Analysis on association between sagittal stem alignment and early functional and radiological outcome following primary cementless total hip replacement

INTRODUCTION

Accurate reconstruction of hip anatomy and biomechanics is mandatory for achieving good clinical outcomes following total hip replacement (THR). Optimal stem alignment is essential to avoid impingement or loosening. This study aimed to evaluate sagittal stem position following cementless THR and its relationship with patient's functional outcome and post-operative radiological parameters.

METHOD

We performed analytical observational study with cross-sectional design on 71 hips (67 patients, ranged 18-85 years old) that underwent primary cementless THR in two orthopedic centers in Jakarta, Indonesia. All hips were operated through either anterolateral or posterior approach using either extended/full-coating wedge-tapered stem or proximal-coated wedge-tapered stem. Clinical outcomes were evaluated at follow-up time using mHHS questionnaire, VAS level of thigh pain, and hip ROM. Stem sagittal alignment and other radiological parameters, including combined anteversion and offset, were measured from conventional radiograph.

RESULTS

There were no significant differences on mHHS score, VAS level on thigh pain, and ROM between stem alignment groups. Post-operative anteversion and offset of the implant were not affected by the stem sagittal position. All influencing factors have significant effect on sagittal stem alignment. Linear regression test on femur morphology showed 0.69° increase in stem posterior tilt for every 1° increase in the anterior bowing (coeff. = 0.502).

CONCLUSION

Stem tilting in sagittal plane did not affect patient's functional outcome or post-operative radiological parameters. In addition, for every degree of increased anterior femoral bowing, 0.69° increase in posterior stem tilting can be expected.

Modified Mesenchymal stem cell, platelet-rich plasma, and hyaluronic acid intervention in early stage osteoarthritis: A systematic review, meta-analysis, and meta-regression of arthroscopic-guided intra-articular approaches

BACKGROUND

Mesenchymal stem cells (MSCs) hold promise for osteoarthritis (OA) treatment, potentially enhanced by combining them with platelet-rich plasma (PRP) and hyaluronic acid (HA). This study aimed to assess the synergy of MSCs, PRP, and varying HA doses, and determine optimal MSC sources to treat early-stage OA in the perspective of Lysholm score, VAS Score, KSS score, and WOMAC score.

METHOD

Original articles from 2013 to 2023 were screened from four databases, focusing on clinical trials and randomized controlled trials. The Risk of Bias in Non-randomized Studies-of Interventions (ROB-2) tool evaluated bias, and a PICOS criteria table guided result construction. Revman 5.4 analyzed outcomes such as Lysholm score, VAS score, KSS, WOMAC score, cartilage volume, and defect size using MRI. This systematic review adhered to PRISMA guidelines.

RESULT

Nine studies met the final inclusion criteria. Meta-analysis revealed a significant improvement in Lysholm score (MD: 17.89; 95% CI: 16.01, 19.77; I2 = 0%, P = 0.56), a notable reduction in VAS score (MD: -2.62; 95% CI: -2.83, -2.41; I2 = 99%, P < 0.00001), elevated KSS (MD: 29.59; 95% CI: 27.66, 31.52; I2 = 95%, P < 0.0001), and reduced WOMAC score (MD: -12.38; 95% CI: -13.75, -11.01; I2 = 99%, P < 0.0001).

CONCLUSIONS

Arthroscopic guided high-dose subchondral application of primary cultured synovial MSCs in popliteal PRP media with HA effectively regenerates cartilage defects and improves clinical outcomes in early-stage osteoarthritis. Clarification of MSC sources and quantities enhances the understanding of this promising treatment modality.

Functional, radiological, and quality of life outcome of unstable acetabular fracture with quadrilateral plate involvement at a tertiary care center in Jakarta, Indonesia

INTRODUCTION

Unstable acetabular fracture remains a complex fracture that requires technically demanding surgery for orthopedic surgeons. Quadrilateral plate (QP) fractures of the acetabulum are a challenging group of acetabular fractures to manage. However, the literature regarding the management of these injuries are limited. The QP is a relatively thin medial wall of the acetabulum and intra-articular; thus, anatomical reduction and stable fixation are required for satisfactory outcome. This study aims to determine the functional, radiological, and quality of life outcome of unstable acetabular fracture with QP involvement.

METHODS

This was a retrospective cohort study conducted at Cipto Mangunkusumo General Hospital during the period of 2010-2020. Patients with unstable acetabular fractures with and without QP involvement were included in this study. They were followed up postoperatively at 1, 6, and 12 months. Functional outcome was assessed using the Harris Hip Score (HHS), Merle D'Aubigne, and Oxford Hip Score (OHS); while radiology outcome was assessed using Matta Outcome Grading; and quality of life was assessed using the SF-36.

RESULTS

This study involved 53 subjects with a median age was 29 (18-75) years of age. Twenty-eight (52.8%) subjects had unstable acetabular fracture with QP involvement. Twenty-five (47.2%) subjects had unstable acetabular fracture without QP involvement. Twenty-five (47.2%) subjects were fixed using quadrilateral hook plate, 3 (5.7%) with infrapectineal plate, 10 (18.8%) with posterior column plate, and 15 (28.3%) with suprapectineal plate. The median intraoperative bleeding in those with unstable acetabular fracture with QP involvement was 600 (300-4000) ml, which was higher than those without QP involvement (400 [100-1700] ml). Those with QP involvement achieved anatomical reduction in 20 (71.4%) subjects. Whereas, the subjects without QP involvement achieved anatomical reduction 23 patients (92%). Subjects with QP involvement had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement based on Harris Hip Score (p = 0.046), Merle D'Aubigne (0.001), Oxford Hip Score (0.001), Matta Outcome Grading (0.004), and SF-36 (0.001). Patients with quadrilateral hook plate showed no significant functional, and radiological outcome difference compared to patients with infrapectineal plate based on Harris Hip Score (p = 0.582), Merle D'Aubigne (0.698), Oxford Hip Score (1.000), and Matta Outcome Grading (1.000). In addition, we also found no significant functional, radiological, and quality of life outcome difference between posterior column plate and suprapectineal plate group based on Harris Hip Score (p = 0.200), Merle D'Aubigne (0.643), Oxford Hip Score (0.316), Matta Outcome Grading (1.000), and SF-36 (0.600).

CONCLUSIONS

Patients with unstable acetabular fracture with quadrilateral plate involvement subject had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement. Both quadrilateral hook and infrapectineal plates demonstrated non-significant functional and radiological outcomes difference. Posterior column plate also resulted in the same functional, radiological, and quality of life outcome compared with suprapectineal fixation.

Scoliocorrector Fatma-UI for correction of adolescent idiopathic scoliosis: Development, effectivity, safety and functional outcome

BACKGROUND

Adolescent idiopathic scoliosis remains a major problem due to its high incidence, high risk, and high cost. One of the aims of the management in scoliosis is to correct the deformity. Many techniques are available to correct scoliosis deformity; however, they are all far from ideal to achieve three-dimensional correction in scoliosis.

AIM

To develop a set of tools named Scoliocorrector Fatma-UI (SCFUI) to aid three-dimensional correction and to evaluate the efficacy, safety, and functional outcome.

METHODS

This study consists of two stages. In the first stage, we developed the SCFUI and tested it in finite element and biomechanical tests. The second stage was a single-blinded randomized clinical trial to evaluate the SCFUI compared to direct vertebral rotation (DVR). Forty-four subjects with adolescent idiopathic scoliosis were randomly allocated into the DVR group (n = 23) and SCFUI group (n = 21). Radiological, neurological, and functional outcome was compared between the groups.

RESULTS

Finite element revealed the maximum stress of the SCFUI components to be between 31.2 - 252 MPa. Biomechanical analysis revealed the modulus elasticity of SCFUI was 9561324 ± 633277 MPa. Both groups showed improvement in Cobb angle and sagittal profile, however the rotation angle was lower in the SCFUI group (11.59 ± 7.46 vs 18.23 ± 6.39, P = 0.001). Neurological and functional outcome were comparable in both groups.

CONCLUSION

We concluded that SCFUI developed in this study resulted in similar coronal and sagittal but better rotational correction compared to DVR. The safety and functional outcomes were also similar to DVR.

Clinical evaluation of intralesional umbilical cord-derived mesenchymal stem cells, conditioned medium and triamcinolone acetonide injection for keloid treatment: A pilot study

Topical keloid therapy is performed with triamcinolone acetonide (TA) intralesional injection. However, the recurrence rate is high with various side effects. Mesenchymal stem cells (MSCs) have high proliferative abilities and reduce the activity and proliferation of fibroblast cells in keloids. To overcome the costs and limitations, conditioned medium (CM) is used. This study aims to evaluate feasibility of intralesional injection of umbilical cord MSC (UC-MSC) and conditioned medium (UC-CM) compared to TA for keloid therapy. Twenty-four patients with keloids who met the inclusion criteria were included, randomized into three treatment groups and then got assessed for the sociodemographic data, keloid volume, histopathology (type 1:3 collagen ratio), interleukin-10 (IL-10) levels and Patient and Observer Scar Assessment Scale (POSAS) score during visits. Largest volume regression occurred in the UC-MSC group, followed by UC-CM and then the TA group (UC-MSC: 45.32% ± 2.61%; UC-CM: 43.61% ± 3.67%; TA: 28.34% ± 3.81%; p = 0.003). Similar pattern was also observed in increase in IL-10 levels, the decrease in POSAS scores and the reduction of type 1:3 collagen ratio. Hence, UC-MSC and UC-CM are promisingly more effective than TA for keloid therapy, showcasing their superiority in reducing keloid volume, symptoms and type 1:3 collagen ratio, as well as increasing the levels of IL-10.

Umbilical cord mesenchymal stem cells combined with secretome for treating congenital pseudarthrosis of the Tibia: a case series

INTRODUCTION

Most patients with congenital pseudoarthrosis of tibia (CPT) do not have promising outcomes despite multiple attempts using conventional surgeries. The combination of umbilical cord-derived mesenchymal stem cells and conditioned medium (secretome) contains major components pivotal for the enhancement of fracture healing. The purpose of this study was to address fracture healing in CPT cases that were treated using the combined implantation of umbilical-cord mesenchymal stem cells (UC-MSCs) and secretome.

MATERIALS AND METHODS

From 2016 to 2017, six patients with CPT who were treated by one senior pediatric orthopedic consultant at a single center (3 girls and 3 boys; mean age of 5.8 years) were included in this case series. A combined procedure including resection of hamartomatous fibrotic tissue, implantation of MSCs and secretome, and fixation using a locking plate and screws was performed. Patients were followed up for a mean of 29 months. Leg-length discrepancy, refracture rate, functional outcome, and radiological outcomes were assessed preoperatively, immediately postoperatively and at the final follow-up.

RESULT

Five out of 6 (83%) of the patients experienced primary union. One patient experienced refracture; however, 8 months later, after another implantation and reconstruction were performed, union eventually occurred. Significant functional improvement was achieved after at least 1 year of follow-up.

CONCLUSION

This case series suggests that the combination of secretome and UC-MSCs is a potential treatment for CPT, it highlights the efficacy of the combined procedure in treating CPT and in achieving satisfying results. A larger number of subjects and longer follow-up are required for further study.

The Outcome of Orthopedics Treatment of Lombok Earthquake Victim 2018: A Cohort of One-Year Follow-Up Study-Lesson Learned After Lombok Earthquake

Introduction

There was a magnitude 7 on the Richter scale earthquake on Lombok Island in 2018, causing more than 500 deaths. In the event of earthquakes, there is often an imbalance between overcrowding in hospitals and inadequate resources. The initial management of earthquake victims with musculoskeletal injuries is controversial, arguing over whether to utilize debridement, external or internal fixation, or conservative or operative treatment in an acute onset disaster situation. This study aims to determine the outcome of initial management after the 2018 Lombok earthquake, between immediate open-reduction and internal fixation (ORIF) and Non-ORIF procedures after one year follow-up.

Methods

This is a cohort study to evaluate radiological and clinical outcomes one year after orthopedic treatment in the Lombok earthquake 2018. The subjects were recruited from eight public health center and one hospital in Lombok in September 2019. We evaluate radiological outcomes (non/malunion and union) and clinical outcomes (infection and SF-36 score).

Results

Based on 73 subjects, the ORIF group has a higher union rate than the non-ORIF group (31.1% vs. 68.9%; p = 0.021). Incidence of infection only appeared in the ORIF group (23.5%). Clinical outcome as measured by SF36 showed the ORIF group had a lower mean of general health (p = 0.042) and health change (p = 0.039) clinical outcomes than the non-ORIF group.

Discussion

The most affected public group is the productive age with significant impact on social-economy. ORIF procedure is a major risk factor of infection in initial treatment after earthquake. Therefore, definitive operation with internal fixation is not recommended in the initial phase of a disaster. Damage Control Orthopedic (DCO) surgery protocol is the treatment of choice in acute disaster setting.

Conclusion

The ORIF group had better radiological outcomes than the non-ORIF group. However the ORIF group had higher cases of infection and lower SF-36 than the non-ORIF group. Definitive treatment in acute onset disaster setting should be prevented.

The management of pelvic ring fractures in low-resource environments: review

Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.

Management of pelvic ring fractures in limited resources country: a retrospective study

PURPOSE

Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country.

METHODS

We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient's management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score.

RESULTS

From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score.

CONCLUSION

The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment.

Double-bundle ACL reconstruction versus anatomic single-bundle ACL reconstruction combined with anterolateral ligament reconstruction: a comparative study of clinical outcome

INTRODUCTION

Recent studies showed increasing evidences of anterolateral ligament (ALL) reconstruction in conjunction with anterior cruciate ligament (ACL) reconstruction that proves to be more superior to the previous double-bundle (DB) ACLR technique especially in improving knee stability in biomechanic studies. However to date, there have been no studies evaluating the functional outcome of DB-ACLR vs single-bundle (SB) with ALL in ACLR.

METHODS

A total of 138 patients with ACL deficient knee were enrolled to the study. Double-bundle ACL reconstruction (DB-ACLR) was performed in 75 patients and single-bundle ACL reconstruction with anterolateral ligament reconstruction (SB + ALL) ACLR was performed in 63 patients. Surgical outcomes were compared with The International Knee Documentation Committee Subjective Knee Form (IKDC) and the Kujala score at the 3rd, 6th and 9th month post-operative.

RESULTS

The IKDC score in the 3rd and 6th month was superior in the SB + ALL group compared to the DB group. However, this difference was not statistically significant. In the meantime, there were no statistically significant difference between the Kujala Score at the 3rd, 6th, and 9th months consecutively. There were no statistically significant differences in the functional outcomes of DB-ACLR and SB + ALL groups at the 3rd, 6th, and 9th months post-operative period.

CONCLUSION

The functional outcome comparison showed non-superiority of SB + ALL group compared to the DB-ACLR group. The patellar pain was less found in DB-ACLR group at 6- and 9-months post-operative period.

Allogeneic umbilical cord mesenchymal stem cell conditioned medium (secretome) for treating posterior cruciate ligament rupture: a prospective single-arm study

BACKGROUND

Outcomes of the current management of posterior cruciate ligament (PCL) rupture are still unsatisfactory. Recent literature demonstrated the efficacy of the paracrine action of mesenchymal stem cells (MSC) in ligament rupture healing. This study aimed to evaluate the outcome of arthroscopic administration of allogeneic umbilical cord-derived MSC (UC-MSC) conditioned medium (secretome) for the treatment of PCL rupture.

PATIENTS AND METHODS

This is a prospective study including 12 individuals with PCL rupture grade 1 or 2 who were performed arthroscopy and secretome administrations. The functional and radiologic outcome of the knee was examined one year following intervention.

RESULTS

Preoperatively, posterior drawer test revealed three cases of grade 2+ and nine cases of grade 1+, whereas the final follow-up revealed two cases of grade 2+ and ten cases of grade 1+ PCL rupture. At final follow-up, the mean scores for the IKDC, modified Cincinnati, and Lysholm were 90.58 ± 4.30, 90.90 ± 2.15, and 89.42 ± 3.16, respectively. The means of the serial hop tests were 90.33, 94.16, 93.66, and 95.33 for single, triple, crossover, and time hop tests, respectively. Five patients were able to resume competitive sport after an average of 25.8 weeks (25-38). The final MRI analysis revealed that six knees (50%) regained PCL continuity with low signal intensity, five knees (41.6%) returned near-normal PCL continuity, and one knee (8.3%) regained PCL continuity but with deformed outlines.

CONCLUSIONS

Short-term follow-up indicated that the secretome generated from allogenic UC-MSC produces excellent functional and radiographic results in grade I-II PCL rupture.

The Banff Patellar Instability Instrument: validity and reliability of an Indonesian version

BACKGROUND

The Banff Patellar Instability Instrument (BPII) is a valuable scoring tool for assessing patellofemoral instability in patients suffering from patellofemoral pain syndrome (PFPS). The BPII 2.0 is a shortened version of the BPII. However, there is no Indonesian edition of BPII 2.0 that has been validated. This study aimed to determine the validity and reliability of the Indonesian version of the BPII 2.0.

MATERIALS AND METHODS

This was a cross-sectional study that used a forward-backward translation protocol to create an Indonesian version of the BPII 2.0. Thirty patients with PFPS were given the questionnaires. The questionnaire's validity was evaluated by analyzing the correlation between score of each subscale and the overall score to the Indonesian version of the Kujala score using Pearson correlation coefficient, while the reliability was evaluated by measuring the internal consistency (Cronbach α) and test-retest reliability (intraclass correlation coefficient).

RESULTS

The Indonesian version of BPII 2.0 and the Indonesian version of Kujala score had a strong Pearson correlation coefficient for construct validity. For all subscales, Cronbach α was 0.90-0.98, indicating adequate internal consistency. The test-retest reliability was high, with intraclass correlation coefficient ranging from 0.89 to 0.98 for all subscales. There was no difference in the Indonesian version of BPII 2.0 response between the first and second administration of the questionnaire which was taken 7 days afterward.

CONCLUSION

The Indonesian version of BPII 2.0 was determined to be valid and reliable and is therefore an objective instrument to evaluate patellofemoral instability in patients with PFPS in the Indonesian population.

Radiological Outcomes of Reduction Surgery for Degenerative Lumbar Spondylolisthesis Using Long Arm Pedicle Screws

Objective

Until now, the spondylolisthesis reduction technique has relied on posterior instrumentation using long arm pedicle screws. In this way, the segments will be brought into alignment with the other vertebrae with the pedicle mats being tightened. The aim of this study is to acknowledge whether reduction surgery for degenerative lumbar spondylolisthesis (DLS) using long arm pedicle screws is able to correct the listhesis and spinopelvic parameters.

Methods

We carried out a retrospective study of patients with degenerative lumbar spondylolisthesis who went through reduction surgery using long arm pedicle screws in our institutions from January 2019 to March 2022. Preoperative and postoperative radiological outcomes consisting of listhesis and spinopelvic parameters were assessed.

Results

We found a statistical difference between the magnitude of listhesis immediately after surgery and preoperatively (p<0.001), with a successful correction of 85.85%. There was significant decrease in the value of pelvic tilt (p=0.044) and increase in the value of sacral slope (p=0.008) after surgery.

Conclusion

Reduction surgery using long arm pedicle screws for DLS was able to reduce the listhesis effectively up to 85.5%, and also to restore the parts of spinopelvic parameters, the pelvic tilt and sacral slope, approaching normal values.

Oral L-arginine supplementation for fracture healing: a systematic review of preclinical studies

Introduction

Approximately 5 to 10% of all patients with fractures experience deficient fracture healing that results in fracture nonunions. Previous studies have shown that nitric oxide production from arginine could improve fracture healing by improving local blood supply, supplementing growth factors, and improving collagen synthesis. Apart from its simple oral mode of administration, this amino acid provides a non-toxic and inexpensive option for fracture healing. To date, no systematic reviews regarding oral L-arginine supplementation for fracture healing are available. We present the first systematic review of oral L-arginine supplementation for fracture healing.

Methods

A systematic literature search was carried out using PubMed, Google Scholar, and ScienceDirect until February 1, 2021 using a combination of text words. No date limits were set. Studies investigating the use of oral L-arginine supplementation for fracture healing were included. Reference lists of relevant publications were assessed for additional references. In addition, bibliographies from other reviews were searched.

Results

Four studies were included. Of these, 3 were animal studies, and the other one was an in vitro study. Animals that were given oral L-arginine supplementation had significantly increased angiogenesis, reduced defect area, higher osteoblasts and osteoclasts, and higher rate of bone formation compared to controls.

Conclusions

The available preclinical studies suggest that oral L-arginine supplementation is a potential new therapy for fracture healing. This amino acid supplement is not only affordable and non-toxic; it is also simple. Further clinical studies are required to investigate the optimal dose of oral L-arginine supplementation for fracture healing in human subjects.

A rare case of oxidized zirconium - All polyethylene tibia unicompartmental arthroplasty failure: A case report

Oxidized zirconium (Oxinium) implants has been claimed as the best material in terms of wear reduction. However, longevity of an all polyethylene uni knee arthroplasty (UKA) has been a long debate. We reported a rare case of 74 year old female who was performed all polyethylene UKA 6 years prior and fell 3 months prior. After the incident, patient was wheel-chair ridden afterwards. There was no evidence of fracture upon conventional radiography examination. Conversion of UKA to total knee replacement (TKA) was performed and patient was able to walk with aid after the surgery. The failed Oxinium all polyethylene UKA failure in this case is suspected due osteoarthritis progression.

The Effect of Secretome, Xenogenic Bone Marrow-Derived Mesenchymal Stem Cells, Bone Morphogenetic Protein-2, Hydroxyapatite Granule and Mechanical Fixation in Critical-Size Defects of Rat Models

BACKGROUND

Recent studies have shown that human bone marrow-derived mesenchymal stem cells (hBM-MSCs) have several drawbacks in treating critical-sized bone defect (CSD). Secretome may offer considerable advantages over living cells in terms of potency, manufacturing and storing easiness, and potential as a ready-to-go osteoinductive agent. However, thus far, there are no studies regarding the efficacy of secretome in bone healing. The objective of this study is to investigate the effect of the secretome in rat models with CSD.

METHODS

This was an experimental study with post-test only control group design using 60 skeletally mature Sprague Dawley rat which was divided evenly into 5 treatment groups (MSC only, Secretome only, MSC + Secretome, MSC + Secretome + BMP-2, Control group using Normal Saline). We used Bone Marrow derived MSC in this research. The critical-sized bone defect was created by performing osteotomy and defect was treated according to the groups. Rats were sacrificed on 2nd and 4th week and we measured the radiological outcome using Radiographic Union Score for Tibia (RUST) and histomorphometric (callus, osseous, cartilage, fibrous, and void area) evaluation using Image J.

RESULTS

There was no difference in the weight of rats between groups before and after the intervention. RUST score in all intervention group is significantly higher than the control group, however, the MSC-only group was not statistically significant higher than the control group. There is no statistically significant difference in RUST Score between intervention groups.Histomorphometric evaluation showed that total callus formation is the widest in the MSC+Secretome+BMP-2 combination group while the osseous area is found highest on the secretome-only group.

CONCLUSION

Secretome, whether used solely or combined with BM-MSC and BMP-2, is a novel, potent bone-healing agent for CSD in rat models.

The Role of Lateral Retinacular Release in Preventing Patellofemoral Malalignment in Double-Bundle Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Background

Loss of internal rotation stability is the major cause of pain after an anterior cruciate ligament reconstruction (ACLR). Many authors described measures to treat this problem to no avail. This is the first study evaluating the role of lateral release with double-bundle ACLR to prevent patellofemoral malalignment after ACLR.

Methods

A total of 100 patients were included in this prospective study between January 2018 and December 2019. We compared single-bundle ACLR (group 1, n = 30), double-bundle ACLR (group 2, n = 30), and double-bundle ACLR with lateral release (group 3, n = 40). Clinical outcome was evaluated with the Kujala score while radiological outcome was evaluated using the tibial tubercle-trochlear groove (TTTG) distance in magnetic resonance imaging. The preoperative and postoperative values were compared.

Results

At the final follow-up of 6–18 months, group 3 showed the lowest TTTG value (6.7 ± 4.69) compared to group 2 (9.1 ± 4.83) and group 1 (11.74 ± 1.76) (p = 0.03). The Kujala score was significantly improved in all groups: from 68.83 to 89.90 in group 1, from 70.02 to 91.23 in group 2, and from 69.71 to 95.05 in group 3 (p = 0.03). Group 3 showed the most superior improvement in the Kujala score (25.34) compare to group 1 (21.07) and group 3 (21.21) (p = 0.012).

Conclusions

Concomitant lateral retinacular release significantly improved the Kujala score. It may serve as a valuable option to overcome patellofemoral pain syndrome in ACLR.

Effectiveness of Kyphosis Reduction Using Cantilever Method in Thoracolumbar Spondylitis Tuberculosis: A Short-Term Follow-Up

Background

Kyphosis in spondylitis tuberculosis (STb) is more than just a cosmetic issue. It has a potentially detrimental effect on both spine-associated structures and cardiopulmonary function. It can be corrected in any stage of STb; however, the corrective surgery is challenging, especially in the late case, in which the additional stiffness of the spine can come into consideration. To date, the cantilever technique is still a gold standard for sagittal plane deformity correction. However, no study to date has explored its effectiveness for thoracolumbar kyphotic deformity, especially that caused by spondylitis tuberculosis.

Methods

This is a retrospective study of 16 consecutive cases of spondylitis tuberculosis with thoracolumbar kyphosis that underwent corrective surgery in our center in the period of 2020–2021. We aim to evaluate the effectiveness of the cantilever technique that we use for kyphotic correction in thoracolumbar STb patients.

Results

At the 3-months follow-up, the mean Cobb angle was 14.6°±10.27°, with the mean gain of 20.90°±12.00° and positively correlate with the thoracolumbar kyphosis (TLK) correction (68.69%, r = 0.654, p = 0.001). The mean thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis were 30.6°±13.08°, 39.4°±16.02°, and 1.4±4.09 cm, respectively, with sagittal Cobb difference of 12.70±9.85.

Conclusion

The kyphotic Cobb angle reduction by cantilever technique in the thoracolumbar area significantly improved the thoracolumbar kyphosis and realign the spinal sagittal axis. Thus, the cantilever technique remains the gold standard for sagittal plane deformity correction which can be applied for kyphotic deformity correction in thoracolumbar STb cases.

Evaluation of patellar dimension and Bristol Index in Asian population: An MRI study

Background

Restoration of patellar thickness is pivotal during a total knee arthroplasty (TKA). Several studies showed there are differences in the knee measurements between Asian and Western population.

Purpose

This study aims to evaluate the patellar dimension and Bristol Index of patellar width to thickness (BIPWiT) using magnetic resonance imaging (MRI) in Asian population.

Study design

This is a descriptive epidemiology study.

Methods

101 MRI scans of young adult patients with normal patellofemoral joint (PFJ) age 17-40 were evaluated from January 2019 to December 2020. Exclusion criteria included patella-femoral pathology and degenerative joint disease. Data of gender, body height and weight were obtained from physical examination, while patella height, width and thickness were obtained using MRI measurement. Descriptive analysis was used to get the mean and standard deviation of patella dimension, whereas correlation between patella thickness with patella width and length were analyzed using Pearson correlation and BIPWiT ratio was obtained by dividing the patellar width and patellar thickness.

Results

Mean patellar length was 30.06 ± 2.94 (29.48-30.64); patellar width was 44.13 ± 4.44 (43.26-45.01); and patellar thickness was 23.89 ± 2.33 (23.43-24.35). Patellar dimension in male were significantly larger compared to female (P < 0.001). However, there was no difference in cartilage thickness between male and female (P = 0.305). There was strong correlation between patellar width and patellar thickness (r = 0.66; P < 0.001) with BIPWiT ratio of 1.85 ± 0.15.

Conclusion

BIPWiT of 1.8:1 between patellar width and patellar thickness was recommended as a guide for patellar thickness restoration during TKA. There is no difference of patellar dimension between Asian and Western population in a healthy knee.

Clinical relevance

The result of BIPWiT ratio found in this study may aid upon pre-operative planning prior TKA for surgeons in order to achieve optimal patellar thickness and avoid patellofemoral problem.

What is known about the subject

Currently there are raising concerns about the different sizes of knee measurements between Asian and Western population which will affect techniques during TKA to achieve optimum result.

What this study adds to the existing knowledge

This study not only prove that there is no difference between patellar dimension of Asian and Caucasian but also found a similar BIPWiT ratio for patellar resection during TKA with previous literature.

Level of evidence

Level III.

Sacrum morphometry and spinopelvic parameters among the Indonesian population using computed tomography scans

This is a cross-sectional study. This study aims to describe the characteristics of sacrum vertebrae and spinopelvic parameters among the Indonesian population and compare them with studies from other populations. This study also intends to determine the sexual dimorphism of sacrum vertebrae and find the correlations between spinopelvic parameters.Morphometry of the sacrum is necessary for designing sacral prosthesis and instrumentations. Knowledge of spinopelvic parameters further supports the prosthesis installation procedure to restore the physiological spinal alignment of the patients. However, previous studies showed varied results among different populations. This is the first study to be conducted among the Indonesian population.Morphometric dimensions of sacrum vertebrae and the spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis) were analyzed using thin-cut (1 mm) computed tomography images in 150 males and 150 females, aged 25 to 50 years without any spinal pathology.Generally, the size of the sacrum vertebrae was greater in males (P < .05). The sacral index, curvature index, and corporo-basal index were statistically different between genders (P < .001). Lumbar lordosis was the only spinopelvic parameter found significantly greater in females (P < .001). Significant positive correlations between all spinopelvic parameters, except for lumbar lordosis and pelvic tilt, were found in the present study (P < .001).The study serves as the first large series database of sacrum morphometric characteristics and spinopelvic parameters of the Indonesian population. There was significant gender-associated differences in various dimensions of sacrum vertebrae. The sacral index was found to be the most useful parameter for sex determination. There were strong significant positive correlations between various spinopelvic parameters. A comparison of populations revealed morphometric characteristic differences, which is proved to be critical in surgical implications.

Cross-cultural adaptation and psychometric validation of the Indonesian version of the Oxford Hip Score

Aims

The aim of this study was to perform a cross-cultural adaptation of Oxford Hip Score (OHS) to Indonesian, and to evaluate its psychometric properties.

Methods

We performed a cross-cultural adaptation of Oxford Hip Score into Indonesian language (OHS-ID) and determined its internal consistency, test-retest reliability, measurement error, floor-ceiling effect, responsiveness, and construct validity by hypotheses testing of its correlation with Harris Hip Score (HHS), vsual analogue scale (VAS), and Short Form-36 (SF-36). Adults (> 17 years old) with chronic hip pain (osteoarthritis or osteonecrosis) were included.

Results

A total of 125 patients were included, including 50 total hip arthroplasty (THA) patients with six months follow-up. The OHS questionnaire was translated into Indonesian and showed good internal consistency (Cronbach’s alpha = 0.89) and good reliability (intraclass correlation = 0.98). The standard error of measurement value of 2.11 resulted in minimal detectable change score of 5.8. Ten out of ten (100%) a priori hypotheses were met, confirming the construct validity. A strong correlation was found with two subscales of SF-36 (pain and physical function), HHS (0.94), and VAS (-0.83). OHS-ID also showed good responsiveness for post-THA series. Floor and ceiling effect was not found.

Conclusion

The Indonesian version of OHS showed similar reliability and validity with the original OHS. This questionnaire will be suitable to assess chronic hip pain in Indonesian-speaking patients.

Cite this article: Bone Jt Open 2021;2(9):765–772.

Histological Analysis of Bone Callus in Delayed Union Model Fracture Healing Stimulated with Pulsed Electromagnetic Fields (PEMF)

Delayed union and nonunion fractures are clinical challenges for orthopedic surgeons. The development of fracture complications, such as delayed union and nonunion fractures, is still difficult to predict. Various methods are being investigated to improve fracture healing and prevent complications in patients. There are various methods to promote fracture healing, broadly divided into biological, chemical, and physical methods. One of the most widely used physical methods to promote fracture healing is the pulsed electromagnetic field (PEMF). This study aimed to evaluate the healing process of delayed union fracture after being stimulated by PEMF. Twenty-four rats were randomly divided into two groups: the control group (n = 12) and the PEMF group (n = 12). Delayed union fracture was performed on the left femur of all rats. Subsequently, the PEMF group was given PEMF stimulus with a magnetic field intensity of 1.6 mT and a frequency of 50 Hz for 4 hours/day and 7 days/week. The fracture healing process was evaluated on days 5, 10, 18, and 28 based on the bone callus histology using safranin O fast green (SOFG) staining. The results of the histological analysis showed that bone cartilage was higher in the PEMF group than in the control group throughout the observation period. In addition, the PEMF group had less fibrous tissue at the beginning of the healing. This finding indicates PEMF stimulation has an effect on inducing osteogenesis on fracture healing and reducing the risk of delayed union.

Management of Complex Pelvic Fracture with Associated Both Column Acetabular Fracture Judet-Letournel Type and a Coccygeal Fracture in a Severe Polytrauma Patient

Comprehensive emergency managements and early stabilization are pivotal upon treating complex pelvic and acetabular fractures. A thorough operative strategy is required to determine the best operative approach based on the patient’s general condition, available facilities, and surgeon preferences in such complex fracture configuration. Advanced technique of the fixation is necessary during a skillful execution of surgery in order to achieve good treatment results. An 18-years-old female crushed by a bus upon crossing street, presented with hypovolemic shock with ISS polytrauma score 50 consisting of right acetabular associated both column fracture, bilateral pelvic fracture anteroposterior compression type 3, and coccygeal fracture with bilateral drop foot. She underwent emergency laparotomy, had her ovary, bladder, and intestine primarily sutured, and then we immobilized the pelvic using anterior frame external fixator, which was maintained for 6 days. Upon stable condition, we performed right ilioinguinal approach and modified Stoppa with lateral window for the left side, while Kocher-Langenbeck technique was used to approach the posterior acetabular column. Postoperative radiology showed an adequate internal fixation in both right acetabular columns, successful reconstruction of pelvic ring which was fixated the left ischium, left superior and inferior pubic rami, and full restoration of left sacroiliac joint disruption. Majeed pelvic outcome score was 54, while Hannover pelvic outcome score was good and the patient was able to sit without pain 2 months postoperative. Management of complex pelvic-acetabular-coccygeal fracture requires a holistic chain of treatment by emphasizing the prompt emergency management, accurate preoperative planning, and excellent execution of reconstructive surgical strategy to achieve satisfactory outcome.

Umbilical cord mesenchymal stromal cells as critical COVID-19 adjuvant therapy: A randomized controlled trial

One of the main causes of acute respiratory distress syndrome in coronavirus disease 2019 (COVID-19) is cytokine storm, although the exact cause is still unknown. Umbilical cord mesenchymal stromal cells (UC-MSCs) influence proinflammatory T-helper 2 (Th₂ ) cells to shift to an anti-inflammatory agent. To investigate efficacy of UC-MSC administration as adjuvant therapy in critically ill patients with COVID-19, we conducted a double-blind, multicentered, randomized controlled trial at four COVID-19 referral hospitals in Jakarta, Indonesia. This study included 40 randomly allocated critically ill patients with COVID-19; 20 patients received an intravenous infusion of 1 × 10⁶ /kg body weight UC-MSCs in 100 ml saline (0.9%) solution (SS) and 20 patients received 100 ml 0.9% SS as the control group. All patients received standard therapy. The primary outcome was measured by survival rate and/or length of ventilator usage. The secondary outcome was measured by clinical and laboratory improvement, with serious adverse events. Our study showed the survival rate in the UC-MSCs group was 2.5 times higher than that in the control group (P = .047), which is 10 patients and 4 patients in the UC-MSCs and control groups, respectively. In patients with comorbidities, UC-MSC administration increased the survival rate by 4.5 times compared with controls. The length of stay in the intensive care unit and ventilator usage were not statistically significant, and no adverse events were reported. The application of infusion UC-MSCs significantly decreased interleukin 6 in the recovered patients (P = .023). Therefore, application of intravenous UC-MSCs as adjuvant treatment for critically ill patients with COVID-19 increases the survival rate by modulating the immune system toward an anti-inflammatory state.

Core Decompression and Biological Treatment in Osteonecrosis of the Hip due to Systemic Lupus Erythematosus, 8-year Follow-up: A Case Report

BACKGROUND: Osteonecrosis most commonly affects the femoral head, especially in middle-aged adults. It can be caused by trauma, chronic inflammation, or infection. It leads to collapse of the entire femoral head and culminates with total hip replacement. CASE REPORT: A 29-year-old female with systemic lupus erythematosus (SLE) had a chief complaint of bilateral hip pain. She was diagnosed with early osteonecrosis of the femoral head (FICAT stage II) using magnetic resonance imaging and core decompression surgery was performed using three small diameter (4 mm) drillings and added biological treatment. She was evaluated with a visual analog scale (VAS), Harris hip score (HHS), and plain radiography in the pre-operative stage and post-operative follow-up. RESULTS: Functional outcome at 8-year follow-up showed improvement with significantly decreased VAS (pre-operative: 5, post-operative: 0), significant improvement of HHS from 52.725 points (poor) pre-operative to 92.025 points (excellent) post-operative, and subsided femoral head lesion. CONCLUSIONS: Surgical decompression and biological treatment result in decreased intraosseous pressure and enhanced osteogenesis. It can restrict the SLE disease progression and limit the number of cell death.

The role of angioembolization and C-clamp fixation: Damaged control orthopaedic in haemodynamically unstable pelvic fracture

INTRODUCTION

Unstable pelvic fracture may emerge to major bleeding complication. Angioembolization is one of method to stop the bleeding effectively. This case series aims to analyze whether the bleeding of unstable pelvic fracture is managed by angioembolization to achieve the better functional outcome.

PRESENTATION OF CASE

Three cases of haemodynamically unstable pelvic fracture were studied retrospectively and prospectively. A staged approach using damage control orthopaedic surgery was performed. Initial resuscitation began from fluid resuscitation, pelvic wrapping using binder. All patients followed with pelvic external fixation, while 2 patients immediately replaced binder to C-Clamp, and 1 patient with anterior frame. Angioembolization was done to all patients. All patients required definitive internal fixation, while only 2 patients reach the definitive surgery. Finally, we measured the functional outcome of all patients using Hannover Pelvic score, Majeed pelvic score, and Iowa Pelvic score.

DISCUSSION

We review some literatures regarding pelvic angioembolization. The previous study suggested to resuscitate patients when the hemodynamic is unstable, the angioembolization procedure is still preferred. The indication and successful definition of this procedure is still unclear, yet it shows decrease of mortality rate of pelvic injury if this procedure starts ahead a schedule.

CONCLUSION

Angioembolization as a part of damaged control orthopaedic has been shown a favorable result in managing unstable pelvic injury.

Clinical Application Prospect of Human Synovial Tissue Stem Cells from Osteoarthritis Grade IV Patients in Cartilage Regeneration

Osteoarthritis (OA) is a joint problem that continues to increase in prevalence as life expectancy increases. OA can affect any joint, especially those that support body weight such as the knee and hip joint. Although both primary and secondary OA have the same clinical symptoms, it can be caused by different etiologies. OA is no longer considered a degenerative disease, although age is still a major factor. Various attempts have been made to regenerate joint cartilage damaged by OA. The use of stem cells in OA therapy is a very promising opportunity. Stem cells are undifferentiated biological cells and are multipotent to differentiate into specific cells. In principle, local stem cells are the best source of stem cells to regenerate the surrounding tissue. The synovial membrane is a tissue in the joint that can regenerate. After synovectomy surgery, repair, and growth of synovial tissue occur rapidly. Synovial tissue as a source of stem cells only provides a limited amount. One source of synovial tissue that can be used is tissue taken from the total knee replacement process in grade 4 OA patients. However, it is necessary to prove the potential of synovial tissue stem cells originating from old-age donors.

Meniscal bearing dislocation following minimally invasive Oxford medial unicompartmental knee arthroplasty treated with simple open reduction: Case report

INTRODUCTION

Dislocation of polyethylene insert is one of the most common complications of mobile bearing-medial unicompartmental knee arthroplasty (MUKA). Bearing dislocation was diagnosed by radiograph examination in these cases upon trivial injury.

CASE PRESENTATION

We reported one case of meniscal bearing dislocation after an Oxford MUKA treated with a simple open reduction technique.

CLINICAL DISCUSSION

Simple open reduction surgery without change of the bearing and the use of knee brace for 6 months was effective in preventing re-dislocation.

CONCLUSION

Mobile bearing dislocation is one of the most common complications in mobile-bearing MUKA. Besides the prevention of technical errors, usage of UKA with a frequency of 10-15 per year is recommended to increase the surgeon's learning curve.

Emergency orthopaedic surgery in the pandemic era: A case series at Cipto Mangunkusumo national tertiary hospital in Jakarta, Indonesia

INTRODUCTION

Every emergency surgery performed is aimed at saving lives; however, during COVID-19 pandemic, surgeries are often postponed. Many existing recommendations take into account postponing surgery during a pandemic. How these surgeries can lead to increasing infection rates has not been widely published. This study aims to investigate the relationship of emergency orthopaedic surgery and the incidence rate of COVID-19.

PRESENTATION OF CASE

This was a case series of 14 patients. The study was performed at the emergency department unit at a national tertiary hospital in Jakarta, Indonesia. A total of 14 patients underwent orthopaedic surgery in the emergency room of our institution. The mean age of the subjects was 40.07 ± 20.5 years. Twelve (85.7%) were male patients and 2 (14.3%) were female patients. The average duration of surgery was 125 minutes. The most used type of anaesthesia was general anaesthesia for 6 operations (50%). Patients were hospitalized for an average length of 4 days. Three patients had infiltrates found on plain x-ray examination, which required further examination to determine whether the cause was COVID-19 infection or not. There was no ground glass appearance (GGO) in the three patients in further follow-up examination.

CONCLUSIONS

We found that emergency orthopaedic surgery was not associated with increasing number of COVID-19 cases. Factors including duration of surgery, length of stay, types of anaesthesia and comorbidities were also not associated with COVID-19 cases in this study.

Enhancement of the Therapeutic Capacity of Mesenchymal Stem Cells by Genetic Modification: A Systematic Review

Background

The therapeutic capacity of mesenchymal stem cells (also known as mesenchymal stromal cells/MSCs) depends on their ability to respond to the need of the damaged tissue by secreting beneficial paracrine factors. MSCs can be genetically engineered to express certain beneficial factors. The aim of this systematic review is to compile and analyze published scientific literatures that report the use of engineered MSCs for the treatment of various diseases/conditions, to discuss the mechanisms of action, and to assess the efficacy of engineered MSC treatment.

Methods

We retrieved all published studies in PubMed/MEDLINE and Cochrane Library on July 27, 2019, without time restriction using the following keywords: “engineered MSC” and “therapy” or “manipulated MSC” and “therapy.” In addition, relevant articles that were found during full text search were added. We identified 85 articles that were reviewed in this paper.

Results

Of the 85 articles reviewed, 51 studies reported the use of engineered MSCs to treat tumor/cancer/malignancy/metastasis, whereas the other 34 studies tested engineered MSCs in treating non-tumor conditions. Most of the studies reported the use of MSCs in animal models, with only one study reporting a trial in human subjects. Thirty nine studies showed that the expression of beneficial paracrine factors would significantly enhance the therapeutic effects of the MSCs, whereas thirty three studies showed moderate effects, and one study in humans reported no effect. The mechanisms of action for MSC-based cancer treatment include the expression of “suicide genes,” induction of tumor cell apoptosis, and delivery of cytokines to induce an immune response against cancer cells. In the context of the treatment of non-cancerous diseases, the mechanism described in the reviewed papers included the expression of angiogenic, osteogenic, and growth factors.

Conclusion

The therapeutic capacity of MSCs can be enhanced by inducing the expression of certain paracrine factors by genetic modification. Genetically engineered MSCs have been used successfully in various animal models of diseases. However, the results should be interpreted cautiously because animal models might not perfectly represent real human diseases. Therefore, further studies are needed to explore the translational potential of genetically engineered MSCs.

Allogeneic umbilical cord-derived mesenchymal stem cells for treating critical-sized bone defects: a translational study

INTRODUCTION

The current 'gold-standard' treatment of critical-sized bone defects (CSBDs) is autografts; however, they have drawbacks including lack of massive bone source donor site morbidity, incomplete remodeling, and the risk of infection. One potential treatment for treating CSBDs is bone marrow-derived mesenchymal stem cells (BM-MSCs). Previously, there were no studies regarding the use of human umbilical cord-mesenchymal stem cells (hUC-MSCs) for treating BDs. We aim to investigate the use of allogeneic hUC-MSCs for treating CSBDs.

METHOD

We included subjects who were diagnosed with non-union fracture with CSBDs who agreed to undergo hUC-MSCs implantation. All patients were given allogeneic hUC-MSCs. All MSCs were obtained and cultured using the multiple-harvest explant method. Subjects were evaluated functionally using the Lower Extremity Functional Scale (LEFS) and radiologically by volume defect reduction.

RESULT

A total of seven (3 male, 4 female) subjects were recruited for this study. The subjects age ranged from 14 to 62 years. All seven subjects had increased LEFS during the end of the follow-up period, indicating improved functional ability. The follow-up period ranged from 12 to 36 months. One subject had wound dehiscence and infection, and two subjects developed partial union.

CONCLUSION

Umbilical cord mesenchymal stem cells are a potential new treatment for CSBDs. Additional studies with larger samples and control groups are required to further investigate the safety and efficacy of umbilical cord-derived mesenchymal stem cells for treating CSBDs.

Functional and Radiological Comparison of Umbilical Cord Mesenchymal Stem Cells, Somatotropin, and Hyaluronic Acid Injection for Cartilage Repair in Early Osteoarthritis of the Knee: A Randomized Controlled Trial

The umbilical cord-mesenchymal stem cells (UC-MSC) has been shown to improve the viability of degenerated chondrocytes in knee osteoarthritis (KOA) in cellular level. Additional somatotropin injection also shown clinical improvement in patients. The present trial is conducted to assess the efficacy of umbilical cord mesenchymal stem cells (UC-MSC) in comparison to somatotropin and hyaluronic acid (HA) injection to treat and slow the progression of knee osteoarthritis.

Management of recurrent hip dislocation in Down Syndrome using modified Ganz periacetabular osteotomy: Follow up after 5 years

Recurrent hip dislocation in a Down Syndrome patient with dysplastic hip is a very rare and challenging case to treat even for an expert orthopaedic hip surgeon. Least compliant patient and family, lowly educated with low socioeconomic status, young age and several anatomical variations forces limited option as a treatment. Several literatures mentioned Despite requiring only minimal implant, this technically demanding surgery requires a thorough understanding of the hip anatomy. This is the first case worldwide reporting 5 year follow up of dysplastic hip with DS treated successfully with periacetabular osteotomy (PAO) technique. An eighteen years old female with DS had multiple posterior hip dislocation episodes since 3 years prior our hospital admission. A modified Ganz PAO was performed under image intensifier guide. Patient was able to talk and hip was never dislocated again within 5 years follow up. Ganz periacetabular osteotomy, although a technically demanding surgery, is a preferable treatment in recurrent hip dislocation for Down Syndrome patient with good to excellent clinical and radiological outcome.

Posterior dislocation of left hip joint with closed fracture of left acetabulum Judet-Letournel type posterior wall, femoral head fracture, management and follow up: A case report

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Hip dislocation combines with femoral head fracture, and acetabular fracture is complex and rare case.

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The complication of operative reduction is avascular necrosis.

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Failed of closed reduction or instability of hip joint are indications to perform open reduction and internal fixation.

Introduction

Traumatic dislocation of the hip is a very severe injury. Posterior hip dislocation can be associated with acetabular fracture, which can ultimately result in a higher incidence of complications.

Case presentation

We present a case report of 26-year-old men with a motor vehicle accident and suffered a posterior hip dislocation on left hip joint and acetabular fracture with Judet-Letournel type posterior wall and femoral head fracture. This patient was performed closed reduction, however, due to dynamic instability of hip joint, internal Fixation through Kocher Langenback Approach and insertion of Herbert screws for femoral head and acetabular posterior wall fracture and interfragmentary screw for trochanteric osteotomy. The patient was followed up for 2 years and have a painless hip with full hip range of motion.

Discussion

Posterior wall acetabular fractures sometimes occurs after posterior dislocation of the hip. Posterior wall fragment of the acetabular wall fracture can compromise the stability of the hip joint. The reduction can be maintained by closed means or by operative reduction if there is an obstacle to performed closed reduction or followed by sciatic nerve palsy after closed reduction. The complication of operative reduction is avascular necrosis which compromises the integrity of the femoral head and contributing to posttraumatic osteoarthritis.

Conclusion

Careful examination of acetabular fracture in posterior hip dislocation is required and failed of closed reduction or instability of hip joint are indications to perform open reduction and internal fixation.

Teriparatide for treating delayed union and nonunion: A systematic review

INTRODUCTION

Fracture nonunion remains a great challenge for orthopaedic surgeons. Approximately 5-10% of bone fractures do not heal promptly, and require another surgical procedure. Previously, several small studies have found that teriparatide, a parathyroid hormone (PTH) analogue, has been found to induce union in those with delayed union and nonunion. However, to date, no systematic reviews regarding the use of teriparatide for delayed union and nonunion are available. The present review aims to investigate the safety and efficacy of teriparatide in delayed union and nonunion.

METHODS

Systematic literature search was performed in PubMed, ScienceDirect, and Google Scholar until September 26, 2019. We included studies involving adult patients (age >16 years) diagnosed with delayed union or nonunion fracture regardless of location (long bone, short bone, flat bone or irregular bone). The language was restricted to English and Indonesian. Outcomes that were recorded were fracture union and adverse events.

RESULTS

Initial search found 5416 abstract and titles. Of these, 20 articles consisting of 64 subjects were retrieved. Of these, 15 case reports, 4 case series, and one prospective study were included. All of the studies administered subcutaneous injection of teriparatide 20 μg/day with mean duration of 7.3 ± 1.5 weeks to 9.7 months. Sixty-one (95.3%) of 64 subjects developed complete union. The follow-up ranged from 3 to 24 months. No side effects occurred during the follow-up period.

CONCLUSIONS

Limited evidence demonstrates that daily subcutaneous injection of teriparatide 20 μg is a potential new safe treatment for delayed union and nonunion with no side effects. We highly suggest the use of such drug, as it is highly effective and safe. However, further clinical studies are required to investigate its safety and efficacy.

Umbilical cord-derived mesenchymal stem cells for treating osteoarthritis of the knee: a single-arm, open-label study

BACKGROUND

Despite being a common cause of quality-of-life impairment, there are no efficacious therapies that could prevent the progression of knee osteoarthritis (KOA). We conducted an open-label trial of human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) and hyaluronic acid (HA) for treating KOA.

METHODS

This open-label study was conducted from July 2015 to December 2018 at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Patients diagnosed with KOA were injected three times, comprising of 10 × 106 units of hUC-MSCs in 2-ml secretome implantation and 2-ml hyaluronic acid (HA) injection in the first week, followed with 2-ml HA injection twice in the second and third week.

RESULTS

Twenty-nine subjects (57 knees) were recruited. Seventeen (58.6%) subjects were male, and the mean age was 58.3 ± 9.6 years. Thirty-three (57.9%) knees were classified into Kellgren-Lawrence grade I-II KOA (mild OA). hUC-MSCs significantly decreased pain measured by visual analogue scale in severe KOA from initial to 6th month follow-up [5 ± 2.97 to 3.38 ± 2.44 (p = 0.035)]. The International Knee Documentation Committee score significantly increased at 6th month follow-up (53.26 ± 16.66 to 65.49 ± 13.01, p < 0.001, in subjects with grade I-II and 48.84 ± 18.41 to 61.83 ± 18.83, p = 0.008, in subjects with severe KOA). The Western Ontario and McMaster Universities Osteoarthritis decreased significantly in both groups from initial to 6th month follow-up (from 22.55 ± 15.94 to 13.23 ± 10.29, p = 0.003, and from 27.57 ± 15.99 to 17.92 ± 19.1, p = 0.003, in those with mild and severe KOA, respectively).

CONCLUSIONS

hUC-MSCs could be a potentially new regenerative treatment for KOA. The maximum effect of hUC-MSCs was achieved after 6 months of injection.

LEVEL OF EVIDENCE

Therapeutic level II.

Autologous mesenchymal stem cell implantation, hydroxyapatite, bone morphogenetic protein-2, and internal fixation for treating critical-sized defects: a translational study

INTRODUCTION

Critical-sized defect (CSD) is one of the most challenging cases for orthopaedic surgeons. We aim to explore the therapeutic potential of the combination of bone marrow-derived mesenchymal stem cells (BM-MSCs), hydroxyapatite (HA) granules, bone morphogenetic protein-2 (BMP-2), and internal fixation for treating CSDs.

METHODS

This was a translational study performed during the period of January 2012 to 2016. Subjects were patients diagnosed with CSDs who had previously failed surgical attempts. They were treated with the combination of autologous BM-MSCs, HA granules, BMP-2, and mechanical stabilization. Post-operative pain level, functional outcome, defect volume, and radiological healing were evaluated after a minimum follow-up of 12 months.

RESULTS

A total of six subjects were recruited in this study. The pain was significantly reduced in all cases; with the decrease of mean preoperative visual analog scale (VAS) from 4 ± 2.2 to 0 after six month follow-up. Clinical functional outcome percentage increased significantly from 25 ± 13.7 to 70.79 ± 19.5. Radiological healing assessment using Tiedemann score also showed an increase from 0.16 ± 0.4 to 8 ± 3 at one year follow-up. No immunologic nor neoplastic side effects were found.

CONCLUSIONS

The combination of autologous BM-MSCs, HA granules, and BMP-2 is safe and remains to be a good option for the definitive treatment for CSD with previous failed surgical attempts. Further studies with a larger sample size are required to be done.

Evaluation of bone marrow-derived mesenchymal stem cell quality from patients with congenital pseudoarthrosis of the tibia

Background

The treatment of congenital pseudoarthrosis of the tibia (CPT) remains challenging in pediatric orthopedics due to the difficulties in bone union, continuous angulation, joint stiffness, and severe limb length discrepancy. Mesenchymal stem cells (MSCs) therapy offers a complementary approach to improve the conventional surgical treatments. Although the autologous MSC treatment shows a promising strategy to promote bone healing in CPT patients, the quality of MSCs from CPT patients has not been well studied. The purpose of this study is to investigate the quality of MSCs isolated from patients with CPT.

Methods

The bone marrow-derived MSCs from the fracture site and iliac crest of six CPT patients were isolated and compared. The cumulative population doubling level (cPDL), phenotype characteristics, and trilineage differentiation potency were observed to assess the quality of both MSCs.

Results

There were no significant differences of the MSCs derived from the fracture site and the MSCs from the iliac crest of the subjects, in terms of cPDL, phenotype characteristics, and trilineage differentiation potency (all p > 0.05). However, MSCs from the fracture site had a higher senescence tendency than those from the iliac crest.

Conclusion

MSC quality is not the main reason for delayed bone regeneration in those with CPT. Thus, autologous MSC is a promising source for treating CPT patients

Neglected acetabular fracture: Fix or replace?

INTRODUCTION

Operative treatment of acute acetabular fractures has shown better results than the non-operative approach. There is, however, limited data regarding the operative treatment of neglected acetabular fracture.

METHODS

We present six subjects with neglected fracture of the acetabulum in Cipto Mangunkusumo National Hospital, Jakarta, Indonesia. One had only open reduction and internal fixation, three had open reduction and internal fixation first before we performed arthroplasty later, one had both open reduction and internal fixation with arthroplasty, and another had immediate arthroplasty.

RESULTS

Our subjects were 4 males and 2 females with the average age of 41.1 years and the average neglect period was 18 months. In four of our subjects, the fractures had posterior wall involvement, one had an anterior column-posterior hemitransverse fracture, and the last one had transverse fracture. All fractures were classified to either Elementary or Associated type according to the Letournel classification. We observed all subjects up to eighteen months post-operatively. One subject had poor outcome, four subjects had fair outcome, and one subject had excellent outcome according to the Harris Hip Score.

CONCLUSION

Even in neglected acetabular fracture, open reduction and internal fixation where possible should be attempted to restore the anatomical relationship to facilitate immediate or late total hip arthroplasty. Surgical treatment of such fractures should be based on individual case characteristics, which includes age, associated comorbidity, neglect period, as well as the type and union state of the fracture for a better outcome. Neglected Associated acetabular fracture types are more difficult to reduce and have poorer outcome compared to Elementary types. Likewise, malunited acetabular fractures are more difficult to operate on than non-united neglected acetabular fractures, where reduction is relatively easier.

Modified Masquelet technique using allogeneic umbilical cord-derived mesenchymal stem cells for infected non-union femoral shaft fracture with a 12 cm bone defect: A case report

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A case of infected non-union fracture with critical-sized bone defect.

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Modified Masquelet technique was used to overcome the defect.

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The addition of allogenic UC-MSCs, BMP-2 and hydroxyapatite encourages healing.

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This technique may serve as an effective way to overcome large defects.

Introduction

Non-union due to large bone loss often causes significant long-term morbidity. We incorporate the use of allogeneic umbilical cord-derived mesenchymal stem cells (UC-MSCs) as part of the diamond concept of regenerative medicine in a case of infected non-union fracture.

Presentation of case

We reported a 54-year-old female patient presenting with pain on the right thigh. She was previously diagnosed with a closed fracture of the right femoral shaft and underwent four surgeries before finally being referred to Dr. Cipto Mangunkusumo General Hospital with infected non-union of the right femoral shaft. The patient was treated with a combination of UC-MSCs, bone morphogenetic protein-2 (BMP-2), Hydroxyapatite (HA), and mechanical stabilization using Masquelet Technique. The combination of allogeneic MSCs, BMP2, HA, and Masquelet Technique was successful in creating new bone with no apparent side effects.

Discussion

Bone loss might be caused by external factors (true defects), or structural loss of the existing bone. The combination of allogeneic UC-MSCs, BMP-2, HA and an induced membrane technique pioneered by Masquelet allowed for faster regeneration process and more optimal bone healing. This paper aims to assess and compare the result of such procedures with the previous four surgeries done to the patient, which did not yield satisfactory results.

Conclusion

The application of allogeneic UC-MSC, BMP-2, HA and Masquelet technique as proposed in the diamond concept is a viable method in treating critical-sized bone defect and provides an effective way to overcome non-union caused by large defect.

Internal fixation of S1-S3 iliosacral screws and pubic screw as the best configuration for unstable pelvic fracture with unilateral vertical sacral fracture (AO type C1.3)

BACKGROUND

Although internal fixation is the definitive treatment in unstable pelvic fractures with disruption of the anterior arch and a vertical fracture of the sacrum (AO type C1.3), there have been no agreement of the best technique of internal fixation yet. We aimed to derive comparable objective data on stiffness and load to failure in this type of fracture fixations.

METHODS

Synbone was modified into AO type C1.3 fracture model, while treatments were divided into six internal fixation treatment groups using tension band plate (TBP), symphysis pubis plate (SP) with iliosacral screw at S1 and S2 (IS S1-S2), pubic screw (PS) with iliosacral TBP, PS and IS S1-S2, SP and IS S1-S3, PS and S1-S3 and finally PS and IS S1-S3. Sensor was applied to detect the shifting and rotation of fracture fragments. Mechanical strength test conducted with the application of axial force on the sacrum vertebra (S1).

RESULTS

The highest translational stiffness was observed in the group IS S1-S3 + PS (830.36 N/mm, p = 0.031) and there was no difference on the rigidity of the rotation between the groups posterior fixation using IS S1-S2 and IS S1-S3 ( p = 0.51). Meanwhile the highest load to failure was found in group IS S1-S3 + PS (1522.20 N). PS provided advantages compared to the use of plate.

CONCLUSIONS

Group of PS and S1-S3 IS is the configuration of internal fixation with best translational and rotational stiffness and the largest load to failure compared to other techniques in AO type C1.3 fracture.

Autologous mesenchymal stem cell (MSCs) transplantation for critical-sized bone defect following a wide excision of osteofibrous dysplasia

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No recurrence of osteofibrous dysplasia at 84 week following a wide extraperiosteal excision.

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The combination of autologous BM-MSCs, HA granules and BMP-2 successfully created new bone tissue.

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The newly formed bone tissue filled in the gap of critical-sized bone defect and was able to improve the patient’s quality of life significantly.

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No neoplastic, immunologic or other side-effects were noted at 84 weeks after autologous MSC transplantation.

Introduction

Osteofibrous dysplasia is a rare non-neoplastic disease that is almost exclusive to pediatric tibial diaphysis. Wide excision of the lesion is recommended to avoid recurrence. However, such radical surgery will results in large segmental bone defects that will require further extensive reconstructive surgery. We report a novel approach of treating bone defect by implementing the diamond concept of bone healing using autologous bone marrow derived mesenchymal stem cells (BM-MSCs).

Presentation of case

An eight-year-old Indonesian male presented with severe bowing deformity of the left lower leg. Radiographic and histological analysis confirmed the diagnosis of osteofibrous dysplasia. A wide excision of the defect was made leaving a critical-sized bone defect. A combination of autologous transplantation of 50 million BM-MSCs, hydroxyapatite (HA) granules, bone morphogenic protein 2 (BMP-2) and Djoko-Zarov hybrid circular external fixator was used to treat the defect. The outcomes measured were subjective complaints, functionality based on LEFS and radiological assessments.

Discussion

Radiographic assessments showed successful new bone tissue formation and integration of implanted HA granules. The external fixator was removed at 42 weeks after adequate callus formation and clinical stability was achieved. The patient underwent progressive functional improvements and reached a near normal functionality of 90% LEFS at 84 week. No therapy side effect or complication was reported.

Conclusion

Osteofibrous dysplasia was successfully excised without signs of recurrence after 84-week follow-up. Autologous transplantation of augmented BM-MSCs has successfully created new normal bone tissue without causing any side effect and had significantly improved the patient’s quality of life.

Transplantation of mesenchymal stem cells, recombinant human BMP-2,and their combination in accelerating the union after osteotomy and increasing, the mechanical strength of extracorporeally irradiated femoral autograft in rat models

BACKGROUND

Delayed union, nonunion, and mechanical failure is still problems encountered in limb salvage surgery (LSS) using extracorporeal irradiation (ECI). This study aimed to determine whether bone marrow mesenchymal stem cells (MSC) and recombinant human bone morphogenetic protein-2 (rhBMP-2) improve hostgraft union after osteotomy and also increase its mechanical strength.

METHODS

Thirty Sprague Dawley rats were randomly divided into five groups. Group I (control) underwent LSS using ECI method with 150 Gy single doses. Similar procedures were applied to other groups. Group II received hydroxyapatite (HA) scaffold. Group III received HA scaffold and MSC. Group IV received HA scaffold and rhBMP-2. Group V received HA scaffolds, MSC, and rhBMP-2. Radiograph were taken at week-2, 4, 6, and 8; serum alkaline phosphatase and osteocalcin were measured at week-2 and 4. Histopathological evaluation and biomechanical study was done at week-8.

RESULTS

The highest radiological score was found in group IV and V Similar result was obtained in histological score and ultimate bending force. These results were found to be statistically significant. There was no significant difference among groups in serum alkaline phosphatase and osteocalcin level.

CONCLUSION

Combination of MSC and rhBMP-2 was proven to accelerate union and improve mechanical strength of ECI autograft.

Pelvic haemophilic pseudotumour: a case report

We report on a 30-year-old haemophilic man with a pelvic pseudotumour compressing adjacent structures causing pain and swelling and destruction of surrounding soft tissues and bones. He underwent evacuation of the pseudotumour, acetabular reconstruction using the Harrington procedure, and total hip arthroplasty.