Limb reconstruction after traumatic bone loss

Establishing a bone bank within a hospital setting in India: early insights from a tertiary care center in Northern India-a review article

When addressing bone defects resulting from trauma, infection, or tumors, the use of allogenic bone is often necessary. While autografts are considered the standard, they have limitations and can lead to donor site morbidity. Consequently, there has been exploration into the feasibility of utilizing allogenic bone and bone graft replacements. Allogenic bone transplants are acquired from donors following rigorous procurement, sterile processing, and donor screening procedures. To ensure the safe storage and effective utilization of allograft material, a bone banking system is employed. Establishing and managing an orthopedic bone bank, entails navigating complex legal and medical organizational aspects. This paper examines the establishment and operation of bone banks in India, drawing upon our first-hand experience in managing one at a tertiary care center in Northern India.Level of evidence: Level IV.

Long-term outcome of fibula flaps in complex limb reconstruction compared to alternative procedures, a median follow up of 41 months

INTRODUCTION

Complex open long bone fractures present a multidisciplinary surgical challenge. Various treatment options are discussed with no consensus. Fibula flaps (FF) are frequently used in maxillofacial surgery, however their use in limb injuries is less common. With the tremendous improvement in microsurgery, orthoplastic surgery gained importance. Our retrospective study aims to assess the long-term results and the quality of life of the patients operated by FF for complex traumatic limb reconstruction.

PATIENTS AND METHODS

We conducted an observational mono centric retrospective study from the year 2011 to the year 2021. Patients operated for complicated traumatic limb fractures using FF were included in the study. Not only long-term clinical results were evaluated, but also Patient-reported outcome measures (PROM). These included the Lower Extremity Functional Scale (LEFS), Quick Disabilities of the Arm, shoulder and hand (Qdash), and the Visual Analogue Scale (VAS). The statistical analysis was done using the R Software.

RESULTS

Twenty patients were included in our study. 80% achieved complete union with no re fracture rate at a median follow-up of 41 months. All of the patients (n = 4) who underwent amputation were smokers (p = .09), were operated for lower limb fractures (p = .54), and were males (p = 1). The length of hospital stay was associated with an increased duration to complete bony union (p = .01, coefficient = 2.88). At the end of follow-up, the LEFS median score was 67 for the total population and 63.5 for the lower limb reconstructed sub group.

CONCLUSION

VFF is an important tool in the armamentarium of orthoplastic surgeons. Encouraging long term functional and clinical outcomes were obtained in patients with complex traumatic limb fractures.

Facile fabrication of linezolid/strontium coated hydroxyapatite/graphene oxide nanocomposite for osteoporotic bone defect

Hydroxyapatite (HAp) coatings currently have limited therapeutic applications because they lack anti-infection, osteoinductivity, and poor mechanical characteristics. On the titanium substrate, electrochemical deposition (ECD) was used to construct the strontium (Sr)-featuring hydroxyapatite (HAp)/graphene oxides (GO)/linezolid (LZ) nanomaterial coated with antibacterial and drug delivery properties. The newly fabricated nanomaterials were confirmed by X-ray diffraction analysis (XRD), Fourier-transform infrared spectroscopy (FTIR), and X-ray photoelectron spectroscopy (XPS) analysis and morphological features were examined by scanning electron microscope (SEM) analysis. The results reveal multiple nucleation sites for SrHAp/GO/LZ composite coatings due to oxygen-comprising moieties on the 2D surface of GO. It was shown to be favorable for osteoblast proliferation and differentiation. The elastic modulus and hardness of LZ nanocomposite with SrHAp/GO/LZ coatings were increased by 67 % and 121 %, respectively. An initial 5 h burst of LZ release from the SrHAp/GO/LZ coating was followed by 14 h of gradual release, owing to LZ's physical and chemical adsorption. The SrHAp/GO/LZ coating effectively inhibited both S. epidermidis and S. aureus, and the inhibition lasted for three days, as demonstrated by the inhibition zone and colony count assays. When MG-63 cells are coated with SrHAp/GO/LZ composite coating, their adhesion, proliferation, and differentiation greatly improve when coated with pure titanium. A novel surface engineering nanomaterial for treating and preventing osteoporotic bone defects, SrHAp/GO/LZ, was shown to have high mechanical characteristics, superior antibacterial abilities, and osteoinductivity.

Differences in macrophage expression in induced membranes by fixation method - Masquelet technique using a mouse's femur critical-sized bone defect model

INTRODUCTION

Masquelet's induced membrane technique (MIMT) is an emerging method for reconstructing critical-sized bone defects. However, an incomplete understanding of the underlying biological and physical processes hinders further optimization. This study investigated the effect of different bone-defect fixation methods on macrophage expression in an induced membrane using a novel mouse plate-fixed Masquelet model.

METHODS

Mice were divided into Plate-fixed Masquelet (P-M), Intramedullary-fixed Masquelet (IM-M), Plate-fixed Control (P-C), and Back subfascial (B) groups. In the P-M and IM-M groups, a polymethylmethacrylate (PMMA) spacer was implanted into a 3 mm bone defect, while the defect in the P-C group remained unfilled. In group B, a spacer was inserted under the back fascia to examine membrane formation caused by a simple foreign body reaction. Tissues were collected at 1, 2, and 4 weeks postoperatively. Hematoxylin and eosin (H&E) staining and immunohistochemistry (CD68 and CD163: macrophage markers) were performed to assess macrophage expression within the membrane. qPCR was performed to measure the expression of CD68, CD163, and fibroblast growth factor 2 (FGF2).

RESULTS

Four weeks post-operation, the P-M group presented with minimal callus growth, whereas the IM-M group exhibited vigorous growth. The P-M and IM-M groups displayed a tri-layered membrane structure, which is consistent with the results of previous studies. The IM-M group had significantly thicker membranes, whereas the P-M group exhibited higher expression levels of CD68, CD163, and FGF2. Group P-C showed no osteogenesis, whereas group B maintained a thin, cell-dense membrane structure. The P-M group consistently showed higher gene expression levels than the P-C and P-B groups.

CONCLUSION

This study introduced a mouse plate fixation model for MIMT. The induced membranes could be adequately evaluated in this model. Induced membranes are formed by foreign body reactions to PMMA spacers; however, their properties are clearly different from those of simple foreign body reaction capsules and granulation tissues that infiltrate bone defects, suggesting that they are more complex tissues. The characteristics and expression of macrophages within these induced membranes varied according to the bone defect fixation method.

Immunomodulation Using BMP-7 and IL-10 to Enhance the Mineralization Capacity of Bone Progenitor Cells in a Fracture Hematoma-Like Environment

Following biomaterial implantation, a failure to resolve inflammation during the formation of a fracture hematoma can significantly limit the biomaterial's ability to facilitate bone regeneration. This study aims to combine the immunomodulatory and osteogenic effects of BMP-7 and IL-10 with the regenerative capacity of collagen-hydroxyapatite (CHA) scaffolds to enhance in vitro mineralization in a hematoma-like environment. Incubation of CHA scaffolds with human whole blood leads to rapid adsorption of fibrinogen, significant stiffening of the scaffold, and the formation of a hematoma-like environment characterized by a limited capacity to support the infiltration of human bone progenitor cells, a significant upregulation of inflammatory cytokines and acute phase proteins, and significantly reduced osteoconductivity. CHA scaffolds functionalized with BMP-7 and IL-10 significantly downregulate the production of key inflammatory cytokines, including IL-6, IL-8, and leptin, creating a more permissive environment for mineralization, ultimately enhancing the biomaterial's osteoconductivity. In conclusion, targeting the onset of inflammation in the early phase of bone healing using BMP-7 and IL-10 functionalized CHA scaffolds is a promising approach to effectively downregulate inflammatory processes, while fostering a more permissive environment for bone regeneration.

Massive traumatic articular bone loss of the capitulum humeri treated by costal osteochondral autograft reconstruction: A case report

INTRODUCTION

Articular traumatic bone loss is a severe condition with heterogeneous outcomes, often necessitating complex technical solutions and posing challenges in managing both bone and cartilage loss. Thus, some surgeons have used a technique of osteochondral autograft using a rib to fix an articular bone loss to manage both of these tissue losses.

PRESENTATION OF CASE

We present the case of a 25-years-old patient, who had a complex open elbow injury. He presented an association of a terrible triad of the elbow injury with an open traumatic bone loss of the capitulum humeri and unfixable lesion of the lateral collateral ligament complex of the elbow. We initially managed these lesions with an external fixator for 2 months followed by a reconstruction of the capitulum humeri using a costal osteochondral autograft. Unfortunately, the patient was lost to follow-up after the 1 month post-operative consultation but he had some encouraging results.

DISCUSSION

In this case report, we describe our technique using an osteochondral autograft to address complex bone and cartilaginous losses, thereby expanding the treatment options available to trauma surgeons.

CONCLUSION

This case report shows that a reconstruction of the capitellum humeri for a traumatic bone loss with an osteochondral autograft using the eighth rib can be easily performed. More generally, this technique could even help to manage complex traumatic substance loss of both bone and cartilage in other locations.

3D printed β-tricalcium phosphate versus synthetic bone mineral scaffolds: A comparative in vitro study of biocompatibility

BACKGROUND

β-tricalcium phosphate (β-TCP) has been successfully utilized as a 3D printed ceramic scaffold in the repair of non-healing bone defects; however, it requires the addition of growth factors to augment its regenerative capacity. Synthetic bone mineral (SBM) is a novel and extrudable carbonate hydroxyapatite with ionic substitutions known to facilitate bone healing. However, its efficacy as a 3D printed scaffold for hard tissue defect repair has not been explored.

OBJECTIVE

To evaluate the biocompatibility and cell viability of human osteoprecursor (hOP) cells seeded on 3D printed SBM scaffolds via in vitro analysis.

METHODS

SBM and β-TCP scaffolds were fabricated via 3D printing and sintered at various temperatures. Scaffolds were then subject to qualitative cytotoxicity testing and cell proliferation experiments utilizing (hOP) cells.

RESULTS

SBM scaffolds sintered at lower temperatures (600 °C and 700 °C) induced greater levels of acute cellular stress. At higher sintering temperatures (1100 °C), SBM scaffolds showed inferior cellular viability relative to β-TCP scaffolds sintered to the same temperature (1100 °C). However, qualitative analysis suggested that β-TCP presented no evidence of morphological change, while SBM 1100 °C showed few instances of acute cellular stress.

CONCLUSION

Results demonstrate SBM may be a promising alternative to β-TCP for potential applications in bone tissue engineering.

Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects

BACKGROUND

Treating long bone defects of the extremities caused by trauma, infection, tumours, and nonunion has been challenging for clinical orthopaedic surgeons. Bone transport techniques have the potential to treat bone defects. However, inevitable docking site complications related to bone transport techniques have been reported in many studies. The purpose of this study was to investigate the risk factors associated with docking site complications in patients who underwent the Ilizarov bone transport technique for the treatment of tibial bone defects.

METHODS

This retrospective study included 103 patients who underwent bone transport for the treatment of large bone defects in the tibia from October 2012 to October 2019. Patient demographic data, complications and clinical outcomes after a minimum of 2 years of follow-up were collected and retrospectively analysed. Additionally, univariate analysis and logistic regression analysis were used to analyse the factors that may affect the development of docking site complications in patients with tibial bone defects treated with the Ilizarov bone transport technique. The clinical outcomes were evaluated using the Association for the Study and Application of the Ilizarov criteria (ASAMI) at the last clinical follow-up.

RESULTS

All 103 patients with an average follow-up of 27.5 months. The docking site complications rate per patient was 0.53, and delayed union occurred in 22 cases (21.4%), axial deviation occurred in 19 cases (18.4%) and soft tissue incarceration occurred in 10 cases (9.7%). According to the results of the logistic regression analysis, the bone defect length (P = 0.001, OR = 1.976), and bone defect of distal 1/3 (P = 0.01, OR = 1.976) were significantly correlated with delayed union. Bone defect length (P < 0.001, OR = 1.981) and external fixation time (P = 0.012, OR = 1.017) were significantly correlated with axial deviation. Soft tissue defects (P = 0.047, OR = 6.766) and the number of previous operations (P = 0.001, OR = 2.920) were significantly correlated with soft tissue incarceration. The ASAMI bone score at the last follow-up showed a rate of excellent and good bone results of 95.1% and a rate of excellent functional results of 90.3%.

CONCLUSION

The Ilizarov bone transport technique is a practical and effective method for the treatment of tibial bone defects. However, the incidence of complications at the docking site is high, of which bone defect length, external fixation time, the number of previous operations, soft tissue defects and the bone defect of distal 1/3 are statistically significantly associated with the occurrence of docking site complications.

Silver-Coated Distal Femur Megaprosthesis in Chronic Infections with Severe Bone Loss: A Multicentre Case Series

Periprosthetic joint infections (PJI) and fracture-related infections (FRI) of the distal femur (DF) may result in massive bone defects. Treatment options include articulated silver-coated (SC) megaprosthesis (MP) in the context of a two-stage protocol. However, there is limited evidence in the literature on this topic. A retrospective review of the prospectively maintained databases of three Institutions was performed. Forty-five patients were included. The mean follow-up time was 43 ± 17.1 months. Eight (17.8%) patients had a recurrent infection. The estimated recurrence-free survival rate was 91.1% (93.5% PJI vs. 85.7% FRI) 2 years following MP implantation, and 75.7% (83.2% PJI vs. 64.3% FRI; p = 0.253) after 5 years. No statistically relevant difference was found according to the initial diagnosis (PJI vs. FRI). Among possible risk factors, only resection length was found to significantly worsen the outcomes in terms of infection control (p = 0.031). A total of eight complications not related to infection were found after reimplantation, but only five of them required further surgery. Above-the-knee amputation was performed in two cases (4.4%), both for reinfection. Articulated DF SC MP in a two-stage protocol is a safe and effective treatment for chronic knee infection with severe bone loss.

Management of bone loss in acute severe open tibial fractures: a retrospective study of twenty nine cases-a treatment strategy with bone length preservation

PURPOSE

The present study investigated the outcomes of bone loss associated with acute open tibial fractures classified as Gustilo-Anderson classification grade III B (GIIIB) using a bone length preservation strategy.

METHODS

Among acute GIIIB open tibial fractures, 29 limbs of 29 patients requiring bone loss treatment were included. The reconstruction methods for bone loss were selected among the Masquelet technique (MT), bone transport (BT), acute shortening followed by gradual lengthening (ASGL), and free vascularized fibula graft (FVFG). Primary outcome measures were the rate of bone union and time to bone union.

RESULTS

The median radiographic apparent bone gap (RABG) was 46.75 mm. Bone loss was treated with ASGL only in two patients in whom it was not possible to cover large soft tissue defects by a single free latissimus dorsi (LD) myocutaneous flap (with the serratus anterior (SA) muscle). The other 27 patients underwent soft tissue reconstruction and bone loss treatment with the preservation of bone length, including the MT for 23, BT for six, and FVFG for one. The bone union rate was 75.9%, and the median time to bone union was six months. Salvage surgeries were performed on all seven patients with nonunion; all of whom eventually achieved bony union.

CONCLUSION

Bone loss associated with acute GIIIB open tibial fractures were treated with "bone length preservation" if the size of the soft tissue defect was less than the size that was covered by a single LD myocutaneous flap (with the SA muscle).

Clinical outcomes of bone transport using rail fixator in the treatment of femoral nonunion or bone defect caused by infection

Purpose

The rail fixator can improve the treatment outcome and provide good stability in patients with femoral bone transport. The purpose of this study is to investigate the clinical outcomes of bone transport using the Ilizarov technique by rail fixator in the treatment of femoral nonunion or bone defects caused by infection.

Methods

Clinical feature and treatment outcomes of 32 consecutive adult patients with femoral nonunion or bone defect caused by infection from January 2012 to January 2019 at a minimum of 2 years of follow-ups were retrospectively analyzed. Data were collected on participants' demographic details. All difficulties related to bone transport were documented according to Paley's classification. The clinical outcomes were evaluated using ASAMI criteria at the last clinical visit.

Results

All 32 patients with an average follow-up of 33.5 months. There were 17 problems, 21 obstacles, and 8 complications, and the complication rate per patient was 1.4. The main complications were pin-site infection (53.1%), axial deviation (21.9%), joint stiffness (18.8%), the delayed union of the docking site (18.8%), soft tissue incarceration(15.6%), delayed consolidation(6.3%), malunion(6.3%), and refracture (3.1%). All the patients achieved bone union, and no recurrence of infection was observed. The excellent and good rates of ASAMI bone and functional results were 87.5% and 81.3%, respectively.

Conclusion

Bone transport using the Ilizarov technique is an effective method for the treatment of femoral nonunion or bone defect caused by infection, and rail fixators have obtained satisfactory results in terms of bone and functional results.

Risk factors of transport gap bending deformity in the treatment of critical-size bone defect after bone transport

Background

The purpose of this study was to investigate the risk factors of transport gap bending deformity (TGBD) in the treatment of critical-size bone defect (CSBD) after the removal of the external fixator.

Methods

From January 2008 to December 2019, 178 patients with bone defects of the lower extremity caused by infection were treated by bone transport using a unilateral external fixator in our medical institution. TGBD was defined as the bone callus in the distraction area with a deviation to the force line of the femur (> 10°) or tibia (> 12°) after removal of the external fixator. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes. After the data were significant by the T-test or Pearson’s Chi-square test was analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of TGBD.

Results

A total of 178 patients were enrolled in the study, with a mean follow-up time of 28.6 ± 3.82 months. The positive result of the bacteria isolated test was observed in 144 cases (80.9%). The rate of excellent and good in the bone outcomes (excellent/good/fair/poor/failure, 41/108/15/14/0) was 83.7%, and 92.3% in the functional results (excellent/good/fair/poor/failure, 50/98/16/14/0) according to the ASAMI criteria. TGBD after removal of external fixator occurred in twenty-two patients (12.3%), including 6 tibias, and 16 femurs. Age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, osteoporosis, glucocorticoid intake, duration of infection > 24 months, EFT > 9 months, EFI > 1.8 month/cm were associated significantly with a higher incidence of TGBD in the binary logistic regression analysis (P < 0.05). The incidence more than 50% was found in patients with femoral defect (76.1%), osteoporosis (72.7%), BMI > 25 kg/m² (69.0%), diabetes (59.5%), glucocorticoid intake (54.7%). In the multivariate logistic regression analyses, the following factors were associated independently with TGBD, including age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, and osteoporosis.

Conclusions

Bone transport using a unilateral external fixator was a safe and practical method in the treatment of CSBD caused by infection. The top five risk factors of TGBD included femoral defect, BMI > 25 kg/m², duration of bone infection > 24 months, age > 45 years, and diabetes. Age > 45 years, BMI > 25 kg/m², femoral defect, osteoporosis, and diabetes were the independent risk factors. The higher incidence of TGBD may be associated with more risk factors.

[Effectiveness of bone transport with a locking plate versus conventional bone transport for tibial defects]

OBJECTIVE

To investigate the effectiveness difference between bone transport with a locking plate (BTLP) and conventional bone transport with Ilizarov/Orthofix fixators in treatment of tibial defect.

METHODS

The clinical data of 60 patients with tibial fractures who met the selection criteria between January 2016 and September 2020 were retrospectively analyzed, and patients were treated with BTLP (BTLP group, n=20), Ilizarov fixator (Ilizarov group, n=23), or Orthofix fixator (Orthofix group, n=17) for bone transport. There was no significant difference in gender, age, cause of injury, time from injury to admission, length of bone defect, tibial fracture typing, and comorbidities between groups ( P>0.05). The osteotomy time, the retention time of external fixator, the external fixation index, and the occurrence of postoperative complications were recorded and compared between groups. The bone healing and functional recovery were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria.

RESULTS

All patients of 3 groups were followed up 13-45 months, with a mean of 20.4 months. The osteotomy time was significantly shorter in the BTLP group than in the Ilizarov group, and the retention time of external fixator and the external fixation index were significantly lower in the BTLP group than in the Ilizarov and Orthofix groups ( P<0.05). Twenty-two fractures healed in the Ilizarov group and 1 case of delayed healing; 16 fractures healed in the Orthofix group and 1 case of delayed healing; 18 fractures healed in the BTLP group and 2 cases of delayed healing. There was no significant difference between groups in fracture healing distribution ( P=0.824). After completing bone reconstruction treatment according to ASAMI criteria, the BTLP group had better bone healing than the Orthofix group and better function than the Ilizarov groups, showing significant differences ( P<0.05). Postoperative complications occurred in 4 cases (20%) in the BLTP group, 18 cases (78%) in the Ilizarov group, and 12 cases (70%) in the Orthofix group. The incidence of complication in the BTLP group was significantly lower than that in other groups ( P<0.05).

CONCLUSION

BTLP is safe and effective in the treatment of tibial defects. BTLP has apparent advantages over the conventional bone transport technique in osteotomy time, external fixation index, and lower limb functional recovery.

Skeletal regeneration for segmental bone loss: Vascularised grafts, analogues and surrogates

Massive segmental bone defects (SBD) are mostly treated by removing the fibula and transplanting it complete with blood supply. While revolutionary 50 years ago, this remains the standard treatment. This review considers different strategies to repair SBD and emerging potential replacements for this highly invasive procedure. Prior to the technical breakthrough of microsurgery, researchers in the 1960s and 1970s had begun to make considerable progress in developing non autologous routes to repairing SBD. While the breaktthrough of vascularised bone transplantation solved the immediate problem of a lack of reliable repair strategies, much of their prior work is still relevant today. We challenge the assumption that mimicry is necessary or likely to be successful and instead point to the utility of quite crude (from a materials technology perspective), approaches. Together there are quite compelling indications that the body can regenerate entire bone segments with few or no exogenous factors. This is important, as there is a limit to how expensive a bone repair can be and still be widely available to all patients since cost restraints within healthcare systems are not likely to diminish in the near future. STATEMENT OF SIGNIFICANCE: This review is significant because it is a multidisciplinary view of several surgeons and scientists as to what is driving improvement in segmental bone defect repair, why many approaches to date have not succeeded and why some quite basic approaches can be as effective as they are. While there are many reviews of the literature of grafting and bone repair the relative lack of substantial improvement and slow rate of progress in clinical translation is often overlooked and we seek to challenge the reader to consider the issue more broadly.

Risk factors associated with infection recurrence of posttraumatic osteomyelitis treated with Ilizarov bone transport technique-a retrospective study of 149 cases

BACKGROUND

Post-traumatic tibial osteomyelitis is considered as complex clinical problem due to its unique characteristics such as prolonged course, multi-staged treatment and high recurrence rate. The purpose of this study is to identify and analyze the causes and risk factors associated with infection recurrence of tibial osteomyelitis treated with Ilizarov technique.

METHODS

From January 2011 to January 2019, a total of 149 patients with post-traumatic tibial osteomyelitis treated with Ilizarov bone transport technique were included in this study. Demographic and clinical data were collected and analyzed. Univariate analysis and logistic regression analysis were used to analyze the factors that may affect the recurrence or reinfection of post-traumatic tibial osteomyelitis after treated with Ilizarov bone transport technique.

RESULTS

All included patients were successfully followed up with an average of 37.5 month (18-78 month), among them, 17 patients (11.4%) occurred with recurrence or reinfection of tibial osteomyelitis in which 2 cases were in distraction area and 15 cases in docking site. Among them, 5 patients were treated successfully with appropriate intravenous antibiotic, the remaining 12 patients were intervened by surgical debridement or bone grafting after debridement. Univariate analysis showed that Pseudomonas aeruginosa infection, bone exposure, number of previous operations (> 3 times), blood transfusion during bone transport surgery, course of osteomyelitis > 3 months, diabetes was associated with recurrence or reinfection of postoperative tibial osteomyelitis. According to the results of logistic regression analysis, Pseudomonas aeruginosa infection, bone exposure, and the number of previous operations (> 3 times) are risk factors for recurrence or reinfection of posttraumatic tibial osteomyelitis treated with Ilizarov bone transport technique, with odds ratios (OR) of 6.055, 7.413, and 1.753, respectively.

CONCLUSION

The number of previous operations (> 3 times), bone exposure, and Pseudomonas aeruginosa infection are risk factors for infection recurrence of posttraumatic tibial osteomyelitis treated with Ilizarov bone transport technique.

Free flap transplantation combined with Ilizarov bone transport for the treatment of severe composite tibial and soft tissue defects

Objective

To evaluate the clinical efficacy of free flap transplantation combined with Ilizarov bone transport in the treatment of severe composite tibial and soft tissue defects.

Methods

We retrospectively analyzed the clinical data of 40 patients with severe composite tibial and soft tissue defects who underwent free flap transplantation combined with Ilizarov bone transport. The clinical efficacy was evaluated according to the following criteria: success rate of wound repair by free flap transplantation, incidence or recurrence rate of deep infection, healing rate of bone defects and external fixation index, incidence of complications, and functional score of affected extremities.

Results

All infections were generally well controlled by radical debridement and negative-pressure therapy, and all 40 patients’ wounds healed after repair and reconstruction of the tibia and soft tissues. Postoperative complications were alleviated by active treatment. The mean external fixation time was 12.83 ± 2.85 months, and the external fixation index was 1.55 m/cm. According to the Association for the Study and Application of Methods of Ilizarov (ASAMI) score, an excellent or good functional outcome was attained in 85% of patients.

Conclusion

Free flap transplantation combined with Ilizarov bone transport is an effective treatment for severe composite tibial and soft tissue defects.

Clinical and radiological assessment of the induced membrane technique using beta-tricalcium phosphate in reconstructive surgery for lower extremity long bone defects

AIMS

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

METHODS

A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using β-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups.

RESULTS

There were ten and 25 defects in the femur and tibia, respectively. Median LEFS improved significantly from 8 (IQR 1.5 to 19.3) preoperatively to 63.5 (IQR 57 to 73.3) at final follow-up (p < 0.001). Bone healing was achieved in all limbs, and median time from the second stage to bone healing was six months (IQR 5 to 10). Median time to bone healing, preoperative LEFS, or postoperative LEFS did not differ significantly between the defect size groups or among the treatment groups.

CONCLUSION

IMT using β-TCP provided satisfactory clinical and radiological outcomes for segmental bone defects in the lower limbs; surgical outcomes were not influenced by bone defect size or operated part. Cite this article: Bone Joint J 2021;103-B(3):456-461.

Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites

Background

The purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity.

Materal/Methods

From January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed.

Results

External iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery.

Conclusions

Although limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon’s best efforts.

Clinical observation of mineralized collagen bone grafting after curettage of benign bone tumors

Curettage of benign bone tumor is a common cause for bone defect. For such bone defect repair, autogenous bone, allogeneic bone and traditional artificial bone graft substitutes have many disadvantages. In recent years, a biomimetic mineralized collagen (MC) with similar composition and microstructures to the natural bone matrix was developed and used for treating various bone defects. In this work, a retrospective study analyzed clinical outcomes of patients treated with curettage of benign bone tumors and bone grafting with MC, in comparison to another group treated with the same surgical method and autogenous bone. Lane–Sandhu X-ray score of the autogenous bone group was superior to the MC group at 1 month after the operation, but the two groups had no statistical difference at 6 and 12 months. The MC group was better in Musculoskeletal Tumor Society scoring at 1 and 6 months after the operation, and the two groups had no statistical difference at 12 month. Therefore, the MC performed not as good as autogenous bone in early stage of bone healing but achieved comparable outcomes in long-term follow-ups. Moreover, the MC has advantages in function recovery and avoided potential complications induced by harvesting autogenous bone.

[Trifocal bone transport by using monolateral rail system in treatment of bone defects caused by post-traumatic tibial osteomyelitis]

OBJECTIVE

To study the effectiveness of trifocal bone transport by using monolateral rail system in the treatment of bone defects caused by post-traumatic tibial osteomyelitis.

METHODS

The clinical data of 28 patients with tibial defects caused by post-traumatic osteomyelitis treated with trifocal bone transport technique by using monolateral rail system between January 2012 and June 2017 were retrospectively analyzed. There were 26 males and 2 females, aged 22-59 years (mean, 41.3 years). The causes of injury included 13 cases of traffic accident injury, 9 cases of falling from height, 4 cases of heavy object injury, and 2 cases of crushing injury. The disease duration was 4.5-17.0 months (mean, 7.1 months). The length of bone defect was 6.5-16.8 cm (mean, 10.3 cm). And the range of soft tissue defect ranged from 3.5 cm×2.0 cm to 18.0 cm×11.0 cm. The bone transporting time, external fixation time, duration of regenerate consolidation, and external fixation index were recorded, and the complications were observed. At last follow-up, the bone and functional results were evaluated according to the criteria given by Association for the Study and Application of the Method of the Ilizarov (ASAMI).

RESULTS

All patients were successfully followed up after removing the external fixator with an average of 35 months (range, 24-65 months). The bone transporting time was 41-136 days (mean, 60.2 days), the external fixation time was 7.5-20.0 months (mean, 13.4 months), the external fixation index was 1.1-1.9 months/cm (mean, 1.4 months/cm), the duration of regenerate consolidation was 6.0-16.5 months (mean, 10.5 months). Pin tract infection occurred in 12 cases, delayed union on docking site was occurred in 9 cases, axial deviation was observed in 2 cases, poor regenerate consolidation was presented in 1 case, and refracture on docking site after fixator removal was occurred in 1 case. There was no recurrence of infection, amputation, vascular and neurologic complications, and osteofascial compartment syndrome. At last follow-up, according to ASAMI criterion, the bone healing results were excellent in 17 cases, good in 7 cases, and fair in 4 cases, with an excellent and good rate of 85.7%; the functional results were excellent in 15 cases, good in 10 cases, and fair in 3 cases, with an excellent and good rate of 89.3%.

CONCLUSION

Trifocal bone transport by using monolateral rail system is an effective method in the treatment of bone defect caused by post-traumatic osteomyelitis which can reduce bone transport time, external fixation time, and complications.

Functional Reconstruction of Hindfoot With Total Calcaneus and Talus Loss by Ilizarov Technique: A Case Report

Total calcaneus and talus loss in the hindfoot is an unusual but severe condition encountered in clinical settings. This condition affects lower-extremity function and poses a significant challenge to limb salvage. We present a case of a 43-year-old man with total calcaneus and talus loss in the right foot treated by Ilizarov technique. A staged treatment protocol was planned to reconstruct and optimize the heel for weightbearing and walking. During the 15-month postoperative follow-up, the patient reported no significant discomfort in the targeted foot and regained satisfactory function, including shoe wearing, walking, driving, and climbing stairs. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 71, which was an improvement from a preoperative score of 40. This case is the first reported on the functional reconstruction by Ilizarov technique of hindfoot with total calcaneus and talus loss. This treatment protocol provides an effective approach to reconstructing the hindfoot with massive bone loss, although the long-term outcome remains unknown.

Towards Understanding Therapeutic Failures in Masquelet Surgery: First Evidence that Defective Induced Membrane Properties are Associated with Clinical Failures

The two-stage Masquelet induced-membrane technique (IMT) consists of cement spacer-driven membrane induction followed by an autologous cancellous bone implantation in this membrane to promote large bone defect repairs. For the first time, this study aims at correlating IMT failures with physiological alterations of the induced membrane (IM) in patients. For this purpose, we compared various histological, immunohistochemical and gene expression parameters obtained from IM collected in patients categorized lately as successfully (Responders; n = 8) or unsuccessfully (Non-responders; n = 3) treated with the Masquelet technique (6 month clinical and radiologic post-surgery follow-up). While angiogenesis or macrophage distribution pattern remained unmodified in non-responder IM as compared to responder IM, we evidenced an absence of mesenchymal stem cells and reduced density of fibroblast-like cells in non-responder IM. Furthermore, non-responder IM exhibited altered extracellular matrix (ECM) remodeling parameters such as a lower expression ratio of metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinases (TIMP-1) mRNA as well as an important collagen overexpression as shown by picrosirius red staining. In summary, this study is the first to report evidence that IMT failure can be related to defective IM properties while underlining the importance of ECM remodeling parameters, particularly the MMP-9/TIMP-1 gene expression ratio, as early predictive biomarkers of the IMT outcome regardless of the type of bone, fracture or patient characteristics.

Mettl3 Regulates Osteogenic Differentiation and Alternative Splicing of Vegfa in Bone Marrow Mesenchymal Stem Cells

Bone mesenchymal stem cells (BMSCs) can be a useful cell resource for developing biological treatment strategies for bone repair and regeneration, and their therapeutic applications hinge on an understanding of their physiological characteristics. N⁶-methyl-adenosine (m⁶A) is the most prevalent internal chemical modification of mRNAs and has recently been reported to play important roles in cell lineage differentiation and development. However, little is known about the role of m⁶A modification in the cell differentiation of BMSCs. To address this issue, we investigated the expression of N⁶-adenosine methyltransferases (Mettl3 and Mettl14) and demethylases (Fto and Alkbh5) and found that Mettl3 was upregulated in BMSCs undergoing osteogenic induction. Furthermore, we knocked down Mettl3 and demonstrated that Mettl3 knockdown decreased the expression of bone formation-related genes, such as Runx2 and Osterix. The alkaline phosphatase (ALP) activity and the formation of mineralized nodules also decreased after Mettl3 knockdown. RNA sequencing analysis revealed that a vast number of genes affected by Mettl3 knockdown were associated with osteogenic differentiation and bone mineralization. Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis revealed that the phosphatidylinositol 3-kinase/AKT (PI3K-Akt) signaling pathway appeared to be one of the most enriched pathways, and Western blotting results showed that Akt phosphorylation was significantly reduced after Mettl3 knockdown. Mettl3 has been reported to play an important role in regulating alternative splicing of mRNA in previous research. In this study, we found that Mettl3 knockdown not only reduced the expression of Vegfa but also decreased the level of its splice variants, vegfa-164 and vegfa-188, in Mettl3-deficient BMSCs. These findings might contribute to novel progress in understanding the role of epitranscriptomic regulation in the osteogenic differentiation of BMSCs and provide a promising perspective for new therapeutic strategies for bone regeneration.

Evolution in Management of Tibial Pilon Fractures

PURPOSE OF REVIEW

Tibial plafond, or pilon, fractures can be some of the most difficult fractures to manage. As they are often associated with high-energy trauma, both the soft tissue involvement and the comminuted fracture pattern pose challenges to fixation. Furthermore, the complex anatomy and trauma to the cartilage at the time of injury predispose pilon fractures to poor functional outcomes and high rates of posttraumatic arthritis. This review will discuss the recent developments in the treatment of tibial pilon fractures.

RECENT FINDINGS

Historically, surgical management of pilon fractures has been associated with high rates of complications, including wound complications, infections, nonunions, and even the need for amputation. In response, staged protocols were created. However, recent studies have called this into question, demonstrating low wound complications with early definitive fixation. Additional studies are evaluating adjuvants to minimize wound complications, including the use of vancomycin powder and oxygen supplementation, while another study challenges the 7-cm myth regarding the distance needed between skin incisions. Additional research has been focused on alternative methods of managing these complex, and sometimes non-reconstructable, injuries with the use of external fixation, minimally invasive internal fixation, and primary arthrodesis. Tibial pilon fractures remain difficult to treat for even the most skilled orthopedic trauma surgeons. With improvements in surgical techniques and implants, complication rates have declined and outcomes have improved; however, the overall prognosis for these injuries often remains poor.

Clinical Applications of Bone Tissue Engineering in Orthopedic Trauma

Purpose of Review

Orthopaedic trauma is a major cause of morbidity and mortality worldwide. Although many fractures tend to heal if treated appropriately either by nonoperative or operative methods, delayed or failed healing, as well as infections, can lead to devastating complications. Tissue engineering is an exciting, emerging field with much scientific and clinical relevance in potentially overcoming the current limitations in the treatment of orthopaedic injuries.

Recent Findings

While direct translation of bone tissue engineering technologies to clinical use remains challenging, considerable research has been done in studying how cells, scaffolds, and signals may be used to enhance acute fracture healing and to address the problematic scenarios of nonunion and critical-sized bone defects. Taken together, the research findings suggest that tissue engineering may be considered to stimulate angiogenesis and osteogenesis, to modulate the immune response to fractures, to improve the biocompatibility of implants, to prevent or combat infection, and to fill large gaps created by traumatic bone loss. The abundance of preclinical data supports the high potential of bone tissue engineering for clinical application, although a number of barriers to translation must first be overcome.

Summary

This review focuses on the current and potential applications of bone tissue engineering approaches in orthopaedic trauma with specific attention paid to acute fracture healing, nonunion, and critical-sized bone defects.

Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

INTRODUCTION

Post-traumatic bone defects of the tibia present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularised fibular graft (either free or pedicled) and bone transport technique.

PATIENTS AND METHODS

Fourteen patients with an average age of 34.1 years at operation (range, 12-65) with post-traumatic bony defects of the tibia were selected for reconstruction with vascularised fibular graft combined with Ilizarov external fixation. There were 12 male and two female. The size of the bony gap was 10.4 cm (range, 7-13) and the average length of the fibula used was 16.4 cm (range, 14-21).

RESULTS

The mean follow up period was 20.4 months (range, 10-37). All patients had bony union at both proximal and distal ends of the fibula primarily except one patient that required secondary iliac bone graft at the distal end of the fibula to obtain union. The average time for bone healing was 3.9 months (range, 3-9). The average time spent in Ilizarov frame was 5.9 months (range, 5-11). Unprotected full weight-bearing was achieved within an average of 7.3 months (range, 6-12).

CONCLUSION

Vascularised fibular bone graft combined with an Ilizarov frame is a successful approach to safely and effectively reconstruct bone defects of the tibia. It has the advantages of vascularised fibular bone grafts together with the biomechanical advantages of Ilizarov frame that allows weight bearing to start almost immediately after surgery. This leads to a good outcome regarding the union and function.