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Lu F, Groven RVM, van Griensven M, Poeze M, Geurts JAP, Qiu SS, Blokhuis TJ. Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study. J Orthop Traumatol 2024; 25:21. [PMID: 38637406 PMCID: PMC11026327 DOI: 10.1186/s10195-024-00763-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/01/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity. MATERIALS AND METHODS Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18 months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis. RESULTS A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively. CONCLUSIONS Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Fangzhou Lu
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
| | - Rald V M Groven
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
| | - Martijn van Griensven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
| | - Martijn Poeze
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Jan A P Geurts
- CAPHRI Care and Public Health Research Institute, Department of Orthopedic Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, Maastricht, the Netherlands
| | - Shan Shan Qiu
- Division of Plastic Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Taco J Blokhuis
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
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Chang X, Ma Z, Zhu G, Lu Y, Yang J. New perspective into mesenchymal stem cells: Molecular mechanisms regulating osteosarcoma. J Bone Oncol 2021; 29:100372. [PMID: 34258182 PMCID: PMC8254115 DOI: 10.1016/j.jbo.2021.100372] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/14/2021] [Accepted: 06/02/2021] [Indexed: 02/05/2023] Open
Abstract
The origin of osteosarcoma cells from osteoblasts and mesenchymal stem cells remains controversial. Mesenchymal stem cells regulate the development of osteosarcoma by influencing the tumor microenvironment and mediating cell communication. Mesenchymal stem cells and exosomes secreted by them can be used as good genes and drug carriers for the treatment of osteosarcoma. Mesenchymal stem cells from different tissue sources have different regulatory effects on the development of osteosarcoma.
Mesenchymal stem cells (MSCs) are multipotent stem cells with significant potential for regenerative medicine. The tumorigenesis of osteosarcoma is an intricate system and MSCs act as an indispensable part of this, interacting with the tumor microenvironment (TME) during the process. MSCs link to cells by acting on each component in the TME via autocrine or paracrine extracellular vesicles for cellular communication. Because of their unique characteristics, MSCs can be modified and processed into good biological carriers, loaded with drugs, and transfected with anticancer genes for the targeted treatment of osteosarcoma. Previous high-quality reviews have described the biological characteristics of MSCs; this review will discuss the effects of MSCs on the components of the TME and cellular communication and the prospects for clinical applications of MSCs.
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Key Words
- 3TSR, Three type 1 repeats
- 5 FC, 5-fluorocytosine
- AD-MSCs, Adipose-derived MSCs
- AQP1, Aquaporin-1
- BMSC-derived exosomes, BMSC-Exos
- BMSCs, Bone marrow mesenchymal stem cells
- CAFs, Carcinoma-associated-fibroblasts
- CRC, Colorectal cancer
- CSF, Colony-stimulating factor
- Cellular communication
- Clinical application
- DOX, Doxorubicin
- DP-MSCs, Dental pulp-derived MSCs, hUC-MSCs, Human umbilical cord MSCs
- ECM, Extracellular matrix
- ESCs, embryonic stem cells
- EVs, Extracellular vesicles
- GBM, Glioblastoma
- HCC, hepatocellular carcinoma
- LINE-1, Long interspersing element 1
- MCP-1, Monocyte chemoattractant protein-1
- MSC-Exos, MSC-derived exosomes
- MSC-MVs, MSC microvesicles
- MSCs
- MSCs, Mesenchymal stem cells
- OPG, osteoprotegerin
- OS, osteosarcoma
- Osteosarcoma
- PDGFRα, Platelet derived growth factor receptor α
- PDGFRβ, Platelet derived growth factor receptor β
- PDGFα, Platelet derived growth factor α
- S TRAIL, Secretable variant of the TNF-related apoptosis-inducing ligand
- SD-MSCs, stressed MSCs
- SDF-1, Stromal cell-derived factor 1
- TGF, Transforming growth factor
- TME
- TME, Tumor microenvironment
- TNF, Tumor necrosis factor
- TRA2B, Transformer 2β
- VEGF, Vascular endothelial growth factor
- hASCs, human adipose stem cells
- iPSCs, induced pluripotent stem cells
- yCD::UPRT, Yeast cytosine deaminase::uracil phosphoribosyl transferase
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Affiliation(s)
- Xingyu Chang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China
| | - Zhanjun Ma
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China
| | - Guomao Zhu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China
| | - Yubao Lu
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China
| | - Jingjing Yang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu 730000, China
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Mazzotta A, Stagni C, Rocchi M, Rani N, Del Piccolo N, Filardo G, Dallari D. Bone marrow aspirate concentrate/platelet-rich fibrin augmentation accelerates healing of aseptic upper limb nonunions. J Orthop Traumatol 2021; 22:21. [PMID: 34089398 PMCID: PMC8179859 DOI: 10.1186/s10195-021-00582-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 05/04/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Nonunions remain a significant burden in orthopedics, often afflicting young males of working age. Positive findings have been published using bone marrow aspirate concentrate (BMAC) and platelet-rich fibrin (PRF) for the treatment augmentation of lower limb nonunions. The aim of this study was to investigate if the treatment augmentation with BMAC and PRF can also accelerate the healing of nonunions of the upper limb. Materials and methods Sixty-eight patients (45 men, 23 women) affected by 75 nonunions of long bones of the upper limb were treated and divided into two groups. The first series was treated with standard surgery alone (group A); afterwards, the second series benefited from standard surgery with the addition of BMAC and PRF applied on lyophilized bone chips. Nonunions were classified radiographically according to the Weber–Cech method and prognostically using the Calori and Moghaddam scores. All patients were radiographically assessed at 1.5, 3, 6, 12, and 24 months of follow-up. Results Baseline demographic characteristics did not present differences between groups. No differences were documented in terms of complications (two in group A and three in group B). Significant differences were instead documented in terms of healing time. The first healing signs were observed 1.5 months after surgery in 90.7% of patients in group B and 34.4% of group A (p < 0.0005). At 1.5, 3, 6, and 12 months, a higher radiographic score was found for group B (all p < 0.0005), while no difference was found at final follow-up of 24 months (90.6% of group A and 97.7% of group B achieved radiological healing). Faster healing with BMAC/PRF augmentation was confirmed for all bones, as well as for the subgroup of patients affected by atrophic nonunions (p = 0.001). Conclusion This study showed the benefits of restoring both mechanical and biological aspects when addressing nonunions of the long bones of the upper limb. In particular, the association of BMAC and PRF to lyophilized bone chips was safe and able to accelerate healing time. These good results were confirmed for humerus, radius, and ulna sites, as well as for challenging atrophic nonunions of the upper limb.
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Affiliation(s)
- Alessandro Mazzotta
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Cesare Stagni
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Martina Rocchi
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy. .,, Via di Casaglia 28, 40135, Bologna, Italy.
| | - Nicola Rani
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Nicolandrea Del Piccolo
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy
| | - Dante Dallari
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
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Periosteal and endosteal microcirculatory injury following excessive osteosynthesis. Injury 2021; 52 Suppl 1:S3-S6. [PMID: 33280891 DOI: 10.1016/j.injury.2020.11.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We examined the endosteal and periosteal circulations in a patient with fracture non-union who had undergone excessive osteosynthesis applications (two long plates had been placed medially and laterally on the left tibia extending from the proximal 2/7 to the distal 6/7 parts of the bone, while a tibial component of a total knee prosthesis with a long stem had been inserted at the same time). METHODS Concomitant perfusion changes were determined in the anterolateral and anteromedial periosteal sheath of the non-united bone ends and intramedullary nearest the osteosynthesis materials during their surgical removal on re-operation. The blood flow in the periosteum and endosteum was recorded by a laser-Doppler flowmetric device using a novel approach. Control measurements were made at identical points of the right tibia. RESULTS Considerably lower blood flow values were measured along the tibial periosteal region of the re-operated limb than on the contralateral side (the average perfusion unit (PU) was 76 vs. 106 PU, respectively). Perfusion values were markedly lower in the endosteal region (average values of approx. 30 PU) in the control tibia and were even more diminished in the re-operated tibial endosteum (average 9 PU). CONCLUSIONS Our study was conducted to characterize the microcirculatory changes of a long bone in response to intramedullary implantation and to provide quantitative data on the insufficiency of local perfusion in a patient with fracture non-union. Our results highlight the association between local perfusion failure and the unfavorable outcome (i.e. fracture non-union), confirming that the vital aspects of the microcirculation should not be disregarded when aiming for mechanical stability. Microcirculatory measurements constitute a new area of improvement in planning the adequate treatment for fracture non-unions with an unclear aetiology. Further refinement of the laser-Doppler technique could have potential benefits for bone surgery and postoperative trauma care in the future.
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倘 艳, 杨 玉, 李 红, 习 嘉, 叶 晔, 岳 辰, 刘 又. [Application of "diamond concept" in treatment of femoral shaft fractures nonunion after intramedullary fixation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1012-1017. [PMID: 32794671 PMCID: PMC8171911 DOI: 10.7507/1002-1892.201912028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/08/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effectiveness of the treatment under the guidance of "diamond concept" for femoral shaft fractures nonunion after intramedullary fixation. METHODS Between January 2014 and December 2016, 21 cases of femoral shaft fractures nonunion after intramedullary fixation were treated with auxiliary plate fixation combined with autogenous iliac graft, and autologous bone marrow concentrate and platelet-rich plasma (PRP) gel under the guidance of the "diamond concept". There were 13 males and 8 females, with an average age of 32.5 years (range, 17-48 years). All fractures were closed femoral shaft fractures. Four patients underwent internal fixation with plate and resulted in nonunion, then they were fixed with intramedullary nails, but did not heal either. The rest 17 patients were fixed with intramedullary nailing. Fracture nonunion classification: 4 cases of hypertrophic nonunion, 17 cases of atrophic nonunion; the length of bone defect was 1-3 mm; the duration from the last treatment to the current treatment was 10-23 months (mean, 14.3 months). The operation time, intraoperative blood loss, the time between operation and full loading, fracture healing time, and complications were recorded. The visual analogue scale (VAS) score and the imaging system of fracture healing of the extremities (RUST) of patients before operation and at last follow-up were recorded to evaluate the fracture healing; the function of the affected limb was evaluated according to the Schatzker-Lambert efficacy score standard at last follow-up. RESULTS The operation time was 105-160 minutes, with an average of 125.6 minutes; the intraoperative blood loss was 160-580 mL, with an average of 370.5 mL. All incisions healed by first intention, without vascular or nerve injury. All patients were followed up 22-46 months (mean, 26.5 months). All the fractures healed, with a fracture healing time of 3-7 months (mean, 4.8 months). During the follow-up, there was no infection, loosening, implant breakage, re-fracture, and other complications. The VAS score at last follow-up was 0.8±0.3, showing significant difference ( t=7.235, P=0.000) when compared with preoperative score (5.2±3.7); the RUST score was 3.4±0.3, which was significantly higher than the preoperative score (1.5±0.7) ( t=8.336, P=0.000). According to the Schatzker-Lambert effectiveness evaluation standard, the limb function was excellent in 16 cases, good in 4 cases, fair in 1 case, and the excellent and good rate was 95.42%. CONCLUSION Nonunion after intramedullary fixation of femoral fracture treated with auxiliary plate combined with autogenous iliac graft, autogenous bone marrow concentration and PRP gel in accordance with the "diamond concept" can not only restore the stability of the fracture ends, but also improves the biological environment of the fracture site, and can improve the rate of fracture healing.
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Affiliation(s)
- 艳锋 倘
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - 玉霞 杨
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - 红军 李
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - 嘉宁 习
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - 晔 叶
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - 辰 岳
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - 又文 刘
- 河南省洛阳正骨医院(河南省骨科医院)髋部损伤中心(河南洛阳 471002)Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
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Owston HE, Moisley KM, Tronci G, Russell SJ, Giannoudis PV, Jones E. Induced Periosteum-Mimicking Membrane with Cell Barrier and Multipotential Stromal Cell (MSC) Homing Functionalities. Int J Mol Sci 2020; 21:E5233. [PMID: 32718036 PMCID: PMC7432450 DOI: 10.3390/ijms21155233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/15/2022] Open
Abstract
The current management of critical size bone defects (CSBDs) remains challenging and requires multiple surgeries. To reduce the number of surgeries, wrapping a biodegradable fibrous membrane around the defect to contain the graft and carry biological stimulants for repair is highly desirable. Poly(ε-caprolactone) (PCL) can be utilised to realise nonwoven fibrous barrier-like structures through free surface electrospinning (FSE). Human periosteum and induced membrane (IM) samples informed the development of an FSE membrane to support platelet lysate (PL) absorption, multipotential stromal cells (MSC) growth, and the prevention of cell migration. Although thinner than IM, periosteum presented a more mature vascular system with a significantly larger blood vessel diameter. The electrospun membrane (PCL3%-E) exhibited randomly configured nanoscale fibres that were successfully customised to introduce pores of increased diameter, without compromising tensile properties. Additional to the PL absorption and release capabilities needed for MSC attraction and growth, PCL3%-E also provided a favourable surface for the proliferation and alignment of periosteum- and bone marrow derived-MSCs, whilst possessing a barrier function to cell migration. These results demonstrate the development of a promising biodegradable barrier membrane enabling PL release and MSC colonisation, two key functionalities needed for the in situ formation of a transitional periosteum-like structure, enabling movement towards single-surgery CSBD reconstruction.
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Affiliation(s)
- Heather E. Owston
- Clothworkers’ Centre for Textile Materials Innovation for Healthcare, School of Design, University of Leeds, Leeds LS2 9JT, UK; (G.T.); (S.J.R.)
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (K.M.M.); (P.V.G.); (E.J.)
- Institute of Medical and Biological Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Katrina M. Moisley
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (K.M.M.); (P.V.G.); (E.J.)
- Institute of Medical and Biological Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Giuseppe Tronci
- Clothworkers’ Centre for Textile Materials Innovation for Healthcare, School of Design, University of Leeds, Leeds LS2 9JT, UK; (G.T.); (S.J.R.)
- School of Dentistry, St. James’s University Hospital, University of Leeds, Leeds LS9 7TF, UK
| | - Stephen J. Russell
- Clothworkers’ Centre for Textile Materials Innovation for Healthcare, School of Design, University of Leeds, Leeds LS2 9JT, UK; (G.T.); (S.J.R.)
| | - Peter V. Giannoudis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (K.M.M.); (P.V.G.); (E.J.)
- Academic Department of Trauma & Orthopaedic Surgery, Leeds General Infirmary, Leeds LS2 9NS, UK
| | - Elena Jones
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS9 7TF, UK; (K.M.M.); (P.V.G.); (E.J.)
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Early efficacy evaluation of mesenchymal stromal cells (MSC) combined to biomaterials to treat long bone non-unions. Injury 2020; 51 Suppl 1:S63-S73. [PMID: 32139130 DOI: 10.1016/j.injury.2020.02.070] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/08/2020] [Accepted: 02/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND STUDY AIM Advanced therapy medicinal products (ATMP) frequently lack of clinical data on efficacy to substantiate a future clinical use. This study aims to evaluate the efficacy to heal long bone delayed unions and non-unions, as secondary objective of the EudraCT 2011-005441-13 clinical trial, through clinical and radiological bone consolidation at 3, 6 and 12 months of follow-up, with subgroup analysis of affected bone, gender, tobacco use, and time since the original fracture. PATIENTS AND METHODS Twenty-eight patients were recruited and surgically treated with autologous bone marrow derived mesenchymal stromal cells expanded under Good Manufacturing Practices, combined to bioceramics in the surgical room before implantation. Mean age was 39 ± 13 years, 57% were males, and mean Body Mass Index 27 ± 7. Thirteen (46%) were active smokers. There were 11 femoral, 4 humeral, and 13 tibial non-unions. Initial fracture occurred at a mean ± SD of 27.9 ± 31.2 months before recruitment. Efficacy results were expressed by clinical consolidation (no or mild pain if values under 30 in VAS scale), and by radiological consolidation with a REBORNE score over 11/16 points (value of or above 0.6875). Means were statistically compared and mixed models for repeated measurements estimated the mean and confidence intervals (95%) of the REBORNE Bone Healing scale. Clinical and radiological consolidation were analyzed in the subgroups with Spearman correlation tests (adjusted by Bonferroni). RESULTS Clinical consolidation was earlier confirmed, while radiological consolidation at 3 months was 25.0% (7/28 cases), at 6 months 67.8% (19/28 cases), and at 12 months, 92.8% (26/28 cases including the drop-out extrapolation of two failures). Bone biopsies confirmed bone formation surrounding the bioceramic granules. All locations showed similar consolidation, although this was delayed in tibial non-unions. No significant gender difference was found in 12-month consolidation (95% confidence). Higher consolidation scale values were seen in non-smoking patients at 6 (p = 0.012, t-test) and 12 months (p = 0.011, t-test). Longer time elapsed after the initial fracture did not preclude the occurrence of consolidation. CONCLUSION Bone consolidation was efficaciously obtained with the studied expanded hBM-MSCs combined to biomaterials, by clinical and radiological evaluation, and confirmed by bone biopsies, with lower consolidation scores in smokers.
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Abstract
PURPOSE To present our experience in the management of acute large bone defects treated with the use of vascularized fibular grafts supported by Ilizarov circular external frames. PATIENTS AND METHODS During a period of 6 years (from 2007 to 2013) 8 patients with acute large bone defects (IVB according to Winquist modified classification) were treated at our institution with early bone reconstruction by means of microvascular fibular grafts. All patients were evaluated by the use of the following parameters: X-ray consolidation, discharge time, duration of treatment, malalignment of the lower limb and final leg length discrepancy, knee and ankle mobility (ROM), pain (VAS), number of eventual additive treatments (plastic surgery, etc.), walking independence (use of crutches), possibility to get back to work, subjective evaluation about the treatment and the result (SF-36, personal feelings about circular external fixator dressing) RESULTS: The mean treatment time, often connected to the mean consolidation time, was 61 weeks and the mean number of operations was 7.6. Six of the eight patients got back to their previous daily activities and work, without any further issues. DISCUSSION based on our experience, Ilizarov and fibular vascular grafts are not alternatives, as often reported in literature. Their combined use, especially in lesions as those classified as Winquist IV B, can represent an effective tool in the surgeon's hands to solve the most difficult cases of acute bone loss caused by severe high-energy traumas.
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Affiliation(s)
- B Battiston
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy.
| | - D Santoro
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy
| | - R Lo Baido
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy
| | - F Pasquero
- Orthopaedic Dpt., Città della Salute e della Scienza, Torino, Italy
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Ciclamini D, Tos P, Guzzini M, Soldati A, Crosio A, Battiston B. The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study. Injury 2019; 50 Suppl 5:S54-S58. [PMID: 31711649 DOI: 10.1016/j.injury.2019.10.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments.
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Affiliation(s)
- Davide Ciclamini
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy
| | - Pierluigi Tos
- Microsurgery and Surgery of the Hand, Gaetano Pini Hospital, Milan, Italy
| | - Matteo Guzzini
- Orthopaedics and Traumatology Department, University of Rome "La Sapienza" - AO Sant'Andrea, Rome, Italy
| | - Alessandra Soldati
- Orthopaedics and Traumatology Department, Ospedale del Mare, Naples, Italy
| | - Alessandro Crosio
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy
| | - Bruno Battiston
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy.
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Raven TF, Moghaddam A, Ermisch C, Westhauser F, Heller R, Bruckner T, Schmidmaier G. Use of Masquelet technique in treatment of septic and atrophic fracture nonunion. Injury 2019; 50 Suppl 3:40-54. [PMID: 31378541 DOI: 10.1016/j.injury.2019.06.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of atrophic non-unions and large bone defects or infections remains a challenging task for the treating surgeon. In the herein study, we present our experience of the 'Masquelet technique' according to the 'diamond concept' for the treatment of complex long bone reconstruction procedures. METHODS Between February 2010 and March 2015, 150 patients (mean age 51.4) with atrophic and- /or infected non-unions were included in this prospective study. All patients received autologous bone graft, a graft expander (TCP (tricalcium phosphate)) and BMP (bone morphogenic protein). Clinical and radiological parameters were assessed at 6 weeks, and at 3, 6 and 12 months. The SF-12 questionnaire was used to evaluate the subjective health of patients. RESULTS A successful bony consolidation of the non-unions was observed in 120 (80%) cases with a median healing time of 12.1 months. The mean defect gap was 4.4cm. Initial infection was documented in 54 cases. The most frequently identified pathogen was staphylococcus epidermidis and staphylococcus aureus. A successful removal of microorganisms with subsequent healing was achieved in 39 cases (72%). The SF-12 scores of subjective physical and mental health increased from PCS 31.5 preoperatively to 36.7 one year postoperatively, while MCS increased from 45.5 to 48.7. CONCLUSIONS Our study showed that the Masquelet technique according to the 'diamond concept' is a valid method to treat complex atrophic non-unions with large bone defects and associated infection. Following the principles of the 'diamond concept' (targeted optimization of tissue engineering and bone regeneration) a high rate of success can be expected in these difficult reconstruction cases.
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Affiliation(s)
- T F Raven
- ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center for Trauma Surgery, Orthopaedics and Sports Medicine, Hospital Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany; HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany.
| | - A Moghaddam
- ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center for Trauma Surgery, Orthopaedics and Sports Medicine, Hospital Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany; HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - C Ermisch
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - F Westhauser
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - R Heller
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - T Bruckner
- Institute for Medical Biometry and Informatics, Im Neuenheimer Feld 130.3, D- 69120, Heidelberg, Germany
| | - G Schmidmaier
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
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11
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Andrzejowski P, Giannoudis PV. The 'diamond concept' for long bone non-union management. J Orthop Traumatol 2019; 20:21. [PMID: 30976944 PMCID: PMC6459453 DOI: 10.1186/s10195-019-0528-0] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/20/2019] [Indexed: 11/15/2022] Open
Abstract
Long bone non-union continues to be a significant worldwide problem. Since its inception over a decade ago, the ‘diamond concept’, a conceptual framework of what is essential for a successful bone healing response, has gained great acceptance for assessing and planning the management of fracture non-unions. Herein, we discuss the epidemiology of non-unions, the basic science of bone healing in the context of the diamond concept, the currently available results and areas for future research.
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Affiliation(s)
- Paul Andrzejowski
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK.
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