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Choi W, Kim BS, Cho WT, Lim EJ, Choi JS, Ryu YK, Cho JW, Sakong S, Oh JK. Efficacy and safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) combined with autologous bone for the treatment of long bone nonunion: A report of a prospective case series. Injury 2024; 55:111711. [PMID: 39003882 DOI: 10.1016/j.injury.2024.111711] [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: 02/05/2024] [Revised: 05/13/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Recombinant human Bone morphogenetic proteins have been used for the treatment of nonunions with promising results. We have been investigating both experimentally and clinically the efficacy of the rhBMP-2 with the macro / micro-porous hydroxyapatite carrier granules on the potency on the reconstruction of long bone defect. The purpose of this study was to prospectively evaluate the efficacy and safety of this specific rhBMP-2 with HA carrier granules mixed with autologous cancellous bone in patients with nonunion and bone defect resulted from the fracture related infection. MATERIALS AND METHODS This was a retrospective review of a prospective cohort at a university hospital. Patients diagnosed with nonunion under the definition of the United States Food and Drug Administration with bone defect after long bone fractures were enrolled from January 2020 to February 2021. We included patients with atrophic and oligotrophic nonunion, and hypertrophic nonunion with malalignment that needed to be corrected. The other patient group was consisted of segmental bone defect resulted from FRI. The maximum amount of rhBMP-2 allowed in this clinical study was 6 mg and was added to autologous bone at a 1:1 ratio. Autologous bone was added to the mixture if the volume of mixed graft was insufficient to fill the bone defect. Patients were followed 3, 6, and 12 months post-operatively. Each visit, a radiograph was taken for assessment. Visual analog scale (VAS), questionnaire for quality of life (SF-12 physical component summary [PCS], mental component summary [MCS]), and weight-bearing status were collected for functional outcome assessment. Drug safety was assessed by examining BMP-2 antibodies. RESULTS Of the 24 enrolled patients (mean age: 57 years), 15 (62.5 %), 2 (8.33 %), and 7 (29.17 %) presented atrophic nonunion, hypertrophic nonunion with deformity, and bone defect after fracture related infection, respectively. Thirteen patients had nonunion in the femur, 9 in the tibia, and 1 in the humerus and radius. The average amount of harvested autologous bone was 9.25 g and 4.96 mg of rhBMP-2. All 24 patients achieved union after 1-year follow up. The union rate was 95.83 % and 100 % at 6 and 12 months postoperatively, respectively. Preoperative SF-12 PCS (mean: 34.71) improved at 6 and 12 months postoperatively, respectively. Preoperative SF-12 MCS (mean: 42.89) improved 12 months postoperatively (49.13, p = 0.0338). Change of VAS was statistically significant 3 months postoperatively (p = 0.0012). No adverse effects or development of BMP-2 antibodies were observed. CONCLUSION BMP-2 combined with autogenous bone resulted in excellent radiographical and functional outcomes in a relatively small prospective series of patients with nonunion and bone defect, without adverse effects. Further investigations are necessary to support our finding and optimize treatment strategies in nonunion patients.
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Affiliation(s)
- Wonseok Choi
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopaedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Won-Tae Cho
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Kyungki, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Jeong Seok Choi
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Yun Ki Ryu
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Jae-Woo Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Seungyeob Sakong
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Kyungki, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea.
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Cho WT, Jang JH, Park SR, Sohn HS. Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing. Sci Rep 2024; 14:8364. [PMID: 38600312 PMCID: PMC11006881 DOI: 10.1038/s41598-024-59136-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/08/2024] [Indexed: 04/12/2024] Open
Abstract
This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.
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Affiliation(s)
- Won-Tae Cho
- Department of Orthopaedic Surgery, School of Medicine, Ajou University Hospital, Suwon, Republic of Korea
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, Dong-eui Hospital, Busan, Republic of Korea
| | - Seung Ryeol Park
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 162 Ilsan-dong, Wonju, 26426, Republic of Korea
| | - Hoon-Sang Sohn
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 162 Ilsan-dong, Wonju, 26426, Republic of Korea.
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Chandran M, Akesson KE, Javaid MK, Harvey N, Blank RD, Brandi ML, Chevalley T, Cinelli P, Cooper C, Lems W, Lyritis GP, Makras P, Paccou J, Pierroz DD, Sosa M, Thomas T, Silverman S. Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review. Osteoporos Int 2024:10.1007/s00198-024-07059-8. [PMID: 38587674 DOI: 10.1007/s00198-024-07059-8] [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: 10/10/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing. BACKGROUND Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing. METHODS Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT). RESULTS Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans. CONCLUSION Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.
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Affiliation(s)
- M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE NUS Medical School, Singapore, Singapore.
| | - K E Akesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - M K Javaid
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - N Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R D Blank
- Garvan Institute of Medical Research, Medical College of Wisconsin, Darlinghurst, NSW, Australia
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - M L Brandi
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Largo Palagi 1, Florence, Italy
| | - T Chevalley
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - P Cinelli
- Department of Trauma Surgery, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - C Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
| | - W Lems
- Department of Rheumatology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - G P Lyritis
- Hellenic Osteoporosis Foundation, Athens, Greece
| | - P Makras
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
| | - J Paccou
- Department of Rheumatology, MABlab ULR 4490, CHU Lille, Univ. Lille, 59000, Lille, France
| | - D D Pierroz
- International Osteoporosis Foundation, Nyon, Switzerland
| | - M Sosa
- University of Las Palmas de Gran Canaria, Investigation Group on Osteoporosis and Mineral Metabolism, Canary Islands, Spain
| | - T Thomas
- Department of Rheumatology, North Hospital, CHU Saint-Etienne and INSERM U1059, University of Lyon-University Jean Monnet, Saint‑Etienne, France
| | - S Silverman
- Cedars-Sinai Medical Center and Geffen School of Medicine UCLA, Los Angeles, CA, USA
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Dragosloveanu S, Petre MA, Gherghe ME, Baz RO, Cergan R, Scheau C. Elbow Reconstruction with Megaprosthesis: An Effective Strategy for Salvage Surgery in Trauma Patients. Diagnostics (Basel) 2024; 14:724. [PMID: 38611636 PMCID: PMC11011899 DOI: 10.3390/diagnostics14070724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/17/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Delayed fracture healing can have devastating functional consequences, including pseudoarthrosis. Many factors can contribute to delayed healing, including decreased vascularity, micro-motion at the fracture site, large fracture gaps, multiple traumas at the same site, compromised metabolic status, surgical complications, and other conditions. A 61-year-old female patient was referred to our hospital with left distal humeral pseudarthrosis, accompanied by chronic pain and disability. Two years prior, the patient suffered a traumatic incident. At another medical facility, the patient underwent open reduction and internal fixation surgery with simultaneous ulnar nerve transposition. She showed favorable postoperative recovery. Unfortunately, approximately one year later, the patient sustained a second trauma to the same arm. This led to peri-implant fracture and post-traumatic aseptic degradation of the osteosynthesis system which was subsequently removed. Twelve months after the last surgery, the patient was referred to our hospital and, after thorough consideration of the therapeutic options, we decided to perform left elbow arthroplasty with left distal humeral reconstruction by using Zimmer's Comprehensive Segmental Revision System. This approach is generally reserved for tumors, and only a handful of cases of megaprostheses for non-tumoral indications have been previously reported. The surgery and perioperative care of our patient were optimal, there were no complications, and the patient recovered arm functionality following rehabilitation.
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Affiliation(s)
- Serban Dragosloveanu
- Department of Orthopaedics and Traumatology, The “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Mihnea-Alexandru Petre
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Mihai Emanuel Gherghe
- Department of Orthopaedics, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Radu Octavian Baz
- Department of Radiology and Medical Imaging, Faculty of Medicine, “Ovidius” University, 900470 Constanta, Romania
- Department of Radiology, “Sf. Apostol Andrei” County Hospital, 900591 Constanta, Romania
| | - Romica Cergan
- Department of Anatomy, The “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Radiology and Medical Imaging, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
| | - Cristian Scheau
- Department of Radiology and Medical Imaging, “Foisor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, 021382 Bucharest, Romania
- Department of Physiology, The “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Ferrie L, Premnath P, Olsen A, Larijani L, Besler BA, Rancourt DE, Duncan NA, Underhill TM, Krawetz RJ. Exogenously delivered iPSCs disrupt the natural repair response of endogenous MPCs after bone injury. Sci Rep 2023; 13:9378. [PMID: 37296277 PMCID: PMC10256810 DOI: 10.1038/s41598-023-36609-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 06/07/2023] [Indexed: 06/12/2023] Open
Abstract
Promoting bone healing including fracture non-unions are promising targets for bone tissue engineering due to the limited success of current clinical treatment methods. There has been significant research on the use of stem cells with and without biomaterial scaffolds to treat bone fractures due to their promising regenerative capabilities. However, the relative roles of exogenous vs. endogenous stem cells and their overall contribution to in vivo fracture repair is not well understood. The purpose of this study was to determine the interaction between exogenous and endogenous stem cells during bone healing. This study was conducted using a standardized burr-hole bone injury model in a mesenchymal progenitor cell (MPC) lineage-tracing mouse under normal homeostatic and osteoporotic conditions. Burr-hole injuries were treated with a collagen-I biomaterial loaded with and without labelled induced pluripotent stem cells (iPSCs). Using lineage-tracing, the roles of exogenous and endogenous stem cells during bone healing were examined. It was observed that treatment with iPSCs resulted in muted healing compared to untreated controls in intact mice post-injury. When the cell populations were examined histologically, iPSC-treated burr-hole defects presented with a dramatic reduction in endogenous MPCs and cell proliferation throughout the injury site. However, when the ovaries were removed and an osteoporotic-like phenotype induced in the mice, iPSCs treatment resulted in increased bone formation relative to untreated controls. In the absence of iPSCs, endogenous MPCs demonstrated robust proliferative and osteogenic capacity to undertake repair and this behaviour was disrupted in the presence of iPSCs which instead took on an osteoblast fate but with little proliferation. This study clearly demonstrates that exogenously delivered cell populations can impact the normal function of endogenous stem/progenitor populations during the normal healing cascade. These interactions need to be better understood to inform cell and biomaterial therapies to treat fractures.
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Affiliation(s)
- Leah Ferrie
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
| | - Priyatha Premnath
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- College of Engineering and Applied Science, University of Wisconsin Milwaukee, Milwaukee, WI, USA
| | - Alexandra Olsen
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
| | - Leila Larijani
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryce A Besler
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
| | - Derrick E Rancourt
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Neil A Duncan
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
- Department of Civil Engineering, Schulich School of Engineering, University of Calgary, Calgary, AB, Canada
| | - T Michael Underhill
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Roman J Krawetz
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada.
- Department of Cell Biology and Anatomy, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Tjandra KC, Novriansyah R, Limijadi EKS, Kuntjoro L, Hendrianingtyas M. The effect of green mussel ( Perna viridis) shells' hydroxyapatite application on alkaline phosphatase levels in rabbit femur bone defect. F1000Res 2023; 12:631. [PMID: 38915771 PMCID: PMC11195609 DOI: 10.12688/f1000research.132881.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/26/2024] Open
Abstract
Background: A non-union fracture is one of the most common complications arising from an untreated fracture. Bone grafts are able to fasten bone healing which can prevent and cure non-union fractures. Therefore, alternative hydroxyapatite bone grafts from waste resources are needed to increase the availability of bone grafts in the healthcare system. A bone substitute, hydroxyapatite (HA), has the ability to prevent non-union fractures. Green mussel shell contains 95.69 percent HA, allowing for an annual production of 133.97-287.07 tons per ha of HA, and is a potent alternative material in the manufacture of HA. Methods: This research was conducted for four months using a true experimental research method with a post-test-only control group design. This study used 36 New Zealand rabbits ( Oryctolagus cuniculus) which were divided into 9 groups: positive control, negative control, and intervention at weeks 2, 4 and 6 after the intervention. All groups were subjected to three general procedures: pre-surgery, surgery, and post-surgery. Results: The findings demonstrated that green mussel shell HA has efficacy in accelerating bone healing, better than HA bovine, as compared to the 6-week negative control group and demonstrated a significant difference ( p< 0.05). Conclusions: Green mussel hydroxyapatite is proven to be able to fasten and maximize the bone healing process as fast as bovine HA, and even has higher efficacy than bovine HA.
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Affiliation(s)
- Kevin Christian Tjandra
- Kariadi General Hospital, Semarang, Indonesia
- Department of Medicine, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Robin Novriansyah
- Kariadi General Hospital, Semarang, Indonesia
- Department of Surgery, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Edward Kurnia Setiawan Limijadi
- Kariadi General Hospital, Semarang, Indonesia
- Department of Clinical Pathology, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Lydia Kuntjoro
- Kariadi General Hospital, Semarang, Indonesia
- Department of Radiology, Medical Faculty, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Meita Hendrianingtyas
- Kariadi General Hospital, Semarang, Indonesia
- Department of Clinical Pathology, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
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Kook I, Park KC, Kim DH, Sohn OJ, Hwang KT. A multicenter study of factors affecting nonunion by radiographic analysis after intramedullary nailing in segmental femoral shaft fractures. Sci Rep 2023; 13:7802. [PMID: 37179404 PMCID: PMC10183035 DOI: 10.1038/s41598-023-34939-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 05/10/2023] [Indexed: 05/15/2023] Open
Abstract
The factors affecting the outcomes of segmental femoral shaft fractures are currently unknown. We evaluated the outcomes of intramedullary (IM) nail fixation and investigated factors affecting nonunion of femoral shaft segmental fractures. A total of 38 patients who underwent IM nail fixation for femoral shaft segmental fractures (AO/OTA 32C2) at three university hospitals with a minimum 1-year follow-up period were retrospectively reviewed. The patients were divided into union (n = 32) and nonunion (n = 6) groups. We analyzed smoking status, diabetes mellitus, location of the segmental fragment, segment comminution, filling of the IM nail in the medullary canal, residual gap at the fracture site, use of a cerclage wire or blocking screws as factors that may affect the surgical outcome. In the union group, the average union time was 5.4 months (4-9 months). In the nonunion group, five patients required additional surgery within an average of 7.2 months (5-10 months) postoperatively, whereas one patient remained asymptomatic and did not require further intervention. On comparing the two groups, insufficient canal filling of the IM nail (union, 25.0%; nonunion, 83.3%; p = 0.012) and the presence of a residual gap at the fracture site after reduction (union, 31.3%; nonunion, 83.3%; p = 0.027) were significantly different. In the multivariate analysis, only insufficient canal filling of the IM nail was found to be a factor affecting nonunion, with an odds ratio of 13.3 (p = 0.036). In this study, a relatively high nonunion rate (15.8%) was observed after IM nail fixation. Insufficient IM nail canal filling and a residual gap at the fracture site post reduction were factors affecting segmental femoral shaft fracture nonunion after IM nail fixation.
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Affiliation(s)
- Incheol Kook
- Department of Orthopaedic Surgery, Hanyang University Hospital, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Ki-Chul Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri-si, Gyeonggi-do, Republic of Korea
| | - Dong-Hong Kim
- Department of Orthopaedic Surgery, Hanyang University Hospital, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Oog-Jin Sohn
- Department of Orthopaedic Surgery, Yeungnam University Hospital, 170 Hyeonchung-ro, Nam-gu, Daegu, Republic of Korea
| | - Kyu Tae Hwang
- Department of Orthopaedic Surgery, Hanyang University Hospital, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Sparks DS, Savi FM, Dlaska CE, Saifzadeh S, Brierly G, Ren E, Cipitria A, Reichert JC, Wille ML, Schuetz MA, Ward N, Wagels M, Hutmacher DW. Convergence of scaffold-guided bone regeneration principles and microvascular tissue transfer surgery. SCIENCE ADVANCES 2023; 9:eadd6071. [PMID: 37146134 PMCID: PMC10162672 DOI: 10.1126/sciadv.add6071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
A preclinical evaluation using a regenerative medicine methodology comprising an additively manufactured medical-grade ε-polycaprolactone β-tricalcium phosphate (mPCL-TCP) scaffold with a corticoperiosteal flap was undertaken in eight sheep with a tibial critical-size segmental bone defect (9.5 cm3, M size) using the regenerative matching axial vascularization (RMAV) approach. Biomechanical, radiological, histological, and immunohistochemical analysis confirmed functional bone regeneration comparable to a clinical gold standard control (autologous bone graft) and was superior to a scaffold control group (mPCL-TCP only). Affirmative bone regeneration results from a pilot study using an XL size defect volume (19 cm3) subsequently supported clinical translation. A 27-year-old adult male underwent reconstruction of a 36-cm near-total intercalary tibial defect secondary to osteomyelitis using the RMAV approach. Robust bone regeneration led to complete independent weight bearing within 24 months. This article demonstrates the widely advocated and seldomly accomplished concept of "bench-to-bedside" research and has weighty implications for reconstructive surgery and regenerative medicine more generally.
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Affiliation(s)
- David S Sparks
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Southside Clinical Division, School of Medicine, University of Queensland, Woolloongabba, QLD, Australia
| | - Flavia M Savi
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Constantin E Dlaska
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Siamak Saifzadeh
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane, QLD, Australia
- Medical Engineering Research Facility, Queensland University of Technology, Chermside, QLD, Australia
| | - Gary Brierly
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Edward Ren
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Amaia Cipitria
- Department of Biomaterials, Max Planck Institute of Colloids and Interfaces, Potsdam, Germany
- Biodonostia Health Research Institute, San Sebastian, Spain
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Johannes C Reichert
- Department of Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, Greifswald, Germany
| | - Marie-Luise Wille
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Michael A Schuetz
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane, QLD, Australia
- Jamieson Trauma Institute, Royal Brisbane Hospital, Herston, QLD, Australia
| | - Nicola Ward
- Department of Orthopaedics, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Michael Wagels
- Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Southside Clinical Division, School of Medicine, University of Queensland, Woolloongabba, QLD, Australia
- Australian Centre for Complex Integrated Surgical Solutions (ACCISS), Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Dietmar W Hutmacher
- Centre for Biomedical Technologies, School of Mechanical, Medical, and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Additive Biomanufacturing, Queensland University of Technology, Kelvin Grove, QLD, Australia
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Wen Q, Gu F, Su Z, Zhang K, Xie X, Li J, Sui Z, Yu T. Gamma Nail Combined with One Cannulated Compression Screw Fixation for Treating Pauwels Type III Femoral Neck Fractures in Young and Middle-Aged Adults: Clinical Follow-Up and Biomechanical Studies. Orthop Surg 2023; 15:1045-1052. [PMID: 36846936 PMCID: PMC10102304 DOI: 10.1111/os.13683] [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: 05/15/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE Recently, some clinical studies have reported the use of an intramedullary nailing system for treating unstable femoral neck fractures or femoral neck fractures combined with femoral shaft fractures in young adults, and the results have indicated certain advantages. However, no study has investigated the mechanical properties of this method. We aimed to evaluate the mechanical stability and clinical efficacy of the Gamma nail combined with one cannulated compression screw (CCS) fixation for treating Pauwels type III femoral neck fracture in young and middle-aged adults. METHODS This study consists of two parts: a clinical retrospective study and randomized controlled biomechanical test. Twelve adult cadaver femora were used to test and compare the biomechanical properties among three fixation methods: three parallel CCS (group A), Gamma nail (group B), and Gamma nail combined with one cannulated compression screw (group C). The single continuous compression test, cyclic load test, and ultimate vertical load test were used to evaluate the biomechanical performance of the three fixation methods. We also conducted a retrospective study of 31 patients with Pauwels type III femoral neck fractures, including 16 patients with fractures fixed with three parallel CCS (CCS group) and 15 patients with fractures fixed with Gamma nail combined with one CCS (Gamma nail + CCS group). The patients were followed up for at least 3 years, and all were evaluated for surgical time (from skin incision to closure), surgical blood loss, hospital stay, and the Harris hip score. RESULTS In mechanical experiments, we have found that the mechanical advantages of Gamma nail fixation are not as good as those of conventional CCS fixation. However, the mechanical properties of Gamma nail fixation combined with one cannulated screw perpendicular to the fracture line are much better than those of Gamma nail fixation and CCS fixation. No significant difference was found in the incidence of femoral head necrosis and nonunion between the CCS and Gamma nail + CCS groups. Moreover, there was no statistically significant difference in the Harris hip scores between the two groups. One patient in the CCS group showed significant withdrawal of cannulated screws at 5 months after surgery, whereas in the Gamma nail + CCS group, all patients, including those with femoral neck necrosis, showed no loss of stability of the fixation. CONCLUSION Among the two fixation methods evaluated in this study, Gamma nail combined with one CCS fixation showed better biomechanical properties and may reduce complications associated with unstable fixation devices.
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Affiliation(s)
- Qiangqiang Wen
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China.,Department of Orthopedics, Xi'an No.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, Shaanxi, China
| | - Feng Gu
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
| | - Zilong Su
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
| | - Ke Zhang
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
| | - Xiaoping Xie
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
| | - Jiangbi Li
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
| | - Zhenjiang Sui
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
| | - Tiecheng Yu
- Department of Orthopedics, First Hospital of Jilin University, changchun, jilin, China
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10
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Smolinska V, Csobonyeiova M, Zamborsky R, Danisovic L. Stem Cells and Their Derivatives: An Implication for the Regeneration of Nonunion Fractures. Cell Transplant 2023; 32:9636897231183530. [PMID: 37462248 PMCID: PMC10363876 DOI: 10.1177/09636897231183530] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Despite advances in biomedical research, fracture nonunion rates have remained stable throughout the years. Long-bone fractures have a high likelihood of nonunion, but the specific biological pathways involved in this severe consequence are unknown. Fractures often heal in an organized sequence, including the production of a hematoma and an early stage of inflammation, the development of a soft callus and hard callus, and eventually the stage of bone remodeling. Deficient healing can result in a persistent bone defect with instability, discomfort, and loss of function. In the treatment of nonunions, mesenchymal stem cells (MSCs) prove to be a promising and safe alternative to the standard therapeutic strategies. Moreover, novel scaffolds are being created in order to use a synergistic biomimetic technique to rapidly generate bone tissue. MSCs respond to acellular biomimetic matrices by regenerating bone. Extracellular vesicles (EVs) derived from MSCs have recently gained interest in the field of musculoskeletal regeneration. Although many of these techniques and technologies are still in the preclinical stage and have not yet been approved for use in humans, novel approaches to accelerate bone healing via MSCs and/or MSC derivatives have the potential to reduce the physical, economic, and social burdens associated with nonhealing fractures and bone defects. In this review, we focus on providing an up-to-date summary of recent scientific studies dealing with the treatment of nonunion fractures in clinical and preclinical settings employing MSC-based therapeutic techniques.
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Affiliation(s)
- Veronika Smolinska
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
- National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Maria Csobonyeiova
- National Institute of Rheumatic Diseases, Piestany, Slovakia
- Institute of Histology and Embryology, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Radoslav Zamborsky
- National Institute of Rheumatic Diseases, Piestany, Slovakia
- Department of Orthopaedics, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
- National Institute of Children's Diseases, Bratislava, Slovakia
- Centre for Tissue Engineering and Regenerative Medicine-Translational Research Unit, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Lubos Danisovic
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
- National Institute of Rheumatic Diseases, Piestany, Slovakia
- Centre for Tissue Engineering and Regenerative Medicine-Translational Research Unit, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
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11
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Munk SA, Harsevoort GJ, Gooijer K, Edens MA, Franken AA, Janus GJM. Incidence and nonunion rates of tibial fractures in adults with osteogenesis imperfecta: a retrospective cohort study of 402 patients with 42 fractures at an expert clinic. BMC Musculoskelet Disord 2022; 23:1077. [PMID: 36482324 PMCID: PMC9732987 DOI: 10.1186/s12891-022-05966-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 11/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Tibial fractures are the most common fractures seen in adults and lead to the most nonunions. Osteogenesis imperfecta (OI) is characterized by increased bone fragility and higher risk of fractures. No studies have been published on the incidence of tibial fractures and nonunions in adults with OI. This study aims to summarize the incidence of tibial fractures and nonunions in this population. METHODS A retrospective, descriptive study. All medical charts of adult patients in the OI database of our OI expert clinic were analyzed for tibial fractures between 2008 and 2020. Tibial fracture incidence, nonunion rate, treatment modality and potential risk factors were determined. RESULTS The database consisted of 402 patients, 34 of whom had suffered one or more tibial fractures, resulting in 42 fractures. The incidence of tibial fractures in adults with OI is 870 per 100,000 person-years. Two out of 42 fractures led to nonunion (5%). It was not possible to adjust for risk factors or type of treatment. CONCLUSION There is a higher incidence of tibial fractures in patients with OI, but a nonunion rate comparable to the general population. With only two nonunions it is not possible to draw conclusions on the influence of risk factors or treatment of tibial fractures on OI.
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Affiliation(s)
- Simone Amber Munk
- grid.452600.50000 0001 0547 5927Department of Orthopedic Surgery, Isala, Zwolle, The Netherlands
| | - Gerrit Jan Harsevoort
- grid.452600.50000 0001 0547 5927Department of Orthopedic Surgery, Isala, Zwolle, The Netherlands
| | - Koert Gooijer
- grid.452600.50000 0001 0547 5927Department of Orthopedic Surgery, Isala, Zwolle, The Netherlands
| | - Mireille Angélique Edens
- grid.452600.50000 0001 0547 5927Epidemiology Unit, Department Innovation and Science, Isala, Zwolle, The Netherlands
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12
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Lu Y, Sun L, Wang Q, Ren C, Xu Y, Ye H, Li M, Xue H, Huang Q, Li Z, Zhang K, Ma T. Osteoperiosteal decortication and bone grafting combined with wave plating for femoral shaft aseptic atrophic nonunion after intramedullary nailing. J Int Med Res 2022; 50:3000605221139667. [PMID: 36447128 PMCID: PMC9716611 DOI: 10.1177/03000605221139667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Femoral shaft nonunion after intramedullary nailing fixation remains a challenge for orthopedic surgeons. This study evaluated osteoperiosteal decortication and iliac bone grafting combined with wave plating as a treatment for aseptic atrophic nonunion of the femoral shaft after intramedullary nailing. METHODS The study included 22 patients (two female, 20 male; mean age 40.8 years [range, 19-61]) with aseptic atrophic nonunion of the femoral shaft who underwent osteoperiosteal decortication and iliac bone grafting combined with wave plating between January 2016 and January 2020. Cases with infected nonunion, hypertrophic nonunion, and nonunion after plate osteosynthesis were excluded. Clinical outcomes were assessed retrospectively using the Samantha X-ray and Paley scale scores. RESULTS The mean follow-up period was 18.8 months (range, 12-35). Bone union was achieved in all patients. The average clinical healing time was 5.7 months (range, 3-14). The mean Samantha X-ray score was 5.7 ± 0.45 and the Paley scores indicated excellent or good clinical results in all cases. One patient developed sterile wound leakage that resolved after a dressing change. CONCLUSIONS Osteoperiosteal decortication and bone grafting combined with wave plating is an excellent treatment for aseptic atrophic nonunion of the femoral shaft after intramedullary nailing.
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Affiliation(s)
- Yao Lu
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Liang Sun
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Qian Wang
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Cheng Ren
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Yibo Xu
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Haobo Ye
- Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Ming Li
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Hanzhong Xue
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Zhong Li
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Kun Zhang
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Teng Ma
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China,Teng Ma, Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, 555 Youyi East Road, Xi’an, Shaanxi Province 710054, China.
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13
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No difference in clinical and radiological outcomes following fixation of transverse patella fractures with either suture tape or metallic cerclage: A retrospective comparative study. Orthop Traumatol Surg Res 2022; 108:103053. [PMID: 34530129 DOI: 10.1016/j.otsr.2021.103053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/14/2021] [Accepted: 03/22/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Several surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HYPOTHESIS The hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-operation than metallic cerclage but no differences in other clinical outcomes. PATIENTS AND METHODS A retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months postoperatively to evaluate clinical scores and complications. RESULTS A total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at 2 months postoperatively due to painful prominence. There was no significant difference in re-operation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of fixation throughout the series. At the final clinical follow-up of 18months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. CONCLUSION No significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. LEVEL OF EVIDENCE III.
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14
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Ull C, Ehlers H, Yilmaz E, Lotzien S, Schildhauer TA, Reinke C, Kruppa C. Injuries after Forklift Trucks Accidents - Injury Patterns, Therapy and Outcome in the Context of the Statutory Accident Insurance. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:539-548. [PMID: 33873228 DOI: 10.1055/a-1402-1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The use of forklift trucks during work has a high accident potential. The aim of this study is to describe injury patterns, treatment and outcome after forklift truck accidents in the context of the employers' liability insurance association. METHODS Retrospective data collection of all cases between 2004 and 2019. Excluded were patients < 18 years, without follow-up or with definitive external treatment. Trauma mechanism, injury patterns and distribution, treatment, complications, time of incapacity for work, return to work and impairment of earning capacity were recorded. RESULTS Of 109 patients with 110 injuries, 52.7% showed isolated injuries and 47.3% combined injuries, which affected the lower extremity in 95 cases. There were fractures in 85.5%, including 32.7% in open form. The mean length of stay was 29.1 days (range 1 - 129); an indication for surgery was seen in 80.9%. Surgical treatment required an average of 3 interventions, with significantly more operations for soft tissue closure than for the fractures (p ≤ 0.023). Amputations were necessary in 8 cases; complications occurred in 29.1%. Return to work was possible in 90%, after a mean period of incapacity for work of 33.6 weeks. A total of 40% showed a pensionable impairment of earning capacity. CONCLUSION Accidents with forklift trucks result in complex lower extremities injuries with the need of multi-stage treatment and show relatively high complication rates. A return to work is often possible after a long period of convalescence, and a pensionable impairment of earning capacity often persists.
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Affiliation(s)
- Christopher Ull
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany
| | - Hans Ehlers
- Department of Anaesthesiologie Intensive Care Palliative Medicine and Pain Medicine, BG University Hospital, Bochum, Germany
| | - Emre Yilmaz
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany
| | - Sebastian Lotzien
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany
| | - Charlotte Reinke
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany
| | - Christiane Kruppa
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany
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Marshall WG, Filliquist B, Tzimtzimis E, Fracka A, Miquel J, Garcia J, Fontana MD. Delayed union, non-union and mal-union in 442 dogs. Vet Surg 2022; 51:1087-1095. [PMID: 36053918 PMCID: PMC9804201 DOI: 10.1111/vsu.13880] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/23/2022] [Accepted: 08/08/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES (1) To estimate the prevalence of delayed union, non-union and mal-union in canine fractures; (2) to describe fracture, demographic, and treatment characteristics for these outcomes; (3) to identify risk factors for delayed or non-union. STUDY DESIGN Retrospective study. SAMPLE POPULATION Four hundred and forty two dogs (461 fractures). METHODS A review was conducted of clinical records and radiographs from 2 teaching hospitals. "Union," "delayed union," "non-union" and "mal-union" were defined, and fracture, demographic, treatment, and outcome variables described. Differences in proportions or medians between "union," "delayed union" and "non-union" were tested using χ2 and Mann-Whitney U-tests for categorical and continuous variables respectively. Potential explanatory variables for "delayed or non-union" were tested using logistic regression to identify risk factors. RESULTS Median radiographic follow up was 53 days (14-282). Delayed union occurred in 13.9% of fractures (64/461), non-union in 4.6% (21/461), and mal-union in 0.7% (3/461). Risk factors for delayed or non-union were age (OR 1.21, 95% CI 1.12-1.31); comminuted fracture (OR 4.24, 95% CI 2.4-7.5); treatment with bone graft (all types) (OR 3.32, 95% CI 1.3-8.5); surgical site infection (OR 3.24, 95% CI 1.17-8.97), and major implant failure (OR 12.94, 95% CI 5.06-33.1). CONCLUSION Older dogs, dogs with comminuted fractures, surgical site infection, or major implant failure were at increased odds of delayed or non-union. Radius and ulna fractures in toy breed dogs were not at increased odds of delayed or non-union. CLINICAL SIGNIFICANCE The identified risk factors should inform fracture planning and prognosticating. The prognosis for radial fractures in toy breeds appears better than historically believed.
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Affiliation(s)
| | - Barbro Filliquist
- Department of Surgical and Radiological Sciences, School of Veterinary MedicineUniversity of California DavisDavisCaliforniaUSA
| | - Emmanouil Tzimtzimis
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Agnieszka Fracka
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Jose Miquel
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Javier Garcia
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Maria Dalla Fontana
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
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Shapiro JA, Stillwagon MR, Tornetta P, Seaver TM, Gage M, O’Donnell J, Whitlock K, Yarboro SR, Jeray KJ, Obremskey WT, Rodriguez-Buitrago A, Matuszewski P, Lin FC, Ostrum RF. Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients. J Am Acad Orthop Surg 2022; 30:e1179-e1187. [PMID: 36166389 PMCID: PMC9521813 DOI: 10.5435/jaaos-d-21-00366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/20/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.
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Affiliation(s)
| | | | | | | | - Mark Gage
- Duke University Department of Orthopaedic Surgery
| | | | | | | | - Kyle J. Jeray
- Greenville Health System Department of Orthopaedic Surgery
| | | | | | - Paul Matuszewski
- University of Kentucky Department of Orthopaedic Surgery and Sports Medicine
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Sun J, Li Q, Wang S, Wang G, Zhao J, Li H, Liu C, Shi Y, Li Z, Yu H. Establishment and Evaluation of a Rat Model of Medial Malleolar Fracture with Vascular Injury. Orthop Surg 2022; 14:2701-2710. [PMID: 36098492 PMCID: PMC9531110 DOI: 10.1111/os.13455] [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: 08/19/2021] [Revised: 07/12/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objective A stable animal model was needed to study bone non‐union caused by insufficient blood supply, the main object of this paper is to develop a medial malleolar fracture model with controllable arterial vascular injuries in rats for revealing the biochemical mechanism of non‐union by insufficient blood supply. Methods A total of 18 rats were randomly divided into three equal groups: the Sham group, the Fracture group, and the Fracture + Vascular group. The animals were subjected to unilateral medial malleolar bone fracture and vascular injury using customized molding equipment. The fracture site was scanned by micro‐CT, and vascular injury was evaluated by laser Doppler flowmetry (LDF) 24 h after modeling. Histological examination (HE), alkaline phosphatase (ALP) and tartrate‐resistant acid phosphatase (TRAP) staining, immunohistochemistry and immunofluorescence were conducted on the medial malleolar fracture tissues of three rats randomly selected from each group 24 h after modeling. Subsequently, to further confirm the success of fracture modeling, the fracture sites of three other rats in each group underwent micro‐CT scanning again 6 weeks after surgery. Results The results of a 24 h micro‐CT showed that all rats used to create the fracture models showed controlled injury of the medial malleolus. The model was stable, and the satisfaction of the homemade equipment agreed with the expectation. LDF showed that the blood flow of rats in the Fracture + Vascular group decreased significantly 24 h after fracture injury, while collateral blood flow perfusion increased by 50% on average. The results of HE, ALP and TRAP staining in the medial malleolus showed that the number of osteoblasts (OBs) and osteoclasts (OCs) in the Fracture group increased significantly, but the number of OBs and OCs in the Fracture + Vascular group decreased sharply relative to the number in the Sham group 24 h later. Furthermore, immunohistochemistry and immunofluorescence results showed that the number of neovessels in the Fracture group was significantly increased, while the number of neovessels in the Fracture + Vascular group was significantly decreased, which was consistent with the above results. After 6 weeks of modeling, the micro‐CT results showed that the fractures in the Fracture group had healed substantially, while those in the Fracture + Vascular group had not. Conclusion This study provided a reproducible and stable experimental animal model for medial malleolar fractures with arterial injury.
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Affiliation(s)
- Jinglai Sun
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China
| | - Qifeng Li
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China
| | - Shuo Wang
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Academy of Medical Engineering and Translation Medicine, Tianjin University, Tianjin, China
| | - Guangpu Wang
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China
| | - Jing Zhao
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China
| | - Huanming Li
- Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Department of Cardiovascular, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Chong Liu
- Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Department of Central Laboratory, Tianjin 4TH Centre Hospital, Tianjin, China.,Department of Anesthesiology, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Yifan Shi
- Department of Imaging, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Zhigang Li
- Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Department of Emergency Medicine, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Hui Yu
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Academy of Medical Engineering and Translation Medicine, Tianjin University, Tianjin, China
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Ditsios K, Chitas K, Christidis P, Charatsis K, Katsimentzas T, Papadopoulos P. Necrotizing Fasciitis of the Upper Extremity – A Review. Orthop Rev (Pavia) 2022; 14:35320. [DOI: 10.52965/001c.35320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/29/2022] [Indexed: 11/06/2022] Open
Abstract
Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.
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Affiliation(s)
- Konstantinos Ditsios
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Gennimatas”, Greece
| | - Konstantinos Chitas
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Gennimatas”, Greece
| | | | - Konstantinos Charatsis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Gennimatas”, Greece
| | - Triantafyllos Katsimentzas
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Gennimatas”, Greece
| | - Pericles Papadopoulos
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Gennimatas”, Greece
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Perioperative Radiographic Predictors of Non-Union in Infra-Isthmal Femoral Shaft Fractures after Antegrade Intramedullary Nailing: A Case-Control Study. J Clin Med 2022; 11:jcm11133664. [PMID: 35806947 PMCID: PMC9267532 DOI: 10.3390/jcm11133664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
Antegrade intramedullary (IM) nailing is the gold standard treatment for femoral shaft fractures; however, the non-union rate of infra-isthmal femoral shaft fractures is still high after antegrade IM nailing. This retrospective case−control study aimed to determine the association between perioperative radiographic factors and the non-union of infra-isthmal femoral shaft fractures after antegrade IM nailing. Univariate and multivariate analyses were used to evaluate the radiographic risk factors of non-union. Ninety-three patients were included, with thirty-one non-unions and sixty-two matched controls between 2007 and 2017. All were regularly followed up for 2 years. Receiver operating characteristic analysis revealed that a ratio of the unfixed distal segment > 32.5% was strongly predictive of postoperative non-union. The risk factors for non-union were AO/OTA type B and C (odds ratio [OR]: 2.20), a smaller ratio of the distal fragment (OR: 4.05), a greater ratio of the unfixed distal segment (OR: 7.16), a higher ratio of IM canal diameter to nail size at the level of fracture (OR: 6.23), and fewer distal locking screws (OR: 2.31). The radiographic risk factors for non-union after antegrade IM nailing for infra-isthmal femoral shaft fractures were unstable fractures, shorter distal fragments, longer unfixed distal fragments, wider IM canal, and fewer distal locking screws. Surgeons must strive to avoid non-union with longer and larger nails and apply more distal locking screws, especially for unstable, wider IM canal, and shorter distal fragment fractures.
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Cohn-Schwartz D, Schary Y, Yalon E, Krut Z, Da X, Schwarz EM, Gazit D, Pelled G, Gazit Z. PTH-Induced Bone Regeneration and Vascular Modulation Are Both Dependent on Endothelial Signaling. Cells 2022; 11:cells11050897. [PMID: 35269519 PMCID: PMC8909576 DOI: 10.3390/cells11050897] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/10/2022] Open
Abstract
The use of a bone allograft presents a promising approach for healing nonunion fractures. We have previously reported that parathyroid hormone (PTH) therapy induced allograft integration while modulating angiogenesis at the allograft proximity. Here, we hypothesize that PTH-induced vascular modulation and the osteogenic effect of PTH are both dependent on endothelial PTH receptor-1 (PTHR1) signaling. To evaluate our hypothesis, we used multiple transgenic mouse lines, and their wild-type counterparts as a control. In addition to endothelial-specific PTHR1 knock-out mice, we used mice in which PTHR1 was engineered to be constitutively active in collagen-1α+ osteoblasts, to assess the effect of PTH signaling activation exclusively in osteoprogenitors. To characterize resident cell recruitment and osteogenic activity, mice in which the Luciferase reporter gene is expressed under the Osteocalcin promoter (Oc-Luc) were used. Mice were implanted with calvarial allografts and treated with either PTH or PBS. A micro-computed tomography-based structural analysis indicated that the induction of bone formation by PTH, as observed in wild-type animals, was not maintained when PTHR1 was removed from endothelial cells. Furthermore, the induction of PTH signaling exclusively in osteoblasts resulted in significantly less bone formation compared to systemic PTH treatment, and significantly less osteogenic activity was measured by bioluminescence imaging of the Oc-Luc mice. Deletion of the endothelial PTHR1 significantly decreased the PTH-induced formation of narrow blood vessels, formerly demonstrated in wild-type mice. However, the exclusive activation of PTH signaling in osteoblasts was sufficient to re-establish the observed PTH effect. Collectively, our results show that endothelial PTHR1 signaling plays a key role in PTH-induced osteogenesis and has implications in angiogenesis.
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Affiliation(s)
- Doron Cohn-Schwartz
- Department of Internal Medicine B, Division of Internal Medicine, Rambam Healthcare Campus, Haifa 3109601, Israel;
- Skeletal Biotech Laboratory, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel; (Y.S.); (E.Y.); (D.G.); (G.P.)
| | - Yeshai Schary
- Skeletal Biotech Laboratory, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel; (Y.S.); (E.Y.); (D.G.); (G.P.)
| | - Eran Yalon
- Skeletal Biotech Laboratory, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel; (Y.S.); (E.Y.); (D.G.); (G.P.)
| | - Zoe Krut
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Xiaoyu Da
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | - Edward M. Schwarz
- The Center for Musculoskeletal Research, Department of Orthopaedics, School of Medicine & Dentistry, University of Rochester, Rochester, NY 14642, USA;
| | - Dan Gazit
- Skeletal Biotech Laboratory, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel; (Y.S.); (E.Y.); (D.G.); (G.P.)
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Gadi Pelled
- Skeletal Biotech Laboratory, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel; (Y.S.); (E.Y.); (D.G.); (G.P.)
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Zulma Gazit
- Skeletal Biotech Laboratory, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel; (Y.S.); (E.Y.); (D.G.); (G.P.)
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Correspondence:
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Landrino M, Alberio RL, Clemente A, Grassi FA. The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review. Orthop Rev (Pavia) 2022; 14:37889. [PMID: 36213618 PMCID: PMC9534743 DOI: 10.52965/001c.37889] [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] [Indexed: 02/05/2023] Open
Abstract
Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.
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Affiliation(s)
- Marco Landrino
- Department of Health Sciences, University of East Piedmont, Novara (Italy)
| | | | - Alice Clemente
- Department of Health Sciences, University of East Piedmont, Novara (Italy)
| | - Federico Alberto Grassi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia (Italy); IRCCS Hospital San Matteo, Pavia (Italy)
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Serum Calcium Level Combined with Platelet Count May Be Useful Indicators for Assisted Diagnosis of Extremity Posttraumatic Osteomyelitis: A Comparative Analysis. DISEASE MARKERS 2021; 2021:6196663. [PMID: 34745387 PMCID: PMC8568509 DOI: 10.1155/2021/6196663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/01/2021] [Accepted: 10/16/2021] [Indexed: 11/17/2022]
Abstract
Background A previous study had reported that patients with osteomyelitis (OM) appeared to be more likely to develop hypocalcemia before and after surgery. Calcium sulfate (CS) is frequently used as a local antibiotic vehicle in the treatment of OM, which may also affect serum calcium level. However, whether changes of serum calcium level are caused by OM and/or local use of calcium sulfate remains unclear. Also, platelet (PLT) count plays a crucial predictive role in periprosthetic joint infections (PJIs), but its role in assisted diagnosis of OM is largely unknown. The purpose of this study was to determine whether serum calcium level and PLT count may be helpful in assisted diagnosis of PTOM. Methods Between January 2013 and December 2018, we analyzed 468 consecutive patients (392 males and 76 females), including 170 patients with posttraumatic OM (PTOM), 130 patients with aseptic bone nonunion (ABN), and 168 patients recovered from fractures with requirement of implant removal set as controls. Preoperative serological levels of calcium, phosphorus, and PLT were detected, and comparisons were conducted among the above three groups. Additionally, correlations and receiver operating characteristic (ROC) curves were displayed to test whether calcium level and PLT can differentiate patients with ABN and PTOM. Results Outcomes showed that the incidences of asymptomatic hypocalcemia (PTOM vs. ABN vs. controls = 22.94% vs. 6.92% vs. 8.82%, χ2 = 21.098, P < 0.001) and thrombocytosis (PTOM vs. ABN vs. controls = 35.3% vs. 13.84% vs. 12.35%, χ2 = 28.512, P < 0.001) were highest in PTOM patients. Besides, the mean serological levels of phosphorus in PTOM and ABN patients were significantly higher than those in the controls (P = 0.007). The Area Under the Curve (AUC) of the ROC curve outcomes revealed that, with the combination of serum calcium level with PLT count, the predictive role was acceptable (AUC 0.730, P < 0.001, 95% CI 0.681-0.780). Also, serological levels of calcium of 2.225 mmol/L and PLT count of 246.5 × 109/L were identified as the optimal cut-off values to distinguish patients with and without PTOM. However, age- and gender-related differences in serum calcium levels (age, P = 0.056; gender, P = 0.978) and PLT count (age, P = 0.363; gender, P = 0.799) were not found to be statistically significant in any groups. In addition, no significant correlations were identified between serum calcium level and PLT count (R = 0.010, P = 0.839). Conclusions Asymptomatic hypocalcemia and thrombocytosis appeared to be more frequent in this cohort with PTOM. Serological levels of calcium and PLT count may be useful biomarkers in screening patients suspected of PTOM.
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Müller SLC, Morgenstern M, Kuehl R, Muri T, Kalbermatten DF, Clauss M, Schaefer DJ, Sendi P, Osinga R. Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis. Injury 2021; 52:3489-3497. [PMID: 34304885 DOI: 10.1016/j.injury.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.
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Affiliation(s)
- Seraina L C Müller
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland.
| | - Richard Kuehl
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Thaddaeus Muri
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Dirk J Schaefer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Parham Sendi
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - Rik Osinga
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
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Houston J, Armitage L, Sedgwick PM, McGovern M, Smith RM, Trompeter AJ. Defining the Mean Angle of Diaphyseal Long Bone Nonunions-Does Shear Prevail? J Orthop Trauma 2021; 35:e322-e327. [PMID: 33395179 DOI: 10.1097/bot.0000000000002050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To define the mean angle of a series of diaphyseal nonunions based on radiographic analysis. DESIGN A retrospective cohort study. SETTING Two level-1 trauma centers. PATIENTS One hundred twenty patients presenting with nonunion. INTERVENTION A mean nonunion angle was calculated from a series of AP and lateral X-rays using a standardized technique. The nonunion angle was then estimated in a single plane by considering the greater of the 2 measured angles. Additional data collected included patient age, sex, nonunion site, initial fracture angle, and original fracture pattern. MAIN OUTCOME MEASUREMENT Single plane nonunion angle. RESULTS The mean angles of all nonunion in coronal plane was 42 degrees (SD 17 degrees) and 42 degrees in sagittal plane (SD 18 degrees) and 48 degrees (SD 15 degrees) in single plane. The single plane nonunion angle in fractures which were originally multiplanar was steeper to those occurring in originally single plane fractures (P 0.002) although both were close to 45 degrees. There was no significant difference in the nonunion angles on subgroup analysis of cohort location, sex, or anatomic location. CONCLUSIONS This study demonstrates the mean angle of diaphyseal nonunions from long bones of the lower limb approaches 45 degrees. This is noted in all types of fractures and is irrespective of anatomic location or sex. This confirms the hypothesis that shear is likely to play a role in the development of a nonunion. This study provides further evidence that nonunions occur primarily because of mechanical instability. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James Houston
- Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Leanne Armitage
- Institute for Medical and Biomedical Education, St. George's, University of London, London, United Kingdom
| | - Philip M Sedgwick
- Institute for Medical and Biomedical Education, St. George's, University of London, London, United Kingdom
| | - Madeline McGovern
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; and
| | - Raymond M Smith
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Alex J Trompeter
- Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, London, United Kingdom
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Oliver WM, Molyneux SG, White TO, Clement ND, Duckworth AD, Keating JF. Open Reduction and Internal Fixation for Humeral Shaft Nonunion: Bone Grafting Is Not Routinely Required and Avoids Donor Site Morbidity. J Orthop Trauma 2021; 35:414-423. [PMID: 34267148 DOI: 10.1097/bot.0000000000002032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To document union rate, complications and patient-reported outcomes after open reduction and internal fixation (ORIF), with and without bone grafting (BG), for humeral diaphyseal nonunion after failed nonoperative management. DESIGN Retrospective. SETTING University teaching hospital. PATIENTS AND INTERVENTION From 2008 to 2017, 86 consecutive patients [mean age 59 years (range 17-86), 71% (n = 61/86) women] underwent nonunion ORIF (plate and screws) at a mean of 7 months postinjury (range 3-21.5). Eleven (13%) underwent supplementary BG. MAIN OUTCOME MEASUREMENTS Union rate and complications for 83 patients (97%) at a mean of 10 months (3-61). Patient-reported outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12, satisfaction) for 53 living, cognitively-intact patients (78%) at a mean of 4.9 years (0.3-9.2). RESULTS Ninety-three percent (n = 77/83) achieved union after nonunion ORIF. Complications included recalcitrant nonunion (7%, n = 6/83), iatrogenic radial nerve palsy (6%, n = 5/83), infection (superficial 7%, n = 6/83; deep 2%, n = 2/83), and iliac crest donor site morbidity (38%, n = 3/8). The union rate with BG was 78% (n = 7/9) and without was 95% (n = 70/74; P = 0.125), and was not associated with the nonunion type (atrophic 91%, n = 53/58; hypertrophic 96%, n = 24/25; P = 0.663). Median QuickDASH was 22.7 (0-95), EQ-5D 0.710 (-0.181-1), EQ-visual analog scale 80 (10-100), SF-12 physical component summary 41.9 (16-60.5), and mental component summary 52.6 (18.7-67.7). Nineteen percent (n = 10/53) were dissatisfied with their outcome. CONCLUSIONS ORIF for humeral diaphyseal nonunion was associated with a high rate of union. Routine BG was not required and avoided the risk of donor site morbidity. One in 5 patients were dissatisfied despite the majority achieving union. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Samuel G Molyneux
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Timothy O White
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Nicholas D Clement
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | | | - John F Keating
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
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Van Vugt TAG, Geurts JAP, Blokhuis TJ. Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series. Injury 2021; 52 Suppl 2:S67-S71. [PMID: 33039177 DOI: 10.1016/j.injury.2020.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/17/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented. METHODS In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication. RESULTS Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection. DISCUSSION These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.
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Affiliation(s)
- T A G Van Vugt
- Dept. Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - J A P Geurts
- Dept. Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - T J Blokhuis
- Dept. Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
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Van Camp N, Verhelst PJ, Nicot R, Ferri J, Politis C. Impaired Callus Formation in Pathological Mandibular Fractures in Medication-Related Osteonecrosis of the Jaw and Osteoradionecrosis. J Oral Maxillofac Surg 2021; 79:1892-1901. [PMID: 34097863 DOI: 10.1016/j.joms.2021.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Nonsurgical treatment of mandibular fractures secondary to medication-related osteonecrosis of the jaw (MRONJ) or osteoradionecrosis (ORN) mostly results in nonunion, whereas nonsurgical fracture treatment of atrophic fractures can achieve favorable results in selected cases. The aim of this study was to compare callus formation in pathological mandibular fractures due to MRONJ, ORN, or extreme mandibular atrophy. METHODS A retrospective cohort study reviewing the medical records of all MRONJ-, ORN-, or atrophy-related fractures treated at the departments of maxillofacial surgery in the Leuven or Lille university hospitals between 2010 and 2019 was undertaken. The primary predictor variable in this study was disease state (MRONJ, ORN, or extreme mandibular atrophy). The primary outcome variable was callus formation after 1 month of follow-up (present, absent). Additional study variables measured included patient age and gender. T-tests, Fisher exact tests, and multiple logistic regression were used for statistical analysis. The significance level was set at P < .05. RESULTS Seventy patients were analyzed (12 MRONJ cases, 54 ORN fractures, 4 atrophic fractures). The callus formation prevalence in nonsurgically approached fractures secondary to ORN and MRONJ after 1 month of follow-up was 3.03% (2/66 cases). In contrast, callus was detected in all patients in the mandibular atrophy-related fracture group. Osteonecrosis was statistically correlated with impaired callus formation (P = .0121). CONCLUSION Whereas one would expect indirect fracture healing and thus callus formation to occur in all non-surgically treated fractures, our data demonstrate its absence in the majority of MRONJ- and ORN-related fractures. Multiple plausible explanations for this phenomenon were identified: periosteal damage with loss of callus-forming cells, compromised vasculature, and bacterial colonization.
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Affiliation(s)
- Nathalie Van Camp
- Resident, Oral and Maxillofacial Surgery - Imaging and Pathology Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Department of Oral & Maxillofacial Surgery, University of Leuven, Leuven, Belgium.
| | - Pieter-Jan Verhelst
- Resident, Oral and Maxillofacial Surgery - Imaging and Pathology Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Department of Oral & Maxillofacial Surgery, University of Leuven, Leuven, Belgium
| | - Romain Nicot
- Staff Physician, Stomatologie, Chirurgie Orale et Maxillofaciale, Department of Oral and Maxillofacial Surgery, U1008 - Controlled Drug Delivery Systems and Biomaterials, Université de Lille/CHU de Lille, Lille, France
| | - Joel Ferri
- Professor and Department Head, Stomatologie, Chirurgie Orale et Maxillofaciale, Department of Oral and Maxillofacial Surgery, U1008 - Controlled Drug Delivery Systems and Biomaterials, Université de Lille/CHU de Lille, Lille, France
| | - Constantinus Politis
- Professor and Department Head, Oral and Maxillofacial Surgery - Imaging and Pathology Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Department of Oral & Maxillofacial Surgery, University of Leuven, Leuven, Belgium
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Treatment of severely open tibial fractures, non-unions, and fracture-related infections with a gentamicin-coated tibial nail-clinical outcomes including quality of life analysis and psychological ICD-10-based symptom rating. J Orthop Surg Res 2021; 16:270. [PMID: 33865407 PMCID: PMC8052745 DOI: 10.1186/s13018-021-02411-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Implant-associated infections depict a major challenge in orthopedics and trauma surgery putting a high burden on the patients and health care systems, strongly requiring improvement of infection prevention and of clinical outcomes. One strategy includes the usage of antimicrobial-coated implants. We evaluated outcomes after surgical treatment using a gentamicin-coated nail on (i) treatment success in terms of bone consolidation, (ii) absence of infection, and (iii) patient-reported quality of life in a patient cohort with high risk of infection/reinfection and treatment failure. METHODS Thirteen patients with open tibia fractures (n = 4), non-unions (n = 2), and fracture-related infection (n = 7) treated with a gentamicin-coated intramedullary nail (ETN ProtectTM) were retrospectively reviewed. Quality of life was evaluated with the EQ-5D, SF-36, and with an ICD-10-based symptom rating (ISR). RESULTS At a mean follow-up of 2.8 years, 11 of the 13 patients (84.6%) achieved bone consolidation without any additional surgical intervention, whereas two patients required a revision surgery due to infection and removal of the implant. No specific implant-related side effects were noted. Quality of life scores were significantly lower compared to a German age-matched reference population. The mean ISR scores revealed mild psychological symptom burden on the scale depression. CONCLUSION The use of a gentamicin-coated intramedullary nail seems to be reasonable in open fractures and revision surgery for aseptic non-union or established fracture-related infection to avoid infection complications and to achieve bony union. Despite successful treatment of challenging cases with the gentamicin-treated implant, significantly reduced quality of life after treatment underlines the need of further efforts to improve surgical treatment strategies and psychological support.
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Khatkar H, See A. Stem Cell Therapy in the Management of Fracture Non-Union - Evaluating Cellular Mechanisms and Clinical Progress. Cureus 2021; 13:e13869. [PMID: 33859917 PMCID: PMC8038927 DOI: 10.7759/cureus.13869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Bone, as a physiological and anatomical construct, displays remarkable intrinsic healing capacity. The overwhelming majority of fractures will heal satisfactorily, if aligned anatomically, compressed and immobilised appropriately. Of the 10% of fractures that do not heal, even under ideal mechanical and biological conditions, further consideration must be given to augment bone healing. Management strategies for non-union pose a significant clinical challenge to the practicing orthopaedic surgeon. Stem cell therapy is beginning to demonstrate significant potential for augmented bone repair in the context of non-union. This review attempts to contextualise the function of stem cells within this clinical setting, reviewing the relevant cellular mechanisms and clinical applications. From evaluating the literature base, there is a lack of high-quality evidence examining the role of mesenchymal stem cells (MSCs) within this research focus. Appropriately designed randomised controlled trials are required to evaluate this research area further, with a view to guiding future treatment options for the practicing orthopaedic surgeon.
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Affiliation(s)
- Harman Khatkar
- Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, GBR.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, GBR
| | - Abbas See
- Trauma and Orthopaedics, Kettering General Hospital, Kettering, GBR
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Stürznickel J, Schmidt FN, von Vopelius E, Delsmann MM, Schmidt C, Jandl NM, Oheim R, Barvencik F. Bone healing and reactivation of remodeling under asfotase alfa therapy in adult patients with pediatric-onset hypophosphatasia. Bone 2021; 143:115794. [PMID: 33301963 DOI: 10.1016/j.bone.2020.115794] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/16/2020] [Accepted: 12/03/2020] [Indexed: 01/13/2023]
Abstract
Hypophosphatasia (HPP) is a hereditary musculoskeletal disorder caused by inactivating variants in the ALPL gene and subsequently reduced serum tissue-nonspecific alkaline phosphatase (TNSALP) activity. This inborn error of metabolism results in decreased bone quality, accumulations of osteoid, and reduced bone mineralization. Increased incidence of fractures and prolonged bone healing are characteristic features for HPP. Available enzyme replacement therapy (asfotase alfa), was reported to recover bone mineralization and bone quality in adult HPP patients. Moreover, it was shown that asfotase alfa improved fracture healing of former nonunions in two adult HPP patients. We hypothesized that the nonunions are filled partially with osteoid, offering great potential to benefit from the treatment with asfotase alfa to promote bone healing. In the present study, we report three adult patients with pediatric-onset HPP and detected ALPL-mutations with prolonged bone healing after arthrodesis, tibial stress fracture, and osteotomy. After the initiation of asfotase alfa, immediately increased levels of alkaline phosphatase (ALP) and bone-specific ALP, as well as decreased levels of pyridoxal-5-phosphate (PLP), were detected in biochemical analysis. Importantly, even after up to 5 years of non-healing, a progredient consolidation was shown, assessed by a custom three-dimensional evaluation of repeated cone-beam computed tomography (CBCT) images, characterized by rapidly increasing levels of bone volume per tissue volume (BV/TV) within the volume of interest (i.e., the region of the non-healing bone). These radiographical findings were in line with the reported restoration of functional ability and pain-free full weight-bearing, as well as increased neuromuscular parameters (e.g., improved muscle strength). Taken together, our findings indicate that asfotase alfa improves the osseous consolidation of nonunions likely due to re-mineralization of osteoid tissue filling the former gap and improving the functional ability in adult HPP patients, characterized by increasing levels of BV/TV assessed via an innovative three-dimensional evaluation of CBCT images.
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Affiliation(s)
- Julian Stürznickel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix N Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Emil von Vopelius
- 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
| | - Constantin Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Maximilian Jandl
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Andersen C, Wragg NM, Shariatzadeh M, Wilson SL. The Use of Platelet-Rich Plasma (PRP) for the Management of Non-union Fractures. Curr Osteoporos Rep 2021; 19:1-14. [PMID: 33393012 PMCID: PMC7935731 DOI: 10.1007/s11914-020-00643-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW The treatment of non-union fractures represents a significant challenge for orthopaedic surgeons. In recent years, biologic agents have been investigated and utilised to support and improve bone healing. Among these agents, platelet-rich plasma (PRP) is an emerging strategy that is gaining popularity. The aim of this review is to evaluate the current literature regarding the application and clinical effectiveness of PRP injections, specifically for the treatment of non-union fractures. RECENT FINDINGS The majority of published studies reported that PRP accelerated fracture healing; however, this evidence was predominantly level IV. The lack of randomised, clinical trials (level I-II evidence) is currently hampering the successful clinical translation of PRP as a therapy for non-union fractures. This is despite the positive reports regarding its potential to heal non-union fractures, when used in isolation or in combination with other forms of treatment. Future recommendations to facilitate clinical translation and acceptance of PRP as a therapy include the need to investigate the effects of administering higher volumes of PRP (i.e. 5-20 mL) along with the requirement for more prolonged (> 11 months) randomised clinical trials.
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Affiliation(s)
- Christian Andersen
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK
| | - Nicholas M Wragg
- Centre for Biological Engineering, Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK
- School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Keele University, Stoke-on-Trent, Staffordshire, ST4 7QB, UK
| | - Maryam Shariatzadeh
- Centre for Biological Engineering, Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK
| | - Samantha Louise Wilson
- Centre for Biological Engineering, Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK.
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Ismailidis P, Suhm N, Clauss M, Mündermann A, Cadosch D. Scope and Limits of Teriparatide Use in Delayed and Nonunions: A Case Series. Clin Pract 2021; 11:47-57. [PMID: 33573004 PMCID: PMC7931020 DOI: 10.3390/clinpract11010009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/08/2021] [Accepted: 01/21/2021] [Indexed: 11/22/2022] Open
Abstract
Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the “off-label” character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing.
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Affiliation(s)
- Petros Ismailidis
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
- Department of Biomedical Engineering, University of Basel, Gewerbestrasse 14, 4123 Allschwil, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056 Basel, Switzerland
- Correspondence: ; Tel.: +41-789490281; Fax: +41-61-265-73-21
| | - Norbert Suhm
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
| | - Martin Clauss
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
- Center for Musculosceletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
- Department of Biomedical Engineering, University of Basel, Gewerbestrasse 14, 4123 Allschwil, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056 Basel, Switzerland
| | - Dieter Cadosch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
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Ferreli A, Nonne D, Russo A, Dessì G, Marongiu G. Poller blocking screw augmentation to treat delayed union of proximal tibial shaft fracture after locked IM nailing. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 91:e2020119. [PMID: 33525305 PMCID: PMC7927535 DOI: 10.23750/abm.v91i4.9206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/01/2020] [Indexed: 11/23/2022]
Abstract
CASES We present the cases of two adult male patients with painfully delayed union of proximal tibia diaphyseal fracture after intramedullary nailing. Patients underwent to nail dynamization and Poller blocking screw augmentation at 3 and 5 month, respectively, after the index surgery. Both patients were pain-free after the surgery and bone-union were radiographically evident after 3 months. At 12-month follow-up, patients returned to their previous activities. CONCLUSIONS Although nail dynamization is the choice treatment to obtain fracture compression for delayed union of tibial shaft fractures, augmentation with Poller blocking screw could provide additional mechanical stiffness in unstable supra-isthmic shaft fractures of the tibia and favour bone union.
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Affiliation(s)
- Alberto Ferreli
- Division of Orthopaedics and Traumatology, Brotzu Hospital, Cagliari, Sardinia, Italy.
| | - Daniela Nonne
- Division of Orthopaedics and Traumatology, Brotzu Hospital, Cagliari, Sardinia, Italy.
| | - Angelo Russo
- Division of Orthopaedics and Traumatology, Brotzu Hospital, Cagliari, Sardinia, Italy.
| | - Giuseppe Dessì
- Division of Orthopaedics and Traumatology, Brotzu Hospital, Cagliari, Sardinia, Italy.
| | - Giuseppe Marongiu
- Orthopedic and Trauma Clinic, Ospedale Marino, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
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Zhu ZD, Xiao CW, Tan B, Tang XM, Wei D, Yuan JB, Hu J, Feng L. TiRobot-Assisted Percutaneous Cannulated Screw Fixation in the Treatment of Femoral Neck Fractures: A Minimum 2-Year Follow-up of 50 Patients. Orthop Surg 2021; 13:244-252. [PMID: 33448703 PMCID: PMC7862148 DOI: 10.1111/os.12915] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/07/2020] [Accepted: 11/29/2020] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the long‐term clinical efficacy of TiRobot‐assisted percutaneous cannulated screw fixation in the treatment of femoral neck fractures. Methods This retrospective study included 50 patients with unilateral femoral neck fractures who were treated with TiRobot‐assisted percutaneous cannulated screw fixation from September 2017 to May 2018. After at least 2 years of follow‐up, the results of treatment, including operation duration, frequency of fluoroscopy use, intraoperative bleeding, hospital stay, medical expense, screw placement accuracy, rate of fracture healing and necrosis of the femoral head, and Harris hip scores at the last follow up, were recorded and compared with those of 83 matched patients who underwent conventional manual positioning surgery. Results The TiRobot group had longer operation duration (83.3 ± 31.2 min vs 44.1 ± 14.8 min) and higher medical expenses (28,407.1 ± 7498.0 yuan vs 22,672.3 ± 4130.3 yuan) than the conventional group. The TiRobot group had significantly less intraoperative bleeding (11.3 ± 7.3 mL vs 51.6 ± 40.4 mL) and shorter hospital stay (8.6 ± 2.8 days vs 11.1 ± 3.41 days) than the conventional group. Screw parallelism (1.32° ± 1.85° vs 2.54° ± 2.99° on anteroposterior radiograph; 1.42° ± 2.25° vs 3.09° ± 3.63° on lateral radiograph) and distance between screws (58.44 ± 10.52 mm vs 39.69 ± 12.17 mm) were significantly improved. No significant difference was found between the two groups in terms of the use of fluoroscopy (40.1 ± 28.5 times vs 38.6 ± 21.0 times) and Harris hip scores at the last follow‐up (93.2 ± 10.3 points vs 88.4 ± 11.9 points). Two cannulated screws penetrated the femoral head during manual insertion in the conventional group but not in the TiRobot group. The rate of nonunion and necrosis of the femoral head in the TiRobot group was reduced compared with that in the conventional group (0 vs 7.2%; 6.0% vs 24.1%). Conclusion TiRobot‐assisted percutaneous cannulated screw fixation of femoral neck fractures is accurate and minimally invasive and helps in reducing late complications, particularly necrosis of the femoral head and nonunion of fractures.
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Affiliation(s)
- Zong-Dong Zhu
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Cheng-Wei Xiao
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Bo Tan
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiao-Ming Tang
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dan Wei
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jia-Bin Yuan
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiang Hu
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liao Feng
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Lee CL, Liu SC, Yang CY, Chuang CK, Lin HY, Lin SP. Incidence and treatment of adult femoral fractures with osteogenesis imperfecta: An analysis of a center of 72 patients in Taiwan. Int J Med Sci 2021; 18:1240-1246. [PMID: 33526985 PMCID: PMC7847618 DOI: 10.7150/ijms.53286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Osteogenesis imperfecta (OI) is a rare disease characterized by increased bone fragility and susceptibility for fractures. Only few studies have compared the management for femoral fractures in children with OI. Nevertheless, no cohort studies have described the treatment for femoral fractures in adults with OI in Taiwan. This study aimed to investigate and compare the incidence of union and non-union femoral fractures and the best treatment options to avoid non-union fractures. Methods: We enrolled 72 patients with OI who were older than 18 years at MacKay Memorial Hospital between January 2010 and December 2018. Femoral fracture incidence, non-union rate, and treatment modality were analyzed. Results: Of 72 patients with OI, 11 patients had femoral fractures and 4 patients of them had >1 femoral fracture. The incidence for all types of femoral fractures was 651 fractures per 100,000 person-years annually. In 15 total fractures, 4 fractures resulted in non-union, and patients with type 4 OI mostly had shaft fractures. The best outcomes for non-union shaft fracture is achieved by surgical treatment. Conclusion: Adults with OI tended to develop femoral fractures and non-unions. Adults with type 4 OI were particularly at high risk for non-unions in shaft fractures with conservative treatment.
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Affiliation(s)
- Chung-Lin Lee
- Department of Pediatrics, MacKay Memorial Hospital, Hsinchu, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Chia Liu
- Department of Orthopedics, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chen-Yu Yang
- Department of Orthopedics, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chih-Kuang Chuang
- Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan.,College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Hsiang-Yu Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shuan-Pei Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Ernst M, Baumgartner H, Döbele S, Höntzsch D, Pohlemann T, Windolf M. Clinical feasibility of fracture healing assessment through continuous monitoring of implant load. J Biomech 2020; 116:110188. [PMID: 33444926 DOI: 10.1016/j.jbiomech.2020.110188] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Current fracture fixation follow-up is based on subjective radiological and clinical examination. Efforts to objectify the procedure have been undertaken since decades. Assessment of implant load as an indirect predictor of callus maturity has so far failed to enter clinical routine due to limited practicability, technical obstacles and its snap-shot nature. We recently introduced the concept of continuous implant load monitoring to aid in diagnosing fracture healing progression. This study aimed at investigating the feasibility of the system in a clinical context. Ten patients treated with Taylor-Spatial-Frame external fixators following pathological tibia fractures were equipped with a Fracture Monitor device attached to a fixator-strut and were monitored until hardware removal. Two patients were excluded due to technical issues. Implant load and fracture activity was continuously and autonomously measured for 139 ± 89 days (mean ± SD). Data was wirelessly collected with consumer smartphones. Relative implant load initially rose for 34.1 ± 22.2 days and finally declined to a level of 45.0 ± 33.8% of the maximum implant load. In five patients the load dropped below 50% of the maximum load. These patients underwent hardware removal according to the clinical assessment. In three patients, whose external fixators were exchanged to internal fixation at the end of the study, implant load did not drop below the 50% margin. The continuous measurement principle allows resolving implant load progression and appears indicative for the bone healing status. Data can be acquired in a homecare setting and is believed to provide valuable information to support timely healing assessment and enable patient specific after-care.
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Affiliation(s)
| | - Heiko Baumgartner
- BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stefan Döbele
- BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Dankward Höntzsch
- BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
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Bhure U, Agten C, Lehnick D, Perez-Lago MDS, Beeres F, Link BC, Strobel K. Value of SPECT/CT in the assessment of necrotic bone fragments in patients with delayed bone healing or non-union after traumatic fractures. Br J Radiol 2020; 93:20200300. [PMID: 32663034 DOI: 10.1259/bjr.20200300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the value of single-photon emission computed tomography / computed tomography (SPECT/CT) compared with planar bone scintigraphy (BS) in the assessment of necrotic bone fragments in patients with delayed bone healing or non-union after traumatic fractures. METHODS Retrospective evaluation of patients with traumatic fractures and suspected delayed healing or non-union and/or persistent pain or suspected infection who had undergone planar late phase BS and SPECT/CT between 2011 and 2018. On the BS and SPECT/CT images, a necrotic fragment was considered if there was an area of absent radiotracer uptake (photopenia) related to bone at the fracture site. Histology served as a reference standard (presence or absence of necrotic bone fragments). If histology was not available, intraoperative findings and combined clinical and imaging follow-up served as reference standards. RESULTS In 37 consecutive patients with traumatic fractures (femur (n = 18), tibia (11), humerus (6), radius (1), jaw (1)), necrotic bone fragments were suspected in 11 fractures (29.7%) on BS and in 16 fractures (43.2%) on SPECT/CT. 35 fractures (94.6%) had metallic implants. Histology showed necrotic fragments in 10/11 (90.9%) patients. For the detection of necrotic bone fragments, SPECT/CT showed sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%, 95%, 94%, 100%, and 97%, respectively, and BS 67%, 95%, 91%, 81%, and 83%, respectively. SPECT/CT significantly outperformed BS with better area under curve (AUC) for SPECT/CT (0.9773) compared to planar imaging (0.8106) (p-value < 0.01). CONCLUSIONS SPECT/CT is an accurate tool in the assessment of necrotic bone fragments in patients with delayed bone healing or non-union after traumatic bone fractures and is superior to conventional planar BS. ADVANCES IN KNOWLEDGE SPECT/CT is accurate and superior to planar BS in identification of necrotic bone fragments, responsible for delayed bone healing/non-union after fractures.
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Affiliation(s)
- Ujwal Bhure
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Christoph Agten
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Dirk Lehnick
- Biostatistics and Methodology, University of Lucerne, Lucerne, Switzerland
| | | | - Frank Beeres
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Klaus Strobel
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
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Hassibi H, Farsinejad A, Dabiri S, Voosough D, Mortezaeizadeh A, Kheirandish R, Azari O. Allogenic Bone Graft Enriched by Periosteal Stem Cell and Growth Factors for Osteogenesis in Critical Size Bone Defect in Rabbit Model: Histopathological and Radiological Evaluation. IRANIAN JOURNAL OF PATHOLOGY 2020; 15:205-216. [PMID: 32754216 PMCID: PMC7354065 DOI: 10.30699/ijp.2020.101715.2013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/09/2020] [Indexed: 01/05/2023]
Abstract
Background & Objective: This study aimed to investigate the effect of decellularized allogeneic bone graft enriched by periosteal stem cells (PSCs) and growth factors on the bone repair process in a rabbit model, which could be used in many orthopedic procedures. Methods: In this experimental study, a critical size defect (CSD) (10 mm) was created in the radial diaphysis of 40 rabbits. In group A, the defect was left intact with no medical intervention. In group B, the defect was filled by a decellularized bone graft. In group C, the defect was implanted by a decellularized bone graft enriched with platelet growth factors. In group D, the defect was treated by a decellularized bone graft seeded by periosteal mesenchymal stem cells (MSCs). Also, in group E, the defect was filled by a decellularized bone graft enriched with platelet growth factors and periosteal MSCs. Radiological evaluation was done on the first day and then in the second, fourth, and eighth weeks after the operation. The specimens were harvested on the 28th and 56th postoperative days and evaluated for histopathological criteria. Results: The radiologic and microscopic analysis of the healing process in bone defects of the treated groups (C, D, and E) revealed more advanced repair criteria than those of groups A and B significantly (P<0.05). Conclusion: Based on this study, it appears that implantation of concentrated PSCs in combination with growth factors and allogeneic cortical bone graft is an effective therapy for the repair of large bone defects.
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Affiliation(s)
- Hadi Hassibi
- Department of Veterinary Surgery, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Alireza Farsinejad
- Department of Hematology and Medical Laboratory Sciences, Faculty of Allied Medicine, Kerman University of Medical Science, Kerman, Iran
| | - Shahriar Dabiri
- Pathology and stem cell Research Center, Department of Pathology, Kerman University of Medical Sciences, Kerman, Iran
| | - Darioush Voosough
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Abbas Mortezaeizadeh
- Pathology and stem cell Research Center, Department of Pathology, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Kheirandish
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahnoar University of Kerman, Kerman, Iran
| | - Omid Azari
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
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Liao F, Zhu Z, Xiao C, Tan B, Tang X, Wei D, Yuan J, Xiang X, Hu J. Effect of changes in serum levels of endogenous hydrogen sulfide on fracture healing: Study protocol clinical trial (SPIRIT compliant). Medicine (Baltimore) 2020; 99:e19684. [PMID: 32243406 PMCID: PMC7440181 DOI: 10.1097/md.0000000000019684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Fracture is a common disease; many factors affect fracture healing. Recent studies have confirmed that hydrogen sulfide (H2S) plays an essential role in bone formation, but most of these studies are drawing conclusions based on animal experiment; whether H2S could promote fracture healing in patients is still unclear. We aim to investigate the change of serum H2S in fracture patients, and analyze its effort on fracture healing. METHODS This is a single-center, prospective cohort study. Patients with spinal or limb fracture will be recruited. Patient's serum and urine will be collected at baseline for examination (serum H2S, β-CTX, OC, PINP, 25-OH-VitD3, S-CTX, urinary calcium, and urinary creatinine). All patients will be followed-up for 24 months in outpatients settings, the image of X-ray or CT will be reviewed and fracture healing will be judged by 2 experienced orthopedic physicians. The difference in serum parameters especially H2S will be compared between patients with fracture healed within 9 months and those with fracture unhealed at 9 months. DISCUSSION Results of the trial could provide insight into influence of H2S on fracture healing. ETHICS AND DISSEMINATION The study was approved by the ethics committee of School of Medicine UESTC & Sichuan Provincial People's Hospital Ethics Committee. All the participants will be asked to provide written informed consent before data collection. The findings of the study will be published in peer-reviewed journals and will be presented at national or international conferences.
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Affiliation(s)
- Feng Liao
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Zongdong Zhu
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Chengwei Xiao
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Bo Tan
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Xiaoming Tang
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Dan Wei
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Jiabin Yuan
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
| | - Xuemei Xiang
- Jane lab. Big Data Research Center, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiang Hu
- Department of Orthopaedics, Affiliated Hospital of University of Electronic Science and Technology & Sichuan Provincial People's Hospital
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Stewart SK, Tenenbaum O, Higgins C, Masouros S, Ramasamy A. Fracture union rates across a century of war: a systematic review of the literature. BMJ Mil Health 2020; 166:271-276. [PMID: 32217686 DOI: 10.1136/bmjmilitary-2019-001375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Fractures have been a common denominator of the injury patterns observed over the past century of warfare. The fractures typified by the blast and ballistic injuries of war lead to high rates of bone loss, soft tissue injury and infection, greatly increasing the likelihood of non-union. Despite this, no reliable treatment strategy for non-union exists. This literature review aims to explore the rates of non-union across a century of conflict, in order to determine whether our ability to heal the fractures of war has improved. METHODS A systematic review of the literature was conducted, evaluating the rates of union in fractures sustained in a combat environment over a 100-year period. Only those fractures sustained through a ballistic or blast mechanism were included. The review was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Quality and bias assessment was also undertaken. RESULTS Thirty studies met the inclusion criteria, with a total of 3232 fractures described across 15 different conflicts from the period 1919-2019. Male subjects made up 96% of cases, and tibial fractures predominated (39%). The lowest fracture union rate observed in a series was 50%. Linear regression analysis demonstrated that increasing years had no statistically significant impact on union rate. CONCLUSIONS Failure to improve fracture union rates is likely a result of numerous factors, including greater use of blast weaponry and better survivability of casualties. Finding novel strategies to promote fracture healing is a key defence research priority in order to improve the rates of fractures sustained in a combat environment.
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Affiliation(s)
- Sarah K Stewart
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
| | - O Tenenbaum
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
| | - C Higgins
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
| | - S Masouros
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
| | - A Ramasamy
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
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Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes? J Orthop Trauma 2019; 33:591-597. [PMID: 31211717 DOI: 10.1097/bot.0000000000001562] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. DESIGN Retrospective comparative cohort study over a 2-year period. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. INTERVENTION Time to initial debridement and definitive management. MAIN OUTCOME MEASUREMENT Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. RESULTS Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. CONCLUSIONS Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Medhat D, Rodríguez CI, Infante A. Immunomodulatory Effects of MSCs in Bone Healing. Int J Mol Sci 2019; 20:ijms20215467. [PMID: 31684035 PMCID: PMC6862454 DOI: 10.3390/ijms20215467] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/29/2022] Open
Abstract
Mesenchymal stem cells (MSCs) are capable of differentiating into multilineage cells, thus making them a significant prospect as a cell source for regenerative therapy; however, the differentiation capacity of MSCs into osteoblasts seems to not be the main mechanism responsible for the benefits associated with human mesenchymal stem cells hMSCs when used in cell therapy approaches. The process of bone fracture restoration starts with an instant inflammatory reaction, as the innate immune system responds with cytokines that enhance and activate many cell types, including MSCs, at the site of the injury. In this review, we address the influence of MSCs on the immune system in fracture repair and osteogenesis. This paradigm offers a means of distinguishing target bone diseases to be treated with MSC therapy to enhance bone repair by targeting the crosstalk between MSCs and the immune system.
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Affiliation(s)
- Dalia Medhat
- Medical Biochemistry Department, National Research Centre, Dokki, Giza 12622, Egypt.
| | - Clara I Rodríguez
- Stem Cells and Cell Therapy Laboratory, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Plaza de Cruces S/N, 48903 Barakaldo, Bizkaia, Spain.
| | - Arantza Infante
- Stem Cells and Cell Therapy Laboratory, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Plaza de Cruces S/N, 48903 Barakaldo, Bizkaia, Spain.
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Mitxitorena I, Infante A, Gener B, Rodríguez CI. Suitability and limitations of mesenchymal stem cells to elucidate human bone illness. World J Stem Cells 2019; 11:578-593. [PMID: 31616536 PMCID: PMC6789184 DOI: 10.4252/wjsc.v11.i9.578] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/31/2019] [Accepted: 08/27/2019] [Indexed: 02/06/2023] Open
Abstract
Functional impairment of mesenchymal stem cells (MSCs), osteoblast progenitor cells, has been proposed to be a pathological mechanism contributing to bone disorders, such as osteoporosis (the most common bone disease) and other rare inherited skeletal dysplasias. Pathological bone loss can be caused not only by an enhanced bone resorption activity but also by hampered osteogenic differentiation of MSCs. The majority of the current treatment options counteract bone loss, and therefore bone fragility by blocking bone resorption. These so-called antiresorptive treatments, in spite of being effective at reducing fracture risk, cannot be administered for extended periods due to security concerns. Therefore, there is a real need to develop osteoanabolic therapies to promote bone formation. Human MSCs emerge as a suitable tool to study the etiology of bone disorders at the cellular level as well as to be used for cell therapy purposes for bone diseases. This review will focus on the most relevant findings using human MSCs as an in vitro cell model to unravel pathological bone mechanisms and the application and outcomes of human MSCs in cell therapy clinical trials for bone disease.
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Affiliation(s)
- Izaskun Mitxitorena
- Stem Cells and Cell Therapy Laboratory, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo 48903, Bizkaia, Spain
| | - Arantza Infante
- Stem Cells and Cell Therapy Laboratory, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo 48903, Bizkaia, Spain
| | - Blanca Gener
- Stem Cells and Cell Therapy Laboratory, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo 48903, Bizkaia, Spain
- Service of Genetics, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo 48903, Bizkaia, Spain
- Centre for Biomedical Network Research on Rare Diseases, Instituto de Salud Carlos III, Madrid 28005, Spain
| | - Clara I Rodríguez
- Stem Cells and Cell Therapy Laboratory, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo 48903, Bizkaia, Spain
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Scott RM, Buckley HR, Domett K, Tromp M, Trinh HH, Willis A, Matsumura H, Oxenham MF. Domestication and large animal interactions: Skeletal trauma in northern Vietnam during the hunter-gatherer Da But period. PLoS One 2019; 14:e0218777. [PMID: 31483781 PMCID: PMC6726200 DOI: 10.1371/journal.pone.0218777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 06/11/2019] [Indexed: 11/19/2022] Open
Abstract
The aim of this paper is to test the hypothesis that healed traumatic injuries in the pre-Neolithic assemblage of Con Co Ngua, northern Vietnam (c. 6800-6200 cal BP) are consistent with large wild animal interactions prior to their domestication. The core sample included 110 adult (aged ≥ 18 years) individuals, while comparisons are made with an additional six skeletal series from Neolithic through to Iron Age Vietnam, Thailand, and Mongolia. All post cranial skeletal elements were assessed for signs of healed trauma and identified cases were further x-rayed. Crude trauma prevalence (14/110, 12.7%) was not significantly different between males (8/52) and females (5/37) (χ2 = 0.061, p = 0.805). Nor were there significant differences in the prevalence of fractured limbs, although males displayed greater rates of lower limb bone trauma than females. Further, distinct from females, half the injured males suffered vertebral fractures, consistent with high-energy trauma. The first hypothesis is supported, while some support for the sexual divisions of labour was found. The prevalence and pattern of fractured limbs at CCN when compared with other Southeast and East Asian sites is most similar to the agropastoral site of Lamadong, China. The potential for skeletal trauma to assess animal trapping and herding practices prior to domestication in the past is discussed.
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Affiliation(s)
- Rachel M. Scott
- Department of Anatomy, University of Otago, Dunedin, New Zealand
- * E-mail: (RS); (MO)
| | | | - Kate Domett
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Monica Tromp
- Department of Anatomy, University of Otago, Dunedin, New Zealand
- Department of Archaeology, Max Planck Institute for the Science of Human History, Jena, Germany
| | - Hiep Hoang Trinh
- Department of Prehistoric Archaeology, Vietnam Institute of Archaeology, Hanoi, Vietnam
| | - Anna Willis
- College of Arts, Society and Education, James Cook University, Townsville, Australia
| | - Hirofumi Matsumura
- School of Health Science, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Marc F. Oxenham
- School of Archaeology and Anthropology, Australian National University, Canberra, Australia
- * E-mail: (RS); (MO)
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Abstract
Non-union of bone following fracture is an orthopaedic condition with a high morbidity and clinical burden. Despite its estimated global prevalence of nine million annually, the limit of bone regeneration therapy still results in patients living with pain, a reduced quality of life and associated psychological, social and financial repercussions. This review provides an overview of the current epidemiological and aetiological data, and highlights where the clinical challenges in treating non-union lie. Current treatment strategies are discussed as well as promising future research foci. Development in biotechnologies to treat non-union provides exciting scope for more effective treatment for this debilitating condition.
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Affiliation(s)
- S K Stewart
- Department of Bioengineering, Imperial College London, United Kingdom
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Ortmaier R, Moroder P, Blocher M, Auffarth A, Wutte C, Freude T, Resch H, Bogner R. Joint-preserving treatment for type 3 sequelae following fracture of the proximal humerus with small head fragments. J Orthop Sci 2019; 24:618-623. [PMID: 30580889 DOI: 10.1016/j.jos.2018.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/12/2018] [Accepted: 11/29/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although nonunions of the proximal humerus are rare, they cause significant disability to patients. Surgical reconstruction is challenging, especially with small and excavated head fragments. A promising surgical option is open reduction and stabilization using the Humerusblock device along with tension wires. The aim of this retrospective investigation was to evaluate the clinical and radiological results of this procedure. MATERIALS AND METHODS Fifteen patients with symptomatic surgical neck nonunions were treated with open reduction and internal fixation using the Humerusblock device without bone grafting. All patients showed a loss of bone stock, leading to excavated head fragments. The mean interval from injury to the described treatment was 6.2 months (range, 3.4-10.7). At a mean follow-up of 40.5 months, the Constant-Murley score was documented, pain and patient satisfaction were evaluated using a visual analogue scale, and x-rays were taken in two planes. RESULTS The patients' mean age was 69.7 years (range, 52-83). The mean Constant-Murley score improved from 24 points before surgery to 62 points at follow-up, which was an average of 80.8% of the score obtained for the contralateral arm. Radiological examination confirmed bony healing in 14 patients. All but one patient felt satisfied with the results. Three patients required revision surgery because of a hematoma, and early metal removal was performed in one patient because of infection. CONCLUSION Nonunions of humeral surgical neck fractures can be successfully treated by fixation using the Humerusblock device along with tension wires without the need for additional bone grafting. Especially in patients with flat, concave head fragments, this procedure remains a promising reconstructive option to arthroplasty. LEVEL OF EVIDENCE Level IV; Therapeutic retrospective case series.
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Affiliation(s)
- Reinhold Ortmaier
- Department of Orthopaedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Teaching Hospital of the Paracelsus Medical University Salzburg, Seilerstätte 4, 4020 Linz, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention, ISAG/UMIT, Eduard-Wallhöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Campus Virchow, Charité -Universitaetsmedizin Berlin, 13353 Berlin, Germany.
| | - Martina Blocher
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Alexander Auffarth
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Christof Wutte
- Center for Spinal Cord Injuries, Trauma Center Murnau, Prof.-Küntscher-Str. 8, 82418 Murnau, Germany.
| | - Thomas Freude
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Herbert Resch
- Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
| | - Robert Bogner
- AUVA Trauma Center Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.
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Long H, Zhu Y, Lin Z, Wan J, Cheng L, Zeng M, Tang Y, Zhao R. miR-381 modulates human bone mesenchymal stromal cells (BMSCs) osteogenesis via suppressing Wnt signaling pathway during atrophic nonunion development. Cell Death Dis 2019; 10:470. [PMID: 31209205 PMCID: PMC6572824 DOI: 10.1038/s41419-019-1693-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 12/19/2022]
Abstract
The osteogenic differentiation of human bone mesenchymal stromal cells (BMSCs) has been considered as a central issue in fracture healing. Wnt signaling could promote BMSC osteogenic differentiation through inhibiting PPARγ. During atrophic nonunion, Wnt signaling-related factors, WNT5A and FZD3 proteins, were significantly reduced, along with downregulation of Runx2, ALP, and Collagen I and upregulation of PPARγ. Here, we performed a microarray analysis to identify differentially expressed miRNAs in atrophic nonunion tissues that were associated with Wnt signaling through targeting related factors. Of upregulated miRNAs, miR-381 overexpression could significantly inhibit the osteogenic differentiation in primary human BMSCs while increase in PPARγ protein level. Through binding to the 3'UTR of WNT5A and FZD3, miR-381 modulated the osteogenic differentiation via regulating β-catenin nucleus translocation. Moreover, PPARγ, an essential transcription factor inhibiting osteogenic differentiation, could bind to the promoter region of miR-381 to activate its expression. Taken together, PPARγ-induced miR-381 upregulation inhibits the osteogenic differentiation in human BMSCs through miR-381 downstream targets, WNT5A and FZD3, and β-catenin nucleus translocation in Wnt signaling. The in vivo study also proved that inhibition of miR-381 promoted the fracture healing. Our finding may provide a novel direction for atrophic nonunion treatment.
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Affiliation(s)
- Haitao Long
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Yong Zhu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zhangyuan Lin
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Jun Wan
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Liang Cheng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Min Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Yifu Tang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Ruibo Zhao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China.
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Prolonged pain in patients with fragility fractures of the pelvis may be due to fracture progression. Eur J Trauma Emerg Surg 2019; 47:507-513. [PMID: 31111165 DOI: 10.1007/s00068-019-01150-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Most fragility fractures of the pelvis (FFPs) are conservatively treated in the early phase. However, the definition of conservative treatment failure and the subsequent treatment protocol is controversial. Fracture progression (FP) sometimes occurs during conservative treatment of FFPs. This study aimed to assess the association between FP and prolonged pain in patients with FFPs receiving conservative treatment. METHODS Retrospective case series in a single institution in Japan. A total of 192 consecutive FFP patients were identified during study period. Seventy-nine patients met the inclusion and exclusion criteria. FFPs were diagnosed using both CT and MRI and FP was diagnosed with CT. Patients met criteria for prolonged pain if they had persisting pain after 2 weeks of conservative treatment and had lack of improvement in mobility. The relationship between FP and prolonged pain was analyzed using Fisher's exact test. RESULTS Of the 79 patients, 18 developed FP. Four of the 18 patients with FP met criteria for prolonged pain. Two of 61 patients without FP had prolonged pain (p = 0.022; odds ratio 8.12). In the entire study cohort, six patients (7.6%) met criteria prolonged pain and underwent elective surgery. CONCLUSION In patients with FFPs, prolonged pain was associated with FP (p = 0.022, OR 8.12). The presence of prolonged pain might help identify FP. If FP is identified, surgical treatment may be required with cautious follow-up particularly in cases, where FFP progresses to type III or IV fracture.
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Liu C, Zhang X, Zhang X, Li Z, Xu Y, Liu T. Bone transport with a unilateral external fixator for femoral infected nonunion after intramedullary nailing fixation: A case control study. Medicine (Baltimore) 2019; 98:e15612. [PMID: 31096468 PMCID: PMC6531196 DOI: 10.1097/md.0000000000015612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 01/27/2023] Open
Abstract
This is a therapeutic study to evaluate the results of femoral infected nonunion using bone transport with an external fixator after debridement and irrigation. We retrospectively reviewed 15 patients with femoral infected nonunion after intramedullary nailing fixation of fractures from October 1999 to January 2010 in our institute. There were 7 males and 8 females with an average age of 32.5 years. First, the infection was eradicated completely, and the medullary canals were continuous irrigated for 2-3 weeks. After eradicating the infection tissues, the mean amount of bone defect was 8.7 cm (range, 4.0-16.0 cm). The unilateral consecutive distraction-compression osteosynthesis technique was applied after long-time medullary cavity-wound exclusion surgery. Enumeration data was described by frequency and measurement data by mean. Bone infections were controlled in all patients except 1 patient after the first debridement and irrigation. All patients have achieved bony union without recurrence of infection during the follow-up period, the mean external fixation index was 43.4 day/cm. According to the criteria recommended by Paley, the bone results were graded as excellent in 13 (86.7%) cases and good in 2 (13.3%) cases; the functional results were graded as excellent in 6 (40.0%) cases, good in 6 (40.0%) cases and fair in 3 (20.0%) cases. In management of femoral infectious nonunion which caused by intramedullary nailing fixation, the surgery of consecutive compression-distraction osteogenesis with unilateral external fixator achieves a highly effective treatment, and the method of debridement and irrigation is a compatible choice on the phase of infection-elimination.
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Affiliation(s)
- Chunfeng Liu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou
- Department of Orthopedics, Suzhou Kowloon Hospital Affiliated to School of Medicine, Shanghai Jiao Tong University, Suzhou
| | - Xianghong Zhang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan
- Department of Orthopedics, Liuzhou General Hospital, Guangxi University of Science and Technology, Liuzhou, Guangxi
| | - Xiangsheng Zhang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan
| | - Zhihong Li
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan
| | - Yaozeng Xu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou
| | - Tang Liu
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan
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Lai PJ, Hsu YH, Chou YC, Yeh WL, Ueng SWN, Yu YH. Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study. BMC Musculoskelet Disord 2019; 20:127. [PMID: 30909909 PMCID: PMC6434807 DOI: 10.1186/s12891-019-2514-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/17/2019] [Indexed: 12/15/2022] Open
Abstract
Background Atrophic nonunion of femoral shaft fracture after intramedullary (IM) nailing is uncommon. The treatment for femoral shaft aseptic atrophic non-union remained controversial. The aim of this study was to compare the surgical results between exchanging reamed nailing (ERN) and augmentative antirotational plating (AAP) for femoral shaft aseptic atrophic nonunion. Methods We retrospectively reviewed the patients with femoral shaft nonunion between the year of 2014 and 2015. The patients with nonunion after plate osteosynthesis, septic nonunion, hypertrophic nonunion, additional surgery during revision surgery were excluded. All the patients were followed up at least 12 months. Results Overall, the union rate after revision surgery was 70.8%. The union rate was significantly higher in the AAP group than in the ERN group. Operating time was also significantly shorter in the AAP group. Regarding the location of nonunion, the union rate was comparable between groups for isthmic nonunions. However, for non-isthmic nonunions, the union rate was significantly higher and operating time was significantly shorter in the AAP group. Conclusion AAP showed an overall higher union rate for management of femoral shaft aseptic atrophic nonunion compared with ERN. Especially for non-isthmic femoral shaft atrophic nonunions, AAP provided a significantly higher union rate and significantly shorter operating time.
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Affiliation(s)
- Po-Ju Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Wen-Ling Yeh
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Steve W N Ueng
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan.
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan.
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