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Buijs MAS, Haidari S, IJpma FFA, Hietbrink F, Govaert GAM. What can they expect? Decreased quality of life and increased postoperative complication rate in patients with a fracture-related infection. Injury 2024; 55:111425. [PMID: 38402709 DOI: 10.1016/j.injury.2024.111425] [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: 07/22/2023] [Revised: 11/05/2023] [Accepted: 02/11/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND By gaining insight into the Quality of Life (QoL) status and occurrence of complications, critical facets in the care for patients with Fracture-Related Infection (FRI) can be mitigated and measures can be taken to improve their outcome. Therefore, the aims of this study were to 1) determine the QoL in FRI patients in comparison to non-FRI patients and 2) describe the occurrence of other complications in both FRI and non-FRI patients. METHODS An ambidirectional cohort study was conducted in a level 1 trauma centre between January 1st 2016 and November 1st 2021. All patients who underwent surgical stabilisation of an isolated long bone fracture were eligible for inclusion. To avoid confounding, only patients with an Injury Severity Score (ISS) <16 were included. Data regarding patient demographics, fracture characteristics, treatment, follow-up and complications were collected of both non-FRI and FRI patients. QoL was assessed through the use of five-level EuroQol five-dimension (EQ-5D-5L) questionnaires twelve months post-injury. RESULTS A total of 134 patients were included in this study, of whom 38 (28%) FRI patients and 96 (72%) non-FRI patients. In comparison to non-FRI patients, FRI patients scored significantly worse on the QoL assessment regarding the index value (p = 0.012) and the domains mobility (p<0.001), usual activities (p = 0.010) and pain/discomfort (p = 0.009). Other postoperative complications were more often reported (p<0.001) in FRI patients (66%, n = 25/38) compared to non-FRI patients (27%, n = 26/96). During the median follow-up of 14.5 months (interquartile range (IQR) 9.5-26.5), 25 FRI patients developed a total of 49 distinctive complications besides FRI. The complications nonunion (18%, n = 9/49), infection other than FRI (e.g. line infection, urinary tract infection, pneumonia) (18%, n = 9/49) and implant failure (14%, n = 7/49) were the most frequently described in the FRI group. CONCLUSION Patients who suffered from an FRI have a decreased QoL in comparison to those without an FRI. Moreover, patients with an FRI have a higher rate of additional complications. These findings can help in patient counselling regarding the potential physical and mental consequences of having a complicated course of recovery due to an infection.
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Affiliation(s)
- M A S Buijs
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - S Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - F F A IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - F Hietbrink
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - G A M Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
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Doub JB, Levack AE, Sands L, Blommer J, Fackler J, O'Toole RV. Feasibility of using bacteriophage therapy to treat Staphylococcal aureus fracture-related infections. Injury 2024; 55:111442. [PMID: 38387121 DOI: 10.1016/j.injury.2024.111442] [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: 09/08/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Staphylococcus aureus fracture-related infections (FRIs) are associated with significant morbidity in part because conventional antibiotic therapies have limited ability to eradicate S. aureus in sessile states. Therefore, the objective of this study was to assess the feasibility of using Staphylococcal bacteriophages for FRI by testing the activity of a library of Staphylococcal bacteriophage therapeutics against historically preserved S. aureus FRI clinical isolates. METHODS Current Procedural Terminology codes were used to identify patients with FRI from January 1, 2021 to December 31, 2021. Preserved S. aureus FRI isolates from the cases were then tested against a library of 51 Staphylococcal bacteriophages from an American company. This was conducted by assessing the ability of bacteriophages to reduce bacterial growth over time. Growth inhibition greater than 16 h was considered adequate for this study. RESULTS All of the S. aureus preserved clinical isolates had at least one bacteriophage with robust lytic activity and six bacteriophages (11.8 %) had robust lytic activity to seven or more of the clinical isolates. However, 41 of the bacteriophages (80.4 %) had activity to less than three of the clinical isolates and no bacteriophage had activity to all the clinical isolates. CONCLUSION Our findings show that Staphylococcal bacteriophage therapeutics are readily available for S. aureus FRI clinical isolates. However, when correlated with the current barriers to using bacteriophages to treat FRI, designated Staphylococcal bacteriophage cocktails with broad spectrum activity should be created.
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Affiliation(s)
- James B Doub
- The Doub Laboratory of Translational Bacterial Research, University of Maryland School of Medicine, Baltimore, MD, United States; Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Ashley E Levack
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, United States
| | - Lauren Sands
- University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph Blommer
- University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph Fackler
- Adaptive Phage Therapeutics, Gaithersburg, MD, United States
| | - Robert V O'Toole
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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Gitajn IL, Werth PM, Carlini AR, Bosse MJ, Gary JL, Firoozabadi R, Obremskey W, McKinley TO, Castillo RC, O’Toole RV. Deep Surgical Site Infection after Fracture Has a Profound Effect on Functional Outcomes. JB JS Open Access 2024; 9:e23.00042. [PMID: 38196850 PMCID: PMC10773708 DOI: 10.2106/jbjs.oa.23.00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Background Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery. Methods This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12). Results After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline. Conclusions This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Paul M. Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Michael J. Bosse
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Joshua L. Gary
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Reza Firoozabadi
- University of Washington Harborview Medical Center, Seattle, Washington
| | | | - Todd O. McKinley
- Indiana University School of Medicine, Indianapolis, Indiana and
| | - Renan C. Castillo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Elliott JT, Henderson E, Streeter SS, Demidov V, Han X, Tang Y, Sottosanti JS, Bateman L, Brůža P, Jiang S, Gitajn IL. Fluorescence-guided and molecularly-guided debridement: identifying devitalized and infected tissue in orthopaedic trauma. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2023; 12361:1236108. [PMID: 37056956 PMCID: PMC10091097 DOI: 10.1117/12.2661243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Following orthopaedic trauma, bone devitalization is a critical determinant of complications such as infection or nonunion. Intraoperative assessment of bone perfusion has thus far been limited. Furthermore, treatment failure for infected fractures is unreasonably high, owing to the propensity of biofilm to form and become entrenched in poorly vascularized bone. Fluorescence-guided surgery and molecularly-guided surgery could be used to evaluate the viability of bone and soft tissue and detect the presence of planktonic and biofilm-forming bacteria. This proceedings paper discusses the motivation behind developing this technology and our most recent preclinical and clinical results.
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Affiliation(s)
- Jonathan Thomas Elliott
- Department of Orthopaedics, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH 03756
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Drive, Hanover, NH USA 03755
- Thayer School of Engineering at Dartmouth, 14 Engineering Drive, Hanover, NH USA 03755
| | - Eric Henderson
- Department of Orthopaedics, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH 03756
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Drive, Hanover, NH USA 03755
| | - Samuel S. Streeter
- Department of Orthopaedics, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH 03756
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Drive, Hanover, NH USA 03755
| | - Valentin Demidov
- Department of Orthopaedics, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH 03756
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Drive, Hanover, NH USA 03755
| | - Xinyue Han
- Thayer School of Engineering at Dartmouth, 14 Engineering Drive, Hanover, NH USA 03755
| | - Yue Tang
- Thayer School of Engineering at Dartmouth, 14 Engineering Drive, Hanover, NH USA 03755
| | - J. Scott Sottosanti
- Department of Orthopaedics, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH 03756
| | - Logan Bateman
- Thayer School of Engineering at Dartmouth, 14 Engineering Drive, Hanover, NH USA 03755
| | - Petr Brůža
- Thayer School of Engineering at Dartmouth, 14 Engineering Drive, Hanover, NH USA 03755
| | - Shudong Jiang
- Thayer School of Engineering at Dartmouth, 14 Engineering Drive, Hanover, NH USA 03755
| | - I. Leah Gitajn
- Department of Orthopaedics, Dartmouth Health, 1 Medical Center Drive, Lebanon, NH 03756
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Drive, Hanover, NH USA 03755
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Gitajn I, Werth P, O'Toole RV, Joshi M, Jevsevar D, Wise B, Rane A, Horton S, McClure EA, Ross B, Nadell C. Microbial Interspecies Associations in Fracture-Related Infection. J Orthop Trauma 2022; 36:309-316. [PMID: 35703847 DOI: 10.1097/bot.0000000000002314] [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] [Accepted: 11/16/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Describe co-occurrence or clustering of microbial taxa in fracture-related infections to inform further exploration of infection-related interactions among them. DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Four hundred twenty-three patients requiring surgical intervention for deep surgical site infection between January 2006 and December 2015. INTERVENTION None. MAIN OUTCOME MEASUREMENT Connection between microbial taxa. RESULTS Methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and coagulase-negative Staphylococcus represented the majority of monomicrobial observations (71%). Gram-negative rods, gram-positive rods, and anaerobes presented more frequently in polymicrobial infections. Enterobacter, vancomycin-sensitive Enterococcus, and Pseudomonas are present in polymicrobial infections with the highest frequencies and represent the top 3 most important nodes within the microorganism framework, with the highest network centrality scores. CONCLUSIONS The present study indicates that there are common microbial taxa (Enterobacter, Enterococcus, and Pseudomonas) that tend to co-occur with other microbes greater than 75% of the time. These commonly co-occurring microbes have demonstrated interactive relationships in other disease pathologies, suggesting that there may be similar important interactions in fracture-related infections. It is possible that these microbial communities play a role in the persistently high failure rate associated with management of infection after trauma. Future studies are needed to study the intermicrobial interactions that explain the frequency at which taxa co-occur. Understanding and potentially disrupting these intermicrobial relationships could inform improvements in the treatment of established infections and in the prevention of infection in high-risk patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ida Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Paul Werth
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Mandarin Joshi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - David Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Brent Wise
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Ajinya Rane
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Horton
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Emily A McClure
- Department of Microbiology and Immunology, Dartmouth, Geisel School of Medicine, Hanover, NH; and
| | - Benjamin Ross
- Department of Microbiology and Immunology, Dartmouth, Geisel School of Medicine, Hanover, NH; and
| | - Carey Nadell
- Department of Biological Sciences, Dartmouth, Hanover, NH
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Hendrickson NR, Davison J, Glass NA, Wilson ES, Miller A, Leary S, Lorentzen W, Karam MD, Hogue M, Marsh JL, Willey MC. Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial. J Bone Joint Surg Am 2022; 104:759-766. [PMID: 35286282 DOI: 10.2106/jbjs.21.01014] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures. METHODS Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM. RESULTS Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points. CONCLUSIONS Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan R Hendrickson
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - John Davison
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Natalie A Glass
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Erin S Wilson
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Aspen Miller
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Steven Leary
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - William Lorentzen
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Matthew D Karam
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Matthew Hogue
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - J Lawrence Marsh
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Michael C Willey
- Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, Iowa
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Rodríguez-Zamorano P, García-Coiradas J, Galán-Olleros M, Marcelo Aznar H, Alcobia-Díaz B, Llanos S, Valle-Cruz J, Marco F. [Translated article] Suprapatellar tibial nailing, why have we changed? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Rodríguez-Zamorano P, García-Coiradas J, Galán-Olleros M, Marcelo Aznar H, Alcobia-Díaz B, Llanos S, Valle-Cruz J, Marco F. Enclavado de tibia suprapatelar, ¿por qué hemos cambiado? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:159-169. [DOI: 10.1016/j.recot.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 08/18/2021] [Accepted: 09/07/2021] [Indexed: 10/19/2022] Open
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Sun T, Yang D, Wu Y, Sheng Q. The function of microRNA-211 expression in post-fracture bone cell apoptosis involving the transforming growth factor-β/ phosphoinositide 3-kinase signaling pathway. J Int Med Res 2021; 48:300060520926353. [PMID: 32720595 PMCID: PMC7388126 DOI: 10.1177/0300060520926353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The underlying mechanism of micro (mi)RNA-211 in bone cell apoptosis after fracture
remains unclear. This study aimed to determine the effect and function of miRNA-211 in
bone cell apoptosis in fracture patients. Methods Serum samples were collected from patients with fractures and healthy controls. Serum
miR-211 expression was detected by quantitative PCR. MC3T3-E1 cells were transfected
with a transforming growth factor (TGF)-β inhibitor and phosphoinositide 3-kinase (PI3K)
inhibitor. The viability of MC3T3-E1 cells was detected by the MTT assay, and apoptosis
was detected by flow cytometry. Caspase-3/9 activity and the protein expression of
TGF-β, PI3K, and p-Akt were detected by western blot and immunoprecipitation. Results In the fracture group, miRNA-211 expression was significantly up-regulated compared
with controls. We used miRNA-211 mimics to up-regulate miRNA-211 expression, and
observed inhibited cell viability and induced apoptosis and lactate dehydrogenase (LDH)
activity. miRNA-211 up-regulation also suppressed the expression of TGF-β, PI3K, and
p-Akt proteins. Conversely, miRNA-211 down-regulation increased cell viability and
reduced apoptosis and LDH activity, as well as inducing the expression of TGF-β, PI3K,
and p-Akt. Inhibiting TGF-β decreased the effect of anti-miRNA-211 on osteocyte
apoptosis. Conclusion Our data indicate that miRNA-211 functions via the TGF-β/PI3K/Akt signaling pathway in
patients with fractures.
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Affiliation(s)
- Tongxin Sun
- Department of Orthopedics, Dongying People's Hospital, Dongying, Shandong province, P. R. China
| | - Dai Yang
- Department of Orthopedics, Dongying People's Hospital, Dongying, Shandong province, P. R. China
| | - Yuanpeng Wu
- Department of Orthopedics, Dongying People's Hospital, Dongying, Shandong province, P. R. China
| | - Qingang Sheng
- Department of Orthopedics, Dongying District People's Hospital, Dongying, Shandong province, P. R. China
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Durdevic D, Vlahovic T, Pehar S, Miklic D, Oppermann H, Bordukalo-Niksic T, Gavrankapetanovic I, Jamakosmanovic M, Milosevic M, Martinovic S, Sampath TK, Peric M, Grgurevic L, Vukicevic S. A novel autologous bone graft substitute comprised of rhBMP6 blood coagulum as carrier tested in a randomized and controlled Phase I trial in patients with distal radial fractures. Bone 2020; 140:115551. [PMID: 32730930 DOI: 10.1016/j.bone.2020.115551] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 12/26/2022]
Abstract
Bone morphogenetic proteins (BMPs) are known to induce new bone formation in vivo but treating trabecular bone defects with a BMP based therapeutic remains controversial. Here, we evaluated the safety and efficacy of a novel Autologous Bone Graft Substitute (ABGS) comprised of recombinant human BMP6 (rhBMP6) dispersed within an autologous blood coagulum (ABC) as a physiological natural carrier in patients with a closed distal radial fracture (DRF). We enrolled 32 patients in a randomized, standard of care (SoC) and placebo (PBO) controlled, double-blinded Phase I First in Human (FiH) clinical trial. ABGS was prepared from peripheral blood as 250 μg rhBMP6/mL ABC or PBO (1 mL ABC containing excipients only) and was administered dorsally via a syringe injection into the fracture site following closed fracture fixation with 3 Kirschner wires. Patients carried an immobilization for 5 weeks and were followed-up for 0 to 26 weeks by clinical examination, safety, serial radiographic analyses and CT. During the 13 weeks follow-up and at 26 weeks post study there were no serious adverse reactions recorded. The results showed that there were no detectable anti-rhBMP6 antibodies in the blood of any of the 32 patients at 13- and 26-weeks following treatment. Pharmacokinetic analyses of plasma from patients treated with ABGS showed no detectable rhBMP6 at any time point within the first 24 h following administration. The CT image and radiographic analyses score from patients treated with AGBS showed significantly accelerated bone healing as compared to PBO and SoC at 5 and 9 weeks (with high effect sizes and P = 0.027), while at week 13 all patients had similar healing outcomes. In conclusion, we show that intraosseous administration of ABGS (250 μg rhBMP6/mL ABC) into the distal radial fracture site demonstrated a good tolerability with no serious adverse reactions as well as early accelerated trabecular bone healing as compared to control PBO and SoC patients.
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Affiliation(s)
- Dragan Durdevic
- Clinical Hospital Center "Sisters of Mercy", Clinic of Traumatology, Draskoviceva 19, 10000 Zagreb, Croatia
| | - Tomislav Vlahovic
- Clinical Hospital Center "Sisters of Mercy", Clinic of Traumatology, Draskoviceva 19, 10000 Zagreb, Croatia
| | - Sanja Pehar
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Salata 11, 10000 Zagreb, Croatia
| | - Dina Miklic
- Clinical Hospital Center "Sisters of Mercy", Clinic of Traumatology, Draskoviceva 19, 10000 Zagreb, Croatia
| | - Hermann Oppermann
- Genera Research, Svetonedeljska 2, Kalinovica, 10436, Rakov Potok, Croatia
| | - Tatjana Bordukalo-Niksic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Salata 11, 10000 Zagreb, Croatia
| | - Ismet Gavrankapetanovic
- University Clinical Center Sarajevo, Clinic of Orthopedics and Traumatology, Bolnicka 25, 71000 Sarajevo, Bosnia and Herzegovina
| | - Mehmed Jamakosmanovic
- University Clinical Center Sarajevo, Clinic of Orthopedics and Traumatology, Bolnicka 25, 71000 Sarajevo, Bosnia and Herzegovina
| | - Milan Milosevic
- School of Public Health "Andrija Stampar", University of Zagreb School of Medicine, Rockefellerova 4, 10000 Zagreb, Croatia
| | | | | | - Mihaela Peric
- Department for Intracellular Communication, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Salata 2, 10000 Zagreb, Croatia
| | - Lovorka Grgurevic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Salata 11, 10000 Zagreb, Croatia
| | - Slobodan Vukicevic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Salata 11, 10000 Zagreb, Croatia.
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11
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Bhandari M, Schemitsch EH, Karachalios T, Sancheti P, Poolman RW, Caminis J, Daizadeh N, Dent-Acosta RE, Egbuna O, Chines A, Miclau T. Romosozumab in Skeletally Mature Adults with a Fresh Unilateral Tibial Diaphyseal Fracture: A Randomized Phase-2 Study. J Bone Joint Surg Am 2020; 102:1416-1426. [PMID: 32358413 DOI: 10.2106/jbjs.19.01008] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Romosozumab is an antibody that binds and inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption. A double-blinded, randomized, phase-2, dose-finding trial was performed to evaluate the effect of romosozumab on the radiographic and clinical outcomes of surgical fixation of tibial diaphyseal fractures. METHODS Patients (18 to 82 years old) were randomized 3:1:1:1:1:1:1:1:1:1 to a placebo or 1 of 9 romosozumab treatment groups. Patients received subcutaneous injections of romosozumab or the placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary outcome was the time to radiographic evidence of healing ("radiographic healing") analyzed after the week-24 assessments had been completed for all patients. RESULTS A total of 402 patients were randomized: 299 to the romosozumab group and 103 to the placebo group. The median time to radiographic healing (the primary outcome) ranged from 14.4 to 18.6 weeks in the romosozumab groups and was 16.4 weeks (95% confidence interval [CI]: 14.6 to 18.0 weeks) in the placebo group, which was not a significant difference. There was also no significant difference in the median time to clinical healing, no relationship between romosozumab dose/frequency and unplanned revision surgery, and no apparent treatment benefit in terms of physical function. The safety and tolerability profile of romosozumab was comparable with that of the placebo. CONCLUSIONS Romosozumab did not accelerate tibial fracture-healing in this patient population. Additional studies of patients at higher risk for delayed healing are needed to explore the potential of romosozumab to accelerate tibial fracture-healing. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Theofilos Karachalios
- Orthopaedic Department UGHL, School of Health Sciences, University of Thessalia, Larissa, Greece
| | - Parag Sancheti
- Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India
| | | | | | | | | | | | | | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.,Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, California
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Parikh S, Singh H, Devendra A, Dheenadhayalan J, Sethuraman AS, Sabapathy R, Rajasekaran S. The use of the Ganga Hospital Score to predict the treatment and outcome of open fractures of the tibia. Bone Joint J 2020; 102-B:26-32. [PMID: 31888373 DOI: 10.1302/0301-620x.102b1.bjj-2019-0853.r2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. METHODS We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman's correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. RESULTS The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. CONCLUSION The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26-32.
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Trickett RW, Mudge E, Price P, Pallister I. The development of a novel patient-derived recovery scale for open tibial fractures. Bone Joint J 2020; 102-B:17-25. [PMID: 31888370 DOI: 10.1302/0301-620x.102b1.bjj-2019-0303.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIMS The aim of this study was to develop a psychometrically sound measure of recovery for use in patients who have suffered an open tibial fracture. METHODS An initial pool of 109 items was generated from previous qualitative data relating to recovery following an open tibial fracture. These items were field tested in a cohort of patients recovering from an open tibial fracture. They were asked to comment on the content of the items and structure of the scale. Reduction in the number of items led to a refined scale tested in a larger cohort of patients. Principal components analysis permitted further reduction and the development of a definitive scale. Internal consistency, test-retest reliability, and responsiveness were assessed for the retained items. RESULTS The initial scale was completed by 35 patients who were recovering from an open tibial fracture. Subjective and objective analysis permitted removal of poorly performing items and the addition of items suggested by patients. The refined scale consisted of 50 Likert scaled items and eight additional items. It was completed on 228 occasions by a different cohort of 204 patients with an open tibial fracture recruited from several UK orthoplastic tertiary referral centres. There were eight underlying components with tangible real-life meaning, which were retained as sub-scales represented by ten Likert scaled and eight non-Likert items. Internal consistency and test-retest reliability were good to excellent. CONCLUSION The Wales Lower Limb Trauma Recovery (WaLLTR) Scale is the first tool to be developed from patient data with the potential to assess recovery following an open tibial fracture. Cite this article: Bone Joint J 2020;102-B(1):17-25.
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Affiliation(s)
- Ryan W Trickett
- Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Elizabeth Mudge
- Department of Wound Healing, Cardiff University School of Medicine, Cardiff, UK
| | | | - Ian Pallister
- Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, UK
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Elliott JT, Jiang S, Pogue BW, Gitajn IL. Bone-specific kinetic model to quantify periosteal and endosteal blood flow using indocyanine green in fluorescence guided orthopedic surgery. JOURNAL OF BIOPHOTONICS 2019; 12:e201800427. [PMID: 30963727 PMCID: PMC7331892 DOI: 10.1002/jbio.201800427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/10/2019] [Accepted: 04/04/2019] [Indexed: 05/22/2023]
Abstract
This letter describes a hybrid plug/compartment (HyPC) kinetic model to fit dynamic indocyanine green fluorescence data acquired in a porcine model of long bone traumatic fracture. Parametric images of periosteal blood flow, endosteal blood flow, total bone blood flow and fraction of endosteal-to-periosteal flow were obtained by applying the HyPC model on a pixel-by-pixel basis. Intraoperative discrimination between healthy and damaged bone could facilitate debridement reducing post-operative complications from non-union and infection. The ability to quantify periosteal and endosteal blood flow could inform nail vs. plate-and-screw decisions to avoid further compromising cortical blood supply.
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Affiliation(s)
- Jonathan T. Elliott
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Thayer School of Engineering at Dartmouth, Hanover, NH
| | - Shudong Jiang
- Thayer School of Engineering at Dartmouth, Hanover, NH
| | | | - Ida Leah Gitajn
- Department of Orthopaedics and Sports Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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