Descriptive Analysis of Surgical Outcomes and Stoma Formation for Treating Sacral and Anal Pressure Injuries in Spinal Cord Injury: A Retrospective Study of Selected Cases

Introduction

Pressure injuries (PIs) arise from sustained pressure on tissue, leading to reduced blood flow to the affected area. In patients with spinal cord injuries (SCIs), these PIs can significantly diminish their independence and overall quality of life. This research sought to assess the frequency of surgical complications in treatment regimens for large sacral PIs involving the anus. Specifically, the study focused on the incorporation of stoma formation in patients with SCIs.

Methods

A retrospective review identified 25 SCI patients who had extensive sacral PIs. These patients underwent intestinal stoma formation as a preparatory step before plastic reconstructive surgery to address the wounds between 2015 and 2020.

Results

Successful wound closure was achieved in all instances. Notably, each patient had experienced a minimum of three unsuccessful reconstructive surgeries elsewhere before this intervention. The observed rate of surgical complications aligned with findings from previous analogous studies.

Conclusion

While often viewed as a treatment of last resort, an intestinal stoma might serve as a valuable strategy, particularly for SCI patients with extensive PIs near the anal region, to promote the healing of such injuries. Tailored decision-making is essential to ensure the best possible patient outcomes.

Selenium-Binding Protein 1 (SELENBP1) as Biomarker for Adverse Clinical Outcome After Traumatic Spinal Cord Injury

Introduction: Traumatic spinal cord injury (TSCI) presents a diagnostic challenge as it may have dramatic consequences for the affected patient. Additional biomarkers are needed for improved care and personalized therapy.

Objective: Serum selenium binding protein 1 (SELENBP1) has been detected in myocardial infarction, reflecting hypoxic tissue damage and recovery odds. As SELENBP1 is usually not detected in the serum of healthy subjects, we tested the hypothesis that it may become detectable in TSCI and indicate tissue damage and regeneration odds.

Methods: In this prospective observational study, patients with comparable injuries were allocated to three groups; vertebral body fractures without neurological impairment (control “C”), TSCI without remission (“G0”), and TSCI with signs of remission (“G1”). Consecutive serum samples were available from different time points and analyzed for SELENBP1 by sandwich immunoassay, for trace elements by X-ray fluorescence and for cytokines by multiplex immunoassays.

Results: Serum SELENBP1 was elevated at admission in relation to the degree of neurological impairment [graded as A, B, C, or D according to the American Spinal Injury Association (AISA) impairment scale (AIS)]. Patients with the most severe neurological impairment (classified as AIS A) exhibited the highest SELENBP1 concentrations (p = 0.011). During the first 3 days, SELENBP1 levels differed between G0 and G1 (p = 0.019), and dynamics of SELENBP1 correlated to monocyte chemoattractant protein 1, chemokine ligand 3 and zinc concentrations.

Conclusion: Circulating SELENBP1 concentrations are related to the degree of neurological impairment in TSCI and provide remission odds information. The tight correlation of SELENBP1 with CCL2 levels provides a novel link between Se metabolism and immune cell activation, with potential relevance for neurological damage and regeneration processes, respectively.

Predicting neurological recovery after traumatic spinal cord injury by time-resolved analysis of monocyte subsets

Monocytes and lymphocytes elicit crucial activities for the regenerative processes after various types of injury. The survival of neurons exposed to mechanical and oxidative stress after traumatic spinal cord injury (TSCI) depends on a multitude of factors. The current study sought to evaluate a correlation between remission after TSCI and dynamics of monocyte subsets in respect to the lymphocytes' responsive potential, cytokine expression, patterns of trace element concentration and clinical covariates. We examined prospectively 18 (3 female, 15 male) patients after TSCI. Blood samples were drawn at admission and 4 h, 9 h, 12 h, 1 and 3 days as well as 1 and 2 weeks and 1, 2 and 3 months after the trauma. Analysis of cytokines (CCL-2, IL-10, Enolase 2, CXCL-12, TGF- β1, TGF- β2) was performed using a multiplex cytokine panel. Plasma trace element concentrations of selenium, copper and zinc were determined by total reflection X-ray fluorescence analysis, Neopterin, selenoprotein P (SELENOP) and ceruloplasmin (CP) by enzyme-linked immunosorbent assay (ELISA) and selenium binding protein 1 (SELENBP1) by luminometric immunoassay (LIA). The responsive potential of lymphocytes was assessed via transformation tests. The monocyte subsets (classical, intermediate, and non-classical) and expression of CD14, CD16, CXCR4 and intracellular IL-10 were identified using a multi-colour flow cytometry analysis. The dynamics of the cluster of intermediate CD14-/CD16+/IL10+/CXCR4int monocytes differed significantly between patients with an absence of neurological remission (G0) from those with an improvement (G1) by 1 or 2 AIS steps (Kruskal-Wallis Test, p = 0.010, G0 < G1, AIS+: 1 < G1, AIS+: 2) in the first 24 h. These dynamics were associated inversely with an increase in Enolase and SELENBP1 14 d after the injury. In the elastic net regularised model, we identified an association between the increase of a subpopulation of intermediate CD14-/CD16+/IL10+/CXCR4int monocytes and exacerbated immune response within 24 h after the injury. These findings are reflected in the consistently elevated response to mitogen stimulation of the lymphocytes of patients with significant neurological remission. Early elevated concentrations of CD14-/CD16+/IL10+/CXCR4int monocytes were related to higher odds of CNS regeneration and enhanced neurological remission. The cluster-dynamics of CD14-/CD16+/IL10+/CXCR4int monocytes in the early-acute phase after the injury revealed a maximum of prognostic information regarding neurological remission (mean parameter estimate: 0.207; selection count: 818/1000 repetitions). We conclude that early dynamics in monocyte subsets allow a good prediction of recovery from TSCI.

Novel approach to an early assessment of a patient's potential for neurological remission after acute spinal cord injury: Analysis of hemoglobin concentration dynamics

Context/objective: Examining hemoglobin (Hb) dynamics with regard to the potential of neurological remission in patients with traumatic spinal cord injury (TSCI).Design: Prospective Clinical Observational Study.Setting: BG Trauma Centre Ludwigshafen, Department of Paraplegiology, Rhineland-Palatinate, Germany.Methods: From 2011 to 2017 a total of 80 patients with acute spinal injury were enrolled and divided into three groups: initial neurological impairment either with (G1; n = 33) or without subsequent neurological remission (G0; n = 35) and vertebral fractures without initial neurological impairment as control group (C; n = 12). Blood samples were taken for 3 months at 11 time-points after injury. Analyses were performed using routine diagnostics.Outcome measures: Multiple logistic regression was used to determine the prognostic value of Hb regarding neurological remission respecting clinical covariates.Results: Data showed elevated mean Hb concentrations in G1 from the third day to 1 month compared to G0, Hb levels were significantly higher in G1 after 3 days (P = 0.03, G1 > G0). The final multiple logistic regression model based on this data predicting the presence of neurological remission resulted in an AUC (area under the curve) of 80.5% (CI: 67.8%-93.2%) in the ROC (receiver operating characteristic) analysis.Conclusion: Elevated Hb concentrations are associated with a higher likelihood of neurological remission. Elevated concentrations of Hb in G1 compared to G0 over time might be linked to both a better initial oxygen supply response and a decreased ECM (extracellular matrix) degradation highlighting the role of Hb as a valuable biomarker for neural regeneration after TSCI.

Evaluation of two different types of radial head prosthesis in practical use. Using either Evolve® or MoPyC® radial head prosthesis in the treatment of comminuted radial head fractures

The aim of this retrospective study was to undertake a comparative evaluation of the Evolve^® modular metallic radial head implant prosthesis and the MoPyC^® pyrocarbon prosthesis in acute care. Seventyfive patients having a comminuted radial head fracture with an Evolve^® prosthesis (=G1) and 11 with a MoPyC^® prosthesis (=G2) were available for a follow-up. Postoperative patient outcomes were evaluated according to a standardized follow-up protocol which included the Morrey rating system. Assessment criteria were range of motion (ROM), functional scores, and rate of complications. G1 showed a mean Morrey score of 86 points. Four direct prosthesis complications were observed in this group (n=75). The average achieved Morrey score in G2 was 84 points. In this group (n=11), 2 direct prosthesis complications were diagnosed. The average range of motion did not differ greatly between both groups. Radial head replacement with either prosthesis yielded sufficient to satisfactory results in a mid-term perspective regarding the range of motion and function of the elbow joint when performed in carefully selected patients. The Evolve^® Prothesis appears to show a slightly lower rate of complication by way of a similar functional outcome.

Selenium and copper status - potential signposts for neurological remission after traumatic spinal cord injury

INTRODUCTION

Traumatic Spinal Cord Injury (TSCI) is a severe incident resulting in loss of motor and sensory function caused by complex pathological mechanisms including massive oxidative stress and extensive inflammatory processes. The essential trace elements selenium (Se) and copper (Cu) play crucial roles as part of the antioxidant defense.

HYPOTHESIS

Remission after TSCI is associated with characteristic dynamics of early changes in serum Cu and Se status.

STUDY DESIGN

Single-center prospective observational study.

PATIENTS AND METHODS

Serum samples from TSCI patients were analyzed (n = 52); 21 recovered and showed a positive abbreviated injury score (AIS) conversion within 3 months (G1), whereas 21 had no remission (G0). Ten subjects with vertebral fractures without neurological impairment served as control (C). Different time points (at admission, and after 4, 9, 12, and 24 h) were analyzed for total serum Se and Cu concentrations by total reflection X-ray fluorescence, and for Selenoprotein P (SELENOP) and Ceruloplasmin (CP) by sandwich ELISA.

RESULTS

At admission, CP and SELENOP concentrations were higher in the remission group (G1) than in the non-remission group (G0). Within 24 h, there were marginal changes in Se, SELENOP, Cu and CP concentrations in the groups of controls (C) and G0. In contrast, these parameters decreased significantly in G1. Binary logistic regression analysis including Cu and Se levels at admission in combination with Se and CP levels after 24 h allowed a prediction for potential remission, with an area under the curve (AUC) of 87.7% (CI: 75.1%-100.0%).

CONCLUSION

These data indicate a strong association between temporal changes of the Se and Cu status and the clinical outcome after TSCI. The dynamics observed may reflect an ongoing redistribution of the trace elements in favor of a better anti-inflammatory response and a more successful neurological regeneration.

Relation of selenium status to neuro-regeneration after traumatic spinal cord injury

INTRODUCTION

The trace element selenium (Se) is crucial for the biosynthesis of selenoproteins. Both neurodevelopment and the survival of neurons that are subject to stress depend on a regular selenoprotein biosynthesis and sufficient Se supply by selenoprotein P (SELENOP).

HYPOTHESIS

Neuro-regeneration after traumatic spinal cord injury (TSCI) is related to the Se status.

STUDY DESIGN

Single-centre prospective observational study.

PATIENTS AND METHODS

Three groups of patients with comparable injuries were studied; vertebral fractures without neurological impairment (n = 10, group C), patients with TSCI showing no remission (n = 9, group G0), and patients with remission developing positive abbreviated injury score (AIS) conversion within 3 months (n = 10, group G1). Serum samples were available from different time points (upon admission, and after 4, 9 and 12 h, 1 and 3 days, 1 and 2 weeks, and 1, 2 and 3 months). Serum trace element concentrations were determined by total reflection X-ray fluorescence, SELENOP by ELISA, and further parameters by laboratory routine.

RESULTS

Serum Se and SELENOP concentrations were higher on admission in the remission group (G1) as compared to G0. During the first week, both parameters remained constant in C and G0, whereas they declined significantly in the remission group. Similarly, the concentration changes between admission and 24 h were most pronounced in this group of recovering patients (G1). Binary logistic regression analysis including the delta of Se and SELENOP within the first 24 h indicated an AUC of 90.0% (CI: 67.4%-100.0%) with regards to predicting the outcome after TSCI.

CONCLUSION

A Se deficit might constitute a risk factor for poor outcome after TSCI. A dynamic decline of serum Se and SELENOP concentrations after admission may reflect ongoing repair processes that are associated with higher odds for a positive clinical outcome.

Safety study: is there a pathologic IGF-1, PDGF and TGF-β cytokine expression caused by adjunct BMP-7 in tibial and femoral non-union therapy?

Background

In this prospective safety study, we investigated if the characteristic cytokine expression during bone regeneration is manipulated by the local application of bone morphogenetic protein-7 (BMP-7) in non-union surgery. Therefore, the levels of insulin like growth factor 1 (IGF-1), platelet-derived growth factor AB (PDGF-AB) and transforming growth factor beta (TGF-β) were compared between patients with the gold standard use of autologous bone graft (ABG) and those with additional application of BMP-7 as part of the diamond concept.

Patients and methods

Between 2009 and 2014, of the 153 patients with tibial and femoral non-unions, a matched pair analysis was performed to compare the serological cytokine expressions. Blood samples were collected preoperatively, 1, 2 and 6 weeks as well as 3 and 6 months after non-union surgery. Matching criteria were smoking status, fracture location, gender, age and body mass index (BMI). Patients in G1 (n=10) were treated with ABG and local BMP-7 while their matching partners in G2 (n=10) received ABG only. The routine clinical and radiologic follow-up was 1 year.

Results

Although the IGF-1 quantification in G2 showed higher pre- and postoperative values compared to G1 (p<0.05), the courses of both groups were similar. Likewise, PDGF-AB and TGF-β expressions appeared similar in G1 and G2 with peaks in both groups at 2 weeks follow-up. Osseous consolidation was assessed in all operated non-unions. The adjunct application of BMP-7 did not cause any pathologic cytokine expression.

Conclusion

Similar expressions of the serum cytokines IGF-1, PDGF-AB and TGF-β were demonstrated in non-union patients treated with ABG and additional application of BMP-7 according to the diamond concept. Our findings indicate that the local application of BMP-7, which imitates the physiologic secretion of growth factors during bone regeneration, is safe and without the risk of abnormal systemic cytokine expression. Studies with higher patient numbers will have to validate these assumptions.

The treatment of nonunions with application of BMP-7 increases the expression pattern for angiogenic and inflammable cytokines: a matched pair analysis

The local application of bone morphogenetic protein-7 (BMP-7) in combination with the transplantation of autologous bone graft improves the outcome in nonunion treatment; however, the specific reasons remain unclear. In this study, we sought to determine if the local application of BMP-7 contributes to improved bone regeneration in nonunion therapy by modulation of the angiogenic and inflammable cytokine expression patterns of the early inflammation response. Therefore, we utilized the analysis of serological cytokine expression patterns. As a matched pair analysis, best-fitting patients who were treated with transplantation of autologous bone graft (G1, n=10) were compared with patients who were treated with additional application of BMP-7 (G2, n=10). The changes in the cytokine expression patterns were monitored and correlated to clinical data of bone healing. Significant differences in angiogenesis potential (vascular endothelial growth factor [VEGF] serum levels) could be found in the first days after surgery (P<0.05). Furthermore, the increase and absolute amount of VEGF levels in the BMP-7 group were considerably higher than in the control group during the first 2 weeks after surgery. The expression pattern of inflammable cytokines showed noticeable differences in the time point of significant elevated levels, in particular, inflammable cytokines showed an earlier peak in G2. Furthermore, interleukin-6 was significantly elevated within the first week only, comparing G2 to G1 (P<0.05). Our findings indicate that BMP-7 induces an early and more intense expression of VEGF via a direct and postulated indirect pathway, thereby providing a favorable environment for bone healing. Moreover, application of BMP-7 leads to an earlier expression of known proinflammatory cytokines. The results of this study show that application of BMP-7 leads to costimulatory effect on both angiogenic and inflammable cytokine expression patterns that may serve as a possible stimulus for bone regeneration.

Does surgical treatment within 4 hours after trauma have an influence on neurological remission in patients with acute spinal cord injury?

Background

The proper timing for surgery in patients with acute spinal cord injury is controversial. This study was conducted to detect if there is an advantage in early (within the first 4 hours after trauma) compared to late (between 4 and 24 hours after trauma) surgery on neurological outcome.

Methods

In this single institution prospective cohort study, data were analyzed from 51 spinal cord injured patients with an average age of 43.4 (±19.2) years. The influence of early (29 patients within the first 4 hours) as opposed to late (22 patients between 4 and 24 hours) decompression was evaluated by comparing data for neurological outcome. Patients of the study collectively suffered acute spinal fractures from C2 to L3 (cervical 39.2%, thoracic 29.4%, and lumbal 21.6%) or nonosseous lesions (9.8%). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades were assessed at time of admission and 6 months after trauma or longer depending on the time of release. Surgical treatment included early stabilization and decompression within 24 hours.

Results

No significant difference between improved neurological function, measured with the AIS, and an early or late surgery time can be seen (P=0.402). Furthermore, binary logistic regression shows no significant difference between sex or age, and AIS improvement as possible confounders.

Conclusion

In our study, all patients with spinal cord injury were treated with spine stabilization and decompression within the first 24 hours after trauma. Surgical decompression within the first 4 hours after trauma was not associated with improved neurological outcome compared to treatment between 4 and 24 hours. In a clinical context, this indicates that there is a time frame of at least 1 day in which optimal care is possible.

Low intensity pulsed ultrasound in the treatment of long bone nonunions: Evaluation of cytokine expression as a tool for objectifying nonunion therapy

BACKGROUND

Nonunion is one of the most common complications in bone healing. After several clinical studies, the effect of low intensity pulsed ultrasound (LIPUS) in the treatment of nonunions remains unclear because of the difficulty in evaluating its effect on bone healing. In former studies, the analysis of serum cytokine expression patterns over time has proven to be an objective method for showing the bone healing process and evaluating nonunion therapies. This study evaluates LIPUS as a treatment option for patients with nonunions based on the analysis of serum cytokine expression.

METHODS

In this prospective, single institution study, venous blood samples from 23 patients were taken from October 2012 to October 2013 before starting LIPUS therapy and at the end of week 1 and 2 and after 1, 2, and 3 months. Patients attended clinical and radiological follow-up examinations at the same intervals. After treating all patients according to the LIPUS therapy protocol, we divided them into two groups: Group 1 consisted of patients with healing at the nonunion site, and Group 2 consisted of patients with failed nonunion therapy. We measured transforming growth factor-β1 (TGF-β1), platelet-derived growth factor (PDGF), and basic fibroblastic growth factor (bFGF) at all time-points.

RESULTS

The TGF-β1 serum concentration increased from the pre-treatment value to 1 week within the unsuccessful group. Otherwise, no significant differences between groups in measured cytokines during LIPUS therapy could be detected.

CONCLUSION

Our findings suggest that LIPUS does not lead to a significant increase in cytokine levels in patients with nonunions. It is likely that "successful" treatment can be attributed to spontaneous healing. Our results suggest that LIPUS is not a proper treatment for long bone nonunions.

sCD95L in serum after spinal cord injury

STUDY DESIGN

A prospective observational study reporting correlation between sCD95L (serum cluster of differentiation 95 ligand) serum levels and remission after traumatic spinal cord injury (SCI).

OBJECTIVES

To describe the correlation between sCD95L serum levels and remission after traumatic SCI in a human protocol compared with animal studies.

SETTING

Rhineland-Palatinate (Rheinland-Pfalz), Germany.

METHODS

We included 45 patients with traumatic SCI. According to their neurological outcome, patients were divided into two groups, patients with (G1, n=26) and without (G2, n=19) remission. Blood was collected on post-admission and according to a fixed scheme, that is, after 4, 9, 12 h, 1, 3 days and 1, 2, 4, 8, 12 weeks.

RESULTS

By comparing G1 with G2, we found a correlation between neurological remission and sCD95L serum concentrations. Consistently elevated levels of sCD95L in G1 between 9 h and 1 month after injury show significantly differing values 7 days after injury. This indicates a correlation between patients with clinically documented neurological remission and elevated sCD95L serum concentrations.

CONCLUSIONS

In opposite to animal studies, our patients with neurological remission show on average higher levels of sCD95L compared with patients without. Therefore, spinal cord-injured patients would probably not profit from neutralizing CD95L. Our results present that the transfer of findings from animal studies to humans must always be considered critically. We were able to show that peripheral serum cytokine expression is suitable to state processes after SCI in humans.

Outcome of Radial Head Arthroplasty in Comminuted Radial Head Fractures: Short and Midterm Results

Background:

Comminuted radial head fractures are often associated with secondary injuries and elbow instability.

Objectives:

The aim of this retrospective study was to evaluate how well the modular metallic radial head implant EVOLVE® prosthesis restores functional range of motion (ROM) and stability of the elbow in acute care.

Patients and Methods:

Eighty-five patients with comminuted radial head fractures and associated injuries received treatment with an EVOLVE® prosthesis between May 2001 and November 2009. Seventy-five patients were available for follow-up. On average, patients were followed for 41.5 months (33.0: 4.0 - 93.0). Outcome assessment was done on the basis of pain, ROM, strength, radiographic findings, and functional rating scores such as Broberg and Morrey, the Mayo elbow performance index (MEPI), and disabilities of the arm, shoulder and hand (DASH). Our study is currently the largest analysis of clinical outcome of a modular radial head replacement in the literature.

Results:

Overall, there were 2 (2.7%) Mason II fractures, 21 (28%) Mason III fractures, and 52 (69.3%) Mason IV fractures. Arbeitsgemeinschaft fur osteosynthesefragen (AO) classification was also determined. Of the 85 patients in our study, 75 were available for follow-up. Follow-up averaged 41.5 months (range, 4 - 93 months). Average scores for the cohort were as follows: Morrey, 85.7 (median 90.2; range 44.4 - 100); MEPI, 83.3 (85.0; 40.0 - 100); and DASH 26.1 points (22.5; 0.0 - 75.8). Mean flexion/extension in the affected joint was 125.7°/16.5°/0° in comparison to the noninjured side 138.5°/0°/1.2°. Mean pronation/supination was 70.5°/0°/67.1° in comparison to the noninjured side 83.6°/0°/84.3°. Handgrip strength of the injured compared to the non-injured arm was 78.8%. The following complications were also documented: 58 patients had periprosthetic radioluceny shown to be neither clinically significant nor relevant according to evaluated scores; 26 patients had moderate or severe periarticular ossification, and scored substantially worse according to MEPI and Morrey. Four patients required revisional surgery due to loosening of the prosthesis and chronic pain. In addition, one patient required a neurolysis of the ulnaris nerve, one developed a neobursa, and one had extensive swelling and blistering. The time interval between injury and treatment appeared to have an effect on results. Thirty-five patients were treated within the first 5 days after accident and showed better results than the 40 patients who were treated after 5 days.

Conclusions:

Comminuted radial head fractures with elbow instability can be treated well with a modular radial head prosthesis, which restores stability in acute treatment. The modular radial head arthroplasty used in this study showed promising findings in short to midterm results.

Quantification of TGF-ß1, PDGF and IGF-1 cytokine expression after fracture treatment vs. non-union therapy via masquelet

INTRODUCTION

Biochemical processes during bone regeneration can be analysed via quantification of peripheral serum cytokine levels. To date, serum levels of cytokines in patients treated with masquelet technique and patients with normal bone healing have not been compared. This comparison is supposed to deliver novel insights into the process of bone regeneration. Our aim was to validate this established method in the monitoring of bone regeneration after non-union treatment in masquelet technique.

MATERIALS AND METHODS

Between 04/2008 and 01/2014 three groups were recruited: G1 (10 patients) with long bone non-unions, treated successfully with masquelet therapy, G2 (6 patients) with unsuccessful masquelet therapy and G3 (10 patients) with long bone fractures and normal bone healing. Peripheral blood samples were collected over a period of six months following a standardised time pattern in combination with clinical and radiologic follow up. TGF-ß1, PDGF-AB and IGF-1 were measured using commercially available immunoassays.

RESULTS

TGF-ß1 levels in G1 and G2 demonstrated a parallel and lower overall concentration over time compared to G3. G3 showed a significant TGF-ß1 peak 2 weeks after surgery compared to G1 (p=0.0054). PDGF-AB concentrations were always lower in G2 than in G1 and G3. G3 peaked at week 2 with a significant higher value than in G2 (p=0.0177). IGF-1 showed lower overall serum concentrations in G2 than in G1 and G3. G1 had a peak level during the fourth week of follow-up. Compared to G2 this peak was significant (p=0.0015).

CONCLUSIONS

This study shows that successful bone regeneration via masquelet technique only partially imitates cytokine expression of physiological bone healing. High expressions of IGF-1 correspond to a successful masquelet therapy while TGF-ß seems to play a minor role. These results assume that objective analysis of an effective non-union therapy with cytokine expression analysis is possible even with a small number of patients.

Non-unions treated with bone morphogenic protein 7: introducing the quantitative measurement of human serum cytokine levels as promising tool in evaluation of adjunct non-union therapy

BACKGROUND

In this study we sought to determine if application of bone morphogenic protein 7 (BMP-7) promotes physiological bone healing of non-unions and to investigate if serum cytokine analysis may serve as a promising tool in the analysis of adjunct non-union therapy. Therefore we analyzed the influence of BMP-7 application on the serum cytokine expression patterns on patients with impaired bone healing compared to patients that showed proper bone healing.

METHODS

Our study involved analyzing blood samples from 208 patients with long bone fractures together with patients that subsequently developed non-unions. From this large pool, 15 patients with atrophic non-union were matched to 15 patients with atrophic non-union treated with local application of BMP-7 as well as normal bone healing. Changes in the cytokine expression patterns were monitored during the 1st, 2nd, 4th, 8th, 12th and 52nd week. The patients were followed both clinically and radiologically for the entire duration of the study. Serum cytokine expression levels of transforming growth factor beta (TGF-β), platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) were analyzed and compared.

RESULTS

Serum expression of TGF-β were nearly parallel in all three groups, however serum concentrations were significantly higher in patients with proper bone healing and those treated with BMP-7 than in patients with non-unions (p < 0.05). bFGF serum concentrations increased initially in patients with proper bone healing and in those treated with BMP-7. Afterwards, values decreased; bFGF serum concentrations in the BMP-7 group were significantly higher than in the other groups (p < 0.05). PDGF serum concentration levels were nearly parallel in all groups, serum concentrations were significantly higher in patients with proper bone healing and those treated with BMP-7 than in patients with non-unions (p < 0.05).

CONCLUSION

Treatment with BMP-7 in patients with former non-unions led to similar cytokine expression patterns after treatment as those found in patients with proper bone healing. Our results suggest that treatment with BMP-7 promote healing of non-unions. Furthermore, quantitative measurement of serum cytokine expression is a promising tool for evaluating the effectiveness of additional non-union therapies such as adjunct application of growth factors.

Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept

Methods

Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied.

Results

A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common.

Discussion

The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. Take home message: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft. Cite this article: Bone Joint J 2016;98-B:81–7.

Failed treatment of long bone nonunions with low intensity pulsed ultrasound

INTRODUCTION

The use of low intensity pulsed ultrasound (LIPUS) in the treatment of nonunions is still controversial. The present study is concerned with whether this procedure has a clinical use and which cofactors influence its therapeutic results.

METHODS

In this prospective, single institution, observational study, data from October 2010 to October 2013 from 61 nonunions in 60 patients treated with EXOGEN(®) LIPUS therapy were analysed. The average age was 45.4 ± 9.81 (18-63) years. Treatment was primarily done on long bones of the lower extremity (75.4 %). All 61 nonunions were examined after treatment, and the rate of healing as well as functional and subjective results were evaluated. Based on clinical and radiological findings, patients were divided into two groups: G1-successful treatment; and G2-unsuccessful treatment. Groups were compared to one another to identify possible factors influencing treatment.

RESULTS

Twenty (32.8 %) patients showed bone consolidation with an average time of healing of 5.3 (2-7) months. In patients without successful treatment, who underwent revision surgery instead, full weight bearing took on average 3.7 months longer, and they were able to return to work 6.8 months later. Most of the treated patients (70.5 %) reported no improvement in pain. In G2, 12 (29.3 %) patients suffered in their previous history from osteitis; in G1 there were only two patients (10 %) (p = 0.012). There were further significant differences in the age of the fracture, the type of osteosynthesis, the gap size, as well as the NUSS score.

CONCLUSION

Despite patients being chosen strictly according to EXOGEN(®) indications, only a small number of patients with nonunions who underwent LIPUS therapy experienced successful treatment (32.8 %). Overall, its use resulted in a clear delay in the time of treatment, so that according to our results, the use of LIPUS should be seen critically in long bone nonunions and use should be made on a case-by-case basis.

Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy

The analysis of peripheral serum cytokine expression patterns has been shown to be a possible method for demonstrating changes in bone metabolism. The aim of this study is to evaluate the effectiveness of this method within the treatment of long bone non-union with intramedullary reaming, a well-established non-union treatment concept.

MATERIALS AND METHODS

Three groups were added to this study: group one (G1) suffered from long bone non-unions, treated successfully with intramedullary reaming; group two (G2) consisted of long bone fractures with proper fracture healing; and group three (G3) included long bone fractures resulting in non-unions. We took blood samples on day 2, and after week 1, 4, 6, month 3 and 6 after initial treatment. Clinical and radiological follow-up were provided for 6 months. We measured transforming growth factor ß-1 (TGFß-1), platelet-derived growth factor (PDGF-AB), and insulin like growth factor-1 (IGF-1) at all-time points.

RESULTS

TGF-ß1 levels in G1 and G2 increased from day 2 to 6 weeks after surgery. In general, G1 and G2 showed parallel TGF-ß1 expression patterns, and G3 had a significant peak during first week compared to G1 (p = 0.023). PDGF peaked in G3 during first week after treatment, whereas G1 had its maximum after 4 weeks and G2 after 6 weeks. We were able to detect a significantly lower PDGF concentration at 3 months in G1 compared to G3 (p = 0.029). IGF-1 showed a peak concentration in G1 during the first 4 weeks. Afterwards, concentration levels in both G1 and G2 were higher.

CONCLUSIONS

Our study was able to show that the cytokine expression pattern in physiological bone healing is similar to that in successful non-union treatment with intramedullary reaming. Our results show that the effect of non-union therapy could be observed objectively by measuring cytokine expression patterns in peripheral blood even in a small group of patients.

Posttraumatic inflammation as a key to neuroregeneration after traumatic spinal cord injury

Pro- and anti-inflammatory cytokines might have a large impact on the secondary phase and on the neurological outcome of patients with acute spinal cord injury (SCI). We measured the serum levels of different cytokines (Interferon-γ, Tumor Necrosis Factor-α, Interleukin-1β, IL-6, IL-8, IL-10, and Vascular Endothelial Growth Factor) over a 12-week period in 40 acute traumatic SCI patients: at admission on average one hour after initial trauma; at four, nine, 12, and 24 h; Three, and seven days after admission; and two, four, eight, and twelve weeks after admission. This was done using a Luminex Performance Human High Sensitivity Cytokine Panel. SCI was classified using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at time of admission and after 12 weeks. TNFα, IL-1β, IL-6, IL-8, and IL-10 concentrations were significantly higher in patients without neurological remission and in patients with an initial AIS A (p < 0.05). This study shows significant differences in cytokine concentrations shown in traumatic SCI patients with different neurological impairments and within a 12-week period. IL-8 and IL-10 are potential peripheral markers for neurological remission and rehabilitation after traumatic SCI. Furthermore our cytokine expression pattern of the acute, subacute, and intermediate phase of SCI establishes a possible basis for future studies to develop standardized monitoring, prognostic, and tracking techniques.

Serum sCD95L concentration in patients with spinal cord injury

OBJECTIVE

To determine serum concentrations of soluble CD95 ligand (sCD95L) in patients with traumatic spinal cord injury.

METHODS

Patients with traumatic spinal cord injury were recruited. Blood was collected on admission to hospital and at 4 h, 9 h, 12 h, 24 h, 3 days, 7 days, and 2, 4, 8 and 12 weeks postadmission. Serum concentrations of sCD95L were determined via immunoassay.

RESULT

The study included 23 patients. Mean sCD95L concentrations were significantly lower at 4 h, 9 h, 12 h and 24 h than at admission, and were significantly higher at 8 and 12 weeks, compared with admission.

CONCLUSION

The serum sCD95L concentration fell significantly during the first 24 h after traumatic spinal cord injury. Concentrations then rose, becoming significantly higher than admission levels at 8 weeks. sCD95L may represent a possible therapeutic target for traumatic spinal cord injury.

A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients

STUDY DESIGN

A retrospective study reporting specific complications of certain skin flaps for treating pressure ulcers.

OBJECTIVES

To describe the rate and type of complications after pressure ulcer surgery in patients with spinal cord injury.

SETTING

Germany, Rheinland Pfalz.

METHODS

We collected data from 352 patients treated with 421 skin flaps to determine the rate and type of complications of each skin flap used.

RESULTS

In this study, we analyzed the results of 421 skin flaps in 352 patients with a total of 657 pressure ulcers from January 2006 to December 2010. Our patients had ischial, pelvic, sacral, trochanteric and lower extremity ulcers. Ischial ulcers were most common, followed by sacral and trochanteric ulcers. There were 87 complications in 421 flaps, which was an overall rate of 21%. Suture line dehiscence was the most common complication with 27 cases (31%), followed by 22 cases of infection (25.2%), 17 cases of hematoma (19.5%), 12 cases of partial necrosis (13.7%) and 9 cases of total flap necrosis (10.3%).

CONCLUSION

Pressure ulcers in spinal cord-injured patients are very common and difficult and expensive to treat. The high rate of complications and the associated costs suggest the importance of evaluating the efficacy of treatment options. Conservative procedures have been standardized, but there still has been limited success in establishing guidelines on how to manage complications arising from flap surgery. Our extensive documentation of flap plastics will be useful managing complications after the surgical treatment of pressure ulcers in spinal cord-injured patients.

Cigarette smoking and its impact on fracture healing

In this review, we discuss current knowledge and studies concerning the pathophysiology of cigarette smoking and its impact on fracture healing. We include studies on the biology of fracture healing and more specifically how smoking affects oxygenation in tissues, serum concentrations of important growth factors, collagen synthesis, and bone mineralization. Also mentioned are clinical studies showing that smoking impacts soft tissue regeneration and the healing of tibial fractures and open fractures, as well as articles discussing the apparent benefits and limitations of presurgical smoking cessation. Our review of the current literature suggests that it is necessary to inform smokers with fractures about their increased risk for impaired fracture healing. They should be closely monitored and additional therapies such as the use of BMP-7, BMP-2, or low-intensity ultrasound should be considered in early stages after trauma.

Multicentre prospective observational study on professional wound care using honey (Medihoney™)

In recent years, the treatment of wounds with honey has received an increasing amount of attention from healthcare professionals in Germany and Austria. We conducted a prospective observational multicentre study using Medihoney™ dressings in 10 hospitals - nine in Germany and one in Austria. Wound-associated parameters were monitored systematically at least three times in all patients. Data derived from the treatment of 121 wounds of various aetiologies over a period of 2 years were analysed. Almost half of the patients were younger than 18 years old, and 32% of the study population was oncology patients. Overall, wound size decreased significantly during the study period and many wounds healed after relatively short time periods. Similarly, perceived pain levels decreased significantly, and the wounds showed noticeably less slough/necrosis. In general, our findings show honey to be an effective and feasible treatment option for professional wound care. In addition, our study showed a relationship between pain and slough/necrosis at the time of recruitment and during wound healing. Future comparative trials are still needed to evaluate the extent to which the positive observations made in this and other studies can definitely be attributed to the effects of honey in wound care.

CD95-ligand on peripheral myeloid cells activates Syk kinase to trigger their recruitment to the inflammatory site

Injury to the central nervous system initiates an uncontrolled inflammatory response that results in both tissue repair and destruction. Here, we showed that, in rodents and humans, injury to the spinal cord triggered surface expression of CD95 ligand (CD95L, FasL) on peripheral blood myeloid cells. CD95L stimulation of CD95 on these cells activated phosphoinositide 3-kinase (PI3K) and metalloproteinase-9 (MMP-9) via recruitment and activation of Syk kinase, ultimately leading to increased migration. Exclusive CD95L deletion in myeloid cells greatly decreased the number of neutrophils and macrophages infiltrating the injured spinal cord or the inflamed peritoneum after thioglycollate injection. Importantly, deletion of myeloid CD95L, but not of CD95 on neural cells, led to functional recovery of spinal injured animals. Our results indicate that CD95L acts on peripheral myeloid cells to induce tissue damage. Thus, neutralization of CD95L should be considered as a means to create a controlled beneficial inflammatory response.

[Kinematic investigations of the talocrural joint in human cadaver specimens. Basic studies for the development of a hinged fixator]

To determine the specifications of a hinged fixator for the upper ankle joint, biomechanical investigations were performed on 20 human cadaver specimens and the talocrural axis was recorded by X-ray cinematography in all levels of the space. The results showed a medium variation of the axis in zero position (mean: 5.8 degrees ) from 3 degrees to 10 degrees in the anterior-posterior view. The span of the axis migration around zero position amounted to a minimum of 3 degrees and a maximum value of 10 degrees (mean: 7.2 degrees ). It could be ascertained that the axis kinetics does not move linearly in all cases. The talus rotation (the axle deviation from the sagittal plane) amounted to a minimum value of 2 degrees and a maximum value of 12 degrees (mean: 5.3 degrees ). In the transverse level, the axis kinetics was tracked by separate X-ray markings of the lateral and medial cortical of the talus in the zero point of the talocrural axis. The results were typical migration curves of the X-ray markings, demonstrating a ventral convex curve at the medial and lateral cortex. This migration of the cortex crossing point of the axis was geometrically entered in a coordinate system. The variance of the axis cortex crossing point at the medial cortical was X(M)=4.2 mm (min: 2 mm, max: 7 mm) and Y(M)=4.7 mm (2-7 mm), at the lateral cortical X(L)=3.7 mm (1-9 mm) and Y(L) =4.1 mm (1-8 mm). Regarding the clinical relevance for the development of a hinged fixator for the upper ankle joint, the results indicate that an external axis guidance of these axoids is not possible, but that an adjusted axis is necessary taking into consideration the values measured using ligamentotaxis.

Interganglionic segregation of distinct vagal afferent fibre phenotypes in guinea-pig airways

1. The present study addressed the hypothesis that jugular and nodose vagal ganglia contain the somata of functionally and anatomically distinct airway afferent fibres. 2. Anatomical investigations were performed by injecting guinea-pig airways with the neuronal tracer Fast Blue. The animals were killed 7 days later, and the ganglia were removed and immunostained with antisera against substance P (SP) and neurofilament protein (NF). In the nodose ganglion, NF-immunoreactive neurones accounted for about 98% of the Fast Blue-labelled cells while in the jugular ganglion they accounted for approximately 48%. SP and NF immunoreactivity was never (n = 100) observed in the same cell suggesting that the antisera labelled distinct populations. 3. Electrophysiological investigations were performed using an in vitro guinea-pig tracheal and bronchial preparation with intact afferent vagal pathways, including nodose and jugular ganglia. Action potentials arriving from single airway afferent nerve endings were monitored extracellularly using a glass microelectrode positioned near neuronal cell bodies in either ganglion. 4. The nodose ganglion contained the somata of mainly fast-conducting tracheal A delta fibres whereas the jugular ganglion contained equal numbers of C fibre and A delta fibre tracheal afferent somata. The nodose A delta neurones adapted rapidly to mechanical stimulation, had relatively low mechanical thresholds, were not activated by capsaicin and adapted rapidly to a hyperosmotic stimulus. By contrast, jugular A delta and C fibres adapted slowly to mechanical stimulation, were often activated by capsaicin, had higher mechanical thresholds and displayed a slow adaptation to a hyperosmotic stimulus. 5. The anatomical, physiological and pharmacological data provide evidence to support the contention that the vagal ganglionic source of the fibre supplying the airways ultimately dictates its neurochemical and physiological phenotype.