphology of these cell organelles in the respective tissues. Compared to other tissues and ligaments of other species, we found a significantly lower rate of PC positive cells. This observation might represent a tissue-specific characteristic of ACL tissue. However, our observations need to be explored in more detail in further studies.

Preclinical evaluation of a prototype freehand drill video guidance system for orthopedic surgery

Purpose: Internal fixation of pelvic fractures is a challenging task requiring the placement of instrumentation within complex three-dimensional bone corridors, typically guided by fluoroscopy. We report a system for two- and three-dimensional guidance using a drill-mounted video camera and fiducial markers with evaluation in first preclinical studies. Approach: The system uses a camera affixed to a surgical drill and multimodality (optical and radio-opaque) markers for real-time trajectory visualization in fluoroscopy and/or CT. Improvements to a previously reported prototype include hardware components (mount, camera, and fiducials) and software (including a system for detecting marker perturbation) to address practical requirements necessary for translation to clinical studies. Phantom and cadaver experiments were performed to quantify the accuracy of video-fluoroscopy and video-CT registration, the ability to detect marker perturbation, and the conformance in placing guidewires along realistic pelvic trajectories. The performance was evaluated in terms of geometric accuracy and conformance within bone corridors. Results: The studies demonstrated successful guidewire delivery in a cadaver, with a median entry point error of 1.00 mm (1.56 mm IQR) and median angular error of 1.94 deg (1.23 deg IQR). Such accuracy was sufficient to guide K-wire placement through five of the six trajectories investigated with a strong level of conformance within bone corridors. The sixth case demonstrated a cortical breach due to extrema in the registration error. The system was able to detect marker perturbations and alert the user to potential registration issues. Feasible workflows were identified for orthopedic-trauma scenarios involving emergent cases (with no preoperative imaging) or cases with preoperative CT. Conclusions: A prototype system for guidewire placement was developed providing guidance that is potentially compatible with orthopedic-trauma workflow. First preclinical (cadaver) studies demonstrated accurate guidance of K-wire placement in pelvic bone corridors and the ability to automatically detect perturbations that degrade registration accuracy. The preclinical prototype demonstrated performance and utility supporting translation to clinical studies.

Sacral Insufficiency Fractures

»

Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures.

»

The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients.

»

Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy.

»

Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences.

»

The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.

Perioperative Radiographic Predictors of Non-Union in Infra-Isthmal Femoral Shaft Fractures after Antegrade Intramedullary Nailing: A Case-Control Study

Antegrade intramedullary (IM) nailing is the gold standard treatment for femoral shaft fractures; however, the non-union rate of infra-isthmal femoral shaft fractures is still high after antegrade IM nailing. This retrospective case−control study aimed to determine the association between perioperative radiographic factors and the non-union of infra-isthmal femoral shaft fractures after antegrade IM nailing. Univariate and multivariate analyses were used to evaluate the radiographic risk factors of non-union. Ninety-three patients were included, with thirty-one non-unions and sixty-two matched controls between 2007 and 2017. All were regularly followed up for 2 years. Receiver operating characteristic analysis revealed that a ratio of the unfixed distal segment > 32.5% was strongly predictive of postoperative non-union. The risk factors for non-union were AO/OTA type B and C (odds ratio [OR]: 2.20), a smaller ratio of the distal fragment (OR: 4.05), a greater ratio of the unfixed distal segment (OR: 7.16), a higher ratio of IM canal diameter to nail size at the level of fracture (OR: 6.23), and fewer distal locking screws (OR: 2.31). The radiographic risk factors for non-union after antegrade IM nailing for infra-isthmal femoral shaft fractures were unstable fractures, shorter distal fragments, longer unfixed distal fragments, wider IM canal, and fewer distal locking screws. Surgeons must strive to avoid non-union with longer and larger nails and apply more distal locking screws, especially for unstable, wider IM canal, and shorter distal fragment fractures.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.

Ceramic bone graft substitute vs autograft in XLIF: a prospective randomized single-center evaluation of radiographic and clinical outcomes

Purpose of the Study

The objective of this prospective, parallel, randomized, single-center study is to evaluate the clinical success of a commercial ceramic bone graft substitute (CBGS) for autograft in eXtreme Lateral Interbody Fusion (XLIF) procedures. Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Cristiano Magalhães], Last name [Menezes]. Author 2 Given name: [Gabriel Carvalho], Last name [Lacerda]. Author 5 Given name: [Erica Godinho], Last name [Menezes]. Also, kindly confirm the details in the metadata are correct.yes

Methods

Forty-five adult subjects were consecutively enrolled and randomized into a single-level XLIF procedure using either CBGS or iliac crest bone graft autograft (30 and 15 subjects, respectively). The primary outcome was fusion rate at 12, 18, and 24 months. Secondary outcomes were pain and disability measured by HRQOL questionnaires. Kindly check and confirm whether the corresponding author and his corresponding affiliations is correctly identified.yes

Results

The fusion rates for both CBGS and autograft groups at the 24-month follow-up were 96.4% and 100%, respectively. For the CBGS group, mean ODI, mean back pain, and mean worst leg pain significantly improved at the 24-month follow-up by 76.7% (39.9–9.3), 77.6% (7.3–1.6), and 81.3% (5.1–1.0), respectively. For the autograft group, mean ODI, mean back pain, and mean worst leg pain significantly improved during the same time period by 77.1% (35.9–8.2), 75.6% (6.1–1.5), and 86.0% (6.6–0.9), respectively (all time points between groups, p < 0.05).

Conclusion

The results of this prospective, randomized study support the use of CBGS as a standalone bone graft substitute for autograft in single-level XLIF surgery. The clinical performance and safety outcomes reported here are consistent with published evidence on CBGS. Improvements in patient-reported back pain, leg pain, and disability outcomes were comparable between the CBGS and autograft groups.

Therapeutic effect of autologous bone grafting with adjuvant bone morphogenetic protein on long bone nonunion: a systematic review and meta-analysis

BACKGROUND

The recombinant human bone morphogenetic protein (rhBMP) is a common graft substitute for treating cases of long bone nonunion. However, the feasibility of combining an autologous bone graft (ABG) with rhBMPs remains uncertain. Thus, this systematic review and meta-analysis aimed to evaluate the synergistic effect of ABG and rhBMPs on the healing of long bone nonunion.

METHODS

A systematic literature search was performed on PubMed, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. Two authors independently screened the studies, extracted data, and assessed the quality of the trials. Statistical analyses were performed using Stata 12.0.

RESULTS

Of the 202 citations, five studies involving a total of 394 cases met the eligibility criteria; thus, they were included in this study. The pooled data revealed no significant differences among the groups in terms of postoperative healing rate (risk ratio [RR] = 1.01, 95% confidence interval [CI] = 0.96-1.06, P = 0.744), healing time (standardised mean difference =  - 0.20, 95% CI = - 0.95-0.56, P = 0.610), and pain (RR = 1.44, 95% CI = 0.25-8.29, P = 0.681). The combination of ABG and rhBMPs resulted in good limb function (RR = 1.31, 95% CI = 1.04-1.66, P = 0.023).

CONCLUSIONS

The combination of ABG and rhBMPs did not result in the healing of long bone nonunion and pain reduction. Nevertheless, it conferred good limb function. Thus, the findings in this study are insufficient to support the use of rhBMPs as an adjuvant to ABG.

Clinical Reference Strategy for the Selection of Treatment Materials for Maxillofacial Bone Transplantation: A Systematic Review and Network Meta-Analysis

Bone graft materials have mixed effects of bone repair in the field of oral maxillofacial surgery. The qualitative analyses performed by previous studies imply that autogenous odontogenic materials and autogenous bone have similar effects on bone repair in clinical jaw bone transplantation. This retrospective systematic assessment and network meta-analysis aimed to analyze the best effect of clinical application of autogenous odontogenic materials and autogenous, allogeneic, and xenogeneic bone grafts in bone defect repair. A systematic review was performed by searching the PubMed, Cochrane Library, and other journal databases using selected keywords and Medical Subject Headings search terms. 10 Papers (n = 466) that met the inclusion criteria were selected. The assessment of heterogeneity did not reveal any overall statistical difference or heterogeneity (P = 0.051 > 0.05), whereas the comparison between autogenous and allogeneic bone grafts revealed local heterogeneity (P = 0.071 < 0.1). Risk of bias revealed nine unclear studies and one high-risk study. The overall consistency was good (P = 0.065 > 0.05), and the local inconsistency test did not reveal any inconsistency. The publication bias was good. The confidence regarding the ranking of bone graft materials after GRADE classification was moderate. The effects on bone repair in the descending order were as follows: autogenous odontogenic materials, xenogeneic bone, autogenous bone, and allogeneic bone. This result indicates that the autogenous odontogenic materials displayed stronger effects on bone repair compared to other bone graft materials. Autogenous odontogenic materials have broad development prospects in oral maxillofacial surgery.

Management of fresh odontoid fractures using posterior C1-2 fixation without fusion: a long-term clinical follow-up study

OBJECTIVE

Posterior C1-2 fixation without fusion makes it possible to restore atlantoaxial motion after removing the implant, and it has been used as an alternative technique for odontoid fractures; however, the long-term efficacy of this technique remains uncertain. The purpose of the present study was to explore the long-term follow-up outcomes of patients with odontoid fractures who underwent posterior C1-2 fixation without fusion.

METHODS

A retrospective study was performed on 62 patients with type II/III fresh odontoid fractures who underwent posterior C1-2 fixation without fusion and were followed up for more than 5 years. The patients were divided into group A (23 patients with implant removal) and group B (39 patients without implant removal) based on whether they underwent a second surgery to remove the implant. The clinical outcomes were recorded and compared between the two groups. In group A, the range of motion (ROM) of C1-2 was calculated, and correlation analysis was performed to explore the factors that influence the ROM of C1-2.

RESULTS

A solid fracture fusion was found in all patients. At the final follow-up, no significant difference was found in visual analog scale score or American Spinal Injury Association Impairment Scale score between the two groups (p > 0.05), but patients in group A had a lower Neck Disability Index score and milder neck stiffness than did patients in group B (p < 0.05). In group A, 87.0% (20/23) of the patients had atlantoodontoid joint osteoarthritis at the final follow-up. In group A, the C1-2 ROM in rotation was 6.1° ± 4.5° at the final follow-up, whereas the C1-2 ROM in flexion-extension was 1.8° ± 1.2°. A negative correlation was found between the C1-2 ROM in rotation and the severity of tissue injury in the atlantoaxial region (r = -0.403, p = 0.024) and the degeneration of the atlantoodontoid joint (r = -0.586, p = 0.001).

CONCLUSIONS

Posterior C1-2 fixation without fusion can be used effectively for the management of fresh odontoid fractures. The removal of the implant can further improve the clinical efficacy, but satisfactory atlantoaxial motion cannot be maintained for a long time after implant removal. A surgeon should reconsider the contribution of posterior C1-2 fixation without fusion and secondary implant removal in preserving atlantoaxial mobility for patients with fresh odontoid fractures.

Changes in Dynamic Postural Stability After ACL Reconstruction: Results Over 2 Years of Follow-up

Background:

The anterior cruciate ligament (ACL) is crucial for knee proprioception and postural stability. While ACL reconstruction (ACLR) and rehabilitation improve postural stability, the timing in improvement of dynamic postural stability after ACLR remains relatively unknown.

Purpose:

To evaluate changes in dynamic postural stability after ACLR out to 24 months postoperatively.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients undergoing ACLR were prospectively enrolled, and dynamic postural stability was assessed within 2 days before surgery, at 3-month intervals postoperatively to 18 months, then at 24 months. Measurements were made on a multidirectional platform tracking the patient’s center of mass based on pelvic motion. The amount of time the patient was able to stay on the platform was recorded, and a dynamic motion analysis score, reflecting the patient’s ability to maintain one’s center of mass, was generated overall and in 6 independent planes of motion.

Results:

A total of 44 patients with a mean age of 19.7 ± 6.2 years completed the study protocol. Overall mean dynamic postural stability improved significantly at 3, 6, 9, and 12 months after surgery, with continued improvement out to 24 months. Notable improvements occurred in medial/lateral and anterior/posterior stability from baseline to 6 months postoperatively, while internal/external rotation and flexion/extension stability declined initially after surgery from baseline to 3 months postoperatively before stabilizing to the end of the study period.

Conclusion:

Overall dynamic postural stability significantly improved up to 12 months after ACLR. Improvement in postural stability occurred primarily in the medial/lateral and anterior/posterior planes of motion, with initial decreases in the flexion/extension and internal/external rotational planes of motion.

Characterization of Induction and Targeting of Senescent Mesenchymal Stromal Cells

Mesenchymal stromal cells (MSCs) from older donors have limited potential for bone tissue formation compared with cells from younger donors, and cellular senescence has been postulated as an underlying cause. There is a critical need for methods to induce premature senescence to study this phenomenon efficiently and reproducibly. However, the field lacks consensus on the appropriate method to induce and characterize senescence. Moreover, we have a limited understanding of the effects of commonly used induction methods on senescent phenotype. To address this significant challenge, we assessed the effect of replicative, hydrogen peroxide, etoposide, and irradiation-induced senescence on human MSCs using a battery of senescent cell characteristics. All methods arrested proliferation and resulted in increased cell spreading compared with low passage controls. Etoposide and irradiation increased expression of senescence-related genes in MSCs at early time points, proinflammatory cytokine secretion, DNA damage, and production of senescence-associated β-galactosidase. We then evaluated the effect of fisetin, a flavonoid and candidate senolytic agent, to clear senescent cells and promote osteogenic differentiation of MSCs entrapped in gelatin methacryloyl (GelMA) hydrogels in vitro. When studying a mixture of nonsenescent and senescent MSCs, we did not observe decreases in senescent markers or increases in osteogenesis with fisetin treatment. However, the application of the same treatment toward a heterogeneous population of human bone marrow-derived cells entrapped in GelMA decreased senescent markers and increased osteogenesis after 14 days in culture. These results identify best practices for inducing prematurely senescent MSCs and motivate the need for further study of fisetin as a senolytic agent. Impact Statement The accumulation of senescent cells within the body has detrimental effects on tissue homeostasis. To study the role of senescent cells on tissue repair and regeneration, there is a need for effective means to induce premature cell senescence. Herein, we characterized the influence of common stressors to induce premature senescence in human mesenchymal stromal cells (MSCs). Irradiation of MSCs resulted in a phenotype most similar to quiescent, high-passage cells. These studies establish key biomarkers for evaluation when studying senescent cells in vitro.

Tibial cancellous bone auto-grafting for medial open-wedge high tibial osteotomy: bone void filling with tissue harvested from osteotomized medullary canal

The aim of the study was to evaluate the clinical and radiological outcomes in a series of patients undergoing open wedge high tibial osteotomy (OWHTO) using tibial cancellous autograft harvested from the osteotomized medullary canal which is not reported in the literature before. Patients with medial compartment osteoarthritis were treated with OWHTO and tibial cancellous auto- grafting performed from the osteotomized medullary canal and used for bone void filling. Seventy patients (seventy-two knees) treated with OWHTO were analyzed. All patients started partial weight-bearing with crutches the day after surgery and full-weight bearing eight weeks after surgery, according to radiological evaluation. Fifty-seven women and 13 men with a mean age of 54.2±8.1 years were evaluated in this study. The mean correction angle was 8.4±2.5° (range: 5.3°-14.3°). The osteotomy sites of all patients were grafted with tibial cancellous autografts. In all patients bony union was detected after surgery. No implant failures or major complications were en- countered. Clinical and radiological findings revealed that bone void filling with the harvested autograft from the osteotomized medullary canal may be a satisfactory and reliable option in OWHTO.

Fracture fixation in extremity trauma with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates: evidence today

PURPOSE

To compare the CFR-PEEK plates with conventional plates in fracture fixation with regards to clinical and radiological outcomes and complications.

METHODS

A systematic literature search was conducted in four online databases independently by two reviewers using the Cochrane methodology for systematic reviews. The identified relevant studies were assessed against predetermined inclusion/exclusion criteria. Independent data extraction and assessment of risk of bias and study quality was carried out.

RESULTS

Nine studies (patient n = 361) out of 6594 records were included for analysis: 2 RCTs (n = 63), 3 prospective cohort studies (n = 151), and 4 retrospective cohort studies (n = 147). Studies were grouped per anatomic area of fixation. Four studies (n = 200) examined fixation of proximal humerus fractures. Two studies (n = 74) examined fixation of distal radius fractures. Two studies (n = 53) assessed outcomes of fixation of distal femur fractures. One study (n = 87) assessed the outcomes of fixation of ankle fractures. All nine studies reported very high union rates (from 91% in distal femur to 100% in upper limb) for the CFR-PEEK plate groups and low complication rates. There was no significant difference in clinical outcomes, and rate of complications as compared to the conventional plate groups.

CONCLUSION

CFR-PEEK plates have high union rates in extremity fracture fixation similar to conventional plates with comparable good clinical outcomes and a very low and comparable rate of complications. Considering their advantages, CFR-PEEK plates seem to be valid alternative to conventional plating.

Nonlinear micro finite element models based on digital volume correlation measurements predict early microdamage in newly formed bone

Bone regeneration in critical-sized defects is a clinical challenge, with biomaterials under constant development aiming at enhancing the natural bone healing process. The delivery of bone morphogenetic proteins (BMPs) in appropriate carriers represents a promising strategy for bone defect treatment but optimisation of the spatial-temporal release is still needed for the regeneration of bone with biological, structural, and mechanical properties comparable to the native tissue. Nonlinear micro finite element (μFE) models can address some of these challenges by providing a tool able to predict the biomechanical strength and microdamage onset in newly formed bone when subjected to physiological or supraphysiological loads. Yet, these models need to be validated against experimental data. In this study, experimental local displacements in newly formed bone induced by osteoinductive biomaterials subjected to in situ X-ray computed tomography compression in the apparent elastic regime and measured using digital volume correlation (DVC) were used to validate μFE models. Displacement predictions from homogeneous linear μFE models were highly correlated to DVC-measured local displacements, while tissue heterogeneity capturing mineralisation differences showed negligible effects. Nonlinear μFE models improved the correlation and showed that tissue microdamage occurs at low apparent strains. Microdamage seemed to occur next to large cavities or in biomaterial-induced thin trabeculae, independent of the mineralisation. While localisation of plastic strain accumulation was similar, the amount of damage accumulated in these locations was slightly higher when including material heterogeneity. These results demonstrate the ability of the nonlinear μFE model to capture local microdamage in newly formed bone tissue and can be exploited to improve the current understanding of healing bone and mechanical competence. This will ultimately aid the development of BMPs delivery systems for bone defect treatment able to regenerate bone with optimal biological, mechanical, and structural properties.

Surgical Fixation of Three- and Four-Part Proximal Humeral Fractures Using the Proximal Humeral Interlocking System Plate

Introduction

The management of proximal humeral fractures ranges greatly from conservative management to surgical treatment. For those fractures requiring surgical treatment, internal fixation is the primary method. The aim of internal fixation is to achieve rigid fracture fixation until union occurs, return of shoulder range of motion, and minimise intra-and postoperative complications. The aim of this study was to evaluate the results of the Proximal Humeral Interlocking System Plate (PHILOS) used for the treatment of three-and four-part proximal humeral fractures.

Materials and methods

This study included 30 patients with a mean age of 54 years (range 20-80 years). Results were checked post-operatively with standard radiographs and clinical evaluation according to the Constant-Murley shoulder score. All patients were followed up for 12 months.

Results

Union was achieved in all patients with a mean neck/shaft angle of 130° (range 108°-150°). The mean Constant-Murley score at the final follow-up was 82.28 (range 67-96) correlating with good results. No patients developed an intraoperative or postoperative vascular injury, wound complications, or avascular necrosis of the humeral head.

Conclusion

Our study has shown that the surgical treatment of three- and four-part proximal humeral fractures with the use of the PHILOS plate leads to a good functional outcome. It has also demonstrated the PHILOS plate and is an effective system for fracture stabilisation provided the correct surgical technique is used with awareness of potential hardware complications.

3D printing applications in spine surgery: an evidence-based assessment toward personalized patient care

PURPOSE

Spine surgery entails a wide spectrum of complicated pathologies. Over the years, numerous assistive tools have been introduced to the modern neurosurgeon's armamentarium including neuronavigation and visualization technologies. In this review, we aimed to summarize the available data on 3D printing applications in spine surgery as well as an assessment of the future implications of 3D printing.

METHODS

We performed a comprehensive review of the literature on 3D printing applications in spine surgery.

RESULTS

Over the past decade, 3D printing and additive manufacturing applications, which allow for increased precision and customizability, have gained significant traction, particularly spine surgery. 3D printing applications in spine surgery were initially limited to preoperative visualization, as 3D printing had been primarily used to produce preoperative models of patient-specific deformities or spinal tumors. More recently, 3D printing has been used intraoperatively in the form of 3D customizable implants and personalized screw guides.

CONCLUSIONS

Despite promising preliminary results, the applications of 3D printing are so recent that the available data regarding these new technologies in spine surgery remains scarce, especially data related to long-term outcomes.

Cell-controlled dynamic surfaces for skeletal stem cell growth and differentiation

Skeletal stem cells (SSCs, or mesenchymal stromal cells typically referred to as mesenchymal stem cells from the bone marrow) are a dynamic progenitor population that can enter quiescence, self-renew or differentiate depending on regenerative demand and cues from their niche environment. However, ex vivo, in culture, they are grown typically on hard polystyrene surfaces, and this leads to rapid loss of the SSC phenotype. While materials are being developed that can control SSC growth and differentiation, very few examples of dynamic interfaces that reflect the plastic nature of the stem cells have, to date, been developed. Achieving such interfaces is challenging because of competing needs: growing SSCs require lower cell adhesion and intracellular tension while differentiation to, for example, bone-forming osteoblasts requires increased adhesion and intracellular tension. We previously reported a dynamic interface where the cell adhesion tripeptide arginine-glycine-aspartic acid (RGD) was presented to the cells upon activation by user-added elastase that cleaved a bulky blocking group hiding RGD from the cells. This allowed for a growth phase while the blocking group was in place and the cells could only form smaller adhesions, followed by an osteoblast differentiation phase that was induced after elastase was added which triggered exposure of RGD and subsequent cell adhesion and contraction. Here, we aimed to develop an autonomous system where the surface is activated according to the need of the cell by using matrix metalloprotease (MMP) cleavable peptide sequences to remove the blocking group with the hypothesis that the SSCs would produce higher levels of MMP as the cells reached confluence. The current studies demonstrate that SSCs produce active MMP-2 that can cleave functional groups on a surface. We also demonstrate that SSCs can grow on the uncleaved surface and, with time, produce osteogenic marker proteins on the MMP-responsive surface. These studies demonstrate the concept for cell-controlled surfaces that can modulate adhesion and phenotype with significant implications for stem cell phenotype modulation.

Bioinspired Surface Functionalization of Poly(ether ether ketone) for Enhancing Osteogenesis and Bacterial Resistance

In orthopedics, developing functionalized biomaterials to enhance osteogenesis and bacterial resistance is crucial. Although poly(ether ether ketone) (PEEK) is regarded as an important engineering plastic for biomedical material with excellent mechanical properties and biocompatibility, its biological inertness has greatly compromised its application in biomedical engineering. Inspired by the catecholamine chemistry of mussels, we propose a universal and versatile approach for enhancing the osteogenesis and antibacterial performances of PEEK based on surface functionalization of polydopamine-modified nanohydroxyapatite and lysozyme simultaneously. The characterizations of surface morphology and elemental composition revealed that the composite coating was successfully added to the PEEK surface. Additionally, the in vitro cell experiment and biomineralization assay indicated that the composite coating-modified PEEK was biocompatible with significantly improved bioactivity to promote osteogenesis and biomineralization compared with the untreated PEEK. Furthermore, the antibacterial test demonstrated that the composite coating had a strongly destructive effect on two bacteria (Staphylococcus aureus and Escherichia coli) with antibacterial ratios of 98.7% and 96.1%, respectively. In summary, the bioinspired method for surface functionalization can enhance the osteogenesis and bacterial resistance of biomedical materials, which may represent a potential approach for designing functionalized implants in orthopedics.

CMC Mimickers: Differential Diagnosis and Work-Up for Radial-Sided Wrist Pain

In patients with radial-sided wrist pain, a myriad of possible etiologies exists and as such, a detailed history, examination, and, where indicated, imaging is obtained to try and aid with its diagnosis. The purpose of this article is to provide an overview of radial-sided wrist pain, diagnostic modalities and discuss current treatment options. More detailed information is out-of-scope for this article and if needed, we would guide the reader to seek out other selected texts, as indicated.

An on-demand and on-site shape-designable mineralized hydrogel with calcium supply and inflammatory warning properties for cranial repair applications

Although more than 2.2 million cranial repair surgical operations are performed every year, orthopedic doctors still dream of excellent artificial repair materials with suitable strength, on-site and on-demand fast-shaping properties, and bone induction properties. However, fast-shaping and high-strength properties seem to contradict each other, and even mineralized hydrogels, which already have excellent strength and bone induction properties, are not ideal candidates, since they lack the plasticity needed for complex craniofacial surface use during the essential mechanism of the process of the cleavage of inorganic ions, nucleation, and growth. Here, we report a novel mineralized hydrogel based on dispersing mineral ions prior to use and then inducing inorganic formation by decreasing the temperature, which endows the hydrogels with the characteristics of precise customization at an appropriate degree of mineralization and simultaneously achieves suitable mechanical properties and sufficient calcium supply for bone regeneration. Additionally, the calcium ion content in the water of the matrix will change with the temperature, and, thus, the conductivity of the mineralized hydrogels will change accordingly. This implements the ability to warn of inflammation in a timely fashion in the form of a temperature sensor. Therefore, this temperature-responsive hydrogel effectively achieves the aim of versatile material design.

Necrotizing Fasciitis of the Upper Limb: Optimizing Management to Reduce Complications

Background: Necrotizing fasciitis (NF) is a severe, potentially life-threatening condition. The aim of this study is to identify strategies aimed at reducing complications in patients with NF of the upper limb. Methods: We conducted a retrospective study on patients admitted to our Unit for suspected NF of the upper limb. The analyzed data included patient characteristics, delay before primary care, clinical and biological signs upon arrival, pathogens involved, and the rate of amputations and mortality. Results: A total of 21 patients presented with confirmed necrotizing bacterial dermohypodermitis-NBDH with NF (NBDH-NF) affecting the upper limb. The mean delay between the onset of symptoms and the clinical examination in the Emergency Dermatology Unit was 48 h (range: 6 to 72 h). The mean delay between admission and primary surgery was 150 min (range: 60 min to 280 min). No amputations were performed. All patients were alive one year after the first surgical procedure. Conclusions: Our study demonstrated that it is possible to reduce mortality and morbidity rates in NF of the upper limb. Timely diagnosis and early treatment and a multidisciplinary medico-surgical dedicated team providing care can significantly modify the outcomes. Early surgical debridement is the most important factor affecting the prognosis of these infections.

The Effect of Low-Processing Temperature on the Physicochemical and Mechanical Properties of Bovine Hydroxyapatite Bone Substitutes

Bovine bone grafts (BBX) require protein removal as part of the manufacturing process to reduce antigenicity and, in consequence, to be safely used in humans. Deproteinisation may have direct effects on the characteristics of the bone material and on in vivo material performance. This research aimed to comprehensively study the physicochemical and mechanical properties of BBX processed at low deproteinisation processing temperatures. Cubes of bovine bone (8 mm³) were treated with temperatures between 100 °C and 220 °C at 30 °C intervals and with pressures ranging from 1.01 to 24.58 Bar. The samples were characterised topographically and mechanically using scanning electron microscopy (SEM), atomic force microscopy (AFM), and uniaxial bending tests. The organic content and the chemical composition were determined using thermogravimetric analysis (TGA) and Fourier-transform infrared spectroscopy (FTIR). X-ray diffraction (XRD) and FTIR were also used to quantitatively determine the specimen crystallinity. Increasing temperature/pressure was associated with decreasing protein levels and compressive strength and increasing surface irregularities and crystallinity. The findings suggest that low-temperature processed bone is likely to exhibit a rapid in vivo degradation rate. The deproteinisation temperature can be adjusted to tailor the graft properties for specific applications.

Hawkins wiring for three-part fractures of the proximal humerus: A case series

Three-part proximal humerus fractures in the elderly continue to be difficult to surgically treat. We evaluated the Hawkins wiring (HW) technique, which utilizes figure-of-eight tension band wiring, to treat three-part proximal humerus fractures involving the greater tuberosity. Currently, there is a paucity of data detailing patient outcomes and radiographic follow-up of this technique. The purpose of this case series is to evaluate patient reported outcomes and radiographic follow-up for fractures treated with this technique. Over two years, six patients at our institution underwent HW to treat three-part proximal humerus fractures. Average DASH and Oxford Shoulder scores (OSS) were 20.4 (range, 1-40) and 40 (range, 33-46) respectively. All patients had satisfactory return of function after surgery. Radiographic union was achieved in all six patients and there were no reported complications. HW technique is an efficacious treatment for three-part proximal humerus fractures in elderly patients.

Adipose tissue provides a cushioning effect in low-energy isolated blunt thoracic trauma: a prospective observational study

INTRODUCTION

This study aimed to investigate the specific effects of subcutaneous adipose tissue thickness (SATT) on trauma-related injury (TRI) development in patients with low-energy isolated blunt thoracic trauma.

PATIENTS AND METHODS

This prospective observational study was performed between March 2018-March 2019. Patients admitted to our hospital because of blunt thoracic trauma were enrolled. SATT in axial CT images of the thorax was measured using the four anatomically designated localizations. Patients were analyzed in terms of demographic data, BMI, comorbid diseases, causes of injury, vital parameters, visual analog scale, trauma score, injury type, treatment, and hospitalization. A poor clinical outcome was defined as the development of a TRI.

RESULTS

The study group consisted of 152 patients (43 female, 109 male). The mean age was 49 ± 19.1 years. There was a positive linear association between the BMI and SATT for all the patients in the study. TRI frequency was higher in the low-SATT subgroup than in the high-SATT group (p < 0.001). BMI and mean SATT values were related to a poor logistic regression analysis outcome (p < 0.01). Being in the low-BMI subgroup was a risk factor for TRI development (p < 0.01; OR:0.23;95% CI:0.08-0.61).

CONCLUSION

We found that a low SATT and BMI were related to a poor clinical outcome in our study group. It is essential to carefully examine these patients in detail, even in low-energy trauma. Subcutaneous tissue over the thorax serves as a protective shield for other thoracic structures in patients with LEBTT.

Additive Manufacturing Technologies for Fabrication of Biomaterials for Surgical Procedures in Dentistry: A Narrative Review

PURPOSE

To screen and critically appraise available literature regarding additive manufacturing technologies for bone graft material fabrication in dentistry.

MATERIAL AND METHODS

PubMed and Scopus were searched up to May 2021. Studies reporting the additive manufacturing techniques to manufacture scaffolds for intraoral bone defect reconstruction were considered eligible. A narrative review was synthesized to discuss the techniques for bone graft material fabrication in dentistry and the biomaterials used.

RESULTS

The databases search resulted in 933 articles. After removing duplicate articles (128 articles), the titles and abstracts of the remaining articles (805 articles) were evaluated. A total of 89 articles were included in this review. Reading these articles, 5 categories of additive manufacturing techniques were identified: material jetting, powder bed fusion, vat photopolymerization, binder jetting, and material extrusion.

CONCLUSIONS

Additive manufacturing technologies for bone graft material fabrication in dentistry, especially 3D bioprinting approaches, have been successfully used to fabricate bone graft material with distinct compositions.

Diagnostic and Therapeutic Management of the Thoracic Outlet Syndrome. Review of the Literature and Report of an Italian Experience

The Thoracic Outlet Syndrome is a clinical potentially disabling condition characterized by a group of upper extremity signs and symptoms due to the compression of the neurovascular bundle passing through the thoracic outlet region. Because of the non-specific nature of signs and symptoms, to the lack of a consensus for the objective diagnosis, and to the wide range of etiologies, the actual figure is still a matter of debate among experts. We aimed to summarize the current evidence about the pathophysiology, the diagnosis and the treatment of the thoracic outlet syndrome, and to report a retrospective analysis on 324 patients followed for 5 years at the Padua University Hospital and at the Naples Fatebenefratelli Hospital in Italy, to verify the effectiveness of a specific rehabilitation program for the syndrome and to evaluate if physical therapy could relieve symptoms in these patients.

The Induced Membrane Technique—The Filling Matters: Evaluation of Different Forms of Membrane Filling with and without Bone Marrow Mononuclear Cells (BMC) in Large Femoral Bone Defects in Rats

The Masquelet technique is used to treat large bone defects; it is a two-stage procedure based on an induced membrane. To improve the induced membrane process, demineralized bone matrix in granular (GDBM) and fibrous form (f-DBM) was tested with and without bone marrow mononuclear cells (BMC) as filling of the membrane against the gold standard filling with syngeneic cancellous bone (SCB). A total of 65 male Sprague–Dawley rats obtained a 5 mm femoral defect. These defects were treated with the induced membrane technique and filled with SCB, GDBM, or f-DBM, with or without BMC. After a healing period of eight weeks, the femurs were harvested and submitted for histological, radiological, and biomechanical analyses. The fracture load in the defect zone was lower compared to SCB in all groups. However, histological analysis showed comparable new bone formation, bone mineral density, and cartilage proportions and vascularization. The results suggest that f-DBM in combination with BMC and the induced membrane technique cannot reproduce the very good results of this material in large, non-membrane coated bone defects, nevertheless it supports the maturation of new bone tissue locally. It can be concluded that BMC should be applied in lower doses and inflammatory cells should be removed from the cell preparation before implantation.

Evaluation of the Proximal Tibia as a Donor Site of Cancellous Bone for Intraoral Grafting Procedures-A Retrospective Study

Background: Autogenous bone grafts remain the “gold standard” in maxillofacial reconstructive procedures. The objective of this study was to evaluate the proximal tibia as a donor site of cancellous bone for bone grafting procedures of the mandible on the basis of intraoperative parameters and clinical observations. Methods: The study was based on a medical record search of 40 patients who underwent surgical procedures because of benign pathological lesions of the jaws resulting in 3-wall bone defects of the mandible and qualified for surgical removal of the lesion with simultaneous bone grafting of the defect with autogenous cancellous bone harvested from the proximal tibia. Results: The use of the proximal tibia for bone grafting procedures enables large amounts of cancellous bone (15.09 cc in average) to be obtained. The procedure is characterized by a low risk of early and late complications, which include excessive bleeding, wound infection, lengthy healing time, scars, a loss of sensation around the scars, aching, a dip in bone, swelling and tenderness. Conclusions: The ability to obtain large amounts of cancellous bone and a low risk of intra- and postoperative complications make the proximal tibia an attractive donor site for the bone grafting procedures in maxillofacial surgery.

Ectopic bone formation causing chronic pubis symphysis pain: successful management with resection and pubic fusion

Chronic musculoskeletal anterior pelvic pain may originate from a variety of different sources making the diagnosis difficult. Ectopic bone formation on the pubic symphysis is extremely rare and may cause significant disability. Reported herein is the case of a very active patient with symphysis pubis ectopic bone formation causing disability for more than 10 years. Resection of the ectopic bone combined with pubis symphysis fusion led to a successful outcome allowing the patient to return to his previous recreational activities.

Osteitis Pubis in Athletes: A Literature Review of Current Surgical Treatment

Osteitis pubis (OP) is a self-limiting, noninfectious inflammatory disease of the pubic symphysis and the surrounding soft tissues that usually improves with activity modification and targeted conservative treatment. Surgical treatment is required for a limited number of patients. This study aims to investigate the current literature on the surgical treatment of OP in athletes.

A systematic review was conducted on two databases (MEDLINE/PubMed and Google Scholar) from 2000 to 2021. The inclusion criteria were adult patients with athletic OP who underwent surgical treatment and studies published in English. The exclusion criteria included pregnancy, infection OP, or postoperative complications related to other surgical interventions, such as urological or gynecological complications.

Fifty-one surgically treated cases have been reported in eight studies, which included short-term, mid-term, and long-term studies ranging from one patient to 23 patients. The surgical treatment methods were as follows: (a) pubic symphysis arthrodesis, (b) open or endoscopic pubic symphysectomy, (c) wedge resection of the pubic symphysis, and (d) polypropylene mesh placed into the preperitoneal retropubic space endoscopically.

The main indication for surgical intervention was failure of conservative measures and long-lasting pain, disability, and inability to participate in athletic activities. Wedge resection of the pubic symphysis has been the less preferred surgical treatment in the recently published literature. The most common surgical method of treatment of OP in athletes, which entailed the existence of posterior stability of the sacroiliac joint, in the current literature is open pubic symphysis curettage. Recently, there has been a tendency for pubic symphysis curettage to be performed endoscopically.

Does the incorporation of strontium into calcium phosphate improve bone repair? A meta-analysis

Background

The application of calcium phosphate (CaP)-based bone substitutes plays an important role in periodontal regeneration, implant dentistry and alveolar bone reconstruction. The incorporation of strontium (Sr) into CaP-based bone substitutes appears to improve their biological properties, but the reported in vivo bone repair performance is inconsistent among studies. Herein, we conducted a systematic review and meta-analysis to investigate the in vivo performance of Sr-doped materials.

Methods

We searched PubMed, EMBASE (via OVIDSP), and reference lists to identify relevant animal studies. The search, study selection, and data extraction were performed independently by two investigators. Meta-analyses and sub-group analyses were conducted using Revman version 5.4.1. The heterogeneity between studies were assessed by I². Publication bias was investigated through a funnel plot.

Results

Thirty-five studies were finally enrolled, of which 16 articles that reported on new bone formation (NBF) were included in the meta-analysis, covering 31 comparisons and 445 defects. The overall effect for NBF was 2.25 (95% CI 1.61–2.90, p < 0.00001, I² = 80%). Eight comparisons from 6 studies reported the outcomes of bone volume/tissue volume (BV/TV), with an overall effect of 1.42 (95% CI 0.65–2.18, p = 0.0003, I² = 75%). Fourteen comparisons reported on the material remaining (RM), with the overall effect being -2.26 (95% CI − 4.02 to − 0.50, p = 0.0009, I² = 86%).

Conclusions

Our study revealed that Sr-doped calcium phosphate bone substitutes improved in vivo performance of bone repair. However, more studies are also recommended to further verify this conclusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02092-7.

PTH-Induced Bone Regeneration and Vascular Modulation Are Both Dependent on Endothelial Signaling

The use of a bone allograft presents a promising approach for healing nonunion fractures. We have previously reported that parathyroid hormone (PTH) therapy induced allograft integration while modulating angiogenesis at the allograft proximity. Here, we hypothesize that PTH-induced vascular modulation and the osteogenic effect of PTH are both dependent on endothelial PTH receptor-1 (PTHR1) signaling. To evaluate our hypothesis, we used multiple transgenic mouse lines, and their wild-type counterparts as a control. In addition to endothelial-specific PTHR1 knock-out mice, we used mice in which PTHR1 was engineered to be constitutively active in collagen-1α+ osteoblasts, to assess the effect of PTH signaling activation exclusively in osteoprogenitors. To characterize resident cell recruitment and osteogenic activity, mice in which the Luciferase reporter gene is expressed under the Osteocalcin promoter (Oc-Luc) were used. Mice were implanted with calvarial allografts and treated with either PTH or PBS. A micro-computed tomography-based structural analysis indicated that the induction of bone formation by PTH, as observed in wild-type animals, was not maintained when PTHR1 was removed from endothelial cells. Furthermore, the induction of PTH signaling exclusively in osteoblasts resulted in significantly less bone formation compared to systemic PTH treatment, and significantly less osteogenic activity was measured by bioluminescence imaging of the Oc-Luc mice. Deletion of the endothelial PTHR1 significantly decreased the PTH-induced formation of narrow blood vessels, formerly demonstrated in wild-type mice. However, the exclusive activation of PTH signaling in osteoblasts was sufficient to re-establish the observed PTH effect. Collectively, our results show that endothelial PTHR1 signaling plays a key role in PTH-induced osteogenesis and has implications in angiogenesis.

Properties of tests for knee joint threshold to detect passive motion following anterior cruciate ligament injury: a systematic review and meta-analysis

BACKGROUND

Threshold to detect passive motion (TTDPM) tests of the knee joint are commonly implemented among individuals with anterior cruciate ligament (ACL) injury to assess proprioceptive acuity. Their psychometric properties (PMPs), i.e. reliability, validity and responsiveness, are however unclear. This systematic review aimed to establish the PMPs of existing knee joint TTDPM tests among individuals with ACL injury.

METHODS

The databases PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL and ProQuest were searched to identify studies that assessed the properties of knee joint TTDPM tests in individuals with ACL injury. The risk of bias for each included study was assessed at the outcome level for each test. Overall quality and levels of evidence for each property were rated according to established criteria. Meta-analyses with mean differences were conducted using random-effects models when adequate data were available.

RESULTS

Fifty-one studies covering 108 TTDPM tests and 1632 individuals with unilateral ACL injury were included. A moderate-to-strong level of evidence indicated insufficient quality for all of the following: convergent validity, known-groups validity, discriminative validity, responsiveness between subgroups, and responsiveness to intervention. Subgroup meta-analyses for known-groups validity did however find that a starting angle of 15° resulted in significantly worse TTDPM for knees with ACL injury compared to those of asymptomatic persons (mean difference 0.28°; 95% CI 0.03 to 0.53; P = 0.03), albeit based on only three studies. Due to the lack of evidence, it was not possible to estimate the quality of reliability, measurement error, and criterion validity, nor responsiveness from a criterion and construct approach.

CONCLUSIONS

Among persons with ACL injury, existing tests of knee joint TTDPM lack either sufficient quality or evidence for their reliability, validity and responsiveness. Significantly worse thresholds for ACL-injured knees compared to those of asymptomatic controls from a 15° starting angle and trends towards significance for some validity measures nevertheless encourage the development of standardised tests. Further research investigating the influence of modifiable test components (e.g. starting angle and motion direction) on the PMPs of knee joint TTDPM tests following ACL injury is warranted.

Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient

BACKGROUND

Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly.

METHODS

We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up.

RESULTS

Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%.

CONCLUSION

In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.

Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle

Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.

Current Role of Reverse Total Shoulder Arthroplasty for Fractures of the Proximal Humerus

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

Clinical parameters and radiographic resorption of a novel magnesium based bone void filler

BACKGROUND

Bone voids can present challenging problems for the Orthopaedic surgeon, and are often treated with backfilling followed by structural stabilization. Recently, a magnesium based, and presumably resorbable, bone void filler (BVF) has been developed, but has limited longitudinal clinical data. Therefore, the purpose of this study was to investigate clinically relevant parameters and radiographic resorption characteristics of this novel magnesium based BVF (MgBVF) with long-term clinical data.

METHODS

All patients who underwent surgery by a single surgeon in which MgBVF was utilized from 2019 to 2020 were retrospectively reviewed. Clinical parameters including evidence of infection, wound breakdown, and wound drainage were reviewed. Radiographic resorption, evidence of joint extrusion of BVF, heterotopic ossification, and subsidence was assessed at each post-operative visit. Those with less than 6 month follow up were excluded from radiographic analysis of resorption. Postoperative images at two weeks were compared to each subsequent radiograph during follow up, and reviewed by each of the three authors in blinded fashion. Interval radiographs were assigned a grade of radiographic resorption which corresponded to estimated percent resorption: grade 1 (0-25%), grade 2 (25-50%), grade 3 (50-75%), or grade 4 (75-100%). After 2 weeks, this process was repeated, and both inter and intraobserver reliability scores were calculated.

RESULTS

Forty-two patients were identified for clinical review, and 18 for radiographic review. Average length of follow up was 209±113 days. Five patients experienced a postoperative complication: two wound infections, one delayed wound healing, one sterile serous drainage, and one catastrophic failure of the fixation construct. Four patients were noted to have postoperative joint subsidence of 2 mm or less. Average grade of resorption was found to be 1.5 ± 0.8, 1.7 ± 0.9, 2.9 ± 0.9, and 3.6 ± 0.6 at 6 weeks, 3 months, 6 months, and 1 year, respectively (p<0.001). Average kappa (intrarater reliability) was found to be 0.61, 0.41, 0.55, and 0.63 for each time interval, respectively. Interrater reliability increased form 0.19 at 6 weeks to 0.42 at 1 year.

CONCLUSION

This novel MgBVF demonstrates clinically relevant resorption, provides structural support in challenging bone voids, and does not appear to significantly increase risk of complications, setting it apart from previously described BVF's.

Treatment of Infection-Related Non-Unions with Bioactive Glass-A Promising Approach or Just Another Method of Dead Space Management?

The treatment of infected and non-infected non-unions remains a major challenge in trauma surgery. Due to the limited availability of autologous bone grafts and the need for local anti-infective treatment, bone substitutes have been the focus of tissue engineering for years. In this context, bioactive glasses are promising, especially regarding their anti-infective potential, which could reduce the need for local and systemic treatment with conventional antibiotics. The aim of this study was to investigate the osteoinductive and osteoconductive effects, as well as the anti-infectious potential, of S53P4 using a standardized non-union model, which had not been investigated previously. Using an already established sequential animal model in infected and non-infected rat femora, we were able to investigate bioactive glass S53P4 under realistic non-union conditions regarding its osteoinductive, osteoconductive and anti-infective potential with the use of µCT scans, biomechanical testing and histological, as well as microbiological, analysis. Although S53P4 did not lead to a stable union in the non-infected or the infected setting, µCT analysis revealed an osteoinductive effect of S53P4 under non-infected conditions, which was diminished under infected conditions. The osteoconductive effect of S53P4 remained almost negligible in histological analysis, even 8 weeks after treatment. Additionally, the expected anti-infective effect could not be demonstrated. Our data suggested that S53P4 should not be used in infected non-unions, especially in those with large bone defects.

PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis

Purpose: The aim of this study was to quantify the rate of complications and reinterventions in patients treated with PHILOS plate for proximal humerus fractures (PHFs) synthesis. Methods: A comprehensive literature search was performed on the PubMed, Web of Science, Embase, and Cochrane databases up to 7 October 2021. Studies describing medium and long-term complications in PHF synthesis using the PHILOS plate were included. A systematic review and meta-analysis were performed on complications and causes of reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black’s “Checklist for Measuring Quality”. Results: Seventy-six studies including 4200 patients met the inclusion criteria. The complication rate was 23.8%, and the main cause was screw cut-out (4.1%), followed by avascular necrosis (AVN) (3.1%) and subacromial impingement (1.5%). In patients over 55 years, the complication rate was 29.5%. In the deltopectoral (DP) approach the complication rate was 23.8%, and in the delto-split (DS) it was 17.5%, but no difference between the two approaches was seen when considering the type of fracture. The overall reintervention rate was 10.5% in the overall population and 19.0% in older patients. Conclusions: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.

Marker- three dimensional measurement versus traditional radiographic measurement in the treatment of tibial fracture using Taylor spatial frame

Background

The Taylor Spatial Frame (TSF) has been widely used for tibial fracture. However, traditional radiographic measurement method is complicated and the reduction accuracy is affected by various factors. The purpose of this study was to propose a new marker- three dimensional (3D) measurement method and determine the differences of reduction outcomes, if any, between marker-3D measurement method and traditional radiographic measurement in the TSF treatment.

Methods

Forty-one patients with tibial fracture treated by TSF in our institution were retrospectively analyzed from January 2016 to June 2019, including 21 patients in the marker-3D measurement group (experimental group) and 20 patients in the traditional radiographic measurement group (control group). In the experimental group, 3D reconstruction with 6 markers installed on the TSF was performed to determine the electronic prescription. In the control group, the anteroposterior (AP) and lateral radiographs were performed for the traditional parameter measurements. The effectiveness was evaluated by the residual displacement deformity (RDD) and residual angle deformity (RAD) in the coronal and sagittal plane, according to the AP and lateral X-rays after reduction.

Results

All patients achieved functional reduction. The residual RDD in AP view was 0.5 (0, 1.72) mm in experimental group and 1.74 (0.43, 3.67) mm in control group. The residual RAD in AP view was 0 (0, 1.25) ° in experimental group and 1.25 (0.62, 1.95) °in control group. As for the lateral view, the RDD was 0 (0, 1.22) mm in experimental group and 2.02 (0, 3.74) mm in control group, the RAD was 0 (0, 0) ° in experimental group and 1.42 (0, 1.93) ° in control group. Significant differences in all above comparisons were observed between the two groups (AP view RDD: P = 0.024, RAD: P = 0.020; Lateral view RDD: P = 0.016, RAD: P = 0.004).

Conclusions

The present study introduced a marker-3D measurement method to complement the current TSF treatment. This method avoids the manual measurement error and improves the accuracy of fracture reduction, providing potential advantages of bone healing and function rehabilitation.

Effects of Induction Culture on Osteogenesis of Scaffold-Free Engineered Tissue for Bone Regeneration Applications

BACKGROUND

Restoration of the bone defects caused by infection or disease remains a challenge in orthopedic surgery. In recent studies, scaffold-free engineered tissue with a self-secreted extracellular matrix has been proposed as an alternative strategy for tissue regeneration and reconstruction. Our study aimed to engineer and fabricate self-assembled osteogenic and scaffold-free tissue for bone regeneration.

METHODS

Osteogenic scaffold-free tissue was engineered and fabricated using fetal cartilage-derived progenitor cells, which are capable of osteogenic differentiation. They were cultured in osteogenic induction environments or using demineralized bone powder for differentiation. The fabricated tissue was subjected to real-time qPCR, biochemical, and histological analyses to estimate the degree of in vitro osteogenic differentiation. To demonstrate bone formation in an in vivo environment, scaffold-free tissue was transplanted into the dorsal subcutaneous site of nude mice. Bone development was monitored postoperatively over 8 weeks by the observation of calcium deposition in the matrix.

RESULTS

In the in vitro experiments, engineered osteogenically induced scaffold-free tissue demonstrated three-dimensional morphological characteristics, and sufficient osteogenic differentiation was confirmed through the quantification of specific osteogenic gene markers expressed and calcium accumulation within the matrix. Following the evaluation of differentiation efficacy, in vivo experiments revealed distinct bone formation, and that blood vessels had penetrated the fabricated tissue.

CONCLUSION

The novel engineering of scaffold-free tissue with osteogenic potential can be used as an optimal bone graft substitute for bone regeneration.

Low-Intensity Pulsed Ultrasound Promotes Osteogenic Differentiation of Reamer-Irrigator-Aspirator Graft-Derived Cells in Vitro

Recently, reamer-irrigator-aspirator (RIA) systems have been increasingly used to harvest autologous bone grafts. RIA graft materials contain bone marrow, which provides a viable source to derive large numbers of mesenchymal stem cells. Low-intensity pulsed ultrasound (LIPUS) significantly accelerates the differentiation of stem cells derived from bone marrow. This in vitro study investigated the effect of LIPUS on the osteogenic activity and differentiation of RIA graft-derived cells. A small amount of RIA graft was obtained from seven patients. After the cells derived from RIA grafts were cultured, they were divided into two groups: the LIPUS and control groups. LIPUS was applied once daily for 20 min (1.5 MHz, pulse duration: 200 µs, pulse repetition rate: 1 kHz, spatial average-temporal average intensity: 30 mW/cm²). Alkaline phosphatase activity (113.4% and 130.1% on days 7 and 14), expression of osteoblast-related genes (ALP, Runx2) and mineralization (135.2% on day 21) of the RIA graft-derived cells were significantly higher in the LIPUS group than in the control group. However, LIPUS did not affect the cell proliferation of RIA graft-derived cells. This study indicates that LIPUS may enhance the healing of non-union and critical bone defects treated by autologous bone grafting using the RIA system.

Management options for proximal humerus fractures - A systematic review & network meta-analysis of randomized control trials

AIMS

The purpose of this study is to systematically review the randomized controlled trials on the various treatment options that can be utilized in the management of displaced proximal humerus fractures.

MATERIALS & METHODS

Based on the PRISMA guidelines, three independent reviewers performed a systematic review of the literature. Randomized control trials (RCTs) focusing on the outcomes of the following interventions in the management of PHFs were considered for inclusion; (1) non-operative or conservative (NOC) management, (2) open reduction and internal fixation (ORIF), (3) intra-medullary nailing (IMN), (4) shoulder hemi-arthroplasty (HA), and (5) reverse shoulder arthroplasty (RSA). Network meta-analyses were performed using R and studies were ranked according to their P-score.

RESULTS

Our study included 13 RCTs. RSA had improvements in abduction, constant score, flexion, as well as lowest rates of malunion and osteonecrosis when compared to other management modalities (P-Score = 0.9786, P-Score = 0.9998, P-Score = 0.9909, P-Score = 0.9590 and P-Score = 0.8042 respectively). HA was found to have improvements in health-related quality of life scores when compared to other management modalities (P-Score = 0.9672). ORIF had the highest improvement in quick disability of arm, shoulder and hand scores and visual analogue scale scores (P-Score = 0.8209 and P-Score = 0.7155 respectively). NOC was found to have the lowest rate of conversion to surgical intervention, with RSA having the lowest rate of surgical interventions (P-Score = 0.9186 and P-Score = 0.7497 respectively).

DISCUSSION & CONCLUSION

RSA offers satisfactory improvements in clinical and functional outcomes when compared to other non-operative and operative treatment options in the management of carefully selected proximal humerus fractures, with a minimal revision rate when compared to other surgical management modalities.

LEVEL OF EVIDENCE

I - Systematic Review & Meta-Analysis of Randomized Control Trials.

Quantitative Analysis of Growth Factors From Cancellous Bone Graft Collected With a Reamer-Irrigator-Aspirator System From Native Long Bones Versus Previously Reamed Long Bones

OBJECTIVE

Collection of bone graft with the Reamer-Irrigator-Aspirator (RIA) system has become common practice across the field of orthopaedic surgery. While RIA bone graft is typically obtained from native long bones, grafting material can likewise be harvested from long bones that have previously undergone the placement and removal of an intramedullary nail, a process termed re-reamed RIA (RRR). The purpose of this study was to evaluate the total protein and growth factor concentrations present in native-RIA (NR) compared with RRR samples.

METHODS

NR and RRR bone grafts were collected intraoperatively with the RIA system and processed to evaluate both the aqueous and the hard tissue components. Total protein concentration and specific growth factors were analyzed using standard bicinchoninic acid and multiplex assays, respectively. Analyte levels were then normalized to the total amount of protein detected.

RESULTS

Total protein levels were comparable between NR and RRR samples for both the aqueous filtrate and the hard tissue samples. When normalized, while levels of bone morphogenic protein-2 and vascular endothelial growth factor were comparable in the hard tissue component, the aqueous filtrate from the RRR sample was found to have elevated levels of growth factors, with bone morphogenic protein-2 reaching statistical significance.

CONCLUSIONS

This study demonstrates that ample protein is found within both NR and RRR samples, with comparable or elevated levels of osteogenic growth factors found within RRR samples. Future, larger, prospective studies will be required to evaluate the osteogenic potential and clinical efficacy of NR and RRR cancellous bone grafts to validate their equivalency.

RIA versus iliac crest bone graft harvesting: A meta-analysis and systematic review

BACKGROUND

Reamer-Irrigator-Aspirator (RIA) of long bones is increasingly being used as an alternative to iliac crest harvesting for bone-grafts. This meta-analysis compares both harvesting techniques with regard to donor site morbidity, healing potency and implantation site morbidity.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) with corresponding 95% confidence interval (95%CI).

RESULTS

A total of 5 studies were included. RIA carries a lower risk for chronic pain (0% versus 14.2%, OR 0.08, 95% CI 0.02 - 0.35) and infection (1% versus 5.9%, OR 0.29, 95% CI 0.09- 0.9) at the donor site compared to iliac crest harvesting. Iliac crest bone-harvesting has an inherent additional risk of neuropraxia of the lateral femoral cutaneous nerve and numbness of the scar which is not encountered in RIA harvesting. Risk for other reported complications such as hematoma and iatrogenic fractures appear equal in both groups. The clinical healing potential of both bone grafts, in terms of union rate (OR 1.53, 95%CI 0.62 - 3.75) at the implantation site and time-to-union (MD 0.44 months, 95%CI -1.72 - 0.83), seems equal.

CONCLUSION

The main difference between RIA and iliac crest bone graft harvesting is the considerable higher risk of chronic pain of the pelvic procedure. Although risk for infection was also higher for the iliac crest group, the absolute difference is relatively small. Evidence suggests an equal healing potential of the grafts themselves irrespective of harvesting method.

[Salvage options following failed total ankle arthroplasty]

The number of patients with osteoarthritis of the ankle, which are treated by arthroplasty, has continuously increased in recent years. The survival time of these implants is far below the results following hip and knee arthroplasty. In some cases a failure rate of approximately 1% per year or a survival rate of 70% after 10 years has been reported. The most frequent reasons for revision of an ankle prosthesis are aseptic loosening, technical implantation errors and persisting pain. For the revision of an ankle prosthesis there are basically two treatment options. For a long time, ankle arthrodesis was considered the gold standard after a failed prosthesis. In recent years, there has been an increasing trend towards re-implantation of an ankle prosthesis, as this preserves the functionality and mobility of the ankle joint as far as possible. Depending on the reason for failure and the size of the bony defect, a decision must be made regarding a one-stage and a two-stage procedure with bone augmentation. This article presents the advantages and disadvantages of arthrodesis and revision arthroplasty after failed primary ankle arthroplasty and highlights the special features of surgery.

Approach to Humeral Shaft Nonunion: Evaluation and Surgical Techniques

Humeral shaft fractures account for 1% to 3% of all fractures. Traditional nonsurgical treatment with a functional brace is still the standard treatment of these fractures; however, modern studies have reported that nonunion rates may be as high as 33%. Recent information suggests that the development of nonunion after nonsurgical treatment may be identified as early as 6 to 8 weeks postinjury. Even with surgical treatment, nonunion rates as high as 10% have been reported. Regardless of the original treatment method, nonunion results in poor quality of life for the patient and therefore should be addressed. A thorough preoperative evaluation is important to identify any metabolic or infectious factors that may contribute to the nonunion. In most cases, surgical intervention should consist of compression plating with or without bone graft. Although most patients will achieve union with standard surgical intervention, some patients may require specialized techniques such as cortical struts or vascularized fibular grafts. Successful treatment of humeral shaft nonunion improves function, reduces disability, and improves the quality of life for patients. In this article, we outline our approach to the treatment of humeral shaft nonunion in a variety of clinical settings.