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Siverino C, Metsemakers WJ, Sutter R, Della Bella E, Morgenstern M, Barcik J, Ernst M, D'Este M, Joeris A, Chittò M, Schwarzenberg P, Stoddart M, Vanvelk N, Richards G, Wehrle E, Weisemann F, Zeiter S, Zalavras C, Varga P, Moriarty TF. Clinical management and innovation in fracture non-union. Expert Opin Biol Ther 2024:1-19. [PMID: 39126182 DOI: 10.1080/14712598.2024.2391491] [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: 05/21/2024] [Revised: 07/18/2024] [Accepted: 08/08/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION With the introduction and continuous improvement in operative fracture fixation, even the most severe bone fractures can be treated with a high rate of successful healing. However, healing complications can occur and when healing fails over prolonged time, the outcome is termed a fracture non-union. Non-union is generally believed to develop due to inadequate fixation, underlying host-related factors, or infection. Despite the advancements in fracture fixation and infection management, there is still a clear need for earlier diagnosis, improved prediction of healing outcomes and innovation in the treatment of non-union. AREAS COVERED This review provides a detailed description of non-union from a clinical perspective, including the state of the art in diagnosis, treatment, and currently available biomaterials and orthobiologics.Subsequently, recent translational development from the biological, mechanical, and infection research fields are presented, including the latest in smart implants, osteoinductive materials, and in silico modeling. EXPERT OPINION The first challenge for future innovations is to refine and to identify new clinical factors for the proper definition, diagnosis, and treatment of non-union. However, integration of in vitro, in vivo, and in silico research will enable a comprehensive understanding of non-union causes and correlations, leading to the development of more effective treatments.
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Affiliation(s)
- C Siverino
- AO Research Institute Davos, Davos Platz, Switzerland
| | - W-J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - R Sutter
- Radiology Department, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - E Della Bella
- AO Research Institute Davos, Davos Platz, Switzerland
| | - M Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - J Barcik
- AO Research Institute Davos, Davos Platz, Switzerland
| | - M Ernst
- AO Research Institute Davos, Davos Platz, Switzerland
| | - M D'Este
- AO Research Institute Davos, Davos Platz, Switzerland
| | - A Joeris
- AO Innovation Translation Center, Davos Platz, Switzerland
| | - M Chittò
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | - M Stoddart
- AO Research Institute Davos, Davos Platz, Switzerland
| | - N Vanvelk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - G Richards
- AO Research Institute Davos, Davos Platz, Switzerland
| | - E Wehrle
- AO Research Institute Davos, Davos Platz, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - F Weisemann
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau am Staffelsee, Germany
| | - S Zeiter
- AO Research Institute Davos, Davos Platz, Switzerland
| | - C Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - P Varga
- AO Research Institute Davos, Davos Platz, Switzerland
| | - T F Moriarty
- AO Research Institute Davos, Davos Platz, Switzerland
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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März V, Vogt PM, Schlottmann F. [Reconstruction options for infection-related defects : Plastic surgery armamentarium]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:567-572. [PMID: 38748218 DOI: 10.1007/s00113-024-01439-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND The occurrence of infections has always been feared in all surgical disciplines. Plastic reconstructive surgery faces the challenge of treating infection-related defects on a patient-specific basis, which requires a multidisciplinary treatment concept. Satisfactory treatment success can only be achieved through radical debridement for infection cleansing, optimization of the perfusion situation paired with targeted anti-infective treatment and, if necessary, with soft tissue reconstruction by plastic surgery. OBJECTIVE This article presents the current possibilities of plastic and reconstructive surgery with respect to the reconstruction of infection-related defects. MATERIAL AND METHODS Proven and reliable strategies are presented and supplemented by promising experimental approaches. RESULTS Due to the often multilayered defect situation caused by infections, from the epidermis to cancellous bone, the entire armamentarium of plastic and reconstructive surgery is used for reconstruction. CONCLUSION The early involvement of plastic surgery in the treatment of infections and the interdisciplinary and multimodal treatment approach have proven their worth in the treatment of complex infection situations.
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Affiliation(s)
- Vincent März
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Peter M Vogt
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Frederik Schlottmann
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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Grünewald D, Dolt A, Barzen S, Rehme-Röhrl J, von Rüden C, Hoffmann R, Schweigkofler U. [Is the 95°blade plate still important in the treatment of proximal femoral pseudarthrosis?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:589-596. [PMID: 38748217 DOI: 10.1007/s00113-024-01435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 07/30/2024]
Abstract
Due to demographic changes, fractures and subsequently delayed fracture healing as well as pseudarthrosis of the proximal femur are on the increase. In the acute fracture situation, a load-stable treatment with an intramedullary implant (cephalomedullary nail) is generally sought. To date, there is no uniform consensus on the optimal treatment for complicated cases. The aim of this study was to evaluate the clinical and radiological outcome after revision of pseudarthrosis using a 95° blade plate in aseptic proximal femoral pseudarthrosis and to identify the specifications of blade plate treatment.The retrospective study design was used to evaluate data, some of which were prospectively collected. The study period covered January 2010 to December 2020 and 22 patients (10 women, 12 men) with an average age of 59 years were included in this single-center study. All patients showed pseudarthrosis after a femoral fracture type AO 31 A1-A3 or proximal femoral fracture type AO 32 A-C. Clinical and radiological follow-up were performed after 3, 6 and 12 months. Functional outcomes were assessed using the modified Harris hip score (mHHS), the numerical rating scale (NRS) and the short form health survey (SF-12).The postoperative radiological results after reosteosynthesis using a blade plate showed good results and 86.4% of the patient population were healed during the observation period. Pseudarthrosis persisted in four patients and was surgically revised.The functional results showed good results on average, albeit with a high dispersion of 17-91 points in the mHHS. The SF-12 averaged 42.6 (±10.4) points and the psychological score 49.4 (±9.6) points. The postoperative pain level was low both at rest and under stress.It was shown that reosteosynthesis with a blade plate is a surgically demanding but effective treatment option with a low potential for infection and safe bone consolidation, especially for the correction of high-grade axial deviation or varus malalignment.
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Affiliation(s)
- Dag Grünewald
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland.
| | - Annika Dolt
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
| | - Stefan Barzen
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
| | - Julia Rehme-Röhrl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418, Murnau, Deutschland
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, 92637, Weiden in der Oberpfalz, Deutschland
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
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Choi W, Kim BS, Cho WT, Lim EJ, Choi JS, Ryu YK, Cho JW, Sakong S, Oh JK. Efficacy and safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) combined with autologous bone for the treatment of long bone nonunion: A report of a prospective case series. Injury 2024; 55:111711. [PMID: 39003882 DOI: 10.1016/j.injury.2024.111711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/13/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Recombinant human Bone morphogenetic proteins have been used for the treatment of nonunions with promising results. We have been investigating both experimentally and clinically the efficacy of the rhBMP-2 with the macro / micro-porous hydroxyapatite carrier granules on the potency on the reconstruction of long bone defect. The purpose of this study was to prospectively evaluate the efficacy and safety of this specific rhBMP-2 with HA carrier granules mixed with autologous cancellous bone in patients with nonunion and bone defect resulted from the fracture related infection. MATERIALS AND METHODS This was a retrospective review of a prospective cohort at a university hospital. Patients diagnosed with nonunion under the definition of the United States Food and Drug Administration with bone defect after long bone fractures were enrolled from January 2020 to February 2021. We included patients with atrophic and oligotrophic nonunion, and hypertrophic nonunion with malalignment that needed to be corrected. The other patient group was consisted of segmental bone defect resulted from FRI. The maximum amount of rhBMP-2 allowed in this clinical study was 6 mg and was added to autologous bone at a 1:1 ratio. Autologous bone was added to the mixture if the volume of mixed graft was insufficient to fill the bone defect. Patients were followed 3, 6, and 12 months post-operatively. Each visit, a radiograph was taken for assessment. Visual analog scale (VAS), questionnaire for quality of life (SF-12 physical component summary [PCS], mental component summary [MCS]), and weight-bearing status were collected for functional outcome assessment. Drug safety was assessed by examining BMP-2 antibodies. RESULTS Of the 24 enrolled patients (mean age: 57 years), 15 (62.5 %), 2 (8.33 %), and 7 (29.17 %) presented atrophic nonunion, hypertrophic nonunion with deformity, and bone defect after fracture related infection, respectively. Thirteen patients had nonunion in the femur, 9 in the tibia, and 1 in the humerus and radius. The average amount of harvested autologous bone was 9.25 g and 4.96 mg of rhBMP-2. All 24 patients achieved union after 1-year follow up. The union rate was 95.83 % and 100 % at 6 and 12 months postoperatively, respectively. Preoperative SF-12 PCS (mean: 34.71) improved at 6 and 12 months postoperatively, respectively. Preoperative SF-12 MCS (mean: 42.89) improved 12 months postoperatively (49.13, p = 0.0338). Change of VAS was statistically significant 3 months postoperatively (p = 0.0012). No adverse effects or development of BMP-2 antibodies were observed. CONCLUSION BMP-2 combined with autogenous bone resulted in excellent radiographical and functional outcomes in a relatively small prospective series of patients with nonunion and bone defect, without adverse effects. Further investigations are necessary to support our finding and optimize treatment strategies in nonunion patients.
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Affiliation(s)
- Wonseok Choi
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopaedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Won-Tae Cho
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Kyungki, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Jeong Seok Choi
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Yun Ki Ryu
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Jae-Woo Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Seungyeob Sakong
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Kyungki, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea.
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Tjandra KC, Novriansyah R, Limijadi EKS, Kuntjoro L, Hendrianingtyas M. The effect of green mussel ( Perna viridis) shells' hydroxyapatite application on alkaline phosphatase levels in rabbit femur bone defect. F1000Res 2024; 12:631. [PMID: 38915771 PMCID: PMC11195609 DOI: 10.12688/f1000research.132881.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 06/26/2024] Open
Abstract
Background Non-union fractures can be prevented with bone grafts, such as hydroxyapatite made from green mussel shells. Green mussel shells contain a high percentage of HA, making them a promising alternative for bone healing. This research aims to reveal the effectiveness of green mussel shell HA as a bone substitute material and to provide knowledge for further research. Methods This research was conducted for four months using a true experimental research method with a post-test-only control group design. This study used 36 New Zealand rabbits ( Oryctolagus cuniculus) which were divided into 9 groups: positive control, negative control, and intervention at weeks 2, 4 and 6 after the intervention. All groups were subjected to three general procedures: pre-surgery, surgery, and post-surgery. This study utilized histological evaluation and biochemical assessment, specifically measuring serum alkaline phosphatase (ALP) levels, to investigate the effects of hydroxyapatite (HA) from green mussel shells on bone healing in rabbits. Results The findings demonstrated that green mussel shell HA hashad efficacy in accelerating bone healing, better than HA bovine HA i.e. green mussel shell hydroxyapatite showed superior efficacy compared to bovine hydroxyapatite in accelerating and maximizing fracture healing, as compared to the 6-week negative control group and demonstrated a significant difference ( p < 0.05). Conclusions Green mussel hydroxyapatite is proven to be able to fasten and maximize the bone healing process as fast as bovine HA, and even has higher efficacy than bovine HA.
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Affiliation(s)
- Kevin Christian Tjandra
- Kariadi General Hospital, Semarang, Indonesia
- Department of Medicine, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Robin Novriansyah
- Kariadi General Hospital, Semarang, Indonesia
- Department of Surgery, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Edward Kurnia Setiawan Limijadi
- Kariadi General Hospital, Semarang, Indonesia
- Department of Clinical Pathology, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Lydia Kuntjoro
- Kariadi General Hospital, Semarang, Indonesia
- Department of Radiology, Medical Faculty, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | - Meita Hendrianingtyas
- Kariadi General Hospital, Semarang, Indonesia
- Department of Clinical Pathology, Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia
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Bixel MG, Sivaraj KK, Timmen M, Mohanakrishnan V, Aravamudhan A, Adams S, Koh BI, Jeong HW, Kruse K, Stange R, Adams RH. Angiogenesis is uncoupled from osteogenesis during calvarial bone regeneration. Nat Commun 2024; 15:4575. [PMID: 38834586 PMCID: PMC11150404 DOI: 10.1038/s41467-024-48579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/06/2024] [Indexed: 06/06/2024] Open
Abstract
Bone regeneration requires a well-orchestrated cellular and molecular response including robust vascularization and recruitment of mesenchymal and osteogenic cells. In femoral fractures, angiogenesis and osteogenesis are closely coupled during the complex healing process. Here, we show with advanced longitudinal intravital multiphoton microscopy that early vascular sprouting is not directly coupled to osteoprogenitor invasion during calvarial bone regeneration. Early osteoprogenitors emerging from the periosteum give rise to bone-forming osteoblasts at the injured calvarial bone edge. Microvessels growing inside the lesions are not associated with osteoprogenitors. Subsequently, osteogenic cells collectively invade the vascularized and perfused lesion as a multicellular layer, thereby advancing regenerative ossification. Vascular sprouting and remodeling result in dynamic blood flow alterations to accommodate the growing bone. Single cell profiling of injured calvarial bones demonstrates mesenchymal stromal cell heterogeneity comparable to femoral fractures with increase in cell types promoting bone regeneration. Expression of angiogenesis and hypoxia-related genes are slightly elevated reflecting ossification of a vascularized lesion site. Endothelial Notch and VEGF signaling alter vascular growth in calvarial bone repair without affecting the ossification progress. Our findings may have clinical implications for bone regeneration and bioengineering approaches.
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Affiliation(s)
- M Gabriele Bixel
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany.
| | - Kishor K Sivaraj
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
| | - Melanie Timmen
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, University Hospital Münster, D-48149, Münster, Germany
| | - Vishal Mohanakrishnan
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
| | - Anusha Aravamudhan
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
| | - Susanne Adams
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
| | - Bong-Ihn Koh
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
| | - Hyun-Woo Jeong
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
- Max Planck Institute for Molecular Biomedicine, Sequencing Core Facility, D-48149, Münster, Germany
| | - Kai Kruse
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany
- Max Planck Institute for Molecular Biomedicine, Bioinformatics Service Unit, D-48149, Münster, Germany
| | - Richard Stange
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, University Hospital Münster, D-48149, Münster, Germany
| | - Ralf H Adams
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine and University of Münster, Faculty of Medicine, D-48149, Münster, Germany.
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Rodham P, Khaliq F, Giannoudis V, Giannoudis PV. Cellular therapies for bone repair: current insights. J Orthop Traumatol 2024; 25:28. [PMID: 38789881 PMCID: PMC11132192 DOI: 10.1186/s10195-024-00768-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Mesenchymal stem cells are core to bone homeostasis and repair. They both provide the progenitor cells from which bone cells are formed and regulate the local cytokine environment to create a pro-osteogenic environment. Dysregulation of these cells is often seen in orthopaedic pathology and can be manipulated by the physician treating the patient. This narrative review aims to describe the common applications of cell therapies to bone healing whilst also suggesting the future direction of these techniques.
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Affiliation(s)
- Paul Rodham
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - Farihah Khaliq
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK
| | - Vasileos Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
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Gómez-Barrena E, Ehrnthaller C. Long bone uninfected non-union: grafting techniques. EFORT Open Rev 2024; 9:329-338. [PMID: 38726992 PMCID: PMC11099576 DOI: 10.1530/eor-24-0032] [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: 05/12/2024] Open
Abstract
Long bone non-unions represent a serious clinical and socioeconomical problem due to the prolonged episodes, frequent sequelae, and variable treatment effectiveness. Bone grafts, classically involving the autologous iliac crest graft as the 'gold standard' bone graft, enhance bone regeneration and fracture healing incorporating osteoconductive and/or osteoinductive/osteogenic capacity to the non-union under treatment. Structural alternatives to autologous bone grafts include allografts and bone substitutes, expanding the available stock but loosing biological properties associated with cells in the graft. Biological alternatives to autologous bone grafts include bone marrow concentration from iliac crest aspiration, bone marrow aspiration from reaming of the diaphyseal medullary canal in the long bones, and isolated, expanded mesenchymal stem cells under investigation. When the combination with natural and synthetic bone substitutes allows for larger volumes of structural grafts, the enhancement of the biological regenerative properties through the incorporation of cells and their secretoma permits to foresee new bone grafting solutions and techniques.
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Affiliation(s)
- Enrique Gómez-Barrena
- Department of Orthopaedic Surgery and Traumatology, Hospital La Paz-IdiPaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Christian Ehrnthaller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Germany
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Lu F, Groven RVM, van Griensven M, Poeze M, Geurts JAP, Qiu SS, Blokhuis TJ. Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study. J Orthop Traumatol 2024; 25:21. [PMID: 38637406 PMCID: PMC11026327 DOI: 10.1186/s10195-024-00763-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/01/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity. MATERIALS AND METHODS Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18 months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis. RESULTS A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively. CONCLUSIONS Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Fangzhou Lu
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
| | - Rald V M Groven
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
| | - Martijn van Griensven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
| | - Martijn Poeze
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Jan A P Geurts
- CAPHRI Care and Public Health Research Institute, Department of Orthopedic Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, Maastricht, the Netherlands
| | - Shan Shan Qiu
- Division of Plastic Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Taco J Blokhuis
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands
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Perut F, Roncuzzi L, Gómez-Barrena E, Baldini N. Association between Bone Turnover Markers and Fracture Healing in Long Bone Non-Union: A Systematic Review. J Clin Med 2024; 13:2333. [PMID: 38673606 PMCID: PMC11051214 DOI: 10.3390/jcm13082333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Fracture healing is a very complex and well-orchestrated regenerative process involving many cell types and molecular pathways. Despite the high efficiency of this process, unsatisfying healing outcomes, such as non-union, occur for approximately 5-10% of long bone fractures. Although there is an obvious need to identify markers to monitor the healing process and to predict a potential failure in callus formation to heal the fracture, circulating bone turnover markers' (BTMs) utility as biomarkers in association with radiographic and clinical examination still lacks evidence so far. Methods: A systematic review on the association between BTMs changes and fracture healing in long bone non-union was performed following PRISMA guidelines. The research papers were identified via the PubMed, Cochrane, Cinahl, Web of Science, Scopus, and Embase databases. Studies in which the failure of fracture healing was associated with osteoporosis or genetic disorders were not included. Results: A total of 172 studies were collected and, given the inclusion criteria, 14 manuscripts were included in this review. Changes in circulating BTMs levels were detected during the healing process and across groups (healed vs. non-union patients and healthy vs. patients with non-union). However, we found high heterogeneity in patients' characteristics (fracture site, gender, and age) and in sample scheduling, which made it impossible to perform a meta-analysis. Conclusions: Clinical findings and radiographic features remain the two important components of non-union diagnosis so far. We suggest improving blood sample standardization and clinical data collection in future research to lay the foundations for the effective use of BTMs as tools for diagnosing non-union.
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Affiliation(s)
- Francesca Perut
- Biomedical Science and Technologies and Nanobiotechnology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.R.); (N.B.)
| | - Laura Roncuzzi
- Biomedical Science and Technologies and Nanobiotechnology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.R.); (N.B.)
| | - Enrique Gómez-Barrena
- Department of Orthopedic Surgery and Traumatology, Hospital Universitario La Paz-IdiPAZ, 28046 Madrid, Spain;
- Facultad de Medicina, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Nicola Baldini
- Biomedical Science and Technologies and Nanobiotechnology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.R.); (N.B.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40136 Bologna, Italy
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Chen J, Wu W, Xian C, Wang T, Hao X, Chai N, Liu T, Shang L, Wang B, Gao J, Bi L. Analysis of risk factors and development of a nomogram-based prediction model for defective bony non-union. Heliyon 2024; 10:e28502. [PMID: 38586399 PMCID: PMC10998093 DOI: 10.1016/j.heliyon.2024.e28502] [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: 12/19/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
Objective To explore risk factors for defective non-union of bone and develop a nomogram-based prediction model for such an outcome. Methods This retrospective study analysed the case data of patients with defective bony non-unions who were treated at the authors' hospital between January 2010 and December 2020. Patients were divided into the union and non-union groups according to their Radiographic Union Score for Tibia scores 1 year after surgery. Univariate analysis was performed to assess factors related to demographic characteristics, laboratory investigations, surgery, and trauma in both groups. Subsequently, statistically significant factors were included in the multivariate logistic regression analysis to identify independent risk factors. A nomogram-based prediction model was established using statistically significant variables in the multivariate analysis. The accuracy and stability of the model were evaluated using receiver operating characteristic (ROC) and calibration curves. The clinical applicability of the nomogram model was evaluated using decision curve analysis. Results In total, 204 patients (171 male, 33 female; mean [±SD] age, 39.75 ± 13.00 years) were included. The mean body mass index was 22.95 ± 3.64 kg/m2. Among the included patients, 29 were smokers, 18 were alcohol drinkers, and 21 had a previous comorbid systemic disease (PCSD). Univariate analysis revealed that age, occupation, PCSD, smoking, drinking, interleukin-6, C-reactive protein (CRP), procalcitonin, alkaline phosphatase, glucose, and uric acid levels; blood calcium ion concentration; and bone defect size (BDS) were correlated with defective bone union (all P < 0.05). Multivariate logistic regression analysis revealed that PCSD, smoking, interleukin-6, CRP, and glucose levels; and BDS were associated with defective bone union (all P < 0.05), and the variables in the multivariate analysis were included in the nomogram-based prediction model. The value of the area under the ROC curve for the predictive model for bone defects was 0.95. Conclusion PCSD, smoking, interleukin-6, CRP, and glucose levels; and BDS were independent risk factors for defective bony non-union, and the incidence of such non-union was predicted using the nomogram. These findings are important for clinical interventions and decision-making.
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Affiliation(s)
- Jingdi Chen
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
- Department of Orthopedics, 95829 Military Hospital in PLA, Wuhan, 430000, China
| | - Wei Wu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430000, China
| | - Chunxing Xian
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Taoran Wang
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Xiaotian Hao
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Na Chai
- Department of Radiology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Tao Liu
- Department of Orthopedics, 95829 Military Hospital in PLA, Wuhan, 430000, China
| | - Lei Shang
- Department of Health Statistics, Air Force Medical University, Xi'an, 710032, China
| | - Bo Wang
- Department of Epidemiology, School of Public Health, Air Force Medical University, Xi'an, 710032, China
| | - Jiakai Gao
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Long Bi
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
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Koç-Demir A, Elçin AE, Elçin YM. Magnetic biocomposite scaffold based on decellularized tendon ECM and MNP-deposited halloysite nanotubes: physicochemical, thermal, rheological, mechanical and in vitrobiological evaluations. Biomed Mater 2024; 19:035027. [PMID: 38537375 DOI: 10.1088/1748-605x/ad38ab] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
The development of new three-dimensional biomaterials with advanced versatile properties is critical to the success of tissue engineering (TE) applications. Here, (a) bioactive decellularized tendon extracellular matrix (dECM) with a sol-gel transition feature at physiological temperature, (b) halloysite nanotubes (HNT) with known mechanical properties and bioactivity, and (c) magnetic nanoparticles (MNP) with superparamagnetic and osteogenic properties were combined to develop a new scaffold that could be used in prospective bone TE applications. Deposition of MNPs on HNTs resulted in magnetic nanostructures without agglomeration of MNPs. A completely cell-free, collagen- and glycosaminoglycan- rich dECM was obtained and characterized. dECM-based scaffolds incorporated with 1%, 2% and 4% MNP-HNT were analysed for their physical, chemical, andin vitrobiological properties. Fourier-transform infrared spectroscopy, x-ray powder diffractometry and vibrating sample magnetometry analyses confirmed the presence of dECM, HNT and MNP in all scaffold types. The capacity to form apatite layer upon incubation in simulated body fluid revealed that dECM-MNP-HNT is a bioactive material. Combining dECM with MNP-HNT improved the thermal stability and compressive strength of the macroporous scaffolds upto 2% MNP-HNT.In vitrocytotoxicity and hemolysis experiments showed that the scaffolds were essentially biocompatible. Human bone marrow mesenchymal stem cells adhered and proliferated well on the macroporous constructs containing 1% and 2% MNP-HNT; and remained metabolically active for at least 21 din vitro. Collectively, the findings support the idea that magnetic nanocomposite dECM scaffolds containing MNP-HNT could be a potential template for TE applications.
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Affiliation(s)
- Aysel Koç-Demir
- Tissue Engineering, Biomaterials and Nanobiotechnology Laboratory, Ankara University Faculty of Science, and Ankara University Stem Cell Institute, Ankara, Turkey
| | - Ayşe Eser Elçin
- Tissue Engineering, Biomaterials and Nanobiotechnology Laboratory, Ankara University Faculty of Science, and Ankara University Stem Cell Institute, Ankara, Turkey
| | - Yaşar Murat Elçin
- Tissue Engineering, Biomaterials and Nanobiotechnology Laboratory, Ankara University Faculty of Science, and Ankara University Stem Cell Institute, Ankara, Turkey
- Biovalda Health Technologies, Inc., Ankara, Turkey
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Ehrnthaller C, Hoxhaj K, Manz K, Zhang Y, Fürmetz J, Böcker W, Linhart C. Preventing Atrophic Long-Bone Nonunion: Retrospective Analysis at a Level I Trauma Center. J Clin Med 2024; 13:2071. [PMID: 38610836 PMCID: PMC11012355 DOI: 10.3390/jcm13072071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Among the risk factors for nonunion are unchangeable patient factors such as the type of injury and comorbidities, and factors that can be influenced by the surgeon such as fracture treatment and the postoperative course. While there are numerous studies analyzing unchangeable factors, there is poor evidence for factors that can be affected by the physician. This raises the need to fill the existing knowledge gaps and lay the foundations for future prevention and in-depth treatment strategies. Therefore, the goal of this study was to illuminate knowledge about nonunion in general and uncover the possible reasons for their development; Methods: This was a retrospective analysis of 327 patients from 2015 to 2020 from a level I trauma center in Germany. Information about patient characteristics, comorbidities, alcohol and nicotine abuse, fracture classification, type of osteosynthesis, etc., was collected. Matched pair analysis was performed, and statistical testing performed specifically for atrophic long-bone nonunion; Results: The type of osteosynthesis significantly affected the development of nonunion, with plate osteosynthesis being a predictor for nonunion. The use of wire cerclage did not affect the development of nonunion, nor did the use of NSAIDs, smoking, alcohol, osteoporosis and BMI; Conclusion: Knowledge about predictors for nonunion and strategies to avoid them can benefit the medical care of patients, possibly preventing the development of nonunion.
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Affiliation(s)
- Christian Ehrnthaller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany; (K.H.); (Y.Z.); (J.F.); (W.B.); (C.L.)
| | - Klevin Hoxhaj
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany; (K.H.); (Y.Z.); (J.F.); (W.B.); (C.L.)
| | - Kirsi Manz
- Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie (IBE), Medizinische Fakultät, LMU München, Marchioninistr. 15, 81377 München, Germany;
| | - Yunjie Zhang
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany; (K.H.); (Y.Z.); (J.F.); (W.B.); (C.L.)
| | - Julian Fürmetz
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany; (K.H.); (Y.Z.); (J.F.); (W.B.); (C.L.)
- Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Straße 8, 82418 Murnau am Staffelsee, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany; (K.H.); (Y.Z.); (J.F.); (W.B.); (C.L.)
| | - Christoph Linhart
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany; (K.H.); (Y.Z.); (J.F.); (W.B.); (C.L.)
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El-Alfy B, Abououf A, Darweash A, Fawzy S. The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases. INTERNATIONAL ORTHOPAEDICS 2024; 48:1105-1111. [PMID: 38227010 PMCID: PMC10933179 DOI: 10.1007/s00264-023-06085-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/26/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries. METHODS Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities. RESULTS The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results. CONCLUSION Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.
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Affiliation(s)
- Barakat El-Alfy
- Department of Orthopaedic Surgery, Mansoura University Hospital, Mansoura University, Mansoura, 7650001, Egypt
| | - Alaa Abououf
- Department of Orthopaedic Surgery, Faculty of Medicine, Aswan University, New Aswan City, 81528, Egypt.
| | - Ahmed Darweash
- Department of Orthopaedic Surgery, Faculty of Medicine, Suez University, PO Box 43221, Suez, Egypt
| | - Salam Fawzy
- Department of Orthopaedic Surgery, Mansoura University Hospital, Mansoura University, Mansoura, 7650001, Egypt
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15
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Wei H, Chen W, Chen S, Zhang T, Xiao X. 3D printing of MOF-reinforced methacrylated gelatin scaffolds for bone regeneration. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2024; 35:443-462. [PMID: 38104316 DOI: 10.1080/09205063.2023.2295057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
Scaffolds based on gelatin (Gel) play a crucial role in bone tissue engineering. However, the low mechanical properties, rapid biodegradation rate, insufficient osteogenic activity and lacking anti-infective properties limit their applications in bone regeneration. Herein, the incorporation of ibuprofen (IBU)-loaded zeolitic imidazolate framework-8 (ZIF-8) in a methacrylated gelatin (GelMA) matrix was proposed as a simple and effective strategy to develop the IBU-ZIF-8@GelMA scaffolds for enhanced bone regeneration capacity. Results indicated that the IBU-loaded ZIF-8 nanoparticles with tiny particle sizes were uniformly distributed in the GelMA matrix of the IBU-ZIF-8@GelMA scaffolds, and the IBU-loaded ZIF-8 growing in the scaffolds enabled the controlled and sustained releasing of Zn2+ and IBU in pH = 5.5 over a long period for efficient bone repair and long-term anti-inflammatory activity. Furthermore, the doping of the IBU-loaded ZIF-8 nanoparticles efficiently enhanced the compression performance of the GelMA scaffolds. In vitro studies indicated that the prepared scaffolds presented no cytotoxicity to MC3T3-E1 cells and the released Zn2+ during the degradation of the scaffolds promoted MC3T3-E1 cell osteogenic differentiation. Thus, the drug-loaded ZIF-8 modified 3D printed GelMA scaffolds demonstrated great potential in treating bone defects.
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Affiliation(s)
- Haodong Wei
- Fujian Provincial Key Laboratory of Advanced Materials Oriented Chemical Engineering, Engineering Research Center of Industrial Biocatalysis, Fujian-Taiwan Science and Technology Cooperation Base of Biomedical Materials and Tissue Engineering, College of Chemistry and Materials Science, Fujian Normal University, Fuzhou, China
| | - Weixin Chen
- Fujian Provincial Key Laboratory of Advanced Materials Oriented Chemical Engineering, Engineering Research Center of Industrial Biocatalysis, Fujian-Taiwan Science and Technology Cooperation Base of Biomedical Materials and Tissue Engineering, College of Chemistry and Materials Science, Fujian Normal University, Fuzhou, China
| | - Shunyu Chen
- Fujian Provincial Key Laboratory of Advanced Materials Oriented Chemical Engineering, Engineering Research Center of Industrial Biocatalysis, Fujian-Taiwan Science and Technology Cooperation Base of Biomedical Materials and Tissue Engineering, College of Chemistry and Materials Science, Fujian Normal University, Fuzhou, China
| | - Tao Zhang
- Department of Orthopedics Institute, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Xiufeng Xiao
- Fujian Provincial Key Laboratory of Advanced Materials Oriented Chemical Engineering, Engineering Research Center of Industrial Biocatalysis, Fujian-Taiwan Science and Technology Cooperation Base of Biomedical Materials and Tissue Engineering, College of Chemistry and Materials Science, Fujian Normal University, Fuzhou, China
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16
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Jagannathan C, Waddington R, Nishio Ayre W. Nanoparticle and Nanotopography-Induced Activation of the Wnt Pathway in Bone Regeneration. TISSUE ENGINEERING. PART B, REVIEWS 2024; 30:270-283. [PMID: 37795571 DOI: 10.1089/ten.teb.2023.0108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background and Aims: Recent research has focused on developing nanoparticle and nanotopography-based technologies for bone regeneration. The Wingless-related integration site (Wnt) signaling pathway has been shown to play a vital role in this process, in particular in osteogenic differentiation and proliferation. The exact mechanisms by which nanoparticles and nanotopographies activate the Wnt signaling pathway, however, are not fully understood. This review aimed to elucidate the mechanisms by which nanoscale technologies activate the Wnt signaling pathway during bone regeneration. Methods: The terms "Wnt," "bone," and "nano*" were searched on PubMed and Ovid with no date limit. Only original research articles related to Wnt signaling and bone regeneration in the context of nanotopographies, nanoparticles, or scaffolds with nanotopographies/nanoparticles were reviewed. Results: The primary mechanism by which nanoparticles activated the Wnt pathway was by internalization through the endocytic pathway or diffusion through the cell membrane, leading to accumulation of nonphosphorylated β-catenin in the cytoplasm and subsequently downstream osteogenic signaling (e.g., upregulation of runt-related transcription factor 2 [RUNX2]). The specific size of the nanoparticles and the process of endocytosis itself has been shown to modulate the Wnt-β-catenin pathway. Nanotopographies were shown to directly activate frizzled receptors, initiating Wnt/β-catenin signaling. Additional studies showed nanotopographies to activate the Wnt/calcium (Wnt/Ca2+)-dependent and Wnt/planar cell polarity pathways through nuclear factor of activated T cells, and α5β1 integrin stimulation. Finally, scaffolds containing nanotopographies/nanoparticles were found to induce Wnt signaling through a combination of ion release (e.g., lithium, boron, lanthanum, and icariin), which inhibited glycogen synthase kinase 3 beta (GSK-3β) activity, and through similar mechanisms to the nanotopographies. Conclusion: This review concludes that nanoparticles and nanotopographies cause Wnt activation through several different mechanisms, specific to the size, shape, and structure of the nanoparticles or nanotopographies. Endocytosis-related mechanisms, integrin signaling and ion release were the major mechanisms identified across nanoparticles, nanotopographies, and scaffolds, respectively. Knowledge of these mechanisms will help develop more effective targeted nanoscale technologies for bone regeneration. Impact statement Nanoparticles and nanotopographies can activate the Wingless-related integration site (Wnt) signaling pathway, which is essential for bone regeneration. This review has identified that activation is due to endocytosis, integrin signaling and ion release, depending on the size, shape, and structure of the nanoparticles or nanotopographies. By identifying and further understanding these mechanisms, more effective nanoscale technologies that target the Wnt signaling pathway can be developed. These technologies can be used for the treatment of nonunion bone fractures, a major clinical challenge, with the potential to improve the quality of life of millions of patients around the world.
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Affiliation(s)
- Chitra Jagannathan
- Department of Applied Sciences, University of the West of England, Bristol, United Kingdom
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Kammerer A, Hartmann FA, Nau C, Leiblein M, Schaible A, Neijhoft J, Henrich D, Verboket R, Janko M. The Impact of Defect Size on Bone Healing in Critical-Size Bone Defects Investigated on a Rat Femur Defect Model Comparing Two Treatment Methods. Bioengineering (Basel) 2024; 11:287. [PMID: 38534561 DOI: 10.3390/bioengineering11030287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024] Open
Abstract
Critical-size bone defects up to 25 cm can be treated successfully using the induced membrane technique established by Masquelet. To shorten this procedure, human acellular dermis (HAD) has had success in replacing this membrane in rat models. The aim of this study was to compare bone healing for smaller and larger defects using an induced membrane and HAD in a rat model. Using our established femoral defect model in rats, the animals were placed into four groups and defects of 5 mm or 10 mm size were set, either filling them with autologous spongiosa and surrounding the defect with HAD or waiting for the induced membrane to form around a cement spacer and filling this cavity in a second operation with a cancellous bone graft. Healing was assessed eight weeks after the operation using µ-CT, histological staining, and an assessment of the progress of bone formation using an established bone healing score. The α-smooth muscle actin used as a signal of blood vessel formation was stained and counted. The 5 mm defects showed significantly better bone union and a higher bone healing score than the 10 mm defects. HAD being used for the smaller defects resulted in a significantly higher bone healing score even than for the induced membrane and significantly higher blood vessel formation, corroborating the good results achieved by using HAD in previous studies. In comparison, same-sized groups showed significant differences in bone healing as well as blood vessel formation, suggesting that 5 mm defects are large enough to show different results in healing depending on treatment; therefore, 5 mm is a viable size for further studies on bone healing.
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Affiliation(s)
- Andreas Kammerer
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Frederik Alexander Hartmann
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Maximilian Leiblein
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Alexander Schaible
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Jonas Neijhoft
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Dirk Henrich
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - René Verboket
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Maren Janko
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
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Chen G, Xin Z, Kong W, Wu F, Li X, Qiao Y, Yan X, Liao W. Anterior Full-endoscopic Single-port Double Transcorporeal Spinal Cord Decompression for Noncontinuous Two-segment Cervical Spondylotic Myelopathy: A Technical Note. Orthop Surg 2024; 16:754-765. [PMID: 38287224 PMCID: PMC10925512 DOI: 10.1111/os.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE In clinical practice, noncontinuous two-segment spinal cord cervical spondylosis is a particular form of cervical degenerative disease. Traditional anterior open surgery frequently comes with severe trauma, risks, and debatable treatment options. This study aimed to describe for the first time a novel minimally invasive technique, namely, anterior full-endoscopic single-port double transcorporeal spinal cord decompression for the treatment of patients with noncontinuous two-segment cervical spondylotic myelopathy. METHOD From February 2020 to May 2021, five patients with noncontinuous two-segment cervical spondylotic myelopathy were treated with anterior full-endoscopic single-port double transcorporeal spinal cord decompression. Two bone channels were established by the trephine through the vertebral body oblique upward and downward to the herniated disc osteophyte complex, and the full-endoscopic system could decompress the spinal cord through the channels. All cases were followed up for over 2 years. The modified Japanese Orthopaedic Association (mJOA) score and visual analogue scale (VAS) score before and after operation and during follow-up were used to evaluate the clinical effectiveness. Radiological examinations, including CT and MRI, were utilized to evaluate the efficacy of spinal cord decompression and bone channel repair. RESULTS All operations were successfully completed and the average operation time was 185 min, with no operation-related complications. Compared with the preoperative evaluation, the mJOA score and VAS score were improved at each time point after operation and follow-up. Postoperative CT and MRI scans showed that the intervertebral disc-osteophyte complex was removed through the vertebral bone passage, and the spinal cord was fully decompressed. After 24 months of follow-up, CT and MRI scans showed that the bone channel was almost repaired and healed. CONCLUSION Anterior full-endoscopic single-port double transcorporeal spinal cord decompression is an effective minimally invasive technique for noncontinuous two-segment cervical spondylosis. It provides precise and satisfactory spinal cord decompression under endoscopic visualization with minimum trauma.
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Affiliation(s)
- Gang Chen
- Department of OrthopedicsThe Second Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Zhijun Xin
- Department of Orthopedic SurgeryThe Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Weijun Kong
- Department of OrthopedicsThe Second Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Fujun Wu
- Department of Orthopedic SurgeryThe Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Xuyan Li
- Department of Orthopedic SurgeryThe Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Yanyu Qiao
- Department of OrthopedicsThe Second Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Xiang Yan
- Department of OrthopedicsThe Second Affiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Wenbo Liao
- Department of OrthopedicsThe Second Affiliated Hospital of Zunyi Medical UniversityZunyiChina
- Department of Orthopedic SurgeryThe Affiliated Hospital of Zunyi Medical UniversityZunyiChina
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Evans AR, Giannoudis PV, Leucht P, McKinley TO, Gaski GE, Frey KP, Wenke JC, Lee C. The local and systemic effects of immune function on fracture healing. OTA Int 2024; 7:e328. [PMID: 38487403 PMCID: PMC10936162 DOI: 10.1097/oi9.0000000000000328] [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: 12/13/2023] [Revised: 12/28/2023] [Accepted: 01/04/2024] [Indexed: 03/17/2024]
Abstract
The immune system plays an integral role in the regulation of cellular processes responsible for fracture healing. Local and systemic influences on fracture healing correlate in many ways with fracture-related outcomes, including soft tissue healing quality and fracture union rates. Impaired soft tissue healing, restricted perfusion of a fracture site, and infection also in turn affect the immune response to fracture injury. Modern techniques used to investigate the relationship between immune system function and fracture healing include precision medicine, using vast quantities of data to interpret broad patterns of inflammatory response. Early data from the PRECISE trial have demonstrated distinct patterns of inflammatory response in polytrauma patients, which thereby directly and indirectly regulate the fracture healing response. The clearly demonstrated linkage between immune function and fracture healing suggests that modulation of immune function has significant potential as a therapeutic target that can be used to enhance fracture healing.
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Affiliation(s)
- Andrew R. Evans
- Warren Alpert School of Medicine at Brown University, University Orthopedics, Inc, Providence, RI
| | - Peter V. Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Level D, Leeds, West Yorkshire, United Kingdom
| | | | | | - Greg E. Gaski
- University of Virginia School of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - Katherine P. Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Joseph C. Wenke
- UTMB Department of Orthopaedic Surgery and Rehabilitation, Shriners Children's Texas, Galveston, TX
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20
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Lee S, Kang BJ. Surgical Reconstruction of Canine Nonunion Fractures Using Bone Morphogenetic Protein-2-loaded Alginate Microbeads and Bone Allografts. In Vivo 2024; 38:611-619. [PMID: 38418118 PMCID: PMC10905487 DOI: 10.21873/invivo.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND/AIM Effective treatment of nonunion fractures is challenging as it requires a biological and mechanical environment to promote sufficient osteogenesis. Herein, we present a case series in which we evaluated the clinical efficacy of bone morphogenetic protein-2 (BMP-2)-loaded alginate microbeads and allografts in two dogs with nonunion fractures. CASE REPORT A 3-year-old, 2.3-kg, spayed female Pomeranian (Case 1) presented with intermittent lameness of the left forelimb after radial and ulnar fracture repair 8 weeks prior. A 4-year-old, 4.8-kg, spayed female Pomeranian (Case 2) was referred for non-weight-bearing lameness of the left hindlimb due to implant failure following left tibial fracture repair. Both dogs had atrophic bone ends and no bridging calluses at the fracture site on radiographs, and were diagnosed with nonviable nonunion fractures of the radius/ulna and tibia, respectively. The surgical approach involved implant removal, debridement, and fracture gap reconstruction. BMP-2 was loaded into alginate microbeads for a prolonged release with bone allograft chips in both cases. In Case 1, bead grafts were applied directly at the fracture site, while in Case 2, they were implanted inside a frozen cortical bone allograft as a scaffold to fill the large gap. Postoperative radiography revealed excessive callus formation, early radiographic bone union, and cortical bone remodeling, in line with improved lameness scores. At the final follow-up, gait was improved and the desired bone length and shape were achieved in both cases. CONCLUSION Simultaneous use of osteoinductive BMP-2 alginate microbeads and osteoconductive bone allografts yielded functionally and structurally favorable outcomes in canine nonunion fractures, without major complications.
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Affiliation(s)
- Seoyun Lee
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul, Republic of Korea
| | - Byung-Jae Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul, Republic of Korea
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21
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Harrison N, Hysong A, Posey S, Yu Z, Chen AT, Pallitto P, Gardner MJ, Dumpe J, Mir H, Babcock S, Natoli RM, Adams JD, Zura RD, Miller AN, Seymour RB, Hsu JR, Obremskey W. Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation. J Orthop Trauma 2024; 38:168-175. [PMID: 38158607 DOI: 10.1097/bot.0000000000002740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. METHODS DESIGN Retrospective case series. SETTING Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS Success rate of nonunion surgery. RESULTS Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Noah Harrison
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander Hysong
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Samuel Posey
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Andrew T Chen
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Patrick Pallitto
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
| | - Jarrod Dumpe
- Department of Orthopaedic Surgery, Atrium Health Navicent Medical Center, Macon, GA
| | - Hassan Mir
- Department of Orthopaedic Surgery, Florida Orthopedic Institute, Tampa, FL
| | - Sharon Babcock
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN
| | - John D Adams
- Department of Orthopaedic Surgery, Prisma Health, Greenville, SC
| | - Robert D Zura
- Department of Orthopaedics, Louisiana State University, New Orleans, LA; and
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - William Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
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22
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Devendra A, Patra SK, Velmurugesan P, Zackariya M, Ramesh P, Arun Kamal C, Dheenadhayalan J, Rajasekaran S. Results of a simple treatment protocol for aseptic femoral shaft nonunion in 330 patients. Injury 2024; 55:111412. [PMID: 38341997 DOI: 10.1016/j.injury.2024.111412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/21/2024] [Accepted: 01/27/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Our primary aim of the study was to assess the results of a treatment protocol for aseptic femoral shaft nonunion treated by three techniques - Exchange Nailing (EN), Plate Augmentation (PA), and Exchange Nailing combined with Plate augmentation (NP). The secondary objective was to assess the radiological outcome, duration of surgery (DOS) and need for blood transfusion (BT) in all the three groups. MATERIALS AND METHODS We analyzed 330 patients treated for AFNU between Jan 2007 and Dec 2019. Using a simple treatment algorithm, EN, PA and NP were performed in 24,183 and 123 patients respectively. Patients in all the three groups were assessed for radiological-union (union rate and time to union), DOS and BT. RESULTS Of these 330 patients, 327 (99 %) patients achieved radiological union at a mean duration of 6.07 months. Union rate is highest with NP followed by PA and EN. The union rate in patients with NP, PA and EN were 100 %, 99.5 % and 91.7 % respectively (p < 0.01). Time to union was lowest for NP followed by PA and EN (p < 0.001).The mean time to union for NP, PA and EN were 3.76, 7.2and 9.21 months respectively (p < 0.001). The mean DOS in minutes for NP, EN and PA was 107, 94 and 82 respectively (p < 0.01). The mean need for BT in the form of packed red blood cells for NP, PA and EN were 1.95, 1.87 and 1.38 units respectively (p < 0.01). CONCLUSION Following a simple algorithm to decide treatment protocol on a case-to case basis helps to achieve good results in an optimal time period. When compared with EN and PA, NP is associated with 100 % union rate with least time to union making NP a reasonably effective procedure with a very high success rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Agraharam Devendra
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India.
| | - Sudipta Kumar Patra
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - P Velmurugesan
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - Mohd Zackariya
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - P Ramesh
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - Chandramohan Arun Kamal
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
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23
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Hackl S, von Rüden C, Trenkwalder K, Keppler L, Hierholzer C, Perl M. Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria. J Clin Med 2024; 13:1414. [PMID: 38592249 PMCID: PMC10933962 DOI: 10.3390/jcm13051414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| | - Katharina Trenkwalder
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Lena Keppler
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian Hierholzer
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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24
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Garabano G, Amadei Enghelmayer RE, Perez Alamino L, Viollaz GM, Pesciallo CA. The polymicrobial infection affects the infection recurrence rate (not failure) in treating femoral and tibial bone defects with the Masquelet technique-a comparative retrospective analysis of 54 patients with mono- and polymicrobial infections. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:789-797. [PMID: 37702802 DOI: 10.1007/s00590-023-03689-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/13/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION This study evaluated whether polymicrobial infection affects reoperation rates due to infection recurrence and treatment failure with the Masquelet technique in infected posttraumatic segmental bone defects of the femur and tibia. METHODS We retrospectively analyzed patients treated between 2012 and 2021 in two trauma referral centers. We evaluated demographic data, injury, treatment, infection recurrence, failures, and bone healing rates according to whether the infection was mono- or polymicrobial. After uni-bivariate analysis between patients with polymicrobial and monomicrobial infection, we identified the variables associated with infection recurrence and failure through multivariate analysis. RESULTS We analyzed 54 patients, 30 (55.55%) with tibial and 24 (44.44%) femoral segmental bone defects, with a mean follow-up of 41.7 ± 15.0 months. Forty-four (81.48%) presented monomicrobial, and 10 (18.51%) polymicrobial infections. Comparatively, the need for soft tissue reconstruction and the infection recurrence rate was significantly higher in patients with polymicrobial infections. There was no significant difference in the failure rate (20 vs. 6.81% p = 0.23). Multivariable logistic regression analysis identified the polymicrobial infection as the only independent variable associated with infection recurrence (Odds Ratio = 11.07; p = 0.0017). CONCLUSION Our analysis suggests that polymicrobial infection is associated with a higher risk of infection recurrence in treating the femur and tibia segmental bone defects with the Masquelet technique. This information can help surgeons to inform patients about this and give them a realistic expectation of the outcome and the possibility of reoperation.
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Affiliation(s)
- Germán Garabano
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina.
- Scientific Advisory Committee, British Hospital of Buenos Aires, Buenos Aires, Argentina.
| | - Rafael E Amadei Enghelmayer
- Orthopaedic and Trauma Surgery Department, Hospital Alta Complejidad Cuenca Alta, RP6 Km 92.5 PC 1814, Cañuelas, Buenos Aires, Argentina
| | - Leonel Perez Alamino
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Gonzalo M Viollaz
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
- Orthopaedic and Trauma Surgery Department, Hospital Alta Complejidad Cuenca Alta, RP6 Km 92.5 PC 1814, Cañuelas, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
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25
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Luengo-Alonso G, Bravo-Gimenez B, Lozano D, Heras C, Sanchez-Salcedo S, Benito-Garzón L, Abella M, Vallet-Regi M, Cecilia-Lopez D, Salinas AJ. Osteogenic Potential of a Biomaterial Enriched with Osteostatin and Mesenchymal Stem Cells in Osteoporotic Rabbits. Biomolecules 2024; 14:143. [PMID: 38397380 PMCID: PMC10887093 DOI: 10.3390/biom14020143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/25/2024] Open
Abstract
Mesoporous bioactive glasses (MBGs) of the SiO2-CaO-P2O5 system are biocompatible materials with a quick and effective in vitro and in vivo bioactive response. MBGs can be enhanced by including therapeutically active ions in their composition, by hosting osteogenic molecules within their mesopores, or by decorating their surfaces with mesenchymal stem cells (MSCs). In previous studies, our group showed that MBGs, ZnO-enriched and loaded with the osteogenic peptide osteostatin (OST), and MSCs exhibited osteogenic features under in vitro conditions. The aim of the present study was to evaluate bone repair capability after large bone defect treatment in distal femur osteoporotic rabbits using MBGs (76%SiO2-15%CaO-5%P2O5-4%ZnO (mol-%)) before and after loading with OST and MSCs from a donor rabbit. MSCs presence and/or OST in scaffolds significantly improved bone repair capacity at 6 and 12 weeks, as confirmed by variations observed in trabecular and cortical bone parameters obtained by micro-CT as well as histological analysis results. A greater effect was observed when OST and MSCs were combined. These findings may indicate the great potential for treating critical bone defects by combining MBGs with MSCs and osteogenic peptides such as OST, with good prospects for translation to clinical practice.
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Affiliation(s)
- Gonzalo Luengo-Alonso
- Orthopaedics and Traumatology Service, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
- Orthopedics and Traumatology Service, Hospital Universitario 12 de Octubre & Imas12, 28041 Madrid, Spain;
| | - Beatriz Bravo-Gimenez
- Orthopedics and Traumatology Service, Hospital Universitario 12 de Octubre & Imas12, 28041 Madrid, Spain;
| | - Daniel Lozano
- Department of Chemistry in Pharmaceutical Sciences, Universidad Complutense & Imas12, 28040 Madrid, Spain; (D.L.); (C.H.); (S.S.-S.); (M.V.-R.)
- Networking Research Center on Bioengineering, Biomaterials, Nanomedicine, CIBER-BBN, 28040 Madrid, Spain
| | - Clara Heras
- Department of Chemistry in Pharmaceutical Sciences, Universidad Complutense & Imas12, 28040 Madrid, Spain; (D.L.); (C.H.); (S.S.-S.); (M.V.-R.)
| | - Sandra Sanchez-Salcedo
- Department of Chemistry in Pharmaceutical Sciences, Universidad Complutense & Imas12, 28040 Madrid, Spain; (D.L.); (C.H.); (S.S.-S.); (M.V.-R.)
- Networking Research Center on Bioengineering, Biomaterials, Nanomedicine, CIBER-BBN, 28040 Madrid, Spain
| | - Lorena Benito-Garzón
- Department of Human Anatomy and Histology, Facultad de Medicina, Universidad de Salamanca, 37007 Salamanca, Spain;
| | - Monica Abella
- Department of Bioengineering, Universidad Carlos III de Madrid, 28911 Madrid, Spain;
| | - María Vallet-Regi
- Department of Chemistry in Pharmaceutical Sciences, Universidad Complutense & Imas12, 28040 Madrid, Spain; (D.L.); (C.H.); (S.S.-S.); (M.V.-R.)
- Networking Research Center on Bioengineering, Biomaterials, Nanomedicine, CIBER-BBN, 28040 Madrid, Spain
| | - David Cecilia-Lopez
- Orthopedics and Traumatology Service, Hospital Universitario 12 de Octubre & Imas12, 28041 Madrid, Spain;
| | - Antonio J. Salinas
- Department of Chemistry in Pharmaceutical Sciences, Universidad Complutense & Imas12, 28040 Madrid, Spain; (D.L.); (C.H.); (S.S.-S.); (M.V.-R.)
- Networking Research Center on Bioengineering, Biomaterials, Nanomedicine, CIBER-BBN, 28040 Madrid, Spain
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26
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Godbout C, Ryan G, Ramnaraign DJ, Hegner C, Desjardins S, Gagnon S, Bates BD, Whatley I, Schemitsch EH, Nauth A. Optimal delivery of endothelial progenitor cells in a rat model of critical-size bone defects. J Orthop Res 2024; 42:193-201. [PMID: 37416978 DOI: 10.1002/jor.25658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/21/2023] [Accepted: 07/01/2023] [Indexed: 07/08/2023]
Abstract
Nonunion and segmental bone defects are complex issues in orthopedic trauma. The use of endothelial progenitor cells (EPCs), as part of a cell-based therapy for bone healing is a promising approach. In preclinical studies, culture medium (CM) is commonly used to deliver EPCs to the defect site, which has the potential for immunogenicity in humans. The goal of this study was to find an effective and clinically translatable delivery medium for EPCs. Accordingly, this study compared EPCs delivered in CM, phosphate-buffered saline (PBS), platelet-poor plasma (PPP), and platelet-rich plasma (PRP) in a rat model of femoral critical-size defects. Fischer 344 rats (n = 35) were divided into six groups: EPC+CM, EPC+PBS, EPC+PPP, EPC+PRP, PPP alone, and PRP alone. A 5 mm mid-diaphyseal defect was created in the right femur and stabilized with a miniplate. The defect was filled with a gelatin scaffold impregnated with the corresponding treatment. Radiographic, microcomputed tomography and biomechanical analyses were performed. Overall, regardless of the delivery medium, groups that received EPCs had higher radiographic scores and union rates, higher bone volume, and superior biomechanical properties compared to groups treated with PPP or PRP alone. There were no significant differences in any outcomes between EPC subgroups or between PPP and PRP alone. These results suggest that EPCs are effective in treating segmental defects in a rat model of critical-size defects regardless of the delivery medium used. Consequently, PBS could be the optimal medium for delivering EPCs, given its low cost, ease of preparation, accessibility, noninvasiveness, and nonimmunogenic properties.
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Affiliation(s)
- Charles Godbout
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Gareth Ryan
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - David J Ramnaraign
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Christian Hegner
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Desjardins
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Stéphane Gagnon
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Brent D Bates
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Ian Whatley
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Emil H Schemitsch
- Department of Surgery, Division of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
| | - Aaron Nauth
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Division of Orthopaedic Surgery, St. Michael's Hospital-Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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27
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Qiu M, Tulufu N, Tang G, Ye W, Qi J, Deng L, Li C. Black Phosphorus Accelerates Bone Regeneration Based on Immunoregulation. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2304824. [PMID: 37953457 PMCID: PMC10767454 DOI: 10.1002/advs.202304824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/25/2023] [Indexed: 11/14/2023]
Abstract
A fundamental understanding of inflammation and tissue healing suggests that the precise regulation of the inflammatory phase, both in terms of location and timing, is crucial for bone regeneration. However, achieving the activation of early inflammation without causing chronic inflammation while facilitating quick inflammation regression to promote bone regeneration continues to pose challenges. This study reveals that black phosphorus (BP) accelerates bone regeneration by building an osteogenic immunological microenvironment. BP amplifies the acute pro-inflammatory response and promotes the secretion of anti-inflammatory factors to accelerate inflammation regression and tissue regeneration. Mechanistically, BP creates an osteoimmune-friendly microenvironment by stimulating macrophages to express interleukin 33 (IL-33), amplifying the inflammatory response at an early stage, and promoting the regression of inflammation. In addition, BP-mediated IL-33 expression directly promotes osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs), which further facilitates bone repair. To the knowledge, this is the first study to reveal the immunomodulatory potential of BP in bone regeneration through the regulation of both early-stage inflammatory responses and later-stage inflammation resolution, along with the associated molecular mechanisms. This discovery serves as a foundation for the clinical use of BP and is an efficient approach for managing the immune microenvironment during bone regeneration.
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Affiliation(s)
- Minglong Qiu
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of Medicine197 Ruijin 2nd RoadShanghai200025P. R. China
| | - Nijiati Tulufu
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of Medicine197 Ruijin 2nd RoadShanghai200025P. R. China
| | - Guoqing Tang
- Kunshan Hospital of Traditional Chinese MedicineAffiliated Hospital of Yangzhou University388 Zuchongzhi RoadKunshan CityJiangsu Province215300P. R. China
| | - Wenkai Ye
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of Medicine197 Ruijin 2nd RoadShanghai200025P. R. China
| | - Jin Qi
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of Medicine197 Ruijin 2nd RoadShanghai200025P. R. China
| | - Lianfu Deng
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of Medicine197 Ruijin 2nd RoadShanghai200025P. R. China
| | - Changwei Li
- Department of OrthopaedicsShanghai Key Laboratory for Prevention and Treatment of Bone and Joint DiseasesShanghai Institute of Traumatology and OrthopaedicsRuijin HospitalShanghai Jiao Tong University School of Medicine197 Ruijin 2nd RoadShanghai200025P. R. China
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Amouzadeh Omrani F, Sarzaeem MM, Noorbakhsh M, Baroutkoub M, Afzal S, Barati H, Panjeshahi A. The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions. THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:204-210. [PMID: 38577507 PMCID: PMC10989721 DOI: 10.22038/abjs.2023.73572.3407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/18/2023] [Indexed: 04/06/2024]
Abstract
Objectives The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical-sized bone deficiency resulting from nonunion. Methods The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period. Results A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51-1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%). Conclusion Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment.
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Affiliation(s)
- Farzad Amouzadeh Omrani
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Sarzaeem
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Noorbakhsh
- Cellular and Molecular Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Mojtaba Baroutkoub
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sina Afzal
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hasan Barati
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Panjeshahi
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ramanathan M, Shijirbold A, Okui T, Tatsumi H, Kotani T, Shimamura Y, Morioka R, Ayasaka K, Kanno T. In Vivo Evaluation of Bone Regenerative Capacity of the Novel Nanobiomaterial: β-Tricalcium Phosphate Polylactic Acid-co-Glycolide (β-TCP/PLLA/PGA) for Use in Maxillofacial Bone Defects. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 14:91. [PMID: 38202548 PMCID: PMC10780666 DOI: 10.3390/nano14010091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/23/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
Maxillofacial bone defects are treated by autografting or filling with synthetic materials in various forms and shapes. Electrospun nanobiomaterials are becoming popular due to their easy placement and handling; combining ideal biomaterials extrapolates better outcomes. We used a novel electrospun cotton-like fiber made from two time-tested bioresorbable materials, β-TCP and PLLA/PGA, to check the feasibility of its application to maxillofacial bone defects through an in vivo rat mandibular bone defect model. Novel β-TCP/PLLA/PGA and pure β-TCP blocks were evaluated for new bone regeneration through assessment of bone volume, inner defect diameter reduction, and bone mineral density. Bioactive/osteoconductivity was checked by scoring the levels of Runt-related transcription factor x, Leptin Receptor, Osteocalcin, and Periostin biomarkers. Bone regeneration in both β-TCP/PLLA/PGA and β-TCP was comparable at initial timepoints. Osteogenic cell accumulation was greater in β-TCP/PLLA/PGA than in β-TCP at initial as well as late phases. Periostin expression was more marked in β-TCP/PLLA/PGA. This study demonstrated comparable results between β-TCP/PLLA/PGA and β-TCP in terms of bone regeneration and bioactivity, even with a small material volume of β-TCP/PLLA/PGA and a decreased percentage of β-TCP. Electrospun β-TCP/PLLA/PGA is an ideal nanobiomaterial for inducing bone regeneration through osteoconductivity and bioresorbability in bony defects of the maxillofacial region.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Takahiro Kanno
- Department of Oral and Maxillofacial Surgery, Shimane University Faculty of Medicine, 89-1, Enya-Cho, Izumo 693-8501, Shimane, Japan; (M.R.); (A.S.); (T.O.); (H.T.); (T.K.); (Y.S.); (R.M.); (K.A.)
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Abdulaziz D, Anastasiou AD, Panagiotopoulou V, Raif EM, Giannoudis PV, Jha A. Physiologically engineered porous titanium/brushite scaffolds for critical-size bone defects: A design and manufacturing study. J Mech Behav Biomed Mater 2023; 148:106223. [PMID: 37976684 DOI: 10.1016/j.jmbbm.2023.106223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
Repairing critical-size bone defects still represents a critical clinical challenge in the field of trauma surgery. This study focuses on a physiological design and manufacturing of porous composite scaffold (titanium Ti with 10 % mole iron doped brushite DCPD-Fe3+) which can mimic the biomechanical properties of natural cortical bone, specifically for the purpose of repairing critical-size defects. To achieve this, the principle of design of experiments (DOE) was applied for investigating the impact of sintering temperature, mineral ratio, and volume fraction of porosity on the mechanical properties of the fabricated scaffolds. The fabricated scaffolds had open porosity up to 60 %, with pore size approximately between 100 μm and 850 μm. The stiffness of the porous composite scaffolds varied between 3.30 GPa and 20.50 GPa, while the compressive strength ranged from approximately 130 MPa-165 MPa at sintering temperatures equal to or exceeding 1000 °C. Scaffolds with higher porosity and mineral content demonstrated lower stiffness values, resembling natural bone. Numerical simulation was employed by Ansys Workbench to investigate the stress and strain distribution of a critical size defect in mid-shaft femur which was designed to be replaced with the fabricated scaffold. The fabricated scaffolds showed flexible biomechanical behaviour at the bone/scaffold interface, generating lower stress levels and indicating a better match with the femoral shaft stiffness. The experimental and numerical findings demonstrated promising applications for manufacturing a patient-specific bone scaffold for critical and potentially large defects for reducing stress shielding and minimizing non-union risk.
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Affiliation(s)
- Dina Abdulaziz
- School of Chemical and Process Engineering, University of Leeds, Leeds, LS2 9JT, UK.
| | - Antonios D Anastasiou
- Department of Chemical Engineering, University of Manchester, Manchester, M1 3AL, UK
| | | | - El Mostafa Raif
- Faculty of Medicine and Health, School of Dentistry, University of Leeds, Leeds, LS2 9JT, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Animesh Jha
- School of Chemical and Process Engineering, University of Leeds, Leeds, LS2 9JT, UK
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Findeisen S, Gräfe N, Schwilk M, Ferbert T, Helbig L, Haubruck P, Schmidmaier G, Tanner M. Use of Autologous Bone Graft with Bioactive Glass as a Bone Substitute in the Treatment of Large-Sized Bone Defects of the Femur and Tibia. J Pers Med 2023; 13:1644. [PMID: 38138871 PMCID: PMC10744955 DOI: 10.3390/jpm13121644] [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: 10/11/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Managing bone defects in non-union surgery remains challenging, especially in cases of large defects exceeding 5 cm in size. Historically, amputation and compound osteosynthesis with a remaining PMMA spacer have been viable and commonly used options. The risk of non-union after fractures varies between 2% and 30% and is dependent on various factors. Autologous bone grafts from the iliac crest are still considered the gold standard but are limited in availability, prompting consideration of artificial grafts. OBJECTIVES The aims and objectives of the study are as follows: 1. To evaluate the radiological outcome of e.g., the consolidation and thus the stability of the bone (three out of four consolidated cortices/Lane-Sandhu-score of at least 3) by using S53P4-type bioactive glass (BaG) as a substitute material for large-sized bone defects in combination with autologous bone using the RIA technique. 2. To determine noticeable data-points as a base for future studies. METHODS In our clinic, 13 patients received bioactive glass (BaG) as a substitute in non-union therapy to promote osteoconductive aspects. BaG is a synthetic material composed of sodium, silicate, calcium, and phosphate. The primary endpoint of our study was to evaluate the radiological consolidation of bone after one and two years. To assess bone stabilization, we used a modified Lane-Sandhu score, considering only radiological criteria. A bone was considered stabilized if it achieved a minimum score of 3. For full consolidation (all four cortices consolidated), a minimum score of 4 was required. Each bone defect exceeded 5 cm in length, with an average size of 6.69 ± 1.92 cm. RESULTS The mean follow-up period for patients without final bone consolidation was 34.25 months, with a standard deviation of 14.57 months, a median of 32.00 months and a range of 33 months. In contrast, patients with a fully consolidated non-union had an average follow-up of 20.11 ± 15.69 months and a range of 45 months. Overall, the mean time from non-union surgery to consolidation for patients who achieved final union was 14.91 ± 6.70 months. After one year, six patients (46.2%) achieved complete bone consolidation according to the Lane-Sandhu score. Three patients (23.1%) displayed evident callus formation with expected stability, while three patients (23.1%) did not develop any callus, and one patient only formed a minimal callus with no expected stability. After two years, 9 out of 13 patients (69.2%) had a score of 4. The remaining four patients (30.8%) without expected stability either did not heal within two years or required a revision during that time. CONCLUSIONS Bioactive glass (BaG) in combination with autologous bone (RIA) appears to be a suitable filler material for treating extensive non-unions of the femur and tibia. This approach seems to show non-inferiority to treatment with Tricalcium Phosphate (TCP). To ensure the success of this treatment, it is crucial to validate the procedure through a randomized controlled trial (RCT) with a control group using TCP, which would provide higher statistical power and more reliable results.
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Affiliation(s)
- Sebastian Findeisen
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, Schlierbacher Landstraße 200a, University Hospital Heidelberg, 69118 Heidelberg, Germany; (N.G.); (M.S.); (T.F.); (L.H.); (P.H.); (G.S.); (M.T.)
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Menger MM, Tobias AL, Bauer D, Bleimehl M, Scheuer C, Menger MD, Histing T, Laschke MW. Parathyroid hormone stimulates bone regeneration in an atrophic non-union model in aged mice. J Transl Med 2023; 21:844. [PMID: 37996876 PMCID: PMC10668449 DOI: 10.1186/s12967-023-04661-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Non-union formation still represents a major burden in trauma and orthopedic surgery. Moreover, aged patients are at an increased risk for bone healing failure. Parathyroid hormone (PTH) has been shown to accelerate fracture healing in young adult animals. However, there is no information whether PTH also stimulates bone regeneration in atrophic non-unions in the aged. Therefore, the aim of the present study was to analyze the effect of PTH on bone regeneration in an atrophic non-union model in aged CD-1 mice. METHODS After creation of a 1.8 mm segmental defect, mice femora were stabilized by pin-clip fixation. The animals were treated daily with either 200 mg/kg body weight PTH 1-34 (n = 17) or saline (control; n = 17) subcutaneously. Bone regeneration was analyzed by means of X-ray, biomechanics, micro-computed tomography (µCT) imaging as well as histological, immunohistochemical and Western blot analyses. RESULTS In PTH-treated animals bone formation was markedly improved when compared to controls. This was associated with an increased bending stiffness as well as a higher number of tartrate-resistant acid phosphatase (TRAP)-positive osteoclasts and CD31-positive microvessels within the callus tissue. Furthermore, PTH-treated aged animals showed a decreased inflammatory response, characterized by a lower number of MPO-positive granulocytes and CD68-positive macrophages within the bone defects when compared to controls. Additional Western blot analyses demonstrated a significantly higher expression of cyclooxygenase (COX)-2 and phosphoinositide 3-kinase (PI3K) in PTH-treated mice. CONCLUSION Taken together, these findings indicate that PTH is an effective pharmacological compound for the treatment of non-union formation in aged animals.
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Affiliation(s)
- Maximilian M Menger
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany.
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany.
| | - Anne L Tobias
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany
| | - David Bauer
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany
| | - Michelle Bleimehl
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany
| | - Tina Histing
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg/Saar, Germany
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Zhang H, Fu J, Jie S, Wang X, Wang S, Wu H, Hu Y, Huang C. Induced membrane technique versus one-stage autografting in management of atrophic nonunion of long bone in the lower limb: clinical and health burden outcomes. J Orthop Surg Res 2023; 18:853. [PMID: 37946277 PMCID: PMC10636875 DOI: 10.1186/s13018-023-04296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE In this study, we aimed to compare the outcomes of the two-stage induced membrane technique (IMT) and one-stage autografting in the treatment of aseptic atrophic nonunion in lower limb long bones. METHODS From January 2014 to January 2022, we reviewed all surgically treated long bone nonunion patients, including patients aged 18 years or older with atrophic nonunion, who were either treated with the two-stage induced membrane technique (IMT) or one-stage autografting. Outcome parameters interns of clinical, quality of life and healthcare burden were recorded and retrospectively analysed between the two treatment populations. The follow-up time was at least 1 year. RESULTS In total, 103 patients who met the criteria for aseptic atrophic nonunion were enrolled. Among them, 41 (39.8%) patients were treated with two-stage IMT, and 62 (60.2%) patients were treated with one-stage autologous bone grafting. The follow-up time was 12 to 68 months, with an average of 28.4 months. The bone healing rate was comparable in both groups (IMT: 92.7% vs. one-stage grafting: 91.9%, P = 0.089) at 12 months post-operation, and the bone healing Lane-Sandhu score was superior in the IMT group (mean: 8.68 vs. 7.81, P = 0.002). Meanwhile, the SF-12 scores of subjective physical component score (PCS) (mean: 21.36 vs. 49.64, P < 0.01) and mental health component score (MCS) (mean: 24.85 vs. 46.14, P < 0.01) significantly increased in the IMT group, as well as in the one-stage grafting group, and no statistically significant difference was found within groups. However, the total hospital stays (median: 8 days vs. 14 days, P < 0.01) and direct medical healthcare costs (median: ¥30,432 vs. ¥56,327, P < 0.05) were greater in the IMT group, while the complications (nonunion 8, infection 3, material failure 2, and donor site pain 6) were not significantly different between the two groups (17.1% vs. 19.4, P = 0.770). CONCLUSION The data indicate that two-stage method of IMT serves as an alternative method in treating atrophic nonunion; however, it may not be a preferred option, in comprehensive considering patient clinical outcomes and healthcare burden. More evidence-based research is needed to further guide clinical decision-making.
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Affiliation(s)
- Hu Zhang
- Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Jingshu Fu
- Banan Hospital of Chongqing Medical University, Banan District, Longzhouwan Street No. 659, Chongqing City, 400038, People's Republic of China
| | - Shen Jie
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Xiaohua Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Shulin Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Hongri Wu
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China.
- Department of Orthopedics, Navy 905th Hospital, Naval Medical University, Shanghai, People's Republic of China.
| | - Yongjun Hu
- Banan Hospital of Chongqing Medical University, Banan District, Longzhouwan Street No. 659, Chongqing City, 400038, People's Republic of China.
| | - Chunji Huang
- Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China.
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Metwaly RG, Younis AS. Augmentation plate without bone graft in the management of distal tibial diaphyseal non-union. Injury 2023; 54:111057. [PMID: 37752033 DOI: 10.1016/j.injury.2023.111057] [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: 07/08/2023] [Accepted: 09/17/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE The objective of this study was to assess the efficacy of augmentation plating with retaining of previous implant in situ in cases of non-united oligotrophic or atrophic aseptic distal tibial diaphyseal and metaphyseal fractures without bone grafting depending on the unified bone healing and non-union theory. METHODS Through the period between December 2019 and December 2022, twelve patients with distal third tibial non-unions who were fixed at time of fracture either by intramedullary interlocking nails (seven cases) or by minimally invasive plate osteosynthesis (five cases) were included. Non-union was diagnosed on basis of absence of any healing progression in three months period or absence of fracture healing after six months from index surgery. All patients had oligotrophic or atrophic non-union. Augmentation plating through an anterolateral approach was done on average of 7.25 months after initial surgery (6-9 months). Circumferential exposure of the fracture site and debridement of fibrous tissue were not necessary. No bone grafting was done as no cases had major bone defect. RESULTS All patients achieved complete radiological union with a mean time of 21.8 weeks (range 18-30 weeks) that mean full callus formation in all cortices. All patients were walking independently after three months (13weeks) from surgery and returned to work even in cases of absent complete radiological union. No cases had been complicated with wound healing problems (infection or dehiscence). One patient had incomplete ankle dorsiflexion (10°) due to tight calf muscles and one patient had paresthesia on the dorsum of the foot that was not improved at last follow up (one year after surgery). CONCLUSION Augmentation plating is a safe and effective option for management of distal tibial diaphyseal nonunion even in cases of oligotrophic or atrophic non-union.
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Sung J, Barratt KR, Pederson SM, Chenu C, Reichert I, Atkins GJ, Anderson PH, Smitham PJ. Unbiased gene expression analysis of the delayed fracture healing observed in Zucker diabetic fatty rats. Bone Joint Res 2023; 12:657-666. [PMID: 37844909 PMCID: PMC10578971 DOI: 10.1302/2046-3758.1210.bjr-2023-0062.r1] [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: 10/18/2023] Open
Abstract
Aims Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy. Methods Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq). Results Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation. Conclusion These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients.
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Affiliation(s)
- Jonghoo Sung
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Kate R. Barratt
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Stephen M. Pederson
- Bioinformatics Hub, School of Biological Sciences, The University of Adelaide, Adelaide, Australia
- Black Ochre Data Labs, Indigenous Genomics, Telethon Kids Institute, Adelaide, Australia
| | | | | | - Gerald J. Atkins
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Paul H. Anderson
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Peter J. Smitham
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Hempe S, Bieler D, Braunegger G, Schilling T, Waldeck S, Kollig E. [Extracorporeal shockwave therapy as an alternative treatment in cases of posttraumatic delayed bone union]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:779-787. [PMID: 36018349 PMCID: PMC10520103 DOI: 10.1007/s00113-022-01225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Impaired posttraumatic bone healing is a relevant complication of fractures. Usually, the standard treatment is surgical revision. For about 30 years extracorporeal shockwave therapy (ESWT) has emerged as an alternative treatment option with similar consolidation rates but less complications. OBJECTIVE This article aims to present our data in context to the current literature MATERIAL AND METHODS: From 2007 to 2016 a total of 97 patients diagnosed with impaired posttraumatic bone healing were treated with ESWT. Clinical and demographic data of this population were retrieved and analyzed retrospectively. RESULTS The general consolidation rate was 60.8%. Multiple variables were analyzed. A preinterventional bone gap ≥ 5 mm, initial dislocation > ½ of the bone shaft, nicotine consumption and a long time span from fracture to ESWT (> 6 months) were found as factors which significantly impair bone healing after ESWT. CONCLUSION ESWT is a safe and promising alternative treatment option for delayed unions. Regarding risk factors of a poor outcome may be identified before and increase the rate of success.
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Affiliation(s)
- Sebastian Hempe
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungschirurgie, Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Str. 170, 56072, Koblenz, Deutschland
| | - Dan Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungschirurgie, Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Str. 170, 56072, Koblenz, Deutschland.
- Klinik für Orthopädie und Unfallchirurgie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
| | - Grit Braunegger
- Klinik für Nuklearmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - Thomas Schilling
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungschirurgie, Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Str. 170, 56072, Koblenz, Deutschland
| | - Stephan Waldeck
- Klinik für Radiologie und Neuroradiologie, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - Erwin Kollig
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungschirurgie, Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Str. 170, 56072, Koblenz, Deutschland
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Menger MM, Bauer D, Bleimehl M, Scheuer C, Braun BJ, Herath SC, Rollmann MF, Menger MD, Laschke MW, Histing T. Sildenafil, a phosphodiesterase-5 inhibitor, stimulates angiogenesis and bone regeneration in an atrophic non-union model in mice. J Transl Med 2023; 21:607. [PMID: 37684656 PMCID: PMC10486066 DOI: 10.1186/s12967-023-04441-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Non-union formation represents a major complication in trauma and orthopedic surgery. The phosphodiesterase-5 (PDE-5) inhibitor sildenafil has been shown to exert pro-angiogenic and pro-osteogenic effects in vitro and in vivo. Therefore, the aim of the present study was to analyze the impact of sildenafil in an atrophic non-union model in mice. After creation of a 1.8 mm segmental defect, mice femora were stabilized by pin-clip fixation. Bone regeneration was analyzed by means of X-ray, biomechanics, photoacoustic and micro-computed tomography (µCT) imaging as well as histological, immunohistochemical and Western blot analyses at 2, 5 and 10 weeks after surgery. The animals were treated daily with either 5 mg/kg body weight sildenafil (n = 35) or saline (control; n = 35) per os. Bone formation was markedly improved in defects of sildenafil-treated mice when compared to controls. This was associated with a higher bending stiffness as well as an increased number of CD31-positive microvessels and a higher oxygen saturation within the callus tissue. Moreover, the bone defects of sildenafil-treated animals contained more tartrate-resistant acid phosphatase (TRAP)-positive osteoclasts and CD68-positive macrophages and exhibited a higher expression of the pro-angiogenic and pro-osteogenic markers cysteine rich protein (CYR)61 and vascular endothelial growth factor (VEGF) when compared to controls. These findings demonstrate that sildenafil acts as a potent stimulator of angiogenesis and bone regeneration in atrophic non-unions.
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Affiliation(s)
- Maximilian M Menger
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany.
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg, Saar, Germany.
| | - David Bauer
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg, Saar, Germany
| | - Michelle Bleimehl
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg, Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg, Saar, Germany
| | - Benedikt J Braun
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany
| | - Steven C Herath
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany
| | - Mika F Rollmann
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg, Saar, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, 66421, Homburg, Saar, Germany
| | - Tina Histing
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076, Tuebingen, Germany
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Panos JA, Coenen MJ, Nagelli CV, McGlinch EB, Atasoy-Zeybek A, De Padilla CL, De la Vega RE, Evans CH. Segmental defect healing in the presence or absence of recombinant human BMP2: Novel insights from a rat model. J Orthop Res 2023; 41:1934-1944. [PMID: 36850029 PMCID: PMC10440238 DOI: 10.1002/jor.25530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/16/2023] [Accepted: 02/08/2023] [Indexed: 03/01/2023]
Abstract
This study defined and compared the course of native, impaired and growth factor-stimulated bone regeneration in a rat femoral defect model. A mid-diaphyseal defect with rigid internal fixation was surgically created in the right femur of male Fischer rats and serially analyzed over 36 weeks. Native bone regeneration was modeled using a sub-critical, 1 mm size defect, which healed uneventfully. Critical size defects of 5 mm were used to analyze impaired bone regeneration. In a third group, the 5 mm defects were filled with 11 µg of recombinant human bone morphogenetic protein 2 (rhBMP2) impregnated onto an absorbable collagen sponge, modeling its clinical use. Native bone regeneration was characterized by endochondral ossification with progressive remodeling to ultimately resemble intact femora. An endochondral response was also observed under conditions of impaired bone regeneration, but by week 8 medullary capping occurred with fibrofatty consolidation of the tissue within the defect, resembling an atrophic non-union. rhBMP2 treatment was associated with prolonged inflammatory cytokine expression and rapid intramembranous bone formation occurring with reduced expression of cartilage-associated collagens. Between weeks 4 and 36, rhBMP2-treated bones demonstrated decreased trabecular number and increased trabecular separation, which resulted in inferior mechanical properties compared with bones that healed naturally. Clinical Significance: Recombinant human bone morphogenetic protein 2 (rhBMP2) is used clinically to promote healing of long bones. Our data suggest that it drives intramembraneous ossification producing an inferior regenerate that deteriorates with time. Clinical outcomes would be improved by technologies favoring endochondral regenerative ossification.
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Affiliation(s)
- Joseph A. Panos
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
- Graduate School of Biomedical Sciences, Mayo Clinic; Rochester, Minnesota, USA
- Medical Scientist Training Program, Mayo Clinic; Rochester, Minnesota, USA
| | - Michael J. Coenen
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
| | - Christopher V. Nagelli
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
| | - Erin B. McGlinch
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
- Graduate School of Biomedical Sciences, Mayo Clinic; Rochester, Minnesota, USA
- Virology and Gene Therapy Graduate Program, Mayo Clinic; Rochester, Minnesota, USA
| | - Aysegul Atasoy-Zeybek
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
| | - Consuelo Lopez De Padilla
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
| | - Rodolfo E. De la Vega
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute; Maastricht, The Netherlands
| | - Christopher H. Evans
- Rehabilitation Medicine Research Center, Mayo Clinic; Rochester, Minnesota, USA
- Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic; Rochester, Minnesota, USA
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Toro G, Cecere AB, Braile A, Cicco AD, Liguori S, Tarantino U, Iolascon G. New insights in lower limb reconstruction strategies. Ther Adv Musculoskelet Dis 2023; 15:1759720X231189008. [PMID: 37529331 PMCID: PMC10387789 DOI: 10.1177/1759720x231189008] [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: 04/11/2023] [Accepted: 07/04/2023] [Indexed: 08/03/2023] Open
Abstract
High Energy Musculoskeletal Traumas (HEMTs) represent a relevant problem for healthcare systems, considering the high social costs, and both the high morbidity and mortality. The poor outcomes associated with HEMT are related to the high incidence of complications, including bone infection, fracture malunion and non-union. The treatment of each of these complications could be extremely difficult. Limb reconstruction often needs multiple procedures, rising some questions on the opportunity in perseverate to try to save the affected limb. In fact, theoretically, amputation may guarantee better function and lower complications. However, amputation is not free of complication, and a high long-term social cost has been reported. A comprehensive literature review was performed to suggest possible ways to optimize the limb preservation surgeries of HEMT's complications in order to ameliorate their management.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonio Benedetto Cecere
- Unit of Orthopaedics and Traumatology, San Giuliano Hospital, Giugliano in Campania, Naples, Italy
| | | | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy Unit of Orthopaedics and Traumatology, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Azaman FA, Brennan Fournet ME, Sheikh Ab Hamid S, Zawawi MSF, da Silva Junior VA, Devine DM. Enhancement of Scaffold In Vivo Biodegradability for Bone Regeneration Using P28 Peptide Formulations. Pharmaceuticals (Basel) 2023; 16:876. [PMID: 37375823 DOI: 10.3390/ph16060876] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
The field of bone tissue engineering has shown a great variety of bone graft substitute materials under development to date, with the aim to reconstruct new bone tissue while maintaining characteristics close to the native bone. Currently, insufficient scaffold degradation remains the critical limitation for the success of tailoring the bone formation turnover rate. This study examines novel scaffold formulations to improve the degradation rate in vivo, utilising chitosan (CS), hydroxyapatite (HAp) and fluorapatite (FAp) at different ratios. Previously, the P28 peptide was reported to present similar, if not better performance in new bone production to its native protein, bone morphogenetic protein-2 (BMP-2), in promoting osteogenesis in vivo. Therefore, various P28 concentrations were incorporated into the CS/HAp/FAp scaffolds for implantation in vivo. H&E staining shows minimal scaffold traces in most of the defects induced after eight weeks, showing the enhanced biodegradability of the scaffolds in vivo. The HE stain highlighted the thickened periosteum indicating a new bone formation in the scaffolds, where CS/HAp/FAp/P28 75 µg and CS/HAp/FAp/P28 150 µg showed the cortical and trabecular thickening. CS/HAp/FAp 1:1 P28 150 µg scaffolds showed a higher intensity of calcein green label with the absence of xylenol orange label, which indicates that mineralisation and remodelling was not ongoing four days prior to sacrifice. Conversely, double labelling was observed in the CS/HAp/FAp 1:1 P28 25 µg and CS/HAp/FAp/P28 75 µg, which indicates continued mineralisation at days ten and four prior to sacrifice. Based on the HE and fluorochrome label, CS/HAp/FAp 1:1 with P28 peptides presented a consistent positive osteoinduction following the implantation in the femoral condyle defects. These results show the ability of this tailored formulation to improve the scaffold degradation for bone regeneration and present a cost-effective alternative to BMP-2.
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Affiliation(s)
- Farah Alwani Azaman
- PRISM Research Institute, Technological University of the Shannon (TUS), N37 HD68 Athlone, Ireland
- Tissue Bank, School of Medical Sciences, Health Campus, Universiti Sains Malaysia (USM), 16150 Kota Bharu, Malaysia
| | | | - Suzina Sheikh Ab Hamid
- Tissue Bank, School of Medical Sciences, Health Campus, Universiti Sains Malaysia (USM), 16150 Kota Bharu, Malaysia
| | - Muhamad Syahrul Fitri Zawawi
- Tissue Bank, School of Medical Sciences, Health Campus, Universiti Sains Malaysia (USM), 16150 Kota Bharu, Malaysia
| | | | - Declan M Devine
- PRISM Research Institute, Technological University of the Shannon (TUS), N37 HD68 Athlone, Ireland
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Agnes CJ, Karoichan A, Tabrizian M. The Diamond Concept Enigma: Recent Trends of Its Implementation in Cross-linked Chitosan-Based Scaffolds for Bone Tissue Engineering. ACS APPLIED BIO MATERIALS 2023. [PMID: 37310896 PMCID: PMC10354806 DOI: 10.1021/acsabm.3c00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
An increasing number of publications over the past ten years have focused on the development of chitosan-based cross-linked scaffolds to regenerate bone tissue. The design of biomaterials for bone tissue engineering applications relies heavily on the ideals set forth by a polytherapy approach called the "Diamond Concept". This methodology takes into consideration the mechanical environment, scaffold properties, osteogenic and angiogenic potential of cells, and benefits of osteoinductive mediator encapsulation. The following review presents a comprehensive summarization of recent trends in chitosan-based cross-linked scaffold development within the scope of the Diamond Concept, particularly for nonload-bearing bone repair. A standardized methodology for material characterization, along with assessment of in vitro and in vivo potential for bone regeneration, is presented based on approaches in the literature, and future directions of the field are discussed.
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Affiliation(s)
- Celine J Agnes
- Department of Biomedical Engineering, McGill University, Montreal, Quebec H3A 2B4, Canada
- Shriner's Hospital for Children, Montreal, Quebec H4A 0A9 Canada
| | - Antoine Karoichan
- Shriner's Hospital for Children, Montreal, Quebec H4A 0A9 Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec H3A 1G1 Canada
| | - Maryam Tabrizian
- Department of Biomedical Engineering, McGill University, Montreal, Quebec H3A 2B4, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec H3A 1G1 Canada
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Zuluaga M, Cadavid S, Reina F, Reyes-Arceo A, Benedetti F. Orthoplastic management of distal tibia bone infection using Masquelet technique and PRECICE nail: A case report. Trauma Case Rep 2023; 45:100834. [PMID: 37200770 PMCID: PMC10185742 DOI: 10.1016/j.tcr.2023.100834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/20/2023] Open
Abstract
The orthoplastic treatment of post-traumatic bone infections is complex and requires a multidisciplinary approach using both orthopedic and plastic surgery principles. Its primary goal is to achieve rapid control of the infection through aggressive debridement of the affected tissue, in order to perform a complete reconstruction of the limb. This allows both its salvage and restoration of function. We present a patient with septic non-union secondary to distal tibia fracture with a bone defect of 7 cm and severe soft tissue injury. The treatment was divided into three stages. First, the infection was controlled by radical debridement, limb shortening, and temporary stabilization. Second, early reconstruction was initiated utilizing the first stage of the Masquelet's induced membrane technique (MIMT), and soft tissue coverage with free flap. Third, MIMT was finalized, and bone lengthening with PRECICE nail was performed. We consider this approach effective as it can offer early recovery with optimal functional and aesthetic results in bone defects associated with coverage defects.
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Affiliation(s)
- Mauricio Zuluaga
- Limb Lengthening and Reconstruction Unit, Clínica Imbanaco Grupo QuirónSalud, Cali, Colombia
- Faculty of Health Sciences, Pontificia Universidad Javeriana Cali, Colombia
- Corresponding author at: Carrera 38A #5ª-100, Tower A, Office 803, Cali, Colombia.
| | - Sergio Cadavid
- Orthopedic Surgery Residency Program, Fundación Universitaria de Ciencias de la Salud FUCS, Bogotá, Colombia
| | - Federico Reina
- Limb Lengthening and Reconstruction Unit, Clínica Imbanaco Grupo QuirónSalud, Cali, Colombia
| | - Alma Reyes-Arceo
- Limb Lengthening and Reconstruction Unit, Clínica Imbanaco Grupo QuirónSalud, Cali, Colombia
- Faculty of Health Sciences, Pontificia Universidad Javeriana Cali, Colombia
| | - Fernando Benedetti
- Limb Lengthening and Reconstruction Unit, Clínica Imbanaco Grupo QuirónSalud, Cali, Colombia
- Faculty of Health Sciences, Pontificia Universidad Javeriana Cali, Colombia
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Poutoglidou F, Krkovic M. The Cambridge Experience with Lower Limb Long Bone Non-union Following Fixation and the Treatment Algorithm. Strategies Trauma Limb Reconstr 2023; 18:100-105. [PMID: 37942431 PMCID: PMC10628614 DOI: 10.5005/jp-journals-10080-1589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/06/2023] [Indexed: 11/10/2023] Open
Abstract
Aim Non-unions have been traditionally classified as atrophic, oligotrophic and hypertrophic and their management was primarily dictated by that. In our Unit, we have based our treatment rationale mainly on the stability of the metalwork and the presence of symptoms rather than the radiologic appearance of the non-union or the presence of infection. The aim was to present the treatment algorithm for lower limb long bone non-union following operative fixation. Materials and methods All patients treated for a femoral or tibial non-union following fixation between 2014 and 2020 in our unit and with a minimum follow-up of 2 years were included. Non-union was defined as having no evidence of fracture healing in any cortices six months after the index procedure. Union was defined as bridging callus in at least three cortices visualized on at least two orthogonal radiographs. Information retrieved included demographic and fracture characteristics, presence of infection, evidence of metalwork stability and treatment. Outcome measures included union rate, time to union and complications. Data were analysed with the Statistical Program for Social Sciences (SPSS) using contingency tables and linear regression. A p-value of less than 0.05 was considered statistically significant. Results Seventy-seven consecutive patients were included in the study. Union was achieved in 91% of the cases, while union was noted in all the patients treated non-operatively. The mean time to union was 14.49 months (9.98). Complications were encountered in 20 of the patients and the most common were docking site non-union and metalwork breakage. Infection was the only factor that affected time to union in a statistically significant manner (p = 0.006). Conclusion The results of our study suggest that in cases of long bone non-union following operative fixation using signs of metalwork instability and the presence of clinical symptoms as the main indication for surgical intervention provides a satisfactory outcome. This approach prevented operative management in a large proportion of patients. Clinical significance This article presents an algorithmic approach that could aid clinicians in their decision-making in long-bone non-union management. Level of evidence Therapeutic level III. How to cite this article Poutoglidou F, Krkovic M. The Cambridge Experience with Lower Limb Long Bone Non-union Following Fixation and the Treatment Algorithm. Strategies Trauma Limb Reconstr 2023;18(2):100-105.
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Affiliation(s)
- Freideriki Poutoglidou
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals NHS Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals NHS Trust, Cambridge, Cambridgeshire, United Kingdom
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Arlettaz Y. Augmented osteosynthesis in fragility fracture. Orthop Traumatol Surg Res 2023; 109:103461. [PMID: 36404483 DOI: 10.1016/j.otsr.2022.103461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 11/06/2022]
Abstract
Due to poor bone quality and complexity, some fractures are difficult to treat, with high risk of failure. Moreover, general health is often poor in elderly patients with multiple comorbidity and poor compliance, necessitating perfect first-line management to avoid re-operation. The armamentarium comprises specific internal fixation implants and also complementary methods such as autologous, homologous or heterologous bone graft or bone substitutes with varying mechanical and biological characteristics. Associating these options is what is mean by "augmented fixation". The present review of augmented osteosynthesis addresses the following questions: What are the characteristics of fragility fractures? Fragility fracture is caused by low-energy trauma on bone with poor structural quality and low mineral density. Treatment aims to enable early mobilization and weight-bearing while avoiding mechanical failure of fixation. Prolonged bedrest, loss of mobility and surgical revision are aggravating and sometimes fatal factors in these fragile patients. What are the biological techniques of fixation augmentation in fragility fracture? Autologous or homologous bone graft are the most widely used biological augmentation techniques. They fill spaces and promote osteoconduction and consolidation. Some bone-like phosphocalcic structures are opening up promising lines of research. What are the non-biological techniques of fixation augmentation in fragility fracture? Hydroxyapatite, phosphocalcic cement and acrylic cement are the most widely used synthetic materials. Biological and mechanical effects are variable according to composition, requiring specific implementation. What are the mechanical techniques of fixation augmentation in fragility fracture? There is at present no consensus as to the augmentation techniques to be applied in fragility fracture. Cerclage or complementary plating, or external fixation associated to internal fixation are possibilities. However, the literature consists only of small series reporting surgical techniques specific to a given surgeon or team. When and how should osteosynthesis for fragility fracture be augmented? The choice of augmentation depends on fracture location, comminution, available material and local experience. The more severe the fracture, the more complex the fixation. The approach needs to be adapted to the preoperative planning and the associated mechanical means (plate, complementary cerclage) and prosthetic replacement should be considered in certain joint fractures or fractures close to load-bearing surfaces. LEVEL OF EVIDENCE: V; expert opinion.
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Affiliation(s)
- Yvan Arlettaz
- SANTECHABLAIS, Chemin Du Verger 3, 1868 Collombey, Switzerland.
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45
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Garabano G, Pesciallo CA. Definitive fixation in the first stage of the induced membrane technique for septic segmental bone defects. Why not? J Clin Orthop Trauma 2023; 37:102089. [PMID: 36632342 PMCID: PMC9826849 DOI: 10.1016/j.jcot.2022.102089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/02/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Background Infected segmental bone defects (I-SBD) are challenging and complex to manage. This study aimed to show the outcomes achieved in I-SBD of the femur and tibia, treated with the induced membrane technique performing a definitive bone stabilization in the first stage. Methods We retrospectively reviewed 30 patients with infected non-articular segmental bone defects of the femur (n = 11) and tibia (n = 19), operated consecutively between January 2015 and May 2021. The need for fixation exchange, bone defect length, allo/autograft ratio used, bone healing, reoperation (discriminating between mechanical and infection-related causes), and failure rates (graft resorption or nonunion) were recorded. Results Fixation in the first stage was performed with 28 (93.33%) intramedullary nails, ten coated with antibiotic cement, and 2 (6.67%) locked plates. None were removed during the second stage of the technique. The mean length of the bone defects was 5cm (range 3.5-12). The most commonly used allo-/autograft ratio was 50-50. The bone healing rate was 93.33% (n = 28), with a median follow-up of 7 months (range 3-12). The reoperation rate due to mechanical instability was 3.33% (n = 1) and for recurrence of infection was 10.0% (n = 3). The overall failure rate was 6.67% (n = 2). The median follow-up was 42 months (range 12-85). Conclusion Masquelet technique appears feasible and effective in treating infected segmental bone defects of the femur and tibia. Definitive fixation at the first stage showed a success rate of 93.33%, with a re-operation rate of 10.0% related to infection.
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Affiliation(s)
- Germán Garabano
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires, Argentina
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Agnes CJ, Murshed M, Takada A, Willie BM, Tabrizian M. A 6-bromoindirubin-3'-oxime incorporated chitosan-based hydrogel scaffold for potential osteogenic differentiation: Investigation of material properties in vitro. Int J Biol Macromol 2023; 227:71-82. [PMID: 36535349 DOI: 10.1016/j.ijbiomac.2022.12.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Effective treatments for critical size bone defects remain challenging. 6-Bromoindirubin-3'-Oxime (BIO), a glycogen synthase kinase 3β inhibitor, is a promising alternative for treatment of these defects since it aids in promoting osteogenic differentiation. In this study, BIO is incorporated into a new formulation of the guanosine diphosphate cross-linked chitosan scaffold to promote osteogenic differentiation. BIO incorporation was confirmed with 13C NMR through a novel concentration dependent peak around 41 ppm. The rapid gelation rate was maintained along with the internal structure's stability. The 10 μM BIO dose supported the control scaffold's microstructure demonstrating a suitable porosity and a low closed pore percentage. While pore sizes of BIO incorporated scaffolds were slightly smaller, pore heterogeneity was maintained. A proof-of-concept study with C2C12 cells suggested a dose-dependent response of BIO on early stages of osteogenic differentiation within the scaffold. These results support future work to examine BIO's role on osteogenic differentiation and biomineralization of encapsulated cells in the scaffold for bone regeneration.
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Affiliation(s)
- Celine J Agnes
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada.
| | - Monzur Murshed
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada; Shriners Hospital for Children, Montreal, QC, Canada.
| | - Adrien Takada
- Institute of Parasitology, McGill University, Montreal, QC, Canada.
| | - Bettina M Willie
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada; Shriners Hospital for Children, Montreal, QC, Canada; Department of Pediatric Surgery, McGill University, Montreal, QC, Canada.
| | - Maryam Tabrizian
- Department of Biomedical Engineering, McGill University, Montreal, QC, Canada; Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada.
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Haeusner S, Jauković A, Kupczyk E, Herrmann M. Review: cellularity in bone marrow autografts for bone and fracture healing. Am J Physiol Cell Physiol 2023; 324:C517-C531. [PMID: 36622067 DOI: 10.1152/ajpcell.00482.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The use of autografts, as primary cell and tissue source, is the current gold standard approach to treat critical size bone defects and nonunion defects. The unique mixture of the autografts, containing bony compartments and bone marrow (BM), delivers promising results. Although BM mesenchymal stromal cells (BM-MSCs) still represent a major target for various healing approaches in current preclinical research and respective clinical trials, their occurrence in the human BM is typically low. In vitro expansion of this cell type is regulatory challenging as well as time and cost intensive. Compared with marginal percentages of resident BM-MSCs in BM, BM mononuclear cells (BM-MNCs) contained in BM aspirates, concentrates, and bone autografts represent a readily available abundant cell source, applicable within hours during surgical procedures without the need for time-consuming and regulatory challenging cell expansion. This benefit is one reason why autografting has become a clinical standard procedure. However, the exact anatomy and cellularity of BM-MNCs in humans, which is strongly correlated to their unique mode of action and wide application range remains to be elucidated. The aim of this review was to present an overview of the current knowledge on these specific cell types found in human BM, emphasize the contribution of BM-MNCs in bone healing, highlight donor site dependence, and discuss limitations in the current isolation and subsequent characterization procedures. Hereby, the most recent and relevant examples of human BM-MNC cell characterization, flow cytometric analyses, and findings are summarized, with a strong focus on bone therapy.
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Affiliation(s)
- S Haeusner
- IZKF Group Tissue Regeneration in Musculoskeletal Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany.,Bernhard-Heine-Center for Locomotion Research, University of Wuerzburg, Wuerzburg, Germany
| | - A Jauković
- Group for Hematology and Stem Cells, Institute for Medical Research, University of Belgrade, Belgrade, Serbia
| | - E Kupczyk
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - M Herrmann
- IZKF Group Tissue Regeneration in Musculoskeletal Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany.,Bernhard-Heine-Center for Locomotion Research, University of Wuerzburg, Wuerzburg, Germany
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48
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Duda GN, Geissler S, Checa S, Tsitsilonis S, Petersen A, Schmidt-Bleek K. The decisive early phase of bone regeneration. Nat Rev Rheumatol 2023; 19:78-95. [PMID: 36624263 DOI: 10.1038/s41584-022-00887-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/11/2023]
Abstract
Bone has a remarkable endogenous regenerative capacity that enables scarless healing and restoration of its prior mechanical function, even under challenging conditions such as advanced age and metabolic or immunological degenerative diseases. However - despite much progress - a high number of bone injuries still heal with unsatisfactory outcomes. The mechanisms leading to impaired healing are heterogeneous, and involve exuberant and non-resolving immune reactions or overstrained mechanical conditions that affect the delicate regulation of the early initiation of scar-free healing. Every healing process begins phylogenetically with an inflammatory reaction, but its spatial and temporal intensity must be tightly controlled. Dysregulation of this inflammatory cascade directly affects the subsequent healing phases and hinders the healing progression. This Review discusses the complex processes underlying bone regeneration, focusing on the early healing phase and its highly dynamic environment, where vibrant changes in cellular and tissue composition alter the mechanical environment and thus affect the signalling pathways that orchestrate the healing process. Essential to scar-free healing is the interplay of various dynamic cascades that control timely resolution of local inflammation and tissue self-organization, while also providing sufficient local stability to initiate endogenous restoration. Various immunotherapy and mechanobiology-based therapy options are under investigation for promoting bone regeneration.
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Affiliation(s)
- Georg N Duda
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Sven Geissler
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sara Checa
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Serafeim Tsitsilonis
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ansgar Petersen
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Schmidt-Bleek
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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49
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Schulze F, Lang A, Schoon J, Wassilew GI, Reichert J. Scaffold Guided Bone Regeneration for the Treatment of Large Segmental Defects in Long Bones. Biomedicines 2023; 11:biomedicines11020325. [PMID: 36830862 PMCID: PMC9953456 DOI: 10.3390/biomedicines11020325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
Bone generally displays a high intrinsic capacity to regenerate. Nonetheless, large osseous defects sometimes fail to heal. The treatment of such large segmental defects still represents a considerable clinical challenge. The regeneration of large bone defects often proves difficult, since it relies on the formation of large amounts of bone within an environment impedimental to osteogenesis, characterized by soft tissue damage and hampered vascularization. Consequently, research efforts have concentrated on tissue engineering and regenerative medical strategies to resolve this multifaceted challenge. In this review, we summarize, critically evaluate, and discuss present approaches in light of their clinical relevance; we also present future advanced techniques for bone tissue engineering, outlining the steps to realize for their translation from bench to bedside. The discussion includes the physiology of bone healing, requirements and properties of natural and synthetic biomaterials for bone reconstruction, their use in conjunction with cellular components and suitable growth factors, and strategies to improve vascularization and the translation of these regenerative concepts to in vivo applications. We conclude that the ideal all-purpose material for scaffold-guided bone regeneration is currently not available. It seems that a variety of different solutions will be employed, according to the clinical treatment necessary.
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Affiliation(s)
- Frank Schulze
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Annemarie Lang
- Departments of Orthopaedic Surgery & Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Georgi I. Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Johannes Reichert
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
- Correspondence: ; Tel.: +49-3834-86-22530
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50
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A New Osteogenic Membrane to Enhance Bone Healing: At the Crossroads between the Periosteum, the Induced Membrane, and the Diamond Concept. Bioengineering (Basel) 2023; 10:bioengineering10020143. [PMID: 36829637 PMCID: PMC9952848 DOI: 10.3390/bioengineering10020143] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
The lack of viability of massive bone allografts for critical-size bone defect treatment remains a challenge in orthopedic surgery. The literature has reviewed the advantages of a multi-combined treatment with the synergy of an osteoconductive extracellular matrix (ECM), osteogenic stem cells, and growth factors (GFs). Questions are still open about the need for ECM components, the influence of the decellularization process on the latter, the related potential loss of function, and the necessity of using pre-differentiated cells. In order to fill in this gap, a bone allograft surrounded by an osteogenic membrane made of a decellularized collagen matrix from human fascia lata and seeded with periosteal mesenchymal stem cells (PMSCs) was analyzed in terms of de-/recellularization, osteogenic properties, PMSC self-differentiation, and angiogenic potential. While the decellularization processes altered the ECM content differently, the main GF content was decreased in soft tissues but relatively increased in hard bone tissues. The spontaneous osteogenic differentiation was necessarily obtained through contact with a mineralized bone matrix. Trying to deepen the knowledge on the complex matrix-cell interplay could further propel these tissue engineering concepts and lead us to provide the biological elements that allow bone integration in vivo.
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