Bony Healing Research Articles

Impact of Vancomycin Treatment on Human Mesenchymal Stromal Cells During Osteogenic Differentiation

Category: Basic Sciences/Biologics Introduction/Purpose: Vancomycin is often delivered locally for surgical site infection prophylaxis. Recent reports of possible osteotoxicity have led to uncertainty concerning vancomycin’s safety in the setting of arthrodesis and bone healing. Bone formation during arthrodesis takes place as recruited human mesenchymal stromal cells (hMSCs) proliferate and differentiate into mature osteoblasts. The purpose of this research was to determine the impact of vancomycin treatment on hMSCs during osteogenic differentiation. Methods: Human MSCs were cultured in MSC growth media to an appropriate confluence. Cells were cultured for 24 hours to facilitate adherence, after which the media was aspirated and replaced with osteogenic differentiation media (Lonza, Switzerland). Osteogenic differentiation media was supplemented with vancomycin powder to yield solutions with concentrations of 0, 50, 500 & 5000 µg/mL. Fresh vancomycin powder was added with every media change. MSCs viability and proliferation were assessed via live/dead staining with 1 µM calcein-AM and 0.5 µM ethidium homodimer-1 (EthD-1) after 1, 3, and 7 days of differentiation and vancomycin treatment. Mineralization of differentiated cells was assessed via staining with 40 mM alizarin red (ARS; pH 4.1) after 21 days. Semi-quantification of the degree of mineralization was performed by measuring absorbance values at 405 nm using a microplate reader. Microscopy was used for qualitative evaluation. Results: Cell viability decreased with increasing vancomycin concentrations. Impairment of hMSC proliferation was also observed with increasing concentrations of vancomycin. MSCs treated with 5000 µg/mL vancomycin demonstrated significantly less cell growth compared to all other treatment groups (P=0.0001). Absorbance measurements from each well stained with alizarin red was used for semi-quantification of the degree of mineralization. As vancomycin concentrations were increased, absorbance levels decreased (Figure). This reduction in mineralization was also demonstrated qualitatively; with alizarin red less apparent in the wells with increasing vancomycin concentrations (Figure). Conclusion: Local vancomycin is utilized for prevention of infection, often in procedures that necessitate the formation of new bone. Bone healing requires migration, proliferation and differentiation of hMSCs. This work demonstrates impaired viability and function of hMSCs following vancomycin as well as decreased osteoblastic mineralization. Future work will require in vivo studies aimed at determining relative nonunion rates in the setting of vancomycin prophylaxis. Still, the results of this study suggest that vancomycin may be toxic to hMSCs and caution should be exercised by providers when considering vancomycin in foot and ankle patients requiring bony healing following fracture or arthrodesis.

Z-cut Osteotomy for Correction of Adult Acquired Pes Planovalgus Deformity

Category: Ankle Introduction/Purpose: Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, three plane step-cut osteotomies were described for each of these and offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb (“Z-cut”, Figure 1) alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy achieves clinical and radiographic flatfoot deformity correction with a high union rate. Methods: This was an IRB-approved retrospective study of 17 patients who underwent Z-cut osteotomy for treatment of moderate to severe symptomatic adult acquired flatfoot deformity, Stage IIB. Mean follow up was 8.3 months. Radiographic correction was assessed via weight bearing radiographs taken pre-operatively and at a mean of 26 +/- 2 weeks post operatively. Measurements included Meary’s angle (talo-1st metatarsal angle), talonavicular joint (TN) uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates, calcaneocuboid joint arthritic changes and clinical outcomes via Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired t-test was used to compare both clinical and radiographic outcomes with statistical significance set at p<0.05. Results: Nine patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 (p = .002). Calcaneal pitch improved from 13.2 to 15.3 (p = .004), medial cuneiform/5th metatarsal distance improved from 13.3 to 18.5 (p = .004), TN coverage angle improved from 22.4 to 9.7 (p < .001), TN uncoverage % improved from 34.3 to 21.2 (p <.001), TN incongruency angle improved from 39 to 20.1 (p < .001). Deformity correction was well maintained in 14 of 17 patients at final follow up. Union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially, one patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection. Conclusion: The Z-cut osteotomy is a novel, technically simplified, single incision, single osteotomy alternative to previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity which offers comparable short term clinical and radiographic outcomes with acceptably low complications.

Causes and strategies for postoperative bone nonunion after bone transport of lower limb bone of chronic osteomyelitis with bone defect

To explore causes and strategies for postoperative bone nonunion after bone transport of lower limb bone of chronic osteomyelitis with bone defect. From June 2012 to December 2015, clinical data of 38 patients with lower limb bone of chronic osteomyelitis with bone defect were retrospectively analyzed, including 23 males and 15 females aged from 20 to 56 years old with an average of 36.5 years old; 5 cases occurred on 5 femoral osteomyelitis and 33 cases were tibial;the time from injury to bone transport ranged from 2 to 19 months with an average of 7.4 months; the distance of bone defect ranged from 4 to 12 cm with an average of 7.3 cm. Bone transport were performed at 1 week later after operations, and transport directions were from near-end to far-end for 30 cases, from far-end to near-end for 3 cases and bidirectional transport for another 5 cases. The alignment and transport speed were adjusted and weight-bearing was encouraged. Regular follow-up was performed and X-ray films were taken to observe complications such as poor mineralization in transport gaps, nonunion of docking sites, and recurrent fracture. Paley scoring was used to evaluate clinical effects. All patients were followed up for 12 to 36 months with an average of 23.1 months. No recurrence of osteomyelitis, but multiple complications associated with poor bony healing occurred. In the process of bone transport, 3 cases occurred poor mineralization in transport gaps, 17 cases occurred ununion of docking sites, 5 cases suffered fracture gap, 1 case occurred fracture without remove of external fixation, and 4 cases occurred facture after remove of external fixation. The time of taken fixation ranged from 9 to 27 months with an average of 16.3 months; index of external fixation ranged from 1.7 to 2.7 months/cm with an average of 2.24 months/cm. According to Paley's scoring, bony results showed 12 cases excellent, 16 good, 3 moderate and 7 poor;and functional results showed 14 cases excellent, 18 good, 3 moderate and 3 poor. Bone transport technique could effectively solve clinical problems of long bone osteomyelitis with bone defect. However, long treatment period influence prognosis. Therefore, indications should be chosen strict, and operations should be precise and accurate, also monitored across whole process and followed up in time. Doctors should be actively guide corresponding prevention strategies.

The Malunited Distal Radius Fracture - Extraarticular Correction without Bone Graft

In open wedge osteotomies of the distal radius, bone grafts increase initial stability and enhance bone formation but are frequently associated with complaints and complications at the donor site. Previous studies have suggested that bone grafting may probably be unnecessary. Between 2013 and 2016, 19 patients with symptomatic extra-articular fractures of the distal radius, malunited in extension, underwent corrective osteotomy using a palmar locking implant without an additional bone graft. 3 patients dropped out for implant related problems. One patient refused the follow-up investigation. 12 patients (7 male / 5 female) showed complete remodeling of the defect at 5.5 ± 3.5 (1.5-13) months. Palmar tilt improved significantly, from a mean of 17° to -1°, the DASH score from 41 ± 26 (7-94) points to 26 ± 25 (0-75). Radial inclination and ulnar variance and pain level showed only slight, non-significant improvement. Final range of motion and grip strength did not improve. In the modified Mayo wrist score, 5 excellent, 1 good, 3 fair and 3 unfavourable results were obtained. Three female patients showed no remodeling at 10 ± 3 (6-12) months. In the modified Mayo wrist score, 1 fair and two unfavourable results were obtained. One of these patients underwent reoperation with iliac crest bone grafting. Though remodeling of the distal radius only failed in female patients, no statistically significant dependence of bony healing on gender, age at the date surgery or size of the defect was found. In the healed group there was no statistical correlation between the interval from surgery to bony fusion and gender, age at the date of surgery or width of the osteotomy gap dorsally. A correlation was found between the widths of the osteotomy gap palmarly and the interval to bony fusion. After open wedge osteotomy of the distal radius, remodeling may occur without filling the defect by a bone graft. Since bony healing is not predictable and may require more than 12 months in single cases, we will continue bone grafting in our own practice.

Is the Scotty Dog Sign Adequate for Diagnosis of Fractures in Pediatric Patients with Lumbar Spondylolysis?

Introduction Recent advances in diagnostic imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), have allowed early diagnosis of lumbar spondylolysis (LS). However, few outpatient clinics are equipped with such imaging apparatuses and must rely on plain radiographs for the diagnosis of LS. The aim of this retrospective study was to identify how accurately fracture lines can be detected on plain radiographs in patients with LS. MethodsPatients with a diagnosis of LS were staged as early, progressive, or terminal. We evaluated whether fracture lines could be detected on plain radiographs and compared the detection rates under the following conditions: two directions including anteroposterior and lateral views (2 views), four directions including both oblique views (4 views), four directions including dynamic lateral views (4-D views), and all six directions (6 views). Results In early LS, the fracture line detection rate was 11.4% using 2 views, 20.5% using 4 views and 4-D views, and 22.7% using 6 views. In progressive LS, the fracture line detection rate was 54.2% using 2 views, 70.8% using 4-D views, 75.0% using 4 views, and 79.2% using 6 views. The respective detection rates for terminal LS were 85.0%, 100%, 100%, and 100%. Conclusions Although terminal LS was diagnosed accurately on plain radiographs in all patients, the detection rates were only 22.7% and 79.2% in patients with early and progressive LS, respectively. These results suggest that plain radiographic films can no longer be considered adequate for early and accurate diagnosis of LS. Advanced imaging procedures, such as MRI in the early diagnosis or CT for persistent cases, are recommended to obtain an accurate diagnosis of early stage LS in pediatric patients requiring conservative treatment to achieve bony healing.

Evaluation of two internal fixation techniques for mandibular parasymphyseal fractures comparing conventional titanium miniplates with customised titanium CRB omega miniplates: a prospective study

Our aim was to compare the efficacy and outcome of customised, titanium, CRB (Chandrashekhar Rushiji Bande), omega miniplates with those of conventional titanium miniplates in the management of parasymphyseal fractures of the mandible, with or without involvement of the mental nerve, after clinical and radiographic evaluation. A total of 252 parasymphyseal fractures in 200 patients were selected for the study over the period of seven years (January 2010–January2017) and divided randomly into two groups. The first group included 126 fractures treated with two conventional titanium miniplates (conventional group) and the second 126 fractures treated with one customised, titanium, CRB, omega miniplate (customised group). All operations were done by the same surgeon. Duration of operation (from placement of incision to closure of the defect) was recorded. Postoperative paraesthesia, infection, and acceptability of the plate to patients were also recorded. Postoperative healing was evaluated radiologically at one week and six months postoperatively. Operations were significantly shorter, and significantly fewer patients developed paraesthesia or infection, in the customised group. These patients were also happier with their miniplates, and had good radiological bony healing. In conclusion, a single customised, titanium, CRB, omega miniplate is an effective and economical alternative to two conventional titanium miniplates in the management of parasymphysis fractures of the mandible.

Research progress on early diagnosis of nonunion of long bones

Nonunion showed abnormal manifestations in early healing of bone fracture, which is characterized as repeated pain and radiological evidence including expansion, distraction, atrophy, induration and a visible fracture line of fracture ends. Clinically, orthopedists make a diagnosis based mostly on the healing time and bony healing standard. There is no uniform defini-tion of nonunion. The internationally recognized definition is that fracture which is at least 9 months, and no signs of healing for 3 consecutive months. Given lack of studies for early diagnosis and treatment of nonunion, most nonunion patients who have been confirmed always possess a bad prognosis. Nonunion is classified as six types among which dystrophy nonunion is the most diffi-cult type for early diagnosis based on X-ray. Besides, given its decreased callus formation, it could result in dystrophy nonunion without stress stimulus or turn into hypertrophic nonunion with the stress. Clinical assessment of early nonunion depends on utili-ties of plain radiographs, double energy X-ray, spiral CT, quantitative CT, CT image digital technique, ultrasound, radionuclide bone imaging, MRI as well as other laboratory detection, among which ultrasound and CT image digital technique showed better applications in diagnosis. For the cases of fracture internal fixation, because the fracture ends are blocked by internal fixation, the original data such as CT and MRI are usually needed to be further digitized and then the fracture healing is accurately judged. Practically, combined with the medical history and clinical manifestation, utilities of multiple clinical detection and imaging tech-niques make an effective diagnosis of nonunion, especially in determination of difficult cases.

Fractures of femoral medial condyle treated with contralateral less invasive stabilization system through a medial-posterior approach

Objective To investigate the therapeutic efficacy of contralateral less invasive stabilization system (LISS) through a medial-posterior approach for fractures of femoral medial condyle. Methods From December 2010 to December 2014, 14 patients with fracture of femoral medial condyle were treated surgically at our department. They were 10 males and 4 females, aged from 33 to 64 years (average, 44.6 years). By AO classification, 10 cases were type 33-B2 and 4 cases type 33-B3. Causes of injury included traffic accident in 7 cases, falling in 6 and heavy object crush in one. Internals from injury to operation ranged from 3 to 10 days (average, 5.4 days). All the patients were treated by open reduction and internal fixation with contralateral LISS plate or T plate through a knee medial posterior approach. Results The 14 patients were followed up for 12 to 24 months (average, 18 months). All fractures got bony healing after 3 to 5 months (average, 3.5 months). No collapse of joint surface, joint stiffness, joint infection, malunion or nonunion occurred. According to the Schatzker-Lambert criteria for functional recovery of the distal femoral fractures, the function of the affected knee was assessed at the last follow-up as excellent in 9 cases, good in 3, fair in one and poor in one. Conclusion Open reduction and internal fixation with contralateral LISS plate through a medial-posterior approach is effective for fractures of femoral medial condyle due to its strong buttress, rigid fixation, advantage for early functional exercise, and satisfactory therapeutic outcome. Key words: Femoral fractures; Fracture fixation, internal; Bone plates; Posterior median approach

Orthograde (non-surgical) treatment of large apical lesions

Many clinicians believe that large apical lesions, sometimes as small as ø ≥1 cm, should be treated surgically, as the size of the lesion leads to the assumption that it is a cyst that cannot be treated conventionally. According to Nair (1996), however, only 9% of all lesions are true radicular cysts. In the surgical treatment of large endodontic lesions, it is difficult to achieve good bony healing. Sometimes only scar tissue healing occurs (classification according to Rud and Molven). Due to the surgical procedure, a resti tutio ad integrum does not always result with regard to osseous healing even after the placement of a membrane.

Analysis of curative effect of traditional Chinese bone setting manipulation for the treatment of femoral neck fracture

To analysis the outcome of modified closure bone setting manipulation for the treatment of femoral neck fracture. From January 2012 to December 2012, 47 cases of femoral neck fracture were treated and included 25 males and 22 females with an average age of (44.58±10.32) years old ranging from 23 to 61 years old. All patients had a history of trauma, hip pain and movement limited, limb shortening extorsion deformity, X-ray showed fracture between femoral head and femoral neck basic. Among them, 32 cases were Garden type III and 15 cases were type IV. Patients were performed surgical treatment at 2 to 5 days after admission with 45 degrees abduction and extension position, internal rotation reduction, and 3 guide pins were inverted in a equilateral triangular structure of upside down arrangement. The postoperative recovery quality, fracture healing, femoral head necrosis and hip function were observed. Operation time was 40 to 70 min, intraoperative bleeding was 20 to 50 ml. All patients received good reposition, and the intraoperative perspective was 12 to 25 times. Forty-five patients were followed up for 24 to 36 months, and 2 cases were lost. Fracture of 45 cases were got bony healing, 3 cases with partial necrosis of femoral head, both in the ARCO stage II. Twenty-four months after operation, Harris hip function score was 43.24±2.74 in pain, 42.82±1.95 in function, 3.72±0.45 in deformity, 2.77±0.52 in activity, 92.56±4.42 in total;the outcome was excellent in 39 cases, good in 4 cases, fair in 2 cases, without unbroken nails, infection, deep venous thrombosis, fracture and other complications. Treatment of femoral neck fracture with the modified bone setting manipulation has an advantages of good effect, postoperative hip function recovery, curative effect.

The impact of diabetes on treatment in general dental practice

Diabetes is a chronic disease currently known to affect at least 5% of the UK's population and is expected to continue to increase in prevalence. The disease has significant effects on the immune system and increases inflammatory responses. Diabetes affects various parts of everyday general dental practice including: the altered host-pathogen relationship on periodontal disease and its management; the dental pulp and, therefore, endodontics; and both wound and bony healing, thereby impacting surgical procedures. Educating diabetes patients about the effects of the disease and associated risks to their treatment is important in patient management. CPD/Clinical Relevance: Diabetes is a prevalent chronic disease in the UK and can adversely affect oral health and dental treatment outcome.

Outcomes of lesser tuberosity osteotomy in revision anatomic shoulder arthroplasty

Lesser tuberosity osteotomy (LTO) is a common surgical approach during anatomic shoulder arthroplasty. Outcomes of LTO have been shown to be similar to subscapularis tenotomy and peel techniques, but little is known about the outcomes of LTO during revision arthroplasty. This retrospective case series included 10 consecutive patients who underwent LTO during revision shoulder arthroplasty at a single institution from 2012 to 2016. Patients underwent a preoperative computed tomography scan to evaluate the lesser tuberosity bone stock. Demographic information, radiographic evidence of LTO healing, outcomes of range of motion, subscapularis strength, and visual analog scale pain scores were analyzed. Revision total shoulder arthroplasty with LTO was performed for glenoid arthritis after hemiarthroplasty in 10 patients. Average age at surgery was 59.8 years, and no humeral stems were revised. Eight of 10 patients had prior subscapularis tenotomy. Average follow-up after revision surgery was 9.2 months. LTO union was documented in 80% and nondisplaced nonunion in 20%. At follow-up, 50% reported mild pain. Subscapularis strength testing was graded normal in 80% and weak in 20%. Average visual analog scale pain improved from 9.4 prerevision to 4.8 postrevision (P < .05). On average, range of motion improved in active forward elevation from 123° to 141° and remained unchanged in active external rotation from 42° to 42°. Patients undergoing LTO during revision anatomic shoulder arthroplasty demonstrate successful LTO bony healing, improvement in pain, and improved forward elevation. In select patients not requiring humeral stem revision, LTO is a safe and effective surgical approach to subscapularis management during revision anatomic shoulder arthroplasty.

Lesser Tuberosity Osteotomy Outcomes After Anatomic Shoulder Arthroplasty in Patients With Atraumatic Avascular Necrosis

Introduction Lesser tuberosity osteotomy (LTO) is an attractive option for subscapularis management during anatomic shoulder arthroplasty due to the biomechanical strength and reliable bone-to-bone healing. Patients with humeral head avascular necrosis (AVN) may have compromised bone healing, and the outcomes of LTO during AVN are unknown. Methods A retrospective consecutive case series of 6 patients with Cruess grade 4 or 5 humeral head AVN who underwent anatomic shoulder arthroplasty with LTO from 2010 to 2016 was performed. Postoperative radiographic evaluation for LTO healing at 6 months was analyzed, and clinical outcomes at latest follow-up, including range of motion (ROM), strength, and pain were studied.&gt; Results Average age was 50.3 years. AVN was secondary to sickle cell in 1 patient, steroid use for systemic lupus erythematosus in 4, and chronic alcoholism in 1. By 6 months after arthroplasty, 100% had radiographically united and healed LTO. Patients averaged 140 ± 21° of active forward elevation and 42 ± 7° of active external rotation. Patients reported an improvement in visual analogue scale pain from 8.3 preoperatively to 3.8 postoperatively. All patients had a normal abdominal compression test. No patients required revision surgery. Conclusion The use of LTO during anatomic shoulder arthroplasty for AVN has an excellent bony healing rate with improvements in pain, ROM, and strength. The diseases that cause humeral head AVN do not negatively influence LTO healing outcomes during anatomic shoulder replacement. Level of Evidence IV Case Series

SURG-16. THE TREATMENT FOR PRIMARY CERVICAL SPINAL TUMORS

AbstractPrimary tumors of the spine are uncommon and represent < 5% of all bone neoplasms as compared with secondary metastatic disease, multiple myeloma, and lymphoma. Moreover, the treatment of cervical spine tumors requires complex therapeutic and reconstructive strategies depending on the tumor’s pathology, location, aggressiveness, and proximity to the surrounding neurovascular structures, and influence the prognosis. A purpose of this study is to explore the clinical characters, surgical methods, and prognosis of the primary cervical spinal tumors. The subjects were 35 patients with an average age of 45 years, 20 male and 15 female. We examined the histological types, surgical methods, and prognosis. Malignant tumors were 11 including 4 chondromas, 3 chondrosarcomas, 1 angiosarcoma, fibrosarcoma, alveolar soft part sarcoma (ASPS), and epithelioid hemangioendothelioma. Intermediate tumors were two giant cell tumors (GCT), and benign tumors were 24 (8 osteochondromas, 6 osteoid osteomas, 3 Langerhans cell histiocytosis (LCH), 2 osteoblastoma, 1 Aneurysmal bone cyst (ABC), Pigmented villonodular synovitis (PVNS), and fibroma. As surgical methods, total resections with spinal reconstruction were performed in 21 cases (18 benign tumors, 2 GCT, and fibrosarcoma), subtotal resections in 10 cases (all of malignant tumors except for fibrosarcoma), and biopsies in 2 LCHs. Two cases (chondrosarcomas) underwent several surgeries for relapse. All of benign tumors showed no relapse and adequate bony healing. Eight of 11 malignant tumors were died on disease. Remaining 3 cases of disease free were 1 fibrosarcoma and 2 chordomas with adjuvant heavy particle beam therapy. Total resection has been difficult in some of these tumors, particularly malignant tumors, due to complicated anatomical features with vertebral artery and carotid sheath (highly risky anatomical region). The improvement of the further surgery technique and establishment of adjuvant therapy are expected in future.

Biocompatibility and Biocorrosion of Hydroxyapatite-Coated Magnesium Plate: Animal Experiment.

Magnesium (Mg) has the advantage of being resorbed in vivo, but its resorption rate is difficult to control. With uncontrolled resorption, Magnesium as a bone fixation material has minimal clinical value. During resorption not only is the strength rapidly weakened, but rapid formation of metabolite also occurs. In order to overcome these disadvantages, hydroxyapatite (HA) surface coating of pure magnesium plate was attempted in this study. Magnesium plates were inserted above the frontal bone of Sprague-Dawley rats in both the control group (Bare-Mg group) and the experimental group (HA-Mg group). The presence of inflammation, infection, hydrogen gas formation, wound dehiscence, and/or plate exposure was observed, blood tests were performed, and the resorption rate and tensile strength of the retrieved metal plates were measured. The HA-Mg group showed no gas formation or plate exposure until week 12. However, the Bare-Mg group showed consistent gas formation and plate exposure beginning in week 2. WBC (White Blood Cell), BUN (Blood Urea Nitrogen), Creatinine, and serum magnesium concentration levels were within normal range in both groups. AST (Aspartate Aminotransferase) and ALT (Alanine Aminotransferase) values, however, were above normal range in some animals of both groups. The HA-Mg group showed statistically significant advantage in resistance to degradation compared to the Bare-Mg group in weeks 2, 4, 6, 8, and 12. Degradation of HA-Mg plates proceeded after week 12. Coating magnesium plates with hydroxyapatite may be a viable method to maintain their strength long enough to allow bony healing and to control the resorption rate during the initial period.

Nanomedicine for safe healing of bone trauma: Opportunities and challenges.

Historically, high-energy extremity injuries resulting in significant soft-tissue trauma and bone loss were often deemed unsalvageable and treated with primary amputation. With improved soft-tissue coverage and nerve repair techniques, these injuries now present new challenges in limb-salvage surgery. High-energy extremity trauma is pre-disposed to delayed or unpredictable bony healing and high rates of infection, depending on the integrity of the soft-tissue envelope. Furthermore, orthopedic trauma surgeons are often faced with the challenge of stabilizing and repairing large bony defects while promoting an optimal environment to prevent infection and aid bony healing. During the last decade, nanomedicine has demonstrated substantial potential in addressing the two major issues intrinsic to orthopedic traumas (i.e., high infection risk and low bony reconstruction) through combatting bacterial infection and accelerating/increasing the effectiveness of the bone-healing process. This review presents an overview and discusses recent challenges and opportunities to address major orthopedic trauma through nanomedical approaches.

Simulated Weight Bearing and Articular Injury From Transarticular Screws In A Lisfranc Injury Model

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Successful treatment of Lisfranc injuries, relies upon anatomic reduction [1-3] and rigid fixation until bony or ligamentous healing has occurred and inherent stability has been restored. Historically, transarticular screw fixation has been the most common method of fixation, but optimal treatment remains controversial. Articular injury from transarticular screw fixation may lead to arthritis of the Lisfranc joints and future morbidity. To our knowledge only two studies have evaluated articular injury from transarticular screws [6,7]. Neither of these studies, and no other study to our knowledge has investigated relative increase in articular damage after simulated weight bearing. The aims of this study were: (1) create a ligamentous Lisfranc injury model and (2) compare relative increase in articular injury pre- and post-simulated weight bearing from screw toggle. Methods: 10 cadaver specimens underwent transarcticular screw fixation with 3.5 mm cortical screws in a ligamentous Lisfranc injury model. Digital photographs of the articular surfaces of the first and second tarsometatarsal joints were taken before and after cycling. Simulated weight bearing was performed with each specimen cycled 1,000 cycles at 222.4 N in a custom jig fixed in approximately 20 degrees of plantar flexion. After creation of the Lisfranc injury and prior to cycling with screw fixation, each specimen was cycled for 20 cycles to ensure we had created a reliable injury model. At each stage we assessed total relative rotation and diastasis between each of the bones of the Lisfranc complex. After simulated weight bearing hardware was removed and digital photographs were again taken. Articular injury was measured as a percentage of total articular surface pre- and post-cycling and was compared and statistical analysis performed. Results: Our model produced motion consistent with a ligamentous Lisfranc injury. Overall, the articular injury increased by 44.22% (p&lt;0.001) after cyclic loading. With respect to each individual surface, the second metatarsal (M2) showed the greatest increase in articular injury (53.89%, p=0.0047) whereas the first metatarsal (M1) showed the least (34.71%, p=0.0083). The increases seen at the medial cuneiform (43.51%, p=0.0387) and the middle cuneiform (44.24%, p=0.0292) were intermediate between the values seen at M2 and M1 (Table 1). Conclusion: Our model produced motion consistent with a ligamentous Lisfranc injury. The articular injury from transarticular screw fixation showed a significant increase in articular injury with cyclic loading at each of the articular surfaces of interest and a 44% overall increase in articular damage with simulated weight bearing. This relative increase in articular injury has never previously been studied. This increase in articular injury from screw toggle with simulated weight bearing with use of trans- articular screw fixation is significant and may increase the risk of arthritis and future morbidity when using this fixation strategy.

Indirect pars repair for pediatric isthmic spondylolysis: a case series.

Isthmic spondylolysis (ISY) is a common cause of back pain in the pediatric population. Historically, non-operative treatments have had a very high success rate. The purpose of this study was to review the mid-term results of an indirect pars repair technique on reducing the visual analog score for pain (VAS), spondylolysis defect healing, complication rates and rates of return to pre-surgery activity level in pediatric patients who failed conservative care for ISY. A retrospective review of all pediatric patients (<18 years old) treated surgically by one surgeon over a 5-year period was performed. Patients were treated with indirect pars repair utilizing pedicle screws and laminar hooks and local autograft. Preoperative VAS was compared to the final follow-up score, and return to activity was evaluated. Radiographs were reviewed to evaluate healing. Nine patients (6 females, 3 males) were treated surgically. Average age at the time of surgery was 15.4 years, (range, 13 to 17 years). Average length of final follow-up was 11.9 months (range, 6 to 24 months). Preoperative VAS averaged 5.6 points (range, 2 to 8 points) compared to final follow-up of 1.2 (range, 0 to 3). Definitive bony healing was noted in 7 of 9 cases (77.8%) with at least 6 months follow-up. Eight of nine patients (88.9%) returned to preoperative competitive sports activity level. No complications were noted during the follow-up period. Pediatric patients treated surgically with indirect pars repair appear to achieve satisfactory mid-term outcomes. This technique appears safe, and has both a high healing rate and return to competitive athletics. Further study is needed to determine durability of this procedure.

Comparison of Screws to Plate-and-Screw Constructs for Midfoot Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Arthritis of the midfoot’s 1st, 2nd, and/or 3rd tarsometatarsal joints (TMTJ) are routinely treated with arthrodesis when nonsurgical treatments fail. This surgery is traditionally performed with trans-articular screws, but newer plate- and screw constructs placed across the TMTJs may confer greater rigidity to the midfoot fusion. While in vitro biomechanical studies show advantages to using plate-and-screws over screws to achieve a solid midfoot arthrodesis, there have yet to be clinical comparative investigations about this subject. The purpose of this study is to prospectively evaluate and compare clinical and radiographic outcomes of trans-articular screws versus plate-and screw constructs for arthrodesis of the midfoot’s 1st, 2nd, and/or 3rd TMTJs in a single surgeon’s practice. Methods: Between April 2010 and December 2015, 68 patients presented with arthritis of the 1st, 2nd, and/or 3rd TMTJs that failed nonsurgical management. Of these persons, 50 enrolled in this study to receive a midfoot arthrodesis with either trans- articular screws or plate-and screw constructs. On the day of surgery, 25 patients were randomized to receive 4.0 mm partially- threaded cannulated cancellous screws (Synthes, Paoli, PA) while the remaining 25 were randomized to receive plate-and-screws (ALPS, Biomet, Warsaw, IN) at their involved TMTJs. Preoperative and postoperative function and pain was graded using the Foot and Ankle Ability Measures (FAAM) Scoring System and a Visual Analog Scale (VAS) of pain respectively. Radiographs were assessed for bony healing and hardware stability at the arthrodesis. Postoperative data regarding complications and revision surgeries were also recorded. Patients were routinely followed for 12 months from arthrodesis and then invited for updated longer-term follow-up to collect further data. Results: Of 25 patients with screws for arthrodesis, 21 (84%) achieved fusion within 6 months. Mean FAAM and pain scores changed from 46.4/100 and 8.3/10 preoperatively to 82.7/100 and 2.1/10 respectively at final follow-up. Three (12%) patients developed wound complications. Four patients (16%) experienced delayed union or nonunion of their arthrodesis. Of 25 patients with plate-and-screws for arthrodesis, 23 (92%) achieved fusion within 6 months. Mean FAAM and pain scores changed from 48.2/100 and 8.0/10 preoperatively to 86.3/100 and 1.8/10 respectively at final follow-up, which were not significantly different from patients with screws. Six (24%) patients developed wound complications, which is significantly higher than patients with screws. Two (8%) patients experienced delayed union or nonunion of their arthrodesis, which is less than patients with screws. Conclusion: A comparison of outcomes from performing midfoot arthrodesis with screws or plate-and-screw constructs has not been previously reported in the orthopaedic literature. This study demonstrates that using either screws or plate-and-screw to achieve TMTJ fusion results in a high rate of improving midfoot function and pain. While using just screws generate significantly less wound complications (P&lt;0.05), employing plate-and-screws produce less problems with delayed union or nonunion of the fusion (P=0.30). Studies with a larger patient population may be needed to further confirm these results when using different types of implants for midfoot arthrodesis.

Arthrodesis of the trapeziometacarpal joint

Bony fusion of the trapeziometacarpal joint. High demands concerning stability and strength of the thumb in primary or secondary osteoarthritis (e.g., posttraumatic osteoarthritis following injuries to the carpometacarpal joint of the thumb); instability in the absence of osteoarthritis due to malformations, ligamentous laxicity, and joint hypermobility; malformations; improvement of hand function in neurological disorders; salvage procedure after carpometacarpal arthroplasty provided bone stock is sufficient. Osteoarthritis or stiffness of adjacent joints, activities demanding maximal mobility of the thumb, insufficient bone stock. Resection of the articular surfaces of the trapeziometacarpal joint via adorsal approach. After temporary K‑wire transfixation, application of adorsal T‑shaped plate (fixed angled or not), replacement of the K‑wire with alag screw. Immobilization for 8weeks (radial below-elbow cast including the thumb metacarpophalangeal joint); standard radiographs on second postoperative day and after 8weeks; removal of stitches after 2weeks; with bony healing after removal of the cast, guided exercises to increase strength and mobility; full loading for manual tasks after 3months. With regards to strength, stability, and pain reduction, results are rated as good and excellent with ahigh degree of patient satisfaction. Disadvantages are implant-related complications and nonhealing of the fusion in an average of 13% of patients. Nevertheless, the procedure is still indicated in young manual workers who tolerate some limitations of mobility.