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Hoveidaei AH, Ghaseminejad-Raeini A, Esmaeili S, Sharafi A, Ghaderi A, Pirahesh K, Azarboo A, Nwankwo BO, Conway JD. Effectiveness of synthetic versus autologous bone grafts in foot and ankle surgery: a systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:539. [PMID: 38997680 PMCID: PMC11245794 DOI: 10.1186/s12891-024-07676-8] [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: 04/29/2024] [Accepted: 07/09/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND All orthopaedic procedures, comprising foot and ankle surgeries, seemed to show a positive trend, recently. Bone grafts are commonly employed to fix bone abnormalities resulting from trauma, disease, or other medical conditions. This study specifically focuses on reviewing the safety and efficacy of various bone substitutes used exclusively in foot and ankle surgeries, comparing them to autologous bone grafts. METHODS The systematic search involved scanning electronic databases including PubMed, Scopus, Cochrane online library, and Web of Science, employing terms like 'Bone substitute,' 'synthetic bone graft,' 'Autograft,' and 'Ankle joint.' Inclusion criteria encompassed RCTs, case-control studies, and prospective/retrospective cohorts exploring different bone substitutes in foot and ankle surgeries. Meta-analysis was performed using R software, integrating odds ratios and 95% confidence intervals (CI). Cochrane's Q test assessed heterogeneity. RESULTS This systematic review analyzed 8 articles involving a total of 894 patients. Out of these, 497 patients received synthetic bone grafts, while 397 patients received autologous bone grafts. Arthrodesis surgery was performed in five studies, and three studies used open reduction techniques. Among the synthetic bone grafts, three studies utilized a combination of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) and beta-tricalcium phosphate (β-TCP) collagen, while four studies used hydroxyapatite compounds. One study did not provide details in this regard. The meta-analysis revealed similar findings in the occurrence of complications, as well as in both radiological and clinical evaluations, when contrasting autografts with synthetic bone grafts. CONCLUSION Synthetic bone grafts show promise in achieving comparable outcomes in radiological, clinical, and quality-of-life aspects with fewer complications. However, additional research is necessary to identify the best scenarios for their use and to thoroughly confirm their effectiveness. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Amir Human Hoveidaei
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | | | - Sina Esmaeili
- Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ali Ghaderi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Kasra Pirahesh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Azarboo
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Basilia Onyinyechukwu Nwankwo
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA
- Department of Orthopaedic Surgery and Rehabilitation, Howard University Hospital, Washington, DC, USA
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA
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2
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Jain A, Rathsam AM, Springer KJ, Perumbala K, Parker A, Burns PR, Manway JM. Morbidity Associated With Distal Tibial Autograft Harvest. J Foot Ankle Surg 2024; 63:345-349. [PMID: 38246336 DOI: 10.1053/j.jfas.2024.01.002] [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: 07/27/2023] [Revised: 11/29/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024]
Abstract
Distal tibial autograft harvesting has been studied in the past, but morbidity at the level of the donor site is unclear. The purpose of this retrospective review is to assess morbidity in distal tibial autograft harvesting associated with foot and ankle arthrodesis procedures. A retrospective analysis was performed utilizing patients treated in the last 13 years at a large, multicenter, academic, tertiary referral, research institution. Included patients were between the ages of 18 and 80 years old. One-hundred and seven patients (39 male; 68 female) underwent ipsilateral distal tibial bone graft (n = 110) harvesting to augment the index procedure. Patients were followed for an average of 11.2 months after surgery (Range: 1-73 months). The incidence rate of distal tibial stress fractures was 4.5%, with an overall postoperative complication rate of 8.2%. Overall, low complication rates associated with distal tibial autograft harvesting were found, supporting the use of the distal tibia as an appropriate site for autograft harvesting in foot and ankle surgery.
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Affiliation(s)
- Akshay Jain
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA.
| | - Aaron M Rathsam
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA
| | - Katie J Springer
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA
| | | | | | | | - Jeffrey M Manway
- University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, PA
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3
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Elattar O, Christophersen CM, Farber D. Pain and Complications Following Bone Marrow Aspirate Concentrate Harvested From the Iliac Crest in Foot and Ankle Surgery. Foot Ankle Spec 2024; 17:23-28. [PMID: 34142581 DOI: 10.1177/19386400211017379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Autologous bone graft is the gold standard in orthopedics, with the iliac crest the most common harvest site. In an attempt to minimize morbidity with open bone graft harvest from the iliac crest and still maintain the benefit of collecting and transplanting live cells and growth factors, bone marrow aspirate concentrate (BMAC) from the iliac crest has become increasingly popular. However, any harvest procedure can potentially cause pain and complications. The purpose of this study was to evaluate the safety and complications of BMAC from the iliac crest for use in foot and ankle fusion procedures. METHODS A retrospective chart review was performed on all patients who underwent BMAC harvest from the iliac crest with their foot or ankle procedure by 1 of 4 fellowship-trained surgeons (2014-2017) with a minimum of 6-month follow-up. Patients were evaluated for complications, pain, and functional limitation secondary to the harvest. The final outcome follow-up was conducted using a specifically designed telephone questionnaire to assess patient satisfaction. A total of 55 patients were included, with a median age of 58 years (range 31-81 years) and 69% were women. RESULTS Out of 55 patients, 52 (94.5%) reported good to excellent results, and satisfaction with the procedure at the time of the questionnaire. Three patients reported persistent complications and some element of dissatisfaction after 6 months. Some patients reported transient complications (hematomas and numbness) that eventually resolved. Fifty percent of patients reported some element of immediate post-operative pain. However, at the time of final follow-up, only 2 reported persistent pain at the harvest site lasting up to 6 months, but it was not activity limiting. CONCLUSION BMAC harvest is a safe procedure with a high rate of patient satisfaction and minimal morbidity. LEVELS OF EVIDENCE Level IV: Case series.
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Affiliation(s)
- Osama Elattar
- Clinical Orthopedic Surgery, University of Toledo, Toledo, Ohio
| | | | - Daniel Farber
- Clinical Orthopedic Surgery, University of Pennsylvania Medicine, Philadelphia, Pennsylvania
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4
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Lee W, Prat D, Chao W, Farber DC, Wang C, Wapner KL. The Efficiency of Highly Porous β-Tricalcium Phosphate With Bone Marrow Aspirate Concentrate in Midfoot Joint Arthrodesis. Foot Ankle Spec 2023:19386400231213177. [PMID: 38018529 DOI: 10.1177/19386400231213177] [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: 11/30/2023]
Abstract
BACKGROUND Nonunion is one of the most common and devastating complications following midfoot joint arthrodesis. Many different types of bone grafts and bone substitutes have been used to promote osseous fusion. However, there is no consensus on the gold standard bone grafting material and whether biologic materials should be used alone or in combination. The purpose of this study is to investigate the efficiency of highly porous β-tricalcium phosphate (β-TCP) with bone marrow aspirate concentrate (BMAC) in midfoot joint arthrodesis. METHODS This retrospective comparative study included patients who underwent midfoot joint arthrodesis using compression screws. Patients were classified into 2 groups: arthrodesis with highly porous β-TCP and BMAC (group A) and arthrodesis without them (group B). The osseous union rate was compared between the 2 groups. A total of 44 patients (46 feet) including 89 joints were included in this study. RESULTS There was a significant difference in the union rate between the 2 groups: 91.5% (43/47 joints) in arthrodesis with highly porous β-TCP and BMAC (group A) and 76.2% (32/42 joints) in arthrodesis without highly porous β-TCP and BMAC (group B; P = .048). CONCLUSION This study investigated the efficiency of highly porous β-TCP and BMAC to promote bony healing in midfoot joint arthrodesis. A significantly higher union rate was shown when arthrodesis was performed with highly porous β-TCP and BMAC, compared with arthrodesis performed without them. We suggest that highly porous β-TCP and BMAC can be a viable and effective adjunct to the fixation in midfoot joint arthrodesis. LEVEL OF EVIDENCE Level III: Retrospective comparative analysis.
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Affiliation(s)
- Wonyong Lee
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, Guthrie Medical Group, Sayre, Pennsylvania
| | - Dan Prat
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wen Chao
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel C Farber
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carol Wang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith L Wapner
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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5
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Iturregui JM, Moses AM, Shi GG, Haupt ET. Contemporary Review: Autograft Bone Use in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231153153. [PMID: 36825255 PMCID: PMC9941600 DOI: 10.1177/24730114231153153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Bone autografts are frequently harvested for use in foot and ankle surgery. A commonly used harvest site is the iliac crest; however, because of known morbidity with this site, the tibia and calcaneus are attractive alternatives. There remains limited understanding regarding the osteogenic potential of autografts from each of these locations. In this review, we provided an update of the known data on bone autografts from the iliac crest, tibia, and calcaneus, focusing on the total cells harvested from each site as well as the presence of osteogenic osteoprogenitor cells. Level of Evidence Level V, expert opinion.
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Affiliation(s)
- Jose M. Iturregui
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Alex M. Moses
- Department of Orthopedic Surgery, University of Florida, Jacksonville, FL, USA
| | - Glenn G. Shi
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Edward T. Haupt
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA,Edward T. Haupt, MD, Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
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6
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Lee TY, Wu CC, Yang KC, Yeh KT, Chen IH, Wang CC. Midterm outcomes of midfoot and hindfoot arthrodesis with strut allograft for Müller-Weiss disease. BMC Musculoskelet Disord 2022; 23:715. [PMID: 35897013 PMCID: PMC9327191 DOI: 10.1186/s12891-022-05629-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Müller–Weiss disease (MWD), a rare dysplastic disorder of the foot, is characterized by deformity, sclerosis, and fragmentation of the lateral part of navicular bone. Arthrodesis is the mainstay treatment for MWD. Generally, arthrodesis can be achieved through internal fixation with metallic implants, and morselized chip bone may be packed into the gap for better bone union. However, with this procedure, the original foot size is not maintained and support for the foot arch is not provided. Sequela of short foot, or flatfoot is commonly observed even though these complications of surgery had not been reported with cases of MWD treated by arthrodesis. Herein, we present a retrospective analysis of treating MWD through midfoot and hindfoot arthrodesis combined with strut allograft. Methods From August 2006 to June 2019, 20 patients with MWD (mean age, 59.6 years; range, 40–80 years) underwent midfoot and hindfoot arthrodesis with strut bone allograft and were followed for at least 24 months. The patients were able to ambulate and participate in rehabilitation programs 3 months postoperatively. Results The used four radiographic parameters (Meary’s angle in anteroposterior and lateral view, talonavicular coverage angle, calcaneal pitch) demonstrated significant differences (P < .05) preoperatively and postoperatively, but those between the postoperative values and the values at the last follow-up session did not, indicating that strut allograft was able to maintain normal alignment. The mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scores at 2 years postoperatively revealed significant improvement from baseline, from 60.2 to 84.2 (P < .05). The 12-item Short Form Health Survey scores also improved significantly (P < .05). All patients reported substantial pain relief and exhibited improved functional outcomes and gait patterns. Conclusions For advanced-stage MWD, arthrodesis with a precisely shaped, size-matched strut allograft provided strong support for biomechanical alignment and enhanced functional performance.
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Affiliation(s)
- Tung-Ying Lee
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan
| | - Chang-Chin Wu
- Department of Orthopedics, En Chu Kong Hospital, New Taipei City, Taiwan.,Departments of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu City, Taiwan
| | - Kai-Chiang Yang
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan.,School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuang-Ting Yeh
- Department of Orthopedic Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Ing-Ho Chen
- Department of Orthopedic Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Chen-Chie Wang
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan. .,Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan.
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7
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Cifaldi A, Thompson M, Abicht B. Tibiotalocalcaneal Arthrodesis with Structural Allograft for Management of Large Osseous Defects of the Hindfoot and Ankle: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2022; 61:900-906. [PMID: 35585002 DOI: 10.1053/j.jfas.2022.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/26/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
Large osseous defects of the hindfoot and ankle pose a surgical challenge. Tibiotalocalcaneal (TTC) arthrodesis utilizing a structural allograft may be required to fill the osseous void, preserve limb length and achieve fusion. Several authors have reported small case series on this topic, however outcomes have varied and no systematic review of this data has been published to date. The primary aim of this study is to report rates of osseous union, limb salvage and complications in patients undergoing TTC arthrodesis with a structural allograft. A total of 11 publications were identified that met the inclusion criteria. One hundred seventy-five patients were included with a weighted mean age of 60.5 (range 50-72) years and follow-up period of 29.7 (range 3-62) months. Femoral head allograft was the most commonly utilized structural graft and a retrograde intramedullary nail was the most common fixation construct. Results demonstrated an overall union rate of 67.4%, limb salvage rate of 92.5% and complication rate of 26.6%. Allograft-related complications were rare with an allograft fracture rate of 0.1% and allograft collapse rate of 1.2%. There was no significant difference in union rate when using a retrograde intramedullary nail versus a plate construct (p = .9148). TTC arthrodesis with use of a structural allograft is a viable treatment option for limb salvage when faced with complex hindfoot and ankle pathology involving large osseous defects. Despite high rates of radiographic nonunion, this approach can provide patients with a stable and functional limb while avoiding amputation.
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Affiliation(s)
- Andrea Cifaldi
- Podiatric Medicine and Surgery Resident, Gundersen Medical Foundation, La Crosse, WI.
| | - Mitchell Thompson
- Podiatric Medicine and Surgery Resident, Gundersen Medical Foundation, La Crosse, WI
| | - Bradley Abicht
- Department Chair and Attending Staff, Podiatry Department within Orthopaedic Center, Gundersen Health System, La Crosse, WI
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8
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Primadhi RA, Gunawan H, Rachmayati S, Nagar Rasyid H. Autologous osteophyte grafting for ankle arthrodesis. SICOT J 2022; 8:10. [PMID: 35363135 PMCID: PMC8973299 DOI: 10.1051/sicotj/2022007] [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: 01/06/2022] [Accepted: 02/14/2022] [Indexed: 01/15/2023] Open
Abstract
Purpose: Various graft sources had been identified to facilitate gap-filling in ankle arthrodesis procedures with related articular defects. This was a preliminary study with the aim of analyzing the efficacy and feasibility of using autologous osteophyte as a grafting source. Methods: Retrospective evaluation of ten patients having ankle arthrodesis procedure using identical anterior approach and plate fixation technique was conducted. Basic anthropometric measurements and underlying disease were recorded. Functional outcome and fusion rate were assessed at a 12-month post-surgery follow-up visit. Results: The underlying diseases include primary osteoarthritis (OA), post-traumatic OA, rheumatoid arthritis, and Charcot arthropathy. The patient’s age mean was 56.6 years (range 36–71 years), and BMI varied from 17.9 kg/m2 to 29.3 kg/m2. Nearly all patients had improved functional outcomes as described by foot and ankle ability measure (FAAM) score and fusion rate as described by modified radiographic union score for tibia (RUST). One patient had failed surgery due to implant failure with diminished protective foot sensory. Conclusion: Osteophytes from the distal tibia and talar neck were a viable source of bone graft, especially for ankle arthrodesis using anterior approach among various ages and BMI, in which the surgeons would not need additional incision for graft harvesting.
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Affiliation(s)
- Raden Andri Primadhi
- Department of Orthopaedics and Traumatology, Universitas Padjadjaran Medical School/Hasan Sadikin Hospital Jalan Pasteur 38 Bandung 40161 Indonesia
- Corresponding author:
| | - Hendra Gunawan
- Department of Dermato-Venereology, Universitas Padjadjaran Medical School/Hasan Sadikin Hospital Jalan Pasteur 38 Bandung 40161 Indonesia
| | - Sylvia Rachmayati
- Department of Clinical Pathology, Universitas Padjadjaran Medical School/Hasan Sadikin Hospital Jalan Pasteur 38 Bandung 40161 Indonesia
| | - Hermawan Nagar Rasyid
- Department of Orthopaedics and Traumatology, Universitas Padjadjaran Medical School/Hasan Sadikin Hospital Jalan Pasteur 38 Bandung 40161 Indonesia
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9
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Oliva F, Migliorini F, Cuozzo F, Torsiello E, Hildebrand F, Maffulli N. Outcomes and complications of the reamer irrigator aspirator versus traditional iliac crest bone graft harvesting: a systematic review and meta-analysis. J Orthop Traumatol 2021; 22:50. [PMID: 34851462 PMCID: PMC8636545 DOI: 10.1186/s10195-021-00612-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/17/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The reamer irrigator aspirator (RIA) is a relatively recent device that is placed in the medullary canal of long bones to harvest a large volume of bone marrow, which is collected in a filtered canister. This study compares outcomes and complications of the RIA versus a traditional iliac crest bone graft (ICBG) for the treatment of bone defects. METHODS This meta-analysis was conducted according to the PRISMA guidelines. The Embase, Google Scholar, PubMed, and Scopus databases were accessed in June 2021. All clinical trials comparing the RIA and ICBG with a minimum of 6 months follow-up were included. RESULTS Data from 4819 patients were collected. The RIA group demonstrated lower site pain (P < 0.0001), fewer infections (P = 0.001), and a lower rate of adverse events (P < 0.0001). The ICBG group demonstrated a greater rate of bone union (P < 0.0001). There was no difference between groups in VAS (P = 0.09) and mean time to union (P = 0.06). CONCLUSION The current evidence supports the use of the RIA, given its low morbidity and short learning curve.
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Affiliation(s)
- Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 31, 52074, Aachen, Germany.
| | - Francesco Cuozzo
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
| | - Ernesto Torsiello
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
| | - Frank Hildebrand
- Department of Orthopaedic and Trauma Surgery, RWTH University Hospital Aachen, Pauwelsstraße 31, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.,School of Pharmacy and Biotechnology, Keele University School of Medicine, Thornburrow Drive, Stoke-on-Trent, England
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10
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Migliorini F, Cuozzo F, Torsiello E, Spiezia F, Oliva F, Maffulli N. Autologous Bone Grafting in Trauma and Orthopaedic Surgery: An Evidence-Based Narrative Review. J Clin Med 2021; 10:jcm10194347. [PMID: 34640364 PMCID: PMC8509778 DOI: 10.3390/jcm10194347] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/19/2021] [Accepted: 09/23/2021] [Indexed: 12/11/2022] Open
Abstract
Autologous bone grafting is common in trauma and orthopaedic surgery. Both the Reamer Irrigator Aspirator (RIA) and Iliac Crest Bone Graft (ICBG) aim to obtain autologous bone graft. Although the process of harvesting a bone graft is considered simple, complications may occur. This study examined morbidity and pain at the donor site, blood loss, and iatrogenic fractures, comparing RIA and ICBG. The source of the autologous bone graft, the alternative graft sites, and the storage modalities of the harvested bone marrow were also evaluated. In May 2021, PubMed, Embase, Scopus, and Google Scholar were accessed, with no time constraints. RIA may produce greater blood loss, but with less morbidity and complications, making it a potential alternative source of bone grafting.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-0241-80-35529
| | - Francesco Cuozzo
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
| | - Filippo Spiezia
- Ospedale San Carlo Potenza, Via Potito Petrone, 85100 Potenza, Italy;
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Salerno, Italy; (F.C.); (E.T.); (F.O.); (N.M.)
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, London E1 4DG, UK
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11
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Oliver WM, Molyneux SG, White TO, Clement ND, Duckworth AD, Keating JF. Open Reduction and Internal Fixation for Humeral Shaft Nonunion: Bone Grafting Is Not Routinely Required and Avoids Donor Site Morbidity. J Orthop Trauma 2021; 35:414-423. [PMID: 34267148 DOI: 10.1097/bot.0000000000002032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To document union rate, complications and patient-reported outcomes after open reduction and internal fixation (ORIF), with and without bone grafting (BG), for humeral diaphyseal nonunion after failed nonoperative management. DESIGN Retrospective. SETTING University teaching hospital. PATIENTS AND INTERVENTION From 2008 to 2017, 86 consecutive patients [mean age 59 years (range 17-86), 71% (n = 61/86) women] underwent nonunion ORIF (plate and screws) at a mean of 7 months postinjury (range 3-21.5). Eleven (13%) underwent supplementary BG. MAIN OUTCOME MEASUREMENTS Union rate and complications for 83 patients (97%) at a mean of 10 months (3-61). Patient-reported outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12, satisfaction) for 53 living, cognitively-intact patients (78%) at a mean of 4.9 years (0.3-9.2). RESULTS Ninety-three percent (n = 77/83) achieved union after nonunion ORIF. Complications included recalcitrant nonunion (7%, n = 6/83), iatrogenic radial nerve palsy (6%, n = 5/83), infection (superficial 7%, n = 6/83; deep 2%, n = 2/83), and iliac crest donor site morbidity (38%, n = 3/8). The union rate with BG was 78% (n = 7/9) and without was 95% (n = 70/74; P = 0.125), and was not associated with the nonunion type (atrophic 91%, n = 53/58; hypertrophic 96%, n = 24/25; P = 0.663). Median QuickDASH was 22.7 (0-95), EQ-5D 0.710 (-0.181-1), EQ-visual analog scale 80 (10-100), SF-12 physical component summary 41.9 (16-60.5), and mental component summary 52.6 (18.7-67.7). Nineteen percent (n = 10/53) were dissatisfied with their outcome. CONCLUSIONS ORIF for humeral diaphyseal nonunion was associated with a high rate of union. Routine BG was not required and avoided the risk of donor site morbidity. One in 5 patients were dissatisfied despite the majority achieving union. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Samuel G Molyneux
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Timothy O White
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Nicholas D Clement
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | | | - John F Keating
- Edinburgh Orthopaedics - Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
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Abraham S, Vives M, Cottrell JA, Mitchell A, Lin HN, Effiong L, Iqbal E, Jingar N, Kim B, Shah N, Munoz W, Chaudhary SB, Lin SS, Benevenia J, O'Connor JP. Local insulin application has a dose-dependent effect on lumbar fusion in a rabbit model. J Tissue Eng Regen Med 2021; 15:442-452. [PMID: 33608970 DOI: 10.1002/term.3182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/05/2021] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to determine if locally applied insulin has a dose-responsive effect on posterolateral lumbar fusion. Adult male New Zealand White rabbits underwent posterolateral intertransverse spinal fusions (PLFs) at L5-L6 using suboptimal amounts of autograft. Fusion sites were treated with collagen sponge soaked in saline (control, n = 11), or with insulin at low (5 or 10 units, n = 13), mid (20 units, n = 11), and high (40 units, n = 11) doses. Rabbits were euthanized at 6 weeks. The L5-L6 spine segment underwent manual palpation and radiographic evaluation performed by two fellowship trained spine surgeons blinded to treatment. Differences between groups were evaluated by analysis of variance on ranks followed by post-hoc Dunn's tests. Forty-three rabbits were euthanized at the planned 6 weeks endpoint, while three died or were euthanized prior to the endpoint. Radiographic evaluation found bilateral solid fusion in 10%, 31%, 60%, and 60% of the rabbits from the control and low, mid, and high-dose insulin-treated groups, respectively (p < 0.05). As per manual palpation, 7 of 10 rabbits in the mid-dose insulin group were fused as compared to 1 of 10 rabbits in the control group (p < 0.05). This study demonstrates that insulin enhanced the effectiveness of autograft to increase fusion success in the rabbit PLF model. The study indicates that insulin or insulin-mimetic compounds can be used to promote bone regeneration.
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Affiliation(s)
- Sangeeta Abraham
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Michael Vives
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Jessica A Cottrell
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Ashley Mitchell
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Hsuan-Ni Lin
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Linda Effiong
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Emaad Iqbal
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Neel Jingar
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Brian Kim
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Neel Shah
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - William Munoz
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Saad B Chaudhary
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Sheldon S Lin
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Joseph Benevenia
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - J Patrick O'Connor
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
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Lukasiewicz AM, Bagi PS, Yu KE, Tyagi V, Walls RJ. Novel Vacuum-Assisted Method for Harvesting Autologous Cancellous Bone Graft and Bone Marrow From the Proximal Tibial Metaphysis. FOOT & ANKLE ORTHOPAEDICS 2021; 6:2473011420981901. [PMID: 35097423 PMCID: PMC8702698 DOI: 10.1177/2473011420981901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Autogenous cancellous bone graft and bone marrow aspirate are commonly used in lower extremity fusion procedures to enhance fusion potential, and frequently in revision situations where bone loss and osteolysis may be a feature. The tibial metaphysis is a common donor site for bone graft, with the procedure typically performed using a curette or trephine to harvest the cancellous bone. Some limitations of this technique include suboptimal harvest of the marrow portion in particular, incomplete graft harvest, and loss of graft material during the harvest process. We describe a novel vacuum-assisted bone harvesting device to acquire cancellous bone and marrow from the proximal tibia. Methods: This is a retrospective study of a single surgeon’s consecutive patients who underwent foot and ankle arthrodesis procedures using proximal tibia autograft obtained using a vacuum-assisted bone harvesting device. Descriptive statistics were used to summarize patient and operative characteristics and outcomes. We identified 9 patients with a mean age of 51 years, 4 of whom were female. Results: On average, the skin incision was slightly more than 2 cm, and 27 mL of solid graft and 16 mL of liquid phase aspirate were collected. At 6 weeks after the procedure, there was minimal to no pain at the donor site, and we did not observe any fractures or other complications. Conclusions: We report the use of a novel vacuum-assisted curette device to harvest bone graft from the proximal tibial metaphysis for use in foot and ankle fusions. This device has been reliable and efficient in clinical practice. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
- Adam M. Lukasiewicz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Paul S. Bagi
- Department of Orthopaedic Surgery, University of California San Diego, La Jolla, CA, USA
| | | | - Vineet Tyagi
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Raymond J. Walls
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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14
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Abstract
Union rates vary for arthrodesis sites and bone healing in foot and ankle surgery. The ultimate goal is to achieve complete bone healing within a reasonable time. There are many factors that surgeons cannot control, such as the patient's compliance and ability to heal. However, surgeons can control osseous preparation, stable fixation, preservation of soft tissue, and the osseous fusion initial healing environment. Modification of the healing environment can be achieved with the use of bone graft and orthobiologics. This article discusses the grafts and orthobiologics that can be used in bone healing for the foot and ankle.
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Affiliation(s)
- Sean T Grambart
- Des Moines University, College of Podiatric Medicine and Surgery, 3200 Grand Avenue, Des Moines, IA 50312, USA; Unitypoint Health - Iowa Methodist Medical Center, 1200 Pleasant Street, Des Moines, IA 50309, USA.
| | - Danika S Anderson
- Des Moines University, College of Podiatric Medicine and Surgery, 3200 Grand Avenue, Des Moines, IA 50312, USA
| | - Travis Drew Anderson
- Des Moines University, College of Podiatric Medicine and Surgery, 3200 Grand Avenue, Des Moines, IA 50312, USA
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15
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Del Vecchio JJ, Chemes LN, Bertollotti L, Ghioldi ME, Dealbera ED, Galli Serra M, Parizzia W. Patient-specific three-dimensional printed hemi talar prostheses for the treatment of talar osteonecrosis, case report and literature review. SAGE Open Med Case Rep 2020; 8:2050313X20919223. [PMID: 32537160 PMCID: PMC7268162 DOI: 10.1177/2050313x20919223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 03/23/2020] [Indexed: 11/16/2022] Open
Abstract
We present the case of a 43-year-old boy who presented with progressive pain as a result of history of lateral avascular necrosis of the talus secondary to traumatic open ankle luxation 20 years ago. Conservative treatment (12-month period) prior to surgery failed. It consisted of physiokinetic treatment, insoles and analgesic medication. A diagnostic injection was used in the ankle (positive) and subtalar joint (negative) in order to recognize origin of pain. Hemilateral avascular necrosis of the talus is rare. There are no prior reported cases of the use of hemi-implants. This case highlights the potential use of a patient-specific three-dimensional printed Ti6Al4V prosthesis presented in a complex scenario.
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Affiliation(s)
- Jorge Javier Del Vecchio
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine.,Department of Kinesiology and Physiatry, Universidad Favaloro, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lucas Nicolás Chemes
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | | | - Mauricio Esteban Ghioldi
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Eric Daniel Dealbera
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Marcos Galli Serra
- Orthopaedics Oncology Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Walter Parizzia
- Orthopaedics Oncology Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
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Niazi NS, Aljawadi A, Pillai A. Shaped titanium wedges for subtalar distraction arthrodesis: Early clinical and radiological results. Foot (Edinb) 2020; 42:101647. [PMID: 32035402 DOI: 10.1016/j.foot.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/05/2019] [Accepted: 10/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Displaced intraarticular calcaneum fractures are associated with late symptomatic hind foot malalignment and painful arthrosis for which distraction subtalar fusion might be considered. During subtalar distraction arthrodesis, a structural graft is often used to fill gaps. Autograft, the current gold standard, is limited in availabilityand is associated with donor-site morbidity and collapse. Allografts have the risk of infectious disease transmission, rejection and failure to integrate. The clinical outcomes and midterm results of subtalar distraction arthrodesis with biofoamtitanium wedges are presented. METHODS A review of 4 patients (3 male and 1 female) undergoing subtalar bone block distraction arthrodesis using biofoam titanium wedges is reported. Results were evaluated clinically and radiologically Mean time from trauma to surgery was 27.5 months and mean follow up was 12 months. RESULTS The mean FAAM ADL score improved from 31.4% preoperatively to 74.2% postoperatively and mean AOFAS score improved from 23.4 preoperatively to 69.6 postoperatively.There was improvement in all radiographic parameters, with 44% improvement in calcaneal pitch, 23% improvement in talocalcaneal angle, 21% increase in talus-first metatarsal angle, and 13.5% correction of talocalcaneal height. VAS Pain scores wasimproved from a pre-operative mean of 8 to a post-operative mean of 2. Mean time to fusion was 13 weeks. Union was achieved in all cases. CONCLUSION Our data suggest titanium wedges may be used as a structural graft option for subtalar bone block distraction arthrodesis. Fusion rates and time to incorporation are comparable to autogenous bone graft without the associated morbidity. Level IV Case Series.
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Affiliation(s)
- Noman Shakeel Niazi
- Trauma and Orthopaedics Department, Wythenshawe Hospital, Manchester University Foundation Trust, United Kingdom.
| | - Ahmed Aljawadi
- Trauma and Orthopaedics Department, Wythenshawe Hospital, Manchester University Foundation Trust, United Kingdom.
| | - Anand Pillai
- Trauma and Orthopaedics Department, Wythenshawe Hospital, Manchester University Foundation Trust, United Kingdom.
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Abstract
Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.
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18
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Daniels TR, Anderson J, Swords MP, Maislin G, Donahue R, Pinsker E, Quiton JD. Recombinant Human Platelet-Derived Growth Factor BB in Combination With a Beta-Tricalcium Phosphate (rhPDGF-BB/β-TCP)-Collagen Matrix as an Alternative to Autograft. Foot Ankle Int 2019; 40:1068-1078. [PMID: 31170812 DOI: 10.1177/1071100719851468] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Joint arthrodesis often employs autograft to promote union; graft harvesting can lead to perioperative morbidity. A Canadian randomized controlled trial (RCT) demonstrated that recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) combined with beta-tricalcium phosphate (β-TCP)-collagen was a safe, effective alternative to autograft. This multicenter North American RCT compared the safety and efficacy of rhPDGF-BB/β-TCP-collagen with autograft for ankle and hindfoot fusion. Subclassification using propensity scores (PS) incorporated patients from previous trials for enhanced statistical power for noninferiority testing and broader review of treatments. METHODS Patients requiring ankle or hindfoot arthrodesis and supplemental bone graft were treated with rhPDGF-BB/β-TCP-collagen (n = 69) or autograft (n = 35). Outcomes included joint fusion on computed tomography (24 weeks), clinical healing status, visual analog scale (VAS) pain, Short-Form 12 (SF-12), American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, and Foot Function Index (FFI) scores over 52 weeks. PS methodology addressed potential selection bias arising from pooling data among these patients and 2 previous RCTs with similar inclusion criteria, surgical techniques, graft harvest techniques, and outcomes. All 132 rhPDGF-BB/β-TCP-collagen-treated patients and 167 of 189 candidate autograft-treated controls were selected for comparison by an independent statistician blinded to outcomes. RESULTS In the PS subclassification, 68.1% treatment patients and 68.4% controls achieved >50% osseous bridging at fusion sites. Clinical healing status was achieved in 84.8% of treated patients and 90.7% of controls at 52 weeks. Clinical, functional, and quality of life results demonstrated noninferiority of rhPDGF-BB/β-TCP-collagen to autograft. Safety-related outcomes were equivalent. CONCLUSION PS subclassification analysis of 3 RCTs demonstrated that rhPDGF-BB/β-TCP-collagen was as effective as autograft for ankle and hindfoot fusions, with less pain and morbidity than treatment with autograft. LEVEL OF EVIDENCE Level I, prospective randomized study.
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Affiliation(s)
- Timothy R Daniels
- 1 Division of Orthopaedic Surgery, St. Michael's Hospital, and University of Toronto, Toronto, ON, Canada
| | - John Anderson
- 2 Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | | | - Greg Maislin
- 4 Biomedical Statistical Consulting, Wynnewood, PA, USA
| | - Rafe Donahue
- 5 Wright Medical Technology, Inc, Franklin, TN, USA
| | - Ellie Pinsker
- 1 Division of Orthopaedic Surgery, St. Michael's Hospital, and University of Toronto, Toronto, ON, Canada
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19
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Black ND, Malhas L, Jin R, Bhatia A, Chan VWS, Chin KJ. The analgesic efficacy of the transversalis fascia plane block in iliac crest bone graft harvesting: a randomized controlled trial. Korean J Anesthesiol 2019; 72:336-343. [PMID: 30886131 PMCID: PMC6676022 DOI: 10.4097/kja.d.18.00352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Iliac crest bone graft (ICBG) harvesting is associated with significant perioperative pain and opioid consumption. This randomized controlled trial sought to determine if the transversalis fascia plane (TFP) block provides effective analgesia for anterior ICBG harvesting. Methods Fifty patients undergoing wrist fusion surgery with anterior ICBG harvesting were randomized to receive a TFP block with either 20 ml of 0.5% ropivacaine or 5% dextrose. Patients additionally received a brachial plexus block for primary surgical-site anesthesia and either a general or spinal anesthetic depending on patient preference. Primary outcomes of interest were perioperative opioid consumption (measured as intravenous morphine equivalents [IME]), pain intensity at the ICBG harvest site for up to 48 h postoperatively, and the incidence of persistent postoperative pain at 6 and 12 months after surgery. Results The TFP group used less opioid in the post-anesthetic care unit (PACU) (median 0 vs. 2.5 mg IME, P = 0.01) and in the first 8 h following PACU discharge (median 2.5 vs. 13.0 mg IME, P = 0.02). The patients who received a TFP block also had lower pain scores in PACU (median 0 vs. 4.0 out of 10, P < 0.001). Although opioid consumption and pain scores were lower in the TFP group at later timepoints, this difference was not statistically significant. Persistent pain at the ICBG site was reported in only 4.3% and 6.5% of all patients at 6 and 12 months, respectively. Conclusions The TFP block provides effective early analgesia for anterior ICBG harvesting. The incidence of persistent postoperative pain was low.
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Affiliation(s)
- Nicholas D Black
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Laith Malhas
- Department of Anesthesia, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Rongyu Jin
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Anuj Bhatia
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Vincent W S Chan
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Ki Jinn Chin
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
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20
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Matthews M, Cook EA, Cook J, Johnson L, Karthas T, Collier B, Hansen D, Manning E, McKenna B, Basile P. Long-Term Outcomes of Corrective Osteotomies Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction. J Foot Ankle Surg 2019; 57:924-930. [PMID: 29891128 DOI: 10.1053/j.jfas.2018.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Indexed: 02/03/2023]
Abstract
Common corrective osteotomies used in flexible flatfoot deformity reconstruction include Cotton and Evans osteotomies, which require structural graft to maintain correction. Auto-, allo-, and xenografts are associated with a number of limitations, including disease transmission, rejection, donor site morbidity, technical challenges related to graft fashioning, and graft resorption. Porous titanium is a synthetic substance designed to address these flaws; however, few studies have been reported on the efficacy, safety, and long-term outcomes. A multicenter retrospective cohort of 63 consecutive preconfigured porous titanium wedges (PTWs) used in flexible flatfoot reconstructions from June 1, 2009 to June 30, 2015 was evaluated. The primary outcome measure was the pre- to postdeformity correction efficacy. The secondary outcomes included maintenance of correction at a minimum follow-up point of 12 months, complications, graft incorporation, and graft safety profile. Multivariate linear regression found a statistically significant improvement in all radiographic parameters from preoperatively to the final weightbearing radiographs (calcaneocuboid 18.850 ± 4.020 SE, p < .0001; Kite's, 7.810 ± 3.660 SE, p = .04; Meary's 13.910 ± 3.100 SE, p = .0001; calcaneal inclination, 5.550 ± 2.140 SE, p = .015). When restricted to patients with >4 years of follow-up data, maintenance of correction appeared robust in all 4 measurements, demonstrating a lack of bone or graft resorption. No patients were lost to follow-up, no major complications or implant explantation or migration occurred, and all implants were incorporated. Minor complications included hardware pain from plates over grafts (8%), 1 case of scar neuritis, and a 5% table incidence of transfer pain associated with the PTWs. These results support the use of PTWs for safety and degree and maintenance of correction in flatfoot reconstruction.
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Affiliation(s)
- Michael Matthews
- Chief Resident, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA; Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA.
| | - Emily A Cook
- Director of Resident Training, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA; Instructor, Department of Surgery, Harvard Medical School, Boston, MA
| | - Jeremy Cook
- Instructor, Department of Surgery, Harvard Medical School, Boston, MA; Director of Research and Quality Assurance, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
| | - Lindsay Johnson
- Instructor, Department of Surgery, Harvard Medical School, Boston, MA; Chief, Department of Podiatry, Atrius Health, Boston, MA
| | - Timothy Karthas
- Chief Resident, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA; Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Byron Collier
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Daniel Hansen
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Elena Manning
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Bryon McKenna
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Philip Basile
- Instructor, Department of Surgery, Harvard Medical School, Boston, MA; Chief, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
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21
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Abstract
There are several reconstructive procedures in foot and ankle surgery wherein structural grafts are needed to fill defects, restore height, and maintain correction while providing an osteoconductive environment until fusion occurs. Traditionally used autografts and allografts have their disadvantages and limitations. Porous tantalum, with stiffness similar to bone and its biocompatibility, can be a viable option in foot and ankle reconstructive procedures.
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22
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23
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DeVries JG, Scharer B. Comparison and Use of Allograft Bone Morphogenetic Protein Versus Other Materials in Ankle and Hindfoot Fusions. J Foot Ankle Surg 2018; 57:707-711. [PMID: 29703460 DOI: 10.1053/j.jfas.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Indexed: 02/03/2023]
Abstract
Bone grafting is a common procedure in foot and ankle surgery. Because autogenous graft use results in comorbidity to the patient, the search has been ongoing for the ideal substitute. A novel processing technique for allograft using bone marrow, which retains many of the growth factors, has shown promise in the spinal data and early reports of foot and ankle surgery. We performed a retrospective, comparative study of patients undergoing hindfoot and ankle arthrodesis, with a total of 68 patients included. Of the 68 patients, 29 (42.65%) received a bone morphogenetic protein allograft and 39 (57.35%) did not. The patient demographics and social and medical history were similar between the 2 groups and both groups had a similar time to union (p = .581). Of the 29 patients in the bone morphogenetic protein allograft group, 3 (10.3%) experienced nonunion and 4 (13.8%) developed a complication. Of the 39 patients undergoing other treatment, 7 (17.9%) experienced nonunion and 14 (35.9%) developed a complication. The difference for nonunion was not statistically significant (p = .5). However, the difference in the overall complication rate was statistically significant (p = .04). We found that this novel bone graft substitute is safe and can be used for foot and ankle arthrodesis.
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Affiliation(s)
- J George DeVries
- Foot and Ankle Surgeon, Orthopedics and Sports Medicine, BayCare Clinic, Green Bay, WI.
| | - Brandon Scharer
- Foot and Ankle Surgeon, Orthopedics and Sports Medicine, BayCare Clinic, Green Bay, WI
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24
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Shenoy U, Peter V, Mathew P, Thomas T. Transversus abdominis plane block supplementation during iliac crest bone graft harvesting - Effect on postoperative pain. J Anaesthesiol Clin Pharmacol 2018; 34:472-477. [PMID: 30787510 PMCID: PMC6360909 DOI: 10.4103/joacp.joacp_62_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Transversus abdominis plane (TAP) block is a technique proposed to minimise pain after anterior iliac crest bone harvesting. This study aims to evaluate the postoperative pain in patients who receive ultrasound-guided TAP block to supplement routine wound infiltration. MATERIAL AND METHODS A total of 143 patients aged between 6 and 22 years were randomised into two groups. Patients in group A received supplemental TAP block on the same side. Patients in group B received local anesthetic wound infiltration alone. Pain scores were compared at the first and 24th postoperative hours. RESULTS TAP block significantly reduced pain and delirium in the immediate postoperative period. The mean FLACC (Face, Legs, Activity, Cry, Consolability) score after 10 min was 0.8 in group A versus 1.8 in group B (P = 0.001). The mean Watcha scale at 10 min was 1.0 in group A versus 1.2 in group B (P = 0.001). After 24 h, 81.7% of patients in group A had no pain versus 59.7% in group B (P = 0.004). The incidence of intolerable pain at 24 h was 5.6% in group B versus 0% in group A (P = 0.04). Cumulative ambulation scores were significantly better in group A (P < 0.05). There was a strong and positive correlation between the analgesia and ability to ambulate comfortably at 24 h postop (Pearson's coefficient 0.95). CONCLUSION Supplemental ultrasound-guided TAP block given intraoperatively reduces the postoperative pain. The incidence of emergence delirium was low. These patients were also able to ambulate earlier.
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Affiliation(s)
- Usha Shenoy
- Department of Anaesthesiology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Vigil Peter
- Department of Anaesthesiology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Philip Mathew
- Department of Faciomaxillary Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Tom Thomas
- Department of Social and Preventive Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
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Hirao M, Ebina K, Etani Y, Tsuboi H, Noguchi T, Tsuji S, Hashimoto J, Yoshikawa H. Use of autologous bone grafting from the calcaneus and interconnected porous hydroxyapatite ceramic for bone transplantation in rheumatoid foot surgery. SAGE Open Med Case Rep 2018; 6:2050313X18784413. [PMID: 30013786 PMCID: PMC6041860 DOI: 10.1177/2050313x18784413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 05/31/2018] [Indexed: 11/27/2022] Open
Abstract
Cancellous bone grafts from the calcaneus have been used for the foot and ankle
as well as iliac bone graft; however, there is a sparse report for calcaneal
bone transplantation in the field of rheumatoid foot surgery. In this study,
safety and usefulness of calcaneal bone grafts, and combination with
interconnected porous hydroxyapatite ceramic, was evaluated in rheumatoid
arthritis foot surgeries. Of six rheumatoid arthritis cases, three
(talo-navicular joint fusion) used a calcaneal bone graft alone, and the
remaining three cases (subtalar joint and talo-navicular joint fusion) used a
combination of calcaneal bone graft and interconnected porous hydroxyapatite
ceramic augmented with dense calcium hydroxyapatite for subtalar bony defect
(1.5–2.0 cm) after the correction. Pre- and postoperative Japanese Society for
Surgery of the Foot rheumatoid arthritis foot ankle scale scores were obtained
for the clinical assessment. As radiographic assessment, tibio-calcaneal angle,
calcaneal pitch, talo-1st metatarsal angle, and pronated foot index were also
evaluated. After starting weight-bearing or walking, there was no pain and skin
trouble at the fusion and harvesting sites. All cases achieved bony fusion
within 6–10 weeks. Japanese Society for Surgery of the Foot rheumatoid arthritis
foot ankle score was improved in all six cases. Furthermore, tibio-calcaneal
angle, talo-1st metatarsal angle, and pronated foot index were also improved at
latest follow-up in all cases. In conclusion, autologous bone grafting from the
calcaneus was safe and convenient even in rheumatoid foot surgeries. For larger
bony defects (1.5–2.0 cm), combination use with interconnected porous
hydroxyapatite ceramic augmented with dense calcium hydroxyapatite was also
useful.
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Affiliation(s)
- Makoto Hirao
- Department of Orthopaedics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kosuke Ebina
- Department of Orthopaedics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yuki Etani
- Department of Orthopaedics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hideki Tsuboi
- Department of Orthopaedics, Osaka Rosai Hospital, Sakai, Japan
| | - Takaaki Noguchi
- Department of Orthopaedics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shigeyoshi Tsuji
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, Japan
| | - Jun Hashimoto
- Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedics, Graduate School of Medicine, Osaka University, Suita, Japan
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Aubret S, Merlini L, Fessy M, Besse JL. Poor outcomes of fusion with Trabecular Metal implants after failed total ankle replacement: Early results in 11 patients. Orthop Traumatol Surg Res 2018; 104:231-237. [PMID: 29407072 DOI: 10.1016/j.otsr.2017.11.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/19/2017] [Accepted: 11/30/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One of the reasons for revision of total ankle replacement (TAR) implants is loosening due to subchondral cysts. Reconstruction and fusion of the ankle is often the first choice for revision procedures due to the large bone defects, which are typically filled with autograft and/or allograft. Filling the defect with a trabecular metal tantalum implant is a potential alternative given the biomechanical properties of this component. HYPOTHESIS Using tantalum as a spacer provides primary stability and contributes to fusion of the ankle joint after removal of failed TAR implants. METHODS Eleven patients underwent arthrodesis an average of 6.9 years after TAR. The mean height of the bone defect was 32mm. It was filled with a specially designed quadrangular implant (Trabecular Metal™, Zimmer/Biomet) combined with an iliac crest graft. Ten patients underwent tibio-talo-calcaneal (TTC) arthrodesis fixed with an angled retrograde nail and one patient underwent talocrural arthrodesis fixed with two plates (anterolateral and anteromedial). The clinical, functional (AOFAS and SF36 scores) and radiological (plain X-rays and CT scan) outcomes were determined. RESULTS At a mean follow-up of 19.3 months, the mean total AOFAS score was 56 (21-78) and the mean SF36 score was 60.5 (19-84). One patient was lost to follow-up and four patients still had pain. The tantalum implant was integrated in six patients. Five patients achieved fusion of the subtalar joint and 8 achieved fusion of the talocrural joint. Three patients required surgical revision. DISCUSSION Our hypothesis was not confirmed. The clinical outcomes after more than 1 year of follow-up are disappointing, as was the large number of nonunion cases and the lack of tantalum integration. These technical failures can be explained by insufficient construct stability and/or insufficient implant porosity. LEVEL OF EVIDENCE IV (retrospective cohort study).
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Affiliation(s)
- S Aubret
- Service de chirurgie orthopédique et traumatologique, centre hospitalier Lyon-Sud, hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France; Service de chirurgie orthopédique et traumatologique, université Clermont Auvergne, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France.
| | - L Merlini
- Service de chirurgie orthopédique et traumatologique, centre hospitalier Lyon-Sud, hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - M Fessy
- Laboratoire de biomécanique et mécanique des Chocs, IFSTTAR, LBMC UMR-T 9406, université Lyon 1, 69675 Bron cedex, France; Service de chirurgie orthopédique et traumatologique, centre hospitalier Lyon-Sud, hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - J-L Besse
- Laboratoire de biomécanique et mécanique des Chocs, IFSTTAR, LBMC UMR-T 9406, université Lyon 1, 69675 Bron cedex, France; Service de chirurgie orthopédique et traumatologique, centre hospitalier Lyon-Sud, hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France
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Karslioglu B, Tekin AC. Obtaining local bone graft for Evans calcaneal osteotomy: Think twice. Foot Ankle Surg 2018; 24:76. [PMID: 29413779 DOI: 10.1016/j.fas.2017.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 08/19/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Bulent Karslioglu
- Okmeydani Training and Research Hospital Department of Orthopedics and Traumatology, Turkey.
| | - Ali Cagri Tekin
- Okmeydani Training and Research Hospital Department of Orthopedics and Traumatology, Turkey
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López JB, de Bengoa Vallejo RB, Iglesias MEL, Doblaré M. Mechanical Stress Redistribution in the First Metatarsal Bone After Autologous Bone Harvesting. J Am Podiatr Med Assoc 2017; 107:497-510. [PMID: 29252028 DOI: 10.7547/16-030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The first metatarsal bone is a viable source for autologous bone grafting in foot and ankle surgery and may serve as another convenient graft site to correct a flail toe deformity. We aimed to determine how progressive bone removal from the first metatarsal affects the mechanical redistribution of the foot and whether this bone removal increases the risk of fracture. METHODS A three-dimensional finite element model developed from computed tomographic images obtained from a healthy man were used to evaluate traction stresses on the first metatarsal bone as a function of applied loads on the talus and Achilles tendon at two phases of the gait cycle (and according to the depth of bone removal). RESULTS Simulations indicated that when maximum load was applied to the Achilles tendon, tensile stress increased from 2.049 MPa in the intact foot to 5.941 MPa in the area of maximum bone harvest during the stance phase. Furthermore, as the volume of bone extracted from the first metatarsal increased, there was a redistribution of stress that differed significantly from that of the intact foot. CONCLUSIONS Although the maximum stress on the first metatarsal was not significantly affected by increasing the volume of bone harvested, the ankle should be splinted in plantarflexion during the postoperative period to eliminate the stance phase of gait and reduce the risk of metatarsal fracture.
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Affiliation(s)
- Javier Bayod López
- Group of Structural Mechanics and Materials Modeling, Aragón Institute for Engineering Research (I3A), University of Zaragoza, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Escuela de Ingeniería y Arquitectura, Universidad de Zaragoza, Zaragoza, Spain
| | | | | | - Manuel Doblaré
- Group of Structural Mechanics and Materials Modeling, Aragón Institute for Engineering Research (I3A), University of Zaragoza, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Escuela de Ingeniería y Arquitectura, Universidad de Zaragoza, Zaragoza, Spain
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Sun H, Lu PP, Zhou PH, Sun SW, Zhang HT, Liu YJ, Yang X, Shen XF, Yang HL. Recombinant human platelet-derived growth factor-BB versus autologous bone graft in foot and ankle fusion: A systematic review and meta-analysis. Foot Ankle Surg 2017; 23:32-39. [PMID: 28159040 DOI: 10.1016/j.fas.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 02/04/2016] [Accepted: 02/05/2016] [Indexed: 02/04/2023]
Abstract
Today, autogenous bone graft (ABG) is still considered as the gold standard for joint fusion. Recombinant human platelet-derived growth factor-BB (rhPDGF-BB) which is of chemotactic and mitogenic to mesenchymal stem cells and possesses outstanding osteogenetic potentials has been used for ankle and foot fusion in recent years. The goal of this article is to evaluate the safety and efficacy of rhPDGF-BB versus ABG in foot and ankle fusion. The PubMed MEDLINE, EMBASE, Web of Science, and Cochrane Library were systematic searched. Finally, three randomized controlled trials (RCTs) with 634 patients were enrolled in this study. Results of radiologic effectiveness which included CT and radiographic union rates revealed that there was no significant difference between rhPDGF-BB approach and ABG approach. Analysis of clinical results held the same outcomes expect that ABG group was superior in long-term Short Form-12 physical component scores. The pooled results also demonstrated that rhPDGF-BB was as safe as ABG in foot and ankle surgery. However, autograft harvesting procedure has some drawbacks such as donor-site pain and morbidity, additional operation time, blood loss, and scarring, which can be overcome by rhPDGF-BB. Thus, rhPDGF-BB is a viable alternative to autograft in foot and ankle fusion surgery. Yet, more high-quality RCTs with long-term follow-up are still required to make the final conclusion.
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Affiliation(s)
- Han Sun
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Pei-Pei Lu
- Nursing College, Liaoning Medical University, No. 40, Section 3, Songpo Road, Guta District of Jinzhou City, Liaoning Province, 121001, China.
| | - Ping-Hui Zhou
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Si-Wei Sun
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Hong-Tao Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Yi-Jie Liu
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Xu Yang
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Xiao-Feng Shen
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
| | - Hui-Lin Yang
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, 188 Shizi Street Gusu District of Suzhou City, Jiangsu Province, 215006, China.
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Dodd A, Daniels TR. Injectable Recombinant Human Platelet-derived Growth Factor in Collagen Carrier for Hindfoot Fusion. Foot Ankle Clin 2016; 21:777-791. [PMID: 27871411 DOI: 10.1016/j.fcl.2016.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrodesis of the hindfoot is a common procedure for degenerative joint disease and/or severe deformity. Nonunion is a common complication from this procedure, causing an increased burden to the patient and health care system, often resulting in the need for revision surgery. Recombinant human platelet-derived growth factor (rhPDGF) has been shown to be a safe and effective tool to enhance arthrodesis rates in hindfoot surgery while avoiding the potential morbidity of bone grafting. This article provides a review of the role of rhPDGF in hindfoot fusions, and the surgical technique for performing an rhPDGF enhanced double-arthrodesis through a medial approach.
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Affiliation(s)
- Andrew Dodd
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, 800-55 Queen Street East, Toronto, Ontario M5C 1R6, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, 800-55 Queen Street East, Toronto, Ontario M5C 1R6, Canada.
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Abstract
Nonunion remains the most impactful complication following ankle and hindfoot arthrodesis. Historically, surgeons have relied on autologous bone graft (ABG) to combat nonunion risk. Although effective, ABG remains limited in quantity, varies in quality, and can be associated with harvest site pain and morbidity. Use of alternative bone-stimulating agents, however, avoids harvesting an autograft, and provides a more predictable dose-response efficacy. This article highlights findings from basic science, animal, and human clinical research that led to the approval of Augment Bone Graft. We present an adaptation of the surgical techniques described for investigators participating in the pivotal trial.
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Abstract
Bone graft is a common adjunct procedure in orthopedic surgery used for fusions, fracture repair, and the reconstruction of skeletal defects in the foot and ankle. Autologous graft, or autograft, involves the transport of bone from a donor site to another location in the same patient. It is considered by many to be the gold standard of bone grafting, as it is provides all biologic factors required for functional graft. Further, autograft is 100% histocompatible with no risk of disease transmission.
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Abstract
Foot and ankle fusion procedures often incorporate autogenous bone graft to help achieve bony union. Pain and morbidity associated with graft harvest have resulted in decreased autograft use as alternative bone graft substitutes have become available. Recently B2A peptide-coated ceramic granules have been developed and investigated. B2A, a bioactive synthetic multi-domain peptide acting on bone morphogenetic protein receptors of osteoblast precursor cells, amplifies the cell response to bone morphogenetic proteins. Use of B2A-granule has the additional benefit of eliminating autogenous bone graft donor site morbidity. The surgical technique of subtalar arthrodesis incorporating B2A-granule is described.
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Affiliation(s)
- Mark Glazebrook
- Reconstructive Foot & Ankle Surgery & Orthopaedic Sports Medicine, Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax Infirmary, Room 4867, 1796 Summer Street, Halifax, Nova Scotia B3H 3A6, Canada.
| | - Diana S Young
- Reconstructive Foot & Ankle Surgery & Orthopaedic Sports Medicine, Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax Infirmary, Room 4867, 1796 Summer Street, Halifax, Nova Scotia B3H 3A6, Canada
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Younger A, Penner M, Montijo HE. Vancouver Experience of Recombinant Human Platelet-Derived Growth Factor. Foot Ankle Clin 2016; 21:771-776. [PMID: 27871410 DOI: 10.1016/j.fcl.2016.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Joint arthrodesis utilizing autogenous bone graft remains the gold standard of treatment in fusion procedures of the foot and ankle. Graft harvest, however, has been associated with increased morbidity to patients as well as increased costs. With this in mind, multiple clinical studies have evaluated the efficacy of recombinant human platelet-derived growth factor (rh-PDGF-BB) with beta-tricalcium phosphate (B-TCP) to augment in foot and ankle arthrodesis with favorable results. These factors have led to the increased use of rh-PDGF-BB with B-TCP in Vancouver with good clinical results.
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Affiliation(s)
- Alistair Younger
- Department of Orthopedics, University of British Columbia, 560-1144 Burrard Street, Vancouver, British Columbia V6Z 2A5, Canada.
| | - Murray Penner
- Department of Orthopedics, University of British Columbia, 1000-1200 Burrard Street, Vancouver, British Columbia V6Z 2C7, Canada
| | - Harvey E Montijo
- Department of Orthopedics, University of British Columbia, 560-1144 Burrard Street, Vancouver, British Columbia V6Z 2A5, Canada
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The Treatment of Mueller-Weiss Disease: A Systematic Approach. TECHNIQUES IN FOOT AND ANKLE SURGERY 2016. [DOI: 10.1097/btf.0000000000000088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Osteobiological agents are a welcome addition to the surgeon’s armamentarium. These products should always be thought of as a complement to good surgical principles and construct. As history has shown, nothing outperforms the osteogenic properties of autograft bone. Even if allograft is procured for use, an attempt should be made to combine it with autograft if possible, given the primary indexprocedure in which it will be used. Structural support from corticocancellous autografts is also greater than allografts, which lose mechanical strength during the sterilization and preservation process. Bone fillers without structural support should be used only when there are other means of cortical contact. The ability of the human skeletal system to repair itself is amazing. Osseous healing relieson a complicated series of intrinsic and extrinsic factors. Some of these factors include a stable fixation construct, nutritional status, good surgical technique, and good decision making. Autogenous bone graft remains the gold standard, and the presence of native growth factors and osteogenic cells is mandatory to repair these deformities. When this microenvironment is disruptive, nonunion may result.Understanding the mechanisms of bony healing contributes to the available osteobiologics, which give the foot and ankle surgeon additional tools to enhance the reparative process of bony defects and the ability of the foot to restore itself.
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Affiliation(s)
- Lawrence A DiDomenico
- Ankle & Foot Care Centers, 8175 Market Street, Youngstown, OH 44512, USA; St. Elizabeth Hospital, Youngstown, OH, USA; Heritage Valley Hospital, Beaver, PA, USA.
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Effectiveness of the addition of Lidocaine to a hemostatic, bioresorbable putty in the treatment of iliac crest donor site pain. BMC Musculoskelet Disord 2014; 15:415. [PMID: 25482244 PMCID: PMC4295296 DOI: 10.1186/1471-2474-15-415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 12/01/2014] [Indexed: 11/16/2022] Open
Abstract
Background The harvest of iliac crest bone grafts (ICBG) is associated with relevant donor site pain, but may be lowered by the application of lidocaine loaded on biodegradable, hemostatic putty for sustained local analgesic release. The goal of this double-blind controlled trial was to assess the efficacy of adding lidocaine to a hemostatic putty (Orthostat ™) to treat donor site pain following harvest of ICBG in foot and ankle procedures. Methods After ICBG harvest during a foot and ankle procedure, the resulting bone defect was either filled with Orthostat™ (n = 7) or with the same hemostatic putty loaded with lidocaine (Orthostat-L™, n = 7). During the first 72 postoperative hours, donor site and surgical site pain were managed by patient controlled morphine delivery and a peripheral nerve block. Donor site pain was periodically quantified on a Visual Analog (VAS) and a Wong Baker FACES scale. Pain scores were plotted over time to calculate the area under the curve (AUC) to quantify the overall pain experienced in specific time intervals. Results Orthostat-L™ significantly reduced donor site pain over the first 12 hours postoperatively as evidenced by a significant decrease of the AUC in both VAS (p = 0.0366) and Wong Baker FACES pain score plots (p = 0.0024). Cumulated morphine uses were not significantly decreased with Orthostat-L™. Conclusion The addition of lidocaine to a hemostatic putty offers a significant ICBG donor site pain reduction over the first 12 postoperative hours. Trial registration ClinicalTrials.gov NCT01504035. Registered January 2nd 2012. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-415) contains supplementary material, which is available to authorized users.
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Belfi LM, Bartolotta RJ, Loftus ML, Wladyka C, Hentel KD. Benign osseous and articular abnormalities of the pelvis: a review of CT imaging findings. Clin Imaging 2014; 39:186-93. [PMID: 25433854 DOI: 10.1016/j.clinimag.2014.08.005] [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: 07/11/2014] [Accepted: 08/09/2014] [Indexed: 11/29/2022]
Abstract
Computed tomography (CT) has become the standard of care for evaluation and follow-up for a wide range of abdominal and pelvic pathology. Many incidental osseous and articular abnormalities of the pelvis are detected on these studies, most of which have a benign etiology. However, most of these studies are interpreted by nonmusculoskeletal radiologists, who may not be familiar with the CT appearances of these benign musculoskeletal abnormalities. Uncertainty often leads to mischaracterization or unnecessary follow-up, resulting in increased health care costs and patient anxiety. This article reviews the CT appearance of the benign musculoskeletal entities that occur in pelvis.
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Affiliation(s)
- Lily M Belfi
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA.
| | - Roger J Bartolotta
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
| | - Michael L Loftus
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
| | - Christopher Wladyka
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
| | - Keith D Hentel
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA
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The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma 2014; 28:584-90. [PMID: 24625833 DOI: 10.1097/bot.0000000000000086] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study was performed to compare patient outcomes after Reamer-Irrigator-Aspirator (RIA)-harvested bone grafting with the current gold standard, either anterior or posterior iliac crest bone graft (ICBG). DESIGN Prospective randomized controlled trial. SETTING Multicenter study at 3 geographically separate Level 1 trauma centers. PATIENTS/PARTICIPANTS One hundred thirty-three patients with nonunion or posttraumatic segmental bone defect requiring operative intervention. INTERVENTION Patients were prospectively randomized to receive ICBG or RIA autograft. Supplemental internal fixation was performed per surgeon preference. MAIN OUTCOME MEASUREMENTS Operative data included amount of graft, time of harvest, and associated surgical costs. The Short Musculoskeletal Functional Assessment and the Visual Analog Scale were used to document baseline and postoperative function and pain. Clinical and radiographic union was the defined end point; patients considered to have failed treatment if they either developed an infection requiring operative treatment or had a persistent nonunion of the grafted extremity. RESULTS One hundred thirteen of the 133 enrolled patients were followed until union and included in the final analysis. Intraoperative data showed anterior ICBG to yield 20.7 ± 12.8 (5-60) cm of autograft with an average harvest time of 33.2 ± 16.2 minutes, posterior ICBG yielded 36.1 ± 21.3 (20-100) cm of autograft in 40.6 ± 11.2 minutes, and RIA yielded 37.7 ± 12.9 (5-90) cm in 29.4 ± 15.1 minutes. Anterior ICBG produced significantly less bone graft than either RIA or posterior ICBG (P < 0.001). The RIA harvest was completed in significantly less operative time compared with posterior ICBG (P = 0.005). At $738, the RIA setup was considerably more expensive than the ∼$100 cost of a bone graft tray; however, when compared with posterior ICBG, the longer operative time required for a posterior harvest came at an additional incremental cost of $990-1880, making RIA the less expensive option. Patients were followed for an average of 56.9 ± 42.1 (11-250) weeks. Forty-nine of 57 patients (86.0%) who received ICBG united in an average of 22.5 ± 13.2 weeks; 46 of 56 patients (82.1%) who received RIA healed in an average of 25.8 ± 17.0 weeks. Union rates and time to union were comparable between the 2 procedures. There was no difference in complications requiring reoperation for persistent nonunion or infection at the grafted site, nor there was any difference in donor-site complications. Postoperative follow-up showed that RIA patients had significantly lower donor-site pain scores throughout follow-up. CONCLUSIONS When compared with autograft obtained from the iliac crest, autograft harvested using the RIA technique achieves similar union rates with significantly less donor-site pain. RIA also yields a greater volume of graft compared with anterior ICBG and has a shorter harvest time compared with posterior ICBG. For larger volume harvests, cost analysis favors using RIA. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Conway JD, Shabtai L, Specht SC, Herzenberg JE. Sequential harvesting of bone graft from the intramedullary canal of the femur. Orthopedics 2014; 37:e796-803. [PMID: 25350622 DOI: 10.3928/01477447-20140825-56] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/30/2014] [Indexed: 02/03/2023]
Abstract
The effectiveness of using the Reamer/Irrigator/Aspirator (RIA) System (Synthes, Inc, West Chester, Pennsylvania) to obtain bone graft from the intramedullary canal of long bones for the treatment of bone defects and nonunions has been previously documented. However, there is nothing in the literature discussing the potential for reaming the same canal at subsequent surgeries. The authors detail their experience of 8 instances of sequential reaming in 7 patients. Six patients were harvested twice, and 1 patient was harvested 3 times. In each patient, the bone graft was obtained from the same canal. The main outcome measurements were time interval between reamings, reamer head size, indication for reaming, volume of harvested bone graft, and complications. Average volume of graft obtained in the first reaming procedure was 34 mL (range, 25-50 mL). After an average of 9 months (range, 3-16 months), the subsequent reaming was performed. Average volume of graft obtained in the second procedure was 45 mL (range, 28-65 mL). In the authors' series, no reaming-related complications were observed. The graft volume was the same or increased during the subsequent intramedullary reaming in all but 1 case, suggesting that the intramedullary canal is a potentially renewable source for bone graft. There were no complications related to the sequential reaming procedure. Overall, the authors' data suggest that sequential reaming with the RIA has the potential to safely and effectively provide a large quantity of bone graft on multiple occasions.
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DiGiovanni CW, Lin S, Pinzur M. Recombinant human PDGF-BB in foot and ankle fusion. Expert Rev Med Devices 2014; 9:111-22. [DOI: 10.1586/erd.11.76] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Withey CJ, Murphy AL, Horner R. Tarsometatarsal joint arthrodesis with trephine joint resection and dowel calcaneal bone graft. J Foot Ankle Surg 2013; 53:243-7. [PMID: 24388600 DOI: 10.1053/j.jfas.2013.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Indexed: 02/03/2023]
Abstract
Arthritis of the tarsometatarsal joints is a challenging problem to treat. It can cause chronic foot pain and functional disability. We present a surgical technique for tarsometatarsal joint arthrodesis using a trephine to resect the articular surfaces and a dowel plug of an autogenous calcaneal graft with locking plate fixation. The procedure has been shown to result in osseous fusion, and it is technically relatively simple to complete.
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Affiliation(s)
- Christopher J Withey
- Podiatric Surgical Trainee, Norwich Community Hospital, Norwich, United Kingdom.
| | - Anthony L Murphy
- Consultant Podiatric Surgeon, Norwich Community Hospital, Norwich, United Kingdom
| | - Rebecca Horner
- Specialist Podiatrist, Norwich Community Hospital, Norwich, United Kingdom
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Ropars M, Zadem A, Morandi X, Kaila R, Guillin R, Huten D. How can we optimize anterior iliac crest bone harvesting? An anatomical and radiological study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23:1150-5. [PMID: 24363041 DOI: 10.1007/s00586-013-3140-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Anterior iliac crest bone is a widely used donor site for bone harvesting. It provides an autologous bone graft consisting of cancellous bone that can be packed or cortical bone with greater structural support. Uses include spinal fusion and fracture non-union surgery. Although its use is common, dedicated anatomical and radiological studies analysing graft dimensions and optimal harvesting site in relation to local anatomical landmarks [anterior superior iliac spine (ASIS), anterior iliac tubercle (AIT) and lateral femoral cutaneous nerve (LFCN)] have not been described. METHODS Twenty-eight female hemipelvises were dissected for this study. The LFCN, ASIS and AIT were identified. Calliper measurements and CT scan analysis were undertaken to determine the optimum positions in obtaining a 5-mm-thickness tricortical graft whilst remaining safe for the LFCN. RESULTS According to our measurements, the optimal location for harvesting a 5-mm-thick tricortical graft with 35-mm height and 47-mm width is situated anterior to a line passing at the level of the thickest point of the AIT. This thickest point was situated at a mean 67 mm from the centre of the EIAS in our study. CONCLUSION This anatomical and radiographic study determined the anatomical iliac crest landmarks to avoid neurological injury when taking an optimal 5-mm-width tricortical bone graft.
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Affiliation(s)
- Mickaël Ropars
- Anatomy Laboratory, Faculty of medicine of Rennes, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, France,
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Baumhauer JF, Pinzur MS, Daniels TR, Lin SS, Beasley W, Donahue RMJ, DiGiovanni CW. Survey on the need for bone graft in foot and ankle fusion surgery. Foot Ankle Int 2013; 34:1629-33. [PMID: 23986324 DOI: 10.1177/1071100713503815] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Generally, autologous bone graft is felt to be an important treatment adjunct in the presence of structural deformity, surface irregularities, defects (due to trauma, surgery, or degenerative changes), or underlying comorbidities that predispose the patient to healing challenges. This study assessed the prognostic and predictive factors used in the clinical decision making for bone graft supplementation in foot and ankle fusion surgery. METHODS Utilizing standard survey research methodology, key-informant interviews, pretesting, and pilot testing; a survey was constructed. The survey consisted of a web-based 5-point Likert-type scale (never, seldom, sometimes, almost always, always) listing 14 clinical and 11 radiologic criteria that may influence the use of autologous bone grafting or other biologic augmentation in foot and ankle surgery. This survey was sent to Orthopaedic Foot and Ankle Surgeons in North America and Canada. RESULTS A total of 48 foot and ankle surgeons completed the blinded survey (73% response rate). More than 70% of responders felt bone graft was almost always (AA) or always (A) indicated in prior nonunion of the indicated joint (96%). Fewer than 50% of respondents felt poor soft tissue integrity (20%), prior foot and ankle infection (20%), and current foot and ankle infection (4%) needed bone graft. Radiologic factors marked as AA or A in over 70% of responders include radiographic evidence of nonunion (96%), avascular necrosis (87%), and others. Factors chosen as AA or A by fewer than 50% of surgeons include prior adjacent joint fusions (47%), intra-articular deformity (31%), and extra-articular deformity (13%). CONCLUSIONS There was some uniformity of agreement on the number of both clinical and radiologic factors that prompt a surgeon to utilize autologous bone graft to try to avoid the complication of nonunion. Surgeons may wish to consider these factors when making a decision on the use of bone graft to supplement fusion.
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Affiliation(s)
- Judith F Baumhauer
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Flierl MA, Smith WR, Mauffrey C, Irgit K, Williams AE, Ross E, Peacher G, Hak DJ, Stahel PF. Outcomes and complication rates of different bone grafting modalities in long bone fracture nonunions: a retrospective cohort study in 182 patients. J Orthop Surg Res 2013; 8:33. [PMID: 24016227 PMCID: PMC3847297 DOI: 10.1186/1749-799x-8-33] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 09/04/2013] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Novel bone substitutes have challenged the notion of autologous bone grafting as the 'gold standard' for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones. METHODS A retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting. RESULTS The autograft cohort had a statistically significant shorter time to union (198 ± 172-225 days) compared to allograft (416 ± 290-543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159-619 days) or rhBMP-2 (217 ± 158-277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05). CONCLUSION Autologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.
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Affiliation(s)
- Michael A Flierl
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.
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A review of the clinical experience with recombinant human platelet-derived growth factor-BB (rhPDGF-BB) in orthopaedic bone repair and regeneration. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e3182a593e6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Glazebrook M, Younger A, Wing K, Lalonde KA. A prospective pilot study of B2A-coated ceramic granules (Amplex) compared to autograft for ankle and hindfoot arthrodesis. Foot Ankle Int 2013; 34:1055-63. [PMID: 23463779 DOI: 10.1177/1071100713481459] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To reduce fusion nonunion, autogenous bone graft is often incorporated into foot and ankle fusion procedures. B2A peptide-coated ceramic granules, with encouraging results in pilot studies of transforaminal lumbar interbody fusion, were here reformulated into Amplex with a coating concentration of 225 μg B2A/cm(3) ceramic granules (B2A-granule) with the goal of eliminating autogenous bone graft in foot and ankle arthrodesis. The purpose of this study was to perform a multicenter prospective randomized pilot clinical trial designed to compare the safety and effectiveness of B2A-granule to autogenous bone graft in patients undergoing foot and ankle arthrodesis surgery. METHODS This study was a multicenter, prospective, randomized, pilot clinical trial designed to compare safety and effectiveness of B2A-granule to autogenous bone graft in patients undergoing foot and ankle arthrodesis surgery. Twenty-four patients were enrolled and randomized (1:1) into 2 groups: autogenous bone graft control and B2A-granule. Primary outcome measures at 6 months (with follow-up at 9 and 12 months) included radiographic fusion assessed by computerized tomography and Ankle Osteoarthritis Scale scores for pain and disability. RESULTS Radiographic fusion success rates were similar in both groups (100% in the B2A-granule group, 92% autograft). Both the B2A-granule group and the autograft group had improvements in the pain and disability scores over the course of the study. Graft harvest-site pain affected only autograft-treated patients. There were no adverse events attributed to the graft material in either the B2A-granule or autograft group. CONCLUSION The results of this pilot study are supportive of a larger clinical trial to assess the safety and efficacy of B2A-granule as a bone graft substitute in foot and ankle fusions. LEVEL OF EVIDENCE Level II, prospective comparative study.
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DiGiovanni CW, Lin SS, Baumhauer JF, Daniels T, Younger A, Glazebrook M, Anderson J, Anderson R, Evangelista P, Lynch SE. Recombinant human platelet-derived growth factor-BB and beta-tricalcium phosphate (rhPDGF-BB/β-TCP): an alternative to autogenous bone graft. J Bone Joint Surg Am 2013; 95:1184-92. [PMID: 23824386 DOI: 10.2106/jbjs.k.01422] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Joint arthrodesis employing autogenous bone graft (autograft) remains a mainstay in the treatment of many foot and ankle problems. However, graft harvest can lead to perioperative morbidity and increased cost. We tested the hypothesis that purified recombinant human platelet-derived growth factor-BB (rhPDGF-BB) homodimer combined with an osteoconductive matrix (beta-tricalcium phosphate [β-TCP]) would be a safe and effective alternative to autograft. METHODS A total of 434 patients were enrolled in thirty-seven clinical sites across North America in a prospective, randomized (2:1), controlled, non-inferiority clinical trial to compare the safety and efficacy of the combination rhPDGF-BB and β-TCP with those of autograft in patients requiring hindfoot or ankle arthrodesis. Radiographic, clinical, functional, and quality-of-life end points were assessed through fifty-two weeks postoperatively. RESULTS Two hundred and sixty patients (394 joints) underwent arthrodesis with use of rhPDGF-BB/β-TCP. One hundred and thirty-seven patients (203 joints) underwent arthrodesis with use of autograft. With regard to the primary end point, 159 patients (61.2% [262 joints (66.5%)]) in the rhPDGF-BB/β-TCP group and eighty-five patients (62.0% [127 joints (62.6%)]) in the autograft group were fused as determined by computed tomography at six months (p < 0.05). Clinically, 224 patients (86.2%) [348 joints (88.3%)]) in the rhPDGF-BB/β-TCP group were considered healed at fifty-two weeks, compared with 120 patients (87.6% [177 joints (87.2%)] in the autograft group (p = 0.008). Overall, fourteen of sixteen secondary end points at twenty-four weeks and fifteen of sixteen secondary end points at fifty-two weeks demonstrated statistical non-inferiority between the groups, and patients in the rhPDGF-BB/β-TCP group were found to have less pain and an improved safety profile. CONCLUSIONS In patients requiring hindfoot or ankle arthrodesis, treatment with rhPDGF-BB/β-TCP resulted in comparable fusion rates, less pain, and fewer side effects as compared with treatment with autograft.
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Affiliation(s)
- Christopher W DiGiovanni
- Department of Orthopaedic Surgery, The Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
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Müller MA, Frank A, Briel M, Valderrabano V, Vavken P, Entezari V, Mehrkens A. Substitutes of structural and non-structural autologous bone grafts in hindfoot arthrodeses and osteotomies: a systematic review. BMC Musculoskelet Disord 2013; 14:59. [PMID: 23390993 PMCID: PMC3608147 DOI: 10.1186/1471-2474-14-59] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 01/16/2013] [Indexed: 12/31/2022] Open
Abstract
Background Structural and non-structural substitutes of autologous bone grafts are frequently used in hindfoot arthrodeses and osteotomies. However, their efficacy is unclear. The primary goal of this systematic review was to compare autologous bone grafts with structural and non-structural substitutes regarding the odds of union in hindfoot arthrodeses and osteotomies. Methods The Medline and EMBASE and Cochrane databases were searched for relevant randomized and non-randomized prospective studies as well as retrospective comparative chart reviews. Results 10 studies which comprised 928 hindfoot arthrodeses and osteotomies met the inclusion criteria for this systematic review. The quality of the retrieved studies was low due to small samples sizes and confounding variables. The pooled random effect odds for union were 12.8 (95% CI 12.7 to 12.9) for structural allografts, 5.7 (95% CI 5.5 to 6.0) for cortical autologous grafts, 7.3 (95% CI 6.0 to 8.6) for cancellous allografts and 6.0 (95% CI 5.7 to 6.4) for cancellous autologous grafts. In individual studies, the odds of union in hindfoot arthrodeses achieved with cancellous autologous grafts was similar to those achieved with demineralised bone matrix or platelet derived growth factor augmented ceramic granules. Conclusion Our results suggest an equivalent incorporation of structural allografts as compared to autologous grafts in hindfoot arthrodeses and osteotomies. There is a need for prospective randomized trials to further clarify the role of substitutes of autologous bone grafts in hindfoot surgery.
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Affiliation(s)
- Marc Andreas Müller
- Orthopedic Department University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.
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