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De Paolis F, Testa S, Guarnaccia G, Reggio A, Fornetti E, Cicciarelli F, Deodati R, Bernardini S, Peluso D, Baldi J, Biagini R, Bellisari FC, Izzo A, Sgalambro F, Arrigoni F, Rizzo F, Cannata S, Sciarra T, Fuoco C, Gargioli C. Long-term longitudinal study on swine VML model. Biol Direct 2023; 18:42. [PMID: 37518063 PMCID: PMC10388508 DOI: 10.1186/s13062-023-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Volumetric Muscle Loss (VML), resulting from severe trauma or surgical ablation, is a pathological condition preventing myofibers regeneration, since skeletal muscle owns the remarkable ability to restore tissue damage, but only when limited in size. The current surgical therapies employed in the treatment of this pathology, which particularly affects military personnel, do not yet provide satisfactory results. For this reason, more innovative approaches must be sought, specifically skeletal muscle tissue engineering seems to highlight promising results obtained from preclinical studies in VML mouse model. Despite the great results obtained in rodents, translation into human needs a comparable animal model in terms of size, in order to validate the efficacy of the tissue engineering approach reconstructing larger muscle mass (human-like). In this work we aim to demonstrate the validity of a porcine model, that has underwent a surgical ablation of a large muscle area, as a VML damage model. RESULTS For this purpose, morphological, ultrasound, histological and fluorescence analyses were carried out on the scar tissue formed following the surgical ablation of the peroneus tertius muscle of Sus scrofa domesticus commonly called mini-pig. In particular, the replenishment of the damaged area, the macrophage infiltration and the vascularization at different time-points were evaluated up to the harvesting of the scar upon six months. CONCLUSION Here we demonstrated that following VML damage, there is an extremely poor regenerative process in the swine muscle tissue, while the formation of fibrotic, scar tissue occurs. The analyses performed up to 180 days after the injury revealed the development of a stable, structured and cellularized tissue, provided with vessels and extracellular matrix acquiring the status of granulation tissue like in human.
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Affiliation(s)
- Francesca De Paolis
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
- PhD Program in Cellular and Molecular Biology, Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Stefano Testa
- Marseille Medical Genetics, Aix-Marseille University, INSERM, Marseille, MMG, France
| | | | - Alessio Reggio
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Ersilia Fornetti
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Felice Cicciarelli
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Rebecca Deodati
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Sergio Bernardini
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Daniele Peluso
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Jacopo Baldi
- IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | - Antonio Izzo
- Department of Clinical Sciences and Applied Biotechnologies (DISCAB), Aquila, Italy
| | - Ferruccio Sgalambro
- Department of Clinical Sciences and Applied Biotechnologies (DISCAB), Aquila, Italy
| | - Francesco Arrigoni
- Department of Clinical Sciences and Applied Biotechnologies (DISCAB), Aquila, Italy
| | - Francesco Rizzo
- Joint Veteran Center, Scientific Department, Army Medical Center, Rome, Italy
| | - Stefano Cannata
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy
| | - Tommaso Sciarra
- Joint Veteran Center, Scientific Department, Army Medical Center, Rome, Italy
| | - Claudia Fuoco
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy.
| | - Cesare Gargioli
- Department of Biology, University of Rome "Tor Vergata", Rome, 00133, Italy.
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Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review. Plast Reconstr Surg 2023; 151:308e-314e. [PMID: 36696332 DOI: 10.1097/prs.0000000000009861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. METHODS Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. RESULTS A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4-compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. CONCLUSIONS Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4-compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Tucker A, Norrish AR, Fendius S, Uzoho C, Thorne T, Del Hoyo E, Nightingale J, Taylor A, Ollivere BJ. Definitive Taylor Spatial Frame management for the treatment of high-energy open tibial fractures: Clinical and patient-reported outcomes. Injury 2022; 53:4104-4113. [PMID: 36424690 DOI: 10.1016/j.injury.2022.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/02/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided. We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided. METHOD A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant. RESULTS Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work. CONCLUSION Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures. We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.
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Affiliation(s)
- A Tucker
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - A R Norrish
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham, Nottingham, UK; Queen Elizabeth Hospital, Kings Lynn, UK
| | - S Fendius
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - C Uzoho
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - T Thorne
- University of Nottingham, Nottingham, UK
| | - E Del Hoyo
- University of Nottingham, Nottingham, UK
| | - J Nightingale
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK; Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham, Nottingham, UK
| | - A Taylor
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - B J Ollivere
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK; University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical research Unit, Nottingham, UK
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Farhan-Alanie MM, Ward J, Kelly MB, Al-Hourani K. Current Perspectives on the Management of Bone Fragments in Open Tibial Fractures: New Developments and Future Directions. Orthop Res Rev 2022; 14:275-286. [PMID: 35983563 PMCID: PMC9380731 DOI: 10.2147/orr.s340534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022] Open
Abstract
Open tibial fractures may be associated with bone loss at the time of the injury or following surgical debridement of the fracture. This article discusses the various treatment options available and the latest developments surrounding the management of free bone fragments in open tibial fractures.
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Affiliation(s)
- Muhamed M Farhan-Alanie
- Department of Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
- Correspondence: Muhamed M Farhan-Alanie, Email
| | - Jayne Ward
- Department of Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Michael B Kelly
- Department of Trauma & Orthopaedics, Southmead Hospital, Bristol, UK
| | - Khalid Al-Hourani
- Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, UK
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Management of soft-tissue coverage of open tibia fractures in Latin America: Techniques, timing, and resources. Injury 2022; 53:1422-1429. [PMID: 35101259 DOI: 10.1016/j.injury.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America. METHODS A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs). RESULTS The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p<0.01) and plastic surgeons were more available (<24 h of patient presentation to the hospital) in HICs than MICs (63% vs. 26%, p = 0.05), demonstrating statistically significant differences. In addition, respondents in HICs performed free flaps more commonly than in MICs for proximal third (55% vs. 10%, p<0.01), middle third (36% vs. 9%, p = 0.02), and distal third (55% vs. 10%, p<0.01) lower extremity wounds. Negative Pressure Wound Therapy (NPWT or Wound VAC) was the only resource available to more than half of the respondents. Though not statistically significant, surgeons reported having more access to plastic surgeons at their institutions in HICs than MICs (91% vs. 62%, p = 0.12) and performed microsurgical flaps more commonly at their respective institutions (73% vs. 42%, p = 0.06). CONCLUSIONS The study demonstrated that most orthopaedic surgeons in Latin America have received no soft-tissue training, HICs and MICs have differences in access to plastic surgeons and expectations for flap type and timing to definitive coverage, and most respondents had limited access to necessary soft-tissue surgical resources. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.
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Chen C, Xiao D, Li T, Gong M, Zha Y, Hua K, Sun W, Ji S, Jiang X. Comparative study of functional outcomes between OTA/AO type C, Gustilo type I/II open fractures and closed fractures of the distal humerus treated by open reduction and internal fixation. BMC Musculoskelet Disord 2021; 22:939. [PMID: 34758812 PMCID: PMC8582176 DOI: 10.1186/s12891-021-04817-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/25/2021] [Indexed: 11/14/2022] Open
Abstract
Background To evaluate the difference of functional outcomes between OTA/AO type C, Gustilo type I/II open fractures and closed fractures of the distal humerus after open reduction and internal fixation. Methods We retrospectively analyzed the clinical data of patients with OTA/AO-C distal humerus fractures who were treated in our department from January 2014 to December 2016. The patients were divided into an open fracture group and a closed fracture group. Their baseline characteristics and functional outcomes were analyzed and compared. Results A total of 64 patients treated by operative fixation were identified (25 open and 39 closed injuries), and the average follow-up time was 35.1 ± 13.6 months. There were no significant differences in the range of motion (ROM) of the elbow, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, complications, hospitalization time, operation time, intraoperative blood loss, or medical costs between the two groups (P > 0.05). Conclusion OTA/AO type C, Gustilo I/II distal humeral open fractures can yield satisfactory clinical results similar to those of closed distal humeral fractures after open reduction and internal fixation. Level of evidence Therapeutic Level III; Retrospective Cohort Comparison; Treatment Study.
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Affiliation(s)
- Chen Chen
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Dan Xiao
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Maoqi Gong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yejun Zha
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Kehan Hua
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Weitong Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Shangwei Ji
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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Nicolaides M, Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma 2021; 20:101483. [PMID: 34262849 PMCID: PMC8254044 DOI: 10.1016/j.jcot.2021.101483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 12/31/2022] Open
Abstract
Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.
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Affiliation(s)
- Marios Nicolaides
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgios Pafitanis
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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The War after War: Volumetric Muscle Loss Incidence, Implication, Current Therapies and Emerging Reconstructive Strategies, a Comprehensive Review. Biomedicines 2021; 9:biomedicines9050564. [PMID: 34069964 PMCID: PMC8157822 DOI: 10.3390/biomedicines9050564] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 04/30/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
Volumetric muscle loss (VML) is the massive wasting of skeletal muscle tissue due to traumatic events or surgical ablation. This pathological condition exceeds the physiological healing process carried out by the muscle itself, which owns remarkable capacity to restore damages but only when limited in dimensions. Upon VML occurring, the affected area is severely compromised, heavily influencing the affected a person’s quality of life. Overall, this condition is often associated with chronic disability, which makes the return to duty of highly specialized professional figures (e.g., military personnel or athletes) almost impossible. The actual treatment for VML is based on surgical conservative treatment followed by physical exercise; nevertheless, the results, in terms of either lost mass and/or functionality recovery, are still poor. On the other hand, the efforts of the scientific community are focusing on reconstructive therapy aiming at muscular tissue void volume replenishment by exploiting biomimetic matrix or artificial tissue implantation. Reconstructing strategies represent a valid option to build new muscular tissue not only to recover damaged muscles, but also to better socket prosthesis in terms of anchorage surfaces and reinnervation substrates for reconstructed mass.
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