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Fang C, Premchand AXR, Park DH, Toon DH. Peri-articular elbow fracture fixations with magnesium implants and a review of current literature: A case series. World J Orthop 2024; 15:215-229. [PMID: 38596190 PMCID: PMC10999966 DOI: 10.5312/wjo.v15.i3.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/11/2024] [Accepted: 02/02/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND In recent years, the use of Magnesium alloy implants have gained renewed popularity, especially after the first commercially available Conformité Européenne approved Magnesium implant became available (MAGNEZIX® CS, Syntellix) in 2013. AIM To document our clinical and radiographical outcomes using magnesium implants in treating peri-articular elbow fractures. METHODS Our paper was based on a retrospective case series design. Intra-operatively, a standardized surgical technique was utilized for insertion of the magnesium implants. Post - operatively, clinic visits were standardized and physical exam findings, functional scores, and radiographs were obtained at each visit. All complications were recorded. RESULTS Five patients with 6 fractures were recruited (2 coronoid, 3 radial head and 1 capitellum). The mean patient age and length of follow up was 54.6 years and 11 months respectively. All fractures healed, and none exhibited loss of reduction or complications requiring revision surgery. No patient developed synovitis of the elbow joint or suffered electrolytic reactions when titanium implants were used concurrently. CONCLUSION Although there is still a paucity of literature available on the subject and further studies are required, magnesium implants appear to be a feasible tool for fixation of peri-articular elbow fractures with promising results in our series.
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Affiliation(s)
- Christopher Fang
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, National Healthcare Group, Singapore 768828, Singapore
| | - Antony Xavier Rex Premchand
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, National Healthcare Group, Singapore 768828, Singapore
| | - Derek Howard Park
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, National Healthcare Group, Singapore 768828, Singapore
| | - Dong Hao Toon
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, National Healthcare Group, Singapore 768828, Singapore
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Huang B, Yang M, Kou Y, Jiang B. Absorbable implants in sport medicine and arthroscopic surgery: A narrative review of recent development. Bioact Mater 2024; 31:272-283. [PMID: 37637087 PMCID: PMC10457691 DOI: 10.1016/j.bioactmat.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/29/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023] Open
Abstract
Over the past two decades, advances in arthroscopic and minimally invasive surgical techniques have led to significant growth in sports medicine surgery. Implants such as suture anchors, interference screws, and endo-buttons are commonly used in these procedures. However, traditional implants made of metal or inert materials are not absorbable, leading to complications that affect treatment outcomes. To address this issue, absorbable materials with excellent mechanical properties, good biocompatibility, and controlled degradation rates have been developed and applied in clinical practice. These materials include absorbable polymers, absorbable bioceramics, and absorbable metals. In this paper, we will provide a comprehensive summary of these absorbable materials from the perspective of clinicians, and discuss their clinical applications and related research in sport medicine.
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Affiliation(s)
- Boxuan Huang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
- Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing, 100044, China
- National Center for Trauma Medicine, Beijing, 100044, China
| | - Ming Yang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
- Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing, 100044, China
- National Center for Trauma Medicine, Beijing, 100044, China
| | - Yuhui Kou
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
- Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing, 100044, China
- National Center for Trauma Medicine, Beijing, 100044, China
| | - Baoguo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
- Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing, 100044, China
- National Center for Trauma Medicine, Beijing, 100044, China
- Medical School, Shenzhen University, Shenzhen, 518060, Guangdong, China
- Shenzhen University General Hospital, Shenzhen, 518055, Guangdong, China
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Salvato D, Green DW, Accadbled F, Tuca M. Tibial spine fractures: State of the art. J ISAKOS 2023; 8:404-411. [PMID: 37321295 DOI: 10.1016/j.jisako.2023.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
Tibial spine fractures (TSFs) are avulsion fractures at the site where the anterior cruciate ligament inserts onto the tibial eminence. TSFs typically affect children and adolescents aged 8-14 years. The incidence of these fractures has been reported to be approximately 3 per 100,000 per year, but the rising involvement of paediatric patients in sporting activities is increasing the number of these injuries. TSFs are historically classified on plain radiographs according to the Meyers and Mckeever classification system, which was introduced in 1959, but the renewed interest in these fractures and the increasing use of magnetic resonance imaging led to the recent development of a new classification system. A reliable grading protocol for these lesions is paramount to guide orthopedic surgeons in determining the correct treatment for young patients and athletes. TSFs can be addressed conservatively in the case of nondisplaced or reduced fractures or surgically in the case of displaced fractures. Different surgical approaches and, specifically, arthroscopic techniques have been described in recent years to ensure stable fixation while limiting the risk of complications. The most common complications associated with TSF are arthrofibrosis, residual laxity, fracture nonunion or malunion, and tibial physis growth arrest. We speculate that advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of these complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities.
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Affiliation(s)
- Damiano Salvato
- Vita-Salute San Raffaele University, Residency Program in Orthopedic Surgery and Traumatology, Milan, Italy; Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Daniel W Green
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Franck Accadbled
- Pediatric Orthopedic Department, Hôpital des Enfants de Toulouse, Toulouse, France
| | - Maria Tuca
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Chile; Department of Orthopedic Surgery, Hospital Clinico Mutual de Seguridad, Santiago de Chile, Chile.
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Kumar N, Alathur Ramakrishnan S, Lopez KG, Wang N, Vellayappan BA, Hallinan JTPD, Fuh JYH, Kumar AS. Novel 3D printable PEEK-HA-Mg 2SiO 4 composite material for spine implants: biocompatibility and imaging compatibility assessments. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2255-2265. [PMID: 37179256 DOI: 10.1007/s00586-023-07734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE To develop a novel 3D printable polyether ether ketone (PEEK)-hydroxyapatite (HA)-magnesium orthosilicate (Mg2SiO4) composite material with enhanced properties for potential use in tumour, osteoporosis and other spinal conditions. We aim to evaluate biocompatibility and imaging compatibility of the material. METHODS Materials were prepared in three different compositions, namely composite A: 75 weight % PEEK, 20 weight % HA, 5 weight % Mg2SiO4; composite B: 70 weight% PEEK, 25 weight % HA, 5 weight % Mg2SiO4; and composite C: 65 weight % PEEK, 30 weight % HA, 5 weight % Mg2SiO4. The materials were processed to obtain 3D printable filament. Biomechanical properties were analysed as per ASTM standards and biocompatibility of the novel material was evaluated using indirect and direct cell cytotoxicity tests. Cell viability of the novel material was compared to PEEK and PEEK-HA materials. The novel material was used to 3D print a standard spine cage. Furthermore, the CT and MR imaging compatibility of the novel material cage vs PEEK and PEEK-HA cages were evaluated using a phantom setup. RESULTS Composite A resulted in optimal material processing to obtain a 3D printable filament, while composite B and C resulted in non-optimal processing. Composite A enhanced cell viability up to ~ 20% compared to PEEK and PEEK-HA materials. Composite A cage generated minimal/no artefacts on CT and MR imaging and the images were comparable to that of PEEK and PEEK-HA cages. CONCLUSION Composite A demonstrated superior bioactivity vs PEEK and PEEK-HA materials and comparable imaging compatibility vs PEEK and PEEK-HA. Therefore, our material displays an excellent potential to manufacture spine implants with enhanced mechanical and bioactive property.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore.
| | - Sridharan Alathur Ramakrishnan
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Keith Gerard Lopez
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Niyou Wang
- Department of Mechanical Engineering, National University of Singapore, 9 Engineering Drive 1, Singapore, 117575, Singapore
| | - Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Health System, Level 7, Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, National University Hospital Main Building, Level 2, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Jerry Ying Hsi Fuh
- Department of Mechanical Engineering, National University of Singapore, #04-18 Block EA, 9 Engineering Drive 1, Singapore, 117575, Singapore
| | - A Senthil Kumar
- Department of Mechanical Engineering, National University of Singapore, #05-26 Block EA, 9 Engineering Drive 1, Singapore, 117575, Singapore
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Seetharaman S, Sankaranarayanan D, Gupta M. Magnesium-Based Temporary Implants: Potential, Current Status, Applications, and Challenges. J Funct Biomater 2023; 14:324. [PMID: 37367288 DOI: 10.3390/jfb14060324] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/10/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023] Open
Abstract
Biomedical implants are important devices used for the repair or replacement of damaged or diseased tissues or organs. The success of implantation depends on various factors, such as mechanical properties, biocompatibility, and biodegradability of the materials used. Recently, magnesium (Mg)-based materials have emerged as a promising class of temporary implants due to their remarkable properties, such as strength, biocompatibility, biodegradability, and bioactivity. This review article aims to provide a comprehensive overview of current research works summarizing the above-mentioned properties of Mg-based materials for use as temporary implants. The key findings from in-vitro, in-vivo, and clinical trials are also discussed. Further, the potential applications of Mg-based implants and the applicable fabrication methods are also reviewed.
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Affiliation(s)
- Sankaranarayanan Seetharaman
- Department of Mechanical Engineering, College of Design and Engineering, National University of Singapore, 9 Engineering Drive 1, Block EA #07-08, Singapore 117575, Singapore
- Advanced Remanufacturing and Technology Centre (ARTC), Agency for Science, Technology and Research (A*STAR), 3 Cleantech Loop, #01/01 CleanTech Two, Singapore 637143, Singapore
| | - Dhivya Sankaranarayanan
- Department of Mechanical Engineering, College of Design and Engineering, National University of Singapore, 9 Engineering Drive 1, Block EA #07-08, Singapore 117575, Singapore
| | - Manoj Gupta
- Department of Mechanical Engineering, College of Design and Engineering, National University of Singapore, 9 Engineering Drive 1, Block EA #07-08, Singapore 117575, Singapore
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Baldini M, Coppa V, Falcioni D, Cusano G, Massetti D, Marinelli M, Gigante AP. Resorbable magnesium screws for fixation of medial epicondyle avulsion fractures in skeletally immature patients: A comparison with Kirschner wires. J Child Orthop 2022; 16:481-487. [PMID: 36483654 PMCID: PMC9723866 DOI: 10.1177/18632521221136100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/08/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Displaced medial epicondyle fractures are treated with open reduction and internal fixation with K-wires or screws. Rates of implant prominence, failure, or non-union reported are considerable. Magnesium screws have demonstrated biocompatibility, osteoconductivity, and high pull-out strength. The aim of this study was to compare surgical fixation of medial epicondyle fracture using resorbable magnesium Herbert screws to K-wires, in skeletally immature patients. METHODS A retrospective analysis was performed from January 2015 to April 2020. Inclusion criteria were as follows displaced medial epicondyle fracture, <15 years, and absence of concomitant ipsilateral upper limb fractures. Two consecutive cohorts based on fixation device were made: Group A (wires) and Group B (magnesium screws). Alignment, pain, range of motion, Mayo Elbow Performance Score, and radiological healing were assessed. RESULTS A total of 27 patients were included: 15 in Group A and 12 in Group B. Groups were comparable for age and sex. Mean follow-up was higher in Group A (38.73 ± 3.15 vs 26.18 ± 4.85 months; p < 0.001). No significant differences were observed regarding range of motion, alignment, pain, and Mayo Elbow Performance Score, with excellent results in both groups. Two patients in Group A developed a deep wound pin site infection requiring antibiotics. X-rays revealed three cases of non-union in Group A and one in Group B, all of them asymptomatic. No patient required a second surgical procedure. CONCLUSION Open reduction and internal fixation of medial epicondyle fractures with magnesium screws showed comparable results to a widely accepted procedure such as the use of K-wires, potentially with a lower incidence of non-union and infection. No adverse reactions were recorded. LEVEL OF EVIDENCE level III.
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Affiliation(s)
- Marco Baldini
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy,Marco Baldini, Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/A, 60126 Ancona, Italy. Emails: ;
| | - Valentino Coppa
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Danya Falcioni
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Giuseppe Cusano
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Daniele Massetti
- Divisione di Ortopedia e Traumatologia, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Mario Marinelli
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Antonio Pompilio Gigante
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy,Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
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Rotator cuff repair with biodegradable high-purity magnesium suture anchor in sheep model. J Orthop Translat 2022; 35:62-71. [PMID: 36186661 PMCID: PMC9471965 DOI: 10.1016/j.jot.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/01/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022] Open
Abstract
Background Rotator cuff tear has become one of the diseases affecting people's living quality. Conventional anchor materials such as titanium alloy and poly-lactic acid can lead to postoperative complications like bone defects and aseptic inflammation. Magnesium (Mg)-based implants are biodegradable and biocompatible, with strong potential to be applied in orthopaedics. Methods In this study, we developed a high-purity (HP) Mg suture anchor and studied its mechanical properties and degradation behavior in vitro. Furthermore, we described the use of high-purity Mg to prepare suture anchor for the rotator cuff repair in sheep. Results The in vitro tests showed that HP Mg suture anchor possess proper degradation behavior and appropriate mechanical property. Animal experiment indicated that HP Mg suture anchor provided reliable anchoring function in 12 weeks and showed no toxic effect on animal organs. Conclusion In summary, the HP Mg anchor presented in this study had favorable mechanical property and biosecurity. The translational potential of this article: The translational potential of this article is to use high-purity Mg to develop a degradable suture anchor and verify the feasibility of the application in animal model. This study provides a basis for further research on the clinical application of biodegradable high-purity Mg suture anchor.
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Cordunianu MA, Antoniac I, Niculescu M, Paltanea G, Raiciu AD, Dura H, Forna N, Carstoc ID, Cristea MB. Treatment of Knee Osteochondral Fractures. Healthcare (Basel) 2022; 10:healthcare10061061. [PMID: 35742112 PMCID: PMC9222836 DOI: 10.3390/healthcare10061061] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Osteochondral lesions (OCLs) that are frequently encountered in skeletally immature and adult patients are more common than once thought, and their incidence rate is rising. These lesions can appear in many synovial joints of the body, such as the shoulder, elbow, hip, and ankle, occurring most often in the knee. The term osteochondral lesion includes a vast spectrum of pathologies such as osteochondritis dissecans, osteochondral defects, osteochondral fractures, and osteonecrosis of the subchondral bone. When considering this, the term osteochondral fracture is preserved only for an osteochondral defect that combines disruption of the articular cartilage and subchondral bone. These fractures commonly occur after sports practice and are associated with acute lateral patellar dislocations. Many of these lesions are initially diagnosed by plain radiographs; however, a computed tomography (CT) scan or magnetic resonance imaging (MRI) can add significant value to the diagnosis and treatment. Treatment methods may vary depending on the location and size of the fracture, fragment instability, and skeletal maturity. The paper reports a 14-year-old boy case with an osteochondral fracture due to sports trauma. The medical approach involved an arthrotomy of the knee, drainage of the hematoma, two Kirschner wires (K-wires) for temporary fixation to restructure anatomic alignment, and a titanium Herbert screw fixing the fracture permanently. The patient had a favorable postoperative outcome with no residual pain, adequate knee stability, and a normal range of motion. The mobility of the knee was fully recovered.
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Affiliation(s)
- Mihai Alexandru Cordunianu
- Faculty of Medicine, Titu Maiorescu University, 67A Gheorghe Petrascu, RO-031593 Bucharest, Romania; (M.A.C.); (M.N.)
| | - Iulian Antoniac
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, RO-060042 Bucharest, Romania;
- Academy of Romanian Scientists, RO-050094 Bucharest, Romania
| | - Marius Niculescu
- Faculty of Medicine, Titu Maiorescu University, 67A Gheorghe Petrascu, RO-031593 Bucharest, Romania; (M.A.C.); (M.N.)
| | - Gheorghe Paltanea
- Faculty of Electrical Engineering, University Politehnica of Bucharest, RO-060042 Bucharest, Romania
- Correspondence: (G.P.); (H.D.)
| | | | - Horatiu Dura
- Faculty of Medicine, Lucian Blaga University of Sibiu, RO-550169 Sibiu, Romania;
- Correspondence: (G.P.); (H.D.)
| | - Norin Forna
- Department of Orthopedics and Traumatology, Gr. T. Popa University of Medicine and Pharmacy, RO-700115 Iasi, Romania;
| | - Ioana Dana Carstoc
- Faculty of Medicine, Lucian Blaga University of Sibiu, RO-550169 Sibiu, Romania;
| | - Mihai Bogdan Cristea
- Department of Morphological Sciences, Carol Davila University of Medicine and Pharmacy, RO-020021 Bucharest, Romania;
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Clinical parameters and radiographic resorption of a novel magnesium based bone void filler. Injury 2022; 53:947-952. [PMID: 34895713 DOI: 10.1016/j.injury.2021.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 11/15/2021] [Accepted: 11/24/2021] [Indexed: 02/02/2023]
Abstract
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.
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Magnesium-Based Alloys Used in Orthopedic Surgery. MATERIALS 2022; 15:ma15031148. [PMID: 35161092 PMCID: PMC8840615 DOI: 10.3390/ma15031148] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 02/04/2023]
Abstract
Magnesium (Mg)-based alloys have become an important category of materials that is attracting more and more attention due to their high potential use as orthopedic temporary implants. These alloys are a viable alternative to nondegradable metals implants in orthopedics. In this paper, a detailed overview covering alloy development and manufacturing techniques is described. Further, important attributes for Mg-based alloys involved in orthopedic implants fabrication, physiological and toxicological effects of each alloying element, mechanical properties, osteogenesis, and angiogenesis of Mg are presented. A section detailing the main biocompatible Mg-based alloys, with examples of mechanical properties, degradation behavior, and cytotoxicity tests related to in vitro experiments, is also provided. Special attention is given to animal testing, and the clinical translation is also reviewed, focusing on the main clinical cases that were conducted under human use approval.
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Sun Y, Helmholz H, Will O, Damm T, Wiese B, Luczak M, Peschke E, Luthringer-Feyerabend B, Ebel T, Hövener JB, Glüer C, Willumeit-Römer R. Dynamic in vivo monitoring of fracture healing process in response to magnesium implant with multimodal imaging: Pilot longitudinal study in a rat external fixation model. Biomater Sci 2022; 10:1532-1543. [DOI: 10.1039/d2bm00051b] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Rodent models are commonly used in pre-clinical research of magnesium (Mg) -based and other types of biomaterials for fracture treatment. Most studies selected unstable fixation methods, and there is a...
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Espiritu J, Meier M, Seitz JM. The current performance of biodegradable magnesium-based implants in magnetic resonance imaging: A review. Bioact Mater 2021; 6:4360-4367. [PMID: 33997512 PMCID: PMC8111036 DOI: 10.1016/j.bioactmat.2021.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/24/2021] [Accepted: 04/12/2021] [Indexed: 12/01/2022] Open
Abstract
Magnesium-based implants are re-emerging as a substantial amendment to standard orthopaedic implants. A brief introduction of magnesium (Mg) as a biodegradable material and basic magnetic resonance imaging (MRI) principles are discussed. This review aims to highlight the current performance of these implants during examinations with MRI. We also aim to summarise comparisons between Mg-based implants with current standards to emphasise the promotion of biodegradable implants in clinical practice. A comprehensive search of current literature on Mg-based implants and the utilisation of MRI in the studies was performed. Additionally, recorded artefact behaviour of Mg-based implants during MRI was investigated. A total of nine studies were included in which MRI was employed to image Mg-based implants. Of those studies, four of the nine discuss artefact production caused by the implants. MRI successfully imaged regions of interest over all and produced fewer artefacts than other materials used in the studies. MRI was employed in contrast angiography, bone growth observation, bone infection healing, and blood perfusion. Imaging capabilities of an implant material are vital to translating products into clinical application. Positive findings presented in this review suggest and support the use of Mg-based implants due to their successful visual compatibility with MRI techniques.
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Stürznickel J, Delsmann MM, Jungesblut OD, Stücker R, Knorr C, Rolvien T, Kertai M, Rupprecht M. Safety and performance of biodegradable magnesium-based implants in children and adolescents. Injury 2021; 52:2265-2271. [PMID: 33775413 DOI: 10.1016/j.injury.2021.03.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 02/02/2023]
Abstract
AIMS Biodegradable magnesium-based alloy implants represent a promising option in orthopedic surgery, as the clinical outcomes have been reported to be comparable to those of titanium implants and no surgical interventions are required for removal. To date, little is known about the results of the use of these implants in children and adolescents. Therefore, the aim of the present study was to analyze the safety and performance of these implants in children and adolescents. PATIENTS AND METHODS Eighty-nine patients treated with magnesium-based implants for fracture stabilization, osteotomy and osteochondral refixation were analyzed; 38 were treated by osteosynthesis; 18, osteotomy; and 33, osteochondral refixation. The mean follow-up duration was 8.2 months (range, 1.5-30 months). Clinical and radiographical follow-up examinations were performed at 4-8 weeks and 3-6 months, respectively, to evaluate implant performance and osseous consolidation. RESULTS Clinical outcomes were rated as good to very good in all patients. Radiolucent zones were apparent after surgery in all patients but were noted to decrease in size during the follow-up period. Revision surgery was necessary in 1 of 89 patients who had a highly unstable osteochondritis dissecans lesion of the knee. None of the magnesium-based implants required surgical removal. CONCLUSION Magnesium-based implants in children and adolescents results in good clinical outcomes when used for fracture stabilization, osteotomy and osteochondral defect refixation. Future studies are needed to further analyze the significance of the transient appearance and temporal development of radiolucent zones in the growing skeleton as well as the long-term performance of these implants.
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Affiliation(s)
- Julian Stürznickel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian M Delsmann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver D Jungesblut
- Department of Pediatric Orthopaedics, Children's Hospital Hamburg-Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Stücker
- Department of Pediatric Orthopaedics, Children's Hospital Hamburg-Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Knorr
- Department of Pediatric Surgery, Klinik St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Tim Rolvien
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Kertai
- Department of Pediatric Surgery, Klinik St. Hedwig, University Medical Center Regensburg, Regensburg, Germany.
| | - Martin Rupprecht
- Department of Pediatric Orthopaedics, Children's Hospital Hamburg-Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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14
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Baldini M, Coppa V, Falcioni D, Senigagliesi E, Marinelli M, Gigante AP. Use of resorbable magnesium screws in children: systematic review of the literature and short-term follow-up from our series. J Child Orthop 2021; 15:194-203. [PMID: 34211595 PMCID: PMC8223084 DOI: 10.1302/1863-2548.15.210004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/06/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Biodegradable implants are of major interest in orthopaedics, especially in the skeletally immature population. Magnesium (Mg) implants are promising for selected surgical procedure in adults, but evidence is lacking. Thus, the aim of this study is to analyze the safety and efficacy of resorbable Mg screw in different orthopaedic procedures in skeletally immature patients. In addition, we present a systematic review of the current literature on the clinical use of Mg implants. METHODS From 2018 until the writing of this manuscript, consecutive orthopaedic surgical procedures involving the use of Mg screws performed at our centre in patients < 15 years of age were retrospectively reviewed. In addition, a systematic review of the literature was performed in the main databases. We included clinical studies conducted on humans, using Mg-alloy implants for orthopaedic procedures. RESULTS A total of 14 patients were included in this retrospective analysis. Mean age at surgery was 10.8 years (sd 2.4), mean follow-up was 13.8 months (sd 7.5). Healing was achieved in all the procedures, with no implant-related adverse reaction. No patients required any second surgical procedure. The systematic review evidenced 20 clinical studies, 19 of which conducted on an adult and one including paediatric patients. CONCLUSION Evidence on resorbable Mg implants is low but promising in adults and nearly absent in children. Our series included apophyseal avulsion, epiphyseal fractures, osteochondritis dissecans, displaced osteochondral fragment and tendon-to-bone fixation. Mg screws guaranteed stable fixation, without implant failure, with good clinical and radiological results and no adverse events. LEVEL OF EVIDENCE IV - Single cohort retrospective analysis with systematic review.
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Affiliation(s)
- Marco Baldini
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Valentino Coppa
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Danya Falcioni
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedal-iero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Elisa Senigagliesi
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Mario Marinelli
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Antonio Pompilio Gigante
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedal-iero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
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15
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Herber V, Okutan B, Antonoglou G, Sommer NG, Payer M. Bioresorbable Magnesium-Based Alloys as Novel Biomaterials in Oral Bone Regeneration: General Review and Clinical Perspectives. J Clin Med 2021; 10:jcm10091842. [PMID: 33922759 PMCID: PMC8123017 DOI: 10.3390/jcm10091842] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 02/07/2023] Open
Abstract
Bone preservation and primary regeneration is a daily challenge in the field of dental medicine. In recent years, bioresorbable metals based on magnesium (Mg) have been widely investigated due to their bone-like modulus of elasticity, their high biocompatibility, antimicrobial, and osteoconductive properties. Synthetic Mg-based biomaterials are promising candidates for bone regeneration in comparison with other currently available pure synthetic materials. Different alloys based on Mg were developed to fit clinical requirements. In parallel, advances in additive manufacturing offer the possibility to fabricate experimentally bioresorbable metallic porous scaffolds. This review describes the promising clinical results of resorbable Mg-based biomaterials for bone repair in osteosynthetic application and discusses the perspectives of use in oral bone regeneration.
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Affiliation(s)
- Valentin Herber
- Department of Dentistry and Oral Health, Division of Oral Surgery and Orthodontics, Medical University of Graz, Billrothgasse 4, 8010 Graz, Austria; (G.A.); (M.P.)
- Department of Orthopaedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5/6, 8036 Graz, Austria; (B.O.); (N.G.S.)
- Correspondence:
| | - Begüm Okutan
- Department of Orthopaedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5/6, 8036 Graz, Austria; (B.O.); (N.G.S.)
| | - Georgios Antonoglou
- Department of Dentistry and Oral Health, Division of Oral Surgery and Orthodontics, Medical University of Graz, Billrothgasse 4, 8010 Graz, Austria; (G.A.); (M.P.)
| | - Nicole G. Sommer
- Department of Orthopaedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5/6, 8036 Graz, Austria; (B.O.); (N.G.S.)
| | - Michael Payer
- Department of Dentistry and Oral Health, Division of Oral Surgery and Orthodontics, Medical University of Graz, Billrothgasse 4, 8010 Graz, Austria; (G.A.); (M.P.)
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16
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Crozier-Shaw G, Mahon J, Bayer TC. The use of bioabsorbable compression screws & polyethylene tension band for fixation of displaced olecranon fractures. J Orthop 2020; 22:525-529. [PMID: 33132626 PMCID: PMC7588653 DOI: 10.1016/j.jor.2020.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Transverse fractures of the olecranon are commonly fixed using tension-band wiring techniques. However the superficial nature of this area leads to high complication rates requiring removal of metalwork. The purpose of this retrospective study is to report and evaluate functional outcomes of polyethylene tension-band and bioabsorbable Magnesium alloy screw fixation of olecranon fractures. METHODS A retrospective case-control study was undertaken. Demographics, injury type and post-operative details were collected. All patients were treated in the same institution by a single surgeon. Primary outcomes included radiographic healing and post-operative range of motion. Secondary outcome was post-operative complications. RESULTS A total of five cases were identified. Mean age was 52.4. The control group was made up of six patients treated with a traditional tension band wire fixation. One patient in study group was lost to follow up. 80% of fractures in study group demonstrated anatomic post-operative radiographic union, compared with 83% of control group. All patients had range of motion above 100°, with full protonation and supination. One patient did have an extension lag of 15°. CONCLUSION Surgical repair of olecranon fractures is often complicated by the need for re-operation. This method provides both intramedullary fixation and conversion of distraction forces to compression forces with bioabsorbable materials, and aims to reduce the high re-operation rates commonly seen by avoiding the use of permanent indwelling metal hardware.
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Affiliation(s)
- Geoff Crozier-Shaw
- Department of Trauma and Orthopaedic Surgery, Midland Regional Hospital Tullamore, Co Offaly, Ireland
| | - John Mahon
- Department of Trauma and Orthopaedic Surgery, Midland Regional Hospital Tullamore, Co Offaly, Ireland
| | - Thomas C. Bayer
- Department of Trauma and Orthopaedic Surgery, Midland Regional Hospital Tullamore, Co Offaly, Ireland
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17
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Field EJ, Langley‐Hobbs SJ. Bilateral proximal tibial epiphysiodesis for management of bilateral partial avulsion fracture of the origin of the cranial cruciate ligaments in a dog. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2019-000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Elinor Jo Field
- Department of Small Animal SurgeryHighcroft Veterinary ReferralsBristolUK
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18
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Holweg P, Berger L, Cihova M, Donohue N, Clement B, Schwarze U, Sommer NG, Hohenberger G, van den Beucken JJ, Seibert F, Leithner A, Löffler JF, Weinberg AM. A lean magnesium-zinc-calcium alloy ZX00 used for bone fracture stabilization in a large growing-animal model. Acta Biomater 2020; 113:646-659. [PMID: 32553919 DOI: 10.1016/j.actbio.2020.06.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/04/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022]
Abstract
Over the last decade, demand has increased for developing new, alternative materials in pediatric trauma care to overcome the disadvantages associated with conventional implant materials. Magnesium (Mg)-based alloys seem to adequately fulfill the vision of a homogeneously resorbable, biocompatible, load-bearing and functionally supportive implant. The aim of the present study is to introduce the high-strength, lean alloy Mg‒0.45Zn‒0.45Ca, in wt% (ZX00), and for the first time investigate the clinical applicability of screw osteosynthesis using this alloy that contains no rare-earth elements. The alloy was applied in a growing sheep model with osteotomized bone (simulating a fracture) and compared to a non-osteotomy control group regarding degradation behavior and fracture healing. The alloy exhibits an ultimate tensile strength of 285.7 ± 3.1 MPa, an elongation at fracture of 18.2 ± 2.1%, and a reduced in vitro degradation rate compared to alloys containing higher amounts of Zn. In vivo, no significant difference between the osteotomized bone and the control group was found regarding the change in screw volume over implantation time. Therefore, it can be concluded that the fracture healing process, including its effects on the surrounding area, has no significant influence on degradation behavior. There was also no negative influence from hydrogen-gas formation on fracture healing. Despite the proximal and distal screws showing chronologically different gas release, the osteotomy showed complete consolidation. STATEMENT OF SIGNIFICANCE: Conventional implants involve several disadvantages in pediatric trauma care. Magnesium-based alloys seem to overcome these issues as discussed in the recent literature. This study evaluates the clinical applicability of high-strength lean Mg‒0.45Zn‒0.45Ca (ZX00) screws in a growing-sheep model. Two groups, one including a simulated fracture and one group without fracture, underwent implantation of the alloy and were compared to each other. No significant difference regarding screw volume was observed between the groups. There was no negative influence of hydrogen-gas formation on fracture healing and a complete fracture consolidation was found after 12 weeks for all animals investigated.
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19
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Holweg P, Herber V, Ornig M, Hohenberger G, Donohue N, Puchwein P, Leithner A, Seibert F. A lean bioabsorbable magnesium-zinc-calcium alloy ZX00 used for operative treatment of medial malleolus fractures: early clinical results of a prospective non-randomized first in man study. Bone Joint Res 2020; 9:477-483. [PMID: 32874554 PMCID: PMC7437522 DOI: 10.1302/2046-3758.98.bjr-2020-0017.r2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aims This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton. Methods A total of 20 patients with isolated, bimalleolar, or trimalleolar ankle fractures were recruited between July 2018 and October 2019. Fracture reduction was achieved through bioabsorbable Mg-based screws composed of pure Mg alloyed with zinc (Zn) and calcium (Ca) ( Mg-Zn0.45-Ca0.45, in wt.%; ZX00). Visual analogue scale (VAS) and the presence of complications (adverse events) during follow-up (12 weeks) were used to evaluate the clinical outcomes. The functional outcomes were analyzed through the range of motion (ROM) of the ankle joint and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Fracture reduction and gas formation were assessed using several plane radiographs. Results The follow-up was performed after at least 12 weeks. The mean difference in ROM of the talocrural joint between the treated and the non-treated sites decreased from 39° (SD 12°) after two weeks to 8° (SD 11°) after 12 weeks (p ≤ 0.05). After 12 weeks, the mean AOFAS score was 92.5 points (SD 4.1). Blood analysis revealed that Mg and Ca were within a physiologically normal range. All ankle fractures were reduced and stabilized sufficiently by two Mg screws. A complete consolidation of all fractures was achieved. No loosening or breakage of screws was observed. Conclusion This first prospective clinical investigation of fracture reduction and fixation using lean, bioabsorbable, REE-free ZX00 screws showed excellent clinical and functional outcomes. Cite this article: Bone Joint Res 2020;9(8):477–483.
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Affiliation(s)
- Patrick Holweg
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Valentin Herber
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Martin Ornig
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Gloria Hohenberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Nicolas Donohue
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Paul Puchwein
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Franz Seibert
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
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20
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Aktan C, Ertan MB, Turan A, Kose O. Fixation of Small Osteochondral Fragments in a Comminuted Distal Humerus Fracture with Magnesium Bioabsorbable Screws: A Case Report. Cureus 2018; 10:e3752. [PMID: 30820372 PMCID: PMC6388848 DOI: 10.7759/cureus.3752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The treatment of comminuted distal humeral fractures with free osteochondral fragments is challenging. Osteochondral fragments should be retained whenever possible and secured with implants buried beneath the articular surface to obtain a uniform articular surface. Headless compression screws and K wires are commonly used for this purpose. However, certain complications have been reported with these fixation implants in case of the non-union and osteolysis of the fragments such as migration and cartilage damage. Fixation of osteochondral fractures in distal humeral fractures using bioabsorbable implants has been rarely reported in the current literature. Herein, a patient who sustained a comminuted distal humeral fracture with multi-fragmentary osteochondral fragments is presented, and treatment with magnesium bioabsorbable compression screws is discussed.
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Affiliation(s)
- Cemil Aktan
- Department of Orthopaedics and Traumatology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, TUR
| | - Mehmet B Ertan
- Department of Orthopaedics and Traumatology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, TUR
| | - Adil Turan
- Department of Orthopaedics and Traumatology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, TUR
| | - Ozkan Kose
- Department of Orthopaedics and Traumatology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, TUR
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