Resorbable magnesium screws for fixation of medial epicondyle avulsion fractures in skeletally immature patients: A comparison with Kirschner wires

BACKGROUND

Displaced medial epicondyle fractures are treated with open reduction and internal fixation with K-wires or screws. Rates of implant prominence, failure, or non-union reported are considerable. Magnesium screws have demonstrated biocompatibility, osteoconductivity, and high pull-out strength. The aim of this study was to compare surgical fixation of medial epicondyle fracture using resorbable magnesium Herbert screws to K-wires, in skeletally immature patients.

METHODS

A retrospective analysis was performed from January 2015 to April 2020. Inclusion criteria were as follows displaced medial epicondyle fracture, <15 years, and absence of concomitant ipsilateral upper limb fractures. Two consecutive cohorts based on fixation device were made: Group A (wires) and Group B (magnesium screws). Alignment, pain, range of motion, Mayo Elbow Performance Score, and radiological healing were assessed.

RESULTS

A total of 27 patients were included: 15 in Group A and 12 in Group B. Groups were comparable for age and sex. Mean follow-up was higher in Group A (38.73 ± 3.15 vs 26.18 ± 4.85 months; p < 0.001). No significant differences were observed regarding range of motion, alignment, pain, and Mayo Elbow Performance Score, with excellent results in both groups. Two patients in Group A developed a deep wound pin site infection requiring antibiotics. X-rays revealed three cases of non-union in Group A and one in Group B, all of them asymptomatic. No patient required a second surgical procedure.

CONCLUSION

Open reduction and internal fixation of medial epicondyle fractures with magnesium screws showed comparable results to a widely accepted procedure such as the use of K-wires, potentially with a lower incidence of non-union and infection. No adverse reactions were recorded.

LEVEL OF EVIDENCE

level III.

Osteotomy after medial malleolus fracture fixed with magnesium screws ZX00 - A case report

Magnesium alloys have recently become the focus of research, as these implants exhibit suitable biocompatibility and appropriate mechanical properties (Grün et al., 2018 [1]). Through intensive preclinical and clinical investigation, many questions regarding stability, biocompatibility and degradation behavior have been answered (Holweg et al., 2020 [2]). This case report aims to describe handling of these implants in a revision situation, especially when located in situ. To describe available options and relevant considerations, including planning and implementation, a revision surgery of a healed medial malleolus fracture is presented. A medial malleolus fracture was primarily treated by a trauma surgeon with two magnesium screws. Due to an osteochondral lesion of the talus, a revision surgery with osteotomy of the medial malleolus was necessary after 17 months. In this revision, conventional screw removal was not possible due to the degradation of the implant. Taking the degradation and the yield strength of the implant into account, we have chosen on the one hand to over-drill and on the other to leave and perforate the screw. To the best of our knowledge, this is the first case study focusing on the clinical intraoperative site of human bone stabilized with magnesium screws. Despite the hydrogen gas production that occurs during degradation, a solid bone-to-implant interface was evident. With this report, we want to encourage the surgical user to get more involved with resorbable magnesium implants.

Magnesium implantation or supplementation ameliorates bone disorder in CFTR-mutant mice through an ATF4-dependent Wnt/β-catenin signaling

Magnesium metal and its alloys are being developed as effective orthopedic implants; however, the mechanisms underlying the actions of magnesium on bones remain unclear. Cystic fibrosis, the most common genetic disease in Caucasians caused by the mutation of CFTR, has shown bone disorder as a key clinical manifestation, which currently lacks effective therapeutic options. Here we report that implantation of magnesium-containing implant stimulates bone formation and improves bone fracture healing in CFTR-mutant mice. Wnt/β-catenin signaling in the bone is enhanced by the magnesium implant, and inhibition of Wnt/β-catenin by iCRT14 blocks the magnesium implant to improve fracture healing in CFTR-mutant mice. We further demonstrate that magnesium ion enters osteocytes, increases intracellular cAMP level and activates ATF4, a key transcription factor known to regulate Wnt/β-catenin signaling. In vivo knockdown of ATF4 abolishes the magnesium implant-activated β-catenin in bones and reverses the improved-fracture healing in CFTR-mutant mice. In addition, oral supplementation of magnesium activates ATF4 and β-catenin as well as enhances bone volume and density in CFTR-mutant mice. Together, these results show that magnesium implantation or supplementation may serve as a potential anabolic therapy for cystic fibrosis-related bone disease. Activation of ATF4-dependent Wnt/β-catenin signaling in osteocytes is identified as a previously undefined mechanism underlying the beneficial effect of magnesium on bone formation.

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Magnesium implant ameliorates bone defects and improves the impaired bone fracture healing in CFTR-deficient mice.

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Oral magnesium supplementation improves bone quality in CFTR-deficient mice.

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Extracellular Mg²⁺ enters bone cells through Mg²⁺ channels and transporters.

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Mg²⁺ elevates cAMP level to activate ATF4-dependent Wnt/β-catenin signalingin bone cells.

A surface-engineered multifunctional TiO2 based nano-layer simultaneously elevates the corrosion resistance, osteoconductivity and antimicrobial property of a magnesium alloy

Magnesium biometals exhibit great potentials for orthopeadic applications owing to their biodegradability, bioactive effects and satisfactory mechanical properties. However, rapid corrosion of Mg implants in vivo combined with large amount of hydrogen gas evolution is harmful to bone healing process which seriously confines their clinical applications. Enlightened by the superior biocompatibility and corrosion resistance of passive titanium oxide layer automatically formed on titanium alloy, we employ the Ti and O dual plasma ion immersion implantation (PIII) technique to construct a multifunctional TiO₂ based nano-layer on ZK60 magnesium substrates for enhanced corrosion resistance, osteoconductivity and antimicrobial activity. The constructed nano-layer (TiO₂/MgO) can effectively suppress degradation rate of ZK60 substrates in vitro and still maintain 94% implant volume after post-surgery eight weeks. In animal study, a large amount of bony tissue with increased bone mineral density and trabecular thickness is formed around the PIII treated group in post-operation eight weeks. Moreover, the newly formed bone in the PIII treated group is well mineralized and its mechanical property almost restores to the level of that of surrounding mature bone. Surprisingly, a remarkable killing ratio of 99.31% against S. aureus can be found on the PIII treated sample under ultra-violet (UV) irradiation which mainly attributes to the oxidative stress induced by the reactive oxygen species (ROS). We believe that this multifunctional TiO₂ based nano-layer not only controls the degradation of magnesium implant, but also regulates its implant-to-bone integration effectively. STATEMENT OF SIGNIFICANCE: Rapid corrosion of magnesium implants is the major issue for orthopaedic applications. Inspired by the biocompatibility and corrosion resistance of passive titanium oxide layer automatically formed on titanium alloy, we construct a multifunctional TiO₂/MgO nanolayer on magnesium substrates to simultaneously achieve superior corrosion resistance, satisfactory osteoconductivity in rat intramedullary bone defect model and excellent antimicrobial activity against S. aureus under UV irradiation. The current findings suggest that the specific TiO₂/MgO nano-layer on magnesium surface can achieve the three objectives aforementioned and we believe this study can demonstrate the potential of biodegradable metals for future clinical applications.

In vivo stimulation of bone formation by aluminum and oxygen plasma surface-modified magnesium implants

A newly developed magnesium implant is used to stimulate bone formation in vivo. The magnesium implant after undergoing dual aluminum and oxygen plasma implantation is able to suppress rapid corrosion, leaching of magnesium ions, as well as hydrogen gas release from the biodegradable alloy in simulated body fluid (SBF). No released aluminum is detected from the SBF extract and enhanced corrosion resistance properties are confirmed by electrochemical tests. In vitro studies reveal enhanced growth of GFP mouse osteoblasts on the aluminum oxide coated sample, but not on the untreated sample. In addition to that a small amount (50 ppm) of magnesium ions can enhance osteogenic differentiation as reported previously, our present data show a low concentration of hydrogen can give rise to the same effect. To compare the bone volume change between the plasma-treated magnesium implant and untreated control, micro-computed tomography is performed and the plasma-treated implant is found to induce significant new bone formation adjacent to the implant from day 1 until the end of the animal study. On the contrary, bone loss is observed during the first week post-operation from the untreated magnesium sample. Owing to the protection offered by the Al2O3 layer, the plasma-treated implant degrades more slowly and the small amount of released magnesium ions stimulate new bone formation locally as revealed by histological analyses. Scanning electron microscopy discloses that the Al2O3 layer at the bone-implant interface is still present two months after implantation. In addition, no inflammation or tissue necrosis is observed from both treated and untreated implants. These promising results suggest that the plasma-treated magnesium implant can stimulate bone formation in vivo in a minimal invasive way and without causing post-operative complications.