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Chen X, Du J, Zhan W, Shao B, Jiang H, Chen Z, Wang C. Polyene phosphatidylcholine promotes tibial fracture healing in rats by stimulating angiogenesis dominated by the VEGFA/VEGFR2 signaling pathway. Biochem Biophys Res Commun 2024; 719:150100. [PMID: 38763043 DOI: 10.1016/j.bbrc.2024.150100] [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: 03/09/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/21/2024]
Abstract
One of the factors that predispose to fractures is liver damage. Interestingly, fractures are sometimes accompanied by abnormal liver function. Polyene phosphatidylcholine (PPC) is an important liver repair drug. We wondered if PPC had a role in promoting fracture healing. A rat model of tibial fracture was developed using the modified Einhorn model method. X-rays were used to detect the progression of fracture healing. Progress of ossification and angiogenesis at the fracture site were analyzed by Safranin O/fast green staining and CD31 immunohistochemistry. To investigate whether PPC has a direct angiogenesis effect, HUVECs were used. We performed MTT, wound healing, Transwell migration, and tube formation assays. Finally, RT-qPCR and Western blot analysis were used to study the underlying mechanism. The results showed that PPC significantly shortened the apparent recovery time of mobility in rats. PPC treatment significantly promoted the formation of cartilage callus, endochondral ossification, and angiogenesis at the fracture site. In vitro, PPC promoted the proliferative viability of HUVECs, their ability to heal wounds, and their ability to penetrate membranes in the Transwell apparatus and increased the tube formation of cells. The transcription of VEGFA, VEGFR2, PLCγ, RAS, ERK1/2 and MEK1/2 was significantly up regulated by PPC. Further, the protein level results demonstrated a significant increase in the expression of VEGFA, VEGFR2, MEK1/2, and ERK1/2 proteins. In conclusion, our findings suggest that PPC promotes angiogenesis by activating the VEGFA/VEGFR2 and downstream signaling pathway, thereby accelerating fracture healing.
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Affiliation(s)
- Xing Chen
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Jinge Du
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Wenxuan Zhan
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Binghao Shao
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Huaying Jiang
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Zhaolong Chen
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Chunmei Wang
- School of Life Science, Beijing University of Chinese Medicine, Beijing, 100029, China.
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Dabert A, Runtz A, Leclerc G, Sergent P, Loisel F, Pluvy I, Fradin T, Garbuio P. Bone consolidation under septic condition and hardware retention: about 69 patients. Orthop Traumatol Surg Res 2024:103942. [PMID: 39030127 DOI: 10.1016/j.otsr.2024.103942] [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: 06/22/2023] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Management of infection on internal fixation hardware is particularly complex. The main aim of the present study was to assess bone consolidation rates under septic conditions in patients treated for bone and joint infection (BJI) with hardware retention. Secondary objectives were to determine a time limit beyond which it is unreasonable to retain hardware, and to assess risk factors for non-consolidation and functional results. The study hypothesis was that bone consolidation is possible under septic conditions without hardware exchange. MATERIAL AND METHOD A single-center retrospective observational study was conducted on 69 patients for the period January 1, 2009 to December 31, 2019. We included all patients aged over 15 years with infection after internal fixation or fusion whose files had been discussed in the multidisciplinary team meeting during the study period. Bone healing was screened for on X-ray or CT. Study data comprised type of fracture, smoking status, time to treatment for open fracture, initial surgery time, type of hardware, interval between fixation and revision, and type of irrigation. Functional results were assessed at follow-up: walking, pain, return to work and SF12 and QuickDASH scores. RESULTS The bone healing rate was 73.5% (50/68 patients) at a mean 24 weeks (range, 6-68 weeks). Time to revision did not significantly impact consolidation: 60% for 2 weeks (6/10 cases), 80% for 2-10 weeks (35/40 cases), and 64% for >10 weeks (9/14 cases) (p = 0.28). Smoking, longer initial surgery time and Gustilo type IIIb or IIIc were significant risks factors for non-consolidation. DISCUSSION Bone consolidation under septic conditions with hardware retention adhering to an established medical and surgical protocol was reliable and straightforward, without extra morbidity. These findings are encouraging, and in line with the literature. We were unable to determine a time limit beyond which hardware prevented healing. LEVEL OF EVIDENCE IV; descriptive epidemiological study.
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Affiliation(s)
- Alizé Dabert
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France.
| | - Adrien Runtz
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France
| | - Grégoire Leclerc
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France
| | - Pauline Sergent
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France
| | - François Loisel
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France; Laboratoire de Nanomédecine, Imagerie et Thérapeutique EA4662, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | - Isabelle Pluvy
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France; Laboratoire de Nanomédecine, Imagerie et Thérapeutique EA4662, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | - Thomas Fradin
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France
| | - Patrick Garbuio
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, Faculté de Médecine et CHU de Besançon LNIT (UR 4662), F-25000 Besançon, France
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Maisenbacher TC, Libicher S, Erne F, Menger MM, Reumann MK, Schindler Y, Niemeyer F, Engelhardt L, Histing T, Braun BJ. Case Studies of a Simulation Workflow to Improve Bone Healing Assessment in Impending Non-Unions. J Clin Med 2024; 13:3922. [PMID: 38999488 PMCID: PMC11242056 DOI: 10.3390/jcm13133922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/12/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The healing potential of a fracture is determined by mechanical and biological factors. Simulation-based workflows can help assess these factors to assist in predicting non-unions. The aim of this study was the introduction of two use cases for a novel patient-specific simulation workflow based on clinically available information. Methods: The used software is an extension of the "Ulm Bone Healing model" and was applied in two cases with non-union development after fracture fixation to show its principal feasibility. The clinical and radiographic information, starting from initial treatment, were used to feed the simulation process. Results: The simulation predicted non-union development and axial deviation in a mechanically driven non-union. In the case of a biological non-union, a slow, incomplete healing course was correctly identified. However, the time offset in callus bridging was discordant between the simulation and the distinctly slower healing response in the clinical case. Conclusions: The simulation workflow presented in the two clinical use cases allowed for the identification of fractures at risk for impending non-union immediately after the initial fixation based on available clinical and radiographic information. Further validation in a large non-union cohort is needed to increase the model's precision, especially in biologically challenging cases, and show its validity as a screening instrument.
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Affiliation(s)
- Tanja C Maisenbacher
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
| | - Saskia Libicher
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
| | - Felix Erne
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
| | - Maximilian M Menger
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
| | - Marie K Reumann
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
| | - Yannick Schindler
- Project Team OSORA-Medical Fracture Analytics, Ulm University, Helmholtzstr. 20, 89081 Ulm, Germany
| | - Frank Niemeyer
- Project Team OSORA-Medical Fracture Analytics, Ulm University, Helmholtzstr. 20, 89081 Ulm, Germany
| | - Lucas Engelhardt
- Project Team OSORA-Medical Fracture Analytics, Ulm University, Helmholtzstr. 20, 89081 Ulm, Germany
| | - Tina Histing
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
| | - Benedikt J Braun
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Klinik Tuebingen, 72076 Tuebingen, Germany
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Wähnert D, Miersbach M, Colcuc C, Brianza S, Vordemvenne T, Plecko M, Schwarz A. Promoting bone callus formation by taking advantage of the time-dependent fracture gap strain modulation. Front Surg 2024; 11:1376441. [PMID: 38756355 PMCID: PMC11096559 DOI: 10.3389/fsurg.2024.1376441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
Delayed union and non-union of fractures continue to be a major problem in trauma and orthopedic surgery. These cases are challenging for the surgeon. In addition, these patients suffer from multiple surgeries, pain and disability. Furthermore, these cases are a major burden on healthcare systems. The scientific community widely agrees that the stability of fixation plays a crucial role in determining the outcome of osteosynthesis. The extent of stabilization affects factors like fracture gap strain and fluid flow, which, in turn, influence the regenerative processes positively or negatively. Nonetheless, a growing body of literature suggests that during the fracture healing process, there exists a critical time frame where intervention can stimulate the bone's return to its original form and function. This article provides a summary of existing evidence in the literature regarding the impact of different levels of fixation stability on the strain experienced by newly forming tissues. We will also discuss the timing and nature of this "window of opportunity" and explore how current knowledge is driving the development of new technologies with design enhancements rooted in mechanobiological principles.
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Affiliation(s)
- Dirk Wähnert
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Marco Miersbach
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Christian Colcuc
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | | | - Thomas Vordemvenne
- Department of Trauma and Orthopedic Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL of Bielefeld University, Bielefeld, Germany
| | - Michael Plecko
- Department of Orthopaedics and Traumatology, Trauma Hospital Graz (UKH), Graz, Austria
| | - Angelika Schwarz
- Department of Orthopaedics and Traumatology, Trauma Hospital Graz (UKH), Graz, Austria
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5
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Sadeghpour A, Mahdipour S, Ghanjpour Sales J, Aslani H, Moharrami MR, Alizadeh H. Non-cannulated versus cannulated cancellous screws for the internal fixation of femoral neck fractures in osteoporotic patients: A single-blind randomized clinical trial. J Orthop 2024; 51:32-38. [PMID: 38299065 PMCID: PMC10825919 DOI: 10.1016/j.jor.2023.11.074] [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: 07/11/2023] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 02/02/2024] Open
Abstract
Background The incidence of femoral neck fractures in osteoporotic patients is rising worldwide and is associated with significant increases in healthcare and social costs, as well as dependency. Improving minimally invasive treatment strategies, including internal fixation with screws, can result in favorable clinical outcomes and lesser incidence of complications, while preserving the hip. This study compared the outcomes of using non-cannulated cancellous screws (NCS) and cannulated cancellous screws (CS) in the internal fixation of undisplaced intracapsular femoral neck fractures (UIFNF) of osteoporotic patients of Iranian descent. Methods This randomized clinical trial was conducted on the patients referring to an institutional tertiary hospital in northwestern Iran between March 2020 and June 2021. The patients' preoperative, perioperative, and postoperative characteristics were evaluated for at least two years. Primary endpoints were defined as the incidence of hip-related complications, while secondary endpoints were assessed based on the patients' hip function using Harris Hip Score (HHS). Results Fifty-seven patients with osteoporosis and UIFNF were included in the final analysis, with 27 patients in the NCS group and 30 patients in the CS group. The surgical duration, the amount of intraoperative blood loss, and the frequency of C-arm were considerably lower in the CS group (p < 0.05). The incidence of implant failure was higher in the NCS group (p = 0.04). Screw migration occurred more frequently in the CS group (p = 0.03). The HHS values were significantly higher for the NCS group than those of the CS group at both the 1-year and 2-years of follow-up assessments (1 year, p = 0.007; 2 years, p = 0.001). Conclusion Fixation using CS was accompanied by enhanced perioperative outcomes and lower implant failure rates compared to the NCS group. However, patients in the NCS group posed a reduced risk of complications, including screw migration, and experienced a long-term improvement in HHS scores.
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Affiliation(s)
- Alireza Sadeghpour
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahab Mahdipour
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jafar Ghanjpour Sales
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Aslani
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Reza Moharrami
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Alizadeh
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Peng S, Yang X, Zou W, Chen X, Deng H, Zhang Q, Yan Y. A Bioactive Degradable Composite Bone Cement Based on Calcium Sulfate and Magnesium Polyphosphate. MATERIALS (BASEL, SWITZERLAND) 2024; 17:1861. [PMID: 38673218 PMCID: PMC11051185 DOI: 10.3390/ma17081861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
Calcium sulfate bone cement (CSC) is extensively used as a bone repair material due to its ability to self-solidify, degradability, and osteogenic ability. However, the fast degradation, low mechanical strength, and insufficient biological activity limit its application. This study used magnesium polyphosphate (MPP) and constructed a composite bone cement composed of calcium sulfate (CS), MPP, tricalcium silicate (C3S), and plasticizer hydroxypropyl methylcellulose (HPMC). The optimized CS/MPP/C3S composite bone cement has a suitable setting time of approximately 15.0 min, a compressive strength of 26.6 MPa, and an injectability of about 93%. The CS/MPP/C3S composite bone cement has excellent biocompatibility and osteogenic capabilities; our results showed that cell proliferation is up to 114% compared with the control after 5 days. After 14 days, the expression levels of osteogenic-related genes, including Runx2, BMP2, OCN, OPN, and COL-1, are about 1.8, 2.8, 2.5, 2.2, and 2.2 times higher than those of the control, respectively, while the alkaline phosphatase activity is about 1.7 times higher. Therefore, the CS/MPP/C3S composite bone cement overcomes the limitations of CSC and has more effective potential in bone repair.
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Affiliation(s)
- Suping Peng
- School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Xinyue Yang
- School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Wangcai Zou
- School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Xiaolu Chen
- College of Physics, Sichuan University, Chengdu 610065, China
| | - Hao Deng
- College of Physics, Sichuan University, Chengdu 610065, China
| | - Qiyi Zhang
- School of Chemical Engineering, Sichuan University, Chengdu 610065, China
| | - Yonggang Yan
- College of Physics, Sichuan University, Chengdu 610065, China
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Alentado VJ, Kazi FA, Potts CA, Zaazoue MA, Potts EA, Khairi SA. A Sodium Oxychlorosene-Based Infection Prevention Protocol Safely Decreases Postoperative Wound Infections in Adult Spinal Deformity Surgery. Cureus 2024; 16:e56109. [PMID: 38618460 PMCID: PMC11009892 DOI: 10.7759/cureus.56109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION This study sought to determine the efficacy of a complex multi-institutional sodium oxychlorosene-based infection protocol for decreasing the rate of surgical site infection after instrumented spinal surgery for adult spinal deformity (ASD). Infection prevention protocols have not been previously studied in ASD patients. METHODS A retrospective analysis was performed of patients who underwent posterior instrumented spinal fusion of the thoracic or lumbar spine for deformity correction between January 1, 2011, and May 31, 2019. The efficacy of a multi-modal infection prevention protocol was examined. The infection prevention bundle consisted of methicillin-resistant Staphylococcus aureus testing, chlorhexidine gluconate bathing preoperatively, sodium oxychlorosene rinse, vancomycin powder placement, and surgical drain placement at the time of surgery. RESULTS About 254 patients fit the inclusion criteria. Among these patients, nine (3.5%) experienced post-surgical deep-wound infection. Demographics and surgical characteristics amongst infected and non-infected cohorts were similar, although diabetes trended towards being more prevalent in patients who developed a postoperative wound infection (p=0.07). Among 222 patients (87.4%) who achieved a minimum of two years of follow-ups, 184 patients (82.9%) experienced successful fusion, comparing favorably with pseudarthrosis rates in the ASD literature. Rates of pseudarthrosis and proximal junction kyphosis were similar amongst infected and non-infected patients. CONCLUSION An intraoperative comprehensive sodium oxychlorosene-based infection prevention protocol helped to provide a low rate of infection after major deformity correction without negatively impacting other postoperative procedure-related metrics.
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Affiliation(s)
- Vincent J Alentado
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
| | - Fezaan A Kazi
- Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Caroline A Potts
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
| | - Mohamed A Zaazoue
- Neurological Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Eric A Potts
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
| | - Saad A Khairi
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
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Li W, Wang Y, Zhou S, Liu S, Di L, Chen W, Lv H. Development and validation of predictive nomogram for postoperative non-union of closed femoral shaft fracture. Sci Rep 2024; 14:3543. [PMID: 38347044 PMCID: PMC10861573 DOI: 10.1038/s41598-024-53356-x] [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: 06/26/2023] [Accepted: 01/31/2024] [Indexed: 02/15/2024] Open
Abstract
Closed femoral shaft fracture is caused by high-energy injuries, and non-union exists after operation, which can significantly damage patients' body and mind. This study aimed to explore the factors influencing postoperative non-union of closed femoral shaft fractures and establish a predictive nomogram. Patients with closed femoral shaft fractures treated at Hebei Medical University Third Hospital between January 2015 and December 2021 were retrospectively enrolled. A total of 729 patients met the inclusion criteria; of them, those treated in 2015-2019 comprised the training cohort (n = 617), while those treated in 2020-2021 comprised the external validation cohort (n = 112). According to multivariate logistic regression analysis, complex fractures, bone defects, smoking, and postoperative infection were independent risk factors. Based on the factors, a predictive nomogram was constructed and validated. The C-indices in training and external validation cohorts were 0.818 and 0.781, respectively; and the C-index of internal validation via bootstrap resampling was 0.804. The Hosmer-Lemeshow test showed good fit of the nomogram (P > 0.05) consistent with the calibration plot results. The clinical effectiveness was best at a threshold probability of 0.10-0.40 in decision curve analysis. The risk prediction for patients with fractures using this nomogram may aid targeted prevention and rehabilitation programs.
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Affiliation(s)
- Wenjing Li
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Yan Wang
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shuai Zhou
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shihang Liu
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Luqin Di
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Wei Chen
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
| | - Hongzhi Lv
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China.
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
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Craven BC, Giangregorio LM, Côté I, Blencowe L, Miyatani M, Alavinia M. Using Risk Scores to Estimate Lower Extremity Fragility Fracture Risk among Individuals with Chronic Spinal Cord Injury: A Preliminary Model. Top Spinal Cord Inj Rehabil 2023; 29:112-113. [PMID: 38174130 PMCID: PMC10759896 DOI: 10.46292/sci23-00063s] [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] [Indexed: 01/05/2024]
Abstract
Objectives To develop SCI-FX, a risk score to estimate 5-year lower extremity fragility fracture risk among patients living with chronic spinal cord injury (cSCI). Methods Adults with traumatic cSCI (n = 90) participated in a 2-year prospective longitudinal cohort study describing bone mineral density (BMD) change and fracture incidence conducted at the Lyndhurst Centre (University Health Network), University of Waterloo, and Physical Disability Rehabilitation Institute of Québec City. Prior publication and clinical intuition were used to identify fragility fracture risk factors including prior fragility fracture, years post-injury, motor complete injury (AIS A/B), benzodiazepine use, opioid use, and parental osteoporosis. We conducted bivariate analyses to identify variables associated with fracture. Multiple logistic regressions were performed using fragility fracture incidence as the dependent variable and all variables from the univariate analyses with a highly liberal p value at 0.2. Using the odds ratios (ORs) from the multiple logistic regression model, a point system for fragility fracture risk score was developed, and the odds of fracture for each point was estimated. Results All initial variables, with the exception of benzodiazepine exposure, were included in the final model. Conclusion We identified a simple preliminary model for clinicians to estimate 5-year fracture risk among patients with cSCI based on their total score.
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Affiliation(s)
- B. Catharine Craven
- KITE Research Institute, University Health Network. Toronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Kinesiology and Health Science, University of Waterloo, Waterloo, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lora M. Giangregorio
- KITE Research Institute, University Health Network. Toronto, ON, Canada
- Department of Kinesiology and Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Isabelle Côté
- CIUSSSCN - Institut de Réadaptation en Déficience Physique de Québec, Canada
| | - Lindsie Blencowe
- KITE Research Institute, University Health Network. Toronto, ON, Canada
| | - Masae Miyatani
- KITE Research Institute, University Health Network. Toronto, ON, Canada
| | - Mohammad Alavinia
- KITE Research Institute, University Health Network. Toronto, ON, Canada
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Liang C, Jacoby J, Reumann M, Braun B, Ehnert S, Nikolaou K, Springer F, Almansour H. The Impact of Injury of the Tibial Nutrient Artery Canal on Type of Nonunion of Tibial Shaft Fractures: A Retrospective Computed Tomography Study. Acad Radiol 2023; 30:2625-2635. [PMID: 36922344 DOI: 10.1016/j.acra.2023.01.041] [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: 12/30/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 03/16/2023]
Abstract
RATIONALE AND OBJECTIVES Blood supply is vital for sound callus formation. The tibial nutrient artery (TNA) is the main diaphyseal artery nurturing the tibial shaft. The objective is to investigate the impact of TNA canal (TNAC) injury on the development of atrophic, oligotrophic, and hypertrophic nonunion in patients with tibial shaft fractures. MATERIALS AND METHODS Between January 2010 and December 2020, patients with a nonunion of a tibial shaft fracture were retrospectively included. Two readers independently evaluated the integrity of the TNAC and classified nonunion type. A multinomial regression model was utilized to evaluate if a TNAC injury has an impact on the type of nonunion. RESULTS From an initial set of 385 patients with the diagnosis of a nonunion of the lower leg, a total of 60 patients could be finally included in the study. Most patients were males (78%), diabetic (95%), smokers (73%), and had an American Society of Anesthesiologists (ASA) score of 2 (72%). TNAC injury was noted in 24 patients (40%): an iatrogenic TNAC injury was observed in 13 (22%) patients, a traumatic TNAC injury in 11 (18%) patients. Most patients had a hypertrophic nonunion (29 patients (48%)), followed by an oligotrophic nonunion (24 patients (40%)) and lastly an atrophic nonunion (seven patients (11%)). The multinomial regression model showed that there was no impact of TNAC injury on the development of a specific type of non-union (p = 0.798 for oligotrophic vs. atrophic nonunion; p = 0.943 for hypertrophic vs. atrophic nonunion). Furthermore, patients were about four times more likely to develop an oligotrophic/hypertrophic nonunion rather than atrophic one (odds ratio 3.75 and 4.25, respectively), regardless of the presence of a TNAC injury. CONCLUSION In the evaluated patient cohort with tibial shaft fractures, we could not find a statistically significant association between TNAC injury and type of nonunion. However, patients were almost four times more likely to develop oligotrophic or hypertrophic nonunion rather than an atrophic one although common risk factors for impaired (micro)vascular blood supply were highly prevalent in the study group. Multicenter studies with a larger number of atrophic nonunions are warranted to further evaluate this result.
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Affiliation(s)
- Cecilia Liang
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Johann Jacoby
- Institute of Clinical Epidemiology and Applied Biometry, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Marie Reumann
- Department of Trauma Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Benedikt Braun
- Department of Trauma Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Sabrina Ehnert
- Siegfried-Weller-Institute, BG Trauma Center, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany; Department of Diagnostic Radiology, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Fabian Springer
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany; Department of Diagnostic Radiology, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany.
| | - Haidara Almansour
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
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Heyland M, Deppe D, Reisener MJ, Damm P, Taylor WR, Reinke S, Duda GN, Trepczynski A. Lower-limb internal loading and potential consequences for fracture healing. Front Bioeng Biotechnol 2023; 11:1284091. [PMID: 37901836 PMCID: PMC10602681 DOI: 10.3389/fbioe.2023.1284091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction: Mechanical loading is known to determine the course of bone fracture healing. We hypothesise that lower limb long bone loading differs with knee flexion angle during walking and frontal knee alignment, which affects fracture healing success. Materials and methods: Using our musculoskeletal in silico modelling constrained against in vivo data from patients with instrumented knee implants allowed us to assess internal loads in femur and tibia. These internal forces were associated with the clinical outcome of fracture healing in a relevant cohort of 178 extra-articular femur and tibia fractures in patients using a retrospective approach. Results: Mean peak forces differed with femoral compression (1,330-1,936 N at mid-shaft) amounting to about half of tibial compression (2,299-5,224 N). Mean peak bending moments in the frontal plane were greater in the femur (71-130 Nm) than in the tibia (from 26 to 43 Nm), each increasing proximally. Bending in the sagittal plane showed smaller mean peak bending moments in the femur (-38 to 43 Nm) reaching substantially higher values in the tibia (-63 to -175 Nm) with a peak proximally. Peak torsional moments had opposite directions for the femur (-13 to -40 Nm) versus tibia (15-48 Nm) with an increase towards the proximal end in both. Femoral fractures showed significantly lower scores in the modified Radiological Union Scale for Tibia (mRUST) at last follow-up (p < 0.001) compared to tibial fractures. Specifically, compression (r = 0.304), sagittal bending (r = 0.259), and frontal bending (r = -0.318) showed strong associations (p < 0.001) to mRUST at last follow-up. This was not the case for age, body weight, or localisation alone. Discussion: This study showed that moments in femur and tibia tend to decrease towards their distal ends. Tibial load components were influenced by knee flexion angle, especially at push-off, while static frontal alignment played a smaller role. Our results indicate that femur and tibia are loaded differently and thus require adapted fracture fixation considering load components rather than just overall load level.
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Affiliation(s)
- Mark Heyland
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Deppe
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Marie Jacqueline Reisener
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- Centre for Muskuloskeletal Surgery (CMSC), Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Damm
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - William R. Taylor
- Laboratory for Movement Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Simon Reinke
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Georg N. Duda
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Adam Trepczynski
- Julius Wolff Institute, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
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12
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Liu H, Li T, Ma B, Wang Y, Sun J. Hyaluronan and Proteoglycan Link Protein 1 Activates the BMP4/Smad1/5/8 Signaling Pathway to Promote Osteogenic Differentiation: an Implication in Fracture Healing. Mol Biotechnol 2023; 65:1653-1663. [PMID: 36737556 DOI: 10.1007/s12033-023-00677-3] [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: 12/08/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
Osteoblast regeneration, characterized by osteoblast differentiation, is the basis of fracture healing and accelerates fracture repair. It has been reported that hyaluronan and proteoglycan link protein 1 (HAPLN1) is overexpressed during osteoblast differentiation and regulates cartilage regeneration, but its function in fracture healing remains unclear. To elucidate this issue, we collected clinical blood samples of fracture healing, established a femoral fracture rat model, and induced an osteoblast differentiation cell model. We found that HAPLN1 was overexpressed in the serum of patients with fracture healing and the bone tissues of rats with fracture healing. Furthermore, the expression of HAPLN1 was increased time dependently during the osteogenic differentiation of MC3T3-E1 cells. HAPLN1 silencing prevented osteoblast differentiation and mineralization in MC3T3-E1 cells as evidenced by decreased osteoblast differentiation-related factors, suppressed alkaline phosphatase activities, and reduced alizarin red positive staining. Mechanically, the bone morphogenic protein 4 (BMP4)/Smad1/5/8 pathway, a facilitator of osteoblastic differentiation, was found to be inhibited by HAPLN1 knockdown, and inhibition of BMP4/Smad1/5/8 signaling enhanced the effects caused by HAPLN1 silencing. These findings demonstrated that HAPLN1 might promote fracture healing by facilitating osteogenic differentiation through the BMP4/Smad1/5/8 pathway, indicating that targeting HAPLN1 may be a feasible therapeutic candidate for fracture repair.
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Affiliation(s)
- Hu Liu
- Department of Pediatric Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Tao Li
- Department of Pediatric Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ben Ma
- Department of Pediatric Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yue Wang
- Department of Pediatric Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jun Sun
- Department of Pediatric Orthopedics, Anhui Province Children's Hospital Affiliated to Anhui Medical University, No. 39, Wangjiang East Road, Hefei, Anhui, China.
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13
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Schultz BV, Watt K, Rashford S, Wylie J, Bosley E. Epidemiology of open limb fractures attended by ambulance clinicians in the out-of-hospital setting: A retrospective analysis. Australas Emerg Care 2023; 26:216-220. [PMID: 36621412 DOI: 10.1016/j.auec.2023.01.001] [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: 10/27/2022] [Revised: 12/25/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023]
Abstract
BACKGROUND Open limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients METHODS: We undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 - December 2019). RESULTS Overall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22-59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62-144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval. CONCLUSION Open limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohorts.
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Affiliation(s)
- Brendan V Schultz
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia.
| | - Kerrianne Watt
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD Australia
| | - Stephen Rashford
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia
| | - James Wylie
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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14
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Allen E, Houston J, Smith RM, Trompeter AJ. Shear's role in non-union. Measuring mean angle of long bone multi-fragmentary non-unions. Injury 2023; 54:110873. [PMID: 37344268 DOI: 10.1016/j.injury.2023.110873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 05/19/2023] [Accepted: 06/03/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Both mechanical and biological theories have been proposed in the development of non-union. The mechanical theory suggests that a high strain environment in a fracture will predispose it to non-union. While in simple fractures and wedge fractures there are only one and two primary fracture planes respectively, in multi-fragmentary fractures there are many and a non-union may form along any of the original fracture lines, however the plane which experiences the highest strain is at 45O - the shear plane. We hypothesise that in multi-fragmentary fractures the initial fracture line that most often fails to unite will tend towards the plane with the highest strain. OBJECTIVES 1) Define the mean non-union angle in a cohort of multi-fragmentary tibial and femoral fractures. 2) In wedge-like fractures within the cohort, define and compare the mean angle of initial fracture planes which go on to form a non-union to those that unite 3) In comminuted fractures within the cohort, define the mean non-union angle DESIGN: Retrospective cohort study SETTING: Level-1 trauma centre METHODOLOGY: Fractures were categorised into wedge-like and comminuted. A published technique was utilised to measure fracture and non-union angles. In wedge-like fractures, united and non-united initial planes were compared. In comminuted fractures only the mean non-union angle was defined. Demographic patient data was also collected. RESULTS 183 non-unions were screened, 68 patients were included. The mean non-union angle was 56°(SD 18) across all fractures. In wedge-like fractures the mean non-union angle was 59°(SD 18). In comminuted fractures the mean non-union angle was 50°(SD 19). Non-united initial fracture planes in wedge-like fractures showed a peaked distribution about a mean of 58° while united fracture planes were distributed at the extremities of the range. CONCLUSIONS In patients with multi-fragmentary fractures resulting in non-union, the mean tibial non-union angle was 52° while the mean femoral non-union angle was 65°. In wedge-like fractures, non-unions occurred more commonly than appropriate union in fractures between 41°-80°. The non-union angle is closer to 45° in comminuted fractures than in wedge-like fractures. These results support the mechanical theory that strain from the shear plane is an important factor in the formation of non-unions. LEVEL OF EVIDENCE Prognostic level 3.
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Affiliation(s)
- Edward Allen
- Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Eastern Road, Brighton, United Kingdom.
| | - James Houston
- Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom
| | - Raymond M Smith
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Alex J Trompeter
- Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom
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15
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Migliorini F, Cocconi F, Vecchio G, Schäefer L, Koettnitz J, Maffulli N. Pharmacological agents for bone fracture healing: talking points from recent clinical trials. Expert Opin Investig Drugs 2023; 32:855-865. [PMID: 37740660 DOI: 10.1080/13543784.2023.2263352] [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: 04/18/2023] [Accepted: 09/22/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Pharmacological strategies might influence bone healing in terms of time to union or quality of mature bone. This expert opinion discussed the current level I evidence on the experimental pharmacological agents used to favor bone fracture healing. AREAS COVERED This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In April 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, Embase. All the randomized clinical trials investigating pharmacological agents for bone fracture healing were accessed. No time constraint was set for the search. The search was restricted to RCTs. No additional filters were used in the database search. Data from 19 RCTs (4067 patients) were collected. 78% (3160 of 4067) were women. The mean length of the follow-up was 9.3 months (range, 1-26 months). The mean age of the patients was 64.4 years (range, 8-84 years). EXPERT OPINION Calcitonin could favor bone fracture healing. Bisphosphonates (alendronate, zoledronate, clodronate), monoclonal antibodies (denosumab, romosozumab), statins, vitamin D and calcium supplementation, strontium ranelate, and ibuprofen did not influence bony healing. Concerning the effect of parathormone, current level I evidence is controversial, and additional studies are required. LEVEL OF EVIDENCE Level I, systematic review of RCTs.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, Germany
| | - Federico Cocconi
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Bolzano, Italy
| | - Gianluca Vecchio
- Department of Trauma and Orthopaedic Surgery, University Hospital Sant' Andrea, University La Sapienza, Rome, Italy
| | - Luise Schäefer
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, Germany
| | - Julian Koettnitz
- Department of Orthopedics, Auguste-Viktoria Clinic, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, University Hospital Sant' Andrea, University La Sapienza, Rome, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, UK
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16
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Williams A, Miniato M, Pasquinelly A, Gillette M, Sanford C, Graves M. Intercalary Tricortical Iliac Crest Graft for Treatment of Midclavicle Nonunion With Bone Loss: Two Case Reports and Review of Literature. Cureus 2023; 15:e40265. [PMID: 37440817 PMCID: PMC10335879 DOI: 10.7759/cureus.40265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Several articles support the use of cancellous iliac crest bone grafting in the treatment of clavicle nonunion; however, there is very little literature on the use of tricortical iliac crest grafts in the setting of clavicle nonunion with bone loss. When it has been studied, tricortical grafting has been shown to produce radiologically confirmed union in the clavicle, leaving patients satisfied with the ultimate outcome. We present two cases of clavicle fracture nonunion successfully treated with tricortical interposition bone grafting. In the first case, a 45-year-old female presented with an atrophic left midshaft clavicle fracture nonunion with failed hardware that had undergone two previous attempts at fixation without achieving union. She was treated with a structural interposition iliac crest bone graft with plate fixation and regained full painless function of the arm with radiographic fracture union. In the second case, a 50-year-old male presented after a left midshaft clavicle fracture that had undergone acute stabilization, followed by revision for nonunion that was unsuccessful, resulting in persistent nonunion with bone loss. He was treated with a tricortical iliac crest bone graft and plate fixation. Cultures from the time of surgery did grow Staphylococcus epidermidis and Propionibacterium acnes, and he was treated with intravenous vancomycin for six weeks. The patient's clavicle went on to union and he regained full, painless function by his six-month follow-up visit. These cases demonstrate the use of tricortical interposition bone grafting with compression plating as a viable option for rare instances in which previous surgical intervention has failed to progress a midshaft clavicle fracture to union.
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Affiliation(s)
- Austin Williams
- Department of Orthopedic Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Mohammed Miniato
- Department of Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Adam Pasquinelly
- Department of Orthopedic Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Marshall Gillette
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, USA
| | - Christopher Sanford
- Department of Orthopedic Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Matthew Graves
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, USA
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17
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Bouchard C, Sanscartier PK. Nonunion in Orthognathic Surgery: A Case-Series of 15 Patients. J Oral Maxillofac Surg 2023:S0278-2391(23)00396-8. [PMID: 37220869 DOI: 10.1016/j.joms.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/22/2023] [Accepted: 04/27/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Bone nonunion is extensively studied in the orthopedic literature, but the knowledge in oral and maxillofacial surgery, specifically orthognathic surgery, is scarce. Since this complication has a significant negative impact on postoperative management of patients, more studies are needed. PURPOSE To report the characteristics of patients presenting with bone nonunion after orthognathic surgery. STUDY DESIGN, SETTING, SAMPLE This is a retrospective case-series study on subjects who underwent orthognathic surgery between 2011 and 2021 and developed nonunion. Inclusion criteria were mobility at the site of the osteotomy and the need for a second surgical intervention. Exclusion criteria were an incomplete medical chart; the absence of nonunion upon surgical exploration, or radiological evidence of nonunion; cleft lip/palate; or syndromic patients. MAIN OUTCOME VARIABLE The outcome variable was bone healing after nonunion care. COVARIATES Demographics (age, sex), medical/dental comorbidities, type of surgery (type of fixation, bone grafts, Botox injection), amplitude of movements, nonunion treatment. ANALYSES Descriptive statistics were computed for each study variable. RESULTS The sample was composed of 15 patients (11 females, mean age 40.4 years old) with nonunion (maxilla: 8 cases, mandible: 7 cases) out of 2036 patients who underwent orthognathic surgery during the period studied (incidence 0.74%). Nine (60%) were bruxers, three were smokers (20%) and one had diabetes. Mean forward movement of the maxilla was 6.55 mm (4-9 mm) and 7.71 mm (4.8-12 mm) for the mandible. All patients but one (who refused surgery) were treated by curettage of fibrous tissue and new hardware placement. In addition, 11 received a bone graft, and 4 had Botox injections. All osteotomies healed after the second surgical intervention. CONCLUSION Curettage with or without grafting appears to be a good strategy for the cure of nonunion. Bruxism may be a risk factor (60% of patients were bruxers in this study).
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Affiliation(s)
- Carl Bouchard
- Associate professor of oral and maxillofacial surgery.
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18
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The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist. J Hand Surg Am 2023; 48:158-164. [PMID: 35933253 DOI: 10.1016/j.jhsa.2022.05.016] [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: 11/08/2021] [Revised: 04/08/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union. METHODS All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union. RESULTS A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09-4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%). CONCLUSIONS Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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19
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Tucker NJ, Mauffrey C, Parry JA. Are pre- and postoperative true translational and angular displacement predictive of nonunion after intramedullary nail fixation of tibial shaft fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:37-43. [PMID: 34716497 DOI: 10.1007/s00590-021-03154-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/17/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE To determine if there is an association between pre-/postoperative translational and angular displacement with nonunion after intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS Retrospective review of 120 patients with tibial shaft fractures undergoing IMN at an urban level-one trauma center was performed. Demographics, injury characteristics, and pre-/postoperative translational and angular fracture displacement in the coronal and sagittal planes were recorded. True fracture translational and angular displacement (TTD and TAD) were calculated by combining sagittal and coronal displacement utilizing the Pythagorean theorem. RESULTS 10.8% of patients (n = 13) developed nonunion with remaining patients serving as the control. Groups were similar across age, sex, and BMI. Univariate analysis revealed no difference in pre-/postoperative TAD between nonunion and union groups and an increased preoperative TTD (median difference (MD): 6.2 mm, CI: 1.4-10.8 mm) and postoperative TTD (MD: 1.8 mm, CI: 0-3.7 mm) in the nonunion group. On multivariate analysis, however, only tobacco use and type 2 or 3 open fractures were associated with nonunion (OR: 5.1, CI: 1.2-22.8 and OR: 4.9, CI: 1.2-19.2, respectively). CONCLUSION True translational and angular displacement of tibial shaft fractures before and after IMN fixation were not independently associated with nonunion. Tobacco use and type 2 or 3 open fracture are independent factors for nonunion.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, USA
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, USA. .,University of Colorado School of Medicine, Aurora, CO, USA.
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20
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Treatment of Femoral Shaft Pseudarthrosis, Case Series and Medico-Legal Implications. J Clin Med 2022; 11:jcm11247407. [PMID: 36556022 PMCID: PMC9787375 DOI: 10.3390/jcm11247407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/14/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Pseudarthrosis (PSA) is a possible complication of femoral shaft fracture treatment. It is often associated with reduced bone quality and can, therefore, adversely affect quality of life. Its treatment poses a major challenge for orthopaedic surgeons. Several authors have set forth different surgical approaches for the treatment of pseudarthrosis, such as internal fixation with plate and screws, replacement of an intramedullary nail or prosthetic replacement. In cases associated with bone loss, osteopenia, or comminution of fracture fragments, autologous or homologous bone grafts may also be used. The chronic outcomes of the surgical treatment of femoral shaft pseudarthrosis, even when consolidation is achieved, are linked to disabling sequelae of clinical-functional relevance, deserving an adequate medico-legal evaluation. The purpose of this retrospective study is to analyse a clinical case series of patients treated for atrophic femoral shaft pseudarthrosis at the IRCCS Orthopaedic Institute Galeazzi, Milan, Italy, from 2014 to 2020 and their orthopaedic-traumatological and medico-legal implications.
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Proximal ulna non-union: treatment concept and postoperative outcome. INTERNATIONAL ORTHOPAEDICS 2022; 46:2859-2868. [PMID: 36102978 DOI: 10.1007/s00264-022-05577-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/03/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Non-union of the proximal ulna is a serious complication after surgical treatment of olecranon and complex elbow fractures, frequently leading to poor functional outcome. To date, there is a lack of data regarding optimal treatment strategies and functional outcome parameters after surgical revision. METHODS From 02/2010 to 12/2018, 31 patients undergoing surgical treatment of proximal ulna non-union could be included. Follow-up period was seven years (SD 2.5 years). All patients were clinically assessed using a clinical assessment tool set and standard elbow scores (MEPS, OES, DASH score). All complications and unplanned revision surgeries were recorded and all radiographic material was analyzed. RESULTS Initial non-union procedures were performed at an average of 6.6 months (SD 3 months) after the index procedures. Those included the use of autologous spongiosa graft in all patients and concomitant compression re-osteosynthesis in 28 patients. Radiological consolidation was achieved in all patients. Overall, patients achieved a good to fair functional outcome with Mayo elbow performance score measuring 78.5 (SD 9.1), DASH score 34.7 (SD 14.4), and Oxford elbow score 31.2 (SD 6.6) points. Initial malreduction/implant-malposition could be identified as a main reason for the occurrence of the non-union. Furthermore, inferior postoperative outcome was detected in patients > 60 years and BMI > 30 kg/m2. CONCLUSION Using a standardized protocol, bony union and acceptable functional outcomes can be achieved in proximal ulna non-unions. However, surgeons should be aware of potential risk factors and proper initial fracture reduction as key to achieve sufficient bone healing.
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Boishardy A, Bouyer B, Boissière L, Larrieu D, Pereira SN, Kieser D, Pellisé F, Alanay A, Kleinstuck F, Pizones J, Obeid I. Surgical site infection is a major risk factor of pseudarthrosis in adult spinal deformity surgery. Spine J 2022; 22:2059-2065. [PMID: 36084897 DOI: 10.1016/j.spinee.2022.08.022] [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: 03/11/2022] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite the evidence in appendicular skeletal surgery, the effect of infection on spinal fusion remains unclear, particularly after Adult Spinal Deformity (ASD) surgery. PURPOSE The purpose of this study was to determine the impact of surgical site infection (SSI) in ASD surgery fusion rates and its association with other risks factors of pseudarthrosis. STUDY DESIGN We conducted an international multicenter retrospective study on a prospective cohort of patients operated for spinal deformity. PATIENT SAMPLE A total of 956 patients were included (762 females and 194 males). OUTCOME MEASURES Patient's preoperative characteristics, pre and postoperative spinopelvic parameters, surgical variables, postoperative complications and were recorded. Surgical site infections were asserted in case of clinical signs associated with positive surgical samples. Each case was treated with surgical reintervention for debridement and irrigation. Presence of pseudarthrosis was defined by the association of clinical symptoms and radiological signs of nonfusion (either direct evidence on CT-scan or indirect radiographic clues such as screw loosening, rod breakage, screw pull out or loss of correction). Each iterative surgical intervention was collected. METHODS Univariate and multivariate analysis with logistic regression models were performed to evaluate the role of risk factors of pseudarthrosis. RESULTS Nine hundred fifty-six surgical ASD patients with more than two years of follow-up were included in the study. 65 of these patients were treated for SSI (6.8%), 138 for pseudarthrosis (14.4%), and 28 patients for both SSI and pseudarthrosis. On multivariate analysis, SSI was found to be a major risk factor of pseudarthrosis (OR=4.4; 95% CI=2.4,7.9) as well as other known risks factors: BMI (OR=1.1; 95% CI=1.0,1.1), smoking (OR=1.6; 95% CI=1.1,2.9), performance of Smith-Petersen osteotomy (OR = 1.6; 95% CI 1.0,2.6), number of vertebrae instrumented (OR=1.1; 95% CI=1.1,1.2) and the caudal level of fusion, with a distal exponential increment of the risk (OR max for S1=6, 95% CI=1.9,18.6). CONCLUSION SSI significantly increases the risk of pseudarthrosis with an OR of 4.4.
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Affiliation(s)
- Alice Boishardy
- Université de Bordeaux, Bordeaux University Hospital, Department of Spinal Surgery Unit 1, C.H.U Tripode Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux, France.
| | - Benjamin Bouyer
- Université de Bordeaux, Bordeaux University Hospital, Department of Spinal Surgery Unit 1, C.H.U Tripode Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - Louis Boissière
- Université de Bordeaux, Bordeaux University Hospital, Department of Spinal Surgery Unit 1, C.H.U Tripode Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux, France; Clinique du Dos-Bordeaux and ELSAN Polyclinique Jean Villar, 33520, Bruges, France
| | - Daniel Larrieu
- Institut de la colonne vertébrale, Spine Unit 1, Bordeaux University Hospital, Bordeaux, France
| | | | - David Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Ferran Pellisé
- Spine Surgery Unit, University Hospital Vall D'Hebron, Barcelona, Spain
| | - Ahmet Alanay
- Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | | | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Ibrahim Obeid
- Université de Bordeaux, Bordeaux University Hospital, Department of Spinal Surgery Unit 1, C.H.U Tripode Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux, France; Clinique du Dos-Bordeaux and ELSAN Polyclinique Jean Villar, 33520, Bruges, France
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Mazur M, Beyer J, Elsamaloty M, Patel D, Liu J, Ebraheim NA. Surgical outcomes of periprosthetic distal femur fractures after total knee arthroplasty classified by Su et al. system. J Orthop 2022; 34:260-265. [PMID: 36148178 PMCID: PMC9486061 DOI: 10.1016/j.jor.2022.09.005] [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: 06/19/2022] [Revised: 08/26/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background Periprosthetic fractures of the distal femur remain a challenge to treat due to variations in both patient- and fracture-specific factors. This study was designed to analyze the outcomes of different subtypes of periprosthetic distal femur fractures based on the Su et al. classification system. Methods Thirty-six patients were classified with Su et al. system. All Type I and II fractures were managed with a locking plate. Most Type III fractures were managed with locking plate, while two were managed with long-stem revision arthroplasty due to evidence of implant loosening. Outcomes were measured and analyzed based on healing time, revision rate, and complication rate. Results Of the 36 patients, 30 (83.3%) achieved acceptable fracture union, while the remaining 6 (16.7%) experienced either delayed union or non-union. Type I fractures showed a significantly lower healing time than Type II and III fractures managed by locking plate. Delayed union was present in the Type II group, while non-union was recorded for two Type III fractures. Need for revision was more prevalent in fracture Types II and III. Conclusion The Su et al. system of classification for periprosthetic fractures of the distal femur matches the clinical outcomes of this study and would seem to be useful in the approach to the treatment of these fractures. The majority of these fractures can be managed with locking plate with reasonable results. However, if the implant is loosened in Type III fractures, revision arthroplasty is suggested.
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Affiliation(s)
- Matthew Mazur
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Julia Beyer
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Mazzin Elsamaloty
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Devon Patel
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Jiayong Liu
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Nabil A. Ebraheim
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
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Kan T, He Z, Du J, Xu M, Cui J, Han X, Tong D, Li H, Yan M, Yu Z. Irisin promotes fracture healing by improving osteogenesis and angiogenesis. J Orthop Translat 2022; 37:37-45. [PMID: 36196152 PMCID: PMC9513699 DOI: 10.1016/j.jot.2022.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 06/27/2022] [Accepted: 07/15/2022] [Indexed: 11/08/2022] Open
Abstract
Background Osteogenesis and angiogenesis are important for bone fracture healing. Irisin is a muscle-derived monokine that is associated with bone formation. Methods To demonstrate the effect of irisin on bone fracture healing, closed mid-diaphyseal femur fractures were produced in 8-week-old C57BL/6 mice. Irisin was administrated intraperitoneally every other day after surgery, fracture healing was assessed by using X-rays. Bone morphometry of the fracture callus were assessed by using micro-computed tomography. Femurs of mice from each group were assessed by the three-point bending testing. Effect of irisin on osteogenic differentiation in mesenchymal stem cells in vitro was evaluated by quantitative real-time polymerase chain reaction (qRT-PCR), alkaline phosphatase staining and alizarin red staining. Angiogenesis of human umbilical vein endothelial cells (HUVECs) were evaluated by qRT-PCR, migration tests, and tube formation assays. Results Increased callus formation, mineralization and tougher fracture healing were observed in the irisin-treated group than in the control group, indicating the better fracture callus healing due to Irisin treatment. The vessel surface and vessel volume fraction of the callus also increased in the irisin-treated group. The expression of BMP2, CD31, and VEGF in callus were enhanced in the irisin-treated group. In mouse bone mesenchymal stem cells, irisin promoted ALP expression and mineralization, and increased the expression of osteogenic genes, including OSX, Runx2, OPG, ALP, OCN and BMP2. Irisin also promoted HUVEC migration and tube formation. Expression of angiogenic genes, including ANGPT1, ANGPT2, VEGFb, CD31, FGF2, and PDGFRB in HUVECs were increased by irisin. Conclusion All the results indicate irisin can promote fracture healing through osteogenesis and angiogenesis. These findings help in the understanding of muscle–bone interactions during fracture healing. The Translational Potential of this Article Irisin was one of the most important monokine secreted by skeletal muscle. Studies have found that irisin have anabolic effect one bone remodeling through affecting osteocyte and osteoblast. Based on our study, irisin could promote bone fracture healing by increasing bone mass and vascularization, which provide a potential usage of irisin to promote fracture healing and improve clinical outcomes.
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Lu F, Wu X, Hu H, He Z, Sun J, Zhang J, Song X, Jin X, Chen G. Emodin Combined with Multiple-Low-Frequency, Low-Intensity Ultrasound To Relieve Osteomyelitis through Sonoantimicrobial Chemotherapy. Microbiol Spectr 2022; 10:e0054422. [PMID: 36069576 PMCID: PMC9603654 DOI: 10.1128/spectrum.00544-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
Treatment of osteomyelitis is still challenging, as conventional antibiotic therapy is limited by the emergence of resistant strains and the formation of biofilms. Sonoantimicrobial chemotherapy (SACT) is a novel therapy of low-frequency and low-intensity ultrasound (LFLIU) combined with a sonosensitizer. Therefore, in our study, a sonosensitizer named emodin (EM) was proposed to be combined with LFLIU to relieve acute osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) through antibacterial and antibiofilm effects. The efficiencies of different intensities of ultrasound, including single (S-LFLIU, 15 min) and multiple ultrasound (M-LFLIU, 3 times for 5 min at 4-h intervals), against bacteria and biofilms were compared, contributing to developing the best treatment regimen. Our results demonstrated that EM plus S-LFLIU or M-LFLIU (EM+S-LFLIU or EM+M-LFLIU) had significant combined bactericidal and antibiofilm effects, with EM+M-LFLIU in particular exhibiting superior antibiofilm performance. Furthermore, it was suggested that EM+M-LFLIU could produce a large amount of reactive oxygen species (ROS), destroy the integrity of the bacterial membrane and cell wall, and downregulate the expression of genes involved in oxidative stress, membrane wall synthesis, and bacterial virulence, as well as that of other related genes (agrB, pbp3, sgtB, gmk, zwf, and msrA). In vivo studies, micro-computed tomography (micro-CT), hematoxylin and eosin (H&E) staining, enzyme-linked immunosorbent assay (ELISA), and bacterial quantification of bone tissue indicated that EM+M-LFLIU could also relieve osteomyelitis due to MRSA infection. Our work proffers an original approach to bacterial osteomyelitis treatment that weakens drug-resistant bacteria and suppresses and degrades biofilm formation through SACT, which may provide new prospects for clinical treatment. IMPORTANCE Antibiotic therapy is the first choice for clinical treatment of osteomyelitis, but the formation of bacterial biofilms and the emergence of many drug-resistant strains also create an urgent need to find an alternative treatment to effectively eliminate the infection. Recently, LFLIU has come to be considered a safe and promising method of debridement and antibacterial therapy. In this study, we found that ultrasound and EM have a significant combined antibacterial effect in vivo and in vitro, which may play an antibacterial role by stimulating the production of ROS, destroying the bacterial cell wall, and inhibiting the expression of related genes. Our study expands the body of knowledge on the antibacterial effect of drugs-specifically emodin (EM)-through combined physiotherapy. If successfully integrated into clinical practice, these methods may reduce the burden of high concentrations of drugs needed to treat bacterial biofilms and avoid the growing resistance of bacteria to antibiotics.
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Affiliation(s)
- Feng Lu
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
- Zhejiang University School of Medicine, Hangzhou, China
| | - Xinhui Wu
- Wenzhou Medical University, Wenzhou, China
- Department of Orthopedics, Taizhou Hospital Affiliated with Wenzhou Medical University, Linhai, China
| | - Huiqun Hu
- Zhejiang University School of Medicine, Hangzhou, China
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zixuan He
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
- Zhejiang University School of Medicine, Hangzhou, China
| | - Jiacheng Sun
- Wenzhou Medical University, Wenzhou, China
- Department of Orthopedics, Taizhou Hospital Affiliated with Wenzhou Medical University, Linhai, China
| | - Jiapeng Zhang
- Wenzhou Medical University, Wenzhou, China
- Department of Orthopedics, Taizhou Hospital Affiliated with Wenzhou Medical University, Linhai, China
| | - Xiaoting Song
- Wenzhou Medical University, Wenzhou, China
- Department of Orthopedics, Taizhou Hospital Affiliated with Wenzhou Medical University, Linhai, China
| | - Xiangang Jin
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
- Zhejiang University School of Medicine, Hangzhou, China
| | - Guofu Chen
- Department of Orthopedics, Taizhou Hospital Affiliated with Wenzhou Medical University, Linhai, China
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Panagiotopoulou VC, Santolini E, Jones E, Jha A, Giannoudis PV. Adhesives for treatment of bone fractures: A review of the state-of-the art. Injury 2022; 53 Suppl 2:S20-S25. [PMID: 33752878 DOI: 10.1016/j.injury.2021.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 11/29/2020] [Accepted: 02/10/2021] [Indexed: 02/02/2023]
Abstract
Treatment of fractures remains challenging and carries a high economical burden to both patients and society. In order to prevent some of the complications, the use of bone adhesives has been proposed, but up to date, bone adhesives are not part of the current clinical practice. Early results of use of bone cements and bone glues are promising, focusing in the areas of highly fragmented fractures, fixation of long bone fractures, filling bone voids and defects, promoting osseointegration, preventing non-union while maintaining the reduction of fracture fixation. This review aims to describe the state-of-the-art of the development, properties and use of adhesives in fracture treatment.
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Affiliation(s)
| | - Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy
| | - Elena Jones
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Animesh Jha
- School of Chemical and Process Engineering, University of Leeds, Leeds, LS2 9JT, United Kingdom
| | - Peter V Giannoudis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom; Leeds General Infirmary, Department of Trauma and Orthopaedic Surgery, University of Leeds, Leeds, United Kingdom
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Giannoudis PV. Letter to the Editor Response: 'Classification of non-union: Need for a new scoring system?'. Injury 2022; 53:3565. [PMID: 35778303 DOI: 10.1016/j.injury.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds Teaching Hospitals, Leeds, UK.
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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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Jiang Y, Wang X, Huang W, Zhu Y, Zhang K, Feng D. A novel bone graft technique combined with plating for aseptic recalcitrant long bone nonunion. BMC Musculoskelet Disord 2022; 23:873. [PMID: 36127646 PMCID: PMC9487050 DOI: 10.1186/s12891-022-05830-8] [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: 02/24/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background To evaluate the outcomes and efficacy of a new technique of autogenous iliac crest bone grafting combined with locking compression plate (LCP) vertical fixation for aseptic recalcitrant long bone nonunion. Methods From July 2010 to September 2020, 36 aseptic recalcitrant long bone nonunions were treated with a bone-forming channel technique and internal LCP fixation. All the patients had received one or more failed treatments. The injury mechanism, nonunion type and duration, and prior treatments were recorded pre-operation. The routine treatment process included nonunion area exposure, previous implant removal, sclerotic bone debridement, LCP fixation, bone-forming channel creation, and iliac bone grafting, and a second LCP fixation when required. At follow-up, X-ray images were obtained to assess bone healing and implant failure. Visual analog scale (VAS), fracture site stability, limb function, activity, muscle strength, limb length, and complications were recorded. Results A total of 34 patients (24 males and 10 females) were finally enrolled, with a mean age of 49.8 ± 12.3 years. At a mean follow-up of 35.6 ± 22.0 months, 32 patients displayed bone union, with a healing rate of 94.1% and mean union time of 6.8 ± 2.4 months. The VAS score was 0.7 ± 1 at the final follow-up. The functional results showed that 19 patients were excellent, 11 patients were good, 2 patients were poor, and 2 patients did not heal. Conclusion Bone-forming channel technique combined with LCP vertical fixation is an excellent option to treat recalcitrant long bone nonunion. Level of evidence Therapeutic Level IV.
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Affiliation(s)
- Yuxuan Jiang
- Department of Orthopaedic Trauma, Hong Hui Hospital, Xi'an Jiaotong University School of Medicine, Youyi Road, Xi'an, Shaanxi Province, 710054, China
| | - Xiaolong Wang
- Department of Orthopaedic Trauma, Hong Hui Hospital, Xi'an Jiaotong University School of Medicine, Youyi Road, Xi'an, Shaanxi Province, 710054, China
| | - Wei Huang
- Department of Orthopaedic Trauma, Hong Hui Hospital, Xi'an Jiaotong University School of Medicine, Youyi Road, Xi'an, Shaanxi Province, 710054, China
| | - Yangjun Zhu
- Department of Orthopaedic Trauma, Hong Hui Hospital, Xi'an Jiaotong University School of Medicine, Youyi Road, Xi'an, Shaanxi Province, 710054, China
| | - Kun Zhang
- Department of Orthopaedic Trauma, Hong Hui Hospital, Xi'an Jiaotong University School of Medicine, Youyi Road, Xi'an, Shaanxi Province, 710054, China
| | - Dongxu Feng
- Department of Orthopaedic Trauma, Hong Hui Hospital, Xi'an Jiaotong University School of Medicine, Youyi Road, Xi'an, Shaanxi Province, 710054, China.
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Gencer B, Doğan Ö, Igdir V, Çulcu A, Caliskan E, Biçimoğlu A. Searching for a New Parameter in the Healing of Tibia Pilon Fractures: Fracture Area Measurement. J Am Podiatr Med Assoc 2022; 112:20-137. [PMID: 33734386 DOI: 10.7547/20-137] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tibia pilon fractures are associated with high complication rates, decreased quality of life, and low patient satisfaction. Although many factors such as reduction quality and soft-tissue coverage have been identified, researchers continue to investigate the factors that affect healing in tibia pilon fractures. Our objective was to investigate the effect of initial fracture crack width and displacement degree on clinical functional results in tibia pilon fractures. METHODS In this retrospective cohort study, 40 patients with Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association type 43B and 43C tibia pilon fractures and operated on through the extensile anteromedial approach were analyzed. The demographic data of the patients, injury mechanisms, fracture type, reduction quality, clinical results, and postoperative complications were recorded. To evaluate the objective quantity of initial fracture crack width and displacement, a new parameter was defined: "fracture area." All measurements were conducted using a feature from the picture archiving and communication system on anteroposterior and lateral radiographs taken separately in standard fashion. RESULTS With an average follow-up period of 29.2 months (range, 24-40 months), 34 patients (85%) had excellent or good results, whereas only two patients (5%) had poor clinical results. Age, injury mechanism, and reduction quality have a significant relationship with Maryland Foot Score (P < .001, P < .037, and P < .001, respectively). Preoperative fracture area, measured on both the anteroposterior and the lateral views, are significantly related to both Ovadia-Beals Score and Maryland Foot Score (P < .001 for each). CONCLUSIONS Preoperative fracture area measurement has a major effect on healing of tibia pilon fractures. Increased initial fracture area is correlated with poor clinical functional results. High-energy injuries, older age, and poor reduction quality are also related to worse clinical outcomes.
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Affiliation(s)
- Batuhan Gencer
- *Ankara City Hospital, Orthopaedics and Traumatology Clinic, Üniversiteler Mahallesi, Çankaya, Ankara, Turkey
| | - Özgür Doğan
- *Ankara City Hospital, Orthopaedics and Traumatology Clinic, Üniversiteler Mahallesi, Çankaya, Ankara, Turkey
| | - Volkan Igdir
- †Batman Education and Research Hospital, Orthopaedics and Traumatology Clinic, Batman, Turkey
| | - Ahmet Çulcu
- ‡Yüksekova State Hospital, Orthopaedics and Traumatology Clinic, Hakkari, Turkey
| | - Emrah Caliskan
- §Koç University Hospital, Orthopaedics and Traumatology Department, Istanbul, Turkey
| | - Ali Biçimoğlu
- *Ankara City Hospital, Orthopaedics and Traumatology Clinic, Üniversiteler Mahallesi, Çankaya, Ankara, Turkey
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Xu S, Wu Q, He B, Rao J, Chow DHK, Xu J, Wang X, Sun Y, Ning C, Dai K. Interactive effects of cerium and copper to tune the microstructure of silicocarnotite bioceramics towards enhanced bioactivity and good biosafety. Biomaterials 2022; 288:121751. [PMID: 36031456 DOI: 10.1016/j.biomaterials.2022.121751] [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: 12/21/2021] [Revised: 07/09/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022]
Abstract
Endowing biomaterials with functional elements enhances their biological properties effectively. However, improving bioactivity and biosafety simultaneously is still highly desirable. Herein, cerium (Ce) and copper (Cu) are incorporated into silicocarnotite (CPS) to modulate the constitution and microstructure for degradability, bioactivity and biosafety regulation. Our results demonstrated that introducing Ce suppressed scaffold degradation, while, co-incorporation of both Ce and Cu accelerated degradability. Osteogenic effect of CPS in vitro was promoted by Ce and optimized by Cu, and Ce-induced angiogenic inhibition could be mitigated by cell coculture method and reversed by Ce-Cu co-incorporation. Ce enhanced osteogenic and angiogenic properties of CPS in a dose-dependent manner in vivo, and Cu-Ce coexistence exhibited optimal bioactivity and satisfactory biosafety. This work demonstrated that coculture in vitro was more appropriately reflecting the behavior of implanted biomaterials in vivo. Interactive effects of multi-metal elements were promising to enhance bioactivity and biosafety concurrently. The present work provided a promising biomaterial for bone repair and regeneration, and offered a comprehensive strategy to design new biomaterials which aimed at adjustable degradation behavior, and enhanced bioactivity and biosafety.
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Affiliation(s)
- Shunxiang Xu
- The Education Ministry Key Lab of Resource Chemistry and Shanghai Key Laboratory of Rare Earth Functional Materials and Shanghai Frontiers Science Center of Biomimetic Catalysis, Shanghai Normal University, No. 100, Guilin Road, Xuhui District, Shanghai, 200234, PR China; Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology Faculty of Medicine, The Chinese University of Hong Kong, No. 437, Ma Liu Shui, Shatin, New Territories, Hong Kong SAR, 999077, PR China
| | - Qiang Wu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, PR China
| | - Bo He
- The Education Ministry Key Lab of Resource Chemistry and Shanghai Key Laboratory of Rare Earth Functional Materials and Shanghai Frontiers Science Center of Biomimetic Catalysis, Shanghai Normal University, No. 100, Guilin Road, Xuhui District, Shanghai, 200234, PR China
| | - Jiancun Rao
- AIM Lab, Maryland NanoCenter, University of Maryland, MD, 20742, USA
| | - Dick Ho Kiu Chow
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology Faculty of Medicine, The Chinese University of Hong Kong, No. 437, Ma Liu Shui, Shatin, New Territories, Hong Kong SAR, 999077, PR China
| | - Jiankun Xu
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology Faculty of Medicine, The Chinese University of Hong Kong, No. 437, Ma Liu Shui, Shatin, New Territories, Hong Kong SAR, 999077, PR China
| | - Xin Wang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, PR China
| | - Ye Sun
- Department of Orthopaedics, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Gulou District, Nanjing, 210029, PR China
| | - Congqin Ning
- The Education Ministry Key Lab of Resource Chemistry and Shanghai Key Laboratory of Rare Earth Functional Materials and Shanghai Frontiers Science Center of Biomimetic Catalysis, Shanghai Normal University, No. 100, Guilin Road, Xuhui District, Shanghai, 200234, PR China.
| | - Kerong Dai
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, PR China.
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Lahoti O, Abhishetty N, Al-Mukhtar M. Transfocal Osteotomy to Treat Shear (Oblique) Non-union of Tibia. Strategies Trauma Limb Reconstr 2022; 17:117-122. [PMID: 35990182 PMCID: PMC9357796 DOI: 10.5005/jp-journals-10080-1555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aseptic non-unions of tibial shaft fractures often need surgical treatment which carry significant socio-economic implications. The causes for non-union include patient co-morbidities, high energy trauma, open fractures and fracture geometry. Oblique fractures are subject to shear forces and, if not adequately neutralised, will fail to unite. Experiments have shown that callus formation is poor in oblique fractures due to local shear stresses. We report a technique of minimally invasive transfocal transverse osteotomy and compression in a hexapod circular fixator, Taylor Spatial Frame (TSF) for 12 patients treated with a shear non-union of tibia between 2010 and 2019. There are four female and eight male patients. The average age is 49 years (range from 26 to 72 years). The fracture pattern was oblique (30–45°) in all cases. Healing of the non-union occurred in 12 cases with one case needed additional treatment with bone marrow aspirate and demineralized bone matrix. The technique of creating a minimally invasive transfocal transverse osteotomy through the oblique non-union of tibia and the use of a hexapod circular fixator to compress the osteotomy is described and adds to the range of treatments available for aseptic non-union of tibia.
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Affiliation(s)
- Om Lahoti
- Department of Trauma and Orthopaedics, Kings College Hospital, London, United Kingdom
- Om Lahoti, Department of Trauma and Orthopaedics, Kings College Hospital, London, United Kingdom, e-mail:
| | - Naveen Abhishetty
- Department of Trauma and Orthopaedics, Kings College Hospital, London, United Kingdom
| | - Mohannad Al-Mukhtar
- Department of Trauma and Orthopaedics, Kings College Hospital, London, United Kingdom
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Lackington WA, Gehweiler D, Zhao E, Zderic I, Nehrbass D, Zeiter S, González-Vázquez A, O'Brien FJ, Stoddart MJ, Thompson K. Interleukin-1 receptor antagonist enhances the therapeutic efficacy of a low dose of rhBMP-2 in a weight-bearing rat femoral defect model. Acta Biomater 2022; 149:189-197. [PMID: 35840106 DOI: 10.1016/j.actbio.2022.07.012] [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: 03/21/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/01/2022]
Abstract
In the clinical treatment of fractures, rhBMP-2 administration is associated with a well-established profile of side-effects, including osteolysis and ectopic bone formation, which are driven by pro-inflammatory processes triggered by the use of high doses. Immunomodulatory strategies could minimize the incidence of side-effects by enabling the use of lower, and safer, rhBMP-2 doses. This study investigated whether interleukin-1 receptor antagonist (IL-1Ra) can enhance the therapeutic efficacy of a low dose of rhBMP-2 in a weight-bearing femoral fracture healing model. Exogenous IL-1Ra, in combination with rhBMP-2, was delivered using a collagen-hydroxyapatite scaffold (CHA) to attenuate IL-1β produced in response to fracture. Femoral defects were treated with CHA scaffolds alone, or loaded with IL-1Ra (2.5 µg), rhBMP-2 (1 µg), IL-1Ra (2.5 µg) in combination with rhBMP-2 (1 µg). Bone healing was assessed over 14 weeks in comparison to control groups, empty defect, and a higher dose of rhBMP-2 (5 µg), which were recently demonstrated to lead to non-union, and successful bridging of the defect, respectively. The combination of IL-1Ra and rhBMP-2 led to significantly faster early bone formation, at both week 4 and 6, compared to a low dose of rhBMP-2 alone. By 14 weeks, the combination of IL-1Ra and a rhBMP-2 promoted full bridging of femurs, which were 3-fold more mechanically reliable compared to the femurs treated with a low dose of rhBMP-2 alone. Taken together, this study demonstrates that IL-1Ra can significantly enhance femoral bone healing when used in combination with a low dose of rhBMP-2. STATEMENT OF SIGNIFICANCE: Enabling the use of lower and safer doses of rhBMP-2, a potent inducer of bone formation, is of clinical relevance in orthopaedic medicine. In this study, the immunomodulatory interleukin-1 receptor antagonist (IL-1Ra) was investigated for its capacity to enhance the therapeutic efficacy of rhBMP-2 when used at lower doses in a weight-bearing femoral fracture healing model. The combination of IL-1Ra and rhBMP-2 led to significantly faster early bone formation, and resulted in more mechanically reliable healed femurs, compared to a low dose of rhBMP-2 alone. This demonstrates for the first time in a rat long bone healing model that IL-1Ra can significantly enhance bone healing when used in combination with a low dose of rhBMP-2.
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Affiliation(s)
- William A Lackington
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland; Present address: Empa, Swiss Federal Laboratories for Materials Science and Technology, Laboratory for Biointerfaces, St. Gallen, Switzerland
| | - Dominic Gehweiler
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Ensi Zhao
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Dirk Nehrbass
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Stephan Zeiter
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Arlyng González-Vázquez
- Tissue Engineering Research Group, Dept. of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin, Ireland; AMBER Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal J O'Brien
- Tissue Engineering Research Group, Dept. of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin, Ireland; AMBER Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Martin J Stoddart
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Keith Thompson
- AO Research Institute Davos, AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland.
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Egol KA, Walden T, Gabor J, Leucht P, Konda SR. Hip-preserving surgery for nonunion about the hip. Arch Orthop Trauma Surg 2022; 142:1451-1457. [PMID: 33635401 DOI: 10.1007/s00402-021-03820-4] [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: 08/20/2020] [Accepted: 02/04/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Nonunions about the hip occur as a result of femoral neck, intertrochanteric, and certain subtrochanteric fractures. Treatment of a hip fracture nonunion allows for the choice between hip preservation or arthroplasty. The goal of this study was to examine outcomes of hip-preservation nonunion surgery METHODS: Patients who underwent hip preservation for a fracture nonunion of the femoral neck, intertrochanteric and subtrochanteric region to 1 cm below the lesser trochanter over a 10-year period were identified in our nonunion registry. Patients were followed for a minimum of 1 year. Functional outcomes were recorded at follow-up visits. For comparison regarding surgical and hospital outcomes, a group of 23 patients who underwent conversion total hip arthroplasties (cTHA) at the same academic medical center was reviewed. Quality measures such as length of stay, reoperation, and complications were collected. All statistics analysis utilized IBM SPSS 25 (Armonk, NY) RESULTS: Thirty patients who underwent 30 hip-preserving nonunion surgeries were analyzed and compared with 23 cTHA patients. Twenty-nine nonunions went on to heal (average time to union 6.3 months). There was improvement in functional outcome scores for the hip preservation group between baseline and latest follow-up (p < 0.001). Reoperation was required in five patients (17%), including four failed to heal and required a second repair to gain union and one failure that was converted to THA rather than attempt a second nonunion repair. Hip preservation failures were older than those that healed with the index treatment (p = 0.11). There was no significant difference in hospital length of stay, complication rate, or need for reoperation when compared to cTHA group. CONCLUSION Hip-preserving surgery is an option that should be considered for patients with nonunion of fractures about the hip. The rates of complications (20.3 vs 17.3%) and reoperation (16.7 vs 17.3%) were equivalent to conversion THA. Excellent outcomes can be achieved in terms of radiographic union and function with hip preservation.
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Affiliation(s)
- Kenneth A Egol
- NYU Langone Orthopedic Hospital, New York, NY, USA. .,Jamaica Hospital Medical Center, New York, NY, USA.
| | | | | | | | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, New York, NY, USA.,Jamaica Hospital Medical Center, New York, NY, USA
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Ganse B, Orth M, Roland M, Diebels S, Motzki P, Seelecke S, Kirsch SM, Welsch F, Andres A, Wickert K, Braun BJ, Pohlemann T. Concepts and clinical aspects of active implants for the treatment of bone fractures. Acta Biomater 2022; 146:1-9. [PMID: 35537678 DOI: 10.1016/j.actbio.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/24/2022] [Accepted: 05/02/2022] [Indexed: 12/17/2022]
Abstract
Nonunion is a complication of long bone fractures that leads to disability, morbidity and high costs. Early detection is difficult and treatment through external stimulation and revision surgery is often a lengthy process. Therefore, alternative diagnostic and therapeutic options are currently being explored, including the use of external and internal sensors. Apart from monitoring fracture stiffness and displacement directly at the fracture site, it would be desirable if an implant could also vary its stiffness and apply an intervention to promote healing, if needed. This could be achieved either by a predetermined protocol, by remote control, or even by processing data and triggering the intervention itself (self-regulated 'intelligent' or 'smart' implant). So-called active or smart materials like shape memory alloys (SMA) have opened up opportunities to build active implants. For example, implants could stimulate fracture healing by active shortening and lengthening via SMA actuator wires; by emitting pulses, waves, or electromagnetic fields. However, it remains undefined which modes of application, forces, frequencies, force directions, time durations and periods, or other stimuli such implants should ideally deliver for the best result. The present paper reviews the literature on active implants and interventions for nonunion, discusses possible mechanisms of active implants and points out where further research and development are needed to build an active implant that applies the most ideal intervention. STATEMENT OF SIGNIFICANCE: Early detection of delays during fracture healing and timely intervention are difficult due to limitations of the current diagnostic strategies. New diagnostic options are under evaluation, including the use of external and internal sensors. In addition, it would be desirable if an implant could actively facilitate healing ('Intelligent' or 'smart' implant). Implants could stimulate fracture healing via active shortening and lengthening; by emitting pulses, waves, or electromagnetic fields. No such implants exist to date, but new composite materials and alloys have opened up opportunities to build such active implants, and several groups across the globe are currently working on their development. The present paper is the first review on this topic to date.
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Jensen SS, Jensen NM, Gundtoft PH, Kold S, Zura R, Viberg B. Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis. EFORT Open Rev 2022; 7:516-525. [PMID: 35900220 PMCID: PMC9297052 DOI: 10.1530/eor-21-0137] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Signe Steenstrup Jensen
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Niels Martin Jensen
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
| | - Per Hviid Gundtoft
- Department of Orthopedic Surgery and Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Kold
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Robert Zura
- Department of Orthopedic Surgery, Louisiana State University Medical Center, New Orleans, Louisiana, USA
| | - Bjarke Viberg
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Abstract
Physiologic bone healing involves numerous parameters, such as microstability, fracture morphology, or tissue perfusion, to name just a few. Slight imbalances or a severe impairment of even one of these factors may, as the figurative weakest link in the chain, crucially or completely inhibit the regenerative potential of a fractured bone. This review revisits the physiology and pathophysiology of fracture healing and provides an insight into predispositions, subtypes, diagnostic tools, and therapeutic principles involved with delayed fracture healing and nonunions. Depending on the patients individual risk factors, nonunions may develop in a variety of subtypes, each of which may require a slightly or fundamentally different therapeutical approach. After a detailed analysis of these individual factors, additional diagnostic tools, such as magnetic resonance imaging (MRI), dynamic contrast-enhanced MRI, sonography, or contrast-enhanced ultrasonography, may be indicated to narrow down the most likely cause for the development of the nonunion and therefore help find and optimize the ideal treatment strategy.
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Affiliation(s)
- Paul Mick
- Center for Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
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Bohner M, Maazouz Y, Ginebra MP, Habibovic P, Schoenecker JG, Seeherman H, van den Beucken JJ, Witte F. Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification. Acta Biomater 2022; 145:1-24. [PMID: 35398267 DOI: 10.1016/j.actbio.2022.03.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.
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Wang JH, Chuang HC, Su WR, Chang WL, Kuan FC, Hong CK, Hsu KL. The characteristics and influence of iatrogenic fracture comminution following antegrade interlocking nailing for simple femoral shaft fractures, a retrospective cohort study. BMC Musculoskelet Disord 2022; 23:456. [PMID: 35568932 PMCID: PMC9107635 DOI: 10.1186/s12891-022-05418-2] [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] [Received: 12/10/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
AIM The incidence and characteristics of iatrogenic comminution (IC) are unknown, and the influence of IC on fracture union is unclear. This study was aimed to investigate the (1) incidence and characteristics of IC and (2) the outcomes of IC following antegrade interlocking nailing of simple femoral shaft fractures. METHODS We retrospectively collected data on patients who experienced simple femoral shaft fractures and underwent antegrade interlocking nailing between February 2009 and December 2016. The incidence and characteristics of IC were examined. According to the presence of IC, patients were divided into two groups: an IC group and a non-IC (NIC) group. Demographic information and nonunion rates were compared between the two groups. Potential risk factors for IC (age, gender, body mass index (BMI), nail fit ratio, reduction technique, and greater trochanter nail entry) were analyzed using univariate and multivariate logistic regression. The aforementioned variables, along with IC occurrence, were also assessed as potential risk factors for nonunion at 12 and 24 months after operation using multivariate logistic regression. RESULTS Of the 211 total patients, IC occurred in 20.9% (n = 44) of patients. Most ICs were found at the level of the isthmus, and involved the medial cortex. Compared with the NIC group, higher nonunion rates were observed in the IC group at 12 months (31.8% vs. 12.5%, p = 0.002) and 24 months (18% vs. 6.5%, p = 0.017) after surgery. Age older than 35 years old was related with the occurrence of IC in univariate analysis. Multivariate analysis found no risk factor associated with IC. Open reduction technique, IC occurrence and higher BMI were identified as the risk factors of nonunion at 12 months and 24 months after surgery in multivariate analysis. CONCLUSION IC is a non-rare complication in antegrade interlocking nailing of simple femoral shaft fractures and was associated with higher nonunion rate. Age older than 35 years old showed a trend toward increasing risk of iatrogenic fracture comminution. In multivariate analysis, open reduction technique, IC occurrence and higher BMI significantly correlated with fracture nonunion. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Chun Chuang
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Lun Chang
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital DouLiou Branch, National Cheng Kung University, Douliu, Yunlin, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Division of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital DouLiou Branch, National Cheng Kung University, Douliu, Yunlin, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
- Division of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital DouLiou Branch, National Cheng Kung University, Douliu, Yunlin, Taiwan.
- Department of Orthopaedics, National Cheng Kung University Hospital, No.138, Sheng Li Road, 704, Tainan, Taiwan.
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Patient and Surgical Factors Affecting Fusion Rates After Arthroscopic and Open Ankle Fusion: A Review of a High-Risk Cohort. Indian J Orthop 2022; 56:1217-1226. [PMID: 35813539 PMCID: PMC9232662 DOI: 10.1007/s43465-021-00580-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/21/2021] [Indexed: 02/04/2023]
Abstract
ABSTRACT We present a case series with the objective of identifying risk factors for nonunion after open and arthroscopic primary ankle arthrodesis. Eighty-seven patients who underwent primary ankle arthrodesis and met inclusion criteria were divided into open (N = 46) and arthroscopic (N = 41) groups. Patient and operative characteristics were retrospectively analyzed as possible risk factors for nonunion within each technique. The nonunion rate was 11% in the open and 12% in the arthroscopic group. Obesity, smoking, and ASA class 3 were highly prevalent in both groups. In the arthroscopic group, a remote history of infection and the use of headed screws had notably higher risk of nonunion, though not statistically significant. In the open group, use of bone graft trended toward lower risk of nonunion, though also not statistically significant. The results of this study demonstrated, nonunion rates are comparable between open and arthroscopic ankle arthrodesis in high-risk patients. For patients with a remote history of infection, open ankle arthrodesis may be preferable, and bone graft importance may vary with open versus arthroscopic technique. LEVEL OF EVIDENCE III.
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Hildebrand M, Herrmann M, Gieling F, Gehweiler D, Mischler D, Verrier S, Alini M, Zeiter S, Thompson K. Development and characterization of a predictive microCT-based non-union model in Fischer F344 rats. Arch Orthop Trauma Surg 2022; 142:579-590. [PMID: 33174612 DOI: 10.1007/s00402-020-03680-4] [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: 06/21/2020] [Accepted: 10/28/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Non-unions remain a clinical problem and are characterised by the failure to heal after a defined period of time. Current preclinical non-union models apply a wide variety of techniques to diminish intrinsic healing potential deviating from the clinical situation. The aim of this study was to develop and characterise a non-union model in rats using internal plate fixation without the need for additional healing insults, whereby bone healing can be longitudinally assessed using microCT. It was hypothesized that healing/non-unions can be accurately predicted at early time points by microCT. MATERIALS AND METHODS Female, skeletally mature Fischer F344 rats received a 2 mm or 1 mm femoral osteotomy, stabilized with either a 2 mm thick plate or a 1.25 mm thick plate. Healing was monitored by microCT over 14 weeks and histological analysis at euthanasia. The mechanical environment was characterised using finite element (FE) modelling and biomechanical testing. RESULTS The majority of animals receiving the 2 mm thick plate displayed poor healing responses in both the 2 mm and 1 mm defect size groups. Bone and cartilage formation were markedly improved using the 1.25 mm thick plate. MicroCT could accurately predict bone forming capacity at early time points (3-4 weeks). CONCLUSIONS The 2 mm thick plating system confers poor healing responses in female Fischer F344 rats, comparable to atrophic non-unions. By reducing plate thickness to increase interfragmentary strain within the defect site healing is improved, leading to borderline healing situations or increased abundance of cartilage tissue present in the defect site with ultimate failure to bridge the defect (hypertrophic non-union). Furthermore, microCT can reliably identify delayed/non-healing animals within 4 weeks, thereby allowing their selective targeting for the testing of novel, clinically relevant treatment strategies in different clinical situations aimed at restoring impaired bone healing.
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Affiliation(s)
- M Hildebrand
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - M Herrmann
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland.,IZKF Research Group Tissue Regeneration in Musculoskeletal Diseases, University Hospital Würzburg and Orthopedic Center for Musculoskeletal Research, University of Würzburg, Würzburg, Germany
| | - F Gieling
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - D Gehweiler
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - D Mischler
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - S Verrier
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - M Alini
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - S Zeiter
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland
| | - K Thompson
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos-Platz, Switzerland.
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Upadhyay P, Syed F, Ramoutar DN, Ward J. The missing piece of the trauma armoury-medial femoral condyle plate. Injury 2022; 53:1237-1240. [PMID: 34839895 DOI: 10.1016/j.injury.2021.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 10/16/2021] [Accepted: 11/14/2021] [Indexed: 02/02/2023]
Abstract
Fixation of distal femoral fractures is often challenging due to the fracture configuration and associated poor bone quality. Dual plating (lateral and medial) has become an acceptable option to provide improved stability versus a single plate fixation. Though there are several commercially available anatomically designed plates for the lateral femoral condyle, there is no anatomic plate available in UK specifically for medial fixation of distal femur fractures. Our aim is to determine the best suited pre-contoured plate for stabilising the medial femoral condyle (MFC). Right sided femur sawbones were used to determine how well 18 different pre-contoured anatomical plates (Depuy Synthes, Leeds, UK) fit the medial femoral condyle. Some of these had variable angle (VA) option. Lift off, fit and notch penetration were assessed and recorded independently by 4 orthopaedic trauma surgeons. The number and distribution of screws in the MFC that each plate allowed was also determined. To do this the MFC was divided into quadrants: Proximal anterior (PA), distal anterior (DA), proximal posterior (PP) and distal posterior (DP). The ipsilateral anterolateral proximal tibial (VA and 4.5 mm non-VA), PHILOS, posteromedial proximal tibial and ipsilateral lateral extra-articular distal humeral plate offered good sagittal fit, less than 2 mm lift off at the condyles and no diaphyseal lift off. Plate positioning in the PA quadrant offered the best fit. The ipsilateral anterolateral proximal tibial plates (VA) and PHILOS allowed at least 4 screws to be placed in the PA and 2 in the PP quadrant with no notch penetration. The Tomofix provided good fit, but all 4 screws were in PA quadrant, with distal screws causing notch penetration. The non-VA and PHILOS plates did not offer the VA advantage. The ipsilateral anterolateral proximal tibial VA plates provided the best anatomical fit for the MFC with the greatest number of screws in the condylar quadrants with the option of variable angle screw placement.
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Affiliation(s)
- Piyush Upadhyay
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK; School of Engineering, University of Warwick, Coventry CV4 7AL
| | - Farhan Syed
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK.
| | - Darryl N Ramoutar
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Jayne Ward
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
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Nasser AAH, Fenton P, Bose D. Single stage versus two-stage orthoplastic management of bone infection. Injury 2022; 53:984-991. [PMID: 35063261 DOI: 10.1016/j.injury.2022.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. METHODS Using an existing 2009-2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. RESULTS A total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. CONCLUSIONS The single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.
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Affiliation(s)
- Ahmed A H Nasser
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK.
| | - Paul Fenton
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
| | - Deepa Bose
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
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Natalwala I, Chuo CB, Shariatmadari I, Barlow G, Moulder E, Bates J, Sharma H. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2022; 16:161-167. [PMID: 35111255 PMCID: PMC8778722 DOI: 10.5005/jp-journals-10080-1536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures. Materials and methods Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation. Results A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3–13) compared to IMF at 1 day (IQR 0–3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation. Conclusion Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation. How to cite this article Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161–167.
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Affiliation(s)
- Ibrahim Natalwala
- Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
- Ibrahim Natalwala, Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom, e-mail:
| | - Cher Bing Chuo
- Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Isla Shariatmadari
- Department of General Surgery, Bristol Hospitals NHS Trust, Bristol, United Kingdom
| | - Gavin Barlow
- Department of Infectious Diseases, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Elizabeth Moulder
- Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Joanna Bates
- Department of Radiology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Hemant Sharma
- Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
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Sinnott B, Ray C, Weaver F, Gonzalez B, Chu E, Premji S, Raiford M, Elam R, Miskevics S, Parada S, Carbone L. Risk Factors and Consequences of Lower Extremity Fracture Nonunions in Veterans With Spinal Cord Injury. JBMR Plus 2022; 6:e10595. [PMID: 35309860 PMCID: PMC8914149 DOI: 10.1002/jbm4.10595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022] Open
Abstract
We used Veterans Health Administration (VHA) national administrative data files to identify a cohort (fiscal years 2005–2014) of veterans with spinal cord injuries and disorders (SCID) to determine risk factors for and consequences of lower extremity fracture nonunions. Odds ratios (OR) for fracture nonunion were computed using multivariable‐adjusted logistic regression models. We identified three risk factors for nonunion: (i) older age (OR = 2.29; 95% confidence interval [CI] 1.21–4.33), (ii) longer duration of SCID (OR = 1.02; 95% CI 1.00–1.04), and (iii) fracture site (distal femur), with OR (comparison distal femur) including distal tibia/fibula (OR = 0.14; 95% CI 0.09–0.24), proximal tibia/fibula (OR = 0.19; 95% CI 0.09–0.38), proximal femur (OR = 0.10; 95% CI 0.04–0.21), and hip (OR = 0.13; 95% CI 0.07–0.26). Nonunions resulted in multiple complications, with upwards of 1/3 developing a pressure injury, 13% osteomyelitis, and almost 25% requiring a subsequent amputation. Our data have identified a high‐risk population for fracture nonunion of older veterans with a long duration of SCID who sustain a distal femur fracture. In view of the serious complications of these nonunions, targeted interventions in these high‐risk individuals who have any signs of delayed union should be considered. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Bridget Sinnott
- Charlie Norwood Veterans Affairs Medical Center Augusta GA USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs Hines VA Hospital Hines IL USA
| | - Frances Weaver
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs Hines VA Hospital Hines IL USA
- Parkinson School of Health Sciences and Public Health Loyola University Maywood IL USA
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs Hines VA Hospital Hines IL USA
- Feinberg School of Medicine Northwestern University Chicago IL USA
- Department of Biostatistics University of Illinois Chicago IL USA
- Department of Mathematics Northeastern Illinois University Chicago IL USA
| | - Elizabeth Chu
- Division of Rheumatology, Medical College of Georgia Augusta University Augusta GA USA
| | - Sarah Premji
- Division of Rheumatology, Medical College of Georgia Augusta University Augusta GA USA
| | - Mattie Raiford
- Division of Rheumatology, Medical College of Georgia Augusta University Augusta GA USA
| | - Rachel Elam
- Charlie Norwood Veterans Affairs Medical Center Augusta GA USA
- Division of Rheumatology, Medical College of Georgia Augusta University Augusta GA USA
| | - Scott Miskevics
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs Hines VA Hospital Hines IL USA
| | - Stephen Parada
- Department of Orthopaedic Surgery, Medical College of Georgia Augusta University Augusta GA USA
| | - Laura Carbone
- Charlie Norwood Veterans Affairs Medical Center Augusta GA USA
- Division of Rheumatology, Medical College of Georgia Augusta University Augusta GA USA
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Bleeker NJ, van Veelen NM, van de Wall BJM, Sierevelt IN, Link BC, Babst R, Knobe M, Beeres FJP. MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients. Eur J Trauma Emerg Surg 2022; 48:3683-3691. [PMID: 34984496 DOI: 10.1007/s00068-021-01836-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/08/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia. MATERIALS AND METHODS All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities. RESULTS A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes. CONCLUSION Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.
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Affiliation(s)
- Nils Jan Bleeker
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Nicole M van Veelen
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Inger N Sierevelt
- Specialized Center of Orthopaedic Research and Education (SCORE), Orthopaedic Department, Xpert Clinics, Amsterdam, The Netherlands
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland.,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
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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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48
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Mondanelli N, Troiano E, Facchini A, Cesari M, Colasanti GB, Bottai V, Muratori F, Caffarelli C, Gonnelli S, Giannotti S. Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem. Geriatr Orthop Surg Rehabil 2021; 12:21514593211067072. [PMID: 34992896 PMCID: PMC8725223 DOI: 10.1177/21514593211067072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/30/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases. SIGNIFICANCE This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present. RESULTS Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period. CONCLUSION Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.
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Affiliation(s)
- Nicola Mondanelli
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Martina Cesari
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | | | - Vanna Bottai
- Second Clinic of Orthopedic and
Traumatology, University of Pisa, Pisa, Italy
| | - Francesco Muratori
- Section of Orthopedic Oncology and
Reconstructive Surgery, Azienda Ospedaliero-Universitaria
Careggi, Firenze, Italy
| | - Carla Caffarelli
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Internal Medicine, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Stefano Gonnelli
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Internal Medicine, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
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Risk Factors for Development of a Recalcitrant Femoral Nonunion: A Single Surgeon Experience in 122 Patients. J Orthop Trauma 2021; 35:619-625. [PMID: 34596060 DOI: 10.1097/bot.0000000000002276] [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] [Accepted: 09/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. DESIGN Longitudinal observational cohort study. SETTING Academic Level 1 trauma center. PATIENTS/PARTICIPANTS One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018. INTERVENTION Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion. RESULTS Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures. CONCLUSIONS The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion. LEVEL OF EVIDENCE Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence.
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50
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Neumeister MW, Winters JN, Maduakolum E. Phalangeal and Metacarpal Fractures of the Hand: Preventing Stiffness. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3871. [PMID: 34729287 PMCID: PMC8553242 DOI: 10.1097/gox.0000000000003871] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/24/2021] [Indexed: 11/26/2022]
Abstract
Fractures of the phalangeal or metacarpal bones of the hand are common. Many of these fractures are treated without surgery. However, both conservative and operative management of fractures of the hand can result in stiffness. Stiffness is the most common complication in the management of hand fractures. The key to preventing stiffness is early range of motion exercises. This article challenges many of the current treatment regimens offered to patients with the so-called unstable fractures. The evaluation of the patients' function is the primary factor that should determine the course of conservation versus operative management. X-rays do not demonstrate function and therefore act as an adjunct only to the care of the patient. The goal of treating hand fractures is to restore function. Early motion may not only improve healing but may also hasten the return to normal hand function. The tenets of how to prevent stiffness are described in this review.
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Affiliation(s)
- Michael W. Neumeister
- From the Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - James N. Winters
- Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
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