Flexible intramedullary nails for limb lengthening: a comprehensive comparative study of three nails types

Multifunctional scaffolds for bone repair following age-related biological decline: Promising prospects for smart biomaterial-driven technologies

The repair of large bone defects due to trauma, disease, and infection can be exceptionally challenging in the elderly. Despite best clinical practice, bone regeneration within contemporary, surgically implanted synthetic scaffolds is often problematic, inconsistent, and insufficient where additional osteobiological support is required to restore bone. Emergent smart multifunctional biomaterials may drive important and dynamic cellular crosstalk that directly targets, signals, stimulates, and promotes an innate bone repair response following age-related biological decline and when in the presence of disease or infection. However, their role remains largely undetermined. By highlighting their mechanism/s and mode/s of action, this review spotlights smart technologies that favorably align in their conceivable ability to directly target and enhance bone repair and thus are highly promising for future discovery for use in the elderly. The four degrees of interactive scaffold smartness are presented, with a focus on bioactive, bioresponsive, and the yet-to-be-developed autonomous scaffold activity. Further, cell- and biomolecular-assisted approaches were excluded, allowing for contemporary examination of the capabilities, demands, vision, and future requisites of next-generation biomaterial-induced technologies only. Data strongly supports that smart scaffolds hold significant promise in the promotion of bone repair in patients with a reduced osteobiological response. Importantly, many techniques have yet to be tested in preclinical models of aging. Thus, greater clarity on their proficiency to counteract the many unresolved challenges within the scope of aging bone is highly warranted and is arguably the next frontier in the field. This review demonstrates that the use of multifunctional smart synthetic scaffolds with an engineered strategy to circumvent the biological insufficiencies associated with aging bone is a viable route for achieving next-generation therapeutic success in the elderly population.

Impact of telescopic intramedullary rodding on the growth of tibia: Comparative experimental study in dogs

INTRODUCTION

The most commonly accepted method of long bone deformity correction in children with osteogenesis imperfecta is surgical realignment with transphyseal telescopic intramedullary rodding. This approach ensures reinforcement of the bone throughout the growth period. Although longitudinal growth does occur with these implants there has been very little work carried out to calculate the effect of such factors as rod position or implant material on growth. We carried out a prospective comparative study on 12 puppies using titanium alloy telescopic tibial rods with and without hydroxyl-apatite coating. The aim of this non-randomized controlled experimental study was to assess the impact of telescopic intramedullary rodding on spontaneous growth of the tibia.

MATERIAL AND METHODS

Twelve mongrel puppies aged of 5 months underwent intramedullary transphyseal rodding of the right tibia. In group I (6 dogs) a titanium telescopic rod was used, in group II (6 dogs) a titanium rod with hydroxyapatite (HA)-coated threaded end was used. The following radiological criteria were assessed before surgery and every month until age of 12 months (natural fusion of physes in dogs): length of tibia, amount of superposition of inner (male) rod into external (female) rod; alteration of anatomy in terms of joint angles (mMPTA, mLDTA, mPPTA, mADTA); positioning of threaded ends in proximal and distal epiphyses and evidence of premature growth arrest. Parameters were compared with left tibia serving as control segment. The null hypothesis was that neither rod position nor implant material altered growth.

RESULTS

The transphyseal rods did not lead to irreversible epiphysiodesis in either group. In group II (HA-coated) some loss of residual length was found in all six dogs, over 7mm (5.9%) in comparison to left intact tibia. In contrast to that, in group I (titanium nail) only one animal (16.7%) demonstrated a tibia length discrepancy of 8mm (4.8%). Eccentric ( posterior) positioning of the rod in the distal epiphysis resulted in a procurvatum deformity (increased anterior distal tibial angle) in both groups. We found no failure of telescoping and no loss of fixation of threaded parts in either epiphyses.

DISCUSSION

The presence of telescopic rods with HA-coated threads parts clearly contributes to inhibition of spontaneous longitudinal growth. We hypothesize that HA stimulates maturation of chondrocytes of growth plate. Our findings regarding the potential adverse effect of thread position in the distal physis demonstrate the importance of attempting to place the rod as central as possible.

CONCLUSION

Titanium alloy telescopic rods did not reveal significant effect on physeal growth in puppies in comparison to HA-coated implants. Transphyseal HA-coated implants did however inhibit growth plate function with mean loss of length of 5.2% compared to the other side. Eccentric positioning of rods relative to center of physis resulted in angular deformity due to irregular growth. There were no cases of mechanical failure or loss of telescopic function with either group of titanium implant.

LEVEL OF EVIDENCE

II; prospective comparative experimental study.

Physical stimuli-emitting scaffolds: The role of piezoelectricity in tissue regeneration

The imbalance between life expectancy and quality of life is increasing due to the raising prevalence of chronic diseases. Musculoskeletal disorders and chronic wounds affect a growing percentage of people and demand more efficient tools for regenerative medicine. Scaffolds that can better mimic the natural physical stimuli that tissues receive under healthy conditions and during healing may significantly aid the regeneration process. Shape, mechanical properties, pore size and interconnectivity have already been demonstrated to be relevant scaffold features that can determine cell adhesion and differentiation. Much less attention has been paid to scaffolds that can deliver more dynamic physical stimuli, such as electrical signals. Recent developments in the precise measurement of electrical fields in vivo have revealed their key role in cell movement (galvanotaxis), growth, activation of secondary cascades, and differentiation to different lineages in a variety of tissues, not just neural. Piezoelectric scaffolds can mimic the natural bioelectric potentials and gradients in an autonomous way by generating the electric stimuli themselves when subjected to mechanical loads or, if the patient or the tissue lacks mobility, ultrasound irradiation. This review provides an analysis on endogenous bioelectrical signals, recent developments on piezoelectric scaffolds for bone, cartilage, tendon and nerve regeneration, and their main outcomes in vivo. Wound healing with piezoelectric dressings is addressed in the last section with relevant examples of performance in animal models. Results evidence that a fine adjustment of material composition and processing (electrospinning, corona poling, 3D printing, annealing) provides scaffolds that act as true emitters of electrical stimuli that activate endogenous signaling pathways for more efficient and long-term tissue repair.

Antibacterial Ferroelectric Hybrid Membranes Fabricated via Electrospinning for Wound Healing

In the present study, wound healing ferroelectric membranes doped with zinc oxide nanoparticles were fabricated from vinylidene fluoride-tetrafluoroethylene copolymer and polyvinylpyrrolidone using the electrospinning technique. Five different ratios of vinylidene fluoride-tetrafluoroethylene to polyvinylpyrrolidone were used to control the properties of the membranes at a constant zinc oxide nanoparticle content. It was found that an increase of polyvinylpyrrolidone content leads to a decrease of the spinning solution conductivity and viscosity, causing a decrease of the average fiber diameter and reducing their strength and elongation. By means of X-ray diffraction and infrared spectroscopy, it was revealed that increased polyvinylpyrrolidone content leads to difficulty in crystallization of the vinylidene fluoride-tetrafluoroethylene copolymer in the ferroelectric β-phase in membranes. Changing the ratio of vinylidene fluoride-tetrafluoroethylene copolymer and polyvinylpyrrolidone with a constant content of zinc oxide nanoparticles is an effective approach to control the antibacterial properties of membranes towards Staphylococcus aureus. After carrying out in vivo experiments, we found that ferroelectric hybrid membranes, containing from five to ten mass percent of PVP, have the greatest wound-healing effect for the healing of purulent wounds.

Biocompatibility and Osseointegration of Calcium Phosphate-Coated and Non-Coated Titanium Implants with Various Porosities

The aim of the investigation was to study the influence of pore size and the presence of a biologically active calcium phosphate coating in porous 3D printed titanium implants on the process of integration with the bone tissue.

Materials and Methods

Samples of cylindrical implants with three different pore diameters (100, 200, and 400 μm) were fabricated from titanium powder on the Arcam 3D printer (Sweden) using electron beam melting technology. A calcium phosphate coating with a thickness of 20±4 μm was applied to some of the products by microarc oxidation. Cytotoxicity of the implants was determined in vitro on human dermal fibroblast cultures. The samples were implanted in the femoral bones of 36 rabbits in vivo. The animals were divided into 6 groups according to the bone implant samples. The prepared samples and peri-implant tissues were studied on days 90 and 180 after implantation using scanning electron microscopy and histological methods.

Results

All samples under study were found to be non-toxic and well biocompatible with the bone tissue. There were revealed no differences between coated and non-coated implants of 100 and 200 μm pore diameters in terms of their histological structure, intensity of vascularization in the early stages, and bone formation in the later stages. Samples with pore diameters of 100 and 200 μm were easily removed from the bone tissue, the depth of bone growth into the pores of the implant was lower than in the samples with pore diameter of 400 μm (p<0.001). There were differences between coated and non-coated samples of 400 μm pore diameter, which was expressed in a more intensive osseointegration of samples with calcium phosphate coating (p<0.05).

Conclusion

The optimal surface characteristics of the material for repairing bone defects are a pore diameter of 400 μm and the presence of a calcium phosphate coating.

Biodegradable intramedullary nail (BIN) with high-strength bioceramics for bone fracture

About 10 million fractures occur worldwide each year, of which more than 60% are long bone fractures. It is generally agreed that intramedullary nails have significant advantages in rigid fracture fixation. Metal intramedullary nails (INs) can provide strong support but a stress shielding effect can occur that results in nonunion healing in clinic. Nondegradable metals also need to be removed by a second operation. Could INs be biodegradable and used to overcome this issue? As current degradable biomaterials always suffer from low strength and cannot be used in Ins, herein, we report a novel device consisting of biodegradable IN (BIN) made for the first time with bioceramics. These BINs have an extremely high bending strength and stable internal and external structure. Experiments show that the BINs could not only fix and support the tibial fracture model, but also promote osteogenesis and affect the microenvironment of the bone marrow cavity. Therefore, they could be expected to replace traditional metal IN and become a more effective treatment option for tibial fractures.

Composite Ferroelectric Membranes Based on Vinylidene Fluoride-Tetrafluoroethylene Copolymer and Polyvinylpyrrolidone for Wound Healing

Wound healing is a complex process and an ongoing challenge for modern medicine. Herein, we present the results of study of structure and properties of ferroelectric composite polymer membranes for wound healing. Membranes were fabricated by electrospinning from a solution of vinylidene fluoride/tetrafluoroethylene copolymer (VDF-TeFE) and polyvinylpyrrolidone (PVP) in dimethylformamide (DMF). The effects of the PVP content on the viscosity and conductivity of the spinning solution, DMF concentration, chemical composition, crystal structure, and conformation of VDF-TeFE macromolecules in the fabricated materials were studied. It was found that as PVP amount increased, the viscosity and conductivity of the spinning solutions decreased, resulting in thinner fibers. Using FTIR and XRD methods, it was shown that if the PVP content was lower than 50 wt %, the VDF-TeFE copolymer adopted a flat zigzag conformation (TTT conformation) and crystalline phases with ferroelectric properties were formed. Gas chromatography results indicated that an increase in the PVP concentration led to a higher residual amount of DMF in the material, causing cytotoxic effects on 3T3L1 fibroblasts. In vivo studies demonstrated that compared to classical gauze dressings impregnated with a solution of an antibacterial agent, ferroelectric composite membranes with 15 wt % PVP provided better conditions for the healing of purulent wounds.

Lower limb lengthening and deformity correction in polyostotic fibrous dysplasia using external fixation and flexible intramedullary nailing

The study describes preliminary experience of the use of external fixators for limb lengthening and deformity correction in combination with flexible intramedullary nailing in management of polyostotic fibrous dysplasia.

Patients and methods

The retrospective study included 8 patients (mean age 11.6 ± 3.38 years; range 7-17 years) with polyostotic fibrous dysplasia operated on using external circular frame and flexible intramedullary nailing. Mean follow-up was 2.6 years. Surgical technique consisted of percutaneous osteotomy of a segment and application of circular external frame. The intramedullary nailing was done using two bent nails. Hydroxyapatite-coated nails were applied in three patients; five patients had titanium nails. Amount of lengthening (cm and %), amount of deformity correction, duration of external fixator use, index of external fixation, "nail/medullary canal at narrowest site" ratio, "nail-medullary canal at osteotomy site" ratio were analyzed. Results and complications were assessed according to Lascombes's classification.

Results

The mean amount of lengthening was 4.5 cm (or 13.7 ± 6.0% per segment). This gave a mean external fixation index of 32.5 ± 13.97 days/cm. The mean ratio of IM nail diameter/medullary canal diameter at the narrowest site was 0.22 ± 0.07 (range, 0.125-0.3 mm). No migration of IM nails into medullary canal were noticed. But in one case there was external migration of Ti-nail. In a year after frame removal, the results of treatment were classified as grade I in 7 cases and IIb in one case.At the latest follow-up control, mechanical axis deviation was found within normal limits in six patients. Two patients had excessive MAD of 11 and 28 mm. In the first case a partial varus deformity recurrence occurred at middle shaft site where a large dysplastic zone was presented. In the second case, a specific shepherd's crook deformity developed and caused excessive MAD. Mean lower limb length discrepancy varied from 1 to 15 mm.

Conclusion

There are advantages of using elastic intramedullary nailing and external fixation in the treatment of limb length discrepancy and deformity of long bones in patients with PFD. This strategy ensures reduced external fixation time and high accuracy of alignment. Intramedullary nails left in situ, especially nails with HA-coating, seem to prevent deformity recurrence and stimulate remodeling in dysplastic fibrous zones.

Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society

Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.

Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.

The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.

The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.

Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.

The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.

Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037